Isolating the Last Tooth in the Arch #RubberDamFam – PDP183

Jaz’s Introduction:
And for me, I’ve talked about before, like for me, rubber dam is my tranquil environment. It’s when I’m least stressed. I’ve got rubber dam on, the patient can’t talk, the tongue is abolished, and I’m just falling in love with a little micro steps that makes our profession so much fun, right?

But when you’re isolating the last tooth, like let’s say it’s a wisdom tooth or whichever is the last tooth. And then that tooth also needs a restoration. Then we have some issues, i.e If you clamp that tooth, then how can you get a matrix on that tooth? And that’s the problem that we’re solving today with the real superstar of dentistry.

Her name is Dr. Celine Higton. I know so many of you probably already have heard of her. And I think it’s so fitting that April, we’re focusing April on mental health. So I’m going to talk a little bit more about mental health this month. And how is isolating the last tooth rubber dam relevant to mental health?

Well, I told you already, it reduces my stress. I’m in my happy place when I’ve got rubber dam on. I want everyone, I want all dentists to experience this level of isolation whereby they’re just listening to classic FM and everything’s under control and the patient’s not going to lick anything.

So it’s a great stress reducer for me. But also because in the conversation that I had with Celine, I think it’s so obvious that, look, you guys know I’m super enthusiastic about what I do in dentistry. And I think that’s really important for a long career and fulfillment and enjoyment of your work. And I think the same can be said about Celine.

Celine is someone who loves documenting her work. You can tell that on her Instagram, she’s super enthusiastic about it. And I think that is a secret ingredient that we need to have. So if you just practice dentistry as a means to an end only, and you’re constantly clock watching, that’s not a great place to be. I gain great satisfaction from falling in love with those little details.

And it’s really mastering your craft. That journey of becoming good at something. The journey of problem solving that me and Celine will talk about a bit later in the interview. And I hope that will inspire some of you. If you’re not in a great place, then sometimes an episode like this just reignites you.

And then you think, you know what, I’m going to try to master Rubber Dam. And I spend the next six months to a year master rubber dam, and you’d be amazed how just focusing on your craft can really re engage you in our wonderful profession and actually help you to deliver better care. Now, of course, when you’re learning a new trick or when you’re trying to do more complex cases, there is a frustration associated with learning, but that’s all part of the journey, it’s all part of the fun.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Before we join the main episode, every PDP episode I give you a Protrusive Dental Pearl. And today’s pearl is something that I’ve taken from the main interview and it’s basically Cow Mode. Like I used to call this wiggle your jaw but I love that Celine called it Cow Mode.

Now what is cow mode? So when you look in a patient’s mouth and you notice that they’ve got fairly good oral hygiene, looking at the upper first molar, upper second molar, and when you get to the last molar you see that because their cheek and their coronoid process, remember that piece of anatomy, part of the mandible, right, the coronoid process, it is impeding access of their toothbrush, i. e. they can’t actually get the toothbrush on that wisdom tooth, on the buccal surface of the wisdom tooth, because the coronoid and the cheek are in the way.

So what do you do? You tell them to look like a cow. You tell them to half open, and you get them to move their jaw so they look like a cow all the way off to one side. Now I usually say, open a little bit and then wiggle your jaw all the way to one side. And then they usually ask, okay, which jaw should I move? Should I move my upper jaw or my lower jaw? And you can just smile and say, please, can you move your lower jaw today?

Anyway, once they move their mandible off to one side, whether you say wiggle or whether you say cow mode, i. e. just look like a cow, then you can show the patient that, look, now you’ve got all this space and now you can access that wisdom tooth, that poor, neglected buccal surface of the wisdom tooth. Now, why is this even relevant to rubber dam dentistry? Well, when we’re clamping the terminal tooth, this could be a second molar, this could be a wisdom tooth, we have the same issues.

We’re cramped for space there. So to go into cow mode can really help you to get that clamp on. And so you need to coach your patient to be able to do that to help facilitate rubber dam isolation. Listen, I hope you enjoy our conversation. There’s a few laughs in there. I hope you like it. One last thing before we hit the main episode.

As you know, the protrusive app has been just a great revolution. It’s like our Netflix moment. You know how Blockbuster got very old and stale and Netflix came. This is kind of why we’re moving away from our Facebook group and our lovely little community on Protrusive Guidance. The theme of this month is mental health.

And you know a wonderful exchange happened on our private little chat group on the app. So once you get the app, you get access to our private chat group. And one of the Protruserati, she’s been a Protruserati for years. It was, I think, one evening after work, she just messaged saying, do you guys sometimes feel that this is not for you, that you shouldn’t be doing dentistry anymore? Do you have those days?

And I tell you, the amount of support from Protruserati all over the world. From Greece, Italy, America, you name it, it was just absolutely special. You guys truly are the nicest and geekiest community in the world. And from that little chat discussion, I wish I could frame it, some wonderful ideas and suggestions came.

So tune into the next episode PDP184 with Marco Maiolino. We’re talking about perfection and actually imperfection. We celebrate imperfection, we’re not perfect. The whole thing about ideal standard, get rid of it. What Marco will talk about next episode is the daily standard. Because sometimes that extraction that was supposed to take you half an hour will take you an hour.

Sometimes with that wedge, what that was supposed to close the apical seal of your matrix band just wasn’t good enough. And you know what? We beat ourselves up and it really takes a toll on our mental health. So in that message, there was too many announcements. One is check out Protrusive Guidance and thank you so much for being just a fantastic community and showing so much support to your peers.And number two, watch out for the next episode. Continuing on for Mental Health Month with Marco Maiolino. Let’s catch the main episode now.

Main Episode:
Dr. Celine Higton, welcome to the Protrusive Dental Podcast. How are you?

[Celine]
I’m great. I mean, thank you for having me, Jaz. It’s absolutely amazing to be on here. I’ve watched your podcast from afar for a very long time, so it’s great to be on this side.

