Dahl Part 2 (The Spicy Bit) – PDP017

Jaz’s Introduction: Hello, everyone, and welcome to Episode 17. The one that so many of you have been pestering me about. I sort of teased you with the first episode with Dr. Tif Qureshi Dahl part one, and then I threw in the 12 rules of dentistry which was please say greatly received. And then a lot of people got value from that. And now to continue on from that cliffhanger I left you on with Dr. Tif Qureshi. I’ve got dahl Part Two for you today. So this will be the spicy part. Now, before we get into an excellent conversation with the top man that is Doc Tif Qureshi some important things. Firstly, a very Happy New Year to all my listeners. Thank you so much for tuning in in my first proper year. 2019 was really the first year I started podcasting. And honestly, I really, really appreciate you taking your time to listen to it. I struggle to listen to myself, you know, I make myself cringe. But the fact that other people are listening to me is just it blows my mind. So thank you so much. A massive shout out to one of my listeners. I’m not gonna ask him but he messaged me to say thank you. Because somehow the episode with Druh Shah and myself episode 3 transition to private had such an influence on him that he decided to change his environment, change his mindset. And he thinks that good things have happened because of it. So now he’s in, his goal was to be in full time private practice, and now looks like in the coming months he’ll be able to achieve that. So if I’ve had that sort of influence on him, that has literally made it completely worth my while. And that’s exactly what I like to do for as many people as I can. I love sharing my enthusiasm and my love for dentistry. And it’s so great to hear stories like that. So thanks so much for reaching out to me. And thank you Dhru Shah as well for a great episode that we did in Episode Three. Secondly, I’m really sorry that I didn’t give you a Protrusive Dental pearl with the last episode to make up for it. I’m going to give you today a really, really awesome pProtrusive Dental pearl which can save you hundreds of pounds potentially. Okay, so Hear me out this pearl or this hack will save you money on buying a composite heater. So the first question that some people ask when we talk about heated composite or a composite heater is why would you heat the composite in the first place. So from my understanding from in-vitro studies, it’s suggested that there are improved physical properties, high percentage of cure, micro mechanical details of that sort apparently heated composite is a good thing to use. However, I like it because of the physical changes that happens when you heat composite, it becomes much less viscous. The wettability of the concert significantly improves. So people use it for bonding, Emax onlays, for example, posteriorly I use it also for injection molding ala David Clark, ie the bioclear technique, which I love, I’m huge fan of bioclear. So to use heated composite ensures that it will flow into all the nooks and crannies of the bioclear matrix and prevent any air gaps and air voids. So it’s a great thing to use. So that’s why you would essentially use heated composite. So what is a less expensive way to heat composite you know, these composite heaters can cost a significant amount. I’ve tried the following methods before over the last six years, I’ve tried a cheap three pounds Chinese make coffee mug heater like a USB one that worked well, you know, actually did work and you know, broke few times just buy a new one, it’s really cheap, you know, buy cheap, buy twice, and all that sort of stuff. So it would work well. But the only issue is that I had no control over what temperature I was achieving. And apparently the literature suggests, and when I mean the literature, I mean Jason Smithson and wrote on Facebook, so it’s gospel, it should be about 55 degrees. So I didn’t know if I was hitting that 55 degrees or not. Another thing I’ve tried is by putting the compule up by the operating light, so you know you’re operating like a lot of these lights have like a little gap like you can almost get your finger inside this little gap, it’s difficult to explain. So you can put your compule inside this little gap and our light gets really hot. So the composite compule can get really hot through that method. And that worked really well. The problem with that is what happened to one of my patients once I was moving the light around and the composite compule becomes, you know sort of fell on his head, which was funny at the time I guess but in the patient is cool about it. So that can happen. Also, again, there’s no control over what temperature I’m actually hitting by using the compule up in the light. The hack I have for you, the pearl I have for you is to buy a really posh coffee mug heater, so it’s a really posh one it’s by a company called COSORI and it’s sort of available on Amazon, I’ll put a link to it on my Facebook page and my blog www.jaz.dental under this sort of Episode 17. So you can click through. And it is phenomenal. If Tesla made coffee mug heaters, that’s what it would look like. It just looks really Swish, it connects to your mains, and you can actually control the temperature. So I’m going 55 fix degrees and I can be confident that we’re hitting that so it looks really nice in front of patients it looks professional, and it doesn’t actually look like coffee mug heater at all, you can you can make it what he wanted to be. So it’s in that using that which is just 30 pounds is fantastic. So that’s my major Protrusive Dental pearl to make up for lack of a pearl last time. I think if you haven’t got a composite heater and you like to use heated composite, it get it, it’s just fantastic. The Gold Standard obviously is to buy a proprietary composite heater, but these can cost upwards of 400 pounds to 1200 pounds. I’m not against buying it I just you know so if you please buy the best you can afford. But here are a few reasons why I am not in a position to buy a 600 pound composite. Number one, I’m an associate that’s pretty self explanatory. I’m taking my gear to different practices. So I don’t want to be you know, moving around such expensive gear all the time. And number two, the money that I don’t spend on equipment I get to spend on courses and you all know how much I love going on different courses. So you know for me I value courses way more than paying you know, apologize saying but over the odds for some materials. So I mentioned about this composite heater on a Facebook group and Steve walked in from Optident big shout out Steve, awesome guy, awesome company, which is Optident. He actually made a counter argument said, hey, look, if you’re undercutting the UK, dental suppliers, and you’re going to Amazon to buy this tool to hit composite instead of buying a proper concert heater, then I might as well go to Turkey and get my implants done. Well, you know, I respectfully disagreed with him. It’s very different to that. What I’m not recommending here is to go on eBay and buy counterfeit hand pieces. I’m not saying that. What I’m saying is where you can save money on things that you know, you don’t actually have to put in a patient’s mouth? Do it. Why should we pay over the odds for something that we can achieve in simpler and cheaper means? I know plenty of people that use a baby bottle warmer to heat their local anesthetic or hypochlorite. So same principle, really. So I’m totally cool with that. If you think it’s immoral, then go ahead, buy the expensive composite heater. Can afford it, do it totally, that’s the best thing to do. I hope that pearl was useful to you. And now we can jump in and join Dr. Tif Qureshi, what you’ve been all waiting for.

