Communication Masterclass for Periodontal Disease [B2B] – PDP086

When treating periodontal disease there is more to it than removing biofilm. Our role is to be a motivator and lifestyle coach – only then can we see successful periodontal outcomes in the longterm. What’s your spiel to patients to explain what periodontal disease is? Do you show diagrams, draw or use your fingers? Listen to how Dr Ian Dunn explains Perio and you will want to implement his way of communicating on Monday morning! Brought to you by the Back to Basics series of August on Protrusive Dental Podcast.

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

Protrusive Dental Pearl: Have some tools to be able to communicate via drawing (draw teeth, draw bone or periodontium etc) whether it’s digitally, on whiteboard or paper. There is beauty and magic about being able to draw something while your patients are watching beside you.

“Communication has to be a two-way street. It shouldn’t be a monologue, it should be a discussion.” – Dr Ian Dunn

In this episode we discussed about,

  • Communication Masterclass between Dentists and Perio patients (12:38)
  • How to communicate with more resistant patients (17:33)
  • Referrals done by GDPs that could have been manage at their own practice  (21:22)
  • Trying to get out of comfort zone in Perio (26:20)
  • How to communicate risks in Perio treatment (32:08)

Catch Dr. Ian Dunn’s Perio courses and be able to communicate to patients effectively about periodontal diseases.

Do join us on our Facebook community, the Protrusive Dental community!

If you like this episode, be sure to watch Finding Your Niche in Dentistry with Dr Pav Khaira

Click below for full episode transcript: 

Opening Snippet: So this is the bit where you explain to a patient that they're rubbish at brushing their teeth but you do it in a way that you don't offend them because that was the thing I find most difficult. Mrs. Jones bacteria builds up on teeth. It reaches your trigger points. Your body triggers inflammation, that inflammation damages the bone...

Jaz’s Introduction:I’m Jaz Gulati and welcome to another episode in the back to basics series of the Protrusive Dental podcast. You are going to be blown away by today’s episode is with Dr. Ian Dunn of periodontist, on communicating. Communication in perio specifically, for example, how do you explain to a patient that they have periodontal disease like six significant things a chronic condition that could potentially live with for the rest of their life? It’s such an important thing for them to grasp so that they can get better outcomes. And you can get better success as a clinician. Like what’s your spiel? What’s your way of communicating that I think lots of Dentists have different ways of doing it. Now, you will probably get your way whichever way you’re doing at the moment. And Ian will show you the way to do it. I mean, his way of explaining to patients, how periodontitis works, and to get them on board is just the best I’ve ever heard. So I’m so excited to share these gems with you, we will talk about communicating risk of treatment with patients. And he does that in such a great way as well. And the relevant Protrusive Dental pearl I have for you today is to have something one-eight, whether it’s digital, or whiteboard or paper base, an opportunity for you to be able to draw certain things because certainly one of the tools that Ian Dunn uses is to draw certain things draw teeth, draw bone or periodontium. So therefore, I think it’s a really useful thing sometimes to be able to draw something. Yes, we have our intraoral cameras or DSLRs. But sometimes there’s a beauty and magic of being able to draw something while your patients watching, you know annotating as you’re talking to them. So that’s the main Protrusive Dental Pearl. I hope you enjoy this episode. Stick around for the outro and if you’re watching on YouTube, and if you haven’t already, I’d really appreciate if you hit that subscribe button. I know loads of you have you been enjoying the back to basics series I’m so grateful to for you to join me again in this episode. And now on hit the main episode with Dr. Ian Dunn, all about communication when it comes to periodontal disease.

Main Interview:

[Jaz] Ian Dunn, welcome to Protrusive Dental podcast How are you my friend?

[Ian] Yeah, I’m very good, Jaz. It’s really good to be here. It’s nice to be on this and not be listening to it all the time if I’m on my commute to work. [Jaz] I’ve said it before. I’llsay again, I’m just amazed when clinicians are of your caliber. And I mean seriously, listen, honestly, he said it’s the highest praise for me. You are someone who I have seen as a brilliant educator, because you know, not only just the crown lengthening sort of workshop I did a few years ago, you’ve been on my radar, you taught my wife perio at dental school in Liverpool, and as a tutor you are you know, you’re a big favorite. I think I remember going to something very unique about Liverpool undergrad scene was this. We will shall not reveal details as per the contract. But it was that evening that you had lots of funny skits and whatnot. [Ian] Oh, yeah, the smoker. Yeah. [Jaz] The smoker that was just a brilliant experience, like into in Leeds and Sheffield and various dental school, we had the dental review, and you know, there’s like pre recorded videos and stuff. But what you guys put on in there. Live performances, and comedy skits was a level of wit I’ve never seen in dentistry before. So that was just amazing. So you came on my radar then. And then on the workshop, it was really nice. you’re logged into Dentinal Tubules Congress recently and you’re on the first workshops to sell out so it just speaks volumes about you as an educator. But for those people who might not know you, probably you know it outside in case someone hasn’t heard of you, for example, just give us an idea of the kind of your little background and what drives you?

