Recession is one of the those diagnoses we make all the time – lots of our patients have recession. I always struggled to decide when we should be proactive with recession and suggest surgery – it is very easy to monitor recession through photos and measurements. Specialist Periodontist Dr Amit Patel discusses his decision making when it comes to recession defects. He also discusses his journey which is very encouraging as it teaches us that you DON’T have to have it all figured out from the start….
Protrusive Dental Pearl: What do you do if your patient is bleeding after an extraction and you’re struggling with haemostasis? You can try placing a hot tea bag on the socket (no, really!) – the tannic acid in the tea bag will aid blood clotting. So next time you have a bleeder in the chair, remember, ‘time for a cup of tea!’
In this episode we discussed:
- Knowing when to refer recession to a Periodontist for surgery vs monitoring (23:39)
- Communicating to patients whether to have some treatment done now or later (26:02)
- Miller’s classification (30:05)
- Why can we get 100% root coverage (32:36)
- Do GDPs have a role in carrying out Perio surgery (42:53)
- Advice for patients to prevent recession to get worse (48:30)
- Realistic expectations to patients about what kind of aesthetic complications to accept as a compromise (52:01)
If you liked this episode, you might also enjoy the episode, Should you specialise?
Click here for Full Episode Transcription:Opening Snippet: I've got to be honest the referrals that I've had, the patients don't want to have the surgery okay which is interesting because you know they've obviously been told that they've got a problem, they've got recession but they're just thinking i don't want to go through this hassle, right? So which is fine but what i have noticed during lockdown, I've had a lot more patients contacting me about their gum recession...
Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome to PDP 082, all about the management of recession defects not like the crazy like you know get the scalpel out let’s all start doing root coverage. More like how to assess it as a GDP because i find that recession is one of those things right? Where it’s like tooth wear in the sense that it’s common but that doesn’t make it acceptable, that doesn’t make it something that we don’t write down as a diagnosis because i find that you know people ignore tooth wear and people ignore recession because why we see it all the time of varying degrees. Some patients will take it really seriously whereas others will have recession for years and you might be the first dentist to have that conversation with them about recession and it can obviously lead to sensitivity and aesthetic issues So it’s a huge issue and i think soft tissues as a whole is something that needs better coverage i guess if that’s a pun I’m allowed to use.
This episode, I’m joined by Amit Patel, who is a I want to say youthful like. This guy’s like got a baby face right and he’s such a good guy. He’s one of the nicest guys in dentistry very knowledgeable and he’s been on the lecture circuit for like years and years and years. Although you wouldn’t tell from his face he like i said he’s a baby face. He’s going to talk all about how he assesses as a periodontist specialist the tissues and how he manages the cases that get referred to him with the recession and it’s amazing how a lot of these cases, he’s just reassuring patients he’s not actually picking up a scalpel and it’s great to know when we can reassure patients and how far we can go that versus when we actually kind of need to intervene or refer so that the situation doesn’t get out of hand so we cover all those things including prognoses and the beginning we also cover the journey like Amit Patel’s journey and it’s another example of how and why you don’t need to have everything figured out straight away Sometimes things happen, signs come your way, you meet people, mentors and that leads you to a certain path. So hope you enjoyed this episode all about recession as a GDP with Amit Patel.
Oh i almost forgot the Protrusive Dental Pearl, so on the theme of recession, recession coverage i guess which is bloody. I’m gonna give you a bloody pearl okay? The bloody pearl is if you’ve got a bleeder right? What i mean by a bleeder is if you’ve got someone carried out an extraction and they’re not settling and they’re bleeding profusely, okay? Here’s a little trick okay? You get the nurse to boil the kettle and you’re gonna make a cup of tea okay except you’re not gonna drink this cup of tea you’re gonna pull out this hot tea bag okay and you’re gonna put it on the socket okay? This works wonders okay? This is something i got taught as a student on an oral surgery seminar and it’s always stuck with me and i saw it recently again on a Facebook group where someone was talking about this trick i was like yeah that’s an amazing trick. So if you’re ever stuck okay then just remember time for a cup of tea. Let’s join Amit Patel and I’ll catch you in the outro.
[Jaz] Everyone knows you in the UK, right? and i don’t know if you know this or not but you were the for me the poster boy for perio chip, right? Like I’d open my cupboard and I see a poster of you, I see you with your little mop and be like five millimeter pocket, think periotive. You and that white shirt and the hair and stuff, so that’s why i think everyone in the UK knows you but for those who don’t know who you are, can you tell us a little about yourself, Amit?
[Amit] Thanks yes, well I’m a specialist in periodontics and I’m from London originally, I went to Liverpool university in ‘92 and worked all over the country and then I decided to do Perio training at Guys in St Thomas’ for four years and that included a bit of implant training and then again I worked all over the country until I moved to Birmingham and started my own little practice here in the city center, Birmingham Dental Specialists and it was going really well until 2020. So because we were going to expand we now just have to wait a bit longer before we do that.
[Jaz] Well let’s see, it’s all hard and I hope things pick up for you again I mean you totally deserve that but how soon did you know after qualifying that you wanted to pursue Perio?
[Amit] Man, that’s a good question, Jaz, that’s a really good question. Let me tell you a secret. So i’m not the best student really bad. I would have left school at 16 become a plumber or join the military or something and just you know been quite happy but my mates went off to you know to do the a-levels that they’re all tagged along and then I went to a careers day the teacher said look you’re good at woodwork maybe you should be a dentist and I’m like okay fine that’s what I was going to do. So then the problem was i went for my interviews and I didn’t get a place because my interviews were so bad because they kept asking why you want to be a dentist I didn’t have an answer then I filmed my levels because i wasn’t the best student in the world i had to reset and then I went again when it came to my university interviews, i went back to some of the universities and they reject me and the only place that was gonna offer me a place was Liverpool that was the last place, the last interview and they sort of said I, we suppose we have to offer you places you haven’t been given any offers and I’m like yes please. That was it they gave me they gave me and then it was i mean there was three Bs you know for the recess but before the resets it was a b and two c so it was it was a bit easier to get in then at that time i did pass my a levels and then went to Liverpool. So the question you asked was why did I, how did I want to do perio?
[Jaz] No. But after admitting that you weren’t the best student yeah after saying that you weren’t the best student and then you end up doing a whole perio program what was that about?
