To Drill or Not to Drill? – PDP027

Jaz’s Introduction: Hi, guys I’m Jaz Gulati, I will not keep you or bore you any longer. I won’t go straight to the episode with the legend that is Louis McKenzie. The story behind this episode is that some months ago, I posted on the two main UK dentist Facebook groups as a UK Dentist and For Dentist, By Dentist and I post some photos of anterior caries. And I got around about I think 5000 dentists in total to actually view it according to stats I have, and 1500 or thereabouts engagement, so people actually clicking on several comments, and it split the nation down the middle. Half of you wanted to drill the life out of these legions, half of you want to slap on some fluoride and review it. So we’ll find out what Louis McKenzie wanted to do was because he was anti lesions, approximately the crack line there. A lot of you are itching to get your handpiece out right now while you’re watching this. But you know, it’s a fun. It’s a fascinating topic really is. So I’m really happy to have Louis on. Please join us for this full episode on to drill or not to drill. The answer is around about somewhere halfway, if you want to skip straight to that, but why would you? There’s so much useful stuff that Louis McKenzie shares with us for caries detection process, and so much more insight and into the complexity of when or when we shouldn’t be drilling into teeth. The Protrusive Dental Pearl I have for you is something that I borrowed from Louis McKenzie, and it’s on my course, the resin bonded bridge masterclass, which, by the way, on the 31st of May, is going up to $90, or after the 31st of May, before 31st of May if you use the code may2020, it’ll give you $68 off so it’s $22 only, I’m doing this a lot for charity because a lot of the money is going to charity and the rest of its fees, ads I’m doing basically it’s my way of contributing for lockeddown. And I’ve already had some great feedback people who said it’s perfect for E-learning people who have messaged me to say that it’s made RBBs very clear for them. I’m so pleased to hear it. I personally do think after spending weeks on creating this course that it is the best value CPD you will do the entire lockdown period. So if I’m wrong, I’ll give you a money back. That’s how confident I am. So please join me on the RBB masterclass The website is rbbmasterclass.com And the pearl I have for you is that sometimes if you’re doing an immediate resin bonded bridge, I’ll just show you a few slides from from the course itself. When you’re doing an immediate, you’re taking a few risks, you’re taking a few aesthetic risks, and a few technical risks, so what if your lab work doesn’t quite come back as you want it? And you’re going to be removing a tooth that day and placing the bridge there. So your lab work needs to be on point. So that communication aspect comes in. And the other aspect is the aesthetics. What if the aesthetics are not ideal, and then you’re going ahead and placing this bridge? Well to overcome the risk of the aesthetics, ie the shade match of the bridge pontic not being ideal, or the shape or morphology not being ideal for the day that you’re going to fit the immediate resin bonded bridge, you can do a split pontic. So here are some photos that Louis gave to me, to as part of my online lecture on resin bonded bridges, on the split Pontic technique. And basically what you do is you request a laboratory to make the framework as normal. And on top of the framework, there has been some composite placed as a core, and then you get a separate Pontic, ceramic Pontic that actually can bond on to the composite core. And the benefit here is that you can check the fit of the framework and obviously bond that on and then you can check whether you’re happy and the patient’s happy with the shade and aesthetics of the Pontic. Because if the patient is not happy, then all you need to do is cement the Pontic in with a temporary cement. But if you’re happy you’re going to go ahead and follow your adhesive protocol which we discussed on the course. So the split Pontic technique is really good for immediate resin bonded bridges on patients with high expectations and high smile lines. So that’s one of the pearl I’m gonna share with you today. So let’s jump straight to the episode now with Louis McKenzie all about to drill or not to drill caries, when and why?

Main Interview: [Jaz] Today is not I mean, today is not about sexy composite, veneers aesthetics. This is something that needs to be more Instagram rather than that sort of stuff. Because on the social media platforms in dentistry, this is a massive, huge daily topic.

[Louis]
You’re right. It doesn’t lend itself to Instagram. But for me, it is a sexy subject that says probably too much about me.

[Jaz]
To have you within the podcast, it’s an absolute honor to have you.

[Louis]
Thank you, Jaz and nice to meet you as well.

[Jaz]
Thanks so much. I mean, it’s your first time sort of you’re virtually meeting me but I’ve been to quite a few of your lectures. And the reason I thought of you to bring you on, on this topic of of caries management in primary care, which is such a huge topic is you really had a massive influence on me in about I think was 2011 2012 BDA conference, you were at the mainstage, about 400 people, you had this massive widescreen. And it was not only a very informative educational lecture, it was very funny as well. And I really liked your teaching style. So I then came on to future courses as well. But at that lecture, the way you had managed caries, was like a paradigm shift for me, it really was. So you’d always stuck in my mind. And, you know, now and again, and I see a bitewing. And I sometimes think, what would Loius do? Honestly? 100%. So when this podcast came to be I’d already earmarked he was one of the people I really want to have on the show to talk about this. So just for the listeners out there who are small minority who don’t know who you already, just tell us about about, you know, your daily life and work and whereabouts you’re working at the moment.

