The Most Important Part A Beautiful Smile – Pink Esthetics With Dr Tidu Mankoo

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Innhold levert av Jaz Gulati. Alt podcastinnhold, inkludert episoder, grafikk og podcastbeskrivelser, lastes opp og leveres direkte av Jaz Gulati eller deres podcastplattformpartner. Hvis du tror at noen bruker det opphavsrettsbeskyttede verket ditt uten din tillatelse, kan du følge prosessen skissert her https://no.player.fm/legal.

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The Southwest’s Wildest Outdoor Art: From Lightning Fields to Sun Tunnels 30:55

for 13 dager siden30:55

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30:55

A secret field that summons lightning. A massive spiral that disappears into a salt lake. A celestial observatory carved into a volcano. Meet the wild—and sometimes explosive—world of land art, where artists craft masterpieces with dynamite and bulldozers. In our Season 2 premiere, guest Dylan Thuras, cofounder of Atlas Obscura, takes us off road and into the minds of the artists who literally reshaped parts of the Southwest. These works aren’t meant to be easy to reach—or to explain—but they just might change how you see the world. Land art you’ll visit in this episode: - Double Negative and City by Michael Heizer (Garden Valley, Nevada) - Spiral Jetty by Robert Smithson (Great Salt Lake, Utah) - Sun Tunnels by Nancy Holt (Great Basin Desert, Utah) - Lightning Field by Walter De Maria (Catron County, New Mexico) - Roden Crater by James Turrell (Painted Desert, Arizona) Via Podcast is a production of AAA Mountain West Group.…

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The Most Important Part a Beautiful Smile – Pink Esthetics with Dr Tidu Mankoo – PDP208

for ca. et år siden 54:28

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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:

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#Science #Medicine #Fitness #Podcasting Education #Self-Improvement #Jaz Gulati

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The Most Important Part a Beautiful Smile – Pink Esthetics with Dr Tidu Mankoo – PDP208

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#Science #Medicine #Fitness #Podcasting Education #Self-Improvement #Jaz Gulati

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Understanding TMD Radiographic Imaging – Pano vs CBCT vs MRI – PDP223 1:06:27

for 3 dager siden1:06:27

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Which imaging techniques should you prioritize for TMD patients? Does a panoramic radiograph hold any value? When should you consider taking a CBCT of the joints instead? How about an MRI scan for the TMJ? Dr. Dania Tamimi joins Jaz for the first AES 2026 Takeover episode, diving deep into the complexities of TMD diagnosis and TMJ Imaging. They break down the key imaging techniques, how to use them effectively, and the importance of accurate reports in patient care. They also discuss key strategies for making sense of MRIs and CBCTs, highlighting how the quality of reports can significantly impact patient care and diagnosis. Understanding these concepts early can make all the difference in effectively managing TMD cases. https://youtu.be/NBCdqhs5oNY Watch PDP223 on Youtube Protrusive Dental Pearl: Don’t lose touch with the magic of in-person learning — balance online education with attending live conferences to connect with peers, meet mentors, and experience the true essence of dentistry! Join us in Chicago AES 2026 where Jaz and Mahmoud will also be speaking among superstars such as Jeff Rouse and Lukasz Lassmann! Key Takeaways: Imaging should follow clinical diagnosis → not replace it. Every imaging modality answers different questions; choose wisely. TMJ disorders affect more than the jaw → they influence face, airway, growth, posture. Think beyond replacing teeth → treatment should serve function, not just fill space. Avoid “satisfaction of search error” → finding one problem shouldn’t stop broader evaluation. Highlights of this episode: 02:52 Protrusive Dental Pearl 06:01 Meet Dr. Dania Tamimi 09:04 Understanding TMJ Imaging 16:00 TMJ Soft Tissue Anatomy 21:04 The Miracle Joint: TMJ Self-Repair 24:26 The Role of Imaging in TMJ Diagnosis 28:15 Acquiring Panoramic Images 39:35 Guidelines for Using Different Imaging Techniques 41:26 Case Study: Misdiagnosis and Its Consequences 45:46 Balancing Clinical Diagnosis and Imaging 50:17 Role of Imaging in Orthodontics 53:18 The Importance of Accurate MRI Reporting 58:27 Final Thoughts on Imaging and Diagnosis 01:00:54 Upcoming Events and Learning Opportunities 📅 Upcoming Talks & Courses by Dr. Tamimi 🔔 AES 2026 Conference (Chicago): Topic: “Telling the Story of Your Patient Through Imaging” Focus: Understanding patterns in imaging and how they reveal the patient’s full clinical picture 💻 “How to Read a Cone Beam CT” Virtual Course (Concord Seminars) If you enjoyed this episode, don’t miss out on [Spear Education] Piper Classification and TMJ Imaging with Dr. McKee – PDP080. This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes A, B, and C . AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Imaging techniques) Aim: To enhance clinicians’ understanding of TMJ imaging modalities, improve diagnostic reasoning, and empower dental professionals to make evidence-based imaging decisions for temporomandibular joint disorders. Dentists will be able to – 1. Differentiate between panoramic radiography, cone beam CT (CBCT), and MRI for TMJ evaluation. 2. Identify the appropriate imaging modality based on specific TMJ diagnoses (e.g., soft tissue vs. hard tissue pathology). 3. Recognize the risks of under- and over-imaging and apply a diagnostic question-driven approach to imaging selection. # PDPMainEpisodes # OcclusionTMDandSplints # OralSurgeryandOralMedicine…

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Connective Tissue Disorders and Dentistry – PDP222 57:10

for 9 dager siden57:10

57:10

Why do some patients struggle with anesthesia, requiring multiple cartridges just to get numb? Could your TMD patients have an underlying systemic condition that’s been missed? Are you overlooking the signs of a connective tissue disorder? https://youtu.be/gaoJKPTV_Z0 Watch PDP222 on Youtube ”When you can’t connect the issue, think connective tissue!” Dr. Audrey Kershaw joins Jaz for a fascinating deep dive into the world of connective tissue disorders and their hidden impact on dentistry. Together, they explore how hypermobility, unexplained joint issues, and even a history of spontaneous injuries could be key indicators of an underlying disorder. They also break down why dentists play a crucial role in screening and identifying these conditions, ensuring better patient outcomes and a more holistic approach to care. Because sometimes, when things don’t seem connected… they actually are. Protrusive Dental Pearl: Don’t just take a “relevant” medical history—take a comprehensive one! Encourage patients to share all health issues, even those they don’t think relate to dentistry. You might uncover important clues about conditions like connective tissue disorders or sleep-disordered breathing, leading to better care and stronger patient trust. Need to Read it? Check out the Full Episode Transcript below! Key Take-aways Ehlers-Danlos Syndrome is often misunderstood and underdiagnosed. Patients with connective tissue disorders often face skepticism from healthcare providers. POTS is a common condition associated with EDS that affects blood pressure regulation. Many TMD patients may have undiagnosed connective tissue disorders. Awareness and education about EDS are crucial for better patient outcomes. The healthcare system can be challenging for patients seeking diagnoses. Research on local anesthetic effectiveness in EDS patients is lacking. Personal experiences can help in understanding and diagnosing connective tissue disorders. Collaboration between healthcare professionals is essential for patient care. Genetic testing is crucial for diagnosing rare types of Ehlers-Danlos. Dental professionals should be aware of the signs of connective tissue disorders. Diagnosis can empower patients to understand their health better. Holistic care is vital in managing symptoms associated with EDS and TMD. Medical histories should be seen as relevant in dental practice. Highlights of this episode: 02:17 Protrusive Dental Pearl 04:21 Dr. Audrey Kershaw’s Journey and Insights 09:45 Personal Experiences and Professional Observations 11:55 Diagnosis and Management of Connective Tissue Disorders 13:31 POTS (Postural Orthostatic Tachycardia Syndrome) 15:30 Understanding Ehlers-Danlos Syndrome (EDS) 24:55 Hypermobile EDS and the Need for Awareness 27:53 International Consortium of EDS GP Checklist 28:34 Genetic Testing and Red Flags 31:44 The Role of Dentists in Identifying EDS 40:32 Journey to Diagnosis 43:47 The Value of a Diagnosis 48:43 Dental Implications of EDS 55:00 Final Thoughts and Resources “If you know one case of EDS, you only know one. Every case is different. Many are severely debilitated, unable to work or carry out daily tasks, often denying their struggles after years of being dismissed.” – Dr. Audrey Kershaw Promised Resources Podcast Recommendation: Linda Blustein’s Podcast (about POTS and connective tissue disorders) Specialists & Research: Dr. Alan Hakim – A specialist in Ehlers-Danlos Syndrome (EDS) research based in London. Norris Lab (U.S.) – Researching genetic markers for hEDS Local Anesthesia Information Resources for Screening & Diagnosis: Diagnostic Criteria for Hypermobile Ehlers-Danlos Syndrome Download 5-part-questionnaire-for-hypermobility Download Symptomatic Joint-Hypermobility Guide Download Red Flag Patients Download Educational Conferences & Talks: Scottish Dental Show – Audrey is involved in raising awareness at this event. Podcast with Periodontist Reena – Discussing HbA1c meters for diabetes screening in dental practice. “If you can’t connect the issues, think connective tissues”. An EDS talk for professionals. Advocacy & Support: Learn more about EDS and Dr. Audrey Kershaw Ehlers-Danlos Support UK Scotland – Audrey collaborates with them for better patient care pathways. EDS PATIENT EMAIL Template April 2025 GMP EDS EMAIL TEMPLATE April 2025 Connect with specialists like Dr. Audrey Kershaw Pack to aid identification of possible HCTD/EDS cases in the dental setting 1. Watch YouTube video made for Prof Tara Renton , by Drs Kershaw and Bluestein 2. Read this – https://gptoolkit.ehlers-danlos.org/ 3. Fill out Oral Surgery Scotland Advanced Medical History Form 4. Fill out this – International Consortium of EDS GP Checklist OR use this link – https://apps.apple.com/app/id6642710534 5. If appropriate, give patient EDS information email EDS PATIENT EMAIL Template April 2025 6. Send email to GMP GMP EDS EMAIL TEMPLATE April 2025 7. For any issues, or feedback, please contact Dr. Audrey Kershaw If you loved this episode, make sure to watch Periodontal and Systemic Link – Correlation or Causation? 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: 150 Health medicine and nutrition Aim: To enhance dentists’ awareness and understanding of connective tissue disorders (CTDs), particularly Ehlers-Danlos Syndrome (EDS), and their impact on dental treatment, local anesthesia effectiveness, TMD, and overall patient care. Dentists will be able to – 1. Identify key dental manifestations of EDS, including local anesthesia failure, TMD, and periodontal considerations. 2. Apply a multidisciplinary approach to managing complex TMD cases with suspected connective tissue involvement. 3. Appreciate the dentist’s role in identifying and supporting patients with suspected connective tissue disorders. # PDPMainEpisodes # BestofProtrusive # BreadandButterDentistry Click below for full episode transcript: Jaz's Introduction: When you can't connect the issue, think of connective tissue. This message has really hit me like a bus. As you know from a few episodes ago, I had my own health issues with a spontaneous lung collapse. Don't worry, I'm okay now. That was scary and strange, but it made me look into my own health. Jaz’s Introduction: Like I’ve had a dislocated shoulder and I’ve got stretchy skin and numerous other things, which you’ll see from this podcast with our amazing guest, Dr. Audrey Kershaw. She’s an oral surgeon and she’s so passionate about screening for and helping patients connect these seemingly unconnected issues to discover that they may have a connective tissue disorder. And so why is it important for dentists to know about this? Well, me personally, and for Audrey, our TMD patients are highly likely to have some sort of connective tissue disorder, or at least have this label of hypermobility. And you’ll see why in the podcast where this label perhaps does it in justice also, we would’ve all had a patient at some point that was just difficult to numb up. Like, you’ve given like five cartridges and this tooth is not going numb. Did you know that this could be a sign of a connective tissue disorder? And nowadays, we’re not tooth mechanics, right? We are really integrated in the health of the patient. The clinics that I see thriving are talking about the patient’s health. Think about sleep disorder breathing, and how dentists are playing a key role in managing and screening for patients, obstructive sleep apnea, how we are giving this message of reducing sugar that’s so important for a patient’s overall health. Periodontists are getting very good at screening for and helping patients get diagnosed with diabetes. And now we get to screen for connective tissue disorders. So for those of you who want to play a role in the patient’s overall health, which I think makes our career more fulfilling, this episode will really be right up your street. This episode is of course, eligible for CPD or CE credits. We are a PACE approved provider. The way to get that is through the Protrusive Guidance app. The website for that is protrusive app. We have over 3000 dentists on there. It’s the nicest and geest community of dentists in the world. And we don’t use the Facebook group anymore. The Facebook group is now defunct, so please do join us on the app. So I would suggest going on Protrusive app, the website, making your account, and then downloading the Android or iOS app and then using those credentials to log in. Dental Pearl : Now, every PDP episode I give you a Protrusive Dental Pearl, and one of the messages from this podcast is about the medical history. Now, I know we all take a medical history and we update it, but the problem is the word relevant. We often take a relevant medical history, and if you only take a relevant medical history, you miss out on the patient’s overall health. For example, if I was going to the dentist where it says relevant medical history, I would never have thought to write about my several dislocations I’ve had on my right shoulder or various other health issues, which I just don’t think are relevant for my dentist. So for example, your patients might have IBS or other things, and they aren’t telling you ’cause you’re the dentist. Why do you need to know? How is it gonna affect dental care? But actually all these things are important in the medical history ’cause part of screening for a connective tissue disorder, they are incredibly powerful and incredibly relevant. So let your patients talk about their medical health and really encourage ’em to open up about everything. You’ll have a bigger and more complete picture about their general health. And the patient will also understand that, hey, this dentist, he’s more than just a dentist. This dentist, he or she is genuinely interested in my health. So if you’re trying to practice dentistry in a way that looks after the patient’s general wellbeing, then this is a really important step. Like I said, it makes our job more enjoyable, more fulfilling, and it’s why I think airway and sleep disorder breathing in dentistry has really lifted off ’cause clinicians really feel that they’re making a difference. Like for example, when I do my sleep testing and I get it reported from a sleep physician, and those times I’ve got a positive diagnosis, which is more often than not. So more often than not when I suspect that a patient has sleep disorder breathing and they get tested, I’m right. And you know what? That gives me a huge boost that I was able to help potentially add 10 quality years to this patient’s life. Now you would’ve heard about that when I recorded that episode with Max Thomas. Go back a few episodes, check that one out if you haven’t already. We go deep into sleep testing and the role of the general dentist in screening for sleep disorder breathing. But I very much see this in the same realm. It’s all to do with the patient’s general health and wellbeing. So hope you enjoy this podcast and I’ll help you to look out for things which perhaps seemed unconnected, but actually you’ll see that they may be connected. I’ll catch you in the outro. Main Episode: Dr. Audrey Kershaw, one of the newest members of our community, and it is so, so nice to finally see you virtually, I guess, and have this long anticipated chat. Now, honestly, since I spoke to you on the phone, since my lung collects happened and everything just aligned, people are messaging me saying, have you spoken to Audrey? And like wow, there you are. How are you doing? [Audrey] I’m very excited Jaz to be here. It’s just like everything is falling into place to try and help a lot of our patients and a lot of ourselves. [Jaz] Yeah. And the first thing I wanna unpack is, just tell us about yourself into your journey into oral surgery, but then also why are you so well known? Why did you niche into connective tissue disorders and Ehlers-Danlos and relevance to dentistry, which we will unpack today, but your journey is gonna be really fascinating I think. [Audrey] So I qualified from Glasgow in 1987 and I didn’t want to go straight into GDP, so I left Glasgow to Birmingham. I got a house job there, enjoyed oral surgery, so just kept sort of traveling around England. I fell into a lot of good jobs, Jaz, and at that time the Sunderland job probably still is a brilliant job. Sunderland job came up after Birmingham, and then the Walton job in Liverpool. Your younger listeners won’t maybe recognize these names, but there was word booth in Sunderland and or in Liverpool. There was Il and David Vaughan. I just landed in good jobs. I enjoyed oral surgery, so I kept on, I got my fellowship. Ended up in Dundee, made it back to Scotland and ended up in Dundee. [Jaz] At that time, Audrey, were there many women in oral surgery? ‘Cause I see so many women in oral surgery now. Was it always the case when you were training as well? [Audrey] I don’t think there were just so many, Jaz, weren’t so many. So I have always changed what I’ve done in my career. ‘Cause I think if we’re going to be working for 35, 40 years Jaz, I don’t think we can keep doing the same thing. And I think you are doing that, aren’t you as well? So, I was doing a lot of Max Facts jobs and then went into sort of Dundee, dental hospital, the teaching there. Then I went into medicine and surgery teaching. I left there about seven years ago, seven or eight years ago, and I went into private practice. I’ve always kept sort of just moving on and do you know those patients, Jaz, that we know there’s something going on. Local anesthetic doesn’t work. I’ve known my whole career, there’s something going on. The patients are not making it up. They’re not putting it on. They’re trying their very best. And we have some colleagues that will say to these patients, you’re just feeling pushing. This isn’t sore. You’re just feeling pushing. I dunno who these colleagues are ’cause nobody will admit to it. But I knew there was something going on with all these patients. And about seven years ago or so, I discovered what it was. [Jaz] And just to clarify, this wasn’t just the redhead patients, which are famous also for that. And so sometimes, we as dentists, we think that, oh. The patient is just very nervous. Hence why they’re feeling it, but it’s not always just the case. [Audrey] So I discovered what it was chatting to a very good medical friend, joy, and she said, do you think this is Ehlers-Danlos surgery? I said, you’re talking rubbish joy. You’re talking rubbish because Ehlers-Danlos, as we all know, Jaz is blue sclera, stretchy skin, and very mobile joints. Now that is what I was taught back at dental school, and that is really still just about what’s taught these days. As far as I can see. I didn’t understand Ehlers-Danlos, and a lot of our colleagues don’t understand it. So what I say in the lectures we give here is there is no place for doctor or dental bashing in this. Everybody’s trying their very best. There’s probably a very good lecture that I gave Tara Renton asked me to do a lecture for them. We gave it in December. Could you maybe put the link to that on your site? [Jaz] Certainly. [Audrey] On that talk, we have Linda Bluestein, who does a Bendy Bodies podcast in the States. I think I sent you her details already. Linda’s amazing. Linda is now 59. Linda shares her details very, very openly. She was only diagnosed when she was 47. Now Linda is a doctor. I’ve also picked up several doctors on my travels now who have been unaware that they’ve had Ehlers-Danlos. Linda speaks very, very openly. She does amazing podcasts on this. She’s got 140 podcasts on all different things to do with connective tissue disorders, and we don’t pick it up unless we know what we’re looking for, and that is why I am excited to be here Jaz, and be excited to share all this with your listeners. [Jaz] It’s something been so topical for me and you helped me so much because as many of our listeners know that last month I had a spontaneous pneumothorax. [Audrey] Could we also add the word minor in there? Love that word. Minor pneumothorax Jaz. [Jaz] Minor pneumothorax, this is a small little thing, which I mean, that hit me hard, right? And so when I was looking into that, and then you sent me some literature, show me that, okay, there’s actually a red flag for a connective tissue disorder. And that’s saying, I’m seeing it crop up everywhere when you can’t connect the issue, think connected tissue. And it makes so much sense. And then you told me I was on the phone in the taxi on the way back from hostel and you said to me, how stretchy is your neck? And I was like, well, it’s about this stretchy. And then so you’re like, okay, well, and then my shoulder dislocations sub locations, history of that stretch marks in my chest. I dunno if that’s one, but it’s a strange location to have stretch marks. So who knows? And then obviously because I’ve been so strung up trying to get my lung actually sorted. So seeing the thoracic people now, they weren’t interested ’cause I had this chat with ’em. No one was interested in exploring further or even thinking about, it wasn’t even their remote differential that this could be something, anything to do with connective tissue. They just think, well, it happens sometimes. [Audrey] So just to tell your listeners, I think it was on the Wednesday that a colleague in Glasgow, Lorna. Hi Lorna. Lorna put my name forward to you saying you might want to talk to Audrey to learn about connective tissue disorders. Julia was organizing for us to talk on the Monday and she sent me a message at the weekend saying, Jaz should be okay to talk. But he’s had a minor collapsed lung and I spent a fairly sleepless night Jaz thinking, I just feel this guy is an undiagnosed connective tissue. And then on the Sunday morning I put a lovely message to you saying I know that you’re asking what could this be? And you think it’s nothing. And I thought, I’m blowing my chances for a podcast with you here, and then 12 hours later, you replied saying, Audrey, you’re a hundred percent right. And so the timing of this Jaz was just out of this world. It was like, how do these things happen? Yeah. [Jaz] It’s the universe’s way of telling us. [Audrey] You feel that there’s maybe some underlying cause for your pneumothorax? [Jaz] Yes. The more I think about it, the more I look at everything and the more I look into it. But again, like I said, the doctors were just not interested. Now I know you put me in touch with some people that I’m gonna chase up on the emails, but it very much is the onus on the individual to get your diagnosis. So I’d like to know how you ended up getting your diagnosis. [Audrey] Just to take a step back, your story is so, so familiar. Nobody is going to suggest a connective tissue disorder to you with everything. It’s gonna be some crazy dentist in Scotland that’s gonna send you a text on a Sunday saying, oh, do you think? It’s such a familiar story. I laugh ’cause if you don’t laugh, you’re gonna cry. I found last year, 120 patients with a possible undiagnosed connective tissue disorder, 120, and it breaks your heart, Jaz, because these people go to their doctor and say, I’ve got this, I’ve got that. They get nowhere, absolutely nowhere. So you’ve got to have all your ducks in a row before you go and get help. And then you’ve got to be very, very, forceful is not the word I want to use, but you have to be very, very sure of what you want. Now it is easier for you and me to do that because we have the knowledge education, eloquence sort of to do that. Can you imagine what that’s like for somebody from one of the less well off areas, less well educated, less confidence to do that? It’s very, very hard. So Jaz, this is the first time being open about my diagnosis. This is the first time I’m being open about it. This is not about me, this is about our patients. And I haven’t been open before because the journey has been very hard. I still have people in my life that don’t believe me, and it’s taken time after my whole life to get my mind around this and to be able to be confident enough to be able to talk about it. I also professionally don’t want people knowing too much because I don’t want people pointing the finger thinking, oh, well, if she’s got all this going on, how can she possibly be a oral surgeon? So I’m still finding my feet on this. Whereas you are much maybe more open about it. But I’m very, very happy to share my journey. I’ve made a few notes here, Jaz, so excuse me if I just sort of read them. So I knew for my whole life, Jaz, there was something going on. I knew there was something that wasn’t making sense. I knew it and I couldn’t put my finger on it. So I will tell you from a professional point of view, some of the things that people would notice if their colleagues are like me. So I said my first job was in Birmingham. Every Wednesday in Birmingham, we had a GA list for six months. Without fail, everybody waited for me to fall over to faint. Now that’s a sign of low blood pressure, maybe POTS, something like that. I thought I was going to have to give up being a oral surgeon because I couldn’t stand upright. [Jaz] So it wasn’t necessarily like the site of blood, which some people might associate with that is, yeah. [Audrey] I didn’t have a clue what it was. I think in those days, I don’t think the diagnosis of POTS was around, people didn’t know. [Jaz] Tell us more about POTS, ’cause POTS only came into my radar when one of my TMD patients, she had POTS and I looked further into it basically. And obviously it’s all interconnected. [Audrey] POT says Postural Orthostatic Tachycardic Syndrome. It’s all quite difficult ’cause some people fit the criteria of pots on certain days, but not others. So it basically means your blood pressure can be low. It doesn’t have to be low, but it means when you stand up, you can’t keep your blood pressure up. There can be many different reasons for pots, and at this point I would ask you maybe to put on the notes for this Linda Blue’s podcast on it because she gives a really good, yep. [Jaz] A hundred percent. [Audrey] So it basically means we find it very hard to stand up. Now, I don’t know about you and I don’t know if things will come out in this conversation that you think, ah, light bulb’s going on here again. I have had several nurses, they sit with their arms crossed on clinic. They stand with their arms crossed, they’re being told off on a regular basis. Would you stop crossing your arms? And I don’t know if you can see me. We sit with our legs crossed as well. Now what we are doing there, we’re not just being closed off, we are pushing on our vena cava to try and get the blood back up to make ourselves feel better. Now we just think we’re being difficult ’cause everybody’s told us we’re difficult. So when we’ve pointed out a lot of these signs and symptoms, I hope that your listeners will just spot people and they can maybe help them. So that’s POTS. When I was 28, I went to the doctor because my blood sugar was so low and I was told there’s no reason for having low blood sugar unless you’ve overdosed on diabetic drugs. [Jaz] How low is low? Do you remember the measurement? [Audrey] Somewhere between four to eight millimoles per liter is the normal blood sugar. Depends if you’re a diabetic or not a diabetic. And when I taught medicine and surgery, this was argued about every year anything under four can be seen as low. Anything under three, definitely low. [Jaz] So the reason I mentioned that is just so the chiming in basically, it’s nice little self-discovery here as well. I did one of those, not Zoey, but there’s another brand, I forgot which one it was and I was like, it was like a blood glucose monitor the whole time. I don’t know how accurate they are, but mine was consistently 3.9, 3.8 at rest, basically. [Audrey] Very interesting. Very, very interesting. I have also tried one of those monitors a few times because with Ehlers-Danlos syndromes, you can also get a higher blood glucose than you deserve with your lifestyle and your diet. So you can have it low, but you can also have trouble controlling your blood sugar. The way that I found a 10-year-old patient few years ago was she came in to have ortho teeth out and the letter said, a borderline blood sugar. And I thought, okay, so we’re going to see quite a maybe und. Girl come in here quite, quite a grown up girl. She looked like a seven or 8-year-old stick thin. We then asked more and more questions. Why did they find the blood glucose like this? Oh, because they sent us to Glasgow because she had GI symptoms. And GI symptoms are also a sign of Ehlers-Danlos syndrome. So, it was like more and more of the story came out. She was anxious, she was whatever. She ended up being an undiagnosed Ehlers-Danlos case. [Jaz] What this is already reminding me of, you know how TMD tempomandibular disorders. They are known as the the great imitator, but already, Ehlers-Danlos with this varying presentation and this multisystem effect, it can be really difficult to nail a diagnosis. So I’m excited to see how actually. What advice do you give throughout the episode for our patients ultimately? [Audrey] I think we’ve discussed TMD before Jaz. Almost every TMD patient I get referred to me as an undiagnosed connective tissue disorder. Now you’ve got to remember, I don’t see representative sample of the population. I see T MDs when people have struggled for like 18 months and think, what can we do, send it to Audrey. But almost all T MDs I see are that and TMD is a sign of, yeah, so when I was pregnant, really bad. Really bad morning sickness. That’s not the correct term these days. I can’t remember what it is, but really bad morning sickness. That’s a sign of Ehlers-Danlos childbirth. Age of 31st one almost bled to death. You just gotta laugh. They saved me, but almost bled to death. Again. Bleeding is a sign and symptom of undiagnosed connective tissue disorders. I then moved to Dundee at the age of 33. People thought I was a final year student at the age of 33, this is another sign in symptom of Ehlers-Danlos. I’ll come a little bit nearer to the camera. I am in my sixties. It’s not showing off in any way, but it’s another thing is when you go out to the waiting room to call your patient in, you’re looking for a 35-year-old and there’s a 17-year-old sitting there. Had a patient last week, 38-year-old curriculum lead for the English in a busy high school. People mistake her for a pupil in the school. It’s just a bit funny really. And the thing to say to somebody with Ehlers-Danlos is not, it’s so lucky you look young every other sign and symptom going, I think most people would give a good old wrinkly body to just not have it. But hey, you’ve just got what it is. You’ve got, so I was always cold and cold as well as a sign of dysautonomia. But you get with, so lot of our colleagues are very, very cold. They come in with their leggings on underneath their chin X. They always have the long sleeve top on things like that. That is me. Everybody knows I’m always called. We also forget names. Jaz, that’s another thing amongst our colleagues. We forget names. I think it’s you’re raising those eyes to the ceiling there, Jaz. What’s that? [Jaz] I’m terrible at names. Like I refuse to go to events where people don’t have their name on their chest. I mean, that is so reassuring to me. When I go to an event and have people have a name badge, I feel relaxed. When people don’t have name badges, I get anxiety. [Audrey] Jaz, I can’t even remember my own son’s names. I call one of my nurses my dog’s names. But it takes it as a compliment, Jaz, it’s a compliment. There are all these little things. We don’t do caffeine very well after a certain age maybe. So we don’t seem very sociable, if you don’t go for coffee with the nurses or the staff, it can sort of look as though you’re not trying to fit in. We also don’t do well with sugar and an unhealthy diet. So, if somebody’s offering you a cake and work, you say, oh no, no thanks. It’s not that I’m being really good, it’s just I know I’m gonna suffer a high gi. Diet as in too much sugar in your diet that makes your POTS worse. So, there’s many reasons and what we find about a lot of people like ourselves is we’ve already taken on the lifestyle without knowing there’s something wrong with us. So we always make sure we’re well wrapped up. I noticed a post you put on today, Jaz, about going to bed at nine o’clock. We need a lot of sleep. We get tired really, really easily. So that’s another thing as well. [Jaz] Very relatable. [Audrey] So that was basically my journey. I had failed LA when I was 47. It was surgery under spinal. And I said, excuse me, because some of us elders done lost patients. We’re very polite. We do have our faults, Jaz, but excuse me. I can actually feel what you’re doing to be told by one of the team? No, no. You’re just feeling pushing. I left it a few minutes longer and I said, excuse me. You just got to laugh, Jaz. It was horrendous. I said, and excuse me. It’s not just pushing, I do actually feel it very, very sharp and sore, just really to be told. No, you’re making this up. I hope I don’t have a those down. ‘Cause like you said, you wish you don’t have it. So my lower four incisors. Loss vitality. Huge apical infection. We think it’s because orthodontics, yes, that’s the only source of trauma I had to her teeth. So, loss of vitality, my lower incisors. Fast forward many years. I now have a resin bonded bridge for my lower incisor. One of ’em lost, fractured, and my old principal, Amit, shout out to Amit Mahindra. He was there removing my retained root of my lower incisor. Now, lower incisor classically an easy area to numb up. Okay? And he’s luxating it, and I can feel everything right. I can feel everything. So a lot of relatable things that you are saying. I don’t know. I haven’t been officially diagnosed, but just connecting all the dots. [Jaz] There’s a very good paper as well that you could maybe put up on the link to it. It’s the best. We’ve got, I think it’s a 2019 explaining about local anesthetic. We need so much more research, Jaz, and if any d listening to this, wants to help in any way, wants to get into research with all of this, we need so much more research. Certain types of LA work. Better than others. It’s all in the paper. So I always knew there was something wrong. Every so often I would find myself sitting in my doctors thinking, what am I here for? I just know there’s something wrong and I now know. So it was when I was 53 years old, a very good friend of mine, joy, who is medically qualified. Joy, knows everything about me. We have wonderful chats and joy just said in the middle of a conversation, oh Audrey, do you think you’ve got tell, it’s Ehlers-Danlos. I said, you’re talking rubbish, Joy. And then within two or three minutes it was, oh my goodness. Oh my goodness me. So one of the things that’s a little bit confusing, but it didn’t delay me finding out Ehlers-Danlos is I am not overly flexible. I don’t have the shoulders of pop out Jaz. I am flexible. If you come to a Pilates class or a yoga class with me, you’ll think, my goodness, she’s fairly flexible. That’s good. I used to think it was the rest of the population, Jaz that had issues, they really need to do a bit more exercise ’cause they’re just not all that flexible. And then the discovered is me. That’s the one that’s just that little bit more so I can’t do the thumb back to the wrist trick, like that doesn’t come up. My elbows are not overly flexible. It’s not easy to see how flexible you are when you’re over 50 or whatever. Or sometimes it’s just not easy at all. But you know, I was always a little bit more flexible, but I was never overly flexible, and that is one of the things that confuses patients and confuses everybody, these are called hyper mobility syndromes. I don’t like the term because it’s not easy to see if somebody’s hyper mobile. There may be where in the past, but not now. And some people like myself really, were not overly hyper mobile at all, but we do have Ehlers-Danlos. It’s interesting because that’s worth exploring because what I was taught in the past and what I’ve been doing in clinic as well is yeah, we do the BA score, like a mock version. Can you put your thumb and stuff? And if they can’t do all that, we think, okay, maybe you’re not a hypermobile and therefore maybe that’s not important in your etiology. But what you’re really saying is just ’cause they don’t have that feature doesn’t mean that they don’t have Ehlers-Danlos. But we’ve been using that as like a yardstick. [Audrey] So we have a specialist in London, Alan Hakeem, who I’ve sent you his details. Alan is an amazing man. Alan is internationally, I think one of the leaders in Ehlers-Danlos. Alan will say, if you have a bait and score high enough, good. And if you don’t have a bait and score high enough, still fine. And the bait and score, I mean that’s only looking at what so many joints out of 300 joints in your body. And sometimes we have people that had a patient last week, she had very, very bendy was the dislocated and hips, but she wasn’t doing well on the beaten or the Alan and the Hake and Scream score is out of five, and that’s maybe a better one to use for your clinic. But as Alan says, if you score over three on the Hake and scream score, fine. But if you don’t, and another thing Alan will quite often say is they get annoyed because if you don’t score highly enough, if you’re not hypermobile enough, you don’t get let into the party. And we need to let these other people into the party. It was actually Alan that gave me the Ehlers-Danlos label. He saw me in London. Yeah. [Jaz] And how does one get that for myself, but also for patients? Because I had this conversation, like I told you on the phone, I had these conversations with my TMD patients that, look, you are hyper mobile and that could be a sign of a connective tissue disorder. And we talk about it. But really, I’ll be honest with you. I haven’t found, like no one ever says, okay, can you phone me to a GP? Because then they get lost. Like there’s no clear pathway. So I’m sure we’ll develop into how to do that. But how does one get a label? How does one get a diagnosis? Is it only through genetic testing or how is it done? [Audrey] Up in Scotland, I struggled until about two years ago. I got this email out of the blue from Janet Ner and she’s a osteopath now working in cell Daikin fife, and it was one of these emails, I got Jaz. I thought, who is this from? Are they winding me up? No, she wasn’t. She had moved up from Chichester. I think Janet, excuse me, I’ve got that wrong. And she had come up to Fife to settle and Janet also says on our website that she is also a bendy and I send my patients to Janet. Now, I have completely swamped Janet with patients. If you can see, I found sort of 75 patients last year and 55 or so others. Janet cannot keep up. With the number of cases that I’m finding for her. So we have to be very, very careful who I now send on to Janet. So I am lucky up here. I I’ve got Janet, you know Janet can diagnose Ehlers-Danlos. Now, I love the way Janet works. Janet’s got a mind probably like mine and yours, Jaz. We don’t just assume, we want to look for all the evidence. I know where my knowledge is lacking. I think the more you know, the more you realize you don’t know. So it’s very easy just to get a diagnosis of hypermobile e Ds ’cause that’s the most common. There’s another 13, 14, or so different types of Ehlers-Danlos. But they’re very, very rare, supposedly now any type of Ehlers-Danlos, when my friend Joy first said to me was supposed to be one in 5,000 people had it. So I thought, right, I’m really, really rare. Hey, I’m special. And I thought it’s going to take me 1 77 years at the rate I work, I’m going to find an Ehlers-Danlos case. So when I found my first one, I thought that’s it for seven years or so. I see one in eight of my patients with an undiagnosed connective tissue disorder, one in eight everyday. I’ll say that again. Speaking to other people, there’s a Welsh study that says one in 500. There’s a Northeast of England study from last year that said one in 227. There’s limitations to these studies because these are only the people that have been diagnosed. So I feel one in eight is maybe a little bit high, but that is what I find in my patients because people suss me out. They don’t know why they’re sussing me out, but they suss me out and they find me. Yeah, I think it’s maybe more like something, one in 30, one in a hundred, but it’s definitely much, much more than we think. I’ve gone off at a tangent. How do we manage this? I have got Janet up in Scotland for this. Even the patients I see from the north of England, they come and see Janet. People will travel three hours or so to see Janet. It’s very hard if we don’t have a Janet in our lives. Have you seen Jaz, the international consortium of EDS GP checklist? [Jaz] Unless you sent it to me. ‘Cause you sent me some things that I- [Audrey] I can send to you, whatever we need. This is a checklist to see if you fulfill the criteria for having hypermobile Ehlers-Danlos, and it’s in three different sections, you have to have the bait and score, you have to have all the other signs and symptoms. And then the third paragraph is you have to not have other genetic conditions going. It’s okay, but it’s got it’s drawbacks. I believe that is going to be updated by the International Consortium this year. If you fulfill the criteria for that, great. Fine. You get your diagnosis, but there’s those people that don’t quite fit in. If you have got a rarer sort of Ehlers-Danlos, that’s where I was starting to talk about genetic testing. The leaflet I sent you, it was talking of the red flags. If you’ve got any of those red flags, you should be able to get genetic testing. We have patients that go to rheumatology, genetic. They get turned away from rheumatology ’cause maybe rightly so. That’s not the right place for them. I personally have been through all of this and it’s very interesting as a experienced clinician sitting in front of someone who will not take you seriously. And I have come out and I’ve walked around the nearest park. Crying my eyes out in floods of tears because it was so, so difficult. So Janet and I are also picking up many, many more rarer types of Ehlers-Danlos, and they go for genetic testing. It takes time to pass through that national health service. We can try that. We can go privately as well. Janet would be better talking at this than I am NHS. If you go to get tested, you don’t get tested for all the other 300 or so connective tissue disorders as it could be. If you go privately, which is about 500 pounds, you can, so it’s not easy. In Scotland, I work with the Ehlers-Danlos support UK, Scotland. Got a family friend who’s an MP member of the Scottish Parliament. Okay. I got him involved. Mike Mara. Mike has been great and he has been helping us get this through the Scottish Parliament to try and get better care pathways for patients. So the answer, how do we do this, is we say to the patient, you’ve got a few signs and symptoms of a connective tissue disorder. I am not qualified to diagnose you. I’m not an expert, but I do know something on this. I sent them some links, I think they were maybe the links I sent to you for the Ehlers-Danlos websites and whatever. And also Linda Stein’s, Betty Bo Bendy body podcasts, ’cause I’m finding that so much more useful now than anything else. ‘Cause Linda’s great as I kept saying. So we give them that. We say, do you want us to write to your doctor? I have a standard letter to write to the doctor to say, we’ve met so and so. They’ve got all these signs and symptoms. It may be suggestive of a connective tissue disorder. They’re interested in taking this further. Some patients get places other patients don’t. So it’s basically very, very hard Jaz. Very, very hard at the moment, and that is what we’re trying to campaign for and push for through the parliaments and the healthcare providers. I’m also trying it in my own way by doing these podcasts and lecturing, going to the Scottish Dental Show. We have now lectured to about a thousand healthcare professionals, and I now have people who have been on my talks saying they’re now picking up. Undiagnosed Ehlers-Danlos cases or undiagnosed connective tissue disorders. [Jaz] But just to clarify, the main way, therefore, for those who don’t fit in the consortium sort of standard pathway is genetic testing. [Audrey] There is no genetic test for being hypermobile EDS. There is no genetic test at the moment. The Norris lab in the states, they think last year they’ve maybe found four different causes that could be genetic for hypermobile Ehlers-Danlos, but we’re not there yet. So we’re in this no man’s land of, there’s no genetic test. It’s a clinical diagnosis. You need to find somebody who can clinically diagnose you, that knows what’s going on. GPs should be able to clinically diagnose, but to me the problem is it’s like somebody saying, I’m a dentist. I should be able to diagnose your perio disease. I’m a oral surgeon, Jaz, don’t they asking me to do this? Yeah. Very hard because as I said before, there’s no place for doctor bashing. These GPs have been taught very little about connective tissue disorders. They’ve been taught that it’s blue sclera, stretchy skin and mobile joints. If you don’t fit into that, that’s not you. I’ve been there with my GP and it’s very, very difficult. You’re told you’re being anxious. You’re depressed. It’s like I don’t get depressed. [Jaz] Interesting. It reminds me of something that James and Spencer in the US taught me, right? He taught me that, and I share this and I always name drop him is TMD patients are NUTS. Okay. I’m sure you know where I’m going with this. And so it sounds like, these suspected ED patients are nuts. And really what NUTS stands for is not understanding their symptoms. Right? That’s what NUTS stands for. And then that is a whole plethora of consequences, but let’s just connect it all together. One in eight patients that you see, now, is that one in eight of your TMD patients? [Audrey] One in eight of all my patients. All of them. [Jaz] Okay. So what about specifically your TMD patients? What percentage or what ratio of those? [Audrey] Almost every TM joint patient I see is an undiagnosed connective tissue disorder. [Jaz] Okay. Let’s go with that then. [Audrey] Yes. [Jaz] Because I see plenty of these as well that individual, what should the dentist be saying to them, because I feel as though the pathways, like you said, aren’t quite clear yet. So what is our role in communicating and screening and helping them? [Audrey] Jaz as I was making up my own template and I had a massive medical history that I would ask everything going, and I would send this to Janet and it would be all over the place, and I couldn’t ask enough. Linda Bluestein, again, has come to the rescue and she has got a sheet on her bendy body’s website, and it’s basically just listing all of the possible signs and symptoms or most of them. So what I do now is I go through this and I just tick them off. Did this for a patient yesterday. I just go through it. So do you have acid reflux issues. Do you have irritable bowel syndrome? Do you get anxious? Do you have poor sleep? Do you this or that? We just go through it. It doesn’t give you a score or anything, but it just has the patient opening up. Just to go back to what you said about TMD, what I feel sometimes throughout my career on TMD was we just see the TM joints. We don’t think the TM joint is connected to the rest of the body, and I do remember whether it was, what, 20 or so years ago, 30 years ago. It was said people with TMD were more likely to have GI issues. One thing that you had said in a podcast, a TMD podcast, because I’ve listened to so many of yours when I’m traveling, so thank you for keeping me company on that. You had mentioned that you can only see a certain number of TMD cases because they exhaust you. For want of a better word. They are so demanding is not emotionally. [Jaz] Emotionally, no, yeah. Not in a bad way for them, but like as a clinician, like, therapists need a therapist. It is draining mentally and emotionally. And concentration. [Audrey] Absolutely. And that wrong, true for me when I was listening to it, and I so appreciate you being so honest in these podcasts. ‘Cause I find it because I’m highly sensitive with my elders Danlos. It may be difficult to, to find people that can understand and talk to about this. What I find about my Ehlers-Danlos cases is, I so want to be there. But I have to give so much a consultation telling somebody who came in thinking they were fit and well saying, do you think your unconnected signs and symptoms are connected? I think you might have this. The supporting them through it, we absolutely want to be there. My job wouldn’t be the same if I didn’t, but it really does take it outta us, and we have to be so, so careful to look after ourselves when we’re doing these things. Some cases are much more draining for want of a better word than others. I mean, I will be drained by any day. I’ll give as much as I have. Some are more draining than others. All of them are so rewarding. [Jaz] Rewarding is a huge element and that that balances out and it’s so great to do that. But you know, TMD patients, it’s a category of chronic pain and they are just like any sort of medical issue, dental issue, once they have it, once they’re prone to have ebbs and flows, right? And so flareups are normal course of TMD, it’s not like a straight line goes up and down, up and down and it varies depending on so many factors. So I’ll give you an example, right? The other day I opened my email inbox and a patient who I’d seen who travels hundreds of miles, see me. She saw me and she was having a flare up, and I’d just read her email and I started to get palpitations. Now, I haven’t done anything wrong here. I helped her big time. She was in a really bad way. Some conservative care. Later she was feeling amazing. A year later I see an email, and now she didn’t mean to upset me. It was me that I got upset. I’m not upset, but like I started getting palpitations. Just reading that she was getting a flare up and it affected, it is like it really affected me. Cut me. And so this is how, just a peripheral. Drainage that can happen as well on the side when you feel everything your patient feels. [Audrey] Yes, and I think the T MDs and the Ehlers-Danlos centers, we’ve gotta be so, so careful that we keep our energy levels up so we’ve got enough to be able to give these patients. Because I think if I didn’t have Ehlers-Danlos patients to pick up, I don’t know if I would still be a working because it is so rewarding. And I think another thing I meant to see was I feel very humbled that I have discovered about Ehlers-Danlos syndromes, and I am in a position to be able to help so many people, and that is not supposed to sound bigheaded whatsoever. I am so humbled to be able to do this, and as I said before- [Jaz] Even a major facilitator. [Audrey] Yes, it is not just me that can do this. I have taught others to do this and before I stop working, I dunno how many years next year, five, six years, seven years, I need to have left enough dentists to be able to pick up all these cases and to help them. And it is such an honor to be able to do that Jaz. I think you u of D can get that as well. [Jaz] The famous study, the opera study- [Audrey] And that is so well known about these days. If you listen to Tara Renton, go on about TMD these days. TMD is related to sleep disorders, headaches, migraines. There are papers to say migraine sufferers and Janet knows this paper are 95% chance of having an undiagnosed connective tissue disorder. So if I see on a patient’s record reflux headaches and migraines, you are just, it’s like, oh my goodness. There’s another one. So this is one of the things I’ve got in my list to speak to you about here, Jaz. We need a better dental flow chart for how we manage this. Until very, very recently, Jaz was very alone with this because I was stepping outside of what all my other colleagues did and I was willing to do it because I’m in my sixties. An outlier. [Jaz] An outlier- [Audrey] And it’s like, I know there’s still a lot of people out there thinking, what is she up to? Don’t care, Jaz, don’t care. I feel we are just having a chat together. We’ve gotta remember so many other people going to be listening. I want and I need help to get something sorted. Last year I listened to a talk, Tara Renton did, and it was a TMD one, I think to do with sleep apnea and oh. Tds and everything else. It was a great talk, as in all Tara’s talks are, and I thought, I’m going to email this woman. I’m emailing her a as I do a lot of people, I thought, I don’t expect her to answer. And she wrote back saying, dearest Audrey, count me in or something. And it was like, Tara, I love you. And so Tara has also had her eyes opened to Ehlers-Danlos syndromes. So that was the start of me feeling I was getting somewhere. I was so pleased to hear from you as well, Jaz. I need people to join with and we need to sort this out for our dentists to be able to take this forward. We basically need to go over the medical history. Tara says as well, lot of medical history says relevant medical history. I get so annoyed about that. Tara gets so annoyed about that. I want to know everything. I want to know if your shoulders pop out. I want to know if you’ve had a collapsed lung. I want to know things that don’t seem to tie in, because all this is very relevant. When we do go through the medical history with the patients with the Linda Bluestein sheet, they’re just so funny. They’re just so funny because you say, do you have any acid reflux issues? Well, I don’t really listen, want a yes. I don’t, no. Do you or don’t you? Because throughout their whole life they have, and this is me as well, the normalized it. It’s just, oh, this doesn’t matter. This is just ’cause I’m being silly. It’s because I’ve eaten the wrong thing. It’s because I’ve done yoga too soon. We had a very interesting patient, Beth, who appears on the talks with me and Beth is great, and she’s so funny. Beth says, she just always knew. She had to eat a few more veggies and do a few more yoga classes and she would be okay. And she came in to see me to have a wisdom tooth out. And we just laugh about this now. We knew before she came in from Poppa’s in her medical history, she’s going to be another Ehlers-Danlos case. [Jaz] And so let’s talk about her, if that’s okay. ‘Cause she obviously comes on with you with these talks. How did she in this individual came to you for a wisdom tooth distraction. You noticed these things and then how did she end up as a case study, get her diagnosis. [Audrey] I also wanted just to say, Jaz, how would you like to do another podcast with four or so of my dental patients that I’ve picked up? I’ve been looking for somebody to help me with podcast Jaz, and I was so delighted to hear from you. I’ve got great patients that would come on and tell their stories, and I think it would be great for your listeners to hear. So, when Beth came along, she needed a wisdom tooth out. Her medical history had a few little bits in it. Maybe like reflux anxiety. There wasn’t a lot in it, but I work in about eight or nine different places, Jaz throughout Scotland. The reception team, my treatment coordinator. The nurses, they pick them up before I do. Now they pick them up the same way as I sort of wondered about you. We just need a little hint and we’ve picked them up. So most of the time we know before these patients come in. So Beth, thank you so much for letting us share your story seriously. So Beth came in, she had horrendous wisdom teeth. She was very anxious. Absolutely lovely girl. We’ve been for dog walks on Ti Ferry Beach together. Patients with Ehlers-Danlos can also Jaz, have a very similar personality and that was one of the things that made me write you that message on the Sunday morning. You are very sensitive, you’re very caring, you’re very kind, you’re very in touch with your feelings. And we can pick this up with patients, you know that patient, that sort of phones a couple of times before they come to ask. Would it be okay if they come 15 minutes early? Where are they going to park their car? Blah, blah. It’s like, ah, we think they’re s done lost, we can pick them up. So Beth, we suspected it. Wisdom teeth were horrible. I told Beth, there’s no way I’m doing those wisdom teeth for you, Beth, because you’re so anxious and you need to get Beth on because she gives a really good story. Beth knew what I was saying was right. Beth knew that she could trust me. This is very, very humbling, Jaz. And these patients know when they can trust you because we listen to them. We don’t tell them they’re talking rubbish. We listen to everything nobody’s ever listened to before. So in the end, Beth ended up in tears and said, there’s nobody I’m going to trust apart from you, Audrey. So, my treatment coordinator wondered what I was up to and we brought her back later on. But Beth trusted me. Beth, I said, I say to some of my patients, you need to see Janet. Beth went to see Janet. Beth found Janet. So, so helpful. And Beth and Janet have got on and Beth got her Ehlers-Danlos hypermobile diagnosis from Janet. Beth will tell you how their lives have been changed. It is utterly life changing. Now, it’s not just me that can do this. It’s any dentist listening. It is utterly life changing. I know how life changing it is, Jaz, because when I discovered what I had completely changed me as a character and changed my life. [Jaz] And let’s talk about that. In what ways? Because it may not be obvious to someone who hasn’t had any health issues before. Because ultimately there’s no treatment. There’s no cure, there’s no, what is it that you gain from that label and how important that is. [Audrey] A lot of doctors and gps will ever say, there’s no point in knowing about this ’cause, nothing we can do. We cannot cure it ’cause it’s a collagen defect. But if we take the POTS for example, there are so many different things you can do to make that better. I go to little because the cues are shorter. If I go to Tesco, I feel so ill, I can’t go into Tesco. ‘Cause of the bright lights, the heat, and the standing in cues, you don’t stand around. You move from food to food. You have a chair in clinic, you have to drink plenty of fluids. That was a way that a colleague discovered I was, I had Ehlers-Danlos syndrome because I’d agreed the great. Big water bottle. You have to increase your salt intake. You need to get very, very fit. You have to exercise. There was a German study that showed most of the symptoms of pots could go if you had a really good exercise regime. That’s not what it’s like for every day, and that’s an interesting study in good on them. But you have your fluids, your salt, your exercise, your sleep. But we’ve also got to remember with all this Jaz, and it’s the same for TMD, you cannot see one thing in isolation. Everything is tied in. If your POTS is worse, that’s going to make you more anxious. If your anxiety’s worse, that’s gonna affect your sleep. If your anxiety’s worse, you’re not gonna be able to cook so well and everything. And then if you’re not eating so well, it’s just everything is so tied up. So one lady I found. She said that what her son always said to her was that she is always living on a knife’s edge. And that’s how I sometimes feel. We have to be so, so careful to do everything we need to do. And you’ve had a podcast, I think with Simon about this and that was a really interesting podcast ’cause he was saying about the really important things, and this really goes for patients with Ehlers-Danlos syndromes. The fluid, the diet, the exercise. He had some letters that said about it. Sorry Simon, I can’t remember what they were. And that is so, so important. So there are very much things we can do, but what it matters. Getting the label is you don’t doubt yourself anymore. You don’t let people put you down. Oh, why are you being so difficult? Or why you’re always so cold? Or, why do you have to do that? Why do you have to sit with your arms crossed? We can now say to people, yes, I know. It’s funny. I always sit with my arms crossed. But this is me trying to keep my blood pressure up. So can we just laugh about it and get on? Can you just remember I’m one of these funny people? For example, you were saying Jaz about not remembering people’s names. I was in one job. Where I got such a hard time for not being able to remember people’s names. And that was before I even knew about Ehlers-Danlos. And I would say, listen, it’s just something about me. I cannot do names. I don’t even do my children’s names nowadays, when it’s on about names. I can address these people with much more confidence and eloquence. I say thank you so much for bearing with me. I don’t even give my own names, my own children’s names. This is something just to do with the brain fog, with the low blood pressure, and it’s just easier. Rather than people saying, you’re just being stupid, Audrey. [Jaz] I totally get that. I think it’s to understand a lot more about yourself and when you stand about yourself, you can then live a life more purposefully, more optimized for you. And then when things just make sense in your life, then you can actually proceed with be your best foot forward. I think that’s the main benefit. [Audrey] I think just being allowed to own our own issues, like I luckily don’t really get sore joints because I’m not allowing myself to have sore joints. But a few years ago I got really sore joints. I had to stop learning Spanish on my phone because moving my fingers hurt my elbows. Sometimes I have to get rid of my big herbal tea cup because that was hurting me. Just to understand that we’re not being silly and think I need to exercise, I need to do more weights, I need to do more Pilates, rather than just I’m just being stupid and go away in a corner and hide away. What I would say though, Jaz is, a lot of people are striving to get a diagnosis. A diagnosis is not a be all and end all. And I would say to patients, if we get a diagnosis, fine, good. But what I say to them is, I’m not telling you anything you don’t know, but all I’m saying is do you think all your seemingly unconnected signs and symptoms are actually connected? Go away and live with that. It doesn’t really matter at the moment, the label we’re slapping on it. Yes, it would be nice to get a label at the end of the day, but let’s just work with what we’ve got and let’s get you off to the exercise classes. Let’s get you increasing your fluid, improving your diet, improving your sleep. Yeah, that’s what I feel. I love that. [Jaz] I mean, it is a total health message and so as we come to the last 10 minutes of the show. Patients, I know you see so many TMD patients as an oral surgeon for the general dentist listening, what other things that do you want them to know to look out for, for example, anesthetic. That doesn’t work. Okay. We know, I remember from dental school that s dentist was linked to periodontal disease. Okay. I remember that, but not much more in terms of relevance. It has to- [Audrey] What I do is direct your listeners to my lecture that is on YouTube channel. I think I’ve sent that to you already, but I’m very happy to send it all on again. [Jaz] Yes, I’ll put that one. [Audrey] Have a look at that, because that is really the dental implications of EDS. So local anesthetic doesn’t work. They can have white spots on their teeth. Molar incisal, o hypo mineralization. I’m on only a neural surgeon. So I don’t know when something is hypo mineralization or a white spot. So I just call it a white spot because I don’t wanna get in trouble with anybody. So patient I saw this week, even before we said very much, I could see the white spots on her teeth. I made a little list just to remind me because I knew there was so much to talk about. So failed local. When you give the local, these are the ones that don’t like adrenaline in it because they get palpitations. MIH. These are the patients that are anxious because anxiety and depression goes with Ehlers-Danlos. So they’re anxious. But Jaz, if you listen to these people, if you’re on the right side of them, if your receptionist gets them sorted. They will trust you to the moon and back. And they will not be anxious. They just need to know. So the anxious ones, they have a narrow V-shaped palette. Orthodontics works faster than usual. They have pulp stones. So they are the big ones that I find. I think that’s about all of them. [Jaz] Great. And then, so what’s the main message that from that lecture that you did, for example, what’s the main takeaway that you want dentists who have enjoyed the listening to your journey, but also how we can look out for things in our patients, how we can support them, and how the saying when you can’t connect the issue, think connected tissue. What’s the main message that you want to give to the general dentist? [Audrey] All the medical history is relevant. If we are aware of connective tissue disorders, we can make our lives much easier. ‘Cause we know those patients are gonna need a couple of minutes more chat on the phone before they come in to get them less anxious. We can make it much easier for us when we’re doing the local, we might pick up that it’s not going to work, it’s just gonna make our lives much easier. If we know we are also going to make the patient’s life’s much easier and those patients are gonna be so delighted, so loyal, we’re just gonna make it so much better. We also have to remember, Jaz, I have had many, many of our, let’s call them practice staff come to me after watching my clinics and say, Audrey, I think I’ve got this. I was trying to figure out how many practice staff I’ve picked up. We’re probably talking about 50 or so people who come to my lectures. There’s always people afterwards that contact me saying, Audrey, this is me. So we need to see everything is relevant. It was last week I had a 26-year-old man in with really hypoplastic sixes. That’s very likely Ehlers-Danlos, he was anxious, he was depressed and he had gastric reflux. Now, if somebody had picks up those, I dunno why anybody hadn’t sorted those hypoplastic sixes, but I was taking one of them out. He was educated, he was at whatever else, but nobody had said. Listen, I think maybe something’s going on here. Luckily the local anesthetic worked, so I think it’s just be aware and if we can, I’m not saying everybody needs to pick up every case, but this is gonna be life changing. All these patients, I see it’s absolutely life changing. [Jaz] I think it’s important because before dentists used to be very much tunnel vision, the tooth, and we’ve grown so much as a profession away from that. And so now we are incorporating sleep disorder breathing. And screening for that, we’re a stop back and in generally steep, in general, we helping to manage patient’s anxieties and this is one facet of it, right? Looking a reminder, a really helpful reminder today to look at the patient as a whole and connecting the systems together and helping to speak about health. A wonderful thing to speak about health ’cause who’s not speaking about health to patients? The general, the GPs, because they’re seeing when the patient has a problem, they’re speaking about that problem or one or two problems. We have a great opportunity in dentistry to speak about their health in general, and you know what? I think that makes our career more fulfilling. [Audrey] What I would say about the GPS is. As somebody that works privately, I can have as long as I want for a patient. I’ve heard you say before you have 75 minutes for a TMD patient. If a GP is listening to this they are wondering, how can they manage on a 10 minute appointment, so I really, really feel for the GPs, but I listen to the talk from the very nice per girl who, I can’t remember her name, obviously. [Jaz] Rena? [Audrey] Rena. She has bought a, was it a hba one C meter? [Jaz] Yes. [Audrey] How wonderful is this? Because all of these things tie in with everything we’re doing, you know? I’ve started asking for hba one Cs whenever I can for patients because it is also relevant, whether it’s a burning mouth or, and also vitamin D levels as well. And I know this has said a lot in your podcasts, Jaz, we’re all thinking along the same lines and I’m so glad you contacted me, jaz, and I am so glad we’ve got a chance to spread the message and a chance for all those guys to get to know each other and maybe work together. [Jaz] Well, thanks for joining the community on Protrusive Guidance. It’s been great to have your contributions on there already. And also thanks for making us all vulnerable today in this episode. Honestly, thank you for doing that. That really is- [Audrey] I appreciate that. [Jaz] A real, real pleasure to to hear your story. Thank you for sharing that with us. ‘Cause it’s gonna inspire so many of us and I think to continue to pedal that health message. I think this podcast has been so good and eye-opening. And this might then trigger a chain of events to help us help, get that health message across to our patients. Talk more about health to our patients. Do some further learning for me, I mean, you’ve been incredibly helpful in terms of getting me to think more about my own health. And what’s more precious, valuable than that. Right. So, hoping everyone enjoyed that. And Audrey, I appreciate your time. [Audrey] Pleasure, Jaz. A pleasure to come on and chat to you. [Jaz] I will put all the resources in the show notes, so your video, any links. So basically if you just send me a mega bundle and so I just don’t miss anything and I’ll put it in the show notes. So in Spotify they scroll down, YouTube rather. They can find your lecture, they can find any goodies that you think will help dentists. That will be one. [Audrey] I want to say to any of your listeners if they have any questions, whether they’re personal or work related, please my email is hello@oralsurgery.scot, if you just Google me, Audrey Kershaw, you’ll find me. Please, we’re here- [Jaz] Also on Protrusive Guidance so you can DM you as well and that’d be great. [Audrey] So pleasure guys. [Jaz] Thanks so much all appreciate you. [Audrey] Take care. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. Slightly different theme of the podcast. So for some of you who love the clinical details. You may have not loved this episode as much and that’s, that’s totally cool, right? But I think the vast majority of you really would’ve loved Audrey’s journey because this is an oral surgeon, really, she wears her heart on her sleeve and she really made herself vulnerable and shared so much. So thank you so much again, Audrey. And dentists were humans first, then dentists. And you may be able to recognize things about your journey, about your life and your health. Anytime we can talk more about health that conversation that we have with yourself about looking after your health or the conversations we have about health with our patients. It can only be for the better. So if you’re watching or listening to this episode on the app right now, scroll down. You could download the premium notes, you could download the transcript. You can download all the goodies that Audrey promised, and of course, answer the quiz. Get 80% and you get your CPD certificate, like you’ve done all the hard work, you’ve listened all the way. Why not get that certificate now to prove you’ve learned something? It also gives you opportunity to reflect, which is important for your personal development plan. Yes, all this requires a subscription, but I think it’s genuinely one of the most valuable subscriptions going in dentistry, especially if you listen to every single episode. Or most episodes, it just becomes cost effective for you and you help to support this podcast and help it grow. So if you wanna join our best plan, that’s the Ultimate Education plan. You’ve got all our masterclasses as well. The easy link for that is protrusive.co.uk/ultimate, and that’ll take you to the right page. Thank you once again for listening all the way to the end. Catch you same time, same place next week. Bye for now. Oh, and of course, thank you to Team Protrusive. Without the team, I would be lost and I would’ve quit podcasting four or five years ago. So thanks so much for Team Protrusive and of course, thank you, the listener for helping spread the word and helping us to make dentistry tangible.…

