Composite vs Ceramic with Dr Chris Orr – PDP030

Jaz’s Introduction: Hello, everyone, and welcome to another episode of the Protrusive Dental podcast. I have got an absolute Rockstar and I use that term purposefully because I’ve got a story associated with Chris Orr. Dr Chris Orr who’s coming on the show, say to discuss about a mammoth topic, which is basically composites versus ceramic, which is best and how do you choose? So the story with Chris Orr is when I was a student, when I was about a fourth year student, we’d have these dentists who were several years qualified, come in, and they will be learning how to place implants. And we’d be like on these clinics just floating around as students do doing nothing much. So anyway, I got talking to another dentist, and he was giving me some advice as me being a fourth year dental student, he wanted to give me some advice, just thought was very kind. And basically, he was basically blowing off some steam. He was having a rant about the state of dentistry in the UK, he wasn’t a very happy dentist in terms of how dentistry was in the UK. And he kept saying, look, if you really want to be a great dentist, if you really want to be an amazing dentist, you have to go transatlantic, you have to go to the USA and do some training there or get to a American Dental do a postgraduate degree or do some courses in USA, and basically move to USA is essentially what he was saying to me. But then he said, however, there is one dentist in the UK that I think is amazing. He said, Have you heard of Chris Orr? At the time I hadn’t heard of Chris Orr, and he said to me, Chris Orr is a rockstar dentist. And that has never, I’ve never forgotten that, that has never left me. So whenever I see the name Chris Orr I always think Rockstar dentist basically. So obviously, that dentist, I think I see where he was coming from. But I think nowadays, with the UK also producing such we already have lots of great dentists. And I think that perception that USA has better dentist and UK, I don’t think it’s 100% true at all. Whether the training is better may be a different story, but definitely the color of dentistry in the UK, something I’m proud of. And we have some huge names and one of them is Chris Orr so it’d be great to chat to Chris Orr today. The Protrusive Dental pearl I have for you is I’m going to show you how you can quickly rotate and edit your photos and crop them. So they look more presentable. So there’s a typical lower occlusal shot that you have. And when it comes out the SD card onto my Mac, there’s what looks like it’s in the wrong orientation, it’s got excess on one side that we want to get rid of. So all I do on a Mac, and it’s very similar process in a Windows is I’m gonna click on Edit, crop. What I do then is a first one define my borders. So here we are on the buccal surface at seven. I mean, this is a good occlusal shot, not perfect occlusal shot, because it would be nice to have a bit more retraction in a lower labial segment. And we get all the way to the seven, which is pretty good. And there we are, so I’m happy with that. So then I’m gonna do is I’m gonna rotate twice, once, twice. And then of course, because a mirror image, you have to flip it. And that’s it easy as that quick as that I’ve got my correctly orientated occlusal photo. And the other question I get is, how did you get those posterior quadrants, sort of quadrant photos? Well, one way to do that, which is not the way I like to do it, but one way if you want to do is again, once you go to the right orientation, you crop it. And let’s say you want the lower left side, because you’re going to show the patient that everything is not doing so brilliantly in this area. So you’re going to crop it around about like that. When I click save, there we are, that’s something you can show the patient. The problem with this is that it’s not as crisp, the quality isn’t amazing compared to let’s say, when I’m doing a quadrant of let’s say caries. Here the difference is, and again, I can still crop and edit this. The difference is that in this photo, I’ve actually zoomed in on my camera lens and got a high quality zoomed in photo. Whereas the other one, you’re taking it from further back, you’re taking a 3:1 ratio, and then you’re zooming and the photos, it doesn’t look as crisp. So depends on what you use it for the other one may be acceptable, but to see this level of detail, then you only want to put it to 1:1.5 for example, and get zoomed in shot like so. So I hope that helps as the Protrusive Dental Peal for today. So over to Chris Orr and the discussion, composites versus ceramic, which is best and how do you choose?

Main Interview:

[Jaz]
So Chris, Dr. Chris Orr, thank you so much for coming on the show on the Protrusive Dental podcast.

[Chris]
Thank you for having me.

[Jaz]
You are someone you know you are someone that a lot of my listeners have sort of messaged me proactively say, can you please get Chris Orr on the show? And I think that’s one good thing that came out at lockdown, enough to get your free enough in your schedule to pounce on the opportunity, I guess. So I really, really, really appreciate it. And the people on the Instagram page were quite excited to learn from you today. And the topic we’ve chosen is something that as I said before, you can write a thesis, several theses on this topic. So it’s composite versus ceramic, how to choose, which is the best basically, tell us about what why you think this is a good topic to discuss.

[Chris]
I think it’s very pertinent for high practicing at the moment, not just returning to work post Coronavirus, locked on. But just generally, over the last probably 20 odd years, we’ve seen quite a few trends in the material science that underpins what we do on a daily basis. We’ve moved away from restorations which are retain mechanically. So a lot of the traditional Shillingburg stuff of preparation geometry, making a restoration stay on a tooth that has largely fallen by the wayside because we rely on adhesion for the vast majority of restorations that we place. And also, of course, the materials that we attach on to that adhesion have become a lot better. So composite has improved hugely away from the stuff that we had 20 years ago, which you have to be super talented, sort of Didier Dietschi, Newton Fahl kind of level brands have any kind of level of skill to achieve a good result. And their work was awesome. And it still is, but if you gave those guys, you know, playdough, they could make a tooth on a banana would look perfect. Today, we have materials that are composite materials that are really, really wonderful. They’ve been designed for a whole range of usages. So a dentist with an above average level of skill, and above average level of motivation. And a sensible amount of clinical time can do a really decent job, just great. Porcelaina also got a lot better. A lot of the thing, the materials that we had used historically, which were either very difficult for the technician to make, or didn’t look all that nice, they are sort of falling by the wayside. Not every material is dying a death. But most things do still have a place. But in how much of a place those things have. That’s something I think we’ll explore during the rest of the podcast. But essentially, it means both of these things mean that we can be very, very conservative, we can hopefully produce a restoration that’s going to be durable for the patient over whatever timescale we happen to want it to last over. So we’re in a very, very good place. And the difficulty, I think, is that the there’s always these sort of pendulums that swing back and forth, in dentistry, we’ve seen the professional regulatory pendulum swinging far too far over to the side of witch hunt, which is where we’re at. I think we’re we’re sort of starting to swing back the other way with the GDC at the moment from what I can see. But the pendulum of you know, do you prep the tooth? Do you try to do it no prep? Do you, What do you try and do? At the at both extremes, outcomes are not good. So we can prep teeth very heavily, we can get things that may look very nice. But sometimes when you think about survival, I wonder sometimes if we’re thinking about the survival of the wrong thing. So if the restoration lasts 25 years, and at the end of that 25 years, a tooth has to be removed. You know, on some level, are we really doing the patient a favor? Whereas on the other side of the pendulum, the idea to do it no prep, which is very easily achievable with a direct restoration in many cases. And there are some situations where we can do it, an indirect restoration with no prep, provided that the patient has grown a tooth that’s in the right shape, to allow us to fit the restoration on

[Jaz]
that’s a good way to put it.

