Cracked Teeth Management with the Direct Composite Splint Technique – PDP098

Jaz’ Introduction: Hello, Protruserati. I’m Jaz Gulati. And welcome back to another episode of The Protrusive Dental podcast. On this episode, today, we’re talking about something called The Direct Composite Splint Technique for managing cracked teeth. Now, if this is the first time that you’re coming across this, it is a completely alien, weird, crazy concept like the first time I came across this, like, you know, our natural instinct when managing crack teeth is to take it out of occlusion, right? You see a crack, ah, let me remove it out of occlusion. But what this technique actually does is the opposite, it actually puts that same cracks tooth in Supra occlusion, right? And by doing that, you will by wrapping some composite over the crack molar, let’s say, basically prevents the cusps from flexing and therefore maintaining the crack rather than allowing it to propagate. So that’s how it works. And then to even add the controversies of this technique, what happens over time is that, that composite is left in the patient’s mouth over the offending tooth, the cracked tooth, right? And then what happens over time is what we call relative actual movement. So that tooth, which is proud in the bite, eventually, over time is no longer proud in the bite. And suddenly, it’s almost pretty much in the patient’s maximum intercuspal position. So that when you remove that composite, you now have restorative space. Now, if I’ve gone too fast then don’t worry, we’ve got a whole hour or something with two leading experts on this technique. So if you’re listening, if your buddies listening from the USA, from across the pond in Canada, maybe you need to sit down for this one, okay? Maybe grab a stiff drink, because there’s going to really challenge some paradigms that you have. But I think that’s the beauty of dentistry. There’s so many different ways of doing it. And this is a very minimally invasive way of managing cracked teeth. So I’m not going to blab on too much about this technique. Because we got a whole episode on that. I will give you the Protrusive Dental pearl for today, though, it is, you know, it’s an obvious one, okay, we’re dealing with cracked teeth, we need magnification. So the reason I’m putting this pearl in now for Episode 98, is one of the top five most common questions young dentist asked me is about magnification. And specifically, it’s like, hey, Jaz, do I go for three times? Or do I go for five times? Or do I go five times? Or do I go for seven times? The answer is super simple, okay? You need to go for as much as you can. And as much as you can afford. Magnification is like a drug I say it again, it’s like a drug you want more and more and more. I’m on 7.5 now, and I do everything with I even do children’s checkups with my 7.5 magnification. It does not leave my face. And I love it. And if there was like tomorrow, if the same company I bought my loupes from release a 10 times I probably get it, right? Yes, there’s a whole thing about you know, maybe the next step is a scope. And I’ve tried the scope and I and enjoyed using the scope. But in my surgery at the moment, it’s just not feasible, it’s not possible. And also the whole thing about being associated with a scope and that kind of stuff, which I totally respect. I know some associates have their own scopes, which is awesome. But talking, generally speaking, most of us all have a good pair of loupes. So the pearl is get the largest magnification you can afford and you think you can sustain. So if you are deciding between three and five, go for five, if you decide between five and eight, go for eight, you know, go for as much as you can. One tip that Pascal Magne shared at the BACD Conference recently is and he shared it based on the findings of a paper is the probe itself, the sharp probe has got like the ability to feel a resolution of like 40 microns, okay, that’s like the resolution of a sharp probe. Whereas our human eye is at 200 microns. Eight times magnification is at 25 microns. So when we’re dealing with cracked teeth, you want to use something with a resolution, ideally, superior to your sharp probe. So that’s just another reason to go for as much magnification as possible. And you will adapt. Don’t worry, I know many dentists are concerned or worried about not being able to adapt. But I think you will, I think everyone almost everyone does. And usually most people say, most people regret the fact that they didn’t go for higher magnification. So in a nutshell, go for the highest magnification so, so important, especially when we’re looking for cracks. Anyway, let’s join our guests Dr. Subir Banerji and Dr. Shamir Mehta, who are absolutely brilliant pioneers in this field of managing cracked teeth. With this technique they’ve done. They’ve contributed to research in this as well. So the papers of course will be on the blog and on the Protrusive Dental community Facebook group. I’ll catch you in the outro.

Main Interview:
[Jaz] Welcome everybody to this very rare live Protrusive Dental Podcast. Today, I’m joined by Professor Shamir Mehta. So congratulations professorship we’ll talk about in a second and Dr. Subir Banerji. Two absolutely great people in restorative dentist and I’m really excited to share what they have today about the Direct Composite Splint Technique for managing cracked teeth. Let’s start by welcoming our guests and give them a warm welcome, Professor Shamir Mehta. Tell us about yourself. Where you’re working at the moment? Tell us about the PhD that you told me that you recently did. What was that on?

[Shamir]
Thank you, Jaz. It’s a pleasure to be involved with this podcast. So yeah, my name is Shamir. So I do a number of things. Sort of I’m a practice owner in northwest London and do a little bit of practice. I’m the senior clinical advisor to the GDC largely with fitness to practice. I am Subir’s deputy with the MSc in Aesthetic Dentistry at Kings which we’ve been working together on for since around 2009. And more recently, I’ve been appointed a professor in Aesthetic Dentistry at the College of Medicine and Dentistry, which is with the Ulster University. So it’s a bit of a varied week. And yeah, I’ve recently done my PhD in toothwear in Nijmegen as part of the Radboud Tooth Wear Project in the Netherlands. And so that’s me.

[Jaz]
Yeah, well, I’ve seen so many of your publications, including dental update, and a few papers are very, very practical, very helpful things that you share all the time. So very, very excited to share those nitty gritty little details with you. Subir, I was just telling you before we hit the record button that either I seen you lecture, to in a small room in a pub in Twickenham in about 2013, 2014. You inspired me that evening, show me what’s possible with composite resin. I’ve seen you in even bigger stages, the BDA, on a massive big screen showing your beautiful work. Tell us about where you work at the moment? How much teaching do you do? And a little about yourself in general?

[Subir]
Oh, thank you very much for a very kind introduction, Jaz, and I’m admiring your mastery of technology, I have to say, and yeah, my actually bread and butter is in general practice, I’m not in Ealing. I’ve actually been in the same practice ever since I qualified so I kind of been there ever since. So that’s where my bread and butter is. As far as my academic areas concerned, I’ve been teaching at Kings for about just over 20 years or so. I teach on the prosthodontic program and as a director of the MSC esthetics program that Shamir mentioned to you. And I’ve also got my own private teaching academy, the Academy of Dental Excellence on which we run some diploma and masters courses for restorative dentistry. I’m an associate professor in the Department of Prosthodontics at the University of Melbourne in Sydney. So I’ve been kind of very varied background academic. I’ve always been partly an academic, but I have to say my bread and butter is in practice, in general practice. And that’s where my passion is mostly. And yes, I do remember meeting you in the pub, which is kind of likely location to find me mostly, but not all the time. I hasten to add, but yes, I do. Remember.