[Louis]
Okay, so yeah, I’ve been qualified for 30 years this year, I’ve worked continuously in the same practice, which I think immediately makes you more minimally invasive anyway, because you see, all your failures come back to haunt you. And, you know, the big stuff, sometimes there’s no plan B. So yeah, I still consider myself to be a GDP but as a small part of what I do now. And so my main job is sort of teaching, undergraduate teaching at Birmingham, dental school and post grad teaching, mainly post grad courses, sort of private post grad courses, but also I do plenty of work with young graduates FDs and my sort of latest sort of roll around the MSc in restorative dentistry at a Birmingham dental school that’s just in its third year now. So I’m certainly enjoying that

[Jaz]
Is that with our Professor Buck?

[Louis]
Yep, that’s with Trevor. Yep. It’s the new course, Trevor’s run the has the longest running MSc in advanced general dental practice. And now that has been sort of evolved into an MSc in restorative dentistry, which is a two year blended learning program. Also do a bit down at Kings as well in the post grad department there with the two Banerjis, Abby Banerji, on the MI masters and Subir Banerji on the esthetics masters as well. So a real range of things, lots of different bosses to keep happy.

[Jaz]
Brilliant, and I’m a big fan of Dipesh Parmar, his work, his philosophy, and I believe you were his inspiration, his mentor. I mean, that’s certainly at least he credits you for that. So that speaks volumes about you as an educator I think

[Louis]
That’s kind of switched roles now. Because he

[Jaz]
has become the master.

[Louis]
Jedi. So he’s [Jaz] You must be really proud. [Louis] Oh, extremely. Yeah, absolutely. I mean, right, from the word go, I think over the years, one thing I think I have become pretty good at is actually spotting talent. And right from the word go, there’s just something different about Dipesh, you just got this natural eye for stuff. And, yeah, it’s been an absolute delight to watch him go from strength to strength, sort of an internationally famous, famous lecturer, and the stuff that he’s doing with composite is just off the scale. And so yeah, it’s fantastic. As often say, to the behind, you need to be as good as me. I’m trying to be much, much better, and they are, every year. But Dipesh is one of the first a real sort of innovator. And there’s lots of people snapping at his heels. But he’s moving fast.

[Jaz]
Certainly is but today is not I mean, it today is not about sexy composite, veneers aesthetics. This is something that needs to be more on Instagram, rather than that sort of stuff. Because on the social media platforms in dentistry, this is a massive, huge daily topic, daily controversies that we face, caries. And I want to just dive right in and ask you some really pertinent questions about caries, and I might start straightaway with the following one. So I think most gdps are not using a caries assessment system. Would you agree with that, in your experience to talking to GDP in the field and when you educate about this stuff, and what is your advice to the GPS about the caries systems out there? Because it can it can get very confusing, especially if you haven’t been taught that at undergraduate level.

[Louis]
Yeah, I think probably most dental schools do teach it but I don’t know how strong the focus is on at King’s with Avi Banerji. It’s literally front and foremost, I teach those particular subjects at Birmingham. But, you know, certainly from your question. Yeah, I think what you’re implying is that the majority of people don’t use a caries assessment system. And many from unfortunately, people I’ve also taught, don’t even know that one exists.

[Jaz]
From my experience of reading people’s notes, working main practices, internationally, Singapore, here, also working alongside American US trained, Harvard, you name it, dentist in Singapore when I was there, doing I’ll check their notes, no one would mention anything in their diagnoses, that would suggest that they were A) aware or B) happy to utilize that system. So this seems to be an international issue and hoping that we’ll change it, if you think it has a place. And that’s what I’m going to lead this conversation about, you know, have they got a place in contemporary dentistry?

[Louis]
I think definitely. Not just, Well, for a number of reasons. Just to sort of recap, I mean, the system that sort of internationally recognized is the ICDAS system, International Caries Detection and Assessment System originally dreamed up by some cariologists in a dark room over many days, and so the actual system itself is actually quite a complicated system. But a simplified version of it is something that’s really really easily put into clinical practice. Because basically, caries as we know, every single lesion is different. And it is difficult to detect, it’s difficult to monitor. But having a system, which is literally just a one to six numbering system actually makes you think about the disease and helps monitor it. And also most, you know, very importantly, from a sort of a dental legal point of view, just literally by writing sort of one digit. It demonstrates that you’ve detected it, and you’ve diagnosed it, and you know that it’s there. So certainly in this sort of increasingly litigious environment, I think the system works well.

[Jaz]
Where can one go to if there’s a dentist listening to this and thinking, whoa, I didn’t know systems exists, or you know what, I really should be using a system, Where is the best resource for them to learn? Because I think it’s a bit beyond this podcast episode to go through that all I mean, if you want to do a quick summary, if that’s even possible in audio format, but where can one go to learn more about that if they want to implement it in their workflow and diagnosis?