[Chris]
But it is we think about it. The classic example if you can think of a peg shaped lateral incisor, that’s like an ice cream cone.

[Jaz]
Yeah perfect.

[Chris]
And the orthodontist has opened up all the space perfect, you take an impression you glue on you’re at a ceramic job done easy. You could also do it in porcelain or porcelain composite but the number of that exact presentation you’re going to see in your life, it’s going to be quite small. So it’s the reason the discussion is interesting is that some people seem to believe that every problem in dentistry can be sorted out with composite. A lot of problems can, wonderful material. But there are some there comes a point sometimes where depending on where you started from with the patient. And depending on how long you want things to last, then there may be some other things you and the patient may wish to consider, I think is the best opening statement. Other thing is, I think probably looking at some of the, and again, it’s very common when I’m talking to a group of colleagues, that a lot of the questions are along the lines of, what do you always do? Do you always do this? Do you always do that? And unfortunately, one can never be completely black and white. I wish we could. If you want to do, if you see this, and you always do that, you’re practicing probably about 50 years too late. Because if you think about the 1960s, and 70s, if you had a small hole, you did an amalgam filling, if you did medium or large hole, and amalgam, maybe an inlay, big hole crown, easy. Bigger holes not to take it out, [Jaz] way more complex [Chris] Other decision tree was very easy. Blessing and curse. Dentistry is very sophisticated these days, which means we’ve got to be really mindful of exactly what would Jesus I think the only answer that I would give to, what do you always do is look and think, lose your brain. Every one of your listeners is smart enough to make those decisions. They’ve all got good brains, we know that because they were able to get into dental school in the first place with A-level grades that are so high that I don’t know if I could get back in again, if I had to do A-levels again today. And everybody’s able to get out again at the end with a degree. So unfortunately, those require a little bit of mental effort, which can be challenging in the busy practice environment that some people have.

[Jaz]
Perfect. Well, with that in mind, one thing I can automatically say is in that position of someone who’s got into dental school is now qualified a couple of years, I’m just putting myself in that position again. And I think a lot of very young dentists were abusing composite. These were doing very, very big, large composites, for a couple of reasons. And one thing that no one really discusses about or certainly, I think we could discuss a bit more is because sometimes the and this is a communication thing is that the dentist, the young dentist is afraid to prep because of the lack of experience in preparations, they’re far more confident with something direct. And that might be hugely influential to why they may choose the direct composite, but also talking financially, a concert is always usually going to be, you know, several factors cheaper than or less expensive than a indirect ceramic, for example. And I think sometimes as a young dentist one year two year qualified, you’re not really confident enough to then say to a patient, okay, that’d be 1000 pounds for crown rather than 300 pounds for a composite, just made up those figures. So that also has a role to play in that I think?

[Chris]
It’s okay, I can understand completely where that call that sort of problem can come from. And yeah, there are a number of things that I think is thinking back to when I was in that position, a couple of years out of dental school. At that time, my world was very different. The I was I spent probably about three years working in the NHS in a variety of different environments. The diversity of the NHS I worked in, is probably closer to what you are to work in either Northern Ireland or Scotland have, where you get a fee per item without a very good fee. But you know, you get paid for unlike the current system, which is just nuts. At that time, also the if things went wrong, if you had a complication, there was often a way of it being repaired and sorted out without the patient having to pay and nothing usually, and without the NHS really noticing unless you really went crazy with your guarantee claims. These days, I understand it’s a little bit more challenging. But certainly the big talking, I think actually it I think probably for your listeners what I would say it’s an important skill to learn to look to talk to your patients to say, look, here is the problem. We can here are the choices as to what we can do, we can do this option, which has the following pros and cons. We can do this one does the following pros and cons. And we can do this one, but whatever it is. And our job is not. I don’t think our job is ever to sell any treatment to anybody. Our job is to explain and the patient makes the choice to make an informed choice. And very often the patient will say well, what would you do? And then the answer and even I get that question very often. What would you do that okay, if you were a member of my family, brother, sister, mother, whatever. Then I would choose this thing for these reasons because I think it’s the best balance A lot of patients will trust you. It’s a lot of it is building up rapport with the patient. That is not something you can manufacture, it takes time. And it takes confidence to look people in the eye and say, Okay, I really sorry, this is not a good situation, we have to take the two tides, I’m sorry. But just that sort of honesty is quite helpful. The big advantage that we have today that I didn’t have when I started off in practice, is digital photography, makes it extremely easy. Get a photograph, put it on the screen, people understand. In my day, we used to take metal film based expert hold up to the light and go to see that there. And the patient’s looking back at it retrospectively, I don’t know how anybody ever agreed to treatment on the basis of that, because they have no idea what they’re looking at, what you’re talking about, and they just go, Okay, I trust you, let’s go for it. But I think the advice would be use the humans, we are visual creatures. So use all the visual tools that you have, learned how to use a camera, so that you can show patients things so that they can understand better, and then the explanation becomes an awful lot easier.

[Jaz]
Well, I think just because it when I was a couple years, I mean, I’ve done hundreds of Restorations in direct composite, which really should have been indirect in my career so far. And that was because of all the things you know, lack of confidence at the time. And the lack of the right communication skills and rapport building and establishing enough trust with your patient. But that was just a little something. It’s not I don’t want to be your main focus or anything. That’s all interesting point. So when one thing

[Chris]
It is actually irrelevant, this is actually a relevant thing. Because we do see, and we’re all influenced by what we see on social media. And we see beautiful things. And you look at these clinical works of art. Some of them are gorgeous. And you look you think, wow, that’s fantastic. It’s much better than I can do. And you ask the person, how long did this take you to do? They go three hours. And let’s say it’s an MOD composite. That’s an unrealistic amount of time. So the next question should be, you know, how much of that time did your patient pay you for? And then the following a follow up question, but they never ever answer. How does your boss feel about that? So what I think it is an important thing that when we’re thinking about direct versus indirect, we have to be pragmatic about, can we get something that is clinically acceptable for that patient for where that varies a little bit from patient to patient, perhaps, can we get something in an acceptable amount of clinical time and amount of clinical time the patient will pay you for. And we also think about longevity. Some, there are other some situations where having something that is medium term. So that’s that let’s think about how long we mean by short, medium and long term, short term, for me, probably a is up to three years. So what’s gonna happen in the most sort of reasonably immediately foreseeable future for the patient, medium term, probably between five and seven years, and long term 10 to 15 years. And if we think about restoration, longevity over those kinds of times, and compare, time and motion. A composite restoration, we see very good data for posterior composites lasting 10 years in we’ve gone way past the time when posterior composite was pretty awful. Certainly, when I graduated, it was pretty terrible. And you had to have this conversation with the patient, saying, well, we can change those amalgams for composite, but it’s not going to last as long, not a good material. With improvements in our ability to control shrinkage stress. So the stress at the interface between the tooth on the resin and also our ability to get good tight proximal contacts, the medium larger sized coppers they perform well. And the screener will get good data to show with up to 10 years. The longevity is not different from that of amalgam. And that those are papers have been published