[Amit] Yeah, so the thing is again it goes back to you know I realized when I went to uni went to Liverpool within the first term you know we did an operative tech you know op tech and I realized I can’t do this rest of my life you know drilling and filling i was like this is really not going to be for me and but I’d committed myself to the five years and i was having a good time at university so i wasn’t gonna walk away from it. So I carried on you know just scraped through I wasn’t the best student. It wasn’t you know yeah wasn’t liked very much but you know and then in the fourth year we were doing a week at a hospital called Walton and I turned up and on a monday morning and these dentists were doing head and neck cancer operations and I’m like what what is this right and then they said yes we’re dentists but we’re also doctors and I’m like okay so then what was really good about that week was because i was really enjoying it and really enthusiastic they kept dragging me back in to do zygomas and all this stuff to let me do lots of stuff you know plating and all this sort of stuff as an undergrad and i thought I’m gonna do medicine right?
So then the plan was that i was going to go do meds after i qualified and i got my house office job, SHO jobs MFDS and then i also applied to medical school and i got into a three-year medical course at Leeds so yes that was good something now you know I’m, I mean trumpet or whatever but you know i do feel quite fortunate that you know i got that place especially a short course and then i also could make an informed decision that maybe this isn’t the career for me do you know what I mean? and i think a lot of people who do Maxfacts, I’m not again I’m not criticizing their career choices but you know how many of them actually go on and do head and neck cancer surgery? Most of them will become GPs when you look at the questionnaires and all the studies have been you know been published on the doubly qualified clinicians what do they end up becoming? It’s red you know it’s not all of them will become Maxfacts surgeons
[Jaz] So that’s a very very good point for anyone thinking about doing medicine after dentistry i think you’ve raised a good point though.
[Amit] Yeah i mean it’s you know because you look at majority of them they’re either GPs or they go off and do ENT or plastics it’s like well so.
[Jaz] Other specialties skin or whatever yeah exactly
[Amit] Yeah so you know like i know here in Birmingham I’ve met a Maxfacts guy and he’s like niche this is like you know you’re actually a dentist so you know do they dislike dentistry that much? I didn’t really dislike it but what i learned was because i did VT, i did VT for one year and what i realized there i started to enjoy just talking to patients you know i mean having a laugh and stuff like that so i just realized it wasn’t you know i could have done anything because in VT i did we spent one day with an endodontist in Manchester, David Cohen and he works with a guy called Phil Green who’s a Periodontist and David Cohen was just so enthusiastic about endos and i was like i could do this because i realized that i only need to be around somebody who’s got so much energy and i think right i could do that and you know i mean it’s really sad you know i mean you know you know for example i am digressing quite a bit but i went to a lecturer in London a few years ago with a guy called Frank Spear he came and he gave a lecture and i just sat there and i thought if I’d met him 20 years ago i would have done his course and i would have been you know a restorative specialist or something like that you know what i mean and so it’s just it just depends on whoever
[Jaz] Frank Spear is like you know god’s status in this podcast
[Amit] But you see i never heard of him until then and i thought i like this guy you know he’s amazing and you know the same time there was other other people who spoke there and some well-known people that you’ll know and they just did not impress me in this life but he did. He just simplified occlusion and and cosmetic dentistry and there’s all these other people talking about it in a very complicated way and i thought no but he was very good and maybe because he had age on his side and you know he wasn’t you know hasn’t had got anything to prove or something like that but it was good but going back to the reason why I did perio so I met this endodontist and then they took me out for dinner Endodontist, Periodontist and they sort of said i said right i’m not sure i think i’m going to become a specialist because at that point the specialist training pathways were put forwards and the register was already set up at that point just like a year before and so the periodontist said ‘are you good with the scalpel?’ said I’m all right with a scalpel because i did loads of oral surgery right and he says well then do perio and that was the only reason why I did Perio no other reason so then i rocked up at Guys in St Thomas’s for my interview and like i said before my interviews are really bad right and that was one of my worst interviews ever. So my CV said you know Maxfacts, SHO here you know there or whatever and he’d done this publications and all this sort of rubbish and the restorative guy there I’m not going to mention his name who i dislike quite strongly and he knows how i feel about him because I’ve had a conversation with him
[Jaz] Maybe he’s the same guy I dislike, actually we’d love to have the chat about. We’ll have a little chat about who that is after the podcast ends to see if he’s a mutual person that we dislike
[Amit] He’s a very prominent individual and he will now walk the opposite way because he knows I’m not going to take any conversation from him but so he sort of said so your CV says you should be doing Maxfacts and I’m like yes but I’m making an informed decision because i want to do i said you know i really enjoyed dentistry and you just wouldn’t give it in and I wanted to turn and say do you realize that i have a place at medical school and you never did so (beep sound) I had to keep my mouth shut you know what i mean which is fortunately they did turn around I mean the the head of department turn and says you know essentially we’re going to offer you a place because you’re the only British candidate and so I got in otherwise there’s no way on this planet it’s so competitive you know there’s so many you’ve heard of all these some of these on social media
[Jaz] You’re being way too harsh on yourself i mean getting way too harsh yourself
[Amit] No, it’s the truth it’s honest truth because you know there’s all these social media periodontists and and you know they have you know they have worked very hard they’re very very you know academic and and you know they’ve got there because you know they’ve ticked all the right boxes there’s no way you know if I applied against them I would get in you know what I mean but what’s funny is that someone will ask me saying you must have been a a-star student or whatever it is and I’m like no really I just scraped through you know and it’s a really really bad story because essentially when I did the first year so I deferred medicine for one year really and that was a that was just because i was trying to play the odds you know and I did the first year and it was I was just we were just cleaning teeth and i was thinking this is what am i doing this for for another four years? So then a really good lecturer his name is Dr City, Allen City, he works on Portland place in Central London and I just said to him listen, I have I’m thinking about dropping this course and going back to leasing to finish just doing medicine and do Maxfacts and he goes listen have it come to my practice and see what I do.
