Implants can fail – we all know that…but what are the medico-legal implications when they fail at 6 months after restoring them…

Is it all the restoring Dentists’ problem? ‘He who touched it last’? Or does the implant placing surgeon also need to be involved in the ‘post-mortem’?

How can we handle the upset patient (and prevent this in the first place!)

In the latest podcast episode, we introduced Dr. Joe Bhat and Neel Jeiswal, both prominent figures in Dentistry. Neel, representing PDI, has a rich background in clinical dentistry and medico-legal matters, while Dr Joe Bhat is a dual specialist in Oral Surgery and Prosthodontics. Joe established a pioneering multi-disciplinary clinic 20 years ago, which continues to thrive with numerous referrals.

Both guests provided deep insights into implant failures, patient management, and the importance of effective communication and collaboration in dental practices.

Need to Read it? Check out the Full Episode Transcript below!

Check out Dr Joe Bhat’s place of practice – Moor Park Specialists

Due a renewal for your indemnity/insurance? Get a quote and special discount from PDI

If you liked this episode, you will also like 4 Ways to Boost Osseointegration of Your Implants – PDP155 – Protrusive Dental Podcast

[Jaz]
You potentially have an upset patient on your hands. This patient is potentially pointing some fingers. Now who should the finger go towards? Should the finger go towards the implant placing dentist? or the implant restoring dentist. It’s a bit of a medical legal minefield. So I’m joined today by Dr. Joe Bhat, who’s both an oral surgeon and a prosthodontist, so he’s in a great position to be our expert today, as well as Dr. Neel Jeiswal, who I rely on so much when anything, when it comes to medical legal, and indemnity

This episode is CPD eligible on the Protrusive app called Protrusive Guidance. I think you’ll learn a lot about communication, consent, and a proper medical legal management when things go wrong, how they work with each other. So we can benefit and really help our patients because ultimately everything we do is It’s for the benefit of our patients.

Dr. Joe Bhat, welcome to the Protrusive Dental Podcast for the first time. And Neel Jeiswal, welcome again, my friend. Neel, you are the representative of PDI and a clinical dentist that we love having on because your medical legal perspectives are absolutely fantastic, and also your years of clinical experience. But Joe, I don’t think we’ve met before properly, so it’s great to be introduced by Neel. Joe, tell us about yourself as a practicing dentist. What are your interests?

[Joe]
Thank you so much for the invite. I know it came via Neel, but I’ve heard a lot about you, Jaz. So good to be e-connected finally. I am a dentist. I’m a prosthodontist and an oral surgeon. So I started my life as an oral surgeon, did six, nearly seven years of Maxfax, did my, the old time fellowship, the FDS- RCS. And then I went back to dental school and did my specialist prosthodontic training. So I did my MClindent and MRD. We were the first batch.

I was the first student, my surname beginning with B meant that I was my first student ever to get a monospecialty training pathway in prosthodontics. So I became a dual specialist in 2001. So that’s 23 years ago. And we set up a specialist practice. The idea of the specialist practice at that stage was at that time, when I set up the practice more than two and a bit decades ago, was all the specialty centers were more specialty training pathway, more specialty clinics.

So, there was a periodontal clinic, or you could send it to Lister house for endo and so on and so forth. So we were the first ones to set up a multidisciplinary one stop shop for specialist referral center. We had nine specializations under one roof. So, 20 odd years ago, it was a crazy concept.

Now there are multiple centers, which are multidisciplinary specialty centers. We are proud still to have all nine specializations under one roof, which is great. They have a great team. So it’s a 10 surgery practice and we take about 1, 700 referrals a year from 370 dental practices. So it’s a well established practice.

We are less known because we are not on the social media very much. Everything is done through word of mouth. And we sold to Dentex about 18 months ago. So having run it for as many years as I did, I thought, I think I needed to offer the platform for somebody else to take you to the next level up. So we were successful practice.

We are very happy doing what we do. I’m a full time implant surgeon. That’s all I do for the last two and a half decades. And I’ve gone through various phases of placing and restoring to. Pretty much now I only place implants. So I have a team of prosthodontists with me who restore my implants for me.

[Jaz]
But this is a very unique show because I’m very excited now based on what you’re saying, because I didn’t know you were both oral surgeon and prosthodontist. And the reason that excites me because the topic we’re covering today, like I’m very grateful to have your specialist knowledge in both the prosthodontic restoring side, but also the surgical side.

I guess if I was speaking to someone who’s just an oral surgeon, there might be some bias. If I was speaking to someone who is just a prosthodontist, there might be some bias. Okay. But I’m really excited to see what, hear what answers you, have actually in terms of satisfying, from the perspective of both those individuals, if you like.

[Joe]
Yeah, we’re fortunate. I think five of us in the UK who are prosthodontists and oral surgeons. So it’s a small select group of guys who are nerdy enough to go back to dental school and doing one specialist qualification is bad enough. Doing two is a complete nutcase you know? So, I’m-

[Jaz]
That’s up to you, someone’s got to do it.

[Joe]
Somebody’s got to do it. So it was me, I had M U G written on my forehead.

[Jaz]
Not at all, not at all. I’m very excited to break down a conversation. Neel, my friend, just for those who haven’t listened to our previous episodes about indemnity versus insurance or the various scenarios that we’ve covered already. Just give us a refresher on who you are, Neel.

[Neel]
Thanks Jaz. And again, thank you, Joe. Nice to see you again. Joe is such a great guy. Brilliant at what he does. Understated, family man, always be there for you. Although we tried to arrange Sunday and you didn’t get back to me, did we? We’re trying to arrange a family day out.

I know you’ve been busy, but no I’m a practice owner. I practice in Hertfordshire, very much like Joe. My background was going to Frank Spear about 10, 11 years ago and realizing we need to link all these specialties together and there’s a pathway of doing it the right way. So again, we had probably not nine specialties, maybe four or five, and we’ve kind of developed that over the years, but still a small family practice.

And a couple of years ago, maybe five, six years ago, a lot of my friends were getting in trouble with the GDC for no reason. And indemnity was looking like they were letting people down. So I kind of fell into indemnity and it’s been a lovely pathway of helping dentists. That’s the way I look at it. And that’s what we do. We help dentists at PDI.

[Jaz]
Amazing. So I’ll put the links to PDI and everything as well, as well as Joe. Joe, again, I’ll ask you again at the end about any teaching, any resources that you have, but we’ll be sure to put your websites.

[Joe]
And a little plug that I’m also a client of Neel. So. You know, so I, myself am-

[Neel]
A good client. There you go.

[Jaz]
Someone like Joe is a client and that speaks volumes, I think, as a mind, as you guys know. But anyway, scenario. This is a really cool scenario that Neel has written. If there’s anything wrong about the scenario, blame Neel. But essentially a 55 year old male patient, night shift worker.

Now, every time I say something, I could let you, Joe, break it down, but there’s so much to discuss in this that I’m just going to, like, say what comes to my mind as we go through the scenario. So, I’m basically thinking, why did Neel put this in? And if I get anything wrong, Neel, you tell me. So, 55 year old nations, age is important always, the younger we are, the potentially the better we might also integrate, or maybe the decision making may change in terms of age night shift worker.

So quality of sleep that might be a detriment here, non smoker, which is important. Obviously smoking, we know has an impact on your osseointegration, but Joe, you’re the expert on that, upper right first molar, upper first molar. So Joe, I’m setting the scene for you seen this already, but I’m just reminding the guests, you guys, and also the audience about this.

So upper right first molar on this 55 year old male, there’s some crowding. The perio is stable. The patient is a snorer. Okay. And there is bruxism. So potentially higher occlusal forces, potentially. Now I’ll be interested to ask you, Joe, later about how you may or may not treat a bruxist differently to a non bruxist kind of thing, if they exist, et cetera.

But we’ll talk about that. Now, the dentist refers the patient out to an implantologist. Doesn’t exist, but let’s go with that. Who successfully places the implant without complications. Okay. Patient returns a few months later for the crown fitting, okay, with the referring dentist, okay. However, six months after the crown fit, because there’s two ways you can do this, so the surgery’s been done, we’ve waited some time, a few months later for the crown to be fit, and then six months after the crown’s been fit, okay, the implant fails due to peri-implantitis, leaving the patient dissatisfied and wanting compensation. Anything do you want to probe on so far before you go for the individual questions, Joe?

[Joe]
No, I think it’s pretty, pretty explicit. It’s quite well written, case study.

[Jaz]
Well done, Neel.

[Joe]
So, there, and the good news or the bad news, I suppose, is that it is not a scenario that is alien. It happens quite often. And it only comes to surface, I suppose, when things go wrong, because a lot of the training of pretty much all the dentists that we do in implant dentistry is training how to do things right. Not a lot goes into what happens when things go wrong. So when you are sitting and looking at these kind of scenarios is obviously something is going wrong. Where do we go from here? So from a question, but if you know, I don’t have any more to probe. I kind of understand the scenario because I’m well versed with it.

[Jaz]
Brilliant. And I think the way to think about this, the rest of the episode is, whilst it’s good to have some clinical gems in there, like what kind of restoration was done, screw retained, cement retained.

I’m sure we’ll go into that and have those little clinical nuggets to reduce our complications. Really the crux of this episode is the medical legal side, the communication. Ultimately it’s communication, ultimately it’s consent, ultimately it’s how do we liaise and communicate with our colleagues when something like this happens. So that’s the mainstay of it. Neel, anything to add now that I’ve read out this scenario? Is my interpretations correct in terms of why you included certain factors?

[Neel]
Well, I think definitely, we’re all seeing bruxism on the rise. We’re all seeing sleep apnea on the rise. We’ve seen a modern diet is appalling. So glucose control. So what I’ve seen shift workers, they don’t sleep well. And we know this for a fact, generally they don’t sleep well. And that leads to AOSA, you’ve touched on this in the past, Joe and Jaz. So I think there’s an element of bruxism, but there’s also an element of glucose control.

I find shift workers eat very erratically and all at the wrong times. And I’m also going to ask Joe later, he’s like, in terms of what does he feel about glucose control and pre diabetes in terms of managing these and evaluating these patients.

[Jaz]
So it’s good you planted those things in there because this is all systemic health, which is related because ultimately surgery, the results of surgery will be impacted by the patient’s health. And the other one commonly is vitamin D, how many of us are lacking vitamin D, which I’m sure Joe is going to talk about kind of thing in terms of when we look at the patient factors and medical factors associated with failure, which I’m sure are so vast. And because we don’t know, even more details.

We don’t have radiographs. We kind of have to infer and come up with our own scenarios, but ultimately to answer the following questions, which are number one, how should the dentist deal with the situation of the implant failure and the patient dissatisfaction? Number two, discuss where the responsibility lies of a case of implant failure and patient dissatisfaction, i. e. Do we point the finger at the surgeon? Do we point the finger, he who touched it last kind of thing, right? If you touch it, you own it. So is it the fact that it was, once it was restored, is it now the prosthodontist or the dentist who placed the crown?

Is it their fault or question three, which is what considerations should a referring dentist look out for regarding the choice of an implant surgeon based on this scenario? Very fascinating, actually. So, one at a time, you have an upset patient, Joe, in front of you, not in front of you, but the referring, the dentist is the patient’s upset because their implant, which they paid some money for and had some surgery for, had some time and money invested into, is now failed. How do you want your dentist to manage the initial part of such a scenario?

[Joe]
I only but presume that the patient is obviously going to go back to the referring dentist or to the restoring dentist rather to start with. I’ve not made any notes about this because I think I want it to be a free expression of how I feel about this case.

With regards to dissatisfaction, unsatisfied patient, one of the primary reasons is they were not informed in the first place of the scenarios of what is possible. I wouldn’t mind a patient being saddened by an event of an implant failure. A dissatisfaction, meaning the satisfaction has been dashed. That means the communication fell apart to start with.

Patients often ask us, will this last forever? And my last response always is you and I don’t last forever. Everything has a finite life expectancy. So one has to manage expectations. And this is where we go wrong so often, a statement I make sometimes saying, don’t promise them the Earth and give them Uranus, it’s very, very important for us to make sure that we promise the right things.

Do not over promise and under deliver. You’re better off under promising and over delivering because that is where the issues tend to lie because the patient is dissatisfied because he did not even expect it that it could fail. at this early stage did not have-

[Jaz]
Joe, can I just stop you there? Because firstly, I’m loving what you’re saying. And I love that distinction between being saddened, which you would expect anyone to be sad when this fails, right? But dissatisfied has different connotation. It means there was a problem with the consent. It was a problem with the communication. And so the next question I will be asking you on this vein is, okay, just like you said, you under promise, over deliver, but what kind of actual verbatim do you use your patients in terms of, okay, how likely is this to happen?

What happens in the event of that? What kind of conversations you have beforehand, before it even happens. And the reason I say this, because the theme we’re talking about now, you can apply it to a lot of other things in dentistry. For example, specialists and endodontics. A patient can have a fantastic root canal under a microscope and six months later, they need a tooth out because the root canal failed.

It can be in all sorts. So we can actually use a similar theme. The patient was saddened, but maybe if the patient wasn’t told that there’s a risk of failure, and then that wasn’t made tangible enough for the patient, then they would be dissatisfied. So tell us about what kind of conversation do you do so that you don’t have a dissatisfied patient, but you have a saddened patient.

[Joe]
Yeah, I think when people ask me, will this implant fail? And I will always say in my experience, everything that a human being does on another human being has a failure rate. The question of failure is if it’ll fail or not. It is when will it fail and how much of longevity will I get out of this in my life expectancy.

I use all kinds of analogies, including saying the Lord created the teeth for you. If they could fail, what are the chances of something that a human being is doing for you? So we have lots of little, little things I use to make sure that nothing is more healthier than a natural tooth. Remember an implant is not being done as a replacement of a tooth.

It’s being done as a replacement for a space. Okay, so there’s a big distinction between the two. You’re not giving a like for like replacement for a tooth. You’re just providing the best replacement for a gap. In all the choices of having either dentures or bridge work or implants, this is my favorite choice.

So we have literature, we have data, and one of the key things that I always show my patients is my own data. I have an Excel spreadsheet going back to 2001 to 2024 of every single implant that I have placed. I placed implants since 1996, but from 1996 to 2001, I did not own a computer. So I didn’t have any data set.

So it was handwritten notes, which I still have it somewhere, but I’ve lost most records. But so I’ve got data stretching back 23 years of every implant that I have placed. And therefore, when I give data, I can’t quote my own data. I don’t quote literature because that is irrelevant. It is probably done in test conditions in a teaching hospital and so on and so forth.

So I always make sure that I manage their expectations realistically. I say it will fail. What are the things that may make it fail? Is if just like your teeth failed because of either lack of maintenance or things that have gone wrong in dentistry, et cetera, same things can happen with implants.

In other words, If you’re not taught how to clean around implants, it will fail. If you develop gum disease, it’s bound to fail because as you progressively get older, your manual dexterity will fail you. When your manual dexterity starts to fail you, your ability to clean around the implant will start to fail. That’s when implants starts to fail.

[Jaz]
Let’s talk about your data. If you don’t mind, Joe, what is your data showing since 2001 to now? Firstly, is it success and survival? And then how do you make those distinctions? And how do you, what do you communicate to the patient?

[Joe]
Currently, the data is only on survival rather than success because we have, if you look at success, there are so many parameters, so many parameters, even a loosened crown is considered a failure.

[Jaz]
Or porcelain fracture could be a failure.

[Joe]
The parameters are too huge for us to record it in a clinical environment, in a dental practice, in teaching hospitals far easier. Because they’re providing the implants for free for patients so they are willing to come back for their checkups. Here it’s a bit more challenging.

So it’s more to do with survival rather than success and the data for us that we have in non smokers, in non periodontal disease patients is 99. 6 percent. So it’s very, very high over a 10 year period. Do we follow up all our patients back in our clinic? The answer is no. But we follow it up with a telephone call.

So we have a recall set up. So we do our recalls at yearly for the first five years and then five yearly from that point onwards. But of course, those five year appointments, sometimes patients turn around and say, I don’t have any problem, so I don’t want to come. So we record that as patients saying that there was no problem. In other words, the implant is still there. So you have to find your own mechanisms of recording your data. There is no hard and fast rule. There’s literature and there’s literature.

[Jaz]
Well, the next question I have then is, this scenario that we’re talking about, this 55 year old male, peri-implantitis. And so I’m going to go back to the scenario and I’m going to pull it up, right? So he said the implant fails due to peri-implantitis. Now, according to the survival criteria, would this go down as actually it’s succeeded because it will be a positive in the survival data or was this count as a negative because the implants still in the jawbone? Interesting distinction here.

[Joe]
For me, if the patient got peri-implantitis and has a problem as practically the removal of the implant is imminent, then that’s a failure. That success has turned into a failure. That’s it, zero. If that’s the only implant you’ve placed, you have a 100 percent failure rate.

So, this is important. The reason I’m saying that is because people make a lot of promises on their implant success rates. The people who say that they don’t have implant failures, they belong to two categories. Either they don’t place any implants, or they lie. Because anybody who places implants knows that there will be failures. It’s just how to manage them. So-

[Jaz]
It’s the same with any part of dentistry, right? Anything with this endodontics or occlusal appliance therapy, whatever it could be, there’s no one going to have a hundred percent. And so always be careful to people who claim anything is a hundred percent. So we’ve already established the whole thing about dissatisfaction and saddening, which I think is this brilliant distinction.

Neel, anything you want to add in terms of in the medical legal space, have we seen a trend that a lot of the complaints that are coming, are they implant related or are they not so much in terms of the, because it’s a heavier fees involved often people might think that, okay, there might be more litigation.

[Neel]
From what I’ve seen is the people doing lots of implants, and when I started doing implants, I was jack of all trades. So I placed maybe 50 in my life and I got to the point where is I need to invest all my time to do this well. So I cut back on it. So we’re finding a lot of people like Joe who do lots and lots of them.

We don’t have really any problems with them. And to be fair, they pay a low premium. They’re a great risk for us in terms of we don’t hear from them and they know how to manage their patients with great communication skills, all those kinds of things. You do get the odd blip where there’s suddenly a couple of hundred grand payout, for big implant cases, all on fours and that kind of stuff.

And what happens in those cases, those dentists then become uninsurable. Some dentists aren’t as nice as others and they just think, fine, I’ll take one on the chin and I’ll just keep going down the route I’m going. But actually, they’ll get to a point where nobody wants to insure them and they’re sort of forced out.

So in a way, the system encourages good dentists to keep doing what they’re doing and it drives out bad dentists. So I generally think if you look at ADI, if you look at ITI, if you look at some of the people doing courses, we’re really taking implants seriously as a profession and not just dabbling in it so much.

So I don’t think it’s a higher risk. I don’t think placing or restoring is a higher risk either way, and we don’t charge more for restoring. So I actually think it’s a good thing to get into, but I would do it well and devote your time on it. And what I wanted to ask Joe really was, do you have referrals from restoring dentists?

[Joe]
Yes, but in my experience of 20, now 24, 25 years of staying in the same center is the number of dentists who restore my implants has significantly gone down. So-

[Neel]
Why do you think that is?

[Joe]
I think the initial influx of dentists restoring and somebody else placing in a different center, I’m talking about a different center, I suppose there has to be a distinction as well on is it being done by visiting surgeon and restoring in the same center.

Are you talking about two separate centers? So let’s start with two separate centers first. I am placing it in my specialty center and they’re restoring it in general practice is the dentist kind of feels now that the initial drive came from implant companies, implant companies wanted, oh, we’ll get all these dentists to refer to you.

So, and we’ll teach them how to restore in their practice. It’s literally like, I think there’s a rule. Not that I know much about NHS dentistry, but you cannot have two lots of treatment, or it can be an NHS and a private treatment on the same tooth.

[Jaz]
And the mixing component.

[Joe]
Exactly. So if you’re treating the same missing tooth rather with an implant, and then one person is doing the surgery, one person, where does the responsibility lie? Hence the discussion, this whole discussion is all about that. So as time has gone on where people have not had a distinction of where the responsibility lies, my referring dentists are more and more opting to not restore. Okay. Is it right? I’m looking after their general dental health. Please feel free to place and restore and when it’s done, let me know the number of restoring dentists in our practice out of 370 referring practices, not practitioners who refer to us.

The percentage has fallen substantially. I would, if I were to give you a number today, I would say less than one percent of the implants I placed are restored outside of my practice. To give you a comparison, as recently as, well not recently, as, as 10 years ago, that number would have been closer to 10 percent. 10 percent down to one percent in 10 years.

[Neel]
And do you think that’s a good thing, Joe? Do you think that’s a good thing? Do you think it’s safer?

[Joe]
I personally think it’s a good thing for one person and one person alone, which is the patient. Because I think at the end of the day, he’s the one who’s putting his hand in his pocket and paying us for our services.

As I say in most of my lectures, when a patient can place their hand in their pocket and give us three grand or four grand for an implant, they can put the same hand in the same pocket and give a grand to a solicitor. So if they can afford me, I promise you they can afford any solicitor. And therefore I always look at any case as a litigious case just to make sure that I can provide the right level of care.

[Jaz]
Chaps, for the summary of this question one then, really it’s all to do with the initial consent and the initial discussions that you have and that’s what’s good communication.

[Joe]
Communication key.

[Jaz]
Now let’s say the communication was, obviously it would have to be not good enough to get to a stage where someone is dissatisfied. And so now we have a scenario where the patient is dissatisfied, not just saddened and dissatisfied. They want their money back, something they’re like, this is ridiculous, I’ve only had it six months, and now you’re telling me that this, I spent so much time and surgery on this tooth, it now needs to come out because there’s been this gum disease around the implant.

There’s a question too, as Neel wrote, is, where does the responsibility lie in such kind of an implant failure, i. e. is it with the implantologist in quotation marks who placed the implant or the restoring dentist? How do you tackle this?

[Joe]
From my perspective, it is very, very straightforward. So that before we even communicate with the patient, there should have been absolute perfect communication between the surgeon and the restoring dentist. So before even a first patient is ever seen, we got to establish the responsibility protocol. Who is doing what? And any case like this scenario that you just posted, I have no doubts in my mind that both are responsible.

Because there is no way an implant surgeon could say, I gave you a fully integrated implant, now it has failed. Surely it’s your responsibility. An unrestored, an unloaded implant, placed into either poor quality of bone, or even into bone which has no buccal shell, for example, it’ll still integrate.

But the tooth will only surface when you then start loading it. So as soon as you start loading it, that implant fails, not because the loading was poorly done, but the implant was poorly placed. So, the responsibility can lie straight from that corner of initial assessment, right up to the final fit, in a bruxer.

You know how is the occlusal platform of this tooth maintained? There is nothing other than shared responsibility that I would accept on a case like this. Because I think, just because the implant was integrated at the time of start of restoration, implies that the implant was well placed.

[Neel]
What would you do, Joe, if I rang you and said, Joe, the upper right six that I restored, the patient’s kicking off now. Can you help me here? Because obviously, I can’t place the implant, so. Even if you felt it was my responsibility, I’m relying on you. What would you do as my referring implantologist to help me out?

[Joe]
This is unfortunately when we stop working with our head and start working with our heart and we start feeling, and so we should, we are a caring profession. Why wouldn’t we work with our heart, you know? So we need to work with our heart because we want to convert the dissatisfied customer or patient to then being singing your praises. So taking them under your wing, say, you know what, I will give you my time for nothing. I’m very happy to replace that implant at no additional cost to you.

But of course, I’ll communicate that with the referring dentist to say that, you know what, as long as you are happy to then do the crown on top of that, so have I done mistakes? You bet, there are tons of mistakes that I’ve done over the years, but then I’ve been placing for so many years. I have looked at my own cases that I did 15, 18 years ago, I looked at the case thinking, Oh my God, Joe, Bhat what were you thinking?

Because at that time, the teaching protocols were different compared to what they are today. We were very, very small handful of people who were placing implants. When I placed my first implant 28 years ago, I think there were about 10 of us in the UK. We were placing implants. So it was a very small number. So, but the responsibility has to be joined, but I think that also kind of a failure needs to be used as a trigger for the two dentists to get their hands heads together to sit down and have an honest heart to heart chat to say you know what this shouldn’t have happened.

This implant shouldn’t have failed here are the protocols that I followed here the protocols that you followed what could we have done differently remember we do not comment on what went wrong. Whenever I do my teaching I always talk about what did we do right? And what will you do differently? It’s a more positive spin to a negative result and what we do differently, we could have done this, we could have done this and we learn from it.

If you have a failure and if you don’t learn from it, you might as well have not have bothered. So I think learning from, from your experience is so, so critical and have I placed in word commas, free implants for my patients over the years? You bet. You know.

[Jaz]
Because that’s been the right thing to do with that because you genuinely care for the patient. But here’s the interesting distinction playing devil’s advocate, right? The scenario we’ve pitched you is the dissatisfied patient because obviously something down in the communication didn’t go so right.

Imagine you do as you do now with the years of experience you have, you think you’ve nailed the communication. You’ve told the patient, look, you’re a shift worker and you’re a bruxist, although you don’t smoke, which is brilliant, but there is a real chance that this could fail here, right? And there aren’t any refunds here.

You’re paying for my time and expertise. And then when it does go wrong, the patient is perhaps unjust, unjustifiably, dissatisfied. They’re saddened, but they’re converting that saddening into dissatisfaction to try and reclaim some funds or just this is their way of coping with this scenario now. In that patient, would you then also be like, oh, come on in. Let’s see if we can sort you out. Or is that now a different scenario?

[Joe]
Let me understand this question better. So you’re saying what additional thing would I do just because he is dissatisfied to try and win him over or, what is the-

[Jaz]
I think the difference here is I love what you said that from the heart you’re going to do an implant, I have to restore a dentist, and that’s a great way to, to help someone, right? But, and thankfully our success rates are high, failures are low. And so when that failure happens, we learn from it and we help the patient out. But the whole thing is that you did your consent and your communication so well at the beginning, such that the patient should not have an expectation of a free implant.

And so you expand it and the patient should pay again, really in an ideal world. If it’s going to be like, lawyers and that kind of stuff, like, okay, you pay for my time, you pay for my time kind of thing. And so I guess what I’m trying to ask is, is the implant surgeon and the dentist justified to say that actually it’s failed?

We’re sorry, but it’s failed. But this is out of our control. If you’d like to have the procedure again, it will be a fee to remove the implant and it’ll be a fee to do a new one. Would you like to go ahead or not kind of thing. So someone who doesn’t want to get involved in that.

[Joe]
I think part of it, Jaz and Neel, also depends upon your loyalty to the center or the business where you’re working in. How much of goodwill do you want to create? Being in the same center for as long as I’ve been, of course, my whole ethos is to create goodwill. And if I’m a visiting surgeon to a center, would I have the same goodwill? I would do, I should do. But is it across the board that every visiting surgeon has, the keenness to develop goodwill within a center, perhaps not and that’s when it comes to roost, why do sometimes practices get visiting surgeons come and visit their center because they want to keep the money in the house.

Why is a visiting surgeon coming to visit you? Of course, to earn money, does he have loyalty to that one center when he’s going to say 15 different centers? Why would he? So the loyalty, in my opinion, with those kind of visiting surgeon, genuinely tends to lie with the practice owner while in the center.

Where the surgeon is see, embedded and concreted into the floor and the wallpaper of the fabric of the building. Then, so the answer is very simple. I would do that free implant because I want to maintain the goodwill within my center. I want it to go back, God forbid, if the good news spreads from one person to another person, bad news spreads from one person to 10 other people, you know?

So I want him to go back and say, you know what, Joe Bhat’s practice, yes, there was a problem with the implant, but he sorted it out for nothing, you know? I would rather take that gesture all day long. I’ve always, always learned very early in my life, you can’t win them all.

[Jaz]
That’s fantastic. I appreciate again, the human side and the care that you’re showing is fantastic. I think we can all learn from that and take a leap from that. Neel, what do you feel about the medical legal aspects that when something like this happens, do you think someone with a Joe’s experience and let’s say Neel, if you are the referring dentist, for example, you both experience your great practitioners, in my opinion, and therefore, are you happy just to crack on with it and manage the patient like this just in the textbook way?

And let’s make it right for the patient? Or do you think this needs to be done as well as informing the dentine ad by the way, this has happened, but we’re going to crack on with it. We’re going to look after the patient. Don’t worry. So is there any role and responsibility of any of the individuals to actually inform their indemnity insurance provider at any point? Is this something that surfaces?

Interjection:
Hey guys, it’s just Jaz interfering here. Hopefully you’re enjoying this episode so far. I just want to remind you that if you’re in a situation where you’re renewing your indemnity or your insurance. Do take a look at what Neel has to offer with PDI, that’s Professional Dental Indemnity.

Both me and Joe Bhat are clients of PDI, and I’ll be honest with you, the main reason I switched at the beginning was I need to save some money. I mean, indemnity was getting really expensive and I never even had a complaint. So when I discovered the thousands I was saving with insurance, it kind of appealed to me.

But I trust Neel a lot and he guided me through the whole process. Including when I jumped between different insurance products. And what Neil’s taught me is that there is a difference between every insurance product. And to be careful not to fall into a trap whereby your previous years may not be covered if you’re with the wrong type of cover.

Now, if none of this is making sense to you, please understand the difference between indemnity and insurance. And listen to episode GF019, that’s Group Function 019, where Dr. Neel Jeiswa will fully explore, he educates me on insurance versus indemnity. And as part of the episode, we encourage you to get a quote.

Get a quote using protrusive.co.uk/insurance. That’s protrusive.co.uk/insurance. And see how much money you could save by switching to an insurance product. And on top of that, you get a hundred pounds off. This is an affiliate link, which means it does support Protrusive. But you’re doing it in a way that it saves you thousands as well. And of course, Neel is always happy to help and guide you. He’s even on the Protrusive Guidance app. And you can totally just DM him. Let’s now rejoin the rest of this episode.

[Neel]
Good question. Yeah, I think that was my, you know, patient and in the kind of patients we have in our practice, we try and develop long term relationships with them. So you would hope that yes, it’s failed and this is what we’re going to do. And Joe’s going to come and help me and we have Joe is going to come and help me because he cares about the patient, but also he cares about our friendship and he’s not going to let me down. And also commercially for him. You want to get more referrals, and I’m not going to refer to him again if he drops me in it.

So, generally I would agree with Joe that we would do the right thing, we’d always want to do the right thing. If we’ve consented everything and done everything beautifully, should the patient pay? Probably? Maybe? But, you’re opening up a can of worms, because if it becomes litigious. The amount of stress you’ll go through, the amount of issues it will cause with your family life, with your practice, with all these things.

Some of us have very thick skin, I don’t. And I just want to get this sorted, let everyone move on and everyone be happy as quickly as possible. But when you’re starting to get involved with lawyers and you’re waiting for that letter or they’ll use a GDC as a weapon, and we’re going to start looking at everyone notes, and in this scenario we would be looking at the implant notes to say, was it placed buccally, lingually?

Was the emergence profile correct? Did they report on their CBCT? Did they get a medical history? There’s somewhere there could be a flaw that’s going to drop Joe in it. Or, same with me, they’re going to look at it and say, well, did you discuss whitening? Did you discuss ortho before this implant was placed?

Did you, well, you’ve been remiss, you’ve been remiss there. So, it’s not going to end up well for either of us, I don’t think. Even if we’ve done nothing wrong, there will be something in there that might be pervasive. So we want to look after our patients. I, we work in a small village where Joe works, it’s, it is London, but it’s a community, it’s rural, and with all those referring dentists, as you said, Joe, word gets out.

So you want to do the right thing. But yeah, if it became medical legal, there would be a dissection of the notes. And it would be me versus Joe on where the blame lied, or we would share the responsibility. And that’s really a matter for the indemnity to get together to figure out how they’re going to deal with it. But it’s not nice.

[Jaz]
You two, you wouldn’t need to necessarily approach, you’re very well capable of managing this patient. And there’s no need to bother in them and say, oh, by the way, this is happening because you guys are very happy to help this patient out.

[Neel]
I would, I would. One, there’s no complaint letter. There’s a dissatisfied patient and we’re managing it. And if I rang my indemnity company up, which is the same as yours and Joe’s, and I said, I’ve got this patient, this implant’s failed. We’re managing it really well. I think the patient’s on track. If anything happens, I’ll let you know. They’ll go great, they’ll log it, they’re not going to hold it against me.

They’re going to probably think, actually, Neel’s a decent chap, he’s being really honest with us, and he’s letting us know what’s going on, and we’ll log it. And if that does develop, there’s no issue of me not telling them, or, you’ve handled it the wrong way, or, why did you not do that and not do this. And not to say that they would do that.

But informing them, it just makes you look like a better proposition to be honest, you look honest because as we know Joe, we all have failures. So you’re just saying I am human, this has happened and we’re dealing with it and they’ll go brilliant. And it won’t come to rise at all if nothing happens.

And if it does happen, they’ll be like, Neel’s been really honest with us from the start. We can do everything we can to help him. So, you have to play it by ear. Now, if it’s a broken filling, I might not tell them, because we’re managing it. But implant has more consequences, medically, legally, and cost wise, and and two people involved.

[Jaz]
And also, I guess it depends on the tone of the patient as well. If they’re a newer patient, not a long term patient. If they’re particularly disgruntled, if it’s heading towards potentially a complaint, even though you feel you’ve done everything right, I guess it depends on the character of the patient as well, where you think this is likely to go.

[Neel]
Yeah, you know your patients, you know how they are, you know if you can communicate with them. I’ve had some horrible patients where I’ve told my indemnity. I’m not happy about this. We’re managing it, but I just want to tell you, I don’t feel good about it. And luckily nothing happened. So I think you’re absolutely right.

I’ve got patients for 10 years who are my neighbors. They’re not going to be different to working in central London, you’ve only seen them once and they’ve flown in from Azerbaijan. It’s a different rapport. So I think that’s why I like staying in one place and getting to know, it does make you safer when you know your patients.

[Jaz]
Great. So last question then is, I think you guys covered this already, like what should a dentist look for in the choice of an implant surgeon to work with? And I think you guys talked about it already, that relationship, that communication, that rapport with your placing dentists and having an understanding like Joe mentioned about each other’s protocols and helping each other out. Is there anything else, Joe, that you want to mention about that relationship between the referring dentists that may be restoring and the placing dentists that may be visiting?

[Joe]
I think it’s two separate In either way, in either case, I think communication or meeting the person per se and spending time with him, understanding his experience, what he does, can this implant surgeon guide me because I’m still new in the restoring world.

Is he there available for me to communicate with and chat to if there was a problem? And then God forbid if there’s a problem, is he there to help. I think as a referral practitioner, where 95% of the patients I see are referred to me by a dentist, 95% as high as that. So my client is not a patient.

My end product is a satisfied patient. My client is a dentist, so it’s quite different. I belong to a very small cohort of. or specialist whose clients surprisingly are dentists much more than they are. So my delivery is at this side. My input is from a different source, so the communication channels.

