What We Ought To Know About Full Arch Implant Dentistry – PDP093

Jaz’s Introduction: FP1, FP2, FP3. Do you know what I’m talking about? No, I’m not talking about filtering facepieces ie FFP3 masks like we’re all experts now on FFP2 masks and FFP3 masks, unfortunately, due to the COVID pandemic, but do you know what I mean, when in the context of implant restorations, what I mean by FP2 and FP3. Well, I’m embarrassed to say I had zero idea when it came to talking to our guest, Dr. Harpal Chana, who’s a consultant restorative dentist, and the pinnacle of full arch implant prosthesis like this guy does some most complex work. The kind of work Harpal Chana does is based on referral work, complex full arch prosthesis work. So it’s a great honor to have him on the show today. He is someone who I’ve looked up to for many years, like all the clinicians that I have on the show, I had a impromptu lunch with him in Pizza Express actually just behind his practice in Denton, when I was absolutely starstruck. I was like one year qualified, and that then I knew who he was and I knew he was about and I went to a few more of his study clubs in the local area, and he just has a brilliant clinician. What he has to share today is all about the classifications like basically his implant classifications, and we’re gonna delve deeper into what a GDP, what the average GDP ought to know about full arch prosthesis like okay, fine, you may or may not be placing implants, you may or may not be restoring full arch implant dentistry, however, do we owe it to our patients to understand what FP1,FP2, FP3 means, what the surgery might involve, and to basically be able to give our patients more information rather than just take a massive step back and say, ‘You know what, I don’t know speak to the specialist. I don’t know, you just speak to a specialist.’ I think we can do better. So I’m hoping this episode will benefit you as much as it benefited me. Sometimes you have to just be straight up honest about what you do and what you don’t know about. So I know a fair bit about occlusal appliances, resin bonded bridges, managing tooth wear, occlusal design, what I don’t know much about is implants. Okay? So this is like my big weakness area because I don’t place but I think like I said before, I owe it to my patients to learn more. So this is part of my journey. And I hope I’m sharing that journey with you and you will find benefit from. For those of you who are listening on high quality speakers or headphones, you probably realize that my voice sounds a little bit hoarse at the moment, this is because I just recently I was at the Tubules Congress, that’s called the Dentinal Tubules Congress. It’s the best dental event of the year. There was Ed McClaren, Marco Veneziani and some of the Great Bridge lectures that I absolutely adore the specialist which actually inspired me so much. And you guys, so many of the Protruserati were there, it was so great to see you. I’m not going to begin to name all of you people that I met for the first time and we’re reunited with for many times over. It genuinely felt like we used to have these events called the BDSA as a student with the British Dental Students Association. And they were the best nights out like we’d go to like a dental school, maybe like Manchester, and we’d all meet up and it’d be the best thing ever having dental students from every uni around the country, it really had that great positive, inclusive vibe that only a Tubules Congress can offer. So save the date in your diary for sixth and seventh of October next year. Location to be confirmed we’re thinking maybe Midlands, so we’ll keep you updated on that but it was so great to see and speak with every one of you. Thanks for saying hi for those of you who listen to podcasts and it was just, it was actually really weird people coming up to me, dentists coming up to me and you know you are guys thanks so much, saying, ‘Let’s take a selfie.’ I was like ‘Yeah, cool. Let’s take a selfie.’ Or some of you coming up saying ‘Oh, I’m just a massive fan girl or whatever.’ That was really weird for me but it was just absolutely amazing. It’s such a great time. It was lovely to see every one of you and I hope that we can continue to meet up in face to face events. My next one will be the BACD, Pascal Magne, 12th of November, that sort of the next so if you’re there and you listen to the podcast please do say hello. The Protrusive Dental Pearl I have for you today is non implant because I can’t teach you anything implant related but what I can teach you or share with you based on what _ birth shared to me many years ago there’s probably a BAAD, British Academy of Anesthetic Dentistry meeting about four, maybe three four years ago now. And a really cool thing he shared with me about the protocol for placing a crown or placing indirect restorations. He encouraged me to stop booking my patients in for a fit appointment because that puts a lot of pressure on you as a dentist and on your technician especially when you start doing more complex cases so what I mean by that is sometimes you may have had it before where you sit the crown on and the either the occlusion is way off or there’s an open contact or there’s an aesthetic compromise and the patient is not happy. So in those scenarios, it’s like ‘Oh I’m so sorry we have to remake this now.’ Whereas, the better way to do it what _ taught me and I’m happy to share with you is to tell your patient that ‘Hey, this is not a fit we’re going to do a try in, so it’s a try in appointment. It’s just a change of name it’s really as a fit appointment but you’re changing, you’re framing it as a try-in appointment, and if everything goes well the aesthetic’s good, the fit’s good, the contacts are good and you’re happy with the level of work, then you will go on to cemented that day, but if there’s anything that you’re not happy with or if anything the patient not happy with that’s a perfect opportunity to say ‘Okay, this is what we learned from today’s try in, let me get this corrected for you at the next appointment we will do another try or a fit.’ So 19 out of 20 times you’d probably go ahead and fit anyway at that appointment but it’s just the labeling of the appointment which I quite like. So sometimes I have a tricky case or a complex patient and I think I will brand it as a try in I know some dentists who always brand it as a try in. It’s about the way that the patient perceives that to be but I think there’s merit in using that terminology for your appointments. So I hope that communication gem was useful. Hat tip to give him the birth of sharing that one with me some years ago. So let’s join Harpal Chana and learn all about full arch implant dentistry.

Main Interview:

[Jaz]
Harpal Chana, welcome to the Protrusive Dental podcast. How are you?

[Harpal]
Very well. Thank you, Jaz. Very kind of you ask, I’m fine. I hope you’re well as well.

[Jaz]
Yeah, absolutely brilliant. We just had a little chat before we started the recording about how COVID has affected our different worlds. And, you know, it’s been tough and we’re still you know, while we’re recording now, it’s still ongoing and the extreme pressures, [Harpal] Absolutely [Jaz] but I think we are, you know that we’re getting vaccinated and stuff. Hopefully the end is in sight. And we’re having a little chat about that. But yeah, health is wealth as you know. And that’s the main mantra. I wanted to do a small introduction for you for those dentists around the world listening, and then I’m going to get you to introduce yourself. So Harpal, we met at a Pizza Express many years ago, outside.

[Harpal]
I’m not a cheapskate I would have taken you somewhere else. Honestly.

[Jaz]
It was geographical convenience. I’m sure if it was mentioned it was still gonna take that. [Harpal] Absolutely [Jaz] You practice in Teddington, where you practice. I always go Teddington. Now when I go to the Nando’s I always see your practice and say yeah, Harpal works there. So that’s your sort of claim to fame for me as well. But you know, you’re a well known restorative consultant, you do a lot of advanced cases, when I think of zygomatic implants, I think of you. Now, I don’t know much about zygomatic implants. And you can help us a little bit with that. But even more, we’re going to dumb it down even more to just fixed or full arch cases for the GDP, right? So GDP is that aren’t doing them or are starting to dabble to give us some insight so we can better inform our patients. That’s the point of today. And I can’t think of anyone better than you who’s so vast experience in all forms of full arch cases. So tell us how did you get involved with full arch cases, a little bit about your sort of history as a you know, restorative consultant, how much of that, how much time you spent in hospital now versus practice? Give us a flavor of that kind of stuff?

