#AskJaz – Picking Courses, Reduce Root Resorption Risk, Treatment Options, Which Facebow? – AJ002

Welcome back to the second episode of #AskJaz where I answered questions from the Protruserati – from communication to caries management, I will try my best to help. When I don’t know the answer (far too often!) I usually know someone who does!

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In this #AskJaz I tackled:

  • Picking Courses – Which Year Long Restorative Course? 4:45 
  • Which Facebow should I buy? 10:16 
  • When giving the patient some options goes too far 12:02 
  • Reduce Root Resorption Risk for relapse cases 17:50 

Do join our Protrusive Dental Community Facebook Group. It has so many great gems and pearls shared in our little community!

Click below for full episode transcript:

Opening Snippet: Hello Protruserati, I'm Jaz Gulati and welcome back to the second ever AskJaz

Jaz’s Introduction: I’ve just come back from Porto in Portugal. And it was an amazing trip. Let me tell you about it because it’s very relevant to the podcast. The way this trip came to be is that in Episode 89, I had Dr. George Andre Cardoso on the podcasts and we were discussing Digital VertiPreps IE, how to scan when you do the BOPT, or the shoulder less technique, they’re slightly different, right? So one’s shoulder, this one’s edgeless. We can talk about that another time. But essentially, this crown preparation or bridge preparation technique, which is pretty much all the rage at the moment, and for good reason. You know, I’m a big believer in vertical preps, they are much more conservative, they help you to gain ferulle, they help you help you to preserve the horizontal ferulle, and their soft tissues. Love it. So I’m a big fan of this prep. I’ve been doing it for some years now. But I knew that so many dentists in the UK wanted to learn. And so in that episode, Episode 89, Andre says, Hey, why don’t you guys come on over and we can do something, we were just chatting. And I was like, Yeah, that sounds great, you know, maybe if anyone’s interested if you want to go on his website and register your interest.

Fast forward, maybe six to eight months later, and we had enough people interested that I’m actually organized 16 dentists. They happen to be all from the UK. And we flew over to Porto in Portugal, and George Andre Cardoso and his team. Thank you, Catia. Thank you, Joanna. Thank you, Gustavo. They treated us to a fantastic course on vertical preparation hands on. So morning was theory, afternoon hands on. All the dentists that came walked away with their own bur kits. But the best thing about it all was the people, the company because it reminds me very much of being at Andre’s dad’s restaurant, his dad seafood restaurant in Porto, which is part of a package, you know, you come. We do a course. We include lunch. We include dinner at Andre’s Dad’s seafood restaurant in Espinho. It was phenomenal. And we’re there at dinner. And George Andre Cardoso, he shares some life philosophy, we’re talking philosophy. And he says Jaz, you know, I came to realize that life is not about the destination. And I said, Yeah, of course not. We all know it’s about the journey. He goes, No, life is not about the destination. Life is not even about the journey. Life is about the company. And at that moment, with this packed restaurant full of all these colleagues, which are some of them I’ve never met before. They are Protruserati, which I met for the first time, which was amazing. It made me realize, Wow, this is special. You know, when you go away for trips, it reminded me of being at Uni. We just got these ski trips at dental schools and that they were the best. And so the vibe here was just amazing. It was just so much fun. It was a great city tour of Porto. We had great food, Francesinha, if you guys don’t know Francesinha is I mean, I’ll just wrap this up really quickly because you probably want to get to the AskJaz questions. Francesinha, you can’t call it a toasty because Portuguese people will get very upset if you call a Francesinha a toasty, but it is a toasty. Okay, so toasties has two slices of bread. It’s a toasty, inside the Toasty is steak, bacon, sausage. I’m sorry if I’m getting anything my Portuguese people. And then on top of this toasty is a fried egg, okay? So awesome meaty, toasty, fried egg on top, wrapped, covered, smothered in melted cheese. Wow. Okay, now the whole thing is served swimming in a tomato broth. It was just phenomenal. They call it heart attack on a plate. And oh my god, I had far too many on this trip. It was just amazing. It was the first time I went to Portugal. And it was a bit selfish of me to choose Portugal because I like to go new places. And I realized that dentists were hungry to travel abroad. Now obviously, because of pandemic’s hopefully coming to an end and travels opening up. And I think there’s a real hunger from everyone to travel abroad to learn from great clinicians, but also to get tax deductible holiday.