Protrusive Dental Podcast

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Pascal Magne on Occlusal Veneers and Material Selection – PDP221 1:26:44

for 16 dager siden1:26:44

1:26:44

Can composite really outperform ceramic in the right case? Do you know when to choose an inlay over an onlay? What makes occlusal veneers so effective — even at just 0.6 mm thickness? After years of anticipation, Dr. Pascal Magne finally joins Jaz Gulati on the podcast for an episode packed with adhesive dentistry gold. They dive deep into occlusal veneers, material selection, and why indirect composite may be the best-kept secret for worn, root-filled molars. They also unpack the full bonding protocol step-by-step—from air abrasion and IDS to silane application and cementation with preheated composite. Whether you’re doing full rehabs or composite repairs, this episode is your go-to guide for smarter biomimetic dentistry. https://youtu.be/WTsF1mD-nTo Watch PDP221 on Youtube Protrusive Dental Pearl: After applying silane, don’t just let it evaporate—let it react for 30 seconds, then air dry, and crucially, use a heat source (like a hairdryer) for 60 seconds to activate it properly and achieve optimal bond strength. This enhances the effectiveness of silane and significantly improves the bond strength of indirect restorations like composite or lithium disilicate. Key Takeaways: Occlusal veneers can be as thin as 0.6 mm. Indirect composite is often a superior choice for restorations. Proper bonding protocols are crucial for successful restorations. Focusing on strengths rather than weaknesses is key in dentistry. Conservative approaches in dentistry can preserve tooth structure. The vital tooth is always preferable to a non-vital tooth. Composite resin has wear properties similar to enamel. Occlusal veneers provide excellent protection for compromised teeth. Porcelain veneers have long-term durability compared to composites. The evolution of composite materials has led to better options for restorations. Zirconia is strong but difficult to adjust and bond effectively. Immediate dentin sealing is crucial for successful bonding and patient comfort. The Dahl principle allows for minimal preparation in certain cases. Composites can be as effective as ceramics when used correctly. Understanding the properties of materials is essential for successful restorations. Thin occlusal veneers can be successfully bonded with proper techniques. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 0:00 Introduction 02:52 Protrusive Dental Pearl 04:42 Dr. Pascal Magne on His Current Focus 10:16 Understanding Cusp Coverage and Material Choices 15:48 Conservative Approaches in Dentistry 23:16 Unsupported Enamel: Can it Still be Reinforced? 28:05 Occlusal Veneers Indications 37:00 Material Selection: Composite vs Ceramic 01:24:42 Outro Referenced Studies – all below are available to download on Protrusive Vault in Protrusive Guidance Effect of immediate dentine sealing on the aging and fracture strength of lithium disilicate inlays and overlays Short-fiber Reinforced MOD Restorations of Molars with Severely Undermined Cusps Ultrathin CAD-CAM glass ceramic and composite resin occlusal veneers for the treatment of severe dental erosion Strains in the marginal ridge during occlusal loading Antagonist Enamel Wears More Than Ceramic Inlays Outcomes of resin-bonded attachments for removable dental prostheses Performance of ceramic laminate veneers with immediate dentine sealing Keep the learning going with Magne Education If you enjoyed this episode, don’t miss A Geeky Discussion on Adhesive Onlays – that’s PDP161! This episode is eligible for 1.25 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcomes B and C . AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Indirect restorations) Aim: To provide clinicians with evidence-based guidance on occlusal veneer indications, material selection, and conservative restorative protocols—emphasizing the role of adhesive techniques and biomimetic principles in long-term success. Dentists will be able to – 1. Differentiate between inlays, onlays, and occlusal veneers, and select the most conservative option suitable for each clinical scenario 2. Make informed decisions on material selection based on occlusal anatomy, antagonist material, and long-term clinical performance. 3. Assess the biomechanical behavior of composite vs ceramic materials, including their effect on stress distribution and enamel wear Click below for full episode transcript: Teaser : An onlay is always going to make the tooth stronger than an inlay. However, the chances of catastrophic fractures with an onlay are bigger than with an inlay. And I know it's not unanimous, some of my colleagues, they don't like the fact the composite has a lower elastic modulus. But again, you have to understand a non-vital tooth is a handicapped tooth. Teaser: So the damping affect the damping behavior of this occlusal volume of composite in our studies actually proved to protect the remaining tooth structure at the level of the root. With the occlusal veneer, there’s no need- Element of biomimetic dentistry is to say that the restoration should be allowed to fail in order to protect the tooth. Zirconia is the opposite. Jaz’s Introduction: It finally happened. Finally got Dr. Pascal Magne on the podcast. If you remember episode 100, I was in Edinburgh at the BACD in the queue to get my book signed by Dr. Magne. And I said to him, please, will you come on the podcast one day? And that day finally came a few years later than I wanted, but we finally made it guys. And let me tell you guys, you are in for a treat. We’re talking about occlusal veneers. How thin can you go? Like think of a lower molar that is worn and is spawn into dentine possibly because erosion and attrition and you don’t have much space and you don’t really wanna prep so much, we can go as thin as, let’s say 0.6 millimeters. And what if I told you, you can do it in indirect composite? And that’s probably in many cases, the preferred choice. At the end of the podcast, we discuss the exact protocol of bonding and indirect composite which actually is also gonna help you if ever you’re doing a composite repair, how to bond new composite to old composite. Now we covered so many geeky adhesive and restorative themes, like why not use zirconia? Why is indirect composite a superior choice, especially for your root filled molars that need cuspal coverage? Which is interesting because I have been doing lithium disilicate for many years thinking that composite was like a cheaper option, was like a second rate option. Actually, Dr. Pascal Magne says that if it was his tooth, he’d want indirect composite. Well, you are in the right place to find out why he said that, and also why we should not be so aggressive in capping cusps. Hello, Protruserati. I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. If you’re returning again, thank you so much for being a Protruserati. If you are new to the podcast, you picked a really good one. I’ll tell you what all our podcasts are awesome, thanks to the wonderful guests we have on, so please don’t forget to hit that subscribe button if you like what you hear or see today. Dental Pearl Every PDP episode, I give you a Protrusive Dental Pearl, and today’s one is of course inspired by Pascal Magne and an adhesive protocol tip. The tip is when it comes to the silane step, that step is so critical in whether you’re bonding an indirect composite or an indirect ceramic such as lithium disilicate. Once you’ve done the correct surface preparation of your indirect restoration, so that’s different for composite, which you’ll hear at the end, and that’s different for ceramic. And once you get into the silane stage, here’s what you don’t do. You don’t just apply silane and leave it on the side to let it evaporate. No, you want to let it react for 30 seconds, then you want to air dry it. But then you want to use something like a hair dryer. You need to use some hot air to achieve the perfect layer and the perfect chemistry of your silane. And this surface preparation with silane, such a critical step that it makes a huge difference in the bond strengths you can achieve. So makes your guys that you are air thinning your silane, and then you’re using some sort of a heat source to achieve that optimal layer. And you’ll hear about the the geeky justifications and the steps for this towards the end of this podcast. Do not go anywhere, guys. You’re gonna enjoy this a lot. And remember, our episodes are eligible for CE. This episode is worth 1.25 CE credits, and we are a PACE approved education provider on our platform, which is called Protrusive Guidance. The website for that is protrusive.App. That’s www.protrusive.App. You’ll have access to over 350 hours of CE. This includes the podcast episodes, but also our mini courses and on demand webinars, which are thoroughly enjoyed by our members. So we’ll remind you at the end how to claim CE for this episode and all the others. Let’s now join Dr. Pascal Magne to dive deep into occlusal veneers. I’ll see you in the outro. Main Episode Dr. Magne, we had that mentorship session about, I don’t know, six weeks ago or something, right? And I didn’t tell you this at the time. But I only slept for two hours that night ’cause my baby was up and he was very sick the whole night, right? And I was exhausted the whole day. But I knew that I was speaking to you and my wife could tell that there were the energy levels. As our call was coming, my energy levels were rising again. And it was so great to spend that hour and a bit with you. And it was so great to see you in London last week. You’re an absolute inspiration. You’re a man who needs no introduction. Like you, your legacy is so much in academia. You are the author of a most fantastic book, and- [Pascal] Thank you. [Jaz] It’s a great pleasure to bring you to the Protrusive Dental Podcast. How are you feeling now that you’ve done a little mini tour of Europe and back home now? [Pascal] Yeah, I’m good. I’m great. Back to Europe very soon, actually, in a few weeks with the Barcelona, two days lecture there, but I’m good. I’m good. I travel a little bit less than in the past because now we focus on our center here at home in Los Angeles, Beverly Hills, more precisely. Our new center, Magne Education, where I try to focus on hands-on education. We have also online education. We have a whole bunch of programs, and you see, this is my focus, but I still travel, let’s say. Approximately eight times a year overseas for lecturing and different things. Yeah. But otherwise, it’s great and exciting to be a dentist in those new times. Amazing technology coming out. Artificial intelligence. [Jaz] You make it exciting, Dr. Magne, honestly, with everything that you’re sharing, you honestly have that effect. I’m sure you hear that all the time. Today we’re talking about something very cool. Occlusal veneers, like I’ve done injection molding posteriorly. I have never done these ultra thin occlusal veneers, so I really want to learn a lot more about them. And before I dive in, just as part of the introduction, I wanna just heart to ask you this one thing, because you’ve done so much in academia and now you’re running your training center, which by the way, just looks spectacular. I hope to visit you one day there as well. Do you miss the academia? [Pascal] Yes. I have to say there are some aspects of academia that I miss more than others. [Jaz] Let me guess. Your students? [Pascal] My students. Exactly. So, my students, I consider them like my babies. And I’ve had so much satisfaction teaching. Really teaching is what I like doing the most. Sharing knowledge. Of course there is research, but I still do research a little bit less than before. But, research was also a big part of my academic life, so having visiting scholars from all over the world to join. So I consider them also my students. So yeah, these things, I miss a little bit. I don’t miss the politics and the committee meetings and all the things, I think that’s what’s beautiful with aging. To try something positive, to try to find something positive about aging is when you’ve been successful, you end up choosing more what you like. And discarding what you don’t like. And again, with age, you come to do more and more. What you’re good at and less and less what you are not necessarily good at. And that’s always my advice to the young generation is to focus on your strength. Because you will never be good trying to improve your weaknesses. You will never be as good as developing your strength. And that’s what I think maturity is bringing you to do more and more what you are really good at and less and less the stuff that are more distractions, you know? [Jaz] It’s like niching down and we talk about that on the podcast a lot about and finding your niche. Have you ever read this book called Strength Finder? [Pascal] Exactly. That’s where I’m getting my inspiration. I actually did a whole retreat. [Jaz] Oh, no way. [Pascal] Actually, with my wife, because the goal was to develop the strength in our relationship. So we both did the strength finder assessment and then based on that, to try to put our strength together and coming to the conclusion that if you have the same strength actually is not an advantage. It’s better to have different strength in different areas and put them together as a couple. And that’s what we learned at this amazing retreat, which was interesting because we did that through the church, but we had to do the strength finder assessment, which I really recommend to everybody. [Jaz] Me too. [Pascal] If you don’t know yet your strength, but you should by now, you should know what you’re really good at and it’s the same with the left and the right side of the brain. You remember when I was in London? We talked about that. Some of us are more analytical, temporal, and then some others are more creative, and we have to put that together in the best way possible. And it’s called balance, right? It is like an aesthetics left and right. Left and right side of the brain have to be in balance. [Jaz] I love how you made that connection with taking it full circle. Once again, a great lecture in London last week. Today’s topic is a hot one, occlusal veneers. But before we get to that, I wanna talk about more of a daily scenario, and then I guess we can evolve into occlusal veneers. I bet one of the most common questions that you get asked all the time is Dr. Magne, when I’m doing an overlay on a lower molar, let’s say it has an MOD amalgam, let’s say it’s root filled, and you’ve decided that you will be cusp capping the buccal and the lingual. How much should I do my occlusal reduction for my restoration? i.e. How thick should I have my lithium disilicate? [Pascal] So we’ve studied that quite extensively. And to be honest with you, it’s a very difficult, even with the science, it’s a difficult question to answer because it’s a little bit. I like there, there were a few original studies by a fellow in Holland called Fennis, F-E-N-N-I-S, Fennis, and I got a lot of inspiration from his publications, and they were about overlapping, this is not overlapping, a cusp, which is the everlasting debate, right? When to overlap, what’s the residual thickness of the cusp that should be overlapped or not. And dentist, we are very analytical, so we want recipes and we want to say, okay, if the cusp is this amount I should cover is this amount, I can’t keep it, et cetera. And things are not so mathematical as it appears. And let me tell you why. Because we know that the biggest variable in any procedure is the operator and not necessarily the material. Okay? There are choices we have to make with materials and we’ll talk about that. But still, when I look at research articles. The problem I have is, let’s say there’s an article about overlapping versus, oh, not overlapping cusps, weakened cusp cracked cusps, and they are using a different bonding protocol than my protocol. They are doing an inlay, but without immediate dentine ceiling versus an onlay, you know? And now you are not comparing what is actually what you are doing clinically, right? So that’s why for a lot of those research we had to do our own investigations with our own bonding protocols. Because as you know, it’s all about the protocols and how strict you are with your bonding protocols. And there are so many ways of bonding today. And there are, maybe, I don’t know, it was like 10, 15 years ago, we counted like over 100 dentine bonding agents on the market. I’m sure it’s much more than that today. And most of them are poor products. [Jaz] Wow. I did expect you to say that. Wow. [Pascal] Yeah. There’s only a certain, a limited amount of adhesive that have a proven long track record. And so imagine your question is diluted in this whole approach. And what’s going to be, you see, for instance, there’s a good study by my dear friend Marco Gresnigt and still in Holland. I tell you the dentist, some of the professor in the Netherlands are really good. They ask the right questions and I follow their research. And Marco is also one of my students in the sense that he came to my lab to do some of the research about veneers. And I contributed also to his articles about onlays. And he was showing clearly that if you do an inlay with immediate dentine sealing, this inlay will make the tooth as strong as a an onlay without immediate dentine sealing. You see what I mean? So the stronger you bond, the less those decisions are important. They are equations in adhesive dentistry, like the stronger you bond, the less important your preparation. The less important is a choice of overlapping versus not overlapping a cusp. The stronger you bond, the thinner your material can be. The stronger you bond, the weaker your material can be. The stronger you bond, the less you need retention, resistance form. And today there is all these materials because there’s not only the question inlay versus onlay, but then there is composite versus lithium disilicate versus zirconia versus all of this. So the question is huge. And I would like to say personally, I could pull out articles that say, bond well and you can do inlays even in non-vital teeth. And articles that say, no, no, an onlay is always stronger than an inlay. And in general that is true by the way that an onlay is always going to make the tooth stronger than an inlay. However, the chances of catastrophic fractures with an onlay are bigger than with an inlay, you know? So when you overlap a cusp, you make the tooth stronger, but when is going to fail? In case of overload, in case of overstress and there is a crack that will initiate, this crack will more likely end up progressing subgingivally. And rendering the tooth much more complicated to re restore, right? So your question is more like, choose your poison, in other words. An inlay more conservative, maybe less strong, but more re restorable. And that’s where I stand personally. Just as a personal story, I have a two teeth in my mouth and both upper maxillary molars that had big MOD amalgams, they are very likely the tooth you were talking about. And, I have not an ideal bite like most of the dentists, right? We strive for the best bite for our patient, but we don’t take care of our own bite. I’m class two with overjet and stuff and no anterior guidance but guess what? I don’t have a single root canal treatment yet in my mouth. And to me, that is the victory. That is the victory, is to have all your teeth vital. Because we know that the vital tooth is always a winner, and the non-vital tooth is always a loser. And what I like to say is, if you have a non-vital tooth, you cannot win the Olympic Games of restorative dentistry with that tooth. It is a handicapped tooth. So the goal is really to prevent that first root canal treatment is to prevent that first crown, is to prevent and be conservative. So just to be honest with you, I would always choose an inlay over an onlay because I can always do the onlay later. It’s like I will always choose a direct composite over a more invasive preparation. Then I can do a more invasive preparation. So we realize that you always wanna have one solution left after, right? And you don’t wanna be in this place where, what do you do after the crown usually is extraction if you have already a root canal, et cetera. So that’s why we stop doing those invasive preps. And I know that, you know, and social media is opening so many windows on what is happening in the world with your question precisely, which is onlay versus inlay. And when I see so-called biomimetic dentist advocating cusp, aggressive cusp coverage in a way that you end up cutting off intact tooth structure more than you would for an occlusal coverage of a crown, then I would never call that biomimetic anymore. So then there is the topic of thickness of the cusp. So when is it that the onlay is unavoidable? When is it that the only is unavoidable? For me, for the only to be unavoidable, I have to have extremely severe signs of suffering of that cusp. When you see the occlusal surface has been really beaten down, the enamel is already cracked and crumbling apart, you have cracks going underneath the cusp, visible on the outside of the tooth from the inside to the outside. Those are signs that okay. I have to consider the onlay. Now, the thickness of the cusp to me is rarely the reason to be honest with you. Because we’ve done some research about super compromised cusps and very thin only enamel left. But when you do immediate dentine ceiling. And you restore the cuspal thickness with your buildup. And nowadays we know our latest research is about fiber, short fiber, reinforced composites like ever X. When you use those material to give back the thickness of the cusp, then you new thickness if you want, is the one after the buildup. And now you can restore that. You can fill in those undercuts. You can make that cusp strong. Even if you have to wait for this inlay to be processed. Whatever is your technique, maybe you have to wait for 10 days or two weeks that buildup with immediate dentine ceiling, using the right product, using the right protocol will make that cusp strong enough for that interim. And then the final strength given by the bonding of your inlay. So back to my story. I had two MOD amalgams on my first maxillary molar that became sensitive because of cracking inside the dentine. So cracked two syndrome, enormous pain in biting air, cold, warm. Anything would hurt. And I was like, okay, my time has come for my first root canal. No, we bonded it. We did inlays actually back then. I of course said a colleague of mine- [Jaz] Indirect inlays. Yeah? So ceramic inlays. [Pascal] Yeah, indirect inlays. They were in composites. I made them myself on a fast setting silicon model. And one was a silicon model, one was a stone model. Anyway, I did my inlay with my regular clinical composite. Nothing fancy, but a hybrid material. Micro hybrid, nano, hybrid style. Back then, it was 25 years ago, and more. And so, and that was bonded. And guess what? 25 years later, both teeth are still vital. And I am, again, if you see these occlusal surfaces, I’ve still kept wearing my teeth. I will be ready soon for my occlusal veneers. But you know, I’m 59 and that may be the next step. Let’s not burn the steps. That’s my problem today is when we go straight to the invasive solution and my old mentor, Dr. Belzer, always told me, you know, Pascal, you always need to have a solution left at the end. So don’t burn the steps. Don’t go too fast and people ask me all the time, ah, this aesthetic is, should I do composite resin direct or ceramic veneers? Well, if you are asking, that means start with the composites. You can always do the veneers later. And same thing. I look at social media today and sometime I feel bad for those patients who received 10, 12 veneers. Now the first molar also veneer then like a 12 pack of veneers when that could have been the next step. Not now. Not as the first restoration on those teeth, you know? And so we need a lot of wisdom when it comes to those decisions. So I know it’s not a short answer to your question, and maybe it’s not an answer at all, I don’t know. But I would always choose the most conservative solution first, knowing that a failure of that solution will most of the time allow you to still perform the next one. So a failure of your- [Jaz] That gives it justice. ‘Cause we can’t just give a number sometimes. Right? And you made a great point that, and you taught me this last time in our mentoring session as well, that the inlays that are well bonded, following a good protocol, they will significantly reduce that cuspal flexure. And we don’t necessarily need to cap those cusp. So for me, that was really good to hear. My only worry is if someone takes that information away. And what do you feel about the situation they’re presented with is that the enamel is like, by the time you move the caries and the old amalgam, the enamel is now unsupported. There is the full thickness of enamel where there’s no dentine. Are you still okay to reinforce it with fibers and IDS? [Pascal] Absolutely. Yes. Yes. And actually, one of the studies we did about Ever X was about really totally undermining the cusps and using Ever X to build back the missing dentine. Short fiber in force composites are the best dentine replacement today because of their fracture toughness. I think the team of Dr. Pekka Vallittu in Finland, in Turku, they did an amazing job in establishing a standard for the size and shape of those fibers. You know, what they did is really because, by the way, a short fiber-reinforced composite is nothing new. In the nineties, there were at least two materials that I know, Alert and Restolux. They were short fiber in force material, but the fibers were chopped so short that the fibers were acting more like a filler rather than a fiber. And Dr. Vallittu and his team, they came up with this formula where they say, when the fiber is 70 times longer than the diameter, then it’ll behave like a fiber. And so that’s the value they established for their first product, which was EverX Posterior. And we tested this material. I was totally surprised by the results and this material. But then the thing is, with this size of fiber, the material becomes a little bit viscous and you would have to preheat it to place it. And you could actually not mix it, but combine it with flowable composite so that the areas, and if you have a complex cavity with lot of little extensions and stuff EverX posterior might not go everywhere there. So you wanna line first the preparation with a little bit of flowable composite. Now they have EverX Flow and EverX Flow, by the way, is the only version we have in the US. The officially EverX Plus is not sold in the US. It’s approved by ADA, but not sold. So if you combine EverX Flow to fill the bottom of your preparation and you can leave it un polymerized and then use EverX posterior preheated. It’s easier to place and you have a wonderful dentine replacement with the material, the fibers of which will act really as a reinforcement. And to me, I would favor that over continuous fiber. I’ve never been a big fan of continuous fiber. We tried it, we did some research. We could never get the result we got with the short fiber. And it’s simpler to apply. [Jaz] Do we have any clinical data to back this up of using short fibers to replace the dentine and then having that unsupported enamel and now supporting it with the fibers. Do you have any clinical longevity data? [Pascal] Yeah, absolutely. And the Turku team actually, they have clinical data now. They are even looking at the next step, which is using, because the flowable material with the very short fiber, the flowable material. The thing is they did a compromised. They made the fibers smaller and shorter. So now the fiber length by diameter ratio is a bit less for EverX flow, it’s only 30 instead of 70. That’s why the material flows more, but there is more fiber inside. And what it is, it makes the material always almost polishable, which is really amazing because of course you would never use EverX Posterior to the surface of the two. But EverX flow might be possible to use. All the way to the surface, and they are investigating that. So yeah, the reasons are extremely encouraging where yes, we need more clinical result, but it’s coming. And honestly, I’m very confident based on the in vitro result we got with this material. I really see no reason why the clinical results should follow the same trend. And I think that this is making a huge difference. Now, back to your question, how those inlays are being prepared, the base liner, what adhesive system you use, all of these are very important parameters in addition to your own hand, right? So we have to be careful when we read any research article that we are considering all those elements together. [Jaz] Excellent. And now we can move towards the main topic which is occlusal veneers, right? So what would you say is, are there indications for occlusal is because we said now that in that made up scenario of the lower molar with the MOD amalgam, that actually what the lesson to learn from, from when you answer that is try to preserve the cusp where possible, unless it’s looking like it’s stressed. And just on that actually, if it is stressed and you are gonna cap it, how thick do you want your lithium disilicate over that cusp. [Pascal] Right, exactly. So that was what we studied in a number of studies, especially with my dear ex-student and friend and now colleague and professor Luis Schlichting , who is from Brazil, but now teaching at the University of North Carolina in Chapel Hill. And with him, PhD actually, topic was that questions, how fit we can go with those veneers and depending on the material. So we started with in vitro data and we did a lot of experiments using different materials from composites to Empress, cAD, Emax and even some fiber in force composite at that time. But anyway, so we went from 1.2 millimeter down to 0.6 millimeter with those venues. And what was really fascinating, because this series of experiments followed another series of experiment when the teeth were non-vital, and we are doing like thick onlays, like three millimeter occlusal coverage on non-vital teeth, simulator tooth, that it’s really been beaten down. The cusps are already gone. And you do more like endocrine type onlays if you want. And those Endo-Crown type onlays, whether they were in ceramics or composite, we were able, according to our load protocols, we were able to break them. And we have a load protocol that’s well established. We start loading those teeth at 200 Newton, then we go 400, 600, 800, 1000, 1200 Newton. We keep ramping the load until we have a failure, right? And usually, I think we went to 12 or 1400 Newton, and then we stop and we see how many teeth survived. Well, with a non-vital teeth and those different onlays, we never had teeth surviving the test. However, with the occlusal veneers. Guess what? We had all the teeth surviving the test, all of them with the same load protocols. We could not break them catastrophically. And that tells you why. Why? Because in the other group of experiment, the teeth were non-vital. The teeth had lost a lot of structure. We were dealing with what I told you before is called a handicapped tooth. A nonvital tooth with a lot of structure lost. So this tooth starts the race really with a huge handicap. The occlusal veneers, we did them on intact wisdom teeth with the molars with a minimum reduction. So the main coronal structure was intact. Only the occlusal part was re substituted with the different materials. So result, because the main structure of the tooth was intact, the pulp roof, the enamel dome and all that stuff was intact. The teeth survived. No catastrophic failure. Not even a fracture of, let’s say, a piece of the occlusal veneer coming off. The only thing we observed- [Jaz] So that’s why I wanted to ask. I was saying, did the restoration failed, but the tooth survived? But you’re saying actually the entire complex survived. [Pascal] The entire complex survived. The only thing we were observing was cracks in the restoration cracks. And we always considered the cracks more than three millimeters because less than three millimeters really, nobody will see them necessarily. Okay. So this is amazing. So this is the first message for you, whether the veneer was 1.2 millimeter down to 0.6 millimeter, the only thing we could see were cracks. And what was surprising in this case is that the ceramic, even Emax, had more cracks than the composite veneers. So this was really surprising. The composite occlusal veneers, thin ones displayed very little amount of cracking. [Jaz] Now with the composite then that’s very fascinating. But this is a different beast. I just want people to understand that. Would you have expected the same result? If something like genial injectable was used in a direct technique and then cured through like a stent, but because you’re using an indirect composite, that that gave it a more superior mechanical properties. Would you expect the same result from a direct? [Pascal] No. Direct composite is a different animal. Direct composite is light cured in the mouth. The degree of cure is not as good as a CAD/CAM milled occlusal veneer like the ones we did. So the degree of cure is less, is less dense. There’s porosities, there is imperfections. And actually we also tested that in the previous group of studies with endodontically treated teeth. So, by the way, in those studies about thick onlays on endodontically treated teeth, the winner was very clearly the composite. And I like to say on an endodontically treated tooth, I like the idea of having the composite act as a stress absorber. And we had like this effect of absorbing the occlusal load by deformation and protecting the root structure. So with the ceramic, we had more of a stress transfer straight into the root and more subgingival fractures also. So I like the idea of the composite, and I know it’s not unanimous. Some of my colleagues, they don’t like the fact the composite has a lower elastic modulus. But again, you have to understand a non-vital tooth is a handicapped tooth. So the damping effect, the damping behavior of this occlusal volume of composite in our studies actually proved to protect the remaining tooth structure at the level of the root. With the occlusal veneer, there’s no need of such a protection if the tooth is pretty intact. Like say I’m talking, we talk like a tooth that maybe had a root canal, like just a little axis occlusally, but the endodontist, and then you were asking me, what are the indications, right? So a typical example is the patient went to endo as an emergency. What do endodontists do? They reduce the cusp immediately to prevent fracture, and now you are missing like half a milimeter of enamel on that cusp, maybe more. And that’s where the occlusal veneer is fantastic. Now you have- for patients who might not be able to afford an occlusal veneer. You could do also what I call an addictive composite. You can extend the composite over the cusp and if it’s well bonded and it’s thick enough, it’ll serve the patient well for many years. And I’ve done that in- [Jaz] But it has to be thick enough. Therefore, if the endodontic has just shaved it half a millimeter, then you’re gonna have to then shave it down a bit more. So what thickness of the composite are we looking for in this additive? [Pascal] Yeah. When I meant, thick enough, I meant in the central aspect because where are those restorations going to fail? Mainly, in the central groove. And so you wanna be very careful. You see, that’s another element that makes the question tricky is about occlusal anatomy. So when you have a very deep mesial distal groove, there is more chances of the tooth splitting than when you have strong marginal ridges. And strong transverse ridges. So when you build your anatomy, it’s very important to reproduce those structure. And so that’s why we know that. And there’s lots of study by a fellow from Australia and or New Zealand. They called Messer, M-E-S-S-E-R. And they were actually also in Minnesota when I was doing my PhD there. And they show that if you have intact marginal ridges on a posterior tooth and you have an endo. Preparation and endo treatment, but the marginal reaches are intact. You need nothing else than an occlusal composite because of the remaining structure protecting the tooth. But it might be that the endodontist has reduced those cusp and in that case you could extend the composite or you could do an occlusal veneer. The occlusal veneer definitely will be a little bit of a plus in terms of protection and for the choice of the material. That’s another important decision you have to consider occlusion and antagonistic wear. So if the tooth facing that onlay is a natural tooth with enamel, I would always choose composite because you have to look, there is a very good study about wear of antagonistic cusps. So you have to look at the wear as a volumetric wear. That’s very important because most studies they measure wear, height of wear. And you have to understand, and I try to explain that in my book Depth of Wear is an occlusal property. Because imagine when you have a very, very pointy cus you will lose a lot of height, but not necessarily a lot of volume. When you have a wide cusp, you might lose less height, but still a big volume. So the depth of wear is an occlusal property. But what is characterizing a material is the volumetric wear. So when you look at this study and there’s excellent study by Kunzelmann in Germany, Kunzelmann, and they look at enamel wear against different materials, but they look at the volumetric wear and suddenly you see that enamel against composite. It’s 50/50. You will see 50% on one side, 50% on the other side, and the total wear, the additive wear of those two volumes is always going to be less than with ceramics. So if it’s ceramics, the ceramic itself will wear its itself very little, maybe only 30% of the total wear, but the 70% or more will be the wear of the antagonistic enamel. But the fact is that this 100% of volume loss will be much bigger than with composites. So when people ask me what is the most biomimetic material in general, I tend to say the most biomimetic material is composite resin. Why? Because composite resin has wear properties very similar to enamel and elastic modulus, which is the damping behavior of the dentine. So wear and damping behavior, and that’s what makes the tooth very unique. The enamel resists wear the dentine is a damping structure to absorb the deformation. You see, you lead the Protrusive podcast, right? Your topic is occlusion. So this is modern. I call this modern gnathology. It involves biomaterials. Understanding that occlusion is not just cusp touching occlusion is the biomechanical response to occlusal stress. And that involves how the tooth, the forms under load. Imagine implants. Now, implants is a bio mechanical challenge because there is no damping behavior except for the supporting bone. And that’s why there are some studies that says, oh, short implants are great because they have more flexibility because it’s shorter. It gives a little bit more deformation, right? Now that’s not necessarily good for the bone, but it’s good for the occlusion because it gives a little -. I always say myself, if I needed an implant one day, I would have a composites in crown on that implant. Because we measured that the damping behavior of a composite crown makes that implant respond biomechanically similarly to a tooth with a PDL and intact dentine, et cetera. So back, I know it’s a lot of- [Jaz] Before you continue though, just the thing that’s going through my head, Dr. Magne is, how many dentists in the US and around the world, they see composite as a second grade material. And actually, I’m just, while you’re talking, I’ve gone back to a podcast I did three years ago, it was called Composite Veneers versus Edge Bonding. And we talked about biomimetic dentistry with a very talented British dentist called George Cheetham. And one of the comments was the words biomimetic and composite do not belong in the same title. [Pascal] That’s interesting. [Jaz] And so there are these strong opinions that everything has to be lithium disilicate. So it is very fresh to hear your views. [Pascal] Yes, yes. So my statement was not against ceramics. ‘Cause there is a room of course for ceramics and when we speak about porcelain veneers, for instance. There’s no doubt that nothing can beat porcelain veneer in the long run. When I see my patients 25, 30 years later, the ceramic still looks great. I cannot say that about the composites. But again, it’s about respecting the steps and I think that in young patients, adolescents, why would you do veneers in adolescents? This is a nonsense to me. You can unless it’s a very, very bad, severe problem, general dysplasia of enamel, malformations, severe fluorosis or stuff like that. Otherwise, you can handle a lot. But still, even those cases, you could handle them with composites. But there is room for both, you know? But yes, it is true that my original book was called The Bonded Porcelain Restorations. Because at that time I have an absolutely outstanding collaboration with the best ceramist in the world. My brother and we had this amazing synergy and by the time I wrote the second book for different reasons, but one of them was the university not allowing us to work together as brothers because of the trade, basically politics there. I ended up having to do much more work by myself using composites and that’s why my second- [Jaz] Indirect composite. Just to- [Pascal] Indirect and CAD/CAM. Also CAD/CAM composite. And I guess our research group was one of the first to really go deep into the investigation of CAD/CAM composites when CAD/CAM composites were still used, were still called composites. Nowadays, companies call them hybrid ceramics and nano ceramics and this and that. And they are still fighting the stigma of what you said, which is composite is not biomimetic composite is a very poor brother in the field of restorative dentistry, ceramic is the normal- [Jaz] A poor man ceramic as they say, a poor man ceramics. [Pascal] And now what do you see? You see that here, I think the definition of ceramics was upgraded. Like you will not believe that. I don’t know if you’re aware, but anything that has more than 51% in content of ceramics can be called a ceramic, which means all are composites. According to this new definition. And I believe it’s the even for the coding, because the company is what they wanted. They wanted insurance to pay for a composite crowns especially now that we have printed composites. Right? So the goal is to have those composite crowns being covered by insurance. And so just put 51 plus something percent ceramic content. I believe it’s in weight. I believe it’s in weight which is even worse because the volume would be even less. And volume would be 40 something and, and then you have a ceramics. And so the thing is, this is important. I’m glad you raised that question. You know what happened in the eighties? In the eighties, a few companies wanted dental technicians to use composite resins. And in order to make those laboratory materials, companies, thought technicians are used to take a brush and ceramics in form of the very fluid paste and put on the teeth. And so they said, we are going to make the composite feel like that, which is a flowable. So they made flowables and you were maybe not born in those days, but there were a few materials that were complete disaster. One of them was called Targis and Vectris by Ivoclar. It was a fiber in force framework covered with flowable composite. There was a material called SINFONY by 3M. There was different material. They were designed to feel like porcelain, but they were flowable composites with less filler, more diluent in the resin, which is more shrinkage, less wear resistance, et cetera. And so these created and influenced all the data, clinical data, especially produced about composites made in the lab because those materials behaved really badly. The flowable composites are not designed to be definitive restoration, so they ended up hurting the scientific pool of data about laboratory made composites. Nowadays, composites are back in form of CAD/CAM material, which is much, much better. Of course, now they are highly filled, viscous, because they are made in the factory, they can be heat cured under pressure. So they are really better. And so this revival took time when 3M came with the first composite block, which is part of the material we studied for the occlusal veneer studies. And we had amazing result. Jaz, you will not believe the composite, those ultrathin Z 100, it was called Paradigm Z 100. The name of the block was the first composite block. They had no commercial success. 3M was actually not even selling the material in Europe, I think only in the US. And this paradigm, Z 100 composite never made it really as a commercial success, but we studied it a lot. Dr. Kunzelmann in Germany studied it a lot, and the results were amazing because it’s a spheroidal zirconia filler nano hybrid. Well, back then we called it micro hybrid spheroidal, but very rare resistant, strong, amazing. But guess what? The stigma of the eighties about composites did not make this material kind of make the cut. And so the manufacturers decided to switch, approach and call those material ceramics. And the first really of its class was Lava Ultimate because remember what material from 3M is called lava. Lava Zirconia. 3M had a zirconia material, I don’t know if they still have it to us, called Lava, and they used the name Lava for the composite resin, which is basically a new formulation for Filtek material that they came up, you know, during the nineties and they called it Lava Ultimate, the Composite, but they called it resin Nano Ceramics. So they tried hard. Now we have a new problem, and the new problem is the printed materials. Because the printed materials have low filler content, they have barely above 50% so that those material can be sold as a crown material and reimbursed by insurance, but they are not as good as the CAD/CAM materials, and this is going to hurt until we have highly filled printable material. And there’s a first step that’s been taken by sprint tray with a new system called Midas. I don’t know how you call it, in the UK which has 70% of filler content, so that’s good. It’s not yet as good as CAD/CAM composites, but it’s a first step and we hope that it keeps developing like that. But meanwhile, I’m afraid that a lot of dentists are going to use printed material as a definitive restorative material for inlays, onlays crowns, and it is not going to go very well because of the properties of those materials. Personally, I promote printing and for mockups and provisionals, and things like that, which is amazing when you do full mouth rehabilitation, when you have to open the bite deprogram the patient printing those onlays and mockups is amazing. That’s the best use you can do of, of it. Okay. So- [Jaz] You talked about wear and that’s what went into the composite and you spoke very highly of the fact that that’s where the volumetric sort of wear is less with composite. And then we mentioned that, you gave this history about why composite has a bad rep, but actually it shouldn’t be the case. It sounds like if you, God forbid, tomorrow lower right, your lower right molar has an amalgam and then you needed a root canal, that your restoration of choice for your molar may be a indirect composite just Yes. Based on what you’re saying, right? [Pascal] Yeah, sure. Absolutely. [Jaz] Now, back onto occlusal, ultra thin occlusal veneers. Zirconia the elephant in the room, the wear of that when you read the data, when it’s like highly polished zirconia. It can be quite kind to the enamel. [Pascal] Absolutely. That’s true. So that’s one of the thing with zirconia, because of the structure and it’s so smooth, the wear is not bad at all. Okay. So, but the problem with zirconia is different. The problem with zirconia is it’s extremely difficult to adjust, and I would say it might not as predictable for bonding. So you need MDP. MDP will be highly sensitive to hydrolytic degradation, the bond. So, when you bond ceramics, we do two things. We do etching and silane and there’s synergy in there. With zirconia, you don’t have that synergy. It’s only a chemical bond with the MDP. And so you have to use cements that have MDP, like Panavia or specific zirconia primer. You could also use CoJet and or, which doesn’t exist anymore, but like CoSil, or SilJet from Danville, and you could silicote the zirconia and then use silane. I just wanna tell your audience here, don’t use silane on zirconia. It’ll not help. It’ll not do anything unless you silicote the zirconia by air braiding it with silicated sand like CoJet CoSil, or SilJet , et cetera. If you are not doing that, the silane is useless. The only monomer that will be useful is MDP. It’s a phosphate monomer that’s going to covalently bonds to the zirconia, but again, that bond is susceptible to hydrolytic degradation. So you are making your life a little bit more complicated. I would like to say, when people ask me about zirconia veneers mm-hmm. What I tell them is, if you are used to take your restoration and drop it on the floor, throw it against the wall, step on it, and make those kind of things, then zirconia is perfect for you. You have more chances to have an intact restoration to bond. But if you are careful with your restoration, you really don’t need zirconia because the strength is going to be obtained by the bonding and it’s the story, my dear friend Roberto from Italy, had this funny way of saying it. He said, bench test versus the restoration on the tooth is like the story of the helmet and the wool cap. If you take a helmet and you drop it from the top of a bridge and you let it crash at the bottom there, it’ll break in in pieces, right? You take a wool cap, you, you drop it from the top of the bridge. The wool cap will go down and float down, and you take the wool cap, it’s intact, right? So you would tend to see the wool cap is better. Of course, the thing is there is a head together with the hat or with the helmet, right? So a bench test means nothing. So you can have 700 mega pascal of flexural strength. But that’s not going to help. And actually, like my mentor, Dr. Douglas was saying, those super strong material, they make the inside of the tooth become hyperfunctional. And that the stress that’s not absorbed by this part is going to go near the margin, into the deeper structure. So we are back to the discussion about the cusp if you want, right? What is stronger, stiffer, always better. The answer is no, because something will have to give at one moment. And you want the restoration to give, not the tooth, right? And like I was telling in London, this is one of the biggest element of biomimetic dentistry is to say that the restoration should be allowed to fail in order to protect the tooth. So zirconia is the opposite. It’s never going to fail because it’s so strong by itself, but it’s not going to necessarily protect the tooth from failing. And it’s a difficult technical material occlusion adjustment, contact adjustment. [Jaz] Well, the issue there is when you do an occlusal adjustment, you’re losing that highly polished, you’re now getting a rough zirconia. And then you have to impose the polish again. [Pascal] Exactly. And you affect the properties of the material too by doing that. [Jaz] And you get micro cracks- [Pascal] And it is very complex. And I think zirconia is really, I would consider zirconia mainly for bridge work. That’s where you have connections, but this is not biomimetics anymore when you are replacing a missing tooth. And I have to tell you, I have huge respect for the works of Matthias Kern in Germany. Kern, who published so much about resin bonded, fixed partial dentures. And the long-term results, with simple panavia on zirconias and one cantilever pontic, and the results are fantastic, I think. Many patients in a young age especially should be given that before an implant and look at the implant later. You see, it’s always the same principle of wisdom. Let’s do the simple stuff first. We can always make it more complicated later. And when we see with implants, the problems are long, long term. I mean, if you place an implant in a patient in his twenties or thirties, what is going to happen after they are 50, 60? This is big because those implants don’t move. So if it’s a single implant, you can expect some possible problems and that’s why I would try to delay. I always say, if you can wait after age 40, 45 for an implant, that’s better. [Jaz] I totally agree. And I also vouch for, huge fan of resin bonded bridges, and especially for lower incisors. Why would anyone do an implant for lower incisor? It’s just when you have great success with resin bonded bridges. Now, back to occlusal veneers. One indication, which you kind of touched on when you mentioned about. The printed materials being very good for those interim and mockup and provisional rest scenarios, which it makes complete sense, but also when you have the wear patient and you are opening the vertical dimension and they have maybe mostly anterior wear and then their posterior is not very worn, therefore you have that lovely enamel. Now you open the vertical dimension and classically, what someone may do is. They may drill the cusps down to give them the correct thickness of the traditional thickness of occlusal veneers. But nowadays we can go very thin, as you’ve said, with the occlusal veneers. So you can do minimal prep or no prep. How thin can we go with either indirect composite and or ceramic? [Pascal] So, according to the studies with Dr. Schlichting, we went down to 0.6. Right? So those were the minimum. But then we have a manufacturing limitations, right? Less than that, it’s going to be extremely difficult to have clean margins. And so my question to you would be, when you are getting that thin and the teeth are in good shape, you just use the DAHL principle, you don’t restore them, you know? So in your side of the world, this is actually very well known, right? It’s much less popular here in the us. Still a number of dentists who never heard the name DAHL here. [Jaz] And many lecturers in the US who really frown upon it, they see DAHL as a very sloppy orthodontics. They see it as a sloppy way whereas we love it here. We are big proponents of it. And same as Scandinavia, you know? [Pascal] Absolutely. Yeah. So to me, for localized anterior bio corrosion and wear, there’s no doubt that DAHL is my go-to most of the time. If posterior teeth do not show any signs of suffering and corrosion or wear, you let them come back together. And I always say, I don’t do DAHL, I do micro DAHL or sometime even nano DAHL, because when you look at the original studies in the seventies from DAHL, they were opening those bites enormously and the patient were hold open with fixed metal appliance, like resin bonded bridges type and they were the posterior teeth were left to extrude like millimeters, literally. I do like tens of millionaires of passive, eruption and that goes very fast. It’s a few weeks, a few month at most. And that allows you to just open like a lingual space to place, or direct composites if you have just the notches. Sometime you have those tight, I call those the tight bites, right? So you get free of a tight bite by opening the bite or, and deprogramming. Then you place the composite there to hold the bite open while the DAHL principle is happening in the back. To me, this is the most, the best kept secret in full mouth rehabilitation. And if you deprogram, you open the front, there’s a gap in the back. You look at this gap, if it’s a big gap, you can restore or you can still do DAHL if it’s a small gap, you can do DAHL or small, tiny direct composites. So I’ve done low cost, full month rehabilitation with that technique which is amazing. And so localized anterior wear bio corrosion. That’s my go-to approach. Now when it’s generalized, now you have to look at the anterior relationship because some cases. So if you have a ideal, when you have generalized wear, bio corrosion, very severe, generalized, you might end up in a class three situation, right? Because when you lose height quickly as you can imagine, a class one becomes a class three by the movement of the mandible, right? So these cases are very easy. You just open them, you recreate anterior, overjet and you restore it. When you have a class two, in those cases, that’s when you have to be a little bit more careful because if you deprogram you make the class two worse. And so some of this case might be really indicated to open the by without the programming so you don’t make anterior relationships worse. And so that’s why you have to be careful with those cases. But when there is major damage in the posterior, those are perfect indications for occlusal veneers, and as you asked me, yes, we can go down to 0.6. [Jaz] So yeah, 0.6. But, so here’s my new knowledge for me. So my understanding is 0.6 on enamel, but in that scenario of the generalized worn dentition, let’s say there is a dentine exposure posteriorly, are we still comfortable in having 0.6 millimeters of composite or ceramic on the dentine, which behaves differently to enamel? [Pascal] Exactly, and that was the situation. By the way, in the studies we made with Dr. Schlichting, we always exposed the dentine completely occlusally. We were only with a rim of enamel, but the dentine was completely exposed. So guess what I’m going to tell you about this question. My answer will be if you do immediate dentine sealing, and I’m going to be totally clear on that, if you do IDS correctly with the right product, and my golden standard is OptiBond FL for many, many different reasons. If you do IDS correctly with Optibond FL, we find that basically. You are like an enamel. And so that parameter disappears for me. When you handle dentine bonding correctly, which is with immediate dentine sealing, you are in a full enamel situation and we can see dentine basically disappeared. The moment you do ideas correctly, dentine disappears. You are in an enamel only situation. Patient will not have sensitivity anymore, and you can bond your onlay as you would do if the preparation was only in enamel. That means you clean this prep by air abrasion. Etch. You can etch the entire surface. Etching is not going to affect the IDS layer and then apply fresh adhesive and your luting composite. And by the way, Jaz, you see that’s another thing when we are talking about those thicknesses. In our studies, not only we used IDS, but we bonded those thin onlays with a highly filled restorative material. We used a restorative composite as a looting agent and you can find those articles with Dr. Gresnigt that we co-published where we looked at the strength of thin Emax veneers, anterior veneers. Not posterior veneers, but Emax on full dentine preparations. And if you do IDS and you bonded them with a highly filled restorative, that will be really a difference compared to bonding them with RelyX veneer or, Variolink Esthetic or things like that, which as I told you, they are not as strong because they are flowable. For a material to flow, you have to pay a cost, which is the filler content or the quality of your resin matrix. So those highly filled materials, we preheat them. And we use them as cement. [Jaz] And can you give an example of which composite to use? ‘Cause there’s different thicknesses and you can’t get the thinness enough. [Pascal] Yes. Not all those composites are created equal. And the problem today is because of the nanotechnology. The nano fillers by themself make composites very viscous. And in order to fight that problem, manufacturers have to include pre polymerized filler complexes in the material. Those are bigger chunk of composites of it’s pre polymerized filler. It’s made of the same filler, but it’s pre polymerized ground and included to decrease the viscosity of those highly filled nano hybrid. Those pre polymerized fillers can be very big up to 20, 30 micron. Those material will never work as a cement because those chunks are too big, right? So you have to use more traditional micro field. And in a recent article in the Journal of Aesthetic and Restorative Dentistry, we published like tests about what material will do a decent thickness, film thickness. And amongst those you have Gradia Direct, you have Transcend by Ultradent, you have Filtek Z2 50. Very surprising. You have APX by Kuraray. You have ENA HRi by Micerium and there’s a bunch of product. But also we notice that some material may become more viscous when you hit them too long and some product for. Unknown reasons to me have heat initiators, and one of them is APX. APX will work as long as you don’t hit more than five, 10 minutes. I would say maximum. After that, it’ll start to become more viscous and it seems it’s because of the present of a heat initiator, which I don’t understand to why there would be a heat initiator. [Jaz] I mean, you’ve covered so much and so thank you so much and it’s really nice to hear about indirect composite and these views about it being a second rate material, it really needs to change with the data that we have at the moment. So with that in mind now, could you just describe for our listeners, the step-by-step protocol of the thin occlusal veneer comes back, which is, let’s say a CAD/CAM composite, the try in and the risk of it, let’s say breaking, doing try-in, checking the occlusion. Should we check, should we not check? And then the actual steps to bond that in as our final question. [Pascal] Yeah, so you always have to keep into account the fact that when you try the restoration, are you going to try just the fit or are you going to test the occlusion? So we did some publications about that. And of course there is always a risk of breaking the restoration if you let the patient bite. So with thin ceramics, it’s a little bit more tricky than with thin composites because composites, again, has this flexibility that the ceramic doesn’t have. So you wanna be extremely careful when you do these tests. One thing that will help you a lot is immediate dentine sealing. And do you know why? [Jaz] No. Go for it. [Pascal] Because when you do IDS, the patient doesn’t have sensitivity anymore. The dentine is sealed is desensitized. So you can test your restoration without anesthesia. And if the patient is not anesthetized, as you know very well, the proprioceptive response is much higher. They will less likely bite strong when you test the occlusion. So, IDS will actually be the most important element. You don’t need to anesthetize and your patient is much, much more sensitive to the occlusion and to the biting, and you have less risk of breaking that restoration during the try in. So that’s important. But in general, the beauty is with composite resin, if the bite is a little bit off, it’s so much easier to adjust than with lithium disilicate, or even worse with zirconia. So it’s not going to be that of a big deal. If it’s a little bit off with composites, it’s going to be a little bit more complicated with ceramic, with zirconia because then you have to repolish and repolishing in the mouth is a little bit more labor intensive for those ceramic materials. So in general, I would say yes if it’s an onlay as we talk, if you look at our studies, you will see that. Interjection: Hi friends. Just interjecting here. One thing I asked Dr. Pascal Magne, there was an error with a video is, is there a difference in trying in composite versus trying in ceramic? And does it matter if it’s an inlay or an onlay? If you take inlays trying in the mouth, a ceramic inlay is a safer bet than trying in a composite inlay, you’re more likely to break the composite inlay than the ceramic inlay when you’re trying it in. Of course, you have to be careful in either scenario. Now, when it comes to the onlay, interestingly, you’re more likely to fracture the ceramic onlay and the composite onlay is a safer restoration to try in with the occlusion. Why? Because it has more give, more flex. Back to the episode [Pascal] Because it’s an extra coronal strengthening inlays will very likely break at the isthmus between the box and the occlusal surface, especially when you have a very strong, a narrow isthmus like that between the box and the rest of the occlusal. If you have a little high marginal ridge there, that’s when you have the like the most risk of breaking it. So you have to be careful. But here my answer is immediate dentine sealing will give your patient much more sensitivity and then composite resin will be much more forgivable when you do those triads. [Jaz] And so rubber dam and just, are you gonna air abrade the intaglio of your CAD/CAM composite? [Pascal] Yes. So CAD/CAM composites, they need to be treated like an aged composite. Basically when you repair composites, you have, if you repair a composite that you did recently, you just air abrade leave it wet with adhesive resin. If it’s a composite that’s been in the mouth for six months a year, then you have to air abrade with CoJet, silanate and add adhesive resin. So those materials, CAD/CAM materials, because they’re highly polymerized, you have to treat them like a repair. So what I like to do is to air abrade them, I would preferably use CoJet. You can use aluminum oxide, but I will preferably use CoJet to maximize the effect of the silane. And then you use the silane and the silane you have to be careful because this is where there’s a lot of misuse of the silane. The silane has to be placed for no longer than 30 seconds wet and then air dry. You never let the silane dry by itself. You have to air dry and heat dry the silane because when the silane reacts with the filler in those composites, it’s going to develop equivalent bonding and one molecule of water is going to come out of this reaction. It’s called a condensation reaction, and that water has to be evaporated along with the alcohol, which is the solvent used in the silent solution. So the hot air is going to make a big difference in the reactivity of the silent, in the covalent bonding, and the hot air is going also to increase the inter layer cohesiveness when you have too much silane on the tooth, which is almost unavoidable. The silane, ideally you would like one layer, one monolayer with each molecule aligned like a little soldier with the hydrophilic part against the restoration, the hydrophobic part against the adhesive resin. But you have more than one molecule. They are stacking on each other and the use of the heat will increase the cohesiveness between those layers of excess silane. But when you leave the silane in excess dry by itself for 60 seconds, for instance, then you create a huge excess of silane. And then more excess means more problems with the cohesiveness of those layer. The good use is when you heat dry, the silane, you increase the cohesiveness between those layers. You improve the performance of your silane by two times according to an old study by my dear friend and colleague, Jean-François Roulet. So the heat drying of the silane is very important. And then when you use preheated restorative material, it’s very important to wet the restoration with adhesive resin. For my part, I use the second bottle of OptiBond FL. So the tooth is air abraded and etched resin coated with OptiBond FL bottle number two. Unless you notice that you have missed some dentine, in that case, I would apply the primer. But if there is no dentine exposed because you did such a good IDS, you don’t need the primer. The second time. So etch, air abrade etch, rinse, dry, apply adhesive resin, no polymerization you don’t need. And then on the restoration you do your air abrasion. Preferably with CoJet you can use aluminum oxide, 30 micron, at low pressure, and then CoJet if possible. And then you apply the silane for 30 seconds. Air dry, heat dry for one minute, and then adhesive resin unpolymerized. And then you use the preheated composite as a cement. That’s how we did in our study where those occlusal veneers were unable to fail if you want, because of the extreme strength of the bone. In the other study about the non-vital teeth with the thicker onlays, what was really amazing is IDS was so efficient that when those onlay broke, the fracture went from the restoration into the tooth straight. There was no failure of the bone. And we took the teeth. Actually, when I said none of the teeth survived, it was wrong. With the composite resin onlays, like, which was Paradigm Z100, we had a number of teeth survive. And when we took those teeth that survived our very demanding occlusal pounding after the test, and we measured the dentine bond strength, the value was still as it was originally in the unfatigued teeth, which is about 57 to 58 megapascal. Remember, the dentine enamel bond strength, biological bone strength is around 50, 51 Megapascal. So, I’m not telling you we are better than God, but when the bond is so good, the higher the bond, the less it’ll degradate. So you wanna start higher than the dentine enamel junction because it is going to go down. It is going to go down. It’s unavoidable, but the rate of degradation will be less when your original number is very high. If you start at 58, maybe one year later you lost, maybe at worst 10%, but when you start at 35, 1 year later, you lost at least 30%. And that’s one of the study by Van Meerbeek demonstrated the meta analytical review of all the adhesives studied on the market. It was about 10 years ago. Number one was OptiBond FL, number two was SE bond with the- Also not only the highest bond strength, but the best stability of the bond. [Jaz] Amazing. Well, I’m gonna summarize this episode in four sentences. Number one, above everything preserved tooth structure ’cause that is the biomimetic way. Number two, good quality bonding protocol will allow you to do that and allow you to be a biomimetic. Number three, the importance of IDS and doing that well and how imperative that is for these protocols. And number four, the use of indirect composites for, in all these scenarios, especially for root filled teeth. Thank you so much Dr. Magne, for spending the time with me. It has been a dream to bring you on the podcast. That dream has now been realized and that honestly, I’m so, so happy to know you and to have this opportunity. Please, can you tell us about the upcoming courses at Magne Education? I know you have so much going on. We’d love to know. [Pascal] Yeah, yeah, absolutely. Thank you for this opportunity. And yes, so, we are trying to serve everybody with our courses because I know that for some people they are more local. They travel easier. Some countries it’s really difficult to travel, get visa and travel organization can be a nightmare. So we have online programs for that. It’s called Press Room, and we offer Press Room the two most common language in this world. Well, actually I’m wrong. I should learn Chinese maybe, but it’s English and Spanish. So we have Press Room once a month. It’s a program of 10 sessions, 10 month, and we cover really the essentials of biomimetic restorative dentistry. We have like usually 70 minutes, 75 minutes of presentation, and then we have question answers for at least 20 minutes. So it’s really nice, it’s interactive and if you miss the day of the live. You can watch it recorded inside our intranet platform. We have a great, by the way, website. We spend a lot of energy on this website, which is the intranet, the portal. And in the portal we have forum discussions and stuff for each course. It’s really nice. So then if you wanna visit us, we have our hands-on courses and one of our flagship courses called The Continuum. This is our mini residency, five time, three days, and we again cover from aesthetics and morphology all the way to the advanced bonding technique and veneers. And then we have what we call summer school. So we have, usually we do two semesters of those continuum courses, and then we have summer school in between, which is extra courses. And in those extra courses, we talk more about customizing your CAD/CAM restoration. For instance, you have a chairside CAD/CAM system and you wanna mill your veneers and you wanna be able to maybe even customize your Emax by yourself. So with a little cutback and micro layering. So this, we teach in a course called CADPlus. And then we have our extra wear course, which is full mouth rehabilitation of the worn bio corroded dentitions, using, again, occlusal increase of the vertical dimension and stuff like that. And how to sequence and your treatment plan in a way that’s going to be very easy, very common sense using printed mockups or analog mockups. I still love analog, but we wanna be surfing the wave of technology. And now with printing, it’s amazing. I’m a huge fan of exo cad. I am learning exo CAD very fast because I think it’s an amazing tool for digital approach. And so we will teach exo cad printing and full mouth rehabilitation. This is CAD, where it’s a three day course and we have other stuff that- [Jaz] That’s the one I wanna come to the most. [Pascal] Information is available on magneeducation.com and Jaz, you did it yourself. One of my favorite thing is what we call mentoring. And, you can book with me, one-on-one time like we are doing now if you want. And that’s called the mentoring program. It’s also available. [Jaz] I will put the links to that, including Magne education in the show notes. So it’s easy for you guys to find. I highly condone it. I mean, everything, every time I’ve seen you speak, you just come back energized Edinburgh, London. And I really want to come to your full rehab course one day, especially as I’m not doing many of these printed restorations. I’m new to that area, so much to learn. So I’ll put all those links and I just wanna say thank you so much for everything you do. [Pascal] Thank you. [Jaz] With the knowledge to this world. Thank you. [Pascal] Thank you, Jaz. It’s been a great pleasure and God bless you and the Protrusive podcast. We love you. [Jaz] Thank you so much. Well, there we have it guys. Pascal Magne, it happened and it was awesome and I’m really hoping you enjoyed it. Loads of gems in there. Look, this is one of those episodes where you need the premium notes, our premium subscribers can access the PDF transcript and the premium notes where we kind of summarize everything in an easy to digest way. And what that serves to be is like a rocket for your learning. Like I know you pick so much up from this episode, but why not increase that retention of information to allow you to apply those techniques to harness the power of the knowledge? And that’s where our premium notes absolutely shine. Check out one of our paid plans if you’re interested in that. And the way to access it is www.protrusive.App. Now, top tip visit on your browser, ’cause that’s how you can access the one week free trial and the best price. Once you’ve made your login, you can then download our Android or iOS app and then use your newly made login credentials. If you’re not already on there, it’d be great to have you in the nicest and geekiest community of dentists in the world. And another one of our mottoes is Fall in Love with dentistry. Again, it’s easy when you’ve been practicing for many years to eventually get disengaged with work. And what I want my legacy to be with Protrusive Guidance is to allow you to engage with your geeky side, allow you to enjoy your dentistry, allow you to be scientific and proper about your dentistry, whilst having fun and satisfaction knowing that you are doing the best for your patients. You’ll also get access to the Protrusive Vault where I’ll put all the papers that Dr. Pascal mania mentioned. I mean, what a guy, please check out all his educational stuff. I’ll put those links to his courses below. So scroll down and you’ll see them. And thanks so much once again for listening to the end. I’ll catch you same time, same place next week. Bye for now.…

