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Adhesive Full Mouth Rehabs in 11 Appointments (Part 1) – PDP103

Happy New Year, Protruserati! In this episode we geek out with Dr Dev and Jaz as they discuss the initial stages of a Full Mouth Rehabilitation. In this 3-part series we will go on to describe the step-by-step stages for an Adhesive Full Mouth Rehab . Before we dive into the meaty part of this series later on, Dr Devang Patel will take us to the journey  of the clinician’s mindset who’s doing full mouth rehab and how to communicate effectively with patients.

Check out this full episode on YouTube

Need to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl: Write down one good thing that happened each day of 2022 on a post-it note, fold it and put it in a jar. By the end of the year, you’re gonna have 365 post notes of all the good things that happened that year. Check out the RipeGlobal Facebook Group that inspired this pearl!

“However, learning is nothing without action. So you can learn and learn and learn and learn…but if you don’t take any action, then you’re not going to get anywhere.” Dr Devang Patel

In this episode we talked about:

  • The mindset of the dentist doing a full mouth rehab 12:19
  • The three step technique 25:32
  • Appointment 1: Diagnosis and Treatment Plan 26:00
  • Communication with Patients 37:57
  • Reorganizing versus Conforming Occlusion 40:30

If you enjoyed this episode, be sure to check out the second part Adhesive Full Mouth Rehabs Part 2 – Wax Up and Temporaries and the third part Adhesive Full Mouth Rehabs Part 3 

Click below for full episode transcript:

Opening Snippet: Were you looking at step one is your diagnosis and treatment plan. That's the biggest step ever. The second step would be your anterior reconstruction and third step is posterior reconstruction...

Jaz’ Introduction:
Happy New Year 2022. Protruserati, welcome back to your favorite dental podcast. I really appreciate you coming back. And if you’re a new listener, welcome to this podcast. Hope you get lots of value from it. And today’s episode is part of a three series. So this first part is about full mouth rehabilitation, adhesive dentistry, so an adhesive rehab, ie using some sort of composite resin, either direct or indirect, and how to transfer that from the wax up to the mouth. So we’re gonna break it up into three different episodes with Dr. Dev Patel, who came on before, and he talked about private dentistry versus public dentistry and how we can be comprehensive in public dentistry. So in today’s episode, we’re looking at the mindset of the clinician who’s doing full mouth rehab, because we can’t just dive in talking about how to do these beautiful wax ups, and how to do all the big composites and indirect work as well, which we mentioned, that comes in episode three, actually. But we need to first start off on the right foot. And we need to know why you want to get involved with full mouth dentistry. What the mindset of the clinician is, how to diagnose, how to communicate, what to say, and how to say it at your treatment plan presentation appointment, to be able to then lead you with the correct patient, with the correct diagnosis to treat that patient in a full mouth manner. This series is titled 11 steps have a decent format rehabs and so really, this episode looks at appointment zero, ie your mindset, you as a dentist, and appointment one. And also when you bring the patient back and you speak to them. So those are the first couple appointments. The second part of the series coming probably in about four weeks time when we record is going to be appointments two to five, this is when you actually do, your mounting, your wax up, your transferring of the wax up to the mouth and you’re assessing the phonetics and the aesthetics and you send them home to test drive. And then the final part getting to there are really meaty bits. Okay, but I think it’s good for you to listen to these foundational parts one and two, before you come to that one, which will be around about six or seven weeks. And what we’re looking at the final one is appointment 6 to 11. Now the final few appointments are about splint provision and we don’t go too much into that, so we’re looking at appointments six to about nine, which is how to now bond your composite. What are the different ways to transfer the wax up to the mouth? Do you do anteriors first? Do you do posteriors first? Do you do left first? Right first? We cover all of those things in really great detail. I know you’re absolutely in for a treat. And I know you’re going to really gain a lot of value from this. So I’m excited for both of us. I enjoyed so much. I learned so much. And I know you will too. Before we joined Dev, wanna give you the Protrusive Dental Pearl for today, it’s kind of like a wishy washy one. Now we need these now. And again, it is looking at the New Year. Okay, so New Year, it’s January, it’s 2022. What can we do that can really make a big impact next year, so that we reflect at the end of the year. And we look back and we think wow, you know, that was a really good year. So my friend, colleague and mentor Michael Melkers, we are admins on the Ripe Global Facebook groups, if you’re not part of Ripe Global, please searched up on Facebook, it’s where a community of dentists post up their full protocol cases that you will learn so much by watching this full protocol cases. And this is a great community of dentist who are just hungry for knowledge and hungry to learn and hungry to share. So in this group, recently, Michael posted a photo of a jar of post it notes. And he suggested that every day, okay, in 2022, every day, we should write down one good thing that happened that day, and write it on a post note, fold it and put it in the jar. By the end of the year, you’re gonna have 365 post it notes of all the good things that happened that year. And so on 31st of December, you’re going to open that jar and just read it. Okay. And I love that. So I’m going all in. I’m doing it. And I hope you do too. So that’s my Protrusive Pearl, why don’t you get involved and it doesn’t matter if it’s March by the time you discover this podcast and you’re listening to this, start now. Start now and get perfect later. That’s always been the motto. So I hope you enjoy that little pearl. Hope some of you will act on it and start making these post it notes of positivity to reflect back on at the end of the year. Now with this episode and the future episodes if Dev or any of the guests share something like a PDF or a link, it’s always going to be on the blog on protrusive.co.uk or whichever podcast player you’re using, you scroll down something like Google, Apple, you should be able to see the links but you can always check back on the main blog. Let’s now catch Dev Patel.

