Relapse, Retention and Compliance – Orthodontics Medico-Legal Perspectives – GF023

[Shivani]
But another thing that we do at our practices, when we have complaint cases, we always have two clinicians in the room, and I think that sometimes dampens that defensive, especially for the clinician that is at question. And then you do have another clinician with another set of eyes is looking at the scenario completely unbiased and patients value that.

Jaz’s Introduction:
We’ve got three real world orthodontic scenarios that have the theme of communication and medicolegal considerations. For example, that patient that complains that their lateral incisor has rotated and they’re upset and you need to figure out is it ’cause they haven’t worn their retainer? Or the retention has let you down, and what kind of soft skills do you need to have to pacify this scenario?

The second scenario is one that we’ve all faced, that patient that just has terrible compliance with their aligners and they need a whole set of 14, for example, again, and they’re upset because this was only supposed to take a year, and now we’re on year three. Why? Because of the patient’s crappy compliance.

But how do you handle this scenario when the patient is upset both clinically and the medical-legal perspectives? And finally the very saucy and difficult scenario three of an associate leaving a practice and leaving behind some patients who need their orthodontic cases finishing off. This is a really stressful scenario when you have to take over someone else’s orthodontic cases and the medico-legal challenges that this brings.

So I’m pleased to be joined today by Dr. Shivani Patel and Dr. Neil Jaiswal. Shivani is a specialist orthodontist. She’s a consultant in private practice, and Neil Jaiswal is our resident medico-legal guy. He’s a dentist as well, and it’s just great to have his medical legal perspectives as a representative of professional dental indemnity.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the group function series where we come together to tackle real world scenarios. Whilst this episode has got clinical gems. We also cover so much about communication and the medico-legal perspective. So it really is a triple threat of an episode, which is eligible for CPD.

And of course we are a PACE approved provider. So whether you want CPD or CE, we’ve got you covered. Let’s now join the main interview and I’ll catch you in the outro.

Main Episode:
Doctors Shivani Patel and Dr. Neel Jaiswal. Thank you so much for joining us. Neel, a veteran, you are like the medico-legal, like you have an angel and a devil on each shoulder. You’re like my angel. This always gives me good advice. Shivani. I’m hoping you’re not gonna definitely not fulfill the role of devil today because you are another angel, orthodontic angel and basically your job today is to discuss some really tough topics that are hard hitting, but they’re very real world issues.

We’ve got some really great scenarios, and your specialist opinion and input is gonna be so valuable. There’s gonna be clinical gems in here in terms of learning about relapse and success rates, but also how to manage those tough scenarios from a communication and management perspective. Now, for those who haven’t come across you before Shivani, tell us about yourself as a specialist, orthotist, and all the various hats that you wear.

[Shivani]
Thank you Jaz, for this invitation and nice to see you, Neel. I’m Shivani Patel. I am a specialist orthodontist, born and brought up in Kenya. So I have an East African background and I came here as an international student, so I did all my training at Guy’s Hospital, which was at that time known as UMDS, so that was a long time ago.

And then worked through the ropes of VT, MaxFax community. Did my orthodontic training at the Royal London Hospital, and then went on to do my consultant training at the Queen Victoria Hospital and my cleft training at Guy’s. So that’s my background. So being in hospital for quite a long time, continued working in hospital with John Radcliffe, and then ventured off to do private orthodontics when orthodontics was quite threatened in the hospital setting when you know the government is thinking that orthodontics, even though it’s maxfax is considered cosmetic. 

Since then, having looked back, I left the hospital setting about 16 years ago and been purely private. I’ve only worked for myself, so I think I’m unemployable now and always worked in partnership in my practices, so, based in London and Wimple Street, so that’s 11. We were also in Henley and now very newly based at Parkland Orthodontics in Reading. 

[Jaz]
Literally down the road from me, where I work as an associate. So we must catch up in person as well. Neel, thanks so much for joining us again. For those who haven’t listened yet to a really popular episode, we did Indemnity versus Insurance.

What’s the difference? You covered that really well. You gave us great analogies to actually understand that very confusing topic. Just remind those who haven’t had any interaction with you yet, and to listen back to the episodes we covered other scenarios like, pain after a crown fit, a patient that doesn’t like their veneers, implants that don’t quite go to plan.

So these medico-legal episodes have been really quite popular. But Neel, remind us about you and your journey and your passions. 

[Neel]
Yeah. Thank you Jaz, for having me as always. I am a private practitioner. I’ve got my own practice, Neel Dentistry. It’s about 12, 13 years now. Before that, as an NHS practitioner worked in Australia, did house jobs, max fax, everything.

So I think I had a good broad spectrum of background, but what really sort of kicked me up a notch was going to Frank Spear in Arizona and doing quite a lot of those courses. And that really elevated me. And since then, we’ve always had an orthodontist in the practice because you were saying, Shivani, it’s cosmetic.

It’s definitely not cosmetic. We know that. So any treatment we do has to be functional, long lasting, and ortho is such a huge cornerstone for that. So we’ve always had either an orthodontist or associates doing ortho. So really crucial. And then probably about six, seven years ago now. I sort of fell into helping some insurers with their product and we formed Professional Dental Indemnity, nearly 500 clients now, so that’s quite good considering it’s just me and Gary really.

But with support from people like Jaz and friends and family and peers and Facebook. We’ve just grown by word of mouth really. And as Jaz was alluding to the podcasts that we’ve done with Jaz, to be honest, it’s not really me, it’s the other guests. So entertaining and informative and educated. So anyone I would really suggest you go back and look at those videos of Jaz intimated. 

[Jaz]
Your angelic voice and experience of dealing with so many clients who come to you looking for advice and this scenario you’ve seen before, is very valuable, including today. So let’s go ahead and hit that first scenario.

We’ve got three scenarios. If time permits, we shall cover. The third one being the most challenging. The first one’s quite more clinical. Second one’s more about a complaint handling and third one’s like, okay, an orthodontist is gone and another one comes in, and that kind of dilemma that creates.

So giving you a flavor. So you guys stick around, but the first one is, I’ll read out the scenario, but then actually we’ll just get into like, the TLDR version, which is Mrs. Jones had successful orthodontics done in your practice two years ago. So it’s been two years, she’s probably been discharged and being looked after by GDP or if you are the GDP, you’re seeing this patient for checkups. And then when she attends her routine exam and hygiene, she complains that her upper right lateral incisor is now rotated. Okay. She claimed that she’s wearing the retainers every night okay. But is unhappy with this relapse, which is understandable.

