Protrusive Dental Podcast

Move over, traditional crowns! These ceramic onlays are way more conservative and just downright sexier. But let’s not go crazy – like with all aspects of Dentistry, case selection is key. https://youtu.be/Rl9BF-sIHqI This is going to number 1 for 2021 – it HAS to! This episode is one for true Dental Geeks. Nik Sethi will adhesively blow your mind (wait….what did I just say?) Imagine a 1 hour podcast episode after which you will improve your Onlays like never before – THIS is that episode. From the painful temporisation of onlays to the delicate bonding procedure, Nik leaves no stone unturned. Grab a pen and paper! Protrusive Dental Pearl – use air abrasion on your Tanner/Michigan splints to help to see articulating paper marks more easily. Also it can be used to test compliance of your patients, as they will polish/grind away the abraded surface. Thank you Dr Tilly Houston for sending that one in! In this episode we cover: When to place large composites vs opting for indirect ceramic restorations How to incorporate Immediate Dentine Sealing in to your workflow without feeling you have done anything different or additional How to become more efficient with your adhesive onlay preps When to start overlaying cusps, and when to leave them be (the answer may surprise you…) The full bonding protocol with heated composite (etch and all!) HOW TO TEMPORISE THE BLOODY THINGS When to shoulder….when to bevel? Nik was really great – my only contribution to the show was the term ‘Vonlay’. You’re welcome, everyone! If you loved Nik’s down-to-earth style of teaching, do check out their courses: Elevate 6 – Elevate Dentistry (elevate-dent.com) By very popular demand Riaz and Niks hands on 2 day course covering their FIPO protocol: Leeds 12th & 13th March 2021 London 9th & 10th April 2021 London 23rd & 24th April 2021 Leeds 7th 8th May 2021  Leeds venue- Optident, Valley Drive, Ilkley, LS29 8AL London venue- Blue room venue 220, Headstone Lane, HA2 6LY 2 Day – FIPO – Elevate Dentistry (elevate-dent.com) Finally their pride and joy: Advanced Aesthetic Diploma. Diploma – Elevate Dentistry (elevate-dent.com) If you enjoyed this episode, you will love Emax Onlays and Vertipreps with Jason Smithson!

I am joined by a Dentist fellow podcaster himself, Dr Payman Langroudi, to help you improve your teeth whitening results right away! https://www.youtube.com/watch?v=n-PSjGsICbw Yes – that’s a fluorosis case I treated in the thumbnail! Protrusive Dental Pearl: Using the patients’ aligners as a whitening tray – and better yet, the use of Vivera retainers and Enlighten whitening to Guarantee B1 shade! https://youtu.be/VSQp-etyhZI Are all whitening gels the same? In this energetic and conversational (yet educational!) episode, we discuss: Light based systems – surely it’s all BS? OTC products? Is there a dark horse? Why and HOW to do more whitening cases (simple but effective!) Predictors of poor whitening response (watch out for these patients) Why impressions are still better than scans Whitening tray seal The best way to improve sensitivity If you enjoyed this episode and want more free training with Dr Langroudi, check out his free online training for Dentists You will also like my episode with Manrina Rhode on the nitty gritty details of Porcelain Veneers

Is it time to ditch the analogue occlusion tools like facebows in favour of Digital Dentistry workflows? In this special feature episode with Ian Buckle, we will explore the world of Digital Occlusion. https://youtu.be/M0OR0XJdUvg I was tempted to make this a 2 part, but the flow is too good. Protruserati, get your onions ready for chopping (lots of them) – this is a behemoth episode! We tackled a lot of key themes, include Specialising vs Private courses route (a common question I get sent by Dentists). One of my fav quotes from this episode:‘If you don’t have a clear goal, don’t be surprised if you end up somewhere you didnt expect’ – what we can learn from this is to MAKE a best guess! I also mentioned how it was through Ian that I learned about the FACE Group (Roth) of Orthodontists. These are Orthodontists who are well versed in articulators, facebow, occlusion and ‘stable condylar position’ (or Centric Relation, to many!) There are a good few gems in here about face scanning apps, use of photography, inciso-facial mock-ups, but my favourite gem I want to share on this blog is this:If you record your bite registration AT the DESIRED vertical dimension, you will eliminate any errors in opening the bite on an articulator/digitally. You may need to read that again or listen to that part of the episode again. Once it sinks in, it can be a ‘ah-ha!’ moment. If you want to find out more about future courses by Ian, check out his website. The SplintCourse is just weeks away from the launch offer – have you signed up for the big update? If you liked this episode, you might enjoy the Posterior Guided Occlusion 2 parts with Dr Andy Toy!

