‘The Routine Check-Up’ – The Breakdown – PS003

Protrusive Dental Podcast

I remember being a dental student and a simple ‘check up’ could take HOURS! Then the tutor would come along and complete the observation in 30 seconds…

‘How does a routine general dental examination work in the real world?’, asks Emma, our Protrusive student.

The humble ‘check-up’ – as far as you can get from sexy before and after cases. The stuff no one is posting about on socials…until now!

https://youtu.be/AutQvQBlg4o

Watch PS003 on Youtube

Jaz and Emma dissect a ‘routine oral health exam’ and Jaz even includes a full video of a standard check-up, complete with the banter, bitewings and bad explanations! 😉

Be sure to check out this additional video freely accessible on our platform, Protrusive Guidance!

Need to Read it? Check out the Full Episode Transcript below!

HIGHLIGHTS OF THIS EPISODE:
04:28 – Emma’s Dive into Dentures
05:45 – Pop Quiz Time: Testing Dental Composite Knowledge
06:30 – Success in Dentistry: It’s in the Details
08:13 – What Does a Check-Up Look Like?
09:20 – Personal Touch: Jaz’s Check-up Style
10:50 – Defining a Healthy Mouth
14:55 – Neck Lumps Discovery
16:33 – Masseter Muscle Insights
18:29 – TMJ Movement Evaluation
21:21 – Temporalis Muscle Assessment
38:27 – Patient History
39:10 – Soft Tissue Evaluation
39:28 – Basic Periodontal Exam
40:25 – Magnification Importance
51:10 – Confidence

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore! 😉

If you liked this episode, you will also like PS002 – Adhesive Dentistry for Beginners

Click below for full episode transcript:

Jaz's Introduction: When I was a dental student, I remember being on clinic and doing an examination, and it would just take me so long. And it's overwhelming when you're learning and you realize, oh my goodness, there's so much to check. You try and remember the oral medicine lectures. They tell you to check every single lymph node under the sun.

Jaz’s Introduction:
And then of course, you remember the occlusion, the very few occlusion lectures you had, and you get the patient to bite together and you don’t know what you’re doing. You don’t know what you’re checking for, but you’re just checking that the bite exists. And then to try and compute all the things you’re seeing and try and put it in some sort of diagnosis and explanation, when you’re a student, it’s tricky.

Which is why I’ve got Emma, our Protrusive Student on today to talk about routine, just routine, gold standard, daily examinations, something that you will see in general practice in the future. Whilst I am recording with Emma Hutchinson, the student, this is suitable for anyone who wants to learn, any dentist at any stage of career, who just wants to get back to basics, back to foundations.

For a, what I call a Real World Examination. The reason I call it a real world examination is because the things that I’ll be discussing today and what I’ll be sharing video form on the Protrusive app under the student scholarship section is a real world exam. So, for example, a comprehensive exam evaluation could take an hour, 90 minutes.

You ask different people. Some people do two hour full examinations. And they have my highest respect, and that’s amazing. But that level of service is not for the masses. It’s not for the general public. Look, some of my colleagues just get 10 minutes to do an entire examination. So I’ve had to find somewhat of a halfway house.

I’ve just kind of assessed, okay, well, these are essential and these are desirable. Actually, these guidelines already exist. In the practice at the moment, we’re doing these audits. We’re auditing each other’s notes. It was actually been a really great exercise to do this because the guidelines, there’s a tick box for, hmm, did you discuss the diet?

And did you grade the level of tooth wear? And the biggest one, which a lot of colleagues miss is, was there a clear written diagnosis? Was there a discussion? There’s so many different checkpoints. And what I’ll do actually is I’ll share the parameters of this audit. So this is more like an aspirational thing.

Like what is the gold standard checkup according to regulators up? I’ll put that on there, but please don’t listen to today’s episode or watch today’s episode and think, ah, this is what I’m going to do cause that’s how Jaz does it. Today is very much foundational stuff that any question that Emma had, I just answered.

And I hope that it gives you a dose of reality, like a real world examination. And there’s different levels that you could do a bit more basic than what we discussed and you could do a lot more advanced than what I discussed as well. And really, you have to just find your feet, get the basics right, and grow and skill up even your examinations from there.

I really believe the examination you do has to be suited to the level of the population you’re treating. i. e. if you are in a public health setting and you’ve got five, ten minute examinations, not that I condone that or I like that, but I’m just saying, you’re probably not going to check every single lymph node under the sun.

You’re probably not going to have an in depth discussion about diet with your patient if all you have is ten minutes. So I hope this gives you some sort of inspiration to really critically evaluate what you are checking and what you are actually omitting due to either time constraints or maybe a lack of knowledge or experience in that area.

So before we join Emma, our Protrusive Student, to just geek out on the basic examination, bread and butter, please do check out Protrusive Guidance, the home of the geekiest and nicest dentists in the world. And now we have a student space for you as well. It’s called a Student Scholarship. Remember, if you want to join as a student, and get access to a secret space with some goodies, just for you students.

Make sure you email [e-mail] with your proof. And so when Mari accepts you to network, she’ll also invite you to the secret space. And remember, don’t hoard this stuff. People are going to find out anyway, share it with your student colleagues, let them learn, let us grow together. That’s what the ethos of Protrusive is all about. I’ll catch you in the outro.

Emma Hutcheson, welcome back again for the student edition, our monthly update. And today we’re going to be obviously releasing some new revision notes. So we’ll come to that at the end. But before we do, just tell us how is life at dental school right now? What have you been up to recently? What have you been learning?

[Emma]
So recently I was actually off last week because I had COVID. A wee bit embarrassing to have it in 2024, but it’s fine. We’re all good now. So yeah, it’s been good. Really getting stuck into the clinical side of it. I’ve got a few patients on rotation, so I’m only seeing about two patients a week at the moment.

First on, like, I’m in on a Thursday afternoon, I’m making dentures and things like that, which is really tricky. Actually really, really tricky. Just the sort to understand it all and really understand what’s going on.

[Jaz]
I remember having a chat with you before, Emma, and you mentioned that, it’s so difficult and then therefore, I think you told me that it was such a tricky topic that you really went all in on it. And I feel like we’re promised when it’s prosthetic month, some really epic notes for that.

[Emma]
Yeah, yeah, definitely. I think it’s so theory heavy for prosthodontists, especially that it’s good to know all the information, all the things you need to tick off and everything. But actually doing it and maybe watching someone else do it, it’s just a whole other ballgame. I think you don’t really understand it. I mean, I’ve heard dentistry, you really don’t understand profs until after you’ve graduated. So that’s definitely something.

[Jaz]
I think you don’t understand dentistry until you’ve actually graduated. It’s like, same like driving a car, right? You don’t understand how to drive truly until you pass your test.

[Emma]
Absolutely.

[Jaz]
So it’s the same no matter what discipline it is, Emma. Whoever said that to you, it should apply to all aspects of dentistry. Let’s not be shy about that.

[Emma]
Yeah, definitely. So I’m going through that whole process and I say I’m making a set of dentures. I’m playing dentist and someone is there with me the whole time telling me what to do. And so it’s still very much at the being spoon fed kind of stage, but it’s good. It’s going well. And I’m in restorative on a Friday, I got a big composite to do last week. So, no, it’s good. That’s going well. Really starting to feel like-

[Jaz]
So test time, in the last month’s edition, we discussed about longevity of composites. Do you remember the success rates and what were the determinants of the success rates? This is just like revision for the Protruserati listening right now from last month’s episode, testing you, putting you on the spot, off script.

[Emma]
So after 10 years, was it about 80%?

[Jaz]
I think it was, it was a lot better than that. If you think about the annual failure rate, right. Like in the low risk group, it was like one to three percent in general, but let’s see. I know you’re right. It’s 82%.

[Emma]
Oh, okay.

[Jaz]
You actually nailed it. But it was higher in the low risk group and it was lower in the high risk group. But it does, you’re completely right. It does average out to 80%, which is amazing. So well done. So that’s a 10 years, right? Do you remember the two most important factors that determine the longevity of your composite restoration?

[Emma]
I think a huge takeaway was just to make sure that if this restoration is going to have the best chance, you need to reduce your case’s risk rate, you can do the most beautiful restoration in the world, but if it’s not being looked faster at home, then, you know it’s not got as good a chance as someone who does do all X, Y, and Z, and all the rest of it.