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Communicating Fees, Treatment Plans and More – PS015 51:26

for 22 dager siden51:26

51:26

What is the number 1 communication advice for Dentists? Are you confident in discussing treatment fees with your patients? Do you struggle with communicating your worth without feeling awkward? How do you shift your mindset to charge what you’re truly worth without feeling guilty (a money mindset issue)? https://youtu.be/vapDrnVqHRw In this enlightening conversation, Jaz opens up about his own struggles with money mindset and how he overcame them to confidently charge for his dental services. Joined by dental student Naveed Bhatti , they explore the challenges of pricing treatments, offering empathetic solutions to patients, and using the power of visualization to boost confidence in fee discussions. They also dive into the importance of being transparent with fees, managing discounts, and recognizing your true value as a dental professional. Whether you’re new to the field or have years of experience, these strategies will help you navigate the financial side of dentistry with ease and confidence. Key Takeaways Communication is crucial in dentistry, often more than clinical skills. Active listening is essential; avoid interrupting patients. Nervous patients may talk excessively; guide the conversation gently. Patients may withhold information due to fear or anxiety. It’s important to make treatment recommendations based on patient needs. Asking open-ended questions can help gather more information. Experience builds confidence in patient interactions. Being authentic while adapting to patients is key. Patients can sense when a dentist is confident or insincere. Building rapport leads to better patient relationships. Kindness is essential in patient interactions. Patients often reflect the values of their dentists. Effective communication can bridge the gap between jargon and patient understanding. Long-term relationships with patients enhance trust and satisfaction. Discussing fees requires confidence and transparency. Visualization techniques can improve communication skills. Empathy is important, but it should not compromise business integrity. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 01:46 Introducing Naveed Bhatti and His Journey 02:53 The Importance of Communication in Dentistry (Do’s and Don’ts) 08:13 Handling Nervous and Quiet Patients 10:51 Dealing with Patients Who Don’t Tell the Whole Truth 14:35 Making Treatment Recommendations 17:56 Asking the Right Questions 21:36 Balancing Professionalism and Personal Connection 25:49 Handling Difficult Patients 31:38 Effective Communication with Patients 35:05 Discussing Treatment Fees with Confidence 40:25 The Power of Visualization in Dentistry 48:56 Concluding Thoughts and Future Plans Support Nav’s YouTube channel, The StuDent If you enjoyed this episode, don’t miss out on Think Comprehensive – Communication Gems with Zak Kara – PDP010! This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC Outcome B . AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS Aim: To enhance dental professionals’ communication skills by exploring effective strategies for patient interaction, treatment planning, and fee discussions—ultimately building trust, improving patient outcomes, and boosting confidence in everyday clinical practice. Dentists will be able to – 1. Recognize the importance of active listening and body language in patient communication. 2. Explain treatment options using patient-centered language and analogies that promote understanding and buy-in. 3. Discuss treatment fees with clarity and conviction, addressing money mindset barriers and building perceived value. Click below for full episode transcript: Teaser : If you ask seven dentists, you'll get 12 opinions. You see what I mean? Right. So firstly, okay, you must appreciate that there are so many opinions out there. Every dentist will give a different opinion, which is absolutely mad to just remember. But then remember that when a patient comes to you, they're coming to you, they're seeking your opinion. Teaser: They’ve selected you either by a geographical convenience or recommendation or whatever. They now ended up in your chair, right? So, all you are ever giving them is an opinion. That’s it. Okay. Here’s the stupid thing, Nav, right? You say to a patient 120, and they’re still gonna be like, oh, 120. That’s too much, right? And they didn’t even know that was one 50. You just counted it. The worst you could do is you give a discount, but the patient ever knows that you got a discount. That’s the worst thing, that’s the stupidest thing ever. [Nav] Well, I’m with you. Jaz’s Introduction: Patient communication is one of those things that you just don’t get taught at dental school, like a few other things. Again, not their fault. We always talk about it never being the fault of dental school. They just need to make you a safe beginner. But the kind of things we worry about once we qualify is how do we actually make a connection with the patient? How can we communicate fees with the patient? And just how do you communicate the patient’s options without coercing them into a particular treatment or trying to be salesy to a patient. These are all things I cover with Nav Bhatti. Now, Emma is doing her finals at the moment, so we wish her all the best. You got this, Emma. But I tell you this episode really packs a punch. We talk about body language, we talk about building rapport. We talk about patients that you just won’t get along with and how you should manage those, and how over time your patients become a reflection of you. And interestingly, we also discuss your money mindset. It’s actually important when you’re communicating with key paying patients. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the student arm, but I tell you, these episodes are not just for students, especially this one. Anyone who’s struggling with communicating fees to patients or anything around being a more effective communicator, I really think you’ll gain a lot from this episode. So make sure you listen all the way to the end. This one is eligible for CPD or CE credits. There’s only one place you can get that, and that’s on Protrusive Guidance. Please do download the app on. iOS or Android store, but to actually make an account, the best way to do that is on the website. That’s protrusive.app. You can try one of our paid plans, and I’m convinced you’ll love being part of the nicest and geekiest community of dentists in the world. Let’s now join Nav, who’s a dental student in Slovakia. As he asks some truly wonderful questions around patient communication, catch you in the outro. Main Episode: Nav Bhatti. Today’s filling in for Protrusive Student. Emma is doing her finals as we speak right now. We’re excited to grow this with you as well, my friend. Just remind everyone about yourself, my friend. [Nav] No worries. I’m trying to fill in for Emma for now, which is huge boots to fill by myself and a fourth year dental student in Slovakia of all places, which is a six year course. So I’m not quite at my penultimate year. But, we are almost there, so, it is going quite well. [Jaz] And if anyone hasn’t listened yet, we know we talked about your journey right, in a previous episode, and that was really cool. You inspired a lot of people, so please do listen to his backstory, how you went from country to country. And finally, you are still a little bit, few years away still, but your enthusiasm, your passion, your drive is amazing. [Nav] Thank you. A lot of it I must thank sort of Protrusive as a whole community. Your podcast. It kind of keeps myself and my colleagues sort of kicking, inspires us on a daily basis. I’m not just saying that for the sake of it, it genuinely does to see so many people out there supporting us on our journey is just amazing. [Jaz] And it’s been nice to also see your contributions on the Protrusive app. Like you took out some teeth recently, you saw some surgery recently, and you’re posting about that. So it’s great to have your student viewpoint. And of course today, probably in the title, this may not even be a Protrusive student episode because communication is communication. This is like the biggest thing in dentistry is far more important than your clinical skills. I’ll just say that right off the bat. Far more important than your clinical skills. So I’m excited to record this episode with you today and just any questions that you have in this sphere and to take it. So Nav, take it away, my friend. How can we help? [Nav] For sure. I think communication obviously is huge, as you quite rightly said, but for some weird reason, it’s just never taught. At university, you get all this theory, you get all this clinical kind of workload and they teach you how to do fillings and extractions and whatnot, but they never really get you to communicate with the patient effectively. So this whole realm, I thought, who better to ask than yourself? And kind of drill into it. So I think to start it off as a question, what are the typical do’s and don’ts as a top layer with patients when it comes to communication? And then I’d love to ask you more about sort of dental team and dealing with sort of tricky patients, but we’ll get into it, but if you don’t mind starting with that top layer, then we can go from there. That’d be great. [Jaz] Okay. So I have read a fair few book, smart communication over the years. One of the first books I read is like The Power of Body Language or something like that. So immediately when you said that, the first thing that came to my mind in terms of do’s and don’t, so guys like those listening, watching. Me and Nav don’t rehearse these questions that I don’t really prepare for. I just let them come and we just talk about it in a candid way. So automatically the don’t I that I think of is you are typing and your patient’s talking. Okay. Or even you are writing things, and the patient’s talking and your eyes are actually looking at the paper. Okay? So then you’re like, well, how do I record everything if the patient’s talking? Well, we’re at an age now. Maybe that was an issue. A few years ago now we use AI. I use Digital TCO, I use DAN to audio record and my nurse as well. So before it was my nurse. So I would be heavily relying on my nurse, kind of being a typist, like doing a complete transcript with what the patient says. So I’ve got a record of everything there. If I wanna look at it again to like bring, collect all my thoughts, but I’m really attentively looking at the patient and really making them feel like, hey, this guy really cares. He’s listening, and doesn’t interrupt. So the ultimate two don’ts of not to do is don’t have your back to them. Don’t have your eyes away from them. Keep your eyes on them. Face them, face them front on. And what I also want you to do is make sure you are genuinely an active listener and not really listening to respond. Because there was some sort of stupid stat whereby a dentist on average. We’ll interrupt the patient in the first five seconds of them talking. [Nav] Oh, one thing that I’ve got right, which you’ve definitely hit the nail on the head there in terms of interrupting, but I feel as though this is also linked to confidence almost. Now, forgive me if I’m wrong here, and correct me if I’m wrong, but I feel as though I probably do it and a lot of my colleagues do it, that when we do have the opportunity with a patient, we kind of blur and is that a confidence thing? Because we’re trying to collect all of our information, everything that we’ve been taught, and then we’re trying to diagnose and we’re trying to do everything at once. How do you like, put that in the back of your head and just relax and ease and as you said, just listen. Because there’s been cases, I’ll give you an example. Like there’s been plenty of times where a patient will say something and immediately your head as a student says, is that irreversible pulpitis? Or, I better start diagnosing it now, otherwise I’m gonna forget. So then you start asking questions like, is it pain when you get cold, stimulus is pain when you get hot. It’s like, shut up and just let ’em talk. But how do we as students kind of just ease off because it’s so hard to do, but what’s your best kind of advice for that? [Jaz] My advice for you, Nav, is I think you’re being very harsh on yourself, right? You are literally at a stage now where just like you said, you are consciously trying to collect those information. Like for someone who’s got more experience. It just comes naturally because they’ve done it. They’ve heard the patient a million times talk about this. If the patient walks in, they know the diagnosis already. Okay? So that is a very different position to where you are, where you are actually actively learning still as you are still conversing with the patient. So it is very tough what you’re doing actually, because you’re trying to make the patient feel listened to, but at the same time, you’ve got this million thoughts in your head and you are trying to figure out, wait, am I off the market? Is this correct? What’s the R stand for in Socrates, again? [Nav] Exactly. [Jaz] You know what I mean? So you are collecting your thoughts so don’t be so harsh on yourself. That’s normal, and I think that will come with experience. The more you do it, the more slick you become, the more fundamental understanding of dentistry that you collect. Your conversational flow will come. And so I think, I don’t think there’s a cheat code except you’ve gotta do your reps. And so, but the thing is that you are up already because you are actively thinking about that. And the fact that you are already, you’ve told the universe that you care about communication. You wanna become a better communicator in time. You will. I would say that now the best way to do it is maybe jot a few keywords down. Because obviously and where you are now, you’re able to access the kind of things I mentioned, but write a few key words down, but really focus on being an attentive listener. Having said that, I said that not interrupting the patient, but do you know Nav? What kind of patients will blabber and just cook and talk and talk and not give you the dentist a chance? Do you know what kind of patient? [Nav] That was genuinely gonna be where I was gonna segue into, because that is the next issue, is that if you shut up, sometimes they kind of feel as though. I gotta just keep talking. Yeah. Because is that the awkward silence? Right. And it’s like who fills it? Yeah. So what do you do with that? [Jaz] Well, let’s first identify a telltale sign. Okay. So when a patient is doing that and they say their bit, but they’re just going on and on and on and on, that is a classic sign of something. Can you think of what? Have you experienced this? [Nav] I’m gonna say, is it anxiety, maybe nervous? [Jaz] Absolutely. Nailed it. It’s anxiety. They’re nervous and they do that. So I’ve seen it time and time again. So if you recognize that sometimes what these patients, what they’re really craving for, they’re not telling you is that, hey, I feel listened to, but can you just take hold of me and just direct me? Okay. So for most people who aren’t nervous, I mean it’s normal to be nervous a little bit at the dentist, right? But for those who have manageable anxiety, then what I recommended first is good, let them speak and then have your thing. So ask open-ended questions first, and then narrow in on closed questions. So questions that you’re looking for, yes or no, that’s closed. But how was your journey? Today is an open question. Tell me more about your toothache. That’s an open question. Whereas is it the top left one that hurts, is a yes, is a closed question, right? So you wanna narrow it down. So later in the conversation as you’re starting to nail your diagnosis and they’ve given you enough information to feed on. But if they’re just going in a waver direction and they’re lacking structure and they’re kind of crying out for help. And so sometimes, depending on your rapport with a patient and how you feel this will go, is sometimes saying, hey, patient. By the way, look, I’m gonna just help to direct this conversation ’cause I think we’re really close now and I’m gonna help you just remind them. I’m gonna help you. But I just say, patient, how are you feeling? Are you nervous about being here today? And then sometimes they kind of like. Ah, yes, I am nervous. And they had the opportunity to just let you know about them and then what they’re craving from you at that point and say, hey, don’t worry. Me and my nurse are really gonna look after you. We’re gonna be really kind to you and then direct them. I think that’s a really nice touch to add to nervous patients. [Nav] Okay, and let me flip this for you. What about those that don’t talk enough? How are you gonna get that vital information extracted out of ’em? Because I’ll tell you now. I’ve had that issue before. People just don’t wanna tell you anything. I sometimes look at them and think, are they just scared to talk to me? ‘Cause they don’t want me to work on them. But surely you’ve probably come across the opposite ends. So how do you deal with extracting information when you need it? [Jaz] Listen, if the patient is not saying much, but they’re saying what a few words they’re saying, they’re very impactful and you are able to nail your diagnosis and you have enough and some people just aren’t very talkative. Right? And that’s okay. And that’s their personality type. Maybe they’re a quieter individual, maybe they’re introverted and that’s okay. But if you are still not getting enough, you then just need to probe more. And sometimes just give the silent and then raise your eyebrows and nod and invite them. Okay. And repeat back what they said. So you said this, but can you just please expand more on this? ‘Cause I just need more information about that to get my diagnosis so that I can help you. So keep waving the carrot. I’m gonna help you. So that I can help you, I just want more information. Can you tell me more about this? So you’re still keeping it open-ended. Tell me more about this. But then eventually you can narrow into the close ended questions. [Nav] Okay. I love this idea of like the filter of starting open and then just getting to your target point. That’s also, I’m gonna actually start using that a lot, so thank you for that. More so with my colleagues and myself as I’m talking as a group almost, but we are as a group coming across a lot of patients that are beginning to what we think, and this is assumption. Not telling us the whole truth. And we don’t know why. We kind of have conversed with each other and said, is it because they’re scared? Because they don’t want a certain treatment? Have you ever come across this? Is this like a common thing that people are not telling you the whole truth? ‘Cause maybe they don’t want an injection or they don’t want a feeling done, they’re just trying to lie to us to get out the chair. How do you overcome that? Maybe clinically you’ve noticed there’s something blatantly obvious, but then they’re like, nah, no, no, it’s not painful. It’s absolutely fine. But they’re flinching on percussion, let’s say, for example. How do you deal with that? [Jaz] Yeah, that’s a tough one. At the same time, you wanna be respectful to the patient and you don’t wanna disrespect them by saying, Hey, you’re not being true. But as House MD said, patients lie. Okay, so it’s a fact of life, and you have to kind of dig deeper into, okay, what do we think? And assumptions are not good. Assumptions are not good, but sometimes if we genuinely think the patient’s having us on here. We wanna find out what could be their motive. And I think if you encounter that scenario, be like, like let’s say you tap a tooth, okay? And the patient’s flinched, but they’re saying, no, no, it doesn’t hurt. Be like, well a patient, you know what? I’m just really worried for you because of the signs, you’re not telling me that it’s hurting, but it looks as though it should be really painful and so that can help you. Can you just really confirm that? Are you sure that wasn’t even a little bit? So sometimes you wanna just encourage them a little bit and explain. So a big theme of what I wanna discuss with you now today is one of my things, which most things I’ve learned in communication are always learned either from books or from colleagues or shadowing people. But this one I believe I probably got from Zak Kara, and it shows you are working out. And I just love this so much. Cause anytime I’m giving options to my patients or anything I’m explaining, I give them things like the background, how I arrived at this question, how I arrived at this conclusion. There’s this famous study in psychology whereby there’s a long queue back in the days when there used to be photocopiers, right? There was a long queue and these students were waiting to photocopy something, right? I think it might have been a Harvard study, right from memory. Anyway, so imagine there’s a long queue, okay? And then you’ve got something in your hand that you wanna photocopy. Now imagine you go right to the front of the queue, okay? You tap on the person who’s photocopying right now, or the next person actually, and you say, hey, can I please go in front of you? Okay? And if you say that. You’d be amazed that a significantly higher percentage of people actually surprisingly said, okay, fine. And they did it okay, but it wasn’t like really, really high. Okay? But then if you say, can I go in front of you because I need to photocopy? Now, obviously you need to photocopy. You got a paper in your hand and you’re going to approach a photocopier. But just by giving them a reason, it shot up like 93%, like it significantly made a difference in terms of the person letting you skip the cue. And so this is a psychological experiment. What it teaches us is, don’t just say something. If you actually give them a why, that actually matters a lot more. And that’s kind of the base of the show you’re working out. So for example, like telling someone that they’d benefit from a root canal potentially to save their tooth. Like, hey, I think for you, I think to save the tooth with a root canal is probably the best idea. I know it’s gonna take more time. I know it costs more, but the reason I came to this conclusion is that if you lose this tooth, you won’t have a bite on the left side anymore, and then you’ll be chewing only on the right side and over time that can cause its own issues. For that reason, I think we should do this rather than, hmm, I think I like to save teeth. Let’s do a root canal. It’s just giving them more context and sometimes you try to speak their language. [Nav] Yeah, I love that. I love that. I think that is something I wanna ask you about terminology, and if you don’t mind, just before I ask you that, kind of bringing it back a bit when it comes to almost offering treatments. I love this idea of giving the why, but is there like a fine line almost between doing that and almost pushing and encouraging people to take a certain treatment option? Because apparently that’s like a big no-no, right? Like we shouldn’t kind of just say you should do this, but you also have this option. How do you manage the wording for that? Especially when it comes down to being a professional dentist and then you’ve got so many legal issues involved. How do you word things correctly when you are giving options? But then obviously in your head you probably know what the best option should be for the patient. How do you present that? [Jaz] That’s a million dollar question. I love that because that’s something I’ve really tackled with and a big confusion area for me, and I think I’ve gained a lot of clarity over the years through experience and speaking to mentors and great people in communication, and I think we all need to remember, okay, that anything, so firstly, that’s all I remember. Whenever you post an image on Protrusive Community or anywhere you post it, right? I mean, I know actually the agreement rate in Protrusive is pretty high amongst each other. Okay. But even now, they all disagree with each other respectfully. What I like about our community is that we’re very respectful and disagreeing with each other, right? But you ask a dentist for your opinion, right? And if you ask seven dentists who get 12 opinions. You see what I mean? Right. So firstly, okay, you must appreciate that there are so many opinions out there. Every dentist will give a different opinion, which is absolutely mad to just remember. But then remember that when a patient comes to you, they’re coming to you, they’re seeking your opinion. They’ve selected you either by geographical convenience or recommendation or whatever. They’re now ended up in your chair, right? So, all you are ever giving them is an opinion. That’s it. And so remember, I know we’re very international people all over the world listen to this podcast, but our standards that we follow in the UK and I’m sure and we’re one of the strictest regulators in the world, right? GDC. So if it satisfies us, it probably satisfies where you are in your country, which is we are allowed and we should make a recommendation. It actually says in the standards, you should make a recommendation. And so we are allowed to make a recommendation. So you’re not saying anything wrong. You’re not coercing the patient, you’re not persuading them down a certain way by making a recommendation. But really the question really is the recommendation that we’re making, is it on a sound basis? And it should not be for profit. It should not be for your gain. It should genuinely be in the patient’s best interest. So if you’ve got five different options to treat a problem, okay, and you are not sure which one to recommend, that just means one thing. That one thing that means that you haven’t asked a patient enough questions. For example, you should ask a patient, would you like something removable? Or do you like something fixed? It’s like playing guess who? You know that game? Guess who? [Nav] Yeah. Right. [Jaz] Once you’ve asked enough questions, there’s like two dudes who could be, that’s it. And then be like, okay, well is this option or that option? ‘Cause you told me already that you want something removable because of the idea of a fix and you want something that’s gonna be on this budget and you want something as quick as possible based on that, it’s either gonna be do nothing or a denture. Okay, because of the fact that you told me that you’d like to choose steak. I think based on that, I would recommend the denture. It would cost this much. It’ll involve disappointments. The other option is to do nothing. But then by doing that option. This is the disadvantage, basically. And so I think that’s a very simple way to do it. Once you’ve figured out what the patient’s goals are by asking lots of good questions, it’s just like, guess who? You kind of know what to recommend and you are allowed to recommend. Yes, you should give the other options, including do nothing. But it’s totally fine to recommend and I think make peace with that. And all yours is, is an opinion and that’s okay. [Nav] I love that. Okay. So as long as that’s the case, that’s great. And I mean, one thing that you mentioned there is obviously about questioning and I think that is the way that we’re gonna get down to everything. But where’s the sweet spot? Or is this also an experience thing? Because surely, I’m guessing that you’ve seen this newly qualified dentists or even students like myself, we probably babble a lot and we probably ask a million questions and bore the patient or we ask for too much. What’s kind of the sweet spot? And I’m guessing is it only learned through experience or is there any kind of tips that you can give us there as always as to not overdo it? [Jaz] I think experience is a huge one, and your environment actually matters as well. And what I mean by that is when I started my career, like most dentists in the UK, I was in NHS practice, right? And so some days I’d see 26, 35 patients in a day. Okay? And now I see like one patient, it’s a holiday treatment or like eight patients or 12 patients. Do you see what I mean? It’s a different flow. And so you have to become very efficient in that practice, in interest practice. I’m not saying that that’s the best way or the worst way. I’m not saying either of those things. It’s just the way it is because you are catching targets. You are in a publicly funded environment, okay? And that’s how it is. And so that makes you think fast. That makes you be like, okay, well here’s the problem. Here’s my differential diagnosis. I’ve nailed my diagnosis. Therefore, the option of this, you become very slick at doing that. And so being in that environment accelerates it. And then the difference now is I use those same skills, but I really work on building a rapport with a patient so that they really feel listened to. And I get to actually talk to them through their radiograph. I get to show them their intraoral camera photos. And once they have that done, they’re just amazed because most colleagues they’ve seen before may have not done that. And therefore they come to you and they’re never going to wanna see anyone else ever again. Because the way that you explained it, the way how patient you were, how open you were to welcoming questions and the clarity in which you explain those options in their own language without using jargon was something that they’re always gonna remember. So it comes to experience in a way. So that’s the honest answer. It comes with experience, but you experience working in both those environments, a fast pace and a slower pace. And then sometimes you just use skills from either one. [Nav] Okay. So definitely experience. It seems like quite a lot of this is experience based and so at least it’s putting me in a good frame of mind that I’m not just completely failing at this stage. [Jaz] And now I’m like, let’s see, I am 12 years qualified now? Which is still a baby, in terms of the long career that we have, okay, so I take advice and I take the experience and mentorship from those who’ve been in the game for 30 years, right? And what they’ve all told me is that over time, maybe it’s the gray hairs or whatever, but like getting patients to agree to treatments, okay? And I say that in a way, not for profit, not for case acceptance and grossing and that kinda stuff. I say it in a way that when you recommend a treatment for their benefit, for their health that the patient actually values their health and goes ahead with it because that’s the best thing for them. So in that kind of frame, the dentists have said that either it’s because they’ve seen the patient for so many years, or just the way that the dentist now says it, right? When the dentist has so much experience, honestly, you don’t care if the patient says yes or no. It doesn’t matter, right? If you eat tonight or not, it will not depend on that, okay? And when you are not desperate for it, and you are literally just there as an advisor to the patient, okay? And you’re like, what would you like to do this over to you? How can I help you? Okay? When you come with that frame over time and you get those gray hairs and you get the experience and you’ve been there before, and I think patients can smell the confidence, okay? And so a lot of it will come from time. Maybe it’s ’cause one of the reasons I don’t dye my beard yet is ’cause I like the gray hairs. It shows a lot of experience and so maybe it’s just, they all tell me that, maybe it’s with experience that patients don’t have to try as hard patients actually just want to do everything you say because of you just having more experience. [Nav] Okay. You said their patients can smell the confidence. On the other end of the stick, can they actually smell the BS is all? And the reason I ask you that, there’s two types of people, right? There’s two types of, let’s say dentists for the sake of it, there’s those that have one personality and they’re true to themselves and they do it with everyone. And there’s the chameleon, right? That’s doing a bit of everything because they’re seeing the patient and they’re adjusting according to. What’s your advice on that? Because again, patients aren’t thick, right, and they can figure things out. So how do you approach that? What would be your advice around kind of personality and how to kind of exude that in a way that isn’t BS basically? [Jaz] Again, you asked some amazing questions. I’m gonna say be a modified chameleon. What I mean by limited chameleon is because I value individuality. So I did a Tom Rath StrengthsFinder book years ago, and one of my five strengths is individuality. So one of my core strengths is individuality, meaning that I treat the individual as an individual. I know there’s protocols and stuff that we apply to everyone, but if someone, if a teenager comes or if a kid comes, I’m gonna talk about that kind of stuff and I become a big kid and stuff and it’s very easy, very fluid for me to do that. And then when the sweet old lady comes. I change, I adapt very easily. So I think it’s good to be the chameleon. And good to, and when that engineer comes, okay, you talk like an engineer and you put a different frame on, you put a different mask on, right? And I think the other topic that’s just very related before we cover this in a bigger way, but very related to this, is the fact that we are in theater, not the medical theater. We are in showmanship. We are in Hollywood, baby. Okay. What I mean by that is when you have a tough day and your kids are not having their breakfast and you had a, maybe a tiff with your wife and then you’re going into work whatnot, and you woke up on the wrong side of bed and last night there was an issue at home or whatever. You have to forget everything you put on this mask, okay? When you put on those gloves, the lights are on the makeup camera. Action. At that moment in time, the patient must feel that they are the only person in the world. That’s how important that you need to make them feel. You need to forget everything ’cause we owe that to our patients. So there is a degree of showmanship and turning up and putting on a performance, okay? And some people don’t like to hear that. This is what I’ve been taught by one of my first principles, Dr. Hap Gill. And I think it’s true. I think what we do is performance. And just like performers, when you act, you act in a different role according to the movie, alright? And the movie will be different every time, and the script is different every time. You are still the same person. You still have your mannerisms, you still have your, I’m not saying change yourself, you are yourself, but you are being this modified chameleon to blend to the scenario, to blend to the individual. Now, the reason I mention the word modified is that because you need to draw a line in the sand and set some standards. What I mean with that is I’ve decided a long time ago, that if any patient right, is rude or just not a nice person or you know what? That we are really not seeing eye to eye and that we are clashing. Okay. Thankfully it doesn’t happen very often, but there are some patients that it can happen to. I’ve got some funny stories I can tell you about this later. But the other way to think about this, it’s a long way of saying it, but when you look at your career. And then let’s say you have been in one practice for several years, you’ll notice that you attract patients that are similar to you, right? Oh, so my patients are the ones that don’t gel with you. They’ll go somewhere else eventually. Or see the other dentists. My patients are bubbly, my patients are talkative, and they’re very much like a representative of me. And that happens over time. You’ll notice, and that’s a sign of you doing something well, and that’s a sign of happiness. You get along with your patients. It’s a gelling that you have, basically. And so the reason I mention that, and going back to I decided a long time ago. There’s a certain type of patient that I still have a duty of care to and I’ll still make sure they’re out of pain and stuff. But if I’m only doing any elective treatment, right, if I’m only doing a smile makeover, if I’m doing any orthodontics, if I’m doing a full mouth rehab, I’m doing a tooth wear case. Okay? I’m not gonna touch that. I’m gonna say, look, maybe it’s better you see someone else for this kind of work. Interjection: Hello YouTube Protruserati. I know you’re watching on YouTube and I hope you enjoyed this episode so far. But I wanted to highlight, in case you don’t know yet, we have an amazing viewing experience on Protrusive app, our website, our network, our platform. So I just wanna spend a minute to show you what this looks like. On the left side, you see the navigation, and when you join the app, you get a one minute video tour of the entire network. Now, in terms of where the magic happens, that’s in the Protrusive Community. ‘Cause you might come for the content, but you’ll stay for the community of the nicest and geekiest dentists in the world. We have all these polls. We have a chat group. There’s always active chats and dentists helping dentists, and really what I want to do is create a really supportive environment that’s not like the environment we have on Facebook, and it’s built on the values of niceness and geekiness. If you are nice and geeky, you belong here. Now, to make this a safe space, we have a manual process of approval. We actually verify that you are a dental professional before you get in here. So we have hundreds of applicants a day. So if it’s been about two days and you haven’t heard anything either something’s in your junk or you need to reach out if you’re still waiting to join your tribe. Email mari@protrusive.co.uk, that’s M-A-R-I mari@protrusive.co.uk, and she’ll investigate what’s happened. Now, all the videos you have on YouTube are also on here, but you actually have some extra ones for free that you don’t have on YouTube, so you get some bonus content that’s not on YouTube. And actually for the future, I’m not taking things out of YouTube, but some things are not appropriate for the wider public. And I wanna sort of safeguard that information, which is like dentist talk if you like. So that’s why a lot of the content is only here and not on YouTube. So you’re kind of missing out if you’re not on here. That’s why I’d love for you to join there. And if you join one of our paid plans, then what you get is access to the CE quiz like this one, and you can get CPD or CE certificates. And also you get our premium notes. So these are a great aid memoir or revision for an episode. It’s really cement your learning. And whilst we have ads and YouTube places ads on YouTube, we don’t have that on our network. So for the paid plan, you get to see all of the premium notes without any of the ads, and of course you get to support Team Protrusive and help us to continue what we’re doing. I’m just gonna gloss over the Protrusive Vault, which has all our infographics and downloadables. These are all our mask classes at this moment in time, and they’re always planning to add more. And if you look at, there’s about 1, 2, 3, it’s about seven of them. But actually, if you look at the replay sections, some of the live masterclasses that I’ve done and some of the training that people pay for on other websites is all on there included as part of the masterclass subscription. And if you’re a student, don’t fear, we have a special section for you with all the student notes, which anyone can access. So for example, here is one on exodontia. So it’s all there waiting for you on Protrusive Guidance. Please head over to the website, which is protrusive.app. Make an account on your browser. This could be Safari, Chrome, however you wanna do it. And once you’ve made your login, then you can download the iOS or Android app and then log in through there. So the reason to make the subscription primarily on the website first is that you get access to a free trial, which you don’t get if you do make an account on Android iOS. If you make it on the website, you get access to the free trial, and you get our best price if you sign up through protrusive app. So our best deals and free trials are only on protrusive.App. Of course, we always put the link below in description. Thank you so much for enjoying our videos on YouTube, but it’s now finally time to level up your experience. Back to the episode. [Jaz] I’d rather see the patients that we truly have a connection. Because if we don’t have a connection, I’ll get them out of pain. I’ll still be courteous and respectful of them, but if I generally do not think that we will gel together. There are someone else that will do your work, but they’ll gel much better with that patient, with that dentist. Sorry. And so, there is teamwork. There are other dentists out there who will gel better with other patients and let let the universe find that solution for them. [Nav] I like that. And then obviously you mentioned there about rude patients and then you don’t try to distance yourself from them. As students, especially when we are Yes men, let’s be fair. We don’t really have the power to tell people to like, do wanna go to another practice? How do we deal with it? Because we’re not ever seen as dentists, right. We’re seen as understudies and maybe we don’t get as much respect as fully qualified practitioners. What advice would you give to students in my position that might come across a tough day where somebody’s not respecting us? Treating us like doormats. How do we kind of put that professionalism back into that workplace between patient and dentist and then not let it affect us mentally? Because let’s be fair, we are probably the most fragile creatures. When we’re students, because any critique and suddenly we’re like, oh. We’re in the wrong profession. We’re not good enough, yada yada. How do we deal with difficult patients? What would be your kind of communication tips for that? [Jaz] I mean, that’s brought so many thoughts to our mind. The first thought is that they say that when you go on a first date with someone, right? And you are in a restaurant, okay. You look at how they treat the waiter. Before you think about it, okay, so I go on a second date. Should we eventually come in a relationship with someone? You look at how they treat a stranger, look at how they treat other people. That tells you a lot about them, right? And so, in a similar vein, some of my receptionists will tell me that, Jaz, the patients are so lovely to you, but when they come out to us, they’re really rude to us. And that’s important information because that’s not nice. I mean, if your values are that such that everyone deserves to be treated nicely, then you should record that in your mind and just be mindful of that. ‘Cause sometimes patients can turn. So for me, like niceness is a parative value. One of the reasons that I market Protrusive Guidance as the home of the nicest and geekiest dentist in the world is ’cause I genuinely believe that, if you’re there for the free downloads and you’re not actually wanna contribute, not actually be nice to one another, then you don’t belong in Protrusive, right? I actually want a collection of just the loveliest humans, humans first, then dentists. So I believe in that and I truly hold that. However, having said that, to answer your question, you as a student, sometimes they’ll be rude to you, but ever so nice to the professor, to the tutor, and you, I’m sure you will experience this, okay? And that tells you a lot. But in your scenario, you’ve gotta get through it. You’ve gotta suck it up buttercup. Be respectful, be courteous. You’ve got to get through your dental school training. But when you come out in the real world, if you come across patients who are rude to you or rude to your staff, you need to have a policy and a protocol in place. Okay? So again, we have a duty of care to these patients, okay? And we will get them outta pain and we will speak nice to them and best we can. But you have to think twice whether you really want to make this patient, are you seeing eye to eye? Have you got enough rapport because you need rapport? Because we don’t have a hundred percent success rates. If you tell a patient that there’s a deep filling and there’s a crack in your tooth, you didn’t put the caries there, you didn’t put a crack in the tooth, the patient came with that. If they don’t own that, right, and they’ll be quick to blame you, the dentist. Okay? Do you really wanna treat that kind of patient? Do you wanna take that patient on? Not really. So you need to make sure that you see eye to eye with that patient, okay? And then over time, you’ll find that if you adopt this mentality, you will genuinely attract the kind of patients that share the same values as you. Your patients become a reflection of you. [Nav] I love that. I absolutely love that. I think that’s kind of connects to what you said before about over time you’re gonna just have people that are so pretty much you versions of Asians and over time you’re just gonna build that kind of client base or patient base, whatever you’re gonna call it. I’m looking forward to that. I’m looking forward to just seeing loads of Navs. Eventually that’d be quite fun. [Jaz] There’d be different forms of Navs, you know? The old lady with a slight Navism, whatnot. And those patients that they don’t genuinely feel that connection and it’ll be the feeling will be mutual. You don’t have a connection. And I’m very much coming it through a lens of general dentistry is really fascinating. Like, you go to your doctor, you go to your GP when there’s a problem. Okay? And every time I go to a gp, I’m seeing someone else. We, in dentistry, are such a unique and beautiful position. Like one of the therapists, hygiene therapists retired recently. And she’s been seeing, one of my patients, I’ve been seeing this patient for five years, but she was seeing that therapist for 30 years. [Nav] Oh, wow. [Jaz] And on the last day, they both shed a tear. They both cried. Why they cried? And I asked her, tell me more about that. And she said. Well, you know, she was there when I gave birth to my first child. She was there when this happened. You know, she’s been the constant in my life. And now she’s going, and we actually, if you choose to go into general dentistry, family dentistry, and be in a practice, which most of us will do, we cannot. And honestly underestimate the power of this, to build a relationship. And dentistry is so, so powerful. And when you connect with a patient right, and you have that lovely rapport, they will follow you around. And that’s the best kind of scenario, right? And the patients that you don’t gel with. You still could be respectful. You still don’t care for them, but you’ll find that eventually they’ll be what we call an attrition rate. As soon as they have to move a mile down the road, they won’t come back to you. And that’s probably for the best. That’s probably for the best, right? They only came to you ’cause of geographical convenience, and that’s all. And that’s okay. Okay? You are there to serve them and help them, but the kind of pace that you genuinely have a connection with. So that’s what I mean. Over time you’ll find that patients that you’ve held and retain are such a great reflection. And so many dentists tell me that they love their job and they love it more, now more than ever before. Now they’ve been in one practice for 20 years. ‘Cause it genuinely feels like a chat. It genuinely feel like a patient’s coming in for a chat and when something goes wrong, like a tooth, a bit large filling that happened 18 years ago now breaks down and you say to the patient, okay, oh well I can help you. This will be a post crown. We can do that. This is how much it’s gonna cost and the trust is there. And they’ll be like, yeah, sure. When can we book in? Because the trust is the currency that we deal with. Not economical. It’s all about trust. [Nav] I love it. This is just sounding like a barber shop to me now. It’s like going in there like almost buying- [Jaz] I dunno, I would never know. I’ve never been to a barbershop. [Nav] You’re missing out. I’m telling you. It’s where all the guys get together and have their secrets. But yeah, no, I like this idea, this concept. I think that longevity within our career is rewarding more than just from the financial aspect, but there’s so much big time kind of inter personality within there as well. That’s amazing. I mean. Going back a few steps and kind of trying to weave this together, so to speak. You spoke about language, which is super important. Students make this mistake all the time. We speak to our patients as though they know everything that we read, right? So we we’re talking to ’em about, oh, you might have a paragraphical lesion here. We did this and yada. And you need X, Y, and Z. And they just sort of sit and they’re like, what the hell are you talking about? Right? It’s very easy to do that to students. Is this something that you see progressing into dentists that have qualified and they still do it? And what would be your advice to, I don’t wanna use the word, dumb it down, because we’re not trying to say our patients are dumb, but how do we almost normalize the vocabulary with patients? What’s your advice for that? [Jaz] Yeah, great question. And the answer is yes. The jargon. Everyone in dentistry, and I’ve seen some really qualified dentists like you 20, 25 years out, and then the way they’re talking to the patients, like they’re literally, I saw a prosthodontist look at a patient in the eye and tell the patient that in lateral excursion when you go to the left, these teeth are touching. Like there’s only a very niche engineered type of patient that will understand what that means and actually the ramifications of it. A lot of dentists might not even understand. So like, I’ve seen this happen, right? And they’re literally saying like, you have a peri apical infection. And even just like I know periodontist right at uni, and he said to a patient, and is this contemporaneous with what your dentist said? And so I’m not saying dumb it down. But like, is that really appropriate? So, if you feel as though the patient has that level of language and you’ve sussed that out, then absolutely. ‘Cause I’m a big believer in that modified comedian and therefore, I must speak like this, isn’t it? If I see someone who’s from the street, I’ll be like, bro, listen. Yeah. You’re two needs to come out and very much I go like that. And that’s fine. And they respect me a lot. And we get it. I don’t actually do it in that extremity. I was a bit dramatic effect there, but I’m very much like, if the patient wants to fist bump me, I’m gonna fist bump them. Right? So you’ve gotta really meet them where they are. And the best person I saw do this was Raj Patel in Sheffield. Like when he saw a patient who was a gardener, right? He would literally describe just like that. It’s such a wonderful way he would describe everything that he was doing in dentistry. Like in gardening terms. Oh, if you had a builder or plumber, he’d like it. It was the most magical thing ever. And I learned a lot that day seeing that. So try and speak to a patient on their own terms. Right. So for example, if you have a teenage girl, right, which was a real world, world scenario, teenage girl, good looking teenage girl. And she was thinking that she had an ectopic canine and she said, oh, you know what? I don’t want braces. I’d rather have it out. And I’m accepting of this. And then he really spoke her language and said, look, fair enough, it doesn’t bother you now, but when you are 30, when you’re 40, think about your long-term future. And when you smile and I think forgot what he said now, wedding day or whatever, let’s try and just let, help them see the long-term connection and about their friends and stuff and bringing it all in. And the way he spoke to her was like, yeah, you know what? And she was there with her dad that day and she was like, yeah, you know what? You’re right. I think I should get the braces and I think that’s the best for me. And he made her realize that by really connecting with her. And so when you connect in the patient’s own language and when you connect with someone’s own language, then it’s easy to actually avoid periapical pathology. It’s like, look, you see this black thing over here to some person, to most people, I say, that’s infection. Okay. To the guy off the street, I might say, listen, yeah, that is mush. That is mush in there. Trust me, you want that out. And they are very receptive. [Nav] Okay, so this is going back to this modified comedian thing over and over. I feel like this is the theme, so I’m gonna definitely have to take this in and just adjust depending on the patient. This is amazing information. Thank you very much. My kind of future question, ’cause obviously we’re not there yet. Might be a great way to wrap up to you, but finances, payment, how the hell do you do it? Like I find it weird to ask my mate for that five back. How do you go and speak to strangers and say, this is the treatment options that you got available and it’s gonna cost your ex, I don’t know how you do it. Do you do it at the beginning? Do you do it at the end? Do you get someone else to do it for you? Like do you have a card reader in the surgery and you say, pay up now? Or do you send them away? Explain because this, I think we all have sleepless nights as students thinking about this, so please do enlighten us. [Jaz] I’m laughing here because literally like everyone, like this theme has been a big one throughout my career and I’m at a comfortable place now with my fees and stuff and I can, I’ll tell you how I do it now, but over the time I tried every method, like I tried this method whereby, ’cause I hate to talk about fees as well, so I’d be like, okay, Zoe will tell you the fees. Now I just look away. Zoe would like, okay, and she’ll do the work. And some people have treatment coordinators and so they never have to worry about talking about fees. Okay. And so for me, I think it’s a bigger thing here. And a lot of this Lincoln Harris inspired me and some of this, my own little masala here as well. Which is, it’s a money mindset thing. I come to refugee from Afghanistan. Money is not something that was very prevalent growing up and then coming into dentistry where, me, even me coming in, right? And my parents would never spend the amount, I would then be even then be charging for restoration. My parents wouldn’t have that kind of money. And then so knowing that and knowing the kind of, it’s like the relationship you have with your parents and how their money mindset goes into you. And for me, I remember and I talked about this, another podcast episode, right? A really, really sad, but funny thing. A patient who was also a refugee, actually. So this patient’s a refugee, okay. And I’m obviously, I came in with, I was six years old and this patient came from Afghanistan like a few years ago, right? And then I took his tooth out and then he asked me, how much does it cost to replace something here? And I went through all the options, said, okay, how much is an implant? I said, well, it’s about 2,500 pounds at that point. I said, right, probably more than that. Obviously now it’s definitely more than that. And I even then I remember saying it a little bit like, Hmm, yeah, it’s quite a lot of money, that’s how I said it. And he literally just started to laugh. He literally started to laugh. Like, not like in a rude way. But in a genuine tickling like hysterics, like that’s hilarious. What are you kidding me? That’s hilarious. It can’t cost that much. Like it was that kind of laughter. You know what I did? I started laughing with him and even I was like, okay. And so that was like when I was like in my DF one year, one year qualified. And so I had a huge money mindset issue. Because I didn’t have money in my life. And therefore it was difficult for me to talk about money with my patients. When that kind, the kind of treatment plan to do a post crown and this denture was way more than what was in my current account at that point. And so there was a money mindset issue and I think that’s normal to have that if you don’t come a place of money. I think it’s normal to have that. And so over the years, it is not just that because IQ makes more money and had more income, it’s genuinely, I worked my money mindset and I really read some things. And really money is a flow of energy. And when you become grateful of a, every time you see money, leave your bank account. You need to look up and say, thank you. Thank you for allowing me to be in a position that I can pay for something. And then when money comes in, be like, again, look at the universe, say, thank you. Okay. Money is just flowing in. Money is flowing out. Money is just energy and that’s all it is. And so when you then realize that actually you are totally worth it, you are totally worth it. Okay? Because you can go to a fancy place and there could be a wardrobe. A bloody small wardrobe for 40,000 pounds. And people will buy it and they produce it and people will buy it. Okay? And then when you realize that actually we are not in the money business, we are in the values, the value that you can bring to someone, okay? What we’re selling is health. We are selling health and longevity. If someone can chew better and digest better, once you realize that we are in a health space and there’s nothing more valuable than that, now there are some patients who genuinely cannot afford your fees, and that’s okay. So when they say no, don’t take it personally, okay? If someone genuinely cannot afford it, okay. Then that’s fine. Now, just because someone has got 50,000 pounds their bank count, don’t think that they’re gonna take your 2000 pound treatment plan. Yeah. Don’t think that it’s a no brainer for them because they may not value it. So either you haven’t communicated the value or genuinely the patient has a value issue basically. And so the top tip I give here is fix your own money mindset issue. ‘Cause that’s a big part of it. Once you fix your money mindset issue, it becomes easier to talk to. And then I tried all those various ways. Never was comfortable talking with money, but once you overcome your money mindset issues. And then I had an experience whereby the patient went down and they felt as though I didn’t communicate the fees properly. And if a fee is a surprise to a patient, then that’s not good either. So now I’m in a place now where I’m very open and honest and very direct on my fee is like, okay, so that we can get this done. The total fee will be 4,500 pounds. Okay. And I say it very confidently. I don’t look away, I don’t blink. I say it very confidently and sometimes what worked for me in the past as well, and perhaps I is worth mentioning ’cause it might help someone, is one of our values in this practice is to be transparent in our fees. The total fee for everything is 4,500 pounds. This will include all your appointments. The lab work and by the time you come to the end of it, you would’ve paid that amount and you’ll get this work done basically. And so just explain that so that we are transparent with our fees. This is how much it costs, this is what it includes. Is this something that you’d like to go ahead with or do you have any questions, that kind of stuff. [Nav] Ah, I like this. I like this. I think the money mindset is huge as well. It’s how we perceive things. So this is all going in. I’m gonna have to probably do some role play with a few, our mates and that- [Jaz] Yes, Nav, you’re so right. Role play is really, really important. Okay. And wow, so I’m listening to a book at the moment called Psycho-Cybernetics. It’s from like the 1950s. It is like the godfather of self-help books, right? And so it gave birth to the sort of self-help era, basically. The Tony Robbins of the world, et cetera. And really what it talks about is, is the power of role play and power of imagining yourself. So if you imagine yourself, right, being in the clinic looking confident, being kind and courteous to the patient and with a smile, be able to say, oh, actually it’s gonna cost this month. And the patient saying, thank you so much, I can’t wait to get started. Okay. And that visualization and then role playing in your head, because here’s a fascinating thing, right? The brain, your brain does not know what is real and what is imagined. So if you literally imagine yourself in a dark room, okay, and all, like you see ghosts and stuff, right? And you’ll start to sweat. You’ll actually like start as a terrible, terrible example, which is the first thing that came to my head, right? But like your nervous system will actually put a if in, depending on how vivid your imagination is, and how big your fear is. You’ll start to sweat, you’ll have a palpitations. Your brain does not know if that was real or that was fake. So the other thing is, right, for example, there was another experiment whereby these people do free throws in basketball. They try and get the free throws in, right? So group one does a free throw training every single day. So for 21 days, every single day, they will practice. Okay. Every single day. Okay. And then group two only practices on day one. And then they get tested at day 21. So group one practices every single day, and then their test is on day 21. Group two only practices on day one. And then they get tested on day 21 between day two and day 20. They did no practice. And group three, here’s a fascinating one, right? They practice on day one. They do a test on day 21, but in between, they don’t actually practice for real. They practice in their brain, they imagine practicing. Now, the worst group was the one that didn’t practice at all. The best group was the one that practiced every day, but only by like a whisker because the group that imagined getting the ball in. They were literally only a whisker behind, okay? And they were significantly better than a group that didn’t practice. And so what this experiment shows us athletes do this all the time, the power of visualization. Every time I have to give a lecture somewhere, okay? Like recently I was teaching inclusion in Norway, a full day, like half day lecture. I was a little bit nervous, but I literally use the power of visualization. What’s my face gonna look like? How am I be dressed? How am I gonna deliver this piece of content? And that really helps me a lot. And so going back to your point when, if anyone’s struggling discussing fees, the power of visualization, the power of roleplaying, even you, you don’t actually need to really do roleplay. You can roleplay in your mind. You don’t even need a mirror. Just we can do the mirror, but classically do. But if you imagine you doing this and you imagine yourself communicating in the way that you like to portray yourself, then that’s gonna happen. [Nav] Oh, I love that. Do you know when you were saying all that, I just remember something from ages ago. I’m pretty sure David Beckham used this because it was once on a documentary or something and they were mentioning that he does a lot of visualization. And he just repeats. [Jaz] Athletes are renowned for the top athletes all say in golf, in various sports, in top athletes, they do this, they visualize exactly what they’re trying to do, and the brain doesn’t know if it’s real or fake. The brain’s actually figuring out, even there was an experiment whereby the people are lifting weights. And then people just imagine. Like vividly imagine lifting the weights and they actually got stronger and they’re able to do, they actually got stronger. Okay. This is a real thing. They actually gained muscle mass. There’s a limit to that obviously, but it’s just a fascinating, see that actually even compared to doing nothing, but just by visualizing you actually grew a bit. [Nav] That’s insane. That is actually a power of the mind. Okay. I love this ’cause this is gonna probably help me in more than just the financial and asking people for or telling them what their costs are for dentistry more. So- [Jaz] Look, the patients need to know how much it costs, right? Like they need to know. And so don’t be embarrassed about the fees, basically. ‘Cause that’s very normal to feel that way, especially for a money mindset issue like I used to have. So, be proud of your fees because you are providing an incredible service, incredible value, right? And so one thing that helped me a lot as well is because when I was charging someone, let’s say 300 pounds for a restoration, okay, it’s a restoration, not a filling. A filling is what goes in a sandwich, by the way? So when I charged 300 pounds for a restoration, okay, at that point I was questioning, oh my God, I’m charging this much because that’s the how much a practice charges. But in my own mind is like, is what I’m delivering actually worth 300 pounds? It was a self-doubt, right? And so one of the reasons I went on so many courses, like my first five years, was course, after course, after course, okay? Now, if I’m charging for an hour of my time and I’m charging, let’s say complex, MODB, complex buildup, okay? And I’m charging 450 pounds, okay? I think I’m cheap. I can charge more than that. And I’d be more happier because honestly, the clarity in my protocols I have, I know my patients are not gonna come back with post-op sensitivity. I know that using air abrasion, I know I’m doing this. I know that occlusion is gonna be on point. And I’m gonna serve them well. I have this much, and please, I don’t want anyone to see this as arrogance or anything. I really hope it hasn’t come out that way. It is conviction in my training and my belief that I’m gonna really help my patient so that now I come to a point where I’m very easy for me to charge that amount. ‘Cause I truly believe I’ve done so much training, I’m ready for this. I can’t wait to deliver you the best restoration you ever had. [Nav] I love this. I don’t wanna take up too much of your time here, but I do have one question I wanna ask you off the back of this, right? Surely, there must be a time where sympathy kicks in. I can almost imagine myself being an idiot and feeling sorry for patience and sometimes being like, oh, it’s all right. I’ll just discount that, or, that’s right. I’ll just do it for free. Does that happen? Is this just me? Is it everyone? [Jaz] All the time. All the time. Done that. [Nav] How? [Jaz] It’s like what we call a Neuro-fiscal Drag, right? So early in my career, let’s say the figure in my mind is 150 pounds ’cause that’s how much it should be. By the time it comes outta my mouth, it’s lost 30 pounds. Right? It’s 120 right? Now here’s a stupid thing, Nav, right? You say to a patient 120 and they’re still gonna be like, oh, 120. That’s too much, right? Yeah. And they didn’t even know that was 150. You discounted it. The worst you could do is you give a discount, but the patient never knows that you got a discount. That’s the worst thing that that’s the stupidest thing ever. [Nav] Well, I’m with you. [Jaz] Like literally you gave ’em a discount and they don’t even, they didn’t even feel that. And so what was the point? Oh, you could have said 400. The reaction would’ve been the same. Okay, so, so really? Yeah, I mean, it’s normal, especially for my money mindset background and my refugee background. I felt very sorry for patients and I discounted my treatment plans left front and center. I don’t so much anymore. I tell you why. As an associate, if you do the maths if you look at profitability of dental practices, when you give a discount, you really, really screw yourself over, but you screw your practice over a lot, like in a massive way. They have so many overheads, materials and everything. It’s an injustice. Because you gotta gross a certain amount per hour for them to keep the lights on. And so you have to really remember to be respectful to where you work in your principal. And it is a business because if there’s no money in the business, there’s no practice anymore, there’s no job for you anymore, okay? And so it’s important to charge what you’re worth and charge the right amount. But it’s normal to want to give discounts. And I get it. But over time, when you really appreciate that you are delivering a really good service, and the fact that you need to be respectful to who you work for. Then I think when you realize that, then I think something clicks and then whilst you can be empathetic and sympathetic of the patient, look and if someone has told you, look, that’s a lot of money. It’s like, look, I appreciate lots of money and how can I help you? Well, can do it in phases. There’s finance plans. If not now, then we can always save up and do the right thing. Next year, we’ll still be here for you and just be there to, if someone can genuinely cannot afford it, you give them the options and financing and stuff and or come back in the future. Sometimes, John Kois famously said this, like, just because you don’t wanna do the right thing doesn’t mean that I have to do the wrong thing. [Nav] Aha. I like that. [Jaz] And so sometimes if you’re gonna make the situation worse for someone, then say, look, it’s better you actually do nothing and save up and then come again next year and then we can help you better. And I genuinely think that’s the best thing for you. And so again, it’s one of those things now that comes with experience. [Nav] So we start with experience and I think we’re ending with experience. I think this has been extremely enlightening and I’m sure everyone else who’s in my position and probably even qualified. Really love this. So Jaz, seriously, man, as always, absolutely pleasure. You smashed it, man. [Jaz] Nav, thank you so much. Honestly, your questions were absolutely sick. They’re amazing questions, so I really appreciate it and we’re definitely gonna bring you back on to do more of these. I think you and Emma bring something, a different flavor, which is wonderful. I think that that synergy is gonna be amazing and maybe we’ll have you both on together as well one day. So that’d be good. But we all wish Emma the best with her exams. And have you got any exams coming up? Nav? [Nav] I’m still a couple of months away from it, so I’m still good. And it’s year four, so the hard stuff starts in year five and then six, so I’m taking it easy. [Jaz] Great. Well, I can’t wait to publish this. And please plug yourself, you’ve got some stuff out there for dentists and dentist students as well. Please tell us more about your channels. [Nav] Yeah, so I’ve got a YouTube channel called the_stu_DENT, just trying to be cool, then mix dentistry into it somehow, where I’m covering my journey as a dental student, what we cover as dental students the highs, the lows, and vlogging my time here in Slovakia as well. So if anybody can find me on YouTube or I’ll send you the link you can edit. [Jaz] I’ll put the link. Please do subscribe to Nav as well, guys. As you can see, his energy is brilliant and he’s very giving and sharing. So be supportive. And you can message Nav on Protrusive Guidance. He’s on there. He’s very active and so we’re very grateful for that. So Nav, thanks so much for your time as well. I’ll see you in the next one as well. [Nav] Lots of love, man. Thank you very much. Jaz’s Outro: Well, there we have it guys. Thank you so much again and again, again for listening to the end. If you are on the app, scroll down below, answer the quiz to claim your CPD certificate. We are a PACE approved provider for those of you who call it CE. And if you are new, thanks for joining us today. Please do give us a subscribe and a thumbs up if you enjoyed this episode or you learned something. What a wonderful job Nav did today. So well done Nav. Really, really great questions. I thought you really helped the flow of this episode. I wanna thank all of the Protrusive team, especially Gian, Erika, Krissel, Mari, Julia, and of course Nav with everything he’s doing. Remember that our community Protrusive Guidance is not just for dentists, it’s for dental students as well. In fact, we have a whole little section for you guys, including Crush Your Exams. There’s all these notes that Emma has produced and they’re stacking up really nicely at the moment from indirect restorations to dental materials. There are loads of student friendly notes ready to download. Just make sure if you are a student, you email student@protrusive.co.Uk with your proof to unlock some hidden areas. Thanks so much again for listening. I’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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My Neck, My Back (Fix Your Posture While Removing Plaque!) – PDP220 44:27

