I know some of our colleagues who have completely lost confidence in extractions and they are crippled by the thought of failure or having to ‘start a surgical’. I think being good at exodontia is fundamental for successful Dentists and it was my mission to bring on Oral Surgeon Chris Waith who will help you regain your confidence. The secret, we think, lies in your ability to section and elevate roots! Listen or watch now to find out why – guest featuring Dr Zak Kara!
Protrusive Dental Pearl: Be able to section teeth. If you can learn how to section roots and know WHEN to do it and HOW to do it safely, you will dramatically increase your success rate for dental extractions.
“I always say to Dentists that you should have a plan A, plan B, plan C etc. Don’t just go in with plan A and carry on with it..” – Dr Chris Waith
Dr Chris Waith and Dr Zak Kara are here to join help us in stepping up our extractions game.
In this episode, we discussed:
- Clinical and Radiographic features of tooth that need reassessment – what makes it a ‘difficult extraction’? (13:46)
- How to make sure that your patient is on board – communication skills for oral surgery (20:23)
- Importance of positive conversation to surgery patients (21:06)
- When to and when not to section a tooth during extractions (29:31)
- GDPs not sectioning due to lack of equipment and how to overcome this (32:14)
- Advice on sectioning teeth technique (41:15)
- Is the inter-furcal bone important? Or can we drill it away? (50:08:)
Check out Dr Chris Waith’s oral surgery course.
If you enjoyed this episode, check out Why and how you need to Improve your Tooth Morphology – PDP046
Click below for full episode transcript:Opening Snippet: Because i've had lots of painful and embarrassing experiences in the past which made me realize I need to skill up and the number one thing i found is that when i started to section teeth that's when extractions became much more predictable for me. That's when i managed to really gain a lot of confidence in extractions, the ability to section...
Jaz’s Introduction: So guys one evening in Singapore as you guys know i used to work in Singapore and it’s a fascinating country and a brilliant dental system and the interesting thing about it is that sometimes i’d start my shift at 9 00 a.m and finish my shift at 9 00 pm. Now i know that sounds really crazy like oh my god you’re overworking, you’re going to burn out kind of thing but it really didn’t feel like that. The busy periods were like the morning session and the evening session and the afternoon session was almost like a siesta you know you can go to sleep, you can have some dim sum, you can go out for an extended lunch, i can go with my wife. It was a cool experience you know and it wasn’t very stressful at all. I really enjoyed working in Singapore. Now the fascinating thing is that one day i finished my shift at 9 00 pm and i was getting on their mrt, their train system back home and i was just walking to my apartment i had these famous noodles with me and they were hot and ready to eat and i was so excited to go home and actually devour these noodles right but here’s the thing right? You guys might know that my wife is also a dentist and as i’m walking up to my flat i’m getting i get a call from my wife and she says ‘Jaz i need your help i’m like what do you mean would you need my help? What’s wrong? What happened? It’s like it’s past nine o’clock. Why are you even still at surgery.’ right? She goes well i kind of started this extraction at 8 30 and this tooth is not moving like i cannot remove this tooth can you please rescue me. Now in my past as a DF1 as a young dentist, i’ve been rescued a few times okay it’s always embarrassing in a way to ask for help but it’s always like it’s something that you just you know when you’re struggling with an extraction it’s so great to have someone next door who can come in and help you and i’ve been rescued so many times and of course it’s my wife i was never going to say no. I had to leave my hot noodles and absolutely literally run to the clinic and the clinic was about a five-minute runaway. So literally i put my massive suitcase down had all my like camera my loops everything inside i didn’t need any of it and i literally ran from my flat in Singapore like a condo apartment to the clinic which is five minutes away. So i was running running running by time i got there i had to just wait in the air conditioning to let all the sweat sort of dry off and i come in and thing is it was it was an awkward scenario because i kind of wanted to maintain that professional feel and i couldn’t just come in and be like hey i’m the the hero husband who’s gonna save you. Firstly i didn’t even know if i could rescue the scenario or not right? I mean at the time, i’m pretty confident extractions now at the time i was really gaining my confidence i wasn’t like super confident I guess it was probably one of the first few times that i was called for help so i felt like wow i need to step up it and help i didn’t really know what the situation was anyway i come in and i maintain my professionalism, I pretended to the patient that this wasn’t my wife this was just a dentist colleague who needed my help i’m like ‘oh yes hello Dr Kaur, how can i help you?’ She was ‘oh yeah this is so and so and we’re extracting the upper left second molar and the the crown is broken off. can you help us? So i do a quick medical history check, I chat to the patient it’s like ‘okay don’t worry sir, I will remove this tooth for you okay?’ And so here is the thing right? When i’ve been stuck in the past, when it comes to extraction it was because i did not know how to and i did not know when to section roots and elevate the roots, basically okay? So sectioning is a huge skill and at that time i just recently started to become more confident in it. So all i did was i got my handpiece and i sectioned this upper left second molar into its three different roots mesiobuccal, distobuccal and palatal and that’s all I did. I sectioned it and i popped my elevator in and i said to the patient you will hear a crack, okay? So it cracks and literally within about 10 minutes i had everything out and everything came out beautifully like yes it was a tough extraction if you don’t know how to section and if you don’t know how to section, elevate. The funny thing is all that time i was maintaining a sort of professional feel and inside i was really chuffed, i was really pleased that i managed to rescue my wife and get this tooth out and i felt like the real hero and at the end you know when you’re the hero when you take out the extraction what you what do you do well you take all the credit and you walk away and you and you let the dentist who’s asked for help you let them do the suturing right because you’re like the king like you’ve done your bit you can walk away right but the funny thing is right in the last moment i said ‘hey babe can you stitch up for me i was like hey babe can you stitch up for me and i was like really embarrassed because this patient wasn’t supposed to know that this is my wife but anyway that was kind of awkward so i said i just walked away and i just like i don’t know i started drinking something in the staff room while my wife was finishing off this scenario and the thing is it wasn’t a difficult scenario if you knew how to section and this is why i’ve created this episode i’ve got Chris Waith, who’s an oral surgeon based in northwest of England and what i’ve always admired about Chris is his reputation on social media like whenever someone talks about gaining some sort of oral surgery mentorship or oral surgery advice, he’s the first person to help. So i want to bring him on to help you regain your confidence and extractions and the number one way which is a Protrusive Dental pearl is to be able to section teeth. If you can learn how to section roots and know when to do it and how to do it which this episode will cover. You will dramatically increase your success rate when it comes to extractions. You can really be quicker at extractions, more efficient, less invasive less traumatic by learning how to section i think it was that skill i talk about my experiences in this episode we’re also joined by the way with by Zak Kara. So it’s gonna be a really fun episode you know it because accident as well. So i hope it’s gonna give you a lot of value and i’ll catch you in the outro.
