Basics of Indirect Restorations Part 2 – The Crown Fit – PS007

You’re doing a routine exam when you spot it – a stained hairline crack snaking across the marginal ridge of a molar. Your patient hasn’t mentioned any symptoms… Yet. Should you sound the alarm? Monitor and wait? Jump straight to treatment? Cracked teeth are one of dentistry’s most misunderstood diagnoses. Colleagues debate whether to crown or monitor. And that crack you’re staring at? It could stay dormant for years—or spiral into an extraction by next month. So what separates the teeth that crack catastrophically from those that quietly hold together? In this episode, I am joined by final-year dental student Emma to crack the code (pun intended) on cracked tooth syndrome.  We break down the easy-to-remember “position, force, time” framework to help you spot risk factors before disaster strikes, and share a real-world case of a 19-year-old bruxist whose molar was saved by smart occlusal thinking. If you’ve ever felt uncertain about diagnosing, explaining, or managing cracked teeth, this episode will change how you think about every suspicious line you see. https://youtu.be/mU8mM8ZNIVU Watch PS019 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Risk factors include large restorations and bruxism. Occlusion plays a significant role in tooth health. Diet can impact the integrity of teeth. Every patient presents unique challenges in treatment. Communication about dental issues is key for patient care. Certain teeth are more prone to fractures due to their anatomy. The weakest link theory explains why some patients experience more dental issues. Patient history is crucial in predicting future dental problems. The age and dental history of a patient influence treatment decisions. Understanding occlusion is essential for diagnosing and treating cracked teeth. The location of a tooth affects the force it experiences during chewing. Bruxism increases the risk of tooth fractures. Tooth contacts and forces play a critical role in diagnosing issues. Opposing teeth can provide valuable insights into tooth health. Effective communication is essential in managing cracked teeth. Stains on teeth can indicate deeper issues with cracks. Monitoring and documenting cracks over time is crucial for patient care. Highlights of this episode: 00:00 Teaser 00:49 Intro 03:25 Emma’s Dental School Updates 07:18 What is Cracked Tooth Syndrome (CTS)? 10:02 Crack Progression and Severity 12:45 Risk Factors 14:54 Position–Force–Time Framework 21:53 Which Teeth Fracture Most Often? 25:32 Midroll 28:53 Which Teeth Fracture Most Often? 30:37 The Weakest Link Theory 34:05 Diagnostic Tools 37:56 Treatment Planning 39:42 Case Study – High Force Patient 47:27 Communication and Patient Management 51:03 Key Clinician Takeaways 53:03 Conclusion and Next Episode Preview 53:42 Outro Check out the AAE cracked teeth and root fracture guide for excellent visuals and classification details. Literature review on cracked teeth – examines evidence around risk factors, prevention, diagnosis, and treatment of cracked teeth. Want to learn more about cracked teeth? Have a listen to PDP028 and PDP098 – both packed with practical tips and case-based insights. #BreadAndButterDentistry #PDPMainEpisodes #OcclusionTMDandSplints This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.  This episode contributes to the following GDC development outcomes: Outcome C   AGD Subject Code: 250 – Operative (Restorative) Dentistry Aim: To help dental professionals understand the causes, diagnosis, and management of cracked teeth through a practical, evidence-based approach. It focuses on identifying risk factors using the Position–Force–Time framework and improving patient outcomes through informed communication and tailored treatment planning. Dentists will be able to: Explain the aetiology and progression of cracked tooth syndrome Identify high-risk teeth and patient factors—such as restoration design, occlusal contacts, and parafunctional habits—that predispose to cracks Communicate effectively with patients about the significance of cracks, prognosis, and monitoring options, improving patient understanding and consent Click below for full episode transcript: Teaser: Sometimes, you have a tooth position problem. Sometimes you have a tooth force problem, and sometimes you have a tooth contact time problem. So time, force, position. A crack is an end product of overload. So risk factors for cracked teeth, right? Teaser: So if we think, again, that is to do with overload, right? When you have a patient who’s got large amalgam restorations, MOD, I don’t remember the last time I removed an amalgam and I didn’t see a crack underneath. Why is it that maxillary premolars are more likely to crack than mandibular premolars? This is really fascinating. If all you do is remove the crack and put a composite, the composite will also fail through overload eventually. So you must change something about the environment to reduce the crack propagation. Jaz’s Introduction: I’ve been involved in dental communities for many years now. I run my own community, the Protruserati, Protrusive Guidance. And one of the questions that keep propping up week by week, month by month, year by year… it’s just all seasons, all time, is about cracked teeth management, diagnosis, cracked tooth syndrome, and getting very patient specific, describing the symptoms and signs, and all the discussions are about cracked teeth. So there’s still obviously some uncertainty about the best way to diagnose and manage cracked teeth, which is why we created this episode. I know it’s part of the PS, Protrusive Student series, but honestly, the way I ended up explaining cracks in my philosophy and the way I think about how cracks form and how the management very much depends on so many patient factors is pretty unique, I think. I don’t think I’ve ever spoken about cracks in this way, and I think it ended up being a really wholesome episode. Again, thanks to some wonderful questions from our student, Emma. Now, alongside this episode in the show notes, we’ve put together some essential reading and some great PDF, excellent data and visuals on cracked teeth, and I mentioned a good review, literature review on cracked teeth. That’s also referenced in the show notes. If you are watching or listening on Protrusive Guidance, just scroll below and download it. And if you haven’t yet joined the community, what are you waiting for? We’re waiting for you on protrusive.app. I really enjoyed recording this episode, Emma, and I hope you enjoy listening or watching it. Oh, and this episode is eligible for CE. There was so much substance. So whether you’re gonna collect CPD hours or CE credits, whoever you are in the world, this episode is eligible again through the Protrusive Guidance app. Let’s catch the main episode. Main Episode:Emma, the Protrusive Student. Welcome back to the Protrusive Dental Podcast. It’s so nice to have you. We’re talking about cracked teeth today. Look, I can talk about cracked teeth for days. It’s something when I, in the early episodes, one of the early episodes, it’s titled I Hate Cracked Teeth. I still hate cracked teeth. We all hate cracked teeth. No one likes cracked teeth. But you know what? Over the years, I’ve learned so much about cracked teeth, and now I’ve got some things to share with you and I’m really excited to share with you that will really change how you approach cracked teeth and how you communicate cracked teeth and all that kind of good stuff. But what I wanna start with is what’s more important to you as a student? You are connected to students and young dentists better than I am. You are right there in the trenches, okay? Like asking these questions that no one wants to ask anymore because they’re afraid to ask, right? Because, hmm, maybe I should know this already, but you have no fear, no shame because you’re a student, it’s fine. So it’s cool. Like, you don’t have to know everything. And so you are in a position to ask, to represent everyone and ask those questions. So firstly, Emma, tell us, give us an update. How’s final year going at uni? [Emma]Yeah, final year’s going good. Just the same as when I caught up with you a couple weeks ago. It’s just our finals are out the way, so I’ve got a lot more time in the evening to sort of decompress and focus on the things that I know will be in my book the day after. If I’ve got a crown prep or something or something that I need to look up on, I know what I’m gonna be doing. I can go home and I can focus on that for the next day rather than stressing about exams. But it’s good. It’s going really well. It’s going good. I’m enjoying it. [Jaz] Good. You made me remember something, right? Like I was just trying to remember how long does it take for you not to… like for example, I remember being a student, and you get a root canal the next day, you’d have to like revise the steps for a root canal. Did you do that? [Emma] There’s a lot of things that I don’t do that for anymore, where I probably would’ve in about third year or something like that. But for something like root treatment, I’ll always just remind myself, just look over, make sure that I know. ‘Cause I’m always gonna be asked questions, so just to keep on top of everything. I do still do that, yeah. [Jaz] I won’t forget, Emma, I was playing FIFA. That’s what we did. With that clinic, we’d come home, we’d play FIFA. That’s all we did. So maybe, I dunno if student life’s changed yet for the guys or not. But that’s kind of how we lived life. And so I remember playing FIFA and it was like 20 minutes to go until my clinic starts, right? Okay, one more match. One more match kind of thing. And I was there, I was living in the fifth year. I was third year, and I was just revising with him, okay, I’ve gotta wax your registration for complete dentures. Let’s go over the five things I wanna check for while I’m button-mashing and playing kind of thing. So it’s just-in-time learning, it’s revision. I was just trying to remember, as a dentist, a qualified dentist, how long did it take me before I was comfortable not even looking at my day list anymore, and whatever life’s thrown my way, I’ll be able to deal with it. And it’s a good number of years, maybe 5, 6, 7 years until I got to a stage where, you know, whatever comes through my door now, it’s okay, I got this. I think the only caveat here is if you go down the path of comprehensive dentistry, right, and there are multiple steps involved and long appointments. You have to do your due diligence. So sometimes you’re checking the day list not to like, oh, let me revise the steps for how I’m gonna raise the OVD and do the mockup and preps, or whatever. It’s more, has the lab delivered the lab work? Let me make a checklist to make sure that my nurse is gonna be happy supporting me on that day for that treatment. It’s other challenges that it brings. So it’s all fun and games as long as you relish it and enjoy it. And part of the enjoyment is that every patient is different. Every patient has unique challenges. Even cracked teeth in one individual is treated completely differently to a cracked tooth in another individual. So with that, Emma, what would you like to know about cracks? [Emma] Yes. So this idea about cracked tooth syndrome episodes came to me because it was one of the first questions we had in our finals, and it was one of the last lectures that we ever received in fourth year. And you know, at the very end of— [Jaz] So what question? What’s a typical finals question look like about cracked teeth? Amuse me. [Emma] So I think for one of the—so the topic was cracked tooth syndrome, and one of the first questions was: give me however many modalities of diagnosing a cracked tooth, signs and symptoms, things like that. I’m one of those people that typically forget everything that is asked as soon as you walk out of an exam. But I remember this one, and I remember it because it was one of the last lectures that was given to us. And because it was the last one, it’s not something that I really looked over. It was the first question. I’m sure it was one of the first questions in the paper, and I was like, oh no. [Jaz] You were kicking yourself. [Emma] Yeah. Yeah, I was kicking myself. So the first question I had for you was just, in your own terms, what is cracked tooth syndrome and does it differ from like a fully split tooth? [Jaz] Okay, great question. So cracked tooth syndrome is a set of symptoms and signs that tell you—that’s why it’s called syndrome, right?—it’s a set of symptoms and signs that lead you to a diagnosis towards, okay, this tooth is cracked, and that’s the cause of the symptoms. Symptoms could be like cold sensitivity, hot sensitivity, classically pain on biting, especially on the release. So that’s like the classic syndrome, and then you kind of make that diagnosis. The reason why it’s difficult to diagnose sometimes is because it’s not easy for patients to pinpoint exactly where the pain’s coming from. Quite often with pulpitic pain, like, it’s somewhere around here, and as you know, it spreads. And that’s the pulp involvement. The other one is that these cracks can sometimes be very difficult to see, and only when you start wearing more magnification, and like literally more and more magnification, you can start to see it. And just because a crack looks innocuous doesn’t mean it can’t actually be responsible for the patient’s pain. So these can be some challenging factors. Now, how does cracked tooth syndrome differ from a split tooth? Well, split tooth is like—imagine a spectrum, right? Split tooth is like, okay, this tooth is absolutely shot. Split tooth is like vertical root fracture in a way. So it’s completely split, it’s vertical root fracture. So on one end of the spectrum, that is like completely hopeless prognosis. Is that what you’re expecting with split tooth? [Emma] Yeah. So from my understanding, like cracked tooth syndrome, you know, you can have pulpal involvement, but you don’t need pulpal involvement to still get symptoms. But then if you’ve got like a fully fractured tooth, I don’t know if that would even come under like cracked tooth syndrome. I don’t really know. [Jaz] So split tooth and vertical root fracture… like the difference between them is kind of academic. Like what started it? The end result of both those is that the tooth is for the bin, right? It needs the forceps. So just like what I’ll do is, in the show notes and in the student section of the app, I’m gonna put the American Association of Endodontics’ whole guide. They’ve got on cracked teeth, really good visuals, absolutely fantastic. And the way it shows visuals for a split tooth is something that starts by the cusps and the crack goes all the way down, and then the tooth is like in two pieces. Imagine a premolar with the buccal cusp and the lingual cusp like completely split. And now that tooth’s unrestorable. Whereas a vertical root fracture, we commonly associate with like an upper central that’s got a metal post inside. The crack started at the point of where the post is, right where that stress is. So it’s subgingival, and the crack extends upwards. So either way, when you look at the end product, they’re both shot. And they’re kind of like massive cracks. So though at one end you’ve got the split tooth and vertical root fracture, but they all have to develop into that. There’s often the initial crack. Now ignoring the whole vertical root fractures, go with split tooth: every split tooth begins life with a more innocuous crack, higher up by the cusp. And if you are lucky, if a patient’s lucky, the direction that that crack travels… it kind of goes like, let’s say marginal ridge, but then it starts to go more buccal or more lingual. So if it’s going more buccal or lingual, what will be sacrificed when that breakage event happens? When that force exceeding event happens? What, Emma, will be sacrificed? [Emma] So one of the cusps. [Jaz] Exactly. So that’s when you get someone coming in and the cusp is broken off. You must have seen that, right? [Emma] Yeah, yeah. [Jaz] So that’s fine. But if the patient’s unlucky and the trajectory of that crack is going straight down, straight down into the gingiva eventually, and then it’s going through the floor of the pulp chamber, if you like, and eventually the whole tooth is being split… that’s way more advanced. So there is like the very tiny crazing in enamel, then there’s a crack that goes further into dentine. Then that crack kind of propagates and propagates and goes spread across, and it goes subgingival. And our job is to really intervene in a timely manner. So it’s a difficult one because if we all lived to age 400, right? Then every one of us, no matter how much low force you produce, or I don’t clench or whatever, every one of us would all have cracked teeth, split teeth, if you live to age 400. Now, some people, they generate so much force or various other factors, anatomical as well, that they’re able to split a tooth in their forties, whereas someone in their eighties may do it as well. But it kind of depends on what kind of pressures. Ultimately, a crack is an end product of overload. Overload is a process. There has to be some degree of overload that is beyond the adaptation of the enamel and dentine. That flexure. If you imagine a molar, Emma, and when every time you’re chewing, there is—believe it or not—the cusps are like moving away from each other. The tooth is flexing. It’s hard to imagine, but when you start getting a crack, okay, then those cusps, they start to flex even more. Like because imagine microscopically, they’re waving around. And then as the crack gets bigger and bigger and longer and longer, that sort of waving around gets more and more, and then that just makes the situation worse. [Emma] Yeah. So I was going to ask as well about particular risk factors. So I’m guessing the number one is things like bruxism, parafunctional habits, things like that. I was also gonna ask if there’s certain teeth that are more commonly affected, like i.e. molars more than a central, like more force put on those teeth. [Jaz] Okay, these are great questions. Let’s do it in two parts. Okay. So risk factors for cracked teeth, right? So if we think, again, that is to do with overload, right? When you have a patient who’s got large amalgam restorations, MOD, I don’t remember the last time I removed an amalgam and I didn’t see a crack underneath. It’s just the nature of it. You’ve got this stiff, really strong metal restoration, okay? And every time the patient’s chewing, those cusps are flexing. That metal’s not bonded to the tooth. Those cusps are flexing, and often those big MOD cavities, they render the walls very weak and flexible. Therefore, you are more prone to getting a crack. So if you already have a large restoration inside the tooth, that’s like more than a third of the isthmus, if you like, classically, as they say, right? So the bigger the restoration in the kind of buccolingual direction, and the deeper the restoration, the more the tooth’s gonna crack. It’s a bit like if you get a virgin tooth and you do those experiments that you see whereby they load and load and load a tooth until it cracks, okay? You know that the virgin tooth is going to survive until a very high load, whereas the tooth that has essentially got a big hole cut down the middle—because all you’re replacing that hole with is metal—metal’s not protecting that tooth. So essentially you have this naked tooth with a giant cavity, and you’re loading it. You can imagine that at 20% of the force of what it would’ve taken to break the virgin tooth, that tooth’s gonna split completely. So having a large restoration is absolutely a risk factor. The other risk factor—and sometimes I see cracks on virgin teeth, so teeth are completely unrestored—and this is a red flag for a high-force patient. If you see cracks on virgin teeth, then that is something to really pay attention to. So this could be someone… and what I like to do in my occlusion stuff that I teach, this is how I like to break it down. Please, Emma, let me know because very few people have heard this spiel. I’m working on like the ultimate occlusion lecture 2025, 2026, like every year trying to make… break down the occlusion. And this is my new way of presenting it. So let me know what you think. First person ever to hear it, right? If we—like obviously the joints are very important, and if you change anything about both joints or one joint, both TMJs or one TMJ, then you change the occlusion, okay? But when we’re students, young dentists, it’s very difficult for us to think in that kind of plane. You wanna just… let’s think dental for a moment. Let’s think the teeth together. And sometimes you have a tooth position problem. Sometimes you have a tooth force problem. And sometimes you have a tooth contact time problem. Time, force, position. So stay with me now. With the position, if two teeth—let’s imagine premolars, because that kind of leads onto your second question about which teeth are at risk of fracturing. Well, premolars: classically very steep cusps, okay? And if you keep loading it, they flex and they’re very prone to vertical root fractures and split tooth. The premolars are very prone to that. But let’s imagine upper premolar. When you bite together, the buccal cusp or the cusp tip of that lower premolar sits right in the middle of the fossa. The cusps are not bending, they’re not asked to bend in any way. However, if the lower molar is a little bit off and maybe it’s a little buccal position, can you now imagine that with the upper premolar, the force contact is not in the fossa? It’s somewhere up the buccal wall. Do you know what we call that contact? Go on. It’s called an incline contact. Don’t worry—I had no idea when I was on stage. I had no idea it was called incline contact. [Emma] No, I didn’t know that. I didn’t know that. [Jaz] It’s an incline—but can you imagine what I mean? Like it’s not in the flat area, it’s on an incline, right? So you can imagine you’re loading the incline. And what’s that incline exacerbating? What’s it encouraging? It’s encouraging that buccal cusp to flex away from the tooth. So that is a tooth position problem. Loads of our patients have really suboptimal occlusions. They’ve got incline contacts everywhere. In nature, we see incline contacts. So why isn’t everyone destroying their teeth? Okay, well, because position is one factor. It’s not the factor. It is one factor. So tooth position and the malocclusion can predispose someone to a crack. Number two is tooth force. Can you guess or extrapolate where I’m going with this tooth force? [Emma] Bruxism habits. [Jaz] Bruxism, yes. But bruxism is also linked to the third one, which is tooth time contact. But yes—so essentially you’re putting… you’re overloading. So clenching, okay? So act of clenching, getting your masseter and temporalis and medial pterygoid. So that one’s linked more to the tooth time contact as well. When the patient’s elevator muscles contract, a force goes through the teeth, and so the more force you put through a tooth, the more you are overloading that tooth. And so yes, clenching is one, but also a patient who’s got large hypertrophic muscles, square jaw… you can imagine that they’re gonna put more force through their teeth. Now, I don’t know of any great evidence that, Emma, your tooth, your premolar, your first premolar, is way stronger naturally than my first premolar. I don’t know if that’s true. I don’t know if like you put your tooth in the machine and put my tooth in the machine that genetically—unless we have like amelogenesis imperfecta, that kind of stuff. But let’s assume that me and you, our first premolars are very similar. Maybe 1 or 2% difference. Genetic variation. Maybe Scottish enamel is stronger than Afghani enamel. So it’s probably true. So you can imagine that there might be minor difference, but if I have got like strong muscles—which I do—in my jaw, and if I’m clenching a lot and you are not… The lifetime of how much force is gonna go through that tooth is different. So it’s force. And then that also ties in with diet in a way. Now I don’t buy that, oh, we should avoid eating nuts. But however, the harder the food you eat… imagine trapping some food between your premolars. Like imagine you put an almond between your premolars, and then you bite and you crush it. What happens is that the teeth overload the almond. The almond doesn’t overload our teeth. Our teeth overload the almond. However, to be able to produce that load to crack the almond, some load had to be received into the premolars. Now if you have a very big, hard diet… I mean the worst are ice chewers. Imagine someone who just chews ice. So you have to constantly break ice, and how you’re breaking it—you’re breaking it with your cusps. What your cusps have to do every time you clench together… they have to flex. So you are promoting cusp flexure. So diet actually plays a role as well. Someone who’s an ice chewer, eating a lot of nuts—they are more likely. Okay, it’s not the only thing, but if they’re also clenching, if they’ve also got incline contacts, you can now imagine all those factors add up to someone having more cracked teeth. The other one that goes hand in hand back with tooth position is the fact that some people have steeper cusp angles and other people genetically have shallower cusp angles. Can you figure out why this may be significant? [Emma] If you’ve got deeper cusp angles, are you more likely to have that sort of incline contact? [Jaz] Well, well done. You’re more likely to have an incline contact, but also the following. The patient, when they chew on ice or an almond… when you’ve got steeper inclines and you chew on it, there’s more flex, there’s more pressure going in right in the middle, and there’s more flexure versus a shallow one. And also imagine if I give you like a model of a tooth, one with steep angles and one with shallow angles, and I told you, you have to break it with your hands. The one that’s got steep— you get it, and you kind of wedge in between and you can break it way more easily. If I give you a flat tooth and I say break this flat tooth, what are you gonna grip onto to break it? It’s just physics, right? So it’s just physics. And so the last one is tooth time contact. It goes back to if someone’s touching their teeth together for 18 minutes a day and that’s it… that’s completely different to someone who’s doing it for four hours a day, or three hours they’re touching their teeth together. So not one of these factors is more responsible than the other, but all of these together are resulting in overload of individual teeth. And the systems, the muscles get overloaded, right? Everything is a system. Has this helped you to maybe—and be honest, Emma—is this useful to think about it in terms of tooth position, tooth force, tooth time contact, in terms of the scope, the triad of what can happen to a tooth? [Emma] Yeah, I would think so. It almost reminds me of like those diagrams and you see the triangles. That’s what I’m picturing in my head, but I think that’s so interesting, especially about the almond analogy that you used there. I’ve never really thought about it like that before, and people’s diets and things. That’s really, really interesting. [Jaz] I’m looking forward to making like an introduction to occlusions, and there’s one way to explain it, and then I wanna bring the joints into it and the muscles and describe symptoms, talk about the importance of adaptation, the variables in occlusion. So that’s a little starter piece, so I’m glad you like it. Now, going with that, there are certain teeth that are, just evidence-based, more likely to fracture than others. First premolars—very prone to fracture. And so these are teeth that are more prone to splitting. So first premolars. Second molars. So first three molars because of that steep angulation that they have often. Second molars. Can you guess why second molars? [Emma] Just a large amount of force generated on the seat? [Jaz] Correct. Why is there more force being perceived through a second molar? [Emma] Closer to the TMJ, like the Nutcracker analogy. [Jaz] Perfect. It’s closer to the fulcrum, the TMJ. The muscles are right there as well. Like actually, where is your muscle? It’s right there. But your muscles are right there. And then also when you’re gonna chew ice, where are you gonna stick it? Stick it between your back teeth, right? You put the ice right between your sevens and go for it. And also if there is bruxism, you’re clenching, squeezing together, then that cusp flexure and the contacts and the strain absolutely is felt on those. Now this is all from my memory, right? It’s first premolars, second molars. I’m trying to think. And then I think it’s first molars. I’m going to now validate this. Let’s do a validation. So we’re gonna validate this, guys. I’ve been talking now, and this is from memory. But let’s see if I’m right. I probably have made a mistake somewhere. But let’s see—cracked teeth, a review of the literature—and let’s see what it says. Lovely. Good. Oh, you see—so those of you listening, there’s some great visuals there. Again, I’ll share this paper in the show notes. So when I share the American Association of Endodontists’ guide on cracked teeth, which is awesome, and this paper as well. And let’s find out. I think it’s lower mandibular molars. So it talks about different prevalence of incidences. Most of the studies reporting the incidence or prevalence of incomplete tooth fractures agreed that cracked teeth were significantly associated with intracoronal restoration. So that’s the first thing I said, right? If someone’s got a large restoration, it will crack. And were most prevalent in mandibular molars. Mandibular molars. So second molars and first molars. The highest prevalence rates appeared in patients over 40 years. So there we are, okay. So why is that significant? Why 40 years? Why not 18 years? [Emma] Just over time. [Jaz] It’s that third part, the triad, right? [Emma] Yes. [Jaz] It’s tooth time contact, right? Not only just during the day, but extrapolate it throughout life. And so women—okay, I have no idea why women—women being more affected than men. I think women are just more stressy. I dunno if I’m allowed to say that. Am I allowed to say that? Is that sexist? [Emma] Oh, no, that’s fine. [Jaz] I can’t speak for women. I’ll speak for just my wife only. My wife is more stressy than me. Therefore, she’s more likely to get cracked teeth than me. There we are. Fact, okay. I can’t generalize about any genders and that kind of stuff. Although one study showed an almost—I’m gonna get cancelled on—almost equal distribution between gender groups. Fact. They’ve got a little table in this study, right? And it looks like the study author, the tooth type, the incident rate… so mandibular molars, overwhelmingly the most likely to crack. And then followed by maxillary molars, and followed by maxillary premolars. But look here, how rarely mandibular premolars fracture, relatively. Can you figure out why that’s the case? [Emma] For the mandibular? [Jaz] Yeah. So why is it that maxillary premolars are more likely to crack than mandibular premolars? This is really fascinating. [Emma] I’m just putting, I guess, forward, something to do with different bone densities down there, or you’ve got a more amount of bone on your mandible. I don’t know. [Jaz] That’s an interesting one, Emma. You know what? It could have something to do with that, but here—oh, here’s another. This is so good. So another thing you reminded me of is, have you seen many perio patients? [Emma] A few, yeah. [Jaz] Okay. I dunno if you are maybe too young to have made this observation. And I’m hoping some of the more experienced colleagues can be like, “Oh yeah, I’ve seen that,” is: our perio patients don’t tend to get cracked teeth. Their teeth look beautiful. Their teeth anatomically don’t look worn and they don’t have cracks. They just look stunning. I dunno if you’ve noticed that. [Emma] No, I haven’t noticed that. No, not… [Jaz] Okay. So this is going back to something called the weakest link theory. Okay. Now we’re gonna pause that for a second. You’re saying you’ve seen the lectures on OBAB, so okay, well we’re talking about that. We’ll come back to that in a moment. So we’ll come back to the weakest link theory in a moment ’cause you made a great point there. But the point I was gonna make is: the reason why mandibular premolars… go back to anatomy, right? If you feel your lower first premolar, look how tinchy that lingual cusp is. There’s nothing for food or a cusp to come into and split the tooth. If I had a giant version of a lower premolar in my hand and I had to crack it, I’d really struggle to crack that. Whereas a maxillary first premolar—oh yeah, I can grip on those cusps and really go for it. Okay, it’s in the anatomy of the teeth, which is really, really interesting. Again, this is consistently reproduced in the studies that I’m seeing here. Mandibular molars—most crack. Followed by maxillary molars. Closely followed by maxillary premolars. And yeah, mandibular premolar is very rare. So isn’t that just a fascinating observation? [Emma] Mm-hmm. Yeah. It’s strange. [Jaz] So now we’ve answered your second question. Now let’s just touch on the weakest link theory. The weakest link theory says that—and it’s just a theory, but I love it because it explains our perceptions and what we see in the populations—which is that when you observe your patients, they’ve got something like: when there’s overload in the teeth, there are certain systems that are affected. So it’s either the periodontium that’s suffering the system, or it’s the muscles and the joints, or it’s the teeth—whichever is the weakest link. And quite often you have two of the systems affected together. Very rarely you have all three systems. So let’s break this down. How does this actually work? And I think it’s best explained by: why is it that the periodontal patients don’t often get cracks? Or can you figure out, Emma, why a perio patient is less likely to get cracks and wear? [Emma] So over time their teeth are gonna become more mobile and almost move out of the way. They’ve got a bit more give in the PDL. [Jaz] Exactly. So when there’s more give, when there’s softer bone, when there’s mobility and you are chewing on something hard… the pressure has to dissipate somewhere. Now on the opposite end of the spectrum: that big bloke with mandibular tori, hard stiff bone that you are afraid to do an extraction on because you stick a luxator in and nothing is budging. Your luxator is gonna break, but the tooth’s not going to budge, right? That’s the patient that gets the cracks. Because when they’re chewing, the bone is not helping. The bone is not absorbing the force. The PDL is not absorbing the force, so the force is going into all the stress in the cusps. But when you have a system or a patient whereby they’ve got a bit more give in the system, instead of the cusps flexing, it’s the PDL taking the load away. I think we’ve touched on this before, Emma, previously, but it’s worth mentioning again that someone who’s got a grade one or grade half mobile tooth—that patient, if you use that tooth as a resin-bonded bridge abutment—will be more successful than a patient who’s got no mobility and you use that tooth as a resin-bonded bridge abutment. Because when he loads that bridge, the patient who’s got really stiff, hard teeth or hard bone, and there’s no give—when you load that pontic, all the load is absorbed by the lute, by the cement. But when you’ve got the mobility and you’re chewing, some of the pressure is eased off—is absorbed by the PDL before it actually gets to hit the cement. It’s the same kind of concept, and that really helps to explain cracked teeth. I’m really enjoying this. I’m hoping you are. [Emma] Yeah, yeah. No, it’s really, really interesting. I’ve never really thought about it. I know about the weakest link theory, but I never really thought to bring that into cracked teeth and things like that, so that’s quite interesting. Another question that I did have for you, Jaz, which you might find boring, but we had in an OSCE scenario—it must have been BDS2 or BDS3. It was about diagnosing, I think it was cracks in teeth from memory. Just like, extra points if you can answer these kinds of questions. And I know that the answers are a Tooth Slooth, a bite test, transillumination, but I’ve never seen—I don’t even know if that’s available in Glasgow Dental Hospital—transillumination. Is that something that you’ve ever, ever used before? [Jaz] You know what, Emma? I’ve actually never used transillumination, okay? I’ve just never had it. I’ve actually got the tip, I’ve actually got the tip that you put in your… but quite often it’s a different light source or something, and I never bought it. I didn’t have access to it, so it’s one thing I haven’t used. But I know that the light kind of stops, it doesn’t go through, because there’s a break in the crack, and there’s a very characteristic appearance. So no, I haven’t used it, but it can be quite helpful. I’ll tell you what’s really helpful to me: just really high magnification. At least five times, eight times better. At least five times. Dry teeth and having a really good look. Good photography as well, and you’ll be able to pick up these cracks, even virgin teeth. And sometimes it’s difficult to see if they’re not stained, but when they’re stained, they’re further along the pathophysiology. When your probe is getting in there, that’s really bad news. You’ve left it too late. You are really now reactive and not proactive anymore. Even though the patient’s having no pain, if you can feel a crack with a probe… I think Pascal Magne said it’s something like 200 microns or something like that. So Pascal Magne taught me that if your probe is getting in the crack, that’s like 200 microns at least resolution. Whereas when you’re using high magnification, you can actually detect cracks that are way smaller than your probe ever could. So if you’re just relying on your probe, you’re leaving it too late. You really need high magnification. I don’t trust any dentist that doesn’t use loupes, honestly. Like you must. I wouldn’t let anyone near my mouth without magnification. [Emma] Fair. Okay. So is a Tooth Slooth something that you have in your surgery? [Jaz] Oh, of course. Yeah, yeah, yeah. I think Tooth Slooths are very common. They’re autoclavable, they’re very readable. And so I think that the good thing is you can test cusp per cusp. And then the patient bites together. And then one cool thing that Karina taught us in that episode—I think it was episode 28, all those years ago—is that what I used to do is: you put the bit that slots onto the cusp to get the patient to bite together. But then just give it a tiny wiggle. Give it a tiny wiggle when the patient’s biting together. That helps with your diagnosis basically. So Tooth Slooth is one aspect. Doing cold testing, see what kind of response you get. Visually taking a look. Yes, there’s transillumination, but it’s something I don’t have experience with. But very often, it is like, you know the epidemiology. You know it’s mandibular molars, maxillary molars, maxillary premolars. You kinda know which teeth are more likely. And then you look at the patient. You look like, okay, if they’re missing teeth on the other adjacent side, find out why were they taken out. Because quite often, it’s like someone who’s had difficult extractions in the past—that’s the best predictor of a difficult extraction in the future. Is that right? And so if you’ve lost teeth to cracks before, then you’ve got… not only do you have to be more vigilant, but you have to then consider that, okay, I’m probably dealing with a cracked tooth again. The past is the best predictor of the future. [Emma] Okay. And if you see a crack in a tooth and if you’ve got a radiograph and you can’t see much on the radiograph… [Jaz] You won’t. So with a radiograph, it is very rare. I’ve got a radiograph I took this year that shows a crack beautifully, because the crack—the plane of the crack—just happens to be exactly going down the plane of the X-ray. But very rarely does that ever happen, basically. So it’s extremely rare. It can happen, though. But very often we are only taking a PA just to confirm what is the apical situation, okay? But the radiograph is not gonna help us that much when it comes to crack diagnosis. It’s a clinical diagnosis. [Emma] Okay. And if you’re seeing no periapical pathology on the radiograph, is often treating that crack and the symptoms in the tooth going in and removing the crack and seeing where you end up? What’s sort of the treatment options for that? [Jaz] Really good question. Because now we’re getting into decision-making treatment planning. This is a wonderful question. And like with everything complicated, everything occlusion, that kind of stuff, it depends, unfortunately. But let’s talk about what it depends on. Because if you just leave it as “depends,” then that’s no good. But if we talk about: okay, what does it depend on? And play different scenarios. And I’ll give you real-life scenarios. I have a 19-year-old patient. She’s got huge masseters. Huge. She is a major clencher. I’ve confirmed on something called a brux checker, and I’ll put the image here. Her parafunctional pattern one night is just so broad, and she’s got huge muscles. Every two years she destroys her splint and she gets a new one. But before she ever started wearing splints, okay, she’s just 19. She’s just 19. And she presented to me with a virgin… a crack in a virgin lower first molar. And so the first time it presented to me is it was symptoms. And so really had to dry the tooth to see it. It was like, oh wow. Yeah, there is a crack there. It wasn’t stained, but it was symptomatic. For this individual, it is a completely different treatment to someone who is 56 years old and they’ve got a giant MOD amalgam and you diagnose cracked tooth syndrome. You know that the giant MOD amalgam is gonna get a crown or an onlay or something. Whereas the 19-year-old—it’s a distal crack. Would I really want to reduce the cusp by two millimetres all day round on a 19-year-old? So what I decided to do on this 19-year-old is: okay, well if the crack is distal, let’s explore distal. What I’m gonna do now, guys, is—those who are listening on Spotify and Apple—I’m gonna keep it very descriptive. I’m gonna show Emma some photos. If you’re watching on Protrusive Guidance on YouTube, you’ve got some visuals. But don’t worry—my numero uno are always the audio listeners who’ve been with me since day dot. I’m gonna make sure you’re not feeling alienated. So the first image I’m showing you, Emma, is an Essix retainer—because you had context before—absolutely destroyed, right? And then what’s the next thing you wanna know when you see an Essix retainer like this? What’s the next thing you want to know? [Emma] When you see an Essix retainer like this— [Jaz] When you see a destroyed Essix retainer, like chewed up, okay? [Emma] Like how long they’ve had it for. [Jaz] There we go. Okay. Because if it’s been like seven years, I’m like, okay, that’s fine. I can deal with that. But if this is six months—which is what it was—what can that tell you? What information do you now gain from seeing this retainer after six months and it’s in this stage? A lot of chewed-up holes. Perforated. [Emma] Yeah. A lot of, you know, prolonged tooth time contacts. [Jaz] Wonderful. Beautiful tooth time contact and tooth force. It’s a combination of the two. And even position, because there’s a lot more back tooth contact than there is front tooth contact, right? So that’s kind of leading to it as well. So anyway, she comes to me. Let’s see… yeah. So here’s the situation, though. Lower molar, we said. This crack that I’m showing you—and those listeners—it looks fairly harmless. It looks like a fairly harmless crack. Like this. We see this in teeth all the time. But she’s complaining of symptoms. And she’s just 19, but she’s a high-force patient. Now, on the photo I’m showing Emma, there are some articulating paper marks. I’m firstly highlighting my mouse around a cusp tip contact. That’s a cusp tip contact there. And then here, it’s on the occlusal table of the cusp. But can you now describe what kind of contact this is? [Emma] An inclined contact. [Jaz] Well done. So I’m showing Emma an incline contact. The dot is not in the fossa. The dot should be here. But actually the dot or the smear, the large contact, is actually halfway up the cusp. No wonder there’s a crack here on this high-force patient. Now, just to confirm—I didn’t need to do this, but because you have the retainer as evidence—but we did something called a brux checker. And a brux checker is like this thing, which is like… it’s painted red and your patient just wears it for one night. Then anywhere there’s tooth rubbing going on, the ink wears away. And it’s not like every time it touches the ink is gone. It takes a fair bit of effort to rub this ink away, which is important because you don’t want a false positive, right? So you can see how much force is going down the molars. And actually she’s bruxing onto her front teeth as well, but this just confirms that, yeah, for sure, she’s a bruxist. And we have the incline contact again. I’ve got blue ink here now. And then there’s an aggressive cusp of the upper molar. So the other thing that you see on this molar is on the mesial half the molar—this part of the tooth, right guys?—it looks completely like a six-year-old’s tooth. Look how pristine the anatomy looks here, right? And then now when I move the angle of view to the distal half of the same molar, can you see how aged the tooth looks? So my question, guys, for those listening is: why would that happen? Why would one half of the tooth look like pristine, no wear, and the other half is the one that’s got the crack? It’s got some wear. It looks like it’s been in the mouth far longer than it has been. [Emma] Is there a— [Jaz] It’s not a trick question, but it’s something that… it is an interesting discussion point when we look at the tooth level. Go on. [Emma] Is there a bit of like a rotation on the opposing tooth? [Jaz] Beautiful. So essentially what you’re saying, Emma—I mean, it may or may not be rotation—but what you’re thinking of is the opposing tooth, right? So imagine the best way to describe it is: imagine the mesial half of the tooth doesn’t have an opposing tooth. Imagine a missing tooth. But the distal half of the tooth has one. It is just as basic as that. For example, I’m just making this up in this scenario just to help to explain the point. But when you see some damage on the cracked tooth, you always must—it’s a lesson I’m teaching you guys—look at the opposing tooth. Because that will give you a clue, right? Often there’ll be something sharp there. Something that’s gonna like—a dagger—something that’s gonna be damaging there. So always look. And actually a great point to consider is: if all you do is remove the crack and put a composite, the composite will also fail through overload eventually. If you do not change something about the upper tooth, i.e. lightening the force there, or changing it from a sharp dagger to a rounded soft cusp, or maybe changing it so that now you are converting it from an incline contact to fossa contact. So you must change something about the environment to reduce the crack propagation. Anyway, so what I did, guys, for those listening, is: I actually reduced the incline, the angle. Can you see? I reduced the angle. So now I’ve actually converted this tooth from a steep angle to a shallow angle. And some people may be saying, “On a 19-year-old, you removed enamel?” Well, listen: this 19-year-old—if I didn’t do this, she’d be the 40-year-old with a virgin tooth who has split her tooth because all the dentists said the cracks were harmless and then she lost her tooth. So we have to sometimes be appropriately invasive to preserve teeth in the long run. So I’ve sacrificed some enamel. Now that’s what occlusion is all about. Practical occlusion is all about these decision-makings. Actually taking a bur to a tooth and doing that for the greater good. And so you can see, when I explored the crack, okay, you can actually see it quite clearly now, right? And what do you often find in a crack? You find caries. So can you see there’s some caries? Guys, I’m showing Emma some caries which were not present radiographically, right? But wherever there’s crack, there’s demineralisation. It’s the entry point of caries. So thank goodness we intervened. And we didn’t allow this to become worse or bigger and actually become radiographically evident. I restored it with a composite. And what I didn’t do is: I didn’t just recreate the old anatomy and make it steep again. I kept it shallower. So now the opposing palatal cusp, when it now grinds on this molar, it’s doing so in a shallow way. And what I’m showing here, guys, for the audio listeners, is an image which is just one of my favourite images in education, okay? Because that point I made about the mesial half of the tooth looking good and the distal looking battered… but now you see this across the first molar and the second molar. There’s like: this tooth is age 19 and this tooth is age 70. Like the distal half of the tooth is age 70. Yeah. And so it really drives home the point of tooth contact time, tooth force, and tooth position. All those things that I spoke about earlier are being manifested here. And so her pain went away and everything was good, except actually she’s having the same issue on the left side, and I ended up treating her left side as well. So you have to look at the patient as a whole. And the main lesson here, guys, is: if you are treating a cracked tooth, your treatment modality will depend on how old the patient is, how bad the crack is. So here, for her: composites. But not just a composite—it’s composite and careful and judicious adjustment of both the existing tooth angles, where the occlusal contact will be, and being purposeful for that, and doing some opposing adjustment to remove the noxious stimulus. [Emma] Yeah, that’s really, really interesting, and I think it’s fun because I usually just spring these questions on you. I usually ask, “Oh, do you want me to send you over the questions that I have in advance?” And you’re usually like, “No, let’s just go for it and see what happens.” But I think it’s really interesting that you had such a good case to show there. I thought that was really, really interesting. That was really interesting. [Jaz] I’ve got great images as well, guys. I’ll put them on the app, on Protrusive Guidance, but like when you air-abrade teeth, once you remove that amalgam and you air-abrade, you’ll see the cracks pop out at you. So if you’re not able to see the cracks before, when you air-abrade, suddenly they all come out of the woodwork and you can see the cracks basically. So really important diagnostic tool. And so the final thing—talk about running out of time here—but communication. That’s the thing that stressed me out the most because the patient’s like, “Hang on a minute…” Vast majority of patients who’ve got cracks are asymptomatic because not only do cracks come in a spectrum, but the patient’s development or progression of a crack also comes in a spectrum—at what point they present to you in life and how proactive you are. And so if the crack has just formed and is barely in enamel and just about entered the dentine and they have no symptoms, you might even miss it. In a quick exam, you might even miss it, right? Then they come back. The crack gets a bit deeper. A few years have passed by and the crack’s getting a little bit bigger. Maybe it’s starting to stain now. And stain is significant because—do you know why stain is significant for a crack? [Emma] Does it go back to possibly caries in there? [Jaz] Kind of, because a crack can only stain when it’s wide enough to allow the stained particles and bacteria through. So basically, if the stain’s getting through, we know the bacteria’s getting through. So vast majority of these cracks are completely asymptomatic. But it’s up to us as the dentist to take photos, to explain to the patient that, okay, you may be low-risk caries, you may be low-risk perio, but you are high-risk for cracks. You have four cracks, two of which I think are gonna be okay, but the other two I think I’m a bit concerned. I think let’s watch this one, but I think we need to investigate the other one. So yeah, cracks come in all sorts of different presentations. So it’s up to us to lead the patient and really advise them and let them own their problem. And it’s like, “Listen, the crack is in your mouth. You have overloaded your tooth and caused this crack. I can help you, and this is what we take, but a cracked tooth is a really upset tooth. The nerve—even though you’re not in pain—the nerve is always, always a little bit traumatized from a crack.” “We will try our best to do it, but I wish there was no such thing as cracked teeth because cracked teeth really, really reduce the chance of your tooth surviving throughout lifetime. So if you want to give your tooth the best chance, we can restore it now with X, Y, Z restoration. But know that the nerve may already be damaged.” “We’ll only find out. If we do nothing though, then you are heading towards a split tooth. And these things—they don’t just appear overnight. They all start like the crack you have. I can’t predict, with your diet and with your clenching, how fast it will progress in your case.” And very often you’re monitoring photographically. You’re monitoring symptoms. Very often with general practice, we have this beautiful relationship we get to form with patients. So very often we see these patients year on year on year. And we mention, “Okay, yeah, that decay’s doing fine. It’s not progressed.” “The crack on this tooth, however, based on my photos and what I remember, I think this one’s got worse.” And by the time you’ve been seeing them four years, they trust you. They get it, okay? And it’s one of those things where patients are very… unless they have a relationship with you, something that doesn’t hurt them—they won’t really do anything. Something that A: doesn’t hurt them, and B: they don’t want—no one wants to have their back teeth drilled for cracks, okay? If it’s aesthetic dentistry, then they don’t have to trust you. It’s something they want. They’ll go for it, kind of thing, right? So it’s one of those things. Cracks that are asymptomatic can very quickly lead to tooth loss, and that’s why the communication element really comes into it. [Emma] Yeah, that is really interesting. And I think I was gonna ask you before what your number one piece of advice would be, but I know that you already said, like, look at the patient as a whole, and especially looking at the contralateral tooth on the other side and also the opposing— [Jaz] Opposing, yeah. Contralateral, opposing. Look at them. The shape of their jaw. When you get them to bite together, have they got giant golf balls that come out as masseters, or are they very gentle, okay? And these things are so, so important. What their retainers look like. What do the other teeth look like? What does the opposing tooth look like? Does it look like a plunger cusp that’s right overlying where the crack is? [Emma] Yeah. Yeah. So very, very interesting. And I like all the—you just had to hand all the photos that were so, so helpful in visualizing that there. So that’s good. I like this episode. [Jaz] Amazing. Brilliant. Well, which notes are you gonna make available to all the Protrusive students for this time around? [Emma] So I can make… I know that the American Endodontic Society has really good notes on cracked tooth syndrome. And I can just release anyway. I already have. I know we were gonna do a boring episode about medical histories, but I think we decided against that. But I have some really good notes anyway, so I might just use that. [Jaz] I would love that. It’s such an important thing, right? Medical histories. Yeah. It’s just so boring to talk about, and it’s like where do you draw the line, right? So I think let’s make this—because students will need this for their exams and stuff—so let’s make medical histories available. It’s not really relevant to cracks. So we’ve given you something clinical and highly actionable and relevant, and something that hopefully will stay with you for life in how you practice and how you look at cracks. Never look at a cracked tooth the same way again after these episodes. Now you also have medical histories to keep your examining board happy as well. So all that is available on the StuDent’s protrusive section. And of course, all our Protrusive on the app, you all have access to it, whether you’re a student, young dentist, experienced dentist. It’s always nice to listen to a different way of explaining things and connecting back with the basics. The basics can be beautiful. [Emma] Yeah, for sure. And it’s easy enough to answer these questions in an exam, but when it comes to actually doing dentistry and being dentists, it can just take a bit more explaining. [Jaz] Well, Emma, thanks so much for your time. All the best with the rest of your final year. We’ll catch you in the next episode. Have you got an idea of what you wanna talk about next episode? [Emma] So I think when I’ve been in outreach centres recently, I’ve been seeing a lot of failed composites—not from me, but from previous students before. So maybe even a conversation about that. Who, where, what, why, when went wrong. Failing composites. [Jaz] Beautiful. Again, another clinical topic. I love it. Oh, there’s so much we can talk about. Okay. Excellent. Let’s talk about failed—maybe, well, we can talk about failed composites in general because there’s a whole decent protocol. There’s the occlusion management, there’s the layering management, all that kind of stuff. And then some things we say will be more applicable to posterior teeth, some to more anterior teeth. And we can talk all about that. Amazing. Okay. I’ll look forward to it. Thank you so much, Emma. [Emma] Perfect. Thank you. Jaz’s Outro: Well, there we have it, guys. Thank you so much for listening all the way to the end. Please do answer those questions below to claim your CE. We are a PACE-approved education provider. Hope you enjoyed my take on occlusion in terms of position, force, and time, and how the combination of these results in overload, which is the ultimate cause of cracks. If you did enjoy this episode, please comment below. Tell me what was your biggest takeaway from this episode. If you’re watching on YouTube, hit subscribe. If you’re watching on Protrusive Guidance: A, don’t forget to answer the quiz. And B, it’s always lovely to read your comments. We hope you’re enjoying these kind of basic student-based series. But as you can see, it’s not really for students. It’s a nice geeky chat on some of the fundamentals, and there’s beauty in the basics. I wanna thank Team Protrusive, as ever, for all their hard work, and thanking you once again, Protruserati, for sticking around. I’ll catch you same time, same place next week. Bye for now.

