Sub-Gingival dentistry: the dark, scary, bloody world you don’t see as much on Instagram. Straight talking Dr Lincoln Harris will help you choose the right retraction cord protocols to reduce your stress during subgingival caries removal and crown/onlay preparations.
Join us to see Lincoln Harris LIVE in London for a full-day keynote lecture: From Class 1 Composites to Complicated crown preps.
Protrusive Dental Pearl: When inverting/tucking in the rubber dam, instruct your DA to blow air continuously at your flat plastic instrument as it works around the sulcus. This will effectively and efficiently tuck/invert the rubberdam for a better seal (and sexier photos!)
Highlights of this episode:
- 3:33 Protrusive pearl regarding inverting/tucking the rubber dam
- 6:40 Deep Subgingival Caries cases
- 11:44 Deep Subgingival Caries Protocol
- 22:44 Which Retraction Cords to Use
- 25:10 Retraction cord protocol on Silicone Impression
- 30:50 Retraction cord protocol on Digital Scanners
- 31:48 Teflon as Retractor
- 35:53 Isolation of Class V restorations
- 42:02 Place of rubberdam on class V restorations
Check out Ripe Global, one of the biggest groups in Dentistry with 80,000+ members!
As a bonus, check this one-page summary of this episode
Head over to protrusive.link under the Infographics Tab for the other one-page infographics summary of the past episodes
Click below for full episode transcript:Jaz's Introduction: Hello Protruserati. I'm Jaz Gulati and welcome back to this episode on such a huge topic. We are finally talking about the DEEP DARK WORLD of SUB GINGIVAL DENTISTRY.
This is the real world of dentistry that you don’t see on Instagram as much. It’s bloody. It’s fiddly and it just gets a little more complicated when it’s sub gingival. Every now and then I ask you guys for a recommendation for a topic to cover on the podcast. And so many times you guys have requested SUB GINGIVAL DENTISTRY and RETRACTION CORD. Which cord shall use when? Shall I always use double cord? Single cord? Shall I use PTFE? Should I soak both cords or soak one cord? Is it okay to sometimes remove the gingiva? Sometimes, can I remove the papilla to allow my matrix to access the restorative margin? All these things we’re going to cover today with Dr. Lincoln Harris.
Now as a Protruserati you probably already know who Lincoln Harris is, but just in case you don’t, you should totally check out Episode 54. Dr. Lincoln Harris is one of my heroes and one of my mentors. I’ve seen him twice once in Sydney, once in Singapore live. These are live lectures. His energy, his engagement. He is well known all over the world. He’s got one of the biggest groups in dentistry of 80,000 members of Ripe Global’s. I’ll put the link in the show notes. This is a movement that he started. He encouraged dentists to share full protocol photos and now it’s evolved into ripe global. Which is making dental education accessible to all the world and in a brilliant way with remote dentistry.
And we talked about that a few episodes before, but essentially today, I’m going to steal him and his expertise to talk about this very sought after topic of sub gingival dentistry. Lincoln Harris is the definition of a super GDP. He’s just annoyingly brilliant at everything with all facets dentistry. His communication powers that he shares. His trim planning advice he shares is the best that I’ve ever come across. It helped me a lot in my career so far. If you’re in Europe or anywhere near London, then I would invite you to come and join us to see Lincoln Harris live in London for a full day keynote lecture. From class one composites to complicated crown preps. We’ve got Lincoln Harris over all the way from Australia to talk about all these things to young dentists, I’m just gonna be very blunt when I say this, I paid thousands when I saw a Linc in Singapore, I paid thousands when I saw him for a two day lecture, just pure theory lecture in Sydney. And I got every pennies worth, I made tenfold back just from his communication gems alone. And Lincoln is now coming from Australia, to Europe to London to lecture specifically for young dentists because he wants to give back. This lecture is going to be a bargain. Because what he wants to do is make dentistry accessible just like he’s doing with Ripe Global. So if you’re in London on first of October, that’s a Saturday, at the Guy’s Hospital Campus, then do join us for this live event. It’s very rare that he’s in England lecturing by the way, so must see lecture. He’s a very engaging lecturer. He’s a brilliant educator, his energy is brilliant.
So if you haven’t ever seen Lincoln Harris, for sure, come and join us the events called De-stress Dental and the URL for it is destress.dental. So if you check out destress.dental in your browser, check out the date. And if it all works for you, come along! Come along see Lincoln Harris. It’s going to be a sold out event and we’re excited to host Lincoln Harris. The early bird rate expires on the 14th of September and it’s just 149 pounds if you’re more than five years qualified, if you’re less than five is qualified it’s 99 pounds. And if you’re a dental student, DM me. I can sort you out with something even more special than that.
The Protrusive Dental Pearl:
Today’s Protrusive Dental Pearl, Imma keep it really quick because I want to jump straight to the main interview, which is full of so many gems with Lincoln Harris. So the Pearl is when using rubber dam and you’re trying to INVERT that RUBBER DAM, you’re trying to tuck it into the sulcus, so you don’t want the rubber dam coming out. You want to TUCK IN nicely around the gingiva. It leads to prettier photos but also actually improves your seal as well. So how do you do that effectively and efficiently? Well, I’ve always instructed my nurse to hold the three in one and my nurse is instructed to blow air or my DA is instructed to blow air as I’m using my flat plastic instrument around the sulcus. So if I am on the buccal he or she is blowing air at the buccal where my flat plastic is, and I’m just tucking that rubber dam in. And as I’m going around the mesial, she’s following with the air as I’m going around the palatal and distal. So, where all times where my instrument is the air should follow. This makes it stupidly easy to invert you’re dam if you do without there, it’s frustrating, it’s difficult. So, that’s my top tip when inverting rubber dam and for those of you who are watching on YouTube, you just saw a video of me doing that. Now let’s join the one you’re waiting for Lincoln Harris to learn more about how to make these STRESSFUL SITUATIONS just a little bit MORE BEARABLE.
