Protrusive Dental Podcast

Why are principals and associates always at loggerheads with each other? Why can it be almost impossible to find the right associates to work at our amazing practice, but also almost impossible to find that amazing practice to work at as an associate? 

Join myself and Dr Sarika Shah on this episode where we learn more about self leadership and the ways to prioritise our values to help us find the right working relationships and places of work to be a part of. Let’s figure out how to bring all members of a team together and create the zen we are all in search for while working in our day to day lives. 

Protrusive Dental Pearl:

Be willing to accept rejection. A ‘no’ from a patient today is often a yes tomorrow. Plant seeds for high quality dentistry and you will find yourself harvesting many of these seeds at a later date. Those who fear rejection routinely offer less than their best, which cheats patients out of rightfully making their own economic decisions – inspired by Dr Lane Ochi (the ORIGINAL Dental Geek!)

Check out Flourish as a Female: https://www.flourishasafemale.com/

Use discount code ‘protrusive’ (No financial interest)

Highlights of this Episode:
02:18 Protrusive Dental Pearl
04:30 Introduction – Dr Sarika Shah
10:10 Transition to Private Dentistry
13:40 Practice Ownership
17:20 Managing the Practice
24:55 Internal Leadership
29:40 Principals vs Associates Friction
41:56 Women in Dentistry
47:15 Supportive Partners
55:25 Top Advice from Sarika
58:28 Flourish

This episode is eligible for 1 CE credit via the quiz on the Protrusive Guidance App. 

This episode meets GDC LEARNING OUTCOMES A and B

AGD Subject Code 550 Practice Management and Human Relations

Aim:
To explore the importance of self-leadership and effective communication in building successful relationships between dental associates and principals, enhancing teamwork, and optimising practice performance.

Dentists will be able to: 

If you liked this episode, be sure to check out IC025 – Parenthood and Dentistry

Is Sodium Hypochlorite still the best irrigant for endodontics? Or do we have something novel and superior?

How can we improve the efficacy of our endodontic irrigation?

What % of NaOCl should we be using?

Dr. Brett Gilbert rejoins Jaz Gulati to tackle all things endodontic irrigation after a brilliant episode on pre-emptive endodontics.

Advanced activation and delivery systems could change the game—are we on the brink of a major shift in endodontics?

Protrusive Dental Pearl: Before performing a molar extraction, challenge yourself to first complete an endodontic access on the tooth. This will enhance your understanding of the canal anatomy and improve your precision in sectioning the tooth. By visualizing the canals and the pulpal floor, you’ll refine your angulation for more accurate sectioning.

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

Highlights of this Episode:

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. 

This episode meets GDC Outcomes B and C.

AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment)

Dentists will be able to: 

1. Gain insight into the role of sodium hypochlorite in endodontic disinfection and assess its effectiveness compared to new innovations.
2. Discover the cutting-edge irrigation methods, including surfactants, ultrasonic activation, and laser-assisted irrigation, and their impact on endodontic outcomes.
3. Explore emerging technologies and innovations that could revolutionize endodontic irrigation.

If you liked this episode, be sure to watch the 1st Part – ‘PDP202 – Elective Endodontics? It’s all about Communication’

Teaser: When you use a lower percentage, you really aren't reducing or eliminating the risk of sodium hypochlorite accident. If you get 3% sodium hypochlorite out the end of the root, it's going to cause a sodium hypochlorite accident, as will 6%. If you're trying to eliminate risk using a lower concentration, I don't think it's as effective as you think, but you are taking away some of the strength that you're looking for to kill the bacteria and dissolve the tissue. So my advice would be go full.

Teaser:
We recognize that training our general dental colleagues on endo is paramount because we don’t want the option of implant to come in place of saving the natural tooth simply because of fear or the fact that they just don’t feel well enough trained to do the endo. So I believe as a dental community, the more we feel comfortable and proficient in endo, the more teeth we save and the better our patients are.

Jaz’s Introduction:
Is sodium hypochlorite still the best thing in irrigation? If it is, what percentage should we be using? This one might actually surprise you. Is there ever a time when to use chlorhexidine. Whatever irrigant we’re using, how can we improve its effectiveness?

Hello, I’m Jaz Gulati and welcome to the part two with Dr. Brett Gilbert. How awesome was he? Please do check it out if you haven’t already. We talked about elective endodontics or preemptive endodontics. I love the clarity and the passion in which he speaks with. And he definitely continues it on into this episode. He’s so knowledgeable, he’s so passionate about endodontics in general, but especially the innovation in irrigation.

Because after all, endodontic success is all about killing those bugs. And Brett has so much experience in trying all the different things out there. And towards the second half of this episode, he really talks about what are the innovations. What’s around the corner? What’s the next best thing in irrigation?

But then I also squeeze out of him the all important real world question, which is no matter what clinic you are in the world, how can you improve your irrigation? So we also talk about GP pumping right towards the end. This episode is eligible for CPD or CE credits. This one’s 0. 5 CE credits under the topic of 070 endodontics as Protrusive Education is a PACE approved provider. Make sure you’ve got the Protrusive Guidance app, so you can just answer the questions after this episode.

Dental Pearl
Every PDP episode, I give you a Protrusive Dental Pearl, and can you believe we already have 291 episodes? That’s across all the group functions and the interference casts. And combining all the stuff we do in the podcast, we’re almost at 300. We’ve also reached a really cool feat recently, whereby we now we’re ranked in the top 1% of podcasts worldwide in any genre. So I really want to thank you, the listener, the watcher for supporting Team Protrusive. Your support, your subscriptions, your wonderful engagement has meant so much to us and allowed us to create this content and bring on guests just like Brett and all the 200 plus guests we’ve had on. I want to thank all the guests who come on the show as well.

But before we join the main interview, let me give you today’s Protrusive Dental Pearl. How can you improve your endodontic access? Well, let me tell you the secret of improving anything in your dentistry. Any technique you want to improve in dentistry, you just have to do more of it. Now, what I don’t mean is every patient start accessing their first molar, trying to find MB2 just for the fun of it. That would be wrong, but here’s a really cool idea. As you know, every time I extract a molar, 95% of the time I will be sectioning that molar.

So for a lower molar, section around the middle to separate it into its mesial and distal root, and for an upper molar, more often than not, it’s separating it into its three roots. So I’m very pro sectioning, it’s kind to the bone, it makes your extractions easier. Makes extractions more predictable. I already have podcast episodes on this, and I also have sectioning school, my mini masterclass on Protrusive Guidance, if you want to learn more about sectioning.

But here’s how we can kill two birds with one stone. How can you improve your sectioning? Because when you start sectioning, the most difficult thing is getting that angulation of the bur correct, so that you cleanly cut through the fication or the root exactly where you want it. So how about this? The next time you’re going to do a molar extraction, How about you challenge yourself to first do an endodontic access?

The tooth’s coming out anyway, right? So how about with your bur, you go in for the kill. You get to the canals. What this will do is teach you about endodontic anatomy. It’ll teach you about where the canals live. And the more you do this, the more you’ll end up improving when you actually have to do a real access.

It’ll actually make you quicker as well. Because you have nothing to lose in that scenario because the tooth’s coming out anyway, you’re not going to be afraid to perforate. Because the point is, for sectioning, once you can see the canals, you know exactly where to section. When you see the pulpal floor, it makes the angulation of your section so much better.

So, now with the sectioning, you’ve improved your extractions, and now by the fact that you accessed it first, you’ve improved your sectioning, but you’ve also gained more experience in doing an endodontic access. So I hope you enjoy that pearl. Hopefully it’s applicable to you. Any limiting beliefs you have, oh I can’t do this in my clinic for x, y, and z, just do it.

Even if it just means you book an extra five minutes and that five minutes is what you spend on the access. Oh, and please use some good burs. It makes a huge difference to being efficient. Anyway, let’s join Dr. Brett Gilbert on how we can improve our endodontic irrigation.

Main Episode:
Irrigation! Okay, so I know you’re really hot on this. So the proper disinfecting protocols, let’s talk about where we are in 2024. Cause I was taught that sodium hypochlorite is the gold standard. So the first question is, is there anything better yet? Are we still relying on 3%, 5.25% wherever it is sodium hypochlorite?

[Brett]
We are, but what we’ve learned is a few things that are important to know, which is that the commercial store bought household bleach is not the way to go. And the reason is, is that what we’re dependent on for the antimicrobial bacteriology is to actually have free chlorine ion and the amount of free chlorine ion in bleach, it’s very unstable. It’s very fragile. We think of bleach as this noxious, hardcore substance, but it’s actually very fragile. It’s sensitive to air to light.

It can become contaminated. And even though it’s still, unfortunately, we’ll put a bleach stain on our beautiful new fig scrubs like you’re wearing there Jaz. It doesn’t mean that the free chlorine ion concentration is high. So we want you to be using a proprietary blend sold by a dental company where there are controls, there’s an expiration date.

And most importantly, what we found through our studies is that adding a surfactant to sodium hypochlorite really changes its effectiveness because surfactant lowers the surface tension of the solution, allowing it to flow into these crevices. We have to think, we think of the root canal as a vertical line, but it’s so much more.

And so we want to get penetration as much as possible. So for really not much more of an investment, we’d like to see you using some type of branded proprietary solution. And many, many dental companies sell these. So that would be the biggest change. Yes, sodium hypochlorite, but in the form where we can really control more of understanding that when we put it in the tooth, which is the most important part of the procedure, the chemical disinfection is the most important part.

And you would hate to be trying to do that with the solution that actually wasn’t very strong or active, even though you in your perceptible senses would have no way of knowing. So that would be the biggest thing is proprietary with surfactant.

[Jaz]
I was always taught with using these grocery store bleaches, which they used to back in the day. I mean, people still probably do now, but that was very popular back then. I know there’s a grocery chain here called Sainsbury’s, and apparently their bleach was what the endodontists used to go for, get a trolley full of 30 of them and go out. But one of my endodontist mentors taught me that, yes, apparently there’s lots of crystals and lots of other nasties in there that you don’t really need for your root canal. The whole thing about surfactants, is that already in the bottle or is this something that additionally you add.

[Brett]
Yeah, no, it’s part of it. It’s already pre mixed. And in fact, there’s even a solution from a company called Brass or that’s a one stop shop. So, you’re looking at organic debris removal and inorganic debris removal.

So you might be chloride is organic, right? It’s tissue. It’s bacteria. It’s biofilm. Then you need like an EDTA type material, which is going to be the inorganic, the dentine proteins, any harder substances that are removed from the walls. And so it’s always been this funny mix of the two. And now there’s actually a solution that’s all in one.

And so it’s becoming easier to be able to do this. I would say that one of the most important, there’s a ton of devices. I’d love to discuss if we’re going to get into it today, there’s been incredible explosion of technology in endodontic irrigation, but I think this is the most basic investment that each dentist needs to make is finding the right sort of proprietary stabilized solution that you can trust when you put it into the tooth.

[Jaz]
When I was a dental student, we used to use something like, 0.5% or 1% because that was like a safer amount as a dental student when you were learning. And then I learned that, okay, use something like 3% or 5%. And then if you use it heated, it actually makes it more effective and that kind of stuff.

What advice are you giving to general dentists out there? What percentage should they, now they’re, they’re converted. They’re like, oh yeah, Brett said you have to use a propriety, put down that Sainsbury’s bottle, go on the website or to an official endo supplier, buy the propriety stuff. But what percentage should they be putting in their basket?

[Brett]
Well, I know it’s going to be upsetting for, cause I know in Europe it’s taught differently, it’s very low percentages, but the way that I look at it personally is when you use a lower percentage, you really aren’t reducing or eliminating the risk of sodium hypochlorite accident.

If you get 3% sodium hypochlorite out the end of the route, it’s going to cause a sodium hypochlorite accident as will 6%. And so what you do though, because we know that, again, as I mentioned, sodium hypochlorite is very unstable and it’s deactivated very, very quickly. So the higher concentration actually isn’t going to be that for very long.

So we recommend in my school of thought and where I learned and I think pretty much across the U. S. that the full strength is the best bet. And so most of these you’ll be able to find will be more of a 6% solution with surfactant. The material I mentioned, Triton, which is the all in one is actually two canisters within the same bottle.

And it’s actually 8% on one side. But once mixed, it’s actually 4% when it goes into the tooth. So there’s a lot to it, but my advice is, is if you’re trying to eliminate risk using a lower concentration, I don’t think it’s as effective as you think, but you are taking away some of the strength that you’re looking for to kill the bacteria and dissolve the tissue. So, my advice would be go full.

[Jaz]
Go hard or go home. But what about the use of chlorhexidine 2%? Like I’ve been in clinics before in the way in the past where they weren’t that well run. And then you look at the nurse and say, can I get some irrigation please? And then they give you Corsodyl 0.2%. And I’m thinking this is doing nothing. There’s no dissolving of the organic matter, et cetera. So where are we at now in terms of chlorhexidine? Is it something that we just need to just bin or is there still a place?

[Brett]
Well, it has a place as an additive. So for instance, if you’ve heard of Q mix or there’s a number of different product called smear off, it’s sort of the EDTA solutions for the inorganic debris removal. You’ll often see chlorhexidine included in there as an additive. There was a time in my early days where 2% chlorhexidine was in vogue in retreatment. But ultimately the research never really stood behind it as much as we thought, and so I don’t really ever use it anymore. And to your point, it would be ideal as an endodontic irrigant if it dissolved tissue, which it doesn’t.

And that’s why sodium hypochlorite remains the king because ultimately there’s nothing else that will dissolve tissue. And that is the most critical part of using endodontic irrigation. We have to get those bits and pieces out of there and you can’t just deliver it all out in mass. We really need the dissolution of it through solution.

[Jaz]
And when chlorhexidine is mixed with hypochlorite, is it true it makes a carcinogenic product that you should totally avoid that kind of stuff, right?

[Brett]
It does if you’re using just essentially the store bought bleach and just a regular chlorhexidine. If you’re using these proprietary blends, you can actually interact them without reaction. So that’s another advantage.

[Jaz]
I did not know that. Okay, fine. That’s very interesting. I definitely didn’t know that. Not that we’re recommending using CHX anyway, unless it’s an additive, as Brett said, but good to know. So now tell us about these new technologies. What is Dr. Brett Gilbert using in his clinic to maximize that disinfection and tell us about the evidence base. Is it established yet? Or is it up and coming? I would love to know what’s new and great in the world of disinfection.

[Brett]
Yes, let’s start on the most basic level, which is that at this point, probably the gold standard in terms of evidence is passive ultrasonic irrigation. So you put the irrigation solution in the tooth and you use some type of ultrasonic tip to activate it.

And by doing so, you’re hoping that you’re producing some cavitation. Cavitation is the implosion of a liquid molecule, and once it implodes, it has sort of this bombardment force against the wall. So you’re basically able to essentially hit the walls of the canal with the solution to get better penetration.

So you would use that in an in and out motion. Now, ultrasonic and sonic are different. Now, sonic activation is very common. The endo activator, my good friend, Cliff Ruddle developed this. It’s been an incredible seller and to your eyeball, you see it swirling and moving. And that is good. It’s better than nothing, but the studies would show ultrasonic activation to be better penetrating into lateral canals, apical anatomy.

So that’s sort of our basis point. If you can at least do ultrasonic activation with these proprietary solutions that I’m mentioning, you’re basically at the gold standard, but there’s been so much development in terms of the use of laser assisted endodontic irrigation.

Multisonic irrigation. So I’ve been very lucky in my career to have been able to test pretty much everything, you know? So if you look at what’s really kind of changed the paradigm of irrigation, it kind of created a new category. Very disruptively was the gentle wave, which many of you may have heard of.

This is from a company called Sonendo out of California. This is a closed system. So basically you build a little platform and then the handpiece fits right into that standard platform. And then basically you hit the gas and it’s an eight minute cycle. It’s cycle sodium hypochlorite, it cycles distilled water.

And by closing the system, it creates a situation where you’re able to essentially de-gas the solution. So if you think about if you had a glass of water and you wanted to propagate energy through it, any little bubble in the water, we know this from physics would dissipate some of that energy. And so what this console does is it actually pulls all the gas out.

So if you can imagine the inside of the tooth being filled with solution. But no bubbles at all. And now it has this energy, this broadband multisonic energy. And so it’s very disruptive to the walls. It creates a negative pressure so that it allows you to really get the solution down to the end of the route. And so it’s an eight minute cycle and there’s been some tremendous visual effects of that. Now, from a research standpoint-

[Jaz]
I mean, while are you talking, cause I’ve never heard this before. I’m Google imaging this. I’m looking at it. It’s looking like a big bulky machine, right?

[Brett]
Oh, it is. Yeah.

[Jaz]
It’s pretty sizable.

[Brett]
Yeah. It’s significantly. And it’s a costly machine. I mean, it’s getting towards six figures and even per procedure, they call it the procedure instruments are one use and they’re expensive. And so this did really change the game, but there are limitations to where it can be used.

If there’s any communication to the sinus, you have to be very careful. If there’s any type of decay or leakage under a margin. This will tear right through it. You really have to be very specific about where it’s used. But ultimately, as I mentioned, visually, you see some incredible cases with just sealer, just through three canals at the apical end and out lateral puffs, et cetera.

And a much of the research it’s out there is favorable, but we do have some question marks about the unbiasedness of it. Just being totally honest. I have some of my best friends who swear by it, who teach it and they get great results. And so that’s one option that really started this new game, but then lasers have sort of come into play.

And so laser activated irrigation. And by this, we mean that the laser energy is both able to sort of activate and stir up the solution, but also the laser energy can be absorbed by the water and dentine, creating an opportunity to really effectively debride and disinfect the dentine. And so, I’ve been lucky.

I’ve used the gentle wave. In my practice, I’ve had two different stints with it. I don’t have it right now. I have three different lasers in my practice right now. One which is Erbium YSGG. And with this Jaz, you actually have the solution in the tooth and it’s like a little fiber tip, maybe about a 21 at the tip, right?

Think of like a small hand file. And you take it down halfway. And as you activate, you bring the tip out at two millimeters per second. So basically it’s a eight second cycle. And then I go into the next canal and the next canal, refresh my solution, do it again. I can also use this with water.

So then I can take the tip closer to working length, again, withdraw, and it has what’s called a radial firing tip. So if you imagine like a cone coming out, almost like an inverted cone bur right? So as you’re in the canal, this radial cone is able to basically paint the walls with the laser energy.

So that’s one option. The next option is Erbium YAG. Now, what’s different about this one is again, solution goes into the tooth, but now the tip simply goes into the chamber. It’s about three to four millimeters off the floor, hit the gas, and there’s a tremendous impact that you can see through the microscope.

You can see a lot of this on my Instagram channel If anyone’s interested, I have a lot of videos related to this. So those are the two primary lasers that are available right now. We’re seeing really nice results the advantage. There really aren’t limitations to its use. Whether you have a sinus perforation, anything like that, we also find that we are having tremendous success doing endodontic surgery, as well as resorption repair with the lasers.

And these are technologies that are very versatile in the office. And so we’re very excited about that. Very recently, I’ve just test drove and actually it’s my last post right now. Another company came up with basically a little tip that goes down into the canal. It’s a 19 at the tip. Okay. And it actually drives saline.

So by driving it out at a certain speed out of the 19 tip, it creates a cavitation flow. And so now you have an opportunity to basically power wash inside the root canal. And the reason that this is unique is we’ve never been able to do this before because sodium hypochlorite is too risky. Even EDTA, we don’t want to drive that out of the end of the route, but by utilizing saline, we have an opportunity to have more velocity and more cavitation to sort of essentially power wash inside and I’m really impressed with the potential of it.

Again, if you look at the general dentist doing endo and you look at what your heart rate does, right? You look at the stress that comes because of the risks. And so if we did have a day and age where we could irrigate very passively with the sodium hypochlorite, not trying to drive it down.

So eliminating the potential accident, be able to finish the job with saline in a powerful force, and then ultimately obituary with a material that would not ever have to be worried about extrusion. Now, I believe we open up endodontics to general dentist in a greater way where there’s not so much worry and risk.

And so there’s a lot of exciting things happening. I think as an endodontist, we recognize that, training our general dental colleagues on endo is paramount because we don’t want the option of implant to come in place of saving the natural tooth simply because of fear or the fact that they just don’t feel well enough trained to do the endo.

So I believe as a dental community, the more we feel comfortable and proficient in endo, the more teeth we save and the better our patients are. And there’s no question there are not enough endodontists in this world to even come close to eating the whole pie of endo. So it’s critical that we educate.

And that’s why I appreciate you having me on because I think your community obviously, or they’re advanced learners are looking to get better. And so exposing them to every discipline, especially the ones that most people would like to just punt, just, I don’t want to deal with this. I had a bad experience.

I had fear. So I have an online program called access endo. It’s a community I formed in 2019 where I really mentor dentists in endo. So that includes curriculum, but it also includes live coaching. And the best is like dentists send me their cases and I actually guide them through their cases.

And with the electronic medium online, I can actually be like you’re supervising, attending in your clinic. So I’m really putting myself out there to help dentists because I believe there’s a tremendous payoff for the dentist, for the patient and for all of us to see a more proficient level of endo across the board.

[Jaz]
That level of mentorship you described, it really is the pinnacle. Something that we’re setting up is called a Intaglio, Intaglio dental, whereby we’re going to make mentorship much easier because it’s difficult to find the right mentors. And I think it’s great. You’ve identified yourself as if anyone needs an endodontic mentorship, definitely check out Brett.

I’ll put all his links there. That sounds amazing. But one thing that we’re trialing basically is just like you said, having the system whereby they have a loop mounted camera or the scope camera is being fed into zoom and then you’re in their ear saying okay, yeah, that’s good, that’s good, okay, do this, try this now, and I know they use it in medicine, doing crazy surgeries from halfway across the world to get the best brains on board, and I think totally it needs to be tapped into in dentistry and sound. It’s amazing to hear you’re already doing that.

The question I have regarding going back to clinical is, we had an episode with Pasquale Venuti. He talked very interestingly about process based and being outcome based. And a lot of times we are like process based. The different steps and the different techniques and the fancy gadgets and stuff, whereas ultimately to have the outcome based evidence, unfortunately, there’s no shortcut.

We need to wait 10, 15 years to then look at the data and say, okay, yeah, this improved success rate in this scenario by 20% or 18%. What evidence base do we have? Is it too early? Is it too primitive? Or do we have any established evidence base on these novel techniques? Are they actually making a difference? Because we know that root canal treatment is actually quite predictable. How much of a difference is it actually making?

[Brett]
So it’s a great point. And the reality is, is we call this advanced disinfection protocols and we don’t have a lot of evidence. That’s the bottom line. I mean, we’ve had to rely on, which is eyeball evidence.

You know, what are we doing? We’re seeing more lateral canals filled with sealer, right? So I always say, when you look at sealer extrusion through little apical foramina, we know there’s multiple portals of exit. We know there’s lateral canals. And when you see the sealer, if nothing else, it’s a storyteller.

Hey, it’s a storyteller of anatomy. You now at the end of the procedure, like, wow, that’s why there’s this lateral vertical bone loss on this tooth because I had a lateral canal there that I can see now. You also know that in order to get sealer to go into these spaces. They have to have been cleared of debris because we know even on a level of smear layer, it’s going to block sealer from exiting out of a lateral canal and so the story is that yes, I use the laser.

I use the gentle wave and now I see the sealer. That’s pretty much what we have. We have had cases that we see heal tremendously fast. But we have had cases that we don’t see heal. And what’s important to realize is that the reason that we’re doing this is because we recognize that minimal preparation is key for dentine conservation. And most importantly, for all the dentists out there that are part of your community, recognizing that the pericervical dentine, the dentine, four millimeters above the CEJ and four to six millimeters below is the key dentine that supports the strength and fracture resistance of the tooth.

If your access is too big, it’s going to put more force on that pericervical dentine, we actually find that the preparation and the taper of that preparation doesn’t impact the fracture resistance as much as how big you open the orifice.

So being aware that we want to conserve the dentine. And so what these advanced technologies do Jaz is they allow us to keep the prep small, but still get the cleaning down inside there. And that’s what we’re after. Do we have the evidence of outcome? We don’t. I wish we did. We’re spending an awful lot of money over here around the world and in endo on these devices because we so want to improve.

We want to get better outcomes. We want to save teeth, but ultimately it takes time. So you have some that put their necks out there first. I’m one of them for whatever reason. I’ve always felt like someone has to try this for the sake of everyone else, even though at times it feels a little risky, but ultimately I think we’re at a point now where we are going to start to see some more studies, but like I said, if you look at the gold standard from evidence or outcome, it’s the passive ultrasonic activation that has the most evidence and that would be a great starting point because it’s not expensive to institute into your practice and your protocol, but ultimately you can have evidence based understanding that it’s definitely better than needle irrigation alone. No question.

[Jaz]
Well, you’re definitely a pioneer and that’s absolutely clear from speaking to you. An old fashioned technique that I still do is GP pumping. Your thoughts on dentist GP pumping. And therefore, can you also give us some guidelines how best to do it? I remember one dentist, old school dentist who taught me to dip the master GP cone, just the tip of it in some chloroform, just a tiny bit.

And then take it to the end and then they’ll kind of make the shape of the apical foramina and then use that to GP pump. I was like a little bit concerned about doing that, but what is a good safe protocol, a good safe way to do GP pumping and just describe for our younger colleagues what that actually is.

[Brett]
Yeah, so again, so GP pumping is just manual agitation again, just trying to get the solution to flow a little bit more. Obviously, that’s going to have very little impact in comparison to an ultrasonic energy coming through it. The custom cone, dipping into chloroform. Obviously, the last thing we really want to do is introduce chloroform to the apical end where it can escape.

And as I mentioned before, It’s not the Gutta-Percha we’re hoping to seal. It’s the sealer. So to me that, although I was taught the same way, I don’t think that that holds a lot of weight. In fact, I think we really want to just have chloroform be out of our operatory in general. Why bring something noxious and carcinogenic to our patient’s mouth?

Yeah. So at a very minimum, doing some type of gutter percha agitation of the solution. But as I said, if you’re here, if you’re listening, if you’re interested in endo, you can buy an ultrasonic activation tip that goes on an ultrasonic unit, very inexpensive and ultimately gives you a much better flow and activation of that solution.

[Jaz]
Can you recommend a brand?

[Brett]
Yeah, so there’s one Vista Apex out of the us. They have a handheld unit called the Endo Ultra, so that’s just like a single unit. But if you’re using an ultrasonic and if you learn endo from any endodontist, you’re gonna learn that an ultrasonic tip for uncovering canals.

Finding your preps is so key. You want to find MB2, you want to be able to kind of be thorough and finding the canals. And so something like there’s a tip called Irrisafe, from a company called Acteon that also is very inexpensive. It can be used 50 times it’s autoclavable and on an ultrasonic, you can see if you go in and out, it creates that cavitation. So those would be two suggestions. Just top of mind.

[Jaz]
Amazing. Brett, that was absolutely fantastic. I’m so, so happy to have you. I’m so thankful to Tom Levine from the community once again for connecting us. Please tell us how can we learn more from you? So obviously you’ve got on the cusp podcast for those who’d like to have mentorship and identify you as someone.

And I have to say, Brett, I really appreciate educators like you. And I think everyone else as well. My community going to love you because we love direct. We love direct answers. Here’s how it is. You’re also very balanced, but you’re also just no fluff. You give us the answers and we absolutely love that. So I know everyone’s going to love you. So how can they learn more from you?

[Brett]
Yeah. So again, my access endo community, you can find me at accessendo. org. You can message me on Instagram, but we have a great community. You can take a free training and just sort of get a really great training on different aspects.

And then at the end, learn a little bit more about joining our community. Really, really want everyone to tune into on the cusp. It would be so honored to have you. This is different than what we’re talking about here. This is really for clinicians about clinicians, but it’s about sharing the journey, the human journey, and the ideas that as more of us share about our journey and how we’ve managed stress and how we’ve dealt with burnout and how we sort of do daily practices to keep ourselves going and healthy because I believe when you are doing work on yourself, you’re investing your time during your day to work on yourself as a human. That human walks into the operatory and is a better doctor and that better doctor provides better treatment.

If you’re bringing the weight of the world and stress and sadness and trauma into the operatory with you, you’re not going to be as good of a doctor and neither will be your treatment. So on the cusp is about tuning in, hearing these amazing stories and journeys and having something resonate with you. Something someone says that becomes that instigation to say, you know what? I’m actually more interested in finding fulfillment in life than a full bank account, a fancy car and a big house.

Because as youngsters, we choose this profession. We don’t know anything about anything. We don’t even know who we are, but we make an investment of time, money, and energy that is so tremendous that you really can’t turn around and walk back out. So why don’t we learn from others journeys of how they’ve managed this stressful, burdensome profession, where, as you mentioned from the jump, we sometimes take everything so personally, that’s what my podcast is about.

It’s about finding fulfillment in life and doing it while still bridging the gap as this clinician who cares, but also has this other side as a human to make sure that when you come home from work, you’re not so dead tired that you can’t talk to your family. You have nothing to offer. You’re just dead. And I’d rather see you come home and be still ready to interact with the kids.

Do something that your spouse asked you to, because you might work all day long and take care of a million people, but when you get home, you haven’t done anything for them. And so the goal of this podcast is to get you feeling more fulfilled in your life so that you can be a fuller person. Everywhere you go and ultimately find that healthy balance between the stress of work and the joys of being alive because it’s a short period of time and I’m trying to make the most of it. So that’s what the podcast is about.

[Jaz]
Absolutely beautiful. I’ll definitely put the show links on YouTube and on the podcast below. So please guys check it out. I think that we all need this. We also have coming up in December on our podcast, dentist life, work life balance. So I’ll be sure to bring you on again to just go. Cause there’s so much we talk about and I’d love to explore this further. Brett, thank you so much for giving up a time to really enhance us in our endo, our irrigation protocols, our judgment on preemptive endo and giving us that lift that we all need. You are absolutely brilliant at doing that. Thank you.

[Brett]
Thank you. And I want to acknowledge you. The podcast is awesome. You’re doing a great service. You bring great energy to the show and that’s what you need, right? You want energy so that the information is absorbed. It’s something that actually excites you and gets you feeling excited. So I feel pumped after being here with you, Jaz. So I’m ready to get back in the clinic tomorrow and get after it.

[Jaz]
Amazing. Thank you so much.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. The future of endodontics is very exciting. And don’t you just love the human side of Brett? And the mission that he’s on. So to support that, I’m going to put all the show links to Accessendo and his community on there. He’s obviously a fantastic mentor to have, and I’m very grateful for him sharing his time with us over this two part episode.

Now, if this is the first one you’re listening to, please do go back an episode. You missed a really good one on elective endodontics. And of course, if you’re on our community, Protrusive Guidance, answer the questions, get your CE certificate. And if you’re not part of the Protrusive community yet, if you identify yourself as a nice and geeky dentist, this is a home for you.

Head to www. protrusive. app, make an account, and then you can check us out on iOS or Android. It’s all singing, all dancing app we have. I think you’ll be quite impressed. We also host monthly webinars live, sometimes me, sometimes I’ve got a guest on, in addition to what we do on the podcast. If you do want to get CE, there are paid plans available, and they’re the ones that support the podcast.

So if you’re gaining great value from the podcast, please do show your support by signing up as a premium member or for the ultimate educational plan if you want access to things like sectioning school. I want to thank the team as always. Thank you Erika for doing fantastic production. Thank you to Mari, our CE Queen.

Thank you to Nav and Krissel for making sure everything is quality controlled and scientifically correct. This podcast would not exist without the team. And thank you to the listener, once again, for listening all the way to the end. Hit that subscribe button. I’ll catch you same time, same place next week. Bye for now.

What’s the difference between radiolucency and burnout? 

When’s the best time to use a bitewing vs a periapical radiograph? 

When should we pick up the bur for interproximal caries?

Have you heard about the 4 white lines an OPG radiograph? 

This episode is packed full of great tips and techniques that will help you understand how to produce great radiographs as well as being able to properly figure out what they are trying to tell us. Radiographs can be tricky, whether that’s due to them being flipped, upside down or due to cone cut, that’s why this will help shine some light on how to get comfortable with radiographs as well as how to manage our patients after we know what we are dealing with.

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

Don’t miss the special notes on Radiology and Radiography for Students available exclusively in the Protrusive Guidance app! (Join the free Students Section)

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

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, check out PS003 – Routine Checkup

Teaser: This episode is the bare basics of radiography and radiology, i.e. the taking of the radiograph and the interpretation. How do you really know if that radiolucency you see is cervical burnout or is it actually caries? What are the four white lines on an OPG radiograph and why are they important? And why you should be really careful with radiographic interpretation? And it's really important to marry the clinical picture, because that's how you come up with a clinical diagnosis.

[Jaz]
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This is for young dentists, students, but a lot of qualified dentists have been really enjoying this basic series, this Protrusive Student series.

And so what we’re going to do from the next episode is we’re going to make it CE eligible. The next episode is actually on basics of extraction, but before we do that extraction, we need a radiograph. And it’s a topic that you guys asked for on the YouTube comments. So there we have it. And remember, if you are a dental student, make a free Protrusive account.

Go to protrusive.app and then email your username or your name on the platform to [email protected]. And you’re going to get access to a secret area, which has a bit more of the premium goodies inside. Every PS episode, we have some student notes to provide you as well, made by Emma Hutchison, our Protrusive student. And the ones today are all about radiography and radiology. Hope you enjoyed the main episode, I’ll catch you in the outro.

Main Episode:
Emma Hutchison, our Protrusive Student. Welcome back to the student’s edition of the podcast. I know you’ve got exam results coming up and you’re going on your elective soon. How exciting.

[Emma]
Yes, very exciting. So I’m just finishing up the last bits and bobs of my elective project and then I’m going traveling for two months. So, I should also get my exam results next week sometime when I’ll be away. So, hopefully everything’s good.

[Jaz]
We’re all rooting for you. We know, you know, fingers crossed you’ll do well and you’ll report back to us. If anyone in Asia is a dental student or a dentist, and you happen to see Emma walking in a mall, an air conditioned mall, take a selfie with her and tag us on Protrusive. Let’s see if this social experiment works. Let’s see how much we’re spending. That’d be cool, right?

[Emma]
Yeah, it would have to be an air-conditioned place because I’m from Scotland, so I’m not going to do well with the heat over there at all.

[Jaz]
Excellent. Well, today’s chat and the subsequent protrusive notes which will go on the Protrusive Student Section at of Protrusive Guidance, which is our app, our community, is about radiology and radiography, right? And before we go further, I kind of have like to put a disclaimer and a lot of the Protruserati are used to me using this disclaimer now and again.

There are some things that I teach and there are just a small part of dentistry. Most of dentistry, that I do, I share. I don’t teach, I share, because to be honest with you, I’m not in a position to teach that kind of stuff, but I’m there to share my own experiences, and there’s some that my unknown unknowns I’m always just seeking to learn more and more and more.

So when it comes to radiology and radiography, I’m sharing, and what I have on you, Emma, is I’ve got like, 13, 14 years of experience over you. And that’s why I have to offer you in terms of the kind of things that used to bother me when I was a student. But I want to just say that take everything with a pinch of salt what I’m saying, because I’m trying my best to guide you and students and young dentists listening, but I’m not the radiology expert here. So it’ll be just to unpack the experience that I have.

[Emma]
Yeah, not a problem. Not a problem. I think in dentistry, there’s always so many opinions and everyone has so many different experiences. So everyone will have an opinion, everyone will think differently, this, that and the next thing. So yeah, we’re all just learning. So.

[Jaz]
Well said. Well said. So come at me, Emma. What have you got?

[Emma]
So first question, I’m going to say. For yourself, Jaz, we’re always taught to be really methodical. Let’s say you’ve got a pair of bite wings there. What are your essential steps in reading and interpreting dental radiographs? Like, what should students look for?

What does your method look like? Because it can be really overwhelming, especially in an exam. I was faced with full mouth peri-apicals, and it was just questions, boom, boom, boom, boom, boom. And you just had to be really methodical. But what does that look like for you?

[Jaz]
Great question. I think I’m a big believer in checklists when it comes to radiographs. So first thing to do is make sure it’s rotated and flipped correctly. The right way, like usually I don’t have to flip it, but make sure it is correct and it’s orientated correctly. The next thing to check for is that is it good enough quality doesn’t need repeating and you’d hope that 95 percent plus a time it’s acceptable quality.

So you have to grade your radiograph. So it used to be like grade one, two, three. Now it’s like A or N. So it’s either acceptable or not acceptable. And you have to obviously justify in your notes the reason for taking a radiograph. So Emma, what would be the typical reason to justify a bite wing from what you’ve learned?

[Emma]
Caries and bone levels, perhaps?

[Jaz]
Yeah. And specifically, it’s interproximal caries, right?

[Emma]
Interproximal caries, yeah.

[Jaz]
What I say to my patients is that, I need to take these x rays because there are bits of teeth that I can’t see. I can’t see between the teeth. This is where x rays help me. And so it’s very important when writing the justification.

It’s interproximal caries. And so really interesting point. Early on in practice, you just get into a rhythm of doing things and you need to start questioning why we do certain things. Why do we take this bite registration? Why do we do a certain stage in dentures? And so, I remember being a newly qualified dentist and just, oh okay this patient hasn’t had bite wings in like three years, let’s take some bite wings.

And you take a bite wing and you see that actually this patient has like every other tooth missing and no history of periodontal disease. So if I can see the interproximal surfaces, why did I just take this bite wing? You see what I mean? So you really have to think critically and I’ll share a, I guess an honest mistake I made recently.

Okay, I’ll share an honest mistake. I know this is deviating a little bit, but I think it’s really nice to learn from the failures and mistakes of others. Had this really nice gentleman who has had an issue whereby the wisdom tooth was causing decay in the second molar. So low wisdom tooth impacted, that wisdom tooth was removed.

Okay, and the decay seemed minimal and it was really deep down. It was like covered by the gum. So I thought, okay, maybe we can just safely monitor this. When we came around to the interval of taking bite wings. Okay, I did not capture the distal of that second molar.

[Emma]
Right. Okay.

[Jaz]
Didn’t capture it. And so lo and behold, he came in an emergency and he had pain from that tooth and there was a much, much bigger caries than what we initially had some years ago. And so it’s really important that, yes, we want to see the interproximals, but we have to tailor it to the individual. If we know that actually someone’s not got any restorations or no historical caries, or you’re not watching the premolars, then maybe in that patient, the distal of the second molar for those patients is more important.

And sometimes you can’t capture everything. So it’s important to tailor it to that individual. Going back to what you asked, though, in terms of the checklist and actually being systematic about it, totally the right word is systematic here. So what I would do is once I’ve made sure everything’s correct and orientated and acceptable quality, I will always just start with the bone levels.

I’m having a look at bone levels and I’m reporting on that. So I’m doing as a percentage bone loss, although. Arguably, you need a PA to see a percentage because you can’t see the whole root. But you can kind of guesstimate. We know average how long teeth are. So it’s not like a mild bone loss, moderate or severe bone loss.

And then I’m looking at the interproximal surfaces where they touch very, very carefully. It might be changing the contrast. And what we do in practice, actually, is we have this code that we use on the charting. So you guys are probably, are you guys computerized? Are you guys like paper notes?

[Emma]
We’re still paper notes, yeah.

[Jaz]
Okay. So what we do is on the computer, like do from previous bite wings stuff. If we know it’s like a little radiolucency, we’re going to mark on the chart, on the digital chart, a WB. WB stands for watch bite wing. That means we’re watching this area on bite wings. So as well as clinically, we’re checking on bite wings.

So I will have a look at my chart on one screen. I say, hmm, there was a watch bite wing place in 2017 on the distal of the upper left second molar. Let me have a look now. And often it’s nice to compare old radiographs. to see any changes and that’s really important stuff. So maybe I’ll have the left bite wing from a few years ago and left bite wing now and I’ll just compare the bone levels and I’ll compare any watch bite wings, any changes.

I’m then looking at the restorations and any sort of radiolucencies or any ledges or all the issues with restoration. So starting with the bone, then the heart structures and I would report on those.

[Emma]
Okay. Yeah. So just your checklist, like you were saying, I know for me when I’m in clinic and I’m doing a radiographic report, I have everything written down, like, teeth present, restorations present, boom, boom, boom, and just keep yourself right in that respect. I think that’s a very important thing to do.

[Jaz]
In the real world, like, to write teeth present, I just feel it’s very laborious, right?

[Emma]
Yeah, yeah.

[Jaz]
So we’ve got the chart already, right? I’m looking more for, like we did the routine checkup episode we did, and we added the video. I don’t know, did you watch that video, Emma, of the routine checkup I did, yeah?

[Emma]
Yes, yes, I have done, yeah.

[Jaz]
Was it useful?

[Emma]
Yeah, I think it was. I think it’s always useful to see other people’s methods and how they go through things, et cetera. I think it’s definitely-

[Jaz]
Even some dentists have messaged on there saying, well, you know what Jaz, I’ve been a dentist for so many years and it was just nice to see some validation routine, check up how you do things. So that was good. So in that one, you’ll see that I’m comparing previous radiographs and we know we have the charting already. So I just feel like in a time efficiency, when I’m doing a report, I’m not reporting on all the teeth present. That goes without saying, but I know at your stage, that’s what you’re expected to do because you’re learning the bare foundations.

But in the real world, I don’t report on all the teeth present. It’s like, okay, teeth present as expected. Okay, I’m just looking for, okay, good bone levels and no obvious caries. And then I’m looking for the actual things to watch out for, and that’s just the honest truth.

[Emma]
Yep, no, a hundred percent. I think when you get into the real world, it’s a lot more fast paced. Not that that’s a bad thing. I mean, you have the time to report on your radiograph what you need to report, but at Glasgow we’re still expected at this stage to do full radiographic reports for absolutely everything, which takes such a long time, but it is good to getting you used to looking at radiographs.

Being methodical in your approach, and then by the time you get to your VT, hopefully and beyond, you’re a lot quicker at doing your radiograph reports and you see things straight away. Whereas at the moment, I still have, it’s still very overwhelming. So-

[Jaz]
Take your time. We’ll take several minutes at this stage. But just one thing on that, I think the most common mistake you can do is just like, imagine you’re taking bite wings because you suspect, okay, there’s something perhaps going on around the upper left first molar and you take your bite wings and your eye immediately goes to the upper left first molar and you kind of like skim over the rest.

It’s really important to check the follow, trace the bone levels everywhere. And the most common one is like the distal of the second molar. There’s something there and you just didn’t spot it. And then years later, you see a patient comes back with symptoms. Oh yes, there was something there I didn’t see at the time.

So it’s really important just to check every single area, like typically where you’d find cervical burnout, right? Like that radiolucency by the neck of the teeth. And just look at those areas and look at the contact areas where caries typically starts just for every single tooth, just tick it off mental checklist.

And the most important thing medical legally is have you justified the radiograph in your report? Have you graded it and have you noted that the findings and it’s really important just to comment on the bone levels and any radiolucency, anything of concern that you’re watching for?

[Emma]
Yeah, absolutely. Like, what is it called? I think it’s satisfaction of search. If you’re looking for one thing and you find that and then you just lose everything else. So it’s so important to have that wee checklist. Either in front of you, I have mine sitting in front of me, written down in a notebook or just mentally as you get a bit more experienced, I’m sure. But just as you were talking there about cervical burnout, what are some more common pitfalls or mistakes to avoid when you’re reading and interpreting dental radiographs?

[Jaz]
So common pitfalls, but also just rewinding a bit to what we said about satisfaction and looking at something and satisfying your query. OPGs are the big one. Like, OPGs, there’s a lot more noise, right? And then you see so much, but you were concerned about the wisdom teeth.

And so you look at the wisdom teeth, but there’s so much data in OPGs. So my top tip for OPGs, this is what I was taught in dental school, is that, what are the high risk areas? Like, think cancer, right? If there’s something cancerous going on, something worrisome going on, the four white lines. Have you heard of the four white lines for OPGs?

[Emma]
Four white lines. No, I don’t think I have. No, I don’t.

[Jaz]
No one else knows about this. It’s not just because you’re a student. Because when I speak to other dentists, I was like, I speak to them and said, do you guys report on the four white lines for OPGs?

Then they look at me like puzzles. So it must have been a Sheffield thing that we were taught basically. The four white lines we look for are the hard palette. Can you see the hard palette? Right? You see that? Okay. That’s the horizontal line radio. Opaque line going cross, right? So can we see the hard palette?

Are there any abnormalities there? The next one is the floor of the sinus. Okay. So you want to see, trace the form. You don’t want to see a break in the lining, the cortical lining of the sinus, because that could be a worrisome, that could be maxillary sinus cancer or whatever, or some sort of issue going on.

So really important to check that. So that’s the two white lines. The third one is the posterior wall of the sinus. So the way you see that is, although it’s a posterior wall, you will see it on OPG as a vertical line. So the floor becomes vertical, okay, as you go distal, and that’s the posterior wall of the sinus. So again, I’m just checking that white line. So that’s three white lines checked. And the last one is the zygomatic buttress. Okay, the zygomatic buttress. Are you familiar with the zygomatic buttress?

[Emma]
Yes. Yep.

[Jaz]
It’s kind of like where the zygoma bone makes like this radioopaque line as well. And it’s important just to trace that. And I just mentally tick those off. Now, to date, I have never found one that had an issue or a breakage, but this is where I report my OPG for white lines. Check, check, check, check, like a checklist. And then I check the border, the external border of the mandible, the ramus. I’m looking for like any fractures, any radiolucencies, basically.

So that’s usually intact as well. Then I comment on the bone levels. Then it’s really important to check systematically upper right last molar. So this could be the wisdom tooth, check tooth by tooth by tooth. You’re looking at the apices, any abnormalities, anything that you think needs more investigation.

So sometimes we supplement OPG with a PA to get a bit more data. Although nowadays the OPGs are so good. The qualities are so good that machines that we have that can really negate the need for additional PAs. But the common pitfalls is one of them. Yeah, looking for what you want and then skipping past it.

With bite wings and stuff, I think it would be like the actual taking of it would be like a cone cutting. Are you familiar with cone cutting?

[Emma]
Yeah. Is that your collimation is not quite right or?

[Jaz]
Correct. So you’ve got the beam and you’ve got the film and the kind of out of alignment. And so the x ray managed to miss the film a bit and therefore you get this like white space on the radiograph.

I mean, that may or may not be detrimental. If you get like half the radiograph gone and the reason why you took it was to see all the interproximal areas, then that’s not acceptable. And you have to repeat that basically. In terms of interpretation, the other common issue, other than like in a missing distals of certain areas because your eyes don’t go there is a confusing cervical burnout for caries.

Caries typically starts at or just below the contact area. So if you’re seeing another radiolucency a little further down by the bone level, you really have to question, hmm, could this be cervical burnout? And cervical burnout happens because as the radiograph goes through the tooth and at the neck area where there’s little curvatures and how thin it is, it appears a slightly radiolucent there.

And so we don’t want to confuse that as caries. Have I ever done this before? Yes, I have. I have confused cervical burnout as caries before. And you go and you think, whoa, okay, fine. That was not caries. Okay. And so it really needs to be hot on it. So little clues you can have is, you look at the mouth in general.

If someone’s generally not got many restorations and you’re seeing this area, then you’re probably thinking, hmm, it’s not the typical place that I’d find caries. This could be cervical burnout. The other thing to do is remember, that radiographs are just one data point, we do not treat radiographs.

Technically one of my, I think Prof Avijit Banerjee taught me that you cannot diagnose caries from radiographs. You can only diagnose radiolucencies. It’s up to you to add the clinical picture to then be able to diagnose caries. So actually, technically, if I ever write and I do this, I’m being honest, I write sometimes, yes, caries, we see, we do this, right?

Caries noted on the radiograph, upper right 5 distal. That’s technically wrong. Radiolucency noted, upper right five distal in the inner third or in the outer third of dentine, for example, you make that comment, but we cannot technically say it’s caries. So we to add now are clinical checks. So clinically I would check on the high magnification, my lighting, feel gently with my probe, not to like probe hard into it, but check like the surface, right.

Using the sort of sideways of my probe or maybe even using a ball ended probe. And if in doubt, there’s a really cool technique whereby if you’re really unsure where there’s a cavitation. Because the difference between, I don’t know if you guys are taught this, but the difference between potentially restoring something that’s early, enamel or just interdentine and not restoring that one is whether it’s cavitated. Do you guys follow this as well?

[Emma]
Yes, more so in, like, paediatric patients, maybe. What do you mean? Do you mean, like, for whether you would restore it or not, like, early caries, or?

