Protrusive Dental Podcast

How are periodontal diseases managed in general practice? Join us for an engaging conversation with Emma Hutchison, our Protrusive student, as we explore Periodontology (Perio) in the real world. This conversation delves deep into the practical protocols, patient communication strategies, and real-life scenarios every dental student and practicing dentist should be aware of. https://youtu.be/X5ahZ9bzsc4 Watch PS008 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 0:37 Emma’s Dental School Experience: Special Care Dentistry 03:02 Emma’s Denture Adjustment Case  06:11 Periodontics Month  06:54 Communicating with Patients about Gum Disease 10:15 Managing Non-Engaging Patients 15:04 The Psychology of Habits 17:13 Referral Protocols in Dental Practice 20:00 Risk Factors in Periodontal Treatment 25:03 Genetic Factors in Periodontal Disease Don’t miss the special notes on An Introduction to Periodontal Diseases available exclusively in the Protrusive Guidance app! This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App! For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. If you love this episode, be sure to recap PS007 – Basics of Indirection Restorations Part 2 – The Crown Fit Click below for full episode transcript: Jaz's Introduction: Welcome to another episode of Protrusive Students. We're joined by Emma Hutchison, our Protrusive Student, to talk about Perio. Look, I'm no periodontist. I'm no specialist, but I can share a few pearls of wisdom for treating Perio in the real world. [Jaz]Emma had some absolutely fantastic questions about protocols, communication, and what to do if you have a non engaging patient. Because let’s face it, that’s what happens in the real world. Our patients don’t floss and they don’t brush how well we want them to. So how do you manage that? Here at Protrusive Students we try and cover the themes just for you guys. And of course, if you’re a dentist watching this, then it’s also relevant to you. We just go back to basics. Let’s get to the main part of the interview and I’ll catch you in the outro. Main Episode:Emma Hutchison, our Protrusive Student. It’s now perio month, so it’s great to have you back. Just give us an update, basically, in terms of what new things have you learned at dental school? What are the interesting experiences that you’ve had? Any ups or downs that you’d like to share with us? [Emma]So, I’ve only seen one patient in the last week, because I’ve had a few no shows last week and it was for a denture ease, so it wasn’t anything too tricky, which was fine for me. But, yeah, it was good, just a wee denture ease. The elderly gentleman was very happy, so that made me happy. In terms of lectures, lots of special care dentistry at the moment. We’re very heavy with special care dentistry in our second half of third year at Glasgow. [Jaz]I know in some countries they don’t have that as a speciality. Can you explain to everyone listening and watching what special care dentistry is? [Emma]Yeah, so I suppose special care dentistry, a lot of patients that have very complex medical histories. I mean, this week we were doing people with mental health problems, schizophrenia. We’ve been doing cardiology, oncology, patients with very learning disabilities as well. Patients that I suppose you could consider a bit more medically compromised or that can be a bit more trickier to treat. So we’re very heavy on that in our third year at Glasgow. [Jaz]So if you can treat those medically compromised patients and you can treat anyone, right. It really tests us in terms of what medicines are on, which antibiotics you can and can’t give, what the guidelines are in terms of when it’s safe to treat, when it’s not safe to treat, all those things. [Emma]Yeah, definitely. And a lot of it is refer to the BNF and all your drug interactions. But no, it’s good. It’s really interesting to learn all about these medically compromised patients. And it’s amazing how much you need to change of your regular dental routine to suit these patients, I suppose, and make accommodations for them as well. [Jaz]Interesting thing to reflect on based on a couple of things you said is one, the slow pace of dental school in terms of when you have some DNAs, which happens a lot, unfortunately, in dental school, just the nature of the beast. And then how do you fill your time to make sure you’re actually doing something productive? I felt like a lot of time when I was studying dentistry, patient wouldn’t turn up and then you’re just there doing suctioning for someone else or nothing. You’re having like an impromptu tutorial or something, which is good, but sometimes you kind of be there. Like looking out the window. And so it’s really important to make sure you’re not doing that. So I’m hoping everyone’s going to have their productive student notes ready, reading them, taking them with them. So if a patient doesn’t show up, they can have that. So this is just the nature of the beast. The other reflection I have is denture ease. What do you think caused this patient to have an area that needed adjustment for this denture? [Emma]So I had delivered this denture, it was a wee while ago, the patient was, had unfortunately been in hospital for a wee while, so I had planned to see him two weeks after the denture delivery, just as standard protocol to see if there was anything wrong with it. He was in hospital for a month, so it had been a while. And when we fitted that denture, it was perfect. It was like a glove. And then he said, when he went home obviously, it’s a brand new denture, it’s going to take some time to get used to, but when he started eating, that’s when he noticed it was painful and it was really digging into his freedom down there, but it was easy enough to see he had a huge ulcer there, the poor man, and pressure indicating paste, showed me exactly where to adjust it as well. So it is quite tricky with those things because it can take a wee while for it to almost heal start hurting these new dentures. It’s tricky as well. I’ve seen a patient before who hadn’t been wearing the denture because it was sore. And then it’s a bit more trickier to see where the pain is actually coming from because you’ve not got redness or something like that. [Jaz] So it’s a couple of lessons to share then based on that. Just so I don’t forget is, always warn your patient that this is normal. Like you should say to your patient. It’s like you said, like a glove. That’s exactly it. It’s like a brand new pair of tight shoes, right? You’re going to get some foot blisters on your feet, right? It’s normal and to adjust it. And when they come in and it’s like the ulcers there, you could use pressure spot indicator paste. But do you guys have Dycal in your clinic? [Emma]We do have Dycal, but not on our Prosth clinic. I don’t think- [Jaz]It’s something I was taught by Mark Bishop to use just on the ulcer, just the base, actually, not even the Dycal, just the base on the ulcer and then put the denture on and then see and pick it up. It’s like anything that will just mark because what you’re testing for pressure is where it’s actually too much pressure. But for the ulcer, you just wanted to rub off on exactly where to adjust the denture. So you can actually use anything that marks off onto the denture. So that’s a good thing to use. We actually had an episode with Mark Bishop, I think it’s episode 28 of the podcast. So anyone who’s new to dentures, check out that episode with Mark Bishop. We talked about the use of pressure spot indicator, the use of the Dycal in that way. And it really talks you through everything. Now, one thing to bear in mind, like your one is obvious because it was like overextended probably in that frenum area. But number one thing before you do an adjustment on the teeth on the actual chewing surface of teeth themselves is before you adjust anywhere on the inside of the denture, check the occlusion because it could be the fact that the patient bites together, it actually is hitting on an incline and the entire denture is then moving and then the teeth bite together. And so you need to make sure it’s got a nice, clear, easy, repeatable bite. Because if it isn’t, it’s actually the bite that’s the problem, not the fact that it’s overextended anywhere. Do you know about that? [Emma]Yeah. No, I’ve never actually really thought about it like that to check the occlusion first. Because then I suppose nothing’s going to get much better if you don’t address that. [Jaz]Because imagine the denture itself is actually perfectly flush to the tissues, but it’s the bite being off and then the pressure gets on that’s causing it. So really good top tip is to check the occlusion first in those areas. But anyway, we digress. It’s Perio Month. Thanks for sharing your experiences with us, always gives us a few things to talk about there. Tell, ask us your student based perio questions. How much experience have you had of treating periodontal, or managing should I say, periodontal disease in your student clinic so far? [Emma]We don’t get on to our perio clinic until fourth year, so we’ve had a lot of teaching on periodontal diseases, but I’ve not seen any perio patients at all yet. [Jaz]You haven’t seen any perio patients yet, but I bet you’ve studied all the, I bet you can name all the bacteria. [Emma]Yeah, yeah. [Jaz]Well, this month’s notes, revision notes in crush your exam section will be your perio notes. So it’ll be good to have all that. But now that you know you’re going to be treating more and more and managing this next year and whatnot. So what kind of questions have you got then? [Emma]So the first question that I have almost stems from my nursing career, I suppose, where many clinicians you would never actually say the words gum disease to a patient, you could talk about bone loss or you’ve got inflammation, but when you start to say the words gum disease, the patient sort of freaks out. Why didn’t you mention this to me before, X, Y, Z. So is that something that you would avoid saying? Is it something you would actually encourage saying the words gum disease? And what would you do personally in that situation? [Jaz]Okay, well, firstly, I’m going to direct everyone to the episode, the fantastic episode I did with Ian Dunn on communicating periodontal disease, okay, really fundamental episode. I want you to watch it, Emma, before you go on clinics. It’s fantastic. Ian’s way of explaining perio is phenomenal. But in the same way that if you see a lesion on a patient and you suspect that, oh, this needs an urgent referral, this could be cancer kind of thing, do you use the C word? Do you say it’s cancer to the patient in the same way? Not in the same way, but I think if you discuss this scenario, and recently I asked this to Amanda, Dr. Amanda Phu Nguyen from Australia, and we’ve got an Oral Med episode coming soon. But essentially, she said that for some patients who are extremely anxious, you probably don’t want to use a C word, but you want to say that it’s really important to get checked out. We don’t know. It could be something suspicious, but it’s really important to get checked out and that’s enough for them. For some people who are really blase and they really need the kick up the butt, then maybe for that individual, right? Who’s not going to have sleepless nights for it from it. You should say actually, this could be the C word. It’s really important you go to this appointment because otherwise they won’t be bothered towards the appointment. So let’s take the patient’s personality type. If they are someone who’s highly anxious stuff, then maybe you want to explain it in other, other ways. But as long as they understand that there is a bacteria, there’s plaque, there is inflammation and swelling of the gums. Okay. And this is either reversible or irreversible and talk about that. And then eventually you can then bring in the whole gum disease. But if you feel as though that that’s too strong of a word, I get that. But in some patients you need to actually really spell it out that this is gum disease. You could lose your teeth because these are the patients who perhaps are really not taking their oral hygiene seriously. They’re not engaging. So I would say it depends on the individual, but I would drive out everyone to listen to that episode because to talk about whole 45 minutes on this, that Ian Dunn episode will be fantastic. So thank you Emma. We will link that in the show notes because Ian does a far better job than I could ever do. [Emma]Yeah, no, that’s good. I think a lot of things in dentistry, very patient centred depends on the patient. So I think that’s another situation there for you need to figure out a bit more about your patient first, which can actually be quite a difficult skill to have. Tailoring your communication, I suppose, to the patient, I think that can be quite difficult. Probably takes a wee while to develop that skill. [Jaz]This is all the realms of emotional intelligence, right? Really figuring out who it is in front of you and speaking in their language. is what sets apart a good communicator to an excellent communicator. [Emma]Yeah, yeah, and I think as dentists, often as very academic people, sometimes we’re maybe not the best with emotional intelligence, but it is something that you can work on definitely. But that also sort of ties into my second question. When it comes to patients who just aren’t really motivated, what implications does this have on future treatment? Is it enough just to say to this patient, if we don’t do this, then we can’t do this, you know? [Jaz]Yeah, totally. It’s a fantastic question. And now every country has their own guidelines and the British periodontal guidelines, I know, I think are good. And I will make that available for those who want to see it in the show notes to look at. But I love the term they use, which is engaging and non engaging patients. And there’s different pathways of how you manage these and a non engaging patients that you’ve tried everything. You’ve spent the time, the due diligence to really explain the issue to them, teach them the tools, give them the tools to be able to improve the oral hygiene. But they’re just not engaging, they’re not putting the hard work in. So is it fair that we give these patients the full blown periodontal treatment, because a day later it’s going to be covered in plaque again? And plaque is the source of the disease. So really, what we need to do is, just like you wouldn’t do complex crown bridge work on someone who’s got poor oral hygiene, then maybe we shouldn’t be doing the actual root planing and actual hands on stuff until the patient has mastered the delicate skills of really good, high quality oral hygiene. So I would say that every patient deserves your best firstly, every patient deserves a chance and give them the chance to try and communicate in their own language in a way that works best for them. This could be drawing on a whiteboard. This could be make sure you show them in a mirror exactly how to clean, get them to demonstrate in front of you. And when they come back, we can’t just rely on subjective. We need objective data. Let’s look at plaque scores, because maybe their plaque score is 50% and next time they come back, it’s 30%. Now, it could be better, but at least we’re seeing improvement, right? And then, okay, you’re going to help this patient. But if you’re seeing 50%, 50%, 70%, 50%, and the patient is just lying, and you know that the level of hygiene isn’t good enough, then for that patient, they don’t progress through a flowchart. You just go back to base one. There’s no point spending any more time and money on doing periodontal therapy with scaling, root planing, root surface debridement, whatever they call it, whatever the cool kids call it nowadays. But we need to make sure we get the foundations correct, which is excellent oral hygiene. So base it on your patient, give everyone a fair chance, but quickly recognize who is following what you’re saying and who is not. And I’m not saying don’t give them your best, but they can’t then move to the next stage if they’re not getting the foundations right. [Emma]Yeah, definitely. And I think, again, that’s another thing that can be hard to communicate to your patient, especially, if they’re saying that they’re brushing, they’re brushing, but there’s been no improvement. It’s hard to sort of communicate that. [Jaz]So tough, Emma. Like, I don’t want to hurt my patient’s feelings either. So what I tend to do, is I firstly find out, okay, what are you using to clean in between your teeth? And I wait for them to say something and you say, oh, I’m using the little brushes. Okay. That’s great. How often are you doing it? Okay. Now at this point I say, yeah, you know what? Not as often as I should. That then gives me permission to say, okay, you know what? I think it’d be great if we did it more frequent. I just see things a bit slipping and I want to make sure that we’re set up for success in the future. So how about we do a bit more and that’d be great. But then sometimes I say, yeah, I do it every day. And I have a look and the oral hygiene is horrendous. That’s an opportunity for me to discuss technique. Well, firstly, you’re already doing better than most of my patients because you’re actually doing it. And you’re doing it, once, twice a day. This is amazing. But strangely, when someone says they’re doing it a few times a day, usually I should see like no plaque. But in your case, I’m seeing this hidden bacteria in between the teeth, like in your blind spots. Is it okay if I can show you? Then I’ll show them in the mirror exactly where it is. I pick it up my probes. Ah, I think this is a technique issue. I think you’re doing it like you said, but it’s a technique issue. Let me go through the technique. And so with an interdental brush, I show them how to insert it and actually really massage it into the gum. And sometimes it’s just making sure they’re using the correct size. Right? It’s got to be big enough, snug enough that it’s going to actually brush the sides of both the teeth, adjacent teeth, and they need to also massage it into the gum and into the sides of the teeth. So it’s not just a matter of going in and out. So this is an opportunity to educate them on the technique aspect, I find. [Emma]Yeah, you saying that actually, that’s a good sort of pathway into oral hygiene instruction and things like that as well. I’ve never really- it’s all about taking that as an opportunity to then try to like educate them on their oral hygiene and things as well. No, that’s good. That’s good. [Jaz]We want to be non-judgmental, but we want to make sure that they’re doing it. So I have found that works for me in practice at the moment. I don’t want to make them feel bad. So I just ask questions and based on what they say, I’ll then show them or just encourage them to do it more frequently. And I often offer, you’re seeing the hygienist next, should we go over the right color brushes for you? What I mean is technique, but sometimes they just want an excuse. Oh yeah, you know what? It’d be nice to see which brushes to use again. And then they get a demo again. And sometimes, life gets busy. People got kids, people got ill parents, people got pets, people got all these things in life, busy work, life, stress, all that kind of stuff. And sometimes it’s not your highest priority. Now, one thing I make a big deal of nowadays, my own lessons is out of sight, out of mind. Meaning that if the teepee brushes are not there by your washbasin right in front of you, like to use, they’re not going to get used. It’s just a thing to realize. Now, for example, it’s human psychology, it’s human nature, whereby if there’s a step, if there’s an extra step involved to doing something, It will much, much less likely to get done. So it reduces the chance of something getting done massively if there’s one extra step. Let me give you an example. Recently, we had this system whereby we’re changing the way that we give antibiotics to our patients in our practice. So before the antibiotics, the nurse knows where it lives. Zoe, can you get me some amoxicillin, please? Right. And she’ll go, she’ll get the amoxicillin. We just fill in the log and we give it and we prescribe it. Now, we have to use a key to open a lock, get the antibiotics out in the right order, and then go open an Excel sheet and insert it, okay? There’s no audit done yet. I have a feeling that the percentage of I’m just being very real, honestly. I’m making myself vulnerable. As a practice, okay, our numbers of antibiotics has gone down. And so I think every practice in the world should do this, right? Making the kind of habits that we want to discourage make it more difficult, but the kind of habits that we want to encourage make it easier. Same with dental photography. Those dentists who have their camera out and ready. The lens is ready. The flash is ready. The retractor is there. It’s all ready to go. They will take photos. For those who have to now, they’ve got a patient. They want to take a photo. Now they have to go to a different room, get the kit, attach the lens to the body, charge the battery, whatever. It’s not going to happen. So, it’s just human nature to make the habits that you want, those healthy habits that you want to foster, make it easier. And it’s the same with Perio. [Emma]Okay, so yeah, have your teepee brushes out in front of you. [Jaz]It’s got to be there. It makes a big difference to me anyway. [Emma]Yeah, I worked in a practice as well at some point where the answer was like drawer was locked and you had to write it in a wee notebook and then you had to put it on an excel sheet and just no one ever really prescribed them anymore. [Jaz]So true. [Emma]Yeah. So my next question for you, Jaz, is about referrals. I know you’ve got periodontal specialists out there, hygienists and therapists. What warrants a referral and to whom? [Jaz]Okay, fine. So firstly, there should be a every practice should have a perio protocol, right? Every practice should have a perio protocol. Like this practice, this is how we treat perio. And it really is a good, because it involves the hygienist, and the dentist to really have dialogue and have meetings and talk about this. And so everyone does things a set way. So everyone gets good quality care. So everyone has a staging and a grading. So diagnosis is covered by everyone. We have set intervals where we make sure we do a basic periodontal exam. And then based on those scores, we have some guidelines, right? And so a lot of times it’ll be, okay, off you go to the hygienist and you’re low risk, or if you’re high risk, then we’re a bit more prescriptive with the hygienist. And sometimes if it’s refractory, they come back to and then if we find that the patient is engaging and doing their best and we’re still not getting the right results because we’ve been really good at record keeping. We’ve got the six point pocket depth charts and whatnot. At that point, we have to consider, okay, perhaps this patient needs a specialist. And the funny thing is, right, working with specialists, I feel as though they do the same thing that we do. The patient’s paying a lot more money and suddenly they start getting the results. Because now you value what you pay for and suddenly they’re paying all this money back. I better start TePe brushing kind of thing. And so sometimes it’s that and sometimes it is the skill and the diagnosis and sometimes a surgery is needed basically. So I would say there’s a lot we can do with Perio when it comes to doing it in house because a lot of it is reliant on excellent, the foundations, the pillars of excellent oral hygiene and working in tandem with your hygienist therapist and seeing those scores come down is a beautiful thing as a practice. But we need to also feed our specialists with those refractory cases and following a protocol or a guideline, whether it’s the one in your practice or a nationally recognized protocol. So whichever country you’re in, follow your local periodontal societies guidelines. [Emma]Yeah. Yeah. I think we’ve got the SDCEP guidelines in Scotland. What is it in England that you use? [Jaz]The BSP, the British Society of Periodontology. [Emma]Yeah, that’s a wee bit tricky one for us because we learn some SDCEP and some BSP and they’re mix and match a wee bit. [Jaz]Look, Scotland’s still in Britain, that’s how much it’s so good. [Emma]Well, yeah, sorry, sorry. Scotland, England. The British ones, the Scottish ones. So we learn a wee bit of both, but mainly SDCEP and the dental hospital. [Jaz]You know what, honestly, like as long as you’re following a system and you know that system well. I think they all have good intentions and are backed by evidence and I think that’s the best thing to do. [Emma]Yeah. Okay. Cool. And then my last question that I had for you, Jaz, was what sort of risk factors and things need to be addressed or controlled before you start with perio treatment? [Jaz]Okay. So defining periodontal treatment, treatment is like when you’re actually picking something up and you’re carrying, scaling biomechanical plaque removal, introducing a scaler subgingivally, that kind of stuff. So what kind of risk factors? Well, things we look out for is smokers right now. Smoking is a tough topic because we’d love for our patients to all quit smoking once they’ve diagnosed a perio, but that’s not how it happens. Okay. It doesn’t happen in the real world, but even just by quitting by half, like Instead of 20, have 10. That’s a sign that someone is an engaging patient. And so maybe that will have a better impact. So we need to first ask the question. Are you smoking? Did you know there’s a link? Medical, legally, we need to inform them, did you know there’s a link? This is actually causing, it’s making your gum condition much, much worse. Have you ever considered smoking? If they say, yes, I’ve considered it. Okay, maybe now you can help them. There’s local pathways and guidelines, NHS, et cetera, in the UK, for example, to help them to quit smoking. If they say, you know what, I’m not interested in quitting smoking at all. And therefore they’re showing like a poor attitude. It’s a tough one because we still need to help them. So we still need to perhaps give the best we can in terms of oral hygiene, instruction, and oral hygiene education. And then once they’ve mastered that, then proceed to biomechanical plaque removal. The thing is, if it’s someone who doesn’t have the right attitude towards smoking, and they don’t have the right attitude towards their oral hygiene, then that’s a non-engaging patient. But sometimes, smoking, they can’t give up, but they then overcompensate by doing really well with oral hygiene and that’s going to help them a lot anyway. I sometimes emphasize, look, because you’re a smoker, whilst I get most of my patients to spend four to five minutes a day in front of the mirror, you have to spend 15 minutes a day in front of the mirror. And that’s why I say to them, so they have to kind of make up for it. So that’s my view on smokers and not to dismiss them entirely, give them the best shot. But I want to see that they’re really working the oral hygiene, if they’re not going to be reducing smoking. The other one is diabetes to look at. And we want to make sure we work with the GP to make sure that diabetes is controlled. Sometimes they’re an undiagnosed diabetic and if their perio scores are continually getting worse and they’ve got a history of diabetes, maybe. And so you ask the patient, when was the last time you had a blood test? It’d be really good for you to get checked out. And of course, if they’re already a known diabetic, we could keep asking, look, how’s your control? Is your GP happy? Is your healthcare team happy about how you’re doing it? And there’s a relationship whereby if you improve the perio, you improve the diabetes. You improve the diabetes, you improve the perio. Did you know that? [Emma]Yeah. What sort of a relationship is that again? [Jaz]I want to say symbiotic, but I’m not sure if that’s a more of a bacterial thing. But yeah, so diabetes is really important. Smoking as we addressed the other risk factors is stress, actually stress, obesity, all these things, but stress is a big one. Make sure that patients are directed towards getting help for stress and just making them aware that look, we need to focus on the stress because that’s important as well. Occlusal things aren’t as much recognized. So let’s not go there. But I do think that if someone is a, there was a study done and I’ll reference it whereby they had these patients and they follow them up and they see whose perio got worse and whose didn’t. And if they had active periodontal disease and they were a Bruxist, and if they didn’t wear an occlusal appliance to manage the Bruxism forces, then they actually had worse periodontal outcomes. So perio plus Bruxism, you can imagine the occlusal trauma. The jiggling forces on the teeth. So I’m not saying for a second that bruxism or occlusal considerations cause periodontal disease. No, but they can exacerbate it. They can induce jiggling forces. They can have a role in accelerating it. So managing those as well. Are there any that you have in mind that haven’t covered yet based on your perio lectures? [Emma]Not at the moment. I know the two main ones, smoking, uncontrolled diabetes, definitely. It wasn’t until a few weeks ago in an ortho lecture that I came across, jiggling forces, bruxism and perio and how that can all be linked together, so. [Jaz]Did you know about the stress one? [Emma]No, I don’t think I did. I don’t think I’d really learned about stress. I wonder why that is. There’s some science behind it, definitely. [Jaz]I think it’s the effect on your immune system. [Emma]Yeah, yeah. [Jaz]It is an immune condition in a way. When we look at periodontal disease, it’s inflammation. So we have to really step back and be a real healthcare practitioner overall. And look at your patient and give them that advice. I think it’s good to point that out to them. And it’s difficult sometimes to be the main helper. But as someone who treats and manages a lot of TMD, I often recommend an app called Balance to do meditation. If they’re having a real crisis to speak to a GP and not to stay quiet and have that conversation. And sometimes that’s all they need. They just need someone to care for them, look out for them and say, look, it’d be really good for you to take this next step. [Emma]Yeah. I suppose fundamentally, the more you can control the risk factors before you start perio treatment, the better the outcome you’re probably going to have from your treatment as well. So yeah. [Jaz]Very good. Now, I wanted to say one last reflection for students. Perio is one of those things where there is such a huge genetic component. I have patients in their seventies and eighties who will look me in the eyes and say, Jaz, you’re I’ve never flossed in my life, and I’m not going to start now. All right. And you know what, yes they’ve had caries, crowns, root canals, but you look at their bone levels and they’re winning. On the other side, I’ve got patients who, if they don’t floss three or four times a day, they’ll be in big trouble by the time they’re 40. So there’s a huge genetic element when it comes to periodontal disease and to be mindful of that. And then, I know we should treat everyone the same in a way, but when it comes to healthcare, we should be specific to the individual. So if you’re noticing that your patient is, scores are getting worse and there’s more inflammation, then we need to coach our patients that, look, I’m seeing something here where in you, you can’t follow the blanket advice of brush two minutes a day and use some floss. That’s not enough for you. And have that very customized approach to healthcare when it comes to Perio. [Emma]Yeah, I think a common theme is dentistry is it’s very customizable towards your patient. But a lot of this, that you were talking about your gene expression, your family history, all of that, there’ll be a good deal of that in the notes as well. And Perio is something that I really quite struggled with last year. Going through the lectures. All the pathology of it, what goes on at an immune level, that’s something that I really quite struggled with and it took me a while to go through these lectures and translate that into my notes, which makes sense to me. So yeah, I’ve spent a lot of time on those perio notes and something that I’ve really struggled with. So hopefully these notes will include all the things. [Jaz]I’m sure they will go right in the crusher exam section. Thanks to Emma Hutchison always. And we’re so grateful to have your notes. And I think it’s going to help a lot of students all over the world. So guys, if you’re not already on protrusive. app, remember the email to email is student@protrusive.co.Uk and therefore you send in your proof that you’re a student and you get added to the area and you get access to Protrusive Vault as well. But Emma, we’re going to see you at the same time next week, but obviously we’re trying to film all these now because you’re going to get busy with your exams and I want to make sure that you do really well. So we’re trying to record these now. It’s funny that we discuss some denture stuff today and hoping that’s going to spark some ideas for you in terms of coming up with some good questions. We’re going for removable prosth, like I am no expert when it comes to removal pros, but as someone who’s been practicing a little while now, I think I have enough to offer in terms of guidance for students. So come up with any questions and remember, if I don’t know the answers, there’s probably an episode I can direct you to that’s covered it, or I know some clever people that can help us. [Emma]Yep, perfect. Next week, Removable Prosth. [Jaz]Amazing. Thanks so much, Emma. [Emma]Thank you. [Jaz]Well, there we have it, guys. Thank you so much for listening all the way to the end. Remember, you can download Protrusive Notes. So Emma works really hard on these fantastic notes. And for all students, this is absolutely free. All you have to do is sign up to Protrusive Guidance. It’s completely free. And when you email student@protrusive.co.Uk, your student ID or proof of being a student, we give you access to a few secret exclusive areas just to help you guys out. Now, please do share this with your student colleagues. Why keep it a secret? They’re going to find out anyway. Be the one to share this with them. Share the revision notes. Sharing is caring, and especially comes to education. Always adopt an abundance growth mindset. There’s totally more than enough to go around for everyone, and everyone can benefit. If you’re a fan of the show, then hopefully you are our tribe. You are our Protruserati. You are our selfless. You are sharing. You are caring. So let’s foster those values, And share away. Thanks so much for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.