Lincoln Harris once again for the third time back on Protrusive Dental Podcast as always, you know we love having you on. So, thanks so much for for making time for these really important topics. Linc, today we’re talking about a real pain area because you’re so good at covering these. I’ve seen so many of your infographics. You introduced me to ViscoStat Clear, and we’ll come on to that later, obviously. So, sub gingival dentistry, the dirty dentistry that you don’t see on Instagram, that’s what we’re talking about. For those few people once again, every time you have to do this, in who may not have heard of you, maybe it’s the first ever time they visit the Protrusive. And they’ve clicked this episode. And like, who’s this Australian guy? Please just introduce yourself and what you represent.
Hi, Jaz. It’s a great pleasure to be here. So thank you for having me back again. Always entertaining for me to join you on these podcasts. I’m a general dentist, I have a practice full of general patients who have problems who, you know, that my patients don’t have nice gums, they turn up with perio. They bleed. They carries a sub gingival. They have all of the problems that regular patients have. And but beyond that, obviously I run helped found the largest cloud, and only actually, cloud delivered procedural training company in the world. So I do some lecturing as well. But our complete focus is on helping people get the best education in the world, as long as they have internet. [Jaz]
Guys, that was a very humble intro from Linc, because I’m the first one to always say. And so many of my peers out there, listen to you, following you, Linc. You’re one of the best educators there are, your cases. You created this movement of full protocol learning, which I think you know, when we look back, I do feel from my exposure anyway, that you are the real pioneer in convincing us that, ‘Hey, before and afters aren’t really that valuable to a community of dentists, that’s all about sequential photographs.’ And you’ve really taken that to the next level. So, we owe you a lot as a refreshment. I know we talked about that a lot in the sort of last episode we’ve done. So in this episode, we’re gonna dive right in, right? We’re talking about those deep sub gingival cases where you’re sweating, you’re changing matrices all the time, you’re constantly battling that internal voice in your head, ‘How do I get this dry? How do I isolate this and you’re just, it’s full of stress?’ So let’s take a more particular scenario, which I think be more helpful to our listeners. Deep sub gingival caries, let’s say a lower second pre molar, deep sub gingival caries, and you’re deciding to treat this direct so you can do a composite, DO restoration. What works best in your hands to isolate those kinds of cases? [Lincoln]
Well, that’s actually the wrong question. The question is how do you treat them, because it’s not just the isolation. So there’s two types of deep, direct restorations. The one is where you know it’s going to be deep, and you can plan accordingly. And the other one is where you don’t know that it’s going to be deep. And you get caught by surprise that two different scenarios. And the reason why I outlined them is that if we go back to extractions, for a moment, when you are very experienced, you can look at the radiograph and go, that will be a difficult extraction, or that will be an easy one. This one looks easy, but it’s going to take me 45 minutes, even though I’m a very experienced dentist. But the problem is that when you’re inexperienced dentist when you most need the help of being able to tell that it’s difficult, you can’t tell. When I was for the first however many years of my practice, maybe 10, I would just get caught by surprise because I couldn’t tell the difference. So if we go back to the deep restoration, once you have all of the skills to deal with this in a cool, calm and collected way, probably you’re not going to get caught by surprise, you know, which is easy, and which is difficult. And I’m going to just lay out now that I have been through the full process of how you deal with these deep and difficult restorations.
And what I can say now is that if you can recognize them ahead of time, and it’s in any way possible, either do the surgery yourself or send it to a perio and get it turned into a sub gingival restoration. Because after many years of proving that I can treat a deep sub gingival restoration. I’ve now worked out what happens is it takes a long time, I can’t charge any more for it. Whereas, if I do Crown Lengthening I get to charge for the surgery, I turn a very difficult situation into an easy one. And so that would be my first thing is that I’ve been through the full cycle from every patient must have perio surgery, otherwise, you’re a biological width criminal too. I can solve everything with restorative which is true, I can too. Now it doesn’t make sense to work that hard for the same pay. So that would be my first thing. If you can get it done or charged for the Crown Lengthening so it’s a very simple procedure. I mean Crown Lengthening is easier than dealing with it-[Jaz]
I mean on the note Crown Lengthening, one but one people who may argue against Crown Lengthening would be that you lose the papilla. And therefore some guys are proponents of it. I actually am a fan of the gingivectomy using a thermal cut bur as well, get rid of the papilla and then now you have access. Your matrix can get in, your wedge can get in, those kinds of sub gingival cases. In your experience, where do you lie in sort of crown lengthening, getting rid of the papilla and that causing issues further down the line? [Lincoln]
So I have done a lot of perio surgery for soft tissue grafting. And in many of those surgeries, you lose the papilla. This part of the procedure. Papillas are extremely important in anterior for aesthetics. Papillas in the posterior, the posterior aesthetics is only important to dentists who take buccal photos with a mirror. Like even a direct photo, you can’t see the papilla. So it’s not like you get more plaque because you do or don’t have a papilla. I mean, you can get more volume of plaque, but you can’t get. The presence or absence of plaque is not determined by the papillas to turn by whether you clean or not, it’s easier to claim when there’s no papilla.