Main Interview: [Tif] And this is gonna be one of the questions that we were sort of thinking about here was, Why do people not appreciate it and one of the biggest problems is I think a lot of people use dahl on the wrong patients when it’s too late. And dahl is really for patients that you’ve had a relationship with you, they understand what’s going on. And you actually say to imagine to brand new patient who’s got a bit of wear on the anterior teeth. Imagine trying to say to them, right? “I need to build your anterior teeth out to improve your anterior guidance and disclude your posterior teeth blah, blah, blah.” This guy talking about

[Jaz]
I’ve been that, Tif, I’ve done that. So you must teach me and my listeners that hopefully I’m better at now than I was. But tell me about how you would approach that. And then how to actually communicate to patients Oh, you’ve lost your canine guidance interseptally, you’d benefit from a interceptive dahl technique. So how do you approach that?

[Tif]
It’s all part of a, for me, a much more everyday comprehensive checkout. And I don’t mean a comprehensive checkup as in our comprehensive exam. I mean, you have your comprehensive exam, which you know, you deal with a new patient, but actually, every chapter, there’s lots of little things that we can also be looking for, talking to the patients about, explain to them, that then helps them understand the dynamic picture what’s going on. So, you know, we’ve already mentioned tooth surface loss, you know, looking very carefully at dentin and making sure we understand that, you know, this stuff is six to eight times softer than that stuff. A lot of people don’t understand that when I actually give a lecture and I asked dentist and I talk about dentin, enamel and I say, you know, what do you tell patients about how soft that is compared to I mean literally one handlebar in the room. So it’s not something dentist potentially confident in saying but actually patients need to know that that stuff is a lot softer. And as a result it will wear, erode and whatever quicker. That’s one thing

[Jaz]
I tell my patients but only because I went on your course in Sydney. So I do tell to patients, I show them because I take my DSLR photos in a comprehensive new patient examination. And I showed him that yeah, that you know what that is? And I say, No, is it well, you know, that’s a dentin that is seven times softer, that’s what I’d say I just leave him with that. So it’s co diagnosis

[Tif]
Exactly. But then the key thing is, you know, if you do that on a check up, you then reshoot that image six months a year down the line, what I’ll say to the patient is okay, that’s there is some wear there. I said it’s not that’s not how it should be but don’t panic because you know, the tooth isn’t gonna fall out for being like this. But what we want to do is to see how it looks in at you know, in a few months time, see if your bites change, see if you any of the anterior contacts. And critically also, of course, see if your teeth are moved. Because if there’s if you have a combination of anterior crowding, and wear then you have this whole kind of concept of potentially constricting envelopes, not every patient but if some patients and I found that a really easy concept for people to understand And you know, if they see a lower tooth sticking forward and and then an upper one subsequently sticking forward as well. And an upper one sticking back and a lower one sticking back doing a very simple this is a thing that I do every checkup. I do a very simple fremitus check on every single check every time to make patients aware of the tooth position. And the very simple way of doing it is I literally put my finger on their teeth, I lean on their teeth from four fingers on the front eight teeth, and I’m literally squeezing the ligament and I just say, you know, it’s going to lock the complaint piano on your teeth. I said, Now I want you to bite fully on your back teeth. And actually, what often happens is a tooth that’s out of position, one tooth or two teeth that are out of position, they start to knock more heavily against one of the lower teeth. And I think that both Can you feel that? And they’ll say yeah, so Well, that’s probably happening, not 100%, but probably happening because that lower ones drifting forward a little bit. And it’s the key point is it’s continuing to slowly drift, but it’s slow. So we’ll look at again, in six months or a year, we’ll take a photo, now I’ve got a scan out, I’m telling him, we’ll scan it and then I said you don’t, what we’ll do is we’ll look and see whether we have to change it. You know, what usually happens one year, two years out, it’s happened five years later, and patients come in and said, you know that you’re telling me that those wear and I think that tooth is moving. And I’m sure that he’s darkening a little bit as well. Then we say, Okay, this is what we can do, as we’ve discussed, and we go from there. And that I mean, in a nutshell, a lot of those cases described in that way and not even with tooth position but just tooth surface loss. You know, it’s come back a little bit later becoming a bit more aware of the color, the shape, the edges, the sharpness, and then they say, yeah, let’s get it fixed. So

[Jaz]
Hats off to you, Tif, because no one actually talks about, I mean, no one ever talks about, oh, five years later, I’m then gonna give him the treatment plan. No one talks about that. So ultimate respect for you for for having such a long term view with that. And also that’s it you know, that’s a great clinical tip to use your two hands, four fingers, front teeth push down, ligaments squeeze, bite together. And that really makes it tangible for the patient.

[Tif]
The key thing is not you know it You mustn’t panic people it’s about I just say I always reassure them that this is normal. This happens with a lot of people, you know, tooth movement, and wear it’s a normal thing. Some people might call it aging, But actually, it’s preventable. So, the key thing is that the problem is so we go back to what we said earlier, you know, there’s this whole kind of selling pressure people have, and there’s all the gurus that teach you how to sell and somehow if you don’t make the sale on the day, you’re upset at the way I described, it is what you should actually do is tell don’t sell. If you tell people what’s going on with me. A lot of dentists don’t tell, you know, they talk about caries, they talk about perio, but they don’t look at occlusion, they don’t look at slow occlusal changes, they don’t look that slow tooth positional changes, if you tell people about that patients are not as stupid as we think, okay? You know, patients do understand I talked about envelope with function every day in my practice in Kent, and every single day, one patient walks back into the door and asked me how their envelope of function is. And I’m not joking. And then that comes from literally a two minute demonstration of how their teeth should be moving. And then how their teeth are actually likely moving and how much overjet they’ve got and how much overbite they’ve got. And that is a normal patient.