Think of this episode as a love letter to the Protruserati. We share the same struggles, and this episode could easily have been called the 6 STRUGGLES of a Comprehensive Dentist. https://youtu.be/DCTgR93Tk3c The struggle is real Here they are: You take your work home with you Dentistry was either mis-sold to me, or I was just naive. When I was a Dental student I read a young dentist magazine. It had a segment dedicated to interviews with DF1 Dentists who had finished their first year in practice. ‘What do you love most about being a Dentist?,’ was one of the questions. One answer caught my eye: ‘I love that I do not take my work home with me.’ I loved that! But after almost 8 years out of dental school, I can tell you (and my wife can testify!) that I find it impossible to be a comprehensive Dentist and NOT bring my work home with me. Treatment planning, organising photos, letters to patients, clinchecks and the list is endless – it will be a longer list for practice owners! New patient examinations will drain you It takes a lot of emotional energy to see new patients. There is a difference between the 15 minute new patient exam and the 45 minutes or 1 hour new patient exam. The longer appointments to learn what the patients goals are and help find the right solutions can be extremely challenging and require intense focus, and dare I say, showmanship. As my principal (Hap Gill) once taught me, we are in show business. You have more to give and more to say The classic sign of this is that your Nurse is always nagging you that ‘you talk too much’. You just want to make the patient’s experience as valuable as possible! You dont earn enough money Controversial. I know. If I could double your income but simplify your Dentistry and limit you to single tooth dentistry – you would probably say no. THAT speaks volumes.You do it for the bigger picture and for passion.Yes the comprehensive Dentist MIGHT gross more, but the amount of money you spend on equipment and courses can be eye-watering. That, and your hourly rate from all the work you do it home is ever-diminishing. Patients always say ‘you are the first person who told me this’ or, the more sinister cousin, ‘why has no dentist ever told me this before?!’ I never know what is the right way to handle this. I just smile and say ‘I love my job so much, that sometimes I care more about a patient’s mouth than they do!’ To clarify, I am suggesting I care more than the patient (not more than any previous Dentist – we should never throw our colleagues under the bus). 6. If someone ever stole your laptop, they would be so dissapointed Admit it. Your phone and laptop is full of forum screenshots, lecture photos, teeth, abscesses, shade matching photos (heaven forbid) and the odd bitewing for good measure! If you enjoyed this episode, you will also like 12 Rules for Dentistry with David Bretton!

Finlay Sutton has made Dentures sexy again. His teaching style is world-famous and it was an absolute thrill to chat to him. Protruserati – this one is going to be clinically IMPACTFUL. https://youtu.be/6Hz208Zv6yU The KING of Removal Prosthodontics We started by discussing the benefits of using Loom for video communication with patients and lab – it adds a personal touch. Genius! What do you do when the framework does not fit?!Finlay will firstly trial the denture on the model. If in doubt, rehearse the path of insertion several times and you can ask your lab.You can use occlude spray on the denture fit surface Regarding Immediate Dentures: Leave your patients in immediate denture (plus relines) for 9-12 months to get maximum shrinkage before upgrading to Chrome. Sometimes you move quicker but need to reline (use ZOE) and then alginate pick up 12 months later. Should you use high impact acrylic? It seems a sensible idea!How about metal mesh? What if your partial denture wearer is a bruxist? We talked about how your partial denture can BECOME a splint. Precision Attachments and Milled Crowns Why Finlay has moved away from precision attachments and true ‘milled’ crowns as they are maintenance heavy. It is simpler to have crowns that are shaped appropriately with guide surfaces that will improve the denture. He does use Stud Attachments, which he uses just twice a year, to resurrect a root-filled retained root to negate the need for a clasp in a high smile line patient. Tell the patient the root may split, AND the tooth in front will need a clasp in the future. Metal backings are amazing for bracing – ‘My dentures are like removable resin bonded bridges’. Hidden away but provide great resistance to rotation and adds rigidity and bracing. Another gem was the use of dimples in to the crowns palatally and distal guide surfaces – with metal backings. The metal backing would have small balls that would slot in to the dimples. ‘What I hate is patients coming back with problems after they spent lots of money. If it all fell apart in a few years time, which these do, we’re in dickie’s meadow’ – there we are, keep it simple! You can use Zirconia crowns with rest seats and dimples but ensure, smooth, round, organic shapes. Be careful about making upper palatal too bulky as affects speech – hence why preferences to make these dimples substractive. If you want to learn more from Finlay, do check out his website for denture courses and learning resources. If you enjoyed this, you may also like the episode about Complete Dentures with Mark Bishop!