It’s your first night on-call and you are bleeped at 3am – there’s a nasty facial laceration waiting for your urgent attention. You have never sutured the face before…”who you gonna call?” – well sometimes even the Ghostbusters will be more helpful than the on-call trainee! https://youtu.be/3RKZG3yy2sU Watch PDP194 on Youtube Our good friend Dr Ameer Allybocus joins us again for another episode where he gives us a lowdown of his experience when he was a DCT trainee many years ago. There is a lot to learn in this podcast from Ameer as he dives into the Trials and Tribulations of being an Oral and MaxilloFacial Surgery DCT during the early years of his career.  There are laughs and tears in this one, so hold on to your seats for an emotional podcast that will leave you wanting more. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:  00:00 Introduction01:37 Protrusive Dental Pearl03:26 Introduction to Dr Ameer Allybocus19:40 The MaxFax Beginnings24:00 MaxFax at UCL29:37 MaxFax isn’t all bad36:05 DCT Oral Surgery 42:16 On Call 48:26 Book Recommendations49:15 Working at the Queen Elizabeth Hospital54:13 A Life Changing Experience59:57 MaxFax: Benefits, Tips & Tricks65:26 Tips from Ameer66:25 Trauma and Accidents70:56 MaxFax Puts Dentistry Into Perspective74:33 Closing Words For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. If you liked this episode, you will also like: Getting Ahead after Dental School 2023 – IC042 – Protrusive Dental Podcast Click below for full episode transcript: Jaz's Introduction: Is a maxillofacial surgery post right for you? Maybe you've already done one before and you want to like reminisce about your time as a DCT, as a part of a residency or any post and standalone post you've done in a maxillofacial department. Jaz’s Introduction:Now my colleagues who’ve done it tell me that it gives you thick skin, it’s character building, it’s these amazing experiences and they have no regrets. Whereas I have other colleagues who have major regrets about doing a maxillofacial post. My guest today, returning again, Dr. Ameer Allybocus, does absolutely fantastic job of summarizing the highs and the lows of working in a maxillofacial position as a dentist. Now in the UK, we have these DCT, Dental Core Training positions, but around the world, being attached to a hospital in the maxfax department and helping the registrars and consultants with everything from trauma to cancer and sometimes not always exodontia. And we’ll talk about all these themes with Ameer. I actually really wish I had an episode just like this when I was considering whether to do a maxfax position or not. There’s actually a bit where Ameer actually cries in this, and I’m just respecting so much for making himself vulnerable and sharing those feelings. It was related to a patient story, and there’s so many great tips and different characters and different personalities that he describes in his stories of working in these different posts. There’s so much incredible value provided in this episode. It’s a longer one, and I didn’t want to split it into two. So you might need a couple of commutes or lots of onions to get through this one. The Protrusive Dental Pearl today is provided by our guest, Dr. Ameer Allybocus, and it gives you a flavor of the rest of the podcast of what’s to come. There’s so many great tips and stories attached to it. So let’s hear today’s protrusive dental pearl. Dental PearlSo Ameer, what is the protrusive dental pearl for today? [Ameer]My Protrusive Dental Pearl is whatever procedure you’re doing, if it isn’t going the way you want it to, if you find yourself getting stressed, hard, you’re not seeing what you want to see, there’s nothing in dentistry that you can’t stop and take a pause, give the patient a break, set them up. Walk away, have a glass of water, gather your thoughts, think about what exactly you’re trying to do, and then come back with a fresh set of eyes once you’ve had a chance to calm down and do it again. And not enough people do that. People get a bit stressed out and get themselves in a tizzy. You have the tools you need up here to solve these problems. So yeah, just take it easy. Don’t be so hard on yourself. [Jaz]I think otherwise the flight or fight response takes over. And I think that’s really good. When was the last time you had to utilize this? [Ameer]Oh man, placing an implant on my aunt. Like, yeah, don’t treat family like that’s my other pearl, but if you do end up treating family, I had to do a bone graft and it just, the membrane just wasn’t sitting right and she was moving around and I was getting stressed out, the bone graft materials were leaking and everything and I was just like, okay, like, put the flap back over, I’m just going to walk away. Have a little sip of water, like, these scrub, like it’s fine. And then the nearest is all, I had a little break. And then, we just had a chat. We joked around a little bit, and we were like, okay, should we get back to it? Yeah, okay, cool. Sat down, and it was as if, there was, nothing was wrong. There was no problem, everything just went super smooth. And I’m fitting her crown on Friday, so everything’s fine. Everything’s great. So yeah, like that’s my- [Jaz]No matter what field you’re in, I think you can utilize that technique. Thank you. Now let’s listen to the main episode. Remember, it’s a long one. Get those onions ready, but I guarantee if you listen to the end, you will gain so much from this episode. It’s got so many facets to it. Enjoy. Main Episode:Dr. Ameer Allybocus, welcome again to the Protrusive Dental Podcast. You were so good last time when it comes to talk about bleeding sockets and managing them, the stories that you told, the exchanges we had about your experiences and just generally sharing good guidelines advice, so it’s great to have you again. How are you, my friend? [Ameer]I’m great. Thanks for having me back, Jaz. I’m looking forward to this. So I think this one’s going to be a bit more fun than managing bleeding sockets. So- [Jaz]I don’t know which direction is going to go in exactly. I’m sure you’ve got some cool stories because you’re man of stories. So maybe I think that’s what’s good. Maybe that’s what’s on your mind, making it spicy. But for those who perhaps haven’t heard of the previous podcast, I encourage them to go back to it. And obviously I’ll link them in the show notes, but interesting thing that you’re doing lots of oral surgery and practice you’re doing sedation as well. And therefore, one of the questions I asked you before we hit record was how many practices are you working at? And you said way too many. So the really, the number one thing I want to know about is have you ever turned up to the wrong practice? That’s what I want to know. [Ameer]I have, but luckily it was on the same square. So I just had to walk across the road. So apart from that, no, I’ve turned up to practices I work at on the wrong day. And they’re like, oh no, we’re booked for next week, but that’s the worst it’s been. So yeah, I’ve never mixed it up that badly. [Jaz]Very good. And what advice would you give to someone who’s, I mean, you work in a lot and that’s kind of atypical, most people I know they work in one or two, but with the nature of the kind of more niche services that you provide with sedation and visiting sedation and visiting oral surgery type service, do you find that this is working for you in terms of lifestyle and work life balance and that kind of stuff? [Ameer]It was, but I found that in terms of managing your relationships, well, actually, you know what? I got a dog recently and ever since I got two dogs, actually the brother and sister, that’s a mistake. Never buy two dogs from the same litter at the same time. That’s my, like, that’s a protrusive tip. [Jaz]It’s like having twins, never had twins. [Ameer]Yeah. Ever since I got these two dogs, I’ve found that I need a much more regular work pattern. Before that, I was very happy working lots of different practices. I still work in lots of practices, but I’ve had to scale the radius down to 90 minutes from my home base, rather than wherever, there were days where I was traveling across the country from, like, Cornwall to Sheffield to treat patients, which is crazy. And you can do that when you have less ties, but once you start to settle down a bit I think you need to kind of pick a patch and stick with it. But also, the other thing is if you have a vision for how you’re going to run a service like that If you team up with people in different parts of the country have a similar vision Synergize team up you can form a joint company and then you can work that way and that way you can build a brand that’s trusted and also continue to service those practices that you used to work at. So that’s another way to look at it. So, you can still maintain your clients, but yeah, I think you have to remember that at the end of the day, it’s the end of the day. Go home, relax, put your feet up, be with your family. That’s what’s important. We have to work to live and not live to work. [Jaz]So well said, but it’s important to have that as part of your past, as part of your blood, sweat and tears, your phase of being a sponge and doing all these things to gain your 10, 000 hours, if you like. So you’ve done all that. And that was important part of your journey. [Ameer]Yeah. You’ve hit the nail on the head. It’s all about that 10, 000 hours to get that mastery. And in fact, that reminds me, I’m going to be recommending a lot of books throughout this podcast. So number one is Outliers by Malcolm Gladwell. Everybody needs to read that book if you haven’t read it. Outliers by Malcolm Gladwell, 10, 000 hours, become a master of what you do. And immerse yourself as much as possible. And that also means traveling around the country as much as possible. Because you will meet experts in their field. And you’ll meet A who says do it this way. And then you’ll meet B who says A is an idiot, do it that way. Then you’ll go back to A and say B said this. And you’ll start to test these ideas and methods against each other. And you will distill it. So it’s purest form and take away the best of both worlds. And that’s what’s going to make you unique clinician number C, who’s going to pass your skills on to D. [Jaz]So that’s exactly been my experience of occlusion, by the way, everything you said there, like the different viewpoints that you’ve definitely summarized that well. [Ameer]So, yeah, I’m not going to say young, but while, because I don’t want to be ageist, but while you have the ability to move around, do it, make the most of it. [Jaz]Yeah. Life comes in seasons. I’m a big fan of thinking and life comes in seasons. And then if you miss the boat of that season, it doesn’t come back, I find. So there is a time, for example, there’s a time to go out every night and get smashed and have a great time. There’s a time for that. If you decide 15 years later that actually want to go back to that time, or we want to live that time because he’s never got to live it. It’s just not going to work in life. It’s just, there’s a time for everything. And so there’s a time where you are sometimes having to be a workaholic in your early stages to get those 10, 000 hours. Then there’s a time to focus on your family and dogs, children, whatever it could be, basically. And then there’s a time. On the other side of that, so life comes in seasons. So you’ve got to prepare for that. So speaking of seasons, one season that many people choose to experience is the season of maxillofacial surgery. Now, did you know in America, there’s no such thing as maxillofacial surgery? It’s just oral surgery. So you are an oral surgeon and they don’t have a separate maxfax, which I didn’t know until recently. So to make this appeal to everyone around the world, lots of listeners and watchers appreciate you from the States and stuff. So what we’re talking about here is a post or residency or a one year thing, which you might do after you get your BDS or DDS, after you get your qualification, you then do one year attached to a hospital as part of a maxillofacial service. So very much trauma, mouth cancer, and that kind of stuff. Now, before I ask you the questions I have, Ameer, about what’s it like, the pros and cons, and how to make the most out of that year, the trials and tribulations, the stories definitely want to get to the stories. Let’s talk about motivations because I wrote down some different reasons and there’s going to be a little bit of a monologue here. So bear with me, but interject whenever you want. Different motivations that I did not do a Maxfax post. Like I told you before, I did a restorative and oral surgery post, right? And so the reason I did it is for me, it was in a way, it was a means to an end because at the time I wanted to be a restorative specialist and I had to do this, but it was also a taste for the future. Do I really want to do this? And so that was the main reason I was doing it. And for me, it was, it proved to be very useful, not only because I learned so much, I was a sponge. I really wanted to, my mindset was every day. I just wanted to learn as much as I could. And of those two posts that I did, one was fulfilling for that and one wasn’t. And that’s just the way it is. But those are my reasons for doing it. Whereas other people might do it just purely for the tick box. Think of someone who wants to get into ortho and is doing a Paeds (Paediatric) post because they kind of need to do it. They don’t like kids. They don’t want to chase children to fluoride, but they have to do it. To get to ortho, then there’s someone who might not be confident in oral surgery. And they think, you know what? If I do a maxfax first, maybe it might, maybe better than extractions. I’m sure you’ve got lots of opinions on that, which we’ll get to. Here’s a big one. I mean, being afraid of going into general practice? Like the fear of going into the rat race or that, is that one that you’ve heard of before? [Ameer]Oh, that was me. I was so scared of telling a patient it’s going to cost this much. And meeting UDA targets. I was terrified of that. So, I mean, to understand where I came from, I’m going to go off on a tangent, but I’m going to circle back, I promise. But some people are going to be like, this guy shouldn’t be a dentist. I finished telling these stories. But I remember when I was 15. It was like I was in school, we’re having a careers fair. And I was obsessed with filmmaking and cinema, and all I wanted to do was that. But having Asian parents, they’re not going to be like, yeah, go to film school. That’s that’s fine. Like, live out to the back of your car for the rest of your life. No problem. They were like, well, you can get a career, and then you can become a filmmaker. And I said to them, alright. I really want a RED cinema camera. RED had just been founded by Jim Jannard, the Oakley founder, and a guy called, it’ll come to me, I’m having a blank now, but they just founded this disruptive digital cinema company, RED, and I really wanted a RED camera. And being a 15 year old, you just think, how can I make money, buy a camera, make a movie, become a rich, like, filmmaking millionaire? Great. I said, how can I make the most amount of money with the least amount of effort? And then my parents lied to me and said become a dentist and then from that moment onwards I thought, oh dentistry is easy. Like it’s not easy. We all know that. Anyone who’s watching this podcast knows that. So that was my initial motivation to go to dental school, to buy a RED cinema camera. Obviously I didn’t say that in my interview. So I went into dentistry with terrible motivations compared to everybody else who was passionate about the science of dentistry and the art of dentistry, and then I developed, and I felt really out of place in dental school. The way I got into dental school is an interesting story as well, but that’s for another time, I guess. But I don’t want to go off on a tangent too much, but I just didn’t really find my tribe in any of the departments in dental school, because it wasn’t something I was innately passionate about, until I stumbled into the oral surgery department, and then I was like, Oh, thank God. This is what I want to do. I want to do oral surgery and I used to spend my free sessions when you’d have a free set free period or something. I’d go everyone else would go home, we got library or whatever. I’d go to the oral surgery department and be like, can I help you take teeth out? And they were really supportive in Birmingham and I had some great mentors, Prof. Dietrich, Bilal Ahmed , Kaushik Paul, who’s now the medical director at MyDentist, so he- [Jaz]When they smell that from a student, when they smell that desire and that hunger, the best mentors, the best tutors will really fuel that and take it to the next level. So it sounds like the experience you had with that. [Ameer]So that, I found my thing. I was like, I want to do oral surgery. I’m not really that interested in the other aspects of dentistry. And I just focused in on that. And my whole thing at that point was, I have a very addictive personality. So once I pick one thing, that I’m not interested in anything else, I’m just laser focused on that, which isn’t necessarily a good thing, but that’s just the way I am. So I went into foundation training, and I was doing all this general dentistry, but what I was craving was oral surgery, and I just hated the idea of finishing foundation training and then going into general practice and having to do everything not so well. And every now and then getting thrown a tooth to take out, and then I was like, Oh, Maxfax and oral surgery, I can just focus on my passion. Great. Which, again, like later on in the conversation, we’ll come back to why that’s a good thing and sometimes not a good thing, because I’ve now discovered an interest in dentistry in general, thanks to the other courses I’ve done. But yeah, that time I was just terrified of going into practice. I just wanted to do oral surgery. So that’s why I did it. So that’s just to give people an idea of where I’m coming from in this conversation. But I have a diverse group of friends who some did Maxfax, some didn’t. And I’m going to talk about them as well and the paths they’ve gone on and hopefully some of the younger dentists or students who are thinking about if this is the right path for them, that’s going to be valuable. So anyway, I’ve been talking for a long time, so I’ll let you. [Jaz]No, no, you’re good. I mean, it’s a very popular choice. I mean, I don’t know, maybe I don’t know how many places there are, but it felt as though after DFT, about 30, 40 percent of people went to do a hospital post. I don’t know if that’s accurate or not. I mean, it just felt like a lot of people, maybe because I was in it. So I felt it was more, but a significant percentage go into hospital training. [Ameer]Yeah, I think it’s one of those things that it’s like, do a year of DCT. Now, my personal opinion, and I’m going to justify this later, I think DCT 1 should be mandatory, as mandatory as foundation training. A lot of people would disagree with that statement, but I think, and as we have this conversation, I’m going to make that case. And not necessarily to learn dentistry, okay? Like, there are certain life skills that you’ll get doing that kind of job, and hopefully, I’m going to pique some people’s interest and they’ll want to do a Maxfax job after this. But I think that, I mean there’s so much to say about it, I’m really excited to get into it, but like, I wouldn’t be who I am if it wasn’t for the Maxfax jobs. I’m not talking about the surgical skills I picked up, I’m talking about the personal skills and the tests you go through, the trials and tribulations. [Jaz]He said the title. [Ameer]He said it. He said the title. But like, yeah, it’s definitely something that I think makes you when you’re a dentist. Not to say that people who haven’t done Maxfax are any less or lacking, but I just think that for a lot of people this is going to mold you into a resilient calm, cool dentist. And it’s just going to put dentistry into perspective with the rest of the body when you’re treating your patients. [Jaz]I like that word perspective. And the reason I like it, because what you just said there reminds you of something. Firstly, to track back, I know people who say, who swear by your experience. They say, even though it’s not relevant to what I do today, I’m so glad I did it. It was character building. It was such an important part of my story. If you like my career story, which I get. Equally, I know a couple of people. I know one individual for sure. Very close to me, actually, who halfway through in the Midlands was like, screw this. I hate being a pen pusher and just left. It was like, I don’t want to do this. You guys are BS kind of thing. And he just left. So I’ve had both. I’ve had people having fantastic experiences learning so much, whereas others, doing a lot of admin and not even having a laid forceps on a tooth. So the different posts will determine it like, like with everything. So that all happens. But the thing about perspective, you said it’s a bit like this when you are there. Cause I’ve been to a few of these MDT meetings now and I’ve been to one of these posts during dental school, we like had to go to two weeks. I was in like a Lister hospital. So I got a taste of MaxFax to some degree, right? And so there was a big case happening. There was like a neck dissection and stuff. And so they were using this sort of like zapping thing to stop the bleeding, I think, right? You probably know exactly what I’m talking about. They were zapping this stuff, right? And I was there holding this guy. And every time they zap it, like the pectoralis major would contract. That was pretty cool. Okay. So that was pretty cool. Right? But the whole thing about perspective is that I’m looking at this, right? Like, wow, this guy’s having a neck dissection. His whole chest is, I can see it’s all his muscles here. And then next time someone comes in and like you break a root tip, it really puts things into perspective. Or when someone comes in and says, oh, that compensated, that’s a tiny little chip over here. Do you see what I mean? It helps to put things into perspective. I totally agree with that. It’s a level of calmness that you appreciate to what you perhaps would have stressed about before. [Ameer]When I mentor younger dentists. There’s a lack of confidence. And the patients are like sharks smelling blood in the water. They can just smell you’re scared. Then they get anxious. So yeah, exactly. I mean, let’s say you crown prep a tooth and you graze the tooth next door. You shouldn’t, because you should be using a metal strip on every adjacent tooth. But let’s say it happens. Before MaxFax, you’d be like oh my God, I’ve, I’ve grazed the tooth. How am I going to break this to them? Like, oh, I’ve ruined this person’s life. That’s it. It’s a black retentive factor. Yeah, when when someone’s blown half their face off with a shotgun and you’ve pulled the pellets out one by one with some forceps, you’re just going to be like, oh, yeah, we touched the teeth. It’s fine. We just moved it off It’s whatever like and the patients are like okay, life happened that had things happen and I’m not justifying that. I don’t want any restorative dentist. [Jaz]No, no, true, true. But it did the whole perspective. It’s just perspective. [Ameer]Yeah, like, what you’ll find is a lot of patient complaints come from them detecting that you’re shitting yourself. You have to play it cool. And again, this puts things into perspective. And there’s so many tangents we can go off on each point, but it makes you realize that your dental degree is much more expensive than the vocation we practice, in the sense that we have this baseline of knowledge that allows us to actually practice as doctors. And a lot of people make jokes like, oh, dentists aren’t real doctors, etc, etc. I saw Rhona Eskander put a post up about this a couple weeks ago, and she had all these doctors, trying to downplay us as medical professionals. You’re doing the same job in MaxFax that a doctor is doing in any other medical specialty, and at a senior house officer grade, not in an F1 or F2 grade, and what you’ll realize is you do have that ability, and a lot of dentists don’t realize they have that potential in themselves to step up and do more than just the math that you’re going to be managing a patient’s entire body, their medications, everything, liaising with other medical teams, going to multidisciplinary team meetings. And it gives you that confidence as a clinical practitioner. So, again, that’s a very important thing for us to take away in our profession as well. And to put some respect, your name, when you say I’m Dr. Someone, so you’re in that title and you realize you earned it. [Jaz]Well said. Well, so tell us about your maxfax. I see. I mean you feel free just goes away did it or you don’t have to do so disclose exactly where you did. But like how is your post before I talk about some other experiences perhaps didn’t go so well and just let’s learn about sounds like you had a really fun memories of your time. [Ameer]Yeah, definitely All right, so I did my foundation training at the Eastman like district in London and then I did a week in the Eastman Dental Hospital, and I was like, Oh my god, I want to be here. It’s such a shame they’ve shut it down now, and it’s become a wing in the UCL Hospital, but this used to be the actual Eastman building on Grazing Road. And it was just my dream to get that job, and I didn’t think it was possible. I went to the DCT interviews and at that time it wasn’t national recruitment, it was local recruitment. So each district had their own DCT interviews. I went in and the first question I got asked in my interview was, what do you think of the MFDS? And I don’t know what came over me, I was very honest with them, and I just said, it’s a bit pointless, isn’t it? Oh, why? I was like, well, everyone’s just told to do it as a tick box exercise, no one’s actually like reflecting on I shouldn’t say no, I can’t speak for everybody, but let’s be honest, everyone is just like, do the MFDS as soon as you graduate from dental school. Why? Just shut up and do it. Okay? Like, and you just do it, and it becomes a tick box exercise. You’re not doing it with any reflectivity in mind. Not everybody, but let’s be honest, most people just do it to say, I’m MFDS RCS, Edinburgh. And you do the MJDF first because it’s easy, then you do MFDS part two. I can tell from your smile, you know what I’m talking about. And then, I think that resonated with him and they gave me full marks for that question. And then I just relaxed into the- [Jaz]Brave, but we’re very true and you deserve it. So good. [Ameer]That’s not always going to work. I’ve been ballsy in other situations and that hasn’t paid off, but it’s high risk, high reward. [Jaz]You’re either going to rank like first or last. [Ameer]Like, yeah, but anybody who knows me, I’m the guy who just says it how it is. And a lot of people will be like, yeah, and it’s gotten you in a lot of trouble in there, but I just say, I say it now it is. Okay. So anyway, results came out, I wasn’t expecting anything special, and then I ranked second in London. I’m doing myself a favor, saying that there were two people ahead of me who ranked joint first. One of them didn’t take a DCT job at all, and she just went into private practice and is doing very well for herself. The other guy also ended up working at Eastman, so he was doing the restorative post, which was amazing. He had a great year, and I was doing the oral surgery maxfax post. So my post was with six other people. So we were paired up. I was working with a lady called Aisha Shabir, who’s just opened up Every Smile in Leicester. She’s doing sedation, oral surgeries and cool stuff there. So she was my like DCT partner and we had a great year together. So we went, we were all paired up and there were, that was split into three hospitals. So this is my first tip. When you’re doing DCT1, pick diverse posts. And the reason I say that is maxfax jobs come ten a penny, to be honest. Even outside of DCT recruitment, if you go on NHS Jobs and just type in Maxfax SHO, as long as you’re not worried about where to move, there will be a Maxfax job somewhere, and I’ll tell another story about a young chap I’ve kind of guided towards a post in Cornwall later on. But pick one, pick diverse posts. So my post was three months Maxfax in UCL, three months oral surgery at the Eastman, and then three months kind of pediatrics, orthodontics, Maxfax at Great Ormond Street. So that was taking a lot of boxes. [Jaz]Basically, you’re suggesting take a post which has more than multifaceted and it allows you to mix with different mentors and tutors and rotation. [Ameer]Yeah, because as you go up the DCT years, those posts become far and few between. So there’s quite a few restorative oral surgery posts and orthodontic posts and pediatric posts. But then when you’re applying for DCT two, those become a little more hard to come by, and then by the time you’re DCT3, you’re going to be knife fighting for those posts, so, get it done early on, because you can do Maxfax later, if you want to specialize, because if you want to specialize, you need to look on the Recruitment COPDEND website and find out exactly which specialties you need to have done in order to qualify to apply for those jobs. If you’re interested in specializing, especially orthodontics, you need a pediatric post, even if it’s just three months like the one I did, for now. They’re constantly changing the goalposts, so that might change in the future. Anyway, so UCL Maxfax was basically Maxfax with training wheels, so it was 9-5, there was no overnight on call, and we had medics who were interested in doing ENT and Maxfax working alongside us. This is why I say you are a doctor, because we were doing the same job that our doctor colleagues were doing within that specialty. Yeah, so that was my first Maxfax position, and so now it’s story time. How much am I allowed to swear? Because if I’m going to really like bring the passion to these stories, I’m going to need to quote a few people, but I don’t want to add any profanity to