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44:27

Are ergonomic loupes and fancy chairs really worth the investment? Is back pain an inevitable part of being a dentist—or can it be prevented? Are you setting yourself up for a long, pain-free career in dentistry? What’s the number one thing you should be doing right now to protect your body for the long haul? Dr. Sam Cope is back, and he’s not just any dentist—he started as a physiotherapist before training in dentistry. That means when it comes to musculoskeletal health, posture, and career longevity, Sam knows his stuff. In this episode, Jaz and Sam revisit the crucial topic of back pain in dentistry and dive even deeper into what actually works to keep you practicing pain-free. So, if you clicked on this because you’re worried about back pain, take this as your sign—your future self will thank you. https://youtu.be/lUC45aLXZKk Watch PDP220 on Youtube Protrusive Dental Pearl: Motion is lotion. Staying active prevents back pain and keeps your career strong. If you’re not making time for exercise, it’s time to rethink your habits. Knowing isn’t enough—action is what matters. Prioritize your health now. Key Take-Away: Posture and back pain have no direct correlation. Apprenticeships provide invaluable experience and learning opportunities. Investing time in learning and shadowing can accelerate career growth. Ergonomic tools can enhance comfort but should be tailored to individual needs. Mental health is crucial for dentists, and seeking help is a sign of strength. The human body can adapt to various postures with training. Choosing a specialization should align with personal interests and strengths. Preventative measures in ergonomics can improve career longevity. Continuous learning and adaptation are essential in the dental field. Choosing the right dental chair is crucial for comfort. Preventative strategies for back pain include regular exercise. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:05 Protrusive Dental Pearl 04:26 Sam’s Journey from Physio to Dentist 10:33 The Value of Apprenticeships and Mentorship 16:24 Niching in Dentistry 22:30 Ergonomics in Dentistry: Loupes and Chairs 27:03 Choosing the Right Chair for Your Comfort 29:54 Top Tips for Dentists to Prevent Back Pain This episode is eligible for 1 CE credit via the quiz below. This episode meets GDC Outcomes A and C . AGD Subject Code: 130 ELECTIVES (149 Multi-disciplinary topics) Aim: To highlight the importance of ergonomics and physical well-being in dentistry. To share strategies for preventing occupational strain and burnout. Dentists will be able to – 1. Assess the role of ergonomic loupes, chairs, and posture in reducing strain and improving long-term musculoskeletal health. 2. Understand the significance of muscle conditioning over posture correction. 3. Incorporate exercise routines to manage physical strain during long procedures. If you enjoyed this episode, you won’t want to miss Got Your Back – Physios and Dentists – PDP025! #PDPMainEpisodes #BeyondDentistry #CareerDevelopment Click below for full episode transcript: Jaz's Introduction : Over 270 episodes ago, I had on Dr. Sam Cope when he was a a baby dentist, and he's unique because he's a physio who trained to then become a dentist. Back then, we discussed about back pain and dentistry and how to prevent it, and we talk a bit more about those themes today. Are ergo loops worth it? Jaz’s Introduction: Are those posh Bambach kind of chairs. Are they worth it? What’s the number one advice to have a career with longevity and good health from a back pain perspective and as a physio come dentist, what does Sam do? What are the things that he practices? Because he’s a bit like when Christiano Ronaldo rejoined Manchester United. He was like a, he was a big deal, right? He is the goat. He’s the greatest of all time. I’m a Ronaldo fan. Anyway, when he was in the canteen of Manchester United, he was like eating with all other players. Everyone just looked at Ronaldo, what was on his plate. They wanted to model Ronaldo. So why do I mention that? Because I’m looking at Sam, whatever Sam’s doing with his posture, with his back, et cetera, I wanna be doing that because he has the most knowledge. He’s musculoskeletal with his physio background. He’s a really good dentist. So let’s see what advice Sam has for us today. Now, after this episode, if you wanna go deeper into back pain, chronic back pain. We’ve got Ben Physio and Sam Physio come dentist, that was PDP 025, like I said, over 280 episodes ago. In fact, it’ll be good for you to revisit some of the old episodes to see my journey and the journey of Protrusive now that we have team members and whole production line to bring you all this content. And a special thanks for all of you that member listening to that episode on Spotify all those years ago. There is some new information, applicable information, and Sam’s no longer a baby dentist. He’s really accelerated a fast rate. So I made a big deal over at the beginning of this podcast to talk about his journey. Because his journey really exemplifies the advice I give to every single young dentist. I get the question all the time, how do I structure my career? How do I grow at the fastest rate possible? How can I find the right clinic? How can I be doing the more of the higher end dentistry? Well, Sam’s playbook is there, and he shares it with us in this episode. So you’ll get some career advice as always, plus how to get more longevity from your career. Dental Pearl The Protrusive Dental Pearl is a nonclinical one, and it’s taken from this episode and it’s just something that you already know, but it’s just important to hear again, and that is motion is lotion. Too many of my dentist friends are talking to me and saying that, oh, I just don’t have time to excise, and oh, I really let myself go. I’m not prioritizing it, and that is the wrong way to go. Your physical health and mental health is super important, but just focusing a little bit on the physical aspect, spoiler alert, that is the number one way to prevent back pain and to give you a career with longevity. And you’ll hear later in this episode whether deadlifts are recommended or not or what’s the best type of exercise. But as long as exercise is part of your life, and for many of you, you guys are running or jogging when you’re listening to the episode and you guys are already living and breathing that and more power to you. But so many of you in the car on the train, and maybe the most exercise you get is when you are going upstairs and downstairs of your surgery and you need to really reevaluate life and your life decisions and how you may be neglecting your physical health. Again, it’s stuff we already know, but one of the first dental pearls I ever shared with you may actually have been number one and number two was to know something and not actually do it is as good as not knowing it in the first place. So Protruserati, I’m trying to look out for you here. Are you making time for physical exercise? Are you practicing motion is lotion? I hope you are, and if you’re not hoping, this is gonna give you to kick up the backside to make some sort of regime, some sort of promise to change that by yourself. Because the reason you clicked on this episode is ’cause something piqued your interest about back pain and having a career with longevity. And if you’re not even doing that, then losing out on so many benefits. Anyway. Hope you enjoyed the rest of this episode. I’ll catch you in the outro. Main Episode: Dr. Sam Cope, welcome back again to the Protrusive Dental Podcast. So nice to see you and your growth and your journey and to see you live at the Protrusive events on the app and doing wonderful things on social media, my friend. Welcome. How are you? [Sam] Thanks very much and thanks for having me back on the podcast as well. It’s a real honor I’ve seen, ’cause it was in the early stages that I was on last time and it’s really grown and kind of kicked off. [Jaz] You were about 270 episodes ago, mate. [Sam] Wow. Yeah. Crazy a dinosaur. [Jaz] Well, honestly, you did so well then. But there’s some unfinished business, right? The unfinished business is a little bit of a stir that we created and we talked about being no correlation between bad posture. Back pain. Okay. So we wanna just talk a little bit about that, little finer points about that, and also just revisit your journey from physio to dentistry. But now that you’ve been in the game for a bit longer, right? How do you feel? Do you have any regrets and that kind of stuff. And I hope you like the title of this podcast, My Neck, My Back Fix your posture while removing plaque. I just wanted to go into some sort of a funny theme, but Sam, for those who didn’t listen to that episode, looking at back pain, it was two guests I had at the same time. And so for those who haven’t listened to that, please do check it out, but just remind us about your journey and where you practice today? [Sam] Yeah, so I started off, I did physiotherapy at King’s from 2011 to 2014, and I actually met some, I was on a course this weekend and met somebody that was there at the same time who was doing dentistry at the same time. And we were kind of reminiscing because we were in halls and every time you’d go into the kitchen in great Dover Street apartments, which is where we were. You’d see the shard being built a little bit more every time you went for breakfast. So yeah, so I started off at Kings. I did physiotherapy, really enjoyed it. And after I finished physiotherapy, so when you do physio, you do respiratory, neurological physiotherapy, and musculoskeletal. The musculoskeletal element is the bit that most people know that physios do. And whenever somebody says, oh, are you a physio? You’d say, yes. And then they’ll say, how good are you at massages? And you’d say, you’d roll your eyes and think, oh God. But yeah, we are actually pretty good at massages. I remember the very first, like when we got into physiotherapy, like the icebreaker, they just said, right, everybody get your tops off. Then we’re gonna do some massage. And I was like, Jesus, here we go. Like this is what’s gonna happen. But I did physiotherapy. That was really good. And then once I finished, I realized that there was a bit of a ceiling effect with musculoskeletal physiotherapy. So whilst I was doing physiotherapy at Kings, I was also doing physiotherapy for the London Irish Gaelic football team and Mill Wall rugby team. And it was really cool because you’d be doing first aid on the pitch, but when the players are coming to you, they’re coming to you because they need help or because in almost like a negative way, because obviously it’s their career almost at risk for them having to come and see you, even though you are part of the team. I would’ve rather have been actually playing with them, like on the, you know, being part of the team that way. Especially once I started Musculoskeletal physiotherapy, if I really wanted to progress, I’d have to start being with a football team or something like that. And that comes with connotations in terms of, it’s difficult to have a family because you’re lying around the world all the time. And I just thought, hmm, is this really for me? And then I looked at dentistry and I had looked at dentistry for many years before. My uncle and granddad are both dentists, so I thought, do you know what? Actually, this is gonna be the only chance I’m ever gonna have to kind of do dentistry. So I luckily got on the four year program at Liverpool, did the four years of dentistry. I didn’t leave the physiotherapy behind because I didn’t want to be a poor student again. So I was doing physiotherapy Monday, Tuesday nights and Saturdays. And that was great because not only was I getting experience from the dental field, but I was also seeing a very diverse patient range. And I was doing quick, quicker consults and examinations and learning about communication, which I think that’s probably, 90% of dentistry, I’d say at the moment is communication. [Jaz] Well, I see you now in your evolution into a private practice doing aesthetic work. Everyone has to, at some stage who those who want to, those who wish to get over some imposter syndrome, get their communication gear, get their skills in gear, and then make that jump to private practice should you wish for that to be part of your career. And I’ve seen you do that and we can talk about that in the podcast, but I think your skills of the University of Life in the real world, in your physio as you were studying probably helped you being able to speak to people, get those reps in so to serves you well later in your career. Would you agree with that? [Sam] Yeah, definitely. It’s definitely helped. It helped me progress faster too, so I found that, yeah, so once I’d finished physio and dentistry, then I went on to do my foundation years, and then I went and worked at the dental house in Liverpool with Stuart Garton. He’s a lovely guy, and I found there it was a little bit different. So when I was doing NHS dentistry, I’d have half an hour for my checkups so that you can sell more private dentistry, but there was a dental therapist model there where any fillings I would send, well, simple fillings or child extractions and things I could send to the dental therapist. So it meant that I built my skills more with preps and also eventually going on to more I could do preps, veneers, composite veneers and things. And the only way that I got confident doing that was by, I mean, in the early days I’d be doing like five, six days a week and on the days off I would be shadowing different dentists from like orthodontists. There were of quite a few restorative dentists that were there as well be shadowing them. You’d gain loads of techniques and you’d gain lots of communication. There’s some things that are hard to do to communicate to patients, and sometimes you’ll hear a clinician say something and you’d be like, wow, like they’ve just summarized maybe like three paragraphs of communication into about three sentences. So that was really, really helpful. And then I went on the postgraduate diploma. Then with Monik Vasant, I did the totally composite course first, and after that I remember being on the train, coming back thinking like, wow, that was the best course I’ve ever been on. And the reason was just because he’s so charismatic. He’s a good guy, and there’s the way that he can teach. When you finish a course, you want to feel like on Monday you can deliver that exact thing on a patient. And when you come back from a course, especially with the composite, you want to look at your model and think, wow, that’s the best posterior composite, the best anterior composite that I’ve ever done. And that’s what you get from a course like that. So I did his yearlong course after that. He then was, must have been looking at my work, but he asked me to be his apprentice after that. So I worked as his apprentice for a while. And then- [Jaz] What was that entailed? Because this is new to me, right? So you watch the show with the apprentice, right? You think, okay, this is what or there’s apprenticeships. So just delve into that model and before you delve into that model, I just wanna highlight something for those listening and watching, right? If you look at Sam’s career and the way he’s describing it, there’s a few prominent themes that you should not go unnoticed, which is drive. You had the drive and the hunger, right? Who else? Okay, so I look at people, right? And they’re like, oh yeah, I wanna be successful. I wanna be this kind, and someone do that kind of work. Okay? But then they’re not putting the hours in. They’re not as hungry. Basically, they’re choosing to spend their weekends watching Netflix rather than doing what you’re doing, working five, six days a week. And then they’re also shadowing on top. Now, some people might say, you know what? That’s obsessive. That’s too much. But if you don’t do it in your first five years, when you’re gonna do it, you’re not gonna do it. When you have kids, you’re not gonna do it when some sort of health crisis happens later on, kick us, as you’ve learned, that can happen, right? So what I love about you is you had the drive and you played the season of life, my friend. You had that season. You got your reps in, you had mentors, not only the ones you shadowed, but the ones that courses you went on, and you obviously had this wonderful thing about you that you connected with him and then you opened yourself to allow Monik to take you under his wing. But just tell me now more about what an apprenticeship looks like nowadays? [Sam] Yeah, so I mean, it was very new to me and it was very new to Monik at the time. He’d taken will on to start off with and it was basically where I was helping him out on the course. So on the year long course I was helping him out on the course. And then as you got more confident, then you would do more things in the clinic. [Jaz] So you’re working in his clinic, so you are an associate of his, is that right? [Sam] You are salaried. So the start, you’re basically helping out on all his teaching courses. And then you are also seeing patients as well, maybe like once or twice a week, but the majority of it, just because of the sheer volume of courses that he’s doing, he really needs you there to kind of help and kind of mentor some of the dentists and you gain more experience from that than you would. On a patient. And the reason is because say on the totally composite course, people are doing composite veneers. You’ve got 20, 30 people that are doing composite veneers that are making mistakes. You are going round, fixing those mistakes. Things that you’d think could never have even happened. And it’s quite nerve wracking ’cause you’ve gotta be confident enough to fix it in front of them. But it’s very, very good ’cause then you’ve done that day, but it’s almost like you’ve just completed 20 separate composite veneer cases and you fix those mistakes. So then when you come into the clinic. And something like that happens, you’re just like, oh, well yeah, I know how to fix that ’cause I’ve done it 20 times, or I know a fast, efficient way of doing it. And it was great meeting so many dentists because you would gain so much experience from them just talking to them about different things. I was even on a course this weekend. And we were talking about doing a trial smile, and he was saying, yeah, well, the key thing with a trial smile is when you first place it in, you know it’s really important to block out the black triangles. And he said what a key thing is you can get some orthodontic wax palatally and place that in. And then I said, actually I’ve tried doing those things, I find wax a bit fiddly, so I usually get a really small tip and then place it on the palatal, and I just use light body and just eject a very small amount just into where the black triangles are. Then use my finger to kind of smear it over so that I don’t get any bulbous points. And then when you do your trial smile, you get a lovely trial smile, and then when you take it off, you can just tear all of the like body off in one go. And he was like, oh yeah, that’s an interesting way. But it’s great how we can all learn from each other. And just little tweaks and techniques ’cause we’re figuring things out. As dentists, we are problem solvers, so we’re always trying to problem solve how to do things. And something that you do all the time and take for granted can be a real nugget for another dentist. So yeah, learning from all of those different dentists was great ’cause you’re picking up nuggets. All the time. So it really helps your practice. [Jaz] Well, again, I just wanna highlight, and I’m not here to make you blush or anything, but people always ask me for advice, right? They come to me, they see me. Okay, Jaz has been in the game very long time, especially those who are a couple years qualified, they look up to me and then they message me and I would love to point him to an episode like this and say, look, listen to Sam’s got the playbook, right? Like, this is how you do it and so, I’m proud of you because again, the another thing that you exhibited is again, you just said you are in a course this weekend. Okay. Now eventually that will stop ’cause the season of life will change. And now you are doing more teaching as well, which is wonderful. It’s a great way to learn. It’s like the taxonomy of learning. When you teach something, that’s when you really learn something. But you had to get to a certain level to be able to do that. I’m sure you would’ve had some imposter syndrome going for that. But having the faith and the guidance of Monik must have really meant a lot to you. I mean, I don’t wanna talk about money too much, but let’s just face it that when you do an apprenticeship thing, right, like apprenticeship post, am I right in saying that you could earn more as an associate than it just side by side? Earning more as an associate than an apprentice? Would you say that’s correct? [Sam] A hundred percent, yeah. You take a salary cut even, you’d probably earn more on the NHS than you would as an apprentice, but it’s not, but then the experience is more valuable than any money. [Jaz] So I’ve said this story before and a few times, and those maybe are new to the podcast. I was once in a situation where I got offered a very lucrative position on Harley Street, or just out of town, a really lovely principal and again, a fairly, affluent area. Like it was a day and night difference in terms of my future earning potential. Okay. But with one practice, it was there. I was gonna learn a lot. It was very clear the principal was gonna be there. I’ll shout him out. Dave Winkler legend, he was gonna be there. Okay. And I learned so much from him. And then the other Harley Street practice, I knew it would just be me on my own. And so I took the pay cut. When you are young, work to learn, not work to earn. And I just wanna highlight, you’ve got the playbook my friend. You got the playbook, so, well done. I think you make some great decisions. Speaking of decisions, did you ever, ’cause I see the trajectory you’re going in, mate. You’re doing some fantastic aesthetic work. I can see that lights you up which is great. So people are finding niche, in fact, someone messaged me on the app recently on the Protrusive Guidance community, I think it was James, James Murray. He said he’s a young dentist, few years qualified and he’s feeling a bit nervous. Or unsure about the following thing, where he’s like, I don’t enjoy endo so much, and I enjoy these things. Am I too young to drop those things and focus on this? And you know what? He’s getting some wonderful advice on there from people like Sandra Hulac and stuff. It’s like, listen, you do you right? Yes, it’s good to get your footing and as a young dentist be good at everything before you choose a niche. But sometimes when you have, you identify your strengths and identify your passions, it’s okay to say, you know what dentures are, refer, endo are refer. And I’m gonna focus on these two, three things. And I think that is really a key recipe to niching and flourishing. Even Pascal Magne had a session with him recently. His advice to the young dentist was, don’t try and be good at everything he actually said, just pick a few good things. And so I see that you are focusing Sam on aesthetic dentistry. It obviously lights you up, but did you ever consider with your physio background that you are in a great position to be that TMD guy, right? You could be the TMD guy. Right? Because I prefer so many of my patients to physio, especially Krina Panchal in London. We get together, we get far better results alone. Did you ever get tempted by that path? [Sam] I did, and I did a few courses as well, ’cause at Liverpool they have kind of physio courses on TMD. I think it was a similar struggle with Ben. So me and Ben were trying to put together a back pain course. And for those that don’t know Ben, he is an extremely good physiotherapist and he deals a lot with chronic back pain. And he said, Sam, I dunno how you get the time to kind of do dentistry and do this, but I can’t do my job and then help you with this big course. And the reason is because when he’s at work, when you are dealing with chronic back pain, these people need a lot of help and they need a lot of kind of TLC and pain is such a multifactorial component that it is not just about the tissues, but it’s also about the psychosocial- [Jaz] Psychosocial wellbeing. [Sam] Wellbeing. Yeah. And some of these people have had really traumatic pasts that you almost need to help them with to get over the pain. They say you shouldn’t take your work home. You can’t not take that home. And I felt that there was a very similar pathway with regards to that and TMD and I think hats off to any dentist that deal with patients with TMD. I just felt like I probably wasn’t the best person to deal with that. [Jaz] I think you’re very intelligent, my friend. I’ll tell you why. Look, you know you set hats off. I’m living that at the moment. There’s a reason why I’ve limited my TMD days to Mondays only. Like I only do TDS on Mondays ’cause you’re so right. Like I was sat next to someone at the BACD conference, right. And he’s a young dentist and he was there with his partner and she was a therapist, like a psychological therapist. And she told me that all therapists. Have a therapist and I’m like, oh my God. Immediately I was like, I’ve never resonated with someone so much. ‘Cause we were talking, I was like, oh my God. Like, and you’re so right. TMD patients need that TLC, they need that whole holistic package. And I could tell you some really sad stories and obviously I won’t for patient confidentiality and it does affect me. Psychologically it does affect someone and so it takes a certain type of person and I appreciate where Ben’s coming from. Dealing with chronic pain patients takes its toll on you. So what I’ve done is create some boundaries. Like I only do emails on Wednesdays to my patients. ‘Cause I just can’t deal with chronic pain emails every single day. I can’t, it would just break me. Okay. I only see A TMD patients on Monday. So I’ve set boundaries to be able to help these patients, but also make sure it doesn’t affect me and my family and my mental wellbeing. And certainly I see therapy being part of my future as well. So I think you’re a smart cookie. So if everyone’s wondering why I didn’t go into that, I respect that and I appreciate that ’cause it needs to be right for you. [Sam] Yeah, exactly. I remember the last time we were talking. The different books that you read and a lot of the self-help books, and there’s a reason why I think dentists go into that because our lives are so fast-paced. We’re seeing lots of patients, but also we’re living in a 21st century environment, which our genes and our brains just aren’t geared for. I’m living in London now. And walking past like, hundreds of strangers every day, that’s not normal. 10,000 years ago before the agricultural revolution when everybody was hunter gatherers, you’d be living in a tribe and you’d know everybody. And there’s a reason why people want to be famous and things in society because back then, everybody knew who you were. So then people want to be famous because people want people to know who they are and things. But yeah, it does take it, I think subconsciously it does take its psychological toll. So I always think, if you want to be stronger, then you should get a personal trainer. So why would you not get a therapist to help with your psychological well being? That’s not gonna just help you with problems such as family traumas or if you are depressed or something at the time. But why not get them when you’re feeling normal so that they can help maximize how you can live and how you can use your brain. ‘Cause your brain is a tool and a lot of therapists can help you unlock that tool and help you become more resilient, especially when you do face challenges in the future. I dunno what you think about that. [Jaz] Totally. Ah, a hundred percent. We had Mahurkh Khwaja on the podcast as well. We had Simon Chard recently. They said, we need to put the prevention back into mental health, especially for dentists. We do such a tough job. So to try and get some regular mental toughness, resilience training is totally worth it. Now, I’m gonna make a little analogy, right. When Christiano Ronaldo rejoined Manchester United for a second spell, there was this famous thing I remember reading where all the other players, they stopped like eating what they’re usually eating. They’d all look at Ronaldo’s plate, right? Because they’re like, okay, I wanna be like Ronaldo, right? So I’m gonna make this comparison that you are the Ronaldo in a way, because you have this edge. Okay? You are the Ronaldo of posture and physio of dentistry. Okay, so you own it, my friend own it. Okay. Because you are so much more than that. But in this realm, like, I’m gonna be looking to you as like, what’s Sam doing with his posture? How’s he sitting in his clinic? Okay. Because whatever Sam’s doing, I wanna be doing that ’cause you can’t unlearn what you’ve learned. You can’t unlearn the years of physio. I’m sure you treat your body like a temple. How many times a week do you work out? [Sam] Usually like, yeah, three, four times a week. [Jaz] You look in great shape. I’m sure you do more stretching than the average dentist, et cetera, et cetera. So let’s talk about best practices, right? So let’s start with, am I naughty if, am I naughty if I make an expensive purchase of ergo loops in the promise from the marketing that it will help my neck pain, stroke, back pain? What’s your stance and analysis of these ergo angled loops? [Sam] I love them. I’ve got ergo loops as well. And I think having ergonomic loops is great because you are sat in a position where you are having the least amount of muscles strain, and I find it a lot more comfortable now. Some people might not find it comfortable, but I’d say probably in the majority of people you would. And the reason is because when you are doing longer procedures and you are looking down, you are going to be under a bit more muscular strain than usual, and you might not be able to hold that position for as long. I think the key thing is that your body is completely adaptable. So if you train your body to do something, you want to train your body to hold your arm out for four hours, you can train your body to do that. If you started to do it straight away, that’s gonna feel uncomfortable. If you’ve spent your whole life with a certain loop set and you’ve had your head over a patient, you can train your body to hold you in that position and not get uncomfortable. [Jaz] I’ve never thought about it that way. It makes so much sense ’cause the thing I was gonna add here is. I was skeptical about when I made the switch to ergo loops, I was skeptical. But when I started to wear them, okay. I didn’t feel immediate benefit. I’ll tell you why I didn’t feel immediate benefit, because then when I put my ergo loops down and then I went back to my normal loops, that’s when I felt like, holy crap, my neck’s on fire. Do you see what I mean? Because exactly I’d adapted to that. It’s a bit like going from somewhere like, hot to warm and then hot again, and then warm. Now you feel that heat basically. It’s a terrible analogy, but like, yeah, I only felt it when I had that neck declination again with the normal loops and now I very much prefer my ergo loops. Obviously, I’m sure there’s no double blind trials, systematic reviews on this because it’s a difficult thing. It’s a bit like musculoskeletal. It’s like a difficult thing to study, but I think the message is if it feels good to you, okay, then do it. But I think musculoskeletally, it does make sense, doesn’t it? [Sam] Yeah. I think the basic principles are research to kingdom come. We know that the stronger you are, the more able you are to be in one position. And I think you have to take those principles and then apply common sense to those principles. It’s like there’s no double blind research trials to say that jumping out of a plane with a parachute or without a parachute. So if we can apply common sense to these things maybe we don’t need, it’s only anecdotal evidence that jumping out of a plane with a parachute is actually beneficial. But yeah, I mean everything is about muscle adaptivity. Like if you look at a cyclist, if you look at their posture, like that flexion posture and that head tilt up, you would argue that is a terrible posture. [Jaz] Same with hockey players, also hockey players. A few times I’ve tried to play hockey, I was like, what the hell is happening in my back? I don’t wanna play hockey anymore. [Sam] Yeah. But, and also if you look at a chimp’s posture. It’s terrible. Like if you were looking at that kind of Victorian ideal of how posture should be, because I think posture in the past has always reflected kind of status and sex appeal and then it’s kind of been linked into this is how you should sit because this is good for your pain. But sitting up in an upright position with your head at a certain angle. Or even standing up in a very upright position can be comfortable for some people because everybody’s back and the way that people sit and stand are very, very different based on their own anatomy. Some people might find it extremely comfortable, some people might find it extremely uncomfortable. So it’s about figuring out where you are on that spectrum. If it feels really comfortable to sit up really straight, then doing that. In terms of the Ronaldo play, I don’t care about what posture that I’m in. And the reason is because there’s lots of long-term trials that say that if you do care about what posture you’re in, it create almost a fear of what posture you should be in and therefore you actually end up being in more pain. [Jaz] I’m getting deja vu, I’m getting deja vu from our episode, 270 episodes ago. I think you must have the same thing ’cause I then made the exact same comment. This like patients obsessing about their occlusion. And how their bite feels in a way. [Sam] Exactly that. Yeah. [Jaz] Okay. That’s very fascinating. So it makes sense to have ergo loops. I get it. Okay. And it’s amazing what we talk about. You can train your muscles to adapt to a certain posture. I think you, you made that point really well. What about these bambach chairs, and I think Brian have got this no bad or something, novic or whatever chair as well. Are they worth it? They’re not cheap. So ergo loops, I think is a big tick from Sam. Where do you think about these postures? [Sam] I think with these chairs, in terms of the trials that are out there, they say that it can improve your posture, whatever that means. So it can put you into that more ideal posture, whether that reduced or even increases. Pain is set to debate, but in terms of are they good for you as a dentist, that will solely depend on your own anatomy and the positions that you prefer. The crazy thing is if you believe that it will be good for you. You will almost train like the same way with your loops, Jaz. If you train yourself to sit in that position, eventually you’ll get to a point where you don’t wanna sit on any other chair, but a saddle chair or one of the Brian chairs because you’ve adapted to that chair, whereas you can adapt to other chairs. It’s just trying to figure out which one is the most comfortable for you. And people hate this because I’m not giving it one size fits everyone, but it’s because that isn’t really, I mean, that’s why with dentistry, we’ve got millions of teepees because there isn’t one size that fits everything and it can change. [Jaz] So if it feels right to you, get it. But maybe if you’re happy in your chair and you believe your own chair is working, then you know it’s fine as long as you are feeling good. But perhaps if you’re looking for change and you’re gonna buy one those chairs and you can also make that work. The human body is a very adaptable. But would you say that someone’s absolutely fine? Like I don’t get much back pain, touch wood? I don’t at the moment. And so would it make sense for me preventatively, as a strategy to improve my career longevity? Would it make sense? I mean obviously we’ll never know ’cause you don’t have the evidence for that, but what’s your gut telling you? [Sam] In terms of my gut, I don’t think it would make a massive difference. In terms of what chair you were going to get, but if you wanted to try them out, I think it’s a great idea. You might find that once you sit in it, you’d feel more comfortable. So I’d probably recommend when you’re at one of these dental shows, go and sit in one of those chairs and if you feel like, wow, this feels really, really comfortable, then I’d say for you, yeah, get it. But if you went to one of those shows and you sat in the chair and thought, wow, I feel really strange in this position, then it’s not to say don’t get the chair because your body will most likely adapt, but you might find that it takes a bit of time to kind of get used to it the same way as if you went from using ergo loops to go back to your loops, you would get used to it. Like you said, you get that kind of bit of burning pain in your neck and all that is is muscle fatigue. But you would get used to being in those position. So yeah, that’s what I’d recommend. I think it is just taking everything on an individual basis because every single person’s back and neck is completely different to the other person’s, just in terms of how it all works. [Jaz] And so before we pivot then to some aesthetic dentistry type stuff, I wanna just then tackle that unfinished business, right? So overall we’re suggesting, okay. If a chair feels right, go for it. Ergo loops. Probably will help you, but what are your like top three bits of advice that you wanna give to dentists that you follow, that perhaps we should be doing more to look after our bodies that may be with a physio hat on. [Sam] Help us prevent back pain in the future. [Jaz] How can you guide us? Because we made that bold statement, that posture, back pain are not really well correlated. A bit like occlusion and TMD is not well correlated, but in some individuals it could be the cause in some individuals the bad posture could be the cause of their back pain. I think you mentioned about acute and chronic. Do you wanna just talk a little bit about that? [Sam] Yeah. I think in terms of what we were talking about last time and this time with posture. Say if I was doing a difficult procedure, say I’m quite stressed, I’m doing a composite veneer procedure. It’s taken about three or four hours to complete, which sometimes they do. I’ve seen dentists take 10 hours doing a 10 unit case. Say if you’re doing that procedure, you start to get a little bit stressed. You are kind of in a position that is unnatural for you. You’ve got your head down and you are in that position where it’s quite, you’re putting a lot of strain on your muscles and you get some pain from that. Then if you were to get some back pain and the next day you wake up and you’ve got some back pain and you’ve got some neck pain, then there’s specific things that you can do to help that. I think the key thing, firstly, don’t worry because there is a massive between feeling pain and actually getting an injury. There is a massive kind of space between that. Your brain is very, very protective. It’s almost like a very sensitive car alarm system. So the alarm will go off. Before it causes injury ’cause evolutionary, it wouldn’t make sense for you to get pain once you’ve given yourself a serious injury. So firstly, like if you do start to feel pain, then that’s what I do. And we can delve into that a little bit more later in terms of what to do with acute and then we can delve into chronic pain in terms of preventative strategies and what I do. [Jaz] I think, Sam, let’s talk about prevention, because in that episode we did with Ben, actually, yourself and Ben, we talked a bit about just chronic pain and the signs behind that as well and how your best postures, your next posture and motion is lotion. All those wonderful things we talked about. So maybe talk about prevention before we pivot to some of the composite veneer stuff. So tell me about prevention. [Sam] Yeah. So in terms of prevention of back pain, all the evidence is geared around exercise almost everything, even though there is evidence to say that some postures can be more uncomfortable for others in, in dentistry and for different things. It doesn’t really make any sense because we did a survey a while ago looking at dentists in Liverpool, and we found that almost like 30 to 50% believed that having a good posture would prevent you getting lower back pain. That just simply isn’t the case because let’s take the common sense principle again. If you want to be in a position for a long time, your muscles have to be very conditioned to do that. If I said to you like, oh, you’re going skiing next week, you wouldn’t be practicing your posture. You’d be practicing, you’d be doing squats against the wall. You’d be kind of getting your legs conditioned, if you’re going to do a sport. You’re gonna want to condition your muscles to be ready for that sport. And that’s exactly the same for dentistry. You can be in those long positions, you can sit for more than 30 minutes, and it’s not a problem. You just have to condition yourself for that. So say if you are a student. You’ve not really done any long procedures before, and then you go into doing dentistry and all of a sudden you’ve gone from being on your summer holiday to then starting your foundation dentistry, and all of a sudden you’re seeing 20 patients and you’re sat on the chair and you’re a bit stressed. You are much more likely to get a back or neck pain ’cause you’re just not conditioned to do that. But after a period of time, after say, a month or two or something of doing it, it’d be much less likely for you to get back on neck pain because you have conditioned yourself to be in that kind of routine. And that’s the same with the gym. If you were conditioning yourself and you were started to do, a hundred pages squats or something, and then you took a six week break and then you went back to doing those same squats with the exact same weight, you are much more likely to injure yourself doing that. And that’s the same from if you were going from lots of short procedures and then you decide, actually I’m gonna start doing more composite veneers, and you spend three or four hours doing a composite veneer session, you’re more likely to feel a bit of pain ’cause you, again, you’re just not conditioned. So I’d say in terms of what I do, if I do start to feel pain- [Jaz] Go, Ronaldo, what’d you do? [Sam] I’m just thinking like, what has caused that pain? What’s going on? But then in the gym, all I do is I just do normal kind of exercises. I’m doing running and things a couple of times a week. I’m just doing the exercise that I enjoy- [Jaz] Because I’ve heard on like random BDA posters that Pilates is supposed to be superior and recently Simon Chard came on the the podcast and he said, deadlifts, he’s actually recommending deadlifts for dentists. He’s saying that’s good. But he’s not physio. So I’ll take your the Ronaldo a bit. So what do you think about deadlifts? Should we be doing deadlifts or, ’cause I know some dentists who avoid deadlifts ’cause they don’t wanna mess up their back for dentistry. But actually, should we be doing deadlifts to sustain what we do? [Sam] Yeah. I don’t see why not. Yeah, I mean, it is just keeping yourself stronger and keeping yourself active. You could do deadlifts if you want to, but some people don’t like going to the gym. And especially when I was at uni, I know a lot of girls didn’t really like doing deadlifts because sometimes they’re in like the kind of the weighty male section of the gym and they feel a bit intimidated- [Jaz] Or that grunting. [Sam] Yeah, yeah, yeah. So like it’s just doing the exercise that you enjoy. If you are doing lots of running or if you enjoy that or swimming- [Jaz] It’s a concept of gamifying, right? It is gamifying your exercise and actually fulfilling and enjoying it. I think you’ve hit the nail on the head because if you do stuff because Jaz or someone said in the podcast or do deadlifts and then you don’t really enjoy it and it’s awkward for you and it doesn’t really work out in your schedule or your environment. Then it’s not gonna be applicable in a daily world. You can’t make a habit out of it. But if you love swimming, you absolutely love swimming. Okay? And then you can take your kid swimming at the same time, whatever, and it works in your life, then that’s the way to go, right? [Sam] I think a good analogy is if you are sat down for a long period of time, imagine if you’ve got a machine and you are keeping it still for all that time, or even when you ask. Still, you can find that, when you pass, you can click your fingers or you can click your neck because you’ve kept still for that amount of time. So with a machine, you would oil the machine and that would help lubricate the joints. And you can do that with your body just through exercise. When you run, swim, do or do deadlifts, you will be compressing the spine. You will be releasing sign over your fluid, you will be lubricating your joints, you will be getting everything supple and moving. [Jaz] Motion is lotion once again. [Sam] Exactly. Yeah. Jaz’s Outro: Well I’m really pleased we covered all the back prevention stuff. That’s so, so a lot of the CPD questions for this episode will be linked to that, but I know one of your passions is composite veneer. Right? And then you mentioned about using stents. Let’s just pivot to that. So I think, just to summarize, previously ergo loops. Great chair. See how it goes for you. You made some great points about muscle adaptivity and making sure that as dentists, the most important thing we can do to protect our longevity is make sure that we have exercise. And I think it’s something that we all know. But sometimes hearing it like this, people, like one of my good buddies, message me saying, look, I’m really out of habit. I need, I need to, everyone says I need to get back in the gym. And it’s about actually taking that action and getting to it. And that could be gym for some people, it could be paying basketball. For some people it could be whatever it is, but making sure they have exercise regime and that will support them having a long career because it means your muscles, your core muscles are conditioned and primed to do what we do, which is very challenging physically. But you mentioned composite veneers and how that can take its physical toll on you, and I think you mentioned about using stents, so different ways of doing composite veneers. Freehand. Then there’s different, the smile fast kind of ways. Then it’s injection molding. What kind of techniques do you like, case by case, obviously it varies, but what are you favoring? Well, there we have it guys. Thank you so much for listening all the way to the end. This one is eligible for CPD or CE credits. We are a PACE approved provider, and if you’re watching the podcast on the app, Protrusive Guidance, just scroll down, whether it’s the web app or the actual mobile phone app and answer the quiz. If you get 80%, you can get your certificate emailed to you by our CPD Queen Mari. And interesting on the chat the other day, Ben, who used the app a lot, and I see him on our little community, almost 4,000 strong community that we have on the app and could be way more than 4,000. But I try and keep it within the podcast ’cause I really want to attract the nicest and geekiest dentist in the world. The quality of the dentists that we have on our little platform is far more important than the quantity. And so what Ben said was that he didn’t actually know, he wasn’t aware that there are premium notes for the episodes and there are transcripts for the episodes. So all these episodes we have like a cheat sheet you can download. And the way we are sort of redesigning the cheat sheets now, or the premium notes as we call them, is we’re gonna have a PITC section right at the top. So what does PITC stand for? Okay, it stands for Patient in the Chair. So this part of the notes is basically you’ve got a patient in the chair and you urgently need something from the podcast. You remember listening to a really important gem that’s gonna help you with your patient that’s in the chair right now. I need to find that piece of information. I know that people have done this before when they have a resin bonded bridge to fit and they’re frantically going through my resin bonded bridge course before they fit that bridge. And so in the same vein, PITC, the patient in the chair, I’m gonna give you the top five or six most actionable tips right at the top from all the future notes including this one. Obviously it wouldn’t be relevant for this one ’cause he wouldn’t have like a patient with back pain in the chair. It’s more to do with you. But you get the idea. It’s a new thing that we’re starting, but the whole, all the episodes of the past have got premium notes and transcripts and some of you absolutely swear by them. Shout out to Kostas and Harpardeep who’ve been absolutely pivotal in our little community. I know you guys enjoy the premium notes and the transcripts. I wanna take a moment to thank all the team that responsible for this episode. That’s Gian, Krissle, Nav. And of course our CPD Queen Mari. And thank you once again, listener, watcher, whether on YouTube or on our very own app. I really appreciate you. Thank you so much, and do not miss the next episode. The next episode is just full of so many gems. It’s a short but punchy episode on composite veneers and namely how and why Sam does not like the flowables like a Gaenial injectable for composite veneers. He likes to use the paste compule, find out which exact brand that he names drop. And they’re different companies, right? Different companies. He names drop these brands, which ones he’s using that he’s tested and are suitable for injection molding. That’s right. Compule composite, not flowable. Compule Composite for injection molding. What kind of stents he goes for? Who makes the best stents in his opinion? Because Sam himself has been on so many courses related to injection molding and composite veneers that he shares everything he gives away so much. So tune into the next episode where you pivot with Sam more into the composite veneers theme and a really interesting story of how things didn’t go to plan and what he learned from that, and the lesson he wants to pass on to us. So don’t forget to hit that subscribe button so you get notified for the next episode and catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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Minimal Preparation Veneers – PDP219 1:09:25

