5 Things I Do Differently 10 Years after Dental School – AJ004

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There are five things I want to share with you that I do differently now compared to what I was taught in dental school. Dental school is great for laying the foundation, but real-world experience and continuous learning have taught me valuable lessons that have transformed my approach.

  • 1 – Sectioning and Elevating – I routinely section and elevate multi-rooted teeth which simplifies complex extractions and preserves buccal bone for better patient outcomes. This is a skill I had to learn and develop post graduation.
  • 2 – Using air abrasion to aid with plaque removal which has benefits for adhesive dentistry and beyond, like cement removal and bonding zirconia. I cannot imagine practicing without air abrasion!
  • 3 – I use a ‘wedge guard’ during proximal drilling to prevent scratching adjacent teeth, ensuring precise breaking of the contact without causing iatrogenic damage. I know that for many new grads, breaking contact can be stressful and the mission to prevent iatrogenic damage means overly tapered and aggressive preps. The simple use of a wedge-guard has really helped me overcome this.
  • 4 – Onlays! I seldom prepare for full crowns anymore, instead opting for onlays where possible which preserve tooth structure and provide a scientific and artistic challenge in contemporary adhesive dentistry.
  • 5 – Vertical Preparations – when I do require a crown and the tooth is not suitable for adhesive dentistry (poor quality and quantity of enamel, deep subgingival margins) then using ‘vertipreps’ as been a game changer.

Overall, these changes have added value to my practice and improved patient outcomes. Remember, clinical Dentistry is a journey of constant growth. Stay curious and keep evolving – whilst still respecting the best available evidence.

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

Hello Protruserati! Welcome back to the fourth episode of #AskJaz where I answered a question that was sent on the Telegram group – “Jaz, what are some things that you do differently now compared to what you are taught at dental school?”

Watch AJ004 on Youtube

Highlights of this episode:

0:24 Dental school inexperience
1:04 Section and Elevating for Extractions
4:02 Air abrasion for Biofilm removal
6:27 Wedge Guard – prevent iatrogenic damage!
9:39 Onlay preparations
11:39 Vertical preparations

If you enjoyed this episode, check out this episode 6 Signs You are a Comprehensive Dentist

Click below for full episode transcript:

Jaz: Hello, Protruserati. I'm Jaz Gulati, and in this Ask Jaz series, I'm going to answer a question that was sent on the Telegram group. It was, 'Jaz, what are some things that you do differently now compared to what you are taught at dental school?' And the honest answer is so much, right? At dental school, you lack experience big time, right?

Think about how many procedures you actually get to do at Dental School, how many crowns you actually get to fit. So Dental School is just there to make you a safe beginner, and as you navigate through the real world. You combine your previous experiences with some mentors and courses that you go on and your own individual experiences that you get in practice, which are so powerful.

Your failures teach you so much, your network teaches you so much, and eventually you become the average of the five dentists you spend the most time with. But decided to make a list. And the list I made was of five main things that I do differently now compared to at Dental School. And I think these are all things that have a lesson attached to it or some sort of value attached to it.

So let’s start the list. Number one of the five things that I do differently now compared to a dental school is EXTRACTIONS. Now at Dental School where I trained in Sheffield, we were mostly taught forceps because they were worried about us using luxators and causing damage or an injury, right? Like if you slip with a luxator that can cause a lot of harm.

Now towards the end of Dental School with some mentors, they were showing us how to use luxators, which is great. So luxators became a part of my arsenal during dental school. But I’ll tell you what made me significantly improve my extractions and has made me pretty much fearless. I guess maybe fearless might be an irresponsible term, right?

And sometimes the word fearless can mean irresponsible. I don’t mean it at all. I just mean that previously when I see a molar radiograph or an extraction, I used to have palpitations. I used to get nervous. Can I remove it? Can I not? Should I refer this? Should I not? Kind of thing.

But now I don’t get phased by extractions, even wisdom teeth I’m quite competent with. And only those which are close to the ID canal or show signs that they’re close. Would I refer? And the number one thing which allowed me to become confident with extractions and was not taught to me at dental school is SECTIONING and ELEVATING.

Now, there’s a whole episode we have on the podcast with Chris Waith, about exactly this topic, right? How to make extractions easier by sectioning and elevating, and I wish I learned this technique sooner. I remember being one or two years qualified and trying to take out this lower molar, and the crown completely broke off, leaving the roots behind.

And looking back, all I need to do, all I generally just need to do is section the roots in a bucco-lingual direction so that now the mesial and the distal root are separate and literally just luxate out. Because quite often there’s some bulbosities or slight curvatures that prevent the roots from lifting up vertically.

So by sectioning them, you create two passive insertion, and you convert a multi rooted extraction into two times single root extractions if we’re dealing with the lower or three roots when we’re dealing with an upper. So taking this on board. Now I say that I actually section 80% of the molars that I remove even from the start, if it’s not budging, I’m not getting enough movement within the first 15 seconds or so, my threshold for sectioning is very low.

I’ll be very, very quick to section. The added benefits of sectioning is that you don’t need to do those horrible bucco-palatal, bucco-lingual movements because that’s only going to harm your valuable, your precious buccal bone, which is required for a future implant.