We pay for orthodontics. We want a smile and we wanna maintain that smile. And then she is suggesting legal ramifications and she wants to know what the costs involved are, and she just wants to get this fixed. Okay, so the TLDR is, there’s relapse, there’s rotation. And the first thing to point out, I guess clinically, I’m doing this, she knows it already, but for the benefit of everyone.

Rotations in general are a tricky movement. I was always taught to treat rotations early and they are one of the highest to relapse along with diastemas and stuff as well. So just give us a clinical perspective, Shivani, on what are the different high risk movements that are at risk of relapse?

[Shivani]
So you’re actually right, Jaz. Rotated teeth are one of the high risk movements. Space dentition, very, very high risk movements. They almost need bonded retainers and sometimes double bonded retainers. Diastemas fall into that category as well. Extraction cases, children and adults will relapse very often, or spaces.

Small slivers of spaces will open up, periodontal cases because they don’t have much alveolar bone and gum supporting those teeth. So they do need belt and braces when it comes to retention. And then of course, complicated cases such as orthodontic surgery. Have to be retained full time, very, very well long term.

[Jaz]
You mentioned double retention, just what do you mean by double retention? 

[Shivani]
So this is what I’ve learned over the few years when I mean double wires, especially when it’s median diastemas. We’ll always run a bonded retainer three to three, but we’ll also run an additional wire one-to-one, and it’s all bonded together.

And that for me has worked because retention is absolute, and I think that’s what you have to educate your patients through continuous communication. You’re seeing your patients long enough for you to be constantly consenting and communicating with them through the whole process, whether it’s for retainers or anything active is telling them that for us and bonded retainers and removable retainers go as a pair. When I’ve tried to do one and not the other in my hands, I’ve always had some sort of movement no matter how mild or severe the case has been. So- 

[Jaz]
Well, in this case, I think, Neel, when you wrote this scenario, I think I’ll be assuming that this patient only has removal retainers based on when I’m reading the scenario again. Would you agree with that, Neel? Is that the kind of scenario we’re going for? 

[Neel]
I think having seen a lot of these cases come through, it’s either removal retainers only, and there is a bit of give in the retainers, but also they’ve had a fixed wire as well, so there may have been. The wires snapped that they don’t realize. So it can be both. Would you agree, Shivani? 

[Shivani]
Agree. It could be anything. I think the important thing, I think with any complaint first to start off with, rather than diving into the clinical, is to show that overall empathy, perhaps they’ve already mentioned this at reception. And that’s where the empathy starts to prevent this from escalating. I’m so sorry to hear that, Mrs. Jones. Let me see when I can fit you in Dr. Patel’s diary. So that empathy, that whole you are building that experience before it escalates to anything legal and training your staff that when there is a complaint booking in the right amount of time, this is not something that can be rushed once they’re in your chair.

I think listening to what it is inspecting, if there is a bonded retainer, is the integrity there. If they have an Essix retainer, that’s where the education comes with reception. Please bring your retainers with you so we can have a look. Inspecting the fit, looking at the wear and tear. Asking them how often they wear it because patients forget. Every night sometimes means once a night or less than four nights, and that’s where we start seeing the movement.

[Jaz]
Is there any quick way, Shivani, before we continue that, when someone says they’ve been wearing their retainer every night, let’s say it’s a removable retainer, is there any clinically accepted way to validate? 

[Shivani]
How comfortable are they with taking it in and out? The wear and tear on those retainers, they will be worn, especially adults. You’ll start to see cracks or even, because generally majority of them are grinders, you’ll start to see cracks at distal of the sevens. Sometimes the canines have little pinpoint holes on them, so those are telltale signs that they are actually wearing them, and of course, the way they fit. They fit very well.

They’re not looking brand new as if they just come from the lab and nobody’s actually put them in the mouth. So there are a few telltale signs. Also, you can gauge compliance because remember, you’ve seen these patients over months, so you know your compliant patients, the ones that wore the elastics, the one that turned up on their appointments, they wore their aligners.

So you can gauge that as well. The thing with laterals moving is, as we said, it could be that the bonded retainers lose their integrity and the patient doesn’t know. It could be that you’ve just finished the bonded retainer at that lateral point, and this is where we’ve been learning our lessons, having been in the same practice for 15 years, as you see your cases come back, it’s too short.

It does need to be extended to the canines because as soon as you put short retainers and they stop wearing the Essix, those laterals will flare up guaranteed at some point. So it could be that, or it could be that there is absolutely nothing wrong. The patient just thinks that tooth has rotated, and that’s where photographs come into handy. Of course, at debond, it’s assumed that you are taking those records. But at our practice, which is good clinical practice for a whole year, we see our patients and retainers, because you’re enforcing, you gotta wear these retainers every night. You gotta wear these retainers every night.

So it’s at three months, six months, nine months, and we take photographs then as well. So you have a comparison and a baseline. And it could be, there’s nothing wrong. You’re like, look, it all looks great. Nothing to worry about. Or it can be, yes, I can see this tooth has moved, the bonded retainer has come away.

We have some options here. So now this is where your goodwill starts to kick in. If they’ve had aligners, then they may be in their warranty because it’s only been a year or two years. Fabulous. We are in our warranty period. How about we tidy this up, put on our bonded retainers again. And get you back to where you are.

If they’ve had fixed braces, I’m not shy of saying, let’s put on sectional. Let’s put it on. A couple of visits. We’ll derotate this, it’ll be absolutely back to where it was, and we’ll put our wires back on again. And this is the whole experience and that’s what counts because this patient may have brought three children.

She may have already sent her husband, or she’s gonna do all of that and talk about you. And that’s what counts the whole package from where the reception has booked in the way you’ve dealt with it. And it’s not a big deal in the grand scheme of things where to. 

[Jaz]
I think dentists sometimes make this a big deal. They feel like they failed massively. They take it personally. And I think retention is one of those things where, and relapse is one of those things that is kind of inevitable to, when you treat enough patients, there’ll be a small percentage from either compliance reasons or biomechanical reasons and certain movements that this will happen.

So if you don’t mind sharing this, how many patients are per year? I mean, hopefully there’s not very much, but this happens in all specialist practice, especially GDPs, I’d say. We have the odd one where we need to help out. And I think what I’ve learned in the past as well is, when this happens, you can really show your color and your patient dedication to a patient and really look after ’em. And what they will do for word of mouth, hopefully afterwards, will more than make up for the extra time and expenses that incurred by you as a clinician. 