So when this patient implant fails, I would invariably write to the patient saying, we’re so sorry that you feel, that you’re unhappy about the implant failure, but we are here to help you. Nice kind words to that effect saying please do not worry. I appreciate that you’ll be giving us your time but we will make sure that there are no financial implications to this aspect of the surgery.

I would done that after having communicated with the restoring dentist to make sure that patient is being looked after, so what does one have to do? Is it essential to be a specialist compared to a non specialist? That’s the other thing that I get asked quite often. The answer is no, there are very, very, very skilled implant surgeons who are non specialists.

I don’t have a problem. I think, as long as they are in ‘well read’, well trained in the art of implant dentistry and are able to manage complications. I think it’s all well and good. I know implant surgeons who go place implants. But when the failure starts to happen, for some reason, the dentist is not calling on that implant surgeon.

They’re sending it to a specialist referral center. So in other words, they were there to take on the good bits. So nearly two days a month. Two days a month, Jaz, I am not an implantologist, if there’s a term like that. I am a more peculiar term. I’m an explantologist. Two days of the month, I’m explanting implants because we are, ‘the dumping ground’ for implants that have gone wrong.

So we are explanting faster than I can blink now because we are the center in the Northwest of London, which are taking on so many cases. The number of failing implants being sent to us is, let me rephrase that. The number of failed implants. I remember doing a lecture I think it was in Berlin many years ago with Andrea Mombelli, who’s Mombelli, Professor Mombelli has written the most amount of papers on, on peri implantitis, ever, researched, and he was sitting next to me and I said, oh, how are you handling your peri implantitis?

And how are you handling your failing implants? And his statement to me was, Joe, there is nothing called a failing implant. There’s no present continuous tense, either there’s a successful implant or a failed implant. So there’s only a past tense or a success, but there is no failing implants.

Because if once an implant starts to fail, it will only but progress. All you’re doing is reducing the progression of it. But handling, this is what I said earlier, you need to make sure that you are with the person. Who does not only know how to do things right, but also knows what to do when things go wrong.

That’s where the issue is. Is he able to handle? Because things will go wrong. It’s surgery, it’s a human body, it’s blood, it’s tissues, it’s bone grafting, it’s anatomical structure, the sinuses, nerves. There’s so many factors to take into, and so things will go wrong. Anybody who says otherwise is lying. Is he able to handle that?

If this visiting surgeon comes once a month, I just don’t get it when visiting surgeons come once a month. What happens to those patients for that whole month? If there’s a day’s sense of wound, if there is a graft that’s failing, if there’s an implant that is separating, if the, who is there to assess that patient?

Nobody. Or the implant surgeon, if at best, would say, okay, you can send him to my other clinic somewhere else on the other side of London, so that I can have a look at it for you. That is not quality of service. Not for a patient who’s paying an awful lot of money.

[Jaz]
That’s a really good point to watch out for in that relationship when you’re picking an implant dentist. Now, one reflection is something that I learned from listening to Frank Spear. So Neel, I know you’ll be able to resonate as well, is that when something goes wrong, you just want to literally just want to go in there and fix it. That’s your number one aim. It’s really like a typical bloke. You just fix it.

Okay. What’s the problem? When my wife tells me a problem, I don’t want to listen. Which that’s what she wants me to do. I want to go in and fix it. And I think that serves us well in dentistry. You should go in and fix things. And that was very clear from our conversation.

So that’s good. But talking of failure, I think it’d be, and I’m really happy with how this episode’s gone, I think we covered some great points, but those two bits in the history, I think now we can go a little bit more clinical for the next five minutes, is let’s talk about, Joe, your opinion and experiences in bruxist patients and how they do to your implants, long term, and also the impact of obstructive steep apnea on such patients. Any insights you can provide us on those?

[Joe]
My philosophy with Bruxism is, historically, the failure of implants in bruxists used to be much higher. Not necessarily from loss of integration, but mainly because of fracture of components. Abortments you would fracture, screws would fracture, sometimes implants would fracture.

Those days are now behind us, because the components are made stronger, the connections are better, the screws are taking much more tensile forces on it. So, Things are getting stronger. So the number of incidents of fractures compared to even 20 years ago, 15 years ago, has reduced dramatically. I tend to do two very, very fundamental, basic things.

One, keep the cuspal inclines as shallow as I can. Two, I reduce the occlusal table to narrower than what natural, the natural teeth are, and three, a bite guard of sorts. Okay. Those are the incidents of implant failures in bruxist. Pretty much these days should be or needs to be close to zero or should be equitable to what a non bruxist patient would be.

Because there is so much data on it that we have so many clever things one can do to make sure that it is not even a factor. With regards to other factors, the sugar contents of your blood, the sleep apnea aspects of it, all those are factors that have a very, very small, but sometimes significant, but very small impact on implant health.

I think the generic health problems of proper full fledged diabetes, full fledged, immunosuppression, full fledged bisphosphonates. So my analogy for any of those patients is anything that is uncontrolled is a no no. Walk away, or at least make sure that you treat. In other words, do I treat patients who are diabetic?

Yes, I do. Hypertensive? Yes, I do. I do all, but none of them which have a prefix called uncontrolled. If it’s uncontrolled diabetic, I don’t treat. Uncontrolled hypertensive, I don’t treat. Uncontrolled psychosis, I don’t treat. Because they’re patients who come with mental health issues. Uncontrolled, so anything that has the prefix uncontrolled-

[Jaz]
Even the Bruxism, if you leave it uncontrolled in a way, you are shaping it with the bite guard. You’re shaping it with the restorative design to get some degree of control over it. You can’t stop the behavior, which is bruxism is a behavior, but you are influencing how it’s perceived by the implant.

[Joe]
So the word uncontrolled is critical. So if a patient comes in, look at the medical history, this is diabetic. Mrs. Smith, how well controlled is your diabetes? Oh, it’s really well controlled. When was the last time you had your blood sugar checked? Because these are all standard questions that we should be doing. We don’t need to be super clever and start micro dissecting medical conditions. Fundamental stories is plenty. And your success rate will shoot off the scale because you’ve asked some really basic questions.

[Jaz]
Fantastic. I’m very, very happy with that. A nice little concise summary. I’m very happy with that. Neel, anything you want to add to our discussion that we’ve had about the dissatisfied patient? I think we covered a lot of the communication stuff, which I think it’s the crux of all of our episodes that we do in the medical legal series, Neel, isn’t it really?

But we had this little blame game thing, but I just love the direction it went in. And I think it speaks volumes about, Joe as someone who places implants for the referring dentist and how that really works. relationship. If you take anything away is to work with someone with that kind of relationship, kind of like what Joe has with his dentist.

That’s a beautiful thing to have and someone who can rescue you because when the failure happens, it’s really nice to have confidence in the implant surgeon that A, there’ll be present and B, there’ll be on your side when that happens, basically any additions to that, Neel?

[Neel]
I think generally, as we all covered it’s communication. It’s the relationship with you and the surgeon and the patients. If you are trying to find a peripatetic surgeon, Or if someone else is placing implants for you, ask them to have a look at their notes. Just do what we would do from an indemnity point of view. Are they writing ISQs? Have they taken PAs, grade A’s as they now called, you know.

What are the notes like? Are they recording everything? I’ve seen lots of notes, CBC taken, no justification, no report. And you just start thinking-

[Jaz]
I didn’t even think about that. That’s a really good, about saying I forgot who it was, but how you do anything is how you do everything. So when you see that their notes are really good, then maybe that’s a surgeon is going to be really good and precise and stuff as well.

So how detailed are they going? Who knows? But this is something, if you’re working with someone and you know, when the proverbial hits the fan and P and people’s notes are being looked at, you want to see that, okay, that my dentist was like a partnership that their notes also carrying the weight that are worthy of.

[Neel]
I mean, and then that’s what it will come down to and it may not be you that gets dropped in it because their notes might be bad. But it’s a team and you don’t want to you want to work together for a better outcome. Joe, would you be offended if I asked you to just do you mind sending me the patient’s notes?

If I asked oh just you placed enough for right six for me, do you mind if you just send me the notes so I can have a look?

[Joe]
I do it, no, I do it all the time.

[Neel]
There you go.

[Joe]
I do it all the time. Nothing to hide. There should be nothing to hide. I think even when you’re picking a visiting surgeon to come in and help you through your surgeries, please do some research on that person to find out what kind of portfolio of cases does he handle?

Does he handle the whole spectrum, including all on four? What kind of experience has he come in? Who has he done work for before? Let him give you the 10 names that he’s been to. You’re bound to know one of those 10 people. Don’t be embarrassed to ask questions like oh is there a clinic that you worked in where you have left and not don’t work there anymore?

You said yes oh, yes. I have two clinics, but I don’t go anymore. Why did you leave those clinics? We want to know what broke down for you to go to a clinic, two years later after having placed 30 implants you have walked away what made that this is crucial. Because the patient will only ever come back to your practice to ask you for your problem for their problem to be solved. But the surgeon if he’s not there, so you’ve got to do some research You’ve got to be able to speak to some of the other clinics that he goes to to say can you please if you don’t mind?

He’s trying to come to my practice as well. Can you please tell me a bit about him? How is he with his patients? Why do you want him to come and place your first implant without even asking? I see this routinely. People don’t even ask other dental practices, so how is he with your patients? No, they’ve got him in on board because somebody may have mentioned a passing name and they want to keep the work in house. That is the only criteria.

[Neel]
Very good. Due diligence.

[Jaz]
Due diligence, be selective and, really know the person who’s placing implants. Joe, I’m so, so privileged to meet you today and just hear what you have to say. Your sayings, your verbatage, you’re already from this conversation. If I ever need an implant, I know where I’m going. But tell us, where can we learn from you, my friend?

[Joe]
Oh, you know what? In all the years that I have been doing implant dentistry, my door out here, is an open door. It’s anybody and everybody is welcome to spend time with me. I have never in my life charged for anybody to come and look over my shoulder, ever.

All they do is, Joe, they say specific, Oh, I’m just starting off my implant journey. Can I come and see some simple ones? Or I’ve been my implant journey for many years. I want to take it to the next level. Can I come and look over your shoulders, see you doing a sinus graft or, or, you know, or anything a bit more complex.

I do run a foundation level modular course at our practice, it’s run over five modules. Four of the modules are run in Moore Park Center here. We are a 10 sergeant practice with a training center upstairs. And one module is normally run abroad. For the last couple of years, I’ve been running it in Sarajevo, in Bosnia, because we have a massive international strawman and neodent training center there. In the university, the main government university hospital. So that’s where we normally run it out of, and we run it normally.

[Jaz]
Any website we can check. I mean, I’m going to, I’ll put everything in the show notes anyway. So you have to tell me now, but if you know it by heart, I know lots of people are looking for great implant mentors and you’re in that category. So if you know the website, I’m happy to just direct everyone.

[Joe]
Sure, sure, sure. www.moparkdental. com is the best place to reach me at. And then I have a modular course brochure, which I’m very happy to share. I take a very, very small cohort of people, because I think anything more than six or even eight is a crowd. When people run modular courses with 14, 15 people, I generally believe quality of education is not as intensive. But if anybody wants to learn anything, I’m here to help.

[Jaz]
Certainly. And I’m always there to shine a light on great educators and people who are any profession got so much experience. So that’s my role to get these people pick your brains. And so we certainly have done that today. Joe, so much for your time. I really appreciate it. I’ll put all those links in the show notes and Neel had to go because his battery died, but Neel guys represents PDI Professional Dental Indemnity.

If you need to contact Neel, check him on the protrusive guidance app. He’s there. You can DM him, but also it’s a [email protected]. But again, we’ll put all that in the show notes. Joe, thanks so much for your time.

[Joe]
Pleasure is all mine. Thank you Jaz for the invite.

[Jaz]
Well there we have it guys. Aren’t you so impressed by Dr. Joe Bhat? Super knowledgeable man full of wisdom. Now if you want a certificate to prove that you’ve gained from this wisdom today, this episode is fully verified one hour of CPD. You just have to answer a few questions on the Protrusive Guidance app. And our CPD Queen Mari will send you a certificate.

She will send it to you the Wednesday following once you’ve answered the quiz. And then also quarterly she’ll send you a summary of all the CPD you’ve gained through Protrusive. And that includes the masterclasses like Vertiprep for Plonkers and Sectioning School, all the good webinar replays and topics that we’ve covered before.

Do check out www. protrusive. app if you love the podcast. And if you want to now formalize the learning that you’re doing. I want to thank Neel and Joe once again. I put the links in the show notes. So check out these courses from Joe Bhat and also the indemnity PDI with Dr. Neel Jeiswal. That’s protrusive.co.uk/insurance. Thanks for listening again. I’ll catch you same time, same place next week. Bye for now.

Let’s face it – CQC inspections can be scary stuff for principals and managers (and even associates!)

As per your request, I brought on a CQC Specialist Advisor, Dr Chita Davda to share her top tips to passing with flying colours.

We discussed the common things that CQC checks on a practice, common questions they ask, and some tips on how to pass the examination. The emphasis is on understanding that the CQC and dental professionals share the same core ethics. Inspections aren’t about catching each other out but ensuring the best possible care for patients.

Need to Read it? Check out the Full Episode Transcript below!

If you want to learn more about Dr Chita, you can check out her website https://www.trainwithchita.co.uk

In the upcoming CPD event at The Shard, attendees will get a rare opportunity to hear from a lead inspector from the CQC. This provides a chance to debunk myths and understand common errors, offering clarity to dental professionals.

If you want to be a part of this event, head over to https://protrusive.co.uk/shard

If you enjoyed this episode, you will also like Indemnity vs Insurance 2023 – Which one is best for you? – GF019

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

[Ruchita]
Yeah, so we try and keep it as fair as possible. And obviously we’ll ask permission of the dentist just to make sure they’re okay for us to go through it.

[Jaz]
And if they say no, is that a cheat code?

[Ruchita]
If they say no, then we feel like you want something to hide. Try not to say no. I’ve had it queried a couple of times, but also we have like a warrant when we go into a practice. So in theory, we are able to access what we need to. But I’d also, as a fellow dentist, I like to just keep that respect for everyone.

So even if I have to look at the drawers inside a dent, like a surgery, I’ll always just be like, do you mind if I have a look? If there’s anything you don’t want me to see, maybe just get rid of it for a few minutes and then put it back in if that’s okay.

Jaz’s Introduction
Hello, Protruserati. I’m Jaz Gulati and welcome to a group function. We haven’t done one of these episodes in a long while. A GF episode is basically when we take a question from the Protruserati. And you know what? I’ve always kind of shied away from compliance, right? Compliance type things don’t excite me so much, but it’s important to cover because that’s what allows us to practice our dentistry safely.

And that’s exactly what today is about. So there’s something in the UK called the Care Quality Commission or the CQC, and every dental practice needs to have some sort of inspection at some point from the CQC to make sure that everything is safe and well for that practice to deliver patient care.

So I brought on today Dr. Ruchita Davda to talk us about what are the common pitfalls we make when it comes to these CQC inspections and how to make sure we pass with flying colors. There are no premium notes for this episode, but at the end you can get CPD for this by answering a few questions on the app. Otherwise, those of you listening, please enjoy those of you watching.

It’s not a super visual episode, but there’s so many important nuggets. If you are a UK practitioner and you have a practice, or you’re thinking about buying a practice one day, it gives you great insights into what the CQC actually does and how to make sure you are prepared for that eventuality. Please enjoy the episode and I’ll catch you in the outro.

Main Episode:
Chita Davida, welcome to the Protrusive Dental Podcast. How are you?

[Ruchita]
I am good. Thank you. And how are you, Jaz?

[Jaz]
You know what? I’ve had the sniffles. I’ve been trying to shake it off for the longest time. And I emailed everyone about it, the list and stuff. It’s something in the air. Something’s going around.

[Ruchita]
Yeah. A good little tip, which I don’t know if it’s fine to share. But if you keep drinking lots of water, then make sure you’re having vitamin D for like your immune system. So you don’t slack on that, basically.

[Jaz]
I’m definitely taking my vitamin D. And also after, there’s an episode I did with Prav Solanki a while ago. And he got me into making sure that I do the three of a blood testing every three months, which I think you’re quite into as well. These kind of like it checking your body. Cause obviously when I get you into yourself, you’re so much more than a dentist. Like your whole facets about health and stuff. So let’s start with that Chita. Tell us about you, yourself.

[Ruchita]
Cool. So I’m a general dentist qualified around 12 years ago. And then three years ago, it’s actually just before COVID I wanted to kind of get into health and I kind of had a bit of a transformation where I lost a little bit of weight, but I found.

That my journey was probably longer than it could have been by working with like different personal trainers, online coaches, and I was like surely it must be easier than this, like surely I don’t just have to eat broccoli every day to lose weight and work out loads in the gym. So I did like a personal training course, I’ve worked with various mentors, and I’m also like an online coach.

So I basically mainly help women lose weight, feel like the best version of themselves, so super confident, but whilst focusing on health. So we look at like blood test analysis, and woman analysis, it just works really well. And I actually work with a lot of dentists, so it’s quite nice because I know how stressful our lifestyle can be, how sedentary it can be as well.

But I’ve always got little tips and tricks up my sleeve to help. And then also three years ago, I started working with CQC as a specialist dental advisor, which I’m really excited to kind of talk about on the podcast today.

[Jaz]
So what is that? I mean, that’s we’ll invite you back when they talk about health and stuff. I’m always into that, so that’s exciting already. But something that I want to reserve the audience is for those my listeners and watchers outside the UK, I’m so sorry. kind of skip the next episode before episode, maybe jump back 100 few episodes ago. This is more for the UK group, basically, because CQC is a UK thing.

So our mission statement, Chita, by the end of this episode is kind of like a CQC for dummies. It’s kind of like, explain CQC to me, like, I’m 12 years old, like I’m having my first inspection, like, that’s kind of like the angle we want to go, right? So what capacity do you work with in CQC? Like, what is your role?

And how and to what capacity can you help us? Like, can you spill all the beans? What are you allowed and not allowed to do?

[Ruchita]
I can spill a lot of beans, but like within reason. So I don’t know if you remember, maybe I’m showing my age, but a really, really long time ago. So when CQC first started, they used to basically have like general people coming out to inspect dental practices.

So they may have been like policemen, teachers, and they didn’t really understand what a dental practice was. So they may be like, show me a rubber dam kit for an extraction. You’d be like, well, you don’t use one for that. And that’s when they realized, actually, we need to have dentists or like therapists, hygienists, dental nurses on board.

So what happens in a CQC inspection is you have your lead inspector. So they’re like the main person. They write the report. And then they get to invite like a dentist or a therapist or a hygienist or a dental nurse, which is someone like me. And then we kind of make it realistic. So, working in practice, we know that everything cannot be perfect, but the purpose of a CQC inspection is just to make sure that patients are being looked after and that everyone is safe and we’re just following the correct guidelines.

So as a dentist, I’m going to be honest, before I worked with CQC, there were some things that I probably thought, why are they asking this? Or it’s a bit stupid, or it’s a little bit, like, why do they need to know? And then actually, since having my role with them, I’ve learned that the way I do dentistry isn’t how, like, everyone else would do dentistry.

So that, unfortunately, there are some people who don’t follow guidelines, who won’t follow DECON and things like that. And then that’s why CQC have had to kind of had a big role. So it’s just making sure, like, everyone just following the right things. We’re never there to catch anyone out. We’re actually there to help dentists as well and it’s more just patient safety. So and sometimes we can get whistleblowers and it’s actually just knowing that could be a disgruntled staff member. It may not actually be that the practice is unsafe or dirty. But we’re just kind of doing the checks before someone takes it further to like the media or something like that and we can say actually we’ve checked it. We’re happy with it. So yeah hopefully that means.

[Jaz]
The way I see CQC, like any regulator for any profession, forget dentistry, right? You will always like, have that bitterness towards your regulator. You’ll always be like, oh no, it’s them again. Like I just want to continue on my life. But the way I see it, the way I see CQC, and please correct me if my analogy is wrong here, is when you go to a restaurant or any takeaway, they’ve got that food safety like one to five, right?

And like, you will still eat out of four. People, okay, I’ll see it at a four, three I might snub at, okay, even me, okay, three I might snub at, but like they’re there for a reason to make sure that things are safe for the consumer. Is that a good analogy, good comparison to what the CQC you think does?

[Ruchita]
Not far off. I guess we can’t rate it with CQC. So it’s either you’ve been fine in an inspection or you may have to do a little bit of work or you’ve not been fine. So for us, it’s really hard to actually rate a practice because CQC can only actually inspect around 10 percent of practices a year. So say, for example, if you were a patient and you’re comparing to a practice that has never been inspected, it’s not fair because you’re not kind of comparing like to like.

So if someone was graded like a 5 out of 5 and someone else didn’t have a grade, it’s just because they’ve not had an inspection. And because we can only inspect so many in a year, that’s why we don’t grade it on that system. So it’s more just, if you’ve had one, you’ve had one, you get a report written about how the practice is.

If you haven’t had one, you’re probably going to get one. So just keep up with everything because-

[Jaz]
And listen to this all the way through because there’ll be some gems in here, right? So let’s cover it. So how often is a practice supposed to be CQC inspected? And also answer that in the realms of let’s pretend I’ve literally started a squat practice yesterday, right?

So when can I expect my first one? Or if you’re an established practice, what’s the cycle?

[Ruchita]
So with, if you’re like a squat practice, in order to have like been able to be allowed to open up, you would have had to register with CQC, so they would have done like a primary analysis, like a phone call with you just to make sure that you’re fit to run a practice, let’s just say.

But there is a big backlog because a lot of squat practices are opening up at the moment and obviously we know that can be aligned with like how the NHS is going. And then if you’re just like a normal general practice, been open for years. It’s actually, they have a list so they just try and get through every practice as much as possible.

It’s kind of a bit like luck of the draw a little bit. So if someone’s like had concerns and patients are whistleblowing, they’re going to be like being inspected. But you’ll be told on the day of the inspection that that’s why you’re having your inspection. CQC are actually really open. We never hide anything from anyone because we were actually on the dentist side because we want you guys to do well because then patients are happy.

And then everyone loves dentists and then we’re media free, if that makes sense. So it can feel like luck of the draw. Some people may say, well, I had one five years ago. I had one seven years ago. Someone may say I’ve not had one. And it doesn’t mean if someone’s had one two in ten years that they’re riskier.

It’s just to do with algorithms a little bit. In fact, so it’s really hard to-

[Jaz]
So there’s no minimum requirement that every three years, every six years you should have one. There’s no minimum requirement, right?

[Ruchita]
No, no, but they are trying to change things. So what they’re hoping to do is maybe annually, you may have to release a bit of an annual statement. So a bit like how we have to like infection control and stuff like that. But that’s all the things that they are going to be announcing. And they’ll always tell dentists like, you always get those emails from CQC. So you’ll always kind of be aware if they’re changing things and it may not be necessarily an inspection where we come out. But you may just have a phone call or like a team’s meeting or you may just get asked to submit data a bit Like how GDC asked for R. C. P. D. and stuff like that. So, that’s the realm.

[Jaz]
Once a practice get informed that they’re having an inspection, it’s like a stressful time. It’s like you’re preparing for an exam, right? It’s like everything that you do, your livelihood, your work is going to be examined and you know that there’s a benefit of the examination. You know it should happen, but it’s still, still stressful. So how much notice is typically given to a practice?

[Ruchita]
So typically, on average, you do get around a two week notice period. But what’s really great, actually, with CQC is they’ll also have a call with, like, the registered manager of the practice. So they’ll actually go through what kind of things we’re going to be looking at on the day, because we never want anyone to be surprised.

But what we actually tend to find is the list can sometimes feel a bit overwhelming if someone’s not kept up with everything. So it’s all things that we know we should be doing, in all honesty. But sometimes, seeing patients, running a practice, managing patients, it can feel a bit too much, so I guess it’s just our reminder just to say, if we keep up with this, it kind of makes life a little bit easier.

So once you’ve had an inspection with us, it’s kind of having an action plan and just saying to the team, look, every few months, let’s just keep up with everything. And the way we kind of say leave an inspection is if we were to turn up unannounced, just have your practice ready to that level because you never know, it could happen and have things.

[Jaz]
You’re suggesting that an unannounced visit could happen?

[Ruchita]
Yeah, if something’s been quite massive, so if there’s been like a massive patient issue and they’ve informed CQC and we kind of deem it to be very, very unsafe that that practice may not be, shouldn’t really be seeing patients, we can sometimes turn up on the day. And it’s just literally for patient safety reasons.

[Jaz]
So it is a bit like an exam then, because if you’ve been doing your revision every day, bringing your homework every day, you got your highlighters, everything, all that, and then you’re going to be fine. Right? Cause that last minute revision is not going to really help. Whereas if you’re like me, if you’re a crammer, then yeah, you’re going to have a stressful few weeks.

It’s one of the reasons that I don’t own a practice and having said that actually as an associate, right? We still have a responsibility to our practice to make sure they’re looked after. We want them to pass with flying colors, obviously, right? What if some people nowadays, I’ve spoken to you about this before is they are renting a surgery within a practice.

Does that individual who’s renting, him or her, do they need to he or she, do they need to register as a separate entity with the CQC or are they sort of working in the license or the CQC of that practice?

[Ruchita]
So that one, I’ll be honest, I may not give the best answer to, so it could be worth maybe speaking to a lead inspector about that. Because it’s all kind of to do with what registration the practice provider has. So it can really vary from practice to practice on that side. But I guess as a clinician and when we’re like really passionate about what we do, we’ll follow all the right things, I’d like to hope anyway. So we’re going to make sure that the drawers are clean or our record keeping is going well.

And as a dental specialist advisor, I actually just look at the clinical side of things. And then it’s the lead inspector who looks at everything else around it. So I’m the person who would speak to the dentist, speak to the hygienist, actually have a look at records, make sure we’re following FGDP guidelines.

Seeing if audits are happening, are they relevant or are we just like, ticking we’re doing it and it’s the same audit that we see like four or five years in a row and we’re not doing any action plans from it. Is decon being carried out? So again, it’s one thing to say it’s being done well, but then it’s another thing if we see instruments and they’ve got GIC and stuff all over them and they’re in the cupboards.

So I’d like to hope it’s a bit like just having a fresh pair of eyes, because when we work in our own clinic every single day, there’ll be things that we may not think about, there could be a TV hanging off the wall and you just think that’s normal nowadays. And then someone fresh comes in and is like, oh, that could be like a bit of a trip hazard for someone or so it’s more I know, like dentists do get really, really worked up.

But I think one thing I like to hope is when I go to an inspection, I’ll always try and just reassure everyone. And just to say, even if something’s not right, we’re not gonna publicize it. We’re not gonna like say bad things, we’re actually just going to help you have an action plan, give you like a time frame to sort it by.

Any feedback, we’re always welcome for it. And then we just want you guys to be compliant. That’s all we want. No one wants anyone to fail or to breach or anything like that.

[Jaz]
So we’ve also just described all the things that you guys check for. So next question is. What are the common pitfalls? What kind of things? So what we can learn from is obviously, mistakes is a harsh word, but things that we can improve on. So having done so many inspections and whatnot, what are the top tips that you can pass on to the Protruserati hack here? Okay, actually a lot of practices are weak here. Focus on this to make sure that you don’t fall into the same trap these other practices have done?

[Ruchita]
So it’s a really good question, because I actually find most practices do have the same common pitfalls. So one of them, which is the most common one I see, is that CPD has never been done. And literally, the day we announced the inspection, we typically see that two weeks, the dentist, the associates, the team, are literally doing CPD, like nonstop. So that could be-

[Jaz]
But to me that’s shocking. For those who are like listening on Spotify. They didn’t see my reaction. My jaw, my eyes like went, popped out because I’m such a CPD junkie. I can’t imagine that. But you know what? I know what you mean actually. And sometimes it’s those course that coming onto it, IRMER.

[Ruchita]
Yeah.

[Jaz]
Disability awareness, all those core subjects. Mouth cancer. These are the ones that you often miss out, I think.

[Ruchita]
Yeah. And I think as well that there can be a lot of confusion out there of what we’re supposed to be doing, like the GDC guidelines and things like that, so, and I obviously appreciate it takes time to do CPD and things like that as well, but that’s like a typical one that I tend to see, and in fairness, on the day of inspection, the CPD has been done, so we’re never going to flag anyone up for it, like, it’s been ticked off, but I just know as a general dentist, the stress that would put someone through for like that two week period of trying to do like 50 hours or whatever you need to do of CPD.

So that’s like one thing that I would always just really love to encourage all the dentists, just keep up with it on a regular cycle if you can. And just pick topics that you are interested in, but also just covering, like, the main ones, because as you mentioned, like, there are some that people won’t know are now, like, mandatory, essentially, so, like, the disability and autism awareness, and so, again, a lot of practice will go to, because they can be quite isolated, they may not know about a lot of these things, so, yeah, so that tends to be one of the main ones, and audits tends to also be a little bit of a tricky one.

And again, I know they’re like not the most interesting things, but if you’re doing x rays and they’re not to a good standard and it keeps happening, again, it has an impact on the patient. So we just want to make sure that things are being completed on a regular basis. But they tend to be like the main ones and also just keeping sure like your recruitment records are in check. So that all the staff have got their DBS completed, their hep B titre levels. Not just that they’ve had the hep B, we actually want to know the titre levels, so again, safety for patients, and it’s just kind of just being organised, I’m going to be honest, is what we look out for as well.

[Jaz]
So the role here of the practice manager is instrumental, having a really organised, intelligent practice manager who’s been doing their due diligence is super important.

[Ruchita]
Yeah. And also I think having a really lovely team where like the dentists also want to get involved. Because a lot of the time I can appreciate there can be a bit of a kickback from dentists because they just want to really treat patients, they want to do really, really good quality work.

And if you’ve got someone kind of nagging you for like an infection control certificate, you’ll just be like, oh, I’ll do it later, I’ll do it later. So I tend to find when it’s like a nice team ethos and everyone understands the reason behind it. You could just see those inspections just flow really nicely, and it makes my day a lot nicer as well, I’ll be honest.

But out of interest, Jaz, have you had an inspection, like, at all when, in the last five years or so?

[Jaz]
I think so. In the last five years I’ve been across a few practices, and this one currently I’m coming into my fourth year. I’ve had a Denplan inspection, I don’t think I’ve had a CQC. So I’ve kind of escaped it. And I think at one practice where we had one, I was on holiday. It was like perfect time.

[Ruchita]
Convenient. It is always so many dentists seem to have annual leave on the day that we visit. Because it’d actually be quite interesting hearing it from like your point of view of like, if a practice that you were working at, say, for example, the practice manager goes, look, we’ve got an inspection in two weeks.

What would be like your dread or your worry? Or like, what would be your thoughts to be that? Oh, my God. What’s gonna happen?

[Jaz]
I guess as an associate, you think that, okay, all the biggest stuff is on the shoulders of the principal on the practice manager, compliance, that kind of stuff. So yeah, CPD is one to make sure all those important topics are ticked off.

And the other one would be. And then one of the question was to ask you is record keeping, make sure that you know, my record keeping is good enough to show to the people inspecting. And so my question to you, Chita is, do you go through the notes? Is there a sort of a protocol you follow to go through every associate, every dentist notes? How does that work?

[Ruchita]
Yeah. So we try and keep it as fair as possible. And so obviously we’ll ask permission of the dentist just to make sure they’re okay for us to go through it.

[Jaz]
And if they say no? Is that a cheat code?

[Ruchita]
They know, then we feel like you want something to hide. Don’t try not to say no. I’ve had it queried a couple of times, but also we have like a warrant when we go into a practice. So in theory, we are able to access what we need to. But I’d also as a fellow dentist, I like to just keep that respect for everyone. So even if I have to look at the drawers inside a dent, like a surgery, I’d always just be like, do you mind if I have a look if there’s anything you don’t want me to see, maybe just get rid of it for a few minutes and then put it back in if that’s okay.

So for records, we are just looking at, we’re following the FGDP guidelines. So, I guess it’s one of them, right? To me, it seems quite obvious, but just that we’re taking off medical history form. We’re getting consent from patients and we’re actually looking at x rays and we’re analysing them.

We’re diagnosing possibly going through a treatment plan, printed if needed. And, yeah, just kind of the, I like to think obvious things, but I know, again, it depends on the generation of dentists because the older generation, like, are still quite used to maybe saying exam done, S&P done, and that’s what we’re not looking for, I’m going to be honest.

[Jaz]
Yeah, well said. And so my final question then is, because you’ve mentioned what are the things that you check for your role within that capacity, the common mistakes that people are making that we can easily fix up on. What are your top tips to pass with flying colours?

[Ruchita]
So, first of all, I’d actually just say have a really supportive team, because if a team looks a little bit sticky on the day we’re going to think there’s alarm bells, in all honesty. So if everyone flows well, everyone’s getting on. So I’m not saying you put it on just for us, but that helps us see, like, are patients really the priority of this practice? Because at the end of the day, that’s all we’re really concerned about.

And then when you have your call with the lead inspector, which they’ll do, like, a week before, a few days before your inspection, just make sure you’ve gone through that checklist. So that’s where we’ll kind of say what we’re going to be looking for on the day. And also just to collaborate with us, so remember we’re not there to catch you out, to freak you out.

If we’re asking for something, just chat to us. If you haven’t got it, just be really, really honest. And then, as I said, as long as we kind of have an action plan to get it sorted, then you’re gonna be fine. So, just making sure, like, medical emergency drugs, like, they’re checked, they’re updated regularly.

That decon is being done well. The drawers and things are looking clean. All of your staff members at work with you. They’re safe. You’ve got all their records and things like that. And just be as friendly to us as we are to you guys. I kind of like to hope as well.

And I know everyone’s always nervous. So we always do try and relax everyone as best as we can. And just to see it as a learning experience more than anything else, not to see it as like with a to get you, I know it’s a regulatory body. I know it’s really scary but well just, just be honest.

[Jaz]
Well, when you mentioned about the medical emergency drugs, the practice I work at, they’ve got, that should do a really good job. And, the kit that we have for medical emergencies is so nicely labeled. Every single thing is just asthma attack, allergic reaction, it’s all really nicely labeled.

It just shows the level of care and detail that’s gone into it. And on a higher level, I’ve been listening to a book recently, literally on the way into today. I was listening to a book called Surrounded by Idiots. Have you heard it?

[Ruchita]
Oh yeah, I’m reading that right now. I’m literally reading that right now.

[Jaz]
I’m on like chapter eight or something. I don’t know, audio version. Cause I listened to like this one. I’m listening to at 1.7 speed because I want to digest it a bit more. And so to explain to everyone who’s watching, listening at the moment, it’s like the whole disc thing, right? About your personality type.

So if you’re red, you’re like really results orientated, like wham, bam, thank you, ma’am. Let’s go. Whereas if you’re blue, you’re very analytical, you’re slow, you’re slow with a purpose to make sure everything’s quality. So I feel like when, if you’re starting a squat, practicing, looking at hiring. I want my manager to be a blue red combination and have a strong blue so they go everything through a fine tooth comb and be very meticulous, but also red so that they can get the results and actually be very forward in their communication as well. What do you think about that?