Main Interview: Chris Waith, long awaited. Welcome to Protrusive Dental podcast my friend. How are you today? I’m really well thanks mate. How are you? – Yeah absolutely brilliant really buzzing for this episode and today we are also joined by Zak Kara, who’s an absolute veteran to the podcast, good to get you back again even though your audio sounds so noisy i think the listeners will forgive you. Thank you i’m so sorry in advance. I obviously, you’re obviously gonna have to upgrade and go pro level. I’m clearly a small timer compared to you, Jaz. Not at all the most important thing is that Chris sounds great and this is really important because extractions and i’m titling i think i’m going to title this episode regaining confidence in extractions and the reason that title came to me is because and we were just talking about this before i hit the record button. Chris you were saying that you made a lot of your big mistakes in the first few years. The time i’ve been most embarrassed is when i have started an extraction and not been able to finish it and then either the patient has had to go a couple miles down the road to my principal who’s working on the surgery or someone had to have a massive delay in their day to rescue me or unfortunately on one occasion sending someone home just with the roots there you know after a bloody mess and that made me realize i need to do something ie I need to skill up in extractions and i’m hoping that from today we’re going to help a lot of people who may be about to enter that scenario or those who are on the other side and now like some of my colleagues they don’t want to do extractions anymore, they completely refer them on. So i’m hoping that’s going to add a little value for everyone. Zak has that happened to you, my friend? Big time. Do you know the thing that i found i needed to really upskill it is the ability to sort of tell the story. Almost not that you’re commentating too much because you know the too much you say you land in a hole verbally if that makes sense during the procedure but the thing that i found that you need to do as things are maybe not quite going on course is you kind of need to wriggle your way through this and the things that you do and you say and how you say it steer the conversation into you know basically what you’re trying to do on a daily basis is is under promise and over deliver isn’t it? So the more that you guide that into and look like a magician at the end of a procedure you get to the end and you go yep that’s you know that feeling everyone’s got had that feeling a few times over there and we will love it of somebody going is that it or is it that thing. We love that don’t that’s like oh yeah i just checked my cape is this nice and straight there that’s superhero style that kind of stuff that. How do you get there is really the key thing. So how do you get there. – I think a massive bit of oral surgery is what you say and when you say it like once a week i’ll have a patient where and i mean i take what patients tell me with a massive pinch of salt but when they come in and they’ll say things like so you’re gonna peel my gum back or you’re gonna break my jaw and you kind of look at them and just think ‘ah i’m already losing’ i was like if you just said the right thing to begin with. So you avoid all that negative language and it’s like you know this is just a little bit of pulling and pushing, this is a noise just like the drill when you have a filling, it’s only a bit of rattling and water and so i’m the one in control and i’m the calm head because my patient won’t be calm, my nurse might not be but i can control them as long as i’m kind of saying and doing the right thing so i know it comes with like practice and over time but i think the way you behave in surgery will make your day better or worse and sometimes i think you almost need to kind of take a step back that if you like, Jaz said if you’re getting to that point where you’re losing your confidence a little bit. You’ve kind of got to look at how you work and break your work down into easier manageable chunks and then just concentrate on that little chunk and then once you’ve got it sorted in your head everything else will click into place then. So i always say to people it’s like you know have you plan A, plan B, plan C, plan D. Don’t just go in with plan A and carry on with it because that’s that patient where you look at the clock and you’ve just spent 50 minutes trying to elevate a tooth and after 10 minutes she could have looked and said ‘ah this isn’t happening actually.’ So it’s time to pick my drill up and in our head i think we’ve got that like barrier where we think ‘oh no i’m not going to pick my drill up because it’s traumatic for the patient’ but it’s the other way around it’s like now pick your drill up so they’re not on 40 minutes of elevating that’s doing no good. That’s going to be the meat of the episode i think talking about the importance of section and elevating. Actually we’re going to we’re going to say that for the real meat and potatoes of it but before Chris you became the master of extractions, did you have any of those embarrassing moments like i have had where you failed an extraction is this a gut-wrenching you know you feel like a massive failure did that happen to you as well in your journey? Yeah I mean my two or three biggest cock-ups and like we were saying before offline you know the first few years when i’m looking at me working i kind of look back and think i don’t know whether i was overconfident or under-prepared or a little bit of both but i’ve had a nerve injury, taken a cyst out. I’ve had a nerve injury taking a wisdom tooth out. I’ve burned her lip and doing some difficult extractions on a patient and i look i look back now and think you know compared to me five years ago i feel loads happier than i was then and from that point to five years earlier i felt loads happier and it’s all right kind of building up your experience and getting a little bit more kind of competent and confident but i think the hard bit it’s those first few years it’s kind of starting off on a strong foot and get everything in place and actually you know accept the fact that you can’t do everything because there’ll still be a patient where as long as your assessment’s right draw a line and say no and that’s all right. It’s not failing, it’s doing the right thing for the patient and that’s what i didn’t do when i was younger. There were a few patients where i should have said. There’s a huge aspect to this Chris i don’t know if you’ve got any sneaky shortcuts and things to help people with but one huge part of that though is that you don’t know what you don’t know do you so you can easily walk into traps and i’ve you know i remember it very clearly as a VT asking for a assistance from an associate dentist who was two years more qualified than i was and this was in an outreach practice in Sheffield as well so we were used to this kind of training environment and i remember very clearly working through lunchtime trying to pull on this swinging on this upper six like Johnny Mcenroe you know like double-handed technique because it’s going to come out sometime i’m just going to keep going kind of thing I wasn’t actually too handy just to clarify but you know what i mean and the associate friend of mine, colleague of mine come in and try to use a different technique and use his left hand since the upper left molar, stood behind the patient pulled with like within with his left hand and just gave it an enormous yank to the buccal right and it all went horribly wrong and basically landed me with OAC and a buccal plate fracture and i’m sitting there thinking oh holy moly what on earth mess am i in now kind of thing but i didn’t