[Jaz]
Well, we’ve just had this little pre chat and some things that we can’t reveal, which is very exciting and that stuff. But you said that you’re exhausted and I’m exhausted, but just knowing that I had you on the show, I’m a huge fan of your work. I think you make adhesive dentistry and isolation so sexy and brilliant.

And it’s just great to see all your work over the years, your tips, your photography, how open you are. But you know, one thing that you definitely weren’t expecting me to say, and I’m going to say, I don’t know how you’ll take it, but I’m going to say anyway. Okay, is I don’t often have time to watch Instagram stories.

Okay. So my Instagram is now managed and really I’m posting, I’m directing. The odd time, the odd time I just click on something and usually when I clicked on yours, it’s beautiful dentistry. One time I click and you’re in the the Alps or something, you’re skiing, your dad’s there and you had this wonderful moment, right?

Where he was like, you’re talking about your brother, you’re telling your dad. He’s a bellend, isn’t he? He’s a bellend. I just love that Celine. I just love that you shared that. We need more of that in life, you know? So that was amazing. So thanks for sharing that moment. Do you remember that?

[Celine]
I do. I remember so well. It was this Christmas. My younger brother, he kept skiing into every single shot that I was filming, like an idiot going hello. Yeah. And he was a bellend.

[Jaz]
I bet you weren’t expecting that one.

[Celine]
That’s great. That’s such a good opener. You can tell you’ve done this before, Jaz.

[Jaz]
Well, it’s always a pleasure to speak to guests like you. You’re someone who I feel like everyone on my Instagram and podcast listeners probably knows already, but some people who may not have heard of you yet, please tell us about your story. How did you get to be at this level of dentistry and how awesome you are at isolation, adhesion, the wonderful dentistry you do, all that. It doesn’t happen by accident. What has been your lines? How are they connected?

[Celine]
God, I mean, it’s a really good question, and I love that you’ve asked this question. I actually started off doing an architecture degree, so I did three years of architecture and then realized it’s not for me because I love math, physics, and art.

I do a lot of drawing, a lot of art, always have done, but I’m not particularly creative. So if you put a kidney bean down in front of me, I see that as a bean. I don’t see that as a concept for a building. Whereas if you put an upper left central in front of me, I’ll copy it into an upper right central quite happily.

So it’s a kind of, I’ve got like a mathematical kind of creativity, if you like. So when I was, when was it, it was 2010, I stopped the architecture, so I was already 22 at this point. Essentially, long story short, it was my genius father, who’s a chemical engineer, said, you love art, you love people, and you love science, be a dentist. And I said, you’re mad, dad ’cause my experience of going to dentist-

[Jaz]
Is this because your dad knew any dentists you had any dentist family or?

[Celine]
He’s had a lot of dental work done and at this point I’d never even had a feeling. So I’m looking at him like, dad, what have you been smoking? Like my experience with the dentist is kind of rolling back, opening my mouth, rolling up and walking out.

So I was thinking like, what a boring job. And he said, no, go do some work experience. And then it just, the penny dropped and it was from that point on, I’ve always followed gut feelings. I do go with evidence based, but I do love a good gut feeling. And it just felt like the right thing. So anyway, long story short, dental school went really well.

I’ve always had an artistic side. So the artistic side of dentistry, which is, let’s be honest, quite a big side of it, came out quite strong and I qualified during the era of Instagram and that was just starting. So I think that played into my hands a little bit because if you are able to make things look pretty, unfortunately in this day of social media, things can get seen a bit faster maybe.

But the rubber dam thing, my first job was actually in a practice on Wimpole Street and they didn’t have any rubber dam equipment, none.

[Jaz]
No way. Okay, this happened to me before, but I wouldn’t expect a Wimpole Street.

[Celine]
Yeah, yeah, yeah. No rubber dam equipment. But, the guy, this was the start of my journey. So I said, look, at uni I did everything under a rubber dam. I wouldn’t say it was taught particularly comprehensively. It was here’s a clamp, here’s a dam, put it on. But he said, yeah, order whatever you need. Here’s the order book. Just go to town. So I have this order book, the one that short people use to prop themselves up like thick.

Sorry if any short listeners out there. And I had this order book in front of me and I’m looking at a thousand different clamps thinking, well, which ones am I going to order? And that’s when I started thinking, right, square tooth, square clamp. Asymmetric tooth asymmetric clamp. Okay, that clamp needs to be supporting a lower second molar, that clamp needs to be supporting an upper second molar, or anchored onto.

So that’s when the thought process of kind of where it all started, and that for me has been the backbone of my rubber dam kind of teaching and journey, really has been the clamps, kind of select the right clamp, your dam will go on. And then the rest is kind of followed. I did a course in my vocational training year, VT year, in 2017.

The first course I did was with a dentist called Thomas Taha. Or by a dentist called Thomas Taha. And it was actually his very first course. So it was his posterior composite course, which back then was one day, now it’s two. And he’s mentored me and taught me so, so, so much. I can’t thank him enough. But a big part of his course there was rubber dam as well.

So I learnt a few things on there. And then it’s kind of evolved, really, I think a lot of people, you might know this, but a lot of people who teach rubber dam, a lot of them will say that they are kind of mostly self taught. And the reason being is rubber dam and matrixing especially are two areas in dentistry where if you’ve got time to problem solve, you can learn new techniques on the job. You don’t need to be taught. You can teach yourself. You can’t respond.

[Jaz]
And you get to be innovative as well when you’re doing that.

[Celine]
Exactly. Exactly. And I’ve always had a mind like that anyway. I’ve always loved problem solving and an analytical mind, if you like. So rubber dam and matrixing have kind of come really naturally to me.