for 5 weeks siden1:09:25

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Are “contact lens veneers” just fake news? Why is the traditional 0.7mm prep approach outdated? Are you truly preserving enamel in your veneer preparations? Should you ever bond veneers to root dentin or cementum after crown lengthening? Why is the Galip Gürel technique the gold standard for minimal prep veneers? https://youtu.be/5BEFD1XaZtE Watch PDP219 on Youtube Dr. David Bloom joins Jaz for an insightful episode, sharing his 36 years of experience in cosmetic and restorative dentistry. With over two decades in the same practice, he’s seen what works—and what leads to failure—when it comes to veneers. We also cover the key steps in mock-ups, planning, and veneer preparation. Protrusive Dental Pearl: Always Wax Up for 10: When planning veneers, start with a 10-unit wax-up (even if the patient initially wants 4 or 6). This allows them to visualize their full smile with a mock-up, compare different options, and make an informed decision. It’s not about upselling – most patients will appreciate the fuller look. Key Take-aways: Health and diagnosis are foundational in cosmetic dentistry. Visual try-ins are crucial for patient engagement and satisfaction. Minimally invasive techniques are preferred for cosmetic procedures. Communication with patients about their options is essential. Bonding to enamel is more reliable than bonding to dentin. Permission statements help in guiding patient expectations. The transition from veneers to crowns should be carefully considered. Staining is not the primary concern when bonding to dentin. A change in surface texture is key in modern dental preparations. Visual aids are crucial in helping patients understand their treatment options. The Gurel technique emphasizes minimal preparation for veneers. Effective communication with patients can enhance their treatment experience. Understanding occlusion is fundamental in aesthetic dentistry. Veneer thickness should be as minimal as possible for aesthetic results. Patient involvement in the design process is essential. Cementation techniques can vary based on gingival health. Maintaining a facial path of insertion is important for aesthetic outcomes. Building a good relationship with lab technicians is key to successful restorations. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:56 Protrusive Dental Pearl 04:15 Interview with Dr. David Bloom: Journey and Expertise 11:54 The Importance of Enamel in Veneer Longevity 13:46 Prepless Cases and Visual Try-Ins 18:54 Permission Statement 22:24 Visual Try-Ins Protocol 25:13 Decision-Making: Veneers vs. Crowns 28:35 Bonding to Root Dentine and Long-Term Outcomes 33:34 Opening Embrasures: Techniques and Tips 35:19 Visual Try-Ins and Patient Communication 38:50 Wax-up in Occlusion 41:25 The Gurel Technique Explained 47:09 Black Triangles 49:40 Guidelines for First Veneer Case 54:10 Contact Lens Veneers 56:18 Cementation Preferences and Techniques 01:00:15 Final Thoughts and Educational Resources Need expert guidance on veneers and smile design? Join Intaglio Mentoring and connect with top mentors for real-time case support and level up your Dentistry. Dr David Bloom is also a mentor on Intaglio . Watch this space for David’s new educational website coming soon – he teaches Veneers hands-on too. If you loved this episode, make sure to watch How to Temporise Veneers Step by Step FULL GUIDE – PDP214 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/COSMETICDENTISTRY (Tooth colored restorations) #PDPMainEpisodes #AdhesiveDentistry Aim: To provide an in-depth understanding of minimal preparation veneers, focusing on enamel preservation, diagnostic workflows, patient communication, and clinical techniques to enhance the longevity, function, and esthetics of veneer restorations. Dentists will be able to – Identify when a prepless approach is feasible and when minimal preparation is necessary. 2. Use visual try-ins effectively to enhance patient understanding and involvement in treatment decisions. 3. Understand long-term maintenance, including managing black triangles, embrasure shaping, and repairs. Click below for full episode transcript: Teaser : We were used to heavily prepping and it was fine, but what I found was after seven or eight years, these units were popping off. And I mean, I'm a fourth generation bonding guy. I'm OptiBond FL was using the same bond then. I don't think it's about bond strength, it's about the enamel and longevity is enamel. Teaser: So I found after typically seven or eight years, the units were popping off and I wasn’t sure why. It’s gonna feel artificial, it’s gonna feel strange, but I don’t care what it feels like or I get what it looks like because within five or 10 minutes they’ll have adjusted it. It’s how it looks. I mean, originally when we had Feldspathic, you might say, oh, well just use a completely clear feldspathic portion in there. And that’s where that it sucks in the color from the underlying tooth. Some people are using Feldspathic and have for many years and it’s a great material. But any veneer is gonna, generally, unless it’s a high opacity, is gonna pick up color as long as it’s thin. Jaz’s Introduction: It’s another veneers episode. But with someone who’s got so much experience, 36 years and counting, and a wonderful man. Great dentist, a true GDP, who is pivoted into cosmetic and restorative. The key theme of today’s episode when it comes to veneer is not just the full workflow. I’ve done episodes on that before. And yes, we do go deep into the workflow. It’s a lovely perspective to have, but really the main focus is minimal preparation, the importance of preservation of enamel. But what about those scenarios where, let’s say you have some aesthetic crown lengthening. You have a gum lift. Am I naughty if I’m now partially bonding this veneer on root dentine or cementum? Are those cases more like to stain in the long run? Well, you see from speaking to Dr. David Bloom, he’s been in one practice for 24 years, so he knows what works and what doesn’t. And he mentions he’s seen some cases that come back as failures. And what was the reason for that failure? We essentially dissect the Galip Gürel technique. This is a really contemporary and essential way of prepping for veneers. Like when I qualified, I was taught that, okay, for veneers you’ve gotta do like, 0.7 millimeter of prep. And so in my mind, whatever tooth you have in front of you, you put a 0.7 millimeter margin on all these teeth that is totally wrong. And you’ll see for many reasons why that is wrong and why the Gürel technique is really the way to go. It helps us to give the patient the smile they want, but in the most minimal way. We don’t go too deep into temporization ’cause we did that in a recent episode with Aidan. So to check out that episode, if you haven’t ready, if you wanna go deep into temporaries, but in this one we talk about the mockup, the planning, and the prep itself. Find out in the end why contact lens veneers are fake news and why you should never do a depth groove at the cervical region. Hello Protruserati, I’m Jaz Gulati and welcome back to Your Favorite Dental podcast. This episode is totally eligible for CPD or CE credits. You’ll just have to answer the quiz at the end. Dental Pearl The Protrusive Dental Pearl, which I give you in every PDP episode. Gosh, we’ve got hundreds of those. Now I struggle to keep up. Sometimes I get anxiety that I’m repeating a pearl, but it is what it is. And for those of you now listening, I’m examining my hoodie, my Protrusive Hoodie for stains. I went to my mom’s for a curry today. I had some butter chicken, not butter chicken, butter chicken. And I look to have got some on my hoodie. So, thankfully it’s hidden in the camera, but I can tell you now, the aroma in my office is fantastic. By the way, butter chicken, like is one of my pet peeves. Like Indian people, when they go to Indian restaurants, they always seem to order a butter chicken. It has become, for me, the most like boring vanilla thing that you can get an Indian restaurant. So my recommendation if you wanna be a bit different like me, is next time you go to a good Indian restaurant. Order the Lamb saag. So this is like a spinach and lamb dish. Much tastier, much richer, much more adventurous, and way less boring than the butter chicken. Anyway, that was a massive digress. I was just coming on to the Protrusive Dental Pearl. So your patient comes in and they want, let’s say four veneers, upper lateral to lateral, or maybe they want six and there’s a reason why you should never do six, and maybe they want eight, maybe they want 10, you don’t know. But in your wax up, go for 10. Okay? In your wax up, go for 10. Because actually what you’ll do is when you do the mockup i.e., you transfer the putty with the physical into the mouth, and you and the patient assess together how it looks to give the patient an opportunity to see the full smile is so key, because then what you can do is that you can take off the second premolars and the first premolars and the canines and then see, okay, well this is what lateral to lateral looks like. But we could actually beef out the buccal corridors. Which one do you like better? And this isn’t like a sales technique, it’s actually doing your patients justice. Think of Chandler from friends. Remember his smile? He had these horrible buccal corridors and then he had that corrected. And so by going for this 10 unit approach from the get go, it’s the ultimate level of consent, and more than likely, your patient will probably end up going for it, which is great news because they’ll have a more beautiful, fuller smile at the end. The downside is it costs more in terms of lab bill, but your patient is paying your lab bill and they’re paying for your time. Again, it’s a theme that we cover with David in this podcast. Hope you enjoy it and I catch you in the outro. Main Episode: Dr. David Bloom, oh, it’s so, so, so lovely to have you on the podcast. Usually, when I see you nowadays, it’s like we both had our drink. We’re outside, hotel somewhere, usually after like BACD or something and it’s always so nice to connect with you. I went to, I dunno if you remember this lecture I attended of yours maybe 10, 11 years ago. Chloe’s Diamond Event. And you talked about veneers. That was my first lecture I attended of yours. Do you remember that? [David] I do remember, yes, absolutely. Yeah. Long time ago. [Jaz] You must have spoken so much. I don’t even know how you remember those events. And then that on that day I walked away just learning about your meticulous process and how important the wax up was as a blueprint, which I’m sure we’ll talk about. And that was really inspiring. And so it’s so great to have you on today. You are very well known in the UK in terms of high-end cosmetic dentistry. So it’s an absolute pleasure to have you on to talk about something that you are very passionate about, minimally invasive veneers. Before we delve into that, just for those people who haven’t heard of you, perhaps across the pond and around the world, tell us about yourself, David, how did you venture into cosmetic dentistry? [David] So, I qualified in ’89, so I am 35, 36 years qualified in June. I worked with my father for many years. I’m a GDP and did that for 10 years. And then a certain gentle book called Larry Rosenthal came across to the UK. I started with Larry after I was already 11 years qualified, and a few of us started on his course and that was an eye-opener. And then from there we got onto the AACD ’cause we didn’t have the BACD, but thank goodness we do now. We spent a lot of time traveling and from the AACD, we started the BACD and that was the whole journey. I’ve learned so much along the way and that lots of what we’re gonna talk about is I am reinventing the wheel because I didn’t develop this, but I’m happy, very happy to share it, and it is a journey and a process and so. Even when you were talking about closed diamond events, I think we’ve evolved from there now because that was the wax up, but now it’s how you do the wax up and how you use it. [Jaz] And that’s exactly, I wanted to get into as little details and you are very much, I don’t want anyone to think that you are a veneereologist in any way because you are so much more than that. You may not remember this. I came ’cause I did the diploma with Ortho when I came to Shadow Mohammed Almuzian and I remember you were there at the clinic. I was, oh, okay. David, nice to see you. And then you were there and you were doing some lingual ortho at that time. So you’re doing some lingual ortho at the time, and I know you do a fair amount of ortho and tomorrow you got like a full case tomorrow. So you are a very complete dentist. What would you advise, and this is a little bit off tangent, but what would you advise to young colleagues newly qualified who want to get to this level where they are complete dentist? What advice would you give them nowadays? [David] So I consider myself a cosmetic restorative dentist, but first and foremost, a GDP, so basics. And from there I studied occlusion. I was lucky enough to study with Roy Hixson and BSOS, and that got me started. So the foundational work to be able to add all things to your armamentarium, and I did a lot of, we did, veneereology unfortunately was a bit of a thing 25 years ago, but thank goodness we’ve moved on from that. We have pre-restorative alignment. Lots of colleagues have been involved with that. And so yes, I’ve learned ortho and it’s continually evolving, but I also was lucky enough to be in the same practice for 24 years. And it’s an eyeopener to see what works in the long term and what doesn’t. Ortho has been amazing and short term ortho, but we still have our orthodontic colleagues. Then the other thing I would add to that is my Bible, my dental Bible is Schillingberg. So understand how to do old fashioned resistance and retention forms, and we both love verti preps. That makes it a little bit easier, and so the knowledge, the basics, but then the hand skills to be able to get retention on anything and Herodontics is also a bit of a passion of mine. Only because implants are great, but only if we have to. [Jaz] I’m glad you mentioned that. I saw a patient today and we’re gonna be doing a hemi section of a upper left second molar, in a few months time. And the occasional time I get to do it, and touch wood, my case selection has been good enough that ’cause I’m done millions of these, right? The cases are, you have to be very, very selective these cases. But it’s great to be able to do such Herodontics actually says good fun. I’m glad you mentioned that. And you definitely are very, very complete from what I’ve seen you, so I’m really thankful for you to even answer those little tangents and give advice about doing the basics. Yes? [David] And one other thing to add, I mean, if we’re talking about Herodontics . Let’s not forget Lindhe-Nyman bridges. [Jaz] Please explain for our younger colleagues what these bridges are. [David] So, Scandinavian dentist, Lindhe and Nyman 30, 40 years ago, they realized that you could splint terminally mobile teeth together. And I was lucky enough to be mentored by one of my mentors was Hubba Shah, who’s a periodontist, and he believed in it. I have a patient now who has 28 years of a Lindhe-Nyman bridge on teeth that otherwise would’ve been taken out. [Jaz] How many abutment teeth? [David] She was quite a few, but I mean, splinting them helps. But I had my father in, before we knew what we did about implants, I had him on a Lindhe-Nyman bridge on two canines for 18 months. [Jaz] And this was just replacing canines, canine, also like a cantilever to premolars. [David] He had, for many reasons. We kept it going and whilst we transitioned him to implants, we had him on two upper canines on a 10 unit bridge for 18 months. [Jaz] So, yeah, I mean, you guys search the Lindhe-Nyman bridges, there’s great data and for those patients who are suitable, this can be a great option. So it can delay implant placement or sometimes even avoid it for many years. So I’m glad you mentioned that. [David] And I believe in all of four. I’ve been doing all-on-four for 20 years, but it’s the last resort is what I’d say. And so. Herodontics and let’s learn in answer to your question, let’s learn how to save teeth whenever we can. [Jaz] Wonderful. And what I love about you, David, is that you talk the talk, you walk the walk in terms, you do it. But then you surpassed the daughter test, right? You have the daughter test and then you have the self test. ‘Cause I was there when, when Tom Sealey was doing your veneers. And so just happened to shadow Tom Sealey that day and seeing his wonderful work. And it was you, the patient that walked in and was, oh my god, it is David Bloom. And so I, saw the whole process of your veneers being done. So there we are, the daughter test. Yes. But then it’s a self test. You believe in this protocol and your smile looks great. And I saw, I was very lucky to witness it. [David] Thank you very much. I mean, it’s also, I mean, I’ve treated my mother, my father, my mother-in-law, my father-in-law, my wife. I think we shouldn’t be a afraid of embracing the daughter test as long as we know. We’re doing it responsibly, Jaz. You, you know, you, [Jaz] You say all those things. But that scares me, David, because all the dentists I speak to, all the stories come out when you talk about treating family, right. Treating family and friends is when all the stories come out. I dunno how you do it. [David] Well, I mean, it’s again, like everything, it’s a privilege. But I mean, I treat them like I would any, I make contemp lots of notes when I’m treating my family. Just ’cause it’s a deep. [Jaz] That’s a secret because if you put your guard down and then you become too familiar, that’s when things go wrong. [David] Absolutely. So once we put our white coats on, or not our scrubs on, but we used to be a white coat. And I think you’re right actually. And treat everyone the same. And then they are a patient, not a relative. [Jaz] Brilliant. Well, minimally invasive veneers. Okay, so we have so many questions. Like recently, I hosted an Australian chap, Aidan, and we talked about the temporizing element of it. And so I wanna touch on your protocol, so there’s so many different questions I have for you. I wrote them down and I know you sent me a wonderful summary as well. So guys, there’s so much meat in today’s episode, I have to say. But the first thing when I learned about veneers, and from you as well, is the importance of enamel as like, being a, such a key requisite. And then you already mentioned actually, in terms of your evolution, right? And what you were taught perhaps in Rosenthal and the kind of preps that were then back in the day compared to now, and how therefore your protocols involved. Tell us about the importance of staying enamel, why that’s important for longevity, for those who don’t know. And then I want you to then bring in the kind of protocol that you use now so that we can remain in enamel the best way possible. [David] So I touched on that, having been in the same practice and starting with what we were all doing, quite aggressive preps, we would offer ortho, but ortho would classically be a year to 18 months. We didn’t know that we could just do anterior arrangement like we can now. So we used to heavily prepping and it was fine. But what I found was after seven or eight years. These units were popping off. And I mean, I’m a fourth generation bonding guy. I’m OptiBond FL. I was using the same bond then. I don’t think it’s about bond strength, it’s about the enamel and longevity is enamel. So I found after typically seven or eight years, the units were popping off and I wasn’t sure why. And then we realized that for longevity we need to be an enamel because that is a permanent bond and we all know the water and that’s what it tends to degrade. And I believe in dentine bonding. I’ve studied with Pascal, we’ve done IDS, so I understand all of that. But if we’re gonna be certainly elective treating the patients, we need to be as minimal as we can for the longevity. And we will talk about a 10 to 15 year lifespan. I think that’s fine. But the purpose of that for me is so that someone understands that it is gonna have a lifespan. It’s gonna fail eventually. But I think bonding to enamel, I’ve got cases that are going 20, 25 years. Because they’re bonded to enamel. [Jaz] And when we want to plan to bond to enamel, there’s the whole concept of no prep. But what you are talking about is minimal prep. So is there a place, firstly of no prep, for example, you just take an impression, take a scan, send the technician, and they literally just send you back some veneers. Does it ever happen that way that you can just do no prep? [David] So first of all, what are they sending back? So I mean, we have to go through our workflow, which first of all is a comprehensive exam. We have our photographs, we have our conversations with our patients. What do they want? All all of that we are taking is a little bit of a given. But how do we plan to smile? So first of all, it all boils down to smile design. We have to be really very confident. First thing I’ll do is after our social graces and finding out what our patient’s concerns are, is I’ll take my photographs, I’ll take my standard BACD shots, I’ll take my M sound for lips At rest, I’ll take my e sound. For maximum gingival display, I’ll take a shade picture and that’s all for my diagnostic. So even with a prepless case, I’m going to be giving a diagnostic to the lab ’cause I have done prepless cases. They are rarer than s teeth for for reasons we’ll get onto. But even with that, we need to start with a diagnostic because I would still do what we’re gonna talk about as a visual try. And so before I touch anybody’s teeth, even with a prepless case, I want to have their buy-in and their understanding of the process. And prepless cases are great, but reality is a veneer generally is half a millimeter thick. Can you add that whole half a millimeter without making things too bulky? And so the analogy or the patient would come and say, I would like you to do a case without touching my teeth. We’ll do a visual try and if they say they’re too bulky, they’ll understand why I have to prep their teeth. And if they’re not too bulky, then fair enough. So prepless is great. [Jaz] And this is before you even get like an additive wax up. What you are alluding to is doing a chairside mockup in terms of visual trying. Is that what you mean? [David] Absolutely. So the workflow is, does someone to make the changes. We discuss what that is to help them visualize it. And even actually for your routine patients, it’s entirely reasonable to say, well, I’ve got something I’d like to show you because you might have a small and deficient back back of corridor. You might just have some chipping. So yes, I’ll do some mockups, direct mockups, and it’s all about the workflow of helping them move forward. So that would then take them to a wax up. Now a wax up is always gonna be additive. The question is how much additive and if you want a prepless case, then you are trying to add the whole half a millimeter. Now that might be okay. It might not. Generally speaking, I find that it’s not always okay without making things too bulky. But the real crux is that you can always add 0.2 or 0.3 of a millimeter. Always. And I’ve been doing this for 20 years, since my eyes were opened when I did a member’s pearl at AACD about visual try, and I was introduced to the idea of an additive wax up. The question you’re asking is how additive can we be? Mm-hmm. And we can’t always add it be additive that 0.5, but we can always be additive that 0.2 or 0.3. Now we therefore have an opportunity to show the patient, confirm that we’re on the right path, and they understand why some preparation. And therefore, if we’re only prepping 0.2 or 0.3, ’cause we’ve added 0.2 or 0.3, and we’ll talk about how we can be sure we’re doing that. That means we’re a hundred percent enamel. And that’s the only way I think we can really be responsibly prepping teeth. And if we pre align, that’s always possible as well. [Jaz] When you are seeing these patients, first time you’re doing your full photos, full diagnosis, you wanna hear their wishes. And in our sort of pre-chat and the discussion that we’ve had by email. Like, I don’t want anyone to think that dentists are just going into veneers. You are very much a GDP first. You are stabilizing caries. You made a point about making sure that their periodontal health is good and kind of yes, that is a given in a way, but it’s just worth mentioning because it is a such an important phase of it that not everyone qualifies themselves to have veneers because they don’t show you that they have the commitment. Would you agree with that statement? [David] Absolutely. Health, first we have to do a diagnosis prevention. I’ve worked with a hygienist since I qualified. My father had a hygienist, some well-known hygienists I work with, and it’s a prerequisite health first and elective treatment. Explain to a patient, whatever I do, however well I do it. It’s gonna have a lifespan and the key is to do as little to your teeth to achieve what you want to achieve as possible. So we all know aligned bleach and bond or aligned bleach. Correct. Whichever. Same thing with just different terminology. Absolutely. Pre alignment. I’d said we do a lot of short term ortho and we can talk about composite veneers as well, but it’s a pathway and sometimes people want more than can be achieved with just aligning bleaching bond, whether that’s a color issue. So it’s the responsible pathway and giving the patient the options. And my job really is to give a patient the information so they can make the choices that they feel are right for them. However we do that though, we have to do that as a responsible as possible. [Jaz] And when you are speaking to them about their smile, let’s say they are stable now, caries, perio, they are a gold star patient that you wish to go further with because the last thing you wanna do is do your lovely veneers when there’s inflammation, bleeding, et cetera. So we know that okay, the patients are on board, they’re an, you know, as a, in the perial world, they call it an engaging patient, right? So you have an engaging patient, fine. And you wrote an interesting note to me. You wrote about a permission statement. When you’re communicating, tell me what you mean by a permission statement. [David] Well, sometimes, I mean, I’m a GDP, so sometimes now at this stage in my career, I often have people coming to me saying they want to change their smile, which is lovely. But also as a GDP, you see people’s smiles and you know that you can make some changes for them that they don’t know, but you have to ask their permission essentially to say, can I show you what I can see in my mind’s eye? And obviously we can do Photoshops, we can do imaging, but there’s nothing as powerful as being able to show someone in someone’s mouth. So it’s polite to say, can I show you something that might be of interest? And it might be ’cause you’ve been on a course or you just said something I think you might see. And that it’s really powerful when they say, oh, I didn’t realize that. And I’m not trying to sell anybody anything, but I’m passionate about having a lovely smile and a cosmetic smile and how can they understand what’s possible if we don’t show them? So I think it’s entirely reasonable to advise people of what’s possible without trying to sell them anything. But if we’re gonna do the work, we have to do it responsibly. [Jaz] I think the great example of that, and I think you’ve spoken about this before, is if someone comes in with the preconceived idea that they need upper two to two, so lateral to lateral for our American colleagues, or canines, canine. But then once you do the visual mockup, then you can show them, but actually it’s your duty to look after the buccal corridors and show them, because the last thing you want is a patient to complaint in the future. And so that’s when you get their permission so you can show them. And when you do that, do that one side or do you have both sides or they can see a difference left and right. [David] Well, so if we’re talking about the workflow, it’s everything is a step to help them move forward. So for a buccal corridor, for example, I probably might not touch three to three. I will just show them widening the buccal corridor. And I mean, classically the number of teeth I like to do is one four or 10. Six is a bit of a bug bear for me, but almost a much of a bug bear is eight. So people won’t necessarily understand that. But if we wax up 10 and we do a visual try, what you can do is just take off the last two units and suddenly they realize that they have negative space if you don’t do enough teeth. And similarly, so it’s all an education process and a demonstration process because some people say, well, I want you to do six. I may not choose to, but at least I’ve shown them why I might not. But asking their permission to show them and then the additive wax up and then the visual triad, which is the key, which is before we touch their teeth, we have a putty index of their additive wax up, and we can put that on. And that allows us to take extra units off. So you can show them 10, you can show them eight, you can show, et cetera. So it’s in- [Jaz] So the trick there is wax up second premolar, second premolar, but then you can always take units off to show them the lateral collateral canine to canine. [David] And especially in the UK where historically we might have had more premolar extractions than we’d presently, like, so a 10 unit would involve premolarizing the sixes, so look like a premolar. And again, it’s not about selling them the extra units, it’s saying what I think would look best. And once they see it, they invariably do. And the power is that you can take off the extra units and allow them to visualize it and everything that, and my journey started with the visual diagnostic try, which is basically a try as we get onto, it’s what Galip started, but we prepped through that. During them see it stage by stage, and therefore they decide and choose the treatment that visually looks best. [Jaz] Tell us about when you are seating. So you’ve got the wax up, you’ve got the putty of it, which brand of bisacryl you’re using, and are you just drying the teeth and loading it up or are there any other tricks that you’ve learned to make the visual try and just pop a little bit more and have a bit more of a gloss, ’cause sometimes the last thing you want is a bisacryl that’s like bubbled and feels really uncomfortable and sharp and annoying. ‘Cause then they’re drawn to that rather than actually what it looks like. [David] Very good point. And I do explain to ’em that it’s gonna feel artificial, it’s gonna feel strange, but I don’t care what it feels like or I get what it looks like because within five or 10 minutes they’ll adjust it. It’s how it looks. From there, I think it’s a lot easier now we have digital wax up so we can have really good quality, surface anatomy, which obviously was a lot harder when we were doing that analog. And then a putty index that I would generally say get reline. So there’s ways that you can, there’s a putty with a light body flow. And then my favorite go-to, and we’re not sponsored by DMG, we should be, they’re a great company. So luxatemp for me, there are many others. And the reason I like luxatemp is that it’s actually got a significant amount of composite in it. So what we’ll talk about is that you can add to it. So part of the skill is I don’t, and I say to a patient, this is our starting point, not our end point. So we start with vision. So you should be able to re-contour that, know how to re-contour that. That’s a skill that’s essential to learn because they say, well, I don’t like that. And then you say, well, I can make these changes. And suddenly they see that it’s actually a process, not this is how it’s gonna look. But a good bisacryl, my preferred is luxatemp. Being able to recontour it and then just a glaze. But also pre-warning the patients of what to expect. It’s gonna feel artificial. Like everything. Once they know, they understand, I’m just showing you how it looks. Don’t worry about how it feels ’cause it’s gonna feel very alien. And then you may not be right, but pre-discussion, do you like open abrasions? Do you live in Essex or Liverpool? And do you want straight white teeth? Which obviously there’s the move for, try not to encourage that. But we talk about shade before and when I do a visual trying, I try not to go for a very bright shade. I try to go for a natural shade. I want them to see the teeth, not the color. So those are the tips I would suggest. But again, it’s a process and every time you have touch points that help the patient be very involved and medical legally, they can’t really say they didn’t know what they’re letting is or they themselves in for, and probably one of the favorite things I say to a patient, a patient’s gonna say to you, well, what are they gonna look like? And old school dentists will say, trust me, they’re gonna look great. Well, that’s not really want, I’m gonna show you how they’re gonna look. We’re gonna work it out, and then we’re gonna have a lab copy that. [Jaz] Lovely. So we’re gonna get into the workflow of this. ‘Cause there’s a lot involved here, but in terms of just going, taking another step back now and decision making, I just wanna know from you and your experience of doing all these units is there comes a point where you’re gonna transition away from a veneer to a crown because of, it is a huge composite, or for whatever reason, can you give us some guidelines of these teeth can be a veneer ’cause they meet this minimum criteria, but actually to get a good, stable, long-term result, I’m gonna have to put a crown in the mix to make sure that this tooth actually will get some longevity and predictability. [David] So first of all, I explain to a patient that the fee is per unit, whether it’s a crown, a veneer, or a veneer onlay, however you like to call it. From there, it’s one of my previous mentors, Bill Koic, said, be a thinking dentist. And we all think and solve problems every day. So take out the previous restoration, have a look, do you have the enamel? Can you do a veneer onlay? And I’ve been doing onlays for 30 years. They’re wonderful. But again, sometimes it’s possibly easier, not easier. Maybe it’s correct to do a full coverage. A zirconia. And as you’ve said on some of the cause, it’s not that much more aggressive. So I think there isn’t a hard and fast cookery rule you can give, but have you got enough enamel? And sometimes a veneer onlays a great preparation, but then sometimes to just do a little bit of palatal preparation, suddenly you’ve got a crown. But again, you’ve gotta be comfortable with your prosthodontist skills to be able to get retention. So there’s the mix, but I’m happy with any of them. Reverse three quarter crowns really don’t have a base, I don’t think. ‘Cause reality might not be on enamel. But at the same time, do I do slice preps? No, but I’m okay with a slice prep. In certain situations, if we’ve got diastemas, you’ve got pre-existing class threes, you can do a slice prep or you can replace the class three with a a direct composite and keep it more minimal. So it’s get a feel for what is correct for that patient given the state of their teeth, the preexisting. And if we’re talking about new cases, then obviously it’s much easier. But we live in a real world where people have pre-existing large MOD restorations, they have class three restorations. And so be a thinking dentist. [Jaz] So if it’s a small class three, you would just replace the composite and then put your veneer on that? [David] Absolutely. I would want to be on fresh composite, but at the same time I would still like, ideally one restorative margin. And there’s many ways to do it. Mine isn’t just the right way. It’s what you feel comfortable with. And if I’ve got enamel, I’d rather bond a restoration on, but sometimes you’ve got so little enamel, why are you trying to do things that aren’t necessarily gonna work in the long term? And we have the luxury now that we don’t have to think about PFM, we don’t need that much space. So we can do things that are almost as conservative. So I love traditional resistance and retention and cementation, but I also love bonding. [Jaz] That’s very clear. And I like balance clinicians. I don’t like the idea of I only do verti preps or I only do this. It’s really like you said, being a thinking dentist. So let’s challenge you as a thinking dentist. Let’s picture a scenario whereby you’ve got, and you mentioned this in email as well, crown lengthening case. Once you do the aesthetic crown lengthening, now you are on a root dentine. Now to actually do some veneers that will finish and bond to root dentine, but then you get to the other benefits of a veneer. In that scenario, how do you feel about those scenarios and what have you seen in your experience spanning so many years? How do they actually hold up long term? Do they stain more, are they more likely to fail, or do you find that the remainder of the enamel in that tooth actually covers you? [David] Well, I think you just said it, you gave it away and you gave my answer at the end. Thank you for that. I am not anti-dentine bonding. I believe in dentine bonding in dentine. It’s not that we can’t, I think if you have a significant amount of root or cement, some you’re bonding to ’cause you’ve done crown lengthening. Often, it’s not as much root as you think it is, but I think the priority there is you have to have enamel for the rest of it. And if you are doing, and Galip’s done a lot of work, the structural integrity of the tooth is, if you’ve got then slice preparations. Even though you’re an enamel, that’s when I think you’re more likely to have cervical failures. If you can keep the structural integrity, then I’m very happy to bond to root surface, although it’s probably not as much root surface as we imagine it to be because the rest of it’s enamel. So once you’ve got a compromised tooth, then I’d be more likely to think full coverage. But a lot of these cases where they are gum lift cases, they’re not restored teeth. So as long as we’re additive, we then predominantly on enamel with a little bit of root service. I’m absolutely fine bonding to that. But once you then have significant compromises interproximally, they will work and they’ll work for a significant amount of time. But that’s when we see the cervical areas pop off. It looks like a class five. But if that happens, I wouldn’t necessarily rush in to replacing that unit. And one of the things is we can repair porcelain more than we think we can repair with composite. And I’ve had that because I’ve had cases that are 20 years old. What do you do? And they know that they may need replacing at some point, but I wouldn’t necessarily rush. And if there’s bit pings off, they keep that piece air abrade it, HF, acid etch it, you can bond that on. And I’ve had a number of those repairs that can carry on. So again, be a thinking dentist, but if you’ve got significant amount enamel, I’m okay bonding cervically to root. [Jaz] And just a small one on that, like do you perceive or have you seen objectively those margins on cementum, root dentine, do they stain more? Is that something you’ve observed? [David] The staining is not the issue. The issue is that eventually that’s gonna be your weak spot. I’m not even concerned 10 years or less. I mean, I think it’s still worse 10 years, but it’s not the same as bonding to enamel. But you’re still gonna have a very good expectancy, they shouldn’t stain. It’s only that eventually will be the weak spot where you’ll get a failure in your ceramic. [Jaz] And are you still putting a little, I mean, we’ll talk about the prep when you prep through and the using the Gürel technique when you prep through the try in. But when you are on the root cementum or the high by the gingiva in those gum lift cases, are you still putting a bit of a little chamfer in there or are you like not touching it ’cause you don’t want to? How are you managing those areas? [David] So my margin generally is always a micro chamfer, which is technically a slightly exaggerated vertiprep, but it’s certainly not a a a J loop chamfer. Those days are gone. So, and we’ll talk about it, but you are talking about root surface, but whether that’s enamel or not, it’s gonna be the same preparation, which is vaguely, you can just about see a vague sculpting line, Equigingival, and that would be the same whether it’s on root surface or on enamel. And when we talk about the Gürel technique, and he’s too modest to call it his technique, but it is him, I don’t put a depth cut cervical because a depth cut classically is 0.5 and cervical enamel is about 0.3. So I will put two depth cuts in, but I won’t go cervical. So the preparation will be the same if it’s enamel or if it’s root surface, but it’s a very minimal micro chamfer. [Jaz] One thing I really like that Attiq Rahman says about this exact theme, a topic is that he says, we’re not gonna call it a my A source semantics. Let’s not call it a margin. But then what he says is a change in surface texture. And I really like that as a term for someone to understand that actually it is a change in surface texture. And you get to see that actually we’re definitely not making anything resembling a schellenberg chamfer. It is a very, very subtle in that regard. [David] Absolutely. And we’re not reinventing the wheel. When I first qualified, I used to give my father a really hard time because he used to do the knife edge prep, and that’s effectively what we’re doing every time. And he’s different from BOPT, which I have no issue with, but you’re right. A vertiprep is just a change in direction. And so me, I like the lab to know where the margin is. It’s equigingival, and I have no problem doing prepless veneers. So if we can do a prepless veneer where there’s no margin, why do we have to put a heavy margin on anything else? [Jaz] Brilliant. So now let’s talk about the stage whereby. You have got the try in the mouth, you are using your luxatemp. And then you said a wonderful thing whereby, okay, you’re opening up embrasures and I’m being greedy. I wanna learn in terms of exactly what you’re using, because sometimes I find soflex disc there, they can be a little bit aggressive. So I’ve heard people say, get those metal discs, which then you can make cute little abrasions and widen them as you go along. Well what’s your preferred method to open up abrasions without then taking off too much physical, which isn’t the end of the world ’cause you can add it back a flowable, but how do you work in those sort of delicate margins? [David] So soflex are great. I use them a lot. They call them coarse, medium, fine and super fine. I call them one, two, three, four, much easier. I don’t tend to use one a lot. I use two a lot. One and two are cutting two and three and four are polishing. So, and a great tip that a lab ceramic gave me is that when you’re contouring, the embrasures, do it from the palatal. Because you can round it more. But again, we’ve had a pre-discussion of what sort of look they want, and going to those details is important, but patients will tend to know what look they like. And the top tip I’d give about a- [Jaz] How do you get them to, you come to it now, but how do you get them to communicate that? Because some people will bring in photos of celebrities. There are textbooks with stunning visuals dedicated to this. Do you use any of those aids? [David] I found just having a con, an honest conversation with them. I mean, do you like the look? And we can look at that, but equally well, it’s actually quite easy to open an embrasure or close an embrasure with flowable or with soflex. I think the soflex don’t use two courses of soflex and always know that if you open it too much, it’s actually quite easy to and flowable and the tops would be spend some time contouring against your teeth, getting a model and just practicing because it actually is probably the simplest bit. But my top tip would be for a visual try and it’s all the workflow. So we have either a patient that’s come in wanting veneers or a patient that’s preexisting. You’ve seen that you can make some changes. We’ve maybe done some mockups to help them understand that I want to move them forward to the next stage, which is an additive wax up from the additive wax up. We’ll do the visual try. Now, this is the only time I get a little bit cheeky is that I don’t like to send a patient away with a visual try. ‘Cause the most powerful part of that appointment is to take it off and give them a mirror back. ‘Cause then they really understand what a change it makes for them. And again, it’s not trying to sell anybody anything. It’s te helping them to understand how water change it makes, and it can be massive. So explaining to them that this is the starting point, it’s not the end. We could change the shapes and you could easily say, well, you could open the abrasions on one side or not on the other side. And let them understand because it’s a very personal thing of how they want their teeth to look. But my top tip and Pascal Magne obviously sends patients away and I think that’s very good. I would rather they bring their significant others to that appointment or- [Jaz] I was just gonna ask about that because the last thing you want is someone to go home and a comment be said, and then therefore they’re back with you. And then you are repeating that work is really important that there’s significant others involved in that sort of discussion. [David] And I’ll also take photos. I put everything on Dropbox, so I’ll share the Dropbox with them. But they understand that it’s a start of the design process that we can have open, we can have close. You must understand how you can achieve that with soflex. But as it answer your question, maybe a two or two, certainly not a one, but if you do overdo it, you can fill it in. But then it really is powerful when A, they first get the mirror, but B, when you take it off and you give them the mirror back. And it’s all about helping people to see it visually themselves. ‘Cause looking on a screen, how do you diagnose it? You can have the photos up, you can show other people, but nothing is as powerful as showing them in their mouth. And they won’t understand an open embrasure or a closed embrasure until you show them. And when you show them, say, well, I like this side, or lots of tips you can do one side, as you said, not the other side, but it’s helping them work out what is visually appealing to them. [Jaz] Over your years of experience, how long are you booking for that appointment now, where the first time you’re gonna do it because, it’ll be a lot more time for someone who’s less experienced. But, just so know when you reach your level of experience and how many units you’ve done, how long is David booking for these? [David] I’m certainly not rushing it. And the reason is that I don’t charge just a lab fee. I incorporate my surgery time for the visual try and appointment. So whether they say yes or no, my time is covered. I’m not trying to sell them anything. So a wax up might be, let’s say it’s 30, 35, 40 pounds a unit. I might be charging 75, 80 pounds a unit. So my time is covered. For four units, I’d probably allow 30 to 40 minutes for 10 units an hour. But we might get the time to touch on the fact that sometimes it might be more, it might be a full mouth. Generally not more than an hour. But certainly not less than half an hour. And I want to have them have time to have a look at it, get used to it. I’ll take photos on their phone and again, I want to stress, it’s not a sales technique, it’s helping them appreciate what’s possible and the best way to show them that is in their mouth. Then they could decide what they like, what they don’t like and they don’t have to proceed from the wax up. But generally, if you’ve got the diagnostics right, they will do. [Jaz] And at this stage when we can call in additive wax up ’cause we’re trying to stay in enamel and that’s great. But is this wax up at this stage? Does it dial in some of the occlusion, like to make sure the edge to edge is correct, nice and broad to make sure that when they come on to crossover, everything’s respected or would that come in later? [David] So I tell the patients that the wax up, the diagnostic wax up is for them. It’s as much for me as it is for them because I’m working out where we are. I exclusively, can I build in the guidance and. Obviously occlusion is fundamental, but there’s techniques where we can actually enhance the function with our restorative, because we can build in guidance and different conversation. But the hardest part of an equilibration is not removing the CRCO slide is picking up the guidance. If you’re doing restorative dentistry, sometimes that works very well in our favor, so I am involving that for me, but I’m not necessarily taking them down the complexities. Although if I’ve got a D type personality that needs it, or even I might involve that, but I am using it for myself as a diagnostic. [Jaz] Brilliant. So whilst we are doing the embrasures, we’re doing the aesthetics, you are also maybe adding a little bit more to the canine to pick up more guidance. For example, allowing you to lengthen that lateral to check the crossover position to make sure not only does it look good, but you are satisfied that what you’re doing is something that you can actually deliver in that patient’s occlusal scheme. [David] Absolutely. So, the diagnostic is for me to check functionally. And when I do the diagnostic, I won’t actually give them a mirror until I’ve checked it functionally and I’ve checked aesthetically I’m happy. However, once I show it to the patient, they may well say, can we tweak this? Can we tweak that? Absolutely. At that point, I will take a new scan or a new impression so that next time if they proceed, we are one step further on rather than having to make those changes. So I’ll then take a new scan and I’ll mark on the putty, old putty and I’ll get a new putty made. And that will be our starting point, but it’s all part of it and I will get myself comfortable before I’ll give them mirror. But I won’t take photos and scan until we’ve had the opportunity to review it together. [Jaz] That’s a real gem there, because someone who’s new to this could get very excited, put the try in in, show the mirror straight away, but then actually they can’t deliver that because actually the lower canine will be exactly. And that lateral and then, so you are very right. And that’s a great point that I don’t want people to miss. [David] Thank you. [Jaz] I’m gonna now just pivot to the next appointment where we’re gonna do the Gurel technique. I know we’re moving really fast and there’s so much more to this, but just to give our colleagues an overview. You mentioned already the Gurel technique. You also mentioned a slice prep, which I want you to explain where that is a bit later. But just describe what the Gurel technique named after Galip Gurel, one of the best dentists in the world in a Turkish dentist. So please don’t think that it’s all about Turkey teeth and Turkey. There are some fantastic dentists in Turkey, Galip being one of them. Tell us about this technique. [David] Well, I was just, I’m very glad you mentioned that, ’cause that is the same, I mean, it’s more about dental tourism than Turkey teeth. and there are some great dentists everywhere in the world. Okay? [Jaz] Absolutely. [David] There’s also places you can go for dental tourism anywhere in the world, but Galip wrote the original book on it, the Art and Science of Laminate Veneers and I explain it to patients and we all have our terminologies for explaining it to patients, but I would say let’s start with the end in mind. We can add. If we can add, it’s not too bulky, we know that then we don’t have to make the space people think of veneer. You have to prep half a millimeter. Well, you don’t. Okay. If you can add 0.2 or 0.3, you’re already prepping 0.2 or 0.3. But then how do we deliver that correct amount of space? And that is by starting with the end in mind. And so we’ve done an additive wax up, we’ve done a visual try, we’ve confirmed that it’s not too bulky. We can add that amount and then we would do the same visual trying, but with a guide to where we prepare the teeth. So if we’re starting with the end in mind and we put our bisacryl, our luxatemp on, we know that we’re only making space where we need to. And that’s the essence of the Gurel technique. The only addition is that we generally be looking at a 0.5 depth cut. I will put the visual trial on which I’m gonna prep through. I will do my incisal edge reduction. And a top tip there is have a conversation about the amount of translucency, because that will guide how much reduction. But bear in mind that often we’re being additive, so we’re adding length. I mean, how often are we adding length? So incisor reduction is less of a concern than people think it is because when you’re doing your incisor reduction, you’re generally all on bisacryl. But measure the diameter of your bur. That’s how much incisor reduction you are doing straight away. [Jaz] If someone wants really a translucent, again, your lengthening teeth. So very often you’re probably not gonna be prepping much incisally anyway. But how much are you looking to give the lab in terms of a wiggle room space for someone who wants ultra realistic, lots of fantasy translucency. [David] I think the minimum is half a millimeter. That’s not gonna give you any space for translucency from there. One to one and a half, possibly even two. But I don’t think there’s that many patients that crave that degree of incisal translucency. But again, there’s publications where you can have that discussion, but the reality is because we’re lengthening you are gonna have the amount of room for fancy pants translucency or not whatever you like. I think the key there, and we’ll come back to that if we may, but the key first of all is the depth cuts, 0.5, but don’t do it cervically. So I’ll do my incisal edge reduction and then I’ll go a little bit lower for two depth cuts lines. But away from the cervical. [Jaz] But where are horizontal lines going across, like traditionally using, there are those burs, I dunno what the name of those burs are. They’re probably veneer depth cup bur, but they typically got like two or three little bits on ’em. [David] Very good point. I don’t like the triple ones because that is, so I use a single depth cup bur rather than the triple ones. And we can get lost in the nuances, but you have to be aware that the facial plane isn’t flat. So you’re gonna be aware of the different facial planes. And even the three doesn’t really work because you’d think that’s a flat facial plane. Well, facial planes aren’t like that, so why would you use a three anyway? But my point is I don’t want that third cut because I’m going too cervical. And the other thing that, that it’s important to touch on, ’cause we’re getting onto preparation, is that when you do your incisal edge reduction, we are looking for a facial path of insertion. So our incisal edge reduction must always be angled away from the palate. Okay. ‘Cause once we go like that, we introduce an undercut and we can’t have a facial path of insertion. The key is that the wax up is guiding us to our end in mind, and that’s guiding the preparation. Then when we’re doing the preparation, we set incisal edge reduction, but angle that away from the palate. If you angle like this, you can’t have the facial path of insertion. Then we’ll do our depth cuts, and then it’s a question of joining the dots as regards to a slice preparation, because we lose a lot of structure integrity for the tooth, and Galip has shown this. That’s when veneers tend to crack because you lose the tooth rigidity. So out of choice, I’ll do an interproximal finish line, but without breaking the contact. [Jaz] And so slice prep is essentially breaking the contact and just slicing through it, basically. Essentially, that’s the way to describe it. [David] It is. And the times I use a slice prep is if there’s a diastema case. You’re not weakening the tooth if the tooth’s already compromised because it’s got a pre-existing class three. We have to make the judgment call. What’s the quality of the contact? Would we rather? And in that case, we are not weakening the tooth ’cause the tooth’s already weakened. So if I’ve got a virgin tooth, I’m not gonna do a slice prep unless it’s a diastema case. If there is a structurally compromised tooth already, then I will consider it. But the alternative, as we touched on before, is you can replace the class three, because you are going to weaken the tooth less, but a slice prep can have a place, but only in a tooth that’s pre preexisting restorations or a diastema. Again, you’re thinking that slice is gonna weaken the tooth and we wanna do everything to not compromise that tooth structure any more than we need to. [Jaz] It’s a bit like when you’re working on molars, premolars, when you’re doing your a caries removal, marginal ridges, how important they are. It’s a similar concept in that regard. What about black triangles when you are feeding those tricky black triangle cases? [David] Again, a very good question. I think you have to assess the quality of the contact and when you’ve got a black triangle, Pascal and his brother Michelle have spoken about many wings and there is ways you can get round that, but that’s quite a high level for a ceramic to get to, and so black triangles are probably more inclined to, I don’t then have a problem breaking contacts. But the key then is that wherever possible keep that path of insertion facial, because when you start to really prep teeth is when you say, well I need a facial path of insertion. That’s when you are heavily prepping. And then- [Jaz] Do you mean when you have a vertical path of insertion, you heavily prepping? [David] Yeah, absolutely. But black triangles, you can still hide because if you’ve got a triangle like this, you can have a tooth in front with a long contact point that you can still hide it. And it depends on, obviously, lip line and assessing. Do you think a dentist and seeing is this black triangle gonna be going to be closed? Having the conversation with the patient and them understanding that there are compromises. If you don’t, and I’m not anti prepping, I have schellenberg, I understand prepping teeth, but it’s about certainly with elective treatment, keeping it as minimal as possible. And with black triangles, the reality is you may well be doing a slice prep. [Jaz] But what I like there is what I’m learning is ’cause black triangles, those cases I have done in the past, they have been, for example, with orthodontics doing IPR to bring the teeth closer together to reduce the black triangles. Or often with composite, so we can just be complete additive. But I had this misconception that when you have black triangles, you need to give it a vertical path of insertion, which again, is so much more destructive. But you’ve clarified that actually we can and should be doing the same facial path of insertion, even with black triangles. [David] And that’s the key, is the facial path of insertion. And the lab would like to be able to take the emergence from the palatal. Okay. But again, think three dimensionally is that that may will still be possible with a facial path of insertion. But then we have the issue, we’re gonna have longer contact points. You need the skill ceramics to be able to build in the line angles so that they’re not looking like they’re long teeth. [Jaz] If anyone’s thinking if they’re younger than thinking of doing their first few veneer cases, please don’t do a black triangle case. And don’t do a, like a class three incisal edge relationship case with tricky cases. Do a nice easy case erosive wear and additive as much as possible. What other guidelines for your first few cases, what kind of characteristics are we looking for? [David] I think again, it’s yes, simpler cases. Try not, maybe not a 10 unit case, a four unit case, absolutely. But also having a good relationship with your lab tech. And they will guide you as well. [Jaz] Totally. There’s so much we can learn, and especially the people who be making these veneers and you get all the glory, but they’re the ones who are doing the hard work behind the scenes, scanning versus impressing. So you’ve done, okay. Just one last thing on the Gurel technique is, have you found that when you are prepping through the mockup, as per the Gurel technique, that the actual mockup starts to flake away, break away. Is there any way that you can keep the mockup there for as long as enough that you’ve got your perfect depth grooves without it sort of breaking away and visually obstructing the field? [David] Very good question. Again, you touched on with the visual try. I find that the lock on works, I mean, when it comes to temporaries, I’ll spot etch them. Talk about that. But I don’t find you need to, and I suppose the answer to your question is let your luxatemp set fully. And once it’s rigid, it’s not gonna come off. [Jaz] It is fairly well locked in. [David] It will lock in. [Jaz] It’ll shrink onto it. [David] It shrinks onto it, it shrink fit and you can spot etch it, but I don’t find you need to. And the other thing to remember is that when you’re doing a Gurel technique, the luxatemp only stays on for your incisal edge reduction and your cervical grooves. I’ll then take a pencil and we’ve all seen the videos of- [Jaz] Cervical grooves, just- [David] Oh, not cervical. Your facial. [Jaz] The mid facial grooves. Yeah, because you know what, I love that what you’re saying, and this is different to what I’ve seen before in other courses, is that they do say, okay, do the cervical, but I like your idea of not doing a depth groove cervical and kind of free handing that and to make your something for the lab to see, to give them just some guidance of where to finish. Right? [David] Absolutely. And the reality is you can then get everything joined up when you are doing your preparation. But to help you with that, the bisacryl just stays on for your two facial depth cuts, which you pencil mark and then it comes off. Then you are left with either pencil marks or no pencil marks, and all you’re doing is joining up the dots. And when it comes to the cervical, you just have a, by the time you’ve joined or you are microchamfer with the three planes of the reduction, you will find you have enough cervical reduction. That you don’t have to do the depth cuts. [Jaz] Absolutely. Brilliant. In terms of at this stage, are you scanning? Are you impressing? What’s your preference? [David] Well, you touched on this a couple of episodes ago, so I’ll agree with you that, scanners are great, but if you can’t see it, it’s not gonna record it. And when you’re looking at these micro chamfer, I think PVS impression that flows gives you a lot of detail. Now, don’t get me wrong, that’s what works in my hands. I’ve got colleagues who do fabulous work digitally, and of course it’s all possible. But I do verti preps a lot. I have done retraction cord many times. I don’t use, I haven’t used retraction cord in however many years. I use a lot of retraction paste. And since we’re on it, a top tip there is to tap it in with a pledget that you’ve wet and dampened and then squeezed dry. You could tap the retraction pace in. And I find that that gives enough retraction in that. But then the PVS impression flows a lot more. And if you’ve got a, maybe a prime scan, it’s gonna record it probably better than a different scanner that we can mention lots, we won’t go there. But it’s harder to record with a scanner than it is with an Impression. Yes. So- [Jaz] Totally. I think if you’re want that highest quality detail, although scanners are brilliant and I think they’re getting there. But in terms of the crisp and the whole avoidance of doubt of that, the impression material has flowed in all the nooks and crannies, where the limitation is the light when you’re scanning. [David] But lots of colleagues managed to do that. But I haven’t seen their preparation. I know that for me, putting on a very micro chamfer, as you said, change of direction, that is harder to pick up with a camera than it is with an impression material that flows in. So generally I impress, but I respect people that do it with a scanner. And it again, like everything is what works in your hands, but you need to go in with your eyes open and understand the differences. [Jaz] I’m now gonna, in the interest of time, I mean, I could talk to you about days and I know you teach courses on this stuff and this is something that you can talk about for days and I’m just here just picking up these little pearls and gems, so thanks so much. I’m really enjoying this so far, but I just wanna make sure we cover these little bits, contact lens veneers, the whole term. We see it in social media and stuff, but how do you feel about the term of contact lens thin? [David] I think that’s for the marketeers, ’cause it’s the marketing term. Any veneer should be as thin as possible, therefore a contact lens. And so people, I mean, originally. When we have feldspathic, you might say, oh, we’ll just use completely clear feldspathic portion in there. And that’s where that it sucks in the color from the underlying tooth. Some people are using feldspathic and they have for many years, and it’s a great material. But any, the near gonna, generally, unless it’s a high opacity, is gonna pick up color as long as it’s thin. So a contact lens is that you want to have the color from the underlying tooth. Other than that, it’s ultra thin veneers. Well, that’s another most- [Jaz] You said, it’s not 0.5 millimeters generally, but in the cervical, how thin does it get? [David] 0.3, I think 0.3. And then ultra thin veneers. Well, any veneer should be as ultra thin as you can make it. And I mean, we are additive again, for different reasons. Sometimes people want to give some more volume and rather- [Jaz] So let’s say a class two div, two retrocline upper incisors. And then you have, you actually want to bring it out into the smile and you hardly doing any prep at that stage. Therefore, by the nature of it, you are gonna be thicker. [David] You would, but then again, I’ve realized over 35 years that actually class two, div two is an issue because they’re gonna wear down their lower teeth and you put veneers on there, that’s probably not gonna help that situation. I’d say realign first. However, patients may not choose to, as long as they’re aware of the downsides, but it’s more that they have small diminutive teeth. And you’re right, a class two, you can bring it forward. But I’d be more concerned about the div two than adding to the facial because they’re effectively a restricted envelope of function. And over 50 years of 60 years of functioning, they’re gonna have worn lower teeth. [Jaz] Spot on. And I know we could talk about vertical dimension, all those things ’cause that really preserves or makes your lower veneer prep so much, you mentioned that about making ’em so much more conservative as well. But in just time-wise, I’m gonna ask you what’s David’s favorite time-tested veneer, cement, resin cement that you’re using? What’s your favorite? [David] Again, it sounds like I’m acting for a company. I’m not, but there’s a company that I particularly like. It’s all about the feel of the material you like. And there’s probably three market leaders we use in the UK, Variolink, Vitique, and Nexus. I think Variolink, they’re all great companies. Kerr, Ivoclar, DMG. Variolink for me is a little bit sticky, so it’s a much harder cleanup. But the way it’s formulated deliberately to be like that, that when you place a veneer, it doesn’t bounce back. The flip side is that it’s a very heavy cleanup. Nexus is probably in the middle for me. Vitique is light and fluffy, so it’s a much easier cleanup, but you have to make sure it’s fully seated against the tooth whilst you’re curing it because it will come back, it won’t stay in its position. So it’s a trade off if you want a sticky material to clean up or you want a lighter fluffier. And just one other thing you said there that I think something to touch on is we’ve said we can be additive facially on uppers. We must have forget what about lower veneers now, lower veneers is historically problematical, certainly for a class one patient, but there is, and I wouldn’t advocate it as being entry level, but if you open vertical, it’s amazing what you could achieve. Because you can then have all the space you like. [Jaz] You get your overjet and you get your lengthening. [David] And patients that say, well, they’re open my teeth. And they don’t like showing their occlusal surface of their old teeth magically you get space. [Jaz] Occlusal veneers. I’m actually gonna get a Pascal Magne on the show soon to talk about occlusal veneers. So I’m excited to delve deeper into that which is great. But I just wanna go back to the cements because I love the fact that you talked about it, not mentioning megapascals. ‘Cause actually they’re all really good. ‘Cause our substrate is enamel, right? We’re using properties of protocols and it really, it does come down to handling and how you like it. So I really like how you did that rubber dam or no dam. What kind of cementation system do you like? [David] Gingival health is essential, and I have done it both ways. But if you have someone that has good gingival health, you could rapid cement all 10 at a time. And the reason that can be a lot easier is if you think of you’re tiling a wall. If you put one tile out. All of your tiles are out. And so when you do 10 at a time, it’s not because it’s quicker, it’s because actually they tend to locate each other. And I’ve done it always, but you can’t do that unless someone has excellent gingival health. So yes, you can individual butterfly each tooth and and do that. But the reality is the more minimal the preparation, the harder it is to cement one at a time. And so you’re not gonna have that location you would get from example, from a reverse three quarter crown. So as long as you have excellent gingival health. And that goes back to making sure that things are healthy first. I will make sure that they can clean the gingival embrasures. I will encourage ’em to do that. And I have a couple of prepless cases that I show and it fit, it looks like they have back triangles. Well, they can’t talk ’cause I haven’t prepped the teeth. That’s because they’ve been using TePes in their temporaries and TePes or interproximal cleaning. We shouldn’t go onto brands, but interproximal cleaning is essential. But I tend not to ask patients to approximately clean upper three to three normally, but with their temporaries absolutely. So with good gingival health, rapid mentation with the whole arch together is my preferred. [Jaz] I loved your tile analogy there. ‘Cause I think, I’m just guessing when you speak to dentists and they tell you about their veneer experience, they tell you about that. When I got to put my last veneer on, it just wasn’t fitting and everything. ‘Cause it is a common thing that we speak about with dentists and I think you just absolutely nailed it with that analogy. So thank you for that. David, honestly, I can speak to you for days. It is almost 11:00 PM now. You’ve got a full case through tomorrow. You are such a man of wisdom and experience and such good work. Tell us where can we learn more from you? Do you have any education that you put out there? I know you are involved with the BACD as well. Tell us about you and the organizations that you represent. [David] So, BACD, absolutely always a great place to learn myself. I have my own site. I do teach with another Protruserati, Kushal at Ace. And that, I believe I did ask him because I do run this course as a day course, which isn’t a veneer course. It’s a minimal intervention, but it is at least hands-on with the whole techniques we’ve been talking about. And that is ace-courses.co.uk. And we are just launching another colleague of mine, Elaine, we have a new website that’s launching, which is ppcontinuum.com, which is where we’re going to be putting a lot of our educational. [Jaz] Is that protrusive podcast continuum.com? [David] So that will be coming shortly, but that is gonna be the web address where we’ll have a lot of basically online education that people can resource. So it’s both online and then hands on as well. [Jaz] Lovely. I mean, like I said, I’ve been to your talks. I’ve seen you talk, I’ve seen you work on your patients. I’ve seen work being done on you as a patient, so I’ve seen every facet of it. So guys, please do to check out these, I’ll put these links in the show notes. And of course, ACE and, Kushal have all my love. I’ve done lots of Ace courses over the years, so I’m a big, advocate of those as well. I’ll put the links in the show notes. But David, thank you so much for guiding us through answering our little questions. And I really appreciate, every time I see you at the BACD, you are just so kind and lovely and encouraging over the years. It’s been like six years of doing it. And every time I’ve seen you, just from the beginning, from year two, you were like, Jaz, keep going, keep going. And so I want to thank you from my heart for your encouragement. It means a lot. [David] And Jaz, I’d just like to say, first of all, thank you for having me on. It’s been a privilege and it’s a great thing you’re doing. It’s a great community and well done. [Jaz] Thank you so much. It means a lot coming from you. Honestly. It means a lot coming from you. Thanks for your time. And, we are gonna both need some sleep. Well, there we have it guys, thank you so much for listening all the way to the end. It’s always a pleasure to host lovely people like David, who is a Protruserati. Honestly, it just makes me so happy having members of the community that I get to interview them and learn from them. Like, I always thought black triangles, you have to go vertical path of insertion. But he corrected me. You can go facially. And of course, as I say, these guests that come on, I want you to support them if you resonate with any guest. Go on one of their courses, learn from them. You’ll never, ever, ever regret investing in yourself unless you invest in yourself, and then you don’t get to actually apply that technique. So if you don’t have many veneer patients, maybe do a technique whereby you start identifying suitable patients and then telling them, look, I’ll be soon going on a veneer course. Would you like to be one of my first patients? I know for some of you that may sound crazy, but why would you want to ever lie to a patient that I’ve never done a veneers before? And yeah, I’m used to doing it all the time. Like you’d never want to be in that scenario. In my experience, whenever I’ve done techniques for the first few times, I’ve been really honest to my patients, and you’d be amazed how well this works. Patients are so trusting and when you tell them that, okay, I’m literally just going and I’m learning from this awesome dentist, and while it’s fresh, I’m gonna come and I’m gonna help you with your smile. And so I’d like for you to be one of my first patients, just give you some ideas, guys, in terms of how to actually start implementing and applying all the knowledge from the courses you gain. Of course, mentorship is so, so key. So now by the time this episode comes up, we’ve launched intaglio mentoring. So the website is intagl.io. It’s intaglio, right? And so this is the online mentorship platform that we have created. So let’s say you have a veneer case coming up, or you’ve got loads of smile photos and you’re just not sure how to treat this case, like should you do veneers? Should you do ortho first? Should anyone, these are be crowns. How long should you make the teeth? Do you need to open the vertical dimension? All these questions that you may have, you can now go on intaglio. There’s so many great mentors on there already, and we’re just in the beta phase, right? You can identify them, you can see when they’re available, and you can book them for like an hour, two hours, wherever you want on Zoom. Show them your cases and let some people who are experienced guide you. What I’ve found from being on both sides of the equation, being a mentor and also being mentee, even last year I was paying a handsome sum of money to be mentored for some complex cases. It is a phenomenal return on investment and it just really is like a rocket for your career. So do check out Intaglio if you are interested, if you need a mentor, or if you are in a mentor and you want some mentees, we want you come and make your profile on Intaglio. We’ll look after you. Thanks again, guys. Don’t forget to answer the quiz for CPD or CE credits. We are a PACE approved provider and I’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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Decontamination CPD Made Enjoyable! – PDP218 1:01:03