[Harpal]
Oh, yeah, thank you, Jaz. Well, my experience really is from a general practice perspective. I started life as a general practitioner, I worked in general practice pretty good four years actually, but I was very keen and hungry to learn. I was very much keen on fixed and removable prosthodontics. I sort of one area I decided to sort of focus on really and a little dabble in the early days of orthodontics and although I thought that was my chosen career pathway, I soon learned to actually do to relapse problems that it just didn’t tickle my fancy so it was a big awakening and I, you know you’re finding your path in your early careers as to what you like and I’ve always enjoyed fixed and removable prosthodontics but there’s always something about it that I didn’t quite understand and I was very keen to do the MSc in fixed prosthodontics at the Eastman so actually a year or so after qualifying I started to apply to Guys and the Eastman and no surprises I didn’t get in straightaway because you know the competition is quite high. I hadn’t had fellowship and my background is very much general practice but I’ve played it on and I continued applying and third time round I managed to get in and thanks very much to great mentors actually at that time I was mentored by people like Martin Sein, Kash Uhbi as well. Kash, I’m sure you know off as well a great guy and Martin Kelleher actually who was my local consultant to Kings and I used to take a lot of cases over to him. Just to discuss how to manage them because it was like a great Enigma to me, I didn’t know how to do a full mouth reconstruction. So a lot of wear patients and I wasn’t quite sure how to manage these cases. So I have a great rapport

[Jaz]
Harpal, I just want to sort of interject now actually. You actually pass the baton along yourself. You mentioned Martin Kelleher, Kash Uhbi, people who inspired you and whatnot. But some episodes ago I had Richard Porter on and he mentioned you as a mentor that you inspired. So you know, it’s great that you were inspired, but it’s also wonderful to know that you have also mentored and inspired other great clinicians. So you know, it’s, you receive and you gave. It’s fantastic.

[Harpal]
Absolutely, I you know, I think what Martin’s always taught me is actually education is one of those things that it’s a never ending sort of curve of learning basically. And half the education is actually getting people around you to discuss things in an open fashion so that you can clarify things in your own mind. And I think Martin has great at that and he still is I know he’s retired but I still have contact with him and he’s still quite inspirational on that front. So I’m glad other people are taking on board what I’ve learned basically over the years and you know, the baton gets passed on from generation to generation from that sense, but yeah, now going back to the Eastman, I finished my course there and you know, it’s one of those things I finished now for I still have all these questions, you’ve learned a huge amount, but it actually just opens more pages for you that you don’t really understand or don’t really get clear in your mind at the end of it. And so the hunger was there to get more and more information. And, thankfully, actually, I managed to carry on at the Eastman for about six to nine months as a registrar so I was able to complete more cases. And thankfully, an opportunity opened up as a specialist registrar at that time in restorative and I thought, Well, yeah, why not? Let’s give it a go. It’s not something I intended to do. But thankfully, it was the right pathway for me, I think, and it just opened a whole new avenue of further doors to explore and improve my education and understanding of fixed and removable prosthetics. So yeah, I get the StRs in restorative dentistry, and I credited over 20 years ago now. And, again, soon as I got appointed as a consultant in restorative dentistry, one of my links used to be queen Mary’s Roehampton, which is now closed, so you probably never heard of it, which is not a million miles away from Kingston, but it used to be quite an epicenter actually, for maxfacts prosthodontics since the Second World War and a lot of research was done there. And that’s when I first came across Peter Blenkinsopp who’s one of the maxfact consultants, and Professor Bonemark, who used to come over roughly once a month and help do these rather large reconstructions. And that was my first ever experience

[Jaz]
And you had exposure directly to Prof Banemark.

[Harpal]
We were in theaters with him and an operating it was you and he was a very open guy. I mean, you know, you were half the time mesmerized by his presence. But he was actually a very down to earth clinician as well though he was not a dentist, actually, or even a maxfacts surgeon. He could relate things very, very easily to the maxfacts field and dental field. And I never quite understood that I never had the chance to really ask him either. Why did he explore a dental route? It’s, for an orthopedic surgeon, you would have thought someone would have been thinking more along his specialty lines. But just shows you how great a man he was. He was very interested in dental alveolar defects and hence the relationship with Peter Blenkinsopp and he had an honorary fellowship appointed for him as well so that he could actually work in the department. And he brought a great amount of experience and wealth to our department. So much so I actually got the plaque and I put it on my wall actually at the practice when we sadly closed down because like most great things in the NHS, things move on. And the services got pushed elsewhere basically and we ended up fragmenting some of that service in the end. So that’s really where my interest in implant reconstructions sort of came from mostly cancer patients, atients who have large maxillofacial defects, missing half their face, basically I’m working with some great prosthodontist Martin Kelleher was there. He’s one of the first people who just threw me in at the deep end. There you go, you know, get on with it. And it was a sharp learning curve basically, at that period of time, and zygomatics at that time.

[Jaz]
And What percent of your work now is full arch complex implant reconstruction and what percentage of it is, is the more initial stages of your, you know, full mouth traditional reconstructions?

[Harpal]
Yeah. At the practice, I spend roughly sort of 60 70% of my time at Haddonfield house where I take on a lot of referrals basically, on patients who have miserable time with dentures, or they present with a lot of tooth wear I don’t actually have a lot of clinical time available now for true restorative dentistry, I have to say, hence why I know you asked me initially whether I talk about gold onlays, because that was my baby, you know, 20 odd years ago. But actually, I do very little of it now. And so much so that actually I’ve got great people like Harjot and Manish at the practice, who are also at the Eastman. And they’re pretty much at the forefront. So if a patient comes in with a lot of tooth wear and need a full mouth reconstruction, I still assess the patient, I still see the patients jointly with Harj and Manish and we jointly plan it together so that I don’t lose touch and that sort of thing. But by and large, a lot of that work on teeth anyways, is managed by the prosthodontist at the practice. My sort of interest is when they’re missing teeth, and having a debate, we have lots of debates at times, you know, when is it the end of the road for those patients with failing teeth? What is a terminal dentition? And that’s quite a difficult question to answer sometimes. And hencewhile we do like having joint consultations, because I may have my own views. Manish may have his and as well as Harj and we sometimes see the patient join me just to work out what is save-able and what needs to go.

[Jaz]
I don’t think that happens enough in private practice, because I can see it happening more, certainly meetings in a hospital based setting. But in a private setting, I don’t think it happens enough. And I think we need more of that it’d be great to do that. It’s just, you know how it is the way the business works, the way the diaries work, it can be difficult to arrange it. So I know I’m going off tangent, I just love to know, a couple of minutes on how do you actually zone everything so that you have these opportunities to have multi disciplinary sort of a meeting about a patient?