[Jaz]
Yeah, so let’s imagine we have a lower molar, right? And mesially, you see that the enamel’s got full radiolucency, okay? And now, it’s just into dentine. There are so many factors to consider whether you treat this or not, right? Like the patient’s oral hygiene status, their dry mouth status, are they using a fluoride toothpaste, their history of caries, all this stuff is really, really important, their caries risk in general. But actually, at a tooth level, If that enamel is still uncavitated, so still a shell of enamel that’s not broken, that potentially may sway you to, hmm, let me tell the patient that there is some decay there and talk about perhaps being conservative and monitoring it very closely and doing repeat radiographs in the future.

But the deal breaker often is if it’s cavitated, i. e. there’s a surface breakage, then that is a deal breaker to perhaps, okay, we need to restore this. And so do you know about any ways that you could check if it’s cavitated or not clinically?

[Emma]
Clinically? I don’t know, actually. No, like, apart from just looking, like, clinically and seeing if it’s cavitated, or would you call it clinically?

[Jaz]
You would, but it’s very, very difficult. And you try and fill with your probe, but you often can’t get to that area. And it’s tricky and it’s very difficult to do. So can you think of another way? I was blown away when I first saw this as a student, by the way.

[Emma]
I don’t know if this would just be for paediatric patients, but could you put a separator in there?

[Jaz]
Yes. Well, you could put a separator. It’s more amenable in paediatric dentistry, but a really cool way to do it. Now, I don’t know if you’ve heard of Louis Mackenzie.

[Emma]
No, I don’t think so. No.

[Jaz]
Fantastic dentist. Unfortunately, he passed away last year. So, you know, rest in peace, Lewis. He did an episode with us called To Drill or Not To Drill. It’s one of the early episodes of the podcast and this guy was a fantastic speaker, really humble man, really one of the sweetest dentists ever. So his presence in dentistry will always be missed. So just paying a tribute to him. I saw one of his lectures, I was a fourth year student, it was the BDA conference, saw one of his lectures and he described this exact scenario.

It was like, hmm, how can you tell if a tooth is cavitated or not? And this is what he said, he said, I am so sad that this is what I will do. I’ll place a wooden wedge inside. So now you get some separation. And now, he will squirt some light bodied silicon into that interproximal area. Let it set a bit and then use the tweezers to pull it out. And now that will show you whether if it’s smooth in that area or has the light body silicon actually, for want of a better word, evaginated or extended into that cavitation. And that can be the difference between whether it’s restoring or not. So when I saw that, and I’ve used that a few times and I’ve been unsure basically. So it’s another little trick that you could use.

[Emma]
That’s very, very interesting. Very interesting. The only other way that I’d heard of was pediatric patients may be using a separator to open that space a wee bit, but even I don’t imagine you would ever do that on your adult patients.

[Jaz]
You could do and I know some people that can do this, but I think with this little trick it saves the patient some grief and going home and having the inconvenience of having a separator.

[Emma]
So another question that I had for you Jaz was, what sort of strategies do you use to use your radiographs as a communication aid with your patients, like I’ve seen a lot of clinicians do this very well, but how do yourself use these bite wings to say to your patient and even motivate your patient, this is what we’ve got going on and this is what we need to do to treat it to get them to understand.

[Jaz]
Yeah, really great. And I don’t know if you’ve heard of this relatively new ish software called Pearl. There’s some other ones as well, basically, I think. But this is like AI to read the radiographs. And basically, their slogan is Radiographs now in color. So what it does, it like, instead of the radiolucency, it’ll like paint it red. And so the patient can see clearly.

[Emma]
Wow.

[Jaz]
‘Cause quite often in the scenarios you’re showing the patient like, can you see the radiolucency? And they’re look at you blank. Like, no, I cannot see that. And that’s happened to me. Like, when you are learning, probably you will not see things that I can see ’cause of the difference experience.

But are patients are the same, like you show them a radiolucency and like, wait a minute, what are you sure I can’t see it. So sometimes having it colored by AI is just so some of these softwares are great. I don’t use them myself yet, but that’s cool. That’s very exciting, right? So what I would do is I’d have it on my flat screen TV I’d stand next to a radiograph is that can you see this is your tooth over here.

See this white area here That’s a big metal filling you have in the tooth. Can you see where the teeth kiss together where the teeth kiss together? That’s called the contact and that’s where decay starts. This is why it’s really important to floss or teepee, etc. Can you see there’s a shadow over here?

The shadow is a black area. It’s black because the x ray goes through mush. The mush can’t stop the x ray. So the x ray goes right through the mush and it’s not as hard. It’s softness. It’s soft mush inside your tooth. And so I’ve counted them and you have X number of areas. Now, these ones are gonna be okay.

But can you see this one over here? Can you see that it’s much, much bigger? And hopefully they can see it and you highlight it. That’s the one that we need to treat. Because if you don’t treat it, it’ll become here. And can you see this other little black area? That’s the nerve. So every tooth has a nerve.

And although you’re not feeling pain yet, most dental conditions are painless. When the pain starts, that is too late. That is a very late stage start. So most dentistry is painless, but when the pain comes, it’s often too late. This is what we’re presenting to you in the x ray. So then I’d maybe describe the bone level as well.

I often describe the bone as these are your roots and this is your bone. Thankfully, Mrs. Smith, you got plenty of soil around your roots, okay? Your soil is good, okay? And it helps them to understand it.

[Emma]
Yeah, no, that’s good. A few wee tips in there, I think. It can be really difficult.

[Jaz]
Because your experience as a nurse, right? What have you seen that you liked? Anything that you remember that you, oh, I really like this.

[Emma]
A dentist that I worked with, John McCall, I remember him talking through radiographs with patients. Just making it really simple, again, big TV in the practice, radiographs up there. So these are your teeth, this is the upper, this is the lower, this is the left, this is the right, and the spongy bit round here is your bone.

And just sort of setting that base for your patient to know what you’re looking at, first of all. And then, like you said, again, just going in, can you see this, this darker area here? And just going from there. I think it can be really difficult for students to do that in layman’s terms. If you’re with a patient, you just want to dive right in and then, oh, you’re pulp, blah, blah, blah, and they don’t have any idea of what you’re talking about.

I find that quite hard to use radiographs as a communication aid at the moment, because at the moment they overwhelm me, but I think definitely that’s something that will come with experience.

[Jaz]
100 percent.

[Emma]
Yeah. Just quickly looking at a radiograph and then instantly knowing what to say to your patient and using that in a way that they can understand can be huge for patient motivation as well and just getting them to understand your treatment options.

[Jaz]
It’s about the understanding and communicating the issue well. The radiographs are very important and the explanation, but that will come. The more you do it, the more second nature it will become and the more layman’s terms you will use, which is so, so important. In the routine checkup video, which is available on the student section again, I’m just reminding everyone.

I made a mistake because I never had done this before. I promise you that I would. And so usually I record procedures and it’s just me in silence recording procedure. And then later I might narrate it. For example, in sectioning school series, we have all these extractions that I’ve done and I’ve narrated it.

But when I was doing this, like the whole conversation with the patient was being recorded. And so I was a little bit self conscious about that. And so they came to one bit of explaining some treatment. And you might’ve seen my commentary on that saying there was too much jargon here. This is not how to do it.

So, very often you’ll feel that way. And it’s really important to, after every patient says, hmm, what went well? What went wrong? What, how can I improve my communication? If you keep doing that for years and years and years, you’ll find that actually, the more you simplify, the more you go back to basics, the more you make it softer and easy to understand, the more effective of a communicator you become.

[Emma]
Yep. And I think radiographs are obviously hugely essential in dentistry, but they just have so many other benefits in terms of communication with your patients. But that’s a really good skill to have is just putting that into something that the patient will understand, which of course, like I’ve said, just comes with experience.

So my last question for you, Jaz, was, and this might be a big question, but let’s just see quite generally. Let’s say a patient has irreversible pulpitis, it’s going to need an extraction or a root canal. You take a peri-apical at what point does the extent of the caries call for an extraction over a root canal?

[Jaz]
Oh, I love this question so much. A reason is because I’ve just posted a radiograph yesterday on the community on Protrusive Guidance, okay? And I said, okay, what are you guys gonna do? I sort of pitched it. Okay. So this is the scenario and what I used to see as the worst part of dentistry. It’s like everyone’s got different opinions.

I now see it as the beauty of dentistry. Okay, so you must see it like this, otherwise you will have a miserable career. So the beauty of dentistry revealed that everyone has, okay, some people use some sort of bioceramic materials. Some people say root canals. Some people say, actually give the pulp a chance.

Let’s try and restore it. Unless you can get a seal. Some people suggested a hemisection, all sorts. All right. So it was all in there. And it goes down to that question where, at what point do you decide, it’s a question whether it’s restorable or root canal is an optional, just remind me the question again precisely.

[Emma]
Between extraction and root canal, like at what point does it just need to go?

[Jaz]
Okay, so, extraction and root canal, the other way of pitching that is restorable or unrestorable.

[Emma]
Okay, cool.

[Jaz]
Should we go with that? Because sometimes a tooth may be restorable, but the patient will not consent to a root canal. It may be restorable, but to restore it, it needs a root canal because the pulp is either necrotic or it’s irreversibly inflamed, and therefore it needs a root canal. But actually what we’re going to gain more from is, okay, what are the radiographic parameters to use when we’re deciding whether if root canal is even an option here, right?

Okay. So if we have a PA, okay, and you’re getting to the territory where you’re thinking, hmm, I’m not sure if this tooth is restorable, the first thing to do is take a bite wing. Have you heard of this one?

[Emma]
No, I don’t think so.

[Jaz]
PAs often vastly overestimate how much caries there is. And they can make the situation much worse or, or different to what is going on. Sometimes by having a bite wing, because the angulation, you get a much better degree of assurance of the exact level of the caries. So in those cases, you should supplement your PA with a bite wing. So now you have a bite wing and now you can better access the exact extent of that radiolucency.

A really good tip that was given to me by a guy called Dr. Barber from Sheffield. This was when I was at DCT was when the radialucency extends below the floor of the pulp chamber. Let’s look at a molar, lower molar. Okay. Imagine young patient, large pulp chamber. We have the top of the pulp chamber and the floor of the pulp chamber. Imagine now the radialucency is getting towards the pulp chamber, but now it’s getting so far low that it’s getting to the floor of the pulp chamber.

When it gets towards the floor of the pulp chamber, that is one consideration. it’s not a hard and fast rule, but if it’s getting that deep now that it’s at towards the floor, it’s gone beyond the top. It’s now approaching the floor of the pulp chamber. It’s now on very shaky grounds. So the one I posted is on very, very shaky grounds.

So now you’re thinking, okay, how important is this tooth in this patient’s mouth? How strategically important is it? What kind of patient do we have here? Do we have an A plus patient with fantastic oral hygiene? With the otherwise low care he’s experienced? Bit of bad luck here? Maybe a wisdom tooth kind of issue?

And how much are we willing to fight for this tooth? And what is a patient’s attitude? And the way we sometimes, if we have those 50/ 50 scenarios, It’s really nice to pitch it to a patient in this way. I like to say this to a patient inspired by some communication tips I picked up from Lincoln Harris.

I said to him, imagine, dear patient, that you spent a fair chunk of change on this tooth. Imagine six months later it had to be extracted, because the root canal failed, because you never got a good seal. Would you say, you know what, I’m glad I tried, because there was a chance that this could have lasted 10, 20 years.

Or would you feel absolutely devastated? We feel like an idiot for spending money on it. What would your mindset be? And that will answer it sometimes. If they say that, they’ll be absolutely devastated. That’s six months later to have tooth out, then that answers it because it’s not very predictable.

Predictability is the key word here because when it gets that level of deepness of the caries, then it’s not as predictable. To get that seal is not as predictable. So that’s number one, right? If they say, oh, you know what? I’m, I’d be glad because I really want to say this truth and willing to give it a shot and willing to accept that in six months time, I’m not going to cry about it.

I’m going to be a big boy kind of thing. Okay. So if they say that, then, okay, if you think that your clinical skills are good enough and the patient’s up for it, then that may still sway you. Now, if it’s going well below the floor of the pulp chamber, then okay. That’s bad news. Because then you’re really, by the time you restore that A, to get the seal, to get the matrices that far down low is very, very difficult to actually do a good precise job is very, very difficult. Also biomechanically, that tooth is very weakened. The next thing to consider is would you perhaps need something like a crown lengthening? Do you know what a crown lengthening is, Emma?

[Emma]
Yeah, I’ve nursed in a few crown lengthening surgeries. Do you use like an electrocautery or something?

[Jaz]
It can do, to remove the gum.

[Emma]
Yeah. That’s I’ve only ever seen it on a few anterior teeth.

[Jaz]
It’s more common on anterior teeth and so, posteriorly, so there’s aesthetic crown lengthening whereby we’re changing the gum levels to get a nicer smile, and then there’s functional crown lengthening, we’re making the tooth a bit bigger by removing some bones, so imagine you’ve got distal caries and a molar really deep, like almost kissing the bone, so if we can make the bone go more apical, drill away some bone there, and allow us to restore this tooth in a much easier fashion, i. e. allow our matrix, allow our wedge to actually get down there and make a seal, allow our crown to actually sit, our future indirect restoration. Sit on healthy tooth structure and not near the bone, basically, that’s a good thing to do. So, we have to then think about finance as well. So whilst it could be restorable and it’s debatable, we have to think, hmm, at what expense?

Once you factor in crown lengthening privately, once you factor in a root canal, once you factor in a crown, you might be in implant territory. And so, cost benefit analysis, and how predictable and how easy or otherwise it is to get a seal. These all will play in in the real world when you’re decision making.

So in terms of purely a radiographic level, I very much look at this where it is in relation to a pulp chamber. I look at the patient as a whole. You take a step back, look at the patient. Is this patient deserving? And it’s not a nice way to think about it. But really, if they’ve got a gob rot, this one tooth is the last of your worries, right?

In that mouth, the most predictable thing for sure would be an extraction. But if it’s a well cared for mouth, then sometimes we do do a little bit of heroic dentistry as long as the patient understands that what we’re doing here is really higher risk, higher reward. We get to keep the tooth, which is great, but it’s higher risk, higher reward.

[Emma]
Yep, that makes sense actually. And I’ve never really thought about it in that sort of way where you do need to take a step back and look at the patient. The patient, there’s so much room for the patient to make decisions in their treatment planning and I think coming back to communication, like for me if I was a patient that could be quite hard to grasp without being shown, okay this is where this dark bit is and I don’t think that’s going to be able to be saved xyz. I think that’s a good way to look at it, your landmarks and being able to show that on a radiograph can be good for the patient as well. But no, that’s interesting.

[Jaz]
So top tip there, remember to supplement with a bite wing. Really important as well. And so, yeah, to look at the bigger picture. I remember being a DCT at Guy’s Hospital, oral surgery department, and all day long we’d be doing extractions and extirpations, right? I remember these two American students came to Shadow, for like the elective kind of thing, right? And so I think they’re American Australian. I forget now. Anyway, I saw this one lady, And she had caries and a molar that was causing pain and the diagnosis, the official diagnosis was irreversible pulpitis.

The tooth was restorable. Like, it was a home run. It was like way above the bone. It was a home run. It was decay into the nerve, but it was a home run root canal. But after having a discussion with the patient, we decided that the extraction would be the best for her. And she left and she went to get an extraction and these students were gobsmacked.

They’re like, wait a minute. What? This tooth was savable. Why didn’t you do the excavation and send this patient back for root canal? And it was an important lesson I was able to pass on to them because it’s a lesson I’d learned some years ago was actually, yes, it’s restorable, but just because you can doesn’t mean you should, because that patient, okay, you have to look at the tooth factors.

If that tooth, right, doesn’t have an opposing tooth, then what value does that have compared to, okay, it doesn’t have a tooth now or an implant in the future. If the patient is really not in a financial position to consider and they express that, like, look, I’m actually not looking to spend any money on this tooth.

I would actually like to have my patient preference is to have this tooth out. You’ve got to take that preference. Now, if it’s healthy pulp and it’s reversible pulpitis, I would dress that tooth. Right? I would not extract it. I’d be like, no, I don’t think there’s a reasonable option for what you present with.

But when the alternative is a root canal and the patient doesn’t want that, then you have to think about the patient as a whole. So it’s not just about the depth of radiolucency and whatnot. It’s about looking at the patient, their own preferences, their history of dental work, what’s opposing it and all these factors.

[Emma]
Yep. And I think that can be quite frustrating when you’re going through, not frustrating, but you’re going through dental school, learning how to save all these teeth, and then when it comes to the real world, sometimes that’s just not feasible. And like you said, you have to go with the option that A, the person can afford, or that the treatment that they are willing to tolerate.

[Jaz]
Tolerate, afford, and maintain as well. Like you might be able to afford it, they got gob rot everywhere. They got super, super dry mouth, and it’s going to be difficult for them to maintain. But equally, Emma, you might have a scenario where in anyone else’s mouth, you’d extract. But because that patient is on bisphosphonates, IV bisphosphonates, they are higher risk of things going wrong and the bone not healing.

And therefore, in that patient, you’re going to really do a bit more heroic dentistry and try and do what you can to save that tooth. So this is where the patient’s medical history and all those factors come into play as well. One last thing, which you haven’t mentioned, which I think is really worth mentioning in the realms of if predicting if something is restorable or not on a radiograph is remember that the radiolucency you see on the radiograph, the clinical caries will be 33% more. I remember this being taught this. It’ll be worse clinically than it is on the radiograph. Always remember that.

[Emma]
Okay. Yeah, that’s a good one to remember. And also a good exam question. A good exam question.

[Jaz]
Yes. And I was, it reminds me of another lesson I was taught as a third year dental student. I had this really carious premolar I was treating and it was making me stressed. Like as a student, like just, seeing so much caries was a stressful experience for me. I was stressing. I was sweating. I was like, Oh my God, when do I stop? There’s still more caries. I’ve got to go. There’s still more caries. I’ve got to go. And it took me like two hours to put this GIC, right? And the patient leaves and the tutor looks at me and he wrote a comment.

His name is Abdul Rahman Elmougy. He’s now a restorative consultant. So Abds, if you’re watching, listen to this shout out to you, my friend. He wrote in the book, he’s like, don’t be shy with a tooth of poor prognosis. Let me say that again. Don’t be shy with a tooth prognosis, okay? We didn’t owe that tooth anything, okay?

The tooth had served its time, okay? We were doing this tooth a favor. We were trying our best, okay? This tooth was on shaky grounds. So the way I approach this situation now is A, you tell the patient this is an investigation. We’re not doing a filling. We’re actually just seeing if this tooth can be saved or not.

I will tell you what the outcome is once I remove all the decay and I address it, okay? So you’re going to walk away with this information whether we can even save this tooth or not. Your tooth. This is like doing CPR for the tooth. Right. So that’s what I pitch it. But when you’re removing caries on a tooth, which is already really poor prognosis, don’t be shy.

Don’t be like little tickles. Okay. Get the big bur out. Okay. Be responsible, be precise, but don’t like be very gentle. Start tickling. You need to get this mush out. Go for it. Okay. Yeah. See what’s left. And so that really served me well, actually don’t start stressing because there’s huge caries.

That’s it’s the patient’s fault. You didn’t put the caries there. And sometimes hit the patient who sometimes you get certain types of personalities and they get very like, well, but do this and do that. And just remember, hey, well hang on a minute. I didn’t put the decay there.

I’m helping you, but I didn’t put the decay there. So it might take some years, Emma, to be able to be confident enough to say that to a patient, but it’s one to have up your sleeve.

[Emma]
Yeah. I’ve heard people saying before it might have been yourself actually like you didn’t put the caries there, and if there’s moosh there, then it needs to go. I think a lot of patients sort of demonize dentists. Like, I didn’t do that to your tooth. That’s hard to sort of, I wouldn’t ever say, oh, it’s your fault, blah, blah, blah.

[Jaz]
But it’s a hard one. I hear, Emma, is patients saying that, Oh, my dentist drilled too much. And so that really for me is a failure in the communication department. So it just means that, oh, we’re going to do a filling today. There’s some decay. Let’s crack on. Really? That kind of conversation should be like, there’s some decay here. I don’t know how deep it is. I think it’s actually, look at the radiograph here. So look at this x ray. This is the dark area. That’s the mush.

But actually in the real world, this mush is going to be much deeper. So I’m telling you now, although you’re not in pain now, there’s a real chance. Your nerve might be in pain because your decay is really uncontrollable. And although you’re not in any pain now, this could become a painful scenario. If you’d wish not to have this treatment done, that’s fine.

But you’re looking at having this tooth out. But if you still wish to try and save this tooth, remember the kind of symptoms to look out for are X, Y, and Z. And now your patient is really much more informed than their understanding that actually is their problem, not yours.

[Emma]
Yeah. No, definitely. I think and another one is I wasn’t in pain before I went to the dentist and-

[Jaz]
Classic.

[Emma]
I don’t need treatment done because it’s not sore. But again, that communication like, well, if you don’t get something done, then it will be sore down the line but she pick up along the way.

[Jaz]
A hundred percent. And as per the GC criteria in the UK, we have to tell the patient the risk of the treatment, but always the risk of not doing treatment. So, Miss Smith, I know you’re concerned the decay is deep, and actually after this procedure, you might be in a lot of pain, you might have a sleepless night because it’s very, very close to your nerve, and this is the reality of the really deep decay that you have in your tooth, Miss Smith, right? So your tooth is in a really troubled state, so we need to do CPR for the tooth here, but if you want an alternative, the option of not doing anything, although you’re not in pain now, this is going to be potentially a very painful issue in the future and whilst we might be able to save it now, we probably won’t be able to save it in the future. So the risk of doing nothing is not recommended and I’m not recommending this treatment, although you may choose to do nothing because you are well within your right.

[Emma]
Yes. Yep. The option of doing nothing is always there, but it’s not often recommended.

[Jaz]
Correct. And patients have to consent to doing treatment or not doing treatment. And so we put it on the table, but it’s the way we communicate and the gravitas that we explain things, which is really important.

[Emma]
Yep. Yep. Absolutely.

[Jaz]
Amazing. Emma. So we’ve covered now some degree of real world radiography. We talked a little bit about OPGs, periapicals, and grading and assessing. Looking at things in a systematic way and actually drawing out the real world, the communication gems, which I think this episode really evolved into in the second half. Please tell us about the notes, the Protrusive Student notes that you’re adding on every time you do an episode. Tell us about what you’re going to cover in this round.

[Emma]
So this month’s notes about radiography, of course, I’m going to go through what we’re taught at Glasgow about your radiographic reports and your checklist. And what I personally have in my wee book that I carry about with me, a bit of localization and parallax technique, common mistakes that we make when we’re interpreting radiographs and it’s just, yeah, basic interpretation, things like that.

[Jaz]
Excellent. Very excited to put that on. So Emma, thanks so much for all the hard work you do for Protrusive and I hope you have a fantastic elective. We will meet again. Obviously, people will not know the difference because we’re recording ahead of time, but we can’t wait to hear in the next episode your stories about your elective and from the Protrusive Community, we’re thankful for all that you’ve done so far, but we look forward to rejoining and continuing your good work.

[Emma]
Perfect. Thank you so much.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for making it all the way to the end. Please let us know what should we cover next in this basic series, in this Protrusive Student Series. Like I said, the next one’s on extractions, and it will be CE eligible because I find that so many dentists are also tuning in, and it’s nice to reconnect for validation when it comes to the basics.

If you know a colleague who will benefit from these episodes, please send them a link to our podcast, and at least join the community of the nicest and geekiest dentists in the world. That’s Protrusive Guidance. You can get it on iOS and Android, and our thriving community is absolutely awesome.

Nice people. Not like what you see on Facebook. Facebook is junk, in my opinion. So if you are a keen listener of Protrusive and you want to connect with other Protruserati, that’s the place to be. Thank you so much for listening all the way to the end. Once again, I’ll catch you same time, same place next week. Bye for now.

Does ‘elective’ or ‘pre-emptive’ endodontics have a role in Restorative Dentistry?

It almost feels dirty to me as I try my best to PRESERVE pulp vitality!

But sometimes this bites you, and you wish you had carried out root canal treatment before cementing that crown.

At what point can pre-emptive root canal be justified in a world where MTA and biodentine exist?

In this episode, Jaz sits down with renowned endodontist Dr. Brett Gilbert to delve into the intriguing world of elective or pre-emptive endodontics. Together, they explore challenging cases where teeth with uncertain pulpal health may require root canal treatment, whether due to caries or crown prep. Dr. Gilbert sheds light on patient communication strategies, the role of bioactive materials like biodentine and bioceramic sealers, and how to make crucial decisions about preserving pulp vitality.

Protrusive Dental Pearl: Dr. Pav Khaira suggests using Alvogyl, commonly used for dry sockets, to treat pericoronitis! After cleaning and disinfecting the area, place a small amount under the operculum for immediate relief and to soothe inflammation.

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

Highlights of this Episode:

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. 

This episode meets GDC Outcomes B and C.

AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment)

Dentists will be able to: 

1. Learn what elective or preemptive endodontics entails and recognize scenarios where root canal treatment may be required due to caries or crown preparation, and how to approach them.
2. Discover effective strategies for explaining treatment options to patients, improving trust and decision-making.
3. Gain insights into the use of bioactive materials like biodentine and bioceramic sealers, and their benefits in preserving pulp vitality.

If you liked this episode, you’ll love Post Operative Pain after Endodontics – Prevention and Management – GF017

Teaser: I do believe in these instances, you are justified to recommend the treatment. You're not demanding it. You're not saying it's dogma, but you're having a conversation so the patient understands. Because what happens if you don't is you do your work, you're doing it in best faith. Patient winds up in pain, and they become very angry.

Teaser:
They become agitated, and they want to blame the dentist. And without a conversation, without a dialogue, they’re clueless, and all of a sudden, they just think you did something wrong. You are a human, and you are the doctor. Speak to yourself. Let the words flow out so that you can explain all the different possibilities in a way that the patient feels heard, understood, but also nurtured, and at the same time you realize this is biology. We are not in control.

Jaz’s Introduction:
In a world where we want to do everything to preserve pulp vitality, is it ever appropriate to carry out elective endodontics? Another terminology that our guest today, Dr. Brett Gilbert shared with me is preemptive endodontics.

For example, you have a tooth with dubious pulpal prognosis. And you know that by prepping it for a crown or by removing the caries, this tooth may need root canal treatment. Is it okay to just go ahead and do the root canal so it doesn’t bite you in the behind in the future? You see, I was always taught to do everything possible to preserve pulp vitality.

So I started my career being very much against it. And yes, I burnt my fingers a few times. So we’ll ask our guest today, who’s a specialist endodontist, and you know what, Protruserati, you’re going to absolutely love him. He’s so direct, he’s so quick, he’s so punchy with his answers. And whilst this episode is just half an hour, it’s part of a two part special.

So this half an hour we focus on elective or pre emptive endo. We talk about things like biodentine and bioceramic sealers. And this is worth 0.5 CE credits or half an hour’s worth of enhanced CPD. The subject code for this one, because we are a PACE approved provider, is 070 endodontics. And in the part two of this episode, we’re going to discuss irrigation.

Is sodium hypochlorite still the best thing around? How can we improve the efficacy of our irrigation? How can we get all those bugs? Because endo is all about getting rid of the bug. So that’d be in part two. So don’t miss that one next week.

Dental Pearl
Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. And this one comes straight from the protrusive community. As you know, we have our platform, it’s called Protrusive Guidance. It’s been going strong for about seven months now. There’s over 2000 dentists on our community now that have been approved.

So there’s hundreds of people who want to join, but we manually approve each one because A, we want there to be only dental professionals in our group. You want this to be a safe space and I want the nicest and geekiest dentists in the world. So if you identify yourself as that, please join us because today’s pearl comes straight from the community.

We have a very busy chat section of our community, and someone was asking about the management of pericoronitis. And then came Dr. Pav Khaira, who’s like the implant guru, but he dropped such a powerful pearl that I really want to share this with you all. He says that you can use a bit of Alvogyl. You know that stuff we use for dry sockets, we put inside the dry socket?

He suggests putting just a tiny bit of that under the operculum. So where that inflamed tissue is, just tuck it under. Obviously you’ve got to do this after you’ve irrigated, you got rid of the debris, you’ve disinfected the tissues, and now you leave a bit of Alvogyl. And this stuff gives immediate relief to patients.

Now, this was so good that community member Dr. Nikhil Misra said that he’s used this technique for three patients this week with immediate relief. And he’s very grateful that that tip was shared. So thank you to everyone on Protrusive community. Thank you Pav for sharing such a powerful little tip. It’s something we virtually all have in our clinics.

And now we have another use for it. So once again, if you missed it, Alvogyl for pericoronitis. Now, totally unrelated, let’s get back to endodontics and let’s join our wonderful guest, Dr. Brett Gilbert. You’re going to absolutely love him. I’ll catch you in the outro.

Main Episode:
Dr. Brett Gilbert from the U. S. So, so good to have you on the podcast. You were recommended to me by Dr. Tom Levine, who’s a member of the community, and he did some CE with you, which I love to hear about. And the more I research and look into you, the more amazed I am. So I’m super, super excited in a geeky way to chat endo with you today. Specifically irrigation, but there’s so many communities, so many, so many questions the community has actually asked, and I can’t wait to dig in.

But for anyone who hasn’t heard about you before, tell us about yourself. I see you’ve got your lovely little box there on the cusp podcast and you do so much in education, but tell us about you, Brett.

[Brett]
Yes. So thanks so much. Jaz excited to be here. And I do think Tom, he was at my AGD presentation and within, after the first break, he came up, he goes, do you know, Jaz? And I said, I’ve heard of him. I’ve seen his podcast. He said, well, you guys have to meet. Cause there’s so many just synergies between your energy and your message. So very grateful to be here.

So I’m a full time clinical endodontist. I’m board certified. I’ve been in practice for 21 years. I have a ton of passion for the profession, but as I’ve gotten a bit older into my career and dealt with burnout and the mental distresses and the burdens of the stress of being a dentist, I’ve also become super passionate and a student of personal growth and development and just sort of that ability to manage our stress.

And so I really try to balance them both out because I really feel it’s really important to have the opportunity as a dentist to study the X’s and O’s to understand technique, rationale, the way that we approach dental treatment in whole, but before we do that, we really have to make sure we’re also focusing on the human being inside the scrubs.

And that’s another area of passion that I have. And so I know you share that and I’m really grateful to be here and to meet your audience and to talk it up a little bit and let’s get into some endo.

[Jaz]
Absolutely. What I’d love to start with is your journey from the perspective of did you spend much time as a GP before you niched into endo or for you was it like you’re always you’re calling since after dental school?

[Brett]
Yeah, interestingly enough, so I’m a son of a dentist, general dentist and my whole life I was going to be a general dentist and practice with my dad and then after one year of dental school, I started to feel a little out of sorts. I just felt like pulled in so many directions with all the different disciplines of dentistry.

And that’s when the discussion of specializing came up. And my dad sent me to all of his different friends, offices, ortho, oral surgery, perio, and then endo. And I got there and this gentleman, he just was incredible. His name was Barry Jurist. He was doing rotary at this time. He had microscopes. He was showing me videos of his surgeries.

And I was just struck. And from that moment on, I was full go for endo. I picked up my studies. I really focused down and I was lucky enough to be accepted right out of dental school into my endo residency at the University of Maryland.

[Jaz]
Great. It’s nice to learn about someone’s background and story. Now I’ve got a million questions and also it’s just great about your background in or your passion in self development growth, the human perspective.

And I’m sure wherever we can weave that in. We should, but I’m going to start with a few questions from the community. So community, which Tom is part of is called Protrusive Guidance. I’d love for you to join on there and help us out with our endo woes and queries. There’s always a radiograph being popped up saying, oh, what’d you think of this?

So you’d be great for that. But the first question I’m going to start with, amazing. I’ll make sure I’ll get you hooked up. The first question I’m going to start with is about what I emailed you about. I called it Elective Endodontics. And you introduced me to the term, Pre-Emptive Endodontics, which I’d never heard of before and I really like it.

And so from the background, the context of this question is I have always been taught never expose the pulp. Like whatever you do, avoid the endo. And actually an endodontist’s first response responsibility is to protect the pulp and avoid the endo, which is great. And then taking that on board, I had these scenarios where the caries were so deep, the tooth was still vital.

And my diagnosis. was still reversible pulpitis at that stage. It wasn’t irreversible pulpitis. So I thought, okay, maybe there’s a chance that by placing a restoration on here, I can avoid the endo. And then a few times it happened where a few days later, the patient’s in agony and you think, Oh man, I wish I just did the endo.

So I know in other countries, it’s more popular. It’s more accepted in other countries whereby anytime they’re doing any sort of indirect work, they’re thinking, ah, let me go ahead and kill the pulp off so it’s not going to be an issue in the future, which I think is at the other extreme and perhaps irresponsible, I would say. Where do you lie in terms of, is there a time and a place for pre-emptive endo or elective endo? And how do you assess that kind of situation?

[Brett]
Yeah, by all means there is. And I think what’s important to remember is that all of these decisions aren’t done just by the clinician, right? It’s a collaborative decision based upon a very specific conversation with the patient. And so the decay issue is different because the more I study restorative, schools of thought, some are comfortable leaving some decay, as part of the underlying parts of a restoration and others are not.

But ultimately, I think we have to look at the history of symptoms first and foremost, because if you have a patient that you were describing with reversible pulpitis, that you feel very confident is reversible. We do have to recognize that there’s probably about a 50 50 chance that it either calms down underneath the restoration or it doesn’t.

And sometimes that’s a conversation to be had. Sometimes I’ll explain to a patient, listen, we may be able to send you back and have the crown cemented and you’ll be just fine. I don’t know. It’s possible we send you back and you’ll have symptoms as you mentioned a week, a day, a year later, and endo may need to be done through the restoration.

So what I need you to understand is, are you comfortable moving forward with the understanding we may have to go through the restoration later? And if not, then understand that there is the option of pre-emptive endo now, meaning we can do the root canal now so that the foundation underneath your restoration is sound.

It’s not going to cause problems later. It’s surprising. You can never go into these conversations with an expectation of how they will answer. That’s what I’ve learned. So it’s about giving them the A to the Z. Explaining the situation if they opt to not do endo at that time. It’s fine I do recommend having an extra little consent line that the potential for endodontic treatment after the restoration is place was discussed.

Patient defers and will prefer to wait and see what happens. Have them sign it. It’s amazing how helpful that piece of paper becomes later when the patient’s upset and they realize that now their brand new crown has to have a small access opening, but I also do tell patients, listen, it’s pretty non intrusive for us to be able to go in and do endo through a crown.

So it’s not like the end of the world, but it’s important for you to understand the situation now where that starts to become more clinician centered as far as the decision is to your point. There was a lot of decay. You’re very close to the pulp. In fact, you might even see it. Our studies would show that really anywhere from about 1. 8 millimeters away from the pulp, there are already destructive changes happening into the pulpal cells. So you have to then take into account, this doesn’t seem very good.

[Jaz]
Is that a radiographic, Dr. Gilbert, is that a radiographic measurement?

[Brett]
It’s really more probably just eyeball to be honest, because you’re probably looking at some huge change in the dentine that would indicate where you are. Domenico Ricucci out of Italy has done a lot of work with this, as far as when it’s appropriate to leave the pulp and when the appropriate to take it out, but ultimately in the global scale of dentistry, I think ultimately it comes down to your gut instinct as the clinician with a really good conversation with the patient and allowing them to be a part of the decision making process.

[Jaz]
In your week to week endodontics, or month to month, I mean, how often does this pop up with the kind of work you do? Is this something that you’re doing on a weekly, monthly basis, or not so much?

[Brett]
Yeah, I mean, I think ultimately it depends on what kind of restoration you’re placing to, right? If it’s a direct composite, if it’s a standard restoration that does not involve cementation, I think we’re often much more patient before we institute endodontics, because, of course, once endodontics is completed on a molar, then typically some type of cuspal coverage is recommended afterwards.

So that’s a lot of dentistry. That’s a tremendous amount of expense for the patient. So really it comes down to more of the cemented type of restoration where this conversation really takes hold. And so, if you’re just doing fillings, et cetera, et cetera, then ultimately a veneer even.

Then really the conversation can lean more toward, let’s see what happens. But once it’s full coverage or cuspal coverage, it’s cemented, you know you have to go through it. Then that’s where this conversation of pre-emptive treatment becomes more profound.

[Jaz]
Well, I’m going to share my screen now for those who are listening on Apple and Spotify. They won’t get to see this, but I’ll describe it literally today on the community, I posted this like hot, cold, like a poll, and I said, how do you feel about elective or pre-emptive endodontics? Example, deep carries and will need indirect, RCT it pre-emptively or no, I’m not comfortable with this. I wouldn’t do this.

It’s like a hot and cold. And as you can see, the audience is generally veering more towards cold, not freezing, but towards cold. And there’s a few in the middle like me. And then there’s a few to the right of me, a bit warm. No, one’s hot in it, which is good. We don’t want as a community to be trigger happy doing these endos.

We still value and respect the importance of preserving pulp vitality. But then from the chat here, Brett, what came here is a great discussion whereby colleagues, what they’re doing, and essentially here’s the question, what colleagues are doing in those scenarios is yes, it may benefit from cuspal coverage because a lot of these are huge MOD amalgams, recurrent caries.

So they’re going to need cuspal coverage. But what our clinicians are opting to do is remove the caries, remove the old restoration, clean everything up, and then just put a well bonded composite and tell the patient, look, It needs something more definitive than this, but let’s see how it goes for a year. What is your thought on this kind of approach?

[Brett]
I mean, it’s very conservative and that’s great. We always love conservative treatment. You’re going to be in the same situation a year from now, though, when you go to do a more significant prep and place and cement the crown, we often find that the actual, it’s like the last little straw that breaks the bow is the cementation.

And what it does to the pulp through the dental tubules. So I think it’s always again about this conversation and about consent and about what’s your gut instinct for the patient because the patient says, I’m so busy. I travel a lot. The last thing I want is to all of a sudden start having tooth pain.

It sounds to me like you’re saying that’s possible. So I would prefer just moving forward with the root canal now. And then another patient says, well, my insurance is running out. I don’t have a lot of out of pocket resources. I think I’ll take my chances. And so you have to look at the actual patient’s lifestyle and their thought process, because I do believe in these instances, you are justified to recommend the treatment.

You’re not demanding it. You’re not saying it’s dogma. But you’re having a conversation so the patient understands because what happens if you don’t is you do your work, you’re doing it in best faith, patient winds up in pain and they become very angry. They become agitated and they want to blame the dentist and without a conversation, without a dialogue, they’re clueless and all of a sudden they just think you did something wrong. So whether you wind up pre-emptively treating or not having the conversation, I believe is paramount for building the relationship and ultimately managing the patient winding up in pain later.

[Jaz]
Thank you. And one thing I struggle with in informative years and a lesson I pass on a lot on the podcast, especially for our younger colleagues, Brett, and I think you’d be great to give a perspective with your interests on the human side is when colleagues are communicating this to their patient, I feel as though sometimes our colleagues, our friends, end up owning the problem.

They’re thinking like it’s their tooth, right? And I think it’s really important for our mental health, our anxiety, that we’re just there to help to guide the patient, to do what’s best for them and dissociate themselves from the problem. Because if you start stomaching the problem with yourself, and you start being a bit too vested in it, then that can have bad health effects on us. What do you think about owning the patient’s problem when it comes to the ultimate decision?

[Brett]
I mean, this is the one of the biggest stressors we carry as dentists. We are very empathic people. We want to help people. We also have been trained in an era of we are expected to be perfect, whether it’s been imposed on us in our dental school training or self imposed.

And so when something doesn’t work out the way you had hoped, and now someone else is suffering, it’s very, very challenging to separate The human being, the tender soul inside of you and the dentist. And that’s where the identity as a human first is so important. And that only comes with addressing it, feeding that human inside of you so that you can have some separation.

I, as a young clinician took everything personally. I went to bed thinking about it. Terrified of what might happen or what had happened, and then I make it a little sleep. And the second I wake up, it’s right there. So the advice is this. It’s important to understand that when you are a dentist, there’s a full spectrum of reactions that an individual patient might have to our treatment.

Now, are our treatments ever going to be perfect? Let me just say from my own pursuit of it every single day. Nothing’s perfect. So what we should be striving for is excellence, not perfection. And within the frame of excellence, you have to be aware that there are different reactions. And what’s important is to understand how to have these conversations, just like the pre-emptive conversation.

And what I suggest, especially to the younger dentists who haven’t quite been through as many situations, talk to yourself in the mirror. You are the patient and you are the doctor. You are human and you are the doctor. Speak to yourself. Let the words flow out so that you can explain all the different possibilities in a way that the patient feels heard, understood, but also nurtured.

And that at the same time you realize this is biology. We are not in control. And so you do your very best. And Jaz, if every dentist that hears this within your community can recognize all that’s expected of you, not to be perfect, not for everything to be 10 out of 10, all that we can ask is that every day that you show up, you have the intention of doing your very, very best.

That’s it. And if you do that, then when a patient does have a problem, you can look back and say, yes, Mrs. Smith, I have to say, the treatment that we did looks good, but I understand you’re suffering. Let me explain why. And ultimately, let me give you sort of a view of what might come down the road.

I don’t know that you’ll need potentially this tooth to be extracted, but I want to put it out there to you that ultimately, if that were to happen, I just want you to know that there will be a game plan to replace the tooth. But in the meantime, for now, let’s focus on just getting the symptoms to settle down.

I’ll have you back for frequent followups. So, you know, I’m here for you, right? I like to say that to patients, just so you know, I’m here for you. I will be here if you need me. That’s all patients need. Sometimes the pain isn’t as much physical as mental and emotional and financial, right? They’ve gone through all of this time, energy, they miss work, they spent all this money and now the tooth hurts when they bite on it.

Well, that’s upsetting to them. So it’s important to meet them as a human where they are, but also separate yourself as a human, as someone that has done their best in every moment. And that’s all that was ever asked of us.

[Jaz]
This is absolutely communication gold. If anyone was multitasking when Brett was given this most wonderful monologue, you need to hit rewind, just go back the last couple of minutes and just listen to this again.

And just for a few days, just that was absolutely fantastic. I love that. The whole thing about rehearsing in the mirror, we don’t do that enough. And that connection that you make with the patient and yes, ultimately patients need to have that feeling that, okay, I’m in safe hands here. This guy will look after me and that can’t be emphasized enough just to reflect on what you said.

I had a guest Marco Maiolino from Italy on recently and we talked about how we’re always striving for perfection this gold standard but he very much resonates with what you said where if you show up and do our best every day and we call that the daily standard. So what he suggested was Instead of like one or two cases going 10 out of 10 and the rest going four or five out of 10 because you’re particularly putting too much energy.

And if you lift your daily standard to eight out of 10 consistently, we will better serve our patients and try and do that rather than chasing that 10. So I just want to remind everyone of that great reflection. And then going back to clinical on that point of pre-emptive endodontics, selective endodontics.

So once again, April from our community, she mentioned that actually she has been using biodentine with some good success. So previously when she’d be wondering about, ah, should I be having this conversation with the patient? How much are you using biodentine as part of your armamentarium to further reduce your risk or help this scenario? And based on the evidence base and your experience, is this a silver bullet?

[Brett]
So biodentine is an interesting material. It’s been around for a while. I haven’t used it as much as I think a lot of other dentists. And I don’t know if it’s a US thing or a global thing. But we do use the bioceramic materials in the same way, right?

Like a material that is non irritating to the pulpal tissue, that’s a nice insulator that can sort of rebuild where the natural dentine protection of the tooth structure has been removed, whether by biology or by bur, but these things are nice because in the past, all that we had to put close to a pulp was irritating, something with huge and all, etc.

And now what we have is examples of something like biodentine or any of the MTA products, the bio ceramic putties, where we actually can sort of kind of protect the pulpal tissue in a way that’s non irritating so that we could potentially extend the life of the pulp. And so I think that’s a very valid way to go.

Again, I think when you’re talking about fillings and things like that composites, that’s going to be a really important part of your armamentarium to maybe put something close to the pulp instead of something that was considered a base back in the day using something like this, that’s a little more biocompatible.

But ultimately, when it comes down to crowns and full coverage, cost full coverage, that’s where cementation comes into play and that’s where it becomes a little bit trickier. So I think bio dentine is a wonderful material. I think one of the reasons it’s not as in vogue is just because to my knowledge, still, it needs to be triturated.

And a lot of the bioceramics, you just basically just push a little bit out of a syringe already premixed, but I think you get a similar result. And so I think it’s a valid comment and definitely a material worth having in your office.

[Jaz]
Here’s a real world spit off from that question. We have an international audience here all around the world, and some countries, it’s just not something that they can afford in their clinic. And that’s the truth, right? So out of glass, iron and cement, composite, even amalgam if it was your tooth and it was a deep one and the dentists wanted to try their best to give It the shot for vitality. What should the dentist be using in what’s most likely going to be stocked in their cupboard already? What’s the kindest protocol to the pulp in terms of restorative material to place when you are close to the pulp?

[Brett]
That’s really interesting. I think it’s more of like how close are you and are you actually exposed. So if I have any type of exposure, I want to buy a ceramic cement against my pulp tissue 100 percent because the studies would show over volumes using MTA is the sort of essential baseline.

But since then, the bio ceramics as we learn, you know, bio ceramic putty, bio ceramic sealer. They’re all the same material. They’re just different consistencies based on particle size. But what we see is that the pulpal cells will actually grow against it without any zone of necrosis. So to be honest with you, once something like a bio ceramic is up against the pulp, you really need something of a resin to sort of hold it in place and seal it.

So there’s been an advent of something called resin ionomer. One example is from Brasseler, USA. They have what’s called BC Liner. And what’s interesting about this material is that it bonds to both the dentine as well as the bioceramic material. So for instance, if we flip it around from a pulpal exposure and you think about like a perforation.

Same type of scenario, you would put the bioceramic putty down against the vital tissue, and then with this resin ionomer, you can basically just put a bandage over it, light cure it, and it’s bonded to dentin, it’s bonded to the bioceramic, and now that is essentially sealed. So whether it’s a healthy pulp that you’re trying to seal or perforation, this protocol to me is ideal in this day and age.

To your point, though, unfortunately, some of these materials are costly and therefore, some dentists may not have that. So in that situation, I think we have to still go with the old tried and true, which would be something like an I. R. M. Or using some type of base material. But ultimately, we used to talk about pulp exposure or indirect pulp capping, direct pulp capping as death of the pulp.

And with the advent of these bioceramic and bioactive materials, it’s just not so,. And a whole nother topic for your podcast would be vital pulp therapy, which really has come into vogue because we now have biomaterials that allow us to actually protect the pulp. And so if you have an immature tooth, you can do the same protocol over a pulp exposure, even like Cvek pulpotomy and actually allow for the natural Apexogenesis to occur because that pulp tissue will remain vital.

So there’s a lot of exciting things happening. We’ve learned that, there are parts of the world where even from an endodontic perspective, I still teach hand files and I still teach cold lateral condensation because that’s what they have. So it’s important as educators, I believe, to meet our doctors where they are. We can talk about the highest level of expensive materials and the lowest level. And fortunately, the beautiful part is you can still get a great result with either.

[Jaz]
Excellent. I mean, that’s very encouraging to hear. And I think you’ve given some good guidelines to consider. The final question I have is from Christos in the community before we talk more about irrigation, right?

So that’s gonna be the more like the part two. The final question is, because on the topic of bioceramics, he asked, is this the death of gutta-percha, GP, are we now doing these bio ceramic sealers in the canals or using the bio ceramics as an alternative to GP, which I know many endodontists have been doing for a while now.

So is there still a place for GP? And I think just to give you some background as a general dentist, I was recently advised by an endodontist that if a general dentist is doing an endo and you’re thinking, hmm, there’s something in doubt here, I don’t think I can get a perfect result due to a myriad of different reasons, then please use something like Tubli-Seal and GP because the re treatment will be easier.

If you, in that scenario, when you can’t get patency or you’re not 100 percent confident, if you use a bioceramic material to fill it, then that re treatment may become more difficult. So I want to learn from you in terms of how far have we come and how have we moved away from GP?

[Brett]
So a couple of things on this. So GP, what you have to look at it as, and the way I like to teach it is the gutta-percha is simply a vehicle and it’s a vehicle to essentially drive the sealer against the walls into lateral canals into dental tubules into apical rarifications and all kinds of apical deltas. We know that there is such a tremendous amount of anatomy within the root canal wall.

So you’re using a match cone system, ideally in modern systems where the gutta-percha and the final file that you finished with are the same dimensions, which means that what you’re depending on the gutta-percha to do is to fill the bulk of the center of the canal. While allowing this hydrodynamics, this condensation of hydraulics to push the sealer against the walls.