Yeah. So stuff like, etch, prime, bond. You can’t just suddenly decide to put the prime on before the etch. You have to follow the manufacturer’s instructions. Whereas mechanical dentistry, I kind of call it mechanical and chemical dentistry. Mechanical dentistry, like clamping teeth, like placing rubber down, like matrixing, you can really think outside the box and problem solve.

So anyway, that’s kind of where the journey came from and I think I’ll finish that question. Sorry. This has been the longest answer ever.

[Jaz]
No, no, it’s been great. I’m loving it.

[Celine]
I think if you get good at rubber dam, I’ve got kind of a tagline that I use for my courses. Master rubber dam, master adhesive dentistry, because dentistry these days, it’s so complex. I’m not saying it hasn’t been complex in the past. I see things in patients mouths that I just don’t know how they’re there and they’ve been there longer than I’ve been alive.

So, incredible witchcraft and wizardry, but adhesive dentistry that is primarily being done these days, especially in private practice, kind of the sexy dentistry, we’re not just private practice, mixed practice, but it is the dentistry of the day.

It’s very step intensive. It’s very challenging and it’s done on a micro level. So the working environment that we work in, the kind of the wet, hostile, dark, moving, wriggling mouth on the end of a live patient, it’s no longer conducive to this. So by mastering rubber dam straight off the bat after uni, I’ve been able to up my game in all of the areas of dentistry, I think much quicker. Then I would have done if I hadn’t mastered rubber dam, because it takes out all of those variables that make dentistry so much harder. Would you agree with that?

[Jaz]
Absolutely. And I think for me, rubber dam, and I’ve talked about this before, it was like the number one benefit I get from rubber dam is reduction of stress. When the rubber dam is on, classical FM is on, I’m in a happy place. I don’t know what you listen to. I’d love to know what does Celine listen to when she’s got rubber dam on and she’s in a happy place. What do you listen to?

[Celine]
Ah, a lot of Celine Dion! Smooth, Smooth Radio was playing today, but we couldn’t get the radio working. So for my first patient, actually, my nurse put on, it was this thing, she put on instrumental, like, kind of instrumental music, but it was like an instrumental version of Celine Dion’s My Heart Will Go On. And the patient, once the rubber dam came off at the end, he was like, I have to say, I hate Celine Dion. I was like, Oh my God, if you’re listening to an instrumental version of My Heart Will Go On, like, I don’t know how the guy stayed alive. But yeah, I love Smooth FM. Smooth UK.

[Jaz]
Good. So now we know what Celine listens to when she’s. Everyone can picture that when you see the lovely rubber dam cases on Instagram. But great. Look, it’s always lovely to hear everyone’s journey. Whenever I don’t want to be biased towards British dentists, like dentists from all over the world listen to this podcast and I’m so grateful for the listenership. But in UK is where it started. And I feel as though in the UK, we have this perception from outside the world that our dentistry is lacking, or it’s not to standard.

But when I see great clinicians like yourself, I just get really proud and happy. So keep doing what you’re doing. It’s you’re flying the flag for team GP. It’s absolutely fantastic what you do. So more of that. And I want to talk about your courses and all the wonderful things that you do. And I want to talk about that as a feature at the end.

But you mentioned about problem solving. And a huge problem we have is isolating the last tooth. So let me hit you with the scenario, Celine. So let’s say a patient who’s 25 does not have any wisdom teeth.

[Celine]
Yeah.

[Jaz]
Okay. And it’s the upper right second molar that has an MO mesial occlusal caries on the upper right second molar. We’ve got all the other teeth. Okay. So when we’re putting the clamp on to put your rubber dam on, we are stuck because when you put the matrix on sometimes a clamp is interfering and then when you extend that to an MOD, now you can’t at the same time usually use a clamp and your matrix at the same time. So really what I want to unpack today is how has your rubber dam journey evolved?

Like how you used to manage this and what did you learn along the way and because I’m sure there’s no one size fits all you kind of depends on well actually, if the coronoid is here and that and whatnot, so I’d love to just hear your approach to isolating and mixing the last tooth in the arch. And if you start maybe with the upper, then the lower, because they all have different nuances. You’re the master of this. You lead the conversation in that way.

[Celine]
Yeah. Great question. I guess when I first started doing cases like that, I used to pray. I used to swear with my inside voice, I used to take about an hour longer than I should do, because I was using every different tool in the book, and this is where the problem solving comes in.

But jokes aside, there is a really logical approach, so we’ll start with the upper one. So it’s the upper second molar, so the first thing I always do with isolation, always, is I look at the tooth and I look at the shape of the tooth. What shape is my tooth? Therefore, what shape is my clamp? So upper second molars are triangular, normally.

They normally have a smaller palatal aspect and a larger buccal aspect. So the perfect clamp for an upper second molar is either a B2 or a B3 brinker. Now, the reason I use those is they’re wingless. I use all of the clamps I use are wingless. I don’t know if you’re a winged or wingless man, but-

[Jaz]
I should probably chop off the, I use a soft clamp. I love soft clamp. So I use it. I love good soft clamp. I don’t know. You made a face though. You don’t love soft clamps. But what I’ve started to do is I’ve chopped the wings off the soft clamp. And so, yeah, I am team wingless. Like if I’m working with my metal selection, I’m always wingless as well.

[Celine]
Yeah. Yeah. And that’s the reason I go wingless. So at uni we used winged. That was all we were shown. And then it was in my VT year on a study day, we did an endo day, actually, with two amazing dentists, Aaron and Vish, you probably know. Fantastic. And they were teaching with wingless and my eyes were opened.

Why? Wingless clamps are smaller. They’re much smaller. There’s a guy, David Gerdolle, he’s like the godfather of DAM. He’s a French dentist that works in Switzerland.

[Jaz]
Amazing guy.

[Celine]
Phenomenal mentor, friend, love the guy. He always says, and anyone who really teaches rubber DAM will say, the smaller your clamp, the better, because the whole point of isolating is to simplify your working environment.