So if you feel like you want to join us in the next Protrusive tour, or whatever it may be, haven’t got anything in mind just yet. But I think the demand is there. I mean, the same group, I’m speaking to them on WhatsApp daily, and they’re keen, let’s go again somewhere, right? So I think the scope is there to organize more trips in the future, to have fun, to learn, to experience new culture to learn from new dentists from around the world. And to just have a community of dentists which are like minded, having a good time, all that is tax deductible. So if you like the idea of that go to protrusive.co.uk/excursions, and that will take you to a page where you can keep up to date in any future trips and planning because this one went so well so amazing that I definitely want to help facilitate and organize something like this again. So if you’re wondering why my voice is hoarse, it’s because I’ve had a very crazy few days in Porto with some lovely people. Anyway, let’s hit the questions, right?

Main Podcast:
So first question from Instagram, I’m gonna block out the names you know, but when I get the questions and I help someone out, it then to go back in time and to ask permission to use their name or whatnot. So you can see the screenshots but I’m gonna blur out the name because I haven’t got permission to share the name to the podcast just yet. So it’s question is ‘Hi Jaz, hope you’re well, long time listener of your podcast. (Amazing, loved to hear that). I wanted to ask your opinion on further postgraduate training. I’m getting a bit bored and comfortable with simple nhs work. I want to do a year long course, is there any that you recommend either through first hand experience or from people you know. I’ve looked at the tipton courses, Chris Orr’s course, and Dr Banerji’s masters through Portsmouth Uni. Any advice would be welcome.’ This is such a common question such a big question, a question that ran through my own mind when I was a relatively young dentist, and I was considering Okay, what am I going to do? Now, the reason I did not do a paid private year long course, is because I did 18 months in total of restorative DCT. So those of you abroad, it’s Dental Core Training like a residency in hospital and I got really good exposure when I was at Sheffield. For that one year in Sheffield, I got really great hands on exposure, thinking full mouth, thinking facebows, articulators, lots of dahl cases, one full mouth rehab, which is pretty crazy when you think about it. Re-root treatment on the microscope, so I got great experience, it was a fantastic post. I loved it. And because I had that sort of experience under my belt, I didn’t think it would be necessary for me to splash out on a year long course. As much as I was tempted by the Aspire Academy Richard Porter, and Tipton and Chris Orr, all these great names Dr. Banerji, everyone that, this gentleman name, this dentists name.

So there are so many great educators I mean, I’m not gonna name them all but just add a few more Dominic Hassell, Monik Vasant, if you’re in the States or Australia, there’s even more to consider Singapore, wherever you are. There are great dentists near you who run year long courses, which are going to really upskill you. But how do you pick? How do you pick which is the right one? I think that cost is pretty much similar for all of them, right? So cost is not really, it’s a factor but it’s not the factor. I mean, let’s be honest, you what you’d rather go to someone who’s the best, like who’s the most renowned for whom your friend has been through their training and your friend has something good to say, you’re probably going to trust your friend over just a perception that you have. But how good someone will train you out. There’s a big problem in dentistry, it’s a huge, huge, huge toxic culture in courses when it comes to dentistry, which is we see all the time positive reviews about courses, but where are the negative reviews? And I guess it’s a nice thing, I guess that there aren’t negative reviews defaming people, which is a good thing. Yeah, that’s a nice, sensible thing. But at the same time, if everyone’s always saying that, Oh, this course is awesome. This course is awesome. This course is awesome. Now we know that every course is not awesome. So how do you read between the lines and figure out, Okay, which course is more likely to help me more than other one, and which course is not going to sit well with me. Now put it this way. I know a fantastic educator, for whom many people keep raving on about, I had one of my close friends. And he said, Oh, he runs on it. And he thought it was a waste of money. It was terrible. And, you know, like and trust my friend here.