[Jaz]
I feel sorry for these patients who when they geographically relocate, and they find a new dentist, and they ask their dentist, how’s my envelope of function? And how startled the

[Tif]
You know, the thing is, yeah envelope of function, it’s quite an interesting one, actually. Because it’s theorized, you know, Pete Dawson’s work on Frank Spears work on it, there’s not a portion of it that needs to be, there needs to be real good clinical data on it. Because what I found quite amazing is that inside our profession, some people not even heard of it. Right? You know, in orthodontics, there are some orthodontist who’ve never even heard of it. Never.

[Jaz]
It’s true. I’ve just finished my ortho diploma. And that was not mentioned. And this is quite a comprehensive diploma. You know, and there was not mentioned once about envelope of function at all. And I think it’s a key concept. But you know, we have to be honest, Tif, And you know, there’s more than anyone that there are some camps who believe that actually, there is no impact and they believe it’s purely parafunction, whereas other camps in a believe that yes, there is no element of that constriction, the teeth knocking together more. So, you know, technically, we will never know when we can never make the study. But it just makes sense in terms of clinical observations we all make we can see this.

[Tif]
That’s exactly right. And you know, what the way the way I would say those in doubt, please show me your case follow ups. 10, 15, 20 years later, please show me that. You know what, they haven’t got them. There’s a lot of people that love to talk the talk, but they never see that patient again. And this is the thing if you don’t see your patients again, but you think you’re you know, a real hot shot, got no position despair. That’s the problem. And it goes back to what I said, what’s the core problem in our profession? I think actually, our professional curriculum has been created for our own convenience, not for the patients. So people you advance through your career and you get all these labels, but you’re not necessarily actually doing anything better for the patient. What would be best for the patient? Is it you looked after that person if you carry out a complex treatment, and even if you can’t, you made sure the work they had carried out gets looked after? And, you know, let me tell me anywhere in our profession where that occurs. I think the only area it does I believe is a perio. I think perio has just got that long term mentality to it, but it’s quite controversial.

[Jaz]
And the studies in perio, you know that x was on paper 30 years and stuff, and that, you know, they’re really into that. So I agree that’s probably the area of density. We have such beautiful long term

[Tif]
As well, but for different reasons, basically. Yeah. You know, and I think a longitudinal view on everything is a good thing, because it teaches us if not everything, we do works, and that stuff changes over time. So, you know, and it’s GDPs always going to be the person that’s going to see that

[Jaz]
True. Next question I want to ask you is do you routinely deprogram your patients before starting a dahl case?

[Tif]
I have to say, my dahl buildups are my deprogrammer. So once upon a time I never did then once upon a time I started doing and I started learning about splints, the deprogrammers. And then actually it sort of dawned upon me, why am I doing this when actually the thing that I’m bundling in their mouth is a deprogrammer. Okay? And so actually, now, if it’s appropriate dahl case, I mean, come on to that what’s an appropriate dahl case, because there are a few things that aren’t appropriate. But if it’s an appropriate dahl case, actually, the dahl build ups are the deprogrammer, so I, what I tend to do is I tend to just build them up so that my initial point of contact is just slightly posterior to maximum intercuspal. And you could say, Are you guessing, and actually, for years and years, I guess, and then actually, I started to try to take records. And I then started to set my dahl up to my supposed CR records, and it doesn’t, it made no difference whatsoever. So the key thing is you put the dahl, you put the buildups in, but then it’s critical, you get the patient back two weeks, four weeks later, because at that point, you may well find the patients now reprogrammed and suddenly you develop there’s an interference posteriorly, I have to say.

[Jaz]
Fantastic and I’m glad you’ve said that. So how many times has that happened to you? Because you’ve done dahl more than anyone probably so how many times that happened to you?

[Tif]
Well, I’d say is quite rare because it’s probably 1 in 25 cases, maybe something like that. And the reason why is that if you think about it, you’re actually separating the back teeth and so therefore Yes, of course the jaw can receed and then it can find a new position but because the back teeth are separated, what effectively then happens is a process of you know, in inverted natural equilibration so it’s quite rare I have had to you know, there’s been your tooth or you find a you know, a cusp of lower seven or upper six or something is knocking where it wasn’t before, but it’s not that common and

[Jaz]
It’s happened to me in my fifth, probably the fifth dahl case I’ve done and the patient of deprogramming I was Oh, okay, this is interesting. So I’ve had to follow that up and treat it and there’s a really good dental update paper actually put on as well were these clinicianss I think Leeds Dental hospital had a case where they just went ahead, wax it up, did a dahl, and then the patient deprogram to a quite a significant horizontal reconcler repositioning so that now they were extremely class two div one, they’ve lost all that anterior guidance. Yeah. So it’s rare, though, I agree with, I was in a postulate 2-3%, you said 1 in 25. So that we don’t have any, I suppose we don’t have any data on this, but that’s, you know, coming from you, I totally respect that. So this is why Personally, my philosophy is I do deprogram, but I’ll tell you about the Okay, how about you tell me if there’s anything else you want to tell me? But also tell me that Okay, once your patients have dahled in, what do you, how are you managing them with splints or not with splints.

[Tif]
Okay, just come back come to that in a second. But basically, another thing just to say and you know, all the papers that are written on these, if you look at the patients that have been treated, a lot of the train wrecks already, this is the key, you know, brought the cases end up in universities and hospitals cases that Dentists have left far too long. And so a lot of the patients are you kow the patiens have proper sort of severe occlusal issues, if I showed you and I’m not saying that those patients shouldn’t have been treated, and of course, they need to treat it. But if you look at a lot of the cases that I’ve treated, their patients that are early phase, you sort of get my point? So what I and that’s the thing, it’s quite a difficult thing to kind of explain and I’m not saying that you The point being is that the patient that was treated in Leeds or wherever should never have probably got that far. That’s the point and that patient has ended up there because the dentist you know, couldn’t do anything about it. Dahl is a treatment for everyday for your patient, it’s a treatment that I actually believe virtually every single person no you put it at a high percentage of people at some point in their life will benefit from if it’s only used to treat the train wreck. If it’s used to treat the train wreck it will be unpredictable and it won’t always work for it should be for preventing a train wreck. That’s kind of the way we think about it. It’s preventative treatment it should not be as severe I have used it in cases where they you know there is a lot of wear already but they’re just about the patient now just starting posterior wear because you can see there a really heavy bruxist, they are quite young and they’ve gone through the tip quite quickly.