[Jaz]
[Nick Optam] is a big paper by [overlapping conversation] [Chris]
actually, yeah, it gets ignored by some of the UK academics because it doesn’t suit their point of view. I’m trying to think of the other one Hindson Rusan was a 2012 paper. Optam was one I think was 2014, the one you were mentioning. But yeah, those sort of papers show us that composite is no longer the peer relation of amalgam. I think probably controversial statement. One of the controversial statements that I regularly make is that what that means is that the place for inlays in today’s clinical practice is becoming much more limited. Because you look at something and you can almost gauge the age of the book you’re reading by what they suggest you do with a medium sized amalgam cavity sort of thing you inherit from an old big class two. The older books will say, shrinkage is a problem, contacts are a problem do an inlay, the newer books will tend to say composite is fine, or heaven forbid, even bulk fill composite works very nicely. So, you know, composites a wonderful material, but as long as it’s going to work for that situation for the patient. There are some situations of course, where composite is definitely better class four fractures, for example, let’s try to do an indirect restoration. I’ve seen it done. The people who are doing it have either are wonderful technicians themselves, or they have a wonderful technician. And they always say, if we tried to do a class four in ceramic, make sure you make about three of them, and you fit the one that is the most. It’s ridiculous. It doesn’t stack up against direct composite. Although, in some situations, if you think about longevity, over, let’s say, a 20 year period, if you have multiple anterior restorations, you can do it in composite. But it may need to be replaced at let’s say 5, 7, 8 years after placement, which is good longevity for composite. But ceramic will need less maintenance over 10, 15, 20 years. And if you stack it all up over 20 years, the two things may end up costing the same amount of money for the patient.

[Jaz]
Well, the one thing I want to focus with you, Chris, for the duration is yes, we can talk about anterior but a lot of the questions that I run sending in is actually more based on posterior. So I’d like to give a conversation more towards posture. And I think you answered one of the points ready, which is one of the first things I want to ask you is does Chris Orr believe in inlays? I want to hear your view in inlays because I’m going to give because because that’s you know, it’s something I mean, I personally I can tell you, I believe is I think it’s a robin hood dentistry. You’re stealing from the from the rich and you’re giving to yourself. And that’s something I heard a lecture saying, I love that. Do you think there’s a place for inlays?

[Chris]
Oh, okay, everything has its place, but I think inlays are extremely limited today. I’m thinking, I can probably count the number of inlays I do every year on one hand, and have many fingers left over. In all seriousness, the sort of situations where an inlay becomes something that I think about, if I’m treating a quadrant or group of teeth. With indirect restorations, one tooth has a large restoration that needs to be replaced. So let’s say it’s two MOD molars to right to the sort of a six with a MOD, seven with an MOD, and the five has an MO. And it’s possibly simpler, just rapid as an inlay and get the technician to make an all in one go. In those situations, I charge the patient the same fee as I would for the filling, which just about covers the lab bill, so I don’t make any money on it. Or there are some situations where in that exact situation, the plan is to do composites to replace the amalgam and you think I’m not, you know, we’re running a bit short of time here. Let’s just prep that and take an impression that will stick something in. So for those sort of situations, it can be helpful. Otherwise, no.

[Jaz]
I’m really glad you said that. Okay, so the next question is in a nutshell, What so really, the conversation is not it is about concept versus ceramic. But another way to think about it is direct versus indirect. Right? So at what point does something become indirect for you and no longer direct? What guidelines? Can you share with the listeners?

[Chris]
Okay, a few things in no particular order. The balance of longevity versus maintenance. How long is it going to last? How good is it gonna look along the way? And sometimes that stacks up in favor of indirect restorations. How long is it going to take you to get it to look good with the technique you’ve chosen at the chair side? And it’s going to take you longer with a direct technique and an indirect technique, then you have to seriously question your motives for doing it directly. Or you have to practice your direct technique a lot more. Because, unfortunately, we go on all these wonderful composite courses. And what you realize is that you’re probably not booking enough time to do the finishing and the polishing of the restoration, particularly anterior restorations, where the finishing. I’ve learned a lot from our mutual friend Joe Bansal about this, that you should spend at least 35, if not 50% of the total time doing finishing and polishing, which is much longer than many people think is correct, but certainly spend more time in the that, because that stacks up in favor of doing something indirect than in direct. Other thing of course, is the I cannot think of a scenario where the direct restoration is going to be less conservative. than the indirect. The indirect is always, not always, very often that will be some kind of preparation. And most commonly preparation is to remove any undercut relative to a path of insertion. Like we said a little while ago, if the tooth has been has grown itself in the perfect shape, unrestored peg shaped lateral incisora are rare but good example. Upper premolar is that are unrestored. Upper premolar, very often extremely suitable for no prep veneers, bond on to the enamel, like your buccal corridor works very, very nicely. And again, the other thing of course, we’re thinking about how much prep do we need to do? That’s possibly the wrong question. The question really is how much space Do you need for the material to do? So if you think about, again, some in standing upper premolar, you want to build them out let’s for the sake of argument, say the occlusion is favorable, then you don’t need to touch the teeth because the space is already there. Very easy. And I think but those are probably the major factors, probably on the other thing I think we should be mentioned is what, Where are you starting from? Are you starting from an unrestored tooth? Are you starting from a tooth where you’ve inherited some previous baggage? Baggage from previous treatments that, you know, old fillings, the results of old caries. Is the tooth significantly compromised because caries and endodontic treatment have already taken a big chunk out of the tooth. And in that situation very often where you’re trying to restore the tooth. And I don’t want to say strength cause good restorations rarely strengthen teeth, was to try and do the thing that will last the longest and do the least damage. Then again, sometimes indirect, thankfully, posteriorly can be very helpful.

[Jaz]
Well posteriorly is the the main thing I want to grasp about is when you’re looking at molars, and you look at the various configurations of cavities, how large they are and the remaining tooth structure, remaining once you remove the old restoration or the disease. At what point when you did the classical literature suggest that you know more than a third of the isthmus is something that you should consider cuspal coverage is that something that you follow?