So it was mixed opinions I was getting about this course, I guess the lesson there is that for some people’s values and who you are as a person and what you’re, what kind of lens you were and their perception lenses or your as you want to call them. The way you see the world will be different to someone else. So when you go on Facebook, and you say Oh, I would recommend this course, I would highly recommend Tipton, I would highly recommend Chris Orr or whichever course you’re thinking of. More than likely you’ll be happy as well. But remember that, that person’s experiences, training requirements, learning needs will be different to yours. So I guess the long winded way of me saying is A) it’s almost impossible to choose the right course for you the perfect course for you. Because there’s no Trustpilot, right? In dentistry courses, there’s no place where you can write good and bad reviews. And if you write bad reviews, you will not get ostracized or judged because imagine, you go out in the open and you write something bad about a course that you went on, or dentistry is a really small world. That’s why people are afraid to write Oh, you know what, this course is average. No one says that. No, this course, no one says on social media, Oh, this course is very average. Because they know that the educators probably on that forum, they’re going to read it and educators maybe a nice guy or girl and they don’t want to offend them. So the really now give you the final answer is it doesn’t matter. All right? These are all respected clinicians. They’ve got an army of fans on social media, raving about how awesome their courses are. Chances are if one course is going to be 98% satisfaction, the other one might be 94% satisfaction. Do you see? It’s very unlikely that these tried and tested courses that have been running for so many years, with such great reviews, which are really out in the open, it’s unlikely that you’re going to be one of the very few people who are unhappy with it. But the best way to do is find someone who’s similar to you. Similar learning needs, similar position when they did that course and ask them and sometimes you know, if you’re in Mancheste, find a course that’s in Manchester. If you’re in London find the course that’s in London, you know, you got to think about cost of travel time away from family, because really how much of a big difference will it make if you choose one educator over another? I don’t know. Because they all seem pretty awesome to me. So don’t read into it too much. Figure out which days suit you best, what’s your budget suits you best, which location suits you best, and just trust in the process and go into the course with a willingness to learn and willingness to implement that knowledge. That’s far more important than if you do educator A or educator B.

Now I know lots of people may disagree with me that no no no, this educator is the best. I don’t see it that way. I think that these are all brilliant clinicians. Yes, a few percentage points difference but how are you going to find out? Until you do every single course you’re not going to find out. So do what feels right to you my friend and just run with it, go with it, trust the process.

Okay, next question is from my buddy Pri and he asked me, which is the facebow that I should buy? So most common ones use in the UK, particularly, the Denar. Denar is probably the most common one use. There’s also Artex which is the one I have. Although nowadays I’m doing more and more techniques to avoid having to use Articulator and stuff I’m using digital techniques. Over here the right bite registrations at the correct desired OVD, lots of photos, a stick bite, using the TMJ as the best articulator and being very comfortable to adjust the temporaries to refine the occlusion how I want it before then moving to definitive. So that’s a good way to bypass all of that, but I still think, it’s so important to, for the restorative dentists be familiar with Facebows and articulators. So the question is, which Facebow, like I said, there’s Denar there’s Artex, there’s SAM® 3, there’s a few other brands out there, I think the best way to decide is to speak to your technician ceramist or your lab who you think is going to be there for you for the comprehensive cases. So you find out which articulator your lab is using, because guess what the lab that I use, they prefer not to use Denar, believe it or not. And I use another lab, which actually prefers the Denar system and they don’t have. So if I send them my artex Facebow transfer jig, they can’t use it. They prefer me to use a Denar. So the lab I use now is the one that I can send them my Artex Facebow to and they have the Artex articulators. Do you understand what I’m trying to say? The best person to advise you on this is a person who’s going to be mounting. Yes, you may be mounting yourself, fair enough, but you want to be working in tandem with your laboratory, with your technician, with your ceramist. So the best Facebow is for the articulator or the system that your technician prefers. Simple as that. And that will be my go to. Pick up the phone, call your technician and find out which Facebow they want you to buy.

