Protrusive Dental Podcast

Last Live Occlusion Course of 2024 – Book Now: https://courses.iasortho.com/courses/gb/occlusion POV: You spend a fortune on a composite anatomy course and are excited to implement on Monday morning. However, every time you apply those concepts, you end up drilling it away because it’s proud in the occlusion! It essentially now looks like a tooth coloured version of the amalgam you just removed! Your nurse’s eyes are like pools of fire – that’s half her lunch break gone. This happens a few more times until you realise that you’re missing a trick… Enter this podcast to save your career! 😉 https://youtu.be/5MVvknCNV-8 Watch PDP200 on Youtube Dr Jaz Gulati and Dr Mahmoud Ibrahim will teach you how to radically minimize adjustments on your daily restorations. Key Takeaways: Always check the patient’s occlusion before starting any restoration. Utilize shim stock to ensure accurate occlusal contacts post-restoration. Pre-op visual checks are crucial for successful composite placement. Don’t compromise on the anatomy of the restoration for aesthetics. Use thinner articulating paper for more precise occlusal markings. Communicate effectively with your dental nurse about new protocols. Involve your senses to assess the quality of your restorations. Document occlusal marks pre and post-restoration for reference. Adjustments should be minimal if pre-op checks are thorough. Educate patients about their occlusion to manage expectations. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:05:24 Introduction – Dr Mahmoud Ibrahim08:42 Posterior Composite14:15 Shim Stock Foil16:35 Effects of Numbing on Occlusion18:23 Lower First Molar Example22:06 Shim Stock revisited26:22 Lateral Excursions30:32 Fissure Staining?31:56 Old Restoration as a Guide35:33 Restoration Techniques and Adjustments38:03 Tips and Tricks43:28 Event Discussion45:09 The Importance of Marginal Ridges46:25 Anatomy or aNOTomy?48:17 Post-Op Checklist: Final Adjustmentsand Polishing Tips54:19 Wrapping Up: Using Your Senses in Dentistry56:43 Outro This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance App. This episode meets GDC Outcomes A and C. AGD Code: 250 Operative (Restorative) Dentistry (Direct restorations) Dentists will be able to: Evaluate and manage occlusion during posterior composite restorations, ensuring that patient bite and interdigitation are maintained post-procedure. Effectively use shim stock foil and articulating paper to achieve precise contact points and occlusal balance, minimizing the need for post-restoration adjustments. Apply practical techniques, such as using occlusal stamps and soft flex discs, to streamline posterior composite restorations while improving the durability and aesthetics of the final result. If you liked this episode, check out: IC046 – 4 Ways and 6 Great Reasons to Document Your Dentistry Click below for full episode transcript: Teaser: The cuspal inclines and using visual references that I take before I prep the tooth. So I'll look at where the marginal ridge is compared to the base of the cavity. Where's the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. The angle of the cusp is probably, for me at least, one of the most important ones. Teaser:Some patients are like princess and the pea, whereas other patients are like everything feels amazing. And the very last thing you check is how does that feel? That’s like the last. Why are we getting patients to feel their bite? They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say, how does it feel? How does it feel? They’re feeling their bite. Something that really should be not really present for them, if you like. Once you get quicker and slicker, I would urge you to start checking front teeth as well. Because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock. And I think you’ll be surprised. Jaz’s Introduction:So you go on a posterior composite course, you brush up on your anatomy and you’re excited to place posterior composites that actually look like teeth instead of just white amalgams. And so what happens is that you have like the best fun ever, trying to create all the fissures and the inclines and anatomy. And with rubber dam on, you take that photo and you just stare at it for five seconds and you think, yeah, this is a work of art. I’m going to post this one on Instagram. And then you already know where I’m going with this. You already know what I’m going to mention next, which is you take off the rubber dam and you get the patient to bite together. And literally like the bite is so open, right? You have to get the big bur, right? You have to get a big bur throughout and just grind away all the anatomy. Now you have a white amalgam left. Obviously, it’s composite, but it’s now flat. It may as well just been a white amalgam. All that fun you had was wasted and you’re getting evils from your dental assistant because you just wasted up to anything up to 20 minutes. Earlier in my career, it could take that long to get the bite right. And you think, wow, what a waste. What a waste of time to doing anatomy. What a waste of clinical time. What a waste of my DA’s lunch hour. And this is not profitable. This is not fun. It’s depressing. So this is why this episode will give you such a good framework to eliminate or at least significantly reduce how much adjustment you have to do for your composites. So they can still look good. Like I’ll be honest with you. Sometimes you just can’t do a beautiful composite in that scenario, because guess what? All the other teeth in that arch are quite worn and you can’t give a 70 year old a 12 year old’s tooth. But in our daily scenarios, we give you some really tangible pearls and tips and technique advice to reduce the amount of adjustment, be more purposeful in your composite placement, but still take some degree of pride in the anatomy that you’re placing. Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re a regular watcher or listener, please do hit that subscribe button. You’ve been listening to us for so many years, you might as well give us some love. And if you’re new to the podcast, definitely hit subscribe because you don’t want to miss another episode and you want the algorithms to show you all the other episodes we’ve done over the last six years. This is an important episode because this is episode 200 of PDP as a podcast we have almost 300 episodes including all the other branches of the podcast we do. But in terms of the original PDP it’s such an exciting number and I’m especially grateful to about five to eight hundred of you who’s literally stuck by me from episode one. So when I used to make my first 10 episodes, so there’s about five to 800 people that would listen to watch full stop back then we were audio only. And now I look at the numbers and it’s amazing. We are a top 1 percent podcast in the world, in any genre. And it’s thanks to you guys sticking with Protrusive, the feedback and the guidance you give me, to allow us to make great content. I’m not going to take up too much time. I just want to say thank you again for being a Protruserati. Dental PearlNow every PDP episode I give you a Protrusive Dental Pearl. This one’s regarding our basic posterior composites. So it’s very much in line with the theme of today, getting the occlusion right in your posterior composites, but actually this is due with cavity configuration. We want these proximate exit angles, which are smooth and flowing. And so recently I posted a pre molar I did, and I was quite happy with the anatomy I achieved, and yes, it was perfect in the occlusion. And I posted my cavity prep on Protrusive Guidance, and I said, guys, please do critique me. Is there anything I could do better? And despite me using an old science scaler to remove the Friable enamel. I’m using like a needle diamond bur just to smooth out those exit angles. One of the Protruserati Sai still said that, you know what, we can get this a bit smoother. Have you considered using a soflex disc? And I’m like, whoa, I use soflex discs all the time. So at the end of every composite, I will always use a soflex disc. And for my anterior dentistry, I’ll reinforce my bevels with a soflex disc. I find discs great to get rid of the friable enamel, the unsupported enamel. But I did remember now that I’m out of habit of using these discs posteriorly at the time of cavity configuration. I usually pick them up after I’ve completed the composite restoration. And so really it’s reinforcing what I re learned and reminding you guys that a flexible coarse disc used in the backhand stroke can really help you to get nice, smooth, flowing enamel, those lovely exit angles that we desire for our composite bonding. So thank you Sai and thank you everyone who commented on that post on Protrusive Guidance. If you’re not already on there, it’s the home of the nicest and geekiest dentists in the world. There’s no such thing as a silly question. I’m really enjoying seeing the chat thriving and people posting more. Now we’ve already got six years worth of podcast data on there. Plus all the feed posts for the last six months. And so the search function is so valuable. If you’re looking to learn something, just search it on Protrusive Guidance. More than likely, we’ve already covered some element of that before. Anyway, let’s join a familiar face, Dr. Mahmoud Ibrahim, to make sure you don’t have to remove the beautiful anatomy of your composites anymore. Main Episode:Dr. Mahmoud Ibrahim, welcome back again to the umpteenth time to the Protrusive Dental Podcast, my occlusion brother from another mother, as I say. How are you today? [Mahmoud]I’m good, man. I’m good. I’m feeling like a bit of part of the furniture now in Protrusive. So that’s a good thing. [Jaz]It’s a good thing. You’re an integral part of the Protrusive community. It’s great to see your minimally invasive Mahmoud Ibrahim, the Mimi cases on PG. You need to get back on those and your contributions. Like anytime someone asked, like Nabila was asking the other day on the community, can someone just explain to me like what different composites are out there and like which one should I use and stuff. And I gave a little, I chimed in a little bit, but I was like, okay I’m going to tag Mahmoud and he’s going to take it away. And you wrote this beautiful like essay and when I say essay like not in a boring way like every sentence had so much value. So thank you for all that you bring in terms of from occlusion perspective and composite perspective. And so we’re marrying exactly those two themes together on today so we can help dentists to stop doing this mistake that we all have made, we all continually make on a daily basis, which is you place your composite. This could be anterior, gosh I’ve been there, and this could be more commonly posterior, rubber dam or not, whatever, rubber dam police, pipe down for a second. You place your posterior composite, and it looks beautiful, like you’ve been studying the books, you’ve been going to some courses on anatomy, and you think you’ve absolutely nailed the three buccal cusps, the slopes, everything, the secondary and tertiary, the marginal ridges, everything and the patient bites together and you’re like, holy crud. You now have to adjust everything away. And then by the end of it, it just looks like a squashed banana or something, right? And so it’s no good. But before we discuss these pain points and then more importantly the solutions, this is not like a clickbaity episode. We’re going to give you brilliant solutions that you can apply straight away and this is going to absolutely solve this problem. So this hopefully will be the most career changing daily tangible podcast you may have ever listened to because we make so much of our income from just bread and butter direct restoration. So I’m hoping this will have a huge effect over those who haven’t. For some reason there’s the, like they saw the title, this is the first ever episode they’ve clicked on Mahmoud. Can you just tell us about yourself? [Mahmoud]Well, yeah, so my name is Mahmoud. I’m a general dentist. I’m nearly 20 years qualified now, like I said last time. And yeah, when you combine occlusion and composite for me, that’s where my passion lies, you mentioned the little essay I wrote. And honestly, sometimes I need to reel it in, right? Like I’m sitting there, I’m trying to answer this question as comprehensively as I can, but I’m also conscious of like my wife shouting at me and kids are climbing up on my head, but yeah, those two things really, really get me sort of get the creative juices flowing and want me to give as much value as I can. And yeah, if you ever want to check out sort of what I do, I post a lot of it on Instagram, so it’s a DR M O I Dental is my handle, and you’ll see the kind of stuff I love doing. So day in and day out. [Jaz]I would put that in the show notes link because it’s actually a work of art, your resin stuff. I’m not anywhere near that. I mean, I like to get my primary anatomy, like my line angles and I’ve had a good day and my patients, my specialty is taking patients from a 3 out of 10 to an 8 out of 10 if on a good day. Whereas you’re like taking people from like 7 to a 10, which is a whole another skill. Okay, so kudos to you, my friend. Guys, if you haven’t listened to any of Mahmoud’s stuff before, just go back, like if you’re on Protrusive Guidance, our app, just search, use the search function. We’ve paid a lot of money to developers to have that search function in there, I promise you. Okay. Hit that search button. Just type in Mahmoud and just binge on his posts. But importantly, some of the previous episodes we did on like basics of occlusion stuff, he talks about his journey that you almost gave up dentistry, right? And what a loss to the profession and what a loss to my partner in crime that would have been had, had we lost you to the web development world or whatever it was at the time. But Mahmoud, let’s talk about this problem. Okay. [Mahmoud]Sucked at that too much. I couldn’t do it. [Jaz]I’m glad you managed to reel back into dentistry, my friend. So composite, where do we even begin to discuss this mammoth topic? Let’s just describe, paint the picture, okay? Let’s start posterior, because I think there’s different strategies and tools we can use, posterior and anterior. So let’s start posterior. Occlusal restoration, okay? What do you think is the first thing we should do, okay, because I’m already hinting at the fact that, okay, it all starts at the beginning rather than after you place your composite. How can you do preempt this and actually solve this issue before you’ve even done anything to the tooth? [Mahmoud]Well, we always talk about the fact that 90 percent of our work is conformative dentistry, meaning I’m not going to change the patient’s bite, right? I want to keep things the way they are. You give a lovely, lovely analogy of a kid trying to get a cookie out of a cookie jar, right? The idea is you don’t want to leave any trails. You don’t want anyone to know you’ve been there, but in order to conform to something and not change it, you need to know what was there before. So the first step is always going to be examine the patient’s occlusion before you pick up a handpiece before you numb them up, okay? And generally speaking, actually it’s something I do when I’ve decided this tooth might need a restoration, right? You’ve diagnosed the caries, you’ve done your bitings or whatever it is, right? And it’s at that point that I’ll also have a look, just get the patient to bite together. I’ll just have a look, you know? Early on in my career, this has happened a couple of times where I’ve done the restoration and then I get the patient to bite together and then I realize they don’t have an opposing tooth. And then you’re like- [Jaz]Been there, been there. [Mahmoud]I feel like an idiot. [Jaz]I think we’re all smiling because we’ve all been there. [Mahmoud]Yeah, yeah, 100% happens and you’re like, hey, easy day. So, but yeah, just check what it was beforehand and we’ll go through sort of the steps, but that’s where it needs to start. [Jaz]Now on this point, cause it’s so, so important, this aspect, and it sounds like simple. It’s like, oh, I’ve heard this before, but so many of our friends, our dear friends, our colleagues are just not getting into the habit. All it is, is a habit. Once you do it for 21 days in a row, form a habit, whatever it is, it just becomes second nature. And it doesn’t even have to be, when we say check the occlusion, what we don’t mean is, get a stethoscope, listen to the joint, measure the mouth opening. We don’t mean anything like that. We literally mean a pair of Miller forceps, okay. Articulating paper. I like AccuFilm, which is 24 microns, double sided. What do you use at the moment? [Mahmoud]I use TrollFoil. [Jaz]I love TrollFoil too. So I use that for my anterior stuff as well. And sometimes, yeah, for ease, TrollFoil, if no one’s used it, it’s very clever. It’s like, supposedly it’s like eight, but the data says maybe it’s more 12 micron range, which is still thin. It’s great. Okay, and then you literally like peel it away. So it becomes its own Miller’s forceps. So it’s like a handle that you can hold that’s not going to ink on your gloves. [Mahmoud]I’ll confess. I still use it with Miller’s forceps. [Jaz]Yes, I know you do. [Mahmoud]You still, you can’t move the cheek out of the way without the actual Miller’s. [Jaz]That’s true. I get a little lazy. I just round my fingers in and just get the cheek out of the way like that. But your way is more effective, okay? So TrollFoil is great. So it’s nice to sometimes just talk about what papers we’re using. And note that we’re using thinner papers, because again, we’re going back to basics when I, like I was lecturing or doing a webinar for Generation D in Malaysia the other week. And I just asked the room on Zoom. I said, does anyone actually know what size your articulating paper is? And I think there was like 40 people on that zoom meeting. And I think only one of them knew. Okay. That’s it. So 39 did not even know. And so the problem with that is if you’re using that horrible thick stuff, which has its use, by the way, when you’re checking function and anterior envelopes, that kind of stuff, when we’re using that 200 thick cardboard paper, right, and you imprint the patient’s occlusion, you get them to bite together, you are getting too much data. The whole tooth goes blue, and you’re thinking, okay, what do I actually adjust? And you end up just mowing the whole thing away. That is not being precise. When you get smaller markings which are more truly representing the true contact, even then you get some false positives, i.e there’s ink on the tooth, which does not actually represent a true contact. It’s just a smear a smudge on a tooth. So if you want to be more precise, please first thing find out what size articulating paper you have and make sure you are using something thinner. It doesn’t break the bank and it’s good practice. So first thing to make it actually help the people move the needle forward. So if you’re not already doing this number one check which articulating paper you’re using. Make sure you’re using something thinner and tell your nurse about it as well. Educate them and okay, this is why we’re using this and this is the one I like the most from now on. And then number two, if the Miller’s forceps and the articulating paper is not on your bracket table before you start the procedure, i.e. it’s somewhere behind you, it’s not going to happen. [Mahmoud]Exactly right. I think that probably is the biggest thing. Now we’re in all of dentistry, whether you want to take more photos, whether you want to check the occlusion. Just be prepared. Have it out already. So my nurse knows to have red and blue arctic paper out. Does she always get the red out? No, sometimes I still have to remind her about that for some reason. [Jaz]So Mahmoud, this is red Troll Foil and blue Troll Foil is what you’re using, yeah? [Mahmoud]Yeah, I know it’s expensive. And then some shim stock, okay? And we’ll talk about shim stock in a second. [Jaz]We’ll talk about why shim stock, otherwise not move forward, okay? So we’ve decided that, okay, you’re going to have your correct arctic paper, and we’ll talk about foil as well. And it’s going to be there, and you’ve had that chat, that all important chat about, why you’re doing something because what nurses hate the most is that you go on a course, you come back, you start doing some random shit you’ve never done before, and they’re like, what the hell is going on? Because what nurses crave is routine and predictability. So anytime you’re introducing something new to the scenario, we must do our due diligence. and just have that chat. Oh, Zoe, before we just bring the next patient in and she’ll roll her eyes like, what now? What have you bought now? What have you done? I was like, no, no, no, this is really important. This is what I’m going to do from now on, because- [Mahmoud]This one will really stick, right? As opposed to all the 17 other things you’ve tried you don’t do anymore. [Jaz]It’s like when you explain to someone what you’re doing, fine, but when you tell them why you’re doing it, then they’re more likely to agree, right? It’s one of those psychological experiments, right? So when I tell Zoe I’m doing something new, and Zoe’s great, she actually wants to know why, which I really respect Zoe for that reason. So I tell her, This is what I’m doing. This is why I’m doing it. And this is why I’m not using the old protocol anymore. So if we are still using the same protocols for eight years ago, yes. That’s a comfortable thing, but I don’t see that as evolution. I’m constantly changing my protocols because I hear something better. I like the sound of something. There’s new techniques coming out. So it’s really important to educate our colleagues that work with us day in, day out as well, because they’re the ones who actually selecting the stuff. They’re the ones who are going to make a bigger order of Miller’s forceps, or maybe you don’t have any Miller’s forceps in practice. And maybe that’s a good place to start to order some Miller’s forceps. Right? So now we’ve got our Miller’s, we’ve got our arctic paper and you mentioned the foil. Tell us more about why mean you love shim stock foil. [Mahmoud]So shim stock foil for me probably again is like that makes a huge jump in your accuracy for not much work. And shim stock is essentially, depending on the brand is like eight to 11 microns, non marking foil super thin and it has no ink on it. And the way you use it is you want to get it between the patient’s teeth, ask them to close into their habitual bite into MIP and you’re trying to pull the shim stock out from between the teeth, right? If the patient’s closed and you’re trying to pull it and it doesn’t come out, That is called a shim stock hold. Now, you know that there’s true contact between those two teeth. If the patient is closing and you can pull the shim stock straight out and just come straight out, you know, that actually there isn’t any contact between those two teeth, despite what you might see using the marking paper. There is something in between where you will feel it sort of drag a little bit. And I do think that’s, again, it just takes you up a level where you can notice the drag. That just means that the teeth are close to touching a tiny bit, but not hard in contact. [Jaz]And the reason why this improves our precision is that like this is like the opposite end of that 200 micron paper, right? Which again has its uses but for daily MIP IER tap tap tap bite. It’s a bit overkill. It’s too thick Okay, so at the one end you got less precision. Okay, which is a 200 micron paper and on the other end is this foil which is eight microns. And it tells us is there a true contact in the patient’s bite because if all we rely on is our eye. And we think, oh, this premolar cusp sits nicely into this premolar fossa, this tooth is in contact. But actually, so many times you put the shim stock foil in and you can pull it out and you’re like, ah, actually this tooth is not in bite. Now, why is this important is because once you’ve done your restoration, just like Mahmoud said, guys, if you don’t know what the occlusion was like before, How can you really check it at the end? So maybe your composite isn’t proud. Maybe your composite’s just fine, because yes, the shim is pulling on the premolar, but guess what? It was never in contact in the first place. So when you know where your shim stock holds are, you can truly conform to the correct bite at the end that’s comfortable for the patient, and this is a great way to do it. So we’ve talked about the importance of thin arctic papers. Everyone go out and do a purchase of shim stock. We are not sponsored by Hanel or Coltene. We wish we were, kind of thing but we’re not. We’ve influenced so many dentists to buy Hanel. They’re like, their stock prices are ever rising, right? But anyway, we don’t get any part of that. We just truly believe in some thin foils, other foil products may exist. Okay. Whatever. So we have to say that like the BBC, right? I wouldn’t know which ones, right? So anyway, we’ve now decided that we’re going to be checking the occlusion. Now, here’s my question to you, man. When in terms of maybe our protocols differ here, right? But in the interest of efficiency, what I’ve been doing for the last few years, okay, is, I’ve been doing my usual pleasantries, showing the patient a radiograph, warning them about the root canal, having a nice little chat, basically, and then tipping them back, numbing gel, and as the numbing gel’s working, well, sometimes, even while the LA is working, then I’m doing my checks. Now, is there a concern you have here? Like, you know, does the fact that the patient’s numb on one side, does that change their bite so that your recordings are altered. [Mahmoud]Again, it depends, right, is the best answer to most things. If they’re completely numb, yeah, and I’m doing more than one unit, and they have teeth that don’t interdigitate super well, then, yeah, I would probably do it before. [Jaz]Give us an example of that. Make that point tangible. What do you mean? What’s something that interdigitates well and something that doesn’t interdigitate. I’ve said it very carefully well? [Mahmoud]So people that have like really cuspy teeth. So deep grooves, long cusps, and things fit together really well as opposed to someone who’s ground all their teeth really really flat. And they can sort of you know bite here. They can bite a little bit to the left. They can bite a little bit to right and when you ask them to bite together, they’re like, oh which ones you want? That sort of thing. [Jaz]The analogy I use here is to study models analogy. When you’ve got someone’s models, right and you bring them together, you know you don’t need a bite record. They just fit together like this Mandible belongs in the maxilla exactly here, right? This is like perfect, okay? Well, when you have exactly lock and key, when you have models and you’re like figuring out bloody hell, how do these fit together? That’s someone who doesn’t have great interdigitation because anatomy doesn’t guide you. [Mahmoud]Yeah, so in those patients and like I said, if I’m doing maybe a couple of units on the lower, like I’m doing a lower left first and second molar, I’m going to give them an ID block. Yeah, I’d probably rather take my occlusal sort of analysis, do that before they’re numb, but if it’s, I’m just doing a class II. And they’ve got really good interdigitation. They can find their home base really easily. Then for the sake of efficiency, I’m going to start the numbing process as in do the topical, give them the injection, and then I’ll do my paper and my shim stock as they’re going. [Jaz]And it doesn’t take that long. So just talk us through, let’s talk about a scenario classically, lower first molar. Back in the day, it’s your first restoration you’re ever doing. It’s the lower molar occlusal. Okay, you’re doing an occlusal and you’re going to be really good. You’re going to spend half an hour getting rubber dam on because you saw on Instagram it’s important to do and you’re going to struggle and you haven’t done my quick and slick rubber dam webinar yet on the app, so you’re going to go and get that. But then now you’re going to be slick and you get it in two minutes. Anyway, you got rubber dam on, okay. But actually before you get rubber dam on, when you’re doing these checks, okay, can you just describe what this looks like for a lower right first molar in this pretend patient? [Mahmoud]Okay, so really easy because I would have checked. I can see that they’ve got a repeatable MIP. Yeah, they go the same place. So once I’ve numbed them up, I’m just going to dry the teeth. You can use a tissue or you can use your 3 in 1. Dry the teeth. I’m going to put the blue paper in. We’ll just talk about MIP for now. So I’ll put the blue paper in, I’ll just get the patient to tap, tap, tap. I literally say to them, tap your teeth together and then go like this. Yeah, because I want them to do that. [Jaz]Now what if some patients protrude their jaw and they come edge to edge? Because that’s what some people, when you say bite together, some people do that. [Mahmoud]Yeah, just accept it. Okay, just accept that this step, there’s just no- We get asked this maybe every single webinar, every single occlusion camp. What do you say to patients to get them to do what you want? Sometimes it just takes a little bit of coaching, right? Just a little bit of patience. [Jaz]I found telling him to bite hard. Bite hard sometimes helps a lot actually because they’re not able to bite on their front teeth. Instinctively they’re just, that helps. [Mahmoud]I’d just be careful doing that after you put your restoration in because if it’s high and they bite hard you don’t want to end up having to repair it. But yeah, for me, again, you develop your own words that you use and how you do it. For me, bite on your back teeth and tap tap tap seems to get me there, 95 percent of the time. A few people, yeah, they’ll bite on their front teeth and I’ll say, bite on your back teeth please. [Jaz]And once they get there, just show the mirror. Yes, this is the bite I wanted. This is good. So when I say bite on your back teeth, you’ve now coached them. This is what you do. And they were like, ah, I thought you meant bite on my front teeth when I said back teeth kind of thing. Because I thought my bites, so many patients walk around thinking our bite is supposed to be edge to edge. Like patients think we’re not supposed to have over jet. Like that’s what patients, they look at cartoons and look at like growing up and they think that everyone who’s got even a slight over jet think, oh man, my teeth are crooked. I need to, have you ever encountered those patients? [Mahmoud]Yeah, yeah. And they’re the ones who always want your composite as well your anterior composites to everything like just be straight, but okay. So going back you’ve known the patient I’ve dried the teeth. I’ve got the blue paper in there I’ve got them to tap tap tap on their back teeth and I’ve got some mark. I need a way to remember or document those marks and there’s several ways to do it my preferred and the easiest way is you take an intraoral photo. I think that’s what you do as well? [Jaz]Yes. [Mahmoud]Photo with an intraoral camera, okay, and that stays on your computer and that you can reference that at the end of the appointment. The other way you can do it is you can just make a note, right? So sometimes I used to, before I had a camera, I used to do something called an occlusal sketch. I learned this from Stephen Davies, Dr. Stephen Davies in Manchester. He had this like little arch of teeth drawn and you can print it out and then you can just mark on it where the occlusal marks are and in fact, I’ve adapted this into the occlusal prescription worksheet that we’ll be using on our courses and stuff. And essentially you just want a way of knowing where the marks were beforehand. So take a photo, write it down, make a sketch. Okay. Or if you’re really clever, you can memorize it. [Jaz]When you’re doing this for a while, some younger colleagues may be thinking, whoa, how am I supposed to memorize all that? But actually most straightforward occlusions daily bread and butter dentistry. Once you see it in a class one occlusion, generally the contacts are usually where you expect them, right in the middle of the groove in the lower molar, for example, on the cusp tip of the upper palatal, mesio-palatal cusp on the marginal ridges and the premolars. And it becomes quite easy to detect a bit after a while. [Mahmoud]Yeah. And bear in mind, like I’m not asking you to remember like 17, 000 dots on all the teeth in the mouth, right? You were just doing. We’re treating a lower first molar. I’m probably only caring about maybe the second molar behind it, and maybe two teeth in front. [Jaz]That’s really important, because people get freaked out, and I think you’ve made a great point there, like, don’t worry about the dots everywhere, just in your local area that you’re working, that we need to nail that. [Mahmoud]Next up for me is shim stock, okay? And if someone is thinking, I really like, this is just too much. Honestly, the shim stock makes the biggest difference. And again, on OBAB, I show a case where I was just doing an indirect restoration at the time, but when I put the provisional on, you could see very clearly in the photos where the paper marks were correct. They matched the pre op, but the shim stock was off, right? And the patient could tell. So the shim stock just takes you that little bit. [Jaz]Some patients are like princess and the pea, whereas other patients are like, everything feels amazing. Whatever, you just put a rock in their mouth, and you send them off, and you tape it, and exactly. So, yeah, just bear in mind that patients don’t go. We’ll summarize this at the end, but there’s all the different checks you make at the end to make sure we have conformed well. And the very last thing you check is, how does that feel? That’s like the last. And sometimes, some protocols that some educators taught me don’t even ever ask them that, because the bite is your domain. You’ve done your checks, okay? You’re happy, then you’re all good now, sir. Or ma’am, right? You know, you don’t need to ask him how it feels because then what Barry Glassman says that why are we getting patients to feel their bite? They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say how does it feel? How does it feel? They’re feeling their bite something that you really should be not really present for them If you like. [Mahmoud]It is a little risky nudging them in that direction. However, you do need to build up the confidence So now that I’ve got this protocol and I know that if at the end of the appointment I am convinced myself that the byte’s right, because I’ve done all my checks and stuff. Honestly, even if the patient says, it feels a bit weird, I will say, you’re just a bit numb, leave it until tomorrow and it’ll feel fine. And because I’m so confident in how I say it, they’re like, oh, cool. And then they’re fine, right? Because once you’ve built up that confidence, then you can look them straight in the eye and tell them, don’t freak out, you’ll be fine. [Jaz]Because you’ve done your checks and you’re happy that your objective data, your shim holds are as they were before, your dots are as they were before. And therefore, you’re happy, basically. The other check, well again, we’ll talk about this at the end when we do a summary. There’s muscular checks you can make as well. But right now, I just want to start at the beginning, where you’ve talked about shimstock as the next thing after the Arctic paper. Please carry on. So with the shimstock, I will check the tooth. Obviously, I’m going to be working on it. I want to see if it’s holding shim or not. I’ll now usually do the tooth behind, the tooth in front, and one tooth on the other side. And that, again, I will just get my nurse to document. Let’s say we’re doing the lower first molar restoration. So I’m checking the lower first molar and say, I’ll Get the patient to close on the shim stock and I’ll tug. If I can’t pull it out, I’ll just tell my nurse, lower right first molar or lower right six or whatever you want to call it, hold. Okay, and she’ll just document, write that and she’ll put an H. And if it doesn’t, she’ll put no hold. And if it’s a drag, she’ll put a D, right? And it’s just four teeth. It takes literally 10 seconds. However, like this freaking everyone out, just please do it, right? When you’ll realize actually the tooth that you’re working on is holding shim. So in our case, the lower molar. The lower second molar is also holding shim. Okay, the tooth in front is also holding shim, and on the left side it’s also holding shim, which about maybe 70 80 percent time is the case in case someone’s got a nice occlusion. Then this is, you know, it’s not complicated at all. You just verify. Exactly. It takes literally seconds. Sometimes, like when I’m doing indirect, and I’m going to be feeding this to the lab, and unusually you’re doing posterior teeth, right? I’ll check all the back teeth, some molars and premolars. Most of the time they all hold and my note on the prescription will just be molars and premolars hold on both sides. And as we discussed guys in the couple of episodes ago, if you haven’t listened, we had gray and my technician on and we talked about how to get the occlusal prescription, right? How to make sure our inlet restorations are in the bite correctly. And so we gave some great tips on there about how important it is to give your shim holds to the lab Because the bite record that we sent the lab more often than not There are some errors in it and therefore if you’re relying especially on the digital world, then we’re going to get a lot of errors occlusal errors. So only once we give the shim holds and then the technician calibrates your models, whether digitally or on the actual physical models, then we get the correct occlusion. Again, I’m sorry we’re taking so many detours. Kind of is a big topic to cover, but just to summarize there, it’s not rocket science guys. Just get that shim stock, do it. It takes seconds and now you’ve got objective data. Is there anything else you’re checking? [Mahmoud]So just carry on with the shim stock thing is once you get quicker and slicker, I would urge you to start checking front teeth as well because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock and I think you’ll be surprised and if you are working in the analog world with models, remember, probably one of the biggest problems with models is they will rock backwards and forth. So you can very easily make front teeth touch when they don’t on a model. So again, very valuable information to give to your lab technician. [Jaz]Great. So also as you delve further involved the anterior teeth as well as a reference, which is great. Are you checking excursions? [Mahmoud]Remember when we said I’m checking if the patient A has a tooth opposite the tooth I’m working on, or if it’s going to be a really easy day in the office. Yeah, so I’ve checked. Now while I’m doing that, I’m also then at that point checking my excursion, right? And I’m seeing whether this tooth A is, does it contact in excursions or not? And if it does, is that area, number one, is it likely to be involved in my restoration? So can I see a massive caries bomb that’s going to undermine that cusp? And if it is, what am I going to do about it? And then the other thing is considering, okay, well, if, and if it isn’t contacting it, I just need to make sure once I restore the tooth, it isn’t contacting either. [Jaz]So again, going back to conforming in tap, tap, tap, but also conforming in excursions where it’s appropriate. [Mahmoud]Yep, indeed. Okay. And you can apply a lot of the stuff we talked about in the previous episode about guiding teeth and stuff like that. But essentially when I’m checking, repeatability, I’m also getting the patient to grind, I’m checking if the tooth is involved or not, and then I’m making a decision as to whether it will remain involved or not. [Jaz]And in the case of our example tooth, the lower right first molar, if it’s an occlusal, then you might find that the distal buccal of that lower right first molar is involved in a group function kind of guidance maybe, but that occlusal area probably is not involved very much. You might find little line from the palatal cusp, so just make a note of it, but more often not it’s going to be okay. When you’re doing different surfaces, maybe a distal involving a bit of the buccal might become more of an issue, but it’s important that you’ve made this check. And the way to check it is, again, you use a different color troll foil. Now you’ve got the patient to move, make that movement basically. And it’s also nice to check the other side as well. And you just compare where is that dot and where is that line? Now one thing that we do by line, we mean that excursion. So one thing that I think we both do is it’s often good to check the excursions first, so now you’ve got the lines on there, and then go back to the blue and get them to bite together. So what you have now is the dot has overlaid the line, so now you know exactly where the starting point is and where the movement goes. So just rewind if that didn’t make sense. If you want to add anything to make that more tangible, Mahmoud, please do. [Mahmoud]No, so yeah, sometimes the order in which you explain things isn’t always the order in which you do things. But yes, essentially what I do is I will check the excursions first with the red paper, So dry the teeth, check the excursions with red paper. So red paper in, patient chews, left, right, grind, you know, hard. Check the other side and then I’ll take that red paper out. I won’t let the patient close, I’ll say just open and stay open. Now put the blue paper in and then we’ll do our bite on your back teeth and tap, tap, tap. The reason is blue will overwrite red, so I’ll see my blue dot on top of the red streak. And you’re avoiding, because if you do your excursions after you do the tap tap, it just smudges your MIP sort of mark. [Jaz]So all you then get, if you do it the quote unquote wrong way, there’s no wrong way, but if you do it the other way, whereby you do the tap tap first, then the excursions, when you look at that tooth now, you only really have the excursions data. But if you do the excursion first, then the tap tap, you have both data at once basically. So it’s just more efficient to do it, which is good. So that’s a nice little point there. So in our case, our example tooth isn’t heavily involved in excursions, but it is in occlusion, okay? And so we’ve established that, okay, we want our restoration to hold shim at the end and we need to make sure that we’re conforming. And it would be a disservice, like we talked about this before in a couple of episodes ago, where we are doing a disservice to a patient. If we are putting this composite shallow because we want to make our life easy. We don’t want to spend time doing adjustments and being so precise. We want to do a quick job that we just make a very shallow composite. It’s completely out of the bite and now you don’t have to worry about it. And we are doing a disservice because now you’ve removed a tooth potentially or a part of a tooth from the occlusion. So that’s not what we want to aim for. We want to aim for precision dentistry. So we want to conform. What else are you going to do? Is there anything else in the pre op that you do before we even have touched a bur to the tooth? [Mahmoud]We’re scaring the bejesus out of people now. As we are sticking to back teeth at the moment, that’s probably all I will do. Okay. So I will check my MIP contact, my excursions and my shim hold. [Jaz]So I think you do all this, but you haven’t verbalized it yet. So just chime in here and say that, okay, you’ve done all the objective data. Just have a look, you know? So usually you have like an old leaking amalgam and it’s like flat. It hasn’t really got much morphology and you’re thinking, ah, okay. I can convert this into work of art here. I can really make this tooth look sexy again, get your fissure stain, which I’ve never used before, which you talked about in the Protrusive Guidance app recently. So newsflash, the community, we did a hot and cold poll on fissure staining, and where are you on that spectrum? [Mahmoud]I used to be hot. I used to stain fissures all the time, and now I don’t. [Jaz]Okay. So you’re in the middle or you’re cold? [Mahmoud]A bit towards cold. I do use it when I want to see. So if I’ve carved my anatomy in and it’s really deep and I’m thinking they might be like getting food stuck or anything like that in there, then I might seal it with some tin. [Jaz]You know, with those deeper ones that you do, basically, like someone once taught me, why are you actually putting in fissures and composite? They’re just going to come back and they look terrible. They look ugly. They’ll stain. And there we are. The natural stain just comes in and figures it out. Find this natural place. You don’t actually need to put stain in, guys. It just self staining right? That should be like a feature in composites, like in the box, self adhesive, this, that, self staining, all that kind of, no one will ever buy it. [Mahmoud]You don’t have A5 composite? Just put in A3 and don’t polish it. About a week later, it’ll look like A5. It’s all good. They can just prescribe them espresso coffee for a week. [Jaz]But if it brings you joy, like, there’s another post I saw about millennials and Gen Z and that kind of stuff. And your avocado toast. And I was like, you know what? Can you just let us enjoy our avocado toast and like that one shrivel of joy we have in our life? Let’s just have it right see all the doom and gloom and dentistry if it makes you happy. If it makes your day to stain those fishes by god get the choco stain out go for it, knock yourself out. Okay, and have some fun and take some photos and share with your friends and everyone just enjoy Okay. So anyway. [Mahmoud]I use a lot of tints. I just use them on the front teeth. That’s that’s where my joy lies. [Jaz]That’s your passion. Okay, so you’re looking for joy at the actual occlusal morphology of the old restoration. Okay. And if you see a very flat amalgam and then you’re dreaming about how you’re going to stain it and how it’s going to look and stuff, right? You still need to appreciate the angles of the old restoration, especially if you now see a dot on the old restoration, especially if there’s a dot there, because there’s two facts there. One, it’s in occlusion, but two, you know that because there’s such a flat amalgam, it’s not representative of what used to be there. And so what’s happened over time, there’s been occlusal changes. And if you now put a beautiful composite that’s going, rolling back the ears and making it look like what you used to, it’s no longer going to fit against the opposing tooth. This is the number one place we go wrong. We put some lobes in where there is no space for the lobes anymore because the opposing tooth has eaten the space for that. This, I think, is the number one mistake. What do you think? [Mahmoud]Yeah, and once you start looking at teeth, you’ll notice this a lot, right? I have a theory as to how this starts. Usually it starts by that dentist that was maybe having a rough day. day and thought, okay, I’m just going to make my life really easy when I’m putting this amalgam in. I’m going to take this giant burnisher, right? I’m just going to burnish the bejesus out of the bottom of this occlusal amalgam. And it’s just like a massive well, right? And there’s no occlusal contact and it’s nice and easy. You’re done. The patient goes away. And what happens to that upper tooth is actually that palatal cusp build. That’s opposing it, might tilt and it might come down a little bit and now instead of getting a point contact when the patient’s chewing because that upper tooth has over erupted slightly or the lower tooth has over erupted, it’s now like gouging out more and more of the internal surface of this lower tooth. It’s what we call a plunger or plunging cusp, right? And now you need to replace that lower amalgam, but that upper cusp is sitting so deep and snug into this well in the lower tooth. There’s no way you can then create your ridges and all that sort of stuff. And maybe if that dentist had followed what we’re saying right now, 10, 15 years ago, this wouldn’t be an issue. But I see that a lot. So if you do see this sort of well shape on your lower restoration, look at the tooth above. Chances are you’ll find that it’s hanging down. You need to be aware of that because if you just build this up to how you think it should look, there’s no way it’s going to fit in the bite again. You see this on lower second molars. All the time. Interjection:Hey guys, it’s Jaz again, just interfering. If you are wanting to learn occlusion and it’s just a confusing topic for you, then me and Mahmoud are doing our live course. The next one, we have one in mid October and one at the end of November for 2024 and it’s called The Basics of Occlusion. We’ve got nine different workshops and one of our favorite things is to engage with our delegates and to help to break down the seemingly complex topic into daily protocols. Just like kind of what we’re discussing today. Allowing it to finally sink in and improve the predictability of your dentistry head to protrusive.co.uk/boo. That’s B-O-O, Basics of Occlusion. To secure your place or join the wait list for 2025. Back to the main episode. [Jaz]The reason we’re having to go back and make our beautiful composites that we’ve put on Instagram with the rubber dam on we don’t put the photo after the rubber dam because it now looks like not so nice. Not so pleasant. It looks very flat like it looks dead right, is because we’ve missed this point. And so how do we resolve it because there’s only two ways I see it here is A, you accept it, right? You swallow that pill, you accept it, and then therefore, you’re going to be purposeful when placing this composite. So you’re switching this amalgam to a composite, but you’re going to respect the anatomy and actually where you want to, or you attempted, every morsel in your body wants you to put a lobe there, but instead you’re going to put like a flat area to kind of match the amalgam, and that’s where you have to kind of do, basically, in a way. Or, you have to now think about adjusting the upper tooth. In most cases, you have enough space for the minimum thickness of composite, two plus millimeters, and that tooth is not involved in excursions, and there’s no guidance and stuff. Therefore, why do you need to remove the opposing tooth enamel, right? We kind of reserve that technique. We talk about this technique a lot when we’re encountering challenging situations where we need space, and therefore, it’s a good compromise. It’s a good way to get space. But in that scenario, what do you think? Is it right that we should be amputating? Not, amputating is a bad word, but doing some equilibration, let’s say, adjusting that cusp to give us more space for a beautiful composite. [Mahmoud]Would I do it for beauty? No. Would I do it for other reasons? Yeah, sometimes. Now, if you imagine that upper cusp, usually it’s like really big and it’s got a lot of enamel on it, whereas the lower has been completely shallowed out, and if it’s a lower second molar, it tends to be a little bit short, but also you’ll have like the buccal and lingual enamel walls tend to be thin. Now, chances are, the reason this is being gouged out, it’s not necessarily involved in guidance as such, but during function there’s like a cyclical movement, right? So it’s not like the upper cusp moves up and down. So you’re going to have to maintain the thinness of the cusps on either side if you then want to like keep the chewing space essentially. So sometimes what I will do is not just shorten the upper cusp but I’ll slenderize it a little bit just to give a little bit more sort of freedom for that cusp to move within the confines of my new restoration in order to try and protect those sidewalls from fracturing. I wouldn’t do it just to make my composite more pretty, but I might do it to increase the longevity. And sometimes I’ll say to the patient, you’ve got a really sharp, ragged cusp at the top, and it may well be the reason why the lower tooth has now cracked, right? Because usually the amalgam’s cracked or something’s broken. So I don’t want that to happen to our new filling. Would you mind if I just polish it and round off a little bit? That’s like the language. [Jaz]See, you ask permission and I see why you do that, right? And so just communication here. And the way I picture my patients, like, okay, this is not going to work unless we smooth this upper tooth. It’s miles away from the nerve. You’re not going to feel it, but it’s going to make a world of difference in terms of how long this filling’s going to last. And they kind of nod and we do it. Basically. So- [Mahmoud]I use a carrot. You use stick. It’s all good. [Jaz]Yeah, exactly. Carrot and stick, right? So anyway, so this is an important point guys, to assess the general shape of what you’re starting with. Because this is the number one thing where you can go wrong. So you made a decision that, okay, I’m not going to be able to get as many likes on Instagram today because it’s flat. Or maybe you’ve got space, maybe you’ve had a look and actually. This existing tooth, this restoration isn’t that much an occlusion at all. The upper tooth didn’t manage to over up so much because there was other teeth and larger ridges topping it. There’s the cheek and the neutral zone stopping from tilting that worked in our favor and therefore now we get to think about having some fun and we can actually put some lobes in and it’s all in the planning. Now you know what space you have to deal with, like with everything, you can actually plan for that. The other thing to look for is generally the cuspal inclines, I’ll get my probe and I’ll just put it against the cuspal inclines. And I just get an idea of how shallow or how acute am I going, basically, because it’s going to guide me when I’m actually shaping my composite. I’m using my probe along. It will just give me like a quick guide that just takes like three or four seconds to do. Anything else? [Mahmoud]One trick I did learn. So, well, two things I’ll mention A, in our example, we’re talking about an occlusal. Restoration, right? So you could attempt the stamp technique. Have you ever tried it? [Jaz]A few times, to be honest with you. I just feel though, by the time I get, oh, Zoe, can you get the X to clear out kind of thing? Like, again, it’s one of those things that it’s the same as someone not having the middle forceps. It’s just not there. It’s just to leave the room to get it. And therefore I’m just more than comfortable just eyeballing it and getting it pretty much right in the eye way. But yeah, are you a big fan of the occlusal stamp technique? [Mahmoud]Look, there’s a lot of things that we learn off Instagram or we see on social media. And we think, oh, I give it a go. You give it a go and you, maybe you prove to yourself that you’re capable and then you never do it again. And that was one of those things where I did it. I didn’t use ExaClear. So I just used Liquid Damp. So Liquid Damp onto the existing tooth with a micro brush, pick it up and then final layer of composite before you set it. Put some PTFE on it and you squish your little stamp on top. [Jaz]I find when I did that it just felt very fragile probably because I didn’t give enough bulk but that’s the issue right? I mean to give it enough bulk and there’s an art in make sure you get it exactly right and stuff. But yeah it’s a valid technique and I think everyone should do it at least once and then decide how much they love doing that and that’s fine. I think it totally has a place. [Mahmoud]Yeah so there’s that and the only other thing I’ve picked up over the years is sometimes you can measure the depth of a restoration if it’s an occlusal that you are replacing. There’s an amalgam in there already. You drill half the amalgam out and you can actually measure the height of the amalgam from the base of the cavity to the top. Then it gives you again just an idea when you’re done how high that restoration needs to be. I found it again of not a lot of value because a lot of time you’re removing decay and then the measurement is going to change etc. And I think you know with enough practice all these things can be useful but with enough practice for me the cuspal inclines and using visual references that I take before I prep the tooth. So I’ll look at where the marginal ridge is compared to the base of the cavity. Where’s the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. So