Are you confident in spotting a child at risk of neglect? Do you know what to do if you witness abuse in your practice? How can you raise concerns safely while protecting both the child and your team? This episode with Dr. Christine Park provides tangible actions, practical scripts, and clear guidance for managing challenging scenarios—like seeing an adult hit a child in the waiting room or recognizing neglect in the dental chair. These are situations dental school rarely prepares us for. Every practice needs clear protocols for safeguarding. This episode acts as a North Star, helping you stay compliant while ethically doing the right thing. If you treat children, you must listen to this episode and share it with every colleague who treats children. https://youtu.be/-kYs23Xa4Ls Watch PDP251 on YouTube Protrusive Dental Pearl: Find the phone number of your local child safeguarding board / social services. Verify it, then display it where you and your team can quickly access it. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Dentists are trained observers of family dynamics. Recognizing normal behavior is key in dental care. Unconscious observations can guide professionals. Feeling uncomfortable about a situation is a valid signal. Empowerment comes from trusting your instincts. Dental care professionals see many aspects of families. It’s important to act on uncomfortable feelings. Observation skills are crucial for effective care. Children’s interactions reveal much about family health. Awareness of discomfort can lead to better outcomes. Highlights of this episode: 00:00 Teaser 00:59 Intro 02:40 Pearl – Child Protection Hotline 05:23 Dr. Christine Park’s Background and Expertise 08:37 The Role of Dentists in Safeguarding Children 11:19 Practical Scenarios and Guidelines for Safeguarding 15:35 Recognizing Silent Cases of Neglect 17:29 Team Collaboration and Support in Safeguarding 21:58 Guidelines and Policies for Effective Safeguarding 22:03 Midroll 25:24 Guidelines and Policies for Effective Safeguarding 28:32 Handling a Tough Safeguarding Scenario 32:18 Dealing with Poor Oral Hygiene and Neglect 39:12 Managing Parental Reactions and Consent 43:08 The Importance of Safeguarding in Dentistry 45:34 Further Guidance and Resources 46:10 Outro 📢 Safeguard your young patients with confidence! Catch Dr. Christine Park at the Scottish Dental Show in June or via her NES webinars. Check out the BSPD guidelines on dental neglect —an essential resource for any dentist treating children ✉️ Get in Touch with Dr. Christine: General: [email protected] Patient-info: [email protected] If you loved this episode, don’t miss How to Manage Children in Dental Pain – Paediatric Emergencies – PDP159 #PDPMainEpisodes #Communication #CareerDevelopment This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and D. AGD Subject Code: 430 PEDIATRIC DENTISTRY (Identification and reporting of child abuse) Aim: To equip dental professionals with practical knowledge and skills to recognize, respond to, and appropriately escalate safeguarding concerns involving children in dental practice. Dentists will be able to – Identify key signs and red flags of child neglect, abuse, or welfare concerns in dental patients. Apply clear communication strategies to discuss concerns with parents/caregivers and involve relevant authorities. Follow practice-based and multi-agency procedures for safeguarding, including documenting observations and escalation. Click below for full episode transcript: Teaser: We're so well trained in observing, and we're really, really good at knowing what normal is. We know what looks normal to us, and even if we are not consciously aware of what we're seeing, there is always an unconscious part of us. If we see something that doesn't feel right, it will feel uncomfortable. Teaser:The worst thing is if a dentist or a nurse gets left to deal with it on their own at half past four on a Friday afternoon, when they can’t get through to anybody, and all the rest of the practice are going, not my problem, I’ll see you later. What do I want that child to think about in years to come? When they’re grown up and they’re an adult and they can look back, do I want ’em to look back and say, that dentist Christine, she saw me and knew I needed help and did X, Y, Z, or, that dentist saw me and knew I needed help and did nothing. And never want any of my dental colleagues to be the last health professional to see a child that something then horrific happens to. Jaz’s Introduction: If you treat children, it is your duty to listen to this episode in full, because this is one of those times you get to change a child’s life. You get to potentially save a life, or at the very least, change the entire trajectory of a child’s life. Safeguarding of children is one of the recommended topics from our regulator, and there’s a really good reason for that. We, as dentists, are in a phenomenal position to be able to look out for nuances and really safeguard the children. They only see their medical doctor when there’s a problem, but they see us more regularly. And if you treat children, it should be part of your personal development plan to safeguard them. And this episode will give you CPD for that. But forget the CPD, because more importantly, when you see an adult hitting a child in the waiting room, or you see a neglected child in your dental chair and you need to raise concerns, this episode will give you tangible actions, scripts to follow, and good, safe guidance on how to manage these really tricky scenarios, which dental school just does not prepare us for. This episode with Dr. Christine Park will give you the tools you need to manage these tough scenarios. Now, it’s not a very common thing, thankfully. It’s a bit like mouth cancer. We do screening for mouth cancer every single patient, and we hope not to find it, but when we do find it or are concerned, we refer, we get some expert advice, and we should be doing the same when it comes to safeguarding children. Every practice needs to have clear protocols in place, and this episode is a great North Star to follow, to help us stay compliant, but also ethically do the right thing. So if you treat children, you must, must, must listen to this episode and share it with every colleague that treats children. Dental PearlHello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental Pearl. It’s a very important actionable step I’m giving you for this episode’s pearl. Now, most of us under our computer or near our workstation, we have the phone number to call if the service stops working. Or if we need IT support, and this is almost like universal for all dental practices I’ve worked in. Now, what all practices don’t have is a phone number for when you are concerned about the wellbeing of a child, when you need to do some safeguarding for children, the phone number of social services near you, or a safeguarding authority for children near you. Do you have that phone number easy to find somewhere? And I think it’s our duty to have that number easy to reference. It’s a bit like when a dental trauma comes in, we refer to the guidelines, we follow the steps. Well, sometimes with these high-octane, adrenaline-pumping, tough conversations that we have with parents, we need a quick reference of a phone number to call for help, as well as discussing it with the lead nurse, practice manager, the other dentist. Because when safeguarding and children is concerned, it is an entire practice issue, and it is a community-wide issue. So my top tip is have the phone number. Have a phone number of your local safeguarding authority, and you have to do a bit of work. I would say ask ChatGPT, then verify that what ChatGPT is telling you is correct. You need a local contact to get advice. And I think it’s our ethical duty to do so. Anyway, let’s check out the main episode with Dr. Christine Park, who really breaks it down. Well, we have scripts. We have tangible actions for you to better look after children. I really hope you never have to use these scripts, but when you do, you’ll be way more prepared and you’ll be able to really help children and change their entire life. Enjoy the learning. I’ll catch you in outro. Main Episode:Dr. Christine Park, welcome to the Protrusive Dental Podcast. So nice to have you smiling. You’ve got the a nice little, what, what’s that poster you got behind you? [Christine] So this is a little poster that we had at the Glasgow Science Festival back in June, July. I’d taken some of my students there to talk about the science behind prevention. So we had done lots of sort of public engagement there, so for families as well as children, but all the families doing a bit of public engagement about why we use fluoride and why we brush teeth and all that kind of thing. So I like the, so I keep it. [Jaz] Well, tell us about yourself in terms of which hospital you work in, which trust you work for, and what is your day in, day out role? Obviously Scottish, we’ve had some great Scottish guests in in the past. Scotland is like, I was always taught as a dental student, my lecturer is actually a Scottish lecturer who was teaching me, and he said, in his lovely Scottish accent, he said that Scotland is like the sick man of Europe. But then as a sick man of Europe, it produces the best guidelines. And any guidelines, you bypass England, you go straight to, let me check out the Scottish guidelines. Okay. So isn’t that just fascinating? [Christine] It’s absolutely. [Jaz] Tell me about yourself. [Christine] So yeah, so I work at Glasgow Dental Hospital and School. So I’ve been a senior clinical lecturer and an honorary consultant here for the last sort of nine years. And my day in, day out, I do sort of half university and half NHS. So depending on what day of the week it is, I might have my dental students in the main pediatric clinic at the dental hospital, or I might have them in outreach in some of the more deprived areas of Glasgow, or I might be doing general anesthetic lists myself or intravenous sedation for anxious adolescents, as well as new patient clinics and what have you as well. So I’m also an educational supervisor for one of our STs, and we’ve got some lovely CTs in the department as well. So very varied week, but it’s great. I love it. [Jaz] Very lovely diverse week that you have. That’s awesome. And you are like, your background, is it pediatric, or is it community dental, or a bit of both? [Christine] So my background is pediatric dentistry. So I qualified from Glasgow and then went over to Edinburgh to do my sort of VT stuff and then came back to Glasgow to do specialist in pediatric dentistry training, and then went down to London to Guy’s and St. Thomas’s to do some of my consultant training down there, and then decided to go down the academic route. So managed to get a job back in Glasgow, where the sort of family roots are, round about the same time that they were thinking of starting a family. So it was well timed. [Jaz] Excellent. And the topic today that we want to address is safeguarding. So one thing for sure is the area of expertise and area of experience and what you teach, is that more towards safeguarding in children? Is the conversation very much gonna be more safeguarding in children, because we have a duty of care in safeguarding in children and adults. How much do you, I mean, how much adult interaction do you get and is this something that you’re involved with, the safeguarding adults as well, or is it mostly children? [Christine] So it’s mostly children that I’m involved with safeguarding with. So I’ve done a master’s, initially looking at the dental team’s role in protecting children and the oral health of vulnerable children in Glasgow. And then I have more recently done a PhD developing a serious game to try and help dental teams get over their fears that are involved with referral when they’ve got a concern about wellbeing or welfare, particularly in pediatric patients. I do have colleagues who are much more expert in adult safeguarding, but that’s not particularly my area of expertise. It’s much more the pediatric safeguarding part. [Jaz] Well, it’s nice to go home into a niche and talk about a topic deeply. So I’m quite excited to talk about, okay, safeguarding children because it’s such a huge responsibility that we have, anyone who treats children, and it’s one of the sort of required or recommended learnings from the GDC for good reason, that we should be learning about safeguarding in children. Why do you think as dentists we are in primary care, we are in a good position to be, why is it like an important topic that the GDC have said, hey, you need to learn more about this? What makes us in a position to be able to look after children in this position? [Christine] So especially dentists in general practice, they’re so privileged that they have really good relationships with families and will often see families over a long period of time, much more so than, you know, myself in hospital or even my colleagues in the public dental service. And because of that, they really develop a bond of trust with patients and their families. Dental checkups, dental reviews are one of the only sort of regular healthcare points that children still have, especially once they’re at school, once they’re past the sort of health visitor stage. Their dental checkups are that kind of touch base point that other general medical practitioners won’t have, because generally in the other specialties, they’re only seeing them if they’ve got an issue. Whereas in dentistry, you’re seeing them much more commonly. So we’re well placed to pick up any things that are developing. We’re well placed to see changes in families. If it’s a family you’ve known for a long time and suddenly think, this is not the same as it was before, perhaps there’s a struggle. Or even on the flip side of that, if you’re seeing children for a long time and you’re giving the advice, but it’s not being enacted, or they keep coming back in pain to you and nothing’s changing, you can really be that first link in the chain to offer a family in crisis a bit of help. So dentists and therapists, in fact, all dental care professionals, we’re so good at observing. We’re so well trained in observing, and we’re really, really good at knowing what normal is. We see so many different aspects of families. We know how children interact with their family members. We know what looks normal to us, and even if we are not consciously aware of what we’re seeing, there is always an unconscious part of us. If we see something that doesn’t feel right, it will feel uncomfortable. And I think part of what I want to do is just really help people to know that if you feel uncomfortable like that, then there is something wrong. So don’t just sit on that feeling. If you’ve got that uncomfortable feeling that something’s not right, you will be correct. So you should feel really empowered from that point of view. [Jaz] Can you give us a tangible made up scenario where a general dentist may see a family and then see a, have a child in their chair and their radar’s going off like, okay, something is not adding up today, something’s wrong? Can you give us in like a case report, case study, you can make it up obviously to protect children and stories and whatnot, but like just some scenarios, because as dentists we really, with the scenarios, we can actually identify really well with. [Christine] Yep. So I’ll give you a couple of options. So sort of scenarios that I’ve been involved with. One was a family who has three children, so it was about an 8-year-old, a 6-year-old, and a newborn baby. And I was asked to see them as part of a comprehensive medical assessment. So I was doing the dental bit of that, but it could be any dentally qualified person who’s doing that, can be a general dental practitioner. And I was examining the children, and both older children were really compliant. They were fine for examination. I could look in their mouths, and what I found was that the older child’s oral hygiene at the front of their mouth was generally okay, but the more posterior teeth was very poor oral hygiene, and they had active caries. The six-year-old’s oral hygiene was appalling, and they had active caries. Now, in comparison, the six-month-old child had beautiful oral hygiene, just the lower incisors, but not a speck of plaque on them. Now, in addition to this, both of the older children smelled quite strongly of stale body odour. They were visibly dirty, their skin, their hair was visibly dirty. I could see ingrained dirt in their skin. And then in comparison, the six-month-old baby was beautifully clean, freshly laundered clothes. So this was really an example of where it’s a family who obviously aren’t living in hygiene poverty because they can launder the baby’s clothes. They obviously do have toothbrushes at home, ’cause the baby’s teeth were clean. But for some reason there was neglect happening with the older children. So that might be something that comes up in general practice. And when I spoke to the general practitioner who was involved in that, she said, yeah, the kids are actually really good. They come, they have their dental treatment done, but they never complete a course of treatment, which is one of the warning signs for dental neglect from the British Society of Pediatric Dentistry’s policy documents. So they come, but they don’t get brought to complete their course of treatment, but they’re great when we’re here. It’s not a behavior management issue. So that’s one of the things that you might see in practice. And the other one that comes to mind is a 3-year-old child that the dentist was concerned about because they had gross caries in almost every tooth, and they had then referred them to me, but they didn’t come to see me. And then I couldn’t get hold of them. So what we did with the dentist is we got back in touch and said, have they been to see you? And they said, no, actually, they’ve not. And we got the health visitor’s details from the dentist, who knew the doctor, and we were able to work together to get that child to come in. And what turned out was the dentist was concerned about them, and that’s why they referred them to me, but they weren’t attending nursery because of their teeth. They weren’t eating or drinking properly because of their teeth, and they ended up needing a clearance. But it was just the dentist just bringing that to the attention of the health visitor was just so impactful, because the reason mum wasn’t sending the child to nursery was because of their teeth. So although it was awful that we had to take out the teeth, it’s really been so impactful in that child’s life because now they’re out of pain. Now they’re able to eat and drink better, so their body weight is coming back onto the normal curves we would hope to see. And they’re engaging with education now. Yes, it’s awful that they don’t have teeth, but their mouth isn’t sore anymore. They’ve made a real, that dentist has made a real impact for that child, which as, it’s not one of these things where it makes you a lot of money, but it really is so impactful, that child is… [Jaz] So rewarding. [Christine] So rewarding, and their life is going to be so much better because the dentist took the time to say, something’s not right here, we need to get you some help, and it did take that multi-professional working with the health visitor to go into the house and try and get them to come to the appointments, explain that it was so important, that nobody’s going to be nasty to you, we just want to try and get this child’s health better and then support you in the future so that she can have the best health she can. [Jaz] Well in epidemiology and public health, we know that that’s the tip of the iceberg. That’s what we’re seeing, right? And then there’s so many other cases, which are perhaps not as advanced, or it’s happened but then they’ve slipped the net because the general dentist was not confident. They were scared. They were scared of backlash from the parent. A busy practice, they’ve got like 15 referral letters to write for other things or medicine stuff. And then there’s one thing which requires a lot of energy and effort and finding and health visitor stuff. So what I’d love to do is talk about this similar scenario whereby the patient is, the child is getting rampant caries and maybe they’ve already had a GA before. And one of the things I always remember is like a repeat GA is like a huge, the biggest like red flag you can have, in the sense that this is like a major neglect. So how can we definitely, obviously prevent the first general anesthetic, but to repeat should be a never event. So, again, that’s like the tip of the iceberg. There’s so many that are suffering in silent. And so if we can give dentists some guidelines, some ideas about how to make the right choice the easy choice, how to give them tools that they can use and discuss in their team meetings. But okay, if we spot this, this is our clear protocol, because you know what, Christine? We’ve got protocols. Every practice has got a safeguarding policy that everyone writes their squiggle against. But when the proverbial hits the fan and actually, if something happens, is that easy to find? Because I don’t expect anyone to remember the policy step by step by step. But that’s the point where it should be easy to dig out and have a clear practice plan to follow to help someone. So I guess the next step to then uncover this is when you have that feeling in both those scenarios that you describe, what’s the first thing the dentist should do, whether it be something in the nurse, or a question that’s asked to parents? Obviously it’s very broad ’cause it kind of depends on the nuances, but what’s a guideline approach that you recommend as first line? [Christine] Yeah, so definitely you’ve kind of, you’ve picked a few things there, Jaz. So the fact that actually practicing this before it actually happens is really important, and knowing what everybody’s going to do in the team. The worst thing is if a dentist or a nurse gets left to deal with it on their own at half past four on a Friday afternoon, when they can’t get through to anybody, and all the rest of the team are going, not my problem, I’ll see you later. That is probably, that’s the hardest bit. So my first suggestion is to talk through these things with your team. So whoever it is in your practice, so if you’ve got practice managers, if you’ve got nurses, if you’ve got receptionists, talk through what you’re going to do. So if you have to make a referral to social services at four o’clock on a Friday afternoon, is it going to be such an urgent case that you need to phone the police? If it is, who does that? If it’s one that you’re just phoning for advice, where do you keep the child if you’re not sure whether to send them home? If they are sending them home, who’s had that conversation to say, look, I’m a bit concerned about this, I don’t think things are sitting a hundred percent right with me, it’s my professional responsibility to refer this child. And then in your team, who’s going to support the person who does that? You know, who’s going to be the one to say, we’ve got your back? Who is it in your practice that if you’re not sure about something, who are you going to phone? Is it going to be… [Jaz] A safeguarding lead? Is that what you mean, like a practice… [Christine] Yeah, a safeguarding lead, or in the trust or health board in which you work, you might have a child protection advisor. It varies up and down the country. So, in Glasgow, for example, we have child protection advisors that even I would phone if I’m not sure about something. And you might have a lead doctor for safeguarding, a lead nurse for safeguarding in your trust as well. So who do you phone? And never worry about phoning them. Don’t think that anything is too small. You’re not going to get a row from someone saying they don’t think this is really important. The fact that you’re the health professional who’s got that concern, don’t let them fob you off by saying, I actually don’t think that’s really important at all. So practicing those scenarios. I’m always really happy to share different scenarios that I use in my teachings, for example. What do you do if you see someone, a parent, hitting a child in the head in your waiting room? What would you practically do then? You know, who gets everyone’s name and address who’s been witnesses for it? Who phones the police? Who deals with it in that situation? Do you still see the patient? Do you not? As you mentioned, it will be specific on what the situation is, but always reaching out to the broader team is so important. So leaning on your nurses, leaning on the other dentists in your practice, your practice manager as well, so that you’re supporting what’s happening at the moment, but then also the team going forward, because it can sometimes be really difficult because you don’t always get to see the end of the story. And you’re left with that uncomfortable feeling of, did I do the right thing? I always think wondering whether you’ve done the right thing is better than wondering whether you should have done something. So my research shows that most dentists are worried about getting it wrong. They’re worried about making a referral when there’s nothing to be concerned about, or worse, not making the referral when there is something to be concerned about. That’s what they’re most worried about. So it’s fear about what’s going to happen, and because you don’t, you can’t predict the future, so you don’t a hundred percent know what the consequences are, and dentists are worried that the parents are going to be angry and upset, and that could affect their practice as well if a whole family suddenly decides not to attend. So it’s really just dependent, having that conversation in your practice that you work in to work out how you’re going to support everybody who is involved in it, having those chats about, this happened on Friday, let’s discuss it at the team meeting. What else could we have done? What should we do? How is our practice presenting itself to do with child wellbeing? Are we focused on all of our patients, including our pediatric patients? So it’s not a surprise to anybody if we see something and we’re concerned about it, and we say, I’m concerned about this, even if it’s a bruise that would be unusual, so that they know, okay, you’re a dentist, but you’re concerned about a bruise, or you’re concerned about a bruise when you’re a dentist. So things like that, Jaz, I would definitely say. And having the numbers somewhere you can access, because I don’t know all the numbers off by heart. And sometimes it depends where your patient’s based, it might be a different number to who your practice is. So just making sure that you have them somewhere easily, or that you’re using, I mean, most of the search engines will give you your safeguarding contacts for your trust or your health board. [Jaz] Or you can do a nice ask to your ChatGPT now. [Christine] Exactly. [Jaz] I work in Liverpool. What’s my next step? Like literally to have somewhere that can actually, okay, obviously take AI with a pinch of salt, but one good thing about AI is the way it’s developed is if, for example, when I have asked ChatGPT, should I eat this three-day-old chicken? It will always give me like, but you know what, you probably shouldn’t. Even though you probably could, like you probably should. It’ll give you the safer advice. Now, in the same way, it’ll actually tend to give you safer advice, even if it’s just, okay, I think I need to speak to someone who is near this postcode. And then it’ll actually do a decent job of telling you. Now what you reminded me of, Christine, is in our practice we have IT support, and underneath the computer there is a phone number that if you need IT support, call that number. Why don’t we all have, or do the homework ahead of time, our local safeguarding department just below that IT number? ‘Cause that’s another important, right? Because if it’s not there, we are saying it’s not important enough. Or when the computer goes down, we can’t make any money. That’s important. But when something like this happens, if you don’t have a number, we’re saying to the universe, this is not important. So it’s important to have your leads ahead of time. And so how intricate does this policy need to be? Because like you mentioned, that scenario of a child being hit around the head, for example, in the waiting room. I wouldn’t know at that moment in time, I’d be like, is this even covered in our policy? So it’s a very difficult one. It’s a bit like dental trauma. When dental trauma happens, yes, we know roughly about avulsion and stuff, but when it comes, we all want to just, let me just have a quick look at the guidelines just to make sure it’s current and remind me of the steps, ’cause it’s something that you see infrequently, but it’s important. So infrequent and important, it’s good to remind yourself of guidelines. Are there a particular set of guidelines that are just so brilliant that are the equivalent to the dental trauma guide for safeguarding that covers a range of scenarios? [Christine] So I would say the best ones for neglect, dental neglect concerns, would be the British Society of Pediatric Dentistry’s guidelines on that. They’re the best ones for neglect. The other things about physical abuse, there’s not a particular guideline for that. But what I would say is if an adult wouldn’t take it, it’s probably a crime. So you wouldn’t sit and do nothing if you saw somebody getting punched in your waiting room. If an adult punched another adult, the adult who was the victim would report that crime. So, the child can’t do it. But if a crime has happened against that child, then you are duty bound to report that. So it is illegal in the whole of the UK to hit any child on the head or with an object. So if you’ve seen that in your waiting room, it is a crime. So then phone the police, get advice from that way, and they’ll advise you. They will advise you what to do and for their, you need, obviously you can’t stop people… [Jaz] Let’s talk about this tough scenario. Let’s go deep into this hypothetical scenario, because from this scenario we can learn a lot, right? So you see that happen. You need to step up and speak to the parents, say, hey, please be kind to the child, please stop, okay, like the de-escalate scenario. But now, like if you feel as though you need to, ’cause a child’s crying and maybe they’re in pain, like to have to call the police. Like, I get it. But what a tough thing for a general dentist or any team, practice manager, whoever, to do. Any advice you can give to, because it’s not this specific advice, but anytime you see something that you are concerned about in practice that is worthy of escalation, any advice you can give to general dentists listening or watching this right now, in terms of when you see something to that level where your adrenaline’s pumping that this is not good, that we need help. Any advice? [Christine] So what I would say is don’t feel you have to keep the people there. So if it happens and it’s a child that the crime has been perpetrated against, and the adult perpetrator is there, don’t put yourself in danger. Don’t feel that you have to keep them there. You have to report it. You will have to phone the police and report that you have witnessed a crime. But don’t put yourself in danger. If they’re going to take the child away and they don’t like what you’re saying, let them go. You will probably be asked by the police for names and addresses of who’s been involved. So if they’re your patients, then you will be asked to give those details and like… [Jaz] And we’re okay to do that, right? Because ’cause usually, yeah, so if police ask that, usually they need some sort of a, I don’t know, a warrant or something. I’m trying to remember now. But usually you like to get permission from the parent, but in this scenario with a safeguarding issue, that’s probably not applicable. Am I right? [Christine] Yeah, I mean, we would always love to, but if they’re leaving and you can’t physically do it, then that’s okay. You can always act in… [Jaz] The child’s best interest. [Christine] Absolutely. And you can always speak to your indemnity provider if you want some advice or reassurance in that moment. That’s what your indemnity advisor, that’s partly what you pay your money for, is that they can give you that backup to say, absolutely, you’ve witnessed a crime, you’re well within your rights to give the police the information that they want. Similarly, if you were to see that happen in the street, you would probably be a bit concerned about it. If you saw a child getting hit in the head in the street, you would be concerned about it and phoning the police at that stage. When it happens in your practice, what I would say is be kind to yourself from the other point of view. Don’t, you know, if you have to stop what you’re doing, then be kind to yourself and explain to patients, I’m really sorry, we’ve had a terrible incident earlier, things are going to be delayed, or, I need to cancel your appointment today and rebook. We’re concerned about all our patients, but we’ve had a really dreadful, horrible experience this morning, and we need to make sure everyone’s okay. The same way if your practice went on fire, you wouldn’t keep seeing your patients. As a dentist, if you were ill and unwell and had to be taken to hospital, your book would get canceled. So don’t keep struggling on. I know we all feel so responsible to all of our patients, but remember to look after yourself as well. It’s really important, especially in safeguarding. As you mentioned, Jaz, it takes a lot out of you and it can be really involved. So look after yourself and your team. [Jaz] That’s really important. Now the other scenario then I wanna talk about, which is a bit more. So I think that’s great advice on how to de-escalate, make yourself safe. They don’t have to stay in the building, obviously, but then it’s given you then that space to block the rest of the morning or whatever and call the authorities, which I think is really clear and I like that. So I think that’s good advice to give. But the scenario where there’s a bit more grey, whereby, and something that we see far more often, is poor oral hygiene, odour, just looking like the child’s not being well looked after, kind of like the first scenario you described, right. This is a bit more nuanced because at this point you may wish to express to the parent that, look, I am generally concerned. What is the next step? Like, do you say to a patient, or to a parent, I’m generally concerned, is it okay if I contact blank? Like what’s the best script to use in that scenario? [Christine] Yeah, so that’s a lovely example, Jaz, that sort of, is it okay if I contact, although sometimes I won’t say, is it okay, because they may well say no, and you have to do it anyway. [Jaz] So that reminds me, Christine, of a funny story about that. One thing I teach about bruxism and stuff is never ask a patient, do you grind your teeth? Because you are the clinician. You’ve done your grind-scene investigation, you’ve seen the evidence. There’s no point asking. It’s like asking as a parent, do you neglect their child’s health? Obviously they’re gonna say no. But they have been, right? Yeah. So there’s no point asking in that way. So I get that, and I appreciate that very much. Okay. So what’s the better way to do it? [Christine] So I guess my sort of script is, I’ve had a look, this is what I’ve seen, I’ve noticed there’s dental decay in X, Y, and Z. I’ve also noticed, I guess the other things you might see are head lice infestation, or that their clothes are quite dirty today. I have concerns about your child and I am going to pass them on. So you’re really wanting to inform them that it’s going to happen… [Jaz] Pass them on to? Do you need to specify? [Christine] Social services or social work. If you’re that concerned, that this situation is complicated or it’s not getting any better. Perhaps it’s a situation you’ve been trying to improve. And so we’ve tried X, we’ve tried Y, we’ve tried Z. Their oral hygiene isn’t getting any better. They’re getting more caries. I’m still noticing that their clothes are unwashed. So… [Jaz] So I think what we’re trying to say is there’s a difference between the first time you see a family and then maybe the third time. I think maybe what we’re trying to say here is the first new patients, maybe then to give the advice, maybe just limited to oral hygiene initially, and then see if they engage with that before you then say, okay, oh, what about the clothes and stuff? But it’s a very difficult line to cross, which we shouldn’t as healthcare practitioners, as healthcare. So we are in a right to say, okay, are they being looked after, or have they showered, kind of thing. But I think the easiest thing to talk about is their oral health and put our energy there to see if they’re engaging. It’s like a yellow card before you give ’em the red card. Is that a good way to go? [Christine] That’s a nice way to put it. So what we might do initially, if it was something that I’d seen for the first time, is I might just go, right, the oral hygiene is really poor, and give them some easy targets. So you need to be brushing twice a day with an adult-strength fluoride toothpaste. You need to bring them to the appointments that I’m giving you here. This is what they need from a dental health point of view. And give them those easy, not easy because it’s not easy for all families, but give them the targets that you would think would be the sort of lowest level. So bringing them to appointments with me, brushing twice a day with an adult-strength fluoride toothpaste, with an adult helping them if they can’t do it themselves, and then if they’re not engaging with that, and you’ve given them those targets and they’ve gained those… [Jaz] So for example, I’m just thinking out loud here, like, so it might be that, okay, I wanna see you every three months, but actually can you come in two weeks with the toothbrush and let’s do some toothbrushing together, and then that can actually check that, are they still bringing ’em to the appointments? And that gives you the second yellow card. Potentially, not because you want to dish out red cards, but because you’re generally concerned about this child. And then this is like a little test? [Christine] Yeah. And also you want to make sure that it’s not just because they don’t have the knowledge and they don’t have the toothbrush. So you’re not wanting to condemn families, if you like, just because they don’t have those, they didn’t know how to do it. No one’s ever shown them how to brush their teeth. So how on earth do they know how to brush their child’s teeth if no one’s actually given them that lesson? You can imagine if an adult has a neglected dentition themselves, they probably don’t have the knowledge and skills to be able to teach their children how to brush their teeth properly. So they need the input from dental services, from dentists or therapists or hygienists to say, this is actually how you brush your teeth, and then bringing them back to check that they are doing it. And do they need help in any other way to try and get the teeth brushed? Are they able to get a toothbrush? Are they able to get toothpaste? Helping in practical ways, and then moving on. You would then, you’re sort of almost building evidence, either evidence that things are getting better, or evidence that things are not getting better. Or you’re getting those, the sort of disguised non-compliance where they’ve made an appointment but they cancel on the day and rebook another one, and then they cancel on the day and rebook another one. So suddenly it looks like they’re always going to come to see you, but there might be months or years or huge gaps in dental attendance, and that can be very tricky. It can be obviously very damaging. We know to children’s dental health, because we’ve seen that in our patients. When it happens, you suddenly, and we saw it in the pandemic, when we suddenly didn’t see them for a year, and then they, the impact that had on all the kids’ health. If they didn’t have somebody at home who knew how to brush their teeth, who knew what they should be eating or drinking, and that kind of thing as well. So the BSPD policy document’s actually really good with that. It gives you the sort of first stage, so dental practice management, and then if things are not getting better, it gives you the second stage, which is your multi-agency involvement. So if they’re under five or preschool, getting the health visitor involved. If they’re school age, perhaps contacting the school nurse, who won’t necessarily know that child. But if you contact them, then they’ll find out who that child is, if you think he needs some help from other healthcare professionals to try and get that child’s… [Jaz] The thing where I get stuck here, Christine, I think what a lot of colleagues will get stuck here is first line makes a lot of sense. Work on local measures, bring them back and make sure they’re engaging, and that’s fantastic. That’s really good advice. Second line of multi-agency, it’s always, I think that there’s not a hard thing to do, but the hard thing about that is getting the parent’s consent. That’s always the bit where it gets a little bit scary for the dentist because they’re worried about backlash from the parent. They’re worried about emotions. They’re worried about all sorts of consequences. So any advice on dentists who are scared about how parents may react? Because obviously like, as a father, we look after our children very well, and sometimes things happen in life. And if someone was to say to me, share a concern, you may be thinking that you’re doing a good job, you’d be livid. You’d be all like the, all the seven stages of denial, not denial, grief, like in grief, about that. And then you can get anger and denial and all that kind of stuff. So, that’s probably the challenge in the managing the parent and getting permission and consent. So when it comes to like contacting the school nurse, for example, yes, ideally we need consent to do that. [Christine] Ideally, yes, but if you have got a welfare concern, then you can do it without consent. If you’re raising a notification of concern, there’s usually a tick box on that form. If you’re referring to social services or raising an early notification of concern, those forms are called different things, but on it somewhere will say, parent is aware of referral, and there’ll be a tick box, and sometimes I have to tick no. Because I can’t get hold of the parent to tell them. They will find out that it was dental, because there’ll be some concern about teeth and somebody will want to look in their mouth, so they will find out. I find those conversations easier if I’ve been able to talk to them before. You do get upset parents who think you’re judging them. I usually explain, like, my priority is your child’s health, as I am sure it is yours, and I want to work together with you to make sure that they’re okay and they can have the best outcome from dental health and their broader health, and I have to make that referral to get you some help with this. So I would say probably lots of your breaking bad news skills come into it as well. And generally, dentists should be reassured, we’re actually quite good at that. Because often we have to give bad news, teeth coming out, unable to give them the smile that they want. You know, we use our skills that way. So it is an extension of those skills as well. I don’t think we give ourself enough credit, because we are actually much better at doing that, because we probably do it more commonly than people think. So, yeah. But I totally get your point. And I’m a parent myself, and if the school phoned me and said, oh, we are concerned, my initial reaction would be probably one of shock, but you always… [Jaz] Shock, embarrassment, all these kind of things. As a parent, you think, but you know what, if at that stage a parent is embarrassed, it shows that they do care maybe, and they might then say that, you know what, I’m really sorry, there’s been other things going on, I’m gonna engage. And that’s the ideal response you want from a parent. [Christine] And long term you’re thinking, at least they have my child’s wellbeing at the core of what they’re doing. It does take a bit and a bit of logical thinking for the parent to get to that, but yeah. So sometimes if I’m struggling, and I’m human, so I struggle with these emotions as well, just be careful you’re not taking on their guilt, so that you’re not taking on the parent’s guilt. You didn’t put the caries there. You’re the dentist, you’ve seen it, but we’re all quite empathic. Lots of dentists are really empathic, so be really careful that the feelings that you are feeling are not the parents’ feelings. You’re not taking them on. You didn’t put the caries there. Your job is to help and do what you can to help. And you will feel rubbish that you’ve upset someone. And that’s human. That’s human. But the guilt and the feeling of that isn’t yours. [Jaz] Well done. [Christine] That’s not yours. [Jaz] That’s such a great point. I think to always have that frame of, I am doing this for that child. I’m doing this for this child’s future. And when you wear, when you put that hat on, rather than I’m gonna let someone down, it’s much more powerful to say, I’m gonna help this child, rather than I have to give bad news. And I think when that self-talk, that pep talk is there in that way, I can imagine that being very helpful. Thankfully, I’ve never had to make such a referral. When I was in the NHS, had some times where we discussed it as a practice, but I can imagine it’s a very tough thing to do. But what you’ve given today is some good exercises, some good scripts. The biggest takeaway for me is not to ask the parent that, hey, is it okay if I refer here? It’s like, hey, I have some concerns. I’d like to get in touch with the GP and, not, I’d like to, I’ll be getting in touch with the GP and the school nurse just to make sure that your child’s being well looked after, ’cause our priority is your child’s health. So, I’m just saying, you know, I’ll be doing that. But we’ll be seeing you in a few months’ time for your appointment. Can you make sure that in time, can you do this, this, and this so that their health is well looked after? [Christine] Absolutely. [Jaz] How does that sound to you, Christine? [Christine] Absolutely, and I would say if anyone is ever struggling, what I always go back to is, what do I want that child to think about in years to come? When they’re grown up and they’re an adult and they can look back, do I want them to look back and say, that dentist Christine, she saw me and knew I needed help and did X, Y, Z, or, that dentist saw me and knew I needed help and did nothing. And I never… [Jaz] Because a child doesn’t know, like they don’t know that they, at that moment, you know? And that’s a tragic truth. [Christine] And I never want to personally be, and I never want any of my dental colleagues to be, the last health professional to see a child that something then horrific happens to. [Jaz] That’s a very powerful message. Christine, I’m gonna end at that point because that’s such a powerful thing, that you need to remember why we do this. And if you are involved in seeing children, that’s a real strong duty of care. Now thankfully, thankfully, it depends on where you practice in the world, but thankfully it’s not a common thing. But it’s an important thing. And it may, depending on, you may come across this, it’s a bit like oral cancer, right? It’s not like super common. Like we do our oral cancer screening every single time, and in your lifetime you might find a few. And I imagine it’s similar here, like if you’re looking for it, firstly it starts as screening, looking for it. We all do the training for oral cancer, red patches, and then a bit like that, like quite a lot of times we refer and nothing comes of it, because actually it’s fine. Or they have their management plan. So if we start treating these issues a bit like mouth cancer and not being afraid that it’s a dud referral, but actually sometimes like in painless, and they keep checking up and whatnot, and so I think that, I don’t know if that analogy works for you, Christine. [Christine] No, it absolutely does. And in the same way with oral cancer, you can absolutely save a child’s life or improve their life, improve their family’s life, improve the community’s life. You think what an awful impact that would have if something awful happened to the child, to the family, to the community you work in. So you can make a huge difference. And don’t be hard on yourself about it. [Jaz] Christine, thank you so much for just a wonderful guidance that you’re providing dentists and all the research that you’ve done. I think you’ve made it really tangible for us. Where can we learn more from you? What are the resources you recommend? Obviously, you can email me some, I’ll put them in the show notes, but tell us about if you wanna send some message or thanks or connecting. What’s the best way to do? [Christine] So if anyone does want to come and hear me speak, I’ll be speaking at the Scottish Dental Show in June. So that one’s in Glasgow, so it’s local for me, so that one’s easy. I usually, I run, if you’re in Scotland, I do some NES webinars there as well. I’m always very happy for anyone, anywhere, to email me about any questions they’ve got, so I can give you my email address, Jaz, you can share that. And definitely have a look at the BSPD guidelines on dental neglect. They’re really good. [Jaz] I’ll make those available as well. [Christine] Yeah, absolutely. [Jaz] Amazing. Thank you so much, Christine. We appreciate it. [Christine] You’re very welcome. Jaz’s Outro: Well, there we have it, guys. Thank you so much for listening all the way to the end. This is a recommended topic by the GDC, so you can claim your CPD for this and all the other episodes that we have. If you are a paying member of Protrusive, head over to protrusive.co.uk/ultimate to find out how you can unlock CPD for the episodes and access our vast library of videos and masterclasses from splint course to crown preps and everything in between. Now below in the show notes, I’ll give a link to any of the guidelines that Christine promised. And of course, if you want the full PDF premium notes, they are available for our members on the Protrusive Guidance app. If you find these episodes helpful, please tell a colleague, tell a friend. It really helps team Protrusive to grow and serve more dentists and therefore serve more patients. Thank you, dear friends, I’ll catch you same time, same place next week. Bye for now.