[Ruchita]
Yeah, I completely agree. So a lot of the time we can employ a member of our team just on their role. But actually, I really feel about knowing someone’s personality, knowing their strengths and weaknesses. So maybe another team member can kind of gel if someone’s a bit weaker in one point and is like ideal and in terms of like the red and the blue.

I think that’s perfect because the red person’s just going to get everything done to like your timestamps and stuff like that. And then your blue person’s actually going to analyze it, but not just doing it for the sake of doing it. They’re actually going to digest that information. So similar, actually, like in an inspection, what we’d rather have is that someone’s actually understood the reason for doing things.

So not just like as the dentist, I don’t like just seeing an audit done and then it’s done and no one’s reflected on it. There’s no action plan. Like they’ve just done it. Because we’ve asked them to do it, kind of thing. But what I’d actually love for someone to say is, do you know what? 100 percent of our x rays were all acceptable.

That’s amazing, we’re gonna keep going. Or actually one, there was a bad film, we got a new film and we replaced it. Because again, that’s like someone’s actually thinking about the process. And again, it’s more, then your patients are being looked after. So I think that’s really important. And actually quite a good exercise to do in a staff meeting sometimes, maybe seeing what personality everyone is. And then it’d be quite cool.

[Jaz]
Having a team day to do that. I think it’s totally worth it. Right. And I’ll put the link to this book in the show notes. I think it’s really, really good. If you’re a principal, if you’re a manager, I manage a team. So that’s why I got into it. I thought, okay, let me, let me think about the different personalities.

It’s been really eye opening. I’ve really enjoyed it so far, actually. So it’s just thought a random thought that came to my mind. In the interest of time, you’ve covered so many different things in terms of looking for your CQC and you made it, to me seem less daunting, thankfully. And the thing, the main lesson is do a little bit every day.

Don’t just cram it into the end because ultimately all those little things, they count towards patient safety, which is ultimately what it’s all about. Now part of what you mentioned about CPD as well and the importance of getting it done and the important bits, but also some fun bits. CPD should be made fun and appealing as well, because it’s a time, it’s a day you take out of work, right?

Take it and you want to be fulfilled and enjoy an environment that you can enjoy. So with that, please tell us about CPD at the Shard, which you’ve got going on. I saw that recently and you invited me to be a speaker there kindly, but please tell me more about that.

[Ruchita]
Yeah, so that was actually triggered from my role as working in the CQC. Because as I said, one of the common pitfalls was like CPD wasn’t being done like on time, essentially. And also a lot of dentists are really isolated out there, but there’s also a lot of misinformation that goes out. So if you think about with CQC inspections, your version of like what may happen may be different to someone else’s version.

We may look on the Facebook group and someone may share their experience. So I thought, why not do a CPD day where we’ve actually got a lead inspector from CQC who can kind of go through all the myths, all the common errors that we think about kind of thing. And then I thought, what better way to do it than to do it at the Shard.

We’re like the most amazing view over London. Because a lot of the time, I know CPD is just there to kind of tick a box off at times. I know obviously you run events and they always look really good fun, so I feel like this is in line with that. And it’s just a good way to network, to connect, because I find we’re quite, in that era, we’re good at typing behind a laptop and typing behind a screen.

But when it comes to interacting with each other and kind of gelling, I feel like it’s missing. And obviously, we’ve got an amazing lineup of speakers. So Jaz, I’ll let you kind of talk about what you’re going to be talking about. Then I’ll say who the other ones are as well.

[Jaz]
So you asked me for something clinical because I had a look and he had a lot of non clinical stuff. So one thing I’ll be asking you is, is he intended audience as dentist or is it like the team and stuff? So, treating your team in a tactical way, what might be one element of it.

But for me, I’m talking about Resin Bridges Success Protocol. So I’ve got a fair few videos I’ve collected over the last few years to add to the whole lecture based content, but actually to actually make it engaging as possible to make sure you understand the do’s and don’ts of Resin Bonded Bridges and how to actually get those fine few percentages of success.

[Ruchita]
And when I was, because without being weird, I was like looking at all of your work and stuff. And I was like, you kind of make it seem quite simple in a good way. Like, if you follow the right techniques, it shouldn’t actually be a stressful clinical procedure, I like to hope. And it should be quite predictable.

So that was why we were just so lucky to have you there. Because I know that that can stress a lot of clinicians out, especially dentists. And then a couple of the other topics I’ve picked are things that, again, like, when I go to practices, dentists don’t have the best understanding of. So, we’ve got Richard, who’s a perio specialist, who’s going to be talking about the perio guidelines, because a lot of people still call them the new guidelines, and they’ve been around for a little while now, so we just want to cement that into everyone.

Then we’ve got Dipti, who’s going to be talking about managing trauma in dental practice, because we tend to find this, this is a trickier one for general dentists to manage. And then we’ve got Len D’Cruz, who’s going to be talking about complaints handling, just because we know, like, the area that we’re in.

Complaints are kind of just going up and up and up, but actually it’s really good for like practice manager or like dentists and principals just to have a good understanding of how to be, to manage those really well.

[Jaz]
And that’s a mandatory one, right? Complaints handling is a mandatory training that we should be doing.

[Ruchita]
Yes, exactly. Yeah. So that’s why for the CPD cycle, it’s a fun way to do it versus kind of doing it on on the computer and maybe not taking as much in. Same with infection control. I’m going to be honest, I was probably guilty of that person just ticking next back in the day. And now actually, it’s really important to have that understanding.

So we’ve got Tracy, who’s going to be talking about the guidelines, because it’s not just HTM 01-05, there’s 107. There’s all these other ones that people may not be aware of. And then we’ve obviously got Amanda, who’s our CQC lead inspector. So she’s been part of CQC for 10 years. She will have some stories to share, I’m sure.

She’s amazing. She’s so approachable. So she’ll be going through like the common pitfalls that we see. And as a lead inspector, she sees it. a little bit differently to how I see it as the dentist.

[Jaz]
And that’s quite a rare thing, right? To have someone speak on that kind of topic with the CQC, right?

[Ruchita]
Yeah, it’s actually never been done before. So it’s been a lot of hard work and a lot of planning to speak to CQC to get that done. And I don’t think it’s going to be allowed again. I think we’re just lucky that we work as a team together really, really well. And we just know. Yeah, we both have the same ethics, like, we’re never there to, like, catch each other out, so it’s gonna be really good fun.

She’s also got a lot of knowledge about, like, fire safety, because that’s a lot of the time practice principals won’t be aware that actually we’ve got to have all the right checks done and things like that on that side. And same with like legionella checks and things like that. So she’ll give you a lot more inside info on that side.

And then I’ll be kind of covering a bit of information about like social media. So how to grow your practice social media following just to kind of get the right patients in a good way. And just to kind of get known out there because there are so many practices, so many squats. It’s so hard to differentiate one from the other, so I’d love to think that by the end of that CPD day, not only do you get like 7 hours of CPD, but you’ll go away with some clinical knowledge, some CQC knowledge, some social media knowledge, everything you can basically implement straight away when you go to work.

And then also lunch is included, refreshments are included, some good drinks, good view, good people. It’s just going to be amazing. I’m just so excited about it.

[Jaz]
I imagine it’s going to be a fancy lunch, obviously.

[Ruchita]
And fancy refreshments and fancy drinks.

[Jaz]
So it’s nice to add that luxury element into it sometimes because it’s something you have to do. And if you want to treat your staff and stuff, it’s a good thing to do. Friday, 10th of November, the website for it is?

[Ruchita]
So it’s to do with my online coaching address. So it just made it easier. I’ll be honest. So it’s www.trainwithchita.co.uk, but I’m sure we’ll add the link underneath the show notes, and so if you click on there, yeah, then you’ll kind of see a lot more information about it, FAQs, and yeah, it’s gonna be so much fun, and obviously, I’ve not seen you in ages, so it’s gonna be nice to actually see people, versus having chats over Zoom and stuff like that, so it’s just gonna be amazing.

[Jaz]
I’m looking forward to ticking off those mandatory CPD. So thanks for organizing that. Protruserati, if you’d like to come along to have a nice day out in central London, just by next to Guy’s Hospital at the Shard, a nice bit of food and smooths and come and have a little listen to the talks.

It’d be great to see you there. We’ll put the links in the show notes. Chita, thanks for sharing all those gems about CQC inspection, making us feel like you are actually on our side, but then also I’m looking forward to hearing what Amanda has to say on the day in terms of the stories that perhaps can’t be revealed on the World Wide Web.

[Ruchita]
Yes. Agreed. You’ll be shocked, alarmed, and there’s some good ones, basically.

[Jaz]
So very saucy. Thank you so much, Chita.

[Ruchita]
Cool. Such a pleasure. Thank you so much, Jaz.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. I’ve made it easy for you to find that link basically, for the event on the 10th of November, I’ve done it as protrusive.co.uk/shards, S-H-A-R-D, which is obviously the beautiful building where the course is happening. I’ll be speaking on RBBs, but there’s loads of other topics there, which I kind of need to tick off as well. So I’ll be there, but also to have a nice day out in the shard in central London.

So if you’ve got a team that you want to treat, if you’ve got Fridays off, or you want to be able to take a Friday off to intend important CPD, right? So these are complaints handling, these are something clinical, these are perio guidelines, some really, really hot topics. So if you want to join us, please do. And I look forward to meeting some of you there.

As always, you can get CPD by going to the app either on Android, iOS, or www.protrusive.app. The login actually works everywhere, but as long as you answer a few questions about this episode to test that you actually did listen and watch the whole way through and to test your knowledge and to give feedback, you can get your full certificate as always.

If you find this compliance topic helpful and you’ve got something else in mind for recommendation and if you are watching on YouTube, please type below, or if you’re on the Facebook group, please let us know what you’d like and we’ll try and cover it. Thank you so much and I’ll catch you same time, same place next week.

‘Easy Dentistry on Difficult Patients is still Difficult’ – Dr Lincoln Harris

Patients with small mouth opening can be a huge pain in the back for Dentists – but did you know there are ways we can significantly improve their mouth opening through physiotherapy?

In this episode I’m joined by Dr. Tzvika Greenbaum, a specialist TMJ physiotherapist who’s here to spill the beans on his journey from headaches to jawaches. We bring to light the jaw-dropping collaboration between dentists and physiotherapists, making dental treatment easier for both you and your patients.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:
00:00 Intro
01:02 Dr. Tzvika Greenbaum
03:39 Dentistry meets physiotherapy
09:33 Range of movement
10:23 Asymmetry
11:20 Prevention
12:20 Advice to dentists
14:34 Stretching
16:17 The dental gym
16:57 Sleep bruxists vs. awake bruxists
19:28 Reducing sleep bruxism
20:52 Obstructive sleep apnoea
22:03 Statistics and diagnostic criteria
25:16 At-home exercises
27:20 Pain and discomfort
28:39 Rehabilitation
30:14 When to involve a physiotherapist
31:12 Expected results
32:21 Screening
34:15 Dr. Greenbaum’s event
39:04 Outro

Dr. Greenbaum’s upcoming course: protrusive.co.uk/greenbaum

If you liked this episode, you will also like 3 Simple TMD Exercises

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Jaz’s Introduction:
Hello, Protruserati. I’m Jaz Gulati, and in this Group Function where we just focus on one theme, today’s big topic is “Help! My patient Can’t Open Their Mouth!” And you’ll be amazed with some physio with some exercises with some training if you like your patient can actually open significantly more allowing you to do better dentistry and allowing the patient to get better outcomes. We’re joined today by our first ever Israeli guest Dr. Greenbaum who is a physiotherapist who specialized in the area of TMD and he’ll be coming soon to the UK.

So I thought ahead of his visit, let’s talk about a really important topic that I think is going to help you guys in the real world where our patients are struggling to keep their mouth open. What causes this and how can we get involved either just by yourself or working in tandem with a physiotherapist? Let’s join the main episode now and I’ll catch you in the outro.

Main Episode:
Dr. Greenbaum, welcome to the Protrusive Dental Podcast. How are you?

[Tzvika]
Hey, hi Jaz. I’m very well. Thank you very much. And thank you for inviting me to speak about my favorite topic, which is Rehabilitation of Patients with Temporomandibular Disorders.

[Jaz]
It’s great to be able to help our patients in pain. And this is exactly what it’s about, pain and discomfort. And I’m going to really try and extract all the knowledge and experience that you have. But just share with the Protruserati listening right now, what is your background? How did you niche into rehabilitation of temporomandibular disorders and psychogenic and in that area?

[Tzvika]
Well, my bachelor’s degree was back in 2004 in Haifa University in Israel. And after that, I headed up to Australia, South Australia to learn a master’s degree in musculoskeletal and sports physiotherapy and a very well-known degree. But in that degree, I started to get into the topic of cervical spine.

Upper cervical spine rehabilitation of patients with headaches. It was a new thing for physiotherapists to rehabilitate patients with cervicogenic headaches. And when I came back to Israel after the Masters, I started to see many patients with headaches. And then I realized that many of them are complaining on temporomandibular disorders.

Back then I didn’t know exactly what, how to define it, but it was clicks, lockings, pains, bruxism, all kinds of complaints classically involving the masticatory system. And then I’ve realized that there is a topic that is very relevant to my patients, to a majority of my patients, that I don’t know enough.

And that was the trigger to start the PhD project in Tel Aviv University back in 2012 or 2013. And there was a professor, Professor Winocur in Tel Aviv University that was actually looking for the physiotherapist to join his team to research the involvement of cervical spine in patients with TMD and that was an excellent match because I could learn from the dentists about our facial pain specialist basically about temporomandibular disorder, and I could share my knowledge about cervical spine with them.

So that was a five years of ongoing research project where I was assessing patients with temporomandibular disorders for cervical spine involvement impairments and all kinds of deficits. And during that time, I had the chance to learn about the connections between cervical spine and temporomandibular disorder. And that was my way to that amazing and interesting clinical world.

[Jaz]
So the work you do now, how much of that is clinical? How much of that is alongside dentists and going on from that, what is the best way that dentists and physios can work together?

[Tzvika]
One of the main problems in the physiotherapy clinic is that according to the epidemiological findings data, we need to see much more temporomandibular disorder patients, but actually we don’t see them so much.

So, there is a big gap between the needs, the demand for patients with TMD and the match to rehabilitation, to musculoskeletal rehabilitation. I think dentists are the best professionals to close these gaps because dentists do see patients with TMD how they see them because they ask their patients to open the mouth.

And when you need to open the mouth, that would be the best screening for temporomandibular disorders, even without diagnosing the exact specific diagnosis. But you understand that there is something with the masticatory system, something with the TMJ, and that would be an excellent trigger to refer the patients to the appropriate physiotherapy.

So, we see that in different countries that I teach, such as Belgium, for example, I’ve been teaching in Belgium since 2017. And back then, six years ago, the physios did not know what is temporomandibular disorder? How can they get these patients? And while training physiotherapists and also training them to contact dentists, they started to get more and more referrals.

And now when I come to Belgium, to Brussels and to Leuven and to Ghent, they keep telling, they tell me all the time that it’s an excellent cooperation because they get, the dentists were looking for the clinicians that can help the patients and the physios were looking for the clinicians that can refer them to patients. So that’s an excellent match between the diagnosis and the referral. And the rehabilitation, practitioner.

[Jaz]
I totally agree. And with my management of temporomandibular disorders in practice, I don’t think I can get the results without the physio that I use. So hopefully she’ll be joining us when you are visiting the UK in December, Krina Panchal be joining us.

I’ve told her all about you. So, she’s excited to learn from you. And then, she’s learned from Rocobado and all these people around the world because just like you said, physios, it’s in the UK. And now you said Belgium as well when they come out of physio school. They’d learn from like the neck downwards, right?

They don’t learn about the TMJ, which is just a real loss. But I can see from their perspective, you mentioned that there is a disparity in terms of how many patients should be seeking care from physios compared to what they are. And I think dentists are indeed the link we should be recognizing that physios are in a great position, those who are trained in it are in a great position to help our patients, and we’re going to get better results, patients being more comfortable, less discomfort, better mouth opening, all those things that we want from our patients when you work with a physio.

So, yeah, I strongly believe there should be a synergy between dentists and physios. And you told me recently before we hit the record button that you were in Hong Kong and a lot of the delegates, I attended weren’t just physios or healthcare professionals, there were dentists as well, which I think is amazing. I think we can learn so much from each other by attending sort of each other’s sort of educational circles. What kind of things were the dentists in Hong Kong interested to learn about from you?

[Tzvika]
I think there were two main things for them is one is to understand the specific diagnosis of patients with temporomandibular disorders, not just to know something is wrong with that system.

But to understand exactly based on the available evidence, yeah, the body of knowledge that we have, what is the specific diagnosis? And secondly, what can physiotherapists offer patients with TMD? So, what can we actually offer? And what is the prognosis? How to cooperate with the physical therapist?

So, these were two main things and it was very interesting because in the first day, it was a day for more for the diagnostic component. They were really up to it and wanting to understand everything and be part of doing that. And in the second day, they were just observing the physiotherapist, just mainly observing how physios can actually approach with the hands on.

We had some case studies there, so they were impressed by the ability of the physiotherapist to improve range of motion very quickly as to stretch muscles to understand the connections to the neck, to the cervical spine. So that was very nice to see that there in the first day, they were the one to lead this circle or this combination of cooperation.

And the second day they were just observing and really interested in how the other profession is treating, is rehabilitating the patients. Yeah, so in Hong Kong, it was a very interesting cooperation because the course is divided into two main topics. The first day is more about diagnostics and the second day is more about rehabilitation.

So the cooperation was very nice to see that in the first day, the dentists were the professionals to lead the day, to be part of the diagnostic seeking to the diagnostic criteria, understand the specific diagnostic differences. And in the second day, they were more watching the physiotherapist in action, the ability of the physiotherapist to improve the range of motion of their patients of the case studies that we had in the course, the ability of the physiotherapist to recognize cervical spine involvement, to understand how the neck is affecting the temporomandibular joint.

So that was very nice to see. And also, that the dentist in the first day could actually contribute to the physiotherapist about understanding occlusion, understanding malocclusion, understanding the skills of diagnosing some observing into the mouth. Yeah. Intraoral therapy, palpation inside the mouth. So that was a really nice knowledge sharing between the two professions.

[Jaz]
Yeah, I would love more of that in the UK, and I think hopefully we can spark something with your visit. We’ll talk about that later. Let’s talk about a sign, right? There are symptoms and there’s signs. And one of the signs that the patient may be suffering in the masticatory department the stomatognathic system, the TMJ is a limited mouth opening.

So just cover, for the dental student and going forward to dentist building up. What kind of mouth openings is a normal range of movement, including opening wide and left and right lateral. And then what point do we think something’s going on? And then as we talk about that, we can then try and discuss, okay, it is more muscular intracapsular and how you approach these issues.

[Tzvika]
Well, a functional range of motion is considered 30 millimeters and more, and a normal range of motion is considered 40 millimeters and more. In terms of protrusion, protrusive movement, we want around the 10 millimeters. And a lateral exertion, side to side, we want 5 to 10 millimeters. You can see that asymmetry is sometimes suggests a disorder, but not always. So, some healthy controls may present asymmetry in mouth opening, but if the asymmetry is associated with pain and with limited opening, that would be a significant issue usually. And-

[Jaz]
By asymmetry, Dr. Greenbaum do you mean like deviations and deflections?

[Tzvika]
Yeah, yeah. When you see someone, the opening pattern of a patient, when it’s not straight, most of us actually are not straight. So, it’s quite acceptable to see someone that is not opening completely straight. But if it is associated with limitation of movement and pain, then usually that will be clinically relevant. But if it’s just asymmetry and the patient open wide, more than 40 millimeters without pain, probably it’s just a sign and not a symptom. And many of us, more than 50% of us, are presented with signs. Luckily, only a minority of us presenting symptoms.

[Jaz]
But do you think there’s a merit in checking this in our patients so that we can be aware of the sign and see, can we perhaps give this patient some advice, recommendations to prevent this becoming into so bad that it then becomes symptomatic for the patient in the future?

[Tzvika]
Well, if you see a patient that can’t open more than 40, even if he has no pain, I would say specifically if it’s an older patient, I would say this patient needs to train the musculoskeletal system in order to prevent degenerative disorders. So it could be that if the patient is deteriorating from 40 to 38, 37, and in your checkups, when you take this measurement and you can see a trend of deterioration, for sure that this patient will benefit from physiotherapy.

And also, you can instruct the patient to improve the range of motion quite easily. But you need to know how to do that. So that would be something very quick to learn in the course, but it would be something that you need to prescribe in an accurate manner.

[Jaz]
And the most common time where we struggle as dentists is restorations in the back of the mouth, doing root canals, crown preparations, fillings. And the dream patient is someone who can open 50 millimeters plus, okay? But there’s very few of these dream patients, right? Sometimes you get these men, and they can open just huge. And then you can have your hands, both your hands inside, your nurse can have two hands inside. And it’s just, that’s the best way to go.

But unfortunately, many of our patients really struggle. Now I’m a big fan in general. I’m a huge, huge fan of placing a mouth prop or a wedge in the patient’s mouth. Because I said, what I say to patients, Dr. Greenbaum is, is the difference between you holding your elbow out like this. Okay. And letting that muscle tire versus leaning on something.

Okay. And it’s the same if you’re stretching open, okay, you’re using all the depressor muscles and they’re having to work the whole time as your patient’s open. If you can give them a wedge, the way I sell it to a patient is, allow you to relax into it. I need to relax and that puts them in a relaxed frame of mind.

The language you use is also very important. So that’s how I can help my patients to be more comfortable and get some mouth opening. But sometimes their mouth opening is so difficult to, you struggle. They struggle to even hold a wedge. So for a lot of our colleagues, we want our patients to be able to open a bigger.

What advice would you give the dentist to help our patients to be able to open better, not only for their functional requirements, but to allow us to do our dentistry?

[Tzvika]
First of all, I would be a cautious with the patients that are sensitive. So one specific group within the TMD, which is a pain related group. These are patients that are more sensitive to pain and with these patients, you need to be very careful because if you facilitate or elicit a pain response in their treatment again and again and again, the chances for them to develop a chronic pain disorder is quite high.

So, with this patient, I would not push them too much, but the other, the vast majority of patients. Like any exercise program, a gradual training for mouth opening with extra help of the hands like a stretch, self-stretch, I would just demonstrate it, with some extension of the neck, because the extensors of the neck provide a lot of force and web space can support between the lips and the chin.

[Jaz]
So just to describe to the audio listeners what Dr. Greenbaum was doing is he was opening big and then using the two hands as if he’s choking himself, but he’s choking just below the lower incisors basically. And then he’s giving the extra few millimeters of stretch while you are tilting your head backwards.

[Tzvika]
Yeah. and then you get some force, you get some strength and force from the neck to increase the leverage to open the mouth because you need to overcome a very tight muscle. The closest they can develop up to 90 kilograms in male and up to 70 kilograms in female. In order to overcome the tightness, you need to use a fair bit of strength. And just opening the mouth is not enough to get some overpressure, external overpressure from the hands and from the neck can help quite a bit.

[Jaz]
And how often would you advise your patients to do this before the appointment so that you can get some sort of extra four or five millimeters, which would be good for the patient in general in their function, but in terms of your treatment. So, what is the kind of regime that a patient would do?

[Tzvika]
If the patients are physically fit and they do stretch themselves and many patients do that today. I would recommend it as part of their routine. So, when they stretch the hamstring, stretch the low back, stretch the upper trapezius, et cetera, they need to remember to stretch the most closest as well, because this muscle group is very tight.

It’s anti-gravity muscle because they always walk against the gravity, and they tend to get really tight. So as part of the routine for my patients that are also a sleep bruxist, so they clench the teeth during the night, that would be the first thing in the morning. So, before they brush their teeth, I recommend them to stretch it for 30 seconds twice, 30 seconds, and just to have a nice start of the day after a long tightening of the muscles during the night.

[Jaz]
Absolutely. What I find is my patients who are both sleep bruxist, but also awake bruxist, right? They spend so much of their time. with their masseters and temporalis, everything in a contracted state, right?

Everything is shortened. Everything is contracted, right? And I can only imagine all the lactic acid building up. Is that still an accepted theory? The lactic acid, the buildup of lactic acid in the muscles?

[Tzvika]
Yeah, it’s a fatigue-ability of the muscles. So we are at the, there is a change in the physiology within the muscle. If you take any muscle and you work. Keep working it on a lower level, but for a long period of time. That would be the recipe to have pain. Because the muscle gets the oxygen level gets low, and the carbohydrate gets higher, and then the physiology of the muscle, that becomes a sick muscle. On the other hand, if you do it at night, that would be an excellent recipe to build up the muscle mass.

That’s why the sleep bruxist, they would be hypertrophic, and the awake bruxist, they would be atrophic. Because when you do it during the day, and you do it for a long period of time, and it’s associated with pain, you start to lose the muscle mass. But when you do it at night, in a phasic way, so you do it in cycles. That would be, and you do it and then you relax, you do it, and then you relax, then you build the muscle. Of course, we don’t want it so much.

[Jaz]
It’s the dental gym, right? It’s the dental gym, yeah. And it’s these hypertrophic patients that crack teeth. Dr. Greenbaum, they crack teeth and they put our restorative materials and a lot of stress and strain.

[Tzvika]
It’s a gym for free every night, but not advisable.

[Jaz]
Absolutely. I mean, it’d be interesting to know, because you’ve obviously done so much training, PhD, about if you believe that changing the external factors can stop bruxism. So there’s one theory that once a bruxist, always a bruxist, and it’s very difficult to try and get someone to suddenly stop being a bruxist.

They will still do some activity every night. Whereas, oh, if you just do this one therapy, or if we just reduce your stress, that you will stop bruxing. Anything that you’ve come across in terms of what you believe?

[Tzvika]
Well, let’s divide between the awake bruxism and sleep bruxism, because awake bruxism is a behavioral disorder with sleep bruxism is a sleep disorder, not necessarily they come together.

A majority of patients are either sleep bruxist or awake bruxist. So for the awake bruxist as a behavioral disorder, we can approach it in behavioral therapy and we can change the behavior, can reduce it. Having said that it’s associated with mental stress. So you also need to address somehow the mental stress.

Now you will not make these patients laid back patients. Yeah, the awake bruxist is usually their type a personality, but you can modify it a little bit. You can take the edge of it a little bit. The sleep bruxist is a different story. It’s a multifactorial phenomena. It requires some very accurate assessment for the sleeping hygiene.

It requires a sleep laboratory requires some screening for medication use, alcohol use, and sometimes there is something to do about it, but many other times is mainly protecting the teeth. And the Botox is actually a nice intervention for some of these patients to reduce the strength of these muscles, but awake bruxism, behavioral change, sleep bruxism, sleep disorder, different approach, two different approaches.

[Jaz]
Do you believe there’s anything that we can, for those dentists who want to help the patient stop the sleep bruxism, stop the sleep disorder? What do you feel that they could be doing? So for example, because this is something, if they’re doing more sleep bruxism, their muscles are tighter. Their mouth opening is less.

Like I give my patients occlusal appliances, but I color these occlusal appliances in. And I know that they’re grinding still, even though I’ve given them appliance, they’re still grinding on my appliance. I can see the proof. I can sometimes do lots of fancy dentistry, put all these crowns, get their joint within centric relation.

But they will still Brux, because I know A, on their appliance, but B, things like a Brux checker, which I use my patients and I see that, no matter how beautiful everything is, how balanced everything is, how the center lines match up, they’re still Bruxing because they’re removing the ink from the Brux checker.

So I’ve yet to come across the proof in my own patients that Intervention A will stop the sleep disorder. I’ve yet to find it, but that doesn’t mean it doesn’t exist. I’m open to the universe to learn. Is there anything that you’ve found from your research or from colleagues that has been suggested to limit, reduce, control sleep bruxism?

[Tzvika]
The literature speaks about sleep hygiene. So, getting into sleep slowly with no smartphones around, exercise, if you are exercising not very close to the sleep. Time to the bedtime, but to be honest, it’s a big challenge. I don’t see a breakthrough clinical intervention in that regard. Having said that we are researching today in our laboratory, the relationship between sleep bruxism and obstructive sleep apnea.

Because they have some tendency to come together, and we are testing the option that one of them is actually feeding the other. We believe we are hypothesizing that the sleep bruxism might be perpetuating factor for obstructive sleep apnea by activating the mouth closers and inhibiting.

The mouth openers, which are also stabilizing the base of the tongue. So what we want to see is if the patients with OSA, obstructive sleep apnea, that have also sleep bruxism, if there is some relationship between their severity of sleep bruxism and severity of OSA, and severity of mouth’s closest strength, and the severity of the obstructive sleep apnea.

So that’s another thing that we are trying to assess, but how to get rid of sleep bruxism. That’s a big challenge. That’s usually it’s just by time, after the age of 60, it drops to 3%, before the age of 60, something around the eight or 10% of the population. So maybe it’s just by natural course.

[Jaz]
The problem with that data, Dr. Greenbaum, with the percentages are completely, based on literature and I see that the issue with the data collection on those is, are often surveys of patients while they’re awake. They’re like asking the patient, but most of the time patients are completely unaware of their habit, right?

So my only issue with that data would be that I think that is underestimating the percentage of sleep bruxists out there. If you just look at, not you, but those who are listening, the work behind Giles Levine and looking at rhythmic masticatory muscle activity, 60% to 70% plus, there is a bit of movement of the masticatory muscles at night, which is rhythmic and that’s normal.

And so if you just look at that, if you classify that as a type of bruxism, then already it’s so much. I guess the ones we’re concerned with as dentists and you guys, well, rehabilitating your patients in pain is those patients who are taking something that’s normal, which is rhythmic masticatory muscle activity, and really going above and beyond what should be happening, and now actually causing stress in the system, muscles being upset, and actually damaging the masticatory system.

And so really to find out the true percentage of that, we need the studies, which we don’t have. And that’s why it’s a bit of a dilemma in terms of get that. Is there anything you want to add on that before I talk more about the regimes to help our patients?

[Tzvika]
We have today some clinical, we are trying to establish a diagnostic criteria for sleep bruxism, so it’s still not valid and reliable, but there is a consensus group with Professor Manfredini, Professor Winocur, and some other doctors in Europe and States that are trying to establish the clinical diagnostic criteria.

I feel that we have the ability to at least suspect that our patient is, is asleep bruxist, because the hypertrophic is one. The muscular hypertrophic, specifically unilateral asymmetry. So usually, they have a unilaterally of the side, but they do it on both sides, but one side is more. And then the spouse is also questioning the spouse about the noises.

That’s another important criteria. And then you can also observe the mouth. Of course, you guys, the dentists are excellent in seeing the erosion, but you can also see the marks of the teeth on the tongue and also the linear alba within the internal aspect. So I think when you combine these five factors, you can be quite suspicious that your patient is most likely to be a sleep bruxist.

I think that the muscle hypertrophy is very important. From my perspective as a physio, when I see a patient with a very dominant masseter in temporalis and also medial pterygoid from inside, I can observe when I see the hypertrophy, I strongly suspect that I have a sleep bruxist in front of me.

[Jaz]
I absolutely agree with you. And I encourage all dentists to check, Dr. Greenbaum, a lot of dentists, they get out of the habit of doing a muscle exam and it’s just so, so quick and easy for us to do even externally and just even just to feel the size of the masseters, the size of the temporalis, takes very little time and I think adds to your findings, adds to your diagnosis, even influences exactly which type of restorations I will do, which teeth I will crown, what my crown will be made of to withstand those forces, who are the high occlusal risk patients, who are the low occlusal risk patients.

So I think it’s absolutely fundamental. Now just to go back on track in terms of my patient can’t open their mouth anymore. You suggested that the exercise they do, is it just a once a day that we should recommend our patients do this or is it three times a day? Any sort of guidelines we can give and how soon along with other exercises, which you may go into, can we start seeing results from our patients so that we can have an easier time doing our dentistry?

[Tzvika]
First of all, for stretching, if you are not an athlete, if you’re not a specific athlete, so there is no limitation for stretching. You can say that the more is the better. If you are a contact athlete, like a football player, you don’t want to stretch yourself all day long because you need the muscle tonicity to protect you.

But if you are just a human being that is not a professional athlete, and you want to improve the range of motion, you can do it as much as you want, not into pain. Yeah, don’t cause pain, but a strong believer in a daily activity. So functional activity that encourage full mouth opening. So patients that have been avoiding a full mouth opening, because they just got used that they can’t open.

I would encourage them slowly to return to their, for example, if they were using to cut their, the apple into half. Then I try to avoid that. Stop avoiding that. Or stop the avoidance would be actually exposing the patients into stress. And this, I think, in my opinion as a physio, is the most important behavioral change is stop the avoidance and try to get used to think that you’ve been doing and stopped, been doing because of the limitation, but very gradually. So exercise first. And then activation in the daily activity cycle.

[Jaz]
Yeah, so the functioning is right and proper. And in dentistry, we call this guarding. Patients are guarding. When we get our patients to open, and just to check the mouth opening, they will open a bit. And then we say, can you open as much as you can?

And then they open a lot more. Right? And so patients are sometimes guarding, and so it’s important to get them used to, they don’t actually exercise that additional range because they’re so used to, I completely agree with you. So definitely to encourage our patients to do it. And as in the physio world, as you guys say, motion is lotion, right?

So it’s good, it’s good to use it. Now, how might this change? And so firstly, let’s talk about pain, sorry. If the patient is experiencing some discomfort. Is there any guideline? Like, sometimes I say, well, if you haven’t been stretching something for a long time, A, go gradual, but you might feel a stretch, right?

A stretch is a sensation. When you stretch something, you feel a stretching sensation. It’s not the most pleasant thing in the world. It’s not the worst thing in the world either. So I think it’s important to expect a little bit, but I say, if it gets more of a six out of 10, then stop doing it. Basically, don’t go beyond that limit. Find that safe limit for you. Any guidelines on that?

[Tzvika]
Yes, I totally agree with you, I think that we need to reassure the patients to tell them up to that point is okay, so 5 out of 10 I would say, up to that is fine, more than that is not fine, and specifically what you feel after the stretch. If you feel after the stretch that you’re still in pain, it means you did too much, but if one or two minutes after the stretch you feel normal or even better than before, that’s a very good sign.

So I tell him not only during the stretch, but how do you feel a quarter of an hour after the stretch? Do you feel well after that? You should feel better. You should feel. If you feel more pain after the stretch, maybe half an hour, or if you can’t activate your musculatory system after the stretch, that means you did too much.

That means maybe there is a disorder that requires a rehabilitation. That means maybe there is an obstacle, a mechanical obstacle that a well-trained physio need to diagnose and help you to overcome.

[Jaz]
Well, let’s talk about that. So, what if a patient has got not so much muscular, but they’re having intracapsular issues and they’re getting locking and perhaps we need to focus more on that.

