Bleeding Sockets Management CLINICAL Exodontia – PDP166

And, until I noticed a little pumping and spurting coming from the base of the socket, and what had happened was, by, after curettaging, I’d hit an accessory vessel that had found its way superiorly into the socket and this wasn’t just a little ooze bleed, this was actually, like, an arterial bleed from an accessory vessel. Now, when I saw that there’s a few different ways you can manage this.

Jaz’s Introduction:
Hello Protruserati, I’m Jaz Gulati, and this was such a geeky chat about extractions. Like, recently we had a geeky chat on onlays with Dr. Ash Lifts, and she was brilliant. And Dr. Ameer Allybocus today covers real world exodontia.

Like, imagine you have a bleeder. What are the best ways to manage a bleeder, both in the short term and in the long term? And unlike all the papers we read or all the other lectures we go to about this, we actually go straight for the kill. Like, what I mean is all the information that you could gain from guidelines.

Like there are some guidelines in the UK, there are guidelines all around the world, basically, wherever you practice, about how we should manage patients who are high risk of bleeding. Now, it didn’t feel as though it was worth your time to just revise all the guidelines, because you guys can just easily pick up the guidelines and read them.

So, the kind of scenarios we discuss are the ones whereby you’ve done all the medical history checks, you’ve done all the medicine checks, and you’ve got a normal bleeding wrist patient, yet they still bleed afterwards. Or they call you eight hours later and they say they’re having a bit of a bleed. How do you manage those scenarios? And then much, much more. We just really go in deep into all the facets of exodontia.

Protrusive Dental Pearl
The Protrusive Dental Pearl is very relevant to Exodontia and something that we actually discussed in this episode. It’s about having a plan. So for example, for a crown prep, you might have a plan that looks like this. It’s just from the top of my head, I haven’t written this down.

So it’s like a medical history check, consent procedure, give LA, take a putty impression so that you can make a temporary crown afterwards, remove all the old restoration and caries, build your foundational core restoration. Then do the occlusal reduction, interproximal reduction, create a chamfer. If you’re getting shoulderless like I do nowadays, no shoulder, but a shoulderless preparation all the way around, etc, etc, etc.

Like you have a step by step plan. And sometimes like, hey, if I have lots of bleeding from the gingival sulcus, I will use this retraction cord. However, if I don’t have much bleeding, I will use this technique. And if I have this issue, I will take a scan. If I have that issue, I might take an impression.

You see, there is a plan, but then you account for, well, if this happens, then I’ll go in this direction. And if this complication happens, I’ll manage it like this. And actually, sometimes there’s too much bleeding and you decide that you stick on a temporary crown. And that initial plan of taking an impression is no longer valid.

So you have to be able to ready to change your plan. So it’s the same with extraction. So, just like that, with extractions, we should also have a plan. So, for example, you’ve done all the medical history, consent, you’ve given your LA, what type of LA will you give for this patient? And then you go in with, okay, I’m gonna start with luxating and then I’m going to start elevating.

And if I see some movement, then I’ll continue, but if I don’t see any movement, I’m gonna start sectioning. I’m going to section in this place and that place. Now, if I mess up my section, here’s how I’ll recover it. Which root will I remove first? And then if a bit more of the crown breaks, How will I retrieve that?

At what point will I raise a flap and remove some bone if required? So just like that, having a plan really helps the extractions. It’s something I never really appreciated, but it’s actually so important coming from a restorative background. Now, just before we join the main episode of Amir, I am letting you know that around about 10, 15 minutes time, I will be playing a ad for a fundraiser as some of you might have seen on my Instagram.

I’m raising money for a little girl called Nafisa. She’s one year old and she’s the daughter of a Protruserati, a dentist, just like you. And she suffers with SMA type one. I’m going to go into it in detail, but please, if you can support this fundraiser. It would really mean a lot. And if you’re not in a position to support it financially, would you consider please sharing it?

Okay, so the best place to share it would be for my Instagram. I’ll put all the show links below, but that is coming. I really, really want to help Sakina and her daughter. So please do stay tuned for that. Oh, and by the way, the first part of this podcast, we discuss our journeys, our growth, our failures, and talk about career decisions.

So I hope you enjoy that, but if you’re here for the bleeding complications, then I would probably just skip to minute 15, because that’s when we start talking about bleeding complications. Either way, I hope you get what you want from this episode.

Dr. Amir Allybocus, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Amir]
I’m great, Jaz. It’s great to be here. Thanks for having me on.

[Jaz]
Well, it’s nice to reconnect with you. I remember you from like back in the dental days, like over 10 years ago. And it’s nice to go full circle. What have you been up to, man? Like where are you now? And what was your journey in the last 10 years or so like?

[Amir]
Okay. I’ll try to summarize it as quickly as I can. Yeah. So I started at Birmingham. Graduated, DF1, and then I just fell into the Max Fax Oral Surgery world, and I existed there for three or four years. I worked at Eastman, Great Ormond Street, UCL, Queen Elizabeth, and then I found myself in an interesting position.

I started locuming, and I was working at the Royal Cornwall Hospital as an SHO and through circumstances, I’m not going to go into they ended up without a staff grade and I’ve always been passionate about oral surgery and we can talk about that as well, but, they just said, we don’t have a staff grade.

You’re pretty good. Do you want to do it? I was like, okay. And at the time I was just being thrown in the deep end. I had my own GA list, my own sedation lists, and I was three years out at this point. And I’m leading who checklists and things and running GA lists and luckily I had good support from the consultants and I learned from some fantastic people and they always had my back.

I didn’t have to call them that often, but it was nice knowing that I had that support and that’s where I really cut my teeth in oral surgery, so to speak, pun intended. And on top of that, I was then training DCTs because it was a training hospital as well. So and you learn a lot. When you teach people, so you have to go and research and find out what you’re actually talking about.

[Jaz]
So it’s a taxonomy of learning, isn’t it? The Bloom’s taxonomy of learning, the highest is when you’re having to teach this stuff, then you know, you’ve got to pick it up a grade or two. So that’s good. And then where have you been in the last couple of years then?

[Amir]
Yeah. So after that fellowship leadership program under Jason Wong. Amazing seeing behind the scenes of how everything’s run and he’s doing a great job as interim and hopefully he’ll stay on and work things for us from the inside, which would be great. Then I am joined UK sedation. So I think you’ve had someone on the podcast before Roy Bennett on a sedation podcast really good. So I work with him and Rob and that led me into this kind of visiting dentist role where I visit as a sedationist and I also visit practices and performing oral surgery.

So treating anxious patients, extracting complicated teeth, dealing with patients with complex medical histories. And amongst that, I’ve spent some time teaching at Manchester Dental Hospital as well, supervising the students there. And yeah, now where I’ve landed is basically eye masks, visiting oral surgery, visiting sedation and mentoring as well.

So I have a lot of people who want to learn oral surgery. And I mean, I’m not a professor of oral surgery, but when it comes to GDP exodontia then I have a thing or two I can pass on and then. And I’m always learning as well because I’m teaching, so it’s great. And I work with a lot of great consultants who are constantly teaching me, so it’s the circle of life in, in our profession, I guess. And that’s where we are now.

[Jaz]
Amazing. And just so we get some inspiration from your position, you’re not on the specialist list, right? For oral surgery, who are you?