[Jaz]
Well, patient factors were number one, like, the biggest determinant was how well the patient will look after it, the environment that the composite is being placed into, and the second one, do you remember the second one? You’re going to kill me after this recording, I know it guys. Okay, I’m going I did not tell any of like revision, but now you know what to expect.

Now monthly episodes. I think it’s nice to just revise what we covered before. So how big, how many surfaces are involved, right? Think about it like a giant M O D B L composite compared to a teeny weeny little occlusal. The chance of failure, there’s so many more surfaces involved, so much more contact area.

So that’s it. Yeah. So we’ll, we’ll talk about in the future, at what point does that large composite really need to be indirect? And that’s a whole conversation we can have in the future. But today we’re going to go a little bit back to basics, but the basics, as I refer to it, when I was at your stage, Emma, I’m looking like I would get my tutor over and I’ve just done this examination, which is taking like half an hour and the tutor will come over and kind of just do everything in like 30 seconds. And find five things that I missed. Have you experienced this?

[Emma]
Yes, a hundred percent.

[Jaz]
So it’s an opportunity for us to discuss about this and to answer the student questions that you have in terms of, okay, what are we actually looking for? So where would you like to start, Emma?

[Emma]
So I was hoping to ask you, and it is such a broad question, so you can sort of take this for everyone. Like, what does a check up look like? Cause, they’re all different, I’ve seen so many dentists do so many exams, and everyone does check ups differently, but, I mean, the fundamentals are all the same.

You’re all looking for the same things, so I’m hoping we can just sort of go through it together, sort of step by step, what you’re looking for, what’s going on in your brain, like, your checklist that you have, covering the must haves and then hopefully just picking up some of your own wee personal tips along the way. Because all the tick boxes are the same, but what’s your sort of order of doing things, really? How do you make it the most efficient?

[Jaz]
Checkups are kind of a bit like treatment planning in the sense that there is an artistic element to it. The textbook says certain things, but then some dentists will ignore a few facets and then other dentists will go above and beyond and record five of the things that you weren’t really taught in dental school, right?

And it kind of is something that’s like a censored portion of a textbook or you just never came across it and you think, okay, what’s happening? Why is everyone doing their checkup so differently? So that’s why there has been an art form involved. And you have to remember that time is in the real world is such a key variable.

Like if you go to someone for a half an hour checkup and someone for a five minute checkup, right, there’s going to be a difference. So the pace at which you go at and the number of things that you actually measure will be different. So based on what you just said, I think you’ve inspired me that this month’s clinical student video, which I think will help dentists as well, young dentists as well is, you know, I’ve got my camera that I attach to my loops?

If I just did from the beginning, like the patient walks to the room, my camera’s on, I call the patient in advance, like, listen, this is a deal, I’m going to have my camera on, it’s for students, and my patient’s really lovely, they say yes. And so from the moment they walk in through the door, the whole conversation for 20 minute checkup, it might be a cool thing, like it might be a nice bridge between dental school and the real world, like a point of view thing. Do you think that’d be useful?

[Emma]
Yeah, absolutely. Because I mean, I have three hours for a [inaudible] so 20 minutes and just seeing how that actually works and how it’s like it would be really helpful.

[Jaz]
Amazing. So we will get onto that. So firstly, checkup, right? When I say the word checkup, to me, that’s different to a new patient exam. Like a new patient exam is like extremely thorough, like you’re meeting someone for the first time, you’re building rapport, you’re taking a really thorough history and then a checkup is kind of like reviewing it. One of my buddies, Zak Kara, who, if you listen to early episodes of Protrusive, with some amazing communication episodes with Zak, he calls it a healthy mouth review.

So a new patient comes in, they have four or five issues, and once they’ve dealt with the four or five issues, they’re now eligible for a healthy mouth review, which is basically, okay, you branded the patient as having a healthy mouth. I think that’s amazing. I love that terminology.

[Emma]
Yeah. I think that’s almost quite motivational to come back and keep going back and to keep that status of having a healthy mouth. Yeah, definitely.

[Jaz]
Something to aspire to. And it kind of gives you an idea of the way I see a checkup, right? A checkup is, you’ve seen someone’s mouth before, you’ve done the relevant phase one treatment, if you like, and now you are really reviewing things.

So what I’m a big fan of is like, we discussed a little about notes before we hit the record button. A lot of the notes that you gather, for example, someone’s occlusion, unless they’ve had orthodontics, is not going to change in six months, right? Occlusion is going to be still class one, class two, class three, certain anatomical features that will remain the same.

But there are things that we just need to keep reviewing. So someone, for example, has an amalgam tattoo. It’s in the notes and it just gets copied over. And then rather than having a look, oh, there’s an amalgam tattoo. It’s more like, Zoe, there’s an amalgam tattoo. We knew that, right? Or Zoe will actually do a quick little path tab.

Okay, there’s nothing noted at all in the path tab, and I’ll just do a quick check around. And then she’s pointing me to things. That’s how we can make it more efficient. But again, we’ll come into that in a moment. So, let’s skip the history part. It’s super important, but I think we can save that for a new patient examination one day.

So let’s imagine we’ve done the chit chat. Okay. And the patient’s opened their gob and you’re going in, right? It’s happening. Okay. And I’m going to start actually, before they actually open their mouth, I’m going to do extra oral. Okay. So have you started to do extra oral examinations at dental school yet in terms of lymph nodes and that kind of stuff?

[Emma]
Yeah, yeah, yeah. It’s all happening.

[Jaz]
Okay. So you’re probably better at doing it than I am, right? Because over time, when I see the medical colleagues, they really go down all the way to like the clavicular area. Is that something that you’re taught as well?

[Emma]
We are taught that, yeah, to go right down to the clavicular ones and even like the occipital ones back here and things, which I’ve never really seen anyone do before. It’s usually just a wee tickle under here. And that’s it. But no, like pretty heavy on checking nodes everywhere, really.

[Jaz]
Very good. And that’s because you’re working with professors of maxillofacial surgery and they kind of are used to finding weird and wonderful things there. But for those of you who is, if this is the first episode you’re listening to with Emma, then go back a few and listen to about Emma’s story.

Emma’s nursed for, I don’t even know how many dentists you might have nursed for, but In the real world, in general dental practice, have you seen a dentist actually do the clavicular and go back to suboccipital in that area?

[Emma]
Yes, one private dentist. He’s an oral surgeon, he’s an implantologist. He did the whole shebang, whole shebang.

[Jaz]
Amazing. So specialist, so it makes sense, right? So specialist and they are, again, the more accustomed to that area. In the real world, not that it should be this way, but remember when I said there’s a difference between a five minute and a 40 minute, like you have to draw the line somewhere in your practice.

And so most dental checkups that I’ve seen, okay, in terms of, I’ve shadowed lots of clinicians, okay, no one’s fingers go south of the thyroid, right? They don’t. Should they, in an ideal world, okay, let’s be honest, right, in an ideal world, right, okay, if you had all the time in the world, and money wasn’t an issue, and you didn’t have to see X number of patients a day, then we could do a completely thorough assessment, which could involve going all the way down to the clinical area, suboccipital, that kind of stuff, but in the real world, most dentists, and this is what I do as well, okay, is I start submandibular, so below the angle of the mandible, both sides, okay, I work towards the submental, which is just under the chin, And then usually there’s nothing to find here.

So I’m feeling for lumps and bumps. And I think it’s really important what you actually say to the patient as well. Okay. So I’m not a believer in the silent exam. Okay. I think that’s boring for patients. I think the nurse is finding it difficult to read your mind at that stage. The examination should be a well-orchestrated event with lots of talking and communication and explanation.

I think patients walk out and they’re paying some money. They need to get some value for it. And I think that really adds value. So for example, I’m just going to check some lumps and bumps. Okay. So I’ll have a look around. I feel, I can’t feel anything. And you can often tell with their eyes, if they feel, if they wince, can they feel something?

Have they got some tenderness? a cold recently? That kind of stuff. So, okay. That feels good to me. I’ll say to them and then I’ll get them to and this is like a recent addition four years ago, Emma. I just get them lift their neck up and I’ll just feel kind of like where the parotid, just behind where the parotid would be, right?

Post auricular area, because you get some nasty neck lumps over here, right? And it’s really, really important just under the ear, just behind the angular mandible, just to feel that because a few of my colleagues have been caught out and it has turned medical legal. It’s such an easy area.

