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Контент предоставлен Jaz Gulati. Весь контент подкастов, включая эпизоды, графику и описания подкастов, загружается и предоставляется непосредственно компанией Jaz Gulati или ее партнером по платформе подкастов. Если вы считаете, что кто-то использует вашу работу, защищенную авторским правом, без вашего разрешения, вы можете выполнить процедуру, описанную здесь https://ru.player.fm/legal.
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At the dawn of the social media era, Belle Gibson became a pioneering wellness influencer - telling the world how she beat cancer with an alternative diet. Her bestselling cookbook and online app provided her success, respect, and a connection to the cancer-battling influencer she admired the most. But a curious journalist with a sick wife began asking questions that even those closest to Belle began to wonder. Was the online star faking her cancer and fooling the world? Kaitlyn Dever stars in the Netflix hit series Apple Cider Vinegar . Inspired by true events, the dramatized story follows Belle’s journey from self-styled wellness thought leader to disgraced con artist. It also explores themes of hope and acceptance - and how far we’ll go to maintain it. In this episode of You Can't Make This Up, host Rebecca Lavoie interviews executive producer Samantha Strauss. SPOILER ALERT! If you haven't watched Apple Cider Vinegar yet, make sure to add it to your watch-list before listening on. Listen to more from Netflix Podcasts .…
Endodontic Irrigation – How to Get Better Success – PDP203
Manage episode 448792368 series 2496673
Контент предоставлен Jaz Gulati. Весь контент подкастов, включая эпизоды, графику и описания подкастов, загружается и предоставляется непосредственно компанией Jaz Gulati или ее партнером по платформе подкастов. Если вы считаете, что кто-то использует вашу работу, защищенную авторским правом, без вашего разрешения, вы можете выполнить процедуру, описанную здесь https://ru.player.fm/legal.
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? https://youtu.be/z5h2FzHpG68 Watch PDP203 on Youtube 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: 02:09 Protrusive Dental Pearl 04:23 Is Sodium Hypochlorite Still The Gold Standard? 06:54 The Role of Surfactants in Irrigation 07:58 Concentration of Sodium Hypochlorite 09:47 Chlorhexidine: Is There Still a Place? 11:32 Advanced Disinfection Technologies 21:31 Evidence-Based Techniques in Endodontics 25:22 GP Pumping 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’ Click below for full episode transcript: 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,
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321 эпизодов
Manage episode 448792368 series 2496673
Контент предоставлен Jaz Gulati. Весь контент подкастов, включая эпизоды, графику и описания подкастов, загружается и предоставляется непосредственно компанией Jaz Gulati или ее партнером по платформе подкастов. Если вы считаете, что кто-то использует вашу работу, защищенную авторским правом, без вашего разрешения, вы можете выполнить процедуру, описанную здесь https://ru.player.fm/legal.
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? https://youtu.be/z5h2FzHpG68 Watch PDP203 on Youtube 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: 02:09 Protrusive Dental Pearl 04:23 Is Sodium Hypochlorite Still The Gold Standard? 06:54 The Role of Surfactants in Irrigation 07:58 Concentration of Sodium Hypochlorite 09:47 Chlorhexidine: Is There Still a Place? 11:32 Advanced Disinfection Technologies 21:31 Evidence-Based Techniques in Endodontics 25:22 GP Pumping 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’ Click below for full episode transcript: 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,
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321 эпизодов
Все серии
×How do we decide whether speciality training is right for us? Is the best time to specialise straight after Dental School? Or should we gain some experience in practice first? Dr Beant Thandi joins us today to share his journey into specialising and shares some key experiences that will surely help guide you along the way. We discuss the different specialities within Dentistry as well as what personality types may suit them. This episode will really help you understand what it takes to specialise and how to get there. https://youtu.be/f8ZM8EkjSQY Watch IC056 on Youtube Key Takeaways: – Beant is starting his specialization in periodontics. – His journey began during COVID, leading to a desire to specialize. – Proactive learning and mentorship played a crucial role in his development. – Financial planning is essential when considering specialization. – Choosing a specialty should align with personal interests and strengths. – Periodontics offers a breadth of practice that appeals to Beant. – The importance of community support in dental education cannot be overstated. – Reflection and documentation of cases can enhance learning and confidence. – Understanding the financial implications of specialization is vital. – It’s important to stay grounded and not rush into specialization. Highlights of this Episode: 00:00 Teaser 02:38 Intro to Dr Beant Thandi 04:03 Dental Journey 06:10 What Influenced You? 12:56 Too Young to Specialise 17:50 Judgement by Jaz 21:00 Never too Young 26:05 Cost of Specialising 28:23 Why not the USA? 31:30 Roasting Prostho 34:45 Roasting Endo 37:42 Roasting Ortho 39:49 Roasting Oral Surgery 45:00 Shoutout to Lucy 45:30 Final Thoughts 47:28 End Outro If you liked this episode, check out a classic: Should You Specialise? PDP006 This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan , including Premium clinical workthroughs and Masterclasses.…
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1 Health is Wealth (Wellbeing, Diet and Stress) – IC055 1:03:42
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Two weeks ago I suffered a spontaneous pneumothorax and it shook me. This episode came at the PERFECT time as such health scares remind us that our health and wellbeing are the highest form of Wealth. Should Dentists have a therapist to manage stress and anxiety? Did you know that a BDA survey found 1 in 5 practitioners have seriously considered taking their own lives? Is it the intense work environment, the pressure from patients, the fear of litigation, or the added burden of business ownership? More importantly, how can we address this issue and support dental professionals? Dr. Simon Chard , a cosmetic and implant dentist and co-founder/CEO of Parla (as seen on Dragon’s Den!), joins Jaz to discuss the often-overlooked realities of the dental profession. https://youtu.be/rH7PtjFTOpk Watch IC055 on Youtube Here are the two books Jaz recommended during the intro: The 5 Types of Wealth by Sahil Bloom Hold on to your Kids by Gabor Mate Check out The Dental Growth Retreat by Dr Simon Chard Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Simon emphasizes the importance of balancing personal and professional life. Mental health issues in dentistry are alarmingly high, with many professionals considering leaving the field. Therapy can be beneficial for everyone, including dentists, to manage stress and emotional challenges. Building mental resilience is crucial for handling the pressures of dental practice. Sleep quality and routine significantly impact overall health and productivity. Mindfulness and meditation can reduce stress and improve mental health. A structured approach to self-care can enhance resilience in the dental profession. Exercise is a key component of maintaining mental and physical health. Creating a supportive community among dental professionals is essential for mental well-being. Proactive self-care strategies can prevent burnout and improve job satisfaction. You can’t mess up meditation; awareness is key. Diet significantly impacts mental health and well-being. Interpersonal relationships are crucial for mental resilience. Exercise is a powerful tool for physical and mental health. Purposeful living leads to greater fulfillment. Hydration and nutrition are foundational to health. Loneliness can have severe health implications. Creating time for relationships is essential. A value-based calendar helps prioritize what matters. Retreats can provide tools for personal growth and accountability. This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan , including Premium clinical workthroughs and Masterclasses. Highlights of this Episode: 00:00 Intro 04:25 Introduction to Dr Simon Chard 10:10 Why is Dentistry so Stressful? 14:00 Therapy for Dentists 19:20 Strategies for Mental Resilience 25:20 Mindfulness 31:57 Intake 40:32 Love 45:12 Value Based Calendar 48:32 Exercise 51:57 Managing Everything 54:34 The Retreat If you enjoyed this episode, check out: Mental Health in Dentistry – PDP185 Click below for full episode transcript: Jaz : The BDA, which is the British Dental Association, it had like something like it was 18% or nearly 1 in 5, right, had thoughts about and we'll just say it taking their own life, right? And I'm sorry to everyone to go in this direction, but it's important that we address it head on. Teaser: Incredible the number of individuals who are vitamin D deficient in this country. So I vitamin D test all of my surgical patients. We have a finger prick, point of care blood tests that we do ahead of the surgical appointment. I would probably say in my patient cohort, 75% are vitamin D deficient. The digital connection that we have with people is like a junk connection, like junk food and the real interpresonal relationship that we have with people is like whole food and whole connection. Jaz’s Introduction I agreed to record this episode with Simon a few weeks ago, right? And so it’s amazing how life works, the funny different ways that life works. Because when we agreed on the topic of health and wellness in dentistry, I did not know that two weeks later, I would have a spontaneous pneumothorax, aka a lung collapse, just a few weeks later. And actually, it has completely shaken my life to the core. I’m okay. I’m a little bit short of breath. I have appointments left, right, and center, CT scans, just trying to figure out, piecing it together, why did this happen? And sometimes when something like this happens, it really gives you an opportunity to evaluate your life. And oh my goodness, there’s been so much evaluation happening in the last eight days. And this episode just came such a wonderful time for me personally as well speaking to Dr Simon Chard our guest today because he is so into nutrition and health and well being and the advice he has to share with us all is so key so foundational and I encourage you to listen the entire way. You should not miss it. Some of the gems, especially right at the end, are absolutely beautiful. Even if you just take away one thing from this episode, I think you can implement it and improve your health and well being. So you have a better career, a longer career, better health, better relationships, and of course a more fulfilling life and career. So these are all things that we talk about in this episode. From sleep hygiene, to our diet, to the importance of interpersonal relationships. This podcast episode is full of book recommendations. Me and Simon really connected on all these different books that we like and so we share them. So what I’ll do is in the show notes, if you scroll down, especially from the Protrusive Guidance app, I’ll just put all those books that we recommend. The most recent one, so a couple that I’m listening to at the moment and every month on the Protrusive Guidance community, I ask you guys, what are you guys reading at the moment? I can’t believe how many of you are reading dental textbooks. Come on guys. Okay. It’s important. I get it, but I like to know about what non clinical thing are you reading? It’s really important to just not always read clinical dentistry. I want to see you guys reading and listening to non clinical stuff as well. So the two that I’m listening to this month is Hold On To Your Kids, right? And this is so important because the book talks about how the children of today, if they don’t feel the attachment and connection with their parents, then you know where they’re going to get that attachment void from? They’re going to get it from their peers. And nowadays, the way society is built up is that actually, we are sort of driving this culture, whereby kids turn 11, 12, 13 and instead of looking to their parents, they are looking to their peers, and it’s like the blind following the blind. So, Hold On To Your Kids by Gabor Maté and the other author I forgot, but really enjoying listening to that, and oh my goodness, The 5 Types Of Wealth. I’m just into chapter 2 at the moment, I’m listening to it on my commutes. It has just come at such a wonderful time for me. Because of this whole lung collapse issue, I’ve been really reevaluating my life. And so the five types of wealth talks about, okay, one of those types of wealth is financial wealth. But if it constantly working and chasing that, you are ignoring the four other types of wealth. So let’s see if I can remember this. Okay. So the other types of wealth, which are the most important, the financial one is fifth, because more money does not equal more happiness. We know that already. It does equal more happiness when you are at poverty, right? If someone is really struggling financially, right? And you inject more money in their life, that will improve their happiness. But once you get to a certain level, It doesn’t matter. You can triple it, quadruple it, 10x it. It’s not going to make your happiness sustainably better for the long term. So that’s why the financial wealth is the last type of wealth. The other four types of wealth, which are so important that this book covers so far. And again, I haven’t listened to it all. I’m just listening to it. I just want to share it with you because I’m just in the moment. I’m thinking about my health. I’m thinking about the different types of wealth. It’s just brilliant. And I’ll put that in the show notes and they are time worth. The other one is social wealth, your relationships, the quality of the relationships in your life. And the next two are physical wealth, of course, and mental wealth. Okay. So yes, you can say physical health or mental health, but actually swapping the word health for wealth is really powerful because it gets you to remember that actually this is a type of wealth. If you want to live a wealthy life, it’s not about just the finances. That’s just one part of being wealthy. If you are poor in those other four, then my friend, you are not wealthy. So anyway, I’ll put those book recommendations in the show notes and you are in for a treat. We cover such a wide array of things. I really do enjoy these non clinical episodes and I hope you enjoy them too. This one’s not eligible for CPD, but listen, that shouldn’t matter. This is all about your health, longevity. This episode will do wondrous things for your life. So please listen on. I’ll catch you in the outro. Main Episode: Dr. Simon Chard, welcome to the Protrusive Dental Podcast. For those of you who don’t know, Simon was up early in the gym, 5. 45, he’s now here recording me. He’s one of these super productive people, and so we want to tap into Simon and think, how do you get everything done? It’s a question that people ask me a lot, and I look at you, Simon. Actually, you know what, what I like to do, Simon, is I like to remember my first encounter of an individual, right? =So every time a guest comes on nowadays, I like to remember the first time someone came my radar and any idea when that might be for you when you came my radar, do you know? [Simon] I don’t know. No. [Jaz] It was way before even qualifying. It was at students, right? There was an essay prize, British Endodontic society. Right? [Simon] Oh yeah. Yeah. Yeah. [Jaz] I think I’ve got like third place or second place, right? You got first place. That’s when you annoyingly came in my radar. Do you remember this? [Simon] I remember the prize. Yeah, it was the hearty prize. [Jaz] That’s the one. That’s the one. [Simon] Certainly the highlight of my endodontic career, which is finished very early in my progression. But yes, I went to the pan specialist conference, as the prize for winning that. Yeah, no, that’s a great memory. I didn’t realize that how funny. [Jaz] And then I saw you at like BACD and I saw the wonderful things that you did BACD. And then in, with CEREC training, and not that I ever did it, but I just saw you doing some great things early on. And now you’ve just pivoted in a really fascinating way that I’d love to share your story. Like you are a practice principal as well as having real babies and children and family and stuff. You have the baby of parlor and everything you’re doing there. So I’ll let you give your introduction, tell us about yourself and where you are today in the position that you hold and all the different hats that you wear Simon. [Simon] Yeah, sure. So, firstly, thanks for having me. It’s my first time on here. It’s a pleasure to be here. I would like to start off by saying primarily I’m a father and a husband. Those things are what I hold core to who I am. Professionally, I would describe myself as a general dentist, but certainly sub specialized down into cosmetic and implant dentistry. More and more implants nowadays. I’m the past president of the British Academy of Cosmetic Dentistry. As I say, I’m the co founder and CEO of Parla Oral Care, which is a wellness and sustainability focused oral care brand, which is in Sainsbury’s, Waitrose, Boots, Ocado, started as a side hustle, but has rapidly become a very, very large proportion of my day to day activities. [Jaz] We were all rooting for you on the dragon’s den. So we saw that. That’s good. [Simon] Oh, thank you. Yeah. And then, yes, so I put on my dental practice with my wife, Megan. So we’ve got a seven surgery, multidisciplinary practice, regular dental down in Surrey. And then more latterly, I always like to follow my passions and my sort of moving towards my life mission statement, which I’m sure we can come to later on. But I saw as you’ve already touched on, I’m a real health and wellness obsessive in my own personal life, and it’s had hugely positive impacts on how I am able to be as productive as I am, and my general mental state, as well as my physical condition, being focused on health and wellness. And so I saw the study back in 2020, from mental protection showing that over 50% of the professional want to leave as a result of their personal well being. And I thought those figures were shocking and very, very sad and I’m very passionate about our profession and I think there’s unfortunately a lot wrong with it, but I felt that this area was an area that I could maybe offer something unique and different in education around building a life around dentistry to be resilient. Both in body and in mind. So that’s been my more recent focus with regards to the dental growth retreat. [Jaz] Interesting stat there with dental protection. The other one that’s noteworthy, obviously we have an international audience here, but the BDA, which is the British Dental Association, it had like something like, it was 18% or nearly 1 in 5 had thoughts about and we’ll just say it taking their own life, right? I’m sorry to everyone to go in this direction, but it’s important that we address it head on because this was a publicly published and this was a fact because this is what we think. And who knows if it’s more or less than that, but that’s the best data we have on that. And that was absolutely shocking when I came across it. Well, it’s shocking because it’s gruesome. It’s shocking because it’s worrying for everyone, right? That, that high percentage, but it’s one of those sadly things that it’s not surprising with the kind of world we live in. And every time I record an episode, it’s always a pleasure to talk about this wellness topic, right? Because I often get messages saying Jaz, I love all your clinical stuff. But honestly, keep making the interference costs, because somewhere down the line, if it just helps one person to reevaluate their life, right? Then it means so much to me. And I’m so glad that you’re in this space, but I remember this one story. So I’m just want to quickly share is, was like a family dinner, like a wider family dinner. And I’m like the only dentist there, everyone is in business, import, export, that kind of stuff in like the Afghani Sikh community that I’m part of, and the guys are talking around and they’re talking about stress and managing day to day stress. And they all go around, and they’re like, Oh yeah, my supplier’s gotta pay me, and this, that, and the other. That’s the kind of conversation they’re having. And they look at me like, Oh, Jaz, but you’re a dentist. That doesn’t sound stressful. And I, that day, I went home really angry. I was like, how dare they say that, right? But then I remembered that actually, one day, I remember saying to my cousin, and I was in America at the time, I was at the McDonald’s, right? And they had this thing. If the person serving you doesn’t smile, you get free fries or something. It was actually a real thing in America, right? And I’m being the douche I was at age 17. I said, Oh, you didn’t smile. And the manager gave me some free fries. Okay. And I remember thinking that they are working at McDonald’s, not stressful. And then it really, it literally took me back years and years. I thought, well, I can’t believe I said that about someone working at McDonald’s because I’m sure at that time, even they were super stressed. And so stress is one of those perceived things that we all have, but especially in dentistry. So that’s a roundabout way of asking you, Simon, why do you think our profession is in this state that the dental protection was able to publish that? Right? That BDA was able to publish that. And we know what makes a job stressful. What do you think has particularly increased it now that we’re in 2025? [Simon] Well, I mean, it’s very, very multifactorial, of course. It’s also very unique to the individual. But I think as a profession, if we talk about the actual job to start with. It’s obviously a very intense environment. You have people coming to see you who arrive with an anxious energy, and we do mirror the energy that is shown to us on a regular basis. On top of that, we then have to carry out a job which I often relate to painting a Picasso in a 4×4 driving through some sand dunes, in that you’re going to do something with an immense amount of detail and accuracy on a moving target, which is not easy. And then if the results of that Picasso in the 4×4 are anything other than perfect, and without any failure at all, then you have this hugely high degree of litigation, which we see across even the best of clinicians. I constantly see people who I look up to clinically, and I’ve seen their work, and I’ve seen them on podiums, and they’ve been top of their game for decades, getting these litigation cases against. Now, obviously, we need to be regulated, we need to make sure patient safety is of the utmost importance. But when you see time and time again, individuals that you know, you’ve known them as a person and you and you’ve seen clinician. You can kind of tell that, like, it’s probably the system’s a bit broken there. So we have this fear of litigation over us as a profession. We have this very difficult working environment where we’re dealing with people who are not necessarily in their best frame of mind when they come to see us. And then obviously, if you’re a business owner. You then have all of the normal stresses of business ownership just to layer on top of that, which is even more complicated. So there’s physical strain, there’s emotional strain, and there’s legal strain as well. So I think all of that compiles into the situation that you rightly point out, which is that suicidal ideation level in our profession is ridiculously high. It’s an ongoing joke, or it’s not a joke, definitely not a joke, but it’s ongoing rhetoric within our profession. Oh, second highest risk of suicide. It’s almost like we say with our patients as like a bit of a offhand comment, but it’s really not something that we should be willing to accept as a profession. I mean, we still see individuals that we know and care about. And I’m sure you’ve had this in the last few years. I certainly have lost friends and mentors to this which is very very sad, but it just keeps on happening. We’re not doing anything about it. We’re accepting it and that’s the thing that I just think we’ve got to do something and it takes all of us talking about it. It takes people on Podcasts like this letting people know that they’re not alone and letting people know that there are other people that are going through the similar troubles and thankfully, there’s charities like ConfiDental and those sort of charities where people can go and speak to if they’re having these sort of suicidal ideation or really in a quandary. But yeah, it’s very much a multifactorial thing. And I mean, we can talk about the more general macro issues as well post Covid with regards to loneliness and that sort of thing, which is also playing a big part, especially in younger demographics. [Jaz] I like how you approach this angle of the kind of energy that we see in our patients. Like you said, patients are anxious and nervous. It kind of bleeds onto us, right? And so it reminds me of when I was at the BACD recently, I remember being at the dinner and I was sat next to this like young dentist and his girlfriend was with him, non dentist. And she was actually a therapist. She was actually a therapist, right? For people’s mental health. And what she shared with me was really profound. Because, you’re mentioning how we see these patients, they have their problems, they have their anxieties, and we have to, as a dentist, we kind of have to be like a little bit of a therapist, like a little bit of a counsellor for our patients, right? And then the profound thing that she said to me is that it is a requirement in her profession as a therapist to have a therapist. Did you know that? [Simon] I didn’t know that, no. [Jaz] I didn’t know that, but to me, as someone who, I pretty much dedicate my Mondays to seeing TMD patients for my sins, right? And I love to help them, but it is extremely emotionally and I hate the word say is draining for me. It can get another reason. I limited it just to Mondays where I’m the highest energy because I can’t possibly do that all day every day for the rest of my career. It’s going to be a fast track to not a good place. So it made me realize that. Wow. Yeah, that is so true. And I probably would benefit from therapy from having to be a therapist for my patients in a way. And so that was really an awakening moment for me. And so have you come across like any ways that dentists can access therapy? Do you think in the space that you’re in, you’re very well read up and explored into this wellness and mental health space in dentistry. Do you think that dentists should be having some sort of a therapist or is there sort of a sign that, okay, perhaps we should be talking to someone, talking therapy? [Simon] Well, I think there’s an argument that everyone would benefit from some therapy. We’ve all had experiences in our life, challenging experiences, especially in childhood, which play out in the way that we carry ourselves in adulthood. For me, I’ve certainly utilised therapy. It’s been very powerful for me. Just to be transparent, my sister had cancer when I was seven. She had a bit of bone cancer that meant she was inpatient for six months up in Stanmore, and then she had 23 operations throughout the rest of her childhood as a result of it. Thankfully, she survived thanks to the NHS, and now has a third child on the way. But that certainly had a negative impact on me. I say negative, it’s an impact on me, which has had both positive and negative outputs. And I’m sure given the number of people that you’ve spoken to on your podcast, certainly when I was running my podcast a few years ago, almost everyone who I spoke to, and these were very, very successful individuals, had some form of childhood incident that had led to their, what would be perceived as success in their professional lives. And these negative incidences in childhood certainly can have positive and negative impacts. But we all have challenges. And I think just like going to the gym is a way to create a resilient body. We need a mental gym of a certain kind. Now, whether that’s therapy for you or it’s meditation or breath work, we need to create some space to consider our thoughts. And give our brain a chance to build those muscles in the same way that we do at the gym. Because when that acute period of stress or even acute chronic stress over a more prolonged period presents itself, which it naturally will do in our lives as humans, but also as dentists, when you have this really, really intense, surgical issue or something like that for example. If you’ve built up that mental resilience already through training ahead of the incident, you’re going to be in a much better position to manage that situation. Simple answer to your question. I think that probably all of us would benefit from some therapy. [Jaz] And the strategies like therapy is one strategy that we can employ. And I like the idea that you’re encouraging that rather than wait for that toxic acute stress moment to then consider it that actually we can nip it in the bud right when you’re having, you’re noticing patterns that, okay, maybe not sleeping well, or there are some certain things stressing you out, or you feel as though you need some help to have better coping strategies, day to day. The acute men’s stress hasn’t yet happened, but then to avoid that or to better manage that. Right? We should be having some sort of help and therapy is one way that we can get that. So I’m glad we can encourage that and talk about that. There’s lots of online institutions available, I think. Is it BetterHelp? Is that one? [Simon] BetterHelp. Yeah, that’s the most- [Jaz] So I’ve seen ads for that and that looks really good. And the other strategies I use is, like you said, exercise, right? And just having time away from the clinic, exercise. And for a lot of people, that is the same thing. For me, I love to book my holidays a year in advance. I just know when my downtime is. Like a lot of dentists, we’re commonly, we’re waiting to get stressed and be like, Oh my God, I need a holiday. But then actually you’ve got patients books for the next six weeks. You can’t actually take that whole day. And so that’s the worst way to live. Unfortunately for me, eight days ago, I had a spontaneous pneumothorax. So my left lung collapsed eight days ago. And so I’m no longer going to Dubai next week for half term with the family, which is something we organized 10 months ago when I saw the x ray of my chest. Okay. And I saw the collapsed lung. I wasn’t upset about the pain. I wasn’t upset about the shortness of breath. I wasn’t upset about time of work I was just upset about the loss of opportunity to have make these memories with my children, my family at a very special age and the five and two, I’m sure you can relate very much. But as everyone’s saying to me that Jaz, your health is everything, you get through this, you get better. And then at least you’ll have memories to make in the future rather than if you worry about that now. And so, sometimes like the financial markets, you have these corrections. And I do believe that in life, we also have these very corrective moments, right? And they really make you re evaluate your life. For the last eight days, I’ve been re evaluating my life. So this podcast came at a really good time, Simon, right? And it really made me think about all things. And so sometimes things just come at you at the right time. So this episode now, chatting with you is the right time for me, because I’m in that really, in that frame of mind. Someone who, you know, they’ll be scrolling through podcasts, right? They’ll see an episode about temporizing veneers. And then suddenly they say, Oh, you know, mental health. And then, that’ll be the right time for them to listen to this conversation, right? And listen to the strategies that you’re going to share with us. And so sometimes things do come at the right time. So hopefully for those who are on the right time right now, can you share the strategies that you advise? That can help be it preventive, be it acute management. What are the different strategies that we should be employing as dentists to make sure that we stay mentally fit and resilient? [Simon] Yeah, sure. I hope you’re okay. I didn’t realize that you seem in very good health and energy given that circumstance. So yeah, so for me, as I say, as dentists, we’re very good, as you say, with focusing in on the clinical details, must upskill myself in all these clinical skills, but we fail many times in the core parameters of life. And so the way I’ve structured this, because obviously I’m a dentist, I’ve got a nice little dental acronym, which is SMILE. It’s part of a broader thesis, which is called Great SMILE. Great is more towards building fulfillment in your career, but we can touch on that later, maybe. But for SMILE, it basically stands for Sleep, Mindfulness, Intake, Love and Exercise. And those pillars for me, if you can get those in balance. around your dental life, you’re going to be a much more resilient individual to be ready for whatever life throws at you. [Jaz] Are we going to go through each of the letters? It’d be nicer to maybe touch on each one of those. [Simon] Yeah, absolutely. So, obviously sleep is the pillar of everything really. We know from our physiology training back in the day that natural killer cells go to work and clean up the body while we’re asleep. The impact on our stress resilience from having both good duration of sleep, as well as a good quality of sleep, as well as a consistent sleep schedule, is very well proven in the research now. Listen to anything from someone like Matt Walker, who’s one of the preeminent scientists in this sector. Sleep needs to be a big focus. Good quality sleep starts with a good quality evening routine. I like to talk about the 3-2-1 ratio for the pre bed routine, so you want to be trying to keep your food at least three hours before bedtime, not always easy, especially with kids, water, liquid about two hours before bedtime, and then any technology at least one hour before bedtime. And so if you sort of have a bit of a structure there as to when you start shutting components of your day to day life down, you get a much better sleep situation. You also need to control your sleep environment. So I personally wear an eye mask, which is from Whoop. I talk about this a lot. It’s really lame. But if you’ve tried my mask before, you might just find them not very comfortable or you don’t really get on with them. Try the Whoop one. It is a little bit more expensive. It’s brilliant. I can’t sleep without it. [Jaz] That is a top tip. I’m going to check that out. I mean, Whoop I’ve heard great things about on, when the lady from Whoop appeared on Steven Bartlett’s podcast, and she talked about the impact of consistency on sleep, right? That, really important thing is that the shift workers are the people who have the worst health outcomes because they’re constantly changing what time they’re awakening and sleeping. So having that consistency is so key. Simon, share your, I mean, you don’t have to share this personal, but like your sleep scores. And now that you have, what kind of scores? I think Whoop, I’ve never used Whoop. I’m relying on my less sophisticated Samsung Galaxy health. And I like to look at my sleep score. I like to look at my, like, how much REM sleep did I get? How much deep sleep? I don’t obsess over it, but it’s a nice little dashboard of, of how am I doing in the sleep domain of health? So what kind of sleep scores are you achieving? [Simon] Well, like you, I have three young kids, so, the predictability of a solid block of seven to nine hours of sleep is challenging, but I’m normally around the sort of 80% mark. I do drink alcohol still occasionally, and it’s very evident on Whoop when you do drink alcohol, the impact that has on your sleep and your sleep architecture. I’m very fastidious about the amount of time I spend in bed. I control the controllables, and so I know that my sleep allowance will be broken by one of my children at least. At the moment my two youngest, my youngest is almost one, my second, my middle child is about to turn four, so my four year old is coming into the bed basically every night, my baby is obviously crying on a regular basis, so it’s never going to be perfect, but as I say, I make sure that I’m in bed normally by 9pm at the latest. Which is why I wouldn’t take one of your late night recordings. And obviously, as most people know about me, I wake up early and work out. So I wake up about five. So that normally gives me a good solid block of sleep. And I’m pretty consistent with that as a general rule. Now, I’m not Brian Johnson. I don’t continue that into the weekend with regards to excluding social events in the evening. As I’ve already mentioned, friends and families is most important to me. And so, having that social calendar is very important as a relatively extroverted individual. That’s my focus when it comes to sleep. I also make sure I don’t have any caffeine after midday. So the quarter life of caffeine is 12 hours. So whenever your last coffee is, it will have an impact on your sleep quality. Even if you don’t feel that it does, I’ve never had a trouble with sleep latency. I fall asleep very, very easily, but in a endeavor to improve the quality and the depth of my sleep, I exclude caffeine after midday. I do have about four double espressos before midday. So as I’ve already mentioned, I’ve got very young kids and I love coffee. But after that point, I stick to something softer. So, yeah, that’s- [Jaz] Just before we continue to the next letter, but just on the topic of caffeine, once, sometimes you go into a rabbit hole and so reading about caffeine and how it works and stuff. So the ideal time to have coffee would be not straight after you wake up. It’s an hour afterwards. You want to let the, some sort of biochemistry to happen naturally before you start introducing the caffeine. [Simon] The adenosine, receptors. [Jaz] There you are. You’re a very clever man, right? So all the good stuff happening in your brain. So you have it an hour afterwards which is good. And then yes, have the next one a couple hours after, or, or soon. And then after a certain point, like you say, midday’s a great rule of thumb, stop it. And so I’ve been employing that as well, and I think that works really well for me and I would vouch for that. Great. So sleep is such an important thing. It’s one of those things that we all know we should be doing, but it’s sometimes it takes a conversation, a reminder, a book, why We Sleep by Matthew Walker, which the whole summary of the book is steep, is super important. Guys, please do it. Let’s talk about the next letter, my friend. [Simon] Yeah, absolutely. So M stands for Mindfulness. So this is a broader terminology to cover things like meditation as well as mindfulness or breath work. And meditation for me is something that I’ve been doing now, God, probably for 10 years, I would guess. I tried all sorts of different apps and systems. And at the moment I’ve settled on using the Waking Up app from Sam Harris. So if anyone’s interested in try to build the habit of meditation, because building that consistency is, I think, the hardest thing in meditation. Then I would try their 30 day introductory course that I found to be very, very useful. And I did that 30 day course probably a couple of years ago now, and now I use his daily guided meditation every day. And so why meditation? Well, the research in meditation is incredibly robust. People may think it’s woo woo. It’s not at all, it’s as effective as exercise with regards to its reduction in mental health issues. They actually show that after eight weeks of consistent meditation on MRI scans, they can show that the amygdala reduces in size just after eight weeks. So the amygdala, obviously, our sort of fight and flight fear center, where a lot of our negative emotions stem from actually reduces inside after just eight weeks. So the neurochemical and neuroanatomical impacts of meditation are really profound. For me personally, I found that it has a very good acute stress reduction impact. And it also has a chronic stress reduction impact. And I love things like that. Something, same with exercise, which we’ll come on to later on, but anything that gives me an immediate positive reinforcement and that I know is going to give me a long term positive reinforcement as well, I think is a really great habit to try and build into your life. Now, people say they don’t have enough time. I meditate normally for 10 to 15 minutes a day on the guided meditation. You can toggle it up or toggle it down depending on how long you’ve got. I calendarize this into my diary. Because again, I think that the consistency of meditation is where people fall down. Doing it only when you’re stressed doesn’t really work. You need to build that daily habit. And so I calendarize it and I calenderize it at 145. So when I’m in the clinic, all of my team know when I’m going off to my facial aesthetics room or oscillation recovery room, I’m going to go meditate. And so, I remove myself from the hum and buzz of the surgery and have those 15 minutes, which I find to be really, really rejuvenating. I used to worry about not having a coffee at 2 p. m. after lunch. Now I find that meditation re energizes me for the afternoon session. And that’s very, very powerful. I don’t know, do you meditate at all? [Jaz] I use Balance app and I use it at night before sleeping, which helps me to have a nice sleep basically. You recently commented on one of my Instagrams about your favorite book, our mutual favorite book, The Almanack of Naval Ravikant. And one of the things he says is try and do it before sleep or during sleep. So that, in case you mess up the meditation during your sleep, well, at least you fell asleep. If it didn’t fall asleep, well, you just meditated, which is a nice introduction. It was like nice, easy gateway drug into full on meditation. What you were really saying here, Simon is you are appealing to or satisfying the spiritual health as well, because meditation is form of embedding spirituality. Now, for some people, Simon, like for example, our Muslim colleagues will play pray five times a day, okay? Our Sikh colleagues have their rituals of prayer and then prayer time and that kind of stuff. And meditation for me is very much like a deep thing, whereby it’s like, one of my religious colleagues, they say, I’m praying. I feel good. I feel relaxed. Meditation is totally a form of that. You don’t have to be religious. And by meditating, you are appealing or appeasing your spiritual side. So super important. That’s the M which is Mindfulness. What’s the I, which is Intake, but is that diet? [Simon] Just to jump back on to meditation and mindfulness for two seconds, I completely agree with regards to the prayer and meditation side of things. I think for those individuals that don’t have a religious faith, they shouldn’t push away the concept of spirituality because we all need a spiritual component to our lives, whether that’s an individual religion or it’s your own view on on the world. But I think it’s really, really important. The other thing I just wanted to jump on there was you said mess up around meditation. And obviously I love me about so I would never say anything against them. But the concept of messing up and meditation is a fallacy. And it’s where I see most people fall down. They say, oh, I’ve got a really busy brain. I can’t meditate. I just start thinking about other things. People need to realize that actually the process of becoming aware that you are thinking about something and then coming back to the breath or whatever the type of meditation that you’re doing, a mantra or something, that concept of awareness. That is meditation, like that’s all you need to do so you actually can’t mess it up because even if your brain does get busy and you realize it, you then come back to the breath, you’re then meditating and over time you will be more in control of your brain and therefore you’ll find that you have less of those incidences. So, just wanted to jump on that point quickly, but yes, so moving on to I. So I kind of crowbarred this letter in, to make sure that my SMILE acronym works. [Jaz] It works though! [Simon] It does work. [Jaz] ‘Cause it covers liquids and solids. [Simon] So yeah, so everything that we imbibe obviously has a huge impact on our physiology and our physiology has an impact on our psychology as Tony Robbins has a classic quote saying. And so, yes, intake is a big, big part of mental health as well. Loads of really, really robust studies looking at this, the PREDIMED study, the SMILE study, all looking at the impact of our diet on our health. Huge reduction in anxiety and depression associated with a high quality diet. I don’t like to dive down the diet rabbit hole too much. And- [Jaz] Because that is so polarizing, isn’t it? It’s so different, very, very passionate vegans. You have very, very passionate carnivores. I have my own theory. I’d love to share in a moment, but I’d love to hear what does Simon do? Because I look at you as someone who you’re very clever. You’re very well researched. I feel like you’ve done your homework, right? And before you make a health decision about yourself, you’ve checked out all the facts and you’ve done what works well for you. In the dental world, when I’m unsure about handling of dental materials, I’ll message Chris O’Connor and I’ll ask him, dude, what do you do? And whatever he does, I will do basically. I look at some people, I think, okay, they’re really clever. Whatever Alan Burgin is doing, whatever Chris is doing, I’m going to just do what they’re doing. And so I’m looking at you like, okay, fine. I wonder what approach Simon has taken because if someone like Jordan Pearson, he’s gone full carnival, right. The last time I saw, right. And so I’m thinking, hmm, there’s got to be something to it. If someone so clever has done that. Prav Solanki is someone I really admire in the health space. He is a massive faster. He’s a huge on fasting, which I adopted as well in my life, which I’m probably going to guess that you have as well. But he’s a vegan and he went through a keto phase as well. So it’s just nice to know, okay, what have people internalized and what works for them? Because it’s different for everyone. [Simon] Absolutely. I think that’s the most important point. What works for me doesn’t work for another person. Even with things like fasting, there’s huge gender disparities with regards to the impact of fasting on the body. Something that Megan, my wife and I talk about quite a lot, but my view to diet. I like to keep it very, very simple, so I call it Whys, so W H Y S, so the core pillar is W, whole food. It’s as simple as that. I try to go as close to the raw ingredient as I can do, and I try and avoid anything that has multiple ingredients bound together in a pre packaged environment. So, I would much rather make my own bolognese sauce from more ingredients than go to a Dolmio where inevitably they’ve used rapeseed oil and they have got a load of other stabilizers and preservatives in that environment. Now, I know from my experience with Parla, obviously we’re sold in supermarkets, that I don’t think there’s enough restrictions on products and suppliers who sell into these supermarkets as to the types of ingredients that they can put into their products. I think it’s relatively lapsed. There are certain regulations in place, but just because it’s in the supermarket doesn’t mean that it’s good for you. And so, my big focus, whether you’re a vegan or a carnivore, is get as close to the source as possible. And talking of source, make sure that your sourcing is as good as possible as well. So for me personally, I am a omnivore. Anyone that’s followed me on social media knows that I love steak and I go to my local farm shop where the steak is sourced from the local area, it’s grass fed, and I make sure that it’s of the highest, most quality. Now, not everyone can do that because those steaks are very expensive, comparatively, but I would, for example, 20 pounds. A chicken from Tesco’s for their cheapest chicken is two pounds. How can there be such a disparity in the price of those? Now, there’ll be inflation in the farm shop, I’m sure, for the experience. But similarly, the quality of the experience of that animal, as well as the quality of the experience of actually the output, will be very, very different. So whole food is number one, and the sourcing of that whole food. HY stands for hydration. So I think that we’re vastly dehydrated as a species. There you go. I’ve got mine here. And not wanting to sound like too much of a podcast bro, but I do love Eloments. Eloments tea is how it’s spelt, which is a hydration sachet, which has potassium, magnesium, and sodium in it. I drink that every morning. That’s the first thing I do when I wake up. I have this, basically, which is a liter with one of those sachets in it. And I found that actually rehydrating a huge impact on my clinical performance. So I would find in the afternoon, especially towards the end of the day, I would start getting a headache. I would get a bit tired. And actually, when I started using this rehydration sachet, just one a day, I found that actually all of those symptoms pretty much completely evaporated. [Jaz] I haven’t heard of that. I’ll check it out. Thank you. [Simon] Oh, it’s brilliant. Oh, it tastes incredible as well. Very, very clean ingredient there. And yes, it’s a great product. There’s other ones out there. Humantra, there’s a lot of other similar brands, but The Eloment Tea, which is the original American brand, I found to be really, really good. Their orange salt, especially, it’s very good flavor. So, that’s H Y and then S is just supplementation. So as I say, I tried to eat a very broad diet, high in fiber, high in protein. I have about two grams of protein per kilogram of body weight, and that’s quite a lot. But then anything that I can’t find in a well-balanced diet, I supplement for. So my main supplement recommendations are vitamin D3 with K2. So I use a sublingual spray from a company called Bare Biology. incredible the number of individuals who are vitamin D deficient in this country. So I vitamin D test all of my surgical patients. We have a finger prick point of care blood test that we do ahead of the surgical appointment. I would probably say in my patient cohort, 75% are vitamin D deficient. Or certainly sort of low. And obviously, vitamin D, some of you get some from diet, but largely converted in your skin. And obviously, we don’t get very much sunshine in this country. We spend our life indoors. And so we’re not getting enough vitamin D. And obviously, the darker your skin is, the less the sun is penetrating through it, and therefore, the less conversion of vitamin D as well. So I recommend everyone to supplement vitamin D. Has to be vitamin D3 with K2. You need K2 for absorption. You also need magnesium for absorption. So I use a product called Magnesium Breakthrough which is sort of a broad spectrum magnesium. There’s different types of magnesium, which have different roles. That is helps with sleep as well. Again, a lot of us magnesium deficient. And so that’s a really easy one that I take before bed. And then Omega three, I use, again, Bare Biology, Omega three, you need to be careful with the sourcing of your Omega three, because you want to make sure that it’s been well vetted. The bare biology one doesn’t give you those horrible fish burps, which I used to find with some of the Omega threes out there. So I really liked that product. And then a good quality whey protein I take. Obviously if you’re vegan, then making sure your protein levels from a plant based source is really important. And what else do I take? AG1 I take every day as well, which is, are you familiar with AG1? [Jaz] Oh, I thought it was green. Is that from Huel or is that different? Because I know Huel do a green. [Simon] Huel have their own greens product based off AG1 basically. I wouldn’t be able to compare the two, but AG1, it’s basically just a broad spectrum sort of super greens type product. Has pre and probiotics in it as well. [Jaz] It’s like powder that you put into smoothie and stuff, right? Is it like that? [Simon] That’s it, yeah. [Jaz] It’s nice to have recommendations is like, as I look to you, you’ve gone deep into this, which is great. And I’m going to look into magnesium now. I’m going to look into the omega three that I’m taking at the moment. So that’s really, really good, good tip there. One book I could recommend to everyone is, Metabolical by Robert Lustig. Have you come across this book? I’ve never heard this One. So one of the dentists in the community, Tom, recommended this Tom Levine from the U S, it’s got a fantastic chapter on dentistry. It’s actually got really, really good chapter on dentistry as well. It’s really well rounded. And it is all about how the very first principle, the W, whole foods about just like the book, ultra processed people, the big message is if it has a nutrition label on it, you probably shouldn’t be having it right. And try and I love the fact that they say, try and go as raw as possible. So definitely me and my family home, I’ve been making this change more and more in the last few months to make sure that we are reducing our processed food intake and and I think for my children as well I really look at the kind of junk that kids have access to and trying to reduce that process. So metabolical I’ll put the in the show notes plus there’s anything that Simon recommends. I’ll put that show notes as well. Next one was L. [Simon] Yes. So L stands for Love and interestingly, love is reflective of basically your interpersonal relationships. And I mentioned the Great SMILE as a total acronym before great being the fulfillment arm of what we talk about on the retreat. The only thing that sits in both camps. is your relationships with other human beings. And this is one of the reasons that I wanted to create a physical, in person event, as opposed to just something online. Because our interpersonal relationships have never been poorer as a society. We’ve never been more connected as a human species. But we’ve never felt so alone. And that is based on the research. If you look at, they did a big, big study back in 2022, looking at how lonely people felt and the impact it was having on their personal well being. And what they showed was in the youngest demographics, so in the 18 to 24 year olds, they found that around 60 percent of them self reported that their loneliness was having a negative impact on their personal well being. Whereas the 65 plus age bracket, who you would have thought are getting older, their friends are dying, etc, etc. Not that 65 is that old, but these, you tend to see a downward curve of interpersonal relationships as you get older. They self reported only 25% of them were experiencing loneliness. So, that to me was really, really shocking. 18 to 24 year olds, your most, for me, I was out all the time. I remember talking Monday night, Tuesday night, Wednesday night. It was the most social period of my life. And so I found that really, really worrying. And certainly if you look at the research on being lonely, if you’re self reporting as lonely, it has such a negative impact on your longevity, on your health. But clearly on your mental health, it’s as bad as smoking 15 cigarettes a day for your longevity. And it is so, so important. And I’ve heard this brilliant thing yesterday from Sahil Bloom, which I don’t know if I could describe it any better. [Jaz] No way! You’re listening to, are you reading Five Types of Wealth? [Simon] I’ve just bought it. Yeah. [Jaz] Dude, I was going to actually recommend it on this podcast with you, man. I’m loving it so far. Absolutely loving it so far. [Simon] Yeah. And I was literally reading it last night before I went to bed. But it’s amazing. The clearly we’re very similarly minded individuals because a lot of the stuff we talked about in there is exactly the stuff. This book’s just been released so I didn’t read it first and then made the retreat but it’s very very similar stuff and he said that the digital connection that we have with people is like a junk connection, like junk food and the real interpersonal relationship that we have with people is like whole food and whole connection and I just think that’s such a beautiful way to describe it because we think that they’re the same. It’s like junk food and whole food. Oh, they’re the same. They’re both food. They both look like food. They both taste like food. But actually, the impact on our body is so vastly different. And we are, by our nature, a tribal species. That’s how we’ve managed to out compete all the other species on this planet, is by working together and learning from each other and telling stories to each other and working as a network. And so, that’s why we react so viscerally and it has such an impact on us when we receive negative feedback online and those sort of things, because if you were rejected by the tribe back in our ancestral times, then you would die. Whereas if you were kept within the tribe and kept safe, then that’s where you would thrive. And so this personal relationship piece, I think, is so, so important. And More and more nowadays, we need to be creating the time and the space to do it because we can be so guilty. The whole premise of Sal’s new book is that we’re also focused on money and we’re not focused on the elements of life, which are really the most important. And that’s why I start with who are you, what do you do with, actually I’m a dad and I’m a husband first, because those are the relationships that have obviously caught my circle. But, we need to be creating a life where we do emphasize the connection with other individuals, whether it be friends or family, or even our colleagues. I mean, I see so many colleagues just on their phones, just head down at lunchtime, as opposed to actually Interacting with each other, whereas I see my older team members at the practice, like my dad, for example, who still works there, just very much head up, engaging, and I think that’s one of the reasons why we’re seeing more and more mental health issues in dentistry is that actually we’re going so into ourselves and into our devices. When actually we should be engaging with others. So yes, the love side of things or the interpersonal relationships, I think is vital to our mental resilience and it’s something that we need to make the space on. If we have time, I would love to talk about my value based calendar idea, which I think is one of the best things that we do on the retreat. It basically looks at your calendar. So we have a blank calendar, which I’ve arbitrarily broken up into 35 time blocks across the week day daylight hours. So we sort of leave the evening and sleep onwards as a given, but looking at your calendar and let you physically look at your calendar and go back and write out what your calendar is currently. And then we block out each of the different activities into various buckets. So it’ll be friends and family. It’ll be spirituality, it’ll be fitness, it’ll be work. all these different categories and then basically tally it up and see, you say that you care about friends and family. You say you care about fitness. You say you care about mindfulness. Well, let’s see what the numbers show about actually how you’re living your life, because that is really how we’re going to tell what is most important to you? And if you’re working six days a week and you’re not having time for friends and family and not having time for exercise, well, guess what? Your output is going to be in 10 years. Yes, you might have a great profession, but you’re not going to have those interpersonal relationships. You’re not going to be healthy and without your health. What? What is there? So that I think is, I mean, it’s something people can do at home. As I say, we do it collaboratively on the retreat. We all do our existing calendars. Then we go blank slate right now. Yeah. Look at your calendar and actually, and Megan and I do this all the time, like we’re discussing a new opportunity that Megan’s got on the cards at the moment. And I’m like, right, let’s go back into our calendar. And she literally did this to me. She showed it to me in the sauna the other night. I was like, let’s go show me what your time blocks are like with this new opportunity. And she’s like, right, I’ve got this, this and here I’ve got, I’m going to block this out for the kids here. I’ve got this, this and this is so practical. And it really will have such, I think it’s probably the thing that people can take away the most from the conversation today is if they do that activity, live consciously instead of unconsciously, it’s such a powerful thing to do. And I just think it gives you so much control over what your life looks like. You’ve already mentioned that you do from the sounds of it, a value based annual calendar with regards to getting your holidays locked in and then getting over and building everything else around them. I do a very similar thing. Yeah. It’s really, really powerful. So, have a look at your calendar and see what it looks like. [Jaz] Totally. Because everyone knows we should be doing all those things, exercising, prioritizing sleep, but to know and not to do is not to know, right. It’s implementation is the, really the magic of it. And to just pause and audit your life is so powerful. And to use that calendar approach is really good because that is actionable. That is day to day management that can have future repercussions. So absolutely love that. And going back to. The L of love, so, so key and two things that reminded me of is my colleague, George Andre Cardoso. He said this wonderful thing to me when I was in Portugal with him. He also is just very much like you, Simon, things that he believes in. I just, love the guy so much. And he told me that Jaz, life is not about the destination. It’s not even about the journey. It’s about the people along the way. And so it just highlights that about interpersonal connections. And then one of my favorite books, Outliers, by Malcolm Gladwell, the first chapter about the power of community, right? And how in these communities where they have a good, tight knit community, that the health outcomes were better overall. And that was really eye opening all those years ago when I read that. I’m just going to get you to now just do E and then we’re going to just talk about your retreat as well. Cause it’s sounding really, really cool. Like a really cool exercise. And I know we spoke about Instagram. I would love to come to one of your retreats one day, but at that phase of life, I am with the kids, but never say never, and for some people that might work out actually, but just tell us about the E of SMILE so we just complete the chain. [Simon] Absolutely. Yeah. So E stands for Exercise. Exercise obviously one of the the most powerful tools in our armamentarium with regards to physical and mental health. As Peter Attia said, if it was a drug it would be the most potent and most ubiquitously used drug that we would all be doing. But unfortunately as it requires activity and input, it’s less used than it should be. And so I break up my exercise recommendations into four pillars. So we have stability, we have strength, we have anaerobic and we have aerobic. Those are the pillars recommended by Peter Attia with regards to longevity and health span. And that’s a big, big focus of mine. And so I’ve built out my personal exercise routine based on those. So has anyone that follows me on social media will know I work out every morning. I share my workout every morning because I think that firstly, it’s accountability for me. But also I get so many lovely messages from people saying that it’s inspired them to get out and work out and waking up at 5am and working out every day is the most powerful change that I’ve made to my life, full stop, end of story. It’s made such an impact on my mental health, on who I believe I am, on my physical strength, on how I feel, on my lower back pain, on all these things that can be just sort of a low grade issue in our lives. And so my weekly routine, as I say, is split amongst these different types of exercise. So I do Brazilian Jiu Jitsu first thing Monday morning, I then do strength training, I then do a high intensity workout, I do a Zone 2, sort of long distance, low heart rate run or Peloton, and then I’ll do a sort of shorter Zone 5 which is sort of a very high intensity workout. That’s all with a view to improving my body’s resilience to stress and also improving my longevity and health span as well. So as I say again, consistency is the most important variable here. It doesn’t matter what you do, it just matters that you do something. That’s why I work out every day. Some people say, do you not need a rest day? Because I vary the types of workout that I’m doing. I don’t need a rest day because my Brazilian Jiu Jitsu training is very, very different to my strength training, which is very different to my long distance running. And so, the variability gives me rest in different physiological systems, I guess, for want of a better term, but obviously exercise being good for you is a trite conversation because everybody knows that. But again, I just need to reinforce the importance of it with regards to your disease prevention as well. I mean, reduction in cardiovascular disease, obviously, reduction in diabetes, reduction in Alzheimer’s, reduction in cancer risk, reduction in anxiety, depression. I mean, the list goes on and on. And actually, if you look at the study showing the impact of exercise on depressed individuals versus SSRIs, it’s vastly better than antidepressants with regards to its efficacy against depression. [Jaz] This is why for my TMD patient, Simon, I prescribe a 10 minute walk every day. It’s just people who are in the rut of chronic pain, they really get into these bad habits of not exercising, even just a walk, right? Because it’s so debilitating for them. But just getting to do 10 minutes walk a day is a very nice, easy way to get them into exercising, get them moving again. And this is all so powerful, the power of movement. And I’m very, very glad that you shared the whole SMILE with us. Before I invite you to tell us about your very cool retreat, just one burning question I have, which I know people can be thinking, right. Father of three, Parla, principal, health and fitness obsessive in a good way. Cause you know, I always say to my wife, right. That look, there’s so many things that could have been addicted to, right? It could have been drugs, it could have been this and the other, but just be grateful that I’m doing all these good things in life. So let’s be grateful for that. Let’s celebrate that. Okay. How do you fit it all in? [Simon] Well, I mean, firstly, I have my value based calendar and so I’m very strict with my timeframes and the things that I value are the things that go into my calendar and I have my core values and my life mission statement written in the notes on my phone. I looked at all of the opportunities that are presented to me through the filter of those two things, as well as and again, Sahil’s, I think, also talks about a very similar concept, which is quite amusing, which is this whole, I call it a hundred year old mindset. He calls it 80 year old. I’ve got obviously longer aspirations for my lifespan than this. But it comes down to lying on your deathbed, age 100, looking back at your life. How would you wish that you’d lived your life in that retrospective manner? And that’s how I look at all of the activities that I carry out and all of the new opportunities that are presented to myself. As I say, I have the time to do all of these things because they’re all things that fill me up emotionally. They’re all things that bring me more towards my purpose of my life mission statement. And therefore, as again, as Neval says, I think when you’re doing work that other people see as work, but that you see as play, it doesn’t feel like work to you. And so you can do more. So things like Parla, for example, yes, of course, it’s had its challenges. God, it’s been so much harder than I was expecting it to be. But I’m also so, so passionate about the project. And I feel like it’s got that sweet spot of doing good. And being unique and building and growing and these are all things that are really, really core to who I am. So, that I think is how I’m able to do so much is that the things that I’m doing, I’m not doing them for purely financial reasons. Of course, finances are important and I need to be able to provide for my family. And I like to go on holiday a lot and things are getting more and more expensive nowadays. But, that’s not the only thing that drives me and therefore I think I’ve got a lot more energy to put into these things. [Jaz] It’s about being, like you said, just purposeful about what you commit to and then has to, the main thing you said is being aligned with your mission state and aligned with your value based calendar. So these are all things I imagine that people, when they come on retreats, they get to experience and go through. So, I think you have one coming up. I’d like to open up the mic to just say, look, tell us about, invite us to your retreat. Where is it? What do you have planned? I personally want to say that I’m a big fan of these kinds of things. The last one I was invited to by Andre Cardoso, again, I couldn’t go, family situation, this one as well. I can’t wait to take my family to a retreat where it’s focused about all these such important things. Like how many clinical courses do we go on, right? We go on so many clinical courses. And I’m always, always advocating for every clinical course you do, go on a non clinical one, which is why I’m more than happy to shine a light on the retreat you have planned. Please tell us more. [Simon] Oh, that’s very kind. So yeah, so the next retreat is on the 19th to the 21st of March. So next month it is at the beautiful Wilderness Reserve in Suffolk, which is, I think, 15, 000 hectares. We have the exclusive use of this beautiful converted barn called the Chapel Barn. There’s 15 rooms all around this courtyard. There’s a wild swimming lake on the site. It’s got its own pool and sauna and all these sort of things. And the focus with the event and the reason that I built it is really to give a space for individuals to, again, be conscious about the way that they’re living their lives. So to give them the tools and the frameworks based on evidence, based on research, not just based on my own experiences to make the changes that they want to see in their life. So whether it be to have a more fulfilling career and they’re in a rut in their career, and they don’t know why they’re doing what they’re doing. I see this so much in dentistry because so many people got into dentistry because their parents told them it was a good profession or because they thought it was going to make them loads of money. And then they’re five years in, they’re 10 years in, they’re like, what am I doing? I’m not even enjoying this. So taking a step back to reevaluate why they’re doing what they’re doing, instead of just following their peers and creating a life that, that fills them up and gives them a real purpose. I know why. So building up around that, we call that a vision for victory. That’s the first part. The second phase is building a resilient body and mind. So that’s health and mindfulness and stress resilience, as we discussed today. So we go into that sort of smile and put him in a lot more detail. And then we also have Jamie Clements, who’s an incredible breathwork coach, probably the best one in the country. He comes in and does a workshop for us, which is brilliant and gives us some tools where we haven’t touched on breathwork that much today, but tools that can, again, manage acute stress as well as improving our long term resilience to stress. And then Angela Foster, who was my health and performance coach for many years, brilliant international speaker, especially health and stress for professionals. She used to be a solicitor herself, so she’s very, very well versed in burnout and all those sorts of things, which again is a huge leap, large issue in our profession. So she comes in and gives us a talk on stress management. And then finally, day three is all around implementing and accountability. So we go through all of the tools to implement the habits and the identity based habits, which is a topic that I’m really passionate about, to implement all of the things that we’ve spoken about over the first two days. So it’s very much building up towards, right, how am I going to implement this into my life? And there’s a lot of fun as well. Obviously the wild swimming is always a bit of a highlight. It’s going to be in March, it’s going to be cold than it was last year in September. But yeah, if people are interested, then feel free to send me a DM at Dr. Simon Chard as my handle. Or, check out Dental Growth Retreat on socials or on my website, simonchard.com. [Jaz] Amazing. And like I said, guys, if you’re not doing enough nonclinical, I’m hoping you’ve resonated a lot with Simon today. I thought this be a half an hour conversation. We’ve gone for an hour. I was learning a lot from you. A lot of it was validation, which I love. I love the importance of validation. But some new things I’m going to check out based from you, different frames. So Simon, thanks for sharing your time with us, sharing your journey. Your expertise. And I think you’re doing a great thing does this focus on health and wellness and dentistry is much needed. I welcome it. And I think I’d love to promote more of what you’re doing. So definitely check out what in the show notes guys, I put Simon’s website for the retreat, also his Instagram. And if you liked it, please send a message on Insta. Tell him how good this was and what changed. I would love you to comment below. What changed? What’s one thing in a read? What’s one supplement you can say? What’s one thing in change by sleep, whatever one change they can do. I’d love to read it. If you comment below. Simon, thank you so much for coming on today. [Simon] Thanks for having me Jaz. Jaz’s Outro: There we have it guys. Thank you so much for listening all the way to the end. There is no CPD for this one. There’s no CE credits for this one, but I’m hoping, I’m really hoping that you gained a lot. Are you going to subscribe or listen to a book that we recommended? I can take on one of the Simon’s health tips or supplement tips or whatever. Anything you do that is actionable from this podcast, I think will actually greatly impact you in a positive way for your health and well being. If you have that warm, fuzzy feeling inside you, then please don’t just keep it inside you, share it. Please share this episode. It’s how the podcast grows and how we’re able to impact more dentists and how Team Protrusive, my beloved Team Protrusive, who I’m so grateful for, to edit and publish and do all those wonderful things to make sure that I can have time with my family and stuff. So together as a team, we can do more. Do check out Simon Chard’s links, I’ll put those in the show notes. And thanks again for tuning in. I’ll catch you same time, same place next week. Don’t forget to subscribe. Bye for now.…
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1 How to Temporise Veneers Step by Step FULL GUIDE – PDP214 1:04:51
