‘My patients are choosing cheaper, inferior options’ – GF002

[Jaz] I’ve got Zak Kara, and the question is, I work in two practices, and again, I’ll read the whole question out when we get into the episode. But it’s along the lines of, I work in two practices. One’s private and one’s public funded or in the UK, we know that as a mixed practice and my patients keep choosing the cheaper, inferior options.

So this dentist is finding that she’s having to do a lot of really large, ambitious composites and a lot of MODBL sort of amalgam restorations with a dovetail inside and just patch up dentistry. So she says, why is there such a big difference? Even though I clearly spell out the benefits.

Patients are still going for the inferior option. Why is this happening? So, I got Zak in to really tackle this in a big way, as Zak would do so. So, initially the point of group function was, hey, let’s make, helpful bite sized 10-to-15-minute episodes. But Zak, what can I say? He’s a comprehensive dentist.

He’s a comprehensive guy. So, he really went no holds barred. We have a full on discussion. There’s some role play in there. And you know what? It was all quite kind of fun. And I sort of streamed this as a live. It kind of failed, but then I premiered it and those people who watched it for about an hour and a half.

It was live on the Facebook group. You guys gave some positive feedback. So I hope you guys listening, enjoy this. Let’s go right into onto this mammoth, mammoth question.

Welcome to Group Function number two with one of our fan favorites. This is Zak Kara. Zak, welcome to the show once again.

[Zak] Hey, Jaz, how are you doing? I can’t believe you caught me on a Saturday night for this. We must have uber dedication to this cause or something, or I must really like you. I don’t know.

[Jaz] I can’t think of anyone better. I know, but I can’t think of anyone better for this topic. And basically the purpose of group function, I know you haven’t tuned into the first one, is to help answer questions of the Protrusive Dental community or the Protruserati. And I’ve had absolute banging question, something that’s really, really pertinent.

And I’m just going to bring it up on the screen. Now, I know you can only see the first part of it. And I just wanted to show this because it’s someone who’s a huge fan, which makes you feel all warm and fuzzy inside. And then, she said that she enjoyed Crystal and the communication one.

But what she means by the communication one was your one.

[Zak] No, it’s not.

[Jaz] You know, that’s you.

[Zak] Must be all the other stuff.

[Jaz] So anyway, she sent this amazing question and I’m going to read it out so that those people who will be listening in the future can tune in and really follow what we’re saying. And so Zak, you can see it as well.

So the question is, I read it out. I wondered if you could have some advice, please. Right. “I’m working across two practices, one fully private and one mixed practice.” So those people from abroad, not in the UK, a mixed practice is like public dentistry and fee per item private dentistry. And what one thing I think me and Zak have agreed not to go too far down the rabbit hole of to discuss too much about NHS and public dentistry, because it shouldn’t be about that.

There are other points that we can tackle, which will be much more sort of universal and those are the concepts [that will flow]. Oh, we can, we can touch that. We can touch on that. And then towards the end. “So, at the mixed practice, so this is both the public and the private, often patients of broken teeth don’t want to pay for crowns and onlays, even though I spell out the benefits. Often they will go for a replacement amalgam, which I hate doing, or a large private composite, again, risk of debond due to the size. What would you recommend? If a patient doesn’t want to pay for a crown or onlay, but you spelt it out, I’m not sure what else I can do.”

So let’s hide that and I’m going to join you back on Riverside. Okay, Zak, that is such a real world question. I’ve definitely been there. Okay. In the past before. Where do you even begin to tackle this?

[Zak] Yeah, I completely agree with you. This is stuff that we have all wrestled with and we wrestle with every single day, isn’t it?

It’s classic day to day judgment call type dentistry where, to be straight up about it, it just sounds as though whoever’s written this question, by the way, hi, and thanks for the question. And by the way, I love this group function vibe and I’ll try and keep this short and sweet with you because I know this otherwise turns into an hour and a half podcast. So let’s not go down that rabbit hole, but-

[Jaz] We love those.

[Zak] We do, but this isn’t the time or place. So, but basically it sounds as though. Whomever sent this question has done the damndest to provide the most kind of thorough, in depth discussion of pros and cons and alternatives and all that stuff you were taught as a dental student, which is totally informed consent, which is absolutely the right thing to do.

But then her patients are choosing the worst option in her opinion, right? And it kind of gets to me, it gets you to a point, doesn’t it? Where you get, you bang your head against a brick wall and you think, are my patients just like all thick or not listening or what is it? Why am I not explaining this right?

And I got to a point in my career where I realized that isn’t that it’s just, it’s often more to do with, I guess it all boils down to one main thing, which is context. So when you sent me this question, which is yesterday on WhatsApp, I thought to myself, that’s a really good question. I thought to myself, this is really, really good question because whoever sent this question probably doesn’t have the same values and approach to life as their patients.

Right? In fact, it’s impossible to have the same values, approach to life, the same kind of way of managing and dealing with a problem. As every one of your patients. And so I find it quite ironic, that question we’ve always had from our patients over the years, which is what would you do? What do you say to that, Jaz?

[Jaz] We have that all the time. I mean, I always say that there’s two ways to approach this one. One is just tell them what is it, what genuinely is what you do, which is often the best option for them. And that’s sometimes why that can be effective. The other way to do it is, and I’ve seen some dentists type this on Facebook in this sort of context of discussion and they say, oh, but I’m not you.

And they go into that sort of argument, and that’s, I think that’s a terrible reply to a patient, right? You’re then sort of, you’re arguing with this patient, no, you have to decide because you’re the person behind the lenses. And I don’t want to be responsible for the decisions that you have to make.

