Lingual Infiltrations and Adrenaline for Cardiac Risk Patients (Part 2) – PDP144

[Jaz]
What I love about bread and butter episodes like these is the engagement it gets from the community. So you guys, Protruserati on the Instagram app @protrusivedental, had some really interesting things today.

Like for example, Cony, Cony Caravotas we met in Brighton and also at the Finlay Sutton course. Hope you’re doing well. She said that she hasn’t done an ID block since 2009, so that was 14 years ago. That is bloody impressive, right? I told you I do about one a month. Coney hasn’t done once in 2009. She said, buccal articaine infiltrations all the way.

And there were loads of comments just like that about how we’re all getting really good results with buccal articaine. But of course, Dr. Wayne Williams suggested that it’s only really appropriate for single tooth procedures. But I know many of you, including myself on many occasions, use it for quadrant dentistry in the lower molar.

Now, I wouldn’t use it, like I said in the previous episode of people with large bones, large heads, big bony exostosis. But for the average person, I think it does work well in my hands, and that’s what it’s all about. Don’t change your technique if something is working well, unless there’s more efficiency, more safety involved, or lower cost involved.

But if you’re not compromising a lot on those areas and something is working well in your hands, I wouldn’t change anything about your protocol as long as you’re safe, efficient, and cost effective. So more power to anyone who’s getting great success with buccal articaine. I personally will say that by putting it in the attached gingiva.

Now, something that, @ohheyitsdoctoralbert also said on Instagram is the importance of attached gingiva. I find that the attached gingiva retains it, and probably by going in the attached gingiva I’m entering that coal area that Dr. Wayne Williams talked about in the first episode, and therefore, these em mystery canals, these holes in the mandible to allow our anesthetic to get in the right place.

So if you are not getting good results like our colleagues are with buccal articaine, consider putting some in the attached gingiva instead of just going supra periosteal near the apical area and expecting it to diffuse into the bone. Like Wayne said in the last episode, it’s not as simple as that. One thing I have changed about my technique after talking to Dr. Wayne Williams is although I’m very slow with my anesthetic, I sometimes speed up towards the end, for a subperiosteal, which I won’t be doing so much anymore.

But I think the key point was just always keep it slow and reduce the pressure. Another thing actually I will be changing because a lot of things I won’t be changing because it’s working well on my hands.

But a big thing that will be changing is as a result of this part two, you’re going to find it pretty interesting what happens in part two. Just have a listen or have a watch if you are on the Apple, YouTube to this part. I’ve got a few videos I’ve taken of me giving a lingual infiltration and like if I’ve done a crap job and I’m doing something dangerous.

Say it live on air. I mean, it’s, we’re not live, but you know what I mean. Say it on the podcast. It’s a learning thing for me. And I thought, okay, wow. I get to show someone who’s so experienced and written about local aesthetics and I get to show you this video. So, please, if I’m doing anything wrong, I want to learn and I want everyone else to learn if I’m doing something wrong, if I’m doing something right, please, please let me know as well.

So a cool segment of this episode will be me showing you those videos, which I’m very excited and nervous about. So actually show Dr. Wayne Williams the technique of giving a lingual infiltration the way. I have seen a specialist oral surgeon do it. The story is that I was shadowing a oral surgeon and I saw him do his very interesting lingual infiltration where I thought it was at the time, and I’ve sort of copied him.

Okay, he’s a specialist. He knows what he’s doing. So I’ve been copying him and I’ve been getting, yeah, okay results. But I had this doubt in my mind, is this something that could be made safer? And is it really respecting the anatomy in the best way? Is there a better way that I could give this lingual infiltration?

Do you remember way back when if you’re a original Protruserati, you might remember episode 37. That was in, that was three years ago. My goodness. We had Dr. Shaz Memon and what we did is live on the show. I got him to critique my website. Right. And it was embarrassing because my website sucked and it still sucks cause I haven’t updated it.

Right. But it was an interesting and cool thing to do and I was happy to do it. And it was embarrassing for me, but it’s fine. I’m happy to put myself out there for you guys. Now, I did the same thing here. But with a really high quality clinical video that I recorded showing him how I do my lingual infiltrations.