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What is the best technique for fabricating temporary veneers? How do you ensure they are retentive but not TOO retentive? What’s the best way to shape, polish, and remove them efficiently? In this episode, I’m joined by Aodhan Docherty —an absolute sensation in Sydney when it comes to veneers. He’s mastered the art, and today, he’s on a mission to share everything you need to know to get crisp, stable , and well-shaped temporary veneers every single time. We break down different protocols, troubleshoot common issues, and, most importantly, make sure your temporaries stay put until it’s time for the final fit. https://youtu.be/BI_xMlSXgvc Watch PDP214 on Youtube Protrusive Dental Pearl: Aodhan recommended a chlorhexidine-based mouthwash to reduce inflammation but advises using an ADS (Anti-Discoloration System) mouthwash to avoid staining. The ADS system helps maintain healthy tissue response, preventing bleeding and inflammation on the day of veneer placement while eliminating the discoloration commonly associated with standard chlorhexidine products. Key Takeaways: Temporary veneers serve as a blueprint for final restorations. Facially driven smile design enhances patient satisfaction. Patient adaptation is key to successful cosmetic procedures. Oral hygiene is vital for maintaining temporary veneers. Effective communication with the dental team improves outcomes. Understanding patient biotype is essential for treatment planning. Stress management is a critical skill for dental professionals. Patient-centric approaches are essential in modern dentistry. The shrink wrap technique offers better control and aesthetics for temporaries. Effective communication with patients enhances their experience and satisfaction. Hands-on training is crucial for developing practical skills in dentistry. The importance of assessing temporaries before finalizing restorations cannot be overstated. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 01:17 Protrusive Dental Pearl 04:42 Welcoming Dr. Aodhan Docherty 06:30 Challenges and Rewards of Managing Practice 10:00 Facially Driven Smile Design 14:53 Temporary Veneers: Practical Tips and Techniques 20:51 Non-Staining Mouthwash 22:27 Temporaries: Pros and Cons 26:49 Proximal Papilla Care 31:14 The Trial Smile Approach 35:14 The Shrink Wrap Technique 39:41 Detailed Steps for Shrink Wrap Technique 40:56 Spot Etching & Bonding for Retention 43:08 Removing Temporaries Atraumatically 51:22 Porcelain Veneers Workshop: Course Overview 56:12 Learning from Failures This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C . AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY (Tooth colored restorations) Aim: Aimed to provide dental professionals with a comprehensive understanding of temporary veneers, covering techniques to improve their fit, durability, and aesthetics. Dentists will be able to – Implement predictable protocols for creating stable and well-shaped temporary veneers. 2. Apply the shrink wrap technique for improved aesthetics and retention. 3. Assess and adapt temporaries effectively before finalizing restorations. Ready to take your veneer skills to the next level and create stunning, long-lasting smiles? Join the Exceptional Porcelain Veneers Workshop with Dr. Aodhan Docherty and Dr. Kamran Ashraf ! 📍 2025 Course Schedule: 🦷 Sydney: March 8–9 🦷 Melbourne: May 3–4 🦷 Perth: July 26–27 🦷 Auckland: April 5–6 🦷 London: May 24–25 🚀 Upcoming Course: 🔹 Bulletproof Dentistry – The Foundations of Occlusion & Restorative Dentistry (April 25–26, Surrey, UK) This two-day hands-on course is the ultimate foundation before tackling full-mouth rehabs and tooth wear cases . Join Jaz and Mahmoud to strengthen your force management, longevity strategies, and occlusion fundamentals . 🔗 Check out: bulletproofdentistry.com If you love the idea of learning on the go while earning CE credits, consider joining a paid plan on Protrusive ! It’s tax-deductible and offers incredible value for ongoing dental education. Plus, the full seven-episode series on VertiPreps for Plonkers is now available exclusively on the Protrusive Guidance App—don’t miss out! 🚀 Click below for full episode transcript: Teaser : I use my temporaries in the protocol that we teach and in the protocol that I use every day. My temporaries are blueprint for my finals. They have to be so damn nice that the patient is going to be happy to wear them for three and a half weeks. This sort of high end dentistry is not about getting them in and out. Teaser: It’s about spending the time with them and you’re going to charge appropriately for that. And you need to give, like, for this cosmetic dentistry, it’s not like they’re coming in to get a tooth broke, that’s broken, fixed, or an endo done. It’s like they’re walking into Rolex and they’re buying Rolex. And the person, I hate this phrase, but like customer service, it has to be better than it ever has been. Jaz’s Introduction: This episode goes deep into temporary veneers. They can be really fiddly, they can be really stressful, and we discussed quite a few protocols that exist, but actually Aodhan Docherty here, he’s a sensation in Sydney, and he does so many veneers, he does them so well, I’ve been intrigued by social media, and I told him he’s got one mission today, and that’s to go really deep into temporary veneers, because like I said, they can be a real source of stress for us dentists. The whole veneer process when we’re starting out can be quite stressful. But one thing I promise you today is that if you listen all the way to the end of this podcast, temporary veneers will become so much easier for you. We explore some different protocols that are out there. Some things that I’ve tried, something that he’s tried, but we’ll tell you the exact steps to make sure they get really nice, crisp, temporary veneers. How to get them to stay on, how to shape them, and then how to remove them when you’re ready to fit your veneers. This episode is eligible for one CE credit or one hour of CPD. Protrusive is a PACE approved provider. As usual, you need to be on the Protrusive Guidance app. Head over to the website protrusive.app to get started. If you haven’t already, you need a paid plan to get CE, but the education otherwise is free. We’ve been giving free podcasts for six years now. But if you’d like to show your support, please do consider getting a subscription because that’s what allows us and the team to grow and make good content for you. Dental Pearl Every PDP episode, we give you a Protrusive Dental Pearl. And this pearl is taken directly from a really important thing that I learned from Aodhan. You see, it’s so important that at the fit visit of your veneers, that the tissues are absolutely perfect. You don’t want any inflammation. You don’t want any bleeding. So whilst Aiden does cover which cleaning tools he recommends his patients to use. The thing that I took away I learned is the type of mouthwash to use because he’s found in his protocols that it does reduce inflammation. The pearl is to use something that’s chlorhexidine based, but I know what you’re thinking. You’re thinking, okay, well, what about the staining? Well, turns out there are certain mouthwash brands like Curasept that are ADS, which is an anti discoloration system. For me, this makes absolute sense because you get all the benefits of a really nice tissue response. So you get no bleeding and no inflammation on the day of your veneer fits. But again, you don’t get any of the nasty staining that you can get with chlorhexidine based products. So when prescribing or giving your patients a mouthwash to use in the interim as well as all the oral hygiene instructions, consider prescribing an ADS system, which is an anti discoloration system. So thank you Aodhan for teaching me that which I’m passing on to you and actually this episode is absolutely full of gems. I’ll tell you something interesting guys. Just two days ago, I was diagnosed with a pneumothorax, a spontaneous pneumothorax. Essentially, my left lung is collapsed, and here I am doing this podcast. It was actually supposed to be yesterday, but I moved it today, and I thought, let me see how I feel. And when I wake up this morning at around 5. 30 a. m. to record this podcast, because our guest is in Sydney, I was like, ooh, should I do this, should I not? I’m feeling a little bit short breath. But as soon as I sat down with Aodhan, And we just went all geeky, I absolutely forgot about everything. I feel great. And health comes first. Health is wealth. So why am I sharing this with you? I’m sharing this with you because when you do something and it doesn’t feel like work, that is your true calling. Sometimes when I’m in the clinic, I’m just in the zone. I’m in the flow and I don’t feel like I’m working so this didn’t feel like work I had such a wonderful conversation with him and my shortness of breath considering I’ve just had a pneumothorax two days ago isn’t too bad. The worst thing about this pneumothorax is that we’ve had to cancel our family holiday. I can’t fly. And I just feel so bad for my children because we were talking every day about how much fun we’re gonna have in Dubai and all the water parks we can go to. So I feel devastated for my boys. But health is wealth and there will be more holidays. And thank you so much, Protruserati, for all your messages of support on Protrusive Guidance when I told you guys this happened to me. But as you can see, I’m fine. Thank you so much for your concern. Thanks to my wonderful wife and my family for looking after me so well. And thanks again to you guys for your support. Before we join the main episode now, don’t forget that in April, me and Mahmoud are bringing back the basics of occlusion two day live course. We’ve actually rebranded it to Bulletproof Dentistry. We changed the name because delegates left with so much more than just occlusion. Yes, we had the nine hands on exercises and we had wonderful feedback, but delegates left with a set of protocols and philosophies for force management, for longevity, for how to make their dentistry bulletproof. So it is an occlusion course. It’s really a foundations of restorative dentistry. That course is on April 25 and 26 in the UK in Surrey. Previously we’ve had delegates from all over the UK as well as Estonia and Libya, Italy. So wherever you are in Europe or the world would love for you to join me and Mahmoud to do the course that you should do before you ever do a full mouth rehab, before you do any tooth wear course. This is the foundations of occlusion and restorative dentistry. Check out bulletproofdentistry. com That’s bulletproofdentistry. com to learn more about our two day course. Hope you enjoy and I’ll catch you in the outro. Main Episode: Welcome to the podcast, my friend. I’m very excited to do a deep dive into temporary veneers, right? And so let’s start with you said a little bit about yourself. Sometimes you work in Sydney, cosmetic dentist. Anything else that defines you that, why did you go into cosmetic dentistry? Why not oral surgery? What do you love about the field that you’re in? And it sounds like you own multiple practices. That sounds very stressful. [Aodhan] Yeah, it’d be very stressful. That’s dentistry though, isn’t it? Just a stressful career. Seriously, you can try all you want to implement practices, protocols, and levels to things in terms of checklists and stuff, but there’s always going to be that stress. It’s a weird. I reckon dentistry is one of the strangest mixes of healthcare, business, and just this high level of work that you’re doing on a patient in their mouth, while they’re often, most often, conscious, right? Like, honestly, I don’t think there’s many other careers that juggle that sort of amount of variables. Challenges and Rewards of Managing Practice And when things go wrong, they can go wrong spectacularly and you have to be able to be able to back yourself. But also you have to be able to understand when you shouldn’t take a case on. I think that’s really important. And when to get help and when to ask for help. I do it all the time. If I need help with something or if I don’t feel like I can approach a case, I’d rather bring it to a group of my close colleagues. And we discuss it. We have case discussions and that’s one of the great things about dentistry is. You are all in the trenches. I hate that phrase, but like you’re in the shit together and you just have to be able to pull together and help each other out. Like I spent the six, seven hours this morning with a group of four or five dentists and we basically went through our cases and we basically discussed the occlusion, how we’re going to combat people with parafunctional issues, occlusal dysfunction issues, constricted chewing patterns, and all this sort of stuff. And I suppose, I feel like I have always been someone who likes to take on something that’s challenging and I love science and I love biology and I think dentistry for me was just the perfect fit and practice ownership is a stressful thing, but it’s so, so rewarding when you spend years and years building this practice and you have patients which come back to you and they feel like family, right? I think it’s just so rewarding. [Jaz] I think what I love you said about it is the community of practice that you need around you as well to help you thrive. It is a team thing, not only as a practice owner, but to be at the top of your game. Clinically, you can’t do it alone. You need to listen to others. So often, when I present a case that I’m stuck on someone, it’s like they show you your blind spot and say, oh yes, you know what? I didn’t consider that. And that’s a great shout. Sometimes you just completely miss it, even though you knew it, you miss it. And so great. I love that you said that. I love that you spent the morning in that way. Just an interesting question before we dive into the temps, what do you find as the like peak stress being the practice owner or like doing the 0. 1 millimeter precision cosmetic dentistry on someone who’s got expectations and hopes and fears and that kind of stuff. [Aodhan] Ah, yeah, it’s not a good question. I always say it’s balancing the staff and the dramas and there’s always dramas. There’s always people that have something. I touch wood, I say this and then it’s all going to fall to shit. But right now is so golden for me. I’ve got a great front of house. My nurses are great. The team is like, do you know those times where you’re just like, I need to appreciate the times. And then like sometimes someone leaves or there’s a catalyst for something that goes on or something happens and there’s dramas and then you think, God, why am I doing this? But at the moment, I think, for me having a good team, like what I’ve got right now is just allowing everything every day. I just love it. Absolutely enjoy it. But I think that’s one of the hardest things as being a dentist and a practice owner is managing staff, managing the team and challenging people. And like this year, something different I did. And I know we’re not here to talk about this sort of stuff, but something different I did is I sat down with each person at the start of the year and I asked them, what is it that you want to achieve this year? And I said, where do you see yourself in the next few years? Like, what can I do to help you? So my oral health therapist said, I want to get better at doing proximal fillings. And my front of house said, I actually want to pick up an extra day and I’d love to become a practice manager of one of the clinics. So if I don’t have that conversation, what will have happened to me previously is they will either leave or they will have job dissatisfaction or they won’t feel supported. Facially Driven Smile Design And that’s what, these days, that’s what it’s all about, really. You have to really support your team and make them feel empowered. It’s not like the old days where you just tell them to sit in the corner and do their job because they’ll just leave, especially in Sydney. There’s so many clinics and there’s a lack of staff since COVID. There’s just such a lack of staff and team. They’ll just walk around the corner and get another job in two seconds. [Jaz] I think that really highlights you, my friend, you as the captain of the ship, someone steering the way, the culture that you’re brewing. That’s so important. I read something recently that the success of your business is the most important metric to use is how your staff feel on Sunday night. That is, if you’re led by that metric, then I realized that that was deep. So, already you gave us a little snippet about you as a practice owner as a someone who is going to help your staff to grow and be fulfilled. So I absolutely love that. Now let’s go to the meaty part, right? Temporary veneers. Many years ago, when I was first learning temporaries, I don’t think it was specific to temporary veneers that this advice was given. But you’ve heard the saying that, if you make your temps really crap, then when the definitive comes. The patient will love it. Right. And I just don’t think that there’s a place for that in the veneers because when they’re playing so much money and they want the whole point of getting the veneers, is to look good. Why would they accept looking like not so good in their temps, but there’s still, there’s that saying that, okay, maybe you do want your finals to be a level up. So how are you going to tackle that question? And how good should your temps be? [Aodhan] Well, this is an awesome question. Cause that’s what I was told as well, even in dental school as a laugh rat by the lecturers, but they were being serious. Now, I use my temporaries a bit differently, I suppose. I use my temporaries and in the protocol that we teach and in the protocol that I use every day, my temporaries are a blueprint for my finals. They have to be so damn nice, that the patient is going to be happy to wear them for three and a half weeks. Because I do my temps, which I’m going to discuss with you different methods of that. But I do my temps, and then three to five days later, we do a review. The review is basically to ensure that we have completed a facially driven smile design because it is different these days. It’s not like the old days where you send your alginate and you just write on your lab prescription one five to two five wax up. Totally different. These days we facially drive the design. So I send a facial photo and now as of six to 12 months ago, I send a full face scan. So I have a ray face and I actually send a scan of their whole head. [Jaz] And this is of them like while they’re at rest or while they’re smiling and you like overlay images, is that how it works? [Aodhan] Yeah, correct. Correct. So I’ll take different sets of images and I’ll do different sets of photographs. I’ll take the Emma photo. So the repose photo. So I tell the patients to either lick their lips and swallow, or I’ll tell the patient to say Emma. And then I’ll take a photo, because we are able to set the maxillary incisal length based off that photo, either basing it on the canine being at zero, basically being right on the edge of the lip, as John Kois teaches, or as Frank Spear teaches, having two to three millimeters, depending on if you’re a male or a female. Two to three millimeters of central incisors showing. For me, I think everyone looks good with about two to three anyway. A little more always looks nice, within limits. But I use those parameters to do facially driven smile design and we can basically drive the smile design so we don’t have canting and we can actually build out volume. So I get a big Duchenne smile, like the biggest smile. So we’ve got an Emma smile, a Duchenne smile, and a social smile, which is right in between. And that Duchenne smile is crucial because if you get a social smile, you can’t pick up a lot of things like gingival tissue asymmetry. You can’t really appreciate canting. You need to get them laughing, smiling. And it’s the hardest thing to do in a dental setting, right? Because half the time people don’t want to be there, but in a veneer, in a cosmetic consultation bonding, everything like that, I do the same protocol for all of them. They’re excited to be there. They’re happy. And you get them chatting and you say things like, gimme an aha and then do it a photo and think, or whatever it is, and all that sort of stuff. I get my nurse to make awkward jokes. [Jaz] You feel like a photographer in the studio, like trying to say these remarks to make them laugh and get those emotions. But, one of the cool things I’ve seen is a video, right? You video it and then you get those still frames and that can help. The problem with that, I guess is compared to the sort of resolution of a DSLR or something, or a mirrorless, to get that highest resolution. You probably don’t get that with the moving images, but I think there’s a place for getting some video as well to use some stills to capture the wide array of emotions. How do you feel about that? [Aodhan] Temporary Veneers: Practical Tips and Techniques I use that especially for gummy smiles because for a gummy smile, they train themselves to not show the gummy smile. And they train themselves to have that lower lip sitting down. And then it’s so hard sometimes to get them to smile and to laugh and things like that. You put the camera on and you just start chatting to them. You can take your photos above the camera, which is set below. And you don’t even have to have a, like some expensive sort of camera set up. You can just have a tripod and a camera and just set it on record and essentially just get chatting to them. And as they warm up as well. That’s when you can get those. You might do it like you might not want to do those photos and records right at the start of the console. If you’re trying to like get a bit of rapport with the patient, you might do a little bit into the console, for example, but that’s a really good point. The video can be crucial to seeing that gummy smile, especially. [Jaz] And so, you’re doing facial driven, which is the whole point of getting the blueprint. And that blueprint is going to then dictate the shapes of your temps. And you said that once you place the temps, which will go into deep, you bring them back a few days later, and at that point, how long do you book? And I imagine you’re getting out the disc and the flowable and you’re trying to basically get it perfected. But what I’d love to know is, okay, how often do you need to do that? And how often the patients come and you know what, that what’s in my mouth now is exactly how I want it. Tell us about that. [Aodhan] I would say. Clinically, 7 out of 10 cases come in and they are loving it. And I’m going to obviously jinx myself saying that, but if you go through, like, if you have a good lab, you work with your lab and you guys are on the same wavelength in terms of smile design, and you have a really good technician that focuses on facially driven smile design and you give them good quality records, you’re probably going to get it pretty close with the mockup and the temporaries. If they come back, what are they going to say? They may say, hey, I actually want to have these front teeth a little shorter. You get your red disc, you adjust them up by touch. Hey, can I actually have the lateral incisors a little bit shorter than my centrals or a little bit longer centrals? And I get my flowable and I add it. Can I get my canines rounder? Run it off with a disc, or pointier, because a lot of my patients love pointy canines. And I add the point a little bit more defined, and then I use a red disc. But if I see, for example, there’s a cant, or if I see that there’s a lack of fullness on the fours and fives, I’ll grab my flowable and I’ll build it out on the fours and fives. I’ll polish it. I’ll adjust it. How long does that appointment take? Probably half an hour. I don’t take any longer than that usually. If I was starting and I wasn’t doing this, I do this two, three times a day for the preps that I’ve done in the previous days, I’ll book off an hour. I’m always an advocate for booking off more time than you need because it’s when you don’t book off enough time that as we were saying before, the stressful moments happen. Something goes wrong. You’re bleeding. The patient’s gums won’t stop bleeding. And that’s when the stress happens because you’re looking at the clock and that’s when things aren’t going to go right. It’s always the way. It’s just Murphy’s Law. So I always book off a little bit of extra time. Even if I finish half an hour to 45 minutes early, I’d rather have that time to do my notes and to actually get the patient sitting, chatting, post op instructions and make sure they’re comfortable. For this sort of high end dentistry, it’s not about getting them in and out. It’s about spending the time with them and you’re going to charge appropriately for that. And you need to give, like for this cosmetic dentistry, it’s not like they’re coming in to get a tooth that’s broken fixed or an endo done. It’s like they’re walking into Rolex and they’re buying Rolex. And the person that I hate this phrase, but like customer service, it has to be better than it ever has been, and you have to train your team for that because otherwise, if you give subpar customer service, you’re not going to have a good name. So we’ve got all those protocols like we’re talking about to get that facially driven smile design, right? So our temporaries look beautiful. Now they’re never going to look shiny and the same shade, but they should have the same shape, canting, everything. Like we want them to be beautiful. And that gives your patient then three weeks while your technicians make the veneers to adapt. [Jaz] Just to clarify, then when they come for that review appointment, three to five days later, by the time they come to you, the scan or the impressions have already been taken and sent to lab. So your labs already got the preps already. And what you’re doing either is from that appointment telling the technician, hey, the patient was already happy. I didn’t have to touch anything crack on, or actually I made a few tweaks. Here’s my impression of squint scan. Let’s do this together to get it right. Is that the way it’s going? Right? [Aodhan] That’s exactly it. Do you know what I’d rather not do? I’d rather not. Say to the technicians, hey, I want this done, this done, this done, this done, this done. Change my temps, change this, that and that. Because I can guarantee you, they may get four out of five. They’re not getting five out of five of those changes. So just grab flowable and do it. Even if the flowable breaks off in those three weeks, it doesn’t even matter. But at least, like at the end of the day, it’s probably going to be fine. But if it chipped off, hey, it’s not the worst thing. Every little bit of stain happens. But if you’re able to make those changes, scan it. And I take a full new set of records, right? New photos. And I take a new RAYFace as well. Then I can give that to my lab and facially driven small design. Like, hey, these days it’s amazing having this face scanner, but for the last 10 years, I haven’t used a face scanner or nine years before that for last year I have, but the nine previous to that, I didn’t, I always just used good photographs and either an alginate impression of my temps or a scan of the temps, which I’ve been doing for the last, say, six, seven years now. [Jaz] The only question I have on this, because I know someone’s going to mention it in the comments, is when you’re adding the flowable to, let’s say, lengthen the teeth. Are you aerobrading, bonding, and the flowable, that kind of stuff, or are you literally just drying and adding flowable and then curing and then maybe just disking off and the patient goes home? [Aodhan] Yeah, a little bit of bond. Just cure the bond, put the flowable done. Like we’re not aerobrading. [Jaz] Let’s not overcomplicate it. [Aodhan] Yeah, I’m not aerobrading and doing all that stuff. If the patient came back and there was plaque and there was crap all over the teeth, something’s wrong. Their oral hygiene instructions need to be very clear. Non-Staining Mouthwash I make sure that they have a clean at least two to three weeks prior to the prep visit. By the way, I make sure that they use a chlorhexidine mouth rinse for the week prior, and they use an anti discoloration mouth rinse, so they don’t get the staining that we see with, for example, Curasept or Savacol and their soft tissues need to be really really beautiful pink. They need to use interdental brushes in the lead up or floss. And I scared the life out of them if they don’t do it. Cause I say, we’re not prepping your teeth that day. And it would hurt me more than them because I book off three hours for my prep visit, but we’ve got a mutual understanding. And the patient really wants to impress you at that stage and their soft tissue should be healthy. You don’t want to be like prepping teeth and there’s bleeding and you start finding subgingival calculus and all that sort of stuff. You want to be prepping and there’s no bleeding. You want to make it like a walk in the park. [Jaz] Absolutely. And you mentioned about a non staining mouthwash. Is that like a peroxide based mouthwash? [Aodhan] So it’s a chlorhexidine based mouthwash. You could try a peroxide based mouthwash. For me, my experience has mostly been with chlorhexidine based because I find it you can’t use it long term, but for a short term use of a week or two, the soft tissues react really nicely. Like they look beautiful after that. They’re primed for your prep visit. [Jaz] Okay, fine. So I think the staining worry that we usually have with clorhex, that comes for long term use. That’s why in the bottle it says avoid using for more than two weeks or three weeks. [Aodhan] The trick is don’t use chlorhexidine mouth rinse that is a discoloration branded one. So I should say I’m going to brand a discoloration, but there’s one that’s branded anti discoloration system. [Jaz] I didn’t know that. Okay. [Aodhan] Temporaries: Pros and Cons So, and the God, do you know, someone asked me this about a month ago and I looked up the science and now I’ve forgotten it, but basically. I don’t know if you guys have the brand Curasept. [Jaz] Yeah. Yeah. [Aodhan] So there’s Curasept that stains and God knows why they have that. Then there’s Curasept that isn’t a staining, like it doesn’t stain. So it’s called Curasept ADS and the ADS is anti discoloration system. And that doesn’t stain. [Jaz] I did not know that at all. So that is a pearl right there. So yeah, excellent. Love it. Thanks so much for sharing that. [Aodhan] Imagine you got them to use Curasept and they come in and their teeth are bloody brown and they’re all stained and then you’re trying to clean them and stuff like that, or God forbid the temps go brown because they will definitely go brown if they’re starting to rinse with too much chlorhexidine. So use the ADS one, the Curasept ADS. [Jaz] That is a top tip. Brilliant. And you mentioned about the importance of being able to clean around your temp. So let’s go into the different ways that we can do temps before we learn how you like to do them, how you and Cam, et cetera, like to do them. Just a little, take a step back and overview. I’ll tell you a bit of a journey of me when I was learning temps and it kind of covers the entire spectrum. And then I’d like to see where you fall on this spectrum, or maybe you do it in a completely different way. So the first time I ever learned veneers was from a restorative consultant in the UK, and his argument was that because we are staying in enamel, that we don’t need temps. So that was the most extreme view, right? Because we’re in enamel, we don’t need temps. Obviously, the downside of that is you’re not giving the patient that taste of what’s to come. You don’t get that constant validation like you do. Like, okay, is the shapes correct? Mr. Patient, are you happy with this kind of thing? Right? So you miss out on that. But there is one argument that if you’re doing very minimal prep, there are some challenges actually in making veneers, like contact lens veneers, fine, but contact lens, thins, temps is a bit tricky before we move on. Any comment on that? [Aodhan] I agree. I’ve got this in some bloody slides for you coming up, but you’re doing all the slides for me. [Jaz] You know what? Okay. [Aodhan] I want to hear it because if there’s something that I don’t have in there, after this, I’m just going to open that and I’m going to add everything you said in. [Jaz] This is just what I’ve learned over the years. I just want to like do a little overview because I’m really, what I really want to know about is how you have found to do them. [Aodhan] Exactly. Like you’ve started at the right point. No temps, no tensive. It’s like, if you’re doing minimal preps, which we all claim we are, right. We’re all doing minimal preps or we’re trying to do minimal intervention dentistry. And when you’re not exposing dentine, so that’s critical. You can’t expose dentine and do not do temps. Then no temps is a viable option. Why is that? What’s the biggest thing for no temps? Number one, soft tissues will inevitably be healthier. I guarantee you soft tissues will be healthier without temps. Even if you’ve got someone who is really good at cleaning their temps and really good with oral hygiene, the oral hygiene around something like a bisacryl or a temp material is never going to be as excellent because it’s more rough, it’s more plaque retentive. But number two is what you said, they can’t visualize their smile. So that if they can’t visualize the end goal during the process, they can’t adapt to it. So my ideal is that by the time the veneers come to fit or issue, I like the patient is like, they look beautiful. Thank you. Let’s put them on. They’re actually jumping out of the seat when they see their temps initially. And that’s actually the big excitement for me, like for the patient is when they see them in that stage, because that’s when they’ve got totally different teeth, but when they get their final teeth. The color is going to be nicer, the luster and the shine, but it’s the same design. And that’s where you’ve got the adaptation and you’re going to have, like for me, I find that for my cases, majority I’ve ever done, and I’ve done thousands of cases now and Cam that I teach with is done many, many thousands of cases, is that our cases with no temporaries, you’re going to have a risk that the patient then doesn’t potentially consent to cementation because they’re frazzled or they’re not used to it at that stage. Whereas if you give three weeks, like the three week rule, as we always call it, for them to adapt, they’re much more easy when it comes to the cementation as well. [Jaz] The word adaptation is a great one, Aodhan. The reason I love it is because some people might think, oh, it’s the occlusion or speech and all those things are important, but actually the adaptation is not for them. It’s for the people, their loved ones around them. Because I’m sure you experienced if you give someone, and I love what you’re saying, because you give someone their final smile without a dress rehearsal, without that prototype, then what they instantly need to adapt to is they paid their big bill. Proximal Papilla Care They’re now got these beautiful veneers, which is what they wanted. But then people are like, Oh, your teeth have changed. And sometimes they know it looks great, but that sort of is overwhelming for some personalities, right? And therefore, can be very messy. But if you give them time to adapt in the temps, it’s much better than actually getting to adapt in the defensive. [Aodhan] That’s going on the slide, I’m adding that. It’s so true. [Jaz] Let’s have a look at it, mate. Share your screen. Let’s bring the slides up. And for those on Spotify and Apple, we’re not going to do a dirty one on you. We’re going to pretend the slides aren’t even there. We’re just going to talk you through it like we are. But for the people on Protrusive Guidance and YouTube, you get Aodhan’s got some lovely visuals and stuff. I’ve seen his work on social media. So I’m quite, he’s got beautiful dentistry. Gotta check him out. So to have some visuals for those on video, it’s totally cool. [Aodhan] So what we want to see when you’ve done temporization correctly is you actually want to see little spaces above the proximal papillas. And those little spaces are going to allow you to feed an interdental brush, such as a Pikster or any of the other interdental brush brands. But I use a Pikster. I don’t know if you guys have Piksters, but- [Jaz] It’s like a plastic plastic one, right? [Aodhan] Yes. It’s the smallest one. It’s a little interdental brush. And I use the smallest one interproximally. And when you’ve done your temporaries nicely, you should have a little space above, or incisal too, I should say, the papilla. And that’s your space that you can feed. [Jaz] Like a tiny black triangle. [Aodhan] A tiny black triangle. What happens if you don’t have any space? You’re going to have inability to clean proximally. And you’re going to have a nightmare for your issue appointment. Because one of two things will have happened. You’ll have crushed your papilla and you will actually induce necrosis and you will actually induce an actual black triangle. And also you’re going to have lots of bleeding, so it’s not good for anyone. So you want to actually see a little black triangle, the smallest black triangle, to feed an interdental brush through. And what will happen- [Jaz] And it’s particularly important, Aodhan, just to point out that those people with them a very thin biotype, right? Like even scarier to work on those patients, right? Because of the risk of recession. And you definitely want, don’t want to go anywhere near the soft tissues of those kinds of patients is, is less forgiving. [Aodhan] It is so much less forgiving. And that’s important. Like you have to, during your examination process really identify like we would go through a list of things as I’m sure everyone does, but we would identify the type of biotype and the type of tissue the patient has as well. Because yeah, as you said, thinner biotype more prone to recession and that’s a worst case scenario is to come to the issue appointment and have margins exposed and then you’re re prepping as well. And you started exactly right, like the three main techniques would start with no temporaries where you’ve done minimal prep, you’ve got minimal dentine exposed, so minimal to no dentine, I would really say, so you’re not going to have sensitivity. And that’s going to be excellent for soft tissues, right? But, you’re not allowing the patient to test drive and really critique the final design. And- [Jaz] So as a percentage, how often in your patient base, cause it varies differently on where you are working in the world. I’m a huge believer in that your demographics will greatly change the kind of dentistry you are, have the permission to do on your patients. So, what percentage of our patients get a no temp approach because of their scenario that they’re in? [Aodhan] 0. 0%. [Jaz] And that’s cool. It’s good that you decided that, okay, this is a way, but for the reasons that you’ve already explained very nicely that it’s not in tune with the way that you’d like to do things. [Aodhan] The Trial Smile Approach Agreed. And it really also comes down to the test drive for the patient, the critiquing, the smile design. Cause there’s only so much you’d like. The only other way you can do it really is and I was speaking to Michael Allen, who is an excellent dentist over in Austin, Texas. We have a little beef on Instagram. If you’ve ever seen it, he’s a great guy. Like I was talking to him yesterday about his approach and his approach actually involves doing the trial smile, which I do as well for a patient, but he spends all of the time at the trial smile appointment with the patient, critiquing all of the factors that we spoke about, making sure that the incisal edges are at the level they need to be making sure there’s fullness, the shapes, the size, everything is bang on. But you have got a one hour, whatever 40 minute appointment to do that. You don’t have any time for the patient to go home, start adapting, get any feedback as well. And everything like that. So that’s an approach you could use. That’s the other approach, but I personally prefer to use temporaries for every single patient. [Jaz] I like that. [Aodhan] Now there’s another approach and it’s the traditional approach and all of us will have done this because we were taught this at dental school. Like when you’ve done a crown prep, you use your putty key, you fill the material, you’ve probably put a little bit of glycerin or a bit of Vaseline on the tooth, you seat it, when it’s just about set you pop it off, then you use a disc to shape the actual temporary and then you cement it with some temporary cement. Now you can do that for veneers as well. It’s a little bit more fiddly with veneers because They’re not full crowns, and the prep should be light. So it’s not the easiest thing to handle them and to adjust with a disc. [Jaz] Because it’s very flaky, very thin in my experience. And then, you’ve got to choose your path of insertion, because obviously with veneers, you’re going usually horizontally, like labially. Again, it’s very fiddly to take it off and insert it in that way. But yeah, it’s very much, you make a great comparison. That is how we are traditionally learn to do temps. [Aodhan] And that’s the way we all learn. And that’s the way I did it for years and years, because that’s all I knew. And what did I find happened? I found like the downsides. Number one, God knows I would always use a disc and over reduce around the margins. And I would then go to seat it, and I’ve got a deficiency, and then I’m trying to add flowable, and there’s flowable over the soft tissue, there may be bleeding, there’s different ways you can re add flowable to something you’ve over reduced, but it makes it very hard because the flowable can chip off at the margins in that few weeks that you’re waiting for the finals to get made. I’d often either over or under reduce the interproximal. So I’d induce a very big black, like I’d create a black triangle in my temps that’s too big, or I would leave too much material interproximally. I would take it off and I would break a temporary, like you said, it’s super fiddly and super thin. Or when I would cement the temps, I would have excess that went subgingival or interproximal that I struggled to get out. And then I’d induce bleeding and it would be a mess. Then when I took those temps off later, I’d see lots of interproximal temporary cement. And that was my experience with doing the traditional technique. And that’s why I don’t do that technique anymore. I really only do that technique for crowns. [Jaz] So this is another 0. 0. [Aodhan] Yeah. But it’s closer to that. I literally only do it when I do crowns, because I feel like I can manage the traditional technique with a crown well. And I can, and I’ll talk about the other technique we use, but I find it better than the next technique for a crown in particular. So if I’m going to do crowns on the posterior and veneers on the anterior, then I’ll do my crowns with the traditional technique and segmentally make some temporaries using the shrink wrap technique for the anteriors. [Jaz] The Shrink Wrap Technique And so the shrink wrap technique is the way that you like to do things, which you’re going to describe now, right? [Aodhan] Yeah. So the shrink wrap technique is essentially where we are shrink wrapping the temporaries onto the teeth with our stent. We remove the stent and we’re not removing the temporaries to polish them. We are basically gluing the temporaries to the teeth. And then when we take our stent off, the temporaries are still on the teeth. Now, what are these questions going to be? Number one, how do you keep them on? Number two, don’t they just pop off when you take your stent off? Number three, isn’t that going to have lots of excess everywhere? Well, how do we get around that? I would say number one, you need an excellent stent. It’s not your single phase crappy medium body stent, it is going to be a light and heavy body stent, which is cut perfectly. So when we actually, when we do our courses and things like that, we actually get the delegates. We show the delegates how to do this and we teach them so they can teach their nurses because it keeps your lab fees down. And it’s really easy to do, to make a really good stent makes your life so much easier during veneers. And a really good stent is good for the shrink wrap technique or the traditional technique as well, just by the way. So use a light and heavy body stent and it needs to have little escape pathways interproximally and those escape pathways allow excess to come out and we need to scallop it with a fine blade. Usually an 11 blade is the best. We scallop it around the gingival margins. So it sucks in and sits at that gingival margin really nicely. And that’s how you get crisp gingival margins for your temps. Using a shrink wrap technique. [Jaz] When you load up the stent and you deliver it and there is a temptation to start playing around how long do you wait in terms of nuance to actually wait for some of the initial set to happen before you start removing the the scallopy excess? Because if you remove that too soon that it might kind of disturb the rest of it. [Aodhan] Good question. [Jaz] You find that when you’re able to remove it, it kind of cleaves off at the right time, leaving the actual temp behind on the tooth. [Aodhan] So let me walk, how about I walk you through the technique? So step by step. [Jaz] Before you walk us through, I just want to just quickly mention a few other ways that I’ve done it or heard of actually. One is the direct composite veneer. So spot edge- [Aodhan] I’ve done that too. [Jaz] Yeah, I thought you would have, you’ve got to update your slides. So tiny spot edge and a direct composite veneer. Again, it’s using a lot of material. And again, you’re not being driven by the future shape. You’re just doing quick, quick composite veneers. And for a fussy patient, it’s difficult to get right. The other way, which I have used and probably is something that I’ve used the most is doing it your way, the shrink wrap way, okay, except the putty is cut at the just incisal to the papillae. So basically two thirds of the tooth, okay, so the incisal two thirds of the tooth is exactly this way, and then the gingival third is with a composite veneer basically. So it’s like a hybrid. That’s what Jason Smithson taught me on his course years ago. And that works well again, when I did the Dawson Academy, Ian Buckle taught me your way. So, I feel as though what I would do now, I mean, I’ve got an older patient base, I’m doing a lot more crowns, I’m doing veneers, but I do like the shrink wrap technique in terms of do it once, make it neat, make it nice, and you’re done rather than a two stage, but the reason I mentioned it is because I want to give everyone an idea of there are so many different ways to do it. [Aodhan] There’s many ways. And the way you learned with Jason and that I’ve seen Pascal Magne do it as well is by doing the gingival in composite. And it’s not to like say it’s a bad technique, right? But the idea you controlling where your margins are with composite and also controlling the interproximal in theory is a good idea. However, if you have any bleeding around the gingiva, It can be a bit of a pain because you’re struggling to control bleeding while you’re trying to place a composite onto those areas and I feel like with the shrink wrap technique, the control we have with a really good stent is so much better than trying to place it by hand around the gingival margins, because the stent will crisply suck onto the gingival margins and hold your material there, while you actually use something to clear the interproximal. So you don’t need to rely on your manual. Like, manually working composite around those interproximals. So- [Jaz] Agreed. [Aodhan] Detailed Steps for Shrink Wrap Technique Essentially, what I do is we’ve got our preps done, we’ve done our scan, and we have our cord in. Okay? I take my cord out, I get the patient to rinse, and I take five minutes. Why? So, because you know when you take cord out, there’s always gonna be a little bit of bleeding, probably here or there. [Jaz] It’s that compression. It’s the release of the compression. People get worried, young dentists, when they remove the cord or the PTFE or whatever they’re using and they see that bleeding, they get very worried, but actually it’s to reassure everyone that this is a normal phenomenon due to this kind of decompression of the capillaries. [Aodhan] 100%. It’s totally normal. We’re trying to reduce, basically, bleeding and gingival crevicular fluid with that. And it’s been in, usually we try and only, we limit it from 8 to 15 minutes, like in an ideal world. We all know we all do it longer than that, but like, that’s your ideal. You shouldn’t have caught in too much longer. You’ve got a more, a higher risk of recession and things like that. But as soon as you pop that out, everything opens. You can get bleeding. I see the patient up, have a rinse, have a little chill, go on your phone. I say, you know, this stage, you don’t have any temporaries on. You’re probably not going to want to look at your teeth and start doing selfies or anything silly, but just take a few minutes. Spot Etching & Bonding for Retention So I just go and get a drink of water. That’s when I’m pretty tired at that point. And I, and I go and get a drink of water. I flipped through Instagram for a couple of minutes. I come back in the room and I’m ready to go. And I lie on the patient back and I’ve got my optrogate in or like whatever retractor you use. And I spot etch the center of each tooth with a spot. And I’m talking about like, I put etch onto my glove, or my nurse puts etch on my glove and hands me a probe. And I dip the probe in etch, bop, bop, bop, bop, bop. And I add a little dot of etch into the center of each tooth. And that etch is then able to spot etch a certain area only. So you’re not blanket etching the whole tooth. And then what I do is I actually pop Teflon strips interproximally. And that holds over the papilla and basically covers and protects your papilla. So these little Teflon strips, they’re actually the thickness of a bit of Teflon floss, like your Oral B glide floss. You can use that as well. We actually place those over the papilla as a protection. And then I actually spot bond and what spot bond am I going to use? It’s a total etch adhesive, meaning it’s something like an OptiBond Solo Plus, which allows us to just spot bond that area. So don’t use a universal or something that goes everywhere. Spot bond after you’ve spot etched with a total etch. So that means that you’re going to just etch the center of each tooth. And that is actually going to form a retentive bond to your temporary material. And that’s how we basically keep the temps on because it’s going to go, the temps are going to shrink wrap into all the nooks and crannies and basically hold in. But if you spot it should spot bond in the center of each tooth, then it’s going to give it that extra grab onto your actual preps. [Jaz] I was very scared of doing this years ago, but when Ian Buckle taught me on Dawson. It made so much sense, but initially I was like, Oh my God, why am I using bond? But, the other thing that, you do, obviously, you show us the photos and stuff is. I was taught to take a photo of exactly where you place the etch, so you know your plan of attack when you’re going to remove the temp. Usually you’re trying to do it in the middle anyway, but it’s, it’s nice to sometimes different shaped teeth and one might be, the abutment might be higher or lower. Removing Temporaries Atraumatically And so you know exactly where the etch is and you reference back to that photo so you know roughly where it’s the strongest bond. But I’d love to know, how do you actually come to remove it atraumatically before you put those veneers on. [Aodhan] Yeah, good question. I suppose in terms of removal, we’re going to use a carbide point and I section in between the facial surface, right down the midline of the tooth, across my spottage point, and I open the interproximals. If I have got open interproximals, I opened those up with the carbide point, not a diamond ever because we don’t want to cut tooth, and you can’t cut tooth with a tungsten carbide point unless you’re doing something insane like you’re pushing it through the tooth. It’s going to hit the tooth and just spin otherwise, and you’ll smell it burning if as opposed to holding a diamond and just prepping straight through the temporary and through your prep. So use a tungsten carbide, use it lightly. As soon as it hits the tooth, it’s going to stop. I do it right in the center. And then I do the interproximals. And then what I do is I get a flat plastic or a cord packer, and I actually just go through and I tell the patient, listen, you’re going to hear little pops here, little clicks. And I go through pop, pop, pop, pop, and I pop them all off. And I use a scaler as well, especially on your premolars and I pull from the palatal cusp from that buccal cusp from the palatal aspect and I pull it forward and I just pop all the temps off. [Jaz] What about the residue, the common question is the residue of where you spot bonded? Is it a soflex disc? Because I quite like using soflex too. Just polish that away. But is there anything else that you use? Maybe you use attachment removal burs or? [Aodhan] I just run the tungsten carbide over the top of it. And I’m not changing the tooth anatomy doing that. And then I also air abrade, air particle abrasion it’s gone. So I actually don’t use a disc personally or any diamond at that stage, because I don’t want to change the anatomy and that intimate fit that he has. Even if it’s only a couple of millimeters, I want to keep the most intimate fit possible. And you can also change the optical perception of shade and value. If you go too hard with a bur right in the middle, if you actually dish out because you’re going to have thicker cement layer, technically, especially if you use a white cement or a lighter colored cement. So that’s pretty critical, is to do the most atraumatic removal and keep your instruments away from the gingival margin. But that gingival margin, those tissues should be pink and healthy. Why? Because using the spot etch and spot bond shrink wrap technique with something like Teflon is going to actually cover those proximal papilla and I’m holding my stent on and I’m actually allowing it to go tacky before I remove the excess. Like you asked before, when do you remove the excess? I actually hold the stent and then I have a probe and I just check the excess every so often that forms just apical to the stent, like just under the lip there. And when it becomes tacky, I just flick it straight off. And if you’ve got a really nicely cut stent, the way it flicks off is you get little scallops and they all come off at one. Even if it comes off in a couple of pieces, it doesn’t- [Jaz] Very satisfying. It’s almost as satisfying as giant bits of calculus. [Aodhan] Because it’s comes off in a scallop and it doesn’t take if you’ve got a good putty key, this comes back to that light body and a really well adapted putty key. It doesn’t take from under your like beyond your margin. [Jaz] Cause you have a lovely tight seal. And so it kind of stops the material from being like a tablecloth being slipped under the, or your sort of a magic trick they do. It’s not going to be like that, where everything just gets sucked away. It’s a nice tight seal. [Aodhan] Definitely not. It’s nice tight seal. And the thing is just before you are like at that stage. Just before you remove that excess, I actually take all those Teflon pieces, because my nurse will have cut up 10, 12 X amount of Teflon strips, or Teflon floss, that is sitting in approximately over the papilla, and I actually remove it, and I pull it out and I pull it down against the stent and that allows the papilla to bounce back into the interproximal area. And that is the Teflon is the critical step for this whole thing. If you use Teflon, you’re not going to have to get a bur and go interproximally later to start opening it up. You’ll have this beautiful open into proximal area with that tiny little black triangle we spoke about, where you can then push your interdental brush straight through, and you’re able to minimize the trauma you cause by your own hand piece. And you can minimize the trauma the patient causes later if they’re trying to jam one through there. [Jaz] That was such a brilliant, detailed description, right down to exactly which burs are used. Those who are listening on Spotify and Apple. We were respectfully did not mention any visuals, but if you want to check out the video later, then actually you can see the exact bur that Aodhan was referring to, he’s given it all away. He’s not hiding anything. He’s being very frank and very educational here. So, I now know your protocol to a T. It’s wonderful. Everything makes sense. And all the little secret nuances of the Teflon as well. That was golden, man. Thank you so much for describing all that. Plus the visuals. [Aodhan] It’s a total pleasure. Like when you’re doing your cleanup as well, just some last tips for you. If you want, last things would be the cleanup. Use your pointed carbide, a tungsten carbide that is around your margins. Don’t use any diamond bur. Your pointed carbide will only remove temporary material. It will be atraumatic to the soft tissue, and it will not cause damage to the prep. On the palatal, use an egg shaped carbide to clean up the excess. And then, the big thing is, what handpiece is everyone using? Because I haven’t prepped with a high speed handpiece in 11 years now. Always prep with a red band torque controlled handpiece. If you want really sexy preps because it’s torque controlled, it’s not going to go from zero to a hundred and just cut into your margins, your electric handpiece, your torque controlled handpiece. We’ll give you such a smooth, beautiful prep. [Jaz] I mean, no doubt you’ll cover this on the courses, but at this stage, have you given the interest? I mean, have you given LA yet? Because the what’s next to come is actual try in of the veneers and stuff. So do you give the LA so that you can remove the temps and then try on the definitives, but then you mess up the lips. So how do you do the timing of the local anesthetic, if needed? [Aodhan] Yeah. So when it comes to insert, number one, I’ve given LA. I give us, I didn’t say I give a small amount, but I share a couple of cartridges around the arch, maybe one or two. So I’m aiming to numb the patient for, and not overly numb because when I go to properly insert or when I go to prep, I give a stack of LA. I get four or five cartridges. I don’t want the patient to feel a thing. I want them to be numb for the three hours. And I don’t have any hesitation in making sure they walk out with their lip out here. But for the issue, as you said, it’s critical. Like you want them to assess it properly. So I give them one cartridge kind of spaced out around. So they’re numb. For when we get the temps off, I air particle abrade or I pumice if I don’t have air particle abrasion handy, but I’ll air particle abrade to clean residue. I look in my mirror and I look visually with my head down so I can see if there’s any little spicules of temps that will cause a misseed. And then I try my veneers in and I then will do a full try and process of like a very strict protocol of how would you try in. And then I have the patient view them and they’re probably starting to get their soft tissue feeling back at that stage. Like they can move their lip a little bit. The other way you can do it, as my colleague Cam often does, is he doesn’t really give much LA at all. But for me, there’s always going to be a little, like we all know, there’s always going to be a little bit of discomfort removing temps. If you’ve got any dentine exposure, it’s probably going to be on the cervical of a canine, for example. So you can maybe just give a little bit of LA there. But I often give some LA for my try in, but not much. [Jaz] Porcelain Veneers Workshop: Course Overview Okay. No, it’s good to know. And Aodhan, you’ve covered all my questions there in terms of the technique. So, I mean, I know you’re coming to London. It’s very exciting. I personally will be in Copenhagen on some sort of occlusion symposium, but I’d love for people to learn about what you and Cam have in store. I mean, you guys just heard now. The wonderful no holds barred, like fully covered temporaries and how he does them. And I think a lot of people feel confident with that, but there’s so much more to it in terms of assessment, bonding protocol with cement, et cetera, et cetera. So give us a flavor of what you have in store for delegates in London. Is this the same course that you do in Australia? [Aodhan] It is. Yes. It’s our Australian course. We’ve taught now six or 700 Australian dentists this, course over the last few years. Maybe more even, and for reference, we’ve only got like 15, 000 dentists here. So it’s a fair whack of the population of dentists, but it’s a course we absolutely love and we’re passionate about. Besides dentistry, this is the number one thing I absolutely love doing is teaching. And this course will, I promise you, number one, you’re going to be absolutely exhausted by the end of it. A good exhaustion because we bring our whole team over. So for us, it’s not just me and Cam, two people. I’ve been to courses where there’s 30 people to one person teaching and you don’t get any one on one time or minimal. And you don’t get your preps checked properly. We’ve got four to five people who are going to come for this course. So you’re going to have an amazing ratio. There’ll be like one to three, basically. You’ll have someone with you the whole time. And we’re going to check the preps. We’re going to check the temps. We’re going to start from up here and go through the whole thing. We do consultation. So we talk about how to essentially run your consult from the phone call, all the like that the patient makes, or the initial communication all the way through to them coming in the clinic through to how to actually take records, structure the appointment. Like every single bit of the appointment is broken down by time. So we record our appointments, break it down and show you the candidates and my idea is that I want you to run your consults the most effective way possible with the time you have. So I’ll show you what you need in terms of how much time to allocate to each part, and then how to make the conversion, because dentists are notoriously bad for not being able to make the conversion. So we want you to do this dentistry. We don’t just want you to be able to prep plastic teeth. We want you to go out and actually do it in real life. So we teach you consultation. We then teach you how to do the smile design itself, how to communicate with the lab and use Exocad and other technology to create the facial driven smile design. We go through motivational mock up, which we call the trial smile. So the trial smile and all the types of preparations. So type one to type four preps with cases we go through as well. And then we actually get you to prep teeth and we spend a hell of a lot of time on that. So more than half of the course time is spent on actually working on the teeth like on the models, because I’ve been to a lot of courses and we do all this theory and we don’t really get enough time to do the practical. And that’s something we didn’t want to happen. We want to balance it perfectly that you walk away with the knowledge and the practical hand skills as well. So we actually show you how to prep and we do different prep types. And then we show you how to temporize and we actually temporize the models as well. [Jaz] Using the technique that you described right today. [Aodhan] Yeah, how to assess it then when the patient comes in what to look for and what to adjust and how to adjust and then we go through the issue appointment the cementation and the tryin. So I teach you guys how to try and we teach you guys how to do cementation properly and we go through material science which sounds a little boring the material science, but it’s actually super super new. It’s like using the best new literature for how to bond a precious metal, how to bond zirconia, how to bond lithium disilicate, whether you have Emax or LiSi. We go through how to do it on the actual restorative material and the tooth and how to join them together. And then we finish with actually aftercare post op and maintenance. [Jaz] And no doubt that in the consultation part, you go through consent and consent forms, that kind of stuff. [Aodhan] 100% is so important. And also we go through social media as well, how to market yourself, but how to do it in a way which is legal as well. And what to show patients, how to interact with patients and how to really tailor your Instagram to be able to capture it. Like capture that patient audience. For me now for the past four years, I haven’t seen anyone who’s called the clinic who has walked into the clinic. I’ve only taken booking strictly from my Instagram page, which I never thought was a thing. I always thought that was such a weird world. But I built a pretty decent little audience and that’s how I get all my patients is just through social media. So we want to give you a flavor for how to do that too and what to use to market as well. [Jaz] Learning from Failures And do you share any failures, you and Cam? [Aodhan] Yeah, well we’ve got preps of the like, cause sharing failures is critical, right? You can’t just learn from these sexy cases you see, these beautiful things on Instagram. You’re going to learn from seeing failures and what not to do. So we’ve got stacks of preps from our early days. We’ve got preps from our lab. because for my own personal lab, we’ve got a lot of preps that come in and they will take photos and things like that of the models. And this is like what not to do. Don’t extend your prep here, keep it facial, do this, this, and this don’t go too subgingival, but you need to see failures and you need to see cases that didn’t quite work out, whether it be invaded biologic width, because we have a whole talk on how to crown lengthen and soft tissues. All of those sorts of things come to give that full picture. [Jaz] I was hoping you would say that and I’m glad you did my friend. And that wraps up a absolute really brilliant podcast. It’s the first time I’ve gone deep on just veneer temps and you did such a wonderful justice to dates for your course on the website, please. Cause there’s so many audience in England as well, and I’d love for them to learn from people like you and Cam, website and dates, please. [Aodhan] Yeah, we’ll chuck that straight up on the website. minimax.com will have this seminar, link and the dates, for the course. I don’t , do you know what? I don’t want to give the dates and have- [Jaz] I think it’s May because that’s what I’m going to Copenhagen. [Aodhan] The end of May. [Jaz] I think it 23rd. I remember looking at it and thinking, Hey, hang on a minute. I’m in Copenhagen. Yeah, so I’m in Copenhagen. 22nd, 23rd of May. And I think, but it’s not the last weekend. Cause it’s May’s got 31 days. So it’s like the second last weekend of May, but we’ll put it in the show notes and we’ll have the link so you guys can check it out. [Aodhan] And follow us on Instagram. If you’ve got questions, do you know what? I’m always an open book. A lot of dentists will contact and ask things or say, hey, how do you do this or this or whatever. Even if you can’t make it to the course, just give us a shout and just give me a message. I’m always happy to help. If you’ve got an issue, I’ll try and give you a hand or give you an opinion on, on what I would do. I’m not the be all and end all for this sort of stuff, but we do a lot of it. So I can give you an idea of what I would do in that situation or where I wouldn’t do or where I’ve gone wrong previously. So I’m always happy to have a chat. [Jaz] You and Cam, all the best in your trip to England. Is it, I mean, you’ve been to England before, or is it your first time? [Aodhan] I’ve been before. My mum and dad are from Scotland and Ireland, and I’ve got family all over the UK as well. So yeah, it’s like our second home. So I’m really looking forward to going back. It’s been a few years. So yeah, I absolutely cannot wait. [Jaz] Wishing you all the best. And again, thanks so much for sharing so passionately, so deeply. It was real good fun. Really lovely, geeky chat. These are the ones I love. I just love going deep in detail and you did that so wonderfully. And also appreciate our chat in the beginning about the stress of practice ownership and how our career can be stressful. It’s important to hear different perspectives on how we cope and your leadership and how you’re brewing the culture. These little things are important for everyone to hear. So, Aodhan, thank you so much, my friend. [Aodhan] I really appreciate you having me on and it’s been an absolute pleasure. I’ll catch you later. 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. How good was Aodhan, right? He was absolutely brilliant. So if you mean to go in a veneer course and that mayday is looking tempting to you. Do show your support to Aodhan and Cam go and learn for them. I am always happy to support clinicians who give everything away, who are happy to share everything, who are happy to share their failures. These are the kind of clinicians that I really love and like to support. I’ll put Aodhan and Cam’s Instagram links in the show notes, as well as the link to book onto their course. If you’re watching on Protrusive Guidance, scroll down, hit the quiz, answer 80% correctly and get a cheeky certificate, one hour of CPD or one CE credit. Because let’s face it, I’m hoping you learned so much from this episode and you feel confident with certain aspects of veneer temporization, thanks to the wonderful job that Aodhan did. And so you deserve a certificate. So if you like this idea of listening to the podcast or watching the podcast and collecting certificates as you go along, please do sign up. Please do join a paid plan on Protrusive. It’s tax deductible. And I truly believe it’s one of the best value education you can have, especially cause now we’ve got the full seven episode series on Verti preps for Plonkers. That’s all on the Protrusive Guidance app. If you enjoyed this episode, do not leave without hitting that like button, hitting that subscribe button. Even if you’re listening on Apple and Spotify, please hit that subscribe button. It really does help us. Thanks so much guys. I’ll catch you same time, same place next week. Bye for now.…