So I say to the papilla loving folk, you’re wrong. Papilla-philes, Papillas at the front, worth the effort. Papillas at the back, you know, when they’re gone, it’s easier for everyone. So you don’t need, like, I don’t know, I mean, the cases were one of the big benefits with when I’ve done perio surgery is that when you raise the flap, you actually pretty much like if you do a dissection of the middle, you’re gonna lose some of the papilla. And then often, if you have to do a bit of bone removal, you definitely go from having a and now Papilla is a funny thing because if a papilla is actually like the col. So, the top of a papilla has no effective keratinized epithelium, the way the rest of your tissue does. So actually the cases where I’ve got rid of the papilla, so it’s just epithelium, you know, and you widen out the space between the tooth. You need to actually have a bit of weight to get a proper epithelium developing. It’s easy to clean so papillas don’t care.[Jaz]
There you have it, papilla-philes. I can’t believe you weasel that term in. [Lincoln]
Yep, anterior, I’m a papilla-phile. Posteriorly, papillla-phobic. They’re a pain in the backside, get rid of them. Okay, so, I mean, now let’s get back to the direct restoration where you haven’t recognized or you don’t have the skills or you’re afraid to do the surgery. Or you don’t want to refer it to the periodontist because he, I don’t know, hasn’t bought you enough dinners or something? Okay, so these are all, you know, perfectly logical, evidence based reasons. There are so many variations- [Jaz]
I know it’s a bit of an unfair question. [Lincoln]
The very first thing is prep without mercy. And what I mean by this is often when people start prepping a deep cavity, they start going, ‘Oh, it’s deep.’ And then they start slowing down as if the speed that they prep the tooth that will make any difference to how deep or large the cavity is, it’s like when you go, ‘Oh, this cavity might go to the pulp.’ And then they start like, ‘Ooh.’ Okay, I mean, this is one of the great crimes that gets inflicted on us. Is this idea that pulp exposures are our fault, okay? I mean, yes, we can avoid them in certain circumstances. But sometimes, we can’t. And so if you can’t, you can’t, it’s not like we put the caries there. So when you’re doing sub gingival, prep without mercy, now you might go, ‘But what about the gingiva? I might make it bleed.’ Pretend there is no gingiva when you are prepping the carries. What about the bone? Pretend there is no bone just you must get the caries out. And so just do whatever now from once you have the caries out.
And so this prep without mercy thing, because people are often going, ‘I’m trying not to hit the gum, because I’ll make it bleed.’ You can stop the bleeding, just prep the tooth. In fact, prep the gingiva as well, that’s often better. So, then you got to make a decision. And at that point is where it starts to be many options. So, now you use a thermacut bur. For people who don’t have a thermacut bur, you can use any fine bur, I use my either my flame tungsten carbide polishing bur, which is for, you know, removing the overhang on anterior composites. So use that, turn the water it’s like a 24 bladed tungsten carbide finishing. So, I use that I turn the water off. It’s very hard to cut tooth with it. Like you literally have to sit on the tooth for ages. But the more important thing when you’re cutting tissue is that, if you use a coarse diamond, it does how much trauma to the tissue, you can’t stop the bleeding. And so to stop the bleeding, you have to use some sort of fine bur that cuts the tissue with cauterizing.
Yeah, well no, it doesn’t need to be cauterizing it needs to not be traumatic. And if you use a coarse diamond, it’s putting all these like little tiny lacerations through the tissue and so to stop at bleeding is more difficult. I also use the standard superfine diamond that I use for finishing my crown preps that’s also a great bur for cutting the tissue. And so, if you finish and you look at it and there’s just a mess, then I will cut the tissue away with a gingivectomy. If it’s not too much of a mess, then you know sometimes I will, that’s one step is so one step is you go bam! You cut all the tissue away. You pack some cotton wool soaked in ViscoStat™ Clear in there and you leave it for a few minutes and like if you wait five minutes, it’ll have stopped bleeding. You have to pack that cotton wool-[Jaz]
It will go black or they’ll stop bleeding absolutely? [Lincoln]
Yeah, I mean it mostly goes black. Not always but mostly. And it’s just the clotting blood. And then you decide from there so often, the big trick with the gingivectomy is that most people don’t do enough. That’s number one, because they’re afraid. The difficulty with almost anything is like BASE jumping. If you’re going to base jump, you have to jump with commitment. Otherwise, you’re going to hit the cliff just below where you jumped off and you will die. And so dentistry is the same that if you don’t commit to the procedure fully, then it won’t work. So people go, ‘Oh, well, I tried the gingivectomy and I still couldn’t get the wedge in.’ And that’s because they didn’t commit.
So often, you actually have to take that gingiva right out to the buccal and to the palatal. Because they have these big high bits of tissue that sit there and you won’t be able to place a wedge or a rubber dam. So that’s one option, and then you decide will I be able to place a wedge and a matrix. Now, the second big trick besides cut the tissue. I will say and this is a misconception, if you cut the tissue, it is easier to stop bleeding than if you don’t. So if you have inflamed gingiva, and you don’t cut it, it just bleeds and it bleeds because the surface of the tissue is inflamed. And so all the blood vessels are very ready for inflammation. So if you like poke a cord into the papilla that is inflamed, it will bleed and bleed and bleed and it’s very difficult to stop. Whereas if you cut the tissue back and you when you cut it, you want to at least cut it back to fresh, healthy tissue that it will bleed but that is controllable bleeding and much more controllable.
And so this is a big misconception, then you have to go, ‘Can I get a matrix in?’ If you can get a matrix in, then great, put a rubber dam on put a matrix and so on. But sometimes what happens is you go, ‘Ah I don’t know if I get a matrix in there.’ And then you start packing Teflon. And you can get the Teflon beautifully sitting there. Or you put a wedge in and the wedge sits beautifully against the tooth, everything’s lovely. But then you try and put the matrix and the matrix gets a big kink and goes into the cavity. And you’re going to end up with this massive, like, I don’t know, weird looking composite that has a big dip that goes into the cavity. And then it comes back to the contact point.[Jaz]
Plaque trap. [Lincoln]
Yes. And so this was probably the second, like massive mindset change for me. Often, particularly you have rubber dam on, you pack that Teflon down there to retract the rubber dam down to the base of wherever you did the gingivectomy and to seal the blood. And the Teflon creates this perfect little matrix. And then as soon as you start sticking wedges and things in there, you can’t get a decent contact at large. And so quite often, either the wedge or the Teflon becomes my small matrix for that first little part of the cavity. So the first couple millimeters- [Jaz]
Kind of like a deep margin elevation with the Teflon, right? [Lincoln]
That’s right! Yeah, like do what you have to do. But sometimes the Teflon gives you the best, like you pack it down there and the flat plastic instrument using the packet is kind of smoothing that inside edge and then it pushes down. And then the rubber dam pops it back against the tooth. So the other option is sometimes you have the rubber dam on and everything’s lovely. And then the moment you put a cord or wedge or a matrix, then everything goes terrible. And so in cases like that, I actually use no matrix at all for that first little bit. So you do your like bonding, and then I will use flowable and basically just freehand build up two millimeters or so of follow up.