[Zak] Yeah, yeah, I agree. And it gets to a point where you almost end up losing rapport over that, right? The whole thing, I mentioned the word context. For me, it’s like the context of. And the thing that we’re not taught at dental school, major thing, and we hammered on this about this on the podcast, and I’m sure we will continue to talk about this in depth, it’s all about who that patient is and what their backstory is and what their dental experiences are and basically what their approach to life is.

That’s one part of the context, right? So you kind of have to put yourself in this position where you actually need to just get to know what your, how your patient deals with certain life circumstances. And I know that sounds really fluffy. It’s the kind of thing where you’re like, hang on, patient’s come to me with a broken tooth and Zak you’re telling me I have to get to know their life story.

Well, no, actually, I’m not saying you have to get to know it straight away. I’m saying that it’s part of the decision making process and helping that person find out what the right solution is for them under these circumstances, right? The other thing-

[Jaz] But Zak, it’s interesting that she said that-

[Zak] By the way, I just realized I’ve got a friend. It’s Ralph, by the way.

[Jaz] Oh, hello. Awesome. This is amazing. Okay. What was Ralph there when you, [Michael]?

[Zak] No, no, no, no.

[Jaz] Oh, he would have loved that. Okay. He would have loved that. You’ve got to think of the cats, but it’s interesting how in the question, she said that she works at two practices.

She doesn’t seem to have that problem in the private practice. So, how much of it is influenced by the demographic? How much is influenced, by the, again, the values of the patient? Is it that in one practice, the private practice, the values of the patients may be more in tune with the dentist?

Or do you think it could be something to do with the way this dentist is presenting the options at the mixed practice because she knows that she has to legally offer certain options big to take a box for the whole public dentistry. It could be to do with that.

[Zak] Maybe for me, it’s much easier. And to be fair, I’m giving you this an answer based on my own experiences too. So I’m clouded and biased by the fact that actually it’s been a little while since I’ve worked in mixed practice type environments. And there is a conundrum that you play, isn’t it? It’s a day to day little fight that you have inside your head of actually.

What I could do right now is kind of offer the gold standard, the right thing to do and say, look, this is what I can offer you in the health service. Cause that’s what is the ideal. So you might look at this tooth. If I actually could break it down, do you want to break it down into the different stages of how I actually would approach this situation? So actually in the clinic-

[Jaz] Let’s make it really tangible. She said she specifically mentioned a broken tooth. Let’s say upper first molar broken down. And you know that just as she said, a replacement amalgam or repair amalgam or maybe a large composite is not the best thing. This tooth needs cuspal coverage.

This is what we taught. This tooth is a classic candidate for cuspal coverage, but the patients keep choosing the large composite option said. And the perception here is that it’s due to cost. Okay. That’s one perception. Okay. And whether it is or not, who knows, but the patient keeps choosing the large composite. So upper molar broken down, and now you are addressed with that patient. How would you approach that situation?

[Zak] Okay. So let’s say this is the first time this patient’s met me yet. Easy enough. Okay, so patient comes in, we come up the stairs, we’re building a bit of rapport, we’re getting to know each other a little bit, and I’m kind of finding out a kind of background story of how this is the first time you come to see us at the clinic, or maybe they’ve seen a different dentist in the clinic.

Let’s do it that way, it’s probably a bit easier. So patient comes into the treatment room, this is Tash who’s taking care of us today, or Antonio or whoever, feel free to pop your box, crazy COVID rules, pop your box in the corner, and come take a seat. And so I get the door, how’s the day going today? So Jaz, how’s your day going today?

[Jaz] Yeah, yeah, yeah, good. I just, this molar broke down and yeah, I was hoping you’d just fix it for me.

[Zak] Well, I heard, I heard, Jaz, who is on our front of house actually, sent me a message this morning, said that you were having a bit of trouble. So what’s the issue? What happened?

[Jaz] Oh, yeah, classic. I was just eating chocolate from the fridge and it just broke away. It doesn’t hurt or anything, but I was just hoping you could just, fix that for me.

[Zak] Sorry to hear that does happen sometimes. Is it the first time this has happened to you? Is it a sort of broken tooth situation?

[Jaz] Well, I think it’s just, now and again, it happens, right? It’s happened a few times before and then dentists have just fixed it. Thankfully, it doesn’t ever hurt, thankfully.

[Zak] Okay. Am I right in thinking it doesn’t hurt right now?

[Jaz] Yeah, that’s right.

[Zak] Is it rough to your tongue or anything like that? Is it uncomfortable?

[Jaz] Yeah, it’s a bit sharp. I can feel it in my tongue. That’s why I’m here. It’s a bit annoying to my tongue and I thought, yeah, go to the experts.

[Zak] Oh, that’s kind of you to say. I’m reassured by that. What do you know about us? Because first time we’ve met today, isn’t it? Have you been to see ex dentists who’s otherwise in the clinic in the past? Is that right?

[Jaz] Yeah, I see the hygienist here and I think I’m about due for a checkup as well. So, sorry about that.

[Zak] It’s all good. I can’t believe we’ve got into a role play situation here, by the way. Well, let’s go with it. Okay. So feel free. Don’t apologize. There’s no need to apologize. What we do here is always blame free and judgment free dentistry. So no sweat. It’s no issues at all. Let’s see how we can help you with this problem today, because ultimately what we call this is a get you out of trouble type appointment.

Urgent appointment, emergency appointment, whatever you want to call it, right? And the whole aim of the visit today is to make sure we focus on that one tooth. I’m not going to do a full health check for you today, if that’s okay, but I’ll focus in on that one problem. Let’s make sure there’s nothing else urgent going on and then we can see if we can get that solved for you by the end of the visit. What did you kind of hope or expect was going to happen today?