[Shivani]
As in how many patients this year have I retreated? 

[Jaz]
Yeah, I mean, as a percentage, maybe it was, what I really wanna hear Shivani is that even specialists will be, this happens to everyone. So we’ll try and just get out to the GDPs. 

[Shivani]
Absolutely. Because remember, retention is an absolute, you can’t control the patients when they’re at home and when you’ve discharged them. I would say at the moment, I have two cases going on. But those patients, that was the time when I was finishing the retainers two to two.

And they stopped wearing their Essix. So those teeth have flared out, no issues putting on fixed four to four. We’re aligning. We’re actually debonding today. That’s goodwill because you have, they’ve come back as an orthodontist and that they’re now using other specialties. They come for checkups, they come for hygiene.

They use your periodontist. So I’m building goodwill across the board for my whole team. If I was to charge them and say, no, it’s gonna be a fee. We’re gonna charge you for an upper arch. Again, that’s gonna be very defensive on my part. 

[Jaz]
And Neel, what do you think as a medico-legal perspective, right, if we are convinced that this patient is just, the last two years in this specific scenario, it was two years. And what I encourage is, whether it’s my occlusal appliances or retainers, I say, every checkup, please bring it in. I love to inspect them. I love to see how they’re fitting. I love to see how they’re doing. So I’ve noticed that, oh, maybe Mrs. Jones is not bringing them in for every checkup. I haven’t actually seen these in a while, and now she’s complaining of this rotation. I’m convinced because there’s not enough wear on them. They don’t look rotty enough. She’s salivating a lot. She’s struggling to remove them because obviously it’s a sign that she’s not wearing them.

And I’m convinced that this is on the patient’s part. Even though at the beginning she watched my Loom video explaining how important retention is. She signed my consent form saying how important retention is. This one’s generally on the patient. And I’m upset as a practitioner to deliver good customer service ’cause I feel like I’ve been cheated here.

What do you think as a medico-legal perspective, is this something that we should perhaps say, stand our ground and therefore nothing, we are invincible because we are in the moral high ground here. What do you think? 

[Neel]
It’s a good question because you can’t think, well, I’ve done nothing wrong here. And the patient has gone remiss, we’ve given them every warning. It’s a tricky one because I think you are probably right. If the patient holds a hand, if the patient is saying to you, I’ve worn them, et cetera. Really, it’s a frank conversation and just say, look, I’m here to help you.

I want to meet you halfway with this. They really don’t look like you’ve worn them to be honest with you. You’re struggling to put them in and out. And can I just really ask, because look we’ve gotta help each other out here is have you been wearing them? And I would, if you’ve got that kinda relationship with someone that, and you’re a good communicator, I would just say, look, let’s be honest with each other and then at least we can help each other.

But if we’re not on the same page straight away, it’s gonna be more difficult for us to help you. So I would really push for honesty. And I think most patients will say, oh yeah, my dog ate them. Or I went on holiday for a few weeks. I said, well, okay, look. It’s human nature. I wouldn’t be angry at any patient, I don’t wear my retainers.

Sorry, Shivani, so don’t be angry with me. Life got in the way. So I think we always have to be human. And in that case it may be a scenario is, look, I won’t charge you for the orthodontics, but the fixed retainer is broken and there’s a normal fee for that. Your retainers, we expect ’em to last three years, you’ll need new ones.

‘Cause the teeth, so we made other ways that we can kind of not get our money back, but so to speak, we can kind of try and break even on other little bits. And meet them halfway. But I think if it was like Shivani patient where they’re a really good attender, they’ve attended the practice, you’ve got a really good history with them, I think Goodwill is better. But I can understand where you may haven’t got such a good relationship with the patient. It’s a tricky one because that’s the kind of patient that’s gonna turn on you as well.

[Jaz]
It all boils down to communication, just like you said, and also having that empathetic approach and so they actually, they generally want this clinician actually generally wants to help me and instead of having to charge the patient again, whether they’re getting a good deal here in terms of getting their teeth straightened again. And yes, there’s the maintenance part they may need to pay basically.

So, discussion tab, is that a point you think, Neel, if you’re unsure to, ’cause this was a hot topic on the Protrusive Guidance community recently, right? Should you call your indemnity stroke insurance? Because there’s a huge debate on social media at the moment, Shivani, I dunno if you’ve seen where clinicians are calling every six months they might call their indemnity and they say, hey, I had this issue.

Can I just talk through this patient with you? Get some advice and stuff. And maybe they don’t even need to. Nothing ever comes of it. And then five years later you request your letter of good standing and you see like a log of every single time you call your indemnity, right? And then suddenly the indemnity goes, hey, actually we’ve realized you’ve been calling us a lot here, and therefore we’ve now doubled your indemnity fee, right?

And so people are now thinking, hmm, should I not be calling my indemnity? So this is a little debate that’s been happening behind the scenes. Neel, what do you think, as someone who represents professional dental indemnity, do you think that these phone calls of advice should be acting against our clinicians?

[Neel]
Well, absolutely not. That’s what we pay for. We pay for advice, and I’m gonna be really honest with you. I have seen it where I’ve seen someone’s logs and they’ve recorded everything, and certain indemnifies have asked the client to leave or a new insurer won’t take them on. And I can argue the fact, look, there’s been no claims, no payouts, nothing.

They’ve just had advice. They thought they were supposed to report every little thing, denture loose, whatever. They’ve got 10, 15 things on there and the insurers go, we think one of these is gonna hit. They’re calling too much. And I’ve seen that and I’ve seen that with other indemnity files. For us, we’re part of the project sphere thing that we started, we were very much at the beginning of that, which is an initiative by department health where you can call and it’s not held against you because we think that’s safe for working practice.

So for us, if there’s no letter of complaint, if it’s something like this where a normal thing patients come in, you definitely should call us. You can talk to me if you want it off the record, and I’m happy to talk as a peer or a friend or you can talk to our brilliant legal team or dental legal advisors.

And they would be happy to speak to you because one, you look like a safe practitioner because this doesn’t happen to you very often. So what shall I do? In this case, they’d probably say, yeah, that’s great. Thanks for letting us know, and if anything does come of it. They will indemnify you because you haven’t tried to manage it or cock it up yourself too far down the line without getting some advice, because you can hinder us a lot by starting to do letters or refunds and all that kind of stuff. So I think it’s for, with PDI, you should definitely call us and you might get some good advice. 

[Shivani]
At what point do you charge them and how much do you charge them? Especially when the patient puts their hand up and says, I haven’t been so good at wearing my night time retainers. I have been a little lax.

