Rubber Dam Isolation – PDP026

Jaz’s Introduction: Thanks for everyone who voted on the social media channels. But what you voted was for Harmeet Grewal episode and rubberdam isolation. And the next episode will be to drill or not to drill caries with Louis McKenzie, so I’m looking forward to that one. I won’t blab on for too long. I hope everyone out there. I hope you are doing really well. And I hope you’re getting to spend time with family. And I hope you are thinking about the day that we come back into practice. How can we come back bigger, better, stronger. And of course I hope we can use this opportunity so when we head back to work we can be fresh. My Protrusive Dental pearl is that some episodes ago I shared my customer screen. Now since then, Richard McIndoe shoutout to him, has modified it and added the goals, the patient goals section, which I think is so important. But I had a lot of messages from a lot of people saying, Look, I’ve got this CSV file, the which is the customer screen, but I have no idea what to do with it. So I’ve gone ahead and made a video on YouTube about how to actually install a custom screen, and then also how to pre load the custom screen with text in there. So not having to always type the same thing. So for example, if you take a bite wing, usually 9 times out of 10, the justification for bite wing is to check bone levels and for interproximal caries. And that can be written there within the customer screen. So it’s almost like a template within the custom screen. So if you’re one of my email subscribers to the newsletter, and episodes, you will receive an email already with that. If you’re not, then when you go to protrusive.co.uk pop up box will come up, sign up for the newsletter and the first email you’ll get, the welcome email will have the custom screen and the YouTube link of how to install a custom screen. So that’s all there for you. So that’s getting you to think about when we head back to work. How can we make our note taking better, more efficient? How can we work smarter. So I hope that’s useful to you. Now let’s jump in with Harmeet Grewal and rubber dam isolation.

Main Interview:

[Jaz]
Right, Harmeet, thanks so much for coming on the Protrusive Dental podcast. Great to have you.

[Harmeet]
Thank you.

[Jaz]
You are someone who’s now redoing great things in education with rubberdam, which is such an important thing. But just before we get into that, we’re here in sunny counties, is it Cheshire?

[Harmeet]
I’m not sure. I don’t know where we are just up north.

[Jaz]
We’re in a private area. We could have pretended we’re in a five star hotel, but we’re being very real with you. And we’re here for the Dawson Academy at the moment, we thought be a great opportunity to learn from homie. So yeah, thanks for waking up in the early hours to record this before an intense session with Ian Buckle. For those who’ve done Dawson Academy, you’ll know exactly what I mean. So Harmeet, how did you get started with your journey in sort of getting using more and more rubberdam and getting to a point where you think you’ve been quite proficient with it?

[Harmeet]
It’s just trial and error really, I mean, I was kind of, I started using it as a time where I felt like I needed to use it not necessarily knowing why. So the reason I was using was thinking, I’ve been doing these composite courses. I think that I’ve just done Jason Smithson’s a lot, okay, he’s using rubber dam, I’ll see the logic of this. But there’s no courses out there. It’s kind of for me, it was a trial and error. It was going in and just doing it day in day out making the mistakes, and then learning from them. And then over time, it’s just like anything, isn’t it? You’d more you do something, the better you get at it. And then he kind of got to a point in terms of where the teaching led to. It was literally a conversation with a therapist. So I was working in Hitchin at the time and she said Harmeet Listen, I’ve got group of friends ladies and composite staff but can you teach us like rubber dam as well like a good day on competent rubber dam? So All right, let me put something together. So I started putting something together and I thought actually like a lecture on rubber dam. People think it’s like a quick topic actually, if all the bay, easily.

[Jaz]
Especially if you have a hands on component.

[Harmeet]
Exactly. So we started talking and I set up a course and then the funny thing was I was like I need to price this now. Okay because you know You listen, everyone knows you do a course, there is a charge for it. Okay, so, but then I said, Alright guys, this is what I’m gonna do this how much it costs? suddenly everyone just went quiet. You know what, I’ll put the effort? I made this presentation, I’ve got this idea. So let me just try it. Yeah, let’s roll it out on online and see if there’s any legs in this. And I just put it out there. And I think it was within 30 hours it is sold out the first course. And then I rolled another day out and the same thing. 24 hours, it just sold out again.

[Jaz]
It’s the demand is there. And then that’s exactly what we’re the one the first question want to ask you with that, at least be nicely is. Why is the demand out there? And why should we be using and learning rubberdam?