Protrusive Dental Pearl
And so the Protrusive Dental Pearl is, don’t do what I did. The technique that I showed him is not a recognized technique and it shouldn’t be used. And even though that oral surgeon did it, Dr. Wayne Williams, whose opinion I highly trust, told me there’s a better way, which that’s why I certain I’m going to be changing my technique now.

I’m not going to just expose myself and embarrass myself willy-nilly. This is only for Protrusive Premium members. So if you’re on Protrusive Premium, you’re going to see the whole bit where actually entire video, the same video that Dr. Wayne Williams saw his reaction to it and his feedback in terms of what I should change.

Main Episode:
And I’m happy to make a fool of myself and share that with you guys. So if you’re on Protrusive Premium, you’ll get to see all of that. If you’re not, then it’s okay. I still love you. I still respect you, but you have to understand the feedback that I got in the video that I showed him was absolutely golden and well worth the cost of a $9 per month. And to give you a teaser, this is the way that Dr. Wayne Williams reacted.

[Wayne]
I’m sorry, I’ve never seen that described anywhere. I’m not sure it’s needed. I’m not sure what the benefits of it are. Yeah, I’m not in favor of that technique.

[Jaz]
So let’s join Dr. Wayne Williams to continue on that cliffhanger we left you at, at the end of part one.

Should we fear the large headed redhead? Is that true or false, that myth, or is that real? And any strategies to help the large headed redhead if it’s true.

[Wayne]
So I’m not aware of the redhead. The large I can kind of understand cause it comes back to an anatomy and physiology and understanding and that’s always my starting point on all the courses I present on all the teaching I do globally.

It’s always going learn the anatomy, number one. Then understand the physiology, then the chemistry, and then we go to the techniques. But it has to be in that audio. Don’t try and go for the techniques and then work your way back. You have to have the anatomy, physiology, and pharmacology behind you. But, so there’s different ways I would approach a red head from now that I’ve heard you and Lincoln say that.

And great program by Lincoln, by the way, with yourself as well. High respect to him and basically the guys I’d be more interested in for you and other colleagues in this country would be class three. People with Class three, mandible. Well described in, I brought this textbook along because this is what changed my life 25 years ago.

[Jaz]
Just for the listeners, can you just say the name of it for the listeners that were listening.

[Wayne]
Sorry because I know it’s Hazards of local Anesthetic Injections by Daniel Barnard. Same type of Barnard who did the first heart transplant. Possibly a family member, gentleman who I learned almost everything I know about local anesthesia from certainly the hazardous approach to it.

A valuable, valuable piece of literature. But basically he speaks more about class three patients having a slightly higher lingular. And then certain racial groups, Chinese people have higher lingular, Asian type orientations in terms of their lingular position is slightly higher.

And certainly some of our tribes back in Africa have different positions and much stronger class three mandibles and thicker bone of course. And of course you make your judgements according to that, but often what people miss is look at an OPG. If you’ve got an OPG of a patient, you can actually see the lingular often on that OPG, and you can then figure out from a cusp position in the mouth, you take a cuspal measurement on the OPG, say that the upper six, and you measure, that’s 2.3 centimeters.

23 millimeters. Then immediately you can then take your fingers and estimate a 2.3 milimeters. Put it in the mouth and say, right, that’s where the lingular is lying up at that point. And then get yourself to go in. Just giving yourself landmarks, local landmarks.

[Jaz]
That is a fantastic tip that someone could apply and that’s very useful. So really case by case. And so maybe not the redhead, we don’t know, but, you know, large anatomy, thicker cortical plate kind of thing. That may be a concern, but I guess the real clinical tip there is just aim higher because they probably have a higher lingular and that is a real applicable tip.

[Wayne]
Yeah.

[Jaz]
Now we talked about anesthesia failing. One of the reasons I do a lingual infiltration is to prevent that. Right? Now you’re probably going to say that don’t bother with lingual, it doesn’t work. Okay. That’s totally fine. I’ll stop my practice immediately if you say it. But, what are your thoughts on lingual infiltrations? To supplement and bolster your buccal. Is there any signs behind it?