In this long overdue (sorry, Protruserati!) episode I will go deeper in to Anterior Midpoint Stop Appliances as an occlusal splint for bruxism, myofascial pain and headaches. If you have not already, you must absolutely check out Understanding AMPSA Part 1 as this is the sequel! https://youtu.be/_dSkQFZa55w Protrusive Dental Pearl 55: Remember at Dental School where they taught us that 3 fingers worth of mouth opening is considered ‘good’ or normal? Well, make sure you remember it’s the patient’s fingers, not your fingers! I showed how to use a range of motion scale and the benefits of checking mouth opening objectively: https://youtu.be/LAlKNwedd6w I am so excited to announce pre-registration for SplintCourse – Splints Simplified for GDPs. Sign up for the launch offer which is just weeks away! You dig my logo, right?! I teach what I know, and I know Resin Bonded Bridges and Splints for GDPs as I have devoted my career to their study! “No amount of canine guidance or posterior disclusion or level of osseointegration of your implants will save you from the destructive forces of Bruxism” Jaz Gulati, PDP055 So here is a recap from AMPSA Part 1: Anterior appliances are not as evil as you were taught We myth busted the Dahl-concept-type occlusal changes with normal wear of such appliances I gave the analogy of the ‘locked-in’ patient, and how when you allow them freedom of movement (reduce the resistance in grinding motions) it is like weight lifting and the weights have been removed We looked at some of the contraindications – intra-capsular issues which are rarer – but also those who are just higher risk of anterior open bites Remember, sometimes you WANT patients to get an AOB! In this Episode I summarise: What is the difference between these various anterior appliances and is one better than the other? Deciding upper arch or lower arch, or sometimes both arches? How many of my patients have developed Anterior open bites, which splints caused them, and how to manage such a scenario? Why even an AMPSA can be an overkill and which patients may actually benefit from a soft bite guard, for example! These appliances can bring HUGE solution to a MASSIVE problem for our patients. Many of my patients are pain-free and no longe require painkillers for headaches and jaw pain. My strongest bruxists (whose teeth I have restored) are religious at wearing the appliance (despite a favourable occlusal scheme) and they love it and KNOW that their Dentistry is protected. This is not a cheap piece of plastic. It is a custom made Orthotic Appliance – I charge anywhere from £450 – £1,300 for appliances (simple AMPSAs, complex AMPSAs, Michigan/Tanner appliances – every case is different). One of my previous delegates from The Splint Course (when it was delivered live) called in to the show and asked ‘I am concerned about charging a high fee for this appliance? What is the appliance does not work?’ – towards the end of this episode we discuss this in full depth! If you enjoyed this episode, you will like why Michigan Splints are overrated! Don’t forget to sign up to The Splint Course for an exclusive launch offer.