Now, this is where you start wishing you’re done surgery because then you have to cut the wedding of the rubber dam and smooth that first bit of margin elevation because you haven’t used any matrix at all. So you have to use like some sort of polishing there. That you can fit down in that area to smooth it against the tooth so that you get rid of the overhang because you haven’t used a margin. And then you have to reapply the rubber dam and put a wedge in and so on. So, there is no way to do this. That is easy.
So, I think that the number one realization is if it’s a deep margin, you’re not going to do it in 20 minutes, like everything else unless you’re going to do a terrible job. It’s going to take a while and don’t panic. Just do each step one by one, slowly and calmly. I mean, once you have a matrix and a wedge in then the rest is easy. It’s like 90% of the difficulty is getting to the matrix and wedge with no blood and no extra dice. So, I mean, that’s-[Jaz]
I think the key lesson you’ve shared there, and you did a couple of ways that is, be purposeful. Be purposeful, in your preparation, be purposeful, in your gingival removal, whatever you’re doing, do it purposefully. I think that’s a key lesson to reemphasize that. [Lincoln]
Yeah, look at depths of the cavity won’t change if you prep slowly. So, just prep fast. And if it’s sub gingival, it’s sub gingival, you know, you’re going to cut up the tissue. And then if you are going to cut the tissue, cut it away and you go but it will hurt and you go yes, yes, it will hurt. I used to sleep but- [Jaz]
It doesn’t hurt you. [Lincoln]
It doesn’t. I feel nothing. Okay, I know that sounds like a joke. But what I realized, and actually the big breakthrough for me, was we worried because we get beat up about being dentists, okay. We’re all so insecure about being dentists, because we get told that we charge too much, and we cause pain, and we’re awful people, okay. And we get like smashed with this. And so we’re like, super trying so hard and so desperately, ‘Oh, no! we don’t charge too much. And, we’re lovely people and we don’t cause you any pain.’ And so the big breakthrough for me in dentistry was when I realized I am a surgeon. I cause pain, just accept it. I don’t cause pain when I do the treatment.
But afterwards, yes, I’m going to. And in the scheme of surgeries, that people get the pain that we cause postoperatively it’s hardly worth talking about. So it takes tremendous effort to do pain-free dentistry, because the patients are awake, they’re not asleep. But postoperatively dental pain doesn’t even rate on the post surgical pains. If anyone here has had a foot surgery done, they will know what proper pain is. That’s like three months with your foot elevated, it hurts for six to nine months afterwards. And we’re here worried about them. You know, like at five millimeter gingivectomy that will hurt for maximum four or five days like so I no longer-[Jaz]
That really puts into perspective. I think I love that, that is so true. And I think over the years, I’ve become a little bit more not not numb. I don’t wanna say numb because it’s harsh. I care about my patients, but you have to accept that, you know, the patient will get dry socket, or there will be post operative discomfort as part of the healing process. And to just like you said [Lincoln]
Pain, say pain. Oh, come on. [Jaz]
Okay, pain. There you are. [Lincoln]
Pain. We get pain afterwards. I get on board with this. It’s like soft tissue. Soft tissue grafts- [Jaz]
Like therapy. [Lincoln]
Yeah, it’s just like a soft tissue graft. Okay? Like the patient goes, ‘Will it hurt? Yes.’ Don’t negotiate on this. It’s like, ‘Oh, yes. But do you know? Like, will it hurt? Yes, but you’ll get over it.’ Okay, like literally, I’ve never had a patient go after a soft tissue graft, I’m talking about where I harvest the tissue off their palate. And it’s not a sub epithelial. So it leaves an open wound, which I cover with dressing. But I’ve never had a patient say a year later, that was the most horrific thing, I would never do it again. Okay, after a couple of months, they’ve forgotten. So the problem is, the patient will be afraid of anything that you are afraid of. So the big problem is not the patient’s fear. It’s actually the dentist fear. If you’re afraid of a procedure, then you won’t do it properly. [Jaz]
Yeah, and they totally sense that. Amazing! So we covered that really well. The next thing was it’s such a common question, Linc, and we see all the time on the group, on Ripe Global, is knowing which cords to use. Not I mean, like which brands, the common question I get from young dentist I’m gonna pass on to you is, ‘Do I always need to use two cords?’ Like so you’re doing a crown preparation. And so that decision making process into ‘Okay, when to cord, when not to cord?’ And then if you are cording? Do you always have to use two and then do you always remove that last one they put in? Or is it okay to keep him in? Let’s talk about the sequencing and the troubleshooting and decision making. When it comes to cords. I think that’d be extremely valuable. [Lincoln]
So it would depend on are you taking a silicone impression or scanning because they’re different. So that’s the first thing. [Jaz]
Let’s go with both, let’s talk in them in imps first and then scan- [Lincoln]
Let’s start with the impression because most people will still do that. But within a year or two most people will be scanning and once you go scanning you never go back. But the big advantage of scanning so I was late convert to scanning but now I’d never go back. The big, there’s two big advantages. The occlusal records with scanning are far superior than anything you can do with bite registration. Like the first time I did a full arch of ceramics with prime scan. And like 10 units designed, milled but if I pop them in bang 10 occlusal dots perfect. I’ve never had that from a lab ever in my entire life. It always takes adjustment or a secondary bite record. And then the second one is you can tell if your scan is bad while you’re doing it. Whereas an impression you have to wait three and a half minutes. Pull all the retraction cords out and then you basically want to go outside and drown yourself. So when you find out that but the distal of the second molar has a drag for the third time and you have spent 45 minutes taking impressions. The pain, okay.