So, if someone’s trying to stretch open and they’re getting a pain in the preauricular area and the TMJ area, how might your rehabilitation change for that patient? Or certainly from a dentist perspective, we know that, okay, just because we get their muscles happier, they’re still the disc displacement to deal with. So what advice would you give to the dentist to help our patients whose diagnosis may be not purely muscular?

[Tzvika]
Well, the discogenic patients are more complicated because the potential to irritate them is very high. And the inflammatory potential is higher. With the muscular patient the inflammatory potential, the irritability is not very high.

But with these patients, we need to be very careful, specifically if they have intermittent locking. The patients with intermittent locking, they are unstable, and these patients need to be diagnosed well and need to be rehabilitated in a very accurate way, more in proprioceptive exercise. So more training the muscular compensatory factors.

But those who have this displacement without reduction, so that they are permanently locked, usually are more mechanical patients. And we can actually invest more energy in stretching depth. So we can actually go a little bit further with it. Intermittent locking, be careful with them because they are likely to have inflammatory response and the more this displacement without reduction of permanent lock and you can dare a little bit more to instruct them to stretch.

Having said that, this patient need to be rehabilitated by physios. I think that a dentist by himself should not be the only clinician to deal with this patient. So it’s exactly the synergy that we need with a rehabilitation practitioner and with a dentist that has a case manager and diagnosis.

[Jaz]
100% agree and I think a good guideline for dentists listening and watching to this it would be that if you have a patient who’s just got tight muscles and you’re just concerned that give them those stretching exercises.

And if it’s just a sign, not a symptom, then monitor them, but then maybe plant the seed in their head that, look, you might benefit, have you seen a physio before, this TMJ physios could really help you. And so let’s keep that, that we may be able to consider it.

If someone’s got displacement with intermittent locking or as a displacement without reduction. So they’re permanently locked. As you said, these patients, you really, really, really should try and find your local TMJ physio and work with them to rehabilitate this patient. You’ll really improve the quality of life, the patient, you’ll improve your dentistry because you get your patient to open bigger.

Which leads me to my final question. What are the kind of results we can expect? How much more mouth opening? Because I’ve read some papers. I’m very impressed, but guidelines. Now, how much more either as a percentage or as millimeters improved opening can we get from our patients who have physio assisted rehabilitation?

[Tzvika]
Well, if it’s a pain related patient, if we can professionally reduce their pain and their fear and the fear avoidance. We can improve them, for example, from 30 millimeters without pain until 50 millimeters without pain. So, 20 millimeters would be a very expectable result within few sessions. But if it’s a patient with an intrarticular disorder, displacement without reduction, with limited opening, that would be very gradual.

So if you improve them from 25 to 29 within one month, that’s a good success. That’s quite a good process of progress. With the patients with the degenerative joint disease, usually if they were untreated for a long period of time, it would take a bit more time to get improvement.

If they just started to deteriorate, then we can quite quickly improve them. So it depends how long they’ve been waiting before seeking for help.

[Jaz]
I think a good guideline for dentists is to start looking at your patient’s mouth opening. You can use a three-finger test, for example, as a very basic crude screening, but to get a ruler, it’s just so quick and easy as part of your new patient examination to do that, right?

[Tzvika]
Yeah, for sure. A ruler, we have no excuse to avoid the ruler. It’s so cheap. It’s so accurate. It’s valid. It’s reliable. The therapists that are taking my courses, they get it as a small present, small Israeli present from China because it’s all usually made by China. But I tell them you have to use it because it’s really simple and it gives you a very nice thumb rule if your patient is getting better or worse.

And the patient love it when they are measured. They love it because they see that you are monitoring them. They see that you care about their changes, and I strongly recommend to use it.

[Jaz]
It’s a bit like when we are doing a mouth cancer examination, which we’re doing a mouth cancer screening, right? If we tell our patients, hey, I’m going to do a mouth cancer screening, and then they go away thinking, wow, this dentist did a mouth cancer screening. I feel so good. I feel like I’m good that I was checked and that’s good. Whereas some dentists will do it, but they’re not telling the patient that they’re doing it.

So the patient never knows what’s happening. So A, it’s good to tell your patient what you’re doing. And B, this is just like that. If you tell, if every patient you see, new patient, Okay. And then recall as well. You just measure and say, hey, I’m going to measure your mouth opening. I’m going to see where you score in terms of normal.

And then it’ll be really good for me to check you over time. So I can pick up on any functional disturbances and look after you. Cause it’s something I’m very passionate about is the look, the muscles of the head and neck as well. And they’d be like, wow, this dentist is very detailed, very thorough.

No other dentist has done this for me before. They will get an idea that, yeah, this is a really good thing. So I would heavily encourage dentists to do that. The stretches that you recommended are great and also to pick up those patients who are perhaps a bit more involved in terms of intracapsular issues or degenerative and to really involve your physio.

That is the best thing you could do for your patient. Now I know that when you come in December, you’re going to cover a lot of this stuff the way I think you’re doing it I’m not organizing it, but I am partaking I’m supporting because I want dentists to learn more about TMD. I want physios and dentists to have more synergy in the UK because you’re visiting the UK.

So I’m assisting and organizing this course and I would like everyone, all the dentists listening to learn more from you. It’s a very reasonable offering as well. The way I suggested it is that you do live webinars on Zoom first. Because we want to have the theory in front on a laptop and catch up with the recording.

But when we come to the day, the much, as much hands on as we can do, and as much hands on that we can observe, that’s the best thing. So what kind of things are you looking to cover in this very bespoke special course that you’re organizing for dentists?

[Tzvika]
So we’re going to follow the acceptable diagnostic criteria for Temporomandibular disorder, the DCTMD.

It’s an excellent manual. It’s like a recipe that you follow, and you can get to the specific diagnosis in a UK, Canada, Israel and Belgium with the same patient. And it’s an excellent tool. So we’re going to cover that to learn how to use it and how to follow it and how to use the decision trees to get to the specific diagnosis.

So that would be a very important part. And then, according to the diagnosis, based on the diagnosis, we are going to understand the strategy to rehabilitate each one of the specific diagnosis, patients with a specific diagnosis, pain related, what’s more likely to be the strategy for management.

The intraticular and the degenerative. We will also learn how to understand if the neck is likely to play a role in the clinical presentation or not. That was my PhD. So I’m going to describe it and to present it and to show you in a practical way. A very quick screening to make a decision is the neck likely to play a role or is the neck not likely to play a role in the clinical presentation.

If it is, then of course for the physiotherapy very quickly, if not, you can keep managing the patient. Without considering too much the cervical spine. So that will be another component that we will discuss and train and practice.

[Jaz]
From teaching TMD courses. The dentist, myself, I found that a lot of time just to get the basic palpation skills is very important for dentists. Dentists often when they’re feeling like when they’re supposed to be palpating over the joints and the condyle, they’re actually more in the origin of masseter. And I also find that dentists are usually not palpating firmly enough. They’re a bit too gentle. So, are you going to be covering the more basic, as per the diagnostic criteria, exactly how to do the palpations for the dentists?

[Tzvika]
Yeah, part of the DCTMD is a calibration, is a calibrating the assessors. And it’s about how to build the stress on the palpation and how to consistently find the specific zones and area to cover the whole temporalis, the whole masseter, and specifically the TMJ. So definitely we’re going to specify the palpation skills of the dentist in order to accurately diagnose patients.

[Jaz]
Amazing. Well, we look forward to welcoming you. I will make it the show notes have the link that can click on. The website can easily make is protrusive.co.uk/greenbaum as G-R-E-E-N-B-A-U-M. So, it’s B-A-U-M, Greenbaum. And then that will take you to the landing page once you’ve had fully finalized it.

And like I said, I have no financial interest in this, except I just want education to be widespread. And I’m excited to come and learn from you. I’m excited for those who’ve learned with me, splints and stuff before to come and learn from a world expert physio. There’s so much we can learn and share with each other.

And I know you’re coming to do teach physios as well. But I think it’s a very special thing to organize for dentists. So I’m excited to learn from you further and also to allow accessibility for dentists in this event to get exposure and access to you as well.

[Tzvika]
Definitely. Yes. I think this cooperation is highly important from the few first courses I’ve given in the UK. I feel that the gap is really high. There’s a big gap to close in the favor of patients that having temporomandibular disorders. And that means the cooperation between diagnostic clinicians and rehabilitating clinicians is required and that would be an excellent start for us to be in this cooperation between the two professions. And I want to thank you personally for inviting me for this podcast. It’s been a real pleasure and great opportunity to share my knowledge with you.

[Jaz]
Yeah, thank you so much. And yeah, I look forward to seeing you on the 1st of December and hopefully much more from then as well as it’s great to finally meet you in this way. I know we had a zoom as well, but yeah, it’s great for you to share your knowledge. Thank you.

[Tzvika]
Looking forward to learn from you as well.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. Now, if you want to claim some CPD for this educational episode on the web app, for example, on your laptop, head over to protrusive.app or on your phone. If you already got the app downloaded, answer a few questions and my team will send you out a certificate.

If you’re a dentist who’s new into TMD and you’d like to learn about diagnosing TMDs and how we can work with other healthcare professionals to start helping our patients with temporomandibular disorders, and if you’re in the UK or even if you’re in Europe, come along to our event in December.

It’s not my event, it’s Dr. Greenbaum’s event, but I’ll be there to support him. It’s an area of dentistry that’s not as sexy as veneers and bonding, but it’s so, so important. It helps our patients to be pain free. So, if you’re interested in that, head to protrusive.co.uk/greenbaum, that’s G-R-E-E-N-B-A-U-M, that’s his surname, and I’ll make sure that redirects you to his event.

I hope to see some of you there. Otherwise, to all the podcast listeners, all the watchers, thanks so much for staying all the way to the end once again. I’ll catch you same time, same place next week.

NEW EPISODE LIVE for public access!

Do you know the difference between dental indemnity and insurance? And which one might be better for you? Today we have Dr. Neel Jaiswal, founder of Professional Dental Indemnity (PDI), to shed light on this crucial topic (as our security and sleep depends on it!)

Should you choose a ‘claims occurred’ or ‘claims made’ policy? Dr. Jaiswal’s transparent advice aids in choosing what is best for you at your stage of your career.

Need to Read it? Check out the Full Episode Transcript below!

Get a quote from PDI and save £thousands on your policy.

If you liked this episode, you will also like 10 Commandments for Staying Out of Trouble

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Jaz’s Introduction:
Indemnity vs Insurance. I don’t know if it’s like a UK thing. I’m kind of sure it is. Although when I was in Singapore, I was with dental protection. So let’s give you a bit of background first, right? Indemnity is a bit like the big organizations, mutuals like DDU and dental protection, whereas Insurance are kind of like a newcomer in the last 10 years. There’s these different insurance products.

So what’s the need for these? Well, when I was in Singapore, when I moved from the UK to Singapore, I was paying so much lower to be part of dental protection at the time, like, compared to UK fees, Singapore, it was so much easier to get protected as a clinician.

This is because in Singapore at the time, dentists were getting sued way less than they are in the UK, which is nice, and also taxes are lower, which is really cool. Anyway, came back to the UK, and now that I’ve been paying way less in Singapore, to have to pay what I was getting quoted for with DDU at the time, or Dental Protection, or whoever, It was a bitter pill to swallow.

So already I was thinking surely there must be a better way. Why am I a non-implant dentist who hadn’t had any complaints at that point? Why am I paying so much so that it covers the high-risk dentist, right? Cause that’s the way it works. These mutuals, they work because they’ve divided all the costs between all the members.

And this is why your premium goes up year by year by year, even though you didn’t really use their services. That’s when insurances came my radar and my friend, Dr. Neel Jaiswal, who’s a fantastic conscientious clinician. He started PDI, which is Professional Dental Indemnity. So, I had a chat with him, I went to their evening, I met the underwriters, the lawyers there, and I was very impressed with what he was setting up.

But what he taught me and what I learned also from the Facebook groups and dentistry is that, oh, I had this complaint, and my indemnity organization is choosing not to defend me. Now that’s a big eye opener, right? Because what we learn now is that these big mutuals, their cover is discretionary. Meaning that should they choose not to defend you, they won’t.

They’re not obligated to. They’re not an insurance. Okay. It’s different. And this is something that I’ve been learning. And in this episode, as we learn about Indemnity versus Insurance, you see that I’m relearning all these things all over again. Some great analogies there for you. It’s a very tricky thing to get your head around, but you know what? It is so important, right?

Your career is so important to get the right type of insurance for your career is important to make sure you’re protected, and your patients are protected. This episode is not as sexy as bonding and composite veneers and stuff. But like I said, this is really, really key. So please do listen all the way to the end because I guarantee you’re going to learn a lot.

And if you do listen all the way to the end, you might actually gain so much that you will make sure that you have the right product. You’d be clued up next time when you’ll do a renewal and it’ll probably save you thousands. So, let’s listen to Dr. Neel Jaiswal.

Main Episode:
Dr. Neel Jaiswal, welcome back to the Protrusive Dental Podcast. All those episodes ago, the fourth ever episode was on microscopes and something to do with diva mode and that kind of stuff. It went to a funny little digress and that was gosh, so many years ago now. It’s so great to welcome you back in a different reincarnation. Before we’re talking about magnification loops and I remember I came to shadow you, we use your microscope.

And you’ve kind of pivoted a little bit. I know you were involved in the field of medical legal at the time as well, but you’ve grown PDI. And so we want to talk about that. We want to learn about the difference between Indemnity and Insurance. But for those who hadn’t listened to that episode, tell us about yourself, Neel.

[Neel]
So I’m a general dental practitioner. I’ve got a private practice in Hertfordshire and I’ve been involved in various teaching things over the years with microscopes, with tubules, with study clubs. And most of my education was with sort of Frank Spear in the States. Went there over quite a few times, which really changed my whole dynamic.

And I was sort of heading along the clinical pathway and building up the specialist practice. And I think probably at the time that we did our first podcast, we weren’t so happy with the state of affairs, with the GDC, with indemnity, with being let down. And I kind of, I was trying to help people.

And I met my business partner, Gary, who said he was in indemnity for plastic surgeons. And I told him about what was happening, and one thing led to another and PDI started. And it really just came about from wanting to help our colleagues and having someone on our side really. And that was probably about the time that we did our first podcast. So, I’ve come a long way and congratulations to you as well. I mean, how far you’ve come. I mean, amazing podcast.

[Jaz]
I appreciate it so much. And you reach out to me now and again saying that you and Cam listen to it. And it puts your daughter, Aria, to sleep. You told me a few times. I’m sure it puts a lot of people to sleep.

But yeah, I’m so glad that Aria is getting some sleep out of it, which is great. And when you mentioned Gary, I hate Gary, tongue in cheek because we went to the Dentinal Tubules Congress and it was fancy dress, right? And me and him, right. I thought if I go as Alan from The Hangover. Okay. And I have the baby with me, baby Carlos with me and no one’s going to come as Alan from Hangover, and he came as Alan from Hangover.

It’s like he was wearing the same dress as me. That really annoyed me, but yeah, it’s all fun and games. Tell me in terms of how much of what you do now is revolved around you running your dental practice and how much of it is doing the professional dental indemnity, PDI, which is the product that you at the moment seeing the issues that we were having with the traditional indemnity that you raised.

[Neel]
 I think, as you know, being a dentist, just being an associate is a full-time job with the amount of treatment planning you do. Being a father is a full-time job. And running a dentist company is a full-time job. So I think I’ve got three full time jobs. How I split my time, I don’t really, it just sort of becomes, not firefighting, when the practice is a bit of firefighting. But generally, I kind of work two days a week. And two days a week I’m daddy daycare. And two days a week is PDI. But every evening could be anything. And all our clients can WhatsApp me anytime, any day. And we super quick at responding, which is one of our pluses.

[Jaz]
Which is why all those years ago, I switched from my I’m not going to name who I was with. I mean, when I was in Singapore, I was with Dental Protection. When I was in the UK, I was with another indemnity organization. It was all good and stuff. But the quotes that were coming back were getting higher and higher and higher year by year. And I still to this day, touch wood, it’s going to come.

It’s going to come eventually. Touch wood. I still haven’t had a proper complaint that, there was a few like little hints that I approached indemnity for the, ‘Hey, can you help me formulate a response kind of thing?’ And nothing ever came of it. But it’s something that is going to come eventually.

But despite that, despite me feeling like I was doing all the right things, the quotes I was getting back was higher, higher, higher, wasn’t doing implants, still going ever higher. And so I wanted to try something that would significantly reduce the bill, but it wasn’t just about going something that was cheap.

It was something that was something that would regulate and meet the regulatory standards, but also trust. I’m a huge person of trust and I trusted you, Neel. And I said, okay, Neel. You’ve got this new thing. You are obviously disgruntled with the indemnity organizations. You’re starting something. I attended your evening talk and I thought, okay, this makes sense to me.

And the biggest thing at the time, which we’re going to talk about is learning that indemnity organizations, the cover that they give us is discretionary, right? Which is the biggest beef that we have with them. Can you please explain, because it’s something that you day in day out, what this means?

[Neel]
So obviously, for most of my career, I was a dental, well, let’s not say, a big provider. And they were really good, and at that time, we weren’t having this complaint issue, we weren’t having the no win, no fee, and if you were at the GDC, you’d probably have done something naughty. And then the culture changed, whether it’s from the 90s onwards, I remember my dad being a GP, and suddenly it became patients for customer, and it was all about them, and it sort of devalued us as professionals.

So that, and plus obviously the medical legal things changed. And really what happened was, I think the discretionary companies sort of were almost of a past era and not fit for purpose really, and the government has said this as well in their white paper. So, how I’d explain discretionary versus insurance is, let’s say Jaz, you’ve got a like cars, so let’s say you’ve got, you’re doing really well, and you’ve got a Rolls Royce outside.

And that’s your career. You’ve only got one car for the rest of your life. You want to, it’s really valuable to you. It’s really important to you. It’s really important that it works. And you need insurance. It’s obligatory to have cover. So, you can either go to a mutual, and they’ll say, you’ll say to them, I’ve got a Rolls Royce.

I do 10, 000 miles a year. I’m a bit of a dodgy driver. I do curb the alloys. I’m a bit of a risk. Will you insure me? And they’ll go, we can’t insure you because we’re not licensed for insurance. But we can indemnify you. So what we will do is we’ll have a handshake and say, don’t worry, Jaz, you’re with us.

That’s it. So indemnity is a handshake. It’s two people having a handshake that’s of trust. We’ll look after you and we’ll use our discretionary for the good of our members. The issue is the good of the members might not be the good of the individual. And that’s where they get caught out. Or, you could come to us and say, I’ve got this Rolls Royce, I do 10, 000 miles a year, this is my claims history, this is what I do, this is how I drive.

I’ll go, okay, I’m going to write everything down on paper, you’ve told me what you do, how often you do it, you’ve told me your risk, I’ve looked at your past records, I’m giving you a quote. If you write, if you’re honest with us, that’s all we ask, and we will cover you for that. So, if any issues at all, you’ve got a piece of paper that you can refer to.

And you’ve got an ombudsman you can refer to, and you’ve got a very, very tough FCA that really makes sure that they’re acting fairly. And if I can give an example, which happened yesterday, don’t want to mention any names again, but this dentist has been left without cover. Because he took a vertically impacting wisdom tooth out, and caused tongue burning from parasthesia I think it probably did-

[Jaz]
Could happen.

[Neel]
I think he didn’t even elevate the root out. So, he did a coronectomy in the end, because it wouldn’t budge. So I think maybe the anesthetic has caused something. But his indemnifier, which is mutual, has said, ‘Oh, you didn’t tell us you were doing wisdom teeth. You’ve told us you’re doing implants, but you haven’t told us you’re doing wisdom teeth.’

Now I would call that general dentistry. And we’d cover you. And also, we would take a view on it as well because the brokers that we work with in the writers, that’s what we like about them. They’re reasonable. And if I put an argument to them, they will listen. Now his indemnifier has said, no, we’re not covering you and we’re not covering you retrospectively on this since the time you’ve been with us.

So he’s now going to try and, who’s the lawyers to know win no fee, Irwin Mitchell. He’s going to have to go up against them, who do this day in day out, on his own, unless we find him a lawyer. So, I think that’s mostly unfair, and I would have thought the discretionary could use their discretionary for good, and to say, actually, he didn’t know, we didn’t ask him if he does implants, let’s use our discretion to help him. But they’re using his discretion to exclude him.

[Jaz]
Wait, you didn’t ask him that if he does wisdom teeth, you said implants, but you meant wisdom teeth, right?

[Neel]
No, well, he’s covered for implant. They didn’t ask him, these, nowadays, they’re sort of giving a questionnaire of like, what you do, what you don’t do. But they didn’t send that to him. But they relied on him knowing that, oh, we need to know this. But how is he supposed to know this? Dentists are busy. They don’t get caught. So he got caught between a rock and a hard place. But he’s got nothing to go back. He can’t complain. There’s no complaint service.

When I asked about my indemnity file, I’m really not happy with the service. Can I complain? They said, we don’t have a complaint service, which I think is crazy. So it is, do you want to trust that handshake? Which I think as gentlemen, we could do in the past or, but it’s your whole career. It’s your whole livelihood and it’s the only vehicle you have for the rest of your life and you want to make sure it’s well insured.

Now some people will go with cheaper insurance, and you were saying very much you want a price, but you also want the proper cover. Now do you really want the cheapest cover that if your car goes down, you’re not you’re going to end up with a bicycle for hire, curtsy car.

Or do you want like for like or do you want something in the middle? And I kind of think most people want something in the middle. So, there is a little bit of a race at the bottom. I think that’s changed which is good because that doesn’t help anyone. And there is a fair price for things and what you don’t want to do is have to cover the costs of somebody else’s mistakes.

So with an insurance pool, we put all the good dentists, so to speak, in one pool. And we, let’s call them the distress dentists, paying 30, 40, 50, 80, 100 grand in another pool. So, there’s different risk factors and different prices. So if something happens in the other pool, it’s not having a knock on effect on yours, so your premium doesn’t go up.

Whereas with a mutual, everyone’s in the same pool. So that’s why you could be saying, I haven’t had a complaint, why is my indemnity going up, insurance going up every year? Now obviously some of that’s expenses, cost of living, but it’s disproportionately high, but it’s because you’re paying for other people’s errors and omissions.

[Jaz]
Yeah. One of the questions I was going to ask is why is it that when I get an insurance quote, it is much more palatable than an indemnity quote. And so I think a barrier for some people to switch from traditional indemnities to go from insurance is because it is a significant fee drop. They have this queasy feeling in their stomach.

They’re kind of cheaping out that, hey, probably I’m there’s got to be a catch. And the catch probably is that if I’m in trouble, I’m not going to be well supported. What do you think about that?

[Neel]
That’s an interesting point. I hadn’t heard of that. You almost value something, but it’s more expensive. A bit like we do in anything, you know, a coffee at Harrods is more valuable than Caffe Nero. So I think that’s a great point, actually. So, if anyone has those doubts, do let me know, because we’re happy to put the price up so that they feel it’s like for like.

[Jaz]
Please don’t.

[Neel]
But to be honest, from what I’ve seen, if you look at most of the insurers and some of the younger mutuals who haven’t got as much past history to manage, we’re about the same. So it almost becomes a few hundred pounds difference. We kind of, there is now a settling, which is really good because I think wherever you go. You are going to get, for most people, you are going to find a decent price. And then what you’ve really got to look for is those things of, can I get hold of them?

Do I know them? Can I trust them? Is the service there? Will they look after me? And I think it becomes a bit like choosing a dentist. We don’t really know, as a patient, if a dentist is any good. Even when I recommend a dentist, if I haven’t seen their work, all I can go on is, they’re educated, they’re nice, they’ve got a nice website.

So, we’re going on all the other factors to make our decisions. And one of them is actually Recommendation. So recommendation is fantastic. But also, and we’ve got lots of recommendations, and I’m really proud and you’ve kindly given us one. But you’ve also got to be aware, recommendations are generally from people who have had a good outcome.

And in indemnity, if you’ve had a bad outcome, it’s not something you want to shout about. I got a hundred, I lost a hundred grand, and they did treat me very well, and I’ve had to go to court, and all this stuff. That’s not kind of, the recommendations are skewed. They’re still valid.

But you really want to understand yourself is who are you dealing with? What kind of product is, and that’s something we can touch along later. And it’s trust. And like you said, I think it’s trust.

[Jaz]
Excellent.

Hey guys, it’s just Jaz interfering here with an offer for you. If you want to get a quote from PDI to see how much it would cost you and to see if they’d accept you as part of their insurance product.

If you head over to protrusive.co.uk/insurance, that’s protrusive.co.uk/insurance. And you fill out the form with your specific details in terms of what kind of work do you do? How many hours a week do you work? Have you had any claims before? All the important kinds of stuff that usually would fill in.

You’ll find out if they would accept you and you’ll get a quote as well. Now by filling out that form on protrusive.co.uk/insurance, you get a hundred pounds off. So whatever your fee is, you get a hundred pounds off on top of that as well. So maybe if you’re still within big indemnity company, or maybe with another insurer, and maybe you’ll do a renewal.

Or maybe you’re looking ahead and you’re planning ahead, or maybe you’re just downright curious as to how much it would cost you with your individual circumstances. I just fill in the form and PDI will contact you. Now, as part of being a hundred percent transparent with you, I do get a small commission.

This channel gets a small commission if you do get a quote, and if you do sign up. So Protrusive gets a commission, which helps us support the channel, but I wanted to let you know that as part of transparency, let’s join the main episode again.

With insurance then, like I’ve been with you guys as an insurance for four or five years now. Am I disadvantaged in any way going for an insurance product, as you call it, compared to the more traditional big dental indemnifiers?

[Neel]
I don’t think you’re disadvantaged at all, to be honest. I wouldn’t be advocating it if there’s any disadvantages. I think you’re more secure, I think you’ve got more chance of being heard fairly, I think you’ve got more chance of having the correct cover, more chance of less disputes.

The only thing I would say is insurance based, and this is a tricky one, you have to know the terminology. Now we’re not used to the terminology because we’ve had mutuals for 90% of my career. So it’s really important. And again, with the recommendations, find out from people who understand insurance, they’re the recommendations.

Like we had Prateek Akhoury doing one of our indemnity webinars, and he’s got a medical legal background and he spoke really fairly on the pros and cons and what he looks for. Now he’s a member of ours, but he also said these are the negatives and these are the positives. So someone like him who understands it is a really good recommendation.

Whereas someone who just saved 500 quid may be not the best recommendation. But you have to know terms such as claims made, claims occurred, runoff cover, and retrospective cover. Because people get confused with them all the time. And I’ve even seen some of the-

[Jaz]
We need to cover all those. We need to because- let’s go deep now. We need to cover all those because this is like, in Insurance 101, the questions that you probably get asked day in, day out, every time someone’s inquiring about joining. But before we get to those four things that you mentioned, which are so important, what I’m trying to just get my head around is, do you know what percentage of dentists are with a mutual, with a big indemnity and what percentage are with insurance?

And because I feel as though people are still with the indemnity. More. And why is that the case? With everything you’re saying, with the whole discretionary color. Is it the fear of change is it, what is the reason?

[Neel]
Well, I think mutuals are still the majority. I haven’t got the figures. But I would say my guess is the largest mutuals have got maybe half the population of dentists, maybe a bit more. So gone from 90%, 95% because the only 5% who wouldn’t go mutuals back in the day would be those who won’t be covered. So they’ve had a few cases, they’ve had lots of payouts. They get booted out for the protection of the members.

So I would’ve said it’s gone from 95% to maybe 40 to 50. So the Exodus is there and the exodus is probably the under forties, under fifties. So I think there are a lot of dentists, maybe my age and older who’ve been with a mutual all their life, haven’t had a claim. Happy to pay what it is they’re used to paying that.

And as they come to the end of the career, they don’t really want the risk of being let down because they don’t understand the product and they’re hoping that the mutuals will be around in 10, 15 years, which I don’t think they will be, but they’re going with what’s familiar. And as we get older, we don’t like change.

Some of us don’t like change so much. So we’ll go with what’s cozy. We’ll go with the cozy slippers rather than the new shoes.

[Jaz]
Well said. And so, if someone’s thinking of switching from indemnity insurance, the first question they’re going to have is I’ve been with X indemnifier for 25 years of my career. And now it’s just getting like, I haven’t any claims and now I’m having to pay seven grand.

I don’t even do implants. This is ridiculous. And they have a look at you and they might get a much more favorable quote. But now they’re looking at the terms like how to understand the terms. What is runoff cover? And just explain what runoff cover is, why we need it. And how you factor that into the product?

[Neel]
So I’d have to go back one step. So there’s two types of insurance product. Claims made and claims occurred. Would you like me to explain that now? Because that would help with the next question.

[Jaz]
Please. And if you remind me which, do you know which one I’m on? Because you told me at the time, but it’s just there in the contract somewhere.

[Neel]
For client confidentiality, I’ll tell you later. Because I’ll tell you why Jaz, because you are very influential. And you know what people will do is they won’t make their own decision. They’ll go, Jaz is on this. So I’ll do this. And I think it’s really important-

[Jaz]
You explained it to me at the time and we went with that because we said, okay, that’s what’s best for me as an individual. But that was like five years ago and I haven’t changed. So that’s why I don’t mean to say that I don’t care about my indemnity. It’s important in my insurance, but it’s a distinction which I’m happy to learn about, relearn about from you now.

[Neel]
Sure. Well, there’s no right or wrong and they just both got their pluses and minuses. So Claims Occurred is pretty straightforward. It’s like the mutuals. You pay an insurer for that year. And that year, they bank it, and they cover that year in perpetuity. So if anything happens from a claim from 2017, you go back and you think, I was with dental protection, or I was with the PDI, I had a claims occurred policy, I’ll go back to them. So that’s what we’re used to. We paid our year and it’s covered.

[Jaz]
Let’s just make that really tangible. It’s now 2023, and I saw a patient in 2017. I stupidly took out the wrong tooth. This didn’t happen, by the way. I’m just saying, okay? Or I did something accidental. And the patient now is complaining about something that happened in 2017. So, do I now need to look at my records, like, who was I paying in 2017? Or, is it who am I paying now that’s going to defend me for this claim?

[Neel]
That’s exactly why it’s complicated. It depends if your claims are made a claims occurred.

[Jaz]
Gosh!

[Neel]
I know. So let’s say your claims occurred. You were in dental protection, and you moved to a claim occurred product. Which is the way most people go. So you’d go back to 2017, look back who you were with, and say, right, I’m covered with them for the rest of my life, I’ll go back to them. Now, that’s an advantage is because you can rest assured if you ever stop working, those years are covered for life. So you can stop and start your insurance, you can go on sabbatical, those years are covered.

The baton is being held by that person at that time. The downside is it’s more expensive. Because that insurer or indemnifier has got to cover you for the rest of your life. So if you’re a 23 year old dentist, they’re holding that for another 30 years. The other downside is, we had a friend of mine, two years ago, so 2021, had a claim from 1999.

A perio claim with six other dentists. How the hell do you go back that many years and try and figure out who you were with and look at everything? So, it is a trickier one. I mean, if you were with the same people all the time, he’d chop to change a little bit. So one, it’s more expensive, two, who are you with, and three, will they still exist and in what format?

Now, the mutuals are a funny one, because the government white paper every two or three years ago, pre COVID, when they were basically saying, we don’t like indemnifiers, we don’t like mutuals, no other country does it, no other profession does it. We should change. And that’s kind of put back a bit with COVID and all the other things that are happening.

But they are going to have to have some plan of becoming insurance based, I think. So. I’m guessing the government’s going to let them, not going to let them down, but what premium you’ll pay as they move from indemnifiers to insurers, I don’t know. And whether they’ll want some top up or something. So that’s the downside of claims occurrence.

But the upside is, it’s very secure. You’ve done and dusted, and you don’t need any runoff because runoff implies is a Claims Made product. So I’ll go back to a claims made product. Claims Made products are cheaper which is nice, and the baton gets passed on to the next person, to the next person, to the next person.

So, at the end of 2017, your insurance finishes, and it’s like car insurance, it’s gone. So, no matter what happened, they’ve ended their contract with you, and the next person who comes along will then claim it. So you’re still driving your car in 2018, but the insurance for 2017 finished. Who’s your current provider is, and if you have an accident, it’s reported in 2018.

Doesn’t matter when it’s happened, its claim was made in 2018, and so you would go to them. So my analogy is a bit of a relay race. I’ve used this a few times. Let’s see if it makes sense. So with claims occurrence, there’s four relay runners, everyone.

[Jaz]
And just to clarify, Neel, Claims Occurrence is how the mutuals work at the moment.

[Neel]
Yeah. Exactly. So, you’ve got a 4×100, if you remember back to your school days, and there’s a baton that normally gets passed around, and that races your career. So the first person runs, then the second person, then the third person, then the fourth person. That’s your career. And those four people are different indemnifiers.

Now, with claims occurrence, each person keeps his baton. So he doesn’t pass it on to the next person. The next person just runs with their own baton. Next person runs with their own baton. Next person runs with their own baton. And if you get a claim anywhere in that race, anywhere in your career, you look back to who was holding your baton at the time.

That’s claims occurrence. Claims made is more like a proper relay race. The baton gets passed. So then one person has it, next person has it, next person has it, you get to the end of the career, the last person standing has a baton, he covers the whole race.

[Jaz]
Okay.

[Neel]
So you know who you’re with, you don’t have to go back looking to see who it was, you’ve paid less money because the risk for each insurer until the end is less, but someone always has to hold the baton.

So in claims occurrence, if you stop running for a little bit and say, I’m going to have a rest. You can relax because you’re not paying any insurance, the past race is covered, you can have a, go and have a baby, you can have some time off, you can go on holiday for a year, you don’t have to pay. With claims made, as soon as that last person drops a baton, nobody’s got the baton.

So someone always has to hold the baton till the end of your career life. And even if it’s only a nominal amount, someone still has got to pay because they’re covering all the race. So you can’t just stop indemnifying.

[Jaz]
But, my rationale, my thinking now is because after 2017 or 2016, in 2017, when I switched from a mutual to you guys, everything 2017 and before is already covered always because I was with a traditional mutual company at that point. Right?

So now let’s say, let’s project to 2030 because I’ve remembered which product, I’m with now. Let’s assume I’m with a claims made product and let’s go to, let’s project to 2030. And in 2030, and so just follow me here. I’m going to try and keep numbers. Fine. 2030. we get a claim that, so there was some perio issue in 2023.

So today I did some perio issue and 2030, there’s a case that I just got the letter. And then, so basically, I’m assuming I’m still with you at that stage, right? It doesn’t matter who I was with in 2023. It’s the fact that you’re holding the baton in this 2030 when the claim has been made, you’re the one who’s covering me.

[Neel]
Yes.

[Jaz]
But for the privilege of having the previous seven years covered, I’m paying a runoff cover. Is that correct?

[Neel]
No.