[Louis]
And there’s just loads of stuff out there, don’t go to the sort of the super complicated sort of documents, which are sort of multi page which are all about sort of epidemiological studies on caries, which is obviously incredibly important to base our caries management protocols are. But the basic system literally just click on anything. Click on google images, and you’ll find hundreds of sort of nicely illustrated guides, the basic system is quite simple. It’s sort of zero to six, zero basic, you look at the tooth, looks normal, you don’t have to write a zero. And a code one is one of those lesions that you got to dry the tooth to see it, you know, when you dry the fissures or your dry, smooth surface, and you get that sort of opaque whiteness, that’s the earliest visible sign of of caries. So that’d be a code one, then a code two is a lesion, wherever it might be, which is visible, wet or dry. Three is when you start to get a little bit of cavitation so there’s some enamel breakdown as well. So obviously, by putting these numbers you can actually record their caries lesions getting staying the same or or getting worse. So it’s good for monitoring for I think, is quite an important one because those lesions that we’re quite familiar with, where you’ve got a lot of shadowing under the dentine, no obvious cavity, but you just know that something’s cooking underneath there. And then five is a lesion, which is got obvious denting exposure, so a cavity, you might need to remove some food debris to visualize it. So that’s a five and then six basically is just a big lesion that sort of is covering about half of the tooth. So over 50% would be a classified as a six And so that’s a really, really simple system to show that you’ve detected the lesion. And the thinking about it. And also from monitoring point of view because you know what it’s like if you look at two different you look at the same lesion every six months, you know, if you haven’t got photos, very difficult with the number of patients we see to actually work out has it stayed the same? Has it got worse? But if you’ve got a number they can think Oh, right. Yeah, that was a one last time is still a one now, let’s just keep a watchful eye on it. The good thing about caries of course, is it doesn’t move fast. You know, you’re not going to go from a you know, an early enamel lesion to in the pulp in six months. [Chris Deary], the Dean of your

[Jaz]
He taught me the ICDAS system. So yeah, shout out to him. Of course

[Louis]
I mean, internationally. I think I had the same sort of experience as you did when I saw him lecture at the BDA conference. And it was an absolute revelation. The blogs are fantastic lecture, as well, and lots of things that I remember from that lecture. But one of the things that stood out was I remember, he said, caries isn’t cancer. And you know, it was a fairly

[Jaz]
Can say that again? In his accent?

[Louis]
Scottish surname, but I can’t do that. Too Scottish. So obviously, it was making, you know, quite a blunt point, that, you know, if we miss a leukoplakia, that then turns into something nasty, six months later, that patient, you know, it may be game over, you may have an inoperable lesion. So obviously, from a soft tissue point of view, we’ve got to pounce on those and take a, you know, a very, you know, cautious, very cautious approach. But with caries, because it is moving so slowly, I mean, talking about sort of three years to get through the enamel. In certain patient groups, you can adopt a much more watch and wait, and sort of protocol. But as long as you recording things well, from a dental legal point of view, again, what we don’t want to do is put a lot of, you know, watch a lot of lesions not recorded well, and patient goes down the road to see another dentist. And then even though a minimally invasive strategy has been employed, it just hasn’t been. It just hasn’t been documented. And so yeah, it’s a slow moving disease. That, you know, again, we need to keep a watchful eye on it, especially with class two lesions, because sometimes those sort of D1 lesions can certainly take off. With no sort of obvious change in the environmental conditions, patients still brushing the same, diet’s similar. And so yeah, real sort of watch and wait. But from an occlusal point of view, you know, it’s so easy to watch the occlusal surfaces, and, of course, to seal lesions as well. You know, if you’re worried, you don’t have to drill into it. If you don’t think it’s one for monitoring, just seal it.

[Jaz]
Well, you touched on it just there in your answer that is that if the patient goes down the road, that’s one of the big worries, I think, young Dentists have in monitoring lesions that maybe code three, for example, and you can see it radiographically. And you sort of get this feeling that if you do not treat it and the patient goes down the road, then another dentist would be a different mindset different, no pair of goggles would say, Whoa, whoa, whoa, you’ve got really bad decay, this needs to be treated. So what you know, not only does need to be documented, but I do try and have a very explicit conversation of my patients so that they can really remember this conversation I’m about to have with them. So I say you have got decay. And I’m sorry, to all Americans out there who listen to my podcast, but I say, if we were in America, you’d be having all these fillings on, but you’re not, you’re in Europe and that this is my line, and they seem to remember it right. So again, very sorry to Americans, I really apologize for that being the hot water there. But yeah, I don’t generally make a point to have a conversation on patient and I think that’s the only way tha we can address this without worrying about the patient going down the road to the other dentist, right? I mean, how do you tackle that?

[Louis]
Totally 100% agreed. The patient’s got to know where their lesions are, you know, I will give them photos. You know, email the photos of them so they know exactly where the lesions are. So when the dentist detects something, when they do go to another practice, yeah, it’s not a surprise at all. Yep, I’ve been watching that lesion there. You know, I’m keeping it nice and clean, it hasn’t, you know, it hasn’t changed. It’s been like that, you know, in some cases for 10 years. So yeah, there should be no surprises, patients certainly shouldn’t be surprised, because it is, you know, it is their disease that they’re carrying around. But if it’s arrested, nobody wants an operation, you know, anywhere in the body on something that didn’t need it. So and of course, a good way of looking at it is if you do drill into a tooth, say you make a mistake, and the lesion was active, it progressws, six months down the line, that cavity you actually drill is going to be no bigger than the one that you would have drilled on day one. So and then once the restoration goes in, you know, a patient with a carious lesion is high caries risk by definition. So then you’ve got, once you’ve done the restoration, that high caries risk patient because they’re not high caries risk until they’re proven otherwise, as then go the whole margin of the restoration to look after, as well. And so a non cavitated lesion, compared to say, a class two composite restoration or something like that, is much easier to maintain, than, you know, the material that literally from day one is experiencing sort of nano leakage and micro leakage. So yeah, drilling into teeth, it might feel sort of comfortable to do that, and a safe thing to do that just in case. You know, from a biological point of view. It’s, you know, you could argue it’s not far off butchery to drill into something that doesn’t, that is arrested and isn’t progressing. But your point about patient knowing exactly what’s going on in their mouths is absolutely essential.