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A Clinician’s guide to TMD Management Walkthrough of the latest TMD Guidelines with the authors! What’s the right approach when a patient presents with both acute and chronic painful jaw symptoms? How can the latest RCS guidelines simplify your diagnosis and treatment process? In this episode, Professor Justin Durham and Mrs. Emma Beecroft join Jaz to unpack the latest Royal College of Surgeons TMD guidelines designed specifically to help GDPs navigate these tricky cases. Together, they explore practical strategies for managing TMD, breaking down the step-by-step flowchart that makes handling these cases less intimidating. From understanding the key principles to applying them in everyday practice, this episode will help you feel more confident in delivering better patient care for TMD. https://youtu.be/R0NaBJr5g5E Watch PDP213 on Youtube Protrusive Dental Pearl: Important takeaway: Download the New TMD Guidelines The folder includes: A patient version of the guidelines A dentist version of the guidelines The full guidelines document Video of delivering an equilibrated soft bite guard using heat technique Key Takeaways: The guidelines for TMD are designed to simplify diagnosis and treatment. Self-management is crucial for TMD patients and can lead to better outcomes. Understanding the difference between muscle and joint pain is essential in TMD management. Early intervention in TMD can lead to significant improvements for patients. The importance of patient-centered care in managing TMD effectively. TMD is a common issue that requires a collaborative approach among dental professionals. The role of pain management in TMD is about improving quality of life, not just curing the condition. Continuous education and training are vital for dental professionals dealing with TMD. Understanding the pathogenesis of TMD is crucial for effective treatment. Stabilization splints can provide relief but should be used judiciously. Effective communication can significantly impact patient pain experiences. Tailoring treatment to individual patient needs is vital. Need to Read it? Check out the Full Episode Transcript below! Highlights for this episode: 00:48 Protrusive Dental Pearl 05:20 Introducing the Guests: Prof. Justin Durham and Mrs. Emma Beecroft 13:05 Stigma and Complexity of TMD in Dentistry 17:01 Challenges of Navigating TMD Treatment Perspectives 22:07 Diagnosing TMD: Tools and Techniques 27:09 Simplified Approach to TMD Examination 30:54 Muscle Palpation Pressure 32:20 Acute Limited Opening: Muscle vs. Joint Origin 40:20 Diazepam for Acute Myogenous TMD 54:58 Debating Soft vs. Stabilization Splints 57:17 Patient-Centered TMD Management 01:09:28 Conclusion and Resources This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C . AGD Subject Code: 200 OROFACIAL PAIN (Diagnosis and treatment) Dentists will be able to – Explore the varied approaches to TMD care and how to align them with evidence-based practices. Emphasize the importance of self-management strategies and their role in improving patient outcomes. Advocate for a patient-centered approach, focusing on listening, communication, and individualized care plans. If you loved this episode, be sure to check out this episode: TMD Full Exam with ‘The TMJ Doc’ Dr Priya Mistry – PDP064 Click below for full episode transcript: Teaser : A standard extroral exam involves, the examination of temporalis and masseter, which are the only two muscles that international recommendations would suggest. Teaser: So you don’t need to bother with that lateral pterygoid because you’ve got to be, have a bit of a strange finger to reach it, firstly up and around the back of the tuberosity and not evoke kind of vomit on your shoes. And a medial pterygoid similarly, it’s not a very nice place to have palpated. And actually the vast majority of the diagnoses have been made with pressing on masseter and pressing on temporalis. When you ask them to open to where they feel comfortable, anything less than 35 millimeters is restriction. For the acute restricted opening, anything 10 millimetres or less. So if they can’t get a finger between their teeth, that’s the ones we’re kind of more worried about from an acute restricted opening. Sometimes overrunning by 10 minutes to allow someone to feel heard, to be really clearly explained to them why they’re getting their problem can be what they need to get over the hurdle. Not everyone needs to be in RCP and not everyone needs canine guidance group function. If they’ve already got group function, it’s fine. What they need is smooth and easy movement across the occlusal. Jaz’s Introduction: Finally, some decent guidelines for TMD. Have you checked out the new TMD guidelines? This is exactly what today’s episode is about with Professor Justin Durham and Mrs. Emma Beecroft. They’ve joined me on the show today to discuss the 2024 RCS guidelines for the management of painful temporomandibular disorders, which let’s face it, as GDPs, it can be very confusing for us and very scary for us. In the episode, I likened it to like trauma. When someone comes in and they’ve evulsed a tooth, we’re like, ah, okay, very time sensitive and it’s something that I haven’t done in a long time. What do I do? I pick up the guidelines. I pick up the trauma guidelines which will be a step by step to guide me on what to do. What’s best for my patients. We also have some wonderful periodontal guidelines, and now we’ve got a lovely flow chart to follow for TMD. The main mission of today is to get you, and this is the Protrusive Dental Pearl, by the way, this is the most important pearl I can give you, which is to download all the free resources I’m putting below. Okay. So whether you’re on Spotify and you read the description, YouTube, Protrusive Guidance, wherever you’re watching or listening to this, okay. Please make sure you take some time out today to download the guidelines. In fact, I’ve made it very easy. You don’t have to download individual PDF files. I made a zipped folder with the three main PDFs to talk about today, which is the patient version, the dentist version, and the full guidelines, for a really- want to put yourself to sleep. You read those ones, but the summary document is actually really fantastic. And the patient one is honestly worth its weight in gold because the main thing is we don’t want to reinvent the wheel. Why are we giving our own practice branded guidelines for TMD? There’s no need to give your patient the document that your practice wrote about all the exercises they should do. Why don’t we show them which exercises to do. So what the guidelines for the patient has is a QR code that takes them to the videos where Emma herself, one of the guests of the podcast today is there showing the patient how to do the exercise. And these are the latest guidelines. So I would say replace your current and existing documentation on TMD with this one, which is the latest and best advice with the videos. So patient’s not guessing anymore and how to actually do those exercises. In that zip folder, I’ve also added a video of how I deliver a soft bite guard, because that is the most accessible, the cheapest guard, which may help patients in acute pain. And seeing as so many of us are already prescribing soft bite guards, which I don’t do so much of, but I know that this is the most economical and sometimes the speediest way to get someone care. And when I do these, there’s a specific protocol I follow of heating the splint to get even contact. Think about it. When you give a soft bite guard, they are not balanced. So I’m going to show you a quick and easy way to get the balance. So that video is in there and any other goodies I can think of at a time of me assembling it. So you can download that at protrusive.co.uk/tmd, that’s protrusive.co.uk/tmd those goodies are there for you for free. Now, before we join the main episode I just really need to emphasize the following; which is the supported self care part in there is the most important thing right? Let me explain why. There are so many different schools of thought for how to manage TMD. This is why patients get confused. This is why we as a profession are a little bit confused. There are colleagues who actively recommend orthodontics as the first line to manage TMD. There are colleagues that swear by neuromuscular methods and TENS or BOTOX as first line. Well, I would say that the first line should always be supported self care. The foundational advice that you give for any type of joint injury, taking the load off. Applying heat, applying ice, self massage, there’s so much to it and it’s been all compiled in that document that I mentioned. So whilst I was lucky enough to have these two guests on today, I didn’t want to spend too much time on that because that is available to you and you should be giving that to your patient as first line. Now a lot of what we discuss will upset some clinicians because we may have simplified it or dumbed it down. But the evidence supports that the basic stuff done well, done early, will yield a positive response for the vast majority of patients. And it reminds me of a Jeff Okeson quote. Jeff Okeson is like the OG, the legend of TMD education. He says that when there’s so many different schools of thoughts in terms of how to manage TMDs. There is a core in the middle, which is like the evidence based stuff. The safe and reversible stuff that we could all do. And then there’s stuff that’s out there, which is a little bit on the fringe. And you know what? There is a place for it. I do some things which are on the fringe, but I only do them once I’ve exhausted everything in the middle. Everything that is reversible, everything that is cost effective for the patient first. Things like a timely physio referral or counseling for awake bruxism. These things are incredibly powerful. Then there might come an appliance, and then we reassess. And then if that doesn’t work, then we’re edging more and more towards modalities that may not have as much evidence, that may be a little bit more aggressive, or more of a risk of a bite change, and there’s okay, there’s a place for that. Because that can help our patients, but I would not do that without a bedrock, without a foundation of supported self care. So Protruserati, let’s simplify, let’s simplify TMD management. Let’s disseminate these guidelines. Let’s download them. Let’s read them and let’s put them into use. So next time you had that TMD emergency, you know exactly what to do. And in your own patients who need your help, you know that you are following the latest evidence based guidelines and getting it right first time. And for those non responders, there’s always pathways available as well. Hope you enjoy this episode. I’ll catch you in the outro. Prof Justin Durham and Mrs. Emma Beecroft, welcome to the Protrusive Dental Podcast. I’m so excited to talk about this topic, which is very, very close to my heart and mind, something I think about a lot, something I’ve been on multiple courses for over the years. And I think about this a lot. I see a lot of patients around this, and I really want to contribute to help dentists to help their patients. And I’m particularly excited because what you’ve produced with the guidelines is absolutely brilliant. The main guidelines are 85 page. It’s so detailed. It’s such a lovely summary of all the other guidelines I’ve seen and other evidence based out there. So truly remarkable job. And then you’ve got the eight page clinician summary, and you also got the patient summary. And I will make that available. Obviously it’s already available freely to download, but I’ll just make it very easy for everyone to download. And some of those who are perhaps sitting down, watching, listening, they can actually follow along as we’re discussing, but we’re going to make sure that if you’re on the train, if you’re jogging, if you’re rocking a baby and you’re listening along, whatever you’re doing, you can follow along and you can gain from this, but before we delve any further, introductions, please. Prof, I’ll call you prof one more time. And then it’s Justin. So, Justin, please introduce yourself, tell us about yourself and where you work and how you got into this deep and dark world of TMD. [Justin] Yeah, I’m not sure it would be a dark world, and I do think that if you are rocking a baby, the guidelines might put you to sleep over 85 pages. So I think the first thing to say would be, we are actually about to, as a result of some feedback, produce a two page ultra brief guide so that people can kind of pick it up and know what to do almost immediately to go alongside the flowchart. But I digress. I think firstly, TMD is not a dark world. There’s quite a lot of evidence about TMD. It’s just not very well communicated, and that’s what these guidelines supposed to do. I am a professor of oral facial pain and an honorary consultant oral surgeon, and I’m based at Newcastle University. That’s who employed me in Newcastle hospitals, where I have my honorary consultant practice. I got into TMD because I got it. So I suffer from myalgia temporomandibular disorders, muscle based pain, and I suffer from a displacement without reduction with intermittent locking, which is a posh way of saying occasionally I can’t open my mouth as wide and it’s very painful. And that’s down to the fact that a bit of cartilage moves in and out of place. So I got into it because of that. And that was about scarily nearly 25 years ago now. And it was in my sort of house jobs as they were, a new money. I forget what that’s called. Emma, what’s a house job nowadays? Is it dental core training? I think general professional training, that type of thing. Cause no one seemed to be interested in TMD. And I had it and no one seemed to be interested and it always seemed to be that, you were the house person, the senior house officer, the general junior house officer, and you were given the patient to look after and care for and there wasn’t a lot about. So that’s how I got into the area and that’s why I went off to do a PhD in it. And that’s kind of my background, I suppose. [Jaz] Do you play chess, Prof? [Justin] Badly and not regularly. [Jaz] The reason I ask that is because one thing that I heard Jeff Okeson say once is like TMD is a thinker’s game, right? And you’re very prolific in this field. Every time I attend even like an American webinar, your name pops up somewhere. And so your reach is amazing. Your authority in this is fantastic. So a great privilege to have you on, but you are a true thinker. I can see that. And you are a true clencher. I can see your right master popping as you’re watching that in front of me. That’s why the locking happens. Emma, please tell us about yourself. [Emma] Thank you. And so my name is Emma Beecroft. I’ve been working with Justin for probably about 15 years now. Justin, it feels probably a lot longer for you. [Justin] Are we including your undergraduate degree as well or? [Emma] No, no. So let’s just not add that on. So I work at Newcastle Dental Hospital. I am doing my oral surgery specialty training. I’m doing an academic training. So I’m doing a PhD, which is in pain at the moment. And I loved working on the persistent pain clinic with Justin. And I’ve been doing that for a long period. And the reason that I liked it is that I think for both patients and clinicians, sometimes when people used to say TMD, there were kind of deep sighs and a lot of worry about, Oh, we’re not really sure what to do with it. And for me, it’s about the person. And so there’s a lot of, with pain, it’s individual to that individual person. So we get kind of break down individually, what’s the important bits for them, make positive change to a condition that previously, maybe there wasn’t as much that we could do for it. It’s really nice to see how you are excited about TMD. Because for dentists that doesn’t always happen and Justin and I are trying to kind of blow the trumpet to make people excited about it because it’s something that affects such a large range of the population. We know that with facial pain that the impact, so if we had the same injury or the same level of discomfort anywhere else in the body, it would impact you less. Because the body protects the head and neck region. And so then it’s really important that we manage pain really, really well. I’ve just passed my board exams in America for orofacial pain. And so I’ve just done that and that was a relief. And then moving forward, it’s just working. Thank you. It’s working alongside Justin to try and make positive change for patients that have this condition. [Jaz] I really applaud you just for your focus in this topic and your motive behind it. It’s very clear that you want to make a dent in this and we really appreciate that. And it shows the hard, incredible hard work you’ve done to produce, help to produce the guidelines. So from the community and the profession, thank you so much. And you raise a good point that dentists shy away and it’s not just dentists. I had Andrew Sidebottom on once, Nottingham based maxillofacial surgeon. He’s very much respected in his field. And he even said that, look, in the maxfax department, when the TMD folder comes around, they all kind of pass it around to each other. And so, you know, it starts from primary care. Let’s get that sorted. And then, hopefully it’ll trickle upwards as well. My own personal journey, just to spend 30 seconds, is through wanting to better myself as a general dentist in the occlusion side. So, if I’m doing single tooth dentistry, if I want to now do two teeth or a quadrant or do a full mouth, occlusion 101 is okay. Do an assessment of the joint. Are we going to have an unhealthy joint that needs sorting first? Before we do any occlusal work and through learning about assessing the joint, what is health, how do you get someone healthy enough to have the restorative dentistry is how I got into this. And then, some early wins I had in my career whereby patients come back and years of headaches were much better, or they’re now able to open much better or chew comfortably. That was incredibly rewarding. I don’t limit myself to TMD. I’m very much a general dentist. A restorative dentists, but I would love to help all general dentists through this podcast to just feel a bit more confident because I feel as though TMD is this kind of thing. And using again, TMD umbrella term, by the way, just making it clear, we’re using it as an umbrella term. We’ll, we’ll dive deeper into that, but it’s a bit like trauma when dentists get trauma through the door, because we see it few and far between, we kind of panic and then thank goodness we have some trauma guidelines to look at to help guide us, right? Because in that kind of moment, we need some clarity and I think the guidelines that you’ve produced give us that through the flowchart and I think with the Perio Scientists BSP having a guideline, it really helps dentists a lot. So do you think that the issue we have with TMD being scary or TMD being not a hot topic. Like for example, if you put a course on veneers or composites, that kind of stuff, okay, young dentists will start queuing up for it, right? But I found personally that when people put on TMD events, they often get cancelled. And if you’ve seen they got their cancels because they don’t get enough bums on seats. So why do you think this is the case? [Justin] I think largely because there’s so much uncertainty and Henry McKay, he’s either probably still practicing professor of anesthetics or, or may have just retired. Oxford talks about chronic pain is common, but it’s not sexy. And that’s no comment on Emma or I’s appearance on your screen. For those of us who can see us, obviously we are both extremely sexy, but the topic matter isn’t sexy. And the reason it’s not sexy is because there’s a lot of stigma there. People are still clutching to the 1980s, 1990s perspective of what was called TMJD or facial arthromyalgia and think it’s difficult. It’s only difficult if you layer it up in complexity and what Emma and I, and various other people have been trying to do on this guideline is to take away some of the complexity and make it easier. Because if you treat a TMD patient, again, treating it as a global term rather than the specific diagnosis, if you treat them early in their course, so just after they’ve started to get symptoms, then they will do very well with very simple things. So I think that’s kind of the message we want to push out to the community is that there are easy things that you can do. And whilst we understand that general dental practice is not a bed of roses, and it’s also quite a difficult place to work at the moment, I suspect, there are some simple things that you can do. There are some high quality materials that we’ve produced that are free, that you can signpost patients to and get patients to do things that will help them quite quickly. [Emma] I’d like to add to that as well, if it’s okay. So in addition to what Justin said, I think, I don’t know when people who are listening graduated, but I can really remember going through finals and trying to memorize the table from the RDC TMD, which felt so complex that we had so many subdivisions about what it means. And so even from then, I felt like I never really got a grasp. I didn’t feel confident in my understanding. It had to start that way. So the academics had to kind of try and work out what was causing and all the different types of TMD. But when it started very complex, then we’re almost kind of backstepping now to say, you don’t need to definitely know which one of all the sub diagnoses it is. If you can give us a broad category and you know you’re treating either a muscular or a joint problem. We’ve simplified it slightly so that they can feel confident in their delivery of the next step. So I think maybe the history of where TMDs come from academically, we’ve maybe not helped ourselves making it sexy. We may be, it felt over complicated. And then I think the other thing is that we need to be really understanding of is that people in the healthcare profession want to give a fix. You just said earlier, you’re so excited when you got the patient that came back, the headache was better. You got the patient that came back, the bite felt better after you might have made some changes. When I, from an oral surgery perspective, take out a painful tooth, they come back, they’re not in pain anymore. Feels good. We want to fix. And though the vast majority of time, we can make huge positive steps with temporomandibular disorder. There isn’t a one size fits all where I can definitely give you one thing that will definitely get rid of the problem. And so it’s about managing pain and moving away in some situations from the discussion of a cure. It’s about managing the condition. And that feels maybe not what we usually do as healthcare professionals, or perhaps it’s a flick of mindset for us. So maybe that’s why it’s not as sexy as something else. [Jaz] Great addition. And when I look at the different resources that you put in the guidelines, one of them was the TMJ Association. I believe you linked them. Did you link to TMJ? Was I make that up? [Justin] Yeah. Yeah. Oh, we do. [Jaz] Yes, there we are. TMJ. org. Yeah. Brilliant. The reason I bring that up is the story behind the lady who I believe passed away just last year, her husband’s now taken over, if I’ve got it right, is she was a sufferer and she was just appalled by the lack of pathways and guidelines. And she compared it to gynecology, for example, in medicine, whereby they got such clear guidelines and pathways. And her mission was to prevent patients having aggressive treatment. And so the kind of roundabout way I’m going here to ask you is one of the reasons, one of the other reasons why perhaps you find it so scary and confusing is because we’ve got very eminent authorities and figures around the world lecturing, and they’re all coming about from a very different angle where it would be at neuromuscular, be equilibration, but be it, let’s just focus on the airway and the TMD will fix itself kind of thing. So there’s so much out there. Orthodontics being suggested as certain types of orthodontics being very curative of TMD. So as a clinician, young clinician, we’re scared. Like, okay, what did we learn? It seems so vast. Do you think that has contributed to the fact that there’s so many different alleged pathways that claim to be the cure? [Justin] Yeah, absolutely. And that’s why we produce something that was hugely based on the evidence and what the evidence says or doesn’t say. And I think that’s what we’re trying to do with a campaign that’s about to launch in the next couple of months called TMD think 3D. Detect, diagnose, and deliver self management because if you’re doing that in a de novo, a brand new TMD patient, as long as you’ve excluded red flags, as long as you’ve looked at it and you’ve done a full exam. And you think that’s TMD, you will do very little harm by starting self management. You can always get another opinion as well. And I think the problem with more irreversible therapies is that the evidence base doesn’t allow us to know who they’re going to work on and how well they’re going to work. That’s why you start with the do no harm principle by the fact that between 75% to 90% of TMD patients over the last 30 to 40 years, the research says that they will get better with simple self management techniques and good quality education around the do’s and don’ts and the simple things that they can do to help themselves. And therefore, that’s why we would always suggest starting with that. And actually, that doesn’t stop you from building on other treatments. In fact, if you don’t start with that, lay a foundation, if you like, to build the rest of the house on, then you’re on hiding to nothing, essentially, because the patient is always going to need to have that foundation to fall back on, because it is, as Emma said earlier, it can be recurrent, it can be persistent in some level, so they’ve always got to have some strategies to manage if it waxes and wanes, or if the pain goes up or goes down, it’s similar as if you’ve hurt your leg or your arm doing repeated sports over the years. You know, the ways that that might flare up and that you might then manage it. And then, you know, the kind of time period for healing and the course of the healing and how it might look. So I agree with you, Jaz. I think it isn’t helped. And that’s why we’ve A done these guidelines and we’re about to launch, as I say, ThinkTMD, Think3D, which is an international campaign about detect, diagnose, deliver self management because we recognize, as Emma said earlier, it’s way too complex. And it doesn’t need to be that complex for the level of someone who’s initially in general medical or general dental practice, and they want to start to do something for their patients. And the lady that you referred to is Terry Cowley, who did pass away earlier in autumn, and who was a phenomenon in her own right, and is sadly missed. And we’ve worked with her and the temporandibular joint association for many years now, and they do an awful lot of good and they’ve got a lot of useful information. The thing I would say is, is they are based in America. So a lot of the American challenges that they face within their healthcare system in America, we fortunately don’t face in the UK. So just if readers or listeners or watchers are going to that website. Just bear in mind that they’re facing a lot of different challenges in America than we do in the UK. [Jaz] And you made reference to the early referral, looking for red flags, I just want to highlight that and page six of, I mean, in the full guidelines, there’s loads on it, but even just page six is a lovely table, table three, which just gives you great a little quick reference into when we should be referring. And on that note, when the patient walks into your clinic, the kind of TMD patients that general dentists will see, they are acute emergency, like the emergency appointment, in our practice, we have half an hour blocked out for emergencies and the time where people sometimes WhatsApp me saying, Jaz, can you help? I have an emergency booked at 4. 30. I try to not say 2. 30. There’s a real emergency booked at 4. 30. What do I do? It’s TMD. I what I’m doing, kind of thing. So dentists get very worked up about the TMD emergency. They’re kind of like, I don’t know what to do. And so the other one is the patient who’s been suffering for a long time, the chronic pain, and then they end up getting a referral. But it all starts with getting a good diagnosis. My big worry about this podcast episode is we spend so much time on the diagnosis that we don’t get onto the other bits. So I’m just going to say that everyone just needs to download these guidelines, make a big pot of coffee, right? And just go through it all because it is absolutely wonderful. But I’d like to just spend a little bit of time through each step. Okay. So your patient attends with signs and symptoms suspicious of TMD. And the first step you’ve suggested is, okay, let’s do the three QTMD, which will come to the CPI and the PHQ 4. That already can the dentist who’s only got a 10, 15 minute slot can seem a bit scary in terms of how much it needs to be done. So my first question to you is, when we see a new patient who’s not a TMD emergency, let’s say, when we see a new patient, we do mouth cancer screening, we ask about smoking, alcohol, we ask about all this, should general dentists around the world be adding in the 3Q TMD, like, as though it’s part of their medical history as well? [Justin] Not unless they’re suspicious that there’s some facial pain going on that they don’t think is related to the teeth, realistically speaking. So, if the patient hasn’t got facial pain that, I’ll change that around actually because I’m going to give you a double negative. If the facial pain is attributable to the teeth, then it’s attributable to the teeth. And if you’re confident on that, then you don’t need a 3QTMD. If you think, oh, I’m not sure, then the 3QTMD is pretty straightforward. And it only requires one to two positives for you to say that this is quite likely to be TMD and the negative predictive value for people who are a bit geeky like me is in the 90%+. So it’s very unlikely it isn’t a TMD if they do screen positive and there’s only three questions which are, do you have pain in your temple, face, jaw, jaw joint? Do you have pain once a week when you open your mouth or chew and does your jaw lock or become stuck once a week or more? And there’s an electronic calculator that you could give to the patient to do in the waiting room if you’re going to bring them back free or what have you. You can also get the code off us and you can embed it on your own website because I had it created through university funding and it’s copyright free. So we’re trying to make it really easy but if they answer yes to one or more of those questions the likelihood is is that they’ve probably got at least some TMD. Then the question is, what does your examination tell you? Does your examination tell you that it’s attributable to the pain that they’re complaining about, that they’ve come to see you about essentially? [Emma] I think your specific question is, do you give 3QTMD to every single pain patient that comes through the door? And as Justin said, it would be a no. If you are hearing and you think it may be TMD, it would probably quite be quite a valuable addition because it could give you more clinical confidence moving forward to get and kind of probe and maybe focus your examination on TMD. So 3QD at TMD. It’s great for those that we think has got TMD and from a general dental practitioner’s perspective, it’s really good for people who aren’t that confident in TMD diagnosis because it can be like, oh, okay, I’m going to ask those three questions. There was yes to one of those questions. So I need to look more at TMD. I’m going to examine in more detail, the joint and the muscles. So that’s where it’s probably it’s most beneficial. [Jaz] Recently I did a talk and I compared the 3QTMD to, it’s like doing a BPE, but for the TMD. And the general dentist seemed to like, no, okay, that’s just, it’s like a screening tool basically. And they seem to understand that. Do you like that comparison? [Justin] Yeah, I do. [Emma] Yeah, gorgeous. [Justin] I’m going to steal that now. Gulati et al. 2024. [Jaz] Excellent. Now, the reason I want to go down this approach is because sometimes I’ve seen a patient being referred to me for a wisdom tooth issue, but actually my correct diagnosis ended up being a painful TMD and I’ve had it the other way where I’ve had a clinician referred to me for TMD, but actually it was a cracked wisdom tooth. It was a cracked molar. So there is a bit of overlap, which is why we need to do more probing in the history and examination. Where do you think is a good place to learn the skills of examining, like for example, you’ve got some images in the guideline for palpating the muscles, how to do bimanual manipulation, and you’ve got some images there that I saw. There’s also on the RDC website, I believe a long time ago, I saw they got like a full video there of how to check each muscle. My worry is for the general dentists who may not have as much time. For example, when I see a TMD patient, I have 75 minutes allocated to me in primary care, which is a lot more than what some colleagues may have in general care. I guess I’m trying to ask is what advice could you give to clinicians who are working in the busy practice to be able to get some more skills for the actual examination of the muscles, if you like and the joint. [Justin] Firstly, you’ve got nearly double the amount of time that we have in secondary care. So you’re an incredibly lucky man for 75 minutes. But yeah, I agree. We work on between 30 to 40 minutes for a facial pain patient, be it TMD or a different type. I think we’re about to, as I say, launch that campaign. And with that campaign comes a QR code that does a standardized exam in a simple way for general practice. And we can give you the QR code for that ahead of that because there’s no state secret and it’s a very brief version of the RDC video that you saw many years ago, because we’ve just finished publishing a brief DC TMD. So brief diagnostic criteria for TMD that was aimed at the general dental practitioner. We work with general dental practitioner colleagues nationally and internationally to try and do that. So we’ve got a version of that that we can share. And I think that would be the simplest thing, but I mean, a standard extra oral exam involves the examination of temporalis masseter, which are the only two muscles that international recommendations would suggest. So you don’t need to bother with lateral pterygoid because you’ve got to be a, have a bit of a strange finger to reach it. Firstly, up and around the back of the tuberosity and not evoke kind of vomit on your shoes and medial pterygoid similarly, it’s not a very nice place to have palpated. And actually the vast majority of the diagnoses have been made with pressing on masseter and pressing on temporalis. So you don’t need to bother with any of the digastric or any of the suprahyoids, et cetera. So it is a lot simpler. And I think, again, it’s about demystifying. Cause you know, years ago when I was taught, which was a good 10, 15 years ahead of Emma, we were taught about digastric, medial pterygoid, lateral pterygoid, even getting down to trapezius. You don’t need any of that. You need masseter and temporalis. Make it easy. That’s what you need to do. And then you need to look at the jaw movements in three directions, three times. So forward and back, open and closed, side to side, three times each, one noise means you’ve made a noise. You can record that the noise is there. So one out of three movements with a noise, that noise is present. If you hear it or the patient hears it and you only need three movements, that’s what it says. Three movements times three. [Emma] Yeah, I think that’s a really important thing that Justin said about just masseter and temporalis. That’s it. Two muscles and then jaw opening. That’s the jaw movements and they can be done. I think the video that Justin is talking about, I think when we recorded it, it was 1 minute 41 seconds was our entire examination for TMD, which was the muscles, the jaw movements. And I think I might be wrong, correct me if I’m wrong, Justin, you also had facial and trigeminal nerve in there just in case. So it’s kind of a very short, I think I can’t remember, but it’s very short. [Justin] That was very quick if I did. [Emma] It’s very quick, but you’re right there. It’s about giving people the confidence that that’s enough to do. So the temporalis and masseter, if you’ve got any of the other muscles are sore, the evidence shows that temporalis and masseter will be sore. If temporalis and masseter are, which is why you don’t need to then do the extra ones. And the other thing to add to when you’re doing the examination, Justin and I both routinely ask two simple questions. We’ll be feeling the muscle and we’ll say to the patient, does that feel sore? It’s a yes or no answer. Yes or no. If it doesn’t feel sore, there’s not a muscular pain in that muscle. Okay. So it’s not a myogenous TMD in that muscle. If it’s a yes, the second important question is, does it feel like the pain you are complaining of? And what we’re trying to work out there is familiarity. So familiarity of pain means that a positive diagnosis means that you’re targeting the patient’s complaint. So as an example for that, I’ve got myogenous TMD, exactly the same as Justin has. So when I palpate my masseter, I would say yes. And when, just if you guys examine me, I would say, yeah, that is the pain I’m complaining of. You mentioned earlier that you might have the co referral where they’ve come to you for an eight. And so you might get somebody who says, yes, it’s sore when you’re feeling my masseter there, but the familiarity wouldn’t be there. It would be no, that doesn’t feel, it’s not eliciting the pain that I’m complaining of. So that’s the key thing. So feel the two muscles. Feel the jaw joints. Do the movements Justin’s talking about, and specifically ask, do you have pain? Is this the pain you’re complaining of? And that, that then easily just ticks. You’re either a TMD side or you’re not a TMD. [Justin] The other thing that people often ask is how hard do I feel? Am I pressing too hard? And the answer to that is, is you press on your own kind of thumb area and I’ll do it on camera. But if you press on your own thumb area and you think your nail blanches, that’s about the right pressure. So if you read up on capillary refill time. That’s kind of the sort of pressure that you’re after, but generally speaking, if your fingernail is blanching, that’s as, that’s as firm as you’re going to go. And that’s probably a tiny bit too firm as well, but actually you’ll only get a positive response if there is actually muscular pain and tenderness thing. [Jaz] I think it’s very reassuring. I mean, if you had the luxury of time, like I do, I, yes, I do a few more things. Some for certain individuals, I might get into sternocleidomastoid, but what I wanted to break down today is really make it tangible for the general dentist who’s almost like feeling fearful about examining the masseter and temporalis just to give them confidence that you’re doing enough. And even just for advocate for general checkups, just feel the contractions, okay, because you can learn so much about a patient’s occlusion based on, are they synchronous in terms of how, when they contract, has someone got really large hypertrophic muscles, high bite force, low bite force, we get so much information and the more you do it, the more confidence it will give you is that when you need to assess for a pain type condition and that wonderful question that Emma mentioned about familiarity, which is really, really important in our diagnoses. When you have that scenario whereby and just going off the flow chart a little bit here. The whole thing about acute pain and how it can be a little bit difficult for a patient, for a dentist to manage acute TMD pain. According to your flowchart, there are some things that we could do in that acute scenario when you have limited opening, right? So if a patient comes in, emergency, they’ve got limited opening, you’ve done your assessment, it’s familiar pain, and you can see that they cannot open their mouth very big. First, we’ll start with how many millimeters do we start to worry about and categorize it in terms of acute limited opening? [Justin] Probably about 10. [Emma] Yeah, it’s a really good. [Justin] Go on, Emma, after you. [Emma] It’s a really good question and I think we haven’t really helped ourselves in the previous. So anything as an unassisted opening, which is passive opening by a patient, so that just when you ask them to open to where they feel comfortable, anything less than 35 millimetres is restriction. For the acute restricted opening, anything 10 millimetres or less. So if they can’t get a finger between their teeth, that’s the ones we’re kind of more worried about from an acute restricted opening. Does that fit with what you were going to say? Sorry. [Justin] Yeah, yeah. But it’s got to be their own finger, not your finger. Because everyone’s fingers vary, and I think that is the key bit. Because there are no good data on normal mouth opening, it can vary between 35 to 50 mils, depending on height, weight, build, culture, ethnic group, you name it. It can vary all sorts of ways, in the same way as hair pattern can do, eye pattern can do, etc. So yeah, I think one finger breadth is where we get more concerned that there’s something very acute going on, and then look for the red flags, and then is it the muscle, or is it the joint? And that’s the question to ask yourself is the limitation from the muscle or from the joint? [Jaz] Can you give us more diagnostic clarity in terms of determine, is it more muscle, is it a joint? Only because in the guideline that we’re looking at, it says if you think it’s limited opening, like you said now, about 10 millimeters or so, due to a muscular origin. We’re looking at potentially diazepam, whereas if it’s more a intracapsular arthrogenous issue, something to do with the disc, something to do with the cartilage, something to do with the joint anatomy itself and not the muscles. We’re looking at steroid, oral prednisolone. So how can we make that distinction? It’s quite difficult when they have that limited opening. [Emma] Yeah, well, okay. I think this is actually a really important conversation to have because it’s really interesting to hear that that’s how the guidelines reading. So what we’re saying is if someone comes in with an acute TMD and they’ve got significant pain, whether it’s alphagenous or myogenous, we would want you to rule out red flags, diagnose, deliver supported self management and in a severe acute pain, you will probably be advising routine over the counter analgesics as a first line. There are a very small number of patients who may come in, in very significant distress. And for those people, you will probably be at that appointment, giving them a referral to secondary care straight away. But then, in the short term, in addition to that basic things we’ve talked about that probably everybody should have for an acute TMD. The myogenous ones where they’re, maybe it’s so severe that they can’t maintain their nutrition. So they’re telling you, I can’t eat, it’s so bad. You might consider diazepam. To just give you a little nod to how often this is used. I think I’ve prescribed it once ever. And I’m trying to work out now. I graduated in 2008 and just in. Can probably give you an indication of how many times he’s used it, which is probably either zero or once as well, Justin. [Justin] Yeah, probably three or four. And I’ve been practicing since 2000, but then in my practice is skewed. So I think we need to be careful to say that, we’re not on the front line. They might meet Jaz first and then Jaz would refer to us and things might be better. So I think it is a difficult one and just to pick up on something else. So Emma’s quite right. You said start with over the counter analgesia, non steroidal anti inflammatory three to four times a day, as you would advise, if it was a wisdom tooth, problem or what have you, and then paracetamol a gram four times a day on top of that. First of all, stepped, but if stepped, i. e. you do the ibuprofen, breakfast, lunch and tea, paracetamol in between, if that isn’t cutting it, then the Cochrane review would suggest that if you have the ibuprofen with the paracetamol, you’ll get an uplift in the pain relief that you would get. But also added to that, look at the self management guidelines on using covered ice and moist heat, because that will help with both muscle and joint issues. And I think you asked, how do you know whether it’s muscle or joint? Again, goes back down to history. So if you’ve got a click, and you had a click before this all happened, and the click has suddenly disappeared, the pain’s extremely located and familiar in front of the ear, directly in front of the ear, and when they open, they’re deviating towards that same side, then that sounds very like a joint issue. A bit like it would do if they’d fallen over and traumatized their jaw joint and broken their jaw joint. It would deviate towards that side because the jaw will hinge and slide on the unaffected side, which means the chin will move over to the affected side. points in the right direction and their mouth opening will definitely be less than 15 mil and it will be really, really uncomfortable because they’re basically functioning on a piece of sensory tissue at the back of the disc. When that’s happened as a muscle, generally speaking, they can get down to 10 mil, 15 mil, but they’re really severe if that’s the case, they normally have a little bit more give, and sometimes if you try very gently to stretch them, you’ll feel that it does feel like it will go a little bit further, whereas if you try and stretch it. A mouth opening that is, that’s limited by, say, the articular disc being out of position. It will feel like you’re trying to push a door against a door jam on the other side, or a door stop on the other side. It won’t give at all. Whereas the muscle one will feel like you’re probably pushing against the door with someone who’s not as strong as you, the other side. But if you’re going to try and stretch those jaws, it must be in patients who haven’t had a recent history of trauma. If they’ve had a recent history of trauma, do not stretch mouth opening because it’s more likely that they’ve got a fracture or an issue. And if you’re going to stretch mouth opening in people who haven’t got a history of trauma, make sure you say to them, I just want to have a very gentle feel of what this feels like. I’m not going to do too much. It just tells me roughly where the problem might be to help me guide what I tell you. So they’re kind of, it’s flagged and you won’t need to do more than like literally a second or so, because you’ll feel if it’s a disc problem, it will feel weird. You are not going to move those teeth further apart. [Jaz] Some terms I’m going to just use, Emma, is hard end feel and soft end feel. That’s what you’re referring to, right, as a physiotherapist. Yeah, fine. So just for those who are just marrying it together in terms of some, where they might have previously read it. Yes, Emma, please. [Emma] Yes, I was literally just going to bring that in because if you’re thinking about the pathogenesis, so what is causing the restricted mouth opening? In a myogenous TMD, it’s basically guarding. So the body is trying to resist movement to protect the area to allow healing. So the muscles can move, but they’re trying not to, which is why when you have a gentle stretch, the patient might passively open to that 10, 15 millimeters. But you, as a clinician, when you try to stretch them that little bit further, you will get a degree of give and it feels softer. If you think about what’s causing an arthrogenous restricted opening, the most commonly is the disc displacement without reduction, which as Justin said, the disc is completely in the way of movement. The disc is cartilaged, so it’s hard. So when you try to stretch, you just can’t get that difference. So that’s what I was just going to give it, bring in there. And then with the adjuncts for acute, if they’re really struggling, if we think about the theory behind the diazepam. So diazepam is an anxiolytic, it’s a sedative, but it’s also a muscle relaxant. So from the myogenous TMD that are really acutely guarding and really restricting movement, people really struggling with function and eating the short course of diazepam at a very low dose in a very controlled way might help that muscular issue. And when I say in a controlled way, what we say in the guidelines is that we would advise two milligrams, so a tiny dose, three times a day for just five days. On day five, you should review. If it’s having a positive effect, then you can stop there. If it’s doing something and you’re getting some sort of benefit, but it’s not quite where you’d want to be, you could then consider it for a maximum of a two week in total, but only if you’ve had that review. If it’s not done anything at all, it’s not helping the patient at that day five. So don’t keep it going. There are a lot of contraindications for diazepam. So there are a lot of patients where it’s not appropriate to prescribe it. They’re all in the BNF. There’s would be no surprises there. So people with dependency issues, people, it causes respiratory depression. So any kind of respiratory issues, people with issues with liver or kidney function, and so that people would be looking those up as per normal prescribing practice. But if you think about why you might be using it, you’ve got really sore muscles. They’re really tight. You’re giving a low dose tiny course of a muscle relaxant to see if that helps them get over the acute phase. At the same time, you’re telling them to use ice that reduces inflammation, put heat on that increases blood flow to the area, helps facilitate healing. You’re telling them to use analgesics, the paracetamol, telling them to gently massage. So on top of just having that relaxation from the diazepam, they’re also doing the self care really positively. You might just get them over that really, really difficult period where it is agony and it affects anything that gives us joy. So they can’t talk, they can’t eat, they can’t kiss their partner, they can’t lay down on the area where it goes to sleep. So it just gets them over that hurdle where the impact’s really high. Do you have any questions to ask about that, Jaz? Is that clear from that myogenous adjunct? Are you happy with that for the muscular TMD? [Jaz] Yes. That helps a lot, especially the distinction between the two, which I think a lot of people would be wondering about. And that gives a bit more clarity on that. And also just to know that although it’s there in the guidelines and you took that feedback on board that when I look at the guidelines, my eye gets drawn to the red flag, which is great. We want that, but then it’s almost like in green and like, it’s almost perhaps overplayed that the whole That’s why I wanted to ask you about it, because it’s not something I’ve prescribed before. Diazepam or prednisolone. And so it’s there occupying quite a big space on that. It was something to talk about. [Emma] Yeah, you’re right. And it’s a good point, Jaz. It’s something to think about. What we write isn’t necessarily taken on. It was not necessarily seen how we’d like it. And this is how they always develop, always develop. [Justin] The whole document is about to be typeset because that’s the in press version. So we can actually adjust that in the final version because the college will. Like typeset it in their own way so you can take that on board because I don’t want people to feel that they’ve got to go out and prescribe diazepam or prednisolone. It’s there because it is an option in the acute option. And again, if you were in general practice and you’ve got a good working relationship with general medical practitioners around you, I know for some people, specifically in rural settings, they’ve got really good working relationships with a general medical practitioner because they have to get the INR testing, or what have you done in that general medical practitioner, you could have a conversation with the patient’s general medical practitioner, explain your diagnosis and say, I think, the guidance says this, would you be happy to prescribe this? Because I’m not, it’s not something that’s normally prescribed by me. And they would give you a straight answer one way or the other. And most of them are extremely amenable people because they want to help as well and the patient might call on them after you anyway. So you might be heading that off to say, I’ve had a conversation with patient. I think it’s a TMD. I think it’s this acute version. I think they might benefit from some diazepam. Would you be happy with that? [Emma] It’s in the clinical knowledge summary for GPs. It’s the diazepam. So yeah, that’s a good point to stem. [Justin] The clinical summary for people who aren’t aware is, is it sort of a nice accredited repository of information that GPs quite regularly use. Cause understandably, like general dental practitioners, they have to be master or mistress of everything that they sedate. And sometimes you need to refresh your memory. Cause I certainly do. And I only have a smaller subset of things to deal with rather than everything and anything that can walk through the door. So it’s actually quite a good resource if colleagues haven’t seen it for dentists as well. It’s called, you basically Google NICE clinical knowledge summaries or CKS for short. And it’s got a good section on TMD that’s been updated in collaboration with ourselves. And it’s actually quite a good resource for all sorts of things. [Jaz] Emma, I think you wanted to say something. [Emma] So I was just going to move on to the adjunct that’s mentioned for the arthrogynous TMD in the form of an oral corticosteroid. So in the pop out on the guidelines, we talk about you could use prednisolone orally. Again, a short six day course of 20 milligrams once daily. The theory behind that is that if you’ve got an acute disc displacement without reduction, as Justin says, what that means is that the disc is usually pulled very far forward in front of the condylar head. The reason why that’s so acutely painful is that all of the tissue behind the disc that it’s tethered to has got all the vasculature and all the nerves. And what you’re then doing is it’s that tissue that your joint is working on. So as the condyle moves and opens, it’s functioning on that tissue instead of the nice chunky cartilage that doesn’t have the pain that doesn’t have the nerves and all the blood supply in it. So that’s why it’s so painful. And so the reason why prednisolone might be beneficial in those cases is because prednisolone is really anti inflammatory and so it’ll just calm everything down within the capsule of the jaw joint. Again, I’ve never used this but they come to us later. The evidence is in only for a disc displacement without reduction. So they would have had a history usually of clicking and then what we would call a closed lock. So they’ll come in and they’ll say, I cannot open my jaw. When you try to stretch it, you cannot get any give, and it’s kind of a really firm locked jaw. So there is some evidence that that might be beneficial. Again, same as for diazepam, you have to look at who it’s appropriate to prescribe it to, who it’s not appropriate to prescribe it to. You would be doing it for a short course only, so a six day maximum, and reviewing. It wouldn’t be one even at review, if you’ve had a benefit, you wouldn’t be continuing it for a longer period. [Jaz] Like I said, it’s really good to know about the fact that it’s not something that we’d be expecting to prescribe a lot, but in those acute scenarios that you’ve described, it can be very helpful. You’ve also written here about stabilization splint for those very acute scenarios for disc displacement without reduction. Now stabilization splint just to for everyone is I believe you mean any sort of splint that just gives you even bilateral contact that covers all the teeth, right? Do you make a distinction between hard and soft when you say in the guideline here, stabilization split, and exactly who is the ideal candidate here? Because obviously when this very extreme restriction, like you’ve said here, the muscular or joint related, then you’ve said diazepam prednisone may have a role in those very few patients. But where do you see the guidelines in terms of the rationale behind the stabilization splint at this acute stage, obviously in conjunction, by the way, with the supported self care, right? That which is a whole fantastic area, which you’ve got the patient guidelines, well, the QR code, the videos that they can use, which we’re going to make available, everyone should use those. So everything is on that foundation that was mentioned. So that’s really, really important to just highlight again, but tell me more about the stabilization split here. [Emma] I’ll let Justin jump to stabilization splint. But I suppose one thing to be really wary of is the ones that we’re talking about here with really acute trismus or restricted opening, you won’t. be able to get a stabilization has been probably in their acute period because they haven’t got the opening for the IMPS or I’m afraid we’re a little bit behind the times. We don’t have an intraoral scanner yet, but I believe you’d still have to have a significant degree of opening to get an intraoral scanning done to make your splint. [Jaz] What I find so far is that 26 millimeters is what I need to get my iTero scanner head in. Okay. Anything less than 26 millimeters. I can’t do it. Even then it’s like regular breaks and stuff. So, and that’s what the ITO is quite a thick one. Maybe you can get a little bit lower, but yeah, you need a mouth opening that’s sufficient for either way, whether analog or digital. [Justin] Do you have to say other scanners are available or? Is it specifically iTero that we need to use? [Jaz] Something like that. It’s just the one I use. [Emma] Yeah. So for these with, you’d have to get enough opening to allow a splint, but then I’ll let Justin pass on to what types of splint we use and why they might, what they might be good for. [Justin] Yeah. I mean, I think the splints are one of those things that have been around for eons and they’ve got all sorts of different pieces of evidence about them. Some positive, some equivocal, i. e. they can’t really tell whether they’re useful or not. I think you’ve already stressed Jaz and we don’t need to go on about it. ad nauseam, self supported management, support self management is the most important thing to start with. If the patient isn’t getting on well with that, then you can consider an adjunct to the splint. Simply put, back to Ed Trulove’s study in 2006, which was a good quality study, you do the simplest splint that you can do in the quickest possible time. So he found very little difference between what we colloquialize as a lower soft splint, so a polyvinyl suck down, sometimes called bite raising appliance that covers all of the teeth. He found very little difference between that and a stabilization splint, which generally is meant as a Michigan or a Tanner splint. So it was cold cure acrylic. Opened to say three, four millimeters increase in occlusal vertical dimension, they talk about having it in RCP, retruded contact position, and they talk about having even contacts across the occlusion and canine guidance. The actual answer to that is if you read Ed Wright’s work, he was a retired USA Air Force dentist who specialized in TMD, he quite clearly. explains that not everyone needs to be in RCP and not everyone needs canine guidance group function. If they’ve already got group function is fine. What they need is smooth and easy movement across the occlusal plane. And essentially a splint of any variety is a bumper or a buffer or a bandage or a crutch in the sense of nursing an injured leg to try and help take some of the pressure off the tissues, put a little bit of occlusal vertical dimension in so your teeth are apart. The muscles are not therefore contracted. You’re not loading the joint, perhaps as you would do if you didn’t have the splint in. And that’s essentially their role in this. People do worry that they become a kind of psychological crutch, and people become very attached to them. I’m not convinced by that argument, I think the argument is, is that the evidence base is not good enough to say that you should spend money as a patient on getting that as first line. It’s a second line, a jump to treatment when you’ve tried some supported self management. If you gave it alongside some supported self management, I wouldn’t say you’re doing anything wrong there. I think that’s perfectly reasonable. What I would say is really inadvisable is just to give a patient a splint and say, that’ll help you off your pop because they don’t know why it will help them. They don’t know why they would use it. And some people just don’t tolerate them. Well, some people have a soft splint and they tell you they grind or clench more on it. And I think that is the case. And if they tell you that, believe them and they might be the people who might benefit from having a hard cold cure or bilaminate type splint created. And I think you just have to take the patient on the journey with you and explain to them that these work for quite a lot of people but we’re never quite sure how they work or who they work in, but they’re quite simple, they’re quite non invasive. As long as they’re full coverage, and that’s the critical thing, then you’re going to see very few adverse effects with them, assuming that the patient’s periodontal health is good as well, and they haven’t got rampant caries, etc. [Jaz] I’ve got Dr Wright’s book actually, I believe, it’s a yellow cover one, I think, and in that is a whole section on stabilizer, yes, very good book, Stabilization Splint, and what I like about that is, just like you said, you have to make it accessible and easy for the dentist to do so that they can get good care quickly or get this, this type of care and quickly because if we then focus on we’ve got to get the face bow and we’ve got to get this and make it high precision. That’s a completely different type of this. That’s not pain management, pain management is get something in that gives them bilateral even contact, something nice and smooth for that acute management. And I’m glad that you’re echoing that as well. Cause a lot of clinicians, they think that, oh, I don’t have the means or I don’t have the skill or the precision to deliver a stabilization splint. That’s not true. You can just get something in that covers all the teeth and gives them some balance. And that acute scenario. As an adjunct to support to self care is the way to go rather than worrying about canine guidance and all those features that you read about. [Justin] Full coverage, simple as you want it to be as long as the patient understands what you’re trying to do and as long as you’ve done the sensible things that you would always do as a dental professional. [Emma] I think as well, we would always rather people feel comfortable with what they’re providing and provide that well. And I’m thinking here, the example of a good lower soft splint, rather than them providing an upper stabilization splint that is worse because they don’t know what they’re doing. It’s different for everybody. A stabilization splint will last longer for the patient simply because it’s a harder material. So they might need to replace it less often. It takes slightly longer to fit, but there are good courses that can help you with learning how to do that skill. And then it’s just something that’s in your armamentarium should you need it, but do what you feel comfortable with. Maybe Justin and I need to do a course on splints and how to fit. [Justin] I think Jaz runs one, don’t you? [Emma] Do you? Oh, Jaz, welcome to Jaz then. [Jaz] I do one, but the main thing I want people to take away is the following, whereby, and here’s my bone to pick with oral surgeon, oral surgery departments all over the country and the world, okay? Here’s my bone to pick, and let’s have a bit of a discussion, debate here. Off script, okay? [Emma] The gloves are on. [Jaz] Soft splint, okay? I think it has a role in acute management, absolutely, okay? It has a role, but the way that it’s delivered okay. It’s just like, here you go, pop this on. And there’s probably, if you look closely, it’s probably just one or two cusps, cusp tips touching. That’s not balanced. If you read the Wright’s paper, I think it was in 1992 where they had to N equals 30 basically, but they describe a beautiful protocol of heating the guard and getting the patient to bite into it and to get that nice balance. I personally, I vouch by that. That’s how I teach it. That’s how I do it. Whereas when you just see a soft splint and they’re just bouncing on one side, the muscles are all over the place. That’s not giving them bilateral contact, but no one ever speaks about that. Is this something that you guys do? Why don’t you, if you don’t do it, I would love to know. [Emma] Yeah, well, we actually on the guideline group, we had some really fabulous restorative dentists who had pretty similar opinions to what you’ve just shared on along the lines of a soft splint is a less predictable, less stable, because even if you do that and you heat it and you get them to bite, so you’ve got nice, even contacts, they’re going to wear through it a little bit more, maybe in one area and then another on a soft splint. So that isn’t a longitudinal consistent relationship. And so what I would say is in our unit as a general rule, we use a stabilization splint. But that’s because we feel comfortable fitting them. So we’re talking about the hard acrylic splints then. We feel comfortable fitting them. We feel they last longer. We feel it’s more predictable. But what we’re saying is in the evidence, there hasn’t been shown to be more benefit from one type of splint than the other. So a general dental practitioner should use what they feel comfy with. What do you think Justin? [Jaz] Yes, please. And then also just give some guidelines for those listening who want to do a stabilisation split. Now, yeah, again, in your guidelines, you have a link to, I believe it’s a dental update paper, which is very good of you to link it. And it shows you exactly how to make a well fitting one. Again, my bone to pick with that paper would be, it’s a little bit for acute management of pain, it is a bit too restorative-y, it’s a bit too care and guidance, perfect, facebow, and that’ll be my criticism for what we’re trying to achieve in pain management, but it’s good to aspire to that, and to know the lab side and the ins and outs of it, it’s absolutely good to aspire to that, but I’d like to know how you do it in your limited time that you have in your pain centered clinic, and what advice would you give to general dentists to help make one that is a bit more real world friendly? [Justin] Well, I think one of the things that we did miss was beauty hard wax, cause it stopped because we used to love a bit of beauty hard wax. It shows you how old and traditional we are. And they binned that because that was one of the easiest ways to get the registration right for a position approaching RCP. We would simply use, because we’re not digitally enabled as yet. We would simply dry off the arches and do really good quality alginates upper and lower. We would have then previously ask the patient to get into a position approaching RCP, so we would guide them in. We wouldn’t force them in. It’s not kind of like trying to get them right to the back of the space of the glenoid fossa. It’s where they feel comfortable. And it might be that that’s only like a smidgen away from ICP. And I’m not particularly precious about that. And if you read Ed Wright’s work again, he’s done the work, he’s done the research. And he says, that’s normal, that’s very different to if you’re doing a occlusal rehabilitation for a different type of patient for a complex restorative procedure. You need to be in RCP because it’s reproducible. That’s not what we’re doing here. So I would get them into a position where they think that feels comfortable. I talked to them about, think of your jaw a bit like a gear stick. When you’re in gear, it’s working. When you’re out of gear and in neutral, it’s not working. And I tend to sort of show them, this is my teeth together. That’s ICP. That’s where you can see my muscles bulge. That’s me in gear. When I’m in RCP, this is how my jaw looks. It hangs loose and that’s what the neutral position is that we’re trying to get you to. So then I’d guide them into that a couple of times and then I would literally take a leaf gauge, something between 20 to 25 leaves depending on how deep the overbite is and then blue moose, either side, ask the cast to be articulated up on that position. And then we use biolamina now, which I have to say are a damn sight easier than cold cure, well, the old flask and pack, pack and flask, I forget which way around it goes, it’s so old now. And because they just got a bit of give in them, they’re more comfortable for the patient, are actually easier to adjust as well, because there is a bit of give whereas cold cure, getting it to fit across the arch could have been a bit of a work of art. And Emma and I were the people who did most of those, I think, five, 10 years ago. And they were really challenging. So I think with the bi laminar type. Approach now where there’s a hard surface on the occlusal surface, but a soft surface on the fitting surface to the teeth and the gingiva. They’re much easier to fit and create. And I think they’re easier for labs as well, because they can almost do the initial base work if they are, if it isn’t digital, just using a suck down approach from my understanding of their techniques. And then we would just see them to fit them and look for even occlusal contact and a smooth guidance, rather than a guidance where they’re actually having to make a big movement, like a down and out movement, we just wanted you to slide around nice and easy. Imagine a bit like being on a skating rink and just being able to slide around really easily on that without big movements. [Emma] Yeah, the RCP registration is the thing that probably GDPs want most guidance on because all of them will be happy, I would assume, taking an upper and lower alginate impression. It’s about how do you capture the jaw relationship. And so they basically need something between the front teeth to give them some space. And they need the mandible a little bit further backwards. So they could use a cotton wool roll if they don’t have a leaf gauge. They could perhaps use a softer wax. We, we loved Beauty Hard Wax because it didn’t give us much, but they could perhaps use a softer piece of wax once they’ve almost got the patient to open. Place the tongue on the posterior aspect of the soft palate and then guided closure with both of the dentist’s thumbs on the chin. It’s shown if you do it with just one thumb, you can actually push it to one side or the other. So both thumbs on the chin, just to guide it slightly posteriorly helped by that tongue positioning. And then you need something between the front teeth to just keep them at that point. So it could be a cotton wool roll that probably is a little bit too wide. It could be something like folded gauze. It could be some wax. [Jaz] You can use also some bite registration material anteriorly. Once you found them, let it set on there. [Emma] Gorgeous. Actually, that’s a good idea. Like a harder, a quicker setting putty, maybe anteriorly, and then a softer silicone to then pipe between the occlusal surfaces. And that is enough. So almost upper and lower alginate imps, gently guide them into ICP. Something anteriorly to hold it. And so you can get the squirt of silicon in. That’s what you’re looking for. You don’t need to overthink it. I hate face bows. I haven’t used them for ages. I was never good at using them. You don’t need it as much for pain. [Jaz] I love this real world discussion, which is exactly what we need because you want to make this guidelines implementable. I’m not saying that we need to be taking shortcuts, but what we know, just like you said, Justin, is that there’s no evidence say that this is better or that technique’s better. And what we need to do in pain patients is just reset, go into neutral, get that nice, smooth sort of ice rink analogy that you use is absolutely brilliant. And in the interest of time, I mean, I’m going to say it in my intro, and I’m going to put a few ads in there just for them to download these guidelines. They’re absolutely brilliant. It’s got the whole supported self care manual in there for six to eight weeks. It describes everything. It just needs for dentists to do their due diligence. And then what happens if they don’t respond? What happens if they respond favorably maintenance? What happens if they get a little bit of response? It’s all in there, including the physiotherapy role. And so there’s so much, I mean, you could easily talk eight hours, right? Easy go eight hours, right? Spend a whole day discussing every aspect, facet of it, but that’s not what we’re here for. We’re here just to raise awareness, firstly, and to have those real world conversations like we did about the splints at the end, and about actually maybe we don’t need to be looking at diazepam, prednisone, do the basic stuff first before you think about that, and in which cases those severe cases may warrant referral, which again is covered really well in the guidelines. While you have the microphone on the stage, just a couple, a minute each. Anything else you want to pass on to our colleagues listening and watching? [Emma] I think put yourself in the patient’s shoes. I think sometimes it’s really hard, isn’t it? You need to listen to what they’re telling you is driving their TMD. So a one size fits all doesn’t work. So as an example, I’ve got TMD. Mine’s really bad when I’m stressed and people will tell you things that are giving you information on what might be precipitants for their pain that we’re not hearing. So for me, I get it about three times a year. Usually when I’m stressed, it’s a myogenous TMD. So for me, the splint does less. For me, what works better is understanding my triggers, managing my stress, sleeping well, and then doing things like massage at the time when it’s at its worst. For other people, there may be, for example, a more kind of biological drive. So maybe the people who say my TMD is at its worst after I’ve talked all the way through the day, all day, it builds up, it peaks in an evening, and then I struggle to get to sleep. [Jaz] Teachers, my teachers, TMD patients are exactly that. [Emma] Yeah, exactly that, rather than the other way around. So for them, it’s about breaking that cycle of use throughout the day. So can they, perhaps they’re, in addition to their talking, they’re also clenching. So we do a lot of behavioral management. We tell them to put a spot on something that they look at. All the time throughout the day. So watch, phone, computer screen, teachers, they might just put it on their desk. Every time they look at it, it’s a behavioral reminder to relax, reduce clenching and just make sure everything’s in a neutral position. And then for those people wearing a splint on the nighttime, through the night as they sleep might just allow them to just get the balance a bit better throughout the day. So listen to your patients and target their needs, but also talk to them about why you, make the decisions together. So, this is what you’re telling me. You’re telling me that it’s worse at these times, so how can we make it better at those times? And you just fit the jigsaw puzzle to them, rather than just throwing a splint at everybody, or maybe telling everybody to massage their muscles, whereas actually there’ll be some people where it’s more beneficial and less beneficial. [Jaz] Thank you, Emma. [Emma] Target the patient. [Justin] Yeah. I mean, I think probably a lot of what Emma said already, which is, TMD when it first presents is. It’s quite simple. Don’t let people overcomplicate it for you. It’s simple. You don’t need a splint in every case, but you do need self management in every case. And as Emma says, it needs to be targeted to what the patient’s experiencing and what the patient can do in the time that they have available. And it isn’t simple in its etiology. So it’s not just about grinding or clenching or the bite, so don’t try and oversimplify the etiology. The etiology is quite complex, but what we know is is the management of it isn’t in the vast majority of people, and you can start that as a generalist, and you can start it in an evidence based way that your patients will probably get on very well with, and just don’t be frightened of it, and don’t let people overcomplicate it to you. Again, that’s not to say that we don’t see some really complicated cases, but they are a small minority and we see them because we have a sort of sieve because we’re the people with the special interests in it. The vast majority that will come in through the door will be very straightforward things that you can manage in primary care and can be supported in managing in primary care by people who’ve got specialist interests as well. [Emma] Yeah, can I add one thing? Because I think we work with wonderful pain psychologist, Dr. Chris Penlington and what she really positively does with our undergraduate students is explains that your relationship as the clinician with the patient can have a huge effect on their pain experience. And so what we mean by that is if people don’t feel listened to, don’t feel validated, don’t feel like. We’re picking up on that specific problem. It can actually make their pain worse. And so we’ve said to try and reassure GDPs that temporomandibular disorder is simple. It is, I would never say that to my patient because for them who can’t eat, can’t talk, can’t sleep, it isn’t simple and that would devalue their symptoms. So give them time. Sometimes, overrunning by 10 minutes to, to allow someone to feel heard, to be really clearly explained to them why they’re getting their problem can be what they need to get over the hurdle. Jaz, you said you get lots of referrals and I bet you’ve heard it the same as Justin as I. I’ve been to so many different dentists and they can’t fix my pain. And then when you ask them what they’ve been told to do, they’ve been told to massage, do jaw exercises and analgesics which are the right things. But if you say to me, I’m in agony and it’s really hurting. I say, you’ve got a problem with your muscle. You need to take some painkillers and do these exercises. It sounds like a fob off. If I say to you, the reason muscular TMD is so painful is because the body aggressively protects the head and neck region. I often say we can’t rest our jaw. It’s like if you have the sprained ankle and kept hopping on it over and over and over again. That’s why the pain gets so bad. What we need to do to try and break the cycle of these things. Use heat, it brings blood to the area, it calms it all down. Use ice, it reduces inflammation. Massaging the muscle causes relaxation. It reduces muscular guarding. It eases the tension. And then take analgesics. I’ve told them the same information as the first example. I’ve given the same instructions but the patient might feel more heard and I think maybe, what you’ve just pointed out in the guidelines is that big green box, it maybe pops out in a way that’s different. If that makes sense, it’s been read in a different way to what we thought it would be. Whereas that, so actually being aware of what you’re saying and how it’s interpreted is very important. And Justin and I will often say to the patient. What do you, at the beginning, this is your pain history and I’ll be like, okay, what would you like at the end of this consultation? And they’ll often say, I want to be 100% pain free, or they might say, I want to know what causes the condition. But by asking maybe that one question, giving them a little bit more information on why you’re telling them about the supported self management, how it can be effective. All of a sudden, it’s given them ownership. They’ve been listened to. They’ve got the tools to make the difference. And I think that’s the important thing. [Jaz] What a wonderful contribution there. And alongside the fantastic guidelines, everything, I really appreciate you adding the extra couple of minutes. That was really a wonderful summary. I always say that when communicating with patients especially in a field like TMD where I get patients who’ve had every spin under the sun and tried all sorts, basically, if I’m suggesting something, I want to show them my working out. I just want to recommend, I was like, okay, well, actually, this is what I think is going on because of this factor. And the rationale behind what I’m recommending here is to achieve this effect. If this doesn’t work, then we’ve got a few things, but I think this is a more minimal way of doing it than an aggressive approach, but there’s a pathway. So I think it’s all the delivery and communication. You summarized it absolutely beautifully. In the interest of time, cause I know you probably got things to do. I’m really sorry to run late, but I really am thankful for you to say, if it wasn’t for this extra 13 minutes, we wouldn’t have extra wonderful tips that you gave that Emma as well. So thank you so much for the guidelines. Making it freely available to everyone. The amount of hours it would have taken for you all as a team. People will not appreciate, they’ll just consume and digest this, but I can only imagine the sheer, I mean, it took 11 years, right? But all the hours it did as well. So thank you from the community and the profession to you guys. Helping us to better ourselves in TMD management. [Justin] Yeah. Thank you for having us on Jaz. It’s really helpful and hopefully people will take notice and have a read and move things forward. So thank you. [Jaz] I’m going to shove it down their throats, Justin. Don’t worry. They’re going to listen. [Justin] Don’t give him any TMD for God’s sake, Jaz. Whatever you do. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. I really appreciate Professor Justin Durham and Mrs. Emma Beecroft giving up their time. I think it’s wonderful what they’re doing to help us spread this knowledge so we can help more patients. This episode is eligible for CE credits or CPD hours. All you have to do is answer the five questions, get 80% and you’ll get your certificate. If you’re a regular Protrusive listener, you can easily rack up about 40, 45 hours every year, just from the new stuff, let alone the hundreds of hours of the episodes from years gone by. As well as all the good stuff we put on the Protrusive Guidance platform. You can get that on iOS or Android. The website for that is protrusive.App. And if you’re on a paid plan, you can get your CPD or CE credits. Remember to download all the free resources from this episode. That’s the guidelines that we discuss, the video of me equilibrating a soft bite guard. And all the goodies relevant to this episode. That’s protrusive.co.uk/tmd. I’ll catch you same time, same place next week. Bye for now. Oh, and by the way, how could I forget? Thank you so much to team Protrusive who keep me sane to keep this podcast alive and going and serving you the Protruserati. You guys are the best. Bye now.…
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1 How to Manage TMD When The Evidence Base Sucks – PDP212 1:03:31