So I just rocked up at his practice on a on a monday morning and it was it was so good you know he sort of you know yes you know we clean teeth but he showed me bilateral sinus lifts and he let me you know assist in them quite significantly more than you know you know as in I would do the lifts and he’d do block grafts and all this sort of stuff he did so much in that day and I thought actually this is really good this is lots of surgery that would keep me interested and then i just turned down the place of medical school and carried on with perio really and I’ve never regretted it you know. I’ve really enjoyed it and what I’ve learned
[Jaz] That’s really cool that Allen City that he almost took you under his wing right he almost took his ring and and he if it wasn’t for him you you may have dropped out that perio program so i think sometimes to identify these individuals in your career to trajectory whatever you end up doing and and they sort of swing you and they and they take you and they really change the course of your career so i think it’s great that you’ve identified someone like that and it’s great that he’s part of your story
[Amit] Yeah, he was, you know, he’s such a good friend and you know I always used to ask him for advice and stuff and whenever you know if I’m in London I’ll go and knock on the store i just love hanging around with him because again he was just enthusiastic but he helped me make a good decision you know it wasn’t because i mean for example if i was doing i mean I’m 48 years old now right, I’m 49 gonna be 49 soon but essentially you know i would be a maxillofacial consultant at this age right and i would have probably been a consultant by the age of 44 and you know i would have been anywhere in the country and then I’d be working with it within the NHS constraints because essentially you can’t have so many specialties doing head and neck cancer. You can’t have plastics, ENT and Maxfacts in the same hospital doing the same sort of surgery so you know the funding is reduced. So it’s like you’re so highly trained and then i might be just taking out wisdom teeth or fixing fractured jaws which is not an issue you know but you know I’m really happy and actually what’s been good you know talking about you know people who’ve you know helped me guide me in a really good way because there’s another individual. So when I came to Birmingham Prof Chapple. Iain Chapple offered me a job working there because I had no work you know just trying to you know but Birmingham is very NHS there’s very few specialists here to be honest there’s only three periodontists in the city and you can see why because most the specialty training is in London so you’re to build a network there and you’d stay there and so Prof Chapple, who is just an exceptional individual you know two years ago he won the best scientist award in the world you know that’s pretty impressive you know what i mean and so he’s taking me under his wing and he sort of let me do what i want and he you know he sort of because of him, I’ve been able to get onto the international circuit, Lecturing circuit, you know because he’s part of the EFP, the European Federation of Perio and I’ve lectured twice at Euro Perio where we get like 13 and a half, 14 000 people at that event once every three years. So it’s because of him that you know maybe you know my name’s a little bit more prominent I’d say yeah but going back to the Perio training.
[Jaz] That’s great it’s it speaks volumes about you as well Amit but it does speak volumes about you the fact that Iain Chapple, Prof Iain Chapple, I mean what a huge name in the world of Perio and you know he saw something he knew that he liked. So there there is a lot to be said about that my friend so that’s awesome yeah please do tell us because because what this episode is evolving into is your journey which is important and i like that and so tell us a little bit more about your journey and then I’m going out to the more clinical bits so this episode will have almost two arms, the journey part which will be really useful inspirational for a lot of people and then when i get to the nitty-gritty of recession
[Amit] Yeah, okay cool, so going back to the Perio side about it so you know i did the four years and the training I’ve got to be honest the training within the UK maybe it’s changed now i don’t know but it was quite limited in my mind because you know I looked you know you look at all the colleagues around the world doing so much more and it was like it was very limited I’m not sure why it was limited but I mean in four years i placed only 13 implants and that’s not very good for someone who’s coming as a specialist you see so so obviously when i came out i knew my limitations i didn’t you know just because i had the word specialist didn’t mean i was going to be you know thinking I’m the best and that’s you know and still not it’s not the case. So i went and then sought out other dentists around the country there’s like a friend of mine called Paul Stone, who’s an exceptional implant dentist I’ve been watching these you know there’s some people like him and a guy called Jonathan Ziff you know placing implants and i realized actually you know these are general you know they’ve been doing it for such a long time and it built my confidence about what i could do and then i went abroad for a month to Milan with a another guy called Giulio Rasperini, he’s a professor there in periodontics and i met him at a lecture in London, i don’t know now maybe 11, 12 years ago and we hit it off really well and he then set up a course that i could attend and learned loads about periodontal regeneration because the techniques that we were taught in the UK were very limited in that and the surgical aspects of periodontal regeneration have changed massively in the last 10 years, 10, 15 years so i spent four weeks with him and became part of his research group for a bit so and that network then allowed me to
[Jaz] You doing research, Amit? Sounds very studious to me.
[Amit] It’s not they give you products you use and you have to then you know you know take the correct measurements, correct photographs, the correct surgical techniques and then they’ll be publishing that within a year or something like that yeah so yeah i still do some of that also within the practice with companies like Geistlich and i’m actually in the middle of doing one now but obviously the whole COVID situation made that slowed it down significantly but i’m going to get my friend (Julia Russellini) and his team involved in that as well now . I was working with that with the Professor in (burn) but things are just complicated now. So it’s been good it’s been good actually i’ve you know i’ve met some really lovely people on my journey.
[Jaz] Amit, should we dive into the recession aspects
[Amit] Actually can i digress again? Is that okay? So go back to my journey as you put it. One of the things because you know essentially you know when a dentist meets me they’ll say well I’ve had a few dentists when they especially when they’re a bit drunk would turn around and say how’s it going with the cleaning of your teeth and I’m like he’s going fine and you know but it doesn’t bother me in the slightest right because i do see myself in the glory you know. I have no insecurity about my what i have done, right? I don’t care about anybody else really, okay? But so going back to you know so when i lecture i still say I’m a glorified hygienist, it’s not an issue right? you know I’m quite content with what I do. So you know all the aspects that i thought was going to do all this surgery and stuff it’s not really the case because what I’m finding out is well found out early on as soon as you give the patients the right oral hygiene techniques and and the motivation you know. They fix the problem and that’s just the best fit and that’s what i enjoy about my job because essentially all I’m doing is just talking, having a laugh with my patients and just saying you know if you do this you’re going to be fine you know and okay there are cases when you need to do surgery or whatever but it’s not that often you know and what I’ve learned now that what i like about dentistry is you know the relationship that you build with the patient you know and the way you communicate with them and you know it’s just fun you know it’s you know the work isn’t hard you know it’s just there to build a relationship and you know that yourself you know and that’s what’s gonna give you longevity as a clinician isn’t it?