Your fingers are already there. Just to feel that area. And occasionally, once a year I’ll find someone with something there and then they sort of biopsy it and fine needle aspirate and that kind of stuff. So it’s a simple thing to do that. So that’s as far as the lymph node stuff goes for me. Anything that you’ve been taught that you feel is essential to point out or any questions you had based on that element of it.

[Emma]
On soft tissues, do you mean?

[Jaz]
On lymph node areas.

[Emma]
Not specific to lymph nodes, no. But am I right in saying you’re just checking for any sort of tenderness, any irregularities, hard lumps and bumps, like you were saying, yeah.

[Jaz]
That’s it. I’m just checking for lumps and bumps. That’s all it is, basically. And once you feel, say, several, you know what things feel like. But when you feel like a lymph node, like an actual nodal kind of pop a node or a big lump that’s firm, it will stick out like a sore thumb. And 99 percent of the time, things are absolutely fine, basically.

So that all takes matter of seconds, right? it probably takes 15, 20 seconds. And I guess we’ll time it when I have my video out basically, exactly how long I take. I’ll try and make sure it’s not biased and we run on time 20 minutes and, and not any longer, not any shorter. So it is more reflective of what we actually do in practice, including the chit chat at the beginning.

So we’ve done submandibular, submental, I’ve gone up, check behind the angle of the mandible. Okay. That’s the sub, the lymph node bit done. Okay. I’ll now be moving to the masseter muscles. Okay. So a lot of clinicians I know don’t do this. And when I speak to dentists, oh yeah, they don’t do this or they feel it, but they just kind of massage it for like three seconds and move on.

But what information are you actually gaining from that? Okay. I want my patient to clench together. I want to feel the might of the muscles. because we have to, this is something that’s not really taught or something I didn’t pick up at dental school, but there’s a difference between someone who, when they bite together, you hardly feel any changes and someone who bites together and you feel these two big tennis balls emerge from their jaw.

Muscle force, bite force is something that that can tell you. So I get them to bite together. Okay. And then the most common question I get is Jaz, how do I know what’s hypertrophic, too big? How do I know what’s normal? When you feel a couple of hundred, you’ll figure it out. You’ll know who your top five, 10%, and you get the idea.

So they get stuck in, start feeling it. And that’s again, just a few seconds bite together. Okay, fine. Now, interestingly, over time, this is something that I probably for the first three, four years, I wasn’t even aware of this because it’s all so new to me, but eventually you’ll find a patient where when they bite together, one side masseter fires.

Contracts and the other side doesn’t, or one side contracts and the other one is a significant delay. And when that happens, there’s something to do with the occlusion, something to do with the bite or something that the muscles are trying to, struggling to adapt. Let’s not go there, but I want everyone’s mind and fingers to be open to that basically for the future.

Okay. Just third, maybe it’s the first time you heard it. Maybe you’ve done this before. But that’s that, but essentially you’re feeding for the muscle force. So I will say to my nurse at this stage, because again, we’re constantly talking. I’m saying to my patient, oh, I’m just going to check the size of your muscles.

If they bite together, everything feels normal to me. I’ll say normal. So, or Zoe will say masseters. I’ll say normal. Or I say, oh yeah, that’s really strong. And I’ll say to my patient, oh, you’re in the top 20 percent of the strongest jaw muscles I have, or you’ve got a really strong bite. And then usually they say, oh, is that a good thing?

And I say, no, no, actually, it’s not a good thing. You might crack more teeth. It’s quick little conversation to have there. Now, while my fingers are there, okay, I’m now going to go up to TMJ, right? Because I’m going north. I’m going up to the temporomandibular joint. And again, we can spend so much time discussing about exactly what to check and whatnot, but just keeping it fairly broad for what we do for a normal checkup, not a new patient, okay, is I’ll get them to open

and close all the way. The few important checkpoints here is, can they open to a decent amount? Okay. What’s a decent amount? Do you know what’s a decent amount Emma?

[Emma]
I actually don’t know.

[Jaz]
Like we can talk about 42 to 55 millimetres and that kind of stuff, but in the real world, no one’s going to pull out their ruler and check up. Okay. Some people do, and I do for my TMD, but three fingers. Who’s three fingers? Your patient’s three fingers, not your three fingers. Your patient’s three fingers. So a quick and dirty test is patient, can you put three of the fingers in your mouth? And if they do, they can pass go.

You know their mouth opening is good. And at the same time, you’re feeling the condyle. So as you put your fingers in front of your ears open, you feel a little couple of two balls on either side pop out. That’s the condyle. And if you just press those, the ball, the condyle on either side, you’re feeling what we call the lateral pole.

Outer lateral surface of that condyle. And some people might say it’s tender and that could be a sign of clenching, grinding or some sort of trauma, but let’s not go there. It’s just tender or it’s okay. The other thing that you’re checking for is clicks. I ask the patient before I check the TMJ, I say, are you aware of any clicking, popping or locking?

A click and a pop is the same thing, but you have to say it that way because some people can’t relate to a click, but they can relate to a pop. Do you see what I mean? So are you aware of any clicking, popping or locking? Okay. And most patients say no. Some patients then will give you some history that isn’t relevant.

Okay. But at this stage, I already know about that from the new patient examination. Their TMJ history is already kind of filled in. So I know that, but I’m checking, can they pass go? Have they got mouth opening? And Emma, can you think of why the mouth opening is important for you as a dentist?

[Emma]
You need good access. I suppose you need to be able to see what you’re doing. You need to be able to get your hands and your instruments in there. So if you can’t do that, then you’ve got a problem.

[Jaz]
You say it so elegantly and you’re 100 percent right, right. But when you’re a young dentist, you stupidly forget that. And then you commit to doing a root canal and a molar, right. And the patient comes in and then you look at the radiograph. You had the radiograph in your mind, but you completely forgot that that radiograph is attached to someone’s actual mouth and that mouth can’t open very wide. So what would have been a simple molar root canal or a simple molar filling is now suddenly way more complex.

You didn’t book enough time for it. Or you need to really have ideally referred that or figured out why the mouth opening is not there. So little thing that can catch you out. So quick and simple, check the mouth opening, three fingers, pass, go, check for any clicking, popping, just note it down. Okay.

Yes. There’s a click. Opening click, closing click, and we’ll get to that in the future as we grow, but we’re checking for clicks. Then our next place is I’m going to go north still. I’m checking the temporalis muscles. Again, same thing I’m checking for are they biting at the same time and the size of it?

And then at that point, while I’m there is an opportunity to ask a question. And the question is, are you aware of any headaches? Are you a headachy kind of person? And whatever they say, Zoe will just note it down. So far, yes, we’ve talked a lot, but this all takes a number of 30, 40 seconds, someone who’s got no issues, basically.

NAD, right? Nothing abnormal detected. So, lymph nodes, walk up, masseter, TMJ, temporalis, that’s your extra all fine. And the comment I’d make to a patient at this stage is, your chewing system is working well. And they usually laugh at that. Your chewing system is working well. And I like the term chewing system, right?

They need to understand that there’s more to it than just the teeth. There’s the muscles and the jaw joint. Any nuances or questions to elaborate on this? Because we can literally spend hours talking about the TMJ examination when I do my TMD patients, et cetera. But at this point, from a student perspective, is there anything that is bugging you? Any questions that you’ve got now?

[Emma]
I suppose what I was going I’m going to ask you, because I’ve been working with you for a wee while now and editing or like making the premium notes, et cetera, et cetera, and all these new things that I’ve never even heard of but from your perspective, what aspects of TMJ and like, occlusal evaluation, do you think should be emphasised in the learning process?

Because occlusion and TMD is your special interest. But I’ve never seen shimstock before, not even as a nurse, I don’t think. But what do you think we should be able to do as students, I suppose?

[Jaz]
Okay, so when it comes to occlusion, I’m glad you asked in the extraoral, because extraoral is often a missed component of the occlusal exam, right? It’s so important to make sure that the opening closing is nice fluid mechanic. It’s not like the jaws moving off to one side and then back to the middle. And what that means that the disc is unstable. And so what all that comes to is, will you be able to deliver the dentistry in a way that’s not going to cause any maladaptation?