[Jaz]
I like the fact that you send the photos, I try and do that where I can as well, the intraoral camera photos so that they have a record that this has been discussed, but also that I think that motivates them, and they they really understand what’s happening in their own mouths. On that note, just a side question. How big of an influence does it have on your treatment plan? If the patient with the same mouth but one is a regular attender, and one is an irregular attender? I mean, there’s so many factors that contribute to your treatment planning and caries, but whether that attendance pattern is one of them, so I tend to be a little bit more aggressive in my treatment with someone who is irregular attender. So if there’s going to be a restoration, I’d rather watch it on the regular attender. But if someone is the only comment, there’s a problem, and I diagnose all this caries, which is borderline, I’m more inclined to treat that person than not, but maybe that’s not the right way to do it.

[Louis]
No, no, I totally agreed. And I think, you know, the evidence base would agree with that as well, if you can’t be sure they know if they’re zipping off and you might not see him for another five years. Classic situation if we’ve, if you’ve got this sort of, I don’t know same sort of code two lesion you just wondering, should I seal this or should I drill and again, you know, the sealants so if you think they’re not going to come back for another five years or something like that, and I along with you be much more likely to just drill into that and just open it up because you can keep it super small. You know, just see how far it goes. Whether you know the difference between a conventional filling and a PRR it’s you know, it’s very difficult to sort of actually define one from the other but you could just keep it super small just give put a nice self cleansing restoration in there and Yeah, you’ve stopped the disease and then you haven’t got to worry about them sort of yeah the not caring for it or getting even worse and also you know for patients got a mouthful of them obviously attack the worst ones first. Because you know, you can be really surprised things that you think oh, you know, this is going to be a decent cavity is a tiny and equally, especially working where I work in in Birmingham, you can be surprised the other way where you know, loads of fluoride in the water, the enamel is, you know, very strong, very fracture resistance. So you can get some serious sort of a cult caries, as it used to be called, occurring under there so there’s a massive lesions when you look at the surface, you think they don’t look too bad. I mean, this is one of the things you know, you said at the start that, you know, it’s not a sexy subject, and it probably, you’re right, it doesn’t lend itself to Instagram, but for me, it is a sexy subject that says probably too much about me, because it is actually the core of what we’re here for. And it’s why dentistry exists. At and it is almost a sort of the importance of it is almost a forgotten subject. Or, obviously not forgotten, but it is subject that probably does. It’s never you’re never gonna have much, many Instagram followers with pictures of caries lesions, but

[Jaz]
we’re hoping to change that we’re hoping change that and the way we’re going to change. The way we’re gonna change it now is I said, Now that we’re talking about a, what we mean, you agree is a sexy subject, let’s pull out some photos. Why don’t you share the PowerPoint and we can discuss the case. And I’ll give everyone a background while you’re sharing the screen. So this is a 54 year old male patient of mine, who attended for an examination with me, has been to the practice for over eight years. And one of the great things about the practice I working [Loius] Is that it, Jaz? [Jaz] Yes, perfectly. We do plaque scores and bleeding scores for every hygiene visit. This is someone who’s got quite impeccable oral hygiene, regular attender and first time I was seeing him and that’s what I found, I was like, Whoa, okay, and I had a look at the chart. And nothing was documented for those of you who are driving right now and listening or chopping their onions, and then they can’t see the photos, I urge you to check this out on YouTube to check out you know, how many minutes to see in to podcast, to see the photos, because this is a clinical scenario that you may encounter or may have encountered many times. So this is like as a 54 year old male, regular attender and I really struggled internally, to decide whether I pick up the handpiece or not, and I almost treatment plan it to come back to start some treatment. But I remembered we agreed to have this podcast episode. And like you said, cariess not cancer. So I was totally comfortable to send him with fluoride and say, No, I’m speaking with someone who in my opinion, is very experienced and knowledgeable far more than I am. Let me speak to him. And I’ll tell you what he says. So I’ll be reporting back to the patient after this. But in this scenario, let’s start with the ICDAS, can you tell the ICDAS just from the photos and radiograph? Or do you need some clinical input as well?

[Louis]
No, I mean, they’re clearly fours, aren’t they? So you know, we’ve got shadows, we’ve got no obvious cavities. But we’ve got shadowing under the enamel. Obviously, we got some cracks as well. Yeah, it’s an interesting case that you’ve chosen there. Great photos as well, by the way.

[Jaz]
And I forgot to mention, actually, the background information, this post had around about 5000 UK dentists look at it and 1600 engagements. So what that means that someone’s actually clicked on and actually read more about it and flick through and 169 comments, and they will literally split in half. And some of their responses were Oh, yeah, who would have thought dentists’ saying? And some of the responses were not only very polarized, but some were really passionate. I mean, some people you are extremely negligent. If you monitor this. To others, they they propose the daughter test or the mother test, they say, you know, I wouldn’t have this on my daughter, I’d watch it. So you had really, you know, real polar response and reading these comments has been quite entertaining for me. And one thing that I could just ask you straight off the bat, that is was our right to take a radiograph? Because some someone said that actually, why do you take a radiograph? Didn’t you tell us caries is there? Is that really show anything? Not the air respect. But for me to help me decide whether I want to drill or not the radiograph for me was important. So what do you think about the radiograph adding benefit, does it or did I not? Why should I not have?