know i thought he had some sort of special skills or something i hadn’t seen before and to be really straight i hadn’t actually assessed the morphology’s tooth correctly myself in the first place i shouldn’t even have been there you know i was a DF, i’m sorry new language not old language but in old money that was VT and then yeah.. But before then we that leads nicely to the the first big question which is what are the features that you could assess Chris in helping people determine not to fall into that trap in the first place of you know just like Zak said not assessing morphologically what might constitute a difficult extraction but before we come to that. Zak I just want to add to that you know what that’s exactly what you want in a way when you struggle that extraction you kind of don’t want the new guy to come and just take it out in two seconds because that makes you look like really you kind of the the times i remember is i i’ve struggled then my principal comes and my principal struggles for an hour and then you’re like ‘oh good that justifies it wasn’t just me’ No it’s because you fractured it so subgingivally you broke it down so badly that you made his life a misery mate that’s why if you asked him to come in after 10 minutes in an hour. That’s actually unfortunately closer to the truth but Chris. What are the features clinical and radiographic not wisdom teeth. Let’s talk about molars right let’s talk about molars which are probably the ones that we step up on the most that clinical and radiographic that make you think that hang on a minute don’t just go straight for the forceps or take a step back and reassess the or assess, reassess all the difficulty of it. From a patient point of view i probably just need to know are they on board so can they comply with what i need to do to them and like i mean our service we’ve got a massive sway towards anxious patients so i try to dig into what they’re anxious about because if they’re anxious about the drill we might have a problem because i section a lot of teeth but if they’re anxious about somebody swinging on a molar actually i think if i section that i’ve got rid of that part of it because i’ve made it easier so it’s just about explaining it to them. Physically really i just want to know about access so as long as i can get into the area that i need to get, so we will see loads of upper wisdom teeth and we’ll say you know the access is difficult and i’ll sit the patient back and i’ll just say you know if i’m doing upper right you just slide your jaw over to the right hand side and then let me swing on your cheek and if i can get the tip of my mirror to the tooth i know that i can elevate it and it’s like a 30-second assessment and then i know that I’m good to go. So if the patient’s on board and my access is okay then i’m happy enough to start and then i think if you’re looking at the tooth and if you’re looking at your radiograph just have a systematic way of kind of approaching it. So I kind of go top down. So i look at the crown of the tooth that i’m taking out and the two teeth either side and i want to know how big the filling is? Is there a crown? Is it pinned? Is it post crowned? Is it root filled? I’ll go down to the roots and just think right? Are they tapered? Are the convergent? Are they divergent? How many roots are there and kind of getting increasingly difficult, are they kind of straight? Curved? Dilacerated? Bulbous? Then i’ll go to the ligament and like it’s really rare that i’ll see a tooth that is properly ankylosed but i’ll see loads of teeth where the ligament space is very small and so picking that up on the x-ray i’ll think that’s more likely to be a surgical because i’ve got less wiggle room when ambulating and elevating against it. Then i’ll go to the surrounding bone and just think kind of you know less dense, dense, very dense and then i’ll go to anatomy so i’ll go further and say right are there any nerves close by? Is the sinus close by? It’s the interradicular spaces, the space between the tooth i’m taking out and the teeth either side is that small or large as well how much wiggle room have i got and if i go through all of that i think then i’ve got my answer to say right what’s the way to take the tooth out and then it’s my plan a, plan b, plan c, plan d. Am i just let’s say something in elevating using my forceps? Plan b, might be right pick up my drill section the tooth if that’s not working take out some inter-radicular bone, if that’s not working lift the flap remove some bone and like oral surgery is i think it’s scary because it’s very black and white it’s like you’ve hurt them, you haven’t. The tooth is out or it’s not but actually it’s really simple because we’ve only got a few ways to take the tooth out and all you’ve got to do beforehand is plan your way and when it’s not working, stop and then change to your next way. So you’re just going to tick those boxes a thing I mean. Two things you say i said so far in this episode which i really respect because something we don’t talk about enough in the context of oral surgery and extractions is the communication side which Jack Zachary nicely brought in about communicating through all surgery patients is you know it’s a whole different thing that we need to focus on as well to gain the best results so that’s something that’s seldom discussed and b) something that also you might know this oral surgeon George Paolinelis. -I’m rubbish with names. – George, fantastic guy works at a Guys hospital and practice. He taught me the importance when i was at guys doing dct in oral surgery, he taught me the importance of having a plan like so often we’d say okay i’ve got to take a tooth out right let’s just start with forceps and see where we go whereas actually to have like just like you echoed as well Chris having a plan a, a plan b. a plan c. So my next question oh by the way, when you talked about all those features that you assess one thing that you didn’t mention but i think and i might be wrong here i think it has a big bearing on the difficulty of extraction as well is if the someone has got exostoses or thick cortical plate of bone buccally and that’s caught me out before when you try and take it out and then suddenly the whole bony plate fractures or the the crown fractures because the bone is quite solid. Is that something that you notice as well? Yeah i mean i don’t think it’s a very common one dense bone on its own is. Exostoses, maybe isn’t but there’ll be certain areas regardless, so in Guys i always think it’s lower eight, seven six external oblique ridge is there, you’ve got your thickest part of your mandible, you’ve got your masseter insertion in the bruxes as well they’ll have dense bone. Those teeth i’ll look at that to begin with and think i’ve got a really low level here where i’m going to put my drill up because if i try and take that buccally i’m trying to move the tooth against the thickest strongest bit of bone and as i take it buccally if i ever lose my angle with my forceps then the crown is off and i’ve just made that loads more difficult so before i even start pick my drill up section the teeth and now i’m drilling those bits of tooth mesially and distally and the only thing i’m pushing against is the inter-radicular bone now so i’ve moved the physics in my favor and really that’s all extraction is it? My old max facts consultant had a blinder because he just kind of looked at me and just said well listen you can only do one of two things you either make the socket wider or you make the tooth smaller and i kind of thought Yeah actually that’s so, it’s so simple it’s brilliant i was like yeah. If you’re trying to move a sofa out a window just you know take the door off make your life even bigger just get