[Wayne]
So again, if you’re using the mesial distal approach, then the lingual approach be probably becomes less utilized and less valuable. I think a couple of things with lingual. First of all, I’m not sure that I share concern necessarily about anatomy in the lingual domain.

So yes, we’ve got the lingual artery. I think the more bigger concern is the access to the lingual area. So you’ve got a tongue in the way. You’ve got a a curve of Spee and curve of Monson with your teeth curving in and the lower jaw. So you’re trying to get under something rather than with clear vision if it’s directly in like that, whereas from the outside, everything’s open.

On the inside, you’re trying to get, your visual access to the lingual is always limited, nevermind your tactile and dextrous access to that area is extremely limited. So I think your ability to deliver drugs successfully in the lingual, the main, certainly in the lower jaw is limited palatally in the maxilla.

It’s a completely different ball game. I do predominantly palatal anesthesia that’ll shock you a little bit more. So I’ll probably do more palatal anesthesia than I do buccal anesthesia in the palette. And again, you know, if I ever get to share some of my anatomy lectures and work we’ve done, it is unbelievable how porous the maxilla is.

But to come back to your lingual, I’m not scared of the anatomy. But I am more concerned about access. So the only time I would ever go lingual is if I needed the soft tissue anesthesia as opposed to dental anesthesia. So I would always use buccal infiltrations as you’ve suggested. And I still think that’s an excellent technique, but it has to be using articaine.

I wouldn’t bother too much with lidocaine, lignocaine, and I definitely wouldn’t 2% drugs, and I definitely wouldn’t be bothering with a non-adrenaline Mepivacaine, Scandonest and others. It’s just got no value in my opinion. You need the 4% articaine for those.

[Jaz]
Amazing, well, should we do the bit where, I’m going to expose myself a little bit and honestly, it’s all a mentoring. It’s live.

[Wayne]
Go for it.

[Jaz]
I’ll show you it and if I’m doing something silly, please tell me. And I’m happy to learn. And we could talk about bending needles. Cause there’s one of them. I’m going to show a bend because one way I got around my access was, cause I don’t want to hurt the tongues, so I had to bend it.

And I know that’s a big no-no. So please feel free to tell everyone watching this thing, don’t do what Jaz did, and that’s totally cool.

[Wayne]
Jaz, I can already tell you that. Don’t bend a needle.

[Jaz]
Never bend needles.

[Wayne]
Don’t ever, ever, ever, ever, ever bend a needle.

[Jaz]
Do as I say.

[Wayne]
Don’t Ever bend needle.

[Jaz]
Not what I did.

[Wayne]
The reason I have to say that is from a legal perspective, if I ever went on any platform and suggested even bending of a needle was safe, when it breaks off, I don’t want to be the one in court helping that person get outta trouble.

[Jaz]
Absolutely.

[Wayne]
Honestly. So again, the wand comes in, we bend the wand a lot. The whole hand piece can bend so we don’t have to bend the needle, but I would never, ever, ever bend a needle, ever.

[Jaz]
Great advice. All right. Have a look at this. Okay. So I’ll describe it for the audio listeners. I’m using my mirror to really keep that. I’m getting a good, good, sort of purchase of that tongue. And I’m really moving out the way. This is the case where I was doing a quadrant of dentistry, second molar restoration.

[Wayne]
Nice. Safe device. Very good.

[Jaz]
Yes, we’ve got the Safety Plus device. I’m keeping it out the way, I’m just entering sort of alveolar mucosa just adjacent to the mandible and lingually, I’m just going very slowly.

And sometimes when the patient swallows it will actually assist your needle to go inside, basically. So sometimes it just that little swallow and then it allows it to go in. But I’m very, very, very careful to keep that tongue out of the way. I’m just describing for the audio listeners really.

And then, yeah, I’ll just be here for probably about another 15, 20 seconds. So I’ll just keep that rolling. And there we are. I’m out. So that’s my technique for doing a lingual infiltration. I’ll now show the one for that we shouldn’t do, guys. This is the one where I bent the needle, so please don’t do it this way because this way I was really struggling with the tongue, so I thought, okay I give the buccal as I usually do, and I made a video about that.