[Jaz] Oh, previously people just patched it up and I’ve been on my way.

[Zak] Okay. Well, actually that might be something we can definitely offer for you today to make it a bit smoother perhaps, or at least take away that sharp edge for you. Does that sound like kind of thing that might be on your, does that sound, sound okay to you?

[Jaz] Yeah, that sounds great. Is that, how long is it going to last me?

[Zak] Well, I’ll tell you what, why don’t we have a bit of a look? Why don’t I have a, take a peek at the tooth. I’ll put my magnification on. I’ll put my mask back up. I’ll come around this side and I have a bit of a look and see what’s going on and then once I can have a bit of a photograph of the tooth perhaps or even a 3D scan I can show you what’s happening yourself. We can have a bit of an overview about what’s happening in the rest of the mouth because often when a tooth breaks there’s usually a reason behind it.

Did you have a reason, do you have a kind of inkling why that might be in your tooth’s case or what’s happening?

[Jaz] I don’t know. It was, I shouldn’t have really picked that chocolate from the fridge.

[Zak] I know, it’s always the shock. It’s always the finer things in life, isn’t it? So what we’re trying to do at this point is gauge context, right?

What I’m trying to do is, before you, so you focused in when you explained this situation, you focused in, Jaz, on the tooth. You focused in on the, it was been on upper molar and this, that, and the other. And, and what does, this goes back to sort of training from Panky Institute, for example, and what LD Panky always says is, always said, was, I’ve never seen a tooth walk into my clinic.

And this is the thing we forget. We always forget what that patient’s goals are. So what I’m trying to establish very early on is, yes, okay, I’m thinking, bingo, this tooth isn’t painful today. Actually, that’s giving me an insight into possible diagnosis, isn’t it? I’m probably thinking, okay, why is it not sensitive?

But the patient doesn’t need to know this at this point. Okay. I’m thinking there’s a roughness to the surface of it. So we need to solve that by the end of the visit. Cause the person’s going to be happy if we can tick that off their list. They’re thinking, let’s get this solved. Okay. The third thing that’s going on is, I’m trying to establish a bit of rapport to say, okay, I understand because this person doesn’t want to come in and think, oh, this dentist is completely unarmed.

I’m saying, okay, I’m giving you the context of the fact that the other dentists in the clinic, I’ve maybe even at this point might say, I’ve had a look back at your records or your photographs or your x rays from your previous visits. So I’ve got a bit of an idea of what’s happened in the past and you should have done, right?

So in preparation for your day, let’s hope it wasn’t sprung on you as a complete surprise. You’ve probably got an idea of what’s about what’s happening in this person’s mouth. And only at that point am I trying to just give myself an insight and maybe give the dental nurse I’m working with an insight into what might be happening by the end of the visit.

Okay. But I’m also trying to kind of pitch myself at a certain point where I don’t over promise too early. And also I’m trying to kind of go, okay, what does this person know about me? Because this is all about your values too. Okay. And it’s easier with patients that have known you a longer time because you’ve kind of been on a bit of a dental journey with them.

And the things that you offer or the solutions you might put out there are much easier because you’ve probably had some of those conversations in the past and you can kind of refer back and you kind of go, oh, do you remember the tooth on the other side? It’s kind of a similar situation to this and they can always refer back and go, okay, this guy knows me.

[Jaz] I mean, history is so important. So, I mean what we sprung up to Zach here is a trickiest of all scenarios where this is a patient who’s cold to you. And the reason we picked it, or we went down this path is we want to try and make it more difficult because when you’re challenging your suggestions and advice you give if we test it with the most trickier situations, the ones where you already have years of rapport with the patient, they’re going to be so much easier, right? So let’s go with this trickier scenario.

[Zak] Okay. So let’s say I put my magnification on important because you’re telling the person that I want to see things big.

I want to be able to see things in detail for you so that I can help you best. I’m going to come around the sides. I’m going to pop the chair backwards. Let’s have a bit of a look. Okay, the chair goes back. I’m very fortunate to work in a kind of clinic where there’s a TV on the ceiling and they usually they’ll get a response because they’ve not been into this chair before and they go, Oh, there’s a TV on the ceiling and you go blah, blah, blah, usual stuff.

Okay. So let’s have a bit of a look at your tooth. The first thing I’m going to do actually, though, this might surprise you is I’m going to ask you to bite together. And let me have a gentle feel of your glands under your chin. Let me have a gentle feel of your jaw joints. Open nice and nice and big and close a few times.

And you’re trying to get into this person’s head and signpost the fact that it isn’t just the tooth we need to think about. The next thing we’re going to do is, it’s completely cold patient to me, I would usually do a soft tissue check, but let’s skip over that for a second, let me grab a mirror and see what’s going on. So what I’m doing at this point-

[Jaz] This is something that is actually a highlight for those listening, because I know the way from my previous chats, how you actually do these checkups and something that you’ve spoken about before is people or dentists that do these silent examinations, like they’re just looking at going around and they’re just registering everything in their head, but the patient doesn’t get any value from that. And I love the way that you so openly speak about never have a silent examination and all these things that you’re saying right now, let’s have a look inside. Yeah. But this is the reality that I think most dentists, okay.

Perhaps a lot of us are introverted and we are doing our checkups, like just checking around open close. Okay. You’re fine. But what you do and what you offer and what you discuss. Bring so much more value. So I just wanted to highlight that, all these things that you’re saying to me. Let’s have a look inside. You’re actually doing this.

[Zak] Yeah. The subtleties of it as well. And I kind of intentionally do things like, I use the word gentle just for the sake of it often, because you kind of kind of instilling in this person that you’re not going to do anything rough. You’re not going to do anything sudden.