it out just you know make life simple by the way can i just add something you should have seen the look on Jaz’s face there i don’t know if you saw but the look on his face as soon as you mentioned bruxism and masseters he was like whoa i’m in heaven right now he’s managed to introduce all surgery and for the protrusive dental podcast fusion i love it. – Then i was going to say i’ll try not to mention soft bite guards and stuff we’ll keep that one out in an oral surgery-based episode so we’ll not embarrass you Chris. – There’s one other thing i wanted to say by the way i’ve got something to say Chris you said getting a patient on board or checking if they’re on board have you got any sneaky shortcuts or anything that you kind of have picked up over the years that’s become part of your spiel to kind of ask the right question at the right time as soon as they enter the treatment room because i presume you have a referral practice right? So how do you make sure that person’s on board? The last like 18 months has been more difficult because i’m a big light see the whole face person so i want to see the white of their eyes and actually i like shaking the hand because i can feel the sweat or the warmth or the shakiness. So before i’ve even said anything i’m like right okay so i’ve got a little bit of a battle here i’ll always get the patient in clear specs or kind of tinted rather than sunglasses because i want to see their eyes all the way through. I don’t wear loops i just wear my glasses because i want to be able to see the tooth and the face if i’m talking to the patient i think the there are two different ways that you play it one is don’t introduce any negative language so don’t talk about sharp, pain, hurt. You’ve got to dress it up as if you’re giving your local anesthetic, i’m making you more comfortable rather than saying you know i’m trying to make sure it doesn’t hurt because as soon as you say hurt you’ve planted a seed that’s there and it doesn’t matter if it doesn’t hurt because that’s not how pain works in their head if they feel like it is then it is. So try not to plant the seed which is going to kind of work against you but i think the other thing for patients is just talk about it. If there was one thing that i think patients want sometimes is just our time and to be heard and listened to and so somebody comes in and it’s really obvious they’re anxious i’m not afraid to say to them you know what is it you’re anxious about and if they tell me it’s the injections then i’ll think right let’s get the topical out let’s you know put our TLC gloves on and take a little bit more time with the local anaesthetic bit because once i know they’re not the rest of it’s going to be all right if they don’t like a drill i mean i can try and section a tooth with my hand instruments but i maybe need to talk it up to say i’m making this extraction as easy as i can do and as comfortable as i can do to offset to them using the drill for a couple of minutes i mean i think dentistry is full of that whichever thing that you’re doing, knowing what your patient does and doesn’t like and i mean it’s not that you can avoid it but it’s how you dress it up and how you get the patient through it. So i say Chris, one thing i i say to my patients is that there might be some cutting, there might be some drilling. Is there a better way for me to say that? Because i want them to not live in this fancy world where you know i’m i do section a lot of teeth and that’s going to be the main part of the episode i want to talk about and i’m really excited to get to that but i do want my patients to know to expect that you know there’ll be a bit of cutting, they’ll be drilling don’t worry you will not feel a thing i’ll make sure you’re comfortable but i i do set out for them that hey there’ll be some cutting and drilling is there a better way for me to say that? I don’t think i’d ever say cutting. Only because it’s viewing into that negative kind of connotation with it. In my head if i’m the patient once they’re anesthetized whatever i’m doing to them is probably only going to be one of a few senses for them that it’ll be the noise, the water of the drill if i’m using it, the vibration of the drill and everything else is kind of pulling and pushing. So if i’m raising a flap really what i’m going to prepare them for is some pulling and pushing but I’m not going to say i’m just going to cut this flap and pull it away from your bone because as soon as i do that i’m kind of tearing down the other side and i might say to them you know i’ll pop some stitches at the end but i’ll try and dress that up as oh we’re almost finished the tooth is out wherever i’m just going to put these stitches in they’ll help you heal you don’t need to worry about them, they’ll just dissolve it you know it’s all about being fluffy and warm because really oral surgery is not a fluffy and warm place. So i think you’ve got to take every wind that you can get. – And then you look like a bit of a legend because oh we put extra stitches in and everything oh what a lovely guy he was he really was looking after me he didn’t have to put two in but you know he put two actually he put one extra in just because and you’re thinking well no it was a three three-sided flap so you know two interrupted sutures so… Those little things i mean having that extra little bit for your patient for them to think that you actually care about them, stuff like that and then i like to do my own post-op instructions rather than getting the girls to do it because i want it to be a little bit more personal and i’ll have a really long chat with them about how to control the pain and what dry socket is and things and it’s only because i don’t want them to have a problem that they ring reception i want them to know what it is and maybe not worry about it and then if i’ve done something really difficult we’ll call them the next day and just make sure everything’s all right and then if we need to call them a week later and i think if you do that the patients think you’re great because you actually care about what you’re doing and it’s not just i’ve got the tooth out it’s the patient on the end of the tooth and that you’ve brought kind of back into the fold and you know you’re caring about them as much as you can do. Yeah absolutely. There’s one key thing there there’s one key thing there that i have evolved into my spiel over the years which has now become pretty much the beginning part of any treatment or procedure which is kind of something on the lines of you know you do your continuous conversation rapport building stuff you know continue the chat i appreciate Chris if you’re in a referral practice that’s difficult because it might be the first time you’ve met this person face to face but if we kind of lead into the dental stuff by saying something like just to make sure we’re on the same page by the way what are you expecting to happen today if i lead in like that it’s a very open-ended question and it helps them say things like oh you can rip my tooth out on you and if they say it like that then it gives you an opportunity to kind of go okay my next question is actually going to be how are you feeling about it but i sense that you might not be i might know you know i might not be your biggest fan today kind of thing or you can kind of dress up with a big humor like like you say you can help mold and steer the conversation into a like let’s face it you don’t really want to be here and sometimes i go i don’t really want to be here either but then you can kind of go you know you can dress it with the professionalism as well. So i completely agree with you you need to kind of let them steer the conversation and i also like to introduce very early on in the conversation