[Chris]
If we’re thinking about isthmus, and again, in terms of giving guidelines, a lot of the time we’d like the guidelines to be a certain number of millimeters. And teeth vary in size. So rule of thumb I tend to apply I look at the intercuspal distance. And I look at the size of the isthmus of the restoration relative to that intercuspal distance. So it’s a little bit smaller for premolar, a little bit bigger for molar. Up to a third isthmus relative to intercuspal distance, direct restoration very easy to do, third to a half that’s either direct restoration or inlay. Depending on how good you’re doing direct restorations efficiently. Probably more than half would be where you start thinking about covering cusps. Plus or Minus if you’re in any doubt, and if having usually the decision as to whether you want to cover cusps or not something I learned way, way, way back more than 20 years ago from my, one of my first mentors, Swedish guy called Sverker Toreskog. Sverker always said that you make these decisions cusp by cusp, after you take out the old restoration. And then he carries. Basically same as this three choices. Option number one inlay prep, ie no cuspal coverage. Option number two onlay prep, some cuspal coverage. Option number three, what he called crown prep, finishing at the labial gingival margin. Other people call that different names. Some people talk about laminate onlays to describe that. I’ve heard veneer labeling mentioned I’ve heard people saying vonlay. Yeah, these sort of words that Americans invent to make. I like it a lot. He’s a nice guy. I’m trying to think who else but it’s at the end of it, somebody just extends up the labial surface of the tooth. So basic, and if you are working in the UK, and you’re applying that rule of thumb to the kind of cavities that you get in many of our patients coming in, who had big amalgams placed on the NHS, you’re going to be covering a lot of cusps, and that’s fine, because it’s better to cover the cusp, then have something break off and then did you can’t control where the fracture happens and sometimes fractures happen very far subjgingivally, and it’s not manageable. With all the best will in the world, you have to take the two sides, which is sad.

[Jaz]
Is it fair to say that if anytime a cusp replacement is necessary that your default is going to be ceramic?

Unknown Speaker
Yes, for a couple of reasons. One, because the likely condition to the rest of the tooth is the tooth may be in need of some further protection. Secondly, I know there are some hugely skilled people who are able to do cuspal replacements in composite. I’ll put them out there, but I am not one of them. I can do it, but it’ll take me five times as long and it will not last as long as something done indirectly. In terms of it’s not, it’s not always ceramic. Occasionally, I do get to do gold restorations, once per couple of years. Again, something we offer to patients, some people, most people say oh, yeah, thank you. But no, thank you. Even though you say okay, gold is gonna Outlast everything else that we have. People don’t seem to want it, unfortunately, even dentists who come for treatment, they don’t want gold, unless they have gold in the minds already. There you go.

[Jaz]
Well the next question then is: Composite Onlays – do they have a place in Restorative Dentistry? I mean… I’ll put my hands up say I placed quite a few in my NHS days, not so many now. My default is lithium disilicate. But is there a role for Composite Onlays in Restorative Dentistry? Indirect

[Chris]
Now, when we talked a little bit earlier on direct versus indirect, I chose my words carefully to say that the direct techniques are more conservative than indirect, not to say composite will always be more conservative and ceramic, because I’m not a big fan of composite onlays having done lots of them in 15-20 odd years ago. A couple of problems with them. Number one, they are less conservative than today’s ceramic. Typically, for composite you need minimum 2.0mm of occlusal clearance to make it durable enough to have some chance of surviving. And that’s a lot more to take off than, for example with most ceramics, lithium disilicate, you need one millimetre as a minimum – Second molars you might go to 1.5mm. On the first premolar, you might even get less, 0.7 millimetres. But let’s say 1.0mm for the sake of comparison, Gold half a millimetre. So from the point of view of conservation, NO – composite doesn’t win from the point of view of longevity. When we’re talking about onlays to patients, the conversation is along the lines of ‘this tooth, classically would need a crown’. ‘A crown involves cutting a little bit away from all the way around the teeth a little bit off the top, I’m gonna make it a little cap, called a crown that fits over the top and protects what is left of the tooth from breakage’ and so on. The usual conversation with the patient, ‘but the problem with the crown, it involves cutting away a lot of the healthy tooth is remaining. So an Onlay does the same job as a crown, only more conservatively’. We know again, from the literature that some of the survival rates that crowns versus onlays over a 15 year period… it’s pretty much the same within a couple of percentage points. So I think it’s a reasonable thing to say to the patients that are normally is ‘kind of like an extended filling – it extends over the biting parts of the tooth’ (and hopefully you’re pointing this out on the screen while you’re telling them). ‘It covers over those things, it stops them from breaking it binds what’s left of the tooth together, does the same job as crowns only more conservatively. And the other thing… I have a huge collection of pictures of composite onlays that have failed, broken, debonded etc and they’re all done by me…when I switched to ceramic, those problems went away.

[Jaz]
They’re done by you and they’re still failing then

[Chris]
Well know to be fair, they this was it was early in my career when I wasn’t as good as perhaps I ought to have those problems went away when I went to our move to doing those same things in ceramic. So for all those reasons, I don’t do them. I actively try to talk people out of doing these sort of things in composite. If you’re working in an NHS environment where your budget for the lab work is limited. And I can appreciate that’s the reality of many people. I would encourage your listeners to try and find a lab that will do a ceramic onlay within a reasonable amount of money that will fit into what you can spend on a band three, so that you get some experience of doing it. While you’re doing that, get some photographs, so that you can talk to patients through the sequence of events. Because one day you will not be doing everything on the NHS. For me, offering people private treatment. It’s not just about taking the time with the better materials, it’s not just about offering people stuff that might not be available on the NHS, it’s about you as the dentist having the experience to get the patient from A to B to C to wherever Z may happen to be. And you can anticipate problems so that the patient’s journey is as smooth as possible. And you have to have done things a few times to be able to do that.

[Jaz]
Perfect. I think the answer is about composite onlays. I was gonna ask about the choice of ceramic tools up I think that’s gonna be so mammoth, that I do want to get through some of the questions that some of the listeners have asked. So the one thing when asked just real quickly is there’s a parafunctional status of a patient play a role in influencing your material of choice?