The patient won’t be able to adapt. The bite’s going to be funny. But if you imagine trying to do dentistry on someone and you’ve checked the bite and you’ve done the composite, but then when you check the bite again, they’ve changed their bite and they keep changing their bite. Like when you’re recording a denture bite and they keep changing their bite.

Now, how do you work through that? How do you chase a constantly moving target? So I think the most fundamental thing as a student for occlusion, it’s just to make sure that I use a term pass go monopoly, like pass go. Can you pass go, right? Is it something that, okay, is generally healthy enough that you can continue?

So if it’s clicking fine, but is it painless? If the absence of locking. Okay, so locking means that they’re further along the disease pathway. Locking means that they they get locked, stuck, they can’t open, they wake up and their mouth is kind of shut and they have to wiggle their jaw around and unhinge themselves if you like.

So if there’s just clicking, fine, just take a history of that, get some mouth opening and absence of any locking, then good. You can kind of proceed with most basic things when it comes to that. And then when you are actually checking the muscles, it’d be great to know what kind of bite force you’re dealing with here.

Okay. But that again, that, that develops more experience as well. And then when it actually comes to the teethy bits, can you be a good conformer? Do you know what I mean by conforming?

[Emma]
Yeah. So you’re not trying to change anything. You want to keep the bite as it is.

[Jaz]
Brilliant. So conforming is basically the patient’s bite is working well for them. Like most patients you say, can you bite your teeth together? Yes, they do that funny thing where they bring their jaw forward and they brighten their sizes because they think, oh, a dentist probably wants me to do something funny. A lot of people think that we should bite like cartoons, right?

Once they bite together, everyone thinks they’ve got an overjet because they think that, oh yeah, my lower front teeth are behind my upper front teeth. And you kind of explain that’s normal. And they’re like, wait, what all the cartoons they think of. And so it doesn’t make sense to them. But anyway, once you actually get them to bite onto their back teeth, okay.

Most patients are able to get there very easily. So they’ve got a comfortable bite and if they don’t have severe tooth wear, and if they don’t have a situation where they’re not even able to bite together, cause either it’s not comfortable or they just don’t have enough teeth in most dentate patients, okay, what we’re trying to do when we’re trying to do disease driven dentistry.

Okay, the first time I meet someone, get their oral hygiene sorted, get their fillings, crowns sorted, et cetera, is make sure that when they bite together, that the dentistry that you do, it fits into the scheme. And this is something I’ve never actually talked about in the podcast, but it’s a great way to think about it.

And please tell me if what I’m telling you now, it doesn’t quite register at a student level, but if we assign an age to a tooth. And what I mean by that is a patient could be 50. But their lower molar could be 12.

[Emma]
Okay.

[Jaz]
Do you understand what I mean by that?

[Emma]
No.

[Jaz]
There’s more to it. I wouldn’t expect you to, but I’m just kind of like planting that seed. So if the patient is 50, that’s the chronological age. And that tooth, that lower first molar has been there for 44 years, right? So it comes up at six, been there 44 years, but that molar has still got beautiful, anatomy, right? It’s like the tooth of a 12 year old. You see a molar. Okay. It’s completely unworn.

It’s virgin. There’s no fillings. Okay. And that’s the case. And then you think, hmm, why is that? And then you look at the top and it turns out that they had their upper molar removed when they were 10 years old and they have a gap there. And so they never had the natural chewing force and the attrition and the tooth to tooth rubbing and the hard things, cracking and stuff.

And therefore, although the patient’s 50, the tooth’s younger. So if you go by this logic, Right? Then put it this way. And this is the main thing, right? Your composite that you’re going to be doing on Friday, right? For example, let’s take that, right? When, do you use rubber dam, by the way?

[Emma]
Yeah.

[Jaz]
Okay. You’ve got your rubber dam on. And then, you’re going to do your beautiful filling and you’re going to try and make it look good because your first time you’re trying to sculpt, you open the textbook, what should the lower molar look like kind of thing, right? You’re going to make that lower molar look 12. Cause that’s what the textbook shows you. It shows you a 12 molar, right? How old’s your patient?

[Emma]
In their seventies. Yeah.

[Jaz]
Okay. So what’s going to happen is that you’re going to take the rubber dam off, right? And then you’re going to bite together and I’ll be way proud of the bite. Because you need to actually build in a 70 year old’s tooth. It’s not as fun, unfortunately. It’s very flat. It’s not as sexy. Unfortunately, it’s not going to get many likes on Instagram.

Okay. But the trick is you build a beautiful anatomy in, you take the photo and then you hack it down afterwards, after rubber dam. And then you look like the hero. I don’t trust anything on Instagram unless I see articulating paper marks. Anyway, so does that help too? Is that a different way to think about the age of a tooth?

[Emma]
Yeah, definitely. Because I’m usually just thinking about where, rather than thinking about how long this tooth has actually been in the patient’s head and how long has it been occluding. So that is a good way to think about sort of like the age of the tooth could be so, so much different to the age of the actual patient. Yeah, definitely.

[Jaz]
And there’s so many factors that play into that. Acid erosion is a huge, modern erosive diets, the amount of time the teeth actually spend together, right? So someone might only spend 20 minutes a day with their teeth actually touching together, even then lightly. And other people will do an hour a day, for example, with their teeth really in high force. Well, guess which one’s going to have the cracks and the wear and stuff like that, right? So all those things into play.

But essentially when we’re a student, we’re just trying to conform. We’re trying to make that tooth, that filling, that restoration they’re doing fit in with the rest of the mouth so that the patient could still bite together normally. This is where the shim stock comes in. So the shim stock is eight micron foil, eight thousandth of a millimetre.

So the benefit of this is before, and this is the main top tip is before on Friday, Emma, before you do that composite, okay, I would like you to do, get some coloured articulating paper. Get the patient to bite together and take a mental image of it. If you’ve got a camera nearby, great, take a photo of it.

See where the dots on this tooth at the moment are. Then you get the shim stock foil and you check the tooth behind the one you’re filling, if there is one, and you check the tooth in front of the one you’re filling, okay, and you check one on the other side. Let’s assume they’re holding shim. What holding shim means is they actually truly are in the bite.

Sometimes teeth are not in the bite, but the articulating paper, because it’s so thick, it will catch it, but the shimstock tells you that, okay, within 8, 000 of a millimeter. So basically we are definitely biting on it. And then what you’re aiming to do is when you finish your composite you need to make sure that it’s the exact replica of what you found initially.

That’s conformative dentistry, basically. Now, there are some nuances that we could explain that, okay, you maybe are not trying to copy exactly because there were some things about the anatomy that were perhaps the cause of the failure. But by and large, If you can make sure that the filling is not proud, do you know what I mean by the term proud?

[Emma]
Yeah, yeah, yeah.

[Jaz]
It’s not too big and whatnot. So you’re trying to make it all fit in. That’s where the shim stock comes in. And that’s where the relevance of checking the occlusion with articulating paper before you actually pick up the handpiece is so important. And then doing your checks afterwards. And a top thing that I learned two years after I qualified is, and tell me if you’ve heard this one before, Emma, is listening to the bite.

[Emma]
The only person I’ve heard that from is you. Yeah. No one else. I’ve not heard anyone else yet.

[Jaz]
Okay. Well, it’s not mine. It’s people, it’s mentors that have passed it on to me, but totally, totally get, do this. So for you, listen to the patient’s bite on Friday, get them to go. Okay. And then after you’ve done your filling and it’s going to be proud because your first one and what it is. Right. So then there’ll be like, it’ll be different. It’ll be like a thud, right? And then when you adjust it at the end, once you’re happy that the shim stock is, is sorted, the tooth behind, the tooth in front and the tooth the other side are all biting normally.

And you’re happy with the colors, the dots are in the right place as they were before. And really advanced level now is checking the muscles, but let’s not go there yet for a student based episode. So there’s lots of other checks you can do. The sound is just one other verification check. Does it sound similar as it did at the beginning? Do you know what the final most unreliable check is?

[Emma]
Unreliable, did you say?

[Jaz]
The most, yeah, the final check you should do in the bite, which is the most unreliable, which is why it’s the last thing you do.

[Emma]
Ask the patient how it feels. Yeah.

[Jaz]
Exactly. Cause a lot of patients, some are like princess and the pea and yeah, they’ll get it. Otherwise it’s like you can put a rock in there and be like, yeah, doc, it feels great. Amazing. I’m so happy. You’ve done a great job. And so in most of my colleagues, especially me, a newly qualified dentist, the first thing we do is how does it feel?