If you have a clamp the size of a golf club in your patient’s mouth, it’s not going to help. So I always use wingless. And also the benefit of wingless is you can see where you’re placing it. You can see what you’re doing. And when you’re trying to isolate and up a second molar, third molar, suddenly you’re kind of going by sense of smell a little bit.

You’re going by touch. You’re going by feel a little bit more. And if you’re trying to do that with a winged approach, it can be harder. Anyway, we’ll go back to the clamp. So I will always-

[Jaz]
And the other thing with the whole space, which I really appreciate, and one of the questions that was later, and I think this adds to it, is a lot of times, like the soft clamp, because the ones that have got the wings on it, you put it on the upper molar, but the patient, as soon as they open, the coronoid-

[Celine]
In the way.

[Jaz]
Doesn’t give you a space. So again, wing less also helps you to gain that little bit more space for the coronoid not to displace your clamp.

[Celine]
Exactly, exactly. And I know we’re talking about upper second molar here, but if I’m, I always clamp upper third molars, wisdom teeth are teeth too. And often they’re kind of buccally placed. And I always say to my patients, I mean, this is part of my oral hygiene instruction. I tell them to kind of half it and move their jaw to the side and look like a cow. And I actually say, don’t start at the front, start at the back where you’re brushing.

Because most people start at the front, they go brush, brush, brush, and then they go, look, onto the occlusal surfaces, and they miss the buccal of the first and third molar. So start at the back, cow mode, and sometimes I say to patients, if I’m about to put a rubber dam on, if it’s a really challenging tooth that I’m clamping, If I can get a clamp on your tooth while you’re in that position, it means that it can be restored.

But if I can’t get a clamp on your tooth while you’re in that position, then I can’t. Anyway, wingless clamps, you’ve got the space. So number one, you’re looking at the shape of your tooth. And I’ll be honest, this is why I’m not a huge fan of the soft clamps. Because they’re only square. Unless they’ve brought out new variants, but they only come in that kind of molar shape, and most upper second and especially third molars are very triangular, so you end up with only a three point contact on the tooth.

And to have a really stable clamp, especially if you’re clamping a third molar, lots of tension on the dam, you need that four point contact. Therefore, the triangular clamp is essential. So, B2, B3, wingless, Brinker, so the Coltene do a set of clamps, the Brinker tissue retractors, they come as a set of six. I think they were designed actually to retract the dam, but they work so well, three of them, the B1, B2, B3, work brilliantly as anchor clamps for these tricky teeth.

So, that’s the first thing. The next thing we’ve really touched on it is, how are we going to access it? Sometimes, you can get the clamp of the tooth and then stretch the down over the bow. Sometimes there isn’t space for that. I’ve got quite diddly little, lady hands, but for the guys out there, you know, the six foot four rugby player dentist.

[Jaz]
The rugby players, yeah.

[Celine]
Yeah. I mean, I’ll never forget. There’s a guy I know here at university and I still, still very much in touch with him from time to time. Lovely guy. I won’t say his name, but like huge basketball player, huge hands like dustbin lids. And he, for a time, just really liked pediatric dentistry. And he was just like, mate, this is never going to happen. Anyway, he’s loving the history.

[Jaz]
Well, you could still apply fluoride varnish. It still works.

[Celine]
Yeah, exactly. Anyway, if you know you’re going to struggle to get the dam around the bow, that’s when you can kind of load the dam and the bow together. So even with a wingless clamp, you can still load the two together.

A lot of people call it the parachute technique. I call it the Superman technique because a delegate said it looked like Superman’s cape once. But you essentially push the bow up through the underside of the dam, through the hole that you already punched, you bunch the dam up all around the bow and then you put them both on together.

So the dam’s already loaded around the bow. So you’re not having to heel around the back of the bow and kind of gag your patient at the same time.

[Jaz]
It’s the same that you would do with a winged technique, except you’re adapting it to wingless, right?

[Celine]
Exactly. Exactly. So the disadvantage of doing that is you can’t see what you’re doing so well. So sometimes like I said, I clamp third molars all the time. A lot of the time they’re buccally placed, partially erupted, horrible shape really useful to see what you’re doing. Really useful to see where those campships are going. So that’s another big point. Magnification and good lighting are actually essential.

I used to try and be a bit more kind of politically correct with these comments and I totally understand loops are a huge investment. I get that. But if anyone’s going to make any investment in their career at all, that should be it.

[Jaz]
Totally. And I wouldn’t trust anyone in my mouth about loops, or dam, like if I’m telling you something deceptive. It’s just one of those things that I’ve embodied as part of my values and I believe strongly and I know I can sense that you do as well.

[Celine]
Absolutely.

[Jaz]
It’s just accepted now. It’s a standard of care.

[Celine]
It is a standard of care. I say to all of my patients, if you ever end up seeing a dentist, an emergency dentist, they’re not wearing loops, run out. Just don’t because I look at the work I was doing without loops at university and I still see, I was treating a lot of my friends and I still see that as they come back, I see my savings from university and they’re still going strong, but I still think like, I couldn’t see, I couldn’t see a thing.

So when you are trying to clamp the upper second molar, if you’re trying to do that without loops, game over. It will be so difficult unless you’re experienced at doing it and you’ve got really good forceps. The HuFriedy RDF4 forceps are made of a really strong alloy, and the tactile feedback you get from them is unreal.

Whereas a lot of the cheaper brands of forceps, a lot of forceps, they’re flexible than the clamp does. So you almost can’t feel where you’re placing it.

[Jaz]
That’s an interesting tip. I’ve never heard about the quality of the forceps. That’s a really good one. I think everyone’s screaming now, wanting to know exactly which dams you recommend now. Cause that will definitely be in the comments somewhere. So let’s just address that now before we actually talk further into specific niche scenario. What dams is Celine advocating?