[Chris]
Okay, if we think just about posterior teeth, we get we get an answer that question we’re thinking about ceramic selection. I guess the parafunctional status question is one about strength. And how strong does the restoration needs to be to survive in that patient? If you look at the literature, actually, interestingly, a lady in Innsbruck called Stephanie Byer has been altering a number of papers over the last 20 odd years, they placed a large number of Empress restoration, so the Leucite Reinforced Pressable. And they report at various intervals. Curiously, when they did their study population, they did not like most people do, they did not eliminate bruxers from the study population. So they kept them in. Under the study with it’s a 2012 paper where they reported on the survival of the posterior restorations. They did not notice any significantly higher rate of fracture, on people who they thought were bruxism at the time of placing the restorations. Now, to put that in context of the question about strength, it’s like a game of top Trumps. You’ve got a we’ve played it over the last about 30, 40 years. So on the bottom, we’ve got feldspathic porcelain, then the next thing that was supposedly better was the Leucite Reinforced Pressable, like Empress, which is about two to three times the strength of feldspathic. And during the years, we’ve had all sorts of other variations. We’ve had the sort of aluminous type porcelain, so the original version of Procera, which was probably about three times the strength of the Empress, Emaxs, dilithium disilicate, dilithium silicate type materials. So, Emaxs comes in probably about two, three times the strength of Empress as well. So for me, I’m not concerned about I don’t try to beat the patient’s parafunction by making my ceramic really, really strong. Because the problem with that thought process, you start talking yourself into saying, Well, I do want to do an onlays, it might be too thin. So I’m just going to crown it and you end up doing very destructive restorations. And then of course, your crown will survive beautifully but the underlying tooth fractures. So the short answer is does the parafunction status of the patient influence my ceramic choice? Not really, the patient’s willingness to own the problem, comply with whatever night guard we make for them. Because at the end of the day with bruxism has a lot in common with periodontal disease. Because we have to have these difficult conversations with our patients that you have this problem. I can’t cure this problem for you. I’m happy to help you. But it’s your problem. If the patient is expecting you to be responsible for periodontal failures and loss of teeth caused by their lack of maintenance, or the parafunctioning patient expecting you to repair everything for free forever, because they will wear the night guard or comply with whatever else you want to do. That is not a person you want in your practice. [Jaz] Absolutely. [Chris] And you need to be strict with them. Because at the end of the day, some people are very unreasonable. And you don’t want to be fixing stuff for free and taking responsibility for a problem that you cannot fix or cure.

[Jaz]
I like the comparison of perio and bruxism in the sense that yes, ownership has to come from the patient.

[Chris]
It’s not my problem, but I’m happy to help.

[Jaz]
Brilliant. Well, absolutely. Well, you’ve answered their parafunction, you know, how strong does something need to be. I think you’ve answer that quite well. So how about the situation and when you’re talking about, Personally, I get worried about placing lithium disilicate on second molars. That’s when I’d sometimes I mean, I do a fair amount of gold, for a young dentist, I think. And I also may be more likely to go monolithic Zirconia on a second molar. Then just my concern, am I right to be concerned with lithium disilicate okay in second molars?

[Chris]
Okay, it’s..And there’s another extension of that [hostile] stuff need to be questioned. Because right on the top camps game, you’ve got the zirconia type materials, the majority of which have strength over, the majority of the early versions have flexural strength over 1000 megapascals. When you’re doing monolithic Zirconia, you’re making a choice of either aesthetics or strength. The early Zirconia is that core type materials are very strong, but they’re ugly. So Lava™ is a good example of that very, very good material, but you have to put something else on top to make it work. And until it worked out hard to support the veneering ceramic, lots of tipping happen, the second generation similar crystalline structure materials like BruxZir, or that you can use for monolithic. And then the third generation, the use of Cubic Zirconia [Patana] being the main commercial example of that they much more aesthetic, much more translucent, but a massive drop in strength and the strength is at best two thirds of what the Lava™ BruxZir products are. Now and that means you’re choosing how strong Do you wanted to be versus how aesthetically wanted to be. And you get to a point where actually the, you’re not that far away from things like lithium disilicate. So I think perhaps for if you want to do something that is going to be slightly more conservative, then perhaps the monolithic Zirconia may have an advantage on the second molar where the occlusal forces are higher. If you want to do it in lithium disilicate probably that’s where 1.5 millimeters of prep would be thing. So half a millimeter more than you would do on a first molar, for example.

[Jaz]
By certainly something you don’t worry about as much as long as you do the correct lead to have the correct space for the material.

[Chris]
Yep. Unfortunately, that sometimes it’s a bit of a conflict, that, again, you see people posting cases on social media, where they say, okay, the patient’s got anterior wear, and posterior wear, let’s open them up on the front. And then we’ll place no prep onlays on the back. Yep, fantastic idea. Except that you realize that the anterior teeth have to become either a mile long or a mile thick, in order to get the space on the second molars to do that. So unfortunately, you it’s very, very rarely possible to do no prep onlays on second molars in a wear case, just because you can’t get the thickness. Sadly.

[Jaz]
You may not have to do as much prep. But because you still get some space from opening the vertical. But you still I respect your point there. There’ll be some prep, it can’t be no prep, a lot of the times. Now I’m going to just dive into some of the questions the listeners have sent. Before I do that any last words on No, the very pure conversation about direct versus indirect composite ceramic? Any points that you wanted to cover that perhaps we weren’t able to?

[Chris]
I don’t think so. I mean, it’s it’s really about the conversation, I guess, with your patient. And I think the other point that I would make about choosing, particularly if you’re thinking about choosing ceramics, talk to your technician, ask the technician what they think is best in this particular situation. If it doesn’t appear to be a run of the mill case, get on the phone, talk to the lab, the technicians fix many of the problems that we tie ourselves up in knots about they do it day in, day out. And there’s a huge Bank of experience and knowledge you can draw on. Having said that, don’t be scared to challenge them, because sometimes they will do what’s easiest for them. And you may have to be a more discerning consumer, I guess, to get the best from them.

[Jaz]
I like them. Something I learned only few years ago is that as a young dentist trying to develop and become better, why do sometimes you reach a point where actually you have to learn that you have to actually train your technician as well. And just because your technician maybe twice my age or whatever, they still have something I can, they can learn from me and I can learn from them as well. So have that. That’s a great point you made there. So question is from Nass, and he says, Do you prefer dual cure resin cement or heated flowable for bonding onlays or neither something else?