your podcast. So my first day I go in and I’m meant to be in the theater with this Maxfax consultant. So in MaxFax, I apologize to anyone who’s done MaxFax and that I’m just going over like old rope, but for people who haven’t done it before, it’s very much a hierarchy. So there is the medical director, the managers, the consultants, the registrars, everybody else. And then you’re at the bottom of the pile when you’re in SHO. So, this consultant’s like yeah, you’re the new DCT, right? Yes, sir. Get the patient’s renal records from Queen’s Hospital and I’m just like okay and then he just walks off like down the corridor and I’m just like what the f*ck which Queen there’s a lot of Queen’s Hospitals which one? What renal records? Like who’s the patient? So I’m like flapping around like and the registrar’s. They’ve got their own shit to deal with and they’re just like yeah, it’s real records Just go get the renal records, and I’m just walking to random nurses in the corridor, like, who aren’t even in Maxfax, Renal Records Queens. And then finally, the consultant, like, does a 180 on his heel, walks over to me, he’s like, is this your first day? Yes. Will someone come and supervise this f*cking child? And I’m just like, okay, cool. [Jaz]No way. In those words? [Ameer]This is, yeah. Like, will someone come and supervise this f*cking child? And I’m like, alright, this is how it’s going to be for three months. Cool. Okay. So the registrar pulls me over, he’s like, You haven’t done anything wrong. I’ll help you. But just remember, these guys are the whales. We’re the guppies. We’re like the little fish that swim next to the whale and pick the plankton off it. Okay, cool. I’m like, I understand now. Okay, and it’s not like that in every unit. And this was my first lesson. In MaxFax, you got to have a thick skin. And if you don’t have a thick skin, you’re going to develop a thick skin. Okay, so. And you just learn that you’re going to come across some egos, because at the end of the day, these guys are the most specialized surgeons. In the medical field, we’re dual qualified medics, dentists. They’re on the bleeding edge of medical technology and surgical technology. They don’t have time to worry about your feelings. It would be nice if they did, and some of them do, and they’re extra special. But these guys, they’re dealing with people’s lives, and in dentistry you don’t come across that a lot. Because, how many patients do you come across with where what you do is going to be, like, actual life and death? For somebody not often. I mean, we do amazing things for patients and we create amazing lifestyle changes for them, but I don’t want to be dogmatic about it because there might be some orthodontist saying, well, I saved a life once, but, at the end of the day, MaxFax is life or death, like, we’re talking about cancer, we’re talking about trauma, and you see, I saw some amazing surgeries that year. Now, I’ll put an asterisk there, the first 10 neck dissections you see are exciting, the next 10 are, like- [Jaz]Wow, I can still remember it! [Ameer]It’s like, okay, yeah, it’s good, and then like, the 20 after that, you’re just like- [Jaz]Then your legs are getting tired. [Ameer]You’re holding some skin flap up like this and they’re like, higher, higher. And you’re just daydreaming about like, when does this post end? Two months. Okay. Oh man. Like two months. And yeah. [Jaz]I mean, that’s like anything. It’s a human nature, right? It’s like a hedonic adaptation is exactly what it is, but just going, just circling back to the, having the thick skin element of it. It’s so true. I remember even though it wasn’t Maxfax. Little things that when I was doing my DC post in restorative, the post I had was not as well supervised as I would have liked. And so there was one, the guys who was kind of a supervisor, but he wasn’t reallocated to me per se. But anyway, nice enough guy, except like I got like some cement stuck around a crown, so just fit his crown in and couldn’t floss it because it’s got cement stuck as you do a real shame. No, I hated myself at the time. And then the tutor, the guy pretty much says right in front of the patient, like, you’re old enough and you’re ugly enough to sort this out yourself kind of thing, walked off. So that kind of stuff, but you know what, I get it, thick skin and stuff. And I’m not, I’ve been through a lot in life. I’m not averse to that. But the thing is, it just goes against my values of kindness. Like for me, I mean, one of my highest values is kindness. And I know that, it’s character building and this stuff and that’s why I probably wouldn’t have enjoyed that kind of environment. There’s an element of, it could be perceived as bullying in a way, right? It could be perceived as bullying. It could be perceived as a culture that’s not quite right, but I see it happening. I know it exists. [Ameer]I think I take a lot of shit from people and I think that’s because my MaxFax background and I spent a bit of time in the Royal Air Force and when you’re in the military as well, like the way they talk to you, you’re a grunt and they’ll just find, you might be doing everything perfectly, but part of your training is to just be kind of broadened lines. [Jaz]Just suck it up by the cup. It is what it is. I get it. I’ve been through that, not to the level that you just described, but, and I probably would have just nodded through it, but am I a fan of it? Do I condone it? No, I mean, I’m not a fan of it, but this is how it is. I see that. [Ameer]I wouldn’t treat my nurses or associates like that, or anybody who’s looting from me. So, I don’t have it in me to be mean, like, because I’ll go home and like, lie awake and be like- [Jaz]This is why we’d never be a consultant at MaxFax, this is why we’d never get those, see, because you need to have that. [Ameer]No, no, the thing is, there are nice consultants out there, there are really nice consultants out there. You’re just going to come across some personalities, but it just gets to a point where you kind of laugh about it, and it’ll be a running joke that like, did you get bollocked today? Yeah, I got bollocked. And you’ll like compare how much, how hard you got bollocked, and then it becomes a badge of honor, like how much you got bollocked. The most important thing at the end of the day is the patience and keeping them alive. I’m not going to name the mean ones, because I don’t want to make any enemies in the profession, but I’ll name the nice ones. So, like, there were some real assholes in UCL. Amazing surgeons, massive dickheads. And then there were, like, super nice guys, like, there’s a chap, Colin Liu, who’s such a nice, probably the nicest guy I’ve met in MaxFax, to be fair. Like, so nice, so supportive. [Jaz]So super nice in MaxFax is like average guy in the real world. [Ameer]Yeah, basically. Like, just a normal, polite person. Just a well adjusted person who’s happy with his life choices. And I mean, this is the other thing, but you do get some regi. The ones, the watch out for the registrars because they’re stressed because they’re dealing with you. They have a lot to live up to that. Now. This is their life. [Jaz]Sometimes they have young families. They’re not sleeping well, because of all these things as well because of the stage of career and the season that they’re in. [Ameer]Exactly. And you know you have like, people who’ve given up a lot, I don’t know how much I can say without offending like half the population, if you know what I mean, but some people have given up a lot and they’ve made life choices that have made things difficult for them and in other parts of their life. At the end of the day, here’s what you learn, we’re all human beings, we’re not perfect and we’re not going to be perfect every day. And every now and then, someone’s going to snap at you, someone’s going to take out their frustrations on you, even though you haven’t done anything wrong. And you’ve just got to roll with it. But this is life, I think about everyone’s seen this in every cheesy motivation mashup on YouTube, but I think about Rocky talking to his son, and saying, it ain’t about how hard you hit, it’s about how hard you can get hit, and keep moving forward, how much you can take, and keep moving forward. That’s how winning is done. And I think about that whenever I’m getting low, sorry, that was a really bad Philadelphia. [Jaz]That was really good. I liked it. I like that. You’re a nice one. [Ameer]And to me, that’s the essence of MaxFax. It’s what are you made of and how hard can you push? And like, well, I mean, we’ll get into the on calls and things in a minute, but you will be tested mentally and physically, and you’re going to develop resilience. That doesn’t mean you have to act like that, and you’re going to take those lessons away, but that’s just part and parcel of the job. So, you will encounter egos, and you got to have a thick skin. And another film comes to mind, The Departed, which is in Maxfax. I’m not going to quote the whole speech, because there’s a lot of racist terms in there, but Jack Nicholson at the beginning of the film, he says, no one’s got to hand it to you. You got to take it. And that’s the other thing about Maxfax, is no one’s going to walk up to you and say, you there, would you like an audit? Here’s an audit, here’s an audit to do, and here’s a paper to do as well, and here’s a case report. You have to decide, I need three audits, two papers, a case report, and also I want to reduce amendable, like that’s what I want out of the year, and you’ve got a pass to them, and they’ll tell you to f*ck off a lot, until finally someone’s like, Okay, yeah, you can do it. That’s fine. [Jaz]Someone will give you a shot eventually, if they see that within you, basically, that desire. [Ameer]It’s like asking a girl out, eventually someone’s going to say yes. So, yeah. [Jaz]Well, I’m so glad you made that point because this is my experience. So when I did one of the posts, I won’t name exactly where it was like a split post, oral surgery, restorative, the oral surgery was pretty decent. The restorative, like, just like you said, like you did the hierarchy of Maxfax, whereas when I was in restorative, the highest grade was obviously the consultants and stuff. Then it was, there wasn’t even registrars. It was the international guys, you’re paying the big money to do a specialist training, basically. They’re paying a lot of money, so they need to get their money’s worth, kind of thing. And it was like, the registrars, the specialist trainees, and then you’re at the bottom of the pile. So, I was literally twiddling my thumbs. I was like, this sucks. I really want to learn. I’m really hungry to do all these cases, but I don’t have anything. I have a lack of supervision. I was having all this dead time. So I said, okay, well, this is the year I’m going to do my first publication. I want to do something, I want to get published. I want to write something meaningful and helpful. And so I knocked on a lot of doors and eventually, Prof Avijit Banerjee, let me in, in it to have a little five minute talk with him. And he said, I don’t know who you are. I don’t know what you’re made of. So here’s your challenge. He said it might take about 20 minutes. So go and like, look at all the different dental updates that have happened so far. And let’s find something that we need to talk about. It took me like eight hours like to do this right and do it well, but, but actually they loved it so much that professor Trevor Burke wrote to hand wrote to me a letter saying, you know, well done. We really appreciate what you did kind of thing. And so through that, we found out that actually Resin Bonded Bridges hasn’t been written on in a long time, especially in Dental Update. And then that was a topic that I ended up doing thanks to the consultants who helped me out with that. And then from that, I got published in Dental Update by the end of that year. So if I didn’t actually make it happen, it would not have had, no one would have said, hey, Jaz, do you want to get published? Do you want to do this? Just like you said. So that’s a big, big tip right there. [Ameer]Do you want to know? Here’s something crazy. I have had my first publication go through two months ago. First publication, my big barrier with applying to oral surgery training was I just didn’t know where to start. With getting it written and who to send it to and I was just going around in circles and I never managed to get over that hurdle. And then after our last podcast, so many oral surgeons and MaxFact surgeons reached out and they were like listen to the podcast, what’s going on? You haven’t done oral surgery training yet? And I was like, I don’t know where to get started with this publication. And finally, they were, a lot of them were like, okay, I’ve got a report for you to write, I’ve got a study for you to write up, I’m doing a literature review. And I’ve loads in the pipeline, but don’t be like me. Don’t like leave it and just circle around. Not sure what to do. Like you have to be assertive and say, I need this. So, anyway, like I said, you got to know what you want. No one’s going to hand it to you. You’ve got to take it. And that comes with everything in life. And when you’re applying for jobs, when you’re trying to develop yourself, when you’re looking for a mentor, pester people, people pester me. Sometimes I don’t have time to get back to them, but once they’ve sent me the sixth text message, I’m like, okay, yeah, this guy’s keen. Let’s get him on board. [Jaz]I totally agree there. [Ameer]So I did maxfax and there’s a lot more to say about maxfax in my second year when I was at the Queen Elizabeth hospital, but I’ll circle back to that. Then the second part of my rotation was Eastman oral surgery. And there, I had this baseline oral surgery knowledge, but you don’t really learn how to take teeth out until you’re doing it in an oral surgery department, in my opinion. Now there’s two sides to that, two edges to that blade. Before I was used to like, you have 45 minutes to extract the teeth, no problem. At the Eastman it was like, you have 20 minutes to extract the patient’s teeth. And it doesn’t matter if it’s two impacted wisdom teeth, or one, or a retained root, or six retained roots. Every patient is 20 minutes. Okay, go. And that seems like an impossible task, but this is, again, where you learn to work at quality and pace. And at first, the registrars and the consultants will be helping you out. So I had Josiah Eyeson, awesome surgeon, teaching us, and Dr. Kaushal as well. And you just, again, learn how to work at pace and they won’t let you use the instruments that you’re comfortable with. So I love Luxators. They’re like, yeah, you’re not touching a Luxator. Here’s a Couplands. Get it out with the Couplands. And I put, but I want to use the Luxator. No, you learn to get it out with the Couplands. And that’s how you learn. But through having someone next to you, that’s how you learn. F*cking it up and then having someone rescue you and then rescuing yourself. And you can be more experimental because you have that safety net to deal with. So yeah, again, like that was an awesome experience. And then I worked with an amazing surgeon. [Jaz]Highest form of learning when you need rescuing and then you watch how they do it. Definitely. I’ve experienced that myself and when I did oral surgery at Guys, just being rescued was amazing. And so I was so grateful and I just learned so much. Just assisting for how I could have done it. It’s very valuable. [Ameer]And then I worked with a really good surgeon. I should say really amazing. His name is Tim Lloyd. There’s two Tim Lloyds. This is an older Tim Lloyd who works at the Eastman Dental Hospital. Yeah, I worked with an amazing surgeon called Tim Lloyd. And he’s like the maxfax surgeon to the Saudi royal family and stuff. And they fly them out to do their surgeries and things, and I think, don’t quote me on that, but anyway, he was like the wisdom tooth guy, and he had a general anesthetic list at the Royal Eye Hospital next to the Gray’s Inn Road Eastman Hospital, and we used to go there every Tuesday, and the nurse would say, put patients to sleep, and we’d just be taking wisdom teeth out, horizontally impacted, distally impacted, vertical, whatever, and he just got me so fast at taking wisdom teeth out. Yeah, so he taught me how to take out wisdom teeth basically under general anesthetic, to this date, I’m still using the techniques that he taught me. And a lot of my referrals are wisdom teeth. The dentists don’t feel confident to take it for the simple fact that they’re wisdom teeth. And I have them out in less than a minute sometimes, or even impacted wisdom teeth. I think, these days, the surgery is less than 10 minutes. If it’s taking longer, something’s going wrong. Generally. And that’s all thanks to Tim Lloyd, to be honest. Like, he just got me super slick at taking out wisdom teeth. And again, it’s tell, show, do. That lead that learning pattern. And you get that in MaxFax, and you have that time. And because these are salaried posts, no one is thinking time is money. Well, I don’t have time to teach you. Like we have to go, it’s people take their time and especially generally- [Jaz]You say that, but then there’s a whole 20 minute per patient thing as well. [Ameer]So that’s different. [Jaz]Okay. [Ameer]Yeah. So that’s what I’m talking about is theater. So the 20 minutes is about meeting the patient volume because so many patients are referred for LA and if they took any longer, the waiting lists would go nuts in London. It’s crazy, especially now after COVID. I can only imagine how long the waiting lists are. But even at that time, they were very oversubscribed to the point where a lot of patients go and still get rejected because they’re just like, this is simple, you should be able to do this at breakfast, but so local anesthetic was 20 minutes and it’s not like that in every unit. It’s just like that in Eastman. And I know that when I was working in Birmingham, they had like an hour per patient or something, so it’s not always like that. But that’s the pace that we were working at the easement. It was 20 minutes, sometimes half an hour, if it’s like a particularly difficult ectopic tooth or something. Anyway, again, I come back to tell, show, do. You can watch, and then what’s great is when you get two impacted wisdom teeth, I’ll do one side, you do the other. And you learn a lot basically. And Tim was so supportive and nice and even if you weren’t doing anything perfectly, we’re talking about guys who are like the Roger Federer’s of their profession, and we’re like- [Jaz]Sounds like this guy was also a Roger Federer in his demeanor and the way he was too as well. I think it makes a difference, man. I’m sure there’s got to be some study in the education set somewhere where if you teach someone all the right things, but if you’re miserable to them as you teach it versus it’s like that thing, that the two jars of rice and one jar of rice or whatever you swear at every day. And the other one that you say nice things to, and then something good happens with that. The one gets spoiled and fungi and the other one, like, it doesn’t get ruined. I’m sure it’s the same as that, except you’re the rice. [Ameer]Yeah. You are the rice. Be the rice. Yeah, definitely. I mean, you wouldn’t want Nick Kyrgios teaching you how to play tennis. Let me put it. I don’t know. Maybe you would. McEnroe’s a good coach, right? You will learn something from everybody. Let me put that. There was one guy actually who was banned from having registrars because he was so mean to them. Then it got to a point where he had to privately hire his registrars from abroad and they even stopped him doing that because he was so mean to them. This was a guy in the, I won’t say where. Anyway, so, then I was quite unfortunate when I came to my Great Ormond Street job, the head consultant there, Peter Ayliffe, was retiring. This is a guy who’s a Maxfax consultant in Oxbridge. Arts lecturer, like an apparently an amazing surgeon from what I heard from the other DCTs. [Jaz]Also, very imminent TMJ surgeon, I believe, right? [Ameer]Yeah. Yeah. I never got to work with him, unfortunately, but he was prior to me starting the Maxfax head at the Grand Ormond Street Hospital. That was a bit of a, I was there kind of spinning my wheels, because I hadn’t really figured out what was going on. I got the tick box of, doing a paediatric job and an orthodontic job, but I didn’t get a lot out of that final term. So yeah, like, it was a really good year. Then I came to the QE, which is a major trauma center in Birmingham. [Jaz]This is where the on calls happen, yeah? [Ameer]This is where the on calls happen. So like, when I first got handed the bleep at UCL, my first ever on call day, they handed me the bleep and I was like, okay, so what happens now that we answer the bleep? Okay, if anyone has any questions, a patient comes in, you go see them. I was like, okay. My first belief was this guy had fallen off his bike and scraped all his face and then there’s flaps of skin hanging off. And I remember going into the room and I was just like, okay, I’m in this A& E room, don’t know where anything is, don’t know what I need. So I called the registrar. Nice guy, Michael, he comes down. I’m like what do I do? Okay, anesthetize the patient. Where? Just around the lacerate, because in dentistry, you have like anatomical landmarks and stuff and like, there’s very specific ways to anesthetize people. In MaxFax, it’s just like stick the needle in the face, make it numb, try not to hit the eye or a foramen and you’re all good. So we’re numbing these faces up and- [Jaz]When you’re numbing a face, should you hit bone or not? [Ameer]It’s been way too long for me to answer that question. No, that’s the takeaway from that. Don’t hit the bone. One piece of advice I’d give actually is field block. So like, if someone has some, if you’re trying to numb this area- [Jaz]Just for the listeners, just say which area you’re pointing to. [Ameer]So I’m pointing to my right cheek. So for example, if I wanted to anesthetize that area, instead of just sticking it in the right cheek, I would go around the point of interest and form a square of anesthesia and do it like that. And from my understanding, that’s called a field block. There’s probably some MaxFax consultants screaming at this car radio right now going, It’s not a field block! I think that’s what I was told. By somebody, it’s a field block. [Jaz]So anyway, is it like when you’re injecting into the cheek area, let’s say, is there a lot of space? i. e. Is it like the palate or is it like the buccal mucosa? [Ameer]Yeah, it’s very forgiving. I’m not going to give anybody any like specific Maxfax tips because it’s been five years since I did a Maxfax job now. But one thing. Don’t forget to stitch the muscle, like I’ve seen a few people come in with lacerated eyebrows and people just stitch the skin up and they forget to stitch the muscle back together as well and then they walk around like Clint Eastwood for the rest of their lives. So yeah, remember to layer by layer, okay? And that’s the thing. [Jaz]Let’s talk about that. That makes a lot of sense, but if I had that issue in my first encore night, I’d be like, I’m sorry, I haven’t been trained for this. I don’t know what to do here I’ve only had to do some sutures on some piece of plastic and an orange and a banana skin before. Now you’re telling me to do it muscle. So what type of, what form of training do you get to be able to do these kinds of things? Cause from what I hear, it’s very little. You’re just learning on the job. A lot of time. [Ameer]We watched Planet Earth. [Jaz]Yes, the older ones. I wish I could watch the new ones, but the older ones. [Ameer]Have you seen that clip of the baby iguanas that hatch and they have to run across the snake pit to get to the sea? [Jaz]No, but every planet on earth seems to have like a similar theme of, okay, you need to get through, you need to survive this journey, right? [Ameer]Okay, okay. You know that the turtles who hatch and need to get into the ocean before the seagulls eat them? [Jaz]Yes, yes, yeah. [Ameer]That’s MaxFax’s DCT. You’re the turtle. They just drop you in the deep end. Life is harsh. From day one. Okay, so I’ll tell you a story that, like, basically will give people an idea of what that’s like. So, it’s my first night shift ever, I’m at the QE hospital, and it’s early on as well in the job, so I think I was like the second person to go on call or something, so we’re talking like September, so we haven’t had time to like bed in. And at UCL it was a lot of cancer, not a lot of trauma, because as far as I know it’s not a trauma center, it wasn’t when I was there. So, So QE, you just get all the fractured mandibles and zygomatic fractures from drunk fights on Broad Street in Birmingham and I’m on call, and we have this waiting room on floor six. Six, I remember, ward 620 was like the trauma ward, and the nurse calls me, it’s like, hi, so, is this MaxFax on call? Yeah. Yeah, so we’ve got two fractured mandibles, zygomatic fracture, blah, blah, blah. Also, a girl who’s tried to kill herself by setting a house on fire. Fell down the stairs and split her head open. So she’s got third degree burns and ITU, but her head’s split open, so if you could suture that back up as well, would appreciate it. And I was just like, what the f *ck, like, how do I, like, triage this? Where do I go? What do I do? I have no idea. So everyone’s asleep, nine o’clock at night and ten o’clock. So I call the registrar, this woman, and she answers the phone, and before I’ve said a word, she’s like, I’m here. I have a list tomorrow morning. It’s 10 o’clock at night. You should not be bothering me with this. You’ve done an oral surgery job. Deal with it. Okay. [Jaz]Before you even said a word? [Ameer]Yeah, before I said a word. And then half an hour later she called me back and she was like, right, so what you need to do is reduce the mandibles, get the cannulas in, clerk them, make sure they’re nil by mouth, from midnight, blah, blah, blah, like, and then, you learn, and then I made a point, I got a year long calendar, just for this person, and if they’re listening, I did this for you, I got a year long calendar, And got red dots and put the red dots on every date that she was my on call registrar. And I made a point of not calling her, do not call her. I mean, yeah, and I never did. Never again did I call her, but yeah, so you’re going to get some, there were some very supportive registrars, like the guy, David McGoldrick. I think he’s a consultant now, but really nice guy, like if you were stuck he would come in and be there with you and show you what he’s doing. That’s super patient. Nikki Mahon as well. Lovely consultant. She must be a consultant now because I’m talking about people who are in training five years ago. Really nice people who are just there to they understand where you’re coming from and they’re there to support you. Now, the thing is, if you’re going to do this job, you can’t be like that for the whole year. Maybe for the first month it’s acceptable, but after that, you need to know what you’re doing. And that’s why I would recommend, first of all, this book, for those who- [Jaz]So it’s called On Call in Oral and Maxillofacial Surgery. Back when I was considering it, it was like, On the Ward or something, right? Dentist on the Ward, it was that book. So you’re recommending a different one, which I will put, you got that one, Dentist on the Ward. So I’ll put these books in the show notes for everyone. [Ameer]Maybe we should blur them out for the Protruserati, subscribers only. I’m joking. Everyone can- [Jaz]No, no, no. We’re good. [Ameer]I’m kidding. So, read up what you’re doing so you have some, I mean, it’s difficult because I don’t know how other people and for me, I need context. If I just read that book without doing the job, it wouldn’t mean anything to me. So I had those on me, and I would do an on call, then I’d go and read up on what I’d done and reflect on it and see what I’d done better, you know. And the QE was very challenging because in UCL you had four consultants, so it’s pretty easy to remember how each one likes it. In the QE you have ten consultants who have very differing views on what should be accepted under MaxFax and how to manage the patients, how to clerk them, what they want. And you’re basically like a glorified secretary sometimes and going to Starbucks and getting everybody’s coffee and remembering everyone’s order and they’ll leave you, they’ll hang you out to dry as well. I remember there was a debate within the department because it was like, there was a certain condition. I can’t remember what it was off the top of my head, but it was, some people were like, yeah, that should be accepted under Maxfax and other people were like, no, that’s not a Maxfax issue. So it was like five versus five. [Jaz]Potentially ENT realms or something like that. [Ameer]Yeah. Yeah, exactly. There was five versus five, and I was the idiot who they were like, okay, in the next Maxfax meeting, bring this up. So I put my hand up and I was like, hi, so like, can we just get some clarification on whether or not this is an issue. This is definitely a Maxfax issue. And anyone who says it doesn’t is an idiot. I turned around to the other five consultants and they’re just sitting there, super silently, swiveling on their chairs and looking at the floor. I was like, okay, I see how it is, thanks. So, like, yeah, you’ll often be left hanging out to dry. But like, no, I’m kidding around, but it was, again, that was a year that was very different to the UCL and Eastman year. That was pure Maxfax. And the thing is, you don’t get a lot of oral surgery experience in those jobs, because you’ll get like a list here and there. It’s not the volume that I got at the Eastman, so, like, it’s, they say that it involves oral surgery, but that is a pure MaxFax job, and most of the people who do that job want to go into MaxFax. Now, you’ll get some, in my year, like, one person went into public health, one person went into Paeds, another went into orthodontics, and I think three of them said they were going to do MaxFax, but two ended up doing oral surgery, and only