at the beginning of the appointment sign posting next steps you’re absolutely right i tend to say what you want to the rest of the day by the way because that’s going to help me with my post-op instructions or you did say you know you’re going to go home have lunch blah blah blah but you can then build that in so that it feels like it’s a tied in procedure which is truly customized and personalized for that person. You’re not just another person on a conveyor belt. Yeah it just shows you listen yeah i think if they know that you listen the much more on board with what you’re going to do and actually you know looking worse case you get fewer complaints because that they know that you’re tailoring everything to them, you be more personable about it it’s not just conveyor belt next patient. Zak, do you fancy yourself at extractions do you shy away or are you are you like you know what i got this. I was really fortunate i put together an elective project in madagascar when i was a fourth year student and i went basically in and managed to resource and get a whole load of water surgery equipment and pulled out about 500 teeth in my two-week elective. So i actually got a lot of experience very early doors and then i’ve done a couple well quite a few bridgeway projects so shout out to the bridgeway crew if you’re listening and i was a psych clinical lead with them for a couple of years so i’ve done quite a lot of extractions in quite difficult scenarios with no minimal light and no surgical gear but you’re right Chris there is a downside of that which is that i’ve now gone to the other end of the you know working world which is that i mean you know mostly aesthetically focused private practice and i don’t really take teeth out i don’t need to there’s not this doesn’t hit my radar very often in my week. So now i tend to if i do hit an oral surgery procedure i tend to go too far down the road of making one plan and going with it and so if you were to ask me like out of ten how confident i am compared to how i used to be probably a four out of ten. That’s a very good honest reflection i thought the reason i want to ask you before you move on to Chris’s expertise is i want to gauge what gdps are thinking so you’re an example of someone who actually got lots of experience up front and got really confident extractions but it’s just a lot of people are just doing lots of orthotics in them and lots invisalign, they’re doing the sexy dentistry and you know the extractions aren’t as sexy let’s face it. I enjoy it and i only enjoy extraction you have to listen i only enjoy extractions because i’m happy to say that i’m okay i’m not gonna say i’m amazing but i’m not gonna shy away for a lot of teeth because i’ve had lots of painful and embarrassing experiences in the past which made me realize i need to skill up and the number one thing i found is that when i started to section teeth that’s when extractions became much more predictable for me that’s when i managed to really gain a lot of confidence in extractions, the ability to section. So Chris tell us about what percentage of teeth are you’re obviously based in a specialist referral practice what percentage of teeth do you section and obviously you’d probably be much higher because of the kind of teeth that are getting referred to you but in terms of your plan A, is your plan a usually let’s have a go without sectioning or do is your plan A quite often? I’m gonna section from the start and when would you consider that? I think for a molar teeth now upper or lower molar 80% as a minimum is what i’m sectioning and i could i could get them out without sectioning them but the collateral damage of doing it that way kind of it’s worse than any benefit of being quick doing it. When i look at a socket that i kind of elevate and put my forceps on and compare that to a tooth that i’ve sectioned and just use my luxator to tease out of the socket the difference postoperatively is massive and i only really started thinking like that when i started placing implants and then as soon as you start doing that you just think why am i not doing this all the time because in our head you know i said before i think sometimes we think if we put the drill up, we’re putting the patient through something bad whereas actually if this is a patient who can cope with the filling, they can cope with two minutes of media section in their tooth and then the force that i’m putting onto the tooth to remove it, it’s so diminished compared to trying to take it out into one piece so i’m actually you know i’m giving that patient a lot less to deal with respect to hands and moth, force when I’m pushing head, head moving around when i’m pushing postoperatively touch wood it won’t hurt as much because i’m causing less tissue damage so i think my tolerance for just saying i’m gonna do this section is it almost as low as anybody i know but but actually i’m on board with that because it works for me and the upper molars that are close to the sinus i know that if i section that, that’s my most controlled way of taking that out without causing a problem just having that mindset and changing from thinking plan A is elevation and forceps to plan A is maybe section and then elevate i think that’s a massive difference so yeah.. I think that is, it’s a huge part that we don’t get taught in undergrad and i can see why we don’t get access to it because in hospital settings it’s like oh nurse go get the the unit and they have to plug this unit in and stuff and so they once they want everyone to get cracking with like luxators and forceps and i don’t know how we manage that through our undergrad training and do our outreach and whatnot but it is the reality and i think and correct me if i’m wrong Chris because you’ve taught more people might not. I think most gdps are not sectioning and elevating because they maybe don’t have access to the right equipment but it doesn’t have to be difficult, let’s talk about equipment and before i tell you about the common mistakes i made when i started the section right? First, thing about equipment is the fear of using a regular turbine fast hand piece because it’s drilled into us that because of the air you risk a surgical emphysema so even though i was in a practice where i had a fast hand piece we didn’t have um a surgical motor at that time when i was in this is like seven eight years ago uh and i then had that embarrassing moment where i didn’t know how to section i couldn’t section i didn’t section and i had some failures fast forward many years i was in singapore and in singapore what i did is the nsk electric speed increasing hand pieces were about half the price they are here so i bought one an angled one for wisdom teeth and i bought a normal one for restorative as a smaller head for pediatric density and i started sectioning teeth in singapore. Again i’ve talked about this in previous episodes because what happened in singapore is i felt as though the i broke away from the shackles of the gdc i had less fear i want to say i was gung-ho but i was a bit like you know what i’m gonna step outside of my comfort zone a little bit so i started sectioning teeth in singapore and i haven’t looked back like I like you about eighty percent of molar dissection however am i committing a sin here? Have i somehow bought into the wrong philosophy here? Is it true that you can get away with electric speed increasing hand pieces and they will not cause surgical emphysema whereas the other type do and how common is that So i’ve maybe got two or three different answers there i mean the short answer is simple that i’ve used the high speed for years to section teeth. Wow why all surgeons otherwise are scaring us man like honestly my consultants say ‘no don’t do