[Harpal]
Well, as you say, it’s extremely difficult everyone’s part time, you have to make time available for it to be honest. And the interesting thing is, even with referring dentists, I do try and encourage them to come along, I’ll try and fit around them to some degree. For example, you know, we get quite a few patients referred from Nick Charter as practicing stains. And he always wants to be there at the consultation, I say ‘Absolutely right, it’s essential that you are because often you’re doing the prosthodontic working in tandem with us.’ So it is difficult at times, and we have to sort of throw around our diaries and you know, patient has to accommodate us as well. But we normally make it work, you know, may have to work in an evening some time with it, or late nine o’clock, to see a patient join me. But that time is so valuable, because you can iron out so many problems actually, and we’re all on the same page. And that we all know what each other’s roles on. Ultimately the patient gets, I think a better service by and large. So they will often accommodate that sort of wish. If there are patients that are need to be seen at a particular time, that’s you know, that’s the only time available. If I can’t make myself available to do it for whatever reason I’m doing an NHS clinic, then we just have to impress upon the patient that actually if they want the best outcome, they have to work around us to some degree. And more often than not, they will accommodate to our desires. But really, it’s about given

[Jaz]
Especially in the nature of the complex work you’re doing I guess these patients are a different beast to your normal patient who doesn’t have as many problems though the scale their problems are not as big and the type of treatment will be a bit more simple. I think these patients that you see, I have seen many dentists many specialist in the past and they need a major reconstruction Henceforth, the importance of having that team approach arises more. Now, Harpla, you mentioned the terminal dentition. Now I was actually going to ask you this as the last question, but I think it will flow so nice if you don’t mind me asking you this. When I was a couple years qualified, I went to an implant based lecture in Sheffield and I was absolutely shocked and at that time because of my lack of experience I was disgusted by what I saw, because what I saw was photos of patients. And when you know, their full face photos, when they smile, they had teeth in their own teeth as ‘Oh, brilliant, they’ve got their own teeth.’ Okay, I’m in my head, I’m treatment planning, you know, a bridge here, a bit of periodontal stabilisation, obviously, in the reverse order, maybe a partial denture here, and the patient will be happy or a couple of implants. But then what I saw was a full clearance and then a full arch, a beautiful, full arch reconstruction implants. And at the time, I just couldn’t fathom it. I didn’t understand, right, it didn’t make sense to me. But later, it made more more sense to actually and you can correct me if I’m wrong and elaborate on this, that if you have someone who’s got severe periodontal bone loss, and if you just let that continue and continue and continue, you’ll get to a point where implants may not be a possible option anymore. So I can see why it’s such a tough decision to deem someone as a terminal dentition and decide that actually, we need to start fresh by extracting all the teeth so I there was a huge shock to me. So can you expand a little bit more about that, for dentists who, to help them decide where at what point is someone terminal that they should be considering a reconstruction like that?

[Harpal]
Well, you know, Jaz, that’s a really good question, but it’s actually a really difficult answer at times as well because you, I can get 10 people in a room and I can show them radiographs and put a clinical scenario together. And you can ask 10 dentists, including specialist periodontist, and you can ask them, you know what stages this patient terminal and you will get 10 different answers, because no one really fully understands and grasp what a true terminal dentition is. For a periodontist, for example, they might be hanging on for sort of three to four millimeters of bone. And then there may be others who in fact, I had an interesting patient only last week actually who came to me for our third opinion. And he was missing his posterior premolar and molars in the maxilla. And he had six remaining upper anterior teeth, which had about 20 to 30% horizontal bone loss actually and he’d been around the houses and he said you know, I’ve come to the conclusion I’ve got very little bone in the posterior it makes it I’ve been told I just don’t have enough to consider implants. And I’ve been told that sinus lifts are all you know are possible, but I might have to wait a year or two before I can have the final reconstruction. I’ve decided I really want my front six teeth out. And I’d like to have this all on full type of reconstruction. And I have to say I this is a patient telling me that he felt his teeth were terminal. They were quite rigid, they were quite firm. And I said well, like you know, I don’t agree with you. I don’t whoever’s told you, that is certainly an option. But you know, there’s mileage in those teeth, there’s possibility that those front teeth could give you another 20 years of service with good maintenance. Your problem is at the back, you know we can fix that by ever means. But the criteria for terminal dentition is so variable and I can, I certainly have had joint consultations with periodontist to I’ve got very upset when I’ve said you know the patient’s not happy with the teeth are loose, you know, they’ve got 70% attachment loss, there’s not much bone remaining back in the maxilla now, you know, this is probably the time to deal with it. And sadly, my suggestion may be to take some of those teeth out now. And while they still have bone to consider implants. Before it gets more complicated. It’s never, they can always consider

[Jaz]
Well, Harpal like with anything, I thought you’d give me a magic number. Well, I know I didn’t think that I was secretly hoping you’d say okay, the rule is if there’s 70% bone loss and you got X number of teeth, the formula suggests that you should remove all the teeth and head for implants, it’s never ever in dentistry ever going to be as simple as that. And I think you’ve just summarized it well, that actually it’s a gray area. And this is where you need multiple inputs inside, along with the patient’s values as well. But what determines a terminal dentition. So I don’t envy you at all in these decisions. You have to make such a tough decisions.

[Harpal]
Oh yeah, it can be tough. And sometimes we have real arguments with it, which is actually why I like having joint consultations because I’d like to argue my case. It’s nice to hear from other people’s opinions, you know, Harj just coming along the scene and training quite nicely and he sort of exposed to some of this times and he asks pretty simple questions as well as Why are you taking them out? And why is somebody else the periodontist wanting to save them. And I said a lot of it is subjective experience of how we’ve dealt with things in the past. And there is no magic cure for a lot of these patients. You know, if the patient may have terminal periodontitis, they may well end up with, you know, Peri-implantitis in the future. And that’s something else to bear in mind. It’s not as if the problem stops there. So, you know, it’s really understanding the patient’s perspective and what their goals and objectives are. And sometimes if they’re a complete tangent to yourself It can be a real challenge. I certainly remember presenting a case years ago which actually Simon Sharda I’m sure you know, used to work in our practice and we sort of jointly soar together and she had quite much periodontal disease. Lots of consultation was about three or four consultations with only decided the interpretation of very gummy smile, high lip line, you know, short upper 70-80% bone loss teeth that are loose, ex smoker. And she wanted to avoid wearing dentures. And you know, it really took a very radical decision, we took everything out and put implants in and gave her what I considered a fantastic result. And so, so did she, she thought was a brilliant result. And I presented this at a local PDA lecture group. And I have to say I was quite shocked the amount of attacks from periodontists, you know, periodontist said I could have kept those teeth going for another 5-10 years, you know, you just needed to section some of those teeth and keep some of the roots out and the bone. And you could have spent the others and I said, Sure, you absolutely could have been, but we wouldn’t have been wrong. But a lot of this is discussion and debate. And ultimately, the patient would still have a poor aesthetic result with a high lip line. And once you start getting recession andn the horrible black triangle spaces, the patient can live with that, that’s it, there’s no harm in going down that avenue. But once you show patients photographs of what their teeth are going to look like, once you’ve had a extensive course of periodontal treatment, and all the horrible gummy, black triangle spaces, I said they may not want that. So it’s really part of your consent process. And if the patient says to me, I don’t mind. You know, I’d rather keep my teeth going for as long as possible. You’re not gonna accept the fact that there won’t be pretty, but they’re my own, that’s absolutely fine as well. There’s no hard and fast rules about it’s about tailoring the treatment plan to what your patient’s wishes and desires once they fully understand all the options. And I think that’s the crucial take home point really, for general dentist, this is actually understanding all those options yourself and laying it on the table for the patient. So these are all the various treatment plans that we could consider. There are pros and cons of each. You may not be the right person to do the full arch reconstruction. That’s why we think mentoring is a good thing so that your patients can still have a course of treatment. And we work jointly with the dentist as well so that they understand the reconstruction element. And often do it jointly with us

[Jaz]
Harpal, I’m just imagining the how thick your patient letters are like they probably like a each patient gets a book a volume of all the options, explanation.