the angle of the cusp is probably, for me at least, one of the most important ones. [Jaz]And I think if we were to talk about the scenario where, by now that we’re talking more operative, we’ve taken the birds of the tooth and like you said, you drill half the amalgam away. And if you don’t have to drill anything further at the base, then yeah, that can work well for you. If you rebuild half the composite and then measure it and just do any adjustments, I’d add a bit more or brush some away so that you get the right height that can get you pretty much near or near enough, which is good. And then if we’re doing a M O D O we’re doing involving the wall, the proximal wall, then we can actually measure. the actual height as well before we restore it. So for example, we’ve now cleaned our cavity, we can measure the space that we have, the height that we have, and then when we place our composite we can actually build, like we usually do for class two, we build the wall first, the proximal wall first, and then we can just use a perioprobe again to measure. Is that something that you do? [Mahmoud]Yeah, and that’s very, very handy. In fact, I had someone ask on OBAB. I think probably the most valuable thing I could tell them is once you’ve assessed the occlusion beforehand and you’ve seen that dot, you’ve seen where the dot goes on the tooth before you’ve done it, don’t put an incline there. Do not build an incline in that vicinity because as you’ll see towards once we get to the towards the end, we want our MIP contact on a flat receiving area, right? It’s going to be very difficult to carve that out, out of an incline. So people have crossbites, people have all sorts of weird occlusal contacts and stuff. So don’t just assume that because, I went to dental school and I know that the buccal cusp on a lower molar is a functional cusp and they have always have a contact in the fossa and one on the marginal ridge. That’s where the opposing cusp is going to be. And that might not be the case. So find where the occlusal contact is and just make sure when you’re building that composite up, you have a flat-ish area, small, flattish area there that you can then adjust down to create your new MIP contact. Don’t put a big sort of inclined lobe, whatever you want to call it. [Jaz]That’s a huge tip. So if everyone was multitasking, please reel back in and just remember the place where the opposing cusp will sit. Don’t put any acute angles. And we talk about mountains and valleys. Don’t put any valleys there. Instead, have a nice lake there, where the opposing cusp can come into, right? Yeah, nice quiet lake. It would be good, basically. So just remember that point. Now, also, marginal ridges. A good guide is the adjacent tooth. So look at the height of the marginal ridge of the adjacent tooth, if we’re doing a DO, for example, and just use that as a guide. That’s a very quick and easy win. And sometimes, if you’ve got a matrix band, that’s like kind of like way too high, going too far high. It’s like sticking out of the contact area. Then if you just drill that down to approximately the height you want your composite to be, it just makes it a no brainer. It just helps you quickly put your enough height of composite there in the first place. So that’s another tip that we can give and share to help reduce adjustments because a common area to have to do adjustments is the marginal ridge area. For that reason, people overbuild, they make the wall too high. [Mahmoud]And LM-Arte have like a really cool version, like a Posterior Misura, I think they call it, where you can place it and it can measure the adjacent marginal ridge and transfer that onto the marginal ridge you’re building. [Jaz]Oh my god, I just had an epiphany. So if fissura means fissure, mesura means measure. Oh my god. [Mahmoud]Oh my god, are you serious? You’ve just figured that out now? I don’t know if that affects my estimation. Come on, dude. [Jaz]What does misura mean in Italian? I just want to see if there’s, yes, it means measure. Okay. [Mahmoud]For measure, yeah, obviously. [Jaz]I need to brush up my Italian. [Mahmoud]I’m going to pretend this conversation never happened. He is human, everybody. He doesn’t know everything. [Jaz]Definitely not. You guys, hopefully that’s evident from the kind of stuff I post. Good opportunity to plug the event. So if you’re seeing my mistakes, because my main lecture kicking off the event on 16th of November, where Dr. Michael Frazis and Lincoln Harris will be joining, is I’m kicking off the event. I’m kind of like the warmup act, right before the main, like the big guns come out around, the little warm up act. And I’ve got these videos of me just actually making these huge mistakes. Okay. So I’m actually going to just show you, but I’m also show you what I did to kind of recover the scenario and then if it was irrecoverable, what’s the best way to do in terms of communication and the clinical management. So that’s on 16th of November. It’s a hybrid event. So it’s either a live stream plus a 30 day replay, or you bums on seats. You come and eat with us. You join us. You get some blessings from Lincoln Harris by touching his feet. You know, you’ll know if you’re on my email list what that means. So head over to protrusive.co.uk/rx to join. What I think is about one of a kind event when it comes to. Treatment Planning and failures because also we have a live patient. Okay, we have a live patient that Lincoln Harris, he knows nothing. We’ll just bring up the radiographs and the images on screen. And so he just has a conversation because we’re kind of seeing, okay, how does Linc communicate? But then also now that we’ve put all this information, like a dental school exam, an unseen case, he has to then treat and plan and then, convey that treatment plan to a patient live on stage and then dissect it all with us and give us some tips based on that. So I think that’d be quite unique. [Mahmoud]Make it clear. The patient’s there. The patient’s actually going to be on stage. That’s amazing. [Jaz]Yeah, that’s pretty cool. So I found my main patient and this is not like a all on four and zygomatic, I don’t know, block graph, that kind of stuff. This is someone who needs a few crowns, needs a few fillings, maybe some whitening. Maybe it has some aesthetic concerns. Like, this is like a daily, I was really keen on finding a real world patient, and I found her. So, I need to find a backup patient now. Anyway, mesura, okay? Italian for measure, guys. There’s an instrument that you can get there. We are not sponsored by LM-Arte, but good instrument. I bought one. I have it somewhere. Again, I don’t have it out routinely. So, I just love, I spend the most time on that part of the restoration, right? Where you’re building the proximal wall, right? Usually, the nurses, they’re eager to get the light cure, but when Zoe sees that I’m working on the marginal ridge, you know, she might as well go outside and have a fag, right? Not that she smokes, but I’m just giving an example, right? She might as well just do that because I’m going to save my sweet time here to get that bit right. [Mahmoud]Yeah, there’s so much to do, right? Like, get the seal right, get the height right, get the thickness right. [Jaz]A hundred percent. A composite tip that Andrew Chandrapal taught me and he suggested do the wall, and I’m guilty of this. I’m kind of naughty. I can’t do it in one a lot of times, unless it’s really big. But like he do, he says do half at a time. So do like the buccal side first, then the lingual side. There’s even less like shrinkage stress. Is that something you do? [Mahmoud]No, again, makes perfect sense and it’s a great tip and it’s all about decoupling with time, right? You’re giving the dentine bond more time to mature because you’re just messing around in the box. [Jaz]I like it. It’s a good tip. I don’t always use it. So the whole point is guys, there’s no perfect way to do it. Well, there probably is a perfect way, but then you need to have a patient for like five hours on the chair for a simple composite, but you’ve got to just pick up your wins and this is to help you be quicker and not have to do any adjustments. We’re not even going to get to anteriors. We’ll have to save that for a live in Protrusive Guidance, but let’s just finish off this series. Okay. We’ve done the marginal ridge. If we’re doing a DO, if you’re doing an inclusion, obviously not involved, and you’re going to remember everything at the beginning, do you have space for the lobe or not? And so the begs the question. should we be following posterior anatomy, like the textbook, like you’ve done, is it János or János Makó like billion day course on occlusal morphology and stuff, right? So based on that, right, how can we now implement that? The real tricky thing here is we know, for example, in the real world, the amalgam is flat. There’s no space for beautiful anatomy. And now your composite has kind of conformed to that, but then now you’re not getting the Instagram likes. So what are you going to do? How are you going to make a composite look good, Mahmoud? [Mahmoud]Photo editing. No, I’m joking. The thing is, you can still make it look reasonable by having in some fissure patterns, but it’s important not to just think, okay, I’m just going to take what I saw in the book and stamp it onto these teeth. I love how you describe, when you have like a 75-year-old patient in the chair and you’re replacing this class tooth. This tooth’s been in function for decades, right? They’ve eaten pork scratchings and I don’t know what else on there. And then you want to create this tooth that looks like it’s just erupted in a seven-year old’s mouth. So you say, why are we putting a seven year old tooth in a 70 year old man? It doesn’t make sense. So you do have to respect the space that you have, but you can still get a little bit creative and make sure you have a really sharp probe. And this will go back to our tinting. You can add a little bit of depth by having, running a little bit of poo colored tint into your really deep fissures that you carve. So you can still get that satisfaction, get the likes. But for me, ultimately, I want to make sure this restoration is done efficiently, that the patient is happy and comfortable, and they don’t come back in my chair with this problem again. [Jaz]So number one, you don’t want to be drilling everything away. You want to be there or thereabouts. Okay. So that all comes down to a pre op checks, a visual check of the cuspal inclines, roughly where the opposing tooth is. So you can make that Lake there instead of like a valley. And then, you’re going to make sure that you don’t underdo it either. You’re not going to go so shallow. So if you’re like in two minds, should I add a bit more or not? It’s better to maybe add a little bit more. So you actually have a contact at the end. So you’ve done your composite, you’ve cured, you’ve taken the dam off, and then you’re going to do the checks. And then let’s talk about the protocol for actual adjusting in the way that you’re not going to mutilate your composite. So what’s the first thing you do once the rubber dam’s off and the patient’s like settled down from the trauma of rubber dam isolation? [Mahmoud]Give them the rinse and stuff, because all the blood and crap, and then you want to dry the teeth, right? So you’re going to dry the teeth, you’re going to check – funnily enough, most of the time when I’m doing a posterior restoration, if I’ve decided that the tooth isn’t in guidance or I don’t want it to remain in guidance, a lot of the time I’ll actually go and check the MIP contact first. I’m just being real. You should get into habits. Should you check the excursions first? Probably. I would probably say dry the teeth, put the red paper in, get the patient to grind left and right and then open, stay open, put the blue paper in and get them to tap, tap, tap. This goes back to why I said, Oh, my nurse doesn’t always put the red paper on. And then check the tap, tap, tap. And at that point you’re seeing marks. Now, unless there is one mark, if there’s only marks on my tooth and nowhere else, then I know I’m going to need to adjust. [Jaz]So by tooth you mean there’s only marks on your composite and nowhere else? [Mahmoud]On my comp, yeah, on my restoration. And nowhere else. I know I’m going to need to adjust. Now, sometimes you get marks on your tooth, your restoration. and the teeth next door. That doesn’t mean I’m done. At that point, I will reference my images that I took at the beginning to see, A, are the marks the same, and I will do my shim stock check. [Jaz]I’m just going to make that point tangible because, yes, you have some marks on your composite, marks on the tooth, and the value of that pre op photo that you took is, before, there was a marking on, let’s say, the fossa of that lower molar, and there was no marginal ridge dot, but now, you have a marginal ridge dot, which there wasn’t there before. So perhaps, now we’re obviously extending it more to a DO scenario, marginal ridge being too high. And now you know that, okay, I might be there, but I might be just a little bit proud in this area. And that’s what the power of the pre op visual gives you. [Mahmoud]And then the power of shim stock is then there will be no doubt in your mind. That’s what I love about it is it makes me so confident. If I check my shim stocks, my shim stock after that. [Jaz]So what does that look like? What are you actually checking? [Mahmoud]So I will then check the tooth behind. Okay, and actually often you will find the tooth behind will hold, okay, and it’s to do with sort of the hinge motion of the jaw. You’ll find that the back tooth might still hold, but the tooth in front of the tooth you restored won’t hold, if the restoration is a little bit high. So that’s why I always check both and then check one on the other side. Now let’s say that happens, let’s say my shim stock hold that used to be on the tooth in front is now gone. Now I know that my restoration is a little bit high. I’m not asking the patient how it feels. I’m not asking anything. I’m getting my yellow rugby ball. And the reason it’s a yellow rugby ball is because I have a mark on the tooth in front. That tells me, and I know my paper, right? This goes back to us talking about how thick our paper is. I know that troll foil, doesn’t matter what their marketing machine says, etc. It’s below 20 microns, even if it’s 25. Because there’s a mark on there, I know that those two teeth are so close to touching that I don’t need my red band. I don’t need my coarse bur, I just need to tickle the contacts that I’ve got on my restoration. Because the occlusion is so close to being perfect. I only need to make a minor adjustment. [Jaz]So what you’ve done is you’ve checked, so the right side is the one where you’ve done the restoration, and then that’s the side you’ve used the paper, and that’s how you’ve deciphered that information. Usually what I do is I go on the other side. The contralateral side. So let’s talk about it that way. Let’s say I’m using my 24, 25 micron Parkell paper. I know I’m close, but the shims aren’t quite there. So I know I’m a little bit proud, like maybe 20, 30 microns, I don’t know exactly how much yet. So if I take my 25 micron paper on the left side, the other side, get the patient to bite together, if it’s holding, I know that I’m proud, but I’m proud less than 25 microns. Okay, if I’m using let’s say 15 micron paper okay, and now that’s pulling and for some people really to visualize and imagine and slow down here, right 15 microns pulling It’s not holding. Okay. I know that I’m high between 15 and 25 microns. Not that we do a 15 micron paper. That’s a bit too precise here, but you just know you’re proud by a little bit It’s just like you said the way this is useful is let’s understand the opposite scenario, right? You use a 40 micron paper and it’s pulling on the left side. You’ve done the restoration on the right side, the 40 micron is pulling. So you know you’re proud on the right side. Your restoration is proud by at least 40 microns. You fold your 40 in half. You have now 80. Get the patient to bite together. It’s still pulling. You then fold it again, 160 microns. Now it’s biting. You better pick up your green, or at least your blueber, and you’re going to have to press a little bit harder, and you’ve got to really figure out, look at your pre op images, Ah, I think I’ve got, my marginal ridge is way too high, or I’ve got a valley, I’ve got a slope here, where really I needed a lake, so you’re going to mow away in that scenario. Go for lakes not valleys. I love this. Okay, cool. So that just gives you now an idea of how much pressure you’re going to put with the bur which grit diamond you’re going to use and how long it’s going to take you and how aggressive you’ll be. So this is why this information is important. And hopefully if you’ve done everything correctly with the pre op visualization, you’re going to pick up the yellow Rubby ball, round, if you’re just winding the lake a bit, remove that bit, which probably shouldn’t be there. And actually, Mahmoud, top tip, before I even do this, I’ll get like a mic, because I love Eve Twist polishes, right? Or an Enhance, get a polisher and just rub it all over the tooth, because what we find is that there’s like smears of resin or bond on the teeth. Sometimes that’s what’s making the the tooth proud. Not our composite. So once you get rid of all that stuff and then just wash and dry, you might find that you actually nailed it. You don’t need to do any adjustment at all. So the cleaning polishing protocol, figuring out how much, how many microns you need to adjust, go ahead and do it. And then be proud that you’ve conformed. [Mahmoud]The tip about the enhanced point is huge. Do it on the other teeth as well. Because a lot of the time when you’re doing your, you put your bond on and you’re thinning it and it just goes everywhere. [Jaz]And air abrasion particles. [Mahmoud]Yeah, so just get your enhanced point and yeah, I clean everything up. Great point, great point. [Jaz]And so hopefully now we are looking like the dots are in the places where we wanted them in this example scenario we gave, and we don’t have to now spend ages adjusting our composite away, and we still have something that looks good. Yes, it may not look as good as if you completely ignored the pre op anatomy, right, but sometimes when we have space then we can go back to the textbook and see, oh, so this is how a seven year old’s first molar looks like, and we can give that 50 year old patient a 7 year old’s tooth if you want to, okay? And get the likes and the applause on Instagram. Okay, great. So the final thing to wrap up on is, we didn’t get time to do anteriors, so we’ll do that on protrusive guidance live one day. And what we’ll talk about now is a final, just to wrap it up, use your senses. So I think Riyaz Yar was the first person to talk about it in this way, and I loved it. I was already doing this stuff, but then the way he said using your senses, I love that. So a hat tip to one of our mentors, Riyaz Yar, absolutely a brilliant guy, teaches occlusion as well, really great guy to learn from, so shout out to him. So use your senses, you’re using your eyes. You looked beforehand at what the shape of the composites were. You’re using your fingers, okay? And we didn’t talk about this, but for anterior teeth may be more relevant. You’re putting your fingers. We talk about fremitus. We’ve got a whole episode on fremitus that you guys should check out. Like how much of a thud, how much pressure is going through that PDL, the periodontal ligament through your fingers, okay? So using your fingers, using your eyes, you’re using sound, okay? This is what a feeling sounds like when it’s proud. This is what it sounds like when it’s good. Was that feeding through into your headphones? [Mahmoud]Yeah. [Jaz]Everyone just like save that like a little voice nugget. Okay. And like, hmm, let me just compare this, calibrate this to what Jaz did on the microphone one time during a podcast. When you’re in doubt, when you’re not sure, just like oh yeah, that sounds like a lot of teeth touching at once, and the patients usually laugh. [Mahmoud]Oh, get the patient to do it, not you do it to them. [Jaz]Part of the whole visual is you’re obviously using the ink paper as well, basically, and part of the feel, again, using the shim stock. So all those things means that you now will never have to adjust composites again. Obviously, with tongue in cheek, you will obviously do a little bit, but you know what, hopefully, this is giving you a new perspective, or reinforced some existing perspectives, or maybe giving you one, that one nugget that’s going to shave off one minute from all the composites they can do for the rest of your life. And therefore has saved you two weeks in your career. Who knows, who knows Mahmoud? [Mahmoud]Two weeks, extra holiday. [Jaz]Two weeks of life that you couldn’t bone about some, I don’t know. [Mahmoud]You’re welcome. [Jaz]I don’t know. where I’m going with this, but anyway, I’m tired now, guys. This is a great point to end the podcast. And we just talked about one. A beautiful issue for this long. We didn’t get to anteriors. We’re such sad bastards. Guys, thanks so much for listening. Mahmoud, thank you for the time. If you’d like to learn more from us, we have occlusion. online, occlusion course. We also have the live course running October 11th, 12th, and also November, end of November, and the website for that is protrusive.co.uk/boo not because it’s scary because it’s Basics of Occlusion B-O-O. So come and join us that if you’d like to learn more. Otherwise, we’ve got plenty of other episodes for you to get your sink your teeth into excuse the pun. And we’ll catch you same time same place next week. Thank you. Mahmoud. [Mahmoud]Take care everybody. Thank you. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. This episode is eligible for an hour of CE credits. We are of course a PACE approved provider. We also satisfy the GDC criteria of enhanced CPD. So answer the quiz below and you’re thinking, where is this quiz? Well, you need to get on the protrusive app. It is a stunning app. We’ve invested a lot of time and money into it. So please do check it out. There’s a cool little quiz on there. You get 80 percent to prove to us that you’ve learned something and there’s an area where you can reflect and you get your certificate emailed to you like clockwork. Every Wednesday and every quarter, we send you your entire folder of all the certificates you’ve gathered, because we know what happens. They get lost everywhere. So don’t worry. We always keep your copies. It’s a great way to rack up your CE credits throughout the year. The website is protrusive. app. Make an account if you haven’t already. I look forward to reading the comments from this one. I want to hear from you. What’s the most important thing that you learned or the thing that’s going to make the biggest difference in your practice you think? I do enjoy reading all the comments on YouTube and now I’ve got more systems in place to make sure I don’t miss any comments. And I can reply to them all. Thank you so much for making it to the end once again. I’ll catch you same time, same place next week. Bye for now.

Follow THESE protocols to eliminate teeth whitening sensitivity in your practice – your patients will love you. Have you ever had a patient who had to stop whitening due to severe sensitivity? Should we be whitening when there are active carious lesions? (the answer might surprise you) https://youtu.be/IC3wMpfLo30 Watch PDP199 on Youtube In this episode, Dr. Linda Greenwall is back with another phenomenal episode as we dive into this common concern. Together, we discuss practical tips and effective strategies and protocols to help patients achieve radiant smiles without pain. Protrusive Dental Pearl: We’ve made an infographic to summarise this awesome episode. This one is available freely under the episode in our Protrusive Guidance App. Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode: 03:06 Dr. Linda Greenwald’s Background and Experience 07:09 Teeth Whitening: A Global Perspective 08:31 Diagnosing Teeth Sensitivity 14:28 Managing Non-Carious Cervical Lesions (NCCLs) 22:30 Using Sensodyne for Sensitivity Management 24:36 Exploring Different Sensodyne Products 26:26 Bruxism and Occlusal Forces: Mechanisms of Sensitivity 29:39 Role of Hydration and Tray Design 32:57 Whitening Limitations: Cervical Whitening and Medication Impact 36:41 Dehydration and Discoloration 42:03 Therapeutic Uses of Whitening Trays 48:53 Upcoming Events and Final Thoughts Dr. Linda Greenwald invites the Protruseratis to the “Future Dentistry” conference on November 1st at the BDA, featuring dental AI, restorative, orthodontics, and implant innovations. This episode is eligible for 1 CE credit via the quiz on the Protrusive Guidance App. This episode meets GDC Outcomes A and C. AGD code 780 ESTHETICS/COSMETIC DENTISTRY (Tooth whitening/bleaching) Dentists will be able to: 1. Understand the causes of teeth sensitivity during whitening treatments and conduct thorough diagnostics. 2. Implement pre-whitening protocols such as treating non-carious cervical lesions and recommending desensitizing toothpastes. 3. Gain insights into preventative measures for managing sensitivity in whitening treatments. If you love this, be sure to check out Dr. Linda’s other Protrusive Episodes: Finally, Some Clarity on Teeth Whitening for Under-18s with Linda Greenwall – PDP096 and ICON Resin Infiltration – Step by Step FULL PROTOCOL – PDP140 Click below for full episode transcript: Teaser: Any discolored tooth needs a periapical radiograph, really, really important, because you are looking for undiagnosed periapical lesions. And most dentists don't know, if there is an undiagnosed periapical lesion and you put whitening gel into, so you take oxygen, and you shove it into an anaerobic area, you are going to have max of sensitivity- Teaser:Because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area. So here’s another point. You can’t adequately bleach the cervical area. It’s never going to be the same shade. And that’s a myth- The last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area. And they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that. Jaz’s Introduction:Protruserati, this just might be the most actionable and impactful piece of content you’ll ever consume on the topic of teeth whitening sensitivity to really help our patients to whiten better without having the horrible side effect of teeth sensitivity. I don’t know about you, but for some patients it can be so bad that after about three days they don’t whiten ever again. And you have to have that awkward conversation with the patient. But now, following Dr. Linda Greenwald’s protocols, We can eliminate teeth sensitivity. Like, we could have spoken for like hours and hours and hours. But what we did bring together in this episode is like the top things. Think of the Pareto Principle. I’m a big fan of the Pareto Principle. This principle suggests that 80 percent of your benefits or your rewards or effect happens from 20 percent of the contributions or inputs. So for example, 80 percent of your sensitivity reduction will happen from the 20 percent of the little tweaks and the changes you make in your whitening protocols. Let’s focus on those 20 percent of the protocols that are going to make an 80 percent reduction in your sensitivity, and for some patients, a 100 percent reduction. Hello, Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Because there are so many actionable gems and protocols and so much goodness in this episode, we’ve created a famous Protrusive Infographic. If you’d like to download this infographic, for free, head over to protrusive. app. If you’re already part of our community, you will see this infographic everywhere where we post this episode. But if you haven’t joined yet, what are you waiting for? It is the community of the nicest and geekiest dentists in the world. So the platform is called Protrusive Guidance, and the easiest way to make a free account is www. protrusive. app. And once you’ve made an account, you can download it on iOS or Android. When you click on this episode, you’ll be able to download the infographic. You can laminate it. You can do what you want, but all the goodness is there because sometimes like me, if you listen to podcasts, when you’re driving to actually action on some things to actually have like an aid memoir, a good revision source, we already have the premium notes, which are also downloadable for paid members, as well as claiming the CE credit or the CPD hours. Dental PearlBut as part of the gift from this episode, the pearl for this episode, you can freely download our infographic. Now, I appreciate it may sound a little bit attractive to you now, but wait till you get to the end of this episode. You will definitely want this infographic. So don’t forget, protrusive.app. I’ll see you on Protrusive Guidance. I’m not going to waste a second more. You’re going to absolutely love Linda, as always. Let’s check it out. Main Episode:Dr. Linda Greenwall, welcome back again to the Protrusive Dental Podcast. You are such a welcome guest because we’ve done a few episodes about whitening under 18s and icon resin filtration. Everyone loved those and they love it because I love your direct nature in teaching. I really love direct educators. You tell it how it is. And so I’m especially interested in today’s conversation about sensitivity. But for those few people who, for some silly reason, they have not enjoyed that episode just yet. And they’re, it’s like a gem waiting to be uncovered for them now. Please tell us, because they haven’t heard about you. Tell us about yourself. [Linda]So my name is Linda Greenwall. I’m a prosthodontist, specialist in restorative dentistry. This is my year 40 in practice and I’m still inspired. I still love it every day. [Jaz]Say that again. How many years in practice? [Linda]It is now 40, 40 years. [Jaz]4-0? [Linda]40, 1984. Schooled up at university in South Africa. 1984, we had a special reunion this year because, I said to my colleagues in my class, hey guys, we really need to commemorate this. And the one guy said to me, Linda, I hated everyone in my class then, I still hate them now. I said, forget about that. We need to commemorate. And we got our professors and they came in. And the first thing I wanted to say to our professors, I wanted to say thank you and show gratitude because the way they taught us in the eighties was very, very tough. There was no mincing words. And I wanted to say thank you because our training was excellent and it was tough. And we have all learned from that. So I just wanted to show gratitude because we always, there are always people Jaz, who bring us up with them through mentoring and helping. And even though they may be our biggest critics, we learn from them. So we have to pay gratitude to say, thank you. Each challenge, this is my new thing. Each challenge becomes your opportunity. Every single challenge and you can go through that. So we say, why do we have these challenges? Let’s call it in dentistry. It’s to reach, to help you reach your growth point to your next level. And that’s why it’s coming. It’s not because you’re a bad dentist or anything else. It’s your challenge to grow. And that’s when you learn that, that takes you to the next level of all that we do. It gives you a bit of wisdom. [Jaz]And now of course you do all sorts. You’re in practice, you do so much teaching. I love the webinars that you do. And so, everyone, I encourage to follow Linda on Instagram. All her social channels, they’re very, very active and the Academy and whatnot. So I’m a big fan of yours. [Linda]It was 13 years ago that I decided it was time to give back to dentistry. And that’s when I set up the charity. My husband told me I was mad, but I said, I’m doing it anyway. And it’s brought a lot of joy, really. And again, on gratitude, but we currently look after 60, 000 kids globally, and we do 23, 000 children in Luton, helping them with toothbrushing, screening, varnish application, working with refugees, providing free dental care in our practice. In South Africa, we run 12 soup kitchens daily. We’ve served over half a million meals. since COVID and we have 16 toothbrush mamas who help us and each toothbrush mama helps to look after at least 2, 000 kids a month going to do toothbrushing at schools but also in the communities. So that is kind of how I balance with some of my high end, very, very specific, difficult, anxious, kind of stressed patients with their phones out to check the levels of their bonding at all angles and their selfies, to going into outreach in the less in deprived areas where you can give of yourself and your soul to help others with gratitude. Nobody needs to say thank you to you. You go to give yourself and it puts your whole life into perspective. So it’s a big difference in balancing. [Jaz]I love that. And you’re quite right to mention the contrast. In my faith in Sikhism, there’s something called Sevā. We call that selfless service. And what you described there was exactly that. So hats off to you. And I’d love to support more of what you do. So put any links that are relevant so we can continue to help you support. And so we’ll definitely put that on. Today’s topic is a very pertinent one, very global one. No matter where you are in the world, you’re likely utilizing, hopefully, teeth whitening as one of the most brilliant, minimally invasive ways to help someone smile. We accept that. That is the most minimally invasive way that can have a huge difference to someone’s smile and confidence. In particular, we talk about young people with all sorts of enamel mottling and brown spots. And we also did an episode on icons. So well-versed with the benefits. But one of the drawbacks of the benefits when the side effects is teeth sensitivity, but we all warn our patients about sensitivity. I’ve got so many questions of so many things I want to draw out for you from protocols to different things to try to avoid and case selection. But can we just start off with the very basics? Why does teeth sensitivity exist as a result of using peroxide gel? [Linda]Actually, before we even start that question, Jaz, I’m just going to go back a few steps. [Jaz]Please. [Linda]Because the first thing is that 70 percent of patients walk around with sensitive teeth and we as dentists don’t have any protocols to assist those patients who live with their sensitivity. And so before we even start on whitening, we give everybody listening today a things to do list. So while you’re listening to the podcast take a sheet of paper on one side we’re going to talk clinically and the other side we’re going to talk what to do now and what are your next moves. So that you can make this a habit. So your first thing is to set up a patient desensitizing a protocol for sensitivity in your practice. And you ask every single patient, if you say to them, do you have any sensitivity? They go, no. Then you say, but do you have, you ask the four questions. You know about the four questions? [Jaz]No, please tell me. [Linda]The four questions, really, really important. The first thing is, number one, do you have sensitivity to cold? Because that means they have gingival recession and all kinds of other things. So that’s the first question. Second question is, do you have sensitivity to heat? As you know, the heat question is about pulpitis because there’s a big difference between pulpitis and sensitivity. The patient may not know that. The third question is, do you have sensitivity to sweet? Because that means there’s caries somewhere and we need to look at that. And the fourth question is, do you have sensitivity to cold and pain on biting? Because the pain on biting means that there’s a fracture somewhere. And then you may say to me, well, is that important relating to whitening? And absolutely. First of all, if you’ve diagnosed that they have a cracked tooth, you need to treat the crack, let’s call it a crack tooth syndrome. You need to treat the crack tooth syndrome, whatever you’re going to do, whether it’s replacing the old restoration with a composite, putting on a provisional crown, but you need to manage that immediately. So that is protocol number one. Protocol number two, does it matter about heat sensitivity? Absolutely. Because that a pulpitis left untreated when you will whiten the tooth will lead to needing a root canal, which needed a root canal anyway, but you’ve got an unhappy bunny as a patient because you as the dentist didn’t diagnose and explain to the patient that they need to have a root canal first. First, so the rule coming backwards is that any discolored tooth needs a periapical radiograph. Really, really important, because you are looking for undiagnosed periapical lesions. And most dentists don’t know, if there is an undiagnosed periapical lesion and you put whitening gel into, so you take oxygen and you shove it into an anaerobic area, you are going to have max of sensitivity anyway, requiring a root canal, which it already needed a root canal. But when you do the RCT on that tooth, it’s going to be difficult to control. [Jaz]And the patient’s perception is that, oh, there was a whitening that caused it, or it was an underlying issue all along. You taught me this as I was a third or fourth year student. You were lecturing the BDA. And so this was like 13, 14 years ago. I remember learning that from you on stage. So I always associate with this you, and when I’m thinking about teeth whitening, always look at any discolored teeth, any teeth that have got large composites worth doing a sensibility test before we prescribe the whitening, because hey, this could be, may not be symptomatic, but it could be necrotic. And this could be a flare up. [Linda]Absolutely. And then to try and do a root canal on that, you can’t do it in one visit, you might be able to do it in two and you often need to do in three, which is unusual, but it doesn’t settle down. And so the next thing to also look at while we’re talking about radiographs relating to whitening is post ortho. So as you know, it’s very trendy now, everyone having then aligning and whitening, or first before you even do that, aligning or ortho, and then they want to go into whitening. That’s another topic we can discuss our whole thing on that. But you need to know what’s the nerve status of this. What’s the nerve status of the tooth? Because if they’re post ortho, they’re going to have flattened roots with a little bit of resorption. And again, the whitening is not going to make it worse, but you need to know what are you dealing with now. Where are we with the, what is looking at, at the nerve? So coming back to the sensitivity question, we’ve spoken about sensitivity to heat needing a root canal. We spoke about sensitivity to sweet. Was that sensitivity anyway? It’s all lumped together. And the sensitivity to sweet is normally interproximal decay. . So does that matter? And the answer is not really, because you’re gonna whiten first and then you’re gonna go back and change your restorations with the blended shade of the new composite. [Jaz]Has that changed at all, Linda? Because I’ve seen on social media groups where dentists are, and some dentists have this very strong opinion that, so for example, this is what some dentists do, and I disagree with it because I think you’re double treating. But essentially they all say stabilize the caries first, then do the whitening, then go back. Insult the pulp again and do the restorations again. And that’s why I always follow, especially with anterior work, you bleach, even though you’ve got caries. Okay. And then you treat it with composite. And a few times I felt as though I was being a bit naughty doing this. And I was thinking, Hmm, is this kosher? Is this halal? Is this allowed? Basically, what do you think? [Linda]So you just said Linda Says. Linda says, do the bleaching first, because the research has shown that it shrinks the decay. That’s the whole purpose, because it’s chemically cleansing the decay. Unless we’re talking about a massive lesion, a mega open hole. Of course, you’re going to put a glass on a mirror. You’re not going to leave an open cavity, a huge open cavity. I’m talking about small, little- [Jaz]Small class threes, class twos, that kind of stuff. [Linda]That’s what I’m talking about. When they have sensitivity, the patient may say when I floss, it’s a bit sensitive. So that is a plan. It’s your strategy plan, right? And then coming back to the cold sensitivity, you’re managing the gingiva. So coming back to patients in general, because so many patients experience sensitivity and we just ignore it or maybe give them a soothing toothpaste. So what we would do on all new patients and all patients, discussing, ask the question, do you have any sensitivity? Don’t leave it as no, I don’t. You then put an optogate in and you take the three in one and you spray air onto every single cervical area all the way around the mouth. And you note where they sensitive on the cervicals. Okay. Then you’re going to note, where they have NCCLs. [Jaz]Yep. Non-carious for the students. Yeah, please explain more about what they are for any students listening. [Linda]Okay, so an NCCLs, very big buzzword, which just rolls of your tongue. NCCL, non-carious cervical lesions. We think that we see much more of it these days than ever before because of patient’s diets and the Diet Coke and this busy water and the everything else and their lifestyle of what they drink. Everything that they drink. So we see a lot of it. Now, most dentists, I don’t know why, and we can discuss the why, but I don’t know why they leave it. So you’ve got like a deep class five lesion and you spray air and they’re jumping out the root out the chair. And it’s such a simple restoration to do. But I want to talk about how we would do that. So once we’ve noted where the sensitivity is, and we’ve noted it down, becomes part of our charting. And before we even take a scan these days, or or we take an impression for bleaching trays, we get those restored. We restore them. My restoration of choice is a resin modified glass ionomer. And the reason for that is several reasons. Number one, it retains beautifully. Number two, the resin modified, the GRC loves the dentine. Number three, you don’t get the, you know, you see the, not, of course, not your composites. But when you see somebody else’s beautiful class five composites, number one, they never match. And they’ve got a black line. They’re always leaking at the join. So the GRCs don’t leak. You don’t get a black line around the join. You get beautiful shades because of the new color or coloring. And we would choose a couple of shades larger. So if the patient has, they generally, A3. 5 teeth, I would choose an A2 shade to work onto all those class 5 lesions. And I want you to go through the technique if it’s okay with you of how I’m doing that. [Jaz]Please, I’m sure everyone’s loving this so far in terms of, because these are daily problems that we see in like 70, 90 percent of our patients. [Linda]And so when you ask me, what procedure do you do? Do you do crowns, bridges, onlays, zirconia, etc? I sit and I do my GICs a lot. So let’s just go through the protocol. So number one, we use a micro brush. Which is a tiny, not of a prophy brush. It’s a prophy brush with about a millimeter of bristles. Not the whole cup. And we put in pumice with heavy scrub. We make our own, but you can get consepsis. So you put the pumice and hibiscrub and you clean into that class 5 lesion. So we were just had a hands on course at the practice on Friday and one of the dentist delegates very kindly allowed us to examine her mouth. And actually we showed the protocol because it’s so simple and straightforward and the color looks good. But let’s go back. [Jaz]So hibiscrub is like a proprietary branded product, right? It’s got is chlorhexidine containing that one or? [Linda]Hibiscrub. It’s chlorhexidine. [Jaz]Yes. [Linda]So you take pumice with chlorhexidine, we mix it up ourselves, but the actual product is called consepsis. And then you would polish, clean, polish, there’s so much plaque, you see the toothbrush lines in the class 5 lesion, the vertical, the horizontal lines, pumice and Hibiscrub. Then you clean it, wash it off and take your probe and you check again and you’ll see there’s still, even though you’ve cleaned it, there’s still plaque in the rivers of the toothbrush marks. So, we go back again, but before we even do that, have a look at what the gingiva was doing around the class 5 lesion. Because often, the gingiva was growing back into the lesion. So you need to then retract. We would cut a retraction cord, six millimeters in length and sometimes we double retract. So we use like a thicker one the brown one first then the black one and we tuck it back so that we just bring it back underneath. So we can actually see the full extent of the lesion on the class 5 lesion. So pumice and hibiscrub maybe twice, then we go to the aqua care. [Jaz]I was just going to mention air abrasion and you, yeah, just like that, you got in there. [Linda]Yeah, so you can use air abrasion, you can use your bicarb, you can use your aluminum oxide, any 30 or 50, it doesn’t make a difference. But I put in sylc. S Y L C is got, it’s Novamin. We’re the same as Sensodyne. So the Novamin, we jet wash it inside the tooth. And again, we use it for all restorative. We jet wash, cleanse it. So now the pumice and hibiscrub is soothing and blocking the tubules. The Aqua Seal is blocking the tubules. We then- [Jaz]The Aquaseal is the- [Linda]Aqua Care. [Jaz]Aqua Care, yeah. [Linda]Yeah. We then would etch the tooth. And because you’re dealing with sclerotic dentine, sometimes you need a double etch. Again, there’s so much plaque stuck inside, even though we’ve done all these cleansing procedures. [Jaz]Is this standard 37 percent phosphoric acid etch, or is it the conditioner that often comes with your glass enema? [Linda]No, I personally go to the etch. [Jaz]Okay. [Linda]And then I use HurriSeal. And the HurriSeal is a hema product, which is for soothing, or you could actually use Gluma. And I drip that on into the teeth, drip, drip, drip. So all the time I’ve been treating and soothing all the time. Then I go with my GRC and the GRC I jet into the tooth, there’s many different brands. I like one of the brands called Riva from SDI and it’s quite liquid. So I squirt it in. I take a probe and just retract around there and then I sculpt it with a normal brush dipped in bond and we sculpt up, vertically up and contour around the tooth and then the final bit is the probe, light cure it. And with any excess you remove with a flame and then you do the whole quadrant. Don’t leave any of them out. Because what’s going to happen if you leave it? It’s just going to get worse It’s just going to be more brushing. So I actively believe being proactive and just sort that because that blocks the sensitivity. So that’s why that’s the first stage we do a lot of proactive before we start. [Jaz]So the questions I have now is around about these NCCLs, right. The way I’m managing at the moment is, is differently for if I’m doing whitening or not, because I’ve listened to you for, I’ve done your webinars for, before starting teeth whitening, I follow that. Now the protocol is little micro steps. I love it. I’m going to implement some of those because I think they make so much sense to me. And so for those patients about to start whitening NCCLs to be restored just makes sense to me. In those patients who we’re not talking about, we’re not having that whitening conversation. They have NCCLs, but they are completely asymptomatic. The kind of conversation I have, the kind of assessment I have in my brain is, there are three reasons you may wish to restore an NCCL. A, if it’s sensitive, then it needs doing in my opinion. If it’s so big and it’s the first time you see the patient and they’re so big, then you think, okay, there’s a massive crater here. This needs some sort of protection or if it’s an aesthetic issue. So I guess what I’m trying to ask is, aside from those, these scenarios, is it acceptable to just monitor because it’s not symptomatic, it’s not in the aesthetic zone and it’s small. [Linda]So that is one approach. And again, you put it to the patient. It’s up to the patient with consent, but I just normally just fill them in. I guess you can monitor them, but we start to see inside the ones that are untreated the root decay. There’s a lot of areas. Yes, they’re resorbing and yes they can place topical toothpaste or mousses, et cetera, but nothing really changes in them. So I rather, my tendency is just to restore them. [Jaz]I think you’re right in the sense that when we see these patients year by year by year, and then eventually you find, see patients in their seventies and eighties, and I find that what used to be a very cleansable area of NCCL is now just plaque-laden and there’s gingival inflammation. And so to promote better cleansability, it totally makes sense. And it’s something that’s not very invasive. It is proactive. And I like the idea of it. [Linda]So that’s the option number one. Before, so you’ve seen that we’re still talking about diagnosing the sensitivity because we have to go right back to basics. We’ve spoken about the assessing where the sensitivity is, what is it, what start, what type of sensitivity is, but then if, let’s call it, the gums are a little bit receded, you can’t put a GRC there, and you’re modifying the tooth brushing technique, the research shows that brushing with Sensodyne for two weeks before you start whitening makes a massive difference. So you can put the patient on to a Sensodyne protocol or any soothing toothpaste protocol brushing. Just that, this was early research from Professor Van Haywood, will stop the sensitivity. So there you have the next way. [Jaz]And this is just, so two questions back and back, this is just tooth brushing, not necessarily the protocol where you rub it on your finger and you leave it in those areas. This is just regular tooth brushing. [Linda]Yeah. [Jaz]And is it a specific type of Sensodyne? Like, for example, I think previously you’ve talked about repair and protect. I don’t know if they still have that terminology anymore. Is there one that works better than the others prior to whitening? [Linda]I think all of them are absolutely fine. Absolutely fine. And there’s newer versions of whatever works for the patient. What I do check though is on all toothpastes and soothing toothpastes and in general the current toothpastes that are being used many patients suffer from sloughing of the cheeks of the new codes. I don’t know if you see this. [Jaz]Yes, yes. [Linda]So you need to, I always ask the patient when I’m doing a general exam, what toothpaste they are using because some cause more sloughing of the cheeks. And so we say, change your brand. So when it’s talking about a sensitive desensitizing toothpaste, use it for two weeks, then go on to the next brand and then just change it a little bit. [Jaz]So we want A, the sensitivity sorted and be no sloughing. Sloughing is, do we believe that’s the SLS component? [Linda]Yeah, we think it’s the SLS. Some of them have Covarine blue dye in to make the teeth look whiter, but it may be too strong or, so you need to just check and monitor with the patients. [Jaz]Okay, so you’ve done your diagnosis, you’ve noted the NCCLs, for those that are amenable to treatment, and which most are based on this conversation, let’s use that, you’re going to use a Riva, like you said, you’re going to follow that fantastic protocol, which we’re going to get the video for, and a little checklist, and our team, a lot of people are driving or on a train, they haven’t got access or making a license or download and then also link everything to your website as well, which would be great. [Linda]And we’ve got a new WhatsApp group on bleaching just by the way. [Jaz]Oh, wonderful. I love that. Fantastic. [Linda]It’s really amazing people put their cases on. [Jaz]Brilliant. Now you’ve also talked about using Sensodyne for two weeks prior to teeth whitening and then just brushing. And if they’re having the sloughing or that brand is not working for them, then maybe change a brand. Would you agree with that? Because I found patients where they tried something already using a Sensodyne toothpaste and just by suggesting a change in the chemical formulation, a different brand, then they suddenly come back and their sensitivity is significantly improved. Is that something that you’ve observed as well? [Linda]Yeah. So when it comes to the different Sensodyne brands, there’s a lot of different ones. So you can, again, you can swap between the brands because they’ve got different functions like that. So that’s one option. Then, the next thing is to understand why patients get sensitive during whitening. And we would then- [Jaz]Can I just, before you talk about it, because this is such a big part, but it’s one thing, I just want to cross off before we move to the actual mechanics of teeth sensitivity during bleaching, is with your protocol, which sounds wonderful, are we expecting that patients can hopefully say that, you know what, I can have my ice cream again? Because sometimes they say, like, my centrals are super sensitive, but when you look, you don’t really see much recession, you don’t really see any NCCLs, they just have, generally, they’ve always had, oh, since I’ve been 12, I’ve always had sensitive teeth. Are we going to help that patient as well? [Linda]It helps that patient as well. Just recently, I saw a patient who we did this treatment exactly what I’m talking about, and she had massive erosion on her teeth as well on the occlusal surfaces. So we did a three step technique, written up a lot by Dr. Francesca Vailati. So we did the NCCLs on the outside, we built her up on the occlusal composites, we opened her up to a vertical dimension, I hadn’t seen her for a year, and she said to me, now, finally, I can eat so many different things. I can eat everything now, whereas before, I was so restricted on what I could eat because of the tooth sensitivity, because of the erosion. [Jaz]So that’s controversial question. Does Linda say that bruxism and occlusal forces may be a contributor to sensitivity? [Linda]Yep, because of the micro cracks within the tooth. So when we’re talking about sensitivity to patients, the first thing we need to understand that within five to ten minutes of placing whitening gel we are in the nerve of the tooth. And so, because some dentists think, well, they make up whitening as they go along because they’ve never really learned it and they just think it’s very, very cosmetic. But actually, understand that it goes into the nerve of every tooth. That’s why we need to, that’s why I’m saying take a radiograph. We need to know, what are we dealing with here? Because the way bleaching works and the way sensitivity works, it’s all related to the actual anatomy of that particular tooth. So if, and the way that the whitening works, it goes into the weakest part of the tooth first. So it will go into those micro cracks on those bruxes. It will grow into the crack where the patient has a crack tooth syndrome. It will go into a porous tooth and it will go into the non vital tooth. It will find the weakest link to travel, which is why we need to know, that’s how exactly that’s how it works. And that’s why some patients, I know we spoke about white spots, but some patients, we’ve never had white spots. Suddenly when they were doing whitening, they come become very alarmed that suddenly there is white patchy areas on the tooth that were never there, according to them. [Jaz]This freaks them out, this absolutely freaks them out. And then what the patient does, they stop whitening. Whereas I’m hoping you’re going to say that actually they should be encouraged to continue, reassure them. And then we’ll get a good result. And obviously what you’ve taught me before, and I’m always echoing anything teeth whitening related, I’ve always learned from you, which is that is a sign of enamel damage. What’s that’s highlighting is damaged enamel. [Linda]So what is actually highlighting is there’s porous parts within the tooth and the whitening has, taken up too quickly. So that particular part of the tooth is actually the enamel anatomy is porous. So you particularly find this with the higher strength whitening gels, which is why we like you to go low strength. So suddenly they’re on 16% everything is suddenly all mottled when they never had mottled teeth. We’ve seen a lot of patients referred from other dentists because of this problem. And as you say, it’s reassurance that they need to continue whitening. They also shouldn’t do stop, start whitening where they’ll do two days and they’d stop for a week and then, because