[Jaz]
Subir, are you a cricket fan?

[Subir]
I’m a bit Cricket fan. Indeed. Yes.

[Jaz]
Because I remember you were running this occlusion course, together with the IPL. And I just love that concept, which really caught my eye at the time, but it did that ever go ahead? or did COVID get in the away?

[Subir]
COVID got in the way of that when the idea was to actually hold an occlusion course and a restorative course in Mumbai. And at the same time to actually combine with some the Mumbai Indians fixture but then COVID got in the way. So we might relate that at some stage later

[Jaz]
Please, please Subir do that. I will support you fully with that. I will come and I will get as many of the Protruserati to come with me as possible. I’m a huge fan of cricket. It was good to see India win today. I’m sure you will watch it as well. But yeah, we could easily spend a whole podcast on my cricket. But we won’t because today we’re talking about the direct composite splint technique for managing cracked teeth. So many people listening watching right now will never have heard of it. Some people will have seen it and heard of it and thought what the hell is this? That was my initial reaction. No offense, when I first saw this like this, it just seemed very counterintuitive, right? But then when I actually did it myself in practice, and I saw that, hey, actually, this is pretty clever. And then some people may be well versed in it. In fact, Zain sent a question in which I’ll ask later, so he’s been using it, and he’s found a few challenges with it. So we’ve got three or four different groups of listeners and watchers. So let’s start with the very basics. Either of you wants to go first. What is the direct composite splint technique?

[Subir]
Well, I’ll let Shamir answer that one actually

[Shamir]
Well, it’s a technique that actually evolved. We were just discussing before the session. I see a lot of, I used to see a lot of cracked tooth syndrome in my own practice. And this caused me a lot of difficulty in that, you know, diagnosing was a challenge. Treating it was an even bigger challenge. And, you know, many, many years ago Subir and I both used to teach on in primary dental care at King’s in Denmark Hill. And I remember one Friday, lunchtime, I was sat with him and you know, thought that, you know, asked him, How do you go about managing this? It’s really, really difficult. And then, you know, we got chatting and you know, how about this. And essentially what this technique is, it’s a minimally invasive way of managing cracked tooth syndrome. And this technique involves placing composite resin over a tooth like an onlay, if you like, in supra occlusion, and it can be used before it’s bonded to help diagnose the condition. And then it can be used to help manage the condition as well. And the beauty of it is that where it’s successful through the process of the intrusion, and extrusive movements that take place, it creates the room to put a definitive restoration without having to do very much by the way of any reduction to the effect of tooth. So it’s a way of diagnosing cracked tooth syndrome and treating it.

[Jaz]
Let’s explore that, because what you’ve covered is in a beautiful way, very short way you’ve covered the whole technique, let’s break it down into individual components. Diagnosis of cracked tooth syndrome is a challenging thing in daily practice, sometimes a pain is difficult to localize, we often rely on biting on cotton roll or biting on a tooth sleuth or something like that. Do you still do that as part of your protocol? And then you maybe would then use the direct composite splint? Or would you nowadays go straight for the direct composite splint on the tooth that you suspect maybe exhibiting the signs of cracked tooth syndrome? How would you go about your like decision making and sequencing?

[Subir]
Sorry, I was just gonna say, Jaz, you raised a very important point there in that, you know, in practically, that’s the challenge, isn’t it? To diagnose it. And then pretty much when you want to manage it, you want to do something that is not intrusive, or not invasive, so that if for any reason you got your diagnosis wrong, you haven’t done anything to the tooth. And primarily, when you look at ways in which you actually manage it, there do involve a little bit of reduction and therefore putting, for example, band around it and something like that. So there is that aspect of it. And from a general practice point of view, of course, when you’ve made that decision to actually do that is kind of you’ve made an irreversible change in the tooth. The other thing I think it’s important to emphasize is that unlike osseous tissue bone, for example, when you put two bits of bone together and hold it still enough for long enough, then they fuse back together, the fracture mends but a fracture, a tooth does not fuse back together again, it is there and there forever, and it will only increase never decrease. And so you always manage the situation and to get the result from it. So when it comes to the diagnosis, one of the things you have to remember is that you do have to have a technique whereby you want to minimize increasing the crack that you already may have in a tooth. And all that is difficult to locate, you need to be very careful in the history taking, try and locate it as best you can. And try and arrive at a diagnosis by minimally putting a pressure on the tooth. And so when you have a tooth for example, that you’re suspecting that is kind of giving a little sharp pain on recall, for example, on cotton roll or tooth, my presser preference is cotton wool rather than the tooth sleuth because I find a little bit harder, because you don’t want to put too much pressure on it, is that when you use it at the diagnostic stages, Shamir pointed out where it’s unbonded, the response that you’re looking for is that you put the composite over the occlusal, the lingual or the palatal and the buccal, and then you ask the patient to bite and release. And what you’re really looking for is a complete elimination of the symptom. Okay? So basically, you know, before on release that on that tooth, the patient might have reported a sharp response. And now that when you put it on a diagnostic level, it is completely gone. Because if it hasn’t, then it is usually indicative that the crack is a little bit further or deeper than this technique that perhaps would old allow you to control it with. But that’s one of the things that I will sort of emphasize on it. And then of course, this also helps a diagnostic process because if you actually completely disappears, then you kind of know that by providing some sort of cuspal protection and prevention of lecture, you’re able to get the management starting. Sorry, Shamir I interupt you at the very beginning. So

[Shamir]
I would have pretty much said the same thing in that I still would start off with a history and look for you know, the classic sort of pain on biting or release and the sort of acute thermal sensitivity to cold. Of course, there may be other things as well. And I still do use a tooth sleuth. I know that there are you know, sort of issues with the risk of breaking things with it. And I think that has happened to me once so that there is that risk, but then I would then apply that trial splint as Subir described and then repeat the same test with the tooth sleuth to see if there has been resolution, obviously, you’re looking at the patient’s feedback. And I think the beauty of it is that there are so many conditions, which could be quite easily confused with cracked tooth syndrome, that this kind of does help in that, if the pain still persists with this splint in place, it just gives a further sort of level with helping to ensure that you’ve got the right diagnosis, because I think it is quite easy to get it wrong with there being so many other things which could manifest in a very similar way.

[Subir]
And of course, the other thing to add to that I was going to say is that the evidence shows that when you have a fracture, as soon as you put a bur to it, or you take any reduction of tooth, there is a high probability around about I think 26% of teeth, then going into the sort of endodontic exposure in endodontic requirement, you know, pulpal intervention. So when you have a technique whereby you don’t actually to have to open the tooth up, there is that advantage and with it. So that was essentially a conservative way of managing something in the process, which could be applicable in general practice.