[Celine]
Heavy dam always.

[Jaz]
Okay. That’s interesting. So for me, the recipe I follow is heavy for anteriors, medium for posteriors because it’s easier to floss. So I’m interested to hear why you go heavy always.

[Celine]
So heavy nictone is a latex dam and it is heavy nictone is about twice as thick as heavy isodam or heavy, or the nitrile alternatives that we use. It is so, so thick. So when you get used to using heavy nictone. Every other dam feels like a light dam.

So for me, if I’m using, so for example today I did an anterior bonding case and I had heavy nicotine on because we’re going up to the cervical third because I wanted to retract the soft tissues, but if I’m doing a case where I don’t need to be working in the soft tissues and they’re in the cervical third, that’s when I use heavy isodam.

Because heavy isodam, even though it’s still heavy, it’s still, if you lubricate it properly, it needs to be lubricated on the underside, never with Vaseline, because that’s oil based and that could mess up your adhesion, either with glycerin, but actually, top tip, the best, best, best lubricant is shaving foam.

[Jaz]
Okay.

[Celine]
Obviously, it’s CE marked.

[Jaz]
I use ultrasound gel. So Anagel is a brand on Amazon. I found it. It seems to be working well. I like cause the bottle is splodge it on the anterior teeth and cure through it. I quite like that.

[Celine]
I’ve got a question. What does it taste like?

[Jaz]
I don’t know because I haven’t, because usually everyone, okay. But my patients know I can relate to KY jelly. I don’t know what they, I should probably taste it. I’ve been meaning to do this whole series. I’ve actually been doing a series where, you know those YouTube videos you see where like, kids from around the world try hospital food from around the world kind of thing, right?

So, like, basically it’s kids in America and they try hospital food from the UK, Nigeria, Taiwan, and they taste it and they, like, make their reactions. I would love for dentists to just be, like, blindfolded and taste all the shit we’re putting in our patient’s mouth, right? Yeah. Like, GIC, different for advantages. Guessing what Impregum tastes like versus, oh yes, Viscostat Clear would be the final thing that we serve on the plate, right?

[Celine]
Yeah. Yeah.

[Jaz]
Anyway, I digress, but that’d be a great thing to do. I haven’t tasted Anagel yet.

[Celine]
Yeah. The reason I ask is, I still use a shaving foam called Every Man Jack, but they’ve discontinued it. And the reason I use it is because I was on a call with an American professor years ago and he said, yeah, so I just walked down the aisle at Walmart and I just, I like tried all the shaving gels and that one had no flavor. So amazing. But they just continued it. So recently I found some miniatures of the shaving gel in a hotel and I thought, Oh great. I’ll try this. Try that. It was so foul. It was disgusting. So I’m now on the hunt for a really good lubricant that is taste free, essentially.

[Jaz]
I will taste, I’m going on holiday next week. As soon as I come out of work, I will taste Anagel and I will mess, I’ll DM you what it tastes like, make a little video for you.

[Celine]
Yes, do.

[Jaz]
Taste test, Anagel taste test.

[Celine]
Even with heavy isodam, even though that’s heavy, with good lubricant underneath, it still flies on. It flosses on really quickly. The key here is how you floss your contacts. A lot of the time, what people do, and this is where the mistakes are made, is they’ll stretch the dam across the contact point.

I realize I’m using my hands here, but I’ll make this as kind of audible as possible. They’ll stretch the dam across the contact point, so it almost looks like a valley, so there’s like a valley of dam. If I may say so, it also looks like a butt crack. Essentially, you’ve got the dam, like everyone’s envisaging right now.

So if you now try and pull the floss down the valley or down the crack, you’re trying to pull two thicknesses of dam down between the contact point. And you’re also stretching that dam way more than it’s designed to be stretched, and that’s how you tear it. If you actually place the dam, the interproximal dam that’s going through the contact point, you kind of shunt it to the side.

So you’ve got one thickness of dam about to enter down the interproximal space, down your butt crack or valley. Then you use a waxed floss to kind of grip in, pull it down, and you’ve got one thickness of dam going down between the teeth. And that there is how even heavy isodam, which is heavy but compared to nictone is thin, that will fly down contact points. And nictone, anyone who’s using nictone, you have to use that technique. If you’re trying to get two thicknesses of nictone down between contact points, it will shred like nobody’s business.

[Jaz]
And so you’ve answered that question in terms of how to mitigate the use of a heavy one. And you make a good point about different brands, the heavy ones actually having different gauge of heaviness.

So remember guys, use lubricant and if it looks like a butt crack, make sure you move it to the side. So make what you will of that. Very interesting discussion so far. So far we’ve got to a situation where we’ve talked a bit about clamping and the importance of it. We’ve talked about the position of the tooth.

We mentioned briefly about the coronoid, mentioned about the type of dam you use, the lubricant and also the technique of flossing. Now you’ve got this upper second molar and feel free to add anything more to this, but you’ve got this terminal tooth that’s got the rest that needs the caries removal basically.

You’ve got it isolated. When it comes to actually putting the matrix on, let’s say it’s all clean and ready. You’ve aqua cared it or air abraded it. If you use a small enough clamp, I guess to treat that MO with a sectional, you could probably just about get it in and still do your work. So, expand on that, what you want, but then also want to know, let’s make it a little bit trickier. What if you’ve also got to do an MOD and a DO and that kind of stuff?

[Celine]
Yep. I mean, such good questions. Honestly, I feel like I could talk about this subject for like hours and hours and hours. They just shut me up and I’m really, yeah, there’s a cat in the background playing with a toy. So just ignore it. Ignore that as well.

[Jaz]
It’s all good.

[Celine]
So yes, small clamp means that if you are just doing an MO, you can exactly do that. The small clamp, it doesn’t engage anywhere near the papilla. A clamp is too big. If the clamp tips are engaging in the papilla, firstly, you’ll give them a little papillectomy, but also it’ll get in the way of the wear of the matrix, everything.