I think you also have to put value on retreatment again. And that value could be, that’s why I’m not gonna charge you for my time, but I’m just going to charge you for the Invisalign lab fee. And I think that way, it’s a win-win for everybody. You’ve met them halfway, you’re gonna achieve what they want and they’re expecting you to get them back to where they were, but you’re putting value in not doing that next time because there is going to be a cost element in that.

The other thing about calling the indemnity team, Exactly, that’s what you’re paying them for, for their advice. But another thing that we do at our practice is when we have complaint cases, we always have two clinicians in the room. And I think that sometimes dampens that defensive, especially for the clinician that is in question.

And then you do have another clinician with another set of eyes looking at the scenario completely unbiased. And patients value that and when they have, whether it’s a partner. A senior clinician, a clinician from another specialty, or a clinician from the same specialty. Sometimes Andy and I will see patients together if he has some tricky conversations or some may pop into mind.

And I think patients value that as well to say, leave it with us. And they feel that they heard. If two people are listening, they’re like, okay, this is a big thing, they value what I have to say and what I have to complain about. And that works very often for us. And it- 

[Neel]
Could I add something? Just suggest something, maybe. I’ve had it the other way where the wife has brought the husband along. It wasn’t my case, but a principal I was dealing with. And the husband’s, a big burly, obtuse chap and I felt very intimidated. I was upset about the conversation. So if you have two clinicians and the patient walks in, some patients may feel a little bit ganged up on.

So the way I would do it, and Shivani, obviously it’s different in your practice, you are really nice people, is I would get the patient in. And say, thanks for bringing to our attention. We want all our patients to be happy. I say I live in the village. It’s really important to me that we look after you.

Do you mind if I bring one of my colleagues in as well? Because sometimes two eyes are better than one. I’ll just see if he’s free, he’s gonna be free because we’ve preempted it. But they are not like, oh, these two are trying to get out something by ganging up on me. We are trying to get another opinion because they really care about getting me fixed.

[Shivani]
Yeah, sorry. Perhaps I was like, oh, we’ll be waiting for them as they come up this discuss, I meant that, there would be an invitation to say, is it okay if you know two of us see you and see, it’s always nice to have more opinions and more options on how we can solve this for you.

Interjection:
I’m pleased to say that PDI is over five years old now. I remember the early days when people didn’t really think we could exist. It’s myself who’s a dentist who came into this to try and help dentists. Having had bad experiences with my indemnity provider previous mutual, and with Mr. Gary Monaghan, who’s an expert in insurance from set up, one of the biggest insurance companies in plastic surgery.

So we think it’s a great team and with our partners and brokers and underwriters, we’ve proven to be an excellent commodity of the last five years helping dentists. Another reason why I believe you should come and join us at PDI is that we really look after our dentists. I am a dentist. We do everything we can to support you, to make sure you get great service, the help you need, and we’re often fighting your corner.

Speaking to the principles out there, do you have vicarious liability and do you understand what you have? You may think you have it, but it could be on a discretionary basis. Do talk to us, even if it’s just for information. I’d rather you know what you have and what you need. Whether you come with us or not, I feel it’s really important for my fellow principals to understand this cover and make sure they’re comprehensively covered.

[Jaz]
This reminds me of another initiative that some practices have where they do a second opinion clinic, where if you’ve seen a dentist and you think, you know what, I’ve never been diagnosed with decay. It’s quite common when the first time a young patient in their twenties gets diagnosed with decay.

That’s the time I’ve seen before. Like, wait, hang on a minute. I’ve never needed a restoration before. Uneasy. It’s quite clear on the radiograph they need a restoration. But the patients themselves are like, I’ve never had a restoration before. I’ve never had a crown before, whatever.

And then to have a second opinion system in the clinic whereby you can see another clinician don’t pay again, but just get some reassurance and get a fresh pair of eyes is a nice thing. I’m just gonna wrap this scenario up before we go to the next one just by asking one more clinical question, Shivani, which is efficacy in terms of evidence based, right? 

There is lots of evidence where I’ve seen that saying that the fixed retainer versus remove retainer are equally as effective, right? But we have clinician experience from yourself and many other orthodontists I speak to, whereby they swear that a specific brand or fixed retainer is not as effective as another.

Or they find that when they don’t do the dual approach. They are still seeing relapse and they feel uneasy about that. How effective is a common scenario, which is just giving the patients with their retainers or just removing Essix retainers only. Okay. As a default thing that you do basically. ’cause a lot of practice.

The way they work is okay, that’s included. If you want fixed retainers, that’s extra. And so the patient says, okay, I’ll get my retainers. That’s doing the job. How effective is that overall? 

[Shivani]
I don’t think I have ever fitted a removal or retainer by itself across the board, we are all of the same school of thought. Dual retention for us in our personal experience is the way forward because at some point something is going in a good way or not worn or feeling is done. They haven’t worn their Essix. At least their smiling teeth are reasonable and bonded retainers are something that you can keep checking at checkups, even if it’s not with you.

Somebody’s looking at them, a hygienist is looking at them and she’ll comment and the composite has come away. Or the checkup dentist through their loops will be saying that doesn’t look quite right. Can you go back to your orthodontist? Whereas with removable retainers. Nobody can check compliance, wear, fit or anything.

So for me, in my personal experience, I absolutely recommend dual retention teeth are going to move. There is no absolute retention. This is reiterated verbally and through a debond consent form that we have for all our patients at the end. So that I have something in writing as well as verbally to say that at some point these will fail at some point.

Regardless, these working teeth will still move because the gums are still evolving, the bones are still evolving, your face is still changing, the dynamics is still changing, even though you’re not physically growing, that there will be some movement and they might be movement enough for you to have re-treatment again. That’s basically what the consent form says. So everybody has gone in knowing that this isn’t all, end all, it’s not absolute. 

[Jaz]
I really appreciate that. I think we also had a whole episode on retention with Dr. Angela Auluck, and she also, as specialist said, yes, dual, but as you can say, as a GDP and lots of GDPs as you know, lots of GDPs we will do Essix retainers only and reviewing our patients most are fine. But yes, you do get the odd relapse and I think the lesson, I think we can definitely withdraw to bring like some sort of diplomacy to this debate of should you always do dual or can you get away with Essix is, it should be case by case retention is very specific to each individual.

So I would say that if you’ve got someone who’s got those high risk movements that you should own on the side of caution and go for dual. But if you’ve been doing this for a while and you’re getting good results with the removable retainers using, and it’s a lower risk movement and a lower risk patient that you know is compliant, then you may get away with it. Okay. Do you think that’s a fair way that might appease GDPs out there listening?