We’ll take it step at a time. No sweat. Okay. So nice, nice and wide for me. And I’ll gently stretch the cheek with maybe my finger and I’ll pop my minger into place. And I’ll have a little bit of a look. And okay. So at this point, what I’m trying to do is I’m talking half in dental and half in English.

And the dental nurses that I work with and I’ve trained have a bit of a feel for when I say certain things in certain ways, that means write it down because it’s technical terminology.

And sometimes I’m doing it just for the patient’s benefit. So, what I can see is the very back tooth. So up the very back tooth, Gabri, is broken down to a large extent. There’s about a quarter of the tooth missing and we can see that it’s the inner wall of the tooth that’s broken away. I can also see the existing silver filling still in place.

Okay, so I think so I’ll stop at this point. Okay, I’ll stop at this point and I’ll go. Okay. Jaz, would it be okay if I have a gentle feel around the tooth? So if you close a little bit, so at this point, I’m having a gentle feel maybe in their buccal sulcus and maybe putting my finger on the tooth. I never, ever, ever starts start whacking teeth with mirrors.

That’s weird. Don’t do that. How about just have a gentle feel with your finger? Because if a tooth’s TTP, again, I’m thinking why is this tooth not sensitive? I want to gently tap on the tooth maybe or press with my finger. I’m just going to press a few teeth. I’m going to number them 8, 7, 6 and 5. Would that be okay?

One by one by one you press and you kind of feel for is there a response from this person? Okay, look, I know that we all know this. We’ve all been to dental school. But there’s a different way of doing it when you’re kind of trying to instill certain things in people’s head. As you go, you’re not just doing an examination, you’re doing something where you’re co diagnosing what’s happening in that person’s mouth and in that person’s body.

You’re trying to get into their head. Okay, why is this guy doing all this stuff? And I often say things like, as we go, I often say, how about we translate this to English for you in just a second? Because we don’t want to keep you out of the loop. Okay. I know dentists are weird. We talk technical terminology.

It’s because we try to sound clever. Something like that is generally what I say. I try to sound clever. We talk in Latin sometimes.

[Jaz] Blind them with science.

[Zak] Yeah, yeah, best way. So at this point I’m kind of looking inside the mouth thinking, geez, okay, there’s a great big MOD amalgam. There’s a very thin buccal wall on this upper six, let’s say.

The pallet of walls chipped away. And I have a little gentle feel, maybe with a periproba or Williams. And I say to the patient, I just want to tuck just want to gently feel around the tooth to make sure where the edge of the broken section of the tooth has been or is. I want to have a little feel to make sure it’s above the gum line because when it’s above the gum line that has a difference compared to, or that makes a difference compared to if it’s below the gum line.

Again, I’ll come back to it in a second for you. Do all the way around. Gabri, I’m going to take an x ray of this tooth if that’s okay so that I can see the detail at the root end of the tooth as well as above the surface. So Gabri at this point knows that means a PA. She’s already got it ready because before the patients come in, we have a good idea about which tooth it is, right?

So the PA holder comes out, boom, boom, boom, x ray machine into place, x ray beam into place, come across, press the button, happy days. Okay, we’re going to pass that back to Gabri so that she can go and get that developed so that we can see it. On the big screen in front of us. And in the meantime, when I take a quick photograph, so I’ll grab a mirror and I’ll take a photograph with my SLR, or maybe you’ve got an intro or camera, or maybe clever and you’ve got a 3d scanner and all the works do whatever you need to do.

Sometimes I’ll just do a brief 3d scan of that area because it gives me a good idea as to what’s happening and they can see that you’re actually looking at the details. Jaz, why don’t I just pop, I tend to tap on the shoulder or on the bib that’s on the shoulder. Jaz, why don’t you have a sit up for a second, I’ll click the button on the floor, and let’s, you can feel free to take your glasses off, they’re a bit silly those anyway, and we’ll have a bit of a look at the x rays and the photos.

How about that? Would you like me to give you a bit of a, would you like me to give you a bit of a, kind of a, maybe a brief overview about what’s happening? Does that make sense?

[Jaz] Yeah.

[Zak] There’s two things that’s going on in my mind. One of them is that, wait-

[Jaz] Am I Jaz the patient now or Jaz the podcaster? I don’t know who. I don’t know.

[Zak] Where I am either, mate. This was supposed to be done about 10 minutes ago. I don’t know why I’m still waffling on, but.

[Jaz] It’s cool. Let’s run with it. Because no, you’re adding so much more value. I mean, this is the classic Zak, you know. I ask you a question, but you not only answer it, and you will answer it, because we’re getting there, but you’re also providing umpteen multiple, gosh, times value of what we asked for.

[Zak] Thanks.

[Jaz] So you are really adding so much value. ‘Cause people are following this long and I think the role play bit was just a genius. I think people-

[Zak] Impromptu.

[Jaz] Have a few laughs, but also it’s going to make it extremely tangible.

[Zak] Okay, cool.

[Jaz] Well look, so now you’re explaining to me, I’m the patient, you’re explaining to me.

[Zak] You’re the patient. Okay. So what I’m thinking in my mind at this point is, I need to relate everything that’s happening to Jaz’s world and Jaz’s life, okay? And the reason why, to answer the question kind of in the context of whoever asked the question, is, that I’ve found in the past in some different practice types that people approach their problems reactively.

So you have to put yourself in the context of where you are, what type of demographic you’re typically looking after, and what they have come to accept as normal. Okay, so if they’ve been seeing a dentist for 20 years and it’s patch up with GIC every single time, you’ve got to think instantly in your head, okay, whoa, slow this down because there is no point you coming along and thinking big clever stuff that you learned in textbooks, which has no relevance to their life.