So your clamp needs to be on tooth well out of that abrasive space, and then you can get your sectional on as if the clamp isn’t there. A good clamp on the terminal tooth, if you’re restoring a mesial cavity, shouldn’t get in the way at all of any matrixing system. But, If you’re doing an MOD, so firstly we’ve got our clamp on, I’ll always, by the way, isolate up to the canine, as a minimum I go up to the mesial of the canine, by doing so it opens up the rubber dam, you’ve got better access, better vision, but you’ve also then got reference points for your cusps and cusp tips and fissures and marginal ridges and everything, so, never single tooth isolation, always isolate a few more teeth, you get more kind of stability from the clamp as well.

[Jaz]
Yeah, I think dentists who are new to rubber dam, they think that let me make my life easy. Let me just isolate the one I’m treating and the one in front of it. That actually just makes it way more difficult. If you just spend the extra 30 more seconds to extend it, you seat the dam further apically as well. And it’s just a much nicer field of view to work with. I totally echo that.

[Celine]
Yeah, yeah, definitely. And the more you do it, the better you get at it. So even if I’m doing a root canal, I never do single tooth isolation. I still do a multiple, an arch, because the more you do it, the more you practice, the better you get.

And then it just flies on faster and faster. So now let’s say we’re doing an MOD cavity. So a trick that I’ve been using for a little while now, and I teach it on my courses, and it’s normally, it’s the main thing on the course where people go, Oh my God, this is great. So, place your clamp as normal, expose your teeth as normal, floss all your contacts, invert your dam, make sure it’s all fully inverted, make sure the dam isn’t stuck on the tips of the clamp.

When you place a wingless clamp, if you place your clamp first and then your dam, the problem is, is you end up with the dam kind of, like, ruched up on the tips of the clamp. You get these tiny little areas of pink, which is normally a problem in the lower second molars on the lingual. So you need to, one of the final things you do before you invert your dam, you need to kind of release the clamps.

You open up the clamp, let the dam seal against the tooth, and then seal the clamp back on and then repeat it for the other side. At which point your dam will be underneath your clamp. Your clamp is almost sitting on the dam, the dam is sitting on the gum, and the clamp is sitting on the dam, essentially.

[Jaz]
And this is also good for our colleagues doing endodontic. You wanna like really get a good seal of your hypochlorite.

[Celine]
Yeah.

[Jaz]
It can actually have the clamp pinching the actual dam material. And that really gives you a much superior seal if you’re even just single tooth isolation.

[Celine]
Yeah, yeah. Saying that I do tend to say, not pinching the dam ever. So, it’s always like, I’m always layering it like a parfait here. So you’ve got like a pavlova, so your first layer is your gum, looking at it horizontally. The next layer is your dam, and then sat on top of that is your clamp. So actually, I always try to avoid pinching the dam against the tooth with the clamp.

[Jaz]
Got it.

[Celine]
If that makes sense. So the clamp is only ever touching tooth and it’s just kind of sat on top of the gum. And the reason for that is because this is where the tip comes in. Once you’ve got everything isolated, make a floss ligature. And I use normally a Teflon floss for this. So the Oral B Pro Expert Premium, it comes in a little silver box.

[Jaz]
Oh, I love that one.

[Celine]
Much better. If you try and do it with the blue Oral B Satin floss, it comes out like a pig’s tail and it’s just impossible to make.

[Jaz]
It’s too curly.

[Celine]
Yeah, exactly. We don’t like curly floss for ligatures. No, no. So the Pro-Expert Premium comes out really flat and you can make a double knot self, self-tightening ligature. So one that tightens with just one hand. And you basically loop that underneath the bow of the clamp and almost around the tooth essentially. So it’s going underneath the clamp, if that makes sense.

So you floss it down the mesial of the tooth, you loop it underneath the bow around the back of the tooth. And while you stabilize the clamp with your finger, because as tightening the ligature it might try and push the clamp up, tighten the ligature. And it’s so important that your dam is fully inverted. underneath that clamp and it is not trapped by the clamp because if it’s trapped by the clamp then the ligature will also trap the dam.

So you’ve got to make sure you tighten your ligature and you stabilize your clamp and then once your ligature is nice and tight you put a finger either side of the tooth that’s clamped stabilizing the dam again and then you remove the clamp with your forceps.

[Jaz]
So now you’ve got your Floss Ligature retaining, acting as your temporary, or maybe definitive. I’m excited to see where this goes because I haven’t done it this way. So it’s just taking the place of the clamp, right?

[Celine]
Exactly. It’s taking the place of the clamp. I should add actually. This is all being done once you’ve done your cavity preparation, my bad. So you need to do this once you’ve done your cavity preparation. So I’ll move on to how you do cavity preparation for this, but what this enables you to do, you’re stabilizing with your finger either side. If you remove your fingers either side, while it’s just a ligature, if it’s an upper second molar, there’s still a pretty high chance that down is going to want to fly off.

So you’ve got to have your fingers either side, ideally have a second set of forceps ready to go if you’re swapping a clamp. At this point we’re not swapping a clamp, we’re placing a matrix. So you’ve taken your clamp off, you’ve got your ligature as your temporary stabilizer, your fingers are either side of the tooth, and then you get a matrix.

I use often the Procurve auto matrix, and I’ll do normally a matrix within a matrix because you still don’t get the best emergence with that. And you get a matrix around the tooth, and then you tighten it, and that matrix will then work like a clamp.

[Jaz]
And at this point the floss ligature is still there.

[Celine]
Exactly, floss ligature is still there. And the only thing I’m using that matrix for is the distal wall. I am not going to build the mesial wall with an automatrix. Never. If I can avoid it, ever. You don’t get good enough contact points, even if you use the biggest wooden wedge in the world. So I’m using that matrix to build the distal wall. That’s it. Once that wall is built, matrix comes off, plant goes back on, and then I’m good to go with my sectional matrix.