[Harmeet]
Okay, so two questions. The demands out there because I think it’s one of those things rubberdam that I think it’s not, it’s, it’s poorly taught, if it’s taught at all. Okay, because it’s something that’s skimmed over, why it skimmed over, who knows, it’s, it could be that when people are at uni, there’s people have biases that, you know, some people justify not doing things, that could be a tutor, you know, just saying, Well, I don’t think you need it, therefore, I’m not going to teach it or it couldn’t be someone saying, Well, actually, I don’t know how to use it myself. So therefore, I can’t teach it. So it could be

[Jaz]
I 100% agree with that. So my experience with that was the gdps, who were also part time tutors at the dental hospital. They weren’t using isolation day in day out. You know, I probably even say that, having seen some of their root canals on outreach. They weren’t even let’s not even get into the topic of endodontics. But so if the tutor themselves were not proficient in doing it themselves, how can they teach it to a student? So I think a large part of that is depends on where you were taught and whether the tutor was doing it with them.

[Harmeet]
100%. And then I think the other thing is Why? I think as dentists we always want some evidence, don’t we? We always want some evidence because it..

[Jaz]
We love the nitty gritty.

[Harmeet]
We think it’ll help us sleep at night. Actually, there’s always evidence for, always evidence against.

[Jaz]
Why do you use them?

[Harmeet]
So I always always base my decision on logic. Alright, logic is one thing. And that’s logic around the decent dentistry. Actually, even more important is for me is reduce stress, and improve clinical practice. Now, if you say to any dentist, can I reduce your stress and improve the quality of work? He’s gonna say, No, no, no. The first that’s always stress. Stress is sometimes up because patients are difficult. We’re working in a difficult environment. Patients don’t want to be difficult first of all, you know, they know that they’ve got an awkward mouth and they apologize profusely, don’t they? Often they do. It’s not their fault. But actually, the process of putting a rubber dam on you’re kind of eliminating that patient for a while on you. It’s just you and their teeth. Tongue’s gone. Everything else is gone.

[Jaz]
Everything’s out of the way and quite often they fall asleep.

[Harmeet]
Exactly. And then but that stress element, then I was laughter in my lectures about the situation where you have a matrix band on and about 15 cotton rolls, and your hand cramp. And you remember that? You can’t see your composite and we laugh about it. But we’ve all been there. So now you can put rubber dam and breathe for a minute.

[Jaz]
That’s the main reason I use it. I feel so much more relaxed as a dentist when it’s on. I don’t have to constantly watch everything. Okay. One of my patients I’ve been if that ever happens to you, he probably has because I see it so much is when our patients in the middle of a root canal. I think she was diabetic. And she just had to use a loo. That she had to use. That’s fine. Yeah, go come back. Okay, I am no, no fear that she’s going to look at things like this is a total peace of mind. Yeah, has happened to you?

[Harmeet]
It has but then I kind of I guess I’d normally forewarn people in terms of like, you’re going to be in the chair for while this is how much, it’s longer it’s going to be. So they kind of caught up on that. I need to pay for parking. I probably need to go to bathroom. I need to probably do this. But there’s times I need to go.

[Jaz]
or they need to cough. And they can just go cough into your hand. Mess up anything. Whereas if you’re not using isolation, yeah, to that degree. You’re always stressing about the cough. You’re always stressing about the tongue. You always think about the anatomy.

[Harmeet]
Yeah. I think patients cough because sometimes they don’t know what to do. So a tip for everyone is just your communication with the patient. Actually, for a lot of patients they might have rubberdam, I’m actually explaining before you do the treatment. So examination stage, what you’re going to do, pictures, films, and then obviously in the day, just reiterating what you said.

[Jaz]
Do you use an analogy to explain to patients what you doing with rubberdam?

[Harmeet]
I kind of explain it at least it was one of the reasons actually for using it was on the logic of adhesive dentistry. So when I was talking about you know those questions why to use it, it was I always think of Firstly, let’s look all the guys we look up to Magne, Dietschi. I mean, that does that two in the world, but there’s always a common theme amongst these dentists isn’t it, any work they display, always done on the rubber dam, must be a reason. But I’ll bring it back to like, what are we doing essentially if we kind of being crude with just glueing something to something else aren’t we? So if you’re broke something at home For example, I wouldn’t you know, if I broke a plate, I wouldn’t just pick it up and just try and stick it back together and probably want to clean it, make sure it’s dry. That’s the kind, when you pick up a packet of glue that’s what it says clean dry surfaces. And that’s why think about teeth. So that’s then how I explain it to the patient. Why am I using this?