That’s the goal. Gutta-percha doesn’t seal to anything. So the reality is when bioceramics came into vogue, we started to see this concept of single cone, but the cone was tiny. So it was a bulk of bioceramic sealer and a tiny little central core of gutta-percha. And that’s where the whole retreatment argument began.

Because the reality is, you can’t remove cement from the inside of a canal. So we shifted our thinking and thought, well, we actually could probably get a very similar effect by using a normal size, a match cone gutta-percha to actually drive the sealer against the walls. But still retain the ability to retreat if necessary.

And so that’s essentially what most endodontists are doing. We do the single cone, we put the bioceramic material in the coronal third of the canal. And if you’ll see any of my videos, you can actually see as the gutta-percha comes in like that piston, you see it actually carry the sealer down. And then start to spread it out.

In fact, even getting some extrusion, which we don’t see as harmful at all. In fact, especially with a lesion where it’s more common to happen, it actually has osteogenic potential to actually help the body to form bone because it has hydroxyapatite. That forms on it within about 24 hours, and the body sees that hydroxyapatite as self.

And so it actually instigates healing. So to answer the question for the doctor, no gutta-percha is not going anywhere only because it’s that really nice inert material that can actually facilitate the movement of the sealer where we want it most into the apical rarefications into the lateral walls, et cetera.

But something exciting that’s come onto the market very recently is actually obturation with neither gutta-percha or sealer. And this is a hydro gel material. So a company out of Switzerland named Odne has developed what’s called OdneFill. And what it is, is it’s actually a liquid that you inject and then it has a laser that goes down and actually polymerizes it.

So what you get is an actual root canal filling that is neither gutta-percha and neither sealer. And so we’re seeing some paradigm shifts in thinking. The hydrogel is nice because as it sets, it pushes out just gently, almost like if you think of like oxygen mass being pushed against one’s face to make a seal.

Very similar concept, very easily retreatable. The key though, and again, it’s still in the early stages, but Jaz, think about it with sealer and gutta-percha. You do have some risk of extrusion, right? Whether it’s the sealer gets way out, whether it’s the gutter percha point. And with a material like this, it eliminates the extrusion because it’s basically an aqueous solution.

If it goes past the root, it’s simply absorbed and it can never be hardened because the laser doesn’t go beyond the apex. So just putting it out there to the community, there are some new developments, but right now, what’s nice about the bio ceramic sealer with the gutta-percha, is that there is, and it’s basically, it’s considered single cone, but it’s really called hydraulic condensation.

And the reason is, is you can put some pressure on that gutta-percha and find that the sealer actually can spread. So that’s where you’re seeing these lateral puffs on instagram and you’re seeing these anatomies just get filled with sealer because of the hydraulic nature of the bioceramic sealer, and that’s very exciting isn’t it?

[Jaz]
That’s only possible with the heated techniques, right? We can’t achieve that with lateral compaction. We are, if you don’t have the know how or the kit to do it in the hands of the cold lateral compaction, is bioceramic sealer still a good option for a general dentist to use?

[Brett]
Yeah, as long as you can sear off the top of the gutta-percha, you really are not putting like an apical penetration of heat. It’s really just, again, that piston of gutta-percha. And when you just condense it, it just puts a little more hydraulic force on the sealer. So yeah, it’s exciting time and just wanted to share that because I think it’s important to open the minds of what’s in research and development. And this is actually an approved material that’s available. And it’s a very new paradigm shift. Obviously, we don’t have a tremendous amount of evidence on any of it, but it’s exciting to think about de risking the endodontic procedure, especially for the GP.

[Jaz]
Well, the future of endo is certainly very exciting and that takes us very nicely to irrigation. Okay. So, I know you’re really hot on this. So the proper disinfecting protocols, let’s talk about where we are in 2024. Cause I was taught that sodium hypochlorite is the gold standard. So the first question is, is there anything better yet? Are we still relying on 3%, 5. 25%, wherever it is, sodium hypochlorite?

Jaz’s Outro:
There we have it, guys. Thank you so much for listening all the way to the end. How good was Brett? I told you you’d love him. His direct way of responding is absolutely fantastic. And hopefully now you have a more informed opinion about the relevance of pre emptive endodontics today. Is there a time and place?

Yes. There might be, but it’s all about that patient communication. If you’d like to claim 0.5 CE credits, cause you’ve done all the hard work of actually listening and hopefully we made it just that little bit fun. Head over to the Protrusive Guidance app. Now, if you’re downloading it on Android, you need to first make an account on the website, protrusive. app.

You can actually access it from your laptop, but then once you get your account, you can access it on iOS, Android. And about 99% of the episodes have quizzes. I’ve also got my masterclasses section for those who want to learn further. If you enjoyed this episode and you like what Brett’s doing, then firstly, give it a thumbs up and subscribe.

But don’t forget to join us for part two, where we talk about the latest innovations when it comes to irrigation. But even if you’re not using anything fancy, how can we improve how well your irrigation and disinfection protocols are working in your clinic? today, right now. So it’s another juicy one with Brett coming next week.

I will put Brett’s podcast and links to this episode as well, but the next one he talks more about all the wonderful things he’s doing to support the world of dentistry. Thank you again. I’ll catch you same time, same place next week. Bye for now.

Are single-use diamond burs more efficient at cutting?

When should we throw away a bur and pick up a fresh one? How long are they supposed to last? (it’s measured in minutes!)

Are expensive brands a con?

Tiny, but one of the most important tools of our trade…BURS! In a world full of different identifying numbers and names, it can get confusing and even overwhelming. 

That’s why on today’s episode, we welcome Günter and Marcela from Intensiv, a globally recognised manufacturer of dental burs, where they take great pride in bringing the latest tech to help make our dental procedures that much easier and effective.

In this episode, we cover how diamonds are sourced, what the differences are in colours of burs and how the grain size of diamonds can change our results. There’s lots of amazing tips and tricks here given by the team at Intensiv, so you’ll definitely walk away from this one with something new up your sleeve.

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

HIGHLIGHTS of this Episode:

01:24 Protrusive Dental Pearl

02:03 Introduction to Team Intensiv

05:40 Understanding Bur Codes

10:49 Bur Colours

15:10 When to Use Different Grit Diamonds

18:40 Single Use Burs vs Reusable Burs

24:59 Sourcing Diamonds

29:18 Fixing the Diamonds to the Metal Shank

32:40 Is my bur fit for purpose?

37:30 Drilling Zirconia

39:30 Final Tips

41:20 Contact Intensiv

This episode is eligible for 0.75 CE credit via the quiz below.

AGD Code: 250 Operative (restorative) Dentistry (Preparation Technology)

GDC Learning Outcome:  C

Learning Outcomes

If you liked this episode, you will aslso like: PDP117 – Dental Ceramics in 2022 – Which Ceramic Should I Use

Teaser: Are single use burs better or really more cost effective than our traditional multi use burs? I think the answer is actually going to surprise you. And my biggest pet peeve, the thing I hate the most, is using a bur and it has like zero cutting efficiency. I work in a clinic where we share our burs and we have like different bur kits made up.

Jaz’s Introduction:
And so sometimes I use a bur and I hadn’t inspected it and I find that, oh my goodness, this is taking way longer than it should. And of course I have to ask my nurse to go to the stock room to get a brand new bur. But this is frustrating. Like when you are using a bur with less cutting efficiency. It is annoying and it’s actually downright dangerous for the tooth. So how can you tell? Is there an objective way to tell and subjectively, how can you tell exactly the moment when you should bin a bur? So you avoid that horrible scenario.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m joined today by Günter Smailus and Marcella Roba who represent Intensiv. Intensiv is a Swiss based company which specializes in diamonds, so who better to find out more about the use of diamond burs and everything to do with diamonds. It’s a very geeky episode, but I feel diamond burs and diamonds in dentistry, we use them so much, we rely on them so much. I think it’s worth an episode, it’s worth discussing about different diamonds in dentistry.

I have no financial interest with Intensiv, this is not a sponsored episode. But this is very much for the pursuit of knowledge and disseminating information to Protruserati, i. e. you guys, and making everything to do with diamonds clinically relevant.

Dental Pearl
The Protrusive Dental Pearl I have for you is when you’re cutting off a zirconia crown. I know that dreading feeling, that anxiety you get about drilling off zirconia crowns. And the top tip is, do not be tempted to use a coarse or a super coarse bur. Maybe you know this already, but actually when you use a coarse bur or a super coarse bur on a zirconia, you are not being efficient. You will be slow and it will generate too much heat.

Instead, go for finer diamonds, go for standard blue grit or go for even red grit diamond. You will actually end up being more efficient at cutting that zirconia. To find out the scientific explanation of why this happens, you’ll have to wait till the end of the episode to find that out. Let’s join now the main interview and I’ll catch you in the outro.

Main Episode:
Günter Smailus and Marcella Roba, welcome to the Protrusive Dental Podcast. I mean, for those of you listening right now, Günter is this tall man wearing this lovely red bow tie and in a slightly difference in height, but probably just because Günter’s so tall. We have Marcella and they’re both looking very slick and they’re joining us today from Switzerland. How are you guys?

[Marcella]
Thank you very much. Doing great. Thanks.

[Günter]
You’re great on the sunny side.

[Jaz]
Well, I’m fantastic. I’m really looking forward to a nice geeky discussion about diamonds, because as I was telling you before we hit record, trust me, no matter what you think. When we qualify, we know nothing about the bur codes, about which diamonds indicated when there’s little intricacies.

I think this would be a nice geeky chat and there’s a lot in there for any dentist, because we rely so much on our tools. We rely so much on diamonds. And we ought to know a little bit more and this will actually, I think, make us better clinician. The most frustrating thing ever is when you’re drilling a tooth, removing caries, right?

And things are going slow. And that is not only damaging to the patient’s pulp and the tooth, but it’s also losing us money because time is money. So there’s so much we can gain from this conversation by using the right materials in the correct way. And diamonds are a big part of that. Before we delve in deeper, Günter and Marcella, please can you tell us about yourself? Günter, let’s start with you. Tell us about yourself.

[Günter]
Okay. My name is Günter, as we said. I’m in dentistry since more than 40 years now. Let’s say I grew up in dentistry. I’m running this company and the third generation, the company that was more than 80 years on the market. And my background is not dentistry, my background is economics.

So I get it. I’m running the company here with 45 people. And as I said, the third generation and I took already 20 years duty and still I have to do one other 10 years because the first one gets 10 years, 10 years, 30 years, and then myself 30 years or 90 years is my goal here.

[Jaz]
Very good. And Marcella, tell us about yourself.

[Marcella]
Hi. So I’m Marcella and I come from Italy, but I live here in Switzerland. I’ve been working in Intensiv since 11 years now. I started off as quality manager and now I’m responsible for regulatory affairs. My background is biomedical engineering and surface science, and I’m in this field since, yeah, 11 years.

[Jaz]
Fantastic. And I first met you Günter recently, in Valencia. I know we saw each other online and stuff, but we saw each other in Valencia. We did a really cool IPR workshop working with the Swingle and that’s creation by Intensiv. So, before I discovered Intensiv diamonds, I just saw, oh, the Swingle.

And then I discovered that, oh my goodness, Intensiv is this huge brand in diamonds and burs and stuff. And so that kind of came to me like, whoa, that’s so fascinating. In terms of the range of products that you guys do. So you are in a great position to teach us about diamonds. And what I like about you Günter is when I had that chat with you in Valencia planning this, the position you came from was very much education.

Let’s educate the dentists about diamonds and stuff because it’s an important topic rather than from a commercial background. Yes, you represent Intensiv. Yes, you own a company. But you were very much on board that yes, education, education is so important. And I saw that in action teaching with you in Valencia.

That was real good fun. And there was so much I’ve never seen anyone. I told you this. I’ve never seen anyone plan a lecture minute by minute by minute. Please. I was amazed. You literally made all the slides for me. I just had to enter my photos. That was fantastic.

[Günter]
Yeah. And then growth by growth almost.

[Jaz]
It was phenomenal. It was a lesson on leadership as well. So I admire you as a person, as a leader as well. And it was great to have some good food and drink with you there as well, but getting back on topic. Okay. Where do we start? I think we should start here, right? Basic, basic, basic bur codes, right? So when we are using, let’s say a bur for a crown preparation or a round diamond, for example, to remove some caries, can you just tell us about how the bur codes, the system of naming a bur?

[Günter]
Okay. The system of the bur is historical. Historical because in the beginning, when it starts with the burs, we had only let’s say five or seven different forms. And I just said the ball, the cylinder, or as you see here, the football or the egg, we had only five or four. And they said, then this is 800, this is 801, this is 802.

And then they start creating more and you say, okay, did you call that 023? And this is called size 010. So it is a really grow up, step by step. And we still orientated on this. Standard codes for the different forms in total.

[Jaz]
So that’s the first part. So like a bur code is actually quite a long number, full stop, long number, full stop. So that’s the first part. The first part describes the shape.

[Günter]
That’s right. That’s the shape. But you’re referring now to the number, which is called ISO number. The ISO number is something different. This is complicated stuff because this is almost 12 different digits. And they start actually not with the form number, they start with the shank, if it is in friction grip or the low speed bar, which you have in the contra-angles, that’s a little bit different.

[Jaz]
So the friction grip is 314, from memory it’s 314, right?

[Marcella]
Friction grip is 314 and 204 is the RA. So the right angle, these are the most common, let’s say, so yeah.

[Günter]
I believe me, even if we start teaching, we talk about that since the decades already and dentists, they’re never aligned to the ISO codes. So we do have some companies in the sector that have the ISO codes. Intensiv, never jumped into the ISO codes. We do have the standard form numbers, which we follow, which is a very easy to learn, and then we have our own article numbers. There are companies outside, they have their own article numbers.

For example, when you see this thin bur next to me here, the long one, this one, this is called, well, that’s a D6. Just a D like Delta and then six, that’s easier. So we try an Intensiv to bring barcodes more closer to the customer, making the ball is just a 200 or 199 or 201. It’s more easier, more easier for the assistants instead of having the 12 digit number, because they can error very easy.

So I can tell you, I must tell you, all students, it’s almost better to start with the form numbers and then getting the idea of the different numbers from the industries, because in the industry, they do a lot with ISO codes. None of them works with ISO code. This is something which has been invented sometimes and then was never really followed because there’s a reason behind it.

Just guess just if we would use the ISO code and my colleague my competition would use the ISO code for the same instrument the ball there would be a confusion. Because if I don’t say this is the Intensiv ISO coder, this is the Komet ISO code, that’s not possible. So the ISO code makes a reunification of one Industry, but it’s not we have very many industry and we differ a lot. So one of them could use a different setup from the other one.

[Jaz]
That’s a really insightful and just to talk about that difference. So it is an 802 with one company, the same as an 802 with another company.

[Günter]
The phone number. Yes.

[Jaz]
So it would describe the same shape.

[Günter]
Yeah, the shape. We have about one of the different shapes in the line. And even our competitors, they have, it’s about 100, some they have 90, some they have 110, depends what you define as a shape or a different shape.

But these numbers, they are common. They are common because they are historically grown. And then we have it called the article number or the reference number, and everybody is free. Everybody is free to choose. His own reference number and Intensiv being 80 years on the market far before ISO came in place, and why should we change our article numbers because generation of dentists, they know that this wonderful diamond here is called D6.

So when we start making a 12 digit number for that article, we would lose a lot or they would not cite of that anymore and they would just send it out and they would get from any industry something because they have the same ISO code. ISO code is just telling you this is the length, this is the form, this is the grid size. And that’s it.

[Jaz]
You were pointing to the red grit diamond behind you. So let’s talk about the different colors. If you just describe, do they like K files, for example, they follow ISO colors, basically do diamonds generally follow the same coloring system, i. e. white would be the finest and going up to green and black.

How many different grits of diamond are there and is this standardized? So is a green grit with one company, the same as a green grit in another company? So I want to know that as well, but just give us a little overview flavor of different coarseness of diamonds.

[Marcella]
Yeah. So yes, the colors identify the diamond crystal grain sizes, and they are given by standard. There is an eyes of standard, which specify which color corresponds to which range. In the eyes of standard, there are six colors, which identify a certain range, which is quite broad. Here in Intensiv, just to give an example, we range from finer diamond grain sizes, which is 8 microns in orange, and then we go up to the 150 micron grain size of the diamond crystal, which is identified with the black color which is the super coarse, let’s say, and then there are all these grains in the middle.

So the standard gives six color specifications. What happens here in Intensiv is that we follow the standard, but we also have more colors because we have a special feature. Maybe I could start mentioning something about this now, which is about the dimension distribution of the grain sizes in a lot of diamonds.

So here at Intensiv, we have a very narrow distribution. So if you think of the Gaussian distribution curve, which shows the percentage of diamond crystals inside the population, which have a certain size, the Intensiv Gaussian distribution of its diamonds, it’s very narrow and tall, meaning that, for example, if we’re talking about a 40 microns, a really high percentage of diamond crystals in this plot, they are actually 40 microns. And you have a very, very small percentage, which differ and are a bit lower or a bit higher.

[Günter]
In other words, ISO says, okay, if you have the red ring, that gives you medium, medium grit size and the code then for 25 to 60. So the grade coarse goes from 25 to 60, and in the middle you got most than 40, but you have 25 and 60. Intensiv, they have 25, we have 40, we have 50, and we have 60. So we have instead of one red, one for all four, we have four different ones because we are able to get that crystals much better sorted.

[Jaz]
Are there any advantages? So, for example, if you have a bur that’s red grit and it has some percentage 25, some percentage 40, some percentage 60, how will that result in a clinical difference to a burr that has just 50, for example, throughout?

[Marcella]
Maybe, yeah, so if you have a bur, which is very precise, it’s in its distribution. This is fantastic because this means that you are very precise and very efficient with your cutting with the abrasion performance. If you have a bur where the distribution of the diamond crystals is not so precise and it’s broader, then you have a high percentage of crystals which are lower in dimension.

This means that the bur is less efficient and then you have also a high percentage of crystals which are higher in dimension. This means that the surface is not As smooth as it should be, because maybe you have some cuts and some scratches given by these bigger sizes of crystals. If it is very precise, you don’t have this problem. Efficiency and precision.

[Günter]
This is especially valid for medium and fine grit because of the scratches. If a dentist relies on a red ring bur, they say, okay, this is medium. And they find two, four, five, ten crystals. I enlarge it in, they get scratches on the composite fillings. And that’s always bad, you know that, they take this and that, smoothen that, another rubber polisher to get it smooth because a scratch on a filling is always bad that bad notice, so with Intensiv, we guarantee that there’s no scratches. Absolutely not. When it comes to-

[Jaz]
It makes sense. And I imagine if you were to blow it up and zoom in on a scanning electron microscope, you would see that difference based on uniform, grit versus a variable grit. Just give us an overview if you don’t mind both of you on when bur producers are making different grit burs.

Just a classical indications. For example, when I’m finishing a composite, I might like to use a red or a yellow. When I’m preparing, I’ll pick up the blue green or when do you recommend the black? What is the indication for the black, the super coarse one? I don’t see many of those burs around. Is it because they’re more expensive or is there because there’s not much use in dentistry?

[Günter]
Well, there are not much use. Let’s say that, in the past we had a tendency to the coarse grits because the speed of the turbines, everything was not that good developed and dentists tend to get coarse grits to get the job done as you said before. We count in minutes maybe five or ten minute blocks. I would like to get that preparation done so when they choose when the dentists choose the one the 150 or 125 black or green marked grit they get it faster done, of course because of the corset grain. But it is some kind of traumatic as well for the tooth because it’s really rough that get some cracks. It is a risk of cracks, and you know what a crack mean after 10 years. And that’s why we from Intensiv, we recommend for preparation, the blue one, the blue is 80 micron.

It’s wonderful. Today, it drove by electric tow bike. Red ring is a constant 200, 000 or 160, 000 tons a minute. And that’s wonderful. That’s a wonderful job. The actual bike, I understand that the actual bike, you tend to get that coarser because when you press, you come down from 200 to 100, 000 or 80, 000 turns because you’re pressing, you’re blocking that air system.

And that’s why the trend with the red ring contra angle. It comes more and more to the smoother grains like 80 or we call it standard grain means silver, no color on the bur. And that’s, that’s, I’m happy to see that I must tell you, after all that years being in the sector, I do not like the cost first.

Because even for the patient, it’s really tough having that vibration because they’ve got a lot of vibration in the jaw, and that’s not comfortable. So I always teach dentists, especially young dentists, start with 80. You’re good enough. It’s fine for abrasion. So when you start abrading something, take the 80 micron, the blue ring, and then right here, you can take them the 40.

For the red ring for shaping and then the yellow one for finishing and polishing. We have then in between the 60 micron, the gold bar, we call it gold ring, gold bur. And this is more something in between. You can guess it. That’s 80, that’s 40 and we have 60. Guess what? Veneer preparation, we’d like to have a minimal invasive prep done, just a little bit, maybe partial just a little bit, so we take the 50 and that’s it, we just start with the 50. We do not need a smooth surface for that because we have some adhesion and then that’s why we have that medium grits in between.

[Jaz]
Very good. And I think the next question from this is when we are looking at the different types of burs, because it makes sense to me why there’s so many blue now that I see because your answer just answered that. But now we’re seeing also some clinics that are using the disposable one time single use diamond.

So I would love to know when I speak to some clinicians, they say, I am a prosthodontist and I need to prep quickly. And so I don’t want to use a diamond that’s already been used because the efficiency is less. So if I’m using single use diamonds, yes, it might cost me initially to open the packet.

And this is single use, you don’t get to use it again, but because the efficiency benefits it gives me, they prefer it. Do you think there’s any truth to this? Do you have any opinions or arguments in terms of, okay, what is better for a clinic? Or does it depend? Is a single use better or something that is a multi use like we traditionally have in clinics?

[Günter]
We would say that the single use is probably, if you’re in the high performance, it’s good for a very short job. Let’s say if three minutes or five minutes separation, that’s okay. But then the performance starts going down. So in multiple use bur, they have much longer performance.

From Intensiv, you can easily count on 30 minutes performance. So just guess, making a crown preparation and choosing a single bur half of the job or quarter of the job, you need to reload a new bur. Then you get the second bur, then you reload again and get that bur you know, that’s what we know, that what is feedback from our clinicians that the single bur drives me crazy because I have to reload always because they get weak very fast.

The multiple job bur gets works much longer for longer jobs. For the shorter jobs, of course, it’s wonderful because we have multiple use. You would name the cost, single burs. I always tell dentists when they come to me and tell me why I’m taking seeing it, but cost only $1 that you’re very rich, you know, we are really rich because a multiple bur costs you $10 and use it 20 times. So you pay half, so okay. I didn’t know that. And maybe sometimes people then do not make really calculation what it means having a single per year, maybe the one cost, maybe good.

[Marcella]
Then I’ll supply it by all the time you need to get a new bur. And another thing is that the feedback we have from our doctors and clinicians we talk to, we feel that multiple use is still the major direction that dentists are going towards.

And for various reasons what Günter mentioned now, but also, the fact that to have a sustainable, just single use on the market industry is not ready yet. Because this would mean a lot of raw material. Think about all the burs that we need to multiply by 10, 20 in comparison to what is already now around. There might be in the future, we don’t know, maybe for regulatory reasons, some pressure worth to go in that direction. But, not so far.

[Günter]
Not seen on the horizon. Nothing seen. And we see some trend in some countries, especially the United States, the United States, you may divide already a little bit half of them, they’re using single coarse, but not really single, what we know is they take it a second and third time, and then the other one, they take the multiple ones.

What Marcella said is about the industry, it’s right, if you would guess 500 million words per year in production worldwide, just the guess, I don’t know that this is exact, but more or less it should work. And then you multiply that by 10. The industry is not ready.

We do not have the capacity to do that. And the other point is we can’t get the cost down, you know. What I have heard from many friends from myself is that they say, you know I would go for single bur if I pay 30 cents or 40 cents per bur. It makes sense to do that, I say yes, this is probably the multiple bur cost by time. It’s okay. But yeah, we have metal as raw material. We have diamond crystals. It’s not feasible. The raw material doesn’t deliver that cost. It’s simply not possible to do so.

[Jaz]
I bet that most of the Protruserati, our colleagues listening and watching today did not know that a standard bur should be used for 30 minutes before it starts to lose its cutting efficiency. So, I will include that as one of the questions in the quiz for the certification at the end. So for those listening, watching, remember this answer of 30 minutes at the end. And I think, you know what? There’s always a role of something, right? And I do think that perhaps the kind of environment where the single use could be beneficial is if you run an emergency clinic.

And trying to disinfect things is maybe a bit more difficult between patients. And you need to literally go inside and get to the pulp and put some medicine in and that’s it. And you’re just drilling time is two, three minutes only. That might make sense in emergency clinic. But for someone who’s doing preparations and crown preps, it makes sense that you get more, a better cost effectiveness of using a more traditional bur.

Now, when we are talking about cutting efficiency and time of cutting. Basically, you mentioned something very interesting at the Valencia lecture, and you meant you were talking to the dentist. You were saying that your diamonds are I think you used the word natural. Is that right? Your diamonds are naturally sourced.

And later I asked you is I have no idea what that means. What’s the difference between naturally source and what’s the alternative. So teach us about where your diamonds come from and why is that significant?

Interjection:
Hey guys, it’s Jaz. It’s interfering to ask you, have you joined Protrusive Guidance yet? It is the community, the nicest and geekiest dentist in the world. We have kind of geeky discussions just like these. We talk about cases, we talk about clinical techniques to improve our success and ultimately benefit our patients. We do manually verify that each person applying to join the community is a dentist.

So we will ask for certification and we will look you up. So bear with us in our manual verification checks, but this is super important to create this a safe and thriving network. You can access on your laptop or your phone by going to protrusive. app. That’s the website, or you can just download it on iOS, Android by typing in protrusive guidance. If you love Protrusive, you’ll love Protrusive Guidance. I hope to see you there. Let’s join back to learn more about diamonds.

[Marcella]
Yeah, I can start. So, first of all, diamond is the solid form of carbon in a crystal matrix, okay? So, it, in nature, it is produced over time with extremely high pressures and extremely high temperatures down underneath in the earth mantle, 150 to 250 kilometers usually.

And in billion years they develop and then after volcanic eruptions, maybe they come up third phase. They are brought up by the volcano and then they can be harvested and then they can be used .So, through this process you get a natural diamond, which has a very unique feature. Well, in general, diamond is the hardest material on earth, and so it can basically abrade any surface, any material.

This is why it’s so important in dentistry. And also, the diamond crystals are very irregular, and they have sharp edges. And these features make natural diamonds perfect for doing this abrasive job in dentistry. I don’t know if you want to add something.

[Günter]
Maybe the audience may be interested how we get that, how we get that small pieces, so that’s in it. We do not take this one, the brilliant, no, no. This is for jewelry. Everything what is found larger than a millimeter or two goes to jewelry. We get these piece of very, very small crystal, like a sugar crystal, or even less, more than a little bit crystal.

And this you find in the sand of the desert. For example, in the desert of the southern Afrikan part, it was million of years, this was volcanic area. There’s a lot of diamonds, the most diamond mining is in that areas. And they find it in the sand in the sea sand in the desert sand. So let’s take 20 tons of sand filter that and get then the crystals out, the small small 1%. This is for industry a big profit from this we get it from this. Then these are sorted out in different microns, we take out all the 14 microns all the 16 microns. And as Marcella said, we are very good at making the sortings, the sorting of it.

The other companies, they say, okay, ISO allows me to get a broader range, so I can make a more or less sorting, and Intensiv would take a very precise sorting of these crystals. But interesting is that we take it really from nature. Industrial means that they just take carbon, put it in the oven, making heat. Making pressure and get it out some hours later. So the difference is millions and some hours, and then that’s-

[Jaz]
And so how does that relate to the, is that actually imparting difference in the quality of the final product in terms of the cutting efficiency, this in the oven, a couple of hours versus millions of years. Is that actually a difference?

[Günter]
Well, we would say, yes, there is a different, especially in the shaping and in the pureness of diamonds. When you get that naturally done, you need to get forms for that. And you need to build that into forms. Normally they use metal forms. Then all these diamond crystals, they have metal substances in.

And you’re taking the bur on 200, 000 turns per minute, and with the metal substances you get heat. You have much more heat and with the diamond crystal from nature, it has nothing just carbon. And although that that’s one of the major difference in using the heat, the cutting, the performance of the diamond is different.

You can take the natural diamond is probably more compact than the crystal of the industrial diamond. So when we say to our dentists, they say, sometimes the diamonds are smaller on the bur. No, no. It’s not, you’re just seeing the diamonds deep into the matrix. You just see the iceberg, not really the diamond, the other diamonds, which has been before on the earth, they’re gone, they’re off, they’re not used up, never a diamond, the natural diamond never used up, they won’t break.

[Jaz]
And so I guess the next logical question is how are the actual diamonds fixated to the metal shank? What’s the technology used to actually put the diamond on the metal?

[Günter]
That’s something for Marcella.

[Marcella]
I can try to explain. So we use the electroplating technique. This means that we have a special electroplating containers containing the liquid for electroplating. And then we have diamond crystals inside this liquid and of course we have our instrument inside as well which needs to be coated. So the electroplating starts, we have metallic ions, which are deposited through electroplating on the surface of the bur, and as they deposit and they form a metallic layer, they embed the diamond crystals, which are inside liquids.

Now, to give you an idea, maybe it would be nice to have a picture, like an image in mind. So, we can think about a nice mountain lake, for example. So this lake has all sorts of parts, pieces inside, wooden pieces, for example. Yeah, they’re floating on the surface, or maybe inside if you’re soaked with water.

What happens when winter comes? So the lake, the water freezes, and as it freezes it gets harder, and these pieces which are embedded inside, they get fixed. They are stuck inside the frozen water. So you can think of the diamond coating on a bur just as this mountain lake. So the frozen water is like the metallic matrix and the wooden pieces inside are like the diamond crystals which get fixed, embedded and fixed and hard, very, very hardly stuck inside the metallic matrix. And I hope this maybe was a nice picture to imagine how the process works, but the official term is electroplating.

[Jaz]
And so when we’re using these burs, and they are losing their efficiency, so let’s say we’re getting to a bur that’s been used for maybe 40 minutes, beyond that 30 minute, is the diamond, and maybe you’ve already mentioned this so I apologize, but is the diamond actually becoming smaller, or is it becoming less sharp, or is it actually breaking away from the metal? How is it losing its efficiency?

[Marcella]
The diamond is staying exactly the same. It’s not getting smaller in shape, it’s maintaining its sharp edges. It’s just the fact that it’s been released from the matrix.

[Günter]
Break out.

[Marcella]
It breaks out.

[Günter]
Yeah. It breaks out with the time. We have an outbreak already in the first minute, because we have some always on the shank, which is not anchored that much into the lake. In the frozen lake, let’s say, and then there are pieces that are much deeper into the frozen lake, it’s half in or two thirds in, they stay down there. So then you can estimate that at the end, you may believe that they are used up or gone bad, you’ll see only the small tips out of the frozen lake and then the hot the large pieces inside. So because you can’t use up the nickel matrix, oh, that’s not possible. You can’t get the other ones, the ones and the nickel markets inside. They’re gone They are in.

[Jaz]
This is when we’re looking at a bur that we’ve used for a long time, we see that the color, there’s almost like a color difference, right? You’re seeing more metal show through. So my final question is a very clinically relevant one is the following.

And we have this problem in our practice where we use burs that go to the autoclave and they come back and we have these certain bur pots and all the dentists use them. And the most frustrating thing as a dentist is picking up a bur and it’s no longer fit for purpose or already been used too much.

And I hate that so much. So I’m very hot on, if I see a bur that is a bit knackered because look, the bur does not tell us, oh, I’ve been used for 27 minutes. I’ve been used for five minutes. I’ve been used for four or five days. We need to look and guess. And so can you give us any clues for our dental assistants, nurses, and dentists, when we are looking at a burr, how much magnification do we use, what are the telltale signs that maybe it’s time to order a new bur?

[Marcella]
So I can mention maybe about the signs, which allow to understand if a bur needs to be replaced. When you see that, if it’s totally metallic in color, you don’t see any more diamond means that it’s totally worn out. When you see 50 percent of diamond coverage, that means that it needs to be replaced.

Half, more or less half. This means that it needs to be replaced. I would say that. May I add also another thing that if the bur looks white, then this means that it has enamel or ceramic debris clogged or composite clogged. And so maybe, okay, it’s not no longer efficient. The doctor tries to use it and has to apply a lot of pressure to compensate.

It looks like it’s no longer working. And it will give heat, exactly. But the only thing is that it needs to be rinsed. And cleaned, and this debris and clogging removed. To resume it, to make it proper.

[Günter]
Never accept the white bur. And should never accept the silver bur. And absolutely hate the black bur. Because when the bur comes, black is burnt off, that’s gone, ultimately gone, but if you arrange between white and silver, it’s really good to tell the assistants, if you have a white bur, clean it until you can’t see any white spots on that, because we do not need them.

It’s from the patient before and then the other one is if you see less than half average, take a new one in my bur block because it’s better for me, with the half coverage, I can’t work anymore. So it’s-

[Jaz]
I like this guideline of a half coverage. So this is a visual inspection that we do. I imagine it’s better with magnification, using loops and having a good look and seeing, yes, what kind of coverage there is. I wish there was like a quick test that you could do like, okay, yep, this is gone. This is not, but we have to rely on visual and hopefully before we start using the bur and realize that way.

[Günter]
We have the same wish, the same wish. So far we haven’t find the right feasible technique because it’s too much reflecting. The diamond is transparent, the metal is reflecting and whatever we try to do, it doesn’t work because it gives us different results. And, but anyway, what is properly nice for the office, for the assistant in the sterilisation room, you place some two photographs, the good one and the bad one, the half coverage and the full coverage.

And they said to their assistant, when you see that with a half coverage, that’s gone. Whenever you see close to what I see completely, leave it, place it again, please. So to support that with the picture, because people love picture like this.

[Marcella]
People love picture.

[Günter]
Just telling them, look, is this half? I don’t know. Maybe just start this one. I don’t know.

[Jaz]
Comparison photo makes a lot of sense. If anything, someone’s going to be a superstar. Here’s what they do. They get a brand new bur photo and then they use it for like one patient and then they can photo, and then they use the second page, take it to photo.

And then they have a series of the same bur. That would be, then you’re like the nurse kind of charting it. Like, where is it? Like a scale. That would be cool. Maybe you have this photo already and you can send it to me.

[Günter]
We haven’t done that yet, but we could make it, but please, there are more parameters, not just the usage, you know. I must admit that the 30 minutes with a status, it’s variable. There are dentists, they have good muscle. They are, right, strong, and they press. And then the 30 minute goes down to 20, because the burs goes off easier, because you’re pressing too much. Then there are very feminine dentist, they have a soft plan, very nice, very sensitive, they even give you 40 minutes, no problem.

[Marcella]
It’s actually the diamond which is doing the work, the creation, not the strength. So this is a very important concept.

[Jaz]
And the other thing to bear in mind here then is depends what you’re cutting, the substrate. Like if you’re cutting soft caries, that’s not going to do anything to the diamond. Whereas if you’re cutting ceramic and metal and you’re removing all, you’re cutting old crowns off and you’re having to work hard, that would obviously reduce that time. Is that a fair statement?

[Günter]
That’s absolutely correct. The most worth is zirconia. Zirconia is the most worth for diamond burs. Then we come really in the multiple yield bur becomes a single yield bur because of the material. However, industry is especially intense that we place a special bur for that with a special coating, a special extra coating to get the bonding better done. Because the key for zirconia bur is to leave the crystals in place. That was our goal and we found that after years of testing we found the bonding, which is more expensive of course, but it works much better to cut zirconia. So many dentists-

[Jaz]
I’ve heard and I’ve tested as well that a red grit or a yellow grit diamond is going to be better and more efficient at cutting zirconia. And, but yes, you’ll need to use a few of them than using a coarse burr to cut zirconia.

[Günter]
Of course, because the coarse is clogging, the coarse is clogging. In fact, in seconds, the fine grid, you must just imagine that’s fine or medium grid. You have many crystals on that piece. And the part in between the crystal is not that large. If you have larger crystals, automatically the path between the crystal becomes larger. But there are large neighbors, the neighbors.

So that’s why the coarse ones are clogging much faster than the fine ones and the medium ones. You’re absolutely right. We are from the industry, we say the blue one. The blue one is the ideal one to start cutting zirconia. Oh, it’s good. And double water. Double water helps because of washing of the instrument. Yeah, the rinsing is really important. And then for secondia, just have an extra water supplied. It works better. It’s not because of the heat, it’s because of the cleaning.

[Jaz]
That’s very helpful because often in this scenario, we may need to cut off a zirconia. I personally have been using red grit diamond with good success. Yes, I’m able to use two, but I’m much quicker. Yeah. But if I change that bur quickly, I can get the crown off sooner than if I use, like, if you use a green, like just like you said, it makes sense. Like it’s too coarse. The clogging is happening. So, you’ve given a scientific reason for that.

So I appreciate that. That’s all the questions that I had. Is there anything else you’d like to add that dentists should know about when working with diamonds. Like we covered a few important working tips, like, how to recognize when the diamonds worn out a few little tips about to think about the minutes we learned a little bit, a bit more about diamonds in terms of how it’s made and how it’s affixed to the bur. Is there anything else that you think educationally we should know?

[Günter]
Yes. We have many different sizes in the bur, the bur line. So many days that they ask and say why do I have a long cylinder short cylinder and so on and this is because when the time of burs used you better use a full surface of the bur.

Never use only the tip or only the middle part, you know. That’s not good for the bur, it’s not good for the tooth. So, whenever you have the application, watch on the tooth. The tooth at that size, then choose the right dimension of the bur for that, to applicate the full bur on the tooth.

When we have the occlusion to be done here, larger occlusion, larger egg. Smaller occlusion, smaller egg place. So, it helps a lot, because the burnout of the bur-

[Marcella]
More uniform.

[Günter]
Yeah, more uniform. The other one is, never use a bur for Endo, Exos because then you just get all this, I thought it grew out to make it old.

[Jaz]
So basically don’t use the standard crown prep bur that you rely on for making your margin for the endo access. Because yeah, you’re right, because we look at these burs and 99 percent of the bur looks amazing. And the most important bit, the tip is looking like pretty much metallic, the diamonds are gone and that’s not very good either.

[Günter]
Yeah, that’s right. That’s my addition here. Yeah, that’s right.

[Jaz]
Very useful. Very helpful. Günter and Marcella, thank you so much for your time. I appreciate learning about it. Please tell us more about dentists who want to start looking into different diamonds, your brand, how is it distributed? Where can they get in touch? Learn more about Intensiv. You obviously look after your product very much, your brand very much in terms of the quality of diamonds that you produce. I use your Swingle a lot in for IPR, as you know. Which is why we did the workshop together as well. But tell us more about how dentists can learn more for you guys.

[Günter]
Okay. Mostly dentists can learn on further education courses. We do support a lot of courses from university, from other institutes, but mostly dentists get our products in all markets through dental dealers. So we do work for dental dealer networks, like Shine Dental or Dental Director in UK or GACD in France or whatever, you know, name it.

But this is, we never sell directly to the dentist. However, we are in touch with dentists. We have a website, www.intensiv.Ch for Switzerland, and we get contacts to many dentists. So whenever dentists have questions, of course, they’re invited to contact us directly. We love that. We love to talk to dentists. We go on exhibitions every year, maybe 20 or 30 days of the year.

We are outside in exhibitions. We’re making ourselves a Congress in Lugano, which is a nice place to be because Intensiv is located in the south of Switzerland, in Lugano, in the Italian part. And we run a two day congress here every day, every year, with about 10 to 15 speakers from four different countries almost. And that’s a lot of things to get closer to Intensiv. And to learn more about application, about our instruments.

[Jaz]
I appreciate your time. And Marcella, you’re pretty much working full time with Intensiv at the moment. You’re a very scientific role. Thank you for your time.

[Günter]
Great. Thank you to the audience. A great thank you to you. You had wonderful work. Loved it. You are challenging us here a lot and look forward to getting more of that. Because it’s really good to get challenged and getting this discussion done. We love that. It’s nice.

[Jaz]
Amazing.

[Marcella]
So yeah, we look forward to more, hopefully.

Jaz’s Outro:
Appreciate it. Thank you so much. There we have it, guys. Thank you so much for staying all the way to the end. We now know why we should be using finer diamonds and not the super coarse diamond that you can find when you’re cutting off zirconia. And hopefully now we can actually be a little bit more astute when it comes to assessing our diamonds and knowing when it’s time to say goodbye and opening a fresh pack.

Ultimately, your efficiency will be better and you’re actually not heating up the pulp so much. I want to thank Intensiv for giving up their time, Günter and Marcella. And of course, I want to thank you, the Protruserati. You can get CPD. You can get 45 minutes CPD or CE credit and a certificate sent to you by answering our quiz on Protrusive Guidance.

There are hundreds of hours of CPD to be gained just from the episodes alone, let alone the premium content and the mini courses that we have on Protrusive Guidance. You can either pay monthly or pay an annual, and you get a bit of a discount when you pay annual as well. So if you’re not already part of the nicest and geekiest dentists in the world, do check out Protrusive Guidance.

And I thank you again for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Last Live Occlusion Course of 2024 – Book Now: https://courses.iasortho.com/courses/gb/occlusion

POV: You spend a fortune on a composite anatomy course and are excited to implement on Monday morning.

However, every time you apply those concepts, you end up drilling it away because it’s proud in the occlusion!

It essentially now looks like a tooth coloured version of the amalgam you just removed!

Your nurse’s eyes are like pools of fire – that’s half her lunch break gone.

This happens a few more times until you realise that you’re missing a trick…

Enter this podcast to save your career! 😉

Dr Jaz Gulati and Dr Mahmoud Ibrahim will teach you how to radically minimize adjustments on your daily restorations.

Key Takeaways:

Always check the patient’s occlusion before starting any restoration.

Utilize shim stock to ensure accurate occlusal contacts post-restoration.

Pre-op visual checks are crucial for successful composite placement.

Don’t compromise on the anatomy of the restoration for aesthetics.

Use thinner articulating paper for more precise occlusal markings.

Communicate effectively with your dental nurse about new protocols.

Involve your senses to assess the quality of your restorations.

Document occlusal marks pre and post-restoration for reference.

Adjustments should be minimal if pre-op checks are thorough.

Educate patients about their occlusion to manage expectations.

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

Highlights of this Episode:
05:24 Introduction – Dr Mahmoud Ibrahim
08:42 Posterior Composite
14:15 Shim Stock Foil
16:35 Effects of Numbing on Occlusion
18:23 Lower First Molar Example
22:06 Shim Stock revisited
26:22 Lateral Excursions
30:32 Fissure Staining?
31:56 Old Restoration as a Guide
35:33 Restoration Techniques and Adjustments
38:03 Tips and Tricks
43:28 Event Discussion
45:09 The Importance of Marginal Ridges
46:25 Anatomy or aNOTomy?
48:17 Post-Op Checklist: Final Adjustmentsand Polishing Tips
54:19 Wrapping Up: Using Your Senses in Dentistry
56:43 Outro

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance App.

This episode meets GDC Outcomes A and C.

AGD Code: 250 Operative (Restorative) Dentistry (Direct restorations)

Dentists will be able to:

If you liked this episode, check out: IC046 – 4 Ways and 6 Great Reasons to Document Your Dentistry

Teaser: The cuspal inclines and using visual references that I take before I prep the tooth. So I'll look at where the marginal ridge is compared to the base of the cavity. Where's the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. The angle of the cusp is probably, for me at least, one of the most important ones.

Teaser:
Some patients are like princess and the pea, whereas other patients are like everything feels amazing. And the very last thing you check is how does that feel? That’s like the last. Why are we getting patients to feel their bite?

They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say, how does it feel? How does it feel? They’re feeling their bite. Something that really should be not really present for them, if you like.

Once you get quicker and slicker, I would urge you to start checking front teeth as well. Because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock. And I think you’ll be surprised.

Jaz’s Introduction:
So you go on a posterior composite course, you brush up on your anatomy and you’re excited to place posterior composites that actually look like teeth instead of just white amalgams. And so what happens is that you have like the best fun ever, trying to create all the fissures and the inclines and anatomy. And with rubber dam on, you take that photo and you just stare at it for five seconds and you think, yeah, this is a work of art. I’m going to post this one on Instagram. And then you already know where I’m going with this.

You already know what I’m going to mention next, which is you take off the rubber dam and you get the patient to bite together. And literally like the bite is so open, right? You have to get the big bur, right? You have to get a big bur throughout and just grind away all the anatomy. Now you have a white amalgam left.

Obviously, it’s composite, but it’s now flat. It may as well just been a white amalgam. All that fun you had was wasted and you’re getting evils from your dental assistant because you just wasted up to anything up to 20 minutes. Earlier in my career, it could take that long to get the bite right.

And you think, wow, what a waste. What a waste of time to doing anatomy. What a waste of clinical time. What a waste of my DA’s lunch hour. And this is not profitable. This is not fun. It’s depressing. So this is why this episode will give you such a good framework to eliminate or at least significantly reduce how much adjustment you have to do for your composites.

So they can still look good. Like I’ll be honest with you. Sometimes you just can’t do a beautiful composite in that scenario, because guess what? All the other teeth in that arch are quite worn and you can’t give a 70 year old a 12 year old’s tooth. But in our daily scenarios, we give you some really tangible pearls and tips and technique advice to reduce the amount of adjustment, be more purposeful in your composite placement, but still take some degree of pride in the anatomy that you’re placing.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re a regular watcher or listener, please do hit that subscribe button. You’ve been listening to us for so many years, you might as well give us some love. And if you’re new to the podcast, definitely hit subscribe because you don’t want to miss another episode and you want the algorithms to show you all the other episodes we’ve done over the last six years.

This is an important episode because this is episode 200 of PDP as a podcast we have almost 300 episodes including all the other branches of the podcast we do. But in terms of the original PDP it’s such an exciting number and I’m especially grateful to about five to eight hundred of you who’s literally stuck by me from episode one.

So when I used to make my first 10 episodes, so there’s about five to 800 people that would listen to watch full stop back then we were audio only. And now I look at the numbers and it’s amazing. We are a top 1 percent podcast in the world, in any genre. And it’s thanks to you guys sticking with Protrusive, the feedback and the guidance you give me, to allow us to make great content. I’m not going to take up too much time. I just want to say thank you again for being a Protruserati.

Dental Pearl
Now every PDP episode I give you a Protrusive Dental Pearl. This one’s regarding our basic posterior composites. So it’s very much in line with the theme of today, getting the occlusion right in your posterior composites, but actually this is due with cavity configuration.

We want these proximate exit angles, which are smooth and flowing. And so recently I posted a pre molar I did, and I was quite happy with the anatomy I achieved, and yes, it was perfect in the occlusion. And I posted my cavity prep on Protrusive Guidance, and I said, guys, please do critique me. Is there anything I could do better?

And despite me using an old science scaler to remove the Friable enamel. I’m using like a needle diamond bur just to smooth out those exit angles. One of the Protruserati Sai still said that, you know what, we can get this a bit smoother. Have you considered using a soflex disc? And I’m like, whoa, I use soflex discs all the time.

So at the end of every composite, I will always use a soflex disc. And for my anterior dentistry, I’ll reinforce my bevels with a soflex disc. I find discs great to get rid of the friable enamel, the unsupported enamel. But I did remember now that I’m out of habit of using these discs posteriorly at the time of cavity configuration.

I usually pick them up after I’ve completed the composite restoration. And so really it’s reinforcing what I re learned and reminding you guys that a flexible coarse disc used in the backhand stroke can really help you to get nice, smooth, flowing enamel, those lovely exit angles that we desire for our composite bonding.

So thank you Sai and thank you everyone who commented on that post on Protrusive Guidance. If you’re not already on there, it’s the home of the nicest and geekiest dentists in the world. There’s no such thing as a silly question. I’m really enjoying seeing the chat thriving and people posting more. Now we’ve already got six years worth of podcast data on there.

Plus all the feed posts for the last six months. And so the search function is so valuable. If you’re looking to learn something, just search it on Protrusive Guidance. More than likely, we’ve already covered some element of that before. Anyway, let’s join a familiar face, Dr. Mahmoud Ibrahim, to make sure you don’t have to remove the beautiful anatomy of your composites anymore.

Main Episode:
Dr. Mahmoud Ibrahim, welcome back again to the umpteenth time to the Protrusive Dental Podcast, my occlusion brother from another mother, as I say. How are you today?