And then you wait for the patient to say it feels proud, then you go adjust it. No, you should not ask until you’ve actually, you’ve done your due diligence and you’ve decided that you’re happy with it. So that’s a top tip there in terms of a basic thing to do as a student.

[Emma]
Yeah, definitely. So make sure that you’re happy first before you ask the patient. That makes sense.

[Jaz]
That’s it. But if there’s a one takeaway for students now is check the occlusion before you start, because that itself is something that a lot of dentists don’t do because we’re so busy. It’s so busy, you just like, you take a look at it and then you’re hacking away at the end, but it’s nice to appreciate what we have before, mentally age that tooth, and then make sure you give back that same age, which matches the age of the opposing tooth basically. It’s a long way about saying it basically.

[Emma]
Yeah, yeah, that makes sense. I’ll need to see it. If the dental hospital’s got any shim stock.

[Jaz]
Use the thinnest you can. You know the problem with using 200 micron or really thick paper? Do you know what the issue is with using thick paper? Go on.

[Emma]
Well, it just, it’s too thick. I don’t know. It’s too thick. So, like you were saying earlier-

[Jaz]
You get false, false what? False positive or false negative?

[Emma]
False positives.

[Jaz]
Yes, you’re getting smudges on teeth, which actually are, they’re not actually touching there, but because the blue is so thick or the paper is so thick, so that’s the issue. The other issue is supposedly something really thick. It changed, it might change the way the patient bites together, but it’s not as problematic as getting too much information, too much colour splattering everywhere. And then you don’t know what to adjust because it’s just a sea of blue. So try and go for the thinner stuff is better as a top tip. So if you have got a secret stash somewhere of thinner stuff, then that’s the one to go for.

[Emma]
Yeah, I’ll seek it out.

[Jaz]
Good. Now, we took a little detour there because we’re based on an occlusal question and top tip for students. Yes, please check beforehand. Now, at that checkup, we’re only about a minute into it and all I’ve said is I’ve just checked the joints and extra oral.

Intra oral now, let’s move intra orally. Okay. The first thing I like to do is a mouth cancer check. And so I will tell the patient, I’m just going to do a mouth cancer screening. This to me, when I was a new grad, when I first learned this from a chap called James Goolnick, I was like, whoa, is it okay to say the C word in clinical?

Should the patient kind of know that we’re doing this? It felt weird to me, but now so many years in patients are so appreciative. Every dentist does it. Every dentist will check, okay? But it’s only when the dentist says, I’m going to do a mouth cancer check that they register that this happened.

And so they’ll automatically think, wow, this dentist is so good. He’s so thorough that he even was checking for cancer. I only went in to check my teeth and this guy was looking for cancer. What a great guy, right? So get the courage to say, I’m going to do a mouth cancer screening. And then, so we do a system where I will always check the same thing.

So tongue out all the way. Okay, check the dorsal surface, tongue to the left, so I can check the right lateral border, tongue to the right. Now, if you, for top marks, if you’ve got some gauze to handle the tongue and grip the tongue, even better to see, which is great. So especially if I find something suspicious, I’ll get the gauze out and I’ll look, but some people it’s great practice to actually have the gauze ready.

Helps you to grip the tongue, basically. So tongue is out left, right, and then up. So I can see floor of the mouth. So tongue all clear. cheek left and right, palate, and then the labial mucosa moving the lower lip down. Looking at the lower lip in general, looking at the upper lip and make sure we don’t miss any like potential sinus tracts. Do you know what a sinus tract is? It’s like a little pimple by the gum somewhere. It was a draining infection. Sometimes it’s a tooth of a giant amalgam, but only when reflect the cheek or the lip out the way. Do you see that? Oh yeah, there was a sinus tract there. So just have a look all the way around.

Look for any amalgam tattoos, like those black pigmented areas basically. So this is a soft tissue examination and I even get the patient say, ah, I try and look at the oropharynx basically. And hopefully that, you feed that back. So that’s a quick exam that can take anywhere from 30 seconds, two minutes, depending on the complexities and are there any other issues?

[Emma]
Yeah. Yeah.

[Jaz]
Any questions on that soft tissue examination? I mean, we could go into common pathologies, like four dices spots and cheek ridging and that kind of stuff, but just so you know what we’re looking for, let’s stay on topic. Any questions based on that?

[Emma]
I mean, I suppose if you do suspect something, how do you approach communicating that with your patient? I suppose you can never say a hundred percent something’s going on without doing biopsies, tests, et cetera, et cetera. But how do you not induce panic and hysteria without, but also making sure that the patient understands what’s going on? If that makes sense.

[Jaz]
Really great question. And actually just literally the other week I recorded with an oral medicine specialist called Amanda from Australia. And so this episode is coming out soon. Probably maybe by the time this comes out, it already came out maybe. And she gave such a great piece of advice that I wish I’d learnt it earlier. And I also, we also struggle with this, should we say the C word? Should we not? And she gave such a brilliant rule of thumb, Emma.

And I don’t know, by the way, anything that me and you discuss on a student based episode, what I’m trying to do is bring the real world into it. Everyone be careful and make a judgment call on whether you think this belongs on an examination paper or the answers in a vivo or not. Some stuff with your revision notes and stuff, yes, they’ve been all from uni and stuff, and so that’s fine.

But anything that I discuss, I’m giving that real world perspective, so just be careful if it’s exam worthy or not, but essentially, we’ve got two types of patients, right? Patients when they’re driving their car, right, if you’re driving a diesel or petrol car, basically, they’ve got a little bit of diesel left and they’re like, yeah, I’ll be fine.

And others who’ve got like, 30 percent and they’re panicking already. So in the same thing, it’s the same with the dental world and everything we do. Some patients, okay, they’re massive worriers. They just get completely anxious. And so what you don’t want to do is if you find something that you’re not even that worried about, but it’s good to refer.

If you start using the C word with that patient, then they’re going to have sleepless nights and they’re going to really struggle. That’s different to the bloke who if you underplay it by accident and you are actually concerned and you underplay it, they won’t go to the appointment because I’ve got work, I’ve got better things to do.

So I love this because with that time that you spend in a patient, you kind of suss them out. And if you feel as though that is something that’s all the features of something not nice, something that’s rare, something that’s fixated, something that’s been there for a while on a lateral border tongue, and they’re a smoker, then it’s totally cool to say, look.

This could be cancer. It is really important, Mrs. Smith, that you attend this appointment. They will see you within two weeks. Whereas if you have someone who you know, they’re a worrier, if you say to them, look, there’s something here. If you think it could be something, say, I’m not sure if it’s something serious or not.

So maybe use the word serious rather than C word in that case. I’m not sure if it’s something serious or not, but would you mind if we sent you for a referral and they’d be like, yes, yes, yes, please refer me now urgently kind of thing. So you kind of have to suss it out. And based on that next bit of conversation, you might escalate that seriousness or deescalate it basically.

But it’s good to let them know and show them the photos, this is normal, tell them, ‘this is what i’m looking at, it’s a bit white, it’s probably something that has been caught in your bite, but let’s be thorough and refer you.’ and I think that’s a good way to place it.

[Emma]
Yeah, yeah, that’s good. Because once you have the patient, and even those first few minutes, you can sort of, gauge what kind of a person they are. You’re starting to build that sort of perspective on them. So yeah, that gives you a good idea of how they would react, I suppose, and how to deal with it.

[Jaz]
Yeah. I mean, you’ve got to look at their smoking history and other things. I had a patient recently who had all the signs I didn’t like. And to the extent that I got them to wait outside and I called the hospital, I said, listen, I’ve got someone, can they come through right now?

And they’re so busy. They said, no, can you put a two week wait through basically. So, I really. said this could be something serious. I really wanted to go to the hospital. Very, very super important. There were history of like night sweats and stuff. So hopefully I’ll follow up soon with him.

Hopefully he’s okay. Fingers crossed. But yeah, there’s a whole range that you see. So extra oral, know all the things that are more normal, like Fordyce spots, cheek ridging. We’re not going to get into whole lichen planus and that kind of stuff, fungal stuff. We’ll save that for other episodes. But yeah, so as part of the examination, we’re doing the extra oral exam.