one of them ended up actually doing MaxFax. A couple went to medical school, but dropped out soon after. [Jaz]It sounds like no one went into general practice then. [Ameer]Well, I guess you could say I did, in a way, even though I’m very specific in what I do in general practice. [Jaz]I mean, you’re talking about the DCTs, or you’re talking about the registrars. Obviously, if you’re talking about registrars, then obviously it makes DCTs interesting. [Ameer]The DCTs, yeah. I mean, I’d be very surprised that the registrars went that far and then didn’t continue. [Jaz]Exactly. Then I knew it was just clarifying that really no, no DCTs went into general practice. That’s great. [Ameer]In my year and in QE, everyone was quite like fixated on becoming a specialist. So, like that job. No, I’m sorry. I’m making that up. I can think of three people who did go into general practice. Sorry, I made a mistake. Three people did go into general practice. [Jaz]Waving the flag for general practice, but before you could continue, you mentioned about having different consultants and like learning about their different temperaments, if you like, and their styles and that’s very important. You know what that reminded me of in the general practice? Well, that reminded me of our nurses. Our nurses that have to keep adapting to a different dentist. That’s a tough gig. So I always just want to say shout out to our nurses. They do a really tough job, right. And to have to adapt their style or adapt to the different dentist style, it is very dynamic and very difficult. So it’s one just reflection I want to put in there actually. [Ameer]I’ve often said to principals and other dentists who have been a bit short with their nurses, that I can really relate to them because you’re kind of like a dental nurse to the registrar in surgeries and things. And I think dental nurses, along with therapists and hygienists, are some of the most under appreciated members of our dental team. And that we wouldn’t be able to do our job without them, and the best dentists are, their backbone is their dental nurse. If you look at the most amazing implant surgeons and things who travel around the country, they will travel with their dental nurse because they’re an invaluable partner in providing the treatment that they need. And from everything from greeting the patients to obviously like making the treatment happen with you, presenting treatment plans to patients. And what you have to remember as well is they’re the ones who are taking the patient into your surgery and walking with them to the reception desk. And they’re the ones who are going to seal the deal when you’re presenting treatment plans and things to the patients. So I think people really need to appreciate their nurses. And I think practice owners need to invest more in their nurses as well. But yeah, there definitely needs to be a big change. [Jaz]And the second, I totally agree. And the second thing you said there, which I want to highlight was the whole thing about if you go for a pure maxillofacial post, then you’re right. That actually the oral surgery experience may be less than therefore. One of the reasons I outlined earlier is that you go in to do a maxfax post because you want to improve your exodontia. And really what I’m hearing is that probably that’s not a great reason. What do you think? [Ameer]Let me tell you a few stories and put things into context. When I was, I’m jumping back and forth in the timeline here. So let’s go back to UCL. It’s December 20th. And I’m doing the TTOs, the take out drugs for a patient, that’s what you call it when you discharge a patient. And there were two patients, an Indian guy and a Pakistani guy in opposite beds. They both had the exact same surgery, hemiglossectomy and neck dissection. So that’s where you remove half of the tongue and you do what we call a radial forearm free flap where you take a portion of skin from the radial part of the arm and you basically plummet into the neck, and that portion of skin becomes the new tongue. They both had this exact same procedure, and the Pakistani chap was being discharged. And the nurse comes over to me, and she’s patient in bed 12 doesn’t look so good. Okay, I’ll be there in just a sec. Next thing I know, the crash alert’s going off, so I run over to the bed, and this guy’s just leaning forward, vomiting dark red blood, does not look good at all, so I’m leaning him forward, just trying to see what’s going on. Is there a bleed? Next thing I know, his eyes have rolled to the back of his head, and he’s on the bed. And I’m doing chest compressions and the nurse is trying to clear his airway, the curtains are drawn, we’ve put the crash call out. At the same time, I learned later, there was a pediatric cardiac arrest, and another cardiac arrest in another part of the hospital. So for about ten minutes, it was just me and these two nurses, life support on this guy, and then finally the crash team shows up. And I think we tried to resuscitate him for about 40 minutes, which is a lot longer than you’d usually try. Unfortunately, he passed away. He’d suffered a major bleed as he’d swallowed a lot of blood and inhaled a lot of blood. And the saddest part of that was his family arrived to collect him thinking he’s had his surgery, he’s gone through all this and they’re taking him home. And instead we had to tell them that he’d passed away. And he had a daughter who was pregnant. Sorry. [Jaz]I appreciate you sharing this man. I mean, these stories, these experiences are very real man. [Ameer]She was pregnant and they hadn’t told her that he had cancer. Sorry. [Jaz]Please don’t be sorry, man. You’re tapping into that state, that time, that memory, which is a very tragic memory. [Ameer]Yeah. They hadn’t told her that he had cancer because they were worried about her being stressed during the pregnancy. And him and this other chap had become very good friends, because they’d gone through the same thing, recovering together. And that guy died in my hands, I was covered in his blood. I was just sitting in the UCL, it’s a very tall building, I was just sitting in the staircase for hours afterwards, just. Sorry. [Jaz]Oh, please don’t apologize, man. I’m so sorry. That’s very tragic. [Ameer]And thank God the Indian guy, recovered, was discharged, cleared. But, I think it’s that 50 50, you are on the edge of life in these situations. So it’s not, you’re not on work experience, you’re not dealing with minor things, you’re dealing with major things and you see a lot of things. You see patients who decline to have treatment and then one lady a young girl, 17, left a tumor, didn’t want to go through the surgery, then changed her mind after, when she changed her mind it was too late. So she was brought into the ward, they just made her comfortable. She was there when we walked out of the hospital, and she was gone the next morning when we walked back in. You know? You see some crazy stuff. When I go back to the QE, I’ll tell a few other stories, but- [Jaz]I mean, I just wanted to say that I remember this experience whereby I was making a complete denture for this gentleman, really sweet man, and I’d seen him for the impressions both times. I saw him for the wax jaw reg. I saw him for the try-in. So I think, I’m going with this by the time I got to the fit appointment, he didn’t turn up. I was like, huh, very common in hospitals, the patients in dental hospitals, for them not to come up. So I said to the receptionist, hey, do you know why this guy didn’t turn up? And she had a look. And even this receptionist, she was shocked. She was like, oh my God, it says deceased. And I remember how bad I felt. Right? Just in that, I can only imagine what you would have went through, man. I can only imagine. I was really in a sad mood that day, so that I couldn’t fit this guy’s denture. Not because I want to fit the denture, because I felt like, wow, man, I had a relationship with him, and he died mid treatment. Like he was almost there to having his teeth cut, and I felt so bad. And so the story you describe, again, goes back to that thing, perspective. Right? It goes back to perspective and what you saw, if thick skin comes into play, makes you have thick skin, it makes you experience these things, which is a real shame, but it’s part, it’s a reality of that post. You are pretty much a doctor when you’re doing that kind of post. So thank you for sharing that, that story with us. [Ameer]Sorry, but I went off on a tangent and you were asking about oral surgery. You will see anatomy that you have only seen in textbooks. And again, it will lend perspective when you are sectioning that wisdom tooth or creating a trough to, or even if you’re interested in implantology and developing into bone grafts and for large things, again, you’re getting this perspective that you just don’t get. You will see it over and over again. People are paying thousands and thousands to go on cadaver courses and things and just for a little taster and you’re immersing yourself in this and it gives you that confidence to raise flaps, to do surgery to work with hard tissues. So, that’s the benefit of MaxFax, even if you’re not doing oral surgery. It’s a live anatomy demonstration every day in front of you, and that’s so valuable. What I’d say is this, go for the restorative and oral surgery posts in the first DCT. And then if you want even more, then do that Maxfax job in your second DCT. They are different, but Maxfax, in my opinion, is still worth doing, even if you’re not interested in Maxfax as a career. That’s what I’d say. Yeah, honestly, there’s so much to say about that, but I’ll stick with the QE stories for now and log everything. What I’d say to young dentists who are going into the, them maxfax jobs, is log everything. Log your facial lacerations, your biopsies, any interesting patients you clerk. If you do get to reduce a mandible, log, log, log, because that’s going to be your calling card when you do apply for everything. Jobs, Tier 2, or, I mean, I was applying for Tier 2 oral surgery registration, and the things they were asking for, I actually had to go back to the secretary’s office at the QE recently, and say, can I please have all my letters that I did my biopsies for, because I need, I forgot to log them, and luckily they let me do it. But yeah, so log everything, and work as a team, because I’ve been in good teams and I’ve been in crappy teams and the good teams all thrive and work together and the crappy team’s very individual and it becomes a lot harder. My QE team, we were like a very solid family. Everybody got on well. We were all there for each other and it was a very solid team. What I noticed about the year group afterwards when they were all very individual, which isn’t a good way to be, I stayed on a little bit to kind of shepherd them in. I locum for about a month. And I remember one girl, she was really stressed out about the job, so I was like, okay, come over for dinner, I’ll make a steak, we’ll sit down and I’ll talk you through it. So she comes over and we’re in the kitchen and I’m making this steak and having a couple drinks and then she turns to me at one point and she’s just like, why are you being so nice to me? I was like, huh? Why are you being so nice to me? And I’m like, I don’t know, I’m just like, I like to help people. She’s like, yeah, but like, you know I want to do oral surgery as well. I was like, yeah, and you wanted oral surgery. So we’re like competing, you know that right? I was like, I guess like and it’s such a strange like attitude to have so don’t be like that Like everybody there’s room for everybody in this profession We can all help each other and like just we’re stronger together. So yeah. Go watch a Planet of the Apes film. Apes Stronger Together. [Jaz]I think that’s great what you said. I think everyone needs to remember that cause you can get carried away in the competition when it comes to specialist training there. So on that note, do you think it’s possible to have a social life and do a full on Maxfax at the same time? [Ameer]Your social life will be your Maxfax team, that’s it. Like, we used to hang out together afterwards, go out for dinner, organize our socials. So yeah, most of your social life will be with that team, because you have no regularity in your week, and that’s another issue. You, my ex, I’ve still got the 20 kilograms I put on during that QE year, because my night, I’d go in in the morning, I’d get my Costa, and then I’d have another Costa after the ward ran. And then maybe one before the shift ends. And then you’re up all night. And you’re just stuffing your face with sugar and caffeine to keep you going. And it’s very unhealthy. And that’s the other thing. My sleep pattern is still f*cked up from all the night shifts I was doing. I mean, there was more. I’ll tell you about that later on. But I’d say try and try and be kind to your body. And it’s very difficult. But there will be long term effects on your health after doing a job like this, so that’s something to bear in mind. But social life is difficult when you’re doing Maxfax and that’s why it’s important to do it while you don’t have children and other commitments and things. I’m not saying you can’t, but there’s two issues with that. One, the pattern of the job. And you’ll have, like, a rota that is an eight week rotation, so week one is, like, eight till eight on cult, and then week two is one eight till eight, then theater, nine till five, which never finishes at five, and then another eight till eight, then you’ll have the weekends, and then you’ll have night shifts, etc. And then you’ll have days off to make up for the night shifts and this is the work pattern and it’s a bit crazy. So it’s very difficult to say like, oh, Tuesday is taco night. Tuesday is not taco night. Tuesday is you don’t know what Tuesday is going to be. [Jaz]I’m more of a chippy Tuesday kind of guy myself, but okay. [Ameer]Yeah. Okay. So yeah, you won’t have any regularity in your life during those years. But like you said, it’s a season, you go through it, you do it, and then you leave it behind. Yeah. So it’s part of life. [Jaz]I’m very inspired from everything you said at the beginning. It was like kind of the people who are listening, watching like, hmm, yeah, I’m not convinced this is for me, but then you made some great points at the end about why we should consider it. And I think the strong recommendation you made is that actually you should do it for all the reasons said it is enriching. It will help you. It’ll give you that perspective. Like you said, in the interest of time, my friend, I have time for one more story, one more story, and then I’m going to ask you for a Protrusive Dental Pearl that’s going to feature at the beginning of the episode. This could be a clinical tip. This could be a non clinical tip. It could be anything. It could be related to this episode. It doesn’t have to relate to the episode. [Ameer]Don’t believe your own hype. That’s a low, actually. Let’s start with a low. Don’t believe you’re on high. Now, like, you are going to think you’re the bee’s knees and you’re like some sh*t, and these guys will put things into perspective for you, and also give you an ideal to live up to in terms of the way you operate and the way you act. And you have a lot of dentists these days who’d want to be celebrities immediately. MaxFax really, like, gives you perspective in that regard as well and slows you down and you realize that there’s a lot to achieve and that can be achieved, but you got to take your time and do it the right way. So, that’s one thing. I’ll tell one more interesting case. I’ll tell everyone about one more interesting case. That kinda summarizes the MaxFax experience. So I’m on call, it’s middle of the year, I think, and I get a call, and they say, okay, we got a kid coming in, and he’s been involved in a bar fight, he’s got what we think is a retrobulbar hemorrhage. So, obviously Maxfax is the first protocol. Now, the retrobulbar hemorrhage is when you have a bleed behind the eye. The issue there is, one, risk of blindness, and two, risk of pressure being applied on the abducens nerve, which can then throw off, throw an irregularity into the patient’s heart rate and precipitate the heart attack. The way you treat this is with something called lateral canthotomy, which is where you make a cut, generally above it to the side of the eye while depressing the eye to drain blood from around the eye and relieve this pressure. And this is a very technique sensitive procedure. I call my registrar and I’m like, this dude’s got a retrobulbar hemorrhage. He’s like, okay, do a lateral canthotomy. I’m on my way. The registrar’s aren’t in the hospital. They live there at home. They’re off site. Okay, I haven’t done one. Okay, ping. YouTube link to a lateral canthotomy. I’m in the lift, going down the hospital, watching a YouTube video on how to do a lateral canthotomy. And I’m just like, what the hell, so. [Jaz]Oh my goodness. [Ameer]So I’m going down, I go down to the A& E, and they’ve got like the major trauma area. Go in there, and oh man, this poor kid, I see his two cousins on the floor, like, just with their head in their hands. And basically, this guy, he was studying in America, and he’d come back home to see his family for, it must have been Easter or something, like, the night before he was flying back, his cousins had convinced him to go out for a drink with them on his last night. He does. A brawl erupts next to him, and someone just catches him with a bottle, and his face is just covered in glass, his eyes just bulging. So, thank God the registrar arrived before I had to do lateral canthotomy. He arrives, we anesthetize his eye, well around his eye, and he’s screaming and the nurse is like, do you have to do that here? And if we don’t do it here, he will lose his eye or die. So yes, we have to do that here. So he, must have the Reg does the lateral canthotomy. We drain the blood out. By that time, the CT report comes back, and he actually has a shard of glass embedded in his eye, so he’s losing the eye anyway. And then his parents come, and we have to, me and Westerfield take them to one of the side rooms and explain that their son, he’s a good looking guy. I mean, not that that should count for anything, but he’s a shame. He’s a handsome boy. And we have to explain that, your son, he’s once scarred for life across the side of his face and he’s lost his eye as well. And then, my dad is a doctor. He’s an A& E doctor. And he is so annoying because everything me and my sister do is like, careful, be careful. But, be careful. Are you opening a fridge? Be careful. You’re crossing the road? Be careful. And I used to be like, why is he like this? And when you see the stuff you see in MaxFax, I’ve seen gunshot wounds, I’ve seen machete attacks. Those are like, attacks and fights. But then you see all kinds of little accidents. I mean, we all find ourselves in a bar, we’ve all been next to a fight. Could happen to any of us, it’s scary. [Jaz]I’ve seen some crazy ones. I used to work in Sheffield in a bar and I’ve seen some really nasty stuff. Lots of blood and stuff. So I’ve seen that and you’re right. And you know what you reminded me of? My wife reminded me of your dad because she’s on a Maxfax in Sheffield. And she had to stitch up lacerations on children. And she’s so overly cautious with our children. And I actually forget that actually she did that maxfax I suppose. [Ameer]Yeah, well that’s my daughter. I’m so nervous, because I’ve seen so many, when I worked in Cornwall, and I worked there for in Maxfax a little bit, but so many little foals and things, and that a little kid, I stitched his ear up, he couldn’t go, I can’t remember why he couldn’t go for GA, he was so brave. Cornish kids are built different. He’s just holding his dad, three year old, and I’m anesthetizing his ear and stitching his ear and cartilage and everything back together and while he’s waiting, he was such a good boy, he just sat there, quiet as a mouse, and just let me do it, he was so, I was really impressed by him, but anyway, so I’m off in the tangent, and so we’re telling these parents about this, and, they’re very stoic, and they’re holding it in and then they go to the boy’s bay. And the mom just collapses on the floor on her knees. So, why am I telling the story? You’re going to see extremes, and it’s going to put dentistry into perspective. So, like I said at the beginning, MaxFax puts dentistry into perspective. So, if I was going to quickly reel off why people should do MaxFax to summarize, you’re going to build resilience. You’re going to earn that doctor title. Not that you haven’t just because you haven’t done Maxfax, but I’m just saying like you realize you realize you are a doctor, and you can be a doctor and I always say this. I always say when people say, oh, dentists aren’t real doctors. A doctor wouldn’t last five minutes in a dental practice, and hundreds of MaxFaxSHOs around the country are proving that a dentist can survive in a hospital because we have that base knowledge. We are specialists. We’ve just come to the chase. So, that’s the second point. If you want to do specialty training, MaxFax always looks good on a CV for a variety of reasons, including the actual, the curriculum of practicing MaxFax, and you will just get an appreciation of anatomy and physiology, and it really reinforces that extra stuff we do, the pharmacology, the physiology, then full body anatomy. So it’s definitely worth doing. And you just don’t know where your career is going to take you in the future. You might think you’re going to do one thing, then you’ll want to do another. And this is always going to be that baseline. And you’re working with the best surgeons in the world at the end of the day, like the MaxFax consultants, whether or not it’s they’re dickheads are really nice, whether or not they have an ego or they don’t, they are the best at what they do. They’re the most, it’s the most exciting area of medicine and dentistry and you get to experience that. And I think that’s definitely worth doing when you have the time. So, we could do a part two on this or whatever, because there’s so much to say. And if anybody wants to talk to me about it. I’m happy to discuss it with people, and there’s so much I’ve missed out because there’s so much to say about it. But I really enjoyed my MaxFax years. I look back at it fondly. I don’t regret doing it at all. And if I had the energy to do it again, I would. It was so much fun. I didn’t do MaxFax as a specialty. A lot of people told me I should because I was a good SHO, but my dad told me not to do medicine because the night calls and everything like night shifts, but then he told my sister to do medicine. And now my sister’s like, well, I’m a real doctor. What are you a tooth doctor? No, but it’s sorry. One last thing. One last thing. Just, I’m sorry. I know I’ve gone over time. If you are interested in sedation or PRF or anything like that. A skill that you will get in Maxfax that you can’t get anywhere else is cannulating. I’ve mentored so many sedationists and they know the drug well, they can titrate well, they can manage patients who are nervous, but the most important part of sedation is getting that cannula in, and that’s such a fine skill that you can only pick up when someone’s called you at three in the morning, all the cannula sites are exhausted, and you’re down there with a crusty foot trying to find a vein to put a cannula in or draw blood to get some ABGs or VBGs and you’re only going to get that in the hospital. So another tip I’d give to anyone who’s going to do Maxfax, who’s thinking about it, is when you’re doing it, follow the phlebotomist around on their bleeding wards. They are the most adept at doing that at getting veins. And you will get good at it. That’s what I did on the phlebotomist came around. I said, can I please, I had some time. Can I please come with you? And I’m pretty good at finding veins in our UK sedation team. I’m the vein guy. So it’s you’re going to get that skill in hospital. So, yeah. [Jaz]This is the second time you’ve mentioned on this podcast whereby you took it upon yourself to start following someone. Like for example, back in dental school, you start to go to all the surgery people you went, you follow the phlebotomist. I think that’s a real trait, a real great trait that you have. Yeah. And I think if even a few people listen to this and think, you know what I’m really more like, Ameer, that attitude that you have, then I think no one wants to be more like me. That’s a real great thing. Of course they do, man. Of course they do. You mentioned about people reaching out, which is, I always welcome that. Yeah. I think is great for people to learn more from our guests and stuff. What’s the best way to reach out to you? [Ameer]So, Instagram is DrBocus, D O C T O R, B O C U S. That’s the best place. Follow me on there and send me a message, I will get back to you. Since the last podcast, quite a few people it was weird, one guy walked out of his surgery, because I was operating in another surgery, and was like, are you Ameer Allybocus? Yeah. Oh, I heard your podcast with Jaz Gulati and I was thinking, I’m kind of a big deal now. Like people, I’m a known person and he was like, yeah, your voice just puts me to sleep, man. Like I nearly fell asleep while I was driving. Okay. [Jaz]Thanks dude. Holy moly. [Ameer]Anyway. So I’ve mentored him now for sedation and and oral surgery as well. And so, and another chap who say this is a guy who graduated abroad. Wanted to get into oral surgery and develop those skills, so I sat down with him. We went on the NHS jobs website and I spoke to the team in the Royal Cornwall Hospital got him a job there I mean he got the job himself. He interviewed for it But he’s having a great time there now developing his oral surgery skills. So I’m Here for younger dentists who do want to reach out that are students. And if you just want some career advice, not that I’ve done it the right way, but I’ve done it my way. And if you’re interested in that, just let me know. And I’m happy to give you some tips and tricks so you don’t make the same mistakes as I do. And if, and maybe you’ll do some of the things that I did that I’m happy about. So. [Jaz]And guys, if you play your cards right, maybe he’ll invite you for a steak. Very good. That’s fantastic. I also want to just say, I don’t know if you know about Intaglio, something that we’re working on, we’re developing stuff to make this mentoring platform. It’d love to have you as a mentor on there for people who want to reach out for sedation. Obviously you do a lot of this anyway, but if you have any capacity, we’d love to have you on there at Intaglio. Ameer, thank you so much. Honestly, it’s been absolutely fantastic. So the stories, the emotions, everything. I’m going to leave this as one big, long episode. Actually, instead of cutting it in two, I just think that it captures, people can just do it over two commutes, but I appreciate your time. I appreciate your stories. Appreciate your wisdom. Appreciate experiences. The highs and lows, everything. Thank you so much. [Ameer]And what I’d say is, get some more people on who’ve done MaxFax. Because when you sent me the questions you wanted answered, I asked all my friends who’ve done MaxFax. What would you say? And everybody had such unique experiences in hospitals. They were so different. So what I’d say to people is reach out to people who’ve done MaxFax and they’ll have a lot to say, a lot to say, a lot to say. Jaz’s Outro:Well, I certainly wish I had something like this when I was at that stage just after done school to get some guidance or a flavor of what to expect. I think this has been absolutely fantastic. Wow. There we have it. I mean, thank you so much for getting to the end of that one. That is a long one. That’s a really special one, but I hope you gained a lot of value from his stories. I want you to reach out to him in and tell him, well done and, and thanks for making himself vulnerable, some of those sad stories. I mean, it reminded me of some of the sad moments I had with patients, but man, I have a new found respect for anyone who’s done MaxFax. I always, always did, but even more after today’s chat with Ameer, I’m hoping maybe you’re feeling the same. Maybe you’re thinking about going into MaxFax and maybe this is giving you some answers that you need. I was worried that perhaps after this episode, you wouldn’t want to do MaxFax anymore, but I do think that Ameer obviously made it very clear that he does recommend doing such a post because it kind of is like a once in a lifetime experience. It’s your journey as a dentist. This episode is eligible for CPD. So there’s 90 minutes of CPD to be gained for this episode. The way to do that is by answering a few questions in the quiz. This quiz lives inside our app. It’s called Protrusive Guidance. Now you can access Protrusive Guidance on your laptop, on your browser. You go to www. protrusive. app, or if you want to access it on your iPad, Android, iOS, using the native app, you can download Protrusive Guidance and if you have any of the paid plans, you can get CPD. For those who are looking for CPD in terms of webinars, mini courses, even like extraction, sectioning school videos, that’s all available on Protrusive Guidance. And even if you just join for free, we have such a wonderful community of dentists. It’s the nicest and geekiest dentists in the world. So that website again is protrusive. app, or you can download it from the iOS store or Android store. Now, there were a few book recommendations, so I’ll put them in the show notes. And I’d like you to do me a favor. If you got to the end of this episode, obviously you got a lot of value for this episode, so please share it with someone. Share it with someone who’s considering MaxFax, who maybe you did a MaxFax post with, and you want to send this to them because you want to, like, reminisce about your times as a maxillofacial DC. Maybe you remember some stories or some consultants, and you want to share these memories with a colleague. Well, make sure you share this episode with them. I hope that was good insight for everyone, and I hope to catch you same time, same place next week. Bye for now.