So, impressions, your dental school is correct. Everyone does the right procedure at dental school. They graduate or Satan comes and sits on their shoulder and says, ‘I think you only need one cord or you need no cords.’ Usually Satan comes in the form of temptation comes in the form of you know, some experienced dentist saying, ‘Well, that’s not necessary coming here, young man, young lady, I’ll tell you the correct way to do this.’ So, and then you spend longer taking your impressions because you take the first impression, and then it’s rubbish. And then you take the second impression, and it’s rubbish. And then you take the third impression you go, ‘Look, I got an impression without using two cords. Whoo!’ Okay, so impressions, two cords, you put a skinny cord in. For me, it’s Ultrapak 000, not because it’s the best thing on the market. It’s just because it’s what I have used for many years, and I’m reluctant to change. It is a braided cord so it doesn’t tear apart so much. Someone has told me recently there are better cord, so I might have to change my ways.
So that one, if the tissue is not bleeding, I don’t soak it in anything. If it’s patient with a bloodbath, I soak it in ViscoStat™ Clear. And then I pack that cord that will basically stop the bleeding. And it stops the exudate you know the or crevicular fluid. But it doesn’t give you lateral retraction. Now, cord is not meant to retract tissues vertically. So you’re not trying to get a deep sulcus you’re trying to get a fat sulcus. So then the second cord, which in my case will be a Ultrapak 0 because I don’t like to use too many things. And I’m not usually going to dip this one in ViscoStat™ Clear. Unless once again, it’s still a bloodbath, which preferably it’s not by this point, but if it is, then I will pack. You just dip it in, and then you got to wipe off the excess with gauze. Otherwise, you have too much excess and it’s going everywhere. And it tastes awful.[Jaz]
Ah, the patient’s always complained about the taste. [Lincoln]
Yeah, maybe you should stop slapping it on their tongue, Jaz. So- [Jaz]
I think there’s something to be learned here for me. Yes. [Lincoln]
Advanced techniques. Don’t slop the ViscoStat™ Clear on a patient’s tongue. I mean, yes, they do. I mean, you get those patients who like to be helpful. So you’re doing a very delicate procedure. And I think, you know, I think the best way to help you would be to get my tongue and stick it right in the middle of your bone graft and flick it all about. So certainly, that is a universal patient problem, fat cord. So when you use the Second Cord, which is a fat one. You want to first of all, for neatness and photographic excellence, always start on the same part of every tooth. So always start on the mesial of the tooth. And then you pack always to the buccal, and then you go distal, and then you go lingual or palatal, and then you go back to the mesial. And then you cut the tail. And that way, all your tails will be on the same side of every single tooth. And so when you go to remove them, if it’s like five or 10 in a row, it’s easier to grab the tails. And when you take a photo, it looks nice. Now, the secret, of course, is you have to wait five minutes, if you want your cord to work. This is where everyone goes wrong. And when you pack that second cord, you don’t want to pack it below the tissue. Only packing it equigingival because you’re using it to push the tissue laterally. You’re not trying to get a deep sulcus that’s so important- [Jaz]
I want to add Linc actually, when I made that mistake before of putting the zero in too deep, what tend to happen? And I think you’ve demonstrated this before again, in your cases of how to avoid this is that the tissues then sort of sulk in, right and it has the effect of you want. Collapse, that’s a good word. [Lincoln]
Yeah, it collapses on top. And if you are placing your second cord, it’s really deep sulcus, you sometimes can’t help that as you’re packing it. The tissue collapses over the top and you actually have to then if you’ve got a long enough piece, continue around the tooth a second time, or cut another piece and go around the tooth a second time you have three cords. But you have the second cord cannot have any tissue over the top or the third cord. So there are some times where I’ve had to go around the tooth you know two times. And on the distal of a lower second molar where you’ve got really thick tissue. Or an upper second molars, sometimes you need even three like you do what you have to. Or sometimes have to get a piece of cotton out of your cotton roll and stuff that in to get enough lateral retraction. So it doesn’t matter how many bits of cord you do, but you must not have tissue collapsing over the top and then you have to wait five minutes because if you don’t wait five minutes, the tissue is not retracted.