So by sectioning, I can actually direct the forces in the right way, prevent any damage to the bone, preserve more bone. Make my extractions much easier, and I do feel that the patients heal better. There’s less trauma. The trauma is directed at the tooth, at the enamel, at the dentine, not at the bone and the surrounding tissues.

So if you’re not already doing this, sectioning and elevating is super important. If you don’t see some examples of me sectioning and elevating teeth, there’s some on YouTube. There’s also some on the Protrusive app as well in the premium clinical section. And I’m also going to be adding one next week for a lower left second molar. Very carious, very broken down for you to check out.

The second thing I do now, which I didn’t have access to at Dental School, which I firmly believe in so much, is AIR ABRASION. Now the clinical evidence in terms of does air abrasion really improve the long-term outcomes for our adhesive restorations. It’s to be debated, right?

We don’t know whether the bond strengths are always increase. Some studies say they do. Some studies say they don’t, and I know some colleagues who have never air abraded, they just don’t have an air abrasion unit, aluminum oxide particles. And just to be clear, for any younger colleagues, air abrasion is not like the air polisher.

It’s a little bit more sophisticated than that. It’s a little bit more power than that usually. And it’s using a different type of sand if you like. It’s usually aluminum oxide particles. Now, if you’re fancy and you’ve got an AquaCare unit, I’m very jealous of you. That’s probably the Rolls-Royce of all a abrasion units, but something like a Ronvig is very good, a Microetcher. These are a couple of examples of a abrasion units and what it does, it blasts these sand particles, and supposedly it may aid in dentine bonding and it may or may not help in enamel bonding. But the number one reason why I’m a big fan of air abrasion, oh, by the way, actually cement removal.

Like if you have a resin bonded bridge or an old crown and you want to re cement it and you want to get rid of that old cement, then air abrasion is amazing, right? You just blast off the cement. And of course, if you’re bonding zirconia, then part of the zirconia bonding protocol is air abrasion. So air abrasion is a no-brainer personally, but the number one reason why I use air abrasion is PLAQUE and BIOFILM REMOVAL.

So even if it doesn’t materialize, that air abrasion actually makes your composites last longer. One thing that cannot be doubted is that it aids in biofilm removal. So this is something that David Clark, one of the inventors of the Bioclear Matrix got me onto. I was watching some of his videos and he showed where you take a scaler to the tooth and you disclose the tooth and they’re still plaque and you scale some more.

You use ultrasound, scaler, use all sorts of tools, and they’re still plaque when you disclose, but only once you use air abrasion is all that plaque gone. Now, why is that important? Do you really want to bond to plaque? Do you want to bond to biofilm? Of course not because obviously that means weaker bond strengths.

But number one thing is staining, right, that I don’t get much staining on my composites, and I do believe is because I’m obsessive about getting a nice, clean area. So air abrasion will help you get that cleanliness that you desire, that clean and rough surface that David Gerdolle talked about in our episode called Extreme Bonding, again, all these episodes I’m referencing, I will put in the show notes.

So number one was sectioning and elevating. Number two is air abrasion number three. Number three is the use of a WEDGE GUARD or a Fender wedge. These are like two different brand names of these wedges. Essentially, it’s a plastic wedge with a thin metal shield. I can imagine where I’m going with this now, I do remember seeing some at Dental School, but they were very much hidden away and most of my tutors that were teaching me and helping lead my preparations weren’t advocating the use of it.

And so I didn’t really get to use it much. I probably was using it wrong anyway, but these are absolutely fantastic. Now, there is some evidence to say that when we are drilling the interproximal surface of a tooth, we end up scratching the adjacent tooth a significant percentage of the time.

No matter how good you think you are, no much how much magnification you use if you’re not using some sort of protection like a wedge guard or a Fender wedge, that metal strip really does help because we end up scratching the adjacent tooth many times over. Now going back many years, the thing that scared me the most about crown preparations was breaking the contact because I was so scared about touching the adjacent tooth.

I was really worried. And we all go through an experience where we take off a little bit too much compared to what we had, like, and then we have to get soflex disc out and the fluoride and tell the patient what happened and stuff. So it’s not nice. So what we end up doing to prevent touching the adjacent tooth is we end up over tapering that distal wall, for example, quite a common way we overcome it, which is not ideal because then you lose some retention of your crown and quite often you also over reduce that distal wall, for example, because you’re really trying to stay away from the adjacent tooth.

And so that’s not good either. That tooth structure could have been maintained, but when I switched to using the wedge guard, pretty much 90 plus percent of the times now when I’m doing a onlay prep, a crown prep, or when I’m even removing an old restoration, I just stick this wedge guard in. Now you can use some tweezers or better yet, some mosquitoes or hemostats.

Give it a good pinch and direct it in. And you want to sort of go like you’re suturing, right? You want to put the tip of the wedge in and then you want to go slightly apical, and then you want to put your buccal pressure and then like you would with a suture needle, you’d go up. So you go sort of down and up.