[Jaz]
And that’s exactly the patient that had the condylar repositioning quite significant in my case, actually so that’s why now since then, I’ve started to deprogram but I take your point that actually maybe when we’re using it appropriately interceptively, the need for that may not be as significant as those sort of train wreck patients who have had severe occlusal issues, severe bruxism, that sort of stuff?

[Tif]
Exactly. And actually one you know, when I teach in my courses I’m actually just I’m appreciate a lot of people that come in and listen to that are kind of looking at this for the first time I want to actually tell them it’s in those patients don’t you can identify proper TMD or, you know, some of the massive shifts. I said, don’t do it on that case. I do use it on that case. But I wouldn’t start with a patient that’s got no restricted opening and huge clicks and all that sort of stuff. And masses amount tooth surface loss. Really this is for somebody we build the discussion that with over time, they’re losing their guidance, they’re trying to prevent them through a combination of dahl and potentially ortho you’re trying to prevent canine width collapse, lots of OVD, earlier rather than later. That’s really the key. Now, I guess I do use it on patients who do have kind of more severe tooth wear they’re more into anything, it’s just not got a posterior wear and I’m just about okay to do dahl, but if they’re heavy bruxist, then it might, in my strategy is this, I will dahl them exactly the same way, we go through a period where, and there’s a little bit of worry and risk when we’re waiting, because obviously, actually one issue is when you’re waiting dahl to occur, you can’t really wear full mouth splint or anything to protect it, because you’ve got to try to wait for that compensation to actually occur.

[Tif]
I’m going to come on to that because I want to think about splints. And so at the moment, when you’re dahling in, you’re leaving them new, no splint.

[Tif]
No splints. No, I do sometimes

[Jaz]
like an anterior only splint, maybe?

[Tif]
But that has to be given to a patient that you trust that and you know what I mean by that, it’s a patient that you trust to follow the instructions. And the instructions are, of course, that as soon as they’re back teeth start to touch, when they are eating, and they removed it, they must remove it quickly. And that’s also means that you follow them up quite quickly. Obviously, the last one is leave it there and then end up with an anterior open bite post treatmen. Which is possible, of course, it is possible. So sometimes, if I’m worried about that, I will protect them. But actually, so what I used to do for years and years and years ago, I would dahl them, okay, and then if I was worried about teeth tripping Well, back in those days, we gave them a rubber bite guard, which we know are, well some people actually don’t believe in. But I think they completely useless. Anyway, again, I used to get rubber bite guard. And then I started getting into splints and started, you know, learning how to be splints, you know I use splints, I can still use splins as I use this. But actually, I have to say the vast majority of my more severe wear cases treated with dahl. And now, dahl and an essix retainer. And that’s it. And I found that that in most patients is enough, I can kind of think of the last five years, there’s only one patient whose teeth who kept going through the assets and then ended up giving them a splint. And I think part of the reason being is that actually having the dahl buildups bonded in your mouth is it’s quiet, it will go no one really understands how to why people brux, there’s loads of reasons for it. We know that loads, but it but actually opening the bite, building the anterior is it’s as I say, the way I describe it, it’s like having a deep, anterior splint bonded in your gob that you can’t remove. And actually I found patients, I’ve got loads of examples of patients who I did treatment on who had severe bruxist, and that I dahl them. And actually, somebody didn’t come back for five years, and they came back. I didn’t have no splint, no mistakes, and all the composites still there. And you think, Well, you know, lots of examples, it’s not like one or two but lots. So actually Now, of course, life circumstances might change, the stress levels might reduce, they’re might be sleeping better at night, they might, you know,

[Tif]
But if you think of the mechanics of that situation, I mean, you build someone, you rebuilt the anterior guidance, so even if they are bruxism, the fact that it’s anterior contacts and muscle contractions are less and that’s part of the theory.

[Tif]
Exactly. And then just as a point, you know, even if you’ve been negative at all, you think, well, what are you actually doing, you’re just adding something to the teeth, you’re not spending a fortune on it. And actually, it’s quite simple to do, it doesn’t take very long. And we’ll talk about that perhaps as well, but how to do it. But because I think some people some of the techniques that I’ve seen become so complicated, that actually almost puts people off from doing it. But actually, it’s not that difficult, not that simple. But what the worst can happen, there’s no preparation, I’m prepared to teach at all. So even if after who knows three years, it all wears back down to nothing. The way you look at it is, you’ve got three years where none of, let’s say there’s been no further tooth surface loss. And I take the view really that if I can get anything for five to eight years out of it, even if not all patients, you know, the way you think about it is the five to eight years, your teeth are going to be the same because there’ll be no theoretical aging of those particular teeth. And when it comes back,

[Jaz]
Oh, I love that ageing of your teeth. That’s a communication gem, because patients need to be you know, hear it in a way that they can understand. So I’m writing that one down aging of your teeth. That’s really good.

[Tif]
Because you know, a tooth aging is, it’s tooth surface loss. It’s taken up of color, it’s chipping, it is movement. And you know, and I think another thing people don’t appreciate, is how particularly I think when you see it over the years, you see a patient over the years you notice a tooth that has dentin exposure. If you look at patient over the years, just watch how dark their teeth go. You know, it’s again, it’s a thing that no longer true nor kind of view on it. But teeth go dark and it’s because dentin absorb stain massively and at that particular, some drinks tea, coffee, smokes, you just know that someone with an open dentin have gone to what’s called dentin lesion, the permanent with open exposed dentin, they’re going to get darker teeth and that all contributes to aging. So yeah, the point being is that

[Jaz]
No, I like that very much. And the reason I asked about the splints and basically when you when you’re talking I wish we were videoing actually because I was smiling it because this is a huge part of my I mean I’m massively into splints and I do all types of it but my go to splint for someone and I’m glad you mentioned it who has no temporomandibular issues at all, healthy, who has no muscle issue. Okay? I am totally happy with a passive fitting and actually for me it has to be passive fitting, I get the lab to block out the undercuts essix retainers, so that they’re really comfortable and easy because you don’t want to give someone a really tight essix retainer to put them, you know, the compliance of it. So I’m so glad you mentioned that. And that’s, I use that as a protective appliance. So not really a therapeutic or diagnostic, it’s a protective of go-to appliance, because it’s cheap and cheerful. It works. And it can be comfortable when it’s made the right way. So I’m so glad you mentioned that no one talks about that.