[Mahmoud]
I’m good, man. I’m good. I’m feeling like a bit of part of the furniture now in Protrusive. So that’s a good thing.

[Jaz]
It’s a good thing. You’re an integral part of the Protrusive community. It’s great to see your minimally invasive Mahmoud Ibrahim, the Mimi cases on PG. You need to get back on those and your contributions. Like anytime someone asked, like Nabila was asking the other day on the community, can someone just explain to me like what different composites are out there and like which one should I use and stuff.

And I gave a little, I chimed in a little bit, but I was like, okay I’m going to tag Mahmoud and he’s going to take it away. And you wrote this beautiful like essay and when I say essay like not in a boring way like every sentence had so much value. So thank you for all that you bring in terms of from occlusion perspective and composite perspective. And so we’re marrying exactly those two themes together on today so we can help dentists to stop doing this mistake that we all have made, we all continually make on a daily basis, which is you place your composite.

This could be anterior, gosh I’ve been there, and this could be more commonly posterior, rubber dam or not, whatever, rubber dam police, pipe down for a second. You place your posterior composite, and it looks beautiful, like you’ve been studying the books, you’ve been going to some courses on anatomy, and you think you’ve absolutely nailed the three buccal cusps, the slopes, everything, the secondary and tertiary, the marginal ridges, everything and the patient bites together and you’re like, holy crud.

You now have to adjust everything away. And then by the end of it, it just looks like a squashed banana or something, right? And so it’s no good. But before we discuss these pain points and then more importantly the solutions, this is not like a clickbaity episode. We’re going to give you brilliant solutions that you can apply straight away and this is going to absolutely solve this problem.

So this hopefully will be the most career changing daily tangible podcast you may have ever listened to because we make so much of our income from just bread and butter direct restoration. So I’m hoping this will have a huge effect over those who haven’t. For some reason there’s the, like they saw the title, this is the first ever episode they’ve clicked on Mahmoud. Can you just tell us about yourself?

[Mahmoud]
Well, yeah, so my name is Mahmoud. I’m a general dentist. I’m nearly 20 years qualified now, like I said last time. And yeah, when you combine occlusion and composite for me, that’s where my passion lies, you mentioned the little essay I wrote. And honestly, sometimes I need to reel it in, right?

Like I’m sitting there, I’m trying to answer this question as comprehensively as I can, but I’m also conscious of like my wife shouting at me and kids are climbing up on my head, but yeah, those two things really, really get me sort of get the creative juices flowing and want me to give as much value as I can. And yeah, if you ever want to check out sort of what I do, I post a lot of it on Instagram, so it’s a DR M O I Dental is my handle, and you’ll see the kind of stuff I love doing. So day in and day out.

[Jaz]
I would put that in the show notes link because it’s actually a work of art, your resin stuff. I’m not anywhere near that. I mean, I like to get my primary anatomy, like my line angles and I’ve had a good day and my patients, my specialty is taking patients from a 3 out of 10 to an 8 out of 10 if on a good day. Whereas you’re like taking people from like 7 to a 10, which is a whole another skill. Okay, so kudos to you, my friend.

Guys, if you haven’t listened to any of Mahmoud’s stuff before, just go back, like if you’re on Protrusive Guidance, our app, just search, use the search function. We’ve paid a lot of money to developers to have that search function in there, I promise you. Okay. Hit that search button. Just type in Mahmoud and just binge on his posts.

But importantly, some of the previous episodes we did on like basics of occlusion stuff, he talks about his journey that you almost gave up dentistry, right? And what a loss to the profession and what a loss to my partner in crime that would have been had, had we lost you to the web development world or whatever it was at the time. But Mahmoud, let’s talk about this problem. Okay.

[Mahmoud]
Sucked at that too much. I couldn’t do it.

[Jaz]
I’m glad you managed to reel back into dentistry, my friend. So composite, where do we even begin to discuss this mammoth topic? Let’s just describe, paint the picture, okay? Let’s start posterior, because I think there’s different strategies and tools we can use, posterior and anterior.

So let’s start posterior. Occlusal restoration, okay? What do you think is the first thing we should do, okay, because I’m already hinting at the fact that, okay, it all starts at the beginning rather than after you place your composite. How can you do preempt this and actually solve this issue before you’ve even done anything to the tooth?

[Mahmoud]
Well, we always talk about the fact that 90 percent of our work is conformative dentistry, meaning I’m not going to change the patient’s bite, right? I want to keep things the way they are. You give a lovely, lovely analogy of a kid trying to get a cookie out of a cookie jar, right? The idea is you don’t want to leave any trails.

You don’t want anyone to know you’ve been there, but in order to conform to something and not change it, you need to know what was there before. So the first step is always going to be examine the patient’s occlusion before you pick up a handpiece before you numb them up, okay? And generally speaking, actually it’s something I do when I’ve decided this tooth might need a restoration, right?

You’ve diagnosed the caries, you’ve done your bitings or whatever it is, right? And it’s at that point that I’ll also have a look, just get the patient to bite together. I’ll just have a look, you know? Early on in my career, this has happened a couple of times where I’ve done the restoration and then I get the patient to bite together and then I realize they don’t have an opposing tooth. And then you’re like-

[Jaz]
Been there, been there.

[Mahmoud]
I feel like an idiot.

[Jaz]
I think we’re all smiling because we’ve all been there.

[Mahmoud]
Yeah, yeah, 100% happens and you’re like, hey, easy day. So, but yeah, just check what it was beforehand and we’ll go through sort of the steps, but that’s where it needs to start.

[Jaz]
Now on this point, cause it’s so, so important, this aspect, and it sounds like simple. It’s like, oh, I’ve heard this before, but so many of our friends, our dear friends, our colleagues are just not getting into the habit. All it is, is a habit. Once you do it for 21 days in a row, form a habit, whatever it is, it just becomes second nature.

And it doesn’t even have to be, when we say check the occlusion, what we don’t mean is, get a stethoscope, listen to the joint, measure the mouth opening. We don’t mean anything like that. We literally mean a pair of Miller forceps, okay. Articulating paper. I like AccuFilm, which is 24 microns, double sided. What do you use at the moment?

[Mahmoud]
I use TrollFoil.

[Jaz]
I love TrollFoil too. So I use that for my anterior stuff as well. And sometimes, yeah, for ease, TrollFoil, if no one’s used it, it’s very clever. It’s like, supposedly it’s like eight, but the data says maybe it’s more 12 micron range, which is still thin. It’s great. Okay, and then you literally like peel it away. So it becomes its own Miller’s forceps. So it’s like a handle that you can hold that’s not going to ink on your gloves.

[Mahmoud]
I’ll confess. I still use it with Miller’s forceps.

[Jaz]
Yes, I know you do.

[Mahmoud]
You still, you can’t move the cheek out of the way without the actual Miller’s.

[Jaz]
That’s true. I get a little lazy. I just round my fingers in and just get the cheek out of the way like that. But your way is more effective, okay? So TrollFoil is great. So it’s nice to sometimes just talk about what papers we’re using. And note that we’re using thinner papers, because again, we’re going back to basics when I, like I was lecturing or doing a webinar for Generation D in Malaysia the other week.

And I just asked the room on Zoom. I said, does anyone actually know what size your articulating paper is? And I think there was like 40 people on that zoom meeting. And I think only one of them knew. Okay. That’s it. So 39 did not even know. And so the problem with that is if you’re using that horrible thick stuff, which has its use, by the way, when you’re checking function and anterior envelopes, that kind of stuff, when we’re using that 200 thick cardboard paper, right, and you imprint the patient’s occlusion, you get them to bite together, you are getting too much data.

The whole tooth goes blue, and you’re thinking, okay, what do I actually adjust? And you end up just mowing the whole thing away. That is not being precise. When you get smaller markings which are more truly representing the true contact, even then you get some false positives, i.e there’s ink on the tooth, which does not actually represent a true contact. It’s just a smear a smudge on a tooth. So if you want to be more precise, please first thing find out what size articulating paper you have and make sure you are using something thinner. It doesn’t break the bank and it’s good practice.

So first thing to make it actually help the people move the needle forward. So if you’re not already doing this number one check which articulating paper you’re using. Make sure you’re using something thinner and tell your nurse about it as well. Educate them and okay, this is why we’re using this and this is the one I like the most from now on. And then number two, if the Miller’s forceps and the articulating paper is not on your bracket table before you start the procedure, i.e. it’s somewhere behind you, it’s not going to happen.

[Mahmoud]
Exactly right. I think that probably is the biggest thing. Now we’re in all of dentistry, whether you want to take more photos, whether you want to check the occlusion. Just be prepared. Have it out already. So my nurse knows to have red and blue arctic paper out. Does she always get the red out? No, sometimes I still have to remind her about that for some reason.

[Jaz]
So Mahmoud, this is red Troll Foil and blue Troll Foil is what you’re using, yeah?

[Mahmoud]
Yeah, I know it’s expensive. And then some shim stock, okay? And we’ll talk about shim stock in a second.

[Jaz]
We’ll talk about why shim stock, otherwise not move forward, okay? So we’ve decided that, okay, you’re going to have your correct arctic paper, and we’ll talk about foil as well. And it’s going to be there, and you’ve had that chat, that all important chat about, why you’re doing something because what nurses hate the most is that you go on a course, you come back, you start doing some random shit you’ve never done before, and they’re like, what the hell is going on?

Because what nurses crave is routine and predictability. So anytime you’re introducing something new to the scenario, we must do our due diligence. and just have that chat. Oh, Zoe, before we just bring the next patient in and she’ll roll her eyes like, what now? What have you bought now? What have you done? I was like, no, no, no, this is really important. This is what I’m going to do from now on, because-

[Mahmoud]
This one will really stick, right? As opposed to all the 17 other things you’ve tried you don’t do anymore.

[Jaz]
It’s like when you explain to someone what you’re doing, fine, but when you tell them why you’re doing it, then they’re more likely to agree, right? It’s one of those psychological experiments, right? So when I tell Zoe I’m doing something new, and Zoe’s great, she actually wants to know why, which I really respect Zoe for that reason. So I tell her, This is what I’m doing. This is why I’m doing it. And this is why I’m not using the old protocol anymore.

So if we are still using the same protocols for eight years ago, yes. That’s a comfortable thing, but I don’t see that as evolution. I’m constantly changing my protocols because I hear something better. I like the sound of something. There’s new techniques coming out. So it’s really important to educate our colleagues that work with us day in, day out as well, because they’re the ones who actually selecting the stuff.

They’re the ones who are going to make a bigger order of Miller’s forceps, or maybe you don’t have any Miller’s forceps in practice. And maybe that’s a good place to start to order some Miller’s forceps. Right? So now we’ve got our Miller’s, we’ve got our arctic paper and you mentioned the foil. Tell us more about why mean you love shim stock foil.

[Mahmoud]
So shim stock foil for me probably again is like that makes a huge jump in your accuracy for not much work. And shim stock is essentially, depending on the brand is like eight to 11 microns, non marking foil super thin and it has no ink on it. And the way you use it is you want to get it between the patient’s teeth, ask them to close into their habitual bite into MIP and you’re trying to pull the shim stock out from between the teeth, right?

If the patient’s closed and you’re trying to pull it and it doesn’t come out, That is called a shim stock hold. Now, you know that there’s true contact between those two teeth. If the patient is closing and you can pull the shim stock straight out and just come straight out, you know, that actually there isn’t any contact between those two teeth, despite what you might see using the marking paper.

There is something in between where you will feel it sort of drag a little bit. And I do think that’s, again, it just takes you up a level where you can notice the drag. That just means that the teeth are close to touching a tiny bit, but not hard in contact.

[Jaz]
And the reason why this improves our precision is that like this is like the opposite end of that 200 micron paper, right? Which again has its uses but for daily MIP IER tap tap tap bite. It’s a bit overkill. It’s too thick Okay, so at the one end you got less precision. Okay, which is a 200 micron paper and on the other end is this foil which is eight microns. And it tells us is there a true contact in the patient’s bite because if all we rely on is our eye. And we think, oh, this premolar cusp sits nicely into this premolar fossa, this tooth is in contact.

But actually, so many times you put the shim stock foil in and you can pull it out and you’re like, ah, actually this tooth is not in bite. Now, why is this important is because once you’ve done your restoration, just like Mahmoud said, guys, if you don’t know what the occlusion was like before, How can you really check it at the end?

So maybe your composite isn’t proud. Maybe your composite’s just fine, because yes, the shim is pulling on the premolar, but guess what? It was never in contact in the first place. So when you know where your shim stock holds are, you can truly conform to the correct bite at the end that’s comfortable for the patient, and this is a great way to do it.

So we’ve talked about the importance of thin arctic papers. Everyone go out and do a purchase of shim stock. We are not sponsored by Hanel or Coltene. We wish we were, kind of thing but we’re not. We’ve influenced so many dentists to buy Hanel. They’re like, their stock prices are ever rising, right? But anyway, we don’t get any part of that.

We just truly believe in some thin foils, other foil products may exist. Okay. Whatever. So we have to say that like the BBC, right? I wouldn’t know which ones, right? So anyway, we’ve now decided that we’re going to be checking the occlusion. Now, here’s my question to you, man. When in terms of maybe our protocols differ here, right?

But in the interest of efficiency, what I’ve been doing for the last few years, okay, is, I’ve been doing my usual pleasantries, showing the patient a radiograph, warning them about the root canal, having a nice little chat, basically, and then tipping them back, numbing gel, and as the numbing gel’s working, well, sometimes, even while the LA is working, then I’m doing my checks. Now, is there a concern you have here? Like, you know, does the fact that the patient’s numb on one side, does that change their bite so that your recordings are altered.

[Mahmoud]
Again, it depends, right, is the best answer to most things. If they’re completely numb, yeah, and I’m doing more than one unit, and they have teeth that don’t interdigitate super well, then, yeah, I would probably do it before.

[Jaz]
Give us an example of that. Make that point tangible. What do you mean? What’s something that interdigitates well and something that doesn’t interdigitate. I’ve said it very carefully well?

[Mahmoud]
So people that have like really cuspy teeth. So deep grooves, long cusps, and things fit together really well as opposed to someone who’s ground all their teeth really really flat. And they can sort of you know bite here.

They can bite a little bit to the left. They can bite a little bit to right and when you ask them to bite together, they’re like, oh which ones you want? That sort of thing.

[Jaz]
The analogy I use here is to study models analogy. When you’ve got someone’s models, right and you bring them together, you know you don’t need a bite record. They just fit together like this Mandible belongs in the maxilla exactly here, right?

This is like perfect, okay? Well, when you have exactly lock and key, when you have models and you’re like figuring out bloody hell, how do these fit together? That’s someone who doesn’t have great interdigitation because anatomy doesn’t guide you.

[Mahmoud]
Yeah, so in those patients and like I said, if I’m doing maybe a couple of units on the lower, like I’m doing a lower left first and second molar, I’m going to give them an ID block. Yeah, I’d probably rather take my occlusal sort of analysis, do that before they’re numb, but if it’s, I’m just doing a class II. And they’ve got really good interdigitation. They can find their home base really easily. Then for the sake of efficiency, I’m going to start the numbing process as in do the topical, give them the injection, and then I’ll do my paper and my shim stock as they’re going.

[Jaz]
And it doesn’t take that long. So just talk us through, let’s talk about a scenario classically, lower first molar. Back in the day, it’s your first restoration you’re ever doing. It’s the lower molar occlusal. Okay, you’re doing an occlusal and you’re going to be really good. You’re going to spend half an hour getting rubber dam on because you saw on Instagram it’s important to do and you’re going to struggle and you haven’t done my quick and slick rubber dam webinar yet on the app, so you’re going to go and get that.

But then now you’re going to be slick and you get it in two minutes. Anyway, you got rubber dam on, okay. But actually before you get rubber dam on, when you’re doing these checks, okay, can you just describe what this looks like for a lower right first molar in this pretend patient?

[Mahmoud]
Okay, so really easy because I would have checked. I can see that they’ve got a repeatable MIP. Yeah, they go the same place. So once I’ve numbed them up, I’m just going to dry the teeth. You can use a tissue or you can use your 3 in 1. Dry the teeth. I’m going to put the blue paper in. We’ll just talk about MIP for now. So I’ll put the blue paper in, I’ll just get the patient to tap, tap, tap. I literally say to them, tap your teeth together and then go like this. Yeah, because I want them to do that.

[Jaz]
Now what if some patients protrude their jaw and they come edge to edge? Because that’s what some people, when you say bite together, some people do that.

[Mahmoud]
Yeah, just accept it. Okay, just accept that this step, there’s just no- We get asked this maybe every single webinar, every single occlusion camp. What do you say to patients to get them to do what you want? Sometimes it just takes a little bit of coaching, right? Just a little bit of patience.

[Jaz]
I found telling him to bite hard. Bite hard sometimes helps a lot actually because they’re not able to bite on their front teeth. Instinctively they’re just, that helps.

[Mahmoud]
I’d just be careful doing that after you put your restoration in because if it’s high and they bite hard you don’t want to end up having to repair it. But yeah, for me, again, you develop your own words that you use and how you do it. For me, bite on your back teeth and tap tap tap seems to get me there, 95 percent of the time. A few people, yeah, they’ll bite on their front teeth and I’ll say, bite on your back teeth please.

[Jaz]
And once they get there, just show the mirror. Yes, this is the bite I wanted. This is good. So when I say bite on your back teeth, you’ve now coached them. This is what you do. And they were like, ah, I thought you meant bite on my front teeth when I said back teeth kind of thing.

Because I thought my bites, so many patients walk around thinking our bite is supposed to be edge to edge. Like patients think we’re not supposed to have over jet. Like that’s what patients, they look at cartoons and look at like growing up and they think that everyone who’s got even a slight over jet think, oh man, my teeth are crooked. I need to, have you ever encountered those patients?

[Mahmoud]
Yeah, yeah. And they’re the ones who always want your composite as well your anterior composites to everything like just be straight, but okay. So going back you’ve known the patient I’ve dried the teeth. I’ve got the blue paper in there I’ve got them to tap tap tap on their back teeth and I’ve got some mark. I need a way to remember or document those marks and there’s several ways to do it my preferred and the easiest way is you take an intraoral photo. I think that’s what you do as well?

[Jaz]
Yes.

[Mahmoud]
Photo with an intraoral camera, okay, and that stays on your computer and that you can reference that at the end of the appointment. The other way you can do it is you can just make a note, right? So sometimes I used to, before I had a camera, I used to do something called an occlusal sketch.

I learned this from Stephen Davies, Dr. Stephen Davies in Manchester. He had this like little arch of teeth drawn and you can print it out and then you can just mark on it where the occlusal marks are and in fact, I’ve adapted this into the occlusal prescription worksheet that we’ll be using on our courses and stuff. And essentially you just want a way of knowing where the marks were beforehand. So take a photo, write it down, make a sketch. Okay. Or if you’re really clever, you can memorize it.

[Jaz]
When you’re doing this for a while, some younger colleagues may be thinking, whoa, how am I supposed to memorize all that? But actually most straightforward occlusions daily bread and butter dentistry. Once you see it in a class one occlusion, generally the contacts are usually where you expect them, right in the middle of the groove in the lower molar, for example, on the cusp tip of the upper palatal, mesio-palatal cusp on the marginal ridges and the premolars. And it becomes quite easy to detect a bit after a while.

[Mahmoud]
Yeah. And bear in mind, like I’m not asking you to remember like 17, 000 dots on all the teeth in the mouth, right? You were just doing. We’re treating a lower first molar. I’m probably only caring about maybe the second molar behind it, and maybe two teeth in front.

[Jaz]
That’s really important, because people get freaked out, and I think you’ve made a great point there, like, don’t worry about the dots everywhere, just in your local area that you’re working, that we need to nail that.

[Mahmoud]
Next up for me is shim stock, okay? And if someone is thinking, I really like, this is just too much. Honestly, the shim stock makes the biggest difference. And again, on OBAB, I show a case where I was just doing an indirect restoration at the time, but when I put the provisional on, you could see very clearly in the photos where the paper marks were correct. They matched the pre op, but the shim stock was off, right? And the patient could tell. So the shim stock just takes you that little bit.

[Jaz]
Some patients are like princess and the pea, whereas other patients are like, everything feels amazing. Whatever, you just put a rock in their mouth, and you send them off, and you tape it, and exactly.

So, yeah, just bear in mind that patients don’t go. We’ll summarize this at the end, but there’s all the different checks you make at the end to make sure we have conformed well. And the very last thing you check is, how does that feel? That’s like the last. And sometimes, some protocols that some educators taught me don’t even ever ask them that, because the bite is your domain.

You’ve done your checks, okay? You’re happy, then you’re all good now, sir. Or ma’am, right? You know, you don’t need to ask him how it feels because then what Barry Glassman says that why are we getting patients to feel their bite? They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say how does it feel? How does it feel? They’re feeling their bite something that you really should be not really present for them If you like.

[Mahmoud]
It is a little risky nudging them in that direction. However, you do need to build up the confidence So now that I’ve got this protocol and I know that if at the end of the appointment I am convinced myself that the byte’s right, because I’ve done all my checks and stuff. Honestly, even if the patient says, it feels a bit weird, I will say, you’re just a bit numb, leave it until tomorrow and it’ll feel fine. And because I’m so confident in how I say it, they’re like, oh, cool. And then they’re fine, right? Because once you’ve built up that confidence, then you can look them straight in the eye and tell them, don’t freak out, you’ll be fine.

[Jaz]
Because you’ve done your checks and you’re happy that your objective data, your shim holds are as they were before, your dots are as they were before. And therefore, you’re happy, basically. The other check, well again, we’ll talk about this at the end when we do a summary. There’s muscular checks you can make as well. But right now, I just want to start at the beginning, where you’ve talked about shimstock as the next thing after the Arctic paper. Please carry on.

So with the shimstock, I will check the tooth. Obviously, I’m going to be working on it. I want to see if it’s holding shim or not. I’ll now usually do the tooth behind, the tooth in front, and one tooth on the other side. And that, again, I will just get my nurse to document. Let’s say we’re doing the lower first molar restoration.

So I’m checking the lower first molar and say, I’ll Get the patient to close on the shim stock and I’ll tug. If I can’t pull it out, I’ll just tell my nurse, lower right first molar or lower right six or whatever you want to call it, hold. Okay, and she’ll just document, write that and she’ll put an H. And if it doesn’t, she’ll put no hold.

And if it’s a drag, she’ll put a D, right? And it’s just four teeth. It takes literally 10 seconds. However, like this freaking everyone out, just please do it, right? When you’ll realize actually the tooth that you’re working on is holding shim. So in our case, the lower molar. The lower second molar is also holding shim.

Okay, the tooth in front is also holding shim, and on the left side it’s also holding shim, which about maybe 70 80 percent time is the case in case someone’s got a nice occlusion. Then this is, you know, it’s not complicated at all. You just verify. Exactly. It takes literally seconds. Sometimes, like when I’m doing indirect, and I’m going to be feeding this to the lab, and unusually you’re doing posterior teeth, right?

I’ll check all the back teeth, some molars and premolars. Most of the time they all hold and my note on the prescription will just be molars and premolars hold on both sides. And as we discussed guys in the couple of episodes ago, if you haven’t listened, we had gray and my technician on and we talked about how to get the occlusal prescription, right?

How to make sure our inlet restorations are in the bite correctly. And so we gave some great tips on there about how important it is to give your shim holds to the lab Because the bite record that we sent the lab more often than not There are some errors in it and therefore if you’re relying especially on the digital world, then we’re going to get a lot of errors occlusal errors.

So only once we give the shim holds and then the technician calibrates your models, whether digitally or on the actual physical models, then we get the correct occlusion. Again, I’m sorry we’re taking so many detours. Kind of is a big topic to cover, but just to summarize there, it’s not rocket science guys. Just get that shim stock, do it. It takes seconds and now you’ve got objective data. Is there anything else you’re checking?

[Mahmoud]
So just carry on with the shim stock thing is once you get quicker and slicker, I would urge you to start checking front teeth as well because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock and I think you’ll be surprised and if you are working in the analog world with models, remember, probably one of the biggest problems with models is they will rock backwards and forth. So you can very easily make front teeth touch when they don’t on a model. So again, very valuable information to give to your lab technician.

[Jaz]
Great. So also as you delve further involved the anterior teeth as well as a reference, which is great. Are you checking excursions?

[Mahmoud]
Remember when we said I’m checking if the patient A has a tooth opposite the tooth I’m working on, or if it’s going to be a really easy day in the office. Yeah, so I’ve checked. Now while I’m doing that, I’m also then at that point checking my excursion, right? And I’m seeing whether this tooth A is, does it contact in excursions or not? And if it does, is that area, number one, is it likely to be involved in my restoration? So can I see a massive caries bomb that’s going to undermine that cusp? And if it is, what am I going to do about it? And then the other thing is considering, okay, well, if, and if it isn’t contacting it, I just need to make sure once I restore the tooth, it isn’t contacting either.

[Jaz]
So again, going back to conforming in tap, tap, tap, but also conforming in excursions where it’s appropriate.

[Mahmoud]
Yep, indeed. Okay. And you can apply a lot of the stuff we talked about in the previous episode about guiding teeth and stuff like that. But essentially when I’m checking, repeatability, I’m also getting the patient to grind, I’m checking if the tooth is involved or not, and then I’m making a decision as to whether it will remain involved or not.

[Jaz]
And in the case of our example tooth, the lower right first molar, if it’s an occlusal, then you might find that the distal buccal of that lower right first molar is involved in a group function kind of guidance maybe, but that occlusal area probably is not involved very much. You might find little line from the palatal cusp, so just make a note of it, but more often not it’s going to be okay. When you’re doing different surfaces, maybe a distal involving a bit of the buccal might become more of an issue, but it’s important that you’ve made this check. And the way to check it is, again, you use a different color troll foil. Now you’ve got the patient to move, make that movement basically.

And it’s also nice to check the other side as well. And you just compare where is that dot and where is that line? Now one thing that we do by line, we mean that excursion. So one thing that I think we both do is it’s often good to check the excursions first, so now you’ve got the lines on there, and then go back to the blue and get them to bite together.

So what you have now is the dot has overlaid the line, so now you know exactly where the starting point is and where the movement goes. So just rewind if that didn’t make sense. If you want to add anything to make that more tangible, Mahmoud, please do.

[Mahmoud]
No, so yeah, sometimes the order in which you explain things isn’t always the order in which you do things. But yes, essentially what I do is I will check the excursions first with the red paper, So dry the teeth, check the excursions with red paper. So red paper in, patient chews, left, right, grind, you know, hard. Check the other side and then I’ll take that red paper out. I won’t let the patient close, I’ll say just open and stay open.

Now put the blue paper in and then we’ll do our bite on your back teeth and tap, tap, tap. The reason is blue will overwrite red, so I’ll see my blue dot on top of the red streak. And you’re avoiding, because if you do your excursions after you do the tap tap, it just smudges your MIP sort of mark.

[Jaz]
So all you then get, if you do it the quote unquote wrong way, there’s no wrong way, but if you do it the other way, whereby you do the tap tap first, then the excursions, when you look at that tooth now, you only really have the excursions data.

But if you do the excursion first, then the tap tap, you have both data at once basically. So it’s just more efficient to do it, which is good. So that’s a nice little point there. So in our case, our example tooth isn’t heavily involved in excursions, but it is in occlusion, okay? And so we’ve established that, okay, we want our restoration to hold shim at the end and we need to make sure that we’re conforming.

And it would be a disservice, like we talked about this before in a couple of episodes ago, where we are doing a disservice to a patient. If we are putting this composite shallow because we want to make our life easy. We don’t want to spend time doing adjustments and being so precise. We want to do a quick job that we just make a very shallow composite.

It’s completely out of the bite and now you don’t have to worry about it. And we are doing a disservice because now you’ve removed a tooth potentially or a part of a tooth from the occlusion. So that’s not what we want to aim for. We want to aim for precision dentistry. So we want to conform. What else are you going to do? Is there anything else in the pre op that you do before we even have touched a bur to the tooth?

[Mahmoud]
We’re scaring the bejesus out of people now. As we are sticking to back teeth at the moment, that’s probably all I will do. Okay. So I will check my MIP contact, my excursions and my shim hold.

[Jaz]
So I think you do all this, but you haven’t verbalized it yet. So just chime in here and say that, okay, you’ve done all the objective data. Just have a look, you know? So usually you have like an old leaking amalgam and it’s like flat. It hasn’t really got much morphology and you’re thinking, ah, okay. I can convert this into work of art here. I can really make this tooth look sexy again, get your fissure stain, which I’ve never used before, which you talked about in the Protrusive Guidance app recently. So newsflash, the community, we did a hot and cold poll on fissure staining, and where are you on that spectrum?

[Mahmoud]
I used to be hot. I used to stain fissures all the time, and now I don’t.

[Jaz]
Okay. So you’re in the middle or you’re cold?

[Mahmoud]
A bit towards cold. I do use it when I want to see. So if I’ve carved my anatomy in and it’s really deep and I’m thinking they might be like getting food stuck or anything like that in there, then I might seal it with some tin.

[Jaz]
You know, with those deeper ones that you do, basically, like someone once taught me, why are you actually putting in fissures and composite? They’re just going to come back and they look terrible. They look ugly. They’ll stain. And there we are. The natural stain just comes in and figures it out. Find this natural place. You don’t actually need to put stain in, guys. It just self staining right? That should be like a feature in composites, like in the box, self adhesive, this, that, self staining, all that kind of, no one will ever buy it.

[Mahmoud]
You don’t have A5 composite? Just put in A3 and don’t polish it. About a week later, it’ll look like A5. It’s all good. They can just prescribe them espresso coffee for a week.

[Jaz]
But if it brings you joy, like, there’s another post I saw about millennials and Gen Z and that kind of stuff. And your avocado toast. And I was like, you know what? Can you just let us enjoy our avocado toast and like that one shrivel of joy we have in our life?

Let’s just have it right see all the doom and gloom and dentistry if it makes you happy. If it makes your day to stain those fishes by god get the choco stain out go for it, knock yourself out. Okay, and have some fun and take some photos and share with your friends and everyone just enjoy Okay. So anyway.

[Mahmoud]
I use a lot of tints. I just use them on the front teeth. That’s that’s where my joy lies.

[Jaz]
That’s your passion. Okay, so you’re looking for joy at the actual occlusal morphology of the old restoration. Okay. And if you see a very flat amalgam and then you’re dreaming about how you’re going to stain it and how it’s going to look and stuff, right?

You still need to appreciate the angles of the old restoration, especially if you now see a dot on the old restoration, especially if there’s a dot there, because there’s two facts there. One, it’s in occlusion, but two, you know that because there’s such a flat amalgam, it’s not representative of what used to be there.

And so what’s happened over time, there’s been occlusal changes. And if you now put a beautiful composite that’s going, rolling back the ears and making it look like what you used to, it’s no longer going to fit against the opposing tooth. This is the number one place we go wrong. We put some lobes in where there is no space for the lobes anymore because the opposing tooth has eaten the space for that. This, I think, is the number one mistake. What do you think?

[Mahmoud]
Yeah, and once you start looking at teeth, you’ll notice this a lot, right? I have a theory as to how this starts. Usually it starts by that dentist that was maybe having a rough day. day and thought, okay, I’m just going to make my life really easy when I’m putting this amalgam in.

I’m going to take this giant burnisher, right? I’m just going to burnish the bejesus out of the bottom of this occlusal amalgam. And it’s just like a massive well, right? And there’s no occlusal contact and it’s nice and easy. You’re done. The patient goes away. And what happens to that upper tooth is actually that palatal cusp build.

That’s opposing it, might tilt and it might come down a little bit and now instead of getting a point contact when the patient’s chewing because that upper tooth has over erupted slightly or the lower tooth has over erupted, it’s now like gouging out more and more of the internal surface of this lower tooth.

It’s what we call a plunger or plunging cusp, right? And now you need to replace that lower amalgam, but that upper cusp is sitting so deep and snug into this well in the lower tooth. There’s no way you can then create your ridges and all that sort of stuff. And maybe if that dentist had followed what we’re saying right now, 10, 15 years ago, this wouldn’t be an issue.

But I see that a lot. So if you do see this sort of well shape on your lower restoration, look at the tooth above. Chances are you’ll find that it’s hanging down. You need to be aware of that because if you just build this up to how you think it should look, there’s no way it’s going to fit in the bite again. You see this on lower second molars. All the time.

Interjection:
Hey guys, it’s Jaz again, just interfering. If you are wanting to learn occlusion and it’s just a confusing topic for you, then me and Mahmoud are doing our live course. The next one, we have one in mid October and one at the end of November for 2024 and it’s called The Basics of Occlusion.

We’ve got nine different workshops and one of our favorite things is to engage with our delegates and to help to break down the seemingly complex topic into daily protocols. Just like kind of what we’re discussing today. Allowing it to finally sink in and improve the predictability of your dentistry head to protrusive.co.uk/boo. That’s B-O-O, Basics of Occlusion. To secure your place or join the wait list for 2025. Back to the main episode.

[Jaz]
The reason we’re having to go back and make our beautiful composites that we’ve put on Instagram with the rubber dam on we don’t put the photo after the rubber dam because it now looks like not so nice. Not so pleasant. It looks very flat like it looks dead right, is because we’ve missed this point. And so how do we resolve it because there’s only two ways I see it here is A, you accept it, right?

You swallow that pill, you accept it, and then therefore, you’re going to be purposeful when placing this composite. So you’re switching this amalgam to a composite, but you’re going to respect the anatomy and actually where you want to, or you attempted, every morsel in your body wants you to put a lobe there, but instead you’re going to put like a flat area to kind of match the amalgam, and that’s where you have to kind of do, basically, in a way.

Or, you have to now think about adjusting the upper tooth. In most cases, you have enough space for the minimum thickness of composite, two plus millimeters, and that tooth is not involved in excursions, and there’s no guidance and stuff. Therefore, why do you need to remove the opposing tooth enamel, right?

We kind of reserve that technique. We talk about this technique a lot when we’re encountering challenging situations where we need space, and therefore, it’s a good compromise. It’s a good way to get space. But in that scenario, what do you think? Is it right that we should be amputating? Not, amputating is a bad word, but doing some equilibration, let’s say, adjusting that cusp to give us more space for a beautiful composite.

[Mahmoud]
Would I do it for beauty? No. Would I do it for other reasons? Yeah, sometimes. Now, if you imagine that upper cusp, usually it’s like really big and it’s got a lot of enamel on it, whereas the lower has been completely shallowed out, and if it’s a lower second molar, it tends to be a little bit short, but also you’ll have like the buccal and lingual enamel walls tend to be thin.

Now, chances are, the reason this is being gouged out, it’s not necessarily involved in guidance as such, but during function there’s like a cyclical movement, right? So it’s not like the upper cusp moves up and down. So you’re going to have to maintain the thinness of the cusps on either side if you then want to like keep the chewing space essentially.

So sometimes what I will do is not just shorten the upper cusp but I’ll slenderize it a little bit just to give a little bit more sort of freedom for that cusp to move within the confines of my new restoration in order to try and protect those sidewalls from fracturing. I wouldn’t do it just to make my composite more pretty, but I might do it to increase the longevity.

And sometimes I’ll say to the patient, you’ve got a really sharp, ragged cusp at the top, and it may well be the reason why the lower tooth has now cracked, right? Because usually the amalgam’s cracked or something’s broken. So I don’t want that to happen to our new filling. Would you mind if I just polish it and round off a little bit? That’s like the language.

[Jaz]
See, you ask permission and I see why you do that, right? And so just communication here. And the way I picture my patients, like, okay, this is not going to work unless we smooth this upper tooth. It’s miles away from the nerve. You’re not going to feel it, but it’s going to make a world of difference in terms of how long this filling’s going to last. And they kind of nod and we do it. Basically. So-

[Mahmoud]
I use a carrot. You use stick. It’s all good.

[Jaz]
Yeah, exactly. Carrot and stick, right? So anyway, so this is an important point guys, to assess the general shape of what you’re starting with. Because this is the number one thing where you can go wrong. So you made a decision that, okay, I’m not going to be able to get as many likes on Instagram today because it’s flat.

Or maybe you’ve got space, maybe you’ve had a look and actually. This existing tooth, this restoration isn’t that much an occlusion at all. The upper tooth didn’t manage to over up so much because there was other teeth and larger ridges topping it. There’s the cheek and the neutral zone stopping from tilting that worked in our favor and therefore now we get to think about having some fun and we can actually put some lobes in and it’s all in the planning.

Now you know what space you have to deal with, like with everything, you can actually plan for that. The other thing to look for is generally the cuspal inclines, I’ll get my probe and I’ll just put it against the cuspal inclines. And I just get an idea of how shallow or how acute am I going, basically, because it’s going to guide me when I’m actually shaping my composite. I’m using my probe along. It will just give me like a quick guide that just takes like three or four seconds to do. Anything else?

[Mahmoud]
One trick I did learn. So, well, two things I’ll mention A, in our example, we’re talking about an occlusal. Restoration, right? So you could attempt the stamp technique. Have you ever tried it?

[Jaz]
A few times, to be honest with you. I just feel though, by the time I get, oh, Zoe, can you get the X to clear out kind of thing? Like, again, it’s one of those things that it’s the same as someone not having the middle forceps. It’s just not there. It’s just to leave the room to get it. And therefore I’m just more than comfortable just eyeballing it and getting it pretty much right in the eye way. But yeah, are you a big fan of the occlusal stamp technique?

[Mahmoud]
Look, there’s a lot of things that we learn off Instagram or we see on social media. And we think, oh, I give it a go. You give it a go and you, maybe you prove to yourself that you’re capable and then you never do it again. And that was one of those things where I did it. I didn’t use ExaClear. So I just used Liquid Damp. So Liquid Damp onto the existing tooth with a micro brush, pick it up and then final layer of composite before you set it. Put some PTFE on it and you squish your little stamp on top.

[Jaz]
I find when I did that it just felt very fragile probably because I didn’t give enough bulk but that’s the issue right? I mean to give it enough bulk and there’s an art in make sure you get it exactly right and stuff. But yeah it’s a valid technique and I think everyone should do it at least once and then decide how much they love doing that and that’s fine. I think it totally has a place.

[Mahmoud]
Yeah so there’s that and the only other thing I’ve picked up over the years is sometimes you can measure the depth of a restoration if it’s an occlusal that you are replacing.

There’s an amalgam in there already. You drill half the amalgam out and you can actually measure the height of the amalgam from the base of the cavity to the top. Then it gives you again just an idea when you’re done how high that restoration needs to be. I found it again of not a lot of value because a lot of time you’re removing decay and then the measurement is going to change etc.

And I think you know with enough practice all these things can be useful but with enough practice for me the cuspal inclines and using visual references that I take before I prep the tooth. So I’ll look at where the marginal ridge is compared to the base of the cavity. Where’s the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. So the angle of the cusp is probably, for me at least, one of the most important ones.

[Jaz]
And I think if we were to talk about the scenario where, by now that we’re talking more operative, we’ve taken the birds of the tooth and like you said, you drill half the amalgam away. And if you don’t have to drill anything further at the base, then yeah, that can work well for you. If you rebuild half the composite and then measure it and just do any adjustments, I’d add a bit more or brush some away so that you get the right height that can get you pretty much near or near enough, which is good.

And then if we’re doing a M O D O we’re doing involving the wall, the proximal wall, then we can actually measure. the actual height as well before we restore it. So for example, we’ve now cleaned our cavity, we can measure the space that we have, the height that we have, and then when we place our composite we can actually build, like we usually do for class two, we build the wall first, the proximal wall first, and then we can just use a perioprobe again to measure. Is that something that you do?

[Mahmoud]
Yeah, and that’s very, very handy. In fact, I had someone ask on OBAB. I think probably the most valuable thing I could tell them is once you’ve assessed the occlusion beforehand and you’ve seen that dot, you’ve seen where the dot goes on the tooth before you’ve done it, don’t put an incline there.

Do not build an incline in that vicinity because as you’ll see towards once we get to the towards the end, we want our MIP contact on a flat receiving area, right? It’s going to be very difficult to carve that out, out of an incline. So people have crossbites, people have all sorts of weird occlusal contacts and stuff.

So don’t just assume that because, I went to dental school and I know that the buccal cusp on a lower molar is a functional cusp and they have always have a contact in the fossa and one on the marginal ridge. That’s where the opposing cusp is going to be. And that might not be the case.

So find where the occlusal contact is and just make sure when you’re building that composite up, you have a flat-ish area, small, flattish area there that you can then adjust down to create your new MIP contact. Don’t put a big sort of inclined lobe, whatever you want to call it.

[Jaz]
That’s a huge tip. So if everyone was multitasking, please reel back in and just remember the place where the opposing cusp will sit. Don’t put any acute angles. And we talk about mountains and valleys. Don’t put any valleys there. Instead, have a nice lake there, where the opposing cusp can come into, right? Yeah, nice quiet lake. It would be good, basically. So just remember that point. Now, also, marginal ridges. A good guide is the adjacent tooth.

So look at the height of the marginal ridge of the adjacent tooth, if we’re doing a DO, for example, and just use that as a guide. That’s a very quick and easy win. And sometimes, if you’ve got a matrix band, that’s like kind of like way too high, going too far high. It’s like sticking out of the contact area.

Then if you just drill that down to approximately the height you want your composite to be, it just makes it a no brainer. It just helps you quickly put your enough height of composite there in the first place. So that’s another tip that we can give and share to help reduce adjustments because a common area to have to do adjustments is the marginal ridge area. For that reason, people overbuild, they make the wall too high.

[Mahmoud]
And LM-Arte have like a really cool version, like a Posterior Misura, I think they call it, where you can place it and it can measure the adjacent marginal ridge and transfer that onto the marginal ridge you’re building.

[Jaz]
Oh my god, I just had an epiphany. So if fissura means fissure, mesura means measure. Oh my god.

[Mahmoud]
Oh my god, are you serious? You’ve just figured that out now? I don’t know if that affects my estimation. Come on, dude.

[Jaz]
What does misura mean in Italian? I just want to see if there’s, yes, it means measure. Okay.

[Mahmoud]
For measure, yeah, obviously.

[Jaz]
I need to brush up my Italian.

[Mahmoud]
I’m going to pretend this conversation never happened. He is human, everybody. He doesn’t know everything.

[Jaz]
Definitely not. You guys, hopefully that’s evident from the kind of stuff I post. Good opportunity to plug the event. So if you’re seeing my mistakes, because my main lecture kicking off the event on 16th of November, where Dr. Michael Frazis and Lincoln Harris will be joining, is I’m kicking off the event. I’m kind of like the warmup act, right before the main, like the big guns come out around, the little warm up act. And I’ve got these videos of me just actually making these huge mistakes. Okay. So I’m actually going to just show you, but I’m also show you what I did to kind of recover the scenario and then if it was irrecoverable, what’s the best way to do in terms of communication and the clinical management.

So that’s on 16th of November. It’s a hybrid event. So it’s either a live stream plus a 30 day replay, or you bums on seats. You come and eat with us. You join us. You get some blessings from Lincoln Harris by touching his feet. You know, you’ll know if you’re on my email list what that means. So head over to protrusive.co.uk/rx to join. What I think is about one of a kind event when it comes to. Treatment Planning and failures because also we have a live patient. Okay, we have a live patient that Lincoln Harris, he knows nothing. We’ll just bring up the radiographs and the images on screen. And so he just has a conversation because we’re kind of seeing, okay, how does Linc communicate?

But then also now that we’ve put all this information, like a dental school exam, an unseen case, he has to then treat and plan and then, convey that treatment plan to a patient live on stage and then dissect it all with us and give us some tips based on that. So I think that’d be quite unique.

[Mahmoud]
Make it clear. The patient’s there. The patient’s actually going to be on stage. That’s amazing.

[Jaz]
Yeah, that’s pretty cool. So I found my main patient and this is not like a all on four and zygomatic, I don’t know, block graph, that kind of stuff. This is someone who needs a few crowns, needs a few fillings, maybe some whitening.

Maybe it has some aesthetic concerns. Like, this is like a daily, I was really keen on finding a real world patient, and I found her. So, I need to find a backup patient now. Anyway, mesura, okay? Italian for measure, guys. There’s an instrument that you can get there. We are not sponsored by LM-Arte, but good instrument.

I bought one. I have it somewhere. Again, I don’t have it out routinely. So, I just love, I spend the most time on that part of the restoration, right? Where you’re building the proximal wall, right? Usually, the nurses, they’re eager to get the light cure, but when Zoe sees that I’m working on the marginal ridge, you know, she might as well go outside and have a fag, right? Not that she smokes, but I’m just giving an example, right? She might as well just do that because I’m going to save my sweet time here to get that bit right.

[Mahmoud]
Yeah, there’s so much to do, right? Like, get the seal right, get the height right, get the thickness right.

[Jaz]
A hundred percent. A composite tip that Andrew Chandrapal taught me and he suggested do the wall, and I’m guilty of this. I’m kind of naughty. I can’t do it in one a lot of times, unless it’s really big. But like he do, he says do half at a time. So do like the buccal side first, then the lingual side. There’s even less like shrinkage stress. Is that something you do?

[Mahmoud]
No, again, makes perfect sense and it’s a great tip and it’s all about decoupling with time, right? You’re giving the dentine bond more time to mature because you’re just messing around in the box.

[Jaz]
I like it. It’s a good tip. I don’t always use it. So the whole point is guys, there’s no perfect way to do it. Well, there probably is a perfect way, but then you need to have a patient for like five hours on the chair for a simple composite, but you’ve got to just pick up your wins and this is to help you be quicker and not have to do any adjustments.

We’re not even going to get to anteriors. We’ll have to save that for a live in Protrusive Guidance, but let’s just finish off this series. Okay. We’ve done the marginal ridge. If we’re doing a DO, if you’re doing an inclusion, obviously not involved, and you’re going to remember everything at the beginning, do you have space for the lobe or not?

And so the begs the question. should we be following posterior anatomy, like the textbook, like you’ve done, is it János or János Makó like billion day course on occlusal morphology and stuff, right? So based on that, right, how can we now implement that? The real tricky thing here is we know, for example, in the real world, the amalgam is flat.

There’s no space for beautiful anatomy. And now your composite has kind of conformed to that, but then now you’re not getting the Instagram likes. So what are you going to do? How are you going to make a composite look good, Mahmoud?

[Mahmoud]
Photo editing. No, I’m joking. The thing is, you can still make it look reasonable by having in some fissure patterns, but it’s important not to just think, okay, I’m just going to take what I saw in the book and stamp it onto these teeth.

I love how you describe, when you have like a 75-year-old patient in the chair and you’re replacing this class tooth. This tooth’s been in function for decades, right? They’ve eaten pork scratchings and I don’t know what else on there. And then you want to create this tooth that looks like it’s just erupted in a seven-year old’s mouth.

So you say, why are we putting a seven year old tooth in a 70 year old man? It doesn’t make sense. So you do have to respect the space that you have, but you can still get a little bit creative and make sure you have a really sharp probe. And this will go back to our tinting.

You can add a little bit of depth by having, running a little bit of poo colored tint into your really deep fissures that you carve. So you can still get that satisfaction, get the likes. But for me, ultimately, I want to make sure this restoration is done efficiently, that the patient is happy and comfortable, and they don’t come back in my chair with this problem again.

[Jaz]
So number one, you don’t want to be drilling everything away. You want to be there or thereabouts. Okay. So that all comes down to a pre op checks, a visual check of the cuspal inclines, roughly where the opposing tooth is. So you can make that Lake there instead of like a valley. And then, you’re going to make sure that you don’t underdo it either.

You’re not going to go so shallow. So if you’re like in two minds, should I add a bit more or not? It’s better to maybe add a little bit more. So you actually have a contact at the end. So you’ve done your composite, you’ve cured, you’ve taken the dam off, and then you’re going to do the checks. And then let’s talk about the protocol for actual adjusting in the way that you’re not going to mutilate your composite. So what’s the first thing you do once the rubber dam’s off and the patient’s like settled down from the trauma of rubber dam isolation?

[Mahmoud]
Give them the rinse and stuff, because all the blood and crap, and then you want to dry the teeth, right? So you’re going to dry the teeth, you’re going to check – funnily enough, most of the time when I’m doing a posterior restoration, if I’ve decided that the tooth isn’t in guidance or I don’t want it to remain in guidance, a lot of the time I’ll actually go and check the MIP contact first.

I’m just being real. You should get into habits. Should you check the excursions first? Probably. I would probably say dry the teeth, put the red paper in, get the patient to grind left and right and then open, stay open, put the blue paper in and get them to tap, tap, tap. This goes back to why I said, Oh, my nurse doesn’t always put the red paper on. And then check the tap, tap, tap. And at that point you’re seeing marks. Now, unless there is one mark, if there’s only marks on my tooth and nowhere else, then I know I’m going to need to adjust.