[Jaz] Well I bet your patients absolutely love you, Amit because you’re such a you know a likable guy, your a character who’s just so easy to talk to and the very few phone conversations we’ve had you’re just hilarious so very like straight up real. I think people are sensing that already you speak your mind and that’s exactly what i what i like about you so we could you know speak your mind about recession now because what i want to know essentially, Amit and feel free to tell me I’m an idiot and that I’ve been doing it wrong is that i come across a recession a lot. General practitioners we see in our patients, right? And it’s this mentality that we have sometimes that A) you know what it’s not painful you know Should we just watch it. Should we just watch and wait? So i think i am kind of proactive in the sense that I put it in my diagnosis I inform the patient is there i know about the Miller’s classification to some degree but i want you to just touch on that a bit later i take photos and I kind of follow it up but i feel as though because I don’t do soft tissue surgery myself and i don’t do these procedures that maybe i you know you could say that I’m doing supervised neglect so what i want to know from you is at what stage is just watching and waiting and or and just observing the recession neglectful? At what point do you think GDPs should be referring recession to periodontist?
[Amit] Okay so it’s a really good question. It’s got multiple facets hasn’t it really I mean, see the thing is if you look at all of the historical studies based on you know for recession so for example there’s a guy called Klaus Lang and he looked at you know when, how much attack, how much crystalline tissue, how much attached tissue should you have around a tooth so you can stay healthy? So he sort of came up with a number of two millimeters. Now, there are other studies that almost show that you may not need any keratinized tissue or attached tissue around a tooth because essentially it shows that yeah okay it looks like the tissue’s inflamed but they’re not right? Histologically they’re not. Okay it’s just the way they look and that was the study done by Mia Sato but but the reality is when you think about it in our own patients you know you see patients with you know a loose bit of mucosal tissue around the tooth they can’t clean it, we know that you know what i mean so all these studies are great right? But you need to look at the patient individually and think hang on, you know if they have to pull their lip right out to clean that area they’re not going to do it are they? You know so i think, so i get when i get patients referred to me for recession i mean obviously i can fix it it’s not an issue but i look at it and i think does it actually bother you and if they say, No, I’ll say right fine clean it well, if there’s a problem come back to me in a year’s time and then we’ll look at doing it, do you know what I mean? As long as there’s a lot of there’s you know there’s some band of attached tissue there
[Jaz] But sometimes patients don’t know because a patient may be referred by their general practitioner who’s concerned about the level of recession. Let’s say you have an upper molar and you notice there’s you know a four millimeter of recession and you haven’t got any attached gingiva left so you refer to periodontist. Now for you as a periodontist if the patient says look my dentist is concerned if you say that, if you ask the patient are you concerned the patient might not know what’s around the corner if they don’t have any soft tissue you know treatment i guess so. What’s the best way to communicate to a patient to find out whether it’s in their best interest to have some treatment done now or later?
[Amit] So okay so the way i look at it is so let’s say you’re talking about that upper sixth okay i mean we see loads of recession around up to six and they’re not always the easiest to repair, okay? But the good thing about those is they usually have a quite a good band of keratinized tissue. Now in those cases i would you know just tell them how to clean the teeth and then monitor it enough not for a long time just for like you know for six months or a year and then maybe have a look at it. I’ve got to be honest the referrals that I’ve had, the patients don’t want to have the surgery okay? Which is interesting because you know they’ve obviously been told that they’ve got a problem, they’ve got recession but they’re just thinking i don’t want to go through this hassle right? So which is fine.
But what i have noticed during lockdown I’ve had a lot more patients contacting me about their gum recession and it’s interesting because I’ll say to them if it doesn’t cause you problem that’s cool leave it alone but i think it’s only because they’re looking at themselves on these sort of platforms right and I’ve done far more mucogingival surgeries in the last six months than I have done, you know, all last year right and there’s multiple especially the ones here okay, in the lower anterior region and i think and it’s what’s interesting is you know I like you know I’m very honest with my patients i say to them listen .you’re going to have a lot of bruising while swelling after this. you won’t be able to eat hard foods or brush that area for at least three weeks because we don’t want the gums to be, you know, to be pushed down and you know it’s not that’s not a pleasant thing to go through for three weeks right but now all the patients are quite keen to go ahead with it but I’m going back to the question you sort of said how does the GDP sort of explain to the patient that this could cause a problem
[Jaz] But the urgency of it?
[Amit] Yeah, I don’t know how to word that to be honest because the thing is all around the world I mean
[Jaz] Am I carrying out supervised neglect basically because a lot of times I say what you say i say does it hurt and they say no i say ‘you know is it getting worse no but it’s significant and it’s you know it’s obvious and i’m just thinking sometimes gosh should i be referring more of these people to a periodontist now offer the referral but a lot of people like yeah can we just watch it and i say yeah i guess we could but is there a point would you say there’s a clinical point at which you know is there a number like a x millimeters of recession or whatever at which point we should be a little bit more proactive is there anything like that?
[Amit] No, I’ve got to be perfectly honest with you so there isn’t because as long as you use the classification so i mean i have had patients where we’ve got eight millimeters recession in the lower anterior okay and you know i can still fix that and i can get 100% recovery so there’s no limitation on when you do it so for example if i have a patient who wants orthodontics right? And you know Invisalign or whatever it is you know, it’s usually Invisalign and and it is usually with Invisalign where the teeth are moved out and then you get all this recession okay? So I want them to have the orthodontics first then i can come back and fix the recession defects does that make sense it’s I can do you know you can do stuff.
[Jaz] That’s good to know actually
[Amit] Yeah, you can do stuff like you know you can reshape the enamel and the root surfaces in such a way that they bring them back a little bit so then you can put a big chunk of tissue graft there and it works really really well you know. What i have had recently
[Jaz] You touched on the classification just give us a guide about these just tell us about the classification just educate us about the classification of those listening. We’re talking about miller’s here right? I guess.
[Amit] There’s lots of classifications now that’s the best that’s you know we as dentists love multiple classifications you know you look at a classification and you know you and i will use you know the tile classification which has been around for like so many years and that’s simple you know you go in through you know less less than a third or you know less than two you know all the way through and through is three and then anything in between is two but there’s multiple versions of it with different people with their classifications. So Miller is the first one and i like using that right? There are newer versions and i’m quite content with PD miller’s classification and essentially what he says is if you’ve got proximal bone in between the teeth in between the roots and if that’s higher than the recession then you’re gonna get coverage at that point does that make sense? Because you’re getting blood supply from the peaks of the bone so if you’ve got a tooth and you’ve got mid-recession, recession in the mid of the tooth but the bone peaks are higher than that you’ll be able to achieve 100% root coverage i think does that make sense okay and that’s the Miller class I.
[Jaz] No, it makes perfect sense think that’s sort of described quite well.