[Jaz]
I always mentioned every and every episode, and I’m mentioning quote from Zak Kara. But Zak always says it’s like painting in the rain. And that’s how we know he said,.

[Harmeet]
He said, it’s painting the corridor through the letterbox.

[Jaz]
[inaudible] brilliant analogies, I always. And I always often say it’s like an umbrella and everything is gonna be protected. And also, you don’t need that horrible feeling that you have when you’ve water at the back your throat and you’re sort of flooding. You don’t have that anymore. Yeah. And patients bind to us,.

[Harmeet]
You know, you can say things in a nice way. And then even just think the explanation is like, actually, once it’s on, I can concentrate on doing really nice work for you. Which patients gonna say, I don’t want you to do nice work for me. So don’t use it.

[Jaz]
They won’t say that. But what they will say afterwards is that oh, my God, this is such a new technology.

[Harmeet]
Yeah. It’s funny, isn’t it? It’s have been around since the 1870s.

[Harmeet]
Well, yeah. 1860. And it’s, it’s crazy that you say is taking us this long, but like I said, it’s just because it’s poorly taught, but back to the communication to the patient is purely, I then put it on, explain to them how they can swallow and breathe, you know, so they feel in control. And then give them a few minutes before we start. And that’s probably the best way to communication actually becomes important in this place. Important in everything, isn’t it communication? So yeah, but that’s a different topic.

[Jaz]
Absolutely. Are you part of the rubber dam police?

[Harmeet]
No. I, you know, it’s, I don’t want to be that person who breaks people for not using rubber dam because I think that’s unfair. Because there are some instances where, you know, actually, you’ve got to think, is this gonna be a help or hindrance?

[Jaz]
Let’s get, Well, that was one of my questions. Let’s go into that. So when does rubberdam actually become a hindrance? Rather than a benefit. Any specific scenario for you? I have a few in my mind. But when you recommend?

[Harmeet]
It depends on personal comfort. So some people might say I composite veneers at the moment seems to be the buzzword, doesn’t it? Now, having a rubberdam on with gloss ties, and then you getting resin composite in there. It’s messy, isn’t it? Sometimes it’s not that you don’t use rubber down, but sometimes I apply split dam, might be a different option. It could be that you’ve got a wire retainer. Well, it could just be you’ve got heavily broken down teeth that you might not be able to clamp, you know, then therefore you if you can’t get a clamp on it. So how you’re going to get rubberdam on the teeth. Or it could just be emergency situation.

[Jaz]
Yep. In the real world

[Harmeet]
Real world is like you know, you’ve got small chip on upper incosors. And let’s be honest, easy enough to isolate. Exactly. You could just cotton rolls in the access. It’s why not? I’ve done it. You could have a really good patient with good mouth opening. You’re doing a really small occlusal cavity on the six. I’ve done it without it.

[Jaz]
Stress factor is way less on there.

[Harmeet]
Yeah, exactly.

[Jaz]
Class fives, either. I don’t use rubberdam. Because I feel like it’s just in the way.

[Harmeet]
Yeah. Again, you don’t need to again, maybe on the lowers. It’s a little bit again, I sometimes prefer a split dam. It’s still a little bit of isolate. Yeah. But it’s something but yeah, I don’t like to because I understand that people, you know, we all have different working environments. And you know, it’s, I don’t think that just because you haven’t used rubber dam, therefore, you’re a bad dentist. And yeah, so I don’t really agree. And, and also, you know, I guess another thing this is going social media, I think people think this is been using rubber dam. People think the rubber dam needs to be perfect. You know, if it’s not inverted, or..

[Jaz]
I’m so proud of the rolls on my rubberdam and I’m like, you know, fine as isolated I’m happy. Then you go and make it neat and nice. It’s good. It’s really good for your dentist OCD. It’s good for your stuff. But it doesn’t doesn’t have to be perfect. I love it.

[Harmeet]
And I always say like, you know, if you’re just starting, start now get perfect later. That’s a phrase from a guy called Rob Moore.