[Amir]
No. No. I had my heart set on it, but life happened and it didn’t work out that way. It’s got to the point now where I’d love to be a specialist, but, I’m what you call a dentist with a special interest or a specialty doctor in oral surgery.

And to be honest, through the work I’ve done and through the sedation, seeing all these amazing surgeons in different practices, it’s really opened my eyes to other specialties. So specialty isn’t off the table, but I don’t think it’ll be oral surgery. I think it’s probably going to be. Something I’m less experienced in, so I get more out of the training, but that’s a whole other conversation.

[Jaz]
Okay, brilliant. Well, that’s inspiring in a way because you said that you had your heart set on it and I had my heart set on restorative specialist for the longest time. I said, I would definitely want to be a restorative specialist. And then when I experienced hospital dentistry and I compared it to the private world and this has nothing to do with finances, it’s purely the pace of work.

And I asked myself, what is it that I really want out of this training position? And I just wanted to be able to do transformative, rebuild the dentistry. I want to be able to treat tooth wear cases. I want you to be able to do restorative dentistry at a really high standard. And I realized that actually, I didn’t have to go through all this training to be able to do that.

And I look at you and you see, and I’m not putting words in your mouth, so please correct me. But a lot of those people I speak to are aspiring oral surgeons. They just want to be able to take out teeth, like amazingly wisdom teeth and feel competent and not feel with flaps and exodontia and do a great job with that.

Not everyone wants to do all the niche things within oral surgery. It’s a bit like restorative specialist. Not everyone wants to do the obturators for oral cancers and stuff and that kind of stuff. Those who do, they’re saints and they’re amazing. We need those people, right? So do you now feel as though that if you were to speak to a younger colleague who has their heart set on oral surgery specialty, what advice would you give them in terms of what is it you actually want from that desire?

[Amir]
I think you have to, the way I always explain it to people is if a bunch of aliens visited the planet and they were like, right, what do you do? And it’s well, I’m a dentist who’s really good at taking out teeth. And what do you do? I’m an oral surgeon. So, what’s the difference when it comes to exodontia?

So there’s an asterisk there. I think people get really bogged down with titles and waiting for an institution to rubber stamp you, but at the end of the day, oral surgery is about doing. And some of the best surgeons I work with oral surgeons. Now, having said that, the best surgeons I’ve ever worked with are maxfax surgeons, certain maxfax surgeons.

So I have the utmost respect for specialists and oral surgeons. I’ve worked with a lot of amazing oral surgeons who I sedate for and beyond Exodontia, they’ll do the cysts and the bimax osteotomies and things like that. The really advanced stuff. And I think what’s happening in our profession, and you’ll notice that with the dental therapists as well, we’re increasing the scope of practice for a lot of members of our team.

And as dentists, we’re evolving into those, what we used to look at as specialist roles. So taking out a horizontally impacted wisdom tooth doesn’t have to be the realm of the oral surgeon anymore. That can be the realm of the dentist who spent a lot of time training in oral surgery. And that allows the specialist more time to focus on those larger cases. And those more complex cases because-

[Jaz]
Impacted canines. Another one, right? Exposing canines and stuff. A [jail] is-

[Amir]
Even exposing canines and extracting ectopic canines. If you have a good mentor, you can learn to do that. And it can be within your scope of competence as a GDP. There might be a lot of oral surgeons watching this screaming at the computer right there saying, no, it’s not.

But honestly, it. At the end of the day, it’s doing. It’s getting your hands dirty, and it’s just doing the cases with a mentor who can give you some feedback and guide you. But what I’d say to young dentists is if you want to do oral surgery, do oral surgery. Don’t wait for someone to give you permission to do oral surgery. Do it with a mentor, or have a backup plan in case it doesn’t quite go the way you want it to. But just do it, is my advice.

[Jaz]
Great advice there, in terms of getting stuck in. My own personal experience with oral surgery was, did dental core training in oral surgery, and I watched and I saw a lot of surgery.

It was like monkey see, monkey do kind of thing. And had my hand held as I was doing. It was more watching than doing, I’ll be honest with you. So a lot of the doing I had to do at the edge of my comfort zone and growing and growing and growing and take a few calculated risks here and there and some continuing education.

So now I’m very good at cherry picking which surgical wisdom teeth I will do. I’m very happy to do that as a GDP and most teeth I look at and I can, I know they’ll be tricky, but because of the ability to section and elevate and raise and not be afraid of raising a flap as a GDP have so much confidence going into cases which would previously, I’d be really scared of, and I know a lot of our colleagues are really scared when it comes to exodontia.

They kind of refer a lot of things which they should be taking out. And I think sectioning and elevating really gives you that ability, that confidence to tackle teeth that otherwise you wouldn’t be able to. Would you agree with what I’m saying here?

[Amir]
Yeah, I mean, what surprises me is, you have people cutting crown after crown, and that’s a very technically complex thing to do, if you think about it, because you’re working in millimeters, and you’re working around occlusion and various other factors that you have to take into consideration.

If you can cut a crown, you can section a molar, it’s much more blunt than a lot of the fine restorative work that people do. Now having said that, as an IMAX practitioner, I’d say, I get a lot of teeth that people have had to go at. And the problem I have with that is, first of all, it makes it a lot more difficult for me to extract, although it keeps me on the edge of my game.

But the other thing is, it can traumatize the patient sometimes, so I’ve had patient, I had one patient who came in and we’d given the local anesthetic, but he’d had such a bad time with the previous extraction that he just didn’t want to carry on and just got out of the chair and wanted to leave and he’s been rebooked to have it under sedation.

So what I’d say is, I think GDPs should be having a go and extracting teeth and learning, but try and find a colleague or a mentor who’s happy to be in the room and be ready to come in if it doesn’t quite go so well, or even just be there in the room with you. And that’s how I learned, and that’s how GDPers can learn as well, and for my part, I’m always happy to come to practices and work with people who want to learn.

And at the same time, I still shadow oral surgeons, and procedures that I’ve done a thousand times, I’ll still do it with them, because I’ll see a different technique, or a different approach, or a different way. Because I’ve worked around the country, I’ve got to see a variety of approaches for the same procedure.

And it means that when I get stuck, I’m running through the options in my head. I’m running through the playbook and looking at how can I get myself out of this, based on what I’ve seen in the past. So, a lot of words salad, but the key points are find a mentor, don’t be afraid to take on challenging teeth, but just make sure that you have a backup plan and that’s pretty much it.

[Jaz]
I’ve spoken about this before and I won’t go to too much of it, but on a theme of oral surgery episodes, I remember being two years qualified and attempting a lower first molar, decoronating it and I just couldn’t get the roots out and I felt embarrassingly I had to let the patient go and then when I did it a second time I had to quickly send it to my principal who was five miles away and the patient had to drive 45 minutes there and the big lesson there was, I just spoke to my principal, I was like, what did you do to get the tooth out?

He said, it was easy. I just had to section the roots. And that stuck with me, right? So much, which is why I bang on about it so much. I was like, I need to, why haven’t I learned this? I need to learn this. And when I learned that I haven’t had those issues since, but what I would say, I completely echo what you’re saying.