[Jaz]
Very much so applicable in general practice. I think the way you’ve designed it, and there’s studies that you’ve done, and the protocols that you’ve written about, which I read are very much a quick and easy to apply once you know and that’s what this podcast episode is about is that disseminate that information, making it easy for general practitioners, practitioners tomorrow to be able to utilize the DCS technique in diagnosis. So, you know, is this a cracked tooth. And if you make that blob of concept, we want to a better word over the tooth, compressing the cusps and containing it. And then when they get a negative response, you can then confirm with some relative accuracy. Okay, this is a crack toothache and it was that tooth in question. But that same composite, how many millimeters are you aiming for in terms of thickness? And is it that same composite that you’re bonding onto a tooth? And if so, how?

[Subir]
Well, here you might find a difference of opinion between myself and Shamir. Because the but saying, in my personal experience, what I tend to do is use a sort of roundabout a millimeter on the occlusal, or thickness that I’m using now. Do I use the same one? Often not because sometimes I’m trying to do this very quickly on the diagnosis front, so it’s not very neat. And when I’ve completed the diagnosis, and the symptom has completely disappeared, then I would look for approximately about a millimeter occlusally, and then go around the sides. Now, one of the aspects that I feel is important, although there has been evidence to the contrary that I have read, whereby to keep this supra occluded tooth out of lateral excursions, my preference at the moment is still to have it out of lateral excursions contact. So essentially, if a canine if I can add a canine rise to actually lift that out of lateral excursions or any excursive movements, that would be my preference, rather than having any lateral load. So it’s essentially a axial load on the tooth as far as possible. And I use sometimes a million and sometimes even less than that, for this phase. I don’t Shamir what you feel, but I think you wanted a bit more than that on the occlusal it show

[Shamir]
Yes, for the trial one, I will probably use a you know approximately a millimeter. As you describe sort of flat on the occlusal surface, wrap sort of, you know, 1/3 of the way down the axial walls, buccally and lingually, or palatally. I’ve never reused the same, never rebonded the same thing back. So I would always make a fresh one. My skills with composite artistry are not to the same level of Subir, so it would have to be remade. But I would normally be looking for about a millimeter and half in thickness. Just to sort of, I think that we know from studies that we’ve done with tooth wear, etc, that you know that the actual height you build into the resin restoration has a substantial impact on its survival. So I would normally be aiming for about a millimeter in half. But you know, once I’ve satisfied with the diagnosis, then I would would remake the thing. Pretty much how Subir is described, keeping it flat on the occlusal surface and out of contact during lateral and protrusive movements.

[Jaz]
That the thing that initially confused me when I first heard about the technique because in my mind, only a few years qualify the way how is that possible to build something in Supra occlusion, but then also have it out of excursions. But then when I actually did it, I found that okay, when the patient does excurse and you mark it up and you mark up the centric stop, where if you just get rid of the lines and keep that one dot sometimes it just works out but you’re also raise a good point Subir that sometimes you may need to add a canine riser. How often does it just work? And how often would you actually have to add further anteriorly to aid that disclusion

[Subir]
It depend on the occlusion that is at the moment, you know, depending on the existing canine slope and the existing slopes, cuspal slopes that you have. So it’s very much dependent, but it’s something I feel that needs to be checked. And one thing about canine risers which I think our experience, what my experience has been is that sometimes when you add a canine raise, if you added inappropriate, in other words, it’s too much, or it’s beyond that, if you like threshold of tolerance, then the composite tends to wear off very, very quickly. Whereas when it’s within tolerance, it tends to last for a long time. So if there is some canine wear, then it works best, you know, then it can kind of almost dictate the fact that it’s going to be alright. And if there isn’t, then you might just be a little bit prepared for the fact that they’re composite that you’ve added to give that disclusion, might actually chip away or wear away really, really quickly. And if we have to come back to this mean, in other words, you don’t put the splint and forget about it is you have to monitor the response. So I couldn’t tell you sort of a number on this. But you know, and but it’s quite surprising that you know, the number of times that you have to raise an canine rise, or not that many, but it really must depend upon what is a class one, class two, what sort of whether it’s lateral guidance is shared by a group of teeth or not. And whether or not you know, there is the slopes of the cuspid that involved. So it’s been a combination of those factors.

[Shamir]
So if I just pick up on that, in the actual study that we did, there was a sample of about 150 patients, and Subir is quite right that the number that was only 12 and a half percent or so off the sample where we applied a canine rise. So it’s sort of my experience, anecdotally as well, you don’t end up placing it that frequently. And that’s got it kind of benchmarked in the study data as well.

[Jaz]
And that’s good. That’s what we want as GDPs, we want something quick and easy in that emergency appointment when they got cracked tooth, and to not have to add another additional thing and explain to the patient that, that would be quite helpful actually to have to do that. So when I’ve done it, it has worked out that on excursion, because of the cuspal slopes were in my favor, I was able to avoid it and lateral excursions. Now can either of you or both of you just describe the exact protocol for because a lot of times crack teeth involve amalgam restorations. So do you, are you air abrading the amalgam? And then you’re using a universal bonding agent? And then you’re just building it and molding it using a flat plastic? Or is this under rubberdam? Or is it not? Just describe the workflow and the protocols, if that’s okay?

[Subir]
Well, for me, if I’m kind of facing an amalgam restoration, then yes, you can air abrade the amalgam and then you put it over the top of it in the first instance. And then that would be to give you the emergency scenario the control because then you would actually want that patient back. And then once it is kind of settled down, and you confirm the diagnosis and the response to what the therapeutic measure that you’ve applied, is working, that’s when I would take the amalgam out and then proceed to do the restoration and hopefully, because I’ve got the occlusal height be able to restore that. So that would be my protocol if there was an amalgam in the tooth, initially, because usually when you’re seeing this, you’re seeing it at a time of day when you want to get the patient comfortable and relieved. So you kind of, I would air abrade the amalgam and then go over the top and if it’s an MOD amalgam, I would leave the of course, because it’s just going over the occlusal and the outer surfaces that the amalgam stays, but then on the return visit when we’re confirming that I would remove the amalgam and restored accordingly. So that would be my protocol of doing it. Otherwise, if it was a tooth that was completely unrestored and there is no restoration in it. Then of course, it’s a question of air abrading the enamel making sure it’s sort of nice and clean, isolation is good. And then of course, place the composite bonding agent and then place the bond, the composite on top. My personal preference for bonding still is the three step technique or you can use a two step technique rather than the self etching once that’s that works better in my hands. And then of course enamel bond is very predictable as we know and the more enamel we have, the better and that will be my protocol for restored or an unrestored tooth. Shamir, I don’t know if you want to add something to that as well.