[Louis]
In this situation? Well, certainly from a dental legal point of view, you definitely justified so that’s the first thing to say. So there’s no question about it from a dental legal point of view. But equally, obviously, any radiographic investigation should improve the quality of your diagnosis or improve the outcome to the patient’s treatment. But now, we’re all looking at this lesion there and we’ve got the radiograph. And we’re probably none the wiser. [Jaz] That’s true [Louis] because of course, unfortunately, early lesions do show up terribly on x rays, particularly with an anterior views as well. So I think there’s a good argument. There’s a good argument both ways there. So I’m, so many would say yeah, it’s not justified because it’s not going to give us any more information. But of course, until you’ve got the radiography, you don’t actually know that it’s not

[Jaz]
Yeah, I was kind of hoping that it’d be really clear out for me, and I’m like, okay, I definitely tend to intervene now. But no, you’re right. We’re none the wiser. So what would Louis do?

[Louis]
Well, I’m delighted.

[Jaz]
Is there any more information that you want, I mean, I can give you any information.

[Louis]
I think the key to this one would be I mean, we could use transillumination, that’s probably going to make it look even more horrible. And probably going to push you towards restoring it. I think really, the only way you can be certain is to put a tooth separator in. So orthodontics separator. Now obviously, they’re a bit uncomfortable. And leave that in, sort of, I mean, you can leave it in for a few days. But after a couple of days, you’re going to get tooth separation. And so then you can basically take the separator out and can actually see if the surface is cavitating. If the surface is cavitated, then the decision is made for you, a cavitated lesion cannot arrest, the biofilm can’t be removed, even this patient becomes an Olympic standard flosser. There’s no way that the lesion can not progress, albeit very, very slowly. So if there’s a cavity, the job’s kind of done for us.

[Jaz]
So can I tell you what I did? [Louis] yeah [Jaz] I placed a wedge And I was able to just about feel my probe to confirm there wasn’t a cavity, but that crack that you see, on upper right one, distal, and upper right two, I can just feel the sort of the the crack almost that’s what I was feeling my probe just gently, no cavitation. So to me, that was the crack that was swaying me towards treating because the crack is in, in some ways. It is a cavitation in a way.

[Louis]
Yeah, absolutely. It’s a way for bacteria in there. We know there are bacteria in there, you know millions of them, in fact. And the crack really is a tricky one. Because now, the crack has probably been caused by the lesion. The demineralized enamel from a mechanical point of view is weaker. This patient’s in his 50s is been biting and protruding on these teeth. So it’s cracked because it’s unsupported by the demineralized dentine underneath. But obviously, that crack is not an actual cavity. It’s a wave of bacteria. And but you know, they’ve really got to queue up to get into that lesion. So it I mean, it’s a very good case that you’ve chosen because it is very different, because there is no, if you separate the teeth, and there is no cavity, obviously the crack still there. You know, you can see that. And also from a class two point of view, you often see these cracks, early caries lesions, been there for a while. And then you get a crack right from the center of the marginal ridge all the way down into the lesion. You’ll see these quite often when you extract a tooth, and there’s been a carious lesion on the adjacent tooth, you’ll see these vertical cracks going right down to the lesion there. And so you know, it’s a really, really tricky one to, Because if we drill into that, we go from a crack to a massive hole in the tooth, which is then going to have to be replaced. Patient’s in his 50s. So you know, I’m sure your composites are amazing. So but again, 10 years down the line, great. 20 years down the line, fantastic, let’s get the balloons out. But the likelihood is that that restoration isn’t going to last forever. And then when he’s taken out, as we all know, the coverage is going to get bigger. And of course, the average competition doesn’t last that long. So you know, six to seven years, class three is difficult to do as well. You know, regardless of rubber dam or not. Difficult restorations to get a perfect finish. So then we’ve got excess composite beyond the margins, probably. We’ve got microleakage, nanoleakage. We’ve got polymerization, shrinkage stress, we’ve got expansion and contraction of the material, which is going to be different to the tooth tissue itself. So are we actually creating a worse environment than the environment that was there before? So yeah, it’s a tricky one. Now obviously we all know some of our colleagues won’t be having this argument. The only argument be, which porcelain you’re going to use for the crown onlays.

[Jaz]
Hello, USA. I’m just kidding. I’m just kidding, guys. I’m just kidding. I don’t know if I’m getting or not. Okay, let’s just, that’s a different debate.

[Louis]
So yeah, it is a really tricky one. I think that I mean, the nice thing is, you know, you know your patient well, you’re seeing them regularly. And the other thing in this particular situation, it’s dead easy to remove the biofilm. Caries lesions are driven from the surface, if you can remove the biofilm, kind of doesn’t matter what it looks like. Because if that does progress, it’s going to be so glacial, that the patient is going to be 200 years old before you’ve got anything to worry about, at all, certainly thinking this particular case, I would adopt a watch and wait policy, if you’re making a decision. And to be honest, we’ve got all the information that we would have, I mean, you’ve got great photos, you’ve got a radiograph as well there, we’re going to get no, we’re going to get no more information, if we had the patient actually in the chair, other than the tooth separation. So for me, the patient can look after this lesion, and you can review it regularly. And see what happens. Give you the Deary test.

[Jaz]
The Deary test. Brilliant. I love it.