What makes us reject crowns and send them back to the technician? What are the standards/guidelines to consider before accepting and luting indirect restorations? Join us as we explore the key factors that determine the quality of a crown. From the initial lab communication to the final occlusal checks, we cover it all. This episode is packed with essential tips that are perfect for dental students and professionals alike.  https://youtu.be/ftafglxcBbM Watch PS007 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode: 1:33 Emma Hutchison: Student Life and OSCEs 06:44 Handling Lab Work and Fitting Crowns 14:15 Crown Rejections 18:12 Understanding Occlusal Tolerance 20:09 The Importance of Occlusal Precision 22:24 Building a Strong Dentist-Lab Technician Relationship 24:17 Tips for Dental Students 27:46 Microbiology in Dentistry Don’t miss the special notes on Microbial Ecology and Infection Transmission available exclusively in the Protrusive Guidance app! (Join the free Students Section) This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App! For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. If you love this episode, be sure to recap PS006 – Basics of Indirect Restorations Part 1 – Decision Making Click below for full episode transcript: Jaz's Introduction: Welcome to Part Two of Indirect Restorations for Dental Students, but it's actually suitable for all dentists. But the person who's asking all the questions is our Protrusive Student, Emma Hutchison. Students are so curious and so great at asking questions. I want to make sure that we tailor these more basic episodes to what actually students, young dentists, and those returned to dentistry actually need. Jaz’s Introduction:In part one of this series, we covered what are the different types of crowns that we might go through. In part one of the series, we discussed direct versus indirect, and when we are choosing indirect, which materials can we opt for? Especially focusing on all ceramic restorations, which from my time, were not done that much. As a student, we did PFMs, and it sounds like PFMs are still being done in dent schools. Let me tell you, PFMs are not done that much in the real world. So that’s why we focus a lot on all ceramics. We also discussed on crowns versus onlays. That was in part one. In today’s part two, we’re talking about the clinical details. When you get the crown back, how you assess if this is a good crown or a bad crown? When should you reject? What are the different parameters that we tick off? And how can we avoid? Mistakes from happening so you never have to reject lab work. I’ll give you a clue involves communicating with your lab technicians, so, so important. Another interesting thing we discuss is what about if you try in a crown and it’s completely shy of the bite. So it’s not proud. It’s not popping the patient open. It’s not like eyes too big It’s actually completely shy of the bite. Should we reject that? Should we accept it? What is the standard of care? So we covered this real world scenario and so much more in this episode. So I hope you enjoy. Please do comment below and give us a like, if you like what we do. I’ll catch you in the outro. Main Episode:Emma Hutchison, welcome back again to the Podcast Student Version. Just give us an update in terms of what’s been happening in your world. Are things getting a little bit heated academically? Are you feeling the strain? Are you feeling the pressure? [Emma]Yeah, I’m really starting to sort. At the moment we’re in sort of the end of February when we’re recording this and I’m just becoming a bit more aware. Exams probably end of April, start of May time. So it’s in the back of my mind definitely. So really starting to keep on track of everything, keep up to date. So yeah. It’s at this point in the year where it can really just make or break you, the workload and things and just trying to keep on top of it and try your best not to be overwhelmed, which is so much easier said than done. But it’s just, especially things like OSCEs as well. I think that’s quite a, it’s a different level of- [Jaz] Describe what OSCEs are to an international dent student Maybe it doesn’t know what an OSCE is or maybe it’s caught something else in their country What’s an OSCE [Emma]Yeah. So your OSCEs are like your, what does it stand for again? [Jaz]Objective Structured Clinical Examination. [Emma]Yeah, that’s the one. So you go in this big room and there’s maybe, I think we have 12, 10, 12 stations. We’ve got six minutes per station. You go around and it’s very much about your clinical knowledge, your hands on work, your ability to communicate, they get actors in, like proper actors that they hire and things that they pay. And they’re very good. Yeah, very realistic patient scenarios and it’s all about communication and less about how you do. In written exams and more about how you are as a person and how you are clinically. So it’s a whole different type of stress that I had never, ever, never felt before. And it’s a hard one to get used to, but it’s definitely something that you can learn a skill that you can learn how to manage as it was. [Jaz]Absolutely. Have you done any OSCEs before? [Emma]I had one in second year last year and that was my first one because we never had one in first year because of COVID. So yeah. [Jaz]Well, when you do the next one, let’s have a top tips for OSCEs based on your experiences and where you could have gone wrong, what could have improved, what went well. It’ll be nice to have a little session on that. And I can chime in and give you some, from what I remember, I actually remember some OSCEs from the past. I remember one where there was an actor and you have to explain the therapy, periodontal therapy, non surgical periodontal therapy and the advantages and disadvantages and where the students really didn’t do as well as they wanted is because they failed to identify the fact that there’s going to be recession. Just warning the patient that there’s going to be recession. If there’s been successful, if you’ve been successful, you’re going to get recession. That’s the normal part. And so that’s a lot of students miss that point. So I guess we can do a little session on OSCEs in the future. I think that’d be good. [Emma]Yeah, definitely. And I think a lot of times students will trip up just jargon, jargon, jargon, jargon, and it’s such a skill to be able to put that into patient terms, especially something like perio surgery and recession and putting it in layman’s terms so that someone understands what’s going on can be really quite tricky. So that’s a skill definitely that you can work on as well. [Jaz]It’s like sometimes trickier when you are a student because like in practice, I hope that I’m not using jargon very much. I don’t think I am, but because it’s just me and the patient, I’m trying to make everything understandable using being jargon free. But when you’re actually learning the language of dentistry and you’re deep in it and then you’re kind of trying to flex. You’re trying to flex your knowledge and you’re kind of almost trained to use these words. You’re trying to use all these words of bacteria and everything that you’re learning. But actually, when you go into that OSCE, it’s complete opposite. You don’t want to show off that you know all these terms. You actually want to really, for the want of a better word, dumb it down, basically, for the patient. [Emma]Yeah, yeah, absolutely. And we usually have our OSCE as our last exam. So, a few days before you could be writing about the same scenario, but you have to use all of these trigger words and all the words that you’ve been taught over the last year. And then just to have to switch that off can be really tricky because using your jargon with an actor patient, like they will question you, like, what do you mean by that? What do you mean by that? And you will get marked down if you start to confuse your patient or they don’t understand what’s going on. And then you get flustered and it’s just, yeah, it’s hard to control those sorts of situations sometimes just from a student’s perspective. It’s really tricky. [Jaz]It’s all about preparation and practice. So in a group of students, so please be doing that guys, you’ve got OSCEs coming up and just, I think we spoke about this before in a previous episode about mental health and managing the stress. But something like an app called Balance, a daily five minute meditation, breathing exercises, really, really important. I remember being crippled by fear during exams and whatnot, especially finally, the closer you get. So completely normal, everything you’re going for, all these emotions, all these feelings. I don’t want to mention about failure and stuff, but it’s just funny. The recurring theme. I found in interviewing brilliant guests and speaking to great dentists that so many of them actually didn’t pass first time round or whatever. I’m not saying that you should be in the forefront of your mind, but even if that what seems like the worst thing ever, like that seems like the worst thing ever, but I’ve met so many great dentists who have to repeat second year or third year and they’re absolutely, Amazing. So firstly, forget about it, right? But should you be affected by this theme, then you’re going to be still being okay. So that’s the main thing I want to cover there. Emma, let’s dive into the main question, the main theme for today. Because we kind of had to, we were super busy last time, we had to cut it short, but there’s one really important question when it comes to crowns and indirect restorations, onlays, that kind of stuff. A really great question that you had that I think all students, all dentists actually, young dentists especially, will benefit from. [Emma]Yeah, so, as a lot of you probably know by now, I’ve been a nurse for a few years now, and I’ve seen so many times, lab work comes back, and for whatever reason, it needs to be sent back, and I think I’m quite lucky that I’ve heard the labs in Glasgow Dental Hospital are very, very good. I don’t have much experience with them yet, but, all of the clinical staff rave about them, say, oh, you’ll miss this when you’re out in practice, all the rest of it. But I suppose, are there common challenges that you find during the fitting stage specifically? And even more specific than that, I suppose, what warrants lab work having to be sent back to the lab versus, you know yourself, oh, I can fix that chairside where’s that sort of line, I suppose. Because as much as I’ve seen it, lab works needs to be sent back. It’s never really been explained to me, it’s never had to be, it’s not my job at that point. So that’s just an interesting one for me as well, just, where you sort of, what’s going on in your head when you, something’s just not quite right. [Jaz]Okay. Excellent question. Let’s tackle it a bit by bit. So when the lab work comes back, let’s say to, so they can make it very specific. It’s an upper first molar crown. Let’s say it’s an all ceramic crown about a traditional shoulder, one millimeter all the way around. And the reason we did this crown was it as a root filled molar. And then you prepared it and then you took some impressions or a scan to lab, labs and you got this lovely tooth colored crown that you’re going to fit. So first thing to do actually is to check it on the model. When you check it on the model, what you’re looking for is, are there any major gaps or voids? So where the crown meets the actual prep on the dye model, if you’re seeing gaps and voids, you’ve got to assess what’s going on. Is it perhaps that you’re not able to seat the crown all the way on the model? And maybe the issue is not. That’s an open contact. The issue is that it’s not fully seated because the contacts, mesial and distal, are too proud and they’re not allowing you to seat the crown all the way. Does that make sense? [Emma]Yeah, yeah. [Jaz]So the crown is too tight. It’s not able to go in because the adjacent teeth are not letting it slip through. So that’s the first thing to check. So you want to check with floss on the model, see how it is. And if the contacts are tight, we’re going to talk about how to adjust that in a moment. But let’s assume that there is a degree of an open contact. Well, firstly, before we take a step back, I was always taught, always check that this is the correct lab work for the correct patient. [Emma]Yes. [Jaz]Sounds silly. I know, but you’d be amazed. Okay. So make sure it’s the correct patient. And correct thing was done, correct tooth, et cetera, all that kind of stuff. And then you’re going to do quality control on the model. If you notice that the contacts are fine, you’re flossing them okay, but there seems to be an open contact, that’s a real red flag right there. Really, it should be nice and sealed. So at that point, you’ve got to think, okay, what is my threshold? Because, you know what, sometimes the lab are doing their best they can with what you’ve sent them. Sometimes you’ve sent a preparation and there’s been an undercut or there’s been an issue that the lab had to overcome. For example, another issue could be the path of insertion of the crown was very awkward. Because we’ve got some like rotated and twisted teeth, the lab had to really find out how to insert this crown. Because that path of insertion, it creates an undercut in one area and therefore, now you have to accept the slight open contact in one place. Now, if it’s a straightforward crown and nothing should be wrong, it really should be perfect, then fine. But if maybe you’ve got to re evaluate your prep and think, hmm, at that point, you’ve got to pick up the phone and maybe take a photo, pick up the phone and say, hmm, I’m noticing this. Did you guys struggle? And then you’d be amazed that sometimes you get some feedback that actually, you know what, Emma, we really struggled with this prep. Let us know how it goes and what it looks like. We had a look. We noticed this issue as well, but we think it’s within limits. So if you see a huge, void that your probe can go in. Okay. Then that’s no good. But if it’s a small, tiny little gap, that cement will fill in and it’s pretty much good 90 percent all the way around, then you might want to then take this to the next stage, which is, okay, let’s try it in clinically. [Emma]Okay. Yeah. [Jaz]So if it’s a huge void, then that’s a cause of concern. You need to pick up, take a photo, send that photo to the lab, pick up the phone and have a chat with them. If it’s a small one, then maybe still talk to lab, I know it’s a small void, have a look at the photo and, have a chat with them anyway, but then be willing to go through a try in because it might have been a tricky one for the lab to make. At the try in, you’re going to take off the temporary. So I like to use like these artery forceps or mosquitoes, squeeze the temporary and wiggle it off. You want to clean the the actual prep now because what you don’t want is excess temporary cement Stopping your crown from seating. And then when you do the try in again, you’re checking the same things again are you able to seat the crown all the way or is a tight contact hanging you up? So the way I check this clinically is Just check with floss. I’ll get my nurse to hold the crown. Okay. With her finger. My nurse, a female, so her, but it could be a male nurse. So the crown is now held in place with finger. I will floss myself and just check. Is there a nice click? We don’t want open contacts and we don’t want something that’s so tight that the floss is tearing. Now, when you were nursing, how involved were you in the crown fit appointment? [Emma]Not very, no, not really. I would mix the cement. And that’s about it. There’s a few practices I’ve worked in where I would be the one to put the cement in the crown whilst the clinician is holding it. But that’s about it, really. That’s about it. [Jaz]Okay, so the biggest mistake, I remember fitting a crown when I was like one or two years qualified, and the cement escape, I wasn’t quick enough in removing the cement. And then now the patient was left with a blocked contact because the cement kind of went in that zone and the floss wouldn’t go through. And so the biggest takeaway I had at that, this was actually in hospital, I was a DCT, and the biggest learning I had there is that when you’re doing a crown, when you’re cementing a crown, it’s not a one person procedure, it’s a teamwork procedure. And then really the nurse should be heavily involved. And so the way we do it is, once I put the cement in, once I’ve put the crown on, and I’ve got the patient, let’s say, bite on a cotton roll to fully seat it all the way. At that point, it’s not like I’m doing everything myself. At this point, either the nurse is flossing or I’m flossing and one of us is holding the crown. Typically, the nurse is holding the crown with her finger and I’m going to floss basically. So that is much easier and better than me trying to hold it and then floss it at the same time or just floss it and then the crown could be shaking, could not be stable, for example. So, in that case, we’re going to check how it’s flossing so remember we’re still at try-in stage. We’re checking how it’s flossing and if it’s flossing well, great. Now under magnification and lighting, I’m going to check the buccal. I’m going to check the palatal. I’m going to check my probe. Okay. And then interproximally, sometimes if you just really get the right angle, you can see interproximally. Sometimes you can use a probe to suppress the papilla. And blow some air and really see that mesial and distal margin. If it’s looking sealed all the way, happy day. So you’ve got a nice concept that flosses and you’ve got a good seal all the way around. If you have a doubt or if you see an open contact, reassess the contacts, make sure the contacts are good. But now if you see an open area where there’s a void, at that point, you got to decide, okay, is it within a threshold? Is it for the reasons that we talked about earlier? Or really does this need to be rejected? I reject probably for this kind of a reason. One in thirty crowns. What’s been your experience from nursing? How often have you seen a crown being rejected? [Emma]Mmm, I don’t even know that I could put a number on it, Jaz. Not hugely common though. Probably quite similar to your own experience. Yeah, quite similar maybe. [Jaz]Yeah. So it’s only because I’m quite strict my quality control. So if I say something like that, I mean, you could at this point take a bite wing radiograph, right? And see, okay, how’s it look on a bite wing? Sometimes it’s very obvious on a bite wing as well that it’s open. So if you have a doubt, you could take a bite wing at this stage. You really want the margins sealed all the way. So assuming now the contact’s good and it’s sealed all the way. What are the other reasons why it could get rejected? Okay, for an upper first molar, aesthetics, you’d be amazed. Okay, so usually you shouldn’t, aesthetics shouldn’t be that important, but some patients, for some patients it is. Yeah. And so you could show the patient a mirror, but even before you show the patient a mirror, you got to look at it. And decide, okay, we want for a white crown for a reason, because obviously it’s got to be tooth colored. And if you think it looks good, if you, as your, the clinician feels like it looks good and you are proud enough to cement it, great. That’s a great sign. If you think something’s not right and this looks really bad, then don’t be the guy who shows the patient a mirror and the patient goes, yeah, yeah, it’s fine. Because that could really bite you in the backside one day. The patient comes back saying, Oh, I smiled really big. And actually it’s a bit yellow. You don’t have a leg to stand on because you notice, yeah, actually this looks really out of place. Right. So you yourself have to be happy with it. Once you’re happy with it, you show the patient what you don’t want to say is what do you think? Because then what you’re doing is you’re opening yourself up to criticism. Well, actually this and that is okay. Hey, look how nicely it matches the adjacent teeth. I’m quite happy with this. Just checking. I just want to show you before I glue it in. Oh, okay. All right. Thank you so much. Okay. That’s good. So aesthetics could be a reason that it gets rejected. Very rare in this type of situation, basically. The other one is now occlusion. When the occlusion is proud, you can adjust it, right? If it’s like massively proud, like huge and you’re running short time, then you may wish to record a bite restoration. Send the crown back and get the lab to adjust the occlusion in, very rarely you have to do that basically. Okay. The more significant issue is the other way whereby it’s completely shy of the bite. Like it’s massively shy. So there’s no bite on it at all. And so you might be thinking, okay, is that really important, Jaz? You might be saying, is that really important? Well, on someone who’s got 32 teeth and all the teeth hitting together nicely. One tooth that’s not perfect in the bite is not going to be the end of the world. The patient will likely adapt. There’ll be some overruption and rotation, that kind of stuff. That’s not ideal, but in that case, the patient’s going to live. It’s all right. But if you’ve got like implants around the arch, which you don’t want loaded in clench, if you’ve got a patient who’s periodically susceptible, maybe they’ve got some mobility, then that kind of patient maybe is kind of important. And so it may be that, you remember we talked about shim stock foil, that eight micron foil. [Emma]Yeah. [Jaz]It may be that it’s not holding shim. We’ve got to now re figure out, okay, at what’s our threshold level, at what point do we reject and what point do we accept? And, and there’s no hard and fast rule here. With me, if it’s a patient who’s got generally an okay occlusion, I want the occlusion to be within a hundred microns, within 0.1 millimeters. This is on someone whose occlusion is pretty good. If it’s more than 0.1mm out so for example, I get a hundred micron articulating paper, get the patient to bite together. There is no smudge, there is no ink. Only when I get the 200 micron paper do I see a mark on it, that really is out of the bite. In that case, you could send it back and take a photo and send a bite register, like this has not met my expectations. Okay, so that happens very rarely. However, in someone who actually, this is a strategic tooth and it really needs to be in the bite. It needs to be well in the bite. Your threshold might change. It now might be 20 microns basically. If you try when the shim stock is pulling, but when you try with your 25 micron paper, it’s biting. That’s an okay threshold. It’s going to just do some minor adjustments and it should be okay. So it’s something that we don’t think about and I didn’t think about for many years until after qualifying. So hopefully it’s a nugget in there for someone who might be listening and watching to this. Have you ever thought about that in terms of the occlusal tolerance of a crown fit? [Emma]Not really, but what you’re saying is making sense. And I think quite commonly as students, if we see a blue dot, after using your articulating paper, you just want to take it away. No, there’s so much more to it than that. And I think what has always stuck with me, one of your first episodes I ever sort of made the notes for, was checking the occlusion beforehand. If you have the luxury of being able to do that, then that’s definitely something. Because you don’t just want to take something out of the bite. If you don’t have to, if that’s not the case. So that’s something that’s always stuck with me. And I think, yeah, as students, we just want to grind all the way until there’s no dots that you can see at all. But that’s just not what you want to do, is it? [Jaz]Yeah. That level of precision is not great. And so when you’re a dent student, when sometimes young dentists, some dentists might be watching, listening to this. You might be 20, 30 years qualified. You might be following this philosophy called GABS. Do you know about the GABS occlusal philosophy? [Emma]No, I don’t think we do. No. [Jaz]GABS is a Grind All Blue Spots philosophy. So there’s no precision there. So I wouldn’t recommend it. And it’s something that we do. And then the patient says, Oh yeah, that feels great. And then obviously it feels great. But actually that you’re not really serving your patient at all. Because every time the patient comes in and they have a new crown restoration, it’s out of the bite. Most people adapt, but sometimes people don’t adapt very well. For example, if everyone just adapted, everyone’s bite just adapted, you’d never see a patient with an anterior open bite because their teeth would just compensatory erupt, right? That would exist. But some people don’t have that adaptation capacity. So I would suggest a degree of occlusal quality control. I’m not saying we have to be perfect because no one’s perfect. No one’s going to fit their crown. It’s going to be shim hold every single tooth every time. But to be recognized that patient where it’s absolutely crucial and recognize the patient that, okay, it’s not crucial, but it’s a little bit shy, but it’s not so shy that I can’t sleep at night. So aesthetics, seal and occlusion, those are the main things basically. In terms of checking the contacts once again, again, I’ve talked about this on a podcast, but in case a student hasn’t seen it, here’s an interesting one. Have you fit a crown yet? [Emma]No. Nope. Not yet. [Jaz]So this is really, really important. Like when you come, like, so this happened to me as a young dentist, I’m trying to put the crown on and I’ve said, Oh my goodness, there’s a huge open margin here, but it wasn’t an open margin. It’s just because the crown didn’t seat all the way because the contacts were too proud. And at that, at that time I didn’t really know how best to check that. And I remember a consultant coming over and then putting on a Miller’s forcep, the articulating paper in between the prep and the adjacent tooth. So in between like really like sausage hands, like trying to get in and then trying to seat the crown on the other hand, it’s very claustrophobic, very messy. So the better way of doing it is keep the crown in place, get the nurse, put a finger on the crown. So it’s now stable. It’s not going to the patient’s not going to swallow it. You get some articulating paper and you color in your floss, i. e. you pinch the floss with the articulating paper and you drag it. Now, you’ve got white floss, white floss, and suddenly the floss is red, red, red, and then it’s white again, okay? That red ink on the floss, when you floss that through now, through the crown, it’s going to make a red smudge where it’s too tight. That’s where you adjust. Until you get the perfect flossing and it’s seating all the way. [Emma]That’s good. I’ve never seen anyone do that colour in your floss. That’s a good one. Yeah. [Jaz]As a nurse, if you’ve seen dentists do the traditional way of checking with their fingers is very claustrophobic. It’s a terrible way of doing it. So this was taught to me by a prosthodontist, Ricky Bopal, and I always credit him for this is the best way to do it. And actually, when I shared this on Protrusive, everyone who does this like mind blown, like why wasn’t this ever taught to me before? So top tip there. So just to summarise the episode, there will come a time where you need to reject lab work. We talk about dentures another time and all sorts of things, but talk about a single crown, aesthetics is one reason and make sure you’re happy with it. Is the seal not good? And if the seal is not good, then that’s a big fail. If it’s like there was a tricky prep and it’s like a tiny bit, but you can’t get your probe fully in, you then have to put some faith in your cement to help you out here and seal that. And then occlusion, if the occlusion is really, really shy, then that is a problem as well in some patients. [Emma]Yeah, that makes sense. I think as well, a huge takeaway for me, you’re always told make friends with your lab technicians and that’s so true and just picking up the phone and talking to them can solve so many, so many issues, just having a chat, getting that feedback as well. They’re not scary, they’re not going to bite you or anything, but communication is a huge one with the labs and keeping them on your side because then they’ll do you a favor when you need it. [Jaz]Absolutely. And I would encourage everyone to have a good relationship with their lab. And also, when you qualify and stuff and to maintain that and to ask for feedback, it’s really scary. But if you say, be brutally honest, if you write in your prescription form, be brutally honest about my prep, they will be. And then they will feel comfortable having that relationship with you. And that’s a really great place to be. If you can visit your lab one day as well, it’s a really good thing to do to visit your lab. Okay. That’s a good thing to do as well. See their workflows and develop a really open relationship with your lab. If you can WhatsApp your lab, voice notes and stuff and discuss cases, that’s something I do works really well. So, I think you’ve summarized that really well, having a really good relationship with your lab. Now, here’s a really interesting thing, right? Dentists, especially when you’re new to qualified, we see the lab technician as this like guru. This oracle, right? And they’re like, they know so much. And I’m the insufficient one. And oh my God, my prep is not good enough for this guru. Okay. Now, funnily enough, I’m speaking to lab technicians. They are seeing us as the gurus. Oh my God, it’s the dentist. The dentist knows what they want and I’m just following. And what if I’m not good enough? And so we’re looking at each other as like, you’re the guru. You’re the guru. Basically, actually, we’re both the gurus. We both need to work together. And we have so much to learn from technicians. And technicians can learn something from us as well, for sure. So, sometimes when I used to write that, okay, I’ve trained my technician to do this type of technique. People were like, Oh, really? You can train a technician? You totally can. And technician can train you as well. So have that symbiotic relationship. Has anything been left unclear now in terms of when to reject a standard crown? And any questions your student mind could come up with now as you’ve read about this procedure and when you eventually first come to do it? [Emma]Not in particular. I think you’ve covered things quite well. Loads of good tips and tricks, especially about the floss. I like that one. I’ll bring that into dental school one day. But no, really, really good tips and tricks. And I think as well just assessing each patient individually. Such a common thing in dentistry. Like, oh, it depends, but it really, really does. It’s so case dependent and as well when you’re saying about utilizing your nurse. I think being a nurse myself, it makes your work so much more interesting when the dentist will use you to your full capacity. Like, get me to put my finger on there and get me to floss these contacts. Cause I’ve watched too many dentists struggle and it’s just, I’ve got an extra two hands here. If you need them, then they’re yours. And it makes work so much more fun as well. [Jaz]So brilliant, brilliant. So, so important to involve your nurse And you will have a much less like to have that scenario where cement is now blocked the contact, like it happened to me. So that’s a really great point there. There’s one more thing I was going to say, actually. We haven’t really talked about cementing so maybe we will talk about cementing another day, but you’re, you’re right. That getting the nurse involved is another great tip. Oh, here’s my thing. I remembered. Okay. This is really important, Emma, for all students who’ve got to this point and all dentists got to this point. When you are at dental school, especially, okay. I’m teaching you the shortcuts and the tricks that I’ve learned now because of failure and trial and tribulation and errors and stuff. So you’re able to show, stand on the shoulders of the giants and not have to go through all the mistakes and tears and stuff. You’re able to really leverage this and you’re in a great, so this is a beautiful thing about dentistry nowadays is that we can pick up these tips, but before we were very isolated. However, you got to be really careful in dental school, right? Because your tutor. wants you do it a certain way. So my suggestion is learn the way they’re teaching you to do it, learn the way and learn it well. So if they tell you, okay, this is how you check a contact, you get the red paper and they show you this atrocious way of doing it, please do it. Be good at doing this atrocious way. Only then will you appreciate the way I’m showing you, okay. So please, what I don’t want it to do is all these hundreds of students, generation of students now, every time the tutor shows us something, it’s like, nah, Jaz taught me a better way. Let me show you tutor, we don’t want to create that culture. You must be a learner and have some humility and be like, I’m going to do it this way because this is the way I’m taught. But in the back of your mind, it’s like, Hmm, I know another way. And then try it. So please, please don’t be a smart Alec with your tutors guys. And then I’ll get a bad rep with the tutors. [Emma]But also as well, like as a student, half of the time, these clinical staff, they can be the ones writing the exam questions and writing the marking schemes. So yeah, definitely listen to what they have to say as well. And I would know lots of clinical staff that I would feel comfortable saying. Oh, that’s interesting. This is another way I’ve heard of doing things. And they’re always so open, new techniques and having these conversations. [Jaz]Brilliant. [Emma]They like you to be able to do your own research and have your own back about why you want to do things a certain way. But yeah, they’re the ones writing the clinical exams. [Jaz]There are some tutors like that, and God bless them. So, but not everyone’s like that. So just be tread carefully. So Emma, what notes have you got as part of the student revision notes that you’re giving away in terms of Emma’s famous notes? [Emma]So this month, we’ll go back to first year, and we’re going to do a bit of microbiology. It is quite theory heavy, very examinable, especially in first year. But these things come up time and time again. And as you move on to second year, third year, fourth and fifth year, you just build upon it more and more. And it gets more specific to specific aspects of dentistry. So it’s definitely something that you need to have solidified from your first year going forward. So we’ll do a bit of microbiology. [Jaz]Have you got like the microbiology of cariology like caries that kind of stuff? [Emma]Yeah, I need to dig out my first year books actually. But yeah- [Jaz]Caries process, very important. And then also infections, different bacteria involve anaerobes and that kind of stuff. You’ve got that, right? [Emma]Yeah. Well, it will all be in there. [Jaz] Okay. Every examinable facet of microbiology will be in there. So we look forward to sharing that with all those on Protrusive Guidance in the Student Section. All the instructions about it is on Protrusive Guidance. So Emma, thanks again. And have a lovely week. [Emma]Thank you. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. Hope you found some value from that. Please let me know if you did. The best place to let me know is on Protrusive Guidance. Our app is on iOS, Android, even the laptop when you hit www. protrusive. app. If you’re a student, you get access to the Protrusive Student notes, including for this episode, and the Protrusive Vault. You just have to email your proof to student@protrusive.co.Uk. The community otherwise is completely free to join. So if you haven’t joined Protrusive Guidance yet, What are you waiting for? I want to thank Emma, our Protrusive Student, again, and the whole team for this series. That’s Erika, our producer, Gian, behind the scenes of video, Krissel and Nav, who often do the premium notes, a shout out to Rakesh, who’s just qualified as a dentist, God bless him. Such an exciting time. And of course, our CPD queen, Mari. Please do share this episode if you think someone would benefit from it. I’ll catch you same time, same place next week. Bye for now.