[Harpal]
I’m trying not to make it too thick to be honest, because like most things, you know, I probably write fewer notes than most dentists, surprisingly. And the reason as I want to give it to succinct points, I’ve tried to just highlight really what the discussions were with the patient and what have been used with discuss. And my general rule is try not to make it more than two sides of A4. Because most patients can’t take more than that in and if you provide them with a dossier, which I’ve certainly seen, and I’ve noticed some of my colleagues do that as well. You know, the ability of the patient to retain a lot of that information, although you might be very comprehensive, it might confuse them so much that actually they don’t really understand the nuances of the treatment plan at all, because you’ve given too many, too much information overload basically. So is the same if you ever get a letter from me from the NHS I, my rule there is one side of A4 paper, if you can send on one side of A4, then you may miss out some of the salient features. And if somebody wants to elaborate in what more information, I don’t have a problem in going back and giving them further information as long as you’ve got detailed notes, right. But really, I’ve tried to give a summary sort of option. If somebody else is carrying out a treatment plan, of course and you’re giving them advice, clearly you need to give the dentist a lot more information at that point. But when it comes to to patients and writing to them, I try not to overload them with information actually, I’d rather give them a few pointers and actually get them back in and discuss again with them because that time is so valuable talking to them face to face. And understanding their concerns and fears and what their desires are because as I say if you write them a huge letter, I guarantee you, you’ll end up probably scaring the life out of them and probably not seeing them again. So it’s always better to have a good follow up appointment, write to them with, in my view no more than two a4 sides of paper and getting them back in and discuss it again to make sure that they understand what the options are and why they want to choose what they want to choose.

[Jaz]
Brilliant, I’m not going to if you don’t mind I’m gonna go back onto the implant theme because we’re going on some tangents it does a very valuable tangent I have to say. So we talked about the gray area of deciding if someone’s a terminal dentition or not, I think you covered that beautifully. I think the last part of when you summarize that was just phenomenal about the way you pitch it to patients. And that’s fantastic. We then talk about obviously, I joked about your, the letters to patients but now I want to bring it back to edentulous patient so if you’re a GDP and you have edentulous patient in front of you, and they’re struggling with their denture, and then you want to say okay, I’m gonna I can refer you to someone who might be able to help or maybe you’re the dentist who can place some implants, What are the usual options that people can explore in terms of you know, either you know, there are fixed implant reconstructions there are removable, there are a hybrid, can you just break it down for the GDP, the newly qualified dentist who doesn’t really know where to begin with classification and what’s available?

[Harpal]
Yeah, that’s a good question. I actually before we even go down the implant Avenue, I think the most important part, as you say, is unsuccessful dentures, just try to understand why they’re unsuccessful. If a patient comes in with a whole bag of dentures, and says they’re being trying 20 different dentists, etc, and I can’t seem to find one that works. But this set and that set mixed together seem to be the best. You know, those usually are a big warning signs that perhaps those patients are going to struggle. But equally I recall, when I was a registrar, I used to have to work up cases for full arch reconstructions with Professor Roger Watson, I don’t know if you recall him at Kings and David Davis. And one of the procedures they always used to make me do was to do a workup, make them a new set of dentures. And it was interesting that half the patients are made new dentures would say thank you very much. I don’t need implants now. I’m actually quite happy with these. And they’re much better than they were before. I really don’t think I want implants. So I’m like okay, maybe a lot of these patients don’t always need implants, they just need to have well fabricated dentures. And making good full dentures is, you know, it can be extremely challenging as well. But a good prosthodontist should be able to make them, a good general dentist should be able to make them if they spend time and effort. And that’s always the first port of call, I would always say because if a patient is struggling, you need to work out whether the those concerns are really genuine either actually technical problems in the denture, as the patient actually just one of those that can’t tolerate dentures. And that’s what you’re trying to ascertain in the early stages. And you’ll be surprised how many patients actually would be satisfied with just that alone. I certainly was. And these were patients on a waiting list for implants so that and they were getting it free. So it was no financial incentive for them not to say no at a particular point. So it was certainly an eye opener. And it is a very valuable exercises because it taught you how to plan for the implants as well. Space creation and half the technical and restorative problems you could pick up actually in the wax try in stage of how much interocclusal room that you have. So all of the basic stuff which you think, you know, probably not that important for implants is actually crucial for implants because it sets the footing for when you go down the implant Avenue, what type of treatment avenues you may be considering for a patient. So there’s one very good article by Carl Misch who sadly passed away on implant reconstruction designed from FP1 to RP5 now that’s you may come across there are some dentists who may not have come across it. And it’s very much to do with whether you give a patient a fixed reconstruction or removable and an FP1, So FP, fixed prosthesis usually graded into 1, 2 and 3 with FP1 just replacing the white part I should say, of a patient’s dentition, so the crown part. So if there hasn’t been a huge amount of volume loss and periodontal disease or trauma and all those things, then that patient may be suitable for what we call an FP1 type of design. But if there’s been a bit of recession, or sunburn loss, if you have this thing called an FP2, which is also a slightly more complicated sort of a gradation, so slightly more recession, so you’re replacing not just the white part of the crown you’d be possibly replacing part of the small part of the root form as well. If the patients lip liners quite low, they don’t show it too much, then it probably doesn’t matter if those teeth are slightly clinically longer than their appearance because the patient never shows it. Then you have the FP3 which is actually replacing not just the white part of the tooth but the pink stuff as well so you you can understand there’s been quite a lot of volumetric bone loss in these cases. So you are trying to replace both hard and soft tissues of the bone structure. Now that then leads on to the removeable, RP4 and RP5. Now RP4 is actually going to an implant reconstruction which is purely supported by implants but it’s still removable, so you may say have four implants holder prosthesis in place so it’s replacing all of the white and a lot of the red stuff, the pink stuff, but it’s anchored by four implants in is supported by implants. And then you’ve got the other, the RP5 and in his list which is basically same sort of volume loss but it’s maybe supported by two implants or one implant for that matter. And there’s partly mucosa supported and partly Implant Supported

[Jaz]
If you don’t mind me asking, Harpal because I learned so much from that because because I don’t do implants myself sometimes you never get exposed to the air because I’ve seen it all you know bandied about on social media and in papers and lectures or yes I did an FP3 or whatever. And he sort of think you know, but you know, I’ve never had I’ve never done my due diligence to actually go through it. So I learned so much now I know people listening and watching would have learned a lot just basically you’ve just gone through and so from F1 to RP5, and it was crystal clear. I just remembered I was a DCT at guys hospital. And I used to work with restorative consultants, Sara who might know she taught me once that and then some of the consultants told me once that what I was making for my patients at a time they had two implants in the lower canine region. We had put some locator abutments and housings inside the dentures. But Strictly speaking, she told me that this is not an implant supported over denture and I should use the term implant retained overdenture because and is that just semantics? Or is there something in there? Is there a difference between something that’s implant retained and Implant Supported? Or can you mix and match them?