[Shamir]
Yeah, I think mine’s pretty much the same. I tried to put a matrix band around the tooth when sort of doing the adhesive conditioning to try and help make sure that the material doesn’t stick to the adjacent teeth. In terms of the contouring, just a flat plastic or, you know, composite instruments. There’s no merit, there’s no yeah, the old finger, spade, there’s, it’s kept fairly basic, there’s this, there’s no real attempt to sort of, you know, make it look anything fancy. And as long as it’s splints, the fracture is in the right location, and obviously has to be kept flat, to try and help sort of putting those lateral loads on the tooth.

[Subir]
I think it’s an important aspect here to also draw attention is when you do go to, it’s quite interesting that in both my practice, I’ll find as well as I think we found in our study is that, of course, when patients get very, very comfortable with this and the occlusion equilibrates, after a period of time, patients are very reluctant to have this off again, you know, particularly if this very, very comfortable, so you kind of have this sort of a flattish molar at the back. But if you were to restore and replace it with something like indirect restoration, once you have that space, then it’s important to stress that the cuspal angles that you want to put in after on your restore on the indirect restoration have to be fairly free in excursive contacts, because you really don’t want to recreate a scenario where there’s any chance of this sort of forces that split the tooth, or create courses like that, again, developing in your sort of range. So looking at it from an aesthetic point of view, you may be compromising a little bit on the lovely cuspal angles and fissure bands for the sake of limiting the load on that tooth. Because you really, because it like I mentioned before the crack actually never heals, it’s always there. You’re just managing the problem.

[Jaz]
I’m just gonna acknowledge that Vimal has been asking some questions on the live and I will get those very shortly. But just so in the interest of the of the workflow. So thanks for describing the step by step. Now, if you’ve played this, according to the research you’ve done, how long do you typically need to wait before you are happy about the pulpal diagnosis and the diagnosis that okay, that the pain is now gone and you can proceed. And also, just describe the what you mentioned before, Subir, about the relative axial movement, it’s almost as though in my mind is as though the supra occluded restoration and the tooth itself is intruding? And then that gives you the space to add your cuspal coverage. So you can be very minimal. Is that all that’s happening? Or is the opposing tooth intruding a bit as well? Do we know exactly the mechanics of this a bit like, how does a dahl work, right? How does this technique work in terms of the relative actual movement?

[Subir]
In my view, I think this is sort of a combination of several things. And it’s very difficult to determine how much of what happens in the other. In my opinion, I think there is an element of intrusion extrusion that takes place posteriorly. But the very first thing that happens is a condyle repositioning element. So essentially, it’s like putting a little jig in if you like, and the first thing that happens is a condylar repositioning at the back. And then that immediately creates a bit of room as you know, there’s a little bit of room co CEO and CEO and a lot of patients. And that’s the first thing that happens following that it’s a kind of a sort of axial movement, both intrusion extrusion, eruption, overeruption of the surrounding teeth. My thinking on this, and this actually, when I used to lecture about it, almost 20 years ago, in places like America, where this concept is quite can be challenging to explain them except the issue is really, that when you have something like this, that the teeth are coming, drifting back into what I would term as the neutral zone, you know, and kind of reestablishing the contact, according to that. And the fact that there is a few like an obstruction in the way that teeth that are moved back into the. Now sometimes we find that we may have pushed this technique, so in other words too high, and so it comes almost back, but not quite. And of course, if you’ve done it in something reversible material, then you can adjust slightly in order to fine tune the equilibration in that way. But in a lot of cases, particularly if there’s tooth wear, the amount of adaptation that takes place is quite surprising and quite consistent in my experience, it’s very rare that it doesn’t. So that would be the kind of criteria there for it. So it’s a combination of movements. I think initially it’s a condyle repositioning, and then it’s a combination of the intrusion extrusion of certain teeth. And of course, there is no permanent increase in the vertical of the patient at all because it’s sort of reestablishes back into work actually kind of showed and then you’re going to establish that but then the professor is that sometimes if you’ve just overshot the threshold and the tooth and some of the teeth do not restore back And the timeframe you’re looking at is around about a three month period when these sorts of things happen, then you may have to adjust the occlusal of the composite. To answer your question as to when you would replace this composite. Like I was saying to him, practically pragmatically, what happens, a lot of patients resist this change. And sometimes if they do, if you’re using nanohybrid, composite, which is flat, and they’re not worried about the aesthetics, I have instances left behind and then carefully monitored, and made sure there’s is no wear and to be honest, it’s a sort of a safe default position to be in if you kind of control the situation like that, if not round about the sort of the, I would say the month to month limit is where you would look to sort of replace it if you wanted to. But I have a lot of cases whereby, once managed, very few patients do not take it to the next level.

[Jaz]
It’s a bit like some patients, when you place the ortho in, you used to place the ortho band and as some practice will do, and then they like it, and they don’t want you to then place the crown or the indirect restoration, because they’re happy to have this ugly ortho band on but it’s not really a symptom, so very much in that way. Shamir, did you want to add anything to that in terms of how long to wait in your experience?

[Shamir]
Yeah. So in terms of our study, which is obviously based on our own experience, my sort of thinking is, normally would say to patients that look, if you’re not happy with anything with the symptoms, let me know, straightaway. Usual review period initially would be two weeks. And what we found in our study is actually all the wear, all the problems were, that kind of happened within those first two weeks. So we had about 20 patients of which 16 they developed irreversible pulpitis or the fractured progress to a complete fracture. And those patients, those were identified fairly quickly, we had four patients who sort of expressed intolerance. And that all happened within the first two weeks, the rest of the sample pretty much progressed to the end of the three month period. And we did a review at four weeks, and at three months. And again, what we kind of found is that all this sort of niggles, and the adaptation, that all took place within the first two weeks, yes, at four weeks, these patients were quite happy. And I suspect that may well have something to do with the you know, the adaptation, the condylar repositioning that Subir was talking about, together with some central adaptation with a patient sort of brain starts to accept that I’ve got something that’s foreign, which is proud. Many,, it was quite interesting to see that the change in, you know, the sort of things that people were complaining about going from the two week to the four week. So usually, in my experience, if you’re going to see things wrong, you see pretty quickly.

[Subir]
Yes, and I think Shamir hit upon something quite important that is patient management, because the patient has to be carefully managed to see what to expect here, you know, because to them, of course, you’ve just explained to them that this tooth is cracked, and you’re making it high. And the first thought that going through their mind is well you know, this is a little bit contra productive, isn’t it? Contra-intuitive, rather. And it’s just basically the management scenario because of course, when you make that tooth high, the forces on it, the general bite force is actually a reduced on it, because of the fact that it’s sort of a if you like an interference on that in the thing in occlusal system. So there is that aspect.