you want to have slow and low. Still, Jaz, that particular part of the protocol is still the same slow and low concentration as you go along. [Jaz]Excellent. So we now know the mechanisms. We know that the peroxide is reaching the nerve within 10, 15 minutes and always go the path of least resistance. In terms of predicting who is acceptable. Obviously, now that we know this background information about, okay, the four questions that we’re going to be employing using restorative materials like Riva Light Cure, for example, to restore those NCCLs using desensitizing toothpaste. beforehand and finding the right formulation before you even start whitening. So already we’re on to a winner, but I found it a surprise that some patients, I warn everyone on sensitivity and some people come back with significant sensitivity that they just can’t do it. My wife being included, like she, within like two days, she can’t do it anymore. I get a bit, but not too much. Whereas some patients, there’s a particular patient I saw a few weeks ago, And bless her, she’s so sensitive to everything. Every time I’ve done a restoration, super sensitive, the bite needs time to settle, go very slow with her, easy with her, warner of everything. And I double, triple warned her before we started teeth whining that, okay, I think your teeth will be very, very sensitive. I just have a hunch. She came back and she said, nothing, zero. Okay. And so, and her teeth looks fine. There’s no NCCLs and there’s no difference to some other patients. Are there any individual characteristic traits that people’s baseline level sensitivity is more than the others? [Linda]I think it also depends on tolerance. And I also think it depends on hydration. Hydration is a new area they’d be looking at. Because a lot of patients who have like a high lip line like me, the lower third of the tooth is darker. And the hydration, it’s to do with, if they’re not hydrated, the tooth, it’s dehydrated. And the whitening dehydrates as well, and so I think that contributes to the sensitivity. So now, we also, with our patients, and especially with the little kids with the white spots, we’re looking at their hydration levels, and we’re looking at their dietary levels. Because the patients have high lip lines, class 2, sticking out teeth, they’re dehydrated, they’re not drinking enough water. And the teeth are porous and so they’re accumulating more stain. But we go back to, first of all, water for all patients, because none of us actually drink enough water. So we look at the hydration and looking at why they’re sensitive. But most of the time, you can’t predict. So the research shows up to 80 percent of patients are going to be sensitive during whitening. And this is particularly with higher strength. We try and predict and we look at what would cause them to be more sensitive. So some of the protocols would use the whitening gel 15 minutes in the morning, 15 minutes in the evening, and they discovered those protocols were more sensitive. [Jaz]Oh, wow. [Linda]And so, there are a lot of protocols like that, oh, you just do 15 minutes of double whitening a day, makes it more sensitive. Then it comes back to the tray, the tray design, and they think that a rigid tray makes it more sensitive. They did a study, and they just put bleaching trays in, and they discovered with no gel that 30 percent of people were sensitive just with a tray sitting around it. [Jaz]Wow. [Linda]So then the next study they did was they cut off the last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area and they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that. So if they’re so sensitive, like you were talking about your wife, cut back two millimeters off the bleaching tray on the cervical area. So it’s not rubbing. [Jaz]So you’re shying away from the gingiva. You’re like supragingival two millimeters. [Linda]You’re supragingival two millimeters above or even a millimeter above. And you may find that will improve it. [Jaz]That’s fascinating because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area. [Linda]So here’s another point. You can’t adequately bleach the cervical area. It’s never gonna be the same shade and that’s a myth. It’s never going to end. When patients come to see and they go, look, look, look, this is not right. And then we go, well, then just don’t bring, don’t bring your teeth down. Nobody’s going to see that. You have to be realistic of what whitening will do and what it’s not going to do. On the root area, it’s not going to be B1++. Ever. With whatever whitening gel you’re going to use. So that’s an important factor. Again, it’s to do with the root anatomy and all that stuff. [Jaz]The thin enamel in that region, enamel being so important in the good whitening effect. [Linda]It’s not going to be the same. So that’s really, really important. The other factor is medication that patients take. When you were saying you need to look at medication, we also talking about roaccutane at the moment because roaccutane, I don’t know if you know this, but roaccutane, because we’ve got the ortho kids who whitening in the retainers. And Roaccutane, again, it dries out the teeth, it dries out the skin, but some patients have dry mouths. And those little kids, often after Ortho and Roaccutane, because Roaccutane is a long period of time, the teeth are grey green. I was just looking it up last night again. And they think it’s due to the dehydration, because the Roaccutane dries out the mouth and the saliva as well. And you get the- [Jaz]I’ve never heard of this Roaccutane. Can you tell me what it is? I’ve never heard of it. [Linda]It’s called isotretinoin and it’s a medication like a vitamin A. It’s called isotretinoin and there’s different versions. The U. S. is Accutane. We call it Roaccutane, but it’s kind of standard protocol for the dermatologist to put the kids onto Roaccutane. There’s a lot of write ups. I’ll send you some of the press releases about it, but let’s call it the Daily Mail, often those kind of papers will cover stories about Roaccutane because what it does, it causes depression in kids and suicidal thoughts. So this is quite an important thing. So coming back to always checking medical history on all our patients. And if the kid is on Roaccutane, you need to tell them, well, you need to discuss with the parents and you need to discuss with the dermatologists. The other new drug, and they give it together or they swap them, is Lymecycline. You’ve heard of that one? [Jaz]Yes, heard of that one. That’s for, is that for acne? [Linda]Yes, but it’s the same. So either they’re on LYME, Lyme cycline, because we used to do minocycline, tetracycline, and doxycycline. But either on that, or they’re on roaccutane. And the roaccutane doses, the way it goes, it goes 20 milligrams, 40 milligrams, 60 milligrams, and it goes on for two years. So then you have to balance the acne versus the discoloration on the teeth. And again, discussing with parents, of course, we’re not going to say with the child, but out the children’s welfare is really important. So we are understanding that on the racket and how long they’ve been on it. And not every child gets great teeth when they’re on reaction. And then again, you come back to talking about hydration levels. So my next new business marketing idea is to actually print water bottles with our practice name on to give to the kids. And to give to the adults about drinking water, just drinking more water because of hydration effects, discoloration effects, and healing the mouth with water. I will write a paper on this, there just hasn’t been enough time. [Jaz]I love it because it’s putting the mouth back in the body, it’s reminding us that, we are, the theme of the AES, which I like to go to in Chicago, for 2026 is the oral physician and about the putting us back in the body, putting the mouth back in the body, which is so important. So it’s a nice holistic approach and step back approach on this theme of hydration and dehydration. I’ve seen before exactly that kind of patient described, which had like a two tone appearance of their teeth. And they’re very, very grey. And I have found that on one instance a few years ago, this patient just did not respond as well to whitening as I wanted. And it makes sense that, okay, it’s because of the fact that they have this profile whereby the lower incisal third or half is too dehydrated, I imagine, but it’s got this grayish appearance. Is there any hope for this patient with teeth whitening? Or are they looking at veneers? [Linda]There is hope and everybody responds, so everybody’s difference in their response and sometimes on those patients, because it’s dehydrated enamel, so think of it thinner, desiccated, more dentine laid down, so you get that two tone effect. You need to go for the six to eight week protocol, whitening with low strength, coming back to the five percents. 5% carbamide peroxide, low and slow, but it can change and it can make a big difference on those patients. [Jaz]Can you name a brand of 5% carbamide peroxide? [Linda]Yeah, we’ll talk about that, but the last patient yesterday, short lip, the two thirds is dehydrated. Obviously, I spotted it straight away, but we were just having a general discussion about that, about her teeth in general and sensitivity in general. And that is a factor that is a factor and an interesting thing is that her boyfriend said you need to fix your teeth. First fix your teeth, darling and so we come back to understanding diet sheets coming back to those old fashioned diet sheets we was taught. Get the patient to fill out diet sheets. Either a weekend day two normal days and have a look email it to them and email it back. And just have a look at what they’re actually drinking. You’ll find it’s not enough and that comes back to the discoloration. So when you say the whitening is difficult, check on the, the whitening gel being water and it still can dehydrate the enamel during the whitening process. And for those patients who already dehydrated the results may take longer. So you keep going you keep going and going and they will get there, but it’s slower. [Jaz]With the dehydration often when we’re doing like rubber dam on with dehydration, we see the teeth get whiter, but I think in this instance, it’s like a chronic dehydration, which has the grayish effect. Have I got that right? [Linda]Yes, a chronic dehydration and it’s grayish because it’s the enamel is so dehydrated. It’s picked up some internal stain within the food, et cetera, that they’re eating. So yes, so then I want to talk about putting on a rubber dam and the rate of dehydration on a patient. You know when you’re about to start composite bonding. The first thing you have to do even almost before the rubber dam is on is choose your composite shade because so quickly the teeth dehydrate and you’re choosing lighter and lighter composites, which don’t blend. So coming back to that the same rate that a tooth dehydrates is the rate that a tooth whitens. Now when you put on your rubber dam, just watch the tooth as it’s dehydrating because it doesn’t always dehydrate evenly. It will be a little bit patchy in places as it’s losing water losing water losing water. That’s the same pattern as how the tooth whitening would appear. It’s again associated to the path of least resistance. [Jaz]And this is again where we have to reassure a patient after they’ve got up and they remove the rubber dam why they got those patches in the same way with the whitening. You’ve repeatedly said about using a low insert protocol which makes a lot of sense. In other countries, they’re using ridiculous percentages, 25, 30% sometimes, in Singapore I remember using such percentages actually. And it’s good in a way that we use low percentages here. 5% for carbamide peroxide. Any proprietary brand that you recommend? [Linda]There’s not many on the UK market. Basically, it is, the main one is Novon Mild from OptiDent, Henry Schein. And it’s got a special soother inside, which is a toothpaste, glycosine phosphate is the soother inside. So when we’re talking about concentration, we’re talking about, we can also talk about it doesn’t mean carbamide and hydrogen. Carbamide has 16%, 10% and 5%. You should always have 5% available for a certain category of patients. Number one, those who’ve always like you, like you’re talking about your wife. He’s been so sensitive to whitening, they need to go on the 5%. Then, patients with Medically compromised history, health history, who have got complex medical issues for them. Then those patients who’ve tried whitening before, and also you can see, we spoke about bruxers. If you ask a dentist, if they’ve done whitening, and then they had sensitivity, they’ll all tell you that they have on the lower incisors, they’re sensitive because we all bruxing, we all stress bunnies, and so we get sensitivity just on those lines, lower incisors, little micro cracks. So on all those patients, and patients who’ve never been able to manage whitening before, It’s all with a 5% carbamide peroxide. There is another brand called Cavex, it’s from Amsterdam, 5% carbamide peroxide. But we would use that for those patients that are super sensitive. 5% carbamide peroxide is also used for therapeutic aesthetics. I don’t know if you’ve heard of this term. [Jaz]No. [Linda]Okay, I’ll send you my publications on this. So we use the bleaching tray as a therapeutic tray, which comes back. [Jaz]Oh, I see what you mean. Okay. Yes, carry on. [Linda]It comes back to all aspects of a patient’s oral health. So the bleaching tray becomes this therapeutic tray and we deliver different chemicals. So tooth mousse, MI Paste particularly, is really good for soothing and desensitizing. So on top of our normal protocol, which we’ve gone through before on home whitening, and that they just do the upper and then they do the lower. And just by the way, the reason for that protocol is because the upper teeth are not as sensitive. So we always go to the positive upper whitening first. But because of that, we would always give our patients a brand of proprietary soother. There’s quite a few different ones, but I’ll just tell you, tell them to you. The main one is, it’s either tooth mousse or MI paste because it’s got ACP inside. And ACP is a tubular blocker, and it also works on the enamel to smooth the enamel and the defects in the enamel. So, that is great. [Jaz]And also good for ortho demineralization, early white spots. It can be quite curative without teeth whitening, right? [Linda]Yeah. Decal’s really, really good for that. Yes, you can use the DuraPhat toothpaste as well, but to put in the bleaching tray, we can use Tooth Mousse, MI Paste, and there’s a new one, which is MI Paste Plus. [Jaz]That’s the one with fluoride? [Linda]Yeah, the tooth mousse doesn’t have fluoride, but the MI paste does have fluoride, different concentrations. Then the proprietary one, there’s one from called Relief Gel, and that’s from Philips, night white, Relief Gel, and Philips brand has got ACP, potassium nitrate, and fluoride inside. And you put that, you run a line into your bleaching tray, and the patient would wear that an hour a day. An hour before lightning. An hour instead of whitening or an hour after whitening, and that should solve your issues with sensitivity. [Jaz]And that’s a top tip right there, I think. I mean, did you use it, which I do, and I was going to ask you about that in terms of what you recommend to put inside it. How about those high, in the past what I’ve done, not related to teeth whitening actually, but high caries risk patients, patients where root caries prone patients, patients who’ve had, let’s say radiotherapy, and their saliva is going to be low and poor quality. I often give them like a very passively fitting Essex retainer. And then I encourage them to use certain agents like Toothmousse. I go and I show them on Amazon, which one to get. Do we have sufficient evidence base for that? Or is that something that you’re a fan of? [Linda]Oh, yes, we do have evidence. It’s not just a random thing. There is a lot of evidence on that. And Professor Van Haywood has published a lot on this. Then, the other study that was done by a guy called Lazarchik, 2010, was for special needs patients. So but you use also for those special needs patients, the carbamide peroxide in the low concentration. So those patients who are high caries rate patients, they did a study and the guy’s name is Yao, 2013, where they looked at the difference between chlorhexidine, and chlorhexidine and carbamide peroxide, and they found that carbamide peroxide was more bactericidal to help the gingiva than actually Chlorhex. So on another WhatsApp group that I’m on, a digital group, they were showing a case where the patient, they did new crowns, the gums were all swollen afterwards, they redid the crowns, the gums were still, upper 3 to 3, gums were still swollen. So I said to them, put in a bleaching tray with carbamide peroxide 5% inside, and just heal the gingiva. Then go back to taking all those crowns, putting provisionals, keep with the carbamide peroxide to get everything balanced. Make sure you don’t invade the biological work before you go to be able to do that. But this is quite a top tip in terms of that. Your elderly patients who have poor oral hygiene, the five, on the label, this is a little controversy because on the label it says, only for tooth whitening purposes. 5% or all of them say for tooth whitening purposes, but we use it for healing because it’s been used for healing for 70 years. This was the whole discussion. That’s how the whitening was invented because the orthodontist nurtures the gingiva with swell. So that was, why we would do that, but 5% in the tray, 5 percent upper, 5 percent lower, 1.2 percent. So the other soothes, which we didn’t mention this Pola soothe, Pola soothe is from SDI and that contains potassium nitrate and fluoride. And then you also have Opalescence. It’s called Ultra Ez. It’s from Utah products. Again, it’s another Henry Schein Octanet product. That one is just a syringe of potassium nitrate. So the way that potassium nitrate works for sensitivity is it stops the polarisation of the nerve. So stops the nerve continuing to fire, it cuts it with the potassium nitrate and just kind of temporarily paralyze if it stops it. So the nerve is not firing. So that’s why we use fluoride for blocking the tubules. We use potassium nitrate to stopping the repolarization of the nerve. We use ACP for blocking the tubules. And another product which you use, which we mentioned when we’re doing the NCCLs is the HurriSeal or the Gluma. So the Gluma is just a liquid, or the HUrriSeal is a liquid, and again you’re blocking the tubules. You can use it as an intermediate dentine seal as well. If you’re finding that a lot of your composites don’t work, I’m not you personally, you really know what I mean, but once composites, you do your normal protocol and patient has post operative sensitivity, which we all hate, but sometimes we need to re remove the composite because it’s pulling in, all those stories. Actually, we do it, you do your etching, you put the HurriSeal in and that stops it. That was a colleague of mine, Dr. Mervyn Druian told me about that. So the HurriSeal is very useful for all those sensitive patients, for all those ones, and again for restorative care/post-operative care [Jaz]I think you’ve taught me as well, because I believe your son’s doing wonderful work with AI, actually, and notes and stuff, and I’ve been in this space as well, and often, I don’t know if you’ve actually counted how many words are spoken, in a one hour consultation, it’s like 10, 000 plus, it’s actually crazy, and I feel with the pace that me and you both speak at, we’ve probably hit 20, 000, and I know that dentists have got incredible value from you. One personal takeaway now, I mean, all the protocols said brilliant. Some things are great revision for me. But what a wonderful reminder you gave us, right? That the cervical region just won’t ever whiten as well as the others. And I think we forget that. And when we, when we talk to patients and we take that photo with the shade tab, we say, it’s going to go this way. Just pause and say that, oh, but not this part. It’s like, imagine you’re in Lion King. Okay. You can go there, but you can’t go there. Like, just think of Lion King next time you’re whitening your patience. And I think it’s a great reminder and I look forward to adding more resources from you in the show notes. I know you’re involved with so much. You’ve got some amazing events coming up. I’d love for people to come and learn more from you. Cause every time I speak with you, I learn so much. Every time people meet you, your energy is brilliant. How can we get more of this energy? Where are you next speaking at? [Linda]So our next gig is an important conference. It’s called Future Dentistry. It’s on the 1st of November at the BDA. And we would like more dentists to attend. We have an amazing lineup. First of all, talking about dental AI and how we can implement it into our practice from all different aspects. We talk about the future of contemporary restorative zirconia crowns in there’s an onlays, there’s an zirconia veneers. We talk about early intervention orthodontics because there’s this whole thing everybody waits to the right time but Professor Peter Mossi will be talking about how you really properly early intervene and what you need to do. We’re talking about the latest techniques in implants. What is new? What’s the future? How are we going to go with this digital dentistry? How we integrate it? the different scanners and all the different techniques. The dental technicians will be talking from their angle. We also have to have a medical legal update, a safeguarding update. So you are fully up to the- [Jaz]Core CPD is ticked off as well then. [Linda]All your CPD or your core subjects is all ticked off. But the benefit of this is that by attending the conference, you actually are contributing to the charity, to the work of the charity to help more patients attain dental wellness, which is really important. [Jaz]Well, I’m definitely gonna put the link but you know for those who are maybe driving around click check the show notes but do you know, is it the BDA website? Is that what they book? [Linda]They book through event brite and i’ll send you the link. It’s first of November, BDA. [Jaz]Perfect. And those topics that you covered are very sought after topics that Protruserati ask about, especially the inceptive orthontics. AI is such a big thing. I’m a big fan of it. And I encourage everyone to explore these avenues. I think people are sometimes shy or they’re like, I’ve been doing it for 10 years, I don’t have a problem. When they learn to embrace AI, they suddenly gain four or five hours a week that they never knew they had, they could possibly to have, and it reduces your stress, improves your quality of your notes. So it’s amazing you’re talking about that. And also yes, zirconia, partial coverage restoration. Something I’ve talked about, not talked about, but such I asked about on the podcast. It’d be interesting to hear an update on that. So I’ll definitely put the link in the show notes and fantastic topics. Linda, I’ll put all your show notes, all the sort of follow links and all your wonderful things that you do. Thank you so much from the Protrusive community for all you do, the charity work, the education. I can’t believe you’ve been in this game for 40 years plus. That’s amazing. Please can we have another 40 years because we don’t retire anytime soon. [Linda]So nice to talk to you. It’s lovely to talk to industry with you. You’re very inspiring. You do amazing work and thank you for all you do on your education and all you do to inspire so many leaders. Your impact is huge all over the place. Whenever I go to dental meeting there, I heard you from the Jaz podcast. It’s all up to you, Jaz, and all the Protrusive things and all the wonderful things you do. Thank you so much. Jaz’s Outro:Thank you. Thank you so much. There we have it, guys. Thank you so much for listening all the way to the end. Don’t you just love Linda’s direct nature? She is brilliant. Please go and support her, learn from her and her colleagues on the 1st of November. And if you want any of the resources, some of them will be available on YouTube or wherever you’re watching this. And the rest are on the Protrusive Guidance. Don’t forget to get that infographic only on Protrusive Guidance. I want to thank my team as always. Erika, Mari, Gian, Krissel, Julia, Nav, Emma. Our team has been growing throughout the years, as have you guys. The subscriptions on YouTube and everything, they mean a lot. But if you really want to support Protrusive and get the most out of it, we’d love to see you on the app. I’ll also put any papers, any links that Linda suggested, including the Eventbrite link for her event on the 1st of November. And if you found this episode useful, please share it with a colleague. This is how the podcast grows. This is how we’re able to attract wonderful guests like Linda to help make dentistry tangible, which is the ultimate mission of this podcast. For those on a paid plan and Protrusive Guidance, scroll down, answer questions in the quiz. Mari, our CPD queen, will email you a certificate. And yes, we are PACE approved. So if you’re in the US, you’re going to love it too. Thank you so much again for listening to the end. I’ll catch you same time, same place next week. Bye for now.

Emma Hutchison, a dental student, shares valuable insights on navigating the complexities of occlusion and centric relation. She discusses the dilemma of whether to cement a crown that feels off-bite but looks good. The conversation also dives into the GABS occlusal philosophy, and practical techniques for checking occlusion effectively. Emma highlights the importance of mastering dental terminology and emphasizes the need for personalized maintenance plans in long-term care, making it essential listening for dental students aiming to enhance their clinical skills.

“Defensive Dentistry and the fear culture is the number 1 cause of anxiety amongst Dentists” How can we instead foster a culture where we can focus on growth and supporting each other? Does Dentistry have a social media problem? https://youtu.be/wsiENbuIXcE Watch IC053 on Youtube Join us on this episode with Dr Mehy Lo-Presti as we navigate dentistry and social media, the pros and cons of using the online world as part of our portfolio and how we can remove anxiety through effective communication. 2 Events to Attend: DentoRama 18th October Treatment Planning Symposium (Hybrid Event) 16th Nov Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:02:05 Introduction – Dr Mehy Lo-Presti06:42 Mehy Early On12:04 Dento-Rama15:30 Social Media in Dentistry20:35 Life Before Social Media21:25 Social Media is a Business 23:40 What Causes Anxiety for Dentists?29:45 Overcoming the Fear Factor34:45 Fast Tracking to Success41:20 Wrapping Up47:14 Booking the Event and Getting in Touch This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance. GDC LEARNING OUTCOMES: A AGD Code 770 (Self Improvement) Dentists will be able to: Gain insights into how social media affects clinical practice, patient perceptions, and professional image, learning how to use these platforms responsibly. Manage the pressures of online validation, minimising the impact on their mental health and maintaining a healthy work-life balance. Develop stronger communication methods both online and offline, ensuring clearer patient education, reducing complaints, and fostering better relationships within the dental team. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous ‘Vertipreps for Plonkers’ series. If you liked this episode, check out IC035 – Best Practices in Social Media for Dentists Click below for full episode transcript: Teaser: It depends again, what you want to show, who you want to be in social media. I always have this debate. I asked this many times in my events. Is it okay to share your personal life and your professional life at the same time? And some people will say yes. And, but there are consequences of that. And the consequences is that- Teaser:I don’t believe in fast tracks. I don’t believe in that things can go very quick because you’re going to miss a lot of learning in the process. So I think exploring and making mistakes and allowing yourself to fail. It’s something that. It will make you grow way faster. People are happy in their jobs when they feel that they are treated as adults. And this is something I learned from the employees from Google and Netflix and all these super fancy offices. They understood that people don’t care if you give them free food, they have a gym, you have cinema, you have all this super cool things in their office. So if you don’t treat them as adults and you don’t give them this freedom, they won’t be happy. Jaz’s Introduction:What’s the number one thing holding you back as a clinician? What’s holding you back from growing as a dentist and actually sleeping well at night time? It is an F word. Me and my guest today, Dr. Mehy Lo-Presti, we believe that fear is holding us back. When all of our decision making and all of our judgments and our communications are processed through this filter of fear and our dentistry is fear driven and therefore defensive. This is what may thought was the number one contributor of anxiety for dentists. Hello, Protruserati, I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. This is an interference cast, where we discuss more of the non clinical themes, which are super important, because we touch on communication, we touch on fulfillment, and we also touch on social media, because we can’t avoid it. Is there a place on social media for us all? Should we all be on there? And how do we conduct ourselves on social media? And how do we avoid the negative stuff on social media? I. e. the anxiety that social media itself actually brings. This episode is still eligible for CPD or CE credits. There is one CE credit or one hour of enhanced CPD, and the AGD code for this one is 770. That’s self improvement. And I truly think if you make it to the end of this podcast, you will feel so uplifted. You will appreciate that the themes we discuss on this episode are so real, so current, and they’re the kind of things that just need to be discussed more in dentistry. Two events that I recommend on the back of this podcast is October 18th Dentorama by the Global Dental Collective. This is like a combination of theatre, comedy and dental debate for the entire dental team. That’s in London and also in London on 16th of November is the Treatment Planning Symposium. This is where Lincoln Harris and Dr. Michael Frazis will be coming from Australia to London and I’ll be joining them as well to talk all about failure and then Lincoln will take over with a treatment planning masterclass. We’ve got a live patient consultation plan, like an unseen case for Linc, as well as asking the sauciest and the hottest questions on the live panel debate. For both those events, I’ll put the link in the show notes. Now let’s join the main podcast and I’ll catch you in the outro. Main EpisodeDr. Mehy Lo-Presti, welcome to the Protrusive Dental Podcast. I’ve been following you for a while. I don’t know if you remember the first time I actually met you, right? Was that, it was a Pascal Magne. I think it was in Glasgow. I think, right. It was a BACD and then you were there with extra Rupert Munkhouse, right? And I was like interviewing you, right? And then that’s when I first got exposed to you. And then I didn’t realize you were just like mega superstar. Then I see you on the stage. You’re like, gosh, I don’t want to say Jerry Springer, but like the male Oprah Winfrey, you’re just like completely ruling it. And now here we are recording today. So for those who don’t know about you, Mehy tell us about yourself. [Mehy]Wow. Wow. That’s, what an intro actually, no, the expectations are very high, maybe not as funny, but yeah, I can manage an audience. [Jaz]Edinburgh. [Mehy]Well, yeah, that’s true. We met in Edinburgh, right? It was at the BACD and then you were recording and interviewing people and then I already was following you because I think you have one of the best educating content in the dental world. So the pleasure is mine. Well, I’m a dentist. I was born and raised in Spain. I practice in London now. And basically I got to the point where dentistry was a struggle for me. I got a lot of people around here and I found healthcare events very boring in general. So I needed to find a way to make them more fun. I needed to find a way to also talk about everything that goes around dentistry that can help us to have a happier- [Jaz]What aspect of it did you struggle with most? So the common ones we hear is, just like the clinical, the big step that we have from dental school to real world, that’s a huge knowledge gap, right? And then you realize actually, in dental school, you really barely scratched the surface, right? And which is very disheartening to all our young listeners. I know, but that’s the real world. And, or was it the managing expectations of patients or was it just transition to adulting? What aspect of it did you find trickiest? [Mehy]I think what creates a stress in ourselves, it’s the not knowing what is going to happen. I’m not having a hundred percent control of what is going to happen in any scenario, right? And in dentistry, especially in the first years. This is very common. You don’t know how well your treatment is going to go because you’re not as good. You don’t know how the patient will react. You don’t manage your team that well. You take your work to home. So it’s a never- [Jaz]You own the patient’s problems, which is something I talk about. You end up owning the patient’s problems. A lot of young dentists, people still do it all throughout their career. But that for me was very peak when I was a newly qualified, this patient had this really tough decision to make between a root canal and extraction. And I felt it was me having to make a decision. I take that home with me, maybe in my stomach in bed, even like a minor thing like that, or a patient has a dry socket and it’s almost as though you had the dry socket. And this is a sign of a caring practitioner, so anyone’s resonating with this, it’s kind of a good thing that you have that compass inside you and you are sympathetic, you’re empathetic. But we must learn to detach ourselves and be there to guide the patient in their journey, but not to own their problems. [Mehy]A hundred percent. And not having those tools to do so was basically what took me to have the decision to make the decision to like, okay, maybe this is not for me. And especially after COVID, like COVID and going back in those conditions that we went, having all this stress that what you already have, it wasn’t great. And then I realized that I needed help. I spoke with colleagues that had the same issues. I did some courses I started working on myself. I left that black hole, I would say. And then I go, okay, we need to speak about this. And when we did this, our first event, which was almost three years ago, there was not many people talking about mental health in dentistry, probably where the first event, actually, we were just bringing this onto the table. And it was amazing to realize that actually the whole industry was having the same issues. And then figures came out and then you realize that, wow, actually. I’m happy in this profession, so there’s must be something that we need to do. [Jaz]Tell us a bit about you now in your working situation. What are the kind of, what does Mehy like to practice? What kind of a dentist are you? What do you love most about dentistry? What do you hate most about dentistry? Tell me about you as a dentist who kind of took this break or a pause. But then now you are re reengaged in it, but you also have this second purpose, right? We all have this purpose dentistry, but I love your second purpose of actually creating community similar to me in a way, create a community. You’re making it a safe place for everyone to talk about these issues and you’re bettering everyone’s mental health in my view, as I see it, but you do far more than that. So tell us more about the yin and the yang, this mix of two things that you do, the clinical and the nonclinical. [Mehy]Well, the clinical, I’m enjoying a lot of my work right now, but I started not knowing what to do. Like I was not even sure I wanted to do dentistry and I’m from a background of doctors. So it was probably the safe bet in my case. [Jaz]You’re the black sheep. You’re the failure. [Mehy]Exactly. And I always say like, my dad is Palestinian. So we have three options. We need a doctor, lawyer or a failure. And I was clearly, I remember telling my dad, I wanted to do fashion illustration. And it was like, no, we don’t do fashion illustration. I mean, first he said, I don’t even know what’s that, but we don’t do that. So you can probably be a dentist. Might be easier than being a doctor. [Jaz]You use the F word basically. That in a way is also an F word. [Mehy]I mean, yeah, I knew exactly that was like, Oh my God, what I’ve done to reserve that. But anyway, so I finished my career and I didn’t really know which specialty I liked and I didn’t know much about, I wasn’t exposed to much about to all these different options. So I started doing perio, a full year periodontist, then I saw that, okay, maybe blood and soft tissues is not what I wanted. [Jaz]Let me pause you there, mate. Let me understand this. Did you do a four year perio program? You did a program, a full perio program? [Mehy]Yeah, it was like a pre, so to get into the masters in Spain, it was a three years master. It was one of the hardest perio programs in the world, which is directed by Mariano Sanz, that he trained people like Miguel Stanley and the biggest people in the world. So to go that, you need to do a one year of pre perio. You need to become an expert to actually go in there. So I started studying for that course. I started shadowing some of the best perios in Spain, which are, there are a lot like Mariano, all these big guys. And then I realized I don’t feel like leaving. Put in my life three years in the beam to do patio, maybe to do something else. And then I started working in a place where root canals, they were a must, like there was a lot of, for some reason there was a lot of root canals needed, the demographic for the work that was done before, for the kind of treat patients that we were receiving. But then I think I did like maybe 150 root canals in a year. And my family in the states are endodontists in LA. Several clinics after and also I was always under I understood the work, but again, I found it extremely I was like, I can’t do this the rest of my life I mean no way. Probably no and now I regret to be honest now seeing them in the longest. I probably now would love to be in and around this. I found it like very profession to do right so young dentists, endodontists it sounds like it’s not sexy. But it has a very good life. I don’t know if you agree with me on that I finally agree good speciality to know that I decided to move to London to do my Master’s in the Aesthetic and Restorative Program. And that was a part time, so I needed to find a job here while I was doing my Master’s. That was a bit difficult because I didn’t know how the NHS worked. I didn’t have any I had no clue about how the system worked and I was lucky enough to end up working in a clinic in West Palm Grove in Nottingham. Super cool clinic. The guy liked the work that I was doing and like he was also Spanish that helped. And that gave me already open doors to private dentistry. So I’ve never done NHS. And I could pay my university at the same time. So I was very lucky. And from there, basically restorative slash prosthodontist, which in your case not very well defined. What I do in getting more and more and more and more complex cases, and now what I love to do is basically work occlusion, full mouth rehabilitation dentistry, whatever involves patients to have a normal life. Again, as much as we can and always looking from a very holistic approach. So working with nutritionists, working with chiropractors, I work a lot in getting a lot in sleep medicine, something that I’m very passionate about. This is the kind of patients that I get. They work in Kensington, they work in a clinic in Archery. So our patients that normally they need a lot of help and we try to help them from the very, very beginning of their problems, which are, gets to manage dentitions, right? [Jaz]Well, when you started to re engage back in dentistry, and take this further, and now you’re working in a clinic where you have the right tools and the right mindset that’s constantly growing, you’re delving more into sleep medicine, for example, when you realize that actually it wasn’t just you who went through that rough path, that we all go through it, and there’s still many clinicians who are suffering in silence, how we can be a very isolated, went into creating a little bit more about these events. Tell me more about that, tell me about did Dentorama come first, or which one came first? Give us a flavor about that because the next thing I want to jump to is came to your most recent one. It was just amazing. Like, the full stage all around the debate that was happening. The conversations that were happening, the kind of people that you tracked was truly brilliant. So tell us more about how you ended up going into that, or we talk about some of the themes that came such as anxiety from social media. Is it a good thing and a bad thing? But tell us more about how you actually got started with that. [Mehy]Well, this was, it’s going to be now almost three years ago and two or three years ago. And I had a concept of an event. Me with my friend Bruno, we wanted, who is not in dentistry, he’s in music, now he does sound frequency, which it’s another science, but we wanted to basically create events to help the healthcare provider, what to, how they can work on their breathing, how they can work on their posture, how they can work on their mental health, everything that is around the clinical side. I had that in mind the way that I wanted to look, which is one of the ventures, which is the debate on this very dark room with a white in the middle that is pointed to the speakers and makes a bit very mystic atmosphere. We, our paths cross with Joe Lovett, one of the most well connected networker in the industry, and he also had in mind to do an event. So we kind of merge forces. He was bringing basically companies and huge following that he had. And I didn’t know anyone here, so I guess like, this is my idea. Let’s see if it works. So the ingredients worked very well. People loved it. People felt safe. People love to have a space where they could actually open up to their feelings and not being judged. Everything in a very cool set up, like you’ve never seen before. And after that, we were throwing a party with an open bar, which everyone loves. So all these ingredients made it very magical and successful. And people were like, okay, what’s next? And we’re like, I don’t know. We didn’t think to do anyone else. It’s like, yeah, yeah. We need to continue that. We did another one, but the problem that we have is that every time we do an event, we need to change something and we need to make it more innovative and people are expecting from us. It’s like, oh, let’s see what’s next. At some point, the idea of creating a theatrical debate came on board, which basically is something that happened in Morinther and arts, which is basically a very, very basic concept of what we do now. We had to transform it in what is then drama now, which is theater with the real actors that play real life scenarios that happen in a dental clinic. And last year was a lot about problems of the patient with the dentist expectations and unhappy patients. And the dentist trying to commit frauds to make some extra money. The insurance theater at some point freeze or stops. And we had a panel of experts last year. We have a lawyer, one of the directors of dental protection, actually deserves to learn this. And we talk about what happened in the theater, but the coolest bit, and I think it’s the one that people like more is that for a hundred people that are in the room, they can share and open and talk about what they’ve seen. So it’s like a little bit like a forum, but not only to see who is speaking. Also, you have the chance to express yourself. And obviously we think we finish all of this with a very nice network, a very nice party. So, everyone goes home happy. But so this is how everything evolved. And with the years we managed to build this very beautiful community. People that want to have a better career and they are concerned about creating a better work through dentistry. [Jaz]I think it’s very innovative what you did. I think it’s very timely and I think it’s just an artistic expression. These debates are happening, but what you’ve essentially created, you’ve funneled it into a very creative way. Beautiful artistic expression. So it was really great to be involved with the debate that you had, but now looking forward to in October, the Dentorama. I love the theater. I love the production. So I can’t wait to see what surprises you have up your sleeves. But one of the themes that you did discuss the most recent event with the debate, I think Rona was an audience and you asked her about social media and you don’t have to have the kind of following that she does. It could be anyone. The thing I found to struggle with was many years ago when social media was new. To actually have the confidence to post a photo of a clinical image. That’s a big step for a young dentist to do that basically. But the other thing I realized is that a lot of dentists just don’t want to engage in that and you have to respect that. But then the question I’m asking is in this time that we are now, 2024, is it a must? Should every dentist have a presence on social media, whether they like it or not? It’s kind of like, should we all have a LinkedIn? Should we all have an Instagram? How imperative is it to have a social media? Because one of the downsides of social media, which we’ll touch on is the anxiety. It creates, you’re constantly seeing beautiful work. You’re constantly seeing, it’s no different to seeing all these beautiful fashion magazines and seeing these models, which are not realistic. Some have been Photoshop, et cetera. People start comparing, having anxiety about that. We apply that to dentistry. We see that through social media as well. So what are your thoughts on the dentist and their role, their presence in social media and the whole package that comes with it? [Mehy]I think it depends. It depends on what you want to be in this profession, and who is the audience that you want to talk to? It depends on your audience is in between 25 and 35, then probably you need Instagram, right? Or- [Jaz]By audience. Do you mean your patient base? Is that the way of saying your patient base? [Mehy]Yeah, let’s say, okay. Yeah. I mean, kind of both at the same time, it depends on, first of all, do you want to use it professionally? Do you want it to attract patients or do you want it to educate? Do you want to use it to just know about your friends or it depends on, I think the question is what do you want to be in social media? Because right now in social media we are actors and this is how I see. No one really shows. I haven’t met anyone that shows the real life every day. So right now in social media we are actors. [Jaz]I love that and I love where you’re going with this, but I’m going to add that actually It’s not just social media. I feel like when we are in the operatory, we are also actors. We are also putting on a performance. [Mehy]A hundred percent. And this is what you need to decide. I need to decide when I’m in front, in the stage, when I’m doing public speaking, when I’m in front of a camera, I need to decide, okay, who are you right now and what you want to express. So if I want to empower my audience and I want to speak about things that they’re going to make my audience happier. Of course, I’m not going to show who I am today. Because that might not help them and the reality of who I am. So it depends on which actor are you deciding to be in social media. And you can be many actors, but this is what you need to understand. That when you know this, you understand that whoever is in social media is not you. Then you can use it as you wish. And that probably will remove a lot of the anxiety that this is creating. Because one of the things that you said about that first post about your case, how difficult it is. This is because we are seeking validation. And this is a trauma that we’re having since we were kids. So this is not a problem. Social media is our problem that actually social media is bringing up. You have a problem because you need to be liked by everyone. And you need to, everyone said, wow, what a great job. And you won’t accept criticism. So when you worked on that, and then you were actually like, I’m ready to learn from my mistakes and I’m ready to show and see what they’ve done wrong, then that anxiety will probably disappear. Another thing is that if you really want to show that, and if you really want to show your weaknesses, that it’s not always necessary, like it depends on, it depends again, what you want to show, who you want to be in social media. So I always have this debate. I’ll ask this many times in my events. Is it okay to share your personal life and your professional life at the same time? And some people will say, yes. And, but there are consequences of that. And the consequences is that, as I know, a lot of my colleagues, they had such a strong presence in social media and they show so much about their life that the patient, they go to the clinic to meet them. They almost don’t care about their clinical skills. They want to know and now I’m a big fan of you and okay, whatever you do, I’m going to from being a great dentist or bring a clinician that we think that that people will go to you depends on what you’re showing and they’re like amazing clinicians that we all know very well that they only show their clinical work and you almost don’t even know their face. I actually, they’re clinicians. I don’t even know how they look. They only show teeth. [Jaz]But you know, that style of dental photography. And when you see the photo, you don’t have to see the handle, whose photo that is and the work and it’s like a signature that you leave on your dentistry. And they’re showing that, and they’re obviously very passionate because one way you could be the absolute best dentist in the world, right? But if you can’t communicate with your patient, right, that goes nowhere. In the same way, you could be an exemplary clinician. But your colleagues will not refer to you because you haven’t communicated it to your colleagues and you haven’t communicated to your patients in the modern way that we do now in this day and age. [Mehy]Yeah, I agree. And back in the days, I was actually talking with a very, very, very brilliant orthodontist, Dr. David Young, which has 30 years of experience. And actually, I was asking him, how were you doing before? And like, how were you when, before social media, before internet, and he was actually talking to me about the slide projector where you had to take all your pictures and take it to reveal. And then they were creating this slides for you. And then you had to take. It was almost like a DJ that goes with the vinyls around. So you had to go and this is the only way you could show all your work. And then how many people could see your work was whether it was in the room. And if you were lucky, maybe a thousand people that normally it’s 10 to 10 study clubs. So social media is a great tool on that. [Jaz]It’s a great megaphone. It’s a great amplifier, but we need to make sure two things, which message I’ll be giving to the world. But also which message are we receiving as well, because we are at the mercy of the algorithms and we start looking at things and the algorithm wants to feed you more, but then you get blind to the other perspectives that are out there. [Mehy]100%. Social media is a business, right? And as a business, there are interests. And I mean, I had my personal experience where I, at some point I was showing or trying to raise awareness about the political issue, right. Or about some kind of a war or I’m Palestinian, right. So I wanted to raise awareness about what was happening in the world. And my view, my posts were shown. I don’t have a huge following. I don’t know how many thousands, something they were shown to 10 people. Now, when I was posting about my holidays in Ibiza with a beer in my hand and with my daughter or whatever, there are 400 views. So there’s clearly an indication of what you can show as a filtering. So, and that is in any sense in any case, and so you have also to consider that you are part of a business and you’re going to be showing whatever the business wants you to show. So as far as you understand how it works and as far as understand what is social media and as far as you understand yourself, what you want to be on those platforms and who you want to talk, how you are going to receive, as you said, those messages, then you can be safe. But again, it creates addiction. It creates an anxiety. There’s a very dangerous tool to use, in my opinion. [Jaz]I think it’s good that you mentioned, and it’s the first point you mentioned. I think just, if anyone’s multitasking and missed that, really important to say is that Mehy clearly said that social media is fake and just always remember that. And then this is how it is, is that it always will be. Because no one’s going to show the new wart that came on their pinky toe, right? No one’s going to share that stuff. Okay. So that’s too real. When they get their nails done, they’ll show that. So just remember that the warts and all the experience is very rarely happening. And what you see is the best of the best. So never feel anxiety or compare yourself to what you see on social media. The best metric is to compare yourself from two years ago, compare yourself to you three years ago. And if you’re not happy with that progress, you need to really have a sit down and think about, okay, what’s the next two years going to look like? What’s the next six months going to look like? Now on the topic of all this, it may may or may not be social media. I’m leaving it to you because what I see you are really on the field discussing this a lot, right? What do you think is the number one source of anxiety for young dentists? So it could be social media, but I don’t know. I’m not convinced it is. I feel as though it’s other things, but you may say it is from speaking to his colleagues. What is the biggest source of anxiety? [Mehy]I don’t think I mean, social media is a huge factor, but something, I mean just imagine that once you’re taking your driving license, right? And then the teacher is telling you, once you’re going to get your license, and like, by the way, I didn’t tell you that, but you’re going to crash your car at least twice in your life and you might die. This might affect the rest of your life in the way you drive. And it’s going to make you drive very insecure, very scared. You’re expecting always something going to happen. So there’s something that shocked me a lot when I arrived to this country is that the indemnity companies, they assure to the young professionals that they are going to get sued. At least twice in their career. [Jaz]That must have changed Mehy. That must have changed because the one I heard many years ago, but that the most latest one I heard is that not necessarily sued, but you will get five complaints in your first two years. Now, what determines the complaint? It could just be like a small thing. But some of these complaints go on further. So, in the UK, as you mentioned, it’s country specific UK, at some point did overtake the States, did overtake other countries in terms of being the most litigious country in the world, and I love your analogy of the driving instructor telling you that you’re going to crash. And then your whole life you’re driving with anxiety, you are holding your hand piece of anxiety. When you’re speaking to your patient, you are filtering so many things you are then getting confused because there’s one thing you want to say. But you can’t say it because you are then scared to do something that may be in the best interest of the patient, but it may be a riskier approach. It may leave you to defensive dentistry. You’re practicing defensively. [Mehy]Exactly. And I don’t think this is fair. One thing is okay. You need to understand there are rules. There are things that you need to be careful with, but I practice dentistry in five different countries. Studying to