Let’s be honest – the occlusion after Aligner cases can be a little ‘off’ (even after fixed appliances!) How do you know if your patient’s occlusion after aligner treatment is acceptable or risky? What practical guidelines can general dentists follow to manage occlusion when orthodontic results aren’t textbook-perfect? Jaz and Dr. Jesper Hatt explore the most common challenges dentists face, from ClinCheck errors and digital setup pitfalls to balancing aesthetics with functional occlusion. They also discuss key strategies to help you evaluate, guide, and optimize occlusion in your patients, because understanding what is acceptable and what needs intervention can make all the difference in long-term treatment stability and patient satisfaction. https://youtu.be/e74lUbyTCaA Watch PDP250 on YouTube Protrusive Dental Pearl: Harmony and Occlusal Compatibility Always ensure restorative anatomy suits the patient’s natural occlusal scheme and age-related wear. If opposing teeth are flat and amalgam-filled, polished cuspal anatomy will be incompatible — flatten as needed to conform. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Common mistakes in ClinCheck planning often stem from occlusion issues. Effective communication and documentation are crucial in clinical support. Occlusion must be set correctly to ensure successful treatment outcomes. Understanding the patient’s profile is essential for effective orthodontics. Collaboration between GPs and orthodontists can enhance patient care. Retention of orthodontic results is a lifelong commitment. Aesthetic goals must align with functional occlusion in treatment planning. Informed consent is critical when discussing potential surgical interventions. The tongue plays a crucial role in orthodontic outcomes. Spacing cases should often be approached as restorative cases. Aligners can achieve precise spacing more effectively than fixed appliances. Enamel adjustments may be necessary for optimal occlusion post-treatment. Retention strategies must be tailored to individual patient needs. Case assessment is vital for determining treatment complexity. Highlights of this episode: 00:00 Teaser 00:59 Intro 02:53  Pearl – Harmony and Occlusal Compatibility 05:57 Dr. Jesper Hatt Introduction 07:34 Clinical Support Systems 10:18 Occlusion and Aligner Therapy 20:41 Bite Recording Considerations 25:32 Collaborative Approach in Orthodontics 30:31 Occlusal Goals vs. Aesthetic Goals 31:42 Midroll 35:03 Occlusal Goals vs. Aesthetic Goals 35:25 Challenges with Spacing Cases 42:19 Occlusion Checkpoints After Aligners 50:17 Considerations for Retention 54:55 Case Assessment and Treatment Planning 58:14 Key Lessons and Final Thoughts 01:00:19 Interconnectedness of Body and Teeth 01:02:48 Resources for Dentists and Case Support 01:04:40 Outro Free Aligner Case Support!Send your patient’s case number and get a full assessment in 24 hours—easy, moderate, complex, or referral. Plus, access our 52-point planning protocol and 2-min photo course. No uploads, no cost. [Get Free Access Now] Learn more at alignerservice.com If you enjoyed this episode, don’t miss: Do’s and Don’ts of Aligners [STRAIGHTPRIL] – PDP071 #PDPMainEpisodes #OcclusionTMDandSplints #OrthoRestorative This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and C. AGD Subject Code: 370 ORTHODONTICS (Functional orthodontic therapy) Aim: To provide general dentists with practical guidance for managing occlusion in aligner therapy, from bite capture to retention, including common pitfalls, functional considerations, and case selection. Dentists will be able to – Identify common errors in digital bite capture and occlusion setup. Understand the impact of anterior inclination and mandibular movement patterns on occlusal stability. Plan retention strategies appropriate for aligner and restorative cases. Click below for full episode transcript: Teaser: The one thing that we always check initially is the occlusion set correct by the aligner company. Because if the occlusion is not set correctly, everything else just doesn't matter because the teeth will move, but into a wrong position because the occlusion is off from the beginning. I don't know about you, but if half the orthodontists are afraid of controlling the root movements in extraction cases, as a GP, I would be terrified. Teaser:I don’t care if you just move from premolar to premolar or all the teeth. Orthodontics is orthodontics, so you will affect all the teeth during the treatment. The question’s just how much. Imagine going to a football stadium. The orthodontist will be able to find the football stadium.  If it’s a reasonable orthodontist, he’ll be able to find the section you’re going to sit in, and if he’s really, really, really good, he will be able to find the row that you’re going to sit in, but the exact spot where you are going to sit… he will never, ever be able to find that with orthodontics. Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati. Welcome back to your favorite dental podcast. I’m joined today by our guest, Dr. Jesper Hatt. All this dentist does is help other dentists with their treatment plans for aligners. From speaking to him, I gather that he’s no longer practicing clinically and is full-time clinical support for colleagues for their aligner cases. So there’s a lot we can learn from someone who day in day out has to do so much treatment planning and speaking to GDPs about their cases, how they’re tracking, how they’re not tracking, complications, and then years of seeing again, okay, how well did that first set of aligners actually perform? What is predictable and what isn’t? And as well as asking what are the most common errors we make on our ClinChecks or treatment plan softwares. I really wanted to probe in further. I really want to ask him about clinical guidelines for occlusion after ortho. Sometimes we treat a case and whilst the aesthetics of that aligner case is beautiful, the occlusion is sometimes not as good. So let’s talk about what that actually means. What is a not-good occlusion? What is a good occlusion? And just to offer some guidelines for practitioners to follow because guess what? No orthodontist in the world is gonna ever get the occlusion correct through ortho. Therefore, we as GPs are never gonna get a perfect textbook occlusion, but we need to understand what is acceptable and what is a good guideline to follow. That’s exactly what we’ll present to you in this episode today. Dental PearlNow, this is a CE slash CPD eligible episode and as our main PDP episode, I’ll give you a Protrusive Dental Pearl. Today’s pearl is very much relevant to the theme of orthodontics and occlusion we’re discussing today, and it’s probably a pearl I’ve given to you already in the past somewhere down the line, but it’s so important and so key. I really want to just emphasize on it again. In fact, a colleague messaged me recently and it reminded me of this concept I’m about to explain. She sent me an image of a resin bonded bridge she did, which had failed. It was a lower incisor, and just a few days after bonding, it failed. And so this dentist is feeling a bit embarrassed and wanted my advice. Now, by the way, guys, if you message me for advice on Instagram, on Facebook, or something like that, it’s very hit and miss. Like my priorities in life are family, health, and everything that happens on Protrusive Guidance. Our network. If you message me outside that network, I may not see it. The team might, but I may not see it. It’s the only way that I can really maintain control and calm in my life. The reason for saying this, I don’t want anyone to be offended. I’m not ignoring anyone. It’s just the volume of messages I get year on year, they’re astronomical. And I don’t mind if you nudge me. If you messaged me something weeks or months ago and I haven’t replied, I probably haven’t seen it. Please do nudge me. And the best place to catch me on is Protrusive Guidance. If you DM me on Protrusive Guidance, home of the nicest and geekiest dentists in the world, that’s the only platform I will log in daily. That’s our baby, our community. Anyway, so I caught this Facebook message and it was up to me to help this colleague. And one observation I made is that the lower teeth were all worn. The upper teeth were really worn, but this resin bonded bridge pontic, it just looked like a perfect tooth. The patient was something like 77 or 80. So it really made me think that, okay, why are we putting something that looks like a 25-year-old’s tooth in a 77-year-old? But even forgetting age and stuff, you have to look at the adjacent teeth in the arch. Is your restoration harmonious with the other teeth in the arch, and of course is the restoration harmonious with what’s opposing it? Because it’s just not compatible. So part one of this pearl is make sure any restoration you do, whether it’s direct or indirect, is harmonious with the patient’s arch and with the opposing teeth and with their occlusal scheme. Because otherwise, if you get rubber dam on and you give your 75-year-old patient beautiful composite resin, it’s got all that cuspal fissure pattern and anatomy, and you take that rubber dam off and you notice that all the other teeth are flat and the opposing teeth are flat amalgams, guess what? You’re gonna be making your composite flat, whether you like it or not. You created a restoration that’s proud, right? That’s why you did not conform to the patient’s own arch or existing anatomical scheme. So the part B of this is the thing that I get very excited to talk about, right? So sometimes you have a worn dentition, but then you have one tooth that’s not worn at all. It’s like that in-standing lateral incisor, right? Think of an upper lateral incisor that’s a bit in-standing, and you see some wear on all the incisors, but that lateral incisor does not have any wear in it because it was never in the firing line. It was never in function. It was never in parafunction. Now, if you give this patient aligners or fixed appliances, you’re doing ortho and you’re now going to align this lateral incisor. So it’s now gonna eventually get into occlusion and it will be in the functional and parafunctional pathways of this patient. Do you really think you can just leave that incisor be? No. It’s not gonna be compatible with the adjacent teeth. It’s not going to be compatible with the opposing tooth and the occlusal scheme. So guess what? You have to get your bur out or your Sof-Lex disc out, and you have to bake in some years into that tooth. Or you have to build up all the other teeth if appropriate for that patient. You’ve just gotta think about it. And I hope that makes sense so you can stay out of trouble. You’re not gonna get chipping and you can consent your patient appropriately for enamel adjustment, which is something that we do talk about in this episode. I think you’re in for an absolute cracker. I hope you enjoy. I’ll catch you in the outro. Main Episode: Doctor Jesper Hatt, thank you so much for coming to Protrusive Dental Podcast. We met in Scandinavia, in Copenhagen. You delivered this wonderful lecture and it was so nice to connect with you then and to finally have you on the show. Tell us, how are you, where in the world are you, and tell us about yourself. [Jesper] Well, thank you for the invitation, first of all. Well, I’m a dentist. I used to practice in Denmark since I originally come from Denmark. My mother’s from Germany, and now I live in Switzerland and have stopped practicing dentistry since 2018. Now I only do consulting work and I help doctors around the world with making their aligner business successful. [Jaz] And this is like probably clinical advice, but also like strategic advice and positioning and that kinda stuff. Probably the whole shebang, right? [Jesper] Yeah. I mean, I have a team around me, so my wife’s a dentist as well, and I would say she’s the expert in Europe on clear aligners. She’s been working for, first of all, our practice. She’s a dentist too. She worked with me in the practice. We practiced together for 10 years. Then she became a clinical advisor for Allion Tech with responsibility for clinical support of Scandinavia. She was headhunted to ClearCorrect, worked in Basel while I was doing more and more consulting stuff in Denmark. So she was traveling back and forth, and I considered this to be a little bit challenging for our family. So I asked her, well, why don’t we just relocate to Switzerland since ClearCorrect is located there? And sure we did. And after two years she told me, I think clinical support, it’s okay. And I like to train the teams, but I’d really like to do more than that because she found out that doctors, they were able to book a spot sometime in the future, let’s say two weeks out in the future at a time that suited the doctors… no, not the doctors, ClearCorrect. Or Invisalign or whatever clear aligner company you use. So as a doctor, you’re able to block the spot and at that time you can have your 30 minutes one-on-one online with a clinical expert. And she said it’s always between the patients or administrative stuff. So they’re not really focused on their ClearCorrect or clear aligner patient. And so they forget half of what I tell them. I can see it in the setups they do. They end up having to call me again. It doesn’t work like that. I would like to help them. [Jaz] It’s a clunky pathway of mentorship. [Jesper] Yes. And so she wanted to change the way clinical support was built up. So we do it differently. We do it only in writing so people can remember what we are telling them. They can always go back in the note and see what’s been going on, what was the advice we gave them, and we offer this co-creation support where we take over most of the treatment planning of the ClearCorrect or Clear Aligner or Spark or Invisalign or Angel Aligner treatment planning. So we do all the digital planning for the doctor, deliver what we think would be right for the patient based on the feedback we initially got from the doctor. And then the doctor can come back and say, well, I’d like a little more space for some crowns in the front, or I would like the canines to be in a better position in order to achieve immediate post disclusion. And so we can go into this discussion back and forth and adjust the digital setup in a way that is more realistic and predictable and do it all for the doctors. So they, on an average, they spend four to six hours less chair time when they use that kind of service compared to if they do everything themselves. And on top of that, you can put your planning time. She was responsible for that and it works quite well. I still remember when we initially got on all these online calls and we would see fireworks in the background and confetti coming down from the top and all of that. [Jaz] Exactly. So excuse that little bit, but okay. So essentially what you’re doing is, for an aligner user myself, for example, you’re doing the ClinChecks, you are helping, supporting with the ClinChecks, the planning. And I’ve got a lot of questions about that. The first question I’ll start with, which is off the script, but there’s probably a hundred different mistakes that could happen in a ClinCheck, right? But what is the most repeatable, predictable, common mistake that you’ll see when a new user sends a case to you to help them with their planning? What’s the most common mistake that you will see in a setup? [Jesper] Two things, actually. The one thing that we always check initially is the occlusion set correct by the aligner company. Because if the occlusion is not set correctly, everything else just doesn’t matter because the teeth will move but into a wrong position because the occlusion is off from the beginning. And so we always check that as the first part. How does this— [Jaz] So let’s talk about that ’cause that might be confusing for a younger colleague because they’re like, hey, hang on a minute. I scanned the bite left and right. What do you mean the occlusion is wrong? Because surely that gets carried through into what I see on the ClinCheck. So what do you think is the mechanism for this to happen? [Jesper] Two different reasons. I’m from a time when I graduated in 2003, so that was before digital dentistry. So when I went to the Pankey Institute and learned everything about functional occlusion and all of that stuff, I also found out that most of my patients, when I put silicone impression material between the teeth and asked the patients to bite together, they would always protrude a little bit unless I instructed them to bite hard on the posterior teeth. And when we got the scanners, when we put a scanner into the cheek and pull the cheek, most patients, when we asked them to bite together to do the intraoral scan of the bite, they also protruded a little bit, not much, but enough to set the bite wrong. So that is the one challenge when the technicians of the aligner companies put the models together. The other challenge is that some of the aligner companies, they let the technicians set the models. We always, as the first thing when we see a case, we always look at the photos, the clinical photos. And that’s why the clinical photos have to be of great quality. So we look at the clinical photos of the patient— [Jaz] And also in those clinical photos, Jesper, you have to coach them correctly to bite. You have to notice if they’re biting wrong even in the photos ’cause then it just duplicates the error. And that’s why good photography and actually being able to coach the patient is so imperative. [Jesper] Yes, that’s correct. But we compare the two and usually if we see a difference, we ask the doctor, is what we see in the photo correct, or is what we see on the digital models correct? And because we don’t like differences. So that would be the first step to look for. And what’s the second? The second thing is that when you look at the setup, the anterior teeth are usually—I’m trying to show you—the anterior teeth are very, very steep. Typically with aligners it’s a lot easier to tip the crowns. So when you have a class II patient, deviation one, where the anteriors are in a forward position, proclined, and you have a lot of space between the anteriors of the maxilla and the mandible, then the easiest thing on a digital setup is to just retrocline the anteriors of the upper to make them fit the lowers, which you could then procline a little bit, but usually you have very steep relationships between the two and this— [Jaz] So you’re more likely to restrict the envelope of function, functional interference anteriorly. You are obviously reducing the overjet, but you may end up reducing like a wall contact rather than an elegant, more open gate. [Jesper] Yes. And there’s another dimension to this because when we work with orthodontics, one of the most important things to look for is actually the profile of the patient. Because let’s say I’m trying to illustrate this now, so I hope you get a 90— [Jaz] So describe it for our audio listeners as well. So we’re looking at a profile view of Jesper. [Jesper] Yes. So I’m turning the side to the camera. I hope you can see my profile here. So let’s say I had flared anterior maxillary teeth and I wanted to retrocline them. It would have an effect on my upper lip, so the lip would fall backwards if I just retrocline everything. And every millimeter we move the anteriors in the maxilla in a posterior direction, we will have a potential lip drop of three millimeters. In addition, if we don’t get the nasolabial angulation correct, we risk the lower face will simply disappear in the face of the patient. So soft tissue plays a role here, so we cannot just retrocline the teeth. It looks great on the computer screen, but when it comes to reality, we’ll have a functional challenge. We’ll have a soft tissue support challenge, and in addition we’ll have long-term retention challenges as well. Because when you have a steep inclination, the anterior teeth in the mandible, they don’t have any kind of support. They will not be stopped by anything in the maxillary teeth, which you would if you had the right inclination between the teeth, which would be about 120 degrees. So why do aligner companies always set the teeth straight up and down in the anterior part? We wondered about this for years. We don’t have a strict answer. We don’t know exactly why it’s like this, but I have a hunch. I think there are two things to it. First of all, the easiest thing to do with aligners is to move the crown, so we can just tip the teeth. You take them back, you make a lot of IPR, and then you just tip them so they’re retroclined. Secondly, all aligner companies, they come from the United States. And in the United States there is a higher representation of class III patients. Now why is that important? All our patients can be put into two different categories in regards to how they move their mandible. They are the crocodiles that only open and close, like move up and down, and then we have the cows. And then we have the cows that move the mandible around, or the camels. I mean, every camel, if you’ve seen a camel chew, it’s just moving from side to side. [Jaz] Horses as well. Horses as well. [Jesper] They kind of do that. [Jaz] But I’m glad you didn’t say rats ’cause it’s more elegant to be a crocodile than a rat. [Jesper] Exactly. And I usually say we only tell the crocodiles. So why is this a challenge and why isn’t it a challenge with class III patients? Well, all real class III patients act like crocodiles, so they don’t move them side to side. From a functional perspective, it’s really not a problem having steep anterior inclination or steep relationships as long as you have a stable stop where the anteriors—so the anteriors will not elongate and create the red effect. So they just elongate until they hit the palate. If you can make a stop in the anterior part of the occlusion, then you’ll have some kind of stability with the class III patients. But with class II patients, we see a lot more cows. So they move the mandible from side to side and anterior and back and forth and all… they have the mandible going all kinds of places. And when they do that, we need some kind of anterior guidance to guide the mandible. I usually say the upper jaw creates the framework in which the mandible will move. So if the framework is too small, we fight the muscles. And whenever we fight the muscles, we lose because muscles always win. It doesn’t matter if it’s teeth, if it’s bone, if it’s joints, they all lose if they fight the muscles— [Jaz] As Peter Dawson would say, in the war between teeth and muscles or any system and muscles, the muscles always win. Absolutely. And the other analogy you remind me of is the maxilla being like a garage or “garage” from UK, like a garage. And the mandible being like the car, and if you’re really constrained, you’re gonna crash in and you’re gonna… everything will be in tatters. So that’s another great way to think about it. Okay. That’s very, very helpful. I’m gonna—’cause there’s so much I wanna cover. And I think you’ve really summed up nicely. But one thing just to finish on this aspect of that common mistake being that the upper anteriors are retroclined, really what you’re trying to say is we need to be looking at other modalities, other movements. So I’m thinking you’re saying extraction, if it’s suitable for the face, or distalisation. Are you thinking like that rather than the easier thing for the aligners, which is the retrocline. Am I going about it the right way? [Jesper] Depends on the patient. [Jaz] Of course. [Jesper] Rule of thumb: if you’re a GP, don’t ever touch extraction cases. Rule of thumb. Why? Because it is extremely challenging to move teeth parallel. So you will most—especially with aligners—I mean, I talk with a very respected orthodontist once and I asked him, well, what do you think about GPs treating extraction cases where they extract, you know, two premolars in the maxilla? And he said, well, I don’t know how to answer this. Let me just explain to you: half of my orthodontist colleagues, they are afraid of extraction cases. And I asked them why. Because it’s so hard to control the root movement. Now, I don’t know about you— [Jaz] With aligners. We’re specifically talking about aligners here, right? [Jesper] With all kinds of orthodontic appliances. [Jaz] Thank you. [Jesper] So now, I don’t know about you, but if half the orthodontists are afraid of controlling the root movements in extraction cases, as a GP, I would be terrified. And I am a GP. So I usually say, yeah, sometimes you will have so much crowding and so little space in the mandible, so there’s an incisor that is almost popped out by itself. In those cases, yes. Then you can do an extraction case. But when we’re talking about premolars that are going to be extracted, or if you want to close the space in the posterior part by translating a tooth into that open space, don’t. It’s just the easiest way to end up in a disaster because the only thing you’ll see is just teeth that tip into that space, and you’ll have a really hard time controlling the root movements, getting them corrected again. [Jaz] Well, thank you for offering that guideline. I think that’s very sage advice for those GPs doing aligners, to stay in your lane and just be… the best thing about being a GP, Jesper, is you get to cherry pick, right? There’s so many bad things about being a GP. Like you literally have to be kinda like a micro-specialist in everything in a way. And so sometimes it’s good to be like, you know what, I’ll keep this and I’ll send this out. And being selective and case selection is the crux of everything. So I’m really glad you mentioned that. I mean, we talked and touched already on so much occlusion. The next question I’m gonna ask you then is, like you said, a common error is the bite and how the bite appears on the ClinCheck or whichever software a dentist is using. Now, related to bite, vast majority of orthodontic cases are treated in the patient’s existing habitual occlusion, their maximum intercuspal position. Early on in my aligner journey, I had a patient who had an anterior crossbite. And because of that anterior crossbite, their jaw deviated. It was a displaced—the lower jaw displaced. And then I learned from that, that actually for that instance, perhaps I should not have used an MIP scan. I should have used more like centric relation or first point of contact scan before the displacement of the jaw happens. So that was like always in my mind. Sometimes we can and should be using an alternative TMJ position or a bite reference other than MIP. Firstly, what do you think about that kind of scenario and are there any other scenarios which you would suggest that we should not be using the patient’s habitual occlusion for their bite scan for planning orthodontics? [Jesper] Well, I mentioned that I was trained at the Pankey Institute, and when you start out right after—I mean, I spent 400 hours over there. Initially, I thought I was a little bit brainwashed by that because I thought every single patient should be in centric relation. Now, after having put more than 600 patients on the bite appliance first before I did anything, I started to see some patterns. And so today, I would say it’s not all patients that I would get into centric relation before I start treating the teeth. But when we talk about aligner therapy and orthodontic treatment, I think it’s beneficial if you can see the signs for those patients where you would say, hmm, something in the occlusion here could be a little bit risky. So let’s say there are wear facets on the molars. That will always trigger a red flag in my head. Let’s say there are crossbites or bite positions that kind of lock in the teeth. We talked about class III patients before, and I said if it’s a real skeletal-deviation class III patient, it’s a crocodile. But sometimes patients are not real class III skeletal deviation patients. They’re simply being forced into a class III due to the occlusion. That’s where the teeth fit together. So once you put aligners between the teeth and plastic covers the surfaces, suddenly the patients are able to move the jaws more freely and then they start to seat into centric. That may be okay. Usually it is okay. The challenge is consequences. So when you’re a GP and you suddenly see a patient moving to centric relation and you find out, whoa, on a horizontal level there’s a four- to six-millimeter difference between the initial starting point and where we are now, and maybe we create an eight-millimeter open bite in the anterior as well because they simply seat that much. And I mean, we have seen it. So is this a disaster? Well, it depends. If you have informed the patient well enough initially and said, well, you might have a lower jaw that moves into a different position when we start out, and if this new position is really, really off compared to where you are right now, you might end up needing maxillofacial surgery, then the patient’s prepared. But if they’re not prepared and you suddenly have to tell them, you know, I think we might need maxillofacial surgery… I can come up with a lot of patients in my head that would say, hey doctor, that was not part of my plan. And they will be really disappointed. And at that point there’s no turning back, so you can’t reverse. So I think if you are unsure, then you are sure. Then you should use some kind of deprogramming device or figure out where is centric relation on this patient. If there isn’t that much of a difference between maximum intercuspation and centric— [Jesper] Relation, I don’t care. Because once you start moving the teeth, I don’t care if you just move from premolar to premolar or all the teeth. Orthodontics is orthodontics, so you will affect all the teeth during the treatment. The question’s just how much. And sometimes it’s just by putting plastic between the teeth that you will see a change, not in the tooth position, but in the mandibular position. And I just think it’s nicer to know a little bit where this is going before you start. And the more you see of this—I mean, as I mentioned, after 600 bite appliances in the mouths of my patients, I started to see patterns. And sometimes in the end, after 20 years of practicing, I started to say, let’s just start, see where this ends. But I would always inform the patients: if it goes totally out of control, we might end up needing surgery, and there’s no way to avoid it if that happens. And if the patients were okay with that, we’d just start out. Because I mean, is it bad? No. I just start the orthodontic treatment and I set the teeth as they should be in the right framework. Sometimes the upper and the lower jaw don’t fit together. Well, send them to the surgeon and they will move either the upper or the lower jaw into the right position, and then we have it. No harm is done because we have done the initial work that the orthodontist would do. But I will say when I had these surgical patients—let’s say we just started out with aligners and we figured, I can’t control this enough. I need a surgeon to look at this—then I would send them off to an orthodontist, and the orthodontist and the surgeon would take over. Because then—I mean, surgical patients and kids—that’s the second group of patients besides the extraction cases that I would not treat as a GP. ‘Cause we simply don’t know enough about how to affect growth on kids. And when it comes to surgery, there’s so much that is… so much knowledge that we need to know and the collaboration with the surgeons that we’re not trained to handle. So I think that should be handled by the orthodontists as well. [Jaz] I think collaborative cases like that are definitely specialist in nature, and I think that’s a really good point. I think the point there was informed consent. The mistake is you don’t warn the patient or you do not do the correct screening. So again, I always encourage my guests—so Jesper, you included—that we may disagree, and that’s okay. That’s the beauty of dentistry. So something that I look for is: if the patient has a stable and repeatable maximum intercuspal position, things lock very well, and there’s a minimal slide—like I use my leaf gauge and the CR-CP is like a small number of leaves and the jaw hardly moves a little bit—then there’s no point of uncoupling them, removing that nice posterior coupling that they have just to chase this elusive joint position. Then you have to do so many more teeth. But when we have a breakdown in the system, which you kind of said, if there’s wear as one aspect, or we think that, okay, this patient’s occlusion is not really working for them, then we have an opportunity to do full-mouth rehabilitation in enamel. Because that’s what orthodontics is. And so that’s a point to consider. So I would encourage our GP colleagues to look at the case, look at the patient in front of you, and decide: is this a stable, repeatable occlusion that you would like to use as a baseline, or is there something wrong? Then consider referring out or considering—if you’re more advanced in occlusion studies—using an alternative position, not the patient’s own bite as a reference. So anything you wanna add to that or disagree with in that monologue I just said there? [Jesper] No, I think there’s one thing I’d like the listeners to consider. I see a lot of fighting between orthodontists and GPs, and I think it should be a collaboration instead. There’s a lot of orthodontists that are afraid of GPs taking over more and more aligner treatments, and they see a huge increase in the amount of cases that go wrong. Well, there’s a huge increase of patients being treated, so there will be more patients, just statistically, that will get into problems. Now, if the orthodontist is smart—in my opinion, that’s my opinion—they reach out to all their referring doctors and they tell them, look, come in. I will teach you which cases you can start with and which you should refer. Let’s start there. Start your aligner treatments. Start out, try stuff. I will be there to help you if you run into problems. So whenever you see a challenge, whenever there’s a problem, send the patient over to me and I’ll take over. But I will be there to help you if anything goes wrong. Now, the reason this is really, really a great business advice for the orthodontists is because once you teach the GPs around you to look for deviations from the normal, which would be the indication for orthodontics, the doctors start to diagnose and see a lot more patients needing orthodontics and prescribe it to the patients, or at least propose it to the patients. Which would initially not do much more than just increase the amount of aligner treatments. But over time, I tell you, all the orthodontists doing this, they are drowning in work. So I mean, they will literally be overflown by patients being referred by all the doctors, because suddenly all the other doctors around them start to diagnose orthodontically. They see the patients which they haven’t seen before. So I think this is—from a business perspective—a really, really great thing for the orthodontists to have a collaboration with this. And it’ll also help the GPs to feel more secure when they start treating their patients. And in the end, that will lead to more patients getting the right treatment they deserve. And I think that is the core. That is what’s so important for us to remember. That’s what we’re here for. I mean, yes, it’s nice to make money. We have to live. It’s nice with a great business, but what all dentists I know of are really striving for is to treat their patients to the best of their ability. And this helps them to do that. [Jaz] Ultimate benefactor of this collaborative approach is the patient. And I love that you said that. I think I want all orthodontists to listen to that soundbite and take it on board and be willing to help. Most of them I know are lovely orthodontists and they’re helping to teach their GPs and help them and in return they get lots of referrals. And I think that’s the best way to go. Let’s talk a little bit about occlusal goals we look for at the end of orthodontics. This is an interesting topic. I’m gonna start by saying that just two days ago I got a DM from one of the Protruserati, his name is Keith Curry—shout out to him on Instagram—and he just sent me a little message: “Jaz, do you sometimes find that when you’re doing alignment as a GP that it’s conflicting the orthodontic, the occlusal goal you’re trying to get?” And I knew what I was getting to. It’s that scenario whereby you have the kind of class II division 2, right? But they have anterior guidance. Now you align everything, okay, and now you completely lost anterior guidance. And so the way I told him is that, you know what, yes, this is happening all the time. Are we potentially at war between an aesthetic smile and a functional occlusion? And sometimes there’s a compromise. Sometimes you can have both. But that—to achieve both—needs either a specialist set of eyes or lots of auxiliary techniques or a lot more time than what GPs usually give for their cases. So first let’s touch on that. Do you also agree that sometimes there is a war between what will be aesthetic and what will be a nice functional occlusion? And then we’ll actually talk about, okay, what are some of the guidelines that we look for at the end of completing an aligner case? [Jesper] Great question and great observation. I would say I don’t think there’s a conflict because what I’ve learned is form follows function. So if you get the function right, aesthetics will always be great. Almost always. I mean, we have those crazy-shaped faces sometimes, but… so form follows function. The challenge here is that in adult patients, we cannot manipulate growth. So a skeletal deviation is a skeletal deviation, which means if we have a class II patient, it’s most likely that that patient has a skeletal deviation. I rarely see a dental deviation. It happens, but it’s really, really rare. So that means that in principle, all our class II and chronic class III patients are surgical patients. However, does that mean that we should treat all our class II and class III patients surgically? No, I don’t think so. But we have to consider that they are all compromise cases. So we need to figure a compromise. So initially, when I started out with my occlusal knowledge, I have to admit, I didn’t do the orthodontic treatment planning. I did it with Heller, and she would give me feedback and tell me, I think this is doable and this is probably a little bit challenging. If we do this instead, we can keep the teeth within the bony frame. We can keep them in a good occlusion. Then I would say, well, you have a flat curve of Spee. I’d like to have a little bit of curve. It’s called a curve of Spee and not the orthodontic flat curve of Spee. And then we would have a discussion back and forth about that. Then initially I would always want anterior coupling where the anterior teeth would touch each other. I have actually changed that concept in my mind and accepted the orthodontic way of thinking because most orthodontists will leave a little space in the anterior. So when you end the orthodontic treatment, you almost always have a little bit of space between the anterior teeth so they don’t touch each other. Why? Because no matter what, no matter how you retain the patient after treatment, there will still be some sort of relapse. And we don’t know where it’ll come or how, but it will come. Because the teeth will always be positioned in a balance between the push from the tongue and from the cheeks and the muscles surrounding the teeth. And that’s a dynamic that changes over the years. So I don’t see retention as a one- or two-year thing. It’s a lifelong thing. And the surrounding tissues will change the pressure and thereby the balance between the tongue and the cheeks and where the teeth would naturally settle into position. Now, that said, as I mentioned initially, if we fight the muscles, we’ll lose. So let’s say we have an anterior open bite. That will always create a tongue habit where the patient positions the tongue in the anterior teeth when they swallow because if they don’t, food and drink will just be splashed out between the teeth. They can’t swallow. It will just be pushed out of the mouth. [Jaz] So is that not like a secondary thing? Like that tongue habit is secondary to the AOB? So in those cases, if you correct the anterior open bite, theoretically should that tongue posture not self-correct? [Jesper] Well, we would like to think so, but it’s not always the case. And there’s several reasons to it. Because why are the teeth in the position? Is it because of the tongue or because of the tooth position? Now, spacing cases is one of those cases where you can really illustrate it really well. It looks really easy to treat these patients. If we take away all the soft tissue considerations on the profile photo, I mean, you can just retract the teeth and you close all the spaces—super easy. Tipping movements. It’s super easy orthodontically to move quickly. Very easy as well. However, you restrict the tongue and now we have a retention problem. So there are three things that can happen. You can bond a retainer on the lingual side or the palatal side of the teeth, upper, lower—just bond everything together—and after three months, you will have a diastema distal to the bonded retainer because the tongue simply pushes all the teeth in an anterior direction. [Jaz] I’ve also seen—and you’ve probably seen this as well—the patient’s tongue being so strong in these exact scenarios where the multiple spacing has been closed, which probably should have been a restorative plan rather than orthodontic plan, and the retainer wire snaps in half. [Jesper] Yes, from the tongue. [Jaz] That always fascinated me. [Jesper] Well, you’ll see debonding all the time, even though you sandblast and you follow all the bonding protocol. And debonding, breaking wires, diastemas in places where you think, how is that even possible? Or—and this is the worst part—or you induce sleep apnea on these patients because you simply restrict the space for the tongue. So they start snoring, and then they have a total different set of health issues afterwards. So spacing—I mean, this just illustrates the power of the tongue and why we should always be careful with spacing cases. I mean, spacing cases, in my opinion, are always to be considered ortho-restorative cases. Or you can consider, do you want to leave some space distal to the canines? Because there you can create an optical illusion with composites. Or do you want to distribute space equally between the teeth and place veneers or crowns or whatever. And this is one of those cases where I’d say aligners are just fabulous compared to fixed appliances. Because if you go to an orthodontist only using fixed appliances and you tell that orthodontist, please redistribute space in the anterior part of the maxilla and I want exactly 1.2 millimeters between every single tooth in the anterior segment, six years later he’s still not reached that goal because it just moves back and forth. Put aligners on: three months later, you have exactly—and I mean exactly—1.2 millimeters of space between each and every single tooth. When it comes to intrusion and extrusion, I would probably consider using fixed appliances rather than aligners if it’s more than three millimeters. So every orthodontic system—and aligners are just an orthodontic system—each system has its pros and cons, and we just have to consider which system is right for this patient that I have in my chair. But back to the tongue issue. What should we do? I mean, yes, there are two different schools. So if you have, let’s say, a tongue habit that needs to be treated, there are those that say we need to get rid of the tongue habit before we start to correct the teeth. And then there are those that say that doesn’t really work because there’s no room for the tongue. So we need to create room for the tongue first and then train the patient to stop the habit. Both schools and both philosophies are being followed out there. I have my preferred philosophy, but I will let the listener start to think about what they believe and follow their philosophy. Because there is nothing here that is right or wrong. And that is— [Jaz] I think the right answer, Jesper, is probably speak to that local orthodontist who’s gonna be helping you out and whatever they recommend—their religion—follow that one. Because then at least you have something to defend yourself. Like okay, I followed the way you said. Let’s fix it together now. [Jesper] That’s a great one. Yeah, exactly. [Jaz] Okay, well just touching up on the occlusion then, sometimes we do get left with like suboptimal occlusions. But to be able to define a suboptimal occlusion… let’s wrap this occlusion element up. When we are completing an orthodontic case—let’s talk aligners specifically—when the aligners come off and the fixed retainers come on, for example, and the patient’s now in retention, what are some of the occlusal checkpoints or guidelines that you advise checking for to make sure that, okay, now we have a reasonably okay occlusion and let things settle from here? For example, it would be, for me, a failure if the patient finishes their aligners and they’re only holding articulating paper on one side and not the other side. That’s for me a failure. Or if they’ve got a posterior open bite bilaterally. Okay, then we need to go refinement. We need to get things sorted. But then where do you draw the line? How extreme do you need to be? Do you need every single tooth in shim-stock foil contact? Because then we are getting really beyond that. We have to give the adaptation some wiggle room to happen. So I would love to know from your learning at Pankey, from your experience, what would you recommend is a good way for a GP to follow about, okay, it may not be perfect and you’ll probably never get perfect. And one of the orthodontists that taught me said he’s never, ever done a case that’s finished with a perfect occlusion ever. And he said that to me. [Jesper] So—and that’s exactly the point with orthodontics. I learned that imagine going to a football stadium. The orthodontist will be able to find the football stadium. If it’s a reasonable orthodontist, he’ll be able to find the section you’re going to sit in. And if he’s really, really, really good, he will be able to find the row that you’re going to sit in. But the exact spot where you are going to sit, he will never, ever be able to find that with orthodontics. And this is where settling comes in and a little bit of enamel adjustments. [Jaz] I’m so glad you said that. I’m so glad you mentioned enamel adjustment. That’s a very dirty word, but I agree with that. And here’s what I teach on my occlusion courses: what we do with aligners essentially is we’re tampering with the lock. Let’s say the upper jaw is the lock. It’s the still one. We’re tampering with the key, which is the lower jaw—the one that moves—we tamper with the