Intra oral exam, soft tissues first. Then what I will do is just do a quick oral hygiene assessment. This could just take five, ten seconds. You kind of suss out already in terms of, okay, is this patient know the correct end of the toothbrush or not? Or they could have brushing fine, but you could tell that they’re not really doing anything incidentally.

You can’t just suss it out straight away. I will then do a BPE. So for our international listeners, a BPE in the UK is the basic periodontal exam. And it’s like a score that we give each sextant of the mouth. Whereas in some countries they don’t have a BPE and some countries they kind of do a full six point chart which is crazy.

And other countries that just look at the gums and say, okay, I think there’s a disease. Well, there’s no disease basically. So it’s a variable one as I learned about international scales, but let’s go with what we do in the UK, which is a BPE. And so I will use my ball ended probe.

I’ll put it distal buccal of the last molar. This could be the wisdom tooth, could be the second molar, and I will go all the way around and kind of walk it tooth by tooth in the sulcus and then you scale it. So we’re not going to go into the different grading of the PPE, but essentially you’re doing the PPE that hopefully won’t take too long.

Obviously you’re going to be slower at first. Of course, I could take you a whole 10 minutes to a PPE. I get it. Okay. But do you wear loops yet? And do you have good lighting yet?

[Emma]
I do have loops. Yes. Saved up my pennies on our year out that we had because of COVID. I bought myself my loupes.

[Jaz]
I’m so proud of you. I’m so, so proud of you. Okay. So have you got a light?

[Emma]
Yeah.

[Jaz]
Makes a world of difference, right? So I have three pairs of loops. Because I constantly live in fear that my loops will snap or break in half. And then the same thing extends that what I thought, what if happened something to my backup one while the eight weeks it takes to repair the first one, and therefore I have three pairs.

This is the level of fear that I have within me, right? It’s expensive thing, but my philosophy in life and this, again, deviating from dentistry, but my philosophy in life when it comes to spending money is, if it’s something that you’re going to use every single day, go big. If it’s something that you’re going to use occasionally, borrow it from someone, go cheap out, go on TEMU or whatever, go on Wish, get it as cheap as you can, basically.

Okay, that’s my logic in life when it comes to that kind of stuff. So loops, super important to me. Use them daily. And so that’s why I splashed out into three. It wasn’t all at once, basically. One was like year, year three, or was it year seven? One was last year. So yeah, they’re a significant investment, but they are definitely a great investment to your health, for your back and for the quality of dentistry.

So you cannot see anything. You can’t even do a good BPE, I think, if you haven’t got loops in the light. So we’ll do the basic periodontal examination. The nurse will record the BPE and here’s a cool thing. Ideally, the guidelines suggest that BPE should be done at least annually, right? Now we have enough data for our patients that we know, six, seven years since we went digital in 2015 of their BPEs.

If it’s someone who’s always had zeros, ones and twos, okay. And it’s not been a full year yet that we haven’t done a BPE, it’s okay. I’m going to say, okay, BPEs look good. The oral hygiene, my quick check looks good. We’re going to save the BPE until one year has last.

[Emma]
That makes sense, yeah.

[Jaz]
It just makes sense to me. It just makes sense. But if it’s a new patient or you haven’t got that rapport, you haven’t got enough history, or if you’ve ever had a code three in the last few years or more, then I’m definitely going to do the whole BPE again. So do the BPE. Right. Next step then is three in one tip. Make sure it’s there.

Okay. And I’m going to start blowing some air. Okay. And I’m going to start upper right. Do you get taught to start upper right, by the way?

[Emma]
Upper right, yeah.

[Jaz]
Some dentists are starting lower left. I don’t know what this is about, but the nurses get really confused when they work someone different. As a nurse, do you find there are some dentists who start with other areas?

[Emma]
I’d say in Scotland most dentists would do on your upper right to left and then lower left to right. But there are a few dentists who have thrown me off with that, or a few hygienists as well with their pocket charting and things that will throw me off, but no, mostly right to left.

[Jaz]
I don’t know what’s up with that. I don’t think dental school taught them that, right? I literally think they woke up one morning and they forgot that they start upper right and they start upper left and they just stuck with it. I genuinely think that’s what happened. If anyone would like to enlighten us in the comments, please do because I strongly believe it should be upper right to upper left and then lower left to lower right. It just makes sense that way.

[Emma]
Yeah, we’ve been taught that as well.

[Jaz]
Good. So we’re on the same page in case you got loops on, you got your light on, you got your mirror. And then for me, if you’re in a checkup with me and I’m doing a checkup and you’ll hear this when I make the video, you’re constantly hearing the air.

Cause if the tooth surface isn’t dry, you can’t do it. So air, air, air, lots and lots of air, basically. And I’m checking for the upper right seven, let’s say, for example, if they ever got a second molar, I’m checking the buccal, the occlusal, and the palatal of it. I’m looking for any cavitation. I’m looking for any crack lines.

And so I don’t know how you guys do it in dental school in terms of charting. One system that we have is, so the point I’m trying to make is have a system. And so the system that I use in practice is If I see something funny about a tooth, okay, if a cavity is a cavity, I say that’s caries there, okay, that gets charted, right?

But if it’s like, hmm, a bit of shadowing, a bit of discoloration, I’ll give it a watch, but the grade of watch I’ll give it will be a grade one, two, or three. Grade one just means, okay, it’s probably a little stained margin, I’m not so worried. Two is, I’m on the fence a little bit. Three is, I think there’s something really going on here.

I’d like to see a radiograph to marry the clinical image and radiographic image. More than likely I’m going to have to do something, but I’m not so confident to give it a full-on-full blown caries diagnosis. So we’re charting. So remember this, this is a recall examination, right? So the charting should already be there.

So because we’ve already got all this watch data on there. So here’s what Zoe does. So I’m having a look around. I’ve already started to have a look around upper right, seven, six, five or first molar, three molar. And Zoe says, oh, the first watch we have is the buccal of the upper right first molar. So I’m rechecking all the watches, okay, and I’m checking for new things.

I’m feeling in my probe as well. I’m getting my probe in. Can it fit between restoration and tooth? And one thing I really like, because I know a dentist who, who does the following, and tell me if you’ve met this dentist Emma as your, as your time as a nurse is, they will go around the upper right and check all the buccal surfaces, anterior and upper left, okay.

Then they’ll check all the occlusals, then they’ll check all the palatals, and then they move on. Have you ever seen anyone do that?

[Emma]
No, I don’t think so. No, I don’t think so.

[Jaz]
I haven’t either. And I’m not going to do it because my nurse would kill me if I did that. Okay. And I respect my nurse now and I want her to have a fruitful career because I think she’s good.

And I don’t want to drive her mad or you introduce so many changes and stuff. So the reason I like that Emma is it’s systematic and you’re not going to miss anything. So many times, even me, I’ve done it. I’ve done it before where I’ve probably missed something, you know, buccal of the upper second molar.

Cause I just didn’t reflect the cheek way. I’m kind of just, you’re going haphazardly. So it’s really nice to have a system. So check buccal first bit of air. Okay. Is there abrasion and get that charted, check the occlusal, check the palatal. If you have a system like that?

[Emma]
Yeah. It just makes a lot of sense.

[Jaz]
What I love to do, and you probably don’t have the luxury of doing this, I don’t know, but what I love to do while I’m doing my checkup is have the previous or most recent bite wings up on the TV screen in front of me.

So I’m looking at the tooth and I’m looking up, I’m seeing the radiograph, I’m looking at the tooth, looking at the radiograph, and just marrying those two bits of data is just so efficient and so good.

[Emma]
Yeah, I mean, we do have the opportunity to do that, like we do if the monitor is working, because half of them don’t in the dental hospital, and I do have the radiographs up, but I honestly, sometimes I’m just so overwhelmed that I forget, and I forget, oh, I actually do, yeah, I do have the radiographs there, but no. If I remember, then yeah.

[Jaz]
It’s like the visual stimulus you get as a brand new person, like looking into a mouth, obviously you’ve got a nursing background and stuff, but like, when you’re a newbie dentist learning, there’s so much stimulus and overload, right? That your brain’s like the matrix, like it’s always an equation going on your brain.

I totally get it. So that’s normal. Okay. But you’re going to get faster and faster and better and better. The principles, which I’m going to get across is use a three in one tip and be generous with the air, be systematic and work all the way around, okay? And then using your probe in between here and there, just checking restorations, the actual tactile feedback.