[Jaz]
Absulutely. Rob Moore. His podcast is called the Disruptive Entrepreneur.

[Harmeet]
Exactly. So he’s brilliant. And it’s just, yeah, people just, that’s admirable, we all want to be perfect. Okay, but like, you know, sometimes just make a start. And at the end of the day, always realize what we’re doing it for. It’s not for social media, which is nice, because I do think social media is brilliant. But there’s, it’s for the patient, isn’t it? Then it’s going to benefit us in terms of our clinical work, but then the afterthought is Alright, this could be a good tool that I use, whether that’s to teach people, teach patients or the dentist, but that should be an afterthought not, you know, the forethought?

[Jaz]
Well, if you’re getting started in rubberdam, then I think like you said, start now and get perfect later. So book in that extra 10, 15 minutes for your first case, for example, talking therapists, young dentist to fit I know plenty of not so young dentists who don’t use rubberdam actually now clocking on that they want to do rubberdam just book in some extra time, right? Take it slow. It might be embarrassing first few times as your nurses trying to floss and that sort of stuff. And you’re struggling. Yeah, it’s just like you said, start now get perfect later.

[Harmeet]
Well, that’s it, it’s just giving yourself that time. I think sometimes as dentists, we’re guilty, we don’t give ourselves time we go and try and implement something in the times that we would, you know, doing it in previously, if that makes sense. You know, might have do Michael Melkers and not be booking 45 minutes for the composite, and then still expect to do their rubberdamn now, in addition, I say, just give yourself time, you know, like you need to,.

[Jaz]
And your nurse needs to be in, you know if your nurses never used rubberdam before and you’re suddenly going to rubberdam course and you come back and say, right, we use rubber dam, and you just start using it. And the nurses, you know, finding this dusty pack of rubberdam. Everyone needs to be in on it.

[Harmeet]
Yeah, you’ve got to train your nurse and you know, what? Would you want to be sat there all day, not doing anything? It’s, you know, I just think sometimes we underutilized on nurses, and we don’t give them the credit that they do. Because one, they have to deal with a lot of us and we’re not easy personalities. And, you know, it’s not an easy job. It is a funny thing. Actually, I want to give it my best joke on the course I’m giving it away now. But there’s a video I do like some pre film videos of techniques. And then my nurses and often asked people I was like, You must think my nurses inherently really good. And I must have trained phenomenally. And people are kind of like Well, yeah, she must be, you must have trained her you know? And then I kind of say well, actually in that video, it’s not my nurses, that my mother in law. My wife’s in the chair as the patient and it was just literally a case I needed to film these videos. I said are you free? Can you help me? Yeah, like somebody’s got no nursing background actually just the act of me saying that can you just hold this and do this? It was easy.

[Jaz]
If a non nurse can do it and you know you can train your own nurses.

[Harmeet]
But then I always say to everyone we always quick as dentists we blame everything else but actually it’s often starts with us. And what we need to do is we haven’t communicated often dentist we communicate in eyebrow raises. Weird eye looks Huff’s and puffs. And Grandpa, but not words. Yeah, if we just use our words, we probably think you know, life would be a lot easier. So that’s another tip. You know, just talk to your nurse, get her involved and get I guarantee you there’s..

[Jaz]
Get the practice involved. Get the whole practice, you know, it treatment coordinator reception, you know, so that in the future when they say, Oh, you know, what’s that dentist like? What’s the treatment like? And I want people to have reception is that Oh, by the way, he used something called rubberdam It’s amazing. You’ll be very comfortable. So yeah, that’s maybe a far fetched example. But you know, with any treatment modality that you’re offering that you’ve changed your practice, the whole team should be in on it.

[Jaz]
That’s it treat your staff with it. I do any work my nurses needed, done it for free, done it on the rubber dam you know, she now she came from a practice and never use rubber dam we use is to the point I don’t have to. It used to be when she first started working for me “Harmeet, do you need rubber dam? [inaudible] Even for stuff I don’t need it for. she’s got the rubber dam out. I was like “Jesse won’t need it.”

[Jaz]
In fact she’s probably surprised. Oh, you’re not using rubber dam in this case?

[Harmeet]
She rarely surprised. She’s disappointed? When you say “Jesse, we don’t need rubber dam today.” Because it makes her life easier as well.

[Jaz]
Which the opposite of that is when you ask the rubber dam and then your nurse raises like, again rolls her eyes. That’s when you haven’t had that sort of session beforehand, whatnot.