Okay, next one is from one of my Splint Course delegates, we were just talking on our secret group, and there was a case posted where there was some deviation on mouth opening. And this patient was a potential for orthodontics. So we were doing joint health screening prior to orthodontics, which is really, really important, right? So I talked through the process and we decided that okay, this patient should be consented appropriately on the risks and whatnot. But it’s probably safe to have orthodontics, knowing what we know the lack of locking, and generally no certain no pain symptoms, and the signs which are manageable, we decided that okay, this patient is suitable for orthodontics but with appropriate consent that okay, there is potentially a weakness in your jaw joint. And then we looked at, I helped her to look at the ClinCheck together on Zoom. And we looked at the ClinCheck, this patient had a crossbite. Now, I think this was a posterior crossbite in one area. And I suggested that okay, it’s interesting, the crossbite isn’t that one side and this may have something to do with the reason why the jaw deviates on opening actually is trying to get back to a centric position, but the crossbite forces the jaw to move to another position. But I suggested Hey, why don’t you do the bite registration for the ClinCheck in the centric relation contact position. So one things that taught me on my orthodontic diploma is it’s not enough. When you’re presenting your orthodontic plan to a supervisor. It’s not enough to say okay, the patient has a cross bite, you should never just say the patient is crossed bite, you should say the patient has a cross bite with or without displacement. Because this is very important. So if someone has a cross bite, we know what cross bite is, if they have a cross bite with displacement, it usually means that in their centric relation contact position, they are hitting onto that cross bite tooth or cross bite teeth. And then the jaw is deviating or deflecting in to another area to move around the cross bite, so cross bite with or without a displacement. So if the jaw moves it’s displaced, but if the jaw is not affected by the cross bite tooth or teeth in any way, and it’s nothing to do with the centric relation contact position, then is without displacement.

So this is important because when we’re planning for orthodontics, sometimes or always you should check whether the crossbite has a displacement or no displacement. And if it does have a displacement, we then must consider, should we treat from that position. So for the either optimum joint health or to improve the prognosis of being able to move the teeth so for example, in their MIP, it may look like whoa, this crossbite is really extreme, but in their centric relation contact position, the crossbite doesn’t look so scary anymore. So that is so important. Now, the crux of it is this, when I suggested to this dentist that Hey, you know, you should scan the bite in the centric relation contact position, because you found out that there was a cross bite with displacement, run a ortho simulation or ClinCheck from there, and then decide which is the best plan for the patient in terms of their joint health and the tooth movements, and then present that plan to the patient. Now, here’s the interesting thing that the dentist said to me. She said, Okay, I will give the patient an option, whether I should treat her in this bite or in that bite, I was like, no, no, no, you can’t do that. It’s like an orthopedic surgeon saying to you, Okay, should I, You want me to treat your hip in this position? Or that position? Right? Like, how would the patient know whether, how the orthopedic surgeon should place the hip in a different position, right? So just like that, can you imagine a patient having to make a decision where, What the hell is MIP? What’s the central relation contact point? Some of the dentists listening to this may have heard of all these things for the first time if you’re a new graduate, right? So how do you expect the patient to understand the pathophysiology, the mechanics of orthodontic movements, kinesthetics of temporomandibular jaw body movements, etc, etc, etc, right? How can you say that to a patient that, Okay, you want me to treat your position A or your position B? That is a clinician lead decision, you need to decide what compromises you will be made if you treat position A or position B. And you should recommend and present the plan that, Okay to treat your issue, we need to fix you in this bite. You don’t give the patient the option of, can I treat you in this joint position or that joint position. I guess in some cases with ClinCheck what it is that you can do because you can simulate different bites and different scenarios. Usually, yeah, we can say okay, if I treat you this way, it’s going to cost you, not cost you. It’s cost you time and cost you twice amount of time by treating you this way. But when it comes to joint health, I feel as though we decide okay, is that joint important or not? And if it is, can you improve anything by planning your orthodontics in a better way, even though some orthodontist listening to this right now. Saying Jaz, you’re on shaky grounds here, you know, you cannot improve or deteriorate the joint health from orthodontics, etc, etc. But come on, guys, if there’s an option to treat the patient in centric relation contact position, and that improves your tooth movement mechanics. And that’s a better position for the jaw joint, and there’s a better position for the TMJ, we should explore that. So sorry if that got a little bit complicated, but I guess the crux for those younger dentists here is sometimes you need to pick and choose the way that you communicate to a patient and what you actually, it’s a bit like asking the patient, you have a cracked tooth, when I treat this tooth, do you want me to chase the crack? Or do want me to not chase the crack? I mean, can you understand that? Like, why would a patient know whether to chase a crack or not? It’s the same way you can’t tell a patient, Oh, do you want me to treat in position A or position B. So remember some things, you are the dentist you need to use your best knowledge and experience and mentorship to present the plan that is appropriate for the patient. You cannot give this kind of control to a patient ie chase the crack or not chase the crack or treat you in this position or treat in that position. So just be careful how you present things to patients. Sorry if that one got a bit confusing.