[Jaz]
So by tooth you mean there’s only marks on your composite and nowhere else?

[Mahmoud]
On my comp, yeah, on my restoration. And nowhere else. I know I’m going to need to adjust. Now, sometimes you get marks on your tooth, your restoration. and the teeth next door. That doesn’t mean I’m done. At that point, I will reference my images that I took at the beginning to see, A, are the marks the same, and I will do my shim stock check.

[Jaz]
I’m just going to make that point tangible because, yes, you have some marks on your composite, marks on the tooth, and the value of that pre op photo that you took is, before, there was a marking on, let’s say, the fossa of that lower molar, and there was no marginal ridge dot, but now, you have a marginal ridge dot, which there wasn’t there before.

So perhaps, now we’re obviously extending it more to a DO scenario, marginal ridge being too high. And now you know that, okay, I might be there, but I might be just a little bit proud in this area. And that’s what the power of the pre op visual gives you.

[Mahmoud]
And then the power of shim stock is then there will be no doubt in your mind. That’s what I love about it is it makes me so confident. If I check my shim stocks, my shim stock after that.

[Jaz]
So what does that look like? What are you actually checking?

[Mahmoud]
So I will then check the tooth behind. Okay, and actually often you will find the tooth behind will hold, okay, and it’s to do with sort of the hinge motion of the jaw. You’ll find that the back tooth might still hold, but the tooth in front of the tooth you restored won’t hold, if the restoration is a little bit high. So that’s why I always check both and then check one on the other side. Now let’s say that happens, let’s say my shim stock hold that used to be on the tooth in front is now gone.

Now I know that my restoration is a little bit high. I’m not asking the patient how it feels. I’m not asking anything. I’m getting my yellow rugby ball. And the reason it’s a yellow rugby ball is because I have a mark on the tooth in front. That tells me, and I know my paper, right? This goes back to us talking about how thick our paper is.

I know that troll foil, doesn’t matter what their marketing machine says, etc. It’s below 20 microns, even if it’s 25. Because there’s a mark on there, I know that those two teeth are so close to touching that I don’t need my red band. I don’t need my coarse bur, I just need to tickle the contacts that I’ve got on my restoration. Because the occlusion is so close to being perfect. I only need to make a minor adjustment.

[Jaz]
So what you’ve done is you’ve checked, so the right side is the one where you’ve done the restoration, and then that’s the side you’ve used the paper, and that’s how you’ve deciphered that information. Usually what I do is I go on the other side.

The contralateral side. So let’s talk about it that way. Let’s say I’m using my 24, 25 micron Parkell paper. I know I’m close, but the shims aren’t quite there. So I know I’m a little bit proud, like maybe 20, 30 microns, I don’t know exactly how much yet. So if I take my 25 micron paper on the left side, the other side, get the patient to bite together, if it’s holding, I know that I’m proud, but I’m proud less than 25 microns.

Okay, if I’m using let’s say 15 micron paper okay, and now that’s pulling and for some people really to visualize and imagine and slow down here, right 15 microns pulling It’s not holding. Okay. I know that I’m high between 15 and 25 microns. Not that we do a 15 micron paper. That’s a bit too precise here, but you just know you’re proud by a little bit It’s just like you said the way this is useful is let’s understand the opposite scenario, right?

You use a 40 micron paper and it’s pulling on the left side. You’ve done the restoration on the right side, the 40 micron is pulling. So you know you’re proud on the right side. Your restoration is proud by at least 40 microns. You fold your 40 in half. You have now 80. Get the patient to bite together.

It’s still pulling. You then fold it again, 160 microns. Now it’s biting. You better pick up your green, or at least your blueber, and you’re going to have to press a little bit harder, and you’ve got to really figure out, look at your pre op images, Ah, I think I’ve got, my marginal ridge is way too high, or I’ve got a valley, I’ve got a slope here, where really I needed a lake, so you’re going to mow away in that scenario.

Go for lakes not valleys. I love this. Okay, cool. So that just gives you now an idea of how much pressure you’re going to put with the bur which grit diamond you’re going to use and how long it’s going to take you and how aggressive you’ll be. So this is why this information is important. And hopefully if you’ve done everything correctly with the pre op visualization, you’re going to pick up the yellow Rubby ball, round, if you’re just winding the lake a bit, remove that bit, which probably shouldn’t be there.

And actually, Mahmoud, top tip, before I even do this, I’ll get like a mic, because I love Eve Twist polishes, right? Or an Enhance, get a polisher and just rub it all over the tooth, because what we find is that there’s like smears of resin or bond on the teeth. Sometimes that’s what’s making the the tooth proud.

Not our composite. So once you get rid of all that stuff and then just wash and dry, you might find that you actually nailed it. You don’t need to do any adjustment at all. So the cleaning polishing protocol, figuring out how much, how many microns you need to adjust, go ahead and do it. And then be proud that you’ve conformed.

[Mahmoud]
The tip about the enhanced point is huge. Do it on the other teeth as well. Because a lot of the time when you’re doing your, you put your bond on and you’re thinning it and it just goes everywhere.

[Jaz]
And air abrasion particles.

[Mahmoud]
Yeah, so just get your enhanced point and yeah, I clean everything up. Great point, great point.

[Jaz]
And so hopefully now we are looking like the dots are in the places where we wanted them in this example scenario we gave, and we don’t have to now spend ages adjusting our composite away, and we still have something that looks good. Yes, it may not look as good as if you completely ignored the pre op anatomy, right, but sometimes when we have space then we can go back to the textbook and see, oh, so this is how a seven year old’s first molar looks like, and we can give that 50 year old patient a 7 year old’s tooth if you want to, okay? And get the likes and the applause on Instagram.

Okay, great. So the final thing to wrap up on is, we didn’t get time to do anteriors, so we’ll do that on protrusive guidance live one day. And what we’ll talk about now is a final, just to wrap it up, use your senses. So I think Riyaz Yar was the first person to talk about it in this way, and I loved it. I was already doing this stuff, but then the way he said using your senses, I love that. So a hat tip to one of our mentors, Riyaz Yar, absolutely a brilliant guy, teaches occlusion as well, really great guy to learn from, so shout out to him.

So use your senses, you’re using your eyes. You looked beforehand at what the shape of the composites were. You’re using your fingers, okay? And we didn’t talk about this, but for anterior teeth may be more relevant. You’re putting your fingers. We talk about fremitus. We’ve got a whole episode on fremitus that you guys should check out.

Like how much of a thud, how much pressure is going through that PDL, the periodontal ligament through your fingers, okay? So using your fingers, using your eyes, you’re using sound, okay? This is what a feeling sounds like when it’s proud. This is what it sounds like when it’s good. Was that feeding through into your headphones?

[Mahmoud]
Yeah.

[Jaz]
Everyone just like save that like a little voice nugget. Okay. And like, hmm, let me just compare this, calibrate this to what Jaz did on the microphone one time during a podcast. When you’re in doubt, when you’re not sure, just like oh yeah, that sounds like a lot of teeth touching at once, and the patients usually laugh.

[Mahmoud]
Oh, get the patient to do it, not you do it to them.

[Jaz]
Part of the whole visual is you’re obviously using the ink paper as well, basically, and part of the feel, again, using the shim stock. So all those things means that you now will never have to adjust composites again. Obviously, with tongue in cheek, you will obviously do a little bit, but you know what, hopefully, this is giving you a new perspective, or reinforced some existing perspectives, or maybe giving you one, that one nugget that’s going to shave off one minute from all the composites they can do for the rest of your life. And therefore has saved you two weeks in your career. Who knows, who knows Mahmoud?

[Mahmoud]
Two weeks, extra holiday.

[Jaz]
Two weeks of life that you couldn’t bone about some, I don’t know.

[Mahmoud]
You’re welcome.

[Jaz]
I don’t know. where I’m going with this, but anyway, I’m tired now, guys. This is a great point to end the podcast. And we just talked about one. A beautiful issue for this long. We didn’t get to anteriors. We’re such sad bastards. Guys, thanks so much for listening. Mahmoud, thank you for the time. If you’d like to learn more from us, we have occlusion. online, occlusion course.

We also have the live course running October 11th, 12th, and also November, end of November, and the website for that is protrusive.co.uk/boo not because it’s scary because it’s Basics of Occlusion B-O-O. So come and join us that if you’d like to learn more. Otherwise, we’ve got plenty of other episodes for you to get your sink your teeth into excuse the pun. And we’ll catch you same time same place next week. Thank you. Mahmoud.

[Mahmoud]
Take care everybody. Thank you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. This episode is eligible for an hour of CE credits. We are of course a PACE approved provider. We also satisfy the GDC criteria of enhanced CPD. So answer the quiz below and you’re thinking, where is this quiz?

Well, you need to get on the protrusive app. It is a stunning app. We’ve invested a lot of time and money into it. So please do check it out. There’s a cool little quiz on there. You get 80 percent to prove to us that you’ve learned something and there’s an area where you can reflect and you get your certificate emailed to you like clockwork. Every Wednesday and every quarter, we send you your entire folder of all the certificates you’ve gathered, because we know what happens. They get lost everywhere. So don’t worry. We always keep your copies. It’s a great way to rack up your CE credits throughout the year.

The website is protrusive. app. Make an account if you haven’t already. I look forward to reading the comments from this one. I want to hear from you. What’s the most important thing that you learned or the thing that’s going to make the biggest difference in your practice you think?

I do enjoy reading all the comments on YouTube and now I’ve got more systems in place to make sure I don’t miss any comments. And I can reply to them all. Thank you so much for making it to the end once again. I’ll catch you same time, same place next week. Bye for now.

Follow THESE protocols to eliminate teeth whitening sensitivity in your practice – your patients will love you.

Have you ever had a patient who had to stop whitening due to severe sensitivity?

Should we be whitening when there are active carious lesions? (the answer might surprise you)

In this episode, Dr. Linda Greenwall is back with another phenomenal episode as we dive into this common concern. Together, we discuss practical tips and effective strategies and protocols to help patients achieve radiant smiles without pain.

Protrusive Dental Pearl: We’ve made an infographic to summarise this awesome episode. This one is available freely under the episode in our Protrusive Guidance App.

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

Highlights of the episode:

Dr. Linda Greenwald invites the Protruseratis to the “Future Dentistry” conference on November 1st at the BDA, featuring dental AI, restorative, orthodontics, and implant innovations.

This episode is eligible for 1 CE credit via the quiz on the Protrusive Guidance App.

This episode meets GDC Outcomes A and C.

AGD code 780 ESTHETICS/COSMETIC DENTISTRY (Tooth whitening/bleaching)

Dentists will be able to:

1. Understand the causes of teeth sensitivity during whitening treatments and conduct thorough diagnostics.

2. Implement pre-whitening protocols such as treating non-carious cervical lesions and recommending desensitizing toothpastes.

3. Gain insights into preventative measures for managing sensitivity in whitening treatments.

If you love this, be sure to check out Dr. Linda’s other Protrusive Episodes: Finally, Some Clarity on Teeth Whitening for Under-18s with Linda Greenwall – PDP096 and ICON Resin Infiltration – Step by Step FULL PROTOCOL – PDP140

Teaser: Any discolored tooth needs a periapical radiograph, really, really important, because you are looking for undiagnosed periapical lesions. And most dentists don't know, if there is an undiagnosed periapical lesion and you put whitening gel into, so you take oxygen, and you shove it into an anaerobic area, you are going to have max of sensitivity-

Teaser:
Because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area.

So here’s another point. You can’t adequately bleach the cervical area. It’s never going to be the same shade. And that’s a myth- The last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area. And they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that.

Jaz’s Introduction:
Protruserati, this just might be the most actionable and impactful piece of content you’ll ever consume on the topic of teeth whitening sensitivity to really help our patients to whiten better without having the horrible side effect of teeth sensitivity.

I don’t know about you, but for some patients it can be so bad that after about three days they don’t whiten ever again. And you have to have that awkward conversation with the patient. But now, following Dr. Linda Greenwald’s protocols, We can eliminate teeth sensitivity. Like, we could have spoken for like hours and hours and hours.

But what we did bring together in this episode is like the top things. Think of the Pareto Principle. I’m a big fan of the Pareto Principle. This principle suggests that 80 percent of your benefits or your rewards or effect happens from 20 percent of the contributions or inputs. So for example, 80 percent of your sensitivity reduction will happen from the 20 percent of the little tweaks and the changes you make in your whitening protocols. Let’s focus on those 20 percent of the protocols that are going to make an 80 percent reduction in your sensitivity, and for some patients, a 100 percent reduction.

Hello, Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Because there are so many actionable gems and protocols and so much goodness in this episode, we’ve created a famous Protrusive Infographic.

If you’d like to download this infographic, for free, head over to protrusive. app. If you’re already part of our community, you will see this infographic everywhere where we post this episode. But if you haven’t joined yet, what are you waiting for? It is the community of the nicest and geekiest dentists in the world.

So the platform is called Protrusive Guidance, and the easiest way to make a free account is www. protrusive. app. And once you’ve made an account, you can download it on iOS or Android. When you click on this episode, you’ll be able to download the infographic. You can laminate it. You can do what you want, but all the goodness is there because sometimes like me, if you listen to podcasts, when you’re driving to actually action on some things to actually have like an aid memoir, a good revision source, we already have the premium notes, which are also downloadable for paid members, as well as claiming the CE credit or the CPD hours.

Dental Pearl
But as part of the gift from this episode, the pearl for this episode, you can freely download our infographic. Now, I appreciate it may sound a little bit attractive to you now, but wait till you get to the end of this episode. You will definitely want this infographic. So don’t forget, protrusive.app. I’ll see you on Protrusive Guidance. I’m not going to waste a second more. You’re going to absolutely love Linda, as always. Let’s check it out.

Main Episode:
Dr. Linda Greenwall, welcome back again to the Protrusive Dental Podcast. You are such a welcome guest because we’ve done a few episodes about whitening under 18s and icon resin filtration. Everyone loved those and they love it because I love your direct nature in teaching.

I really love direct educators. You tell it how it is. And so I’m especially interested in today’s conversation about sensitivity. But for those few people who, for some silly reason, they have not enjoyed that episode just yet. And they’re, it’s like a gem waiting to be uncovered for them now. Please tell us, because they haven’t heard about you. Tell us about yourself.

[Linda]
So my name is Linda Greenwall. I’m a prosthodontist, specialist in restorative dentistry. This is my year 40 in practice and I’m still inspired. I still love it every day.

[Jaz]
Say that again. How many years in practice?

[Linda]
It is now 40, 40 years.

[Jaz]
4-0?

[Linda]
40, 1984. Schooled up at university in South Africa. 1984, we had a special reunion this year because, I said to my colleagues in my class, hey guys, we really need to commemorate this. And the one guy said to me, Linda, I hated everyone in my class then, I still hate them now. I said, forget about that. We need to commemorate. And we got our professors and they came in.

And the first thing I wanted to say to our professors, I wanted to say thank you and show gratitude because the way they taught us in the eighties was very, very tough. There was no mincing words. And I wanted to say thank you because our training was excellent and it was tough. And we have all learned from that.

So I just wanted to show gratitude because we always, there are always people Jaz, who bring us up with them through mentoring and helping. And even though they may be our biggest critics, we learn from them. So we have to pay gratitude to say, thank you. Each challenge, this is my new thing. Each challenge becomes your opportunity.

Every single challenge and you can go through that. So we say, why do we have these challenges? Let’s call it in dentistry. It’s to reach, to help you reach your growth point to your next level. And that’s why it’s coming. It’s not because you’re a bad dentist or anything else. It’s your challenge to grow. And that’s when you learn that, that takes you to the next level of all that we do. It gives you a bit of wisdom.

[Jaz]
And now of course you do all sorts. You’re in practice, you do so much teaching. I love the webinars that you do. And so, everyone, I encourage to follow Linda on Instagram. All her social channels, they’re very, very active and the Academy and whatnot. So I’m a big fan of yours.

[Linda]
It was 13 years ago that I decided it was time to give back to dentistry. And that’s when I set up the charity. My husband told me I was mad, but I said, I’m doing it anyway. And it’s brought a lot of joy, really. And again, on gratitude, but we currently look after 60, 000 kids globally, and we do 23, 000 children in Luton, helping them with toothbrushing, screening, varnish application, working with refugees, providing free dental care in our practice.

In South Africa, we run 12 soup kitchens daily. We’ve served over half a million meals. since COVID and we have 16 toothbrush mamas who help us and each toothbrush mama helps to look after at least 2, 000 kids a month going to do toothbrushing at schools but also in the communities. So that is kind of how I balance with some of my high end, very, very specific, difficult, anxious, kind of stressed patients with their phones out to check the levels of their bonding at all angles and their selfies, to going into outreach in the less in deprived areas where you can give of yourself and your soul to help others with gratitude. Nobody needs to say thank you to you. You go to give yourself and it puts your whole life into perspective. So it’s a big difference in balancing.

[Jaz]
I love that. And you’re quite right to mention the contrast. In my faith in Sikhism, there’s something called Sevā. We call that selfless service. And what you described there was exactly that. So hats off to you. And I’d love to support more of what you do. So put any links that are relevant so we can continue to help you support. And so we’ll definitely put that on.

Today’s topic is a very pertinent one, very global one. No matter where you are in the world, you’re likely utilizing, hopefully, teeth whitening as one of the most brilliant, minimally invasive ways to help someone smile. We accept that. That is the most minimally invasive way that can have a huge difference to someone’s smile and confidence.

In particular, we talk about young people with all sorts of enamel mottling and brown spots. And we also did an episode on icons. So well-versed with the benefits. But one of the drawbacks of the benefits when the side effects is teeth sensitivity, but we all warn our patients about sensitivity. I’ve got so many questions of so many things I want to draw out for you from protocols to different things to try to avoid and case selection. But can we just start off with the very basics? Why does teeth sensitivity exist as a result of using peroxide gel?

[Linda]
Actually, before we even start that question, Jaz, I’m just going to go back a few steps.

[Jaz]
Please.

[Linda]
Because the first thing is that 70 percent of patients walk around with sensitive teeth and we as dentists don’t have any protocols to assist those patients who live with their sensitivity. And so before we even start on whitening, we give everybody listening today a things to do list. So while you’re listening to the podcast take a sheet of paper on one side we’re going to talk clinically and the other side we’re going to talk what to do now and what are your next moves. So that you can make this a habit.

So your first thing is to set up a patient desensitizing a protocol for sensitivity in your practice. And you ask every single patient, if you say to them, do you have any sensitivity? They go, no. Then you say, but do you have, you ask the four questions. You know about the four questions?

[Jaz]
No, please tell me.

[Linda]
The four questions, really, really important. The first thing is, number one, do you have sensitivity to cold? Because that means they have gingival recession and all kinds of other things. So that’s the first question. Second question is, do you have sensitivity to heat? As you know, the heat question is about pulpitis because there’s a big difference between pulpitis and sensitivity. The patient may not know that.

The third question is, do you have sensitivity to sweet? Because that means there’s caries somewhere and we need to look at that. And the fourth question is, do you have sensitivity to cold and pain on biting? Because the pain on biting means that there’s a fracture somewhere.

And then you may say to me, well, is that important relating to whitening? And absolutely. First of all, if you’ve diagnosed that they have a cracked tooth, you need to treat the crack, let’s call it a crack tooth syndrome. You need to treat the crack tooth syndrome, whatever you’re going to do, whether it’s replacing the old restoration with a composite, putting on a provisional crown, but you need to manage that immediately.

So that is protocol number one. Protocol number two, does it matter about heat sensitivity? Absolutely. Because that a pulpitis left untreated when you will whiten the tooth will lead to needing a root canal, which needed a root canal anyway, but you’ve got an unhappy bunny as a patient because you as the dentist didn’t diagnose and explain to the patient that they need to have a root canal first.

First, so the rule coming backwards is that any discolored tooth needs a periapical radiograph. Really, really important, because you are looking for undiagnosed periapical lesions. And most dentists don’t know, if there is an undiagnosed periapical lesion and you put whitening gel into, so you take oxygen and you shove it into an anaerobic area, you are going to have max of sensitivity anyway, requiring a root canal, which it already needed a root canal. But when you do the RCT on that tooth, it’s going to be difficult to control.

[Jaz]
And the patient’s perception is that, oh, there was a whitening that caused it, or it was an underlying issue all along. You taught me this as I was a third or fourth year student. You were lecturing the BDA. And so this was like 13, 14 years ago. I remember learning that from you on stage. So I always associate with this you, and when I’m thinking about teeth whitening, always look at any discolored teeth, any teeth that have got large composites worth doing a sensibility test before we prescribe the whitening, because hey, this could be, may not be symptomatic, but it could be necrotic. And this could be a flare up.

[Linda]
Absolutely. And then to try and do a root canal on that, you can’t do it in one visit, you might be able to do it in two and you often need to do in three, which is unusual, but it doesn’t settle down. And so the next thing to also look at while we’re talking about radiographs relating to whitening is post ortho.

So as you know, it’s very trendy now, everyone having then aligning and whitening, or first before you even do that, aligning or ortho, and then they want to go into whitening. That’s another topic we can discuss our whole thing on that. But you need to know what’s the nerve status of this. What’s the nerve status of the tooth?

Because if they’re post ortho, they’re going to have flattened roots with a little bit of resorption. And again, the whitening is not going to make it worse, but you need to know what are you dealing with now. Where are we with the, what is looking at, at the nerve? So coming back to the sensitivity question, we’ve spoken about sensitivity to heat needing a root canal.

We spoke about sensitivity to sweet. Was that sensitivity anyway? It’s all lumped together. And the sensitivity to sweet is normally interproximal decay. . So does that matter? And the answer is not really, because you’re gonna whiten first and then you’re gonna go back and change your restorations with the blended shade of the new composite.

[Jaz]
Has that changed at all, Linda? Because I’ve seen on social media groups where dentists are, and some dentists have this very strong opinion that, so for example, this is what some dentists do, and I disagree with it because I think you’re double treating. But essentially they all say stabilize the caries first, then do the whitening, then go back.

Insult the pulp again and do the restorations again. And that’s why I always follow, especially with anterior work, you bleach, even though you’ve got caries. Okay. And then you treat it with composite. And a few times I felt as though I was being a bit naughty doing this. And I was thinking, Hmm, is this kosher? Is this halal? Is this allowed? Basically, what do you think?

[Linda]
So you just said Linda Says. Linda says, do the bleaching first, because the research has shown that it shrinks the decay. That’s the whole purpose, because it’s chemically cleansing the decay. Unless we’re talking about a massive lesion, a mega open hole. Of course, you’re going to put a glass on a mirror. You’re not going to leave an open cavity, a huge open cavity. I’m talking about small, little-

[Jaz]
Small class threes, class twos, that kind of stuff.

[Linda]
That’s what I’m talking about. When they have sensitivity, the patient may say when I floss, it’s a bit sensitive. So that is a plan. It’s your strategy plan, right? And then coming back to the cold sensitivity, you’re managing the gingiva. So coming back to patients in general, because so many patients experience sensitivity and we just ignore it or maybe give them a soothing toothpaste. So what we would do on all new patients and all patients, discussing, ask the question, do you have any sensitivity?

Don’t leave it as no, I don’t. You then put an optogate in and you take the three in one and you spray air onto every single cervical area all the way around the mouth. And you note where they sensitive on the cervicals. Okay. Then you’re going to note, where they have NCCLs.

[Jaz]
Yep. Non-carious for the students. Yeah, please explain more about what they are for any students listening.

[Linda]
Okay, so an NCCLs, very big buzzword, which just rolls of your tongue. NCCL, non-carious cervical lesions. We think that we see much more of it these days than ever before because of patient’s diets and the Diet Coke and this busy water and the everything else and their lifestyle of what they drink.

Everything that they drink. So we see a lot of it. Now, most dentists, I don’t know why, and we can discuss the why, but I don’t know why they leave it. So you’ve got like a deep class five lesion and you spray air and they’re jumping out the root out the chair. And it’s such a simple restoration to do.

But I want to talk about how we would do that. So once we’ve noted where the sensitivity is, and we’ve noted it down, becomes part of our charting. And before we even take a scan these days, or or we take an impression for bleaching trays, we get those restored. We restore them. My restoration of choice is a resin modified glass ionomer.

And the reason for that is several reasons. Number one, it retains beautifully. Number two, the resin modified, the GRC loves the dentine. Number three, you don’t get the, you know, you see the, not, of course, not your composites. But when you see somebody else’s beautiful class five composites, number one, they never match.

And they’ve got a black line. They’re always leaking at the join. So the GRCs don’t leak. You don’t get a black line around the join. You get beautiful shades because of the new color or coloring. And we would choose a couple of shades larger. So if the patient has, they generally, A3. 5 teeth, I would choose an A2 shade to work onto all those class 5 lesions. And I want you to go through the technique if it’s okay with you of how I’m doing that.

[Jaz]
Please, I’m sure everyone’s loving this so far in terms of, because these are daily problems that we see in like 70, 90 percent of our patients.

[Linda]
And so when you ask me, what procedure do you do? Do you do crowns, bridges, onlays, zirconia, etc? I sit and I do my GICs a lot. So let’s just go through the protocol. So number one, we use a micro brush. Which is a tiny, not of a prophy brush. It’s a prophy brush with about a millimeter of bristles. Not the whole cup. And we put in pumice with heavy scrub. We make our own, but you can get consepsis. So you put the pumice and hibiscrub and you clean into that class 5 lesion.

So we were just had a hands on course at the practice on Friday and one of the dentist delegates very kindly allowed us to examine her mouth. And actually we showed the protocol because it’s so simple and straightforward and the color looks good. But let’s go back.

[Jaz]
So hibiscrub is like a proprietary branded product, right? It’s got is chlorhexidine containing that one or?

[Linda]
Hibiscrub. It’s chlorhexidine.

[Jaz]
Yes.

[Linda]
So you take pumice with chlorhexidine, we mix it up ourselves, but the actual product is called consepsis. And then you would polish, clean, polish, there’s so much plaque, you see the toothbrush lines in the class 5 lesion, the vertical, the horizontal lines, pumice and Hibiscrub.

Then you clean it, wash it off and take your probe and you check again and you’ll see there’s still, even though you’ve cleaned it, there’s still plaque in the rivers of the toothbrush marks. So, we go back again, but before we even do that, have a look at what the gingiva was doing around the class 5 lesion.

Because often, the gingiva was growing back into the lesion. So you need to then retract. We would cut a retraction cord, six millimeters in length and sometimes we double retract. So we use like a thicker one the brown one first then the black one and we tuck it back so that we just bring it back underneath. So we can actually see the full extent of the lesion on the class 5 lesion. So pumice and hibiscrub maybe twice, then we go to the aqua care.

[Jaz]
I was just going to mention air abrasion and you, yeah, just like that, you got in there.

[Linda]
Yeah, so you can use air abrasion, you can use your bicarb, you can use your aluminum oxide, any 30 or 50, it doesn’t make a difference. But I put in sylc. S Y L C is got, it’s Novamin. We’re the same as Sensodyne. So the Novamin, we jet wash it inside the tooth. And again, we use it for all restorative. We jet wash, cleanse it. So now the pumice and hibiscrub is soothing and blocking the tubules. The Aqua Seal is blocking the tubules. We then-

[Jaz]
The Aquaseal is the-

[Linda]
Aqua Care.

[Jaz]
Aqua Care, yeah.

[Linda]
Yeah. We then would etch the tooth. And because you’re dealing with sclerotic dentine, sometimes you need a double etch. Again, there’s so much plaque stuck inside, even though we’ve done all these cleansing procedures.

[Jaz]
Is this standard 37 percent phosphoric acid etch, or is it the conditioner that often comes with your glass enema?

[Linda]
No, I personally go to the etch.

[Jaz]
Okay.

[Linda]
And then I use HurriSeal. And the HurriSeal is a hema product, which is for soothing, or you could actually use Gluma. And I drip that on into the teeth, drip, drip, drip. So all the time I’ve been treating and soothing all the time. Then I go with my GRC and the GRC I jet into the tooth, there’s many different brands.

I like one of the brands called Riva from SDI and it’s quite liquid. So I squirt it in. I take a probe and just retract around there and then I sculpt it with a normal brush dipped in bond and we sculpt up, vertically up and contour around the tooth and then the final bit is the probe, light cure it.

And with any excess you remove with a flame and then you do the whole quadrant. Don’t leave any of them out. Because what’s going to happen if you leave it? It’s just going to get worse It’s just going to be more brushing. So I actively believe being proactive and just sort that because that blocks the sensitivity. So that’s why that’s the first stage we do a lot of proactive before we start.

[Jaz]
So the questions I have now is around about these NCCLs, right. The way I’m managing at the moment is, is differently for if I’m doing whitening or not, because I’ve listened to you for, I’ve done your webinars for, before starting teeth whitening, I follow that.

Now the protocol is little micro steps. I love it. I’m going to implement some of those because I think they make so much sense to me. And so for those patients about to start whitening NCCLs to be restored just makes sense to me. In those patients who we’re not talking about, we’re not having that whitening conversation.

They have NCCLs, but they are completely asymptomatic. The kind of conversation I have, the kind of assessment I have in my brain is, there are three reasons you may wish to restore an NCCL. A, if it’s sensitive, then it needs doing in my opinion. If it’s so big and it’s the first time you see the patient and they’re so big, then you think, okay, there’s a massive crater here.

This needs some sort of protection or if it’s an aesthetic issue. So I guess what I’m trying to ask is, aside from those, these scenarios, is it acceptable to just monitor because it’s not symptomatic, it’s not in the aesthetic zone and it’s small.

[Linda]
So that is one approach. And again, you put it to the patient. It’s up to the patient with consent, but I just normally just fill them in. I guess you can monitor them, but we start to see inside the ones that are untreated the root decay. There’s a lot of areas. Yes, they’re resorbing and yes they can place topical toothpaste or mousses, et cetera, but nothing really changes in them. So I rather, my tendency is just to restore them.

[Jaz]
I think you’re right in the sense that when we see these patients year by year by year, and then eventually you find, see patients in their seventies and eighties, and I find that what used to be a very cleansable area of NCCL is now just plaque-laden and there’s gingival inflammation. And so to promote better cleansability, it totally makes sense. And it’s something that’s not very invasive. It is proactive. And I like the idea of it.

[Linda]
So that’s the option number one. Before, so you’ve seen that we’re still talking about diagnosing the sensitivity because we have to go right back to basics. We’ve spoken about the assessing where the sensitivity is, what is it, what start, what type of sensitivity is, but then if, let’s call it, the gums are a little bit receded, you can’t put a GRC there, and you’re modifying the tooth brushing technique, the research shows that brushing with Sensodyne for two weeks before you start whitening makes a massive difference.

So you can put the patient on to a Sensodyne protocol or any soothing toothpaste protocol brushing. Just that, this was early research from Professor Van Haywood, will stop the sensitivity. So there you have the next way.

[Jaz]
And this is just, so two questions back and back, this is just tooth brushing, not necessarily the protocol where you rub it on your finger and you leave it in those areas. This is just regular tooth brushing.

[Linda]
Yeah.

[Jaz]
And is it a specific type of Sensodyne? Like, for example, I think previously you’ve talked about repair and protect. I don’t know if they still have that terminology anymore. Is there one that works better than the others prior to whitening?

[Linda]
I think all of them are absolutely fine. Absolutely fine. And there’s newer versions of whatever works for the patient. What I do check though is on all toothpastes and soothing toothpastes and in general the current toothpastes that are being used many patients suffer from sloughing of the cheeks of the new codes. I don’t know if you see this.

[Jaz]
Yes, yes.

[Linda]
So you need to, I always ask the patient when I’m doing a general exam, what toothpaste they are using because some cause more sloughing of the cheeks. And so we say, change your brand. So when it’s talking about a sensitive desensitizing toothpaste, use it for two weeks, then go on to the next brand and then just change it a little bit.

[Jaz]
So we want A, the sensitivity sorted and be no sloughing. Sloughing is, do we believe that’s the SLS component?

[Linda]
Yeah, we think it’s the SLS. Some of them have Covarine blue dye in to make the teeth look whiter, but it may be too strong or, so you need to just check and monitor with the patients.

[Jaz]
Okay, so you’ve done your diagnosis, you’ve noted the NCCLs, for those that are amenable to treatment, and which most are based on this conversation, let’s use that, you’re going to use a Riva, like you said, you’re going to follow that fantastic protocol, which we’re going to get the video for, and a little checklist, and our team, a lot of people are driving or on a train, they haven’t got access or making a license or download and then also link everything to your website as well, which would be great.

[Linda]
And we’ve got a new WhatsApp group on bleaching just by the way.

[Jaz]
Oh, wonderful. I love that. Fantastic.

[Linda]
It’s really amazing people put their cases on.

[Jaz]
Brilliant. Now you’ve also talked about using Sensodyne for two weeks prior to teeth whitening and then just brushing. And if they’re having the sloughing or that brand is not working for them, then maybe change a brand. Would you agree with that? Because I found patients where they tried something already using a Sensodyne toothpaste and just by suggesting a change in the chemical formulation, a different brand, then they suddenly come back and their sensitivity is significantly improved. Is that something that you’ve observed as well?

[Linda]
Yeah. So when it comes to the different Sensodyne brands, there’s a lot of different ones. So you can, again, you can swap between the brands because they’ve got different functions like that. So that’s one option. Then, the next thing is to understand why patients get sensitive during whitening. And we would then-

[Jaz]
Can I just, before you talk about it, because this is such a big part, but it’s one thing, I just want to cross off before we move to the actual mechanics of teeth sensitivity during bleaching, is with your protocol, which sounds wonderful, are we expecting that patients can hopefully say that, you know what, I can have my ice cream again?

Because sometimes they say, like, my centrals are super sensitive, but when you look, you don’t really see much recession, you don’t really see any NCCLs, they just have, generally, they’ve always had, oh, since I’ve been 12, I’ve always had sensitive teeth. Are we going to help that patient as well?

[Linda]
It helps that patient as well. Just recently, I saw a patient who we did this treatment exactly what I’m talking about, and she had massive erosion on her teeth as well on the occlusal surfaces. So we did a three step technique, written up a lot by Dr. Francesca Vailati. So we did the NCCLs on the outside, we built her up on the occlusal composites, we opened her up to a vertical dimension, I hadn’t seen her for a year, and she said to me, now, finally, I can eat so many different things. I can eat everything now, whereas before, I was so restricted on what I could eat because of the tooth sensitivity, because of the erosion.

[Jaz]
So that’s controversial question. Does Linda say that bruxism and occlusal forces may be a contributor to sensitivity?

[Linda]
Yep, because of the micro cracks within the tooth. So when we’re talking about sensitivity to patients, the first thing we need to understand that within five to ten minutes of placing whitening gel we are in the nerve of the tooth. And so, because some dentists think, well, they make up whitening as they go along because they’ve never really learned it and they just think it’s very, very cosmetic.

But actually, understand that it goes into the nerve of every tooth. That’s why we need to, that’s why I’m saying take a radiograph. We need to know, what are we dealing with here? Because the way bleaching works and the way sensitivity works, it’s all related to the actual anatomy of that particular tooth.

So if, and the way that the whitening works, it goes into the weakest part of the tooth first. So it will go into those micro cracks on those bruxes. It will grow into the crack where the patient has a crack tooth syndrome. It will go into a porous tooth and it will go into the non vital tooth.

It will find the weakest link to travel, which is why we need to know, that’s how exactly that’s how it works. And that’s why some patients, I know we spoke about white spots, but some patients, we’ve never had white spots. Suddenly when they were doing whitening, they come become very alarmed that suddenly there is white patchy areas on the tooth that were never there, according to them.

[Jaz]
This freaks them out, this absolutely freaks them out. And then what the patient does, they stop whitening. Whereas I’m hoping you’re going to say that actually they should be encouraged to continue, reassure them. And then we’ll get a good result. And obviously what you’ve taught me before, and I’m always echoing anything teeth whitening related, I’ve always learned from you, which is that is a sign of enamel damage. What’s that’s highlighting is damaged enamel.

[Linda]
So what is actually highlighting is there’s porous parts within the tooth and the whitening has, taken up too quickly. So that particular part of the tooth is actually the enamel anatomy is porous. So you particularly find this with the higher strength whitening gels, which is why we like you to go low strength. So suddenly they’re on 16% everything is suddenly all mottled when they never had mottled teeth. We’ve seen a lot of patients referred from other dentists because of this problem. And as you say, it’s reassurance that they need to continue whitening. They also shouldn’t do stop, start whitening where they’ll do two days and they’d stop for a week and then, because you want to have slow and low. Still, Jaz, that particular part of the protocol is still the same slow and low concentration as you go along.

[Jaz]
Excellent. So we now know the mechanisms. We know that the peroxide is reaching the nerve within 10, 15 minutes and always go the path of least resistance. In terms of predicting who is acceptable.

Obviously, now that we know this background information about, okay, the four questions that we’re going to be employing using restorative materials like Riva Light Cure, for example, to restore those NCCLs using desensitizing toothpaste. beforehand and finding the right formulation before you even start whitening.

So already we’re on to a winner, but I found it a surprise that some patients, I warn everyone on sensitivity and some people come back with significant sensitivity that they just can’t do it. My wife being included, like she, within like two days, she can’t do it anymore. I get a bit, but not too much.

Whereas some patients, there’s a particular patient I saw a few weeks ago, And bless her, she’s so sensitive to everything. Every time I’ve done a restoration, super sensitive, the bite needs time to settle, go very slow with her, easy with her, warner of everything. And I double, triple warned her before we started teeth whining that, okay, I think your teeth will be very, very sensitive.

I just have a hunch. She came back and she said, nothing, zero. Okay. And so, and her teeth looks fine. There’s no NCCLs and there’s no difference to some other patients. Are there any individual characteristic traits that people’s baseline level sensitivity is more than the others?

[Linda]
I think it also depends on tolerance. And I also think it depends on hydration. Hydration is a new area they’d be looking at. Because a lot of patients who have like a high lip line like me, the lower third of the tooth is darker. And the hydration, it’s to do with, if they’re not hydrated, the tooth, it’s dehydrated. And the whitening dehydrates as well, and so I think that contributes to the sensitivity.

So now, we also, with our patients, and especially with the little kids with the white spots, we’re looking at their hydration levels, and we’re looking at their dietary levels. Because the patients have high lip lines, class 2, sticking out teeth, they’re dehydrated, they’re not drinking enough water. And the teeth are porous and so they’re accumulating more stain.

But we go back to, first of all, water for all patients, because none of us actually drink enough water. So we look at the hydration and looking at why they’re sensitive. But most of the time, you can’t predict. So the research shows up to 80 percent of patients are going to be sensitive during whitening.

And this is particularly with higher strength. We try and predict and we look at what would cause them to be more sensitive. So some of the protocols would use the whitening gel 15 minutes in the morning, 15 minutes in the evening, and they discovered those protocols were more sensitive.

[Jaz]
Oh, wow.

[Linda]
And so, there are a lot of protocols like that, oh, you just do 15 minutes of double whitening a day, makes it more sensitive. Then it comes back to the tray, the tray design, and they think that a rigid tray makes it more sensitive. They did a study, and they just put bleaching trays in, and they discovered with no gel that 30 percent of people were sensitive just with a tray sitting around it.

[Jaz]
Wow.

[Linda]
So then the next study they did was they cut off the last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area and they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that. So if they’re so sensitive, like you were talking about your wife, cut back two millimeters off the bleaching tray on the cervical area. So it’s not rubbing.

[Jaz]
So you’re shying away from the gingiva. You’re like supragingival two millimeters.

[Linda]
You’re supragingival two millimeters above or even a millimeter above. And you may find that will improve it.

[Jaz]
That’s fascinating because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area.

[Linda]
So here’s another point. You can’t adequately bleach the cervical area. It’s never gonna be the same shade and that’s a myth. It’s never going to end. When patients come to see and they go, look, look, look, this is not right. And then we go, well, then just don’t bring, don’t bring your teeth down. Nobody’s going to see that.

You have to be realistic of what whitening will do and what it’s not going to do. On the root area, it’s not going to be B1++. Ever. With whatever whitening gel you’re going to use. So that’s an important factor. Again, it’s to do with the root anatomy and all that stuff.

[Jaz]
The thin enamel in that region, enamel being so important in the good whitening effect.

[Linda]
It’s not going to be the same. So that’s really, really important. The other factor is medication that patients take. When you were saying you need to look at medication, we also talking about roaccutane at the moment because roaccutane, I don’t know if you know this, but roaccutane, because we’ve got the ortho kids who whitening in the retainers.

And Roaccutane, again, it dries out the teeth, it dries out the skin, but some patients have dry mouths. And those little kids, often after Ortho and Roaccutane, because Roaccutane is a long period of time, the teeth are grey green. I was just looking it up last night again. And they think it’s due to the dehydration, because the Roaccutane dries out the mouth and the saliva as well. And you get the-

[Jaz]
I’ve never heard of this Roaccutane. Can you tell me what it is? I’ve never heard of it.

[Linda]
It’s called isotretinoin and it’s a medication like a vitamin A. It’s called isotretinoin and there’s different versions. The U. S. is Accutane. We call it Roaccutane, but it’s kind of standard protocol for the dermatologist to put the kids onto Roaccutane.

There’s a lot of write ups. I’ll send you some of the press releases about it, but let’s call it the Daily Mail, often those kind of papers will cover stories about Roaccutane because what it does, it causes depression in kids and suicidal thoughts. So this is quite an important thing. So coming back to always checking medical history on all our patients.

And if the kid is on Roaccutane, you need to tell them, well, you need to discuss with the parents and you need to discuss with the dermatologists. The other new drug, and they give it together or they swap them, is Lymecycline. You’ve heard of that one?

[Jaz]
Yes, heard of that one. That’s for, is that for acne?

[Linda]
Yes, but it’s the same. So either they’re on LYME, Lyme cycline, because we used to do minocycline, tetracycline, and doxycycline. But either on that, or they’re on roaccutane. And the roaccutane doses, the way it goes, it goes 20 milligrams, 40 milligrams, 60 milligrams, and it goes on for two years. So then you have to balance the acne versus the discoloration on the teeth.

And again, discussing with parents, of course, we’re not going to say with the child, but out the children’s welfare is really important. So we are understanding that on the racket and how long they’ve been on it. And not every child gets great teeth when they’re on reaction. And then again, you come back to talking about hydration levels.

So my next new business marketing idea is to actually print water bottles with our practice name on to give to the kids. And to give to the adults about drinking water, just drinking more water because of hydration effects, discoloration effects, and healing the mouth with water. I will write a paper on this, there just hasn’t been enough time.

[Jaz]
I love it because it’s putting the mouth back in the body, it’s reminding us that, we are, the theme of the AES, which I like to go to in Chicago, for 2026 is the oral physician and about the putting us back in the body, putting the mouth back in the body, which is so important.

So it’s a nice holistic approach and step back approach on this theme of hydration and dehydration. I’ve seen before exactly that kind of patient described, which had like a two tone appearance of their teeth. And they’re very, very grey. And I have found that on one instance a few years ago, this patient just did not respond as well to whitening as I wanted.

And it makes sense that, okay, it’s because of the fact that they have this profile whereby the lower incisal third or half is too dehydrated, I imagine, but it’s got this grayish appearance. Is there any hope for this patient with teeth whitening? Or are they looking at veneers?

[Linda]
There is hope and everybody responds, so everybody’s difference in their response and sometimes on those patients, because it’s dehydrated enamel, so think of it thinner, desiccated, more dentine laid down, so you get that two tone effect.

You need to go for the six to eight week protocol, whitening with low strength, coming back to the five percents. 5% carbamide peroxide, low and slow, but it can change and it can make a big difference on those patients.

[Jaz]
Can you name a brand of 5% carbamide peroxide?

[Linda]
Yeah, we’ll talk about that, but the last patient yesterday, short lip, the two thirds is dehydrated. Obviously, I spotted it straight away, but we were just having a general discussion about that, about her teeth in general and sensitivity in general. And that is a factor that is a factor and an interesting thing is that her boyfriend said you need to fix your teeth. First fix your teeth, darling and so we come back to understanding diet sheets coming back to those old fashioned diet sheets we was taught.

Get the patient to fill out diet sheets. Either a weekend day two normal days and have a look email it to them and email it back. And just have a look at what they’re actually drinking. You’ll find it’s not enough and that comes back to the discoloration.

So when you say the whitening is difficult, check on the, the whitening gel being water and it still can dehydrate the enamel during the whitening process. And for those patients who already dehydrated the results may take longer. So you keep going you keep going and going and they will get there, but it’s slower.

[Jaz]
With the dehydration often when we’re doing like rubber dam on with dehydration, we see the teeth get whiter, but I think in this instance, it’s like a chronic dehydration, which has the grayish effect. Have I got that right?

[Linda]
Yes, a chronic dehydration and it’s grayish because it’s the enamel is so dehydrated. It’s picked up some internal stain within the food, et cetera, that they’re eating. So yes, so then I want to talk about putting on a rubber dam and the rate of dehydration on a patient. You know when you’re about to start composite bonding. The first thing you have to do even almost before the rubber dam is on is choose your composite shade because so quickly the teeth dehydrate and you’re choosing lighter and lighter composites, which don’t blend.

So coming back to that the same rate that a tooth dehydrates is the rate that a tooth whitens. Now when you put on your rubber dam, just watch the tooth as it’s dehydrating because it doesn’t always dehydrate evenly. It will be a little bit patchy in places as it’s losing water losing water losing water. That’s the same pattern as how the tooth whitening would appear. It’s again associated to the path of least resistance.

[Jaz]
And this is again where we have to reassure a patient after they’ve got up and they remove the rubber dam why they got those patches in the same way with the whitening. You’ve repeatedly said about using a low insert protocol which makes a lot of sense.

In other countries, they’re using ridiculous percentages, 25, 30% sometimes, in Singapore I remember using such percentages actually. And it’s good in a way that we use low percentages here. 5% for carbamide peroxide. Any proprietary brand that you recommend?

[Linda]
There’s not many on the UK market. Basically, it is, the main one is Novon Mild from OptiDent, Henry Schein. And it’s got a special soother inside, which is a toothpaste, glycosine phosphate is the soother inside. So when we’re talking about concentration, we’re talking about, we can also talk about it doesn’t mean carbamide and hydrogen.

Carbamide has 16%, 10% and 5%. You should always have 5% available for a certain category of patients. Number one, those who’ve always like you, like you’re talking about your wife. He’s been so sensitive to whitening, they need to go on the 5%. Then, patients with Medically compromised history, health history, who have got complex medical issues for them.

Then those patients who’ve tried whitening before, and also you can see, we spoke about bruxers. If you ask a dentist, if they’ve done whitening, and then they had sensitivity, they’ll all tell you that they have on the lower incisors, they’re sensitive because we all bruxing, we all stress bunnies, and so we get sensitivity just on those lines, lower incisors, little micro cracks.

So on all those patients, and patients who’ve never been able to manage whitening before, It’s all with a 5% carbamide peroxide. There is another brand called Cavex, it’s from Amsterdam, 5% carbamide peroxide. But we would use that for those patients that are super sensitive. 5% carbamide peroxide is also used for therapeutic aesthetics. I don’t know if you’ve heard of this term.

[Jaz]
No.

[Linda]
Okay, I’ll send you my publications on this. So we use the bleaching tray as a therapeutic tray, which comes back.

[Jaz]
Oh, I see what you mean. Okay. Yes, carry on.

[Linda]
It comes back to all aspects of a patient’s oral health. So the bleaching tray becomes this therapeutic tray and we deliver different chemicals. So tooth mousse, MI Paste particularly, is really good for soothing and desensitizing. So on top of our normal protocol, which we’ve gone through before on home whitening, and that they just do the upper and then they do the lower. And just by the way, the reason for that protocol is because the upper teeth are not as sensitive.

So we always go to the positive upper whitening first. But because of that, we would always give our patients a brand of proprietary soother. There’s quite a few different ones, but I’ll just tell you, tell them to you. The main one is, it’s either tooth mousse or MI paste because it’s got ACP inside. And ACP is a tubular blocker, and it also works on the enamel to smooth the enamel and the defects in the enamel. So, that is great.

[Jaz]
And also good for ortho demineralization, early white spots. It can be quite curative without teeth whitening, right?

[Linda]
Yeah. Decal’s really, really good for that. Yes, you can use the DuraPhat toothpaste as well, but to put in the bleaching tray, we can use Tooth Mousse, MI Paste, and there’s a new one, which is MI Paste Plus.

[Jaz]
That’s the one with fluoride?