[Ian] Okay, wow. Well, I mean, thank you for that very, very generous introduction. My background believe it is a general practitioner, I never set out to do specialist training. I feel a bit like I listened to Amit’s podcast recently. And he sort of wandered into perio by accident and I feel a little bit the same. But I will I qualify in ’98, the specialist list we’ve just been established. So none of us knew whether they were going to be any good or not or whether they’re going to last for a long time. So I was a general practitioner for many, many years. But I also had this small role in the hospital that was basically just working in the A&E department and it morphed into a small perio teaching job. And from there I just I was bitten by the perio book, so to speak. And I just found that I really enjoyed it. I found that I think undergraduate perios a lot to answer for in the UK, though this is particularly dynamic, I don’t think we get access to the better patients. So I don’t know that undergraduates see what real perio is about. And I also think that people don’t understand that periodontist, don’t just spend all day scraping rubbish off people’s teeth. You know, we, Amit was talking about recession management, we also do implants, implants management. We do the sort of regenerative perio surgical stuff. It’s a very surgical discipline. And so yeah, I eventually got onto the specialist list about 10 years ago, after a 10 to 12 year career to GDP. And I sort of hope that I’ve never lost that general practice background, I hope that’s one of the things that keeps me relatively real. And I think the thing that drives me is, I just genuinely love passing on knowledge and trying to demystify perio.

[Jaz] That is so evident in your teaching. Honestly, I’d say that is really evident the way you explain things. And then the passion behind it is oozing out of you, when you’re teaching. So please keep it up. Because, you know, we need this and in every desperate discipline, but especially in perio, to inspire the new generation of dentists, because as you said, it’s a great point you made about the type of patients I mean, literally, it gave me flashbacks to kind of perio patients I had as an undergrad, and you know, you don’t see that success when they come back. And then you wonder why and then you sort of lose hope in perio. And let’s not even get into the system of the UK and how you practice and how that might have been not not be conducive to getting the best results. But you raise a really good point there. But we need clinicians like you to inspire the next generation.

[Ian] Yeah, well, I think you’re right, I know, Liverpool, one of the problems I used to see and I was the Perio in Liverpool for many years, was the type of patient we would have would be the professional patient, you know, the patients who’ve been in the system for 20 years. I mean, those patients were effectively maintenance cases not true disease management cases are so undergraduate perio was mainly blooming plaque and bleeding skills and six point pockets, yards and a little bit of debridement. But they never actually saw the juicy, you know, eight, nine millimeter bleeding pockets. And so people just get a real misunderstanding of what perio is and what it’s about. Not to mention the fact that as some of the academics make it very, very complicated, you know, you’ll have signed lectures on, I don’t know, hyperactive macrophages, and all these amazing host response lectures from wonderful scientists, but not necessarily real world perio on how you treat perio in practice, and that’s one of the things that when I, when I got involved with perio courses, in Phil Ower 12, 13 years ago, I’d already been on Phil’s courses as a delegate. And I just remember thinking, Oh, my God, that’s it that that Penny drop moment of, that’s all perio is it, some very simple concepts delivered very, very well. And for 70, 80 90% of the population that will do most of the time. And that passion surpass that simplicity on, is that one of the things that drives me, people overcomplicate stuff, as you well know. I mean, occlusions are classic, isn’t it? Occlusion is one of those massively over complicated subjects, when actually there’s some very fundamental principles that if you do that, right, most of the time, most things work, and it’s the rare cases where you need the, is my experience. [Jaz] That is the way you said that is I can completely know for those who are listening, I’m nodding all the way through. You’re so right. And I think the real world, like you said, is exactly what this episode is going to be about. It’s about the whole communication side. Because, like with every disciplined dentistry, especially my restorative background, it’s not so much about how good you are with your hand skills. It’s not about how good you are in delivering any piece dentistry is about how your patient perceives it and how the patient feels when they’re communicating with you. Like I’ll give you an example. Give those listening example. I used to do this [inaudible] Riverside communicators, it was Toastmasters. Even we were Toastmasters communication. So as a Toastmaster so almost like training for podcasting, I was trying to put myself in unfamiliar, awkward scenarios. So I can develop as communicator. So we used to do these talks in Richmond by the riverside communicators and it really you know, I remember first time our heart was pounding. And as the weeks came by, I was getting more and more confident it was a great experience. I highly encourage anyone to do that, to put yourself in an out of your comfort zone to try and become a better speaker, a better communicator. And we’re doing a one, telling one story or one communication pearl about I was talked about my son or something. When I won this little prize that evening, I put it on YouTube and everything. But later on, and he just knew I was a dentist. I didn’t really talk about dentistry at that much at all in presenting. But he came to me later this guy in the audience, he said, Wow, you are amazing. I want you to be my dentist and driving home that day and I was like wait a minute, I don’t understand this. He hasn’t, he knows nothing about me as a dentist. He just saw me deliver a speech very well because you know I polish it and I practiced it, and he saw me as a good communicator. And that’s what he, that’s why he wanted me to be his dentist. And that’s when I really realized, actually, it is all about the communication, which is what we’re going to make this episode about. But I suppose that’s been your experience as well.