[Harpal]
Yeah, that’s a good word that terminology is crucial to this and understanding the detail because you’re quite right or she’s quite right I should say in the sense that the vertical load in that the implants if you just got two implants taken the full load those two implants or can we take a pretty hefty occlusal battering basically. And usually you just want to stop the denture falling out. A lot of patients problems is they can’t keep the denture in place. So, you know, many years ago, we were talking over 20 years ago, the McGill conference suggested two implants as you suggested was a brilliant way of sorting out patients lower denture problems. In fact, even one implant is satisfactory to improve denture, simply not so much support resistance to falling out. And often this was the biggest problem for patients is keeping the dentures in place. So technically you’re right and that’s the distinction between the RP4 and the RP5 because an RP4 has implants and you got to removable prosthesis, the implants are taking all the load. The RP5 implants are there just to assist so I call those important assisted dentures, stop the denture falling out. But the occlusal loads are still taken by and large by the supporting alveolar tissues, basically, the soft tissues and the bone around it. And that creates other problems as you know, because over time, that patient will get continued resorption in most regions and therefore maintenance of those cases is much greater. You often have to rely on those cases to avoid overloading the implants in the long term. But you’re quite right there is a distinction and understanding that distinction is quite important because if you expect those two implants to take all the occlusal load and they still to be there many years later. It can certainly open your eyes in terms of functional problems and implant complications. In fact, we’ve had a case recently at Kingston hospital, an oncology patients mouth opening is very very restricted. And I’ve just about managed to get two implant at a very acute angle in the mandible because his mouth opening is so poor and I thought well, you know we’re trying to extend the prosthesis as far as possible, so an RP5 design with two locators and it was a sharp rude awakening when he’s fractured. Well one of the implants is fractured and the other one actually was explanted by the denture. It literally came out with it, and I thought blimey. So maybe these situations now we’re having to redo it with further risk reduction space problems because these patients often post oncology, have very limited mouth opening have had to do quite a lot of risk reduction just to create space for the prosthesis. To try and extend the prosthesis now so that you can actually take a bit more support from the alveolar tissues. So yeah, those cases can be quite challenging as well.

[Jaz]
And well, since you touched on the number of implants, the next question want to ask it and just leads beautifully that is when I used to see patients at work in Oxford, and my principal was an implant placing dentist and he was happy to do full arch cases. But when I saw my own patient who had the “terminal dentition”, or were struggling with an unsuccessful denture, and they needed some help, I’d have to always meet with my principal dentist at lunch, I’m saying, here’s the photos. I don’t know what to quote because I don’t know how many implants this patient needs. And every time I take a patient photos, you get a different answer. And obviously, everyone knows, every dentist every student dentist, probably knows that the famous AO4, all on four. Right? But is that the rule of thumb that four implant solves everything? I assume not. But tell me how to even begin to fathom how many implants are going to be needed for a case and why is it sometimes very between 4, 6, 10? Is it purely financial? Or Is it much more anatomical?

[Harpal]
Yeah, well, there are lots of reasons there are multiple factors to be honest, and I’ve went from, you know, from my early training, I’d be trying to put as many implants in as possible. And it’s interesting how you almost come full circle. As you know, I’ve worked very closely with all on four centers as well. And you have to be very careful with the number of implants versus long term maintenance and complications. For example, as I said to you, you may have a patient who’s got an edentulous mandible and just as miserable, can’t cope with dentures, and they’re okay with the full upper denture. Surprising even a single implant in the mandible in the midline to help secure that denture is more than enough. Most people would probably put two and consider it an RP4 because it’s much easier putting two in and getting some support both sides. But if you got an 82 year old, who was struggling to, you know, eat satisfactory, a single implant to help secure a lower denture is more than adequate, believe it or not. You may choose to put too, but he sometimes find they can’t always get the prosthesis out with two because their manual skills and their dexterity may not be as good and the retention may be so good that you have to then deactivate one and then go back to one. So it’s horses for courses, you have to put so many factors in the patient’s wishes desires, the all four really sort of took off, I would say probably about 20 years ago as the base standard. We’re trying to provide a cost effective way of giving patients fixed reconstructions. Now there are certain problems and we’ve certainly seen them on our own clinic, when only four are used, especially in some patients who are susceptible to perio or their quality of bone is not so good. And it’s interesting having done that for a number of years and we’ve managed to repair and try to remedy some of the problems with patients with all on four I’ve sort of gone back and put extra implants and now on the maxilla. So I’ve taken a slightly more dim view now for the maxilla if we go for a fixed reconstruction, which is often what patients are referred to me for that I very much have the view that perhaps if I can get six in and get a good AP spread then I probably give myself a better insurance policy in the future for any potential complications. Part of the problem with four

[Jaz]
Can you define AP spread for some of younger dentists who may not know what that means?

[Harpal]
Yes, AP is really the anterior posterior spread and the cantilever design and I’ve certainly been to lectures and I’ve heard people who are very well versed in this that they don’t worry so much about the extent of the cantilever, especially in the upper jaw. Actually I do I get very paranoid about the extent of cantilevers because we know the longer the cantilever, it’s basic physics from, you know from A level physics on levers, basically, the longer the lever, the greater the force you can generate. And no surprises if you’ve got a large cantilever, especially in the maxilla, you’re going to get more prosthetic and in my view, surgical complications of bone loss around the implants. Perhaps the Peri-implantitis isn’t always Peri-implantitis, it may be overload of the implants. The difficulty is managing those cases in the long term, especially 5, 10 years down the road, the patient’s invested quite a lot of time and money need to put a lot of effort into it as well. So that if you do get complications, you know, how do you deal with it and hence why I’m sort of gone back partly to some degree what I used to do in the old days, and I try to over engineer it’s I don’t see a problem with over engineering because at the end of the day, You it depends on what kind of service and maintenance program you’ve got for that patient. So ironically, we did a case just Saturday, George Xirogiannis, my periodontist and myself did a upper and lower fixed arch reconstruction. For a patient with complete dental clearance. And the mandible went perfectly well we managed to get six. Pretty much straight implants in the mandible, great baby spread up to the first well actually the second premolar stroke small cantilever to replace the molars where there was insufficient bone. But the upper proved exceptionally difficult, we manage to get four good implants and it’s canine region. But the posterior implants were an absolute nightmare really worst. I struggled to get pterygoids in. The pterygoid bone was really quite hopeless using all the tricks, and it nearly took me three hours just try and get the additional implants in those regions. But in the end, I ended, we ended up with eight implants in the upper jaw, two of which were buried, just to wait for the bone to repair because there were another two which weren’t so great, you know, their stability, primary stability wasn’t that great. So you still walked out with fixed teeth, the same data, I didn’t plan to put a implants in the upper jaw, we were planning just to put maybe four stroke six with possibility of two zygomatic implants or pterygoids. But life doesn’t always work out like that. So you often have to go in with one expectation and you start struggling a little bit with zygomatics mouth opening wasn’t as great as I thought I couldn’t quite get the angles to get the zygomatics in I was hoping and praying that the pterygoids would go in and they proved to be absolutely you know, very well. They weren’t as good as I thought. So you often have to think outside the box. And certainly George know well, now what we’ve got four good ones at the front. But they’re only as far as the canine region, I’m not going to do a huge cantilever. Because the AP spread now and this is so large, I’ve got potentially three pontics cantilever it, you know, you’re asking for trouble, you need something further back. And sometimes you have to compromise. So I’ve managed to get additional ones in with a little bit of a compromise.