[Shivani]
Completely. Because bonded retainers, there’s a skill to putting them on who makes them, how they’re put on. Is there enough clearance? Have you cleaned the teeth well enough for them to think? What wires are you using?

Because there are wires that now show like the coaxial wires that they’re leading to relapse. What composites are you using? There’s a whole host of factors that can work for you or against you and your experience of putting them on. And then also. Having to know in the long run when these things break or give up, they’re going to constantly be coming to your practice.

And sometimes, that’s why they don’t put them on, on the NHS because they don’t want these patients coming back. So it’s that responsibility. So absolutely each case has its own merit. Judge it on your own individual experience and then do what you feel is gonna work in your hands. Because at the end of the day, it comes down to your judgment and your experience. 

[Jaz]
There are three things certain in life, death, taxes, and relapse. I think we should just say that to all patients. So the next scenario then. So thanks for that one. Next scenario is Mr. Jones, this time is an aligner patient who is now a year into treatment. He’s been a poor attender. So massive red flag here. And compliance hasn’t been great. Just off script, I remember patients right coming to my Invisalign review appointment without their liners in their mouth. I’m like, where is it?

I was like, oh, I forgot at home. That just blew my mind always. And yes, they were the ones who were always the troublesome ones. As per the theme of this one. Anyway, he manages to get to his last aligner a year later. And you note that he needs another 14 sets of refinement aligners, or additional aligners.

Okay. He’s very unhappy, as he was told. This would’ve taken a year and now is coming up to three years. He’s wanting his money back and is considering suing for his time loss and altered bite, because now we’ve entered the path of no return, right? Things have moved, the bite has changed. We can’t just only just undo the orthodontics.

So that’s where the altered bite statement comes in. So themes of compliance, communication, and now complete handling. Shivani, how do you begin to approach this scenario? Have you met such patients? 

[Shivani]
Yeah, it happens. I would have to say that communication is key right from the beginning, right from your consultation to the report that you write, to the clinchecks that you do. I know a lot of clinicians send off their clinchecks as emails. Absolutely. There’s nothing wrong with that, but I do a voice over the clinchecks, so then I’m talking over the whole clincheck what the aligner numbers mean at the end, what the attachments are, where the IPR is.

So that way it’s not just a video that they just play and they’re like, oh, that looks fantastic. And they don’t know what that commitment is. And I think a lot of the patients also feel that aligners, oh, lovely. Put these plastic things in. They’re gonna do the magic. They’re actually quite hard because the onus is entirely on the patient.

That’s what I tell my patients. Do you want me to do the hard work then let’s put fixed braces on, or do you wanna do the hard work? Then have aligners because it’s gonna be entirely up to you what the outcome is with the number of hours you’re gonna wear, your attendance, your chewies, all these things are gonna play a big part in this.

So compliance comes from seeing them regularly. Remote monitoring for us hasn’t worked at any of our practices because we are unable to then build that trust with our patients because they will not. You can’t tell, you can’t reinforce let you, and you can’t build that relationship. So the minimum we have is eight to 10 weeks between our aligners. 

And then they have that accountability because as you said, where are those aligners? They’re in the pocket, they’re in a school bag. They’re at home. What number? Sometimes I had a patient that didn’t even know what number they were wearing. So you know all those things and you start to record all of that because it’s a contractual agreement, right? You are giving them your time and your expertise, but in return, what you want is their compliance because without the two, it’s not gonna work out. And then- 

[Jaz]
Shivani, those compliance indicators on Invisalign, are actually any good ’cause when they were free and they trialed it. I just did them and I never, I looked at them like, I can’t tell. Have you had mixed luck with those? 

[Shivani]
No. Neel asked me the same question last night. I’m like, no, I don’t use those. Yeah, they’re there too, that’s the put to put the fear in the patient. It’s the fear factor to put in your patient, I’ll know, this will tell me whether it tells you or not, a whole different ball game, but- 

[Jaz]
I might tell my patients this, this indicator sinks to my app, and if you’re not wearing it, I get a heat map over here. So I might scare them like that. 

[Shivani] It will, let’s see if it works. But yeah, those indicators haven’t worked. So I think in this, it’s not all, end all that he wants to end it. I think you can say, come on now, let’s just drive that enthusiasm again. We can make this happen. It’s 14 aligners.

Wear them every week. I need to see you. This is only gonna work if I see you, if you wear them these 22 hours. So let’s do it. We can do this. And it’s just putting that enthusiasm, encouragement back in that patient again and again, just resolve that agro locally. 

[Jaz]
And this reminds me of a patient, I was seeing this teenager and as I was treating him and on the sofa in the treatment room, the patient’s mom was wearing Invisalign. And she was just saying that, oh yeah, I’ve been doing it for like two years now, and moving so slowly. And I realized that every five to 10 seconds she was clicking the aligners off with her tongue and putting ’em back in. And I told her, you do know that by doing this movement, you’re not actually giving the ligaments of your teeth actual time for the orthodontic movement.

And she was shocked. She was like, oh, is that a bad thing that I’m doing this? And I was like, yes, it is. So I actually figure out what your patient’s doing. Where there’s aligners, just ’cause they’re in, are they in, in. Neel medico-legal perspective, if you have an upset patient like this, okay.

But their compliance is an issue and now you’ve entered that point where things are irreversible. Shivani made a great point of really connecting with that patient and trying to get them enthused, given that same fire in the belly that they had at the time of actually starting the aligners and motivating them.

Look, I know it’s disheartening. But I think you could have done better and we will make sure that you get there and let’s get that smile back. But if the patient’s upset, this is a really tough scenario because then now if you’re going to stop treatment midway through, remove the attachments and figure out how you’re gonna solve this occlusion. This is really, really messy. Any advice that you have in terms of medico-legal perspective? 

[Neel]
Again, personally I think it’s about a frank chat with the patient. So I would get them in and I know it’s great to enthus them, but they’ve also got to enthus themselves and they’ve got to realize they started something and they haven’t delivered.

They haven’t delivered. So I would ask the question, I can see you’ve struggled with wearing these. Can you tell me why? And it was like, oh, time or whatever, and okay. And said, okay, they’re all valid reasons. Obviously the treatment’s not going to work because you are struggling to wear them.