Here we are. Here’s the bend. So don’t do this guys, please. Right. But here’s what I did. Oh, let me just switch off the volume here. Okay, there we are. So, but same thing, and it’s clearer of you exactly what I’m aiming for. And I’m getting some soft tissue anesthesia. Here I was using a thermacut bur to trough through the lingual papilla because it was deep margin elevation and whatnot.

So that’s what I’m doing. So some people get very worried about the anatomy. You are less worried about anatomy. You’re rightfully quite concerned about the access, which is tricky.

[Wayne]
Well, I’m now a bit more worried about the anatomy. I wasn’t quite sure that you were in the floor of the mouth when you used the term lingual. You’re actually in the floor of the mouth where you are right now, so that’s completely different to me. I was assuming you were on the attached mucosa in the lingual aspect.

[Jaz]
No, I was, as you saw, I was at the junction of the floor of the mouth. So what do you think? I’m happy to stop it like tomorrow if you tell me that’s-

[Wayne]
Jaz, I would never, ever, in my entire career, I’ve never given an injection where you were giving that injection. And I think the point I’m really trying to make there is you don’t need to. So maybe maxilla facial surgeons, if you’re taking a lesion out in the floor of the mouth, yes.

If you’re taking something out where you can’t get to it through any other means, yes. But that as an adjunct or as a primary or even secondary anesthetic technique. I’m sorry, I’ve never seen that described anywhere. I’m not sure it’s needed. I’m not sure what the benefits of it are. And maybe someone, you know, would perhaps-

[Jaz]
The context of where it was taught to me is on the same vein of, you know, how far can we go with articaine infiltration, right? So, it was to, you know, it was first taught it to do extractions without an ID block, and therefore you don’t get that lingual anesthesia. So I would give the buccal, let’s say it’s a second molar.

Buccal in the attached gingiva and then also the lingual. That’s where I first started to do it basically. And then now, and again, I might do it just to enhance, cause I was doing a quadrant there, so I was like, let me just get an, there’s a clamp and whatnot. We might be on the lingual gingiva and I haven’t done, ID block here.

So its a way of me getting that lingual sort of anesthesia. But, from what you said, in terms of the other techniques that are available that perhaps is not necessary, but for an extraction, you were just given ID block anyway. Right. So-

[Wayne]
I would absolutely give an ID block. But again, only in my context because I know it’s going to be successful and in the 0.001% perhaps in our particular case, we fortunate. I’m very fortunate in the sense of if I do get a failure there, I just give the CIA technique as a supplement, by the way.

So I would always give an ID block for all extractions in the posterior segment. Now it is very interesting because, and I’m sure you’ll find this interesting, so our perio visiting periodontist who puts in thousands of implants every year, he’s highly highly qualified and experienced.

He was one of my teachers at university and now works for me, which is brilliant. I can tell him what to do. It’s fantastic. And basically when he puts implants into the posterior mandible, he prefers not to give an ID block. And the reason he doesn’t want to give an ID block is he wants the patient to be able to respond if he’s getting close to the inferior alveolar nerve.

And that’s all, despite using CBCT planning and guided surgery and all the rest of this. But his view on that is he wants to give a very localized soft tissue supra periosteal, perhaps a slight lingual, but into the attached gingiva rather than the floor of the mouth where you were. The floor of the mouth where you were, I think does hold inherent danger.

I think you can have going, there are spaces down there where if you’re going to press that needle too far and you made the point of the patient lifting their tongue and then you lose control of how deep that needle is because it then penetrates, Yeah, potentially more deeply. So, I’m not in favor of that technique.

I’d much, much rather have teachings around the CIA technique and around supraperiosteal and around proper inferior. I think if people are trained properly in the inferior alveolar block technique, we should be using that with articaine.

[Jaz]
Well, I certainly feel much better today. I’ll speak to you about ID blocks in general, and you know, cause you see all the stuff that we talk about and what’s posted on social media and also in the BDJ, et cetera.

People are dentists, young dentists especially, are more and more afraid of ID blocks. But I feel I can tell you now, I thank you so much. Cause I feel much better about it. I felt like this is the right thing to do to phase out of ID blocks. I thought that was the right thing, but from speaking to you, I feel way more confident about going back to ID block. So I thank you for that.