So if you place the second cord and then one minute later pull it out the tissue immediately collapses and you lose everything. And then if it was bleeding, it immediately starts bleeding. And why do you need two cords because when you place one, it always starts bleeding when you pull it out. Unless you’re one of those dentists where every single patient who had perio surgery and soft tissue grafting and stuff, and that’s just not realistic for most general dentists. And the reason that the width of the sulcus is so important is because silicone has a certain surface tension. And so if that gap between the tooth and the tissue is too narrow, the silicone actually can’t flow in there. So it exceeds, the viscosity is not low enough, even the Light Body silicone is not low enough to flow into such a tiny gap. Or if it does, it will be like this tiny fin of silicone and it will tear off as you pull in and push it out. So if you have a big fat gap, you know, that’s half a millimeter wide or a millimeter wide, the silicone will just fall in there and it won’t get bubbles, and it’s easy. So that’s-[Jaz]
Do you use electrocautery for when the tissue start to collapse over? Do you have an electrocautery unit? Do you recommend using it as an adjunct to your cording? [Lincoln]
So, if you have one and you’re good at using it, then sure use it, I don’t have one. Oh, I do have one it’s in storage somewhere. It’s like, I don’t know, I just never got in the routine because I didn’t need it very often. And then when I did, I couldn’t find it. So it’s currently with the amalgam carrier. [Jaz]
So real world. [Lincoln]
I mean, it’s the same with lasers. Lasers are great. If you have a laser use a laser, I don’t have a laser and and when I teach because most people don’t have lasers, I don’t want to teach a procedure that most people can’t do. What I do know is that I have to reiterate five minutes of waiting will seem a very long time. If you don’t set a timer, you won’t wait. And so if you don’t wait five minutes, your second cord does nothing you most will not use it. Now, if we go to scanners, often with scanners, you don’t need a two cord technique, but you may need to go to an even bigger cord than a zero. So with a scanner, if you have one big fat cord, and you can get it down and it retracts the tissue laterally. Particularly if you’re only doing a small number of teeth, then that gives you a clear margin. And that’s all you need. Because with a scanner, you don’t need very much or almost no vertical depth to your sulcus at all. You just need a clear edge. So basically, as long as that big fat retraction cord is very slightly below, then you’re going to get a good impression, whereas- [Jaz]
A good scan. [Lincoln]
Well, yeah, sorry, good scan. So, now I’m only moving into trying that technique. Now with both of them though. That is when I’m using doing a standard prep like a prep with some type of margin. So chamfer shoulder something like this. The moment I’m moving to vertical preps, now I’m moving to Teflon because with vertical preps you can first of all you can prep on top of Teflon. Whereas you can’t prep on top of cord because if you prep on top of cord, even with a safe ended bur, the cord will helicopter and frightened the life out of you. You know it’s like you know, nice relaxing afternoon, warm sun trickling through the windows, leaving dappled light on the floor and mixing. And you have a piece of cord helicoptering on your high speed bur frightening everyone so.
So Teflon, you can prep on top of and you can prep even with a diamond bur but it will erode it away. But with safe in the burs, I will pack Teflon sometimes. Sometimes I had a case the other day where I actually purposefully, it was a perio case and there’s just a few little areas where it wasn’t healing. And in a case like that, I will actually purposely prep without Teflon as close to the bone as I can and cause as much damage to the surrounding tissues as I can and prep the surface of the tooth. So it’s perfectly clean and the tissue heals very, very well. It’s like the ultimate periodontal therapy so well as good a periodontal therapy as you get without flipping the entire arch. So-[Jaz]
But in that case, Linc, like you’re probably doing a long term, temporization provisional. And then when you come to actually scanning at that point, you’re gonna go back to your PTFE at that point? [Lincoln]
Depends. So Teflon is the cord of choice. First of all, if you haven’t used Teflon, go and read on Instagram, I’ve got a little infographic on how not to get incredibly sad when you try and use Teflon for the first time. Because the first time you use Teflon, it will just keep coming out. It’s not an easy thing to use. So we’re I’ve prepped down to to the gingiva. And I’ve created a giant mess and whatever and I’ve let it heal. When I come back the next time it will depend on how the tissues looking. Teflon is very aggressive. It’s a very, very aggressive retractor. So it retracts far more deeply and aggressively than cord does. Because to get it to actually stay on the sulcus you have to pack it really, really hard. And so it would depend on how much retraction I want as to whether I’m going to use Teflon at the second visit or not.
I mean, if you have theoretically, if you’ve had beautiful temporaries in there for a while, then you shouldn’t need any cord that’s the original BOPT technique or any little fine cord. This is where you get into and I think it’s very important for people to know that you don’t always just like choose the method and you get it right. Like sometimes you’re getting halfway through you go, this is not working and then you do something else. So mostly I’m using Teflon when I want to do a single stage, vertical prep, take the scan on the same day. And I’m going to place a thin cord that’s usually either a thin cord that’s been treated and then put Teflon over the top. Or I’m going to place just prep and then place Teflon and then place a thick cord to retract the sulcus and do the scan then. And scanners love Teflon, because the color contrast between the white Teflon and the edge of the tooth is so profound. They just pick it up really, really, really, really well. So this is like there’s the standard method and then there’s the ‘This is not working. I have to try something else method.’[Jaz]
Well, yeah. Oh, you mentioned it in Instagram, the Teflon frustration posts. I’ve got it up now. That got so much love on Insta because it’s such a pain. I said it look, I said pain point for dentists all over the world. So I think that was awesome. So guys, if you haven’t seen it, I’ll pop it up on the screen now. So you can see that and follow the link in the show notes, to find that post and all other post by Lincoln. And Lincoln is actually Lincoln and Pasquale Venuti. When I went see them in Sydney some years ago, who taught me about reconsidering how I cord, or how I isolate for class fives. I went through the stupid phase of using rubber dam and the yen, the breakers and as Pasquale described at that event, it was like a circus. And then I switched to Teflon, in the sulcus and under magnification, I noticed how much drier I was able to keep my field. And so, I, my bias for class fives is Teflon. Now, how about you? Is that something that you’re still doing? Or have you changed? Or have you found a different way to isolate the sulcus of class five restorations? [Lincoln]
There are many things in dentistry where you do them first to prove that you can and then once you’ve proven that you can do them. Now you’re well able to choose whether it’s a good idea or not. So I went through a stage of rubber daming everything. So I proven that I can do it and now I can not rubber dam where I think it’s inappropriate. And there’s a number of times when rubber dam is inappropriate, and one of them is the class five, mostly particularly at the front of the mouth. My isolation technique of choice will be an OptraGate to hold all the lips and cheeks out of the way. And then if it’s a deep class five, in particular, I’m going to place Teflon and then I’m going to often do a gingivectomy down to the Teflon. So I can find the margin because often, when you have a deep class five that’s slightly sub gingival, then the tissue gets inflamed and it gets even bigger still. And also that inflamed tissue, you can never stop at bleeding.