that you’ll get surgical emphysema and whatnot and i it’s just a real shame because restorative dentists we’re using the handpiece day in day out right? We should be like this easy for us we should it’s sectioning should be easy for us nail on head is an absolute barrier to entry for the average gdp because you basically are so used to holding your handpiece in a completely different way i know if i say this not all not all oral surgeons will agree with me which is fine but if i make my case i think there are a few different things that if you just look at any general dental practitioner the thing they use all day every day is their high speed. So if they can use that safely to do deep MO restorations, the some gingival crown prep so they can use an ultrasonic subgingivally. All of those procedures can cause subcutaneous emphysema but we trust them to use the instruments that they’re taught to use in the right way to minimize the risk which is really what all dentistry is so i think if you say to that same dentist oh well it’s all right for all of those but you can’t use it to section a tooth that doesn’t really sit well with me because then you kind of castrating all dentists removing the tool that they’re probably most comfortable with now you need to teach this skill and say to people this is how to do it so you know don’t raise a flap because that’s going to give you an issue you’re opening up a tissue plane where that air can go. Do it flapless. Do it the first thing you do before you even put your luxator up so you’ve not even niggled a little bit of the gingival margin away from the tooth. Just go in and section it and then once you’ve sectioned it back yourself to deal with the bits that you’ve sectioned. Now if you look at the kind of subcutaneous emphysema thing, the thing is that there is a risk there but i think the magnitude of that risk has kind of been overplayed way beyond the numbers that you see in their journals and in their systematic reviews it’s much more common in restorative dentistry although i’d said that it’s used more often in restorative dentistry and then the oral surgery ones, some of those they they’ve performed their operation in a way that i wouldn’t and that they’ve raised the flap and then use the high speed that’s a bad idea because that’s just asking for trouble because you’ve got an open tissue plane and some air but if you’re just talking about simply sectioning a tooth i think saying to a gdp don’t do it that way is not the most sensible approach and if i look back to years of being in hospital i can’t tell you a single emphysema patient that i saw i could you know go on and on and on about all the infections that i’ve saw and all of the patients in really bad pain where i just think you know what we could have knit this in the bud if we say to our dentist right this is how you do this and go ahead and do it and actually it’s like in undergrad you write that i think as an undergrad we get taught a very academic process which doesn’t necessarily translate into general practice and the problem becomes that academic process then becomes the law and so we’re worried about litigation, we’re worried about our regulators but it’s almost like they’ve lost sight of the bigger picture, of what’s going on and there are loads of teeth that i take out i think you know what this person i bet i could get this person taking this tooth out and actually for the patient it’s loads better for the patient to have it done at that practice than it is to wait a few weeks to come and see me and then the number of those patients who’ve had multiple courses of antibiotics they’ve ended up in a e they’ve had a few nights lost sleep, they’ve got quality of life issues i think yeah that’s really that’s what we should be about as like it comes back to what we said at the start that if oral surgery is anything it’s getting our patients out of pain and so why stop dentists getting patients out of pain and granted because the risk is there educate them about it so this is how you do the technique these are the things that you look for but let’s not kind of throw the baby out with the bath water but that’s that’s my take on it. i am so happy chris honestly you won’t believe i’m so pleasantly surprised that you you’re saying that this okay and i know it makes sense to me because you know i’ve been doing it in this way uh with that and you raise a great point don’t raise that flap first because you introduced a plane of tissue and then you significantly reduce your risk of that happening is my rationale got some legs that if you actually switch to electric does that reduce your risk or not if i just made that. Yeah no, a hundred percent because there are there are two things so separate things so what Zak said makes sense so if you’re in a general dental practice and you don’t want to spend loads of money on a micromotor then get a hand piece that is reinventing so even if you just have one handpiece to section teeth with the air comes out of the back of the nozzle it’s not going down towards the tissues so it’s already safer for you and then you’ve got your micromotor which is electric so there is nowhere so really your micromotor is 100% safe because there’s no air there the only thing you’ve got there is water but it’s really unlikely that your water is under enough pressure to cause emphysema so you drill away i mean really with a micro motor you could raise a flap and drill bone away because there’s no air there altogether so you know you’ve got hour high speed you’ve got reinventing high speed and then you’ve got your micro motor and you’re getting kind of progressively safer and in an ideal world if everybody had a micromax, a great why not yourself out. We’ve removed the problem all together but it’s an expensive way of dealing with a problem. Does you say micro motor but using one of these like nsk red ring hand pieces that’s the same thing right is that okay is that what you mean? – Yeah. Well that’s what we got. Loads of dentists have that especially now in the pandemic to to the whole agp non-egp thing the way we’re getting around it is we’re using these red ring electric hand pieces below 15 000 rpm and i’ve seen loads of practices recently purchased this. No now’s the time guys you put your fear in associate you probably have the kit now start sectioning teeth Move to singapore and buy your hand pieces cheap first. Yeah i didn’t say that i’m sorry in this.. He’s onto something really big here when i started to section teeth the first 50 teeth I section like i did a pants job right because you’re doing it the first time and my angulations it was good that i reflected it’s a good that i stopped for a pause for a second i thought okay next time how can i do better but now i’m pretty much spot on every time but before i was always veering off a little bit i could still section it but i made myself my life a bit more difficult. So any top tips you can give in terms of when you starting to section teeth. I mean the main one is looking at your x-ray because as much as i have a shape that i aim for i’m like thinking upper six i’m more or less a peace sign or a mercedes sign whichever way your bread sputtered but it’s never completely the same because you’ll have a tooth where the palatal room might be a bit more distal or a bit more mesial so i’m going to change my cut slightly the distobuccal root is almost always the smallest. So if i’m going to cut up sectioning it’s almost always that i’ve drilled into the distobuccal root a little bit but actually in my head i don’t mind that because it’s usually the mesiobuccal root which is the curved one so that’s going to be the tricky one and then the palatal root i want the buccal roots out of the way so that i can