Clinician Development Tool: https://protrusive.co.uk/cdt Did you know, there’s a cheaper, quicker and more natural treatment option than using Dental Implants, WITHOUT compromising on longevity? Sounds too good to be true right?  You already know about it. You most likely studied it already at Dental School and just haven’t given it much thought in a clinical scenario. Meet Dr Lukas Huber who will remind us of the power of Autotransplantation for such cases, which in turn can massively help our patients who have missing or hopeless teeth, all while keeping laboratory costs down and success rates up. https://youtu.be/CjUdDsuCWQA Watch PDP193 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:02:10 Clinician Development Tool03:34 Introduction – Dr Lukas Huber07:40 Autotransplantation Procedure12:45 Example Autotransplantation18:40 Step by Step Autotransplantation26:35 Placing the Donor Tooth30:15 Transplant Restorative Augmentation35:00 Learn more from Lukas I thought that Dr Lukas is an inspiration to all the general Dentists and am so grateful he is part of our Protrusive Community – thanks for sharing your entire protocol! Don’t forget to claim CE Credits on Protrusive Guidance by completing the quiz. Check out Dr Lukas Huber’s Instagram! If you liked this episode, you will also like Atraumatic Extractions Click below for full episode transcript: Jaz's Introduction: You may already be familiar with an auto transplantation. Essentially, it's a scenario whereby, for example, you remove a pre molar from a patient, and on that same patient, you put that pre molar and you re implant that pre molar in to the central incisor socket. So for example, you've got a central incisor of poor prognosis, you remove that, and then you put this recently freshly extracted pre molar in to the central incisor. Jaz’s Introduction:And essentially you let nature do its thing, you let it heal. And literally you’ve kind of given this patient the best implant there is. You’ve given them a human tooth, their own human tooth. Another common scenario is replacing a premolar, for example, an upper premolar, with an upper wisdom tooth that’s potentially over rupted or non functional. That’s another common indication. But all these things, we’ve all seen it in like an orthodontic lecture at dental school. And then it lives somewhere at the very far back of our minds. And it’s not really an option that we discuss with our patients very much. Or when we’re treating planning, we kind of have it in our blind spot. It’s just not something that we see a lot of, which is why I’m very excited to welcome to you, Dr. Lukas Huber, a general dentist, ladies and gents, who has a few of these procedures up his sleeve and is happy to share the full protocol. Look, some of you will go away today and the stage of your career, where you’re at, you will probably be able to offer this treatment to your patients. And you’ll actually remember that, ah, yes, this is an option. And if I follow the steps, I can get a good result. In fact, Lukas very kindly shared all the evidence space that he uses in his decision making. So I will put that in the Protrusive Vault on Protrusive Guidance app. Now, for the rest of us mere mortals, who may not feel confident despite the full protocol being shared with you on the podcast today, most of us will be like, you know what? I’m actually just much more educated about this option now. I know what to say to a patient. I now know which kind of cases would be suitable for an auto transplantation and which ones are not suitable. And so now hopefully this option will not be living in the very back in the corners, deep dark areas of our mind somewhere. It’s come a little bit more to the front of our minds. So we can actually consider this as a realistic and actually damn right cool option. Dental PearlHello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. And so today’s pearl I’m sharing with you is a really cool tool that you can use online. It is amazing for that scenario, for that stage of your career, where you’re just not sure what courses you should do next, or where should you start focusing? What are your weaknesses? Which disciplines or facets of dentistry Should you be focusing more time and energy on? It’s a question I get all the time from the Protruserati, which is why when I discovered the clinician development tool, I was really impressed. This is really well curated by Ripe Global. And yes, it takes about five minutes, some deep thinking to answer this quiz. But I tell you the information and the detail that you get is the best I’ve seen from an online resource like this. It’s a really clever tool that assesses your confidence in the different disciplines and is very mindful of what your goals are and what stage of career you’re at. And your current income level and your projected income level. And how much time you spend in the clinic and how much time you would like to spend at the clinic. How much restorative you do and how much complex restorative you want to do. And all these really key factors which makes this tool just the best. I made a little short link for you so you can check it out. Go to protrusive.co.uk/cdt, that’s clinician development tool. So that’s /cdt, just three letters. I’ll put it on YouTube, the show links and Protrusive Guidance. I’ll put it everywhere. It is well worth doing. Even if you’ve got lots of experience behind you, you’ve got 15, 20 years experience behind you. It’s nice to see what this tool suggests is the next step for you. Hope you found that useful and outro. Main Episode:Dr. Lukas Huber, welcome to the Protrusive Dental Podcast. I am in awe of the work you do. And I just, before we hit the record button, I asked you, are you a specialist? Are you a general dentist? And you said general dentist and I celebrated, right? I celebrated so hard, right? So please tell us about yourself. Where do you practice and tell us about your career so far? [Lukas]Okay, so my name is Lukas Huber, originally I’m from Upper Austria, like a really, really small village. I think we have more cows than we have people. I then went to Vienna to study dentistry there. And afterwards I worked in a quite big insurance company. I recently thought of it because of you the Protrusive app about like burnout in dentistry. And this was quite a crazy time. I had like 20, 25, 30 patients in six hours, then started to looking for something else, you know? [Jaz]So can I just say this? So this was like a public funded system or? [Lukas]Yes. Yes. So I had like, most of them were just pain patients. Yes. And I decided to look for something else and then got great job offer here in Konstanz. Never been to Konstanz before. I asked my partner, she said, I know you’re crazy. We love Vienna. Why should we go then? We just tried. We said, okay, we will try it for six months. And if it’s good, it’s good. And it was crazy good. [Jaz]My geography is poor. How far is Konstanz from Vienna? Like how far is it? [Lukas]It’s like 600 kilometers, so it’s like a five hours car ride, which is quite a lot for an Austrian boy. [Jaz]Absolutely. And did you get headhunted, or like, how did you find this position? [Lukas]Facebook. It was crazy, yes. Yeah, we took a dog and we’re really happy here. We are like in Southern Germany, like the Southern part. We are near a big lake called the Bodensee. So if any Protruserati is ever here in Konstanz, let me know. I am more than happy to show you around. [Jaz]Amazing. And then what have you done in the additional, like a master’s degree? I see your work is like, it’s exceptional. Tell us about what led you there. What are the sort of career development steps that you took? [Lukas]So we are a general practice here. We are four dentists and we cover like nearly everything in dentistry. So we do aligners, we do ortho, resto, we do surgery. We don’t do like big stuff of surgery, like, I don’t know, external sinus lift, for example. But we cover, I would say like 90 percent of dentistry and I really enjoy being there. So we are doing really high quality dentistry. My boss is really like letting me buy everything I want, everything I need. He’s always like, if you are happy, I am. And that’s just really, yeah, like a big chance for me to develop. I took a lot of courses in surgery because I’m really interested in this topic. Yes. And here I am. [Jaz]That’s amazing. And I love how you have such a supportive principal who is happy to help you get the toys. It’s not about the toys. I mean, it’s about the toys, but it’s also not about the toys. It’s about the mindset, right? It’s about the mindset, really, that I want to help support my associate, be the best they can be. And that kind of mindset goes a long way. Like, I do hear stories whereby associates buy things and they don’t use them. And that’s why some principals, they worry. But if you find the right person and it looks like you found the right team, but credit to you because a lot of people, if they got an offer that was almost too good to refuse, but it was 600 kilometers away. They would be like, you know what? It’s not for me. I’ll wait for something down the road. So, you took a massive action basically to make the create, to find the environment. [Lukas]Yeah. But I’m like exactly this person, and also my partner. So it was really, the deal was, okay, we do this for six months. We sub rented our apartment in Vienna, went here also into a sub rent and we were quite sure to leave again. But it was like fantastic. And here we are. [Jaz]And how long has it been now you’re in Konstanz? [Lukas]Two years. [Jaz]Two years. Okay, good. Well, thanks for telling us a little about yourself and the topic of today is auto transplantation. Now, autotransplantation is something that I got exposed to just from the orthodontic lectures. Like I did a diploma in ortho and at dental school. It was like something that was mentioned, but like you’d never ever, like you could pretty much go your entire career without ever seeing it, touching it, smelling it, like just a buzzword that every three years might just pop up. Oh, that’s interesting. That’s cool. Right. And that’s it. How well you documented and share on Instagram. That really inspired me. Okay. And to know that you’re a general dentist who did that. I am just so, so happy to just learn from you and share with the Protruserati about how do you even get into this? So tell me, how did you even get into this? How much of the autotransplantation cases have you actually done? [Lukas]So it’s quite a rare indication. So you don’t do this on a weekly basis. [Jaz]Exactly. [Lukas]You have like, you don’t have these many cases where, where you can perform that. I got in touch with it at university. So we had a professor who is doing that, like I think one of the most cases in Austria, but even he is doing that, I don’t know, every one or two months, so it’s not something you do really often, but it is underestimated. I think it is not that widespread as is that, but it is a really good and really like it has a lot of advantages for the patients. So I’m more than happy to spread it around. [Jaz]Yeah. And it might be something that perhaps should be an option to consider, but because it’s like such a, the back of your mind somewhere, it doesn’t even come to the surface. And then you miss out some of those cases where actually this might be a good case. And what you prove is that if you’d like a bit of surgery, then you don’t have to be a specialist to do this kind of work, basically. That’s what you’ve proven that. And so tell us about what is the ideal case for an autotransplantation and just for the students maybe listening just from the beginning, what is an autotransplantation? [Lukas]So, autotransplantation basically is when you transplant a tooth into another side of the mouth. Basically, you can transplant every tooth into every side you want, but a lot of that doesn’t make sense. So you have like the main indication and also like the beginner case is when you take the wisdom tooth and transplant it into another side where the tooth is totally destroyed and you cannot rescue that tooth anymore. For example, the first or second molar if that is totally destroyed or if you have a genesis of the second premolar you can also transplant in there. And that’s the best case scenario because it’s so easy to explain to the patient, you tell the patient you have a tooth here that is totally destroyed, we cannot rescue that anymore, and you have your wisdom tooth that has to be extracted anyway. I love the idea because it’s patient talk a little bit, a lot of patients tends to simplify dentistry, you’re telling them the tooth is probably like five millimeter beneath the gums and they are saying, Oh, just put a pin into it, do a crown over it. And that’s easy. And that’s like the talk you have, both tooth have to be extracted. We just take this one that’s good and put it there. And then patients love the idea and they are more than happy with it. [Jaz]So excuse me for diving into a nuance straight away, but really you just mentioned something interesting that’s piqued my interest. Like you just said a genesis of a second premolar, for example. In my mind, autotransplantation was like you remove the tooth. So now you have the socket and then you are able to put a different tooth, like a wisdom tooth, for example, into that socket. What you’re describing is you pretty much has to do an osteotomy, like for implants, right? And then you put the tooth there. Is that correct? [Lukas]Yeah, that’s totally correct. So you have two possibilities. So when there’s a disjoint tooth, as you say, you just have to extract it, but you can also have the possibility that there is no tooth anymore, maybe for a year, maybe five years, or anagenesis. And yes, you pretty much do as an implant surgery, you just do a osteotomy, you create space for the transplant. And that’s also a scenario which works as well as if you extract it out into it. So that’s no problem at all. [Jaz]Very fascinating. That’s good. That’s good to consider. And then therefore, what is the most common, like which is the most common donor tooth and which is the most common recipient tooth, if you like, which are the teeth that are more commonly restored by auto transplant and which tooth is sacrificing itself to move into different position. [Lukas]So mostly I will consider to take the wisdom tooth and transplant it into I would say mostly the first molar because everybody knows that that’s a really important tooth and you want to replace that one. That’s the most common thing, but what is also commonly done is you take the first pre molar and put it into the central incisor position. I think that’s also the case what we learn at universities, which is done a lot. You can take like mandibular incisal if you have a lot of crowding, put it into agenesis of lateral incisor at the maxilla. You can do primary canine, put it into central incisor position in a child. So you have a lot of possibilities, but that are the most common indications. [Jaz]Okay, well, let’s go to the scenario whereby we’re considering removing an upper wisdom tooth and we want to put it into the upper first molar. So maybe the upper first molar is failing due to, I don’t know, resorption or a crack. And then therefore, because of a crack, we can’t restore this tooth anymore. So what is the sort of success rate and predictability? Because really if you’re not going to be doing it, we’re either accepting a gap or maybe considering implants, for example. So let’s forget bridges and stuff. So when there is a toss up between implant and a wisdom tooth, what may sway us more towards an implant? What may sway us more towards an auto transplantation? [Lukas]That’s a really good question. Because like when you are performing out to transplantation, it has a lot of advantages by an implant. I mean, as you say, that’s like the most reasonable comparison. So that’s the most reasonable comparison. So when you’re doing implants, I think, what many of us don’t consider or don’t have in mind that the implant is like an ankylose tooth. Everybody knows, but our natural teeth passively erupting a whole life. The alveolar process is like growing a whole life and over 50 percent of the implants are in intraposition after some time, even if we are like over 18. So that’s the most common age where people start to perform implants and the tooth itself, the PDL. It’s like, osteoinductive, that’s what we all want. We want it osteoinductive sources. So that’s the best thing that can happen to us. When we perform auto transplantation, we have proprioception, so the tooth is still maintaining a healthy alveolar process, a healthy alveolar bone. We have a really good aesthetic outcome, so it has a lot of advantages. It is really cost effective. You can move this tooth orthodontically afterwards. You don’t have any complications with that. So that are the main advantages. But frankly, if I have a patient who is like 40, 50, 60 years, most often we don’t have the chance to extract a third molar because it is already extracted. And it really makes sense to put an implant because the implant has really high success rates, but so does the autotransplantation. So we have survival rates over 90 percent even after 10 years, we have really long term data. So we know that it works. We know that it works really predictably. So it has a lot of advantages and therefore, yeah, it should be like more in our minds when educating patients. Yes. [Jaz]And hopefully after our chat today, people will consider it as another option. Now in that scenario, we are essentially avulsing you’re like kind of doing an avulsion. You’re doing a trauma, a guided trauma to avulse the wisdom tooth, right? And then you’re moving it over to the first premolar and I’ll get you to talk through it a bit more scientifically. But sometimes when you experienced an avulsion, sometimes you are committed to perhaps doing a root canal, 10 days, two weeks later, basically, I imagine because of how sterile or how quick everything is. And the cells are still alive that perhaps is root canal always there is? Is it part of the protocol? [Lukas]That’s a good question. If the apex is still open so if the apex is like more than one millimeter you don’t have to do root canal treatment at all. Over 95 percent of the cases are showing revascularization, so you have a vital tooth there, but if the apex is already closed, if the root formation is completely finished, root canal treatment has to be performed. The cases where we have revascularization are really seldomly, it’s like, around 10 percent of the cases. So you should not wait, you should perform root canal treatment if the root formation has already finished and if the apex is already closed. Yes. [Jaz]Okay. So, and then what about when trauma cases, the most long term complication we warn our patients about when re implanting an evolved tooth is resorption and ankylosis and that kind of stuff. So, how prevalent is that amongst auto transplantation cases? [Lukas]That’s a good question, because that’s like, we always learn from the failures of others, but hopefully not of ourselves, but that are the most common complications. So you can have, as you said, it can have root disruption and you can have encloses, you have that in a round 5 percent of the cases so it’s quite comparable to an implant actually. Because when you are looking at the data of peri implantitis, you have like crazy crazy numbers going from I don’t know 10 percent to 100 percent. That are like a crazy variation of numbers depending on the study. But when you are doing autotransplantation these failures are about 5 percent. But if you have root disruption, what you have left is bone. So perfect situation for a healthy alveolar process later and a good site for an implant. So that’s actually not a big deal. If you have ankylosis, what you have is basically a tooth implant there. I mean, you can perform the coronation if it’s like an aesthetic issue or not an aesthetic issues. If it’s like a functional issue there, if you need the bone, if it doesn’t grow, you can perform like surgical extrusion or you just let it be and like perform the restorative in a restorative way and just build it up. So that are the two complications you can have. They are quite certain if you are having a good protocol and we will talk about the protocol. Then we are talking about like three to 5%. Okay. So it’s really, it’s like something which is quite handable. [Jaz]And exactly what I was gonna ask you next was about the protocol. And I think to make it more specific and make it tangible for everyone, that case I saw of yours recently on Instagram just beautifully executed. I really enjoyed watching that. And I’ll put the link for everyone to check it out. Just talk about that specific case and then use that case example to describe the whole thing about getting the 3d printed tooth and everything and the sequence and the protocol of it. [Lukas]Okay. So the case was like a 20 year old boy or man, and he had like a fracture around 2mm and beneath the gums at the second premolar, and the tooth was completely destroyed. So we couldn’t rescue that tooth anymore. We talked about orthodontic extrusion, but that would also just be a temporary approach. So we have no chance to rescue that tooth. We talked about implants. I have a genesis of my second premolar as well. So, kind of related with the patient. [Jaz]You connected with him. [Lukas]I told him that. And I said, you’re 20 years old. We can do an implant. Normally, I will never do implants before the age of 25 in the aesthetic zone here, they’re like a real broad smile, so it was the aesthetic zone for him, and I told him I wouldn’t do implant there, I would never do that, so I started 25 in the aesthetic zone where we do implants. And I said, what we can do is just take your wisdom tooth, which has no sense there anyway, because at the opposite, there was no tooth at all. So he couldn’t chew with that. That tooth made- [Jaz]It was a non functional wisdom. [Lukas]It was non functional. It was already extruded. So it had no sense that anyway, it was just a shoe trap. And I said, we can just take the tooth and transplant it into that site. So there was this root which we had to extract anyway, there was this wisdom tooth non functioning and patient said, yes, that’s quite, you can understand that. So sure. We talked about alternatives, but that was for him the best treatment option. And yeah, so we began, it’s always the most important thing when you’re doing any surgeries like planning. You have to get an idea what what to expect. And the best thing you can do, and we also have a lot of studies about that, is to perform CBCT scan and get a three dimensional expression. You can just send the CBCT data to your technician. If you can do it yourself, please do that. But we couldn’t do that in our office, so I sent it to my technician. He just deleted the rest. Just extracted that tooth virtually. So the wisdom tooth, the donor tooth, and just made an STL file. And we know that these STL files are really, really good. They don’t have any deviation to the real truth or like minor, which are not affecting our surgery. And he just- [Jaz]Just to make this tangible, what we’re aiming for here is, as well as having a look at the anatomy and making sure there’s no red flags to doing this procedure. What we want to do is, we want to 3D print that wisdom tooth. [Lukas]Yes. We come onto cut off that tooth. [Jaz]Yes. And the technician help you to delete all the bone, delete all the maxilla, delete everything, and just preserve a nice 3D printed tooth. And then now you’re gonna explain some, a lot of people ah, that’s clever and I got it. And some people thinking, hmm, why do you want a 3D printed tooth? So you’re gonna come onto that in a second. [Lukas]Yes, for sure. So you just print that as you said, you can also take biocompatible material. You can just disinfect it into alcohol because you need this one later, then just do anesthesia and then in my case, you extract the hopeless tooth. If there is no tooth at all, you can also make an incision. You have to create some space for the transplant. That’s just implant thinking. Okay. So you have to create space, you have to drill, you do that slowly. You do that with water cooling, you’re handling with bones. So just normal procedure. And it is perfect to take the replica and just check, do I have enough space? So that’s like the perfect condition you can have. [Jaz]And we’re talking about space not only in the osteotomy, but we’re also talking space like mesial distal. [Lukas]Yes. [Jaz]So you might have to do some enamel plasty, right? Mesial distal to allow the tooth to actually engage in, right? [Lukas]Yes, yes. And always, you shouldn’t expose the dentine, but you can do like 0.5 millimeters mesially distally of the gap. You can do 0.5. [Jaz]Is that the most easiest IPR ever? [Lukas]Yes. I loved it. And you can also do it on the transplant tooth and then you have two millimeters, for example, which you can use and that, as you said, you have to create some space for the transplant in the bone. You can just check with your replica, you just move it a little bit mesio-distally. You can check, can I move it a little bit? You just move it a little bit buccal lingually, if you cannot move it, okay, buccal lingual, I have two less space. I have to create some space. [Jaz]And what are you aiming for? Like, how do you know when to stop? Because you know, how much primary stability can you even get with an auto transplanted tooth, right? I mean, imagine the socket is too big, then it’s like kind of swimming around. So it’s interesting to know how you handle that scenario. But equally, if it’s too tight, like I imagine, obviously, you can’t start shaving the root tip because you’re getting rid of all the PDL, you have to remove the bone, right? But then what do you do in a scenario, basically, is it a no go, is it a abort mission if the extraction site is just way too wide for your donor tooth? [Lukas]No, because the PDL cells can differentiate into osteoblasts. So you really have the most osteoinductive force you can have. And that’s what we always aiming for in implantology. So here you have it. So you really have the most osteoinductive force and you get really a lot of bone growth. Okay. So best case scenario would be like 0. 