So you want to place the Teflon, cut the tissue away if you need to. And then scrub with this ViscoStat™ Clear Or put some cotton on there that soaked in ViscoStat™ Clear and leave it. Where people have the massive stress is they panic. So they cut the tissue and then it’s bleeding. And they go, ‘Oh, my goodness it’s bleeding? How will I ever do this filling I’ll never be able to do the filling. Oh my goodness!’ And so what you need to do is go first of all, I’m going to retract the tissue. Do not think about anything else, except that one part of the procedure. I’m going to retract the tissue, and I’m going to retract it properly. And that’s it. So then get your Teflon and retract the tissue. Now you’re going to go I need good access to the cavity. Do I have that? If not cut the tissue and don’t think about the bleeding and all the other things because you deal with that later.
What happens is once you start thinking about okay, right now I need to do retraction. But what if I start bleeding? Okay, now you’re thinking about two parts of the procedure simultaneously, and then you go, but if I retract, and then I can’t see the cavity, I won’t be able to restore it. And then it might start bleeding. Now you’re thinking about three parts of the procedure. And then you go, and then how will I shape it? Now you’re thinking about four parts of the procedure, and you’re not even done one. And so what’s happening is that you are using up your entire mental capacity, and you haven’t even started doing something. And so now it’s really tiring because you’re thinking about four things simultaneously. And people cannot multitask. The idea that you can multitask is wrong it is not physically possible to multitask. What you actually do when you think about more than one thing at a time is you switch. So a fighter pilot, they can’t multitask. But fighter pilots are chosen because they have a very low switching cost, that energy that they burn to switch between three different tasks is very, very low. And they’re physiologically chosen, because they can do that.
Now as dentists we’re not chosen, we don’t go through a fighter pilot selection test, which like a fighter pilot selection test is a heavy like a little video game that they have to pay whilst recognizing colors and doing math equations simultaneously. So that’s how the selection criteria, we don’t get that in dentistry. So, if you continually change and think about four different things, you are draining your brain’s energy massively. You’re fatiguing yourself. The second thing that happened is that if anything goes wrong in the procedure or anything is not quite right, you are already maxed out. You have no reserve left to deal with this. And that’s when you’re just staring at the tooth. And you pick up an instrument and you put it down, you pick up another instrument, you put it down, and you’re actually doing nothing effective. It’s because you’ve actually, you’re like a computer that has maxed out their memory, it’s now crashed. And so it’s common for dentists to crash and that’s when they just go, ‘I don’t care anymore, just do anything.’ Okay, because they literally have given up because they have no capacity left. So only do one thing at a time. So, place the retraction, get it perfect. Like imagine you’re not allowed a second chance. So, if you don’t get it perfect the first go, you’re not allowed to go back ever. Okay, and a crocodile eats you. So like, cool down-[Jaz]
Only in Australia, does that happen? [Lincoln]
I’m trying to think of something dangerous in the UK. [Jaz]
There’s no such thing even when you compare it to Australia, it’s just there’s everything’s tame. It might you know, it’s everything’s- [Lincoln]
You turn up to Wimbledon, and you’re wearing the wrong clothes for high society. Okay, that dangerous? [Jaz]
Yeah, that sounds more like it. [Lincoln]
You’re dressed in a tux and everyone else is wearing cool whites. Oh! That level of danger. And then if the tissues in the way, cut the tissue, only focus on that like gingivectomy’s very simple procedure. You get a tungsten carbide bur, bat bur any sort of bur actually just not a coarse bur. And then trim the tissue out. Turn the water off so that you get sort of a cautery effect. And then you go okay, now I need to stop the bleeding and then pack some cotton to ViscoStat™ Clear. And that’s it, don’t do anything else and wait five minutes and do nothing else until it stopped bleeding. Okay, now, you can focus on the cavity. So like, this is why dentistry gets stressful because when it’s a procedure that’s like multi-stages. So you know, it’s first you’re doing a DO composite, okay, single procedure. Now you’re doing a DO composite, plus, dealing with sub gingival restoration and gingivectomy and bleeding gums. Now you’re doing actually like three procedures. And if you try and think about all three at once, you’ll just crash. So you only do each step one at a time. This is when dentistry stops being stressful when you do one thing at a time. [Jaz]
I think that’s going to resonate so well. With everyone listening certainly it reminds me of errors I’ve made. And I think everyone listening is just nodding their head. And I think that was, you know, you’ve been on point today with your humor, Linc. I’ve enjoyed it a lot. So the lesson there was guys with class fives one thing at a time. And yeah, Teflon is something that you’re still a fan of as well. And it works well for class fives. And certainly you made it clear that rubber dam isn’t really well suited for Class Five, right? [Lincoln]
Yeah, I mean, it depends. Rubber dam is well suited for easy Class Five. So if it’s an easy Class Five use rubber dam. If it’s a deep one, or it’s sub gingival, then I can do it. But the thing is, you’re going to place a Brinker, you’ve got to retract the tissue, there’s always a risk that your Brinker will slide off the tooth right at the most crucial part. And then it rubber dams don’t necessarily give you good water seal. And so quite often, the water is wicking up underneath rubberdam. And so then you have to place Teflon anyway. And so at that point, it’s silly. I mean, another example of this is, we have to do bonded restorations. But if you look at most deep margin elevation books in the world, the deep margin elevation bid, which is the most crucial part of the entire restoration is done without rubber dam, because it’s impossible. So like, you know- [Jaz]
So true. [Lincoln]
And also keep in mind that there are significant differences between how clinics run. So like my experience in many parts of Europe, particularly Eastern Europe is that people don’t use the same amount of dental assistant capacity as countries get more expensive. And as time and money get more expensive. So you know, in London, your rent is very expensive. And so it’s not the cost of having staff is less of a concern and is more just a mindset of you know, you have one assistant or maybe even two so that you can work really fast. And so if you’re working with one really, really good assistant, they can help you or two, particularly if you’re working with two. You can have one assistant that’s entirely devoted to isolation and controlling moisture. And then you can have another one who’s doing all the other stuff. And so this makes a big difference. Whereas if you’re in a small, you know, like I have some colleagues who are amazing dentists, but they work often alone. Like they have one assistant who also does reception, and sterilizing. And so that assistant is off a lot and these dentists have to use rubber dam for everything because it’s like their dental assistant. So there is a huge variation in you know, culture and the business practices of how practices run and that actually has an impact on the way that you isolate as well. [Jaz]