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CORE CPD ALERT! 🚨 How dare I veer away from our beloved clinical topics to talk about… decontamination!?! 😱 Have you ever wondered how you should be disinfecting occlusal mirrors without getting them scratched ? Should we be using PTFE inside the pulp chamber if it’s not been autoclaved? What are the most common decontamination mistakes that we make day in and day out that are so easy to fix? In this episode, Jaz sits down with Decon Pete, the go-to expert for all things dental decontamination, to drive into the nitty-gritty of keeping your practice squeaky clean (and compliant!). He shares practical tips to make your decontamination process safer, smoother, and stress-free. Common decon mistakes, PPE slip-ups, distilled vs. RO water, HTM guidelines vs. manufacturer guidelines – this episode will help you feel more confident in decontamination and up your infection control game. How to reach Decon Pete: Facebook group: IPC Support by Decon Pete – a private space for dental teams to ask decontamination-related questions. Website for practice support and consulting: www.deconpete.co.uk https://youtu.be/013WuXzWE3g Watch PDP218 on Youtube The Protrusive Dental Pearl: Pete’s Expert Recommendation on Cleaning your Loupes Ideally, loupes should be disinfected between every patient, but at the very least, at the end of each clinical session Avoid submerging loupes in any liquid – instead, use distilled water and a microfiber cloth or cotton buds for frames and nose pads For lenses, use 70% isopropyl alcohol wipes – no acetone or bleach! If you’re using a visor with your loupes, you won’t need to clean them as often Need to Read it? Check out the Full Episode Transcript below! Key takeaways: Decontamination is essential for patient safety in dental practices. Using proper protective equipment is crucial for staff safety. Transporting instruments safely is a key aspect of decontamination. Manufacturer guidance should always take precedence over general guidelines. Policies must be relevant to the specific practice. Manufacturer’s guidance should always be followed. Disinfecting instruments is crucial for patient safety. Water quality impacts the effectiveness of dental procedures. Distilled water should be used quickly after opening. Reverse osmosis water is more sustainable for practices. Proper storage of instruments prevents contamination. Highlights for this episode: 00:00 – Intro 03:52 – Protrusive Dental Pearl: Pete’s top tips for cleaning your loupes 06:02 – Introducing Decon Pete: Pete’s background in dental decontamination 12:40 – Manual cleaning and PPE errors 17:51 – Washer Disinfector 27:06 – Instrument Transportation 30:08 – Guidance vs. Manufacturer Instruction 36:05 – PTFE Tape: Sterilization and best practices 41:06 – Occlusal Mirror Care 48:18 – Distilled vs. RO Water 56:37 – Water for Ceramics 57:22 – Outro This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance . This episode meets GDC outcomes B and C. This is a GDC Recommended CPD Topic – 5 Hours of Disinfection and Decontamination every 5 year Cycle. AGD Subject Code: 550 Practice Management and Human Relations. Dentists will be able to: Identify common decontamination errors and implement strategies to enhance infection control standards Appreciate the appropriate methods for cleaning and maintaining dental equipment Apply best practices for instrument handling, including proper PPE use, safe transportation, and effective sterilisation protocols If you loved this episode, be sure to check out this one: PDP018 (Don’t Get Sued) Click below for full episode transcript: Teaser : Manual cleaning instruments just with surgical gloves on. And I see so many practices doing that and it offers them no protection whatsoever. You don't need to use sterile gauze. Teaser: If you’ve got sterile gauze in, great. But yeah, the cheaper way of doing it, just get non-sterile gauze, or you can use lint-free cloth. The two fundamental waters that we have to use within dentistry for everything is distilled or RO. And the only reasons why we are using those two types of water is because both of them are deemed good quality water. They’ve got no magnesium, nothing like that. And thirdly, they have no endotoxins in them. Jaz’s Introduction: Protruserati, I’d never thought I’d see the day that I’d be publishing an episode on decontamination. How dare I veer away from those beloved clinical topics to talk about decon? Well, in the UK as you know, it’s a required topic. It’s a recommended topic by the GDC. The problem is a topic like decon is violently boring until now. I’m so pleased and proud to announce that Protrusive is going to reduce your CPD burden by recording and publishing episodes that are relevant to the recommended fields, but with a twist. Instead of those incredibly boring lectures that are used to in the field of decon, medical emergencies, and radiation protection, I’m actually gonna try my best to make it fun, to make it tangible in true Protrusive nature. So now you can not only learn something, enjoy the conversation, I hope, but do a massive, big fat tick to the end of year CPD declaration so that by the end of your cycle, you complete your five hours of decon and your recommended hours for medical emergencies and radiation. So, all the good stuff will come soon. This is core CPD, but not as you know it. It’s gonna be different. It’s gonna be hopefully enjoyable. The reason I think we’ve made it enjoyable is three reasons. Number one, I’m an inquisitive idiot. There are certain fields of dentistry, like implants, like decontamination that I literally know nothing about, and I am learning so much, and I’d love for you to be a fly on the wall and learn, because at the end of the day, sometimes when you are tuning into a conversation, like a podcast type conversation, you soak up and you learn so much more than just being talked at like in a webinar or in a lecture that you may be used to. Number two, we don’t just cover the usual how many degrees in autoclave we actually cover real world scenarios. For example, how to properly disinfect your mirrors without scratching them, or should we be using PTFE inside the pulp chamber if it’s not been autoclaved. And what are the two most common mistakes that we are making day in, day out that are so easy to fix? Our guest Decon Pete is gonna answer all those questions. And number three, Decon Pete, our guest today, he’s super knowledgeable, but he’s relatable. He’s a human, he shows us human side, and he’s just so knowledgeable and it was absolutely brilliant to chat with him. I’m so excited for you to listen to this episode and again, put that big fat tick next to CPD. Now, hundreds of you are used to getting CPD from Protrusive, but understandably, many of you, this will be your first time. I welcome you. I’d love for you to join the Protrusive family. The way to get involved is www.protrusive.app. It’s best to make your account on the web browser so you’re not paying all your money to Apple. And we Protrusive don’t get anything. I’m just saying the truth. If you wanna actually support Protrusive, you go on the web browser www.protrusive.app, and you choose one of our paid plans, either Podcast CE only, so you get podcast CPD hours and CE credits, or you get access all areas through the Ultimate Education plan. It is tax deductible, and I think it’s the best value CPD going in the universe. Of course, I’m a little biased. But if you love these episodes, why not answer the quiz at the end of the episode and get your CPD. Also, once you make an account, you can download our native app on Android or iOS and join the nicest and geekiest dentist in the world. I guarantee you, you’ll sign up for the CPD, but you’ll stay for the people and the friends that you’ll meet on the Protrusive Guidance app. So if you are sick and tired of paying for CPD memberships that you never actually log into. Pick Protrusive ’cause this is the one that you use every single day. Even one of our dentists, Megan recently said that she checks the app every day as though it’s Instagram. So like I said, if you’re paying for a subscription and not using it, what’s the point? There is so much to learn on the Protrusive community and I’d love for you to join us. If you wanna get the Access All Areas plan, go to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate. And we, the Protruserati, are excited to see you on the app. Dental Pearl The Protrusive Dental Pearl I have for you is something from the community. You guys asked, what’s the best way to clean your loops? Now, unfortunately, I ran out of time to ask him this question, but I called him up later and I said, Pete, we need to know the answer from you ’cause you are the expert. And so this is how it goes. Firstly, how often should we be cleaning and disinfecting our loops? Well, technically, if you wanna aim for the highest level, you should be doing it between every single patient. That’s right, every single time you use them. And every time you change a patient before, then you need to disinfect them, because very often there’s aerosol that could be droplets. So for that reason, they should be, ideally, he said, clean between every patient, but the very least for practicality reasons at the end of every clinical session. So I think it’s out for judgment as well. Like if you’re doing lots of aerosol based procedures, then I would just clean before the next patient. But if it’s checkups and there’s not much aerosol produced, then at the end of the clinical session is practical. So how do you clean them all? Firstly, what you shouldn’t do is ever submerge your loops in water, for example, like don’t submerge them in any liquid that’s gonna mess up your lens. What Pete suggests is to use something like distilled water and a microfiber cloth on the outside, like the frame and the nose pad, and you can even use like a Q-tip or a cotton bud, get in a nooks and crannies and as well as your microfiber cloth to actually clean the lens. The most important and expensive part of your loops, you want to use something like 70% isopropyl alcohol. So one of those alcohol based wipes that you have in the clinic. They should not contain acetone or bleach. There should be 70% alcohol. You can disinfect them with that wipe and then go over it with your microfiber cloth. Once again, allow that to air dry and then store away safely. Now, if you are using shields, then technically you don’t need to disinfect them as often. Using a shield means that your lens and loops are protected. But if like me, you’re not using a shield, then yes, we must disinfect them because the worst thing can happen is like a droplet falling from the actual lens part. So make sure at the very least, you’re disinfecting the lens itself and you can use a 70% isopropyl alcohol wipe, as I said. So thanks Pete for answering that question, and we’ve got so many more questions that we covered in the episode. Let’s join it now and I’ll catch you in the outro. Main Episode: Pete Gibbons, AKA Decon Pete, welcome to the show, my friend. How are you? [Pete] I’m very good, thank you. Yeah, thank you very much. Looking forward to it. [Jaz] How long have you been in this space and how did you get into decontamination? Because we’ve touched base four years ago and you know what? Yeah. I’m so nervous about recording something that will put my drivers, people who are driving to sleep. And then, the podcast gets blamed for not, it’s just decon is one of those things that we do it not because no one wants to do it, we do it because we wanna legally have to do it. But until today we’re gonna make it interesting and actually answer questions that you want to know. But tell us about your journey into this piece. [Pete] Yeah, we’ll try to decon, it’s a very dry subject, let’s put it that way. It’s not the most riveting of subjects, however, I find it quite riveting. I absolutely love it. I mean, I’ve worked in dentistry for 19 years this year. And I’ve primarily worked with sort of manufacturers and also distributors as well. And I first got introduced into decon in 2009, which was just when the English HTM obviously landed on every NHS practices door. And everyone was fretting about it. And it was another document that came out and we’d seen these documents come and they’d go and everyone kind of thought that it’s not really gonna stay. There was a lot of uncertainty about the document and a lot of people kind of read it and didn’t really know what they needed to do, what they didn’t need to do. And it kind of, I was working for a medical device company at the time and one of the things that really became apparent to us at the time was that we had an area where we could really help dentists, we could really help dental practices, nurses, we could really help the whole team sort of navigate this new guidance document that was just coming out that was in its early fledgling, sort of ethos, sort of arena. And yeah, it’s kind of stuck to be honest. I’ve loved kind of helping teams along the way, just kind of navigate what they need to do. And you’d be surprised, we still get a lot of questions. There’s a lot of teams that need that help and advice. And I worked for a very large distributor and headed up all their decon and looked after the education program and were really just a go to for dental teams to come to understand what this new HTM was telling everybody to do, and then kind of morphed into the WHTM, the Welsh Arena. Then you had the Northern Irish, you’ve got Scotland, and I was working very closely with Ireland as well, with the Republic and, you know, the Republic. [Jaz] And did they greatly differ these countries in terms of what they had? [Pete] Yeah, I guess they do. I mean, England and Wales are very similar. Wales generally always followed the English guidance, and they’re always a year behind. But the documents were very, they pretty much mirrored each other. I mean, and the same with Northern Ireland as well. I mean, at the end of the day, you had this big English document that people have spent a load of time doing for why rewrite it at the end of the day? And, so Wales and Northern Ireland kind of took that document, made their own regional changes, and made it their own. And Scotland’s, when you look at the English document, we very much took lead from Scotland, because Scotland’s document, Scotland’s guidance is really at the highest stake. [Jaz] You know what? I’m glad you said that because something about Scotland, right? One of my lecturers in pathology in dental school, he called Scotland the sick man of Europe in terms of health economics and that kind of stuff. Yet they come out with the best guidance. Even like the SDCEP guidance, right? Like antimicrobials, MRONJ. Like why are Scotland so good at guidelines? [Pete] I think ultimately what happened many years ago, sort of 2004, 2005, the state of Scottish dentist dentistry needed a complete overhaul. Each individual practice was completely different, and we hear a lot of horror stories from what’s happened up in Scotland. There’s been several high profile cases that have come from Scotland. One up until 2010 was Alan Morrison, who had two practices in aha. One in come knock and one in gon and it was the Daily Mail clicked onto that story and it was quite unbelievable what was kind of happening within Scottish dentistry. And so, Scottish government just took belt and braces and invested a load of money into dentistry. Scottish Dentistry got a lot of support in terms of decon rooms. So they got given money for decon rooms, they got given some money to relocate practice. If they had no room for decon rooms, they obviously took away, when you look at our guidance, they took away that essential quality and those best practice elements and just made everything best practice and make everything mandatory. And there’s no like, um, and RN about it. I love the Scottish guidance purely because you know where you stand with the Scottish guidance. And that’s kind of where I wish the English guidance would go and I kind of wish, and I talking to a lot of my peers and a lot of people in the industry, that’s kind of where just everyone wants, everyone just wants to know what to be told, what to do. [Jaz] It reminds me of like, I’m an associate, right? So like most associates, they have a vague familiarity with the decontamination protocols. But when you’re a principal, this is your business. You are really deeply ingrained in it, and you feel it a lot more. And this is really palpable during Covid. So when SOPs came and like the amount of stress it caused principles, ’cause suddenly it’s a bit like when the HTM the one came out is like a brand new thing. Everyone’s trying to figure out how best to do it. So it’s good to get some clarity from you that yes, you know what the Scottish guidance is great. And I like the idea that yes, ideally there should be more unified and England should follow that. And what we look for is clarity. Now you must go to a lot of practices and I am sure that the kind of stuff you are teaching and helping to improve ’cause ultimately you are in the business of safety. You are in the business of patient safety and high quality care. People think of high quality care, like, really seamlessly blending in veneer margins and stuff. No high quality care is, safety is paramount. And everything we do in infection control is exactly that. So it is a really important parameter. Like when I go to a practice and when I’m applying to a practice for a job, I actually look at, okay, how seriously do they take their decon? Because that’s a sign that okay, if they take that seriously, that they’ll take over the care of the other things importantly as well. I’m sure you are teaching your nurses that you train very basic things. So the question I was asking you, Pete, actually, the question I was asking you is, so I’ve seen your website, you visit a lot of practices. You are kind of like the detective guy. You’re kind of like a CQC kind of chat, you’re like investigating. You’re seeing are they doing best practices. So the first thing I’d love to know from you, which I think will give so much of value to everyone, ’cause yeah, we go to the mandatory CPD, we do the Irma, we do the Decon. But I really would like with your expert knowledge, try and answer the questions that we really wanna know about. And I think the lowest hanging fruit is what is the silliest mistake, common mistake that you just wanna bang your head in because this is such an easy, easy, lowest hanging fruit. [Pete] Actually, two things. One of them is manual cleaning instruments just with surgical gloves on. And I see so many practices doing that and it offers them no protection whatsoever. [Jaz] So what you’re trying to say is that the nurses are leaving themselves vulnerable and exposed by just using like the nitrile gloves. Is that what you mean? [Pete] So they’re using either nitrile, surgical or clinical gloves. That’s all they’re using. I say to a lot of practices when I first go there, look, at the end of the day, everything about infection prevention and control is about protecting, firstly, you guys, everybody that works in healthcare, and then secondly, your patients coming in. And thirdly, those outside visitors coming into those high risk areas. Nobody wants to come to work in the morning and leave at the end of the day with something that didn’t have first thing in the morning. Nobody wants that. You don’t sign up to a job to think, oh, I know what I’m gonna do. I’m gonna contract something today because that’s really what I want to do. Nobody wants that. And I think as human beings, we can become very robotic in our day-to-day work. When you know your job inside out, it can often make us lazy. We can often look at cutting corners. We can often look at trying to shortfall things where, when it comes to infection prevention control. [Jaz] I’m gonna give you an example off the bat. Like you mentioned a really good thing that, you know, we might drop our guard, let our guard down. So, and a classic example is, yeah, the nurse leaves the room and at that exact moment you need something. So not that we shouldn’t doing this, but with a gloved hand, you then open the door and you pick something up and look, yeah, I’m being honest, like, we do this, we shouldn’t do it. Okay. But it’s one of those things, right? That okay, no, take the glove off. You’ve gotta do it properly. All these rules are there for a reason. But yes, carry on. You are about to come to two mistakes. So one is the gloves. So what should they using? [Pete] So, one is the gloves. They’ve got to be using a heavy duty glove. They need to do- [Jaz] Marigolds? [Pete] Marigold gloves are fine. What I say to a lot of practices is ’cause for some reason, I think as humans we find that, that you get to a lot of people where they almost get the ick, we put their hand into a glove that somebody else has put their hand into. So I always say to them, look, you can wear your gloves underneath the marigolds, but always make sure you wear the marigolds because okay, no marigold in the world is puncture resistant, but they’ll offer you a lot more protection than just that surgical glove on its own. And you have to take your protection. But protection, I think personal protective equipment is as it states, and it is not there to be shorted. It shouldn’t be cut. You shouldn’t be cutting corners when it comes to personal protective. [Jaz] See, I didn’t know this by the way. I know I’m gonna learn so much from you. So I didn’t know about this. So I’m gonna go in to work tomorrow and I’m gonna be looking in the decon rooms. Are they protecting themselves? And you know what, I’m sure they’d be so grateful if I was say to you can protect yourself more by using this. So is the concern that the surgical glove, the nitrile or latex, whatever they’re using, it’s porous and it’s battered- [Pete] Oh, two things. Yes. It’s porous. And I think a lot of people forget that they are porous. And this is why we disinfect our hands. This is why you are disinfecting your hands in between glove changes as opposed to washing your hands in between glove change. Because a disinfector will act like a varnish and it’ll realistically give you protection. It’s a second barrier protection for your skin is that alcohol rub. And a disinfector generally is designed to kill anything that comes into contact with it. So any airborne pathogens, anything that seeps through the glove is gonna be killed by the disinfector you’ve just applied to your skin underneath. So that’s the first thing is obviously they’re porous. Second thing is they’re not puncture resistant. They’re not puncture proof. And there is a risk that you could develop a sharps injury because of the nature of manual cleaning. Yes, you are supposed to keep use a longhand or bristle brush, and you are supposed to immerse the instruments underneath the water and then scrub underneath the water. So in theory, by doing that, your scrubbing hand is not getting near that sharp end. And your hand that you’re holding the instrument with is not getting near the sharp end. In reality, it doesn’t always happen like that. That’s not the reality of it. And we have to be practical with a lot of things. And when it comes down to cleaning all this kind of stuff, if we can cut things because we are being pressured and the nurses are being pressured to get the instruments back in a big throughput, quick throughput, that’s where the corners get cut. And this is why we kind of see as the guidance that what should disinfectors are becoming best practice. The reason being is because they almost 99% eliminate any manual cleaning whatsoever. Don’t need to do any manual cleaning. The only time you ever need to manually, [overlapping conversation], glass ionomer, aqua chem, poly F, stuff like that on there. There’s no washer in the world that will remove GIC when it’s when it’s stuck on. Or they’ll remove cement. They just won’t do it. So it’s always advisable to get that off while it’s wet, whether you as the clinician remove it while it’s wet or before it’s handed over to the nurse, or whether the nurse does it while it’s still wet, but obviously not trying to remove it. If you have got anything like that on the instrument, then yes, you do have to physically remove that first before putting it into the washer. [Jaz] I’m gonna censor the bit where you said the dentist should do- [Pete] It’s either, to be honest, it’s either or and what I find it’s very much down to the relationship. [Jaz] Sometimes they do it because it is how you work in practice. [Pete] Some dentists do like doing it themselves and some nurses rather do it themselves. It’s very much how that working relationship goes. There’s certainly no right or wrong way of doing that. It is just advisable to get it off while it’s wet because ultimately what you’re trying to do is minimize any level of manual cleaning whatsoever. If you can minimize any level of manual cleaning, then you minimize the sharps risk and the inherent risks afterwards. So you increase the protection of the members of staff that are there as well by doing that. So it is one of those things, and that’s why we see washer disinfectors being best practice in terms of England and Wales, you know, mandatory in Scotland and Northern Ireland, they are mandatory in there already. They’ve had them mandatory for many years. They have to use them. [Jaz] What percentage of clinics in England do you think are still relying on manual cleaning? [Pete] It is diminishing, I must admit, and I’ve seen it diminish over sort of the last sort of five or six years I would say. We’re still in manual cleaning. We’re still probably about 55, 60% still manually cleaning. [Jaz] Wow. For those who are listening on Spotify and Apple, like my jaw, my mandible just dropped. I’m shocked. [Pete] It’s probably that high. Yeah. The thing is that we’ve gotta think- [Jaz] How much is a washer disinfector? [Pete] So washer disinfector, typically anything from 4,000 pounds to. Seven and a half, 8,000 pounds depending on the configuration that you have in it. But most washer disinfectors, the problem is with washer disinfectors is they’ve not got the best or they’ve not had the best history. And we have to remember that when HTM first came out in 2009, well actually came out of the draft in 2008, and then we had the hard copy hitting in 2009, and that was talking about this whole thermal washer disinfector scenario. There were no small benchtop washer disinfectors, so of course manufacturers, they looked to the one market that has them already, which is the domestic market. So they look to the dishwasher and how can we take a dishwasher and slightly retrofit it to fit into this medical arena? Bearing in mind your dishwasher only heats up to 60 degrees, so they needed to get something that would heat up to 80 degrees and hold that for 10 minutes and so forth. And of course that that’s all they changed. They didn’t really change anything else. And you use your dishwasher once a day, you are using a thermal disinfector 2, 3, 4, 5 times a day. So the reliability really wasn’t great for them and they had a bad history in terms of buying a washer and it forever being broken down. So everybody just decided to ditch them. And revert back to manual cleaning because the one thing about manual cleaning or the main thing is it does obviously pose the highest risk, but the one thing about manual cleaning is it’ll never break down. Unless all your staff go sick, nothing, it’s not gonna break down at all. The problem with it is it’s a non validatable process. And it’s an inconsistent process. Everybody will clean differently. Whereas a thermal disinfector is very much, every single cycle is the same. They are a lot more reliable now. They’re made as medical devices. They’re made from the ground up. They’re not converted dishwashers in the sense of a converted dishwasher. They are very much built for. [Jaz] The analogy is very powerful. I didn’t know that. Now, Decon Pete, do you sell these pieces of equipment? [Pete] No, I don’t. I advise practices on pieces of equipment that are out there. So- [Jaz] Do you have a financial interest with any company? [Pete] No. I freelance work. I do some freelance work for a German company called MELAG, and I work with them on promoting, but I will genuinely help practices decide because there’s items that MELAG have that aren’t gonna fit with every practice. So it is got to be a product. And a lot of the suppliers that I work with, and a lot of the companies that I work with are very much built on the history and the years I’ve worked in the industry. I will openly tell a practice if a product is good or not. If a product is good, in my opinion. And they are all purely my opinion if products are good or not. But no, no financial, no. You know, I do a lot of- [Jaz] No, I was just wondering, but it makes sense. I was just say, can I have a recommendation for if someone’s starting a squat practice? Brand new practice. And, you know, probably for a squat practice, you want to start on the right foot. You probably don’t want to, I mean, obviously people are cash strapped. Maybe they would start with manual cleaning and then eventually when they got better revenue, then buy the Washington Vector. But if they were gonna buy one, what’s the most reliable one that you’ve come across? [Pete] I would say it’s probably two that are fairly reliable. So SciCan do one which is called the SciCan C 61, which is their new G 4 technology, which is sort of cloud technology, cloud-based. So the idea behind it is that your daily logs and so forth all get stored on the cloud. And then, by doing that you can have error codes sent to your service provider, for example. So, if your washer throws up an error, normally the service provider will get a report and they’ll know what that error is. So it’s very much the way technology’s going. And we are very much in that digital element, not just in dentistry, but also in Decon. Everything is going digital. Trying to make it as easy as possible. And it’s the future of dentistry, it’s the future of where it’s going and MELAG, I would say, at two different avenues. So, the side can, in terms of a bench top, something that’ll sit on the bench or something that will also go under the bench because it depends on if space is a premium within a practice. And then a MELAG unit would be under bench. I would kind of recommend MELAtherm10 again, very future-proofed. It very much depends on the number of surgeries as well. I always advise practices when they’re looking at washers, match a washer to the number of surgeries that you have. Really, really talk to somebody about what procedures are you running in a day worth of checkups? It’s very much different to doing all surgery or something like that, the number of instruments you’re using. So it’ll very much depend on what procedures you’re doing. What kind of instruments you’re using, what kind of kits you’re using. Are you using clip, trace, things like that. And then look at the various manufacturers out there and have a look at what internal furniture they offer for that washer as well. Sometimes, big is not always better. Everyone looks to the big washer disinfectors. That’s not always the best thing. Have a look for something that is going to be relatively quick. The smaller the unit, the less water it’ll use, the quicker the cycle will be, rather than the big unit having to use more water and take in longer cycle times. [Jaz] Well, that reminds me of the question actually. We’re moving in a direction of trying to be as green as possible as well. Are there any brands or models out there that market themselves and being proud of being very green carbon footprint, that kind of stuff, or not? [Pete] When it comes to washer, I mean, ultimately I would say when it comes to was disinfector is looking for something that is a 13 amp power supply is gonna be better than utilizing something that’s 16 amp or 30 amp. They’re gonna use more electricity. So from a sustainability aspect, that’s far better. Use a washer that is a cold water fill rather than a hot and cold fill. Because again, from a sustainability aspect, that’ll be slightly better. You’re not having to use your boiler to heat up using energy so forth. Use something that utilizes a small chamber. We’ll use less water to fill up that chamber. So again, from sustainability aspect, you’re being far better in that sense. So, there’s different ways that you can be more sustainable and I work with a lot of practices on how to be more sustainable and what they can look at. It’s very difficult when it comes to capital equipment, when it comes to Decon equipment, but there are certainly things that you can look at, and I would say they’re the main ones. Look at the water, look at the electricity usage and look at the incoming supply, whether it needs hot and cold. There are a lot out there that need hot and cold. [Jaz] These are kind of conversations that make me so, so happy that I’m not a practice owner. But I mean, so much, so much to think about, but you know what? Someone like you to advise is just, I can see why you create a wonderful niche in terms of having an advisor can save you a lot of headache and ultimately will probably save you money as well. [Pete] Yeah, definitely. [Jaz] And you mentioned already that the main issue, one of the main, simple, low hanging fruit was the incorrect use of surgical gloves. When they’re cleaning, what was the second low hanging fruit? [Pete] The second, I would say in the way that the nurses are transporting the instruments, I see a lot of practices. Two things. I see a lot of practices literally just transporting the instruments on the tray into the decon room, which is completely incorrect. Got to be in a leakproof box because there’s a risk if they do trip up, then if those instruments are gonna go everywhere. So that’s the first thing I see in a lot of practices and also see a lot of issues in the practices where they are carrying the box with both hands because it’s too heavy. ‘Cause it has a water solution in there. Now when it comes to that transportation box, that dirty box, that box should not be too heavy, that you cannot carry it with one hand. If you have to carry it with two hands, it’s too heavy. Because how do you open the door? [Jaz] So it’s kind of like having like a handle one of those systems with a handle, right? With one hand handle. [Pete] Having something with a handle would always be quite good. I see some of these boxes that have got so long as it’s got a lockable leak proof lid. So that the idea is that if you drop it, it’s not going to crack. The lids not gonna come flying off. Or even if the lid doesn’t come flying off, the water’s not gonna come out if there’s water inside it. So that’s the first thing. Secondly, yeah, the ones with the handles are quite good because you can obviously get a few more instruments in there if you need to. But if you don’t have one with a handle on the top, then it’s got to be not too heavy that you can’t carry it just one hand. You’ve gotta be able to carry it one hand because you need a naked other hand to be able to open the doors as you go through. You shouldn’t be placing that box down somewhere whilst you open the doors to then pick the box back up and then walk around. It’s all health and safety at the end of the day. [Jaz] So do any clinics use a trolley? To transport? [Pete] Not really, no. Because where we find a lot of, I mean, it very, it does very much depend on the clinic. I’m not suggesting that there aren’t surgeries that don’t do that. But, no, I haven’t really seen any using a trolley. I have seen a practice incidentally using the old or the not old, these money canisters that you see in the supermarkets and they used to shove them up the air vent and it used to go shooting around the supermarket. I’ve seen practices using those for instruments where they’ve installed a pressurized tubing system in the practice. And each clinic has a little area where they can just load the instruments into a pod and it just gets shot straight into the deep. [Jaz] The telescope in a hospital as well. I’ve seen that recently. [Pete] Exactly, exactly that exact same thing. And I suppose in sense, if you’re doing it from brand new, and these were brand new builds, so they kind of factored it all in straight away. But if you are doing it as a brand new build, it does negate anybody having to walk to the decon room to go and try. So takes out that whole transportation issue out the integration. [Jaz] All bells and whistles, brand new site, you have the option. So it’s good to talk about, that option does exist. [Pete] Yeah, you can have it and there’s no right. There’s nothing to say that you can’t have it. When we look at anything HTM, WHTM and all that, they only guidance documents. They are only guidance. Ultimately, practices need to be following manufacturer’s instructions. For whatever they’re using. It doesn’t matter if it contradicts everything within HTM, you follow manufacturer’s guidance. [Jaz] Are there instances whereby what the manufacturer’s guidance is saying contradicts HTM and tell us more about that. [Pete] So water bottles is the prime example. I was going about water bottles, but it’s a key example. THM, WHTM, SHTM, the new Scottish HTM, which has superseded the SDCEP or that deone element of SDCEP that talks about it. And it also dates that your water bottle should be removed at the end of every day. It should be rinsed out, inverted and left to air dry throughout the night. So the idea is that you basically drain your treatment center of all water. You take your bottle off. And that’s for Legionella and it’s for biofilm production. Now, what HTM and WHTM doesn’t take into account is what if you have an additive in your water. So something like Alpron or something like Clean Certs or Bioclear Daily, there’s other little additives. There’s a little A-dec tablets, things like that. There’s other little additives that you can use. Now all of those tablets are all telling you keep the bottle on. So they say keep the bottle on at the end of the day and- [Jaz] Screwed into your surgery unit, basically right? [Pete] Into the surgical unit with the additive in the solution, and it remains in there for up to seven days. Now when you look at it, which guidance are you to take? You’ve got HTM telling you to remove the bottle off. But the manufacturers of the additive that you’re putting in your water are telling you to leave the bottle on. You always follow the manufacturer’s guidance. Always follows it. It supersedes everything. HTM, oh, absolute note. [Jaz] And medical, legally, like, and guidance is there to your broken, obviously. ‘Cause you’ve got manufacturer guidance. [Pete] Manufacturer wins. [Jaz] Manufacturer wins basically. [Pete] In the absence of manufacturer’s instructions, that’s when guidance comes, falls into play. Guidance talks about things like, so if we look at what, so look at ultrasonic baths, for example. Okay. Guidance documents talks about weekly protein testing of an instrument. And it also talks about a quarterly soil test for the ultrasonic bath and a quarterly foil test for the ultrasonic bath. Now, HTM and all those documents talk about foil being done in a three by three grid. So nine pieces of foil. Whereas most common small dental ultrasonic baths would all say one piece of foil or three pieces of foil. Again, whose guidance do you take? You follow the manufacturers. In the absence of any manufacturer’s instructions, that’s when you refer back to HTM or WHTM or something like that for advice. [Jaz] When you tell dentists about this, about the fact that actually manufacturers guidance trumps what the guidance says. Are they shocked? Are they very grateful? Are they surprised or- [Pete] I say a lot of ’em are surprised because they seem to think that they should be following what HTM says. And I get a lot of questions through social media and I get a lot of questions via the website on this exact thing through WhatsApp and so forth on we’re being told to do X, Y, Z, but the guidance is telling us to do this. What do we follow? And ultimately, you always follow that manufacturers because when we look at things, it’s a bit like if you have a policy written up and there’s a lot of compliance companies out there that will have policies, a lot of practices will be signed up to compliance policies and there’ll be most of these compliance, manufacturer compliance companies will have generic policies that they’ll send out. Now the idea is that generic policy is looking at, so say a policy for decom, for example, and it goes step by step, the full decom process. So that’s general policy covers manual cleaning, ultrasonic bath. Wash disinfector because that’s what the guidance outlines as well. Now, if a practice doesn’t change that policy as far as the practice is concerned, that step-by-step policy says, first of all, you manually clean, then you ultrasonic bath, then you wash a disinfector. But if the practice doesn’t have an ultrasonic bath or a wash disinfector, then that policy doesn’t become apparent at all. It’s non-applicable to their practice. [Jaz] To give you a clinical analogy, I’m sure we can give one is a bit, is that when we are removing a lower tooth, but in our notes it says, careful the sinus risk told. [Pete] Exactly. As your clinical note taking as well. It’s got to marry up with what you’re physically doing, smoking cessation, stuff like that. It’s got all got to marry up and that’s exactly the same as it comes to the policy. Ultimately, as far as the practice is concerned, that policy should be pertinent to their practice. And that policy trumps everything, and that’s all CQC will look at HIW, HIS whoever your inspector body is, whether it be in Ireland or Northern Ireland or mainland UK, they will be wanting to see that your policy, whatever that policy be, is actually pertinent to your practice. Regardless of what HTM says, HTM, as I said, is your fallback in the absence of any of that manufacturer’s support and help you fall back to HTM because it’s a bit like, and I used an analogy of things like cars. Now, years ago, your car manufacturers would always say, if you buy a brand new car, don’t drive it over 70 miles an hour for the first 5,000 miles or something like that. You had to let the engine warm up and embed itself. Obviously that’s not the case anymore. Now, there’s no way that you would buy a brand new car and go against what they’re telling you to do with that car. And that’s another way to look at it when it comes to manufacturer’s guidance. You follow what they say. It trumps everything. [Jaz] I’m learning a lot I have to say, because again, this is something that has never really piqued my interest, but I have to say that all this is very relevant, very good. And especially I think the practice owners out there, or prospective practice owners are really, really listen ing closely to this. I wanna just change it up to make it applicable to all clinical dentists. And we’ll talk about PTFE. I messaged you before. PTFE is something that we use universally. We get buy it from the hardware store. We cut it up, we stick it in the surface. We stick it in root canal chambers. We have a myriad of uses that are intraoral and extraoral. Should we be disinfecting in any way the PTFE before it enters the oral cavity? [Pete] It’s difficult with regards to disinfecting of PTFE. You can sterilize it. I would advise if you’re gonna sterilize it, best practice puts that as the clean side of the decon room. So very much similar to things like root elevators and stuff like that. Something you’re not gonna use that often. You’d store it either outside of the clinic or in the clean side of a decon room. And in that sense. And you bring it out when you need it, by doing that- [Jaz] Well, no, PTFE, like it is just, I use it daily. So for me, it lives in the surgery, but we lives in the drawers. Covered. [Pete] Yeah. You’d wanna keep it covered in a box because the problem is, is every time you open that drawer. That aerosol that’s been generated within the air will take about 10 to 15 minutes to constantly fall down to floor level. So there is a risk of when you open that draw, you’ve still got that aerosol falling down, which is why we clean and disinfect the treatment center in between every patient because of the droplets still falling down to floor level. So ultimately you would want to store it in a box, to keep it as protected as possible and then bring it out. I mean, realistically, if you want to sterilize it, there’s nothing to say that you can’t. However- [Jaz] I think there’s a place for that. But I think the place for that is a niche one, because when we are dressing root canals, yeah, classically, I was trained on using cotton pellets years ago. And cotton pelles are, are the worst. If you look at it in a scanning electron microscope. They’re hairy. They reach out, they come out of the restorative, they’re full of bacteria laden. So I’m sure you agree that actually cotton is the worst thing. You could use sponges. Then nets came in. I use these little sponges. They were good. But then PTFE is just so nice to work with. So nice to pack and so in root canal systems where we’re trying to keep as aseptic as possible and where we actually don’t need the PTFE to be so nice. [Pete] No, no, no. [Jaz] When we are actually sometimes doing it up against teeth and we’re putting composite up against it, we actually don’t want those folds in the PTFE, but where we are scrunching it up on purpose in the root canal system in the pulp chamber. I think to autoclave that is grand. So your advice of putting some blobs in a pouch. Stick in the autoclave and then using it when you need it, in the root canal system. [Pete] Yeah. I mean, there’s nothing, there’s no right or wrong way. There’s nothing to say. You can’t do that. I mean, at the end of the day, you have to risk assess it. Realistically, what are the risks associated with using PTFE in a canal? The risks are minimal. There are other items that pose greater risk than the use of PTFE tape and if you’re keeping it as aseptic as possible, so you’re minimizing that cross. Like everything we use within dentistry, you wanna keep everything as aseptic as possible. Then the risks are- [Jaz] I mentioned this in the community, Pete and then Ashley Peile. He said something brilliant. He says, if you’re gonna open the can of worms by asking about disinfecting PTFE, I might take a screenshot so we can put it on the video. Actually. He then said, what about matrices, cotton wool, tips for flowable, gloves, wedges, retraction wedjets, , rubber dam. [Pete] Exactly, exactly that. You don’t sterilize your rubber dam, you don’t do any of that. I see it with non-sterile endo files, K files, things like that, that come into practice. They’re not pre sterile and they’re used straight away. Now, realistically, they should be sterilized first. But again, aseptically, it’s aseptic, the risks are minimal. Yes. You don’t wanna be using those afterwards. So you could argue with a lot of things. There are other instruments that mustn’t not go through those procedures, and they are the instruments that you have in situ already in the practice, and you are using day to day from one patient to the next patient, to the next patient. You’re not using PTFE from one patient to the next patient. So. Yeah. The risks are minimal. Absolutely minimal. [Jaz] Brilliant. And then the next one, the next common question I see in the community, I’ve been seeing this question in the community for years and years and years, and it’s actually a cost saving measure because of these occlusal mirrors. They can cost a lot of money and they get scratched. And it’s a real shame ’cause over the years you start to see your images, your occlusal images get very scratchy. So I would like to know from you, what’s the best practice that you have observed in a clinic that are correctly disinfecting occlusal mirrors. But in a way that it’s gonna preserve the sort of reflective element and, and prevent scratches. [Pete] So, a couple of things. So first of all, there are mirrors out there that are non scratch, that are scratch proof that they bought out. I know, Acteon bought some out a little while ago that are scratch resistant for that exact reason because suddenly there is a niche market that requires something that doesn’t scratch and rightly so. So in terms of, not, in terms of not having ’em scratch, I wouldn’t put them into ultrasonic baths for starters, purely because the way the cavitation works, and if you’ve got an ultrasonic bath. Say like a hygeia three or something that works on an incredibly high frequency and that has an incredibly vigorous cavitation to it that can actually create some pitting in there, so you wouldn’t wanna put it in there. [Jaz] And that’s overkill because really, a lot of the times the mirror’s not even touching any part mouth. This is hovering above the teeth. [Pete] Well, this is the thing. So when we look at the UK, we have no distinction between an invasive and a non-invasive instrument. And what I mean by that is whether it’s gone subgingivally, or whether it’s just gone into like a, whether it’s just gone into the mouth. Okay. They are all classed as invasive. So it goes through the same process, the cleaning, the sterilization, the storage, and so forth. Even if the instrument hasn’t been used, it goes through the full process. Whereas in many parts of Europe, they’ll have that distinction. So mirrors are a prime example. In Germany, for example, mirrors non-invasive. They just need to be clean. They don’t need to be sterilized. And there’s other markets that are like that, that have that clear distinction. UK, we just have belt and braces. Everything goes through the full process. Now, ultimately, when it comes to cleaning, you’d wanna be cleaning it with a soft bristle brush. You don’t wanna be cleaning it. I would even probably acid, I would even probably move away from using a bristle brush even on it. Even on that lens because you don’t wanna be scratching it. So I would use sort of a water-based wipe, for example, to wipe that end. Something in a non linting cloth is quite soft and that is a cleaner and a disinfector at the same time. So it’d be a water-based cleaning disinfector products. There’s loads of them on online. [Jaz] Can you just name a couple of brands? [Pete] Bio Cleanse Ultra is one of them. That’s a water-based product. Schülke & Mayr Mikrozid AF, they do one which is, or Micro Z, which is a water-based cleaner and disinfect. [Jaz] These just wet wipes. The fancy wet wipes. [Pete] So these are wet wipes? Yeah, these are wipes that you would just wipe over that because as you say, it’s a non-invasive instrument. It’s not gone subgingivally, it’s literally just gone into the mouth to look at the area. So cleaning disinfection is slightly lower. So you certainly wouldn’t wanna scrub it because that’s where you’re gonna create scratches on the mirror. You certainly don’t wanna place it into an ultrasonic bath- [Jaz] And classically, what I see, which breaks my heart, is the box that we have where the nurses use to transport to the decon room. And that’s like full of probes and sharp instruments. That is just put over that, and that’s how they get scratched. So we need to also isolate the mirror away from the other instruments. So what’s the best way there? [Pete] So you’ve got a couple of options. I mean, ultimately if you can keep it completely separated in its own box, that would be the first, because you don’t want it to come into, they do come with any other instrument. [Jaz] Metal brackets, I think like a little bracket boxes. [Pete] You can get brackets for them. Yeah, you can get them. Or the other way, slightly less expensive would be to wrap the head in gauze or something. Like a sterile gauze pack. And just put it in between gauze just to protect it. ‘Cause you can sterilize it in that as well. So sterilize it in the gauze, in the actual sterilizer and do the whole lot in one. [Jaz] This is golden. Okay. So this is what I want to, so I’ve read, yeah, I’ve read colleagues, helping colleagues that the way to do it would be. To get some sort of like I don’t know, a lint cloth or something. Wrap the mirror in the cloth, then put that in the autoclave pouch. Now I didn’t, I never tried it because I don’t wanna be the guy who’s on BBC who put it on autoclave and that lint cloth went 137 degrees and then the fire happened. So this is where I always wanted clarity. [Pete] I would use a sterile gauze or a non-sterile gauze, a surgical gauze that you’re using in the pocket. Stick the head in between it. Put that into the pouch, in the autoclave. Yeah. [Jaz] Okay. [Pete] That would probably be recommended. ‘Cause the thing is with- [Jaz] That’s like gauze sandwich. Like gauze mirror gauze. [Pete] Yeah. Or even get the gauze and just ply it. So you can slightly open it in between and stick the head in between just to give it a bit of protection. Put that in the pouch, stick that in the autoclave. And then because the gauze itself will be poorer. So the gauze, so the steam will go through the gauze as well as going through the pouch that’ll sterilize the mirror. And then you’ve got the drying function on the sterilizer afterwards that will then dry the pouch and it’ll dry the gauze and it’ll dry the mirror. So it go right the way through. And then you can store that afterwards. [Jaz] I mean why use sterile gauze? That’s expensive way. Just use non-sterile gauze. [Pete] Just use non-sterile gauze. Yeah. Yeah. You don’t need to use sterile gauze. If you’ve got sterile gauze in, great. But yeah, the cheaper way of doing it, just get non-sterile gauze. Or you can use lint free cloth. A lint-free wipe, lint-free cloth, something that you are using to dry the instruments. You could use that. That’s even less expensive just to put over the head. Stick it in the pouch so it keeps it in place. ‘Cause you don’t want it loop moving around. [Jaz] So lint-free cloth and then sterilize healthy and the autoclave is not gonna cause a fire. [Pete] It’s not gonna cause a fire. No, no. It is not gonna cause a fire. You won’t get any fire from that at all. You don’t forget you’re sticking paper in there. You are sticking a paper pouch in there. The only time it’ll ever create a fire. And I’ve seen this happen. Oh my goodness. A couple of times is, if the heating element is exposed, which on a lot don’t really see it much on modern autoclaves to be honest. They’ve housed them all now. So the heating elements tend to be housed, which is basically an element where there’s the water comes over it then heats it up, and that’s where you get your steam coming out of. In some older autoclaves, those heating elements were exposed. And what can happen is if you put your tray in and the pouch touches that heating element, that’s where it can create a fire. And I’ve seen that happen before. Or you get tarnishing on the paper, you get a burn marks on the paper where it’s heated it up. But yeah, other than that, no, it’s not gonna create a fire. [Jaz] Brilliant. We now have a nice way to keep those mirrors scratch free, although buying mirrors that are scratch free, take my money. That sounds like I didn’t know they existed, so, my next round, I’m sure they come at a premium, but, for someone who’s obsessed about good quality photography, I think I’ll be looking into that. Next question for you, Pete. I’m really enjoying this so much. Actually, I never thought, ’cause on this software that we used to record podcast, I have this little marking button and every time I, something is like really good I press, so this is like the record for 2025 so far of how many times I’ve marked it. So thank you so much, Pete, for covering these, but us dentists, we’re stupid when it comes to, well, I am anyway, when it comes to, to decon. [Pete] You have too many other things to think about this that is kind of lasting. [Jaz] Very polite of you, sir, thank you. [Pete] Now you’ve got far too many things to think about. [Jaz] Appreciate it. So distilled water. Distilled water. It’s piqued my interest because, I’m in the realm now of using ultrasonic, mini bath to clean my ceramics for watching the hydrofluoric acid etch off and getting the nice etch pattern and improving my bond strengths. So for that, I need to use distilled water. Now, distilled water, you can buy quite cheap in in gallons. Are there any other requirements for practice to be using distilled water? So I don’t need to buy my own, I can just nip at the decon room and take some of that one, because from what I’ve seen that seems to be reverse osmosis and that’s different. [Pete] Yeah. You’ve got two types of water. You have either that you can use distilled or reverse osmosis. Both of them are very different. So distilled water uses obviously the distillation process. So superheated evaporates it re evaporates back down, and that’s where you get your distilled water. The problem with distilled water is you have to use distilled water incredibly quickly. So no longer than sort of 24, 48 hours, it’s got to be used within, because what happens with distilled water is when it goes through that distillation process is, that freshly distilled water when it comes in contact with oxygen, it draws in carbon dioxide, which then makes that water acidic. Then anything it comes into contact with it absorbs it. It’s a natural absorber, distilled water. It’s a bit like the distillation process of whiskey, for example, if you’ve ever seen that happen when they freshly distilled whiskey, it’s clear. But what they do then is they take that freshly distilled whiskey, they put it into a soft wood, a redwood oak, or a cask. Leave it there for six months to a year or 15 years if you’ve got the good single stuff. And then what happens is it draws in the color of the wood, and it also takes on the flavor of the wood. It’s a natural absorber, which means distilled water has, and that’s what the document talks about when it talks about using water as quickly as possible. It’s talking about distilled water. [Jaz] But in terms of my use of it, let’s say I get a small bottle, right? Let’s say I get like a one liter bottle, right? Yeah. Now I open the cap, I pour literally, I only need a small amount to do what I need to do with my ceramic. I close the lid again. I can still continue using that bottle. Or are you trying to say like some sort of food you buy, you have to use within seven days? The whole bottle? [Pete] You would find, if you look at it when that bottle is opened, you need to use it within 24 to 48 hours. [Jaz] Wow. [Pete] Because what will happen is that as soon as you have opened up that bottle, oxygen’s going in, it’s absorbing carbon dioxide, gonna absorb more. And it’ll absorb the impurities from the actual plastic that’s in the bottle as well. If you want to prefer preserve it to store it longer, put that water in the fridge. [Jaz] Ah, okay. [Pete] At about three or four degrees. That cold temperature will slow any of that process down altogether. [Jaz] Brilliant. [Pete] So I would say you put it in the fridge, RO water on the other hand is completely different. [Jaz] Yeah. That’s obviously uses, that’s not suitable for ceramics ultrasonic at all. [Pete] RO water is. RO water you can use. [Jaz] I thought RO water had all this minerals still in there and that would interfere with it. [Pete] RO water, reverse osmosis water utilizes different filter levels to draw all of the minerals out of the water altogether. So what you find with RO water, as you’ll have several different either three filters or five filters. So there’ll be a carbon filter that’s drawing carbon out of the water, a magnesium outta the water. You’ve got sediment filters that are taking all the impurities out. They’ll go down generally to a 0.3 micron filter, which the smallest waterborne pathogen organism in water is 0.3 microns. So nothing is lower than that. So that’s all of those minerals stripped out of it. And then what you end up with is basically pure water that’s got nothing in it at all. [Jaz] So, distilled water is less pure. So, so reverse osmosis is more pure than distilled. [Pete] Distilled water when it’s in its initial stage is purer than RO water. But RO water can be stored for longer. Because RO water isn’t an absorber, it doesn’t absorb everything it comes into contact with. It’s a way of achieving distilled level water, but through filtration. Through a series of filters and what you find, you’ll have different grades of filters that the water will be passed through with the very fine RO membrane being that 0.2, 0.3 micron filter that the water has then pushed through. The problems with RO in the way that it works is it has a very high dump rate. So for every liter of water you put through an RO system about 700 to 800 mils of it is wasted. It’s only about two to 300 mils that’s actually used for RO water, usable room. [Jaz] So I’m obviously using it in the clinic for the ultasonic bath in a very small amounts for my ceramic. But in the decon room, which water is king, what’s being used? [Pete] RO water is becoming more of a king than distilled water. I think distilled water, historically is what we’ve always used. We’ve always used distilled water. Now, the downside to distilled water, as I said, is you’ve gotta use it really quickly. It also generates a lot of heat. [Jaz] And that’s pre-purchase or is it produced in the decon room? [Pete] Produced with a water distiller. Produced with water distillers in the decon room. Distillers with a distiller kettle that are, then you pull water in the kettle, it then super heats it, and you get your distilled water coming out the other side. [Jaz] And that is like you said, with RO water, you put a a liter in. You only get a small amount out. What’s the ratio like with distilled water? [Pete] Distilled water? It’s probably slightly best than that. Most virtually all of the water you put in, you are using 95, 90% of it for distilled water. So the ratios are far in favor of distilled water. However, distillation process takes a lot longer to produce the water that you need. Hence, they’re always left on, they generate loads of heat, they use a lot of electricity and also you have to use the water straight away. RO water, which is why it’s kind of becoming more and more favorable is you have RO water on tap. Generally they all come with big storage containers. So you’ve generally got a five liter up to, I think one manufacturer does a 70 liter container that you’ve got your RO water satin, and you can just draw from it. All the time. As soon as the system then gets down to a certain level, the RO unit then starts to produce more water. So it’s constantly keeping that tank up to date. They use a lot less electricity, they use nothing. They don’t generate any heat, so they are more sustainable. The only downsides to RO water is if your practice is water metered. So if you pay per liter of water that you have rather than a fixed rate, RO water can become incredibly expensive because of the debt. [Jaz] That is a top pearl, I think. [Pete] So if you are fixed in terms of your water, what you pay each quarter or each six months or whatever, RO water is definitely the way to go. Definitely the way to go. [Jaz] No, but you said RO water’s the one that’s- Oh, if you’re fixed. If you are metered. [Pete] If you’re fixed. If you are metered, yeah. RO water becomes incredibly expensive if you’re metered because it has such a high dump rate. [Jaz] Got it. And for me, the big change is obviously like, I’d like to use distilled water ’cause that’s what the manufacturers say for the ceramics, ideally to use, either that or ethanol. Therefore, I’m gonna go into my decon room and see, are we producing any, I don’t need to buy any bottles. If you’re producing fresh distilled water. [Pete] If you’re producing distilled water, I mean, I’m very, to be honest, Jaz, I’m pretty sure the practice will be, I mean, I would consult with the manufacturers. I can’t see from a decon perspective with any ceramics personally, any reason why RO can’t be used. Because the two fundamental waters that we have to use within dentistry for everything is distilled or RO. And the only reasons why we are using those two types of water is because both of them are deemed good quality water. Secondly, they have no minerals in them. They’ve got no deposits, they’ve got no lime scale, they’ve got no magnesium, nothing like that. And thirdly, they have no endotoxins in them. So they’ve got no bacteria in them or negative gram organisms in them at all. They are both deemed good quality water. So I can’t see a reason why it can’t be used. But it very much depends on the manufacturers. It is very dependent on what, they may have a reason as to why that’s the case. [Jaz] Yeah. I’ll look into that and I’ll add it in and add on. Pete, you’ve answered so many questions. There’s so many unanswered one, so you must come back for a part two one day, but for now, I just like to highlight like the wonderful work you do, in terms of consulting practices, consulting teams. I know you do programs for like practice visits and kind of like doing a bootcamp to make sure that everyone’s doing the right way. Please tell us how can you support our community, our practices? How can they book on to get some advice from you basically? [Pete] So WhatsApp’s probably the easiest way to contact me, to be honest. I would go through WhatsApp. I would encourage all of your teams to join our Facebook group. We’ve set a Facebook group up. We set it up about a couple of years ago. IPC support by Decon Pete. It’s a private group. Get the teams to join up. We’ve created it as a safe space for everybody to ask those questions that they may feel stupid. I don’t think any stupid is a stupid question. Any question is a stupid question. But we created this group as a safe space for like. For like people to communicate, to help each other, to support each other, in all things decon. And ultimately, we are there to help everybody to keep safe. So yeah, either visit a website, WhatsApp, or, or join the group. We get a lot of questions on the group, and if I can’t answer something, there’s always somebody in that group. I’ve got CQC inspectors in there. I’ve got various other inspectors in there that they help and help the community. We try and help as many people as we can. [Jaz] Well, it’s been very clear from recording this episode with today that you are here to help and you are a friend of the profession, so thank you so much for what you give. [Pete] Perfect. No problem. Jaz’s Outro: Point everyone to the Facebook group, and to a website as well. And, I look forward to learning more from you. That was absolutely fantastic Pete, thank you so much. Well, there we have it guys, thank you so much for listening all the way to the end on a decontamination episode. Can you believe it that you just listened to or watched through entire hour of content on decontamination? Now, please tell me, was that useful? Is it useful to go through these traditionally boring core CPD topics in the style that we did to help you, putting the targets and everything aside, are these less sexier topics helpful? I would love to know if you can comment and hit the like button. Please do scroll down if you’re watching on the Protrusive Guidance platform, answer the quiz and get your all important shiny golden core CPD. This is the one that’s mandatory. This is the one that we have to do a big fat tick for this year’s decontamination training. If you want to get CP or CE credits for the episodes that we do, including this one, and check out all our courses, like if you wanna start doing Vertipreps or sectioning teeth, or doing rubber dam or watching through entire videos of step-by-step lithium disilica, onlays, and all sorts of procedures. We’ve got them on the Protrusive Guidance app. Check out protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate. I know you’re gonna love the content, but what you’ll love even more if you’re not on there is the community, the community of the nicest and geekiest dentist in the world. So thank you to all the Protruserati for supporting what we do over the years, and so empowering us to do these kind of episodes and there’s so much more planned where this came from. Thank you again. I’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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Work Life Balance + Setting Priorities – PS014 54:45