[Chris]
Right for a veneer. I prefer a light cured cement because I tend to fit them all at once on one thing to set on command. For an onlay, my preference is a dual cure adhesive resin cement, preferably a self etching one. My favorite one at the minute is Maxcem Elite™ Chroma, Kerr product, this one that goes pink when you mix it and when it’s ready for you to do the cleanup. It’s gone from pink to transparent or whatever. If I can give you your list One top tip for cementing onlays, please use it the dual cure cement. Please wait for it to set chemically and do the cleanup when it is easy. Do not do what I have wasted, probably days of my life if you added on up by trying to be clever and tack cure it with your light, always overset it always stick some things together. And it’s really really difficult to get something in between that upper six and upper seven to clear the contact, anteriorly we have those wonderful little serrated strips interproximal saws that you can go in and clear the cement with they’re fantastic. They work posteriorly but getting them in with like cutting lips and fingers and things not worth it. And the reason that I learned that when that Maxcem product came along, the color change the reaction from pink to transparent, it forced me to wait. And my nurse one day said You do realize that we’re spending on average 45 minutes less perfect appointment for multiple onlays than we used to? So even though you’ve got to wait for it initially, and I recognize that persuade dentists to wait for something is really really difficult. Because we’re all very impatient, myself included. Overall, the whole thing takes less time. So dual cure cement definitely. Now the issue about heated composite. I’m not sure why you’d want to heat flowable specifically to make it more

[Jaz]
Yeah, they said heated flowable, but maybe they meant heated composite, those will become flowable [overlapping conversation] [Chris]
The heated composite idea, that’s a thing, again, from many, many years ago, the very early version of CEREC, where the version one basically where you had to finish the occlusal surface yourself. And the marginal fit discrepancy was typically about 400 microns. One of the workarounds at that time was you put normal restorative composite, heated restorative composite into the tooth, and you seated the on the inlay, because that was all they did at that time, you see to the inlay into that. So the margin was filled up not with cement with regular composite that would be more wear resistant. So those that technique work, yes, is a pretty good evidence base of the early CEREC literature on it. Do I do it? No. Just because sometimes particularly when we’re thinking about the other end of the spectrum with our restorations, where today we’re increasingly doing very, very minimal thickness, no prep type restorations. The big advantage of all the strength that we talked about a moment ago, the restoration is-the material sorry, is strong enough that it will survive manufacturing in the lab, heating and cooling and glazing and cooling, etc. without it breaking. It’s durable enough to survive us fitting it. The number of restorations that break on fracture during cementation is very, very low fortunately. And it’s that’s an interesting name because the all the survival studies that we have, the clock starts the moment the restoration goes on the tooth. They don’t tell you how many things they broke in the lab or the dentist broke before they fitted them up.

[Jaz]
It’s interesting, never thought about that way.

[Chris]
So the strength means that we can make super thin restorations and unfortunately if you’re rough with them, they do break and for that reason, the seating pressure, hydrostatic pressure on for seating, even the hottest, regular composite. I find it’s too much and I’ve tried it and broken restorations. So, then particularly the person who talks a lot about this technique is Pascal Magne. The material he recommends for cementing veneer with heated composite is a denting shade of HFO, the Micerium, Vanini’s material. I don’t know if you’ve ever used that one. But it’s one of the stiffest composites in the universe and heating it is obligatory to make it workable for anybody, including Vanini. So how he fits things, and I’ve asked him, you know, many, can you just run me through how you fit things without breaking them, particularly the way of thin veneer that he just been showing in his presentation. And I must be missing something. Because it doesn’t make logical sense to me. So I use resin cement all the time.

[Jaz]
So even for anteriorly?

[Chris]
Well, absolutely. I mean, you could, I guess you could use flowable. I’ve used Variolink, the lighter version of Variolink which is Ivoclar material. I’ve used that for many years. I’ve used Nexus™ which is Kerr material. Either those two to be ever done any light cured cement for veneers, any dual cure cement for onlays just wait for it to cure cement to set please.

[Jaz]
Excellent. Very good tip. And then the other question which Yeah, I think this will help a lot of young dentists is do you always go for some sort of preparation join circumferentially or do you sometimes leave the buccal or lingual walls with no preparation or just a small bevel? So I think sometimes let’s say you’ve got, if I’ve got a example cavity I can show you. Okay, let me see if I can get this up just a second. It’s sometimes nice to have a visual as well. So I’m going to share this photo here. So here is a, I think it was a lower molar at the time, and we can see that crack on the buccal wall. So for me, I would be taking this buccal and I’d probably the entire buccal tie down. And I probably preserve the if I said it was a lower molar, let’s say, upper molar-sorry..Upper molar, let’s preserved this palatal. I think that’s what they’re asking is, are you happy to preserve some cusp or bevel or do you always cover them over?

Unknown Speaker
Okay, I think there’s a couple of answers to that question. One, what do you cover? And two, What sort of design do you do? So coverage, if there’s no doubt in my mind as to whether the cusp is going to be viable, I will cover it. In the example that you’ve shown the buccal cusps definitely they need coverage, I can see a lovely crack there. But so definitely cover the buccal cusps. The palatal cusp, I’d be tempted to leave and then use then life becomes more complicated. You think is that a functional cusp? It’s an upper tooth so it shouldn’t be functional. It was a lower lingual cusp I’d probably covered. How much overbite does the patient have? Do they have sufficient canine guidance or anterior guidance to make the posteriors disclude? So, if in any doubt, cover the cusp over. Second thing, what finished do we do? If I go back again to the days of using Empress, so, probably about a third of the strength of lithium disilicate, maybe not the material of choice today for that reason. Empress was beautifully translucent, and a flat butt joined would blend in really, really beautifully. Slightly paradoxically, sometimes you had to use a very broad color of cement to get it to do that trick, but all right. So it can be the flat butt end and even an upper premolar was okay. Emaxs is a little bit less translucent than that. So for a visible surface, I will place a small bevel, that small bevel will be probably two to three millimeters long, the angle will be roughly between 45 and 60 degrees. Please don’t get your protractor and try and measure it. Just something to allow, we everybody just how many millimeters is that, very dentist question. But just something to allow the ceramic to sort of feather in. I would try to keep that within enamel. I see. I do see people putting up pictures of baby preparation joint is the term that those people use where they do, it’s almost like a little mini crown prep or the, There’s a lot of reasons I don’t do that. I can understand why people think that they should do it because there’s lots of diagrams like they’re trying to illustrate onlay preparations where they show exactly that. To be perfectly honest, there’s very rarely enough tooth to allow you to do that. And if the tooth is enough to let you put that big joint onto it, you probably shouldn’t be covering the cusp over in the first place because it doesn’t need it. Also, it tends to mean that you’re cutting more enamel away than you need to, more tooth away than you need to. And then you sort of halfway down the tooth, you think I’ll just do a crown, and you end up doing something much more invasive. So for all those reasons that that type of joint, No, I don’t. So let’s say we’re doing an upper premolar so very visible tooth, the buccal surface will have a little bit of a bevel, the palate surface will be a flat butt joint, upper molars, maybe a bevel. And again, the advice I always gave when you’re doing these type of things the first time, an upper first molar is a good twist to practice your own because they’re commonly heavily restored on they’re far enough back that we don’t quite get the bevel quite right and learn how to blend the margin in this time. You can learn from it. Whereas an upper first premolar that’s one that you save for later when you’ve learned through the margin blending in trick because it’s a much more visible location.