**UPDATE** Discount codes for RipeGlobal valid until 31st January 2021 – thank you RipeGlobal for sharing these for the Protruserati! 20% off standard monthly membership Code: RipeLearn 30% off standard annual membership Code: RipeAnnual 30% off premium annual membership Code: RipeJaz https://youtu.be/-iSs8v3pz7Y This man has taught me so much! I would like to share with you 5 Key Lessons that Lincoln Harris has taught me (out of hundreds!). It was a tough list to whittle down to just Five. I have learned so much from this incredible Dentist, Mentor and Leader in Dentistry. [convertkit] When I first asked Linc to come on the podcast, I thought to myself, ‘This guy is ridiculously gifted in every aspect of Dentistry. What should the theme be for this episode?!’ https://youtu.be/QjM3YYM2o84 A great way to think about Written Consent: Setting Realistic Expectations I then settled on timeless, non-clinical lessons that I have picked up from him over time: Lesson 1 – The Stages of Grief I sometimes noticed that as I was explaining a treatment plan to a patient, their body language started to shift. They started to fold their arms. What was going on here? The penny dropped when Lincoln taught me how the stages of grief apply to Dentistry! Lesson 2 – When Dentistry get complex, slow down We all want to be efficient Dentists. However, Lincoln Harris taught me that the more complex Dentistry becomes, the more you need to slow down. This has been powerful. Lesson 3 – Photos – Every patient, every time!How that fits in to the workflow of a consultation Well, I was already taking a hell of a lot of photos before I met Lincoln. But now even the emergency patient that has been squeezed in at 4.50pm on Friday afternoon will get a few clinical intra-oral photos! Lesson 4 – There is no evidence for what is the best treatment for YOUR patient. How we give our patients too many options https://youtu.be/VhkTUOerLkw Evidence Based Dentistry, anyone? I have agonised and agonised over what is the best treatment plan for patients. You then end up sounding unsure of the plan yourself. Sometimes we have to go with our gut! Lesson 5 – How to overcome being uncomfortable discussing fees with patients We all have a number. Above this number, we get a funny feeling in your stomach. What’s your number? If you enjoyed this episode, then do check out eMax Onlays and Vertipreps with Jason Smithson!

TIME SENSITIVE – 50% off Maciek’s Online Contact Point Ambassador Course! Click here https://youtu.be/xVWlZbzSrKE It’s the big debate in General Restorative Dentistry: Which is the best Matrix band to rule them all? In the red corner we have the trusty circumferential Siqveland and Tofflemire bands that got us through dental school and have served billions of restorations…but surely they have no place in contemporary adhesive Dentistry anymore? In the blue corner, we have the sexier, younger sectional matrix systems that are the future (and hopefully the present for many of you!). But even within this category, there is a plethora of choice. Are bioclear celluloid matrices the King of Class II composites to create beautiful, voluptuous contact areas with an enviable seal and an Instagram worthy photograph? Or are the tougher, heavyweight metal sectional bands the one true matrix to rule them all? ‘But there are so many brands!’, I hear you cry. You’ve got Palodent, Garrison, Tor VM to name just a few. Surely one is champion? We haven’t even started talking about the plethora of Restorative Rings yet to get the ideal separation and adaptation of the matrix – even they differ from brand to brand. It’s no wonder that it’s sometimes easier just to pick the disposable circumferential matrix band and be done with this restorative debate… Oh but the wedges! Wooden? Plastic? Teflon floss? Wait, what? Yes you read that correctly. Maciek Czerwinski shares with us the Teflon Floss technique as a substitute for a wedge. It IS very likely the perfect Wedge! https://youtu.be/mEYpDtSNJUg Ladies and Gents: The Teflon Floss Technique! You’re welcome. Most importantly, what is the best matrix – ring – wedge combination! If you have ever struggled with an open contact, an imperfect cervical seal, a collapsed matrix band or a cheeky wedge entering your cavity (hopefully not all for the same restoration), then this episode will blow your mind. As promised, the Matrix Selection System: Matrix Selection System has really helped me with Decision making for Class II Composites https://www.youtube.com/watch?v=u16rST2H5sk Teflon Floss Technique Check out Maciek’s impressive Facebook page to stay up to date! Be sure to sign up to the newsletter for episode updates! If you are in the UK and Ireland and want to avoid fake Tor VM matrix bands from eBay, buy from a reputable source: Incidental Ltd If you enjoyed this episode, you might like Rubber Dam with Harmeet Grewal!