[Jaz]
Could you describe, Subir what you actually say to patients if you don’t mind? Because you touched on it, I’d love for you to just give me like your one minute spiel on what you warn the patient. I mean, I know Shamir said, even, you know, if any symptoms raise any issues, you know, let me know. But is there anything else you say in terms of fine tuning movements may be affected? Take some painkillers, I don’t know. What is your spiel?

[Subir]
My most feed in practice is once I’ve identified the tooth and kind of confirmed a diagnosis with the patient, as if this is what has happened. I think the analogy that I used about bone fracture, which a lot of patients can identify with is quite useful in the sense that bone fuses to back together if you hold it still enough, but a tooth is not going to do that. It is a splint and it’s splint there for Life is nothing you can do about it. And there’s nothing, even if I make it short and you bite on it, there’s nothing that will happily come back and erupt and the same forces will apply. You’re never going to stop chewing on this tooth. And that’s the reality of the situation that this is the problem that we have. And the next step of that is that to going through the all the alternatives. And it’s very important to point out to the patient that all the alternatives that are available, including the if you like the bands, etc, etc. And then of course, for then when you look at this particular option, and you look into the advantages and disadvantage of it, the reason why it kind of appeals to patient that you kind of say, well, I’m going to put it on right now I’m not going to cut your tooth, and all I’m going to do is probably not even a local that’s required for me to do it. And hey, if it doesn’t work, I can always reduce it and there’s that added factor and this of course you have to throw into that factor of the disadvantages is that if I use some of the other techniques and there is a higher proportion according to the evidence of the going necrotic, or reading root canal treatment. And then of course, when they get, when you get them on board on that is to just be absolutely plain, you know, honest with themselves, you’re not going to like me for this, and this is the exact words I use it in, I’m going to do this and you’re not going to like me for this. And but there is a reason I’ve just explained to you the reason I’m doing it, you’re going to find it very difficult to eat, and swallow and find satisfaction to eating with this. But usually in about the two week time, you will start to tolerate it better. And you’re tending not to get pain from it, but more of an annoyance, it’s not going to. If it hurts, you let me know, okay, give me a call and let me know straight away. If it’s annoyance, and it’s just bugging, you can’t chew properly and you can’t get the satisfaction of chewiing, then please tolerate it, we’ll see you in two weeks to see how you’re getting on. So that’s the sort of the spiel I kind of used. Because I do paint a picture of that we are in a situation which is very difficult to manage something that is not going to heal. And, of course, it’s important to also point out to the patient that the situation can escalate. Because it’s a crack, it’s we’re trying our best to hold it together. But nature is what it is. And the forces are what they are, this is going to be an issue. So that’s my usual, the build up to it and preparing them for uncomfortable time. But for a good cause. And that, it’s also the fact that it is got a reversible element to it. And I haven’t cut the tooth, which is if you like the seller of it and his tooth colors in there is not, you know, there’s the knob looking at something that’s metal. I don’t know, Shamir, if you have any other added tricks with that?

[Shamir]
No, not really, I think it’s the same thing, same sort of spiel that I would normally give in, of course, where we’ve used the trial version to assist with the diagnosis, they’ve already had that experience of what it feels like with having something proud. And I know with some of my patients, you know, you put it No, no, I’m not having that, you know, I’ll come back or go for Plan B, but I’m not having that. So that I think having the trial thing, there’s also you know, help with the process of obtaining the consent, but the spiel is pretty much it, this is how you described it.

[Subir]
Can I ask you Jaz? I mean, I know you have done this yourself. What we have said, is there some something else you would say to this? Or how do you or when you do it for your patients, what sort of do you say?

[Jaz]
Very much the same as what you guys done, you know, undersell overdeliver, explain that, you know you’re gonna hate me initially, I love saying that as well. They’re gonna hate me but it’s for a better cause. The bone, the thing that you said, my old principal Amit Mohindra in Oxford, he used to use the same thing. So I also use. So it was cool to see that you also communicate in the same way to patients. So very much the same. So I don’t have anything to add to that except whenever I’m explaining the different things that can happen. I do like to quote study. So for example, Shamir, you mentioned that in that study that you did, I think you said 16% went on to experience irreversible pulpitis or the crack, becoming, making the deem the tooth unrestorable. And I would say, you know, in some studies, this could happen. So let’s say one out of five times your tooth, because the crack is already quite bad is not going to make it. And I like to just give those figures to a patient. Obviously, we can’t apply studies to that individual. But when it’s more average case, I like to just give them a few numbers about Okay, well, we’re aiming for about this percentage of success rate. Is that a fair thing to do Shamir with your position in the GDC? Is that a fair thing? Or is that? Is that incorrectly applying study to an individual?

[Shamir]
Well, I was gonna say that whatever I say, is my own opinion, and not the GDC. Let’s just make that clear, but I think it’s fair that to, you know, when you’re looking at trying to attain consent, you know, you’ve got to be done in a logical balance, accurate. And of course, we’re trying to do it in a scientific way. So I think it’s fair to use studies, and is you said that there was 16 patients out of the 150. So not quite 16%. So yeah, it was a lot less than 16%. But if we look at the number of the overall sort of 20 patients, whether there were problems, effectively, that’s in line with what you see with most of the other protocols, which were just sort of mainstream. So, in terms of the success of the procedure, it is in line with what you may expect with you know, a direct composite onlay or an indirect composite onlay, or even a crown. However, as severe said in the beginning with crowns, we know roughly a fifth of these teeth are non vital within the first six months. And we also know that the prognosis of root field crack tooth is also poor that you don’t certainly that’s not what we found within our study. So look, what we would say to patients, what I would say is that whatever of these techniques that you use, there is a chance it is not going to work because we don’t know how deep this crack is. And it’s very possible, it’s hovering right near the pulp chamber or right near the sort of the periodontal ligament. And it won’t matter which technique we use there about, you’re still going to get the same outcome. But I think I kind of do like the idea of quoting studies how you do, as long as it’s articulated in a way that the patient understands, and sort of can make an informed decision from that.

[Subir]
I think this is important point, as you raise Shamir as you build more talk about discussing, everything should be fairly comfortable discussing evidence, of course, the numbers might not be in there, but you generally are quoting, you know, quoting evidence. And I think that’s important. And I think in level of consent, I would go more towards Montgomery on this one, rather than Bolam, where you can actually go to every little bit that and it’s easy to describe because it is a situation that is non healing. And it’s kind of, if you kind of stress that with the patient, that is, this ain’t going to get any better, I’m just managing the problem, and make sure that they’re aware of the risks. And that is the best way. And I think I offer not just in this particular instance of cracked teeth, but in a lot of treatments I do, I’m always looking at reference, quoting references in a way that the patient understands. You know, in fact, I hope just to go through one particular patient for tooth wear he came in, and then he’d read all the papers that were written. And so he was quoting the stuff that I’ve written several years back, which I actually didn’t remember at the time, which is a bit embarrassing. So, you know, our patients are very knowledgeable nowadays. So you have to be aware of that.