Don’t push into carries because you might cavitate something that may not have cavitated, but you’re kind of having a gentle feel of scrape across with the side of the probe. And then that’s all being fed back in terms of a watch grade one, two, three, or carries or crack lines, right? Crack lines we do as a hashtag sign, which we, we’d like to keep an eye on.

And then photos in the real world, we take these intraoral camera photos, which are just so, so useful. So every one of my patients, look in their notes, they’ve got reams of intraoral photos. So I know if a cracks got worse, change color. Do you know the significance of a crack that goes from a craze line stroke, not stained crack to in the future come back as a stained crack line? Do you know the significance of that?

[Emma]
No, don’t think so.

[Jaz]
Stained crack means that stain was able to, stained particles were able to come inside that crack. So probably bacteria is going to be able to get inside that crack as well.

[Emma]
Okay. Yeah. Yeah.

[Jaz]
Still doesn’t mean that with just that one piece of information that you should be crowning or whatever, but it’s something has changed. So it’s really important to have these photos and then it’s amazing to see the changes in your patients over time. It’s a great way to be a practitioner who’s got a good track record. You’re seeing the history because a lot of times if you don’t have the history, you’re kind of sometimes taking things a bit too seriously. You’re looking at other things and you’re underplaying it. So to have the historical data, photos or visuals is just absolutely amazing.

[Emma]
Yeah, definitely. I feel like it can be really motivational for patients as well, being able to show them what’s going on in their mouth.

[Jaz]
They love it. Like, wow, technology has come a long way. And then they feel again, value, right? They feel like they got a value from this checkup. Now, embarrassingly, I’m close to the occlusion guy and I, and I kind of miss, okay, just quick note of the occlusion, right? Because I already have that data. Remember I said that there’s still going to be class one. So I guess get the bite together.

Okay. Zoe will say class one. I’ll just verify. Yeah, I’ll have a look at the teeth and then on the charting. We actually chart for erosion signs, attrition signs. So W E is watch erosion. W T is watch attrition. And we actually chart that on basically. And there’s a B W and loads of indices for me. There’s nothing that beats the intraoral camera.

[Emma]
Okay. Yeah. Yeah.

[Jaz]
I appreciate they don’t have a luxury of that in dental school, but if you are in a dental school where you have someone who comes and takes a photo for you or you get to take photos on your patients, it’s such a brilliant thing to do.

[Emma]
Yeah. I think The only opportunity we really get to take photographs is for our case presentation. They do have an actual photographer and a whole setup, which is quite good, but nothing on clinic that’s easy to just grab and take a picture yourself. It would be very handy.

[Jaz]
Do you know for sure who’s going to be your case presentation case?

[Emma]
So my first patient, that I ever saw. I finished the treatment plan now, but I had so many restorations that needed doing, and my clinician that day was like, definitely take pictures of this. This could be a potential case press. But this year they’ve changed it, well, for our year anyway. We now need two case presentations, one for the mock and one for the actual thing. So, if nothing else, this patient would be a good transfer to the mock at least, so, yeah, it’ll be a good solution.

[Jaz]
Bank it for the real one, find someone else for the mock. Is my top advice there.

[Emma]
Yeah, yeah.

[Jaz]
Bank it, keep it on the sly. The main point I’m asking you that is, sometimes you just don’t know who will be your case press, so if it’s possible, when, if you’ve got a new patient that day, ahead of time, say, can you please make sure you come up for 3. 30? I’ve got Mrs. Smith coming. I would like some photos, please. It’s a good thing to do basically. So it’s nice to have those photos.

So we’ve done the extra roll. We’ve done the soft tissue. We’ve just checked the occlusion again from before. And we’ve checked tooth by tooth. And using the radiographs in the previous charting, we have some information and then we can start relaying to the patient what our diagnoses are and what information we have. Without going into detail, in any one aspect as an overarching overview, basically, are there any aspects which you feel you wanted to know in terms of what’s going to make you better, faster, more confident? Because I think it’s better I answer your questions, then go down a rabbit hole of all sorts of facets that we can go to in this final segment.

[Emma]
I mean, for me, at the moment, I know that I’m not meant to be this great dentist that can do everything. I’m literally in my third year of dental school. But, I know we were maybe, maybe going to talk about this on another podcast as well, but just, how do you sort of deal with that? Emotion of just not feeling, I don’t know, not feeling adequate enough, not feeling confident enough to say these things to your patient, or not having the confidence to say something without your clinician being there. When does that go away, I suppose? Like, when does it go away?

[Jaz]
You know what it reminds me of? Like first day after qualifying in what was DF1 back then. So, just whatever your first job would be and this weird feeling that, hang on a minute, I’m flying solo, right? There’s no one here to check every single stage.

And that is so weird when you qualify to have that. So it’s nice to have it when you have it, but don’t get over reliant on it. I think you need to give yourself some credit that you do know what caries looks like once you get through 50 years, you do know what the main things look like.

And if in doubt, just stick to basic principles. Get the patient out of pain, make them feel comfortable, be nice to your patient, right? Get a diagnosis, a problem list, okay? And then present some reasonable treatment options, okay? And then if you’re unsure, noone expects, no even patient expects starry eyed young dentist to know ABC, say, hmm.

This one, you’ve got some decay, it needs a filling. This one I’m unsure of, I’ve taken a photo of it. I’m going to speak to my senior colleague and we’ll get back to you whether it needs treatment. And if you say that with confidence, there’s nothing wrong with that. Don’t feel shy about that. And I think that feeling of, am I doing this right?

It kinda takes some years to do, like, I think I told you last episode we were discussing about, me playing FIFA and then me asking my friend, at what stage can you go in and do a root canal without having to do all this prep, the mental prep the night before the stages of a root canal and that kind of stuff.

It will come. It will come like completely second nature that whatever, I don’t look at my day list anymore. And to you, that sounds, for me, at that stage, your stage, I was like, that sounds crazy. How can you see five, 15 patients without exactly knowing the exact procedure that you have?

You can. It takes some time, but you will get there. But if ever you’re in doubt, as a young dentist and students basically, just say, you know what? This I’m sure of, this I’m unsure of. And the wonderful thing that I established with Zak Kara in one of our communication episodes, which I love, the reason I love Zak for is show your working out.

[Emma]
Okay.

[Jaz]
When you say to a patient that this bit is clearly cracked, and that’s why I think this truth would benefit from a crown or whatever it could be, an onlay, whatever, and explain what that is, but this tooth is an interesting feature. And we could go either way. But because we’re unsure here, I’m going to suggest that we come back to this tooth.

Let’s deal with a more urgent thing first. If you just go back to logic and show you’re working out, and there’s nothing wrong with taking a photo, the most important thing to do when you come out of dental school is start taking photos so that you always can show your mentors. There’s nothing worse than with the Instagram messages I get saying, hey, I have a patient and then I have an essay and literally all of that could have been done with one photo. The exact scenario can describe it, one photo, and I can just voice note back some advice. But when you’re asking for quality advice, you need to give quality data.

[Emma]
Yeah, definitely. And I think as well, like you were saying, having that confidence and not being embarrassed to say I’m actually just not really sure about this. I’m going to go and double check with the clinician. And all of the patients in the dental hospital, they know you’re a student. They know you’re not a fully qualified dentist yet. So I can take things, like I’m still not super confident saying, I actually really have no idea what I’m talking about right now, but I’m just going to go and double check anyway. So I think that’s a good skill to learn as well.

[Jaz]
And it’s something that, even if an experienced dentist has made it this far into this episode, there’s a guy called Barry Glassman, American based dentist, does lots of TMD, oral facial pain, amazing guy. And there’s a beauty at any stage in your career from saying.

I don’t know. And I love it. I love, based on the advice he gave me, I’m totally confident. Before I felt like, oh, this is admitting weakness is admitting. I don’t know things, but actually when they ask a question, I generally don’t know. Like, hmm, like, why is it that this happened? Or why do I have a click here?

There was no trauma history. There’s nothing I can give a best guess. It’s like, I don’t know for sure. Here’s my best guess, but I don’t know. And sometimes there’s something beautiful and liberating about saying, I don’t know. I’m just putting a smile on. At your stage, I’ll say, here’s what I think’s going on.