[Linda]
Yeah, the tooth mousse doesn’t have fluoride, but the MI paste does have fluoride, different concentrations. Then the proprietary one, there’s one from called Relief Gel, and that’s from Philips, night white, Relief Gel, and Philips brand has got ACP, potassium nitrate, and fluoride inside. And you put that, you run a line into your bleaching tray, and the patient would wear that an hour a day. An hour before lightning. An hour instead of whitening or an hour after whitening, and that should solve your issues with sensitivity.

[Jaz]
And that’s a top tip right there, I think. I mean, did you use it, which I do, and I was going to ask you about that in terms of what you recommend to put inside it. How about those high, in the past what I’ve done, not related to teeth whitening actually, but high caries risk patients, patients where root caries prone patients, patients who’ve had, let’s say radiotherapy, and their saliva is going to be low and poor quality.

I often give them like a very passively fitting Essex retainer. And then I encourage them to use certain agents like Toothmousse. I go and I show them on Amazon, which one to get. Do we have sufficient evidence base for that? Or is that something that you’re a fan of?

[Linda]
Oh, yes, we do have evidence. It’s not just a random thing. There is a lot of evidence on that. And Professor Van Haywood has published a lot on this. Then, the other study that was done by a guy called Lazarchik, 2010, was for special needs patients. So but you use also for those special needs patients, the carbamide peroxide in the low concentration.

So those patients who are high caries rate patients, they did a study and the guy’s name is Yao, 2013, where they looked at the difference between chlorhexidine, and chlorhexidine and carbamide peroxide, and they found that carbamide peroxide was more bactericidal to help the gingiva than actually Chlorhex.

So on another WhatsApp group that I’m on, a digital group, they were showing a case where the patient, they did new crowns, the gums were all swollen afterwards, they redid the crowns, the gums were still, upper 3 to 3, gums were still swollen. So I said to them, put in a bleaching tray with carbamide peroxide 5% inside, and just heal the gingiva.

Then go back to taking all those crowns, putting provisionals, keep with the carbamide peroxide to get everything balanced. Make sure you don’t invade the biological work before you go to be able to do that. But this is quite a top tip in terms of that. Your elderly patients who have poor oral hygiene, the five, on the label, this is a little controversy because on the label it says, only for tooth whitening purposes.

5% or all of them say for tooth whitening purposes, but we use it for healing because it’s been used for healing for 70 years. This was the whole discussion. That’s how the whitening was invented because the orthodontist nurtures the gingiva with swell. So that was, why we would do that, but 5% in the tray, 5 percent upper, 5 percent lower, 1.2 percent. So the other soothes, which we didn’t mention this Pola soothe, Pola soothe is from SDI and that contains potassium nitrate and fluoride. And then you also have Opalescence. It’s called Ultra Ez. It’s from Utah products. Again, it’s another Henry Schein Octanet product.

That one is just a syringe of potassium nitrate. So the way that potassium nitrate works for sensitivity is it stops the polarisation of the nerve. So stops the nerve continuing to fire, it cuts it with the potassium nitrate and just kind of temporarily paralyze if it stops it. So the nerve is not firing.

So that’s why we use fluoride for blocking the tubules. We use potassium nitrate to stopping the repolarization of the nerve. We use ACP for blocking the tubules. And another product which you use, which we mentioned when we’re doing the NCCLs is the HurriSeal or the Gluma. So the Gluma is just a liquid, or the HUrriSeal is a liquid, and again you’re blocking the tubules.

You can use it as an intermediate dentine seal as well. If you’re finding that a lot of your composites don’t work, I’m not you personally, you really know what I mean, but once composites, you do your normal protocol and patient has post operative sensitivity, which we all hate, but sometimes we need to re remove the composite because it’s pulling in, all those stories.

Actually, we do it, you do your etching, you put the HurriSeal in and that stops it. That was a colleague of mine, Dr. Mervyn Druian told me about that. So the HurriSeal is very useful for all those sensitive patients, for all those ones, and again for restorative care/post-operative care

[Jaz]
I think you’ve taught me as well, because I believe your son’s doing wonderful work with AI, actually, and notes and stuff, and I’ve been in this space as well, and often, I don’t know if you’ve actually counted how many words are spoken, in a one hour consultation, it’s like 10, 000 plus, it’s actually crazy, and I feel with the pace that me and you both speak at, we’ve probably hit 20, 000, and I know that dentists have got incredible value from you.

One personal takeaway now, I mean, all the protocols said brilliant. Some things are great revision for me. But what a wonderful reminder you gave us, right? That the cervical region just won’t ever whiten as well as the others. And I think we forget that. And when we, when we talk to patients and we take that photo with the shade tab, we say, it’s going to go this way.

Just pause and say that, oh, but not this part. It’s like, imagine you’re in Lion King. Okay. You can go there, but you can’t go there. Like, just think of Lion King next time you’re whitening your patience. And I think it’s a great reminder and I look forward to adding more resources from you in the show notes.

I know you’re involved with so much. You’ve got some amazing events coming up. I’d love for people to come and learn more from you. Cause every time I speak with you, I learn so much. Every time people meet you, your energy is brilliant. How can we get more of this energy? Where are you next speaking at?

[Linda]
So our next gig is an important conference. It’s called Future Dentistry. It’s on the 1st of November at the BDA. And we would like more dentists to attend. We have an amazing lineup. First of all, talking about dental AI and how we can implement it into our practice from all different aspects. We talk about the future of contemporary restorative zirconia crowns in there’s an onlays, there’s an zirconia veneers.

We talk about early intervention orthodontics because there’s this whole thing everybody waits to the right time but Professor Peter Mossi will be talking about how you really properly early intervene and what you need to do. We’re talking about the latest techniques in implants.

What is new? What’s the future? How are we going to go with this digital dentistry? How we integrate it? the different scanners and all the different techniques. The dental technicians will be talking from their angle. We also have to have a medical legal update, a safeguarding update. So you are fully up to the-

[Jaz]
Core CPD is ticked off as well then.

[Linda]
All your CPD or your core subjects is all ticked off. But the benefit of this is that by attending the conference, you actually are contributing to the charity, to the work of the charity to help more patients attain dental wellness, which is really important.

[Jaz]
Well, I’m definitely gonna put the link but you know for those who are maybe driving around click check the show notes but do you know, is it the BDA website? Is that what they book?

[Linda]
They book through event brite and i’ll send you the link. It’s first of November, BDA.

[Jaz]
Perfect. And those topics that you covered are very sought after topics that Protruserati ask about, especially the inceptive orthontics. AI is such a big thing. I’m a big fan of it. And I encourage everyone to explore these avenues.

I think people are sometimes shy or they’re like, I’ve been doing it for 10 years, I don’t have a problem. When they learn to embrace AI, they suddenly gain four or five hours a week that they never knew they had, they could possibly to have, and it reduces your stress, improves your quality of your notes.

So it’s amazing you’re talking about that. And also yes, zirconia, partial coverage restoration. Something I’ve talked about, not talked about, but such I asked about on the podcast. It’d be interesting to hear an update on that. So I’ll definitely put the link in the show notes and fantastic topics.

Linda, I’ll put all your show notes, all the sort of follow links and all your wonderful things that you do. Thank you so much from the Protrusive community for all you do, the charity work, the education. I can’t believe you’ve been in this game for 40 years plus. That’s amazing. Please can we have another 40 years because we don’t retire anytime soon.

[Linda]
So nice to talk to you. It’s lovely to talk to industry with you. You’re very inspiring. You do amazing work and thank you for all you do on your education and all you do to inspire so many leaders. Your impact is huge all over the place. Whenever I go to dental meeting there, I heard you from the Jaz podcast. It’s all up to you, Jaz, and all the Protrusive things and all the wonderful things you do. Thank you so much.

Jaz’s Outro:
Thank you. Thank you so much. There we have it, guys. Thank you so much for listening all the way to the end. Don’t you just love Linda’s direct nature? She is brilliant. Please go and support her, learn from her and her colleagues on the 1st of November.

And if you want any of the resources, some of them will be available on YouTube or wherever you’re watching this. And the rest are on the Protrusive Guidance. Don’t forget to get that infographic only on Protrusive Guidance. I want to thank my team as always. Erika, Mari, Gian, Krissel, Julia, Nav, Emma.

Our team has been growing throughout the years, as have you guys. The subscriptions on YouTube and everything, they mean a lot. But if you really want to support Protrusive and get the most out of it, we’d love to see you on the app. I’ll also put any papers, any links that Linda suggested, including the Eventbrite link for her event on the 1st of November.

And if you found this episode useful, please share it with a colleague. This is how the podcast grows. This is how we’re able to attract wonderful guests like Linda to help make dentistry tangible, which is the ultimate mission of this podcast. For those on a paid plan and Protrusive Guidance, scroll down, answer questions in the quiz.

Mari, our CPD queen, will email you a certificate. And yes, we are PACE approved. So if you’re in the US, you’re going to love it too. Thank you so much again for listening to the end. I’ll catch you same time, same place next week. Bye for now.

It’s Friday and you’re fitting the last patient’s crown. It is completely shy of the bite – but it looks good. The patient says ‘it feels great! I can hardly feel anything!’

Do you cement it (plant it low?) and let it grow? Is that acceptable?

How about the ‘GABS occlusal philosophy?’

Is ‘centric relation’ full of unicorns and rainbows?

What is an efficient protocol in ‘checking the occlusion’?

Join us in this episode where we discuss some key techniques to help ensure we are managing occlusion as a primary focus when dealing with restorative treatment. This episode is packed with essential tips that are perfect for dental students and professionals alike. 

Don’t miss the special notes on Occlusion, CR & All Things Confusing available exclusively in the Protrusive Guidance app! (Crush Your Exams section)

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

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

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PDP109 – Articulating Paper is Lying to Us

Teaser: Here we are, a little bit late, but this is the Protrusive Students version for Occlusion Month. We've got our Protusive student, Emma Hutchison, who once again has done a wonderful job to create these student notes.

Jaz’s Introduction:
You can download these for free on the community, there’s a special students area, and you can also catch up with the previous nine other Protrusive student notes, bespoke notes, just for students. Very visual and written by Emma herself, inspired by what she’s learning at uni and also what she’s learning online. Head over to protrusive. app to check that out.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This episode is huge. Like when I was a dental student, anything to do with occlusion was mega confusing. Like even down to adjusting a basic composite. Like you’ve just placed a composite, and you’re picking up the bur, and you have no idea what you’re doing. Was it just me, or is that you as well?

Well, how about we cover in this episode for the benefit of students, and of course, anyone in dentistry, or dentists can actually learn something from this episode, I think. We need to talk about some specific protocols taught to me that I’m sharing with you guys, and we go deeper into what actually happens if you start leaving teeth out of occlusion, i. e. You restore a tooth and now that tooth is no longer actually touching the opposing tooth. It’s no longer contributing to the patient’s occlusion.

Is it always a sin? Is it acceptable? And how do you actually go about avoiding that? Like, how can you actually be more precise in your occlusal adjustment? We also, of course, talk about the influence of different thicknesses of articulating paper and why you should avoid using thick papers. There’s a lot to unpack here, so let’s join the main interview and I’ll see you in the outro.

Main Episode:
Okay, Emma, you just had some exams. Okay, so welcome back. How was it? How did it go?

[Emma]
It was okay. I think they’re always going to be a bit rough. This year I had two written papers. I had one multiple choice paper, which was okay. And then the second one was like a multiple short answer, which is always the trickier of the two, I think, for me anyway.

But they changed the format of our MSA short answer one this year. So it was just a wee bit different. They changed it from, I think, 20 questions worth 10 marks to 15 questions worth 13 marks or something like that. So it was just a wee bit different to what I’m used to.

It meant maybe things went a wee bit more into debt, which is difficult for dentistry because you need to know, I think for the exams, you need to know a wee bit about everything, and then sometimes that’s enough to sort of get you the marks that you need, but especially this year, less questions more focused. So it was a bit of a shock to the system, but I think it was okay.

[Jaz]
Good. And the OSCE was?

[Emma]
The OSCE was okay.

[Jaz]
So just because there might be some international students who maybe they don’t have OSCEs in their uni. I don’t know. Like, can you just tell us about what an OSCE is?

[Emma]
Yeah. So our OSCE is quite similar in the UK for your entry to dental school. You’ll have what’s called an MMI, Multiple Mini Interviews, I think it is. And you are in a clinic or a group of rooms, you stand outside the door and you have one minute to read whatsoever’s on the door. And it’s the worst feeling in the world.

And you have to go in, do this station. Sometimes there’s actors there, like paid actors that you’re interacting with, and you’ve got a clinician there who’s marking you on what you’re doing and in Glasgow. In third year you have 10 stations and each of them are five minutes long and then you get one minute each to read your instructions. So it’s just boom, boom, boom, boom, boom.

[Jaz]
So it could be like a Paeds thing, then a perio thing, then a restorative thing, like study models on the table. Give us an example of a one OSCE station that you remember.

[Emma]
I can tell you all of them. So this year I had rubber dam. Three to three on the upper, canines to canine, and you had five minutes to put it on wedjets in each side and floss ligatures on the two centrals.

[Jaz]
Nice.

[Emma]
And we had the exact same station-

[Jaz]
So, well, I think it’s impressive that as a student you’re doing floss ligatures. That’s pretty cool. Right? Okay. You don’t think so?

[Emma]
Obviously. Well, everyone got it finished. The thing is, like, with the OSCEs, you don’t have to do the station perfectly to pass. I think all of them are marked out of, like, 10 or 15. So last year, we didn’t have a nurse there to help us. So I managed to get the dam on, but I didn’t get any ligatures on at all. And it was my, I think it was, one of my last stations last year, I was fatigued.

I was tired. But this year it was my first station and I don’t think I’ve done rubber dam since my last OSCE a year ago. So I went in to this station and it was my mentor James Don standing there. I was like, oh no, what is this going to be? Some end of station ended on six stations. So I’m standing there and I’m reading it and it’s like rubber dam three to three. Floss ligatures, but we had a nurse there to help us this time, which was good. So like getting the nurse to tend to the dam for me, she helps me floss and I managed to see-

[Jaz]
You’re probably getting marked on also the communication with the nurse or how you are instructing them to help you. So that’s good. I think it’s really good that you got to do that in your OSCE. I never had a rubber dam station in OSCE. I remember having some orthotic models. No, it sounds like a good one. Is it like a phantom head? Is that what it was?

[Emma]
Yeah, bonafide some hedge, yeah. We had an ortho one as well this year, yeah, so writing a prescription for a upper removable appliance, yeah, which was okay.

[Jaz]
Lab prescription, yeah?

[Emma]
Yeah. Yeah.

[Jaz]
Okay. Very good. There was a four letter acronym or whatever, or the way to remember. What’s it called when you use four letters, mnemonic. There was a four letter mnemonic for-

[Emma]
We use ARAB.

[Jaz]
That’s it.

[Emma]
We use ARAB, A R A B. That’s what we use.

[Jaz]
Go on, you have to say now what it is now. It’s like Anchorage?

[Emma]
The first A, well in Glasgow anyway, is your active components. R is your retentive components. Then your anchorage and then your base plate.

[Jaz]
Yep, yep. Very good. Well done. Let us know how you get on with the results. I’m sure it’ll be fine. Well done. So today we are catching up after a little while because we had a little break for exams and stuff. Obviously this is coming out much later in the year. But you got some exciting things planned. Is it a good point to tell us about? Actually, I think when you come back from your elective, it’ll be good for you to tell us about how it went and what you got up to and stuff. But just give us a flavour of what you got planned for elective.

[Emma]
Yeah, so we have changed our electives in Glasgow to the end of third year rather than fourth year, so that you don’t have such a big gap in between your fourth and final year. So basically you get a mentor. As I said, my mentor’s name is Mr. Don, and he’s an endodontist. So I’m going to be doing, what’s the word, a literature review. I’m going to be doing a literature review about hypochlorite injuries. And putting together some statistics for that and hopefully constructing a guide for students and maybe other dentists on how to communicate this sort of risk with your patients.

So that’s mine. I’ve got friends that are doing all sorts of things. I’ve got friends that are going to the other side of the world, which I am going to be doing, but I’m going to be finishing my elective before I go away. And then I’m going to be traveling Southeast Asia. So it’s very exciting.

[Jaz]
Well done. Really important to do that when you get a chance as a student. I had great memories of doing my elective in Vietnam actually, and then traveling Thailand. It’s a great opportunity in life. It’s very difficult to get that time and opportunity in life, especially, being young and stuff. So well done for taking that opportunity, which is great.

So exciting. Today’s episode, and then you can tell us about the student notes you’re going to add on as well. But today’s episode is Occlusion. One of my favorites. So we have had a few episodes on Protrusive before when we talked to students about occlusion. So I’m interested to hear what kind of questions at this stage in third year you have, because the issue with being in third year, you haven’t seen enough cases, you haven’t seen things come back.

You haven’t seen a lot of the issues with occlusion, like the fractures that could happen, the fremitus, the tooth movement that can happen. So you are very much led by the textbook, but you crave that clinical experience to really connect the dots. So please, questions do you have?

[Emma]
So first question again, I always like to start with a bit of a broad question. We only recently started being introduced to fremitus at the end of our third year, and sort of when to conform to an occlusion and when to reconstruct. So just in terms of your experience at dental school, what were you taught about occlusion and how has your sort of understanding and your approach evolved since then? Like, what’s different?

[Jaz]
Okay, so at dental school, not that it was sold to us or taught to us this way, but dental school, it was the GABS occlusal philosophy. Do you know about GABS?

[Emma]
No, no, I don’t.

[Jaz]
Okay, so GABS stands for grind all blue spots. Someone taught me, I went to Chicago recently and he mentioned this and I was like, oh my God, that’s, it’s genius because it reflects my own experience because I don’t know about you, Emma, but when you’ve done a restoration. And then, okay, let’s take it way back. When you are doing a restoration, before you pick up the handpiece, do you check the occlusion?

[Emma]
I do now because I’ve worked with you for a year.

[Jaz]
You do now. But I’ll tell you what, most dentists, okay, I want to say most, a lot of dentists, especially younger in your career, me, myself included earlier in my career, you pick up the handpiece first, you fix the caries, you do the restoration, then you pick up the articulating paper, then you have no reference or baseline.

So the first thing is that we went, okay, maybe I was taught or not, but I wasn’t doing it as a student. I wasn’t checking the occlusion. And then when you place the restoration, I pick up the biggest, thickest paper in the world, the 200 micron Bausch articulating paper. I don’t know which articulating paper you have in your dental department.

[Emma]
Similar. It’s pretty thick. Yeah.

[Jaz]
Yeah. And so do you know what the issue is, Emma, with using thick paper versus using thinner paper?

[Emma]
I don’t know. I suppose it, is it just not as accurate? You’re not going to get that sort of those pinpoint blue dots that you want to see. I don’t know if it’s too bright and you’re just going to get so much contact.

[Jaz]
Perfect. You’re going to get false positive. You’re going to get ink smears, which aren’t really representing a tooth contact. It’s just the ink was in the way. So imagine you’ve got something that’s 200 microns thick, which is the paper, let’s say. Now your filling is out of the bite by a hundred microns, but because you’re using something that’s thick enough to fill that hundred microns plus more, you’re going to think, ah, it’s an occlusion.

Just giving you an idea there. So by using a paper like that, you get too much data and that’s an issue. And so I did not use that in practice, eventually when I learned about the different papers that exist, I realized that actually we should be using thinner papers. So I have access to 8 micron paper, which is TrollFoil, it’s a brand, but my day in day out is something called AccuFilm, and it’s 25 microns, and that gives me nice, neat, pinpoint marks and reduces the chance of false positives.

So going back to GABS occlusal philosophy, grind all blue spots. What I meant by that is you place a restoration, you check the occlusion, and then tell me about what are you thinking? What are you doing when you’re adjusting that composite?

[Emma]
In terms of where you see the blue spots?

[Jaz]
Yep.

[Emma]
I don’t know really, it’s, I don’t know. Like you’re just-

[Jaz]
I was the same.

[Emma]
I suppose as soon as you start grinding away the ink goes away and then you just, I don’t know, I find myself using articulating paper so much and watching other students do it because as soon as you put the bur over it, the ink goes and then you just have to do it again and again and again. I don’t know.

[Jaz]
And then when do you stop?

[Emma]
Yeah. When do you stop? When all the blue spots are gone. I don’t know.

[Jaz]
That’s it. That’s it. Right. So that was my understanding of occlusion at dental school because I didn’t know what was going on and you do it. Okay. All right. How does it feel when the patient says it feels great. It feels as though you’ve hardly done anything at all because you’ve now put this restoration in hypoocclusion, not hyper, hypo.

It’s now shallow, it’s shy of the bite. So you have to think then, okay, is that really doing your patient justice? Is that a precision dentistry? It’s not, right? So moving on from dental school, learning about these things, using the correct papers, being trying to be a bit more precise, really looking at the anatomy of the teeth, studying the anatomy beforehand to make sure.

That I can minimize the adjustment, but at the same time not be proud. So when you go thinner, you are less likely to grind things away and also, what you can do at that point is just check bit by bit. So for example, really top tip I can give you is if you’ve just done a restoration on the right side, the first thing to do is use your articulating paper, let’s call it a hundred microns, to make it maths easier.

So you’ve done the restoration on the right side, you put the a hundred microns on the left side, you get the patient to bite it together, the patient is now holding the paper, i. e. you cannot pull the paper out. It’s scrunched between the teeth. Okay. So what this tells you is that the left side is touching, but it’s touching within a hundred microns.

Now what you do, is if you get your 50 micron paper, you might find that actually the left side is pulling. Emma, what does this mean? The 50 micron paper is now, you’re able to pull it out. There’s no, the teeth aren’t grabbing on the left side. What could this mean?

[Emma]
So there’s maybe a discrepancy between 50 and 100 microns.

[Jaz]
Yeah, spot on. But what is causing this discrepancy?

[Emma]
Your restoration that you’ve just done on the other side?

[Jaz]
Perfect. Right. Yeah, exactly it. Right. Exactly it. So because the 50 is pulling, 100 was biting between 50 and 100 microns. Why is this information useful? Because it tells you how close or how far you are, which will guide you already in terms of what grain of diamond bur you’re going to pick up.

So I can pick up the softer red one or the aggressive blue one. And if you’re out by like that much, I’m probably going to pick up the blue one in that case or the red one, just spend a bit more time, press a bit harder. It just gives you information. And so then when you’re biting on the left with something like eight microns of shimstock foil, for example, then, you know you’re pretty much almost there.

And that gives you a nice little guideline. So little tricks like this I picked up along the way. Lots of mentors taught me, including a hat tip to Dr. Michael Melkers, who taught me a lot of my foundational stuff, Dr. Riaz Yar as well. So I think that’s how it evolved. It’s an evolution you’re always learning, but just getting the simple tap, tap, tap, correct. Even that was a learning experience moving out of dental school.

[Emma]
Yeah, definitely. And I think having all your armory of articulating papers would definitely help with that. And once I’m out of dental school and I’m away from the 200 microns, we’ll be getting all the three, four or five different types of articulating paper.

[Jaz]
Absolutely. But just to clarify, you don’t need more, you just need shim stock foil, which is eight microns and something like a 20 micron, 25 micron paper. That’s genuinely pretty much all you need. So yeah.

[Emma]
Yeah. Okay, cool. So what are the consequences of if you do go into this hypo occlusion and you’ve taken this restoration straight out of the bite, what does that mean for the patient?

[Jaz]
Great. Have you heard of the term, or the saying, plant it low, let it grow?

[Emma]
Yes. Over eruption?

[Jaz]
Exactly. You’re absolutely right, Emma. If you actually have it in hypo occlusion, i. e. you plant it low, usually some over eruption will happen, some tilting of the molar will happen, and eventually you’ll find that in six months time it’s gone in the bite.

Is this a massive sin? Maybe not. But imagine every time this patient has a filling, right? And the tooth over-erupts and the tooth over-erupts. And then by the end of it, they’ve kind of lost control of the occlusion. They’re kind of in all sorts of non ideal positions. So it’s not a good thing to aspire to.

It’s not level of dentistry we want to do, but that’s kind of what happens. But then you have to think a really important thing is every patient is different. Imagine that a patient has an anterior open bite, meaning that the front teeth don’t touch and there’s a big space between their front teeth, right?

So only their molars are touching. Imagine actually only their second molar and first molar touching on each side. So even the premolars aren’t touching. So you’ve seen anterior open bite cases like an ortho teaching and stuff, right?

[Emma]
Yeah. Yeah.

[Jaz]
Good. So now imagine you need to do a crown on one molar on the right side. You do the crown and you notice that it’s completely shy of the bite. For this individual, right, they only had four occluding pairs, right, now they’ve only got three occluding pairs left. Now, you’ve actually demolished 25% of the occlusion. That’s a lot in one go. So maybe what’s going to happen with them is their muscles are going to go a little bit funny.

The joints are going to seat a little bit more on one side. So you have to think about the greater articular system. And so what I’m trying to say is that if someone’s got a really nice occlusion, lots of teeth, lots of contacts, I wouldn’t cry if your tooth is in hypo occlusion because as long as your intention was there to be precise and you learned something from that case.

And usually when we’re shy of the bite, we’re only like, 10-20 microns shy, which is really not too bad. When they’re chewing food, it’s going to be irrelevant, right? But in the long term, you don’t want to do sloppy dentistry where you’re doing GABS, you’re getting rid of it all because yes, there was some overruption that’s going to happen.

You might introduce some inclined contacts, meaning that it’s not contacting the middle of the tooth anymore. It’s contacting halfway up and that has consequences like cusp fractures and stuff in the future. So it’s not something good to aim towards.

[Emma]
Okay, okay. So I suppose best practice, yeah. Don’t do, grind all blue spots. No, I’ll definitely keep that in mind. Because I suppose then, if you do that over and over again, on the same tooth, more and more restorations, I suppose could you end up getting sensitivity in the future? Like if your teeth start to over-erupt, is that something that could happen?

[Jaz]
Not in my experience. I don’t think the over eruption per se is going to cause that. If you look at studies whereby a molar has been removed and you look at the upper molar, in the first two years, I think it is, right? You get over eruption. I think that the reference is Craddock. Let me just find this for you guys.

Craddock studies. Which is the name that comes to mind when I was doing my DC training. Craddock overruption. The data on eruption is pretty cool actually. So let’s see. Okay. Craddock et al found overruption of a maxillary first molars after loss of opposing mandibular first molars, right? So this is, yeah, so it’s called a study of the instance of over eruption interferences and unopposed posterity. So imagine you lose a molar, how much will that opposing molar overrupt? Okay. So let’s have a look. 81 males, 74 females. One thing you’ll learn in the future is the how to read a paper and software. Just looking at the abstract, looking at the mean age, let’s see.

83 percent of sites displayed overruption. So more than likely, right? Overruption will happen more than likely. So that’s the first thing. The next thing to know from the study is it ranged from half a millimetre to 5. 4 millimetres. Okay, so that’s a lot, right? Do you know sometimes you might see in a case where the upper molar has completely now grown down to touch the gum of the lower?

So that’s in those cases where it happens so much. So the reliability of the observation was found to be good. A total of 51 percent of unopposed teeth were involved. The takeaway here, yeah, 83 percent of unopposed teeth will over erupt and the extent can vary from memory though, when I looked at this paper in detail, it says, yeah, 0. 5 to 5. 4, but the average is around about two millimeters from memory.

So this is the eruptive potential of the teeth basically, but when we’re doing restorations, we’re not leaving them out. I hope by two millimeters. It’s usually a much finer degree. So it’s quite predictable that most of these teeth will over-erupt basically into position again. But again, that’s not ideal of it happening. It might actually swing one way and it might mess up the occlusion long term every single tooth that it happens to.

[Emma]
Yeah, that makes sense. And I suppose if you can avoid that, then avoid it as you can.

[Jaz]
It’s all about taking the joy in being a bit more precise and actually making it like, I’m trying to do my best here and you don’t cry about it when you get wrong. Cause actually trying to balance a 32 legged stool is a bit difficult when you think about it. So, if you’re off by a few microns, it’s okay. The PDL will just sort that out for you. But if you’re consistently half a millimeter shy, then I worry about the level of precision you’re working at.

[Emma]
Yeah, a 32 legs still. That’s funny. I’ve never heard of that. The other thing I wanted to talk to you about, Posselt’s envelope. I know that’s your thing. That’s your jam. Retruded contact position versus centric relation. We had a lot of zoom discussions, like revision discussions with like me and my friends going through questions, et cetera, et cetera.

And I know that there’s a difference. I just, I honestly didn’t know how to explain it that well. The only reason is because of doing premium notes on past episodes with yourself, and I know that there’s a difference, but I just don’t really know how to explain it very well. So you could help me with that?

[Jaz]
Absolutely. So the question is a difference between RCP and centric relation. Is that what you mean? Is that the question? RCP versus CR. Is that the question?

[Emma]
Yeah.

[Jaz]
Okay, fine. So, they essentially are the same thing. The intention of the person who writes it in their textbook or how it’s used, they mean the same thing. However, retruded contact position is a very old term. It comes from a time whereby we used to think that the position that the condyle was supposed to be in was up and back. So distal most uppermost kind of thing. So we used to think that, right. I think it was like seventies, eighties, and then eventually progressed to actually nowadays is superior anterior.

So to use the word retruded means that someone’s got to retrude their condyle. Actually, it’s a term we don’t tend to use anymore. You’ll see in the older textbooks because actually we don’t think of it as that anymore. So the newer terms actually are stable condyle position. Okay, I know it gets confusing, all these terms stuff, but stable condyle position is a more accepted term.

Centric relation, these are all similar terms. Essentially, they describe the condyle. Okay, the condyle, it’s all through the condyle. It’s nothing to do with the teeth. Okay. It’s all through the condyles when they are superior, anterior, and they’re up against the articular eminence. And they’re like in a nice snug place where they can nicely rotate and the shapes are roughly matching. And it’s a nice, like, it almost like snugly seats inside, like an egg into an egg bowl. So if you think of it like that, it’s a nice stable position.

[Emma]
Yep, okay, okay. I’ll need to dig out that, that question that we were looking at because it was a multiple choice question and fair enough we don’t have like past papers or anything at Glasgow so it was questions that other students had written and it was something about the different choices were like RCP, centric relation, ICP.

So I’ll need to dig it out and see what you think of that question. Nothing like that came up in our exam actually. But yeah, I’ll dig it out and I’ll see what you think because I like did not know the answer and just praised that it didn’t come up in the exam and it didn’t.

[Jaz]
Good it didn’t. But you know what? This is highlights an issue that’s worth spending a few seconds to talk about, which is, the number one confusion when it comes to occlusion is the definitions, the changing definitions and the difference in how people interpret those definitions. So for example, C O, right, it actually means two different things, two different people.

You have two different people in the room and you say centric occlusion. One person will think it’s the MIP, it’s their normal bite. The other person will think it’s the first point of contact when the condyle is in centric relation. So this is why we need to really start trying to understand where someone’s coming from and maybe move away from these older terms and speak in a way that’s a bit more universal and everyone understands where we’re coming from.

[Emma]
Yeah, yeah, I think that’s what’s tricky about Occlusion, Posselt’s Envelope. There’s a lot of terminology, but I know that you’ve got a lot of good teaching out there and definitely lots of episodes that I’ve taken part in with the premium notes and watched myself, so those are definitely things to have a wee look at if that’s something that’s just like myself, it’s just a bit overwhelming sometimes.

[Jaz]
Totally. And I’ve got the whole student video section. So we’ve added two videos so far. The routine checkup, we’ve added a full one. And also we added another one recently, a rubber dam one that was requested by Mohamed Abo-Basha. And I’ve also got like simple infiltrations, ID blocks, that’s all coming as well, basically in there.

And so anything inclusion related that you could think of, just ask me, we could do that. But when it comes to the Posselt’s envelope, which you mentioned, are you happy with what that envelope represents?

[Emma]
I think I’m relatively comfortable with Posselt’s Envelope. A few of the definitions I know like we were just talking about can be a bit overwhelming, but like as far as I’m aware, Posselt’s Envelope, mid sagittal view of your maximum border movements.

[Jaz]
Well done. It is. So basically the extreme positions that you’re lower incisor can go. All the way open, all the way protruded, and tracing all the way back, basically, the extreme border movements. But you’re right, it’s mid sagittal, but actually, the Posselt’s, it’s actually a 3D thing. Because there’s a side to side as well, right?

And in one of the Scandinavian unis, which Posselt’s was, I believe, a professor at, they have like a statue of Posselt’s envelope 3D at that uni. Exactly. So do you know which one it is? Yeah. Is it Gotham or not? Is it Gotham? That’s from Batman, right?

[Emma]
I couldn’t, I couldn’t tell you. I couldn’t tell you where it is, but I’ve seen a picture of it because I know Dr. Alani, who I know that you know. We had him in first and second year for a lot of occlusion type things, tooth morphology, and I remember him showing this, a picture of that statue in one of his lectures. So yeah.

[Jaz]
Good. And so people confuse it for the Posselt’s envelope of function. It’s not to do with function at all. It is just anywhere that the lower incisor could be in space and time, it’s just like a diagrammatic representation of that.

[Emma]
Yeah, I think it can be quite overwhelming, especially because there are three planes of view. But definitely in Glasgow, we very often get quizzed on our mid sagittal plane, but no, it’s very interesting. It’s very interesting, but we’ll pop in maybe a wee, a wee picture of that statue and we’ll find out where it is. Not Gotham.

[Jaz]
Definitely not Gotham. Batman would not allow it.

[Emma]
So in terms of, let’s say you’re choosing to reconstruct a patient’s occlusion for whatever reason, for reasons that I probably don’t understand yet. We’ve not really gone into anything too in depth about reorganizing occlusion.

[Jaz]
And you wouldn’t, it’s more like a postgraduate thing anyway, so.

[Emma]
No, yeah, no. But just out of curiosity, what measures would you take for long term stability and sort of maintenance of those occlusal outcomes for your patients? Like, are there specific follow up protocols or patient instructions that you would give to your patients to support that? Or like, what do you do?

[Jaz]
Good question. Okay. So firstly, even before you start cases like this, it’s important to do phase one. Bread and butter, oral hygiene, carrier stabilization, perio, make sure they’re dentally fit and well before they do any complex work like crowns, onlays, changing the vertical dimension, that kind of stuff.

Imagine you’ve done all that and you’ve placed your crowns and dentures and everything and maybe they’ve opened up the bike because there was severe wear or whatever. At that stage, okay, we need to then explain to them beforehand actually that what you are buying from us, what we’re doing for you, what we’re doing in the form of care that we’re giving you is you’re buying a very fancy car.

Okay. You have a Ferrari in your mouth, right? Therefore, we need to make sure we use a different oil for this Ferrari than any other oil. Okay. We need to make sure that you have your servicing. Your servicing is going to cost a lot more than the Vauxhall one, but it’s going to be something that’s necessary to maintain your Ferrari so you can actually enjoy it for the rest of your life and get as long out of it as possible.

So you kind of have that chat beforehand. They know what is involved and they know that there’ll be a maintenance regime. So for example, if In terms of like a warranty in a way, a lot of letters that I do will explain that it’s really important to me to do good work. So I’m going to honor, like if something happens the first five years, I’m going to honor it, providing that you’ve been attending your hygiene visits and an individualized recommendation for that patient, twice a year, three times a year, whatever, depending if it’s got peri or not.

Are you going to see me for two checkups? One of which might be a longer checkup. Okay. So instead of the usual 20 minutes, it might be 45 minutes and they’re paying a bit more and then they know upfront, this is like their annual service. So they have that. So what you’re then doing at that point, you’re checking like we talked about the routine checkup before in the previous episode, you’re checking for changes and deviations.

You’re checking the radiographs for the restorations. Is the marginal seal good? Are the muscles happy when they bite together? Do they have any complaints? Are there any occlusal changes? Is there any fremitus? Is there any movement of teeth which you didn’t plan for? Sometimes you need to pick up the bur and refine the occlusion.

And just make it happy. Sometimes you need to smooth a few things. Sometimes if it’s composites, you need to just polish and rebuff it. And once you’ve had that upfront conversation and got that maintenance plan, you just have that 45 minutes, you do the full check, you do your usual basic periodontal exam, you do some polishing of the composites, and that’s a good way to monitor it.

The other thing which I recommend thinking about is, if the reason they ended up needing a rehab, the reason that they ended up needing a reconstruction, if you think about it, a lot had to go wrong in their mouth before they need this reconstruction. Therefore, if part of that was attrition and bruxism, and they’ve spent a lot of money on their restorations, then it would be prudent to protect their investment with some sort of appliance at night time.

So they should bring their appliance every appointment for us to check, okay, are they still wearing it? Is there anything we do to make it more comfortable? How’s it going? Is it starting to show cracks in wear that perhaps we need to start thinking about replacement? So, those are the very rudimentary checks that we do, but the most important thing is, are they comfortable?

Are they happy with how it’s looking still? Have we noticed any changes? Because a lot of things will be signs. Signs come before symptoms. So the patient might not feel anything, but we’re the first one to find that actually there’s some pocketing now, which has been completely painless. We’re the first ones to see that there’s some fremitus.

Oh, do you notice that your tooth’s moving a bit? It’s a bit mobile. The patient’s like, no, I had no idea. So we’re basically looking for all the usual signs of health that we look for. And then we manage each sort of deviation as appropriate.

[Emma]
Okay. Okay. That makes sense. So yeah, something that you would definitely prep patients on, and this is definitely going to be an investment and something that you need to follow up on afterwards.

[Jaz]
This is a big deal, you know, and so we want to make sure that it’s not just like they go into your normal checkup and hygiene protocol, right? It needs a special eye and therefore having that upfront conversation, the whole thing about a service for your car, your service, your mouth, that’s a little bit more involved because you’ve got a lot more going on in your mouth and the maintenance of that will be a little bit more involved.

[Emma]
Yeah, of course. And would you say that that sometimes would put people off that sort of a treatment plan if they’re not up to it? Or have you found that?

[Jaz]
Not really, because I think when they’re spending that much money to just tell them that there’s an upfront maintenance fee. Patients understand. Patients buy cars and they know that they’ve got to take it for annual service. So they’re kind of used to that and they understand that. And they know that every so often they’ve got to do their kitchen again. Every so often they’ve got to change their carpets. Every so often they’ve got to change their mattress.

People are understanding of that. So that, I wouldn’t say it puts them off. But I would say that if any patient is put off by the hygiene visits that they’d have to maintain the visit that they’d have to maintain to keep everything healthy and happy, then that is a red flag patient. So if they’re not playing ball with that, then you thank God that you didn’t end up treating this patient and they didn’t become your problem because when things start failing, they’re the ones sending that email saying, hey, this tooth is now playing up.

I’m not happy. This is happening. That’s happening. You check their record. They haven’t been for two years. So that’s the kind of patient you don’t want on your books. And so if someone is not happy with that, then that patient’s mindset is an issue and therefore you don’t treat that patient. They don’t deserve complete dentistry from you.

[Emma]
Yep. No, that makes sense. But I suppose the patients are aware they need all this change and they’re briefed on it appropriately, then they’re so much more likely to comply as well. So that’s good to know.

[Jaz]
Very true. Amazing. Emma, thanks so much for these questions. I like the fact that you picked slightly different ones to the previous student occlusion ones. So well done for trying to keep Protrusive unique and fresh. For anyone who wants to check out the previous episodes, please do so as they’re all on the Protrusive Guidance. Remember, we have our own section, a student section on Protrusive Guidance as well. That’s also where we’re uploading Emma’s famous notes. Emma, which notes are you providing for this month to help our colleagues?

[Emma]
So this month’s notes are going to be about Posselt’s Envelope. We’re going to do your occlusion, your basic occlusion, your skeletal classification, molar classification, incisors. We could do some TMJ anatomy as well, so I’ll pop that all together. And that can be this month’s notes.

[Jaz]
Amazing. So we’re loving what you’ve provided so far and the team have been doing a good job of making them nice and neat as well. So it’s a good team approach here. And so looking forward to inclusion ones. I’ll have a look at them as well and see what we can add. And by then, by the time this episode comes out, the video section of Protrusive Guidance for the students clinical video section will be a bit more full of videos because your requests are coming in thick and fast.

So we’re trying to keep up and make it really valuable to you. So thanks for sticking all the way to the end. Emma, welcome back. It was nice to have you back from the exams and we’re all rooting for you. I hope it goes well and we’ll catch you again next week for the next month’s episode after that to catch up a bit more about what’s next week’s episode or next month’s episode even.

[Emma]
So next month we’re going to be talking about radiology, how to diagnose from radiographs, sort of how to orientate yourself on radiographs as well, which can be really tricky and just some tips and tricks on how to read radiographs as well on the notes. So.

[Jaz]
Great. And you’ve got some premium notes for that, so student notes for that as well to help them with that as well.

[Emma]
Yep.

[Jaz]
Amazing. Thanks so much, Emma.

[Emma]
Yep. Thank you so much.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end, especially with a dry topic like occlusion, but I’m hoping we made it tangible. I’m hoping we answered some questions that were niggling in your head. We start to make a little bit more sense.

We’ve got a lot more occlusion based episodes on this podcast. They’re a little bit heavy. I think they’re not so student friendly, which is why I’ve started to create these student friendly episodes. Once again, head over to Protrusive Guidance, our app, make an account on protrusive. app website. And email student at protrusive. co. uk to let Mari know that you’re a student. Prove it to her and she will gift you something. I promise you it will be worth the email.

And lastly, if you’re finding this student series useful, can you comment, let us know if we’re doing something good. Is this something that we should continue? And if so, please do share it with your colleagues.

This is how we grow. Thank you so much. And I’ll catch you same time, same place next week. Bye for now.

“Defensive Dentistry and the fear culture is the number 1 cause of anxiety amongst Dentists”

How can we instead foster a culture where we can focus on growth and supporting each other?

Does Dentistry have a social media problem?

Join us on this episode with Dr Mehy Lo-Presti as we navigate dentistry and social media, the pros and cons of using the online world as part of our portfolio and how we can remove anxiety through effective communication.

2 Events to Attend:

DentoRama 18th October

Treatment Planning Symposium (Hybrid Event) 16th Nov

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

Highlights of this Episode:
02:05 Introduction – Dr Mehy Lo-Presti
06:42 Mehy Early On
12:04 Dento-Rama
15:30 Social Media in Dentistry
20:35 Life Before Social Media
21:25 Social Media is a Business 
23:40 What Causes Anxiety for Dentists?
29:45 Overcoming the Fear Factor
34:45 Fast Tracking to Success
41:20 Wrapping Up
47:14 Booking the Event and Getting in Touch

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

GDC LEARNING OUTCOMES: A

AGD Code 770 (Self Improvement)

Dentists will be able to:

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous ‘Vertipreps for Plonkers’ series.

If you liked this episode, check out IC035 – Best Practices in Social Media for Dentists

Teaser: It depends again, what you want to show, who you want to be in social media. I always have this debate. I asked this many times in my events. Is it okay to share your personal life and your professional life at the same time? And some people will say yes. And, but there are consequences of that. And the consequences is that-

Teaser:
I don’t believe in fast tracks. I don’t believe in that things can go very quick because you’re going to miss a lot of learning in the process. So I think exploring and making mistakes and allowing yourself to fail. It’s something that. It will make you grow way faster. People are happy in their jobs when they feel that they are treated as adults.

And this is something I learned from the employees from Google and Netflix and all these super fancy offices. They understood that people don’t care if you give them free food, they have a gym, you have cinema, you have all this super cool things in their office. So if you don’t treat them as adults and you don’t give them this freedom, they won’t be happy.

Jaz’s Introduction:
What’s the number one thing holding you back as a clinician? What’s holding you back from growing as a dentist and actually sleeping well at night time? It is an F word. Me and my guest today, Dr. Mehy Lo-Presti, we believe that fear is holding us back. When all of our decision making and all of our judgments and our communications are processed through this filter of fear and our dentistry is fear driven and therefore defensive. This is what may thought was the number one contributor of anxiety for dentists.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. This is an interference cast, where we discuss more of the non clinical themes, which are super important, because we touch on communication, we touch on fulfillment, and we also touch on social media, because we can’t avoid it. Is there a place on social media for us all? Should we all be on there? And how do we conduct ourselves on social media? And how do we avoid the negative stuff on social media? I. e. the anxiety that social media itself actually brings.

This episode is still eligible for CPD or CE credits. There is one CE credit or one hour of enhanced CPD, and the AGD code for this one is 770. That’s self improvement. And I truly think if you make it to the end of this podcast, you will feel so uplifted.

You will appreciate that the themes we discuss on this episode are so real, so current, and they’re the kind of things that just need to be discussed more in dentistry. Two events that I recommend on the back of this podcast is October 18th Dentorama by the Global Dental Collective. This is like a combination of theatre, comedy and dental debate for the entire dental team.

That’s in London and also in London on 16th of November is the Treatment Planning Symposium. This is where Lincoln Harris and Dr. Michael Frazis will be coming from Australia to London and I’ll be joining them as well to talk all about failure and then Lincoln will take over with a treatment planning masterclass.

We’ve got a live patient consultation plan, like an unseen case for Linc, as well as asking the sauciest and the hottest questions on the live panel debate. For both those events, I’ll put the link in the show notes. Now let’s join the main podcast and I’ll catch you in the outro.

Main Episode
Dr. Mehy Lo-Presti, welcome to the Protrusive Dental Podcast. I’ve been following you for a while. I don’t know if you remember the first time I actually met you, right? Was that, it was a Pascal Magne. I think it was in Glasgow. I think, right. It was a BACD and then you were there with extra Rupert Munkhouse, right? And I was like interviewing you, right? And then that’s when I first got exposed to you.

And then I didn’t realize you were just like mega superstar. Then I see you on the stage. You’re like, gosh, I don’t want to say Jerry Springer, but like the male Oprah Winfrey, you’re just like completely ruling it. And now here we are recording today. So for those who don’t know about you, Mehy tell us about yourself.

[Mehy]
Wow. Wow. That’s, what an intro actually, no, the expectations are very high, maybe not as funny, but yeah, I can manage an audience.

[Jaz]
Edinburgh.

[Mehy]
Well, yeah, that’s true. We met in Edinburgh, right? It was at the BACD and then you were recording and interviewing people and then I already was following you because I think you have one of the best educating content in the dental world.

So the pleasure is mine. Well, I’m a dentist. I was born and raised in Spain. I practice in London now. And basically I got to the point where dentistry was a struggle for me. I got a lot of people around here and I found healthcare events very boring in general. So I needed to find a way to make them more fun.

I needed to find a way to also talk about everything that goes around dentistry that can help us to have a happier-

[Jaz]
What aspect of it did you struggle with most? So the common ones we hear is, just like the clinical, the big step that we have from dental school to real world, that’s a huge knowledge gap, right? And then you realize actually, in dental school, you really barely scratched the surface, right? And which is very disheartening to all our young listeners. I know, but that’s the real world. And, or was it the managing expectations of patients or was it just transition to adulting? What aspect of it did you find trickiest?

[Mehy]
I think what creates a stress in ourselves, it’s the not knowing what is going to happen. I’m not having a hundred percent control of what is going to happen in any scenario, right? And in dentistry, especially in the first years. This is very common. You don’t know how well your treatment is going to go because you’re not as good. You don’t know how the patient will react. You don’t manage your team that well. You take your work to home. So it’s a never-

[Jaz]
You own the patient’s problems, which is something I talk about. You end up owning the patient’s problems. A lot of young dentists, people still do it all throughout their career. But that for me was very peak when I was a newly qualified, this patient had this really tough decision to make between a root canal and extraction. And I felt it was me having to make a decision. I take that home with me, maybe in my stomach in bed, even like a minor thing like that, or a patient has a dry socket and it’s almost as though you had the dry socket.

And this is a sign of a caring practitioner, so anyone’s resonating with this, it’s kind of a good thing that you have that compass inside you and you are sympathetic, you’re empathetic. But we must learn to detach ourselves and be there to guide the patient in their journey, but not to own their problems.

[Mehy]
A hundred percent. And not having those tools to do so was basically what took me to have the decision to make the decision to like, okay, maybe this is not for me. And especially after COVID, like COVID and going back in those conditions that we went, having all this stress that what you already have, it wasn’t great.

And then I realized that I needed help. I spoke with colleagues that had the same issues. I did some courses I started working on myself. I left that black hole, I would say. And then I go, okay, we need to speak about this. And when we did this, our first event, which was almost three years ago, there was not many people talking about mental health in dentistry, probably where the first event, actually, we were just bringing this onto the table.