[Amit] And then the Miller class II essentially is the recession defect that has gone beyond the mucogingival junction which is where the band, the keratinized tissue is and then you’ve got the loose mucosal tissue and then as long as you’ve got no bone loss then you can get 100% coverage. Miller class 3 where you’ve got some bone loss between and i’ll tell you why actually in a Miller class III, you got bone loss and essentially you’ll only be able to if you’ve got two millimeters bone loss you’re only going to be able to achieve root coverage two millimeters below the cementoenamel junction so where the bone is does that make sense? So you’re only gonna you still get exposed dentine but you’ll get attached tissue in that area and a Miller class IV is technically periodontal disease because you’ve got recession that is the bone is below the level of the recession so essentially you’ve got a pocket
[Jaz] Tell us about why we can get 100% and then i’m going to tell you about a scenario with a patient i had actually
[Amit] Okay, so let me explain this to you actually because going back to you know [Julia rasporini] and some of these Italians, the techniques have you know they’ve pushed the boundaries they understand the anatomy of you know the tissues and the tissue planes and they understand what they’re trying to achieve right? So i’m a, you know, technically I’m gonna, I’m a refer, you know, a referral oral surgeon that’s why my friends call me i’m a reformed oral surgeon. So when we were ever trying to close a flap and we couldn’t get closure we just make a cut in the periosteum right okay and then you just keep slashing the hell out of it until you get closure, would you agree? that’s what you’re taught at university right? Now the problem with that is you’re making a cut that’s into muscle and when you’re cutting muscle, you’re cutting nerves, you’re cutting blood vessels and that’s why patients get tons of bruising and swelling right? So that’s what i would do on a regular basis because that’s what i was taught and even when i was doing my perio training that’s what i was taught right? And so when i was doing like say if i had an eight millimeter recession defect in the lower central and i try to currently reposition that i would never get 100% root coverage because you’ve traumatized the muscle to the point where it’s gonna shrink back significantly.
So in the last ten years there’s a guy called Massimo de Sanctis and there’s another chap called Giovanni Zucchelli. The two of them sort of looked at coronally repositioned flaps and mucogingival surgery and they proposed the technique of split, full and a split incision in the flap. Now you know it’s easy to say you know you’re splitting the tissue first and then you’re doing a full fitness flap and then you’re doing a split further on. Now this may be a bit complicated but essentially what you’re doing is you’re making an incision in the periosteum and you use a sharp blade just making a small incision in the periosteum and when you do that and unless i mean you know if you know people are listening if you’re doing any surgery on the next day or whatever it is maybe try and just have a look you make incision in the periosteum and you’ll sort of see it gape okay then you’ll see the little fibers of the muscle there so all you have to now do is you get a periosteal elevator and use the back end of it and you gently start stretching it and as you stretch it you’ll see the fibers spread so now you haven’t cut the muscles you haven’t, you’re not going to get the bruising and the swelling that you would have done if you cut the muscles and by doing that you then going to get a significant movement in the muscles sorry in the mucus or in the mucosal flap then what Giovanni Zucchelli does is then gets it then takes a scalpel and he then makes an incision a superficial incision so that the muscle separates from the mucosal tissue, right? So essentially what you then do is you know we know that the mucosal tissue is elastic so that’s going to advance all the way to the palate if you want halfway down the palate it’s amazing when you use that technique. So now utilizing these techniques i’m now able to get 100% root coverage before especially the lower anterior because of the mentalis muscle my predictability wasn’t that high and now i can guarantee my patience i get they’ll get 100% root coverage
[Jaz] Why are Italians so amazing?
[Amit] Right? I think it’s their food and their wine it.
[Jaz] Must be because honestly in every field of dentistry at the moment where it comes from when you talk about verti preps to perio to any field nowadays there’s always some italian you know thought leader or someone really progressing there you know.You’ve got your Marios and Menzers and [Macerarones] of the world and whatnot and prosthodontics as well so it’s just crazy
[Amit] I’ve got to be honest and I’m going to be very critical of you know the training we have here in the UK you know as a dental student or as a specialist trainee. You’re still being trained within the national health service right? It doesn’t mean you’re going to be good right and i think when you look at you know so for example you know i talk i do accelerated orthodontics and you make Piezo incisions into the bone you know we have patients whose teeth will move if you have an in you know orthodontics which could take two years you can do it in six months you know so you and I know majority people around the world have this done right but here in the UK you know your people will turn and say well the evidence is very weak but you know you’re choosing to find evidence to say that and it’s like you know the truth is if you look at the evidence as well for it it’s very very good you know and I’m definitely not in the camp where i want to limit myself to not give my patients all the best options.
So i think when you look at the Italians I think their litigation rate is significantly low you know the patients trust their dentists massively and so they just push the boundaries and you know and if it wasn’t for people like you know the Italians or some of the, there’s another guy called Istvan Urban, he’s a hungarian you know all these people pushing the boundaries you know we won’t be using these new techniques but yet you know people are bringing them here going look what i can do and actually it was done about 10, 15 years ago you know. So it’s for me very few
[Jaz] Two great points there, Amit. One being the training and I think that’ll be a bitter pill to swallow for many people but i think you’re being very real and i respect that and i can see where you’re coming from with the training that is present undermined within this national health system and i completely respect that but the other thing is that dentists in other countries where they’re less regulated they can be and i don’t want to use this term by will a bit more gung-ho but I mean that in the sincerest way right they can do something wanting to do the best for that patient but not worrying about oh but if it goes wrong then this is the end of my career. They can do something to advance, science advanced dentistry and to for the benefit of that patient without worrying about the potential repercussions so for example when i moved to Singapore I actually, I did feel as though this massive weight had been lifted over my shoulders and i can just push my own boundaries a little bit. So wisdom teeth for me, surgicals I gained so much more confidence because i wasn’t it’s like i broke away from the shackles of the GDC for that time which is i think it’s wow i didn’t you know you really raised a great point there
[Amit] Yeah, so let’s see that’s it see this is the problem you know you know so there’s a is it Frank Herbert, he wrote the book ‘Dune’. I’ve read that and the most important thing that i that was good in that book was you know fear is the mind killer right and it is this is the problem you know you meet all these young qualif- young dentists just qualified and they’re all you know you speak to these VTs and or they call VTs or foundation dentists or whatever it is but i like to them on a regular basis but and then you sort of ask maybe 15 of them and seven of them say they want to get out of the profession it’s because they’re worried about being sued and they’re worried about being struck off by the GDC and it’s like you know when did that happen and you know it’s really bad you know and you’re right about gung-ho you know we know there are some rubbish clinicians out there who will you know try to find a technique and sell it to you but you know fortunately you know people like yourself and myself we know who are the right ones. We want to affiliate ourselves with and you can see they’re showing consistent results you know so but i think here in the UK. Are we pushing the boundaries here? The answer is no, right? And you’re right about the bitter pill to swallow you know if i was a trainee and you know people will say oh i met you know he’s talking again and but you know what i don’t care because I was i did the same thing and i saw the limitations now the problem is they need to justify that you know what they’re doing. I don’t have never had to do it you know I’ve just been plotting along i mean if i had a real plan i would have taken over the whole world you know but I’m just like yeah I’ll just give this a go, I’ll do this whatever you know but i think the sooner..