So we can either stop here, but your bite is altered. Now we can do some minor things to try and improve that, but if you wish to stop and you can’t go forward, we can stop. If you wish to see someone else and see a specialist, you can put some fixed braces on or somebody. You can do that. I’m happy to treat you going forward, and I won’t charge you anymore for the time, and it’s going to take 14 more aligners and there’s a cost to that.

We really want our patients to be happy, but I can’t do it without you. So if you want to stay with us. It’s up to you to show me that and then we can move forward. But otherwise, if you wish to stop here, there are consequences to that. But that is your decision. 

[Jaz]
There is still time, energy, and money involved to correct where we are now. Even if you see someone else, whether it’s a prosthodontist or another, or orthodontist or another colleague, sometimes reminding ’em that, okay. You might be in a bad place with it. And to re-engage has a lot of benefits in terms of time and money and energy as well. Any final points on this very tough topic. It’s very much case by case, but any final comments on this scenario before we move to the very sourcey scenario number three? 

[Neel]
I think I’ve seen the remote monitoring. And again, I had a chap who wanted to do it initially, he was trying to sell me something and he wanted to do it by Skype. And I said, we’re not going to get a connection, which means I’m not gonna really like you as well as I could if you were in person.

So to me, you just get so much more of a connection with a person. And as you can, you know where their personalities are, they’re wearing it, all those things. And bringing that back in. So I’m a little bit wary of remote. Is it in the patient’s best interest or are you doing it for your best interest?

[Shivani]
Yeah, it’s like having a remote pt. Those baby dumbbells and kind of put in the effort, there’ll be lack of accountability. When somebody’s standing in front of you. There are only so many lies you can tell. And with an experienced clinician, they can see, you can see right through patients you’ve been through most scenarios. So, communication.

[Neel]
The other thing, Shivani, is why Invisalign does a ClinCheck before and the after you go through the aligners and it hasn’t got there. I find that quite frustrating. Is that poor treatment planning? Is it poor from Invisalign or, and how often is that treatment time doubly extended? And should we be warning most patients that that could happen?

[Shivani]
So I tell my patient that and it’s really hard to tell them that this is a computer simulation. I can move anything anywhere on the computer. What it hasn’t taken into account, your age, your bones, your gums, your compliance, the difficulty of tooth movement, hours of wear, it hasn’t taken any of that.

So what you see is maybe just half of what we’re going to achieve. You have to set that standard right from the meeting, and we are going to need refinement, maybe one, two, or three. It just depends on where we set out to be. So this is just a guidance and a treatment planning tool. It isn’t the be all, end all of what we’re going to achieve, I think.

And yes, sometimes Invisalign sends the same amount of aligners. I think you have to know how to tinker the system yourself. Look at the movements. What is achievable in that time? Are they doing movements too slowly, or most of the time they’re doing them too fast? And yeah, you have to know how to manipulate that system, but also manage that this is just a computer. It’s not what is gonna be looking like in the mouth. It’s just- 

[Neel]
I see a lot of youngsters getting into trouble, believing the computer, doing it remotely, thinking they haven’t had the experience to realize there’s failures in dentistry. And honestly, two years, two or three years qualified, doing lots and lots of Invisalign, lots of bonding, thinking they’re great. And then the trouble hits two years later. 

[Shivani]
And I think that’s where orthodontists are, because we can’t bond and mask and do any cosmetic work, it’s purely just alignment and functional for us. Whereas the GDPs, they have that armamentarium where if a tooth really hasn’t quite tracked or something, there is a chance that they can mask it and everything is looking good and functional.

But yes, you are actually right. And that’s why there are so many of us that enjoy mentoring when it comes to Invisalign and we’re happy. There are services out there that will do your Clinchecks for you. And sometimes it’s worth looking at those services, especially when you’re starting off where your mentors will sit with you. They will physically do your Clinchecks with you, so you understand and the outcomes are so much better. 

[Jaz]
Yeah, mentorship is huge in all implants and orthodontics as well. Like to have that hour to sit with someone like Shivani, like if I had a case right. And I want to address it from the get go and to just have an hour with you on Zoom and just show you all my photos, show you my radiographs, and for you to say, oh, this looks good.

Your plan looks good, but please watch out for this and make sure you go for that double retention at the end. And did you know that this rotation will be very, very tricky and oh yeah, your Clincheck. I think the movements are going too fast here. Slow them down, double the number of liners to get that perspective from someone is so golden.

‘Cause it really gives you faith in your treatment planning. So mentorship is huge. And so what we’re starting with Shivani is something called Intaglio. It’s in the final stage of development and it’s basically a service connecting mentors and mentees. So I’ll definitely be sending you a link to come in, join us in that and share your mentoring, but also give you an opportunity to tell us about any mentorship opportunities with you at the end. I would love that as well. 

Now, just two points here. I remember a Protruserati, one of our colleagues messaged me on Instagram a few years ago, showed me a Clincheck and saying. I am shocked and disappointed because I treated this deep bite case and I was expecting the ClinCheck to show in the patient’s mouth.

But I look at the mouth and at the end the line is, and I look at the ClinCheck and I’m like, hang on a minute, this isn’t what I’m getting. And then you had that conversation that actually, it’s a simulation of force. It’s cartoon dontics. It’s not real. You have to get that to internalize that before your patient internalized that. And if in case anyone was multitasking, Shivani says something really, really golden when she shares her ClinCheck. It’s not just a ClinCheck, it’s a voiceover. I don’t know what you use, Shivani. I use Loom. 

[Shivani]
Okay. I use the quick movie time play thing.

[Jaz]
Okay, fine. So you can use that, you can use QuickTime, you can create screen recording and speak over it. Or you can use something like loom.com. We’ve got an episode with Prav Solanky talking about how to send your treatment plans via Loom, and I love that. And I show them that yes, this number means aligners.

These are the buttons, don’t worry, they won’t be red, they’re gonna be white. That kind of stuff, basically. And it gives you a nice personal touch. That level of consent that you get is something brilliant. So it’s a nice little tip that in case anyone missed it, wanted to highlight what she finally said.

Before, finally. Now scenario three, which is a tough one. Okay. And it’s a tough one for both of you. Okay. So Mr. Edwards has seen one of the associates of your practice where you are the principal, so very applicable to you, Shivani and you Neel. And in the midst of some limited outcome orthodontic therapy.

Just before we continue, ’cause so our younger colleagues might be listening to this, Shivani, what do you define as limited outcome orthodontic therapy? 

[Shivani]
It varies. Is that limited? 

[Jaz]
I think maybe Neel. ‘Cause Neel wrote that question. Should we ask Neel what he meant? 