[Ian] Without doubt, I mean, perio is, I don’t know, probably 80% psychology and 20% dentistry. You know, we, the largest change that takes place in my surgery is behavior change. You know, we are manipulating patients, that’s not the right word manipulation, but we are, we’re manipulating patients to do the things they need to do that’s right for them. And we’re doing it in a way that they think it’s their idea, we want lasting behavior change, we don’t want that sort of join the team in January, not having been in February type approach, we want a lasting change. So the patient really needs to understand them and buy into it. And once we get that behavior change in our specialty, and in general practice, everything else clicks, everything else works, the simple stuff works, the complicated stuff works. But the behavior change takes place first, and that’s one of the things I really like, I like those. I like those even those difficult patients, particularly patients who think they know it all and they just want me to roll my sleeves up and get stuck in. I love the challenge of the communication of making them understand, I really enjoy it really enjoy.

[Jaz] Dhru says, Dhru Shah says that his role, he’s seeing more and more as a Mr. motivator type of role, more than anything, more than anything behind what you got taught at perio, It’s a Mr. motivator. Also, you’re totally right about communication. And that’s why communications is a big topic. I’m so excited to delve deeper into this topic. So let’s go for it. [Ian] Yeah, Let’s do it. [Jaz] People need to hear, dentist need to hear the following. Right? I saw it must have been about couple of years ago now my first experience and a lot of people have talked about before but you the way you explain perio to patients, Ian is something that every single dentist in the world right now every single dentist, every single hygienists, every single therapist, everyone needs to hear this explanation. And eventually, all our patients need to hear this, because I’ve tried it various ways when you cover this, well, you explain perio in various different ways. I just thought your way of doing it. Something that you’ve inherited or something that you’ve modified over time was just brilliant. Would you mind sharing that way? I think you’re familiar with what I’m talking about, right?

[Ian] Yeah, it’s a fairly big part of my day, and it’s fairly repetitive.

[Jaz] Your nurses must roll their eyes every time.

[Ian] She know. I feel sorry for the poor girl. She’s just sits behind me rolling her eyes. She could deliver this speech herself all the time.

[Jaz] Please, I really want to, I want to hear this.

[Ian] Okay, well, the first bits a bit of a chat. And then there’s a picture that I draw on them. I’m going to try and draw that picture on the screen. And I remember watching your canine risers bit. I’m watching your drawings, I’m hoping my drawings are a bit better than yours, Jaz. [Jaz] It’s very difficult. [Ian] So we tend to these, we sit the patient back, we do the examination, we sit them back up. And we start the conversation along the lines of ‘Mrs. Jones. I’ve just looked in your mouth, and I can see that you have some gum disease. Do you know anything about gum disease? And we always ask the question because we want to engage, we want the patient, the communication has to be a two way street. It shouldn’t be a monologue, it should be a discussion. The beauty of asking that question is also that you get to understand their misconceptions, anything they don’t get, or they’ve got wrong or you know, the classic Well, I lost the tooth for every baby I had or you know, just that the classic old wives tale. ‘So, Mrs. Jones, I’ve looked in your mouth, I can see you’ve got some gum disease. Do you know anything about gum disease? Once they’ve had the chance to speak? I say well, that’s not quite right Mrs. Jones. Gum Disease is a disease of inflammation, your body produces inflammation and that inflammation damages the bone that holds your teeth in place. Do you know anyone with arthritis, Mrs. Jones?’ And often they’ll know somebody who’s got arthritis. I said, Well, well that patient they have inflammation that damages the joints and the bones in the joints. You have a similar disease where your body produces inflammation, that inflammation damages your bone. Mrs. Jones the one thing we know about gum diseases that’s a bit different to arthritis is why gum disease starts Mrs. Jones gum disease is triggered by bacteria. Bacteria builds upon teeth, it triggers inflammation, and that inflammation damages your bone. So this this is the bit where you explain to a patient that they’re rubbish at brushing their teeth, but you do it in a way that you don’t offend them because that’s that was the thing I find most difficult. Mrs. Jones, bacteria builds up on teeth, it reaches your trigger points. Your body triggers inflammation, that inflammation damages the bone. Mrs. Jones, it sounds a little bit like we’re criticizing your cleaning. I’ve looked in your mouth Mrs. Jones and your cleaning would be about a seven out of ten. And if everybody walked around with seven out of ten cleaning, I’d be out of a job. Mrs. Jones.