They don’t have the time, money, effort for it. They don’t give a damn because they’re used to waiting for stuff to break and hope to their cross their fingers that there’s something left to fix. Okay.

[Jaz] And I just want to add to this one specific point because I work in a practice that has a well known capitation plan, right? So, people pay a monthly fee and everything’s included. They just have to pay the lab fee, right? So this is something that’s probably there in anywhere in the world. You have something like this now, get this.

Sometimes I’ll say to a patient, okay, you need a crown or whatever, but they’re so used to having patch ups that even though it’s costing them a real absolute bargain, it’s a fraction, there’s only paying the lab fee compared to what a private patient would pay.

It’s for them. It’s not about the cost or the fee at all. It’s just they’ve actually, they’re accustomed to getting patch ups. They’ve found these patch ups to be successful, painless, easy. And this is what they’re paying for.

[Zak] And they use it as their insurance policy. They treat that type of kind of approach as, I tell you what I do is I pay my X pounds per month and all I can do, that gives me the opportunity to phone up at any moment something goes wrong and I get it solved within a day or two. Usually without any hassle or stress.

[Jaz] It’s not sometimes about the fee, because the fee for, in these patients, I’m telling them, you can have a crown, which is the best thing for this tooth, it’ll last longer, it’ll protect your tooth, and it’s not so much money compared to a prior patient. But they’re like, no, you know what? I’ve had patch ups all these years. So again, it’s a value thing. It’s it’s what they’re used to. Exactly what you’re saying.

[Zak] It’s also to do with the fact that some of some people have got this in a monologue and a thing that you will never, ever solve, which is that they believe that’s how the world is.

Some people believe that it’s OK to lose your teeth. The type of patient who comes to see you and they go, oh, haven’t I done well to keep my teeth for this long? And in your head, you’re like, no, actually, it’s weird that you lost any of them, to be honest. Because your values are different.

Your training and your professional training means that you approach the world in a completely different way to them. And remember that they believe in what their parents and their grandparents and then whatever else went through and there’s only so much emphasis and value that they’ll place on your professional expertise, and don’t kick yourself for that.

That isn’t something you’re going to fix. It may be in a very small minority of your patient base. You can turn them around, but it takes so many years to change mindsets. And some of that can be solved a little bit with you putting out, for example, your own content. For example, if you’re a patient, your patient base is something that I’m always looking at.

Your blogs or maybe have a great practice newsletter or something. You can kind of extol the virtues of what type of dentistry you believe in. And then you might become the person in that clinic, the lady or the gent or whoever it is, whoever you are that they come to because they believe in comprehensive stuff too.

And you know what happens is your patient base is self selecting. You actually get the patients you deserve because if you believe in comprehensive stuff, and that’s what you do every day. And actually, you can quite fairly say to somebody that if you want to have something patched up that’s completely acceptable to me, what I can do to buy you some time, actually, should we go back to the role play? Should we do that?

[Jaz] Let’s do it.

[Zak] We should have some sort of video effect at this point. Let’s go back to that for a second, because at this point, I’m showing you a photograph of this broken tooth, right?

[Jaz] Is that what my tooth looks like?

[Zak] Yeah, isn’t it crazy? I can’t imagine having a job where you have to look at this all day long. So shall I talk you through? And do you know what? All of this stuff lightens the tone. It makes, it sets the scene for you’re not going to get old school weird dentistry here. And that matters a lot to me. Perceptions matter a lot to at this point I might show the photograph. and I will kind of give you a summary. Can I give you a summary of just for two minutes based on what I can see? Would that be okay?

[Jaz] Sure.

[Zak] Great. So there’s three things that we always look at on every single tooth. Whether it’s in a photo and x ray and the x rays coming in just a second, by the way. So some of the things I’m telling you, I’m going to mold around what’s about to appear on the screen.

Okay. But basically I’m looking forward. Is your tooth well embedded in its foundations? Teeth are kind of a bit like tent pegs in the ground. So imagine there’s the ground, this is an upper molar tooth, so the ground is here and your tent peg is well embedded inside. In fact, funnily enough, your tent peg’s got three roots, like this.

So it’s quite well embedded, a bit like, when you go bowling, you put your fingers in a bowling ball like that. It’s kind of really well embedded, okay? It likes it there. But what can happen over time is the foundations can shrink away. Let’s turn it into one single root because it’s a bit easier.

So the ground and the foundations can shrink away. I’m checking on the x ray in a second to see, has it got good does foundations. That make sense so far?

[Jaz] Yes. Yeah.

[Zak] So that’s the first thing, but really the main reason why you’re here today is chunking and checking there. What was that?

[Jaz] In the most basic of communication skills at dental school that we basically had was you keep chunking and checking. That’s essentially what you’re doing.

[Zak] And I didn’t get that training. That’s good. I like the terminology. Thanks, Jaz. Thanks for embellishing as always. I wish you’d do this podcast together. So that was the first thing. The second thing. And the main reason you’ve come to see us today, let’s face it, is because every tooth that we look at needs to be mechanically sound, okay? One thing that’s important that you know is that when a silver filling is put in a tooth, just like yours, can you see on the photograph that it’s the channel in the middle of the tooth? Did you know that it’s actually not glued in place? Did you know that?

[Jaz] No.

[Zak] Okay. So here’s something that a lot of our patients tell us. They’re unaware that a filling stays in a tooth in that way. Basically a filling has to stay in a little bit like it has to be deeper at the base and narrow at the top.