[Shivani]
Okay. 

[Neel]
I think if you’re an orthodontist, you are trying to get things as perfect as you can. So you’re looking for class one occlusion, stability, canine guidance, all the things we really want. And that’s especially achievable in childhood and teenage years. In adults, crossbites might be harder to change and you might be doing preemptive orthodontics to do your veneers or your bonding before. So not necessarily trying to have the same outcomes. So you have a definite goal in mind awake, trying to get to, which may not be perfect, but it’s either an aesthetic or pre aesthetic movement. 

[Shivani]
Yeah, so it’s an improvement. It would be like deep bite cases, you would say, I improve the deep overbite, whereas in a child, you know, you’re gonna, if they’re compliant and the case goes well, you will be able to correct it. So limited outcomes will be, yeah, you can’t change skeletal aspects, you can’t intrude for deep bite cases. So crossbites are hard to correct as well. 

[Jaz]
Shivani, there’s a game we play on this podcast sometimes, right? It’s called Am I Naughty if? Okay. And I’m happy to show some skin in the game here and say am I naughty if I have a 55-year-old female patient who has like a imbricated, a crossed over upper centrals and rotated lateral, and I’m very happy to tackle that and do that, and I’ve got a good result.

But I chose from the beginning not to correct the crossbite on the upper right, first molar and upper right premolar. I chose not to correct that crossbite, but I did everything else pretty much looking good at the end. Am I naughty if I do that? 

[Shivani]
Well, you have to warn the patient what the long-term implications of that would be. Because in Crossbites there is a chance that they will fracture those teeth, those fillings. There will be some, something will happen along the whether’s gonna happen next year, five years or 15 years. That is what you can’t predict. But if you have noted that there is something that needs correction, but you have purposefully not corrected it because it would be difficult to correct. You have to inform the patient that there can be long-term implications, but we’re gonna have to accept it because it’s gonna be impossible to correct. 

[Jaz]
That’s fine. I’m happy with that. I’m happy with that. So, a little bit naughty, but really the naughtiness is actually when you don’t communicate that to the patient and you don’t justify, I’m a big fan when it comes to communicating my density to my patients by showing you’re working out.

And the reason I chose this scenario to do that is because I’ve had scenarios in the past where I’ve tried to correct the posterior crossbite and it’s really dragged on. The patient says, look, I’m really, really happy and this is the one thing that, I really didn’t need this. And sometimes you’ve gotta pick and choose your battles, right?

And obviously you’ve gotta do an orthodontic assessment. So occlusal assessment to make sure, okay, are there any interferences from this and whatnot, but let’s not go into that. So yeah, limited outcome, orthodontic therapy that this patient’s having, the associate who’s been doing this treatment has now left the practice on bad terms, leaving the principal to manage several of the unfinished cases. Now you’ve asked your in-house orthodontist to take over the case. The orthodontist on seeing the patient isn’t happy with the progress or treatment plan, and wishes to start again at full cost to the patient.

Now the patient, Mr. Edwards, isn’t happy to pay for the further treatment. And he feels that the original dentist was remiss, but lies the fault at the door of the practice. Like, hey, I know the dentist left, but I came to you as a practice, right? And now this is unfinished business. I would like it finished. I don’t have to pay again ’cause I’ve kind of paid for my new smile and I want this finished. So I completely understand the patient’s perspective here. Shivani, what do you think? 

[Shivani]
This is a very tricky one. I think when it comes to associates. Good associates will not leave practices just like that because they know the dental world is very small. People are gonna talk about reputation, but it happens. Associates do leave. I think you need to vet your associates very well. At our practice, when we have a new associate that joins an orthodontics, the first 10 cases are planned with the partner. So that we know that we’re all doing the same school of thought of orthodontics. We’re all saying the same things. 

[Jaz]
I really like that. 

[Shivani]
And so the first 10 cases are with shared responsibility. So that way you are building their confidence, but also telling them, this is the way we like to treat our patients, and this is how we look after them. Gosh, it’s hard when somebody leaves.

Surely in their contract with orthodontists, especially we do put it in that they have to finish their cases. And then you do have a retention fee, which would at least be a case and a half. Either way, they’ve left, they’ve tried to finish, or you’ve kept that money. The practice is gonna be at a loss because even if you don’t charge your patient, which I think you can’t, the patient is absolutely right.

They’ve paid their due, but the orthodontist is going to, what about their time? So, okay. Retention money to pay whatever it is, 40%, 50%. But the rest of the money is gonna come out of the expenses of the practice. So you as a practice owner, have to look at the reputation of your practice, plus the goodwill of these patients that you’re gonna keep.

For me, I personally mop up cases from my associates when it comes to anybody leaving the team. But if you can’t, because not everybody has the skill of those specialties. My endodontist left. I couldn’t mop up his cases. Then you’d ask the in-house orthodontist, but I think this is a conversation with the orthodontist beforehand because you know, they’re gonna be seeing these several patients that have been transferred, and these are your transfer cases. Let’s talk about these. Why don’t you take the records? Let’s go through what’s remaining to do, what has been done well, what hasn’t been done well, and how can we work it out?

So I think rather than having that conversation on television. I don’t agree with this and I’m gonna charge you this. That is not the right way of handling. The right way of handling would’ve been, hi, I’m going to see you, a transfer case. So let’s take your record so I can go over the plan with you and let’s book you in again so that we can go through what more needs to be done and how we can finish this case off in good time for you.

And that’s then when the partner or the practice owner goes in and says, okay, what have we got? How are we gonna figure this out? How can we both not upset the patients, but at the same time rerate you and value you for your time that you’re helping me to finish these cases off? 

[Jaz]
So it’s having those difficult conversations, including with the orthodontists that’s inheriting these patients potentially in that practice and having that just like you said, having that chat with them.

And I think the interesting thing that Neel wrote here in the scenario, what makes it interesting is that clinician A, the associate that’s leaving was doing anterior alignment orthodontics or STO, short term ortho, whatever. Call it what you want. Whereas the orthodontist, because they have a set way of doing things, okay.

And they may wish to treat that posterior crossbite and they feel upset that, okay, I’m gonna be finishing without posterior crossbite. And that’s a real world concern. And so I understand where the ortho is coming from, which is what adds that extra masala to this case. Neel, what can you tell us about this case and any medico-legal perspectives here about, do you see much in terms of one clinician taking over another clinician, and do you think there’s a risk of any blue on blue crossfire and promoting litigation?