[Jaz] One thing that leads to..
[Amit] The better really then you can you know like you said get away from the shackles and just become you know better than you want you know better than you are now do you know what I mean?
[Jaz] That’s fantastic and what i want to know now is it leads very nicely to GDPs now doing soft tissue surgery perhaps to do some recession coverage. So i know that in other countries gdps have been upskilled to do soft tissue surgery whereas in the UK because of all the things that we said about litigation and stuff in fact i’m not gonna name him but this fantastic truly brilliant dentist in Yorkshire, I believe he unfortunately had a GDC hearing about a perio surgical case that he was doing actually and it was so sad to see that he was going through it because he was truly remarkable GDP but then you may know who i’m thinking of we’ll again we’ll chat at the end about who this person is really great dentist and then unfortunately he fell short because he wasn’t a specialist you know it was almost felt as though he overstepped the line. So where do you see the role of GDPs and doing perio surgery is that, do we have a place in that?
[Amit] See the thing is i don’t ever read any of the GDC newsletters to send me. So i’m not in no so i don’t know what goes on only because you know but you know it’s just not you know but so when i’m teaching so i teach you know GDPs on how to do root coverage and does do many of them go and do it, no, right? But i do tell them you know you should try to do this you know and the way i look at it and i have and i’ve got to be honest right so again when i came out of Guys i did 12 root coverage procedures after four years that’s not good enough right? Okay so and there were others in my year that had done, okay?
So going back to that so what i the way i worked my way around that was to say to a patient listen we’re gonna do this procedure and we’re gonna try to improve the quality of the tissue here okay and so that you know it’ll be easier to brush and that’s what that’s essentially what we’re trying to do right now I’m not going to say to my patient I’m going to get 100 coverage because you know especially when i haven’t done that many does that make sense and you know even now when i talk to my own patients i say you know i say the same thing so we’re gonna try to improve the quality tissue and we’re gonna try to cover as much as we can and see what happens you know and it just i want to play down my patient’s expectations but if i can then do better then it’s sorted but that’s a real shame about this individual because i do think dentists should do it right because if you think about this dentists are replacing implants right? They’re doing a surgical procedure and they’re doing something that’s even more complicated well not really but it’s still complicated and you know so why not try to use these techniques as well do you know what i mean but don’t over you know and the way i also when i’m explaining to my the delegates who on the courses i say to them you know ‘do on a case where it’s not an aesthetic issue so it’s only going to get better. ‘So when you’re doing these sort of root coverage procedures one of the most important thing is you can’t technically mess it up, okay? Because you’re putting soft tissue on the gum next to the tooth and if you cover it up nicely it should work and if it doesn’t if get some shrinkage of the flap you’re still going to get more root coverage than you had before does that make sense?
So that sort of gave me confidence thinking okay i can do more of this and when i was doing these at the beginning you know you know even up to even five years ago I’d be charging a couple hundred pounds to do a two hour procedure two or three hour procedure you know and even now you know when i see patients that i want to do on i’m gonna charge them like the same price because i really want to do it you know. It’s not a massive issue i just like keeping my skill set up really. Yeah so going back to the case. Sorry i do think dentists should be doing these sort of procedures really i mean you know within their remit you know this if they don’t you know if they’re doing recession from six to six then maybe you should get a little bit more experience in it but you know if you’re doing the odd one you know it’s not an issue especially if it’s part of a cosmetic case you know if you’ve got, you know, I mean how many dentists are doing crown lengthening right? So if you’re doing crown lengthening you know then you could do some root coverage procedures and actually the way i look at it is you know when i call when i went to university in 1992 you know dentists came out when they qualified back then before i did they were doing perio surgery, they were doing free gingival graphs, they were doing you know really difficult wisdom tooth. They’re doing such complex restorative work and now it’s sort of almost limiting what a dentist can do and that’s a real shame really i think you know why spend five years at university when you could just do
[Jaz] Massive shame
[Amit] Yeah it is a real shame and i think you know young dentists
[Jaz] And i think the fact that you’re encouraging GDPs to do soft tissue is like it adds a you know variety is the spice of life it’s the same in our careers as GDPs if you can do if you can dabble in a few other things safely and i like what you said there you know choose the easier cases and build up so i think that’s definitely food for thought for any dentist out there who thinks that is beyond their scope i think you know a bit of root coverage once you have the training should be within any one scope and certainly I’ve seen loads of GDPs you know university or Facebook nowadays sharing their cases which is the beauty of social media. We get to see humble GDPs and specialists and whatnot share their cases and you we get inspired from what other GDPs are doing especially in other countries so i think we can definitely take a leave from their book but i mean because in the interest of time two main questions left now two main questions. One is when you have that patient who’s been referred to you and you’ve had that sort of conversation and the patient really doesn’t want to have anything done because quite often they don’t want to have anything done right like you said and you’re happy to monitor it. What advice are you giving them to prevent their recession from getting worse? What’s the blanket advice that you would give it would be really nice to know?
[Amit] Yeah so that’s just the same as everything in perio for me so you know we get the patient to, so in my practice i get my patient only to use an oral b electric toothbrush okay the circular headed one and you know if and i show them how to use it in a particular way so that they can’t cause any more recession okay and i think the problem is with dent with with patients is they usually try to hold a toothbrush in their fist right so they scrub away and we know that you know you know there’s multiple risk fact, you know multiple causes of recession and one of them is over self brushing and i do think i mean let me ask you, how do you hold a toothbrush?
[Jaz] I do hold it with the fist grip but I, you know, i’ve got the sensor, I use oral B i’ve got a sensor so i’m not you know going beyond the red center right?