[Wayne]
Oh, pleasure.

[Jaz]
The next question I had is adrenaline being avoided for certain patients. Is that a myth or are there some patients that we should be avoiding adrenaline on?

[Wayne]
Very good question, and again, I think appeals predominantly to our younger colleagues, newly qualified colleagues. It’s just amazing going through this talk today with you, Jaz, about all the fear. I almost feel like we are in a political arena here for a minute, but you know, there’s just all this fear mongering and don’t do this and don’t use that drug and this will happen and that will happen. Well, the first point about adrenaline is I think we lose sight often of kind of where we are with that.

It’s a produced adrenaline is produced by ourselves in our suprarenal glands. Our body produces adrenaline and tons of the stuff. Much, much more than you can ever imagine to be in a local anesthetic cartridge. So we produce a lot of adrenaline, so nobody in the world that I’m aware of to date is allergic to adrenaline.

[Jaz]
Yeah, I’d love to be a fly on the wall. Who told you that? That I’m-

[Wayne]
And who’s still breathing? So those are not breathing. They might not be, but they might have been allergic to adrenaline because then that’s what causes the problem. But the truth is no living human being can be allergic to adrenaline not one that I know of.

So any patients that do tell you that at any point you need to probably run away because they’re a ghost or something else. So once you’ve told the patient that, I think we have to be highly respectful of the fact that a lot of patients will tell you that. As a result of a potential vasovagal attack previously with the giving of adrenaline.

And what will have happened there was the patient will have a vasovagal, they’ll feel faint, they’ll pass out, they’ll feel all the symptoms related to that, and at the end of it all the doctor will go. The dentist will go. Oh, I’m never using adrenaline for you again. That’s what I used for this time in the dent, and the patient goes, oh, it’s because you used adrenaline, right?

So that’s where the problem starts. The next thing is almost all of those, almost all of those cases, are intravenous or intra arterial injections. So because people are not aspirating and because aspiration is so non-effective in almost all anesthetic devices other than the wand, even all the quick sleeper, all of those, because they have a certain mechanical aspiration technique, the wand aspirates from a foot piece.

So I take my foot off a pedal and the device aspirates, every other device has to have a hand attached to it. Some way or another, or a needle or a lever pulling. So you’re always going to have the potential for a false negative, but the point I’m going to make here is adrenaline if given at the right speed, go and look back at the textbooks.

How fast, minimum times 60 seconds for any cartridge of local anesthetic. Time yourself, colleagues, time themselves. If you’re ever giving a full cartridge of anesthetic in less than 60 seconds, it’s a long time. Trust me, a lot of my anesthetics take me three or four minutes to give. And I warn the patient of that before the time.

I say this is going to take much longer. However, when I take that needle out and my drill goes straight into their pulp.

[Jaz]
I’m going to replay this to my nurse. Cause I’m that slow as well. And then my nurse, sometimes they just, like every other dentist I’ll work with is just give the damn injection, you know, so –

[Wayne]
so if your needles in the wrong place, you’re into arterial or if you intraosseous even and you go in at speeds that these drugs are not designed for, you’re going to have vasovagal attacks. And it’s then when people go and it is then when the adrenaline will play a role. So the adrenaline will play a role in those cases.

It’s less likely to be a problem. In fact, almost not going to happen. If you are using mepivacaine 3% or you’re using, you know, any kind of non-adrenaline drug, Citanest and Felypressin. And we need to come back to separate point in a moment. Cause that’s a whole different ballgame that I’m going to share something with you with.

But the truth is with adrenaline, given safely, given correctly with good aspiration, making sure you’re not intravascular. Given over at least a minimum of 60 seconds for 1.8 milliliters of a drug. If it’s a larger cartridges, the 2.2 s that we have in this country, we need to go even slower. Minute to minute and a half, then adrenaline usually doesn’t play a role.

Now, I have in my entire practice of thousands and thousands of patients, it come to me from all over the world. I have two patients who I don’t use adrenaline on, and neither of them are proven medical cases of not to use adrenaline, but I’ve experimented with that, if you want to use that word, where I’ve gone, listen, I’m the guru of local.