[Jaz]
Okay. Now this is okay. This is where I understand. Okay.

[Neel]
So with your claims made policy, so going back to that relay race and you got to the end of the race and you’re on a claims, let’s say claims a current policy. You can relax, you can retire. All the past years are covered. So the last guy might have been us, the guy before them might have been Densura, the guy before them might be BDA, all claims are current, and before that was under protection.

You can think, I’ve gotten to the end of my career, I’m all covered, as long as those people exist, or whatever form they’ll exist, they’ll have to indemnify you in some way, you’re covered. Now with claims made, it’s only the last person standing who’s covering the whole lot. So it’s not in his interest to keep carrying it for years and years and years. Because it’s like, well, why am I, you’ve paid hardly, I’ve only paid one year’s premium and I’m covering the whole lot and now you want to retire.

So each claims made policy has a built in runoff. So what they’ll say is, I’ll hold this, I’m at the end of the race, I’m a bit knackered now, I’m sweating. I’m holding this. How long I hold this for is my runoff cover. So you’ve retired and it’s back 10 to 15 years. So they’ll say, I’m going to hold this for 10 years and most claims come within 3 to 8 years.

So 10 years or 15 years or whatever it’s going to be when you retire, you don’t have to think about it until then. I will hold that baton. So you’re covered at, now if you got a claim at 20 years, you’d be really unlucky, and also a claim has to be put through, as you know, from the time that the patient find out about it within three years.

So they’d really have to find something really a long time away, they don’t have to go to the dentist for 25 years and then find they have a problem. I mean, it’s not, it doesn’t happen. So runoff is-

[Jaz]
So runoff is for when you take a big break or retire?

[Neel]
Not a big break, just retirement. Just retirement.

[Jaz]
Ah, okay, okay, okay. But what if someone’s going to take a sabbatical for a year? Right? And you’re with an insurance product and its claims made, you still need to pay for runoff cover, right? For that one year?

[Neel]
It’s not runoff cover, you just pay for cover. It’s not runoff cover. It’s just, you need to go and cover because even though you’re not working that year, someone’s got to pick up the last year and the year before and the year before.

They might be a nominal amount. And to be fair if it, maternity, we tend to just pause it. The guys are really good. They could ask and we just say, look, actually, your risk probably isn’t any higher. And in COVID, we extended it as well. So for a couple of months, so it’s a chat with your indemnifier and you say, look, I’m going off for a year and it might be that, okay, look, we’re covering 15 years’ worth of you.

We need something, or actually you’re on maternity. You’ve been with us a long time. You’re a good client. We’ll just pause it and put you back on cover. But with claims occurrence, you can have those holiday break. You either pay now or you pay later. With claims occurrence, you paid earlier. So you paid bigger premiums to cover it.

With claims made, you pay a bit later because at some point it’s going to catch up with you. So it really depends on whether you want to deal with your current insurer all the time, or whether you want to go back retrospectively. So I’ve got claims made, and I’m sure Cam won’t mind she’s got claims occurred.

So I know I’m going to be working for the next five, six, seven, eight years. I’d rather pay less of a premium. I’d rather deal with the person. I don’t want to go back and try and figure out who I was with. I can look at my current indemnifier and I’m happy with that. Now, Cam might have a career break and she’s paying, let’s say 600 pounds more than I am, but she knows she can stop for a year or two and just not have to worry about keep insuring herself.

[Jaz]
Okay, so for those two years, she doesn’t need to pay and she doesn’t need a product for those two years.

[Neel]
Yeah, but she’s paid more for that privilege. So, it swings and roundabouts, there isn’t a right or wrong, and again-

[Jaz]
It’s an individual thing-

[Neel]
That’s why we you to have claims occurrence is if you’re chopping and changing. So, if you went from a claim made to claims occurrence to a mutual, you could end up with gaps in your cover. So, that’s why it’s really important, if you are thinking of moving, luckily, we’ve got like 99% retention, but we always say, look, not every dentist and every patient works together.

If you want to leave us, that’s really fine, but don’t just go without telling us. Because they’re the way that we have to make sure that you’re being looked after. Because I know people who, I know one person who went to another provider and they didn’t pick up the retrospective, which we would do. And it’s very naughty.

It makes their premium a bit lower. But they don’t tell the client. Now that client has got three years without cover. Because they went from a claims made to claims occurrence and the claims occurrence didn’t pick up the retro cover. So where you get mixed up is-

[Jaz]
Now this is where it’s getting a little bit confusing. Yeah, that’s where I was getting mixed up, my friend. So I understand now that runoff cover is something more to worry about in retirement. So that if you’re in your 70s, there’s a claim that you are covered. So I get that now. But this retrospective cover, can you just give an example scenario of what might happen if someone left an insurance product, but how could it transpire that they would have, give a scenario where they might, they have gaps in their cover. How could that transpire?

[Neel]
So let’s say you had a claims made product, then another one, and then another one. The baton gets passed so that the third person is covering the three years.

So you’ve just stuck with claims made and the baton keeps passing. So the latest guy is covering the whole lot. Now you move to a claims occurrence policy. And the claims occurrence policy is with a different, newly formed big indemnifier, let’s say. That’s British. And, they naughtily weren’t covering more than three years back.

So they would say, yeah, here’s our premium, it’s five grand, and we’ll cover, in the beginning, they weren’t covering anything. To be fair to them, now at least they’re covering three years. I think three years. So they would cover the last three years of claims made. But if you are within the fourth year, you’ve now got a gap.

So they aren’t covered, they’ve left you without a gap. They may not have told you you’ve got a gap, but unless, I mean we have this so been-

[Jaz]
If you’ve been in four years of insurance and then you go to this-

[Neel]
Claims occurrence policy.

[Jaz]
Let’s say in the fifth-year, claims occurrence, yeah. So the previous three years are covered, but that fourth year back, that will get left uncovered. Yes, because there’s no retrospective cover beyond three years. Whereas with you guys, let’s say people are moving away from other insurance products, and they’re coming to you. If you do a claim made one, then it doesn’t matter because you’ve got the baton, you’re holding that baton for all years.

But which I finally sussed it out now, but now if you, for some reason, that dentist like Cam wanted to have a occurrence one with you for that year, you would then also include in that product, okay, but now we also need to give you retrospective cover for X number of years.

[Neel]
Yeah, we’d pick up the whole lot. Now again, I said things around about, it’s going to cost you a little bit more because now we’re not just covering one year, we’re covering four years or 10 years. But we would ensure there’s no gaps in your cover. It’s really important for us that when you’re with us or you leave us, we really want you to have no gaps in your cover because it’s really dangerous.

And I think it’s remiss of some other insurers who might go on price or whatever their reason of doing not to be, because they’re not insurers. They may not understand what the consequences are. They’re just looking at this is the product we’ve got. This is what you could have. And the dentists don’t know what they’re getting.

So, it’s really important, again, that you actually speak to an expert. And I’m just a dentist, and I’ve learned, like, you’re learning, in front of my eyes, and you’re picking things up. And I’ve picked it up for four years. But you speak to Gary. He’s been doing it 10, 15 years. He will tell you straight.

And the great new, the really good thing about us, we give you honest advice. We never tweak the facts to suit us. As a dentist, as you’re my friend, there’s no way I’d want you to be cajoled into anything. We would just say, this is what it is. These are the pros and cons. If you want to leave, this is what you need to do.

We just want the best for you. And it’s a bit like our patients, we just feel like we do the best for them, then the business will grow, whereas I have found some insurance companies, they think differently, they’re not healthcare, like, in healthcare, we care about the patient first and hope for the rest, generally, I don’t know if that’s changing, but insurances, let’s make our, it’s a business, and the money comes first, and then the dentist comes second, which is why I think what we’ve got is really kind of valuable. It’s dentists first.

[Jaz]
Okay. Just so that I’ve cemented, because I’ve only got one more question after this is, just so cause I’ve learned a lot here, just so that I’ve cemented my learning, is the following statement correct? I am a dentist who’s been practicing, I’m making this up, I’m a dentist who’s been practicing for five years.

For these previous five years, I have been with either, DDU, Dental Protection, a big mutual, okay, indemnifier. So, therefore, that’s a claim occurred agreement that I had with these. So, last five years, I’ve been with a traditional big company. I will now move to, let’s say, your insurance product, and I will decide with you which one to go for.

The only real option, the only logical option there is a claim made one, because the previous five years will always be covered, right? Am I right in saying that?

[Neel]
Yeah, the previous five years, but whether you have a claim made or a claims cleared in your sixth year is entirely what you want to do. We don’t have to pick up the retro, but you might think I want that year claim that year covered for life, like I have been.

[Jaz]
Ah, okay.

[Neel]
Or, do I actually just want to have one year and then it finishes and then move on? And again, that depends on your circumstances, career breaks, how you feel about things. And also, what we’re tending to do is maybe five years before your retirement, we’re moving from claims made product to a claims occurrence product, and bundling the whole thing together.

So you don’t have to worry about runoff. We’ve put it all together, so your runoff then becomes indefinite as it would with claims occurrence. So again, if you have five, six years before retirement, we might just look at you as an individual and think, okay, do you want to pay a bit more now? But then the advantage is rather than 10 years runoff, you’re going to get that for a perpetuity.

So that’s why it’s really important just to not just, don’t just sign something. Don’t just go and quote, have a chat. Here are my circumstances. What do you think is best for me? Let’s get from there.

[Jaz]
Yeah. This is why I appreciate it. Every time I renew, and I just check and you keep me on the right course, which is great. It’s nice to have that personal service from you. But yeah, what I meant, but yes, you’re right that if you’ve been with a indemnifier traditional one for the last five years, you definitely don’t need any retrospective cover. But which policy you choose, claims made, claims occurred, depends on you and your circumstances.

So it’s good to have that chat to decide what’s best for you. And would you say for the majority, it probably would be a claim made policy for the majority who are thinking they’re going to continue to work for the next however long. Would you say that’s the case?

[Neel]
I think for a youngster, define that how you will, 10, 15, 20 years ahead of them. Maybe they’re early in the career, they’re cost focused, they’re not going to have a career break and they just want to put their head down for the next 10 years, claims made is absolutely fine. I think if you’re in your last five years of retiring, if you’re looking to have a year or two out, whether you’re studying or sabbatical, maternity, then probably have claims occurrence.

That’s kind of a broad stroke. Just to clarify one point, we’ve said the mutual act like a claim’s occurrence product. They aren’t a claims occurrence product because they’re not an insurance-based product, but just for making things clear, they act like one. But again, they aren’t insurance based.

There’s no policy. There’s no document. There’s no regulation. It’s a handshake. If they were insurance, they’d call themselves insurers and they’re not allowed to, which is why this word indemnify comes along, because it’s another word to kind of say, well, not insurance based, but we kind of need to come up with a word. So it’s indemnity, lower than insurance, as it were.

[Jaz]
I’m just going to pitch you another random scenario because I think these scenarios help us to understand. Let’s say you’ve been qualified five years and you have been going with an insurance product such as yourselves, and you decided, because you’re a youngster, and you envisaged that you’re going to be working hard head down, and you want, you’re saving towards a house, so you want to keep your cost lower as well. And you don’t want to pay for the claims occurred. You want to do claims made. It’s going to save you some money, but also, you’re going to make sure the baton is held for the next however many years every time you renew the product.

But life happens. Life happened and you just, and you fell in love with a girl from Costa Rica and you go to Costa Rica and you, and you want to spend the next three years and you want to go fishing for three years, right? So at that point, for those three years, would you still then get a product, a non-clinical insurance product saying, okay, I’m going to be, I need a product from you to cover me retrospectively for the last how many years I’ve been practicing, but I’m not practicing now. And then you just give a quote for that.

[Neel]
Yeah. So you can buy sort of retro cover, like you stopped working, but you still need to have the last year claim covered. So you can have that year covered, and then the next year you can have it covered, and then the next year you can have it covered. The problem is it’s really expensive. It’s a premium again.

So it’s almost like if you pay three grand for a premium, and you stopped working, but you still need to cover last year’s, and you need that retro cover for one year as a separate policy, that retro policy might cost you a couple of grand. It’s really expensive to do it. And it’s not just a one off. That one off doesn’t pay you for the rest of it.

You have to keep paying it until the next 30 years. So you can do it, but it’s mega expensive. What we would rather you do is either you continue as an insurance product, but you say I do nought days a week, and so, but I’ll still keep covered, so you can go on our lowest premium possible and pay fifteen hundred or whatever you’re paying, which would be a cheaper way of doing it until you come back, or if you could say to the Venezuelan lady, ‘Can we just go in six months, and I’m just going to move to claims occurrence.’

I’m going to tie up all the retro, and then we can just do what we like. So certain decisions are a bit harder to manage. We’d rather you just give us a bit of time that we can move it to claims occurrence. It’s a cheaper way of doing it, rather than having to pay that retro cover every year for the rest of your life, or leave it exposed.

And GDC, I think, doesn’t allow you not to be undercover. So actually, if you have a missing year, and that’s why we’re talking about when someone went to another indemnifier and they missed a year. They’re actually putting that person in breach of the GDC because they’ve left them without a year of cover.

So I think it’s really important. I think the bottom line is it is complicated. It is a bit confusing. It’s taken me a couple of years to get it. You got it very quickly.

[Jaz]
No, but this is why, Neel, I think this is why 50% potentially plus are still with an indemnifier because there’s so much to get your head around that, and I’m hoping this episode has helped in some way for people to understand, but ultimately whoever you’re going to choose, you need to be able to be able to WhatsApp them, pick up the phone with them, have a chat and decide what’s best for you.

And I think this is why I go with you because I’ve got you at the end of the phone and I just, I just say, Neel. Here’s my scenario. What do I do? And obviously I came out from Singapore, and he explained to me and stuff. So I think that’s why I’m with you and that’s why I’m happy to recommend you on this podcast if you like.

But wherever you go with, make sure they don’t leave any gaps in your cover. Make sure that you understand what product you’re signing up to and that they’re going to be there to support you and help you with your decision making.

[Neel]
And the safest way, if you’re not so concerned about the intricacies and cost saving is probably a claim occurrence policy with the retrospective period back to your mutuals. They’re the two things you need to look for. Is it claims occurrence and are you retro covering me for the last few years until before, when I left the mutuals? If you’ve got those two things-

[Jaz]
If you’re literally just leaving the mutual now, if you’re jumping the ship now, then you don’t even need retrospect to cover.

[Neel]
Just stick with them and then claim occurrence and you’ve got a not a like for like for like product It’s better, but you’ve got a thing that works in the same. You have a claim you go back, and you can you speak to them.

[Jaz]
Great. Now the biggest thing that we want from anyone who’s looking after us and indemnifiers, insurance product is when you get that complaint letter or when you just have that queasy feeling in your stomach, and you just need to speak someone and on the forums X speak to indemnity speak to an insurance. Speak to whoever you get tagged whatever how easy is it to get in touch? Is it email? Is it phone calls? Like how is support available? Because that for me is the most important thing. I’ve only had to use you guys once and it was like a really minor thing and just dealt by email and was like, I did nothing ever came of it.

And so I never even replied to that email. I’m sorry that never applied guys. It just never happened. So what’s the support like?

[Neel]
Well, I think the support is very good. And I think the way I feel it best works is. When you get a complaint, and I’ve had complaints, it’s really soul destroying. You feel like you’re stabbed in the back, you’ve done your best for the patient, you’ve really tried. Now, whether it’s communication, whether it’s the system you work in, or whatever, but whatever you do, we’re all trying to do our best. So, you’re upset, you’re angry, and you want to talk to someone quickly.

So, most people, and I would say, just WhatsApp me. So, you can WhatsApp me and Gary, and I think I’m on my WhatsApp eight hours a day, unfortunately. You know, that’s the phone. I will normally say, when’s a good time to speak, and I’ll talk to them. And they’ll either just want, what’s the helpline number, or who do I contact, or I’ve got a letter, and I’ll put them the right way.

Or they might say, well, nothing’s happened yet, but I’m upset about something, and I just wanted to chat. So, we’re always there to put an arm around you and just say, okay, what happened, okay, let me explain. And see where it is. And then if they want to go to some proper advice, I mean my advice is reasonable, but you really want, if it’s getting serious, you want some proper advice.

What we’ll do is we’ll put you to, we’ll give you the broker’s number, email, whatever you, however you want to contact them. They’ll data gather what’s happening, i. e. the notes, records, put everything together. And from there, we’ll make a decision. Do you need to speak to a dental legal advisor? I. e. it’s something more clinical or something that based or actually is this a lawsuit now you need to speak to lawyers.

And the two act very in different ways really and you have to have courses for courses. There’s no point having a dental legal advisor trying to represent you in court. So we try and add that way for the funnel you and then figure out which pathway and then you will liaise with them. And with us, if you have any issues whatsoever, if you feel like someone’s letting you down or you’re not getting through someone, WhatsApp me.

I’ve got the hotline to Batman, and we will get it sorted for you. So, sometimes mistakes might happen, emails going to junk, you’re not sure about something. What we do is we’re your advocate. You’re not alone. We want to help you through the process emotionally and making sure you’re getting the right people.

And our lawyers are probably the biggest law firm in England. So I think to be honest, most lawyers deal with a few different insurers anyway. So whether you’re with dental protection or with us or whatever. There’s a cross reference of lawyers that people will use, so you know you’re getting a very experienced and the best lawyers and the best advice. And if you’re not, you come and let me know and we’ll make sure anything’s sorted out.

[Jaz]
Neel, having you on WhatsApp is like having your technician on WhatsApp and sending cases and just communications there. And I feel supported, which is great. But I’m going to ask you a tricky question, a bit of a curveball. I’m sorry for it, but I have to do it.

Let’s say you decide that for a family move, you want to, in five years’ time, you want to move to Singapore. You, Cam, are you going to move to Singapore, live the good life in Singapore? And you said, you know what? I’m going to sell PDI. I’m going away. How are things, how are contingency plans and insurance products there to make sure that everything is well looked after and everything’s in order? Is it just you or like, how does it actually work? I’m sorry if that’s a tough question, but I think these are things that we need to know.

[Neel]
Well, it’s a very good career because your career will be longer than my career in indemnity. So we have to see where we’re going after that. And you want that support and help. So as you know, my little one is two, so I don’t envisage ever retiring. So, I’ll probably cut my clinical right down. But to be honest, the indemnity side of thing is actually, I wouldn’t say it’s fun because insurance is a really boring subject. And if you’re just based on insurance and getting premiums and be a salesperson, it’s not for me.

But what’s really nice about my job is helping a dentist pick up the phone, sharing my experience, helping them get better. A bit like you, educating dentists to be better, record keeping, I know you’ve done some brilliant stuff on that. So I can’t see myself retiring, or at least not being a figurehead or being part of it.

And also Cam will be there as well, and she’s a little bit younger than me, so she’s always there as well. So the continuity is going to be there. And by that time, Aria will be a dentist as well. So we’ll have, so it is there, but to be honest, if we just disappear, let’s just say, COVID three, whatever-

[Jaz]
You mentioned, you’ve hinted a few times that there is a doubt whether these other products like the claims occurred, traditional mutual company may not be able to do the handshake product for much longer.

You never know, but this could be the case. And so there’s that uncertainty, but there’s uncertainty with any insurance product that you take basically, but because the baton is renewed every year, I guess that’s what keeps you, keeps it alive, right?

[Neel]
And also your product actually isn’t with us. We are introducers. We are there as your advocates. We are there to help dentists get looked after. Your actual product is with the insurer. And the insurer is, the amount of capital they have is much, much higher than the mutuals. I mean, they are, billion-dollar companies that aren’t going anywhere with the city of London tower blocks.

So your product is always safe for now. And if we’re not there, they’ll still be there. Brokers will still be there. And hopefully we’ve instilled such a good relationship with the team and the brokers that you’ll be equally well looked after. And that’s what you want from a practice, isn’t it? But the principles there are not, you’re going to be there well looked after.

So, hypothetically, 10 years, 15 years down the line, will we still be there? I can never say. But your product will still be there. Your underwriter will still be there. Some form will be there. And hopefully our legacy will still be there.

[Jaz]
Amazing. I think I’m happy that we covered everything because I want to dispel this topic. I learned a lot, as you know. I feel like relearning and stuff because I feel like you explained this stuff to me before, but it’s something I don’t often think about. Thankfully, indemnity insurance is a boring topic. Let’s admit it, right? But it’s such an important one. That’s why we had to talk about it.

So is there anything else that you feel we need to touch on to make sure we’ve armed dentists with enough knowledge about this topic of traditional indemnity versus insurance?

[Neel]
I think probably the take home message is don’t just go on recommendation unless it’s someone learned who understands the product and don’t just go on Facebook if 10 people say something it’s not valid it’s still good to have and it’s a start but do your own understanding make sure you understand the terms even if you don’t want to go with us ring me up and just say Neel I don’t quite understand I’m happy to spend 10 minutes with you explaining it for your own good because you might not want to come to us, but you’ll come to us next year or the year after.

It’s all goodwill. So if you’re not sure, if your indemnifier is not helping you understand, give me a shout on Facebook, Instagram, whatever. So, the bottom line is I’m here to help you whether you’re a client or not in terms of understanding the policy. And second thing is please in an environment of a practice which is supportive where all the team are on board because complaints happen right from the start, when the patient walks in the reception doesn’t smile.

So make sure you’re in that real team effort where you’re supported. And then obviously, third thing is writing your notes and keep learning. And again, I learn every time I watch one of your podcasts and even at my age, it’s really good to just keep going. Don’t get down a funnel of misery because learning is fun and learning new things is fun.

And so don’t feel it’s all doom and gloom and indemnity insurance. You can have like lots of dentists, never a claim, happy patients, productive life. It is possible, so don’t let this topic, understand it, but don’t let it think it’s doom and gloom. This is actually here to support you. And then the odd niggle comes along, we’re there for you, that’s what you’re paying for.

[Jaz]
That’s right, and it’s something that I think you should focus a lot of time and energy on, well not time, but energy and thought and brain power into when you’re at the decision-making stage. Once you did it, once you signed the deadline, set and forget and enjoy your life, right? And then if you ever need it, then have that support.

And we’ll have to discuss how you want people to contact you for advice and stuff, because I imagine a lot of people will be like, you know what, Neel talks a lot of sense, let me get in touch with him. Do you want your phone number, lots of phone calls and stuff, or maybe email and to filter things on Instagram. So we have to figure out a way of doing this.

[Neel]
Well, yeah. I’m happy to email me. That would be easiest. And it’s a Neel, [email protected].

[Jaz]
Amazing. I’ll put that in the show notes as well. Neil, thanks so much for your time and we have got a whole series coming up of staying out of trouble.

And so we’re going, I’m not going to reveal any more about that just yet, but there’s lots of different scenarios. We’re going to cover real world scenarios, because I think it’s part of education. Whilst it, this was a big burning question indemnity versus insurance. I’m a big, I like scenarios.

Like those random scenarios I gave you. I love scenarios of what happens if, literally I Instagram saying, Jaz, can you help me? I gave a restored an upper lateral. I gave some local anesthetic articane with adrenaline, and now the patient’s got a droopy eyelid. Now they’re getting severe headaches the day after.

I’m panicking. Any random scenario, basically just what are the things that we should be doing? And then we can look at the factors before it happened. Factors during factors afterwards, how to make sure ultimately our patients are well looked after, but also so it doesn’t steal your piece of today that you can sleep well at night. So those are the focus scenarios that we’ve got coming. So I look forward to that.

[Neel]
Absolutely.

Jaz’s Outro:
So there we have it guys. Thank you so much for listening all the way to the end. Hopefully it’s a little bit clearer now indemnity versus insurance, claims occurred versus claims made. I enjoyed the Rolls Royce analogy. I enjoyed the baton analogy. So who’s holding your baton right now and who’s holding your batons of the past?

If you want to take action on this episode, if you want to find a quote for yourself with PDI, who I trust a lot, I’m a big fan of Neel, such a conscientious, lovely guy. And just anytime I needed him with these kinds of matters, he’s been there for me.

Once again, you go to protrusive.co.uk/insurance, fill in the form and get your quote. You can inquire further by protrusive.co.uk/insurance once again. And for those Protruserati as part of the Protrusive membership, head to protrusive.app on this episode or on your app, answer the few questions and you get this very useful CPD when it comes to medico legal CPD.

Okay. So, you’re going to get a CPD certificate with the reflections all on their email to you by our team. Thanks so much again for listening all the end. I’ll catch you guys in the next episode.

One of the most common questions I get from colleagues is ‘Which Intra-Oral Scanner should I buy?’ – I don’t have the breadth of experience of testing all the scanners out there, but Dr. Gulshan Murgai does!

We discussed which scanner is best for your practice and how to choose the correct one for your needs. I hope you gain insight into the differences between the different scanners and help you move forwards a decision.

For me, one of the biggest takeaways was that it may not be so much about which scanner, but more about ‘what is the customer support and guidance like after I invest in one?’

Highlights of this episode:

Check out Dr. Gulshan Murgai supply company Implant Solutions Direct and also 4D Ceramix, which is a full-production crown and bridge lab

Connect with Dr Gulshan Murgai

If you liked this episode, you might enjoy the Story Of Digital Occlusion

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Protrusive App!

From the entire Protrusive Community – we wish Sanj a speedy recovery – keep smiling Sanj and stay strong!

In the previous episode with Sanj Bhanderi on ‘how to extirpate properly and efficiently‘, we briefly touched on postoperative pain control. In this episode, we’re focusing more on postoperative pain and the dreaded severe pain after the obturation appointment (or in-between visits).

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this episode:

Dr Finlay Sutton is coming down South for his one-day signature RPD Masterclass on Saturday 14th of January 2023!  Limited to 12 delegates, reserve your seat now!

If you enjoyed this, you might also like my episode with another talented Endodontist, Dr Ammar Al-Hourani, on Is Single Point Obturation Acceptable? 

Jaz’s Introduction:
I bet this scenario sounds very familiar to you imagine you’re on a course you having a great time. I personally love courses, I think you all know that. You’re on your fifth coffee, and everything’s going great. And suddenly your pocket starts vibrating. You’ve got a call from the practice or text message informing receptionist saying that, ‘Mrs. Smith, you know, the root canal that you saw yesterday, she’s in absolute agony.’ And you curse because you think wow, you know, that was a completely straightforward root canal procedure. The patient was asymptomatic before you even started. Why is this happening for me? Look, post-op pain after endodontics is an absolute bitch. It’s one of those annoying things ever actually puts me off doing root canal treatment because of the one in harmony of a chance that post op pain instance is going to happen. And I’m going to discuss with Sanj Bhanderi who does such a brilliant job in that GF016, where we talk about how to extirpate properly and efficiently. So if you haven’t listened to that one, oh my goodness, you are in for a treat. Go back and listen to that one. But in this episode, we’re focusing more on post op pain like how do you manage that kind of scenario? What do you say to the patient? How can you prevent this from even happening in the first place? You know, it’s funny I’ve actually had four root canals on my own self and before you think, ‘Oh, Jaz is disgusting, you got caries, etc.’ No, it’s actually trauma from orthodontics. Can you believe it? Orthodontics devitalize, my lower four incisors, and I’ve had all sorts of issues and root canals and fractures, etc, etc. And now have a resin bonded zirconia bridge, hence why I’m so passionate about those bridges. Anyway, I experienced post op pain myself, it was a nasty thing. It was lots of inflammation. And so I’ve been there and I totally empathize with my patients. Before we joined the main episode I want to say yesterday I released new tickets to Finlay Sutton’s mass class. So Finlay Sutton, he travels all around the world. He’s in USA last week. He goes Scandinavia a lot. He teaches us everywhere. If you think removable prosthetics you think Finlay Sutton. He’s just a phenomenal educator and the best in the space when it comes to removal pros. Now he came on for episode 56. How to make Chrome dentures easier. So check that one out if you haven’t already either. But he’s doing a live one day partial dentures maths class on Saturday, the 14th of January 2023. So if you’d like to join us go to protrusive.co.uk/finlay, that’s F-I-N-L-A-Y. It’s limited to just 12 delegates only. And it’s very rare chance to see him down south usually have to go to practice up north, or you have to go abroad. So this is very rarely comes south. And so if you’d like to join us, including the dinner, the night before, it’d be great to have you. So once again, the link is protrusive.co.uk/finlay. And there’s also a payment plan to split your payment into three if you need that.

[Jaz]
Anyway, let’s join the main episode.

Main Episode:

I recently created a gentleman I talked about this gentleman on the podcast necrotic canine very strange, severe bruxists, I think I suspect some airway issues we’re investigating at the moment, like to the extent that 50% of his canine is just shot. That canine was dark in color. My dentist who I inherited his list has been putting his, he’s had a couple of bouts of antibiotics in the past for this tooth, and he just felt he’s too young. He’s late 20s To have a root canal on a canine and he just couldn’t figure out why it went necrotic but it did. I tested everything. It was necrotic I went inside his canine. It was necrotic, it was infected. So I confirmed that, and then I did a root filling. And my goodness, and I’d followed all the right protocols hypochloride, gutta-percha, everything was done, took a high standard radiograph look good. There was no extrusion of the GP or anything. But my goodness was this chap in so much pain, and he ended up in a&e. They did some bloods on them. They didn’t find any sepsis, but they found high inflammatory markers in his blood is actually interesting enough. So that was my one really bad experience about four months ago. Otherwise, I don’t tend to get significant post op pain. But I’ve been with dentists at conferences and we’ve been at a conference on a course and the dentist nips at 11am because there was a root canal heated yesterday, the patient’s now in agony after finishing the root canal. What do we know in terms of Iiterature? You’re probably there lecturing and speaking your phone were vibrating. Mrs. Smith from yesterday? What is behind that? What causes that? Even in your expert hands, is it just bad luck? Or do you, do we know what causes it and then therefore, what steps can we take to minimize its occurrence?

[Sanj]
I think it’s quite multifactorial, some of it is, it is unpredictable. There are certain conditions that seem to predispose patients having what’s called a flare up of flare up by definition, the endodontic definition of flare up is this is in between treatment after treatment of treatments been performed, and the patient gets acute pain that requires treatments they have to attend to. That’s the definition of a flare up. There are a few things that I suppose we break down to patient factors, which are we told the anxiety levels we’re talking about. There are some certain genetic factors, some patients are more predisposed to pain, period. And definitely there’s a-

[Jaz]
yes, yes, absolutely. We know that from TMD, chronic back pain, the study of pain itself is we know that people are much more susceptible pain than others. Yeah, yeah.

[Sanj]
So on those physicals patients, and also talked about this symptomology, it’s patient management, if you pre-warm them, it doesn’t mean that there’s not gonna be out of pain, but they can handle it, it’s when they’re not expecting their pain. That’s when it the problem started in the, you know, just increases anxiety. And so it’s been a patient management and those patients who you’re going to kind of arm bells, these patients are a bit tricky. Or if you’ve seen patients before previous treatment, they’ve always taken the two second ages to settle down or even root. So that’s the first thing in terms of the actual tooth itself. It’s the inflammatory state of the two. So pre existing lesions, if there’s an apical lesion, radiographic lesion, those teeth are more susceptible for post operative or interrupted pain. Okay, so for me, the before the endodontic treatments, we always preload our patients with anti inflammatories, not just emergencies, but routine root canals, and especially retreatment. And especially if there’s a lesion already on the tooth. We know that they’re more predisposed to flare up. So, just preload them anyway, with anti inflammatories or painkillers. And then during the procedure, you’re going to do utmost to follow what we now call is everyone knows a crown down protocol, you do not want an necrotic case, the whole majority of that canal space is going to be infected. Often, it’s actually not the apical tissues are actually not infected. Just because there’s an apical lesion that apical lesion unless there’s an abscess, or separation, it’s not infected. It’s just the inflammatory process, we need to remember that. Because the last thing you want to do is put bugs into the apical area or even worse through and it can happen easily, I do. I’m sure one of the main reasons you get a flare up is because we’ve inadvertently push biofilms through, it happened some time. So we’re just gonna do our utmost to go down, Crown down. And so as you as you do that, part of the reason for that approach is you’re flushing out bacteria progressively without with minimal risk of pushing it ahead of the instruments. This is one reason going back to emergency treatment, you don’t fish around the root canals because if the canal happens to be necrotic, in that module, two of them are flying the other one and he shoved bacteria further down, you’re going to inoculate areas which weren’t actually infected. So that’s another reason not to fish around the root canal going back to the emergent situation. So this, in this situation, when it’s necrotic, that canine, you do your utmost just to work your way down. Now some endodontists, traditional endodontist, say you should be dressing all those cases, you don’t do those in one visit. That’s another area just decrease the bacterial load because calcium hydroxide. That’s the evidence suggests it’s probably doesn’t matter. He can do those in one visit. But there is the evidence for one visit.

[Jaz]
That reminds me actually that yeah, I think we’re coming to the same point. I believe there was a systematic review comparing one visit, two visit, and they found that they’re both equally successful, but you might get more flare ups and one was it is that where you’re gonna come to the

[Sanj]
Post-operative pain may flare up beat the patient, they will get more post operative pain that is

[Jaz]
post op pain. Yeah, that’s what I mean. So yeah.

[Sanj]
Flare ups a different situation. There’s also the patient factors in terms of their immune response. Everyone’s different, we’re dealing with immune responses, which are we can’t control apart from maybe anti inflammatories. And I think the body, when this happens, again, this happens in, they’ve got lesions, apical lesions, there’s an inflammatory process been going on for a long, long time, the patient has been asymptomatic. The body’s kind of, in simple terms, the way I explained to the patients, the body’s got to use to having an infection in the tooth, and it’s reacting slowly. Sometimes when we go in, it may not being that we’ve pushed every through, we’ve changed the balance, whether it’s pressure, whether it’s something else has changed. And we just disrupt that. And it’s a short term reaction they’re going to get I gotta warn them, when there’s a big you know, radiolucent area. You think these, these are cases they’re gonna kick off with doesn’t matter what how well you do the endo is going to kick off. I pre warn those patients. There’s a chance this is going to kick off. Okay? So it’s patient management, and if it does kick off, then you can deal with that. But it’s the fact that they know about it, they often won’t bother contacting you. They’ll say I just took anti inflammatories you see them on the second visit, visit to visit and thing was fine. It was settled down. So there are those situations you are-

[Jaz]
Now, Sanj you speak to your patients afterwards. You warn them big time, you document it, and you still have that you know you’re teaching at a conference and your your phone is buzzing. And you speak to Miss Smith from yesterday who had that feeling finally finished, and then she’s experiencing post op pain. Now, the temptation, oh my goodness, the temptation is so much for her to come in and then to do something and use that something is his amoxicillin 500 mg, or something like that. And that temptation is there and I don’t cave in. And that time he ended up in hospital and the hospital doctors gave him antibiotics. He got better, eventually. Okay, but do I honestly think it was due to antibiotics? I think he would have got better anyway due to inflammation is what because they found no microbials in his body. They found a high inflammatory marker in this particular instance, how should we manage it? Is it okay just to say ‘Look, don’t worry, you’ll be fine. Give it time’. Or is there ever a situation where antibiotics is justified?