I mean, is that if you’re a young dentist or just not experiencing enough extractions as you would like to be, not as confident as you would like to be. Please, don’t shy away from it, take the calculated risk, but please have someone next door pre arrange, have that chat, hey, you know what, Thursday, I’ve got a tricky one, can you just make sure you’re on standby to rescue me, should I need rescuing?

That’s the best way to grow. And I think oral surgery would really benefit as a whole in terms of our skill level. If we just had those calculated risks with someone there to help us and mentor us, it would be great. So I totally echo what you’re saying here. Today, though, is about bleeders, right?

Let’s make it very clinically relevant. That’s why it does. I mean, we could go down. Initially, I was thinking, should we talk about a pixaband and warfarin? And what should we do if they’re on aspirin and a pixaband and that kind of stuff? And you know what? A lot of this stuff is on guidelines. And I realized that the Protruserati are an international audience all over the world.

And the guidelines that we have in our little island might be different to what they have in a lot of other countries. So I was thinking, okay, maybe we save that to the end. Let’s go real world, right? Literally, this happened to me the other day. Actually, this scenario, I’m going to say for scenario number two, and it happened to me the other day.

We’ll talk about that. Scenario number one is you take out a tooth, right? Let’s say it’s an upper molar. Okay, take it out. For me, typically an upper molar, I just 80, 90 percent chance I will be sectioning it and then removing it as a traumatic as possible. That’s just what I do nowadays. Interestingly, I just like to know from you is that do you just routinely go in and section or do you just try to attempt forceps extraction first?

[Amir]
Depends how many patients I have on my list.

[Jaz]
Such a truthfully spoken answer.

[Amir]
Yeah, I’m honest, man. I’m telling you how it is. And it depends what they want at the end of it. Like, if a patient wants an implant, then I’m gonna do my I’ll always do my best to preserve the buccal plate and make sure there’s a lot of bone left and be as atraumatic as possible. But if this is being added onto their acrylic denture, they’re not that bothered. They don’t want to be in the chair too long.

They hate the sound of drilling and they just want the tooth out ASAP. Then, I’ll look safe, I’ll get movement, and I’ll gently achieve. Mobility and slowly lift that tooth out. But, gold standard is just section the teeth, if you can. but it’s an analysis of the x ray, sometimes the roots aren’t spread out enough to clearly section.

You might end up making a mess. If the roots are really close together, you might be better off. Like, say, if you use better off just luxating and elevating out. So, you have to look at the pre op x ray and just decide, is it worth sectioning? Cause let me put it this way.

There’s not a hard and fast rule. You don’t have to be dogmatic about this. You approach each case individually. But yeah, sectioning, if you can get good at sectioning, it just makes it that much easier. And just practice, practice, practice. And when you extract teeth, look at, just analyze the roots, look at them.

I still mess up my angles. I’ll go and section a tooth, and sometimes I’ll be a bit too distal, I wouldn’t have got the angle quite right. And I’ll beat myself up about it. You’re not going to get it perfect every time. I don’t. Oral surgeons don’t. MaxVax consultants don’t.

[Jaz]
Hey guys, it’s just Jaz interfering with a timely message. Me and Amir have just discussed the importance of sectioning and elevating, but so many dentists reach out to me saying, I need more help. Are there any courses that I can go on? And sometimes you want that knowledge now, then and there. You don’t have to wait for the course. So what I’ve done is recorded lots of extractions that I’m doing.

That demonstrate the through the loupes view of sectioning. I’m going to call this sectioning school. It’ll be kind of like the isolation library on the app, but it’ll be video after video after video of exodontia specifically sectioning roots. If you want to stay up to date with this, then join protrusive. app or hit the subscribe button below. So when it comes out, you will be first to know.

Now to a more serious and kind of sad message, but I really need to hear and support. So over to the next message now. Protruserati, I’m very emotional right now, and there’s gonna be like a little bit of an emotional plea.

So really, listen. Now this is really, really important. I’m a father of two boys. One is age four and one is five months. And what I’ve learned as a father is you, you look for milestones, right? So when they’re about four months, you start to look, okay, are they able to roll over? Are they able to turn around, roll over.

And around about six months, can they support their neck fully and can they sit up properly? And you look, and these are special moments as a father, as a mother, and some of you listening, Protruserati, might be grandparents, or some of you don’t have children in your life yet. If you want them, then something to look forward to, right?

Now, imagine you have a child who at four months is not rolling over, yeah, and is not able to support their head very well and you get to six months and still no rolling over and then you take him to the doctors and you find out that they have a rare disorder called spinal muscular atrophy, SMA.

Now, this doesn’t affect my son, who’s five months old, Sihan, it affects a little girl called Nafisa. Now, Nafisa is a one year old girl in Tanzania. Now, what has this got anything to do with you guys? Well, she’s the daughter of a Protruserati. Just like you guys listening right now. You listen to this podcast, you have a connection, we learn, we grow together, and it’s amazing the community we’ve built.

But Sakina is a dentist, and we’ve been speaking by email for some years now, but recently she emailed me asking for help out of desperation. Because Nafisa was born and diagnosed, she was diagnosed at six months with SMA, spinal muscular atrophy, and basically there’s a gene called the SMN1 gene, and basically it means that she has a weakness in her muscles.

Now, because of this missing gene, she’s not able to feed or even breathe properly. And so sometimes she needs ventilation. Sometimes she needs to use a nebulizer. A lot of times they’re aspirating because even the swallowing is affected. Now, there is a treatment possible for Nafisa. It’s basically like this genetic therapy.

And this genetic therapy is made by a company called Novartis. It’s a Swiss based company and it’s quite popular in America and Europe. And basically if this therapy is given to Nafisa before the age of two, there’s a 90 percent chance that she’s going to live a normal life, which is just amazing the prospect of it.

The problem is this therapy costs over 2 million US dollars. They’ve actually sent me the bills and the statements and stuff, and I’ve seen it and it’s quite crushing to see that because I’m putting myself. In the shoes, like, put yourself in the shoes of Nafisa and Moise, who’s Nafisa’s father, who’s actually a doctor and he works many months in the US and then he comes home to Tanzania and he works in the US to make enough money to be able to keep the dream alive so that we can get this genetic therapy for Nafisa.

If this genetic therapy isn’t given to a child with SMA by the age of two, then what happens is atrophy takes place and it’s not going to be successful. So, guys, we need to raise money for Nafisa. Right, because I had a good think about it and as a father, I’m putting myself in the shoes of Sakina and Mois, and if my child or if your child was affected by this rare genetic disorder and you suddenly had to raise two million pounds, two million dollars, wherever it might be, wouldn’t you find any way possible?

Any means possible to try and raise this money. And this is exactly what they’re doing. Tanzania is a third world country. We’re trying our best. And can you believe it? That even in this country, they’ve raised over half a million dollars already. So there is so much hope that we need to raise around about 1. 3 million dollars in the next six to eight months to reach the goal to be able to help Nafisa.

And I know that’s a lot of money and Sakina and Moyes, they know that this is a lot of money. But if it was your child, wouldn’t you be doing the same thing? And this is exactly why I’m coming to you guys, because I always imagine, I put myself in their position.