[Louis]
There we go. you know, and if it moves, you’ve got great pictures there. And so,

[Jaz]
So let’s talk about something that would change my management in this. So if it was an irregular attender, and the surfaces were covered in plaque, and the bleeding sort of came in, the plaque scores were consistently in there, you know, 30s and 40s. And maybe you know, the quality slider wasn’t so good, then my protocol, a call or decision making here would not only be to pick up the handpiece, but I’d actually treat them all even because of the patient going to have an anesthetic procedure rubberdam. And that moment, I just get even the smaller ones, I just restored it. That’s it for me, it’s all or nothing. And now it is my all or nothing approach, just fireball in that sense, if I’m going to do, if I going to drill one, I’m a drill them all. I sometimes do that

[Louis]
I keep an open mind, keep an open mind do the finishing, I think in dentistry, we should always have that, you know that flexibility to just keep all of our options open. And the nice thing about sort of lesions sort of opposite each other is treat the worse, you know, so you decide for whatever reason to drill into it, or do test drill or whatever. And then the nice thing is, once you’ve done that, you can actually look directly at the adjacent tooth. Quite often you will see, especially on posterior class twos all the time, and you prep one, you will always see some demineralization of the opposing teeth, just because they’ve been living opposite a carious lesion for ages. So it’s demineralized, no coverage at all. And as soon as you put the restoration in, that tooth is going to fix itself. Tooth are very, very good at repairing themselves. You know, we, you know, we know that the odontoblasts are working day and night against a carious lesions, if we can give teeth a chance to actually remove the environmental factors, then they’re going to fix themselves. So yeah, if you sort of have prepped one, and then just have a really good look with magnification, ideally, at the adjacent tooth, you can actually feel the surface carefully with the probe, obviously, you know, not probing into the lesion, but coming across the lesion, you can see if that surface is broken. And then if not, again, take a nice photo of that. You let the patient know, we’ve got this lesion here. You know, you mentioned the daughter test, which I think is an excellent benchmark for any operative procedure. You know, would you drill into it on your daughter and if you wouldn’t leave it alone, because you’re only going to make a massive hole and fill it with something where really you’ve just got to you know, either no defect or little crack.

[Jaz]
Brilliant. So now we know what Louis would do and I feel I can sleep well tonight knowing I did exactly that. But now I’ll email the patient as well and say, okay, it was split opinion. But here’s what we think, there’s no right or wrong answer, you know, because this one is a bit borderline, you know if it was way less in terms of size of these lesions, then maybe we’ll be having a different conversation but I picked a borderline one on purpose obviously. So for those of you on the pages on Facebook who said that I would definitely treat it. You know, don’t I wouldn’t be you know too hard on yourself, whatever. Because,

[Louis]
Yeah, there’s no right or wrong answer. Of course, if you drill into that lesion, again, you’d say, Oh, yeah, I did the right thing there’s caries there. Because you just [Jaz] you justify it to yourself. Yeah [Louis] it’s not the same. But unfortunately, you drill into almost any fissure in the mouth. You will find the process of demineralization knocking around, you could argue that every human has got the caries process going on all the time. The world’s most common disease, but it’s only if it’s progressing at that it’s an issue, but yeah, it’s a great case that you’ve chosen there because, I mean, you mentioned about it being 50-50 I remember a good quote from one of my friends, Professor Giles Perryer who said that there’s only one thing that two dentists will agree on. And that is that a third dentist is wrong. As it were, you know, that’s one thing nice thing about there isn’t a unified theory of dentistry and you know, that’s what I like about it, that it is a subject whether it’s sexy or not that it is easy to discuss one lesion for what 10 minutes or 15 minutes like we just have

[Jaz]
Certainly is. So what will I ask you, Louis is just switch off the screen share now? If that’s okay?

[Louis]
What’s cooking on the toward the apices of those incisors?

[Jaz]
You know, I haven’t even looked at before. Yeah, so it looks like canine but it can’t be, surely not because this person has a canines, but yeah, there is an opacity there isn’t it? On the above the upper left one.

[Louis]
There’s another one for you to investigate next time another podcast coming up.

[Jaz]
Yes. That’s it for part two, just we can use to part two. But thank you so much for sharing that. Thank you for laying those images out. So neatly there. So you’ve answered actually a lot of the other questions that I was gonna get into. So the final question want to ask is, many dentists believe that a radiographic lesion that’s into dentine is automatically pick up the handpiece. What message do you want to send to these dentists?