[Amit] It means nothing you see the problem is you’re still holding in your fist. Now can you write with your fist, you can’t, can you?
[Amit] So would you drill a tooth with your fist? you drill that you drill a tube like this don’t you? and this is why i tell my patients when they brush the teeth you do each tooth individually painting each tooth where the gum line meets and think about exactly where each tooth meets does that make sense and it’s always a vertical action and then you can use your left hand to get in the lingual aspects whatever you need to because then there’s more dexterity does that make sense and that’s the most important thing information. Use the oralB toothbrush correctly like a pencil and paint each tooth individually and that’ll maintain everything but all my patients will use interdental brushes because when we look at all the evidence which is now about six years and i looked up all the systematic reviews and they showed that essentially we should be using interdental brushes because we’re not very good at flossing and that’s it really. So if they do that i can monitor it, take a nice photograph, see the patient six months a year and if nothing has changed then you know then we’re good but if they’re complaining of sensitivity or whatever then we can you know get them to use a desensitizing toothpaste on it or you might then perform mucogingival surgery to achieve root coverage
[Jaz] Brilliant! The next one is as a patient-specific one. I want you to throw this scenario at you and the listeners there’s a patient i had who had periodontal disease and this would be something like a 3c right with the under the new classification for those listening there were pockets of around about let’s say five six millimeters anteriorly there was inflammation and i consented the patient i said look if we start improving your oral hygiene obviously first and then we will start doing some non-surgical periodontal treatment you will get recession because all this gum that I show in the photo is is almost like a diseased fake gum this has got to go you know you’ve lost it this is this is bad, this is going to go you’re going to get recession and then for that reason the patient funnily enough denied treatment she was no longer wanting to have non-surgical periodontal treatment and i said to her well this is in the old saying right it’s better to be long in a tooth and have a tooth no longer but yeah but how can you, the question I’m trying to get to, is how can you set realistic expectations to patients about what kind of aesthetic complications they will or compromise they will get after periodontal therapy?
[Amit] Okay so that’s, it’s a really good question and i also like the way you just said that you know better to be long in the tooth then tooth no more so that’s good but so one of the things. So if you think about this right so when i when i become a periodontist you know all i was teaching people was how to brush your teeth right and that’s not easy is it because you know the patient when i used to try to do that the patient says you know would make a complaint that i wanted the filling and I’ve not had a filling. Well they didn’t need a filling they’ve got periodontal problems all right so I’ve sort of learned to work things differently without being offensive do you know what i mean because the guy would you know the patient would say well this young up starts trying to teach me to brush my teeth you know so and one thing that i so for example i ended up having to do the Ashley Latter course okay not because i wanted to do it right? I had really good friends implant dentists that do it on a regular basis you know friends like Bill Schaeffer and Stephen Jacobs and bill Paul Stone. They did it on a regular basis and they said i meant you need to do this and my girlfriend was saying you need to do this course because you don’t you haven’t got a clue how to make any money right? So i did the course and i learned from that in the way you need to communicate with the patient but someone like you, Jaz right you know how to communicate with the patient and get the best out of the patient do you know what I mean? Whereas i don’t think many dentists understand that so i obviously Debatable, i mean it’s very kind of you’d say i’m still always improving Yeah, i think you do i mean when i talk to you on the phone and just sensed and you know i can sense the way you are but so for example when i have a patient they’ve been referred to me and they have the same sort of problems as your patients have and I’ve had patients like your patients who never come back and see me all, right? The most important thing here is that you’ve written your notes down and you’ve told them they’ve got a problem that’s it you’ve done your job right? So that’s the most important thing the the take-home message for all anybody listen to this you’ve written your notes down, you’ve told them the score and that’s the end of it you’re telling losing you know if you’re not going to have periodontal treatment you’re going to have increased recession, increased sensitivity to your teeth and that’s it.
Now going back to after Ashley Latter’s course what i learned was i had to find something positive to say about a patient. You see the problem is as dentists when the patient comes and sees you the first thing they’ll say oh you’re going to tell me i’ve got bad teeth you’ll tell me i ate too much chocolate and then all you know the same old rubbish that we’re supposed to talk about right and so when a patient comes and says to me oh you’ll say that i drink too much i say listen it doesn’t have an impact on your periodontal problems i’m not fussed right it’s your decision right? so that’s fine right a patient says to me they smoke 20 a day i said well let me let me just tell you once i want to say once only smoking increase your risk of periodontal problems and if you even there’s evidence shown that if you cut down that improves things and even if you decided to vape you’d be able to give up and i give them the spiel and i said but it is your choice i will still help you know what i mean i think the more you inform the patient and treat them like a human being so when it comes to these cases where they’ve got a huge amount of periodontal problems and you’re going to cause massive aesthetic issues and i do that to all my patients right? so what I’ll be saying to them is listen all right I’m not i let me apologize first I’m not here to patronize you so i do apologize so what’s the first thing that patience says to me?
[Jaz] I don’t know i mean i like where this is going because you’re starting off with the setting they’re setting a really nice comfortable environment right you know you’re saying a comfortable environment here for the patient
[Amit] Yeah but Jaz if I turn around and said to you so listen you know you know let me apologize to you know everything i want to say to you is going to come across patronizing so i must you know so please forgive me i apologize what are you going to say to me?
[Jaz] I’m saying oh no that’s fine carry on.