Like, if my child was diagnosed with this, I would be doing this exactly right now. I’d be pleading to you guys, can you help? Can everyone, can all the dentists listening to this, just club together and donate 10 bucks, 50 bucks, 100 pounds, wherever you can. As a practice, do a fundraiser, do whatever you can, because I truly believe, and Sakina believes, and Moise believes, that if all the dentists club together, if all the doctors club together, we’ll make more than what’s needed, and we can have many more children.

But for Nafisa, this girl who’s just so smiley and so innocent, and her parents are so determined to help her, and they’ve done such an amazing job so far. I really want to help them through this platform, through this community that we’ve built, Protruserati, that I really, really want you, I really need you to donate to this cause. So if you can spare any cash and donate, you can help Nafisa.

We give her ventilation with, via a bio machine we provide her suctioning, sterilizations imagine the stress that we are going through as parents. she’s very passionate about it.

If you are a parent, if you want to be a parent, if you’re a grandparent, if you can just put yourselves in the shoes of these parents. Asking for money to help Nafisa, or if you just love learning from this podcast, even just for that reason, could you just please go to the GoFundMe page and donate today?

I would really love for the legacy of Protrusive Dental Podcast to be that we club together as a community to help Nafisa. So please go to the GoFundMe page. I’ve actually made this page protrusive.co.uk/nafisa. That’s N A F I S A. That’s her name. Okay. So if you go on her Instagram as well, it’s smiles for Nafisa.

Every episode I’m going to keep you guys updated on how we’re doing in terms of how much money we raised for Nafisa. At the moment of the time of recording, it’s six, just over six hundred thousand dollars raised. If this is one thing you donate to this month, make it this one. That’s protrusive. co. uk forward slash nafisa Thank you so much, Protruserati.

[Amir]
So don’t shy away from it. And it’s not always going to be perfect, but it’s going to make it a hell of a lot, a lot easier if you get good at it. So.

[Jaz]
It reminds me of something I was taught as a DCT, which is, I mean, it sounds very routine to you. I’m sure I’m here, but a lot of people listening, right? There’s especially younger colleagues. This is a really good lesson or surgery. I think is like have a plan. I know it sounds really funny. And then you’ll be like, yes, I heard this one before. Like having a surgical plan, even it comes to exodontia is really important. I never appreciated it when someone, when my neurosurgeon first taught me this, guys, I was like, oh, okay.

Usually I just start with the luxators and I see what happens. I just make it up as I go along and you know, see which way the tooth’s going. And you’re running on adrenaline. You’re just figuring out what’s the next move, but actually if you should actually go in with, okay, I’m first going to try this.

If this works, I’ll do B. If this doesn’t work, I’ll do C, for example, right? And so when you get good at sectioning, it actually opens up a whole new pathway to you. So for example, that case who suggested that if it’s part of a denture and they don’t like drilling and you’re going to try and go for four steps only.

But then if it was to fracture, then because you can fall back on, okay, now I’m going to go on my plan B, you can still do that efficiently. Right? So it’s really important to another reason to have that skill is that actually there’s only so much you can do with having just one skill set, one way to do things.

One way to skin a cat is not going to be enough. There’s many ways and we need to explore them all. And that’s part of your growth in oral surgery. So anyway, you remove this tooth, right? Back on the bleeding. You remove this tooth. And typically get the gauze wet a bit. And for it’s dental students. I was taught to wet the gauze because-

[Amir]
 I’m glad you said that.

[Jaz]
Yeah, yeah. Good. I’m glad you agree as well. So if you don’t wet the gauze, okay. And then you take it out afterwards, the blood clot will stick and it’ll come out. Right. And that’s like an instant dry socket. Right. I dunno if it actually works like that, but, okay.

Let’s assume it is. So yeah, let’s wet the gauze. Let’s sort of squeeze it, get the most of the moisture out, get the patient to bite on it. We are not squeezing sockets. Oh, do we? Can we agree on that?

[Amir]
Yes. No, I don’t know where that came from, but when I was in dental school as well there, we’d take a tooth out and they’d be, and now squeeze the socket.

[Jaz]
Yeah. Yeah. I was taught that too. What was up with that?

[Amir]
I’m like, now I’m like, why would you do that? That’s the worst thing you could possibly do. But yeah, don’t, everybody stop squeezing your sockets, okay? Just let it go.

[Jaz]
Yeah, you’re doing it, that poor buccal plate has had enough damage, so let’s not be squeezing it, so fine.

[Amir]
There must be periodontists, they’re looking for work.

[Jaz]
Yes, must be. So, you got the gauze in, right? And then, typically, look. I like to think I give it two, three minutes, it probably ends up being a minute, right? In the real world, right? Because time and stuff, if I ordered it, right, I’m sure it’s probably a minute.

It feels like five minutes, but it’s probably a minute, two minutes, right? And usually take the gauze out and I have a look and I’m just observing and I do my diligence here for 15, 20 seconds, sometimes 30 seconds, especially their medical history is a bit funky. I’m just watching. Okay. And things are stable, happy days, give all the post op instructions and off you go.

But if you have someone who’s just is just filling up and bleeding still, just talk us through the management of that scenario and how that could potentially escalate and what should be our next steps.

[Amir]
The worst thing that you can think is it’s probably fine. So it’s probably fine. The worst three words when it comes to post op for oral surgery. If it’s pooling and it’s not like jelly like, then it’s not grafted yet. And it might be fine, you might send them away, it might be fine. You might just say, you know what, just keep biting on the gauze, go home, throw it away in 20 minutes, it’s probably gonna be fine. But it’s those patients that end up continuing to bleed late into the night.

That you have a problem. So what I would do in that situation is get a surgical suction tip, and just hold, I, myself, sometimes the nurses don’t have the dexterity for this, I’ll hold it just over the edge of the socket, and I’ll just see how much is that pulling, how much blood is that pulling out of the edge of the socket, and if it’s not really lifting up, then I know that it’s pretty secure and solid in that socket.

If it’s immediately suctioning away, and I’m seeing bone in the base of the socket, then I know that blood isn’t taking, so, I’ll suck all that blood away, and then I’ll get another wet gauze and place it on top. And I’ll just say, look, wait in the waiting room for 15 20 minutes, we’ll check on it again.

And that’s the best thing to do at the end of the day, just make sure that there’s no active bleeding before you let them go. Later on I’ll get into an anecdote to explain why that’s important, and also why it’s very important to have illumination in loupes when you’re looking at these sockets as well. But we’ll go down that road.

[Jaz]
Okay, sure. So I agree with you. Get the patient to wait 50 minutes outside. And actually tell me if you do this routinely or not. I’d be interested to know is, there’s all surgical sponges. When I do my section of it, I like to cut them into three, put them into each root.

I don’t know if that’s more effective than doing one whole sponge or whatever. And then sometimes just suturing as well, doing like a mattress suture. I’d like to do like an X shape. Where does that come in in the pathway? Is it better just to do the wait 15 minutes, and you won’t need a suture either, or is it some people might jump straight into the suture. Any advice on that?

[Amir]
That’s a really good point, Jaz. Like, if you’re ever not sure, I always, I always [err on], if I’m not sure, I’d rather suture and not need it than need it and not have it. Let me put it that way. So, if it doesn’t look like it’s, the blood is stopping, then a suture is always worthwhile.