key and the lock, and we expect them both to fit together at the end without having to shave the key and to modify the lock. So for years I was doing aligners without enamel adjustment ’cause my eyes were not open. My mind was not open to this. And as I learned, and now I use digital measuring of occlusion stuff and I seldom can finish a case to get a decent—for my criteria, which is higher than it used to be, and my own stat—is part of my own growth that’s happened over time is that I just think it’s an important skill that GPs are not taught and they should be. It’s all about finishing that case. And I think, I agree with you that some adjustment goes a long way. We’re not massacring enamel. It’s little tweaks to get that. [Jesper] Exactly. I like the sound there because sometimes you hear that “ahh,” it doesn’t really sound right, but “tsst,” that’s better. [Jaz] That’s the one. You know, it reminds me of that lecture you did in Copenhagen. You did this cool thing—which I’ve never seen anyone do before. You sat with one leg over the other and you said, okay guys, bite together. Everyone bit together. And then you swapped the legs so the other leg was over the other and bite together. And then you said, okay, whose occlusion felt different? And about a third of the audience put their hand up, I think. Tell us about that for a second. [Jesper] Well, just promise me we go back to the final part because there are some things we should consider. [Jaz] Let’s save this as a secret thing at the end for incentive for everyone to listen to the end—how the leg position changes your occlusion. Let’s talk about the more important thing. I digressed. [Jesper] Let’s talk about the occlusal goals because I think it’s important. I mean, if you do enamel adjustments in the end—so when we finish the treatment, when we come to the last aligner in the treatment plan—I think we should start by breaking things down to the simplest way possible. Start by asking the patient: are you satisfied with the way the teeth look? Yes or no? If she’s satisfied, great. How do you feel about the occlusion? “Well, it fits okay.” Great. Now the patient is happy. There’s nothing she wants to—or he wants to—change. Then you look at the occlusion. Now, it is important to remember that what we see on the computer screen, on the aligner planning tools, will never, ever correspond 100% to what we see in the mouth of the patient. And there are several reasons for that. But one of the things that we have found to be really interesting is that if you take that last step and you say, okay, the occlusion doesn’t fit exactly as on the screen, but it’s kind of there… if you use that last step and you don’t do a re-scan for a retainer, but you use the last step of the aligner treatment as your reference for your aligner retainer… We sometimes see that over six months, if the patient wears that aligner 22 hours a day for another three to six months, the teeth will settle more and more into the aligner and create an occlusion that looks more and more like what you see on the screen. Which to me just tells me that the biology doesn’t necessarily follow the plan everywhere in the tempo that we set throughout the aligner plan. But over time, at the last step, if it’s just minor adjustments, the teeth will actually move into that position if we use the last stage as a reference for the retainer. Now, if we do a scan at that point and use that as a reference for creating an aligner retainer, then we just keep the teeth in that position. Now, if the teeth are a little bit more off— [Jaz] I’m just gonna recap that, Jesper, ’cause I understood what you said there, but I want you to just make sure I fully understood it. When we request, for example, Align, the Vivera retainer, it gives you an option: “I will submit a new scan” or “use the last step.” And actually I seldom use that, but now I realize you’re right. It makes sense. But then on the one hand, if the occlusion is—if the aesthetics are good and the patient’s occlusion feels good, what is your own judgment to decide whether we’re still going to allow for some more settling and occlusal changes to happen over a year using the Vivera retainers based on the ClinCheck last-aligner profile, rather than, okay, let’s just retain to this position? What is making you do the extra work, extra monitoring? [Jesper] To me, it’s not extra monitoring. It’s just basic. I mean, it’s just part of my protocol. I follow the patients. And honestly, to me, it’s just time-saving to just use the last step in the aligner. Because I mean, if the plan is right and if the teeth have been tracking well, they should be in that position. Why do I then need to re-scan for Vivera retainers or for other kinds of retainers? Now, if the occlusion is a little bit more off—and in a minute you’ll probably ask me when do I see which is which, and I can’t really tell you; it’s about experience—but that’s the beauty of this. If I see there’s a little bit more deviation and I like some teeth, the occlusion isn’t really good on one side compared to the other side, I would rather have a bonded retainer from first premolar to first premolar in the mandible, combined with a Hawley or Begg or something like that retainer for the upper. And you can order them with an acrylic plate covering some of the anterior teeth so they keep that position, but that allows the teeth to settle. And over three months you should see some kind of improvement. If you don’t see enough improvement and let’s say you still have a tendency for a kind of an open bite on one side, you can always add some cross elastics, put some buttons on the upper, on the lower, instruct the patient to use these, and then in three months you will have the occlusion you want. Now, once that is established—you have that kind of occlusion—you need to keep the teeth there for at least six months before you do some kind of equilibration or enamel adjustment. Because if you do the enamel adjustment right after you have reached your final destination for the teeth, the teeth will still settle and move. So you do the equilibration, two weeks later everything looks off again. You do the equilibration, two weeks later things have changed again. So I prefer to wait six months before I do the final equilibration. Now, in this equation what we’ve been talking about here, it goes from very simple to more and more complex. And then we have to consider, well, did I expand the mandible posterior segment? If so, I can’t just use a bonded retainer on the lower and I need to add something to keep the teeth out there in combination with whatever I want in the upper. Do I want to keep the Begg retainer or the Hawley, or do I want to change to something differently? So these kinds of considerations have to be there from the beginning of the treatment because, I mean, it costs additional money to order a Begg retainer compared to just an aligner. [Jaz] A Begg retainer is the same as Hawley? [Jesper] Well, no. It has a little different design. [Jaz] Oh, a Begg as in B-E-G-G? [Jesper] Yes. [Jaz] Yeah, got it. Got it. Okay. [Jesper] And then in Denmark we use the Jensen retainer, which is a Danish invention, which goes from canine to canine or from first premolar to first premolar but with a different type of wire which keeps the teeth more in place compared to a round wire. So there are different variations. The most important part here is it allows the posterior teeth to settle so they can move, which they can’t in an aligner to the same degree at least. Now, this is all really nice in teeth that only need to be moved into the right position, but most of our patients are adult patients, or they should at least be adult patients. Most of my patients were more than 30 years old. So if you have a patient with anterior crowding and you move the teeth into the right position where the teeth should be, the teeth are in the right position, but they still look ugly because they have been worn anteriorly by the position they were in when they were crooked. So when we position them, we still need to do some restorative work. Then what? We still need to retain those teeth. The patient wants to be finished now as fast as possible, so we can’t wait the six months to make the final touches. So we have to figure out: what do we do? And then we have to think of some kind of retention strategy to keep the teeth in place during that restorative procedure. And I mean, at the end of an aligner treatment or any orthodontic treatment, two days is enough to have relapse in some patients. Some patients it’s not a problem. The teeth are just there to stay in the same position for three months, and then they start to move a little bit around. But other patients—I mean, you just have to look away and then go back to the teeth and they’re in a different position. You can’t know what kind of patient you have in your chair right now. So you have to consider the way you plan your restorative procedure in regards to how you retain the teeth during that phase. So if you want to do anterior composites or veneers, do it all at once. Put in a bonded retainer, scan, and get your aligner retainer as fast as possible. Or use a Begg or a Hawley or something like that that’s a little bit more flexible. If you want to do crowns, then we have a whole different challenge and then we have to consider how do we then retain the teeth. [Jaz] Okay. Well I think that was lovely. I think that gives us some thoughts and ideas of planning sequence of retention, which is the ultimate thing to consider when it comes to occlusion. Okay, yeah, you get the occlusion, but how do you retain it? But in many cases, as the patient’s wearing aligners, the occlusion is embedding in and is fine. And you take off the aligners, the patient’s happy with how it looks. They bite together. It feels good. You are happy that yes, both sides of the mouth are biting together. Now, it might not be that every single contact is shim-hold, but you got, let’s say, within 20 microns, 40 microns, okay? Then some bedding happens. In that kind of scenario, would you be happy to say, okay, I’m gonna scan your teeth as they are because I’m happy with the occlusion, the occlusal goals are good, and they’re near enough the ClinCheck, and go for the retainers to that position? Or is your default preference as a clinician to go for the Vivera or equivalent based on the last aligner, on the ClinCheck projection? [Jesper] I would still go for the last aligner because I think the planning I’ve done is probably a little bit more precise than what I see clinically. However, I still expect that I will have to do a little bit of enamel reshaping at the end after six months, but that’s okay. I mean, the changes are so small, so you can still use the last aligner or the Vivera retainer that you already have ordered. So it’s not that much of a problem. [Jaz] Which goes back to your previous point: if it’s a big deviation, then you’ve gotta look at the alternative ways, whether you’re gonna go for refinement or you’re gonna allow some occlusal settling with a Hawley and a lower fixed-retainer combination, or the elastics like you said. Okay. Just so we’re coming to the end of the podcast—and I really enjoyed our time—I would like to delve deep into just a final thing, which is a little checklist, a helpful checklist for case assessment that you have for GDPs. [Jesper] Yeah, thank you. First of all, one of the big challenges in a GP practice is being able to take a full series of clinical photos in two minutes without assistance. I think most dentists struggle with that, but that is a foundational prerequisite to any aligner treatment. Once you have the photos, I would sit down with the photos and I would consider six different steps. One: is this a patient that I could treat restoratively only? Because that would be the simplest for me to do. Next, moving up in complexity: would be, do I need periodontal crown lengthening? Or next step would be: do I need to change the vertical dimension, or is there something about centric relation that I should consider? Moving up a little bit on the complexity: are there missing teeth? Do I need to replace teeth with implants? Next step would be orthodontics. So this is step five. The next most complex case we can treat is actually an aligner case—orthodontics in general. And the last part would be: are the teeth actually in the right position in the face of the patient, or do I need surgery to correct the jaw position? So these six steps, I think they’re helpful to follow to just think, how can I break this case down into more easy, digestible bits and pieces to figure out what kind of patient I have in front of me? Now, if you consider it to be an orthodontic case or ortho-restorative case, here comes the challenge: case selection. How do you figure out is this an easy, moderate, complex, or referral case? And here’s the trick: do 500 to 1000 treatment plans or treatments with clear aligners. And then you know. But until then, you really don’t. This is where you should rely on someone you can trust who can help you do the initial case selection. Because you can have two identical patients—one is easy and one is super complex—but they look the same. So it’s really nice if you have done less than 500 cases to have someone who can help you with the case selection. And I don’t say this to sell anything, because we don’t charge for that. Because it’s so essential that we don’t do something that is wrong or gives us a lot of challenges and headaches in the practice. I mean, the practice runs really fast and lean-oriented, so we need to make things digestible, easy to work with. And I think that’s really important. [Jaz] It goes full circle to what we said before about having that referral network, staying in your lane, knowing when to refer out, cherry-picking—it all goes back full circle with that. And not even orthodontics, but restorative dentistry—case selection is just imperative in everything we do. [Jesper] Yes. And there is—we always get the question when we do courses and we do consulting—can’t you just show me a couple of cases that are easy to start with? And it works with implants, kind of. But with orthodontics where we move—I mean, we affect all the teeth—it’s just not possible. I know the aligner companies want to show you some where you say, you can only just do these kinds of cases and they are really easy. The fact is they’re not. But they want to sell their aligners. [Jaz] I get it. They are until they’re not. It’s like that famous thing, right? Everyone’s got a plan until they get punched in the face. So yeah, it can seemingly be easy, but then a complication happens and it’s really about understanding what complications to expect, screening for them, and how you handle that. But thanks so much. Tell us—yeah, go on, sorry. [Jesper] There are three things I’d like to end on here. So, first of all, we’ve been talking together for about an hour about a topic that, if you want to take postgraduate education, it takes three years to become an orthodontist. And there is a reason it takes three to four years. However, I want to encourage the listener to think about this: Mercedes has never, ever excused last year’s model. Meaning that they always strive for perfection. So if we go into the practice and we do the very best we can every single day, there is no way we can go back and excuse what we did because we did everything to the best of our ability. And I think we all look at some of the work we did when we were in dental school and think, Jesus, did I do that? And so that is one thing that I took with me from the United States. Mercedes has never excused last year’s model. Secondly, when you’re really frustrated and you think this is so overwhelming and why did I ever get caught up with aligners, and you think it’s just crappy because there’s so much to learn… look, there is a reason it’s called a dental practice. Practice, practice, practice. So over time you grow. You become more knowledgeable. And the most annoying part of this is once you reach the age where you wanna retire, there’s so much knowledge you have picked up that you can’t just magically give on to the next generation. I think that’s probably the most frustrating part. But practice. Keep on making mistakes and just tell your patient—be honest—and say, thank you for learning me how not to do this. Let me do it the right way now. What’s that gonna cost? That’s the great part of it. This was a course that I’m paying for, so it will not cost you anything except a little bit of time. And then I send them some flowers or something like that. [Jaz] Lovely. Because the complications will happen. It’s not an if, but when. And that’s a very elegant way to manage—I’ve said “elegant” more today than I’ve ever said in a podcast. Something about you. [Jesper] Should we reveal—you know, you were teasing for the connection between the feet and the teeth. [Jaz] So why is it that when, for a certain susceptible individual, when they change the way they sit, it changes their bite? [Jesper] I believe that all muscles in humans are interconnected somehow. So sometimes the foot position or the muscles in the legs affect the muscles surrounding our face and neck, which affects the teeth and how they work together. And a lot of doctors question this and say, can’t be. There’s no connection between the teeth and the legs. So to all the listeners out there, if you doubt me, sit on a chair relaxed, both feet on the ground. Try to bite together. Register the very first point of contact, so the very first contact you register in your bite. Where is it? Hold onto that. Cross one leg over the other. Bite together again. Is there a difference between the initial bite that you had with both feet on the ground and with one leg crossed over the other? And if you want to try it, just go from one leg and then switch to the other leg and cross that over. Most listeners will feel some kind of difference. There will be some that don’t. But the beauty of this is it illustrates to us how everything in the body is interconnected. Sometimes problems arise from the legs or the hips or the back and affect the teeth, and then we have to refer the patients to someone who can treat that part. Sometimes the problems start with the teeth, and the teeth and your occlusion give patients neck problems, back problems, hip problems, and foot problems. But we really don’t know until we start to diagnose which is which, which we can do with deprogrammers and bite plans. [Jaz] I wanna add to this by saying something that one of my mentors, Bobby Supple, taught me. You’re familiar with the T-Scan, right? [Jesper] Yes. [Jaz] So it measures the timing, the force mapping, and so much. And then they made the similar version for the feet. So imagine you’re standing on essentially the T-Scan of the feet. Essentially you’re seeing the heat map. When someone plants their foot—what hits first, how much pressure, what percentage of the force is going on this toe versus that toe and that part of the foot. And the fascinating thing was everyone standing. Obviously the colour map is completely static. And then when you clench together… it changes. All you did was clench together, okay? And then the heat map of the foot—you did not move your foot at all—but the colours shift. How fascinating. So thanks for sharing that. And I think everyone’s gonna be like, “Oh wow, that’s pretty cool,” as they experiment on each other. But tell us about you. I wanna learn about—okay, if anyone’s been inspired by today and wants to learn more from you, how can they find your website? How can they learn about your consulting services? [Jesper] They can go to alignerservice.com, I think. Can I share a link with you? [Jaz] Yeah, I’ll put it in the show notes. Yeah, absolutely. [Jesper] Ah, perfect. Because I’ll give you a link to a landing page where they can get access to—we have, first of all, a patient assessment note that is quite useful. There’s a link to a free online course that helps the dentist and their assistants take a full series of photos in two minutes without assistance. There’s access to our own protocol when we treatment plan the patients. We have—I think it’s 52—different points that we go through, which is pretty helpful when you start out. It’s there for free as well. There’s a little bit about patient communication, how to sell the treatment. And if you like it, you can always give us access to whatever aligner tool you’re using and let us access that to assess your patient. So if you have a patient where you say, I’d like help with case selection, simply send us an email with the case number and we will guide you to how to let us connect to your doctor platform so you don’t have to upload anything to our platform. We simply tap into your information, and within 24 hours you will get an email back with an indexation of this patient. Is it easy, moderate, complex, or a referral case, and why? And it doesn’t cost you anything. So this is the kind of free stuff that we have. Of course, we hope that if you like this and you find that, okay, these are dentists and orthodontists only helping me here, well, maybe you would like to take it to the next step and use our treatment planning service where we help you co-create the treatment plans. [Jaz] Great. I’ll definitely put all that in the show notes, Jesper. But thanks so much for geeking out on occlusion and everything in between. Appreciate your time. It’s been nice to connect with you again and looking forward to another time. [Jesper] Likewise. [Jaz] Thank you so much. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. Thank you to my guest, Dr. Jesper Hatt. I’ll put all the links in the show notes. Scroll down below, wherever you’re watching or listening, so you can check those out. This episode is eligible for CPD or CE credits. We are a PACE-approved education provider. Look, if you’re a regular listener to Protrusive Dental Podcast, you need to get on the membership. Even if you just listen to one episode a month and you answer a CE quiz, that’s 12 easy CPD credits—CPD hours you’ve gained—and you would’ve learned so much. If you actually start logging into the app and seeing over 400-plus hours of the content we have… some of our premium clinical videos are just amazing. We have an entire library of webinar replays and every month we do a new live. And these are really cool clinical walkthroughs. Just last week we did “Fiddly and Wide Class II Cavity,” and we often do them during breakfast time US, lunchtime UK, late night Australia. And the reviews we get for those webinars are just absolutely amazing because they’re full walkthroughs. You know, my loupe-mounted camera’s on. We’re pausing. We’re thinking, okay, which matrix should we choose, and what went well and what didn’t? And I think that’s the highest form of learning. If you like how that sounds, head over to protrusive.co.uk/ultimate. And honestly, the amount of CPD/CE credits you’ll get… you won’t care about the numbers anymore. It’s all about the learning, and also as well as the learning, we bring the community. It’s the nicest and geekiest dentists in the world. I wanna thank you guys again for watching to the end. I’ll catch you same time, same place next week. Bye for now.

Do you have a “hopeless” retained root you’re ready to extract? Think implants, dentures, or bridges are the only way forward? What if there’s a way to save that tooth — predictably and biologically? In this episode, Dr. Vala Seif shares his experience with the Surgical Extrusion Technique — a game-changing approach that lets you reposition the root coronally to regain ferrule and restore teeth once thought impossible to save. Jaz and Dr. Seif dive into case selection, atraumatic technique, stabilization, and timing, all guided by Dr. Seif’s own SAFE/SEIF Protocol, developed from over 200 successful cases. https://youtu.be/2TyodqgAP9w Watch PDP249 on YouTube Protrusive Dental Pearl: When checking a ferrule, consider height, thickness, and location of functional load. Upper teeth: prioritize palatal ferrule. Lower teeth: prioritize buccal. Tip: do a partial surgical extrusion, rotate the tooth 180°, then stabilize. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Surgical extrusion is a technique-sensitive procedure that requires careful planning. Case selection is crucial for the success of surgical extrusion. A crown-root ratio of 1:1 is ideal for surgical extrusion. Patients are often more cooperative when they see surgical extrusion as their last chance to save a tooth. Surgical extrusion can be more efficient than orthodontic extrusion in certain cases. The importance of ferrule in dental restorations cannot be overstated. Proper case selection is crucial for successful outcomes. Atraumatic techniques are essential for preserving tooth structure. The ‘Safe Protocol’ offers a structured approach to surgical extrusion. Patient communication is key to managing expectations. Flowable composite is preferred for tooth fixation post-extraction. Understanding root morphology is important for successful extractions. Highlights of this episode: 00:00 Surgical Extrusion Podcast Teaser 01:07 Introduction 02:38 Protrusive Dental Pearl 05:53 Interview with Dr. Vala Seif 08:57 Definition and Philosophy of Surgical Extrusion 15:30 Indications, Case Selection, and Root Morphology 21:37 Comparing Surgical and Orthodontic Extrusion 25:54 Crown Lengthening Drawbacks 28:39 Occlusal Considerations 33:53 Midroll 37:16 Definition and Importance of the Ferrule 43:07 Clinical Protocols and Fixation Methods 01:00:01 Post-Extrusion Care and Final Restoration 01:05:04 Learning More and Final Thoughts 01:09:29 Outro Further Learning: Instagram: @extrusionmaster — case examples, papers, and protocol updates. Online and in-person courses in development (Europe + global access). Loved this episode? Don’t miss “How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique” – PDP061 #PDPMainEpisodes #OralSurgeryandOralMedicine #OrthoRestorative This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C. AGD Subject Code: 310 ORAL AND MAXILLOFACIAL SURGERY Aim: To understand the biological and clinical principles of surgical extrusion as a conservative alternative to orthodontic extrusion or crown lengthening for managing structurally compromised teeth. Dentists will be able to – Identify suitable clinical cases for surgical extrusion, including correct root morphology and crown–root ratios. Describe the step-by-step SAFE Protocol for atraumatic surgical extrusion, fixation, and timing of endodontic treatment. Evaluate the advantages, limitations, and biomechanical considerations of surgical extrusion compared with orthodontic extrusion and crown lengthening. Click below for full episode transcript: Teaser: I always had a problem with extracting teeth. Not a problem technically, ethically. If highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants. [Teaser]So what I’m referring to here is that the most sophisticated and complicated solutions are not always the smartest one. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. We must keep that in mind that there is no such thing as a master key that opens up all of the doors for us. Surgical extrusion, over the years… it actually was presented to dentistry in the early eighties. They were really trying to work on surgical extrusion. And guess who comes out? I have done over 200 cases with a follow-up of up to six, seven years. That is something that you can rely on. In such cases, I take out the tooth and rotate it and put it back in. No way. Jaz’s Introduction: Yeah, so you have a retained root and you think this is hopeless and you’re headed towards an implant, denture, a bridge or whatever. But then this episode comes along and reminds you about the power of the surgical extrusion technique. In plain terms, you are partially extracting the root, and now you have the most important thing in restorative dentistry. You have ferrule, you have tooth structure, you can now crown. Whereas before everything was subgingival and it was impossible to restore. Hello, Protruserati, I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. This is the podcast where you make dentistry tangible and make you fall in love with dentistry again. Four years ago, with Dr. Peter Raftery, the endodontist, we spoke about this very topic, the surgical extrusion technique. I’ll put that episode in the show notes ’cause that was really valuable as well. But in this episode it is special because it’s an update from someone who’s done more than 200 cases. So what he believes, and what I also believe, is he is the most experienced clinician in the world when it comes to the surgical extrusion technique. I haven’t seen anywhere in the literature the kind of numbers that he’s done—so, so much. We can learn from Dr. Vala Seif from Iran, and Protruserati, you’re gonna absolutely love him, right? His storytelling, his analogies. I actually really geeked out and had a great time, and I know you’re gonna love him. Even all the way to the end, the last few seconds, he still gave another tip of how to stop bleeding when you do this technique so you can then add your composite splint to secure the root. He’ll give you that right at the very end. So make sure you don’t miss any of this episode. Dental PearlNow, every PDP episode I give you a Protrusive Dental Pearl. This one’s an occlusion conceptual one, a biomechanical one when it comes to restorative dentistry, but it’s also very relevant to this episode ’cause a really cool, fascinating technique was advised by Dr. Seif, which I really am excited to share with you. So firstly, conceptually, the pearl I’m giving is to remember the following: that when you have supragingival structure all the way around 360 degrees, we call that the ferrule. Something a crown can grab onto, and it’s important that this ferrule is as tall as possible vertically—ideally two millimeters plus—but it’s also important that the tooth structure remaining is thick because if it’s very, like, if it’s paper thin, that’s not really a ferrule, that’s not really contributing biomechanically. Now the conceptual pearl I’m giving to you is to think about the position of the ferrule. If you have three millimeters on the palatal side and one millimeter on the buccal side, then this is still pretty good, especially for upper teeth, because the location of the ferrule is actually really important. Think of the way that the upper incisors are loaded in a class one and class two patient. When a patient is chewing, the palatal of the upper incisors is taking load in clenching, is taking load in mastication and chewing as the food is pushed into centrals, and as you are cutting and incising, the crown is kind of going in a buccal direction. The tooth, the crown of an upper incisor, is heading in a buccal direction, and so it is trying to grip onto that palatal tooth structure. And in a lower incisor, the buccal part of tooth structure is gonna be under more strain because the lower incisor is trying to bend inwards. So why is this important? Well, pragmatically speaking, if you have a scenario where you’re trying to restore a canine and you’ve got lots of tooth structure palatally and not very much tooth structure buccally, then probably you’re gonna still be okay because that palatal tooth structure for an upper tooth, that’s usually more valuable and more precious. It just helps us to remember how teeth are loaded in a biomechanical way. Now, the absolutely fascinating thing that Dr. Vala Seif spoke about is: let’s say you have a scenario where we have a retained root, like a crown–root fracture, and let’s say you have loads of tooth structure buccally but you don’t have much palatally for an upper incisor. Remember: upper incisor, we want more palatal tooth structure. Well, the fascinating thing that he spoke about is: let’s say you do the surgical extrusion technique. You partially extract this tooth out, and so now you’ve got more tooth structure to work with. And don’t worry, the entire protocol will be broken down in this episode. But the thing he said which really wowed me was: okay, you have this scenario. But how about now? You partially extract it and then you basically twist it 180 degrees, and that’s the new position of this tooth. Suddenly you’ve gone from a situation where you had a lot of buccal tooth structure and not much palatal, to now rotating the tooth 180 degrees, and so now you’ve actually created ferrule palatally for this upper incisor. I thought, wow, that’s really clever, because guess what? The PDL don’t care if it’s the buccal or the palatal. The PDL don’t know. The healing mechanism will still be the same, but now you’ve gained a biomechanical advantage. So thank you, Dr. Vala Seif, for sharing that, and I wanna just talk about it because it was just so awesome. It blew my mind. So, dear friends, let’s check out this main interview. I know you’re gonna absolutely love it, and I’ll catch you in the outro. Don’t forget to pay close attention so you can get 80% on the quiz to get your CE credits. Main Episode: Dr. Vala Seif, thanks so much for joining us today. Where are you from? Where are you speaking from? [Vala] Thank you very much for having me. I’m very glad to be here today. I’m based in Tehran, Iran, and obviously I’m from Iran. [Jaz] Well, I appreciate you joining me. I try and think, have I had any guests from Iran before? I don’t… yeah. I’ve got lots of Iranian friends. I love Iranian food. I love you guys’ food. You know, my favorite thing ever to see on TikTok—like my TikTok, I rarely go on TikTok, but when I do, I just see that the algorithm knows what I love so much. It’s like that giant, giant rice dish that you turn upside down and you take off. Like is that an Iranian thing? [Vala] We do have something similar, but what you’re referring to more sounds like Arabic food. But you actually can find a lot of similarities between the food that we are making in Iran and Arabic countries, and obviously even Pakistan and India. So the taste is very close. There’s a good chance that you’re referring to. [Jaz] Man, I love it. I mean, Indian food, I love biryani. But when I see the— [Vala] Oh, I love that too. [Jaz] — the Iranian cuisine and the kebab and stuff, man. I’m a big fan of that. But it’s great to be speaking to you from Iran. [Vala] Thank you, sir. [Jaz] We’re talking about surgical extrusion today, so very excited about that. But just give us a bit of a background on yourself. Are you restorative dentist? What is your background? What are your passions within dentistry? [Vala] Sure. [Jaz] How did you fall to get to the stage where you’d like to talk more about surgical extrusion? [Vala] Yeah. Alright. I have been working as a… I got into university in early 2000. So basically I’m a graduate of 2008. So over 25 years—almost 25 years ago—I got into dental school. So after that, I actually completed a course in a master by research in oral surgery. And then I am a former resident of oral and maxillofacial surgery. For some reasons I had to stop the training for family matters, and I have been in private practice for the past 15 years, almost. [Jaz] And what do you love? What aspect of oral surgery do you enjoy the most? Is it wisdom teeth? Is it implants? [Vala] Area of interest is cosmetic dentistry and implants. So basically in my clinic I’m working on ceramic and porcelain veneers and also implant dentistry. But my passion for surgical extrusion started about seven years ago because I always had the problem with extracting teeth. Not a problem technically—ethically, basically. So that was when I was exposed to surgical extrusion because it’s actually a very forgotten type of treatment in dentistry. And I was very glad when I realized that you also shared the same passion as I have for surgical extrusion because it’s going to save millions of teeth probably if it becomes— [Jaz] It was approximately seven years ago when I came across it as well. I think that’s when some of the research, some of the Italian people were talking about it a lot more. And now recently I’ve been on orthodontic extrusion course actually, so that was wonderful. By Dr. Guido—Guido Fichera—I’m probably saying his name wrong. I mean, what a genius guy. And so that was really cool to learn how to use brackets to rapid orthodontic extrusion. But you know what, in real terms, to have the materials, to have the patience, to have the technique to be able to do orthodontic extrusion… whilst when you compare to surgical, I do think it does have a lot of benefits doing the orthodontic, but it’s not accessible to every single dentist, right? [Vala] Correct. [Jaz] It’s more difficult to get by, and a lot of patients will not accept having brackets of any form, so I do like the more instant, if you like, potential of surgical extrusion. So I guess the best place to start is: define. Let’s define. What is surgical extrusion? And then when we go from there, we’ll talk about, okay, what were the earlier ways—seven years ago, ten years ago—they were doing it, and what changes may have happened? And I’d love to obviously learn about your protocols, but let’s start with that. What is surgical extrusion technique? [Vala] Alright, Dr. Jaz, I’m pretty sure this is going to be a wonderful chat between you and me because I have a lot to share with my colleagues. The first thing is we look at surgical extrusion from two different angles. One is technical, the other one is ethical, or basically the philosophy behind doing surgical extrusion, right? So number one, technical, is that you are going to, through a very delicate surgery, you are going to reposition the tooth more coronally in order to have sound tooth structure with a 360-degree ferrule, as well as doing it in such a way that you are preserving gingiva and PDL and bone altogether. And the reason that I’m a very big fan or defender of this idea is that many, many beautiful, great articles that I can share with you later are referring to this fact: that if highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants. So body is going to outperform titanium in any given circumstances. [Jaz] I totally agree. And I think implants are not the panacea we once thought they could be. And we are seeing so many more complications—peri-implantitis. Implants are great when you have a gap and there’s no other options. But when there’s one more chance—and then we’ll talk about case selection later—when there’s one more chance to work with nature, in a modified way, I guess, in enhanced way… Then let’s take that, because it’s so much better to have an implant when you’re 50 or 60 than an implant when you’re 30. And I don’t think any—even the most astute implantologist in the world—will disagree that for their own daughter, for their own mouth, they’d like to save their teeth for as long as possible. [Vala] That is very true. And that’s when the philosophy behind a treatment comes up. Let me put it this way. May I give you two simple examples? That is going to help us understand this philosophy better. You know that when NASA engineers were trying to send man to outer space—this is a funny story, it’s an interesting story—they were trying… there was no gravity. They were trying to make sure that they were gonna find a way to… when the astronauts were trying to write down the information necessary, there was no gravity so the ink could not flow to the tip of the pen. So there was a project—thousands of dollars—they were trying to spend to make a pressurized pen. And I’m sure you know how the story ended, right? The Soviets used a pencil. And I’m going to give you another, really, I’m gonna give you another example. It happened in my country many years ago. There was this company; they were making very nice chocolates and exporting it to the European countries. And there was a small problem. This was actually happening around 50 years ago, 40-plus years ago. And the small problem was this: some of the chocolate packagings were actually empty, so the machine was doing the packaging but there was no chocolate inside. So there were some complaints and the board of directors sat together and they were deciding… they were trying to find a way to solve the issue. There were devices to detect the faulty packages, to get them out of the lines and everything. And one day, the board of directors were actually walking through the factory to locate a designated area for the machines, and they realized one of the very old workers of that company who was there for so many years, right in front of the rails that take the packaging to put in the boxes and everything, he actually put up a stool with a fan. So the fan—the air that was flowing toward the empty packages—because they were very light, there was no chocolate inside, the empty packages were flying away. And the board of directors were actually very surprised by the fact that they were ready to spend thousands. So what I’m referring to here is that most sophisticated and complicated solutions are not always the smartest ones, are not always the best ones, are not always the… because as dentists, we are trusted that we are coming up with the best decision for the patient. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. So we are working in patients’ best interest. Surgical extrusion… I’m not against implants. Please keep that in mind that I am a big fan of implants. It is one of my passions. I do implants every day in my practice. Sometimes implants are miracles. But we must understand one thing: if we are having weapons in our arsenal, if we are having tools in our toolbox in dentistry—veneers, onlays, inlays, implants, surgical extrusion, bone grafting—we must keep that in mind that there is no such thing as a master key that opens up all of the doors for us. We must keep that in mind that each and every one of these tools are going to be great for us and for the patient if the case selection is correct, picking up the right tool is correct, applying it is done correctly, and at the end of the day, we are having promising long-term results that we can completely rely on. That’s the fact. [Jaz] That was so eloquently put. I absolutely love that—there’s stories that you weaved in there to really drive home the point there that we don’t need complicated solutions. Sometimes we need to look to simplicity. And so you led very nicely to case selection as well. So which teeth, where in the mouth is this technique suitable? And there must be some radiographic markers of predictability. There must be some clinical markers of predictability. Do you mind just going through: which is the ideal case for whether it’s your first case, your 500th case—universal principles to adhere to? [Vala] I have worked on over 200-plus cases. It’s not 500— [Jaz] Two hundred is a significant amount for a very niche technique like this. That is a lot. You’re probably up there in the top five in the world probably who’s done this technique so many times, in my opinion, based on… it’s to actually find the case. That’s like sometimes you’re trying to find the perfect case to do this on, and then you have to wait for that case to walk through. To get 200 is a significant number. [Vala] Dr. Jaz, I’m very honored to say this: based on the searches that I have done through literature, actually this is the biggest data set in the world. I’m really honored to say that no one has done this before, because if you browse through all of the articles that have been published before, many of them are actually just case reports. The biggest ones that I have come across are 50-plus or near 60 teeth. The rest of them were 10, 20, 30 cases. And normally there is no follow-up for the long term, but because I had enough time and I have done it in my practice—and these are the patients who are always showing up to make sure that everything is okay—in a university setup it is different. Sometimes you cannot call the patients back. But I have done over 200 cases with a follow up of up to six, seven years. That is something that you can rely on. Anyhow, back to your question. Case selection is extremely important, because if the case selection is not done properly, you are actually getting ready for big failures. As there’s this idiom: if you fail to plan, you’re planning to fail. So basically number one is: we need to make sure that, number one, the root length should be proper. Meaning after you have done your extrusion, after you have removed the decay or the fractured part, you need to make sure that after everything is done, the crown–root ratio of one-to-one is going to be there. That is number one. [Jaz] So what we’re looking for is that, by the end of it, you’re not having a crown that will be longer than the remaining root. So the first thing that comes to mind is someone who’s already had orthodontic resorption would then be a bit more difficult, and also someone who’s had periodontal disease. So whether they’ve lost the bone or whether they’ve lost the root from the apex—i.e., the resorption—or they’ve lost the bone from perio. But usually these perio cases are not the ones that will come in your clinic with the fracture at that level because usually the mobility cushions it and all that weakest link theory. So yes. Okay, that’s a good point. So one-to-one is obviously… if you’re better than one-to-one, if your root is longer than the crown, that’s better. But bare minimum one-to-one. That’s a very good starting point. [Vala] Alright. If we want to go—let’s put it this way—if we want to look at the indications of doing this treatment: number one, some of the teeth, actually many of the teeth with… they say severely decayed, non-restorable teeth. So that is number one. Number two is crown–root fracture. Number three is even external resorption. Alright. These are the cases that I have done and it worked wonderfully. So when you want to pick the cases: crown–root ratio is important. Number two is: you don’t have to have active perio problem. Number three is: you don’t have to have active infection. We’ll get there. Number four is—this is done especially to the colleagues that are going to start doing this for their patients—it is important to know that this extrusion works best for single-rooted teeth. Alright. And when it comes to morphology of the root, we must understand this: in order to be able to extrude the tooth properly, the shape of the root has to be conical. Otherwise, if you have a curve or you have hypercementosis, it is very difficult to get the root out. So it’s not going to be atraumatic. So if you cannot do it atraumatically, please don’t do it because we are negotiating with the body to talk the body into accepting something again. And these are the important parts when you want to pick the cases. And obviously if we go further, I’m going to explain how we deal with infection and other problems. [Jaz] Okay. It’s the—classically—it’s central incisors, lateral incisors. The only thing I probably mention here that you haven’t mentioned yet, and something that with your experience you’ll know very well, is just a marker of predictability and success for the future could be some occlusal factors. Because if the patient—for a central incisor—if the patient’s very class three or class two div 2, a deep bite, then already… yes, you extrude the tooth, but you’re extruding the tooth in a mouth which is gonna be putting a lot of biomechanical loads as well. And so therefore, pre-restorative orthodontics. But then if you’re doing orthodontics, you may as well extrude orthodontically. So I think maybe just having a good enough occlusion that you do all this effort that is gonna be working. [Vala] Correct. [Jaz] But that’s like a bigger global thing. Same thing like oral hygiene. You want a patient who looks after, like you said, no periodontal disease, and those are some wider factors. But when you are assessing for the case selection, is it just enough to have a periapical? Or do you feel as though the need for a cone beam CT scan—to do a proper assessment of not only the morphology in three dimensions but to be able to do this treatment with success? [Vala] Alright. Number one is yes, CBCT is always helpful, especially when you are coming across a patient who you feel, or you see, that the bone is very thin, the biotype is very thin. So it’s always better to get a CBCT. However, if you allow me, I’m going to have a very small comparison between surgical extrusion and orthodontic extrusion, if I may. Or if you want to postpone it to the other part. [Jaz] No, no. Let’s talk about it because we’re talking about… you gave some case selection. So it’s totally fair to look at the alternatives, ’cause one alternative is: you extract the tooth, you do an implant or denture or a bridge or something. But the other good way to work with biology is orthodontic extrusion. [Vala] Yeah. Even if you allow me, we can also bring in crown lengthening surgery so I can explain better to the fellow colleagues how to do it. So please, you guide me which part of it you want me to explain first. [Jaz] Let’s do ortho extrusion first, and then we’ll talk about crown lengthening as well. I think that’s a very good point. [Vala] Sure. When we are doing orthodontic extrusion—as we have mentioned before—all of these are weapons in our arsenal. It’s not that one is the best and we should throw away everything else. I have done ortho extrusion as well, but for some reasons I find surgical extrusion more efficient and more effective. Number one is: when you do orthodontic extrusion, obviously it takes time. And if you want to come up with best results, sometimes you need to call the patient for a fiberotomy to cut the fibers. And the other thing is: when you put all of those appliances or the— [Jaz] Brackets. [Vala] —brackets and everything in the patient’s mouth, it is more difficult for the patient to keep it clean. And sometimes, because of the appearance, patients are not really eager to go for the treatment. And the other thing is: sometimes when you are moving the tooth, the gum and the gingiva are also moving with it. So at the end— [Jaz] But the reason for the fiberotomy that you mentioned is to minimize that, to reduce that. There are techniques for that. But yes, exactly—quite often a complication if you don’t get the protocol just right, or particular biotype, then you get the migration of the gingiva, which you don’t want because you want the ferrule, you want the tooth. You kind of want a pure extrusion without the dentoalveolar complex to come with it. So you have the pure ferrule. But yeah, sometimes it may not work fully that way. [Vala] Exactly. Especially if the patient is not fully cooperative. You may need to do an additional surgery. And the other reason that we are doing fiberotomy is because there is a chance of relapse to some extent. [Jaz] Relapse—I’m just saying for the listeners—is what we mean by relapse here is: relapse, i.e. intrusion of the tooth. Once you do orthodontic extrusion, the tooth will go back in. But also, sometimes you extrude but then the gingiva will just come down thereafter, which again—you don’t want to lose all that space that you gained. [Vala] That is very correct. So when you are trying to do it with surgical extrusion, it is done in one session. You get the results almost immediately and it’s much faster. You are sure that if you do it in an atraumatic way, nothing else is gonna come down with it—not the gingiva and the bone. In terms of how it looks in the patient’s mouth, the patient is actually—in my experience—they accept it better. And one more thing: as compared to other treatments, like removing the tooth and replacing it with something else… in my experience, it is very interesting, Dr. Jaz. The patients are much more cooperative and thoughtful with keeping it clean because they see it as their last chance. Emotionally, they don’t want to lose a tooth. So when you are giving them the warning, “Hey, this is the last bullet in the magazine, so please help me help you,” they’re very cooperative. So yes, I think for the reasons that I counted, surgical extrusion works—in many cases—works better. [Jaz] I get the patient aspect, especially for those who don’t want to go through a longer, regular recall for fiberotomy and the brackets and stuff. So I think it’s a very viable alternative for sure. And then, with crown lengthening, it’s easy to say that with crown lengthening you are removing bone. Quite very often you are removing gingiva. And then therein lies the issue whereby now if you have the gingival zeniths that are even, now one tooth will migrate up and then you have to do it all together. And so there are some surgical considerations and complications there. Anything else you wanna add to crown lengthening as a disadvantage? [Vala] Yes, sir. Absolutely. Dr. Jaz, when we are doing crown lengthening surgery—especially in cases that are high lip lines or the ones who have a gummy smile—a big issue is this: you are going to have a long, whitish, ugly crown that most of the patients can’t live with. So that is number one. Number two is: you’re gonna have probably dark triangles. Number three is: it is very difficult to keep them clean. So here comes the issue: when you have food getting stuck there, there is a chance that cavities or gum problems start again for the same tooth or the adjacent teeth. So now you are facing a new challenge. There is a risk for perio problem or new cavities in this area. And the things actually don’t stop here. I am trying to bring your attention and all of my colleagues’ attention who are viewing or listening to us to this matter. Let’s say—God forbid—one day you have to take that tooth out. What is going to happen? Obviously you are going to put an implant, right? What was the previous problem? You had a long, ugly, whitish crown and you couldn’t keep the area clean. So it’s either putting an implant there and redoing the whole scenario. So at the end of the day, the same thing is gonna happen. The implant is going to have peri-implantitis, whatever. Or the adjacent teeth are going to face the problem. Or you are going to have to rebuild everything that you had removed before. [Jaz] So it’s removing the precious bone, and now you’ve lost it when you… yeah. You’re lost now in terms of this scarce resource. [Vala] That is very true. So I believe that surgical extrusion—for the very same reasons that I just explained—I believe that surgical extrusion is the treatment to go in cases like this. [Jaz] Right. So I think that’s a very nice overview of the alternative options. And so I think what we’d love to know now is: we’ve talked about case selection. We talked about ideally to have a CBCT—would be great—but I appreciate that, from what I’ve seen in the literature, sometimes periapicals are just fine. Especially if things are looking quite straightforward, and not everyone around the world has access to cone beam CT scan. And so let’s talk about a classical case, and for those who are watching—obviously we’re being very good for the listeners on Spotify, Apple and whatnot. But those who are watching, I don’t know if you wanna maybe share a case and just be descriptive for the audio listeners for when we talk about the protocol. Step one, the patient comes in, presentation, this is what you say to them, and then that’s what you do. And then how many weeks—all the nitty-gritty details. [Vala] Sure. But before we go to that, part of your question was left unanswered, if you allow me to answer to that part. You were mentioning occlusion. Alright. [Jaz] Oh yeah. You’re such a great guest. You know that? You are an amazingly clear guest. Thank you so much. [Vala] I appreciate. Thank you. Thank you, sir. So what I want to point at is this: obviously you do implant in your practice. So when you want to do implants—especially in practices that the same doctor does the surgery and does the crown—the best way of doing it, we all know, is that it’s not surgically driven. It’s prosthetic driven in terms of putting the implant. Am I right? [Jaz] Mm-hmm. Yes, absolutely. Restoratively driven, basically. [Vala] Yes. So basically, Dr. Jaz, it’s kind of a reverse engineering. When I want to put implants, this is what I do: I’m going to try to imagine this: “Okay, this is where my crown needs to be in order to be beautiful, in order to be able to get cleaned very well, and in order to withstand all of the forces of mastication that are going to be applied on this tooth.” Am I right? So the same thing happens with surgical extrusion. Please note this: surgical extrusion is not extracting a tooth. Surgical extrusion is not a simple extraction. Surgical extrusion is a very technique-sensitive surgical treatment. You are not just going to take the tooth out and put it back in and then, okay, boom, the crown comes on and everything is solved. No. Same reverse engineering is going to happen. You have to keep that in mind, especially when it comes to front teeth, Dr. Jaz, because when you look at, for example, if you look at a central incisor—the upper one—or the upper canine, the tooth comes out of the gum and then there’s a divergence, and then it comes back, and the tip of the tooth becomes smaller and smaller. And the root is actually very thick. So if you do not consider the occlusion or the bite—let’s say I’m having a canine extruded—if I do not adjust the angle correctly, there’s a good chance that a problem in occlusion is going to happen. Maybe sometimes when we are splinting the tooth, we are going to remove the excess and everything… okay. The healing is uneventful. But when it comes to the prosthetic part, then you don’t have enough space to put the crown. [Jaz] For someone here like—I don’t do implants, right—but I know this much: that if I’m doing an implant for the, let’s say, lower molar, right? Lower first molar. I want to make sure that the implant, when it’s pointing, that it’s gonna be going towards the fossa of the upper molar. You don’t want it pointing too much buccal so it’s in crossbite, or lingual so it’s in crossbite. So what’s fascinating here is: you raise a good point that yes, when you extrude the canine or extrude the central, the sort of projection that’s gonna take is important to make sure you have enough overjet, enough clearance. It makes sense. But here’s something I didn’t appreciate: how much wiggle room do you have? How much freedom do you have? So when you do a surgical extrusion, let’s say you surgically extruded three millimeters, right? Or four millimeters—and we’ll talk about exactly roughly how much it ends up being—but when you have it, obviously now the root is gonna be a little bit loose inside the socket, right? So how predictably can you change the angulation a bit more buccal to maybe not be so involved in the envelope of function? [Vala] Alright. Here’s the key. As I mentioned before, this technique is done on all of the single-rooted teeth. So we’re starting from the upper central incisors, laterals, canine, first premolars provided that they are single-rooted, or the furcation is very low—very apical—and then obviously second premolar. Same goes for the lower teeth. So when you are talking about premolars, it’s okay to have the tooth extruded more than 2, 3, 4 millimeters if the root is really long and strong. But when it comes to front teeth, because we have overbite and overjet, you are not allowed to pull it out as much as you think it is okay. If you have two millimeters of ferrule, it should be enough for you. That is number one. [Jaz] And I think it’s important to talk about ferrule because we have so many episodes—we have done episodes about post crowns and ferrule and importance. But someone who may be listening to the podcast for the first time: a student, a young dentist… I think it’s really important to spend a couple of minutes to pay respect to the importance of ferrule and how it is one of the most important prognostic factors of our dentistry. So, can you just tell us about: define ferrule? Which part is the ferrule? And if it’s subgingival and you can grab onto it—does that still… is that still good enough to call a ferrule because biomechanically it’s giving you something? Because some clinicians I see, they’re very strict, that they only see the bit that is supragingival—the clinical crown. They say, “That’s the ferrule. Anything subgingival, consider it not a ferrule.” It’s an interesting distinction. Whereas I always say that, look, if I can do a vertical crown and go half a mil to a mil subgingival and I’m actually grabbing onto that tooth, that will biomechanically assist me. And I’m counting that as a ferrule very often. But where do you see that? [Vala] Dr. Jaz, I am very, very, very careful when it comes to going subgingival. I respect the gingiva and the periodontium a lot, so I really do not appreciate going subgingival too much. Maybe half a millimeter. But basically yes, when I am doing surgical extrusion, to me ferrule is what is above our sulcus. What is above our gingival level. So yes, to me that is ferrule. And for the listeners who are probably younger dentists or our future colleagues or the dental students: ferrule is defined as this—the supragingival structure of at least a minimum of two millimeters of the tooth with the thickness of at least one millimeter around the— [Jaz] That’s the bit we often forget, right? The thickness. We are all talking about, okay, the vertical ferrule, but we don’t appreciate the horizontal ferrule, right? Because there’s no point in you having a tooth—and we’ve all done this, right—and you think you’ve got two millimeters of ferrule, but actually the endodontic access is so huge, or the caries destruction was so huge, that actually it’s very thin and it’s just… it’s going to snap. That is not serving you in a biomechanical way. [Vala] That is correct. And when you forget that, what happens is your post and core is going to have a wedging effect. And then you’re gonna have a root fracture. So all of the effort that you have put in treating something that you were not diagnosing correctly in the beginning is going to end up terribly, and you’re going to—at least—lose your patient’s trust. [Jaz] And in your case studies so far of 200-plus cases… [Vala] Yes. [Jaz] The ideal gold standard will be that you do achieve 360-degree ferrule of two millimeters. [Vala] Correct. [Jaz] But there are some pragmatic concerns, that sometimes that may not be easy or not possible. And so in some schools of thought—depending on the occlusion—if you have someone who’s class two, a bit more class two, a bit more overjet, then maybe if you are getting a bit of palatal ferrule, maybe you get two, three millimeters palatal ferrule in the way that the tooth broke, but you only have one millimeter ferrule buccally, then maybe this could suffice. Or do you think that you get such good results because you’re very strict? Like, how strict should we be with this 360 degrees, two millimeters? Because sometimes the way the teeth fracture, the crown–root fractures, you’ll end up with four millimeters ferrule buccally and two millimeters palatally—and that’s great. But sometimes you get three on one and one on the other side. How strict are you, Vala? [Vala] Okay, Dr. Jaz, that is an excellent question. I’m going to give you two answers. The second one is going to surprise you. I’ve already surprised you. Alright. Number one is: you are absolutely correct, sir. In so many cases, for example, you are having a very deep cavity on the surface of the root and you remove everything and then you extrude, and then you realize that, okay, you cannot extrude more than this and you cannot achieve 360 degrees. But you realize that three-quarters of the tooth is going to give you good ferrule. In that case, I have done so many and, so far—touch wood—they are in the patient’s mouth. Functional, clean, healthy. So yes, there are some flexibilities. But please, I’m asking our listeners to bear in mind that if you want to start, please start with simpler cases. Just like when we are learning to put filling in patient’s mouth—we are starting with class one, and then class two, and then we go to cosmetic and all that. For implant, same thing applies. So yes, there is a chance that you don’t achieve 360 degrees—you get three-quarters of a tooth. That is going to be enough. And sometimes—this is gonna surprise you—sometimes you realize that, okay, if I had ferrule on this side, it was better. Or if I had ferrule on that side and the other side was a part of our casting post, it was much better. In such cases, I take out the tooth and rotate it and put it back in. [Jaz] No way. [Vala] Yeah. [Jaz] That’s so cool. Okay, cool. That’s like reimplantation. That’s pretty cool. I didn’t even consider that. That surprised me. But I love that because my mind always said that, okay, when you do this technique, you take it out a bit and then, you obviously do the suturing—we’ll come onto that—and then fixation. But I didn’t actually think that, okay, let’s say you have a lot of… for an upper incisor, that you have a lot of buccal ferrule and no palatal ferrule. But actually you want to have that palatal ferrule to resist, and then to do a 180-degree… that’s really clever. I like that. [Vala] Yeah. And sometimes—this is one more thing I need to talk about because there’s a chance that I forget—it’s not… sometimes when you are trying to extrude the tooth, you don’t need to do a full extraction. Especially if the tooth has not undergone endo treatment. So you just try to take it out, and once you reach that ferrule, just leave it. [Jaz] Yeah. That’s what’s going to be your air-time, right? Your air-time is zero. Right? So every time you take it out, now it’s exposed to the environment that is coming against you. But I know that, like you said, if you’re going to do the 180, then you can take it out, inspect it, make sure there’s no cracks, that kind of stuff, and then put it back in. But I think you’re going to give us some nuances now. [Vala] Yeah. That is very true. What I wanted to refer—I wanted to point out—is normally, if you have a tooth that is having a severe decay but has not undergone endo treatment, you just need to pull it out a little bit, get the ferrule, and that’s it. But if that tooth has undergone endo treatment, you need to do a full extraction. Take it out, do a complete careful visual inspection to make sure that there is no perforation, there is no crack whatsoever, and then you can put it back in. This is something I didn’t want to forget. [Jaz] Okay. Yeah, excellent point. Okay, lovely. I’m enjoying this so far. Okay, so now let’s talk about the clinical protocol, because the question that will come is: okay, let’s say in the non-endodontically treated tooth, obviously it’s more than likely gonna be necrotic—it’ll need the root canal. But when you do extrude it, and you don’t need to take it all out all the way because there is no existing root canal, what are the different methods of fixation and stabilization? How long should you wait? And ideally, before in your protocols—before you do the root canal—any considerations that you need to do? Like, sometimes you may even think that if you have pulled the tooth out and maybe it’s come out fully by accident in that moment in time, maybe you should get the ruler and get your perfect working length at that moment in time and put it back in. I don’t know if you’ve ever done that, but I’ve heard that one before. But we’d just love to know the waiting times, the loading protocols, the temporization. Are antibiotics necessary? Last time I asked this question to a lecturer, he said, “No, we don’t think antibiotics are necessary.” However, someone else once I asked said, “Yeah, I just give antibiotics,” and I don’t know where you lie in your protocols. And I think we can learn a lot, because something that one of our mentors, Lane Ochi, taught me is: you can have all the in-vitro studies in the world, you can have 500 simulations of this technique, but the one case study that you do—just the one clinical case study—is worth a thousand times more than all those in-vitro studies. So your experiences are extremely valid because clinical experience is one-third of evidence-based dentistry, and your evidence is very, very important. So if you say that in those 200 cases you did it with or without antibiotics, or you have some clinical guidelines that you’ve made, that is very valid. [Vala] Sure. First of all, one thing that I would love to say here is that surgical extrusion over the years—it actually was presented to dentistry in early eighties—and the problem that it was not very popular, it did not become very popular, was that… try to imagine this: there is a singer, young, very talented, with great future in the music industry, who is going to be presented to the world of music and fans and everything. But—I don’t know if I call it bad luck or whatever—the same time that this guy is going to be presented to the world is going to be exactly the same time that the fame and popularity, or the explosion of fame, of Michael Jackson happens. So this guy is always overshadowed by MJ. I’m a big fan of MJ, by the way. So during those days, they were really trying to work on surgical extrusion. Guess who comes out? [Jaz] I’ve got his name now, the Godfather of Implants, who passed away a few years ago. I forget his name now. [Vala] Per-Ingvar Brånemark. [Jaz] Brånemark. That’s the one. Yeah, yeah, yeah. Rest in peace. [Vala] The implant. Yeah. Peace be upon him. The implant comes out, and the implant steals the show. Becomes the rockstar. Becomes the new technology and everything. Everyone is screaming and shouting. So this little guy was pushed away. So here’s the thing— [Jaz] But also, you know what? It’s important to mention, Dr. Seif, that a lot of things that become mainstream in dentistry are not necessarily what’s the best for the patient or what’s best for clinical dentistry. It’s also dictated by the market, manufacturers, the industry, because you can’t—industries cannot monetize… they can a bit here and there—techniques to do atraumatic extraction. We talk the Benex, etc.—that kind of stuff, right? They exist. You can’t sell lots of units of anything or market lots of units. 3M can’t produce anything for… so innovative and different types. So for the industry and the business of dentistry, implants are obviously where the money of research and all the attention and the conferences and education would go to as well. There’s something just worth considering. [Vala] Very true. So for the past few decades that here and there they were doing surgical extrusion, everyone was trying to do it in such a way that made sense to them. But after doing 200 cases and having a follow-up of seven years, I have come up with a final protocol. It is called the SEIF Protocol for Surgical Extrusion. [Jaz] I love that because guys—because his name is Vala, Dr. Vala Seif, right? Seif is spelled S-E-I-F. So do you call it “SEIF” or do you call it “SAFE”? [Vala] Alright. In this case it’s obviously my name, SEIF. But it’s still… it is actually— [Jaz] It’s pronounced “safe.” That’s awesome. [Vala] Yeah, correct. [Jaz] It’s the SAFE protocol. I love it. [Vala] Thank you very much. I appreciate it. So finally we have a protocol, and in this protocol these are the 1-2-3 that we should go through. Number one is obviously case selection. For case selection we are working on single-rooted teeth. I have done it on lower molars—I’ll send you the pictures. It works really well. It is actually similar to bicuspidization; however, you bicuspidize and you extrude it. [Jaz] Okay, so bicuspidization is like a hemisection, right? [Vala] That is true. [Jaz] And then maybe you remove one of the roots, or do you keep both as two separate units? [Vala] Alright. It really depends. For example, one of the cases that I did for one of my friends—it’s been in his mouth for two years now—the mesial root was fine; the distal one was not. So I extruded the distal one and splinted it to the mesial. Once everything was settled, then I did the prostho part. And sometimes you have to take out both, and then the rest is obviously known to the listeners. So number one, case selection: it is going to be single-rooted teeth, with conical shape, long enough, because after extrusion you’re gonna have to have a crown–root ratio of at least one-to-one in the absence of active infection. And number two is atraumatic extrusion. Please understand this. [Jaz] Now, before we get to number two, I just wanna cross off a thought on number one. Sure. So let’s go stage by stage. Okay. The only question mark I have now about stage one—case selection—is: you said no active infection. Okay, but what if you do have infection, but you’re gonna be root-canal treating it anyway, and therefore if it has an active infection but has got potential and structure is looking good, what’s the protocol like? Would you root-fill it? But then the problem with actually root-filling it is you don’t have enough ferrule to put the rubber dam on. So how do we talk about that scenario? [Vala] Alright. This is the way I’m going to do it. Normally, postpone endo treatment to the time that I’m sure that everything is healed and reattached. However, if you have an abscess, if you have any kind of infection, this is what I do: we do the first stage of endo treatment. We put calcium hydroxide, and then we wait for the symptoms to subside, and then we do the surgical extrusion. Once everything is done and the tooth is reattached to the PDL and the bone and then gingiva and it is stable, we go for the endo treatment and post, core, and the final or temporary restoration. [Jaz] That makes sense. Okay, great. I’m now fully happy with stage one, case selection—including the bonus tip of, okay, if you do have an active infection, this is what the SAFE protocol advises. Lovely. Stage two, sir. The actual—the make or break—the bit where you’re doing it for the first time, you’re a little bit nervous. You’re sweating because everything now hinges on you taking this root out without it fracturing to pieces. Because then, okay, then you have to say, “Okay, yeah, we’re gonna do an implant.” [Vala] Yes, that is true. That is very true and that is the very important and the very difficult part because you have to be able—first, you need to be good at doing extractions. You have to have a very expert hand when it comes to extractions, because it is not a normal extraction. When you want to take the tooth out, it has to be done in a very atraumatic way, number one. So we are talking periotomes. We are talking very delicate forceps. And you mentioned Benex. I also use that, but not in all cases, because if you want to extract a tooth that is hopeless, when you are trying Benex, even if the tooth breaks, it’s okay. But when you promised your patient that “I’m saving it for you anyway,” that one is a bit risky—unless the root is very thick and everything. So, we’ll get there. [Jaz] So this is because when you use the Benex, I think something screws inside the tooth, right? [Vala] That is true. [Jaz] That’s the point where it could induce some weaknesses and propagate a fracture. Is that what you mean—when the force applies? [Vala] Exactly. [Jaz] Okay. [Vala] Not the force applied by itself; when you are screwing the… engaging that screw inside the root—that is going to have a wedging effect sometimes, and then it gives you a vertical fracture. So the important part when you are taking the tooth out is: you need to make sure that you are not doing it buccolingually. You have to be able to rotate it and take it out. So if you… that’s why we are emphasizing the shape of the root, that it has to be conical. Otherwise you cannot rotate it and take it out. [Jaz] So if a tooth… some centrals, they’re in a bit like—not rectangular—but you know what I mean. They’re very wide-ish; they’re not like a pure circle. They’re more like an oval. And that oval one… I didn’t know it makes hearts on the screen if I do that. There we are. That’s the first time I’ve seen that. I’m loving this so much. You see? So Vala, you’re saying that the oval-shaped one may be… because you can’t rotate that so well, that’s maybe something to consider as not an ideal root morphology. [Vala] No, no, no. It’s not that, Dr. Jaz. If you remember, I emphasized on doing it atraumatically. So atraumatically means minimal manipulation. When I’m asking everyone to do a rotation, it does not mean that you have to—it’s not a watch winding, alright? [Jaz] It’s very minuscule. It’s a micro-movement. [Vala] That’s meticulously—exactly what you referred to. The word that you picked was perfect. It’s a micro-movement. So please make sure that you’re spending enough time on it. There shouldn’t be any rush. [Jaz] How long does it take you—a central incisor—typically from your cases? Obviously every tooth is different, everyone’s different. But someone might think, okay, I’m gonna spend five minutes. Someone else might say, you know what, actually you might say that typically I spend half an hour and I spend my time. How many minutes? Obviously for the novice it will take longer, but as a guideline, how long is a reasonable amount of time spent on this very crucial part? [Vala] Correct. When I started for the first time—obviously I didn’t take any courses whatsoever; I was just trying to self-educate myself on this. However, we are having courses now and I’m trying to teach other dentists. For the first time when I did this—just like the first implant I placed 16, 17 years ago—it took me one hour and 55 minutes. After 16, 17 years, I do the same thing within 14 to 15 minutes. But I’m not proud of that because we are not setting a record here. We are doing the correct, perfect job for the patient. Normally for a routine extrusion for me—after doing 200-plus cases over seven years—it takes around 10 to 15 minutes from the start to the end. But two weeks ago I was doing a lateral incisor for a young patient; it took me around 45 minutes to take the tooth out because the fracture line was palatally and very deep. So I needed to spend as much time as necessary to make sure that I’m keeping this tooth for the young patient who came to my clinic with tears in her eyes saying, “I’m too young to lose a tooth.” So that comes first. Take as much time as necessary to do the perfect job for the patient. Normally within a half hour you should be done, but for the first cases it goes up to one hour, which is okay. Practice makes perfect. So no rush. [Jaz] No rush. That’s the main lesson here. You gotta be so delicate—and no rush. But again, consent the patient that, look, we’re trying our best here, but sometimes the tooth can crack and whatnot, and therefore we always have our plan B but we will try our best. Nothing is promised. [Vala] Yes. Yes, correct. [Jaz] Has it happened to you before—when you tried to do it and then actually, no, it’s fragmented, it’s broken, and then you’ve had to no longer proceed? [Vala] Yes, there was. But one thing is very important, and that is: you must—if you feel that this case is going to be too risky—you must explain to the patient before you touch anything. Because if you are explaining to your patient before you start, it’s an explanation. But if you don’t, and you do the job and something happens that you predicted but you did not inform the patient—if you have all of the explanations, the correct ones in the world, to the patient—it is an excuse. It’s not explanation. [Jaz] Absolutely. [Vala] So I tell my patient: “Okay, I have done this for so many years; I know what I’m doing. But this specific tooth is too risky. So please understand that I am doing whatever in my power to save the tooth for you. There still is a chance that it fractures, it doesn’t work. So be prepared, because if you go to 99 out of 100 clinics, they would take the tooth out and place an implant for you. I’m trying to save it for you. “So if something happens, please be aware or understand this.” [Jaz] That’s a good way to frame it, for them to understand that if you walk into any other clinic, there’s always still a plan B, and to be a bit more forgiving. So it’s all about adequate conversations before you do the treatment. Okay. So atraumatic extraction: stage two. Obviously you teach this on your courses and stuff and there’s only so much we can talk about it now. But let’s just, for the sake of completing the SAFE Protocol: Case selection, number one. SAFE atraumatic extraction, number two. What’s number three, sir? How do you fixate the tooth? [Vala] Alright. There are different ways of doing it. Number one is: they used to suture the tooth. I am not a big fan because to me it is not reliable. Others—they actually use wire and composite, which is fine. I have done this. But after a while, I started only using flowable composite, which works for me. But the key here is: do not use too much composite. Because number one is: when you have a bulk of composite there, it is difficult to keep it clean. And the other thing is: we are talking about semi-rigid fixation. Semi-rigid fixation allows you to… it actually prevents ankylosis and root resorption, which are two risk factors here. [Jaz] Okay. But I’m just trying to visualize this now. The patient’s gonna walk around with flowable just like tags… like, let’s say it’s an upper left central incisor, some flowable is attached to the fragment and the adjacent teeth next door. So like the central and the lateral. But then that’s not a very aesthetic solution. How are you managing the patient expectations in terms of temporization during this time? [Vala] Alright. How are you going to deal with a patient who has lost enough bone to have an immediate insertion and needs bone grafting and soft tissue grafting, and you cannot give the patient an immediate prosthesis? [Jaz] Essix retainer with a composite inside or something is a popular choice? [Vala] Is that… is a choice, but not all the time you give it to the patient. Because sometimes you have to give the tissue enough time and space to heal. Obviously aesthetic is a big part of the patient’s expectations, but we must understand that—and we must try to make the patient understand that—it is a part of the solution that we are having. The patient is going to walk around with that tooth for about probably four weeks. So it is much faster than implants in many cases. So basically, no. My answer is always no to a temporary—unless you give the patient an Essix and the patient’s occlusion and bite allow you to place it inside the mouth and you can relieve around the, for example, palatal part of the root that you have extruded. Not in every case. Initially I used to give the patient an acrylic temporary crown immediately after I did the extrusion, but I realized that gum healing is not best when we do it. So we really need to talk to the patient before the treatment and discuss everything and say that, okay, this is the healthiest type of treatment that we can do for you, and these are the facts you must understand, and try to help us help you to get the best results. [Jaz] Okay, so the no-temporary—while aesthetically is a downer—allows for the best healing and cleansability. [Vala] That is true. [Jaz] Okay, great. So now we’ve talked about flowable as a fixation. Obviously I’m sure there’s more nuances, other ways to do it. But in the interest of time, what’s the next step? [Vala] The next step is removing the splints. So after two to three weeks, the patient comes back in and then we remove the splints. I’m asking my colleagues to not be terrified when they remove the composite and they realize the tooth is still moving—is mobile. It is going to be okay after a while, because very mild stimulation on PDL is actually good for reattachment and everything. So after two to three weeks, we remove the splint. And normally after four weeks, I send the patient to our endodontist for endo. And then post and core comes, and then we are going to either give the patient a temporary crown or the final restoration, depending on the soft tissue, because at that time soft tissue may not be perfect. So we’re giving the patient the temporary, waiting for a while, and then we will go for the final restoration. [Jaz] Okay, great. And so that’s the full protocol explained, right? That’s all of it. [Vala] Obviously, as far as… I don’t remember. [Jaz] There’s so much deeper—obviously you go deeper in your education stuff. But as an overview, it’s okay. Fine. So what questions do I have at this point? Let’s see. So just to summarize: the splint stays on for two to three weeks, the composite splint. Is that fair? [Vala] Yes, correct. [Jaz] Yep. And then, when you remove the splint, that’s the same time that you have the endo, or you give it a bit more time after you remove the splint but before the endo? [Vala] Dr. Jaz, when you remove the splint, the tooth is still mobile. And if you are going to do a perfect endo, we know that we have to put clamps and rubber dam is necessary. Sometimes you can put the clamp on the adjacent teeth, but usually I do not risk applying any force on that tooth. So I always ask the patient to wait for a while, and after probably four weeks the tooth is strong enough. So then we go for endo. [Jaz] Perfect. Okay, so now that’s making sense to me. And then, the last consideration actually is about post crowns. There are some philosophies that if you have enough ferrule, then you don’t need a post, because now our core is being retained by our adhesive system. And therefore we can use the sort of canal space and stuff—or the access cavity area, if you like—to get it. So how important do you think it is to have a post? Is this like, yeah, in your protocol it always gets a post? And then if so, does it matter for you if it’s a fiber or a metal cast—that kind of stuff. Tell us a bit more about your philosophies on posts, because it’s a very popular question we get from listeners, as you can imagine. [Vala] Alright, sure, sure. Absolutely. Number one is: we must understand one thing—that every case might be different from others. So yes, sometimes for some of my cases, there is no need for a post. So a very good restoration—a buildup—is going to do the job. Sometimes, because the more and more I go into this technique, the cases that I am treating become more complicated. So yes, most of the times I prefer to go for a post and core. And in many of the cases, I prefer casting posts and cores. [Jaz] Okay. It adds a bit more time and extra step, but I appreciate that philosophy, because the more tooth destruction you have, the more rigidity can help you. And basically, people always say about, oh, the fiber post is more retrievable—when it fails, the adhesive will fail. But the way I always view it is: when that fiber post fails, this is a complete disaster. Who’s going to retrieve that? It’s the end of the line. So why don’t you give something that’s more rigid, and then it’s probably gonna last longer overall? Is that your thinking? [Vala] I have retrieved many, many, many posts before. [Jaz] Okay. Nice. [Vala] Fiber posts, those casting posts, and prefabricated posts—which I call the prefabricated ones the lazy posts. Because in my opinion, when there are better ways of doing something for the patient, you always should do that. I understand that sometimes time matters. Sometimes it’s the cost of treatment and everything. But most of the posts—with proper technique and spending enough time—they are retrievable, unless they have broken very deep inside the root, and then no, we’re done. But you are absolutely correct. When the post fails, it’s a disaster. [Jaz] Fine. So your preference is cast post. I get it. You’ve answered all my key questions. I’m so happy. I’ve really, really enjoyed it. Dr. Seif, tell us, how can we learn more from you? Tell us about your Instagram page, about your courses. Are they all in Iran? Or are they around the world? Are they online? Tell us more about that. Because this hour is a really great introduction to the surgical extrusion technique. You’ve told me you’ll send some papers—please send them to us so we can make them available. But to have absolutely spoken for eight hours on every little point and shown cases and stuff… I think that’s only fair from your education. So tell us more about that. [Vala] Sure. Basically, we are trying to connect with other colleagues around the world, especially in Europe, to organize courses which will be announced later. But in order to have better access to colleagues all around the world—and for them to have access to me—I set up an Instagram page. The name is Extrusion Masters. Yes, in a very humble way, by the way. In a very humble way I chose the name. So they can follow us on Instagram. I’m going to gradually put up a lot of my cases on that page, along with some good papers. I’m going to have a review on them. I’m going to write my opinion of the way they have done the work—again, in a very humble way. And also we are having online courses. So for the people who are… for the colleagues that are not able to travel to different countries, or they are too busy, or they want to spend a weekend learning such techniques—it is available very soon again. [Jaz] So follow the Instagram Extrusion Masters to find more information about that, right? [Vala] Yes. Correct. Correct. [Jaz] Amazing. Dr. Seif, I really enjoyed the SAFE protocol and your humility, your storytelling. It was a perfect episode, right? A great introduction to surgical extrusion. [Vala] Thank you. [Jaz] A great revisit. I know I visited it once before, but it’s really nice to connect again—new colleagues, new ideas around the world. And you answered my questions so nicely. I wish you all the best. I’m gonna put all your links and everything in the show notes, and I really value your time. Thank you so much. [Vala] Thank you so much. Really enjoyed it. And I’m really glad that… obviously I texted you many times. I know you are a busy man. But let me—seriously—let me tell you this: the last message I sent to you, I was this close to actually deleting and unsending it because I waited for so long for an answer from your side. But I said, okay, it is worth it to send another text to you because many of my colleagues—and their patients, obviously, eventually all around the world—can benefit from this. And I would like to add one more thing when it comes to technique, because a few years ago you talked to a colleague who was an endodontist from the UK, and he mentioned something that I… I came up with a very simple solution. It helps all of my colleagues. Do you remember, when you were chatting with that endodontist, this esteemed colleague mentioned something. He said: “When I want to do the bonding to do the splinting, I’m having a very hard time to do the bonding because the saliva and the blood and everything comes out.” You remember that? [Jaz] Yes. Yes, yes. [Vala] Alright. The answer to that is very simple, my friend. You just take the tooth out, put it back in, blood is coming out—give it five minutes. Don’t do anything. Just give it five minutes. The bleeding stops. And then you irrigate, and then you can do the bonding without any hassles. [Jaz] There we are. Yeah. So actually, how important is the taking out and putting it back in? So let’s say it’s a non-endodontically treated tooth—for the sake—are you saying that for the sake of bleeding, to take it out and put it back in actually is… [Vala] No, no, no. [Jaz] Is it a secret? Okay. [Vala] No, no. The secret is: once you are done with repositioning—whether you are taking it out fully or you are partially taking the tooth out—obviously you’re gonna have bleeding. [Jaz] Yep, yep. [Vala] Don’t do anything. Leave it there for five, six, seven minutes. Try not to splint and bond and etch and everything. Just give it time. After five, six minutes, once you irrigate and you wash everything, there’s no blood coming up. [Jaz] Amazing. You’re the man that keeps giving, man. I appreciate that very much. I’ll have to put that episode in the show notes, let people revisit that as well. But yeah, I appreciate you tuning into that. And thanks for the messages. At the moment sometimes life gets very crazy with the DMs, and I appreciate sometimes that’s the best way people reach out. But I’m so glad we did get this arranged. I wanna thank manager Alex who helped arrange this and the team. So this was an absolute goldmine of information. And hopefully if you’re in the UK one day, we’ll go out for some food and catch up again. [Vala] Absolutely. [Jaz] It was very, very lovely to talk to you, my friend. [Vala] Same here. I really appreciate it. And thanks for having me. And I hope that we have a chat in the future sometime soon. [Jaz] Absolutely, my friend. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. And even right at the end, he gave us that little tip. The previous episode we did—which was episode 61, four years ago with Dr. Peter Raftery—I’ll put that in the show notes. I’ll put any papers that Dr. Seif sends me. I’ll put the link to his Instagram, Extrusion Masters, so you can see his cases and papers and join his courses and that kind of good stuff. And I just want to thank him again for being such a wonderful guest. I want to thank you for liking this video, subscribing, or if you’re on Protrusive Guidance—the nicest and geekiest community of dentists in the world—please do drop a comment as well. And if you’re not on our community, what are you waiting for? We have so many premium clinical videos, webinars, Verti Preps for Plonkers, the whole shebang. It’s there. Head over to protrusive.app to discover more. We are a PACE-approved education provider, so if you are on Protrusive Guidance, scroll down, answer the quiz, and claim your CPD. You’ve done the hard work—you’ve listened, you’ve learned. Now it’s time to validate with reflection that forms part of your PDP and a certificate that’s valid everywhere in the world. Thank you again, dear friends, and I want to thank Team Protrusive as ever. I’ll catch you same time, same place next week. Bye for now.