[Louis]
Well, that, again, it’s a good one. And I don’t know whether I’m actually changing my personal opinion on this subject. And so just to sort of refresh, we’ve got the ICDAS system, which is the proper ICDAS system is actually a two digit system. And the first digit describes whether it’s a tooth surface or it’s the margin of a restoration or margin of a sealant. So it’s actually a two digit system. So but the just the basic ICDAS system is that you could just use your simple one digit. A different system, not to be confused with the ICDAS system is the radiographic grading of the carious lesions. Because the radiographic appearances is something very different. The radiographic appearance we know is, you know, on average, six months behind what’s actually going on inside the tooth from a histological point of view. So that, the recognized system is through the system that basically says two digit system, so two so basically an E1 lesion so if you’re looking at a bite wing, and you’ve got a lesion that’s less than halfway through the enamel, radiolucency, then that’s an E1 lesion. When the lesion then extends beyond the center of the enamel, wherever it might be, then that’s an E2 lesion, but it’s still short of the denting, no obvious dentine changes, then a D1 lesion is one of those lesions where you see some radiolucency in the outer third of the dentin. Sorry, I meant D. So a D1 lesion is the outer third of denting, a D2 lesion is where you’ve got radiolucency in the middle third of dentin. And then a D3 lesion is when you’ve got deep caries sort of inner third of dentine. You know, even if you’ve got sort of pulpal exposure to the system doesn’t really go beyon D 3. So it’s a useful system again, for assessment as Professor Banerji I’m quoting all the legends today. Professor Banerji or Professor Kidd that, you know, a single radiograph in time, you could argue is you know, it’s important information, but it’s actually meaningless when it comes to carious activity, the only way you can show from a radiograph that a lesion is active is if you’ve got two radiographs taken a minimum of six months apart, if the lesions got worse, then that’s by definition, an active lesion. So that’s going to be sway you more towards operative management. But equally, if you’ve got a series of radiographs showing a lesion, even if it is a D1 lesion, and it’s not changing, and then, you know, you can basically say from all the evidence that you’ve got, and especially from a dental legal point of view, that is an arrested lesion. The only thing that it’s, and again, this is quite sort of anecdotal, I did a lecture once, too. I did a lecture not just on one tooth, I did a lecture on one surface, an hour lecture on one surface of one tooth. And this exact scenario happened. And it was a lesion that I followed, it was a D1 lesion for a six years, no change at all. Bitewings looked exactly the same. It was one of those lesions where you look at it and you think day one drill, this patient had a number of these lesions, a lot of them about 20 of them. So the deeper ones were treated. But then I adopted a sort of watch and wait policy, and was really surprised that because the patient completely transformed his diet, and oral hygiene lifestyle, and that the lesions just stopped. Now he was one of them not dissimilar to your patient that you just showed us where the lesions are not just interproximal, you can see the old demineralization coming around onto the buccal surfaces, and the palatal surfaces. And so these lesions Do you know, can be quite deceiving when you look at them radiographically. But anyway, I saw I’d watched this lesion quite comfortably for six years. And then six years, after six years, patient just came in for a checkup. And I noticed that a marginal ridge and actually fractured. Occlusal load, so that actually fractured I’m still there. But now the lesion had progressed. So it’s one of those tricky ones with these, the demineralisation, are they sort of slowly, slowly, slowly weakening the tooth? So that under occlusal loads one day, the marginal ridge might give up and the lesion might progress. I mean, the nice thing is, after six years, the cavity was no bigger than it would have been if I steamed in on day one. But again, it comes back to your point that that patient was a regular attender really well motivated, and this is the patient that would have got 20 MODs, if you know, if we’ve taken a transatlantic view, possibly not telling you which direction but so yeah, it’s easy to drill into tooth. But once it’s done, it’s done forever. And you know, you can’t, put the cork back in the bottle. Once a tooth has been drilled a restorative patient is a restorative patient forever and that old, that old saying so but equally, I think, you know, all these D1 lesions just slowly creeping, they separated the teeth on multiple occasions, there was no cavitation of the

[Jaz]
Louis, you’re the first person I ever saw who has ever taken a light body PVS impression of the interproximal surfaces between molars.

[Louis]
Yeah, you don’t get many shadows. You know, that is in you know, that is sort of proper level OCD, it was actually my Prof Perryer, I mentioned before, shared an office with him for 10 years, a real innovator, one of the world’s leading experts on blended learning in dentistry, and yeah, so he showed me that trick that wasn’t. But really, you’ve got to separate the teeth to do that. As ideally, unless it’s an obvious cavity, then it’ll show but if you separate the teeth, then you can just squeeze the impression material in there. Of course, you’ve got other ways of doing the look, you know, radiographic point of view, these various different scanning, scanning procedures that you can use in between the teeth, as well but I think the this, when if it’s an enamel lesion, yeah. And it’s non cavitated on the surface, yeah, again, surely none of us would ever want that done in our own, to our own teeth. But I think when it’s getting into the dentine, I think we’ve definitely got to get away from that sort of that trigger response that dentine caries equals drill. Because that’s just not sophisticated enough for, you know, for the modern clinician,

[Jaz]
Louis, do you watch, Do you watch D2 lesions as well? In the right patient? Radiographically Or is that I mean, that’s such an open question, because it’s so many variables, I suppose. But

[Louis]
Yeah, if it’s a cavity, on the surface, again, the you know, separate the teeth, ortho separator, if it’s a cavity, the decision is made for you.

[Jaz]
But it’s really non cavitated D2 occasionally you know, you find one

[Louis]
You do see them and again, you know, that is real, you know, that is really pushing the boundary, you know, many people would call that, you know, abject negligence, supervised neglect, whatever you like to call it. But the textbooks would tell us that the lesion is driven from the surface, from the biofilm and, you know, and if the patient is cleaning that surface, that even in a D2 lesion. So, yeah, that’s a tricky one. And, of course, most D2 lesions, in my experience, you know, when you actually drill into the marginal ridge to begin with, you make your access cavity, you see straightaway from the inside that there’s you know, there’s a cavity there. And so it’s the right, you know, you’ve made the right decision. Again, tunnel preps, they kind of went out of fashion.

[Jaz]
So are they back in fashion now?