[Tif]
Exactly. I mean, this is the thing, and I’m just, you know, it’s this is kind of what I’m using, I’ve gone through a whole spectrum of usage of various devices. And I did go through a whole period of experimenting Michigan, Tanner, soft splints, and you know, what, I’ve had great results from various things. But what I do find now is that the vast majority of cases if they can be, and remember, these are those appropriate dahl cases. And those are the most of the cases I’m treating, I don’t treat massive train wrecks, because I’m trying to prevent them. That’s the point. I get patient comes in who you know, needs a lot dahl. And you know, I deal with that, and I deal with as I need to deal with it, but most of them end up with build up, which I know have an effect and then vast majority with essix retainers and the ones that break through those or, you know, keep parafunction or who knows begin parafunction later for another potential reason those are more than happy to go on to some other type of splint for that they need to but they’re quite, but it’s quite rare. And you know, the thing is, I think you can only really judge us if you’ve been seeing people for long enough to know it’s very difficult to make an assumption of what how someone’s thinking of a change 5, 10, 15 years later unless you see them again, or you have the intention to see them again. That’s really the key

[Jaz]
Tif, have you heard of a flexi orthotic splint? Have you heard of this FOS appliance by any chance?

[Tif]
I have actually but I don’t [inaudible] know a matter of match. But I had heard a little bit. I’ve heard I’ve heard and

[Jaz]
So I use this in my protocol and I use this in my dahl protocol. And what I’ll go ahead and do is I’ll share a full protocol case on Facebook and I tagged you in it. Okay. I absolutely love this splint for dahl cases. Basically the acrylic that you mixed actually bonds to the polyester copolymer of the splint itself. So I actually use it as an anterior only deprogram appliance first, okay? And then once I’ve done the buildups the patient doesn’t need a new splint, I just gouged out the old acrylic. And I realized,

[Tif]
[inaudible] that sounds quite Yeah.

[Jaz]
Which is amazing, which is so good. And then when the posterior contacts reestablished, I then will convert them to an essix or if they’re really heavy bruxist, because one thing you could do with the splint, you can color in black with the Sharpie pen. And then you can see their parafunctional patterns. And when they come back, they’re like, Oh, my gosh, yes, I’m grinding. So I think you really like this splint I’ll show you. I’ve got quite a few cases with it now with dahl. I’ll put one on, see what you think I’d love to hear what you think about that. So I’ll stick that on and I’ll tagged as part of this episode, so I’ll be sure to them. So make a note to do that now.

[Tif]
Sure. Sure. Yes, please do that sounds really interesting, actually. Yeah.

[Jaz]
Okay. So I think we’ll have to wrap up soon. But there are some honestly, that’s been brilliant so far, I just want to say, Have you seen any dahl cases? No, actually don’t want to talk about that. Let’s talk instead about, Okay, so in those cases, where dahl may not be successful, no, it’s incredibly successful, especially in the cases that you’re doing case, because you’re doing, Tif, because your case selection would be quite good. And so in those cases, where it might not go to plan, I tend to have that discussion beforehand, as part of my consent process, I might say, okay, in a small, very small number of cases, it may not work, what this means for you is more time, a bit more money, and you know, that sort of thing. So how do you have that conversation with patients upfront? And how many times have you had to then sort of add composite or posteriorly, or other restorations posteriorly to actually do more like a full mouth rehab

[Tif]
What do I have to say, honestly, genuinely, I don’t think that ever happened. And I’m not kidding you.

[Jaz]
It’s because your case selection is really good, I’d say.

[Tif]
I mean, then yeah, there must have been your case where maybe I built the tooth up to get into contact or something. But I think part of it is I mean, the case selection is really important. And I think it’s probably important, I’ll run over a couple of things or cases not to do that’s important, because this is where I see. And I have seen some people who are very well known in the industry, and they talk about dahl doesn’t work and you know, you know, and actually even showed some case presentations or write blogs and stuff. And I’m looking at the case of getting those with the wrong cases. Now the problem is, who am I to say that the wrong cases? I think the problem is, there is a lot of luck dahl theory out there. There’s a lot of evidence and whatever it may be, but there’s nothing really that talks a lot about case selection. There’s nothing about, particularly about protocols. And no, I don’t think anyone’s ever done the studies on it. So what I would say is, you know, fundamentally, number one, obviously, we’ve already talked about patients with worn posteriors, it’s not a patient for one with worn posteriors. I’d also say any patient with perio issues is just a no no. And certainly any patients have got you know, significant bone loss or anything like that is out of the question that isn’t

[Jaz]
But Tif you find that your bruxist patients or your you know, extremely parafunctional patients, you know, they sort of select themselves because those who have periods extendibility they would have experienced it in a big way. I think there’s obviously there’s no evidence to support perio, occlusion, parafunction and stuff, but you know what, you know, the client that got like massive exostoses and stuff that might be either medical commodities or those cases to avoid dahling because maybe their teeth