[Sanj]
I think in antibiotic-

[Jaz]
and post op pain.

[Jaz]
Yeah, I mean, with the current guidelines and antibiotic microbial management, whether it’s nice or whether it’s endodontic European whatever. I think, if you start with a systemic involvement, now it’s again you got to be practical about this. If they’ve got, there’s an abscess like you say, fluctuation swelling can be cellulitis kind of symptoms. You know, this is not just localized. An apical periodontitis kicking off there’s definitely soft tissue involvement. Then I think, in the short term, even a short course of an antibiotic with anti inflammatories dosed up, I think that’s justified. If there’s no obvious signs of an abscess, cellulitis spreading infection, then you know, it is high dose and painkillers with or without codeine, if you know if it’s affecting the sleep, something like dihydrocodeine, DF 118, something like that, just to get them through that pain. And hopefully it’ll calm down. It is a tricky one, though, because it’s a nice, there’s a theory

[Jaz]
It’s so tricky.

[Sanj]
When you’re in practice, and you’ve got the patient there, but you shouldn’t really throw them antibiotics, you’ve got to have good justification for doing it. If there’s a fluctuation swelling, incise it, free the area, incise it. If you haven’t finished the endo open the tooth up. In terms of leaving open drainage 24 to 48 hours, you can leave on open drainage just to relieve that pressure, but you’ve got to go back and get them back in. Okay, go back and try and get some drains, so it’s back to surgical.

[Jaz]
Now in those scenarios, let’s say we we are in between visits. And let’s say we’ve done our crown down protocol where we’ve got the canals as clean as we can and we aim to obturate at the next visit. And it’s in between that initial cleaning of the canals and actually obturating the patient comes up with a flare up in between those two visits. So you’re not quite ready to obturate because you haven’t got that diary time to obturate. But the patient’s now sat there. If we were to go back into that tooth, let’s remove our a Cavit or Kalzinol and go back in, in this instance, would you recommend taking the file all the way to the apex? Or how would you manage that scenario?

[Sanj]
If you’ve got the working length, and yeah, just go back in and kind of semi re-prep getting just get the calcium hydroxide out. It may be the fact that you haven’t got the dressing material later length. One thing that actually worth mentioning between appointments always dress the tooth, never leave it dry and empty. Never. Always put something in it, a calcium hydroxide, the thing to do. The difficult thing is getting a calcium hydroxide in volume to length. You can be only squirt at the top end of the crown. So it’s going to have any effect apically, you don’t get the benefit of the properties. So open it up. The fact you open the system up you relieve pressure, because it’s usually apical pressure that’s causing the pain. Whether you get separation, it doesn’t really matter. I think you just opening up the pressure, some endodontists would say you go you got your work length, go a little bit patent, you’re not gonna do any harm. If anything, you might release or relieve any microbes that sits down there. And then wash out again hypochlorite redress and close up. And then your, your chemotherapeutics your anti inflammatories and things like that. Painkillers and things like that after that.

[Jaz]
Well, this was a tough question compared to an emergency one because it’s a scenario we hate, you know, as dentists and as an endodontist as well. We hate this scenario of finishing an endo and then they have that initial acute inflammatory reaction what we believe and they just, you know, just kind of wait it out and eventually it will get better. We know that. Okay. But it’s that, that patient at the end of the chair who’s suffering and we feel bad for it, I felt devastated sounds when that happened to to my patient, but I really do in my heart of hearts believe it wasn’t my fault. And I do think perhaps I shouldn’t have been so heavy handed, maybe. I was using rotary instruments for a canine and maybe some extrusion of the debris or dentin on debris could have happened. Exacerbating that inflammation. I put my hand up there that could, that could have been it. But in those scenarios, I think the lesson is, let’s not be too hard on ourselves. Let’s promote anti inflammatories. Let’s warn them that this could happen. And they can then self manage and not expected. But if it happens, they’re not like completely in shock. And then only if justified with swellings and cellulitis. Consider antibiotics and then I guess during the treatment, the Crown down approac. Now just for any students listening, last thing we’ll ask you is just describe, make it tangible, an example of a crown down approach for a molar inside a molar root canal, for example.

[Sanj]
Okay, I’m glad you asked this question because I think this is quite important from a technical point of view, but also from an antibacterial preventing a flare up. Because I think maybe majority of flare ups are due to back to stuff being pushed to the end, debris infected material. I think that’s the most common reason why. So the protocol is, you found the orifices this is when you got to time. Okay, so going back to the emergency dressing, the golden rule is just to recap the emergency dressing unless you’re going to you’ve got time to go down to full working length and confirm it. Don’t go into root canal space. Okay, that said, see your second appointment you can got the time. You booked into the root canal, you find the orifices and the only thing you’re going to do now is you’re going to confirm the orifice and we what we call the endodontist called scouting and here’s a 10 to 15 size file just to confirm that there is a patent canals there and what I mean patents, I mean patent coronal not to patency we’re talking about the end. Once you canal is there, then you go on to most people using rotary systems or reciprocating. I’ve got slight reservation about reciprocating systems, they’re not as efficient as removing debris. So if you prefer a reciprocating system, way one reciproc, or whichever one, just be careful you wash out more frequently, you clean the files more frequently, because they get clogged up because of the nature of the mechanism the way they think through its work. With rotary, you’re going to use the system in its sequence. Okay. My role is, and this is this, this goes against a lot of what the manufacturers suggest, once you’ve found the orifice, they often say ‘Get down, get a working length’. And then you go through the system. That goes against the principles of of disinfection, because you you could shove coronal bacteria, majority in necrotic teeth, majority of bacteria is at the top end. It’s not actually the apex, which I mentioned. So the last thing want to do is shove biofilm further down. So you’ve got to get rid of that. So the coronal preparation, the mid third is really important before you worry about working length, I do the majority of the preparation up to the estimated working length and knock off a quarter of that, I’ll do that blindly. Without an apex locator reading. How do I know that estimated length? I’ve got a decent pre op radiograph, and knock out a quarter, I’m safe. I know I’m gonna be well short. And I’ll go through the whole preparation sequence to that point. So that all I then got to do once I’ve prepared the canal to three quarters is confirmed the working length, I know everything’s clear, because apically, there’s gonna be no virtually no bad biofilm bacteria. And there’s less chance of me pushing any rubbish through. And also, because I’ve opened the system up, your working length determination is more predictable, it doesn’t change, because working length changes from the start of the preparation to the end, it gets shorter. So another reason if you do your working length at the beginning, by the time you’ve finished, you fled that, you prep, you’re probably going through the apex. If you keep that working length, as do the geometry in the curve canal. So I do the coronal three quarters prep without working, without worrying about the working length. And then I’ll confirm the work and then all it’s doing is finishing off. And you know you’ve disinfect every point with less risk of pushing debris through. So I think that’s really important, which goes slightly against a lot of manufacturers and some endodontic teachers teach. And I’ve stuck by that.

[Jaz]
Biologically, it makes so much sense to me, I think because otherwise in practice, it’s like a race to the apex which it shouldn’t be. It should be clearing just like you said the coronal portions first to allow you to get better access to the apex. So it’s very much. I listen to your lectures Sanj. Listen. I listen to your lectures. Sanj, listen, thank you so much for for giving up this afternoon to speak to me. We’ve made two episodes out of this space you so called group functions where we are answer one key pressing theme. So we talked about extra patients. So if you haven’t listened to that one, go back and listen to that one. It was it was brilliant. And now he’s covered his post op pain and flare up at the end you covered really beautifully. Just a good description of a crown down approach for young dentists and students to really connect and even just the oldies, I know what I should probably go back to doing that rather than going straight to the apex. So Sanj, please tell us about, I know you teach at the moment with institutions, but what kind of private courses do you do? Where do you do them? Is it all in Manchester? Tell us more.

[Sanj]
Yeah, so at the moment, I do, we do a good friend of mine, Ammar Al-Hourani was my post grad student. He’s now established in London. So we both run courses two and four day courses in London and Manchester, for convenience because I’m in Manchester and he comes out and I go down to London. it’s quite good, quite good fun. So we do four day courses and we’re going to be doing a longer program next year. We’ve got plans for doing a longer, summer like a diploma course next year. So we’re looking forward to that. And also do a, it’s a microsurgical course. We did our second one a few weeks ago and it’s the only, it’s a human cadaver course. It’s the only endodontic course that I’m aware of in Europe and that’s been going really well in Coventry so West Midlands we’ve got another one coming up in March I think is gonna be fully booked so that’s quite good and microsurgery is another little area of mine pet subject of mine so and a lot of people live with with interest in endo or specialists don’t come across good surgical training. So that’s something I think it’s really needs to be shared and then-

[Jaz]
Any website you can recommend for us to check out these courses?

[Sanj]
Now, most of the things, when once we’ve got days we wish you on social media and the usual dental forums and instant things like that. I’m very old fashioned like that. I’m getting into that or that sort of thing. But so yeah, that we put posts out we haven’t got a website as such yet so that’s that’s an ongoing thing. So should we getting any website for the practice all the courses will be there but essentially keep a lookout on social media.

[Jaz]
When you do give it to me, so I’ll put it on the on the YouTube and on the podcast in the summary. Because people want to know, you know people people enjoy the content let you know identify with this educator. I like the way he thinks. I like the way he or she speaks. And so therefore, I wanna be able to connect people who want knowledge to person who can help them upskill so please do send me those links when you can. And it’s no surprise that you work with Ammar Al-Hourani . He came on as a guest actually in the podcast some time ago. And we talked about, ‘Is single point arbitration adequate?’ Is it okay for dentists to do? And you know, he gave such a lovely just like you did a very real world, very diplomatic, very sympathetic to the plight of the GDP. So hats off to both of you. I love clinicians like this who don’t have that ivory towers there has to be this way. I hate dogmatic approaches. And so Sanj and Ammar if you’re listening to this, thank you so much, guys. It’s obviously great to have you as the endo buds on this podcast. Thank you so much, Sanj.

[Sanj]
Thank you as well.

Jaz’s Outro:
There we have it guys. The joys of post op pain now covered by Dr. Sanj Bhandari. Sanj, thanks so much for creating these two amazing episodes. And thank you protruserati for listening all the way to the end. Now you come this far, why not answer a few questions to claim CPD for listening to this. I think of all the different memberships that you have or the online memberships. And think when was the last time you logged in? When was the last time you used it? Well, you just listened to a podcast episode and you’ve learned something, hopefully. So once you actually test your knowledge, get the CPD certificate, and actually get some reflections as well. So if you’re on the app, you can do that. Now as a premium member, you get CPD certificates, a whole lot of exclusive content. So if you haven’t already, do check it out. Otherwise, I’ll catch you same time, same place. Bye for now.

When you Extirpate a Hot Pulp – do you need to find ALL the canals? Do you need to file to the apex? Which is the sedative of choice?

In this episode, we’ve got specialist Endodontist Dr Sanj Bhanderi to talk us through the CORRECT way to extirpate teeth in acute pain WITHOUT wasting time or making things worse for future treatment. It’s packed full of gems for pain relief, diagnosis and isolation.

So, what is your protocol for extirpation? This episode is all about how to get the job done right and minimize discomfort for your patient.

“I call it Ninja endodontics – get in and GET OUT – Stealth!” Dr. Sanj Bhanderi

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

Tune in for the Part 2 of this episode – next week we cover post-operative pain after endodontic treatment.

If you enjoyed this, you might also like my episode with another talented Endodontist,  Ammar Al-Hourani, on Is Single Point Obturation Acceptable?

Jaz’s Introduction:
What is your current protocol for EXTIRPATION? So let’s say you made a diagnosis of irreversible pulpitis. Your patient is in raging pain. And you have to squeeze in this pain relieving treatment, a extirpation probably of a lower molar or something in five minutes. What are you going to do? Well, some of you will listen to this and it will be validation and revision. And you’ll be thinking wow, I’ve been doing it right all this time, even though I thought maybe I was taking shortcuts but actually I’ve been doing it right all this time and others will be like whoa, this is so much easier compared to what I’m doing at the moment because the big hint I can give you is that you don’t even need a K file for your molar extirpation anymore after today, because I’ve got Dr. Sanj Bhanderi, specialist endodontist to talk us through what is the right way, the proper way to do an extirpation of your patient who is in pain. And there are just so many gems from pain relief, diagnosis, isolation, and what I love about Sanj in this episode, is that he’s not dogmatic. Yes, he’s a specialist endodontist and so easy for him or anyone say you must always use rubberdam. But yes, he does discuss a scenario that okay, if for whatever reason, you had to do it without rubberdam, how can you optimize the isolation? How can you reduce the saliva getting inside the tooth, so I really appreciated that about this episode. I’m sure it hope you will as well. It’s very much in tune with the real world. And lastly, we do cover his step by step what is the right and proper way to do an extirpation without wasting time and without actually making things worse for future treatment.

Main Episode:
So hope you enjoy this episode. And I’ll catch you in the outro. Dr. Sanj Bhanderi. Welcome to the Protrusive Dental Podcast. How are you my friend?

[Sanj]
Very well. Thank you, Jaz. Thanks for the invitation. Excited. I’ve done one of these before.

[Jaz]
Well, I’m amazed it’s your first time and it’s your real hero of mine, Sanj because I remember 10 years ago, I met you at the British Endodontic Society. Can you believe it was that long ago?

[Sanj]
God. 10 years? You know what? Everything’s a blur nowadays at my age. Yesterday, still seeing the same but no, thank you. It’s lovely to have, to be here. Thank you.

[Jaz]
Thank you so much. And I remember your lecture even then I remember some of your lectures the BDA and probably because our paths haven’t collide. I haven’t seen you. I know you’re very active with your teaching, but our paths haven’t collided since then that much, but it’s great to have you on to talk about a very important topic, which is how to get a patient out of pain in terms of your diagnosis, irreversible pulpitis. We’re going to talk about what is the optimum and best Sanj approved way of dealing with that you wish your referring dentist would do. And the other one we’ll talk about is post op pain. But before we dive into the nitty gritty details, just please tell us, listening it’s an international audience in terms of where is it that you work? What got you into endo a bit of your background?

[Sanj]
Sure. Yes, I’ve been in this game in endo anyway, for, well, dentistry, I suppose we go all the way back. It’s gonna be our 30th anniversary next year. So which is a bit frightening, so now I’m qualified in London, actually in London but I now live in Manchester enough sort of wormed my way up north to the northwest, maybe by accident, really, and just just hospital jobs initially came up, then I did my postgraduate training up here. I mean, back in those days 1995, there was no, there were only three postgraduate endodontic programs outside the hospital training pathway and that was either London or Manchester and I happen to be the right place, the right time in Manchester. I go on to the Masters quite young, actually quite early. I think it was the first one in our batch in our year and guys and I wasn’t I flying student at all. I managed to, there’s one to get an MSc and then I stayed in Manchester that time the mid 90’s I don’t know if you’re too young to remember Jaz but it was quite a good university. And it was a hot thing. I had a better student life as a post grad than I did in London. But, now, it was things were changing in Manchester the Dental School’s good I was teaching. There were not many endodontist one of the reasons I stayed up north actually because I needed a job prospects. This is before endo became really popular and I could see it in fact is by accident fell into endo it was gonna be either implants at that time there was an implant MSc and there was an endo MSC because that was one of the only endo at implant Msc in the country. I was too young I would never go on the people that got onto that were experienced practitioners and I’ve really had no chance but I, that’s where I was gonna go. Ironically, the opposite way and I ended up doing endo and it’s sort of taken off from there and I just got into Endo, the state of Manchester got job offers and I pretty much been full time endo day one from finishing the Master’s since 1997.

[Jaz]
So how many days are you clinical at the moment in terms of doing your endodontics referral practice?

[Sanj]
Yeah, so I’m pretty much now full, full time as in I was four days and at three days now. And I’ve got an associate Rob, Rob Jacobs, who covers me so. So I’m down to three and a half days, teaching now just in private courses up and down between London and Manchester with a couple of friends. So that keeps me out of the practice. But pretty much I’ve always been a hands-on clinician.

[Jaz]
So you’re very wet fingered, very clinical, you, you’ve got a great name in the UK as the person for endo. So again, it’s a privilege to have you on. The reason I have you on is because extirpations, I speak to different colleagues, and we all kind of do it differently. So I wanna find out what is it that you recommend? And I remember asking an endodontist, some years ago, what they recommended, and I got interesting answer from the endodontist. He said that, ‘You know what, as an endodontist, I rarely get to see the emergency extirpation cases anymore, because usually by time they’ve come see me there’s a sinus tract. There’s a perio endo lesion, and they’re really complicated.’ So firstly, I’m just being nosy. How much emergency extirpation do you get? How many of those phone calls you get? How many of you actually treat in that regard?

[Sanj]
In terms of the practice, you’re absolutely right there being an endodontist. We, by the time they get to us, they are non vital previously root-filled, or the dentist has had to go doing it. We get a lot of phone calls, and mainly from dentists. What do I do? How do I numb the tooth up and this sort of thing, we’ll talk about that shortly. But in that way, I’m kind of slightly lucky, although I know how to deal with it. And we have to back in the training, working in dental school, you’re in the emergency dental casualty where they call it nowadays. So you have to deal with that you have to learn pretty quickly. One of the reasons I went into endo is just okay, it’s not just about the white lines at the end of the endodontic treatment right in the beginning getting patients out of pain, immediately out of pain just until they relax and you get them back into the proper endo. That is really important. And in that way, I’m kind of shielded being in specialist practice, because it’s my general dental colleagues. They’re at the coalface and they’ve got to deal with that stuff on a Friday afternoon, just before they close patient will knocks in you know, they haven’t slept for a week and they’re anxious and nervous that never been to dentists, sometimes you got a lot to deal with, and you got to get them out of pain. And we can’t shove them off with antibiotics. It’s just not appropriate nowadays, medically legally, now you could get into well, or if something happens, so you’ve got to be able to get in there and deal with it efficiently, as painlessly as possible. And that’s a challenge because the tooth is extremely inflamed, and just stabilize everything so you can get them back in when you’ve got plenty of time we’ll get someone else to do it with whatever the protocols are. For that is important. Yeah.

[Jaz]
Before we go in for the for the kill and talk about the exact protocol that you would recommend to alleviate someone out of pain. Let’s talk a little bit further for the younger audience listening, those students who are listening right now, just coming up with a diagnosis of when it is appropriate to give antibiotics? Because perhaps necrotic infected and really, it might already root-filled or whatever. And then what kind of history and clinical findings are leading you to towards a diagnosis of irreversible pulpitis that needs that intervention that wouldn’t settle with antibiotics? Can you just give a distinction between the two different types of patients?

[Sanj]
Okay, so you’ve got two different situations, you’ve got the root filled or non root filled teeth, or we’re talking about the root filled tooth yet because that’s a different slightly different scenario, but on a tooth that’s either potentially vital or semi vital or partially necrotic or completely necrotic. Okay, so it starts from the disease process obviously starts at the top of the pulp typically caries, tooth fractures, bugs are going to get into that pulp. Now, sometimes patients will have very low grade symptoms and a niggle, a dull ache, maybe a bit of thermal sensitivity, and they kind of put up with it. And sometimes this pulp will die, but it’s the ones that don’t die or die painfully and they go through an acute phase what we describe as irreversible pulpitis. They’re the ones that the challenge because because the the top of the pulp, the pulp, is the most inflammed closest to the insult, could be caries or a fracture, that bit of the pulp will be difficult to anesthetise. So the whole, when you give a block typically for a lower teeth, you’ll get a block anesthesia, you’re given filtration, the anesthesia will not penetrate up the ID nerve, you won’t get into the pulp, it will get into the pulp, atypically, maybe reticular area, but it won’t get to that point which is the closest to the insult most inflamed. That’s the challenge getting from the, way I describe it to the patients, I show them the X ray, this is your tooth, that’s the top, you’ve got all refilling there we need to go from the top the occlusal surface down to that pulp chamber bit. We’re going to go down to there now a lot of its patient management is preparation. Okay, because we’ll go through the anesthetic protocol, which hopefully will work but sometimes it is not going to work. But you need to know that and you know that from the patient’s symptomology where they can walk in. You just know that as a hot pulp, there’s a chance that they’re not, you’re not gonna melt anesthetise and doesn’t matter what hit them with. There are a few things we’ll talk about how to prep that if they walked in off the street If you know there’s a pulpitis just coming in, you can, there’s a few things you can ask them to do before they come in, just to help the anesthesia process. And then when they get them in the chair, it is management’s a lot of good anesthesia, multiple techniques, different agents, and then going in carefully and managing the patient being empathetic. But up to a point, if they can’t tolerate it, or their anxiety levels too much you sometimes have to do in stages, sometimes you got to gotta go for it. And as it’s sometimes you got to be cool to be kind but in the appropriate patient. You can’t just dive in and you know, you lose a patient and it’s not nice to so you’ve got to imagine yourself in that position. But equally, you want to get them out of pain. It’s a balance. It’s a real fine balance.

[Jaz]
Yeah, so just the other day I saw an acute, patient in acute pain and after getting somewhat good anesthesia, you know objective, you know, I tried with endo frost beforehand, managed to elicit a necrotic response compared to others actually. But he had recent symptoms of irreversible pulpitis. So it was probably mostly necrotic. But there’s still some element of vitality to it based on his symptoms he was presenting with. And so when I did manage to reach the pulp chamber of his lower molar. Place to file just into distal, this wasn’t bleeding. So it confirmed my diagnosis of necrotic. But I saw the white pulpal tissue. So as soon as I put my K file into the distal, he pretty much jumped out the chair so I gave the intrapulpal. And that just settled him. So it kind of leads communists and like you said, I had to be cruel to be kind for that patient. Now, what could I have done? Had I known I didn’t know who was coming in, but what kind of anesthetic supplement or advice could I’ve given on the phone as you alluded to, to help achieve better success rate of anesthesia?

[Sanj]
Yeah, it’s about reducing the inflammatory stages that pulp as best you can and systemically, there’s plenty of evidence to say that loading them up with anti inflammatories, nonsteroidal so four to six of Ibuprofen with or without paracetamol, if they can’t tolerate anti inflammatories, asthma or stomach issues, Tramadol, something like that, or codeine, paracetamol, not as good as an anti inflammatory, but it’s better than nothing. That will just physiologically reduce the inflammatory stages, it doesn’t guarantee that that tiny bit of the pulp that’s inflamed will completely needs to dies. But it will definitely, there’s plenty of evidence saying it will help the anesthesia anesthetic process. In terms of the actual local anesthesia for the lower teeth or is notoriously the worst teeth, molar teeth, first second molars, those teeth are really difficult to numb. And it’s because they’ve got accessory nerve supply as well often. And for me, the baseline technique is ID, we do an ID block, I don’t mess about with intraPDLs and this sort of thing. And, you know, there’s usually to knock them, knock that nerve out and not as much as you can supplemented with buccal infiltration is of an age of this absorb as well. And for me, it’s articaine. So if my ID block, I would give lignocaine. As a start, this is an acute emergency, don’t use lignocaine off, and actually, I’ll tend to fall back on mepivacaine. We’ll come to that later on why I use preferred mepivacaine for routine Endo, but for hot teeth need, you need profound anesthesia. You don’t need longevity. But lignocaine works pretty well as an ID. I’m not a fan of giving ID blocks with articaine. But I know the evidence suggests it is very good. And it’s controversial that the risk of paraesthesia. And it may not be anything to do with the agent, it’s probably to do with the fact that’s trauma from the needle. But I’d rather not if there’s an alternative and it which works just as well. So ID lignocaine wait for that to be to work completely work. So we’re talking, the lip is completely numb. The lingual mucosa are completely numb, not even the patient alveolar thing, then articaine buccal infiltrations, it tends to absorb better through the buccal plate is pretty thick, and especially in the sixth and seventh area. And then I might give PDLs as well, or lingual underpressure I’ve got an intra paradata device called the wand, there are few other devices and now available which do the same sort of thing. They basically under high pressure with a short needle, they can deliver the anesthetic through the PDM. The theory behind that is a PDLs is almost as good as an entry onto osseous. Injustice is the other mechanism, you can drill a hole into the bone through these self drilling devices, which has a pretty good effect. I’ve never got are used to those devices, but some people swear buy them. But you need to get that profound anesthesia in there. And you just got to wait. Make sure you just make sure that the anesthetics work, don’t just dive in. And then you want to patient management.

[Jaz]
Well, with the busy lives of a general dental practitioners, but juggling at getting these patients in, making the diagnosis can take in 15,20 minutes. Sometimes you take a radiograph then give them the block let’s say aren’t getting infiltration, get them set outside while you see a few more patients. I’ll see you in my lunch breaks Mrs. Smith or whatever. Then the lunch rate comes your nurse is rolling her eyes, they swap nurses and so it’s all happening in busy practice. Now, let’s say we made a diagnosis of irreversible pulpitis. And we know we need to extirpate we have given sufficient anesthesia and the patient loaded up with ibuprofen and all the stars aligned when we’re dealing with such teeth. They usually have a large MOD amalgams or something like that. Right? So my first question in terms of making a very tangible for general dentist is in ideal world we’d love to remove the entire restoration. Remove any caries, access cracks but when I’ve 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us?

[Sanj]
At the end of that, this is about patient this is about getting a patient out of pain. Okay, and you just need to get in there. I used to call it ninja endo get in there, get the job done. Get out before a patient realizing it. That’s my principle in endo. Whether it’s emergency or endo, you want to-

[Jaz]
Stealthy.

[Sanj]
Stealth, stealth okay. And the first priority is getting into the pulp. You’re releasing the ,by going into the pulp you will automatically release pressure, there’s pressure buildup, that’s the number one property of inflammation, isn’t it? Then you need to sit basically, you’re applying a sedative material to relieve the inflammation, most common and popular products steroid.

[Jaz]
Before we talk about medicamento and stuff. Yeah, before we talk about the medicaments I just love to ask some real world questions like let’s say you go in you open up the pulp chamber, do you think it’s desirable for the practitioner who’s going to refer to you in the future? Should we be also removing the roof of the pulp chamber as much as possible? So let’s say that lower molar saw the other day had four canals mesio-buccal, mesial-lingual, and two distals, so four canals. And I did. I opened it all up as much as I could to visualize those four canals and it was mostly restorative material I was moving at this point at now. Is it okay, in that short appointment to just literally go in? See the pulp chamber and then proceed the medicaments? Or would you recommend to open it? Or does it depend on any factors?

[Sanj]
Okay, in short, forget about the root canals. Job is getting there, relieve the pressure, open the pulp space up and apply the dressing. That’s simple. That’s all you have to do on a Friday afternoon.

[Jaz]
Even like three or four millimeters in them in the middle that’s insufficient?

[Sanj]
Because what then tends to happen is, so the inflamed part is the coronal pulp, where in fact just the top bit of the pulp horn, you’ll find once you’ve, in those cases, you’ve got to give an intrapulpal going back to that essentially all you doing is crashing the nerves. It doesn’t matter what agent you can use, there are water, but the pressure crushes a nerve and that inflamed pulp, you’ll often find the rest of the pulpit, okay, it might be hyperemic might be bleeding a lot, but they won’t feel that. Remove the coronal pulp if you can, if it’s not painful, and then just dress it. Don’t worry about the root canals at this stage, that’s not the priority. In fact, if you then start fishing around the root canals, you’re going to start shredding pulp tissue. And unless you get the rest of the whole pulp out, that pulp tissue that you leave behind in the apical or mid third, it’s gonna be inflamed, and then the patient just you get equals other problems. So the pain is coming from the coronal pulp, deal with that, dress it and going back to the restoration unless there’s a gaping hole underneath the MOD amalgam, or it’s clearly this care, you know, it’s just the saliva coming in. Don’t worry about the stage, you can temporarily seal that off with Cavit or Kalzinol or whatever you going to use, just close the tooth, sedate it, close it and then get them back in for to dense the teeth apart, if you have to, it’ll be easy to numb up, you can then the resolvability assessment. If it’s not, if it’s too knocked from the outside, then you just refer for an extraction or book in for an extraction. But if you’re not sure, then don’t worry about that you can assess restorability, and then treatment plan for Endo once the patient is out of pain, and they’re easy to anesthetise. So don’t miss about the pulp root canals at this stage. This is about dressing and getting them out of pain, don’t fish around root canals

[Jaz]
This is going to be enlightening Sanj there’s gonna be absolutely enlightning because I know plenty of colleagues who advised me in the past and they swear by this Sanj they said, ‘You won’t get the patient out pain until you file all the way to the apex.’ Now is that a myth?

[Sanj]
Largely yes, it’s a myth because-

[Jaz]
Have you heard this?

[Sanj]
Vital so the pain is coming from that topic. It’s not the rest of the pulp. In fact, we’ll come on to this we get tired things are slightly changing. Now the way we treat vital pulps. Okay, this is an interesting conversation where we are now and it was too early to bring this in. We were in the realms of what’s called Vital Pulp Therapy where maybe we don’t need to extirpate pulps at all or the root canal we can do the coronal pulpotomy as we used to do for kids individual teeth. Remember the Cvek pulpotomy back in the day? That concept is now coming in adult teeth, not just immature adult teeth molars for example evan in mature teeth. And this comes this is the kind of crossover between risk cariology, the caries management and restorative dentists coming in. And they’ve been doing this kind of stepwise technique and all that but I think endodontists we’ve always been, not been happy with that because if you’re not predictable, materials haven’t been appropriate. And the risk is the patient could come back in acute pain, they’ll come back with advanced disease, endo disease with the level of prognosis is low. All the pulps completely obliterate and then when you have to do the endo is a nightmare. Things are changing a little bit with the new materials but at this stage in terms of emergency management is enough just as deal with the coronal part of the pulp. The rest of the pulp often it will stay vital whether you then take the dutiful-

[Jaz]
This music to everyone’s ears, Sanj. This is music.

[Sanj]
So whether you then go and do new canal was, so yeah, do the full Endo. Or you don’t and you apply these new vital pulp therapies. That’s the that’s the next interesting question. Because endodontics is changing now, we didn’t prevent-odontic, like it.

[Jaz]
Very good, very good. I think that’d be a whole new episode. But just to continue on the reign of the emergency management, I think what you’ve said is going to be music to the ears of all the GDPs listening who perhaps had this thought that and they’re going to spend this extra time and extra risk in opening up all the individual canals, filing all the way to the apex. So really, what I’m hearing is to get sufficient anesthesia, get in there, open up the pulp chamber, just enough to get your sedative in and we’ll talk about sedative in a moment. Now, and don’t go sticking your K file. So in fact, your nurse now knows not even to give you a K file for this emergency extirpation, which is brilliant. Would you recommend using hypochlorite? Now before we can get to that, let’s take one step back. I personally I would always use rubber dam you know, with your influence on the BES, I can’t go to BES conference and then not use rubberdam for anything like this. So I always use rubber dam but I’ve got some colleagues that were more experienced. And they say, ‘Jaz, it’s okay, because we’re killing the nerve anyway.’ The endodontic, the endo buds will sort the bugs out afterwards. So just get going put some sedative in and come out. We don’t need to irrigate and we don’t need rubber dam. What do you think on that? What is best practice? What do you want from your referring practitioners?

[Sanj]
Okay, but I mean best practice is you’ve got to isolate the teeth properly, both from a safety point of view and also from microbiological point of view. Now, okay, that dentist may not be doing the endo, and it’s not their problem, it will go to the endodontist. The problem is if bugs get in their, saliva gets in there, it’ll kill the rest of the pulp. Okay, fine. The plan is to do endo, but the problem is if in reverse PYtest actually exist apart from that inflamed bit, it’s actually a sterile situation, which is where relative vital pulp therapy comes in. So you don’t want to introduce bugs there. Because either you don’t know when that patient is going to get to the endodontist. Or when they’re going to have the endo might be weeks, it might be months. And if they get an infection, and it gets into apical, then you’re into different ballgame in terms of prognosis and treatment. So isolation still is important. Now, whether you rubberdam or you compromise, depending on the clinic. And if you’re working in emergency department, and another factors, it’s easy for me to say in my ivory tower of dental school or endo practice, you have rubberdam there and then but again, good isolation, your nurses there good aspiration, open the pulp, give it an irrigation. Remember, it’s only the coronal part, you know, messing about root canals, you just need to bathe the area-

[Jaz]
Hypochlorite, or Corsodyl or whatever. What do you recommend? Hypochlorite. Now, what do you think about people who, because maybe they’re not using rubberdam, then they’re using chlorhexidine 2%, maybe or-

[Sanj]
It’s better than nothing, and then we’ll be using 2%, we’ll be using mouthwash, which is useless to be honest, it’s the surface.

[Jaz]
It’s true,

[Sanj]
It’s the same for sure, because that’s quite expensive. And most people don’t, even endodontist don’t use that one. Not many of you. Even if it’s as simple as opening the pulp chamber, you’ve got isolations, suction to stop saliva getting in there, dipping a cotton will pledge it in hypochlorite and squashing it in there. So at least is bathed, then dress and close. That’s fine. Just be quick. Everything’s efficient, you know what you’re doing. Hence, keep it simple. You don’t need endo Files. The aim is, all you need is your high speed. Ideally, rubber dam but all good isolation. You need an irrigant enough to dip into whether you’re injecting, that’s another issue, you will send some material and close.

[Jaz]
But are you happy for us to use a hypochlorite and using maybe a whole syringe of hypochlorite to irrigate the superficial pulp?

[Sanj]
Yeah. It’s not a problem, whether you’re going to do vital pulp through endo, it doesn’t matter. For the fuse for a minute or to 30 seconds you’re going to do it. It doesn’t make a difference. It’s not going to do anything, any damage.

[Jaz]
But again, we don’t need to go into the canal. It’s just staying very superficially in the pulp chamber, right?

[Sanj]
Yeah, that’s all you’re trying to do get some hemostasis if you can, if you can’t get hemostasis, the agent you’re going to use will hopefully no, no, it’ll kill the pulp off. So when you go back and there’ll be less messy next time. But it’s good to have some disinfected within there. Remember the dressing material probably also have disinfectant effects. So that’s fine. But ideally, yes, get good isolation as best you can. And for the sake of a 30 seconds or a minute, it’s not the end of the world. You know, we can be careful. Another thing you can be careful of to use hypochlorite, you don’t need much. You don’t need a syringe that’s friendo.

[Jaz]
Just in a cotton pellet, as you said is a real gem right there actually.

[Sanj]
Yeah, just so getting in close.

[Jaz]
I really respect you, Sanj. And what I’m saying, I really respect you. Because what you’ve given is you really respected the plight of the GDP there, and you haven’t been dogmatic and I really repeat, it’s so easy for you as an endodontist saying, you know, you absolutely must be committing a cardinal sin, which we know we are if we don’t, but sometimes you only got five minutes, and you’re really 45 minutes into it, whatever. Right? So therefore, I really respect that you’ve given us guidelines in terms of best practice, but you’ve said that, okay, if we have to compromise, let’s do it in this fashion, what’s going to help us either way, so really good suction, dip your cotton pellet in hypochlorite. And those guidelines you gave, so I really respect you for considering our position sometimes. So thank you for that. Now, the last question in this segment for Emergency acute situation before we talk about post op pain is which is your sedative of choice and which is your temporary restoration of choice?