Main Interview:
[Jaz] Dev Patel or welcome back my friend today Protrusive Dental Podcast. How are you?

[Dev]
I’m very well thank you, Jaz. I’m thrilled to be here.

[Jaz]
We spoke, man, you’re very welcome guests, we had you already talking about the complexities of NHS Dentistry and how to communicate better, how can we better communicators in that regard and NHS vs Private. We covered a lot of themes, we’re going to go a little bit more clinical now. So we just want to know the crux of this podcast. And we’re going for, we’re really going for the kill here. Because this theme that we’re going to explore today over that I think will be a two, maybe even three part episode is full mouth rehabs. And this is really the crux of occlusion for me. So the reason why I got more and more into occlusion is because I got to a point where I thought, hang on a minute, I need to treat more than one tooth here. And then suddenly, I’m like, Okay, I treat 6 teeth to 8 teeth. And then the biggest barrier or biggest issue that I had was, how do I make it fit, hencewhy I went to all these courses to learn how to make it fit and how to make it last. And for me occlusion just sums up in terms of how can we do a full mouth rehab, how we plan full mouth rehab, and expect it to last over a long period of time. Now, I know Dev, with how much experience you have, and the kind of case you post, you have got so many more full mouth rehabs under your belt than I have, which I’m so excited to learn from you. But I’m also hoping to break it down for all the Protruserati listening. And I love the way that you really, we’ve had some emails, we had a bit of chat so far, but how we’re going to break it down appointment by appointment, and you told me that it’s roughly around about 11 appointments or so. And obviously, that varies. But for those people who haven’t listened to our previous episode together, just tell us, give us a little bit flavor about you, the type of density that you love. And then we’ll build from there and we’ll start talking about appointment by appointment on the road to full mouth rehabs.

[Dev]
Cool. So let me start with my journey so far. So I was General, I started as being general dentist, as you know, as everyone do. And I’ve worked in NHS dentistry for six years, and I wanted to grow up my skill. During that time I did a lot of restorative courses. What I found that I want to do complex cases and could not do it because although I had knowledge, I didn’t have guts, basically. So I want someone to really mentor me, supervise me, because you know that first case is always very, very difficult. And you know, you don’t know 100 nuances, you don’t know what to do. So that’s why I joined the Masters MSC cons program at Eastman dental hospital. Now, if you don’t know what that is, it’s a one year full time program, where you do lots of full mouth reconstruction, but you also do your own lab work. I didn’t, I mean, I was aware of it, but it’s quite labor intensive. So I was I used to be there 7am to 11pm every day, seven days a week, I managed a caseload implant

[Jaz]
hencewhy this is called the divorce course, remember? So for those who don’t know, when I was considering, I was considering doing it, but then people told me it’s a divorce course. So that’s the reason I never did it.

[Dev]
Fortunately, my wife was very, very supportive. So you know, were still together. And so yes, I managed to do a lot of full mouth reconstructions, and lot of implants. But mainly someone was sitting next to me while I was doing bigger sort of biggest stages, you know, as it was. So if I’m doing full mouth reconstruction, and doing anterior posterior reconstruction, so on sort of consultant was nursing, with me, so you know, he was picking all the small things. And I think that gave me a lot of confidence. So once I finished that, I then started practicing, and the biggest hurdle was communication. And we will touch on that, to be honest, because it’s one of the biggest thing because as a dentist, we love to learn skills, you know, the hand skills, but it’s the communication skill, which will start your car going as if so you may have Ferrari, but if you don’t have fuel, you won’t go anywhere. So communications is kind of your fuel, so to drive your car. So I learned a lot about communication and I’m still learning you know, still in infancy, I believe. So started doing communication and then so I was quite confident full mouth reconstruction. The next step was to improve my surgical skills. So again, being me I mean, I quite scared of doing anything. So I had a mentor which was Fouad Khoury. I don’t know if you know him. He is the king of proffesional bone grafting

[Jaz] Khoury plates, the chap who made the Khoury plates, yeah?

[Dev]
Professor was mentoring me when I was doing surgery. So I really have found that skill. I learned from sort of John West, who is the inventor of Protaper files. So went to San Francisco, learn the pros, sort of how to do re-root canal, root canal treatment from him, been to numerous courses basically. So invested a lot of money and time and effort into doing sort of all the skills. Meanwhile, I was also teaching, so I’ve been teaching occlusion and full mouth reconstructions in 10 years now. And what I’ve realized that I actually I started, I mean, I’ve been teaching but one of the VT who desperately needed a post, and I was in Devon working and there was no one providing sort of VT training for her, so I said, Okay, I will become your VT train

[Jaz]
I just because we have an international audience Dev, I’m going to just break it down VT. For those in the US, Australia, wherever it’s someone who’s just like a year out of dental school in the UK and then a vocational training or dental foundation training, it’s actually a stepping stone to practice. It’s like a residency kind of in general practice.