[Amit] There you go you’ve given me permission you’re giving me permission haven’t you now to almost go for the kill right and then i will say to my patients in a way
[Jaz] Oh this is brilliant i’m so glad you mentioned this because here’s something that I do, Amit and I think you’ll like this a lot actually is when i see patients with with suboptimal oral hygiene right and and this this is definitely something that we’re both doing now i realize is you have to you know if you keep banging on like a broken record like oh you need to do this you need to do that it’s too negative so just like what you do I you know you say that’s your way of getting permission I’m very direct I actually say hey can i have your permission to just show you a couple of areas where if we can improve then I’ll be so much happier and your gums will look amazing that’s why i say i said can i get you i literally say can i with your with your permission with your kind permission whatever and i show in the mirror and i find i get such better results when i instead of saying look you need to brush back here is that hey can i get can would you like to for me to show you can i get your permission and just like what you said it’s so much more powerful
[Amit] It is and this is and this is one thing that works really well you know something I’m not here to blow my own horn or trumpet or whatever but essentially you know something i have a referral practice and my perio uptake is like 98 okay now obviously the dentist done the hard job saying listen you need to see Amit he’s going to help you and then I’ve had to you know convert that so it’s obviously easier right so going back to this this this the way i speak to my patients I’ll say you know but you know we have many patients like you right that have the same problem and I’ve been able to help them so you’ve been positive about it right then I’ll be saying well the only negative is you know we have you know because we have we essentially have this much pocket right and the gum is going to shrink back so i say you know you have a tent. If you have a tent standing on the on grass the tent poles are much further down we need to push the temp down and they’re like they understand the concept of the disease that way and then I’ll say to them you know so the negatives are that you’ll get recession and you’ll also have sensitive teeth but the most important thing is you’ll be able to keep your teeth for many years to come so then you’ve been positive at it you’re ending it with a positive right and majority of my patients I’m happy to have that done and then if i and i think one thing that really works for me is to give them a story you know just like you would you know you I’ll say well listen but my mom has really long looking teeth she’s a smoker smoking from the age of 14 you know and you know even she’s got a recession of a tea around you know the gums and she’s got sensitivity of her teeth and i say well you know it took her six to nine months before she could eat you know an ice cream but she did all these things.
So she’s sort of sort of saying well i did that same thing to my mom so they understand that you know this is part of the process so i think that’s the way that’s the way I give with the aesthetic concerns explain it to them and i always explain look our aim is to keep your teeth for many years to come. That’s the main aim, you know, and that’s what they want to hear and i think that works quite well i mean so if for example if aesthetics is a massive issue they’ll find out at a later date you know because you know i can show them photos of what it can look like but i don’t do that anymore at all just say look we can do this for you and and they’ll go for it but if aesthetics is an issue you know you can make gingival with veneers you know to close up some of the gaps and they work really well. The good ones are ones that are made by it’s a german material called mol plus but val plus is not a good material or acrylic is not good but here in the UK then i don’t think there are anybody making them at this point in time anymore but go back to recession what we can do now it’s so difficult to make and quite costly for the labs to make and it wasn’t profitable so but going back to recession you know so these kind of cases you know they’ll have loads of recession around all their teeth what we now can do because there’s a lot of clinicians out there.
So there’s individuals like [Pat Allen] and who else [Sofia Rocker] as well as [Tony Schoolian] these are all periodontists. So Sophia’s from Paris. Tony’s from Burn university and Pat Allen’s from Dallas Texas and essentially what you can do is you can utilize this thing called [telling] technique all right? So where we are making an incision just in the gingival crevice around each of these teeth and then you’re sliding a connected tissue graft through all of them or maybe a you know another kind of material that you can you can buy off the shelf and essentially what you’re doing is you’re bulking the whole area up and you suture it back up and in time you get some creep back right yes you don’t get pocket formation but you get some creep back and then the aesthetics improve a little bit you know so we’ve i’ve done quite a few of those kind of cases and the patients are really happy with those results they still look like they’ve got periodontal problems but they’ve got a lot more bulk of tissue. So there’s less black triangles.
So perio has changed quite significantly and it’s going to change you know when you because what’s interesting is you know again talking about the Italians they’re utilizing these enamel matrix proteins it’s called (Endogame) and they’re regenerating bone in areas where you think you could never do you’d be taking a tooth upon an implant but the techniques there’s a guy called (Sandra Cortellini) he’s exceptional you know and again he’s going to be lecturing at the congress showing some cases where the teeth are like there’s nothing holding them in the mouth but he’s just splinted them whacked in some materials and it’s just amazing, I’ll send you that video so I’ll try I’ll send it to you right we transfer so you can watch it it’s amazing clinician he’s a good man as well again through what
[Jaz] If there’s any resources you have to share but you know for their ADI or these future congresses and whatnot second one I’ll put them on the protrusive dental community and the website but amit thanks so much for for sharing the in the first half your journey because i think that’s gonna inspire a lot of young dentists who are thinking should I specialize, should i not and i think they’ll take a lot of encouragement to know that hey if they didn’t finish at the top of their class at dental school or they’re just not sure or they’re not enjoying a certain part of that course but the the value of finding someone who can inspire you and then of course we talked about the the recession and the clinical bits but then i think particularly what i think the listeners find valuable a lot of time is the communication gems and i think the whole thing about asking for permission and remaining positive especially in perio. When it comes to perio where you’re always you know almost just blaming the patient trying to be non-judgmental it’s going to be massive so i think we’ve gained a lot from our chat today. So it’s always a pleasure to speak to you any last words, my friend?
[Amit] One thing you just brought up is you know should you become a specialist and I’ve thought about this so when i qualified in 2005 and i met all these implant dentists and and what i realize is you don’t need to be a specialist yeah you need so you look at you right for example you know you’re not you know you i don’t know if you’re going to be a specialist or whatever you know it’s fine but you know you have such an interest within a certain aspect of dentistry so people around you will refer you cases because they’ll think hang on Jaz can fix this right and i think that’s what i learned when i qualified is that if you are good at one aspect and if you’re in a nice area you know dentists in locality will think hang on this is the individual who know who can do it don’t you can have a special interest so being a specialist i don’t think is the be-all and end-all right? I think if you had a special interest in endo perio or restorative, you build up a portfolio cases you can send newsletters out to local dentists, give them lectures or whatever it is and then slowly you’ll get a referral base and i think that that is i think is the future really i mean i’m talking myself out of business right but end of the day i think general dentist i think is a good think.
[Jaz] I think that’s really inspirational what he said then I expected no less i expected a real talk from you and i think that’s definitely what we got today Amit so thank you so much for being so real, for being so giving and being so blunt that’s the best way to be and honestly we really appreciate that all the best for 2021 and well you know obviously stay in touch my friend thank you.
[Amit] Yeah definitely thank you, Jaz it’s been pleasure and it’s been fun.
Jaz’s Outro: So there we have it guys I hope you enjoyed that and now you can approach recession with a little bit more confidence and assurance that you’re doing the right thing. Next month August is all about back to basics. I’m not going to spoil exactly what we’re doing and all the guests are having one but essentially a lot of you requested this you wanted something just you know you wanted something just foundational you wanted something really really basic so I’ve covered a lot of basic themes like for example when is an amalgam truly failed like long-standing amalgams when should you actually cut into them or what is involved in a comprehensive examination and how do you do one. So all these themes we’re gonna cover in August which is back to basics month. Catch me then guys and I’ll see you soon you.