[Sanj]
Sedative choice, very popular one and I still like it, if you can get hold of it as Ledermix. This is purely for a coronal pulpotomy it’s not for sticking down root canals. Okay? It’s got a steroid in it. So naturally, it’s anti inflammatory. The antibiotic component is broad spectrum that’s neither here nor there, to be honest, but it might have some effect. This is the fact that sedative, you just wanna get the patient out of pain. But you need to go back and you can’t leave other beings for long because it does its thing. It doesn’t do much after that. And if there’s any pulp beyond that, it’ll start getting inflamed, the pulp will become inflamed deeper down. So if you’re using Ledermix, it’ll keep it quiet for two to four weeks, maybe. But you need to get back in there and do the full extirpation do the full endo quickly. The alternative and it’s still the gold standard is calcium hydroxide non setting. It hasn’t got the direct anti inflammatory properties, but it’s a necrotising agent, it’s antibacterial. So kind of indirectly, it’ll disinfect the environment it’ll necrotize a pulp because it’s pretty caustic calcium hydroxide is pretty caustic stuff, it’ll fry the pulpit comes in contact with, very alkaline, and it’ll do the job. So when you go back in, you’ve then got the choice whether you do endo or go down and keep preserve the rest of the pulp. Calcium hydroxide’s fine. Nonsetting Calcium hydroxide if you can’t get hold of Ledermix. Because I know that-

[Jaz]
How much do we need here? Because, you know, sometimes nurses will depending on which dentists they work, when they’ve got previous biases, sometimes give you a huge splodge of it and they give you a file because they expect you to take it all the way to the apex because that’s what they used to with a dentist they work with. Or sometimes they give you like the tiniest bit and, and a cotton pellet. And I personally me Sanj, I like to use PTFE instead of cotton nowadays, we can hear your thoughts about that. But then how do you best apply that? And then how much do you put, and how do you seal over that?

[Sanj]
Okay, so what I do is once you’ve got hemostasis, or relative hemo state, if you’ve got hemostasis literally inject the, it’s like cream, Calcium hydroxide cream, into the over the pulp chamber floor, a third of the pulp chamber floor very gently. You can use PTFE. The only problem with PTFE. And I know a lot of endodontists. And everyone goes on about PTFE. The problem is, if you’ve put that into place, you’ve run into a ball you meant to roll into a ball, you squash it in it displaces the calcium hydroxide, it just squirts back out so you haven’t got the volume. So a better material and you’re right cotton wool, there’s plenty of evidence saying you shouldn’t use cotton wool, because you can’t, you often can’t see the fibers and they sometimes protrude through and you’re gonna get an infection, it’ll just penetrate through the temporary material. So better alternative I use is a sponge pellets, these sponge pellets, then either endofrost pellets or VOCO pellets, they’re better. Because it compressible, their porous. So they’ll hold the calcium hydroxide or whatever agent you’re in. And it just holds a bit of bigger volume of dressing material. Unlike probably PTFE as you push it in, you meant to displace it. And it’s good because it’s antibacterial. And when I say antibacterial it because it’s PTFE nothing, bugs don’t stick to the material, which is great as an inter appointment between root canal treatment is great for that, what postoperatively before you send back, but for the dressing, you just end up displacing it out and you want the dressing material to soothe the tooth. So-

[Jaz]
Fair point.

[Sanj]
In terms of material on top, it did get it depends on how when the patient’s going to come back. The options are Kalzinol traditional reinforcing zinc-oxide eugenol If you think the patient is not going to go see a dentist for a long time, either GI or IRM. IRM is my favorite, because it’s super reinforced Kalzinol. It’s rock hard, and in fact, it was designed. Do you know the history of IRM? Where it came from?

[Jaz]
No, I don’t.

[Sanj]
It developed this, I’m not sure this. It’s developed by the I think it was the US Navy for at least during the Vietnam War. So what they used to do is they find the material where they do a dress again is emergency dressings, get the soldiers out of pain, and they knew they wouldn’t come back for months on end. And that’s where IRM was developed. They used it there. So it’s a long term. It’s quite hard. It’s not as hard as amalgam or composite. But it’s pretty rare. It’s the other property it’s got that huge knock components it’s slightly antibacterial, which is why a lot of endodontist love it. It’s called a long term antibacterial and it sort of reflects biofilm and bacteria so IRM is great but otherwise GI capsulated bog-standard GI is hard enough or is resistant enough and is easily accessible for the endo and the choice.

[Jaz]
Cavit, quite soft. Is that okay? For a short term?

[Sanj]
Short term is fine. It depends on the cavity. If it’s an enclosed cavity and literally an occlusal access cavity. You need depth and bulk of Cavit. It’s not very, it’s quite it’s poor wear resistance, but it’s okay. For no more than two to three weeks. And it depends on the patient’s occlusion as well. So it’s okay, it’s okay.

[Jaz]
Sure. Okay, but we do a favor Kalzinol or even more IRM and then use a GIC if appropriate as well. So that’s good. If I was just summarize because the reason I’ve done a whistlestop story of this because I also want to about post op pain, perhaps after doing rc while I’ve got this precious time. For those who don’t know, we’ve been months in the waiting to sync our diary. So I’ve got this very valuable specialist, precious time to extract everything out of your brain and distribute it to Protruserati. So just to summarize so far, guys, we need to get a profound anesthesia. We don’t need to explore in that emergency appointment to get to every single canal. We certainly don’t need to file into every single canal if you open up the pulp chamber, place a sedative like Ledermix or a non setting calcium hydroxide or foam on top, put some Kalzinol or GIC for good measure. IRM maybe if you want something longer lasting, and that should work. Do we have any data? Cause sometimes I’ve done it maybe some years getting patients calls up next day, saying I’m still in pain. But most of the time, I’d say 95% plus patients out of pain the next day because I did throw for a while do an audit the day after especially when I worked at Guy’s in the emergency department. Do we know how successful it is? Or is that not been studied?

[Sanj]
The emergency dressing protocol?

[Jaz]
Yes. Emergency Emergency protocol?

[Sanj]
Yeah, I’m not aware of any specific studies on that. But anecdotally, from when patients can’t had the dressings done, it seems within a couple of days, most patients are out of pain once a denture has been in there. Yeah.

[Jaz]
What advice would you give to your patient in terms of you know, give it a couple of days and analgesics. Let’s just finish off with what advice you’d get before we talk about post op pain.

[Sanj]
Yeah, a woman is going to suddenly get get better. So give her a couple of days I could ask them to continue the ibuprofen if they can take ibuprofen or paracetamol. It was acute pain then Tramadol or something like that, and I want the olders just to in terms of just symptomatic relief, I just flattened the occlusion, get all the deflected contacts out to say there’s no, most of the pain is often on lateral percussion. So just flatten the tooth. The tooth is probably going to be indirectly restored probably anyway. So just relieve any, the tooth will be in hyper-occlusion anyway, if there’s any apical involvement as well in evidence in multiple teeth, one pulp could be vital, inflamed, the other part could be dead. So you might have also a combination of apical inflammation, you don’t really know that immediately. So just relieve the tooth out of occlusion. And then yeah, post operative anti inflammatories it should settle within a couple of days should do and tell them to go to the dentist.

[Jaz]
Amazing.

[Sanj]
You must, they must follow this I’ve been warn than what could happen. Because if there is, again, medical legal hat on, if you haven’t worn them this, it kicks off. They’ll say you didn’t warn them and you know it just to prevent a complaint you need to warn them put in the notes, this is the advice given if you’re not going to come back to your clinic. This needs to be done. So you just protect yourself for the future.

Jaz’s Outro:
Yep, and warn them and also make an entry into notes that patient one that needs to this is not the final treatment. You know, some people just assume that, ‘Oh, I’ve got my root canal and I take a radiograph there’s no root for the material. You see, it obviously has been dressed at some point probably five years ago, whatever.’ So yeah, good point, well made. So Sanj, let’s switch gears a little bit. I recently treated a gentleman. Oh, there we have it, guys, you don’t need to find and open up every single canal. Just get in there, relieve the pressure, place your medicament. And we also talked about what kind of materials we can use afterwards, I feel like we covered a fair amount in this group function. Listen, if you are listening on the app, you’re listening or watching on the premium version of the app, just scroll down now. And then you’ll see a form, fill in a few details and answer a few questions. And you’ll get your half an hour’s worth of CPD certificate with all the aims objectives and the reflective log. So it’s like legit and future proof. And if you’re not already on app, look, you can download it for free. It’s on iOS and Android. And the benefit is you can download these episodes, videos and audios and any PDFs and save it to your device in case you have choppy connection. And it’s one of those membership programs that actually let you download all the stuff like if you’re on a membership website for dentistry, then it’s very unlikely they’ll let you download the videos on your hard drive or on your phone or your tablet. You actually download the video and audio to a device to listen in the future. And if you want CPD and exclusive premium content that I’m making all the time, then I’d really appreciate your support if you support the team protrusive and joined the premium package on a monthly subscription. And I’ll promise you, I’ll make it worth your while. Anyway. Thanks so much for listening all the way to the end, your true Protruserati and I’ll catch you same time same place on the next episode.

Is flapless implant placement really a solid technique? What percentage of cases are amenable to flapless implant placement?

The cynic in me wondered if this is indeed a novel technique, or was it made mainstream to attract Dentists who seldom raise flaps?

I brought on straight-talking Implant genius Dr. Pav Khaira on today’s Group Function to discuss flapless implant placement – ‘what’s the deal?!’

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

Check out The Dental Implant Podcast for information on dental implants and the Academy of Implant Excellence to learn how to place implants or upgrade your skills.

If you enjoyed this episode, you will also like ‘Can I Probe This Implant?’

Jaz’s Introduction:
Are flapless implants a thing or are they a fad? I feel like there is a lure of some courses that want to attract the inexperienced GDP who perhaps is afraid of surgery or averse to surgery who can’t raise a flap and they thought you know what, if we start teaching a guided system that doesn’t involve flaps and maybe the dentist will come and learn implants and place our implants so that is the cynic in me thinking that but I got on the main man who knows everything about implants Dr. Pav Khaira on today on this group function about IS THERE A PLACE FOR FLAPLESS IMPLANTS? And of course from that we go into different directions in terms of okay, when is it suitable? When is it contraindicated? What are the problems? And how we can learn more and get into this field of implantology. If you are a novice if you are someone who’s thinking about it, but you’re afraid to make that next commitment. How does one get into the field of implants are huge daily topic for young dentists.

Main Episode:
So let’s join this group function with Dr. Pav Khaira. Dr. Pav Khaira back again for the third time from the dental implant podcast. How are you, my friend?

[Pav]
I’m very good, how you doing?

[Jaz]
Amazing. And last few times you came on you really busted some myths and you helped us to understand some basic things. Can we probe implants? What happens when an implant is bleeding? The soft tissues are bleeding. How can you tell if you’re too worried or not? So you cover these really fundamental topics. And you guys if you haven’t listened to ready, listen to those. And of course we had you on for finding your niche in dentistry. So you’ve done some pretty big topics. And when this topic came along about flapless implants, which what we’re talking about today, and I can’t wait to dig into that. But just for those people who haven’t listened to that those episodes yet, and I will urge them to check out those episodes right now, those watching on YouTube, the thumbnails be flying up, you need to listen to those previous episodes to really appreciate all the wonderful things we’ve covered so far. But just tell them about your week to week, day to day dentistry that you’re passionate about.

[Pav]
Jaz, firstly, thank you for having me back again. Secondly, all I do is place implants. That’s it, I don’t do anything else. So what’s the best way to frame it as an average implantologist and average busy implantologist that quite happy to place 200 implants per year, I’m very fortunate to be in a position where I’m placing about 1800 to 2000 implants per year. So you know, my, in the last few years, you know, my experience is going up significantly. And I say that from a point of being humbled because I thought I knew what I was doing to start with. And then you start placing that volume of implants. And it’s just like, whoa, actually, this is different game. You got to relearn your skill set. So-

[Jaz]
I see the crazy and amazing you know, life-changing transformation that you do on our telegram group, you know, so good at posting notes and the radiograph before and after. And so if you’re a little bit of burst of blood, you probably don’t look at those posts from Pav. But then he’ll show you anatomy that you never knew existed. He’ll show you what the pterygoid plate looks like. He will tell you all these cool stuff. But with the basic stuff as well, which you cover so well. So it’s been great on the telegram group to see your cases.

[Pav]
Yeah, I mean, you’ve seen some of my zygomatic implant cases, you’ve seen some other cases where, you know, patients been in dentures for 40 years, there’s no bone left or have to think outside of the box a little bit. And we showed you that case where you know, the mandible had atrophied where it was only 11 millimeters in height, and we were placing 10-millimeter implants. So yeah, I get to see some crazy stuff now. And again, it’s just transforming people’s lives. It’s just, you can’t put a finger on it. It’s just amazing. It’s fantastic.

[Jaz]
I can see that in the in the postdoc portrait photos in the eyes of the patients, the kind of work you do is very transformational. So it’s great to do any part of that and to see that, and today we’re covering flapless implant courses and just technique of flapless and the position I come from Pav is as a position of being a cynic, in the sense that a few years ago, I started noticing all these like pop up courses, now I don’t place implants, right? But I’m very keen restorative dentist. So I refer out to colleagues who do place implants, but I did see a surge in courses saying, ‘Hey, you don’t even need to be able to raise flaps to base implants, flapless implants.’ And I’m thinking, my worry Pav was, are these courses being set up because they recognize that dentists who don’t raise flaps who can’t raise flaps, this will be an easy lure to get them in to implants. Is that what it was? Or is flapless a valid technique? And that’s a big level question. You’re probably going to break it down which you’re very good at doing, but that’s the position I’m coming from. Is it a fad or is it a thing?

[Pav]
So let me spin this question around for you. So if something sounds too good to be true, is normally too good to be true, right? So there is a position for flapless implants, here’s the key in the correct circumstance, they’re fantastic. Okay? There are a number of courses available now where it’s very much, as you said, you don’t have to be able to raise a flap, we will do it guided, we will plan it for you, all you have to do is a tissue punch, and then you use the guidance system. And then you place the implant, that’s it. Jaz it’ really not as simple as that, right? You need, you need a certain amount of bone volume around implants, you need a certain amount of soft tissue around implants, not only do you need a certain volume of soft tissue, you need a certain quality of soft tissue as well. And if you’re doing flapless, you may end up having just enough soft tissue, and then you do a tissue punch, and all of a sudden, it’s gone. So what do you do, then, because you’re immediately on the backfoot, with this case, this case is likely to start sliding backwards really quite quickly. And here’s the other thing, as well as what do you do if the guide doesn’t fit? You know? There’s a say, when you get into that implant ecosystem, when you get into that implantology world, once you start doing a number of cases, everybody says the same thing. Guided surgery is great. Okay, it’s really, really good. It’s got a great position in implantology. But you should not be using guides unless you can place freehand. Because your guide doesn’t fit, you’re then relying on this, what’s in between your ears, and you’re relying on your hands.

[Jaz]
I see as a non-placing dentist, I didn’t even occur to me that you know, you can put in there just like obviously, it’s acrylic and whatnot. So there’s a good chance it might not fit or chance that the measurements are skewed or whatnot. And so it makes sense to me now thinking as a restorative dentist, but you’re right, if that doesn’t fit, then your whole plan is gone. And therefore we need to be able to pivot onto a Plan B or Plan C, which is where I guess you need to have the knowledge and skills beyond just as one way of doing it. So I guess my next question is, what percentage of implants do you place that are flapless? And maybe because you’re different, I don’t know, what percentage of implants do you think are amenable to flapless technique?

[Pav]
I’d say about 10%, which is quite low. And the reason for that is quite simple. There’s really good data nowadays, that you need a good band of keratinized tissue around implants. But in addition to the good band of keratinized tissue, it needs to be about two to two and a half millimeters thick. And in a lot of areas, particularly in the mandible, that isn’t enough soft tissue height. In order to achieve that two to two and a half millimeters, okay, then it goes back to what we were saying a few minutes ago, if you do a tissue punch, whatever was there all of a sudden you’ve gotten rid of. So when you don’t have enough tissue, there are a number of tricks that you can use to increase the thickness of the tissue. But you can’t do that with guided surgery. Now, you won’t have any significant problems with it in the short term. In the short term, it’s going to be fine, because you’re like, Wow, this is easy. What is everybody complaining about? All you do is tissue punch, place the implant and put it in through the guide. That’s it. But what happens Jaz, is over a period of time, let’s say over about, it’s the medium term that you start to develop problems, right? So probably about three, four or five years down the line. That’s when you start to get the early stages of kind of like perio-implantitis and you’re getting it for no other reason, then you don’t have enough soft tissue around it. Now there are-

[Jaz]
By that you mean like a cuff of keratinized tissue?

[Pav]
Cuff of keratinized tissue, yeah. So you need a cuff of keratinized tissue, but it needs to be about two, two and a half millimeters thick. Now there are so many factors involved in this right? It’s down to the restorative material that you use, it’s how you do your osteotomy. How long you wait for it to heal. It’s how you deal with the connection. It’s how your lab workers were processed. It’s how your lab works cleaned. It’s how everything’s fit together, when it comes back from the lab, there’s many, many factors that are involved in this. But a very big factor is good quality and good thickness of soft tissue. And without that good quality and good thickness of soft tissue, which you can’t always achieve with flapless is you’re starting to ice skate uphill, and it’s gonna go south. So when I see people out there whether turn around say ‘Oh, just do everything flapless.’ Is that is not the right approach. Now as you can appreciate when you do an immediate placement quite often that is flapless. But it’s still a different skill set.

[Jaz]
And perhaps just because of the you know, some students or younger dentists, who you know, just new to the term ‘Immediate Placement’. I know for you, it’s something that you’re very familiar with, define immediate.

[Pav]
So immediate is basically take the tooth out and put the implant in straightaway. It’s a little bit more intricate than that because it’s like, oh, it’s within a certain number of days and weeks, but let’s just keep it simple tooth comes out and go straight in case. So there’s a tick box that’s that I’m looking at, in my mind. So once the tooth out, I’m looking at a number of parameters, and I’m going tick, tick, tick, tick, okay, let’s put the implant in. If I’m going tick cross crosses, like, you know, I’m just going to do delayed placement in this. So the term immediate implant is the implant goes into place, the same visit that the tooth comes out. And what’s the benefit of this to the patient? Is a shorter overall treatment time, because then you’re not waiting for the site to heal. The downside to it as a surgeon is it’s much trickier to do because you’ve got less bone to play around with. Your implant positioning needs to be pinpoint perfect. You can’t do that with a guide. Not always anyway.

[Jaz]
And so in those cases, where you do immediate, what percentage of your cases do you think maybe not your cases, but because they do so much varied work, but the average GDP, what percentage of their cases do you think they’re able to do it as an immediate technique?

[Pav]
So the immediate technique is not actually an easy technique to do. It’s quite advanced. So I always say to the people that I’m mentoring people that I’m teaching, is just start off, taking teeth out, wait for it to heal, and then put it in. As your skill start to expand, then you start to do immediate implants, because what you’re going to notice, soon as you start immediate implants, your failure rate is going to spike, because you’re not used to doing it. But like everything persists. This is something we’ve spoken about before building muscle memory, okay? Is you persist with it, keep learning, it’s a new technique, and eventually your failure rate will start to come down, your success rate will go up. So how many cases do I think the average GDP could probably do immediate placements? Probably about 40%-50%.

[Jaz]
Oh, wow. So once they’re built in, and once they got their first few dozen cases under their belt, and they’re waiting for the correct healing, and follow the protocols that are a bit more basic, and then they start pushing their boundaries a bit. And then eventually, once you have a lot more experience, you think about 40% of implant techniques are probably suitable or meet the criteria for immediate placement. Fascinating.

[Pav]
Yeah, absolutely. So I mean, my immediate placement is much, much higher, I probably push to about 90%. But then I know how to deal with cases where, you know, the textbook, say, ‘Oh, it’s not suitable for an immediate placement.But I know techniques where you can really quite predictably do an immediate placement. Do you always get it right? No, that’s the nature of what we do. But that’s, that’s true in every single field. But, again, again, it comes back to just a stepwise progression in your skill set and your career and your understanding and your knowledge. You know, we all started as novices, you know, there was one point in my career, I was just like, ‘I am never going to place an implant in my life. I hate surgery.’ And here I am, my day doesn’t start until I cut somebody open and they start bleeding. So it’s been a fantastic journey for me.

[Jaz]
Yeah, I always knew you when I was like a dental student, I was like early years and you were like the occlusion restoratives, TMD splint guy, and I’ve seen you, you know, you did the masters. And you’ve been on all these courses around the world. I’ve seen you, I’ve been following your progress. And now the volume of implants you’re doing it’s just been really lean in, gone in, as we discussed in that episode about finding your niche and how you really went all in on it. And then hats off to you and lots of admiration for that. So I think any is a great example to anyone who really wants to commit to one field. But let’s say a young dentist wants to, as we do at some stage we have to then consider, is implant dentistry for me? And we realized that UK undergraduates, you can barely place a crown yet, let alone think about implants. So once you’ve got your basics, your fundamentals, where does the basics of surgery come into it Pav you think?Because I now, I’m happy to raise a flap. Yeah, my flaps aren’t brilliant compared to an oral surgeon. But I’m pro GDP. They’re pretty good, I think. And I can section elevate, I’m very comfortable that I’m happy to even post videos of that which I do on YouTube. So I don’t worry about that. I am now in a position where if I wanted to implant the surgical bit doesn’t worry me and scare me like it did maybe four years ago. So if you’re that young dentist who is considering implants, what advice would you give them? Would you say go down the path of going oral surgery course first, learn how to take out teeth, learn to raise flaps, lift periosteum suturing and then go and implant course? Or go on the implant course where you might then learn those surgical skills as well?

[Pav]
So the answer to that is, is either all you can do either or, probably the easiest way to do it is to get some surgical experience first. But I know plenty of people who have gotten into implants and they’ve just learned the surgery as they’re going along. Here’s the key. Make sure you have a damn good mentor to show you how to do it properly. Okay, so unfortunately. I have a couple of people that I was mentoring and I stopped mentoring them because they weren’t following instruction. Right. And I was saying to him that this is also what we do in implantology. Whilst the core skills are the same. how you execute it can be slightly different depending on the case. So Periodontal Surgery is not the same as implant surgery is not the same as oral surgery. Although the basic tools may be the same because the old design outcomes are different, right? So if you’re executing treatment based upon what your desired outcome is, so why I always say is that look, if you want to get into implants, don’t let anything stop you. But understand it’s not you do a quick course. And then that’s it, you can do everything. So right, here’s a mistake that I made when I was younger, right? Is when I did my first implant course. And this is one where you go for one day a month for 12 months, right? Is the guy who’s teaching me used to do a lot of all-on-four. And what I used to do is I used to go to his practice, I used to sedate his patients, because I wanted to watch do all-on-four. Because as you’re learning implants, you think, ‘Wow, this is the sexy stuff, this-‘

[Jaz]
The pinnacle.

[Pav]
This is the pinnacle, then you start doing all-on-four, you realize it’s not the pinnacle, even remotely. And not only that, but it’s not as easy with what it looks like as well. There are some people out there who make it look easy, right? And this is the mistake, my third solo implant as a case by myself without a mentor, I decided to do upper and lower all-on-four. Because I’ve seen it 15-20 times I was like, ‘That looks easy.’

[Jaz]
Can I just point out to everyone who doesn’t have, I know Pav having a little bit better than someone who might be listening. And I know that perhaps the kind of guy who in his first year of dental school, he was like, you know, did a fullmouth rehab, right? And he you know, I know your story. So like Pav is really good at you know, he’s a massive geek, huge amount of knowledge. And he is not afraid to implement. So that doesn’t surprise me one bit.

[Pav]
And the deal that I came up to with the patient, because I said to the patient, I said, ‘Look, I’ve done an implant course, I haven’t placed many implants.’ But she because she couldn’t afford the treatment. And I said to her, ‘I’ll do the treatment cost for you, which was 7000 pounds.’ Now the treatment, the treatments supposed to cost 36,000 pounds. So for her, it was insane discount. So I did the treatment, and it went wrong. And I didn’t know how to fix the case. And I had to then ask a mate of mine to come in and fix it. And he was like, fine, I don’t mind doing it is gonna cost you 32,000 pounds. So I had to pay that out of my own pocket to fix.

[Jaz]
Wow. You did right by the patient. And I admire and respect you for doing that. Because you have to. When that kind of happens, but then the lesson you learned there was- you need that. Yeah, you need that mentorship for those educators, right?

[Pav]
Yeah. So and this goes back to what I was saying is with the right mentor, and with the right person just guiding you, they should be able to actually make the process really easy. Because to be honest, is if you’ve got let’s say, let’s say an upper five, or an upper six and upper first molar in a healed site where there’s plenty of bone, right, is in those cases that they’re in the ideal cases, they’re out of the smile line, there’s normally plenty of bone is it’s really easy in those cases to teach implants. Because it just like, right, we’ll show you how to do this. And what happens is four or five cases in you start to pick up the nuances of it like how to hold the blade, which blades to use, and your instruments are important as well, right? A lot of people are using the wrong instruments. And if they’re using wrong instruments, you know, I had a mentoring with with a gentleman, I did virtual mentoring with a gentleman from the States. And he was having a lot of problems, because his kit was old and worn. And I said to him, ‘First thing you need to do is buy a brand new kit.’ They bought a brand new kit. I told him exactly what to get half of his problems went away just with decent instruments. All of these things play a factor. All of these things play a role, but you don’t understand it until somebody shows you.

[Jaz]
Yeah, yeah, absolutely. So in that vein of how do you find that person to show you, so the question is, where can you find impart mentorship? Now I do want to talk about the cool plans that you have. And I’m very excited to read about that. And I want to learn about that. But and then that’s something I know he’s gonna be having an international reach and stuff. But if you talk generically, how do you identify a mentor in implant world? And then please tell us about your mentorship services, because I know that they’re very prominent, like you said, you teach that guy in America, but I know you’ve got really grand plans as well.

[Pav]
So firstly, what I always say is that the people that I mentor I’m very picky and choosey with regards to who I mentor. So I’m not I don’t get on well with people who kind of like want a cookbook approach. I like people who think and want to be challenged and are prepared to put in the work, because that’s exactly how I was when I was younger. And I think that you can’t really teach this type of stuff if you’re looking for a cookbook approach. Because if you look at any one single scenario, there’s probably seven different ways to do it. So you need to think well, if I do it this way, what can potentially happen and then if that happens, how do I fix it? So I only really mentor very select people who think. So my mentoring works in a number of ways, either people bring their patients to see me, or for a day, right, I will go to their practice, but it’s easier for them to bring their patients to me, because for me to get a day in my diary is booking months ahead. But-

[Jaz]
Those are the most common ways because I know a few of my colleagues who’ve gone down the implant path, and then I’m very well, but in the early days, from memory, they pretty much made not much money on the first few cases because all that money was going to mentor, but the experience they were getting was worth it. Because then five years later, they can do those cases and much more complex with the experience and knowledge that they gained, right?

[Pav]
So what ends up happening is you pay to learn in one fashion or another. This is something you said before, right, is you either pay your mentor to show you how to do it. And when you do it that way, you’ll avoid most of the pitfalls, okay? Or you don’t pay your mentor, you have things go wrong. And then you’ve got to pay out of your own pocket. Of those two scenarios, one leads to a happy patient and another one leads to an unhappy patient and having to pay out of your own pocket for an unhappy patient. It’s really not worth it. And the issue is as well, Jaz is there’s a lot of times, people want you to think it’s easy, and it’s cheap getting into implants. It’s not like everything. It’s a journey, right? You’re not going to do a two day course on endo, and be as good as what a specialist is, you’re not going to do a six day certificate in perio and be able to do what a periodontist can, right. But if you put, but nobody was born with these skills, it’s all learned. It’s all trained. It’s all mentored. So if you’re prepared to put in the work, if you’re prepared to to execute the steps properly, everything can be taught absolutely, everything can be taught. And then going back to what we said before is a lot of dentists is it’s just a matter of approaching people for mentorship, you know, is unfortunately there’s a lot of people who don’t want to. It’s just like, No, and then there’s other people like yeah, fantastic calm. And sometimes the best way to start the mentoring is start the restorative process first. And for a busy implant practice. They love it when you want to restore. Because as an implant surgeon, I do the restorative as well. But I’d rather not could see-

[Jaz]
I hear that all the time from surgeons.

[Pav]
Yeah, it’s part and parcel. Do it really quite happily. But it’d be better if I was just placing. And so if you went to like your local Implant Center, and you know, approach them, you know, can you train me, can you show me how to do restorations. And then you get proficient at that. And then what happens is, once you understand how to restore, you’ll understand how the surgical feeds into that. And then what you do is you ask them, whether if you do a course they’ll mentor you for some cases as well. It’s just reaching out to enough people, and making sure that you’re happy with the quality of what they’re doing as well. And that’s the issue is, as a novice, it’s hard for you to gauge what’s an appropriate standard. You know-

[Jaz]
I love that tip, you gave that I think anywhere, any dentist listening in the world right now, if you identify the person you probably refer to already. And they probably had the same problem as you having that, you know, they’re so proficient their surgery, and they, they really learn all these techniques to develop their surgery. But then the restorative is like, okay, fine, I’ll do it. But like, I wish there was someone who I could just give this to. So that’s a great stepping stone. The other things that we covered is it’s good to have some basic surgical skills. But if you don’t then find the implant course, or mentorship, which have been the key theme for all the episodes that we covered, but mentorship is what’s going to save you from those expensive mistakes. And I appreciate you sharing your expensive mistake, and how mentorship and perhaps too soon, you started to go solo. So with that in mind, please let us know because I know you’ve got something pretty exciting coming I’d love for you to share with the Protruserati, in terms, of course, a structured course that’s going to have some sort of a graded system and approval from the higher powers in terms of this being you know, I mean, that takes a lot of work what you’re doing, I appreciate that, but to actually make a curriculum huge. I know. Absolutely.

[Pav]
Yeah. So, it’s you know, I’ve taken everything that I’ve learned from my MClinDent in implantology, all of my mistakes, all of the courses that I’ve been on, because you end up with problems in implant dentistry, and you go, ‘Oh, I’ll go on that course. It’ll teach me everything that I need to know to resolve that problem.’ But it won’t teach you everything is you know, it might reduce your problems by 20%. And then you’ve got to go on another course on another course and another course. And I’ve just taken all of that and I’ve put it into a structured program, which I’m actually going to release online. And it’s going to be modular, so there will be a basic module, there’ll be an intermediate module, and then there’ll be a mastery level module as well. And my aim is to take all of my knowledge that I have up here, cut through the marketing BS that there’s a lot, not just in implant dentistry, but across dentistry as a broad, there’s a lot of oh, well, you know, if you use this, it will make everything 1% better. And all of a sudden that 1% is- So I’m cutting through all of that. And I want to give all of my knowledge that I’ve gained over the years in a succinct course as possible. And the reason why this is important for me is it actually goes back to a promise that I made myself from my grandfather, because I was very close to my grandfather as I was growing up. And in his later years, I’d qualified as a dentist. And I mean, he lived into his 90s. But I remember a phone call that he said to me, he asked me, he said, ‘If I come out to see you, can you give me fixed teeth?’ And this was before I was placing implants, I said to him, ‘No, I don’t know how to do that.’ And he went quiet, because he got upset. And then when he spoke, I could hear that the hope had just gone from him. And that’s when he told me something, which even to this day makes me upset, he’s eternal. And essentially, he said, ‘I can’t eat with the family.’ He said, ‘I’ve got to take my food into my room, because I can’t wear my dentures, I take them out and eat by myself.’ He said, ‘I’m so embarrassed about taking my teeth out.’ He said, ‘That’s why I see if you can give me fixed teeth.’ So I never got to help him. But I made a promise that I would help as many people as I possibly can. So for me that promises helping patients directly, but also helping patients indirectly. How do I help patients indirectly? Well, that’s easy. I train other dentists how to do implants as well. But for me, I do that all of in his memory. And I can’t do that by withholding information that’s up here. You know, I can’t do it. Okay, well, we’ll do a little bit of a course. Because, you know, I only want you to do the easy stuff, because I want the referrals, I have to give 100%. So this has been my philosophy when I’ve been building this course, I really, really want to make this an absolutely phenomenal course. And I’m in the process. And like you said, it is not easy. Because there is so much paperwork involved.

[Jaz]
There’s a white tape to get through to get the correct grading for the proper curriculum of the course, behind it, but I mean, for me that the layers of it is great. They’re pursuing letters, but me and you both will agree that the letters is not so much as in terms of the implementation of the knowledge and how you can actually start placing implants, right? Because Pav I’m sure you know, so many dentists who have been on implant courses, and they just placed one or two or just never did, and they just fizzled out. And it’s only maybe someone said about one in eight dentists actually goes and of course, that actually really, you know, flies afterwards and starts placing implants. So what do you think is the secret sauce to make a course like you are, and I’m sure he had been at the very front of your mind to make sure that all the dentists able to implement as much as possible?

[Pav]
So I think the secret sauce is is building real confidence, and making sure that you’re exposed to enough surgery, so that you can actually build that confidence. So for me, a big issue is a lot of the information that’s given in courses is not succinct, it’s a bit wishy washy. And a lot of people come out confused at the end of it, you know, so I’m not saying, please understand, I’m not bashing courses, because the vast majority of them are actually pretty decent, but I’m talking about trying to, you know, I don’t want to be sponsored by any one implant company, because then you know, you because if you’re sponsored by an implant company, you kind of have to be nice to that implant company, right? Whereas I want to, I want to be able to give people the critical thinking, so that I can think to the source, okay, let’s look at this implant system, what’s the pros and cons to it? How could it work? Because, you know Jaz, the vast majority of implants work, but how you execute them is a little bit different and subtle, depending on the implant, if that makes sense. You need to understand the overall principles that if you choose this implant system, you can execute it correctly. If you choose this other implant system, you can still execute it correctly. And that comes from knowledge. And that’s again, that’s the reason why I want to give as much information as what I possibly can in this course, which I’m aiming to get a do call verified, but that’s not an easy process and go through.

[Jaz]
Yeah, and like I said, That’s not as important as it is good that you don’t know it’s not as important as just like you said, given that secret sauce to get people to implement and just as you said, it’s about giving confidence. So if anyone’s interested, how do they learn more about your online sort of modular content?