[Jaz]
We’re back to scenario one that we discussed a few minutes ago.

[Celine]
Exactly. Just like how you turn a class two into a class one, turn MOD into an MO, essentially.

[Jaz]
Brilliant. And so I don’t do it this way because I’ve definitely learned something because usually what I’ve done is instead of using the Floss Ligature, I’m just relying desperately on my fingers to keep that dam down.

And so it’s a squeaky bum time. So your way is just like better. And it’s worth learning those skills of doing Floss Ligature and stuff and something that really needs to be seen. So I would encourage everyone to check out your courses and stuff for that. Cause I think really, even when you watch your videos, when you have someone there showing you in person, you get to practice it 10, 20, 30 times.

It is a big difference. So definitely a great point made there. In that scenario, I think I like your way a lot because it’s applicable to every dentist anywhere in the world, right? Because the way I do it is not accessible to everyone, which is I have these like the Hallerklammer clamp or the one incidental, the last tooth in the arch.

And so I have to then put that clamp in, then I take my main clamp off on the distal molar and now that’s holding the dam in place and then I’m able to restore it. But I have had to buy this additional clamp, which is like a long and often expensive and whatnot. So I like that just with floss and using the matrix, it’s a much simpler and doesn’t need to order additional kit.

[Celine]
And I mean, it works amazingly almost every time. The only time where it can be a bit challenging is if it’s a really deep distal cavity. So if we’re talking last tooth in the arch, but we’re also talking a deep margin elevation or something like that, at that point, we’re really thinking differently.

So maybe a fifth. You want to go into that, we can at some point, but really, if it’s a kind of a regular cavity, slightly subgingival, but not crazy subgingival, then that technique, honestly, I use it again and again and again, and that the ligature underneath the clamp trick, full stop, is an incredible little trick.

Want to put a ligature on a prepared tooth that you’re trying to put a crown on? Is it possible to put a ligature on a prepped tooth? Impossible. Whereas if you put a little accessory clamp on that tooth first, so you’ve put your dam on, you’ve clamped it, you’ve retracted your dam with a little clamp, again, loop the ligature underneath the clamp, tighten it under the clamp, clamp comes off and you’ve got a ligature underneath, on a prepared tooth.

[Jaz]
Very good. So yeah, with those difficulties that we have with the ligatures, they’re slipping away, but then when you have a clamp first, like a Brinker’s B4 for example, could you use that?

[Celine]
Precisely.

[Jaz]
Okay. I love that. It’s a great top tip there. Thank you so much for that. Any nuances when we’re dealing in the same scenario with a lower tooth or not really quite similar concept, you use the same technique?

[Celine]
Pretty similar concept. The clamp is different. So upper teeth are triangular. So always, always the B2, B3 brinker for me, almost always. I mean, 99 percent of the time, lower teeth are often square. So that’s where I’ll be using a B1 brinker. Or, HuFriedy do a clamp called the 8AD, which has got a long bow.

That can be a really useful clamp, but it falls short because it’s only square. It only comes in a square shape, so if you try to use that for an upper, it’s too unstable. The longer the bow, the more down tension, the more unstable the clamp, so, for lower second molars, lower last standing teeth, the 8AD by HuFriedy can be a good option.

But it’s still very similar techniques, really. It’s, again, clamp on, isolation, as always. I call it everyday dam, because I do it the same way almost every time. You’re less likely to use the parachute or Superman technique in this case, because you don’t have the coronoid in the way. So you can place clamp, then dam, then frame.

So important to reposition that clamp. So important to let the dam seal. Around the tooth and then reposition the clamp, otherwise you will get leakage from the sublingual saliva.

[Jaz]
Have you ever used the CH clamps?

[Celine]
No.

[Jaz]
Well, you need to make it happen. We need to make some clamps called Celine Higton clamps, right? You should redesign the whole thing, right? And you have to have like a one, two. Honestly, you should totally do it. I hope that we listen to this again in five years time and you’ve got your own clamp range or something.

[Celine]
I have so many designs already. You’ll be amazed. I’ve got-

[Jaz]
You need to do this. I implore you to do this. I want everyone to start messaging, annoying you to, to get you to do this, encourage you to do this. I think it’d be amazing. I think it would be well thought out and I think it’d be a great need in dentistry. So we don’t have to rely on different brands. We just buy the CH clamps, call it what you want. You should totally do it. I want you to do this, please.

[Celine]
All right. Deal. If I could shake your hand, I would.

[Jaz]
Amazing. Perfect. The next few questions, we’ve talked about the coronoid already. Anything else you want to add? Cause you mentioned that great tip. And so if anyone missed it earlier. Cow mode.

I love that. Right. So what I tend to say is wiggle your jaw. And I remember my old principal when I used to work in Windsor, Dr. Dave Winkler, he was practicing for 40 something years and he was there as I was doing this on a patient and instructing the patient to wiggle their jaw. And the patient just about understood what that meant. But then he said, in my 40 years of dentistry, I’ve never heard anyone say that, but I like it. But you know what? Cow mode. I like cow mode.

[Celine]
I just think of a cow chewing the cow. Yeah.

[Jaz]
Brilliant. Anything else to add on top of the coronoid or can we move on from that?

[Celine]
I think we can move on from that really. Yeah, it’s practice the placement of the clamp quite a few times before you try the parachute technique. Really get used to it. Use good forceps with a good strong alloy so you can feel what you’re doing. Good vision, good light. But no, that’s pretty much it really.

[Jaz]
Well, you’ve already told us throughout all the different clamps you use, and that was going to be my next question anyway. So I think we’ve managed to cover the principles of isolating the last tooth. And then now, really, I’d love to everyone to learn more from you. How can we, I mean, I know you’re doing a course in Vegas. I know you do course in the UK. If you want to learn more from you, how can we reach out? How can we actually get looking at your content?