[Jaz]
I mean, some people might be listening right now, Harpal. And I remember the first time I came across pterygoid and zygomatic implants, you know, when you’re young dentist or you’re student and you’re thinking implants, and you know you’re looking at implant in the more traditional areas that you’d place them. And then when you first get exposed to wait, you can put implants in these really long things in, you know, your zygomatic arch areas, or your pterygoid it blows your mind as young dentist when you’re first getting exposed to those kind of stuff. So some people may have been listening to you saying that I mean, wait, what a pterygoid. And you know, some people don’t know how to spell pterygoid. So it’s just how it is. So it’s very fascinating. But is there any evidence pointing to, because but what you’ve basically alluded to is, it depends on your level of experience. It depends on your successes in the past as a clinician for anything you do in dentistry, the team that you work in your training about what kind of solutions you can offer your patients, and some dentists do full arches may not be able to extend to zygomatics, for example. But is there any evidence for quality of life studies and that search either fixed versus removal? Or a number of implants or the AP spread? How much research we have about the quality of life so that we can as clinicians inform our decisions based on that?

[Harpal]
That’s an excellent question, Jaz. And the answer is actually, there are lots of quality of life studies available in the dental literature on dental implants. But none of them or very few of them really deal with number of implants per se, they often are just looking at a qualitative sort of factor out as a patient, give them patient orientated outcomes, etc. You know, there isn’t that sort of study where you can evaluate quality of life for the number of implants so to speak. There are some comparing fixed versus removable and there’s a lot of studies comparing quality of life with say just a complete denture versus an implant or an RP4/5 versus an FP 1, 2, 3. And the studies are equivocal to some degree we know most of them seem to agree that most patients if you’ve made a well constructed full denture and they’re still struggling with it, that any form of an implant prosthesis, whether it be removable or fixed will improve the outcome compared with a removable denture that goes probably without saying for most studies. The question really is I don’t know how people will have evaluated outcome for the full dentures have they actually made new dentures for those patients like I used to have to do at Kings. So made a big certain questions there as well those studies are not completely foolproof from that perspective. But with regards to fixed and removable Yeah, you can find some studies or certainly been studies from 20 years ago with off top my head Saltzman it studies took about 20 years ago in university of Bern, comparing fixed versus removable. And they found actually pretty equivocal outcomes from a patient perspective, when you look at quality of life factors. Now, things have moved on a little bit, now you’ve got more assessments and a new quality of life, guided by there’s a lot more detail in terms of questions that these patients have to answer. And there are, these are very subjective questions a lot of the time, they’re sort of often patient lead, which is not a bad thing. But you know, if we want more science behind it, you have to do more of the mechanical studies, look at forces etc. And we know, if you measure forces on patients, certainly, if you look at patient if they’re their natural dentition with 100% worth of occlusal force, if someone’s given a fixed reconstruction, they’re almost 90% there to what their patient had previously, with implant retained dentures is a little bit variable, this sort of between 50 and 70% in general, compared with dentures, which can be you know, zero to, you know, to 20 to 30%, depending on how well the patient can tolerate these things. But certainly from an outcome, perspective and quality of life, it is actually very difficult to dissect whether fixed versus removeable is better. And that’s often where patients input come into and obviously their budget as well because at the end of the day, we are dictated to some degree about what our patients can afford. Hence why it’s very important to discuss all these avenues you can explain to patients the advantages and pros and cons of an implant retained denture versus a fixed prosthesis and also ease of maintenance and hygiene those are the sort of factors patients really do need to understand and depending on their age as well i mean i have a GP who’s only in his late 50s last week who have very little residual bone, his dentist to be monitoring and maintaining his teeth for last 20 years and pretty terminal actually they’re quite loose and they were about to come out and we discussed all these options with him I said you know, you’re still relatively young What would you like to have at the end of the day you know, dentures are removable, they are cleansable, they’re easy to remove and keep clean but they clearly have some coverage of the palate and you know having something removable for this doctor who still practicing and still communicating with his patients he said that’s not for me I don’t want anything removable and also there’s a psychosomatic sort of benefit for these patients because they think removable is still not part of them. It’s still a sort of, you know, a inverted commas a second hand type of problem to fix basically compared with something fixed It’s like my own. Well, that’s important to understand from patients perspectives as well. But it is very different.

[Jaz]
I really like that example you gave with the GP I think it really makes it more tangible. And I know some dentists listen to this, that explanation that you give to patients. That’s really valuable, actually.

[Harpal]
Yeah, I think you have to be honest with them. And just equally I’ve got a patient and the other age extreme I’m dealing with at the moment who’s had an FP3 fixed reconstruction with quite severe bone loss. She’s already had psychosomatic implants placed elsewhere, actually struggling to keep them clean. Her manual dexterity is not as good as perhaps they thought it was going to be. And there are a few other complications I won’t go into which has necessitated her having further treatment with us. But actually, I’ve convinced her to have something removable and I said, I think you’d be better off actually with an RP4 primarily because actually you can take it out and clean it and you can look after things and we’ve done the first preliminary step for her. And she’s over the moon already. She’s like why wasn’t this offered to me at the beginning, I’m actually really upset. So it does make you think with patient so that will maybe we should spend a little more time at the beginning explaining these avenues. And I think unfortunately, in her situation, she had very little discussion with all the treatment avenues that she could have explored in the early days and she’s now in her 80s as well so it’s not as if she’s in the younger age group and we know what tends to happen as we get older, our skills, our manuals, skills go down. So they may have had great intentions of giving her something which they consider superior, but maybe didn’t factor what the patient variable so that they’re a part of the equation is. And that’s always a learning point for me as well, just to say, well, would I have done the same? You know, would I have gone straight to a fixed reconstruction verse? And probably, you know, the sexy factor of having something fixed is the driving factor because you think I’m giving somebody something which is close to what nature gave them at the beginning. Unless you’ve got to think beyond that we’ve got to understand as a patient at the end of it, and how are they going to look after it? Does it give them all they need? Does it gives them all the function of phonetics? and more importantly, this physiological support their lips, and the ability to maintain? I think that part is actually very difficult to answer the maintenance part, which we’re not so good at explaining to patients. We assume naturally.

[Jaz]
That is brilliant. That is fantastic.

[Harpal]
How are they going to look after these things? Are they going to get underneath these prosthesis? We’ve actually just been asked one of, I don’t know if you know, Pynadath George, who is part of the department, Pynadath George, and I’ve been talking to each other about running a course at Humphrey House later this year, which were just in the final process of setting up. I’m trying to explain these differences as well to dentists, and actually how to service and maintain them. So part of the lecture course is not just that saying, This is how we put the implants in and how we restore him. But we’ve got the hygienist and George, our periodontist on board. So all of these are the problems you may encounter. How do you look after these patients? How patients expected to clean around them? And I think that’s perhaps not the told enough, if that makes sense. Because that’s the long term game that’s about keeping things going for the next 10, 15 plus years with hopefully very few complications.