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In this episode, Jaz dives into the complexities of Temporomandibular Disorders (TMD) management with Dr. Suzie Bergman , a US-based dentist and TMD sufferer. They discuss why treatments for TMD vary so much and examine the current state of evidence-based approaches. https://youtu.be/r3QpkMYeTWk Watch PDP212 on Youtube Dr. Bergman shares her personal journey, highlighting conservative treatments, the role of occlusal appliances, and the power of multidisciplinary care. But just when you think you’ve got it all figured out—Dr. Bergman reveals a game-changing insight that could completely shift your approach to TMD management. Ready to find out what it is? Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:40 Protrusive Dental Pearl 04:32 Meet Dr. Susie Bergman: A Personal Journey with TMD 7:27 The Wild West of TMD Treatments 10:32 Challenges in TMD Research and Treatment 13:34 Suzie’s TMD Journey: From Trauma to Advocacy 21:42 Evidence-based Therapies and Occlusal Appliances 27:11 Orthodontics and TMD: A Complex Relationship 33:40 The Role of Occlusal Appliances 35:05 Debating Disc Displacement 39:17 Comprehensive TMD Diagnosis 44:09 Orthopedic Stability in Dentistry 51:04 Splints and TMD 53:52 Managing Bruxism Effectively 58:16 Suzie’s TMD Course and Final Thoughts Listen to Dr. Suzie Bergman’s “Why is healthcare disjointed?” | TEDxStrathcona Women Check out Dr. Suzie’s Course “21st Century TMD Protocols” Looking for an Online course to allow General Dentists to treat 80% of TMD cases and 100% of Bruxists? Check out SplintCourse Online by Jaz Gulati This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C. AGD Subject code: 200 Orofacial Pain (Diagnosis and treatment) Dentists will be able to: 1. Recognize the multifaceted nature of Temporomandibular Disorders (TMD) and the various factors influencing treatment variability. 2. Evaluate current evidence-based treatments for TMD and their effectiveness, including conservative methods and occlusal appliances. 3. Discuss the importance of a collaborative approach in TMD management, integrating different specialties for optimal patient outcomes. If you loved this episode, be sure to check out Deep in to TMD – An Orthopaedic Perspective – PDP172 Click below for full episode transcript: Teaser : I tell them T. A. T. U., which stands for Teeth Apart, Tongue Up, so during the day as much as possible, try to keep your teeth away from each other so that you're not clenching. I tell them, we want you to do the three S's, which are- Teaser: I always tell people it’s unrealistic with chronic pain patients to think that there will be a day that you go to zero in pain. I don’t know what it’s like to not be in pain. Some days might be a little bit better, but there’s never a time that I’m not in pain. And part of that is because- When we have pain for so long, it can become a central nervous system issue. So when we have that central sensitization, our brain interprets non painful stimuli as painful. We have patients who have discs that are either anteriorly and medially displaced, which is most common. It’s very uncommon for there to be a posterior displacement of the disc. We have to think about how that patient’s body has responded to the changes if the disc has been displayed. Some people will adapt beautifully and some people will not. And so, it’s really about the individual patient. Jaz’s Introduction: The management of Temporomandibular Disorders is like the Wild West. I know for a fact that for the same issue you can go to one dentist who will suggest orthodontics, you can go to a surgeon who may suggest some form of surgery, even if it’s like an arthrocentesis, you can go to another person they might suggest some botox to calm those muscles, whilst the next two dentists are still arguing about which splint to make for this patient. And so why does this happen? You see, the number one reason I think this happens is because we still don’t have clear protocols and clear guidelines because there’s a lack of evidence and there’s numerous reasons for that that we unpack in this episode with Dr. Suzie Bergman. She’s a dentist from the US who herself is a TMD sufferer and she’s had surgeries and orthodontics and all sorts. Which is why she can truly empathize with her patients and I love the fact that she’s willing to share her journey. This journey of chronic pain, which so many of our patients suffer with as well. From this episode, what you are going to gain is an understanding of how we can manage temporomandibular disorders in ways that are evidence based and what should be considered from the evidence that we do have, by the way, and in a way that is not irreversible and allows a patient to do more fringe treatments, let’s say, in the future, rather than going in for more irreversible therapies, and you get a good flavor of that. Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Can you believe, by the way, that we’re almost at episode 200? There’s actually almost 300 episodes when you count all the group functions and the interference casts, but that magic 200 number is coming for the PDP as well. If you’re a new listener, welcome. If you’re thinking, why I talk about onions so much, keep listening and you’ll find out. And of course, if you’re a returning Protruserati, keep chopping those onions. Dental Pearl The pearl today is kind of like an emotional one. One of my mentors, Michael Melkers, shared this with me and I want to share it with you because chances are if you clicked on this title then you may be used to seeing patients who suffer with TMD and oral facial pain and you more than likely have had this experience where the patient tells you their story, and disproportionately, this is a woman. Disproportionately, this will be a woman, eight times more than it will be a male, and she will start crying. And this happens a lot in my clinics, and the nature of how we run things, and the referrals that we get with patients with long standing pain. And so what I used to do is me and Zoe would look at each other, and we’d get the tissues, and try to connect with the patient. We’d we’ll be there for the patient at that moment. But what Michael Melkers suggested is that by giving the patient tissues, You’re kind of blunting their emotions. You’re kind of saying, actually, no, no, just dry your tears and let’s move on from this. You’re kind of not allowing the patient to express themselves. So actually listen to that and I change what we do when a patient is vulnerable and they’re sharing such emotions and they’re getting a bit teary. I just listen. I just listen. I let them tell their entire story. And then at the end, I’ll help them with the tissues. But I really want to make sure I’ve listened to everything and I’ve connected and I haven’t missed an important part of their story. And so like with everything, two ears. One mouth. Listen twice as much as you speak. I sound like my year eight history teacher. But it’s true for everything. This episode is eligible for CE and CPD. It’ll be worth one CE credit or one hour of CPD. You’ll be able to get that from the Protrusive Guidance app on the App Store or the Android Store. If you haven’t already made an account, head to protrusive. app and join the geekiest and nicest community of dentists in the world. We’re sometimes a little bit slow by a couple of days to approve you because we actually manually approve each person. We want evidence that you are a dental professional joining our community because this needs to be a safe space. Anyway, let’s join the main interview with Dr. Suzie Bergman and I’ll catch you in the outro. Main Episode: Dr. Suzie Bergman, welcome to the Protrusive Dental Podcast. How are you? [Suzie] I’m great. Thanks for having me, Jaz. And please just call me Suzie. [Jaz] I appreciate that, Suzie. Suzie, I’m so excited to speak to you. You’ve been on my radar for a few years. I know we emailed about some events in the past. And then you sent me recently your TED Talk. What a wonderful job. I’m definitely going to link that here. It’s something that every dentist should watch, but also there are some, unfortunately, so many patients who suffer with TMD who would also benefit from having that perspective. And your story is so powerful. Could you spend a minute? Just tell us about you, your story. How did you niche into TMD? Are you still a general dentist or are you just like, have you niched into TMD? Tell us more about that. [Suzie] Okay, great. So yes, I am technically a general dentist, but I like to call myself a primary care dentist. And I really don’t, I’m not someone who picks up a hand piece and does fillings and those kinds of things. What happened was when I was a teenager, I was involved in a fluke accident where basically I got run over by my friend’s car. And I became a TMD patient even before I became a dentist. And back then the treatments for TMD were archaic to say the least. And so I spent many years trying to figure out what to do and how to be able to continue my career. Because of the experience that I had, patients were drawn to me. So I started treating more and more TMD patients. And now the bulk of my practice is TMD. I also work at a university and do research and I’m involved in advocacy and infrastructure for TMD patients. [Jaz] It’s wonderful to hear your story. And then you obviously talk more about it in your TED talk, which I will direct everyone to. That was so well delivered. It’s a powerful message. And in terms of how I got into TMD Suzie, I mean, I am a general dentist. I am happy to pick up a hand piece. I love doing fillings, rubber dam, crowns, that stuff I love, but I’ve dedicated like Mondays, for example, for me are my TMD days because I get great enjoyment fulfillment. I’m treating TMD, but I still, I just love dentistry. So I don’t want to limit myself just TMD and the way I got into TMD Suzie is when you start learning more about occlusion, the foundational thing about occlusion is, let’s assess the joint health. And I started to feel more confident assessing the joint health. Then I started to realize, oh, this is health and this is not health. And then how can I help my patients become healthy enough to have the restorative care? And then I started to get some early successes, early wins, which really gives you a great boost. Patients who tell you their headaches after 11 years are finally gone. Patients who have a positive outcome and you think, wow, this is really, really great. But then you get into the deep end of treating chronic pain patients. And wow, you have to like pain is such a fascinating beast. And I’ve had some really great learning experiences from lots of mentors. And I’m really excited to have the chat with you because what I told you in that email, Suzie is something I truly believe is true, which is I think TMD care, even today is like the Wild West. in the sense that clinicians all over the world, and I see this a lot in the states, no offense to anyone right, but claims that are made of certain therapies and whatnot but we don’t have any evidence to back it up. This is also partly to do with the lack of evidence and maybe there are good treatment modalities but they’re just evidence isn’t there yet and we need to figure out as a profession, how we can rectify that, how we can get that research. But what do you think about this analogy of the Wild West and how it applies to TMD? [Suzie] 100% agree with you. And I say that as well. I’m from wild, wonderful West Virginia. And I can tell you the things that people have been doing for the past 30 or 40 years that have not been working or have caused patients to not improve and unfortunately, sometimes get worse, are things that we have to accept as a profession that when you know better, you need to do better. And just because someone has fancy equipment doesn’t mean that it’s evidence based. So, I completely agree with you. And that’s part of my message. I went from specialist to specialist. Even when I was in dental school, they used to send me around to all the different departments because they thought it was funny that when I opened my mouth, it would swing over to one side and they would say, Oh my goodness, look what Suzie can do with her jaw. But the truth was that I was very badly injured in that accident and did not really realize that. But I didn’t make the connection. I had bleeding in the joint space. I had, both of my discs were very anteriorly displaced. And I went through a lot of occlusal guards in the nightstand drawer, different treatments that people gave me. And I was a dentist who really felt like I understood this. So, thinking about a patient who doesn’t have that background and that knowledge, sometimes they just get passed from provider to provider before they find someone who is knowledgeable and is also willing to say, there’s still a lot that we don’t know, so let’s be conservative in our management. [Jaz] I feel like you’ve taken the words exactly from my mouth when I say to my patients. So I’m a big fan in dentistry overall, not just TMD, but in dentistry, I’m a big fan of showing patients my working out. So when I recommend a plan, I always say, okay, this is based on the following facts because you have decay in this main teeth and you may want orthorhontics in the future. Therefore, I thought this might be the best for you because X, Y, and Z. So when it comes to TMD, because we lack a lot of truth, I think, okay, because we don’t know which way you’re going, I think here’s the stuff that’s safe to do. That’s conservative as a first line before we escalate or do anything that’s irreversible, that sends to me. And you know what, Suzie, sometimes I feel, sometimes I look at all the claims that are out there and clinicians that are perhaps a bit more aggressive and I think am I missing out in helping my patients? Am I missing out in serving my patients? Because perhaps I’m being a little bit too conservative. Those thoughts do cross my mind. But I think it all stems down to, you mentioned the research, the evidence base. Where are we at in terms, cause you mentioned you do some research, where do you think TMD research is at both in terms of quantity and quality? [Suzie] So, first of all, let me say, I don’t think you should change your approach at all because conservative is safe and effective, and when we have to move to things that are a little bit more involved, at least we have tried the things that will not harm the patient, things that are self management type of thing. In terms of research, that’s something that I really, really feel strongly about because last year in the U. S., we doubled the amount of dollars that we were spending on TMD research. So we had a whopping 35 million dollars of research dedicated to TMD as opposed to 2. 4 billion dollars for diabetes research. So the problem is definitely a quantity issue and then the other problem is that we work in silos Unfortunately, TMD is kind of in a no man’s land where there are people who say dentists shouldn’t even be treating this. It’s multifactorial. We need physicians to treat it. But physicians say, I don’t want anything to do with this. This is the only joint in the body that isn’t treated by orthopedists. When we’re doing our research, I strongly, strongly feel that we need to break down those silos and look at this from an orthopedic standpoint, because we’re talking about joints. So we’re not talking about a little click that has something to do with the way our teeth fit together. [Jaz] Well, there’s obviously a major funding issue there. But even when we look at the research, I draw comparisons to the research in even just occlusion, right? There is very little that we recommend in a practice of occlusion and full mouth rehab and that kind of stuff that is very well evidence based. And I think part of that issue is that there are so many of the confounding factors like tooth contact time during the day. Stress is variable in individual, the perception of pain varies by a factor of four individual to individual. Differences between men and women difference between someone with a long ramus height versus a short ramus height like because there’s so many variations in an individual and also of course trauma history everyone’s trauma different type of trauma because I always thought there’s so many variables that we may never ever get the type of research that may be possible in other realms of health care. And that is sad, but it’s also something that we need to work with that to develop some sort of trials and protocols that we can perhaps draw some conclusions. Would you feel that way as well? [Suzie] I do. I completely agree with you. I think that besides the lack of quantity of research, there’s also a problem with researchers really having yet unraveled the etiologies and the pathophysiologies of TMDs or meaningfully translating that research into improved clinical practice. [Jaz] Would you mind sharing your journey, Suzie? Because I mean, I know that’s n equals one case history, which is the lower down the pecking order, but I would love to know where you are, if you don’t mind sharing, where are you at now with your TMD with your chronic pain? Is that still an issue for you now or is that something that you are managing well now and what steps worked for you? I’m not saying I’m condoning this for everyone. If a PMD patient is listening or watching this doesn’t mean that just because it worked for Suzie it’s going to work for you. You have to be mindful of that. It has to be an individualized approach. But tell us about what helped you? [Suzie] Absolutely. And I like that you said, it’s an individualized approach because my situation is very different from someone who maybe developed some problems from having a dental procedure where their mouth was open wide for a long period of time. And everyone’s path is a little bit different. So I always emphasize that too. Now, my situation was that I was 19 years old when I had this major macro trauma, so outside the body trauma. And it was during the time that treatment for the kind of condition that I had was very controversial and there were implants that were being used that later were taken off the market at the pro class implant because pieces of Teflon would actually break off and go into the patient’s brain. So there was open communication and giant cell body reactions. So when I started my journey, I was just constantly told, avoid surgery at all costs. Even though eventually, someday you may end up needing surgery, which did happen because eventually my joint ankylos, so I had no translation when I opened my mouth, I just had a very, very tiny opening. [Jaz] This is also known as a anchored disc phenomenon, right? Is that the same thing? [Suzie] No, so mine was a little bit different. What happened was the discs were completely gone. They were anteriorly displaced. I had two surgeries to have them reattached, like repositioned and attached, but unfortunately the surgeon that worked with me did cause more problems than he fixed because he did not follow an evidence based protocol afterwards. And so I was definitely emotionally traumatized by what I went through. I wasn’t allowed to pick my baby up for three months. He was 14 months old at the time. I wasn’t allowed to chew for over a year. I wasn’t allowed to sleep in a bed for four months. I had to sleep in a recliner sitting up. I was only allowed to talk for five minutes per hour. These are not evidence based protocols. This was the surgeon’s idea of how he thought that I would improve, but I was wearing an appliance that actually atrophied my muscles because I had no lateral or protrusive excursions with the appliance. So after two surgeries that probably set me on a faster road to what eventually happened in 2019. I started the process of getting TMJ implants, so custom implants. [Jaz] Is that a total joint replacement? [Suzie] Total joint replacement, yes. And so the right side was so bad that I had to have that surgery done in stages. So for a period of about three months, I had no joint on the right side. And then I got the custom joint and then the pandemic happened and I went several years before I was able to get the left side done. I now much better than I’ve ever been, but I always tell people it’s unrealistic with chronic pain patients to think that there will be a day that you go to zero in pain. I don’t know what it’s like to not be in pain, but I used to be- [Jaz] So you’re still in pain now, would you say? Like, would you, if I was to, yeah, you’re just about to give some scores now. Lovely. Please. [Suzie] Yeah, I would at a nine probably for several years and I would say these days I hover around three probably. Some days might be a little bit better but there’s never a time that I’m not in pain and part of that is because when we have pain for so long it can become a central nervous system issue. So when we have that central sensitization our brain interprets non painful stimuli. as painful. And so I’m doing very well taking a medication called low dose naltrexone, which has helped me quite a bit. And I did a lot of physical therapy. I’m very mindful about my sleep hygiene. I understand that I have to modify the way that I do things just so that I can be productive and that I can help my patients and be there for my family. [Jaz] I think what you’re saying is so hard hitting, and I think it’s almost like to tell someone, look them in the eye and say that, there is no cure, right? Essentially you said that you went from a nine to a three. You have come to peace that you may never be a zero, right? And I think the first time a TMD patient may learn that, it’s not a nice message to hear, right? That you can dial it down and there may not be a cure. And I think we’re chasing after this elusive cure. So maybe part of education therapy and then also cognitive behavioral therapy, how your coping mechanisms, did you have any psychological interventions either you’ve had or that you recommend to patients? [Suzie] Yes, absolutely. So when I was in dental school, I was very depressed and I had not made a connection between the fact that I was in pain and the depression. I really just thought that’s what happens when you’re a student. You’re studying all the time, your social life has to take a backseat, you’re tired, all of these things, I did not really make that connection. It wasn’t until years later that I came to understand that anxiety and depression go hand in hand with chronic pain and I really recommend this triad of care for TMD patients. So a lot of times you hear people say there’s a bi directional link between mental health and medical conditions or a bi directional link between medicine and dentistry, but in my mind it’s not bi directional, it’s a triad. So there’s medical, dental, and behavioral health that all have to go hand in hand to treat the whole person. And as I talk about in my TEDx talk, we can’t look at one part of the body, in one exam room and say this has nothing to do with another part of the body or with our mental health. It’s all related. We’re all one person and if we take that more holistic view of things, we can have better outcomes for our patient. I do believe that CBT, Cognitive Behavioral Therapy, is an excellent treatment modality for anyone who’s dealing with TMD pain and that’s something that I’m incorporating into an interdisciplinary practice that I have started with some of my colleagues. So we have behavioral health specialists, physical therapists, speech pathologists, primary care physicians. And we’re getting ready to add a nutritionist and a nurse practitioner to the team. [Jaz] Amazing. Finally, as you said, Ted Talk, putting the mouth back in the body, right? Putting the joint, putting the head back in the body. And that’s wonderful. I think an ideal TMD sensor, which is what we need. We need centers, right? We don’t need solo practitioners. I work very closely with a physical therapist and I have people to refer to nearby, but to have everyone in one house. Wow. In one setting, ideally is what we need to strive to. Moving the conversation more towards perhaps clinical and also some of the conclusions that are safe to make. So for example, there was a recent article in, I think it was the British, it might’ve been the British Medical Journal. And it looked at the evidence base and actually the evidence base suggested that occlusal appliance therapy was the thumbs down. And there’s certain things that thumbs up and occlusal appliance therapy was thumbs down. A lot of what I do is occlusal appliance therapy anecdotally. And also for my audit, I get good success. Is it 100%? No, but it’s reaching, 70%, 80% basically. So what do you think is a good first line approach? Now, obviously there’s a very difficult way to address this topic because TMD is an umbrella term and we have to just take a step back and appreciate, okay, what are we dealing with? But then in terms of moving away from the wild west and going to like a, what is a safe zone? What are the proven evidence based effective therapies that are good to try as first line? If you could help me understand that and our listeners understand that a bit more. [Suzie] Sure. So the things that we do now are that self management is very powerful. Things that don’t sound that impressive, like hot and cold therapy that is safe. It is effective. Things like physical therapy. As you said, I feel my physical therapist, she has magic in her fingers. And I always say she makes me look good because patients come in and I tell them, I really want you to see my physical therapist and they come in the next visit with a huge smile on their face and say, I’m already starting to feel better. I’m understanding that I have exercises that I can do. I give them lots of acronyms. I’m an acronym girl. So I tell them TATU, which stands for Teeth Apart, Tongue Up. So during the day, as much as possible, try to keep your teeth. away from each other so that you’re not clenching. I tell them we want you to do the three S’s, which are softer food, smaller bite, slower chewing, things that put less of a load on the joint. We do sometimes need occlusal appliances. But recently, I was privileged to be part of a group that wrote a paper on the evidence that we now have regarding occlusal appliances, which types are safe, which types should be avoided, who needs one. In the past, we kind of just thought, oh, you have a click, you have a pop, you have pain, here you go piece of plastic, right? It’s not that easy. It’s not that simple. So there are times when an occlusal appliance is warranted, but unlike we believed in the past that once somebody had that appliance, they needed to use it for the rest of their lives. Now we know that an occlusal appliance can just be something that’s used for the short term. While we’re establishing occlusal harmony and our goal is orthopedic stability of the masticatory system. We can also use NSAIDs in certain cases can be used, so non steroidal anti inflammatory medication. I’m a fan of topical applications, the topical creams that don’t have a lot of side effects and the patient can decide when and how much to use. And I am very, very much against things that are irreversible until we have tried the conservative management. So even though I’m a surgery patient, I don’t recommend surgery for the majority of TMD patients. I also don’t like to see patients come in who have been told, we need to put a crown on every tooth in your mouth. I know that can be unpopular. There has been a battle between the occlusion camp and the non occlusion camp when it comes to TMDs, but they came together to have what we call a meaningful discussion, as my friend, Dr. Jeff Okeson said, and that meaningful discussion looked like the battle of Braveheart. Yeah. So we have to understand that anytime we change something, we’re introducing a variable that may be difficult to piece out, if things have changed in a way that’s not easy to go back to what the patient had before treatment. [Jaz] Two modalities you haven’t mentioned yet, which also quite controversial and maybe higher up in the, I use a pyramid. So at the bottom is where we start the foundations. It is self-management. It is physiotherapy or physical therapy as you call it, there basically, and much, much higher up, the plans and much higher up box room toxin and a higher up is like adjustment orthodontics, that kinda stuff. So tooth adjustment and orthodontics. Where are we at now with the evidence base? [Suzie] Okay, so I will just start by saying I am an orthodontic instructor also, so I do a lot of orthodontics and I do orthodontics on patients who are stable. Orthodontics for me is not something that should be a modality to address a TMD complaint. If a patient has some TMD issues and they stabilize and they have an unstable malocclusion, then orthodontics may be necessary. But in the same way that we don’t move teeth in the presence of inflammation, when it comes to periodontal health, we tell our patients we can’t start ortho until you have no deep pockets, no areas of bleeding on probing. We don’t want to make the periodontal condition worse through our orthodontic treatment. The same thing is true of the joint. So if we have someone who’s coming to us and saying, I heard that if I get braces or Invisalign or aligner therapy, my TMD should improve or go away. What we know from evidence is that orthodontics does not cause temporomandibular disorders, but orthodontics also does not cure temporomandibular disorders. And when I say this, sometimes people tell me you are dead wrong, but I actually have research to support that. Now, the caveat is that all of the research was done on growing patients and also in a very controlled environment in universities where the orthodontics was at a very high level. So when patients are growing and adapting, the joint is a very adaptable joint. And if we’re careful with it and we don’t move teeth too fast, the body system can keep up with that. But with patients who are not growing and with sloppy orthodontics. We do see problems and we have to understand that that’s very similar to, let’s say someone did an MOD composite and they hit the nerve and now the patient has to have a root canal. Do we say the decay caused the root canal? No. What caused the root canal was the fact that overtreatment was done or incomplete or incorrect treatment was done. So we have to understand that with orthodontics, we should never make promises to patients that we can’t keep. And I would never tell a patient, when you’re done with ortho, you’ll be cured from your TMD. But I can tell them that there are instances where fixing their unstable malocclusion could be helpful. A lot of people are walking around with stable malocclusions, right? There are lots of people who have crowded teeth, they have class 2, or maybe they have spacing between their teeth, all kinds of different situations that aren’t the ideal occlusion, but they aren’t having issues because they have enough contact on enough teeth, they’re able to chew well, they’re not heavy loaders. They don’t have a lot of parafunctional habit, and because of that, they are able to walk around without the perfect straight smile, but then the people who have malocclusions that are unstable are going to have instability in the entire orthopedic masticatory system. If that makes sense. [Jaz] It does. And I’ve just got some more follow up questions. It’s a very hotly debated topic. This is the kind of stuff like in occlusion camps, people get into fist fights. So it’s really sad, we should really be open dollar, like even some things you said there, I respectfully would say, you know what, I’m slightly, I’m not in the opposite spectrum at all. But for example, do I think orthodontics? I think you made a good point that, okay, if it’s sloppy orthodontics or perhaps some features weren’t accounted for. Could that lead to temporomandibular disorders in the future? Possibly, and whilst the evidence is in support that there is a true link, I’m open that, okay, this could be possible. We just need more research. I mean, the example I can give you is when orthodontics is finished and the orthodontist may not be someone who’s actually checking the masticatory health. So the patient actually isn’t like the patient’s one side temporalis is firing, but the other one isn’t. And then, but they’ve got nice straight teeth. Okay. And at macro level, the teeth look like they’re hitting together, but at a micro muscular level, things are unbalanced. So there’s compensation that has to happen. Now carry that forward many years. Plus the patient’s poor adaptive capacity. plus the patient’s hormonal, whatever. Like, I’m not saying it’s just orthodontics, but orthodontics contributed to various other factors may be a part of it. But I agree that doing orthodontics, I like your perio analogy that we don’t move teeth in the presence of inflammation in the periodontal ligament. So we don’t do an active perio, no ortho. I agree, active TMD, whereas some colleagues will say, no, no, no, you have a deep bite. We need to fix this to cure your TMD. I don’t adapt to that. There’s a really good lecture I saw by Daniele Manfredini once, who looked at different occlusal features. And he said, actually, deep bite is protective of TMD. We look at the odds ratio, right? That was actually fascinating. We actually look at it. So malocclusion definitely does not equal TMD, but potentially orthodontic treatment that, like you said, may be sloppy, may in the future. But it’s not that itself is many other issues. I have a young patient who came in and his diagnosis was unilateral disc displacement without reduction to our colleagues who are younger colleagues who don’t know that sound like gobbledygook. Okay. So on one side, okay, let’s say the left side, the disc is out of place and as the patient’s tries to open up, that’s not coming back into position. So typically you’d find reduced opening, especially if it’s acute. And then the jaw kind of deflects that side on opening. So, he was in a lot of pain, a lot of issues and not able to play basketball, not able to open big, a lot of issues and pain. And then therefore, what that affected was it also affected his occlusion in a negative way. So we often think, as Jim McKee says, think not about how the occlusion causes TMD, think how the TMD causes a change in the occlusion. So because the disc was out of place, his bite was completely out of kilter. It wasn’t balanced. There was no harmony. Use that wonderful word harmony. So a patient with a little harmony, they bite together and their muscles are not there. You don’t feel that healthy clench, right? You don’t feel that masticatory system firing. And so with him, I gave him an occlusal appliance to get the muscles happy. Once his pain decreased, And he was happy. We found that, okay, without the appliance, he’s actually in pain again because the jaw shifts again. That’s the patient I’ve referred to orthodontics. He’s happy to take a break for a couple of years because he’s happy with the appliance at the moment, but because he’s not able to actually physically bring his teeth together, there’s complete malocclusion there, and therefore, there’s no harmony. Basic, a very foundational level, that kind of patient may benefit from orthodontics. I think we can agree on that. And then the other thing you mentioned, Suzie, I just want to highlight to make it tangible is you mentioned that occlusal appliances for the short term may have a role. And sometimes when I say this to my patients, I give them an appliance, okay, they wear it. And then six months has gone, they’re feeling better. And I say, okay, now you can stop wearing it. And they look at me like, no, no, no, I need this. But I think most TMD patients that I’ve seen now, they’re not necessarily the severe bruxist. The severe bruxist, they often are able to withstand all the load and they have an adaptive capacity that’s brilliant. Their teeth have taken all the damage, their joints seem to be fine, right? You see lots of people with lots of wear, but no joint issues. A lot of patients that I see, they have complete unharmonious fight together. The muscles are all over the place, they’re dysfunction. You give them an occlusal appliance, their muscles start firing better. Okay. And then you take off the appliance and the muscles are still happy. The muscles are able to adapt to their own bite again. And then we wean them off. There are some schools of thought though, Suzie, that actually, if you have a disc displacement, that absolutely needs correction. Like you need to have that corrected. Whether it’s an anterior repositioning splint, or through surgical means with disc plication. So where are you at on this debate of on the disc or off the disc? Do you think it is insufficient treatment to help someone’s pain, but they are still off the disc? [Suzie] The latest research that I have read is going away from displacement being an important issue. I know a lot of people don’t like to hear that because that’s what they’ve looked at for so long. There is feel like the disc needs to be recaptured, but the latest research is telling us that the position of the disc is not as important as we thought. The body that used the word adapt several times, and adaptability, the body does an amazing job of adapting. And we do know that sometimes patients will be in a great deal of pain when they’ve had an anterior disc displacement until the body forms what we call a pseudo disc, because the innervation is on that posterior attachment. When the patient is functioning on the posterior attachment where the nerves are, that’s very painful. But after a period of time of pseudo disc conform, which is kind of like when we get a little callous on our, let’s say we cut our hand and it’s painful while the cut is open, but then when a little, callus forms there, it’s fibrous and it’s not painful anymore. So I don’t like disc plication. It didn’t work for me in the two surgeries that I had. The second time I had a disc plication was going to my physical therapist and she was out of town and another therapist came in to see me and was too forceful and the disc placation surgery failed within seven months of having the surgery which was terribly disappointing, right? So the disc was out again and the surgeons that I know who are very, very experienced will say it’s so common for that to happen. You can put it back where it belongs. You can even use my peck, anchors. But if the disc goes out again, then what was the point really of recapturing it? And so as you said, this is a hot topic. There’s a lot of controversy. I think that part of the problem with TMD is that people spend more time arguing about things than they do looking for result or evidence that we need. I think you made a really important point, Jaz, when you said that the patient that you mentioned, he was at a point where he was stable, right? And that’s my metric for doing orthodontics. I don’t do orthodontics while a patient is unstable or in a lot of pain when the TMD is their primary complaint. But if a patient has some TMD symptoms, but they’re pretty well controlled. That’s kind of like doing ortho on a perio patient. If the perio is stable, we can move forward with ortho, and the ortho can actually improve the perio condition at that point in time. So I love that analogy because I feel it’s easy for dentists to understand, and I think that we just have to, like you said, you have to start with conservative modalities. I do like injections, just to go back to that. I do a lot of trigger point injections for myofascial pain with referral, or having these taught bands of muscle fibers in the masseter, the TMJ, a lot of times at the insertion of where the temporalis inserts at the coronoid process. And I do Botox for patients. I’m doing less and less Botox now, but when patients have comorbid migraine, Botox is very helpful. Or when they have trismus, when they have the big, huge masseter muscles. So there are lots of things that we can do for our patients. We just have to make sure that we’ve started with an accurate diagnosis because TMD is, as you said, not just one thing. It’s an umbrella term for 30 different disorders. So the first thing we have to do is come to an accurate diagnosis. So we know what we’re dealing with, and then we have the tools in our toolbox to deal with that. [Jaz] You mentioned about your experience with getting disc plication. Jameson Spencer once taught me that it’s like a, it could be the peanut in a salad and then suddenly it could be off the disc again. Like the stability, there is concerns about the stability moving forward with that and therefore, be careful it’s no silver bullet. Now, interesting question. When you said you were at a lowest point, you were a nine out of 10. Now you’re a three out of 10. When you had the displication, was that a curative for you at the time? Did that help a lot? Or where were you at in that regard? Because a lot of people will claim that, ah, yes, have this treatment modality. It will be the cure. [Suzie] I have never been out of pain since I was 19 years old. So I know everyone is different. I had one patient that I referred for that surgery that did very, very well for several years, but she’s also now in pain again. She’s also looking at possibly another surgery. And I know patients who have had 20 surgeries. So I think the problem is they say TMJ surgery is like a potato chip. You can’t just have one and that’s what’s very unfortunate because when patients get desperate, they want to be out of pain. And if the surgeon says you need surgery, they’ll say, let’s do it tomorrow. And so I do think we have to be very, very cautious with over treatment or treatments that could end up progressing, causing the disease to progress more rapidly than it would have naturally. And when there are patients who have acute TMD who could go back to normal and it could be like it’s a college student who’s under a lot of stress and during the time that they’re in school they have this displacement with reduction and then when their stress levels decrease, their TMD symptoms go away. But when things become more degenerative in nature and more chronic in nature, we cannot reverse it. Just like to go back to periodontal example again, when we have gingivitis, we can do things to get rid of our gingivitis. We can brush and floss and water pick and get our teeth cleaned and be more mindful of the foods that we’re eating. And gingivitis is reversible, but once it becomes periodontal disease, what we’re trying to do is slow down the progression and keep things from getting worse. And that is a very good analogy for me, in my mind, of how things work with temporomandibular disorders. Once somebody has degenerative joint disease in the joint itself, we don’t put them back to a state of complete health again, but what we try to do is maintain mobility for as long as possible. Keep them comfortable and keep the joint lubricated so that we don’t get the situation like I had where you couldn’t tell the difference between my fossa and my condyle. [Jaz] Wow. I mean, I think that’s another, continuing this analogy is really wonderful because in that scenario where you do have that patient who’s maybe lost 50% bone, but we know that, okay, with really good oral hygiene, regular care. We can maintain that and slow it down so that they’d have to live until age 200 for them to lose all their teeth, for example, to slow it down a rate whereby they can outlive their teeth, basically, which is what we want. And so when you apply that to a joint, it’s about good practices early on. I strongly feel that early treatment. So we as clinicians listening to this young colleagues listen to this, knowing about diagnosis and early intervention to stop it becoming chronic. is something that should be, I think, foundational. I also just want to ask you to go back on to hotly debated orthodontic stuff. I have several colleagues who are dear friends of mine, and we have slightly different opinions, and I’ll share them with you. I will not suggest orthodontics without first doing occlusal appliance. It’s just my way of doing it. Only if I can get them out of pain, then also have cosmetic concerns as well. Well, does that help me to suggest? Okay, we can do the line therapy now that you’re not in pain. We’ll straighten your teeth and I’ll try and set it up so that everything is harmonious and very rarely do I go down the orthodontic pathway. Whereas a lot of my colleagues will say, okay, I can see that your bite is locked in. Like you have muscle pain because you’re trying to grind your teeth at night. Your teeth are in the way, your muscles are going crazy. We need to do some orthodontics to give you a bit more over jet to give you more this. What do you think about that? Because logically speaking, some of the characteristics that you give in the splint, these colleagues of ours, they want to give it through the medium of teeth. So they try and create the occlusal appliance through the teeth. I’m too chicken to go through that step because I know pain is a funny beast, right? So, but what do you think about this kind of thought process? [Suzie] I agree with you, Jaz. I need to clarify something I said earlier. I treat a lot of patients orthodontically, but they are not my TMD patients. So those are the only two things I do in dentistry anymore because of the pain that I experienced even when wearing lube, it’s not feasible for me to do clinical dentistry. But because I know how important it is for us to treat the temporomandibular joints conservatively as much as possible, I don’t recommend ortho for many of my TMD patients. I will do it after we’ve treated and stabilized the joint. If I think it’s absolutely necessary, if it’s not absolutely necessary and it’s just for cosmetic reasons, then I let the patients know we have to tread lightly. We have to be careful here. There’s a difference between having a class one occlusion, straight, white, beautiful teeth, which is what society wants us to have, and what is healthy for us as an individual. So we really need to look at the patient, I come back to this phrase so often, the orthopedic stability of the masticatory system. That’s what’s important. We need to have joints that are happy as well as muscles that are happy, right? And we have to think about that so that what we’re doing for the patient is really keeping everything in balance and harmony. And there are people who have very strong muscles of mastication. Our brachyfacial patient, those are patients who are their muscles will become unhappy very quickly. We need to think about more than just the teeth. We need to think about their adaptability, and we are learning more and more about adaptability through the COMT gene, which I am not sure if you’re familiar with, but at some point in the future, we’ll be able to have our patient give us a little saliva sample, and we’ll be able to determine whether they are highly adaptable. Or if adaptability is a very big problem for them and the patients who have a lot of stress in their lives or who are anxious, nervous, have a lot of comorbid conditions, they may not be good candidates for ortho. So we have to choose the patient wisely, and we have to understand that occlusion is one of several possible etiologies. Stress is another etiology that we believe has a lot to do with the patient adaptability. And we have other things that we have to keep in consideration, such as how heavy of a loader the patient is. Do they have a lot of parafunctional habits? Are they grinding their teeth, biting their fingernails, chewing on a pen, doing things that, introducing non nutritive things into their mouth, you know? So those are all things that have to be considered. And then we also need to look at their overall medical health. If you have a patient who has temporomandibular disorders, it’s very likely that they have other coexisting conditions. [Jaz] IBS, fibromyalgia, depressive illnesses, unfortunately. [Suzie] Yes, there are 10 recognized chronic overlapping pain conditions. And beyond those, we see things like Ehlers Danlos syndrome, a hypermobility issue, and those things have to be considered. Before we just jump in and say, I know how to give you straight teeth. [Jaz] I’m asking some tough questions here. I hope you don’t mind. You’re doing great. I’m really enjoying talking with someone who’s very experienced in this field and also thinks similar to me in terms of conservatism, but also I’m happy to have a healthy debate here. You say orthopedic stability. Now, one person who’s also taught me is a Patrick Grossman, who me and him, we don’t 100% agree, but I respect everyone who’s taught me something. But he would say that to have orthopedic stability, you need to be on the disc. So what is orthopedic stability look like for you? [Suzie] In my understanding, and I follow the teachings of Dr. Jeff Okeson very closely, and my understanding is that what we need is for the joint to be seated fully. And I don’t like the term centric relation because centric relation has had 30 definitions since I’ve been a dentist. So instead of saying centric relation, I just like saying having the joint seated with proper support with the condyle in the fossa with the muscles also in balance. And the question of whether or not the disc needs to be seated there is something that even though it has been debated a lot, we’re starting to see good evidence. We’re starting to have research supporting the fact that the position of the disc is not as important as we once believed. And so, even though we have patients who have discs that are either anteriorly and medially displaced, which is most common, it’s very uncommon for there to be a posterior displacement of the disc. We have to think about how that patient’s body has responded to the changes if the disc has been displaced. Some people will adapt beautifully and some people will not. And so it’s really about the individual patient, whether or not they have a full range of motion, if they’re able to open at least 40 millimeters, maximum incisal opening of at least 40 millimeters. If their condyle is rotating and translating, then if that’s happening without pain, then that patient is okay, even with an anteriorly displaced disc. When there’s pain, we need to address the source of the pain rather than the site of the pain. And that’s very strongly supported by research. [Jaz] You mentioned someone who I highly respect, Jeff Okeson, reading his book, listening to many of his seminars. I get the impression that he’s not a big proponent or advocate of anterior repositioning. It’s like he’ll do them, but it’s not a mainstay for him. Whereas other clinicians I’ve learned from, they use that very heavily. And I’m in this phase of my career now where I’m a sponge that has absorbed a lot already. And I’m really just trying to apply this philosophy of listen to everyone and do what feels right to you. And right now what feels right to me is be conservative and escalate. But I’m also over the last few years as the kind of cases I get referred are more and more complex. There is a time and place where I’ve had to use mandibular advancement or anterior repositioning splints basically. Where is that in terms of your protocols? Is that something that you use as well? [Suzie] So to be honest, even though I was a part of this writing this paper about occlusal appliances, and I know that there is a place for anterior repositioning appliances, I’m not a big fan of them because I have seen clinicians who don’t understand how they work or patients who are not compliant. And with an anterior repositioning appliance, you need both of those. It’s very, very important that you don’t try something like that on a patient who could be lost to follow up, right? That patient has to be really committed. And the clinician needs to know how to adjust the appliance when the appliance has done what the goal was of recapturing the disc or making the patient more comfortable, allowing them to have a greater range of motion. But in my hands, it’s not a super useful tool. I really prefer a plain splint, a hard acrylic splint with one point contact per tooth. That just works very well for me and I’m not saying that other people are doing something wrong by using an anterior repositioning appliance. I would not recommend an NTI because I’ve seen too many situations where an NTI has caused in the anterior open bite. It’s irreversible when that happens. And then we do have to do orthodontic treatment. I, sometimes- [Jaz] I just want to point one thing I can share with you is that I’m a big fan, not of the NTI specifically, but anterior midpoint stop appliances, but applied in a way that covers all the teeth. So I give them that benefit of reduced muscle contraction. And that seems to help a lot of my patients are primary muscular brachyfacial and another point is where a lot of patients, I will wean them off the splint. Cause I don’t think it’s a lifetime thing. There is a cohort of patients who are are pathological bruxist and they’re causing microtrauma. And for those that are more likely the ones that when they sleep, they’ll wear the appliance because they will end up destroying that appliance. If they don’t destroy the appliance, the load’s going to go somewhere else. What do you feel about that cohort of patients who most severe bruxist who wear appliances? [Suzie] Yes. So I was going to say, just in terms of the NTI, there are times when I’ll make a little NTI in house. I have a little kit where you just put some blue mousse and just try it while the patient is in the chair, let them wear it for a few minutes and see if it helps their headache. I’m fine with that as a diagnostic tool, but then that’s the time when we realize we’re probably dealing with headache as the primary diagnosis, and so then we need to address the headache first. Now, in terms of bruxism, there’s a really great new tool. You mentioned Dr. Daniele Manfredini. He and Dr. Stephen Bender and a few other doctors came up with a Brux Screener, I believe it’s called. We might have to look that up. But they’ve done a lot of work on looking at bruxism as we used to call it nocturnal bruxism and now call it sleep and awake bruxism because you can be asleep during the day too. So, what we’re really talking about is not bruxism that happens at night, but bruxism that happens while we’re sleeping. We definitely do need to prevent microtrauma when patients are sleeping. We can use occlusal appliances for that. We can also sometimes give them injections, like if we give them some botox in the masseter and we’re reducing the intensity and the duration of the clenching, that can be very helpful. The goal is to reduce the bruxism, right? And I think that the problem is that a lot of patients have been told you’re getting this appliance to protect your teeth, which we do need to protect the teeth, but we are actually trying to stop a habit that is harmful. So it’s the habit that we’re trying to work on. I don’t know if that’s clear. [Jaz] It’s clear, but do you feel as though bruxism is something that we can stop? Because here’s my viewpoint and then happy to share different viewpoints. But bruxism is like if you find the trigger for that bruxism. Great. But often that’s very, very difficult to do. Whether it’s smoking, whether it’s caffeine, whether it’s their stress levels for those patients who I’ve been following up for occlusal appliances for years and I color them in, I do the parafunctional analysis. I’ve also been using the brux checker on my patients. A really cool little thing they wear and they come in and they rub away the ink and stuff. So even if I did a full mouth rehab for restorative reasons and they have this, or they have an appliance and they have some botox as well, there’s still a degree of bruxism that happens. Yes, it’s a less amplitude, less muscle contractions, but I have not found an effective way yet to stop my patient’s bruxism. Is there anything that you found that helps decrease bruxism? Like if my patients come back to me, if I didn’t tell them the bruxism still happening, they say, Oh yeah, my bruxism has stopped. But actually their pain has stopped. The bruxism is still continuing. They’re just now bruxing in a more dentally beautiful way. As I like to say. [Suzie] Dentally beautiful. I like that too. Well, I know that there has been some research about physical self regulation as a tool for decreasing stress. And when stress is lowered, it seems that sometimes that can help with bruxism. There are patients who are always going to brux and there are patients who are going to need that appliance to protect their teeth. And I do agree with that. Anecdotally and empirically, I’ve seen a lot of patients who have told me, I used to grind my teeth. Like when I was a students or when had a very stressful job and my sleeping partner tells me they don’t hear me grinding my teeth anymore. My stress levels have gone down. I don’t think that I currently grind my teeth. And someone I can’t remember who said it, but someone gave me a really good analogy. They said when you identify wear on a patient’s teeth. That’s like an archaeological finding. You know, like it is telling us we see there is evidence that the patient at some point in time in their life was a bruxer. But do we know? Unless we sleep beside them and watch them while they’re sleeping, do we know that they’re still bruxing? So a lot of it comes down to the patient report. And I like to ask them if their muscles are sore when they wake up in the morning. I ask them, when is your pain worse? Do you feel comfortable when you wake up and then your dog gets tired as the day progresses? Are you waking up feeling like? Oh my goodness. I was running a marathon with my masseter last night. [Jaz] I think that’s stiff in the morning as well. Also noises in the morning where you get clicking in other times, basically headaches in the mornings could be a sign as well. I think we’ve covered a lot there, Suzie. Look, I have asked you some tough questions, lots of questions. And what I like is that. You answered everyone with such a nice balance, respecting the other side. And I think we need more clinicians like you that respect all the different views. And so well done for being so respectful to all the different views out there. I know that you do some teaching. I know you’ve got a course coming up. I’d love for you to plug it because for me, it’s all about helping dentists become better with their TMD patients and how we can serve our patients. So please tell us about your hybrid event. Suzie, tell us more. [Suzie] Okay, great. So I teach for an organization called McGann Postgraduate School of Dentistry. It’s located or headquartered in Orange County, California. We have locations all around the world, and we have a sister company called Progressive Orthodontics Seminars, and I’m going to be giving a course that I wrote called 21st Century TMD Protocols, which is a two day course. It’s going to be a hybrid event, so it’s live in Aliso Viejo, California, and also via Zoom, and I go through pretty much everything you could imagine from review of anatomy, the history of what we have done, what we’ve learned from the things that haven’t worked for us. I go through how to do a comprehensive initial exam for doctors who aren’t comfortable treating TMD patients, letting them know at least how to do a good referral, how to work with multidisciplinary teams. I share some case studies and really fun exercise where we watch a patient go to different video that was pre recorded, go to different providers, and then we analyze together what was good about each appointment and what could have been been improved. And how this relates to our clinical practice and it’s just full of practical advice and we do some hands on exercises, which for the people who are not in the room, you can still participate in the hands on exercises by just asking your girlfriend or your aunt or your brother or whoever is around, come over here and let me practice palpating your muscles so that I can learn if I’m doing it correctly. And so I would love to have as many people as possible who have listened to this podcast join. We’re going to offer you a 15% discount if you mention the podcast. And that’s something that is very near and dear to my heart because I wrote this course for patients like myself and for providers like myself. [Jaz] Wonderful. I just want to make clear. I have no financial interest in your course, but I do wish people join you to learn more. Anything we can do to learn more from different individuals, because your experience and background is so unique. I really love that. So I’ll put the link in the show notes. I think the date you said was 23rd and 24th of November, right? [Suzie] That’s correct. [Jaz] Perfect. Brilliant. So I’m going to guys, I’m going to put the link in the show notes. Please do reach out to Susie. I’m also going to put the TEDx talk as well. I’d love for you guys to watch that. Hope you guys like Suzie’s very kind style and the diverse background she has and the great people that she’s learned from. And I’m very grateful that you shared that with us on here. Suzie, thank you so much for giving up your time to talk TMD, some tough questions, but I think ultimately we’ve done a little tiny bit today to advance in the field of TMD. [Suzie] Thank you so much, Jaz. It was a great experience and I look forward to continuing our conversation. Jaz’s Outro: Absolutely. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. Let’s face it. There were some tough questions in there and this was a controversial episode. Especially if you’re in the sphere of managing TMDs some of the things that we discussed you may violently disagree with them. And that’s okay because we still don’t have the answers I hope we inch closer to the evidence base that we need. But in the absence of high quality evidence we do need to be cautious and perhaps sometimes guilty of being a bit too cautious. And certainly I’ve seen success from more aggressive therapies, orthodontics, various types of directive splints that bring the jaw in a certain position. But if there’s one thing that you take away, try and manage it early before it needs any of those more advanced therapies, let’s say. Make sure you answer the quiz if you want CPD. Protrusive Education is a PACE approved provider and the subject code for this one was 200 which is oral facial pain. Please do check out Suzie Bergman’s TEDx talk and I’ll put that in the show notes as well as any education courses from her. If you have absolutely no idea about splints and TMD and you really need a crash course, please do also check out splintcourse. com which is my course for those beginning in TMD and those who want to help protect their dentistry from that high force bruxist patient. And if you want to be able to do splints like stabilization, splint, B splint and the various types of deprogrammers, like I said, I’ll put the links in the show notes below and thank you so much for making it all the way to the end. I do want to thank my team. This one was produced by Gian and for the show notes, I think Krissel and Nav the CPD and the CE certificates, I thank Mari. And lastly, I thank you, the Protruserati who stick with us, even with these very geeky and niche episodes. Thank you. And I’ll catch you same time, same place next week. Bye for now.…
How far should you extend composite resin? When does edge bonding become a composite veneer? How do you decide where to finish the restoration? And most importantly, how do you avoid that dreaded yellow-brown stain line that can form on anterior resins? These are just some of the burning questions tackled in this episode with my guest, Dr. Mahmoud Ibrahim . We dive deep into the artistry and engineering of decision-making in anterior composites. https://youtu.be/_q2O57-Y-d4 Watch PDP211 on Youtube Protrusive Dental Pearl: use a zirconia primer which contains 10-MDP (e.g. Monobond, Z-Prime Plus) on the intaglio of crowns to enhance bond strength, even with conventional cements like GIC. This low-risk, high-reward tip improves retention, especially for teeth with limited height. Incorporating a zirconia primer can significantly improve outcomes without switching to resin cement. Interested in the Unchippable 2 Day Course? Click here to register your interest! Key Takeaways: Choosing between edge bonding or veneers is not a black-and-white decision. The height of contour is key in cosmetic dentistry. Seamless transitions between composite and tooth are pivotal. Aesthetic considerations vary based on individual cases. Material choice is influenced by patient risk factors. Layering techniques enhance the natural appearance of teeth. Patient previews are essential for managing expectations. Thickness of composite affects durability and aesthetics. Understanding angles is key to successful restorations. Not all patients require the same approach to bonding. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 02:43 Protrusive Dental Pearl 04:49 Personal Anecdotes and Health Goals 09:37 Anterior Composites: Edge Bonding vs Veneering 16:00 Importance of Finishing Composite Correctly 17:09 Understanding the Height of Contour 18:36 Importance of Layering in Dental Procedures 21:35 Choosing the Right Materials for Layering 23:56 Importance of Layering in Dental Procedures 27:14 Challenges and Solutions in Composite Layering 32:31 The Marshall Hanson Method 36:29 Mockups and Wax-Ups: Planning for Success 43:03 Treatment Considerations This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance . This episode meets GDC Outcome C – Maintenance and development of your knowledge and skills within your field(s) of practice. AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Direct restorations) Aim: To enhance clinicians’ understanding and decision-making in anterior composite restorations, focusing on when edge bonding transitions to a veneer, optimizing aesthetics and functionality, and minimizing common challenges such as staining and occlusal complications. Dentists will be able to – Understand the key factors that influence the transition between edge bonding to full veneers. Apply guidelines for minimum composite thickness and bonding angles to enhance durability and aesthetic outcomes. Identify high-risk patients and tailor material choices, layering techniques, and bonding approaches to individual needs. If you loved this episode, make sure to watch Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075 Click below for full episode transcript: Jaz's Introduction : How far should you extend your composite resin up a tooth, i. e. like when is it just edge bonding and when is it a composite veneer? Is it somewhere in between? How do you decide where to finish that resin up a tooth? And then how do you avoid that horrible stain line that can sometimes form on your resins anteriorly? Jaz’s Introduction: So that horrible yellow brown line that you see around a composite. And when should you layer like different tints and shades? And when should you stick to monoshade? Just one shade. I’m a one shade one, the kind of guy, right? When is it okay to do one shade? When should you be layering? And related to that question is when can you do free hand and when do you need a wax up to be able to deliver the right result? And something me, my guest Mahmoud Ibrahim also discussed is how the occlusal risk of a patient will also significantly impact what you should and shouldn’t do with your anterior aesthetics. And if you stick with us all the way to the end, Mahmoud will teach you about the minimum thickness, both on the incisal edge and labially, for optimal strength and aesthetics, and what angle should the composite be coming out of the edge. So if you imagine the edge of a tooth and the angle on which the composite is bonded onto the tooth, there’s a specific angle that you should follow ideally. So you don’t mess up the patient’s occlusion. Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Those of you who listening while you’re jogging or you’re on a train or you’re commuting, driving to work. Thanks so much for joining in. Hope you enjoy the show and those of you who are watching on either Procrucive Guidance app or YouTube or MedTube, you will notice that I’m looking a bit different. Well, I am sitting down, right? I’m usually standing for the last six years I’ve been standing and maybe I’m getting old. But you know, I’ve decided now to take a seat, right? I usually feel like I have more energy when I’m standing up, but I want to do more episodes this year than ever before. I want to make more content this year than ever before for you guys. So I’m just looking at my body, right? Get used to me just sitting down a little bit more. Hope that’s okay with you guys. And before we dive into this episode with Dr. Mahmoud Ibrahim, a very welcome guest, as always been on several episodes before and is my co presenter on the occlusion course. His composites are just out of this world. Like just check out his Instagram. He is a true artist and I’ve been encouraging for a long time to do more on composites. So he’s going to branch into that a little bit more this year and I thought it’d be nice to tackle an episode about decision making. I want to tap into Mahmoud’s mind. How does he decide when’s it edge bonding, when’s it veneer, and the overall decision making, treatment planning guidelines he follows for his anterior composites. This episode is eligible for CE. We are a PACE approved education provider, and you’ll be able to do that by answering a few questions at the end if you’re on the Protrusive Guidance app. Dental Pearl Every PDP episode, I give you a Protrusive Dental Pearl, and this pearl is related to an article I published on the app about top tips on bonding to zirconia. You see, in 2017, I asked Dr Nasser Barghi at the STA convention Singapore. He’s a big shot in ceramics, right? And I said to him, look, now that zirconia is getting so good to bond with, should we now move away from lithium disilicate onlays and overlays, and should we move towards zirconia? And 2017, he said, listen, zirconia bonding is really good now, but why move away from this wonderful material, lithium disilicate? I asked the same thing seven years later, so recently at the BACD conference, I asked the same thing to one of my idols, Dr. Chris Orr, and he said the exact same thing. He said, yes, you can bond to zirconia in this strict protocols. But why? When we can do beautiful partial coverage restorations posteriorly that have enough strength and bond just so predictably in lithium disilicate. So just some food for thought there. I know some of us are doing zirconia onlays and overlays that’s fine, go for it. But I have yet to found a reason to deviate away from lithium disilicate. Well, I’m using the adhesive approach. Now, of course, for resin bonded bridges, I’m using zirconia as well as metal and for my vertical preparations. I am cementing zirconia crowns. But the top tip I want to give you from that article I wrote summarizing what I’ve learned of the years about bonding to zirconia one top tip is even if you are cementing by using a zirconia primer for example monobond or z prime plus or clear fill ceramic primer something that contains that 10 MDP. If you use it on the intaglio of the crown, even if you’re not using a adhesive cement afterwards, even if you’re not using resin cement to actually bond your zirconia by using the primer, the zirconia primer, you are actually improving your bond strengths, even with the GIC that you’ll use, for example. So this is really useful. This is like low risk, high reward. If you have a tooth and you’re crowning it and maybe it’s got less height and you’re thinking is that retention form going to be enough, then perhaps you could still use your conventional cement system, but by using the zirconia primer, you actually get a better outcome. So that’s a top tip I want to pass on to you. Now let’s join this episode on decision making on anterior composites. Main Episode: Dr Mahmoud Ibrahim, my brother from another mother, welcome back yet again to Protrusive Dental Podcast. How are you, my friend? Other than sniffly. [Mahmoud] Oh, sniffly and coffee and I apologize everybody if I sound like a frog, but yeah, it’s always great to be back talking about a topic I absolutely love. Yeah. So thanks for having me again. How are you, Jaz? [Jaz] I’m okay, buddy. I’m okay. I’ve just, you know, on Christmas Day, I hosted my sister and my brother in law and their family and stuff. I had my nephew over, that kind of stuff. It was quite nice. And I did this thing where I went around, only because I really wanted to hear what my son, Ishaan, was going to say to this answer. I just went like, did like a question time with everyone. So I asked everyone like, what was your best moment of the year, right? [Mahmoud] People must dread having you over for parties, right? [Jaz] I know, I’m like a terrible host. Well, I was the host. I was a host, so I asked him, what was the best moment of your year? Okay. Well, what’s your song of 2024 and what’s one thing that you’re going to change about yourself in 2025? And so before you answer, I’ll say mine just gives you a bit, buys you a bit of time to think of yours. I’ll say mine. Okay. So my favorite song was Hass Hass by Sia and Diljit Dosanjh. So like a Punjabi, but like with Sia. So it was a nice little remix, which was good. My best moment was probably our family holiday went to Doha. It was. Just holiday, basically. My wife’s was actually our holiday in Tenerife, but that was a different one. So holidays, for us, is a big thing, obviously, so it’s really important. And then, the thing I’m gonna change about myself next year is based on this recent I don’t know if you saw my story recently, right? That I do my regular blood tests as inspired by Prav Solanki, and my HPA1C, my diabetic marker, just crept up a tiny bit, because I’ve got, like, so many tests worth of data. The cool thing they can do is they can test, they can see the trend and plot the graph, and just a tiny little blip! like a slight increase, right? So usually for most people, this is insignificant. Like if it was my first test, I’d be like, yeah, yeah, good. But only because they know it’s the trend going up. Did the GP in his report say, hey, mate, you gotta just be careful diet, exercise, that kind of stuff. I felt so bad. And you know what it is? It’s all that snacking in the staff room that we are the worst, right? All the snacking. So I made a vow to just be a little bit more careful with my diet. Like everyone, my dad’s side of the family is diabetic. So, shout out to Tom Levine, who messaged me a book recommendation on the back of that. He recommended the book, Metabolic, I believe it is by Dr. Lustig. So, just downloaded that on Audible, so I’ll let you guys know next month how it is. But Mahmoud, back to you now, buddy, okay? So, favorite song of 2024. Doesn’t have to be a 2024 song, by the way. It can be a song that represents 2024. [Mahmoud] So, a lot of the time, I think I mentioned this song to you before, but Remember the Name by Fort Minor. Okay. That’s a little bit of a hype song. It’s an old song though, so maybe a lot of your listeners might be like, what? Go look it up. Advisory, like, don’t listen to it in front of kids. [Jaz] Link in the show notes. [Mahmoud] What would I change for 2025? It’s definitely health related though as well. Unfortunately, I don’t need blood markers to tell me that I’m not taking care of myself. I know I’m not taking care of myself. You know, again, it’s just been such a busy, busy year for both of us. I think next year is not going to be any less busy, but I think I just need to get a little bit better at organizing myself and prioritizing certain things. We had a house move, etc. Things are starting to settle back down a little bit now, so I’m going to try and allocate a certain amount of time to just look after myself. Exercise. Eat better and all that sort of stuff. [Jaz] I don’t know how you’re recording me right now. You’ve got three kids. I’m two. Now I’m looking like I’m in my little back room. I’m looking across. I see havoc, forks flying in the air. Like I’m seeing it all like from there. I’m just pretending like I’m just recording. I’m just working right now. But I don’t know how you do it, man. So more power to you. Just amazing what you achieved with three little ones. And so the next question we’ll say, what are you going to improve? And then the highlight moment of 2024. I know it’s been a year with lots of ups and downs and I don’t go into personal stuff and I’m here with you all the way, my friend. Just to remember the positive. Remember the good. What was your favorite moment? [Mahmoud] I mean, if I want to do workers, I’ll split it up. Yeah. I’ll split it up into sort of more worky stuff and more personal stuff in terms of best moments. I think probably one of the most fun moments was us in Chicago. I think that was this year, you know, believe it or not. [Jaz] Crazy. [Mahmoud] It feels like it was a long, long time ago. It was actually this year. [Jaz] Like professionally. Yeah. That was also the top moment for me professionally as well. I go with you to meet all our heroes, shaking hands with the Spear, not washing her hand and then shaking her hand with John Kois so that they actually shook hands in a funny kind of way. It was amazing. [Mahmoud] He didn’t go to the toilet in between. In terms of personal, it’s not necessarily a specific moment, but over the past like month or two, I’ve actually seen quite a change in the maturity of my older son. Like he’s 11. I actually, at one point I stopped and I looked at him and said, I think you’re getting it. And by that I meant you’re getting what it means to become a little bit more mature, to become the older brother that your little brother and your little sister need and that your parents need. That was a lovely moment for me. And I think he really felt like really proud that we noticed. [Jaz] Cometh. Cometh man. [Mahmoud] Personal though. Yeah, yeah, yeah, yeah. That was nice. [Jaz] Very nice. Well, about half the Protruserati are like skip, skip, skip, skip, skip. Get to the good big comes big the other half like, you know what? We love this stuff, right? So whatever guys, if you love it, then we love you too. If you don’t love it, I still love you. Go to the clinical bit, which is now, right? Because right now, Mahmoud, we are discussing a very hot topic. It was always a hot topic. It’s been a hot topic for about 8, 10 years now. Last time I recorded this similar topic was with George Cheetham. Took away so many nuggets. So I had a great time discussing with George, aka George the Dentist, on composite and edge bonding versus veneers, that kind of stuff. That was really fun. I really enjoyed that. The main thing I took away from that episode, the main lesson I took away, which I just want to echo, is when you are doing bonding with your patient, That initial appointment, obviously so, so important gauging expectations, seeing what’s within your skill set, but just telling them that, okay, if you want to do this dance and we do this together, then the maintenance side of it, let’s have an annual appointment, right? Kind of like when you have your car serviced every year, right? It’s like a commitment that you talk about right at the beginning. Okay. And you attach a fee to it. Cause I remember back in the day, like, okay, yeah, you need polishing and rebuffing of your composites now and again in the future. And it’s just like a sentence that you say, but when you actually say, okay, it’s an annual appointment, X fee, and this is your maintenance. If there’s anything chipped or any issues, we will take care of it. We will make them look good. And we’ll also do your examination at the same time, kind of thing. That was a really nice takeaway from that episode for me. But I just want to build on that because I see your work, Mahmoud. It’s phenomenal, right? Absolutely phenomenal. The resin artistry. You’re a multi award winner now. I know you hate that term. I hate it as well, but whatever. You are, it is what it is, right? And your work speaks for itself. So I am happy and excited to just extract your mindset when you’re doing this kind of work. And obviously we did the BACD workshop together, British Academy of Cosmetic Dentistry. We did the unchippable workshop. Okay. You were the workhorse in terms of the beautiful workthat you provided, the demonstrations you did, and you’ve had so many great questions from the delegates. So I’m just going to like go through some of those questions, which are so, so key, right? I guess we have to start with is the decision making process. You have a case in front of you, and it’s quite difficult without a specific case, but just an overarching decision making kind of like flowchart of when would you go for edge bonding? And just to clarify, I remember doing this and someone on YouTube commented, what is edge bonding? Because in different countries, it may mean different things. It literally is adding some composite to the incisal edge of a tooth, everyone. Edge bonding. Whereas resin veneering is when you take it up the labial of a tooth a bit more. So Mahmoud, what principles can you share with us in terms of decision making and which to do when? [Mahmoud] Hmm, yeah, so, I mean, I want to first start by saying George Cheetham’s point is incredibly important, kudos to him, his work’s phenomenal, big shoes to