I didn’t even consider that actually. Very good point. Now Linc, I just want to say a wrap up this episode with an announcement that you’re coming to London to speak to dentists. I mentioned the previous episode as well. And the the main title of your event is brilliant guys, you have to listen to this right. It’s very much in tune what we spoke about today. And as you can see, Linc is such a real world dentist like he’s a world class dentist. But what I love about Linc is he’s real world, he treats real world patients. He understands our struggles, they’re real. So the topic is DE-STRESSING DENTISTRY, from class one composites to complicated crown preps. And I think that what I love is when he wrote this up, he said, ‘According to the University of Instagram, all patients one mouthful of veneers, and tiny little super gingival classroom composites.’ And obviously, I was tongue in cheek, but it’s such a great theme. Just give us a flavor about the other kind of things that you’re talking about on that day. [Lincoln]
I basically just want to talk about the most common procedures that causes stress, which is our everyday procedures. But when they’re difficult and class two composites or composites in general, or crown preps that are deep, badly broken down with patients that are difficult to get down, and they’ve got a big tongue, and that gagging. That is because I’m a multidisciplinary dentist, I can tell you that a deep class two composite can be more difficult than a sinus lift. So, not more difficult than a really difficult sinus lift, because there are some really difficult ones. But on average, the only reason that we think sinus lifts are more difficult than class two composite is usually we’ve done about 10,000 class two’s, and we’ve done about, you know, either zero or a very small number of sinus lifts. And so actually, the most common procedures that we do in dentistry are the most difficult. And the only reason that’s not recognized is due to the massive repetitions that and the fact that we get taught them early in life. But I still have difficulty so the things that we’ll be talking about is the actual techniques of it. But even more importantly, is the psychology of how you maintain a clear head and don’t fatigue. And you will have heard me mentioned some of that, but this is most crashes in aviation, which is the equivalent of when you do a procedure, and it just goes out of control. And you end up, you finish the procedure, you don’t feel good about it.
Because you know, it wasn’t a controlled procedure and so you’re not sure if it’s going to be greater. Mostly that occurs, not because you don’t have the skill or the knowledge, or the ability, it’s because what’s called human factors, which is the stress and the mental fatigue got to you. And under stress, this is well researched, your ability reduces by 85%. So if you can only just do a procedure, when you’re relaxed, you actually cannot mentally do it when you’re stressed. And so it’s not just about how do we make the procedures more of a straightforward protocol. But how do we mentally and psychologically do a procedure and prepare ourselves for procedures so that we don’t end up in that massive mental fatigue state where everything just goes out of control, and you finish the day and you want to quit the profession. So those two things very important that latter part of it is not studied or talked about, but it is talked about very much in paramedics, in fire brigades, in aviation, in anything where people die. They study human factors, which is how you deal with things under stress. So we’ll talk about that, and how to deal with that. And I think that bit is almost as important as the clinical part, maybe even more so.[Jaz]
You’re so right. It’s stuff that’s not talked about enough. And that’s why I’ve always you know, enjoy going to your live lectures, online stuff, because you talk about the real nitty gritty things. And also, you know, you draw these comparisons with other industries. Aviation is a common one that you that you talked about as well, and howwhat we can learn. I know, you talked about ophthalmologists about last episode about how they have so much training and you made that comparison, you’re full of a lot of wisdom, and I can’t wait for you to share it in London with us. So guys, I’ll put everything in the show notes. Linc, thank you for talking about retraction cords. I know for a fact I guarantee it. This episode will get a lot of engagement because something as basic as retraction cords, as we talked about a few times ago, actually, the basic things are the things that really, really, really are the most helpful when we’re creating content to help people. So I think that’s going to go down really well. As always, I thank you for your time despite the time differences. [Lincoln]
Well, it’s always always fun talking to you Jaz. You are a man full of energy and it’s very exciting. But the thing about basics is just because something is basic doesn’t mean it’s easy. This is great mistake. So the basics of dentistry are frequently very difficult thing. So it’s like simple. It’s simple, but that doesn’t mean easy. So we’ll talk about the basics, but it’s going to be mostly the hard basics, the ones that ruin our day. So look forward to it- [Jaz]
It is essential for all dentists I think but if you’re new in your career, I think this will save you a lot of heartache, heartbreak, stressful moments to sort of get into the mindset of how to fulfill the rest of your career. Working in a reduced stress way. So de-stressing from class one composites to tricky crown prep sub gingival dentistry. A lot of what we talked about today. So I know links working really hard to put on really good content for that as you expect from Linc. So Linc, we look forward to seeing you here, mate. [Lincoln]
Well, I look forward to coming and you know, then you can take me to a good British pub afterwards. [Jaz]
Of course! Brilliant. Thanks so much!
Well, there we have it guys. Lincoln Harris on sub gingival dentistry. I hope you gained so much value from that I know I did. Yet again, I’m gonna go ahead and get an infographic made and a summary of this podcast because there’s so many little gems in there and don’t want to miss anything. So I will email you that if you’re not already on my email list, go to protrusive.co.uk forward/emails. And once again, Lincoln is coming to London this is a big deal guys, right. He doesn’t often make this trip and he’s lecturing live for the full day from class one composite to complicated crown preps. Come and join us! Saturday 1st of October that destress.dental, D-E-S-T-R-E-S-S dot dental. That’s the URL. Book on now and definitely do it for 14 to September to get that early bird rate. Anyway, I’ll catch you in the next episode. And of course if you haven’t listened to Episode 54, go back and listen to that one because it’s more of Linc and I know you would have liked that. So I’ll catch you in the next one guys and I hope to see many of you in London on the first of October.