So it’s kind of, if you look at it, looking at it side on, it’s kind of like a pear shape. Okay, and the pear shape matters because what you see on the surface means it’s deeper, lower down, and can you see how thin, so fragile, I always go into that tone, I don’t know why, but I do, it’s so fragile, the outer wall of the surface of the tooth, that I can kind of envision that was what was going on on the inner wall of the surface of the tooth.

And, God forbid, you know when a bridge falls down? Like, literally a bridge over a river. Can you imagine that it wasn’t just the last car that drove over it that caused it to fall over. It was actually the fact that it was going wrong for quite some time. Does that kind of make sense? What I’m trying to say to you is that this tooth hasn’t just instantly broken because of a bit of chocolate.

It’s kind of been headed that way over a period of time, okay? And there’s another aspect to this, which is that I need to look at the tooth biologically. Because when you have a filling inside a tooth, it needs to be sealed all the way around the edges because it’s a bacteria seal. And if bacteria get in and around your filling, they kind of get underneath, kind of, I know it sounds a bit horrible, but basically it means the filling is leaking.

And that leakage is, doesn’t mean you’re leaking by the way, that leakage around the edges is the thing that can actually soften the foundations. And a lot of people come to see us thinking they’ve broken their tooth on an olive stone or something or chocolate. And probably the tooth of a filling has been deteriorating over time. So the filling’s kind of sitting on top of soft foundations.

[Jaz] Oh, right. No, no dentist ever told me this before. You’re amazing, Dr. Zak.

[Zak] Thank you. That’s very kind of you. Zak, by the way, I don’t give the dogs that. That’s weird. But, yeah, that’s very kind of you, Jaz. And do you know what? A lot of people really value the explanation because it matters in terms of what our options are next.

I’ll tell you why. Can I show you a picture of somebody else who’s been in a similar situation to you? Okay, so here’s a picture of my iPad. So here’s a filling inside a tooth. Can you see how we actually, this is Jane who came to see me, always put context with somebody’s name on it. That matters because they can visualize that this is this person’s tooth, not just any old tooth.

Okay. So this is a photo of Jane’s tooth when she had a silver filling in it. And actually we luckily preempted the breakage of this tooth. But can you see how that tiny wall there is starting to crack?

[Jaz] Yeah.

[Zak] So the tiny wall of the tooth is starting to crack. And what happened is that we realized this tooth was going to break at some point. What we decided to do was this. So we removed the filling, swipe on the iPad. Can you see there’s actually a dark brown foundation underneath there. And they usually go-

[Jaz] Oh.

[Zak] Actually to you. And thanks mate. To you and me. As in dentists, we know that that is not to do with, it’s probably not even active carious tissue, right? But we know that a tooth is underneath. But to them, it’s brilliant because it always gets a response. So this is deteriorating underneath. You don’t have to say going wrong in a period of time. And can you see that the wall of the tooth here is very thin? It’s so fragile that if I’d left that in place, Jane would have come back even a few weeks or months later.

And she’s broken that bit of the tooth off as well. So swipe again. Here’s a photograph of what we did afterwards and what we’ve achieved for her is we’ve filled in the missing tooth structure. We’ve actually shaped down the tooth to some degree and put something strong on top. And that strong cap on top binds it all together. Do you know what a jubilee clip is?

[Jaz] I actually don’t.

[Zak] Okay, that’s weird. Okay, why did I say, I said weird a lot today.

[Jaz] I’m going to have to start a poll on the community group to ask, do you know what a jubilee clip is?

[Zak] A jubilee clip is for people that know how to do stuff in their homes. This will be people who like DIY and have actually got their hands dirty in life. Not you, clearly, because you call someone-

[Jaz] I suck at DIY.

[Zak] It’s kind of to do with plumbing and DIY and stuff. Anyway, basically, a jubilee clip binds something together, okay? You basically put it around something like a pipe, and you tighten it up to make it seal together again, okay? And people get that because what it does is it binds the whole tooth structure together, and that means every time that you bite down on the top, a little bit like having a helmet on top of a head.

You’re going to bite down and the force goes through the tooth, or in your case, up a tooth, up through the tooth, okay? What’s been happening in your case, and the reason why it broke almost certainly, is that the flex and flex and flex every day of that little thin section caused it to break away.

[Jaz] Okay.

[Zak] Does that make sense?

[Jaz] Yeah.

[Zak] Do you know where I usually go with it at this point is the x rays come up? Let’s just assume for sake for the sake of argument because it’s going to get way too complicated and way past my bedtime, the tooth has no pathology on it. For example for argument’s sake. It’s just a fracture of the tooth It’s pretty straightforward is we’re just going to restore it. Okay, so can I ask you a question Jaz?

[Jaz] Yes.

[Zak] How much a risk taker are you?

[Jaz] Oh, depends. Have to buy me a drink first.

[Zak] This is only a first day.

[Jaz] Yeah. You actually asked that question to a patient.

[Zak] Occasionally.

[Jaz] That’s pretty cool. I like that.

[Zak] Occasionally.

[Jaz] I see where this is going and I like it. And I have actually put this in a gambling form, are you a bit of a gambler? I like the risk approach much better. ‘Cause gambling has negative connotations. So I would say well, I wouldn’t know what to say to that as a patient. I’d say, a little, I guess.

[Zak] Okay. So the reason I ask you that is because today what I recommend is I’m going to seal this section for you because we want to reduce your chance that that surface of the tooth becomes sensitive at some point.

It’ll also make it a bit smoother so your tongue won’t keep playing with it. We always do that. I don’t know why us human beings do that, but we do it. Okay. And the reason I ask the question about risk taking is because it’s all going to come down to how quickly we get round to proactively helping you with this tooth.