[Jaz]
I mean, I have an episode out with Kreena Patel all about I hate cracked teeth. And we talked about, she talks as an endodontist, about management cracked teeth, and it was very generic cracked teeth episode. But it’s one of those things where I can’t emphasize enough now you guys, I know you guys have done it as well, where we as a group cannot emphasize enough the importance of really over egging the communication part in someone’s got a cracked tooth, because it’s something that can be a source of stress for a dentist that you know, they intervene. And then a condition that was always inevitably going to get worse, because of the nature of root crack get does get worse, and then the dentist ends up owning the problem rather than the patient. So those you know, younger clinicians watching, listening, you know, when it comes to communication and cracked teeth, you have to do your due diligence and have to spend the, even when you run a couple minutes late, just in a calm tone. Explain that, okay, there is a crack, it may get worse. And that’s the reality of it, we’re trying our best. But there’s a you know, this, this could very much lead tooth loss as at worst case scenario. Just in the interest of time, you know, we’ve covered so much ground, which is fantastic. I’ve got some questions in as well. Before we do that I’m gonna just finalize the sort of the clinical protocol element, which is, imagine you’ve put your direct composite splint on, it’s been on a lower molar, on a lower first molar, let’s say, it’s been there for it’s got past the two weeks point it hasn’t dropped off, patients tolerating fine, you haven’t needed to do any adjustment or anything. You see the patient again in three months. And now, would you find that in your experience that the bite or all the other contexts have fully established? Or would you find that they’re almost established, but not quite? And then the second part of that question is, when you flick off, or drill off back end composite, how much space do you usually get? So all that 1.5 millimeters, do you find that you have got 1.5 millimeters or around about a millimeter to play with

[Subir]
In my experience, the various between patients by round about three months, I’m kind of finding all the other contacts reestablished, in my experience, is that three months in probably about six months is probably the longest I’ve seen it personally. But I do believe in the literature that it varies, you know, in that, but I think after the three months, if I haven’t established all the contact, I’m maybe looking at adjusting the splint a little bit until I do that kind of level. So we were looking at that, of course, you know, we make a note of what the occlusal contacts were before we started, which, essentially all shim stock, if I was to be pragmatic about it. As to model space that’s left behind for the ones that we’ve taken away. It’s about that, I think it’s you kind of, if you had placed a sort of a millimeter, millimeter half of composite on it, But then by the time if you are doing something in the sort of within the six months to a year limit, then you’re probably not seeing a lot of wear on that composite you will get, a lot of that space that will never ever fall off because you’re born into enamel, so that I’ve never had a case scenario where they actually fallen off tall because you’re bonding very well to enamel and that’s fine. And that’s what you get. And of course, if you are also managed the patient, I tend to sort of prepare them for a crown which is also rather than onlay not a crown, which is going to be a little bit sort of bulky on the palatal and the buccal aspect because of that control, because I really don’t want to cut tooth after all of this is I’m just going to sort of polish the composite off of that. Now, the difficulty comes in how you provisionalize this in that interim that it takes you to make the indirect one. And sometimes I find I add to the opposing tooth, you know, or, you know, you can actually if you book it with the laboratory as soon enough, then you can actually get the onlay back as soon as you can with it. Or if you’ve got a CAD CAM, I guess that there’s a bit although I don’t have an experience in CAD CAM-ing it, but that’s another way of doing it, if you want to do. The difficulty comes in that interim stage as to managing it for that period of time. But that’s my experience on it. But like I say a lot of patients are kind of what I’ve done, a lot of the times, it’s actually just contoured the composite into making it look prettier, or closer rather than having it flat. And that’s a lot of the time that I do. But that would be my observations on it. And my ingot of choice is gold alloy, but a lot of patients don’t want that, the lithium disilicate, you’re really looking to bond onto the tooth again, in order to really restore the integrity of the tooth. And Electromatic over know that that is?

[Shamir]
Yeah, I mean, my experience is fairly similar. If we go back to the study, in 97% of the sample, the contacts are established. And this is checked with shim stock within that three months. So we know that it is with good case selection, it’s fairly predictable based on this, it’s quicker than what we find with anterior teeth probably to do with the loading. And that comes back to the point that you made with the amount of space, I sometimes find that it’s very difficult to judge whether you’ve actually got that 1.5 or 1 or whatever, I sometimes find the space isn’t quite as much as I would have hoped. And I suspect and this is when I’ve spoken to colleagues of uses, I suspect there may well be some element of wear of that composite, which may also mean that, you know, the contacts are establishing a lot quicker posteriorly than what we see anteriorly where you’re looking at a longer time, certainly with the dowel studies, they’re sort of a nine month period, whereas this is a lot quicker. So I think that there may well be some wear and tear of that composite that takes place. But again, as Subir’s sort of alluded to, more often than not, I will just replace it with a new direct composite, which will look a little bit nicer than what’s already gone on there. Rather than I’ve found that the provisionalization. And what happens in the interim, leads to more headaches. And it’s a case of you sometimes learn from getting it wrong and getting your fingers done.

[Jaz]
So essentially a direct composite overlay?

[Subir]
Yes, essentially. So you kind of just basically refine what you have there, because a lot of it is still bonded, especially if you bonded correctly in the first place. And if you’re not really involved in replacing an amalgam and stuff like that, then of course, you can just modify the one you have placed. And that’s the one with the least risk because then you don’t have to worry about provisionalization not worry about going back to our cutting. And that’s the easiest way to manage it. And if need be if you want to strengthen and weaken add a bit more composite to it on the size if you need to. So that I have to say that is my first preference to manage it with it. And to resist the temptation to actually remove is something that’s working. Because remember, as we said before, we’re managing the problem, it’s kind of thing. The other thing to add to this whole management scenarios, and then just sharing a little bit of my experience here is that with this scenario, and then the thing that I specified to my patients is that I’ve taken the least step possible to get the result that I want, you know, and so when you’re managing a cracked tooth is important to take it in steps like that, rather than go straight for the endodontics as well as you know, start following the crack endodontics. And doing it sometimes as this allows that to happen in a more controlled way.

[Jaz]
Great. And it’s great that you mentioned that in your experiences, they very rarely come away because they’re well bonded. I think that’s partly probably to do with the fact that it’s usually in compressive loading sort of hugs the tooth and probably even cures towards the tooth and just thinking out loud. And the other thing is because you’ve managed the lateral excursions on it, there’s going to be less tensile shear forces on it and we’ll be dipping into the sort of the cuspal incline so very much isn’t compressive. Have you ever seen any cracks split in three or four? Get cracks and come lost in that way?