just put my upper premolar forceps on it and either just rotate it or ever so slightly take it buccally then but i think is when you start sectioning you just take that extra 30 seconds looking at your x-ray just to see what roots you’re dealing with now in a lower lower six lower seven i prefer using a proper straight surgical hand piece which i know is like against the grain for what we’re talking about general dentistry wise but my logic is simple that is if i’m sectioning a lower molar i start at the furcation and i work up rather than starting at the top of the crown and working down because if you start at the top and go down you only need to be off half a millimeter and you’re in one of the roots so instead of making it easier you’ve made it more difficult. Yeah i’ve been there and done that a few times. – I still do it lower six lower seven start at the furcation, work my way up. I wouldn’t do that with a high speed though because the whole thing with a high speed and your air coming out of the front of it is you want to keep the hub of your drill as far away from the tooth as you can so keep a good two three millimeters distance so that as you’re going through the tooth the air has somewhere to go that isn’t into the tissues so you’re saying the biggest fattest longest crown prep bear you can find and so you work with it yeah and well like for an upper six i’ll decoronate it, i’ll leave two millimeters supragingiva. So i’ve still got an application point then i’ll section my roots and then i know that the tip of my bur is pretty close or into the furcation and if it’s not into the furcation i’ll just use my hand instruments to to kind of finish it and finish that section in it but yeah i just want my drill away from the tooth and away from the tissues so that my air is going somewhere else then and it is it comes back to what we’re saying it you know it’s managing the risk you can do anything in dentistry badly it’s just about learning how to do it properly the course that i taught at the weekend and three or four of the girls there had been to the same university and they hadn’t been taught how to use luxators. Manchester. -No. Definitely not sheffield I couldn’t possibly comment but it wasn’t manchester but i kind of look at that and just think you’re missing the point. you’re missing the whole point of teaching people how to take teeth out. It’s like no we’ve only got a few instruments we can use don’t remove one of them from our like arsenal it’s like just teach them how to use it properly. – Chris whilst we’re on the subject of am i being naughty if can i ask a couple of am i being naughty ifs? – This sounds like the answer is yes i mean if i’ve had to bring it up under that banner then probably i am right but you just mentioned luxators right and i quite often use them like say slightly like an elevator but my approach to it is kind of if you’re using the right technique and you actually are holding the butt of the luxator in the palm of your hand the heel of your hand kind of thing and you have got a finger up the shank and you are pushing and wiggling pushing and wiggling how naughty am i if i am into like interproximally between let’s say and upper six and seven and i’m trying to remove this upper seven there’s no eight so as there’s room distally if i lean on the six and lean on the six slightly is that on the scale of zero to naughty, am I? i don’t even need to give you a naughty scale but you’re thinking about the wrong end of the instrument so for your couple and then you’re literally luxator your hand will be the same but it’s the tip that is different. So the whole point of a luxator is it’s so sharp that you’re going to push down you’re going to use it actually to go down the pdl fibers and then push the socket off the tooth a little bit that’s what corporate you work for they’re not sharp mate or if you work in a hospital or you’re like yeah this is a good way and then if you’ve got a Coupland, your Couplands is your elevator but the blade is thicker and it’s designed to lean on the teeth but with your Couplands the other thing is that i think sometimes as an undergraduate we just teach them incorrectly because we tell people to go in kind of horizontally now if you take a couple ending horizontally that’s the time that in your scenario when you rotate that you are going to lean against the you want to go in at like 45 degrees because you’re trying to get the tip of your Couplandsand in between the socket bone and the tooth that you’re extracting so that when you’re rotating then you’re leaning against the socket bone and not the neighboring teeth so i use them both i couldn’t use one or other i’ve always got them both out because i’ll start with a luxator but there’ll be a scenario where i think yeah there’s no more luxating to be done here just pick up my Couplands and elevate it. – How naughty am if I use cryer for every upper eight? – Honestly if you ask everybody listening to this podcast almost all of them will use the let’s say to wrong okay perfect like almost always cryer for operates is that okay or not okay? Of course it is okay come on is that standard behavior yes and well no yes and no i see this isn’t this is another undergraduate thing if you want quick and easy then for ninety percent of upper rates putting your cryer in and turning it is the quick easy option but when you look at that eight and it’s you know low sinus not a lot of alveolar bone complicated root that technique that’s the one that’s going to pop your tuberosity off so those are the x-rays where you’ve got to look at it yeah yeah you’ve got to look and say right cryer put that down. Use myluxator,push the buccal plate off the teeth, use your flat plastic or your mitchell trimmer and actually push all of the soft tissues off off the buccal, off the palatal, off the distal and then when you put your forceps on and take the tooth out then if it still fractures and you take some tuberosity off the best thing you can do is keep all of your soft tissues intact so that if you need to put a couple of stitches across actually two stitches and then it’s pulled everything together yeah so it’s not it’s not that it’s it’s not that it’s wrong it’s just that it’s not always right but it’s like oh what an educator’s answer you’re so pro what about physics forceps am i going to am i going to die if i use physics forceps? So i don’t get physics forceps. – Great me neither. – Everyone says that all the oral surgeons they don’t rate the physics forceps from speaking to them well i just think what problem are you trying to solve because if you’re trying to solve keeping the buccal plate in tap section the tooth whereas if you put your physics forceps on that little rubber band you know to some extent that’s levering against the buccal plate and it might not fracture it but it’s going to crush it so it’s still a you know it’s still a bony injury and i know they work really well for some people but I tend to question things that i do all the time so if i look at that i kind of think no i don’t think that’s gonna give me what i want and it doesn’t give me any benefit over sectioning the tooth i’m going to have to save the the question about the dry socket stuff for a group function one day. So chris we’ll have you back for a group function one day just talk all about dry socket prevention management stuff i’m actually really intrigued in this. The way it’s heading i like that Zak is introduced am i naughty if oral surgery series that’s fantastic yeah this is actually i love this man we should do this in every single speciality. Am i naughty if i go gardening no yeah. No carry on. Am i naughty if i’ve done three six point charts since qualifying? Yes absolutely but the next question the