[Tif]
Not necessarily I mean it, what I would say is one of them Most important things also is to avoid a heavily misaligned posterior arch or arch forms that are heavily tilted. This is a really important one because I found [Jaz] Do you mean like a cant like a maxillary cant? [Tif] potentially or posterior arches were just heavily misaligned, where you’ve got a lot of crossover on the lowers. You know, you’ve got like an ending premolar. And I’ve seen that I’ve actually seen quite a few cases have been posted online, or one or two articles written, you know, people have said, Oh, it’s not sure if it’s going to, actually it’s not going to work. And the way I view it is, if someone’s got an in standing premolar, and they need a dahl, because why not just have, you know, a few mouth, or a couple mouths of ortho, you know, it’s not a rocket science to move that tooth. That’s the point. If you’ve got a little bit of, you know, Dahl is effectively like doing some othro. It’s like doing some ortho, but with it’s like a bacteria about biplane, and I think anyone that’s got, you know, misaligned arches, it the way I think about it, you’re expecting this segment to sort of move. Now, in the study Syed eruption. I think there’s a degree of compensation and potentially a touch of eruption. But the way I view it is that if you’ve got [Jaz] and maybe some joint repositioning, maybe? [Tif] yeah, definitely. I mean, the jaw reposition has been shown and actually, it’s of benefit anyway. But no, absolutely you’re right. But if you think about how the teeth actually move, I mean, I’ve looked at teeth slowly, over the months that they moved, actually, they, you know, they kind of if you think about two teeth touching each other, two molars touch, I think with tiny mesial distal rotations, you see what I mean? Almost tilt a bit. So, it’s much more predictable if a patient’s got a well aligned arch, that simply, quite simply it. So and if the patient’s got really bad arch, so there’s like huge instanding premolars, canine tipped out to the side, then that’s not a dahl case to me. And that’s really, really important. And I don’t think enough people say that. And I’ve seen you know, a few occlusion gurus do cases like that, and then they complain, it’s unpredictable. And reality is it doesn’t work in those cases. Another classic one is the sort of example of a static occlusion, we’ve got someone who’s already had, you know, they’ve got, you know, they’ve basically got a hugely already over compensated three to three region. And I’ve seen people do [Jaz] like a massive curve of spee. [Tif] Yeah, that again, you know, that was 10 years too late backache needs ortho to basically intrude those teeth and level the art in might, you know, you might then do some bonding, whatever, afterwards. Obviously, anterior open bite cases as well, you know, there’s no point as well, yeah, [Jaz] of course [Tif] it’s those sorts of cases that I won’t do Dahl and what I would say is, you know, it’s really, really important to think about dahl. And this kind of what I hope this podcast will help people do is to start to think of it as as interceptor treatment. And if you’ve seen my presentation, but the cases that I show that I’ve used, Dahl at, they’re not crazy cases, these are patients who were starting to get tooth wear, lots of anterior guidance, they’re some of them are combined with ortho, there’s a bit of crowding and stuff as well. But what I did is I treated them hold their teeth in a better, more functional position and critically, a retained position in a better anterior guidance, you know, in 5, 10, 15 years later, you look at the teeth, and you think, well, if we hadn’t done that, where would those teeth be now? You see what I mean? That’s really the key. The key is to try and use it in interceptively, basically, it is not a tr it should not be a treatment that when you see a traditional, you know, heavy tooth wear case, oh my god [inaudible] patient, I’m not thinking dahl, you see what I mean? [Jaz] Yes, I agree. [Tif] Dahl is the alternative to occlusion? No, it’s not. It’s not and actually, it’s an adjunct. And, you know, I know Ian Buckle really well. And it’s a really good friend of mine. And we’re actually

[Jaz]
I’m doing the Dawson modules with him. I’m on module three in January. So yes, Ian’s a top, man.

[Tif]
Exactly. And, you know, Ian and I meet and talk to him all the time. And we, you know, he’s doing running a course with IIS, and is doing some case with us. But he came in and sat, watch my lecture. And he basically said to me, you know, this is the bit that content is missing from a lot of traditional approaches, because what we end up doing is fixing a problem which could be could have been prevented or a lot now, what you’re doing and what you’re learning within your need to learn because there’s always going to be patients that never go to the dentist, you know, there’s always going to be patients who never go their teeth wear they get to that point where what you are learning from it, and you will be able to offer the patient a very viable treatment. But the point being is there’s a lot of patients who go through their whole life seeing a dentist every six months, their teeth are gradually wearing, anterior guidance is reducing the bite potentially could be deepening there may be getting more loss of anterior, loss of canine width. And dentist says nothing and says nothing.

[Jaz]
And dentists don’t diagnose. And I can say this because I didn’t used to, you know, so my story is and I’ve said it in a podcast, Episode Four is when I was a first year after DF1 associate part time, I’d read the prosthodontist notes and the patient’s Not in front of me because the previous practice owner was a prosthodontist. And he’d said there’s a line wear facets you know, upper right five, upper left four, lower left six. And I’d look at the teeth that way. I don’t see anything.

[Tif]
Yeah, I know.

[Jaz]
Oh my goodness. And when you when you start seeing them, you start seeing them and so now on my exact coding, there’s a code we make a TW it’s an orange, tooth wear for me and my system, that’s it and maybe you have a better system, Tif, I’d love to know other than photos, your system of photos is very comprehensive, each individual tooth that’s as comprehensive as it gets. But my charting system is a poor, one tooth wear if there’s been any degree of tooth wear from attrition if you’d like or erosion, but if there’s denting expose, I put two wear times two, there’ll be two TWs on that tooth code. So but I’m the only one I know, especially in my circle of friends, dentists, other associates, principals I work with no one does that.

[Tif]
Well, I think, you know, the problem. The problem is, I mean, we’re actually getting into political territory. And I’m not afraid to do that. But I think the problem is, is that our system has kind of encouraged us not to. The system the way it is now, particularly with UDA it almost gets to the point where if a dentist identifies this problem, you have to tell the patient and then what’s the solution going to be, is that I don’t understand how UDAs work, but I do understand is it from my understanding, the dentist identifies a problem offers a solution to a patient, they’re probably gonna have to spend a lot of a lot of time on it, and they’re not going to get the fee to justify the time is that correct? Or am I incorrect? That’s correct, isn’t it? So actually, our system is sort of dissing discouraging people to actually even talk about it. And you think about it, that is just astounded. I find this particular being in private dentistry for a while. And I think about, you know, you think about what the NHS offers, in my head, if the NHS was fee per item, and actually was a core service, I’d go back to in a heartbeat, I would, you know, I actually believe in it. But I think the biggest problem we’ve got is we’ve got a system which has been created by people. And you know, I’m not going to point the finger in individuals here. But it’s been created by people who actually don’t understand dentistry, they don’t understand long term dentistry. It’s all about fix. And it’s all about politics. And I think the problem is, whenever the reality is, when it was a fee per item, it’s a lot easier to do. It was a long term period. And I came from a very kind of privileged era, or actually, we had fee per item, we had NHS patients, we could talk about the difference between private dentistry and we could offer them different things. UDA meant that became very difficult and actually pushed dentists into a corner. And you know, the way I think about it is those people that thought that UDA was a good idea, I actually think they need to be made accountable for, because the damage they’ve done to the profession over the years is actually spectacular, because it’s made it very, very, very difficult for dentist to actually talk honestly, with their patients. And actually, it’s created this whole, I’m either private, or I’m NHS. And this is kind of one thing, it’s harder for young dentists to be able to convert their patients, it can be done. But the problem is, is, you know, you’ve got this scenario that makes it hard and kind of going off subject slightly. But the but the reality