fill, love to get it. [Jaz] Sending you love, George. [Mahmoud] And I use the phrase to the patient. I say, you need to budget financially and sort of mentally for the maintenance of these, right? Because not only is paying for the maintenance annoying, but also having to attend appointments can be annoying. [Jaz] This is just like car servicing. It is literally just like car servicing. I hate taking my car for service. Half a day out of your life gone. [Mahmoud] Yeah. Luckily, we don’t get a lot of them, and it’s all the principles that we might discuss today. But I also want to say that edge bonding and veneering, it is not a black or white. It is not one or two. There is no dividing line. And this really is the beauty of resin. There is a whole spectrum in between from covering just the insides of the edge to doing a full veneer that I do. And I might do three, if I’m doing six teeth on a patient, two teeth might end up here, two teeth might end up here, two teeth might end up here. [Jaz] Like a spectrum, like a gradient, right? So some is pretty much on the edge, whereas others edge, and maybe covering up the labial by a couple of millimeters. And the other one might be going shy of the gingiva just by a couple of millimeters. That’s what you’re trying to say, right? [Mahmoud] Yes. Yes, exactly. There are certain things I try and avoid. Nobody wants huge, chunky, massively thick composites, whether that is, it’s too thick on the incisal edge or whether it’s around the cervical margin and you’re getting, cause that’ll black trap plaque, it’ll get stained and then you don’t look very good. So obviously my preference is, treat the case if alignment is needed, do the alignment first and do try and minimize the amount of composite I’m going to apply to the teeth. However, the word minimal seems to always, it’s become cool now to try and put the least amount of composite possible on this tooth to affect some sort of change. And for me, I prefer to use the term appropriate. It’s the amount of composite that I need to use that will give the patient what they want. So the patient might come in saying I want composite veneer. But actually what you need to dig down into is what is the look they want and then that will help you decide how much composite you need to use and that sort of appropriate amount of composite rather than minimal. Because I’ll give you a little bit of, just a tiny bit of food for thought here. Just a random example. Imagine you’re doing some edge bonding, yeah? And you’ve covered the edge of the tooth by like a millimetre. Okay, and that’s it. That’s real minimal. [Jaz] So purely on the incisal edge? [Mahmoud] Purely on the incisal edge, just about a millimetre up the incisal edge. And now, you’re very happy with yourself. You’ve put on a very, very small amount of composite, and it looks good. Now, none of us are perfect. What happens if you get a little bit of staining underneath that margin? Now you go in and you try and polish it away. Now you’ve got very little room to play with, right? There’s very little composite covering the surface of the tooth that you can polish away. And end up with an invisible margin, still, and a blend that is good. You just haven’t left yourself very much space. If that composite was maybe two millimeters up, feathered down to super thin, and it does stain, you’ve just got a little bit more room to play with. Okay? [Jaz] To still I remove the stain, but also to still have enough of a blending zone, a blending transition. [Mahmoud] Yes, yes. And I’m not saying I cover the full face of every single tooth because I don’t. I almost never take the composite actual actually to the gingival margin. Okay. Almost never. Because that area is just critical in terms of hygiene, et cetera. So I almost never do that, but there are certain aspects that I sort of consider when I’m trying to decide where on the tooth I’m going to stop it. [Jaz] Is there a no man’s zone? Is there a no man’s land? Like, when you’re we’re playing tennis, right? We’re playing tennis, right? You’re either by the net or you’re at the back. You don’t want to be caught in no man’s land because like it’s really difficult to play shot. Did you know that? Did you know that about tennis? [Mahmoud] I’ve heard about it. Yeah, I don’t play tennis. [Jaz] I know you’re talking. I know you’ve shown some images before. I love this term, right? And maybe if you want to screen share this, for those of you who are more visual here, the chasm of crap. It’s a great time. Chasm. Okay, fine. There we are. See, English is my second language, alright? So, go with me. Third language. Okay, fine. The chasm. Are you sure it’s chasm? Because I like the word chasm. [Mahmoud] It’s a chasm, dude. A hundred percent it’s a chasm. [Jaz] I don’t know what that is. I don’t know what a chasm is. So, there we are. What is a chasm? [Mahmoud] Like a valley. Like a- [Jaz] The Valley of Doom, the Chasm of Crap, which is cool because it has more alliteration, I like it. So, the Chasm of Crap, as Mahmoud once so brilliantly illustrated, is like, if you finish your composite like in a random place on the labial surface, then you get this like little con cavity, whereby it just collects stain. Can you share your screen or not? Have you got that image to share? Tell us about this chasm of crap and this area where you get like this mid facial stain. How can you prevent that? And is that a guideline that you use in terms of where to finish the resin? [Mahmoud] Yeah, a hundred percent. So what I don’t want people to do is have the composite on the edge of the tooth, sort of meet the tooth in like a depression, right? So my guide as to where to end the composite usually is the height of contour of the tooth. Why? Because that allows a smooth, smooth blend. If you end below the height of contour of the tooth. What happens is you get the thickness of the composite and then it dips down into the tooth and then the tooth starts again and you have this like, little V shaped depression between the two. A, it’s impossible to polish. Like, you’re polishing it, polishing, polishing it and you end up with like, this white line. But also, it’s impossible for stain not to get caught in there because the patient can’t brush it very well. That’s why I call it the chasm of crap because you always end up with like pasta sauce and stuff after they’ve eaten. [Jaz] Just for the students and the young dentists who are maybe new to the term height of contour, it’s kind of like the maximum bulbosity in like the gingival third often area, just slightly maybe more incisive than that. And it’s kind of like a good reference point whereby you can put your probe and then, I’m just trying to visualize how to explain this concept to someone who, because we get this question sometimes in the podcast, how do I identify the height of contour? Any guidelines you can give. So like using an occlusal mirror maybe. [Mahmoud] Yeah in a way I mean, okay, so this is why this really does need to be done on a course. But it’s the height of contour relative to the composite. So if you imagine your final facial surface of the composite and whatever angle that is at. What I want that composite to do is to then meet the tooth, and then the surface of the tooth continues that same trajectory as the face of my composite, right? So, that’s how I want you to think about it. Because the position of that height of contour is going to depend on the inclination of the tooth, going to depend on the shape of the facial surface of the tooth, and it’s also going to depend on the angle of your composite, right? If your composite is, really flat up and down, really quite thick at the incisal edge, then the height of contour it’s going to meet is going to be up by the cervical area, right? If your composite is quite thin, rolled inwards incisally, which is something we’ll talk about as well, right, then its trajectory is a little bit more out to the facial. It’s going to meet a height of contour maybe slightly earlier, right? If the tooth has that incisal curve naturally. [Jaz] I think the most important thing to grasp here is that as you take a probe and you take it from the enamel to the resin, it should be seamless. There should be no catch. There should be no depression. There should be no chasm of crap where we’re staying, we’ll do. But the other thing to not do the opposite is don’t just have like a tooth and then edge bonding, like just composite completely glued the edge of the tooth. But you have a great visual for this, which obviously for the purpose of the podcast, which shouldn’t describe, describe the issue there. In terms of having composite just glued to the edge of the tooth. [Mahmoud] So the problem there is mostly optical in nature. You’re asking two completely different materials to behave optically similar in order to fool the eye so that the person looking at this tooth doesn’t see a join between the composite and the tooth, right? But you’re going from an area where the composite is that is sort of 100% composite thickness, 0% tooth thickness, and to immediately go on to an area that is 0% composite and 100% tooth thickness. And those two things cannot act optically the same very easily. It’s better that you have a gradual change. So you go from an area that is completely composite which is basically the edge of the tooth that you’re adding to, right? And that ratio of tooth to composite gradually changes as the composite lips over some of the tooth structure so that when the light hits it, it’s going through a little bit of composite and then a little bit of tooth. And that ratio will gradually changes from a lot of composite towards the incisal edge and less tooth to more tooth and less composite as you go further up the tooth, depending on how much composite sort of you lip over the edge. [Jaz] So you’re right. You don’t want to go from like composite to tooth in a harsh way. It needs to be composite to a bit of composite bit of tooth to then tooth only. But that needs to be like a nice seamless blend. And I think there’s so much in the whole episode, two episodes, we can talk about characteristics and techniques and top tips to get like an invisible blend and stuff. And we could talk about days for that, but just more on the decision. [Mahmoud] We literally do on the course. [Jaz] But in terms of edge bonding and resin veneers, you’ve kind of made it quite clear that it’s a spectrum, right? When you’re doing a resin, you’re deciding case by case, and it can finish anywhere on the tooth, depending on that specific case. But then there are- [Mahmoud] I want to split it up a little bit. And to like, just to summarize, you’ve got your aesthetic reasons, but we also cover things like, your unchippability reasons, right? The reasons for strength or longevity. Aesthetic reasons to cover more of the tooth, obviously if you’re changing the color, but slightly less obvious ones if you’re changing the texture of the tooth. So if the patient’s enamel has natural like pits and stuff and they want to get rid of that. Sometimes the tooth has sort of banding that you can’t get rid of with whitening or icon. But one that might not be so obvious is I do tend to change the shape or even the apparent shape of a tooth a lot by changing the position of the line angles. Now, I can’t do that if I don’t extend the composite up the facial of the tooth a little bit more. So those are just a few of the considerations I’ll make, especially if you have fairly triangular teeth and you’re trying to change them, you have to cover a bit more of the tooth. And then when we talk about longevity, that’s when we start talking about composite thickness, angles, and things like that, which we’ll get into. [Jaz] I think when we’re talking about edge bonding, let’s composite again, and we talked about, yes, this spectrum is in between zone, but there is something that is more of edge bonding, there’s more of a resonating. And like you said, sometimes you do the other mode down for color change, for example, more major shape change playing about with the line angles. When we’re doing that kind of work and that distinction in a way, are you using different materials? Do you think that, okay, because you’re doing more of an edge bonding, you’re going to use a certain type of composite, or because you’re doing more of a resin veneering, or you’re trying to achieve a different objective to do with either shape or color, are you changing the composite that you’re picking up? [Mahmoud] Not necessarily for whether it’s edge bonding or the composite video. So there are certain decisions that I make or survivability reasons. So I’ll give you one example that’s not to do with the type of material. But for example, I don’t charge differently, right? I don’t charge. I don’t have two separate charges for composite edge bonding and it comes with a veneer. Okay, I do get patients ask how much is this versus this. It sounds exactly the same. [Jaz] It’s a per tooth fee. [Mahmoud] It’s a per tooth fee because I want to be free to do what I need to do again to give the patient what they want. So that’s one. Second, the choice of material tends to be based on, so we tend to categorize our patients into a HORP or a LORP. So for those who don’t know, a HORP is a high occlusal risk patient. So it might be a patient that has huge masseter muscles, a patient who we can tell maybe grinds their teeth. They’ve got attrition, tooth to tooth rubbing, right? That is a high occlusal risk patient versus a LORP or a low occlusal risk patient. The patients have still lovely mamelons on their teeth. You can see all the insides of halos and stuff. They don’t grind their teeth. Their muscles are quiet or not hypertrophic. So if I am dealing with a patient who I consider to be a HORP, I will almost always default to using a material that is more chip resistant, more so stronger in the sort of areas that receive a lot of load for me personally, I prefer to Venus by Kulzer. That’s what I use. If the patient is more of a LORP and I am aiming for more intricate sort of layering, I’m going to have some fairly weak materials at the edge anyway, because of the tints and things like that, then I might still use Venus as my palatal backing. To gain a little bit of strength, but then for my layering and stuff and tints, I’ll use either Cosmedent’s Renamel. I use Filtek Supreme XTE and I use Tokuyama Estilite. Those are sort of my three go to that I sort of mix and match. [Jaz] So a nice distinction there, high occlusal risk versus low occlusal risk. And that’s important for decision making, unchippability as we like to call it. Next question then is in terms of getting a good result, how important do you think is it for our colleagues to be thinking about layering, right? Because me, I’m a one shade wonder. You know that, right? I’m always a one shade. All my cases I show, the course stuff, online, I’m just like, hey, I’m going to use one shade and I’m going to do the best I can with that one shade. Like, as I often joke, but it’s kind of true, is my speciality is getting someone from a 4 out of 10 to like a 7 and a half out of 10. You are there taking 7s and turning them into like 10s, right? So that’s the difference between me and you. But how much of that do you think is due to layering? I’ve never actually asked you, what percentage of your cases are layered versus just one shade wonder. [Mahmoud] So I think if you want to make teeth look more natural, like with your incisal effects, it really comes down to two things mainly. Okay. How are you going to cover the transition between the tooth and the composite? And do you want to add incisal effects or not? Those are probably the two biggest decisions you need to think about in terms of whether you’re going to layer or not. If you don’t want to layer, you want to use a single shade, then you’re not going to be able to add incisal effects, so forget that. So if it’s a patient who wants that, you’re not going to be able to give it to them. Do patients ask for that? Not really. I tend to get patients who ask for that, but I think that’s because that’s the work I put out. But in general, patients don’t tend to care. But it’s then about how you’re going to cover the transition between the tooth and the material, okay? If you don’t have enough thickness of composite, the composite might be a bit too translucent and you’ll see that grey line, you’ll see the transition between the tooth and the composite, in which case you might need to resort to a lot of beveling of the tooth, create thicker bit of composite at that graduation where it changes from mostly tooth to mostly composite. That’s where you need to maybe heavily bevel. Interjection: Hey guys, just Jaz interfering here. I hope you’re enjoying protrusive content. Hope you enjoyed all the content throughout the years, and there’s so much to come. Now, if this year you’re wanting to learn how to do Vertical Preparation, as you know, I’m a huge fan of Verti Preps, as you call them. Now, I’ve got a mass class for that on Protrusive Guidance called Verti Preps for Plonkers. I’m going to rename it to the VertiPrep Challenge. Doing your first premolar vertical crown. Like so many of the community have done so. That course is included in the Ultimate Education Plan of Protrusive Guidance. You’ve also got section schools. I’ll show you these high quality 4k videos with my annotations and the whole walkthrough of what I’m doing, what I’m thinking, what bur I’m using, how I’m holding the handpiece, why I took out the root that I took out. And then I’ve got a plethora of a clinical walkthrough, so premium clinical video section, the on demand section for all the previous webinars that we’ve had that have been so successful, and Quick and Slick Rubber Dam. If you’re struggling rubber dam, it’s a great webinar, but then 30 clinical videos, real time, there’s no editing, there’s no cropping here, it’s real time, see me struggle, see me succeed. And that’s not all, we’ve even thrown in Resin Bonded Bridge Masterclass, plus everything that’s to come in 2025, that gets locked into a subscription. So you get all these courses and master classes, plus the ability to get CE or CPD credits for every single episode and retrospectively. And to be part of the community of the nicest and geekiest dentists in the world. If this sounds like your bag, then check out the ultimate educational plan on Protrusive Guidance. We have our own app on Play Store and on the App Store on iOS. And if you’re a bit old fashioned, you can even go on your laptop on the browser. In fact, if you join on the browser, that’s how you get the best price. Head to www.protrusive.app and choose the Ultimate Education Plan to get access all areas. It’s the home of the nicest and geekiest dentists in the world. Hope to see you there. Back to the main ep. [Jaz] See, remember, with my older patient base, they’ve already got like, worn teeth and chipped teeth and jagged edges, so for me, that’s very easy to do, hence why I get away with it, I get a good blend, because again, I make that shape, and I am able to bevel and add my one shade, which is gonna be good enough for that patient in my population, based on the village that I work in, but for your patients, yeah, they’re younger. I’ve seen them. They’re younger and the kind of work you put out and they’re trying to small transformation to do. They are the more cosmetically focused patient. And so I see what you mean in terms of even if you’re going to use one shade, you are perhaps not in a position to bevel or bevel aggressively because of the fact that you are dealing with quite nice enamel already. You don’t have to scratch it. Is that your thought process in that scenario? [Mahmoud] Yeah, but it’s also even more. It’s even trickier in that sometimes, because if the tooth is intact and you still have the incisal one to two millimeters, it’ll have the halo, which tends to look quite opaque, and then you have the band of translucency in the incisal edge. And what’ll happen is if you put a thin bit of composite on there, you’ll actually still see those things through, and it’ll look really weird, because you’ll have a really thick band at the bottom now, where your composite is, and it might blend okay onto the halo, but then you’ll have like this gray bit in the middle, right, which looks really, really weird. So my preference, and I call this sort of transporting the incisal edge, yeah, is I use opaquers in the area of that. So the natural translucency of the tooth. [Jaz] And it is like flowable? [Mahmoud] Yeah, flowable opaquer is because they can be very, very thin. [Mahmoud] That is a white opaque, if you like, but then you can get opaquers that are either vita shaded, so the ones that I like to use, or they’re shaded as A1, B1, A2, whatever. [Jaz] Or would they be A01, for example, over opaque that? Is that kind of how they term it? [Mahmoud] These aren’t named like that, but I guess different brands can call them different things, right? I don’t know. So the ones I use are the Cosmedent ones, and I’m not sure that anybody else makes vita shaded liquid opaquer. I might be wrong. Someone correct me if they know otherwise. Those are the ones I use because they are vita shaded. So they’re not bright white. They will match the vita shade as close as possible. [Jaz] The shade that you use here, for example, let’s say you’re going to create, you’ve done some teeth whitening, okay, because patients want to have white teeth if possible, and then you’re going to go for a bleach shade or BXL, whatever, that’s usually a modal thing. I don’t know how often you do that. It’d be nice to know. So, does that mean that the opaque- Okay, I thought so. Phew. Does that mean that the opaque you’re going to use is going to be the same shade as the shade you’re aiming for, or you’re trying to go halfway between to try and create a blend or transition? What’s the thought process in terms of the shade that you use? [Mahmoud] No, if I’m aiming for a bleached shade tooth, then I’ll use the A1B1LO, it’s called, by Cosmedent, and so it covers everything from A1 to LO. What I would use for teeth that have been bleached, okay, they have a B0, which is even lighter. But I very, very rarely use that one because it’s like an internal shade that I’m trying to sort of mimic the dentine, if you like. I don’t really want it to be super bright and then shine through unless I’m trying to aim to give the tooth those like hypercalcifications or a brighter halo. I’ll use it there. But otherwise I stick to the A1B1LO in a lot of cases just to hide that grayness of the natural translucency of the incisal edge, cover that, and then I move it more incisally using then my gradient to mimic the new translucent band. Does that make sense? [Jaz] Yeah, yeah. [Mahmoud] So there’s no way I can do that if I’m doing a single shade. [Jaz] And so how often are you doing a one shade wonder, versus how often are you using tints and layering? So basically, how often do you get a HORP? How often do you get a LORP? [Mahmoud] I’m probably seeing a lot of lorps at the moment, because you tend to get a lot of people who want nicer looking smiles, but it’s mainly that they’ve got misalignment. You do the invisalign, you do the ortho. And then it’s just about tidying certain things up and the more we look at patients and the more we realize maybe the envelope, maybe it’s envelope issues, we talk a lot about restricted envelopes of function, your lack of overjet, et cetera. And if that is what I think is making the patient a horp, right, once I’ve resolved that with my ortho, I’ve given them a little bit more overjet, I’ve undeepened the overbite, then I’m maybe a little bit more free to then layer and use the materials that I can get a nicer aesthetic result with. Whereas if it’s a patient who I can see clearly, is grinding their teeth, even maybe even during the Invisalign, you can see that the aligners are getting worn out and they’re cracking them. Then no, I’m going to go single shade. I’m going to go with Venus, more than likely Venus pure at the moment. That’s like my favorite one. Yeah, I’d say that’s probably like 30% of my cases. If I put the pictures up side by side, could I choose an absolute personal sort of favorite way of doing it? Me personally, like, obviously I love the layering aspect, the artistry of it, it’s just so rewarding and it’s so much fun to do. But a patient wouldn’t tell the difference, I don’t think. Unless it’s a blown up picture and they say, I want that, fine. [Jaz] Okay, well, in that scenario then, when you’re considering layering, do you always do it whereby you’re being like a 3D printer? You’re like, you’re making the palatal shell, you’re then adding this tint, that tint, that shade, it’s like a recipe book that you’re building, and you’re building a layer upon layer upon layer, and then the final enamel layer, and then polishing it back versus MHM, Marshall Hanson. That’s the Marshall Hanson method. I see a lot of his stuff online. The cut back his technique. Basically you do the one shade like I would do. And then like the next day or the same day, I don’t know when you do it, like in 48 hours, whatever you cut it back. Like you would do an EMAX, right? And then you bake all your tins in. Okay. Have you ever done it that way? [Mahmoud] I have, I’ve done it. I’ve done it, but in the same appointment. So I’ve done cut back. So built the entire shape, get the shapes, right? I think the biggest benefits of it is what scares people from using tints or layering translucent masses and stuff is if they get them in the wrong place, whether it’s gingival incisally in the wrong place, or whether it’s buccallingually in the wrong place, then when you come to finish and polish it, it’s going to look like crap, right? You’re either going to have too much translucency, too little translucency, you’ll get rid of your halo, or your halo would be too thick, or whatever. So the idea with that is if you get the shape perfect frame is perfect, then you can cut back and you know where you need to put your effect and they will look good. So that’s mainly what they’re trying to avoid is getting the effects in the wrong place. I have a pet peeve. I think this is from my childhood, honestly, I love you mom, yeah, mother, I love you. But there is one thing you do. You’ve always done this and it pisses the hell out of me. It’s like repeating stuff. I hate being told the same thing seven times, but I also hate having to repeat something I have already done. Whether it’s through my fault or, or not, I just don’t like it and I don’t like repeating myself. When I did the cut back thing, when I cut it back, layered everything in and then was doing my finishing and polishing, I was like, oh my God, I’ve already done this. And now I have to do it again? And it was really, really annoying. So for me, I don’t like doing that particular method. It has huge advantages as well in terms of the technique he particularly uses in terms of making things stain resistant stuff. Phenomenal technique. I know someone who’s gone on his course in the US and brilliant guy. For me, I prefer to just do it once and get to the end and hopefully be happy. How do I avoid the pitfall of getting things in the wrong place? Couple of things. A, I always make sure I assess everything from multiple directions. And honestly, people talk about looking at your composite work incisal view. So take a mirror, put it sort of in the patient’s mouth and look at the teeth as if you’re staring up its incisal edge. That’s one thing, but you need to also look from the side and do the same thing. Hold the mirror on the buccal of the tooth next door and look at the buccal side of the tooth. You can see like if someone’s watching me work, my head is moving around all the time. And hopefully, I’m going to be sharing some of those workflows in the next year or so. And you’re going to see how much my head moves and what I look at. And even when I’m layering like my final composite, I’m not always looking at the tooth dead on when I’m actually placing the composite. I’ll be looking at it from the side. [Jaz] The one that Nick’s saying the whole time, man. [Mahmoud] Yeah, I know, I’m wrecked. But I get the patience to move as well. That’s one. But also, try and perfect each step before you move on to the other one. So you’ll also see, for example, when I do build my palatal shells, whether I’m doing it freehand, whether I’m doing it from a mock up or wax up, whatever, I will then adjust the edge of that palatal shell so that it’s the correct length, it’s the correct width, before I move on to the next step. Because if you don’t, that could alter where your proximal wall might end up going, right? If you leave the incisal edge too broad, you might move your proximal wall back. So if the edge is too long and you haven’t cut it back, then you might put your halo on and it’s in the wrong place. Right? So I just make sure that each step is corrected. I’ll take a disc, I’ll correct it, then blow the powder off with some air and then I just get some modeling resin on a brush and I’ll just wipe away any of the remaining powder and I can just carry on with my layering. But that’s how I make sure that where my halo ends up is where I want it to be. [Jaz] Because the last thing you want to do is put all this extra work, we’ve all done it. And then you just get away and then what’s the point of creating all that incisal halo and transducency if you’ve just adjusted it away. And that was one of the questions I was gonna ask you actually, is that when you’re doing layer by layer and you’re trying to get things right and then you’re cutting back and you’re adjusting, how do you get rid of that dust? Well, we’ve answered it, air and then modeling resin. And so the other thing which this naturally leads to then is because you’re doing all the layering, right? And 70% of the case, you’re doing layering. Does that mean that in 70% of the cases you have a wax up? Because I do one shade, I can afford to do a lot more cases freehand, right? What advice would you give to those listening about the need for a wax up? Because if you don’t know where your edge is going to be, if you don’t plan this, bake this in from the start, you’re going to get to a big mess, right? You can’t freehand a layering job. [Mahmoud] Agreed. So I would say my objective and however you want to get to it is up to you and I’ll give you some options. My objective is that I want that patient to have a preview of the expected lengths of the new teeth before I book them in for a really long appointment to treat them. How do I do it? I personally, most of the time I do a freehand mock up. So as you like to say, you’ll take your expired composite. Without no etch, no bond, I will mock up the new incisal edge length, the new incisal edge shapes. You know, how big are the embrasures? I like fairly open embrasures. Some patients don’t, and I want to pick that up now, right? And I want to explain to them why the embrasures exist and why it’s important. And then once they have approved the mockup, so, I might need to adjust it. If they think it’s too long, I’ll shorten it. If they think it’s too short, I’ll lengthen it. This is all done freehand. This is done no etch or bond. I can do whatever I want. Right? I can tell them, actually, no, I can’t make it that long because you’re going to chip it. Whatever. [Jaz] Are you doing just incisor palatal here? Like- [Mahmoud] Yeah, yeah. Most of the time. You could do full volume, but I don’t for a couple of reasons. A, it would take a long time. It’s a lot of composite. B, if I give that patient a mirror with this mock up, yeah? Which is like literally just palatal shells. And they go, oh, I love it. You know, I can’t wait. So excited to get my new smile. And they’re all like giddy and stuff. I’m going to take selfies. I know that when I do the actual layering and it’s not half of a tooth. They’re gonna be over the moon, right? If they start going, oh, but it’s like, you know, and they shove the mirror like here and they get their microscope out, then I’m thinking, okay, this is gonna be a little bit, just book a little bit longer. Maybe things might get a little bit more filling right? Just gives you a little bit of an insight into the patient, but it’s also a lot quicker. Like, I wanna be done with this mockup in like 15 minutes. I don’t wanna be there for an hour shaping everything. If I have a reason to think I need to, like if it’s a diastema closure case, right? And I’m figuring out where am I gonna add the width, right? Because sometimes I’ll give a little bit of width to the centrals, a little bit to the laterals, a little bit to the canines, maybe sometimes you’ll give the laterals a little more, whatever, right? Then obviously you need to build up your proximal walls, because I really want to get a good idea of what the proportions are going to be. Harder to do that by just adding to the incisal edge. [Jaz] Case by case, but you could do a lot with incisor palatal, as you said, and it’s a great tip about gauging expectations. I actually love that so much. So, I mean, that helps to answer. And so really you’re using that as your wax up, you’re taking a putty of that, and then you’re using that in the future. But how often are you doing, you actually using, because I know you’re doing wax up. How often are you getting the wax heater out and doing wax? And do you ever use the lab for either a digital or a traditional wax up? [Mahmoud] Yeah. So I will use a lab for either digital or traditional wax up if I don’t think I will have time to do it myself. So over the past 12 months, for example, we had an absolute ton on and I knew that every minute I had, I had to put into the content, the lectures, blah, blah, blah. So I did get a lot of self lab made stuff because I’ve kind of been there and I’ve done that. And I’ve learned a lot from doing the mix ups. Now anyone’s listening hasn’t done their own wax up, man. Please, please. I beg you just do one. Do one, even if you do one tooth, you will learn so much about tooth shape. If you get the models articulating stuff, you can learn so much about occlusion. It’s hugely mind, eye opening, but yeah, I’ll get the lab to do it. If I don’t think I have a lot of time and one tip I do, I can give sometimes is what I’ll do is I’ll collect my data up front. So I’ll do my photos. You do your x rays, you do all that sort of stuff. You’ll do your smile design and I’ll do a mock up of maybe one or two teeth. Intraorally. That’s it. Okay. And then what that will set is because I’ll do the centrals. For example, that’ll set my incisal edge position. Which also sets the incisal plane, because you’ve got two teeth, they’re horizontal. Now the lab know that has to be the horizontal of the smile, and the incisal edge length. And they’ll know where the midline is, because I’ll either put it using my embrasure, or it’s already there. And I’ll take a scan of that, as well as the scan of the upper and lower teeth without those things. So flick them off, and take normal scans. Those will go to the lab. The lab will make me my whitening trays. And they will send me back a wax up. [Jaz] So it’s like, I’ve kind of done a little bit of the work with the direct composite mock up technique, but then you get in the lab to do the rest with the either digital or traditional wax, right? [Mahmoud] Exactly. They’ve got those two teeth. Once you’ve got the incisal edge position and the photos, they can then digitally design everything else. Now, do you need facebow? Do you need fully mounted on a physical articulator to do these things? Now, if this patient is a lorp, and I’m not super worried about occlusal risk, and the lab have the incisal edge position from what I’m giving them and they’re just going to fill in the blank, then no, I don’t think you do. I’ll just get the wax up back. And like I said, my objective is I need this patient to have a preview of their new smile before they say yes. I don’t care how you do it. This method, I will take putty index of the wax up and I’ll use some temporary crown bridge material. So my preference, luxa temp, and I’ll do a mock up on the patient’s teeth. So no etch no bond. You fill the putty stent with your lux attempt, seat it over the teeth, let it fully set, take the putty off, and then they can have a look at the new lengths, just the new aesthetics in general. You can have a look as well. And most importantly, you can see whether you like it or not. Did they actually match the incisal edge position? Is the midline straight? Is the smile canted or not? And if everything’s okay, and guess what, you’re fine. You can go ahead. And the beauty of it, it’s all composite at the end of the day. So even if there is slight adjustment you need to do at the end, you can. Now, if the patient is a horp and I’m designing canine guidance, group function, transition to crossover, blah, blah, blah, all that sort of stuff, then yeah, obviously I’m going to put in a lot more effort. Maybe you’ll get the models mounted and plan the case appropriately. So that’s what I do, but I want the patient to have a preview. 100%. Okay, that is non negotiable for me. So, some people do it where you can have like a video call with the patient and then they come in straight for treatment. I have never done that. I will never do that. That just sounds like a headache. So they will get a preview. I’ll get a preview and I’ll either have a wax up from which I’ll take palatal putty stent or I’ll have my own mock up in which I’ll make a palatal putty stent. Very occasionally I’ll do the mock up and if I’m lazy, I can’t be bothered. But it was like a really predictable mock up. Like I knew exactly where I was putting everything. Then again, they’ve seen it, they’ve approved it. I’ve taken photos and then I’ll just freehand it when I come to do it. But I kind of, again, I’ve already in my head, I know I’m adding a millimeter here, adding a millimeter and a half here or whatever, I know it. [Jaz] That comes with the skill and experience. I think that the main takeaway here is give the patient a preview. And it also is an opportunity to gauge their sort of expectation and beware the chasm of crap. The three things you take away from this episode. And also it’s chasm, not chasm. Thank you so much for giving so much for sharing so much of your secret source. There’s so much we still have to discuss. We’ve got the Unchippable course also launching now as part of our family of education that we provide. Our jingle should have played, I think somewhere in the middle of this, which I’m hoping people got pumped about, but sorry, we’re just going to say something. [Mahmoud] Well, no, I was just going to say there’s two other considerations that make me think, make me decide between whether it’s going to be a veneer or whether it’s going to be purely edge bonding. And it also can impact how many teeth I then need to treat. And these are ones that people probably don’t think about. Now that you’ve mentioned Unchippable, obviously we go into these a lot in detail into in Unchippable, but we are about, I want people to listen to this episode and really take something a way that will help them. And it is, you want your composite to have a minimum thickness, right? But you don’t want your composite to be super thin on the edge. And if you think about it, wherever that incisal edge needs to be, and it needs to be, let’s say, a millimeter, a millimeter and a half thick, that then translates into where the facial of your composite it’s going to have to be right. And then that could dictate whether the composite ends up being a veneer or just an edge bond. Now let’s say you’ve got teeth that are misaligned. You got one tooth that’s a little bit more buccal onto it a little bit more lingual and you need that edge thickness. Now one tooth might end up being veneer. One tooth might end up not being veneer because if you veneer both, they’re going to again still be different facial thicknesses. And this is where obviously pre restorative alignment becomes really crucial. You want that minimum thickness. So think about how that’s going to affect the. facial position of your composite And the last thing we talk about, and again, this may be a little bit more complicated than a podcast episode can take, but it’s palatal angle of the composite. And I want to make sure that that angle isn’t too upright or too, what we call steep, right? I want it to be shallow, as in it’s coming out that way, so down and out on the upper. I had a case in just yesterday. She had some porcelain veneers fitted about a year and a half ago. And she came in and I don’t know where she had them done, but one of the veneers was out already. I looked at it and it is really odd shape. Put it on the tooth. And honestly the incisal two to three millimeters curled politely. So far the tooth looked like a talon. Yeah. It looked like that on all this bit down here was ceramic. Once again, just imagine how this lower tooth when the patient’s chewing and stuff, it’s far more likely to knock into that added length because it’s going in. So I’m going palatally. [Jaz] Which is natural to tooth have a feature and sometimes in certain genotypes it’s more, or phenotypes, it’s more pronounced than others, and you have that curvature, but when we’re doing restorative dentistry, we know to bake that into your restoration is a dangerous thing for the envelope function, for the envelope parafunction, for so many factors there, so yeah, I can see how that would lead to an issue. [Mahmoud] Yeah, because if it’s the patient’s own enamel, right, and they wear it and stuff, they will come to you and say, okay, my teeth are worn, could you fix them? But once it’s your restoration and it breaks your chips, now it’s your problem. So that for me is, I always try and maintain the existing palatal angle of the tooth or shallow it, try not to steepen it. So again, that will have an impact on the facial thickness of the composite and therefore it’ll have an impact whether it ends up being edge bonding or full facial veneer. These are difficult concepts to explain and understand without visuals. But we do spend a lot of time on self and chippable talking about these two things, which I think are crucial. They are probably the two biggest decisions that affect whether I do veneer or edgebond. And whether or not I might say to the patient, actually, no, I can’t do just your two centrals. Because I’m gonna have to build them out and then you’re gonna look goofy. So we do the other two. [Jaz] What I want to finish on is just to reassure everyone that, you know how they said, okay, the market is saturated. It’s too many composite courses out there. And we thought about it. Oh my God, there’s a gazillion composite course out there. But the reason why me and you had no hesitation to come out with this is because this is not a composite course. Cause you’ve been on way more than I have. Like so many, I’ve been on a fair few. No one’s ever talked about the kind of things that we’re going to talk about in the sense of actually getting longevity. They talk about the beauty, they talk about form follows function to some degree in the form and the shapes and whatnot, but how to actually put that in to your patient’s mouth that has the hypertrophic muscles, that has the high risk features, that has got an advanced amount of wear, and how you might mitigate- [Mahmoud] Identifying the high risk features. That’s where it starts with, right? And then nobody talks about that on a composite course. And it’s about not treating the wrong patient with the wrong modality. [Jaz] Correct. But then also when you treat a high risk patient, the different recipe and the rule book, which actually goes against some aesthetic norms. But if you go on composite course that we’ve been on, for example, and then you follow that recipe and hawk two years later, you’re going to get that chip. You’re going to get that break. Hence why we called it a very bold name. I remember being sat next to a very nice man at the BACD dinner. And he said, we looked at your topic on Unchippable and we thought that is very, very difficult to teach. It’s amazing. We love the name. But we thought that was very, very difficult to teach, but we’re very excited with the prototype at BACD went very well, got loads of content. I think we’re going to be a hybrid model. So give lots of people some online learning as much as possible at home before they come in, because this is the future of education, right? So that they can do as much hands on as possible. And that’s kind of model we’ll follow. So Mahmoud thanks again for everything, my friend, for being on here, for sharing your secret sources right to the end moment, and I would encourage everyone to follow Mahmoud on Instagram. I’ll put his handle in the show notes. And of course we’ll catch you next time. Thanks, buddy. [Mahmoud] Thanks dude. Jaz’s Outro: Well there we have it guys. Thank you so much for listening all the way to the end. Hope you enjoyed that geeky discussion all about decision making in anterior composites. This episode is eligible for CE, so if you’re on the Protrusive Guidance app, scroll down, answer those questions, get 80% and Mari, our CPD queen, will email you a certificate. Mari actually emails you a certificate and every quarter, she’ll email you again a summary of all your certificates and then annually will send you a review of all the certificates that you gained. So do check that out on the Protrusive Guidance app. Now, really importantly, if you love what Mahmoud teaches and his resin artistry, then you want to get on the Unchippable course. This is the first course of its kind that tells you how to make these composites beautiful, but actually gets them to work in your patient’s occlusion. This is not an occlusion course, but this is not just an anterior layering course. It is a beautiful marriage of the two. So how to make your teeth look good and last a long time. All about anterior dentistry. We’re thinking of doing a few locations throughout the UK this year, and maybe internationally in the future. But join the waitlist www.protrusive.co.uk/unchippable. I know what a wonderful name, right? That’s /unchippable. Join the waitlist. Enjoy the revolution of actually doing these anterior beautiful restorations but sleeping well at night knowing that they’re not going to chip. We’re going to tell you all our secrets but the hands on element will wow you. We also have like an online course that you join before the course so that on the live course we can focus two days on hands on as much as possible. That’s protrusive.co.uk/unchippable to join the wait list. Thank you once again for reaching all the end. I’ll catch you same time, same place next week. Bye for now.…
What influences your decision when choosing ceramics? What are the main ceramics nowadays—and do porcelain-fused-to-metal still have a place in dentistry? Are the protocols different for various types of ceramics and crown materials? How important is rubber dam isolation, and is a split dam good enough? In this Back to Basics Protrusive episode, Jaz teams up again with Emma Hutchison , ‘the Protrusive Student’, to break down these critical questions and simplify the world of ceramics. From decision-making frameworks to practical rubber dam tips, this episode is packed with insights to elevate your practice. Whether you’re a student navigating the foundations or a seasoned clinician revisiting the essentials, this discussion offers a fresh, evidence-based perspective on mastering ceramics in dentistry. https://youtu.be/z4a8Hv6peVU Watch PS013 on Youtube Key Takeaways: Understanding the role of metal ceramic crowns is crucial in modern dentistry. Monolithic ceramics are preferred for posterior restorations due to their strength. Layered ceramics can enhance aesthetics but may compromise strength. Proper crown preparation is essential for successful restorations. Communication with lab technicians is vital for successful bonding. The choice of ceramic material largely depends on the amount of enamel available. Following manufacturer protocols is key to achieving optimal results. Bruxism patients require careful consideration in material selection. Rubber dam isolation is crucial for predictable bonding. Digital scanning requires more aggressive tissue management. Impressions are still valuable, but digital methods are advancing. Need to Read it? Check out the Full Episode Transcript below! Highlights for this episode: 03:52 Emma’s Exam Experience 07:28 Feedback on Previous Episode 08:00 Discussion on Ceramics in Dentistry 10:51 Practical Applications and Material Choices 19:45 Monolithic vs. Layered Ceramics 24:18 Exploring Milled Cobalt Chromes and Gold Crowns 26:14 Challenges in Fitting Restorations and Bonding Techniques 30:03 Rubber Dam Techniques and Benefits 37:01 Intraoral Scanners vs. Traditional Impressions 40:14 Effective Communication with Lab Technicians 44:25 Conclusion and Future Plans This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C . AGD Subject Code: 010 BASIC SCIENCE (Dental materials) Dentists will be able to – Identify the suitability of ceramics based on their strength, aesthetics, and application. Highlight the importance of proper crown preparation and manufacturer protocols for optimal results. Emphasize the importance of rubber dam isolation and compare the benefits and challenges of analog impressions versus digital scanning. If you love this episode, make sure to watch Composite vs Ceramic with Dr Chris Orr – PDP030 and make sure to read the Protrusive Notes! Click below for full episode transcript: Teaser: I do not place lithium disilicate and I cement it. So for me, the way my mind works is if I'm cementing and not bonding, if I'm cementing just using a GIC based cement, so I'm not relying on enamel for adhesion, why would I use lithium disilicate? Using lithium disilicate posteriorly and bonding it, excellent strength, good, it's going to be fine, as long as you give it enough thickness, 1.5-2mm, you're golden, okay. Teaser: If you don’t respect the thickness, or if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented is a completely different ceramic to the same ceramic lithium disilicate, bonded. You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate. But I know some clinicians who whatever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not it’s clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that. The other thing to bear in mind is, how important is it to you that this molar tooth, looks absolutely gorgeous. How important is it to you? And I wait for them to say the answer. Okay, and I say, okay, you want it to look gorgeous, but what if I told you that if you accept that it’s going to look good, but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you? Longevity or beauty? Jaz’s Introduction: When I was a student, like many things, ceramics were very confusing. And fast forward many years, when I qualified, they were still very confusing. What I present today in this back to basics series with Emma Hutchison, the Protrusive Student, is a simplified overview of ceramics and how I view them. My views are based on the courses that I’ve been on, the evidence that I’ve read, and my daily clinical practice, which makes up a third of evidence based dentistry itself. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Hey, the last one on extractions. I mean, you guys loved it. So thank you so much for everyone who liked it and commented. It really helps us to keep going. I was always unsure about this Protrusive Student series and going back to basics, but you guys are loving it. And I really appreciate that. I mean, Emma will continue to make dentistry tangible for students, but a lot of these episodes are very useful for dentists, like a back to basics, revisiting the foundations. There’s something very validating about that. Sometimes you can only measure your growth when you look back and listen to an episode like this and feel that, you know what? I knew kind of everything and look how much I have grown. There’s a real beauty in that. So in this episode, we cover decision making in ceramics. What influences your decision. What are the main ceramics that I’m using nowadays and do I still use porcelain fused to metal? Are the protocols different for the different types of ceramics and crown materials? How important is rubber dam isolation? Is split dam good enough? And we’ve even thrown in some rubber dam tips in there for you. This episode, like the last one, is eligible for CE. Protrusive education is a PACE approved provider. And we also satisfy the criteria for the GDC. All you have to do to play and collect CPD is answer the five questions and get 80%. That’s only available on www. protrusive. app. Once you make an account, you can download it on Android and iOS, listen on the go, answer the questions, also answer the questions of the past episodes that you’ve listened to, and validate your learning. An opportunity to reflect, which forms part of your personal development plan. We’ve also got the notes from this episode written by Emma, all about dental ceramics, like a cheat sheet for any student. It does go quite deep, but it’s all the stuff that you need for your exams. And that’s in the crush your exam section of Protrusive Guidance. Once you join Protrusive Guidance, you just have to email student@protrusive.co.Uk so we can verify you’re a student and add you on there. Now let’s join the main episode and I’ll catch you in the outro. Main Episode: Emma Hutchison, the Protrusive Student, welcome back. You’ve just had an exam. How did it go? [Emma] It was okay. It was a structured clinical reasoning exam. And which was something that, it’s something that Glasgow only introduced. I think two years ago, it might’ve been last year, actually. So no one really knows what was going on. So. [Jaz] An example question from there that was a tough one. [Emma] Yeah, so you’re basically given a few cases, and you have like an assimilation time to sit in a room and look over these cases. You just get radiographs, clinical photographs, a bit about medical, social history. So you have 25 minutes per case to read over. You don’t know what questions you’re going to be asked, and then you go in, and you’ve got, for each station you’ve got two tutors or clinicians, and you sit in front of them, very closely actually, I thought they were going to be a bit further away across the room, but you were sitting right in front of them, and they just kind of grill you on your treatment plan. If it’s oral medicine, they’ll ask you questions about histology, things about medications as well. Like, we had a patient that was on Warfarin, so they’re going to ask about all the INR, things like that. [Jaz] You knew that. You knew all that, right? [Emma] Yeah, yeah. It’s just hard because you have no idea what’s going to come up. So, a lot of it is reading over your guidelines, SDCEP, American Endodontics, things like that. So, it’s very intense. It’s very intense, but I’m glad it’s over. [Jaz] Which was the question that stumped you? [Emma] So, you get your topics two weeks in advance, so we were restorative and orthodontics as well. And for restorative, I thought I was going to completely fumble because it is such a huge topic with ortho at my level. In dental school, there’s only so much that they can ask you, I suppose. But the ortho one was really, really tricky. They wanted very specific answers. It was kind of good cop, bad cop. It was very intense. [Jaz] It was all surrounding that specific case that they gave you, right? [Emma] Yeah, yeah, so we had a case of a little boy who was like class three. You had to go over all the treatment plans which, in theory I do know, but it was quite intense. But everyone in my year sort of felt the same, so we’ll see how it goes. [Jaz] With dental exams I couldn’t read it when I came out like, when I did maths, back in the day, in A level maths, right, I was pretty good at maths, when I wanted to be. Like, I went into my C4 last exam knowing that all I needed was 13% to get my A. That was the highest grade at the time, they’ve got like A star or whatever now in A levels, but I needed 13%, right? So, I completely didn’t study C4 at all. I just knew that I can just get a 13% like by writing my name. So I’ve got like 55 in that. And everything else I’ve got like 99 and 100s, basically. So I was, when I was wanting to be, I knew I could switch it on for maths. And then, so when I come out of maths exam, I knew, okay, I’ve aced it or I flunked it. I knew, right. When it came to dental school, I was like, I had no idea, especially with those kind, when you’re being interviewed and OSCE’d. And sometimes I come out and think, Oh my God, I flunked this. And then I surprise myself. Like, it’s difficult to read. [Emma] Yeah, it’s really difficult to read. And they said we had a sort of recap of it and they were saying, you know, we did purposefully examine it a bit harder because when it comes to our case pres, and we’ve got another clinical reasoning exam later on in the year. I don’t know, they wanted to give us a bit of a fright, I suppose. They said in hopes that the real thing, the big, big exams that are a lot more heavily weighted, will be a bit nicer. [Jaz] It’s a good approach. They give you a real tough time so that the actual thing will be easier and nicer, so that’s good. Well, today’s topic is ceramics. Our last episode, Extractions, went down really well. Everyone loved it, so well done Emma. It was great questions that you’d asked. Everyone loved the avocado analogy, but more importantly, did you resonate that analogy? Have you done an extraction since? Maybe you haven’t, I don’t know. You tell me. [Emma] You know, I actually haven’t done an extraction since I was on a good roll with extractions and now it’s completely stopped. So hopefully in the new year. [Jaz] But right now, you know what an application point feels like now you know to liken it like an avocado and stuff and then the removal of a nut. So that was good. I enjoyed that very much. And today’s ceramics, right? So ceramics was a topic that again, I mean, so many topics at dental school confuse you, mostly do. But this is in materials. Like I was okay at memorizing about leucite reinforced and then the history of ceramics and stuff. But at the actual practical element of delivering ceramics and actually, what do you actually do in the real world? I had no idea. Like really, it was very heavily, heavily emphasis on PFMs. Like your exam was a PFM, porcelain infused to metal or metal MCC metal ceramic crown, as some people call it. And so, I’ve hardly done many since qualifying of those crowns. Yeah, I still do. And we’ll talk about the indication for that. But nowadays in a world of all ceramic, what I was being taught was already quite outdated. So I’d be interested to know. What kind of crown preparations are you being taught? What kind of materials are you being taught to use on your patients? [Emma] Yeah, so I think in Glasgow, we’re still learning about metal ceramic crowns, how to prep them, but we are also learning about all ceramic alternatives, I suppose. So my first question was going to be about, do metal ceramic crowns still have a role in dentistry today? Like, especially in private dentistry, I wonder. Or have they largely been replaced by all ceramic? [Jaz] The answer is they’ve largely been replaced, but they still have a role. To get PFMs, like, working well, right, and looking good, you need space. You need that 1. 5 to even 1. 7 millimetre, if you’re making it look really aesthetic, right? So you have the metal layer, the opaque to block the metal layer. Then the ceramic and to actually give it a good bulk to make it look pretty. It needs a lot of space. And so that ends up being a very invasive preparation. We’re trying to move away from that. So to do a proper PFM that looks good, it still has a place, but maybe not so much. And so the time that I would use it and a lot of today is very much, if you had a different podcast host, you’d be getting different answers. So a lot of it is based on my opinions and experiences, and everyone’s, I think, everyone’s got a story, everyone’s got experiences that have shaped them, that shape their thinking. So for me, the time I use PFM nowadays is, if I’ve got a severe, high force, bruxist patient, and I would like to have a metal occlusal. Because it’s got very good wear properties. It’s got very good strength and longevity. I can be more conservative by having metal only, right? So I don’t have to drill as much. But then maybe on the facial, I’m not going to go for a super aesthetic. Maybe it’s a first molar, maybe it’s a second premolar. And so I’m still going to be a minimal prep and accept that it’s going to be an ugly looking PFM. Like, only the buccal will have porcelain, but it’ll be a very thin porcelain, and it won’t be very aesthetic, but for this more functional tooth wear case, it’s going to be completely adequate. So that’s where I’m using it at the moment, whereas we’ve pretty much moved to zirconia and lithium disilicate, which are the two main types of ceramics. [Emma] Yeah, yeah. So another question that I did have was, what factors determine your choice of ceramic material for I’m going to say largely for posterior versus anterior restorations. [Jaz] Okay. It’s very simple and it doesn’t change so much depending on anterior versus posterior for me. [Emma] Okay. [Jaz] Okay. So put it this way. If I know that I need to go indirect. So I’ve decided, and so again, recap a little bit. For posterior, you know that it’s too ambitious to go direct here. You’re literally having to do an MODBL. You’re going to find it difficult to get good contact points. Maybe the tooth is root filled and you need to cover over the cusps so that the cusps don’t bend and flex and break. So there’s so many good reasons sometimes to go indirect. So, when we made that decision that we’re going indirect posteriorly, if I’ve got enamel, all the way around, I’ve got a decent amount of enamel and the tooth isn’t so destroyed. It’s still got some enamel to bond to. My substrate to bond to is good. I will go for a bondable partial coverage restoration. So do you know what I mean by partial coverage? [Emma] Like an inlay or an onlay? [Jaz] Yeah. Not so much inlay in this scenario. I’m talking about an inlay is basically you could have done the DO composite, but you asked the lab to do it instead of you. That’s essentially an inlay. Right? The onlay more like covering over the, like an overlay. You’re covering over the cusps. And you’re bonding to the enamel. The ceramic, etchable ceramic, which you talk about, okay, lithium disilicate, right? I will go lithium disilicate because it’s conservative. Why should I have to remove any tooth structure that I don’t have to? If I can bond to the ceramic, it has no retention form. It’s got a tiny, teeny bit of resistance form. We’ll talk about that. But I’m relying on the quality of the enamel for my bonding. It’s very conservative. You literally, all you have to do is remove the old MOD amalgam. Take the cusps down a couple of millimetres and that’s your prep pretty much done. You just smooth it and you block out the undercuts with composite. So the prep is enjoyable. You feel like you’re saving so much tooth structure. And if I’ve got enamel, I will use lithium disilicate. Why lithium disilicate? Because it’s got very predictable bond. I will not use zirconia partial coverage restorations, even though nowadays some clinicians are. And I’ve asked this to real top dogs, okay? I’ve asked this to Dr. Nasser Baghi in 2018, is a top dog in the US on zirconias and ceramics. Recently, where was I? I asked Chris Orr this question at BACD just this year, 2024. And I said, when these zirconia restorations are showing such promising data that we can bond to them, should we be moving away from lithium disilicate? He’s like, no, we have this beautiful material, lithium disilicate, that’s predictable and it’s got so many advantages. Let’s just stick to this. I mean, he’s not yet moving on to zirconia posteriorly. If posterior and has good enamel, I’m going Emax, which Emax is a brand by the way, it’s a brand of lithium disilicates by Ivoclar. Okay. The other one is LiSi by GC. So they are both examples of lithium disilicate. Now that same molar that has got less enamel, maybe the mesial and distal caries is really deep and you’re on dentine now. And you have just generally less tooth structure. I’m instead going to go to for zirconia, I’m going to go a full crown all the way around 360 degrees and I will prepare and this might blow your mind as a student, but something called a vertical preparation. Now being the Protrusive Student you have access to all my webinars. You have access to everything. You should eventually do VertiPrep for Plonkers. It’s something that teaches everyone to do their first vertical crown, but essentially there is no shoulder. There is no chamfer. You’ve hardly drilled into the tooth. It is a super conservative way to deliver a crown in a really lovely conservative way. So I’m getting all the benefits of having retention and resistance, but I’m not sacrificing much more tooth structure to get that. So if posterior is either lithium disilicate, if I have enamel, or zirconia, if I don’t have enamel. And then, like I said, in that severe bruxist patient, if I want metal occlusal, I might go PFM, but that’s rare. Any questions on that before I move to anterior? [Emma] No, it’s a different take to what we’ve been taught at uni, but it’s interesting, like, it makes sense. [Jaz] What have you been taught at uni? I’d love to know. [Emma] So a lot of the things we talk about at uni are purely based on like strength and aesthetics and how certain ceramics are better anteriorly because they’ve got good aesthetics but then posteriorly you want to use something else because they’re stronger, they’re more robust. [Jaz] Can you give examples? Do you remember the names of ceramics? Can you give some examples? [Emma] Is it lithium disilicate? [Jaz] Don’t worry if you don’t remember. It’s okay. I hardly knew anything about ceramics when I was at your age. It’s great already. [Emma] Is it lithium disilicate that’s better for like translucency in the interior or have I got that the wrong way around? [Jaz] No, no, it’s got the different ingot types basically. So it’s like high translucent, low translucent. So yes, lithium disilicates can be quite nice looking. A lot of veneers are done in this type of material, but it is totally appropriate to use posteriorly as well. Let me say again, it is totally appropriate. And here’s the magic bit. Now, the most, probably the most important part of this podcast will be this, providing you have enamel because if you have enamel, you can bond. What I don’t do is I do not place lithium disilicate and I don’t cement it. So for me, the way my mind works is if I’m cementing and not bonding, if I’m cementing, just using a GIC based cement, so I’m not relying on enamel for adhesion, why would I use lithium disilicate? Do you know why? Do you know why I’m against using lithium disilicate? The magic property of lithium disilicate and feldspathic porcelain veneers, the magic of what happens when we bond them. [Emma] No. [Jaz] And that’s totally fine. I wouldn’t have known at your stage, but the main lesson here is feldspathic is a type of ceramic, basically. It’s a very beautiful ceramic traditionally used for veneers. Not so much anymore because the number of technicians who are skilled at this is less and less and less as we’re getting more CAD cam and whatnot, and then labs are getting more digital, but essentially these veneers are beautiful. But they are weak. Something from my mind, I remember like 90 megapascals, let’s say, right? So they are weak compared to 250, 300 megapascals of lithium disilicate. So they’re weak, but they’re beautiful. But once you bond them to enamel, they are so strong. It’s a bit like a tile, a glass tile. If you drop the tile, it’s going to break. If you actually glue that tile on the floor, it is strong. That was the analogy that was given to me when I was a student. I still remember this basically. So using lithium disilicate posteriorly and bonding it excellent strength. Good. It’s going to be fine. As long as you give it enough thickness, 1. 5, two millimeters, you’re golden. Okay. If you don’t respect the thickness. Or, if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented, is a completely different ceramic to the same ceramic lithium disilicate, bonded. [Emma] Yeah, okay. I didn’t know that. I’d never, like, it probably has come up in lectures before, but it’s not something that I’ve ever really thought of. [Jaz] So that’s why I don’t do lithium disilicate cement, because I’ve got this wonderful material, super strong, called zirconia, and that is really amenable to cementing, and I can get my retention resistance form, because I’ve decided I don’t have much enamel here. So I’ll do a vertical preparation crown posteriorly using zirconia, which I’m going to cement. You could be fancy and bond it, but why complicate the protocol? [Emma] Yeah, that’s true. No, that makes sense actually. Think about it. I’ve never heard the analogy with the tiles as well and how it’s a totally different thing once it’s actually glued onto the wall or the floor. [Jaz] They behave differently. But I mean, the other key lesson here is giving enough occlusal clearance. So the biggest mistake we make when giving occlusal clearance is A, we don’t give enough. And we think we’ve given enough, and he gets a lab, and they’re kind of literally squashing and squeezing this material in, okay? And, I don’t know why dentists are so afraid, myself included, back in the day, trying to be as conservative as possible, occlusally. Yes, it’s good to be conservative, but with a lot of these broken down teeth, the occlusal part is like composite. The tooth is lower down, right? So, I’m happy to sacrifice more tooth structure, have a more thickness of crown material that will really make it unbreakable. So, just remember that. And the common place that we will under reduce is the fissure. The actual fissure itself, okay, is the most likely area that will be under reduced. And the other common mistake is, let’s say you’re doing a pre molar crown, right? And what you do is you end up flattening the occlusal. You don’t follow the same anatomy, right? You see like the cuspal anatomy, basically it goes rise and fall and rise. If you don’t respect that and you flatten it, great. The cusps have been reduced nicely, but that middle portion, you’ve hardly reduced it. And that’s a big technicians. That’s the biggest issue they have. So remember when you’re doing the occlusal reduction, follow the anatomical form of the tooth. So it’s a uniform reduction, and then you’re going to get enough thickness where it matters. ‘Cause that’s where the fossa of the tooth is, that’s where the opposing cusp will put the occlusal load down. So if you want ceramics, that’s not going to fracture. You’ve gotta do that. The other thing, which we haven’t talked about, which you’re probably going to ask about anyway, but do you know the difference between something called like, what I mean when I say the term monolithic, and when I say layered, do you know the meaning of this? [Emma] Is this the way that it’s like milled or put together or constructed? [Jaz] Not quite, like once you have that lithium disilicate, right, that block is ready to go on, right, there’s two ways to treat it. One is you accept it how it is. And it’s a really strong material. But it’s not as beautiful as it could be. We can make this. So let’s talk about an anterior crown, right? So if we’re going to do a lithium disilicate upper right central crown, central incisor crown in lithium disilicate, if you have a monolithic, which means that it’s just the pure lithium disilicate material, that kind of like a one shade. It’s got some transparency, but it is like the one bulk basically. Versus the same crown. But what you do now is you shave the buccal of the crown down a bit by 0. 