Your last question guys. This was from our Protrusive Dental community. It’s from my buddy Kjartan in Scandinavia, and he posted a case of a lateral incisor which had a little bit of resorption because this patient had prior orthodontics. Now this patient had relapse and was interested in more orthodontics. And so Kjartan asked, you know, what do I do? Like, what kind of consent do I have to give the patient? What are the risks here? Is it safe to do another round of orthodontics, which is what the patient wants? So, our buddy Farooq Ahmed, if you haven’t listened to Episode 71, please listen. It’s a great one. It’s called the Do’s and Don’ts of aligners. That’s the do’s and don’ts of aligners episode 71. So protrusive.co.uk/071 will take you straight to that. He did such a great job of summarizing which movements with aligners are predictable, which aren’t. And so Farooq came to the rescue on our Facebook group. And he gave a fantastic reply, which was that we don’t know exactly which factors increase root resorption but we know how much of an effect certain features have or certain movements have. So he shared a study by Currell 2019 and Sondeijker 2020. And this little table. So essentially the advice that Farooq gave, and this is what you should apply to any patient who has evidence of root resorption and you are considering to do orthodontics, and you’re consenting the patient, you should stick to light forces. So actually, with aligners, we know that we are giving lighter forces with aligners than fix appliances. And the top pearl that Farooq gave was that you can reduce the velocity of tooth movements with your aligners. So imagine it takes 20 aligners to get the desired result. For that same patient, you would do it in 40 aligners, it’s still the same result. But you’re each aligners doing half the movements, you’re going a much slower pace, which is lighter forces. This is interesting because it’s lighter forces which is really important. But at the same time, one of the factors in the little table he put up and I’ll share that with you now for those watching is duration was one factor which was associated with higher risk of root resorption, so many years of treatment is obviously much worse for resorption risk than just a year or some months of treatment. So the longer the treatment duration, the more likely a patient would have root resorption. The other really important in fact, the greatest thing is intrusion. Intrusion was associated with 11 times greater root resorption than controls in the study. So the other thing to learn is that if you’re going to treat this patient, treat them with aligners, treat them slow, but hopefully not too long duration, I guess, hopefully, maybe manage relapse cases only anything more complex than that send it to an orthodontist. It’s not worth your time as a GDP, the risk is too great I’d say and therefore to additionally reduce your risk, you would prevent intrusive movements, you would prevent intrusive movements and you actually would, if possible, prevent extrusive movements because extrusion was associated with a 4.5 times greater root resorption than control. So avoid long treatment. Avoid heavy forces, avoid intrusion, avoid extrusion.

So if you want to check that out, get joined the Protrusive Dental Community has so many great gems and pearls shared by the community there. That’s all the questions I had time for today. The next episode is on suturing. I’m very excited to share that. And I’ve got so much other great content. I literally just recorded with Ed McLaren the other day, and I’m so excited to share ceramic selection with you guys so you know how to choose your ceramic in 2022. That’s upcoming as well. So thanks for catching this AJ002. Thank you for putting up with my very hoarse voice. Appreciate you listening all the way to the end. I’ll catch you in the next one
Hosted by
Jaz Gulati

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