[Subir]
Not on these? Not on the one’s we bonded well, that’s not been my experience.

[Jaz]
And in the study?

[Shamir]
Yeah, I mean, I have an in the study as well that probably my ones ?? work but not cracks as such, but sort of odd, you know, bit of marginal chipping or something that that which is easily repaired rather than having to go in and redo the whole thing. I think the key is making sure there’s enough height to this, that the height is critical, but there will be some, you know, areas where, you know, maybe towards a marginal ridge area where they you know that the height isn’t quite what it should be. And you see a little bit of chipping or whatever, something that that can be readily repaired, but not a case of, you know, a complete sort of fracture where it needs to be re done, No.

[Jaz]
Okay, great. Well, we reached that point. Now, in the last 30 minutes, we’ll just take some questions. So if anyone’s watching the moment either on YouTube or Facebook, and you got any questions, If you’re on YouTube, please come on Facebook, because I am not reading the YouTube comments at the moment. I’m just reading the Facebook ones. But I’ve got some questions from beforehand on our Facebook, on the Protrusive Dental Community Facebook group. So question one, we’ll go with [Schweter], woudn’t, keeping a painful suspected, fractured tooth high, add occlusal load on the single tooth and make the periodontium sore and worsening the pain? So this is like the very classic, instinctive response of a dentist who comes across your study and your technique for the first time. Right? And it’s those sorts definitely went through my head. But I mean, Subir, you’re a man, you already mentioned before, it’s a bit like those studies where they’ve introduced interference, they found that patients were bruxing less, and they were actually chewing with reduced EMG forces. Is that what you do? Is that what you think’s going on here?

[Subir]
In my view, yes. In fact, it’s not just [Schweter] that sort of had this heartache. Reviews of the article, I know, on hindsight, had the same sort of when it was published in the general dentist, you had the same sort of anxiety. And do just to reassure that though I did receive the written communication from later on quite later after the article and research was published as to how this phenomenon it does kind of doesn’t have that effect that you mentioned, two things that it tends not to happen because of the rationale that reasons you mentioned. And that’s what the color of the study is showing. Of course, this is also a technique whereby you can actually reduce it as well. So in other words, you can reduce that composite doubt, the main issue, the reason why it works is because you’ve kind of eliminated the primary reason why the symptoms of there’s with a tooth flexing. So by doing that, but yes, it was, it is kind of sounds counterintuitive, but interestingly how the actual your own body actually protects against that lower, Shamir, anything to add to that?

[Shamir]
No, not really, I don’t really want to go into the sort of physiology of it, because it probably don’t understand it that well. But I think when you’ve got something that with the simulation of the you know, Periodontal proprioceptors, it probably triggers some kind of a reflex bit like what Jaz was alluding to, which therefore means that it actually isn’t something that gets blasted away. It’s odd, isn’t it? When we put our restorations, which at times a proud by a whisker, patients will come back. Whereas with this, it’s funny that you go through the consent, and you go through the spiel. And you know, you’ve been through it. And on the odd occasion, when you may have not done it as well, that person will call that I think that the psychology has a big role to play as well in that, you know, the patient knows what to expect, and therefore they’re able to adapt it. But yeah, I mean, the concept, when you look at it in the way that, you know, [Schweter] kind of described it, it sounds ridiculous, that why would you do that? But well, the proof is in the paper, or the pudding or whatever you want to call it.

[Subir]
But saying that going back to the, sorry Jaz, as I mentioned, one other study that is actually the it’s not particularly new, this concept in the Senate is reported in the 60s, but in a paper directly forget to pop my head, but essentially, isn’t simply because you wear a particular tooth was put in Supra occlusion, and how essentially that the equilibration took place. So it’s not really something that’s absolutely news being done there as well as other studies. Now, of course, the bit that’s new is this effect that it’s a cracked tooth. You know, that’s the main challenging bit with this bit. But for to answer this question about the periodontium response. That is not unusual. It actually has been done previously. And without these effects. So it’s not, it’s the putting on a cracked tooth doesn’t seem to affect that aspect of it at all. Anyway.

[Jaz]
Great. Next question I’m asked is by Vimal. Let’s see, I think essentially, is once you come to the three month mark, and you’re let’s say, you’ve removed the composite and it’s got an amalgam inside and you can remove the amalgam this is just general crack management, because everyone actually has got a different opinion. Everyone’s got different threshold. So both of you, gentlemen, how far do you chase the crack is the question from Vimal.

[Shamir]
So okay, I’ll go first and this is where we may differ slightly? I don’t know, I tend not to chase cracks, I tend not to chase them. Try to splint conservatively where possible. It’s a question that I get asked all the time, especially from students and colleagues in Australia for some reason about chasing cracks, including on teeth, which are asymptomatic. I tend not to chase cracks. You know, once I know the diagnosis, take the amalgam out if that’s required, and you know, seal that intracoronally and then put the extra coronal overlay on top, I tend not to chase the crack.

[Subir]
I actually, Shamir, I agree with you. I don’t either. And I think that kind of, you know, we could we come across as when I was lecturing in the States, it was a similar sort of phenomena as in Australia, funnily enough, it’s half of Australia. I don’t know what is this little half of it kind of agreed and the other half doesn’t, or something, but it’s quite controversial in the Middle Eastern and Asian countries about this. But no, I don’t chase cracks either. Providing we have kind of established the symptoms are controlled. And I think that don’t chase the crack.

[Jaz]
With me, gentlemen, I went through a phase of at the beginning very early on my career thinking that was the right thing to do, chasing cracks just because that’s what I was taught by the certain mentors I had or clinicians that were teaching me, then a chap called Pasquale Venuti, who I’m recording with on Saturday, he gave a lecture, he said that, the most dangerous part of the crack is the part that you can’t see. So all this bit that you’re chasing, you’re still never gonna get to that bit where you can’t see, which is the leading part of the crack, you know, and you won’t even see that. So why are we weakening the tooth by chasing it? So that really was playing on my mind. And then I was with a group of dentist, very good dentist, and they sort of ostracized me for not chasing crack. So now I’ve gone back to chasing cracks. So I’m glad I met you two. And you two, don’t chase cracks. But there we are. We don’t know really, what is the best way to go. But there we are. Now we know what Subir and Shamir do. Let’s see, I’m just reading some more questions, just for contact points. So what bands do you like to use for to get good contact points? So let’s say Shamir, you’re using your direct composite overlay technique. Any preference of bands to get good contacts? I think it’s a question really.

[Shamir]
Yeah. I like using the the garrison sectional matrices, which are Teflon coated, dead soft matrices. I’ve been using them for quite some time now. And that’s my personal preference. Certainly, for doing standard, you know, regular composite work. I’ve used those as well. I stopped using circumferential bands, which are not good for crack teeth as it is anyway. A while back.