and have people in probably around 10 and no, this doesn’t happen everywhere. People in Spain don’t practice dentistry and there is great dentistry in Spain and there are some of the best in the world. So you don’t have that fear because you know you’re doing the best for the patient and you’re not worried that that patient will sue you. It might happen. I don’t know about you. Don’t go with this mentality. You just do the best of what your abilities and what you think is best for the patient. And you start actually what happens with this. So starting taking on board more complicated cases in an early stage of your career and you stop practicing this very defensive dentistry, which at the end of the day is wrong. And this is form in my opinion, like there’s a lot of, I call it like half way dentistry here, like a half of orthodontic treatment, just move a little bit to being able to put two millimeters of composite bonding. This is not dentistry. This is dentistry for three years, four years, but we all know this is going to break and doing this twice. This is the wrong thing. And this is why, and a lot of people don’t do that because they don’t want to put their patients through a more aggressive and I don’t think it’s more aggressive, but a longer treatment, more aggressive, more expensive, which can bring more complaints and complicate your life. But the reality is that is your duty to at least go for that treatment and if the patient doesn’t want to maybe go for something simpler, but I feel that this is what caused a lot of anxiety on the people like going to their jobs, thinking that something is going to go wrong, that whatever they do, they might get a complaint that if they forget to write the expiry of their anesthesia. They might get sued forever. And as you said, the complaints that you might receive, also, I did a study with the general dental counsel and we brought people from the GDC to one of our events, the numbers are not that bad. And the people that actually they get to lose their license is people that they are almost criminals. Like actually they’ve done some stuff very, very wrong, but you don’t lose your license because you forgot to write something on the notes or because it’s as far as you’re honest and then you made the best out of your capacity and things don’t need to go that bad. [Jaz]I’ll give you an example, right? And I love this direction we’re going in. I think you hit the nail on the head. In the UK, but I do feel speaking to us colleagues, they have a bit of this fear as well. [Mehy]Also the US, yes, for sure. Even worse. [Jaz]And the overarching theme, I think is when you are doing something with fear, if your frame is fear, then what happens is that you are not able to grow a good rate. You’re not able to innovate for sure. You’re not able to grow. And innovation doesn’t mean you make the next big thing in dentistry, it’s innovation for you, where you are at in your career, doing new procedures that already well documented in the textbooks, but now you’re able to confidently do that. Now, when I look at other countries, India, Poland, and some Eastern European countries, and I see how young dentists are doing such great work, it’s because yes, they had the mentorship and the guidance but they didn’t have that fear factor overlying, someone sitting, weighing them down in the shoulder. It’s a bit like the clinical example I can give is a sodium hypochlorite extrusion, right? It could happen, right? It’s not that no dentist ever wants to do that or create that because it’s horrible. No one wants to see it, right? But then now, how many more dentists are referring because they’re just afraid of all the different complications that can happen in endo? They’re not doing the molar root canal. They’re not, skilling up in endo, right? And so that’s a great example because that’s something that’s just happens as a percentage chance that that can happen. Even ID blocks, people, dentists, young kids are scared of doing ID blocks, right? Because they are afraid of causing a temporary or permanent, very rarely paresthesia from an ID block. And you’re such a simple, basic thing and you’re approaching it from fear. So if you can’t get past the ID block, how are you going to do your first ridge preservation? How are you going to do your first implant if you can’t get past the ID block? And so that’s the big issue I think we feel. So how can we even begin to correct that? Not that we’re going to come up with the answers me and you now, but I’m just putting up to debate to the Protruserati something to reflect on. [Mehy]I think having the tools. And understanding where these comments, where are they coming from? First of all, I think universities are not making a favor because they are the first ones putting that fear and talking about ID blocks. I know that for example, there are some universities that they are forcing you or to use different techniques as not as effective maybe so to avoid complications, which if they’re done, I mean, under some circumstances, they can be good, but the problem is that they teach you everything from the fear. So, that mentality needs to change. And I think those numbers about the GDC and complaints that you might receive, as you said, when they tell you, you’re going to receive five complaints. In your career now, they’re saying five, right? They don’t tell you exactly. I mean, let’s just stop saying this. Just let’s start from there. Like what is the reason of you saying this? What is the real reason? So we can increase the rise, the fees of the companies, or asked to practice more conservative. Then they say, what is the reason behind those statement. And this is what I would like to understand where these statements come from. [Jaz]Well, let’s talk about this statements language, right? Barry Oulton once taught me a great example, right? It’s a bit like when you’re speaking to your child, right? You’re speaking to a child. Like if I speak to my five year old Ishaan, this example that he gave me, Ishaan’s got some orange juice in his hand and he’s walking down the stairs, right? There’s one way of saying to Ishaan. Ishaan, don’t drop the orange juice as you’re coming down. Just be careful. Don’t drop the orange juice. Okay. And so he’s constantly walking, thinking about not dropping the orange juice. Instead, if we say to Ishaan, Ishaan come down very carefully, walk carefully and make it to the end and so that we can enjoy our orange juice. Okay. So it’s just the way you frame it. So perhaps we need to talk less or emphasize less about the world’s a bad place. Everyone’s going to sue you. Make sure you do this in notes or this will happen, et cetera. And rather think about, okay, how can we connect better with our patients? How can we get really good consent from our patients? How can we serve our patients better so they are happier? How can we upskill at the correct pace? If we maybe change the language to that, that might be part of the issue or solution. [Mehy]100 percent and is actually the main reason of complain. Normally people don’t complain because you’ve done a bad treatment. Normally people complain because you didn’t tell me that they tell him and explaining that things can go wrong. You didn’t manage expectations and you didn’t communicate clearly. And this is where everything comes from, communication. Communication that we receive and mainly the communication that we give. And this is, I’m very happy to see a lot of forces in communication and a lot of people talking about this because this is very important. And I think it’s the key of success and the key of success in everything, in your relationships, in your work, in your career, everything for me is communication because the really successful people in the world are people that they know how to talk and how to transmit and how to engage and how to make people feel safe. There are no people that have a lot of knowledge and there’s not a lot of people that they’re very good at doing a technique. They are very good at what they do, but if you really want to have success, which means for me, success is have a happy life and means that I go to bed sleeping very well and waking up, not thinking about problems. This is for me, success. Then you need to make sure that you spoke to everyone that you had to talk in a clear way the day before and there was no issues of miscommunication. So you need to work very hard on your communication skills. This is what my number one piece of advice to any person and can be young, can be adults wants to improve that. And once you get to that point where everyone can understand you and you’re not scared of saying what you think, and you said it, say it in the right way, things are going to go easier because skills, you’re going to get them, skills is one after the other. [Jaz]I think the soft skills of that conversation, the communication, we don’t practice enough. I had a great guest on recently, Dr. Brett Gilbert, Endodontist in the States. And a great piece of advice he gave is yes, you might practice on extracted teeth with the K files, et cetera, but how often do we stand in front of a mirror and practice how you say something and practice a hundred times the way you say it. So you become confident in the way you say it. Not because you’re trying to change you as a person, but your delivery is important. The reps that you do in terms of sometimes it’s difficult to say certain things. Sometimes it’s very, some people really struggle to talk about fees. Sometimes dentists really struggle to talk about the risks because they think, oh, if I tell them too many risks, then they won’t want the treatment. But that’s the whole point of consent. So you’ve got to say, look, Mrs. Smith, this might actually fail in a couple of years. And when it fails, it’s very sad. We don’t want that to happen. We’re going to try our best, but you need to consent that. Okay. It’s not always a hundred percent successful. Is that going to be okay with you? Now, some people would really struggle with that, but if you can actually practice that in front of the mirror, that’s a good thing. So what leads me to next is, what top tips can you share in the similar vein of the communication to help dentists fast track their growth in their career? And it doesn’t matter which stage of career they’re at basically, but to really from this point today, to fast track and grow at a faster rate. [Mehy]I am a huge fan of enjoying exploring your life and your options. So I don’t believe in fast tracks. I don’t believe that things can go very quick because you’re going to miss a lot of learning in the process. So I think exploring and making mistakes and allowing yourself to fail. It’s something that will make you grow way faster in a way. But when everything goes right and is planned and no one, you never had any issues, the learning is super slow. And actually when you have that failure in a very late stage of your career, that can be very dangerous because you’re not ready to fail. So for me, it’s like accept failure, accept that things can go wrong, accept the learning, something that in the industry, we’re not very good at that, right? We’re not very good at people telling us, oh, this is not how you should do it. And for me, communication, as I said, is key. So do courses, watch YouTube videos. Understand how to read a room, how to read your patient. No, you can’t talk to everyone in the same way. If you want to do public speaking, you can’t talk in the same way in a room for 2, 000 people than in a room with one person. You’re not talking in the same way to someone that is very confident. That someone is very scared. So once you understand, you can bridge people’s behavior. You need to understand how they feel. And also that goes to your team, which is exactly the same. When you learn how to talk to your team, how to give feedback, how to receive it. It’s very important, how to tell someone, hey, I don’t like this. Which for me was a huge struggle for years. I spent three years of my career not being able to tell to my nurse. I don’t like when you put this action here. And I was scared and afraid of hearing, hurting her feelings. And that was causing me anxiety. [Jaz]Especially young female dentists. They seem to complain about a lot. I hear a lot that get friction with the nurses. There’s so much more to it, I imagine, but we hear this a lot. And so well, one way I approach this, and when I work with a new nurse, right, I work with a wonderful nurse called Zoe, pretty much night and time. We have a great relationship. We worked on it because one of the first things I do when I work with a new nurse, right, is when the patient’s gone, maybe I said to Zoe many years ago, I said, Zoe, I like to work in a way where if anything that I do annoys you, please tell me. And then you’d be amazed what they tell you. Like one nurse once told me that my light is way too bright. It hurts her eyes. I never knew this. So I gave her permission to tell me. But equally what I did, I sought permission from my nurses. Like, can I please have your permission to maybe just share a few things that, I would like tweaked. And then maybe together we can get a win win. And then they say yes. And then when you open up that permission, that’s a wonderful thing. So maybe asking permission is a great example. The other thing I just want to just add on based on what a wonderful thing you said about reading people. There’s a great book. I’ll find it. I’ll put in the show notes. I think it’s called the power of body language or something to do with body language, right? One of the first books I read when I started looking into communication and that book helped me so much because 70 percent of our communication is a non-verbal. You know, the other week I walked in to work 7. 30 a. m. And I just said, good morning. I’m not going to say her name when the receptionist and said good morning. And the way she said it to me and the way she looked, I said, what’s wrong? And she just burst into tears, right? And then there was something and then the other receptionist there to help her. And I just knew if I just said, okay, good morning. Yeah. How you okay? Or I just walked upstairs. But I knew something was wrong just from the way she said it and her body language, her posture. And that is a powerful thing because our patients will give us these cues. Our colleagues will give us our cues. And I agree, not just the verbal communication, not what to say to the patient, how to say it, but how to read it. [Mehy]Agreed. And just say it. Try to find a way to say, because if you don’t say that your colleagues or patients, anyone around you, your partner, they don’t need to guess it. And so yesterday, I was actually shared this in social media because I found it very, very funny, but it’s actually something that I go through every day when you actually look at your nurse with the eyes. You’re expecting her to know exactly what you want. And we don’t really, a lot of the time- [Jaz]Telepathy. [Mehy]Expect people to do telepathy. We expect from people to do things that we never, ever told them to do. And you would think that you say it every day, but I assure you, there are things that you never, ever told them or ask them to do. And you’re expecting for them to do, and sometimes you go back to that, something you’re not perfect every day. And then you have those days that you don’t need to be calm and every day. There are things that happen in your life that when you sit down in the chair where you can need to put your facade off perfect person but inside you’re still thinking about things and on your life and your car broke and there’s a mouse in the kitchen. And there is the school is calling you to pick up your daughter because she’s sick, whatever and then you don’t have the rights, composite, and then you look at your nurse asking like, no, I try, I don’t want the micro particles. I know I want the macro, and probably actually that nurse never worked with you before. It’s actually a temp nurse that is just there. She doesn’t know anything. So I always say, just say, obviously in a very nice and polite way and something I learned very recent. People are happy in their jobs when they feel that they are treated as adults, and this is something that I learned from the employees from Google and Netflix and all these super fancy offices and they understood that people don’t care. If you give them free food, they have a gym, you have cinema, you have all this super cool things in their office. So if you don’t treat them as adults and you don’t give them this freedom, they won’t be happy. So just make sure you treat all your team as adults, as people with their own knowledge and capacity. And then you’re not trying to micromanage everything. And the same with your patients and the same way your family. When you need to make yourself, and we’re going to talk back to talking to kids, you need to, and this is what they say, you need to talk to them like adults, because you need to make them feel that they have an autonomy and they can do things on their own. So this is the way they’re going to develop as independent people, right? So it’s a little the same. And unfortunately, a lot of these big societies and governments and people that they try to control the way we work and live. They don’t treat us as adults, and this is what makes you not being happy or in your job or in your profession or in your life. When you start feeling like, okay, I am an adult and by adult I mean someone that can take his own decisions, then things I think go much better. [Jaz]Amazing. I think what we, I’d love to know now we’re going to wrap up and it’s been really nice to talk about all these themes that we don’t talk about enough. And every guest I talk with about the non clinical stuff, the directions we go in are just absolutely wonderful. Sometimes it’s about 20 percent crossover, but it’s always a themes that we just need to hear over and over again, right? Because just like we hear about the different bonding protocols and the power of etch and which percentage of hydrofluoric acids do you, we hear that over and over again. We also need to hear these themes over and over again. And I think what you brought was a lot of new themes today. So maybe thanks so much. I’d love to share with the Protruserati about your next event. I’m looking forward to joining. I know Andre Cardoso, George Andre Cardoso, my dear friend will be there as well, cause you’re bringing him there. Is that a surprise by the way? Am I allowed to say that? [Mehy]No, no. Anymore. No, anymore. We were trying to, by the way, I’ve got super inspired by you with your podcast. This is how I mean, I knew Andre, from the clinical side. I didn’t know the Andre coach side. So I heard him at your podcast. I fell in love and I said, you know, okay, I’m going to ask him and then I ask you, you know, I was like, hey, I think this is going to happen. And you were so happy. So, and there is there George Cheetam and Georgia, then this is also part of the panel. So there was a big restorative Kings, alumni and the faye Donald, one of the super cool hygienist in this country. So she’s going to bring that perspective so we have the different perspective from the clinic owner to the super associate hygienist to talk about teams. We’re going to be talking about a lot of what we’ve been talking today about communication between your team, how to, the feedback, receiving leadership management. So yeah. [Jaz]Is this something that you think people, dentists can bring their assistants, their nurses to as well? [Mehy]Yeah, I encourage this year and we even have like a super special prize for people that they want to bring their whole team. I think it’s like half price if you want to bring the whole team because I think it’s a very cool group activity where you can learn. I mean, if I could, I would bring my whole team to all the courses that I do. Because it’s the real way that you can implement. So I think it’s a very good activity to do the whole group. So I encourage everyone. [Jaz]Tell us more about the activity in sense of what actually happens. What’s the actual format of the end? We touched on it earlier, but just to, cause there’s a few different types of events that you run, this one is the Dentorama, right? So. There’s the one that’s like the skits and the acting. Obviously you throw most surprises in, but then the panel discussion and audience, is that what to expect? [Mehy]Yeah. So this is the drama is done at the Royal institution in Mayfair, which in central London, which is an incredible venue, has a very majestic theater. If you’ve seen the images that we have in our socials, you can see a little bit of the setup. So what to expect. And then it starts like going to a theater literally like this. We’re going to start with a show where going to put some scenarios, all is in a comedy. So it’s very fun. We write this together with Nicole O’Neill, which is super talented actors and theater director. So it’s very, very well curated. So you’re going to have a lot of fun. And then after that, takes like 10, 15 minutes, 20 minutes, depends on the act. And then we pass to the panel of experts, which will be debating about, and talking about all the dramas that we’ve seen during the act, and then we open up to the audience, we all share, we have then a break or perhaps, you’ll have some complimentary drinks and needles, and then we do this again. Where there’s another act so every act plus the debate is like an hour each and then after we would finish at nine and thirty there is a social in the same venue and then for the late ones the people that they want to continue also we are doing an after party and in another venue nearby so for people you know there are some people like they like to keep socializing. [Jaz]Something in it which is a very fresh approach to what you’re doing. Very much needed in the way of delivering. It is education, but it’s more than education. It’s talking about these higher level topics. It’s talking about team’s a great thing. So I’m going to pitch it to, even though we’re in Reading, the team, I’m still going to pitch it to them. I was like, listen, and I’m sure some of the nurse colleagues would love to come and they hardly get to go to these things. They really do not have that kind of fun that we do. And I think if there’s one event they attend this year, that really makes them feel like, wow, like, I can’t believe my practice took me here. I think that’s, this is going to be a very memorable one for them. [Mehy]100 percent is a huge favor that you can do to your team and they don’t get to experience. Unfortunately, a lot of our nurses and hygienists and therapy is the cool part of dentistry that for me is this conferences network meeting people that they go through the same struggles that you do or success. And it’s very special. So, yeah, I encourage. Bring your whole team. Anyone is more than welcome to join. Everyone will learn. It’s not an event for only dentists for sure. It’s actually this year we’ve designed one of the acts for hygienists and therapists. We talk about it and also we’re going to talk about the problems between dentists and nurses. We’ll have the two different kinds of dentists and nurses and how they treat each other. So the title is The Story Behind the Worst Dental Team Ever. So we’re going to concentrate all our savages situations in a few minutes. So it’s going to be intense. [Jaz]I think we’ll all be able to resonate with a lot of the themes that come across there. How can people book on? I’m going to put the link in the show notes. I’ll be there. I’ll be joining you guys in the audience and I’m very excited for it. If it’s anything like your previous event, I mean, I can’t wait. My only criticism maybe of your event was it literally like it flew by so quick. It was like two hours. Like it’s social already, which is great. I don’t know, don’t get me wrong. I enjoy the social, but it was like, everything just was like in the blink of an eye, I was like, wow, that was so engaging. So, it’s definitely a very fun day. What’s the website? I’ll put it in the show notes for anyone who’s on the laptop now. What’s the website? How can they come to the event? It’s 18th of October, right? Friday? [Mehy]18th of October, Friday. Doors open 6pm, so it’s after work. You can, the show starts at 7. And then, yeah, we’ll be there till late. The website is globaldentalcollective. com. You can get access to the shows and drama. From there, you can get the tickets. We’ve created a special discount for your audience, just for the protrusive podcasts. So we’ll share that, also with you. And then- [Jaz]Try and make it Protrusive. Because everyone’s used to just going and typing in protrusive and coupon codes. People sometimes go on like fashion websites and just accidentally type in protrusive because they’re just so used to using protrusive as a coupon code. So if you can make it that for everyone, they’ll do that. [Mehy]Perfect. And that’s going to be easy. protrusive as a code, and then you’ll get a huge discount. And we want to have as many people as we want. There’s like 400, respecting 400 people. So it’s probably the biggest audience in any one day conference in UK. So then the conference is going to be cool. [Jaz]Amazing. I can’t wait to see that. I can’t wait to see the Protruserati who come there. Please bring your teams. I’m literally going to message Zoe and the team now saying, ladies, do you want to, come to this? I think that’d be pretty, pretty fun. And I think now that we have the Elizabeth line, Reading and London, that’d be quite good for us as well. So that’d be good. Mehy, honestly, thank you so much for coming on, talking about these themes, talking about vulnerabilities, opening up about your past and your dips in that dentistry and then how engaged you are now and your sort of the work that you do, and also just generally thank you for the work you do. You, the Global Dental Collective is the GDC we actually need. I’m pretty sure when you came up with the name, you came up with a name. [Mehy]That was actually, actually, that was, yeah, that was Joe Lovett and it was a bit of a joke. And now we’re a bit of trouble because we can’t really use only the letters. So we’d see what we do with that. But they’re fine with that. They’re happy with that. So I think also, I don’t know if they like it or not, but it’s how it is. But yeah, we don’t want to compete with that. We just want to help. [Jaz]Definitely not. We have different purposes, but brother, thank you so much. I’ll put the links in the show notes. So it’d be great to see you guys there. And thanks so much for speaking about these topics today. [Mehy]Thank you so much, Jaz. Thank you for having me. Jaz’s Outro:There we have it guys. Thank you so much for listening all the way to the end. Hope you enjoyed those really hard hitting themes that me and may covered. And because you made it all the way to the end, if you simply answer the questions in the quiz below, now this is obviously accessible to you. If you’re on the protrusive guidance app, if you’re on a paid plan, you can get CE. or CPD for this episode. We are a PACE approved provider and it’s just a great way throughout the year to listen to podcasts and get CE. It allows you also to add in some reflections and that comes in your certificate so that you actually remember, ah, this episode taught me that and this is what I will change about my practice. Maybe after today you’re going to go get the book The Power of Body Language, by Joe Navarro. Or maybe you’re going to seek permission from your nurse, your dental assistant, and give them permission to give you feedback. Or maybe you’re just going to join us at those events in London in October and November that I told you about earlier. One is the Dentorama that Mehy’s involved in and of course the Treatment Planning and Communication Symposium on the 16th of November. Please do check out the links below for both those events and hopefully I’ll get to connect with some of you there. I want to thank the team. This one was produced by Gian. The CE certificates are taken care of by Mari, with very diligent quizzing and quality control from Krissel and Nav. Thank you again and I hope you enjoy this interference cast. I’ll catch you same time, same place next week. Bye for now.

Dive into the intriguing debate of bridges versus dentures for tooth replacement! Discover why implants aren't always the best choice and what factors influence decision-making. Learn about the risks and rewards of using a root-filled tooth as a bridge abutment. Explore the art of communicating treatment options with patients and hear wild case stories like roundhouse bridges. Plus, understand the balance of ideal treatments versus patients' budgets and preferences to enhance your dental practice.

Treatment Planning Symposium 16th November Hybrid event: https://www.protrusive.co.uk/rx Are you still afraid of raising the Vertical Dimension? You cannot break free from the shackles of single tooth Dentistry if you don’t get comfortable with vertical dimensions changes in Restorative Dentistry. https://youtu.be/Nb-LTyzRKuU Watch PDP197 on Youtube In this episode, Dr. Jaz Gulati and Dr. Mahmoud Ibrahim  simplify the complex topic of increasing vertical dimension.  What is a safe limit of increasing the vertical dimension? They cover the essentials of joint health, muscle stability, and the importance of centric relation (does it actually matter?) Protrusive Dental Pearl: Use Duralay copings for guide planes to ensure stable dentures with a single path of insertion. While eyeballing the prep can be challenging, he suggests requesting acrylic copings from the lab for precise preparation. He explains that technicians survey models to identify undercuts and determine the path of insertion, and instead of manual prepping, he advises using lab-created reduction copings and acrylic jigs to simplify and accurately guide the preparation process.  Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode:  02:05 Protrusive Dental Pearl  Acyrlic Copings for Guide Planes 03:57 Dr. Mahmoud Ibrahim’s Introduction 06:05 Personal Experiences with Vertical Dimension 08:45 Challenges and Techniques in Vertical Dimension 14:17 Clinical Considerations (Restorative Dentistry) and Research 21:15 How to Assess OVD Loss? 24:35 Factors to Consider in Increasing the Vertical Dimension 28:41 Treatment Planning: Orthodontics vs. Restorative Management 32:21 Assessing Cases for Vertical Dimension 34:39 Joint Position and Vertical Dimension 39:47 Occlusal Appliances Prior to Increasing Vertical Dimension  45:26 Joint Relationship 50:49 Reproducibility and Stability in Occlusal Planning 53:00 Summary and Final Thoughts on Vertical Dimension This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. AGD code: 180 Occlusion  (Occlusal therapy) This episode meets GDC Outcomes A and C. Dentists will be able to: 1. Explore key clinical considerations and current research in restorative dentistry related to vertical dimension, enhancing your ability to make informed decisions. 2. Understand the relationship between joint position and vertical dimension, and how to assess and manage this relationship effectively. 3. Recall the guidelines for assessing the vertical dimension and the safe limit for this in dentate patients. If you liked this, you will also like Functionally Generated Path Technique – Conforming to Funky Occlusions – PDP168 Click below for full episode transcript: Teaser: But it can also help you stage treatments, right? It's a great technique to learn because it allows you then to stage those more comprehensive cases. So one of the most useful things about opening vertical dimension is gaining space for your material without having to prep teeth that they're usually already quite worn. Now that is a huge benefit for anterior teeth, but also can come into play on back teeth. Jaz’s Introduction:I used to be petrified of opening the bite, i.e any kind of treatment that would increase the patient’s vertical dimension would be way out of my comfort zone and it really made me worried like, is the patient going to adapt? Are they going to get joint pain? Am I perhaps increasing the vertical dimension too much? And so for the first 18 months of my career, I was focusing on conformative dentistry. Not having to change the vertical dimension, just accepting the patient’s bite for what it is and working with it. You know, a filling here or a crown there. And back then it mostly was small and large composites. I was still finding my feet, I wasn’t confident with indirect dentistry, and like I said, occlusion is confusing to all new grads. And I remember the first couple of cases where I started to think about this, whereby the only way I can solve this patient’s occlusion and give them what they want, be it denture or some new restorations, would involve opening the vertical dimension. I was speaking to my principal and I said, okay, are you sure this is going to work? Is it going to be okay? What if the patient has pain? And I think a lot of you have also been through this and some of you may be in that place right now. Which is why with Dr. Mahmoud Ibrahim, we’ve created this episode specifically devoted to vertical dimension. Look, this short episode, whilst we’re going to really make sure it packs a punch, is not going to allow you to open the vertical dimension, but it’s going to inspire you to think about it more. It’s going to give you some guidelines in terms of how much you can raise the vertical dimension. Is there a magic number? And how is it measured? Which patient should we not be thinking about raising the vertical dimension? And which patients may need an occlusal appliance, and for how long, before we were to think about raising the vertical dimension for that patient. Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. It is Occlusion Month, it is September 2024, devoted to occlusion, and this episode we’ve got something for everyone. We’ve got something for the new grads, really reconnecting with those feelings I used to have as a new grad. And for those of you who have a little bit more experience, we’ll give you a few more ideas about me and Mahmoud record the vertical dimension to make sure we have to do as little adjustment as possible. Dental PearlNow, every PDP episode, we give you a Protrusive Dental Pearl. This pearl is inspired from the last episode about digital dentures. It was a request we had in a YouTube comment. I’d mentioned these duralay copings for the guide plane. So know how we do dentures. We try to build in these guide planes to allow your denture to have one path of insertion. And that generally gives you a more stable denture, one with more retention and stability. But again, when I was a new grad, I had no idea about how to prep for a guide plane. But I’d like to share with you now how I do it currently. And this is something that we can all do. And I think if you get your technician involved, it makes your life a little bit easier. I mean, yes, you can eyeball it. Because as long as you can remove that maximum bulbosity of a tooth, and you can really picture that path of insertion. And kind of like when you’re doing a bridge, you want the surfaces nice and parallel against each other. But sometimes that’s tricky to do, which is why you can ask your lab to make some acrylic copings. So what’s happened is that the technician has surveyed the models, found out where the undercuts are, decided on the path of insertion along with your guidance, and instead of you just prepping the guide planes, you can ask for these reduction copings, whereby the technician has actually prepared the guide planes on the model, actually drilling the teeth on the model, and making this acrylic jig so that all you have to do is put the jig on the tooth, and it will highlight the exact area you need to prepare. So those of you who are listening and commuting right now, if you’ve never done this before just visualize a little like a sleeve going on the tooth and now the belly of the tooth is exposed and you just get like a nice long carbide bur and shave that away until you’re flush against the coping. If you’re watching on Protrusive Guidance app where you can get CPD as you know or on YouTube then you would have seen a visual for that. It’s a cool thing to do, especially when you have loads of guide planes to worry about. As always, as was the theme of the last episode, make sure you have a good relationship with your technician. Have a chat with them. Pick up the phone before you do this kind of work. Anyway, back to occlusion now. Enjoy the episode and I’ll catch you in the outro. Main EpisodeDr. Mahmoud Ibrahim, my occlusion brother from another mother. How are you doing, my friend? [Mahmoud]I’m good, man. How are you, Jaz? You good? [Jaz]I’m all bunged up, as you know, with the kids getting one bug to the next bug. But the show must go on, as they say in Hollywood. And so will this educational podcast. Today we’re talking about the vertical dimension of occlusion. And I think it’s fair to say, Mahmoud, that this topic, podcast topic, when I suggest it, just scared us just a little bit, because it’s so vast, like, how do we even begin to tackle this topic? So, what we did is we came up with some sensible topics that we think is realistic to cover in a podcast, that’s going to give a lot of value to everyone who makes, listens to this, and can take away enough nuggets to really improve their standard of dentistry. So we have a tough one. For the very few people, maybe they’ve just googled occlusal, vertical dimension occlusion, they’ve landed on our podcast, and then you, Protruserati, hello. [Mahmoud]Hello, hello. [Jaz]Just tell us about yourself, Mahmoud. Remind us about you as a clinician, what you stand for, your love of occlusion. [Mahmoud]Ah, yeah, so, I think I said before, I’m almost into my 20th year now as a dentist, which is actually terrifying. But, yeah, it’s been fun. [Jaz]You don’t look a year over 19 years, mate. [Mahmoud]I was expecting that, I was expecting a receding hairline. Can you see? It’s actually got me a little bit paranoid. I’ve got my like, bun cause I’ve got a midlife crisis going on. But yes, my sort of obsession, I will call it an obsession cause that’s what it is with occlusion probably started about 15 years ago. And cut long story short, my sort of area of passion and dentistry is sort of minimally invasive cosmetics. So I’ll do a lot of direct composite work. That’s sort of where my artistic passion lies. I adhere to a lot of occlusal teachings or philosophies that we came up with and we teach together. So we’ve had an amazing couple of years of creating OBAB and lecturing around the country. So it’s been awesome, but yeah, that’s where my passion lies really with a bit of ortho thrown in because it kind of combines both those aspects. That’s me in a nutshell. [Jaz]Great. And the topic to cover today in terms of where to start is, I just want to share my feelings when I tap into my feelings when I was just maybe a year or two qualified. Like everything when you’re a newbie dentist is, and so right, it should be, is very much, you are conforming. So let’s just go back to basics, conforming versus reorganizing. Conforming meaning, we are not really changing the bite so much. We are working on one tooth, we are working on two teeth maybe, and we’re keeping the general features of the bite as they are. And so, as a young dentist, that’s what you do. And then so, what I found is, when I came to a case where maybe even to think about increasing the vertical dimension, opening the bite, all these terms that we use, right, that used to scare me. Did you also have that? [Mahmoud]Yeah, I mean, when we mentioned this topic, we’re going to cover this topic, and you said it scared us both. I think it’s a combination of, yes, it’s a vast topic, and there is very little consensus on this topic, but also there’s a little bit of PTSD, because, at least for me, the first time I was let loose on patients was for complete dentures. I don’t know if it was the same for you guys, but that was, it was complete dentures the first thing you do. I assume the rationale is because you can’t kill a patient with an alginate mold. But at the same time, you’re getting thrown at the deep end, the tutor’s talking to you about vertical dimension and about centric relation, and you have no clue what’s going on. You’re just about competent enough to get most of the alginate into the tray, right? And most of that into the patient’s mouth. So it gets sort of, vertical dimension and centric relation get enshrined in your brain into this area that gets triggered and you crap your pants every time you hear the word, right? [Jaz]And back when you were learning complete dentures, Mahmoud, it wasn’t centric relation, it was retruded contact position, right? Shove them all the way back. So things have changed a little bit since then as well. [Mahmoud]Yeah, yeah. And equally, just like centric relation, some people hold it in this like regard as it’s like it’s magic, right? Vertical dimension also in some people’s view of the world holds a sort of magical place where you’ve got a path you’re going to find the vertical dimension for that patient, right? Like it’s an immutable number and you’ve got to find it I think as we go we’ll discuss how maybe that’s not quite as strict as it must be although I do want to say that throughout this podcast. I’m going to be talking mostly about a vertical dimension on dentate patients, okay, or with a edentulous or mostly edentulous patients, it’s slightly different. [Jaz]And when you’re a student learning complete dentures, or when you’re doing complete dentures, you don’t really worry so much about increasing vertical dimension, because ultimately it’s in wax, and it leads beautifully to the dentate patient. Now, we have a dentate patient, let’s say the patient is worn, it’s one thing when you gain enough knowledge to know that actually, this is pathological wear, and one of the treatment modalities we may use here is to increase the vertical dimension, a. k. a. open the bite, right? That’s one treatment approach you may use. But, to think about the downsides of opening the vertical dimension, right, is the following, right? By opening the vertical dimension, okay, some of the fears that I used to have is, will the patient be able to tolerate it? Will I cause more damage to the TMJ? Am I going to lose control of the occlusion? These are all things that I didn’t know what they meant when I was there, but I was just worried about doing it. But the other thing which we don’t talk about enough is, if you open the vertical dimension, so let’s say the patient’s teeth are all meshing together, and they’re worn, and then on an articulator you open the pin, and so now the teeth are all apart. How do you get the teeth back together again? Well, we’ll talk about DAHL. Let’s ignore DAHL for a minute, okay? Suddenly, you go from someone needing, potentially, 28, 32 restorations to get everything to meet together again. Suddenly now you’re looking at a huge case as someone with not very much experience, right? So that’s why it was a scary thing because it was like a big thing. You’re now committing to treating not necessarily 28, 32 teeth, but at least one whole arch, right? So, for example, you open the pin and then you treat an entire upper arch and get everything to meet together again. The stakes are much higher, just like you said. The fees are higher, the stakes are higher. And again, so many unknowns, unknowns. When we are learning this stuff, because it was like, whoa, what if I mess something up? What if the patient comes back and has TMJ pain? What do I do? Now, I know we can talk about how to mitigate that, and how to discuss it, but for me, and I saved DAHL for later, for me personally, Mahmoud, I’d love to know how you got into it, but the first time I increased the vertical dimension on a patient, non denture patient, was using the DAHL technique. And this was just like two years, one and a half years qualified. And for me, this was like a great gateway drug into occlusion, right? Because you get to open the vertical dimension, but you can do it as little as six teeth, for example. And you’re like, wow, look, I just treated a wear case kind of thing, and I opened the vertical dimension, and guess what? The patient comes back, and they haven’t exploded, and they haven’t complained of all sorts of headaches, and jaw issues, and adaptability issues, and their speech has adapted well. And suddenly you think, hey. Maybe I’m overthinking this. [Mahmoud]Dentists love to argue about semantics sometimes, right? So, I’ll see a case of someone’s posted where they’ve done DAHL, right? So they’ve opened the vertical dimension on the anterior six teeth or whatever. But the patient actually had some posterior tooth wear, right? And then the dentist gets crucified for doing this by people who don’t yet realize that what the patient, the dentist has done is open the vertical dimension using DAHL as a stepping stone. But maintain the space posteriorly using composite or GI. I personally don’t like to use GIC because it wears away too quickly. But you can just use composite buttons at the back. And then you maintain that way and then you can, and then essentially it becomes a conformative case, right? You can do a quadrant at a time. So not only is it a great gateway, to doing, to increasing the vertical dimension or doing slightly more complex treatment on- [Jaz]And thinking more comprehensively, thinking multiple units. [Mahmoud]But it can also help you stage treatments, right? It’s technically, you’re not doing DAHL because you’re not allowing the overruption of the back teeth, the intrusion in front teeth, et cetera, but it’s the thought process is there, or at least the methodology is still, it’s still there. It’s the great technique to learn because it allows you then to stage those more comprehensive cases. And even though I’m now at a stage where, yeah, I can probably do the full arch at once, I actually prefer not to. It’s just too stressful. There’s just too many variables. Why? I’d rather get the anterior sorted, put the posterior stops in, and then I can take my time, the patient can take their time, and I can just put- [Jaz]And either convert the right side and then the left side, or the top arch and then the lower arch, right? [Mahmoud]Exactly. [Jaz]And so I would say that one thing that perhaps you can recommend, Mahmoud, to everyone is if you’re new into dentistry and you want to delve deeper into this, find a patient with localized anterior tooth wear that is suitable for the DAHL technique and if you’re worried about tooth loss, opening the vertical dimension, then that might be a good case to obviously helping the patient, right? There’s localized wear that needs treating and the posteriors are relatively unworn in those cases, which is why it’s such a minimally invasive and fantastic treatment modality. I know our friends across the pond may not believe in it as much, okay, based on our experience. But in Europe, Scandinavia, it’s very much done a lot and done to a very high standard, and it’s quite predictable from what we see. And like I said, once I started to DAHL cases, and my patients didn’t implode and explode and all that kind of stuff, nothing bad happened. And I was like, hey, hang on a minute, maybe now I can, also opened the vertical dimension for my other dentate patients and I was less it kind of gave me the hunger and the bug and the confidence to go further into my occlusal studies. [Mahmoud]Yeah, there’s a there’s a wonderful two part series actually on protrusive with crash here about DAHL. So if you’re thinking what on earth are these two talking about go back watch those. [Jaz]It’s like episode 16 and 18, way back when, like 2019 or something, right? They’re very old episodes, but still very relevant. Tiff Qureshi, absolutely always got time for him. Just a brilliant person to listen to. So go back to those old episodes, they’re very, very informative. Everything to do with DAHL. [Mahmoud]It still applies today, so, old or not, old is gold. [Jaz]So Mahmoud, I want to start by just talking about, I guess the direction we want to go in is, opening the vertical dimension as a focus because there are some patients that may benefit from decreasing the vertical dimension So if you’ve got someone who’s let’s say got an anterior open bite, right and they’ve got a longer lower face height then they may get orthodontics to intrude the back teeth, okay? And then you actually are decreasing the vertical dimension on that kind of patient. But really, the most common time that we, as restorative dentists, what we’re doing more often than not is we’re opening the bite. That is much more common. We’re thinking about vertical dimension considerations. We’re thinking about wear cases. And, but generally in the umbrella term of changing the OVD. I’m just going to talk about three papers and we’re not going to go into too much depth about them but three papers that we recommend in our courses. And just mention about them I’ll put some of these in the resources. But one is from the International Journal of Stomatology and Occlusion Medicine it’s by Rebibo et al. And it’s vertical dimensional occlusion the keys to decision, we may play with the video if we know some of the game’s rules, which is really nice, okay? So, nice way to do it, and it gives us a little table in there to consider, okay, at what point when we consider increasing the vertical dimension, at what points would we consider decreasing the vertical dimension? So that’s a good one, and I’ll put that in the resources. Another paper is in the Journal of Prosthodotics. It’s occlusal vertical dimension best evidence consensus. And this one looks at over 27 articles and talks about the whole resting face high and generally the occlusal vertical dimension, a very step back, holistic approach, and that’s a good one as well. But the main one I want to talk about is the Australian Dental Journal. It’s called Clinical Considerations for Increasing Occlusal Vertical Dimension. So once again, we’re kind of focusing on increasing vertical dimension. Otherwise, we’d be here for five hours on this podcast, talking about increasing, decreasing, resting face height, all that kind of stuff, right? And this is a review. By Abduo and Lyons, okay? And I love this paper, and one of the things it suggests, having looked at everything, is we can actually get away, and something that Tif talks about a lot as well, is increasing the vertical dimension is very predictable, okay? Especially up to 5 millimeters, okay? So, my question to you firstly is, Mahmoud, what have you found in your experience of opening the vertical dimension in terms of tolerance and acceptability to our patients and any side effects of patients. [Mahmoud]Okay, so from my personal experience, I have at most had a patient be aware that their bite is slightly different. But I’ve never had anyone complain of pain, you know, as long as the contacts are well distributed across the arch, I’ve not had anyone complain of pain or TMJ issues or muscle issues. The one thing we got to bear in mind is when you look at increasing the vertical dimension and you’re looking at a full, full denture case, right? Why do people think that’s low risk? It’s because everything’s in plastic, right? You can just take it out, bin it, and you’re done. Why do people think increasing the vertical dimension in a dentate patient is higher risk? Because you’re usually putting in restorations, you’re doing irreversible stuff. However, you do have one thing on your side. It’s that those teeth come attached to PDL, right? There is a study, I think the author’s name was Helsing, which is really cool. But they found that even if you increase the vertical dimension on dentate patients, they use a splint up to six millimeters. A single closure, right, a single closure could actually help them get the muscles to re adapt to the new vertical dimension. So the patient closed once, and as soon as he opened the freeway space, if you like, or the resting position, the manual re established a millimeter and a half below the level of the splint. So while you still have PDL, your muscles can adapt very, very quickly. Okay. So we have that. [Jaz]Can you just make that point tangible about the whole freeway space element? So just make it a different way to just make it tangible for our younger colleagues. [Mahmoud]So for example, let’s say for me, if I’m biting together, okay. That’s my occlusal vertical dimension. Now, just to clarify occlusal vertical dimension, lower facial height, not exactly the same thing. Okay. Some people get that confused as well. Lower facial height from base of nose to your chin. If you choose to measure the vertical dimension as that, then they are the same. But actually you can measure the vertical dimension using any two fixed points. One on the maxilla, one on the mandible. Okay? So, let’s say my vertical dimension when I’m closed is this. Now, if you ask me to just let my mandible hang loose. [Jaz]Give it a number for those listening just as arbitrary number. So we can then, let’s call that 60. I don’t know what that means. Call it a unit of 60 millimeters, whatever. Okay. Let’s call it 60. [Mahmoud]60. Yeah. That’s that, mouth closed. [Jaz]Teeth together. MIP. [Mahmoud]Okay. Now with my jaw resting, so my resting vertical dimension, yeah, let’s say I’m open five millimeters or whatever. Yeah, even though dentures we are trained to give them three millimeters freeway space, but it’s variable. So now, at rest- [Jaz]And as a rule of thumb there, just because we’re talking about this, right, so as a rule of thumb, because you said 65 here, so 5mm freeway space, which is a complete denture term anyway, right, but let’s just go with it, resting face height, you’ve got that 5mm freeway space. In class 2 patients, you tend to have more, in class 3, you tend to have less, as a rule of thumb. [Mahmoud]Actually, I’m a bit class 3, so I’ve probably got like, let’s say it’s 62, yeah? [Jaz]Okay, so you’re resting, your lips are still together, your teeth are just apart, as they should be. Lips together, teeth apart, it’s the rule of life. And now your measurement of those two fixed points is 62 millimeters. Carry on. [Mahmoud]Yeah. What they did is then they get a splint, and the splint opened my vertical by about 6 millimeters. [Jaz]Measured where? Where was the six? [Mahmoud]At the anterior. [Jaz]So measured at those, at the anterior, exactly. Because if you have it, Mahmoud, tell us what would happen if you put six millimetres of a splint measured posteriorly. [Mahmoud]You’d have like 18 or 15 millimetres at the front. [Jaz]It’d be a huge, huge, huge block at the front, basically. So, a really important thing to establish and the guideline that I talked about from the Abduo paper is that actually increasing the vertical dimension to 5mm is very safe, very predictable in restorative cases for those cases that need it, right? Is 5mm is measured at the front, okay? As an anterior reference. So, thank you for clarifying. [Mahmoud]So now, they put the splint in, it’s open 6mm at the front, so when I bite together on the splint, I’m at 66 millimeters vertical dimension. Yeah, as soon as I bite once my muscles readapt and then when I open and my jaw is resting I have two millimeters again- [Jaz]You’re 68 now. Now, there are limits here. It makes perfect sense now, but anatomically there are limits, because sometimes you just cross that threshold where now we don’t get a lip seal anymore, right? So, there’s so many things to look at, and so, now that you mention this, it’s actually a great point to just to do a little mini deep dive into the paper, because there’s a really nice table in this paper by Abduo. It says, described clinical techniques for assessment for OVD loss. So how can we look at someone and say, hmm, this patient has lost OVD, which by the way, just because someone’s lost OVD doesn’t mean that we need to restore OVD. There’s other parameters we’ve got to look at, patient age, function, aesthetics, and we’ll come on to that. But one way is pre treatment record. So, for example, if you’ve got some old models, which no one has, okay, but for some reason they’ve got old models, and then you’ve got new models, and you see, oh yes, I can see that the vertical dimension has decreased, and that’s one way to assess it. The other one is, and this is just what they’ve listed, is measuring the height of the incisors, okay? Which they actually describe as a disadvantage is, it actually poorly represents the actual loss of OVD. So, think of that DAHL patient, okay? Localized anterior tooth wear, okay? That patient might have worn away their anterior teeth, acid erosion, attrition as well, and over time, the teeth have kind of alveolar compensations happened, they’re overerupted. The back teeth are