[Harmeet]
It’s not because they’re closed off. You just need to spend some time maybe just kind of you know with them and training them

[Jaz]
Using the right rubber dam. In my experience in the past and want to hear what you are recommending now. But when I started from dental school, I hate rubber dam. We use a horrible green latex one that kept tearing. Alright, then I moved to that horrible purple one that it’s impossible to tear but it’s just in the it’s the ribbed one. It’s I think it’s latex free? Hated that as well. Then I found the Unodent one with the latex free. And that’s been phenomenal for me. Is that what you’re recommending? Is there something better? And how important is it to use the right rubber dam for the experience as a dentist and maybe even as a patient?

[Harmeet]
I yeah, you you always have your preference towards materials. So I use I mean the two that kind of seem to be go to, the Unodent or Nic Tone and I like the Unodent. It just works in my hands. I mean, all rubber dams can tear but then that’s based on often it’s maybe not punching the hole clean enough, maybe leaving too little distance between hole punches and then even sometimes it’s often the way people manipulate it between teeth, often not being patient and sometimes being a bit too aggressive with floss which pulls tears that can often be the biggest problem. So first it’s learning how to use it and then after that is preference. Now I like Unodent purely in the basis I use a heavy gauge. Benefit of a heavy gauges you get quite nice soft tissue retraction, easy to invert and everything but then also from but I guess photography of things. It gives quite nice contrast when you’re taking Your images and things. So I like that side of things. But again, it’s preference. I mean, if you speak to endodontist, I think some of them suggest that Roeko down the ribbed one because I think,

[Jaz]
I think the single tooth isolation, I can definitely see advantage. Very quick, easy, it’s got a lot of given it. For multi teeth quadrants and stuff, I found that a nightmare personally because he is quite thick and to flush it through is not as nice. So free from trial and error. I’m glad we reached that same illusion about rubberdam choices, but you know, us wherever you want to. I think sometimes you have to go through the difficult periods to realize what..

[Harmeet]
You’ve got give everything a try. But I’d say you know, if you want to start a good place try the Unodent, heavy gauge.

[Jaz]
if you’re getting frustrated from the rubber dam is probably the rubber dam as well. Adding to the frustration, I just felt that way with a green one, I had a massive shift when I switched rubber dam and it became easier and quicker for me.

[Harmeet]
Some time you know, it’s the little, it’s a small little details of rubber dam, that actually make the biggest difference. For example, we talk about the size of the shape, people don’t realize they come in different sizes that can influence maybe how tightly you’re stretching over the frame, or how much material you have to play with. Because you can imagine if you’ve got something stretched quite tightly, because it’s like an elastic band, I always say. So that then makes it more difficult to manipulate. Because if you’ve got something with a little bit of give, it’s easy to manipulate around clamps through. So it’s just little things like that the nuances I guess that make the rubber dam placement then a lot easier.

[Jaz]
It just get up everyone start using more more rubberdam to get that sort of hand skill. Yeah, that’s necessary along with your nurse who, do you get your nurse to floss? Or do you floss?

[Harmeet]
My nurse esentially what she’ll do is I’ll once I’ve got it in place, she’ll kind of stretch it over the contact area, some contacts, it has dropped through some areas it doesn’t but she’ll stretch it. So essentially, by stretching it, she’s thinning it out, holding it there while I gently pass the floss. Again, it’s teamwork. And, you know, it’s you can in terms of learning it, you can do it yourself. I did it myself, you know, you don’t have to go on a course, you know. But I always think the way I’ve kind of got better at dentistry is like why sit there and make a million mistakes? Why not go to the guy who’s already made those mistakes, you can fast forward that process. Hence, the course is.

[Jaz]
Down on the shoulders of giants. And I mean that in your case, your isolation I see is absolutely phenomenal. I messaged Harmeet sometimes I’ve got this clamp, can I modify this clamp in this way? And instantly he responded that Yeah, go for it. So you know, I trust me up to disable that. And it’s Yeah, like I say, instead of wasting that time, that embarrassment with a patient, you get a head start. And when you feel more confident that patient can detect that. So my next question Harmeet is, Oh, so a lot of dentists advocate using the Isovac or the Isolite, which is for those who don’t know, it is a it’s like a mouth prop. But it’s also has a something that sort of pushes the cheek out of the way, pushes the tongue out of the way. Yeah, it’s good. I’ve used it. My bias is still towards rubberdam even financially is a better thing to use rubberdam than Isovac unit per pouch has single use. But What’s your view on that? Someone who’s like very pro on Isovac who never use rubberdam because of it.