The longer we leave it, the higher the chance that other thin wall of the tooth is going to break away. So to finally, finally answer the question of whomever, thank you again for whoever asked the question. If you hate doing amalgams, that are M. O. D. P. s, that are unretentive as hell, that you have to put pins in teeth for, that, you know in your heart of hearts you should overlay the buccal cusps for, but you’ve also got 30 minutes rather than an hour and a half, and also-

[Jaz] Or just a large composite, that way it should have been cusp of protection, yeah.

[Zak] If that’s the case, then perhaps, don’t offer it. Or maybe offer it in such a fashion that you go, this is well, you could say, look, okay, slight facet to this. Quite often I will place a direct composite because particularly for tooth in a situation like this isn’t giving us any symptoms. I will want to restore the core, protect the buccal cusp with an overlay.

By the way, shout out to Nick Sethi and Riyaz Yasser. If you’re interested in finding out more about how to place onlays. So go and have a look at their onlay course because there’s an awful lot of information that we don’t know about adhesives. And we’re not taught at dental school. So, I definitely recommend you look into that.

And placing an onlay direct like that gives us time. It gives you the opportunity to reassess the pulpal health of the tooth. To reassess it periapically to have somebody come back for a complete health check so that actually you can maybe convert this person into a comprehensive thinking person, and you are not going to solve that on day one.

[Jaz] Yep.

[Zak] So I guess that kind of answer the question, but I suppose what we’re saying is, if the person chooses the amalgam every time. Are we saying don’t do it?

[Jaz] Well, I had a good think about this as well before I got you on. I was thinking, so look, I don’t mean this as a criticism to you, Zak, okay? But everything you’ve said sounds great when you are working with time. When you can really focusing and you have that diary time to build a report, although I don’t think you’ve done anything excessive or beyond, but let’s put ourselves in a situation where maybe in a public funded dentistry, NHS mixed practice, maybe a factor, maybe the difference is that this same dentist, so it’s the same dentist with the same values, the same hand skills, same language working in two environments and one environment, they seem to be taking up the treatment approach, which is best for them.

And the one she recommends and the other one, they’re deviating from that. Maybe the difference is that in one practice, she has half an hour, whereas the other practice she has 15 minutes, which is it’s real well, right? Maybe it’s a time and the lack of rapport and the lack of having the ability to show the patient a photograph of an example case and to show them and you be able to give them the opportunity to use language like fragile, that you’ve got a fragile too. That’s one factor.

[Zak] Okay, go on. What’s the other?

[Jaz] But the other factor is, is how you present the option because you just made a great point there. Maybe if a large composite or a M O D B L amalgam is inappropriate and you’re just giving that option for the sake of giving the option was it’s not an appropriate option. Maybe you should say this tooth needs a crown and there’s nothing wrong with saying.

[Zak] Maybe it would be so that we can keep this to take your teeth so we can keep this tooth in your mouth for a long period of time, hopefully years, decades, or maybe even the rest of your life if you’re very lucky. Then we need to do something strong and proactive, and that means we need to protect that thin wall, because my worry with this tooth, Jaz, is that if that remaining portion of the tooth breaks off, we could be in a situation where you come to see me and there’s no tooth left to rebuild. And if that’s the case, then, well, actually, let me ask you, how would you feel? And that question.

[Jaz] Oh, I’d hate that.

[Zak] Okay. So if that’s the case, then we need to do something proactive about it. So what you’re trying to do is kind of, again, contextualize that person’s goals, values, plans for the future. And if that person says, I’m never losing another tooth again, because that was a horrible experience and I hate the gap.

And I’ve always wanted to do something about the gap, but everything just seems to go wrong. Let’s face it. Actually, I have said this so many times. If I hadn’t ended up in dentistry, I could very easily have been a terrible dental patient. I, my sixes are pretty heavily filled. Things could have gone pretty horribly wrong for me.

And I could have ended up in a world where I hated dentistry because that’s not because I’m, maybe not doing the right things, but just because stuff happens and you tend to go down without getting too philosophical. We all go down a kind of directional path in our lives, right? It’s hard to remember what it was like to not know the stuff that we know and take the decisions that we’ve taken.

You can’t backtrack. I find it really hard to remember what it was like not to know how to brush my teeth. Like, and to be honest, I didn’t really know how to brush my teeth until I was taught by a dental hygienist when I was in second or third year at uni. And. And that’s because I was a guinea pig patient, right?

I had no clue how to look after myself and I actually probably wasn’t taught how to give OHI myself. But anyway, conversation for another day. The other aspects and things that I, to answer the question in a little slightly different way, if somebody keeps choosing the option that you think is the worst option of all of them, one thing that might be worth playing devil’s advocate with, and it does depend on how much, how in rapport you are with this person, is to ask, how long are you expecting this to last?

Well, how long would you expect that to last? And they go, what do you mean? And that’s again the point at which you need to kind of rethink the whole situation because, if they, yeah, if they haven’t opted into the fact that we’re just space filling with this problem, then you need to kind of have them understand that actually when you take half a step back, look at your whole mouth, and if you’re chipping bits of teeth off everywhere, again, why do you think that might be?

If you’re even watching this and you’ve got this far down the road of this, God knows how long supposed to be a podcast.

[Jaz] By the way, I’m now having to convert this into a full PDP episode. It’s no longer a group function.

[Zak] Sorry mate, how long supposed to be? 20 minutes? I don’t know, whatever.

[Jaz] 10 to 15 minutes. My producer is going to charge me double the cost now to produce this is good. Let’s keep going now. Let’s do it justice. So it was going to be like, okay, how can we help this lady, this dentist who has a real world issue, and five, 10 minutes, boom. Some, some tangible tips, but you’ve actually gone way beyond that.