The downsides to a suture are this. One, more food retention, plaque retention, and irritation to the soft tissues. And it might be a bit more uncomfortable and be a little tight, while the patient’s healing initially. But the upsides are you drastically reduce the chances of further post operative bleeding.

So for sure, if you’re ever not sure, it’s always worth placing a suture. And the things I’d say about that are number one, please don’t squeeze the sponge, and stick it into the socket. Because the whole point is you want that space in the sponge for the blood to imbibe and fill. And a lot of people squeeze these sponges and shove them into the root sockets and and then it’s not doing anything.

It’s just sitting there and it’ll just fall out eventually. So like you just said, cut them in, cut them into shape and put sponge in each socket or if you have a large socket, one or two sponges without squeezing them, just gently place them into the socket. So what I’ll ask my nurse to do is, or myself, I’ll suction the socket.

So that there’s no blood in there. I’ll place the sponge in, and that will allow the blood to infiltrate and set within the sponge. And then, like you said correctly, I think the best suture is a cross mattress suture. I try to put that in as much as possible.

[Jaz]
I just call it, like, an ex suture, but it’s got a what’s the proper term for it?

[Amir]
I don’t know, I’ve heard people call it an ex suture yesterday, I was speaking to a periodontologist, he calls it a cross mattress. So basically what you’ll end up with is a cross over the socket. And hopefully we’ll have a video for you by the time this is uploaded of how to do one of those. I’ll just find a way to do one tomorrow, pick an unlucky victim and they’ll have a cross mattress suture. So.

[Jaz]
Excellent. Now with that, some silly questions that we want to just for the young colleagues, I’m putting myself in a position, less experienced, I’m thinking, Could you, is it ever worth just putting in the sponges and then and that’s it, no suture? And then also, just putting in the suture without the sponge?

Just can you do either or? Because some people say, you know, I don’t have the sponges or I didn’t have the time to suture. Do we know about if all those other things work or do we just have to do it together?

[Amir]
If you don’t have a suture, you only have a sponge, then just place a sponge, if, or vice versa, if you don’t have a sponge and you just want to place a suture. The thing about a suture is if you do that cross suture, or if you don’t want to do that, do two simple interrupted sutures, it’s going to form a lattice over the top of the socket that will allow the blood to congeal on and clot and form some kind of barrier. And on top of that, when the blood clot does form, those sutures are going to keep that blood clot in place, or at least help. a little bit.

[Jaz]
But really, we’d hope all our colleagues have access to sutures and maybe some people who have access and just have been out of practice. Sometimes, you haven’t done something so long that you feel nervous doing it. And I would suggest that if you’re in that category, when it comes to sutures, it’s so, so important.

Like I know everyone’s doing like veneers and composite veneers and aesthetics, but you know, we’re dentists at the day, right? The most basic thing is getting people out of pain, removing teeth. So it’s always a good skill to just top up with the suturing and regain your confidence in that.

[Amir]
Grab a banana, peel it. Stitch it back together. That’s the best way to learn. And it’s very easy. Placing a suture is very straightforward. Now, when you’re placing a suture, the things that can get you flustered are a lack of vision, and if there’s blood everywhere, that’s gonna make things difficult for you. So, my three tips for suturing are number one, as much life as possible, and ideally wear loupes if you can, so you can see what you’re doing. Number two-

[Jaz]
What mags (magnification) do you use?

[Amir]
Take a guess.

[Jaz]
2.5?

[Amir]
7.2.

[Jaz]
Oh, right, okay, right. Okay, that’s way overkill, man.

[Amir]
I got it for restorative and then as a, they’re the Bryant refractives, and my nurse was like, I bet you can’t take a wisdom teeth out with those, and I was like, yeah, okay, hold my casta, let’s see what happens, and I’m addicted to it.

You get addicted to magnification, the more you go up, you just want more and more, so, but yes, you can do oral surgery with 7. 2 times loupes, 2. 5. When I was coming up, though, I wasn’t using loupes at all, because if I wore loupes, my MaxFax consultants would laugh at me. They were collecting dust in my bag for years, and then one day, when I was working in practice, I left them on.

And, yeah, it’s mainly the light, really. That’s the thing that helps the most. Just having light, not having to angle a chair light that’s going to cast shadows and things that’s going to mess up your vision. So definitely invest in loupes if you’re not using them. And I’m surprised by how many dentists still aren’t, but it’s going to save your back and it’ll save your eyes.

[Jaz]
It’s true. And with the light comment, Mr. McArdle, Austin McArdle taught me back when I was a DCT at Guys, If you can see it, you can remove it. If you can’t see it, it’s a bit like, and I often feel like this, right? I’m a little bit guilty of losing my wallet, like a lot, like if my wife’s listening to this, she’ll be like, she’ll be laughing right now because it’s a thing in my family that I just lose my wallet a lot.

I’m actually gonna get one of those apple air tags and leave it in my wallet. I have one of those have the same problem you have in your wallet as well.

[Amir]
My house is always beeping.

[Jaz]
Yeah, I know. I have one of my keys, right? My Samsung one. Anyway, so, it’s a bit like when I’m going into a bag, right? And I’m just feeling around for my wallet in my bag, right it’s hit and miss. Whereas I can shine my phone light in it. And then I’m much more likely to find it. It’s the same like that with teeth, right? When you’re actually removing distobuccal root is so much easier and better if you get the seat position correct, the light, the magnification, it all matters.

[Amir]
To be honest, Jaz, when, when I take teeth out, I think to myself, how did I do this without loupes? Like, I have no idea what’s going on. But then if you forget your loupes at home, then that’s the other problem. So maybe keep a backup pair in the practice.

[Jaz]
I’ve got three sets, man. I’ve got three sets for this exact problem. If I break one, I’ve got another one. And honestly, I can’t do without it. So I had one day in practice, like three years ago, I had no loupes and it was like the worst. I said, I never want this to happen again. So I invested big time. I’ve got three sets now.

[Amir]
I had to, I sent mine in for repair and yeah, I had to go back to 2. 5. So I still had loupes, but it was just like, I felt blind. You get dependent on it. So. And then maybe every now and then take a-

[Jaz]
Not the worst kind of dependence as well. So, it’s okay anyway, but back on track. So you got the, no, no, no, please. I’m enjoying this. I’m enjoying this. We got the suture in and that’s going to help and that should sort most of those scenarios out. So let’s say that that scenario is done. Now, before I talk about the one whereby everything looked good. And then four hours later, you get a phone call, which is what happened to me the other day. Is there anything else you want to talk about that immediate management? Before we go into the-

[Amir]
Well, I just want to go back onto two other tips with the sutures. So, like we said, magnification and light, number two, very important, if you can’t see what you’re doing and it’s bleeding everywhere, suture everything, but don’t just suction, wash it out, rinse it out.

A lot of people don’t do this. It’s bleeding, blood is clotting all over the place, the teeth are coated in blood, you’re getting flustered. Get you three in one, no air, but just water and just give it a good wash, wash everything away. So you have a nice clean.

[Jaz]
Okay. I’m so glad you said that. I’m so, so glad I said that because there’s a segment of the podcast or something that sometimes do, called, am I naughty if? And because I’ve done this for, and I’ve got some videos on YouTube, do this, I do that. Right. And some of like, wait, shouldn’t you be using like sterile saline and stuff? And I was like, oops, should you be always doing that? And I discussed it with Chris and he was a bit blasé about it. It was like, it’s okay. Don’t worry, it’s better than not using anything. Ideally use sterile, saline. Any comments on that in the real world?