[Dev]
So you need someone to obviously mentor you for that residency, what that sort of a one year, and so no one was available. So I said, Okay, you know what, I’ll help her because she was very genuine. She was hard working. So I started teaching, but not just for during basic dentistry, I was training her for full mouth reconstructions, implants, placements, everything. And within two years, she started doing full mouth reconstruction, placement of implants, everything, full shebang. And so then I started realizing, you know, the impact I can have on the wider population. And that’s when I sort of started putting more effort into online courses, which is occlusion to already habilitation, where I will go through, you know, so from occlusion to full mouth reconstruction, and yeah, so I’ve been teaching now, and I love it that way. Because by teaching, I can have more impact, you know, you can have more patient treated, better quality treatment. And I personally feel that there’s huge underdiagnosis going on, you know, because dentists don’t have confidence in treating. And I just want to share my experience and show every dentist hopefully, that it’s not really rocket science, if I can learn it, anyone can learn it. And yeah, just start their journey in full mouth reconstruction really

[Jaz]
Well, I think what you gave to that dental foundation trainee, that young dentist is you gave direction, you gave knowledge, but you gave confidence, the same confidence that you craved, when you wanted to do rehab yourself or the upper level in surgery, I think the nowadays with education being so widely available, mentorships being so widely available, that this really is the rocket fuel for young dentists to be able to do the kinds of cases sooner and to a higher standard than ever before. So that is a great story. I love your why as to why you do this. So that’s amazing. So let’s take everyone on a journey, Dev of full mouth rehab, and very nicely broken down into 11 appointments. Okay, so Dev, we were emailing some ideas about how to structure this mammoth topic of full mouth rehabs. So let’s just give everyone a bit of a background before we get to that, but you told me that you typically would see someone for 11 appointments as a typical Now obviously, that could be 20, that could be eight, whatever, right? Like, you know, there’s small little nuances in there. But in terms of the big sort of themes of appointments, there’s about 11 stages. And I think that lends itself really well to make a nice podcast episode about the different stages, the different nuances of a full mouth rehab, from the planning, and even before the planning, I like how you labeled appointment zero, as the mindset of the dentist. So you know, not every dentist should be or wants to do this kind of dentistry. And I think that’s where you’re gonna allude to, like, you know, is this your type of gig or not, and then we can work to appointment one, and then we’ll talk about the mock up, and then the planning and the prep stages. And then the bit where I get very excited, and I’m still learning more about how to go from temporaries to definitives, in a predictable way, that itself can be a real challenge in working with a lab and whatnot. So I’ll be just throwing little curveballs at you, and all questions, thinking out loud and stuff. And I’m through that way, just like many of the other episodes, I hope to give lots of value to the Protruserati. So shall we start on appointment zero, the mindset of the dentist doing a full mouth rehab.

[Dev]
Yeah. So I always say that whatever you start, you need to start with why. You need to start why you’re doing you want to do full mouth reconstruction, because as you quite rightly said, full mouth reconstruction is not for everyone. Because it’s more involved than just a single restoration. Because patient can come in just in a single filling, patients gone done. Where as full mouth reconstruction, going to see that same patient again and again. And they a lot of involved, especially when you’re doing first or second case, you know, there are a lot of things involved. So first of all, you need to really, really, really know why you’re doing or why you want to do full mouth reconstruction. Now if financial is your reason, then I personally feel it’s not a big enough reason for you to keep going because you will hit a road where you will get frustrated and you know, you might have problem, complication, failures. And you might just think, you know what, I don’t, because financially it, to me it doesn’t make sense, in the sense that yes, you know, that is this financial aspect of it, but purely if you look at financial aspect, then you can just do general dentistry, do general dentistry and you will be fine. Because if you think about it, reconstruction is nothing but multiple single restorations, right? Coming in together in harmony because of occlusion. So, the only difference between single restoration like 28 single restoration, or full mouth reconstruction is occlusion really, how they’re coming together. And all this facade is to make sure they come together fine, okay, for that patient, not even one original

[Jaz]
Together fine. And they last as long as possible. Because I agree with you, Dev, I find that when I was venturing into bigger cases and full mouth rehab stuff, I found the aesthetic planning actually quite simple, you know, when you listen to like people like Frank Spear and the textbooks out there on aesthetics, and you decided about the upper central incisors, and you work your way around, and you level everything. And as the planning the aesthetics, I didn’t find that complicated is then how to make it fit together in harmony of the patient’s skeletal pattern, and in a way that the future excursions in the future function will be respected. And to get the most longevity possible. That is where the tricky bit comes in. But that’s all in the planning stages, then when you actually get to cut the teeth, you realize, hang on a minute, I’m just instead of doing one crown prep, I’m just doing lots at the same time or whatever, or adhesive rehabs. And then you find that actually, you can do it quite quickly. So it’s all, the all the hard work goes in front loaded at the beginning, what do you say?

[Dev]
And to be honest for everything. So if I’m doing full arch implant reconstructions, if I’m doing upper and lower full arch implant reconstruction, the planning is it takes much, much, much longer. And then once you plan everything, then everything’s like really smooth sale. But if I have any problems, and I’ve had problems, at the end of the treatment, it’s always because my planning wasn’t great in the beginning. So you know, I can always pinpoint, I would say, 80%, almost 90% of the problem to my planning, whenever I have had any problems, so I just take a long time in planning, to make sure that, you know, I know, I’m controlling no known factors, you know, which you don’t, what you don’t know, you don’t know, you know, but at least what you know, you’re controlling it.