[Jaz] Brilliant. I love where this is going because that little bit is so good because it tells them that No, they’re not likely 2 out of 10. Sevens. Okay, that’s not bad. I’m doing okay. But it puts you’re about to put in perspective that they are different, right? There’s something unique about them.

[Ian] Absolutely so yeah, I mean, it’s the, I think Professor Youngson at Liverpool used to call it the poo sandwich, you’re delivering some horrible information wrapped up into nice big bits of warburtons bread. So Mrs. Jones, I’ve looked in your mouth and your cleanings about a seven out of 10. And if everybody cleaned that seven out of 10, I’d be out of a job. Mrs. Jones, unfortunately, your seven out of 10 cleaning is not enough. Because your trigger point is much more sensitive than most people. Mrs. Jones, is it okay if we spend a little bit of time looking at your cleaning, and seeing if we can get you from a seven out of 10 to a 10 out of 10. So that we can get you the right side of this trigger points. And we can switch off this inflammation. And so that’s essentially the opening spiel that develops the concept of bacteria triggers inflammation, inflammation damages bone. And off the back of that we’ve also explained to them that, that this is concept of one size doesn’t fit all because you’ll know yourself, Jaz, you must have seen patients with very clean mouths and very aggressive periodontitis. And then you see patients with filthy mouth and no real disease mild gingivitis. So we know, as professionals, we have this spectrum, we’ve got to get that across to the patients that there are a spectrum, the more sensitive ends and whilst it might be. I mean, you could tell Mrs.Jones a 7 out of 10, you could be thinking 3 but you don’t tell a 3 you tell a 7 you’re trying to meet, you’re trying to break down barriers, you’re trying not to offend..

[Jaz] This is why you’re genius, this is what we’re saying is absolute genius, because you’ve made it palatable for a patient and not to dishearten them because what people wanted to see what we want to us to do is like, Okay, this is, you know, really a bad scenario here. We got plaque here, plaque here, we need to, you know, use the cracked end of the toothbrush. Yeah, it’s something that’s really not motivating the patient anyway, but what you said is, okay, we’re seven. So that gives them a little bit of hope that okay, because they obviously have been giving some you know, they care enough to be there at your surgery right now. So you need to give them that validation. And that’s why so it’s amazing this way of explaining because it essentially teaches them the concept of perio disease, via inflammation in such a way that it’s just absolutely beautiful and engaging way. So that is phenomenal. I’m so glad that you share that. Any challenges. Have you ever had anyone who’s, what do you do with that patient that that bloke in there, you know, bloke or the arms folded, who’s just not engaging? But what if when you say, when you ask that question, Do you know anything about Perio? And they say no. And then they say one word answers? How do you manage that? More complex patient? How do you get how do you draw blood from a stone?

[Ian] Blood from a gum? I think that the next Well, probably before our conversations happen. The first question that I think most dentists will ask is, why are you here? What brings you to us? What is, I always ask what is it you want from your teeth in the next in the next 5 to 10 years? Because I need a buyer, I need a motivational tool or an emotional buying effectively is what I’m after somebody that I can go back to and use against them. So I need to know, they want to avoid dentures, they want to get rid of the halitosis, they want veneers for their son’s wedding, they want to start their orthodontics. I want to know what their motivator is. Because once I’ve got that motivator, everything can teach in them relates back to that motivation. And that there is behavioral science on this, there’s good evidence that shows that behavior change takes place more readily if the information delivered is perceived by the patient to be relevant to them and not just generic. So, you know, the minute I get the patients who said, Well, you know, I, my dad had dentures and I don’t want dentures. Well, that difficult patient you can say to them. You told me at the start of the appointment, Jaz, that you wanted to avoid dentures. But the things that we’re going through now are about avoiding bone loss, avoiding tooth loss and avoiding that transition to denture wear so we need you to understand the following before we can get on with any treatments. And so I think the challenge is always finding the time. And I’ll be honest, if the people always think from a periodontist point of view, that we have this sort of elite group of patients who you know, do everything we say. They do, and they don’t and I also spent many years working in the hospital service where we provide a treatment for free. So it wasn’t just high value treatment. And you do get patients who just don’t care about their teeth. Some people are waiting for the day that they moved to dentures because that was the best day of their parents lives. Everything was great after their dentures and with those patients. You might find that they’re unmotivated? Well, I think you’ve got to find their emotional want, and relate everything back to that, because then they’ll perceive it being relevant to them.