Learning Dental Implants can be confusing. There are so many layers of complexity, from space requirement, restorative components and surgical nuances. This 2nd part of the 2-part series on Implants with Dr Hassan Maghaireh looks to guide us through the fundamentals of assessing your patient for implants. https://youtu.be/VZfWZf1lpoU We cover A LOT of clinical Implantology for GDPs How do you assess the Implant space for the right mouth in the right patient? When patients ask how long Implants last for, what should we tell them? https://youtu.be/COtd1bpx0Jg How long will my Implant Last? How to respond to this? Can you place implants on Smokers? What is the protocol? Bisphosphonates – at what point are implants contraindicated? How can you tell if it’s going to be a complicated case? How about Perio Susceptible patients and placing implants? How will Parafunctional patients fare with implant restorations? Who should take the tooth out?! GDP or Implant placing Dentist I routinely section molars. Is that a good practice? What is ridge preservation and when to consider this? Protrusive Dental Pearl: How to use a pencil to draw line angles for anterior aesthetic composite restorations. I learned this from Dipesh Parmar on the Mini Smile Makeover course (next course in 2021) https://youtu.be/JDEibGUHA1w Please do not use your wife’s Eyeliner If you enjoyed Dr Hassan’s style of teaching, do check out the BAIRD Implant Course. If you liked this episode, you will love revisiting Complete Dentures with Mark Bishop!

When you present your patients with the ideal options, but they end up choosing ‘patch-up’ Dentistry…this is a real world problem, and we will tackle it in a comprehensive way in this Group Function! Thank you Anonymous Dentist on Instagram for sending in this BRILLIANT question: Hey jaz! I’ve been listening to your podcast and I’m a huge fan!I especially enjoyed the Chris Orr one and the communication one.I just wondered if I could have some advice please..I’m working across two practices at the moment, 1 fully private and 1 mixed practice.At the mixed practice, often patients with broken teeth don’t want to pay for crowns/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 /onlay but you’ve spelt it all out then I’m not sure what else I can do?Thanks in advance! X Anonymous Dentist in the UK, Instagram https://youtu.be/Y9xGee14LMg Real world problem in Dentistry…what is the solution? Full episode above You all know what happens when you get Zak Kara to give a quick answer….there is not such thing! Dr Zak Kara goes way beyond the call of duty and delivers us solutions in his signature comprehensive fashion! We tried to steer away from the NHS vs Private Dentistry debate too much – but definitely your environment and the values of your patients plays a huge role. Thank you so much for sending this question in – if anyone has a question they want to submit, do contact me via the website or send your question via DM on Protrusive Dental Instagram. If you found this valuable, share it with your associates and principals. If you liked this, you will also like Zak’s gems on Communication in Episode 10! Here are some comprehensive notes/episode summary was written by fellow Protruserati, Taha Adamji – Thank you, Taha!: PDP GF002 – Communication with Zak Kara – patients always choosing the inferior option ROLE PLAY  Building rapport as you’re coming up/welcoming them in  E.g. How was your journey in today?/How’s your day going today? Feel free to put your things over there and take a seat – give them clear direction when they come in about what to do  What can I do for you? My molar broke – yes I heard, (Receptionist name) told me you’re having a bit of trouble with a tooth on the UL  I’ve had a look through your notes/X-rays/photos etc – from your previous visits – this shows you are well prepared to help them  Sorry to hear that/ that can happen sometimes (empathy) Is this the first time this has happened to you or has it happened before? (History)  Am I right that it doesn’t/does it hurt right now? Is it rough to your tongue/uncomfortable? Patient mentioned the clinic/gave praise Thank you/that’s kind of you to say, I’m reassured by that/what do you already know about us?/it’s your first time seeing me /you saw (x) dentist previously is that right? – all shows you have taken the time time to read their notes/are interested in them and their past experiences Patient apologised for not coming  That’s no problem/Don’t apologise/there’s no need to apologise. What we do here is always blame free/judgement free dentistry Let’s see how we can help you with this problem tooth today: Because this is a “get you of of trouble type of appointment”/urgent/emergency appt, the aim for today is to focus on that one tooth I’m not going to do a full health check/exam today if that’s okay, I’m going to focus on this main problem for you But let’s also check there’s nothing else urgent going on and then we’ll see if we can get this problem solved for you by the end of the visit  What did you hope or expect was going to happen today? (Check expectations) “I was hoping it could be patched up and then I would be on my way” that’s definitely something we could do for you to make it smoother/perhaps take away that sharp edge so that