And it was amazing to realize that actually the whole industry was having the same issues. And then figures came out and then you realize that, wow, actually. I’m happy in this profession, so there’s must be something that we need to do.

[Jaz]
Tell us a bit about you now in your working situation. What are the kind of, what does Mehy like to practice? What kind of a dentist are you? What do you love most about dentistry? What do you hate most about dentistry? Tell me about you as a dentist who kind of took this break or a pause. But then now you are re reengaged in it, but you also have this second purpose, right?

We all have this purpose dentistry, but I love your second purpose of actually creating community similar to me in a way, create a community. You’re making it a safe place for everyone to talk about these issues and you’re bettering everyone’s mental health in my view, as I see it, but you do far more than that. So tell us more about the yin and the yang, this mix of two things that you do, the clinical and the nonclinical.

[Mehy]
Well, the clinical, I’m enjoying a lot of my work right now, but I started not knowing what to do. Like I was not even sure I wanted to do dentistry and I’m from a background of doctors. So it was probably the safe bet in my case.

[Jaz]
You’re the black sheep. You’re the failure.

[Mehy]
Exactly. And I always say like, my dad is Palestinian. So we have three options. We need a doctor, lawyer or a failure. And I was clearly, I remember telling my dad, I wanted to do fashion illustration. And it was like, no, we don’t do fashion illustration. I mean, first he said, I don’t even know what’s that, but we don’t do that. So you can probably be a dentist. Might be easier than being a doctor.

[Jaz]
You use the F word basically. That in a way is also an F word.

[Mehy]
I mean, yeah, I knew exactly that was like, Oh my God, what I’ve done to reserve that. But anyway, so I finished my career and I didn’t really know which specialty I liked and I didn’t know much about, I wasn’t exposed to much about to all these different options. So I started doing perio, a full year periodontist, then I saw that, okay, maybe blood and soft tissues is not what I wanted.

[Jaz]
Let me pause you there, mate. Let me understand this. Did you do a four year perio program? You did a program, a full perio program?

[Mehy]
Yeah, it was like a pre, so to get into the masters in Spain, it was a three years master. It was one of the hardest perio programs in the world, which is directed by Mariano Sanz, that he trained people like Miguel Stanley and the biggest people in the world.

So to go that, you need to do a one year of pre perio. You need to become an expert to actually go in there. So I started studying for that course. I started shadowing some of the best perios in Spain, which are, there are a lot like Mariano, all these big guys. And then I realized I don’t feel like leaving. Put in my life three years in the beam to do patio, maybe to do something else.

And then I started working in a place where root canals, they were a must, like there was a lot of, for some reason there was a lot of root canals needed, the demographic for the work that was done before, for the kind of treat patients that we were receiving. But then I think I did like maybe 150 root canals in a year.

And my family in the states are endodontists in LA. Several clinics after and also I was always under I understood the work, but again, I found it extremely I was like, I can’t do this the rest of my life I mean no way. Probably no and now I regret to be honest now seeing them in the longest. I probably now would love to be in and around this. I found it like very profession to do right so young dentists, endodontists it sounds like it’s not sexy. But it has a very good life.

I don’t know if you agree with me on that I finally agree good speciality to know that I decided to move to London to do my Master’s in the Aesthetic and Restorative Program. And that was a part time, so I needed to find a job here while I was doing my Master’s. That was a bit difficult because I didn’t know how the NHS worked.

I didn’t have any I had no clue about how the system worked and I was lucky enough to end up working in a clinic in West Palm Grove in Nottingham. Super cool clinic. The guy liked the work that I was doing and like he was also Spanish that helped. And that gave me already open doors to private dentistry.

So I’ve never done NHS. And I could pay my university at the same time. So I was very lucky. And from there, basically restorative slash prosthodontist, which in your case not very well defined. What I do in getting more and more and more and more complex cases, and now what I love to do is basically work occlusion, full mouth rehabilitation dentistry, whatever involves patients to have a normal life.

Again, as much as we can and always looking from a very holistic approach. So working with nutritionists, working with chiropractors, I work a lot in getting a lot in sleep medicine, something that I’m very passionate about. This is the kind of patients that I get. They work in Kensington, they work in a clinic in Archery. So our patients that normally they need a lot of help and we try to help them from the very, very beginning of their problems, which are, gets to manage dentitions, right?

[Jaz]
Well, when you started to re engage back in dentistry, and take this further, and now you’re working in a clinic where you have the right tools and the right mindset that’s constantly growing, you’re delving more into sleep medicine, for example, when you realize that actually it wasn’t just you who went through that rough path, that we all go through it, and there’s still many clinicians who are suffering in silence, how we can be a very isolated, went into creating a little bit more about these events.

Tell me more about that, tell me about did Dentorama come first, or which one came first? Give us a flavor about that because the next thing I want to jump to is came to your most recent one. It was just amazing. Like, the full stage all around the debate that was happening. The conversations that were happening, the kind of people that you tracked was truly brilliant.

So tell us more about how you ended up going into that, or we talk about some of the themes that came such as anxiety from social media. Is it a good thing and a bad thing? But tell us more about how you actually got started with that.

[Mehy]
Well, this was, it’s going to be now almost three years ago and two or three years ago. And I had a concept of an event. Me with my friend Bruno, we wanted, who is not in dentistry, he’s in music, now he does sound frequency, which it’s another science, but we wanted to basically create events to help the healthcare provider, what to, how they can work on their breathing, how they can work on their posture, how they can work on their mental health, everything that is around the clinical side.

I had that in mind the way that I wanted to look, which is one of the ventures, which is the debate on this very dark room with a white in the middle that is pointed to the speakers and makes a bit very mystic atmosphere. We, our paths cross with Joe Lovett, one of the most well connected networker in the industry, and he also had in mind to do an event.

So we kind of merge forces. He was bringing basically companies and huge following that he had. And I didn’t know anyone here, so I guess like, this is my idea. Let’s see if it works. So the ingredients worked very well. People loved it. People felt safe. People love to have a space where they could actually open up to their feelings and not being judged.

Everything in a very cool set up, like you’ve never seen before. And after that, we were throwing a party with an open bar, which everyone loves. So all these ingredients made it very magical and successful. And people were like, okay, what’s next? And we’re like, I don’t know. We didn’t think to do anyone else.

It’s like, yeah, yeah. We need to continue that. We did another one, but the problem that we have is that every time we do an event, we need to change something and we need to make it more innovative and people are expecting from us. It’s like, oh, let’s see what’s next. At some point, the idea of creating a theatrical debate came on board, which basically is something that happened in Morinther and arts, which is basically a very, very basic concept of what we do now.

We had to transform it in what is then drama now, which is theater with the real actors that play real life scenarios that happen in a dental clinic. And last year was a lot about problems of the patient with the dentist expectations and unhappy patients. And the dentist trying to commit frauds to make some extra money.

The insurance theater at some point freeze or stops. And we had a panel of experts last year. We have a lawyer, one of the directors of dental protection, actually deserves to learn this. And we talk about what happened in the theater, but the coolest bit, and I think it’s the one that people like more is that for a hundred people that are in the room, they can share and open and talk about what they’ve seen.

So it’s like a little bit like a forum, but not only to see who is speaking. Also, you have the chance to express yourself. And obviously we think we finish all of this with a very nice network, a very nice party. So, everyone goes home happy. But so this is how everything evolved. And with the years we managed to build this very beautiful community. People that want to have a better career and they are concerned about creating a better work through dentistry.

[Jaz]
I think it’s very innovative what you did. I think it’s very timely and I think it’s just an artistic expression. These debates are happening, but what you’ve essentially created, you’ve funneled it into a very creative way. Beautiful artistic expression. So it was really great to be involved with the debate that you had, but now looking forward to in October, the Dentorama. I love the theater. I love the production. So I can’t wait to see what surprises you have up your sleeves. But one of the themes that you did discuss the most recent event with the debate, I think Rona was an audience and you asked her about social media and you don’t have to have the kind of following that she does.

It could be anyone. The thing I found to struggle with was many years ago when social media was new. To actually have the confidence to post a photo of a clinical image. That’s a big step for a young dentist to do that basically. But the other thing I realized is that a lot of dentists just don’t want to engage in that and you have to respect that.

But then the question I’m asking is in this time that we are now, 2024, is it a must? Should every dentist have a presence on social media, whether they like it or not? It’s kind of like, should we all have a LinkedIn? Should we all have an Instagram? How imperative is it to have a social media? Because one of the downsides of social media, which we’ll touch on is the anxiety.

It creates, you’re constantly seeing beautiful work. You’re constantly seeing, it’s no different to seeing all these beautiful fashion magazines and seeing these models, which are not realistic. Some have been Photoshop, et cetera. People start comparing, having anxiety about that. We apply that to dentistry. We see that through social media as well. So what are your thoughts on the dentist and their role, their presence in social media and the whole package that comes with it?

[Mehy]
I think it depends. It depends on what you want to be in this profession, and who is the audience that you want to talk to? It depends on your audience is in between 25 and 35, then probably you need Instagram, right? Or-

[Jaz]
By audience. Do you mean your patient base? Is that the way of saying your patient base?

[Mehy]
Yeah, let’s say, okay. Yeah. I mean, kind of both at the same time, it depends on, first of all, do you want to use it professionally? Do you want it to attract patients or do you want it to educate? Do you want to use it to just know about your friends or it depends on, I think the question is what do you want to be in social media? Because right now in social media we are actors and this is how I see. No one really shows. I haven’t met anyone that shows the real life every day. So right now in social media we are actors.

[Jaz]
I love that and I love where you’re going with this, but I’m going to add that actually It’s not just social media. I feel like when we are in the operatory, we are also actors. We are also putting on a performance.

[Mehy]
A hundred percent. And this is what you need to decide. I need to decide when I’m in front, in the stage, when I’m doing public speaking, when I’m in front of a camera, I need to decide, okay, who are you right now and what you want to express. So if I want to empower my audience and I want to speak about things that they’re going to make my audience happier.

Of course, I’m not going to show who I am today. Because that might not help them and the reality of who I am. So it depends on which actor are you deciding to be in social media. And you can be many actors, but this is what you need to understand. That when you know this, you understand that whoever is in social media is not you.

Then you can use it as you wish. And that probably will remove a lot of the anxiety that this is creating. Because one of the things that you said about that first post about your case, how difficult it is. This is because we are seeking validation. And this is a trauma that we’re having since we were kids.

So this is not a problem. Social media is our problem that actually social media is bringing up. You have a problem because you need to be liked by everyone. And you need to, everyone said, wow, what a great job. And you won’t accept criticism. So when you worked on that, and then you were actually like, I’m ready to learn from my mistakes and I’m ready to show and see what they’ve done wrong, then that anxiety will probably disappear.

Another thing is that if you really want to show that, and if you really want to show your weaknesses, that it’s not always necessary, like it depends on, it depends again, what you want to show, who you want to be in social media. So I always have this debate. I’ll ask this many times in my events.

Is it okay to share your personal life and your professional life at the same time? And some people will say, yes. And, but there are consequences of that. And the consequences is that, as I know, a lot of my colleagues, they had such a strong presence in social media and they show so much about their life that the patient, they go to the clinic to meet them.

They almost don’t care about their clinical skills. They want to know and now I’m a big fan of you and okay, whatever you do, I’m going to from being a great dentist or bring a clinician that we think that that people will go to you depends on what you’re showing and they’re like amazing clinicians that we all know very well that they only show their clinical work and you almost don’t even know their face. I actually, they’re clinicians. I don’t even know how they look. They only show teeth.

[Jaz]
But you know, that style of dental photography. And when you see the photo, you don’t have to see the handle, whose photo that is and the work and it’s like a signature that you leave on your dentistry. And they’re showing that, and they’re obviously very passionate because one way you could be the absolute best dentist in the world, right? But if you can’t communicate with your patient, right, that goes nowhere.

In the same way, you could be an exemplary clinician. But your colleagues will not refer to you because you haven’t communicated it to your colleagues and you haven’t communicated to your patients in the modern way that we do now in this day and age.

[Mehy]
Yeah, I agree. And back in the days, I was actually talking with a very, very, very brilliant orthodontist, Dr. David Young, which has 30 years of experience. And actually, I was asking him, how were you doing before? And like, how were you when, before social media, before internet, and he was actually talking to me about the slide projector where you had to take all your pictures and take it to reveal.

And then they were creating this slides for you. And then you had to take. It was almost like a DJ that goes with the vinyls around. So you had to go and this is the only way you could show all your work. And then how many people could see your work was whether it was in the room. And if you were lucky, maybe a thousand people that normally it’s 10 to 10 study clubs. So social media is a great tool on that.

[Jaz]
It’s a great megaphone. It’s a great amplifier, but we need to make sure two things, which message I’ll be giving to the world. But also which message are we receiving as well, because we are at the mercy of the algorithms and we start looking at things and the algorithm wants to feed you more, but then you get blind to the other perspectives that are out there.

[Mehy]
100%. Social media is a business, right? And as a business, there are interests. And I mean, I had my personal experience where I, at some point I was showing or trying to raise awareness about the political issue, right. Or about some kind of a war or I’m Palestinian, right. So I wanted to raise awareness about what was happening in the world.

And my view, my posts were shown. I don’t have a huge following. I don’t know how many thousands, something they were shown to 10 people. Now, when I was posting about my holidays in Ibiza with a beer in my hand and with my daughter or whatever, there are 400 views. So there’s clearly an indication of what you can show as a filtering.

So, and that is in any sense in any case, and so you have also to consider that you are part of a business and you’re going to be showing whatever the business wants you to show. So as far as you understand how it works and as far as understand what is social media and as far as you understand yourself, what you want to be on those platforms and who you want to talk, how you are going to receive, as you said, those messages, then you can be safe. But again, it creates addiction. It creates an anxiety. There’s a very dangerous tool to use, in my opinion.

[Jaz]
I think it’s good that you mentioned, and it’s the first point you mentioned. I think just, if anyone’s multitasking and missed that, really important to say is that Mehy clearly said that social media is fake and just always remember that.

And then this is how it is, is that it always will be. Because no one’s going to show the new wart that came on their pinky toe, right? No one’s going to share that stuff. Okay. So that’s too real. When they get their nails done, they’ll show that. So just remember that the warts and all the experience is very rarely happening.

And what you see is the best of the best. So never feel anxiety or compare yourself to what you see on social media. The best metric is to compare yourself from two years ago, compare yourself to you three years ago. And if you’re not happy with that progress, you need to really have a sit down and think about, okay, what’s the next two years going to look like? What’s the next six months going to look like?

Now on the topic of all this, it may may or may not be social media. I’m leaving it to you because what I see you are really on the field discussing this a lot, right? What do you think is the number one source of anxiety for young dentists? So it could be social media, but I don’t know. I’m not convinced it is. I feel as though it’s other things, but you may say it is from speaking to his colleagues. What is the biggest source of anxiety?

[Mehy]
I don’t think I mean, social media is a huge factor, but something, I mean just imagine that once you’re taking your driving license, right? And then the teacher is telling you, once you’re going to get your license, and like, by the way, I didn’t tell you that, but you’re going to crash your car at least twice in your life and you might die. This might affect the rest of your life in the way you drive. And it’s going to make you drive very insecure, very scared.

You’re expecting always something going to happen. So there’s something that shocked me a lot when I arrived to this country is that the indemnity companies, they assure to the young professionals that they are going to get sued. At least twice in their career.

[Jaz]
That must have changed Mehy. That must have changed because the one I heard many years ago, but that the most latest one I heard is that not necessarily sued, but you will get five complaints in your first two years.

Now, what determines the complaint? It could just be like a small thing. But some of these complaints go on further. So, in the UK, as you mentioned, it’s country specific UK, at some point did overtake the States, did overtake other countries in terms of being the most litigious country in the world, and I love your analogy of the driving instructor telling you that you’re going to crash.

And then your whole life you’re driving with anxiety, you are holding your hand piece of anxiety. When you’re speaking to your patient, you are filtering so many things you are then getting confused because there’s one thing you want to say. But you can’t say it because you are then scared to do something that may be in the best interest of the patient, but it may be a riskier approach. It may leave you to defensive dentistry. You’re practicing defensively.

[Mehy]
Exactly. And I don’t think this is fair. One thing is okay. You need to understand there are rules. There are things that you need to be careful with, but I practice dentistry in five different countries. Studying to and have people in probably around 10 and no, this doesn’t happen everywhere.

People in Spain don’t practice dentistry and there is great dentistry in Spain and there are some of the best in the world. So you don’t have that fear because you know you’re doing the best for the patient and you’re not worried that that patient will sue you. It might happen. I don’t know about you.

Don’t go with this mentality. You just do the best of what your abilities and what you think is best for the patient. And you start actually what happens with this. So starting taking on board more complicated cases in an early stage of your career and you stop practicing this very defensive dentistry, which at the end of the day is wrong.

And this is form in my opinion, like there’s a lot of, I call it like half way dentistry here, like a half of orthodontic treatment, just move a little bit to being able to put two millimeters of composite bonding. This is not dentistry. This is dentistry for three years, four years, but we all know this is going to break and doing this twice.

This is the wrong thing. And this is why, and a lot of people don’t do that because they don’t want to put their patients through a more aggressive and I don’t think it’s more aggressive, but a longer treatment, more aggressive, more expensive, which can bring more complaints and complicate your life.

But the reality is that is your duty to at least go for that treatment and if the patient doesn’t want to maybe go for something simpler, but I feel that this is what caused a lot of anxiety on the people like going to their jobs, thinking that something is going to go wrong, that whatever they do, they might get a complaint that if they forget to write the expiry of their anesthesia.

They might get sued forever. And as you said, the complaints that you might receive, also, I did a study with the general dental counsel and we brought people from the GDC to one of our events, the numbers are not that bad. And the people that actually they get to lose their license is people that they are almost criminals.

Like actually they’ve done some stuff very, very wrong, but you don’t lose your license because you forgot to write something on the notes or because it’s as far as you’re honest and then you made the best out of your capacity and things don’t need to go that bad.

[Jaz]
I’ll give you an example, right? And I love this direction we’re going in. I think you hit the nail on the head. In the UK, but I do feel speaking to us colleagues, they have a bit of this fear as well.

[Mehy]
Also the US, yes, for sure. Even worse.

[Jaz]
And the overarching theme, I think is when you are doing something with fear, if your frame is fear, then what happens is that you are not able to grow a good rate. You’re not able to innovate for sure. You’re not able to grow. And innovation doesn’t mean you make the next big thing in dentistry, it’s innovation for you, where you are at in your career, doing new procedures that already well documented in the textbooks, but now you’re able to confidently do that.

Now, when I look at other countries, India, Poland, and some Eastern European countries, and I see how young dentists are doing such great work, it’s because yes, they had the mentorship and the guidance but they didn’t have that fear factor overlying, someone sitting, weighing them down in the shoulder.

It’s a bit like the clinical example I can give is a sodium hypochlorite extrusion, right? It could happen, right? It’s not that no dentist ever wants to do that or create that because it’s horrible. No one wants to see it, right? But then now, how many more dentists are referring because they’re just afraid of all the different complications that can happen in endo?

They’re not doing the molar root canal. They’re not, skilling up in endo, right? And so that’s a great example because that’s something that’s just happens as a percentage chance that that can happen. Even ID blocks, people, dentists, young kids are scared of doing ID blocks, right?

Because they are afraid of causing a temporary or permanent, very rarely paresthesia from an ID block. And you’re such a simple, basic thing and you’re approaching it from fear. So if you can’t get past the ID block, how are you going to do your first ridge preservation? How are you going to do your first implant if you can’t get past the ID block?

And so that’s the big issue I think we feel. So how can we even begin to correct that? Not that we’re going to come up with the answers me and you now, but I’m just putting up to debate to the Protruserati something to reflect on.

[Mehy]
I think having the tools. And understanding where these comments, where are they coming from? First of all, I think universities are not making a favor because they are the first ones putting that fear and talking about ID blocks. I know that for example, there are some universities that they are forcing you or to use different techniques as not as effective maybe so to avoid complications, which if they’re done, I mean, under some circumstances, they can be good, but the problem is that they teach you everything from the fear.

So, that mentality needs to change. And I think those numbers about the GDC and complaints that you might receive, as you said, when they tell you, you’re going to receive five complaints. In your career now, they’re saying five, right? They don’t tell you exactly. I mean, let’s just stop saying this.

Just let’s start from there. Like what is the reason of you saying this? What is the real reason? So we can increase the rise, the fees of the companies, or asked to practice more conservative. Then they say, what is the reason behind those statement. And this is what I would like to understand where these statements come from.

[Jaz]
Well, let’s talk about this statements language, right? Barry Oulton once taught me a great example, right? It’s a bit like when you’re speaking to your child, right? You’re speaking to a child. Like if I speak to my five year old Ishaan, this example that he gave me, Ishaan’s got some orange juice in his hand and he’s walking down the stairs, right?

There’s one way of saying to Ishaan. Ishaan, don’t drop the orange juice as you’re coming down. Just be careful. Don’t drop the orange juice. Okay. And so he’s constantly walking, thinking about not dropping the orange juice. Instead, if we say to Ishaan, Ishaan come down very carefully, walk carefully and make it to the end and so that we can enjoy our orange juice.

Okay. So it’s just the way you frame it. So perhaps we need to talk less or emphasize less about the world’s a bad place. Everyone’s going to sue you. Make sure you do this in notes or this will happen, et cetera. And rather think about, okay, how can we connect better with our patients?

How can we get really good consent from our patients? How can we serve our patients better so they are happier? How can we upskill at the correct pace? If we maybe change the language to that, that might be part of the issue or solution.

[Mehy]
100 percent and is actually the main reason of complain. Normally people don’t complain because you’ve done a bad treatment. Normally people complain because you didn’t tell me that they tell him and explaining that things can go wrong. You didn’t manage expectations and you didn’t communicate clearly. And this is where everything comes from, communication. Communication that we receive and mainly the communication that we give.

And this is, I’m very happy to see a lot of forces in communication and a lot of people talking about this because this is very important. And I think it’s the key of success and the key of success in everything, in your relationships, in your work, in your career, everything for me is communication because the really successful people in the world are people that they know how to talk and how to transmit and how to engage and how to make people feel safe.

There are no people that have a lot of knowledge and there’s not a lot of people that they’re very good at doing a technique. They are very good at what they do, but if you really want to have success, which means for me, success is have a happy life and means that I go to bed sleeping very well and waking up, not thinking about problems.

This is for me, success. Then you need to make sure that you spoke to everyone that you had to talk in a clear way the day before and there was no issues of miscommunication. So you need to work very hard on your communication skills. This is what my number one piece of advice to any person and can be young, can be adults wants to improve that.

And once you get to that point where everyone can understand you and you’re not scared of saying what you think, and you said it, say it in the right way, things are going to go easier because skills, you’re going to get them, skills is one after the other.

[Jaz]
I think the soft skills of that conversation, the communication, we don’t practice enough. I had a great guest on recently, Dr. Brett Gilbert, Endodontist in the States. And a great piece of advice he gave is yes, you might practice on extracted teeth with the K files, et cetera, but how often do we stand in front of a mirror and practice how you say something and practice a hundred times the way you say it.

So you become confident in the way you say it. Not because you’re trying to change you as a person, but your delivery is important. The reps that you do in terms of sometimes it’s difficult to say certain things. Sometimes it’s very, some people really struggle to talk about fees. Sometimes dentists really struggle to talk about the risks because they think, oh, if I tell them too many risks, then they won’t want the treatment.

But that’s the whole point of consent. So you’ve got to say, look, Mrs. Smith, this might actually fail in a couple of years. And when it fails, it’s very sad. We don’t want that to happen. We’re going to try our best, but you need to consent that. Okay. It’s not always a hundred percent successful. Is that going to be okay with you?

Now, some people would really struggle with that, but if you can actually practice that in front of the mirror, that’s a good thing. So what leads me to next is, what top tips can you share in the similar vein of the communication to help dentists fast track their growth in their career? And it doesn’t matter which stage of career they’re at basically, but to really from this point today, to fast track and grow at a faster rate.

[Mehy]
I am a huge fan of enjoying exploring your life and your options. So I don’t believe in fast tracks. I don’t believe that things can go very quick because you’re going to miss a lot of learning in the process. So I think exploring and making mistakes and allowing yourself to fail. It’s something that will make you grow way faster in a way. But when everything goes right and is planned and no one, you never had any issues, the learning is super slow.

And actually when you have that failure in a very late stage of your career, that can be very dangerous because you’re not ready to fail. So for me, it’s like accept failure, accept that things can go wrong, accept the learning, something that in the industry, we’re not very good at that, right?

We’re not very good at people telling us, oh, this is not how you should do it. And for me, communication, as I said, is key. So do courses, watch YouTube videos. Understand how to read a room, how to read your patient. No, you can’t talk to everyone in the same way. If you want to do public speaking, you can’t talk in the same way in a room for 2, 000 people than in a room with one person.

You’re not talking in the same way to someone that is very confident. That someone is very scared. So once you understand, you can bridge people’s behavior. You need to understand how they feel. And also that goes to your team, which is exactly the same. When you learn how to talk to your team, how to give feedback, how to receive it.

It’s very important, how to tell someone, hey, I don’t like this. Which for me was a huge struggle for years. I spent three years of my career not being able to tell to my nurse. I don’t like when you put this action here. And I was scared and afraid of hearing, hurting her feelings. And that was causing me anxiety.

[Jaz]
Especially young female dentists. They seem to complain about a lot. I hear a lot that get friction with the nurses. There’s so much more to it, I imagine, but we hear this a lot. And so well, one way I approach this, and when I work with a new nurse, right, I work with a wonderful nurse called Zoe, pretty much night and time.

We have a great relationship. We worked on it because one of the first things I do when I work with a new nurse, right, is when the patient’s gone, maybe I said to Zoe many years ago, I said, Zoe, I like to work in a way where if anything that I do annoys you, please tell me. And then you’d be amazed what they tell you.

Like one nurse once told me that my light is way too bright. It hurts her eyes. I never knew this. So I gave her permission to tell me. But equally what I did, I sought permission from my nurses. Like, can I please have your permission to maybe just share a few things that, I would like tweaked.

And then maybe together we can get a win win. And then they say yes. And then when you open up that permission, that’s a wonderful thing. So maybe asking permission is a great example. The other thing I just want to just add on based on what a wonderful thing you said about reading people. There’s a great book.

I’ll find it. I’ll put in the show notes. I think it’s called the power of body language or something to do with body language, right? One of the first books I read when I started looking into communication and that book helped me so much because 70 percent of our communication is a non-verbal. You know, the other week I walked in to work 7. 30 a. m.

And I just said, good morning. I’m not going to say her name when the receptionist and said good morning. And the way she said it to me and the way she looked, I said, what’s wrong? And she just burst into tears, right? And then there was something and then the other receptionist there to help her.

And I just knew if I just said, okay, good morning. Yeah. How you okay? Or I just walked upstairs. But I knew something was wrong just from the way she said it and her body language, her posture. And that is a powerful thing because our patients will give us these cues. Our colleagues will give us our cues.

And I agree, not just the verbal communication, not what to say to the patient, how to say it, but how to read it.

[Mehy]
Agreed. And just say it. Try to find a way to say, because if you don’t say that your colleagues or patients, anyone around you, your partner, they don’t need to guess it. And so yesterday, I was actually shared this in social media because I found it very, very funny, but it’s actually something that I go through every day when you actually look at your nurse with the eyes. You’re expecting her to know exactly what you want. And we don’t really, a lot of the time-

[Jaz]
Telepathy.

[Mehy]
Expect people to do telepathy. We expect from people to do things that we never, ever told them to do. And you would think that you say it every day, but I assure you, there are things that you never, ever told them or ask them to do. And you’re expecting for them to do, and sometimes you go back to that, something you’re not perfect every day.

And then you have those days that you don’t need to be calm and every day. There are things that happen in your life that when you sit down in the chair where you can need to put your facade off perfect person but inside you’re still thinking about things and on your life and your car broke and there’s a mouse in the kitchen. And there is the school is calling you to pick up your daughter because she’s sick, whatever and then you don’t have the rights, composite, and then you look at your nurse asking like, no, I try, I don’t want the micro particles.

I know I want the macro, and probably actually that nurse never worked with you before. It’s actually a temp nurse that is just there. She doesn’t know anything. So I always say, just say, obviously in a very nice and polite way and something I learned very recent. People are happy in their jobs when they feel that they are treated as adults, and this is something that I learned from the employees from Google and Netflix and all these super fancy offices and they understood that people don’t care.

If you give them free food, they have a gym, you have cinema, you have all this super cool things in their office. So if you don’t treat them as adults and you don’t give them this freedom, they won’t be happy. So just make sure you treat all your team as adults, as people with their own knowledge and capacity.

And then you’re not trying to micromanage everything. And the same with your patients and the same way your family. When you need to make yourself, and we’re going to talk back to talking to kids, you need to, and this is what they say, you need to talk to them like adults, because you need to make them feel that they have an autonomy and they can do things on their own.

So this is the way they’re going to develop as independent people, right? So it’s a little the same. And unfortunately, a lot of these big societies and governments and people that they try to control the way we work and live. They don’t treat us as adults, and this is what makes you not being happy or in your job or in your profession or in your life. When you start feeling like, okay, I am an adult and by adult I mean someone that can take his own decisions, then things I think go much better.

[Jaz]
Amazing. I think what we, I’d love to know now we’re going to wrap up and it’s been really nice to talk about all these themes that we don’t talk about enough. And every guest I talk with about the non clinical stuff, the directions we go in are just absolutely wonderful. Sometimes it’s about 20 percent crossover, but it’s always a themes that we just need to hear over and over again, right? Because just like we hear about the different bonding protocols and the power of etch and which percentage of hydrofluoric acids do you, we hear that over and over again.

We also need to hear these themes over and over again. And I think what you brought was a lot of new themes today. So maybe thanks so much. I’d love to share with the Protruserati about your next event. I’m looking forward to joining. I know Andre Cardoso, George Andre Cardoso, my dear friend will be there as well, cause you’re bringing him there. Is that a surprise by the way? Am I allowed to say that?

[Mehy]
No, no. Anymore. No, anymore. We were trying to, by the way, I’ve got super inspired by you with your podcast. This is how I mean, I knew Andre, from the clinical side. I didn’t know the Andre coach side. So I heard him at your podcast. I fell in love and I said, you know, okay, I’m going to ask him and then I ask you, you know, I was like, hey, I think this is going to happen.

And you were so happy. So, and there is there George Cheetam and Georgia, then this is also part of the panel. So there was a big restorative Kings, alumni and the faye Donald, one of the super cool hygienist in this country. So she’s going to bring that perspective so we have the different perspective from the clinic owner to the super associate hygienist to talk about teams. We’re going to be talking about a lot of what we’ve been talking today about communication between your team, how to, the feedback, receiving leadership management. So yeah.

[Jaz]
Is this something that you think people, dentists can bring their assistants, their nurses to as well?

[Mehy]
Yeah, I encourage this year and we even have like a super special prize for people that they want to bring their whole team. I think it’s like half price if you want to bring the whole team because I think it’s a very cool group activity where you can learn. I mean, if I could, I would bring my whole team to all the courses that I do. Because it’s the real way that you can implement. So I think it’s a very good activity to do the whole group. So I encourage everyone.

[Jaz]
Tell us more about the activity in sense of what actually happens. What’s the actual format of the end? We touched on it earlier, but just to, cause there’s a few different types of events that you run, this one is the Dentorama, right? So. There’s the one that’s like the skits and the acting. Obviously you throw most surprises in, but then the panel discussion and audience, is that what to expect?

[Mehy]
Yeah. So this is the drama is done at the Royal institution in Mayfair, which in central London, which is an incredible venue, has a very majestic theater. If you’ve seen the images that we have in our socials, you can see a little bit of the setup. So what to expect. And then it starts like going to a theater literally like this. We’re going to start with a show where going to put some scenarios, all is in a comedy. So it’s very fun. We write this together with Nicole O’Neill, which is super talented actors and theater director.

So it’s very, very well curated. So you’re going to have a lot of fun. And then after that, takes like 10, 15 minutes, 20 minutes, depends on the act. And then we pass to the panel of experts, which will be debating about, and talking about all the dramas that we’ve seen during the act, and then we open up to the audience, we all share, we have then a break or perhaps, you’ll have some complimentary drinks and needles, and then we do this again.

Where there’s another act so every act plus the debate is like an hour each and then after we would finish at nine and thirty there is a social in the same venue and then for the late ones the people that they want to continue also we are doing an after party and in another venue nearby so for people you know there are some people like they like to keep socializing.

[Jaz]
Something in it which is a very fresh approach to what you’re doing. Very much needed in the way of delivering. It is education, but it’s more than education. It’s talking about these higher level topics. It’s talking about team’s a great thing. So I’m going to pitch it to, even though we’re in Reading, the team, I’m still going to pitch it to them. I was like, listen, and I’m sure some of the nurse colleagues would love to come and they hardly get to go to these things.

They really do not have that kind of fun that we do. And I think if there’s one event they attend this year, that really makes them feel like, wow, like, I can’t believe my practice took me here. I think that’s, this is going to be a very memorable one for them.

[Mehy]
100 percent is a huge favor that you can do to your team and they don’t get to experience. Unfortunately, a lot of our nurses and hygienists and therapy is the cool part of dentistry that for me is this conferences network meeting people that they go through the same struggles that you do or success. And it’s very special. So, yeah, I encourage. Bring your whole team. Anyone is more than welcome to join.

Everyone will learn. It’s not an event for only dentists for sure. It’s actually this year we’ve designed one of the acts for hygienists and therapists. We talk about it and also we’re going to talk about the problems between dentists and nurses. We’ll have the two different kinds of dentists and nurses and how they treat each other. So the title is The Story Behind the Worst Dental Team Ever. So we’re going to concentrate all our savages situations in a few minutes. So it’s going to be intense.

[Jaz]
I think we’ll all be able to resonate with a lot of the themes that come across there. How can people book on? I’m going to put the link in the show notes. I’ll be there. I’ll be joining you guys in the audience and I’m very excited for it. If it’s anything like your previous event, I mean, I can’t wait. My only criticism maybe of your event was it literally like it flew by so quick.

It was like two hours. Like it’s social already, which is great. I don’t know, don’t get me wrong. I enjoy the social, but it was like, everything just was like in the blink of an eye, I was like, wow, that was so engaging. So, it’s definitely a very fun day. What’s the website? I’ll put it in the show notes for anyone who’s on the laptop now. What’s the website? How can they come to the event? It’s 18th of October, right? Friday?

[Mehy]
18th of October, Friday. Doors open 6pm, so it’s after work. You can, the show starts at 7. And then, yeah, we’ll be there till late. The website is globaldentalcollective. com. You can get access to the shows and drama.

From there, you can get the tickets. We’ve created a special discount for your audience, just for the protrusive podcasts. So we’ll share that, also with you. And then-

[Jaz]
Try and make it Protrusive. Because everyone’s used to just going and typing in protrusive and coupon codes. People sometimes go on like fashion websites and just accidentally type in protrusive because they’re just so used to using protrusive as a coupon code. So if you can make it that for everyone, they’ll do that.

[Mehy]
Perfect. And that’s going to be easy. protrusive as a code, and then you’ll get a huge discount. And we want to have as many people as we want. There’s like 400, respecting 400 people. So it’s probably the biggest audience in any one day conference in UK. So then the conference is going to be cool.

[Jaz]
Amazing. I can’t wait to see that. I can’t wait to see the Protruserati who come there. Please bring your teams. I’m literally going to message Zoe and the team now saying, ladies, do you want to, come to this? I think that’d be pretty, pretty fun. And I think now that we have the Elizabeth line, Reading and London, that’d be quite good for us as well.

So that’d be good. Mehy, honestly, thank you so much for coming on, talking about these themes, talking about vulnerabilities, opening up about your past and your dips in that dentistry and then how engaged you are now and your sort of the work that you do, and also just generally thank you for the work you do.

You, the Global Dental Collective is the GDC we actually need. I’m pretty sure when you came up with the name, you came up with a name.

[Mehy]
That was actually, actually, that was, yeah, that was Joe Lovett and it was a bit of a joke. And now we’re a bit of trouble because we can’t really use only the letters.

So we’d see what we do with that. But they’re fine with that. They’re happy with that. So I think also, I don’t know if they like it or not, but it’s how it is. But yeah, we don’t want to compete with that. We just want to help.

[Jaz]
Definitely not. We have different purposes, but brother, thank you so much. I’ll put the links in the show notes. So it’d be great to see you guys there. And thanks so much for speaking about these topics today.

[Mehy]
Thank you so much, Jaz. Thank you for having me.

Jaz’s Outro:
There we have it guys. Thank you so much for listening all the way to the end. Hope you enjoyed those really hard hitting themes that me and may covered. And because you made it all the way to the end, if you simply answer the questions in the quiz below, now this is obviously accessible to you. If you’re on the protrusive guidance app, if you’re on a paid plan, you can get CE. or CPD for this episode. We are a PACE approved provider and it’s just a great way throughout the year to listen to podcasts and get CE.

It allows you also to add in some reflections and that comes in your certificate so that you actually remember, ah, this episode taught me that and this is what I will change about my practice. Maybe after today you’re going to go get the book The Power of Body Language, by Joe Navarro. Or maybe you’re going to seek permission from your nurse, your dental assistant, and give them permission to give you feedback.

Or maybe you’re just going to join us at those events in London in October and November that I told you about earlier. One is the Dentorama that Mehy’s involved in and of course the Treatment Planning and Communication Symposium on the 16th of November. Please do check out the links below for both those events and hopefully I’ll get to connect with some of you there.

I want to thank the team. This one was produced by Gian. The CE certificates are taken care of by Mari, with very diligent quizzing and quality control from Krissel and Nav. Thank you again and I hope you enjoy this interference cast. I’ll catch you same time, same place next week. Bye for now.

JOIN US on 16th November for Treatment Planning Symposium 2024 – Online Event OR In-Person – you decide!

Implants are great but they are not always the best solution for our patient.

There are many times a bridge or denture may serve the patient’s goals, aesthetics and budget better.

So how do we decide between bridges and dentures?

Is it acceptable to use root filled tooth as a bridge abutment?

Are single tooth posterior dentures risky? Or do patients love them?

How do we begin to communicate aspects of replacing teeth with our patients?

Join me with our guest Dr Michael Frazis as we discuss the art form of communication with our patients and some outlandish cases including roundhouse bridges. This will really help upskill you on dealing with patients with missing teeth.

Protrusive Dental Pearl: Failure is inevitable for our Dentistry, but try to set yourself up for smaller failures and not giant catastrophes! The real magic is in proper case selection. Practise at the EDGE of your comfort zone, but NOT out of your depth.

20% OFF Guaranteed on RipeGlobal Fellowship Programs + Free access to their portal – Click here to register for this! protrusive.co.uk/rg20

Follow Dr Michael Frazis on Instagram

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC LEARNING OUTCOMES: A and C

AGD Subject Code: 610 Fixed Prosthodontics

Dentists will be able to:

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous ‘Vertipreps for Plonkers’ series.

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

Highlights of this Episode:
00:01:37:00 Protrusive Dental Pearl
00:03:51:05 Introduction – Dr Michael Frazis
00:10:43:10 Growth in Dentistry
00:14:10:10 Non Implant Tooth Replacement Options
00:18:15:10 Treatment Planning Bridges and Dentures
00:24:35:10 Ideal Treatment vs Budget
00:30:15:10 Single Tooth Dentures
00:36:58:10 Thin Implants vs Bridges
00:39:25:10 Bridge Spans
00:49:20:10 Root Filled Teeth as Bridge Abutments
00:55:35:10 Failures
01:05:35:10 Wrapping Up – Contact Michael

If you liked this episode, check out PDP132 – Resin Bonded Bridges

Teaser: I'm doing that bridge 11 times out of 10. If they're a patient that has money to burn and they want their teeth to be individual, they want to be able to floss their teeth because that's just what they have as their goal. I will go crown implant- And I don't think we as dentists tell patients that. If there's something you can do as a clinician to mitigate that risk, could you use that word, tell them what it is. So to give you a concrete example, when I'm taking out a tooth, I will say-

Jaz’s Introduction:
Implants are awesome, but they’re not for everyone. Now this could be financial. This could be something to do with their medical history. And actually there are some scenarios where a bridge or a denture can be superior. And so many of these scenarios, we need to help the patient decide between a denture and a bridge. We’re going to do a deep dive into decision making and treatment planning when it comes to these modalities. I’m joined by Dr. Michael Frazis from Adelaide, Australia. He’s one of the educational directors for Ripe Global. And very soon he’ll be coming to our event in the UK to talk about treatment planning and failures which will be a live in person event and also a live stream.

In today’s episode, the real world questions we cover are ones like, is there ever a place for a single tooth posterior denture? Can you ever justify using a root filled tooth as a bridge abutment? And how big of a bridge is too big of a bridge? Is there ever a place for a roundhouse bridge? And generally bigger picture stuff. Implant considerations, denture and bridge considerations.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This one’s actually full of some great communication gems and one of them today is what I’d like to make the Protrusive Dental Pearl. To highlight the event we’re doing on the 16th of November on treatment planning and failures. I want to take this opportunity to pitch the notion that you’ve already heard before, which is failure is part of life.

It’s part of dentistry. All our dentistry will eventually fail. And sometimes you make poor decisions and we learn from them and they’re powerful teachers for us. And we experienced all sorts of different modes of failure. And every time we fail, we hope that we will learn and improve as clinicians. But I want to take this one step further by encouraging you that when you fail, try and fail as safe as possible.

And the way you can do that is case selection, but also just generally making sure that you are pushing your boundaries and challenging yourself, but make sure you are challenging yourself at the very edge of your comfort zone. You want to be at the edge of your comfort zone, but not to beyond your comfort zone because that fall from when you go too far beyond can be quite big and when you fail you can fail hard. Let me give you an example. If you’ve never done veneers before, please don’t pick a class 3 patient with crowding who’s got features of a high force bite and a high smile line. Do you get what I’m trying to say?

You’re setting yourself up to fail hard. And sometimes we take these cases on because we really want to do them, but I would encourage you, it’s good to challenge yourself. It’s good to be out of your comfort zone, but please don’t be out of your depth. Now, if you’d like to join the live stream and the 30 day replay of our Treatment Planning Symposium with Lincoln Harris and Michael Frazis, and my very clinical lecture and all the different failures and mistakes you can make in restorative dentistry.

Then please do head over to protrusive.co.uk/rx. The early bird rate is almost over and I don’t want you to miss out. It is an absolute steal at the moment. If you’re able to attend live and network, enjoy that magic of people. Then it’d be great to see you there. But if you can’t come to London, then do join us on the live stream and, or the 30 day replay.

One of the things we’re going to have is a live patient, unseen case. So Lincoln Harris will do like a live consultation on stage and we’re hoping to learn some communication skills, but he’s going to dissect that with us. So we get a better understanding of treatment planning in the real world. And sometimes by going through a case, that’s when we learn the most.

So please do head over to protrusive.co.uk/rx and pick the in person or the live stream pass, whatever suits you best. Now let’s join the main episode. I’ll catch you in the outro.

Main Episode:
Michael Frazis from Adelaide, I believe it is Australia. Welcome to the Protrusive Dental Podcast. How are you mate?

[Michael]
I am very well, Jaz. Thank you for having me.

[Jaz]
I’m really excited to talk about all things non implant replacement like the nitty gritty questions we usually have about, can I restore this with a denture? Can I do a bridge here? But also talk about the overarching theme of replacing teeth, but I just want to fanboy a little bit, man.

Your content that I see, your development that I’ve seen over the years, even back in the day we used to have this page, you should probably still have it, Everyday Dentistry with Michael Frazis. I’ve been following you for probably 10 years now, man. I love what you do, you bring great value to profession, and I’m so excited that you’ll be coming to London as well to share that passion live with us. So I guess I want a little bit of an origin story. How did you get into this sphere of making this educational content?

[Michael]
Well, I was actually making a completely unrelated webinar for some like dental students for next week. And it’s advice to my graduating self. And I’ve been looking through old photos that I’ve taken, back when I first graduated, and old videos that I took, like the first kind of videos that I was doing.

And they were just videos that I was putting on YouTube. They actually probably still are there. Where I was giving instructions to patients on what to do after an extraction or how to look after their teeth, like floss and all that kind of stuff. The stuff that dentists try to do online when they first get out there.

And it was so cringeworthy. I’m so glad that people actually stood by me through these 10 years of growth that I’ve had because I wasn’t looking at the camera. The words were mumbling. I had like the, like it was a 10 second millennial pause at the start of the video just to make sure the video was on, but I still uploaded it.

So weird. But the way that I started was I didn’t have a lot of confidence when I first graduated, mainly because I was told I was too confident and too cocky when I was in dental school, and it didn’t match my abilities. I had very low clinical abilities because I was a student, but I was overconfident.

And so the confidence was beat out of me, rightly so, to keep patients safe. But then what happened was I was very low confidence and very low competence. And so I graduated. I was like, well, I’m really bad at doing everything. And I don’t believe in myself. So time after time, I’d go to courses, I’ll do this, I’ll do that.

And then eventually. I stumbled on like courses with Lincoln Harris and he managed to instill confidence in myself again by just inviting me back to things because after you do one of his courses, if you’re okay enough, he’ll invite you back to help at other courses and then that slowly progressed into a professional relationship within the friendship that has then grown into all the things that I do now.

But I’ve basically done all these things because I realized that there’s that gap between the confidence that you have in yourself and the confidence that you need to create. And so I’m trying to instill confidence in other dentists and young graduates so that they can see that there is a pathway for them to achieve their dental dreams and achieve their goals in life through dentistry, basically.

[Jaz]
So the effect that Lincoln had on you, now you are spreading those vibes in your own style. Now, in your own way, I kind of saw you and I hope you don’t take offense by that. I’m sure you won’t because you’re good, but you’re great buds with Linc, but like, protege, right? I don’t know if you find that cringe worthy or whatever, but I think you know, I see it, but I know, you become your own brand, you become your own person, become your own educator.

And when I look at my sort of journey in education myself, one thing I look back is the taxonomy of learning, the hierarchy of learning, if you like, right? And you know very well that when you teach someone, like when you go on a course and you go back and you teach the other associates you’ve just gained. That’s how you really cement it.

That really pushes you as a learner and so that’s what attracted me to it always and some of the stuff they’re putting out there is absolutely golden. But can we learn about also you as a dentist you as a person tell us give us a little background. So those listening and watching around the world know a little bit more about Michael Frazis.

[Michael]
Yeah, so I was born in Australia. I migrated to Greece. My family was originally from there, so I was raised in Greece for the first three years of my life, then came back to Australia, then lived in Adelaide ever since. I went to school there, went to university there. Graduated and stuck around.

[Jaz]
You went to uni in Adelaide?

[Michael]
Yeah, I went to uni in Adelaide.

[Jaz]
In Australia, it’s like a cultural thing whereby, maybe it’s changed now, but maybe about 15 years ago when I was looking through this stuff, someone Australian told me that if you grew up in Melbourne, you go to uni in Melbourne. If you grew up in Sydney, you go to uni in Sydney. Was that the case? And is that still the case now?

[Michael]
It was and still is the case. The thing with a lot of the universities for dentistry in Australia is Adelaide was and is still one of the few that is an undergraduate course. A lot of the other ones changed to be a postgraduate course. So we had a lot of people from interstate coming to ours only because they just graduated.

They didn’t want to go and do like an engineering degree or a science degree and then go and do dentistry. So we had quite a few interstate people out of the class of 80. That was my year. People came and went in that 80. I think we had 17 that were from South Australia, from Adelaide. Everyone else was interstate or overseas. So the vast majority of people in my year were from interstate and overseas.

[Jaz]
Great. And tell us about you and your interest family.

[Michael]
Yeah. So I’ve got a wife, two kids. I think we were talking before our kids are very similar age. I’ve got two boys, five and two and a half. And, yeah, I’m trying to get them to start coming on these little adventures and stuff with me.

Because it gets a bit lonely on the road when you kind of leave your family behind and then you’re sort of off teaching other people. That’s the lonely part of the education side of thing is no one realizes that when you go back to your hotel room it’s just you by yourself watching Netflix when your family’s at home. So, I want to start getting them to come with me a little bit more.

[Jaz]
Michael, I actually encourage this. I’ve been talking on this podcast about this theme of whether you’re teaching or not doesn’t matter. If you go on a course, even as a learner, if, you know, whether your spouse is a dentist or not a dentist, it doesn’t matter, right?