[Subir]
Yes, my preference is the same as a sectional matrix band, Garrison’s the ones I use as well, are the only thing I would add to that I use a lot of customized wedging, I don’t rake very much customize the interproximal wedging of my band, whether it be with different types of wedges, whether it be PTFE tapes, or most similar, sometimes even Greenstick, just to actually really customize that band.

[Jaz]
Wow, I’ve never had a green stick being used in that way. Pretty cool. [Subir] Yes, I’m showing my age here. [Jaz] Excellent, fine. And it’s got one last question. There are a few more from Vimal by an interest of time. Can I ask one more before we wrap up? This is from Zain Rizvi, really talented young dentist. I found patients just don’t like how it feels. What’s the best way to get around it? Is there anything more than just patient management and communication and underselling and overdelivering? Or Have you got any little tricks up your sleeve to make it feel more comfortable for patients?

[Subir]
I think the explanation is to the non invasive nature of what works with me in the sense that, you know, the all the other things I’ve got to offer are invasive, you know, and the fact that the most likely that I have to put a local in usually swings it my way as well as say, Well, I don’t have to give you a local for this one. What do you think? And the reversibility of it. And I think the combination of the reversibility and the uncertainty of the diagnosis and the manager prognosis of it kind of swings it in my favor. But yeah, I mean it mainly is this fact that I have to say that the all the other ones are very invasive. And but at the end of the day is about informed consent, and the patient will have to consent to the treatment. So that’s important. And they may if they’ve been misled as some of you for some patients don’t like the idea of being high on that. So we have to do something else.

[Shamir]
Yeah, I guess from my perspective, it pretty much the same other than what I can do with this is treatment there and then, whereas, before it would be usually be there’s sort of an amalgam or something I used to splint it with direct composite as an interim measure. Can’t use orthodontic bands or copper rings, or it would be a provisional crown. And again, I used to really struggle with getting these those teeth numbed up. I remember when you know 20 years ago, putting temporary crowns, provisional crowns on these teeth. Trying to get these teeth numbed was a, it was really difficult. And I think patients liked the idea of, well, if I get it treated now, and also that you know that the fact is, if I can’t see them straightaway, it may take a week or two, the crack, make progress, things could get worse. And I think that the selling point being that well, something can be done now and look, hey, if you’ve got problems, come back tomorrow, and we can take it off and we can look at Plan B, that seems to be the thing that sort of flips, it doesn’t always work. But that seems to flip it. It’s patients sort of saying okay, fine, we’ll let’s give it a go.

[Subir]
The other thing that also is supportive is the fact that the diagnostic element, you know, if you put the diagnosing the patient in themselves experience, the completion symptoms being gone, which they did experience a second ago, that’s often sways them as well, because it kind of worked that work, the pain is gone. And yes, it feels awkward, but it’s not hard as I bite, it doesn’t actually hurt anymore, as they were doing because I don’t know if you’ve ever suffered from a cracked tooth, but it’s the pain is quite can be quite unnerving. Excuse, unnerving sometimes actually shoots into the jaw. And so the almost worried about biting and they suddenly think, oh, wow, I can actually really put pressure, and then sometime that convinces them. And so the diagnostic element is quite an important element, both from clinical as well as patient acceptability point of view.

[Shamir]
I suppose the other thing that we have is that we’ve probably been seeing the same patients for a long time, which is a common theme. And I think that trust element probably has a role. And that may well be I think, Zain, you said you know, with a younger practitioner who may have not had that same level of history with that patient and I think that trust thing certainly even when using dahl with the tooth wear cases or whatever, I think it does, I think its got a role to play.

[Jaz]
Very fair point. Gentlemen, The time has really flown by it’s been really great to have you guys on. I really enjoy this chat that our went really quickly just like when I asked you in February to come onto the show. And we booked for November and how quick November came by you two are the busiest people I know. So it’s really great to finally have you guys on. At the end of the show, I usually like to find out where we can learn more from you, if you have any courses or website because a lot of people listen and they you know what I like this person if they got any educational work and I read the papers, etc, etc. So Shamir, tell us where can we learn more from you? Are you running courses? I know you’re really big on tooth wear that kind of stuff?

[Shamir]
Yeah, I mean, but both of us teach at Kings on the MSc in Aesthetic Dentistry. I teach at the College of Medicine and Dentistry on their MSc in restorative. I tend not to do too many courses and stuff outside of that. Yeah, we do write, do a fair bit of writing. We’ve written textbooks, as well. Subir is probably more, does a lot more hands on stuff than what I do.

[Subir]
Yeah, I mean, yeah, apart from Kings, I’ve just launched my own diploma and Master’s program with the University of Portsmouth. So recruiting for March of next year. So if anybody’s interested do let me know. This is a master’s in advanced aesthetic and restorative dentistry program, which you can actually do a diploma in with us, where I teach along with my faculty, and then you can take it to a master’s with University of Portsmouth. If you want to masters from an aesthetic dentistry from Kings, of course I manage that program as well. I’ve stopped doing shorter courses, I do two lectures, the others you have you’ve mentioned Jaz, but I prefer structured learning I always, I’ve always a big advocate of that. I think the shorter courses fit very well after you’ve got the sort of the second sort of foundation of the postgraduate structured learning I think so you have a structured learning and undergraduate level, then you have a structured learning at postgraduate level whether it be towards specialist or a general practice. And then from there on, you can really then add to your skills by adding short courses going around the world and listening to people speak. So I’m a big proponent of structured learning at the postgraduate level, I think that has to get the whole picture whenever I run short courses is very difficult to give the full picture so we’ve always kind of done that and I think that’s definitely my big thing on it. Do it structured and you know, just invest time, it’s worth it. It’s worth pays off in the end.

[Jaz]
I still really want you to think of IPL 2022 And if you can do it in Punjab and not in Mumbai, that will be even better. So I can be there to watch the Kings 11 Punjab play. Gentlemen, it’s an absolute pleasure to have you on. You’ve been absolutely fantastic. Really great to learn from you both just gonna end the live video on Facebook. Goodbye Facebook people. Amazing So yeah, that was absolutely fantastic. I really enjoyed myself. Thanks so much for coming on gents.

Jaz’ Outro: So there we have it. This crazy weird technique called The Direct Composite Splint Technique for managing cracked teeth. Check out the papers. It’s too controversial for you. I think you can still use it as a diagnostic aid. Anyway, hope you enjoy that and I’ll catch you in episode 99. Oh my goodness, we’re approaching 100. I’ve got something special planned for 100. You knew I would, right? You knew I would. Okay. Anyway, I’ll catch you soon Same time. Same place. Take care.