It’s difficult to explain. For those of you watching the video version, I’ve got something up right now of me recording, inserting a wedge guard, which again, I’m a huge believer in. And it’s definitely something I do now, which I didn’t appreciate before at dental school and even as a newly qualified dentist, which would’ve saved me a lot of tears.

So if you’re not using one already, it is wonderful. I can break the contact with much more precision, much more ease, much quicker and less fear that I’m going to adjust the adjacent tooth. I don’t mind if I batter the metal or if I batter the plastic. I’ve got some protection there. It is just much better to use something like a wedge guard.

Now if like I was, you are also anxious about breaking the contact. I’ve been speaking to some young dentists and students, and this is something that definitely worries them that I’ve got a whole series coming on the Protrusive app soon called ‘Breaking Contact’. Basically all it is, it’s about 15, 20 cases of me doing crown preps, and all I’m showing you is 20 examples of breaking the contact and how I didn’t touch the adjacent tooth use of a wedge guard and use of any other techniques I can show you to safely break the contact without over tapering and without reducing too much tooth structure.

So watch out on protrusive.app soon for that. And if you think that would be helpful, please comment below so I can hurry that process up for you. Number four, the use of ONLAYS. Like onlays were just not taught to me at Dental School at all whatsoever, so I had to go in courses by Jason Smithson and all these amazing dentists.

To learn about the adhesive onlay and it’s one of my favorite procedures to do. I’ve got rubber dam on. I’m working on enamel, beautiful clean dentistry. I love this procedure. The single onlay is just a beautiful procedure to do. It’s a way for me to express my creativity, if you like. Right? When I’m doing an onlay, I’m in the zone because I feel good that I’m preserving the apical third, the gingival third of the tooth because we’re avoiding a shoulder or a chamfer and we’re doing contemporary dentistry. We’re doing adhesive dentistry. Adhesive dentistry is fun. There’s a lot of science. There’s a lot of art form, there’s a lot of protocol checklists involved, so it really satisfies that inner OCD that we all have.

So I’m doing onlays where I just did not do them at dental school at all. And so if you’re newly qualified, I would encourage you to go on a course where you learn about different onlays. Now I do both metal onlays, rarely. Usually when I’ve got limited occlusal space and I want to put in some slots and grooves, but lithium disilicate is a material I’ll commonly use for my onlays.

And if I’ve got a good amount of enamel all the way around and the thickness of the enamel is good as well, then that for me is automatically going to be an onlay where I need some sort of cuspal protection or an indirect restoration. If you want to see a full protocol, 35 or so minute video CPD verifiable of me bonding an onlay and also prepping onlays, then do check out the Protrusive app.

That’s protrusive.app for examples of that. So just to recap, for I say number five. So number one was how I extract is different to how I did it at dental school. I’m Sectioning and Elevating. Number two was Air Abrasion. So important for that plaque removal and stain reduction. Number three is a use of a Wedge Guard.

Very trusty wedge guard. I use it so much. It just gives me so much peace of mind. And number four is Onlays. There’s a beauty in onlay preps and really it’s not difficult at all. If you can do a crown, you can definitely do an onlay. It’s just a big deal because if you haven’t done at dental school, it’s like your first time doing onlay kind of thing.

So it’s good to see all the content out there and courses out there that teach you this kind of stuff. So number five in the final one of something I do now, which I had no idea about at Dental School, is VERTICAL PREPARATIONS. So verti preps, as you may have heard of them, are not a new thing, right? They’ve been around for a long, long time, decades, because previously we didn’t have powerful tools now to drill these chamfers and shoulders.

So what dentists would do were these feather-edge preparations, and they kind of went outta fashion and now they’re back in fashion because the modern materials, you can actually mill them to very, very thin. And we get to preserve so much tooth structure. So I’m a big believer in vertical preparations.

When I don’t have enamel or when I want to preserve as much tooth structure as possible, if I want to go sub gingival, try and gain some ferrule, these are times that I’ll be using a vertical preparation. So I got to talk nothing about this I never knew existed while I was at then school. And it has been absolute game changer for me and a lot of my indirect work for when I have decided that this tooth is not the best candidate for adhesion.

I’ll be going vertical preparation. And I just love how much tooth I’m preserving and how good the soft tissues look. Now, if this is an area that’s confusing for you and you want to learn some more, I’m doing a series of five live webinars starting probably in August. If you want to stay in the loop, join protrusive.app premium membership and will be doing Verti Prep for Plunkers, a five part live series that will go on there as well for you to essentially do your first premolar case.

So the challenge by the end of these five live webinars is for you to be able to do your first Verti prep on a premolar preparation and cementation, i.e plunking it on. That’s why it’s called Verti Prep for Plunkers. I’m not calling you plunker. It’s like the act of cementing is plunking rather than doing something adhesive, which is much more intricate.

Right? So I hope you join me for that and I will put the links in the show notes. So thanks so much for listening to this five things I do differently now compared to before. That’s Extractions, Air Abrasion, Wedge Guard, Onlays and Vertical Preparations. Any other suggestions for episodes, please do hit me up in the comments or on the productive app or on our special Telegram group. I love to hear from you and thanks for watching all the way to the end.

Hosted by
Jaz Gulati

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