Are you confident in replacing a single missing central incisor? When is a denture the right option — and when should you consider a bridge or implant instead? Why is the single central incisor one of the hardest teeth to replace to a patient’s satisfaction? In this Back to Basics episode, Jaz and Protrusive Student Emma Hutchison explore the unique challenges of replacing a single central incisor. They break down when each option — denture, resin-bonded bridge, conventional bridge, or implant — is appropriate, and the biological and aesthetic factors that influence that decision. They also share key communication strategies to help you manage expectations, guide patients through realistic treatment choices, and avoid disappointment when dealing with this most visible and demanding tooth. https://youtu.be/czjPQxKpwPw Watch PS018 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways:  Replacing a single central incisor isn’t just about technical skill — it’s about communication and case selection.  Success comes from helping patients understand that a restoration replaces a tooth’s function and appearance, not nature itself.  Clear conversations about expectations, limitations, and maintenance are what turn a difficult aesthetic case into a satisfying long-term result. Highlights of this episode: 00:00 Teaser 00:28 Intro 01:56 From Dental Nurse to Final-Year Student 07:38 Challenges and Considerations in Replacing Central Incisors 12:51 Patient Communication and Treatment Planning 18:33 Discussing Treatment Options and Enamel Considerations 21:16 Communicating Options and Guiding Patient Decisions 25:51 Choosing Between Fixed and Removable Options 27:10 Midroll 30:31 Choosing Between Fixed and Removable Options 31:05 Handling Old Crowns and Patient Communication 34:17 Conventional vs. Resin-Bonded Bridges 37:57 Occlusal Load, Function, and Implant Considerations 43:40 Digital Workflow in Dentistry 45:54 Managing Aesthetic Expectations 48:34 Final Thoughts and Recommendations 52:59 Outro 🎧 Want to feel confident with prosthodontics? Explore these essential follow-ups to this episode: Dentures vs Bridges with Michael Frazis Crowns vs Onlays with Alan Burgin Dentures with Finlay Sutton RBB Masterclass on the Protrusive Guidance App Quick, practical lessons to sharpen your planning, communication, and anterior aesthetics — all in your pocket. #ProsthoPerio #OcclusionTMDandSplints #Communication #BreadandButterDentistry This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C. AGD Subject Code: 610 – Fixed Prosthodontics Aim: To provide a clear, clinical overview of replacing a single missing incisor — focusing on when to choose a denture, bridge, or implant, and how to communicate realistic expectations. Dentists will be able to – Identify the key biological, functional, and aesthetic challenges in replacing a central incisor. Compare the indications, advantages, and limitations of dentures, resin-bonded bridges, conventional bridges, and implants. Communicate realistic outcomes, limitations, and maintenance expectations effectively to patients. Click below for full episode transcript: Teaser: Have you heard of something called central dominance? Teaser:No. So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins. When we lose a central incisor, we have to discuss how was that central incisor lost, and most common cause is trauma. The most important predictor success of a resin bonded bridge is the same as it is for veneers. If you’re not sure what the treatment plan should be, you probably haven’t asked a patient enough questions. Jaz’s Introduction:Welcome to this Back to Basics episode on replacing the single central incisor, why the single central incisor is the most important tooth, obviously, but so that we can just go a little bit deeper into this topic rather than talking about replacement options in general, which you’ve already done on the podcast. There are certain features which are very special when you’re replacing the central incisor and why it is regarded as the most difficult treatment to deliver in terms of patient satisfaction expectations. We’re joined by the Protrusive student, Emma Hutchison, where we’re gonna go into the basic overview of decision making. When is a denture appropriate? Is it ever appropriate for an incisor? How about bridges and what type, and what are the implant considerations, and actually choosing between these options? I think one of the biggest takeaways you might get from this is communication. There’s a specific way I communicate to patients about this, and that’s what I think you’ll probably take away the most from this episode. Hello Protruserati. I’m Jaz Gulati and welcome back to the student edition of your favorite dental podcast. I know we call it Protrusive Students, but young practitioners or those returning back to work often find these episodes very valuable. Of course, we’ve got so much more where this came from. We’ve got all sorts of genres and topics covered in Protrusive Podcast and recently on YouTube. We’ve done the playlist so you can actually pinpoint the different themes of the podcast. On our app, Protrusive Guidance, head over to protrusive.app if you’re interested in that. It’s the community of the nicest and geekiest dentists in the world. We put some extra videos, not on YouTube, on there as well. Let’s now join Emma, and I’ll catch you in the outro. Main Episode:Emma Hutchison, the Protrusive Student, welcome back. How are you doing? How is clinics going? Final year, you’ve done your exams, but it’s the actual more clinical exposure. How’s everything going? [Emma] Mm-hmm. Yeah, it’s going good. So as I was saying last time, it’s just more, lots more experience this year, which is good. So I’m up in Falkirk in Scotland every second week, just Monday till Friday, nine till five, seeing about four or five patients a day. And then the other second week I’m in Glasgow doing more specialized stuff, watching some consultants in restorative and things. So it’s good. It’s good. Just plodding along quite nicely, which is good. [Jaz] Good. And you obviously have been a dental nurse. So once you’re seeing four to five patients a day, you have this extra level of insight that maybe your colleagues don’t have. Like, in the real world it’s 30, 40 patients sometimes, sometimes 12, sometimes one. Like, it’s such a variation. ‘Cause obviously you’ve been an implant nurse as well. So what advice do you want to give to your colleagues who are maybe listening to this and they’re seeing these four to five patients, and you want to prepare them for the real world? What would you say with your very unique perspective? [Emma] Yeah, I think when I was working as an implant nurse, I remember speaking to the dentist I was working with and he was saying why he moved to private dentistry initially is just because the real life just isn’t like the gold standards that you’re taught at dental school. In the NHS especially, you’re time restricted. So I think I do have that in the back of my head. I know that I won’t have the luxury of such long appointments when I graduate. So yeah, I’m just getting myself prepared for the real world. ‘Cause I am gonna do VT or DFT so that I can work in the NHS to start off with and then see where I go from there. But I do know that in the back of my mind it’s gonna get a lot busier as soon as I start VT practice. So yeah, just that you’re not gonna have the best materials that you do in dental school. I know in Glasgow anyway, we tend to have really quite good materials. Good rubber dam. I know I’ve spoke to you about things like that before, and just that it might not be like that in the real world when I graduate and get out there and start working. So just to prepare myself for that. I’m aware of it, it’s fine. And I’m just trying to relish the opportunities that I have at the moment and the staff around me that I have as well. I think that’s one thing. [Jaz] You’ve gotta be like a leech, Emma. You’ve gotta be like a leech, like a sponge. [Emma] And just ask all the questions whilst you have all these specialists and consultants around you and just take note of everything that they’re saying. Especially the way that people communicate with their patients and pick up little things that they’re saying to their patients and make it your own. So I’m trying not to wish away my last year, so that’s good. [Jaz] No, enjoy it. Enjoy the comfort and the bubble and the protection you get in school before you enter the big, bad world. Do you think your experience as a nurse and seeing over the shoulder, you’re suctioning, you’re seeing things close up? Having said that though, I always find that maybe the nurses, we think they’ve got a great view, but they often don’t, especially when you are trying to juggle a million things. ‘Cause recently I’ve been using my clinical loupe camera more and more, and so now the nurses who’ve been working for 20, 25 years, they’re like, “Oh, now I got to see what you are seeing.” So maybe it hasn’t been that much of an advantage that you come from a nursing background. What do you think about that? Just be honest. [Emma] I think initially, when I got into dental school, first and second year, it helped obviously. Premolars, molars, all the very basic stuff. And then maybe second, third year when I started to see patients, I was pretty much at the same level as everyone else. Apart from communication. I’ve found the big thing is that patient communication has came quite naturally to me, and I think that’s because of my dental nursing background. [Jaz] Because you heard those conversations, right? [Emma] Yeah. [Jaz] You were present, and you’d seen the dentist explain the risks and guide patients to certain treatment philosophies and whatnot. That’s a really good point. [Emma] Yeah, so I think communication. Doing it yourself is a whole different ball game. Getting that manual dexterity is something that you need to work on. But even just communicating with patients, I’ve taken so many tidbits from other dentists and how to explain things to patients. I’ve worked with a paeds dentist, John McCall. I worked with him for a year, so I say a lot of similar things that he did to children, and I get on really, really well with children. And then when I worked in implantology, that’s maybe transferred over into oral surgery when I’m talking about those sort of things. So definitely in the communication side of things. [Jaz] Super. Well, we’re talking about more than just communication. We’re talking about replacement of an incisor tooth, right? Because I thought, okay, we could talk about replacement of missing teeth full stop, but I just feel that’s so broad, right? Like when you talk about a molar to a premolar to an incisor. So I thought, why don’t we go a little bit deeper and just talk about incisors. Let’s talk about central incisors, maybe some laterals, that kind of stuff. But just generally somewhere at the front of the mouth, you’re missing a tooth, be it trauma or long-term missing, and we’ll get into it. But we want to discuss the considerations and treatment planning options and the delivery techniques, little details and nuances when it comes to this type of dentistry. So Emma, take it away. What would you like to know in your student lens when it comes to replacing incisors? [Emma] Replacing incisors. So I actually had a patient in my outreach center. He had a missing central incisor and had done for quite some time. He had a single tooth denture in there, wasn’t getting on with it at all. And in student clinic we have the luxury that our patients don’t have to pay anything, and we’ve got quite good labs on our hands and things. So we thought, let’s try an adhesive bridge for this patient. And my clinician at the time said that replacing a single missing central incisor is often considered one of the most difficult things to do in restorative dentistry. So why is it so difficult in your opinion? [Jaz] Okay. I’m gonna turn the question back on you. What is your perception? Why do you think it’s actually more difficult? What did you think? [Emma] So I think from my perspective, seeing that patient, he had no other missing teeth. All his other teeth were natural, a few composites here and there. So I think just in terms of restoring that central incisor… I’m not too sure how to answer this actually. [Jaz] It’s okay, if you’re not sure, I’ll help you out. But I’m just trying to understand from a student’s perspective. Because I remember being a student learning this as well and I was like, wait, why is it so tricky? What are the special considerations for a central incisor? They say the single central veneer or the single central incisor, full stop. You’re quite right to say it’s difficult, and I only really appreciated it more and more when I actually started to replace central incisors, how difficult it actually is. Do you want me to go for it or have you got more ideas? [Emma] Yeah, go for it. Go for it. Go for it. [Jaz] Okay. So have you heard of something called central dominance? [Emma] No. [Jaz] So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins, right? Centrals should be like twins. And so when you’re trying to copy the adjacent central, therein lies the problem, right? Because yes, you may be able to copy the shape, but there might be some compromises. But getting the shade right, getting something to look good, okay. And then also a really important thing is smile line. When I talk about smile line, what is a smile line? What does that mean? [Emma] Like how much tooth is at show when your patient’s smiling or where your lip sits? [Jaz] That’s important, but yeah, where your lip sits. Because more important than tooth is how much gum actually. Because if you have a very gummy smile, so very high lip line, when you smile like curtains, your lip raises really high and everything’s on display. Those are by default considered very challenging cases because now not only are you worrying about white aesthetics, the aesthetics of your restoration and the ceramic and whatnot, but now you’re also worrying about pink aesthetics, which is the gums, right? How it’s so critical not only for the shape of the restoration to be matching so closely to the adjacent tooth, the shade characterizations, but now with someone with a high smile line, when they smile, that gum contour is so critical. And you would’ve seen this in implant dentistry. How much grafting and attention. It absolutely blew me away when I spoke to some of my patients who’ve had… I’m very lucky. There’s a really great dentist that works nearby me called Rob. Okay, I dunno if you’ve heard him. He’s brilliant. Okay. A lot of dentists will refer to him for the single central incisor. And he’s not cheap. And you know what? He fully justifies his fees. Like you could buy a small car. We’re talking about near five figures for a single central incisor. And when I first heard that, I was like, wow, what’s going on here? And as I gained more experience and I restored more centrals, I was like, wow, you know what? That fee is totally justified. Because when I see his cases, not only is he paying for the top-end lab work to try and really match the ceramic, really trying to match that tooth, but more often than not, when we lose a central incisor, we have to discuss how was that central incisor lost? And the most common cause is trauma. And when there’s trauma, there’s often soft tissue loss and hard tissue loss, because the bone, the buccal plate, it’s paper thin. And so what you have with implant is you’re dealing with the scenario where we have less bone in such a critical area. And so there’s soft tissue grafting, bone grafting, and it’s all to do with getting really high-end symmetry and aesthetics. That’s why it costs so much. So ultimately, central incisors are very tricky because we’re always trying to match to nature usually, or the adjacent tooth in general. And there are soft tissue and hard tissue considerations, and that’s why it’s difficult. And so the number one thing is, if ever you’re replacing a central incisor, even if it’s a resin bonded bridge, like your patient you described, you have to explain that, hey, what we’re giving you is gonna be a replacement, but you have to really tell me how perfect you want it to be. Because there’s different levels. Because the way that a restoration reflects light is very different to a tooth. And they need to understand. I used to work with a consultant called Raj Patel, and he would basically wave a tissue in the air to a patient and say, “What color is this tissue?” And they’re like, well, it’s white. And Raj was known for this kind of communication, right? He’d be slightly, okay, I hope he doesn’t mind me saying this, but slightly sometimes, in terms, patronizing. Like he’d ask a patient, “Do you like flowers?” And the patient goes, “They’re okay.” “I guess, okay, I like flowers.” And then like, “What do flowers need?” And the patient’s like, feeling patronized. “Well, sunlight, growth, water,” that kind of stuff. It’s like, whoa. Your teeth and gums are like flowers, and so his hygiene discussion would come like that. And I saw him do this with like a builder man. I was like, what the hell? Like, what’s going on here? Yeah. So anyway, back to the tissue. He’s waving this tissue and he’s like, “What color is this tissue?” It’s like, well, it’s a white tissue. Okay. And then he’d put it on his trousers over his lap, right? And so now that tissue was still white, but it looked like, because you see his dark trousers through it, so it’s kind of like grayish now. Do you see what I mean? And the patient’s like, okay, well yeah, I see that it’s still white, but it’s not the same white. And then he’d try to get the patient to understand that look, we can’t match the adjacent tooth perfectly. He’s very good at that, and I always took that example. So I very carefully choose the patient through that tooth. Does that make sense now? [Emma] Yeah. Yeah, that does make sense. And it’s the first thing that people see, and the ones that people are more aesthetically worried about are their central incisors naturally. And I don’t know if this is maybe good for my first case replacing that central incisor. My patient wasn’t— [Jaz] Have you done it already? That patient, the denture replacement? How did it go? [Emma] It was good. Yeah, so we did a resin bonded bridge, like a Maryland from the other central incisor. But he wasn’t too aesthetically demanding, and for this patient going private wasn’t really an option, just financial wise. And he was just happy to have any sort of replacement other than a denture. And so to me, like it was nowhere near perfect match, you know? But we’d done the best that we could. His contralateral central was three different shades in one tooth. You’re never gonna get it matched perfectly. And with what we’ve got on the NHS, you pick one shade, and that’s sort of what you’ve got to stick with. And he was happy. And I saw him for a review last week and it’s still in there, which is good. And he’s happy with it. But yeah, it was— [Jaz] What did you think? When you look at that central, does the shape match well to the adjacent tooth? [Emma] Yeah, I’d say he was happy with the original denture that he had and the shape of that tooth. And he wasn’t wearing that denture because it was actually broken, and I sent that denture away to the lab as well. [Jaz] Oh, nice. [Emma] I know that they’ve got impressions of the uppers anyway to match to the other, but they might as well just have it to see what this patient’s already happy with, mould-wise. So he was happy with that. I don’t think it’s too bad a result, but yeah, you can definitely tell that it’s not a natural tooth that’s there. But he was happy with it, and I’m happy with it for my first go. But it was tricky. It was tricky. [Jaz] It’s always tricky. Now we’ll talk a little bit more about that, but when it comes to replacing that incisor, you did a resin bonded bridge and therefore, a metal wing or— [Emma] Yeah, yeah, a metal wing, yeah. [Jaz] Okay. Did you find that the central incisor that you were sticking to, the abutment tooth, did it go a bit gray or not? [Emma] Not that I noticed, no, but I know that can happen. [Jaz] Do you know when that would happen? Which kind of patient is particularly susceptible to that? [Emma] Would that be if the tooth has been retreated? [Jaz] Not necessarily. It’s more to do with if someone’s got minimal wear and therefore that incisal, translucent zone. Probably this patient. How old is this patient? [Emma] He’s in his 60s. [Jaz] Okay, so fine. But did he have a bit of wear on the edge? Was it a bit worn? [Emma] Yeah, a bit. He’s got a bit of wear, yeah. [Jaz] Okay. So sometimes when you don’t have much wear, or generally some people have more translucent teeth, right? As a feature of their teeth. And therefore in that scenario, you have to warn the patient about graying. And so one thing you could do is you can get a cotton roll and take a photo of the tooth as it is, get the retractors in, and then you put a cotton roll behind it and you take a photo. And then you see how much impact did that cotton roll have on the tooth. Like if the tooth looks different just by putting a cotton roll behind it, then you know that when you put something black there that is going to look… metal there… it’s gonna look a lot different as well, basically. And so you’ve gotta warn the patient of that. I’ve seen some cases I’ve done before earlier in my career which really grayed up. And then one way to mitigate that is to use opaque cement. Now, before we go deeper into that, just remember the main lesson, the really important lesson: shape with a P is more important than shade with a D. i.e., shape is more important than shade. So if you absolutely nail the shape, that’s actually more important. It’s going to have a more pleasing outcome than if you get the shape wrong but the shade right. Okay? So shape is super, super important. Always remember that. And everything you do when it comes to anterior aesthetics, shape is always more important when you’re trying to match. Did you discuss with that patient any other treatment options, or how did he come to you and your sort of mentor or supervisor come to the decision that resin bonded bridges would be the most appropriate? And did you consider any other options? [Emma] Yeah, so I think just from hearing other dentists talk about replacing gaps in practice and things, I always go and tell my patients that there’s four options usually. Does that sort of ring true with you? So the first option is to do nothing, because we always have that option for our patients. The second option was to try a replacement denture for that patient, and he wasn’t really keen to give that a go. He’s had one… I don’t think he even had it for very long, and it had already broken and wasn’t very retentive, X, Y, Z. And then I say the third option is to do something more fixed, so like bridge work. And then the last option would be to go privately and do something like implants. And it just wasn’t in the patient’s financial budget at the moment. So he was interested more in going for something more fixed. So I discussed with him that we could maybe do a bridge on that tooth, a Maryland bridge with the metal wing. And then I had a chat with him about that, although I didn’t actually mention to him about the metal wing and that possibly shining through. And I did have a chat with him. He had quite heavily restored teeth. He had composite on the other central incisor and on the lateral. It was— [Jaz] Was it a big composite? Was it a large composite? [Emma] It wasn’t… I’d say on the lateral there was quite a large composite. [Jaz] Okay, but what about the central, your abutment tooth? Did it have a big composite? [Emma] It had a distal composite, but it wasn’t massive or anything like that. [Jaz] Okay, good. Good. Because having a large restoration in your abutment tooth for a resin bonded bridge usually has more negative outcomes because there’s less surface area of enamel. Did you know that the most important predictor success of a resin bonded bridge is the same as it is for veneers? So how well your ceramic veneers will bond and resin bonded bridges is the same. Availability of enamel and surface area of enamel. And that is really, really key. That’s the number one factor when seeing if there’s going to be success. So it’s good that fine, it’s a small one. Ideally, unrestored. Okay. So you talk about all those options, and here’s a communication tip for you and your colleagues and anyone listening. I used to do the same thing. I used to say, okay, there are four things you can do and blah, blah, blah. And sometimes for a lower incisor, right, if you’re missing a lower incisor and there’s crowding, you could say, well actually, how about we relieve the crowding and then have three lower incisors. Look, I got three lower incisors here, not four. Okay. So you can do something like me and then we can relieve the crowding at the same time. And so sometimes ortho is an option, but obviously wouldn’t be for an upper incisor, right? ‘Cause that would look weird. So when we give those options, I think it’s much nicer to do it the following way. So Emma, is it important for you to have a front tooth? [Emma] Yes. [Jaz] How important is it? You’re missing a front tooth and you have a denture and you hate it. How important is it to have a front tooth? [Emma] For me, very important, yes. [Jaz] Extremely, right? So really doing nothing is not an option. [Emma] No. [Jaz] Not gonna give you that option because that’ll be inappropriate for what you’re saying here. Okay. Is it important for you that it’s fixed, or do you mind having something removable? [Emma] For me, I would ideally like something fixed. [Jaz] Okay, that’s fine. Would you like to be able to eat corn on the cob with it, or are you not so fussed and you’re happy to be a little bit careful with what you eat? What do you think? [Emma] Yeah, I’d be happy to maybe be a bit more cautious about what I’m eating, yeah. [Jaz] Okay. Do you see, just from those questions, I now know that doing nothing is not an option anymore. A denture is really not an option because you said you want something fixed. So that only really leaves a bridge. And then what type of bridge? We know the adjacent tooth is minimally restored, so maybe not a good candidate for a conventional bridge where you have to prep the tooth. Okay, so fine. We know it’ll be a resin bonded bridge or an implant. And they both are still on the table here. Both are still on the table. Now, if you said to me that, look, it’s really important for you to be able to eat corn on the cob, and really use your incisor a lot, and you like to bite into apples, and that’s really important for you, then I’d say that look, you’re probably best going for an implant. Okay. And then in terms of budget, like is money no question? You want the best there is? Or are we on budgetary constraints? And we talk about that, and then we’re like, okay, well actually based on what you said, that you wanna be able to eat corn on the cob, in a hypothetical scenario, then really you’ve gotta go for an implant. But because of your financial constraints, then a good compromise will be a resin bonded bridge. This is blah, blah. You explain what it is. But remember that this is essentially an aesthetic appendage, something glued. It’s for smiling. It’s not for chewing. You cannot bite your nails with it. You cannot bite tools with it. You cannot cut into… you can’t bite a baguette and tear it. It’ll come away. The worst thing that can happen is it comes away, but you know what? It can be glued back. But you just have to be extra cautious. And when you have that kind of conversation with patients, they get it. And if you choose well, resin bonded bridges enjoy a very, very high success rate. The King et al. study, very famously quoted in Bristol, they had like 700-something RBBs. At four years, 80% were totally fine with no issues. And if they do last four years without debonding, they’ll probably go on to last 10 years and then beyond. And one thing I can tell you is I used to work with… well my predecessor, who I used to work with now, he has been doing resin bonded bridges for years. So I’ve got patients on my books that have had RBBs for 25, 28, 32 years, never debonded. The odd one debonded 16 years ago once, and then it’s been okay. Do you see what I mean? And so my predecessor, using the cements back in those days, did a fantastic job. Case selection was really good. And all the Americans out there: resin bonded bridges indeed can be very successful, but the patient must play a role. I know that my lower zirconia resin bonded bridge I have, I cannot have corn on the cob. It would be a stupid thing to do. You are overloading it and you’ll break the bond. And so those are some important considerations. Now if the patient would like to be able to chew with their front teeth and they’re like, look, I want something fixed. I don’t want to have to worry about it ever coming away. I want something that’ll last the longest term possible. Then you really… you’ve now selected an implant. You’ve self-selected implant. So an analogy I use, in the podcast episode I did with Michael Frazis—have you listened to that one, Emma?—is it’s like you’re playing Guess Who. If you ask enough questions, right, you only have a few people left. And so really, you’ve only got a few options left. So if you’re not sure what the treatment plan should be, you probably haven’t asked the patient enough questions. [Emma] Yeah, yeah. I think that’s interesting how you were talking about almost getting the patient to self-select and guiding them into their own treatment option, which is interesting actually. Because I’m usually just listing off the four options. “Oh, we’ve got four options, do nothing,” and you’re never really gonna do nothing if that patient’s main complaint anyway was that missing central incisor. So that’s interesting. And I know you were talking about, so if you’re going down replacement options and would you like a fixed versus a removable, what other sort of factors do you consider from a dentist perspective when you’re deciding whether a fixed option is appropriate at all, or whether a removable option is one that you would more recommend? [Jaz] Removable has its place. Like, if it’s for a single central, then more often than not removable is not gonna be… it is very much a budget thing, right? Like it is major budget concerns. And look, I can’t afford even the resin bonded bridge, and you gotta go for an acrylic denture flipper. But there’s also things like poor oral hygiene. They’ve got poor oral hygiene. It’s a double-edged sword actually, because if you’ve got poor oral hygiene, then you don’t wanna give ’em a denture. But equally, if you know they’re gonna be losing other teeth of poor prognosis, then you can actually be adding to the denture as you go along. And if they’re missing a central, but they’re also missing a premolar on one side and another premolar on the other side, and then you can actually replace all those teeth in one go, then that is a consideration. Sometimes when you get a little bit fancy chrome denture and you have palatal backings and you kind of make like a splint type framework at the same time, as part of a bigger case for tooth wear. So there’s a lot that can be done, but it’s about understanding the patient’s history, the number of teeth involved. But if we’re talking purely the missing a single tooth only, mm-hmm, which is a front tooth, removable is something that I would struggle to recommend unless it was a budgetary thing. There’d have to be some really good reasons not to. Now, for example, let’s talk about age, right? So we talk about smile line, but we’ve gotta talk about age because if it’s a growing patient right up till the age of 25, you don’t want to do implants. Okay. So therefore, it is a resin bonded bridge, for example, or it’s a denture until you are old enough to have an implant. ‘Cause it’s still growing. And so that’s a very, very common thing. And what happens is they have these resin bonded bridges, and they’re successful for many years, and then maybe in their forties they end up having an implant. It’s much better to have an implant in your forties than it is in your thirties. And some patients, all they need is just a new resin bonded bridge, and that’s all they need. So age is really important, and their growth status. [Emma] Yeah. Yeah. Okay. [Jaz] And then one more thing, when you are deciding, not so much fixed–removal, when you’re deciding the type of bridge… if that other central in your patient’s case was already a crown, then you just take off that crown, polish up the prep, and now you have a conventional bridge. [Emma] Yeah. And that’s what I was actually gonna ask you next. Because one of my friends had a similar case. There was an adjacent crown, and then there were chats about what would your approach to that conversation be about taking that crown off? Because I know that there’s a lot of dentists who would have hesitation around that, to take that old crown off if there’s nothing wrong with that crown to then put a bridge on it. Does that make sense? Does my question make sense? [Jaz] Yeah, totally makes sense. But the question would be, how old is that crown? And if it’s more than about 15 years old, eventually the replacement event’s gonna come anyway, whether you like it or not. [Emma] Okay. Yeah. [Jaz] And I used to worry about this as well, but having done several cases now… you get your pulpal diagnosis, you get your apical diagnosis. If everything’s sound, you just remove the crown as atraumatically as possible. You just give it a nice prep, give it some love, and you put a bridge on. And I haven’t had any issues doing this. And I think everyone’s right to be concerned about it because, fair enough, you don’t know what’s inside that crown, underneath that crown. That core could have been really weak. So yes, you’d be silly not to warn your patient of like, okay, we’re kind of going into the unknown. Okay. But I wouldn’t want to do this if the crown’s been a recent crown, last five, ten years. But if it’s an older crown, it makes sense. But of course you have to warn the patient. You also have to find out, okay, how did this tooth fail? Check the periodontal probing deficit. If it’s like a single isolated pocket and you’re worried, could this tooth already be quite compromised and cracked? Then maybe not. If the tooth already has a big post in it, and maybe mechanically you’re a little bit worried about it, then maybe the implant is the best way to go. And maybe you should be having a denture until you can save up enough money to have an implant, or if the patient can afford it, go for an implant. [Emma] Okay. Okay, that makes sense. So if you know there’s a crown on it about 15 years old, but otherwise looks sound, you’re looking to replace the adjacent gap, as long as you’ve communicated that with your patient and all the risks, you would be happy to go ahead, remove that crown and replace. [Jaz] Yes, I would, and I have done it on many occasions. And it’s a good option, because you already have a… it’s like the worst thing you could do is crown a virgin tooth to do a conventional bridge. But you’re literally replacing for like… it’s just carrying a pontic next to it. And again, the same thing goes with it, that you gotta warn the patient that, hey, you gotta be careful. This one tooth is now carrying another one. Let’s not stretch it by chewing or incising on your front teeth in a harmful way and overloading that unit. [Emma] Okay. And just when you’re talking about overloading of units there, that sort of takes me onto my next question about, especially in the anterior region, is there any situation where you would prefer or recommend a conventional bridge over a resin bonded bridge, or vice versa? Like especially in terms of occlusion and things like that as well. [Jaz] Yeah. So really what you’re asking here is, when you are doing resin bonded bridge, you’re relying on the adhesion, and therefore the point of failure is a debond. Whereas you wouldn’t typically get that with a… you feel more secure, you can sleep well at night. Like, you made that comment a little while ago where you said you saw the patient review and it’s still there. You probably wouldn’t have said that if it was a conventional bridge, right? ‘Cause you know you’ve got the whole 360 degrees, you’re cementing it on. It’d be a much bigger surprise if that came away than a resin bonded bridge. So I see where you’re going with that. And yeah, if you have a deep overbite, then that is a little bit worrisome because when they’re chewing, right, the time in contact, the time that the lower incisors are thrusting up against that pontic… because the rule of bridges in general is that the pontic is allowed to be lightly in contact in MIP or ICP. But in any excursion, any chewing movements, you want to minimize rubbing. But with a deep overbite, as soon as you put some food in between, you’re kind of milling. Like even though it might not be touching, there’s still food trying to push that pontic away. And therefore a deep overbite may be a reason. But then again, would I still prep? Would I still prep a virgin tooth to make it into a cantilever conventional bridge? Probably not. I’m probably gonna say, look, your functional demands are quite high. Would you like ortho? Or would you like to maybe go down implant, which still will have its own issues because we don’t want to overload an implant, but probably it’s less risk. It also matters about the patient’s occupation because if the patient’s a high-level barrister and is doing lots of public speaking and that kind of stuff, you may say, look, with your bite in consideration, then I may suggest, let’s do an implant here because resin bonded bridge is just glued onto the tooth next door. And with your bite, it’s a lot of demand. It could still work, but there’s a little bit of element of risk in there. And you try and assess the appetite for risk for that patient and your patient’s occupation as well. The lip line, all those things. Basically because if the lip line’s really low and you don’t see much, then actually you can get away with a lot more. But if it’s really high, not only are you thinking, okay fine, if you’re gonna do something it’s gotta look good everywhere, and therefore not only is it just an implant, it’s a complex implant where you’re doing soft tissue grafting and really trying to get the best out of the aesthetics. [Emma] Yeah. Okay. Okay. That makes sense. And I think that relates to my patient because the reason he was struggling with the denture… a bit had chipped off, but he wasn’t wearing it anyway. He’s a musician, he was a singer, and he was actually at a gig and his denture came out. And so that obviously is not good for him. And he has quite a deep overbite. And I had like a lengthy chat about him and chatted to the clinician, my supervising clinician, about conventional bridge or a resin bonded bridge. But we were like, let’s try it, let’s try it first and see how we go. And it did need a little bit of adjusting, but that’s why I was quite pleased when he came back two weeks later and it’s still there. We adjusted it a little bit further. Happy with where it’s at at the moment. But yeah, there’s just so much to consider, and so much to consider, and yeah, definitely. [Jaz] I want to remind you and all the listeners that when you do resin bonded bridge… which you guys know I’m a huge fan of. We have the RBB Masterclass on the Protrusive Guidance app as well. Have you done that yet? [Emma] No. I’ve not done the RBB Masterclass yet. No. [Jaz] Okay, fine. [Emma] I was waiting until I was at a point where I understood everything, ’cause I started working with you when I was in second year. So maybe now’s a good time. [Jaz] Now’s a great time to do RBB Masterclass. Yeah, yeah, do it. So I’ve got some clinical videos on there of actually putting bridges on, which you’d like to see. But as part of delivering a resin bonded bridge, it’s totally fine to adjust the pontic palatally to make sure it’s out the occlusion in that scenario. You want to check excursions and protrusive movement to make sure it’s not there. But again, equally it’s really important the patient understands that it’s glued onto the tooth next door. You must not put anything between the teeth, or you must not chew that baguette. I always use a baguette example, or corn on the cob. And once they understand that, then you’ll get success. I had a patient who I did a resin bonded bridge for. I get a very good success rate with resin bonded bridge. I believe in them very much. I do think for a lower incisor, for a single missing lower incisor, the standard of care is the lower resin bonded bridge central. I think if you’re trying to force an implant in that delicate and small area… yeah, why? Why is anyone doing that? I honestly… please, my listeners, if you are routinely advocating an implant for a lower incisor, email me. Give me a justification. I just… honestly, I can’t see. I’m a very open-minded clinician, but in that one scenario, maybe it’s ’cause I’ve been affected by this and I’m missing a lower incisor and therefore I have it. I just cannot fathom how you can try and force and try and get a small implant, all the complexities of that, when you can just have a resin bonded bridge and just be careful with it. Mine’s been going for about seven years now. So just remember that you have to look at the patient as a whole and their chewing habits. Just going back to that again, basically. [Emma] Yeah. That was actually also one of my questions. You sort of just answered. You speak about implants, not a tooth replacement, but… I’m missing… I don’t know if it’s you or if it’s one of the clinicians at uni, it might be yourself, Jaz, that always says an implant is a good substitute for no tooth, but it’s not a substitute for a tooth. Is that you or a clinician? Anyway, I’ve heard that somewhere. [Jaz] I’ve said it before, but it’s not mine. Like, it’s from very clever people. I can’t say who. It’s one of those things, definitely said by a lot of people, speakers and writers, and it’s a great thing, right? An implant is not a replacement for a tooth. It’s a replacement for a gap. And that’s… yeah. Or any restoration you do. And just going back to be it implant, where you’ve gotta manage the occlusion carefully as well, or any form of bridge, especially resin bonded bridge… like, for example, if you’re doing a premolar. I know we’re talking about centrals, but I think the premolar example really drives it home. If you’re replacing a premolar, maybe you’re using the second premolar as an abutment, right? So palatal and occlusal wrapper of the wing. And then you’re placing a premolar. Why does that pontic of the premolar need to have a palatal cusp? There’s no need. You can literally put a canine to replace a premolar. Because ultimately it’s aesthetics. When the patient smiles, it should look like they have a tooth there. It’s not for chewing. And so the same kind of goes to some degree with implant, where we try to make the occlusal table, right… the occlusal table narrower, smaller, so it’s taking less load. Now implants are… you can chew on implants, they can go for it. Okay. Whereas you wouldn’t want to do that on a bridge, so they’re different in that regard. But to make the occlusion really focus on the aesthetics and explain to the patient that this is smaller, that you’re missing half the tooth around the back, because that’s not important. It’s not to chew. And if the patient doesn’t understand that, if they’re not willing to buy into that, then you shouldn’t be doing a resin bonded bridge. [Emma] Okay. And so an implant-supported crown, you talk about that being the gold standard in terms of replacing teeth, but it’s not always in certain situations, especially like— [Jaz] Yeah, lower incisors it’s definitely not. In my opinion, yeah. But an upper incisor… you’re a good surgeon, then you know, if you wanted to get something that’s gonna really be the most secure, longest lasting, then an implant. It just makes sense. Would I be happy to have a resin bonded bridge on my central? I probably would. Okay. I probably would. Honestly, I believe in the treatment protocol. But it depends on the occlusion once again. Like, if you were to do veneers on someone, or if you were to do a central incisor resin bonded bridge, what’s the ideal occlusion to pick? Like, if you wanted to give a lifetime guarantee to a patient, who would you pick? What kind of malocclusion or occlusion would you pick? I’ll give you a clue here. [Emma] A class one. Wait, sorry, say that again. For— [Jaz] On anterior upper anterior veneers or lower anterior veneers, in fact any aesthetic work anteriorly, who is the best occlusion to work on, which is almost gonna give you a lifetime guarantee? Almost. [Emma] A class one. [Jaz] Okay. If it’s a severe class two, then the lowers for sure are gonna last forever. The uppers… there’s always a trauma risk. [Emma] Okay. Yeah, that’s true. [Jaz] An anterior open bite. No contact. Like, you know anterior open bite, right? This is why if you look at your anterior open bite patients, their posteriors are worn. The anteriors, they often have mamelons still. The functional load, the wear on those teeth, are minimal. So if you wanted to give a lifetime guarantee, the only patient I would ever even dream of doing that for is an AOB, right? Obviously you wouldn’t, but you get the point, right? So that is a really good example. We teach this in our occlusion courses that we do, where we think about, okay, think of the patient, think of their functional demands as well. Are they what we call a high occlusal risk patient, low occlusal risk patient? And that always plays a part, by understanding that an anterior open bite actually extends your longevity and prognosis for replacing an upper incisor. It’s a level of occlusion that just is more practical and makes sense. [Emma] Yeah. That makes sense. That makes sense. And then my last question for you, Jaz, was actually just about a digital workflow and CAD/CAM milling. Is that something that you utilize in your day-to-day? [Jaz] I don’t do chairside making. So like, whether you think you’re digital or you’re not, you’re digital. Even if you’re sending impressions, when the lab gets the impression now, they’ll pour it up and then they’ll scan the model, and now it’s all become digital. So everyone’s digital, right? And so, yes. I like my technician to, because the shape is so important, they’ll send me an Exocad file, show me the digital design of the bridge, for example, or the crown or veneer, whatever we’re doing. And so I get to see that on the web browser. I get to move it around, make it translucent, opaque. I get to suggest some amendments, and then it goes for the milling, and then it gets sent back to me. So it’s not I’m scanning, obviously. So scanning. But what I’m not doing is milling in-house, in the practice. But your lab is doing all those things, so whether you like it or not, you are digital. [Emma] Yeah. Is that a thing, like milling in-house? Is that… [Jaz] Yeah. I mean, look at CEREC. People are doing zirconias and Emax and they’ve got a little oven in the practice as well for Emax. I dunno if you’ve ever worked in a practice like that, or have you nursed for a practice like that? [Emma] No. No. Never. No. [Jaz] I mean, it’s amazing. I’d love to be in a practice like that one day. It’s like a whole… I like the idea of same-day dentistry. Like you come in and then they do it all, which is cool. I’m pretty sure you can do good bridges with it, but I see lots of veneers and anterior crowns that are done with it. And it’s great. There’s whole Facebook groups, “Keep CEREC Kicking” is one. I see their work. I’m like, wow, that’s amazing that you didn’t need a technician for that and you did it yourself. That’s so cool. [Emma] Cool. Yeah, I think that’s all the questions that I had today, Jaz. [Jaz] Okay. So the only thing I wanna add to that then, I think for completeness, is when you’re doing the shade, give as many photos as possible to a technician. When you’re doing the shade tab photo, put the incisal edge to the incisal edge. Put the cervical of the shade tab to the cervical of the tooth. Don’t be afraid to tell your technician, look, I think the cervical is A3, the middle is A2, and then there’s white effects here. The more detail you give, the more closely they’ll look. Lots of good photos. You need to make sure that you undersell and over-deliver. So whether you want to use Raj Patel’s tissue technique or whatever, you gotta tell the patient that, look, it’s very difficult to match a central incisor. We’ll never match, will never be perfect. And if the patient’s got a problem with that, they can go somewhere else. Because you run into trouble if the patient’s expecting perfect. Because sometimes we think… oh my God, this is from my first year in practice. I had this patient who didn’t pay any money towards the bridge ’cause she was exempt. And so I did a bridge for her, and she was happy overall, except she had a high smile line and this resin bonded bridge, the way the pontic sat on the gums, right? It kind of made a dark line. So replacing a lateral incisor from the canine, and where the pontic touches the gum. At that time I didn’t have the skill or the knowledge to do an ovate pontic. It was good, but you could just about see a dark line where she could get some floss under the bridge. But you could see a bit of a dark line if you really zoom in. And she said, look, she doesn’t like that dark line. And then I go to my principal trainer, I said, oh, listen, what do I do? Like, the bridge is looking good, we’re happy with it, but that dark line. And the first question he asked me is like, well, okay, how much did she pay for the bridge? I’m like, she didn’t. And he looked at the before, and he’s like, wait a minute, she didn’t pay for the bridge and she has a problem with it? And actually I think he was wrong. I actually think he was wrong, because it doesn’t matter whether… so first, it doesn’t matter if they’re paying or not. You need to warn about everything. It doesn’t matter if they’re fee-paying or not. I should have explained that, look, the way this pontic is gonna sit against it, you’ll feel it, you’ll see it. Why? Because you have a high smile and you show everything. So if you want the highest level, you see a periodontist, do some soft tissue work and get that kind of stuff done. But when a patient is paying a fee, whether they’re paying one onion or five onions… okay, onion can be any currency that you want… basically, if they’re paying, just assume that their aesthetic expectations are sky-high. And so your job always is to bring that down to an appropriate level. I’m not saying always say that it’ll look really bad, honestly, like you’re just gonna look so, so bad. And then when it looks half-decent, be like, hey, what can I say? Don’t tell them a lie, but you need to give them an appropriate… because obviously you wanna do a good job for them, but you can show them and share with them the intricacies and difficulties of doing that. And then when it comes to decision-making tree and planning for an incisor, just make sure that you ask enough questions so you know exactly what direction you feel confident in recommending that option to a patient. And be it a denture, be it an implant, be it a bridge, we’ve kind of done a little bit of a very brief overview. It’s up to our Protruserati to delve deeper into that, and there’s a really good episode that I would recommend. We do “Dentures versus Bridges.” I did that with Michael Frazis. That’s a good one. We also do one called “Crowns versus Onlays” with Alan Burgin. That’s a really good one. Mm-hmm. We also talk about dentures with Finlay Sutton. There’s so many other episodes out there. So for students out there, go back in time and listen out there. And speaking of students, we have some student notes. What are the notes that you are adding to the student section of the app? [Emma] I think I might even… I’ve not put it together yet, but I think I might even just take some bits here and there for just replacement options. Not even just for a central incisor, but just for gaps in general. Even just like a communication guide for talking to your patients as well. Making sure you’re not missing any risks and benefits and alternatives. And yeah, just for replacement options, I think that would be good to put together. [Jaz] Okay. That’ll be available in the Crush Your Exam section of the Protrusive Guidance app. There’s one thing that we didn’t touch on, I just remembered, is when we are replacing with a denture or a bridge… we’re talking central incisors predominantly, but you can actually have weird and wonderful incisors. Like if you’ve got small teeth, you can have small pontics, small dentures. But with implants, we’ve gotta reconsider the dimensions, the CT scan, how much bone is available. There’s a whole biological element, which you kind of, to a large degree, can skip with dentures and bridges. However, the biological for a high smile line is still important because the way the pontic, the fake tooth, sits against the gum… that’s soft tissue. Aesthetics then come in for someone with a high smile line. But you need a minimum distance between one tooth and the next tooth, a minimum distance between the roots. So sometimes you look at the gap, the central incisor, and you think, yeah, this is great, I can put an implant here. But when you take a PA, you see that the lateral incisor and central incisor roots converge. And therefore actually you don’t have the space. You need to have some very complex ortho to torque and fix the roots here. And so there’s so many more nuances. This is why the top dentists that are doing single central incisor implants, they demand a top fee because they deserve it. It’s very, very complex. And, you know, hats off to those clinicians. [Emma] Yeah, absolutely. I think if you’re putting all that work in, then yeah. Charge for it. Absolutely. Absolutely. [Jaz] Good, good. Amazing. Emma, thanks so much for being the Protrusive Student. Thank you very much. Next time… I don’t know if you’ve thought about next time. We were gonna consider doing medical histories, guys, but honestly it didn’t excite me enough because I’m like, okay, am I the expert on medical histories? I can kind of advise, okay, let’s open the BNF kind of thing. But it’s something that I think is important though. So please do some self-reading on medical histories. But are there the more clinical topics that you’d like to— [Emma] What have we not really covered? Bear with me two seconds, Jaz, ’cause I actually have a list of— [Jaz] Okay, cool. [Emma] Let’s see. We’ve not really done any basic oral medicine, have we? Or oral surgery. I know that we did an extraction topic, but maybe we could do something similar… oral medicine— [Jaz] Oral medicine. I defer to this really lovely Australian dentist, Dr. Phoon. We’ve done some red patches, white patches, done oral cancer with her. And so it would be a blasphemy if I was to start answering questions on his pathology of oral cancer and stuff. But we can talk about some other clinical themes. But there has to be a… I love it when you have a patient problem. Like when you have… it is so great that you had a recent patient with that bridge. So I want you to start looking out for real-world clinical dilemmas. ‘Cause that’s what the podcast is about: real-world clinical problem-solving. So over the next few weeks, have a look at what clinical dilemmas you’re facing and then let’s decide the topics from there. Okay. I think we’ll make it more tangible for everyone that way. [Emma] Okay. We’ll do that then. Perfect. Thank you very much. [Jaz] Amazing. And guys, if you’ve got a recommendation to students for what you’d like, or young practitioners… I’m really proud of the series, the previous 17 episodes we have so far. So, so great. It’s really, really good. But if anything else needs a back-to-basics, something for young practitioners that’s not gonna bore me to death, then please do comment and let us know what you’d like. All right. Thanks, Emma. [Emma] Perfect. Thank you. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. If you are a qualified dentist and you’d like to claim CE credits for this episode or enhanced CPD, you can do it. Head over to Protrusive Guidance or scroll below. If you’re already logged in, answer the quiz and claim your CPD. You deserve it. You listened to the whole thing, and now you get to test your knowledge and your understanding, and we will reward you with a certificate. We are a PACE-approved education provider. We’ve got over 400 hours of CE on Protrusive Guidance. All the masterclasses, episodes, and the accompanying premium notes that we provide. Transcripts and infographics are second to none. Now, specifically for students, we have the Crush Your Exam section where Emma uploads her notes, which helped her smash her exams last year. So the one to accompany this episode will be all the replacement options for teeth. Particularly useful for OSCEs and great revision material. Some of the earlier ones that she uploaded were dental materials, for example, which a lot of you found very helpful. If you wanna fast-track access into that, email [email protected]. Send us your proof that you are indeed a student, and you’ll be allowed into that part of the app. Otherwise, thank you all for listening and watching so much. If you are on YouTube, make sure you hit the subscribe and like button, and if you’re on Protrusive Guidance, please do comment. I love reading comments and replying to them. Thanks again and catch you same time, same place next week. Bye for now.