[Jaz]
Well, we’re gonna cover that in a few appointments time. But like you said that the mindset is important. But I also want to just add in about, you may be probably gonna cover this anyway, when it comes to communication aspect is, it’s the mindset of the dentist, but it’s also choosing the right patient, because it’s a bit like, you know, what the orthodontist say to patients or what you probably say to your implant patients, that it is a marriage between you and the patient, you’d have to pick who you’re going to marry as a patient and who you don’t want to marry. And it’s completely okay, you know, even though the case looks like perfectly set up, and you can visualize the end result, and the patient got, you know, the money in the bank, and they want to start, but you get this funny feeling in your stomach that this patient is trouble, there’s red flags, and then you don’t want to treat it, that’s probably the best thing you’ll ever do not treating that patient

[Dev]
100%. And I’ll go through that actually a little bit more in detail later on. When I’m covering the treatment planning aspect, funnily enough, so we’ll go through that 100%. So, with regards to the mindset, you need to understand why we want to do full mouth reconstruction, I the reason I want to do is I want to help patients, because after doing full mouth reconstruction, the smile, you see that the relationship you develop is completely different than you treat someone with a single restoration, because you just changed their whole persona. And by teaching, obviously, then spreading the love to many more patients. And that’s one of the reason. The other thing is you need to have a positive attitude. Because if you are concentrating in this litigious society, about the complaints, about the problems going to have, about the failures going to have, then you will never start because there initially you will have more problems statistically, because, you know, you’re starting, you’re learning, you know, we are all practicing per se. So you are starting so you know, you will have more problem. And that’s where the direct mentoring comes through. And that’s where the learning comes through. However, learning is nothing without action. So you can learn and learn and learn and learn. But if you don’t take any action, then it’s not you’re not going to get anywhere. The third thing is

[Jaz]
It’s all about the implementation

[Pav]
100%. And the third thing is we all have limiting beliefs. And I personally do have as well, and I’m trying to break some of my limiting beliefs. But most of us we think we are not good enough. You know, and people who think we are not good there, they are actually the good people, the good dentist, they think they’re not good enough. Does that make sense? The people who are obviously just crack on most of the time. So it’s the people who are good, they just think you’re no good enough. So you need someone to tell you, critique your work, and then just improve and improve and improve and that where you will help. The other thing I get a lot that you know what, my patients are not right type of patients. And I get that a lot from dentists, or that I live in an area where there is not uptick, you know, no one will uptake that. I mean, I have worked all over UK in almost 11 practices. And I’ve proven everyone wrong, and they are different. None of them was highly influenced practice like that. None of them were like a high practices. So people need treatment, especially actually if you think about it, the lower socio economic area, that’s where the needs are more because you know, people come to you in a desperate situation and when you’re desperate situation, you will do anything. So and also they haven’t had been

[Jaz]
this is a recurring theme, Dev, by the way, I just want to say this is not just you telling me this on other podcasts, but other people have told me that they started these cosmetic clinics in these extremely deprived areas, like for example, Biju Krishna, and when he was starting out doing lots of CFAST up in Scotland in this dodgy part of Scotland, and they became this huge provider of cosmetic dentistry, busier than any other clinic doing lots of short term ortho, whatever, in an area where you would have thought I never want to buy a practice that. And it’s a theme that you hear again, and again and again. And it all boils down to communication and your limiting beliefs, just like you said, rather than just accepting that, oh, my patients won’t take it. If you accept in your mind that my patients aren’t there, they won’t be there.

[Dev]
Either way, I think it is that I just removed, if there are many patient who come to me now because I’m doing a consultation and someone would have referred me, they’ll come to me, sit on the chair and they say, Look, you know what I can’t afford what you’re offering. So that’s fine, you paid for consultation, I’m going to give you what, okay, and then you decide what you want, at least you paid for this, let me do my job. And then you know, I just get for I don’t even think that they can or cannot afford, my job is really to tell them what they need. And then it will be their decision whether they want to have this done. Now if I’ve done my job properly, to show them the value, I’m sure they will have something done because the reason they are usually to see me is because something’s not working, they broken teeth, and you know, quite worn down teeth, which other dental practice cannot, you know, treat. The last thing in the mindset is investment, you need to have a mindset of investor, because you do need to make sure that you invest in courses which are right for you. But also, I’ve seen many times, I’ve seen a dentist not doing Invisalign, because the principal would not invest into IPR strips. Now I’m thinking, okay, you’ve done the course, just buy the strips, you know, buying the strips is fine. Just you know, I understand there might be a reason why this is happening, but I just buy, even if I feel that this is something out of normal general dentistry, I used to just buy it, because it will pay me 10 times more, when I’m started doing cases, you know, so but many times, then it is sometime they feel that it’s quite unethical to buy it yourself while you’re working for the practitioner, you know, your boss, and you’re making money for him as well as you. So you know, but I think you just need to be a bigger person sometime and just get what you need to get you going

[Jaz]
Dev, I love that advice so much. I just want to just add to that I was doing an ortho diploma. And it was like a 20k diploma over two years, right? And one of the guys, I’m not gonna name him one of the guys messaged me saying JAz, like how you doing this with your principal, because my principal is refusing me, refusing to buy me the brackets and wires. And I’m like, Oh, my God, the patient is ready to pay you four grand, or whatever. Your total investment in education is 20 grand, and you’re disputing over 250 pounds worth of to get you going. And I’m like, that’s a mindset issue here. So yes, in an ideal world, your principal should be buying it. And that’s what the licence fee comes in. But once sometimes, just like you said, Dev, sometimes when you buy the stuff yourself, and then you produce the results, and then you put that piece of paper on your principal, just say, Hey, by the way, I did this case, and that was my investment. If you like this work, I can do all this for you but this is what I need. And that point your argument, because to put myself in the principal’s shoes, you probably asked for 10 other things in the past, he never used them, right? And so the principal’s might be little bit worried about putting more money into it. So you have to sometimes prove it.