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Is Work-Life Balance a Myth? How do you find the right balance between your professional responsibilities and personal life? Can you truly have it all…without sacrificing your health or family time? https://youtu.be/wkAv3noFXNk Watch PS014 on Youtube In this episode, Jaz and Emma Hutchison, ‘the Protrusive Student’, dive into the real challenges of balancing parenthood, clinical dentistry, and LIFE! Jaz shares his strategies for managing these demands, revealing that while perfect balance might not exist, navigating life’s seasons with intention can make all the difference. If you’ve ever struggled with finding your own balance, this episode is packed with key takeaways for dentists at every stage of their careers. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 03:34 Emma’s New Year Reflections and Study Habits 12:20 Balancing Family, Work, and Personal Time 19:50 The Importance of Planning and Support Systems 23:16 Recognizing Opportunities and Setting Boundaries 28:15 Understanding Circle of Concern and Influence 30:24 Eat That Frog: Tackling Difficult Tasks First 31:02 Burnout in Dentistry: Real Experiences 39:51 The Importance of Mentorship 41:07 Just in Time Learning 44:03 Decision Making and Confidence 49:15 Effective Time Management Strategies 51:16 Final Thoughts and Takeaways Key Takeaways: Preparation and good mental health are crucial for success during exam periods. Internalizing knowledge helps in better understanding and retention. Finding time for hobbies and self-care is essential for well-being. Planning and prioritizing tasks can lead to more effective study habits. Support systems play a vital role in managing stress. You can achieve a lot by focusing on your big priorities. Eat That Frog: tackle difficult tasks first. Burnout is a real risk for dentists. Finding a mentor is extremely beneficial for career growth. Just-in-time learning is more effective than just-in-case learning. 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. If you enjoyed this episode, be sure to watch Stress in Dentistry 2024 – Life Changing Decisions – IC048 Click below for full episode transcript: Jaz's Introduction : Guys, there is no such thing as work life balance. It's a myth. 'cause sometimes when I'm with my family and we're on vacation, it's all about my family. Nothing else matters, and that's really the way it should be. But there are other times where things get really busy at work and I'm not able to give my children the quality time that they deserve. Jaz’s Introduction: And sometimes that happens. Or sometimes you are sacrificing sleep or your health, which really we shouldn’t be doing. But sometimes this happens. ’cause of other events and other priorities at that time. So to find this daily balance and work-life balance that slots into everyone’s magic week, it just doesn’t exist because there’s a season of life for everyone. And so a lot of what we talk about today with Emma Hutchison, who’s the Protrusive Student. So welcome to this Protrusive Student episode. About 20 or 30% of what we talk about in this episode is related to students, and about 70% is all to do with dentists in the real world. Because Emma asked me, how do I do it? How do I balance everything? How do I balance fatherhood, clinical dentistry, Protrusive? And so a lot of my tactics or the strategies that I use are revealed in this episode. Hello Protruserati. I’m Jaz Gulati. Welcome back to your favorite Dental Podcast. It’s the student series that we do, but as we’ve seen in the comments on YouTube, mostly dentists tune in because they find it’s nice to reconnect with the basics and with a topic like work-life balance and priorities in life. This is applicable and universal to everyone. So if you like the title and you clicked on, thank you so much and I hope you enjoy this listen. As part of this Protrusive Student episode, Emma has released her orthodontics for students notes. So in the Crush Your Exam section of the Protrusive Guidance app, there’s a section just for students. Basically there’s little student forum there. It’s like an up and coming area. So if you’re a dental student, you want free access, please do join the app and email student@protrusive.co.uk proof that you’re a student. And then get, also, get access to the Protrusive Vault. That’s where all our infographics and everything live. That’s how all community service to students. Emma’s just has done a wonderful job of sharing all her notes, so it’s about, I think 14 or 15 sets of notes on there from dental materials to indirect restoration to now orthodontics for students, and if you’re just a geeky dentist that just wants to download them and read them, then you can totally do that as well. Head over to www.protrusive.app to get started with Protrusive Guidance. Those sections I mentioned are absolutely free. In this episode, Emma and I discuss so many themes, and what’s striking is that Emma’s time as a locum nurse, so she’d go to different clinics when she was called and she’d nurse for like a new clinic every time, for example, and I asked her, did you ever come across any miserable dentists? Any dentists that just looked really burnt out or unfulfilled in their profession? Which I think is a really sad thing, right? Everything we do in this podcast is about making dentistry tangible. But also reigniting your passion for dentistry. Reconnecting with that feeling you used to get in your belly when you wanted to get into dental school. I think it’s really important to just remember that feeling. ‘Cause that sometimes helps us to drive us through a difficult patch. But when I ask Emma about this, and she noticed certain trends, certain qualities about the dentist or the practice that she knew within 10 minutes that, okay, this practitioner is burnt out or this practice lacks a culture, and that’s very relevant to work-life balance and priorities and setting boundaries and all those things. So a big higher level discussion today, and it’s laced with themes like burnout, goal setting and setting. Really importantly, what are your non-negotiables in life? It’s really important to do that, but of course you’ll see that all in the main episode, which will check out now, and I’ll catch you in the outro. Main Episode: Emma, happy New Year 2025. Welcome back to the show. You are the Protrusive Student, so tell me what student thinks have been up to over this Christmas and New Year period. [Emma] Over my Christmas and New Year, I’ve been trying to enjoy it, obviously, and I have enjoyed it, but I just know that my big exams are around the corner, so I have been doing work every now and again, just keeping on top of making lecture notes and flashcards and all those sorts of things, but I’ve just not been overwhelming myself. So, that’s what I’ve been. [Jaz] You need to share these flashcards with the students if you’re comfortable to do something. [Emma] Yeah, yeah. I use Quizlet for my flashcards. I know a lot of students use Anki as well. I think that’s quite a popular one. [Jaz] But think these are all digital things, right? [Emma] Yeah, all digital. [Jaz] A flashcard on old school still means like in a paper and pen like I used to back in the day. [Emma] So, no, it’s all there on there. So. [Jaz] Good. And so it should be so great, if you’re happy to do so, ’cause you’ve been sharing your notes so generously, whenever is the best time for you to share those to the students who will help someone in the world to help pass their dental exams, which would be good. Today we’re talking about a different topic as you requested. Basically the story is, guys, Emma wanted an episode on like the student perspective of orthodontics, and I thought that’s gonna be so difficult to do. Right? Like, I was extractions, one was a real success and extractions went really well. But you asked me about ortho, like I think, I won’t be able to help you as a student. When you come to your first ClinCheck and your first, it’s all conundrums. Is this possible with liners or should I refer? I’ll be able to help you then. But actually at the student level, it was always a blur what they wanted and yeah, orthodontics was very, very confusing as a student, I have to admit. [Emma] That is fine. That’s fine. For this episode anyway, we’ve made like orthodontics student notes for this episode, so. We’ve still got our format. [Jaz] They can download him in the Crush Your exam section of the Protrusive Guidance app. But the topic chosen by Emma was an interesting one, actually. Work life balance. So what spurred that one? [Emma] Probably inspired from my Christmas period and my mom’s like, oh, come watch a movie. Come watch a movie. And I’m like, oh, give me an hour. I’m sitting down doing work, blah, blah, blah. And it’s just, I’ve had on my minds that I do have exams coming up. I think I can be quite prone to just shutting myself in my room and not leaving, not seeing sunlight, but I’m determined not to do that so much this year and just to sort of not burn myself out really. ‘Cause I think we can all be quite good at that as dental students. So it was just a bit of a chat about work life balance and I know, well, most dental students will be having exams coming up, so hopefully people can take away something from that just to keep your mental health in, in good condition and not to burn it. [Jaz] Well, I think I’m in a good position to speak about this because I have made all the sins. Like I think I told you in the very first episode, one of my regrets is like in the final year, just like literally not looking after myself and just like being all about, okay, get these exams sorted, gave up everything social, gave up everything, gym, which is very important to me, and I just let myself go so that I can do well in the exams. And yes, I did well. But I don’t know, if I just did those things that I enjoy doing, like exercising and the social aspect and just wasn’t so harsh on myself, like wasn’t so demanding on myself, didn’t stress, didn’t take on so much what I feel is one unnecessary stress in the stomach. Perhaps maybe I would’ve done better or one or 2% less. Like it wouldn’t have been significant. I just like to think and it reminds me. So it’s a quote that recently came my Instagram recently, and it was from Kobe Bryant. And it was basically his confidence on the basketball court came from the fact that he knew that he’d done everything he could to prepare. And that’s what gave him confidence. Anytime, and the most beautiful part of this quote is yet to come, which is anytime he felt anxious, right? It just meant that he didn’t prepare enough. So when we feel anxious, when we feel stressed, it just means that perhaps we did not prepare enough. Okay for it, basically. And so the advice I would give you is pace yourself. Do some, it’s wonderful that you’re doing during this Christmas, but also, it’s a season of life whereby you’re gonna have to work because if you don’t do it now, if you don’t study now, when are you gonna do it? It’s gotta be done. But at the same time, you have to craft yourself and give yourself these breaks. So it is actually a tough one. ‘Cause they say the Mahatma Gandhi quote, if you’re familiar with it, it says “Live each day as if it was your last”. Do you know the next bit? [Emma] No. [Jaz] “Learn as if you’ll live forever.” [Emma] Yes. That is what I, yeah. [Jaz] So really like, I want you to go deep. I want you to really learn, but you also then have to be clever about it. Like there’s no point going off tangent learning something that’s not gonna be on your exam. ‘Cause it is kind of a means to an end because no matter how well you do, it will not determine your success in your career. Like 0%, like your academic prowess and what you achieve unfortunately has no correlation to your success as a dentist. Your success as a dentist will come from your emotional intelligence, your interpersonal skills, a bit of luck thrown in there, right? Your first boss, what they’re like, all that kind of stuff. So do what you can to feel prepared. Don’t look back and say, I regret not working hard enough. But very few people, I dunno, very few people think, go back and say, I wish I worked harder. I wish I spent more nights reading books. Maybe they don’t say that, right? And so, remember that we only need 50%. I always, for me, it was never gonna be enough. I wanted to aim for the highest, and I know you’re the same and I get that. So it’s a tough one because I want you to work your butt off, but also don’t do what I did and give yourself that break as well. [Emma] Yeah. And I think that’s the thing about dentistry, because. You only need a D to pass, right? But you still need to work. You can get a D and you can pass by the skin of your teeth. But in order to do that, you still have to work really, really hard. So if you are someone that’s like me or like yourself, who do strive for those A grades, those B grades, you’re naturally gonna be that kind of person that’s a bit more hard on yourself. And the thing with dentistry is like, you’re never going to learn everything that’s in your content. Like, I was sitting last night and I was saying to my mom, I was like, how is there so much to know about teeth? And she was like, well, you’re not gonna memorize at all, especially not for this one exam. So that you just need to do your best. You’re never, ever, ever gonna remember absolutely everything that your lecturers chuck at you. And I think that’s made harder because you can get made to feel quite bad for that at university, because all of these lecturers, they’re specialists in what they do. They all believe that their lectures are the most important. And then when you turn up to these tutorials and you don’t really know the answer from the lecture you had two weeks ago, you can be sort of made to feel quite a bit silly for it maybe. And you can be dead hard on yourself, but you’re never gonna remember everything. But you just need to try your best. [Jaz] Forget. I mean, the problem with these exams is that like all the exams we had when we were younger, they are to some degree a memory test which is a real shame. So I always try to not worry about like memorizing things so much, but trying to, as long as it makes sense to me, like if something actually makes sense to me, then there’s no chance I’m gonna forget that basically. So, I’m sure you’re the same. Try and make sure you internalize it, understand the why and the mechanics of it. Rather than understand that, insulin resistance and this causes diabetes, understand the actual mechanics of what’s happening with the insulin or whatever. As an example, I’m listening to Robert Lustig’s book, Metabolical, uh, and it’s about your overall health, diet, nutrition. And that’s why that in specific example came up to me basically. But I know it’s relevant ’cause they ask us about that, especially with perio and stuff. But as long as you understand what’s going on. And the why behind it, that will really help you. [Emma] Absolutely. And I think for me, that internalizing it is putting it into my own words in these notes that I share with people. Like I know that for a lot of my friends and it works, they have the slides and they annotate the slides and that’s what they’ll use for their revision. But for me, I need to like you said, internalize that. And I take that and I put that into my own words, and that’s what I study from like a slideshow is not that good to me. I need to sort of sit down and write it in words that make sense to me, and then that’s what I then use. [Jaz] It’s like you have to talk to yourself about it for a while. Like that’s how I to do it. I used to like think about it, okay, well this is what’s written here, but let me say it in my own language that makes sense to me, and then write it down. And then, revise it again closer to time in my own handwriting, no longer needing the textbook anymore. ‘Cause I’ve kind of taken the textbook, I’ve taken the slideshow, I’ve taken, nowadays you guys are lucky. You got chat GPT right? You take what they tell you. And then you internalize it Emma language and then that will give you the best way of understanding and not no longer like regurgitating and memorizing. It’s more like coming from an internal understanding. [Emma] Yeah. And even people who will look at my notes, you’ll take bits from that and you’ll turn it into your own little thing that is relevant to you and that’s fine. But my first real question I wanted to ask you, Jaz, was, I know you’re a very busy man, so how do you structure your day to make sure, you’ve got a young family to make sure that you have time for your family, your friends, hobbies outside of dentistry, how do you keep it together? [Jaz] Yeah, I could ask you, I don’t know. No, I’ve got some guidelines and I think a lot about this. So let’s talk about it. It’s gonna be fun. My life is a beautiful mess at the moment with having two young boys, especially one 19 month old, almost 20 month old now, who just doesn’t sleep well still. Last night it was up like twice. I had to get him one to milk, one to calm him down and stuff. So the lack of sleep or the disrupted sleep, which is the biggest killer when you’re a young parent. And so that’s that. But it wasn’t always like that when me and my wife were just us and there was no kids. It was the other, if you ask me then was I stressed? Was there loads of workload? I always said yes to you. Then I was like, oh, I can’t get more than this, and now you throw kids in. I was like, oh, you can’t get more than this. And so the perception always is that, oh yeah, it’s really difficult. It’s really difficult, but you really need to go back to your north star, your why, why you do what you do. And I think it all goes back to having a mission, having a goal of some sort. So for me, my mission is to make sure I serve my family, I serve my patients and serve you guys, the Protruserati. This is my mission. Now, linked to this mission is a common question that people ask me is, Jaz, why have you opened a practice? Why don’t you run your own practice? And I would love to, honestly, I think I do a good job and I’d give it my all and I’d I’d make it the exactly how I want it to be. But if I did that, that would be the death of Protrusive. Because I know that there’s only so much one can juggle and then doing so much one can delegate as well. So really, I’m at a point now where I know what my priorities are and I live by them, but to be able to serve my priorities, I have had to make some lifestyle modifications. So for example, before kids and before Protrusive, I used to watch every single Manchester United match, like the whole 90 minutes plus the analysis. Like every single match I’d be watching it, right? I just barely watch the highlights Now. I’m a Fairweather fan now, barely watch the highlights and no guys, it’s not because my team sucks at the moment. It’s generally because you have to kind of make a list, right? Like, here’s your big goal, right? So I want to achieve all these things with Protrusive and family and go on this many vacations and help my patients in this way, work this many clinical days. But to be able to, and be a great dad, like that’s really important to me, right? So all those things, but then you have to write down, okay, what are you willing to sacrifice to make that happen? So for me it was okay, I have to sacrifice watching football. Fine. I don’t wanna sacrifice watching the IPL, which is the cricket that happens between like April and June. And for me that was like, okay, fine, I’m gonna watch those fine. ‘Cause that I’m not willing to sacrifice that, right? I was willing to sacrifice Netflix, Amazon Prime, all those things, right? So I hardly watch it. Only just started watching Squid Game season two with my wife. Like, that’s it. That’s the only thing this year, that’s it like two hours this whole year. So really, because I’m so driven and I’ve got all these things I want to do, like if I’m not working. I’m serving my children, I’m teaching my son something. We’re playing, we’re practicing cricket in the living room. We love doing that, right? So it’s about deciding to achieve the goals you want to achieve what is important. And really, sometimes you’ll get these little shiny things that will come and distract you, but realize actually this is a distraction. And that really big thing that you are working towards, don’t lose sight of that. So don’t lose sight of whatever your goals are. It may be. So the answer is it’s hard, but because I know my values and I know my goals. It then becomes easy because I know, okay, I’m gonna not catch up with my friends for, I don’t get to see my friends that much as much as I want to, and that’s the honest truth. Because I put my family above my friends at the moment, and that’s just the season of life I’m in when my kids are a bit older and they don’t care about me anymore. Then it’ll be a different season of life. Okay. So it’s all about the season you are in and the season I’m in at the moment is very much, family first. [Emma] Yeah. I mean, that makes so much sense. But to someone like me, I don’t have kids. I’m still so the baby of my family, out of everyone, I mean, I’m 25 and I’m the youngest. There’s no babies or anything in my family yet anyway. [Jaz] But like you and Rakesh, when you were at the live event, you were talking like, hey, does Jaz sometimes message you like four or 5:00 AM and that kind of stuff, right? [Emma] Yeah. [Jaz] And then you wake up at like 10:00 AM and you check my messages and start writing. I made that better. I don’t actually remember what time I wake up, but like to make it work. Sometimes, when I’m reading to my son, I get so sleepy. I might as well sleep as well. It’s 9.30, 10.00 or, okay, I’ll sleep. Then I wake up at 4:00 AM to make sure I get the stuff done. It needs to happen. And so you’ve gotta squeeze it in somehow some way, and it all needs to work. Me and my wife are absolutely exhausted, like running the home, running the kids, clinical, we’re both clinical as well, so it can get really crazy and having you guys, the team behind me, it means so much to me. So it’s a bit like a practice owner saying, oh yeah, I’m indebted to my practice manager with the associates, the management team, the reception, the nurses or whatever. It’s a bit like that. So you have to have good people around you and a really understanding relationship with your spouse as well. [Emma] Oh, a hundred percent. And my mom and dad are sort of that version for me, like when I’m at home and if I’m studying, like there’s no pressure to do chores around the house or anything like that. Like they’re very understanding and bring me a cup of tea in the morning and they’ll just let me get on with things. But yeah, me and Rakesh still talking about that. Yeah, no, but it’s amazing that my mom and dad are able to do that for me. My dad’s retired, my mom’s part retired, and they’ll do absolutely anything for me, like just to help me get through this because they know it’s my dream. And the same with just, I’ve got such a good support system around me. Friend-wise as well. A hundred percent. My university friends, a million percent because we’re all going through the same thing. But even just my friends from home that I went to school with, when I come back to my mom and dad’s house, it’s so good just to go and speak to them and sometimes talk about dentistry and uni, but sometimes just not to. I think after you’ve graduated, dentistry can start getting a bit more fun. But at university when you’re studying and exams, you can sort of lose that a little bit. Burnout and things. It can get a bit, just not what you want to talk about. Day in, day out. So going home and having those conversations, just about literally anything else. That’s good as well. [Jaz] I was just gonna say two things I didn’t mention is, like you said, hobbies and stuff for me. I watch cricket when this IPL season. I used to play cricket. My shoulder got dodgy. So now my joy is vicariously living through my son. I take him to cricket on Sundays and I love that. But I go to gym three or four times a week and before my mindset was like, if I can’t go for an hour and if I can’t work out for an hour, there’s no point. And that was so, so wrong. And actually the latest research would back up that those who did 25 minutes to half an hour intense workouts, okay? They gained as much muscle mass and achieved all the cardio parameters as someone who did longer sessions, basically. So it’s about doing more intensity, shorter workouts, and that’s the only way I can make it all fit in. So I do these shorter workouts and that keeps me sane. It keeps you away from the teeth, keeps you away from everything. And that’s really important. But you need to decide what it is for you that will give you that sanity. Now, for some people that might be Netflix, and that’s okay. As long as you make peace, as long as you write it down. Things that make me happy and keep me sane. Netflix, that’s fine. For me, gym is more important than Netflix, so that’s why there’s no time for Netflix. But I forced, I literally forced time for the gym ’cause that’s really important. And the only other thing, ’cause you mentioned the word burnout in, I get so close to burnout sometimes, right? But the reason I think I’ve been doing okay, both me and my wife is we are big believers and thankfully, me and my wife are aligned in this, which is having our vacations and holidays booked 12 months in advance. It’s so important to us so you know exactly where we’re going and when things heat up with the children, patients, and the clinic stuff, and protrusive stuff and everything gets too much. And we know that it’s just three more weeks until we go away. And that just is a beautiful thing. So having your breaks, the worst thing you could do is you’re burnt out. Like, oh my God, I need a holiday. And then you start looking and the next chance you get to take a holiday is three months away. Then you know you’re screwed up. So I mean, in a way you kind of know where your breaks are as a student. [Emma] Yeah, yeah, yeah. Always. Pretty much. But my mom always says that as well. You need something to look forward to. Even if that’s, however, many months in advance, you’ve got something to save money for. You’ve got something to look forward to- [Jaz] Something to clutch onto. [Emma] Spend with your partner. Yeah, yeah, absolutely. Like you need those things planned in advantage. Something to look forward to, a good support system around you and what I do as well that. I think I’ve only really been doing the last, I’m gonna say a year, six months maybe, is this probably won’t work for everyone. I don’t know if you’re the same Jaz, you probably are, but I will plan my week ahead. Like I’ll sit down on a Sunday and I’ll give myself half an hour just to make a list of what I’m gonna do every single day, Monday to Friday. I know some people that do it hour by hour. I don’t really do that. I suppose I have to with uni and things. I’ve got clinics at certain times, but just sitting down and saying, right. These are the lectures that I’m gonna watch that day. These are the notes that I’m gonna watch that day. I’m gonna go to the gym after uni. I’ll organize what I’m gonna have for breakfast, lunch, and dinner that day. And I just take that 30 minutes, that hour on a Sunday and I will just organize my next week with it. And it seems like a lot of work, but just give yourself half an hour or an hour. Or sit down the night before and just organize what you’re gonna do. That helps me. [Jaz] You must feel so good after doing that, right? [Emma] Yeah, no, it feels so good. But then with that also comes like if you have a terrible day at uni and you go home and you don’t really feel like having chicken and rice for dinner. You ought to get a big fat McDonald’s. Like that’s also okay. When I first started doing this, I would get so upset with myself if I got to that Sunday and I still had all these things that were left over on my to-do list, but it’s fine. It’s really fine. Like no one’s gonna die. It’s fine. [Jaz] That reminds me of how we, and I said this recently in the New Year’s special episode, but we always overestimate what we can do in a day or a year. If you take a even a day or even just a year, we overestimate what we can complete in a short amount of time. But if you look at 10 years, we always underestimate. So you have to think the long game as well. And you, I mean, it’s so good that you aim high. But you only achieve 60% of those things. But if you’d only aim for just completing two things, you’d be left disappointed. So your greatness comes from that you’re aiming high and you’re being strict, but it’s also being kind to yourself. And sometimes, you know what? There is a season of life you’re in. And because you’re a season of being a student, Emma. Like when sometimes an opportunity will come your way that, you’re 25, you can only do it now, you can’t do it when you’re 35 for example. Or you can’t do it at any other time. ‘Cause now is the time you’re a student, now is the time that you are young. You have energy. So if you don’t do it now, you’ll miss the boat. So when those kind of opportunities come by, it’s about recognizing, hey, this is a rare moment in my life and actually I need to stop these other things and take this opportunity. And it is something special about recognizing that. So it’s a bit like someone who doesn’t going to all the parties and stuff when you’re young, right? And then, first, second year even throughout uni, whatever, right? And you do it. And it is good to get outta your system. It’s good. Now, I think we talked about this before as well, but if you start doing that, you’re now associate, you’re four years in, and then you’re going to late night parties and stuff, and you’re turning up to patients and you’re groggy and whatnot no, that’s not cool, right? Or you’ve got a family, you can’t be doing that. So there’s a time and place for that. And you have to respect that and, and go with the flow of that season of life. [Emma] Yeah, for sure. And I felt that, when I was in my earlier twenties, like sort of covid day times, I’ve not fully got it outta my system. I still love a good party, but it’s now something that I won’t let myself do too often. Because if you’re turning up to lectures nine in the morning, feeling all groggy and horrible and got home at five in the morning, like it’s just not what you want to do anymore. And it just ruins your day after for me. [Jaz] So it’s about quality. It’s about choosing now rather than quantity. It’s about that night, that sounds good. No lectures next day I’m gonna let my hair down have a good time, basically. And so it’s important to do that while you’re there with your friends, and you got the vibe of a student, if I was a student, I know what I’d be doing right now. So, more power to you, you do it. But I like that you respected a bit that okay, you’re more senior in your dental school level now and you need to set some boundaries and that’s really important. [Emma] Absolutely. Yeah. [Jaz] Professionalism. [Emma] Yeah. Especially in fourth year at Glasgow, all of our clinics start at nine in the morning, so you can’t be going out the night before and having a mad on or anything like that. But for me, and like my priorities and what I want to achieve this year at uni. That’s not something that I’m going to be doing anyway. I relate to you saying, I love Netflix, I love watching things, but gym is a non-negotiable for me. So I will say like, I’m only watching one episodes of something a day. Before I go to bed or read a book or something like that. And that’s it. Like gym is definitely, like you said, like it’s my safe space. Like that’s when I get to unwind. So I don’t get as much time to watch Netflix or go out too much or anything like that. So it is definitely like prioritizing what you want out of your time at the moment. And ultimately I think most students would agree, like my priority are my studies at the moment. So you just have to make sacrifices to other. [Jaz] And for other people’s, it is not gym, it’s cooking or it is Netflix for them. And that’s fine. It’s just making peace. Just making peace that you are you, everyone can’t be a gym freak. It is not for everyone. You have your own little things that you do. You might be a certain sport that you play or an instrument that you play, or, or just go into jazz clubs. I don’t know what, it could be anything that you want, right? So as long as you make peace with the fact that, okay, these are your non-negotiables and these are things that you are willing to not be so strict on, to make sure that you fit the big things in. It’s like the whole thing again, I feel like I’m getting deja vu. Like I think we discussed some of these themes in the past, right? The thing where the professor goes about the big rocks, the tiny pet pebbles and the sand. Do you know this one? [Emma] Ringing bells. I feel like you’ve either talked about it on the podcast before or we’ve talked about it. [Jaz] Maybe someone listening to a podcast the first time. So it’s really important we do this. Okay. So it’s like a professor. I’m really hoping, I’m trying to make sure I get this right. So basically the professor goes, he gets a big jar, and he fills it up with these big rocks, basically. And he asked him, is this jar full? And everyone says, yeah, it’s full. Like it’s full of rocks. And then he puts in these tiny little pebbles inside that, which obviously fit into little cracks and crannies and whatnot, nooks and crannies. And then he says, okay, well, is it full now? And I say, yeah, yeah. Now it’s full. And then he gets some sand and he fills it up some more. Now it’s definitely full, right? I’m sure the next step he could have taken is actually put some water inside or something. Right? But anyway, it’s pretty full now. Okay, now if you did it the other way around, if you fill it up with sand. You won’t have space at all for the little pebbles of the big rocks. And so the lesson there is, what is your rock? You gotta prioritize your rock if you fill up your jar with things that aren’t so important. The sand, then we’re gonna have time for the really important things. So that just reminded me of that. So I had to share it. [Emma] Yeah, I feel like we’ve talked about that before, but yeah, it’s so true. Like you need to have your big priorities and then whatever else fits in around it, but I’ve wanted to be a bit kinder to myself this year and not being so hard on myself when I don’t get absolutely everything done because I am an overachiever. [Jaz] Well, especially Emma, if things are out of your control. Have you heard of this, the circle of concern and circle of influence. Have you heard of this? [Emma] No, I don’t think so. [Jaz] Okay, so your circle of concern, I think, I hope I’m getting this right. These are all the years of self-development books are coming into play right now. So the circle of concern basically is anything that you could be concerned about. Anything. Like, for example, if something comes on the news and you look at the weather, right? And oh, it’s gonna be really cold next few days. It’s be snowing and stuff. That’s your circle of concern. These are things that in your sphere of life, okay. That you care about. That all that could impact you in some way. It could be the menu at your dental school cafeteria. It could be the emails that you get or whatever. These are all circles of concern. The circle of influence is actually as a tiny proportion of that, the things that you can actually directly influence. Now, you can’t change the weather. You can’t change the weather, right? So the weather and what’s gonna be like tomorrow or whatnot, and how cold it is, is not in your circle of influence. You can’t influence it. So just making peace with the fact that only those things are in your circle of influence. Okay. Should you focus on circle of concern. It is what it is. And then making peace with that. And if it’s something that, for example, when you can’t push through or you can’t smash your checklist or your to-do list, but it wasn’t your fault, it was like external influences that are out of your control that weren’t in your circle of influence. It definitely, you shouldn’t be hard on yourself at all. That those are things that are outside your control. And it reminds me of another quote where. Life is 10% what happens to you and 90% how you react to it? [Emma] Yeah, a hundred percent. Yeah. How you react to it. It’s just, I know I’m only 25, but I think it’s something that you just get better at as you get older as well. Like I remember, being younger and it’s so easy to do the easy things. It’s hard to do hard things and when you don’t want to get up and go to that 9:00 AM lecture or you don’t want to go to the gym yet, it’s hard to do that when you don’t want to. But I think just as I’ve gotten older. It’s become a bit easier to help myself in that kind of a way and do the hard things because you have this goal in front of you, I suppose. [Jaz] Eat that frog. Have you heard of that one? [Emma] No. Okay. Where’d you get all these from? [Jaz] All the years of finally all those audible credits are shining through, right? So this I believe is Brian Tracy and I think he has got a book, named after it’s called Eat That Frog. And it basically means eat that frog and it means basically, do the most difficult thing first, imagine you had to wake up, right? And you got all these things to do, but the first thing you had to do was eat a frog. Like, what a difficult, disgusting thing to do. All the French people are like, what did he just say? But anyway, like, eat that frog, just get the most difficult thing out the way first, and then everything else will be easier. So that’s the kind of theme. But it reminded me like Emma, like obviously you’ve been dental nursing for many years, right? For lots of dentists. Did you ever come across a dentist who you felt that they didn’t wanna be there? Like they had burnt out. Or they didn’t wanna be there. Can you share some recollections of that? [Emma] Yeah, a hundred percent. And I think because I’ve worked with so many dentists, ’cause I did locum for such a long time, you get dentists that just don’t really care too much and it’s usually in, this is a generalization. From me just watching, it was always in practices that were overbooked. These dentists were overworked or I know they have control over their books, but they’re just cramming everything in like 10 minutes, 15 minute appointment times. Very, very short appointment times, and they just like sort of stopped caring practices that were understaffed as well. I think within the first 10 minutes of walking into a practice I can sort of gauge, the sort of morale in there and how well people get on and things. [Jaz] And it’s the culture. It’s like palpable, isn’t it? The culture of a practice. [Emma] It really is. Like you can walk into some places and everyone’s work ethic is down and people are awful all the time and understaffed and things, and it’s not really a nice place to be. So I think in dentistry it is really, really important to make your workspace as much as you can somewhere that you enjoy being. [Jaz] Like, my idea of hell, and I’ve experienced a little bit of this in certain practices in the past, is like you wake up and you don’t wanna go in. I would hate that. Like, I would say hate that. So, I look forward to going to work ’cause I work in a nice practice and I worked hard for that, don’t get me wrong. I made life designed to work in a clinic and like you said, actually, I can’t believe I’ve forgot to mention this, but people, the Protruserati who listens to this podcast know this about me already, is I work a shift pattern, right? So I work a morning clinic one week. And that’s three days a week at the moment. It used to be more, but now it’s come down to three so I can focus more on Protrusive. So, three days a week in the morning, and then the next week it’ll be like the two till 8:00 PM shift. So the evening shift. That allows me to get dad time in, I can bathe my children, I can do a school pickup or a school drop off or sometimes both on a Wednesday and Friday which is amazing, right? So it is important to consider, how are you gonna design your life? But the reason I mentioned that is on the back of an Instagram post, I made recently, which got so much engagement, right? It was about people working five, six days a week, in dentistry. And I said that I posted something like it’s something that is gonna really push you towards burnout, working five, six days a week. Actually it was Stuart. So Dr. Stuart Yeaton on the Protrusive Community, he’s an orthodontist. And he said that we were discussing on the Protrusive Guidance app about work-life balance and all these wonderful things. And he had this wonderful thing to say. He said, people in business, right? So not dentistry, like in the business world. In the real world, okay? And like law, for example, right? They get very stressed out for days when they have a client meeting coming up, right? So for a dentist, every minute of every day is a client meeting. And sometimes you’re meeting these clients for the first time and they have so many high expectations. Like, think of that, like, that’s like throwing you in a pool of fire. That is a stressful scenario. And our energy levels always have to be right up there in terms of conveying confidence and positivity to the patient. And it’s hugely draining for most in the long term. So the role that we have, like we have to manage expectations. We have to be kind of like a shrink for the patient. We’re kind of being like the psychotherapist for a patient. Sometimes we’re the patient’s only hope. Sometimes we are being a healer in so many different ways. We’re trying to be the scientific person as well. We’re trying to be a carer. It takes a lot out of us caring for so many people and decision making and deciding, hmm, should I crown this? It should be a large restoration trying to apply all. So really dentistry is a really tough gig. And so the reason I mentioned that is ’cause then I said that, okay, when you are young, and that’s the main point is that when you are newly qualified, I was working five, six days a week at that point. Clinical. I had the energy, I had the time ’cause I didn’t have any kids and I was really going on a lot of courses. Okay. Like a lot, a lot, a lot, a lot. Which I’m so thankful for. ‘Cause I can’t do that now with kids. So it’s a wonderful thing to do that when you have that season of life once again, to be able to do that, then to do it, to get it outta your system, right? Yeah. But when you get your 10,000 hours in and you now, for example, no longer need to look at your day list before you go in because you can just, not autopilot. ’cause that’s a bad term to use dentistry, but like you don’t need to revise the stages of crown prep where you need to go in. You don’t need to revise this. You can just do everything. As a student you can relate to that, right? So when you can do that, when you get to that level, right, do you really need to work five, six days a week in this quite stressful environment of a dentist where we’re just dealing with people the whole time. And so some studies have shown that three and a half days is optimum and your income doesn’t really go down that much in case it might even go up ’cause you become more productive and then you have more time for yourself and your mental health and to sometimes work on the business. Okay, so sometimes you’re working in the business, but then you get to work on the business. You get to think, how do we get more patients into the clinic? Or how do I refine this skill so I can start doing implants, whatever. So that’s a really important thing to mention whereby a lot of colleagues, like, you might be thinking, I dunno what you think about that actually. Have you ever thought about how many days a week you’d like to work? [Emma] Not me personally, but like I’ve definitely noticed that a lot of dentists do. Like, they don’t work five days a week for, well, I don’t know most dentists, but a lot of dentists don’t. Three, three and a half, four, even four and a half. And I think that just shows how much of a stressful job it can be because if you are working 4, 5, 6 days a week constantly for a very long time, you will get burnt out. And it’s like you were saying, you almost have to like put on a face all the time. Your brain is constantly working. You have to be that happy person. You have to be the engineer, you have to be the artist, you have to be the medical professional as well like. It’s all of these things. Dentistry is so well-rounded. There’s so many- [Jaz] In such a regulated environment as well, right? Like we’re so heavily regulated and that’s a huge weight on our shoulders as well to add to that. But just a point that you mentioned, like even someone like me who’s working three shifts a week, right? I work three days a week, right? But I still have to do responding to emails. I do these elaborate letters to my patients, like TMD reports and stuff. I have to do my clin checks, right? I have to think about, okay, the week ahead, communicate with the lab and stuff. There’s so much to do in outside of clinical hours as well, and so I dread to think that person who’s working five, six days a week, and then they’re also coming home to do all these additional things, which we all kind of have to do now. It’s very, very tough. [Emma] Very tough. Yeah. I’ve never thought personally about how much I want to work. [Jaz] Oh. Nor that I am, you know what? I realized that was a stupid question by me to you. I’ll tell you why. Right. Because I just remembered that when I was a student, like the only day I could like my life was like, I’m a student right now, and the next dot was I graduate and there was nothing after that. Dot. I graduate, there was nothing. ’cause you just can’t see past that barrier of what happens, what life is like after you graduate. ’cause you’re so engrossed in your studies. And that was me. And so I wouldn’t have been able to answer that as well. [Emma] Yeah. No. But I used to work in a practice that did VT or foundation year, and I remember hearing the practice owner say to the VT, you know, you might think at the moment, this was August, September, you might think at the moment that you’re gonna go in and you’re gonna smash it, whatever. You might be really nervous, but just book time off. End of October, start of November, like book time off because you will burn out. Like book it off now before you get booked up. So yeah, book your time off like you were saying in advance. But do you have any other tips like that? Not so much even for dental students, but like for VT as well, or towards the end of dental school, just about avoiding burnout specifically. [Jaz] I think two things I want to add then, for someone who’s new in the game, right? Yes, of course. Book your time off. Really great advice. But when we don’t know so much and the scary thing is that when you qualify, you think, oh yeah, I got a good percentage in my exam. When you come out in the real world, the first patient that you get, you’re like, what do I do again? Is anyone gonna check this? Like it is just that it’s how it is to apply dentistry is the name of the game. And to do that is sometimes difficult to bring together all your actual lectures and all the academic stuff. You learn how to actually apply it to the living being in front of you and to be able to communicate to ’em and have that relationship in 10 minutes, right? So there’s all those challenges that you have. So when we are new in our career, we are doubting ourselves and we don’t know whether our plan is good. We haven’t seen our failures come back, so we really don’t know what works and what doesn’t work. So to find or gain mentorship as soon as possible, right? So this could be a trainer, for example. Sometimes that mentor figure might come as another associate in the clinic. Or as you may know, Emma, we’re setting up a something called Intaglio, where it’s like a marketplace for dental mentors. So wherever you get a mentor from, and this is like a cliche almost, right? They all say, start taking dental photos. It’s really important, right? But find a mentor. Again, these are all really important things. So mentor, before it was all about do courses, courses, courses, which I truly believe in, right? So do courses amazing, right? Get your knowledge, but to help you implement those courses. That’s the role of the mentor. The mentor will help you to show you your blind spots, so the soon as you can latch onto a mentor, the better, is a top thing I’d say that will really, really, really accelerate your trajectory of your career. The second thing I’d say when you are really young is get the foundations right. Get the basics right, get your communication perio, carries, small class twos, big class twos, extractions. If you get that right, you are gonna be winning, right? People focus on the edge bonding and the aesthetic stuff very, very quickly. Get the occlusion right, get the perio right, get the foundations right, and that will serve you really well. So, don’t run before you can walk. And what goes with that is something called just in time learning. Have you heard of this one? [Emma] I don’t think so. [Jaz] So just in time learning, I often talk about this because it’s so, so important. You might fall into a trap whereby, for example, to relate it to you as a student, Emma, you might say that, oh, you know what you feel as though you are really weak on oral pathology. And you might say, I’m gonna open up Odell’s Oral Pathology Book, but go to chapter eight. I’m just gonna start reading some oral pathology. Okay. So that’s just in case learning. That’s like, okay, I might need this information in the future. Let me just read up on it. Okay. Just in time learning is knowing that you got that oral pathology exam coming up in a month. And they’re gonna test you on this chapter and therefore that’s why you read it. To relate that back to clinical dentistry, there are so many skills out there that we are yet to learn ’cause we don’t get to taught dental school. And so a big mistake that dentists can do, and I’ve made this mistake, so that’s why I’m happy to talk about it, is you go on a course about, let’s say crown lengthening. I always use it as an example ’cause crown lengthening is like, oh, you know what? I dunno crown lengthening. It wasn’t taught to me at dental school. Let me learn this so I can use this to make me a better dentist, help save more teeth for my patients and be able to provide another service to my patients. So you go on this crown lengthening course, and then after it tumbleweed, like you don’t see a crown landing case, and then you find a patient. And then they say, no, they can’t afford it. And then a year goes by, you haven’t done it. And like you feel like you need to pay 1500 pounds all over again to relearn how to do crown lengthening. So is it better that you find that patient who needs crown lengthening? Tell that patient, hey, okay, so we’re gonna do this. I’m gonna learn this skill soon, and you’ll be my first patient. Have that discussion upfront. Go on the course, apply it the next day. That is magic dust right there in terms of learning and accelerating your growth. So be more about just in time learning rather than just in case learning. [Emma] Yeah. I’ve never really thought about that before. Like that’s really using your initiative there. Yeah, ’cause you can spend so much money on these courses and then just not have the right patient come along and then having to go on that course again. Yeah, definitely. [Jaz] It also, similar aligners, right? So when you have a good relationship with your patients and you find four or five patients who’ve got slightly crossed incisors and just slightly lower incisor of crowding. And you have that conversation with that look. Look, is this something that you’re interested in? I’m going on a call soon. I’m looking for ideal patients who might be, wanna be like simple cases like you who can very quickly straighten their teeth. But I’m building up some cases and you’ll be amazed, like, one in 10, one in 20 patients say to you, yeah, you know what? Put me on that list, Emma, when you are ready. I love you so much to my dentist. When you are ready, straighten my teeth, I’ll do it. And I know you’ll gimme a bit of a discount ’cause I’m your first patient. Be like, yeah, sure, of course. Kind of thing. You give ’em free whitening, whatever. And then there we are when you go on that line, of course. You’ve got five simple cases ready to go on patients that already you already know and like, and that’s the best way to do it. [Emma] Yeah. And I think when you’re talking about mentorship as well, ’cause that’s something that makes me very nervous, you know? In six months, I’ll be in my final year, and I still don’t know how to make a decision really. I don’t know when that comes, but it is something that’s probably the thing that I’m most nervous about is being able to make decisions and decisions on the spot within that appointment. And I know that you have, your trainer there that you have to talk to, but at some point you need to gain more independence. And I would still like to think of myself as quite an independent person. Someone that can like, rationalize things and talk things through in my head, but that is still something that I worry about decision making and am I doing the right thing? [Jaz] Oh, we always worry about that, but especially the early stage of your career when you don’t know anything and you haven’t succeeded, you haven’t failed, you dunno where you are, you dunno what level of work is, and there’s so many things that you don’t know. You don’t know all the things that you don’t actually know, and that’s the scary thing, right? You know all these things, but there’s so many things that you don’t know. And then there’s things that you, for example, Emma, do you know how to do functional crowning? [Emma] Uh, no. [Jaz] Okay. So now you know that you dunno that okay. But there’s so many things that you don’t know that you don’t even know exist. Do you see what I mean? [Emma] Yeah. Yeah. [Jaz] You don’t know what you don’t know. And that’s the thing when you’re starting out, and it’ll always say that way, there’ll always be things that you just don’t know, right? And so what I say to you is when it comes to things where you feel you have been appropriately trained. For example, if you have a patient with multiple caries, right? And you are thinking, hmm, should I restore with GIC or composite, or whatever, I’m giving you a basic example, right? When you are a newly qualified dentist, you’ve had enough training at that point to decide, okay? At that point, right? Just go with your gut. Go with your gut. Just go with your gut, okay? But if it’s like, okay. Now is tooth replacement options. Should I refer this patient for an implant or should we do a bridge here? But then there’s slightly dubious things here and things which are a little bit out of your comfort zone that you haven’t really done many reps in. At that point, then just get all the records, get your photos right, get your radiographs and be like, you know what? This is a tough case because of X, Y, and Z. I’m gonna discuss this with my mentor, and the reason I say that is when, like people come on the Protrusive Guidance app and either in the chat or as an article, they’ll put photos and x-rays of like, guys, can you help me? And as a wonderful, nice and geeky community, we are, we help everyone. But the limiting factor is if you only give one image and say, can you please do a full mouth treatment plan? It’s very difficult if you give 20 images, five x-rays and say, okay. This is the problem. This is what I think. What do you think? You’re gonna get so many more replies and so much more help. So the more data when you are, when you are unsure, collect good data, present it to your mentor or mentors. And you’ll really get good advice back. [Emma] Yeah, I’ve seen it on Protrusive Guidance as well. Like whenever I see a notification, I’ll have a look through and I think because you’ve got like the biggest geeks on there, they love talking about it and it is really, really helpful. But I think the thing to remember as well is that a lot of the time there isn’t a right answer. I know we’ve spoken about this before, you’ll get a million different treatment plans for loads of different people. But yeah, I suppose it’s just having, gaining the confidence over time that you’re not making the wrong decision. There’s many different right decisions sometimes, but that you’re not making the wrong one. I suppose. [Jaz] I think that is like, if you look at it from one perspective, then dentistry sucks because there’s like 200 ways to do something. That’s terrible. You could think that, oh, that’s the worst thing ever. But if you flip it and think, actually dentistry’s beautiful because I have 200 chances at doing something, it’s probably gonna work. If you flip it round, it’s like, okay, well this dentist said do this, this dentist said something complete opposite. If you see that as, oh, that’s so stressful. What do I do instead say, that’s amazing. I can literally do two opposite things and it’s gonna work. Right? So see it as a beautiful thing instead of seeing it as a bad thing. Okay. And then just do what feels right to you and then keep learning and refining. And the fascinating thing, Emma, is I speak to all these dentists that I really love and respect that are far more intelligent than me and far more qualified than me. And I show them one of their old cases, I say, oh yeah, you know Dr. So and so you posted this case on social media seven years ago, and you know what they say, oh yeah, that was good, but I would’ve done it differently today. And so at that time they were posting, they were at the top of their game, but they’re still saying now, some years later, oh yeah, you know what? I would’ve done it differently. So it’s never gonna leave you, you are always gonna be changing how you approach it, but you have to make peace with the fact that, with the knowledge and experience that you’ve gained, thus at up to that point in your career, you are making the best judgment call at that stage. And don’t hate yourself for that. You have a certain level of experience to make your decision. But that’s it. That’s at that time it will change and refine as you get more experience and make peace with that. You did the best you could at the time. [Emma] Yeah, and you’ll gain more and more experience as you go. I think it’s something that is scary for me, like thinking of about starting that journey. ‘Cause I know I’ve not even, I’ve barely started that journey and I think as we want to be the best, we’re quite perfectionist. We want the right answers. We want to do the best for our patients. So it’s more of a mental struggle than anything. Sometimes just what do I do? What’s the best thing to do? But it’ll be fine. [Jaz] It will be fine, Emma. You know the community will be there to hold your hand. I’ll be there to help you. You’ll be absolutely fine. [Emma] Yeah. [Jaz] The only thing Emma that you said was planning your date, like you said, on a Sunday, you will look ahead of the week. The only thing I just wanna add on that is that there’s different ways to do it and you’ve gotta find your system. I used to do to-do list. So, I make a big to-do list and hopefully throughout the week I’ll tick ’em all off. When you get extremely busy and you got kids and work and diary issues and whatnot, then I move to a calendar based system. So now, like if there’s a task that needs being done, for example, there’s a treatment plan for Mrs. Smith that needs to be done. And I know the deadline is 25th of January, for example, right? I can’t just leave it in my to-do list and hope that at some point when I get a pocket of time for 25th of January, I’ll do it and I’ll take it off. Okay. Used to work, but now my life is too hectic for that. So what I have to actually do is have to slot it in the diary in my Google calendar. I’ll see, okay. The on the 20th of Jan, between four and five, it Sean’s doing swimming. I will do my treatment plan then, and I slot it in. So not only is it like a reminder for me, but it’s actually there, the time is blocked. So, that’s the way I do it now, whereby I say all these things I wanna do, but until I actually slot it into the diary, it doesn’t actually have a physical manifestation. It doesn’t actually have a place in the, in the universe yet until it’s actually locked in in the camera. [Emma] Yeah. Yeah. And I think it’s easy to say, oh yeah, I’ll get it done by this date, but you can forget or just put it off. [Jaz] You can do that, but I think as life becomes more complicated and you have more complications and family and work and this kind of stuff, I think a lot of students will eventually move on to the calendar based system when they’re ready. When you enter the big, bad world. I think the calendar system is probably the adulting way. [Emma] No, for sure. Yeah. I find it useful to do like my week at a time, and then I don’t do it like hour or anything because my day isn’t too heavily structured. I don’t have kids, anything like that. But no, eventually at some point I think it’ll catch up. [Jaz] It certainly will. Emma, thanks so much for asking these great questions. I hope that was useful. What was your biggest takeaway in terms of, with your upcoming exams and stuff, how has this our chat influenced you? [Emma] I think again, just like making time for the things that are non-negotiables for me. And then like you were talking about your big priorities and then fitting things around that, not just focusing on the easy things that you can do, but just pushing yourself to do all the big hard things as well. [Jaz] Eat that frog. [Emma] Eat that frog, I suppose. Yeah. [Jaz] Excellent. Emma, thanks so much for your time. It is been fun to do all of last year Protrusive Students and happy to continue to into 2025 and you guys can check out the orthodontics notes, all this wizardry that Emma is uploading and if enough people comment below, Emma will share her flashcard notes. Using these techno app widget things that she does all this digital voodoo stuff, unless she’ll add it on the crush your exam section. So only if enough people comment will we do that. [Emma] Perfect. Thank you so much. Jaz’s Outro: There we have it guys. Hope you enjoy that. Please do comment below if you enjoy this or if you want access to Emma’s flashcards. And of course if you did find this episode useful, then please do send it to your practice WhatsApp group. Let everyone listen to it. Share the love. This episode was not eligible for CE or CPD credits. We are a PACE approved provider, but most of the other episodes, I’d say about 95% are eligible for CPD or CE. So if you are a true Protruserati and you like listening to the show and you wanna be able to verify your learning with a certificate and have an area to reflect on your learning, then we can give you a certificate by answering the quiz. You need to be a paying subscriber or protrusive to do that, but for a very small tax deductible amount, you get access to that. And all of the master classes as well. For that section, check out protrusive.co uk/ultimate and join hundreds of dentists as part of the nicest and geekiest community of dentists in the world. Don’t forget to like and subscribe. Even if you’re listing on Spotify, there is a subscribe button there. So many listeners and watches just keep returning, but they never subscribe. Honestly, it would mean so much to us if you hit that button. And as always, little round of applause to Emma, our Protrusive Student who shows up every time. Ask great questions. We’re spurring on for you. We are rooting for you, Emma. You can do it in your exams. Anyway, we’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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Your Endodontics Questions Answered! – PDP217 44:11

for 8 weeks siden44:11

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When Your Size 10 File is not going to length, what is happening? Your apex locator isn’t giving you a zero reading. Your file is stuck. You’re wondering—have you ledged? Or could something else be at play? In this must-listen follow-up episode, Dr. Samuel Johnson returns to tackle the biggest endodontic dilemmas left unanswered from part one. If you haven’t checked that out yet, go back and listen—it’s packed with insights on working lengths, apex locators, and even the role of consent in endodontics. https://youtu.be/1E6pK2iOPjY Watch PDP217 on Youtube Now, in part two, we go deeper. We’re talking blockages, ledges, portals of exit, and the mysterious phenomenon of file gripping. Plus, Dr. Johnson takes on your burning questions from the Protrusive community—like how he responds to biological dentists claiming root canals should be avoided entirely. (Yep, we’re addressing that controversy head-on!) Protrusive Dental Pearl: For a more visual learning experience, dive into the Pre-Endo Build-Up on Protrusive Guidance and see Jaz and Samuel’s insights in action. Sonic Pro Ultrasonic Bath – 15% OFF before 30th April with coupon code ‘protrusive’ Improve your Bond Strengths – purchase while stocks last: Sonic Pro Discount Key Takeaway: General dentists often overlook the importance of taper. Removing too much dentin can weaken the tooth. GP cones can be unstable and affect the procedure. Reshaping GP cones can often resolve length issues. Pre-bending GP cones can help navigate tight curves. Biological dentists have controversial views on root canals. It’s essential to prioritize the patient’s best interest. Using endo frost can aid in manipulating GP cones. Consent should be informed and comprehensive. Communication between referring dentists and specialists is vital. Continuous learning is essential for dental professionals. Ultrasonic activation improves endodontic outcomes. Pulpotomy and root canal treatments have distinct indications. Building a supportive community can alleviate feelings of isolation in dentistry. Dentists should charge for their time and expertise. Need to Read it? Check out the Full Episode Transcript below! Highlight of this Episode: 01:03 Protrusive Dental Pearl 01:49 Common Scenarios and Tips for Young Dentists 05:30 File Gripping and Canal Anatomy 08:30 Master Apical File: The Common Dilemma 11:18 GP Cone Issues and Solutions 17:03 Addressing Root Canal Myths 23:35 Cracks in Teeth: Prognosis and Treatment 25:44 Ninja Access Cavities: Pros and Cons 28:21 Common Mistakes in Emergency Endodontic Treatments 33:51 Obturation: Overextended vs Short 34:41 UltraSonic vs Sonic Irrigants 36:15 Pulpotomy and General Dentistry 39:25 Building a Dental Community As promised, here are the ESE Guidelines on managing cracked teeth. Watch and learn from Dr. Samuel Johnson on Instagram and YouTube! Don’t miss the first part of this series: PDP216 – Working Lengths and Troubleshooting Apex Locators # PDPMainEpisodes # EndoRestorative # BreadandButterDentistry 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: 070 ENDODONTICS (Emerging concepts, techniques, therapies and technology) This episode aimed to provide deeper insights into troubleshooting endodontic challenges, particularly when files fail to reach working length. It explores common pitfalls, advanced techniques, and expert strategies to improve clinical outcomes in root canal treatments. Dentists will be able to – 1. Recognize common endodontic challenges and strategies to navigate them effectively. 2. Evaluate the role of master apical files and resolve common dilemmas in achieving optimal shaping. 3. Identify frequent errors in urgent cases and improve treatment approaches. Click below for full episode transcript: Teaser : So your size 10 file is stuck. It's not going to length and you're not getting a zero recording on your apex locator. What do you do? Have you ledged? Or could there be another reason for this? This is where we answer that question leftover from part one. [Jaz] So if you haven’t watched or listened to part one yet, check it out. It was a great introductory episode. We talked all things, working lengths, apex locators, career and consent in Endo. So do check out part one. In this part two with Dr. Samuel Johnson, gosh, he loves Endo, doesn’t he? And it’s infectious, right? You can totally feel that. We’re going to talk about blockages, ledges, different portals of exit and a phenomenon called file gripping. Then Samuel answers all the questions from you guys, the Protrusive Community. You guys asked some fantastic questions and it was a great pleasure to ask him all those. One of which what does Samuel think about those biological dentists who are suggesting that root canals are bad and that no one should have a root canal? I know, it’s crazy, but how does Samuel handle those kind of patients? We go deep in all the little facets and details of all things endo. Thanks again for all your questions, guys. Dental Pearl The Protrusive Dental Pearl for this episode is you need to see, if you haven’t already, you need to watch my pre endo build up video. It’s so relevant to everything that me and Samuel are discussing. And that video was published just a few weeks ago as part of my POV clinical walkthrough series. You see my full video walkthrough of a couple of cases where I do a pre endo build up and do like a screen recording and interjection and running commentary of everything I’m doing. Very similar to wonderful videos that Samuel makes. So I’ll put the link to that in the show notes if you haven’t already seen that. If you happen to be listening on Spotify or Apple, then do check out the video on the Protrusive Guidance app or just type in on YouTube, Pre Endo Build Up Protrusive. You will find it. Let’s not delay getting to the main part of the episode. I know you’re going to love this just as much as you loved part one. Let’s go with Samuel Johnson. Main Episode: Just talk about the common scenario that you want a young dentist to appreciate that when they feel encountered scenario. A great tip there is don’t force it. Slow down, retract because you don’t want to make it worse. And that’s a top tip already. [Samuel] So I would say, have you reached zero or not? Cause you can get a canal. I’ve had one yesterday. I did distal buccal, which was 17 millimeters and in length. So if you have already reached zero and then at 18, you’re getting this hard stop. You have probably likely ledged it, but don’t panic. I think we might move on later on to talk about managing ledges, but if you haven’t already reached zero with your apex locator, I think the best thing to do first is just estimate where you are actually within the tooth. So, you can estimate the working length in many ways. You can use a radiograph, although, sometimes if you can learn how to draw how long it is on your radiographic software. It’s not perfect, but it kind of gets you in that kind. It’s a useful estimate, isn’t it? Another thing as well is, if you’ve got a multi rooted tooth, you say you’ve got a lower six and you’ve got a mesial buccal and you’ve got a mesial lingual. If the mesial lingual is 19 millimeters or say the mesial lingual is 22 millimeters and you’re getting stuck at 18, you’re probably short. And also take a working length radiograph. I did say I don’t take them, but I do, do take them. Cause sometimes my apex locator is all over the place. And I don’t know why. And sometimes it’s good. [Jaz] This is the one that you said is not routinely advocated by FGDP, but sometimes when you’re getting erratic measurements and just to verify. That’s when you would take it with and you are doing it with a size 10 because obviously you’re stuck there. Is that right? [Samuel] Yes. Yeah, absolutely. So say you are near to the end. Okay, this could be a ledge. It could also be complicated anatomy that the x ray is not going to show these many portals of exit. And I would say a really really common sign that it is complicated anatomy, not a ledge is that you get that kind of sticky feeling. So it’s a hard concept to kind of explain, but if you’ve got a hand file and you’re just sort of negotiating it to length and you’re hitting that hard stop, but then you get in that kind of sort of sticking feeling that is more likely complicated anatomy because you know that the file is sort of getting stuck, in the jammed in the hole. [Jaz] It could have been preempted by a Cone Beam CT, you think? [Samuel] No. So, the cone beam CT scan has many, many uses. And a great thing about a Cone Beam CT scan is that you can measure the tooth really, really well. It’s very, very accurate. But with a cone beam CT scan, it doesn’t show detail very well. That might blow people’s heads, but it’s not the panacea of diagnosis, a Cone Beam CT scan. Although I take a lot of Cone Beam CT scans, we’ve got one in all three practices that work out. Very, very useful. What I would say as well is if you’re getting that hard stop feeling and you are near to the end, it’s probably likely that maybe the end of the tooth goes off to a 90 degree angle. So you see this a lot with palatal canals and distal canals in lower molars. You can kind of sometimes see it on radiograph, where you see the large canal and it kind of flicks off to the end, or you don’t see the flick. You kind of see that kind of apical radiolucency where it’s kind of off to the side of the tooth or laterally to the tooth. That’s essentially where the portal of exit is, again, to talk about how to manage those things. Maybe we’ll talk about that later, but if you’re not near to the end, it’s probably either a join or a split. So it’s where two canals are coming together, or they’re splitting apart, and your file just can’t reach around that kind of double curve, or it’s this concept of file gripping, which I’m- [Jaz] That’s the one I wanted to really expand on, because I think that can really catch people out. When we had a chat about this, I was like, oh wow, that’s right, tell us about file gripping. [Samuel] By the way, file gripping is, I don’t really know what it’s called really. It’s just something that I’ve just sort of made up myself when I say made up just the concept, maybe people do use file, I’m not too sure, but essentially, the problem is, is the file isn’t advancing, and you might think to yourself, well, I’ve got this kind of cylinder. It’s a metal cylinder, which is a circle. And I’ve got this sort of perfect cylinder that I’m pushing down. There’s this tube, but in reality, it’s not like that at all. The inside of the canal space is actually oval. And there’s little places where you can get the file stuck and things, and you might be thinking that the tip of the fire is actually getting stuck, that’s the thing that’s not advancing, but actually. It’s friction from further up the shank. So it’s essentially the canal space gripping onto the file further up. And you know this cause you find this more often in longer canals. So I’m going to exaggerate and do a bit of hyperbole. This is the best tip I could give you with a root canal if you’re starting out. If you are getting, say you’re 18 on a canal, and it’s probably about 20, 22. The best thing for you to do, if you’re getting stuck, the best thing to do is not to jam it down there. You’re going to pull your hand file out. In fact, you’re going to measure first how far you’ve got with the rubber stopper. You’re going to take it out, you’re going to measure it, it’s 18. You’re then going to get a higher diameter file. Okay. And this could be anything. So you’re using a size 10, you just get a 15. Personally, I like to use these glide path files and then I measure the higher diameter file, 17 millimeters. So 0. 1 millimeters away. And then I’m going to shape it with that. Then personally, what I do is I get my master apical file and then I shape it at 16. So listen, you’re not using more files than you would do. You’re going to be used this file later on anyway. So you might as well just use it to shape it up. And what you’re doing is you’re releasing the grip of the canal further up the shank of the file, further up the file. And the amount of times this, this magical, the amount of times I do this every day, I’m not getting to length. I’m just shaping up further coronally up the tooth and then it slips. But what I would say. Again, it’s that kind of temptation to get quicker, get quicker, get more efficient. Say you’re using a glide path file, you’re using a high diameter file and then you feel that this file is what I think I could probably just go a little bit further with this. Don’t resist the urge. Just shape it a millimeter away because again, you’re gonna ledge, you’re gonna perforate. And if you ledge. It’s just a nightmare, isn’t it? It’s just, it’s one of those things that just makes you unhappy for the rest of the day. [Jaz] But I mean, that makes so much sense to move to a higher file. The only thing I didn’t understand there, Sam, just please explain to me is you mentioned that, okay, you go to a larger diameter. Like, so if you were using a 10, you’re going to go to a 15 a millimeter away, which makes sense. And then you said you’re going to go to your master apical file size, but how do you know where your master apical file is if you haven’t yet advanced down and prepped yet? [Samuel] Oh, Jaz. You’ve opened up a can of worms here. Again, another question I get asked all the time from newly qualified dentists is what should be my master apical file? And also I think this is a highly contentious issue in endodontics. So you get the sorts of dentists who use these huge diameters. What I would say, it’s all about the taper. Okay. So it’s not really the tip of the file. It’s how much that file expands later on. So it’s essentially, it’s a contentious issue between endodontists essentially. And it’s all about the taper. So what I would say with the taper is that the tip of the file isn’t the significant point. It’s how thick it gets along its length. [Jaz] So for example, when we say 25, we know that’s the diameter at the tip. But really what I noticed when I used to hang out with endodontists is that they don’t, they never say 25. They say 25/04. The slash taper is so, so important, but as general dentists, sometimes we just see the big number, right? Which is the diameter. We don’t learn to remember which brand is what taper and that’s so, so important. [Samuel] So I’ll actually describe taper. So essentially the taper means that it’s usually a percentage value, the percentage that increases per millimeter. So, if you’re at the tip, a millimeter further up, it’s percent of that so- [Jaz] K file is 2%, right? [Samuel] Yes. Yeah. You can get really high diameter ham files and on the one hand, you can use a low tapered rotary file. It’s not going to cause much dentine. But it’s going to be more difficult to irrigate and also obturate. So at the moment, like I say, there’s a little bit of a bum fight between endodontists about how much you should be removing tooth tissue within the canal space. And then there are- [Jaz] Because the higher the taper, the more pericervical dentine you can remove. [Samuel] Exactly. And there is strong evidence to say, if you remove a lot of dentine, you’re going to weaken that tooth. I personally, I’ve gone through a little bit of a journey with this and people might say this is lazy, but I’ve just used Hyflex for so long. I know that it works. I’ve taken post op radiographs, a year after we know it works. The problem with Hyflex, of course, is it has got a relatively large taper. [Jaz] How much are we talking? [Samuel] It’s variable. So, I think off the top of my head, I think it’s averages about six to seven percent, but then you wave on golds between five and seven, I believe a primary is seven or six, but I think if you’re not into the nitty gritty of endo, I wouldn’t get too concerned about it. [Jaz] Okay, I mean, just the whole point of file gripping, for me, when I first experienced that, wasn’t actually with files. When I took my master GP cone, and I tried to get to length, I noticed that it wasn’t going, and that’s when I realized I was taught, actually it was the friction of the GP. That’s why I really understood when you taught me about file gripping, because it’s kind of the same thing happening with the GP. And then what I learned was, and I think this is going back some years, Sam, so please correct me if I’m wrong, is that actually GP is not that stable and some people keep it in the fridge and stuff and it could be that issue that it expanded a bit or that my shaping wasn’t that good. I didn’t do enough shaping to allow the shape of the file to imprint onto the walls to allow my GP to go to length. What do you think is happening when we get GP gripping? [Samuel] Do you know that I always check the end of the GP. So I’ve got this little gutter cutter. So it essentially cuts the GP to a certain diameter. And every time I get a GP point out, say I use a 25 GP, I’m pushing that into this gutter cutter just to check, to see if the end is actually the correct diameter and I suppose in a way if the tip of the GP cone isn’t great, then obviously you’re going to get this kind of wide variation with the tape with a GP. So what I would say also as well is the dentists who like to do this kind of minimal prep dentistry, say they’re using like a 25/04 taper. So that’s a thin taper. They’re using GP cones, which have the same taper, but the maximum diameter is a millimeter. So if you’re using a bioceramic, say you’re essentially filling the majority of the canal with your bioceramic because it flows nicely. And then you just enter this thin GP cone, which is not going to get stuck down the sides. And this is going to allow for the endodontic bioceramic sealer to sort of flow around it. And I don’t know if people have ever noticed before, sometimes you’re going to get GP sort of touching the walls, but also if you fill the canal space with too much sealer, you kind of get that kind of buoy effect. Don’t you? It sort of floats up and down. This is really, really annoying. [Jaz] Okay. That issue is that GP isn’t as stable. And I think you’ve made that point where you’re having to use a GP cutter at all times. And then therefore what we get isn’t exactly that accurate. And therefore it might be the issue with the GP rather than not having filed enough. [Samuel] Yes. I think if I can’t get to length with my GP cone straight away, what I definitely don’t do is I think, oh, I’ll be alright. Just put it in. Be sound. But you know what? It’s everybody’s thought of. I’m not going to lie to you. Everybody’s thought it. You’re stressed. You’ve got this, that, and the other all going around. But do you know what? This sounds blindingly obvious, but it isn’t in the patient’s best interest. Okay. What you want to do is you just want to pull a GP cone out. You just want to reshape and I would say 99. 999 percent of the time, if I just reshape with my mast apical file. Then, it’s going to go to length, but what I would say yesterday was a really, really good example of my GP cone not getting to length. I just think there was an acute bend at the end and it was an upper six. I could get down the palatal really easily. I got down the DB really easy, but the mesial buccal was really, really difficult. And I shaped the other two canals with a 25 high flex, but I just could not get the high flex 25. Past this sort of, it must have been like maybe five millimeters away from the apex and I could just about get the size 20 past the apex. What I did is the GP cone was still snagging and I don’t think it was this sort of gripping effect. It was essentially where there was like an acute bend at the end and another really, really great thing about it is you can pre bend hand files when you’re trying to get around a tight curve, but you can also pre bend GP cones. Might say to me, well, GP cones are not stiff. So in this case, yesterday, what I did is I got some endofrost and I blasted the GP cone with endofrost. So it essentially froze the GP cone and I was able to manipulate around this canal. So that’s another really great tip is get your endofrost out. [Jaz] That’s a lovely little tip there. Fantastic. Great. You’ve answered a lot of these questions. I think if we go into overcoming a ledge. I think it’s a little bit too technical. I would love to instead go through the community questions if you’re okay with that. [Samuel] Absolutely. Sure. [Jaz] The one I want to start with is extremely controversial and I’ve just enjoyed this conversation so much with you and I, and I know enough about you now and your character that I think you’re going to have a fascinating answer more than anything is I would just love your opinion. Feel free to say no comment if you’d like to. And that’s cool. Okay. These biological dentists. I think you know exactly where I’m going now, right? These biological dentists who are making all this hoo ha that root canals should be a no no. Like if a tooth needs a root canal, at that point, don’t even get the root canal, have an extraction because it’s dead matter in the body. That’s the kind of terminology that they use. So Samuel, these biological dentists, I think you know where I’m going with this now, right? They talk a lot about root canals just being bad news. There’s something stupid thing I’ve read whereby 97% of cancer patients had this one thing in common, which is a root canal. That’s like saying 100% of cancer patients drank water. Do you know what I mean? So like, A, do you ever get patients like this? And then B, I feel like as a profession and as it ends in the community, I know there are white papers, the American board is answering. I don’t know if the BES has had a position statement out, but I feel as though we need to like to put science first and there’s very dangerous advice sometimes to extract perfectly good root canals completely asymptomatic for this. Oh, it’s not biological. It’s not natural. Where do we even begin to talk about this? [Samuel] I watched that documentary on Netflix. It’s just absolutely mental. But I can say two things about this. The first one is, do I get people like that? Well, I take external referrals, internal referrals. I see these patients for a consultation before they even go for the root canal. And I would say if these types of patients, patients are probably filtered out before they get to me. What I would always say as well is that if you don’t want the root canal, just have it out. It’s not really my kind of, if that’s what you believe, there’s no point arguing with people. You’ll notice if you do this job for long enough, that I suppose there’s the concept of you don’t care about patients teeth more than they do. If they’re consenting adults, if they feel like they want to make that decision, that’s on them. If you start taking on people’s issues and problems and things like that. You’re not strong enough mentally to do so. And it’s something we see a lot of the time with new reception staff or new nurses where they say, Oh, so and so needs this and so and so needs that. And there’s a big kind of like, you essentially, again, I give people my opinion. I do this friends and family test. If I understand that a patient’s quiet, they understand things and they say, well, what would you do when people say, what do I do? I always go, well, I love root canal. I say, if you want the root canal, I’d be made up, I’d be in the elements. But I also say, you’ve got to have the appetite to have this. If you’re thinking to yourself, I don’t fancy this at all, then make, that’s the right decision. And this is essentially, it all goes back to consent. A lot of the time I’ve started new practices and the same question all the time. When would you go for a consult and when would you go straight to treatment? We always go for consult. Because you’d be surprised how many people you can filter out where you do this kind of, you tell them all the risks, you tell them the costs and everything. And then they go, it’s not for me. And the other thing about consent is that if you’re a perfectionist, I can’t get rid of this perfectionism just yet. But if you’re a perfectionist, you’re never going to be bulletproof medical legally. But it’s not about that. It’s about kind of telling the patient everything. And if it does go wrong, it goes wrong for me all the time. I do perforate teeth. I do fracture instruments. But when this happens, I sit the patient up and go, this has happened. And then, but they’ve been told, haven’t they? So I think in answer to your question, I just don’t argue with people. I spread the facts out and say, what would you like to do? Again, I remember very early on in my, when I was doing my MSC in ENDO, I had a conversation with another dentist about trying to convince patients. I just think I was what you’re about. You don’t convince people. Honestly, when you’re a new dentist. You’re just desperate, aren’t you, to kind of, to try new things out. You’ve done this new thing and, and listen, you’ve got 30 years of your career ahead of you. And trust me, this new thing that you want to do, you’ll have a hundred thousand ways and opportunities to do it. Never push things on patience. It’s bad news. Honestly, it is. [Jaz] So brilliantly said, and it reminds me of something that Lincoln Harris once said in one of his seminars I was with. And he said that, young colleagues will come to him and say, Oh, but I’m scared of it. I find it difficult to consent because when you give all the risks, it makes the patient want to say no. Well, that’s the whole point of consent, right? Exactly. If the patient’s appetite for risk isn’t there for that very real issue, then that’s the whole point of consent. It shouldn’t be like trying to make sure that you just give them enough to make sure they say, yes, that’s not consent. Consent is making sure they own their problem, but they really want the solution, which you offer in which case is trying to save a tooth. And if they believe this pseudoscience of unfounded claims, then so be it because you’re right. It’s sometimes, exactly. And as long as you just give those options, like here’s what I can do for you. I don’t believe in this pseudoscience. I don’t know if that’s the right term to use those patients or not, but you just need to respectfully, if they opt out, then that’s great. [Samuel] Learn not to judge people. I think that’s another thing as well, as I grow on with my career, I get more and more arrogant and I get more kind of thing, especially when I was newly qualified, I was a little bit unsure. And now I just know if someone comes to the door, I just, I see a problem. I see it straight away, but I don’t judge people because that’s what makes our life rich, isn’t it? That people have different opinions and it’s not the end of the world. Let them get on with their lives. And if they want to do that, go for it. One time I saw a patient for an emergency. A lovely guy, really, really, salt of the earth guy, told him he had apical inflammation and he was hurting all night and blah, blah, blah. So I said, right, I’m gonna numb you up, I’m gonna dress the tooth. I numbed the patient up and he was out of pain and he was like, oh, I’m out of pain now. And I was like, oh, yeah, yeah, but this was just to, and he didn’t understand it and then he just walked out. And the thing is, he was back for sure. And he was all then nice, nice about it. But in the end, you can’t just get overly, like I say, don’t try and take on other people’s problems, obviously be empathetic, go the extra mile for people. But if they have made a consenting adult decision, don’t argue the toss with it because there’s no point. [Jaz] If there was one tip to give to any new practitioner of any discipline, it would be this, not to own the patient’s problem and care for your patients, be non judgmental, really actually, put the word care in healthcare is so, so important, actually generally care, but not more than their own teeth. Some recurring themes in the podcast. That question, by the way, about these myths about root canal, that was from Megan. I just want to give a shout out to Zachariah, who actually introduced me to your channel, like some months ago. So Zachariah, thank you so much. I also have Ben who says he loves your YouTube videos and Ben has submitted so many questions that it’s insane. Thank you, Ben. So I’m going to pick one. That’s going to be the most tangible. Okay. At what point if you spot a crack in a tooth during root canal treatment, do you decide the prognosis is too poor and would advise extraction? How often does this happen? [Samuel] Do you know what? I’ve boobooed a little bit because they’ve just released, I think it’s the ESE has just released a position statement on cracks. So what I would say is my advice given now is that it might be wrong, but in my opinion is that we used to chase cracks out. We now know that that is probably a bad idea because you’re just removing more and more tooth tissue. I was taught personally, if the crack doesn’t extend through and through. So say you’ve got a mesial distal crack and it doesn’t extend through the floor of the pulp chamber, it’s got a poor prognosis. This is where consent comes in. And obviously it’s going to need some sort of cuspal coverage. Also as well, if the crack doesn’t extend into the canal orifice, but like I say, it’s kind of, it’s all about, we always go back to consent or any problems always go back to consent and it always goes back to tailoring your consent to the patient. So, if you see someone for root canal, you just thrust them like a piece of paper and you get them in. That’s no good. That’s no good because it’s doing a disservice to the patient really. And you just give the patient the risk. Okay. And you’re never gonna know how they sort of value risk. So if you say to them this tooth is in a real, really poor state, this could happen, that can happen. What do you want to do? Do you want to have a go? And some people go, yeah, some people say no. And then you just, I suppose in a way, if you’re sort of getting that sort of feeling that they’re not owning the problem, then maybe you’re going to lean towards maybe not doing the treatment, but I would say it always goes back to consent. [Jaz] But in terms of during your root canal, like you mentioned a feature is if the crack is extending into the orifice you’re thinking okay, this is a lot worse than I thought and yeah out and then again running across the floor by time you remove the restoration. That’s like, okay, that’s maybe got a much poorer prognosis. And that’s a really good thing to go by. And we’ll put a link to that position paper on cracks as well. Another question that Ben asked just while we’re here is ninja access cavities. Okay, surely it would compromise straight line access and increase stress on files, increasing instrument fracture. Is it just an endodontist trying to impress on Instagram? Or do you think this has a future? [Samuel] It’s funny you should ask this question, actually. I’m about to do an access course. I do free lectures for HIW, which is the Wales Health Board, essentially. I’m going to do one on the 18th of February. It’s free. So if you’re a dentist in North Wales, there’s still two places left and it’s on access and you know these ninja access I think the problem with these is yes you’re going to be putting major stresses on your tooth. This always brings me back to when I was a vt actually. My nurse was sort of tearing her hair out because I was always trying to do these sorts of minimal preps, but I didn’t really know what I was doing because I wasn’t very experienced. If you’re using some sort of guided endodontics, we’re using the Cone Beam CT Scan and using jigs to sort of know exactly where to drill. I think by the time you’ve sort of drilled a ninja access and you’ve been looking around, you’ve probably not got a really true ninja access. What I would say is if people aren’t aware of what a ninja access is, it’s essentially just making a hole just for your file to reach into the canal space. And the hole is really, really small, almost in the middle of the access cavity. I’m always a little bit reluctant as well to give my opinion restoratively because I’m not a restorative dentist, but I think in the main, if you’ve not breached the marginal ridge, so if you’re not breached the outer end of the tooth and you’ve just caught an access cavity right down the middle of the tooth, then it’s not going to need a crown. It’s just going to fill it, and I suppose in a way it’s a kind of way off, isn’t it? Between, you know, putting major stresses on your files. Missing extra anatomy as well. And also there’s a strong argument to say that you need to remove all the pulpons to get rid of all the bacteria. How are you going to fill a tooth like that adequately? I’m not too sure. [Jaz] Cause if you’re preserving those ridges and stuff, they get in the way. But, ultimately there are very few teeth amenable to this approach. Usually got huge MOD amalgams. [Samuel] I was just about to say, how many teeth do you get? That virgin. You never. [Jaz] Exactly. So the type of case for that is, when you get to do it, I’m sure you guys get a nice little kick out of it. [Samuel] Exciting though, isn’t it? [Jaz] But I think you need to remove the old restoration explorer and stuff. By the time you remove the caries and stuff, you don’t need to do a ninja access. The floor of the pulp chamber is staring back at you. We’ll go for just two more questions, buddy. Okay, here’s a good one. Bernard asks, what would be the main mistakes that you’ve seen in patients referred from GDPs who have initiated endo to relieve pain as an emergency measure? [Samuel] That’s a really good question. Lovely question. Perforation, for sure. [Jaz] Perforation. [Samuel] Absolutely, yeah. It’s such a disappointing thing to do, to perforate, but it’s so easily done, and- [Jaz] I know that too well, my friend. [Samuel] Oh, I still perforate now. But granted, I don’t make the schoolboy era perforations anymore. The really easy ones, it’s usually with highly calcified teeth, but Sanja Banjera, I can never say his second name. I think it’s Sanjay Bhanderi. He’s a Bhanderi, yeah. Lovely guy. Bhanderi, sorry. Yeah. He said something to me that I thought was really rang true. And he was saying, if you’ve never perforated a tooth, you’ve not done enough root canals. Absolutely. So I see a lot of perforations. I think when I did my MSC, I was told that you get a lot of dentists to ledge teeth and then they send it to you, I don’t really see that a lot of, I suppose, my referring dentists are pretty clued up on things. And a lot of my dentists refer to me that they know that kind of, their sort of scope of practice essentially. Yeah. Another thing as well with referring dentists is referring teeth that are unrestorable. So there’s a huge kind of debate now between endodontists about, should you be checking the restorability of teeth or should you just be letting the original GDP to do that? I think it’s down to how busy the endodontist is. So if you’re just starting out with your endodontic career, I think a really great practice builder is to say to your referring dentist, listen just bring them to me. I’ll see if it can be restored. I’ll do everything. I’ll put a core in then to GDP. That’s perfect. But I think as you start to get very, very busy, these kinds of treatments really, I’m now starting to ask my referring dentist just to see if it is restorable before it’s sent to me. [Jaz] Because the time it takes to actually get a removable caries cracks and explore, but get a lovely seal with your matrix band, build up a core. That can take up a significant amount of time. And so that needs to be respected. I remember not having an argument, but it was like a disagreement I had with an endodontist who used to work at our practice. Trey Endodontist, lovely guy, by the way, lovely, really sweet guy. But there’s one case where I’m quite good now at restoring dubious prognosis teeth in terms of the things I have at my disposal, vertical preparation. The whole thing about supercrustal tissue attachment or biological width has totally changed over the years for me, right? So, there was this thing where I could restore it. He’s like, I don’t think this is storable. So we kind of locked horns about that, but eventually he did it. And this case has been going good for four years now, but it’s an interesting one sometimes. And what I like to do now, by the way, is in those cases where it is a bit dubious, I do like to do my pre endo build up myself. Because I like to just, I charge the patient. Okay. Here’s an investigation fee. I will remove the restoration, I will clean it out, and then you’ll know by the appointment whether we should have this tooth out, or you’ll leave with a lovely seal, and the root canal, and the endodontist can do their lovely job and send it back to us. And I quite like doing that. How do you feel about that approach? [Samuel] I think another really, really important thing to sort of tell newly qualified dentists is when you said, I charge them, always charge them. Don’t get this thing into your head where you need to, you need to know your worth. You need to charge for your time. I think the worry with checking the restorability of a tooth is if I think, or do you know, I would restore that, but I’m not too sure if another dentist would. So I’ve got a really, really good relationship with a lot of my referring dentists, a lot of the time, I still am restoring some teeth in one of the practices. And if I just think it’s a bit tough that I’ll say to the patients, do you know what, if the dentist feels a bit, they can’t restore this, then I’ll do it for you. No problem. But you are on real shaky ground there because on the one hand, you’re kind of showing up the other dentist. And that’s not a good thing to do. It’s not, not nice to kind of say, well, I’m better than you. Blah, blah, blah, blah. Another kind of issue is, if you are, and this is a really delicate thing to say now, is that as a referring dentist, you can’t be hoovering up work off of the patients. The referring dentist has sent you the root canal to do. If then you start to like going, oh, I’ll do this for you. I’ll do that for you. It’s kind of like a gentleman’s agreement, isn’t it? Between referring dentists and referrers. You’ve got to have a really great relationship with these people. I used to refer to my root canals when I was early on to a place in Sandstone in the Wirral. It’s run by Kate Blundell. Anyone who lives in the Northwest knows Kate Blundell. She’s also- [Jaz] She taught my wife in Liverpool. And she’s a lovely lady. [Samuel] She’s the sweetest, kindest person you’ll ever meet. And she taught me a lot about referring to dentists, not directly, just how she sorts of conducted herself. And she used to send letters and say, this has happened. Do you mind if we do so? Essentially, it’s just always about communication. You see people on Facebook all the time, but people are arguing about it. Essentially, it all just boils down to communication, doesn’t it? We’re all mostly reasonable people. And I think that’s essential. [Jaz] A hundred percent. And that example I gave of me and the endodontist locking horns, it was actually in a courteous way. And he was looking out for me. He’s like, are you sure you want to do this Jaz? And I appreciate that. [Samuel] Maybe you should have listened to him. [Jaz] Well, it all is going well so far, but it was great for him to understand me as a clinician. And so you’re building that relationship with your endodontist is absolutely brilliant. Last question from your namesake, Samuel, Samuel Zhang. If it was your tooth, Samuel, which would you rather have extruded obturation or slightly short obstration? Which one would you rather have? [Samuel] Oh, I absolutely love this extruded. Oh, my God, that is so difficult. Well, I suppose we go back to the overextended and overfilled. I would say if it’s overfilled, so that’s where it’s out of the apex, but the whole canal space is filled, I’d go for that. Depends what’s out the end, if it’s a bioceramic, you know. Perfect, even better if it’s through the apex and the apex has been destroyed by two larger ham files, probably go for short, but that’s a really good question. I couldn’t give you an answer on that. [Jaz] It’s like choosing your favorite child or something. So, guys, those are amazing questions. Quick one from Rajeev. How important is sonic stroke ultrasonic activation of irrigants? [Samuel] Tell you what, if you buy an ultrasonic activator and you use it once. You will see all of the detritus, everything just sort of vibrating off the canal walls. And then your canal irrigant just starts to become really murky and nasty. And then you will never ever not do that again. And ever again. With the ultrasonic over the What was the other one? It’s ultrasonic and- [Jaz] He said, sonic or ultrasonic. [Samuel] So sonic, you can buy these like endo activators. You can buy them at dental directory for about 700 quid, or you can go on Amazon and buy one and they just buy the really expensive tips. I used to use those, but I think the evidence suggests that ultrasonic is much better. You’ll also know clinically that you’ll see all this out. My irrigation protocol, rightly or wrongly is, sodium hypochlorite activated. So this is once we’ve shaped everything, we’ve done the comfort radiograph, everything’s all ready to rock and roll. I’ll use sodium my chloride, I’ll activate it and I’ll use 17% E. D. T. A. And I’ll activate that. And then I’ll do a final rinse with sodium hypochlorite. And because the E. D. T. A. is going to remove all that smell, all that muck is going to open up all the tubules. You want to get it in there. So, I think the ultrasonic activator you buy the tip, they are all autoclavable It’s a really, really quick and easy way of just increasing the prognosis of the tooth. So definitely buy one for sure. Even if you’re a GDP. [Jaz] You’re totally right. When you see it for the first time and there’s no going back to not using it. I’m not gonna, I said that was the last question, but I’m just seeing these and I just- [Samuel] Keep going. [Jaz] Okay. All right. Lovely. So do you do many parts like pulpotomy kind of stuff or by the time they get to you the end of the line is the necrose kind of thing? [Samuel] So I do general dentistry. So when I went fully private, we gave the patients the option to stay privately with me. And then some people just couldn’t bear to see anyone else. I don’t know why, but I do do general dentistry. I enjoy general dentistry for sure. Like making crowns and things. And I think if I am being honest with myself and maybe I’m opening myself up really wide here, is that my dressing of vital teeth, it’s 50/50 for me. I am still on that learning journey, I think. And I’ve had a few times where it’s been, it’s caught me out. Again, you go on like journeys, don’t you? As a clinician, you kind of work out this sort of new kind of thing that you’ve learned and you can start using it and then we get patients come back and you know, they’re not getting this kind of result that you’d wanted. And again, I’ll say this ad nauseam, I’ll be really, really annoying. It’s all about consent. It’s all about communication with the patients. And like I say, if you’re NHS, if you’re in a kind of a healthcare system, which is just go, go, go, go, go, just get the whiteboard out, just draw it dead quick, tell them, and then let them make the decision again, it’s putting the responsibility onto them because once they’ve taken responsibility for the tooth, whatever happens, they come in and nine times out of ten, they’re going to be like, you did tell me blah, blah, blah, blah. So certainly for sure, I’m not doing these. I always get the difference mixed up between full pulpotomies and pulpectomy. I think a pulpotomy is where you- [Jaz] Remove the coronal. [Samuel] Exactly. And you leave this kind of, personally, I think if I’m down to that level, it’s a root canal for me for sure. But if it’s a pinprick exposure and the patient understands, I think the great thing, if you’re getting you for a general dentist, I’ve got this thing called well root putty and essentially it’s like a little box, it’s got 10 of these like little compule capsules full of bioceramic putty. And essentially they come in these like little tiny sort of a silver lit sort of bags that you can sort of close up and say it’s a really, really great, great liner or a sort of material. I don’t use Dycal. I think the problem with the putty, of course, is it’s expense, but, you can buy this well root putty, you can kind of, as long as you’re obviously not using the sort of compule directly in the mouth, you just squirt it onto like a little pad and you’re manipulating it that way. I’ve got a lot of great outcomes with that. So essentially, if you do like a tiny little pin prick and the pulp is really red and you can see that it’s alive and it stops bleeding as well, of course, that’s really important. Just pop a little bit of this putty over the top, bit of GI. Feeling on top, let the patient know. And I suppose in a way towards it makes sense to do something like that, because the alternative, of course, is root canal or extraction. But you just need to involve the patient in the communication. Worst thing to do is to do a pull cap or direct pull cap, not tell the patient you come back in agony and you go, oh, well, this happened, that happened. So, yeah, I’m on the journey with that for sure. And that is the greatest thing about my job in dentistry. You never, ever, ever, ever stop learning. My principal, my practice in Wrexham, he’s always doing something else. He’s always getting this out. He’s always, and I love that. I love watching him use different things and to be, he’ll kill me for saying this, but to be at the end of my career, he’s not at the end, but he kind of is. It’ll be like, be into it. And I went- [Jaz] That’s the goal. That’s the dream, man. [Samuel] I went to an endodontic sort of conference in Belfast and I was getting the plane home. I shared a taxi with a 70 year old dentist. She didn’t look 70. Put it that way. She looked fantastic, very glamorous, and she was talking about lasers and she was talking about this, that and the other. I didn’t know how old she was. And she was like, oh yeah, I’m in my seventies and only got my laser for like five years and her kind of passion for everything. I was like, wow, it’s amazing, isn’t it? Most people don’t have jobs like this. Trust me. I’ve had a job before dentistry and I despised it. And count yourself lucky. And I know that doesn’t help for people who are having a hard time in dentistry at the moment- [Jaz] But anyone having a hard time, I think, take inspiration for our journeys and know that as long as you have a growth plan and some sort of direction you’re heading in, and sometimes education can be the catalyst for that, like you have experience as well. [Samuel] If you’re having a really, really bad time in dentistry, I know you’re thinking something now that you’re not saying out loud, and you might just feel you’re a bad dentist. And I can categorically say now you probably are a really good dentist. You just care too much. So I know in the past I’ve struggled slightly with certain things about dentistry, about being a perfectionist and I had a CBT and that’s kind of helped me. Manage my anxieties and it kind of shows up things that I was blind to. And so I just want to say to you, you’re having a bad time. It will get better and just be really kind to yourself essentially. That’s what I would say. [Jaz] Well, one of the reasons we set up Protrusive Guidance is community. I think it’s so important to have a community of practice, as they call it, too, because we can feel so isolated. And what I love what you do, you’re building a community yourself. I’m fully supportive of that, Samuel. And what I love about our conversation, very candid, very honest accounts. I love educators and people like you who are real world, happy to talk about mistakes, happy to talk about, there’s always, they’re on a journey and you are just the embodiment of everything that we love in Protrusive, so I suppose we’ll say. Thank you so much for sharing your time on this episode with us. It’s going to be the episode of the year in my opinion. And I’m so excited to get this in there. You’ve absolutely smashed it. Absolutely. [Samuel] Probably, I could talk for Britain. I could. [Jaz] There’s still about 40 questions from the community. There’s still about 40 questions. [Samuel] We could have a Joe Rogan three hour bad boy and I wouldn’t even stop for breath. Okay. [Jaz] I need to go for a wee desperately. So I’ve held it this long. So Samuel, thank you so much. Honestly, more power to you. Keep doing what you’re doing. And I’m going to get everyone to subscribe to your channel because it’s just so wonderful. Thank you so much. [Samuel] Great conversation, Jaz. Keep up the good work. I’ll see you soon. Okay. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. Wasn’t it brilliant? Isn’t Samuel such a great person? I love his outlook on life. I like his philosophy. I love that he loves Endo so much and we learned so much from him. So thank you so much, Samuel. Do check out his wonderful YouTube channel. And of course, if you haven’t hit subscribe on our channel, then please do. Give a like while you’re there as well. If you’re listening on Spotify or Apple, please do subscribe. It costs you nothing and it means so much to me and the team. Speaking of the team, I just want to say a big thank you to Erika for editing this. The premium notes team of Krissel, Nav, Emma, and our CPD queen, Mari. I really enjoy the Q& A aspect, so I will do a bit more of asking you guys. What are the questions that you want to ask our guest? So the only way to get involved with that is by joining the Protrusive Guidance app. If you join the Ultimate Plan, you get access to all our masterclasses and premium clinical videos with CE. Head over to protrusive.co.uk/ultimate. It’s fully tax deductible and it’s one of the best value packages of education you will get. Thanks again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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How to Find a Mentor in 5 Seconds Flat! – IC058 41:35