What if one bad decision completely changed the course of your career? In this exclusive, members-only episode, Jaz sits down with a fellow dentist from our community who shares his raw, honest story about a moment of misjudgment — committing fraud — and the painful lessons that followed. This isn’t about blame. It’s about insight, accountability, and redemption. From the shock of investigation and court hearings, to the struggle of rebuilding trust and identity, this conversation shines a light on what really happens behind closed doors when things go wrong. The aim of this podcast was to hopefully deter colleagues from temptation which can affect anyone at any time. https://youtu.be/QF-UNrlYjcw Watch PDP248 on YouTube How to Watch the Full Episode This is a members-only podcast episode due to its sensitive nature. You can access it by creating a free Community account at: https://www.protrusive.app Highlights of this episode: 00:00 Teaser 00:49 Introduction 05:49 End Screen Love this episode? Don’t miss Divorce, Alcohol and Rough Patches – Overcoming Adversities (IC040) #PDPMainEpisodes #BeyondDentistry This episode is eligible for 0.5 CE credits via the Quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and D AGD Subject Code: 555 Ethics in Dentistry Aim: To reflect on the ethical, professional, and emotional lessons learned from a real-life case of dental fraud, highlighting accountability, insight, and rehabilitation while identifying practical steps to prevent similar incidents. Dentists will be able to – Recognise how workplace pressures, lack of mentorship, and poor oversight can lead to ethical lapses. Understand the legal, professional, and emotional consequences of dishonesty and poor record keeping. Identify support systems, coping strategies, and self-reflective tools to prevent burnout and maintain integrity.

Ever had a patient swear their bite feels “off” – even though the articulating paper marks look perfect and you’ve adjusted everything twice over? Or maybe you’ve placed a beautiful quadrant of onlays, only to have them return saying, “these three teeth still feel proud.” If that sounds familiar, you’re not alone. In this episode, I’m joined (in my car, no less!) by Dr. Robert Kerstein, who was back in the UK to teach about digital occlusion and the power of the T-Scan and ‘disclusion time reduction therapy’. We dig into why a patient’s bite can still feel “off” even when everything looks right, how timing is just as important as force, and why splints and Botox don’t always solve TMD. Robert explains why micro-occlusion is the real game-changer, how scanners could mislead you, and why dentistry still clings to articulating paper. So if you’ve ever wondered why “perfect” cases still come back with bite complaints, or whether timing data can actually prevent fractures and headaches, this episode will give you plenty to chew on – pun intended. https://youtu.be/0lCAsjFhsXI Watch PDP247 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Micro-occlusion, not just “dots and lines,” is the real driver of patient comfort and long-term tooth health. T-Scan measures both force and timing, which scanners and articulating paper cannot capture. Many patients show signs of occlusal damage without symptoms. Disclusion Time Reduction (DTR) treats TMD neurologically without splints, Botox, or TENS. Relying on occlusograms alone for guiding reduction is risky. Dentists can reduce post-treatment complaints by balancing micro-occlusion with T-Scan. Adopting T-Scan requires proper training. CR can be a convenient reference point, but MIP works well in most cases if micro-occlusion is managed. Objective, repeatable data builds patient trust and provides medico-legal reassurance. Highlights of this episode: 00:00 Teaser 01:13 Intro 4:41 Protrusive Dental Pearl –  Removing a Temporarily Cemented Crown 06:39 Introduction 08:48 Global Training Footprint 09:32 What Robert Teaches (DTR & T-Scan) 09:55 Occlusion as Neurologic 10:33 Macro vs Micro-Occlusion 11:33 Neural Pathway 15:00 MIP vs CR Framing 16:48 Signs Without Symptoms 19:16 Silent Majority 20:08 Why Treat Asymptomatic Signs 20:50 Disclusion and MIP 22:28 Occlusogram Caveats 24:53 Midroll 28:14 Occlusogram Caveats 28:29 Why Occlusograms Mislead 29:21 Don’t Adjust From Color Alone 31:47 What Pressure/Timing Enable Clinically 33:02 Prosthetic Reality Check 34:46 Patient-Perceived Comfort 35:29 Why Isn’t T-Scan Everywhere? 36:29 Political Resistance 37:42 CR as Utility 38:18 MIP and Vertical Dimension. 39:48 Macro ≠ Micro 41:00 Material Longevity Benefits 41:57 T-Scan Training 42:58 Three Competencies to Master 44:20 Micro-Occlusion Rules 44:46 Outro If you want to get more clued up on TMD, tune into this episode for the latest insights and guidelines! PDP213 – TMD New Guidelines –  however be warned that the guidelines are contradictory to what Dr. Kerstein advises….ah the wonderful world of TMD!  #OcclusionTMDandSplints #OrthoRestorative This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes A, C. AGD Subject Code: 250 – Clinical Dentistry (Occlusion/Restorative) Aim: to explore the role of micro-occlusion and timing in TMD and restorative success, highlighting how tools like T-Scan provide data that other tools cannot. This episode seeks to give dentists practical insights into diagnosing, preventing, and treating occlusal problems with greater accuracy. Dentists will be able to: Describe the role of micro-occlusion and disclusion time in TMD symptoms and tooth wear. Recognising the limitations of traditional methods of occlusion adjustment. Understand how objective occlusion data supports comfort, longevity of restorations, and preventive care. Click below for full episode transcript: Teaser: Pressure is a force over surface area. And when it gives us the red, the blue, yellow, it's not measuring the force, so it cannot tell us the pressure. So tell us about what the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan. The essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart. No one’s biting. There’s no forces captured. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all. Anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on where the paper marks look. And very often, the most pressure points of contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure. Jaz’s Introduction:Protruserati, the occlusogram is lying to us. Does that sound familiar? Well, we welcome back again, Dr. Robert Kerstein. If you remember way back in episode 109, we made an episode called, “Articulating Paper Is Lying to Us,” and you guys absolutely loved it because Arctic paper is lying to us. You should totally listen to that episode if you haven’t already. And if you haven’t, essentially the arctic paper marks you see on teeth are flawed in the sense that you can’t look at a mark and accurately say that, oh yeah, that’s more force, or that’s less force, or that’s hitting first. You don’t get that data. And not only that, but you also get false positives when it comes to articulating paper. Now, similarly, I’ve got Robert Kerstein back again talking about the occlusogram. Now the occlusogram is that heat map you see when you do a scan, when you do an intraoral scan of a patient, upper arch, lower arch, and then you do the occlusion. Most modern scanners will give you some sort of a heat map of the occlusion and we call that an occlusogram. And we may all at the beginning make this mistake, this very simple error, that when you see red on the occlusogram that means high force. Well, we will absolutely and emphatically bust that myth today. You see the heat map or the occlusogram is just a measure of proximity. How close in space is that cusp to that fossa? And if it’s very close, it’s gonna be red. And if it’s maybe a few microns away, it’ll be a colder colour. Absolutely does not tell you how much force or timing or pressure, none of that stuff. Just contact proximity. So we must be careful in how we interpret that data. It would be misinformation to tell a patient that a certain tooth is having more load because of the colour. Hello Protruserati. I’m Jaz Gulati and welcome back to your favourite dental podcast. Today’s guest is none other than Dr. Robert Kerstein. Rob Kerstein is like the godfather of digital occlusion. When I was in New Mexico a few months ago with Dr. Bobby Supple, he described Dr. Kerstein as the Einstein of occlusion, and it’s an absolute pleasure to chat with him again. It’s a different format of the podcast. We’re driving, well, I’m driving, he’s my passenger. And so one of the team members, when they were listening to this, they said, it’s like carpool karaoke vibes. And don’t worry, we will not start doing a little singing and dance in the middle of this episode, but something a bit different, a bit fresh. Me and Dr. Kerstein were on the way to some DTR training in the UK. DTR is Disclusion Time Reduction, essentially, if you listen to that episode that we did with Nick Yiannios. We talked about frictional dental hypersensitivity, and essentially lots of friction between the back teeth could cause your teeth to become sensitive. So this posterior dental friction is also implicated in TMD, thus resurfacing that old debate: is occlusion a causative factor of TMD? Now, we all know some CAMs and some reviews that suggest that occlusion has no relationship to TMD. Whereas my guest, Dr. Robert Kerstein, says that TMD is a neurological condition and has everything to do with occlusion, and particularly that muscular TMD group would greatly benefit from an occlusal adjustment or something to change about their occlusion, to reduce that sensory input and their noxious muscular spasms. And I saw all this freehand. I can’t wait to share my experience of what I witnessed when Dr. Robert Kerstein came to my practice and I treated three patients. So I’ll leave you on that teaser if you like, ’cause we have another episode coming with Dr. Jeremy Bliss talking all about occlusion, TMD and Disclusion Time Reduction, aka DTR. Dental PearlBut for now, let’s enjoy this episode of occlusogram. And just before we join the main interview, I need to give you your Protrusive Dental Pearl. Every PDP episode, I’ll give you a top tip that you can use right away. And today’s one, like many pearls are, are from Dr. Mohammed Mozafari. Mohammed’s one of the most selfless and caring and giving people on our Protrusive app community, always helping our colleagues. And today it was our good colleague Yazan. And just yesterday on the group, Yazan had a query. He’s got these crowns, definitive crowns, temporarily cemented with TempBond. Now we all know of that scenario that it could have happened to you or a colleague, whereby you put these crowns in temporarily. Even some colleagues, they try in a crown, let’s say a PFM crown without any cement, and they put the crown on and they just cannot take it off, and it’s like impossible to get off. It’s not happened to me yet, but I’ve heard of this happening many times. So quite appropriately, Yazan was right to ask on the group, what’s the best way to remove a definitive crown that’s been temporarily cemented? Because you want to remove it in a way that you don’t damage the porcelain or the material itself, and you want it to be nice and easy and not very uncomfortable for the patient whatsoever. Now, what I was going to say before I read all the comments was there are these like special pliers you can get with these, like these plastic ends, but they can be a bit hit and miss. Sometimes they do slip off, like they have got this like textured surface to prevent the slippage, but it can slip off. So I really like what Mohammed suggested. So Mohammed suggested you get some bite registration paste, you put some buccal and lingual of the crown, then you put some gauze over it. You obviously let that bite registration paste set a little bit, and then you can get your hemostat or your mosquitoes and squeeze and try and wiggle the crown off. The benefit is that the gauze and the bite registration paste are kind to the crown, but at the same time giving you enough of a grip. Haven’t tried this exact way before, but it just sounds amazing to me, and Yazan was able to report back that he was able to get the crown off. So thank you again, Dr. Mozafari. Really appreciate all the help and support you give to all the community members on Protrusive Guidance. Let’s now join the main episode and I’ll catch you in the outro. Main Episode:Dr. Robert Kerstein has entered the UK once again and we’re doing an extremely rare driving podcast. So, Robert Kerstein, welcome back to the UK. How are you today? [Robert] I’m good. Thank you for having me. [Jaz] Absolute pleasure. You know so many dentists around the world, around the world. [Robert] Yes. [Jaz] And you’ve done these trainings where I’m sure you’ve sat in lots of dentists’ cars. [Robert] Yes. [Jaz] And so therefore, I want to start by apologizing for probably the worst car of a dentist you’ve ever sat. [Robert] Oh, it’s very nice. [Jaz] No, no, no. Listen guys, as you guys know, I’m not into my cars at all. I literally googled what’s the cheapest electric car I can go buy for tax efficiency, and I landed on this Chinese car, the MG ZS EV. So I was trying to start by apology, but one of my, like a slight detail for you, talk about the good stuff, is one of my philosophies in life when it comes to spending money is things that I don’t value and I don’t love, I always skimp on. But things that I value, I will spend mercilessly. I will save mercilessly where I can, but I will spend lavishly on the things that I value. And so one of the things I value so much is education. Education and investing in myself, which goes back full circle to why you are here in the UK right now. Myself, Riaz Yar, Shreyas Mhatre, Haider Raza, and then of course the previous group that you trained are also part of this, and you’re gonna do this one week intense tour around the UK with a didactic day on Thursday. And we’re talking about Disclusion Time Reduction and the use of T-scan and all the benefits. And so previously we’ve done the episode on “Articulating Paper Is Lying to Us” that had about thousands of hits. You also very kindly shared lots of papers and that link is still active. If someone wants to download the papers that you kindly shared, that link is active. So I’ll link that episode there. But now that I’ve done like a little introduction, I want people to really understand the scale of your education, the mentoring that you’ve delivered over the years around the world, ’cause it truly is an international operation. So tell me, how far and wide does it take you? How many dentists have you trained and what are you actually training on to help the younger docs understand? What are you actually showing chairside to dentists? [Robert] Well, I’ve trained dentists in many countries, so I’ve been very lucky to travel the world, see dentistry in Korea and Thailand and Japan and Russia and Europe. Many dentists in the UK and the United States, South America, it’s really Canada. It’s hard to– [Jaz] India being a hotspot. [Robert] India, many dentists in India. And so, it’s been a unique experience for me, for sure. But what we teach, what I’m teaching, is how to use the T-scan technology chairside effectively, and Disclusion Time Reduction is specifically to treat TMD muscular patients and how effective it is at resolving it. No appliances, no Botox, no TENS, no jaw repositioning, no appliances, no smaller guards, no acupuncture, no massage, no chiropractic care, no hypnotherapy. It’s the only treatment that’s neurologic, treats the central nervous system. That’s just why it resolves TMD, which is really the occlusal neurophysiology is at the core of TMD, even though there’s unfortunately many incorrect advocates around the world who keep teaching that occlusion has no role. Occlusion is the number one cause of TMD, muscular TMD, and even some breakdown of the joints because of how the occlusion impacts disc position, lateral pterygoid strain, and therefore affecting the internal joint space. [Jaz] So what you’ll be teaching me today is we’ve got three patients booked in and some of these patients I’ve done orthodontic correction on because their occlusion was not conducive to any sort of immediate anterior canine guidance. It was a mess. So I’ve got a good foundation and that’s what you taught me is the macro occlusion. What we’re dealing with today is the micro occlusion, not looking at just the dots and lines, but really the force and the timing being the most important thing, the timing. So as you said, and also something Nick Yiannios has also said recently to me is, as our jaw moves aside and there’s teeth contacts happening, they’re like little speed bumps. And so we want to eliminate these speed bumps. Is that a good way to explain to a young doc who’s trying to understand what DTR is? ‘Cause trying to spread the message and patients will be tied up with this EMG, so muscle data coming from temporalis, masseter, anywhere else you can let us know now ’cause I’ve literally just got the kit in my car, haven’t opened it. So how’s a good analogy, a good way to explain to doctors what you’re training me on today? [Robert] Well, the speed bump analogy really discusses like the tooth contacts that rub together frictionally when people use their teeth. But it’s really the transfer of the neural information from the rubbing of the teeth through the pulp and the PDL that is what causes many occlusal problems. And so the timing of that, the duration of these frictional speed bumps, if you will, sets off long periods of muscle firing. And the muscle firing is directly influenced by the teeth directly from the brain. There’s a single no-synapse pathway from the molars and the premolars, pulps and PDLs. It goes directly to the centre of the brain and it enters a structure known as the reticular formation, which controls five or six different major body systems, mostly as it applies to this, your training today, is swallowing and masticating and pushing food down into your throat rather than into your lungs, because the teeth modulate all of those movements so that you don’t asphyxiate by putting food into your lungs. So all these muscles that are involved in chewing, swallowing, and moving food into the digestive tract are controlled by the teeth. And this is why it goes on without us thinking about it. Nobody sits around and says, I’m gonna chew for a while and I think now I’ll swallow and maybe I’ll chew longer and no, I wanna swallow. None of that happens. You’re just rubbing your teeth together and then all of this physiology takes place with neural control from the brain. And the tooth contacts can hyperfunction those muscles. So you can still use them to do all the things you’re supposed to do, but they get tired, they get sore. They get tight because the tooth contacts create too much contraction information, and the Disclusion Time Reduction minimises the amount of contraction information that the teeth are passing on to the brain to control swallowing and moving food into the digestive tract with the least amount of muscle activity. So when you disclude someone in a rapid timeframe, the least amount of muscle activity is used to perform these actions, and that allows the muscles involved to operate without pooling lactic acid, without becoming hyper-contracted. And then the symptoms that are associated with that: tight throat, facial pain, headaches, clenching and grinding, difficulty chewing, tired chewing, soreness after chewing, those things go away. Because it’s neurologically resolved, not externally resolved with like splints and Botox and TENS and appliances. Those things don’t really work. They try to work, but they never stop the problem because the occlusion is still perpetuating all of this electrical activity that the brain is putting out into those muscles. So it’s a very powerful treatment. It controls how the central nervous system works, and that’s why it’s so effective. [Jaz] We were talking last night over dinner about centric relation, MIP now, but I would suggest that anyone interested in why the treatment we’re gonna be doing today is not an equilibration in the more traditional sense of seating the joints into centric relation and working from that position. The DTR is very much done, carried out, using MIP as a base. And you covered that really well in the previous episode, but one thing I said to you last night is that, if only such a tiny percentage of the population are, have their centric relation coincident with their MIP, for example, as we know, then surely, why is that our goal? So we’re chasing the 1%, where actually we see physiologically that actually 99% plus are in MIP, which is further ahead, forward to their centric relation, right? And so, but in the similar way, a lot of dentists may say to you, Robert, in terms of why maybe the number of T-scan users isn’t as great as other technology adoption, such as the intraoral scanner, for example. They’d be saying that, ah, I don’t need that level of precision because some dentists say that, accept what you say about MIP because of that. Yeah, you’re right, because such few people are in centric relation and they’re doing just fine. We can and should work at MIP, it makes sense for the patient. But then a similar group of dentists might say that, do we really need that microsecond data because yes, there’s a frictional rubbing of the posterior teeth. It is happening. But if you were to T-scan and analyse most people, most population, you would find that the majority, especially after a certain age, are in group function. You’d find that there would be these posterior contacts. So really what we need to fall back on is, okay, there is the kind of patients that come to us as TMD patients, they’ve kind of self-selected themselves as they’re beyond their adaptive capacity. And then that’s the ones that this treatment modality is for. It’s not for the asymptomatic cohort. Am I right in saying these ramblings? [Robert] Well, it’s a very interesting point because a lot of occlusal problems are not chronic TMD. They’re wear, recession, abfraction, mobility, cracking of teeth, chipping of incisal edges, isolated areas of wear or periodontal problems that arise around certain teeth because of occlusal factors, and those people are not complaining about anything really. They’re just slowly destroying their teeth. [Jaz] Which is the majority actually. The silent majority. [Robert] Well, exactly, because they’re not in pain, but they’re still losing tooth structure or root structure. [Jaz] They have signs but no symptoms. [Robert] Yes. And those signs are damage and the same and over. Well, it’s perceived as overload by like vertically. They’re making too much force, but it’s actually not vertical. It’s lateral movements that destroy their teeth. Friction, rubbing of teeth, milling of teeth for fractions of seconds. That then overload the teeth because muscle activity is raised. And so there’s a lot of advantage to treating the asymptomatic patient who has signs of occlusal wear or damage or roots, abfractions. And those things only progress. They don’t go away. They just get worse day to day. And people who don’t address it early on, 10 years later, have a lot worse of a problem and may need reconstructive dentistry. So there is an advantage to treating people that demonstrate occlusal problems in the same way. Because by treating the disclusion time in those patients, then they use their teeth with a lot less muscle-applied force, because the muscle activity is cut way down. That’s what Disclusion Time Reduction does, is it relaxes muscles, it stops hyper-contracting muscles, so the load to the teeth is then greatly minimised while someone uses their teeth, and then the processes of damage are arrested and, or let’s say tremendously minimised, as opposed to continuing to wear their teeth, sand their teeth away, chip their teeth, cause root damage. And those things are often patients don’t treat them or bring them up because they’re not in pain, they just are destroying their teeth. So enzyme reduction. [Jaz] So that’s a proactive, preventive treatment. But I imagine most of the DTR that’s carried around the world is delivered to the symptomatic cohort. Because to the nature of them being self-selecting and actually coming and having the sort of mindset that, okay, I need treatment and I’m willing to invest in this treatment for the result. Whereas trying to have that conversation, like trying to sell aesthetics to someone like, hey, let’s do veneers and stuff, and that kind of stuff might be actually easier to give ’em what they want rather than what they need is just so a psychology. So that’s why whilst, yeah, DTR would help asymptomatic cohorts, because when we look at occlusion and the chewing system long term over time, that this sets ’em up in a better way. And that makes sense to me. But yeah, I think majority of DTR is probably delivered for the symptomatic individual because of the fact that they are the ones who selected themselves. [Robert] It’s treatment for the symptomatic patient, but the application is far-reaching. But most of the dental injuries sustained that are not traumatic, like getting hit in the face with an accident, the dental damage, I should say, you know, again, the same things: wear, recession– [Jaz] Microtrauma. [Robert] Is microtrauma and it comes from the overload that the lack of disclusion creates. And the disclusion, people often think they have disclusion. Dentists will say, yeah, this person has good anterior guidance, but it’s the first millimetre of movement on either side of the central fossa that matters. It’s not that they disclude at the end of their excursion. No one is chewing food with canine-to-canine tip-to-tip. Nope. So the person has to disclude within a very short distance from leaving MIP in all directions, and that’s what controls the muscle activity. And that control can only come from computer analysis. It isn’t possible for us to measure the kinds of pressures that go on in a very short distance. We can’t pick it up in any other way than using the T-scan sensor, which is a highly sophisticated electronic device that is used all over the world in many, many industries. Dentistry doesn’t understand that. Dentistry doesn’t seem to really want the T-scan to succeed. And many people talk it down, but it’s the most sophisticated engineering tool available to dentistry to manage occlusal problems. [Jaz] Well, talking of sophisticated tools, a lot of dentists, and then I love how you just came to the topic of this very short snippet today, is ’cause we’ll do some more content on Thursday and whatnot. And today, hopefully I’ll get to record some of the DTR that we’re doing through my loupes actually, which will be pretty cool. But sophisticated technology, a lot of dentists, they feel that the data they see from an occlusogram– So for the younger docs, occlusogram is when you take a scan, let’s say PrimeScan, iTero, 3Shape, whatever you use, and then you record the occlusion, and then you get this like heat map of occlusion, and some dentists may be fooled into thinking, why do I need the T-scan? Because this is telling me where the forces are highest. This is telling me already. And then what we need to talk about is why, whilst that has some very basic data, we have to be careful how we interpret that data. And the example I want to start off with before I hear your sort of way you expect the dentist that, okay, just be careful with this occlusogram data. But one of the cases that I teach in our foundational occlusion courses is a case where this lady, late fifties, early sixties, she had a history of having Invisalign, had a fixed retainer, and on the upper and behind the upper anteriors, and this fixed retainer snapped in half along the centrals. And every time she bites together there is very clear fremitus, i.e. when she bites together, the front teeth literally move out the way, mobility, then the back teeth are able to come together, which makes sense as to why the wire fracture is, okay. So when you take the scan of that static position, when the teeth come together, you would see that, oh, everything looks okay. Because what you’re seeing is the end product. Once the teeth are fully come together, once the front teeth have overloaded and moved out the way and the occlusogram would fool you into thinking that there is good distribution of load around the arch. But I think even the younger colleagues can understand that, in this example where we have fremitus, that actually that, how can that be true? Because the front teeth were early contact, they had to move out of the way. And that’s not gonna be good for the PDL, ligament, long term. And then the back teeth were able to come together. But that story, that timing is not captured in occlusogram. It’s not telling us that kind of stuff. And when I showed that case and how I treated it was we did some Invisalign, we gave the correct overjet to allow the jaw closure to happen. And then now, three years on, I checked the teeth now and they are solid, okay, because now, and then you look at the occlusogram, it doesn’t look much different. But the first occlusogram and the second, they might look the same, but it’s the timing data you miss out on. And the force data is actually coming from how close the teeth are together, which is not telling you about the actual force itself because, as you said yesterday over dinner, pressure is a force over surface area. And when it gives us the red, the blue, yellow, it’s not measuring the force. So it cannot tell us the pressure. So tell us about the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan. [Robert] Well, the essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart, right? No one’s biting. And so there’s no forces captured. What happens is the software algorithmically puts the scans together spatially– [Jaz] Stitches them, yeah. [Robert] Right, spatially. But there’s no impact pressures. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all. And a recent study showed that clearly they don’t measure pressure. There’s a comparison of the T-scan, force mapping to PrimeScan. And there was way too much overestimation of what appears to be high force in the PrimeScan. But it’s not force at all. It’s distance and tooth proximity, contact intimacy, which is not pressure. And just because you have a good contact, low intimacy, meaning very small distance between opposing teeth, doesn’t mean that tooth generates extreme pressure. That’s a completely false representation that the scanning companies are proliferating and misleading dentists in a very unfortunate way because there’s no impact pressures captured when you scan someone because the teeth are all apart. So that’s a very big difference between– [Jaz] But what do you actually scan? The bite, the teeth have come together, and then held there, and then stitching that. But you’re right, because the actual arch itself is taking the arch in isolation, the lower arch in isolation, that’s scanned when the teeth are apart. And therefore you don’t have the stressors into the teeth. And when the teeth do come together and you scan the left and right bite, and obviously teeth will intrude a bit, hence why you have like minus figures in terms of, someone has intrusion and whatnot, but that’s not giving you force and timing data. So I think that a key lesson for dentists is don’t look at the occlusogram and start doing adjustments on teeth by occlusogram, thinking, oh, the first molars are looking red on the PrimeScan. That means they must be proud. I need to adjust. That would be a very false way to view it. Would you agree? [Robert] Yes, correct. Very, very true. Meaning it’s false. It’s the distance scale does not predict the pressure mapping. And that’s what scanning technology offers is distance between opposing teeth and you know how close or how far apart various surfaces are, and this is not gonna give you pressure mapping because no impact pressures are actually measured in any way at all. So it’s completely false when it comes to force, timing and pressure. [Jaz] So what are the benefits to actually measuring the pressure? So what decisions is a dentist able to make once they know about the timing and pressure data that they weren’t able to do before? Because before, without it, we’re relying on the occlusogram and relying on articulating paper. Now, we talked extensively about why the articulating paper is lying to us. But feel free to revise those concepts for someone who may need to listen to it another time. But what’s the, I guess what I’m trying to say, what’s the advantage of, fair enough, we have data, but it’s the application and the use and how you choose to use the data to help benefit your patient. What is the benefit of the pressure data? [Robert] Well, it allows you to make intelligent decisions about what to adjust and what not to adjust, instead of looking at ink marks that don’t measure pressure at all, or scanning technology which doesn’t measure pressure at all, so that you treat very minimally and definitively without misrepresenting where you should be treating. And of course, anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on the way the paper marks look. And very often the most pressure-responsive contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure. It’s very much like the high heel, the lady’s stiletto heel, right? She steps on that, on your foot with that, it’s gonna hurt you. But if she was wearing a flat sandal and would leave a big imprint, it wouldn’t hurt you as much. So the T-scan data allows you to choose wisely what to adjust. [Jaz] And so, I mean, I think to make it really tangible for dentists is like prosthetics, right? When we are working prosthetics to help our materials, that if you’ve done like multiple crowns, or even nowadays very on vogue is treating wear cases interceptively with composite, and you do a full-arch or majority-arch composite restorations and you check with arctic paper and you see ink everywhere and you think, okay, I have good distribution. But without the pressure data, you know, when you start using, you might see that, oh, 38% of the force is going down one molar. And then the other molars are hardly doing any work. So without that data, you don’t know to lighten it. And the other scenario we talked about last night was the patient that says, you know, I had this work done or whatever, and then these three teeth on the left side, they just feel really proud. And every dentist who has kind of attempted to lighten the occlusion on it, and then still the patient says it’s proud. And then you told me that, okay, when you checked, and this was in front of everyone, you checked it whilst the forces were low on those teeth, it was the timing. They were the first teeth to touch. And it was very subtle. They rise first and then everything comes. And when you adjusted those exact points, led by this data, so not just pressures, timing here obviously we’re talking about, then the patient was able to say, oh wow, now I feel comfortable. And that was a real amazing moment, which I’ve experienced myself. I’ve been using it for a few years, including on some dentists. So shout out to Nikhil Kanani who came to my practice and he wanted me to take it. He was interested in T-scan, so I had a look and I made some minor adjustments and he bit together. Not only did it sound better, which I liked, to listen to the bites as well, but then he actually felt like, whoa, wow, that feels so much more comfortable. [Robert] Yes. Yes, no question about that. [Jaz] There’s no occlusogram that will give you that. Well, as we sort of, we’re about to get to the practice now and start a day of training with you, my last request is any sort of nuances that you want dentists to consider when they’re planning their next case or checking the occlusion and considering about, thinking about technology, digital occlusion, and actually implementing kind of this T-scan technology. Like we discussed yesterday, the adoption of T-scan, whilst it has gone worldwide, to the level that dentists invest in loupes, the level that they invest in intraoral scanners, the level that they invest in so many more bits of equipment, yes, there is a cost to it, but when you look at some of the costs of the other things that we widely purchase, so I don’t accept that it’s the cost barrier because we’re also buying, you know, $80,000 CBCT machines. We’re buying $50,000 intraoral scanners. Why is it that this, 10, $12,000, whatever it is, a T-scan. So I’m not, I don’t think it’s just financial. What do you think’s going on in terms of why are dentists not understanding the benefits of seeing objective data? Like I told you something yesterday, which I say all the time to colleagues who ask me about T-scan, is I felt uncomfortable adjusting teeth without having data, just medico-legally. If I can see that the bite is way off, even in a prosthetic case, or any type of case, and I can do some adjustments to really measurably timing and pressure improve the occlusion, I feel so much safer. But I dunno why that doesn’t translate to worldwide. But obviously you might have a perception or an insight into this. [Robert] Well, the biggest resistance to the T-scan is political. It’s that the T-scan has disproved every occlusal theory. You don’t need to TENS anyone, you don’t need to neuromuscular treat them. You don’t need to put people in CR. CR is a very compromised position that constricts the airway and definitely is not a physiologic position. Putting people there is unnecessary for most dental treatments. And so just by disproving all of these basic principles that people really believe in, no one wants to face that. And the most important one is the carbon paper paradigm, right? T-scan has absolutely disproved the carbon paper paradigm. The big marks aren’t always big force. The little marks always aren’t light force. And making the marks look a certain way doesn’t give you a balanced bite. So there’s a lot of things that dentists have been holding onto politically because they’re teaching these things in continuums and– [Jaz] Can I talk about that? Because it’s something that in my teaching, so I’m involved in teaching occlusion, and so feel free to disagree with me, Rob, I take it, I’m happy to talk about these things, right, is what I teach is centric relation is a position of restorative convenience. It is a utility position. So whilst my patients whose occlusion is generally working for them, I don’t, I work within the MIP. But when we have the opportunity or need to open the vertical dimension, it may be a position of reproducibility and convenience, then I’ll look to use it. ‘Cause when we have lost all references and that’s how me and Mahmoud have been teaching it. What do you think about that? [Robert] Well, the value of finding a reproducible position helps greatly in doing restorative dentistry. I’m a prosthodontist, so I worked a fair amount in centric relation where indicated. But I also found that I could open the bite in MIP and treat the person directly. [Jaz] Didier Dietschi does that. My old principal, Dave Winkler, used to work with, he is now, maybe you know him. Do you know Dave? [Robert] I’ve heard the name. [Jaz] Yeah, so he used to practice here in Windsor. He’s now gone retired in Denmark. Wishing you well, Dave. Hope you’re well, buddy. And so lots of dentists I really respect, you know what, they work in MIP and even when the vertical, like obviously when you open the vertical dimension, MIP is gone. But like what you’re trying to say is like, you’re not really seeking the CR, you just open the bite arbitrarily. And then just trying to create the correct occlusal scheme led by the T-scan in that arbitrary position. And that works well, has worked well for many dentists. [Robert] It works extremely well, actually. And you can mount the casts and then raise the articulating pin and mount them in MIP and raise the articulating pin, and then work in that new vertical dimension, essentially the same way you would in centric relation. So it’s very possible to do. It’s not, let’s say, academically principled that you shouldn’t do it, right, but it’s a reality. [Jaz] A hundred percent. [Robert] And so there is a lack of need for concepts about jaw position being the key to success. You can put someone in CR, but if their micro occlusion isn’t well managed, they’re not gonna be comfortable. It’s not about the position. No jaw position manages the micro occlusion. It’s the micro occlusion that brings about patient health, accurate, not accurate, but physiologic muscle physiology, as opposed to excessive muscle physiology and occlusal comfort for the patient. It’s all about the micro occlusion. That’s why you take a beautiful outcome like Invisalign. The teeth line up beautifully and the patient comes in and says they’re not comfortable. It’s because the micro occlusion isn’t good. The macro occlusion doesn’t make the micro occlusion, and that’s where the T-scan is the huge advantage for finalising cases. That’s the most important thing I would say that the average dentist struggles with is extra visits after delivery. The biggest problem is a patient coming back complaining, saying their bite isn’t right, and then randomly grinding. The T-scan virtually eliminates that. It doesn’t eliminate it in total. Nothing eliminates it in total. But you send the patient out the door with a high quality micro occlusion, there’s a lot less for them to complain about. [Jaz] And also less stress on the materials, ’cause if we’re working with prosthetic materials. Going back to prosthetics now, I’ve had these scenarios whereby, over time in the last few years of using T-scan, patients like, well, some of them, many of them actually, are very accurate. Before the T-scan data comes through, they can tell me that something over here. Now when I check with the arctic paper, everything looks okay. But when I show the T-scan, I can see the early rise or the high point. And they often, for these patients who are very “princess and the pea,” which is amazing. So it’s very validating to them. And the trust aspect is there, but also the flip scenario. Well, the patient says, yes, it feels proud, but I’m going, I’m checking the T-scan and reproducibly, I’m seeing that there’s no timing issue. There’s no pressure issue. Then I feel okay to say, ah, let it settle, kind of thing. You’ll get used to it, or whatever it could be. And then rather than praying and wishing that, oh, hope it’s not proud, and let’s see. So it gives me that again, objectivity, which is why, the reason why I went into– [Robert] Extremely objective and highly repetitive. A user has to learn how to use it. It doesn’t work by itself. You can’t buy it and make it work. You have to take training like you’re about to go through. And didactic training is helpful, but it doesn’t make someone a chairside effective T-scan user. You have to be– [Jaz] It’s a bit like, when you go into implants and you buy implants to use in your patients, there’s a lot of training that comes with implants to be able to do it, right? Same with when you pick an aligner system and you go with them and you go on the two-day course to learn to use the technology. So, fair enough, when I got the T-scan installed, it was like being given an aligner system. But until you learn ortho and diagnosis and actually treatment planning in ortho, and then troubleshooting and retention or everything that goes with the education of orthodontics. So that’s a good analogy to think that, okay, the T-scan is like the aligner system. It’s like the implant, but you need to have the protocols in place to be able to actually get the best results from it. [Robert] And you need to have clinical experience under guidance. It’s not something you can pick up on your own. And this is why people struggle with it. They purchase it. They don’t seek out the training that you’re about to have. That’s what makes someone a chairside effective user. It’s not possible to become chairside effective because you read a book or you read a paper that I wrote about, for example, the disclusion time. Even though it’s well described what to do, it doesn’t make you a clinician. It’s like reading about a crown prep. You can read about a crown prep, but until you’ve cut 50 crown preps, you don’t have the skills to cut predictable crown preps, right? So T-scan is a chairside learning technology that once you understand what to do with it, how to record, how to read the information, how to understand the force versus time graph, which is a critical software feature, and how to apply the information to make intelligent decisions about what to treat, then you can become effective with it. But you have to learn those three things. Recording well, understanding how to read the data, what matters in the movies, what doesn’t matter, what parts of the movies matter, what parts don’t matter, and then how to apply the information by mapping the pressures using carbon paper. But you don’t look at the carbon paper and say, yeah, it’s that one because it’s big, or that one’s too small, we’re not gonna treat that. It’s all data driven. That’s the difference. By doing that you control the micro occlusion and get much more predictable outcomes. [Jaz] Well, excited to walk into the practice now and let’s get into the micro occlusion of it. Well, thank you so much. Alright guys, I hope you’ve got some insight there into the nuances of occlusogram and why that is to be taken with a massive bag of salt, and also a little bit more about the details of micro occlusion, what T-scan does. Uh, and yet wish me luck on my training today. Be kind to me, Robert. [Robert] Yes, of course. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. A few different themes touched here from joint positions to muscular harmony, and of course the main event, which was all about the occlusogram. And now I hope you’re convinced that it’s lying to us, which doesn’t mean it can’t be useful to us. We can still use that information. Just don’t think it’s giving you something that it isn’t. We are a PACE-approved education provider. You need to be either on the Podcast CE Plan or the Ultimate Plan of Protrusive Guidance. If you’re on the Ultimate Plan, you get access to all the masterclasses, including the recently added Splint Course, everything occlusal appliances, and the 21 Day Photography Challenge. Head over to protrusive.co.uk/ultimate if you’re interested in that. Even just to join the community for free, we need to verify that you’re a dentist first, by the way, and we will do that. It’s very important to us that it’s a safe community, we do not want any members of the public on our special forum, so we do have a verification procedure. But if you head over to Protrusive app and request access to Community Plan, we will get you in. So you can see all the good stuff that we have in the chat and the main feed and all these podcasts are on there. And some bonus ones that are not on YouTube or Spotify. Watch this space for that DTR episode that I promised you. And as ever, I want to thank Team Protrusive who do a wonderful job behind the scenes to get these episodes published and allow me to still practice dentistry, support the community, and serve my family, and essentially be a dad. So thanks again, and thank you, the listener, watcher, once again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Is social media killing professionalism in dentistry? Are young dentists really “clowns” online—or is lightheartedness perfectly fine? Is social media a disease? Where’s the line between humor, banter, and outright disrespect? In this episode, Jaz is joined by Joseph Lucido from the States to tackle these tough questions head-on. Sparked by a fiery Facebook rant, they dive into whether social media is harming our profession, how dentists should present themselves online, and if there’s still room for fun without crossing the line. Whether you love or hate dental content on social media, this conversation will make you rethink how we represent our profession to the world. Shout-out to two US doctors creating excellent, entertaining content on social media Dr Brady Smith Dr. Nicholas J Ciardiello Check out the 3-Step Modern Dental Marketing Plan from Clear to Launch Dental — designed to help you simplify your marketing and grow your practice without the overwhelm. https://youtu.be/W7Uh-ML9dZg Watch IC063 on YouTube Need to Read it? Check out the Full Episode Transcript below! Takeaways Social media etiquette is crucial for healthcare professionals. Avoid controversial topics to maintain professionalism. A social media presence is essential for modern dental practices. Patients often check social media to verify a practice’s credibility. Content should reflect the personality of the dentist and practice. Highlight satisfied patients to build social proof. Consistency in posting is key to maintaining engagement. Separate personal and professional social media accounts. Batch content creation to save time and effort. Engaging content can lead to more patient inquiries. Highlights of this episode: 00:00 Teaser 00:31 Intro 01:47 Introducing Joseph Lucido: Social Media Expert 03:21 Social Media Etiquette for Dentists 06:14 The Importance of Social Media Presence 12:04 Balancing Professionalism and Humor Online 17:39 Authenticity in Social Media 19:51 Balancing Personal and Professional Content 21:51 Effective Social Media Strategies 25:27 Time Management for Social Media 27:26 Do’s and Don’ts of Social Media 29:43 The Power of Social Proof 30:49 Conclusion and Resources 32:47 Outro Love this episode? Don’t miss Best Practices in Social Media for Dentists – How to Stay Out of Trouble Yet Be Impactful (IC035) #InterferenceCast #Communication #BreadandButterDentistry 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 walkthroughs and Masterclasses. Click below for full episode transcript: Teaser: What is the correct etiquette in 2025 and beyond for social media for dentists? Teaser:The biggest shortcut a lot of social media questions get would be, we tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. The most extreme version of yourself is gonna get the most attention. So you might get, oh, look, I’m getting a lot of views. But going back to what I said earlier, it’s, well, what are people thinking when they see this? Jaz’s Introduction: I saw a rant on Facebook. Obviously it was on Facebook. Where else do rants belong, right? It was saying, what has happened to our profession? What has happened to our beloved dentistry? The kind of crap we’re seeing on social media. This dentist, who’s basically vexing about the way that he thinks young dentists are portraying themselves on social media, this anonymous poster of course, was saying we’re being clowns, we are disrespecting patients, we’re doing all sorts of unsavory things to get views and likes. So Protruserati, is this the death of professionalism in dentistry? Is social media a disease? Is there a proper way to conduct yourself on social media, or is a bit of humor and banter and a bit of lightheartedness acceptable? I’m a bit of an idiot on social media sometimes, but I know someone who does know. Today we’ve got our guest, Joseph Lucido from the States, and I asked him all these tough questions. He knows a thing or two about social media. So in this episode, you’ll find out what is the proper way to conduct yourself and whether Joseph thinks there is a space for idiots like me. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is an interference cast. This is a nonclinical arm of the podcast. Hope you enjoy the main interview and I’ll catch you in the outro. Main Episode:Joseph Lucido, welcome to the Protrusive Dental Podcast. For those who are listening right now, Joseph has sat in this wonderful, you’ve got this wonderful background, that common look of the books behind you, so it makes you look like you’ve got so much authority. And he totally looks badass. But I had to ask him, is this real or is it fake? And actually he reached out, man, this is a very beautiful library behind you. Joseph, welcome to the show, my friend. How are you doing? [Joseph] I’m doing great. Happy to be here. [Jaz] Tell us about yourself. You’re not a dentist, but tell me how you are connected to dentistry. What makes you an authority? Talk about social media for dentists today, which I’m really excited to get into. [Joseph] Sure. Probably starting around eight years old, I wanted to be a dentist. Just being in the dental office, I always loved getting my teeth cleaned. I had a few uncles that were dentists. It was just exciting for me. And then just through my education, formally marketing degree, and then half of the books behind you are on marketing or psychology. And then it comes down to just different reps over and over and over on different platforms with docs, seeing what works, seeing what doesn’t work. I guess that gives me, I don’t know about the authority, but it gives me a pretty sharp edge on what works and what doesn’t. [Jaz] Well, I think that does give you authority. The fact that they have skin in the game, the fact that you work with people on this, so you totally have the authority. Interesting title we’ve opted for, right? Social media clown or healthcare professional. I really like this. When I first read it, I thought, oh crap, he’s onto me. He’s seen my videos. Because sometimes I’m a bit of a clown, and sometimes I’m very professional. I’m really looking for what your thoughts are on this. So I guess the first place to start is, what is the correct etiquette in 2025 and beyond for social media for dentists? It’s a big topic and we can break it down and go anywhere you like. [Joseph] Yeah, there’s gonna be a bunch of nuance to it, but the biggest shortcut a lot of social media questions get would be, what is the potential patient, the person viewing this, the followers, what are they gonna think after seeing whatever I post? That should just be your starting point for everything social media related. Before you post, you want to be intentional in thinking. Now it becomes intuitive after a while to do it the right way, second nature. But from an etiquette standpoint, we wanna be thinking, I don’t wanna post anything that’s too controversial or too polarizing. Now I’m talking specifically through the lens of a healthcare professional. If you’re trying to get attention some other way, that’s fine. But if we’re talking about being a professional in healthcare, we don’t want to talk about politics or religion. Avoiding these topics can alienate 50% or more of your audience, and it also kind of speaks to your self-awareness. You probably shouldn’t be posting this from a business perspective. Arguing online, never a good look. Taking a combative stance, anyone who sees that, even if you’re defending yourself, even if you’re 100% in the right, that’s not what you wanna do from an etiquette standpoint. We tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. Everyone’s seen the doc that posts and all they’re doing is selling, and you’re not gonna follow them. [Jaz] So what you mean by that is, “Come in for our new patient Invisalign offer,” and just banging on about it every single day, and that’s it, it’s like repeat. [Joseph] Even the other post is too much. And what we’d even argue is, the way that we operate it is we have the docs say, you do nothing from an office level organically. You should be fun, entertaining, posting like that, and then we’ll take care of the direct selling, because that’s what our team has experience in. You don’t have experience in, how do I sell something, specifically the language that needs to be used, the call to actions, where the buttons go. That is so outside of your purview. But what’s inside of you, you’re an expert on you and your office. That’s what you should be posting about. [Jaz] I think one thing that perhaps I should have asked, and I will now, is taking a step back. I think I went too deep too soon. I’m trying to understand what you are trying to say and what we can learn. Like I said, building on that correct etiquette and top mistakes we make. Now we are at a stage where virtually every dental practice has a website, I would imagine. But not all dentists have a social media presence. But those that do, a significant majority of those would probably post on 4th of July and then post on Halloween and then completely abandon it. So let’s tackle that for a second. Do we need a social media presence in this day and age to be a thriving clinic? Because in the past it was, word of mouth is the best and patients refer other patients of the similar kind of caliber and likeness, which works well for clinics. What do you think about that question of the need of social media for every practice? [Joseph] So I think practices still, word of mouth, referrals, those are the best practices. Practices where it’s in the front door, out the back door, they’re always gonna be chasing the new patients. But when it comes to social media, the effort that is required for the return on that investment, if it’s posting once a month, having someone in your office just post strategically once a month. Because what people are really doing nowadays is they’re just checking to see if you have a pulse. Yes, we can get information from your website, but if you have an Instagram account or a Facebook account, you can do the bare minimum. What people are doing is verifying, and it also gives the opportunity to see what it looks like inside of the practice, who works there, what other patients are saying. That’s so important because in a day when people are buying, they’re gonna be looking at multiple different dentists. Even if from a word of mouth standpoint they recommend you and someone searches the internet, social media has an effect where you show up on the internet. Some of your social media accounts will show up. By checking that box at a reasonably high level, with minimal effort, it verifies that, hey, I’m a professional. It gives you an opportunity to make a great first impression outside of your website. [Jaz] I’m aware that, myself included, I had to pick a surgeon for my shoulder. Patients will Google their practitioner, or they’re thinking in their town, they want to get teeth straightening or just find a family dentist. As well as asking friends and colleagues and their new workplace, they will Google, “Who’s best? Name me,” or they might get a hunch about this clinician, “I’ve heard good things about them, let me now Google their name.” Do you think the behavior has now changed so that the “younger folk” are, instead of going to Google, actually searching on Instagram or searching on TikTok? What are your insights showing based on how important presence is, relative to the website presence and what shows on Google? [Joseph] Yeah, we don’t have to guess. The numbers are showing the search volume going up. I think it’s a very well-known fact that YouTube is the second biggest search engine in the world. But then after that, you’re gonna be seeing Instagram, Facebook. People are checking those boxes and looking. Just by having consistency across all of those, you are gonna have the opportunity to put your best foot forward again. So we don’t even have to guess. That is 100% happening. We’ll say younger folk, but younger, I’m starting to date, I’m getting a little old myself. So younger folk being 50 and under is completely applicable in this situation. [Jaz] When it comes to social media, one advice that I took onboard is trying not to be great on all the platforms. Pick one platform at a time and try and make a presence and work on your goal there before you then go elsewhere. Because then what you have is this dead X profile that you never post on, but it just exists and it doesn’t reflect well on you or your clinic. You might as well not have it. Is that what you think as well? [Joseph] I like to have everyone run it through someone else’s perspective. If I see an account, X, Facebook, Instagram, and they haven’t posted in eight months, what are your thoughts? “Oh, they can’t keep up with this. Is this place no longer open?” It puts a seed of doubt that could be completely removed if you didn’t even have it or if you kept up with it. That’s exactly right. I encourage docs, let’s do the main ones. Let’s do Facebook and Instagram. Once we’ve proven that we’ve got a great system in place, and by system I mean someone at the office level putting out great content consistently on those, then you can explore into others. But those are gonna be the main ones that you want to hit. [Jaz] Compared to website, if website has extremely high importance, it’s where you have your testimonials, your contact details, the first place that potential patients see. Is Instagram or a named social media platform the first place that you want to perhaps name drop? How important is it relative to the website presence? [Joseph] People are gonna go different places for different things. Instagram, they’re gonna be looking extremely visual at what they want. On a website, you have the opportunity to highlight exactly what someone is looking for. So if we think of someone who’s doing this great, Dr. Brian Harris out of, I think it’s Phoenix, he is highlighting exactly what the patient experience looks like. Then you also have high profile celebrities who have just gotten their teeth done. He does an unbelievable job of painting a picture for you, and you say, oh, I can go to that office, I know what it’s like, there’s the front desk person. That is more what the website is for, information and guiding people through, “Here’s what it’s gonna be like to be a patient here.” Instagram, TikTok, Facebook, you have an option to entertain and show more of your personality there. Just humanizing yourself is a good way to think about it. They all serve different purposes, but at the end of the day, we wanna paint you as a doc in the best light possible. [Jaz] What if you like to be, I mean, yes, I agree. Religion and politics, that kind of stuff, are perhaps more appropriate on your personal profile, not on your business profile. But I see some hilarious, there’s two really funny US docs. I’ll find their name and I’ll put them in the description. They make really funny content that’s perhaps borderline not appropriate, what dentists talk about, but they do it in a very nice way. They do it not in a disgusting way. It’s good humor and I love it. I love what they do. I don’t know if patients resonate with that, but in terms of, as a dentist looking at it, it’s real talk. It’s hilarious. Is there a place for being funny and being a clown on social media because that could be a true representation of yourself and your values and who you want to attract? Or do you feel that, again, that’s something that belongs on your personal profile? I’m sure you can think of some very successful social media accounts of dentists, doctors who are putting out very funny scenarios. There’s one where the guy’s blind. He’s a dentist, he’s blind, he’s walking in the clinic, and the patient’s like, “Wait, what the hell’s going on?” And it’s like, “Well, you are the one who said you don’t want any X-rays, right?” So you’re doing the whole thing blind, and as a dentist I resonated so much with that. But that’s also being seen by the members of public. [Joseph] Right. I think the idea of entertainment is a loaded word, and there’s a lot of different ways to be entertaining. That’s a very clever way to be like, “Oh, you don’t want X-rays,” but they’re giving the analogy of what it would be like to operate without them. It’s gonna resonate with more docs than it will with patients, but at the same time it’s gonna hit a lot of patients. And I think you hit the nail. [Jaz] It might then get rid of some patients who say, “I don’t believe in X-rays, I’m not gonna go ahead,” and you know what? That’s a win for the dentist and that’s a win for the patient. [Joseph] Yeah, and I think that’s kind of your personality. If you are funny, if you are witty, then yes, being in line doing that. This is where that line, and there’s always gonna be edge cases of someone who does have a big personality and that being entertaining is what they’re gonna do. But entertaining being a loaded word, most people hear entertaining and they think shocking, in-your-face comedy. The reality of the situation is you can be educational, you can be interesting, novel, it can be heartwarming. You could do storytelling, visual. There’s a lot of ways to be entertaining. Planet Earth is a great example of this. It’s not funny at all. It’s very entertaining. It’s very educational. It’s very visual. Completely different than someone who gets a lot of attention. Think of Britney Spears. She got a ton of attention from melting down. Yes, she got a ton of views. That’s not what you’re looking for, so that’s not great. I tell people all the time, the most extreme version of yourself is gonna get the most attention. So you might get, oh look, I’m getting a lot of views. But going back to what I said earlier, what are people thinking when they see this? If you are a clown on social media and you’re dancing and that’s not your personality, or you’re making some jokes that are a little bit too far, then that’s gonna deter people. The problem is, you’re never gonna know that you didn’t get them. Because when you deter people, it’s not like they call and say, “I’m not doing business with you.” They just go somewhere else. So operating on that line of entertainment without being extreme is the fine line that you don’t want to cross. [Jaz] I think it boils down to what kind of frame you wanna put on yourself. I use that word intentionally because of something that one of my mentors, Dr. Michael Melkers, taught me. He was presenting in London. He said something really interesting. He said he doesn’t actually connect with patients in terms of knowing the name of their dog and family and that kind of stuff. The frame he puts on is highly professional. “I’m here to listen to you and diagnose and help in co-diagnosis and helping you.” Whereas I’m very much like, “Hey, how’s your daughter’s football game going?” So I pick my frame. I like to be the friendly neighborhood dentist kind of frame. When he mentioned that, I thought, that’s true. The kind of clientele he attracts and the kind of plans he might be doing will be fitting to that kind of professional frame. Some patients will resonate and enjoy that more. Whereas some patients will be very put off by this friendly dentist and they’re actually looking for someone who’s more of a surgeon than the friendly dentist. So I guess the answer, there’s no right or wrong answer. I think, Joseph, the worst thing you could do is not choose which frame you’re going for. [Joseph] Correct. And I would say there is a right or wrong because you hit the nail on the head. You speak jovially, you’re talking about sports teams and these different things. When people come in there, that’s what they’re gonna expect, and then you don’t have to change personalities in the office. I do like the very professional, very straightforward medical professional who is going to help me with anything that I have going on with my teeth, no nonsense, down to business. So when I’m looking at docs on the internet, I want their content to be about that. You are an expert and you’re no nonsense, and that’s gonna attract patients like me. At the end of the day, you wanna attract patients that you enjoy working with. There’s nothing worse than attracting a bunch of patients that are looking for a different experience, and there’s this subtle disconnect. When that disconnect happens, that’s when you see patients leaving because you don’t have a great relationship with the doc. It’s almost like a mini bait and switch. Docs are like, “Well, I don’t understand, they came in.” It’s like, well, you’re behaving differently online than you are in the practice, and it creates this disconnect that you’re not looking for. [Jaz] Reminds me of something. There was an Australian, I think it was an Australian dentist. His name was Paddi Lund. I think he maybe still operates, but he used to, in the early noughties, teach and do courses about that generation of marketing. I think he wrote this book about dentists, kind of like firing your patients in a way that you eventually kick out the patients that don’t share the same values as you, and eventually you become a liberated and happier professional. One thing he teaches is, if you are passionate about football or soccer, have the jersey of the team hung up there. You’re putting it out there that these are the kind of patients you want. Eventually with time and experience, your list of patients ends up reflecting you. I like to think of it like that. I think what you said there is you just have to decide what kind of person you’re going for and be authentic. It’s all about being authentic and not doing something for the sake of social media, and then patients coming in and saying, “Wait, hang on a minute, this was a different person on social media.” But if you are presenting the same way on social media, you know what you’re gonna get. As long as it aligns with your values, then that will lead to a happier practitioner and actually more fulfillment from their work. [Joseph] Yeah. When you say it like that, it sounds so easy. Just be yourself and you’re gonna attract the people that are coming in there. We call it humanizing yourself. A great way to think about it is, for example, if you’re a dentist and you like to golf, every now and then posting about golf, that’s 100% acceptable, because then other people see, “Oh, my dentist is a golfer. Hey, I’m a golfer, I like this.” You go into his office and maybe he’s got some places he’s been. That’s cool. Now, if you post every week about golfing, then the patient thinks all this guy does is golf. He probably knows more about golfing than dentistry. He doesn’t want to be here, he just wants to be golfing. You do have to think of it through that. But you do want your personality to come out through your social media. Like you mentioned, sports are one of the big ones. If you are a diehard, who’s your soccer team over there? [Jaz] Manchester United. We’ve had very bad, dead seasons unfortunately. I’m gonna have to cut that bit out of the podcast, it’s that bad of a season we had. Anyway, I’m just kidding. [Joseph] Oh no. Historically one of the worst ones we’ve ever seen. Big soccer fan. But if you put that out there, other people are going to resonate with that. Guess what? Eventually you have an office filled with Manchester United fans. Even if you get some Chelsea or Liverpool fans in there, there’s some banter going back and forth. There’s some conversational things. One big thing is we let docs know, on social media you should be shopping or supporting local when you can, letting people know that. Because let’s say you go to a restaurant that’s right down the street from your office and then you post about it. Well, guess what? Everyone that goes there, they tag you. They have a bunch of people that are gonna come there too. Then you’re in the community as well. So there’s a lot of opportunities to be authentic, which is, I think, an overused word in social media. But just be yourself and highlight the things where possible, and you’re gonna get people that really enjoy coming to your practice. [Jaz] You mentioned about not oversharing the whole personal side. I guess it goes without saying that if you want to do the personal stuff on Instagram, have your own personal account and have a separate account for work. Although some people I’ve seen just combine it. They post about their kids and then, “Oh, here’s a smile makeover I did the other day.” What is your stance and advice to dentists who are thinking about, should I have two accounts, or should I just have one and just, that’s the whole package, you get me, you get the whole package? [Joseph] My advice is two separate accounts. One needs to be business related, and you don’t wanna be posting your kids and make it a private account. If someone is a patient and they become, I’ve been in many doctors’ weddings, I’ve become friends with a lot of these docs. There are so many great people in the industry. They follow me on my personal account, and then we also have a business account. What I’m putting out personally shouldn’t be shared with everyone that comes to my practice. So yes, I would say having two different accounts is what I would recommend. [Jaz] Fine. That’s a very clear recommendation. I agree with you. Another thing that’s crossed my mind is with social media, the algorithms and the way it all works so that you have potential to make a good piece of content and it can be seen. One of my reels has over a million views. It’s great, like, wow, this is cool. Now, when clinicians are trying to appeal and raise awareness to patients and attract a certain type of patient, for example, and they do a piece of content that blows up, but actually when you talk about how many inquiries did this lead to, one or zero, because it’s going to the world. If your practice is in Phoenix, Arizona, and someone in Jakarta in Indonesia is seeing this and they’re laughing and they like it and share it to their friends, it’s not really benefited you. So what is the strategy that you advise dentists to do? Because their main goal is not necessarily to entertain, and you can’t deposit likes into the bank. You’ve got to actually be able to be relevant for your local community and solve problems for your local community. How does that change the way that you play the game of social media? [Joseph] I’m gonna steal that, “You can’t deposit likes in your bank account,” because I’ve never heard that and that’s a good one. What I’ll say is there’s nothing wrong with that, but what is your expectation and how did you get it? Did you go viral because you put something so outrageous out there? But let’s say you put out something that was great, clever, whatever it was, and it went viral. There’s gonna be value to that because if a million people are seeing it all over the world, that means the number of people seeing it in your local area is also gonna be high. That’s just how we think about it. Content’s great content. When it comes to the algorithm, highly debated topic. The shortcut for thinking on how the algorithm works: what am I gonna do that is rewarded by the platform? Google’s first algorithm was basically how many websites you were linked to. Now they have hundreds of things that go into that. What is social media rewarding at this time? It’s always gonna be changing, but if you can look around at other people’s content that’s doing well, that’s a clear indication that’s what that particular platform is rewarding at this time. [Jaz] Fine. That helps. As long as there’s good content, it’s good content, and it can only help you. But when you are talking to your clients and dentists about making a difference and actually making, what kind of content do you tell dentists to make? They’re looking to you for advice. Should we just make, “How to brush your teeth better”? “We are doing a fall promotion,” or, “Do you like the fall promotion?” What kind of content is good? We’ll segue from that into the dos and don’ts as a final segment of this podcast. But someone’s listened to this and thought, you know what, Jaz and Joseph are right. I need to have an Instagram presence. Let me reactivate. Let me make one for my clinic. Let me make one for me as an associate or a practice owner and talk about my work. I’m passionate about it, but then they’re like, I don’t know what to talk about. I need some ideas. Nowadays with ChatGPT and stuff, you just need to give the right prompts, you’ll get the ideas. That still needs an expert touch and experienced touch. So with that in mind, what kind of content should colleagues be making? [Joseph] There’s so much nuance to this question. I will try and be brief. Highlighting your strengths. Thinking about the content that you’re putting out. Whatever type of dentist you are, even if you’re a general dentist, why are you good? Highlighting your professionalism. Highlighting patients, because there’s always gonna be this ratio. You don’t want to always highlight patients, you don’t want to always highlight staff. You want to have this blend of it. You want to paint a picture of what it’s like, a day in the life. It’s almost like a mini reality TV show of what your social media looks like. “Oh, I can see these patients. I can see new equipment,” whatever it is. We just want to make sure that it’s your personality being super important and the personality of your office. So you’re saying, “What do I need to post?” I think it’s more, what is the blend that I need to post? Letting people know, these are the type of patients that are here. This is the type of staff that’s here. This is what I’m like personally. This is what I’m like professionally. Then you have just the general throughout the year, like, oh, it is Halloween, it is Christmas, and you can mix those things in. You’ll never be short on content. We have a completely free social media calendar that we put out every single month because it’s just, here’s what you could post every single day of the week, and it’s content ideas. The amount of content that you could post is really unlimited. [Jaz] So we’ve covered there what we could post and there’s so much out there. But the number one thing I hear from colleagues, especially those who are maybe a little bit older, is, how do you find the time? That’s probably the biggest objection: time. So what’s your advice to colleagues who think, where do you find the time? [Joseph] Where do you find the time? This is something that depends on the person. If the person’s on social media and they’re posting on their personal, we can carve out that time pretty easily. But for docs who are not consistently on it or posting, one of the easiest things in the world, because every doc is busy, we know that. They need to be running a business, production, that is the most important. This is something that we typically offload to front desk staff. You can work with them. You do not have to pay them much to do this because it’s so native to someone who is younger. You can also have content days where once a month or once a quarter, you’re gonna get these 20 different pieces of content. That way it’s not an everyday grind. We have some practices that twice a year, two times a year, have a photographer and videographer come in, and you can even do this with just an iPhone. They’ll have a list of, “We are gonna get these 20 photos,” and that is gonna be our posts for the next six months. When it’s, “Can I do content two times a year?” Then the lift seems a lot less heavy versus, “What am I gonna post every three days?” That can be exhausting. So it’s more, we know what to post, now if you’re talking about the tactical, how do we do it, just batch it. If it’s not your thing, outsource it to someone on your team and then batch it a couple of times a year, and you’re still gonna get the outcome. [Jaz] I think a lot of people fall into the trap of they know it’s a good idea, they know they should be doing it, but they don’t have that delegation conversation or some basic training, or imparting the values of what we want to do, and then letting someone on the team and trusting someone on the team to just go for it, then revise it, and have some sort of intention or being proactive about it. So it’s good that we’re talking about this. Let’s then talk about dos and don’ts. Let’s say Joseph’s dos and don’ts when it comes to having a presence as a dentist on social media. [Joseph] I’m such a stickler on, when I see content, it’s impossible for me not to view it from every different angle. So we wanna start with the very basic ones first. Make sure your environment’s clean. Don’t ever show a dirty break room. I can’t tell you how many times I’m like, oh, it’s someone’s birthday, and there’s food wrappers in the background. When I see that, I don’t need to be seeing the back of the house like that, and a patient doesn’t either, because you don’t know how they’re gonna judge you. So just making sure everything’s clean. That’s a big do and don’t, making sure everything is in order and it looks great. [Jaz] It’s like a risk assessment. When you’re in a practice, you have to risk assess every little thing. Before you hit record, it’s kind of like a risk assessment you have to do. What could someone think about this? What could someone think about that? Setting the scene before you press that record button. [Joseph] That’s exactly right. If someone’s new, their only impression of your business, they’re gonna analyze that too. They might not externalize it like we do. It’s like, well, if they can’t even take care of a clean break room, do they have clean ops? Are they good hygiene? Do I really wanna go here? All of that goes through their mind in two seconds and they don’t even realize it. They just know, maybe this isn’t the dentist for me. So step one, make sure everything is clean, organized, highly professional, especially for any photos that you’re gonna be posting. Then dos and don’ts, it’s a lot of the things that we covered. Not selling, not acting crazy, versus running it through the filter of, how are people going to view me in this situation? Once they see this post, are they more or less likely to go on the internet and make an appointment or call me? That’s a very easy heuristic to run through. [Jaz] What’s the number one thing a clinic could do to help see results from their social media? If their aim is, we’d like to see more new patients every month to keep a healthy flow of patients and be able to do the kind of work that we’ve trained to do, and we wanna make sure all our associates are full of patients, what’s the number one Pareto principle? The 20% things that you do that make 80% of the difference. What are the Pareto principles of social media to actually get bums on seats? [Joseph] I think it is very easy. You want to be posting content about satisfied patients. One of the easiest things for us to think about: if we’re working with, say, a peds practice and we know the household decision maker the majority of the time is going to be a female from ages 25 to 50, and they’ve got two or three kids, the more content we can post about them being satisfied. There’s a saying in business: how many satisfied reviews would you need to see to be convinced that I do a good job? Even in our business, when we engage with clients, it’s like, here’s a list, a wall of a hundred testimonials, and if you don’t believe any, reach out to any of them if you want. No one’s ever really reaching out to a lot of these people, but if you think about it at a practice level, if all they see on their social media is happy patients like them, that’s the number one thing. The shortcut is, they clearly know what they’re doing with people just like me and they’re happy. I would also be happy. So that’s the number, that’s the Pareto principle of what do I need to be posting to get bums in seats, as you so eloquently put it. [Jaz] I think it makes so much sense. Social proof, it’s always about that. [Joseph] Yeah. [Jaz] I love this little overview of social media. Joseph, how can we learn more from you? How can we follow you? How can we see what you get up to, my friend? [Joseph] I’m just here putting the good word out. I did mention the social media calendar, which is apt for this episode. It’s something that we put out every single month for free, and it just goes to offices and gives them ideas, inspiration, makes it easier for them. It’s not cookie cutter, it is a framework, and then you put your customization into it. The other biggest thing is, I think it’s been viewed a couple thousand times in the last month, we have a free, everything-you-need-to-know-about marketing plan. It’s the biggest CE that we get paid to teach. It’s everything that you’d ever wanna know about marketing, including social media, how to pick a provider, marketing theory, and how we got to where we’re at today in 2025 in the marketing landscape. So yeah, that’s it. [Jaz] Amazing. If you send me that, I’ll put the link in the show notes. [Joseph] Sounds great. [Jaz] Amazing. Well, thanks for the time and helping us to understand the value of social media, but also the etiquette and, I guess, whether someone decides they still wanna be a clown or not, as long as they feel it’s right, it’s in line with their values, speaking correctly, but also not in a way that’s gonna make people think, what on earth is happening in this clinic, and not causing adverse effects without proper risk assessment, which we delved quite deep into. As long as everything is authentic and purposeful and someone’s put some thought in. It’s like when you’re going out, it’s nice for someone to say that whatever they’re wearing, they’ve put a little bit of thought behind it. I’m the worst person at clothing myself and stuff, but my wife says, look, at least a minimum, someone should say, okay, at least he thought about it a little bit. It’s the way you dress. Your social media should be the same. So Joseph, thanks so much for driving that home, my friend. [Joseph] Oh, thank you. Jaz’s Outro: Amazing. Well, there we have it, guys. Thank you so much for listening all the way to the end. About 99% of our episodes are eligible for CPD. This one isn’t. But I hope you gained value. I hope you get an idea of how to conduct yourself in social media or it inspired you to behave in a certain way or implement some strategies that we discussed today. Please do not forget to hit that subscribe button. It really means a lot. I just want to take a moment to also thank Team Protrusive for all their hard work. I’ll put all the show links so you can reach out to Joseph below and for all of the nicest and geekiest dentists in the world in Protrusive Guidance. Thanks for making a lovely community. And if you’re not already in this community, check out Protrusive app to join us. Protruserati, I’ll catch you same time, same place next week. Bye for now.

Cracked teeth — the diagnosis we all hate as Dentists! How do you decide when to monitor and when to intervene? What is the recommended intervention at different scenarios of cracks? Should we be chasing cracks and reinforcing with fibers; is there actually enough long-term data to support that approach? Over the years, we’ve had some epic episodes on this topic — from Kreena Patel’s “I Hate Cracked Teeth” (PDP028) to Dr. Lane Ochi’s Masterclass on Diagnosis and Management (PDP175). But in this brand-new episode, Jaz is joined by Dr. Masoud Hassanzadeh to bring it all together — not just the diagnosis of cracks, but their management. They explore when to intervene, the role of fibers in preventing propagation, and even the fascinating possibility that cracks in teeth may have some ability to heal, just like bone! This one’s a deep dive that will change how you talk to patients — and how you approach cracked teeth in your own practice. https://youtu.be/VHYRBnfJS3I Watch PDP246 on YouTube  Protrusive Dental Pearl Your patient’s history predicts the future! Ask if past extractions were difficult → clues you into anatomical challenges. Ask how they lost other teeth → if cracks, be proactive with today’s cracks. History isn’t just background—it’s a clinical tool. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Cracks in teeth can be diagnosed using magnification and high-quality imaging. Patient factors such as age and muscle strength play a significant role in crack prognosis. Symptomatic cracks should be treated to prevent further propagation. Understanding the anatomy of the tooth is crucial for effective treatment. The healing mechanism of cracks in teeth is possible but varies between enamel and dentin. Fibers can be used to strengthen restorations and manage cracks effectively. Long-term studies are needed to assess the effectiveness of current crack management protocols. The use of fluorescence filters can help identify bacteria in cracks. Chasing cracks should be done cautiously to avoid pulp exposure. A comprehensive understanding of crack mechanics can improve treatment outcomes. Highlights of this episode: 00:00 Teaser 00:47 Intro 03:08 Protrusive Dental Pearl - The Importance of Dental History 07:18 Interview with Masoud Hassanzadeh 08:22 Diagnosing and Managing Cracks 21:13 When to Intervene on Cracks 25:50 Restoration Techniques and Materials 28:30 Chasing Cracks: Guidelines and Techniques 36:50 Mechanisms of Crack Healing in Teeth 45:11 Exploring the Use of Fibers in Dentistry 52:43 Introducing the Book on Cracked Teeth 54:57 Percussion-Based Diagnostics (QPD) 56:44 Key Takeaways 57:21 Conclusion and Final Thoughts 01:00:07 Outro As promised, here are the studies mentioned during the discussion: Why cracks do not propagate as quickly in root dentin: Study 1a & 1b Root dentin has significantly higher fracture toughness compared to coronal dentin—nearly twice as tough, as demonstrated in multiple studies. The key difference lies in their structure and toughness. Root dentin’s unique collagen orientation adds strength, while its fewer lumens and thinner peritubular cuffs make it less brittle. In contrast, coronal dentin has thicker cuffs, which increase brittleness. Unlike coronal dentin, which fractures uniformly, radicular dentin is anisotropic—its fracture behavior varies depending on direction. These structural features give root dentin greater resistance to cracking, making it more durable under stress. Studies on decreasing crack length due to crack repair in enamel. Study 2 The importance of the modulus of elasticity of the final restoration in arresting crack propagation. Study 3 The role of fiber in restoring cracked teeth and how it can increase fracture strength—even surpassing that of natural teeth. Study 4 Decision Making for Retention of Endodontically Treated Posterior Cracked Teeth - A 5-year Follow-up Study The Cracked Tooth: Histopathologic and Histobacteriologic Aspects Historical Studies on Enamel Crack Healing– 1949 (Sognnaes): The Organic Elements of the Enamel: III. The Pattern of the Organic Framework in the Region of the Neonatal and other Incremental Lines of the Enamel – 1994 (Hayashi): High Resolution Electron Microscopy of a Small Crack at the Superficial Layer of Enamel – 2009 (S. Myoung): Morphology and fracture of enamel Don’t miss out — get instant access to all the research papers discussed here at protrusive.co.uk/cracks! Dr. Masoud Hassanzadeh has written two essential books every dentist should own: 📘 Glossary of Biomimetic Restorative Dentistry🔑 Your quick-reference guide to the language and principles of biomimetics — explained in a way you can actually use chairside. 📕 The Cracked Tooth: A Comprehensive Guide to Cracked Teeth🦷 Everything you need to know about diagnosis, management, and the science behind one of dentistry’s biggest headaches. 🌴✨ Dubai 2026: Occlusion + Family Fun ✨🌴 This Easter, join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for something truly special — a tax-efficient holiday that mixes world-class occlusion training with plenty of family time in Dubai. 🦷 What’s included? ⏰ 20 hours of hands-on occlusion (mornings only: 9 am–1 pm) 🏖️ Afternoons & evenings free to enjoy Dubai with your family 📚 Pre-learning + online content to deepen your understanding 🥂 A not-for-profit event — just dentists, families, and fun! 👉 Learn more & get your quote at: globaldentalevents.co.uk 💡 Make memories with your loved ones while making your CPD hours tax-deductible Want to level up your knowledge on cracked teeth? 🎧 Don’t miss PDP098: Cracked Teeth Management with the Direct Composite Splint Technique #PDPMainEpisodes #EndoRestorative #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and C. AGD Subject Code: 070 ENDODONTICS Aim: To provide clinicians with practical, evidence-based guidance for diagnosing, monitoring, and restoring cracked teeth, with emphasis on prognosis, risk factors, and restorative decision-making. Dentists will be able to - Differentiate between enamel and dentine cracks, and recognize when prognosis is hopeless. Apply appropriate diagnostic tools and clinical criteria to decide when to monitor versus intervene. Select suitable restorative strategies and materials to manage cracked teeth effectively. Click below for full episode transcript: Teaser: After 48 hours, they started to see that the crack is just decreasing, like it's just healing. Is it really possible? But it is possible. Like how there is a crack healing mechanism in the bone, there is also crack healing mechanism in the tooth. When I started to learn about cracks, actually the studies were not from dentists. Teaser: They were fracture mechanic engineering that they just studied about the crack, and nowadays there is a new system, it is called quantitative percussion diagnostic, QPD. There is a stress concentration in that point where the crack is started, so we have to distribute the stress in that place, in that plane. That is the important one. If we are just going to remove the crack and put the restoration on it, I'm afraid it's just going to happen again. Jaz's Introduction: Over the years, we've had some awesome episodes on cracked teeth. If you go all the way back to PDP028 with Krina Patel, the episode was titled, I Hate Cracked Teeth, and you know what? I still hate cracked teeth. They're a damn nuisance. They're everywhere, and it creates major consent and if the tooth goes non-vital, that kind of conversation, which no one likes. Now, years later, we did this epic episode with Dr. Lane Ochi, PDP175. You need to check these two episodes out if you want to geek out on cracks. But you know what? This episode really does a wonderful summary of cracks. Not just the diagnosis, but the actual management. Should we be chasing cracks? Are fibers actually indicated? Is there enough long-term clinical data to support the use of fibers in crack propagation? And the question of, okay, when should you actually intervene? And you know what? The most important one I haven't even mentioned yet. So, Dr. Masoud, the way I got acquainted with him is on social media. I posted this image of a crack, a really nasty crack, and he said something absolutely ridiculous. He said that cracks have an ability to heal a bit like cracks heal in bone. Now, you said that because in this image I posted on social media, it was all about how I communicate cracks to my patients. I say to them, look, when you have a crack in a bone, the bone can heal, it can regenerate, but a crack in a tooth can never heal. Patients seem to resonate and they understand that. But he was suggesting that actually cracks can heal naturally a bit like bone. And so if you listen to the end of the podcast, you will see how that is actually possible. Hello, Protruserati. I'm Jaz Gulati and welcome back to your favorite dental podcast. I've had a month in August which was pretty crazy. I didn't do much recording of new podcasts. We were working on some of the older recordings I had done. We've got a huge backlog as a team, which is a wonderful position to be. We are having so much fun creating these episodes. Thank you to everyone who returns to our podcast, and of course all the new people that find us. If you're not already, you need to join 5,000 of the nicest and geekiest dentists in the world on the Protrusive Guidance app. Go on protrusive.app, make an account. Your only requirement is you must be nice and you must be geeky. If you are those two things, you should come and join us to geek out, discuss, share challenges, share wins.

With the final places remaining for our Occlusion Getaway, we present the official FAQ Podcast! Dreaming of combining occlusion learning with a luxury getaway? Want to earn 56 hours of CPD while soaking up the Dubai sunshine? Looking for a course where you can master PRACTICAL occlusion in Restorative Dentristry and make it a family-friendly, tax-deductible trip? Easter 2026 is set to be unforgettable. Join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for an extraordinary Occlusion Excursion in Dubai — a blend of serious CPD and sunshine that redefines what “continuing education” can be. We’ve always believed in mixing work and pleasure, and this time, we’re taking it to the next level. Think luxury, learning, and laughter — all under the warm Dubai sun. Watch IC062 on Youtube 🦷 What Makes This Course Different? 56 hours of CPD/CE credits, including 20 hours hands-on in Dubai Full online occlusion curriculum and live webinars before you travel Morning workshops (9 AM–1 PM) and free afternoons to explore Dubai Bring your family (Easter school holidays!) or come solo — many dentists are already flying in from around the world. REQUEST A QUOTE - Limited Places Remaining as of November 1st 2025!: https://globaldentalevents.co.uk/  Spaces are limited and flights are rising, so secure your place early.👉 Easter 2026 – Occlusion, sunshine, and CPD in Dubai. 📅 28 March – 4 April 2026 📍 Dubai, UAE 👨‍⚕️ Dr. Jaz Gulati & Dr. Mahmoud Ibrahim, Organised by Global Dental Events Highlights: 04:06 Meet the Organizers 05:59 Why Dubai? 10:40 Delegate Experiences and Expectations 13:21 Course Pricing and Tax Benefits 19:05 Course Itinerary and Logistics 24:49 Final Thoughts and How to Join