[Dev]
Yeah, I mean, when I were coming out, my boss is, you know, is cool. Really, really forward thinking so you know, I mean, really fortunate position where I work, but you’re quite correct, because who which principle would not want to have profit, you know, it just doesn’t make sense. So when you do need to sometime prove, I many times give dentists the example of the pump, you know, what you call the pump the, you pump to get the water from the underground coming up, you have to pump the water to get the water out, but that you have to pump it a lot of time before your water comes through. Does that make sense? So you need to first work in order to show that you get the result. But yeah, so I think in my mind, the mindset is the main main main main thing and many times we don’t even, you just don’t even look at it as a mindset as a main factor of full mouth reconstruction and that’s why I really wanted to put that as appointment zero because without that, your other appointments will never start.

[Jaz]
I love that, Dev I’m going to add one more thing in terms of, because you shared your why and my why in terms of getting into more comprehensive dentistry, more full mouth kind of just viewing things with a lens of a full mouth rather than just a single tooth and moving away from single tooth but look, there’s nothing wrong from single tooth. Some of the The most humble dentistry, the dentistry that the public needs is single tooth, but the, I eventually will get bored. So for me, I start to have more fun when I’m thinking of the bigger picture, and then to see those big changes in the dentition, and then doing work that you can step back and then have a good night’s sleep and think, wow, you know, this was a journey. This wasn’t like a wham bam, thank you, man, this took a year or two years of hard work, and the patients are all made up. So that’s our why basically very similar to yours, Dev. But it’s about also enjoying and falling in love with those little details and the big changes

[Dev]
100%. So it’s life changing, you’re changing someone’s life. And that’s the biggest gift you have. So once we nail the mindset, that further appointment, I kind of break down into three steps. And that’s why I call it three step technique, where you’re looking at step one is your diagnosis and treatment plan. That’s the biggest step ever. The second step would be your anterior reconstruction. And third step is posterior reconstruction. simple three step. Okay, so let’s start with appointment one, where patients sitting in your chair, and I’ve said appointment one, because most of us are general dental practitioners, and you will see patients for a checkup. So the appointment one is really a checkup, which is less than 20 minutes checkup, you’re assessing patients mouth, you probably haven’t seen patient, but if you’re like me, and you know, after doing MSC, you’re seeing the same patients, by seeing them different eyes, you know, your eyes have changed. So you know, you’ve seen the same patients, and now but now you’re seeing the where all of a sudden you think, you know, this patient needs full mouth reconstruction. I mean, I don’t know about you, but how many cases I’m not can’t count the number of cases, which is referred to me for single implant, and they need full mouth reconstruction. I mean, almost 80% of them are like that. And I’m looking at it. And I’m thinking, Okay, I’m not saying 80% patient says yes to that. What I’m trying to say is they are in need of some sort of a more comprehensive treatment. Once I’ve shown them all the photos and everything, I will then tell them what are my concerns, because patient would have their own concerns, but I need to let them know that what am I concerned to give them maybe a reality check, right? So if their expectations is completely out of this world, they need to know that maybe I’m not the person to be able to give them that kind of results what they want. But usually,

[Jaz]
Can you make that tangible? Can you give example of a clinical scenario, what you mean by that,

[Dev]
I’ll give you an implant example actually. So patients comes to me edentulous, jaw lower, flabby ridge, there is not much bone at all. And they can’t afford fixed prosthesis. So I’m doing two implants and a locator based denture, but they don’t want denture to move at all. And they want it to be completely fixed, and they don’t want to be really really, you know, bite completely without any, you know, worrying about denture moving. So I have to tell them that look for what you want, I cannot give you a fixed teeth, you know, the denture will have some mobility in it. So they need to understand. Same thing with patient who has, let’s say, really high lip line, and nice teeth, and showing like four millimeter gum, right? So and then if they want the incisal edge showing just maybe 2 millimeter, I’m giving you example, quite extreme, but just the incisal edge showing like two, three millimeter, they want to reduce all the gum, maybe we can do lip repositioning to make it that awfully bit crown lengthening, but, you know, if they’re showing four, five millimeter of the gum after showing that 10 millimeter length of the incisor, it would be quite difficult to then correct it, you know, so you need to tell them. The other example is if there is implant attached them, you know, you need to tell them that there will be some recession, I mean, I will do my best to do soft tissue grafting and make sure that, you know, gum stays where it is. But there is a good chance that the gum will recede a little bit you know, so this is the time where and the more experience I get, the more I’m scaring the patients. I’m telling them from upfront because I don’t want to them to then have all the treatment gone through especially full mouth reconstruction and then look at the mirror and think this is not what I wanted. And then that’s the heart sinking moment where you know, you haven’t really educated patient enough or you haven’t listened to them properly.

[Jaz]
Everyone should do what I do and just only treat people with their low lip lines.

[Dev]
Yeah, or make them low. So when you take a photo, just don’t smile too much.

[Jaz]
That’s the secret. That’s the secret you give it

[Dev]
The photo’s fine, you know, Jaz, it’s all about the photos. So and then I will show them if they don’t have anything done. What will happen? Because they need to know that so do you know you would have, everyone would have the cases which is really quite a lot of them. But patient never gone ahead with the treatment, you know, you told them everything but you know, it is what it is, maybe I didn’t do my job properly in explaining the value of my treatment, and the patient will say, No, I don’t want to have the treatment done. Because finally, I mean, if someone tells you that your family is in danger, they need so much amount of money, you will find the money. So it’s really, it’s really whether you find that good enough for you to be able to invest in yourself, whatever you you telling the patient so. So patients always have resources, it’s just that whether they want to use them on their teeth or not.

