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!)

https://youtu.be/1CSE9J1w-Pw

Watch GF022 on Youtube

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

Click below for full episode transcript:

Jaz's Introduction: Imagine you have a patient and you refer him to the implantologist, who proceeds to place an implant for the upper right molar. Some months later, you then restore that implant. But unfortunately, this one doesn't go to plan and six months later, you make a diagnosis of peri implantitis and the implant has officially failed.

[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.

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.

https://youtu.be/iLkclWANzsk

Watch GF021 on Youtube

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?

Click below for full episode transcript:

Episode Teaser: Do you go through the notes? Is there a sort of a protocol you follow to go through every associate, every dentist's notes? How does that work?

[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 IntroductionHello, 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,

‘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?

https://youtu.be/v_u9sBAGliU

Watch GF020 on Youtube

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 Intro01:02 Dr. Tzvika Greenbaum03:39 Dentistry meets physiotherapy09:33 Range of movement10:23 Asymmetry11:20 Prevention12:20 Advice to dentists14:34 Stretching16:17 The dental gym16:57 Sleep bruxists vs. awake bruxists19:28 Reducing sleep bruxism20:52 Obstructive sleep apnoea22:03 Statistics and diagnostic criteria25:16 At-home exercises27:20 Pain and discomfort28:39 Rehabilitation30:14 When to involve a physiotherapist31:12 Expected results32:21 Screening34:15 Dr. Greenbaum’s event39:04 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?

Click below for full episode transcript:

Jaz's Introduction: One of my mentors, Dr. Lincoln Harris, once taught me that easy dentistry on a difficult patient is still difficult, and nothing makes our dentistry more difficult than that patient who just can't open, or the patient that keeps closing their mouth. Like, it's impossible to do high quality work in that kind of a patient.

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,

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!)

https://youtu.be/SmLM5cr4mzo

Watch GF019 on Youtube

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?

Click below for full episode transcript:

Episode Teaser: 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 let's call them the distressed 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 can 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 emissions.

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.

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?'

https://youtu.be/ERvzjlQaBRc

Check out this full episode on YouTube

Highlights of this episode:

2:00 Dr Gulshan Murgai Introduction5:43 Which intraoral scanner should I purchase?8:03 The best scanner on the market today and why?12:37 Aligner system available for different scanners15:17 Customer support on scanner companies18:11 Scanner Prices19:12 Caries detection within scanner20:27 Importance of scanner and what’s the best for your practice

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).

https://youtu.be/RJzQZNhBup0

Check out this full episode on YouTube

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

Highlight of this episode:

2:27 Post-op pain after endodontic treatment7:43 Flare-ups9:46 Guidelines in antibiotic microbial management11:03 Flare up in between visits (RCT has not been finished yet) 13:40 Crown Down approach

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? 

Click below for full episode transcript:

Opening Snippet: I wanted to start this podcast with a get well soon message for our guest, Dr. Sanj Bhanderi who did such a brilliant job with our last group function on how to extirpate quickly and properly. Now, unfortunately, after we recorded that episode, and after we recorded this one, Sanj felt acutely unwell. It was actually scary hearing the news of him being ill. But I'm getting some positive updates. And so we the Protrusive Dental Community, and then all dentists around the world. We wish Sanj a speedy recovery. We hope you get well soon. We're so glad you're okay and on the mend. And we want to pass on these wishes to you. It's been quite clear on social media, what a likable guy you are, and how much we all want you to make a speedy recovery mate. So wishing you all the best and get well soon from Team protrusive.

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,

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.

https://youtu.be/SjYWxr1sSDc

Click Here to watch this episode on YouTube. For the full notes check out the Protrusive App on iOS and Android.

“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:

2:38 Dr. Sanj’s journey to Endodontics6:30 Emergency extirpations8:42 Diagnosis Protocol Irreversible Pulpitis11:57 Anaesthetic for Hot Pulps15:33 Caries and Restoration Removal Before Extirpating?19:16 Vital pulp therapy21:19 Isolation Protocol25:30 Sedative Dressing for Acute Pain28:42 Temporary restoration of choice31:39 Post Op Medicaments

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?

Click below for full episode transcript:

Opening Snippet: /Jaz/ In ideal world, we'd love to remove the entire restoration. Remove any caries, access cracks but when I have 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us? /Sanj/ At the end of this. This is about patient, this is about getting the 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 patient realizing it. That's my principal in endo whether it's emergency or Endo. You want to- /Jaz/ Stealthy. /Sanj/ STEALTH. Stealth. Okay?

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.

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?!'

https://youtu.be/679HAttBQ1c

Check out this full episode on YouTube

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

Highlights of this episode:

4:36 The Rise of Flapless Implants7:04 Indications for Flapless implants9:43 Immediate implant placement13:59 Advice to Young Dentists considering implants18:56 Implant Mentorship24:11 Dr. Pav’s Implantology Course27:46 From Course to Implementation

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?'

Click below for full episode transcript:

Opening Snippet: You pay to learn in one fashion or another. This is something I've 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.

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,

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?

https://youtu.be/C1Y_AdDhLzU

Check out this full episode on YouTube

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:

Normal bone loss for average implants 1:53Guidelines for GDPs managing loose implant screws 5:03Universal Implant Drivers? 10:45

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

Click below for full episode transcript:

Opening Snippet: Because screws become stressed and they become strained. That may be one of the reasons why it's come loose. And if you retighten a strange screw you can you can cause it to break, then you're in trouble because you may not be able to retrieve it from the implant head...

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,

"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!

https://youtu.be/pLDfqe8liLE

Check out this full episode on YouTube

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:

Can you probe implants? 5:33Screening Periodontal Health of Implants 11:14Referring patients with Peri-implantitis 16:22

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

Click below for full episode transcript:

Opening Snippet: You just got into the cuff just sweeping it backwards and forwards and you seeing whether that triggers any bleeding because that's a sign of inflammation...

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.