[Neel]
I mean, it’s a very difficult case and it’s a case that happened. I think for me, from what I’ve seen, there’s two scenarios. There’s where there’s a few ortho patients. There might be four or five. That’s a different matter. And again, that’s a conversation between you and the orthodontist. And I think also going back to our Sarah Buxton podcast, really important, if they’re an ortho, if they’re doing orthodontic treatment, I think most contracts don’t have, you saying Shivani, a case and a half, let’s call it, eight, 10 grand retention, plus you have to finish your cases.

I don’t think that’s in a lot of the standard. Associate contracts ’cause we don’t assume we forget about ortho in a sense. So I think going back to those bespoke contracts that Sarah was talking about, especially for anyone doing ortho, that probably preempts a lot of this. So you have that retention amount.

The trickier ones are where there’s three years, 30, 40 cases, or whether there was an orthodontist before, and we’ve had it where an orthodontist has started a job day one, immediately alarm bells, five years ortho spacing, wrong treatment planning, and the corporate wouldn’t let him leave without budget to sue him unless he did three months.

Every day he was in there, he was getting deeper and deeper into telling these patients. They’re afraid to go to the hospital. This is not quite right. It’s not quite right. That’s when I would just call indemnity straight away. If you are taking a bunch of cases on or it’s a big thing. Start early with us.

Let us know from day one. But if it’s a few cases, this happens quite a lot. I think it goes back to the contractors. Shivani was saying, the right retention fee, the right relationship, trying not to fall out. But it happens. But you’ve got to act professionally and both parties have got to look after the patient first.

[Jaz]
Thanks so much guys. In the interest of time, ’cause we’re wrapping up now, I just wanna say firstly thank you both, for this whistle-stop tour, but I think there’s a lot of clinical nuggets, but also communication, complaint handing, medico-legal nuggets. So some meaty CPD here. Shivani, tell us how we can learn more from you. How can we seek mentorship from you? Tell us about where you work so we can refer patients to. 

[Shivani]
Yeah, so, I’m based at 11, which is on Wimple Street. So if you’re in the London region, happy to see patients here. I’m also based in Reading at Park Lane Orthodontics, so that covers a bigger area there. So I’m most welcome if you’re in that area, in and around, for you to refer patients to us. 

But if you wanna learn more about how orthodontics is evolving, especially in 2024. Then I will be speaking at the practice development sessions at the BOC, which is at the end of October. But I’m also running a workshop with Dr. Angela Auluck at the Tubules Conference, and it’s a whole day workshop all on the right diagnosis, mitigating risks, but actually goes through the whole entire new patient journey from the minute they contact you to when you finish.

And because the theme of tubules as horrors, how to mitigate horrors at every single patient stage, and that will give you a good insight of orthodontics, but also what to watch out for if you’re embarking ever, or dipping your fingers into orthodontics at all. 

[Jaz]
I’ll put the link to the BOC and the dentinal tubules Congress for your workshop as well. But is there a good way to connect with you? 

[Shivani]
Email is best, email. Email me. We do run mentorships here at the practice. We invite people to spend a whole day with us to see how our multidisciplinary clinic works. How our patients are seen from room to room or multi clinician planning happening together. And so you can email me at- 

[Jaz]
I’ll put your email, specifically in the Protrusive Guidance. It is public to some dentists, but like, it’s not the whole world. So it’ll be verified dentists who can access that email rather than just giving your email to the whole world. Okay? So I will put that in there as well. So important. Say Neel, thanks so much for giving those medico-legal perspectives, my friend. How can we reach out and learn from you? How can I get some advice? You’re a great guy too, if you have a medico-legal woe to get some advice from. 

[Neel]
Yeah. Just email me again, neil@professionaldentalindemnity.co.Uk, Instagram, Facebook, LinkedIn. I have to check all these things. They’re all, people come up with all sort of different ways of finding you WhatsApp. Or you can sure, text Jaz and he’ll forward it on to me. But no, I really, really, really enjoyed today. I’ve written loads, so I really, I really thought it was a brilliant podcast. Thank you Shivani. And her and Samir have got an award-winning practice and it’s duly award-winning, multi award-winning. So if you get the chance to go and spend the day or hear them speak, I would definitely do it. 

[Jaz]
Yeah. I heard Samir speak of the BDA in Reading. Some months ago. Absolutely. Absolutely brilliant. So, what an amazing pair you are in terms of education as well. That’s fantastic. But I just wanna say one thing that if you are, do a renewal in indemnity, then do check out PDI for insurance. It’s who I’m with and who I trust. I don’t get any discount for saying that. I pay my fee in full.

But there is an incentive that we do have in terms of those who get a quote, you get a hundred pound off if you’re Protrusive member because we’ve identified Protruserati as safer clinicians says protrusive.co.uk/insuranc. Okay. So I’ll put that in the show notes as well. Shivani, thank you so much. Neel, thanks you so much. And Shivani, I’ll see you at Tubules. Neel, will you be there? 

[Neel]
Depends on bump. 

[Jaz]
Okay. Okay, fine. Wow. Okay. Amazing. Okay, so, well, let’s see. Thank you so much guys. 

[Shivani]
Thank you so much, Jaz. Thank you Neel. Good to see you. 

[Jaz]
Well, there we have it guys. Thank you so much for listening. All the way to the end, I managed to squeeze in there, am I naughty? If I’m always happy to put my neck on the line for you guys. I wanna thank our guest, Dr. Shivani Patel and Dr. Neel Jaiswal. I’ll put the links below for the British Orthodontic Conference and the Dentinal Tubules Congress where Shivani is doing a workshop. And if you are on Protrusive Guidance, I’ll also put Shivani’s email so you can reach out.

I think she’s a great role model and if you’re ever able to shadow clinicians like Shivani, I think you should totally take such an opportunity. If you want CPD or CE credits for this episode, and you are already on the app, scroll down below on the premium version and answer the questions. And when you get 80%, you get a certificate emailed to you by our CPD Queen Mari.

If you always listen to the episodes and you’re never claiming CPD, think of how many hours you could have clocked up. Go on. What are you waiting for? Download Protrusive Guidance. Make an account and start collecting your CE. If you’re curious whether insurance for professional dental indemnity could save you money on your medico-legal cover, head to protrusive.co.uk/insurance.

That is an affiliate link, so Protrusive does get rewarded financially, but if you prefer not to get the a hundred pound discount and pay full price, you can totally do that as well. I hope you enjoy the clinical and medical-legal perspectives we discuss. I’ll catch you same time, same place next week.

Bye for now.