[Jaz]
No, not at all, this is important. This is the real world issues that we face.

[Tif]
This is why I think that you know, Dahl is something to, it’s difficult because it can’t be offered. Now, the what I do 32 [inaudible], actually a lot of cases that have dahl sometimes an ortho and the best thing at ortho is, if you know, you don’t have any title, actually, it’s a conversation quite a bit easier. So you can, kind of say, does the whole ortho restorative treatment plan, and you could potentially take your conversation that direction, but I mean, fundamentally, dahl is should be an interventive treatment based on people who you’ve been speaking to, and you’re identifying sort of slow changes. And as I said, you’re trying to prevent, the way I look at it, dahling, is for me to try and prevent a full mouth rehab. And actually, I actually take a view that if I see a full mouth rehab, it’s not something to celebrate, it’s actually an abhorrent reflection of the fact that our profession can’t cope with those patients and failed to prevent those patients from getting there. And our goal should be to always stop it. In my practice, you know, I didn’t really say any patient that’s come to see me and stayed with me has never ever gone on to the need of full mouth rehab, you know, so I treat them I’ve treated some, of course, to treat some because they walked through the door, but no patient who’s I’ve got, actually the patient yesterday is lovely at age 86. And she’s on her fourth dahl recycle and nearly 26 years later. Okay, I want to say, I mean, obviously, they take the material off and put the same material back on. But I mean, as we strip some of the last like questions, I said the term recycle. But I’m getting a bit better thunberg here with recycled stuff. But basically, yeah, it’s when the dahl cases were down and start to look bad, and start to fail. And you know, they’re not guiding anymore. You literally strip it off, start again and deport me that just let it no evidence has nothing to say how many times you can do we do it or what’s actually happening, but she said I’m on my fourth. You know, who knows? Hopefully, we’ll get to my fifth better. But we’ll see.

[Jaz]
That’s interesting, actually. So you know, when we’re doing repeat, will the sort of mechanics of dahl continue to work? And obviously they do because you’ve been doing it? So that obviously works. And I think it’s a great philosophy, it’s a great way you run your practicing life. And obviously, you’re a massive inspiration to young dentist, if I just wanna leave you with three little reflections. I want to hear your views on this and then we’ll go into interest of time for today. Yeah, so first thing you mentioned about the in the in standing premolar sort of scenario. So in that scenario, I’m thinking okay, this patient would benefit or in “benefit from orthodontics” or it’d be an alternative plan. So in that orthodontic plan, would you then be intruding the anteriors to then create the space to then rib in the guide? Is that sort of where you’re getting to as well instead of doing a dahl?

[Tif]
Yep, definitely. Because actually, you know, one of the best ways of fixing the lateral anterior space is with ortho and if ortho is appropriate and if there is actually anterior crowding or anterior tooth movements that need do it. Then that needs to be offered to the patient, the patient may not choose it. And I probably say some patients don’t. And if they’ve only got an instant in standing premolars, and it can be fixed very simply, sometimes they say just fix that. We’ll do the rest of it with the build up. You see what I mean? So but the option has to be a table, as with every option has to be comprehensive, has to be on every you know, [overlapping conversation] the decision really so but yeah, it may well be and it’s happened, you know, it’s happened in many, many cases that I’ve come across in the past, what we’ve done is, we’ve done that, or actually, in many cases, deals that don’t refer to have done that

[Jaz]
Brilliant. And the next good thing, last of the two I want to talk about is now with the advent of an accessibility of digital dentistry. And you mentioned scanners, are you doing this thing whereby your dahl cases, you’re seeing them every couple of months, and then scanning them and doing like little time lapse, because if that, that study needs to be done, we would learn so much from that.

[Tif]
No, I am. I am actually at this quite interesting. I’ve got a new scanner, I had a scanner for about 18 months online, which was wonderful having online, and I did quite a lot of scans on those cases that we’re trying to do now is actually marry up those original scans with those same patients. But anyway, we had a new scanner for about about six weeks or so now, scanning so many patients now for the basis of patient monitoring but Yes Also, I’ve been doing a couple of Dahl cases where I’ve scan those. And now I’m actually going to plan is to then see the patients in a month and then rescan and see the patient three months,

[Jaz]
We had learned so much as a profession from that, and also about the mechanics of it, which was, you know, a little bit disputed, I guess. So that’s amazing that you’re doing that. And I can’t think of anyone better who’s doing that.

[Tif]
I got to give a call out to one of my friends Andy Wallace, who’s been who’s even further ahead on the curve than me on that one, because I know he’s got a couple of cases at the moment. He’s sort of mid scanning. So you know, be interesting, I’m actually waiting to see his

[Jaz]
Andy’s a top guy and part of the tubules sort of a crew and I went to his Inman course actually. So yes, shout out to Andy, thank you so much for the work you do. The last reflection is my theory on why some dentists are against dahl is it because it means that it their big tickets will not come through. So basically, you have to charge the patient way less, you’re being way more minimal, and you don’t get to do the posteriors. And that could be a reason why maybe dahl is not favored.