[Jaz]
Brilliant. I just want to in interest time, I’m gonna ask you a one more question. This is a bit more dentist specific focus terms of training pathways, because you mentioned about in the course in educating dentists that you’re taking part in with Pynadath George as well. So it flows nicely to ask you, With implants, when implant education implant courses are being taught to young dentists for the first time. So let, you know dentists learning how to place their first implant. And the advice we’re taught is, you know, start with a lower molar, maybe an upper premolar away from sinus, good bone, the low lip line patient, low aesthetic expectations as your first case, and that’s what we’re taught. But then I was once speaking to Pynadath George, actually a few years ago on the phone. Before I move to Singapore, I was asking about I was at that time, I was considering getting an implant and stuff. And he was asked me, okay, what kind of implants do you want to do? Do you want to do implants, you know, to replace the old missing tooth? Or you want to full arches? I was like, Gosh, I don’t know. You know, should I start with one? And he was like, You know what, they’re completely different kettle of fish. So is there a case for dentists who, perhaps are passionate about dentures and those big changes that you give to someone from going no teeth to having lots of teeth, and really improving their lives that way, rather than someone who sees a more general population with more teeth, for that dentist, perhaps to skip straight to learning full arch? Or do you think no, every dentist who’s learning implant is better suited to learning how to restore the single tooth in a bounded saddle area? And then, then develop on to full arches? Or is there a case for someone to go straight to full arches and learn the basics of that?

[Harpal]
Yeah, they are totally different skill sets. I have to be honest, but like most things, in the early stages of one’s career, I think, and I certainly, you know, talk dentists around me in this fashion by getting them to restore a lot more of the simple cases. First, I think once you understand prosthodontics, the implant surgery becomes much more straightforward afterwards. Because it’s prosthodontically led, you don’t understand the prosthetics. And I think that’s where a lot of complications arise is because actually, there’s no forethought to where you’re going to end up well work backwards. So if you can understand where the outcomes supposed to be, then the implants would naturally sort of follow on from the prosthetic part of the training. So a lot of the dentists who certainly work around me I don’t let them go wild and start putting implants in straight away because I’ve seen the harm and the damage it can do for patients because they just want to get numbers in they think they’re going to get their confidence by putting lots and lots of them in and all you tend to do is create lots and lots of problems and don’t necessarily understand how to fix them. So my view is actually learned how to restore. Once you’ve restored a few, got your grasp in understanding the space in occlusion. Then move on to putting the implants in and that the natural progression. And Harjot said that point at the moment, he’s missed out a lot of the stages at the moment, with regards to what I used to do, we used to have to work on models, drill a hole in a stone, work out the prosthetic shape before we even, now we’ve got all these clever digital stuff we’ve just invested in the x guide. And he did his first x guide implant on Saturday. And that’s the next sort of progression really is to put implants in, in bounded situations, get a good outcome, understand what gives you a good outcome basically. And I certainly wouldn’t suggest jumping into fixed full arch reconstructions, because often, there are so many nuances of learning which you miss along the way with single teeth, that actually you can adapt to fix big arch reconstructions later on. It might take you a few years, I don’t expect somebody to rush into full arch reconstructions from day one and be an expert within five years, I’ve always said go and learn how to make dentures first, because once you understand how to make full dentures, actually, everything else becomes a lot more straightforward. So from the natural progression perspective, I would say, always start simple build up experience on simple cases, first put implants, and I totally agree put implants in the lower sort of 4, 5, 6 region, as long as you’ve got acres of bone, avoid sinus lifts and all that, because if you make mistakes, and they can really put you off, and I’ve certainly seen patients, or dentists who said, You know, I put an implant in this size, it all went pear shaped the implant got infected a patient and ended up wired communication. I’ve got sued, all sorts of things in it. Okay, maybe that wasn’t a great way to start. Or perhaps they didn’t have the right mentoring at that time. And I think that’s crucial. So I’m very cautious. And I certainly you know we’ve run zygomatic courses, and I’m very cautious on those as well. I certainly have had surgeons who’ve come out after doing a phantom head and said, Oh, this looks really straightforward. I’m ready to do my first case next week. And I did have that a few years ago, actually, I was quite shocked when I said, Well, actually, you know, we might make it look easy on this Amazon course. But there’s lots of technical bits, which you don’t realize until the day of surgery, and he didn’t listen to me, phoned me up Monday morning and said, I’m about to put the zygomatic implant in, can I just run through it with you over the phone and I have to say, I was pretty shocked. I said, I’m really sorry, I can’t help you any further. I did say to you need a mentor, you mustn’t put this implant in, without guidance and supervision. Because if you mess up, the consequences are quite severe. And I take no responsibility for things going wrong. So yeah, I think it’s horses for quite a while, you know, we often have over confidence in ourselves because you learn something, you’re eager to get on with it. But if you don’t understand the hiccups in the trips that are along the way that you are going to encounter, because you’re not experienced enough. And that’s where mentoring i think is crucial. So your boss is absolutely right, you know, you may, you may come up with different answers for a different number of implants, because each case is slightly different. The volume of balance is slightly different, this patient may have acres of bone, then you might say, well, I could put six, eight implants in, you know, versus the standard on four. So each case is different. And you do need a little bit of guidance for it and there’s no cast iron. You know, solution to a lot of these patients, you can often adapt techniques as you as you go along and I treat my zygomatic and pterygoid cases exactly the same way. They still need the workup at the beginning, you’ve got to work out where the final tooth position should be. Those are quite challenging even when you’re putting zygomatic and pterygoid implants in to get the right outcome. But if you do your basics and you do your groundwork, then as you gain more and more experience you’ll get more and more confident in doing things and then you move on progression wise you probably would want to do sinus lifts, etc. Get your experience in sinus lifts and zygomatics yeah, you know and pterygoids are the ultimate, it’s not something even although a lot of Dentists have trained over the years and surgeons including Maxfacts, not everyone gets it and they’re not easy to do. But the most important thing which we do try and get them to understand is not about the surgery, it’s about the outcome, it’s the prosthetic outcome is just trying to get that patient right superstructure to fulfill their needs whether it’s removable or fixed that’s down to you and we’re all have our debates about whether it’s fixed or removable and I certainly, I presented a case a few years ago in Italy actually do Professor showed him pre op studies and I asked her a group in the audience what they would do in this case and nearly all of them you know understand what it looks like an RP4 to us, you know, I can understand lower volume last patient been edentulous for 20 odd years severe bone atrophy of the maxilla and I said that’s certainly an option that’s probably what the patient would benefit from. But that’s not what she wanted, she didn’t want something removable or psychological aspects when she wanted something fixed even though there was severe bone loss, I managed to show how we managed to do a fixed reconstruction with zygomatic implants and she got basically what she desired but it was really still planning it and understanding the prosthetic stage. So even you know that the other extreme you can get professors who are very, the professor I presented this to is quite actually horrified we put zygomatic implants here for this patient that’s fullfil the patient’s needs you know she got the outcome that she wanted. I understand perhaps a removable option might have been feasible for her and certainly easy to clean but I had to deal with the psychological aspects of this patient and she was miserable with dentures and for her even anything removable wasn’t right for her. So those are the other side we have to work within our own skill set I have to say and thankfully I’m blessed with a good team around me, they’re the ones who make us look good at the end of the day and can give us the outcomes that we want you need really good excellent technical support to do these things and thankfully as I said, we’ve got Harjot and Manish who are great prosthodontist as well so they’re always teaching me things you know I never too old to learn as they say you forget certain things at certain stage and you go yeah, I forgot that. Yeah, that’s a good idea. Yeah, that’s a great solution for the patient but it’s really about being open. Having an open discussion with the patient as well I’m being frank with them and we certainly have no problems laying it on the table, telling them the pros and cons so that they can make a decision at the end of the day. They may choose you know one pathway over the other.