it’s more comfortable  Does that sound okay to you? “How long is that going to last me” Well why don’t we take a bit of a look at it/I’ll put my magnification on/mask up (emphasises you’re going to look at it carefully, in detail)  don’t over promise too early – investigate it first, don’t make any assumptions about treatment options yet  Often when a tooth breaks there’s a reason behind it / did you have an idea on why that might have happened in your tooth’s case? “ I shouldn’t have had that chocolate” Patient/dentist may tend to focus in on the tooth in isolation only – but we need to look at the mouth and the patients as a whole   what is the patients goal here?  any pain to resolve? Roughness/sharp edges – we are going to solve this today  Long term goal/expectations? Examination  Let’s put the chair back and have a look your tooth but first: I’m going to ask you to bite together, let me have a gentle feel of your glands under your chin Let me have a gentle feel of your jaw joint – so open nice and big for me  Check the soft tissues etc  Demonstrates to the patient that you are checking not just the tooth but the whole mouth  Keep signposting exactly what you’re doing as your doing it – try not to have a silent examination – describe everything you’re doing as you do it  the word gentle – implies not going to be rough, taking your time, nothing sudden  Describe in lehman terms for the patients benefit and for the nurses – any technical terms means write this down: I can see the very back tooth – is broken down to a large extent/a quarter of the tooth missing/the inner wall of the tooth is missing/the existing silver filling is still in place  Checking if TTP/palpating: Lets have a gentle feel of the tooth/ I’m going to gently tap/press on a few teeth if that’s okay/and number them 8,7,6,5 “If that’s okay?” Press and see if any response – don’t just start whacking teeth with the mirror handle unexpectedly Co-diagnosing with the patient: How about we translate this to English for you in just a second I want to keep you in the loop I know dentists are weird, we talk in technical terminology because we’re trying to sound clever  Checking with a perio probe: I want to gently feel around the tooth to check where the edge of the broken section of the tooth is To check if it broken below or above the gum line – and that makes a difference – we’ll come back to that for you I want to take an X-ray of this tooth (nurses name) if that’s okay – so that I can see the root end of the tooth (knows it’s a PA)  Takes X-ray We’re going to get that developed then we can see it on the screen  In the mean time let’s take a photograph/intra oral camera/scan of the tooth to have a closer look and we can show you  Tap on the shoulder/Why don’t you have a sit up I’ll bring the chair up, feel free to take the glasses off, we’ll take a look at the x-ray and photos together?  Would you like me to give you a bit of an overview of what’s going on? Need to relate everything that is happening to the context of the patients life Demographic  Their expectations What has been done before/what is normal for them – constant patch ups  Cost/budget/practice plan fees Time/effort required  The patients inner monologue/beliefs and values about their teeth – normal for them to lose teeth? Very difficult to change a patients mindset, takes a long time  Instil your values, of comprehensive care to your patient base through your content-  blogs/Instagram/newsletters? patient base becomes self selecting  if they want things patched up that’s completely acceptable too – they need to understand the implications of this however  Shows photograph of broken tooth “Errr Is that what my tooth looks like?” Can you imagine having a job where we have to look at this all day long? (Jokes lighten the tone) Can I give you summary of what I can see here? So there’s 3 things we’re looking at here: Bone support Is the tooth well embedded in its foundations – roots of teeth and bone is like a tent peg in the ground/molar has 3 roots like your fingers in a bowling ball – really well embedded  Does that make sense so far? Chunking and checking – give bits of information then check they understand it – so that’s the first thing  2. Structural stability  The second thing – and the main reason you’ve come to see us today – we need to check that the tooth is mechanically sound  Did you know a silver filling is not glued inside the tooth? It sits inside the tooth/the channel in the middle keeps the filling in place- like a pear shape – it’s deeper at the bottom than at the top  Can you see how thin this part of the tooth is – it’s so fragile – I can imagine that is what was going on before it broke on the other side  You know when a bridge falls down over a river – can you imagine it wasn’t the last car that drove over it that caused it to collapse – it was actually the fact that it probably going wrong for some time – does that make sense? What I’m trying to say is this tooth hasn’t instantly broken from a bit of chocolate – it was probably heading that way for a period of time 3. Biological seal  When you have a filling inside of a tooth it needs to be sealed all the way around the edges because it’s a bacteria seal  if bacteria manage get in and around your filling they can get underneath (I know this sounds a bit horrible) but that means the filling is leaking And that leakage around the edges can soften the foundations   a lot of people come to see us thinking they have broken their tooth on a olive stone or a chocolate – but probably the tooth and the filling has been deteriorating over time because the filling is sitting on soft foundations  Patients value the explanation – because it matters in terms of what our options are next – can I show you why? Can I show you a picture of somebody else who has been in a similar situation to you?  