[Jaz] Protruserati, I just want to highlight that what Ian saying here is not just relevant to perio. This is Dentistry 101. This is something that I wish we were really emphasize more as an undergrad, because it really really is such a big deal on every communication course I’ve ever been on. But that is the takeaway message that you have to relate everything back to the goals of the patient. And if there’s one thing I learned during dental public health, believe it or not, the only one thing I learned was that when you give someone knowledge, we used to think it changes their attitude, which impacts their behavior, but we know that that’s a false model, and it doesn’t work and just arming someone with knowledge is not effective enough. And that’s what you know, in Perio, if you just tell someone about gum disease is not enough, you need to then just like Ian said, we need to relate it back to their own individual goals. So whether you’re planning for perio stabilization, or teeth straightening or veneers or whatever you need to really, really, really make it tangible for the patient with relevance to their goal. And you will see a massive uptake on the treatment that they should be getting done. A massive change in their sort of general attitude and the towards dentistry. And I think what you’ve highlighted there, I just to highlight myself, it is the very crux of communication dentistry. So that is brilliant. Next question I have Ian is referrals, you get referrals, you are in a referral space practice. And I thought this question whereby perio is one of those things whereby you might find that you you get an out and there’s me just postulating because I’m thinking about them when I used to refer a staff and as a dental student, and all these sort of what were the challenges my colleagues face is that you might be getting some patients. And you might think, hang on a minute, all you’ve done is the basic oral hygiene, non surgical drive, and you’ve got the patient a good result. And you think, why couldn’t the GDP do this? Now, obviously, in the environments different like when you’re going to when you get referred to someone, and the patient is coming, or when a patient come to me for a splint must be referred by local GDP. They’re already bought in a little bit. And they already think that this guy’s awesome, because he’s an easy solution. So there is a bit of a change, right? When someone refers someone on, they always think that Okay, so I think people when they come to a specialist, the take up, the buying is going to be more just because that factor. But do you think a lot of your, what percentage of your referrals you think could have been managed in GDP? And where do you think it went wrong in communication? If that’s a fair question that led to them being at your chair rather than being treated at that practice?

[Ian] Okay. Yeah. Great question. I remember reading that when you sent it through difficult question.

[Jaz] It is sorry.

[Ian] If we take away the mucogingival work and the crown lengthening and that type of work that we do. If we just sum up disease management? I would say it’s probably as high as 70 to 80%. Could it be managed in general practice? In the right practice with the right clinicians? And I know, you mentioned the dentist there. But we’ve got to remember our hygienists colleagues and therapists colleagues, did a wonderful job. You know, I have some brilliant referrerals, hygienists and therapists who send these patients to me, with nowhere else to go other than surgical intervention. It’s not that they’ve under treated the patients, it’s, they’ve reached the end of the road. So we, I think, probably Yeah, probably 70%, at least could be could be managed in general practice, because I would say that 70 to 80% of our patients are managed nonsurgically on referral. So you maybe just maybe we can do treatment better than some people, you know, it would be wrong, you know, anything you do all day, every day, you get good that, don’t you? That’s so there are some times when just that little bit of extra skill or knowledge or something makes difference, or the patient Penny dropping communication, but I think there’s no two ways about it. And we don’t want to be too political here. But the system in the UK has devalued Perio. And I don’t just mean I mean, the NHS has devalued it, they’ve never understood it, they’ve never paid for it effectively. And the time allocated to perio is just insufficient. That you know, the communication alone takes me 20 minutes half an hour, that’s before we even treated the patient you’re not going to do that for three days. But even when you take that across the private practice, because of you know, if you spent a decade in NHS practice, you will have the skill both in the perio communication and in your perio treatment skills. And you know, even patients going to a private practice we see them sometimes on the treated on demotivated, and I think it’s the hangover of that NHS mentality, which is desperately sad because it’s the number one reason for tooth loss in the UK in the half of population. It’s essentially a preventable disease. And with the exception of the really lack field, the old fashioned aggressive periodontitis patients, you know, most of the stuff is, like we said at the start of this, the basics been done well, and when when you get the patient’s doing their bit, and when we do our bit to a reasonable standard, most patients would get better.