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‘Mentorship is more important than courses’ – said lots of wise Dentists, and I think they’re right! Do you have a mentor guiding you in your dental career? How do you know if you’re making the right clinical decisions? https://youtu.be/5N0kj2YuFtA Watch IC058 on Youtube In this episode, Jaz is joined by Damian Panchal and Shivani Sadani to discuss the power of mentorship in dentistry. They explore why having a mentor can accelerate your growth, boost your confidence, and help you navigate complex cases with ease. They also introduce Intaglio , a brand-new platform designed to connect dentists with experienced mentors—so you can get real-time guidance, solve cases faster, and elevate your practice like never before. Listen in to learn why mentorship might be the best investment you make in your career. Key Takeaways: Mentorship is essential for professional growth in dentistry. Post-course support is increasingly important for new dentists. Real-world experience is crucial for applying theoretical knowledge. Investing in mentorship can lead to long-term benefits in practice. Effective mentorship can significantly improve clinical confidence and skills. Mentorship is accessible and affordable for all levels. The value of mentorship lies in its application of knowledge. Mentors can help navigate career challenges beyond clinical skills. Relatable mentors can provide the best guidance. Learning from others’ mistakes can save time and effort. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Introduction 00:48 Introducing Intaglio: A New Mentorship Platform 01:45 Damian Panchala and Shivani Sedani – Personal Journeys 04:46 Mentorship Crisis in Dentistry 11:51 The Role of Social Media and Forums in Mentorship 17:41 The Value of Paid Mentorship 21:03 Exploring the Intaglio Platform 23:44 The Role of Mentors Beyond Clinical Help 31:05 Intaglio’s Vision and Future Plans 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: Teaser : Are people willing to pay for mentorship? Okay. And actually, I think it was very validating because this is already happening in the implant space to a very big degree. Like, okay, I don't know the details there. Maybe you guys do. [Jaz] But if you’re someone who’s learning to place implants, though, your first X number of implants, you’re probably going to make a loss on because you’re going to buy all the stuff, buy all the kit, give up your clinical time, but all the fee that your patients paying you, you’re pretty much paying to your mentor. And so that’s a huge investment in yourself, but the ROI is exponential. [Damian] So there’s only one way to learn these cases, which is you need someone holding your hand until that confidence builds. So yes, you may lose a little bit of money, lose a bit of time in the early days. But it’s all going to come back in a full circle and that confidence and that money will return. Jaz’s Introduction: Protruserati, I’m going to say it how it is. Mentorship is the number one thing you need to excel and grow as a dentist. It’s more important than courses. The courses are important because they give you the skills. They give you the knowledge. But you know when you get stuck? At the point of application. That’s when we bounce ideas off each other, even like basic stuff, like should I extract this tooth on this patient on that medication? And thankfully with the Protrusive Guidance app and having a community of practice and like minded individuals, we can help each other. But sometimes you just need in depth help, like someone to just hold your hand and talk you through exactly how to solve a problem or a case. Mentorship is already huge in the implant world and it’s growing in the ortho world and I think there’s a space for it in all disciplines of dentistry. In this episode, I’m joined by Damian Panchal and Shivani Sadani, and the three of us are some of the co founders of Intaglio. We’ve finally launched. This is the platform where you can literally go on and find a mentor, book them, pay them, because we’re promoting fair exchange. But what you get is a dedicated time with a mentor. And like I said, this is already happening in the implant, the ortho world, orthodontists are meeting dentists on zoom and just guiding them on what bracket changes to do or how they would treat implant a certain case. And the mentee, that dentist is now able to solve the case. So mentorship actually has a Better ROI than the courses. Mentorship has the power to give you confidence to move forward in the case, to sleep well at night, and to give you validation that the plan you have or what you want to do is the best way forward for your patient or your problem in your career. Listen to the full episode to find out how now you can find a mentor in five seconds flat. I’ll catch you in the outro. Main Episode: Damian Panchal, Shivani Sudhani. Welcome to the Protrusive Dental Podcast. So, so nice to have you. I’ve been working with you guys for a while now, and it’s great to chat about such a huge, huge problem and a huge solution in dentistry, finding mentors, the whole mentorship dilemma. So quite often when I introduce guests, I like to sort of remind myself and talk out loud about how our first interaction happened. And I remember getting this email from you and you’d email me saying that, look, I have this idea of solving the mentorship crisis, right? And then the first thing I think of when someone has a great idea is something that Gary V said many years ago. And he said, like, everyone had the idea for Uber. Like everyone, everyone wanted KFC to deliver, you guys are veggies, maybe not you, but I wanted KFC to deliver, right? So everyone thought of the idea, it’s the person who implements, okay, that is the person who gets to make that actual change, right? So implementation is difficult. And so when you approached me with this idea of, okay, I think we can solve the mentorship crisis, I was very skeptical. And it’s only when I spoke to you while I was driving back from Reading, and then you just told me your background, I was like, holy crap, okay, here’s someone who actually has some skin in the game when it comes to developing something, to creating something, okay, and is a dentist, and that’s why I signed the dotted line and I just agreed to work with you guys to solve this crisis, so tell us more about you in that kind of domain, Damian. [Damian] Firstly, Jaz, thank you for having us on today, it’s great to finally speak with you again. So, I am a dentist, but I got bit by the entrepreneurship bug many years ago. I cut down my clinical dentistry when I realized my true passion laid elsewhere. Trying to use the knowledge that we’ve got from dentistry and applying it to, like you said, solving the problems within the field. And who better to do that than dentist themselves. So over the years, my clinical dentistry phased down and my entrepreneurship phased up. And it’s been a pleasure and true excitement to work on Intaglio for the past couple of years. [Jaz] Amazing. And then in terms of the type of dentistry you do, it’s just general dentistry, right? [Damian] General dentistry with a focus mainly on clear aligners. I just keep my skin in the game and see what’s happening on the ground and then I can use that knowledge to see what we can do in the entrepreneurial world. [Jaz] And I think what we’ll talk about is, how mentorship in the clear aligner spaces has boomed. I think there’s a such a huge potential there already in implants. It’s such a big thing. And I feel like, with aligners and orthos just scratched the surface, but Shivani, tell us about yourself, where do you work and what are your passions? [Shivani] So, similar to Damian, obviously I started doing full time dentistry. I then eventually started to phase down. So I’m actually from London, but currently working in Hertfordshire. So I work in private practice at the moment. I do general and some sort of, like, cosmetic dentistry on the side, as most people do. But keeping my foot in everything at the moment, really. So yeah, just balancing my time between dentistry and Intaglio. So it’s been adventurous, last few years and we’re coming to the point now we’re sort of ready to launch and we’re amazed by the amount of support we’ve received so far really. [Jaz] It’s true. The emails we get saying that guys, this is what we needed kind of thing. And so, it’s great to have it, but I think let’s just tap into why there is a problem with mentorship and dentistry in the first place. Right? So here’s my analogy, right? You want to achieve a goal, right? And so let’s say you are someone who wants to get, you’re at point A and you want to get to point B. You’ve noticed your destination. You can look at point B and say, okay, I need to get there. Okay. And so the car, the vehicle, is the courses you go on. Because then school didn’t prepare us enough, okay? The vehicle is the car, but you still need the driver, which is you, you still need to work hard to get there. But it is nothing. It’s missing a vital ingredient without either the diesel or the battery. If you’re an EV guy like me, so you need the energy source and and that’s where I think mentorship comes in. Mentorship is what propels you. Mentorship is what’s get you to get you there. The skills you gain from the courses, but the application and the implementation of those skills on those cases that you see, it’s very difficult to do that. And that’s why so many people go on implant courses and never place an implant. So many people go on the ortho courses and have a very slow start. And they could have been way further ahead had they had good mentorship. And you see those people who had good mentorship, like maybe their mom or dad’s a dentist and they’re in the practice the whole time. And I’ve seen those clinicians fly. Because they had a constant mentor there, right? Who’s not going to ask for any money, right? And so that’s why they fly. And so it’s a huge thing. And we all know it. I think it’s been drummed into us enough. It’s one of those foundational things. So tell me guys, in terms of what your experiences have been of this problem of mentorship and dentistry that we’re trying to solve. [Damian] So Intaglio was actually driven out of this exact problem for me as a mentee. So let’s go back to, we graduated in 2018 and you, I’m sure everyone’s experienced with family and friends saying, right, can you sort my teeth out now? So that journey was between me and my sister. So from the day I graduated, it’s when are you sorting my teeth out? And I delayed it and delayed it because I knew that we needed some sort of clear aligners or orthodontic correction. And fast forward four years of nagging, I said, right, let’s go on this aligner course and let’s get her sorted out. [Jaz] See, that’s good, Damian, because you had your first case ready. Like, that is so, so good. Like, any course you go on, if you have the first few cases ready, you’ll be able to apply it. You actually, that’s half the fuel already in the tank. [Damian] Exactly. So I was primed and ready to go. Went on the course, and next day the message, right? Are we ready to go now? You’ve been on the course, you know what you’re doing, right? And I was like, can you just give me a few more months? I just want to practice a little bit more. I just want to do a few more cases. I want to do this properly for you. I don’t want to mess this up. So I pushed her along a little bit further and then I couldn’t kick that can down the road anymore. Now there was no other excuses. The time would come. So we got her in, we did a scan, put it onto Invisalign ClinCheck and looked at it. And I realized, I really didn’t know what I was doing. It was too complicated. There was movements going on, I had no idea whether that movement was going to happen. I realised they need some sort of elastics or buttons, but they just use those words on the course, but they didn’t tell you how to do anything with it. Which tooth with the button, which tooth with the elastic? So I thought, you know what, they told us on the course, we have a, what did they call it? Clinical guidance or mentorship call you can book with Invisalign. [Jaz] It’s like a case cafe kind of thing, right? Just for the younger colleagues who are listening and watching this, maybe the students, like when you go on a course provided by an aligner company, they just tell you how to use their software and their aligner. You still have to learn the ortho yourself, right? And we all fall into this trap. Now, how did I start? I went the same way, except I was lucky. I had Hap Gill at the practice. He was my mentor and he literally held my hand first few cases, right? So, and you need that, you need that. And so I’m guessing you didn’t have that? [Damian] No, I wasn’t in that fortunate position. I was surrounded by a lot of implant dentists, but not many ortho dentists. So, not a problem, it’s okay, I’ve got the support. I’ll log on to this one on one call with the clinical tutor, as I thought. And we did a screen share, I looked at it. And the first question they asked me is, right, what do you think? And I explained what my concerns were. And then I was asking for some advice. How can I do this? How do I fix this? And they said, yes, I agree. It’s quite a complicated case. I suggest you use your own clinical discretion. And that word just stayed with me. Clinical discretion. I don’t know what I’m doing. So the clinical discretion doesn’t really get me out of this hole. So I realised this half an hour call wasn’t going anywhere. I took a couple of pointers and I thought, It’s not a problem. I’ll book another call. Chances are I’ll get someone different. And hopefully we’ll get the answers I need to actually sort this out. So you wait two weeks, three weeks for a call when there’s a next slot. And luckily I was excited. I got someone different. Let’s start again. Let’s start fresh. Pretend I know nothing. And get these questions answered. What do you know? Same words came up again. Use your clinical discretion. And I thought, this can’t be that difficult. Why can’t I just get the answers I need? They helped me on the simpler cases, but when it got a bit more complex, it kind of felt like there was some resistance there, there was a barrier, and they didn’t want to quite truly answer my question. And I thought, okay. So their advice then was, after the clinical discretion was, we suggest you find a specialist. If you’ve got a friend or a family who’s a specialist orthodontist, why don’t you run this case past them and that’s the way to go. So that’s as far as I got with Invisalign. So my sister’s pestering me now. We did a scan, what, four or five weeks ago. How long does it take? Can we get started? And I’m five weeks along and literally not even a millimeter of progress has been made. So you know what, back to the drawing board. Let’s reach out to family, friends, colleagues. A few people suggested some very good orthodontists nearby, so I did a bit of cold emailing. I got a couple of numbers, I texted someone, gave it a week or so, but once again, no response. Then, we’re going round in circles here, and then I had a colleague who had a sister who had a colleague who said, I think I can help you, and she gave me a number, and she said, give me a call, Wednesday, five o’clock, and I’ll go through this case with you. I’m so thankful we’re eight weeks down the line and I finally got someone who knows what they’re talking about that’s going to help me. So I think the call was on Zoom or WhatsApp, can’t quite remember. I was all prepared on my table, ready to make notes, get these questions answered. And she was on her way back from the Lake District in her car with a family of five, with three kids at the back. And I was so appreciative for her time. And I could see how busy of a woman she was, and she was excellent. [Jaz] Wait, three kids is no joke, man. Being an ortho and three kids is like, holy moly. [Damian] A lot of respect for her, a lot of respect. And she was doing her best to help me, considering she was driving through the Lake District with questionable signal, kids demanding her attention in the back, me trying to pester her as many questions I can get out of this 20 minutes that I’ve got with her. And I just thought, this can’t be the answer. There must be an easier way to get this sorted. I just went along with her advice, she gave me the answers that I needed, and I just ordered the case and I took a chance, and it all worked out, which was good, I’ve got no one pestering me for bad results, but I just thought there’s got to be an easier way, and long story short, that’s how Intaglio was derived. [Jaz] Amazing. And this is screams so much about how mentorship is kind of carried out because the other way you could have gone, Damian, is the following. And we see this all the time on social media. Like there’s so much mentorship happening that we never get to see because there are mentors in the practice, like the other associate there. And then you just show them the case and they’ll help you out. It’s like, okay, let’s go for a drink afterwards, lemme just help you out, kind of thing, right? And so they get solved. Amazing. You’re very lucky, okay? If you had someone like me, I’d Hap Gil at my practice back in the day, and he would just help me and he would just tell me what to do. That was like a godsend, okay? So I wish I had that for all of my dentistry, but I had it for aligners with him, because I was working with him on Fridays at the time. What other people do, when they don’t have that, is they go on social media, like a Facebook group, and they will post the case there. But I’ve been observing for a while, and it does not work out that well. Like if it’s a really simple question, right, then it’s a very obvious answer, fine. But when they post like 15 photos, okay, they get no response because no one’s got time. Who’s got time to go through the case and sit down and write an essay what to do? In this world of voice notes and video calls and stuff. The other extreme is that they don’t post 15 photos. They don’t post any photos and they write a long essay describing their case. Okay. And guess what? In the comments, it’s like, can you please send some photos? There’s not enough information here. You need to do a full examination. I would suggest you refer. And so it’s broken. And my own experience as both a mentee. and a mentor is, and lately, last few years as a mentor is people will send me a radiograph or send me a long history of the patient’s issues and whatnot. And like with two kids and a business and work and stuff, I try my best. And a lot of Protruserati listening to this right now, they would have had a voice note from me with my kids screaming in the background. I try my best to help them. Okay, but they need more, they crave more, and I know that, okay, and I want to give more, okay, and this is exactly what Intaglio is. Shivani, what’s your experience of, you do a bit of cosmetic work and stuff, and when you’re starting to do that, that’s a great moment to ask for mentorship. Has mentorship been a part of your growth journey? [Shivani] Oh, 100%. [Jaz] And any challenges? [Shivani] I think it’s similar to Damian, I mean, around the time we founded Intaglio, I was having, similar to what you said, there was, we’d learn all of this stuff at university, the textbook answer. This is what to do in this scenario, this symptom, this sign, everything, what is the diagnosis. And it comes to it in practice, particularly in my first sort of like year, year and a half. And you’re in the chair and you see a radiograph where you see a certain symptom that the patient’s presenting and you’re kind of like unsure of what to do in that situation. Not all the time. Then you see, all right, let me see, who can I send this x ray to? Who can I ask for help, you know? And not everyone’s in that position to sort of know someone who can tell you the exact thing to do. And friends, they might be able to help you slightly, but you don’t get that full sort of hand holding along the way, you know, to explain that case and the time that you need to go through that. So what we’ve done with Intaglio alleviates that issue in that sense. So if you need help with absolutely anything, you’ve got a safe place that you can go to, to do that really. For me now starting to do sort of more cosmetic dentistry, there’s loads of different ways you can do things. And I think mentorships are a massive factor. You’re always learning, always growing, and you’re going on all of these courses. And then even after the course, you sort of do that case with that technique and then you’re wondering, so I have a few questions now. I need to go back on to that course. So again, Intaglio is the place to be for that really. So if you’ve got those few questions and few cases, based on this new technique that you’ve now started to use, you’ve got a place where you can go to, to then ask those questions. So really, we’re sort of trying to hold everyone’s hand along the way and ensure that everyone’s growing and, you know, you’re never alone in that sense. [Jaz] I think dentists are definitely getting more savvy about the importance of post course support. And I see a lot of questions on Facebook groups like, okay guys, which is the best course? And they include, I would like a decent amount of support after the course. And so that varies, right? That literally varies. And I get it. Like as a course provider, it’s like, okay, you did the course, you gave them the education. How can you, in your busy life, then carve time out and not get fairly remunerated for that additional time? Okay. One of the reasons I teamed up with the IAS for OBAB, which is our occlusion online course, right? And now they’re in person as well, is because IAS already had a dedicated forum online, right? So what our delegates do now is, they will pay a fee, but then they get our time, like, we’ll hand hold them, okay, through the entire case. And then three weeks later, the patient comes back, they put all their photos. And so, the reason why our delegates are happy. It’s because they have a place to go to, to ask questions, okay? The problem with that as well, okay, is the clunkiness of it, the back and forth, right? The written base element, the forum base element. I remember a few years ago doing a full mouth rehab and I got stuck at the crown lengthening, the functional crown lengthening. It was like canine to canine. There was not enough tooth structure, there was not enough ferrule. And came to the rescue was Dr. Amit Patel. He’s a periodontist in the Midlands. Lovely guy. Okay, super cool guy. And he’s just the sweetest guy on earth. He just sat with me. I think it was like a Whatsapp actually, we’re just exchanging photos and he drew for me exactly what flap to rudimentary on Whatsapp drew for me using my occlusal photo. I sent him exactly the flap I need to do, he said do this do that. Don’t do that suture. Keep it simple and a week later, I did the case that case has been good for years now I was able to do that full mouth rehab because I was stuck at that stage and that was really powerful for me as a mentee. And now I’ve done that as a mentor and through the forum now, IAS. And it’s so, so amazing when they post their case at the end and they were able to solve it. And it’s just so, so good. So I think initially one of my concerns, Damian and Shivani, when you guys approached me at the start and we started to do this together is, are people willing to pay for mentorship? Okay, and actually, I think it was very validating because this is already happening in the implant space. To a very big degree, like, okay, I don’t know the details there, maybe you guys do, but if you’re someone who’s learning to place implants, your first X number of implants, you’re probably going to make a loss on. Because you’re going to buy all the stuff, buy all the kit, give up your clinical time, but all the fee that your patient’s paying you, you’re pretty much paying to your mentor. And so that’s a huge investment in yourself, but the ROI is exponential, right? Cause then once you, how many, five times, 10 times, eventually you can do that pre molar case. You can do that molar case and then you can grow. It’s a bit like, give a man a fish or teach a man how to fish philosophy. So, when you think about implants, do you think this is applicable to the rest of dentistry? [Damian] Yeah, like 100%. So, going back, I said to you earlier, I was surrounded by implant dentists. Going back a few years, I’d taken out a lower six, cracked off the crown as you do, panicked, take an x ray. And then ran downstairs, showing the boss the x ray, and he goes, like, cut there, cut there, flick that, do that, and then you follow those. It seems like such basic steps, but it didn’t even cross my mind as to how to do it. And I absolutely hated every second of it when I went back upstairs. I was like, I’m not doing this again. I’m never taking a tooth out ever again. And then you build up your confidence again, and then you go back six months later, and what happens again? The exact same thing. And then you go back, you get the exact same advice, and you’re like, hold on. This was the same advice you gave me before. Let me give it another go. And you give it a go, and then all of a sudden, those little tips and that little bit of mentoring and advice whilst it seems so simple, was so valuable. So you fast forward years later, where someone else would maybe refer, you can take that tooth out yourself, and that investment, whilst it seems so insignificant and so annoying at the time, then pays dividends for years and years to come, because you don’t need that advice on that case anymore. You know what you’re doing. So, that applies to oral surgery, never mind when you step into the world of clear aligners. Because a lot of the courses, the mainstream, Invisalign, SureSmile, they’re one, two day courses. So, it’s physically impossible for them to teach you master’s level orthodontics in a day or two. That’s no reflection on them, that’s just as much time as you’ve got. So there’s only one way to learn these cases, which is you need someone holding your hand until that confidence builds. So, yes, you may lose a little bit of money, lose a bit of time in the early days, but it’s all going to come back in a full circle, and that confidence and that money will return. [Jaz] I still think there’s a profit. I don’t like to think of it that way, but I still think for any dentists out there thinking, ah, but then I’m not making anything in this case. That’s the wrong mentality. If you’re thinking, I’m not going to pay someone to be able to do the case, then you’ve lost already. How are you going to grow? How are you going to get to that destination when you haven’t got a tank that’s full? Shivani, when you do a cosmetic case, let’s say you got four veneers, okay, lateral to lateral incisor. How much is the patient paying? [Shivani] Anything from 750 upwards, porcelain, yeah, anything. [Jaz] Per unit, right? [Shivani] At least, yeah. [Jaz] So with the planning and stuff, that could be like a three and a half, four grand case. [Shivani] Yeah, yeah, you’d probably end up referring it if you didn’t feel confident, you’re going to end up referring it, right? So if you’re going on Intaglio and let’s say spending a couple of hundred pounds on this and accepting the case, just, in my opinion, you’re still making a profit, if you look at it that way. [Jaz] 100% and let’s do the experiment now guys. Okay, so obviously we’ve just launched so I wasn’t expecting to do this. But let’s do this guys for those of you listening on Spotify and an Apple and stuff. Let’s go and tag your website right now okay, I’m going to log in. I have a both a mentor account and a mentee account. So by the way, amazing feature. We worked very hard to put in. Where you could be a both a mentor and a mentee that you could be a mentor in composite veneers because you can do them for fun and you’re good at them and you want to share your skill and advise people, but you’re a mentee for implants. You can totally do that. Right? So let’s go find mentors. Okay, and let’s pretend I’ve got a cosmetic case. I’m going to go to filters and I’m going to select area of expertise. Now, for those listening and watching, we are in beta phase at the moment, right? So there are some things like I’m still like, I’m not in love with them yet because they were beta. Like this is like a startup. We’re trying to solve a problem here. And so Damian, I’m going to tell you now, buddy, like when I look at our areas of expertise, I’d like to be able to select more than one. You see what I mean? Because like, I want maybe oral surgery, exodontia, and implants. In case maybe I’m missing someone. Do you get what I’m saying? So I think in the future, we should, this is like the beta phase. But in the future, we should have more of those. [Damian] No, 100%. There’s so much we want to integrate into the platform. And we’re taking it step by step. See what people love, see what people hate. And we’ll work on the feedback. [Jaz] Amazing. And so what I’ve done here is I’ve just selected cosmetic dentistry. Okay. And I’ve set it from price low to high because I’m a cheapskate. So, let’s have a look. So people think, okay, is mentorship like out of my reach? Like I’m only one or two years qualified. And can I afford to pay a mentor? Hell yes. Okay. Upen, who I know Upen. He’s 18 years qualified. And he must just be doing it for like the love of it. Because he’s only charging like if you’re in America, he’s charging $40 an hour. UK is like 32 pounds an hour. And so I know Upen, he’s bloody brilliant. I see him all the courses. I would totally, I mean, take my money, man. Like, that’s amazing, that return on investment, right? I’m looking at these other guys. Ahmed, I mean, I don’t know Ahmed, but I’m looking, he’s got such a slick profile picture. Okay, so he’s got 13 years of experience in restorative dentistry. He’s an aesthetic dentistry enthusiast, okay? And I can book him for two hours for 232 pounds. But if I just want to do a half an hour session, it’s 58 pounds. That’s like 70 US dollars, okay? To actually get someone on Zoom, show them your case, and for them to guide you, like, holy moly, like, you can literally make that back just, like, in the first two minutes of the polishing the damn composite. This is actually unbelievable. I’m actually, like, amazed. I mean, I hate the word cheap. But these guys, they’re obviously doing it out of passion. They’re not doing it to like a monopoly or profitize or anything. But I think that’s important to respect a mentor’s time. But what do you think about that guys? [Damian] The analogy I like to always give is, let’s compare it to our medical colleagues. They’re surrounded by the consultants. These are people who have spent years of their life dedicated to their profession and their area of expertise. And you might be a foundation doctor or a core trainee. You walk around with them and you absorb all of that knowledge on a day to day basis. And, as everyone listening knows, the profession can be quite lonely. It’s you, your nurse, your patient, and the days just kind of twindle by, and unless you’re surrounded by things that excite you and give you passion and people that give you that same passion and excitement, how many people end up burning out the whole mental health within dentistry is a whole different conversation? So by having these people readily available who have got the excitement and the passion to share their knowledge, which has taken them years and years to build. And you can learn in half an hour a fraction of that knowledge. That’s invaluable. I’m just going to interject there. [Jaz] I mean, I just want to be clear that the role of these mentors, not necessarily past knowledge, it’s more to the reason our logo is a door being open, it’s opening doors to allow you to treat that one problem, that case, right? So again, what mentorship is in general, is allowing you to apply the knowledge that you gain from the courses, okay? Because it’s very, very difficult to apply it. That’s what the crux of it all is. It’s application of the knowledge of courses and mentorship is what unlocks that, is what opens your doors to allow you to treat that case and then again and again and again and then you don’t need the mentor anymore for that specific problem. [Damian] 100%. [Shivani] Also, to be honest with you, Jaz, even on the platform it’s not just sort of clinical help. There’s also, we’ve also got mentors on there for like non clinical help, communication, for international students that need help with their ORE. We’ve got a whole range of that and more to come as well. So it’s not just a place where you can go if you need clinical help. [Jaz] I had an orthodontic specialist trainee. So she’s a registrar and ortho and she’s got a little bit of imposter syndrome. She didn’t want to like mentor in orthodontics. Okay. And that’s cool. But what she did want to mentor in is helping someone who’s stuck with that application to specialist training. Like if I was in that stage and I wanted like desperately do special training, I would totally pay someone to just hold my hand, keep me calm. Tell me, like, how to navigate my next big challenge in my career. You don’t even need a case to get a mentor. Sometimes, you know what? I’ll tell you guys. The other week, I would have posted about this on Protrusive Guidance. I paid Pascal Magne 295 US dollars. For an hour of his time. He’s cheap, okay? I’m not going to tell him this because he’ll charge me more than that. But, like I didn’t have a case. I’m not even like my onlays don’t debunk either. So first thing he asked me is so what issues are you having with your onlays? I’m like, I’m not having I just want to see you man. So I talked to you and like geek out with you for now. So I just literally asked him these really geeky questions like high level and we talked about how pure silane. It’s better than the mixed stuff with the MDP and he literally showed me these like diagrams of onlays with these like liquid bubbles on them and the angle, the contact angle they make, and it was like a mega geeky manifestation of knowledge. It was just amazing, I loved it. Okay, we talked about what’s the best way to clean your ceramic. How about using phosphoric acid? I just enjoyed just asking the source of information so much experience, what is the best way? How would Pascal Magne do this? Okay, and I had that one to one time with him. So you don’t always even need cases, you just want to geek out with someone that you respect so that allows you to become a better you. [Damian] Definitely. And this only happened today actually. So, I worked with a nurse today, who, she’s actually a dentist in Turkey and for various regions she’s decided to come over here and she’s currently sitting through all her exams and she’s working as a nurse in the interim. And she was telling me about her journey coming over to the UK. She had to navigate basics on accommodation, getting a job, where to sit the exams, what materials to use to revise for. And I said to her, you’ve got so much knowledge and experience. You’re not valuing how much you’ve learned in the one year you’ve been here. And I said, you’d make an amazing mentor. So literally this afternoon, I checked on her and she’s already signed up and she’s on as a mentor for a dentist who wants to come to the UK and just get some, what seems like basic information, but it’s such a massive step and a massive journey. And to have someone help you. This is not clinical in the slightest. This is just getting your foundation and getting your foot into a whole new environment. Something you’ve never worked as. You’re a qualified dentist, but now all of a sudden you’re working as a nurse. I’ve never had that experience. So to learn from someone who’s had that experience, it’s amazing. [Jaz] This conversation Damian is reminding me of when I was a third year dentist student. I used to live with these fifth year dentists, right? And I felt like I was on such advantage. Because I could just ask them about stupid stuff and they would like, I was like, wow, these are geniuses, right? These fifth years, they know everything, man. And so when you think about it now, when I’m having a beer with them, it’s like, okay, there’s a blind leading the blind. But at the time they knew stuff I didn’t know. They genuinely knew they had done three more molar excavations. And I’d done like zero. So I had something to learn from them. Now that’s an extreme example I’m giving you. But the reason I mentioned this is when you are one year qualified, okay. And you’re doing something for like the first time or the third time, that person who’s done it for 30 times, that person will understand your struggle more than the person who’s done it a thousand times. Cause the person who’s done it a thousand times will forget that you will struggle to hold the suture in a certain way. That person will forget that you’re even struggling to talk about money with a patient. That’s such a far gone thing for someone. So the reason I’m mentioning this is the mentees that we’re collecting, we’re attracting. It’s not necessarily like Pascal Magne and Jason Smithson and stuff. They mentor as well. And I would love to welcome them all to Intaglio, but these people are there to help you. And it’s sometimes it’s not looking at the superstar names is looking for who can help you in your journey with your specific problem. And that’s why I think what we’ve made possible now is to allow people to get help and at a really great price as well, but really, really good knowledge because you don’t have to be a superstar to mentor, okay? And you don’t have to always go to a superstar to get that information because there’s dentists day in, day out doing that work, okay? And when you’re struggling, you’ve only done two of those cases, okay? That’s the person, that’s the guy or gal you need. [Shivani] I think you’ve hit the nail on the head there, Jaz, to be completely honest with you. Some of the best mentors that I’ve had were literally only a couple of years older than me. And because they’ve been through those struggles so recently, they were able to kind of enlighten me on issues they’ve had and how they’ve got through it. And it just makes sense, to be honest, rather than going through all of these struggles, just to learn from someone who’s already been through all of that. There’s no point in you going around the houses and making those mistakes when someone’s already made them. And you can pay someone to learn those and sort of fast track yourself in that sense. So I think you hit the nail on the head there. Really. [Jaz] You reminded me something there Shivani of you could learn from failure and that’s a powerful teacher, right? Or you can learn from the mistakes of others. And then not have to make those mistakes in the first place. So you can learn the hard way, the long way, because you can learn it. You can do everything. I believe, I truly believe you can do anything you set your mind to, but sometimes doing it alone, you’re just going to go through a very bendy path. If you go to a much straighter karma path, and that’s what Intaglio is looking to solve, which is the access to mentorship. But Damian, just as we wrap up, can you just explain, because I think we need to just do some more clarity on exactly what is Intaglio, because we got so excited about solving the mentorship crisis. What problems is Intaglio there to solve? [Damian] Well, going on the point that you guys just said, it reminds me of if everyone’s ever seen Dragon’s Den. When they come in and the entrepreneur asked for 10 percent of their company and they come back and the dragons go, well, actually I want 30 percent and you can see they’re so disheartened at the thought of giving another three times the amount of equity that they wanted to give away, but the dragons justification for that is. I’ve been there, I’ve done that, I’ve learnt all these mistakes, you’re going to sail past all of that, which has taken me ten years to learn, and let’s just get cracking with the job. That three times equity that you’re giving away is going to seem negligible in the grand scheme of things. [Shivani] You’re working smarter, right, not harder. [Damian] So Intaglio is going to solve that problem. Let’s call it two separate divisions. We’ll call it our one on one division and we’ll call it our classes division. So our one on one is exactly like a Zoom call. When you book your mentor, you answer various questions. What are your goals? What are you hoping to achieve at the end of the session? What experience do you bring to this call? And that already sets the groundwork so that the mentor knows what you’re hoping to achieve and what knowledge you already have. So your mentor’s prepared even before you’ve logged on to your dedicated session. Then during this call, however long slot you’ve booked, go back and forth with the mentor and get your questions answered. This is your time. This is what you’ve paid for. Get as much information as you can out of those mentors. And the excitement of these mentors that I’ve spoken to, they’re so happy to help. They want to share. It’s not about the money for them. They’re so happy to give up their time and help someone not go through what they had to go through. So you’ll see the excitement the second that you log on. [Jaz] Totally agree. They’re excited, but I just want to clarify that everyone’s, all the mentors that we’ve been attracting, a lot of them are from the Protruserati as well. They’re just lovely people. And yes, you’re right. It’s not about the money for them. They’re just, you can see by the, how much they’re charging for them. For them it’s like, I can’t believe I get to share my knowledge experience, they’re excited to do that. But what Intaglio allows you to do is, is avoid those awkward conversations on Instagram. It’s like, hey, can you mentor me? Like, I’ve got a case. Can I buy an hour of your time and back and forth and whatnot? Like, this is just, everyone’s got their prices there. You have a problem. You know exactly what you’re looking for. Just book it, right? So it’s there to facilitate. That’s what Intaglio is. So I think our initial concept was, okay, one on one. But I thought, okay, while we’re there, we can do so much. We can help to make a bigger impact and help everyone through the other division. [Damian] So the other division then is what we’re deeming classes. And we’ll split classes into three subdivisions. We’ll go number one, webinars, which is your typical webinar that you’d log on to. That has dedicated time, or on demand. You can watch it as a pre recorded webinar. The second subdivision we’ll call masterclasses. This is like your OBAB course. You’ve got multiple lessons within a class. So, you’ve got multiple parts to the series, so you can watch it in your own time, and you’ve got a more in depth understanding of the topic in question. And the third subdivision, I’m not going to reveal too much now, but I guarantee you it’s going to change the game in dentistry. It’s something we’ve been working really hard on and I’m really excited to tell you guys, keep us in your minds. And when we release it, you’ll be excited too. [Jaz] One miracle at a time though. Like it’s been a lot of blood, sweat and tears to get to launch. We had some developers hiccups. We had some our own personal health hiccups along the way and whatnot. It took a lot to get this out there. Lots of Wednesday evening meetings, Monday evening, like designers and developers and everything. So to get to this point. So guys, mentorship, find a mentor in five seconds flat. Okay. Damian, thank you so much. Shivani, thanks so much for this journey as well, of working with you guys. And I really hope we can actually serve and help so many dentists out there around the world. This is an international mission. So thank you for spending time with me to talk about something that’s really, really important to us. And I look forward to growing this with you guys. [Shivani] Yeah. Thanks for having us Jaz. It’s been a pleasure working with you and excited to see what the rest of this year has got to come really. [Damian] Thank you again, Jaz. Appreciate your time. It’s been a pleasure. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. If you identify yourself as a mentor, please apply to be a mentor on there. If you like to share and you like to give back, then we’d love to have you. The truth is we already have the largest database all the mentors of dentistry in the world already. Okay, at beta launch, we already have it. But if this is the first time you’re hearing about it, or you’ve known about it for a while, you need to now get your gears in action and apply to be a mentor. So you can actually make a difference to lives of mentees. And of course, for the thousands of us who need a mentor. Like I’m literally on the website now looking for a mentor to help me with a specific socket grafting case I have coming up. And none of the associates in my practice are experienced in socket grafting and the implantologist in my practice, we don’t actually work on the same days. So I’m actually looking forward to booking some time with a mentor showing them the radiograph understanding what to do and what not to do and how to apply the knowledge I’ve gained from courses to this specific case. So if you can now think of a problem you have or a case that you’re stuck on, there’s a place for you. You can now find a mentor on Intaglio, which is my favorite word in dentistry. It means the inside surface of a crown or denture. It sounds like a pasta, what’s not to love about Intaglio. So check out intagl.io, sign up as a mentee or a mentor or both. You can actually do both and switch in between, which I think is magic. I’ll put the link in the show notes, and I hope this makes it a dent in dentistry. I really hope that dentists will be able to solve problems faster, grow at a much faster rate, because that’s what mentors do. That’s what mentorship has the power to do, and want to thank all of you listeners, who over the years have signed up for our waiting list and subscribed to our newsletters and stuff. It really means a lot. Now it’s possible. I would love for you to join the action. So check out intagl.io I’ll catch you same time, same place next week. Bye for now.…

Protrusive Dental Podcast

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Working Lengths and Troubleshooting Apex Locators – PDP216 46:29

for 9 weeks siden46:29

46:29

What makes apex locators reliable—or completely misleading? How do you determine the true working length of a root canal? Why is relying solely on radiographs for endo success a risky move? Dr. Samuel Johnson joins Jaz for a game-changing episode that will make you rethink everything you know about endodontics. In this first part of a two-part special, they dive into the nuances of apex locators, the difference between the radiographic apex and apical constriction, and why our radiographs might be lying to us. They also explore the power of glide path files, how to improve your endodontics workflow, and an incredible way to consent patients—something that extends beyond just root canals. Because mastering endodontics isn’t just about technique—it’s about communication, precision, and making the right calls for long-term success. Stay tuned for Part 2, where we go even deeper into endo essentials! https://youtu.be/M2z8Dl_g4XY Watch PDP216 on Youtube Protrusive Dental Pearl: Buy a small whiteboard and marker for patient communication. Draw details, highlight the treatment plans, and list pros, cons, and fees. This builds trust, improves consent, and makes treatment clearer. Snap a photo and upload it to the patient’s records. https://amzn.to/3DzUJfn Key Takeaway: Understanding the difference between radiographic and anatomical apex is crucial. Apex locators are essential tools for accurate working length measurements. The anatomy of the root canal system is complex and requires careful navigation. A well-informed patient is more likely to have realistic expectations about treatment. Glide path files can significantly reduce treatment time. Avoid forcing files into hard stops to prevent damage. Complicated anatomy can lead to unexpected challenges during treatment. Taking radiographs can help clarify uncertain situations. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode: 01:40 Protrusive Dental Pearl: Patient Communication 02:39 Welcoming Dr. Samuel Johnson 04:36 Samuel's Passion for Endodontics 07:07 Reliability of Radiographic Measurements vs. Apex Locators 11:15 Canal Anatomy 14:30 Overextension vs Overfilling 16:23 Combining Apex Locators and Radiographs 20:52 Apex Locators and Hypochlorite: The Perfect Combination? 24:00 Efficiency in NHS Dentistry 26:10 Transitioning from NHS to Private Practice 27:42 Understanding Radiographic vs Anatomical Apex 29:26 The Importance of Consent in Endodontics 33:07 Mastering Apex Locators: Tips and Tricks 37:07 The Role of Glide Path Files in Endodontics 39:19 Troubleshooting Endodontic Challenges Watch and learn from Dr. Samuel Johnson on Instagram and YouTube! If you loved this episode, be sure to watch Elective Endodontics? It’s all about Communication – PDP202 #PDPMainEpisodes #EndoRestorative #BreadandButterDentistry 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: 070 ENDODONTICS (Emerging concepts, techniques, therapies and technology) This episode aimed to enhance clinicians' understanding of endodontic diagnostics and workflow, focusing on apex locators, working length determination, and effective patient communication. By refining these skills, practitioners can improve treatment accuracy, efficiency, and patient outcomes. Dentists will be able to - 1. Differentiate between the radiographic apex and the apical constriction and understand why radiographs alone can be misleading. 2. Evaluate the reliability of apex locators and recognize factors that affect their accuracy. 3. Apply the use of glide path files to improve efficiency and reduce treatment time in root canal procedures. Want More Clinical Gems? Join the Protrusive Guidance App to get access to masterclasses, premium videos,…

Protrusive Dental Podcast

1
Medication Related Osteonecrosis for GDPs – What You Need to Know (MRONJ) – PDP215 43:26

for 10 weeks siden43:26

43:26

Are you confident in managing patients on bisphosphonates or biologics? Which medications increase the risk of medication-related osteonecrosis of the jaw (MRONJ)? How do you decide when to extract a tooth and when to refer to a specialist? In this episode, Jaz is joined by oral surgery consultant Dr. Pippa Cullingham to explore the complexities of MRONJ. They break down the key risk factors, share expert advice on when to proceed with extractions, and discuss the latest guidelines for managing patients at risk. They also discuss the importance of early assessment - by identifying at-risk teeth early, you can help prevent serious complications and ensure the best outcome for your patients. https://youtu.be/KnQoI8Z-FhM Watch PDP215 on Youtube Protrusive Dental Pearl: it is so important to assess patients before they start taking high-risk medications like bisphosphonates or biologics, using radiographs to identify potential issues. Extractions should ideally be done before medication starts to avoid complications, as MRONJ risk increases once treatment begins. Key Takeaways: Medication-related osteonecrosis of the jaw concerns medications other than bisphosphonates. Risk assessment is crucial when considering dental extractions for patients on certain medications. Guidelines from the Scottish Dental Clinical Effectiveness Partnership are valuable resources for dentists. Higher-risk patients require careful management and communication with their medical teams. Denosumab has a different risk profile compared to bisphosphonates. Patients on long-term bisphosphonates may still have risks even after stopping the medication. Dentists should feel empowered to manage certain extractions in primary care with proper guidance. The decision to extract a tooth should weigh the risks and benefits for the patient. Always assess the patient's risk before extraction. Eight weeks is a critical time for assessing healing. Antibiotics are not recommended for preventing MRONJ in the UK. Radiotherapy history significantly impacts extraction risk. Referral to specialists may be necessary for high-risk patients. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:15 Protrusive Dental Pearl 03:52 Interview with Dr. Pippa Cullingham: Insights and Experiences 06:40 Medications and Their Risks 10:02 MRONJ: Incidence and Prevalence 13:13 Biologics and other medications 14:19 Guidelines and Best Practices 17:22 Managing High-Risk Patients 25:03 Prophylactic Antibiotics 26:55 Risk Assessment 28:47 Radiotherapy & ORN Risk 31:49 Tips and Key Takeaways 33:32 New Medications & Prevention Strategies For the best approach to managing MRONJ, check the SDCEP Guidelines and the American White Paper. This episode is eligible for 0.5 CE credits via the quiz on Protrusive Guidance. 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 - 1. Be aware of the medications that increase the risk of MRONJ. 2. Learn how to assess the risk of MRONJ in patients, particularly before starting high-risk medications. 3. Understand when to proceed with extractions and when to refer patients to specialists for management. If you liked this episode, check out PDP206 - White Patches Click below for full episode transcript: Teaser: Patients prescribed a bisphosphonate for cancer were at about a 1% risk of developing an MRONJ following a dental extraction. There's been an update. So it's closer to 5%, we think, but we're not sure if that's because there's increased follow up, increased awareness, more reporting of the condition. So closer to 5 percent on the cancer patients for an osteoporosis. It's bisphosphonate medication, it's around 0. 1, 0. 2,…

Protrusive Dental Podcast

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Associate’s Journey of Growth – IC057 1:04:43

for 11 weeks siden1:04:43

1:04:43

Not quite happy or set with being a GDP? Have you just started as a GDP and want to streamline your learnings for a brighter future? Is an MSc the right plan of action for you? How important are mentors in all of this? In this episode we discuss Dr Kiran Shakla’s journey from University to Australia to working as a Dentist at a Specialist Practice. She shares with us her top tips on how Dentists can make the most of their weekly schedules and reduce stress while dealing with different cases. https://youtu.be/IiecXSpsJmc Watch IC057 on Youtube Key Takeaways: Hard work and determination are key to success in dentistry. Work-life balance is crucial for long-term satisfaction in dentistry. The first ten years post-graduation are vital for career development. General dentistry can be fulfilling without the need for specialization. It's important to recognize when to refer patients to specialists. Kiran emphasizes the value of personal growth and continuous learning.. Finding joy in everyday practice is essential for a sustainable career. Australia taught me valuable skills in private practice. Private dentistry focuses more on patient care than money. Communication is crucial for patient satisfaction. Finding mentorship can be challenging but essential. Shadowing experienced professionals enhances learning. Balancing work and education requires sacrifices. Need to Read it? Check out the Full Episode Transcript below! Highlight of this episode: 02:34 Introduction to Dr Kiran Shankla 06:18 Correlation between Uni and the Real World 07:29 Selling a Dream 10:13 Going Hard Early 12:43 Taking Work Home 14:55 General Dentistry 20:48 Kiran’s Journey 24:23 What did the experience teach Kiran? 31:33 Mentoring 34:38 Work Schedule 37:38 Bone to pick with Master's 43:33 Orthodontic Position 48:53 Working with Nurses 54:33 Networking 56:33 Wrapping Up Connect with Dr. Kiran on Instagram! This is a non-clinical episode without CPD. For CPD or CE credits, visit the Protrusive Guidance app—hundreds of hours and mini-courses await! If you liked this episode, check out: Stress in Dentistry 2024 – Life Changing Decisions – IC048 Click below for full episode transcript: Teaser: They don't have the clinical skill, but they've seen so many people do it, they know what works and what doesn't. And if you get on with them and if they can teach you something, it's like going on a course and someone, I could have paid to go on a course for someone to teach me how to do that. Well, why would I, when my nurse has seen it done a hundred times and she's like, Kiran, this is how it's done. Come on, I'll help you. Teaser:If anyone stops saying, I don't know which course to do. This is another course you can create. And you know, often, it's a secret. It can be free. Often it can be free because there's so many lovely people out there that are willing to say, you know what, if you want to shadow me 12 times in a year on this, like, once a month, I'm happy. You don't have to pay me anything yet. Some people will charge and that's okay. That's worth it too. But if it's free, wow. And if even if it's charged, it's still worth it because to be able to shadow you learn so much. Jaz's Introduction:Being a general dentist is the toughest gig in dentistry. You have to literally be good and know everything. In this episode I'm joined by Dr Kiran Shakla, a general dentist just like me, and we talk about her journey. I feel there's so much we can learn when we dissect an individual's journey. And Kiran's mindset is really quite special. It's really going to inspire anyone who's in the early stages of their career. Or even if you're established in your career but you're not quite happy, you're not quite settled, you have that itchy foot like Kiran had, then this episode will be really helpful to you. You see, Kiran takes massive action.…

Protrusive Dental Podcast

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So You’ve Decided to Specialise? – IC056 52:15

for 12 weeks siden52:15

52:15

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 hisdevelopment.- 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. Need to Read it? Check out the Full Episode Transcript below! Highlights of this Episode:00:00 Teaser02:38 Intro to Dr Beant Thandi04:03 Dental Journey06:10 What Influenced You?12:56 Too Young to Specialise17:50 Judgement by Jaz21:00 Never too Young26:05 Cost of Specialising28:23 Why not the USA?31:30 Roasting Prostho34:45 Roasting Endo37:42 Roasting Ortho39:49 Roasting Oral Surgery45:00 Shoutout to Lucy45:30 Final Thoughts47:28 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. Click below for full episode transcript: Teaser: But one thing I learned from a nurse when I was doing a DCT job was people all progress at different rates. It should be competency based, not necessarily time based things. People learn at different rates. And this was a max fax nurse who's obviously seen regists for decades, where I'm sure like, the junior regists are better than the senior regists. Just because they soak it up more. [Jaz]The whole pros element, right? Multiple crowns, four rehabs, lots of general dentist do four rehabs, lots of general dentists do all on fours, that kind of stuff. So, nowadays it's like blurred lines between, okay, what do they actually need a Prosth for? However, prosth, I think they're very employable. However, lots of people who do an MClinDent Prosth end up being general dentist. We're just like really good general dentists in practice and still doing checkups and stuff. I have seen that. [Beant]The fees are 37 and a half thousand pounds a year and they're subjects- [Jaz]For a home student. [Beant]This is for a home student. I'm a home student. [Jaz]What? How much is it for an international student? [Beant]60, 000 pounds. Jaz's Introduction:I think every dentist in the world at one stage of their career has thought about specializing. And most of us never do, right? About 90% in UK anyway are general dentists or at least non specialists. Only 7% actually enter specialist fields of dentistry like perio, prostho, endo, oral surgery, you name it. How do we decide whether specialty training is for you? There are huge sacrifices one must make both in terms of time and finances. And how can you be sure that you really want to niche and narrow your scope of practice into that one field that you might choose? Is the best time to specialize like straight after dental school? Or is it good to gain a few years experience or many years of experience before you ...…

Protrusive Dental Podcast

1
Health is Wealth (Wellbeing, Diet and Stress) – IC055 1:03:42

for 13 weeks siden1:03:42

1:03:42

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 Intro04:25 Introduction to Dr Simon Chard10:10 Why is Dentistry so Stressful?14:00 Therapy for Dentists19:20 Strategies for Mental Resilience25:20 Mindfulness31:57 Intake40:32 Love45:12 Value Based Calendar48:32 Exercise51:57 Managing Everything54:34 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 c...…

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