[Jaz]
I think that’s a great point. I just want to elaborate on that, Dev, because Steven Hudson, who used to have a blog and stuff about dental law and ethics and communicating patients, and I remember him writing a blog post one saying that, just because the patient has got 50,000 pounds sitting in their bank account, doesn’t mean that they want to treat it and spend it with you on dentistry, because dentistry is maybe so low in their values overall, just like you said, everyone will do anything for their family. But a lot of patients could have no teeth, and they honestly have no aesthetic values or aspirations. They just don’t care about the oral health so much. So for them, it’s not a 50,000 pound problem. Whereas what they want, you know, in ideal world, what they may need, or what they would benefit from, it just doesn’t sit well with them. So that’s again, part of discovering what their goals are, discovering what their values are, so that we can actually make the right treatment for the right patient.

[Dev]
But the important thing is values can change. So not just because you had a check discussion with the patients on the last checkup, about full mouth reconstruction, looked at your notes, and you’re thinking I had a chat with them last time, they don’t want to have anything done, I’m not going to ever talk to them about this this time, then you because things change, people might, I mean my values changed, you know, the health is now becoming much more priority for me, which wasn’t five years ago, you know, five years ago, it was all about, you know, hustle and work, work, work, work, work 24/7 and improve your skills, and now I’m putting more priority on my health. So people’s value change all the time. So, you know, just because patients said no last time six months ago, it doesn’t mean that they’re the same person. So I think that’s something really, really important.

[Jaz]
One more thing actually is sometimes the reason that the values can change is because we’ve reframed the same problem in a way that speaks their language. So for example, we know that from a lot of the aesthetic rehabilitation that we might do, is going to restore their how they look and restore their function, how they can chew. But when you’re telling someone that we can make your teeth look better, look more youthful. And they’re really not listened to that, they don’t care about that. But when you tell them actually, if we don’t do any treatment, we won’t have any tooth structure left, and then you’re looking at dentures, or then you’re going to lose your teeth, then that same message speaks volumes to the patient, and then they’re both true, we can both make them look better, and keep the teeth for longer, but which one they resonate withI is the other ones, you have to pick and choose and speak in their own language, don’t you think?

[Dev]
100%. So it is, as I said, most of the time when patients say no, the treatment is my fault, because I haven’t really spoke, I haven’t spoken their language, if that makes sense? So you know, I’ve been telling them what I feel that is good for them, but not in their own language. So I think 90 or 99% of the time, really, it’s the dentist fault if the patient says no, I don’t want that treatment. And they really need that treatment if you think that they need the treatment. So I showed them, if they don’t do anything, what will happen to their teeth. So you know those cases, which didn’t go ahead, I keep them still as a photograph, and I show them that look, this is you know, 70 year old gentlemen, this is the teeth and you know, worn down so much. Then I show them what is potential, what can be done. So your previous cases, what you’ve done before, I’ve done before, and this is where I see the most conversion happening where when patients come to me I can pretty much do anything, now so I can do you know re-, I can do anything. So I’ve done re-endos, I’ve done full ortho, like conventional ortho, Invisalign. I can do autogenous bone grafting, full arch implants, you know, full mouth reconstructions, everything. So when I’m sitting with them, for me, it’s not what I can or cannot do. It’s really finding that right solution for them. So when I’m discussing the treatment plan with them, I show that confidence so the, if, to me, it wasn’t very obvious, but one of the associates while observing me, who did the my full mouth reconstruction course and he wasn’t converting. And that was like five years ago and he said, Look, can I observe you? Come on in and then he observed me he’s like, You know what one thing is, when you talk to a patient, you’re just having a chat with them, in your back of the mind, there’s no doubt that you can provide them the best treatment what they need, it’s just literally fitting into what they really want and how you can work around it. And I think that’s really confidence is really important. But that comes after experience. So you, again, you have to start somewhere. And what I’ve realized is, when I was referring cases out early in my career, I was much more confident, because I knew that the person I was referring to, was really good. So I knew that the patient would get the best treatment possible. So I was literally telling patient that, you know, you must go that and see them and you go, you will be good. Because of that I have quite a high conversion rate, although I didn’t get any benefit, financial benefit, but I had a quite high conversion. And I think that same thing shows, but now I’m discussing with patients, that confidence really helps.

[Jaz]
That’s a really good comparison, I like how you made that, that when we’re referring to someone that we trust, and then we instill confidence in that other practitioner, and the patient is more likely to go ahead and get what they know something that they need, and something they’ll benefit from, and something that’s gonna benefit them overall. And then now you’re just applying that same logic to yourself that you know, you can deliver a good result and you’re confident in your diagnosis and management plan, and you know, that you can give them so much benefit going forward, that you lose that confidence, and patients definitely pick up on that. So that’s a point well made. And I’m so glad you made it in this part one, because this is the crux of it, you know, if you start doing ortho, you start doing anything, you need to ooze confidence about what your aim is teeth whitening, if you can’t convince a patient, that teeth whitening is going to help them it’s probably because you haven’t probably whiten your teeth ever before yourself. And you’re trying to tell them something that you don’t really believe in yourself, actually. So it says things about showing the patient that actually yeah, I think this is gonna be really good for you, and believing in it, and the patient picking up on those visual cues.