[Jaz] I was Yeah, I was thinking that you would say this, you know, because it’s something that I thought that a lot of our patients just need the basics done well, and it starts with the communication. But I think now that everyone’s listened to the way that you communicate, if like you said, it takes you 20 minutes to really make that connection to figure out what is that patient’s prime motivator, the prime goal, and to be able to listen to them, when you ask them that question, What do you know about perio, and to give a tailored response, and I should go walk through that process, make your diagram. I think if you are in a practice, where you’re not getting enough time, that I still think you can take something away from this podcast episode, and apply it. Just tweak your communication. And I think that itself will get you great results. And if you are, you know, amazing that you mentioned about the hangover from Manchester, if you’re in private practice, and and you feel as though you’re feeling not so confident in your perio skills, and now is a time to upskill through education, through courses, which actually reminds me, Ian, when you started to get into perio as a GDP, and you starting to get into Perio. Here’s an interesting thought I’ve just had, back in, you know, the early 2000s, maybe when you were starting to do these perio type procedures, through mentorship and trying to sort of get out of your comfort zone with procedures and whatnot. Do you feel as though that perhaps in today’s climate, to be able to do these sorts of procedures, I know you teach GDP crown lengthenings, you taught me crown lengthening and stuff. And still I’m happy to give it a go. But it takes me like in a micro steps, baby steps. Whereas perhaps in you know, when you were a young dentist, you were able to maybe go take leaps out of your comfort zone rather than micro stpes because now we’re perhaps practicing in a defensive way. And that might then hamper your development or development of interest in to perio. Because then really, then the only people going to perio is when they go into whole-hog, the specialist pathway. Maybe we’re seeing a dying breed in the special interest in Perio because you’re not able to go out your comfort zone. Does that make sense? The question?

[Ian] No, it really does. It really does. So basically, what you talk about is the old days you’re telling me that I’m old? That’s what your saying, Jaz?

[Jaz] NO.

[Ian] I’ll tell you that. He’s talking about communication guys. That’s a masterclass in, not offending the patient? No, no, it’s I think it’s very valid. I think I definitely see young graduates terrified of litigation. And it does, it paralyzes them in terms of moving on and progressing. And I think it is a more difficult time. And I think we do have to be very confident when we move outside of our comfort zones that we’ve got both the knowledge and some basic skills, there are never going to be enough periodontists. So we do need special interest GDPs in perio. And there are lots of courses out there that develop that now. And I think what people need to do is probably take a leap out the Implant World Book because look at the implant world, those guys. They go from nothing to big surgical stuff, drilling holes in people’s bone. And what do they do? They invest time, they invest in not just courses, but they invest in mentoring. Mentoring is just a standard across implant dentistry. Well, you know, why do we not have that in perio, or in occlusion or in restorative. Go on a course, develop your skills. And when you’ve got your first couple of cases, I mean, I offer this to all of my delegates, they can bring a patient to me and we’ll do the case, the first case together and we can work on the fees and everything else, but at the same time, they can bring that patient to our clinic and we’ll do the first surgical case together or the second or the third. Because sometimes you just need somebody there even though you know it inside out to just hold your hand on the first time you do something. I have the luxury of having that experience within the hospital setting. I was lucky to be taken under the wing of a lady called Eileen Thiele, many of many old Liverpool grads will know Eileen and I just spent a day a week doing perio surgery onto her provision for about three years. It was just amazing. And my surgical confidence grew. I mean one week she’d nurse for me, the week one when I’d guide nurse for her and watch her. The week after I’d be doing the same procedure. She’d be nursing the week after I’d be on the clinic doing that procedure. She’d be in the room next door and it was just that, it was a steep steep learning curve. But I think mentorship is probably the way to go because the implant guys have got that nailed on and we probably need it across the board in dentistry now.

[Jaz] I really like that parallel you drew with with implants and their pathways and I think if you are a young dentist who’s trying to find? Okay, what is it that they want a niche into? And if perio is looking exciting to you, then yes, find a mentor. And yeah, upskill, go on those courses. And yeah, you’re totally right. Look at what they’re doing in the implant world and see how we can model it in endo, model it in perio, modeling all these disciplines as a modern contemporary way in this scenario we’re in, to be able to progress and get out of your comfort zone and try and take those leaps again, rather than just restricting yourself to little micro steps and really suffocating your growth in a way. So I really like that a lot.