[Pav]
So the online modular content I’ve written it I’m in the process of recording it. It will probably be ready to release in approximately six months time approximately. It just depends on jumping through hoops with edge and there might be a few tweaks to the course content. What I am doing is because obviously recording a course is not cheap as well. I am for a very, very few people who prepared to sign up sooner rather than later. I’m offering a ridiculous discount on the course. And I’ll message that over to you later Jaz but basically, it’ll be a cheap way to get into implants basically. And the provider is really simple is you pay now, which allows me to record and edit the videos and you just wait a few months for the videos to come out. Because once those videos come out, then there’s not going to be any discounts after that, because I know what I’ve got is going to be good. And so, you know, I’ve taken everything, I’ve sent it to friends who place a lot of implants, and they’ve looked at it and they go, ‘Well, can we do the course?’ I was like, what you’re gonna gain from this? It’s more than what I learned on my master’s degree.

[Jaz]
Is this for like beginners as well, like for beginners?

[Pav]
If you’re a complete novice never placed an implant? Yes, you can do it, the mentoring separate, but it will give you because theories theory, right, you can learn that online, you can learn it from textbooks that I’m going to make it as succinct as possible. I’ve got a number of guests coming on to talk about their niche topics as well. So if you’ve never placed an implant in your life, and you want to start, absolutely. If you’re already placing implants, and you want to up your game, it’ll also be suitable for you. Now, if you’re placing a reasonable number of implants, and you want to start doing more complex grafting, you want to start to get into sinus lifting, you want to do more aesthetic work in the anterior region, it’s going to be for you as well. So this is why I’ve split the course up to be modular. So there’s what I call a gateway module, which is a gateway into implants. There’s an advanced module, and there’s a mastery module as well. So I’ve tried to make it as all encompassing for everybody as I possibly can, respecting the fact that some people are going to be drawn towards some areas as opposed to others.

[Jaz]
Yeah, well, I appreciate that. If anyone is interested, what’s the best way for them to reach out to you to learn more? Because honestly, it’s a bit of a wait until this all happens. But like you said, for those people who are really keen and they love your stuff, and they want to learn, and they know that okay, I want to learn from Pav and if that would make sense to anyone, I suppose to learn from someone, someone is experienced like yourself, which is amazing. But if they’re ready to sort of learn more, how can they reach out to you?

[Pav]
So probably the easiest way to reach out at the moment is through Instagram, send me a direct message. So you can go to either Dr. Pav Khaira, the Dental Implant Podcast, or I’ve also set up the Academy of implant excellence at any one of those three, basically. There is a landing page being built, but again, that’s in the process. So it’s-

[Jaz]
Well I appreciate you sharing that. Yeah.

[Pav]
Yeah, Instagrams probably the easiest way at the moment, yeah.

[Jaz]
Well, that’d be recurring themes of mentorship and not falling into marketing crap. And it’s going flapless because like you said, I learned a few things, you know, about 10% amenable, I also learned that you know, 40% for the general dentist, okay, you could do immediate and there are some intricacies with that. But I like the way that you propose to the young dentist that perhaps even though you could do an immediate in those first few cases, you kind of describe the ideal first few cases and upper molar out of the smile line. So these are really good nuggets to to appreciate. So Pav, thanks so much for coming on and discussing this very interesting topic of flapless implants. I think we’ve now debunked another myth there. So I appreciate your time always my friend and all the best with this huge project. I’ll follow up again with you in about 6-8 months and see how it’s all going but I can see now how much work you have ahead of you but yeah, very exciting because I know this is your passion. This is your real project that you love so much. So I know you’ll do justice to it.

[Pav]
Thank you. Thank you so much.

Jaz’s Outro:
Oh, there we have it guys. If it sounds too good to be true, it probably is. So remember that with implants and with flapless. And anything, anything in dentistry. If it sounds too good to be true, it probably is. So it’s great that you shared themes or mentorship and I appreciate that Pav shared his big mistake, you know, his 32,000 pounds wherever it was the mistake that he made and that really highlights the importance of mentorship when it comes to implants. So if you’d like to learn more reach out with Pav through his Instagram channels. Otherwise, hit the like button, hit subscribe if you enjoyed this episode, and I look forward to making more for you very soon.

Today we pick up where we left off on the 1st part of Group Function Episode 13 “Can I Probe This Implant?” In this episode I asked Dr Pav Khaira about bone loss around implants – what is normal and when should I worry? Another very interesting and controversial issue we tackled is how to manage implant screw loosening as a GDP?

Need to Read it? Check out the Full Episode Transcript below!

“If every single year you’re losing one millimeter (of bone) that’s obviously an issue and we need to intervene and do something,” Dr Pav Khaira

In this episode we discussed:

If you liked this episode, be sure to check out the first part of this series Can I Probe This Implant?

Jaz’ Introduction:
Hello, Protruserati. I’m Jaz Gulati and welcome back to this second part of the group function. So we split it into two. On the first group function, if you haven’t listened to it already, it was “Can I probe that implant?” Is it cool to probe around implants? Because there was a myth that you may scratch the implant? So is there any truth to that? Should we be concerned? That’s all covered in part one. In this part two, we’ve got Dr. Pav Khaira, we’re talking about What is the normal amount of bone loss around implant? So when I am reviewing patients who had implants placed elsewhere, potentially, and I take a peri-apical radiograph, it’s been five years since they had the implant and my expecting bone loss. At what point do I get concerned? And what point should I refer? So we’re gonna find that out. And another very interesting controversial issue is, how do you as a GDP manage a screw loosening? So if the implant crown is loose, is it cool for us to be going in and tightening it? What about if you don’t have the right equipment? Or how to even identify which system it is. You have to stop every single driver there is? The very real world question there and I think Pav does great justice. So let’s hear it from Pav, and I’ll catch you in the outro.

Main Interview:
[Jaz] When you see a radiograph of an implant, let’s say a peri-apical. And I don’t know when this implant was on, I can ask the patient, the patient like a long time ago, five years ago, 10 years ago, they give me a vague answer. But anyway, am I expecting ever, is it acceptable to have threads exposed supracrestal, ie, all the threads are not in the bone, some of the threads are outside the bone, Is this acceptable? And be what amount of bone loss is normal? Because I understand that after you place an implant, after about a year, you expect to lose “some”, you’re probably gonna say yes, by do all this crazy voodoo magic that they don’t lose any bone. But for the average implant, what is normal in terms of bone loss.

[Pav]
So historically, what’s been considered acceptable is as a rule of thumb, bone loss down to the first thread, then about 0.2 millimeters per year, as you quite rightly said that these is, the modern techniques, the modern concepts, were really shouldn’t be seeing anything at all. But you know, I see loads of patients where they come in to see me where they’ve had implants placed 20 years ago, okay? And I think the issue is in the absence, in the absence of any inflammatory responses, like what we’ve discussed about before, there’s no bleeding, there’s no suppuration, the implants been there 20 years, if you’ve got a 15-18 millimeter long implant, you’ve got three millimeters of thread exposed, I’m really not bothered about it, okay? If an implant was placed last year, and I’ve got three millimeters of threads exposed, all of a sudden, I am bothered about it. So I think it very much depends on the case. And with regards to how many threads are acceptable to be supracrestal, again, that depends on the implant, okay? Because some implants like the Southern that I use, the top three or four threads, it’s actually a machine surface. So if there are threads exposed, it’s not really that impactful, it’s not really that significant. But if you had an implant, such as Nobel, they integrate nicely, but if you look at the surface topography of them, there’s tiny little caves. So what happens is, as soon as that’s exposed, and you start to get inflammation, it zips down the surface of the implant. So it depends as to the surface treatment of the implants. As a general rule of thumb, you should see a bone off down to the first thread in the first year, but even then, I wouldn’t be overly happy with that. But I think if you’re taking consecutive radiographs, and you see everything’s nice and stable, then why should we bother and intervene and do something right? If you’re taking PAs once a year and over a five year period you know, if in year one you’ve had two millimeters bone loss and no bone loss since then, it’s a stable outcome. But if every single, year you losing one millimeter half of it, that’s obviously then an issue we need to intervene and do something. So again, I’m sorry, it’s not a you know, clear cut but…

[Jaz]
Nothing is clear cut but that’s a useful guideline, Pav. I really appreciate that because it’s a bit like a periodontal patients, age is a factor and obviously age of teeth. In your case age of implants, we can apply similar logic to that, so that makes perfect sense and I think that’ll help on the Protruserati and th, have you got a word for the dental implant podcast listeners? Have you listeners have they got like a fan word?

[Pav]
I’ve used the term titani-nerds a few times.

[Jaz]
Say that again? Titani-nerds.

[Pav]
Titani-nerds. Yeah.

[Jaz]
Okay, I love it. Titani-nerds. Okay, so Protruserati, Titani-nerds, I hope you’re getting some value from that. I imagine the Titani-nerds are just know all of this stuff already. But maybe someone who’s interested in implants, interested in getting into implants. And this might be helpful because they’re seeing patients in their helping to maintain implants, which is what this episode is about. So my last question is now that emergency phone call you get, the nurse says or the reception says okay it’s a patient with a loose implant. The first time I had this is embarrassing, the first time I had this as a DF1, patient came in, and the crown was spinning. And in my head I thought, wow, this is like a grade three mobile tooth. I don’t know, I think the implant’s spinning. So I call my trainer and I said, Hey, Reg, I think the implants are like, fully loose. But the X ray looks okay, what’s going on? And he just like took-took-took, took out the access cavity restoration, just tighten it by quarter turn. And that was it. And I was like, wow, that was so easy. And then later on when I got to do this, one, the implant dentist told me that Jaz, you know, I read your notes, you tighten it too tight. And I’m like I didn’t know, what was I supposed to tighten it to? Because that’s what Nobel taught me when I went on course once. So A) Do you think all general dentists should know how to manage this emergency and be any guidelines, any helpful things that you can tell us, is there a standardized number of Newton’s that were tightened to for example, is the kit standardized? Am I expected to have all these kits.

[Pav]
So this is a real bugbear and it’s a real pain in the backside for me, because there are literally hundreds, if not thousands of different implant systems out there. They all use different screw heads, they all use different torques, it can be due to a number of different problems. It could be screw loosening, it could be what’s called a titanium base that’s come loose, it could be the hex that’s threaded, it could be the implant head that’s fractured. And you’re basically taking a shot in the dark with this type of stuff. While probably recommend to a general dentist who doesn’t place implants, the only thing that you should really be looking at doing is at the most is tightening it finger tight, and then sending it to somebody else to deal with, okay? Because I had a patient come out to see me. So what I never do is I never just re-tighten screws, always have to order a brand new screw, okay? So I’ve had a couple of patients recently, come out to see me, the works absolutely beautiful. It’s come loose. So what I’ll do is I’ll hand tighten it, I’ll say, I’ve got to order new screws, I’m going to swap the screws over, because screws become stressed and they become strained. That may be one of the reasons why it’s come loose. And if you re-tighten a strange screw you can cause it to break, then you’re in trouble because you may not be able to retrieve it from the implant head. So you only want to tighten it at finger tightness, and then you want to refer it on somebody else to deal with. So the issue that you have is certain systems like Ankylos, they’re quite happy to take 15 to 20 Newton centimeters. The Southern implant that I use take 14 Newton centimeters, if you get it wrong, you’re going to give yourself a problem. So you need to know exactly which system it is. And there are have been a number of occasions where I haven’t known what system it is. And I’ve had to take an educated shot in the dark. And that’s all that I can do. So the answer to that question is, is are you going to see it? Yes, you are. Okay? And I think another big aspect, another big problem that this is caused by is very frequently, when dentists get the lab work back from the lab, they’ll use the same screw that the labs been using, they won’t order a new screw. And I’d say historically, that’s what I used to do, because I didn’t know any better. But people like why should I spend another 40, 50 quid on a new screw and all that one, there’s one that’s here. Thing is the lab has been screwing it on and off, on and off. And that screw’s strained, it’s not appropriate to use anymore. So this is something that Riaz and I discussed in our podcast as well, Is the lab should order a brand new lab screw and you should get a brand new prosthetic screw for every single case. Not be reusing impression copings you should not be reusing lab analogs, you should not be reusing healing abutments everything should be fresh brand new for every single case. The other issue that you can have, we spoke about this lollipop type appearance on a number of occasions. So another issue that you have is particularly monocytes is if you’ve got a narrow implant, which has had a small healing abutment on it. And the lab is they’re trying to create some sort of contour to the crown. Quite often the lab will put in a little bit of compression onto the gums to try to give it some sort of contour as it’s coming out. And what happens is as you’re torquing it down, let’s say you’re torquing it down to 35 Newton centimeters, that compressions going on to the soft tissue not onto the actual interface itself. So you get patients back quite quickly with loose crowns.

[Jaz]
Yeah because all that’s happening is a soft tissue is getting compressed, but the screw is not engaging where it should be, right?

[Pav]
Yeah, so the screws not fully seated. It’s partly seated. And sometimes you get away with it but a lot of the times you don’t, so my protocol is A) make sure that the crown’s completely passive is going in. I will then torque my abutment to whatever torque it is, depending on which implant it is that I’m using, I will then wait 10 minutes, and then I will re-torque it. Because re-torquing after minutes, make sure that everything’s really nice and secure.

[Jaz]
Amazing. I think that makes perfect sense. But I think the message for someone like me, which I took away from that is, if in doubt, which I’ll always be in doubt, because I don’t know which system was used, I’m going to finger tight in it, and send it back to the person if I don’t know who, you know, what brand of implant it is, and I’ve got my implant placing dentist comes in once a week, they can easily deal with that. And I’m sure they’d be grateful that they get an opportunity to properly deal with that. However they would and like you would. So I think finger tightening is something that a lot of dentists can do. And the drivers, the universal ones. Are they as universal as the name suggests?

[Pav]
No, they’re not. They’re just called universal drivers. But they’re just…

[Jaz]
Oh my goodness

[Pav]
It depends what or what extent you want to go to, you can get little kits for about 300-400 quid, which you’ve got loads of different drivers in and you just try whichever one so the case that I had today, I knew which implant brand it had. But when it was originally placed, it was over torqued to the head of the screw it stripped. So getting it on and off was really, so even with the correct driver getting it on and off was really difficult, okay? So you can have 0.9 drivers, you can have 1.2 millimeters drivers, you can have 1.22 millimeter drivers. Straumann have got their own driver, Nobel have got their own driver. Neodent, they’ve made their driver similar to Nobel, it’s called the Unigrip driver, okay? But Nobel’s, Unigrip driver, and Neodent’s uni driver, they look almost identical, but they don’t fit in the same way. If all companies said, we’re gonna have a standardized universal driver, that’d be one of the best things ever, but it’s just not gonna happen. It’s just not gonna happen.

[Jaz]
It’s not gonna happen, just like Apple’s not gonna switch to the USBC and get rid of that white thing that you have to buy. It’s just not gonna happen. And you can see why. But mate, that has been so helpful. So we have covered in this episode probing, Can you probe? Yes, you can. But take a look at the radiograph first because those lollipop ones good luck, it ain’t happening. Threads are exposed kind of like perio, you have to depends on the patient’s age or ie the implant age, not the patient, the age of the implant and that should guide you. And the loose implant, perhaps consider finger tightening it and sending it back to someone who can deal with it in a more comprehensive manner. Like you would. So Protruserati, I know you found that helpful. Titani-nerds, I hope you did, because you guys are like you know, you’ve been following Pav. Pav taught you so much already. So you know, we could have easily gone on for like five hours talking about each minutiae. You just have so much knowledge and I want to distract. But please, for those people who haven’t heard your podcast, Pav, tell us, remind us how we can listen, how we can tune in, and what’s next on the horizon for your podcast?

[Pav]
So it’s The Dental Implant podcast on Spotify, iTunes and Google podcasts. And, you know, obviously, inspired by yourself Jaz, you know, I’ve said this before, you know, you’re the one that seems to be probably got a lot of knowledge, you need to get it out there. So it’s aimed at kind of like beginners and those kind of like partway through the implant training pathway. There is stuff on there for more knowledgeable people, but they tend to know a lot of this stuff already. And I just cover so many different topics. I mean, as you said, you know, I could write a lecture just on screws, which could last two hours, I can then write a lecture on how to tighten screws for another two hours. So you know, it goes into..

[Jaz]
All the complications in there and whatnot.

[Pav]
Yeah. And, you know, how to avoid complications, and, you know, what we should and what we shouldn’t be doing, you know, taking a part, the bad signs, et cetera. So I just tried to, again, I always say, look, it’s my perspective, you know, this is how I do things. This is my interpretation of the data. You don’t have to agree with it. You don’t have to like it, you know, but as you know, you can take one topic and you got two people arguing both sides of the coin, they’re both right, you know, it’s just, but I just want to help people deliver better care for their patients. This is one of the reasons why, you know, I mentor people as well. So when people like, I want to learn how to place immediate molar implants, it’s like fine, no problem, I’d show you how to do and bring your patients to me. This is why we do the EVO experience at EVO Dental, where you just come shadow us for days and see what we do. Because before I start at EVO Dental I thought I was proficient at full arches. But what we do there is just I wouldn’t do a full arch externally because just because of the way that the place is set up. So I’m done. Just you know, I’m very passionate about dental implants and trying to help others be just as passionate and get better outcomes for their patients because you know, it goes back to what we were discussing today, you know, is if I can teach dentists how to develop emergence profile properly, you’re not going to have these issues, if I can teach them how to place crowns properly and have soft tissue adhesion to the neck of it. We’re not going to have these issues in the future. So you know, that’s just my passion. That’s the reason why I’m doing it basically.

[Jaz]
And if anyone needed one more reason to listen to Pav’s podcast, he hired Morgan Freeman to do the intro. Can you believe it? He got Morgan Freeman. If you haven’t listened to it, you have to listen to it right now. Scroll on, go to Spotify, type in The Dental Implant Podcast. Listen to the intro. You will love it. Pav, thank you so much. Thank you so much for giving your time, really appreciate it. Thanks for all your mentorship and help and I think I won, I gained so much value I know what to do a little bit more now around those three scenarios which confused me every time, so I’m not going to, no longer gonna have my head in the sand now. Really appreciate it and hope you have a fantastic weekend.

Jaz’ Outro:
There we have it guys hope you enjoyed this group function series. As always a pleasure to do this and Pav is just amazing. He answered it really well, both parts of them. So Pav, thank you so much. Do check out The Dental Implant Podcast if you haven’t already, and I’ll catch you in the next episode guys. Be sure to join the Protrusive Dental Community on Facebook

“Don’t probe implants with a metal probe or you’ll scratch it!” – and so for years I was afraid to check the gingival health around implants. Crazy right? Dr Pav Khaira is here to bust that myth – but like with everything, it’s not a simple answer – it has some interesting anatomical considerations. His answer is so eloquent, check it out!

Need to Read it? Check out the Full Episode Transcript below!

“If you can get to the neck of the implant, you SHOULD be probing to the neck of the implant…but you don’t want to do it too aggressively, it should just be very gentle pressure.” Dr Pav Khaira

In this group function we discussed:

Check out The Dental Implant Podcast!

If you liked this episode, you will love revisiting Implant Assessment for GDPs: from Space Requirement to Ridge Preservation

Jaz’ Introduction:
Hello, Protruserati. I’m Jaz Gulati and welcome to this group function. Now if you’re new to the podcast, welcome, great to have you. A group function is where we work together as a team to find out a solution to a common problem. And the problem I’m presenting today and I’m hoping to get a good answer from Pav today is ‘Can you probe around implants?’ And what I mean by that is, I was fed a lie or a semi lie at dental school, like someone told me, I don’t know who it was. But if you use a metal probe, to do a periodontal probing chart of an implant, you will scratch that implant and therefore that will harbor bacteria. And therefore you should not be probing around implants. So for the longest time, I didn’t check the periodontal health of implants and it sounds really bad. But as a GDP who doesn’t place implants, not much to do with implants. I thought that was the right thing to do. I thought I was doing less harm by not inserting my Williams or WHO or CPITN probe in the sulcus to check for the periodontal health because I didn’t want to scratch the implant. I was scared of scratching the implant if you like. So I was expecting this to be a really quick group function. And I thought Pav was saying Yeah, you totally can. It’s all good. But Pav of being Pav, an amazing guy he is. The only does he give us a really good definitive answer at the end, where he talks about the rationale of what the concerns are maybe and how each actually look a little bit deeper than Can you probe? Can you not? Because there’s some anatomical variation, so I’m not going to spoil it for you. Let’s join this group function with Dr. Pav Khaira. That man again. Pav Khaira.

Main Interview:
[Jaz] Dr. Pav Khaira, welcome back to the podcast, my friend. How are you?

[Pav]
I’m very good right now. How you doing?

[Jaz]
Yeah, great. So it is Pav Khaira from The Dental Implant Podcast. And I’m gonna just pick your brains. You need to teach us something today. You need to speak to me like I’m five years old. Because this, the following questions I’m gonna ask you on this group function today is very much basic things that you’re probably gonna laugh at me like Jaz, why you asked me these basic questions? But I’m sure with the referring dentist that you’ve met and your colleagues, like when it comes to implants we come out in dental school, like a lot of other topics. And we’re like, where do we even begin? So just before we dive into that, just reminder on people who perhaps didn’t listen to our episode on finding your niche. I think it was episode 76 from memory. Do listen to finding your niche, it’s a cool one where we discover what is like your calling in dentistry. So do check that one out. But just remind us what is it that you do other than these amazing transformations that you posted on our telegram group.

[Pav]
So thank you very much for having me on Jaz, I’m going to be cheeky and just upload this as the next dental implant podcast episode as well as your record. We have the same video editor. So it’s an easy way. Firstly, I just wanted to say that there’s no such thing as a silly question. This is something that I learned really quite early on, either you know, or you don’t know, it’s really that simple. And I think anybody who doesn’t know who’s asking questions at that point that then they shouldn’t feel embarrassed or anything along those lines. So if I am being overly complicated with my answers, please feel free to remind me because obviously, for me, this is fairly straightforward stuff. And you know, when I get excited about implants, that’s it, mouth starts. Okay? We all know.

[Jaz]
We’re going to start talking about at the cellular level, biological level. No, we’re gonna go way simpler than that today. I know the kind of stuff that you talk about you love that you absolutely love that. And that’s amazing to see though your passion is so..

[Pav]
I’m gonna make it really tangible for you guys as well. So a little bit about me. I graduated in 2002. I did loads of different things. You know, I ended up getting bored quite quickly. It was one point I was doing endo for smile makeovers. And ironically, I just didn’t make surgery. I didn’t make implants. And then I ended up getting into implants. And I was like, Oh, actually, I really love this a lot. I’m now at a position where I am fortunate to be at EVA dental four days a week, and I mentor other dentists and I started working at another practice one day a week as well. And I placed approximately 1800 to 2000 implants a year. So that’s actually quite a big number. And yes, you know, when you when you place big numbers, you learn to prevent a lot of mistakes, but you still see them, you know, anybody turn around and say you have 100% success rate. This is something that I’ve alluded to before, they are either lying or they’re only placing one or two implants per year because if you place one or two implants per year, it’s quite easy to have 100% success rate. So yeah, I mean, that’s just a little bit about myself, I do the surgical aspects of it. I also undertake the restorative, because you can’t separate them. You know, it’s that intrinsically linked together. So that, you know, that’s just a little bit about me.

[Jaz]
Amazing. I mean, it’s crazy. That number you mentioned, you probably do more implants than I do checkups. You probably do more implants than I do composites. You do. You do more implanst than any procedure. That’s pretty spectacular. So you’re totally the right man for this. So question number one of three in this group function is m, can I probe that implant? Now to give you some background behind this question, it’s something that you may have heard before. Now, I don’t know whether it is a myth or not. And I think it is, but let’s just find out the whole thing about if you use a metal like a Hu probe, or a CPITN, a metal probe, or an implant, you will scratch the implant, which will then harbor bacteria, and it’ll be a never ending spiral of peri-implantitis in future. And therefore, dentists all over the world. I’m sure they are. I’m sure they are, are doing their BP and they skip the implant and they carry on. Tell us about this.

[Pav]
So the question that I understand is can you probe around implants?

[Jaz]
Can you probe with a metal probe aroung implant? Or is it a myth that you shouldn’t, you can’t, or just tell us generally about how to check the periodontal health of an implant in a safe way.

[Pav]
Okay. Do you want me to be really unhelpful now? Because you know, what I’m like, it’s one of those. Okay, so the answer to your question is, yes, you can, and no, you can’t at the same time, I’m going to expand on that right now. Okay?

[Jaz]
Sure.

[Pav]
I think we need to take half a step back and understand what’s happening a little bit. Okay. So when you receive the final outcome of or, let’s just say, restored single implant crown, okay? So there’s a number of ways that it can be done. The way to get the best outcome isn’t done very often, because it’s more time consuming, it’s more difficult to do, okay? So the kind of the standard way that most people out there do it, which is kind of accepted is you have quite a narrow implant in relation to your ridge, which is the same height as the alveolar crest. And then radiographically, it looks like a lollipop, tomato on a stick is what it’s called. So you get this sudden, you get this sudden, really, really extreme what we call emergence profile, okay? Now, so probing around implants is different to probing around teeth, okay? Because when you’re probing around teeth, you’re immediately going into the periodontal ligament. If you imagine you’ve got this really wide implant, sorry, really narrow implant, or really wide crown. If you’re probing straight down the side, you’re not actually going to do anything, you almost want to be at 90 degrees, and it ends up being really difficult. Okay, so in those instances, when you’ve got an internal connection, the implant actually needs to be deeper. So you’ve got running room to have a natural emergence, but then you need to condition the soft tissue with a, instead of just a standard healing abutment out of the pocket, you can make custom healing abutments so you get a really nice smooth transition. Okay? Now, the reason why that is important, is because when you’ve got a very acute and sudden emergence angle A) it becomes virtually impossible to probe to the neck of the implant, but it actually answers the bio flora, the biofilm next to the implant neck itself, unfavorably, it becomes anaerobic as opposed to aerobic. Okay? So you’ve actually snookered yourself. So because what you’ve done is you’ve created a situation where you need to probe but it’s actually difficult to probe. Okay? So the other way of doing it is once you place your implant deep enough, the way that I do it, is I use external hex and I use quite wide implants. Because then it’s…

[Jaz]
Only because I think everyone’s like listening like wow, they’re like gripped by this because this is very interesting in terms of the different connections and how to have that runway room to get the best emergence profile. But like if I’m a GDP and which I am, and I see a patient and implant was put in, I don’t place implants. So patient comes in, they got an implant. I’m not going to pause and say, Okay, what kind of connection is that? Now I will because it’s great point you raised. Now I look at the radiograph and I’ll see okay, is this a lollipop or is this not a lollipop? And then but you know, what am I gonna do?

[Pav]
Okay, fine. That’s exactly the point that I was getting to. So first thing that you do is you take a radiograph. Okay, if it looks like a lollipop, there’s not really much point in trying to do it because the angle that you’ve got to get to, the pressures that you’ve got to apply, you’re not really going to be able to approach the neck of the implant, okay?

[Jaz]
Of course.

[Pav]
And now it is my opinion that you know, if you can get to the neck of the implant, you should be probing to the neck of the implant, okay? So you don’t want to do it too aggressively, it should just be very gentle pressure, okay? And what you’re looking for is you’re looking for the same thing as what you would do when you have a tooth. Is there suppuration? Is there bleeding? Okay? Not so much about the depth of the probing itself, okay? Because you don’t have a true periodontal attachment. It’s like a long junctional epithelium. So you’re applying much lighter pressure, you’re automatically going to have pseudo pockets going deeper. But the question is, Is it bleeding? Is there suppuration? And as I said, is if you’ve got this lollipop type appearance, so you’ve got this skinny implant, all of a sudden, really, really big crown on top, I don’t think you can probe those pretty well. So why bother?

[Jaz]
Still probing just to check if there’s bleeding or suppuration?

[Pav]
So no, I mean, the test that you can do in that area is you look at your radiograph to see A) is there any bone loss around the threads? We’re gonna come back onto that in a minute, because I know that’s one of the topics, Okay? The next really, really, really good test is just with a finger, just push the gingiva either side, because if you push the gingiva, either side, you see suppuration coming up one side, that’s a problem. Makes sense?

[Jaz]
I see. So you’re kind of like milking the implant.

[Pav]
Yeah, massage. Exactly what it is. If you’re massaging the gingiva, either side, and you’ve got bleeding, or you got pus coming out without even picking up a probe, that’s a problem, that’s absolutely a problem. Okay? So let’s say you’re looking at the radiograph and you get this nice transition from the implant to the crown, it just looks like nice and smooth. Yeah, pick up a probe, it’s not a problem, just don’t be heavy handed with it. So what you’re not trying to do is you’re not trying to sound down to the neck of the implant, lots of bone, all you’re doing is you’re just going kind of like into the cuff a little bit, you just go into the cuff and just sweeping it backwards and forwards. And you seeing whether that triggers any bleeding, because that’s a sign of inflammation. So there’s not so much probing is you just seeing whether it triggers an inflammatory response, that’s all that it is. But you what you will notice as well is particularly with implants, is you get this little purpley band around the neck of the implant when in early stages of inflammation. So and in those instances, when you’re looking at those perfectly bands should immediately be thinking to yourself, something may not be quite right here. Okay? So I have no problems with people gently probing if you could use a plastic probe that’s better. You got a metal probe, you know, there’s not too much data to go in between because it swings and roundabouts. If you don’t probe, you don’t know what the problem is. If you do probe, but you probe too hard, you’re going to scratch things, you’re unlikely to get to the neck of the implant, or you shouldn’t be able to get to the neck of the implant. I think it also comes into play, what restorative material has been used as well. Okay? So without going too much into it, there is a very good researcher called Tomas Linkevičius, he has done a fantastic textbook called Zero Bone Loss Concepts. He teaches on it. And the restorative protocol that he use is highly polished zirconia on the fit surface against the soft tissue itself. And when you do that, and when you autoclave it and clean it properly, you actually get soft tissue adhesion to the neck of the implant. Okay? So allow me to break this down a little bit more. I know we’re going a bit more advanced, but it’s actually really relevant for what we’re talking about. He did once a day where he did restored single implant crowns. Okay? Using Zirconia. On half of the fit surface against the soft tissue, he used a zero bone loss concept which is highly polished, no glaze, okay? On the other half of the same implant, he used glaze over the surface, and if it’s, and six months later, he programmed the implant, okay? The average probing depth of the polished area was one to two millimeters, the average probing depth around the glazed area was two to four millimeters. So you can actually get a division of the soft tissue onto the surface of an implant if you do it properly. So I think it’s also important to know what material has been used, okay? Because if it’s a PFM, you’re not going to get that adhesion, you need to be much more gentle with your probing technique. The other thing that you can do as well is if you’re going around is as you put the probe in, you take it out and you wipe the probe clean with a clean gauze so you’re not transferring bacteria from one position of the implant to another.

[Jaz]
Wow okay that is a dedication.

[Pav]
Yeah, that’s dedication. But you know that’s something that I heard, but then I thought so that, you know, then I was thinking to myself, you know, you’re talking about not transferring bacteria from one part of an implant to the other, it still sat underneath the implant. It’s still a problem, right? So it’s a, and this is why I’m saying that there’s no 100% correct answer. But I think what you need to do is you need to look at the radiograph. And make an appropriate decision. If you see that lollipop on a stick, you’re not going to get to the neck, forget about it. If it looks like a really nice, what we call emergence profile, that really nice, soft, flowing type thing, then you think to yourself, yeah, I’ll gently probe this. And to be honest, is if I have, like my own implant crowns, now, the zirconia ones, I’m less bothered about probing them, because I know I’m going to get soft tissue adhesion. So I look at the adjacent teeth as well, right? So if the patient’s cleaning everything really, really, really well, you’re unlikely to have a problem with the implant. So don’t take the implant as a standalone thing. Look at everything else around it as well.

[Jaz]
Well, before we now come on to the radiograph, because you touched on that and that was it. Next question about the thread exposure and what is a normal bone loss before I get to that, I mean, when you find if and when you find bleeding, when you’re doing the probing on implant, I think that lends itself to a diagnosis of Peri-implant mucositis I believe pus would mean, I know it might not be a hard and fast rule, but pus usually what I’ve been taught and I’ve read Peri-implantitis. Should I be referring to someone who’s more clever than me in implants? Every time I diagnose Peri implant mucositis, just bleeding or just simple local measures? Improving OH is enough or do you think I should be actually sending him back to the dentist? So Peri-implantitis with pus I definitely would be not, I would not be ignoring that.

[Pav]
Yeah. Local measures. So improve the oral hygiene, explained to the patient what’s going on. And just treat it like a Perio case. So you’re monitor it over. And you assess it over a number of months. And it is really important that the patient improves because the other issue that you have is the crown cement retained and is it cement underneath that’s causing this in which case, no amount of oral hygiene, you can do this. And what the data shows is if you do a cement retain crown and you can’t get rid of the cement, the cement may cause an issue seven to eight years later, sometimes it’s not straight away. So you know, a lot of people are doing well, there’s nothing wrong with cement retained crowns. And you look at this paper and it goes Oh, yeah, you know, after three years, cement retained crowns, I’ve got no issues. There’s that Yeah, but the peri-implant cementitious can be triggered seven or eight years after when you actually cemented it. So I think it’s important to see whether there’s a scratches in it. If there’s scratches in it, then you know, it screw retained. If there’s no screw access, and it just looks like a normal crown, then it’s cement retained. And then we come back to the original issue that we spoke about, if you’ve got this lollipop type thing, being able to get a probing towards the neck of the implant to get rid of all of the cement, never, it’s not going to happen, there will 100% be cement there. So when you have just a little bit of local inflammation, by all means start local measures first, really good OH, there are some products called blue®m, okay? I think that there’s a mouthwash, there’s a gel, they actually worked really nicely. They are oxygenating, they’ve got oxygen in it, and it is ` the biofoam for that to be more favorable. And what you should notice is once you implement those measures, it should maintain, like with gingivitis may get the odd flare up now and again, but you shouldn’t have anything persistent.

[Jaz]
For me your word is gospel, you know, for me, you’re the guy who doesn’t you know, if you don’t know something, it’s not worth knowing when it comes to implant. So I will definitely look into that product for, to help my patients supportively but on to question two now.

Jaz’ Outro:
There we have it, guys. Hope you enjoyed that group function on can you probe that implant? The next one is going to ask about what is the normal amount of bone loss around an implant? So as a GDP when I see a radiograph, a PA, and I’m seeing a little bit of bone loss around an implant, Should I be worried? I don’t know at what point I should be referring on to the person who placed the implant or someone who a periodontist maybe? So that’s the kind of flavor I got. And the third question which all be covered in part two of this group function is what do you do when you get an implant screw loosening? So as a GDP if someone’s implant crown is loose, I now know what that is a screw loosening. You can hear about our use of thing that was but it’s a screw loosening. And is it cool for me to just enter the access cavity and just Yeah, finger tight or tighten it to what I think it should be torque to, is that a good thing to do as GDP? Well, you’ll find out very soon, either a few days or a week, depending on my workload. But anyway, thank you so much for supporting and listening. I really appreciate it. I’ll catch you in the next one.