[Dev]
So you know what, I never had a laser surgery done, because every time I went to see the ophthalmologist or someone, they all wear glasses, I’m thinking they’re wearing glasses. I’m not gonna have it done. So you know that was my thing, anyway. So that’s just I. So once I’ve done the assessment, I would then move on to stabilization phase, because it’s really important to make sure that the dentition is stable before you move on to full mouth reconstruction, even think about it. So when I’m doing their first full assessment, I will tell patient that this is the phase one, where I’m going to take the teeth out, which needs to come out, to re-root canal treatment where it needs to re-root canal treatment, to you know, remove all this old amalgam, clean that up, restore it with composite, and just a core build up, and just make sure that when I’m back, I’ll have a nice dentition. Now, if patient has crowns, I would take the crowns out and restore them with the temporary crowns. In the ICP in their own occlusion, no change of occlusion, just removing out and making sure that the crown’s fine before I start doing full fledged treatment. So first is always stabilization, which is a treatment they really, really need. Even if they’re having full mouth reconstruction or not. They really need these things. So I will start with that.

[Jaz]
So there before we continue on that’s going to ask you something about phase one and communicating finances as well. So something that we can learn about communicating finances. So when you are communicating phase one, and obviously to give the patient the estimate of the phase one treatment, but do you also, because many people do it differently, do you also give them a ballpark figure as a range as to what the future treatment may cost? Or do you think that actually don’t want to scare away just yet? Because regardless, they need the phase one anyway. So you’re going to just quote the phase one. And one thing I also said is that it’s an opportunity for you to learn about the patient as well. Are they a good patient or not as you do phase one, which is something I need for the health?

[Dev]
Yeah, so do you know what I’ve tried both ways, I’ve tried doing the just doing the phase one and telling patient that you know, you need all this and then we’ll look into it once we stabilize your mouth, because this is something you really really need, whether you have the phase two or not, that’s different, but you need this anyway. Or, I’ve done the other way around as well where I’ve told patient that this is phase one, and this is potential phase two, and this will be the whole fees. And in my experience, I haven’t seen any difference. So people who are going to say yes, they will just say yes regardless, to be honest. Having said that, some patients who when you break it down, it becomes a little bit more better for them because they can then, because many patients don’t think long term, they will they think like monthly how much I can pay, how much you know because they are living like that. So you know if you break them down, they’re okay we’re going to do phase one, if you tell them oh it’s going to be 20,000 pounds, then they’ll be like oh 20,000 pounds now whereas if you tell them okay, you know we need to do this crown which is temporary crown which is 100 pounds, we need to do this core builder, which is 120, everything will be to 3000 pounds. We’ll do that first and then you know move on to the next step and then next and then and that helps in just breaking things down. So I usually tend to break down nowadays everything but then give them full fees as well.

[Jaz]
Dev, thanks for sharing that. It’s good that you’ve done it both ways. So you can give us that feedback as to what’s worked in your practice, because these are the real barriers. There’s so many different steps to actually implementing full mouth dentistry. And one of those is having those difficult conversations about fees, which we have covered in previous podcasts well, but as part of the bigger picture, that’s one of the different challenges the actual dentistry is easy bit, but it’s the mindset, like you said, it’s about finding the right patient. It’s about phasing the dentistry. And now we haven’t even begun talking about the occlusion bit yet. Which brings me very nicely to wrap up part one. Is that, okay, I know some great dentists who will plan their rehabs in MIP, whereas traditional schools of thought and many dentists, including myself, I plan for, in most cases, from centric relation. What is your school of thought? Knowing you’re from Eastman, I can guess which but what is your school of thought? And how do you decide between reorganizing versus conforming?

[Dev]
There are a of lot of ways you can decide whether you’re going to reorganize or conform. For me, when I look at the mouth, I’m going to assess how many number of teeth I’m going to treat, right? So if you’re treating as you know, one or two teeth, which are nicely bounded with other teeth then Confirmative. Now, if you thinking full mouth reconstruction, for me, if you’re doing full mouth reconstruction, you’re touching every single tooth.

[Jaz]
Or at least one arch, right? If you’re doing at least one arch, then

[Dev]
Then a bit does automatically becomes a reorganized approach. Now, there are nuances to that. So let’s say conformity approach, the advantages of doing conformative. You can even do single arch Confirmative, right? in your mind? Because to be honest, once you dismantle everything, you’re kind of changing contact points, you’re changing a lot of things. So it depends what you think, what you’re defining as a conformity. And when you’re defining reorganize, for me, even though you’re not raising OVD, it could be reorganized, because you’re just changing your patients contact, the way they change, you’re eliminating slide a little bit so you know, it just changes, so for me, conformative means you keeping everything, keeping the slide the way it is, you know, ICP to MIP slide. So CO for American, CO to MIP slide. So you’re keeping the same, you’re just treating the way it is. And the best way to do that is treat the jaw in sections. So keep your teeth, few teeth, and then just do treat other few teeth and then treat other few teeth. The advantage of that is patient kind of knows that kind of bite. So they’re used to it, there’s less risk of you incorporating something in patients mouth there, which is completely different than what they had. But the limiting factors are that you don’t have much room to be creative and to change the teeth to shape forms, and eliminate some of the, Shall I call it interferences or non working side contacts, if patient has any. So for me, if I’m doing full mouth reconstruction or anterior reconstruction or any zone, dahl technique, or whatever you call it, it is a reorganized approach. Whereas if I am, if patient has one of the very rarely, when I do conformative, while I’m doing full mouth reconstruction is patients got TMJ issues. And I’ve given patient Michigan splint, and it got worse, right, because patient just cannot tolerate that open bite. And they just used to that. First of all, I wouldn’t touch those patients and do full shebang, you know, full mouth reconstruction on those patients until the symptoms are gone. But even some symptoms are gone, I’m looking into doing very confirmative approach where I’m not changing too much. Because the risk is you change things and then the patient back to where they were and start having issues with TMJ.