Take, try and take your family with you. Go on a couple of these courses, but make a nice holiday out of it. I’m a big fan of that, right? So at least some part of it is tax deductible, whereas the other part, you make memories. And so it’s a great thing to do, to travel around the world. You get to learn, so outside of your sphere, wherever you are, US, Australia, wherever you are in the world, you get to learn different perspectives outside your sphere, and it also creates memories that you’ll cherish for the rest of your life.

So I know you’ll be bringing your good lady when you come in November. And I’m actually been invited to speak in Malaysia or August next year. And I’m like, okay, let’s take the family. So I’m a big, big fan of that. So on the topic now of growth, okay, before we actually go to the clinical topic.

Just a, a quick one, if you don’t mind. What do you think is the number one thing? A nice little tip, A juicy tip straight away, right? What do you think is the number one growth? That when you look back at your career, what’s the one thing that made you grow an exponential rate compared to everything else? Because there’s so many things that we, tips we give, but what was the number one thing for your acceleration?

[Michael]
Clinical photography, in all honesty. Taking photos and then the brutal, honest, and fast way of doing it is taking photos of your work and sharing it with strangers online. No idea, Looking back why I did it.

I thought that the internet was a safe space because I was young and naive and maybe it was back then, but that’s just what I did. And then, you get people messaging you and if you do something severely atrocious, you get people private messaging you and telling you, no, that’s not how you do that prep.

This is where you went wrong. This is what you did. This is all the issues that you’ve had. Lincoln would annotate something and then send it back to me and be like, oh wow, that’s exactly what I need to do. And then I’d go and fix it. And so I was getting people solving problems for me without going to their courses, I had Jason Smith and telling me about my preps or my anterior case, or I had Lincoln doing this or Melkers saying something about this and all these people that are big names now and were big names back then as well.

We’re just commenting on my stuff because they say, if you want to get the right answer really quickly on the internet, post the wrong answer first, and then someone’s going to correct you. So if you ask the question, oh, Hey, how do you do a good crown prep? Radio silence. No one’s answering that because like, oh, whatever.

Okay. Post a bad crown prep that you’ve done. A thousand people are going to tell you how to do a good crown prep. But you have to be vulnerable in order to post it in the first place. Some people can do it. Some people can’t. That’s fine. There are a lot safer ways of doing it these days. There’s private groups, there’s forums, there’s all that kind of stuff.

Back in the day, there was, there’s Dental Town from America. There’s DPR in Australia. I know I’m in the UK one. I can’t remember what it’s called, but there’s all those ones. So there’s little subgroups and you can always DM someone these days and just send them a photo of your work and say, hey, can you help me out? And that’s honestly how I grew to where I am now, is just clinical photography and sharing with people online.

[Jaz]
And one thing, because I’m so much into creating this community of letting everyone be vulnerable and share with each other, which is so, so important for your growth and mistakes will happen and your preps won’t be perfect and you gain so much, just like you said.

But the worst thing people can do now is just like you said, how to do a good crown prep and then radio silence. Another way, sometimes you post this long essay describing the malocclusion, describing the issue, whereas one photo, which has done everything and everyone just like to engage as much easier, pictures of 1000 words.

So top tip anyone if you’re not yet taking photos and you’re wondering why am I not progressing at the rate I want to, that’s probably the number one thing holding you back. And the next thing is actually to share those photos to mentors, to strangers, and you will grow so much. You mentioned the term vulnerability and you’ll be talking a lot about that when you come to London about failures.

So the topic I’ve allocated you is to share 10 years worth of failures. So eating humble pie will be great to see you do that. And I’ll be sharing some of mine as well, my video. And maybe at the end, I’ll tell you, ask you about a tooth replacement type failure for this episode. But before we delve into non implant, tooth replacement options. One thing I asked you before we hit recording is that I said, Michael, do you do implants kind of thing? And so you do. So what I like about that is if I was talking about these kind of options, okay, and like let’s say I was the headline guest, you’re the headline guest, but if I was the headline guest for this kind of episode, I’d have a huge blind spot because I don’t do implants.

I’d be massive blind spot. So I really appreciate that you’re a good guest for this because you’ve taught on this topic of non implant kind of tooth placement options, but you also place implants, which is really valuable. So the first question I’m going to pitch to you is, nowadays, with implants being so in vogue, what percentage of your cases do you think are okay? Yeah, this will be an implant and do you think this is increasing as you’re as you’ve gotten better and dentures and the bridges are getting less. It’s more of a dying art.

[Michael]
I think I’m not at peak implant yet. And so the implant side of things is ramping up. I think Andrew Thorpe talks, he’s a oral surgeon in Australia, if people don’t know him. He talks about peak implant and you kind of get to a state, and you do this with anything in dentistry, like peak crown, peak denture, peak aligners. You basically are doing so many that you basically are just churning so many out, more than you actually should be doing, and a lot that you probably shouldn’t have done in the first place.

I don’t think I’m just at that point yet, but I’m probably in the next sort of year or two going to approach that sort of peak implant side. The amount of implants I do for replacing missing teeth has probably dropped a little bit in the last few years just because of what’s happening globally with the economy and things like that.

And there are a lot of people that are saying not yet to an implant. from a financial point of view. So I want to give them an option that allows them to have an implant later on. So you kind of need to keep that in consideration. But there are other patients that are coming to me wanting that all on X kind of procedure where they want everything removed and have implants, but they’re 33.

And I’m like, I cannot in all good consciousness, just take everything out and put implants in not because I can’t. Not because you don’t need it, but what happens in 20, 30, 40 years time when you’re still alive. And those implants start failing. What is your option then? And that’s what I need to start telling and describing to these patients.

Hey, maybe for you, we need to do a denture and a bridge or whatever. So that we can get you through for the next 5, 10, 20, 30 years. And then do that all on X procedure. Because everything’s got a lifespan. And that sort of circle of dentistry, the clinical dentistry wheel where you go occlusal filling all the way through to an implant, you want to slow them down as much as possible.

And if you jump from, carious lesion all the way to implant, you’ve kind of bypassed a lot of good dentistry along the way. And we’re just trying to slow down the progression. So a lot of the times it’s a financial reason or there’s a lot of medical ones as well, but it tends to be a lot of these days, like you probably could get away with something else for a few more years before we go down the implant pathway because you are quite young.

[Jaz]
It’s better to have an implant when you’re 50 than you’re 30, as we know, and I think that that’s exactly what you’re saying. And so you’ve already covered some reasons where you know how when someone’s got a gap, you give them all the options. So do nothing, denture, bridge implant, if everything was on the table, if everything was on the cards, then the kind of reason that someone may not go for implants, could be because of age because if you want to give someone 21 an implant, cause the growth is still happening, right?

There’s alveolar changes and that’s bad news. Financial consideration is a big one for patients. Maybe a reason why they may opt for a bridge or they may opt for denture. Another one could be whereby you already have a crown next door that just needs replacing anyway, and it would make a good bridge abutment and therefore we just need to be strategic in that individual, even though they’ve got plenty of bone, the implant will be simple.

Sometimes you kill two birds with one stone. Tell us more about how the treatment planning comes against. I appreciate it’s a high level question. How do you begin to actually assess this patient for all the different options available?

[Michael]
Because I’m part of the ripe global family, a lot of my treatment philosophies are going to be skewed by my mentors, by Lincoln Harris, by Michael Melkers and kind of that sort of filter system where you have to have obviously the patient’s goal at the start, like what do they actually want to achieve with their smile, with their mouth, with all those things and patients come in and they look at me weirdly.

It’s like, I want to replace my missing tooth. Okay, why? Because it’s missing. It’s like, yeah, it’s missing, but it’s been missing for 15 years. Why do you want to replace right now? Oh, I’ve got a wedding next week. Well, an implant’s not going to solve that problem by next week. So immediately you’re starting to think, okay, to solve this problem, it’s not an implant.

It’s something else. Maybe an implant later, but not yet. So you start to ask enough questions of the patient. How do you want it to look and all those bits and pieces that you’re saying to ask in your head and ask the patient. And I ask enough questions until I can come up with a suitable solution for them based on everything I’ve learned about them.

So it would be based on your goals as I understand them based on the budget that we’ve discussed, all those things, the most appropriate treatment for you is X. If you can’t afford that, that’s fine. We will do this compromise situation. So what I tell patients, like in the scenario that you were talking about, where they have an implant and I’ve got, I think, three at the moment, in the last couple of weeks, I’ve spoken to exactly about this kind of situation.

Two teeth either sides, either have crowns that are roughly failing, or need crowns either side, and there’s an implant in the middle that could possibly be done. Super straightforward case. Put an implant in the middle, two crowns. Or, the exact same scenario, just do a bridge. Or, there’s no, generally most people aren’t going to go down the denture pathway if they’re already choosing between a bridge and an implant.

So I tend not to give them that unless they’re going down the budget pathway or need it for other reasons. And I just go to them and look, ideally we could put an implant in there like you want. However, it’s actually going to be less expensive for you and less work for me and you get it faster if we go down the bridge pathway.

Oh, what are the difference between a bridge and implant? And then we go down those nuances between a bridge and implant. Some patients ask, oh, which one lasts longer? They both last about the same in the literature. They have different complications, but the same complication rates. One has more mechanical issues.

One has more biological issues and all those kinds of stuff. So it depends on what the patient is wanting. If they’re going to have more medical issues, if they’re diabetic, they smoke and they don’t look after their teeth and they’re a high risk of having perio implantitis. I’m doing that bridge 11 times out of 10.

If they’re a patient that has money to burn and they want their teeth to be individual, they want to be able to floss their teeth because that’s just what they have as their goal. And I’ve had a couple like that. I will go crown, implant crown, and that’s just because that’s what they want. They don’t want the bridge where they have to use a special little pickster or a super floss to get underneath it. Some people were just a bit weird.

Interjection:
Hey guys, just Jaz interfering here. As you know, I have a strong affinity for Ripe Global. I am a shareholder. I am an educator on the website and I see people like Michael Frazis, Michael Melkers, Lincoln Harris as my friends and mentors.

And when I got asked this question about Jaz, which course should I do? I’m looking to do a diploma. I’m looking to do a bigger course, something that spans over a year or two years. Then the one I’m recommending is the Ripe Global Fellowship. I’ve seen the incredible results and the growth that my colleagues in the UK and around the world have experienced.

And I mean around the world because Ripe Global is truly global, no matter where you are in the world. They’ve got cohorts at different time zones, and their teaching is top class. Now, because I believe in their education, I believe in their fellowship, and they’ve got one in implants, ortho, and their main flagship one, which is a restorative one, we’ve teamed up to offer you a 20 percent discount.

Now, you might see on the website up to 20%. This is the only way to guarantee 20 percent off one of their fellowship courses. Now, this is an affiliate partnership, and I am a partner. But if you prefer to pay full price, fine, go ahead and do that. But if you want to take advantage of this Protrusive 20 percent discount for any of their fellowship programs, head over to protrusive.co.uk/rg20. That’s protrusive.co.uk/rg20. It’s a one minute form to fill in, and you’ll get sent all the brochures, the fellowships, and more information because it is actually a big step, right? Like, it’s a much bigger course, it’s a big commitment, both in terms of time and money.

But if you’re looking for quality education, confidence, treatment planning, mastery, and communication skills mastery, then the fellowship is the one for you. I’ll put the links in the show note. I hope you enjoy the rest of this episode.

[Jaz]
I think what you’ve done here is answered a really tough question because it was so high level in such a concise and beautiful way. And I think the main message worth emphasizing again is if you’re not sure what to recommend, you haven’t asked enough questions, right? And therefore find out, do they want something? Are they happy to consider something removable? So you don’t have to say, do you want something fixed or removable? Cause they’ll always say fixed in a way, but it’s sometimes, okay.

Would you consider something removable? Or does it have to fix them? But I might consider something removable. And then there’s other considerations like budget and that kind of stuff. And so you, once you ask enough questions, cause some people are very much not, I definitely, if they associate with aging, an old person, so they definitely don’t want same removal and they already decided that then great, 20 percent of the options now off the table.

And so once you can whittle it down, it’s like playing guess who, right? You want to let last couple of people left and you help them, you show them in the face and they pick the face kind of thing, probably not how you play guess who, but you get the idea. You help them give you the answers of what they need. And then the last thing to just discuss is the budget and that kind of stuff as well, which is mega important. It might be something that sways them.

[Michael]
Exactly. And I think the guess who analogy is amazing. And I can’t believe I haven’t thought of that already. And I’m going to steal that in my next lecture slide. I’ll make sure I credit you. But, essentially, yeah, if you haven’t figured out what they need, you haven’t asked enough questions. And I think people ask the budget question too early and pigeonhole themselves. We should always treat and plan dentistry to the ideal. And then work backwards to the budget, especially when you’re doing higher level dentistry or more comprehensive, complex dentistry.

You don’t want to be limited by the patient’s budget when you’re thinking now. When you’re doing bigger, more complex cases, like full mouth rehabs and things like that, the budgets can be a little bit easier because they tend to go in brackets based on material choices. Like if you’re doing a full mouth rehab in resin, it’s going to roughly sit in kind of here.

And if you’re doing everything in ceramic, it’s kind of sit up there. You can get a little bit fuzzy when you’re going, okay, we’ll do the front ones in ceramic, the back ones in resin or vice versa, we’ll do a denture instead of implants. It can mix around a little bit. But that’s where you go.

Okay. If we did everything the best of our abilities implants and crowns everywhere, you’re going to be, I’m just going to use US dollars just because I off the top of my head, like, 30, 000 US dollars. If, however, your budget is 20, 000, that’s fine. The compromise we can make is instead of implants, we go down to bridges.

And then suddenly you get down to 25, 000. If you want to get to below. That 20 grand mark. I can’t remember what I said their budget was, they said it was 20. Then you have to go down to a denture or compromise the material of the crowns. And that’s when you go, either you need to compromise your goal or you need to increase your budget.

And so patients sometimes need to go, okay, my goal is this. I will achieve it because I don’t want anything removable, blah, blah, blah. If I pay an extra 5, 000 dollars, pounds, whatever it is. However, I can’t afford to do that. And so I need to compromise my goal and figure out a way to be okay with having a denture and just say that to them and then stop and just be silent.

Because a lot of the time, and I caught myself about to say something with a patient the other day. And it was really, it was dragging on. It’s the first time I ever met this man. And he was really comfortable with the silence. And I was like, someone needs to say something. And I hope it’s not me.

[Jaz]
He who speaks first loses.

[Michael]
Exactly. But he was like, how about we have a, because this is one of those patients that mouth full of cracks, had been seeing a dentist for six months, every single time for the last 15 years. And I don’t want to be the, I don’t like being the guy that’s like, look, you actually need crowns on a lot of these teeth. It gets a bit awkward having that conversation sometimes, especially when you’re doing it.

[Jaz]
Especially with a stranger. First time you meet them, there’s no exact buildup of rapport.

[Michael]
Yeah, exactly. And so he was like, how about we’ve got the photos now? Cause that’s really important. Taking photos so they can see that there’s cracks. So I’m not lying to them. How about we see what they look like in six months or a year. And if they look worse, we’ll do the crowns then. I was like, okay, that’s a great idea. Let’s do that. I could have easily talked myself out of a couple of crowns in six months time. I’m happy to wait.

But if I had filled the silence, if I had preempted what he was going to say with his budget, with his treatment options, with his goal, with whatever, and didn’t allow the patient to express what’s within them to you, then I would have put my own bias, my own spin, my own prejudice, there’s a lot of patients that I prejudge walking in and they’ve done some of the biggest, best dentistry that I’ve ever done in my life.

And I’m super happy and proud. One of the best dentures, my most favorite denture that I’ve ever done, full upper, full lower. And he grew a mustache to rival yours for my after photos. It was amazing. He was a government patient, government voucher patient. He couldn’t afford to even pay the voucher fees to do the full clearance.

And then he’s like, I’m going to save for six months. I’m going to come back. You tell me a price for the dentures. I’m going to get money and I’m going to get dentures by you because we just got along really well. And I was like, oh yeah, whatever. I just threw a number out there and he was like, done.

I’m going to do it. Came back six months on the dot. He didn’t have enough. He borrowed money from a friend and he paid up front the full amount. And it was the most fun I’ve ever had making a full up a full lower denture and he was just a guy that couldn’t afford to pay his government voucher fee like the equivalent of NHS stuff and yeah, just don’t prejudge patients. Let them-

[Jaz]
Don’t prejudge. Don’t diagnose wallets, which is a recurring. You’re all guilty of it basically, especially earlier on a career. We’re all guilty of it and I think to emphasize a really good point in case anyone missed it that Michael made is the whole concept of having this conversation with the patient and then using this term of okay, we have your goals, but are you willing to compromise on those goals?

And just, you’ve set an anchor now, you know what they could have, right? And some people will adjust their budgets accordingly, right? Me personally, I’m in the market at the moment, right? I’m in the market at the for one of those robot Hoovers mops. Have you got one of those?

[Michael]
Yes, we do. It’s awesome.

[Jaz]
The buying decision, right? I’m going to use you a really quick buyer. Yeah. Everyone says like, it’s the best thing ever. So I’m a really a quick buyer, but this one, I’m just like, oh, okay. I kind of decided I want the eufy X10 because the other one had too many compromises. So I completely, my wife’s budget is down here.

My budget is way higher. And I’m like, okay. But I don’t want to compromise all these other functions. I want it self cleaning, self everything. I don’t have to do anything with it. Right? So sometimes when you learn about the compromises, you adjust your budget because that’s what you value, but sometimes it’s not possible or they don’t value it enough and that’s the way it goes.

Now, one thing you mentioned is that scenario whereby you had the potential implant, but you’ve got two crowns either side. And so you mentioned about dentures, usually not an option there. Let’s talk about this theme. of single tooth dentures, like single saddle bounded, right? So I rarely do this. I’ve probably done it in one count in one hand, how many times I’ve done this, but it’s a popular question that comes up on Facebook actually.

And it seems to me that actually, lots of dentists. There’s a cohort of dentists out there doing this a lot. That’s like their go to for a single missing unit. So I’m obviously missing something and I need some education here because I’ve never done a flexi denture ever. And I know people are fans of those and they suggest that it might work well for that scenario.

So tell me single tooth replacement, they’re like bounded saddle areas. Just a single tooth dentures. How does that work?

[Michael]
So we’ve got three different options for a denture. We’ve got the flexible ones. We’ve got Classic acrylic with some clasps and, or sometimes, the little flipper ones, which don’t have any clasps. And then we’ve got the chrome. I’ve done a couple of the chrome ones. They are really, really secure. They basically look like a spider or a crab. One of them actually accidentally did because I was trying to do like a small little flipper denture for like a pre implant case because they wanted to have something and while everything healed and I don’t know maybe the lab got confused or maybe I wrote the wrong thing on the lab form and it came back as like this chrome thing and I was like, wow, that works. It has a lot of clasps, more clasps than tooth, but it works. So they tend to work really well. Acrylic ones, sometimes you need a couple.

[Jaz]
Can we just pause on that, Michael, on that chrome one, right? So I can imagine if you just prep some nice guide planes and you have enough undercut on the adjacent teeth, that actually that can be quite secure because one of the worries here is a patient swallowing, inhaling, that kind of stuff, right? Obviously you want them to remove it at night, but still it’s a concern. But that kind of denture, I can imagine it having a nice path of insertion and quite a snug fit.

[Michael]
Correct. And then it’s the same thing with the acrylic. It’s just a little bit more looser. You can cover the roof of the mouth a lot more with the acrylic. I’ve done chromes that are single tooth with cross arch support, mainly to make them bigger, but also to minimize the chance of it actually flipping off. The problem with single tooth dentures that are only on one side of the arch is because you don’t have the cross arch support. If it lifts from one side, then it doesn’t actually get held in by the opposite side. So it’s the RPI system for dentures, where you need the rest or the reciprocate. Anyway, I can’t remember-

[Jaz]
It’s the rest plane, guide plane and the eye bar, right?

[Michael]
Yes. Yeah, pretty much. But the point of that system is basically, so if you put a force on the free end saddle. It actually doesn’t cause the denture to sort of dig in and then sort of, it disengages. It’s a similar concept when you’ve got the cross arch support because if you lift the denture up on one side, let’s say you bite into a toffee apple, lift the denture off, the other side actually kind of grips in on that and kind of resists it from being pulled completely cleanly off in a lot of cases.

If you’ve only got the one side, then what happens is it just lifts cleanly off and you can swallow it. I’ve really tried not to do them. Like you, I can probably count on one hand the amount of times I’ve done it in ten years. It’s probably three. And this is completely unrelated to dentures, but my cousin had a upper expander.

This was back when we were like 13, 14. I remember the story because I wasn’t involved with it. So he was on a fishing trip with his dad, sleeping with the expander in it. Obviously they had loosened it a little bit or it had loosened overnight, fell, and then he inhaled the expander. So it’s not even like a single tooth denture, it’s an expander that he’s inhaled.

And then his dad had to like, put his fingers in and sort of fish it out. So I’m very wary of using really tiny devices in patients mouths because I don’t want them to inhale something. And then that’s in the middle of the ocean as well. Like, it’s bad enough if it’s happening to your kid in your house, let alone the middle of the ocean.

Obviously everyone’s alive. Everything’s good. So that’s your normal tooth. A lot of people, when they’re doing single tooth ones, will use the flexible dentures. The problem with the flexible dentures is obviously chrome dentures tend to be tooth supported, acrylic dentures tend to be sort of soft tissue supported.

The flexible dentures tend not to be supported by anything really because they’re flexible and they move and what happens is they look great when you first do them but because they’re flexible and when the patient bites it moves it doesn’t have that support and can actually just strip the gum.

They’re called gum strippers. They just strip the gum off the adjacent teeth really, really quickly, a lot faster than other dentures do. We know that there’s recession and things that can happen with dentures, but they just cause more issues. And I don’t think we as dentists tell patients that. Often enough because if they knew that would they actually choose that as an option?

I don’t think they would I’ve only had one person. I don’t know if there is big in Australia I’ve only had one person asked for one and I said no. I generally don’t ever give them as options for anyone to see that are acrylic or chrome and just for those specific reasons.

[Jaz]
Yeah, same here. I don’t feel comfortable with that mode of modality just because lack of experience as well, lack of education, right? And so it’s not something I offer, but sometimes patients come in with these requests and I’m sure there’s someone out there, one of the Protruserati saying, you know what, I do a lot of these, reach out to me. I’m happy to learn and we could talk about how to get success with those. There’s always a patient who may benefit from that, but it’s nice to do an overview.

So I guess we can conclude that by, yeah, you can do it, but there are some concerns and some safety. And also perhaps there are some other things out there that are superior. And so me and you don’t do this a lot, but it is an option.

[Michael]
Yeah. I mean, I break that when most people say single tooth dentures, they’re talking about the posterior ones. Cause we have all done single tooth anterior dentures. We’ve all done it. We’ll continue to do it when I’m talking about, like, can count on three fingers, how many I’ve done, we’re talking like a pre molar, a molar, a single incisor. We’ve all done that. And that’s fine because you’re covering a reasonable amount of the pallet or you’ve got clips, you’ve got this, you’ve got that. And it’s very unlikely that it’s going to cause issues.

[Jaz]
So, Michael, give me a perspective on this as someone who places implants, right? And please feel free to disagree with this statement, right? Because remember, I don’t do implants, right? So I’ve got a bias, right? I strongly believe with my blindsidedness and the fact that I don’t do implants that for the lower single incisor, that implants are a stupid option.

But that’s what I believe. Okay. And I just think that when you have something like Resin Bonded Bridges, which can be so successful for incisors, especially lower incisors, right? Then why would you try to fudge an implant and mess about with the biology? Cause you’re dealing with a small space and now they come out with thinner and thinner implants to try and meet that. But I just think at this day and age, why would you do an implant when you can do a resin bonded bridge?

[Michael]
I don’t disagree with you for a single lower incisor. I have one patient and she’s a very difficult patient and she’s also a hemophiliac. I didn’t do the implant but I referred it to the oral surgeon. So he did the implant because she insisted, like, insisted that she had to have a surgical procedure as a hemophiliac. And I’m like this is not going to be for me. I’m sorry. You can go somewhere else for them to do it.

[Jaz]
Too many red flags there, because the hemophilia is there, but you’ve got thin bone, right, in that area. The tough, the crappiest type of bone, right? I mean that, you can tell me that.

[Michael]
Yeah, yeah. There are too many things to potentially go wrong. Now that doesn’t mean that they shouldn’t be done in some specific circumstances. I think a lot of times I tell patients, Look, let’s just do a resin bonded bridge.

And then if and when it fails, we can then consider what our options are at that point in time. And what happens is 15 years go past, and then nothing has failed, and then they’re all fine. And then they’ve forgotten about the implant, because they’re like, oh, well, that worked for like a really long time.

Can we just do that again? It’s like, sure, let’s do that. Also, the other reason they tend to fail, like, sorry, lower incisors, you tend to remove them, is for perio reasons, because they’re mobile. So that’s also a really bad place to put implants, is next to where all the calculus happens in perio patients.

So there’s a lot of red flags that happen with that. That doesn’t mean that they shouldn’t be done and that they can’t be done. I have a couple of patients that have really big lower incisors. So be they could probably put like an actual normal size implant in there. I just a smaller one, but just a normal size, not a mini one for those patients you might be fine to do it. For that little old lady, that’s a hemophiliac with perio, resin bonded bridge, all the time.

[Jaz]
Well, on the topic of bridges, then let’s talk about another common question. One of the questions I had for you for this episode is the span of bridge. Cause then sometimes we’re thinking, you get a bridge too far. And so let’s take a scenario which actually can work well, which is the canine to canine bridge. Okay. I myself had reasonable, good success. I’ve had in the limited few that I’ve done, I’ve not had any Issues with them yet. Okay. But I’ve been practicing for 11 years, so that’s still to come. I expect, obviously it will fail eventually, but I’m having enough confidence to treat and plan that because I think these canines make great abutments.

And then, so that is now obviously a six unit bridge in a way using two abutments and four pontics. And so we can forget about the whole Ante’s law. Let’s just say that we disproved that, Ante’s law whereby the total surface area of the roots that you are replacing should exceed or match the surface area of the abutment.

So that’s a myth. And we know that in periopatients, bridges can do really well as well. And so that was, I think, Nyman and Lindhe data, if I’m not wrong there. So the question is, we know the canines in canine can work well, but at what point do you think we should start worrying about the span?

Because I’m sure you, maybe you’ve seen as well. Some other countries, when they do bridges, they do bridges, like they do a full arch.

[Michael]
Like a grandest bridge.

[Jaz]
Yes. I’ve never done one. Okay. But I’ve seen a few and I’m like, how, this is amazing. I just like take photos. Like this is spectacular. So sometimes it’s roundhouse bridge, you take the OPG and there’s maybe it’s like an all on four, but the four is not implants.

It’s actually just teeth. And so the original all on four. So I have no knowledge and experience about this. Tell me what do you know about this kind of bridge and then what kind of guideline can we suggest to dentists listening and watching about the span of bridges?

[Michael]
Yeah, so I’ve done those six unit bridges, those canine to canine bridges. They work really well, they can be quite predictable. The main thing to consider with those ones is not the distance between the canine to the canine, but more so the degree of overjet that you have from the canine to the anterior. So the anterior posterior spread of the teeth. There are some patients that actually have quite a narrow arch in their anterior teeth.

Actually, the ridge actually protrudes quite forward. And in those cases, it’s really probably not the most favorable thing to be doing a canine to canine bridge that goes around the curve. So try keeping things as straight as you can, but obviously following the ridge a little bit. You’re not going to just completely miss the ridge and go completely straight.

So those can work quite well. The forces on the anterior teeth are much different to the posterior teeth. Studies of preliminary data that Michael Melkers and his wife did where the amount of force that is produced by the teeth decreases as you move from the molars to the premolars to the canines to the central incisors.

And so it’s about 30 percent of the force at the central incisors compared to the maximum at those, at the molars. It’s only 70 percent at the canines. So the drop off is really significant from canines to the central incisors. So having the canines, which are built in design to be robust teeth and take all the force in the lateral sort of excursions, really helps stabilize them as bridge abutment teeth.

So, which is great. The problem when you do sort of your roundhouse bridges, your bigger kind of cases, when you go like molar, let’s go ideal situation, molar to canine to canine to molar. The forces are different in the posteriors compared to the anteriors, okay? Over the molars and what we want on pontics is going to be very different.

So with anterior teeth, it’s very similar to pontics. You don’t generally have an occlusion on the anterior teeth or if you do, it’s very light. So it doesn’t really matter if they’re touching or not. With your posterior teeth, they’re going to be touching. So it’s very difficult if you’ve got that many teeth to just have things not touch, because then the patient’s kind of only occluding on two molars the back.

Very easy to overload things. When they’re moving left and right, you only want them to be touching on the canine, if there’s a canine initiated guidance. You don’t want anything happening on the pontics. The problem is when you have everything splintered together, if you’re pushing on that canine, that way, towards the left for the people who aren’t sort of watching the video, if you’re pushing everything towards the left.

The rest of the bridge is connected to that canine, and it’s going to exert a force of there’s going to be compression, there’s going to be some tension happening on that bridge at some point in time, and depending on the material you’ve chosen, then there might be some flexure of the material.

There may not be some flexure of the material, like if you’re doing a zirconia bridge, and that might also be an issue, because instead of flexing, it might crack. If you’ve got a metal substructure, it’s going to take a little bit more of a, maybe a slight flex before it actually, cracks, but still there’s a maximum force that can be applied in the protrusive, in the lateral excursions.

What we also forget is underneath all of these super amazing materials that we have in dentistry, there’s a tooth and the tooth is just biological, mineralized tooth structure. It’s a series of tubes. It’s got enamel. If you’ve got any enamel left, it’s dentine. It’s alive.

Hopefully it’s vital because obviously the success rate of a bridge drops if it’s a non vital tooth even less. So if it’s got a post in there, what we forget is that flexure that can happen can also open up micro gaps between the bridge, or the crown and the abutment and the abutment tooth and then allow passage of bacteria to happen and go in.

So you’ve got a lot more biological issues that can happen a lot more mechanical issues that can happen. And that’s just me talking about the fact that you’re just a normal human being moving left and right. We’re not also talking about the fact that you’re doing these kind of cases on patients that have already destroyed the rest of their dentition, either through wear or decay, where they do come into the play is in the cases like I was talking about before, on that 33 year old who desperately needs an all on four, but you’re trying to push it forward as far into the future as you can.

So she really wants to do all on four. I really want to do a big ran house bridge on her because actually I don’t to be honest because she doesn’t have any anterior pierce. It would be like two molars with like a massive bridge going all the way around. That’s too silly. I actually want to do a precision denture for her, but I don’t know.

That’s a separate story. They’re for terminal dentitions. The dentitions that, this is their last hurrah. You know that it’s going to fail. You’re just trying to do the best you can for as long as you can. They’re not for, what tends to happen is, John goes to Bali, has his bad teeth removed, and comes back with a new massive bridge.

He probably could have had a couple of those teeth fixed or done various other bits and pieces. People just tend to just join all the crowns together for some reason. Because they splint all the teeth because they have really tiny preps, and so they just split them all to stop them falling off.

So that technically is a big ranthouse bridge just with more abutments everywhere. There’s a lot more biological issues. There’s a lot more mechanical issues that can happen and the forces on anterior teeth are different to posterior teeth. But when you’re joining everything together, everything is sharing in the forces.

[Jaz]
I think you hit the nail on the head in the sense that, there’s a place for everything in dentistry. Including a roundhouse bridge for the right patient. And sometimes it is that patient who, like you said, it’s the last hurrah. And sometimes they’ll be there for 10, 15 years. And that’s great. And now you also have to think about the patient as a whole, right?

They’ve got weak muscles, low occlusal risk, and the upper, let’s say the upper is a complete denture. And then the lower you got some teeth and you know what the we know how troublesome they can be and they haven’t got maybe implant money or implant medical complications, then maybe a roundhouse bridge in that patient could work.

And so there’s always these considerations. I think always occlusal design is important, making sure that everything is shared and well considered. And one thing we haven’t actually mentioned on is the technical aspects of yes, material design and time to pick up the phone and speak to your lab, but also the path of insertion, trying to keep things as parallel as possible. It’s a really difficult skill, but nowadays with the scanners and stuff, and you can observe that. So that’s pretty good. Anything on that before we move on to the next topic?

[Michael]
I think that’s probably a good place to talk about year old and day dentistry, like fix movable bridges, where you have a bridge that is in two parts where they connect at sort of that little pier abutment.

So you insert one half of the bridge and then you insert the other half of the bridge. So instead of having, and they work a little bit well when you’re trying to connect a molar to a canine or something like that. And that doesn’t mean if I’m doing like, a molar to a canine, I’m going to do a fixed movable bridge.

It just means that in some cases, if you have a path of insertion issue and you need to have two separate path of insertion, they can work well. If you’ve got an issue where you’re like, I know this canine wants to go left and the molar wants to stay exactly where it is. I need to have a little bit of flexing in the bridge so it can take up some of that slack. Then a fixed movable bridge may be the most appropriate thing. So they can work quite well in some cases when you have those differing forces.

[Jaz]
Yeah, so that negates the need to make them parallel. Great point. I actually did one last year on my father in law and then a few over the years. Hat tip to Paul Tipton, did a really good episode on fixing bridges. I think it was episode 50 something on the podcast and that gave me the confidence to look into that. But again, it’s something that you want to speak to the lab about the first time I did it with the lab. It all went horribly wrong because of the height issues and actually prepping for the connector part was not long enough.

And so you, you learn and maybe we’ll talk about it in our lecture on failures and learning. So I’ve actually got that documented. So we’ll be able to talk about that one. You mentioned a little bit about root filled teeth and how things, the prognosis decreases. And so having that knowledge and someone called professor Martin taught me this at dental school.

It’s just always that same thing always stuck with me you know that root filled teeth because the fact that a root filled tooth is more likely to have less residual tooth structure, less stiffness, there will be some degree of taper for a root canal, the less pericervical dentine, less proprioception, so many reasons why root filled teeth don’t make great bridge abutments.

And so I would say I’m very, very risk averse when it comes to doing a bridge abutment for a root filled tooth. And maybe I would say it’s a big factor in why I don’t do as many bridges because a lot of teeth seem to be root filled and I don’t involve them. I kind of really reduce it. And maybe I’m being a little bit too, I’m taking that by too much gospel, any guidelines you can give in terms of involving and was a topic in the community as well involving root fill teeth as bridge abutments?

[Michael]
So obviously you want to minimize the amount of root fill teeth that you are using for bridge abutments. There’s nothing wrong with doing a crown on a root fill tooth. We know that they need full occlusal coverage. I want to get away from saying they need a full contour crown or anything like that.

There’s a lot of research now that it’s just full occlusal coverage. It minimizes the flexing of the cusp, because at the end of the day, like you said, root field teeth, root canals aren’t done on healthy teeth. They’re done on very broken down teeth, all that have had very large restorations for long periods of time.

And so everyone always goes, oh, it’s the crown that caused you to need a root canal. But why did you need the crown in the first place? Oh, you had a five surface amalgam with a crack in it for 15 years. Okay, that’s probably the reason why the bacteria got in, not the crown that we did. But anyway, so you always have to assess that individual tooth that you have in front of you.

So the literature is great to give you an overview of statistics, the probabilities, all that kind of stuff. But at the end of the day, you have to discuss the patient in front of you with the patient’s tooth that’s in front of you. So I’ve had a couple of root canals where it’s like only the mesial half is missing and it’s only really because it’s just a really deep mesial occlusal decay that really got into a high pulp form.

I know the rest of the tooth is pretty okay and so I might go look there is a higher than normal chance that that tooth will break but if it did we have these options down the track and the patient goes that’s fine I don’t have the budget for an implant let’s go down that pathway or if they do we go this needs a crown anyway and we can do an implant.

And they say that’s fine. But as long as they understand what the risks are long term and it’s an appropriate treatment for them, then it can be acceptable. I wouldn’t say I do it all the time. And I generally try to tell patients, put a crown on that tooth, put an implant in front of it. But I am wary with some people, they’re going to take that risk.

Everyone’s going to be like, you’re probably more risk averse than I am. Some patients are more risk tolerant than I am and so they will try to convince me to do procedures that I don’t feel comfortable with. That doesn’t mean it’s the wrong procedure, it just means that I might not be the right provider to do that treatment for them. Because at the end of the day I want to tell my patients look this is what I expect I can do this is what I expect I can do if it then fails. And when I was really sort of early in my career because I hadn’t seen a lot of my own failures I didn’t know how I would be able to solve those issues.

Because I hadn’t mitigated a lot of my own failures and now I’m mitigating a lot of other dentists failures not because they’re being referred to me, but because I’ve been around the block for a while and you get patients that they go somewhere else, they get something done, they’ll go to Bali, they’ll go to Turkey and then they come to see you like, hey, kind of got this thing done somewhere else and I don’t like it or this hurts now.

Can you fix it? And so you kind of get a little bit better at undoing big problems. So they put your smaller problems into perspective. So now I can comfortably say to a patient, look, if you get decay under that tooth, if your bridge breaks or that it’s not the bridge that breaks, it’s the tooth underneath it.

If the tooth underneath it breaks or something happens to it, that’s fine. What we’ll do is we’ll section the bridge and then you’ll have two implants. I can do both of those implants if you’re comfortable, that’s fine. If you’re not comfortable, then we can just do one implant now and then the crown.

It’s cheaper to do that now than to do two implants later. It’s up to you. What would you like to do? And then depending on their risk tolerance, they’ll go down a specific pathway. But I try to make sure that they understand that, it is a higher risk procedure, doing it that way. And I generally don’t encourage it, but every now and then you might get a patient, like I said, where the root canal was really done for, it wasn’t a five surface cracked amalgam.

It was like a small little buccal filling that for some reason ended up needing a root canal. Those kinds of cases where you’re like, okay, we could probably get away with bending the rules a little bit, but you need to know the rules first before you start breaking the rules.

[Jaz]
Brilliantly said. And I think your overall monologue here about risk tolerance and how sometimes our risk tolerance is different to the patient’s, that’s a beautiful reflection there. I really like that a lot. Actually, I’m going to remember that one. I think you hit the nail on the head when you said that actually there’s always a time and place that you may consider it.

So, for example, I don’t like to use root filled teeth as bridge abutments, but in the lady just a few years ago, I used the centrals, which are root filled, to replace the laterals as a bridge. A, because forces are lower, but she had an AOB and anterior open bite. Okay. So the forces are even lower and I was replacing an old crown and I was able to now, and there was some recession.

So now I was able to use vertical preparation, try and maintain as much percervical dentine as possible. And therefore in that scenario, I was able to know the rules, but then know when I could break them safely, because it’s very difficult to undersell and over deliver. If you find the over delivering part tricky because you’re picking teeth that are a little bit dodged, but when you are, do a calculated decision, looking at the patient as a whole, then we can do it.

And I think definitely you’ve summarized that really nicely in this episode. Last question I have now, I’d kind of like to promote the event on the 16th of November, where you and Linc will be joining us live at Sheraton Skyline Hotel, and your theme I’ve given you is 10 years worth of failures. So you have part one, and then we have a little break, and then part two. Can you share with us a tooth replacement failure that you’ve had that’s got a nice lesson to it that you can share with us all.

[Michael]
Yes, so it’s the only time that I’ve been I wouldn’t say put in front of the board, the dental board, but the patient wanted to put a notification in, for me to APRA, the Australian sort of regulator for dentists, it was an implant, I didn’t place the implant because I wasn’t placing implants when this happened, another clinician in the practice placed the implant. I did the restorative work and it was around the time where the pandemic had just taken, hold, and so the implants have been placed, they’ve integrated, put the crowns on, we’re like, look, we have to shut doors tomorrow, we can’t see you for the review, blah, blah, blah.

So, first issue is obviously, try not to do really big dentistry on complex patients just before you’re about to shut the doors for like three months because of a global pandemic. But a lot of the issues that I had with that patient were communication issues stemming from earlier on. There were a lot of red flags with that patient.

There were a lot of medical history red flags. There were a lot of communication red flags. There were a lot of signs from earlier on. Other treatments that they had said yes to or did, they didn’t follow through, that was going to tell me that they were going to be the kind of patient that would kind of say one thing, do a different thing, or just not give us the full story every time something happened.

She was always breaking things so much so that you remove a molar, then the next molar would crack, and then you remove that molar, and the next molar would crack, and you remove that, and you’re like, oh, let’s put an implant there. Hold on, maybe we should try to figure out why she’s breaking all these moulders and what’s happening there.

So a lot of the the failures that I had in my earlier career you could probably summarize into two categories and they’re the two categories that I’m really going to focus on in the course that we’re doing in November. So the first one is is communication. So everything that you discuss with the patient before the procedure.

So before you start the procedure, before you plan the procedure at the examination appointment is part of consent. Everything you do afterwards is an excuse. And if you frame it in your mind that way, then you need to tell the patient a lot of things that could go wrong and what you’re going to do to try and fix it before it happens.

So that when it does happen, A, it’s not a surprise, and B, you’re not left holding the bill. Because it can get very expensive. And a lot of the issues that I had with that patient, she actually wanted a refund, but didn’t tell me she wanted a refund, which I would have given her refund very gladly. She told the regulators that she wanted a refund and they kindly told her we won’t.

We can’t tell him to give you a refund, but we’ll kindly investigate him for you. So that was three months of stress for no reason. And then the second side of things was the over promising and the under delivering side of things. So when you’re early on, or when you’re new in a procedure, you kind of go, I can do this, I know how to do this.

And then you get stuck into it and you do it. And like nine times out of 10, it will go perfectly fine. It’ll be exactly like you read in the textbook, exactly like you did at the course. But what happens on that 10th time where in the case that I’m going to talk about in November, like the sutures come undone and you’re like, what do I do now?

Like, how do I just fix this? And they’re like, oh, it’s just healed now. And now instead of my flap being where I wanted it to be, it’s over here. And now I’ve got like this join line. How do we fix that? And kind of you’re learning as you’re going along with this case. Which is not the way that you want to do it.

Fortunately, it was a very understanding patient and she had a good discount along the way to sort of smooth things over. With this other patient where I was replacing a tooth because she had lost and broken all her other teeth. I shouldn’t have been discussing things with that patient after the fact I should have discussed it before I should have also had the red flags go off in my head and go.

Actually, you don’t need an implant to replace your lower left molar and your lower right molar. You need a full mouth rehab, you need to quit your job and not stress, and you need to see a completely different clinician that doesn’t work in this practice and is called a prosthodontist that I am not. So, that’s what should have happened with that one.

But essentially, it’s coming down to communicating everything effectively before the case starts so that the patient understands what can happen, both positive and negative, and what you will do to help in the positive and negative aspects, any additional costs that they may or may not have to pay so that both of you are aware of it.

And so whatever I tell patients, look, if this happens, this is what the cost is going to be. If that happens, I generally won’t always charge them that or that same amount. It will either be less or nothing. And also we want to make sure that we’re not, I know it’s the practice of dentistry and I know that we all do procedures on patients and we’re always stretching the boundary just that little bit more, little bit more, but just make sure that the boundary stretching that you’re doing isn’t too much of a leap for that particular patient and your skillset.

Cause sometimes when we’re early on in our career, we don’t see how big the jump is until we’ve made it. And you don’t realize that you’re actually going to land on your face. You’ve already jumped and you can’t unjump and you land on your face. And combined with some communication issues, I had to eat a lot of humble pie with that patient.

The giving the money back was the easy part. There was a lot of slap on the wrist, a lot of learning from the regulators. And in all honesty, by the time that the case was brought up in front of the regulators. I had already started and completed a fellowship in implantology. I’d done a lot of additional research on occlusion.

I had Michael Melkers as a mentor and lots of other people. So all of the problems that had happened, weren’t going to be repeated, moving forward. But I would just made a little bit too big of a leap in that one. It’s because I was focusing on trying to complete that case during a time where the world was not wanting you to slow down. So I was trying to hurry up and make a bigger jump than I probably should have.

[Jaz]
I really appreciate you sharing that failure with us or that experience with us. It’s often difficult to talk about these, but I unfortunately made it your mission to tell us more about various scenarios. And so we can’t wait to hear more because there’s so many powerful lessons that we can take away from that.

I’m going to be starting off that day by actually just showing some, so no, I don’t think any educators ever shown this, right. And correct me if I’m wrong, Michael, if you’ve ever seen this. But imagine, and I’ve got a video, right, of seating and onlay. The seating just goes so wrong, right? And the curing just goes so wrong.

And everything wrong that you can imagine happens. But I’ve caught it all on tape, right? And I’m going to just show everyone that, like, don’t do this. But here’s about five others that went perfectly. But here’s the different thing. And here’s the critical error we make. And it’s all to do with actually before we even picked up the bur and that kind of stuff.

So I can’t wait to show that, but I just want to just reflect on two things. Cause it’s really, really important. We make this reflection. Oop. Hello, balloons. For those watching, really, really important because there’s one golden thing you said, like it’s one of my favorite communication things.

You mentioned it and someone just might have missed it. Cause maybe they’re not ready to hear this yet, but when you tell someone a risk, when you give someone a risk, if there’s something you can do as a clinician to mitigate that risk, cause you use that word, tell them what it is. So to give you a concrete example, when I’m taking out a tooth, I will say your tooth could break in a way that makes our extraction very difficult.

But what I’m going to do is I’m going to actually break it myself in the way that I wanted to break and then this will actually improve your extraction. Just an example, or your tooth is very close to the sinus, so you might have a link between your sinus and your mouth and you might have a new party drink whereby you drink water and water comes out your nose.

But don’t worry, we’re going to prevent that by again, sectioning and being very gentle. But so A, now they know what can go wrong, consent, but B, now you’ve instilled confidence because you don’t want, consent is not just this could happen, that can happen, that can happen. It’s actually Here’s the things that can happen.

Here’s some things I can control. There’s some things I can’t control and now you know that. And so I’m really glad you mentioned that. I just wanted to emphasize that. And the other thing that just really emphasizes everything you said about this last patient you spoke about, on the Protrusive Guidance app, on the community, I posted a question saying, which is your fear procedure?

What is the procedure that you fear the most, right? And our experienced colleagues, they said something kind of like what you said, right? You get to a stage of dentistry where you no longer fear the procedure. You fit the person behind the procedure. So the procedures are not so as fearsome as the mouth they’re attached to, because even a simple restoration in a difficult mouth can be very, very difficult.

Something our good friend Linc talks about as well. Simple dentistry on a complex patient is still complex. So we also look forward to having a treatment planning masterclass from Linc on the 16th of November. Hope you like that little link I made there, Michael. Thank you so much for talking about this.

I had the most fun and I know that the audience would love this. And if they did, you’d better be hitting subscribe and liking and following you and your content on Instagram. Please tell us your Instagram handle and how we can learn more from you.

[Michael]
So you can visit my Instagram. Also on Facebook, if you are still on Facebook, it’s exactly the same. It’s @drmichaelfrazis and you can find all my content there. If you want to go do any courses, if you want to sign up for Jaz’s course, or that I’m doing with him and with Lincoln or any of the other Ripe Global stuff, all the links are in my bio in my Instagram or any one of the billions of ads that we run across the internet. If you click on any of those, it will take you to the relevant place.

[Jaz]
Amazing. I’ll put all the links in the show note. And another lesson that I learned is make sure you ask the speaker, ask your guest how to pronounce their surname properly at the beginning, rather than hear him say at the end, the proper way that you should have been saying it should be in phrases and not Frazis (different pronunciation).

[Michael]
Both are equally as perfectly fine as each other. Colloquial sort of dialect differences between Australia and UK and the US. So we were all-

[Jaz]
That makes you feel better. You’re very kind saving face a really important skill to have in life Michael, thank you so much for and I can’t wait to see you in just two months now and to learn more from you my friend so thanks so much making time for this and i’ll see you in november

[Michael]
Thank you. I will see you there.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. I told you this would be packed full of communication gems. Which one was your favorite? Please do comment below and let me know what you resonated with most. You can get one CE credit by answering the quiz below if you’re on Protrusive Guidance. This is where we have all our master classes and content, but also it’s a community of the nicest and geekiest dentists in the world. Head over to protrusive. app to find out more.

But those of our paying members who like to collect certificates and validate their learning and reflect on their learning, the AGD subject code for this one is 610, fixed prosthodontics, and this was GDC learning outcome C.

Do not forget that the 16th November event that Michael, myself, and Linc will be speaking at with the live panel debate and the live patient will all be live streamed. So wherever you are in the world, head over to protrusive.co.uk/rx to book your ticket now. But of course, if you’re able to join us in London live, it’d be great to see you and be sure to bring a friend if you’re coming.

I want to thank Michael Frazis once again for a wonderful job. I’m sure you all agree. And I’ll catch you same time, same place next week. Bye for now.