Let me check it with my tutor. And what I don’t want you to get the habit of, and all students here don’t get the habit of, you know what? I don’t know what’s going on. I’m going to just get my tutor to treat and plan it for me. I don’t know what’s going on. Let me just get the opinion from this one. You can say to the patient, let me just get this checked.

But so you get the reps in, so you get the practice in, come up in your mind or write it down. Here’s what I think is going on. Here’s what my differential diagnosis is. Here’s what I think is a reasonable solution to this issue. And for the first 50, you’re probably going to get wrong. That’s okay. Right.

But you’re going to be in a much better position because having a go is thinking it doesn’t cost you any money. It doesn’t harm the patient anyway. It’s just your thoughts running free without judgment. If you could just do that, right. Then that’d be amazing.

[Emma]
I know. Very good clinicians. I appreciate it a wee bit more. Even if you’ve got an idea in your head of what’s going on and it’s wrong, it’s better than just saying, I have no idea of what’s going on. If it’s something simple, of course, like, I don’t know, a really obvious bit of caries, I don’t know, they’re going to get into afternoons, sort of, I guess.

Even if it’s wrong, rather than just not even trying to form some sort of a problem list or a diagnosis or anything like that. Always have something, something to say in your head.

[Jaz]
Well done. Have something to say. Have a reasonable suggestion. Show that you had a good stab at it. It’s really, really good. Now, I’m just mindful of this episode was far more complicated because it’s so broad, but the stuff that we didn’t cover were the importance of history, rapport building, the medical history, that all stuff we didn’t cover. We literally, I just talked through, but I think it’d be really helped by the video.

I think that would really compliment this episode really well. So I’ll make sure I release that at the same time. But then what do we actually do with that information? Cause we just talk about what we’re looking at. The real skill of a clinician is the actual putting it all together and coming up with a diagnosis and a treatment plan.

That’s the real skill that comes experience and how much you know and how you apply it. When we make, get that information, it’s really important to give a risk assessment. So what is their perio risk? What is their caries risk? What is their fractures risk? I don’t know if you know about this one. I actually do.

How likely is this patient going to come with a cracked tooth next time? Fracture risk and cancer risk. Okay. So all these different risk, you could even do a aesthetic risk. So aesthetic risk, like some people who are super, super picky, right? Their aesthetic risk is high. If they’ve got high smile line, when they bite together and you see their, all their teeth and stuff, and they show everything, that’s a high.

If they’ve got a low lip line, when they smile, all you see is their incisal edges, you can do anything you want and it’ll look great. Right. So lots of other risk categories. And I guess we’ll dive deeper into that as we develop me and you in terms of our podcasts that are suitable for students, but any last questions that we wrap up the hour mark here, basically in terms of what we’re looking for.

For checkups and what is running through your mind and any doubts that you have when you’re doing a checkup at the moment?

[Emma]
I think for me, it’s so hard, I’ve got my wee book beside me that’s got all my steps, but I find it most hard to just sort of make your own script, have your own little spin on it. And the things that you say Jaz and your wee bits and your sentences that you say, everyone has their own wee, their wee scrap, I suppose. And I was just in the stage of making mine and changing things and seeing what works for patients and how to communicate things to patients. I think that just takes time. It takes actually quite a lot of time, but yeah, like it will take time before you’re confident in your approach.

[Jaz]
Your little quirks will come through. I’m a big fan of showing your true self and showing your true colors to a patient, right? You’ll attract over your career patients that are similar to you, right? So I’m this nutty, quirky, I try to crack a joke here and there. And that’s why I try to find that, I get some lighthearted, nice patients, which I enjoy, I think. And the patient, the people who take life too seriously, they don’t come back to me. They think, wow, this guy’s a bit cuckoo, which is fine. Okay.

But, I’m attracting hopefully the similar vibes, right? So you will develop those quirkisms. What I love that you said and really worth highlighting is you mentioned about referring back to your list. So top tips for students, once again, is in time, develop checklists. And if you start doing implants in the future, checklists will become ever so important, right?

Checklist, checklist, checklist. Okay. So the way you set up your notes template should be an element of checklist inside. So you don’t miss anything because to err is human. You’re totally going to miss everything. That’s why having checklist is golden. And then the whole communication thing. You do you.

It’s totally fine to steal something I’m saying and steal something someone else saying or steal something my lecturer’s saying. That’s fine. Steal it. Make it your own though. Steal it, make it your own. Say it in your own voice. Say it with confidence. And then over time, you’ll notice that, ah, when you say this, patients resonate more because that’s you and you like it more. And then you’ll find your voice. So you’ll always find your voice in dentistry.

[Emma]
Yeah, definitely. I mean, I feel like all the things that I say, it’s just, I’ll work with one dentist. I’ll pick up a nice free phrase there. I’ll take it as my own and put my own respin on it, but it’s good. Yeah. And seeing what, like you said, what resonates with the patients more. No, definitely. I’ve got my way.

[Jaz]
I mean, there are some things I say that a more serious dentist, if they said it, it would just look so wrong. It wouldn’t match the persona. Whereas there are some things that I could say with a patient that way, that just doesn’t seem right coming from him.

So you will find your own voice and your patients will, yeah, the universe will sense it and it will give you your own voice. Emma, thanks for sparring with me here in terms of a checkup. It was actually difficult to try and not, we kind of did already at the beginning, go too deep into one thing, but you know, dentistry, I don’t want this to overwhelm anyone.

Okay. If anything, I want to give an element of the real world into it. And so please do check out on the Protrusive app, the student scholarship section, we’ll put in the video of a checkup, which a lot of young dentists make appreciate as well. A lot of dentists who may be working in a kind of. contractual arrangement, but they only have maybe five, 10 minute checkups.

They want to see what to do in a 20 minute checkup. Actually, Emma, funny story. There was a dentist who joined a new practice and they were so used to seeing like 30, 40 patients a day, and now they were seeing like 10 patients a day. And so they were finishing their checkups in 10 minutes, but they had like 25, 30 minutes allocated.

And so patients coming out saying, what did I just pay for? That was like the quickest checkup ever. Did the dentist even check anything? Kind of thing. And so there is like some people transitioning from a super quick sort of hamster wheel kind of environment to something a bit more thorough and there’s something to be gained from that as well.

So I’ll put that video on. All dentists will be able to access it. But if you’re on the student scholarship, then you’ll be able to get that as well. So please check it out. And Emma, your notes for this month are?

[Emma]
Yeah, so, like I was saying, my wee notebook, I’ve not got it beside me anymore, but I always have that beside me at all times. I’ve got checkups, extractions, post op, all that sort of stuff. I have it all written down and so I’m going to be sharing just my checklist of a checkup and just so that you don’t miss any of the basics, step by step what me and Jaz just went through and how to do a checkup one on one, basically, just so you’ve got all the basics covered. So yeah, I’ll be sharing that.

[Jaz]
And I want to make sure Emma does, guys. Emma brings the academic side into it. She brings the lectures, the more official examinations. So what are you going to write in your essays and stuff as well? Whereas, remember I bring the more real world into it. So I think together we’ll make a good tag team here.

So please do get engaging on the forum, on the community. We’d love to help. What are the topics do you want next month? We’re covering more like mental health kind of stuff, right? Really important to make sure your mental health as a student, such a stressful time as ever. So we’ll talk a bit about that, burnout, work life balance or study life balance when it comes to being a dental student.

So we’re covering all those themes, but the notes you provide next month will be more dental materials based, but we’ll expand on that more in the next episode. So thank you so much for guys listening all the way to the end. And we’ll catch you same time, same place next week, next month, even for the student one. Thanks Emma.

Well, there we have it, guys. Hope you found that useful. So in the vault section, I will be sharing the ideal standards, which I was doing the clinical audit and what the standards suggest that we should be checking for in an ideal examination. So like more like a gold standard and aspirational.

And of course the video in the Protrusive Scholarship, which is open to everyone. Dentists on Protrusive Guidance can actually check this and it’s just a basic checkup. It’s a boring, bog sounding checkup. But you know what? When I was a student, I would have loved to have seen close up. Like, the view you get is through my loops basically.

Through the loops view of exactly what I’m checking for in a basic 15, 20 minute checkup in a fairly stable patient. Hope you enjoyed the real world relevance of that. So that’s going to be uploaded. If not already, it’s going to be up there very soon. Don’t forget to hit that like button and subscribe button and share it with a colleague and I’ll catch you in the next episode.

Bye for now.