[Amir]
What do you think these people are going to do when they’ve left your practice?

[Jaz]
Yes, exactly.

[Amir]
They’re going to go and they’re going to have a cup of water from a non sterile bottle and they’re going to have some tea and the mouth is one of the dirtiest things in our body. So, I don’t understand this thing of like I use surgical hand pieces, always, and I use saline when I’m doing that, but when I’m washing the mouth out, the 3 in 1, the Alpron water is still better than whatever it is they’re going to ingest later on, so, personally, I think it’s fine.

[Jaz]
I’m so glad you said that, so I feel better about that, and I’ve had no complications in the last, so many years of doing this, and it just makes sense, the mouth already is full, and yeah, that is cleansed water we’re using, and it’s probably cleaner than water.

[Amir]
I could go on a whole tangent about all that.

[Jaz]
Yeah, I’m sure there’s some people who might disagree with us, but, I think we’re more in tune with the real world, so that’s fine, yeah, wash out, so carry on with that point, sorry.

[Amir]
Yeah, so what, give it a good wash suction everything, and then you’ll just have a clean field of view, you can see what you’re doing, and third is, don’t get flustered, take a break, if you find your heart rate elevating, and you’re not thinking straight, it’s okay to just put a little bit of wet gauze in, stop, and turn around, have a little bit of water, have a think, look at the x ray, take a few breaths in and out.

I still do it sometimes if I find myself getting a bit het up. And that’s just gonna help you focus more. And just remember, it’s okay to be nervous and fearful, because that’s when your senses are most heightened. So that’s when you’re going to be focusing the most. Just make sure you have a clear mind when you find yourself in that state, because that’s what fight or flight is. It’s focusing on the things that matter. So those are my three tips for suturing and dealing with blood in the moment.

[Jaz]
Amazing. And if any speciality, any subspecialty that has resulted in elevated heart rate and adrenaline is definitely oral surgery. Well, in my experience anyway, so yes, totally agree, my friend.

[Amir]
So grab the tooth out, sutures are in.

[Jaz]
Yeah, sutures are in. And then usually that’s fine. Anything on that before we then talk about the one that everything looked good, but then four hours later you get the phone call or because usually, I mean, we assuming the medical history is all clear.

This is all assuming that they’re not on two different types of in an anti platelets and all that kind of stuff. This is all like the standard, our daily normal patient, right? So this is that will use you to do the trick in my experience and your experience as well. Right?

[Amir]
Yeah, fine.

[Jaz]
So the one that you took out upper molar. And everything looked great. Okay. You took out the gauze. It looked amazing. Looked like a nice jelly clot. You don’t get any oozing. And obviously you warn the patient. A little bit of oozing is normal. Okay. And it’s a mixture of saliva and sometimes it looks worse than it is and whatnot.

But you get four hours later, you get a call saying, yeah, it’s still bleeding. Is this normal? And then the other day, the way I managed it is I said, okay, well, did you bite on the gauze that I gave you? Cause I always give gauze and I’m sure that’s the standard protocol, right? We should be giving gauze.

And she said, yes, I bit on it for two minutes and it’s still bleeding. And I said, okay, well, listen, you need to bite on it for 20 minutes. All right. And then so she did that and that was it. Done. Right. Okay. So no other issues. I called her back a few hours later. Yeah, everything’s fine now. So that was as simple as that.

Any other advice? Because in your roles in MaxFax departments, oral surgery, et cetera, you probably speak into general dentists and giving them some advice. And one advice that I have learned and given before is the teabag. Tell us about the teabag trick. Is it legit? Do you know about this?

[Amir]
Now that you, that’s the first time I’ve heard of the teabag trick in years, so I’ve never used the teabag trick myself.

[Jaz]
It’s different from the teabagging we would do at uni, just for those guys who are just sniggering and laughing at the back, because it’s completely different.

[Amir]
This isn’t Halo teabagging and coagulation.

[Jaz]
So the teabag trick, right, which I’ve used with a few patients. Yeah, I know, right. Just make a cup, I said, make a cup of tea. Right? Make a cup of tea, love. Take the teabag out, wait for it just to cool a little bit so it’s still really warm, maybe not hot, but really warm still, and then bite on the teabag.

[Amir]
So my instinct is not to do that because when you put anything warm in there, it’s going to cause vasodilation, which we don’t want. We want vasoconstriction. I wouldn’t do that. Maybe a cold teabag.

[Jaz]
But yeah, well, but the reason to read the rationale, what Professor Brooke explained to me at the time, this was years ago, is the tannins. It’s the tannins that cause enhanced clotting reaction. And the few times I’ve had to advise this and I call back and everything’s fine now kind of thing. So it’s work. It’s supposedly a thing. It’s not something that you would recommend usually at the moment. That’s totally cool. And so what are the kinds of advice that you would be giving?

[Amir]
Well, now that you’ve said that, we have a lot of tea bags lying around the practice from the nurses, so I’ll ask them to stock them for post op.

[Jaz]
Obviously, it’s something the patients do at home. Everyone’s got tea.

[Amir]
Yeah, yeah, yeah. No, I might try that. So, let’s rewind. So, first of all, post op instructions are so important, and I’ll send you a link to my post op instructions. I take out 20 teeth a day, so what I’ve done is recorded a YouTube video with my post op instructions that I show them and send to them.

And you made a lot of really good points, so first of all, explaining what is bleeding to a patient. Your socket’s gonna ooze. And the way I explain it is, imagine you put a little bit of Ribena in a glass of water and the whole glass turns purple. It’s going to be the same with your mouth. A little bit of bleeding is going to cause a lot of red saliva.

That doesn’t mean it’s pouring blood. It just means there’s a little bit of oozing and that’s normal. Bleeding is bright red clumps forming on the socket. And we’ve all seen it when they come back and they’re these big bits of jelly over the socket. And you pick them up with your suction and they’re all clumped together.

That’s proper post operative bleeding. So it’s defining that to the patient, first of all. I advise people not to spit or rinse for 48 hours. I advise them to swallow everything. They can brush their teeth, but let it just dribble out into the sink. Don’t rinse and spit. And then after 48 hours, start gently swilling with salt water.

[Jaz]
You’re stricter than I am. For me, it’s 24 hours, then you can start the rinsing. You’re stricter, but to be safer then that’s fine. I like that.

[Amir]
Yeah. And then, avoid sucking on anything. Straws. One of the reasons not to smoke say I vape. Is that okay? Any suction is going to create negative pressure in the mouth that will pull out blood clots, so avoid sucking on any straw.

A lot of people, there’s this instinct I’ve been operated on, I’m going to suck on a straw. Drink from a cup, avoid sucking on anything. And then, it’s difficult dealing with people who like to spit. For some reason, it’s come from their body, but it’s suddenly disgusting to them and it has to be removed.

So they just start spitting and spitting. And just explaining, the more you spit, the more it will bleed. It’s counterintuitive, so trust me, please don’t. And then, like you said, make sure they understand that if they’re gonna use that gauze, make sure it’s wet. So, when I was working the Royal Cornwall Hospital, we used to do 48 hour on calls.