[Jaz]
Amazing and I think what I’ve gathered here is that you every time you present something to a group, especially I saw dentist Harpal, you got to have thick skin so I know you must have thick skin in this amount of controversy you must get you know, amount of attacks, amount of debates and I’m sure you’d love it and then you’re great. I can tell you’re great at it and you know, a massive respect to you for what you do. But you have to have thick skin because as you say, you know, there’s so many, I mean there’s gray areas in all dentistry, but from having this chat with you today, implant is a whole different field there was a gray areas and lots of strong opinions and subsplash out that like an oral surgeon might see something completely different to a periodontist, might see come something could be different to a prosthesis, right? And then you have those sort of arguments. So I’m gonna let you have the mic in a moment to just wrap up. But one thing I want to remind you is I think, send me some links for any dentist who wants to learn more about zygomatic, about the course later on. I want to stick it on the website before I get bombarded with messages. And also any closing comments for dentist who listened all the way to the end, and we appreciate that so much.

[Harpal]
Really, I think the most important part is just go over treatment planning, discuss your patient in detail, really take a detailed history from your patient, what their goals and desires are. And that’s so key to the equation, I think you miss so much sometimes if you don’t listen something. Martin Kelleher always used to tell me this at the beginning. And that one thing I do try and listen is just zip up at the beginning. Ask the patient why they’re there. And just keep your mouth shut and listen to what they have to say and write it down. That’s so important because you learned so much about what the patient wants and their expectations. And ultimately, just to spend time with them to explain that you understand their problem. So you can, you may sometimes at the end of your consultation, just say right, So just to summarize, I think you’ve said you really do not like dentures or you don’t mind dentures, you just want to have an improvement in quality of life. You know, it may well be that a fixed solution or removable solution is suitable for either of those cases. The workup in my opinion is often the same. You know, CT scans, getting them back and doing diagnostic setups. See the patient multiple times, don’t rush into it. And I think that’s the other problem. You sometimes see when patients are traveling and trying to get treatment done quickly. Sometimes you miss out on those same questions that the patient doesn’t fully understand. Certainly we’ve seen that when patients have gone for dental tourism, and they’ve come back and their expectations have never been met. We’ve actually probably no one’s listened to what their real desires are or spent time explaining things to them, and what the limitations of those treatment avenues are. And ultimately, if you haven’t got the skills, you know, there are plenty of people out there who will help you, great mentors. So we’re only just one amongst many different clinics throughout the United Kingdom who can help you so you know, I will say to dentists, just pick up the phone, ping us an email. We’ll have a chat sometimes I’ll have a discussion with, I’m over WhatsApp and just look at the scans and look at the photographs and say oh this is possible, give them an outline of likely sort of treatment plans just based on their assessments and then before you’ve even seen the patient and then I often strongly encourage a joint consultation. If the patient is happy to come for a consultation with the dentist that really I think is crucial Firstly, the patient really appreciates it that the dentist is spending the time and as part of their learning experience because they may not have as you say have ever come across zygomatic implants or pterygoid. They don’t often know what to explain to their patients and part of my role is explaining that to the dentist as well so that their patients are well informed as to the treatment options so yeah now keep

[Jaz]
Harpal, when these dentists come to these consultations with you, Do you take them to Pizza Express or Nando’s after?

[Harpal]
At the moment nowhere, I’ll have to bring them sandwiches at this particular moment due to COVID restrictions but you know we’re not averse to having a Pizza Express, I have to be honest, in fact there’s a lovely Italian place around the corner from us and occasionally we have a very nice Italian meal. I love the social environment as well actually because it’s a great way of meeting new people and new minds and you know, I think the future is always the people around you to some degree, even the youth coming up, we’ve got lots of questions and you know, make challenges on you might you think things in a different way. So now I’m always for that I’m very much open. We have an open sort of arrangement. But you know, we have no problems, there’s no wrong or right way we like to discuss things openly with patients as well as the referring dentist and I now all these sort of pros and cons in there. Usually the patient chooses the right treatment option. And more importantly, if they’ve never seen anything like that before they usually go Wow, I didn’t know you could do that. And I didn’t know my patients could have that. And I think that’s always a great reward as well because those patients you know, they thank you, they love the dentures as well, you’ve changed their life often actually in those situations. And there really can be true life changes. So yeah, by all means, you know, just remember, there are patients out there and it’s important to give them all the treatment options even if you don’t know about them yourself. There are plenty of people you can vies and guide you and at least do joint trips and

[Jaz]
I’m hoping this little chat today would have helped a lot of people, I guarantee you, Harpal, to you, the language of FP1, RP4 that sort of stuff is like second nature to a lot of dentists it’s not. And I think they will learn even just from that, the summary and the wonderful things that the way you explained to patients including that GP, I think today’s episode full of lots of communication gems and also, you highlighted the importance of having a support network near you, including mentors like yourself who can pick up the phone and I love the fact that you said that look, Whatsapp you know, despite all the doom and gloom I keep saying there’s never been a better time to be a dentist who’s hungry at knowledge [Harpal] Absolutely [Jaz] it’s never been that time in your life, you can connect to anyone, anywhere in the world with a click of a button WhatsApp or social media, respecting privacy and confidentiality but to gain knowledge and advice so that’s wonderful. And you know I thank you so much for giving your time from your very busy schedule for to make this episode I really appreciate it.

[Harpal]
Thank you for you time as well it’s great to be here.

Jaz’s Outro: There we have it, Harpal Chana everyone, I hope you found that useful. I hope you were making notes. It’s kind of one of those episodes where you have to go back and maybe make notes. But hey, don’t worry if you didn’t, because I’ve got an infographic for you so I’ll finalise or summary, hit the @protrusivedental Instagram, and I put a little infographic on there, also on the protrusive.co.uk website. And some big announcements coming very soon, including, so I know many of you will listen all the way to the end, but many of you will just you know switch off at this point because it’s me blabbering on. However, if you get to listen this bit, I have a secret for you. The secret is that the Protrusive app is coming out very soon and on there I hope to make it a little home for all the different infographics, PDFs references that I share. So it’ll be an easy place for you to catch that up. Anyway, let’s keep that secret for now. And I’ll catch you in the next episode guys. Thanks so much for listening.