5 millimeters, for example. And then you add some beautiful weaker ceramic on layer it. You put these effects in. Okay. That second one, that layered porcelain fuse on top of it, basically. It’s going to look so much more beautiful. We’re going to put those effects in. It’s going to look gorgeous. But it’s now weaker because now you have an interface between the monolithic ceramic and the layered ceramic. And therefore another golden rule here is why would you do a layered ceramic posteriorly? Why? Don’t do it. The reason why zirconia had a bad rap initially, and also Emax, lithium disilicate had a bad rap initially. It’s because dentists were doing these gorgeous restorations posteriorly and they were layered. So they were actually putting this beautiful weaker ceramic in the occlusal loading area and guess what was chipping? It was delaminating, it was chipping away. A bit like, maybe you’ve seen this Emma, have you seen PFMs where the porcelain’s broken away and the metal’s left behind? [Emma] I’ve never seen it, no, but yeah it can happen. [Jaz] Not even as your role as a nurse? Do you remember not seeing it as a nurse maybe? [Emma] Not that I can remember, no, not that I can remember. [Jaz] Fine, so it’s the same thing, like, ceramic is bonded to the metal. In the same way the beautiful ceramic is bonded to the monolithic stronger form, basically. So anteriorly for some patients who are high force, maybe they’re bruxist, you can still do a monolithic Emax or monolithic lithium disilicate. It’ll still look good. Maybe a 7 out 10 before an aim for a 9 out of 10 plus. You want that same ceramic, but you want it layered, basically. And so that’s the difference. So anteriors tend to layer. For most patients posterior, monolithic. Even when it comes to zirconia, you know? Yes. The downside is they look very opaque. They look a bit too white, right? But it really depends. It’s a conversation I have my patients. How important is it to you that this molar tooth right looks absolutely gorgeous? How important is to you? And I wait for them to say the answer. And I say, okay, you want to look gorgeous, but what if I told you, if you accept that it’s going to look good but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you longevity or beauty? And you can’t have both sometimes. And let the patient decide. Because that is then the ultimate level of consent. [Emma] Yeah, and would that still be your same protocol for patients that are heavy bruxists? [Jaz] Okay, so heavy bruxists. So let’s say that I’m treating heavy bruxists basically, some schools of thought say that because you’re treating heavy bruxists like your molars which take the highest force because remember the masseter muscle is right there, right? The medial pterygoid muscle is right there. It’s right by the joint. So the forces felt in the molar region are significantly higher than the forces felt on the anterior region. So then people say oh do gold on the second molars, right do gold restorations. They’re longer lasting the more forgiving or maybe do a milled cobalt chrome something metal is considerable. And I get that but the studies would say that as long as you give your ceramic enough thickness, it will fare well, even in bruxist. And another thing with bruxist is that if it’s a true pathological bruxist, then you, they spend all that money, you want to protect it with an appliance. Things will just last longer. It’s something that we need to accept that. Okay, some patients will need protecting. But when it comes, even without protection, you give enough thickness, the ceramics will survive. But again, posteriors, I will go monolithic. I will not layer. As I say, no need to layer, especially on a bruxist. [Emma] Yeah. Yeah. [Jaz] You’re just asking for trouble. You’re asking for things flaking and breaking away. [Emma] No, that makes sense. And that’s largely what we’ve been taught at Glasgow as well. We’ve went over gold crowns and things like that, but not in too much depth really. But no, that definitely makes sense. [Jaz] The last time I did a gold crown on a second molar, guess how much the lab bill was? [Emma] Cool. I don’t know. [Jaz] It was like 400 pounds. Absolutely crazy. Like the price of gold is so high. And so I went to a British Society of Restorative Dentistry lecture once and there’s a chap, I think his name was Phil Taylor. I think I might be getting it wrong here. And he was a restorative consultant and he suggested that long time ago, he moved away from gold because of the cost reasons to a very good alternative, which is a milled cobalt chrome. And chrome is very kind to enamel. It is stronger and more rigid than gold, which actually is a negative property. The strength of gold that is because it’s softer, it adapts nicely to the opposing dentition. Whereas the cobalt chrome is you have to get the occlusion a bit more spot on. It’s a bit less forgiving, but it is a very good long lasting, and you can still be very minimal in your prep basically. So I have been doing a lot of milled cobalt chromes when I want to do metal in the posterior. [Emma] Yeah, I’ve never heard of that. The milled cobalt chromes before actually. But is there a lot of labs that still do like gold crowns? Like they’re definitely still out there, but. [Jaz] Yeah, oh, they’re definitely out there. But be prepared for a, be prepared to prep as minimally as possible. Otherwise the lab bill will be crazy. So add more core, make sure you max out on the core and then prep back to do the bare minimum basically. But jokes aside, the labs will do it. Still fantastic restoration, right? And a lot of dentists will, when in a dentist in their 50s and 60s, when they need a crown, that busted molar, they will ask for gold. They will ask for a three quarter gold crown or whatever. It’s a beautiful material. And what really inspired me to get into tooth wear was looking in someone’s mouth once. And I was a fine year dental student and just seeing this beautiful posterior gold work. And that really inspired me to go more to restorative. [Emma] My next question was about challenges when we’re fitting these types of restorations. So what are like the most common challenges and how do you overcome them? Because I know in practice, I’ve never done direct restorations myself yet. Hopefully soon. Indirect, sorry. Am I getting that right? [Jaz] Yes, so things that are made outside the mouth are put on. [Emma] Yeah, yeah, so I’ve not done any indirect restorations yet, but I know in practice like I’ve seen etching with acid and air abrasion, like are these necessary steps or are these steps that only some people will take in order to help prevent challenges? [Jaz] Okay, excellent question, okay, and you need to know your material. You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate, but I know some clinicians who wherever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not is clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that. The other thing to bear in mind is you need to have the right tools in your clinic to be able to follow those rules. So for example, if you are going to do a resin bonded bridge, or maybe even a zirconia resin bonded bridge, okay, and these for something like lateral incisors, in the right case, they last so well. The Matthias Kern data is brilliant, but you need to follow the APC protocol, which means you do air particle abrasion. Use a zirconia primer. So if you don’t have a zirconia primer, don’t even bother doing this. Okay. And you use a composite resin cement, basically. And so you need to follow to get the success that you see in the papers. You need to follow the protocol exactly. So the most common mistake I see is lithium disilicate restorations. The dentist doesn’t know if the lab has etched it with hydrofluoric acid or not. They don’t know. And then they are either just thinking, Oh, the lab did it and I’m not going to do it. So maybe it’s never been etched. And the whole way that the lithium disilicate bonds to the enamel is because you want this like tiny little porosities in there to kind of like etched enamel, right? You want the ceramic to actually give you that bond strength. So you need to work with your ceramic properly. So speak to your lab technician, find out who’s taking care of the etching. Once you’ve done the etching, you want to make sure you’re not air abrading something like lithium disilicate, and then you’re following your bonding protocol to a T. When I’m doing my vertical zirconia because I’m not bonding. We call it plonking. We’re plonking this on. It’s so easy. Cut on a roll. Dry the tooth a bit, but I use something called IO clean to clean out the ceramic, but that’s not so important. So I’ve got my nice clean zirconia. I’m justly putting some cement inside. I’m plonking it on my thumb. It is so easy as long as there’s no bleeding and I think it is so, so easy when I’m doing a lithium disilicate, I’ve got rubber dam on. No compromise. Rubber dam has to be on, okay? You’ve got to make sure that you can access the margins beautifully. I got PTFE tape on the adjacent teeth, make sure I don’t get any etch on the adjacent teeth. I’m following everything. You’re preparing the ceramic in a certain way, including the silane. You’re preparing the tooth in a certain way. You’re air abrading. You’re making sure the air abrasion doesn’t touch the adjacent teeth, otherwise they’re going to stain in the future, all these things. So bonding is more technique sensitive. More can go wrong, but if you follow the steps properly, it’s incredibly predictable and it’s a very fun appointment. I love both. I love both plonking my zirconia crowns. And also love spending a bit more time. So zirconia crown is half an hour for a lithium disilicate. Overlay restoration is 45 minutes to account for the extra steps, treating the ceramic, the rubber dam isolation. And so the main answer here is know your material, know the best way to treat it. Make sure you’ve had a conversation with the lab to know how they are treating it. And therefore there’s no confusion and you can follow the right protocol. [Emma] Yeah, definitely. [Jaz] Is there anything about a specific protocol that you want to know, or? [Emma] One question I did have actually, see when you’re saying you’ve got rubber dam on in that scenario, what teeth are you, like, is this like a split dam? I’ve just never seen this before in practice when someone’s got rubber dam on when they’re cementing a crown or bonding a crown, whatever. I’ve never seen that before. Like, are you doing a split dam? What teeth are you bringing through, like? [Jaz] Okay. Good question. Okay. So some colleagues would say that split dam is absolutely fine because then what you’re kind of reducing is you’re reducing that mouth breathing element of the patient. So split dam’s good, but I don’t see the point of split dam for most cases, because the gingiva is still there poking out. And if you’ve got like most of the times when I’m replacing these MOD amalgams, I’m doing these ceramic overlays. You’re literally equigingival or very slightly subgingival. And so if you’re using a split dam, your papillae are just contacting your margins or there’s a fluid, a gingival crevicular fluid or sometimes blood. So I’m not a fan personally of split dam when it comes to bonding of my overlays. And what I will do is I’ll do a quadrant isolation. So if I’m doing a first molar, I will do a quadrant. So maybe something like an upper lateral all the way to the second molar. I’ll make sure I’ve rehearsed the restoration when the rubber dam is on to make sure I’ve got a nice path of insertion, I can seat it, I can locate it well. I’m then following all the steps for getting the onlay ready, the overlay ready. I’m following all the steps to get the tooth clean and ready. And then, while the rubber dam is on, and what the rubber dam does, it suppresses your papillae. Now, you can see clearly, you can walk a probe around your margins, okay? And it also makes it clean up easier as well, basically. Because then you’re not, as soon as you start cleaning up, you poke the gum, it’s going to start bleeding. The rubber dam will protect you. It’ll give you some protection basically. So I’m not a big fan of split dam when it comes to bonding my ceramics. Remember Emma, you’ve got access to all of this and those dentists who are listening, watching, I’ve got example videos of through, POV, point of view. I’ve got my loop camera on. I’m bonding these lithium disilicates exactly how Emma’s described on the rubber dam. So I’ve got all those videos in the Premium Clinical Video Section of Protrusive Guidance, so do check those out guys. [Emma] I think a lot of students can get quite frustrated with rubber dam and I think it’s because we’ve not yet seen the benefit that it can have, you know, we’ve not been doing this long enough to see the failures when you don’t use it. [Jaz] Oh Emma, when I was in third year, I remember being in a locker room and there was a dentist, I’ll name him Michael Spencer, with me and him I just, I remember him being there in the locker room and I said to him, when I’m at dental school, I’m never going to use rubber dam. I said, cut and roll all the way. I said that to him. And now like, although I’ve relaxed in the last couple, I was like very much rubber dam police before I’ve relaxed a bit because I’ve now found like greater curve matrix, which gives such a wonderful seal that I need it less and less. So as long as the patient’s not a mouth breather and it’s the upper tooth. I can pretty much do a lot of it using a nice metal shield, basically, as long as a mouth breather. If I’m working on the lower arch, I’m pretty much always using rubber dam. That’s my recipe at the moment. And for me, Emma, it’s like, forget the increased bond strength. Forget the risk of contamination. Forget the access to the margins and suppressing the papillae. The main benefit of rubber dam for me is relaxation. That rubber dam is on, the patient can’t speak. Amazing. Fantastic. Rubber dam is on. Okay. And I can turn away and know that I can sleep well at night knowing that no one licked anything. I can drop my onlay and it’s fine. It’s because the rubber dam is going to catch it. Comfort for the patient I think is good. I just find it’s a happy place to be. Rubber dam is on. It’s just a beautiful, happy zen zone, that’s my number one benefit. It’s very selfish. I use rubber dam because it reduces my stress. [Emma] No, the few times that I’ve placed rubber dam as well, like it’s very, very frustrating. Like I’m not good at it, but once you saw it. [Jaz] You’re not good at it because you haven’t done it enough. And you’re probably using the crappiest dam in the world, the green one. Right? [Emma] I think for, we actually do have the thick blue ones in the dental hospital, or they give us that for OSCE’s anyway. [Jaz] Well, okay. Again, so posterior, and again, everyone’s different with what they recommend. And for me, posteriors, I like to go medium thickness. Anteriors I go heavy. Because anteriors often you want to suppress the papilla a lot because you’re doing like bonding and stuff, that kind of stuff. Whereas posterior is you want it easy to go on. Right? So medium is a thinner. So, when I was learning, I was using that horrible green dam, right? [Emma] Yeah. I know the one you’re talking about. [Jaz] And the other terrible ones, that purple one, that ribbed purple one, they call that the devil’s condom. You punch one hole. You punch one rubber dam hole in it and you put it over your head. I think someone called a John Cowie, the Endo Chap in Bristol, mentioned from Instagram, it’s hilarious. You put one hole in it and you can literally poke your head through one hole and it’s just a nasty rubber dam. Okay. And so really you want to go something like nictone. I love the unodent stuff, just some thin stuff that doesn’t tear. It greatly, you know, the right tools, the right job. It greatly improves your stress. It reduces your frustration when rubber dam becomes easier. Once you’ve got a system of doing it. For example, I find that dentists, when they’re struggling rubber dam, they’re trying to do too much themselves. When I’m doing rubber dam, it’s a four handed job. Once I’ve got it over my clamp, I’m just setting in place. My nurse Zoe, she knows she’s going to get a floss set out. Floss set, not floss because guess what? All of my nurses have got fat fingers and they struggle to floss my patient’s teeth. So you give them a floss set. And they can easily just go through and take that rubber dam with it, basically. Okay? I joke about the fat fingers. They struggle, right? There’s four hands in there. It’s difficult to get a floss set in. You remove the hand out of the equation. [Emma] Yeah. And I’ve never seen anyone do that. Like, I struggle so much. You feel so silly as the nurse as well. Like trying to floss that through. You’re like, I know how to floss, but it’s, it’s really, really difficult. [Jaz] Angulation and everything’s different. But when you use it, it’s so much easier. [Emma] Yeah. Yeah. And we use the, it’s the unodent one that we have at uni as well. I think we used to have the purple one before, but it just wasn’t good. [Jaz] It’s good you’ve got the good stuff. I would say use it more, but when you next have some direct restorations, please, I really want you, cause you’ve got all the time in the world as a student, right? I want you to go through that difficult period of using rubber dam, quadrant, isolate the quadrant, watch my webinar. I’ve got 30 videos on Protrusive Guidance. It’s like five minutes, 15 minutes of cases I really struggled in, unedited raw footage of me putting on rubber dam. Revise all of those. And I want you to use that technique. And I want you to promise me that you’re going to use rubber dam because now is the best time. You start practicing now. Wow. You’re going to absolutely sail. [Emma] Yeah, definitely. I think it’s so frustrating, but once it’s on, it’s good. And once you’re good at it, you’re good at it, you know. [Jaz] Buy a packet of flossettes, cause maybe you don’t have it in clinic so take your own flossettes with you, okay? You got the unodent rubber dam, which is great. And follow the instructions in those videos and the webinar. Trust me, like you’ll have such a less frustrating time. [Emma] Yeah. And hopefully I get to do some indirects. [Jaz] Even just direct. I want you for, you know, comps, for your comps as well. That’s where you practice. [Emma] Yeah, yeah, definitely. And they’re quite big on rubber dam in Glasgow, so it was good. My next question that I did want to ask you, Jaz, was about intraoral scanners. We have one in the dental hospital to let the students play with. I’m sure it’s on the staff clinics, probably. [Jaz] I can imagine all the things the students have been scanning. [Emma] Yeah, taking us like half an hour. [Jaz] And then lose the handle, it’s a funny thing. [Emma] Yeah. Do you think, like in your practice, like in your surgery, Is an intraoral scanner like an essential for you, or do you think it’s very much possible to achieve the same results with traditional impressions? [Jaz] Oh, I mean, impressions are king. Like, impressions are great. But the question really should be switched. Is it possible to achieve the results with digital that the good results we’ve always had with analog? And the answer, I think, is yes, in most cases, but you have to remember a few rules. When you’re using something like silicon based impression materials, because the flow of it, it can go under the sulcus, it can capture the details. With a scanner, you can only capture where the light goes. And so with digital techniques and scanning, you need to be more aggressive with your retraction, with your retraction cord, with your suppression of the tissues. Tissue management becomes more complex when you go digital. Tissue management, it’s easier because the light bodied silicon will flow in those areas and will save you. So analog is amazing, but digital with these quality scans, I mean, like prime scan, that kind of stuff. They’re really, really great. I use a scanner, which is not that as good for restorative. I use the iTero. I don’t care if I’m saying brands and stuff. It is what it is. They’re good for Invisalign and that kind of stuff. But the one I use at the moment, It’s not wonderful for restorative. I’ve been using it fine. I just have to then take extra time and really suppress my tissues and try and spend what time get as the best scans I can. When it comes to sub gingival areas and especially vertical preparations, You know, I went on Marco’s course in Sicily and he showed me my own scan. Like the, what the technician sees with his scans is sometimes it will make you cry. Impressions for subgingival areas and vertical preparations is still king and scanners are still catching up. But for things that are supra gingival, scanning accuracy and the ability to produce really good restorations with a good fit is fantastic now. So it depends on now if you’re working subgingivally or super gingivally. The answer is scanners are pretty much there, but they still have a bit more improving to do. [Emma] Yeah. Do you think impressions will ever, I don’t know, not not be a thing? [Jaz] I think eventually they’ll be phased out. I think so. I mean, the amount of impressions, I would love to speak to a technician and find out the amount of technicians that are getting in analog work. And what percentage of that work it is. I’m sure it’s declining rapidly at the moment. I’m sure there’s still niche scenarios where impressions are king and analog is king, but most indications, even dentures are going very digital, believe it or not. So digital is the way forward. There’s still the few, sometimes you use your analog to compliment your digital. So I don’t think it’ll be fully obsolete, but I think they might be five, 10%, whereas the digital will be the 90%. [Emma] Well, that’s good. Cause I’m rubbish at taking impressions. [Jaz] You’ll be rubbish at scanning as well. You think it’s easy. iTero scan, I took, like, took me like half an hour. Now it takes like three minutes, but it’s like a steep learning curve with everything. [Emma] Yeah, definitely. But, no, that’s interesting. That’s interesting. The last thing I did want to ask you was about the lab and I know that you’re very specific with your labs. You’ve got great communication with them. Like, are there specific challenges or preferences that you have when working with labs on ceramic restorations specifically? [Jaz] It’s a journey you go on with your technician and a great piece of advice that was given by my technician, Graham, who came to the podcast a few times is try and find a technician who’s like a similar age to you and you work together and you send all your cases to that guy or gal and then you communicate over WhatsApp and you grow together. There’s something really beautiful about that. And then dentists, when I say to dentists that I helped to train my technicians to improve this element of it, they think, but you’re a dentist. What do you know about the technician side? How can you train them? But when you speak to a technician, they’re very grateful. Equally, the technician trains me. And he tells me, he shows me my scans at all. You know, you should have smoothed this amalgam in the mesial, like you didn’t. And it’s made it more difficult for me and you’re constantly learning together. So firstly, the lesson here is communicate with the technician, even if you’re using a bigger lab and you don’t even know the name or the face of the technician that’s making it work, the more information you give them, the better. So if you just say Emax crown, A3 upper left six, okay, how much care love and attention do you think the technician will give they’re just going to put the bottom of the pile and they’ll make you something that’s acceptable. Hopefully. If you say lithium disilicate, overlay restoration upper left six shade A three, but it’s got hints of a higher chroma cervically. My mesial margin was a bit questionable. Please let me know if it was acceptable or not. Please give me some feedback. Okay, so you’re inviting them to give you feedback. There were shim stock holds on the upper left first premolar, second premolar. The second molar wasn’t holding shim, but the third molar was. So now I can verify the bite. Okay. And then you say that please follow the cuspal inclines of the adjacent teeth because this patient’s got group function. And I’d like to keep that because we’re not changing anything about that basically. Try and aim for a couple of contacts with the opposing tooth, where you see the cusp of the opposing tooth, try and create these landing areas in this molar. And so when you give all that kind of information, All right, you’re going to get something much better back. [Emma] Yeah, yeah, and who I have on a Friday morning on my Pros clinic, Mr. Fogel. He was a dental technician before he was a dentist. [Jaz] They are the best dentists. [Emma] And he, yeah, he loves Pros. He loves it so much. And we were doing a tutorial about lab, some, I can’t remember what it was about, anyway. [Jaz] I have no idea what it was about. It was something I just showed up hungover. It was- [Emma] He was talking about inviting your lab technicians to critique you and vice versa. And just about like- [Jaz] Some technicians are scared to critique their dentist because they’re thinking of losing business, losing a client. But when you give them from the get go, from the get go, I tell Graham, listen, don’t beat about the bush with me. If I’ve done something not to your standard, you gotta tell me. Equally, when you cock up, and he does, and I cock up sometimes, and you know, when he drops the ball, I’ll tell him. I’ll send him, because I’m recording my videos of me doing the procedures, unfortunately, he gets the crudest feedback. He sees me struggling to fit the crown that he made, and he’ll see that, oh, yep, I kind of overdid it on that medial contact, and he gets to see video footage, or very rarely, but sometimes I reject a crown, because there’s an open margin there. And you get to see my photos and videos. So it’s painful being a technician sometimes when you’ve got the clients like me, but equally when I’ve done something wrong, he’ll tell me, and it’s a beautiful to grow like that. And our mistakes are getting less and less. And we are able to really serve our patients better. [Emma] Yeah, definitely. And I think it goes both ways. Like, I think dentists, well students anyway, are often scared to speak to their lab or if something’s not gone quite right to talk to them about that. But Mr. Fogle was saying, he’s like, if you phone up a lab, he’s like, I’ve never spoke to some, a technician on the phone that wasn’t very pleasant. It’s like, no one wants to lose business at the end of the day and you want to have a technician. So yeah. [Jaz] I was always taught that a average dentist and a good technician will do very well. So pick your technician wisely. Pay a little bit more premium for your technician basically. Get a good technician and they will save your bacon. [Emma] A hundred percent. And I think that’s all the questions that I had to do, Jaz. [Jaz] Thank you so much. And I’m excited for you to, A, start doing some rubber dam dentistry. I would love for you to do it and feedback, see how it went. And yes, but first, a hundred times you’ll be frustrating, pulling your hair out. And the hundredth first time you’re like, you know what? Today I isolated and I didn’t cry while isolating. It was good, right? So you know, you have to go for it, please. You have to go for it. And then also when you start coming to your first indirect restoration, let’s have a chat. Tell me what material you got in mind, what your technician suggested, what your tutor said. And you’re in this funny position as a dental student where you kind of, you don’t have free mind. You’re kind of led by what your tutor says on the day. And then there might be a different tutor on the day of fit. And they think, what the hell was this initial thing in this life? And that’s how it works. Embrace it, enjoy it, embrace it. As long as you’re there, like a sponge learning, you will fly. [Emma] Yeah, for sure. Like, I’ve been frustrated a couple times with treatment plans changing, different clinicians like, pick their brains about it. They’ll all have different opinions and that can be frustrating at the moment and maybe for the patient as well, but it’s like a goldmine of tips and tricks to pick up on. Just pick everyone’s brains whilst you can. [Jaz] It’s important. So whenever someone changes a plan, that’s totally cool. But can you say, hey, Mrs. Smith, like, I see that you changed this from a filling to a crown. Or, use the other way around, crown to a filling. May I ask the rationale behind that so I can learn this a bit more? And then just, yeah, listen and learn and you know that everything is justifiable. There’s no hard and fast rules and dentistry. You can just justify everything as long as there’s a good why and a good reasoning behind it. [Emma] Yeah, for sure. And I can’t speak for any other universities, but I think dentists that are in education, like they’re all a bunch of nerds. Like they want to talk about it. They want to be asked why they love talking about it. So they will stand there and show your ear off for 20 minutes if you want them to. [Jaz] And you know what, sometimes they just want, like, sometimes it’s a wish that students were more receptive and not on their phone. And sometimes if you’re there to listen, they will give you something. If they suss out that you’re actually really keen. Like, they will give you everything. Like, if you show that enthusiasm and keenness, you will really gain a lot. So, keep that in mind, guys. [Emma] Definitely, definitely. [Jaz] Great, Emma. I hope you have a, okay, by the time this comes out, maybe after Christmas, but happy Christmas, happy new year, and I’m excited to grow together in 2025 and inspire students all over the world. This month’s notes were ceramics, right? [Emma] Yes, ceramics, yes. So those protocols that we’re talking about, air abrasion, acids, all those sorts of things, different materials, when, when not, you would maybe use them, all those sorts of things. [Jaz] Great, and do you remember how many pages it was? [Emma] I don’t actually, no. [Jaz] I saw it was very comprehensive, lots of pages basically, but like lots of good stuff, very visual, nice protocols. So remember students, email student@protrusive.co.uk to prove that you’re a student. We’ll add you to space and you can access the crush your exam section where all the notes are written by Emma. Any images that we take, we always reference them, which is really important to say thank you to all the people because it’s difficult to generate these images sometimes, but we always reference where we got them from. And I think what we’re building here is a really fantastic resource. So, Emma, thanks so much. Keep up the good work and I’ll catch you soon. [Emma] Perfect. Thank you. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end, as always. Thank you to Emma and Team Protrusive. Without the team, I would be totally burnt out. The podcast would have died years ago, but it’s down to you guys, your comments, your love and hard work and dedication from the team that allows Protrusive to continue and thrive. We’ve got so much planned for 2025. The most happening place to be right now is our Protrusive Guidance app, our community of the nicest and geekiest dentists in the world. That’s where you ask your questions that you feel embarrassed to ask anywhere else, and you don’t need the anonymous function. There’s so much toxicity on Facebook groups, but not on Protrusive Guidance, because you, listening right now, watching right now, the fact that you made it this far, it means that you’re definitely very geeky. And you’re probably very nice. If you identify yourself as a Protruserati, I’ve realized that you guys are just amazing people. And so come and join your tribe on Protrusive Guidance. That’s protrusive.app to join in. For those of you on a paid plan, you can get your CE certificates. Just answer the questions below within Protrusive Guidance, and Mari, our CPD queen, will sort you right out. Oh, and don’t forget to like and comment below. What other topics would you like covered? Thanks again for watching to the end. I’ll catch you same time, same place next week. Bye for now.…
What’s the best way to reduce post-op pain after extractions? And why should we never use the term “painkiller” with patients? What to do when you hear the dreaded *crack* of a tuberosity? In this episode we talk about all things post-operative extraction complications! And I’m joined by one of the nicest guys in dentistry – Dr. Nekky Jamal Complications are something we ALL experience, so this episode is great for any dentist. Whether you’re brushing up on dry socket prevention, mastering post-op communication, or just curious about advanced healing hacks, tune in for real-world advice to make extractions smoother – for both you and your patients https://youtu.be/BvB3hDESYDY Watch PDP210 on Youtube Protrusive Dental Pearl: The “Niche Kebab” concept encourages dentists to narrow their focus by reducing the variety of procedures they perform and prioritizing those they genuinely enjoy. By evaluating every new skill or treatment added and strategically dropping less-loved procedures, dentists can avoid overextension and the “jack of all trades, master of none” pitfall. Learn how to Extract Impacted 3rd Molars, don’t miss out on Third Molars Online and use the coupon code ‘protrusive’ to get 15% off! Key Takeaways Pain management is about setting realistic expectations. Dexamethasone can be beneficial but must be used cautiously. Dry socket is often overhyped; proper care can prevent it. Effective communication can alleviate patient anxiety and prevent misunderstandings and complaints. Preoperative care can help manage pain expectations. Understanding the signs of infection is essential for diagnosis. Chlorhexidine rinses can significantly reduce dry socket risk. Patients appreciate being informed about their unique dental situations. PRF can significantly reduce the incidence of dry socket. Dentists should embrace new techniques like PRF to enhance patient care. Patient involvement in post-surgical care is crucial for healing. Dentists should not hesitate to refer complex cases to specialists. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:54 Protrusive Dental Pearl 04:05 Dr. Nekky Jamal 08:39 Managing Post-Extraction Pain and Swelling 21:37 Infection 25:02 Identifying Dry Socket and How to Prevent it 28:30 Case Selection and Communication 37:13 Mitigating Dry Socket with Platelet-Rich Fibrin (PRF) 39:47 The Importance of Nicheing in Dentistry 43:19 Cryotherapy and Post-Surgery Care 47:32 Handling Tuberosity Fractures 55:08 Patient Consent 57:55 Litigation and Patient Communication This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes A, C and D . AGD Subject Code: 310 ORAL AND MAXILLOFACIALSURGERY (Exodontia) Dentists will be able to: Identify and differentiate common postoperative complications, and recognise the key symptoms associated Evaluate the ethical and clinical considerations of case selection for extractions Communicate effectively with patients regarding potential complications If you loved this episode, be sure to check out another epic episode with Dr. Nekky Jamal – Wisdom Teeth Extractions – SURGICAL TOP TIPS Click below for full episode transcript: Teaser: Overexplain and then have them on your page, have them take ownership for their anatomy before you even start. You know what I mean? Dentistry is about talking to patients and Jaz, you've seen how I talk to my patients. I keep everything light, but after I joke around, I say, okay, but seriously, do you understand that this is a risk like this could actually happen and in this case scenario I don't want that to happen for you. Teaser: I’ll do everything I can for you. But there’s things that are out of our control. Do you understand? And patients have to take ownership of it? Otherwise, I’m not doing work. I hate using the word painkiller because that’s just not realistic. It’s more of like a pain reliever. Okay, and so will you be in 100% pain free even with a painkiller or analgesic? No, you won’t, right? And so the job of an analgesic is to make you more comfortable, not to kill the pain. Patients, they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically it’s helping. But for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol. If you’re really interested in extractions or if you’re really interested in endodontics, like, become obsessed. Like become obsessed to the point where you’ve read every single journal article out there. I want you to go home and I want you to dream of it. I want you to feel like, your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to? Jaz’s Introduction: In this episode, we’re one of the nicest guys in dentistry, Dr. Nekky Jamal. We’re going to revise together how to manage the common complications of extractions. There’s a bit of a bias towards third molars, but actually the advice given by Nekky and what we discuss today is pretty much applicable to any extraction or any type of dental surgery. We’ll talk about the best strategies for post operative pain and why you should never use the term a pain killer. Nekky will also reveal why alveolar osteitis or dry socket is virtually non existent in his practice. He’ll tell you exactly what it does to prevent dry sockets. We also discuss the dreaded tuberosity fracture with golden advice on what to do if it happens to you and how to preempt it or prevent it. Lastly, this episode is actually full of communication gems. And actually the last six minutes talk a little bit about some stuff, which isn’t really appropriate for the public eye. It’s real dentist talk, if you know what I mean. And that’s why the last six minutes will be on the Protrusive app only. It’ll still be free, but we only on Protrusive app. It won’t be on Spotify, won’t be on Apple, and it is absolutely golden. So if you’re starting this podcast on YouTube or Spotify or Apple. And now that you know this information, you want to move over to Protrusive Guidance app, please do so now. 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. Some tip or advice that you can apply in your practice. This one’s about your mindset and something that we discussed in the episode. I call it Niche Kebab. The idea of niching down in dentistry and we talk about how by niching into a subspeciality or just reducing the amount of procedures you do and homing in on a few that you really enjoy. This is what keeps the fire burning in dentistry. This is what helps you to fall in love in the details of dentistry and how to be a happy dentist. Me and Nekky truly believe that. So here’s how you apply Niche Kebab. For every new procedure that you offer or you learn, or a new skill set that you add on, which procedure or treatment will you drop? I know that sounds a little bit scary or worrisome or maybe a bit extreme, but do you really want to keep adding procedures and adding procedures and spreading yourself out thin, becoming the jack of all trades, but the master of none? Protruserati, this is growth by subtraction. I just want to give you this idea or help you adopt this notion or this mindset that it’s okay to actually whittle down some procedures that you don’t love to give you the time and energy to focus more on things that you do love or things that you could potentially love or new skills that you can add on. So remember, so don’t just keep adding and adding and adding. Think about what you will remove and eventually you can achieve Niche Kebab. I’m claiming that one by the way. Anyway, hope you enjoy the main podcast and I’ll catch you in the outro. Main Episode: One of my all time favorite dentists in the world, generally one of the nicest guys ever. Dr. Nekky Jamal, welcome back to Protrusive Dental Podcast. How are you, my friend? [Nekky] Jaz, this is a huge honor. Man, I listen to the podcast all the time. I’m just so proud to be a part of it, man. You’ve done some huge things across the world and help so many dentists. I’m just a fan boy over here, man. [Jaz] No, no, no. Look who’s talking, man. Like we all love your stuff, and it’s your charisma is the way. You very much fall into the values, which I’m going for with protrusive, right? The kind of dentist who are nice and geeky and like, you’re solely geeky. Like you love everything you do. It’s just so clear and you’re funny and you’re very likable. And so it’s just great to build these connections, transatlantic connections with yourself. And it’s just great to have you back again. You’re messaging the way you speak. It’s all brilliant. So very excited to delve into third molar extraction complications today, following on from the previous episode that we’ve done. Now, before we hit the record button, you told me something very interesting. You told me that you live six minutes away from where you work. So I want to know, with the amount of extractions that you do, and with the level of extractions, you’re going to get complications, right? Everyone’s going to get complications, okay? Including you, believe it or not, okay? People out there are like, no, surely Nekky doesn’t. I’m sure it does. Have you ever had that patient knocking on your door on Saturday? [Nekky] Yeah, unfortunately. Living in a small town, everyone knows where I live. But you know what, it’s crazy. The only time I’ll get knocks on my door is like facial trauma. Like, a kid falls off their bike and they’ve smashed their front teeth. And you know, they don’t know what to do. And so they’re like, oh, I’ll just go, I’ll go talk to Nekky. And then, we’ve had some fun times. Like, people show up to the door all bloody in their face. And they’re like, you know, can you fix this? And you’re like, yeah, all right, let’s go, let’s do this. And that’s crazy. Man, for me, that’s the best part about being in a small community because you build relationships and it’s not like, I don’t advertise. I don’t do any of that stuff. It’s all about building relationships with your patients. And yeah, I’ve been fortunate. I haven’t had too many knocks on my door for patients in pain. Hopefully I can keep those away forever. But, yeah, no it’s all a part of the fun of living in a small town, a little bit different than London, I would say. [Jaz] Well, you know, I work in Reading. I lived in Reading for a while as well. And it was like a three minute drive to work, right? And so- [Nekky] Oh, nice. [Jaz] What I would experience is, like, you’d go to KFC and you’d always bump into a patient. Or you’d go to this shop and, like, there’d always be a patient, right? And so that was interesting. But the real interesting thing is, like, I personally, I don’t have road rage. But my wife, like, bless her, she doesn’t listen to the podcast, so I can admit it. She’ll never get to know. She’s got some road rage issues, right? My wife, bless her. I love her, but she’s got some road rage issues. And so now if ever I’m the passenger, right. And we’re in the small town, I just always have to tell, listen, this could be a patient of mine. Please just keep it down. You never know who you’re honking at. So you gotta be careful. [Nekky] Yeah. That’s when you put the visor down. And you’re just like, you try to hide behind the visor so no one can see you. We’ve all been there. Come on. [Jaz] Absolutely. My friend. Well, extractions, you are brilliant at them. I’ve done your course. I love your course. I plug your course all the time because it’s of the best piece of education I’ve ever done. But today we’re not here to talk about the course. We’re here to actually really give value to everyone spending their time, whether on the treadmill, the commuting on the train to work or whatever. Let’s make a really impactful piece of education for complications following extractions. Now, particularly third molars, cause that’s your main domain, but a lot of, I’d say 80% of what you’re going to say will probably apply to generic extractions as well. Right? [Nekky] Absolutely, man. I always say they didn’t teach us enough about extractions in school, but really extraction complications. Whenever I’m talking to fellow colleagues, like my goal is always, man, stand on my shoulders. Be a better dentist than me because I’ve made more, more mistakes and caused more complications than all of us combined, but like you live in a small town. I don’t have an oral surgeon to refer to. And so patients come in. And you do the best that you can. And unfortunately there’s not enough knowledge out there of like, hey, what to do in this scenario, what to do in this scenario. And so often the general dentist is left stuck trying to figure it out. And so I wanted to come on today to help demystify some of the complications that we get. And Jaz trust me, man, I’ve made them all. So I’m very proud to share as much as you want. And, and man, let’s just get into it. [Jaz] Well, let’s start with a big one, right? Let’s start with pain. Okay. Because this is so common. There’s going to be some blues in our sort of consent and in our post operative instructions, we say, look, it’s going to hurt, right? It’s not going to be no ride in the park. It’s going to hurt. Expect it. It’s a surgical procedure. There’s going to be swelling associated with that would be some pain. Now you used the word demystify, right? And this just reminds me like this completely off script, but it reminds you of a TikTok I saw like four years ago. I hardly have time for TikTok, but like four years ago, I saw a TikTok. I don’t know where you’re going with this. But this girl literally drinks a gallon of pineapple juice, right? Okay. And said, I’m going to go get my third molars out. Okay. I’m going to drink, watch me drink this gallon of pineapple juice. And then like three days after the wizarding, she’s like smiling, like, hey, no pain, no swelling. Cause I drank a gallon of pineapple juice. Tell me about that. Tell me about pineapple juice. [Nekky] Yeah, yeah, yeah. So, patients are after the bromelain in pineapple juice. And so that TikTok video is right. Like I’ve had patients they’ll come in and they’ll like have a cup of pineapple juice, like still drinking. And I’m like, man, you got to, if you want this bromelain thing to work, like you’ve got to drink like four liters of it, first of all, A, you’re probably going to become a diabetic in the process. Cause that’s just a heck of a lot of sugar for you. But like, man, I don’t know. I don’t know. Like, yeah, bromelain can work in really high doses. And unfortunately, a lot of our patients are on TikTok and seeking those social alternatives and trying to figure out how they can beat the system. But I tell everyone, I’m like, man, the most common complication of any extraction, whether it’s an upper first molar or your third molars, pain and swelling. So how do we tackle that? [Jaz] But Nekky, is it fair to call it a complication? It’s an expected outcome. Complication means that we weren’t expecting it to happen. [Nekky] Yeah, no, I hear what you’re saying. I hear what you’re saying, but maybe, yeah, you’re right. Let’s just call it an expectation then. Because it’s important to get our patient’s expectations on the same page. It’s shocking how many people come in and I’ll take out someone’s third molars, I’ll take out Mrs. Smith’s younger daughter’s third molars. And the mom comes up to me, she’s like, so this is going to hurt after. Are you for real? And I’m like, man, they’re four impacted wisdom teeth. This is surgery. I’m literally removing something out of your daughter’s face. Like, yes, this is going to be sore. And I think the best thing to do is get the expectation straight. Is it going to hurt for a day? No, it’s going to hurt for longer than a day. And so I always tell my patients, I’m like, hey, the first thing that I do is you have to tell them, yes, you will be sore, you will be in pain. And there’s no such thing is like no pain. Like, I hate using the word pain killer. Cause that’s just not realistic. It’s more of like a pain reliever. Okay. And so will you be in a 100% pain free, even with a pain killer or analgesic? No, you won’t. Right? And so the job of an analgesic is to make you more comfortable, not to kill the pain. So that’s a common term that we use is like, pain reliever or like we all use in dentistry analgesic. But for me, it’s almost like, what do we use? And I’ve gone through different things in my career earlier in my career. Opioids were really pushed and now we’ve steered a hundred percent away from opioids. A lot of patients, they come in and they’re like, man, Nekky, you’re taking out these wisdom teeth. I’m going to need some codeine after. And I’m like, codeine, you want to be constipated or you want pain relief? You know what I mean? Like is codeine really what you’re after here? And then some people will say, I don’t know what it’s like in the UK, but they’ll be like, Nekky, I’m going to need some Percocet. And I’ll be like, man, Percocets. I’ll only give you Percocets if you split half with me, because there’s no way I’m prescribing it with you. And so, I always make light of these situations. I’m like, but you know what, in my opinion, and according to the research is the best pain reliever. And that’s a combination of ibuprofen and acetaminophen. And in Europe, I think you guys call it a paracetamol. [Jaz] Yes. [Nekky] Or do you call it acetaminophen? Yeah. Yeah. So paracetamol, paracetamol. Yeah. So depending where you are in the world, it has a different name. But according to the research and according to my own patients, this is what I do. So what I do for every single patient is on their post operative sheet, before the appointment even starts, I show them and I draw a clock and on that clock, I’ll say 12, 3, 6, 9, and I’ll say at 12 o’clock, you can take 600 milligrams ibuprofen, a thousand milligrams acetaminophen at six o’clock, you can take another 600 milligrams, ibuprofen thousand milligrams, acetaminophen, or if patients want to alternate every three hours, they can do ibuprofen. Then three hours later, acetaminophen or paracetamol three hours later, ibuprofen. It depends what you want. I find sometimes patients like to split it up every three hours because that way is one’s kicking in the other one’s coming out and they feel like they’re taking an active role. You know what I mean? And we’ll talk about like taking that active role, patients they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically is helping, but for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol. And the research backs this up. In your opinion, Jaz, what works well for you guys and your patients? [Jaz] Yeah, absolutely. So I believe it’s the Oxford data on analgesics and it definitely shows, I think it shows at its worst point, like if you take 800 milligrams of ibuprofen and a thousand of paracetamol, that can be effective. Now on the box in the UK, I dunno how it’s in Canada, but in the UK and the box of ibuprofen, it says 400. So we have to say that, look, if it gets really bad, it’s okay to double it. Just make sure, be careful with the gastric complications, make sure eat something. [Nekky] That’s right. [Jaz] Very important, the ulceration risk. But yeah, definitely ibuprofen, paracetamol. When I was in Singapore, there was a culture to, I guess that’s the best way to describe it. Culture of giving steroids, prednisolone, like in the UK, it’s much more difficult as a practitioner to prescribe that. And so I think most don’t, but I don’t know, does steroids have a role in anti inflammatory in terms of your active prescription of it? [Nekky] Oh, man, Jaz, I don’t know if I can practice without it because I feel like, so in Canada, we use dexamethasone in the States, they’ll use like Medrol dose packs, but it for me, I regularly routinely use dexamethasone for my patients now, you can inject it at the surgical site. Okay. And it’s just four milligrams at the surgical site. If you do an IV, you can inject it by IV, but you can also take it orally four milligrams twice a day for two days. Now you got to be careful. Like you don’t want to give it to someone who’s medically compromised. You don’t ever want to give it to a diabetic because man, I remember. I’m talking about mistakes, right? I gave it to a patient and the patient calls me from the hospital the next day. And they’re like, Hey, Nikki, I’m in the hospital. And your heart starts pumping and you’re like, why are you in the hospital? And they’re like, well, my blood sugar is just, it’s spiked. It’s out of control. And some dumb dentist gave me a medication that really mess with my blood sugar. And I was like, oh, who is that? You know what I mean? And you get a call from the ER doctor saying, you know Nekky, I know you’re doing your best there, but you can’t be given dexamethasone to diabetics. And I said, absolutely my fault. That’s a hundred percent my fault. We don’t want to give dexamethasone to diabetics, but in my experience, it’s really helps with swelling. Dexamethasone has a longer half life, between 36, 54 hours. I give it for two days, or like I said, you can inject it at the surgical site. And it works really, really well for my patients. There’s a little bit of controversy, whether it helps with pain, but it definitely helps with trismus and swelling. [Jaz] I thought that when I was removing this teeth in Singapore and it was much easier because I think we had them in the practice to actually give to patients. So it was like an easy prescription to do and I felt as though it helped my patients when I reviewed them. And then the UK is some barriers. So my homework will be just to figure out. Okay, how many practices in the UK are actually prescribing dexamethasone or prednisolone or some sort of steroids and how we can go about doing it because I think there is a role. Yes, anti inflammatory at least or the swelling. Sorry the swelling aspect of it definitely has a role whether it yeah makes a difference in pain I do think it does but like you said the gold standard evidence based would be ibuprofen and paracetamol. But it’s good that we covered steroids because it’s a very important part of your regime. And we have to remember that pain is a very variable factor. I believe it’s a factor of four, right? Like someone could say something’s a 2 out of 10 and we have those patients where they come back and it was the messiest extraction ever. And they say, yeah, it was a walk in the park. It was fine. Like it was way better than what you told me than it would be. And then we have those other patients who was like the grade three mobile perio tooth and they come back and it was like an agony and stuff. And so the whole pain internal variation needs to be respected. [Nekky] Oh God. Yeah. One more thing about corticosteroids or dexamethasone you don’t want to give it at night because sometimes like you don’t want a patient to take it at night. Sometimes they act like little caffeine pills and they’ll be up all night. But another complication that. I didn’t like you experience, I feel like when you’re in the thick of things, that’s when you experience your complications. I had a patient, they’re like, Nekky, surgery is going good. I haven’t slept in two days though. And I was like, oh yeah, dexamethasone can sometimes act like caffeine pills. Let’s take it back a bit. They’re like, no, Nekky, it’s not that it’s the hiccups. And I’m like, what do you mean I’ve been hiccuping nonstop for 48 hours. And then I’m thinking, I’m like, could you imagine like when I get the hiccups for like 20 minutes, I’m like, trying to scare myself or like swallow a bunch of peanut butter or whatever these old tricks are, could you imagine having it for 48 hours? [Jaz] Oh, I had no idea. This is a complication of a course. [Nekky] Yeah, man. It doesn’t happen often doesn’t happen often. I’ll get a patient like once every two years and they’ll be like Nekky, I cannot sleep I don’t know what to do. And I’m like, oh my god, like stop these dexamethasone. You gotta let it get out of your system. But here’s the crappy part. It’s in your system for a long time. You got a long half life. So that’s another negative side effect. You’re not going to see it often, but if I can help one dentist out there that has that patient that’s hiccuping, yeah, it’s from your steroid. And it’s not a fun complication to have. [Jaz] Is there a role of how when you have a hot pulp in the endodontics and we advise that, okay, sometimes it’s more difficult to numb this patient up. And therefore we often advise, take some ibuprofen before you come in as a strategy. Is there a place, if you think it’s a particularly gory procedure, tricky one, do you ever advise taking a preoperative analgesics? [Nekky] Yeah, yeah, yeah. So you brought up a really good point that the research says preoperative corticosteroids. That works really well, but the research actually doesn’t support preemptive analgesics. I was reading some papers I think it was like, you know last week. I remember I was shocked I’m like because I usually give ibuprofen to patients prior like I’ll be like a start taking your ibuprofen is the morning of. But a lot of researchers saying, you know preemptive analgesia didn’t do as much as we thought it does but like it makes sense. Like, why wouldn’t you do it? Right? Like, to me, it’s like, why wouldn’t you just have that on board ready to go? But the research is mixed on that. But like, man, these days you can find a paper to say anything you want. Hey, you’re like, on one side, it’ll work on the other side. It’ll work. So I’m often going just straight to common sense. [Jaz] I love that little Canadian A that you said that I was waiting for it. So thank you for blessing us with that. So Nekky, there’s so much to cover, but in terms of pain, stick to the gold standard, paracetamol, ibuprofen, don’t be afraid to go above 400 milligrams, but do check for ulceration risk. Make sure they eat something, definitely manage their expectations. Warn them of pain, some dentists like, oh, but if I overplay the pain element so much, then they won’t have the procedure. Well, that’s all point of consent, right? You need to under promise over deliver. And so definitely yet talk about the pain. It’s going to hurt. It’s going to be really sore, but don’t worry. Eventually everything, like everything like childbirth, you’ll eventually forget about it, but it’s going to be hopefully way better than childbirth. [Nekky] That’s my joke for all us guys. I’m like, you know what? At least we’ll never have to give birth, man. If we have to give up four little wizened teeth, man, so be it. But that’s where it ends for us. [Jaz] Excellent. Now the next thing is, what would you say is the next most common complication? [Nekky] Oh man, you know what, the literature varies so much. I’m just going to go with my own experience. Okay. I think everyone is expecting me to say dry socket or alveolar osteitis. [Jaz] Everyone is, but I’ve done your course and I know your protocols and I know you openly say that. Okay. You very seldom experienced dry socket. So excited to hear about that. So we’ll talk about Nekky’s magic pineapple juice that he gives that prevents dry sockets. But okay. So for you, dry socket is not a big issue. So what is more common? [Nekky] Man, I don’t see too many complications. I think, the most common complication or expectation I’ll see is pain and swelling. And then maybe infection, maybe infection. Okay. Cause I don’t routinely, and I don’t know what it is about for you, or I don’t routinely provide antibiotics for my patients. Do you? [Jaz] No, no, no. We’re discouraged too, right? We’re discouraged too. [Nekky] Yeah. And so for me, if I see a patient and they’re still having pain, I would say a week later and they’re like, you know, Nekky, you told me it was going to get better. It’s getting worse. Okay. So now I want you to play this game. Cause this is a common problem we all see. And we’re at this like decision making crossroad, right? And we’re like, okay, the patient is swollen. They’re in pain. Are they having an infection? Are they having a dry socket or is this normal? And it took me a while to like, you see enough patients and you’re like, how do you decipher between an infection, a dry socket, or if this is normal? Do you know what I mean, Jaz? [Jaz] Oh, totally. Totally. This is a daily experience for dentists taking out teeth. When you have that patient come in and there’s possible diagnoses and it’s important because the ramification is antibiotics indicate, can you justify it or not? [Nekky] Yeah. Yeah. Okay. So before we even get to this, cause I think this is the most important thing I want to talk about is like trying to delineate where we’re at here, right? Like we want to be able to diagnose our patients. The most common thing I see is actually food in the socket. Do you know what I mean? [Jaz] Yeah. [Nekky] Yeah. And so I guess the question is. And I’m kind of getting to this point here is, is do you irrigate your sockets? Like, do you irrigate your sockets? You give the patient a syringe. Are you telling them to rinse with saline or rinse with salt water that they make at home? Are you giving them a syringe to actually clean inside the socket? What do you do, Jaz? [Jaz] Good question. So, in Singapore, I did, actually. And you know what? In the UK, we don’t have, we had a really nice Monoject 1 in Singapore there. And in the UK, I don’t have, we should totally just get one. [Nekky] Yeah, the curbs are in. [Jaz] Yeah, and that was really good. And I think when I used to work in the hospital, we gave that as well. In practice, I’ve fallen out of habit. So, no, we just give the advice. Okay, warm water, a bit of salt, multiple times a day, especially after you’ve eaten, to make sure the food debris doesn’t get caught. But I think I know where you’re going with it. I think you’re saying that the syringe is the pineapple juice. [Nekky] The syringe is pineapple. Yeah. So like you’re irrigating the socket and whether you irrigate with chlorhexine or irrigate with, with saline, you need to get the debris out of the socket. And it’s so funny. Like I had a patient yesterday, day seven, they’re like, Nekky, it’s not getting better, not getting better. And then I go to rinse the socket in like, it’s disgusting. You’re like all the food you’ve eaten is now at the bottom of your socket. No wonder you’re in pain. And I can assure you, I’m going to call her today and I’m going to be like, how do you feel? She’s like, Oh my God, so much better. Right. So much better. But this is when the patient comes in, right? You’re like, okay, they have pain. Do they have swelling? And is it a dry socket or is it an infection? Okay. So I always want to remind everyone the three cardinal signs of infection. Okay. Pain, fever, swelling. But everyone has pain, everyone has swelling, but do they have a fever? Okay. So that’s like a Cardinal sign. That’s how you know it’s infection and also swelling after day three, shouldn’t swelling be going down? If swelling is progressing past day three, you’re like, oh, okay. Could that be an infection? Is there a fever? You know what I mean? That’s where my brain is thinking. However, when you look in the mouth, if they have a large dark hole, which a lot of people do, you can’t just jump and think it’s dry socket, but like how good is their oral hygiene? Is there a ton of food debris in the socket? Does it stink? Do you know what I mean? Like, is it extreme pain in their ear down their neck? And there isn’t swelling, like swelling is subsided. There isn’t a fever. Well then I’m thinking dry socket, right? But I want to clarify one thing about dry socket and I’ll explain how to prevent it, but I found earlier in my career, and I’m sure you’ll agree with me. When I was getting into extractions and it used to take me, a touch longer to take out a tooth and I was pulling on my flap and I was drilling bone at elevate, drill bone, elevate, drill bone, snap, snap, snap, an hour and a half later. Hey, I got the tooth out. I’m a hero, but the patient thinks I’m a bum because it took so long. And those are the patients that end up with dry socket. So everyone talks about like, the dry socket is the like dissolution of the blood clot, but really Birns hypothesis. No one knows why dry socket occurs first of all, but Birns hypothesis is it actually starts with trauma that leads to the activation of plasminogen that breaks down the blood clot. And so if we have less trauma on our patients. Patients heal so much faster if you can get that, if you’re in and out of that surgery quicker, well, patients heal faster with less trauma. I don’t see dry sockets anymore, but there’s one thing that, well, I guess there’s two things that really help with that, that everyone can do. Okay. So the first thing is that preoperative and postoperative chlorhexidine rinse. Okay. Do you guys use chlorhexidine? [Jaz] I did when I was in hospital, but you know, there was a whole phase whereby everyone was like super scared about allergy and this one person died in the UK from like corsodyl and chlorhexidine and then for some reason culturally we were like really worried about the the allergy risk. So I feel as though from that time the usage went down a bit. [Nekky] Really? Yeah. To use that 0. 12 percent chlorhexidine. I actually routinely give it to all of my patients. Whatever I take out a tooth, I get them to rinse with it in the office and then for third molars. I give them a bottle for a week after and it’s actually been shown to have a 40% reduction in dry socket or alveolar osteitis just from chlorhexidine alone. [Jaz] I read this as well, and the evidence was better than some of the other things. Like, some of the best evidence we have for preventing alveolar osteitis is the use of chlorhexidine. And I believe I read that to deliver it in the form of a gel after the extraction. Is that something that you use? [Nekky] Yep. I use the liquid, but 100% you can use the gel. The benefit of using the gel is when you rinse, you don’t want to rinse the first day postoperatively because you want that blood clot to settle in. You know what I mean? And so if you’re using a gel, you can start applying it right away. So that’s the benefit of a gel, but yes, you can use the liquid. You can use the gel. I recommend it. I find in my own hands. Like it really works to be honest. I haven’t seen dry socket in years. I think it’s an overplayed overhyped complication. If you can get your patients to keep the socket clean, if you can get in and out of surgery, the best you can, as fast as you can, while maintaining as atraumatic as possible, but you got to abide by your surgical protocols. Like you can’t be leaving a ton of bone shards and tooth fragments in there, and then like sew it up. You know, call it a day and just run out of the op because that was a fast extraction. No, you got it. You got to be efficient with your extractions, but also Jaz. I’m going to throw something out there. Maybe we don’t have to be taking on all these cases. If you don’t feel ready to take on this case. And if you feel like this, this extraction is going to take you two hours. Why are you taking it on or you’re better off having that patient see someone else you can do other forms of dentistry. It’s much more profitable for you a much more, you know less stress because there’s one thing I teach everyone and you never lose sleep over cases. You do not. Do you know what I mean? [Jaz] Amen. [Nekky] If you’re up at night trying to get like waiting for your phone call from your patient because you know they’re gonna be in pain, man, what kind of life is that? You never lose sleep over cases you do not do. If the tooth looks ridiculous, 45 years old, distal, angular, partially, or fully impacted, you know, minimal opening. Is that really a good use of your time? And as a general dentist, is that something we should be taking on? And are you ready to take on the following three weeks of phone calls and possible dry sockets and delayed healing and, hey, I’m in pain. And don’t go see that Nekky guy. Cause all he does is put me in pain. I can’t, I can’t recommend it. Like, do you really want to do that? And that’s when you see dry socket is on the patients that you don’t want to get dry socket and it took you forever to get the tooth out. And come on, we’ve all been there. And we questioned why we got into the profession after we walk out of the operatory, because that tooth was so difficult and that’s when we see dry socket, you know what I mean? [Jaz] I have a lot of reflections on that because I’m a big fan of moving out of your comfort zone. But we shouldn’t move beyond our comfort zone. We should be at the edge of our comfort zone and that’s where mentorship comes in and the big C word here is case selection right? We as general dentists have the most difficult job in dentistry. Like all the specialties, right? General dentist is the most difficult. And so we need to utilize our one trump card, our one saving grace, is that we get to be cherry pickers. We can pick the most luscious and red and nice cherries and all the rotten cherries. We can send to a specialist we don’t like, okay? And that’s okay, right? There’s a place for that, okay? Obviously I don’t mean that, tongue in cheek, right? I always joke, send to a prosthodontist you don’t like. I always make that joke, but you know what? It’s just a point to make that, it’s really tricky to be a general dentist, so let’s enjoy the fruitfulness of being able to refer the ones, sometimes you know what? On the Protrusive Guidance community, I posted about referring and what’s your threshold and that kind of stuff. And a lot of the experienced colleagues that said the following thing, Nekky. Often it’s not the procedure that scares them. It’s the patient that is attached to the procedure. And that’s why they’re referring. [Nekky] I totally agree, man. You pick and choose your patients that come with the procedures, right? So it’s the patients that you have to manage, someone comes in with their arms folded and they don’t want to be there. And I’m scared. And they’re aggressive. They play the whole, like, if you hurt me, I’ll hurt you type card. They have a really hard tooth to come out. Like, man, do you really want to take on that case? Or would you rather take on like, someone that wants to work with you and if you ever did end up with a complication, you’ve explained it to them and they want to work with you. They don’t want to work against you because the other thing that I’m a huge fan of, like I said, number one, you never leave sleep over cases you do not do, but patients do much better with explanations than they do with excuses. And so what I mean by that is like, if you take the time to explain to someone, Hey, Mrs. Smith, when we take this tooth out, there could be a possibility of you having a tingly feeling in your lip or chin, and that could last for a couple of days, a couple of weeks, a couple of months, a couple of years, I don’t know, I can’t control the position of your tooth in relation to your nerve. However, if this happens, there’s some things we can do, but a lot of the times it’s variable. We don’t know. Do you understand that? And they’re like, oh yeah. And you know, Nekky, I fully understand you didn’t put the tooth there and I’m coming to you later in life to get it out. I expect those things to happen. But if that patient came in after, you took the tooth out, you get the text three days later. Hey, Nekky, is it still normal for my lip to be numb? How long is this freezing going to last? And then your heart just starts pumping, right? And your stomach falls into the floor and you’re like, oh, here we go. And then the patient’s mad at you and they could become litigious and they’re like calling their lawyers saying Nekky messed up my face. And I don’t want that ever to happen to any dentist because we don’t control the position of the tooth in relation to the mandibular canal. However, sometimes patients feel that it’s something we did wrong, right? So, patients do much better with explanations than they do with excuses. Take your time, talk to your patients. I spend sometimes more time talking to my patients than the entire procedure. So, like, but patients aren’t mad at me. I pick and choose my patients, man. I refer risk and I refer patients. Interjection: If you want to check out Nekky Jamal’s Wisdom Tooth course, which both me and Ali have done, and we highly recommend, check out protrusive.co.uk/thirdmolarsonline. That way you get 15% off using the coupon code protrusive, and this is an affiliate link. [Jaz] I love how you talk to your patients. I see your videos and like, I’m in love with the, and only you can do it. Not everyone can do it. It needs to be a certain persona. And so you’re like, you’re given this ID block and like, everyone’s watching you as like, Oh man, I love you. I love you. Like you’re good. You’re good. Like you’re so, it’s just amazing. Like only you can do that. And it’s just amazing. Honestly. Now you raise a really good point. Like we could dedicate more time to talking about numbness and stuff, but we already talked a lot about that in the previous episode, recognizing the high risk science. So I will, signpost the previous episode that me and Nekky did where Nekky really summarizes the how to assess complexity and then the different signs you’re looking for, for a high risk of nerve damage. But the key message here is making sure that everyone has an explanation. You make them understand all the risks. Now, one of my favorite things to do when communication is the following. You make every patient feel special. And I don’t mean like you make them feel warm and fuzzy and special. Like you’re my only patient in the world. Not like that. I mean special in the sense that you make them feel unique because they will remember that for example, if you say to a patient, okay that hey, you know what Mrs. Smith? You grind your teeth. That’s very fast. That’s very, we know it’s a common thing. It’s like, wow, your jaw is actually doing these funny things and that’s grinding and that’s a very special thing that you do, right? And so at the dinner table, like a few weeks later, it’s like, oh, yeah, you know what my dentist told me? I grind my teeth, for example, or in the context of extractions, right? If you have a slight curve on a root, right? And I would say, look, most people, they got a normal straight root, but you have a banana root. And we know a lot of people have banana roots, but when you make them feel special, they remember that. It’s like, oh, why? Yeah, that banana root. That’s why the tooth took a long time to come out. So when you make them feel like they’re a special case, it just heightens the, I guess, the retention of the information. It’s just something that works for me. [Nekky] Such a great idea. And I heard you say that before and I’ve started to do that as well. And I often say like, hey, Mrs. Smith, did you know that you have a root that’s embedded into your sinus? Like, that’s crazy. When I take out this tooth and you’re going to have a hole in your sinus. I want you to think as if I’m popping a balloon, I can’t control them. And like, they immediately think that, and they understand that. And they’re like, so like water, when I drink water, it’s going to come out of my nose if I have a hole, right. And I’m like, yeah, we want to prevent that. And we want to explain all these things to help minimize that. So it closes, but like, that’s a crazy route. We don’t see that every day and it, boom, it almost like, it prepares them for the complication, but it also makes it almost acceptable. Like, Jaz, you didn’t put that banana root there. You know what I mean? You didn’t control my anatomy, but this is what we’re stuck with and thank you so, so much for managing it. [Jaz] That’s the crux of it really. And when you highlight this issue to them, they own it, right? And it’s not like an excuse that he was later. It’s something that you can reassure the patients that and actually one of my things I like to do is yes, you tell them the complication, i. e. the curve route, but then you also tell them what you’re going to do to mitigate that. Is that okay? You’ve got a curve route. That really sucks. That’s a really bad scenario, but you know what? I’m going to carefully split the route so that it has an easier path to come out. That’s how we’re going to navigate it. So don’t worry. We’re going to make sure you’re looked after. That’s my thing to worry about. You just relax, make sure you’re away with the fairies. You’re having a good time. Leave the trouble to me. I’m just informing you what the trouble is. [Nekky] Absolutely. I love that Jaz. It’s like you’re giving them a surgical game plan. Now, usually. What I do in these scenarios is I didn’t come to my second reason on how I really mitigate dry socket or alveolar osteitis, and that’s through the use of platelet rich fiber. Now- [Jaz] I was waiting for it. [Nekky] The PRF. I love it. [Jaz] You love it so much. [Nekky] I love it, man. I tell everyone like, PRF is like ketchup, it makes everything taste better and it makes your surgery just go a little bit smoother, right? And so the only thing with PRF that some dentists fall into trouble with, they’re like, Nekky, you said PRF is so good. My patient comes back and like, it’s not good. It’s not good. What do you, like, you’re feeding me lies here. And I’m like, PRF does not change the fact that if you have a crappy surgery and if you don’t manage your tissue, if you don’t manage your bone, if you don’t stick to sound surgical protocols, PRF is not going to help you. It’s not your superhero, okay? It is going to make your surgery heal faster with sound surgical principles. It really helps the soft tissue. It really, really reduces alveolar osteitis. So all my third molar cases, PRF, or the use of platelet rich fibrin, has actually reduced alveolar osteitis in 95% of cases, according to the research. Just think about it, you’re putting the fibrin clot right in there. What’s dry socket? The loss of the blood clot. So you’re really helping the situation. But man, patients, they love it. And so many dentists are like, Nekky, you expect me to poke my patients? And I’m like, yeah, because you just stuck a needle this big in the back of their mouth. What’s the point of like you already, if you can find someone’s inferior alveolar nerve in the back of their mouth while just by basic landmarks, you can feel a vein on someone’s arm. And with a little bit of training, we can show you how to get blood out of there. You spin it down, you put it right in the socket. It’s all delegatable. Like my assistants are helping me with this. I’m doing the venipuncture, but like it’s such a no brainer for me and it works so well. Patients love it. [Jaz] I guess that’s the barrier of entry, right? Being able to do the venipuncture, but I love how you say that. Okay, if we’re getting that ID block, then you can do this. I like the way you downplay it and I think we sometimes need that encouragement that we can do it. I’ve done it. It’s been so many years I haven’t done it, but in the hospital I was training, I was doing it regularly. So if I can do it, anyone can do it. And I think PRF has a place. I don’t use it at the moment, but my principals, they love it as well. When I used to work for implant work or that kind of stuff that they really swear by PRF and the evidence is out there to support it. And I know from your own audits, the low number of dry sockets that you experienced. Yes, chlorhexidine is evidence based as well, but I think your PRF formula has something to do with it as well, as well as a lovely surgical care that you take, your experience, your, not speed, but efficiency. [Nekky] Efficiency. And have you noticed something in dentistry, Jaz? And I’m sure you’ve noticed this. It’s like when a dentist doesn’t do a certain procedure, they always downplay the effectiveness of it. Do you know what I mean? If they’re like, if they don’t know how to do PRF, they’re like, eh, that’s not doing anything anyway. But then when you honestly, when you start using it, it works really, really well as if, if we don’t understand something, we don’t recognize its massive advantage. So I encourage dentists. Like learn how to do PRF, it’s really helped me in my surgical career. Am I any different than any other dentists out there? Absolutely not. I can’t say I have any different special skills than anyone. It’s just, you get good at something over a long period of time of doing that procedure over and over and over again. If my patient came to see me to do a veneer or to do a root canal, man, I would butcher that because I just don’t know how to do it as well as the next guy down the street does. So like, I encourage you, if you’re really interested in extractions or if you’re really interested in endodontics, like become obsessed, like become obsessed to the point where you’ve read every single journal article out there, I want you to go home and I want you to dream of it. I want you to feel like your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to where like you’re working eight hours a day doing clinical dentistry, and then you jump on Instagram at night and start looking through cases. And then you’re like, I wonder how this works. You’re calling colleagues like dentists. We have such an interesting job. And I just feel so proud to be part of this obsessed profession with everyone here, but like, man, get educated. Just like you said, right? [Jaz] I think the sad truth Nekky, is that, what you describe that is really great and that’s what you want, right? We want dentists to be enthused. We don’t want dentists to be working and not feeling like it’s work, but unfortunately, so many of our colleagues are disengaged, they’re not in a good place, they’re struggling, and I think you hit the nail on the head that for me, what I’ve experienced and what I’ve seen from afar is that when you make it your mission or you just find a focus, a passion area to really just a rabbit hole that you can go down on niching. When you niche down on something, right? I made an episode about finding your niche with Pav Khaira, but I want to make another one called Niche Kebab. So make a Niche Kebab episode, right? And so niche kebab, niche kebab, I know you call it niche, but anyway, Niche Kebab, right? And so basically. Really, you know, yes, when you’re a general dentist, you get to explore everything. But if you can just focus a little bit more on one area, which really, that you can really find affinity towards, and then you grow that area, then suddenly your career just takes a brand new angle. [Nekky] Oh, totally. And you enjoy work so much more. And it’s not work anymore. Like, it’s fun. I get to hang out with my patients. I get to do the procedures that I love. I feel like I’m actually providing a service. [Jaz] And this could be extractions. This could be clear aligners. This could be endodontics. Even though you’re a general dentist, this could be just endo, which is maybe like, specialist level, but you can still pick and choose what you want and create a little referral network where you are, and you can literally niche down in any discipline. This is like, we have to really appreciate the beautiful side of dentistry. And this is one of the good bits of dentistry that we can actually pick and choose, and then we can actually multiply and grow by simplifying and reducing the number of procedures that we do. And there’s a real magic about that, man. [Nekky] Yeah. And that’s the best part about being in general dentist, Jaz. I love it. [Jaz] Good old cherry picking. Now, just before we wrap up, there’s a few different points that I hadn’t covered yet. Ice. Like ice is like a standard thing that we recommend post surgery. Tell me more about ice. Like, do you guys- [Nekky] I got so much, so much. So, cryotherapy. Okay, ice. I want you to think about it. Okay? You put ice on the side of your face. Yeah, it’ll get the outside cold. So we’re trying to cause vasoconstriction. We’re trying to slow down