5 millimeters around the tooth. And you need a bit more apically, like two to three millimeters. But if you have more, it is no problem at all. But as you said, if it doesn’t fit in, you have to create more space and it’s like with an implant, in the upper jaw, when the sinus is there, you can do some osteotomy, you can do bone splitting if you like, but in the best case scenario, you don’t have to do that. So you create the space and you’re checking and checking and checking with replica, like that’s the most crucial part of it. And why the replica? Because otherwise you would have to take the donor tooth and the donor tooth has a really long extra old time and we know that the PDL cells, you’re going to kill them. Okay. So that’s the sound of the replica. That’s why a replica is so advisable and so good. [Jaz]Amazing. And so once you have found the right space, then you extract the wisdom tooth, right? And then you move it across. But one thing I’m interested to know is, do you have to then use particulate bone graft to help secure it, give it some stability or not really? [Lukas]No. So you shouldn’t do any like xenograft for example, or allograft. You really don’t need that. And we also know that if you do that, the survival rates are like decreases so you don’t have to do that. And if you have to like augment some bone before then the question starts to rise is it really the best case scenario for the patient because then it’s like yeah, then you can also do an implant. So yes, and you do like normal extraction of the tooth, as you said, and that’s what we’re doing every day. Oh, that’s not a big deal for us. The only difference to a normal extraction is at least I don’t do that at a normal extraction. You just go with a blade into the sulcus. And going once around that you just do cautious and really like you want to handle it with care. Yes. You want to do it as, as dramatic as possible. And best case scenario again, is like you have a vertical extraction device, but you can also do normal extraction. Just try to don’t touch the root surface. Try to stay in the crown. And that’s the thrilling part of the surgery, you want to get the tooth out in one piece because that’s all it takes. Yeah. So that’s like- [Jaz]The precious PDL layer preserved. And then you move it across and because you’ve already rehearsed with your 3d printed tooth, your path of insertion, and that maybe you need to shave it into proximally because you’ve already practiced that as well. And then you’re going to sink it in, but just tell us a bit about that. But is it just a matter of just sinking it in, in a couple of sutures or tell us about this bit. [Lukas]Yes. So as you said, you have your replica and you just know you taking the tooth out, everything is in one piece and you’re just putting it in and it just fits because you always checked before. And as you say, then you have to do some sort of fixture and there are two possibilities. So you should not do some rigid fixtures. So it should allow some micro movement. That’s really important for the PDL cells. [Jaz]Like a trauma splint, right? [Lukas]Yes, that would be the best case scenario, trauma splint, yes. Or like a really thin wire, like 0.3, 0.4 millimeters. So you have to allow some movement. That’s really important. If you have good primary stability, so if you have like mesially and distally good proximal contact, if you have good primary stability, you can just do X suture. Okay. So you’re just fixating it with a suture. It is important that the tooth is in slight intro position. So you should not have any occlusal contact. You check that with your replica before you put it in slight intraposition. And then you’re just fixating it, as I said, normally with the trauma splint. But if you have really good primary stability and you can really get that. So in the case I had, I’m pretty sure I know that I could have gone without the trauma splint. I am deciding for the transplant. I always like to be on the safe side, but it would have worked really well with just an X suture over it. If you have like really wide gums and the gum isn’t fitting on the new tooth, then you can just do some adaptation sutures that you have like a good dental alveolar seat to protect this blood clot in the new socket. [Jaz]Do you need antibiotics? [Lukas]We know that when you do systemic antibiotics that you have better success rates, so yes, I would do that. Just normal amoxicillin after the procedure for five days, that’s completely enough. You have to have good oral hygiene, so, when you are thinking about contraindications, there are no really major contraindications to the procedure. It’s like with every other surgery. So you have to have good old hygiene. You have to have a compliant patient. We are handling with- [Jaz]No active perio, smoking, the smoking mechanism. I wonder if smoke, I mean, who knows because the end numbers of smokers, the studies probably have never been done. It will never happen, but yeah, it makes sense. Impaired wound healing. [Lukas]It’s wound healing and as I said, it’s wound healing and it defected. And the odds that you lose this graft, it’s probably high, I guess. But otherwise you don’t really have like contraindications. I mean, we are handling with bone, we have to think about bisphosphonates or like real, I don’t know, real heavy and bad diabetes, which isn’t treated. But otherwise you can really perform that like in every patient who is willing to do that and who has a missing tooth. She doesn’t need any more. So it’s really good procedure and you really like have a lot of advantages for patients. [Jaz]And then thereafter, like when do you review them? And then when do you do the root canal? [Lukas]So I always like to keep it simple. I always like to keep it cost efficient. So there are some studies that are suggesting that the sooner you do the root canal treatment, the better, so you can do root canal treatment before even transplanting the tooth. I don’t like to do that at wisdom teeth. So I like to keep it simple, just transplant the tooth. Two weeks later, I remove the stitches or the wire or the trauma splint. And at that time, I’m doing the root canal treatment before. And as I said, if the apex is still open, when the, if the root formation isn’t done, you’re just controlling, doing the fixation away, but you should not perform any root canal treatment because the chances of revascularization are really, really high. [Jaz]Brilliant. And then thereafter, when would you look to do some sort of veneer, crown, restorative augmentation? When would that happen? [Lukas]If you take the third molar, if you take the wisdom tooth and really place it like, as we said, second premolar, first or second molar, then in most of the cases you don’t have to do like any restorative augmentation at all, because as I said, you’re doing it in slight interposition. But the tooth is seeking for its opponent and it’s going to extrude anyway. And mostly it’s imperfect occlusion afterwards. Or you just do the minor occlusion adjustments, like you do after aligners to have like perfect occlusion. Yeah, that’s the way to go. So mostly you don’t need any extra treatment, but otherwise you do it. Around one or two months after the procedure, two months after the procedure, the tooth is like it was there the whole time. So it is like fully healed. You can do nearly everything with this tooth. If you want to remove it atraumatically, you should wait three months or six months even. That it’s really completely healed before you move it. But we know that there are no higher or no significant higher root resorption when you move it. So you can really, it’s like a normal tooth. It’s like it has been there the whole time. [Jaz]Brilliant. Are there any papers you mind Lukas sending over so we can share with the Protruserati, just because you sparked their interest. They’re very geeky. That’d be great to read if you have any. [Lukas]I love that. I’m always trying that everything I say is like evidence based because I love not just sharing my opinion, but really like really papers and we have so much evidence out there. We have like a case reports. We have randomized controlled trials, split moth designs, even meta analysis over 30, 40 years. So we also have the long term data. [Jaz]I’ve just never looked for the literature because it’s something that you come across and then you never realize because yeah, it’s just something that the back of our minds. But you’ve done a great job in bringing it to the forefront of our mind and really reminding us that this is a really cool option. Yes, it has to be the perfect storm. perfect conditions, but you can really do something a little bit spicier and something that’s probably in the best interest of that patient at that time for their cycle of care. So very, very happy with that. Lukas, anything else you want to mention before I ask about how we can follow you and learn more? [Lukas]Not really. I mean, after you’ve performed the procedure, you should check the tooth in a closer interval. So you should check it like one month after it, three months after it, half a year in a year, like with any other trauma case, if you having a hard time extracting the tooth and you imagine that more of the PDL is damaged, then you should just do some kind of healing booster, everyone has a different concept, like hyaluronic acid, you can do Aminogen, you can do platelet rich plasma, you can do doxycycline to prevent root resorption, but you should just boost a little bit that healing, just some failure knowledge to prevent that. [Jaz]What’s your poison of choice in that scenario? [Lukas]I do doxycycline if I have root resorption. I tended to do Aminogen because I think it’s best for the patient. But nowadays I do more Hyaluronic Acid because it’s just not that expensive. [Jaz]It’s the honest answer. And I love it. [Lukas]Yes. [Jaz]No, excellent. I’m so, so happy we covered this. It really helped to remind me about making this an option. I’m sure everyone’s feeling like, Oh yeah, that’s perfect. Not only is that just cool, but you know what, there might be a time, I think all of us listening and watching right now, there will come a time in our career where we can actually implement this or even suggest this as an option and consider it. So thanks so much for reminding us about how cool of an option it is and inspiring us as a GDP to consider this. I’m not saying guys go out there based on this podcast and start doing all the autotransplantations, but it’s something to inspire you to want to learn more. And I would definitely check out Lukas’s Instagram, Lukas, tell us more about how you can reach out to you and learn more from you, my friend. [Lukas]Just one more thing, because it’s so interesting what you mentioned, because I think that as a GDP, when we’re doing implants, you can really perform this procedure. It’s not that complicated. You’re just dealing with bone. You’re modulating bone. I wouldn’t go out and transplant the first premolar into the central incisal position. You have to have a multidisciplinary approach there. You have to have a good orthodontist. But the scenario we made today and the scenario also from Instagram where you just transplant a third molar into the another molar position is like perfect scenario case to begin with and to start with. [Jaz]Not that I do implants, but I always hear that make your first implant on someone with a low smile line, a second premolar or a molar. It’s the same, similar principle, right? You want to start with the easier cases. [Lukas]With the simple cases, sure. Every one of us wants to do that. So how can you follow me? I’m on Instagram. I don’t have a private Instagram account because I was always like, no, I don’t need that. But I’m really happy that I started my professional Instagram account. It’s just such a big chance to get connected. I mean, I’m sitting here talking to you. That’s like crazy and I’m really happy that I have this account. It’s like Dr. Lukas, or drlukashuber, and yeah, I’m sharing my cases. I’m more than happy to get connected. I love to get feedback on my cases. It’s crazy when you post the picture, you zoom like 20 times in and you see every mistake you’ve made like six months ago. [Jaz]I appreciate you, you sharing and also flying the flag for GDPs. And I think it’d be great to a great person to connect to and just get inspiration from and like minded, nice and geeky Protruserati as we like it. So, Lukas. Thanks for giving up some time tonight to talk about this very geeky topic, but I don’t know if anyone else had fun, but I enjoy this chat very much. So thank you so much. [Lukas]Thank you so much for having me and love to get connected. Jaz’s Outro:Well there we have it guys, Dr. Lukas Huber from Konstanz. Thanks so much for staying and listening all the way to the end. I just love interviewing fellow Protruserati so it was great to see his work on social media which prompted me to message him and say you know what can you share this with our Protruserati colleagues and didn’t he just do a brilliant job. Look this episode is eligible for CPD so if you are a regular listener please consider joining Protrusive Guidance. We have two plans available on Protrusive Guidance and with both those plans you can collect CPD for every PDP episode even retrospectively as well. So if you’re already doing the hard work of listening then just answer a few questions and get your CPD. Mari, our CPD queen, will send you the certificate. And she’ll send it again to you in three months, and every quarter, in an annual summary, your little special folder on Google Drive that we make for you, which has got all your certificates. So check out protrusive.App if you’re not already on there, or just download the iOS Android app. I want to thank my team. We’ve got Mari on the CPD side of things. We’ve got our clinicians, Krissel and Nav. We have our editing team of Erika and Gian. Without my awesome team, none of the podcast would ever be possible. And lastly, thank you, The Protruserati, for clicking on such a niche topic. Like you decided to join us today on a topic of auto transplantation. That means you are geeky and I love you. So if you satisfy the criteria of being nice and geeky, I would love to see you in our little community on Protrusive Guidance. Thanks so much. I’ll catch you same time, same place next week. Bye for now.

Dr. Sam Sherif, an expert in bond strength, delves into the best bonding agents for long-lasting adhesion in adhesive dentistry. He discusses the importance of following manufacturer guidelines, evolution of bonding agents, differences in dentine and enamel bonding, and optimizing bond strength with various materials like OptiBond FL and SE-Bond 2.

Delving into the world of crowns and bridges, the podcast discusses the materials used in real-world applications and the ongoing debate between direct and indirect restorations. Topics include the decision-making process for onlays versus full crowns and the challenges faced by dental students in treatment planning.

Dr. Jason Smithson discusses decision-making in discolored incisors and their management. Topics include non-vital bleaching success, restorative approaches, ceramic vs. composite, masking metal posts, and shade selection. Explore biomimetic dentistry, evidence-based practices, and the art of versatility in dentistry. Learn about choosing between ceramic and composite materials, enhancing dental skills, and community engagement in dentistry.

Emma Hutchison discusses practical tooth morphology, moving away from textbook ideals. Topics include changing tooth morphology, differences between premolars, and preserving natural morphology. Real-world application and nuances of dental structures are explored in this engaging episode.

Air Particle Abrasion! Images of Sandblasted teeth look cool but does it ACTUALLY improve clinical outcomes? What are the indications? When is it genuinely critical to use? More pragmatically, are there any decent alternatives eg. roughening with a bur? Air particle abrasion, a technique used to prepare tooth surfaces for bonding, has sparked considerable debate among professionals. This episode discussed its effectiveness, implications, and best practices with  Dr. Veronica Pereira de Lima.  https://youtu.be/oTGQBTyuY-k Watch PDP190 on Youtube Protrusive Dental Pearl:  Two advantages of slicing off a corner of the rubber dam are: Anterior Dam Stabilization: By flossing the cut piece through the front teeth, it acts as a makeshift wedge, securely fastening the dam in place without the need for traditional wedjet. Simplified Orientation: This technique aids in aligning the rubber dam properly, streamlining the entire setup process for more efficient dental work. Check out ‘Quick and Slick Rubber Dam’ online course (on-demand) only available via the Ultimate Education Plan on Protrusive Guidance Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:44 Protrusive Dental Pearl 04:16  Dr. Verônica Pereira de Lima Introduction 07:07 Journey of Dentistry in Brazil 08:34 Academia vs Clinical Practice 09:20 Journey about PhD and Work Surrounding Air Particle Abrasion 11:12 Importance of Air Particle Abrasion to Clinical Dentistry 15:57 Health Concerns Regarding Air Abrasion Particles 18:10 Air Abrasion Contraindication 20:13 Size of the Microns –  Clinical Guidelines 22:25 Pragmatic Approaches in Clinical Practice 24:28 Cojet as an Air Abrasion Particle 27:37 Improper Use of Air Abrasion 30:07 Air Abrasion Guidelines Regarding Different Ceramics 31:40 Alternatives to Air Abrasion 33:29 Dr. Veronica’s Personal Guidelines – Air Abrasion Protocol and Unit 40:27 Learning with Dr. Veronica  Access the CPD quiz either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. If you love this episode, be sure to watch Immediate Dentine Sealing Tutorial Part 1 – PDP173 Click below for full episode transcript: Jaz's Introduction: Air particle abrasion for the restorative dentist. How important is it? Hello, Protruserati. I'm Jaz Gulati and welcome back to the Protrusive Dental Podcast. In this episode, I'm joined by Dr. Veronica Pereira de Lima. Jaz’s Introduction:She was the lead author and a systematic review in 2020 that looked into air particle abrasion and the significance for improving dentine bonding. Some of the key questions that we cover in this episode are how important actually is it? What micron of sand and which sand should we be using? Is there any benefit of CoJet? CoJet is like this sand with silica embedded into it. Does that really make a difference? And ultimately at the end of the podcast, we will answer the question. If you don’t have it at the moment, are you really missing out? And the answer actually might surprise you. Dental PearlEvery PDP main episode, I give you a Protrusive Dental Pearl. Today’s pearl, very fitting with air particle abrasion, because when do we use air particle abrasion? Well, we use it a lot when it comes to adhesive dentistry. And for adhesive dentistry, rubber dam isolation is often favourable. Now, I’m no rubber dam police, but I’m an avid user of rubber dam. And the tip I want to pass on to you today is, are you using things like Wedjet? You know, those stretchy silicon type strings that you use to anchor your rubber dam? And the terminal tooth for example, you’re using a clamp on the molar and then all the way to an incisor, maybe you’re using like a Wedjet or something to secure your rubber dam. Well, instead of using two clamps or a clamp and a Wedjet, I like to use a clamp. And my favorite clamp is a soft clamp. Why? Because it’s softer. It’s kinder. I don’t need to give a lingual anesthesia. As you guys know, I’m a huge fan of buccal, articain infiltrations, even for lower molars. But that’s a whole other episode. In fact, we’ve done that episode already. Do check out PDP 143 if you’re interested in that. But back to rubber dam. So rubber dam, what I will do, instead of using a Wedjet, I will cut a corner of the rubber dam. Okay, now this serves two purposes. One is, once I’ve put the rubber dam on, I’ve got a clamp on one side, and I’ve got the little cut piece, that little triangle of dam that I cut away from the rubber dam. Well, that I can now floss through the anterior contacts, for example, if I’m doing a quadrant, and now the rubber dam is secured by a clamp on one side and by this makeshift Wedjet, using the dam basically to secure it. And it’s super simple. It saves the environment so we don’t have to buy an additional product to secure the rubber dam anteriorly. And sometimes the contacts are tight enough that you don’t need anything. You just have to floss it through and it stays. But if you want that extra security, you floss through, you stretch and you floss through this piece, this little corner, this triangle of rubber dam. Now, the second benefit here is you try and cut the corner which represents the quadrant. So, for example, if I’m isolating the lower left quadrant, then when I punch my holes on the lower left quadrant, let’s say I’m doing the second molar, first molar, pre molars, canine, and lateral incisor, for example, right? On the lower left side is where I’m going to cut my triangles. Why? Because you know when you sometimes put your clamp on, and then you put your dam on, and by the time you’ve got the dam through some of the contacts, and then your nurse is helping you, and you get the frame on, and then you’re thinking, hmm, which corner of the dam goes on which part of the frame? Sometimes it happens, and sometimes what ends up happening is you end up confusing it, and you’ve kind of got this like twisty, funky rubber dam thing going on. Now, because you have the cut corner on the lower left, you know that the cut area of dam is the lower left, and you just put that on to the lower left corner of the frame. Now, you’re much less likely to make this funky rubber dam mistake because it’s aided you in orientation. So two benefits of cutting the corner of the rubber dam. One is that you can floss it through to secure your dam anteriorly instead of Wedjets. And two is it helps with your orientation. It just makes the process slicker. And talking of slicker, if you’d like to improve in rubber dam, check out the quick and slick rubber dam webinar that I did. It’s available on Protrusive Guidance platform. That’s www.protrusive.app. And then there’s 30 plus clinical videos. These range from like two minutes all the way to 15 minutes of tricky cases, loads of different quadrants, anterior, upper left, upper right. All the mouth, basically the entire mouth uncut videos of rubber dam, which so many of you messaged to say it’s really elevated your rubber dam game. So those who are interested, check out quick and slick rubber dam available on Protrusive Guidance. Now let’s join the main episode and I’ll catch you in the outro. Main Episode:Dr. Veronica Pereira de Lima, welcome to the Protrusive Dental Podcast. How are you? [Veronica]Hi, Jaz. Thanks for having me. Yeah, I’m doing great. [Jaz]You are in the Netherlands, but you are from Brazil. And I want to unpack a little bit about that. Actually, I want to unpack your story. I always like to learn our guest story and like why you went into academia, how much clinical you do, what is your future research interests? I have so many questions in my mind already before you can just unpack the air particle abrasion. But I just want to point out that you’re the first of a guest that I sought out on LinkedIn. I read your paper. I read some study that you were involved in with to do with air particle abrasion. I found that you’re doing a PhD and I thought, okay, I must reach out to you to have this geeky discussion that we’re going to have today. So thank you for accepting my spam message on LinkedIn that led to a chain of events to book out time in your super busy diary to record today for the benefit of dentists. So Veronica, tell us about your journey from South America to Europe. [Veronica]Yeah, it’s a quite a journey. So yeah, I’m actually from a city called Manaus, which is a capital of Amazonas, which is way in the north of Brazil. Think of Amazon. So there is where I did my bachelor and master studies and where also started developing my interest for research, of course. With some limitations, like resources and stuff. And that’s why there was also no PhD in dentistry in my city back then. And then I decided, okay, I would like to go for a PhD and then I had to move out of Manaus and went way, all the way to the South of Brazil to a city called Pelotas. And then that’s where I started my PhD. It was not specifically in restorative dentistry, but it was a bit more like in dental materials, more broad area. And during this time, of course, I was really mainly focused on research, not so much in the clinical practice, because of my PhD there, because of the partnership that was between the universities of Pelotas and in Nijmegen in the Netherlands. I came up here this for a period of a year, stayed 14 months and then decided later after I finished my PhD to stay here. And now it’s- [Jaz]Amazing. [Veronica]Yeah. Yeah. Quite a journey when you think about it. And then, after I finished my PhD two years ago, here in the Netherlands, I decided to, okay, I want to go back to the practice. So then I had to learn Dutch. And do the whole validation recognizing of my diploma here, which was quite another particular journey, but which I’m happy to, I might happen to have finished it. And so now I am also licensed as a dentist in the Netherlands and I’m practicing part time and working at the university on teaching and research at the University of Amsterdam. [Jaz]What a nice balance. What a nice balance you have there in terms of practice and academia. I have this perception of a Brazilian dentist that generally, like, I see a lot of literature from Brazil. So I feel as though that dentistry in Brazil has a strong culture of academia. Is that perception correct, you think? [Veronica]No, I think so. I think we just, we’re a big country. We have a lot of universities each state has a few universities and usually research is mainly done in public universities. So yeah, if you think about it and that’s why maybe you can see so much of our publication of research there. And I think it’s just growing in the last couple of years. Yes. [Jaz]It’s definitely something I’ve seen in when I’ve been looking for literature that a lot of from Brazil pops up. And I also have this perception that lots of South American dentists in general like to go to the States and to do like further study, PhD, that kind of stuff. Whereas you went transatlantic. Did you consider the USA as well as when you were looking at options? [Veronica]I was honestly, when I went for my PhD, I was quite open to anywhere. I just wanted to also experience some international opportunities and see other how dentistry is done in other places and research in other places. But I think when the opportunity came for the Netherlands, the topic was also very interesting. It was in the tooth wear, but also with the restorative aspect of it. Not that I’ve done any restorative procedures, but more like following up results of the patients which are treated for tooth wear and yeah, it was just like, that’s a nice thing. I would like to go and it’s a very interesting topic. So it was pretty much what happened and the opportunities that came my way. [Jaz]Good. And now that you are like doing two roles, the clinical practice and academia, do you have a favorite child in that regard? Do you favor one more than the other? [Veronica]Oh, it’s really hard to tell. I can say during the time that I was not back at academia, so after my PhD and I was only at the practice, although I was not fully as a dentist, I was kind of under supervision. So it’s a different story. I really miss academia. I really miss parts of just writing and doing research. And also, yeah, what’s new for me, it’s more also a teaching role. So yeah, I can say that now I’m quite satisfied with the balance. [Jaz]Good. Well, I’m glad you’ve achieved this balance. I think it’s a nice thing to have. And I’m just happy that I found someone to discuss a geeky topic of air particle abrasion. So tell me about your PhD and how you got into work surrounding air particle abrasion. [Veronica]Yeah. It’s also like sometimes, research ideas, they don’t come when you want it. They just show up to you. And of course, when you’re doing a PhD, sometimes that can come from you or from your supervisor. In this case, it was an idea from my supervisor. We came, yeah, I was thinking about this topic. What do you think? We could make like a systematic review. And see what’s there. And of course, initially we wanted to do something like with clinical studies, but that was not possible. And then we decided to say, okay, let’s do it with in-vitro studies, with the laboratory study. So not with patients, but in the lab, and that was not another level of challenge because then you have a variety of studies, but yeah, it was really at the beginning of my PhD. So my second year, I was not with the idea, clear idea of what I wanted to do for my thesis yet, but I said, okay. Sounds interesting. Let’s do it. I also did that with two bachelor students at the time. We were working together on this. So it was quite an immersive topic back then, which it’s funny because even though the paper was published in 2021. The research, the search, was done in 2018, 2019, so it’s quite some time ago already. But yeah, so- [Jaz]But it’s still a very much a hot topic. I see air particle abrasion questions from our community all the time. So some of those things I want to pick apart. So for example, the first broad question I want to ask is, from what you’ve read and the research that you’ve done and also in clinical practice, how important do you think it is for a restorative dentist now, 2024 we’re recording, is it really, I mean, clinically, I would say my clinical experience that I don’t want to practice without it. I love air abrasion. I love the biofilm removal. I love the confidence it gives me my bonding, but I want to know is that perhaps false confidence? What does the literature say about the importance of air particle abrasion when it comes to clinical dentistry? [Veronica]Yeah, that’s very, very interesting question. So I was surprised to see that even though a few years have passed since the research was done, but it’s still quite relevant. I could not find, at least on my last search, any other meta analysis related to it, because unfortunately, there is also a lack of primary studies on that. So you don’t have clinical studies really focusing on that. It’s more of like a side outcome that is still relevant. And there are quite some things I have the impression the same as you. Some things are a bit like a feeling of the dentist, of the clinicians. Yeah, it feels good to work with it. And I also worked with it. So yeah, I can, I understand the feeling, but in terms of evidence, there’s no like a strong clinical evidence that says, oh yeah, we doubt it. Your adhesion is not going to be good. Or with it, your addition is going to be amazing. So it’s something that so far we can say it doesn’t improve a lot, but also it doesn’t harm your addition. So I think I would say in that case, when you have something like this. And it just like, if you know, that’s an extra step, but if you’re good about it and then you, yeah, it gives you confidence and say go for it. So how important it is. It definitely can be an additional step for several procedures related to adhesion, either direct or indirect procedures. Definitely. For example, if you go for immediate dentine sealing that you can definitely use also air abrasion at the later stage, but yeah, just knowing that. If for some reason you cannot have that or don’t have access to it. Yeah. I don’t think that’s going to be the difference to make your procedures, your adhesion or any worse than someone that does. [Jaz]Certainly Veronica. I mean, I speak to lots of dentists who don’t use it and they say, look, my composites aren’t falling off. My composites are still in there and I don’t use their abrasion. And that’s the argument they said. My most compelling argument I found was when I first learned, probably 2013, 2014, I saw this lecture series from Dr. David Clark as part of the biofilm, and he talked about when you start plaque disclosing teeth, and you look at the plaque, and no matter what you use, if you use an ultrasonic scaler, if you use just the brush and the prophy paste, when you disclose again, you will always find plaque. The only way he found that the biofilm was removed fully and there was no plaque being disclosed any longer was from air abrasion. Sometimes we’ll never be able to find evidence per se about how much difference it makes. But if you go back to the foundations of what we’re trying to do, the foundations of adhesive dentistry is having a clean substrate. So that’s why the main conference I get just having clean substrate so that you get the best substrate to bond to and also the least likelihood of getting staining around the margins as well. What are your thoughts on that? [Veronica]Yeah, definitely. I mean, if you have ever have done it clinically, you can clearly see, for example, if you have your matrix, everything placed, and you’re going to do air abrasion afterwards, and then you can see clearly. So, for example, if there is any contamination. That’s also much more clear as well. So for example, yeah, I don’t know, saliva, blood, whatever. You can clearly see after you do that step of air abrasion. So that gives you more also, yeah, let’s say control of your field. But I definitely think that is a two things that are related that because air abrasion is going to promote like this mechanical cleaning, as you said, the removal of any contaminations or incontaminants that are the surface that you’re going to make the adhesion. But also, of course, the mechanical roughness that it produces that also helps increasing the adhesion area, surface area for the adhesion. So definitely, although, yeah, as you said, not because something is not, yet based on if this doesn’t mean