[Tif]
I think it is one reason. It’s definitely similar. The only reason I think what we’ve covered some of the reasons in that perhaps a lot of you know, the view the term gurus, those gurus are seeing those patients way too late. And those gurus perhaps also don’t have regular patients, perhaps, you know, they’re acting like pseudo specialists, you know, it’s like,

[Jaz]
They’re in a niche area where they wouldn’t see the sort of interceptive opportunities,

[Tif]
Exactly and they’re seeing patients who are already too far gone. And that’s completely understandable. But I do, there is definitely an element. I don’t think so much in this country, I really do believe in this country and most of Europe that I think that really our health professionals first and business people second, I appreciate there are other areas of the world that may be a little bit different. But I do think that ultimately, you know, we do hopefully think what’s right, for patients is best. But yeah, there is definitely I mean, I have sort of given lectures on on dahl in various countries around the world. I’ve had a couple of people sort of say to me, you know, well, this is all well and good. But you know, what about the milling machine I’ve just bought? And what about this? And what about that?

[Jaz]
And what about the bottom line?

[Tif]
Yeah, and I you know, that’s fair enough, I kind of it’ll be very easy for me to get angry about that anymore. You know, you’re speaking about a patient, but ultimately, I can understand why they’re thinking that. But I think that’s a very short kind of narrow minded and perhaps short term view. Because, as I said, if you know, if we were all less focused on this big ticket, new patient walks through the door, I’m gonna charge him 5 or 10 grand type of thing. And you’ve thought about a patient about keeping that patient for life, you thought about all the people they were going to refer into, you don’t have to kind of fight with mentally and drive and worry about getting sued by them and all that sort of stuff. You think about, you know, that sort of enjoyment you get out of seeing your worth 5, 10 years later. And you know, I think perhaps that’s the problem. I don’t think enough dentists do because they don’t do enough dentist think that’s the thing to do. And then actually, I think there’s a much this sort of long term view, and I call it a lot of my lectures now call it the lifetime patient. That’s a term that I use. And I think that the more we think about that, and the more that word and that process gets put out there, the more hopefully people will realize that dentistry is not just about, you know, it’s not just about big ticket, it’s not just about Instagram, it’s not about here’s my before and afters, it’s about actually, it’s about here is before, and after five years later, here it is 10 years later failing, and this is why it’s failing and is it failing, you know, the patients don’t have the patience to have loved me. And you know, that’s just a different view. And so I think that there’s a lot, you know, I’ve kind of come away from it helped being a cosmetic dentist, you know, it helped with me being that sort of person that thought I was like this hotshot walking around in the white suit with my name written on it and all that. And I thought, Oh, yeah, I’m a superstar. But over time, I realized, actually, I learned a huge amount from that. And I don’t mean to belittle anyone that does that. But a massive amount from smile design impression taken, but actually, what I didn’t learn was ethics. And I’m not saying that they need to learn that but I think being a general practitioner and seeing the work that you did that you probably realize you shouldn’t have done come back to actually haunt you and you’re having to fix it and you haven’t to, you know, a case I sold with smile design technology, you know, 20 years ago, we had a version of digital smile design. And I remember setting cases like that. And I kind of looked at it 5 to 10 years later thinking, why did I do that? You know, and actually, that’s I think it’s probably the one, you know, for my generation dentist is probably the one it is hot, it’s a terrible thing to go through. But actually, it’s one advantage of way of learning what not to do. I think that’s really, really valuable as well.

[Jaz]
And you’re so honest to talk about these matters. And honestly just highlights your ethos, and everything you’re about. And you know, with this episode, it’s so many gems in there. And even though it’s been, I think, two or three years since I did your course, I retained It was good to see I retain a lot of information. But again, there are some few things a few gems that you gave me that I can implement Monday morning and

[Tif]
that actually so it’s a comeback, as it’s changed quite a bit since then. I’ve kind of restructured it.

[Jaz]
Brilliant. Okay, well, I’ll have to and I’m looking forward to sharing that case that I told you about with the FOS appliance, I really want your input on it. I mean, more than anyone, so I’ll put that on as well.

[Tif]
So does that appliance? Wher it’s come from? Who created that.

[Jaz]
So Gary

[Tif]
Yeah, that was the day I remember missing a lecture is I think it damn I wish I pushed it because then everyone was talking about it after that he might he might be in at BACD or somewhere that I missed it. Anyway, that’s thank you for that. Yeah,

[Jaz]
No, no, I’ll tagged you that when I can. But Tif, thank you so much for coming on and inspiring everyone, as always keep doing your thing. You know, what you’re doing for our profession is amazing. And again, I’m so glad that you’re getting this prize, which obviously means so much to you. And I’m so glad that you’re a dentist from the UK. And we have we have someone to look up or look up to. So thank you so much.

[Tif]
Thank you very much, Jaz, take care speak later on.

[Jaz]
Thank you. Cheers.

Jaz’s Outro: So there we have it, folks. As a dental geek, I absolutely loved having Tif Qureshi on the show. I hope you gained a lot from this two episodes. That case that I mentioned to Tif, the one that I would tag him in it of me using the FOS appliance and my dahl protocol. I did actually post that on Facebook with about 60 photos step by step. I’m a huge fan of doing step by step photos because you know I’ve done it before, obviously, but I don’t like the whole thing. Here’s a before and after, look how awesome I am. I like to teach and share. And I’m open to getting criticized and scrutinized, I feel like if someone can criticize me and scrutinize me, I will gain, I’ll become a better dentist from it. So I actually posted my entire protocol of a dahl case on my Facebook. So the way you can easily access it instead of me giving you a long sort of URL is you just go to www.jaz.dental/dahl as D-A-H-L, then it will redirect you to my Facebook page to the album that has all the 60 photos. Let me know what you think. And you’ll see that the FOS appliance and action which has just been fantastic for my dahl cases. And if you want to learn more about this type of splint, there is a hands on course happening in February. If you want more information, please message me. I mean, it’s me who’s teaching on it, but it’s mostly being marketed internally to the people who use this lab. But there might be a few places available. And if you’re interested in that Chim near Reading up anyway, so please message me if you’re interested in that, you know, hit me up on Instagram. So thank you so much for listening all the way to the end, and I’m really looking forward to next one. Thanks so much.