[Harmeet]
I’ve used isovac I’m, you know, I kind of got it in the last practice. And it was good. But again, expensive. And actually I just found sometimes they’re a little bit faffy to put in. I don’t think they’re always that comfortable. People think like, oh, they’re going to be very comfortable. But actually there’s a lot going on. Sometimes it’s just easier to use rubber dam and issue I found that I still found access wasn’t that easy with the Isovac in. Because you’re kind of limited to the angle of the approach, if you know what I mean. You know, it kind of makes it slightly narrower working corridor for you. So you can only really approach arch in in one direction. So early time I found it useful was for like kids. Okay, you know, if you’re doing like fissure seals and things. Yeah, that’s good. That’s the only time I find it useful. But otherwise, I just find rubberdam this easy, quick, deeper.

[Jaz]
See, that’s what Isovac people say they say, Oh, it’s so much easier than using rubber dam. But it’s what you’ve been exposed to and what you give an opportunity to. Yeah, I think if you I think for the complete beginner. Yeah. Isovac may be easier to you. Yeah, then the nuances of rubberdam. And going through the sort of the pain of the learning process. I can see the entry point into isolate. Yeah, but here’s my argument with those who use Isovac and Isolite is when you’ve got your Isovac in. Okay, and then you let’s say you’re doing a DO on a lower six. Yeah. And it’s getting close to gingiva. How many caries lesions are we restoring that I’m not near the gingiva? Very few probably, you know, often you’re doing the wedging and then there’s a bit of bleeding happening, right? And then you put your matrix in and you’re just having to whisk away some blood. If you just use rubber dam to compress that papilla. Yeah, that bleeding issue is gone. So I think as a macro isolation, Isovac is great, for the tongue and cheek, but on a micro level, the hemostasis it will be rubberdam.

[Harmeet]
I agree. Rubberdam definitely. Entry points. I mean, I guess entry points in terms of ease of use. But I guess financially, isn’t it? I mean, unless you’re going to actually put nice principlas you want to buy or if you’re prepared to fork out as an associate, but rubberdam is just yeah.

[Jaz]
I think my principal was happy that I’ve started, even though we had isovac that I stopped using it and just use rubber dam. I think Yeah, I would say it’s 250 a pop or something like that something something crazy. Right. So last couple of questions then. On when you teach your courses, yeah. And you have delegates of various experience levels. Sometimes as an educator, you realize something new that you didn’t know that your delegates either had a learning need that you didn’t realize maybe, or that in the real world, your delegates might be struggling with something that you maybe hadn’t considered? So what are the most common mistakes you see people make when they’re on your course, hands on the isolating that someone could be making Monday morning, or they listen his podcast? Oh, yeah, you know what Harmeet inspired me. I’m gonna start using rubberdam now in practice. What’s the most common mistakes to look out for that you see?

[Harmeet]
Okay. So in terms of delegates, I mean, I try and be quite good to the delegates in terms of one before they come on courses, I kind of email everyone and say, Listen, if you have any questions, specific questions, just send them to me, any struggles. Because it kind of gives me an opportunity to look through my lecture and say, I have is discovered, and to be honest, is it generally always is if there isn’t, I always say to people, you know, I will then add something in the slide. Okay? Or if it’s something on the day that they come up when I’m actually No, I haven’t thought of that. Let me look into that. And then I’ll get back to you. So I try and be helpful in that way. In terms of how I pitch that I always pitch today in terms of Listen, I don’t know what anyone knows, really. So we start really basic. And I think because I’m actually even in the basic of its people, actually, I actually didn’t think about that, to go through the basics and ramp it up towards the end of the day. But then, in terms of mistakes that I see people, it sometimes you know, it’s not the actual hands on is something I think flossing, sometimes actually flossing, the dam through contacts, actually, dentist, we can be a bit overly aggressive with it, we will be just trying to get this thing through. And sometimes we actually create more headache for ourselves. Because one, it can hurt the patient. Two, if you just forced the rubber dam down too quickly, all that rubber dam might not be through that contact point. So what essentially happens is you’ve got floss, and then you’ve got rubber dam wrapped around it. Yep. So what happens? You pull that floss out, rubber dam pulls with it.