that we have to discard it, it’s just, yeah, maybe after in some years we’ll have that, but I definitely recognize the same benefits that you mentioned. Yes. [Jaz]Okay. Well, in that realm, some other applications that we have for air abrasion, obviously, like for example, if you’re bonding zirconia, the APC protocol, the A stands for air particle abrasion. It’s part of the APC protocol bonding to zirconia. That’s another reason to have it in your toolkit. The other reason is when a crown comes off, and it’s loose and it’s still in a condition to bond it. To get rid of the cement on the intaglio surface, my favorite word in dentistry, intaglio, to get rid of the cement in the inside surface, air abrasion, I found just brilliant to do that. The downside, I mean, exactly. When you’re using like a bur, you might be gouging out the internal surface of the ceramic. When you’re using ultrasonic scaler, it’s a very slow process. And so there are other benefits that we have. The downside of that is perhaps some health concerns. I know I’m jumping the gun here, but that particle. You see it in the air. My beard is always filled with air particle abrasion, because I’m using it so much. So did you find any data or have you come across any data about the health concerns about the use of aluminum oxide, for example, which is one of the most common particles used for air particle abrasion? Should we be worried about it? [Veronica]Yeah, I did check about it. I could not find any like recent evidence about some paper from 2003 and 1999. Yeah, if you think of the air abrasion used chair side, so just for intraoral use with proper suction device and proper individual protection like as mask and this kind of stuff, it seems to be below safety thresholds. It’s just so tiny, so very little that yeah, it’s not believed to really to be a cause of concern. I do think that, for example, if you’re going to use outside of the mouth, for example, in a crown or something like that, that you want to clean up, then I know that it can be really messy and can create a lot of particles. Especially because, in that case, I don’t know, maybe you can ask someone to use the suction device, but I think it’s a bit tricky. So I would say for that purpose would be better to use. There is a type of special air abrasion device, that maybe something that the labs would use as well. It comes in a little box so you can put your hands inside it and then you’ll have a little bit more of controlled environment and then the particles are not going to come off of your face. So then I would definitely suggest that. But again, in that sense, there is no specific studies only about the simulating, the chair sides exposure in that case. Yeah. It seems to be. It’s still safe, let’s say. [Jaz]Well, good point regarding the suction. Also, a lot of times we use it under rubber dam isolation, which will help to some degree. Now, I am going to confess that I also use it without rubber dam, in the mouth, okay? And so, things get very gritty, and so I say to my patient, okay, it’s going to feel like a car wash in the mouth, let me go away, wash it away. And so, it’s a very messy stuff. Are there any concerns that you have, as in part of the experience or research, about using air abrasion in the mouth without rubber dam isolation. I’m not condoning it, but I’m just being very real world with you that me and some clinicians do use it like that. Is there a massive contraindication? [Veronica]No, although of course, in that case, you really need to be more, I think, cautious and aware of not directing it to soft issues. I’ve seen happening once with a colleague that a little bit. I think went on the size of the cheeks of the patient, huh? On the inside and it got a little bit of a reaction which it was nothing crazy, but there’s not about much about it in the literature but I would definitely say even without a rubber dam you can make a proper control of it with suction. So I think definitely and really be aware of not directing it to soft tissues. [Jaz]It’s careful judicious use of it obviously. With that, just a clinical tip for those listening. When we’re using air abrasion in the mouth and when you wash it, there’s still always some particles of sand exactly at the margin and inside the cavity still. So what I always do is I go around with the ultrasonic scaler and that’s when I get the clean surface because I’m using the magnification. That’s just a little thing that I found to be very important. So every adhesive procedure, I always have air abrasion, but I also have the ultrasonic scaler set up so that I can scale around. Otherwise you do, if you don’t use magnification, you’re not realizing there’s a little particles of aluminum oxide still there. So just a little tip there for everyone. [Veronica]And definitely is also, that’s just adding up to it. That’s actually also important for the adhesion itself. Okay. Often people do also the etching afterwards. I mean, there’s some variations in there. There’s a jumping a little bit of a head, there’s no like fixed protocol about it, but it’s very important also to remove the residual of the oxide afterwards. Because otherwise that can also be a little bit against what we wanted, which is improve the adhesion. If there’s a layer of particles of it on steel on the surface. Yeah, for sure. [Jaz]That’s right. So getting rid of all the debris. Now, speaking of the debris and the size of particles, is there much, I mean, I think you’ve said conclusively, we don’t have enough data because I see some papers that are pro air abrasion and also some papers that actually no difference and that kind of stuff. So overall your systematic review, show that, okay, overall, we don’t know if it really is a massive plus point, but are there any variations within 27 microns and 50 microns, which is commonly the two most common particles use? I’ve also seen 90 micron on the market. Any clinical guidelines you can suggest in terms of when is it right to use each particle size? [Veronica]Yeah, no, there is unfortunately no answer to that question. No direct answer on the literature about that. Most of the studies that we included in the review. They were using particles that were equal or higher of greater than 30 microns, micrometers. But also for the little bit below that, overall, you don’t find the big difference in the effect of these particles, except for certain comparisons. And also they were not in the long term. Because when you think of adhesion, it’s not that you, if you reach a high adhesion at the same, like today. It does, you really need to look at in the long term. So after aging and stuff, what’s going to represent and that information we don’t have yet. So I would say if you stick to this most, let’s say commercial, yeah. Frequently used, like for example, 27 to maximum 50, I think you are in the safe side. [Jaz]Lots of dentists actually say, lecturers say that they like 27 microns for cavity because it’s not too abrasive. So if you’re close to the pulp and whatnot, so, it will do the biofilm removal It may be make a nicer surface under the scanning electron microscope. It looks prettier, but maybe it doesn’t achieve the better bond strength. But it’s certainly they like what they see under the microscope or under the scanning electron microscope and then for 50 microns for actual like the intaglio surface of crowns and resin bond bridges which makes sense. Pragmatically though what I do, and this is just pragmatically and some other conditions, I’m just not in the enjoyment phase of switching sands. I don’t like, oh, now is this I have to switch it. It’s a step too much. So I use 50. And that way with the 50, I can use it aggressively on restorations and metal and stuff and removing cement where I need to. But when I’m doing it on teeth, I’m favoring this like, soft sandblasting. So being a little bit further distance away from the cavity and being very careful to aim the sort of the beam, if you like, of the sand to exactly where I want to go and just being careful about that. In your clinical experience or what you’ve seen colleagues do, what you’ve read, is there a good pragmatic approach in practice that you think? [Veronica]I think what you’re saying that you kind of try to compensate a little bit of size of the particle, for example, with the distance. And I think that’s also a good idea in case you either don’t want to, or don’t have the conditions of changing the particles. I think definitely we need to be more mindful about when we are doing it in the mouth on a tooth substrate, because it does cut a lot and it cuts even more when it’s hard tissue. So for example, you already finish your, usually, you finish your bur preparation. So you remove the carious dentine or whatever that you’re working on. And you’re almost reaching that stage that is that hard dentine that’s healthy. So that you don’t want to remove more than you should. So then you have to be, yeah, you cannot be too enthusiastic with the air abrasion because in that case you can really remove more than what’s needed. So I think it’s definitely good that you take these measures and yeah, it’s really like, so you have some factors that can influence the air abrasion effect. So we have particle size, you have pressure, you have distance, you have angle, and you have time just to mention a few, okay? So all of these, they going to play a role of course, but we don’t know what’s the effect of them because some of the studies, they are so different. They use so many things. [Jaz]It’s difficult to study all these grammaticals. [Veronica]It’s really different, difficult to compare them. So we can, because we need to first be able to compare so we can say which is better or not. But I think you’re definitely on the good direction that you’re balancing it a little bit with the particle size and stuff. [Jaz]And with the use of air abrasion, some other clinical protocols I’ve seen is when you’re trying to bond to existing composite, virtually all the clinical expertise that I’ve seen says that, okay, a good step to activate, reactivate the composite. It’s ready to silanate and then re bond a new composite to old composite. But air particle abrasion is used a lot. And then in particular, I’ve read some research about the use of cojet, a particular type of sand. Have you studied or looked into CoJet? [Veronica]Yes. So it’s one of the particles used. So you have just maybe people that are not familiar with it, but the difference with the CoJet is that it’s first of all, it’s a branded name, huh? From, it’s a 3M- [Jaz]I think, it’s a 3M product. [Veronica]Yeah, it’s 3M. And then you have not only the oxide, the alumina oxide, but you also have silicon and that’s especially the silica. It’s what helps with if you’re going to use, for example, a repair, if you want to use a sealant, then you can improve the bonding to the sealant because of the silica. So in case of repairs. Because there is already some evidence that for repairs, it’s nice to use a sealant. And then if you use something that’s going to improve the bone into sealant, then you have an extra. So either you can do something to roughen that surface. For example, it doesn’t need to necessarily be air abrasion. You could also do that with a bur, for example. But then you have, with only air abrasion, without being CoJet, you’re going to still going to have the benefit of the roughening of the surface. So you’re going to improve the quality of that surface for adhesion. But then if you use the CoJet, you also have the benefit of the silica and then you have better adhesion to the better bonding to the ceiling for repairs or for like if you’re bonding to metal or yeah, also zirconium also on the other types of materials that are not only composites that can be a benefit too. [Jaz]And to use CoJet, and this is, excuse my English, I’ve never used it. Is it just a matter of just buying the powder or do you have to buy the whole kit for the air abrasion unit as well? I’m not sure. [Veronica]Yeah, good question. I also, I’m also not sure about it. I know that in a lot of studies when they use CoJet, they combine it with a special type of hand piece or something. So I’m not sure if it’s compatible with any type of what with system. So yeah. Yeah, we need to check that. [Jaz]It’ll be good to look into it. And as part of the research, I’ll look into it for this podcast before we release it. It’ll be good to know because if it is showing promising data for when you are bonding to old composite. And that’s a lot of what we do in modern dentistry, trying to be conservative, minimally invasive, refreshing, old composite is part of what we do. And also with aging populations, we’re probably doing it more and more in the future. Therefore, if this really is the magic sand, if you like, then maybe we should just be stocking it and buying it. But however, if there’s cost concerns that you need to get a brand new unit, then that might tip the balance. So I will look into that. It’d be interesting to know more about a CoJet, but I’ve definitely seen that it’s a quite encouraging data. What I’ve seen. Any times that you’ve come across in your findings about when we should avoid it? Are there any scenarios that we could be doing harm by using air abrasion or perhaps the improper use of air abrasion? [Veronica]Yeah. It’s really difficult to tell, but I could think of a few. So for example, you can use airbrasion if you have just that superficial enamel caries. That’s like, imagine some type of situation where you just use sealant, you not go for the full restoration. And in those cases, it can be useful to use a little bit of abrasion. Fine. But you cannot use it, for example, if you want to, yeah, diagnose caries. I don’t know why would you do someone used that, but I’m just saying that I found an example. [Jaz]People used to, I mean, Veronica, we know that people used to use a fissure bur. They’d be like, hmm, let me see if it’s carious. It’s back in the day. They’d stick a fissure bur in and open it up and then see, ah, is it carries or not? [Veronica]So, yeah. So yeah, so there is a good example. So I could not think like, why would someone do that? But maybe people think, yeah, because I’m going to dry it and then I can see, I don’t know, but that would not be a good case for using air abrasion. Other than that also, as I said, you need to be aware that with air abrasion you’re not going to be able to have that tactile feeling of the cavity of the tissue, so you need to be aware of that, avoid it if you really think maybe that you’re already like really it can also be because you’re in a deep and you don’t want to expose, there’s a risk there, so you should avoid it in that case. Also, if you cannot have proper isolation or protection in, of your field. And I’m not talking necessarily of rubber dam, because sometimes you can also have it like with other ways. So, if you cannot have that, you should also avoid the air abrasion. And another thing that I found very interesting, I think is also a good point. You should not replace the etching, for example, with air abrasion. So skip a step and only use the air abrasion because of what we said before of this mirror layer. And the debris. So that’s not the way to go. So you can add it as an additional step, but should not replace that. It doesn’t replace that. No, no. [Jaz]Absolutely. And I think the other one I could think of is just be careful if anyone’s doing zirconia bonding. Air particle abrasion is a reasonable thing as part of the protocol for the APC protocol. But. if you’re doing it too aggressively, are you causing micro cracks in that zirconia, for example, that’s a concern. So a term I’ve seen is soft sandblasting being used and the other one would be lithium disilicate. For example, I know plenty of colleagues who air abrade lithium disilicate. Any stance you have on that? Because last time I read the Ivoclar guidelines, Emax, for example, it’s a glass ceramic. They specifically say, do not air abrade, but I know some clinics who do and they don’t seem to have any fractures of the ceramic. It’s just that because I read it in Ivoclar. Anything that I have that’s Emax, I don’t do it because I feel as I’m trying to follow the instructions for that. Any guidelines on different ceramics and air abrasion? [Veronica]Yeah, I don’t know. I’m not familiar with this recommendation from Ivoclar, but I can tell that yeah. With lithium disilicate you have not a great problem with bonding because you can just condition it and without having the risk of creating of any- [Jaz]Surface irregularities and microcaps. [Veronica]That’s damage to your, ceramic, with zirconia is definitely needed because then you do have a problem. So you do need to have to do something to increase your possibilities with adhesion. So, that’s a very interesting example. What I know is for the glass ceramics, yeah, it’s just not needed. You can just do the proper conditioning with the fluoridic acid and then, you can reach a good bone strength. [Jaz]Well, lots of colleagues don’t have air abrasion and I feel the number one question I get from the Protruserati community is, I don’t have air abrasion. Can I just use my Prophy Jet instead, like the polishing powders, very much softer stuff. Now, based on what you’ve said so far, because the data doesn’t strongly support the use of air particle abrasion, then really maybe they could just be using for the biofilm removal aspect, just be using the softer powders that are more for the biofilm. Is there anything that you know about in terms of alternatives to air abrasion that people use and they can consider? [Veronica]Yeah. I think if you think of only the biofilm, I even go further with the pumice. So just know some like polishing with the pumice, that’s not going to leave any residue behind. But also if you think of the micromechanical effect of roughening the surface, then I would just go for like, for example, for roughening with the burr. Yeah, that too should also work. So for example, if you have like an old composite and you’re going to make a repair or something like that, you want to reactivate, remove that externally, and then have like a new layer on under it. So I’ll definitely go also with the bur. And even if you don’t have air abrasion, for example, if it’s not a composite, if it’s like a sclerotic dentine that’s very hard and dentine, you can also activate a little bit the surface with the bur. But again, that’s an alternative. Even though, for example, in the paper we saw that when there was a difference favoring the Arab region, it was for some particles and for some pressure, yes. It was usually when it was compared to either to hand excavators or with burs. So sometimes actually in those case, and I’m not saying I’m not going to generalize it, but some of my, let’s say sub comparisons, we found the difference than the air abrasion was better than those mediums. But yeah, if you don’t have it. That’s what I was saying. If you don’t have it, you’re going to use what you have and not think that because you don’t have it, you’re going to have a too bad of an addiction. It’s not like that. I think it’s if you take care of other important details and steps on your clinical procedure, you can still reach a good, effective adhesion. [Jaz]If someone’s listened to this episode and they’re now feeling like they’re a little bit more knowledgeable about the guidelines for air particle abrasion. And just like a lot of research, we don’t have the answers. What was your personal reflection guideline in terms of if someone’s sitting on the fence, and they’re thinking, should I spend this equipment budget on an air particle abrasion unit? It’s a two part question here. One, do you think they should do it? Or maybe because the evidence says it doesn’t significantly improve bond strengths that much, maybe just to skip it and continue to use the bur. That’s part one. And part two is any data on the more fancier units like, Aquacare, the crystal marks, any comment on those? So part one, if someone’s not using air particle abrasion at all, is it time that they invest or maybe should they save their money and buy another gizmo instead? [Veronica]Yeah, it’s a good question. I would say, air abrasion is definitely another tool in the dentist toolkit. So, the same thing, for example, yeah, can you be a dentist without magnification? Or, is it really something that the people that use it there’s a lot of benefits, but if you don’t have it, doesn’t mean that you cannot do dentistry, not necessarily, because we all kind of start without it. So it’s a bit- [Jaz]I like that. I actually love that. Because I love that Veronica, because I don’t trust any dentist that doesn’t use loops. That’s just my fact. Okay. I don’t trust if you don’t use magnification, I would not let you near anywhere near my mouth or my family’s mouth. And actually, if I was going to have an adhesive procedure or my family member was having adhesive procedure. And if I started working in a new clinic, my requirements are always the same. I need air particle abrasion, I need rubber dam. If I don’t have these two things, I refuse to work in this clinic and that has worked well every time I go to a clinic and they always supply those things. So that’s my personal stance. Again, the literature doesn’t support it, but I like the comparison. Okay. Literature maybe can’t support that a dentist who uses magnification crowns will last longer than a dentist who doesn’t use magnification, for example, right? So maybe the literature won’t support it, but in terms of how we perceive it and what do we feel in the absence of literature, because literature is one third of evidence based dentistry, right? It’s patient experience, patient values, and we have to consider that as well. Yes. [Veronica]Yes. Very much. It might get there. We might get there. And yeah, no, I’m out about getting heavy answers, but of course, sometimes you have questions that are more urgent to be answered. So there is also that, but yeah, it’s just to give it, I thought, yeah, just now if it’s a good example, so I would say if you have the means to do it, I think you might really like it, enjoy it and see the benefits and the quality of work and also, yeah, a bit of pleasure and fun that you have using it. That’s about the part one then. So yeah. [Jaz]And part two the fancier ones. The Aqua Care. The crystal marks. They had the water jet with them. [Veronica]That’s the thing. I had the opportunity of also working with Aqua Care and it was fine to me as well, but I don’t know any comparison terms of brands of devices of that. I just felt that okay, it was good, but I was also used. Let’s say in one room in the practice they have Aquacare in the other room they have another type and I was just used to the one that was in my room and I was happy with it. So I could not see from the clinical perspective, like personal perspective, I could not see like a huge difference, honestly. So, yeah. [Jaz]I think that the fans of Aquacare and Crystal Marks, these systems with the water, and there are some cheaper systems out there as well with water, I think twofold. One is that they’re less messy. It’s less messy, it’s easier to clean up because of the whole water with it as well. There seems to be, virtually none, I’m told, in the air and they feel better about the whole safety aspect, right? So that makes sense. And, but there is also the, is it called Sylc maybe?, the bioactive glass, maybe the bioactive beads that come with a particular AquaCare that seems to have some promising soft tissue responses. That I’ve seen some lectures talk about and maybe there’s something in that, but yeah, I’ve never had any compelling evidence research, but it’s one of those things that I’m going to say that just like you said, if you have the means, right, if you have the means and if you can buy the best loops, the highest magnification you can afford, great. But if you only got the brand that you can afford and that will do good for now, I think that’s a good way to go. But to use something is better than using nothing in my opinion. [Veronica]Yes, yes. Yeah, I know that there was some studies that used also the glass beams in the review, but it was just not much. It was just, in that time, it was just a minority of the studies, huh? So as I said, science and evidence, they also need time. So maybe in a few years, we’re going to have more studies that’s used to test those equipments and those other particles so that they can maybe have a different, yeah, interesting, more new information. [Jaz]Veronica, you’re a true academic in the sense that we’ve ended the podcast with the usual sentence that you read at the end of every dental paper ever, which is we need more time, we need more papers, we need high quality studies, but it’s so true. [Veronica]Yeah, unfortunately, yeah, sometimes like, I mean- [Jaz]It’s the same conclusion every time, but this is the reality of it. We don’t have the clinical trials. [Veronica]Exactly. I mean, I’m not even saying clinical trials because honestly, not everything, like imagine clinical trials really need to be like a major important question. Some things are perfectly fine to be also evaluated in the lab. If you wanna compare, for example, different materials, like different composites, different these waves, yeah. You don’t need to necessarily do it in the patient because some concepts are the same, but you wanna, so just see like a tiny details of differences in the bone strengths of that’s perfectly suitable to be tested in the lab. So, I think that’s the case also for air abrasion, but yeah, more studies are needed. [Jaz]Watch this space. More studies are needed. Oh, Veronica. Well, thanks so much for having this geeky discussion. It’s something that the community has asked for a long time in terms of more, just a geeky one about air particle abrasion. My personal stance, as I’ve said, is I’m very pro it, but I just want to, and I’m happy to have you say in this podcast that, look, we need more data. It’s not as nice as you’re saying, Jaz, and I appreciate that. And that’s what the study said, and we can’t argue with the studies, but let’s see what time tells. Personally, the clinical satisfaction I get outweighs any of that. And I know that it’s not doing any harm, but the whole biofilm removal, but when I didn’t have the air abrasion, I was using Pumice, right. And I got by fine as well. So there are some considerations for that as well. [Veronica]Yeah. And even though we don’t have that big fat, yes or positive or go ahead, but we definitely also don’t have it yet, a big fat no. So I think, that’s why like sometimes you also need to balance it a little bit. Are there many risks? Are there many harms that might be overcoming like positive effects? We don’t see that very much so far in a regarding to air abrasion. So I’ll say In this case, it’s okay to go with your feeling, because we might have some more definite definitive answers in the future. But just for now, we also don’t have many major red flags. [Jaz]So good. And are you happy for me to share your systematic review with the community in the download section in the show notes? [Veronica]No problem. [Jaz]Amazing. I will do that. And just tell us what are you working on next? Like what’s what’s next on the horizon academically for you? What are you researching next? [Veronica]Yeah, right now I’m at the Department of Cariology at the ACTA at Tech, from a University of Ment Amsterdam. So, yeah, right now it’s a little bit still very early stages, a bit of qualifications needed and yeah, still developing some work on the tool for, but in terms of research is still open for possibilities. And I will come soon. [Jaz]Good, good. Well, as a community, we wish you all the best. Thanks for giving the time. If anyone wants to send some love your way and a thank you, and maybe a geeky question, how would you accept that? How would you welcome that? [Veronica]Yeah, no, yeah. I’ll be happy to receive that. And I’m always quite active on my research gate page. So yeah, people will sometimes reach out for publications. I do my best to respond really quite fast to send the papers and stuff. And also, yeah, as you could see, also linked in. So yeah. [Jaz]I’ll link them to the research gate and honestly wishing you all the best with the future research endeavors and your new life in the Netherlands. [Veronica]Thank you. Same to you. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. I’d like to thank our guest once again, Veronica Pereira de Lima, for being geeky and being kind enough to accept my invitation. Protrusive is all about the geeky and kind dentist. That’s you. Now, if you want to find the home of the geekiest and kindest dentist in the world, you want to head to Protrusive Guidance. There, under this episode, you can answer some questions in the quiz to get some CPD. You’ve done the hard work of listening to this episode already, so why not get 40 minutes of CPD for this? One of the five questions for this episode is this. Which of these factors determine the cutting efficiency of air particle abrasion? So which of these factors determine the cutting efficiency of air particle abrasion? Is it A, the particle size? Is it B, the pressure? Is it C, the distance away from the substrate? Is it D, the time of air abrasion? How long are you actually air abrading for? Or is it E, all of the above? Now that was an easy one, I know. There’s a few others there. If you can answer those, you’ve got yourself a certificate which Mari, our CPD queen, will email to you. In fact, Mari will send you quarterly certificates and an annual review of all your activity within Protrusive. I want to thank Team Protrusive, so Erika the Producer, Mari the CPD Queen, Krissel, Rakesh, Nav, Emma, who will help with the premium notes, and Gian for his video wizardry. Do me a favor before you go, whatever platform you’re listening on, consider giving it a like, a thumbs up, a subscribe, whatever button you can click on, please click on it. It really helps the podcast grow, so I can continue to bring cool and geeky content to benefit us all. Thanks so much once again, I’ll catch you same time, same place, next week. Bye for now.

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