I’m going to show you, I will get this right slowly and all the rest of it, and they still have some form of excitement or reaction. It’s not a vasovagal attack, but they don’t feel well. A lot of it could be psychosomatic. I can’t prove that it is or isn’t psychosomatic, but in two cases I say to the patient, look, we are going to use Mepivacaine or Scandonest 3%, no adrenaline.

However, if you require a procedure that requires a long period of time that I need profound anesthesia, and you’re going to be jumping around in the chair. Then we are looking at sedation or we are looking at hospitalization or we looking at something else where I can then monitor your blood pressure and pulses rate to the pulse oximeter, and I can make sure that you’re not having some reaction to this adrenaline.

But effective anesthesia, it has to be, and I think that’s a give. The takeaway from this concept is you have to always put good, profound anesthesia ahead of everything else. Now, even if that means that a patient has a mild tachycardia for 30 seconds, whilst you’re giving that anesthetic and you prepared for that, you monitor it with a pulse oximeter, the patient knows it’s going to happen.

And it’s all over and you can control it. And again, slowly and small amounts, but I’m not aware of anybody who genuinely can’t have adrenaline.

[Jaz]
Well what about cardiac risk patients or cardiac health? Cause that’s a, the one where, if someone’s had a heart attack sometime ago. They have a stent and then automatically we think, avoid the adrenaline as a thing is. Is that a thing?

[Wayne]
Wow. Okay. So I want to just read something to you because this is something I’m faced with quite a lot. People ask this question, so I’m going to read you two things if I may. Citanest, is that something you’d possibly consider or would’ve considered in?

[Jaz]
We have that, yes. Absolutely. We were taught that if they can’t have adrenaline because they’re cardiac risk and maybe give a different type of basic constrictor.

[Wayne]
So Jaz, I’m going to hold up four cartridges, especially got these ready for this. talk

[Jaz]
Oh, amazing.

[Wayne]
Now two of them are the same thing. They’re just arctican in a 1.4 or a 2.2 mill cartridge. Only because manufacturers run out, et cetera, et cetera. And then the other two are Lignocaine, one in 80,000 adrenaline. And the other one is the Scandonest 3% Mepivacaine no adrenaline. You will not see Citanest or Felypressin in my clinic. And you haven’t seen that for at least 20 years, at least the last two decades.

And the reason for that is, and I quote Felypressin – Citanest is the active ingredient of Citanest. Felypressin acts on the venular side of circulation with no significant cardiovascular response. It can be seen as a less of a risk in compromised patients. That’s according to respected colleague John Meechan in New Castle, Robb and Seymour in their book, pain and Anxiety Control for the Anxious Patient, however, according to Robinson Pit Ford and McDonald, in their book, local Anesthesia and Dentist.

However, Felypressin has been shown to cause coronary artery, vaso constriction, and cardiac arrhythmia, and is thus not a benign alternative to adrenaline containing solutions in patients with cardiac disease.

[Jaz]
Wow, I had no idea.

[Wayne]
No Citanest. No Felypressin in my clinic. Forget the risks it holds for pregnant patients. If you’re keen on delivering a baby that’s use a bit of that towards the end of the pregnancy, that could help. But you know, the octapressin and felypressin in there. But the truth is honestly, yeah, I would-

[Jaz]
So we don’t want to give an alternative in Felypressin because of those reasons you mentioned, but in that patient who has some sort of a cardiac background, then also avoid the adrenaline by giving the plane. So there is a, there is, yeah. Fine. So there is a –

[Wayne]
Scandonest, yeah. Scandonest 3%. So for a patient with a known cardiac disease, and there are a whole list of those, I won’t go into all of those, but they’re well described in the literature. But for patients who are genuine or recent cardiac, major cardiac surgery and you’re having to do an acute procedure, you’re in a difficult position.

Because what actually happens, and this is back to the point I made about effective anesthesia, is that every single time you hurt that patient, by not having effective anesthesia or long-lasting anesthesia, their adrenaline levels go sky high anyway by self induction. So their own body produces far more adrenaline into their body system than you could have injected.