next question query is how important is let’s say a lower molar and you sectioned it and you managed to use forceps to wiggle out the distal root and you had the mesial root left how valuable, how precious, how important is that furcation bone or can i just whack it away can i just take a chunk out of my cryer or or drill away that interfurcal bone? Yes I definitely come down on the side of that bone is perishable i i think i want my lingual plate intact i want my buckle plate intact i want my medial and distal intact so the first thing i’m going to drill is the inter-radicular bang because if i drill that the socket will still heal nice four-sided defect as soon as i touch the buccal plate i’ve deformed something so yeah the inter-radicular bone whether you’re going to use a cryer to kind of pinch the bone out as you elevate the root or whether you’re going to put your drill in and trough it or even remove it that would be my first step you know if i section the tooth and then i’m chasing my tail a little bit even without raising a flap. take the inter-radicular bone away or at least trough it to get an application point. It makes sense. Sometimes that bone can be extremely thick right and and that can really make it difficult to get your mesial root out so sometimes i’ve been removing i’ve been shaving away at this bone and i’ve been thinking gosh am i am i messing up any implant issues in the future by removing this furcation bone but obviously i think as you say in the hierarchy of importance your buccal and and lingual is much more important now i think if you take your furcation bone the socket’s still going to heal i think if you take the buccal bone then you’re potentially messing up your implant treatment. – Amazing, Zak any last questions for Chris while we have him? Am i naughty if series? I haven’t got any more those are the only sins i’ve ever have ever committed in oral surgery. I occasionally i mean i go crazy and sometimes don’t use a figure of eight technique but you know whatever that’s just a conversation for another day because we’re talking about sectioning and luxating today so yeah. – I’m not a big figure of eight person so that’s fine. That’s a zero on the naughty. – What about about this one this is a technique that i just picked up a few years ago which i occasionally use you know when you’ve got a really chunky upper molar if you think you need to put forceps on this right and i know i’ve sinned already however and if i do and i fancy a Johnny Mcenroe’s double-handed swinging technique. If I open the mesial and the distal contact points of this tooth with a big fat diamond bur and i give myself a bit of room is that yay or nay – 100% like any extraction you do putting a crown prep bur on drilling out the contact points of the tooth you’re taking out is always going to help you because you’re not affecting your application point with you let’s say there or your Couplands but you’re giving yourself that wiggle room with a tooth so and i mean this is like coming back to looking at your x-rays and picking what your plan is if i’ve got a post crown next door or a pinned restoration next door the tooth i’m taking out i’m going to take the contact points off because i don’t want to touch the neighboring teeth when i mobilize them and you’ll see it when you look satan or you’ve got your Couplands on you won’t always see it when you’ve got your forceps on so actually taking the contact points out makes loads of sense. The more of that question by the way is always work in teams and shadow people if you’re in a stage of your career where you i want to absorb a leech ask people if you can spend time in their treatment room you know just observing because these are the kind of sneaky little things that you learn over the years because they’re not in textbooks they’re just oh i picked that up off of and you become this patchwork don’t you we always talk about this, Jaz, the patchwork court that you become and you’re like where did i make that one i don’t know i can’t remember but i nicked it and it’s mine now so it’s now part of my patchwork quilt. -Usually Jason Smithson for me but hey i can’t imagine he uses many crown papers in that fashion but you know. -Chris thank you so much, Zak, both of you thanks so much for giving up both your time today. I think i’m actually amazed i was expecting something really good but what you’ve delivered Chris is something that’s gonna like using Zak’s word empower dentists all over the world to start practicing safely. Being more predictable in their extractions and getting over the fear of sectioning however there will be people who want to learn more learn safer techniques more advanced techniques and i know you do some teaching. Please please tell us. Plug your course for us. Tell us where you’re teaching it, when you’re teaching it because i think everyone should book on that. If you’re not confident in extractions which i know a lot of you are not, hopefully after this episode you will be a little bit more. Where can they learn more from you, mate. and so in two weeks so i guess middle of august the website should go live which is www.theoralsurgerycourse.co.uk and then we’re doing shorthands on courses with some blended online learning at monet’s place in London with Joe Mackin hill over in Enniskillin with martin and james at scottish dental courses in glasgow and with ian paula ideal in liverpool and then for anybody who starts with us hopefully we’ll push a few people into doing a pg dip or a pg search i’ve got to say awaiting accreditation just so i don’t get my hands slapped i think everyone if you’re not if you’re struggling if you get sweaty when an extraction comes through, if you get nervous, if you’re doing lots of endos because you don’t want to do extractions it should be the other way around so you still need to get on this course. Chris thank you so much coming on i’m about to bring you back to talk about dry sockets. Zak, thank you for the twists and the turns and introducing us to ‘am i naughty if’ i’m gonna make this a permanent feature of all the podcasts in the future because this is this is brilliant. There’s probably someone with an american accent he’s going to do a great jingle ‘am I naughty if’ oh my god this is going to happen, John make it happen we’re going to do it. Thank you so much gents for giving up your time. We appreciate you having on today. So there we have it guys thank you so much for listening all the way to the end. If you gained value from this episode if this episode has somehow made you think right that’s it i’m going to start i’m going to learn how to section teeth if i don’t know already and i will become more proficient at my extractions and it’s going to start right now and you feel this helped you and if you listen on apple please do consider giving us a review we’d really appreciate that and if you want to check out more from Chris do check out his website which i’ve linked on the main blog post. He’s running an oral surgery course all over the uk i know it’s gonna be sold out, i know it’s gonna be amazing and i wish i had something like that. It would have really fast tracked my learning because i didn’t learn how to section elevated dental school and something i picked up and it’s an invaluable skill and just like Chris i section 80% of the molars that i extract and it’s a hugely valuable skill and now finally i’m hoping he’s giving you confidence to use a fast handpiece and not have to worry so much about a surgical emphysema.
Jaz’s Outro: So hope you found that useful and i hope you’ll find the rest of the episodes coming out in august which is devoted to back to basics. I hope you found them really useful, really informative and catch you in the next episode.