nerve conduction. You know what I mean? Do you really think by putting ice at the angle of the mandible? It is going to get to your surgical site. Like, do you think it can really penetrate that far? [Jaz] Exactly, right? The penetration depth is ridiculous because you got a whole, you got warm blood circling everywhere, kind of counteracting the cold. But I had like, I think it was episode 27 and 28. Well, I had these two physiotherapists, one who’s now become a dentist, and we’re talking about back pain and dentistry. And they were saying when you put ice on your back or something, they said the exact same thing. Well, there’s only so much penetration microns that the very superficial skin layer that’s getting cold. Are you actually benefiting it? So tell me more. [Nekky] The reason I still use ice. Okay. So we both know it may not be penetrating to the site. However, the patient is taking an active role. The patient is taking an active role in their healing. And for me, that’s worth its weight in gold. So whether ice works or not, it doesn’t matter to me. However, I really feel like if patients wants to get better, they’re icing their face. If they’re icing their face, I know that their diet is going good as well. Like they’re not eating nuts. They’re not eating seeds. They’re not sucking down raspberries and getting those little seeds in the sock. Cause they’re taking an active role in healing. They want to heal faster. They’re listening to all your instructions. So that’s why I always give ice. Cause then people are always taking an active role. Does that make sense, Jaz? [Jaz] Oh, totally. Totally. I mean, same thing with analgesics, if you really explain them so well. So, and then they help do the whole thing where they’re alternating ibuprofen, paracetamol, another example, like you mentioned earlier, they’re being active, they’re doing the ice, they’re looking off their diet, and then they’re looking off themselves and that energy will heal them. [Nekky] Absolutely. So that’s why I use ice. Now, the question is, is ice better in the mouth or is it better outside the mouth? This really came to a head for me when I took out, I was giving someone a lower denture with a couple implants and I removed six lower teeth and they texted me the next day. I always give everyone my cell phone number. I know some people don’t, I always do. And I always encourage patients. And I know I’m one of the few ones. However, it really makes patients feel better. I’m a family member. Okay. My patients call me Nekky. They don’t call me Dr. Jamal, I’m a friend. Okay. I’m here to help you with your surgery. I know there’s a lot of controversy about this and I don’t care. This is just how I do things. And so they’ll text me and they’ll be like, Nekky, I got a problem. And I was like, what? And she’s just like, it looks like I’m wearing a necklace. I’m like, just send me a photo. What are you talking about? And she’s just red, bruising, like purple all the way down here. [Jaz] Yeah. I’ve experienced this from just anesthetic. I’ve just on one side, just from getting a buccal infiltration and then to come down and there’s all that bruising. [Nekky] Totally. [Jaz] Very thin lady, very thin lady by any chance? [Nekky] Yep. Yeah. Very, very thin lady. Very loose skin, right? And you’ll see that. And I’m like, okay, well, have you been icing it? And they’re like, well, yeah, I’ve been icing. It hasn’t done anything, but I’ve been eating really hot soup. And I was like, interesting, interesting. So like, are we increasing vasodilation causing bruising, causing bleeding by really hot fluids? And so I found when I got my patients, I’m like, man, just eat cool stuff for the next two days. Like just eat cool food. Do you really need a hot coffee? No, have an ice coffee, man. Like, do you really need soup right now? No, I have some ice cream. Like, just keep it cool in your mouth. And that’s another thing patients like they, it feels like they’re healing, man. Like just like when you get your tonsils out, are you giving someone hot soup? You’re giving them popsicles. You know what I mean? Like I find that it all relates together. I try to keep everything cool where it can. If cold is getting to the surgical site, I just think it’s better. And whether ice externally or internally does anything, it just makes my patients feel better. [Jaz] Okay. Wonderful. Final thing then. Cause again, we can go on for like three hours talking about everything, but we’re being selective. [Nekky] Let’s do it, man. I’m canceling my day. Let’s just do this. [Jaz] Oh, I wish Nekky. I wish I’ve got to take my little one swimming, but tuberosity fractures. Okay. So, upper wisdom tooth, like literally two months ago, I experienced my first tuberosity fracture, this big gaping cavity in the maxilla. That I was suturing up, but you know what? They heal amazingly. Well, the human body is marvelous, right? But at the time you’re like, you’re really bummed out and stuff. But you know what? I really don’t think I could have avoided it because you know how teeth, sometimes teeth are very difficult to remove because they have this like patchy areas of ankylosis. And so any force that you put because of that ankylosis will go through the bone. And sometimes it’s very difficult to section, especially if it’s like not clearly like divergent roots. So tell me what your strategy, what’s your mind, where’s your mind at in terms of preventing tuberosity fracture. Have you experienced one? [Nekky] Oh man, come on, Jaz. We’ve all experienced tuberosity. I’m surprised this far in your career. You’ve only had like one, like you just had, like that blows my mind away. Now I’m questioning. Yeah. Now I’m questioning. I’m like, I can’t even count [overlapping audio] it’s, it’s poor case selection. That’s what it is. And so, okay. So whenever I see divergent roots on an upper posterior tooth, so like. The very loud, the penultimate, the last tooth in the arch. I’m always nervous. And I’m looking at the tuberosity, man. Can you always tell how dense the bone is from your x ray? No, because it depends, the angle of the x ray. It depends how strong the x ray beam was going through it. It depends how fat the patient’s face is. There’s so many other factors going on, right? So I’m looking at divergent roots. And I find when I just stick a straight elevator between the second and third molar and turn, and I hear a crack and you’re like, oh, shoot, here we go. You know what I mean? I want to give everyone a tip. The problem with the tuberosity fracture isn’t always the small chunk of bone that comes with it, because a lot of times it’s small. If you use a lot of force, you can really create some serious damage there. But the biggest problem is when you go to remove the tooth, all the soft tissue is still stuck to it. And so you just, you’re like, okay, well the tooth’s out. I’m just going to pull it out of here and I’ll suture it up. But then as you pull, you’re going to notice something tear and it tears on the palate. And as you pull more of that tooth coming out, it tears further and further. And now you’re in the soft palate and you’re like, Oh crap, I just need this tooth out of here. It’s literally waving in the wind. He’s either going to choke on the tooth or he’s going to choke on the blood coming out of there profusely. And then you pull more and now you’ve created this huge tear right down the soft palate. And let me tell you, suturing that tear is absolutely brutal. Man. [Jaz] I think everyone just held their breath for like the last 10 seconds. Everyone just held their breath as you were saying that. [Nekky] You put a mirror back there and they start gagging. So now you’re expected to suture that. Oh my Lord. Okay. So the first thing I do whenever I hear the crack, cause I’ll be honest, I’ve broken my fair share of tuberosities and if you haven’t go look in the mirror and be honest with yourself. [Jaz] Remember Nekky, just like in endodontics, we never break a file. We separate the file separated. You never broke a tuberosity. The tuberosity decided to separate. [Nekky] Yeah. It broke itself, man. The patient came in like that. What am I supposed to do? Yeah. So like when you have a divergent roots, I’m always nervous. If that bone behind it, man, if the bone is really soft, it’s going to come with it. If the bone is really hard, well, it’s going to come with it too. I want you to be careful of a couple of things. So when you first hear that crack, if you were putting a lot of force, which I don’t recommend, but let’s be honest, some people it’ll happen. Okay. You put it in a lot of force. If there’s any other piece moving, like if you’re trying to take out the third molar and now the second molar is moving, let’s just back off. Okay, put an arch wire on there. Do not take out the tooth and I want you to refer it to your maxillofacial surgeon. [Jaz] By an arch wire, you mean like a rigid, like a trauma splint kind of thing? [Nekky] A rigid wire, yeah. [Jaz] Yep. [Nekky] Yes, absolutely. Just splint it, take it out. The patient isn’t going to be worse off. However, I want you to refer it to that surgeon at that point. As a general dentist, like, there’s obviously a fracture somewhere else going on and I don’t want that to happen too. Okay, if you can see like the tuberosity moving and you see like nothing else is moving around there, I want you to start separating that lingual gingiva from the tooth. Okay, and do it very gently. This isn’t a race. Okay, take your time, use your periosteal, start to separate that tooth from that gingiva. So as you start to remove the tooth, that the gingiva is not going to rip at the same time. Okay. Now, something theoretically that sounds so great but is a lot harder to do is what if you thought there was a large piece of bone there, if you tried to use a bur and go behind your tooth and try to actually separate the tuberosity bone from the tooth so you can cleanly remove it. [Jaz] So you’re kind of sacrificing the tooth, you’re like drilling into the tooth basically so that you’re not leaning against the bone so much. [Nekky] Yeah, and you’re trying to keep that bone there, depending on how large that tuberosity you think it is. As long as the tuberosity is still connected to the periosteum, it’ll heal. Like, it’ll, you can leave it in place. However, in practice, when a patient can open this wide, and you’re trying to get your bur distal to that third molar, good luck, my friend. You know what I mean? Like it sounds so good and you see it in textbooks and you’re like, oh, this is just so simple. And then you feel like a dork when you’re trying to do it and you’re like, I can’t do this. Like what is going on here? So, do your best. If you hear a large crack and you feel something moving. I’m not like, be careful, but also if you hear a crack and you’re trying to like loosen up that tooth, you remove the lingual gingiva and there’s a lot of pain distal to that tooth. I’d recommend you stop as well. And if you have the ability to take a CBCT, do it and see exactly where that crack is. Cause if it’s far posterior, you may just want to put an archwire on there and send it to the surgeon as well. [Jaz] Could you also put an Essix retainer on that? Like an arch wire followed by an Essix retainer on top as well. What’d you think? [Nekky] I’ve never had to try an Essex retainer. I guess you could, like there’s no problem with that at all, but you just want to stabilize it and get it to the surgeon. Cause if it is a far posterior crack, you can cause some damage as well. And I don’t want that to happen to you. Knock on wood. Luckily. All of my tuberosity fractures, and I’ve taken out some big chunks of tuberosity, none of them have been too far distal. I’ve never had a first or a second molar moving when I was taking out a third molar. In most cases, it’s going to be a small piece of bone distal to that third molar. I just want you to be careful, and don’t just start ripping out third molars without sufficiently elevating. If you have divergent roots and if the patient has good opening and you’re able to section, or you can try that. I find sectioning upper third molar is really difficult. However, if you need to make a buccal trough to kind of loosen up the tooth, so you’re not putting as much force on the tooth and the tooth needs to come out, then you can do that. Like say there’s an infection on the tooth and the tooth needs to go. You can make a small buccal trough. You know, when I make my buccal troughs, it’s half on tooth, half on bone. So I’m not removing a ton of bone. I just feel like we can be a little bit kinder to the tissue and I always teach in all my courses when you use the grip and rip technique, you grab onto a tooth and you just wanna rip it out of there, it often leads to a lot of problems. And one of those problems can be a tubes fracture. So be gentle to your patients because if it happened to you or if you were taken out a tooth on your dad, you wouldn’t want that to happen, right? So why would you let it happen to a patient? [Jaz] It goes back to everything we discussed before, you know? Assess the radiograph, tell the patient that, wow, your tooth has got this funky root. Sometimes a bit of bone comes with it. Don’t worry. We got some techniques to manage it, but sometimes they can be quite nasty. And then we need to sort of put a wire there, but listen, this may or may not happen. I’m just giving you an idea of it. I mean, how far do you go with the consenting for the rarer things, right? And you don’t want to overplay some of the rarer things. So it’s a difficult thing to warn about tuberosity fracture sometimes. [Nekky] It is, it is. But the best part about a tuberosity fracture is when a patient’s like, hey Nekky, can you show me your tooth? And you’re like behind the patient with your elevator, trying to chip off the bone and you’re like, oh man, I got it. I don’t want them to see there’s a chunk of bone there. And so. Yeah, no. I stick to the main ones. I stick to pain. I stick to swelling. On the lower, if there’s close proximity to the mandibular canal, I know we could do an entire episode on just that, right? I tell the patients, oral antral communications, if I’m taking out like an upper second molar, I tell the patients, it’s the common ones. But am I telling patients about like, do you know, Mrs. Smith, I could fracture your jaw here, unless it’s a high risk scenario, which I don’t recommend you take on anyway, like I’m not breaking patient’s jaw. And so like bleeding. Yes. I talk about bleeding. I just talk about, I stick to the main ones. And if I think, a more serious complication is on the table. I’m not doing the case because I don’t take on cases that where I lose sleep, you know what I mean? And I don’t want you to either. That’s why we have specialists. That’s why we have people that we can refer to. Remember we refer risk and like we talked about earlier some angry patients. We can refer those to right? But like never take on cases where you lose sleep. You never lose sleep over cases. You do not do. Keep your life simple. Keep your life easy. Live on the edge of comfort. I get it. But don’t push the envelope because you’re not helping yourself or your patient. [Jaz] And when you are at the edge, make sure you have enough education, experience, mentorship nearby. That could be virtually through like some of the wonderful stuff you put out there or someone holding your hand is great. But always, micro steps and growth at a time. Don’t know giant leaps. It’s always one small step for man and keep it one. Don’t know giant leaps of mankind. Yeah, we’re not doing that in the surgical specialty, right? We’re not doing the Neil Armstrong. Okay. Almost said Lance Armstrong, Neil Armstrong. Listen, so what for the tuberosity, watch out, look at the radiograph, really think, is this a fight that you need to fight? And then the soft tissue is what saved me, right? So I had Chris Waith a long time ago. We talked about tuberosity fracture. It’s And the whole thing about he’s brilliant, right? Moving away that soft tissue lately that saved me. That saved me. Cause I was able to, I had something to stick the suture back and it healed wonderfully. So that is a real top tip. I’m going to ask you a personal question, Nekky, feel free not to answer this personal question. If you don’t mind. Have you had like a complaint that’s gone litigious? Have you had like someone try to sue you before? Jaz’s Outro: Well, there we have it, guys. Thank you for listening all the way to the end. So, this is what we’re going to cut off for those on YouTube, Spotify, Apple. If you want to listen for free, you can. Just head over to Protrusive Guidance. This is the nicest and geekiest community of dentists in the world. And it’s a safe space. It’s a safe space. You have to be a verified dentist to come on there. And I’ve got all the free content there. It’s also paid content on there if you’d like to. If you want to get CE credits for these episodes, we are a PACE approved provider. So the website for that is www. protrusive. app, that will take you to our landing page, make an account, and then use those login credentials on the iOS app or the Android app. Thank you though, for those on YouTube, Spotify, Apple for making it to the end. Really appreciate your listenership. I’m really hoping you enjoy this one. I really enjoyed speaking to him. He’s just a breath of fresh air and he’s like just the nicest guy. You can just sense it in his voice. Very knowledgeable and I always learn from him and I hope you did too as well. Do check out his Third Molar’s online course. For me, it’s the best online course I’ve ever done and I’m pretty sure the Protrusive discount code is valid. It gets you, I think, 15% off. I’ll put that in the show notes. We are an affiliate but if you’d rather pay full price, be my guest, but if you want the coupon code, it is Protrusive. The website to automatically apply the discount is protrusive.co.uk/thirdmolarsonline. That’s /thirdmolarsonline. And you can see the reviews on other websites. This course is just packed full of videos after videos after videos. Every time I’m doing a third molar, I will go in the video library, find a similar x ray, a similar case what I have, and I’ll just like revise it before I do the surgery. It’s that good. Anyway, thanks to team Protrusive for helping this together. I’ll catch you same time, same place next week. Bye for now.…
In this special recap, we’ll explore 12 key lessons from 2024 —insights that have shaped our practice, validated our protocols, and sometimes, inspired small but meaningful changes. Happy New Year from Team Protrusive! As we kick off 2025, we want to express heartfelt gratitude for your incredible support throughout 2024. What were the standout moments that shaped your learning this year? Which episodes gave you that “aha” moment? Whether you’re a seasoned listener or just jumping in, this recap will help solidify the lessons that you can apply to your practice every day. https://youtu.be/OxfRmNhQ7Wk Watch PDP209 on Youtube Protrusive Dental Pearls: Take time to reflect on your goals for 2025 and consider what sacrifices you’re prepared to make to achieve them. Emphasizing the importance of writing down both your objectives and the trade-offs they require, align your time and priorities with your personal and professional aspirations. “You overestimate what you can achieve in a year and underestimate what you can accomplish in ten years.” Productivity is about knowing how badly you want something and what you’re willing to sacrifice to achieve it. Take a deep dive into this literature: Clinical considerations for increasing occlusal vertical dimension: a review Australian Dental Journal – 2012 – Abduo – Clinical considerations for increasing occlusal vertical dimension a review Download Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 01:08 Protrusive Dental Pearl 06:25 Value Your Skills 11:54 Importance of Photography and App Launch 14:42 Audio Notes in Dentistry 16:41 Rubber Dam Mastery 18:07 Composite Techniques and Innovations 21:07 Onlays vs Full Crowns 25:54 Best Bonding Agents 28:55 Digital Dentures Revolution 31:24 Mastering Vertical Dimension 32:29 Perfecting Posterior Composites 34:58 Creating Awesome Dentures 36:27 Extraction Techniques and Avocado Analogy 37:47 Looking Forward to 2025 Here are some episodes and webinars mentioned in this episode that are definitely worth checking out: Value Your Skills – How to Stop Underselling Yourself – AJ006 Your Occlusion Questions Answered by Dr Michael Melkers – PDP015 Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175 NEVER Write Notes Again! How I Use AI for Awesome and Efficient Dental Records – PDP181 Canine Guidance vs Group Function – Does it Matter?! – PDP182 Class II Composites WITHOUT a Wedge + Contact Opening Technique – PDP188 Onlays Vs Full Crowns – Decision Making 2024 – PDP189 Quick and Slick Rubber Dam Vertipreps for Plonkers Premium Clinical Videos My Productivity Secrets Revealed Webinar REPLAY Deep and Dark Class III Restorations Which Generation Bonding Agent is the Best? 2024 Adhesive Systems – PDP192 Digital Dentures for Every Dentist – The Death of Impressions? – PDP195 [OCCLUSION MONTH] Vertical Dimension – Don’t Be Scared! – PDP197 How to Place Posterior Composites without Destroying Your Anatomy – PDP200 Making Awesome Dentures – Border Moulding and Beyond – PDP205 Exodontia for Beginners – Extractions via Avocados! – PS012 Take your practice to the next level with DigitalTCO , Dental Audio Notes , and the Greater Curve . This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan , including Premium clinical workthroughs and Masterclasses. Click below for full episode transcript: Jaz's Introduction: Happy New Year, Protruserati. 2025, from all of us here at Team Protrusive, honestly, thank you so much for an awesome 2024 and looking forward to so much in 2025. In this episode, we're going to look back at all the gems from 2024 and looking forward to 2025. So I'll give you at least 12 takeaways, 12 key lessons from the episodes of 2024. Jaz Gulati: Things that I took away that I’ll be changing in my practice or sometimes things that were validated, lessons and ideas and protocols that were validated. Validation is a really beautiful thing. As you gain more experience in your career, the more courses you go on, you realize that you get to a point where you’re not learning as many new things anymore. And sometimes you go to a course and it’s just one little thing you picked up. And it was all worth it. And so much of it is actually validation. It’s really lovely sometimes to know that there are other people doing it the same way that you’re doing it, or the advice that you were taught a few years ago is still current and best practice according to someone that you really respect. Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Now as this is a PDP episode, before I start, I will give you your protrusive Dental Pearl. And as it is January 1st, it’s 6am as I’m recording this before the kids wake up. And I’ll tell you something really sad, right? Last night was the first time in my living memory, like literally since I was like six years old, I’ve always seen the new year end. I’ve always seen the clock strike midnight. And to wish those around me a happy new year. Last night, me, the kids, everyone were asleep by 10 p. m. And I guess it’s a sign of maturity, it’s a sign of growing up. It’s a sign of a season of life I’m in. You know, life is all about family and the two young boys that we have. And by 10 p. m. we were absolutely exhausted. Which is why I was able to be up at like 4 something this morning to get the studio ready to record this. And the reason I’m telling you this is because it’s very relevant to the pearl I’m going to give you. See, this time of year is really important to me because it was around about this time, six years ago, that I started the Protrusive Dental Podcast. At that time, I had every reason in my mind not to do this, to not start a podcast. Who’s going to listen? I hate the sound of my voice. I don’t have the budget for a studio and I can’t even buy a green screen. What do I do? I don’t even know how to get started. But then I came across a book all those years ago. It was called Start Now, Get Perfect Later by Rob Moore. And that book really motivated me to just get started. Even if one person listens, that I will get something started. Fast forward so many years and we’ve crossed 1. 1 million audio listens, over 2 million views on YouTube in total, and thousands of Protruserati just like you all over the world that me and Team Protrusive are absolutely indebted to. Thank you so much for supporting the show by watching, by subscribing, by commenting and liking. It really means so much. Dental Pearl But, I’m still not at the pearl yet. The pearl is this, that as Protrusive grew and I knew that I have this role to play in the universe. This small little role to play in the universe that means a lot to a lot of dentists actually. Now, we as a team are privileged to receive messages of reigniting dentists passion for dentistry. Helping dentists get out of a bad mindset and to be the best clinician possible. Those messages absolutely gets the team pumped and those are the highs, but we also experienced lows. Sometimes the workload gets a lot. It’s very tricky sometimes being a clinical dentist, family man, looking after the body and the mind and all those things. So number one question I get is Jaz, how do you fit it all in? Now there’s a whole webinar I did on this. It’s called My Productivity Secrets Revealed. I think I did it around almost like two years ago now. Still, 100 relevant including how I hired a team. The daily mantras that I follow that’s all there in the webinar and that’s available on Protrusive Guidance. It’s in the webinar replay section. But the thing I want to share with you and echo with you now as we stride into 2025 is what are you willing to sacrifice? Like, you may have some things that you want to achieve this year, and that’s great. Write them down. Believe in yourself. If you want to own your own practice, if you want to open up a chicken shop, if you want to write a book, or if you want to start doing implants in your practice, or maybe you want to serve your family in a special way. Me personally, I want to do more cooking this year. Whatever it is that you want to do, it’s likely going to require sometime. So where are you going to get this time from? And so I want you to write your goal down, the thing that you want to achieve in 2025. But it’s not enough to just write it down. I want you to write down what you are willing to sacrifice to achieve that thing, to achieve that goal, to reach that summit. And so to give you a flavor of the things that I had to give up to make sure that Protrusive is running and alive and thriving is that me, I don’t watch Netflix. I don’t watch TV basically at all. I stopped watching my football matches. I used to watch Manchester United every single football match the whole 90 minutes, two hours I used to watch it and I knew if I’m going to be serious in my career, I had to stop doing that. So I became a, what we call a fair weather fan. I just watched the odd highlights here and there. And unfortunately my team is not doing so well at the moment, which is sad, but you get the idea. I gave up these luxuries or these pleasures so that I can devote the time. I was absolutely unwilling to give up time with my children and my wife. I was unwilling to sacrifice on time away vacations and holiday. And I also made sure that I leverage my time while I commute to work from London to Reading now, that I am listening to something, be it a podcast, be it audiobooks. Gosh, I’m a massive fan of Audible and audiobooks. Well, I also have a YouTube premium subscription so I can actually play a video on YouTube but then close the screen and the audio of the video is still playing in the background. So I can just consume as I drive and reflect and leverage that time. Now, I did just recently start watching Squid Game Season 2, right? We’re like two episodes in. It’s absolutely brilliant. And my wife is really happy that we’re watching it. It’s our little thing to watch together. But by and large, I try and eliminate the non productive things which don’t bring me so much joy. What brings me joy is the gym. And so I absolutely did not want to give up the gym. So about three, four times a week, I go to the gym and make it happen. Even if it’s just a half an hour workout, which it usually 99% of the time it is. So hope that gives you some perspective, some ideas about writing down what are the things that you will sacrifice that do not give you enough joy. They might give you joy, but not enough to sacrifice that dream or that desire that you have. And if you’re on Protrusive Guidance, I would love if you could DM me what that is. Open up the app, find me and direct message me what that one thing is that you want to achieve. I would just love to know. I need only a few of you will do this. They’ll be really nice. Okay. So hope that was a inspiring and helpful to someone and let’s get the show on the road. Main Episode: Let’s now look at January, 2024’s top lesson. So one of the podcasts I had the most listens and views in January 2024 was Value Your Skills, How to Stop Underselling Yourself. It was an AskJaz006, and I’m quite proud of it, right? Please do check out that video. And really, it’s about how I struggled at the beginning of my career trying to talk fees to patients. I think so many of us experienced this theme. And that’s normal when you don’t have much experience. You haven’t seen your work and how long your dentistry can work. When you lack experience, you constantly doubt yourself. And that often gets reflected in your fees, which I understand. I totally understand. But as you gain more experience and skill and you go on more courses. You have every right to command a fair fee and to stop underselling yourself. So please do listen to that podcast. If you need that kind of a boost, but I’m going to kill two birds in one stone here. Dr. Amit actually commented on that video. And I just realized I didn’t reply to that. Okay. Almost a year ago. I’m sorry, Amit, you are a subscriber. You are someone who comments regularly on the YouTube. I love you so much. Thank you so much. I’m sorry. I didn’t reply to that one. I just noticed. So why don’t we tackle that one? Cause the lesson is here. Okay. So Amit said, bloody amazing video. Thanks Amit. He asked, what’s best way to convince patients of your value? And do you ever think you run the risk of overvaluing yourself, that patients decline treatment plans and go elsewhere is such a hard balance of sticking to your principles and understanding the realities of patients budgets and market competition. What a wonderful question, right? So how can we present our fair fee, but not scare too many patients away. So actually you don’t get through the dentistry because everyone’s going elsewhere. I mean, we could have a whole episode just discussing this, but I’m going to give you one quote from one of my mentors, Dr. Michael Melkers. He’s been on the podcast a few times before and he will come again in the future. Please do check out everything by Dr. Michael Melkers. The quote that was shared to him by a mentor is what I’m passing on to you guys. It’s so relevant to Amit’s question. And the quote is this, “A fair fee is paid with gratitude and accepted without resentment.” So if you just quickly break that down, when a patient pays you a fee and they’re so thankful, like, I remember a landmark moment in my career whereby I was seeing patients under a public healthcare system and they were paying either nothing or next to nothing. Some of the patients, not all, but some of these patients just didn’t value dentistry. And I was doing all this work. I was working really hard and getting paid peanuts not matching the effort and the time I was putting in my work. And I noticed that the gratitude from these patients, some patients was lacking. Whereas when I moved to the private sector, I noticed that patients were paying a much higher fee and rightfully so. ‘Cause to deliver good dentistry is not cheap. So patients were paying a lot more, but I was getting thank you cards and so much more gratitude. How does that work? You see, when patients value good quality care, longevity, and how someone can solve their problems, money becomes A factor but not The factor. And what you’ll notice that when you present yourself to the universe in that way, that patients will pay your fee with gratitude. Now obviously we need to be sensitive of budgets and we can’t just charge a million dollars a crown because that’s just stupid. It’s got to be a fair fee in the way that you are meeting your overheads, you’re making a fair profit, and you’re reflecting your skills, quality, and training. And when you present that to patients, patients can smell the confidence. They can see that, yes, this dentist, he might be charging a little bit more than these other dentists, but I can tell from the social proof, all these cases that you’ve done before, or the way that you made the patient feel, or the way you explain the plan to them that, yes, this is a dentist for me. And they will pay your fee with gratitude. But it must be a fee that’s received by you without resentment. The classic one is this, right? You see a patient, you make some complete dentures, and then you see the same patient for 45 adjustments, and you don’t charge every time for those adjustments. So your hourly fee was probably like $2 an hour by the end of it. And you resent that. You hate that. It’s a bit like when you are lacking experience and you do this silly thing whereby you know something’s not going to work. You know something’s really pushing the boundaries, like trying to crown a lateral incisor. Which has no ferrule at all. But the patient really wants you to save it. So you save this lateral incisor, stick a fiber post in it, you put a crown on it, and three months later, it breaks away. Because it didn’t have any ferrule. Sound familiar? Hopefully not. But, for me it’s familiar, and for many of you it may be familiar. You know you shouldn’t have done it, but the patient really wanted it. But now, because it’s failed too soon, all that warning that you do, patients seem to forget. When you say, yeah, but it might just last one day kind of thing, patients are very good at forgetting, because once there’s a fee exchange, things become a little bit different. And so some people end up working for free, and then they do a bridge for this patient as a gesture of goodwill, that, okay, I’m sorry it failed early kind of thing, and you take it on yourself. So really the lesson is that try and do predictable dentistry, and don’t be in a situation whereby You’re doing dentistry for free and therefore you get that feeling of resent. Or if you really are, are cheap and you’re not charging enough, when a small complication happens, the patient needs to come back. You want to feel like, hey, I charge a fair fee and I like this patient, the patient likes me and I’m going to go to the ends of the universe to help my patient. That’s great. What you don’t want to feel is that you gave a patient a massive discount, and then you’re seeing the patient again and again to sort these little minor issues out, and you’re constantly resenting the fact that, oh man, I wish I didn’t sell myself so cheap. There’s so much extra work here, so much effort and time being placed into it, and you’re not being remunerated fairly. So once again, paid with gratitude, received without resentment. Thank you, Dr. Michael Melkers. And thank you Amit for commenting on Protrusive Podcasts and being a Protruserati. Now let’s move on to February. The biggest episode in February 2024 was with Dr. Lane Ochi, one of my heroes. It’s funny because Dr. Michael Melkers and Lane Ochi, they’re kind of like two peas in a pod. They go together, they go fishing, they lecture together, they’re top blokes. And a great win for Protrusive was having Dr. Lane Ochi, on our app, Protrusive Guidance, in our community, and he’s so regularly posting, helping. Just one of the nicest people in the world. Forget dentists, just nicest humans in the world. And so the reason I’m on my phone here is I’m looking at the premium notes. So all these episodes, they have these premium notes. And to jog my memory, I’m looking through my phone basically and seeing the PDF that was generated. So if you want access to like the cliff notes or the summary notes of every single podcast episode, that’s available on Protrusive Guidance. So download that on Play Store and on iOS. And one of the biggest takeaways from that episode with Dr. Lane Ochi is like, we’re already, most of us are taking photos, right? Either on our DSLR or intraoral camera, but a really quick win is you get the patient to get their phone out. And get the patient to take a photo of that thing you’re showing them. Now, this episode was about crack teeth, should you chase cracks, the decision making process, the patient discussions, really fantastic episode, do listen to it. And all these episodes we’re referencing, we’ll put them in the show notes. But essentially, when you take a photo of a crack, and you need to have a discussion with your patient, you need to involve them. Yeah, I mean, it’s great to show the patient the photo. It’s amazing. And if you ever have a crack, air abrade that and then the crack will look even more obvious because sometimes in photos you can’t pick it up. But when you aerobraid it, it’s a little tip that you can actually see the crack a little clearer. Now what you then do is get the patient take a photo on their phone of their crack because then they take it home with them and they reflect and they think about it and they show their significant other because a lot of times when things are important, but asymptomatic when they’re not having pain It’s like when they leave the office like okay, they’re forgotten about it. But it’s actually something they need to learn live with. They need to own the fact that there’s a crack there and they need to decide with our guidance and discussion of different options available, whether they want to be proactive or reactive, they need to own whichever decision they make. There was a great little tip that I think we can all implement. I’m trying to pick tips here that we can all implement on a day to day basis and that’s the one for February. Now February 2024 was very special because that’s when we launched Protrusive Guidance. We moved away from the Protrusive Education app, which is a great start. Like I’m a big believer in start now, get perfect later. Like I said, so that first iteration of the app we had was great to get us going. But then now we have really the Rolls Royce of an app. The Protrusive Guidance app now is a significant investment and time went into it, but I’m so proud of it. It’s a really lovely community. It’s 3000 strong community of you guys, Protruserati, all around the world and that was launched in Feb 2024. So thanks to all of you who jumped on and are supporting the show and our team. I really appreciate that. Now moving on to March 2024, the top tip from this month’s episode, which had the most views and listens was How to Never Write Notes Again. So the really cool thing happened is I was on a flight to Chicago for the AES, which was absolutely amazing. I would highly encourage everyone to go to the AES in Chicago. It’s a great meeting of all the occlusal minds. And it was just so inspiring. And while I was on the flight, I was looking at different ways to optimize my notes. Cause as you know, I hate two things in life. I hate washing dishes and guess what? Now we have a dishwasher. And I hate writing my notes, but now I use AI and AI has absolutely changed the game for me. Now you must still check the notes that are produced from AI. Make sure it’s accurate. Make sure the microphone that picked up your words that it picked it up correctly. So it’s still our duty to check it, but my notes are so much more thorough, so much more accurate. And I get to save the audio recording, all this with my patient’s consent. So two softwares I’m using at the moment are Digital TCO and Dental Audio Notes. I use both of them. Because I’m so reliant on audio for my notes that I would hate it if one of them crashed and I lost the audio that I refuse to have it. And they’re so fairly priced that saving four to five hours a week for me so I can do more of this stuff is so important that that’s why I subscribe to both. So check out Dental Audio Notes and check out Digital TCO. Digital TCO is the main one I use for my notes. And DAN is what I use a moment for just the high quality audio recording, but it also has fantastic features, AI features, always growing. And again, I’ll put those links in the show notes. If you want special Protrusive pricing on Digital TCO, then head to digitaltco.co.uk/protrusive so you get that top plan at their lowest fee. So it is something like that. 30, 40% off at the moment. And that is an affiliate link, by the way, but absolutely transform my practice. So the main lesson there is, are you using AI in your note taking yet? And if not, why not? My nurse is so much happier. Like God bless her. She’s slow at typing. Okay. Zoe, I’m sorry to say, you know it. I know it. Well, you’re slow at typing. But it’s okay because now you love the fact that I use AI and you just supplement it with little things here and there and we check it together. So it’s absolutely great. Now, moving on to April, we had Dr. Celine Higton, we had so many great guests, but the one that had the most views and listens was Dr. Celine Higton, Isolating the Last Tooth. So it’s all about rubber dam usage, and she’s such a brilliant advocate of adhesive dentistry and rubber dam isolation, which I’m a huge fan of, as you know. On the app, we have the Quick and Slick Rubber Dam masterclass webinar, plus 30 videos showing you how I isolate in real time through loop mounted camera, how I isolate all these cases. Some are two minutes, some are 15 minutes, really tricky cases that I’ve isolated, and that’s available on the app. But the main takeaway I want to give you, or the lesson I want to highlight from that episode, is if you are frustrated with rubber dam usage, you’re probably using the wrong gear because when you use the right type of rubber dam and the correct clamps i. e wingless clamps and use the correct technique i. e is four handed, right? Your nurse should be using the floss and actually I don’t like it when the nurse uses floss. We use flossettes those little harp shaped things Those are like y shaped things with like a little floss going through it like a line of floss. If your nurse uses that they get so much better access. And now you can just hold the dam in place and the nurse can use the flossette. So I know a good trades person never blames their tools, but probably you’re struggling with rubber dam because you’re using the wrong tools. If you use the right tools and the right technique, honestly, it becomes so much easier. And obviously getting those reps in, getting those reps in to become better and better, and even how you communicate rubber dam to your patients. That’s really important. So check out that episode as I now talk about a kind of an opposite episode, right? Cause in May, the most popular episode was Class Two Composites Without a Wedge. Okay. The contact opening technique. That’s PDP188 with Dr. Sunny Sadana. He’s the guy who’s famous for bringing the greater curve matrix and making accessible in the UK and other parts of the world. So the greater curve matrix. Speak to the Americans, they know about this matrix band, it’s pretty slick, it’s pretty good. And I come from a background where everything needs a sectional matrix, and if it can’t be, if it’s too complex for a sectional matrix, it’s got to be indirect, right? And therefore, using rubber dam, and as you know, I love using dam, but since using the greater curve matrix now for a year and a half now, I’m using less dam, okay? Now, I am sinning, if you think that, if you’re probably right to think that I might be sinning here, but look, I’m actually a former head of the rubber dam police. I’m a former inspector of the rubber dam police. Everything was rubber dam before, but now the seal that I get with a great curve matrix means that my gingival seal is perfect. And therefore, if I’m treating an upper premolar, first molar and I’ve got a really great seal and the patient’s not a mouth breather and I can keep it well isolated, then maybe in that patient I’m not going to use rubber dam. Whereas if it’s a lower arch I’m pretty much always going to use rubber dam, Do you see what I mean? I’ve kind of become a little more flexible and that’s down to the fantastic gingival seal that I get from the great curved matrix band. There’s a live webinar I did with Sunny on Protrusive Guidance recently all about my tough composite cases. So I showed everyone videos, me doing a peg lateral with the greater curve band and a couple of class twos whereby I got a good contact and one where I didn’t get a good contact and we kind of critiqued it together. So that’s on Protrusive guidance. The main lesson I can give you from this is that there is a beauty in being able to change your protocols when something more clever or more efficient comes your way. Sometimes you get set in our ways. That something always has to be done in a certain way, and that is dangerous. So it’s important about doing things that work in your hands and not changing your protocols too often. But now, and again, to review emerging technologies or a different mindset, because the contact opening technique is just like, it’s absolutely crazy. I was really against it when I first learned about it. Think about it. You put your matrix band on your circumferential matrix band, you put it on. And now you don’t use a wedge instead to get the contact with a tooth next door. You get a bur and you drill a hole through the matrix to contact the adjacent tooth. It just sounds barbaric. It sounds wrong. Let me tell you, it works. Okay, and now because you get a really good seal and you don’t get that wedge that opens up the contact and distorts your matrix band. There is a place for this. I still use sectional matrix bands I still use other systems but using the contact opening technique It’s totally something we need to have in our armamentarium. Especially for me, my patient base is age 60 plus primarily. I work in like a little village in Reading and therefore my patients have like subgingival caries, root caries, big restorations to do. So this is why I’m a huge fan of this matrix plan. And we’ll just highlight you to be open to different ways of doing it and really try it, critique it before you poo poo something. Okay. That brings us on to May and May had the best performing episode. You guys absolutely loved Onlays Versus Full Crowns with Dr. Alan Burgin. It was the most listened to episode on Spotify, on Apple, on YouTube, you name it. It absolutely outperformed all metrics. And it’s a testament to Dr. Alan Burgin and the wonderful work he does. And it was just a lovely discussion, real world discussion. We look at it too. We think, hmm, how are we going to restore it? You’ve got to begin with the end in mind. So are you doing an overlay, something in ceramic adhesive dentistry, or you can do a full crown, which we’re of course doing less and less of. The exception to that is I’m doing a lot of vertical crowns and vertical crowns is like basically a vertiprep and you’re like minimally preparing and therefore you get to conserve so much tooth structure. And it’s amazing a stat that Alan shared on that podcast is that when you design it, well, a vertical preparation can actually be even more conservative than an overlay in terms of how much tooth preparation you have to do, how much tooth tissue was sacrificed. So we’re at a situation now that we can use zirconia vertical crowns in a very minimalistic way. Now, that doesn’t mean I’m going to be crowning everything because when I have enamel, I believe in adhesive dentistry and I will be doing my overlays. I love doing my overlays. Get the rubber dam on and fall in love with little minute details of bonding and being biomimetic and being adhesive and that’s great. But when you have a dubious tooth that you don’t have that high quality enamel all the way around, I’m totally gonna vertical prep that. I see how much ferrule I gain or how much tooth structure I preserve and it just makes me smile. So if you’re not already doing vertical preparations or overlays, then maybe this is the year that you start learning about these two modes of treatment, which is pretty much how I do my indirect restoration. It’s either going to be an adhesive overlay. Or if I’m doing a crown, it’s going to be a vertical preparation. There’s so many courses out there. Do check them out. I would encourage you to go on a hands on one. But if you want to do something online, then I have that on Protrusive Guidance. So in the premium clinical videos, I have full walkthroughs of doing adhesive procedures. So adhesive overlays and the veneer being bonded. So you can check that out. Or, I’ve got a whole series, VertiPrep for Plonkers, which I’m going to probably rename to the VertiPrep Challenge. Your first premolar vertical crown. These are some of your guys favorite piece of content that we have on Protrusive. Your favorite course that you’ve done is VertiPrep for Plonkers, so do check that one out. It’s on the Ultimate Education Plan on Protrusive Guidance. So guys, if you’re still doing shoulders, I would like you to reconsider. Could you be doing more overlays? Could you be doing vertical prep? Could you be more conservative? By using these two indirect modalities. Okay. So we’ve done half the review so far and it’s almost 7 a. m. in the UK and that’s my wife’s alarm. She’s doing the New Year’s shift today. So it’s New Year’s Day. She’s doing the New Year’s shift. God bless her. Healthcare worker helping out emergency patients on New Year’s Day, and I’ve got the boys. So I’m going to go now and you can join the rest of it on part two. So I’ll come back later. I’ll record part two for you guys. Hope you’re enjoying it so far. And I’ll catch you in part two. And of course, for newcomers, thank you so much for joining the podcast. Please do hit the subscribe button for those who are returning. So many of you have not hit that subscribe button. What’s wrong? Are you allergic to it? Hit that subscribe button, show your support to Team Protrusive, and I promise you, we will support you back with the content we make this year. So thanks so much for listening to this one. Slightly different episode, but I just wanted to do like a year recap. And I’ll also in part two, we’ll finish off the recap and the key lessons. But then also look ahead at what we’ve got planned for 2025. All right. Bye for now. Before my wife wakes up, catch you in a bit. Hello and welcome back to part two of this new year special. It’s funny because. I told you I was up really early 4 a. m. And I had to wrap up part one because it was almost 7 a. m. My wife was gonna be up. I had to look after the kids. I gave you a little glimpse of my life there and now it’s 11 58 p. m. So it’s almost midnight. I was working the evening shift. So remember I work morning shift one week and an evening shift the other week. And this way I get to do a school pickup or a drop off. It actually is pretty good for work life balance in that regard. Yeah, came home this evening, quite late, caught up with the missus. And there we are, we’re recording now. And echoing back to that same theme that we talked about in part one, which is how do I fill it in? I gave you some of my advice about productivity in part one. So if you didn’t check out part one, then do check out part one. It was a nice overview of the first half of the year. Okay. And now we’re going to continue with part two, but the whole productivity thing means that, how bad do you want to achieve something? How bad do you want to do something? And like I said, in part one, there are some things that you’re willing to sacrifice and some things that you weren’t. And once you’ve made peace with that, you can do a lot. They always say that you overestimate what you can do in a year and underestimate what you can do in 10 years. By the way can we make that the pearl for this episode? I realize this is not actually a proper PDP. It’s like a off the cuff part 1 part 2 New Year special. But yeah, I do like that one you overestimate what you can do in a year and you underestimate what you do in 10 years. So where we left off last time was the month of July and in July the most popular episode was which generation bonding agent is the best. Now, this is really popular. You guys love adhesive topics and the main takeaway I want to give you from this episode with Dr. Sam Sherif, and it’s so simple and it’s so foundational and you’ve probably heard me say it before. For any adhesive system that you start using, please, please, please read the directions for use. In fact, read the directions for use for every product you’re using, but especially for the adhesive stuff. These things are so specific and so technique sensitive that you need to make sure every stage is right. In fact, we had a question in the community recently, and the question was, can you use, like, the primer of one system and the bond of a different brand, and will it work? And some of the community members on Protrusive Guidance chipped in and said, actually, I’ve been accidentally doing this for years. And I haven’t had any issues. So you know what? If it’s the same generation of bonding agent, then maybe it’s going to be fine. If you use like a GC primer and an Ivoclar bond, maybe it’s okay, but I would never ever advocate it. I would not sleep well at night if I did this. And I’m a big believer in that, whichever system you use try and use the same brand stuff. Don’t do mixing and matching. Cause just, it’s just anxiety central for me. So on this theme of reading, when you’re using an adhesive system, especially if it’s new to you, maybe you joined a new clinic, read everything you can about that adhesive system. What does the manufacturer say about how it should be used? Are there any clinical papers discussing the sort of deviations in the protocol? What about experiences from your colleagues that use a cement? Sometimes it’d be like, Oh, you know what? With this specific system, make sure you do this or you wait 20 seconds. There’s so much we can learn. from our colleagues. In fact, I remember reading about OptiBond FL. You know that fourth generation bond, OptiBond FL? It’s like the grandfather of all the bonds, right? People love it still, although nowadays the newer generations have pretty much caught up. Okay, let’s face it. But, some of the purists still like to use OptiBond FL and ideally use the primer on the dentine and the bond on the dentine and enamel. And so, correct me if I’m wrong, but the protocol I read was that if you’re bonding to enamel only, you don’t need to use a primer. You go straight to the bond. So you do etch and the bond, you don’t need to prime if you’re working on the enamel. But then if you read the papers, they did these studies whereby they actually did use the primer on enamel and they found that it didn’t work. Did actually improve the bond strengths. So there’s those little nuances and additional evidence that comes out, companies will manufacture and test their products and they’re always gonna be a little bit biased. So any independent research you can read about your adhesive system, that’s like the best way to geek out. So I would definitely encourage you all to do that. Okay, now let’s continue the theme of 12 tips across the 12 months, right? So just to remind you from part one, we’re going to just go over 2024 episodes and like the key things that you can validate your learning or just remember what was shared that month if you’ve been on this Protrusive journey. If this happens to be the first episode you’ve clicked onto, then wow, everything you’re hearing is like, oh, that’s a gem. That’s a gem. But to many of you, Protruserati, this is all familiar. I’m just reminding you of these knowledge bombs that were dropped some time ago. So August. Okay. So August, the top episode was the one with Dr. Rupert Monkhouse. Do you remember the digital dentures? Is this the death of impressions? And what I don’t want to do is like summarize the entire episode. You really need to listen to that one. It’s just so great. The scope for digital dentistry and how patients actually preferring them with a little test that Rupert did. So that was fantastic. But the main thing I want to give you, because it may not be relevant to all of you around the world. Many clinics have not yet embraced digital dentistry. And I think that will change in time. And scanners become ever prevalent. In fact, on the Protrusive Guidance community, some of you invested in these own brand Chinese makes of scanners and you guys are having good success and you guys are liking them. So look, they’re becoming a really affordable, like for two and a half thousand pounds, I think Terence Ong bought one, which is amazing. And he’s been very happy with it. He posted this on the community. But the pearl I want to give you from that episode is something that we spoke before with Rupert as well, and it’s something that’s applicable to everyone, which is finding a great technician. Do you know your technician’s name? Okay, so many colleagues, they don’t actually know who their technician is. Why? Because they’re sending their work to a big lab, which is cool, which is fine. They’re sending it to a big lab. And someone different touches their work all the time. Now, if you feel compelled due to geographical convenience, or your big corporate is making you do it, to send it to a quote unquote big lab, that’s fine. But how about you visit that big lab, look a technician in the eye, and form a relationship with one technician, or maybe two technicians in that lab. And start being on WhatsApp terms with them. Try to understand and develop each other’s philosophies. That would be a wonderful thing to do. In fact, something that Dr. Finlay Sutton himself a few years ago on the podcast, he said is try and find a technician, similar age to you, then you can just develop together over the years. And the other thing here is that as dentists sometimes, me especially when I was younger, I was scared to teach quote unquote teach something to the technician because I was thinking wait I’m just a young dentist what can I teach a technician well actually when I spoke to technicians they felt the same they thought oh what can I teach the dentist the dentist is the king is the guru I need to adapt to them and be guided by them whereas the dentist is like hey the technician is my guru the technician knows so much more than me about this. But actually there’s something that you can both offer the technician and the dentist working together and teaching each other and growing together. So that’s the top tip I want to give you on the theme of dentures and generally with all types of lab work, find yourself a good technician to grow with. Okay, moving on to September 2024. It’s that man, Mahmoud Ibrahim. It was a joint episode we did on Vertical Dimension. This was probably like the second most listened to episode in the entire year after the one about full crowns versus overlays. So if you want a really good summary, if you haven’t listened to this one yet, check it out. It’s PDP197, Vertical Dimension, Don’t Be Scared. And the lesson is, don’t be scared. It is actually quite predictable, especially up to five millimeters. And the thing I want to highlight or the thing I want to give away to you is a really wonderful paper. It’s the review by J. Abduo. It’s been cited by 527, right? And it’s like the first one on Google. So it’s called clinical considerations for increasing occlusal vertical dimension, a review. It is a brilliant review. So I’ll make sure I put in the show notes, but this paper is just such a great thing to read. Me and Mahmoud go over some points and we do some extra bits around it. But if you’re the kind of guy or gal who likes to get it in their hands and read every detail, then this review, look no further. It is truly a fantastic review. So I wanted to include a reference that you can check out and just geek out with. Okay, so I’m on to the next one. I’m smiling. All right, okay, because the one for October literally posted like an exact calendar month after the previous one is again with Mahmoud Ibrahim. So you guys loved our episodes. I appreciate you guys so much. Thank you. And this one was a big one, right? It was how to place posterior composites without destroying your anatomy, right? That the most foundational thing, we’ve all been there, you place that restoration and you make it look beautiful. Cause he went on that course that showed us how to make teeth look beautiful. And then we take off the rubber dam. Patient bites together and you know where it’s going, right? You have to drill it all away and it just looks flat. It looks like a white amalgam and you’re thinking, why did I even bother? What a waste of time. You’re already running late. So this is like a really familiar site. So main takeaway from that episode and there’s all these different strategies that we discussed in terms of how to make sure that you can do the least amount of adjustment as possible. And I think if I was to give you the top tip from that one is the following, right? If you answer this question whereby should the anatomy that you give to your patient in your restoration, should it follow the textbook? Like we all know what a virgin six year old tooth looks like. We all know what a first molar looks like, right? And we look at the textbook, the molar that they show in the textbook, what age is that patient? Like six years old, eight years old. Those anatomical norms that we see in the textbook, they are like pristine teeth. They don’t have any of the natural wear baked in. You don’t even see any evidence of an opposing tooth in that image. So if we give that to your patient who’s 65 and a severe bruxist and you give that kind of anatomy, well guess what? You’re going to be drilling it all away. So we must take inspiration from the textbook, but what we must deliver must be appropriate to the opposing tooth, to the actual arch, and to the entire chewing system of that patient. So the thing I always say is, why are we giving a six year old a 14 year old’s tooth. When you start really thinking about it, and then how you actually place your composites will change for the better. Because now we’ll be doing a lot less adjustment. Because you know that there are certain bits of anatomy that get deleted, that get worn away by the time you get to age 60 or 70. So our restorations, even posterior, must be age appropriate, but more important than age, you actually have to look at your patient. Look, study the occlusion preoperatively really well. So many of us don’t do this, by the way, right? We just dive in, remove the caries, and we check the occlusion at the end. Always, always, always. We emphasize it. Check the occlusion before you start, so you know what you’re conforming to. Okay, almost coming to the end guys. Looking at November, the top podcast was Dr. Mike Gregory on making awesome dentures. I mean, what a, inspirational guy. You know, stuff that he shares on Instagram is just absolutely fantastic. And he’s so giving and visual. And the top takeaway I had from that was when you’re creating undercuts, like sometimes when you’re doing dentures and some of your teeth, like premodels, they’re really flat. They don’t have enough anatomy. And so he teaches to use flowable composite to create buccal and or lingual undercuts. And the best analogy uses is a fried egg, right? So what you don’t want to do when you’re creating undercuts, right? Is you don’t want to make a hard boiled egg cut in half. So basically you don’t want like a pimple coming out of the tooth, because how is that clasp going to engage that? And then how are you going to remove that denture, right? The clasp needs to like slip on and slip off. Right? So you need to imagine a fried egg. A really good way that we didn’t discuss is there, but you know how sometimes you see invisalign attachments or clear aligner attachments, right? And when they’re done by someone who’s not using magnification, and they’re really messy attachments, a bit like that. Sometimes they look like fried eggs, right? So fried egg flowable composite is you basically make it look like a fried egg. So it’s got this like a wide base. And then as you get to the middle, you get to the yolk. It’s got a little gentle raise, right? It’s like a gentle raise and that’s so much better for your class to actually come onto the undercut and then come back off. So that was the top takeaway from that episode. I just wanted to remind you of, and now lastly, December, just last month, the top episode was the one I did with Emma, right? You know, Emma, the Protrusive Student. I hope you guys have been enjoying our back to basics, the Protrusive Student series. There’s more of that to come in 2025 and something really cool happened during this episode whereby she asked me about application points and something that I’ve always had inside me in my head, but I never had the opportunity to discuss was how extractions are like avocados in the way that when you cut an avocado in half and you remove the avocado nut. There’s a special technique of doing so and if you mess it up, then it can take out the flesh of the avocado with it, blah, blah. And so I use that analogy of removing a nut and I compared it to removing a tooth and how you know when you’ve got that application point, what happens if you put too much force? So it actually turned out to be a really cool episode, really well received. I’m glad I managed to get this avocado analogy out to me. So if you know someone early in their career, and I think early in their career, everyone would benefit from an extraction, like a basics of extraction episode, please do send them that as a gift. It would really mean a lot to me if you would just send them that episode, because the younger colleagues absolutely love that one. And now every time I reach for an avocado and I’m removing the nut, I always think of that episode with Emma. So if you haven’t listened to it, do check it out. But remember the way that you remove the nut from avocado, there’s so much we can learn about extraction. So if you haven’t heard the analogy, do check out that episode from last month. So now that brings us very nicely to just looking forward at 2025. And I’m always led by you guys. I would love to know from you guys in the comments, what topics do you want me to cover with a guest? And if you can name a guest, I will do my best to get them on as well. You know, we’ve done over 300 episodes of Protrusive. Can you believe it? Now, can you believe we’ve actually done over 300 episodes of Protrusive? And I think we’ve barely scratch the surface. There’s so much to learn. It reminds me of one of my favorite quotes by Mahatma Gandhi, which is live as though it is your last day. I’m gonna have to get this quote now. It’s from the top of my head but it’s like live as though you’re going to die tomorrow and learn as though you’ll live forever. So I think that the true joy of dentistry for me comes from learning. I’m always learning. I’m learning every day. And that’s a beautiful thing. Like, imagine being in a profession where you didn’t learn something new. And what dentistry presents us is always, there’s new research, new technologies, and every patient comes with unique challenges. That’s what keeps this repetitive thing of dentistry interesting because there are so many nuances in every patient and the more you become comprehensive. Looking at the bigger picture the more exciting it becomes as well. Now before we sign off here this new year special episode is not eligible for CPD or CE. But that’s okay because most of the others are on Protrusive Guidance as you know. And so the ultimate way to subscribe to Protrusive is by signing up for the Ultimate Education Plan. This is what helps to support the podcast and help it to grow so that Team Protrusive can continue to do what we’re doing, which is Making Dentistry tangible. If you’d like to sign up to our masterclasses, and join the nicest and geekiest dentists in the world. Check out protrusive.co.uk/ultimate and check out our best plan. Do not forget to comment below though, and tell me what you’d like to cover next. Now, if you’re not going to be joining us for Protrusive Guidance, then can you at least subscribe on YouTube? For the last few years, our YouTube listeners and watchers has actually exceeded Spotify and Apple podcasts. So I would really appreciate whichever platform, if you’re listening on Spotify or Apple or Amazon, or if you’re watching on YouTube, we’d really severe bruxist and you give that kind of anatomy, well guess what? You’re going to be drilling it all away. So we must take inspiration from the textbook, but what we must deliver must be appropriate to the opposing tooth, to the actual arch, and to the entire chewing system of that patient. So the thing I always say is, why are we giving a six year old a tooth, a 14 year old’s tooth? When you start really thinking about it, and then how you actually place your composites will change for the better. Because now we’ll be doing a lot less adjustment. Because you know that there are certain bits of anatomy that get deleted, that get worn away by the time you get to age 60 or 70. So our restorations, even posterior, must be age appropriate, but more important than age, you actually have to look at your patient. Look Study the occlusion preoperatively really well. So many of us don’t do this, by the way, right? We just dive in, remove the caries and we check the occlusion at the end. Always, always, always. We emphasize it. Check the occlusion before you start, so you know what you’re conforming to. Okay, almost coming to the end guys. Looking at November, the top podcast was Dr. Mike Gregory on making awesome dentures. I mean, what a, inspirational guy. You know, stuff that he shares on Instagram is just absolutely fantastic. And he’s so giving and visual. And the top takeaway I had from that was when you’re creating undercuts, like sometimes when you’re doing dentures and some of your teeth, like premodels, they’re really flat. They don’t have enough anatomy. And so he teaches to use flowable composite to create undercuts. To create buccal and or lingual undercuts. And the best analogy uses is a fried egg, right? So what you don’t want to do when you’re creating undercuts, right? Is you don’t want to make a hard boiled egg cut in half. So basically you don’t want like a pimple coming out of the tooth, because how is that clasp going to engage that? And then how are you going to remove that denture, right? The clasp needs to like slip on and slip off. Right? So you need to imagine a. fried egg You know, a really good way that we didn’t discuss is there, but you know how sometimes you see invisalign attachments or clear aligner attachments, right? And when they’re done by someone who’s not using magnification, and they’re really messy attachments, a bit like that. Sometimes they look like fried eggs, right? So fried egg flowable composite is you basically make it look like a fried egg. So it’s got this like a wide base. And then as you get to the middle, you get to the yolk. It’s got a little gentle raise, right? It’s like a gentle raise and that’s so much better for your class to actually come onto the undercut and then come back off. So that was the top takeaway from that episode. I just wanted to remind you of, and now lastly, December, just last month, The top episode was the one I did with Emma, right? You know, Emma, the protrusive student. I hope you guys have been enjoying our, you know, back to basics, the protrusive student series. There’s more of that to come in 2025 and something really cool happened during this episode whereby she asked me about application points and something that I’ve always had inside me in my head, but I never had the opportunity to discuss was how extractions are like avocados in the way that when you cut an avocado in half and you remove the avocado nut. There’s a special technique of doing so and if you mess it up, then it can, you know, take out the flesh of the avocado with it, blah, blah. And so I use that analogy of removing a nut and I compared it to removing a tooth and how, you know, when you’ve got that application point, what happens if you put too much force? So it actually turned out to be a really cool episode, really well received. I’m glad I managed to. Get this avocado analogy out to me. So if you know someone early in their career, and I think early in their career, everyone would benefit from an extraction, like a basics of extraction episode, please do send them that as a gift. It would really mean a lot to me if you would just send them that episode, because the younger colleagues absolutely love that one. And now every time I reach for an avocado and I’m removing the nut, I always think of that episode with Emma. So if you haven’t listened to it, do check it out. But remember the way that you remove the nut from avocado, there’s so much we can learn about extraction. So if you haven’t heard the analogy, Do check out that episode from last month. So now that brings us very nicely to just looking forward at 2025. And I’m always led by you guys. I would love to know from you guys in the comments, what topics do you want me to cover with a guest? And if you can name a guest, I will do my best to get them on as well. You know, we’ve done over 300 episodes of protrusive. Can you believe it? Now, can you believe we’ve actually done over 300 episodes of protrusive? And I think we’ve barely missed it. Scratch the surface. There’s so much to learn. It reminds me of one of my favorite quotes by Mahatma Gandhi, which is live as though It is your last day. I’m gonna have to get this quote now. It’s from the top of my head But it’s like live as though you’re going to die tomorrow and learn as though you’ll live forever So I think that the true joy of dentistry for me comes from learning. I’m always learning. I’m learning every day Every day. And that’s a beautiful thing. Like, imagine being in a profession where you didn’t learn something new. And what Dentistry presents us is always, there’s new research, new technologies, and every patient comes with unique challenges. That’s what Dentistry is. Keeps this repetitive thing of dentistry interesting because there are so many nuances in every patient and the more you become comprehensive Looking at the bigger picture the more exciting it becomes as well Now before we sign off here this uh new year special episode is not eligible for cpd or ce But that’s okay because most of the others are on protrusive guidance as you know And so the ultimate way to subscribe to Protrusive is by signing up for the Ultimate Education Plan. This is what helps to support the podcast and help it to grow so that Team Protrusive can continue to do what we’re doing, which is making Dentistry tangible. If you’d like to sign up to our masterclasses, And join the nicest and geekiest dentists in the world. Check out protrusive.co.uk/ultimate and check out our best plan. Do not forget to comment below though, and tell me what you’d like to cover next. Now, if you’re not going to be joining us for Protrusive Guidance, then can you at least subscribe on YouTube? For the last few years, our YouTube listeners and watchers has actually exceeded, you know, Spotify and Apple podcasts. So I would really appreciate whichever platform, if you’re listening on Spotify or Apple or Amazon, or if you’re watching on YouTube, we’d really appreciate it. Appreciate it if you hit that subscribe button. Thanks so much for making it to the end once again. I’ll catch you same time, same place next week. Bye for now.…