Get out iPad with photos to show example This is Jane who came to see me (always put context with somebody’s name on it – that matters because they can visualise that this was a real persons tooth) Here is Jane’s tooth with a silver filling in it – luckily we preempted the breakage in this tooth – can you see that tiny wall of the tooth is starting to crack – we realised that this was going to break at some point so what we did was we removed the filling – swipe on the iPad to show the filling removed Can you see the dark brown foundations underneath there – this is deteriorating underneath Can you see that the wall of this tooth here is very thin? – it’s so fragile that if i’d left that in place, Jane would be coming back a few weeks or months later and even this part of the tooth might have broken off as well So here is what we did – we have filled in the missing tooth structure – we shaped down the tooth to a degree and put a strong cap over the top and this binds the whole thing together  Like having a helmet on top of a head/jubilee clip It prevents flexing of the thin part of the tooth from from breaking  Can I ask you how much of a risk taker are you? The reason I ask you that is because today what I’d recommend is that I’m going to seal this section for you because we want to reduce the chance that surface of the tooth become sensitive at some point – it will also make it a bit smoother so your tongue won’t keep going there/feels a bit more comfortable for you  The reason I ask you about risk taking is because it depends how quickly we want to proactively do something for your tooth – the longer we leave it the higher the chance that the other thin wall of the tooth is going to break away  If you don’t want to do a larger MODP amalgam or composite – maybe don’t offer it? or present it in such a way that it is not a good option? If we want to do something that will help keep your tooth in your mouth for a long period of time i.e. hopefully years, decades and if your lucky – the rest of your life  then we need to do something proactive and strong  to protect this thin wall My worry with this tooth (patient name) is that if the remaining part of your tooth breaks off and you come to see me there may be no tooth left to rebuild – so let me ask you well how would that make you feel? (some patients would not be that bothered at this stage – just take it out – but others may really want to prevent this situation) If the patient is still choosing the ‘subpar’ big filling option – then you could play devil’s advocate and ask them – how long would you expect it to last for? Because they need to understand that this will probably not last very long  If they are chipping bits of tooth off everywhere why might this be? NB: Can place a direct composite core overlay – as an interim measure – allows you time to assess pulpal health/periapical issues Always present the best option first  “If it was my tooth…” ? for all the reasons I’ve explained, with the photos etc the tooth would really benefit from protecting these thin walls by putting a cap/onlay on there as you will get the longest lasting result – this will cost £x and I think it will last you a long time You have the option of going for a big filling BUT I don’t think that it’s going to last you as long, and it will cost £x Talk about the better option for longer – not manipulative  “What would you do?” Just tell them what you would actually do (don’t dodge the question) honesty is the best policy don’t try to force them to make the decision themselves and avoid any responsibility because that may just harm your rapport with the patient (seems like you don’t care?) You need to have the context of the patient when knowing what the best option for them is going to be teeth are not in isolation – they in people’s mouths  What are their life circumstances and approach to dealing with a problem in order to find the best solution for them Is the patient okay with continually patching things up or do they value having something that is going to last a long time  do they know how long the patch up will last for and the cost for each time to have it fixed?  Would they rather pay more to have a longer lasting option?  Or are they okay with losing the tooth if it breaks down further?  maybe its better/in the patients best interests to not offer the subpar option? There isn’t just the initial financial implication – but also to do with the number of repeats –  They may be back again soon paying the same amount again to have it fixed  Unlike building work – if everything goes horribly wrong – you can knock it down and start again  but with teeth once it’s gone – the bit that mother nature has given you – is gone