So we’d walk in on Friday morning, get handed the bleep, and we’d walk out on Monday morning. It was nice, because in the winter, you’ll get, like, one to two calls a night. In the summer it was crazy because everyone fancies themself a surfer or some kind of, like, mandaneering genius, and you just get loads of facial lacerations and things from scrap scraping the seabed floor, like, falling, etc.

Anyway, that that’s I’m digressing. But I got a call one night, and it was this patient who had a tooth extraction. And they were very distressed, and they were still bleeding, and they’ve tried they’ve used the gauze, it’s not working, nothing’s working, they’re still bleeding, and I said-

[Jaz]
Did they use a teabag?

[Amir]
They didn’t use a teabag, no. I find none, like-

[Jaz]
Adjust, adjust.

[Amir]
So, I just said, okay, are you wetting the gauze? No, no, I’m putting it in dry, it’s not wet at all. Okay, wet the gauze, wring it out, bite down on it for 20 minutes, and I will call you back in 20 minutes. Waited 20 minutes, called them back.

Yeah, it stopped. Sometimes it’s as simple as that. They may not have actually listened to the instructions you’ve given them, so just be very clear with your instructions.

[Jaz]
And just like my patient, they didn’t do it for 20 minutes, they did it for 2 minutes.

[Amir]
Exactly, yeah, yeah. And they want an immediate resolve. And the other thing to bear in mind is sometimes you will come across people who are undiagnosed hemophiliacs, or who suffer from thrombocytopenia, or von Willebrand’s or something just because it’s not diagnosed doesn’t mean there are people walking around there who don’t have it, and you should treat every patient as though they may have a bleeding disorder that you’re unaware of, in the same way that we sterilize as though everyone has HIV.

Look at every socket as if they have a bleeding disorder and be very wary, because at the end of the day, yeah, you’ll have 99 percent of patients who don’t have any issues, but you’ll have that 1 percent that really does have a bleeding issue that isn’t going to be managed locally or through following your post op instructions and-

[Jaz]
The volume patients that you’ve seen over the last 10 years and extractions that you’ve done, I’m just interested to know, has this happened to you firsthand whereby they just kept bleeding and then you figured out, actually, yeah, you’ve got something going on?

[Amir]
I’m trying to think now that I can nothing springs to mind. Yeah, it is rare.

[Jaz]
I love your point. You have to be, keep your mind open to it. And then so should you give all that advice of the gauze, wet it 20 minutes and it’s still not happening. Then usually if you’re open, like if this was like a 9am extraction and you’re still there at 4pm, they can always come in and you can maybe at that point-

[Amir]
That’s the next point I was going to make, try and schedule extractions in the morning, if you can. So don’t book an extraction at 5 o’clock at night on a Friday. If you can avoid it.

[Jaz]
That’s the one that’s going to always go, yeah, yeah.

[Amir]
Well, or if you do have an on call service or have an agreement with a local practice, have a group of practices get together and say, right. This is our encore rota, etc. So patients have somewhere to go if there’s an emergency. One of the practices I work in in Birmingham is 24 7, seven days a week. I don’t think they been closed once for like 30 years, even through COVID. This guy figured a way to keep running, which means that if there’s an issue, a patient has access all the time.

Now, not every practice is going to run like that, but give them an option. No one wants to sit in A&E for three hours waiting for the maxfax SHO unless they have to. So it’s always worth having a plan, but if you don’t have that, try and schedule the extractions early in the day, and ideally early in the week, because their bleeding issue might not occur until the next day or day after that. So yeah, just try and tactically place your extractions in your diary.

[Jaz]
And so with that patient who continues to bleed, despite you saying, bite on the gauze, make sure it’s wet, be 20 minutes, and they continue to bleed. I mean, there’s really two ways to say that. Okay, now go to your hospital and get seen by the local maxillofacial to assess you, because you shouldn’t be bleeding.

At that point, we can talk about hospital management, tranexamic acid, all that kind of stuff. But is it worth, at the maybe four or five hour mark, then bring them in, numb them up again. And then suture it because you hadn’t because you didn’t need to you didn’t feel like you needed to at the time, is there merit? In that is that something that you would do in hospital when you when you have a bleeder like?

[Amir]
Yes. That’s the first line. So and the thing is like like we were saying earlier if you practice suturing you can do it. Like I don’t mean to be sensitive, appreachy, but these guys in hospital are dealing with mandible fractures, they’re dealing with, inpatients with cancer, all sorts of things. The last thing, or they’re dealing with huge facial lacerations, the last thing they need is the dental extraction socket that needs stitching that the GDP could have dealt with.

But you’ve gone and added that to their enormous list of things to do. Unless you’re in Cornwall, we have nothing to do. Send all your patients to the Royal Cornwall Hospital. Nah, I’m joking. But yeah, you don’t want to, like, unnecessarily burden Maxfax SHOs.

So yeah you’re still in practice, the patient’s still bleeding. So what I’d say is, like you said, get them in, give them some local anesthetic, irrigate and suction everything until the socket is clear again. Clearly something’s gone wrong with the formation of that blood clot in the socket. So just clear everything out, don’t be precious about leaving whatever’s in there in, and then place your sponge suture.

[Jaz]
And just from that point, Amir, how can you promote more bleeding at that point? You know, sometimes you want to create more bleeding.

[Amir]
Like you say always, curettage your sockets, Jaz. Very important. Absolutely. You’ve mentioned that point before on your podcast and it’s underrated. However. I’ll tell you a story about curettaging sockets that led me to some hot water, so, and a tip I learned as well after that. I’d watched one of your podcasts and you’d reminded me that it’s very important to curettage your sockets. So I’d removed the lower left six, with a very large abscess underneath it.

So I was curettaging away all this all the tissue and everything that was left behind. Everything was going really well. I was very pleased with myself. I was 20 minutes ahead on my diary. And until I noticed a little pumping and spiriting coming from the base of the socket and what had happened was by after curettaging I’d hit an accessory vessel that had found its way superiorly into the socket and and this wasn’t just a little ooze bleed.

This was actually like an arterial bleed from an accessory vessel. Now, when I saw that, there’s a few different ways you can manage this. First of all, apply pressure. If that doesn’t work, a tip I picked up, again, I should probably be asking someone, am I naughty if I do this? But you can cut this out if you disagree.

Ideally, use a diathermy to cauterize it if you can. If you don’t have that, if you have any bone scrapings, try and plug the hole with that bone and then apply pressure. If you don’t have the ability to do that, then get a, a ball ended burnisher. Heat it up on a flame, and use that to cauterize. Press it down on, on the bleed, and that will cauterize it.

And I’ve used that trick twice now, and it’s worked quite well. So that’s how you’d manage something like that. And if you don’t think that you’re getting any luck with that, then, at the end of the day, you’ve gotta call the ambulance, because this patient needs to be seen ASAP for diathermy. You don’t want to leave that.

It’ll ooze a little bit initially, but what you’ll find is the patient will wake up with a mouthful of blood later when you have these arterial bleeds, so don’t mess around with those. If you’re seeing pumping blood and you can’t control it, that needs to go to the hospital for diatherm.