And therefore they’re having an adrenaline attack anyway, but it’s just self-induced, so profound and efficient. Anesthesia takes precedent in our clinic for all procedures and should I believe in most clinics, even if that means slow, careful, calculated deposits of adrenaline if you’re having to do a procedure over a long period of time.

My point is, if you doing a small DO composite, Use your non-adrenaline containing drug irrespective. You know, I mean, I don’t use it. I use articaine and lignocaine for almost everything, but on the occasion where I’ve had the doubt, yeah, I’d use that. But if a patient’s coming to me for an extraction and I’m in a 50 50 doubt, they’re getting articaine in a controlled, calculated fashion.

[Jaz]
I’m just in awe. This hour’s gone so quickly. It was an absolute pleasure to speak to you today, Wayne. You were so hard hitting. You were so direct, and you really reassured me in lot of the areas, which me and the Protruserati already had some misconceptions, and that is fantastic.

Wayne, please tell me, like you’re doing, you’ve done lots of teaching in the past. You’re getting into it again. Because I know you got busy with clinics and stuff. Where can, how can we learn more from you?

[Wayne]
So, yeah, contact me directly, Jaz. I’m happy for you to give out my details. My email’s usually the best way to get hold of me. I’m one of those guys. I get up at 4, 4:30 in the morning. You can always contact me between 4:30 and 8:30, but 8:30 I start with my patients most four days a week.

But I do clear my emails on a daily basis, and you’ll know that from your experience with me. But I clear my emails every single day and if anybody gets hold of me by email, If you have my mobile number somewhere, you’re always welcome to contact me. I do in-house training courses for practices, but I don’t-

[Jaz]
What kind of stuff do you teach there? Like Akinosi gal, that kinda stuff?

[Wayne]
Yep. Gow-Gates, Akinosi, the CIA. A lot of it around the wand, of course, but a lot of what I teach will be anatomy, physiology, and pharmacology. That’s the basis of all the courses that I present.

[Jaz]
Wayne, I think any practice is looking for like a team day, right? In terms of something for the clinicians. Local anesthetic is such a, an underlooked at, but such a key thing, you know, rather than sending your associates to a composite bonding. And I think there’s enough of that going back to basics, local, an aesthetics. So do consider giving Wayne a shout because, I just, I’m sure you guys have as well. Absolutely love this conversation. Thank you so much. Anything else you wanted to add?

[Wayne]
No Jaz. As I say, you keep up your good work. I’m in awe of your work and all your Protruserati, I think is the term. I’m very proud to be one of those and please keep up the good work and thank you again for the opportunity.

Jaz’s Outro:
Thank you so much. Well, there we have it, Protruserati. I just realized at the beginning of the episode in the intro, I didn’t even introduce myself. So if you are new to the podcast, my name is Jaz Gulati and thanks so much for making it to the end. That’s pretty cool. Lots to be learned from that episode.

Dr. Wayne William is full of cold hard facts, which might upset some people because you’ve been doing things and they’ve been working and then suddenly someone throws a bombshell of information, which kind of goes against your paradigm, but you have to respect the anatomy, the physiology, and the pharmacology.

But ultimately, remember, like I said right at the beginning, it’s what works in your hands. So if you’re getting good results and you’re safe and you’re cost effective and you are efficient with LA, that’s what matters, right? If you can do it in a pain this way, all the better. So I’m sure you took away a few practice changing gems, but some things that you might just respect.

But if because it’s working in your hands, that’s totally cool to continue the way that you’ve been going. Now, if you want to claim some CPD, then of course as a premium member, you can answer a few questions and get CPD for this episode and the last one and hundreds of others. Otherwise, I’ve got a lot planned this summer.

In terms of podcast episodes, we’re expecting baby number two. Gosh, by the time this episode comes out, it’ll be a few weeks away, so wish me luck guys for baby number two. I hear it’s twice the lows and twice the highs. So if I do go radio silent for about 10 to 12 days, you know where I am at. So my team’s very supportive.

We’ve got a lots of podcasts in the pipeline ready so that when I get busy with baby, there’s still your protrusive fix to keep you occupied in those long and lonesome journeys. Thank you as ever for being a Protruserati, and I’ll catch you in the next one.