still pretty much unworn. So, whilst the anterior teeth are 50 percent worn, The posterior teeth are only 5% worn let’s say, that patient has technically not lost any, much vertical dimension at all. So you have to be careful when we’re using the incisor height measurement when it comes to actually being reflective of loss of OVD, and Mahmoud please button and chime in at any point as I read through these. [Mahmoud]Yeah, no, I think, I see this a lot where they’ll say a patient has localized anterior tooth wear, they’ve lost OVD. They’ve technically lost in size or height and in some patients you’ll see that the overbite gets deeper. But if the posterior teeth are still intact, then they haven’t lost VDO. So does it matter? Well, it only matters in as much as I hardly, well, I don’t think I have ever treated anyone for a loss of OVD in a dentate patient because of tooth wear, okay? I have opened their vertical dimension. But it’s not because they’ve lost vertical dimension. It’s because it gives me certain advantages that we’ll cover later on. [Jaz]Absolutely. The other one is phonetic evaluation, and the thing about this is, again, it actually poorly represents the loss of OVD. The S sound is the closest speaking space that’s often used. It’s a reproducible technique, but it’s more useful in dentures rather than dentate. Patient relaxation is a tricky one because, A, it’s good because it ensures the lips are meeting and the lips are now involved in the facial planning as well, which we don’t want to actually increase, raise someone’s OVD beyond their lip seal. And that’s an important consideration, which I learned much a few years after qualifying actually, but there are disadvantages because minor muscle tension will lead to inaccurate measurements. Assessing the facial appearance, which like you said, is a bit arbitrary as well. Radiographic evaluation using Ceph. Obviously, if you’ve got access to one and doing orthodontic planning, it makes sense, but you need additional equipment for that. And then recording neuromuscular. So for example, EMG muscle activity is another one that’s used. But again, these devices are not often available, and a lot of expertise is required. And we don’t know how well this may represent the need for the patient to restore the OVD at all. It’s a tool. It’s a measurement. It’s objective data, which is good, and it’s accurate and reproducible. But again, they’re not often available in the clinical setting. So I just wanted to give a little overview of how we assess the OVD. But Mahmoud, forget the paper. What do you look at when you look at someone’s dentition and you have a wear case or not? What are the factors that you use to think about, okay, this patient would need increasing the vertical dimension? Interjection: Hey guys. It’s Jaz again for a quick announcement. It’s that time of year again for our annual live protrusive event. This year in London the Sheraton Skyline Hotel. We’ve got Dr Lincoln Harris from Australia and also from Australia Dr Michael Frazis. They’ll be joining me on Saturday 16th of November for a full day. Now, because you guys on the community couldn’t decide between the topic of treatment planning or failures, we combined them both into the Treatment Planning Symposium: Learning from Failures. So in the morning I’ll be kicking off showing you some my own failures and what lessons I’ve learned that I want to pass on to you. And the most unique thing about this is because I’ve been videoing my procedures for a long time some of these restorative calamities that I’ve made I’m going to reveal all. I’m going to show you all and how I actually fix them as well. that lecture itself will be worth your entire day. Then I’ve got Dr Michael Frazis talking about his failures in the last 10 years both in clinical and in communication. And what I appreciate about Educators like Dr Michael Frazis is their willingness to share failures and talk about it. And of course, the main event, the headline act, Dr Lincoln Harris. Last time, he was talking about de-stressing dentistry. This time he’s doing a treatment planning masterclass. We’ve actually got a live patient in store. I’ve taken the photos, I’ve got the radiographs, patient will be there with him live, and he’ll be interviewing the patient taking a history coming up with a treatment plan and communicating it to the patient live, on stage under real time conditions. And then he’ll talk about all his lessons for being an effective Treatment Planner and Communicator. The tickets are on sale right now and they are a ridiculously low price for an event featuring two international speakers. We also have a live stream so wherever you are in the world you can catch it all live including the live panel discussion the live patient and all our lectures on the day. So if you’re local, someone in Europe, please come to Sheraton Skyline Hotel on 16th November come and network and feel that live magic. But if you’re unable to attend, then we’ve got the live stream with the 30-day replay at a really good price. Got the early bird offer at the moment so head over to protrusive.co.uk/rx, Rx as in treatment right? So forward slash rx and the early bird offer ends this month so book your ticket now to avoid disappointment. Once again, protrusive.co.uk/x and look forward to seeing you there. [Mahmoud]Okay, so for me, increasing the vertical dimension comes because of usually one of three things, right? A, aesthetics. So a lot of these wear patients wants to have longer front teeth, right? They’ve worn their teeth down, they want to have longer front teeth. And what is the one thing I don’t want to do on a patient that has worn their front teeth short? I don’t want to, once I’ve restored them, to give them a deeper overbite than what they already have. Because that’s going to put the material that I’ve put on the end of their tooth at risk. A fracture, right? Because it’s in the way of how they want to grind. So one way that you can lengthen upper anterior teeth and lower anterior teeth without increasing overbite is actually opening the vertical dimension. So if you open the vertical dimension and then you can lengthen the teeth. You can maintain the patient’s pre treatment overbite. [Jaz]So if they had a 25 percent overbite to begin with, and you restore those anterior teeth, you can now go to a 60, 70 percent overbite. But actually, if you open the vertical dimension, you can maintain that 25 percent overbite. But now you’ve actually increased the vertical dimension. The downside being now that, okay, you need to think, you need to put your occlusion hat on, do more planning. If it’s not a DAHL, then you’re treating, committing to treat at least one whole arch. But this is where dentistry becomes more fun, right? It becomes more fun. [Mahmoud]You’ve got to remember, ortho is always on the table, right? So this becomes part of the conversation of the patient. A, do they need more teeth treated, right? If every single tooth needs treatment anyway, and the arches are fairly well aligned, am I going to try and intrude everything? No, it doesn’t make sense, right? Opening the vertical dimension becomes a much more obvious choice. But if it’s localized to the anterior teeth, the rest of the teeth are fine, then DAHL becomes an option, ortho becomes an option, and it’s a discussion to have with the patient. Now let’s just say the sort of general rule of thumb I use, if it’s localized to the anterior tooth, where I’m just going to lengthen the teeth, One good way to think about, cause you always get asked, well, how much to open the vertical dimension? If you open the vertical dimension in the front by about as much total length, you’re going to add. Then you’re probably not going to deepen the overbite very much. [Jaz]So if you need to add three millimeters of length, open the vertical dimension by three millimeters. [Mahmoud]Roughly. Yeah. And this leads us onto the second reason or a second advantage of opening the vertical dimension, because as we know, we don’t open straight down. When you open the vertical dimension, the lower incisor doesn’t drop straight down. It goes down and back. So what are you also gaining? You’re gaining a little bit over jet, right? So if I’m adding three millimeters of length and I don’t want to deepen the overbite, maybe I’ll open them up three millimeters. Sometimes that can create a natural contours though. Okay. Because you’re having to add a lot of material. So sometimes you can just open them up by two millimeters. Now you’ll say, okay, well you just said don’t deepen overbite. Yes, true. But I’ve also increased the overjet. So now that leads to a shallower angle of guidance. So even though the overbite might be slightly deeper, the angle of the guidance might be slightly shallower. So it might still happen. [Jaz]But how did you gain more overjet? Sorry, but did you increase the vertical dimension or not in that example? [Mahmoud]Yeah. Opening the vertical dimension, you will decrease overbite and you will increase overjet. Leading to an overall reduction in the angle of the guidance, right? [Jaz]And this is important because the kind of cases that we’re seeing where we have got excessive anterior wear, where we need to think about aesthetics and raising the vertical dimension are the cases whereby one of the etiological reasons they ended up in that scenario is because they had a lack of overjet. [Mahmoud]True. And a lot of anterior tooth wear cases end up becoming more class three, right? Patients become more and more edge to edge and you have no room to restore. Opening the vertical can actually allow you to gain a little bit of overjet in those cases. [Jaz]Make them more class one or tending towards class two. But I just wanted to highlight something important you said. When we have that sometimes tricky scenario whereby we’re thinking, hmm, can I manage this wear case purely restoratively? Or, should we bring in ortho? I just want to highlight a wonderful thing you said, okay? Like, which teeth need treatment? So, what really helps in my planning is I have the occlusal photograph of the patient. So, the upper occlusal photograph and the lower occlusal photograph. And then I will give it a traffic light system. Something I saw Basil Mizrahi do years ago, maybe 9, 10 years ago. And you put like a green light for this tooth just does not need any work. It’s a beautiful tooth, okay? Don’t touch it, okay? Unless you, there’s no reason to, there’s no need for treatment here. Amber means that, okay, maybe it’s got like an MO amalgam, right? It’s not what carries issues, but it won’t be the end of the world if you restart the clock and actually treat that tooth. Red means this tooth absolutely needs treatment, okay? And so if you’ve got lots of red and ambers, then maybe, and as long as the teeth are generally well aligned, then maybe this is a case for purely restorative management. If, however, you’ve got lots of greens and a few localised areas of red and ambers, then perhaps orthodontics can help you to improve those teeth, instead of having to restore a whole bunch of teeth that are green, that don’t need much restorative. Is this a technique that you use as well? [Mahmoud]Yeah, I mean, I don’t use the lights necessarily. I learned this from, I think, is it Spear that uses A, B and C teeth? Something like that. [Jaz]Ah, I think you talked about this before, yeah. Tell us about A, B and C teeth. [Mahmoud]It’s almost exactly the same. It’s like, I can’t remember which way it goes, but like, A teeth would be, look, these need treatment yesterday. B teeth are- [Jaz]Or maybe A is like, this is A plus tooth, this is a good tooth. Or maybe it’s the other way around, who knows? But the concept is the same, right? You’ve identified which teeth need treatment, which teeth don’t need treatment, and that is a useful exercise to do when you’re thinking, hmm, will we benefit from orthodontics or not? The other thing is though, if the patient’s got just like crowding issues as well as restorative issues. It’s just so nice for your occlusal planning to relieve the crowding and get everything lined up and those slightly over rupted teeth to be in line, just getting everything in line as a huge benefit and it helps us to gain the vertical dimension as well sometimes to restore that case. So Ortho I’m a big fan. [Mahmoud]One thing I do harp on about, but maybe too much is the inclination of the upper incisor. Okay. What I found at least is it’s actually very difficult to get a good sort of amount of overjet or freedom in the envelope on teeth that are retroclined purely restoratively. It’s just the shape you’re going to create is going to tend towards creating a restricted envelope because of where the tooth structure is. So proclining those teeth usually, or giving them a normal inclination with ortho usually makes the restorative occlusal planning much, much simpler. So if a patient has really retroclined or very upright teeth, I will almost always push for ortho, even if everything else is relatively well aligned. I think it has a huge advantage over managing those cases purely restoratively. [Jaz]As we say, there’s a lack of chewing space in those scenarios. There’s too much teeth bashing together at the front, or figuratively speaking, if you think of it like that. And that helps us solve our restorative cases so much better. So, so far we talked about how we were scared of raising the vertical dimension. Then we did it, and we realized our patients didn’t implode. We talked about DAHL as a gateway into doing bigger cases. We talked a little bit about the limits of raising OVD and really it’s case dependent, but five millimeters in the Abduo paper, and suggest that it’s very predictable. You mentioned a great reference about the six millimeter splint and how we have the ability to adapt. We talked about which teeth need treatment, which teeth don’t need treatment when it comes to ortho versus purely restorative debate. Then the other thing that we should really discuss in vertical dimension is in fact, before we come onto this, I feel like there’s more to come from you in the sense of what you were answering that question of what do you look at, right? So you already said, okay, which teeth need treatment, which don’t, but also you said overjet. What else are you looking at? [Mahmoud]All right, so we said the aesthetics we said essentially the anterior relationship and then it’s occlusal clearance or restorative- [Jaz]Space. [Mahmoud]Okay. So one of the most useful things about opening the vertical dimension is gaining space for your material without having to prep teeth that are usually already quite worn. Now that is a huge benefit for anterior teeth, but also can come into play on back teeth. And it’s probably one of the most common reasons you open the vertical dimension in relation to back teeth. It’s to gain restorative space, but you do have to be careful because as we already mentioned, for every millimeter you open at the back, You’re going to gain maybe two to three millimeters, depending on the geometry of the jaw at the front. So, if a patient needs restoration of the anterior teeth already, then that might not be such a big issue. But, you do sometimes get patients, especially erosive wear patients, that have localized posterior tooth wear. And your initial reaction might be looking at them thinking, yeah, I’ll just open the vertical dimension, right? But you’ve just got to be very aware of the fact that you’re going to gain a lot of space at the front. And if that patient has like a normal anterior relationship already, you’re going to end up creating a huge gap that you then have to fill with possibly restorations of very abnormal contour. Another case where either surgical crown lengthening or orthodontics need to be on the table. So it’s very important not to just, as soon as you see where you think I’m going to open the vertical. No, think about where you want the teeth first. So make, as in our friend, Michael Melkers says, how’d you want it to look? You want them to look like teeth. How are you going to make it fit? Your options are going to be open the vertical ortho surgical crown lengthening and then take it from there. [Jaz]And how do you mitigate the forces on those teeth as the final step? Hat tip to our good friend, Mike. We spent a good few days with him and Lane Ochi recently. [Mahmoud]Speaking of hats, has he taken any videos with the hat we gave him on? [Jaz]We sent him a nice little Yorkshire based hat, when we saw him in Chicago for AES, so I think he might have sent me a photo, it’s in my private stash, I’ll send it to you sometime. Right, so the elephant in the room now, Mahmoud, is joint position, right? Because I have worked with mentors and principals before who said, listen, Jaz, it’s, we’re overcomplicating it, right? Just open the bite. Give the patient enough contacts and the patient will find their own bite. You don’t need to worry about this old centriculation nonsense and deprogramming and don’t waste your time with these lucia jigs. Whereas there’s other mentors that we have which are, we must find, to the pinpoint precision, the centric relation or the patient will have a heart attack kind of thing, right? So, firstly tell us, when we’re opening the vertical dimension, why do we even need to think about joint position? Where does this come in? [Mahmoud]Okay, so essentially when you’re opening the vertical dimension, you’re going to establish a new MIP position that is slightly open from where the patient is now and ideally what’s happening is that the jaw is rotating open okay, the reason joint position becomes important is if that point of rotation is stable and repeatable then I can take the records on the patient, I can move them to the articulator, whether that be virtual or analogue. I can design the new vertical dimension, the new restorations or whatever. And then I can take it back to the patient and the anticipation is that it’s going to be fairly accurate. Especially if you take that bite registration. at the vertical you want the restorations made at. Okay, I think both of us harp on about this for quite a lot. Now, if that joint position is not repeatable [Jaz]So can we just spend a minute, just talk about that, because before we continue, because I think that’s so, so important, right? That’s a real takeaway from this podcast is, let’s say that hypothetical scenario, we’ve decided that we’re going to increase the vertical dimension here by five millimeters because that’s how we want to lengthen the teeth by about four millimeters or six millimeters whatever. And we’ve decided that we’re going to raise the vertical dimension by five millimeters because in this patient, it’s going to allow us to restore the aesthetics. It’s going to allow us to get more overjet and a better overbite overjet relationship and lots of the back teeth need work. And so we’re kind of doing a full mouth rehab here. But what we don’t want to do so just like we said in the last podcast something we must understand what it isn’t right and the opposite of it. So if in that scenario that patient who needs five millimeters opening, okay we instead send the technician a centric relation bite record, okay, with three millimeters opening, just because we said, okay, I’ll let the technician open up the bite to where we want to be, okay, and then we can wax it up, that is very error prone. Because the articulator is not the TMJ, it’s not the jaw, it’s not the patient, and so when they open up the articulator, that’s creating an error, whereas if we just send the technician the scan, or the stonebite records, the PVS records, wherever you want basically, with the exact vertical dimension that you want the patient to be, you’ve now eliminated the error of opening the articulator. And this has helped us both, and a lot of people, and what we find in the occlusal camps is actually this is a very verified technique, to send the technician the desired vertical dimension exactly. Don’t allow this error to be introduced in opening the articulator. [Mahmoud]What will happen then is you’ll get your MIP, your new MIP contacts will probably be very accurate. [Jaz]Extremely accurate. [Mahmoud]Getting the jaw to move or getting the articulator to move, there’s still error there. It’s not like it’s- [Jaz]And I just want to remember this case, like the first time I did this years ago, a young grad, and I did this, and I was just amazed. It was a DAHL case, again, venturing into tooth wear cases, opening vertical dimension, it was a DAHL case, and I got the patient to bite together, and I saw these six dots. I was like, what? Like, this is amazing. You use one dot, you grind it down, then you get two, then you get four, then you get two again, and then you get six. That was amazing. That was like, holy moly. Why didn’t they emphasize this enough in dental school kind of thing? [Mahmoud]Yeah. It’s secret weapon, right? [Jaz]But it doesn’t take secrets out. So everyone knows it. [Mahmoud]Yeah. But you then need to develop the ability to figure out how much room you need. So one rule of thumb, we already mentioned, maybe open the bite about as much as you’re going to add length. Second one is if you’re restoring back teeth, right? Consider what material you’re going to use and speak to your technician, right? Send them some pre op records. They’ll tell you I need to restore the upper and lower, I need four millimeters, right? You’re going to have to open at the back four millimeters. You know how much you need at the front, that sort of thing. [Jaz]And one thing we haven’t mentioned yet, it’s just important. The caveat dimension is, are patients that haven’t had any issues from raising the vertical dimension. That’s kind of because in our assessment of that patient, we check for joint health, we check for muscle health, and we excluded those patients that are not suitable because either they have active temporomandibular disorders, or muscle pain. They have a joint position that’s not reproducible. So all those things that we talk about in Occlusion Basics And Beyond, live course, online course, that kind of stuff, we have ensured that. And that’s how I got into managing TMDs. Because as part of the Occlusion 101, Lesson 1 is, make sure the joint’s healthy. And I started to learn about the healthy joint. And then I started to help my patients with not so healthy joints. And now it’s amazing which way that your career and interest take you, but it’s all starting in that initial assessment. Which is another now point to discuss is the use of occlusal appliances prior to raising vertical dimension. Lots of my colleagues trained at the Eastman that this is standard protocol. Give everyone a stabilization splint, test the vertical dimension before committing to it to make sure there’s no issues. And I find that, that’s perhaps not necessary with some other occlusal appliances available because it is predictable. But when you have that patient and you’re in doubt, what a wonderful thing if you’re in doubt for that patient because they’ve failed your assessment. They had this dodgy joint, for example, for want of a better word. For that patient to test with an occlusal vertical dimension appliance is a great thing to do because you’re not doing anything damaging or reversible. [Mahmoud]Yeah. Again, I think we do this a lot as dentists and we tend to use maybe sometimes the wrong words or hyperfix it on semantics. Yeah. So, you’ll see a lot of people say, oh, I want to test the vertical dimension with a splint, right? The patient has no joint pain, stable TMJ, stable muscles. Fine. I want to test the occlusion on a splint. What you’re testing is probably the stability of that patient’s joint in terms of, I can give them the splint, I can perfect the occlusion on it, and then I’ll see them again in three months and the occlusion’s the same. What you’re not testing is whether the canine guidance or whether this angle of disclusion or whatever is going to work for the patient. You’re not testing the vertical dimension or the occlusal scheme as such, because you can do things in a splint that you cannot do on real teeth, or it’s very difficult to do on real teeth, or the consequences will be difficult, right? You can get away with a lot more on splint than you can on the edges of your ceramics or your composites. Using splints is a great way of testing the stability of someone’s stomatognathic system and knowing that their occlusion isn’t going to change on you and they’re not going to develop pain or discomfort from what you do. Interjection:Does occlusion confuse you? Do you feel like you need it taught in a way that actually makes sense? Whilst we have got a great online course, we totally understand that some people learn better from in person and hands on programs. Our Basics of Occlusion face to face course will be two enlightening and fulfilling days with nine hands on activities. We cover crowns on dodgy occlusions. No other course in the world covers this and it’s so important because you know what? None of my patients have a perfect occlusion. We often have to work to a non ideal occlusion, but we want everything to work for the longest time possible. We will teach you occlusal assessment, occlusal diagnosis, and occlusal planning to make sure your crowns last, your patients are comfortable, your bonding doesn’t chip, and you can go to sleep at night not worrying about restorative failure because our occlusion course is all about improving the predictability and longevity of our work. The next date is 11th and 12th of October, 2024 in Surrey, UK. And you can book this now via www.protrusive.co.uk/boo. That’s BOO, Basics Of Occlusion. [Jaz]And I very much echo what Lane Ochi with over 40 years of experience working Beverly Hills taught us recently at the course and reminded us is that he will not treat a wear case or he’ll seldom treat these big cases without the patient first wearing an occlusal appliance. Now, not necessarily in the old school way of testing the OVD for six months with an ugly appliance to make sure the patient doesn’t implode. It’s more, can I trust this patient? Is the patient understanding what I’m saying? Are they taking some ownership of their own part in the destruction of their teeth in those high force patients? Relaxing the muscles, okay? And just seeing, okay, is this patient someone you want to take on for comprehensive dentistry ? And then when they come back, could be as soon as four weeks, could be six weeks, could be two weeks, okay? Everyone’s different, could be many months. And there’s a whole thing we can discuss here. But, I am very much the same, is that if I have a high force, destructive patient, I don’t want them to be a patient of mine unless they’re going to commit to wearing an appliance afterwards. And the only way you’ll know they’re wearing an appliance afterwards is they’re willing to wear an appliance and wear it well beforehand. [Mahmoud]Absolutely. And it gives you a chance to get to know them, know what they’re like, know that you want to work with them because these cases can go on for a long time. They can be stressful. And in a way, the more teeth you do on a patient, the higher your risk. It’s just the way it is. It’s just a game of numbers, right? So I said this to a patient earlier this week actually, where I can treat more of your teeth and it will give you more control. It gives me more control of what’s going on. Yeah, and I need that to manage your bite and stuff. But at the same time it means I’ve treated more teeth, right? There’s more of my work in there. So just the probability, the pure probability of you having something chip or break goes up. And I’ll usually say, having one or two things go wrong every one or two years that we need to fix might well be the case. Are you okay with that? To date, that has not been my experience. It’s far less than that. But I want the patient to go in prepared. Okay, because if that does happen, and they start having a hissy fit, then you’re going to be in for a hard time. That was my intention. [Jaz]It’s about identifying those high risk red flag patients and make sure they’re managed well. And you have that kind of conversation that, okay, you’ve destroyed your God given or evolutionary driven enamel and dentine. Enamel being the hardest thing in the body. You’re going to do the same to my restoration, so A, you’ve got to pay every time you do it. But also, let’s protect us by having this occlusal appliance. For those patients who attrition is a big etiological factor, for those patients whose attrition is not a big factor, it’s more erosion, then that’s a lower risk patient, it’s a different kind of patient. But just to give a flavour of what we’re thinking, what Lane Ochi meant when he said that at the lecture. So, back again to joint relationship, okay? What’s the disadvantage of potentially just, opening the patient up on articulator willy nilly without worrying about where the condyle is. [Mahmoud]Okay. So yes, we have a lot of people doing that and saying that. Now that on its own should tell us that, okay, it, it kind of works. I can explain to you why it works, right? Why it can work. Most people who do have a shift between their centric relation position and their MIP position in terms of the condyle that changes within sort of an eighth to a millimetre. So one eighth of millimetre. That’s it. Okay. So the condyle doesn’t move a lot. Now imagine you got this patient, they’re in MIP. While the teeth are still in MIP, you’re just going to take them on your articulator, you’re just going to open things up, and you’re going to fill the space with restorative material, and you’re just going to do a DAHL treatment on this patient three to three in composite. Now, what’s going to happen when the patient is only contacting on their front teeth? Generally speaking, the condyle is going to seat, right, to an extent. And then one of two things is going to happen. [Jaz]What does that mean? Because I’m thinking for our younger colleagues, they may not know what that means. [Mahmoud]Okay, so you’ve essentially now created a tripod, which is basically the same thing as a deprogrammer. You’ve put a fixed deprogrammer in their mouth and the lateral pterygoid will relax and the contraction of the elevator muscles will take the condyle from being somewhere on the eminence up into the fossa, okay? Into its more- [Jaz]Stable position. Or the ball has now sat into the cup, in the socket. So the ball goes into the socket nicely in a snug position, aka centric relation. So that’s what we mean by when we say the condyles have seated. They’ve gone into their stable position. It’s like when you put an egg into a cup, it falls into one position. It’s a bit like that with a joint. It’s a simplification model, but we get the idea. [Mahmoud]Yeah. And obviously, you know me, like I like to overthink things and do these sort of mind experiments. Now, does the condyle always seat all the way? No, if you have overerupted posterior teeth or a really steep curve of spee, right? One of the back teeth might hit first before the condyle is fully seated, okay? And then that may become the patient’s new learned MIP, right? Because that’s how most of us work. If our condyles are seated and we close, we hit one tooth or two teeth and our lateral pterygoid is programmed to bring the jaw forward until we hit more teeth, right? So that may well become their new MIP position. They’ve developed a new interference to closure, the lateral pterygoid has become programmed to create a new MIP somewhere, right? And it happens to hit your composites and maybe one or two other back teeth and then things may be settle. Okay. That may be one way that things work when you open in MIP, the other way it might work is in fact the condyle does fully seat and it just so happens that your composites, your DAHL composites are big enough that even though the mandible has moved back a little bit, it hasn’t moved back far enough to fall off of your composites. [Jaz]But now instead of all six teeth hitting, you might just have a couple of teeth hitting. You should just DAHL that in to get even contacts everywhere. [Mahmoud]Exactly. Right. That’s why you’re reviewing the patient and that’s fine. The problem is, and I had one case that really scared me, right? No, I didn’t treat the patient, but I was doing my normal sort of occlusal assessment. This kid. He was a kid, he was like 4, he had like a five millimeter shift between his MIP and his seated condyle position. Yeah. I had to use my entire wad of the leaf gauge almost. It’s even more than five millimeters. It’s a huge shift. Right? So imagine now you take someone like that and you just open them up on your DAHL composites in MIP and they get deprogrammed and all of a sudden they’re condyle seat fully. So they’re probably only going to have ARBs, massive AOB, you’ve just treated the patient, they’ve lost their MIPs, maybe you can get it back, maybe not. And now you’re stuck. This patient probably needs ortho, maybe even more complicated. So it’s more predictable to design your OVD increase from a seated condylar position. However, for the majority of patients that have a small shift, the consequences of not doing it may or may not be. problematic, but it’s just so easy to screen at the very least, right? Use a leaf gauge, screen the patient, find out how big is their shift. And if it isn’t massive and you want to do it in MIP and adjust it, fine. For me, if I’m doing that, I might as well take the central relation bite at my desired OVD, like we just said, have the wax fill in the space. Design my restorations and then know that on the day that I do the composites, at least my new MIP contacts at the open vertical dimension are going to be so close to ideal. My adjustment time is going to be minimal. And I know that the condyle isn’t going to seat anymore, or at least not much more. Okay, let’s not pretend we’re machines, but it won’t be much. So yes, I will still bring them back in for review in a week, two weeks, six weeks, whatever it is. But the adjustments are still going to be minimal and you’re asking the patient to adapt as little as possible which is always going to mean fewer issues. [Jaz]I think that the key word we haven’t mentioned yet I’m sorry if I missed it. We’ve said it is reproducibility, right? So the ability to reproduce the bite, so for example, the patient bites get and sometimes the patient’s muscles get tired when they’re opening closing and then if you’ve done a major change that sometimes they bite together and don’t quite know where to bite together. But if you can just guide them either through a leaf gauge or gently by hand into their near enough their stable condyle position or CT position, centric relation. Then you can kind of guide them, and it’s reproducible for us. It’s reproducible for us, reproducible for the patient. So if you ever lose control of the case, this is what I aim for on the articulator in my wax up, and this is what we’re going for. And that’s when the ball is in the socket. And so, reproducibility is great. I agree that it’s not a magic position. And even Manfredini and other authors call this a utility position. It’s very useful for restorative dentists to allow us to plan our dentistry around this position of the condyle. So, most schools of thought, most schools of occlusion would condone, if you’re raised in the vertical dimension, do so, do all your planning in the centrifugal or stable position. Other schools include neuromuscular, whereby they’re finding the rested length of a muscle, and you’re going with that. And you know what? That works as well, okay? So if you want to use that method, that’s good. I think the ability to get an even bite left and right, and patient comfort, and as long as the patient can find the same position over and over again, is probably more important than which method you use. But certainly in the major occlusion schools, using central relation is accepted, and when we’re raising the vertical dimension, we may wish to use it rather than what we call arbitrary, rather than just opening up willy nilly. Two downsides of using central relation is, A, that patient, like you said, has got a huge shift, okay? A, you’re making them more class two, okay? So, aesthetics, and also, what are you doing to their airway? So we may choose to, in that patient, use an arbitrary position and hope for the best and try and make sure we’ve got nice coupling of the teeth on the wax so that the teeth can kind of find their own position. There’s only one place the teeth fit together, basically. But that’s a whistle stop tour of vertical dimension. I’m just going to check my questions again, Mahmoud. But, Mahmoud, any other reflections? So we covered about the limits of raising vertical dimension. And we talked about whether it needs to be in centric relation or not, and I would say that yes, ideally it should, but you can get away without. It’s just an element of risk involved, how much risk you want to take. In some patients, the risk is calculated, and you may get away with it. In other patients, you may wish to program that in, and I mean, you certainly tend to plan to CR. Any other points of assessing or increasing the vertical dimension? [Mahmoud]I’ll just quickly sort of summarize a couple of things, but also add the note about relapse, right, because that comes up a lot. But we’ve all, Jaz went through the article that says increasing the vertical dimension up to about 5mm is fine in the anterior, but you do need to make sure that the patient has healthy, or at least stable, TMJs beforehand. Otherwise they do not pass go. And, you know, Jaz has a wonderful, wonderful bit in OBAB teaching how to red light, green light the joints. There is currently no evidence that it’s bad for the TMJs to open up the vertical dimension as long as it’s healthy beforehand, right? And there’s no evidence that it’s bad for the muscles either. I mentioned the Helsing paper and the adaptability of the muscles. Now, and this relates to what I’m going to talk about next, which is relapse. And if you think about it, what’s happening to the muscles when we open someone’s vertical dimension? You’re essentially stretching the elevator muscles, right? The medial pterygoid and the masseter muscles. You’re stretching them. [Jaz]And more stretched than they were before. Because sometimes it’s not really stretching. It’s sometimes restoring the length. Because if someone’s bunched up and overclosed, and the muscles like scrunched together, you’re actually making them the right length. It’s like going from a fist to an open palm, rather than stretching it per se. But yes, the concept is the same. [Mahmoud]Correct. Let’s assume a patient has a vertical dimension that is working for them. And you now then forcibly open that vertical dimension, you’re going to be increasing the muscle length. Okay? [Jaz]Yes. [Mahmoud]And that is why people say that any increase in vertical dimension will relapse, right? Because the muscles want to maintain their contracted length. So, essentially, they close the vertical dimension back in. And it’s not like they jam the teeth back into their sockets. But you get the whole alveolar complex moved. And it’s been shown that that happens over a period of three to four months. Okay. And it actually just generally goes unnoticed by the dentist and by the patient. Bite force actually changes when you open the vertical dimension up to a certain point. So if you open someone by about five millimeters, you’re actually going to increase the maximum bite force they can generate. But again, that goes back to normal ish in about three to four months. And also anyone who’s watched our canine guidance versus group function lecture on OBAB will know that if you take someone who’s got group function and then you give them canine guidance, yes, their muscle activity might actually go down for a period of time, but after about three to four months, things again because of the adaptability of the system will go back to normal. So it’s all of these things that, at least for me, inform my philosophy of how long do I leave someone in provisional when I’m opening the vertical dimension. The number of three to four months keeps coming up, depending on how risky the case is. That’s about how long I will leave them in provisionals for, because I’ll know that most things I’ve changed have normalized. And if by that point they haven’t broken anything, nothing’s come loose, then I’ve got a good ish idea that I’ve created a scheme that at least works. [Jaz]So in the highest X cases, higher risk patients, not only are we utilizing a technique of a occlusal appliance in the pre planning phase, relaxing their muscles and testing compliance, but thinking about provisionals for a longer time as well, which also tests the vertical dimension increase, which we said at the very beginning, in once the patients have got healthy joints, you’ve established that it’s okay to proceed. We shouldn’t be as scared as we used to be because it actually is tolerated really well. It’s very predictable. It’s great to increase the vertical dimension in the appropriate cases. It’s when we have more fun, we get to do more units, do aesthetic dentistry, apply it, treat wear cases. So thanks for that whistle-stop tour. Like, we could go on and on about vertical dimension. There are whole continuums and days dedicated to vertical dimension. But if anyone’s got any questions, please do comment below. But Mahmoud, thanks so much for joining me again on this. So next time in the series, we’re covering how to, and this is a nice clinical topic and really real world applicable, how to minimize adjustments. We don’t like doing beautiful restorations and hacking them and grinding them away. So we’ve got a episode on direct restorations, how to minimize adjustments, and also indirect restorations, how to make sure what we get back from the lab means that we’re doing the least amount of adjustments possible. So we split it into indirect and direct. So I’ll catch you in those episodes Mahmoud to share more occlusion goodness. Thanks so much. [Mahmoud]Catch you then. Jaz’s Outro:There we have it guys. Thank you so much for listening all the way to the end. Thanks as ever to Dr. Mahmoud Ibrahim, who you should check out on Instagram. I put a link to his profile in the show notes. This episode is eligible for CPD. Protrusive education is a PACE approved provider. And all our quizzes, when you submit them, has a little box for your AGD membership where it’s relevant. Our CPD Queen Mari is going to email you a certificate every time you complete an episode and so throughout the year you can easily rack up 40 to 50 hours. So the value for money for a Protrusive Membership is absolutely phenomenal, I’m sure you agree. So if you’re not already on it, go to protrusive.co.uk/ultimate. That gives you access to all areas. All our masterclasses and every month we add new content. You can use the app on the App Store or the app on the Play Store or the good old fashioned laptop on the website protrusive. app. I hope you’re enjoying Occlusion Month so far. If you’ve got any recommendations for topics, we always like them. Please do put them in the chat wherever you’re watching this. And if you are jogging or chopping onions, thank you for doing those things as you listen to Protrusive. I want to thank Team Protrusive whom without this would not be possible. And all the premium members of the app who are on a paid plan because you are the ones subsidizing this podcast and allow us to go episode after episode and spend the time to create this content with the PDF transcript, the premium notes, infographics, and the bespoke videos that we make. Thank you so much once again. I’ll catch you same time, same place next week. Bye for now.

Plant it low and watch it grow? Is that serving our patients? Should we keep our crowns flat to avoid ‘interferences’? How about guiding teeth – how can we recreate and build in guidance and the correct cuspal inclination in our indirect work? https://youtu.be/b2KA84dXhnI Watch PDP196 on Youtube As part of Occlusion month I am joined by my dental technician Graham Entwistle and Occlusion geek Dr Mahmoud Ibrahim. We discuss foundational occlusal concepts relevant to our daily indirect restorations. Protrusive Dental Pearl: Bleeding papilla? Use the HOW technique to QUICKLY stop bleeding – insert a Wedge obliquely (Haemostasis with Oblique Wedge technique) as taught by Dr Sunny Sadana from Drecomposite.com Treatment Planning Symposium 16th November HYBRID EVENT Basics of Occlusion Live 2 Day Hands-On Course with Jaz and Mahmoud Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 0:00 Introduction 03:31 Protrusive Dental Pearl 05:16 Introduction – Graham Entwistle + Mahmoud Ibrahim 08:25 Guiding Teeth 11:40 Why is Guidance important? 16:35 What information should we provide our technicians? 20:00 Excursions and Patient Case 28:00 Complex crown creation 33:33 To Facebow or not to Facebow? 34:40 A Technician’s POV 49:50 What is the Technician aiming for? 51:06 Perfect Contacts – technician perspective 53:23 Final Thoughts This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject code: 180 Occlusion (Occlusal functional concepts) Dentists will be able to: 1. Understand the importance of guidance and occlusion in crown design, ensuring restorations contribute positively to occlusal function and patient well-being. 2. Improve communication strategies with dental technicians, including providing crucial details such as shim holds and occlusal plane guidance, to ensure optimal restorations. 3. Make informed decisions about the distribution of occlusal forces to prevent damage and maintain functional integrity in prosthetic designs. If you liked this episode, you’ll love PDP137 – Q&A with a Dental Technician Click below for full episode transcript: Teaser: If there's one thing people take away from this podcast, it's this point right here, which can easily be missed, okay? When we send a bite to our technician, whether it's a physical bite or a digital bite, more often than not, okay, it's wrong. Jaz’s Introduction:Welcome to Occlusion Month on Protrusive Dental Podcast 2024. I’ve just been a little bit excited for this theme. It’s one of my favorite themes to discuss because it was Occlusion, learning Occlusion. It’s what allowed my dentistry to become more fun. Allow me to move away from single tooth dentistry and through a series of episodes this month, we’re going to help you do the same. Ultimately occlusion is just really good restorative dentistry. It’s part of the package, but It’s perceived as it’s like this dark art, this incredibly confusing thing. I think sometimes it’s pitched that way to sell more courses, etc. But me and Mahmoud want to convince you that occlusion is easy. It can be simplified. Have faith, stick with us this month, and we hope to demystify some elements of occlusion. In today’s episode, we’re covering a theme whereby when you have a guiding tooth. Now, when I said guiding tooth, what did you think of? You probably thought of a canine, canine guidance. So let’s talk about that scenario, okay? Let’s say you’re replacing a canine either with direct restorative material or a crown. Crown’s easier to discuss. If you’re replacing a canine with a crown or even an implant, how do you design the occlusion on that tooth? How do you ensure that you get the correct guidance from that tooth. Now, actually the real world scenario is not canine guidance because very few of our patients are actually canine guided. Most of our patients are in some sort of group function. And so let’s say the next time you’re replacing a molar or a premolar, you check the occlusion beforehand, you get the patient to grind left and right, recreate their power functional movements. You see these wear facets lining up and you realize that this MOD amalgam that you’re about to replace with an overlay or a crown is actually serving that patient in their occlusion. That tooth is being used as a guiding tooth. So you’re probably thinking, okay, so Jaz, where are you going with this? The theme of today is how do we ensure that that is replicated in the final crown? Do we want it replicated in the final crown? Because let’s agree on one thing, right? If a molar is a guiding tooth, it’s involved in group function, and now you’re going to put a crown on it, do you want that tooth just to be completely flat? Of course you don’t, that’s not adding anything to function, it’s not serving the patient anyway. So really what it boils down to is how do you get the lab to give you the right anatomy to give you the right occlusion? Both in static and in dynamic, i. e. moving the jaw around. Which is why I’m joined by not only Dr. Mahmoud Ibrahim, but also one of the technicians I work with, Graham Entwistle. He does all my overlays and vertiprep crowns, and he does a wonderful job, and he has his own ideas and philosophies around occlusion. And so I’m so grateful that he joined us today. Some of those episodes in the past where we’ve had a technician, including him when he came on an episode we did, Five Things Your Technician Wished You Knew. They’ve been received really well. We need to do more collaborative episodes with technicians. Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. This episode is eligible for CE or CPD. We are officially PACE approved, so all the docs in the states and around the world can also have that validation, and we submit it to the AGD on your behalf as well. The way you get CE or CPD for listening or watching these episodes, It’s through our app, Protrusive Guidance. If you’re on Android, make sure you make an account on protrusive. app first, probably the best way. Go on that website, make an account, and then you can use that login on your app that you download from the Play Store or from the App Store. Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl. Today’s one is really cool. I think you’re going to really love it. It’s very, very applicable. When you have that gingiva that just does not stop bleeding and it’s really annoying you and it’s ruining your day, it’s ruining your plans. What are you going to do? You could use some astringent, you can maybe get a cotton pellet, soak it in ViscoStat™ Clear and apply some pressure for three minutes, or you can get your laser or something fancy, but a really easy thing that you could do that every dentist in the world has access to is use a wooden wedge, but not in the way that you think. You see, this is called the HOW technique. H O W. It stands for Haemostasis Oblique Wedge, as taught to me by Dr. Sunny Sadana. So a little turban tip to Sunny. So what you do is if you have a papilla that’s bleeding a lot, instead of inserting the wooden wedge, it has to be a nice meaty wooden wedge, instead of inserting it in like the normal way, right, when you go completely through, from the buccal to the palatal, for example, this time you’re going to angle it so the tip is angled towards the gingiva. Can you imagine it being angled down towards the gingiva? Now, you’re going to get your tweezers, the back of the tweezers, and push. What you’ve essentially done is you’ve kind of stabbed the gingiva. Can you imagine just the gingiva being stabbed? I jokingly call this in a WhatsApp group, I call it stab-o-dontics. But you know what? How is probably a nicer way to frame it. And what you’ll find after about a minute is that the bleeding just stops. The vessels are essentially temporarily occluded or the pressure just stops the bleeding and it can get you out of jail. If that’s not tangible enough, the second part of this pearl is that I will be adding a video. The video will first go on Protrusive Guidance. Because that’s where everything always goes first, to our community, the community of the geekiest and nicest dentists in the world. And then I’ll add it on YouTube as well, so do check that one out. If next time you’re stuck with a bleeding papilla, use the how technique with the wedge in an oblique fashion. Hope you enjoy this episode, I’ll catch you in the outro. Main Episode:Graham Entwistle and Mahmoud Ibrahim. Welcome back Protrusive Dental Podcast. Today’s a special one. We don’t usually do like a, well, I don’t want to call it a three way, but let’s call it a threesome. threesome, a dental threesome. Good to see you guys again. It is a special because very rarely do we get to have a technician input. So it’s great, Graham, we’re always privileged to have you speak. Mahmoud, always a pleasure. And it’s a great topic because it’s something that we don’t talk about enough, right? Guiding teeth. Okay. And we’ll talk about what guiding tooth is and basic crowns. Now, before we hit the record button, there was a few things that we discussed, right? Between us three, we have 10 kids, right? With most of the heavy lifting being done by Graham with five, 10 is good. It’s probably the most number of children, most number of offspring on this podcast ever in one show. So Graham, how on earth do you still have a pulse? How are you still sane? How do you still produce wonderful crowns that you send me. How does this work? [Graham]I’m very lucky. I’m graced with a wonderful team at home and within the laboratory now. And without the support I wouldn’t be able to do it. So, I’ve only got those people really to thank for my sanity [Jaz]And Mahmoud, what do you do to keep sane, my friend, from your lovely three children, by the way? What do you do to keep sane? [Mahmoud]Oh, well, I mean, similarly, you’re only as good as the team around you. So, yeah, at home, my amazing wife is always there making sure I’ve got the brain space to do what I need to do. For me, it’s things like I play basketball. So that keeps you saying it’s something about sport, competitive sport. When you’re there, you literally have no space for anything else in your brain. That is a huge for me. Once a week, I need that. [Jaz]Well, my son now is in the holiday club. I’m recording in the gym. I’ve never done this before. So I’m recording in the gym, little quiet, quiet area. And Ishaan’s at his holiday club, four hours. Don’t worry, Graham. It won’t take four hours. I got a lots crowns and stuff to make, lots of wax ups to do. But we’re talking today about guiding teeth, but while he’s in holiday club, I’ll give you a flavor of my week, last couple of weeks, right? My son, my youngest son, Sihaan, has got moderate sleep apnea. He wakes up every 90 minutes, okay? And a lot of the times, I need to go downstairs and do a milk run, right? Wash the bottle, put some milk in, microwave, bring it back up, give him some milk, right? So, he’s one night, I woke up six times to go downstairs as a zombie, make some milk, right? And then twice, my five year old decided to have growing pains. Twice, at one at two a. m. and one at four a. m., started crying with growing pains. So, this is my sleep deprived. If anyone asks you why Jaz, why are you sleep deprived? It’s not because I’m working too much. It’s because of parenthood and all the wonderful things that come with it. But anyway, I just thought I’d- [Mahmoud]Have you thought about putting a microphone [inaudible]- [Graham]Always something. Always. [Jaz]When was the last time, Graham, you had like a full night’s sleep without any disturbance? [Graham]Actually, the weekend just gone, my wife and I, we actually went to London for the weekend, childless for the first time in seven years, so we had an amazing weekend. [Jaz]Well, that’s why. [Graham]So, yeah. [Mahmoud]It’s funny how you pay for a hotel somewhere abroad just to sleep. [Jaz]The other one is the irony of people who are desperate for sleep trying to beg those who don’t want to sleep. Okay, to go to sleep. So that’s the irony. But anyway, enough about parenthood and sleep. I just wanted to share a little bit of a father-isms with everyone listening today. Guiding teeth now to talk about the scale of this issue Graham. I thought I’d ask you something what percentage of of the work that you get. Firstly, first question is what percentage of the work you get is single crowns? [Graham]So that’s 70, 70 to 75 percent actually. [Jaz]It’s the bread and butter, right? So bread and butter. And equally for us as dentists, yes, we like, we’re into occlusion. We do more wear cases. We do the lovely work, but our bread and butter, our bills are paid with single crowns, right? So what now here’s the next question, Graham, follow up, right? What percentage of those single crowns in the posterior, so in the posterior region. Okay, what percentage of those single crowns are not likely involved in some sort of guidance, i. e. when the patient bites together, grinds left and right, okay, they are not involved in guidance. So for example, how many of those patients are in beautiful canine guidance, and really you can get away with a lot there. So what percentage are not involved in some sort of occlusal guidance? [Graham]Probably about 50 percent, again. [Jaz]Fascinating. I would have thought it would have been less. I would have thought that posterior teeth are more, cause like to find that perfect canine guided patient is not so common. However, sometimes you have a patient with a canine premolar, premolar, and then the second molar isn’t involved in any guidance maybe, and so maybe that’s what you’re referring to. That’s interesting. Mahmoud, any insight on that? [Mahmoud]Well, I think the question probably should be, A, how many crowns do you design to be in guidance versus how many do you design to purposefully avoid contact in movement? And is that usually just something you’re doing or do you normally receive some sort of instruction from the dentist as to what they want? [Graham]Yeah, so normally I get asked to put teeth in a guidance kind of feature within the occlusion. Generally, if you’ve prepped well enough and give me enough space, I can put a tooth that doesn’t go into any sort of guidance, occlusion itself anyway. So Jaz’s question is a bit difficult to answer actually on that front, because it’s how I make it for the most part and whether I think it should be guiding or not as well, and sometimes, say to my clients that this four could probably do with being like in a guidance itself and share some of the forces with some of the other teeth, because the occlusion is like all over the shop and obviously this tooth is being restored for a reason. And the teeth around it are going to be restored for a reason. So can we make actually the situation better for the patient? So yeah, there’s always lots and lots to actually think about, although you’re just looking at some teeth on a cast, but actually it’s not quite as simple as that. And can you improve things for that patient? [Jaz]What percentage of occlusal prescriptions does a dentist tell you about, not only just occlusion, but then do they actually extend and continue on to say whether they want the tooth in guidance or not want the tooth in guidance or any sort of input into the guiding part of the occlusion rather than just the static? [Graham]I think I’ve only really got a handful of dentists with probably [Mahmoud]They’re all called Jaz [Graham]The knowledge of the guidance itself and what they want. I think a lot of them just kind of leave it to myself to make those decisions for them. [Jaz]Fascinating, isn’t it? Fascinating. So let’s talk about why this is important, okay? So when you have a single crown in an otherwise dentate patient, lots of teeth, okay? Simple one. Let’s start basics for the dental students, young dentists, okay? When you do a crown, okay, it would be a disservice, right? Let’s agree that it would be a disservice if you give the patient a crown and it’s completely out of the occlusion, like way out of the occlusion by a millimeter, like it’s just completely not contributing to the patient’s chewing, the patient’s clenching, it’s just not helping the tooth. And yet, when you fit the crown, the patient says, oh, it feels great. It feels as though I’ve got hardly anything at all. And the patient will be happy, right? But actually, you have done a disservice. But if it’s just one tooth, and I’m not condoning this, by the way, but if it’s just one tooth in the entire mouth, then you might get away with it. I’m trying to say that patients are very adaptive, very tolerant, and you might get away with it. But suddenly, when you have less and less teeth, right? And suddenly, the right side molar is the only molar in contact, and you don’t give that tooth some sort of occlusion. Then you’re really disservicing our patient, right? So just starting with basics, occlusion is important at the very basic level just to at least get a tap tap tap. And then we’ll talk about excursions. Mahmoud, anything to add on that? [Mahmoud]Well, kind of like what we say in terms of why bother, the tooth will just erupt into occlusion or whatever and as you say when you’re dealing with simple cases single teeth, it’s fine. But if you ever want to get into doing more interesting dentistry, veneers, the restored, the rehab cases, et cetera. You need to start worrying about these things because you can’t do a full arch of preps and say, leave it lightly out of inclusion. It doesn’t work like that. And it’s building the skills in the small scale that you can then translate onto the bigger scale. [Jaz]Graham, when you’re designing, when you don’t have any instructions given to you, let’s say you’re replacing a first molar crown. So you’ve got the crown prep. Okay. The dentist has sent you in A3, E max. That’s it. Right. What’s your stock? Just tell us, think out loud, what are you thinking in terms of when it comes to the occlusion and the anatomy? What’s your thought process? [Graham]So, my initial thought, so it’s going to be a monolithic crown, and I want to make it look like a new tooth, but obviously you can’t go too far with that, so you’ve got to make it look like it’s in that arch. At least somewhat, or it has been part of that arch, although everything else is gone. [Jaz]What do you mean by that? Extend more about that, because I’m loving what you’re saying, but just tell us more about that. [Graham]So, you’ve got to make the occlusion look like almost the rest of the occlusion, but you want to give that patient something new at the same time. So you’ve got to find a balance between doing something that’s bling bling with all the details, all the cusps, every tiny little ridge, and something that’s completely flat without any occlusion at all. So you just got to really think about what points of contact you want on the tooth and how you can share the load between everything else, how light it’s going to be in that occlusion. Obviously, if your dentist has given you any instructions at all on like shim holds, and sometimes it can be really helpful, especially if digital bites aren’t always the best and like give you the correct position as such because patients can protrude forwards, et cetera, et cetera. So, but with Emax, generally we handhold everything anyway. So, that’s absolutely fine. But yeah, I’ll just look at the cusps and then we’ll just start doing a wax up instantly when we’ve got everything ready and just build up from there and we make our decisions at that point really as we’re building the wax into the actual. [Jaz]At the very basic level in this very open ended question, I appreciate it’s very imaginative right, but at the very simple level are you wanting this crown to be holding shim or not without any instruction from the dentist. What is your stock? A thought process. Are you checking with shim to make sure that the other teeth are holding shim as well as this one? Or do you want this slightly dragging shim or not holding shim? What is your like slightly dragging? [Graham]So I would like the tooth to literally just hold some resistance as I’m pulling through my shim basically. [Jaz]And then what about the guidance? Because if the dentist hasn’t told you anything, what are you looking at to come to a decision and say that? Hmm. I’m going to now wax it up into guidance or not. [Graham]So I look at all the wear facets across the arch, and I’ll just start hand manipulating basically the articulation of how the jaws actually work in how everything moves and does it need to be an occlusion generally a six I wouldn’t have put in a shared occlusion unless it’s a lone standing tooth along with like maybe something in the anterior region. Just mainly help the function and the longevity of the tooth. But yeah, on the whole, I generally wouldn’t put a molar into that situation. [Jaz]I think the reason why you’re saying that, Graham, is we know that molars are not great with lateral forces. They’re better in compression, and our materials are better in compression, something Mahmoud always raves on about, right? Teeth are better in compression, materials are better in compression, so I understand that logic. But sometimes, when everything is shared, Mahmoud, why would you want to recreate a guiding tooth? My question to you is, what are the features you’re looking at to think that, okay, when I send this up a first model to Graham or my technician, I’m going to actually write a few sentences to tell him to recreate the guidance, because surely for the longevity of the crown we’re thinking hang on a minute if we just okay at the one end of shoddy dentistry, keep it totally out of occlusion that crown might just last forever. All right, okay, but it’s not really contributing much to the patient, but on the other end you’ll you have it in all sorts of horrible occlusion and it’s completely too much occlusion And that’s the other side and you’re there adjusting it for ages. So what are the what’s the middle ground? What do you aim for? [Mahmoud]Well, ultimately, I think it all needs to start with examining the patient, right? So the same tooth with the same fracture or decay or whatever it is might not get the same prescription depending on what the rest of the teeth look like and what does the patient do with their teeth. So you need to start by, first of all, looking at the patient. Do they actually have any wear on their teeth? Now, if they do, and there is wear on the tooth, you’re restoring in sort of these guidance, right? The patient is grinding on this tooth and you’re going to restore it. You need to ask yourself, do I want the patient to continue to be able to do this on my restoration? And some might think, well, no, obviously you don’t want that. But actually, again, there’s a question to be asked because if you remove the guidance off of this tooth, yeah, and you create a flatter restoration, patient can’t grind on it anymore. Guess what? That grinding force is going somewhere else. So to give you a hypothetical example, your patient has a crown on an upper canine and an upper first premolar already. And they’ve got decay underneath the crowns, and you’re going to replace them. When you do the occlusal examination, you find that when they do grind to that side of those crowns, they’re touching both those crowns, and there’s actually some mild wear on them. And you think, okay, what I’ll do is I’m going to make my life really easy. I’ll change the crowns, and I’ll just have it so it’s canine guided, right? We know that canine guidance is panacea, right? Just give it canine guidance, the patient’s going to stop grinding. It’s absolute nonsense. What you’re doing when you’re removing the guidance off of that premolar is you’re adding that force that was going on it onto the canine. Can the canine handle it? Maybe, maybe not. It depends on how much decay there is, right? So you need to make a clinical decision and pass that information onto your technician as to whether you want to move the guidance maybe solely onto the canine, or do you want to maintain it the way it is? Because as the force is shared, each tooth is less, is getting a smaller share of the total force. Does that make it a bit clearer? [Jaz]Mahmoud, that reminds me of the lecture that you have on OBAB of converting canine guidance to group function. Okay, and why would you need to do that? It’s exactly that principle. You have to look at the biomechanics of tooth. Can you know, you’ve got to think about where is a load going? And you have to kind of become an engineer to think about this. And also, obviously the other thing, obviously we’re talking about grinding. The other thing that the slopes of these teeth contribute to is function. The slopes allow the jaw to find the home position and outside in. And so if we did deter too far away from there and suddenly every tooth is that gets restored. We’re just making it flat, flat, flat. You’re really confusing the patient’s cycle of function. So that’s to be said as well. But for just the bare basics, we want the tooth to be there, to be taking tap, tap, tap. Usually we want the tooth to contribute to occlusion. And then it’s a case by case decision making whether we would like to have this tooth in guidance or not. So that’s where we start first. Do we want to have guidance on this tooth or not? Maybe it was never in guidance before and you want to add it to guidance and then you’ve got to have that sort of prescription to your technician. The other thing which we haven’t, we’ve talked about but I just want to give an analogy is, and we see this on social media all the time, right, where we see a really worn tooth, okay, old amalgam, flat amalgam, okay, caries. The amalgam is removed, the cary is removed, rubber dam on. You see the most exquisite composite restoration on social media, right? Rubber dam is still on by the way, okay? And the anatomy is fantastic. It’s the anatomy that you would expect a seven year old to have, right? And there’s so many things that I, I wouldn’t say plagiarize, but I always credit my mentors who taught me this, but this is my own rhetorics, my own thinking, so I’ll, I’ll claim this one, right? And I’m always thinking, why are we giving a 54 year old a seven year old’s tooth? So I always think of the shape of a tooth in terms of an age, and I think we have to make our composite restorations, for example, appropriate to the age, but generally to that patient. More important is the patient, not just the number, but generally there’s going to be some physiological wear. We need to recreate that, okay? We need to look at the opposing tooth. And if the opposing tooth is very flat, very worn, we’re not going to be able to get away with having a very curvy and exuberant restoration on the opposing. So we need to make it fit in the arch, just like Graham said. We need to fit in that mouth, in terms of the opposing tooth. And then also make sure that it fits within the TMJ and muscles. So that, for example, one thing that you might not want to do, and here’s an anecdote for me, remember, nine, eight, nine years ago, I did an Emax onlay for a lady. Lower right molar, okay. This was in Singapore. Lower right molar. I bonded it in. Everything looked great. It was fantastic. Tap, tap, tap. Holding shim. Just like the other teeth. So it was shared. On that occasion, I forgot. Many years ago. I forgot to check the excursions. I saw her again for a reassessment in about four months, roughly. And we just got talking. It was part of my screening. Even then, I was talking about headaches and stuff. And she said, yeah, you know what? For about three months, I’ve been getting headaches. And I felt her muscles, right? And compared to the left side, her right side was really, like, tight. I could feel the tight bands on the musculature. And I was thinking, hang on a minute. Could I have contributed to this? So I checked the excursions, right? So she bit together and grind left and right. And guess what? Her jaw just could not move. It was stuck because the molar and the way that I designed it had too steep of a cusp or incline and the patient was what we call locked in. Okay, the muscles want to move, but they couldn’t. Okay, so what I did is I adjusted the occlusion what I should have done three, four months ago. And now the patient was able to freely move her jaw. Okay, and when I saw her again two months later. She’s like, whatever you did, my muscles feel normal again. My headaches are gone. And so that really served a lesson to me at that point. I’m not saying that everyone is acceptable to this. It’s a susceptible patient, but that’s a lesson of why we don’t want to overdo it and over go crazy on creating the cuspal inclines. Cause if now that’s the only tooth in guidance or stopping the jaw from moving, you could get fracture of the restoration, you can get the muscles being overloaded. And this is not the scenario that we want. Any thing to add on that Mahmoud? [Mahmoud]No, I think you covered it really well. The analogy is amazing actually, because a lot of the time the consequences don’t necessarily hit us unless the patient comes in, sits in the chair and says, what you did here is hurting, right? Any other consequences go unnoticed by us, but you could be doing all sorts of stuff. And actually a couple of minutes of just checking what the patient has and then communicating that to your technician and then checking it afterwards. You can avoid so many issues. [Interjection]Hey guys, it’s Jaz again for a quick announcement. It’s that time of year again for our annual Live Protrusive event this year in London, the Sheraton Skyline Hotel. We’ve got Dr. Lincoln Harris from Australia and also from Australia, Dr. Michael Frazis. They’ll be joining me on Saturday 16th of November for a full day. Now, because you guys on the community couldn’t decide between the topic of treatment planning or failures, we combined them both into the Treatment Planning Symposium: Learning from Failures. So in the morning, I’ll be kicking off showing you some of my own failures and what lessons I’ve learned that I want to pass on to you. And the most unique thing about this is because I’ve been videoing my procedures for a long time, some of these restorative calamities that I’ve made. I’m going to reveal all. I’m going to show you all and how I actually fix them as well. That lecture itself will be worth your entire day. Then I’ve got Dr. Michael Frazis talking about his failures in the last 10 years, both in clinical and in communication. And what I appreciate about educators like Dr. Michael Frazis, is their willingness to share failures and talk about it. And of course, the main event, the headline act, Dr. Lincoln Harris. Last time he was talking about de stressing dentistry, this time he’s doing a treatment planning masterclass. We’ve actually got a live patient in store. I’ve taken the photos, I’ve got the radiographs. Patient will be there with him live, and he will be interviewing the patient, taking a history, coming up with a treatment plan, and communicating it to the patient. Live, on stage, under real time conditions. And then he’ll talk about all his lessons for being an effective treatment planner and communicator. The tickets are on sale right now and they are at a ridiculously low price for an event featuring two international speakers. We also have a live stream so wherever you are in the world you can catch it all live. Including the live pound discussion, the live patient, and all our lectures on the day. So if you’re a local or someone in Europe, please come to Sheraton Skyline Hotel on 16th November. Come and network and feel that live magic. But if you’re unable to attend, then we’ve got the live stream with the 30 day replay at a really good price. We’ve got an early bird offer at the moment, so head over to protrusive. co. uk/rx. Rx as in treatment, right? So forward slash Rx and the early bird offer ends this month. So book your ticket now to avoid disappointment. Once again, protrusive. co. uk/rx and look forward to seeing you there. I’ve remembered another lady, really sweet lady. I’ve been seeing for just over a year now. And she had basically, she was gosh, maybe in her fifties and she literally had again the teeth of a seven year old, naturally. It’s a minimal wear, okay, in a physiological wear, but she was in her fifties. And because her teeth were too cuspy, her teeth had too much detail. It’s a bit like, imagine getting two study models that have got just too much detail. You can’t get the cusp to really fit in the fossa, because not enough wear has happened to allow it to sit together. So the consequence of that is that she had a messed up occlusion in the sense that she kept deprogramming herself, her bite kept changing, that was a reason she was referred to me. So, part of the therapy was, she had an anterior open bite as well, which wasn’t helping, but that’s a red flag, the fact that she had an anterior open bite and minimal wear on her back teeth, okay? So, the way I explained to her, look. You have a seven year old’s tooth. You have a 14 year old’s tooth, I used to tell her. And then once we actually ground in and equilibrated, gave her a stable occlusion, okay, that’s it. She’s now got a stable home. So we need a little bit of wear, physiological wear, to find our bite. And so one of the theories of why children brux is to actually, as the teeth are erupting, right, to come into occlusion, we need a bit of bruxism to actually move them into the right position, the arch, and actually get them to bed in and actually lock and mesh together. I just wanted to add that basically. [Mahmoud]It’s like using chewies, right? When you’re doing Invisalign. [Jaz]I like using chewies. Absolutely. Next question I had then, so we talked about what is a guiding tooth, why we should recreate guiding teeth surfaces. Okay. It’s part of being a conformative dentist. Okay. Conformative meaning that we’re trying to give the patient a similar bite to what they had before, because generally their bite is working for them. They don’t need any major dentistry. We’re trying to keep things simple and replace one or two teeth here, and therefore we don’t need to change 28 teeth here, and so trying to fit into the patient’s mouth, and so we are being conformative, and we make a decision whether we want to have guiding or not guiding based on what we discussed. Now, the next thing is, Graham, and correct me if I’m wrong, it’s much easier for me to say to you, please design this crown to be holding shim in static, but I want no excursions, okay? I’m assuming that is easier for you to design then, please make this whole shim, and I would like it to be shared in group function, along with the upper right premolar, first premolar, and canine. Am I right in saying that? [Graham]Yes, yes, you’re right, because there’s less to get wrong. Because obviously there’s lots of variables in how we make everything and how we receive the data anyway, so if there’s anything that’s slightly off, there’s just more chance of things not being quite how you’d like it. But from an actual technical point of view, when you’re doing the waxing yourself and you’re actually designing the tooth, it’s not such a big issue. You can design it really easily. [Jaz]But there’s more things that can go wrong. There’s you can miss the mark a little bit, get too much guidance on it, not enough guidance on it to share. There’s a lot of parameters, but yes, with the technology that you have articulator, it’s pretty good at. So trying to match the cuspal inclines of the adjacent teeth, right? [Graham]Whether you do it virtual articulator or by hand. Generally, I try to do everything with my hands still, everything’s still handmade and pressed, so it’s hand waxed. So, when I’m doing any sort of guidance, I try and get the most shallow guidance possible. So, I try not to make it any steep angles, so the most shallow guidance possible on everything. And I feel that that just really helps the TMJ. I think you’ve mentioned this earlier in one of your comments, which just really helps the TMJ to relax a lot more and not become locked in that function. But virtual articulators also depend on how you’ve taken and registered the bite clinically. And it can be a really big issue, especially if I’m doing a zirconia, for instance. And all of a sudden I’ll get everything back. I think it’s really gone really nicely. I’ll snap off all my supports once I’ve checked the occlusion. And actually a lot of cclusion is miles off, so then I’ve got to sit there grinding the crown in and that’s when it becomes difficult to put that function in as well because I’ve got a hard material now to work with and it takes a long time to adjust that. [Jaz]But in that scenario, when I have, for example, asked you to make sure that this distal buccal cusp of the first molar is in group function all the way along, in that kind of a scenario, what tools do you want from us as a dentist to make that easier for you? Would you, in that case, would you love to have a face bow on your favoured KaVo articulator to get this correct? Or do you feel as though you can get this correct just by looking at the cusp or incline of the adjacent teeth? How can dentists help you better to give them what they want in terms of the correct guiding tooth? [Graham]If you just tell me where the shim stock holds are, and then I can make sure that the positions of the teeth are correct. So, if I don’t feel it’s right from the position you gave me digitally or analog wise in, in your bite that you’ve sent along, you’ve told me where the shim holds are, and I can then put it on an articulator in that position with the holds exactly where you said they are. And I’ve got more chance of survival there and get it right. [Jaz]Can I just stop you there, Graham? Because I think I want to just double, triple emphasize this one point. If there’s one thing people take away from this podcast is this point right here, which is easily missed. Okay. So if anyone’s multitasking, please reeling back in. This is really important. When we send a bite to our technician, whether it’s a physical bite or a digital bite. And Graham will vouch for this. More often than not, it’s wrong. And what you’re getting, you’re having to do some adjustments to actually get it to look like what it should. So to give you the shim holds, it’s so incredibly important to make sure that you’re getting the bite that we are seeing. Is that correct? [Graham]Yeah, so it’s more helpful if you tell me where the shim holds are, if the patient’s got an anterior open bite, or just something about the bite, if it’s irregular. So most patients bite quite nicely in MIP. And I’ve got a natural home position like we’ve said earlier, but some patients have like interferences and they find that home position difficult. So when you tell me where the shim holds are, that’s very important. And it gives me the chance- [Jaz]To verify that the occlusion that we’re seeing on the patient is what you have on your desk. [Graham]Exactly that. [Jaz]Because if that’s wrong from the first position, then the whole case is wrong. [Graham]That’s right. And even with digital records as well, I’ll find that certain clients might actually give me a digital bite record where the patient’s actually like clenching and they’ve gone probably too hard on their bite and then obviously sometimes it’s the other way and they’ve gone too light. And as a result of them being too light, the jaw’s just moved slightly out of position and they’re just not in a natural position at all. So if I was to make something to that position, then it’s going to be wrong and you’re going to phone me up telling me, hey Graham, that bite was off. Actually, what you’ve given me was not so great itself, you know. [Jaz]So top tip is everyone get your shim stock out, get your Miller’s forceps out. And give upper right six holding shim against lower right six, upper right second premolar holding shim against lower right, whatever. And just to give you that detail allows the technician to verify that the bite that they have in front of them is the same bite that your patient has. Because yes, all sorts of issues with scanning the bites, all sorts of issues with physical bites as well. So that’s a top tip. So then to add on for that, as well as the good shim holds, what else could we be giving you to help you recreate that guiding surface on the tooth that we’ve just told you to create a guiding surface on? How imperative is it to have a facebow in your opinion, Graham, or are you thinking that you can create it just fine without a facebow? It’s a top question that we get for a single crown. [Graham]For a single crown in the posterior region. Don’t really need a facebow. It’s just my I mainly use that for the occlusal plane exactly to work out where that is. And it’s detriment for anterior teeth. Especially like when you’re trying to work hand. [Jaz]And when does that change at what point do you think that okay at what point how many units does it might change that you actually to get the predictability here? You may desire a facebow record from your dentist. [Graham]Oh, so like if we’ve got a posterior quadrant perhaps that’d be really helpful, helps us to get the buccal corridor looking nice and get all the cusps in the correct places. So visually it’s important for the aesthetic. [Jaz]And fellow articulator stroker Mahmoud, tell us about your thoughts on to help create the precision in the occlusion when it comes to recreating group function or getting the technician to get the guidance correct. Okay, because an easy case and another plus point of canine guidance and why can guidance is popularized is that technically speaking for a technician to create canine guidance, it’s may easier than saying, can you make sure the upright canine first premolar, second premolar, first premolar, but not the second premolar, but the wisdom tooth are involved in the excursion, right? It’s so much easier to make sure that it’s just one tooth. So that, but when we’re going to actually recreate and conform and we want this premolar or this molar to be adding to the occlusion in excursions. Mahmoud, what are your strategies that you feed your technician to help with this? [Mahmoud]First, I want to say that the job of getting it right happens in the mouth. You can get as close as you can try. Well, you can try and get as close as possible on an articulator, whether that’s virtual or whether it’s analog, whether you’ve used the facebow or not. The chances are you need to do some adjustment in the mouth. Now, for me personally, what I want to do is get it right in the mouth and then get the technician to copy what I’ve created. So I think one of the best ways of doing it is whether you’re going to do a direct composite mockup if you want to call it a functionally generated path. So if you’re doing it in, you’re doing it on a pre molar, for example, you can take some composite, you don’t bond it on properly. Create the shape that you want. You work out the occlusion in the patient’s mouth, and then you can take a scan of that, for example, and send it to Graham. However, one of the main questions when I spoke to Jaz about setting up this sort of this three way, this threesome was, I really wanted to know from your side, Graham, if I give you contours that I’ve checked in the mouth, so let’s say I’ve got canine and premolar and I’ve shaped the provisionals perfectly, they’re exactly how I want them. And I take a scan, and I send that to you. [Jaz]A pre prep scan, for example. [Mahmoud]Yeah, yeah, yeah. Over the provisionals. Okay, so everything’s the way I want it. I want you to just great- [Jaz]And think of that patient recently, and Mahmoud, it’s great you’re asking this, because recently I sent, literally like two weeks ago, Graham, I sent you that case, initials ME, because I wanted his retainer to fit perfectly over his new onlay that I did. And so what I did is, he made that face. So what I did is, I kind of recreated in a temporary crown exactly how I wanted the shape to be. I scanned that and I sent it to you and I said, make sure that the contours of the crown that you’re going to make me, or onlay you’re going to make me, overlay is no wider than this. Because if it’s no wider than this, I know the retainer will still fit. And so similarly to Mahmoud’s question, how easy is it to copy scans that we give you? Is it a really tricky thing or is it a super easy? [Graham]I mean, it can be super easy and it can be super tricky. It just depends on your prep design also, because at that point you have to switch to a digital restoration. I can’t hand wax that to the same, what you’ve given me basically. So I have to go digitally. So then we’ve got the margins to try and keep integrity. And if you haven’t designed your prep as such, then it’s very difficult to get something out of the mill that hasn’t chipped or just any little discrepancy around the margin. So that can be quite difficult to get right. And that’s just like, before we even look at the actual function that you’ve given us. So, and then we’re at the mercy then of the milling tools. Are they sharp enough for the job? Are they actually going to trim it back to the correct accuracy that we need? So sometimes things can be left a little bit proud and you’d find that your retainers just a little bit tight and where’d you go from that? So I would never guarantee you that I can make it fit perfectly, but I can guarantee you that I’ll conform to what you’ve given and that I will put the function back in if it turns out just a little bit high out of the mill, once I’ve gone ahead and kind of almost sintered the material. I can then grind back in if it’s high, the function that you wanted with the shape that was there before the shape that the patient’s comfortable with and their tongue is not going to be like on it all day, every day. So yeah. [Jaz]And then in the case of the anteriors that Mahmoud mentioned, imagine you’ve got some anterior provisionals, the patient’s wearing these anterior provisions for three months, and you’re really happy with the shape. In that case, you copying via, and then you’ve got a scan, for example, that Mahmoud sent you, for example, in this hypothetical scenario, how are you trying to copy the shapes exactly in your ceramic? Are you taking like a palatal putty stent and then hand waxing from there? Or what are your strategies that you’re using? Or are you relying on digital for that kind of scenario as well? Mahmoud, that’s your question, right? That you answered for like anterior provisionals. How do we copy the shapes? [Mahmoud]Yeah, essentially A, how easy is it to get the shape that I designed in terms of the palatal surface? And also if you could later on to give us some tips about, okay, look, if you want me to be able to copy this guidance, make sure the guidance is on a flat area. That’s like a couple of millimeters wide, not some funky, cool, cusp shape just so that the milling machine, all that sort of stuff, the backend stuff. What can I do to make your life easy so you can give me back what I need? [Interjection] Does occlusion confuse you? Do you feel like you need a taught in a way that actually makes sense? Whilst we have got a great online course, we totally understand that some people learn better from in person and hands on programs. Our Basics of Occlusion Face to Face Course will be too enlightening and fulfilling days with nine hands on activities. We cover crowns on dodgy occlusions. No other course in the world covers this, and so it’s important because you know what? None of my patients have a perfect occlusion. We often have to work to a non ideal occlusion, but we want everything to work for the longest time possible. We will teach you occlusal assessment, occlusal diagnosis, and occlusal planning to make sure your crowns last, your patients are comfortable, your bonding doesn’t chip, and you can go to sleep at night not worrying about restorative failure, because our occlusion course is all about improving the predictability and longevity of our work. The next state is 11th and 12th of October 2024 in Surrey UK and you can book this now via www.protrusive.co.uk/boo. Yes, boo, basics of occlusion. [Graham]You can ask your technician, basically, especially when it comes to palatal function. I find that a lot of clinicians generally. They don’t prep enough. They don’t give enough space there. And a lot of the space that you give is around 0. 5 to 0. 8 mil. 0. 8 mil will generally get you what you want, but anything below 0. 5, 0. 4, all of a sudden, When you put it in the mill and you’ve wanted to conform to that shape that you’ve given us, actually the minimum thickness of the material then overrides. And then I’d have to then go in and hand trim everything. And then next thing you know, you haven’t got what you’ve given me, especially if you’ve got multiple areas where I need to do this adjustment. [Jaz]So top tip number one is if you’re trying to copy shapes intricately, especially when there’s functional pathways involved, let’s say palatal is uppers, make sure there’s enough space so that you don’t have to go back and then hand recreate it, it can be then milled into the correct bite. Is that a fair way to summarise it? [Graham]Yeah, that’s right, yeah. [Mahmoud]And this is a, you’re milling a wax pattern, right? [Graham]So you mill a wax pattern or you can just mill straight into lithium disilicate if you’re going to do an Emax or GC LiSi block. Well, same with Zirconia as well. It’s just having enough space in order to recreate what it is you wanted without the parameters of the mill machines and getting everything out of there in one piece because you can encourage micro cracking, you can encourage lots of things by having thin areas and then that goes straight into thick areas. It comes out of the furnace and instantly you’ve got thermal shock. You don’t notice it in the laboratory, for instance. I then go through a few more processes, send it out to you, you fit it in the mouth, patient bites down. Oh, it’s cracked. So yeah, just prepping everything appropriately is pretty paramount to the shape that you’ve given, being able to conform to what you’ve given and give you a restoration that is actually fit for purpose. So maybe if you’ve got the wax up to start with as well, an idea would just be try that in and prep through that just to make sure you’ve got enough room as well. [Jaz]But do you often also take a putty palatal index to then when you’re checking and verifying to make sure you’ve got those shapes right? [Graham]Generally I’ll take that mainly for the tips and the length of the teeth. I can never, if I’m doing any feldspathic adhesion, I can never give you 100 percent what you want. Or what you gave me to start with. So I would prefer to do that in a monolithic. And then I’ve got much more chance of getting sort of like 9, 800 percent of what you gave me. As long as you’ve prepped accordingly as well to give me that shape. So when you transfer into hand layered, felt spathic, you’ve got lots of variables involved here, and you’ve got shrinkage of the porcelains that go onto the substructures. And that can be quite a challenge. And the next thing you know, you add in little bits, and then you can overfire the materials as well, so you kind of got to make compromises. [Jaz]There’s so many parameters, there’s so many complications that can happen that go against you. [Graham]Yeah. So, yeah, it’s all about compromise at this point. Is this patient a stickler for that shape? And if the patient is a stickler for that shape and wants that shape and nothing else, then should really look at monolithic if possible. And if there’s a little bit of give and take and the patient wants some additional aesthetics and translucencies in the teeth, then obviously you’re going to have to go for the feldspathic route. But you’ve got to let the patient know that there might be a difference in the shape when it actually comes to be made by the technician and in lots of laboratories as well. Different technicians have got different ideas. And molds in their head, there’s go to shapes that technicians have and sometimes it’s hard to get away from that and give you what you want. So you might have made something on your digital design that was quite ovate, but the technicians used to making triangles and you’d get something like in between. So yeah, best way to go. [Jaz]I think the first major takeaway, Graham, that you gave is shim holds. The second major takeaway is every technician, just like every dentist does things differently, every technician will do things differently. So if you’re looking to do a case whereby you want to try this out and you want to make sure that the guiding surface is exactly how you want it and you give a prescription, or you’ve got some anterior provisionals and you want to copy the palatal contours, i. e. the functional contours, as closely as possible, pick up the phone, speak to a technician, and find out what records your technician wants to help facilitate this. And also when Graham, when you next get that case in, it’s like, Oh yeah, I had a chat with Jaz about this. And he told me he wanted to copy these for this reason. And therefore, you already have a bit of context when you’re treating that case, right. I’m sure it’s nice to have that. [Graham]Yeah, it really does help. Helps me to give you what you want. And especially if you give me what I want. And when you don’t, then that’s when it makes my life difficult in giving you what you want. [Jaz]And one thing that we touched on, which is the third key takeaway, Mahmoud, you said that you mentioned the functionally generated path technique, which we have a podcast on, so I encourage everyone to check that out. But essentially, I just want to just describe the sequence here before I get you to chime in here, Mahmoud, as well, is lower right molar if it’s broken down. Okay, like a cusp fractured for example It’s broken down and you would like this tooth to be involved and contribute to the patient’s occlusion in the guidance what I typically would do is get some composite. No etch. No bond Just a dry tooth put some of this mock composite expired composite on, just finger shape it get the patient to bite together vaseline on the opposing tooth by the way vaseline on the opposing tooth bite together tap tap tap grind left to right, tap, tap, tap, start chewing, okay? And then with my flat plastic, just trim away all the messy bits around the edges. But now you’ve got the shape of the opposing tooth beautifully carved in, right? So you know that it’s going to be perfect now in the excursions and the function. And then I cure that, I scan that, and I send that to you, Graham. But Graham, again, is that something that you don’t like, or you’re indifferent, or you like to have that? [Graham]I mean, I’m indifferent, really. [Jaz]Just try your best. [Mahmoud]I love it. I love it. [Jaz]Mahmoud, you were going to say something, sorry. Sorry. [Mahmoud]Yeah, no, I was going to say is that I think in, certainly in my head, at least at one point, it was like, okay, I’ve got a scanner now. So if I scan something and I send it to the technician, any technician, yeah, they’re going to plug it into this machine and it’s going to spit out either a copy if that’s what I want, or basically they can do anything. What I’ve come to understand, and hopefully Graham can maybe say that either I’ve got this right or wrong, but you can send that to 10 different technicians and they might have 10 different bits of software, 10 different machines that mill with different types of burs, different settings. And you can get completely different outcomes with the same data put in and the same instructions. Is that sort of correct, Graham? Is that true or false? [Graham]Well, it is true to an extent because all softwares and all like 3D printers or mills, they all have to be dialed in together. So if you haven’t dialed in your settings to how your clients actually like the work done or how you like the work done for your clients, then you’re not going to get the result that you want. And some labs are more meticulous than others at actually getting everything right. And to perfection, where some laboratories are just like, oh, that fits quite well, and then they’ll just roll with that forever. I’ve experienced that in like labs of all levels through my career. Some are happy to accept lower levels of this, that, and the other to make things easier. So, but you’d probably find that those laboratories have got a different business model and they charge less for your work. So, you kind of get what you pay for sometimes depending on what laboratory and yeah, it also just depends on the type of person that’s running the laboratory as well, whether they change their burs often enough, it just comes boils down to a lot and the quality control at the end, does it go through that lead technician, does everything leave by that lead technician? Lots of other laboratories have got like five, six, good technicians, but each one of them have got a different criteria of how they check everything. So, they’ve probably got written protocol that says you’ve got to do it this way, but actually everyone’s different and everyone’s got their quirks. Everyone likes things done certain ways. So it’s an interpretation. Basically, given on, being given to you by a human, it’s been made by humans and everyone’s different. [Mahmoud]Just a little tip for people who do work with a technician regularly is when it comes to contact points between teeth and your crowns, it’s sometimes it’s not necessarily that you need to give them a specific wording to get what you need. It’s about consistency. And this is how I got myself to a point where my contacts on my crowns are almost always perfect. And I’ve used the same wording every time. So I will say. Please give me, I use the word good, but that’s not the point. It’s a good interproximal contacts that tug shim on a solid model. Okay. Wording is very deliberate. Not because if I give any technician holds the models and says, yeah, this tugs. I don’t think every technician is going to get the same thing. But what’s happened at the beginning is when I said that, I got some crowns that were too loose and I let them know that this was too loose. So they will remember what it felt like and they will know that it’s loose. So now they will adjust and adjust until I get it right. So now they know what it feels like to them to tug shim and having it work in my hands, right? So then now it’s, it’s very consistent. So it’s not necessarily the words, but if you just give them the instructions as to what you want them to check and then give them feedback as to how it feels like in the mouth. And then eventually they will calibrate themselves to what it is you want. Does that make sense? I don’t know if I can- [Graham]It makes perfect sense. Cause that’s how I try and teach my technicians as well. They asked me, how is this supposed to be? It’s just like, I can’t really tell you it’s all about feel. So, once we get few right, then you’ll know how it feels. I can. [Jaz]Graham, what are you feeling for when you’re checking contacts? Cause I’ve said your contacts are very, very good. I’m very happy with them. Small percentage times I’m adjusting contacts when it comes to you. So when you are checking the overlay or the crown, let’s say, what are you aiming for on your models based on your printed models and your workflow? [Graham]The contact paper that I use is actually a 12 micron. I will just aim for it to be restrictive as I pull it through. But it’s a light restriction. Like dragging? Yeah, it’s a light restriction on both sides. If there’s anything less than that, then you know you’ll probably, you’ll get away with it, but you should be adding to that crown again. Send it through another cycle if you can, if you don’t feel like you’re- [Jaz]If you really miss the mark, how do you fix that? So let’s say you’ve got a zirconia, and you’re like, oh, oopsie, we’ve got an open contact here. You have to- [Graham]Add some ceramic and then go through that process again. [Jaz]Is that easy to do? Is that time consuming? [Graham]It’s quite time consuming. If you’ve got a lot of work to get out the door, if you’ve got a big case on that you’re under pressure with, and then all of a sudden you’ve got this single crown and the contacts have gone wrong, you’ve just got to go back through the furnace. So you add it, put it back through the furnace, and then you wait in, It can be frustrating. The life of a technician is frustrating. Sometimes. [Jaz]I can totally imagine a life of a technician with five kids, man. Honestly, I, I salute you, sir. Right guys, just a little summary. So far, we talked about what is a guiding tooth, the tooth that’s involved in excursions, let’s say, and why we should recreate guiding surfaces where we want to conform. Well, we want to add to the function, and in some cases we might not, in some cases we will. That’s a patient by patient decision. We’ve talked about the lab, i. e. Graham, just looking at the adjacent teeth inclines and being for single teeth crowns, it’s like, you know what, I think it should go like this, because that’s what the opposing tooth is telling me, but it’s also what the adjacent teeth are telling me. We also talk about the functionally generated path technique, i. e. using some composite and getting the patient to grind in the function and chew in the function so we can copy that. We talk about articulator are not being necessary for a single unit, but as units increase to help the technician get more predictability, like for example, if you’re doing quadrant, you have less landmarks and therefore you need to recreate the patient’s jaw movements on the desk. So that’s when a facebow and articulator may actually be more useful. Is there anything else we need to cover to make sure the Protruserati go away listening to this episode thinking, you know what? I’ve got a little bit more predictability in my mind now. I’m going to start prescribing a little bit more in my lab prescriptions. I’m really going to be careful when it comes to the shim holds. I’m really going to make sure I pick up the phone to my technician and have a chat. [Graham]So anybody who uses articulators, obviously try and get yourself something that’s fully adjustable, but when you check everything on the articulators, you check. [Jaz]Are you sure on that? Fully adjustable is a big step. We usually recommend semi adjustable. [Graham]Yeah, a semi adjustable, anything that you can kind of get as much of a movement on as possible without the articulator breaking on you like a, don’t get yourself a Denar. That’s my own, that’s my opinion. They fall to pieces in my hands, it’s got to be a KaVo for me. So yeah, you check everything on your articulator, and then my suggestion is, and it’s a good tip, is take it off. Check everything by hand. There’s a lot more movement you can gain with your hands that the drawer actually does than your articulator can actually transfer to you. And yeah, it really helps with things like Michigan splints to any sort of like shared guidances and helps you just get rid of those additional interferences. So yeah, maybe you wanted to say something. [Mahmoud]Yeah, no, I was just going to say that, just for the sake of people listening. I know we went through a little bit in terms of what, why are we doing this? And I picked this up from you, Jaz, which is fantastic. And stuck with me is that sometimes to know what something is, you need to understand what it isn’t, right? So let’s say we’re talking about preserving the guidance on the tooth. Now, what happens if you don’t, there’s only really two other possibilities, right? Either you’re going to make the guidance on that tooth shallower, so you’re going to decrease the force on that tooth, which is something that you might want on a really compromised tooth, but remember that force is going to go somewhere else. So at your examination, this is a good chance for you to find out where might it go? It’s going to be difficult to tell 100%, but if the patient generally has a well maintained dentition, then you’re not necessarily too worried. If they’ve got post crowns everywhere, you’re then that might be time to start thinking a bit more comprehensively, get some records, and maybe figure this out in advance. The alternative is you’re going to make the guidance too steep, right? Which is something again we might want to do. For example, we do it with canine risers. But again, you’re going to choose a canine that is unrestored, probably, or has a small restoration, and you know it can take it. However, for example, if you do that on heavily restored tooth, again, it’s going to accept, it’s then going to take more force. So is it more likely to fracture or frustration? Is it more likely to be in the way of how the patient wants to function? So that’s the reason, that’s really the reason. [Jaz]Function or even para function. Like sometimes the function would be and it’s happened to me before where I gave an upper left premolar crown and if I look back at it now, it was way too steep compared to the adjacent teeth. Like it just didn’t fit in that arch and the patient came back a few days later saying every time I’m chewing I’m knocking against his tooth. Whereas if it’s, it was also be too much in parafunction so that in patient’s parafunctioning, it’s only on that one tooth, which is negative consequences for the tooth, the PDL, the muscles, the TMJ. [Mahmoud]So sometimes it isn’t, oh, you should copy what the patient has, right? Like, it’s not like me and Jaz are saying, if you don’t, you’re a bad dentist. It’s just sometimes that the consequences of not doing that could be problematic. [Jaz]And a lot of times, it won’t be problematic and you’ll get away with it, but that’s not the kind of dentistry we want to aspire to. We want to aim high and do precision dentistry, and Graham, it’s great to have your input to help us all achieve this. Graham, just tell us about where you work, what kind of work you are happy to accept. I know you’re super, super busy, but if you’re happy to accept any work, I can match for Graham’s vertical crown. So if anyone’s doing, vertical preps, you’ll have to probably send him a case to check your preps first, because he’s very particular. He wants to make sure he gets good preppers on, send him a case, try one of his vertical zirconias. His overlay ceramic work is brilliant. His wax up stuff is fantastic. Graham, tell us about how we can get in touch with you. [Graham]It’s best off. Give me a call, find my number on Instagram or on the website. Just give me a call. Tell me what it is that you enjoy doing most or do most of. And we’ll see if we can fit you in. I can’t take on any cosmetic works, and I can’t take on large cases currently, because, yeah, I’m pretty stacked. But when it comes to generic crown and bridge works, and biomimetic dentistry, we’re kind of, we’re there. And we can provide that service for a few more. [Jaz]I’ll put that in the show notes for everyone. And Mahmoud, the work you’re doing as always, you’re a veteran in this podcast. You’re very much part of the podcast foundations, but I’m loving your contributions, not only on Instagram, but also on the Protrusive Guidance app. Please keep them up. [Mahmoud]It’s such a fantastic community we’ve got there. So it really is awesome. [Jaz]But tell us how to follow you, mate. [Mahmoud]Yeah, best place is either join us on Protrusive Guidance, please. Because there’s such an amazing group of dentists, so open, people are sharing cases, asking questions. It’s really thriving. So that’s awesome. Otherwise just follow me on Instagram. That’s where I post most of my stuff. Just stick my handle on the show notes. [Jaz]I’ll put the handle in the show notes. Chaps. Thanks so much for a geeky discussion. Awesome. Graham. I know you’re having Legoland next week. So I hope that you’re able to get through today’s work, probably finishing at eight or 9 PM tonight. So that you can actually enjoy that Legoland experience over a couple of days. I hope you have a fantastic time with your family. Keep fighting the good fight, mate. [Graham]Take it easy, Jaz. Thanks, Mahmoud. [Jaz]Thanks so much. Great to speak with you. so much, guys. Mahmoud, thanks so much. Well, there we have it, guys. Thank you so much for listening all the way to the end. What did you learn? What are you going to change? What are you going to implement? Could it be the protrusive pearl of using the wedge? Or could it be the way you’re going to think about the next time you do a crown, and more than likely that posterior crown is actually involved in the occlusion? Are you going to pick up the phone to a technician and just have a nice little chat about occlusion? Like I said, this episode is eligible for CPD on the Protrusive Guidance app. You’ve come this far, you listened to these episodes, you watched them, you enjoyed them, I hope. I’m hoping the value for money is absolutely amazing and therefore you should join Protrusive Guidance and get your CE quiz certificate as well. We’ve got a lot more stored for you in Occlusion Month, so make sure you’ve hit subscribe if you haven’t already. And as always, don’t forget to give us a thumbs up. I want to thank Team Protrusive as always. Erika, our fantastic producer. Mari, our CPD queen. She’s also the one that lets you into the community, so make her life easy. Send her the evidence that you are indeed a dentist because we are a exclusive private network. I also want to thank the support team of Krissel, Nav, Emma, and Gian. My friends, I’ll catch you same time, same place next week. Bye for now.

Emma Hutchison, a dental student with expertise in removable prosthetics, joins to simplify the complexities of dentures. They discuss the vital joint positions for fitting dentures and how to accurately calculate freeway space. The conversation dives into the nuances of Wax Jaw Registration, shedding light on what is genuinely recorded in the process. Additionally, Emma shares valuable exam revision tips and emphasizes the importance of continuous learning in mastering removable prosthodontics. It's a must-listen for students eager to enhance their denture skills!