[Jaz]
Amazing tip. I think someone is going to listen to this and then some years later, they’re going to face this because that could happen to anyone, right? And it’s not happened to me yet, but it’s so great to hear you say that and how you said cool. And so you did the heated instrument trick.

[Amir]
Yeah. Yeah. So he did up a ball in it, burnish it, cauterize, end of story. No problem.

[Jaz]
See, I don’t even know what a diathermy looks like. Like, does it look anything like electrocautery?

[Amir]
Very similar. So it’s like a little pincer and when they come together, they just zap, they zap around and they catheterize them. So you’ll see, I mean, if you’ve done a maxfax job, they use it all the time when they’re doing neck dissections and things. Funnily enough, after I’d done all this, I was speaking to the principal later and I was like, yeah, so this happened and I catheterized it, et cetera.

And she was like, oh, we have a diathermy. It’s in the cupboard at the back. We never use it. Like, I don’t know why I bought it. And I was like, it would have been good to know two hours ago. Nevermind. So yeah. Also be aware of what equipment you have in the practice and-

[Jaz]
But I’m so glad that you were able to share that tip. You know, I mean, if I’m just putting myself in your shoes at that point, I wouldn’t have thought of that to use the heat instruments. So I’ve learned something for sure that that’s amazing tip. And maybe one day. I need to use it. Obviously, you have to be safe about how you do this and stuff.

[Amir]
Yes.

[Jaz]
Microstructures, etc.

[Amir]
Caveat, ID nerve and canal and ID artery. Do not do that in that location because you may end up damaging the nerve. If you have a bleed from the ID artery, just try and get as much pressure as possible and that needs to go to the maxfax, so it has to be microsurgically dealt with.

You don’t want to end up causing a numb lip by using that tip. So this is for accessory vessels where you’re nowhere near any major nerve that you’re aware of.

[Jaz]
Okay, great. So in terms of, because I wanted to keep this very much real world clinical, I think we’ve done that in our chat and I had a good time chatting with you.

Anything else you want to add just on this topic? Because I’m glad we didn’t go too much into the whole medicine because initially we were talking about-

[Amir]
I’ve been revising the SD set. For days in preparation for this.

[Jaz]
Sorry, sorry. But you know you’re welcome at the same time ’cause now you’re so hot on that and that great. And I had this like, this thing about half, I was speaking to my wife, she’s like, yeah, I’ve got you on the podcast and we’re gonna talk about this. And she was saying, oh yeah, that’d be good. And yeah. And then talk about heparin.

And in my mind is like heparin. The last time I saw a patient taking heparin, I mean, that’s not real. That’s not exactly. So I think what we’ve covered, the ground we’ve covered in the last 40 minutes is going to really, really help the majority of dental practitioners and not just the whole more hostile kind of stuff, which maybe we’ll bring you back for a part two, I think.

So if you guys would like to see a part two, please comment below and let us know if you’d like to see a mirror and again, it was an absolutely brilliant. And I like your real world attitude and sharing the anecdotes and stories, which has been great. How can we follow you on Instagram, on social media, that kind of stuff?

[Amir]
Yeah. So on Instagram, it’s doctorbocus, you can put a text.

[Jaz]
Is that doctor dot? Cause we’ll put that.

[Amir]
Yeah, just D O C T O R, and then B O C U S, all one word, on Instagram, and I’m on www.referanxla.co.uk and I’m happy to come to your practice as well if you want mentoring and work with you on your cases, or you’re always welcome to visit one of my sites. There’s no charge for that or anything. Please feel free to come along.

[Jaz]
Oh, that is amazing. If there’s any Protruserati out there anywhere near me and you want to just build get your confidence back up and distractions, you’d be a great guy to shadow and observe. And what you offer is it sedation and you could be the backup guy. You could be the sedationist and the backup guy, right?

[Amir]
I found myself in that position. So I’ll be sedating for dentists and they’ll get a bit stuck. And I don’t like to be a backseat dentist until someone asks for my help, I’ll be in the corner just looking at my pulse rate, but yeah, sometimes people have needed help and I’m happy to guide people and just-

Sometimes you’ll be using an instrument wrong, you just won’t be, you know what, you won’t be looking at the bigger picture and a little tip will help. For example, one of the people I sedate for in Oxford, whenever I take a tooth out, I’ll give my anesthetic, and then the first thing I’ll do is get my probe, and I’ll use that like a luxator and do like a six point chart around the tooth.

[Jaz]
I do the same thing, I’m so glad I’m saying this.

[Amir]
It will start bleeding, it will start socket dilation, and it will also help me identify where are those points that I can sneak my luxator in? Where are my luxation points? And I’ll find little pockets and things through that. And I gave them that one tip, and their principal called me a week later, and they said he’s been using that for all his extractions, and it’s completely changed everything for him, and it’s such a little tip that you’ll pick up on.

So, I get all kinds of little tips myself, just watching oral surgeons and maxfax Consultants. So, we all need to talk to each other and always be prepared to learn and receive. It doesn’t matter how high up you are, or how far along you are in your career, you’re always learning. I’m still doing courses. I watched one of your previous podcast guests, the chap who does the wisdom teeth. Of course.

[Jaz]
Oh, Nekky, Nekky Jamal. Yeah.

[Amir]
And I’m watching his course and I do so many wisdom teeth, but I’m just picking up on so many things that he does differently to me and how he analyzes things.

[Jaz]
And I just love listening to his voice, man. Shout out to you, Nekky, once again, for just always just giving such a positive impression with everyone.

[Amir]
His course is awesome. I’d recommend that to a lot of people. So yeah, but in summary, what I’d say is that key things are if in doubt suture, practice suturing and stay calm and just make sure you have a nice, clear, clean field of view by irrigating and suctioning as much as possible.

[Jaz]
And make sure you have your backup gal or guy nearby. That’s it. Amazing. Amir, thanks so much.

[Amir]
It’s my pleasure, Jaz. Thanks for having me.

Jaz’s Outro:
Well, there we have it, guys. Thanks so much for listening all the way to the end. If you want to get some CPD, you just have to answer a few questions on the app. You know this already. The website is protrusive.app. It’s also on Android or iOS.

I think the best way that the least buggy way would be the web app, basically protrusive.app. Sometimes because my videos are so big, and the reason I have those videos hosted on the app is they can download it for offline use. But sometimes if you’re going through a lot of it and scrolling through a lot, it can be a bit sluggish, basically, because the videos are just so big.

So you always have the option of visiting it on the web app. Or, on the official app, on Android iOS, the login is the same. I want to thank our guest again, Dr. Amir Allybocus, for a lovely chat. I wanted to thank Team Protrusive for their hard work on this episode. So that’s Erika Allen Benitez, the producer and editor.

Rakesh Singh, who did the premium notes for this episode. And Mari Benitez, who’s in charge of CPD. Oh, and if you want to check out Nekky Jamal’s Wisdom Tooth course, which both me and Ali have done and we highly recommend, check out protrusive.co.uk/thirdmolarsonline. That way you get 15 percent off using the coupon code protrusive, and this is an affiliate link.

And the whole time I’ve been recording this intro outro, I’ve been distracted. My son has literally woke up early today and he’s trying to not be a nuisance in the background, but he’s just about made it. So sorry if there was any blips in the sound while I was recording this. I’ll catch you guys same time, same place next week.