[Ian] It’s sacrifice though, Jaz, isn’t? That it’s the thing that I see with some dentists is they don’t want to sacrifice time or income or profit. And, you know, the, we have some great young clinicians who come and spend the day with us and just just to watch what we get up to. And you know, that they’re giving up a day salary or a day’s holiday. And in five or 10 years, I know who the superstars are the next five years or 10 years are going to be because they come and spend the day with the people in our team in five or 10 years time they’re friends, they’re dental school mates to be saying to them, oh, it’s all right for you, you’re dead lucky look at where you are today. And it won’t be luck, it won’t be luck at all. It will have been, it will have been planned, it will have been time, it will have been sacrifice. You’ve done it. I’ve done it. You know anyone who’s anywhere has made that sacrifice. You can’t well, can’t say enough, it doesn’t happen overnight, there’s very little luck in life, most of this stuff is planned.

[Jaz] That is absolutely brilliant. I think that’s gonna be a gem I’m gonna play in the beginning because you’re so right sacrifice is something that, it’s so true, I just can’t say any more than that is is so true that you have to put yourself in these scenarios where you’re not earning for a while and you’re making these big financial decisions, because you’re investing in yourself. And even just time away from the clinic or, or taking that leap of faith that okay, this is what I need for the next step. That is amazing. I’m not talking about the next thing is just being mindful of time. Because while we can talk for forever, you might have to do a two part here. We touched on this with Amit a little bit on the recession episode, but I sort of hear your take on it cuz you know, you’re so great in the way that you communicate, the inflammation process to a patient, how do you, Ian, communicate to the patient that there are some risks involved inherently in Perio treatment, when in terms of blank triangles, recession, sensitivity, to make the patient truly understand the importance of it and what they’re getting self themselves into, and why the juice is worth the squeeze?

[Ian] Yeah, it’s probably the most difficult sell, isn’t it, because most of the time, I am making the patient’s look worse, but also at the same time making them healthier. This is where I tend to do two things, I draw a picture and I have a bank of photographs that I use for patients. So I can, if patients say what’s gonna look like? I can draw a picture, but I can also open my laptop and show them. Because I mean, I know you’re big into photography, a picture tells 1000 words and so if you can show them, if you’ve got a mild perio case in front of you, you can show them mild black triangles. If you’ve got an advanced perio case, you can show them a picture of an advanced disease management case with lots of recession. The most powerful thing I do when it also fits in with the medical legal aspect is a draw a picture. So I’ll try and draw it now I don’t know how well this is gonna work, but we’ll see. So and I’m going to draw it back to front so I say I say to patients, teeth have (it upside down as well, by the way) teeth have roots in the crown. I say your gum should be up here. And when the gum gets a tooth, it’s supposed to do this. It’s supposed to form a little seal on the roof. And that little space Mrs. Jones, we call those pockets, underneath the gum when it’s healthy this should be bone and the tooth on the bone, never touch. There’s a little ligament, the whole tooth against that I’m thinking of like a shock absorber. Mrs. Jones, I’ve just looked at your x rays, and I can see that you’ve got some bone loss. Mrs. Jones, sometimes the gum shrinks and follows the bone. I’ve looked in your mouth and you’ve got a little bit of shrinkage. But you’ve also got these bigger, deeper pockets. Can you see a problem with these bigger deeper pockets, Mrs. Jones, and you’re hoping that she says ‘How am I going to keep those clean?’ And she doesn’t say.. [Jaz] The penny drop moment. [Ian] Yeah, no, I would say that is the, this is the biggest Penny drop moment patients will say to me, ‘Ah, that’s a pocket’ and they’ve been under someone’s care for a decade and never actually understood what a deep pocket meant. And so we explain to patients that they’re going to clean up here like an Olympic gold medal winning toothbrusher. And once they do that we’re going to clean the space. Now this is the bit that answers your question. I say Mrs. Jones when you’re doing your bit and we then do our bit and we clean the pockets, we’re going to switch off the inflammation. Can you think of anything? Mrs. Jones that’s inflamed like a spot or a bruise? What happens when you switch off the inflammation? And they say, well, it shrinks. So yeah, it does, it shrinks. Mrs. Jones, the good news is the gums are going to shrink that way, they’re going to shrink and form a seal on the root of the tooth. The bad news, Mrs. Jones is the gums goes are going to shrink that way, the gum is going to be a little bit lower, there’s going to be a bit more of the tooth exposed, but your pockets are going to be smaller. If your pockets are smaller Mrs. Jones we can keep on top of it, the trigger, and we can keep that inflammation away. Now if they then say, I don’t want my gums to shrink, there’s a really old everybody’s heard it really cheesy line that we all use. And we say Mrs. Jones, it’s better to have a longer tooth and the tooth no longer. And I know that’s cheesy, but it.. [Jaz] I love it. [Ian] The research tells us that 70% of pocket healing is recession. So we know we’re going to get recession when we treat perio. And they either, you know if they want to save their teeth, they’re gonna have recession. And they’re not a choice where we’ll have one or the other or. Success will mean recession, because that is just the nature of the beast, the thinner the biotype, the bigger the recession. But about 70% in pockets over six millimeters is going to be shrinkage. If they want to sit on them, we then, the first thing they’re terrified of, as you you will well know is the aesthetics of that. So we tell them, Look, we’ve got to get things stable. Once they’re stable, and we can establish how much recession is happened. We can then look at managing the aesthetics, we can. But the line I use I say, Mrs. Jones, you’re worrying about the decorating when I’m worrying about the subsidence. You’re redecorating, or you’re thinking about what curtains you’re going to put up or what wallpaper you’re going to use. But you’re footings are insecure and the house is going to fall down. Let’s get everything secure and stable.