[Harmeet]
[Overlapping conversations] [Harmeet]
Because I think most dentists would have that situation where they floss [Overlapping conversations] and you’ve hold it. And you think why is the rubber dam pulling with it? Well, you pull it hard, and then it’s just torn. It has tearing in. But often it’s more the rather than the actual hands on what mistake dentists make is rushing. We sometimes don’t, I talk about a checklist. So you know, Ian’s talked about the Checklist Manifesto is a good book, and having checklist for everything. Because they liken it to aviation, right? Yeah, a pilot might have flying for 30 years, they still go into their cockpit, and..

[Jaz]
They have a co pilot with.

[Harmeet]
And they have a checklist before they take off. And it’s not exhaustive list, it’s the main points. That’s the reason why it’s the most successful industry. You know, if a plane crashes, we hear about it because it’s so rare, then they find a black box, they want to figure out what went wrong. Why not apply that to dentistry, you know, actually having a checklist, again, not exhaustive. Like they say, five to seven point list, with the main points, you’ve got some structure for yourself, you’ve got some structure for your nurse, you know, as you all know what you’re doing, actually makes you more efficient. But sometimes you can give people that checklist and we do during the course. But then sometimes they start skipping..

[Jaz]
That’s when you run into in trouble.

[Jaz]
And that’s when you run into trouble. Because you realize, actually, I haven’t completed that first step. But I’m jumping on to the second and then you jump on the second and you realize the first steps coming undone. Actually, I say if you actually spent a little bit time making sure you’ve achieved each goal, actually, the process does becomes a lot more streamlined.

[Jaz]
When you become slick, then you can do it intuitively. But I think when you’re learning out having a checklist that that would be I think,

[Harmeet]
even even though actually when you’re slick at it, you still need a checklist, because the other thing that happens with human beings is we sometimes just go on autopilot. You know, we can have all have a bad day..

[Jaz]
Unconscious competence.

[Harmeet]
Exactly. We all have a bad days, or sometimes you need that kick up the backside, just to remind you.

[Jaz]
So we’re gonna start wrapping up now in terms of all the tips are giving, I’m going to ask you two things now. One, I’m going to ask you maybe a more experienced question, okay, and how we can get around that. And then, I’m gonna ask you for your, the best tip you want to give us to our listeners in terms of a little hack you can share with us. The first question is, when we’re isolating molars, and second molars, it’s one of those difficult things we can do. Or something I struggle with a lot. What advice do you have with that and also So in that situation whereby, when you put a clamp in, let’s say you put a clamp on the seven or even sometimes a wisdom tooth, but there’s no space because the coronoid process is in the way. And often I get the patient to move their jaw all the way to one side, okay? But it costs an arm just worried about, you know, causing pain problems, is that the only way? Is there a better way? And then generally on that topic of isolating molars, what nugget is going to give us?

[Harmeet]
So first is get a good clamp on the tooth first, because if your clamps not secure, it’s going to pop off and we don’t want that. So generally, for things like you know sevens and eights, you want one of the kind of auto metal clamps, I use these Coltene clamps they called gingival retractor.

[Jaz]
You’ve got a photo?

[Harmeet]
I’ve got a picture actually of a few. Let’s have a little look here.

[Harmeet]
Let’s share the screen with you.

[Jaz]
I think you’re sharing already.

[Harmeet]
Okay, brilliant. So here we go. So these are the kinds of Coltene clamps if you can kind of have a little look there. Okay. So generally, they come as a B1, B2, B3 there’s also a B4. B1s generally, lower molars, B2s upper left sevens, particularly. And then B3s generally, upper right sevens. Because you can see there’s like the difference in you know, the beats of the clamp, different widths. And that’s normally because sevens have that kind of triangular shape. Okay, so these are a bit, they clamp a bit more aggressively, so you get better grip on the teeth. So these are brilliant for that.

[Jaz]
So these are not your primary clamp, they are additional retraction or [ ? ] [Harmeet]
That’s the primary clamp that goes on first and you always want to just put your clamp on first check it secure, right, then you know, you’re good start. Now then the next bit is just maneuvering over and like you said often it is. it’s like when you do an extraction, isn’t it? You get that patient to move their jaw slightly gives you this little bit of wiggle room, maybe even close slightly. That’s the second tip. The third thing is just having, like I said, not stretching the rubber dam sheet of your frame too much.