Are you focusing enough on pink aesthetics in smile design? What role does gingiva play in achieving a truly stunning smile? When should you refer for recession around lower incisors or upper canines? Can you get the gum to grow back through orthodontics? And how about class 5 restorations? Should we do them, or should we work on the gingival recession first? In this episode, Jaz is joined by the expert Dr. Tidu Mankoo , who shares his extensive knowledge on the importance of gingival health in aesthetic dentistry. They dive into the crucial role of the dento-gingival complex. https://youtu.be/Ao_vgJ-IbOg Watch PDP208 on YouTube Protrusive Dental Pearl: Shade Matching Composite button technique – a small blob of composite is applied to a dry tooth without etching or bonding to assess shade match and translucency, avoid excess thickness, which can affect opacity and aesthetics (Jason Smithson’s Tip: take a black-and-white photo to evaluate the composite’s value and ensure it matches the natural teeth) Using a custom composite shade guide like Smile Line by Style Italiano for more precise shade matching. Key Takeaways Gingival architecture plays a vital role in aesthetics. Dentists should focus on patient-centered care. Understanding tooth position is key to treatment planning. Orthodontics can sometimes resolve gingival issues without surgery. Communication with patients is essential for effective treatment. Aesthetic dentistry requires a comprehensive approach. The dental field is evolving, and practitioners must adapt. Root coverage procedures can be effective with proper techniques. Understanding prognosis is crucial for successful treatment outcomes. Aesthetic considerations are a primary reason for root coverage. Restorative dentistry should consider the position of the gingiva. Crown lengthening should not expose root surfaces unnecessarily. Mucogingival surgery plays a vital role in implant aesthetics. Education and training are essential for dental professionals. Need to Read it? Check out the Full Episode Transcript below! Highlights for this episode: 4:29 Protrusive Dental Pearl 6:16 Dr. Tidu Mankoo’s Journey and Inspirations 11:48 Reflections on Comprehensive Dentistryand Lifelong Learning 15:59 Balancing Work and Family in Dentistry 17:52 Understanding Gingival Architecture 19:49 Creating a Harmonious Smile 21:52 Addressing Gingival Aesthetics & Limitations 26:56 Orthodontics and Surgical Interventions 29:40 Root Coverage Procedures 33:49 The Value of Early Diagnosis and Referral 35:01 Indications for Root Coverage 36:03 Root Coverage vs. Class V Restorations 39:50 Managing Gingival Zenith Irregularities 41:23 Role of Mucogingival Surgery inImplant Success 47:47 Course on Mucogingival Surgery with IAS This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C . AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY (Esthetic diagnosis and treatment of intraoral soft tissues) Dentists will be able to – Discuss when and how to manage gingival recession, including the role of root coverage procedures. Explore the anatomy and function of the dento-gingival complex and its influence on smile aesthetics. Promote the value of early diagnosis and timely referrals to specialists for successful treatment. 🚨 Join the Ultimate Masterclass on Implant Soft Tissue and Complex Cases! 🚨 📅 Dates: April 2024 🌟 Event: Implant Soft Tissue and Complex Case Masterclass Join this two-day masterclass to elevate your skills in: ✅ Implant soft tissue management ✅ Root coverage and crown lengthening ✅ Complex case planning and aesthetics If you loved this episode, be sure to check out PDP035 – Case Acceptance in Smile Design with Dr Gurs Sehmi Click below for full episode transcript: Teaser: Young dentists are limiting their knowledge and experience because there are cases where you're not going to have simple wear and simple misalignments. You're going to have complications. You're going to have teeth that are structurally compromised or endodontically compromised or periodontally compromised. Teaser: What are you going to do then? Then it’s not just edge bonding and composite bonding or injection molding or whatever that’s in the current fad. And it’s not only tooth position, it’s root talk. So sometimes, particularly in a lot of, we see this in a lot of orthodontic cases, patients who’ve had ortho, particularly in lower interior region. You see, sometimes the roots have been placed too far buccal outside of the bony envelope and you see clefts and recession typically in the lower incisal region, often as a result. And in those scenarios, if you’d correct the torque, will the gingiva settle? Jaz’s Introduction: If you get the white aesthetics right, what I mean by that is having the incisal edges in the right place, the correct anatomy and surface texture and alignment of your teeth, yes, that’s going to give you a good smile. But what’s going to give you an amazing smile is getting the pink esthetics right. Think of the gums. Think of the dento gingival complex. That’s when your smile design really goes up. And in your career, as you become more comprehensive, you realize that having the gum line and the gums in the right place is so important to an esthetic outcome. Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast, where I’m joined by an absolute legend today, Dr. Tidu Mankoo. Dr. Mankoo is a world renowned expert in all things dentistry. He’s got so much to share, so much experience, extremely comprehensive dentist, super experience in advanced cosmetic dentistry, and so very excited to share this episode all about getting the pink esthetics right. As a foundational thing, when should we consider referring for that lower incisor with that recession? How about the upper canines that got recession because they’re too buccally placed? Can you get the gum to grow back down by doing orthodontics? And how about class 5 restorations? Should we do them or should we work on the gums first? Should you never do a class 5 restoration? And if you did do a class 5 restoration, where should you finish it to make sure that any future gingival surgery is going to work better? At the very least, Protruserati, let this episode inspire you to think beyond just the white esthetics, to consider what the gingiva is doing and to allow you to read more about gingival esthetics, listen to more about gingival esthetics, inspire you to learn and grow in that field. Dental Pearl Now every PDP episode I give you a Protrusive Dental Pearl and today’s pearl is inspired by the community. Dr. Arti on the Protrusive Guidance asked about a scenario where she’s trying to match Genial Composite to the teeth and she’s finding that she’s struggling to get the right shade match. For example, the B1 of Genial was not quite matching the Vita B1 shade. So what I did is I made a quick little video. I went live on Protrusive Guidance, which by the way is our community. It’s a community of of the nicest and geekiest dentist in the world. I don’t pump any money into ads. I don’t advertise this community. I try and keep it to those people who listen and watch the podcast because those people like you who choose to spend some time with me and the guest, really going geeky, really immersing themselves with deep education, wanting to constantly be better and to reinvigorate your passion for dentistry. These are the kind of dentists I want parts of the nicest and geekiest community of dentists in the world. So they are living on Protrusive Guidance. There’s over 2, 000 of us already on our community. So do join us on protrusive. app if you’re not already there, especially if you ever feel lonely in our profession. The Protrusive Guidance community is an absolute far cry from the BS you see on the Facebook groups. We seem to attract the nicest and most caring and most empathetic dentists there are. Anyway, so I went live in the community really quickly during lunch, and I explained that acrylic shade guides, which is what they are, you know, the Vita shade guides are acrylic. How can they accurately represent a composite shade? They can’t. And the other truth is that all composites are built differently. Certain brands of composite will have naturally more value. A B1 of one brand will have more value than the B1 of the other brand. Venus composites, which I use a lot of nowadays, Venus Pure, for example, is more opacious. Estilite, which I also use, is more translucent. So you’ve got to kind of match it to what kind of tooth you have in front of you. So you’re thinking, okay Jaz, what’s the pearl? What’s the pearl beyond recognizing that you can’t just go with a Vita Shade Guide? Well, here are two ways. One which is cheap and easy, and one which is more sophisticated to be able to better shade match to teeth using composite resin. Number one is composite buttons or composite blobs. Just dry the teeth. No etch, no bond. Make a little blob. Place it on the tooth. You don’t want it too thick. The thicker you make it, the more opaque you make it. So remember the thickness of the composite will also determine the esthetics. So a good technique is to put a little bit of blob half on the incisal edge and half like cantilevering off the incisal edge so you get to see the shade match to the tooth. And you get to kind of assess the translucency. So I get to talk about this composite button method of shade analysis. You kind of see, hmm, do I need to put another button here, which is a different shade, which will give me the recipe that I need to use to recreate the esthetics here for this composite. For example, if you’re doing a class four composite. Now, a tip that Jason Smithson gave some episodes ago was to take a black and white photo. That will tell you if you’ve got your value correct, how light it is. And that’s a really good technique to take a quick black and white photo. But if you want to go at a really high level, then I would suggest using a custom shade guide. Something by Style Italiano, aka Stil Italiano, which I think is called Smile Line. I have one of these whereby you can make your custom composite shade guide. So essentially you get the brand of composite that you like using, the paste, you put it into the mold, you press it together, you cure it. And now you have that B1 shade of composite, that is your composite that you use, so that’s much better to have that ready to assess against the teeth than a vita shade, which is not composite. Vita is acrylic, so you could do one for A one B, one B, bleach white, A two. You can actually make your own shade guides, I think opt selling in the UK, and I’m sure there’s some US and worldwide distributors, wherever you are. I just want to open your mind to a few different ways of checking the shade for composites. Now, moving back away from the white esthetics, moving towards the pink esthetics, let’s now join the legend, Dr. Tidu Mankoo, to dive deeper into something so critical in A Beautiful Smile, that’s the dento gingival complex. Enjoy. Main Episode: Dr. Tidu Mankoo, it is an absolute pleasure to host you on this podcast. How are you? [Tidu] I’m very well, thanks Jaz, and it’s a pleasure to be here. Thank you for having me. [Jaz] I don’t know, if you remember this, but it was about 2014, I was at one of your lectures, I think you were doing it in Leeds at the time, right? And I remember being sat, I usually sit in the front row, and I was just amazed, like all of it, as a new grad, okay, this kind of stuff that you’re covering went above me, because I still don’t do implants, right? But it was clear to me, like what you were showing was like world class, and then only once I saw you speak there, did I realize how big of a deal you actually were. I didn’t actually know what I was witnessing. So only later when I spoke to people, I was like, what you sought Tidu Mankoo kind of thing. So your reputation is amazing. Can you tell us for those people who haven’t heard about you, can you tell us about yourself, your passions, your interest in dentistry? [Tidu] I qualified a long time ago, back in 1981. So I’m one of the ancient guys, but been around in practice for what, 42 years now. And still enjoying it and still feel pretty much I’m still at the top of my game. So I’ll keep going as long as I feel that way. When I first graduated, I realized that I didn’t want to just be a normal dentist. I wanted to sort of expand my knowledge. And I really went on a journey fairly early on. One of the things that inspired me was I got exposed to, I went to a course back in 1984, I think it was. And I saw David Garber, who Garber-Salama, the famous atlanta team. I saw him do a lecture and it really blew me away because he was talking about back then sort of mixing interdisciplinary treatment. Okay. It was very basic. It was crown lengthening and veneers. I’d never seen anything like this. You know that people were talking about gums as well as teeth and you could do this stuff to make everything look better. And that inspired me along with a group called the International Society of Dental Ceramics, ISDC. There was a chap called Dr. John McLean or professor John McLean, which you some of you all should really know about him. He’s the father of modern day ceramics and he wrote some textbooks the fundamentals of dental ceramics back in the 60s and 70s. And he was one of my mentors and I learned a great deal from him and others. And then I got exposed to the European Academy of Aesthetic Dentistry back in late ’89. I guess it was around about 1990 and those of you don’t know the EAD or the European Academy of Aesthetic dentistry is this group, which is like all the top lecturers in Europe in this group, and it’s an incredible group of clinicians really working at an amazing standard and they set this incredible standard and I got exposed to. At the time, a chap called Gianno Ricci, who’s a periodontist from Florence, and he’s still one of the major sort of perio guys. And you know how great the Italians are at perio now, and they are the sort of world leaders in sort of muco gingival surgery, the Zucchelis and so on. But I guess, joining that group really stimulated me to sort of wanting to be dentists. I remember seeing David Garber and said, I want to be like this guy. This is a dentistry I want to do. So I went on a journey. I became a nut about reading journals. I used to read voraciously. I read, I think, every single textbook going. Dawson back to back. I learned everything about occlusion I could because I was so fundamental to being able to do decent restorative dentistry. And I went on so many courses and lectures and went all around the world, traveling, to learn from the very best people and then joining this group, the EAD really sort of stimulated me because those guys, everyone’s passionate, everyone really is trying to do superlative dentistry. And that’s what I decided I wanted to do. And I was able to start working with my dad in 1984. I joined, he had a spare room in his small practice attached to his house. And I set up a little surgery there, a little squat started from nothing, just built a little patient base after being an associate for a couple of years and a group practice in Wokingham. And I moved to Crowthorne where my dad was and then I stayed there for 10 years and I remember his first words to me. He said, you know, son, there’s no scope here for private dentistry. This is really NHS. And I said, dad, I just don’t think that’s true. The interesting thing, five years later, we both went completely private. He did as well. And because he showed, I showed him, look, this is what you can do. You just need to talk to people, you need to explain what possible options are and if you can back it up by producing really nice work, your reputation build. And then I guess in 1994, I had the opportunity to move to Windsor, where I’m now at the Windsor Center of For Advanced Dentistry. And we have an interdisciplinary practice there, which is that I built. And it’s been basically that’s it. I’m ongoing there. I guess you’ve got to be passionate about dentistry, passionate about wanting to do your best for the patients. And what I really believe in is trying to do what’s best for the patient in their best interest. And I think, a lot of dentistry today, I have to say I’m a little concerned that a lot of dentistry today is about what’s in the dentist’s best interest sometimes and financially maybe, and business is taking a very strong sort of, I guess influence on decision. [Jaz] Like a commoditization, I guess, of dentistry. [Tidu] Yeah, I think so. I mean, we see so many practices that are, I don’t want to knock, so all on four, for example, all on four is a great technique in specific indications, of course. But, there are so many practices where you go and basically that’s their business model and you go there and that’s what you’re going to get. Whether your teeth can be saved or not. And certainly in my view today, I think, it’s a pity if we as clinicians don’t really expand our knowledge base so that we can do comprehensive dentistry in a true way and really offer our patients what’s best for them rather than what’s convenient or what we like to do and so on. And I guess, after 40 odd years of practice, you really learn to be a little bit more humble and understand that you have, I guess if you’re passionate, then you really want to do your best. And doing your best is also stretching yourself, is going outside of your boundaries, comfort zone to learn things. And after 40 years, I’m still passionate about learning, taking on new technology. There’s digital transformation that’s happened in the last several years and ongoing, always trying to do better. And I think the day you stop, then that should be the day you stop. [Jaz] Brilliant. I mean, never say stagnant, keep learning. So the key word I like to use there was comprehensive as well. It was essentially what today is about because dentists, we fall into this trap when we’re learning about smile design, we focus on nowadays. Okay. Nowadays it’s GDP orthodontics, which is very exciting, you know? Leveling those edges, simple crowding, getting the edge bonding, sometimes the veneers and stuff. But sometimes what makes a good smile to a phenomenal smile is that dento-gingival complex, which is so, so important for the esthetics. And we’re going to be talking about that. Before we get into that, just reflecting on what you mentioned in your career so far, I would love to know your credentials. Like from what I heard from someone, in quotes, comments, you’re just a BDS, right? So is that true? [Tidu] Yep. [Jaz] And that was so inspiring to me. Like that honestly, like I talk about this to lots of people when they’re saying about, oh, should I do this? Should I do that? And I often say your name. I often also say Chris Orr’s name. I say, look, these guys. Ah, quote unquote, just a BDS. You don’t have to pursue the letters to be a phenomenal clinician. What do you say to the new generation, which are qualifying with less and less experience? Do you now look back and think, yeah, you did the right thing by not pursuing the letters, by just pursuing the education? Or do you think now times have changed and perhaps you are encouraging the new generation to take on more structured courses? What are your thoughts on that? [Tidu] Well, you have to remember, back in the early 80s, there wasn’t the availability of many courses. There was a course at the Eastman, which was at the time, a very traditional kind of restorative conservative type prosthodontic course. And, or there was going to the U S. And there wasn’t anything much in between. In Europe, there weren’t any options for English speaking courses, certainly at that stage. Today, there’s so many more options. So I would encourage new clinicians to go on structured courses because it’s easier and quicker to learn that way. People like myself, we made a decision to take a personal journey and invest in educating ourselves by paying for private courses and going and reading and learning, and you don’t have to go on a structured course to become an expert, obviously, as you know, I have shown. But I was very eager to learn everything. So, as I said, I learned everything I could about occlusion. I learned everything about perio, perio and muco-gingival surgery, so prosthodontics, ceramics. [Jaz] It sounds like to me that the drive is more important than the means. [Tidu] Absolutely. [Jaz] The drive and the desire to practice at a certain level and what helped you, which is a common theme of the guests we get on the podcast, is that they saw someone around about two, three years out that just really Inspired them. Like they saw something that they didn’t know was possible. They didn’t see that before and that really triggered them on a pathway to learn more and more. And then the next question I had before we dive into mucogingival esthetics and how we can apply that to our daily assessments is just a work life balance one, if you don’t mind, right? At that time, obviously now courses are a doorstep, lots online, lots to do from home and stuff, which has its place. When you had to do all that traveling and stuff and lots of personal sacrifice time away from family and stuff. Did you find that was difficult in terms of trying to grow as a clinician but also when they keep the home life stable as well? [Tidu] Yeah, I mean, it’s obviously a challenge. You have to have a wife who understands or a husband spouse these days. It doesn’t matter. Another half, let’s say, that understands what you’re trying to achieve and is prepared to share that journey with you. There were times where it was challenging, obviously, because when I was lecturing a lot, I mean, I’m not lecturing as much as I used to do maybe 10 years ago, where I was traveling, probably two or three times a month abroad to speak some way or the other. And at that time, yes it was more challenging, but I used to try my best to go and come back very quickly. If I’m lecturing somewhere, I’d literally go the night before, come back the night of or the day, the morning after. So I try and reduce the time away from home, but yes, I mean, there’s a price to be paid, but nothing comes without some sacrifice. And it’s just making sure that obviously from a marriage point of view, that you communicate well and you ensure that you’re taking care of business when you’re at home. And I have five children as well. So, it wasn’t- [Jaz] Wow. [Tidu] Yeah. So, when we were young, so I was a very hands on dad and always, as soon as I came home, it wasn’t putting my feet up, vegging in front of the telly. It was right, getting stuck in, changing nappies, doing stuff, being a home, a help. [Jaz] A whole new level of respect. I didn’t know that. I didn’t know you had five. That’s a whole another level of respect. We’ll have to have a separate podcast just about navigating fatherhood, I think. But let’s get the clinical nitty gritty bits. Okay. Pink esthetics, why are they so important to a beautiful smile in the sense of we get taught about a golden proportions, we look at the teeth, but when I was studying at dental school and then qualifying, it took me a few years to truly appreciate it, truly appreciate how to go to that next level. Do you think that it’s underplayed and perhaps it is a realization that happens afterwards? [Tidu] Yeah, absolutely. I mean, going back to my first training, all about crown and bridge and because at that time we didn’t have veneers until the mid eighties. That came later, but so, it was crown and bridge. And my journey with the ISDC was all about learning about ceramics and how to make ceramics look natural and real and learning from mentors like Willi Geller, Klaus Mutterthys, and Bob Winter and all these amazing clinicians and ceramists. And I think it became obvious that no matter how good the ceramics are, if the frame for the smile, as in the gingival architecture is not harmonious, then somehow you’re not really making it really, truly, aesthetically pleasing. And so you realize that in order to make it aesthetically pleasing, you have to think more comprehensively, more interdisciplinarily. And, I think, that was what that lecturer went to see, Dave Garber back in 1984, which was actually on a course given by a veneer company selling their techniques. And it was Dave Garber, it was a guy called Ron Jackson, who’s from Canada. He’s passed away now, but Dan Nathanson, another one who’s no longer with us, but I mean, these guys were masters. And when he showed that it just wasn’t about the teeth, it was about creating a beautiful smile with also the pink architecture. [Jaz] With young dentists and students to do then, what we can start with is just back to basics. What do you think creates a harmonious smile with respect to gingiva? And particularly speaking, like, we learn about golden proportion, we learn about smile design when it comes to teeth and width and stuff. But we know that, it has to be a bespoke individual, bespoke individual’s face, and obviously with the gingival architecture, so much of it also hinges on their facial skeleton, their lip mobility, and all those other factors which you can totally go to, so it’s very complex. [Tidu] It’s not something you can just cover in a… [Jaz] Exactly. We’re giving a flavor, we’re inspiring them to look beyond the teeth. [Tidu] I mean, today you have to look at the smile, the dynamics of the smile, the dynamics of the lip architecture, because it’s not just about high lip line, low lip line, it’s about how dynamic. Because some people can have a low lip line, but when they talk and laugh, they show everything, the curtain raises right up. And so, it’s understanding those limitations. It’s not just about mucogingival surgery is orthognathics is orthodontics. It’s everything brought in. You talk earlier, you mentioned earlier about the current. Very popular fad of edge bonding and aligners and this thing, which is I know is a very popular thing these days, but again, it worries me a little bit that young dentists are limiting their knowledge and experience. This kind of becomes a recipe for everyone and that’s not really managing patients with what dentistry can do for the patient’s benefit because there are cases where you’re not going to have simple wear and simple misalignments. You’re going to have complications. You’re going to have teeth that are structurally compromised or endodontally compromised or periodontally compromised. What are you going to do then? Then it’s not just edge bonding and composite bonding, or injection molding or whatever that’s in the current fad. So I think we’ve got to move away from this sort of fad based dentistry and really get back to fundamental principles and learning and understanding. And expanding our knowledge base so that we really understand and know what is possible and then, learning how to do it. [Jaz] When we look at the basics of gingival architecture, the most classic thing is, okay, the central gingival zenith, so students is like the top part of the gum base of the gum line, and then the laterals being a little bit lower down and then the canines being higher up again. But then what I came across the literature is actually, that is one example of something that the public perceive as esthetic, and actually it doesn’t have to follow that, it can have some nuances. But perhaps in the interest of this podcast is, what do you think contributes to a unesthetic smile? What do you see commonly from cases which was a real letdown? What is a major, if we were to give you an example, in orthodontic terms, the midlines being off isn’t as significant, but a midline can’t, can be quite significant. Any features you could tell us about the gingival architecture, which is a big no no? [Tidu] Well, I think when you have asymmetry close to the midline, okay, that’s the biggest one. So, the typical thing I see, and I see it on Facebook a lot, posted, particularly patients showing in some of the forums talking about maybe a single tooth implant, for example, and you see the single tooth implant and the tooth next to it, the gingival level is completely different. But, they’re just showing this, oh, I did this case and I’m pleased with it. But, you haven’t really treated the patient. What you’ve done is you’ve replaced the tooth, but you’ve not looked at the patient. And that frustrates me a great deal because it’s like, well, you had the opportunity, you’re already doing a surgery. You could have corrected that at the same time. If there was a recession or maybe the opposite, maybe the implant is much longer than the natural tooth. And when you’re close to the centrals, of course, the closer you are to the midline, the more obvious it is. And so it has more impact if we’re just purely talking about mucogingival esthetics, then that has more of an impact. I mean, the further you go, as you said, typically the centrals will be higher, laterals a little bit smaller, canines up, and then you follow the balance round, but it’s not a rule. It’s basically, that’s the pleasing architecture, but that’s not the only pleasing architecture. It’s creating harmony and balance, and that may be bespoke for a particular patient. You have to see what’s going to work for that patient. And how do you manage that and correct it? And of course, it’s not just about mucogingival surgery, of course, because orthodontics has a big role to play in mucogingival architecture, because tooth position has a lot to do with where the gingival are. If the tooth is palatally positioned and positioned slightly further back, then typically the gingival will be more coronally placed. If it’s further out forwards, then it’s apically placed and you’ll see more recession or apparent recession compared to other teeth. So it’s understanding what’s the right way to manage that. So when you see a case where you have gingival architecture that is disharmonious and you want to improve it, then you’ve got to diagnose what is the essential problem here. Is it simply muco gingival? In other words, is it simply we have recession or is it recession combined with bone loss? Is it recession due to tooth position? Is it a problem with the architecture? Because the teeth are uneven and some teeth are more palatal, some teeth are more buccal, and therefore you get an architecture which moves up and down and is not harmonious. And obviously what you want to try and do for the patient, if the patient, wanting that obviously there’s some patients that are quite happy as they are and they don’t want to change it. And that’s fine that you accept that. [Jaz] It’s our duty to diagnose and communicate because if we don’t do that, we deny them an opportunity to correct it. [Tidu] Yeah. And exactly that and what we do is, you need to diagnose it. You need to see it. You need to explain to the patient what the issues are and be able to understand how would you best manage that? For example, crown lengthening is crown lengthening, which is a common thing to do these days. If you have a slightly gummy smile or you want to create a more harmonious smile, perhaps if some teeth are shorter than others, clinical crown-wise you may consider crown lengthening. Most commonly in a sort of gummy smile or if teeth proportions are small. And of course everything in, when you’re thinking about this, basically your first and fundamental parameter is incisal edge position. So everything starts with the central incisal edge position. So if you define the correct or the ideal central incisor edge position, then going forwards from there, you can make all your diagnosis and go ahead. So for a classical, in a wear case, for example, the first thing you need to do is establish where is the correct central incisor edge position. Once you’ve got that, then you can say, how long is the clinical crown? Where is the gingival architecture? Then you elaborate, go further, look at the lip and smile, do we want less gum, more gum showing, and all this sort of thing. But it all boils down to define incisal edge position. And then there are other things you need to go from there. Where’s the cemento-enamel junction? Where’s the bone? What’s the biologic width of that particular patient? And these are things that when we do a course or something, we can actually go into details and give people sort of a greater understanding. [Jaz] For those inexperienced to do for those inexperienced people listening to you now. Oh, yeah, this makes sense. That’s interesting. That’s good. But for those with experience are listening to you to do and thinking wow Jaz is asking some really tough questions because it’s actually really tough to start. I’m realizing now how tough this is to summarize in a podcast. So I’m going to ask a tangible question, a specific scenario thing, which we discussed about. Imagine you have a scenario whereby you have reasonable gingival architecture but you have upper canines which have got lots of recession. Because, and the diagnosis here, because of the fact that they are crowded buccally and therefore there’s less bone coverage, it’s kind of almost out of the bony envelope. And so you can imagine this scenario that we can all see in patients whereby they’ve got recession localized to the canines. Maybe bilateral, maybe unilateral because of the tooth position. So it’s a tooth position problem. Can orthodontics alone, so imagine you get now the tooth to sort of bodily move in right? Through your orthodontic mechanics. Can the bone and gingiva adapt or will that case always need surgical intervention? [Tidu] The answer is yes. Sometimes the bone will adapt and gingiva will adapt. So you don’t always need surgical intervention. Sometimes you do, sometimes you don’t. In those cases, we would always do the orthodontics first and then re evaluate and decide. But if you have a problem where you have a healthy periodontium, we have a normal keratinized mucosal band, and your mucogingival junction is at the normal level, but you have a recession as a result of tooth position, you will nearly always gain coronal migration of the gingival margin as you correct the tooth position. And it’s not only tooth position, it’s root talk. So sometimes, particularly we see this in a lot of orthodontic cases, patients who’ve had ortho, particularly in lower anterior region, you see sometimes the roots have been placed too far buccal outside of the bony envelope and you see clefts and recession typically in the lower incisor region, often as a result. [Jaz] And in those scenarios, if you’d correct the talk, will the gingiva settle? [Tidu] It improves, but you may also, depending if you’ve now developed a serious cleft, you may then also have to adjunctively carry out a mucogingival procedure to root cover. However, if you have a mild case of tooth position, the patient’s not willing or not saying, well, maybe I don’t want to ortho, and it’s a case where, look, you could manage it without ortho, then obviously you could do a root coverage with a variety of different procedures, coronally advanced flap, tunnel, modified tunnel, modified flap, combination procedures as well. They can all work. [Jaz] This leads very nicely to, okay, which teeth are amenable to root coverage? Because you’re right in the sense that crown lengthening is something that we’re exposed to. We’ve talked about in this podcast a few times. It’s something that is, esthetic crown lengthening is a buzz thing as well, but for root coverage, it’s like a little bit more comprehensive, a little bit more scary for general dentists. Less general dentists are doing it compared to the amount of general dentists that are happy enough to do esthetic crown lengthening. Obviously to go on courses, obviously to skill up. But can you give us like an idiot’s guide to root coverage in terms of which teeth might be amenable and at what point we should be considering referring? So what informs a prognosis? We’re general dentists now, seeing these issues that you’re talking about, how can we be sure that, hmm, this could have a good prognosis for me to at least discuss with a periodontist or someone in the practice who likes to do this kind of work. [Tidu] The thing is, I was saying, I don’t think you should be trying to do root coverage without having surgical skills, training in perio, or if you familiar with doing implant surgeries and you have soft tissue management skills. So that’s really important. But any tooth that has recession that is periodontally sound and healthy and there’s in the absence of bone loss should be amenable to root coverage procedures as long as tooth position isn’t the main driving factor. Obviously the tooth is very buccally placed and you’ve got to correct that first. However, if you’ve got a tooth that’s in reasonably good position and you have recession through incorrect tooth brushing technique, aggressive brushing, which is commonest one and patients with a thin biotype. A phenotype which is thin, which is more prone to recession, then a root coverage procedure is possible and indicated on those cases for sure. [Jaz] Do you look at how important is the Miller’s criteria, Miller’s index? [Tidu] Well, I mean, that and others is the Cairo index of Miller’s index. I mean, there’s a newer, they are essential in terms of Miller one and two, you can generally get a, do some gain. I mean, in Miller one, you should be able to gain full root coverage. [Jaz] Can you explain for the dental students, the young adults, what Miller one is. Just Miller’s one, just to understand. [Tidu] Well, let me simplify outside of that because Miller is not the only classification used, but essentially you’ve got to look at essentially how our teeth do they have, because there are complicating factors as well, because it’s not just about bone, it’s also about where’s the mucogingival junction, how much keratinized tissue you have. [Jaz] Lots of dimensions. [Tidu] Yeah. So, but if we simplify it all, essentially a patient with normal bone situation, in other words, healthy bone levels. An interproximal bone in the correct position is generally very predictable for root coverage procedures. Where you have some element of bone loss, then it becomes less predictable. If it’s mild, and you still have interproximal bone peaks that are more coronal to the maybe buccal bone, then it still is a more predictable procedure. You may not get 100 percent coverage, but you will gain and cover. Where you have periodontal, where you have horizontal bone loss, in other words, you’ve lost the interproximal bone peaks and you no longer have a scallop, then the root coverage becomes unpredictable and probably not worth doing. In those cases, if we need more tissue, we would then think about orthodontic extrusion and bringing the bone housing and the roots down and reshaping the teeth. That’s the way we’ve managed those. And those are the more sort of periodontal cases, obviously. And those are more tricky and they have to be done in an interdisciplinary team that really understand what’s going on. [Jaz] Yeah, you need to definitely involve a team and a lot of general dentists will be identifying it and referring to a local periodontist or someone who’s got those suitable skills. But it’s really important that one thing I want people to gain from this podcast and this time with you is, just opening your eyes to actually seeing it, because sometimes we look for caries, we look for perio, and then only some years later do you appreciate what a wear facet looks like, because you just learn, you’re constantly learning, and then you’re looking for the wear, and then looking for this, and then eventually you learn about, oh, gingival esthetics, and you start looking for that, maybe you start doing more esthetic work, and then you start noticing these things, and then you have the confidence to talk about it. So, how important is a timely and early diagnosis and referral perhaps for that, you know, the one isolated recession of a lower incisor, for example, how much is that loss of pink aesthetics or not even aesthetics, loss of the actual keratinized tissue going to be an issue in terms of the longevity or the prognosis of that tooth and how important is it to get a timely referral? [Tidu] Well, for the classic lower incisor, the typical cleft that you can see, like a localized recession is usually either related to a thin phenotype with a reduced keratinized tissue band and commonly also with frenal attachments. Maybe you’ve got a frenal attachment in that area that’s pulling and you’ve got a mobile mucosa, but it’s also often to do with post orthodontics or in crowded dentitions where the tooth is more prominent and therefore it’s more receded. You often see recession on canines because when people are brushing and they’re using an incorrect brushing technique, of course, the canine is the most prominent tooth. And as you brush, it will get the bulk of the pressure. And that can often cause a traumatic recession of the tissues. Let me simplify it another way. What are the indications for root coverage? Okay. Number one is esthetics. Okay. Number two is root sensitivity. Number three is if you’re going to be carrying out restorative dentistry, and it will improve the general prognosis and the relative position. In other words, you want to do veneers, for example, but you don’t want to place veneer margins on root surface on dentine. You rather stay in the enamel. So then maybe that you want to root coverage, you want to bring the gingiva back down to where they should be so that you don’t have, otherwise you have longer teeth, but you’re finishing your veneer margin on a dentine or on cementum. Where the bond is less predictable long term and you may have more chance of leakage or fracture and so on. So it’s kind of thinking about those factors and the third option is where if a patient’s concerned if the patient if it bothers the patient. At the third indication, sorry, if a patient says that I don’t like this then obviously, patient is concerned about it. They want to improve it. That’s fine. But what I do see is, a lot of cases where we are very quick to put in a class 5 restoration and because, I mean, let’s face it, a lot of our patients have non carious lesions on the buccal aspects of premolars, canines, and even molars. [Jaz] You haven’t used the word abfraction. Do you believe in abfraction? It would be nice to know what you believe in. [Tidu] Yes, I do believe in it. Because nowadays we call them non carious lesions. But because there’s some controversy, but I mean, abfraction, yes. In some cases, I think abfraction occlusion has something to play with that. I do believe that. And if you look at a lot of cases that have non carious lesions, often it’s a tooth that’s a lateral guidance situation is getting pretty hammered. And I do believe that you see some flexing of the tooth and the enamel pings off at the weakest point, which is at the CEJ and particularly in some teeth where it’s very thin. So I think that has an element, but we do see a lot of non carious lesions and yeah, in many cases, the appropriate treatment is to place a class 5, but in many cases it might be better to do a root coverage because, so that you restore the missing gum with gum rather than with filling. And in some cases, if it’s practically in a younger patient, I think there’s a calling to think about it earlier because a class five in a 25 year old or 30 year old, how long before you have to replace it, and each time you replace it, it becomes a little bit larger, more complex, and wouldn’t it be better in that younger patient to actually restore the gingival tissues. So that that patient then doesn’t have future recession? [Jaz] Where they have loss of volume in that scenario of a NCCL or abrasion, for example, should it be the course of action whereby you get that periodontal opinion because maybe to put a restoration there because it’s sensitive, for example, reduce the prognosis of the periodontal surgery? Is that right? Or any guidelines in terms of if you do a composite or GIC, whatever everyone’s doing for a class five, is that still needed? Because if you have a deeper class five defect, I’m just thinking about the gingiva being advanced more coronally in that area, but now it’s still, there’s a defect there. Does that still need restoring? [Tidu] Yes. The best way to do it, well, basically you’ve got to restore the gingiva to where it should be and the tooth contour to where it should be. Now you can do it before or after the surgery, it doesn’t really matter, but it’s easier to do it before. Because if you have recession then what you should do is place your class 5, and I would recommend to do it in composite, not in a glass IMO. I would use a flowable, personally, and use that. And it’s very easy if you have a recession, then you don’t have so much complications in isolating the area. You should then place your class 5, so the margin, the apical margin of the class 5 restoration is where the CEJ should be. That’s where the filling should terminate. And then the gingiva can be brought down to that level. So it’s restoring the correct anatomy of the teeth. That’s really the things. So, yeah, I think it’s important to restore the correct dental architecture and then do the restoration, but you can in some cases I do the surgery first and then feeling afterwards. It depends. [Jaz] I guess the sin here is not diagnosing, not speaking to the patient, not involving someone with a periodontal set of eyes, but also doing that classified restoration and extending it all the way up to that recess gingiva where perhaps if the periodontal outcome would like it to be, just like a really good guideline you gave was at the CEJ, which I like. In the interest of time, I’m just going to ask you a higher level question. Basically, when you have that scenario, where the gingival zeniths are just all over the place. Some are too coronal, some have had recessions so they are too apical. Is it a predictable procedure to have certain teeth you’ll do crown lengthening on, certain teeth you do advancement or root coverage on? And does that happen in two stage or can that happen, I mean, obviously quite advanced stuff, but does that happen at once? [Tidu] You can do it at once. It depends on your skill level. I mean, I think this is clinician dependent what you prefer. It can be done in one surgery. I often do it in one surgery. Sometimes I do it in multiples. Doing the root coverage is a more difficult procedure. So do that first probably and do the crown lengthening after that’s a little bit easier. So, because often the crown lengthening is a simpler procedure and, to do then the root coverage part, but, in many cases it’s about understanding again, the bone and the influence, where’s the bone, what’s the biologic width of the patient. And whenever we do crown lengthening, the important thing is that we don’t crown lengthening purely for esthetics, if when we crown lengthen, we’re going to expose root. That we should never do, unless we’re going to then cover that with a crown or something like that. If it’s a case, for example, a patient already has crowns, for example, and you need to crown lengthen, then okay, then it may be justified to do it. But if you’re going to expose root, then the correct treatment for that patient is orthodontics. [Jaz] Orthodontics. [Tidu] You can’t crown lengthen onto the root surface. [Jaz] The CEJ is our guide. [Tidu] Yeah, it’s a guide, yeah. [Jaz] And so I know your area of special interest is muco gingival, especially around implants, which is a whole other level. Like, one of the reasons I don’t do implants is because, I’m really going deep in other areas of restorative dentistry and also TMD management, occlusion, that kind of stuff. And I just know that once you go into implants, then the next thing you got to do is, okay, soft tissues around implants. And then different systems. So you’ve got to really go all in. I’m not ready to commit to that, but there’s so many complications that can happen with soft tissues related to implants. What is the role of mucogingival surgery in terms of getting a truly excellent implant? Do you think those who are restoring implants, do they need to have some sort of skill and training? Or is it those who are just placing the surgical aspects? And in what percentage of cases do you think someone would benefit from having those mucogingival skills when it comes to implant esthetics? [Tidu] Well, I typically would be the surgeon that would be doing that aspect of the treatment. I mean, If you’re, in many cases in the UK, the surgeon and the prosthodontist are the same, people like myself, I do the restorative and the surgical and the barrier and everything along with that. So you can manage your, I mean, the muco gingival component is hugely significant and important. We know more and more, and we have a greater understanding. People like myself, I mean, I’m not, you described that, that’s my special interest. That’s not my only special interest. [Jaz] I know that. [Tidu] It’s my special interest, but obviously I have a great deal of expertise and experience in the implant field. I started doing implants 35 years ago. So, obviously have published and stuff on particularly on the esthetic zone, because that’s so critical in terms of getting optimum results going forwards. And the key thing is that, to understand that it’s a synergy between bone soft tissue and the components that we’re utilizing and that everything has a biological consequence. So in implant dentistry, if we want to simplify it, everything we do in implant dentistry is to compensate for what the biology is going to do as a result of the tooth loss, as a result of the components that you’re going to position place in that patient and the surface chemistry. The shape, the form, the materials themselves, the surface topography. There’s so many influencing factors that can influence the outcome. So it’s really understanding how do you optimize the patient. So you’re really thinking from the case of obviously from the prosthetics themselves can influence the way the tissue behaves. The positioning of the implant can, and angulation can influence the way the tissues behave, and obviously the thickness of the tissue, which is very important. We know today that we need to ideally create a situation where you have the supracrestal soft tissue component, or what we’d call the biologic width on teeth, and we can call that the same thing on implants, has to have sufficient thickness to accommodate the biology. And the biology means that you have a sulcus, you have an area of junction epithelium, you have a zonal connective tissue, and then you have the bone. And so your implant must be placed at the correct position relative to the tissue thickness. So for example, if you have thin tissue, you have two options. You can either augment the tissue and then create an adequate thickness of tissue so that the biology can be adequately contained in that situation, relative to where the bone is and the implant connection is, or you place the implant deeper so that you allow for the creation of a normal biologic width or supercrestral mucosal seal. I have to understand that, if we have the data shows us now, and many of us have understood this for many years, but the science is also sort of caught up with it. In the sense that we know that the tissue bone remodeling is inevitable around an implant and is very dependent on a few things, but let’s say, as we’re talking about tissue at this point, it’s very reliant on the tissue thickness at the site. And if you don’t have adequate thickness, then you’re more likely to see more bone remodeling occur, and then you get some crestal bone loss. And if your rough to smooth surface interface is not placed at the level of the bone where it will be at after the remodeling, then you expose rough surface, which then becomes more prone to peri implant issues like mucositis and peri implantitis. And I think, certainly in my practice, we’ve seen a significant drop in peri implantitis since in the last 10 or 15 years, have started thinking biologically. And making sure that we place our rough to smooth interface where the bone is going to be. At the end of the remodeling process rather than at the, where it is now. So very often implants tend to see bone place implant at the bone level or just below it, and that’s their job done. But the other thought is, well, how thick is the tissue? Should I be placing, have I got adequate dimensions of tissue for the biological width? Because if I don’t, then the bone’s going to disappear and you’re going to expose some implant surface. So it’s quite complicated and you have to really know your stuff. But of course, the mucogingival surgery aspects is critical. So, we routinely would place connected tissue grafts, for example, around our implants, particularly in the esthetic zone, or we augment the soft tissues in other ways, roll flaps, maybe the tissue is already thick enough and so on. It’s really understanding the patient and doing what we’re going to do to, as I said at the beginning, compensate for what the biology is going to do. So, in other words, it gives us the best chance of long term success. [Jaz] What I usually echo when colleagues like yourself who are so experienced in implants and it all goes back to begin with the end in mind and you just add another dimension when it comes to the pink esthetics around implants, which is so, so huge. One of the best things I see is when I see a case and I can hardly tell which tooth is the implant and that’s often because the gingiva is just wonderful. And that’s what really hides it. The ceramic work, obviously we applaud that, but it’s a gingival architecture, getting that right, which takes a lot of behind the scenes work and the grafting and planning from the beginning. This is obviously something that you teach a lot about as well. I’m aware with IAS, you’ve got a course coming up. I’d love to, you tell us more about that. Cause I know, like you said, you’re teaching less and less now, so people’s opportunity to learn from you is always valued. IAS, obviously, we’ve got a very good relationship with your Occlusion Foundations course there. Tell us more about your course and what you’re looking to teach there. [Tidu] Yeah, so it’s the first time I’m working with IAS, so it’s a new idea. I actually, I would like to actually do more teaching going forwards again. I think, I’m at a stage where I want to share the knowledge. [Jaz] You have so much to give. [Tidu] So not just in implant dentistry, but in every, every aspect of dentistry. So, I think that’s something what I’m going to be focusing on in the years to come now is to think about, well, doing more teaching and starting to do more lecturing again, sort of cut back a little bit over the last few years, but I think I’m going to sort of pick that up again. So what we’re doing in IAS I think it’s a two day course. It’s a course that there’ll be discussion about mucogingival surgery. So soft tissue management around teeth and then on implants as well. And I guess, it’s a big topic, that’s really all together a topic for at least a week to be fair, but we’ll cover a lot of scenarios in both crown lengthening, root coverage, discussion about different techniques and what we can do wear, where orthodontics is indicated, etc. And diagnosing and making the right decision on what, which technique is appropriate for which case. And then, obviously, there’ll be videos of how we do it and stuff so that people can actually see the technique. There’s no hands on element in this course because it’s it’s not really long enough to do that, but it’s a foundation course I guess really get deep into this aspect of dentistry. And I think it’s a course that’s probably more suited towards people with some experience. So that- [Jaz] Experience in implants? Would you prefer for those who to gain most of it? People who have maybe started in the implant journey? Is that the ideal learner? [Tidu] Yeah. And even people who’ve been doing implants for a long time, take it to the next level. I think it’s patient people who are maybe even considering that journey because, I mean, much like my experience of being exposed to really high level stuff before I was doing it. That was really perfect because actually when you’re exposed to that, you know where you’re aiming for rather than starting at a lower level than trying to build up. It’s good to say well, okay actually, that’s where I need to be. So that’s my end game, my end point, I need to start my journey. How do I get to this point? And that’s really- [Jaz] Definitely when I saw you speak 10 years ago, like fair enough, I never went into implants, but you’re talking about comprehensive dentistry and global diagnosis. That was really inspiring for me. So I can totally vouch for that. [Tidu] Thank you. [Jaz] Well, the masterclass is called Implant Soft Tissue and Complex Case Masterclass. I’m just reading it now from the website. It’s on 10th and 11th of Jan. So, I’ll put the link in the show notes. So, if you guys have the opportunity to learn from Tidu, he’s vast experience, and obviously this was a podcast, there was no visuals, but I’ve seen firsthand the degree of cases and follow ups that Tidu shows, which is just something else. High level. I would love to know Tidu. Any advice you can give to fathers, mothers, parents, basically. Cause we have a lot to learn also with how you somehow managed five. I’m struggling with two here. I don’t know how you did five. What’s your number one parenting tip to raise happy children? [Tidu] Oh, just love them, love them and support them, encourage them. It’s encouragement, love, and- [Jaz] Are you strict when it comes to their education and looking at how they’re doing academically? Are you strict or are you like, not so much? [Tidu] You know, I probably wasn’t strict. I was stricter with my first, probably. I went on a journey. I became much more relaxed as a parent. And probably less disciplinarian as you know, as I had more than I was the first time, because mostly you base your parenting on your own parenting, right? When you start, or at least, and in some ways you kind of know, well, I don’t want to do that because I didn’t like appreciate that aspect of my parenting, but I want to do it this way. But, the fact is that no one gets any training on parenting. But there are a lot of resources available to us. I’m part of a, I feel like a church group as well. And that was really helped me with parenting aspects, because there’s quite a lot of parenting sort of advice and stuff you can go to, but there’s a lot of resources as well online for good parenting and marriage and stuff like that. [Jaz] It’s true, Tidu. I did this 28 day challenge and it was called 28 Challenge Not to Yell at Your Children. I lasted six days. So, give me more courage, everyone. Tidu, thank you so much for sharing that. I appreciate it. Thanks for talking about, your busy time, when you had that aspiration, how things can get better. Because people need to hear that, right? And you can’t just aspire to excellence and do that. There has to be communication with your family. There has to be some sacrifice made, but looking at you reaching for the stars and doing this incredible work is very inspirational. It was a tough podcast for you. I thought to do, I think you did brilliantly. You gave us the foundations, but you also catered a lot for those experienced listeners we have that are doing this day in, day out. And I hope that they’ll check out more content from you to do, thanks so much for your time today. [Tidu] Jaz, much appreciated. Jaz’s Outro: There we have it guys, thank you so much for listening all the way to the end. It was actually a really tough topic, like how do you break down all the different dimensions in terms of lip mobility, tooth position, gingival biotype, and the gazillion different types of different flaps you could do and names of different gingival procedures which are far too clever for me. But like I said, I hope inspired you to look beyond the white esthetics and to really consider learning more about how to manage the pink esthetics. That will really raise the game of your esthetic dentistry. If you want to learn more from Tidu, I’ll put in the show notes the link to join him with his course in January 2025. And of course, if you want to claim an hour of CE credits or one hour verifiable GDC assured CPD, then you can answer our quiz. If you get 80%, then we’ll send you a certificate. If you just listened to half the episodes the entire year, that’s it. Half the episode in one year, you easily get 25 hours of CE credits. And I’m sure you agree, it’s incredible value for money. You’ll also join a community of dentists, of the nicest and geekiest dentists in the world. So head over to protrusive. app to make your account. Thank you so much again. And if you haven’t yet subscribed to the podcast and you keep coming back to it, can you do me a favor? Can you hit that lovely subscribe button for me? I’d really appreciate that. Thank you. And I’ll see you same time, same place next week. Bye for now.…
In this episode, we focus on the link between periodontal disease and the systemic effects on the human body. There’s more to oral hygiene than just saving our teeth, so let’s dive into this fascinating episode with Dr Reena Wadia to learn more about the importance of perio and how it is associated with the rest of our health. https://youtu.be/fldpB_8h2Dc Watch GF024 on Youtube Key Takeaways: There is a strong link between gum health and systemic health. Diabetes and cardiovascular disease are key conditions linked to gum health. Understanding correlation vs. causation is crucial in dental practice. Effective communication with patients can improve treatment outcomes. Treating pregnant patients for periodontal health is safe and beneficial. Proper diagnosis is essential for effective dental treatment. Patients are often unaware of the links between gum health and overall wellness. Motivating patients with health benefits can enhance compliance. Evidence-based dentistry is vital for accurate patient information. Add the word diagnosis to templates for clarity. Team collaboration (dental and medical practices) enhances patient care effectiveness. Screening for conditions like diabetes can save lives. Holistic care in dentistry is becoming increasingly important. A periodontal protocol is crucial for consistent care. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 3:50 Introduction to Dr Reena Wadia 7:14 Systemic Link 12:24 Under Investigation 13:54 Using this with our Patients 17:04 Birthweight-related Studies and Pregnancy 20:14 Make a Periodontal Diagnosis 23:34 Medicine and Dentistry Collaboration 26:29 Understanding the Patient 29:14 HbA1c Machine 32:19 The Perio Handbook This episode is eligible for 0.5 CE credits via the quiz on Protrusive Guidance. This episode meets GDC Outcome A, B and D. AGD Code: 490 PERIODONTICS (Pathophysiology of periodontal disease) Aim: To enhance dentists' understanding of the link between periodontal health and systemic diseases, enabling them to integrate evidence-based periodontal care into their clinical practice. Learning Outcomes: Knowledge and Application: Dentists will gain a thorough understanding of the bi-directional relationship between periodontal disease and systemic conditions such as diabetes and cardiovascular disease, and learn how to apply this knowledge in clinical practice to improve patient outcomes. Patient Education: Dentists will acquire practical strategies for effectively educating patients about the systemic implications of periodontal health, using analogies, visual aids, and evidence-based communication methods. Holistic Treatment Planning: Dentists will learn how to incorporate systemic health considerations, such as screening for diabetes or collaborating with medical professionals, into their periodontal treatment plans to deliver comprehensive care. Enhance your knowledge with Dr. Reena Wadia's Perio School and establish a habit of implementing Perio protocols in your practice. Don't forget to grab a copy of the Perio Handbook by Dr. Reena for valuable insights! If you enjoyed this episode, check out: Communication Masterclass for Periodontal Disease [B2B] – PDP086 Click below for full episode transcript: Teaser: When you hear stories like that, it's like, could that have been undiagnosed diabetes, heart attack, et cetera, et cetera. So I feel so privileged being able to have that ability to do that test on our patients. And yeah, it's not the nicest thing to say to someone, you might have diabetes, but actually like that could save someone's life. Teaser:The guidelines now are, for example, for diabetics, once they've been diagnosed with diabetes, they're supposed to see their dentist, but they need to push it more, because they definitely push the eye appointments,…
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What are the steps involved in Functional Crown Lengthening? Which scenarios/teeth are best for this type of surgery? What is biologic width and why should we care? Is Bone sounding a diagnostic test, or just a genre of music? The answer to these questions and a lot more can be found in this packed episode with Dr Hiten Halai. We cover the right protocols when crown lengthening and understand the difference between aesthetic and functional crown lengthening. https://youtu.be/KRlEtz16I8c Watch PDP207 on Youtube Protrusive Dental Pearl - Bone Sounding Using a periodontal probe, go into the depth of the sulcus, pushing deeply until you hit bone, all while recording the measurement with the probe. This measurement will then guide you on how to carry out your crown lengthening procedure. Push hard to pass the connective tissue and ensure you are touching the bone. Not using AI to write your notes and letters for you yet? Save hours every day and save money using this affiliate link for DigitalTCO: Click Here Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:03:19 Protrusive Dental Pearl06:10 Introduction - Dr Hiten Halai12:56 Functional Crown Lengthening15:41 Understanding Crown Lengthening Types18:42 University of Dental Instagram22:38 Biologic Width aka Supra-crestal Tissue Attachment25:51 Functional Crown Lengthening: Practical Considerations31:09 Assessments & Keratinised Tissue35:47 Understanding Tissue Phenotypes39:16 Case Study: Premolar Treatment43:17 Bone Sounding and Biologic Width46:58 Shape of Gingivectomy50:31 Flap Designs52:37 Burs for Crown Lengthening56:13 Healing and Restoration Timelines58:31 Learning and Training Opportunities Key Takeaways: Hiten's journey began with a passion for periodontics during dental school. Managing time effectively is crucial for specialists with busy schedules. Functional crown lengthening is often underutilized in practice. Aesthetic crown lengthening can lead to complications if not done correctly. Understanding biologic width is essential for successful crown lengthening procedures. Preoperative assessments are critical for determining candidacy for crown lengthening. The type of gingival tissue affects surgical outcomes and healing. Proper surgical techniques can prevent complications and ensure better healing. Postoperative care is vital for achieving desired aesthetic results. Continuous education and mentorship are important for dental professionals. This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcome C. ADG Code: 490 PERIODONTICS (Mucogingival management) Aim: To enhance knowledge and practical understanding of crown lengthening procedures, with a focus on distinguishing between aesthetic and functional crown lengthening, and the importance of biologic width in achieving predictable clinical outcomes. Learning Outcomes: Identify the key differences between aesthetic and functional crown lengthening and the clinical scenarios in which each is most appropriate. Demonstrate an understanding of biologic width and its significance in the success of crown lengthening procedures, including the impact on long-term periodontal health. Apply the principles of bone sounding to accurately assess the need for crown lengthening and ensure optimal restoration outcomes, minimising risks such as gingival recession and bone loss. If you liked this episode, check out: PDP079 - Crown Lengthening Click below for full episode transcript: Teaser: Despite what the University of Instagram tells you, all cases cannot be treated by laser gingivectomy. And that is the truth. Four or five years down the line, when there has been enough time for that tissue to relapse, what happens is they'll come back with that persistent inflammation. And actually the management of it is much more complex now.…
Application points, luxation vs elevation, avoiding common mistakes - this one's an episode that I wish I had when I was at dental school! How do you know when you've found the application point during extractions? What are the key protocols that can help make your extractions more efficient? https://youtu.be/rOBPnCTyAwM Watch PS012 on Youtube This week's Protrusive Student episode is all about exodontia - and again I'm joined by Emma Hutchison, our Protrusive Student Ambassador, to discuss some tips and tricks on how to make extractions that little bit easier. Jaz also shares a memorable analogy—could removing a stone from an avocado be the perfect way to describe an extraction?! Key Takeaways Tactile feedback is crucial during tooth extractions. Understanding application points can improve extraction techniques. Using the right amount of pressure is essential to avoid breaking teeth during extraction. Luxators are typically used to sever the PDL before extraction. Atraumatic extraction techniques are important for preserving bone for future implants. Luxators should not be used as elevators. Understanding the mechanics of elevators is crucial for effective extractions. The ‘six second rule’ helps in assessing extraction progress. Having a plan for extractions can prevent complications. Communicating with patients about the extraction process is essential. Avoid tunnel vision; consider the surrounding teeth during extractions. Breaking interproximal contacts can simplify extractions. Always check the patient's medical history before procedures. An audible checklist can prevent mistakes during extractions. Need to Read it? Check out the Full Episode Transcript below! Highlight of this episode: 00:00 Introduction 02:07 Catching Up with Emma 05:58 Teeth are like avocados! 11:13 Understanding Application Points in Extractions 17:01 Luxators vs. Elevators: Techniques and Safety 24:10 Extraction Technique 25:08 The Six-Second Rule 28:04 Having a plan 29:58 Common Mistakes and How to Avoid Them 38:17 Conclusion and CE Certification This episode is eligible for 0.75 CE credit via the quiz on below. This episode meets GDC Outcomes B and C. AGD Subject Code: 310 Oral and Maxillofacial Surgery (Exodontia) Dentists will be able to - 1. Recognise essential steps to establish secure application points 2. Develop approaches for patient communication around extraction procedures, potential risks, and expected outcomes 3. Implement the “6-second rule” and other practical techniques to streamline extractions and troubleshoot common challenges If you loved this episode, make sure to watch Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth [B2B] – PDP085 Click below for full episode transcript: Jaz's Introduction: This episode on basics of extractions is the episode I wish I had when I was learning extractions when I was a student. But also what I've found from this Protrusive Student series is that so many dentists are listening to them and they're commenting and they're enjoying and they're liking it. Jaz's Introduction:What I've discovered is that it's so good to just reconnect with basics and actually by listening to these kind of episodes you do sometimes pick a few things up or it's validation. It helps to validate some techniques, some ideas, some protocols that you're already using. It's also a wonderful way to see how far you've come. Sometimes we move so far in our career that we forget what it's like to have those struggles like we did when we were a student. So the reason I gave you that little preamble is because now from this episode, most Protrusive Student episodes, I think, will be eligible for CPD or CE credits. And so this one is eligible for 0. 75 CE credits or 45 minutes, if you're in the UK. Protrusive Education is a PACE approved education pro...…
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1 White Patches – When to Refer + Diagnoses ORAL MED – PDP206 1:00:11
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Are you confident in diagnosing white patches? Which white patches need an URGENT referral? How do you tell the difference between lichen planus, lichenoid reactions, and other common lesions? Dr. Amanda Phoon Nguyen is back with another amazing episode, this time diving deep into the world of oral white patches. Jaz and Amanda explore the most common lesions you’ll encounter, breaking down their appearance, diagnosis, and management. They also discuss key strategies to help you build a strong differential diagnosis, because identifying the right lesions early can make all the difference in patient care. https://youtu.be/xlQpuQu2Hl0 Watch this full episode on YouTube Protrusive Dental Pearl: A new infographic summarizing Dr. Amanda Phoon Nguyen’s key teachings. Jaz describes it as an easy-to-follow "cheat sheet" designed to simplify complex ideas and make it easier to apply the concepts discussed in the episode. You can download the Infographic for free inside Protrusive Guidance 'Free Podcasts + Videos' section. Key Takeaways White patches in the oral cavity can be classified into normal variants, non-pathological patches, and potentially malignant disorders. It is important to identify the cause of the white patch and differentiate between different types. Referrals should be made based on the characteristics of the white patch and the urgency of the situation. Clinical photographs are valuable in referrals and can aid in triaging patients. Ongoing monitoring is important for potentially malignant disorders. Lichen planus can have different types and presentations, and a biopsy may be necessary for certain cases. Enlarged taste buds, particularly in the foliate papillae, are usually bilateral and not a cause for concern. Oral lichenoid lesions can be triggered by dental restorative materials or medications, and a change in dental material may sometimes improve the condition. Smoker's mouth can present with white patches and inflammation in areas where smoke gathers, and counseling patients to reduce smoking is important. Oral submucous fibrosis, often caused by areca nut chewing, requires regular review and counseling patients to stop chewing the nut. Need to Read it? Check out the Full Episode Transcript below! Highlights for this episode: 01:22 Protrusive Dental Pearl 05:13 Dr. Amanda Phoon Nguyen Introduction 07:39 White Patches Introduction 09:16 Understanding Geographic Tongue 12:44 Keratosis vs. Leukoplakia 19:02 Proliferative Verrucous Leukoplakia 22:18 Referral Tips for General Dentists 29:56 Understanding Leukoplakia 33:17 Urgent and Non-Urgent Referrals 34:37 Patient Communication 39:17 Discussing Erythroplakia 41:03 Oral Lichen Planus: Diagnosis and Management 47:50 Enlarged Taste Buds 49:47 Oral Lichenoid Lesions vs Oral Lichen Planus 53:43 Smoker's Mouth 55:14 Oral Submucous Fibrosis 57:23 Learning more from Dr. Amanda Phoon Nguyen This episode is eligible for 1 CE credit via the quiz below. This episode meets GDC Outcomes B and C. AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Diagnosis, management and treatment of oral pathologies) Dentists will be able to - Identify the cause of a white patch and differentiate between different types. Understand when and how to make referrals based on the characteristics of the white patch and the urgency of the situation. Appreciate the importance of ongoing monitoring for potentially malignant disorders, including when to consider a biopsy. For those interested in visual case studies and deeper insights into oral lesions and conditions, follow Dr. Amanda on Instagram and Facebook! If you loved this episode, be sure to check out another epic episode with Dr. Amanda - Prescribing Antifungals as a GDP – Diagnosis and Management – PDP151 Click below for full episode transcript:…
What are the key steps and nuances to make awesome Dentures that your patients will love? In this episode, Jaz probes Removable Pros legend Dr Mike Gregory to break down the process. From border molding to primary impressions and the teamwork between dentists and technicians, Mike reveals the key steps to making great dentures. https://youtu.be/snM3PerQ1ko For example, be sure to include a note on the lab sheet for the technician: "Preserve full peripheral depth and width of the sulcus on this impression, to about 2-3mm." This ensures the correct functional width is maintained when the final tray or denture is created. Protrusive Dental Pearl: When checking denture occlusion, it's crucial to keep the patient relaxed. Mike suggests one simple trick: ask the patient to close their EYES before closing their teeth. This can sharpen their senses, helping to improve the bite assessment. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 02:07 Protrusive Dental Pearl 03:31 Mike Gregory's Journey into Dental Technology 10:09 Understanding Border Moulding 13:19 Technician's Role in Denture Creation 15:45 Improving Communication with Technicians 18:34 Special Trays and Custom Trays 25:58 The Role of Green Stick 29:04 Denture Impressions 31:35 Boxing and Beading Techniques 35:08 Additive vs. Reductive Rest Seats 40:46 Guide Planes 42:43 Creating Undercuts for Dentures 45:10 Final Tips and Best Practices 48:54 Learn More with Mike Gregory This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject code: 670 REMOVABLE PROSTHODONTICS Aim: To explore the intricate process of denture creation and provide practical insights on improving denture fit, occlusion, and collaboration between dentists and technicians. Dentists will be able to: 1. Understand the key elements of denture creation, including border molding and primary impressions. 2. Learn the significance of maintaining peripheral sulcus depth and width in denture impressions for functional accuracy. 3. Gain insight into the role of special trays, custom trays, and impression materials in denture fabrication. 4. Recognize the importance of clear communication between dentists and technicians in achieving optimal denture outcomes. If you liked this episode, you’ll love Suction Lower Complete Dentures – Improve your Removable Prosthodontics – PDP073 Click below for full episode transcript: Teaser: This huge misconception that if you get suction on an impression, that impression is the perfect impression to make a denture. But you know, and I know if you take an impression, you fill somebody's mouth with algae, you get suction. You have to break the seal to get it out. That doesn't mean you've got the right depth. Teaser:It doesn't mean you've got the right borders. You've just created a vacuum and that's the worry that people create suction. I think this is it. This is going to be the great denture. But if you create suction, take the impression out of the mouth and look at it. It's going to be big. You can picture this, can't you? It's going to look big, it's going to look like you've just pushed everything out the way. I used to think dentists were rubbish, which is really tough, but as a technician you've seen model after model that's garbage. And then you think, these poor guys are taking impressions, but they don't know what they're doing wrong. How do I do it better? If you were taught maybe not brilliantly as an undergraduate, or you didn't love it as an undergraduate, so you didn't really focus on it. How do you ever get better? You need to be re taught. Jaz's Introduction:Let's face it guys, dentures are a bit of a dark art. You only get so much exposure at dental school, and when you come to the real world, you're faced with flabby ridges,…
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