[Jaz]
Brilliant. That’s a very good answer. And you went above and beyond to answer about hiding the margin there as well and pre molar which is very much appreciated. Thank you. Opinion on pressed Emaxs versus CAD CAM milled emax?

[Chris]
Oh, I’m not the person, the perfect person who’d asked that question. I’m not quite sure why or what specific properties you’re asking. But

[Jaz]
In my mind, I think it was probably the marginal gap in the fit of restorations. That’s why I assumed it or maybe strength or what we discussed already, I suppose but probably how well it fits in seats is there. I believe there is a difference in terms of

[Chris]
There is supposed to be a difference. But then if we’re saying that using heated composite to fill or composite in some shape or form to fill voids at the margins is okay, we shouldn’t get the marginal fit at these restorations is perfectly acceptable or within the acceptable range. The other things that sort of came to mind when I was thinking about that question, there are in some interesting sort of crystalline structure differences, if you look at them under the electron microscope, you think you’re looking at two completely different materials, the crystalline structure of the milled material looks very different to the pressed material, it doesn’t seem to be reflected in clinical performance. I think it’s important to broad distinction between what happens in the lab and what actually happens clinically, because the other version of CAD CAM, and we’re at an interesting time with digital dentistry that there are very few restorations that are done 100% analog, there are very few restorations that are done 100% Digital, each different stage, the technician can hop between the analog and digital workflows. So for some of the very conservative, no prep type stuff, what my technician tells me, when I torture him with one of those types of cases, they prefer to do it off a traditional analog impression. So that they can have a plaster model that they will scan, they will then take the plaster model, they will scan it in their scanner, they will then produce the coping on the computer, they will mill that from wax, rather than milling it from ceramic, and then the wax gets invested and pressed, so that they can go get about five even even at the moment of pressing. And that’s how you get the best of both worlds. So I think the best answer to that question is from a clinical level, I don’t think it’s going to make an impact on outcomes for your patient. But on a production level, I think whoever’s asked the question can have a very interesting conversation with their technician about exactly what the little foibles are. I think another bit of advice I would give to all of your listeners, the amount of CAD CAM your lab is doing is much more than you think. So I would encourage all your listeners when the world hopefully comes back to normal, get in the car, go and meet your technician, go and meet everybody in the lab and just have a chat, look at what they’re doing. Learn about how they’re making your restorations for your patients. It’s a very good way of that sort of first step on the journey of working together as a team with your technician. So do you together produce the best results for your patients.

[Jaz]
Brilliant. I’ve got four more questions. I think two. One is clinical, and three are actually non clinical. So the clinical one is what are your views on the BOPT techniques for those listening and watching is the Biologically Orientated Preparation Technique. There’s a paper by Ignazio Loi I shared some episodes back that you can download. But obviously the other word for it that people are now using is verti prep, Etruscan prep. Chris, can you tell us about your views on this very old preparation, which has now become in fashion if you’d like?

[Chris]
Okay, it’s interesting. The people who do it a lot. The first thing they often say is this is not a new technique. It’s an opposite of a traditional technique with today’s materials. So it’s basically again, it comes back to strength of our materials, we can make restorations much thinner, and they survive, we can make them then we stick them on adhesively generally, and then they work really really nicely. So it’s kind of getting the best of both worlds. A lot of the time we’re thinking about some of the gold preparation principles and applying those onto ceramic, things which previously would have been impossible because the material wasn’t strong enough and thin section. So that’s the and it means that you end up prepping teeth a lot less. What it also I think reminds us of is one of the preparations, bits of dogma that sticks in our heads, which was I was always taught that you should do half a millimeter subgingival margins when you prep the tooth. Brackets for porcelain fused to metal because that was basically the only one of the only way in my day when I was a student It was either PFM or gold. All ceramic wasn’t really done all that much. Feldspathic Jacket Crowns really, but even even they survived people’s mouth somehow. But generally with PFM or gold PFM looks ugly at the margin. So you had to hide the margin subgingival and the problem with that is that half a millimeter isn’t a very easy distance to measure at the chair side. So your brain goes there’s a special bit of your brain that develops when you do the crown and bridge course at uni. It’s the let’s take a little bit more off just to be sure gland in your brain makes you go a little bit further subgingival And the further you go subgingival the harder it is to get a decent impression. You know the classic Valder Hogg paper about 70% of subgingival margins becoming supragingival within five years. On the suggestion of biologic width invasion, I’ve heard it said that you can never diagnose a biologic width envision until you put a well fitting temporary on the tooth. More times that I see that problem, that sort of soggy, red continuous inflammation, and you put something that fits properly on and the inflammation all goes away.

[Jaz]
That’s awesome. Excess cement is something that

[Chris]
That’s been a growing problem in the implant world for the last probably 10 years and people have been openly talking about it, you’re right. So if you get something that is cleanable by the patient, a lot of the supposed biologic width envasion would actually go away. So number one, don’t prep subgingivally, if you have a choice, place your margins equigingivally or supragingivally, if you are the first person to get to the tooth. But the margin, some of it’s easy for you to get a rest and have a good impression of. So where does BOPT come in? The BOPT, It’s nicely written up there. And there’s some very nice clinical examples. I’m thinking of a paper, the one by Loi is nice. There’s another one. Journal of prosthetic dentistry Augustine Palladino, I think is the author. I can send you the reference afterwards. And he shows it very nicely. And what you got to bear in mind with that type of technique, where you’re eliminating a deeply subgingival margin, and placing something essentially knifeedge at gingival level, you’re starting from a position where you’ve got something ugly. And that idea, it’s a wonderful technique for getting you out of that situation where the tissue is absolutely unmanageable. So you cut off the old restorations, you get some beautifully fitting temporaries. And that’s either you take an impression on the lab, make acrylic provisionals the lab or option to the lab, make some shells that you spent a long time relining at the chairside. Or some of your listeners will think that they can, they’re good enough to do it with protemp, quicktemp materials like that. Honestly, the amount of time you spend, I find it disproportionate. Because if you want the gums to heal, the fit has to be 100% immaculately perfect. Otherwise, you’ve got no chance. So in my hand, that means shell provisionals that I will realign with coldcure acrylic trims some of the traditional materials. And it may take a couple of relines to get it fitting perfectly. And then you let the patient go away and keep it nice and clean. And then hopefully the tissue becomes manageable. It’s unfortunately not possible to do it without the provisional stage. Because the shrinkage and again, when you’re explaning it to the patient, you can say Look, your gums are all red and swollen and puffy, put the provisionals on your gums are going to shrink. This is good, this is them getting better. But it may mean that you’re going to get some black spaces in between the temporaries. And some of the edges of the temporaries may become visible, which is why we do them as temporaries because when things are healthy, then we make the finals. So it’s a difficult, it’s an expensive treatment plan for the patient. So your explanation skills have to be really good. So yeah, it’s the summary is it’s an excellent technique if you’re in that situation. Otherwise, the thing that I can’t understand about vertical preps is I don’t know, okay, people have different opinions on when you shouldn’t do an onlays, when should your core build up, when you place a crown. And I can argue the toss with those people over a beer at some point. But what I don’t understand if when you, if you’re doing a margin this prep supragingival magin prep, that’s great. Many people who talk about that technique, they will lut the crown with glass ionomer. And I don’t understand why they don’t take advantage of adhesive cementation, because we can bond on to Zirconia these days. Markus Blatz APC Protocol. It’s very, very easy. So I don’t understand why you go to all this trouble of doing a nice prep, making a nice Zirconia restoration and then you stick it on with GIC. I think they’re missing a trick. But maybe again, something that I’ve missed in presentations and books and other podcasts.