[Zak] I can’t do it half. I can’t do it half fast. Sorry.

[Jaz] You can’t. And you were going to whole hog. So we talked about the values of the patient. We talked about how we should potentially not only give them that one option, but then in a way you have your dentist that says, oh, but you know, GDC says you have to present all the options.

Well, the GDC says that we are, we can and should give them a recommended option. The GC states that, you should give them what’s the best option.

[Zak] It also states you should do what’s in the patient’s best interest. And that is a fundamental thing that we actually miss when we think about treatment planning, because we think about teeth in isolation.

Teeth are not in isolation. Teeth are in people’s mouths and people have parameters. People have time constraints and funding constraints and they have context of their lives where they believe certain things to work in particular ways. Now, there’s only so much you can do in instilling the virtues of what you believe in their minds, in one solitary episode.

So one solitary appointment, you can seal a tooth and make it biologically sealed. Try your best with a bit of Fuji. Classic bit of patch up dentistry to buy some time, but what I’m really doing there is bringing them back for a complete health check. And on a second appointment, you’ve got a better idea of how much they’ve won.

Retain the information or some of which you gave him last time. Give him time to think about options for the future. Maybe I wouldn’t have given the full options about crowns and restorations or whatever on day one. I would have waited till the The complete health check, if you think they need longer, then maybe you, I’m not saying don’t work in a public health type clinic, but I’m saying maybe if you’ve got this, you’ve got this far down the road of listening to this episode, then maybe you are the kind of person that should be thinking about working in an environment where you’ve got so much more time at your disposal and technology at your disposal and invest in your magnification of photography, because if you can’t communicate with pictures, you’re so handcuffed. So for the future, that’s the direction that we’re going.

[Jaz] That’s great. So also an opportunity for this dentist to reflect on there is a difference in these two environments that she’s working in, and that is one part of it as well. I was actually, I told you earlier in the, before we started recording that I spoke to a dentist the other day, and we were talking about communication.

And one thing I didn’t tell you was it’s along the same vein and along the same theme of what we’re discussing about here, about how to talk to patients about the different options. And he was having the same issue. He was saying that I work in a run of the mill and just practice day in, day out. And my patients are just, they don’t want the private options, you know, fine.

It’s a whole gray area about private options and just options. Let’s forget about that for a second, but they don’t go for the superior option. And then I asked him and I said, can you pretend I’m a patient? We actually did role play and can you present the options to me? And he said this, he said, We can do the big filling, it, it will help to restore your function.

It will do the job. And that’s included or that’s, you know, 200 pounds or whatever, making up a figure. Or you can have this all singing or dancing option, but it’s going to cost you 450 pounds. Can you see what’s wrong with that? And I told him that, dude, the way you’re presenting is like, you actually just presented the better option, but then you sort of like, oh, but you know what is a lot more money.

So I told him that instantly, here’s what you need to do. He needs to present them the best option first. Like, listen, if this is my tooth and for all the reasons I showed the photo I showed you, the tooth really benefit from protecting all the cusps and to actually put a cap on there will really mean you get the longest lasting result. This will cost 450 pounds and I think this will last you a long time. You have the other option of going for a big filling, but I don’t think it’ll last as long. It costs that much. Don’t you think I framed that in a much better way?

[Zak] Do you know what you did? Is you used the but. So much more effectively. You used the but in such a way as to portray the negative implications of the worst solution. And that isn’t because-

[Jaz] And Barry Alton talks about this as well, but Barry’s great at doing this.

[Zak] And exactly that. You used a but in the right context and you timed that very well as well because you spent longer talking about the more recommended option, the more proactive option, and you skirted over the other option.

And that isn’t because you’re trying to convince somebody that’s just that, in your heart of hearts that that’s what you’d have done. So say it, explain it. And, and having somebody understand how long it lasts and therefore how much investment you need to put into it to make it make that happen.

Actually, one of the things we talked about again on the previous podcast is that, people forget that it isn’t just a time implication, sorry, a financial implication, but it’s also to do with how many repeats, repeat episodes with this tooth might arise over time. So it is that classic thing of you do something to try and patch something up, but you might be back with this tooth and paying the same amount again in however long, but actually the difficulty with teeth, unlike human, unlike buildings, for example, or building work is that a building, if it all goes horribly wrong, you can knock the whole thing down and start again. The difficulty with teeth is that once it’s gone, the bit that mother nature gave you is gone.

[Jaz] I think that’s the fifth analogy in this episode. You’re always full of these crazy analogies. Not one of these analogies you’ve said on the previous two episodes. So there we are. You got these great ones. I mean, wow. I mean, again, I think we have now answered that question, of this dentist who’s feeling as though that the patients are choosing inferior options. So I hope I hope that helped you. I’ll message you once this is out so you can give us your feedback.

See if you found that useful. I’ve changed my mind. I think I will put this a group function because we helped him answer a question. We did it in just a super comprehensive way.

[Zak] Comprehensive dentistry. Demonstrate comprehensive answers. What can we do? I’m sorry, guys. I just talked too much. I need to go and get on with my life.

[Jaz] No, no, no, no. But it was, it was good. It was good. It was useful. And you know what? I think what this shows is that this is such a mammoth. Topic and we couldn’t have done it justice in 15 minutes.

Again, thank you so much. No, no, no, no. His name is John. Anyway, thank you, Zak. Thanks again. Always, just in case we are live somehow, thanks for tuning in guys. I don’t think this worked out. I need to complain to these people, Riverside. Anyway, Zak, thanks so much for coming on and helping out.

As always, we really appreciate your time and your expertise, and I hope to see you more on the Protrusive.

[Zak] Let’s do this. Cheers, mate.