[Jaz] Genius analogy. Ian that is a genius analogy. I’m so glad you said that. Everyone pinch that. Everyone’s writing that down.

[Ian] Because then I mean, you know we’ve got things like you know, we can do black triangle closure with direct composite bonding. In advanced cases, we’ve got really fabulous gingival veneers that we can use. There’s lots of ways, even Perio or ortho these days, you know, some of the stuff that I’m doing, some of my specialist, ortho colleagues, he’d be surprised that how adventurous we are with some of these ortho advanced perio cases with the ortho we do. There’s a lot we can do to make these patients look better. But we can only do it when we’ve got stable basis. And so they’ve got it, they’ve got to buy into that. And if they didn’t want it. Yeah, their alternative will be things like dentures, extractions, and all on fours, you know, but then we have to educate our perio patients that implants have an increased failure rate in because of the history of perio. So implants are not always the answer to the question.

[Jaz] Ian you’ve covered that absolutely, brilliantly. I won’t have time for my new classifications and perio case because you’ve just covered. So honestly, we covered it so well. I mean, I think this is the, this is what I wanted in the back to basics month in August, I think there’s going to come away and people may feel refreshed and recharged and be able to be excited to implement some of these new communication skills in our daily practice cuz I think this is one of those episodes we record now that people can use on Monday morning straight away. Ian, I want people to be able to know about the wonderful work in education that you do. Please tell us about where they can go to learn more about you know, being able to shadow you, being able to go on your crown lengthening courses, being able to learn from you as a mentor in Perio. [Ian] That’s very kind, Jaz. My teaching brand is perio courses. So the website is www.periocourses.co.uk. And all of our teaching is on there. And we are available all over the country. We do everything from one day courses through to a four day masterclass that includes surgical training. My practice, I’m an associate, I’m based in Liverpool and in Wilmslow to Super practice run by great, great people. And yeah, we have people come to spend the time with us just to see what we get up to and see if they, you know, we get a lot of young dentists who are thinking, you know, do I want to specialize in perio? Is it for me? And even just to hear the communication that we do with patients, we have a lot of people come spend time with us. So yeah, just get in touch through the website. Have a look at the courses. We do a lot about communication on the courses we really delve into that a bit more because it is a big part of the psychology we get we delve into a bit more of that. But yeah, it would be great to see some of your occlusion geeks on some of these perio courses.

[Jaz] I’m sure they’d love every moment of this and i thought i think you know this is the way forward if you’re someone who’s thinking about an interesting Perio. People like Ian are just amazing. I’m so excited to meet you again at two bills in Brighton. Catch up in a drink with you may. So thank you so much for coming on today and you’re absolutely amazing. I can’t wait to get this out in a week or so. And I’ll look forward to catching you in Brighton.

[Ian] Yeah, thanks, Jaz. Keep up the good work. And if anyone we go for tubules get joined up. It’s the, it was the best two days of 2019 when I went It was just an amazing two days. So get signed up.

[Jaz] I’ll put the link on the website you guys if you haven’t like I said you haven’t been to a tubules Congress before it is not a normal conferences. The vibe is just amazing. So I’ll make sure I put that link protrusive.co.uk under the episode. Ian, have a lovely day today. And thanks so much coming on.

[Ian] Take care, Jaz. Have a good day.

Jaz’s Outro: There we have it guys. I told you his way of explaining periodontal disease to patients is just amazing. And I hope you listen to the relevant chapters. Again, if you if you head to YouTube, if you’re watching on YouTube. Now there’s a highlighted bit we can watch that exact moment where Ian explains the way that he speaks to, I think it was Mrs. Jones and Mrs. Smith. I forget who it was now, but it’s just beautiful. It’s just beautiful in every way. And I think it’s going to really make a big difference to your periodontal outcomes. Hope you’re enjoying this back to basics series. Do join us on our Facebook community, the Protrusive Dental community, I’ll put the link below and of course hit subscribe if you haven’t already and I’ll catch you in the next episode.

Hosted by
Jaz Gulati

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