[Celine]
Well, great question. I have a pretty active social media account on Instagram, which is blown up in a way that I was never expecting it to. It started off with just a little blog. I was just kind of sharing work because I’m a massive dental geek and it’s turned into the monster that it is today. So on that page, I try to be educational anyway.

I’m not a before and afters dentist. I’m not saying that’s a bad thing at all, but my page is for fellow dentists. So, for example, if I try a technique and I problem solve something that works really well for me, that’s normally when I reach for my camera and I’m like, bang, that’s a good tip, I’m going to post that.

Because I think if that helped me, likely it is, it will help hundreds of other people, hopefully, and then in turn will help tens of thousands of their patients. So that’s the way I look at it. So my social media for one, it’s pretty good for tips on this kind of thing.

[Jaz]
What’s your handle for someone who’s literally on their phone now about to search your name? Obviously when they’re searching they’ll find it anyway, but what’s your handle?

[Celine]
It’s @drcelinehigton, so it’s at D R, and then my full name, C E L I N E H I G T O N. So @drcelinehigton, and you can find it all there. I’m also really open to people messaging me. I try to respond to absolutely everyone, but I have a big believer in manners matter as well, so I always like to, whenever I message someone, if I want to ask something, I always kind of start with a hello, start with an introduction, as you would at a conference in real life, so Whenever I speak to people on social media, I imagine it’s the same as real life.

So I think that’s really important. I think for anyone listening who does want to get tips from dentists on social media, I say, always be conscious of their time and the effort it takes even to give one little reply and just introduce yourself and stuff first. Not because I think I’m the queen of Shiva at all, but it makes such a difference and you probably noticed this as well.

So yes, approach on social media. And then lastly, in real life, some people for some reason like to get me lecturing places. So if you catch the lecture, great. If not, I do run courses. So I’ve got my rubber dam course that I run in London.

[Jaz]
There’s one Isolate with the eight.

[Celine]
Isolate. Yes. So I designed that. I came up with that name years ago. Actually, I remember I was talking a lot to Minesh Patel at the time. And when I came up with it, I mentioned it to him and he said, this is genius. And then I came up with the logo with the inverted eight and everything and made the logo myself on Keynote. And it’s kind of stayed that way forever.

But yes, the Isolate Rubber Dam course in London, I train, I teach the course on Phantom Heads. And I think that’s so important because every single other bit of rubber dam training I’d ever done was on a typodon and the rubber dam just sits like a trampoline so you don’t get to recreate the tension that the dam is under in an open mouth because the mouth opens like a V.

So it’s taught on phantom heads, there’s a lot of hands on, but I’m also running that course in Dublin, it’ll be going back up to Scotland in the summer and it’s over in the States in Vegas in a few weeks with a future date in the pipeline, so lots of options.

[Jaz]
Amazing. Guys, get following at @drcelinehigton. Celine, thanks so much for giving up your time. I know you’ve had a tough day at clinic, but I just loved everything you had to share. Your journey has been amazing. Your background in studying architecture has been really, I didn’t know that. The tip about cow mode. These communication tips. I live for these.

I love it. The use of the ligature over the bow. It’s a great tip there as well. And the clamp selection. So what I’ll do is the team will summarize all the clamps that you mentioned and put it there, but you’ve given incredible value. And what I love is that, I think we all need to appreciate something for those listening, watching.

Just remember that Celine said one thing, which was she gave a tip, right? Which she said that on her courses is like the game changer. And she just gave it away. Like all for free. She gave it away. Right. And we need to really. salute educators like these who don’t hoard and are very giving.

And so thank you for being that kind of educator. And there’s so much more to learn from. We just covered one niche. So everyone, please go ahead. And if you want to really up your level, up your game in Rubber Dam, and also your fulfillment and enjoyment from Dentistry, you can just tell from our chat today that Celine’s a very happy go lucky person and her philosophy and her values and stuff, and it’s good to align yourselves with people like that.

So I’ll make sure I put the link so you can reach out to Celine. Celine, you’ve been absolutely brilliant today. Thank you so much.

[Celine]
Jaz, I can’t thank you enough. Honestly, my heart’s kind of glowing. It’s kind of my cup run is over from hearing all of those things. I’d like to educate and yeah, thank you for saying these lovely things. It’s been a pleasure to be on your podcast and thank you to everyone listening who wants to tune in. And yeah, I welcome any questions, the more the merrier really. So thanks for having me.

[Jaz]
More power to you. And we’ll bring you back one day for another scenario, I’m sure.

[Celine]
Fabulous. Can’t wait.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. Hope you liked our conversation and reflected on the things I said at the very start of this episode about the whole mental health aspect. You know, falling in love with the elements of dentistry and the problem solving and the actual craft itself.

This episode is eligible for CPD. So if you’re a Protrusive Premium subscriber via our Protrusive Guidance Platform, you just have to answer the questions and you can get your CPD from our CPD Queen, who is Mari. Marie will email you certificates quarterly and an annual review, which no other CPD provider does.

I’d like to thank the producer, Erika, and the clinical team of Krissel, Nav, Emma, Sophie, and Rakesh. For those of you who listened on Apple and Spotify, for any of the visual aids on protrusive guidance, I will go ahead and under this episode on protrusive guidance, in the article that we make, I’ll post a summary of which clamps that Celine recommended.

I also have Celine’s website, which is rubberdamfam. com. I love that. And also USA1, I’ll put that in the show notes, so it’s easy for you to click onto. And also her Instagram, I promise you it’ll be worth the follow. I appreciate you being a Protruserati and making it all the way to the end. Like, if you’re making it this far, I really appreciate you.

Keep chopping those onions and I’ll catch you same time, same place, next week. Bye for now.