The first EVER ‘Prospective’ episode of Protrusive – I interviewed new-grad Dr Triman Ahluwalia in 2023, then again 7 months later in 2024 to see how he gets on with his first year as a *real* Dentist 😉 We uncover what it feels to be a freshly qualified Dentist, the pressures and fears that come with procedures such as endo and surgical extractions, but what we can do as growing clinicians to overcome these hurdles. https://youtu.be/9NtKCIVfMLs Watch IC052 on Youtube This episode is packed with lots of top tips to help you in your journey from the ground up, or as a reminder for those that have been there and done that, that we are forever learning on our journey and there’s always something out there to help us become better Dentists. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:02:02 Introduction to Dr Triman (2023)03:32 Experiences at Dental School07:15 Procedures You Fear + Sectioning Teeth11:25 Thoughts on Social Media in Dentistry15:26 Documenting Work16:30 Future Career Plans18:00 Additional Comments from Triman19:03 Back to the Future: 2024 Triman Update21:50 Dental Photography Progress23:08 Tricky Dental Procedures Update27:46 The Good and the Bad of DFT32:26 Career Path in Dentistry34:49 Triman’s Top Tips37:06 Wrapping Up Don’t forget to check out the Protrusive App where you can find more awesome tutorials on becoming a more efficient and effective practitioner. If you liked this episode, you will also like IC029 – Young Dentist Thrival Guide  This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on on the Ultimate Eduction Plan, including Premium clinical workthroughs and Masterclasses. Click below for full episode transcript: Jaz's Introduction: Welcome to the first ever Protrusive Prospective episode. You see, I interviewed Dr. Triman Ahluwalia in his first month of being a real dentist, i. e. newly qualified. I then interviewed him again seven months later to see how he got on. Jaz’s Introduction:Hello Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every year we make an episode to help those who are in their first year, i. e. they’ve just qualified and they’re entering the big bad world dentistry. And this is a interesting one because I’ve never done a prospective episode whereby I’ve told the guest to wait six, seven months and then we’ll continue the recording. Just to see if the perspective has changed. I think this is essential listening and watching for those who are literally about to enter the first year of dental school, or maybe you’re returning to work again after some time off, or maybe you just want to gain some insight into the mind of the newly qualified dentist. Maybe you mentor some dentists, by the way, speaking of mentorships and big things, Intaglio is almost out. For those of you who don’t know, Intaglio is a new platform we’re making to allow one on one mentorship. Look, it doesn’t matter. How much money you paid to these courses doesn’t matter how many continuums or diplomas you’ve done. When you have that specific case and you need someone to sit down with to discuss that case, step by step for a good hour or even two hours, the course organizes the diploma teachers. They are busy. They don’t have the time to do one on one, which is why we created this platform to allow mentors and mentees to connect and allow fair exchange. Because you know what when a mentee needs help they really value it and they value that one on one time so Intaglio is coming soon and also a big update number two is I’m in my new studio I’ve now moved from reading to West London quite close to Heathrow it’s like little India it’s called Southall. I’m close now to my parents my in laws we get lots of support for family so that was a big reason I’m still working in Reading. But yeah, it’s been a crazy time with moving. But now this is my first episode, first intro being recorded in a new studio. Wish us good luck. And now we’ll join the main episode with Dr. Triman, catch you in the outro. Main Episode:We can say doctor now, Dr. Triman Ahluwalia, I might feel strange to you. How are you doing my friend? [Triman]Yeah, I’m doing great. Big fan of the podcast. So it’s a great honor to be here and hopefully shed some light on DFT. [Jaz]Brilliant. Well, welcome to the Protrusive Dental Podcast, my friend. It’s so lovely to have you. And I’m so thankful, thanks so much for agreeing for the nature of what we’re doing today. It’s going to be delayed gratification. I’m going to talk to you now at the very beginning of your DF1 journey. So those are my international audience. DF1 is basically like your first year out of dental school. It’s kind of like a bridge between dental school and like the real world. We kind of get a bit more support and things are a bit slower to start with, which is good. I definitely learned a lot, enjoy my time, but it’s not about me. It’s about you today, my friend. And so just before we delve further into the questions I have for you, just tell us a little about your journey in dentistry and dental school so far? [Triman]Yeah, so, my name’s Triman. I’m 23 and I graduated dental school from King’s College, London this year in 2023 And I’m currently undertaking foundation training in part of the North London scheme at Ivy House Dental and I also recently wrote an article that was in the BDJ student just looking at the preparedness of newly graduated students like myself for independent practice, which is very on topic for today’s discussion. [Jaz]Excellent. Yeah in case everyone’s watching the video on youtube and seeing me just slightly sweaty. Maybe the camera’s hiding it I’ve just had these korean buldak noodles. I don’t know if you ever had these before. [Triman]No, I’ve not had them before. [Jaz]There’s something else, my friend. So I’m enjoying that very much. So it might get a bit hot and spicy in the discussion as well. Let’s see if it transfers through. Tell me, what is your biggest worry? Like you have been, in fact, let’s take a step back. Tell me, and I hope you’re comfortable discussing this. Tell me about your experience at dental school, generally speaking. And then also how much did you actually get to do? How much experience did you qualify with bearing in mind that you were probably partially affected by COVID as well? [Triman]Yeah. So this was sort of like the big question that was plaguing me towards the end of my summer holidays and I was about to enter DFT and I was actually thinking how prepared am I actually for the real world of after dental school and I think, yeah, as you were saying, COVID sort of was a big factor, especially for my year. I know that’s like the new thing for everyone to say that my year was the worst, but I guess my year I think was the worst. But for me, I started seeing patients sort of regularly from the start of fourth year, I would say, and for reference at King’s, you sort of start seeing patients. Towards the end of second year, which was when COVID hit for us. So I didn’t really see anybody till fourth year and it was also a big backlog as well. But so it was sort of in our heads from the start anyway, for my cohort, that our clinical experience was going to be significantly more limited compared to sort of our predecessors. And I think the Kings overall, they did a pretty good job of getting us up to speed and the amount of time that we had. And we saw sort of as many patients as we possibly could. And I think sort of towards the end, I think me, maybe my colleagues, I think we all started developing a bit of a quiet confidence about the most final year dental students have about seeing patients, getting ready to leave and. But I think, actually, when I actually started looking at my numbers when I was about to start DFT, because when you start DFT, you have to do something called an Educational Transitioning Document. It’s basically just where you write down, sort of, the numbers of procedures that you’ve done, and how confident you feel with them, so you can share them with your educational supervisor going forward. And, for me, I was actually looking at mine, and I was thinking, there’s not actually as much dentistry as I would like. I mean, for example, like I did about say like 50 plus fillings or so, and that seems okay, but then when you break it down and you see that I’ve only done like two amalgams, it’s not exactly the greatest and the most brimming with confidence. And then of course, there’s also procedures that. just haven’t really touched or just haven’t really got sort of like the full depth of experience. So things like endos, sort of surgical extractions, for example. [Jaz]And endo wise, have you not obturated before clinically on a patient basically? [Triman]No, I have. So I’ve done for me anyways, I did three endos. So I did, I’ve done one incisor, canine. I think I did one molar as well. And that was sort of from start to finish, but assisted so I was quite fortunate that I got to at least a mix of sort of like 3 teeth But I think that was sort of the benchmark for most of my cohort as well. I think most people had about that much. I mean, we just had an induction day actually for foundation training and they got everyone sort of general consensus. How many endos has everyone done? I think sort of, it ranged from about one to six, so you could be anywhere on that scale. [Jaz]Yeah. And I mean, that is a bit like, I’ve said this many times on podcasts before when I’ve had a young guest on like yourself, which is, learning to drive, just because you’ve got the driving license doesn’t mean you actually really know how to drive. You actually really learn how to drive once you get the license, then you’re out in the real world, and that’s when you learn. It’s a bit like that in dentistry, and that’s why it’s called the practice of dentistry. So don’t feel bad about that. Definitely start with some simpler endocases, and then obviously read up before, watch some videos of the premolar. And when you’ve got a molar, make sure you pick the molar with the nice young patient with the nice wide canals, easy to find the anatomy, and if you’ve got anything tricky, then make sure that you book extra time and all these things. So I think, this is very, very normal for dentists qualifying nowadays, and it is what it is. So it’s about what you do afterwards. Not a single person’s success in dentistry, I think, was determined by their totals. It’s all about, for me, I think it’s all about emotional intelligence, how you communicate with the patients, how you care for your patients. And that’s the most important thing of all the procedures and stuff that you’ve done. Is there one that you’re particularly maybe scared of? Like imagine next week you had this in your diary, would you be crapping your pants a little bit? [Triman]I mean, I think for most DFT students, they could probably make a little tier list of which ones they hate the most. I’ve probably got one in my mind, but I mean, everyone’s go to is, oh, I don’t want to do a molar RCT, which I won’t disagree with as well. Cause I’m not the best of them either. But I think also surgical extractions in particular, just for me particularly, at King’s, I mean, it was sort of like a code word, if someone said that my extraction went surgical, it meant that they just had to suction for the rest of the section, because the tutor would just take over and do it, and you wouldn’t really know too much of why they’re doing it this way, so I think that would be sort of the procedure that I would be dreading the most, but fortunately, my ES (Education Supervisor) isn’t that cruel, so he’s not going to chuck me in and immediately just do a surgical extraction, but I think we’ve got a bunch of oral surgery study days coming up, so that would be nice to actually get some insight into the theory of actually, how to do a social extraction, flap design, bow removal, sectioning, all that stuff, yeah. [Jaz]Do you mind if we just talk about that a little bit? Do you mind if I almost, like, coach you and give some advice about extraction and stuff, right? So, what you’re saying, it holds true, in my experience, I qualified ten years before you, and when I came out, there are some extractions that, once the crown broke off, and the roots weren’t budging, It was game over for me. I didn’t know what to do. I didn’t feel confident. It was very embarrassing to me. I hated it. And I took that, those emotions that I had within me. At that point, I’m just closing my eyes. I’m just really pitching myself. And that’s, I remember the patient’s face. I felt so low. I felt so disappointed in myself. I let the patient down. And that’s what sort of drove me to really start shadowing some oral surgeons and just generally picking up as many tips. And nowadays, I can look at a radiograph, make a correct assessment, and most extractions I’m happy to do. Very few that I refer out, and nothing fazes me anymore in terms of extractions, even surgical wisdom teeth. And I think that all of that stems from, again, something I’ve talked about in the podcast before, but it’s really important for those perhaps who are new to the podcast to hear this, is most of my molar extractions, are going to be sectioned. No flap involved, flapless, but just section from the start. Don’t wait for the crown to break off before you section. And so the skill I was lacking to remember when I qualified was the sectioning, the ability to section confidence. But the thing I want to say to you and to all your cohort of new grads is, sectioning is just getting the biggest, baddest diamond bur you have, all the tons of carbide, and just cutting the tooth in half. It’s really nothing more than that for a lower molar, for example, right? We did an episode around 80 something with Chris Waith about this topic, and in the comments of that section, someone towards the end of the DF1 wrote, you know, after this episode, I did my first section elevation today. I felt so good. And so don’t be afraid of going in section elevate. Maybe you have a tutorial with your trainer, but the top tip for me is don’t worry too much about flap designs, but do spend extra energy and time and just learning how to section teeth so that that’s going to help make teeth are otherwise difficult to extract for you. For me, they were certainly were much, much more possible. [Triman]Yeah, definitely. I think also just having had a few tutorials so far with, by ES, I think it’s really given me a bit of appreciation of actually the pre op radiograph, as you’re saying, do I need to actually do a flap? Do I need to section the tooth? And what’s the plan going to be? Is there an ABCD plan that I’m going to have? So I think. Yeah, hopefully I’ll sort of get a bit more of an appreciation for that as I go through. [Jaz]Well, I’ll be sure to ask you about that in about nine months time or so. With that, I love that you said that already, and you’re wise beyond your years to say that you should have a plan. I didn’t know that you should have a plan for extraction until I was about two or three years qualified. It’s just a concept I didn’t consider. Like, extraction is like, okay, let me try this. If this doesn’t work on the spot, I’ll think, okay, what should I do next? So really, everything should be premeditated. Like, okay, first I’m going to section. If it comes out great, if it doesn’t section, I’m then next going to do this. I’m next going to remove that furcal bone, for example. I’m next going to then use the cryers and just have some sort of a rough plan which you’re willing to change, but it’s good to go in with a plan. I 100% agree and I think you’re very good to recognize that already. [Triman]Thank you. [Jaz]What’s your biggest worry? You don’t feel particularly prepared. And that’s true, my friend, that you’ll always be that way. You’ve told me already that the procedures, surgical extraction would be scaring your cohort. Molar endos. It definitely was the same for me as well. What kind of plans and goals you have for the year? Because you’re this generation, like when I was qualifying, there wasn’t this Instagram Dentistry at that time. It just didn’t exist. Instagram was mostly for food and that kind of stuff and holidays, basically. There wasn’t a dental home for Instagram. And now you can see all this amazing work. Tell me about your perception of the world of dentistry and what you see on social media and how that might impact you and your vision. [Triman]Yeah, so I mean for me, personally, I wasn’t a big social media guy. Probably before dentistry, but I did sort of, I mean, my sister just last week had to tell me how to teach me how to upload a story, which is sort of how out of the touch I am, so, but yeah, now I’m sort of getting the idea of it and the hang of it, but yeah, there’s a lot of, I think, dentistry, just sort of social media, Instagram is one of them, but, even when you get recently, some of the study days we’ve had, a lot of speakers have come in and literally they will always, always write their Instagram handle. And these are some of the pictures that they have and they’ve publicized. I think it forms a big part of creating that sort of portfolio. And it’s something I’m sort of slowly trying to ingrain myself into as well, just to sort of catch up to what everyone else is doing, but also just to sort of see. I think it’s nice to have, I think particularly with Instagram because it’s image based, having a actual photographic recollection of all the work that you’ve done for not only yourself but for patients and just for colleagues just to share cases as well. [Jaz]Totally agree. So it becomes like a portfolio and I know lots of dentists who’ve been sort of head hunted based on their work that they show me like, Hey, you look decent. Would you like to come to work for my all singing, all dancing practice? I’ve seen that happen before. So that’s one thing. But has it perhaps given you delusional sense or perhaps this worry that you’re seeing this amazing work and then when you’re looking at the very early on the journey and thinking hang on It’s not quite looking like what I’m seeing on social media It’s a bit like I guess in the beauty magazines how everyone’s airbrushed and stuff and then and then people think oh, yeah I’m not so good looking etc. But really it’s the same applied to dentistry. You see all this beautiful, polished stuff on social media that’s been hand picked, cherry picked, the highlight reels. Have you suffered, or do you know anyone who’s been sort of having mixed feelings about that? [Triman]I think, yeah, pretty much everyone in my year. I think, as you’re saying, yeah, I think it’s important to remember that it’s cherry picked, it’s almost a false idealization in some cases. I mean, this is them showcasing their best work. I mean, you don’t really see anybody saying, this is a case that went really badly. And then posting lots of images and how they can improve. It’s more that this is like an amazing composite that I did. Look at it from start to finish. And this is the protocol that I use. And this sort of presented as like a gold standard. But I think a lot of micro what they, sometimes you can get down on yourself. Why is my composite not like that? I mean, I remember just sort of chatting to a lot of my colleagues, all of them sort of say that, I’m really struggled to get the anatomy right on the composites to make it look just like it is on Instagram. And that’s sort of like a common thing, but I think also it’s important to realize as well, a lot of these are also American and they use different instruments and things. So suddenly someone takes out some instrument you’ve never heard of in like a video that you’re watching. But I think it’s important to realize, yeah, that these are sort of their best work that they’re showcasing and they might be doing a completely different protocol to you. And also, functionally, who knows how long what they’ve put in the mouth has also lasted as well. [Jaz]And the saying goes, do you follow football, Triman? [Triman]Slightly, but not the best. [Jaz]Well, there’s a saying in football, right? Where if a team is doing really well, they’re winning all the trophies and they’re playing good. And then you say, but can they do it at stoke on a cold Tuesday night? Can they do it in those, in that different environment, a more hostile environment. So really. Your environment, the kind of mixed practice you might be in, for example, is completely different to what the kind of environments that people are working in. So I would encourage all our young graduates to not to get bamboozled, disillusioned by what you see. Keep a cool head about you. And the only person to compare to is yourself. So Triman, I’d love for you to now, when we speak to you in about nine months or so, to when you look back and say, you know what, I’m looking back on my own work rather than I’m looking to Instagram as the standard, right? So my next question that leads on from that, Triman, is have you got any plans or have you been ready starting to document your work? [Triman]Yeah, so I think one of the first spends for my paycheck is going to be camera and getting a good one at that I think mainly not even just for the so I can post this on social media as you’re saying just to document my work see how I can improve I think it’ll be really telling just to take a picture of my first amalgam and then compare it to one six seven months down the line and see where I improved and why I can actually do better. So I think, yeah, definitely. That’s one of the things on the to do list. Once the first check cash is. [Jaz]I’m so glad you said that. I was kind of hoping you would say that. So amazing. Please do follow through with that. Do not get tempted by that ski holiday. I would definitely say get the camera instead is my top tip to you. So well done for doing that. And I’m going to hold you accountable for that. So remember when you reappear on the podcast, I’m going to ask you, okay, how’s the photos going? So you better have an answer for that, right? [Triman]Yeah, I’ve got one already. [Jaz]Good man. Brilliant. So I’m glad that’s all in check. In terms of career aspirations, it’s funny when you speak to someone who’s newly qualified, they’re a little bit starry eyed and stuff. Just tell me, what kind of direction do you think you want your career to go in? [Triman]Yeah, I mean, this is sort of an interesting one. I mean, a lot of people at dental school, especially even when you like, even in BDS1, the first year, a lot of people will come in saying that, I want to specialize in this or this or this. I mean, for me, I feel like, my stance right now is that, I haven’t actually done enough dentistry to figure out what I like and what I don’t like. I know that we were joking before about procedures that you don’t like to do, but I feel like I haven’t actually done enough of every single procedure to say that with a passion, I don’t like doing this. I don’t like doing this because I just don’t think I’ve had enough experience. I think so far I quite like doing a mix of everything. There isn’t one thing that if I would sort of say I’d really love to specialize in this because I don’t think I’d be able to choose right now. I think. I enjoy doing a mix of everything, just familiarizing myself with all the different sort of specialties that dentistry have to offer and just sort of, yeah, I think in terms of a plan, I think right now, I think my plan is just to become really good at all of the basics and I think that in time would hopefully make me become a lot more efficient and effective. [Jaz]Well said. And I think, the saying goes, you have to kiss a lot of frogs before you find your Prince Charming, right? So, you have to do, you have to experience this, you have to experience failure in endo, failure in extractions, and then you might be inspired on a course one day and then go delve deeper into perio or wherever it could be. So I’m really glad you’re keeping your options open. Again, I’ll ask you again in the future, see, perhaps you’ve niched down, maybe you said, maybe you’ve decided that you never want to do an endo ever again or whatever. Let’s see. It’ll be interesting to see what you say then. Those are all the questions I had for today, Triman. Is there anything else? Anything else that you want to add in this first of two parts when I catch you again nine months to see how you’re getting on? Anything else you want to add to this? Maybe it’s like a time capsule thing, a message to yourself for the future. [Triman]Yeah, I mean, I guess I think if there’s any future advice for future Triman, it would be just to, I think. I think the message is sort of the same as it was for me in dental school. Just try and learn as much from as wide array of clinicians as there is as possible. I mean, we’re very fortunate that we can have our ES at our practice. There’s other dentists at the practice. There’s a wide variety of study day speakers who’ve so far been really good. And I think the same thing at dental school, I think there’s always something that you can take away from every dentist that you see. You might not agree with everything that they’re doing, but if there’s even just one thing, as simple as, oh, I like the way they did that child examination, I might do that next time. I think it’s a good thing to be able to just sort of try and amalgamate as much experience as possible from everybody and, sure, make yourself become a more well rounded dentist overall. [Jaz]Amazing 2023, Triman. I really appreciate chatting to you today. I look forward to speaking to you in 2024, Truman. Okay, Truman, I’ve lost count of when we recorded. It’s been many months, maybe five months, seven months, I don’t know. But whenever it was, I’m eager to know, okay? In the order. Did you buy a camera? [Triman]So the straight answer is not yet, but planning to going to. So the reason is just because as part of DFT, the practice part of the training equipment list is to have a DSLR camera. So I’ve been using that throughout the year. And the main reason is really, because I wanted to just get a better feel as to what settings were best for me before I just blindly bought something just because it was on like a recommended list. And I think doing so has been really useful because it’s given me a better idea as to what settings I’m most comfortable with, what kind of interface I like, so now I sort of have a better idea of what kind of camera I want to go to. [Jaz]So it was like a training ground. You were just perfecting the technique, getting used to it. Tell me this, where, where was the camera actually kept? Like, was it in your surgery? Was it in your principal surgery? Different place? [Triman]So I’m quite fortunate that my ES had given me my own sort of dedicated camera. So it was only me who was using it. I just bought my own SD cards. It was pretty much in my surgery the whole time. So no one else aside from me used it. So I was able to really wear the thing out and sort of get as much practice as possible with it. And so figure out that, I like the Nikon interface, for example, I’m using like a hundred millimeter lens. I’ve got a ring flash currently, but I might experiment with like a twin flash in the future. So it’s given me a good foundation. For getting started with dental photography, because it’s really something that you’re not really taught a lot at university. I mean, I remember when I was at King’s, I mean, for my case presentation, there was just, there’d be one big camera on the whole floor and they’d just hand it to you. And it’s probably like a 2000, 3000 pound camera, but there was no one there to tell you how to use it. You’ve just got to sort of hold it and hope to God that it works. But now that we’ve actually have study days as well on photography in London, so there’s a lot better understanding of actually understanding what the specific settings actually mean. And they give you a prescribed set of things that are settings that they would like you to use. But it’s very different for everybody because people, some people are shorter, some people are taller. Some people will go closer up to the patient some than others. So, it’s a good starting point, but you find that rather you have to adjust some settings accordingly, just how you practice really. And so that’s what I’ve been doing. [Jaz]The most important thing is that you’ve been taking photos, right? So that’s the most important thing for me. The reason I’m asking you whether it’s in your surgeries, because top tip is make sure for anyone out there, make sure it is in your surgery and make sure it’s fully set up. Like the last thing you want to do is, oh, I need to take a photo, but actually you need to now attach the lens to the body and then attach the ring flash. You’re never going to get photos that way, right? So that was just a reminder to everyone to make sure that yeah, fair enough, you have a camera, but if it’s not set up and ready to go, it really has to be in your surgery, set up. Any shots that you struggle with, any shots that you find difficult to take? [Triman]So originally I would say at the start, I was probably struggling the most with taking the occlusal views and I actually watched one of your videos on taking occlusal views. And I actually just screenshotted the positioning on the screen and used that as a reference point. And it’s been going pretty well since then. So I think mainly because I was at the start being trying to DIY it do it all myself. And actually I wasn’t making use of the patient, my nurse who was next to me and once they taking a set of 90 percent of the positioning was just a matter of focusing, positioning myself how I wanted to, to capture sort of the full extent of the teeth, which is what I was sort of missing out on at the start. So I think now I’m a lot better. [Jaz]It’s a classic, it’s very tricky to get the occlusal shot. So glad you watched that video. And the top tip for everyone is this is where all photography is make sure you get a setup light enough. There’s two options, really get a setup light enough. They can hold with one hand or hit the gym really hard. So your one hand becomes really strong so you can pick up your camera. So one of two options, one is easier. So everyone just make sure you actually assess the weight by holding it in one hand, then with the other hand, having the mirror. You don’t even need a nurse then, the patient can just use a retractors. [Triman]Yeah. [Jaz]So that helps massively. So yeah, good. I’m glad. I’m just so pleased you’re using photography. Next question is, you told me, Triman, that molar endo and surgicals were a fear procedure. We all have fear procedures, right? Has that changed? Has that gone deeper? Has it changed for one or both? How much experience have you had of each? [Triman]So I’d say, yeah, definitely. It has changed for being specifically, fear procedure, like you say, I mean it’s definitely both, I still consider very difficult procedures in general, which i’m sure most dentists will but I think the main reason it was more of a fear procedure was because of the limited experience that I generally had coming out of dental school, you know partly due to covid etc I think I probably did about three endos in total coming out of university and I did more than that in like my first month of DFT. So there’s a really big sort of learning curve, but you sort of trial by fire. You really sort of pick up a lot, just doing a lot more. And on my particular scheme, I was fortunate enough that they had like four endo study days throughout the year. So it’s a really, drill it into you and they give you a more of a definitive protocol study as well to use, which is really useful. But I think the main thing that has really reduced the fear associated with the procedure for both of them is just understanding the reasons behind why I’m doing certain things in the protocol. I mean, in university, you’re often just given a protocol and you expect it to sort of just blindly follow it really. But it’s nice actually having an understanding as to why I’m doing certain things for like an example with the access cavity in university, or maybe like told, okay, these are the specific shapes that you need to get. These are cut through. But now, I mean, sort of in our early study days, we’re sort of more told to create like an initial pilot hole and then chase the overhangs. And then, it will naturally achieve that same shape that you’re being told to make, but it’s a lot more conservative and that makes a lot more sense when, especially when things go wrong, like they’re not able to find canal, you can angle, your BP probe, and you can search for areas where you need to get that straight line access. And it is a lot more helpful than just blindly doing like a rhomboid shape and thinking where the canals. So it’s really has been a lot more useful doing just understanding the reasoning behind stuff. And similarly with surgical extractions, having a better understanding of the preoperative planning behind doing even just a routine extraction and having that ABC plan to fall back on. So now if I’m taking out like maybe a heavily broken down tooth, for example, I’ll have a little bit of a better idea of how to appraise the preoperative radiograph. And my plan a might be to look, say maybe use smaller elevators to reduce the risk of fracture, maybe use a cow horns, because the tooth is quite broken down. If that doesn’t work, I might be able to split the tooth in half with the cow horns, or I might need to section it and then elevate the roots out. Or I might need to then, if that doesn’t work plan C, then do an access flap, maybe draw some bone and elevate the roots out separately. But it’s nice having that understanding of what can happen if things go wrong. And that’s made it less of a fear procedure, but not, so much as an easy procedure, but definitely less of a feared procedure. [Jaz]Well, it definitely sounds like you’ve developed and gained some experience, which really is the magic sauce, right? You get the experience and then you gain so much in that year that you have with your educational supervisor, interesting thing you said about having a plan. I love that you recognize that everyone should have a plan for every extraction. Just now I finished a tricky extraction. I knew that I was going to section because there’s tricky molar, root field, gold crown, vertical root fracture. So I spit the gold crown off first, that came out fine. Sectioned the tooth in half straight away, preserved the bone. Mesial root, which had the vertical root fracture, came out very easily because it was all infected. Distal root was an absolute bugger and it kept chipping away, kept chipping away. The main takeaway that I can share with everyone while we’re talking about this is by switching the suction. So you know, that little, the suction, the microsurgical suction tip? Zoe was using it and helping me out, but it just wasn’t good enough. So after about a few minutes, I said Zoe could just switch the suction. I think maybe it’s blocked. And then she got the new suction out and boom, suddenly I could see and then you know exactly where to put your Luxator. And so the reason I mentioned this is because it reminds me of another tip, which people on Protrusive Guidance, our app, they are often saying that this is the number one tip that they gain from the podcast. It’s not even my rule. It’s a rule I picked up from like third degree from someone, which is the six second rule. Are you familiar with the six second rule? [Triman]No, not particularly. [Jaz]Okay, the six second rule. No one knows why it’s exactly six seconds, but it’s just got a nice ring to it. Basically, if you’re doing something when it comes to an extraction, anything, right? And you do that thing for six seconds, and nothing’s really changing or improving, go to the next step. Change it. So if you’re using a luxator for six seconds and literally nothing is happening, okay, think what can you do next? Get a big luxator, get a different instrument, change your angulation, whatever. And that has helped me because sometimes you’re doing the same thing over and over again. And you’re not achieving anything. So the six second rule has been quite a hot one on Protrusive Guidance in terms of people saying it’s their favorite one. So great. I’m glad you’re feeling more confident in Molar endo, Surgicals. You told me already about the camera. Now tell me, overall, what have you enjoyed about your DF1 experience and what have you not enjoyed? [Triman]Yeah. I mean, I would say, I think probably the biggest change is coming from university. The thing I’ve enjoyed the most is actually just the change in pace. From the very long sessions that most people are accustomed to in university, which is, you have one big morning session, one big afternoon session, you do as much sort of treatment as possible. And I think actually having that broad range of patients and just slowly becoming that change of pace and being a bit more quicker and actually being a bit more efficient with the time, I would say is the best way to put it. It’s been a lot more fruitful and it’s well, it makes it a lot more enjoyable, the dentistry rather than there’s a lot of lost time in university, waiting for the tutor to come over and then they’ll agree with the treatment plan. It might change. [Jaz]I used to hate that. I used to hate that so much. I’m making a small talk with your patient. That was the worst thing ever. [Triman]With like a 30 minute wait. [Jaz]Yeah, exactly. [Triman]So now I think having the clinical freedom to actually make use of the time effectively and just call my ES. If I’m struggling with something and they won’t take 30 minutes to arrive, hopefully then it’s been a lot more enjoyable in that sense. I think that’s probably the biggest enjoyment in terms of like particular procedures. Again, I would say actually root canal and extractions and also indirect restorations, like resin bonded bridges and on lays in particular, which I didn’t really get to touch upon at dental school a lot again, for the same reason of, I just have a better understanding of the procedures. And so I really enjoy now actually being able to do them because I have a better understanding of what might happen if things go wrong and there’s a bit more of a problem solving element. Which is sort of I think the main enjoyable part of dentistry really having, when you understand something, it’s really useful and it makes this procedure a lot more enjoyable because you know that, okay, if this doesn’t work, then I’ve got the problem solving, skill set at least to resolve it. Whereas that a lot of those fear procedures is just you being stuck on something for a long time. So that’s probably the thing I’ve enjoyed the most really. And in terms of, less enjoyed. I mean, I’m probably quite easy, easy to please. And I enjoy a lot of everything. I think probably the most uncomfortable thing that I’m probably not as good at and confident at yet is probably discussing costs or so with patients. I would say, particularly around private treatment. And this was sort of one thing I mentioned in one of the recent articles I’ve published in BDJ in practice about being prepared as an associate for next year, as a DFT, because of the nature of the contract, you have to do, I think 95 percent NHS work and a lot of the patients you see up high needs. And so a lot of them are exempt as well. So there’s not a lot of discussion around costs. And so gaining more experience and just being able to naturally communicate these are the sort of the different treatment options available. These are the private treatment options available. And then having that discussion of costs without coming across as too forceful or too passive as well is something I think I would like to gain a lot more experience in just because I haven’t been exposed to it as much. [Jaz]You’re so right. I totally imagine myself back in DF1 and that’s a great point you made and you definitely need to keep practicing and try and get it out of your mouth. That whole neuro physical connection, basically being able to say the price and know how things are supposed to be priced to make sure that your practice is running profitably, to make sure that at the end of the day, we love what you do, but we still need to pay the bills, put food on the plate. So therefore we need to be able to have that skill. And you’re right in DF1, because you’re doing so much of that type of work with the patients who are exempt, you don’t get to practice that as much. So it’s important to be comfortable in your own skin, be proud of your skills and procedures, and be able to also just for transparency and clear communication, the patient needs to know the price, you know who are really bad at telling you the price and stuff, doctors, in my experience, private doctors, and they will just do all sorts, but they’re just terrible. And then the worst thing is you actually speak to the practice manager or the people who are like their secretaries. And I say, by the way, how much will this cost? They’re like, I can’t say, I’m not sure yet. And really the price list that we have for a crown for endo in the medical world, in my experience, that really doesn’t exist. And so, especially in the insurance world, it’s really, really complicated. So I think let’s not be like those doctors. Let’s be really clear with the price. And so that’s a great point you made. And you’re going to gain that experience as you go along. And it’s also the top tip I can give here is when you are communicating the price. It’s really important to be confident when you say it. It’s really important not to look away because just like you said, and I only say this because when you are new to talking about money and not talking about price, a lot of dentists will lack confidence. I certainly did. Okay. I come from a type of background where it made it very, very difficult for me to talk about the cost of dentistry. And so, common mistakes as people, dentists look away or their voice changes a little bit or it cracks or whatever. So to have that practice and conviction, and that’s a great point you made. And so Triman, last question is, did you find a niche or are you happy to still want to experience everything and enjoy all aspects of general dentistry? That’s what you said. You like the idea of general dentistry. Have you found a little passion within dentistry or are you still looking? Are you still searching? [Triman]Yeah, I think probably the one answer that’s probably stayed the same since we last spoke is me probably wanting a bit more experience again, trying to find out which disciplines I really like more than others. And I know I’ve gained a lot of experience throughout this year, but I was still quite new to dentistry in general. Foundation year, no pun intended has lived up to his name and providing me with a good foundation to start sort of building my career as a dentist. And so when I finished dental school, there was quite a lot of gaps in knowledge, which a lot of people have, and DFT really just helps sort of bridge those gaps and close them off. So you now sort of have a nice base to work with. And I feel a lot more well rounded now as a dentist. So I think I’ve dipped my toe in a lot of different disciplines, but I don’t say there’s one thing in particular that draws me in particular to, I think I need to now delve further into areas that I’m interested in. For example, I’ve booked like the composite course this weekend, which I’m going on. So that’s something which I’ve developed the fundamentals on throughout the year, which has been really useful, but now I’m sort of looking to really delve further into that topic. And I think that’s where dentistry goes from being that science to more of that art form and which as well. Patients are going to be paying the premium for the art form part of the dentistry that you’re doing. So I think right now I’m enjoying general dentistry and I’ve sort of got a good hold on certain areas, but now I think it’s just figuring out what I like and maybe going through different courses, maybe doing something else and just sort of exploring topics a little bit further. So, and then figuring out sort of how I progress from that. So right now, somewhat of an interest in lots of different areas, but we’re really sort of exploring. [Jaz]Well, whatever you do, make sure after the composite course, you have someone to implement whatever new skill they’ve learned. It’s really important to do that. Otherwise it becomes lost. There are some courses out there which teach you a very specific technique or a very specific way of doing things. It might take you six months to find a patient. And by then you’re like, Oh my goodness, how do I implement this? It’s human nature, right? So make sure you implement straight away. And so the last question I have, Triman, is, what’s the number one tip you can give someone who’s made it all the way to the end of this episode, listening to you, this little interesting feature that we had six, nine months apart, wherever it’s been, seeing your journey and stuff, and very encouraging actually to anyone, maybe to start a foundation here to hear the story that you’re sharing. What’s your top tip to give to them? [Triman]Yeah, I would say I’ve actually had a quantity of people messaging me recently for tips on DFT, going into my practice. So I’m well equipped for this question. So I would say that the main thing I would say is actually just try and learn as much from everyone around you. I know in DFT, it’s easy to just click on to your ES only, but it actually, in my practice as well, specifically, there’s lots of different associates there who are willing to help you, especially, if you’re fortunate enough to have specialists in your practice as well, like in my case, I have an oral surgeon who comes once in a blue moon or so, but whenever he’s there i’ll always take the opportunity to show him an extraction I’m doing that day where I’ve got planned because he’ll provide him with so many small useful tips. Just from you know his wealth of knowledge and I think it’s really important to just make use of everyone that you have in the practice as well whether that be nurses reception as well and just yeah, general other general dentists there aside from just your ES who is going to be able to help you because it’s really good to gain knowledge from a bunch of different places. And in fact, one of the good things that both my ES do is that they will actually say, you know what? I’m not super skilled in this area with like bridges, for example. Let’s go ask one of the other dentists here who does a lot of resin bonded bridges, for example. And they’ll even learn with me as well. So it’s good to, I think, gain knowledge from a lot of different areas. And so definitely make the most of your practice as a whole, and not just the single ES that’s there. Try and make use of everything and everybody that you have. [Jaz]And that’s a great tip, by the way. And I would say, don’t get frustrated by the fact that the four dentists in your practice will all give you four different treatment plans and four different bits of advice and they may contradict each other. And instead of focusing on seeing that as a negative, see it as a positive that you know what, you could pick any of those paths and you’ll probably be right. And so if you convert that negativity into a positive thing, trust me, you’ll be well placed the rest of your career because it used to really frustrate me, Triman, you know, all these, ah, why isn’t there just one way of doing things? Why’d that, why’d that have to be 50 different ways? Why is one, two to tell me one thing? Why different to it, tell me a different thing. It used to frustrate me, but I’ve learned to see the beauty of it. Actually, either way, whichever one resonates with me on that particular day where I’m making the decision, I’ll go with that and I made peace with that. I think that’s very liberating. So, Triman, thanks so much for sharing those many months apart. It’s been really nice to hear about your journey. What you got planned for next year? Are you thinking about applying for jobs or? [Triman]Yeah. So I’ve actually taken up sort of two associate positions at two different practices next year. So are we making the transition into sort of full finalists? [Jaz]How did you find them? How did you find the associate job? [Triman]So I went on a couple of different job searching website. I think indeed, BDJ jobs, those kinds of areas. And there’s a couple of licensing, not the very licensing agents, but a recruitment agencies that are on those websites. So even if you apply to one job, the recruitment agency will get hold of your info and you’ll see a stream for them in coming afterwards. There’s also lots of different avenues to sort of once you search one place, you’ll end up finding a lot of different places and it’s such a high turnover that you see so many different ones posted every single day. So it’s really just sort of a matter of looking and then calling the practice and seeing if your ideals meet really, that’s sort of how I went about it and eventually I ended up finding two that were in good proximity to me. I had good reviews. I really enjoyed seeing the practice and that kind of thing really. And it was, I think the best sort of way to go about it. [Jaz]Triman, I wish you all the best with your next year. It’s good that you’ve survived DF1. Well done. And you definitely come out, stronger, better for your dentistry, which is great. And I’m excited for your composite course and also for your future, my friend. Keep in touch with the Protruserati. Hope to see you on Protrusive Guidance. It’d be great for you to post a few cases now. And again, that’d be nice to see in your progress. It’s we’re all kind of invested in it now. So we’re rooting for you Triman. You keep going, sir. [Triman]So yeah, thank you so much, Jaz. Really nice speaking to you. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. Hopefully that was useful insights, especially if you’re entering the real world of dentistry. I’m very impressed with Triman’s attitude. I think he’s going to go very far. I think he’s got his head screwed on. I’m very excited to follow up his progress in his career. If you found this prospective episode useful, if you found the library of protrusive episodes helpful, would you mind leaving us a review? We’d really appreciate that. That’s how we grow. There is a team behind us. We have Erika, the producer. We’ve got Krissel and Nav on the notes. We’ve got our CPD queen, Mari. This episode isn’t eligible for CPD, but if you’re a dentist, by the way, and we are now PACE approved. Oh my God. Okay. So I need to do a big announcement about the PACE approval. So probably not many people are going to hear this one, but there’s a big announcement coming PACE is basically like the US governing body for quality controlling education. And it was a long and arduous process, but we are now officially PACE approved. So the US docs can now get official accreditation. So we’re literally this month sorting that out as well. For those episodes that are eligible, but for the rest of the library, which is eligible for CPD or CE credits, that’s on Protrusive Guidance. That’s our app. You can actually scan. If you’re watching this YouTube scan, the QR code below, join us on the iOS or Android, or if you’re like a laptop kind of guy like me, hit protrusive.app in your browser, check out the community of the nicest and geekiest dentists in the world. Thanks so much for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Is this the death of impressions for Dentures? Are digital dentures predictable? Time saving? Cost saving? Are all types of dentures suitable for the digital workflow? Even if you don’t use an intra-oral scanner, your lab may be utilising a digital workflow, so it’s a great time to dive deep into this area. Impression Club’s Dr Rupert Monkhouse joins us for another removable prosthetics themed episode where we discuss how digital dentistry is changing the way we make partial dentures and complete dentures. https://youtu.be/P8XBEU5I6kc Watch PDP195 on Youtube Check out Impression Club courses This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes A and C. Dentists will be able to: 1. Understand the key differences between traditional impression techniques and digital workflows in denture creation, including the benefits and limitations of both methods. 2. Evaluate the accuracy and efficiency of digital dentures compared to traditional methods and implement best practices for integrating digital workflows into their clinical practice. 3. Effectively collaborate with dental technicians using digital tools, fostering better communication and teamwork to achieve optimal patient outcomes in denture fabrication. AGD code 670 Removable Prosthodontics (Emerging technology or techniques) Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:03:18 Protrusive Dental Pearl – Understand the Why05:38 Introduction to Dr Rupert Monkhouse8:11 What kind of Dentures can we do Digitally?13:33 What work still requires Impressions?17:05 Which Scanners?19:55 How Accurate?28:24 Should Digital be the Gold Standard?30:55 Immediate Dentures38:55 Cobalt Chromes47:55 Finding great technicians58:08 Impression Club If you liked this, you will also like GF018 Intra-Oral Scanner Click below for full episode transcript: Episode Teaser: For the workflows where we scan the lab work or we did the reference denture, eight out of eight preferred- When I've got the macro flash on it and my 4G megapixel camera. Yeah. I can see the difference minorly aesthetically in the teeth and things. Beyond that, there's no real downsides from my perspective. So clinically for me- Jaz’s Introduction:Is this the end of impressions for dentures? Have we finally reached a time whereby we can scan the tissues and we don’t need any of that mucocompressive nonsense. Is digital dentistry there yet when it comes to dentures? For our clinical steps, the design and the manufacture of our dentures. Our guest today, Dr. Rupert Monkhouse, back again on the podcast, does a wonderful job of giving us an overview of how digital denture is employed within dentures, not only by us clinicians, but also the lab side and the manufacturer side. But I asked him to truly dive deep and focus onto what we do clinically. How much of what we do clinically can we now do entirely digitally? And the two workflows we discussed today in really good depth are the complete denture workflow and the Cobalt Chrome partial denture workflows. Get your onions ready because this is a really deep and really awesome episode. I think Rupert does a wonderful job. You will find out which scenarios we should be actually scanning and ditching the impressions and whether there are any game changing benefits of moving to a digital workflow for dentures. This episode is our highlight episode for removable prosthodontics month. And next month, i. e. September, will be occlusion month. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I feel like I haven’t connected with you guys for so long. I know you’ve been having an episode every week, but a lot of those episodes actually recorded a while ago. I knew that when the summer would come and my son would be off school, that we would get really busy. And also we’ve moved from Reading to West London. Not too far from Heathrow actually. Moving is not fun, but we’re finally settled now in my new office space and it’s so great to get in front of the camera again and make protrusive episodes because I learned so much. I had a minimal understanding of digital dentures and I gained from this episode and I know that you will too. Here at our new family home in West London we celebrated my son’s fifth birthday and I was thinking, oh my goodness, where did those years go? And I actually remember when my son was born and I announced it on the podcast all those years ago. And many ways we have grown. We as a Protrusive community have grown around the world. Whether you’re watching this on the Protrusive app, YouTube, or listening on Spotify on your commute, however you consume Protrusive, it really means a lot that you tune in. If you aren’t already on our community for the geekiest and nicest dentists in the world, do check out protrusive. app. You can actually access it on your laptop or your web browser or the native iOS or Android app. If you’re going to download the Android app, by the way, make sure you actually make an account on the website first, which once again is protrusive. app. The big change with all this I want to announce is that we are finally PACE approved for those doctors in North America. When you answer our quizzes for CE, you can actually enter your AGD number and we will take care of the CE for you. The American doctors have been asking me for years about this approval and I’m so pleased that we can now contribute to your CE tally. Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl. Today’s pearl is related to the field of prosthodontics, whether it’s removable prosth or fixed prosth. There’s often lots of stages when indirect work is involved. And the pearl is that it’s so, so, so important to understand each and every stage of what you do and why you do it. What benefit is the technician gaining? What challenges are you presenting to the technician? For example, when I was learning complete dentures for many years, I followed the whole checklist in the recipe book for all the things that you check for, for a wax jaw registration. But sometimes I was guilty of not knowing why we are recording certain. Sometimes I was guilty of not knowing why we were recording that piece of information. What benefit will it actually have to the patient or the technician in recording this extra piece of information? And it’s only when you understand the reason for which you are recording something that you can actually be more judicious about your work and actually understand, actually, I don’t need to record this because the technician doesn’t need it in this scenario. I’ll give you another example. I remember taking one of my impressions many years ago to my consultant. I was a trainee and I showed him my impression and I thought, hmm, I think I’ve screwed up because there’s an air bubble. I didn’t notice it before, but I see an air bubble in the impression. Does this mean that we can’t proceed with the crown anymore? And that I need to bring my patient back? But he pointed out to me that yes, there is an air bubble. But where is the location of this air bubble? Is it in a critical location, i. e. at the margin where your seal will be disrupted? Or is it a little bit away from the margin? And actually visualizing what the model, what the cast model will look like. And what this actually means for your crown. Is it critical or is it not? In that case, my air bubble wasn’t critical. I didn’t have to bring my patient back. And so when you really think what the technician is getting from you and what compromises that you may accept, it can really help you advance your prosthodontics. Another example is should you do a half mouth scan or a full mouth scan? Imagine you’re doing a single crown in what kind of scenarios is a half mouth scan acceptable? And what kind of scenarios do you actually need to scan the entire dentition? So Protruserati, make it your mission. If there’s any aspect of prosthodontics that’s always confused you in terms of data collection, what you send to the lab, then please post it on our app. The philosophies and values of protrusive guidance is that we don’t want to be judgmental. There’s no such thing as a silly question and we can all learn and grow together. Hope you enjoyed this episode, I know you will, and I’ll catch you in the outro. Main Episode:Dr. Rupert Monkhouse, welcome back to the Protrusive Dental Podcast once again, we’ve talked about your journey before, which we absolutely loved because if anyone hasn’t heard it, it’s a wonderful story about how you landed your associate position that you’re in that you’re still there now, actually. It was just wonderful. I won’t do the spoiler now because I want everyone to go back and listen to that because it was so good. And then you also talk about complete lower dentures, which we all hate, and then you covered that really well. And then now with so much of the digital stuff around, I was like, okay, who better than our own resident denture geek, Dr. Rupert Monkhouse, to talk to us about digital dentures. Now we were catching up before we hit record, and some people may not have heard of you, very few people, right? You are like the guy associated with hashtag Impression Club. But I would like to know, By the end of this episode, is that in jeopardy? Are you going to start calling it hashtag scan club now? Are impressions dead? That’s one of the questions I have. So Rupert, take it away. Please introduce yourself to those who may not have heard of you and say hello to the Protruserati who already know and love you. [Rupert]Hi guys, thanks for having me back on mate. It’s been a long time actually, virtually or otherwise since I’ve seen you. It’s been probably was that last chat even. But now I’m Rupert. I’m a general dentist based in Reading. I’m just, well, village down the road from you. And as you just alluded to that, I’ve restarted, I’ve gone back to school. I’ve just finishing off the first year of the MClinDent in Fixed and Removable Prosth at King’s. And yeah, I do general dentistry. We’re fortunate to have lots of specialists in the practice, so I don’t do endo, I don’t do perio, I don’t do that much cosmetic stuff. I work with people like Celine Higdon and things. So I do quadrants, crown and bridge, and most of the dentures in the practice as well. And I do a little bit of teaching and speaking on some removable too, including on digital dentures, which we’re going to chat about today. But spoiler alert, we’re still going to do impressions. [Jaz]We’re still doing impressions. Okay. There we are. Now we know, and then we can talk about the indications. Cause my only experience of digital dentures, probably around I don’t know, 2017, 2018, we had the TRIOS scanner and this patient needed like an immediate denture. So we thought, okay, why don’t we just scan and see what comes back? And out came this acrylic immediate denture and it fit pretty good, right? I haven’t been brave enough yet to replace impressions for Chrome work, but I’m feeling that maybe you’re going to convince me that maybe we can, and I just like to know, and I think we’d all like to know those who aren’t using digital techniques for dentures. What’s actually involved? What are the nuances? What are the differences? What are the compromises and what are the benefits? So I guess the first place to start will be what kind of dentures can you actually do digitally, right? Is it partial? Is it complete? Is it Chromes? Is it the world’s your oyster? And what are the sort of boundaries? [Rupert]I mean, if we’re going to talk digital dentures as a whole, yes, you can do it for all of those things. Immediates, partials, completes, chromes, everything. The key thing to break down is, I was like, when I talk about it, I put up a little Venn diagram of three overlapping circles, okay, so there’s three things we can digitize. That’s the data input, so the impression of some sort, and the jaw edge, etc., etc. So we can digitally do that. We can digitally design dentures, whether that’s chromes, completes, partials, and we can digitally manufacture dentures again, mostly at the moment for complete dentures, chromes are getting there, partials are a little bit iffy. So there are those three areas and with a Venn, it’s not a perfect Venn diagram, but they almost work interchangeably. And I’m sure we’ll talk about, you can sort of jump in and out as it suits you. So there’s, as you say, indications and pros and cons. And there’s certain cases where I think this is going to be great for digital, certain where we say let’s do this all analog, some where we’re doing it hybridly. I’m sure it’s something we’re going to cover, but there’s no really yet purely digital workflow. The closest would be Chrome’s. But I’m not sold on the digital manufacturer of Chromes yet, but we’ll get to Chromes later. [Jaz]Well, I guess when we were brainstorming this, Rupert, in my mind, yes, you’re totally right that the whole designing is done by technicians that say digitally, and then there’s digital techniques to actually produce the denture. Is that like printing, for example, right? [Rupert]Absolutely. Yes. I mean, in terms of manufacture, if you’re talking acrylics, you essentially are looking at milling or printing. [Jaz]And can you, for dental students, can you just explain, it’s useful to know what’s the difference in milling and printing, just the bare foundation, which is useful knowledge, even for how zirconia crowns are milled. What does that actually mean? [Rupert]Sure. So in terms of the milling, you’re going to have done a digital design, and then you have a solid block of material. So your crown, you’re going to have like your little solid ingot of zirconia, or Emax or whatever it is. And in terms of the complete dentures you’re going to have the acrylic. Now I do a lot of work with Ivoclar and full disclosure I’m a key opinion leader for them now but they don’t pay me to say anything. And they have a system called Ivotion for instance which is incredibly clever, which is actually a puck of pink and white fused together already that you mill a denture out of in one piece. Other systems you mill the pink so it cuts away, drills it away inside this milling machine like a Cerec machine for instance. Drills it away, and you bond together, then you’re pink and white, and you have a perfectly formed denture. [Jaz]So it’s a reductive technique. Milling is reductive. You get a big block, you make it into a shape that you want. [Rupert]Yeah, so that takes time, which is the downside to that. And there’s obviously wastage as well, because there’s a lot of stuff that you’re not using, essentially. And you can try and be clever with a full set of veneers or something. You can sort of mill them out of one puck if you line them all up correctly inside it. But for dentures, and that’s something I’ll probably talk about later in pros and cons, a full service lab isn’t necessarily going to want to mill one arch of a denture when they can mill 20 zirconia units. So that’s where things get a bit tricky. Printing is an additive thing, so it starts from the ground up essentially, and it is a lot less wastage, it’s faster. But the material science isn’t quite there yet, I don’t think. Dentsply- [Jaz]It’s been limited to resin, right? I mean, the traditional acrylics we use, they’d be different to what we can print? [Rupert]Yeah, so there’s a material called Lucitone from Dentsply, which seems to be the one that’s sort of leading the charge at the moment. We’ve had a play with it. It’s not quite there yet in our hands, but we’ve only done it for partials. It seems to work better for completes. In general with this, complete dentures is the easiest way to get into the digital beyond what you said with immediates and again, well, I’m sure we’ll get to that in a bit. But essentially the printing process there again is in two stages. It prints the pink, it prints the whites and you bond them together. And that’s where the partials is quite difficult. If you’ve got like the single tooth, how do you know you bonded it exactly right? Whereas the completes, when it’s like a horseshoe of teeth, it’s a lot easier to get that into the correct place. But printing’s going to be the future. It’s the same as anything. Additive manufacturers always going to be the future because it’s faster, there’s less waste involved in and so forth. So that’s a manufacturer side of it. I said, it’s just one caveat. It’s a lot more accurate and a lot well, we’ll touch on some cases that I’ve been doing perhaps, but it’s a lot faster, more efficient for the technicians as well. [Jaz]So printing is more efficient. Yeah? [Rupert]Absolutely. Yeah. [Jaz]Okay. So the reason I asked that is because I want to touch on it but really the the main focus I want to do today if it’s okay with you Rupert is the actual dentist, the clinician side of it, right whereby it’s the data input stuff but it’s great that you reminded us that actually digital dentures encompasses so much more than what we do chair side. But if we perhaps focus on a chair side, what stages because we’re talking about so the difficulty in this episode, Rupert, unlike other episodes that usually we’ve honed in on just Chrome’s or just completes and partials. We’re kind of talking about dentures in general, right? So huge scope, but let’s try our best. What stages or what types of work do we still need impressions for? For example, you might say that the secondary impression of this type of denture, where do we still rely on impressions? [Rupert]Fine. So for me personally, in the workflows complete dentures still needs an impression. [Jaz]Both primary and secondary? [Rupert]So in terms of primary and secondary, yes, you can do that. Okay, so let’s just talk completes for a second because it will get sort of, there’s loads. So as I say, I mentioned, we sort of, we teach this and we did a course on this last, I don’t know, when was it, June or something. And even within the course, we worked out like four different workflows because there’s just so many areas that you can use. Okay. [Jaz]So I think what’d be good and useful, Rupert, then is like, I mean, I’m going to want you to continue and explain this, but I think for the purposes of making high quality education here. But not doing injustice to, like, you don’t want to scrape all four, right? If we just discuss one workflow, which you think is the most real world applicable workflow. We’ll talk in detail about that. And then the other three workflows, I want them to go on your course. I want them to learn from you. But there’s no point skimming four workflows, right? There’s no point skimming four workflows. So briefly describe them. But it’ll be nice to example patient, talk about that. It’ll really make it tangible. But yes, complete dentures, you were saying. [Rupert]Yeah, so complete dentures. So for your general dentist or whoever’s listening who hasn’t done anything. You can do everything your side, in the chair, completely analog. Okay, so you can do primary impressions, you can do secondary impressions, jaw edge, etc. And you can scan all of those things. Okay, so you can take a primary impression, you can scan it. TRIOS is fantastic at that and it has a setting for it. So does Medit. [Jaz]I’ve never actually done this. So actually scanning the impression, because I’ve seen people scanning the models, but actually scanning the impression. Okay, cool. [Rupert]Scanning the impression. So you can scan your impression and that will send off to the lab. The lab inverts it and that becomes a cast. Okay, so it’s very cool. The benefits of doing that. My technician Dean is up in Oldham, I’m not posting it overnight. It’s not in this hot weather being left on top of a radiator or something. The bag opens, the alginate dries out. Whatever comes out of the mouth is being replicated by the scan. There’s infection control stuff, you’re not worried about, did the nurse completely, perfectly disinfect that thing that my technician’s going to open. But also things like, we’ve done those lower, as you mentioned, we talked lower completes two episodes ago. We’ve all done it where we’ve got that super scraggly bit of lingual sort of extension that’s super flappy and moving around. When your technician cast that that’s going to distort and your impression is not going to be realistic because you can just scan that it’s going to be perfectly replicated. So you get more accuracy there and of course the scan is that your technician in 45 seconds. It’s not taking a day and a half to get there. So you can do that and get the benefit of that and then they can make a tray for you conventionally, and you can take a secondary impression, and you can do the same thing again and scan it. And you know exactly what you’ve taken has been replicated, and there’s no room for the distortion there. [Jaz]Is there a specific mode on TRIOS for this, for scanning impressions, and also, I don’t know, I don’t trust my iTero. I just, I don’t know, for me, iTero, because I’ve used so many different scanners, I use iTero, yes, we do Invisalign, yes, I do it for my crown prep stuff, but I just have this, and correct me if I’m wrong, I just have this feeling that I’m using this slightly inferior scanner when it comes to restorative, so will it have the fidelity and the quality to do that? [Rupert]Disclosure number two, I’m a Beta Tester for 3Shape. So, you can do this with an iTero. It’s very challenging at the moment. They are bringing out a denture mode on iTero. But the previous stuff that I’ve done with it, it starts scanning briefly, turn it off, turn off the cleanup, and then it will sort of work like a desktop scanner. But there’s no algorithm there for it to work out what’s going on. Things like PrimeScan, Medit, Trios, 3DISC, they do have specific denture settings. And for instance, within Trios, when you say I’m doing a denture, it gives you five different options of how you’re going to do the denture. So again, we’ve got other workflows. But one of them is impressions. And it has a specific scanning path, so it knows you’re going to start at the tuberosity, and you’re going to scan around the arch, etc. So it knows roughly what to expect, so it stitched it together much quicker. So with the TRIOS you can scan an impression in 30 seconds, where in iTero it can take me 30 minutes in my lunch break kind of thing, because you’re literally going back to eating and things like that. So, I’m sure iTero will get there because they’re bringing the system in but at the moment those companies are are ahead of it. But you can say you can scan with all of those. [Jaz]Good because I think people are wondering oh will my scanner be good enough? I think you’ve answered that and I think the future is exciting for that. What about when you get to the wax jaw registration? Can you digitize that? Can we scan that? [Rupert]Absolutely. So again, you can do your wax rims as normal. Do all of your markers and so forth and then take a bite reg and then what you can then do is scan that outside of the mouth. So you can then essentially on the TRIOS you’d call it the reference denture, which again is another one of these five workflows where essentially you’d scan your lower rim 360. So you scan the fitting surface, which is already based off your secondary model. So it should be your working base essentially. You then scan the wax rim all the way around and you have a exact replica of your rim. You do the same for the upper and then you put your bite reg material in between click it all together and you just scan a bite as if it’s an iTero scan like you do on your restorative and then the technician has a virtually mounted set of models, essentially, they can then just invert the wax rims again. They’ve got their models in the correct position and they can design you a denture. [Jaz]Brilliant. And how successful is this? Is this something that there’s no evidence for in terms of accuracy because it’s so new? Or have the papers already been done in terms of, yeah, this is acceptable. But, more importantly, I also want to know your experiences in doing this because you’ve done, you do a lot of this kind of work. So when you have done it, the traditional impression workflow, and now using this kind of workflow. Are you noticing that they’re the same, superior, inferior? [Rupert]So, there’s evidence coming for it, more and more. Yeah, there’s loads of papers on accuracy of scanners, but it is more for crown and bridge and things like that. I mean, anecdotally, from my own, sort of, Dean and I have been experimenting, so I think we’ve done, across various different workflows, we’ve done, I think, eight cases now, where we’ve actually given the patient two sets of dentures. So, for instance, we’ve done cases where all the way through we’ve done the primary impression, I’ve scanned it, and I’ve sent the impression off, we’ve cast it up. We’ve done a secondary impression, scanned it, and cast it up. We’ve done a wax rim, we’ve scanned it, and we’ve mounted it. We’ve done a 3D printed try in, and we’ve done a wax try in. We’ve processed and we’ve milled, and then I’ve given the patient two sets of dentures. said where this one for week one, this one for week two. [Jaz]And did you blind the patient as to which one was which? [Rupert]Blind patient? Didn’t know which all I did was put a dot on, I put a dot on one set of them. So they knew which pair goes together and for the workflows where we scan the lab work, or we did the reference denture, eight out of eight preferred digital. [Jaz]Wow. I mean, that is categorically a preference there. That is awesome. [Rupert]I’m not sure what the power number needs to be for this study, but from mine- [Jaz]That is pretty good. It’s not like you’ve done two, done eight, right. And they’re all preferred. It’s not like, Oh, it was six and two. It was eight. That’s pretty awesome. Now when you actually look at the denture, can you tell just by looking at it, which is the digital workflow, which is the impression workflow? [Rupert]Just about. So Dean’s getting very good at disguising them. So, all of those cases we’ve done were milled complete dentures, and we’ve done the various two different options where you mill the pink, mill the white, glue it together, and you mill the monoblock, the Ivotion. So of course, what it means is, either way, the teeth are all one solid piece. So you don’t get that really nice sort of separation like you do with the conventional mounting teeth inside the wax. So, there’s a lot more sort of work dressing it up to make it look pretty, to sort of disc in between, put a bit of tinting in. Yeah, because I’ve done it, you can look at them and you can work it out. But from extraoral smile photo, things like that, you can’t really tell the difference. The quality of the teeth at the moment isn’t quite as nice. You’ve got those very high-end denture teeth with the layering and the translucency and things like that. That’s coming. That’s coming within these blocks. They’re getting very, very clever with the blocks. But, the average patient on average person on the street is not going to tell the difference when they’re done really, really nicely. And Dean’s got very, very skilled at doing that. [Jaz]What kind of metrics were you assessing for in terms of patient feedback on, and also your feedback? Like, for example, yes, the patient preferred them, but did you notice a difference in the retention and stability, or is that roughly the same as just the patient preferred the comfort? What was it superior and was there anything that was inferior about the digital compared to the traditional? [Rupert]So, the only inferiority is when you’re really, really, really macroing in, and I take my big photos and whatever, and I sit there polishing off all the dark spaces on Photoshop, all of that, when I’ve got the macro flash on it, and my 40 megapixel camera, yeah, I can see the difference, minorly, aesthetically, in the teeth and things, beyond that, there’s no real downsides from my perspective. So clinically for me, much fewer adjustments to the fitting surface. Usually none. The bites, again, very rarely do we even need to adjust the occlusion at all. It’s as sort of, as long as your try in was fine, your fit is going to be fine because it’s a perfect replication. So you’re not doing the whole investing of the wax, melting it away, the teeth might shift a fraction, you put the acrylic in, that distorts, you’ve not got any of that. So there’s no real tweaking of the position of the teeth from the patient’s perspective. [Jaz]Well, can I just check for here now? Because we didn’t talk about this. So the wax try in, is that the digitally produced wax try in when they send it to you, that’s actually still in wax, right? [Rupert]3D printed. No, so we normally 3D print it, so it’s a solid block 3D printed or milled, you can mill it, but that’s more, more costly. So you can print it, mill it. Yeah, in theory, you could dip out of the workflow at that point and do it in wax, but then you’re missing out on the benefit of the digital planning side of it, which I know it says the technician side, but I’ll just briefly touch on that. So as we said, you’ve if you scan your watch rims, you’ve got these articulated digital models. What the technician then does on the software is essentially they can analyze the models like they do they mark certain landmarks papillas, tuberosities, the rugae, the arch form, etc. And then the software automatically puts the occlusal plane and the software will automatically put the teeth on the upper where it needs to be. The technician can then tweak it with their own eye and experience. And then the software automatically makes the lowers go into the best possible position to match the upper. So, Dean’s done this where a full, full setup he can do in two minutes and then tweak it a little bit. I’m only just starting my technical journey in the laboratory bit. It’ll take me half a day to set up a complete and even then it’s one tooth at a time and the chance of getting everything interlocking beautifully is so low. Whereas that you just literally click a few buttons and it’s done for you. So that’s where the accuracy of the occlusion and that’s what I think patients perceive. is they just say it feels tighter, feels better in the bite, and feels softer for the milled surface, feels softer in their mouth for some reason. [Jaz]Okay, and that 3D printed try in, what if you like on a traditional wax trine, if you want to maybe just tweak a tooth, maybe make it a little bit more imbricated, you want to maybe adjust it, obviously you said the occlusion doesn’t need much adjustment, but melt the wax, you intrude a tooth a little bit. You don’t have that luxury anymore in the 3d printed, right? You’ve got to really give the technician enough information and maybe even WhatsApp communicate. Are you happy with this? Are you happy with this before they actually send it over? And that’s what I’m thinking. [Rupert]Absolutely. So yeah, that’s one of the areas where in the workflow, it’s a little bit more challenging because as I say, again, like through though the MClinDent I’m sat there a lot more with the wax, I’m a lot more comfortable with moving the teeth around and things like that. So generally the byte’s pretty spot on already because it’s been worked out by AI and all that kind of stuff. But you can always still tweak and polish as if it’s almost as set denture. Because it’s on this full printed monoblock base, it’s rock solid. So you can sit there and you can adjust it, it’s not, you know, the teeth aren’t going to move and they’re not going to break off and things like that. So you can tweak and adjust them. And then the technician or yourself can even scan that back in and just copy that. A bit like how you do your mock up in the mouth for a veneer case and then you scan it and replicate that for your finals, you can do that again. So it’s a little tricky when you’ve got macro changes to make, like you’ve got the incisal length too long and you need to lop off two millimeters. [Jaz]You could just drill it off, right? And then draw on there. [Rupert]You could just drill it off. Exactly. So that’s what I’ve done. I’ve done it on one of the cases we show where like, just got a sharpie out, sort of scribbled on the incisal edge until the patient was happy. Drilled off one side so the technician can measure it. But then when they go back in, they just chain the teeth together, link them together and just go, right, move up two mil, job done. And they’re not sat there for 45 minutes moving all the teeth up and then dialing the occlusion back in. It does it for them. So it’s a little bit trickier chair side, but actually for the technician doing those changes, it’s easier. And as you say, full face photos always, this is usually an element that we come to a lot. You can’t get away from your classical pros. Digital isn’t going to save you. If you don’t put a retraction cord around your crown prep, your scan isn’t going to be any good. Just because it’s a scanner, it’s not going to save you, yeah? So you’ve still got to do all of that brilliant analogue work, which includes, for me, my workflow doesn’t change. When it’s a wax try in, I’m taking full face portraits, full set, side on, relaxed, smiling, etc, etc. So Dean can sit there as he normally does and says, you’ve got the midline wrong again, yep. Idiot. Yeah, I’m going to do that. Do that. Tweak it across. So all of that and he can still tweak all of those things. But it’s just a little bit, you’ve got to sort of work on, think on your feet a little bit more compared to, as you say, just tweaking teeth a fraction. [Jaz]Well, on that theme about learning and thinking differently, I think Peter Dawson said that, digital was great. But it’s a way to get, maybe it was Frank Spears who said this, it gets you into trouble faster. Like you can like, now you’ve got like a Ferrari and you can actually just crash it much quicker basically. So you’ve got to kind of know the nuances, how to drive it. So my next question really is, now that you did this little experiment, which I highly respect, and we found that actually all this digital stuff we’re doing, it’s actually improving patient outcomes. So that’s already one reason why we should, because, because for me, I’m thinking, look, you’ve done the impressions to scan is actually an added step for the clinician at a time and step for the clinician, right? And the quality of scan was something goes wrong, et cetera, et cetera. So we’re actually adding time in some ways when the clinician to produce this digital result, but we’re getting a potentially a better result. Is it also cheaper? Is it also faster, better in other respects? And do you think that we should be? Moving this workflow, this exact workflow described whereby you take an impression and scan it, should that become the standard? [Rupert]Yes, I think in terms of the laboratory costs at the moment, it’s more or less the same because it can be a little bit more expensive because there’s more time taken in finessing them at the end with the artistry and stuff to make them look good. I mean, in terms of your clinical time, yes, the scanning is going to take a little bit of time, but at the same time, whilst you’re taking the opposing alginate, your nurse could be scanning the impression for you. [Jaz]So the whole no postage thing is also winner. [Rupert]Yeah, exactly. And that’s it. You could say, well, I couldn’t shrink my turnaround time by two days because it’s not going to take two days to get there. And the other models already cast up. They haven’t got to sit there and wait for the stone to set and then trim it and do you know, so there is a lot more efficiency from there. I think the interesting thing for the future is going to be, are you going to end up with these digital labs where you have a master technician and a bunch of CAD guys and the CAD guys set everything up and then the technician comes in and goes move that move that right next print that move that move that right next do that and actually you’ve then got this much more effective efficient laboratory rather than one person there mixing 400 kilos of gypsum every day and that kind of stuff. In terms of the patient outcomes, my patients are preferring it. We are moving more and more towards just doing that. We’re still doing a lot of the comparisons just for our own sort of research, but we’re moving towards that being our main workflow for particularly the complete dentures. And the Chrome dentures and immediates as well. So personally we’re getting there, but even for yourself, if you don’t want to scan it, you can send it to your lab and most labs now have a lab scanner so they can scan it for you. So you don’t even need to own a scanner, but you could still do digital dentures as well. So, yeah, there’s a million different ways that- [Jaz]The scope is so vast, the scope is so vast. So on this topic of you just mentioned immediate dentures is a really easy win to someone who’s never done anything. It’s just really new to digital is to scan someone’s like, imagine you’re doing immediate denture to replace, two upper laterals or something right in the upper left lateral, upper right lateral. And then they’ve got these like dodgy restorations and then about to be extracted. If you scan the arch as standard, you’ve got enough teeth to get your retention. The acrylic can actually engage into the undercuts. Is that a really easy impression free win for immediate dentures? Or am I missing something here in terms of some nuances that we should consider before considering scanning over impressions? [Rupert]100 percent so for me, they’ve pretty much, I’d say 90 percent of my immediate dentures I scan for. The only times I don’t scan for would be if I’ve got a big free end saddle already, because the scan isn’t great at getting the soft tissue that things like the TRIOS and the PrimeScan and things are much better. Obviously things like you mentioned Invisalign again earlier or iTero earlier, that’s Prime before Invisalign. So it wants to see teeth everywhere. It’s not that great at picking up pink. But even if it can pick it up, you don’t have the functionality. So that’s the line- [Jaz]Then you’re taking the impression, you’re scanning that then. That’s why you made that distinction, right? [Rupert]Well, if you’re doing that. So if it’s a free-end saddle and it’s perio teeth or something like that, I’ll still maybe do an impression and maybe we’ll make that analogue, still. But for perio clearances, partial clearances or whatever, for me the scanning is far better, because like you mentioned there, like the acrylic and the undercuts and things. When you’ve got those long receded teeth, black triangles. Alginate is just going to tear. So the technician actually isn’t going to be able to get that colletting really nice. The digital ones where you scan like that, they get such a better fit in that initial stage. It’s just where you have a flange is not going to be accurate. It’s not going to be functional because you’ve not done any border molding. So that’s the area where, again, it comes back to that you need to know your analog, where if I do a digital immediate, when I fit the denture, I will still do inside the denture. After the teeth have come out, I’ll do a light body wash inside, fit the denture in. Patient will then board a mould, and that will show up at the flanges, it will push away the light body where it’s overextended or it’s too tight. And that will show up as just plain acrylic within an island of acrylic within the light body. You get your handpiece out and you adjust that and you’re going to sculpt or carve back a functional sulcus at that point. So, that’s the step you need to bear in mind is that you might need to then do- [Jaz]But then are you sending it to the lab to get that processed then? [Rupert]No. So it’s already processed. So I do the scan. The lab prints off the models and they usually just make it analog on those models. They might duplicate them. But they make it analog on those models. I take out the teeth. I do the denture. I fit the denture in. I do the light body. And I use that as a fit checker to see where it’s overextended. So where that silicon gets pushed away on the flanges is where it’s overextended. The lips have pushed the silicon out of the way. So that acrylic would be too far up into the sulcus. So you just mark that little island of acrylic with pencil or sharpie or whatever. Peel it all off and then you just polish these little hot spots where it’s too tight or too extended and then you’ve now made it functional, but you still need to know how to do that in the first place. But for me those are media digitally 100%, all the way. Periopatient’s amazing. [Jaz]Brilliant. And could you just use pressure spot indicator paste in those scenarios? [Rupert]You can. I find it a little more messy. You can get specific silicons as well as specific fit checker silicons that set faster than your standard light body as well. So you could use PIP. I find PIP is more useful at review when there’s an ulcer and you dry it, put it on the ulcer and see where it transfers. [Jaz]So maybe we’re talking about different brands. I really like the Coltene one. Have you used that one? The greenish one? [Rupert]Yeah. [Jaz]Okay. Cause that’s fairly fast setting. I mean, that’s kind of like a FitChecker quite fast set, but so there’s another one that’s white, almost like toothpaste, that’s horrible. That works well for the dental ulcer, I find. [Rupert]Yeah, but that’s for the ulcer. There’s different ways to do it. I just get regular silicons and just pop it in and then. [Jaz]Which is good because everyone listening to this who doesn’t have PIP, they’ve got silicons they can use, right? So that’s the good thing you mentioned there, because we’ve all got it in our drawers, we can use that. Now you’ve said about finding out where it’s overextended. What about if it’s underextended somewhere? We can just get our chair side acrylic and just add some and then just mold them, do the border molding chair side, right? Ads:Does occlusion confuse you? Do you feel like you need it taught in a way that actually makes sense? 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That’s BOO, Basics of Occlusion. [Rupert]Yeah, absolutely. So you could add to them exactly the same. No problem at all. Whenever I do an immediate, I’ve always got something like Visco-Gel ready to go, which isn’t as a soft sort of temporary liner that it’s quite clever. It’s sort of fixed tropic. So it’s keeps drifting around where it needs to go and things. So you can still add so that you could use chest type acrylic, you could use soft GC reline, silicon, material, whatever you want to use, you could extend it again correctly. And I mean, that’s the interesting sort of one that under extension with a scan as well. And that’s where, that’s the misconceptions that you go, oh, I’m doing a complete digital data. I’m going to scan soft tissues. By the way, that’s the ninth case we’ve done side by side. And that’s the only one where they preferred the analog when we scanned the soft tissue. [Jaz]Okay. So what you’re trying to say is, you actually tried to bypass impressions completely and did it all from scanning any kind of, I imagine you’re like kind of holding the cheek in a certain way to like mimic where you imagine their boulder molding would be, right? Is that what you’re trying to do? [Rupert]We just scanned it and Dean just sort of guessed as much as he could. But yeah, so you can get a bit of under extension, but if we’re talking immediates yeah, you’re relining them at three months. You’re remaking them. So it’s not the end of the world- [Jaz]So even immediate complete is what you described. Immediate complete. Is that what you just described that you did it completely digital? [Rupert]No, that was a standard complete. I mean, we did one recently where this case I’ve just shared on Instagram. Actually, I don’t know when this is going out- [Jaz]But soon it’s removal pros month. [Rupert]Is it? Amazing. Fantastic. Well, it’s called Staged Immediate Dentures on my page. And basically the chap had a load of missing teeth, perio. Had never worn dentures, so I scanned him in the consultation anyway. We made a partial to replace the missing teeth that were already there and a couple of teeth were extracting. See how he tolerated it. And then the same, Dean kept the model on record and said right to take off all the upper teeth and make it complete off the same scan. Again, that’s quite nice. It’s just sat there on the, on the cloud. You can just bring it back, print it off. You’ve not thrown away the model. And that was all over the place, but I just got the GC Soft Reline. It’s a nice silicon material and filled it up basically, and all the board is a silicon, but it fits like a glove still at three months. So, it’s an immediate, that’s the reality of it. It works beautifully for scanning. [Jaz]Excellent. Well, I’m very excited to delve further into this. Cobalt chromes. Can we talk about Chromes? We’ve got time to talk about Chromes and then we can wrap up then. And this would be a nice meaty segment. You suggested that with Chromes, we can actually do a lot more digitally. And in terms of the data input, we might be able to get away with a lot more. Cause remember chromes are tooth-borne in the sense that they’re relying on retention of their teeth more than the mucosa. So can you maybe describe that because you described that complete denture protocol so wonderfully with the impression you scan the impression I think a lot of people that’s really helped it to click in people’s minds. Can you can we do the same for a partial chrome denture that’s probably not free end saddle? That’s a bounded maybe three or four teeth make it a bit easier. Can we talk about that scenario? [Rupert]Sure. So, I mean if you’re looking at a bounded chrome, upper bounded chrome something like that then- [Jaz]Let’s say it’s replacing upper lateral to upper lateral and then a mold on one side. [Rupert]Cool. Fine. So I would look at, for that I’d be scanning as a primary. So scan, usually for me, that’d be in the consultation. I do that anyway from a consultation. Great for communication, either with a patient or with deans a lot of the time. It’s another beauty of it. In that consultation, non invasive thing, take a quick scan. I can send that to Dean, he can then print it off, we can have models together, and we can chat about the case, etc, and plan it, so. We’ll do those scans, it then goes over to Chris, our Chrome technician, he’s going to look at path of insertions, and guide planes, and rest seats, and undercuts, and da da and he can say, ideally rest seats. How are these teeth for rest seats? We need to add, if we’re going to use this as an undercut, etc. And then you can make all those adjustments, do all your preparations, and I would just scan again, try and get as much scan extensions as possible. So my secondary is a scan. [Jaz]So this is after you’ve done your guide planes, your rest seats, all adjusted, right? [Rupert]Yeah. My secondary impressions appointment is preps and scan. [Jaz]And scan again. Okay, great. Now just to talk more nuances of this bit. I quite like nowadays, if I’m doing the guide planes, I get my technician to make me these acrylic copings that just guide me exactly where to drill. I quite like doing that. Do you eyeball it? Do you ask for copings? How do you get the guide planes perfect? [Rupert]Bit of both. Yeah. Eyeballing it usually, but if it’s particularly tricky, like if you’ve got like a, you can have some crazy ones where you’ve got like a lateral and a seven and that’s your sort of bounded area, that’s quite hard to line up. It’s almost like if you’ve got five missing and you’ve got four and a six, it’s like a bridge prep is it’s quite easy to line those up. But yeah, copings are great. Either just making it out sort of an acrylic or you can get some printed, obviously. Now those are really handy just to make things more efficient for you and more accurate because if you’ve got the data and at the moment with, especially the things like the printed, it can take seconds to actually get it made and cost pennies. So why not do it? I think that they’re really, really useful. We had a case last year where we had to reduce the sold abutment. And we did exactly that. It was right. How much space do you need? I want an extra 1. 7 mil, please. So the coping went down. I’ve trimmed off to there. How much buccal space you need prep, like a prep guide. So yeah, those can be really useful to make in the sense of chat to your technician about for sure. [Jaz]And it’s great to use. Also in the fixed prosthodontic world where I remember doing this crown and then the contact with the future implant in the future wasn’t going to be very good. And so he wanted me to prep the mesial some more. So he sent me this digitally printed coping, put it on and just for the few seconds, precisely managed to remove that piece through structure to allow the crown to fit and then now had a better contact area for the future implants. So, it’s great. And to be able to do this so efficiently is absolutely fantastic. So I’m glad we touched on that. I’m thinking some people haven’t seen that before, but, oh, yeah, this is clever. Let me speak to my technician because everything we’re saying that today, guys, it’s going to be wasted if you don’t start a conversation with your technician. I think at the end, I’ll ask you about how to find a technician. I think I’ve asked you that before, but it’s a nice thing to be reminded of. So you’ve done your secondary appointment, secondary Impression, in quotation marks is a scan, obviously, and then what happens next in terms of everything’s being digitally designed by your clever lab? [Rupert]So nine times out of 10, our jaw reg is done with the scan as well, of course. So as long as we’ve got an MIP case, you know, the jaw reg is done as part of the scan, if need, if it’s not an MIP, then, we’ll just do a conventional wax rim, because actually, my lab at the moment still with Chris, with Chris Hesketh is it’s all analog still from him. So he gets his printed model and he just uses that. So we still haven’t dived into the digital chromes just yet. You can do them again. You can do them, you can set aside and mill them or you can print them. It’s not printing. It’s your SLM or SLS, laser sintering and that Selective Laser Sintering, Selective Laser Melting. So again, you’ve got those two options. You can mill them out of chrome, mill them out of titanium, or you can print them out of, again, usually it’s a sort of metal base. The issues with that potentially. [Jaz]I’ve heard of a PEEK. [Rupert]Yeah, so you can use PEEK as well. [Jaz]What is it? Is it a resin? [Rupert]It’s a high impact sort of resin material essentially with a bit more sort of flexural. So you can use that. We’ve looked at it. Space usually tends to be a problem with peak. You need sort of connectors and things need to be quite sort of chunky and it can be quite challenging. We had a case where the patient didn’t want metal. But didn’t want a full palette, acrylic, etc. So we had to do a chrome, essentially, but they didn’t want metal. We didn’t go through with anything, because we said there’s not enough space. You can’t do it. It’s metal or nothing, I’m afraid. But yeah, but peak can be done as well. I’m not sure about printing on peak style materials yet. But the issues for us is that, well, at the moment, we don’t feel it better yet. So if you’re milling, say, usually it’s titanium they do, it’s very, very common in America. America ahead of us on this. If you’re milling it, you can’t use different clasps without not milling the clasps. You mill a framework and then you’ve got to go back in and do clasps conventionally onto the framework. So it’s not that much more sort of efficient. And for the sort of high end chromes we’re doing with Chris, he’s absolutely fantastic. So until it’s better for us, we’re not going to switch. But for health service chromes, for instance, when you get your arm twisted into one of those, it might be a really great option, actually, that’s going to fit really well. But for our workflow, Chris is then making it conventionally analog again. And this is what I said earlier, you can dip in and out. However you like- [Jaz]But the clinician you as a clinician so far, you’ve been fully digital, what you get back, as a clinician and like, okay, it’s good to know that, but I can now crack on. So as far as a dentist concerned it, this has been fully digital. Do you see what I mean? In terms of what you have to do? [Rupert]Yeah, absolutely. From our perspective, chair side fully digital. And I find you’ve got a nicer accuracy with the fit, then we always do a verifier. So either Mill or print a sort of copy of the denture out of an acrylic material so that we can check that our scan is accurate because our chromes are pretty pricey. So I don’t want to have to make those twice. So then we check that’s accurate. Great. So that’s our appointment three. And then you can do a try in tooth trying on top of that as well. If you like, you sort of mill this little framework and it clicks in with some teeth on it. So, the shades rise in the bites, right? And then the chrome gets made and then you fit. So that would be our sort of five appointment protocol there. [Jaz]Do you like to do a tooth try in with the chrome or are you going straight to the chrome with the teeth on because you’ve done a separate tooth try in and a separate chrome verification? Are you going straight to fit? [Rupert]So once we’ve then done the Chrome try we’re then going to fit because ideally with Chrome again, it’s the sort of classic pros ideally you’re doing some sort of tooth trying before you commit to your Chrome framework. [Jaz]Yes. [Rupert]Because you don’t know where exactly your teeth are going to be and where the framework needs to be to accommodate those. Do you need to do backings in type by cases, et cetera. So that’s where, when we’ve done our verifier, we do, usually we’ll just do a verifier that clicks in on its own so I can see everything nicely. And then we have just a separate wax try in that goes in. You can combine them together, but you’re sort of doing neither job at the same time. I’d rather have my verifier. And I can see a bit like an implant guide with windows. You can see that that’s seating fully. So you’ve done that. Then you do your current try-in and just on its own as a framework. And then you’ve already verified the bites, et cetera. So you can go straight to fit. [Jaz]Great. So the main pissing piece is that we all need a Dean and we all need a Chris in our lives. So how’d you go about finding these great people to work with? And what advice you want to give to Petrucciati around the world in terms of finding a technician? Cause so much of what we do hinges on that. [Rupert]Yes. I mean, so my previous technician now works for Ivoclar, Ricardo and Dean. We’re through Instagram. We met online chatting about cases. Ricardo said, let’s work together. Ricardo moved over to Ivoclar. So I said, let’s work with Dean for this case, first case. And now we’ve been working together for sort of three years. Chris is Viadene, Chris only works with a few technicians. A lot of it’s very sort of gate kept and all this kind of stuff. But for me, the main one is Instagram. There’s loads of amazing technicians out on Instagram. So just get out there, find them. And I think the biggest thing with removable is everyone obsesses over locality. Because you’re used to doing relines, additions, repairs. I have a local lab. He’s great. He’s awesome. I send him these absolutely mental additions where we turn like a three tooth partial into a complete denture and stuff like that and he nails it. [Jaz]He loves you for that. [Rupert]Well he loves it because all I send him is relines, repairs and additions. So I pick up the phone and he’s like, what? But I use him for that. And then I use a guy, 200 miles away for the rest of my work. You don’t need to be tied into someone who can do pick up and drop off within the 30 mile radius kind of thing. So there’s loads and loads of great technicians out there. And I mean, this is where the digital gets really cool. You know, we did a case where I did all my stuff in Reading and actually it was a case with Ivoclar and we sent it to a guy in Canada, who’s like the best guy in the world, a guy called Eric Kukucka sent it over to Canada. He designed it. He sent it back to Ivoclar to mill it and then I fitted it, so I didn’t even use a technician in this country, really. Yes, someone in Ivoclar, Ricardo, dressed it all up to make it look pretty. But in theory, you could use anyone with the digital because it’s going to get to Canada in a minute. It’s not going to have to get on a flight. So, as we get more and more into these digital workflows, actually. The world is quite literally our oyster in terms of what technicians we can use. But when you’re looking for one, it’s just about who you can build a relationship with. And, you mentioned earlier, like, WhatsApp and stuff, like, Dean and I spend way too much time on WhatsApp. Probably a good hour, or at least an hour a week, just catching up. Where are we with this case? Where are we with that? Because my, I think I mentioned it before, my lab dockets are horrendously bad. It’s like, try an A2, next time, cheers. See what’s that voice note and there’ll be a two minute voice note about like, Hey man, So I think we need to move this and duh, duh, duh, duh. But we just find that’s a better way for us to communicate because again, you’re busy in practice or whatever just say I’m going to send you a voice note on this day, obviously, and just, and do it there. And I think if technicians- [Jaz]Mind you, there’s a two word prescription, See Email. See Email.. Yeah. And in the email, I’ve got all my stuff, my photos, and my Loom videos saying, Oh, you know, Graham, have a look at this. Can you replicate this? I think I’ll need a guide plan here. What do you think? So yeah, I mean, the world is evolving, even how we communicate is more digital and therefore it’s a mindset shift we need to appreciate because a lot of dentists are like in this fixed mentality that, Oh, I need my technician literally next door building next to me kind of thing. Right. And so it’s good to have that technician, but if you’re not able to do the kind of work you want to, because you think your technician needs to be literally right next to you, then we need to move away from that kind of thinking like you said. [Rupert]A hundred percent. And if the technician doesn’t want to sit there and chat to you about stuff, then we’ll just find another technician. Like, that’s the one we get asked a lot on our impression courses or whatever. It’s how do I find the technician? It’s always the number one question. No one actually cares about taking impressions or doing digital dentures. It’s just literally the way to meet technicians. But if they don’t want to have the relationship that you want to have to do the best work, find someone else. There’s plenty of technicians out there and there’s plenty of other clinicians to work with that technician. Like, we’ve all got enough work, it’ll be fine. But just don’t spend time working on something that isn’t working for you, really. [Jaz]I think what we need to do is we need to create the tinder for technician and dentist, right? Create that, find out what kind of hours we like to work, what kind of a communication methods we like and match them up and stuff. This is a great idea. But if a technician is listening to this, and obviously you’ve listened this far and you’re interested and you are enthusiastic and you like the geeky side of it. If you’ve managed to listen to this far into our chat. Please reach out to Rupert. So he can identify you as, Oh, this is someone who’s interested in help match you up with dentists similarly here. Please message me, join the Protrusive Community, check out the impression club website, which he’s doing great things. It’s about working. I know technicians think, Oh, I’m competing with that technician or whatever. And the same with dentists, but it’s not the case at all. There’s plenty of work to go around and there’s a huge demand for technicians that are just keen beans that we’d like to work with. That are great communicators. And there’s treasure trove of dentists ready to work with you. Should you just put yourself out there? Say, you know what? I’m willing to have these WhatsApp conversations and look at these photos and work closely with dentists. I think they get a better kick out of it, right? They get a lot of enjoyment from knowing who their dentist is, seeing that work on Instagram later, it doesn’t have to be on social media. I’m just giving your example, but you can just have a beautiful relationship with the technician whereby they’re seeing the work that’s being done and fitted because you ask technicians how much of the time this crown that you’re making. Will you ever see it again? No, once a ship is gone, they’ll never ever see. The sad truth is they’ll never see what it looks like in the patient’s mouth. [Rupert]Yeah, and some of the times with our bigger cases, I’ve actually asked the patient, like, is it all right if we give Dean a call? When we’ve done the fit or something and we’ll just sit there on facetime with Dean and he’ll have a chat with the patient because then every time it’s like that absolutely made my day because I document stuff a lot and he’ll see the pictures. And we’ll talk about the lecture about them, etc, etc. But like to actually sit there and have a chat with the patient and Dean’s a main character within my surgery. Yes, it’s me and my nurse and whatever be going right Dean’s going to work on this and he’s got this. They know Dean, they feel like they know him. So then actually at the end they get to have a chat with him a lot of the time. [Jaz]And it adds value as well because the patient’s like, okay, look, you have every right to charge what you charge Rupert, because you take her time, you take use the best materials, you do what you do. But it’s also great for patients to know that it’s not just you. There is a whole team approach behind this. There are really technically skilled people behind the scenes and the technologies that they’re using, which I’m sure you talk about. That’s how you build values. Oh, this gets people, patients are really interested in technology behind the scenes that goes through to make the prostheses that we fit. And if you just engage in that conversation, you’d be amazed how many patients are genuinely interested in what’s happening. And suddenly their perception of what they’re having done is vastly improved for the right reasons. [Rupert]100%, I mean, the number of the patients with these milled completes or whatever that we’re doing, I say this is, I go, Oh, that one’s the computer denture, by the way. And it blows their mind that this thing’s been designed on a computer and a robot has made it. And we’re doing a case at the moment, which I’m really excited about where it’s a upper complete over natural teeth. And patient came in with a lot of expectations, very, very, very high expectations mentioned a certain dentist in the Northwest. And it was going to go up to see him. So, you’re already like sweating at that point where I was like, was it Finley? Yes, yes. Finley. I was going to go up and sit in here. She’s traveling from Oxfordshire to Manchester. I’m going, right. Okay. Pressure’s on. But all I did was another, well, another workflow we haven’t talked about the reference denture, but in the consultation, relined a denture with silicone, scanned it. Dean made a quick mock up. At the next appointment, I said, we can give you this. I’m going to charge you for it. But this is going to gauge both of our expectations. This is 90 percent of what we can achieve. And she went away with it, came back two weeks later and went, this is already 10 times better than my denture. She’s been wearing this printed try in around the house and whatever, and said, let’s go, let’s do this. So, this is incredible technology and it took me five minutes in the consultation and it turned this potentially very stressful case into one of my favorite cases, I’m super excited. [Jaz]Absolutely genius. I love that. This is like the equivalent of doing a really good, not trying, like a temporary veneers that are really good, gives a patient, they know what they’re expecting and they come back and say, yes, this is what I want. There’s no confusion about shade in the future. There’s no friction and communication errors. That is really nifty. [Rupert]Yeah, and that’s the big, I’ve never done it before. So take away the printed try in because it’s always been like, yeah, it’s great. Awesome. Go for it. But for this case, we did. And you know, it’s the old thing of like, they go, oh, can I take the wax try in home? And you go, yeah. So you’re showing my husband, or my wife, or, my daughter, whatever. And you go, well, okay, but like, don’t have a cup of tea, and don’t wear it for too long because it will start to melt and then the teeth are going to move and then we’ve got to start again whereas this is rock solid. If we verified it already. It makes no difference if that thing never returns, if it snaps in half, because they’ve got the file, they just mill it, or print it, or whatever again. So, for those kind of cases, you can say, and I’m going to do it, we’re at the definitive wax try now, we’ve still done our conventional impressions, we’ve done wax, we haven’t done wax rims, because we’ve done reference denture. But we’re going to get the definitive try now, and again, I’m going to say, hmm, we’re not committing yet, you go away for two weeks and wear this at home. And then you tell me you’re happy and then you’ve got consent, right? You can just say you told me you’re happy with this. You can wear this you can eat with this. You can try it all out proper. So that’s a really really cool aspect. And that reference denture, that for me is the gold standard. [Jaz]Well, thanks so much for this whistle-stop tour on digital dentures. I thought you covered a lot. I think a lot of people have gone away thinking, Wow, how am I going to use these acrylic copings to, I can actually scan my impressions to, okay, I can now actually, be more confident when I’m scanning and finding the right technician to communicate with all these factors that we discussed. Rupert, I want them to learn more from you as a guest and a friend. I want them to know about your stuff. Tell us about impression club. Tell us about your next course where people can learn more. Like my job here is whilst I’m not as crazy about dentures as you but when someone, when it comes to learning, I want them to learn from people who as crazy as you are. So tell us about where, what kind of courses you’re running at the moment. [Rupert]So, you mentioned impression club, the impression of podcasts can’t be quiet. Sorry. I’m a bit busy guys, but essentially if you head over to impressionclub.co.Uk, currently we have two courses that are actively running, which is the primary impressions course covering all things, primary impressions with Mike Gregory who- Has Mike been on the podcast yet? [Jaz]Not yet, we had a chat on Instagram and we kind of said yeah we’re going to come on and we never actually got the date. Coming soon. I’d love to have him on. Can you just twist his elbow and just as long. [Rupert]He’ll be there, he’ll be there. So I’ve run it with Mike down in Bath and a dancer called Steph has me up in Manchester who are both awesome and that’s been running for quite a while now. There’s a couple of dates out actually for February if you want to check that out. And then we do a digital denture course as well, which we’re hoping to get launched in again in November. We’re just trying to make sure 3Shape are available, and that is run with both Dean and Ricardo. So it’s quite a unique course where actually we have half the delegates are technicians, half of them are clinicians. So if you want to bring your tech to come along with your technician, then awesome. That’s fantastic. You’re both on the same page. If you want to meet a technician, there’s going to be seven of them there. So, come along. If you want to meet some dentists that want to do it, come along. [Jaz]This is the real world Tinder of a technician and dentist working together. [Rupert]We’re there. So that’s cool. So, in that we cover a lot of these workflows. We go for the clinicians. We do hands on of scanning the imps, doing altered cast technique for free end saddle digital chromes. I’ve got a post about that, I know we didn’t touch on it, I’ve got a post on that on my page if you want to find that. And the technicians do a full full set up on the computers, they do a whole afternoon of working with Dean on characterizing, they get a milled venture in their own hands and get to dress them all up. And it’s just really cool to have both sides together. And then we’re working on a few others in the background, immediate dentures, implant dentures, complete dentures, coming soon. All of those are on the website, available to join mailing lists and things like that. It’s just trying to find the time to put content together, but I know you’re no stranger to that dilemma either. [Jaz]Absolutely, and we appreciate everything you do, including just like hats off again, guys, if you missed it earlier. I’m sure it was at the highlight of the episode where Rupert talked about this experiment they did with his patient. That takes a lot of organization and planning. And so kudos for that. Honestly, I’m so glad you did that. And you were able to share that with us. I’ll put all the links in the show notes. All my followers are already your followers, but I’ll put that in the link as well. So they can, they can follow Rupert’s work is stunning. It is making dentures sexy. So Rupert, thank you so much for coming on the podcast again. You’re always a welcome guest. Thanks for sharing all the wonderful things you do and just making it geeky, sexy, fun. Thank you so much, my friend. [Rupert]And thank you for having me and thanks everyone for listening. And Jaz, a big cheers for getting Andreas on because that was such an epic episode. Jaz’s Outro:It was great. I still get, I was in Valencia on the European aligner, supposing this lady from Cyprus comes in, Hey, you, your Jaz, you interviewed Andreas. That was so good. I was like, Oh wow, this, that’s cool. So thank you for that introduction and the recommendation. Shout out to Andreas. I’m hoping we’ll be listening to this. Absolutely amazing. Just such an impactful hour that you covered on dentures really, really good. So thanks for geeking out with us as well. Well, there we have it guys. Thank you so much for listening all the way to the end. Impressions are not quite dead, but there is a compelling argument to go digital. And I’m so grateful that Rupert covered those two workflows really well. If you want to learn more about digital inclusion, check out Rupert’s courses. I’ll put the links below wherever you’re watching this. I know he’s got an additional date in November with 3Shape. Now this wonderful episode he did for us is worth one hour of enhanced CPD or one CE credit now that we are PACE approved. All you have to do is answer the quiz on the Protrusive Guidance app. We have three plans available on Protrusive Guidance. One is the free community access. Join in our chat, our discussions, ask questions, grow together, be nice and be geeky together. But you don’t get the CE. If you want to get the CE from the podcast episodes, join the premium podcast CE plan. If you want that and you want the access to our webinar replays, masterclasses, mini courses, including VertiPrep for Plonkers and Sectioning School and RBB Masterclass, then you want the Ultimate Education Plan. I think the annual plan is incredible value for what you get, both in terms of the hours and the quality of the education. So do head over to protrusive app to choose the plan that’s best for you. I want to thank Team Protrusive, many of which would stuck with Protrusive for so many years. Thank you, Erika, for the production. Thank you, Mari, our CE Queen. Thank you Nav for the notes on this one, including the PDF transcript and the premium notes that always follow our episodes available for our paying users. With your support, protrusive has been able to grow, so thank you so much. Once again, I’ll catch you same time, same place next week. Bye for now.