[Louis]
Well, they went out of fashion, originally, because they were a glass ionomer was used to do the restoration. And glass ionomer is not strong enough to support the marginal ridge over time. So you tend to find, you know, they worked, they stopped the lesion. But then what happened is that the marginal ridges on average, tend to fracture because the glass ionomer was a bit too bouncy on the underneath. But now of course, you’ve got bulk fill composite materials that we can inject into these cavities. And really quite radiopaque materials as well, always tricky, you know, even with magnification to be certain that you removed all of the caries from the tunnel prep. But I’ve done a few in fairly recent years, because the nice thing is there is you preserve the marginal ridge. And you sort of attack the lesion sort of directly. But tunnel prep’s tricky sort of thing, especially without magnification. You know, obviously, you’ve got a scope, fantastic. Go for it. But both of materials is just so good now that you know, you can just inject them nice, thin canula, very radiopaque, low polymerization, shrinkage stress, obviously, put a matrix band in anyway, so you should get a really good contour because you’re literally filling up from the inside. And you’re not involving the proximal surfaces at all,

[Jaz]
because you’ve got the marginal ridge guiding the matrix that should get quite close to an activity in that scenario.

[Louis]
And you can optimize your wedge, we’ve got a good tip from you mentioned Jason Smithson. Good tip from him, you know, if you’re not getting a great wedge with your matrix band, just modify that with some ptfe tape either round the wedge or stuff in on top of the wedge, or a little bit of flowable composite outside the matrix as well to just optimize your seal. Yeah, restorative dentistry, you know, got lots of tricks, lots of tricks to fill really quite sort of dry, quite tricky, cavity shapes.

[Jaz]
Cavities are something that you know, like I said on social media, you see all these smile makeovers, I tend to post quite a few restorations, just past restoration I think class two is real art to get the correct matricing, the correct wedging, the correct gingival removal in some cases to actually allow the correct emergence profile of your matrix so I it’s an aspect dentistry I enjoy a lot and I think it takes a lot of care and attention to do correctly and it can’t be rushed these things, that’s just the point I made but the question I want to finish on Louis if you don’t mind is DO restoration on a five for example comosite and just see like a discolored margin all around and dentists are drilling this out and I’ve seen it a lot you think “oh yeah, you got leakage, you didn’t any restoration?” Is that just the biggest baloney ever? Is that a robin hood dentistry?

[Louis]
Again, I think Edwina Kidd published Professor Kidd at King’s, Guys, King’s down in London. You know published a lot of the work on this and just showed that will we remove way too many restorations and that most of them are functioning absolutely fine. The correlation between marginal stain and secondary caries is almost zero. And I’m glad that you made this point to end with because we’ve mainly been talking about primary carious lesions, which are difficult enough. But when you add secondary caries into the mix, you know, you take a lighter shade, you’ve got a stain around the margin, you take a radiograph, there’s a radiolucency, cervically. What is it? Is it caries? Is it some sort of lining? Is it bonding resin? Is it polymerization shrinkage? Is it a void? So incredibly difficult. But we do take out way too many fillings that’s been proved beyond doubt. A good, I’m coming out with all the old quotes is that, you know, composites can look you know, can look better than they are. And amalgam can look worse than it actually is. So, you know, these materials can sort of caries, will move more slowly, under an amalgam restoration, that’s for sure. Because the breakdown products of the corrosion, and, you know, bacteria just don’t like those. But it is tricky caries around, work stain around composite restoration is a super tricky one to do. Obviously, if there’s aesthetics that tips the balance, in favor of maybe localized repair, or maybe even restoration replacement. But yeah, if we replaced every single composite with a stain margin, we would never, ever do have time to do anything else. Because you know that the materials do develop positive negative edges over time, even the best restoration, you know, it is going to show up some marginal stain with time. And obviously, when that restorations removed, that cavity is getting bigger. So if we can adopt a more conservative approach to restoration replacement, and let’s face it, more than 50% of everything that you may, every GDP listening to this around the world does involve the replacement of existing restorations, not the management of primary disease. But the more restorations we put in, the more problems we create for ourselves actually diagnosing have they failed or not? The, again, the diagnosis of restoration failure is a complete science, separate science and classification system all on its own very, very tricky And just so subjective. You know, from clinician to clinician, depending on, you know, the clinical experience, the material has been used and what they were taught to replace restoration, but, you know, to think about, does it actually need to be replaced. You know, I think you know that’s why five years of dental school, exactly makes us think about these things, rather than just if it was just knee jerk stain equals replace, then anybody could do it.

[Jaz]
Absolutely. It’s just a point I made because I you know, it’s something that happens still. And you really have to sort of challenge that, I think. And it’s been great having you on the show today, you’ve given some great, what the kids are calling knowledge bombs nowadays. So you really shared. So that’s great. So thanks so much for coming on and talking about a really important topic, and mentioning some great legends in cariology and operative dentistry. And it’s been great chatting to you.

[Louis]
Pleasure to chat to you, Jaz.

[Jaz]
Thank you very much.

[Louis]
Thanks for everyone who listened.

Jaz’s Outro: Thank you so much for watching all the way to the end, please do support the rbbmasterclass.com course I really appreciate to have you on. Subscribe on the YouTube or the IGtv. If you’re watching an either those platforms, or if you’re listening, you might want to go back and check the video part to see what the lesions look like that we’re talking about. Anyway, catch you in the next episode. Thanks again. Thank you so much for listening.