[Jaz]
Okay, [overlapping conversation] [Harmeet]
Exactly, people stretch it over the frame so tightly that it’s quite like given, you know, they’re almost trying to pierce the rubber dam, actually, all you just need it to do is grip on, because then by having access, like having some given there enables you to get it over the bow of the clamp. I always use the analogy of like feeding paper through a printer, you know, you’re just feeding it over, and then you’ve actually got time to flick it over. If it’s too tight. Every time you try and get it on the bow it flips back on.

[Jaz]
Definitely been there.

[Harmeet]
And also, if you have the loose clamp and you’ve got that muscle, elastic energy in there, it’s going to ping the clamp off, isn’t it? So that’s Yeah, that’d be my tip for that one.

[Jaz]
Fine. And then what is your hack that you can share with the listeners about rubberdam? What’s the main one of your pro hacks.

[Harmeet]
Let’s give little hack from one of the lectures. Here we go. Because there’s so many. So people ask about you know stents when you’re using a [inaudible] free composite, rubber dam and my clamp gets in the way. So I say let’s start backwards. If you’ve got your model of your wax up, what I’ll do is decide, say your wax list for this example. So we did composite three to three. Okay, you always you know, you’re going to, obviously have your stent to encompass three to three, but you need something for your stent to sit on. You need your stops. So you think you know, I need to rest on the fives and the fours. So then you’ve got to think Alright, then need to put my clamps either on the sixes, or the fives. Okay? So what I’ll actually do is I’ll get my wax up model, I’ll put my clamps on to the model.

[Jaz]
Like you have done on the..

[Harmeet]
That’s it, and then I’ll put them on I’ve done no, they’re the clamps I’m going to use. And then I’ll just make my putty over the top of that. And then I can see I’ve just cut that back then. So I then know, when I go and put my rubber dam and everything, I don’t have to mess about adjusting things, because I’ve already done it in advance

[Jaz]
That awkward scenario we were going on and then I’m going to backfill so I guess worked for me, whereas yours very predictable is that yeah, it gets through that.

[Harmeet]
It’s actually, you know, can do it quickly in your lunch break. You know, it’s just you’ve saved yourself like 5, 10 minutes of messing about in the mouth and you can actually just crack on and do the work that you need to do.

[Jaz]
Amazing. Well, I think we’ve covered a good few reasons to use rubberdam and a good few reasons not to use rubber dam, how to accelerate your sort of experience and learning rubberdam, which rubberdam to potentially use. Go out there Monday morning start using rubberdam, building the extra time, if you need a bit of help, Harmeet is always available. I’ll put on his link to his sort of event or whatever.

[Harmeet]
Yeah, well just contact me on social media if you want. We do obviously, we did the courses around the country but even you know, practice now we go and teach practices, teach teams so whatever you want.

[Jaz]
Brilliant. It’s a great thing of teaching. I think it’s so nice to see good isolation. I think the patient’s benefit it, I think we as dentists and the wider team benefits overall. So thank you for for coming on.

[Harmeet]
Thanks for this podcast as well. Actually. I really enjoyed it. I mean, yeah, listen to people like Tif and, you know, you’ve had some great guests, actually, I envy it.

[Jaz]
I’ve been very fortunate that people are sharing their, this over what you know what they do day in, day out. And I think it’s been good for learning points including this one. And thanks for doing in a video format so I can share a few snippets from your slides and appreciate that. Thank you.

[Harmeet]
I’m glad to put some makeup on.

Jaz’s Outro: So as always a big thank you to our guest for today’s podcast. Harmeet Grewal, I’ll catch you the next one with Louis McKenzie but in between that episode, well between this episode and that episode, I’ll also have a little bit on what to include in your portfolio and your CV for those especially in DF1 in such difficult scenario for everyone, but especially you know, DF1s because you know, you’re the least experienced dentist in the country, technically right? And then now you’re having all this downtime, not having the ability to refine your hand skills, and then you’re potentially looking for either a DCT position or an associate position. So a competitive content for you in terms of all you know, I’ll show you my CV and my portfolio, which had landed me some good jobs before. So I’m hoping that’s gonna help you out in terms of ideas and thanks as always for listening all the way to the end.