[Jaz]
That’s our concept of working within that adaptive capacity. Right? So someone’s got very narrow, adaptive capacoty. And deviates, even giving them a removal appliance, like a Michigan splint, made them in a position where they were not able to tolerate it. So you want to copy the features of the system that was working in a painless way for them, even though it may not be the gold standard, but need to actually conform to their adaptive capacity.

[Dev]
So yeah, so however, it’s not that common and people scare, you know, it’s quite, you know, Dentist get scared a lot. But I’ll tell you, I mean, I’ve done over 3/4/500 full mouth reconstruction, I can remember two patients who are like that where but they were telltale signs, you know, again, when we do the assessment, we will know when I’m doing treatment planning, I would know how I’m going to plan the treatment and we can go, we’ll go through with that. But one of the thing is the load testing if you’re doing low test, which means you’re using Lucia jig or you Using leaf gauge and patient bites, and patient feels pain, that’s an indication for me to stop, and then rethink, make sure that the pain is gone. Sometimes it’s their lateral pterygoid, just giving the firing wrong way. And sometimes you put a cotton ball roll, ask the patiet to bite, the pain goes quite instantaneously. So it could be but usually, if that happens, then you need to really re evaluate everything before you consider anything. The other thing is when patients got a slide, which is long horizontal, and short vertical, usually when patient closes their mouth, the study shows over 90% of the patient would touch one tooth first, and then slide their jaw forward and upwards and close their teeth. Now that forward and upward movement is not 50-50. Does that make sense? So some patients would go more forward and then less upwards. That’s called long horizontal, short vertical. And then some patient will go more vertical and short horizontal. Now those patients who go more vertical and short horizontal, they’re easy to treat, because if you remove that first point of contact, all they’re going to do is close their mouth, basically, more. Does that make sense? Whereas if you are the long horizontal slide, if you eliminate slide, patient’s going to not be able to do the horizontal slide and it will start closing more vertically. And then you develop anterior open bite. So if you remove that horizontal slide, which is which patient we’re doing in order to get their front teeth in contact, if you remove that they can’t move, they don’t moving their jaw forward. So they just move that you’re like that. And then they have anterior open bite.

[Jaz]
I’m sure you mean anterior open bite or do you mean increased overjet?

[Dev]
Increased. Sorry. Yeah, exactly. So increase overjet. But then the teeth won’t touch. Okay, sometimes or sometimes they teeth start touching on the gum. Okay, so now, if I want to raise OVD in that case, then all the OVD will be raised on the posteriors because patients lost that anterior guidance of the protrusive guidance from the centrals, we want to keep the protrusive guidance, if you follow Eastman mythology, then you want that canine forward. And if you want that, then that’s impossible if you remove that horizontal slide. So that’s something very rarely, again, I’ve treated so many. And thankfully, God is very great. So He has cured us more patients with long vertical and small horizontal, then long horizontal and small vertical slides. So most of the patient or 90% of the patient will fit fine into your normal routine. But there are some patients who you might get caught up by where there is a long horizontal, and those patients, I would still treat in CR, but I would not raise the vertical too much. Because if you raise it too much, you end up losing so much, so much space anteriorly, because of the overjet you create.

[Jaz]
I mean, every case will be independent, and it would work, you know, your workup and your occlusal planning comes into and is case specific is what we’re trying to get to. And and that will vary. So there’s no one formula for every patient, depends on where is their centric relation contact point to begin with? What is the extent of their slide? What is their existing malocclusion? What is their skeletal base? So there’s so much that goes into planning each case. But essentially, when you’re reorganizing case and you’re increasing OVD, you’re beginning from position of centric relation as per the Eastman School of Thought, and you’re building your bite from there is that fair to say?

[Dev]
Yeah, so it’s fair to say so. So my idea is, if I can start with CR, which is opening their bite up even ever, so slightly, I will do that, because then I have a plain sort of playing ground where I can just change anything I want. So I’m already increasing already even one millimeter, two millimeter, I have the full access to that space. And I can move teeth around restoratively as much as I want as possibly as I want. But as a few are even restoring patients in CO which is the first point of contact when patient contacts and that one first point of contact, because there are other theories, or other principles, they will just restore patient in CO because to avoid this TMJ issue, because if some people will say that if you open patient too much, then you might have issues with TMJ because you know, opening their bite up and freeway space, which doesn’t really apply to dentition to be honest, but and I’ll open patients up you know, I don’t even see how much opening I’m doing. I’m looking at the aesthetic result. I’m looking at the prosthetic I’m not looking at I’m going to open to let’s open this patient by two millimeter, I usually don’t think that way. I would think, Okay, how much longer I want the teeth, how much prosthetic space I want. And then I’ll open patient up. And obviously you do trials and you make sure that the patients can tolerate that. But yes, so the one concept is you open patient up in CR, which is patient non teeth occluding position.

Jaz’ Outro:
Well, there we have it, guys, I appreciate you listening all the way to the end. I hope that’s whet your appetite for part two. So part two of this is coming out in about four weeks or so we’re going to cover appointments two to five then, and we really go into a lot more depth in terms of diagnosis, mounting, wax ups, how to control your curve of spee, all those really important things I’m hoping you’re able to follow on that. If you’re a newbie dentist or dental student, I’m hoping we made in a way that you can follow along and we’re going to build you up in the next part. So stay tuned for that. And as always, I’d really appreciate if you can share this with a colleague who you think might find it useful and whet their appetite for the future part of the series. Anyway, thank you so much for listening all the way to the end and I’ll catch you in the next episode. Same time, same place.

Hosted by
Jaz Gulati
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