[Jaz]
I doubt that very much but Okay, fine. So then the last three questions are non clinical. One is what will happen to applications to the Advanced Dental seminars, which you know, a lot of my friends have been on. I guess the only reason I probably didn’t end up going on in my cohort was I went through various DCT restorative positions. And then I spoke to so many people have done your course I’ve learned a lot from these people and your course I think is very oversubscribed every year so people have you know when I put your Photo up. And I said, any questions? You know, it’s no surprise that this question came up what’s going to happen to applications for the next round of your year long course?

[Chris]
Okay, thank you. Good question. Thank you for asking that one. Right. What was supposed to happen was we were supposed to open the bookings next Tuesday, usually two weeks, a couple of weeks after the traditional time that we do it. Because of all the stuff that’s happening in the world, that’s been put off, what I would suggest for your listeners, we will be running a course next year, we need to see actually how the dust is settling down in terms of the easing of the lockdown, and how it’s going to be possible to get people into a room together to do a course together. I would encourage your listeners to follow us or follow the Advanced Dental seminars Facebook page, or keep an eye on our website. Because whatever we decide to do, we will put the information on there. So yeah, we will be doing something, I hope. If we’re all still stuck on our houses together and unable to come together, the world’s gonna be a very sad place. So I hope to see some of your listeners in London in September.

[Jaz]
I’ll put the Facebook link up. So those who are interested in next round, they’ll can keep up to date. The next question is, what have you been up to during lockdown? Chris, people want to know.

[Chris]
Right? In no particular order. I have been organizing lots of photographs, photographs, when you enter photography as a hobby, you spend a lot of time taking things, but sometimes you stick them in the hard this is how can look at it later and you don’t. So we’re doing a little bit of that. I’ve been delivering webinars for our current course participants to keep the engagement with them. I’ve been looking at how we may do some more stuff online, as opposed to face to face. I become increasingly of the opinion that all the reading that we give to people. People don’t really read it. So we need a different way of let’s be honest about the dedicated people who do and we try to not do everything to make sure but some people don’t. And I think a different way of doing that part of it might be helpful. So I’ve been looking during a lot of sort of preparatory work for that. What else I’ve been doing cooking, eating [Jaz] Brilliant. Excellent. Excellent joy.[Chriss] We’re making pizza.

[Jaz]
Very good. Well, the final question I haven’t even it’s been fantastic everyone. And it’s actually my favorite question is by sending by someone called [Surab]. Thanks, [Surab] sending in and it’s basically, if you graduated in 2019. And knowing all that, you know, now, would you have done anything different?

[Chris]
Okay, good question. I think the advice that I would give a younger version of myself, if I was graduating again, right now or any of your listeners who have graduated. Dentistry is a very practical craft, you need to hold your hand skills. And working in high volume environment becomes very, very difficult to do that. But I think I said about it earlier that you have to have experience of doing some techniques before you offer them to somebody privately. Because the private patient journey, it’s not just about the clinical outcome, it’s about the way in which the journey happens. The old version of the NHS that I worked in for a few years, it was actually pretty decent, and letting you round out your skill set. Because even then, the universities could not manufacture examples of every possible clinical procedure for you to do while you were a student. So the idea of VT as it was called it was supposed to help you round things out. And that sadly, doesn’t seem to be the case any longer. So I would suggest to your listeners that they try to make the most of what opportunities they do have, clinical photography, very important skill to develop that starting at undergraduate level now in some places, I’m happy to see that is great, but making sure that you do it routinely so that you can blaze off all those pictures, show the patients, their modes, get patient involvement, engagement. And very often the conversation about doing some of the nicer things comes from doing that. And that also allows you to practice your communication skills. It allows you to practice your treatment planning skills, not just what you’re going to do, but the backup plan in your mind as to what if this doesn’t work out exactly the way that I want? How do I manage the problem? Because often when complications arise, there’s a clinical issue and there’s a person attached to the clinical issue. And the person attached to the problem is the one that makes it the complaint, not the tooth. So all for all those things, it’s to try and take advantage of those opportunities. Also, any information that is out there, take advantage of it. This podcast is wonderful. So download all the back episodes and listen to that, because lots of very, very eminent people really done some very nice podcasts for you. What else, join all the societies of whatever you’re interested in, whatever that happens to be commonly courses in whatever you’re interested in. That’s also helpful. And I think the other thing, the environment that I grew up in is a lot of parallels, I think, between Irish families and other cultures, where your mum wants you to be a professional. And then once you become a professional, you must be a specialist in that profession. Similarities with other cultures, completely coincidental. Being a specialist is not the be all and end all. How you are with your patients. How you can talk to them. How well you can build rapport with them. That is far more important than having a paper on the wall, even though your mum might not be too happy about that. So develop communication skills.

[Jaz]
Brilliant. Well, thank you very much. Well, Chris, thanks for all the clinical nuggets. And right at the end there some very nice non clinical stuff as well. I wish you all the best for the rest of the lockdown. And I hope ADS can get running and soon for all the hungry people for the knowledge who after that. And thanks again for coming on. It’s been really great having you on today.

[Chris]
Thank you very much. Thank you.

Jaz’s Outro: So there we have a fantastic episode with Chris Orr. There who you know really proved his rockstar status. Thanks so much for listening all the way to the end. And remember, if you want to claim your enhanced CPD, if you just wait a few weeks, there’s a bit of a backlog but eventually it will come on to Dentinal Tubules, where you can actually watch it there again or watch it for the first time if you’re listening to it, and then you can also answer the questions, acknowledge the aims objectives and have your fully enhanced CPD certificate. Thanks again for joining and I’ll catch you in the next one.