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เนื้อหาจัดทำโดย Jaz Gulati เนื้อหาพอดแคสต์ทั้งหมด รวมถึงตอน กราฟิก และคำอธิบายพอดแคสต์ได้รับการอัปโหลดและจัดหาให้โดยตรงจาก Jaz Gulati หรือพันธมิตรแพลตฟอร์มพอดแคสต์ของพวกเขา หากคุณเชื่อว่ามีบุคคลอื่นใช้งานที่มีลิขสิทธิ์ของคุณโดยไม่ได้รับอนุญาต คุณสามารถปฏิบัติตามขั้นตอนที่แสดงไว้ที่นี่ https://th.player.fm/legal
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Managing Extractions Complications with Nekky Jamal – PDP210

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เนื้อหาจัดทำโดย Jaz Gulati เนื้อหาพอดแคสต์ทั้งหมด รวมถึงตอน กราฟิก และคำอธิบายพอดแคสต์ได้รับการอัปโหลดและจัดหาให้โดยตรงจาก Jaz Gulati หรือพันธมิตรแพลตฟอร์มพอดแคสต์ของพวกเขา หากคุณเชื่อว่ามีบุคคลอื่นใช้งานที่มีลิขสิทธิ์ของคุณโดยไม่ได้รับอนุญาต คุณสามารถปฏิบัติตามขั้นตอนที่แสดงไว้ที่นี่ https://th.player.fm/legal

What’s the best way to reduce post-op pain after extractions? And why should we never use the term “painkiller” with patients? What to do when you hear the dreaded *crack* of a tuberosity?

In this episode we talk about all things post-operative extraction complications! And I’m joined by one of the nicest guys in dentistry – Dr. Nekky Jamal

Complications are something we ALL experience, so this episode is great for any dentist. Whether you’re brushing up on dry socket prevention, mastering post-op communication, or just curious about advanced healing hacks, tune in for real-world advice to make extractions smoother – for both you and your patients

Watch PDP210 on Youtube

Protrusive Dental Pearl: The “Niche Kebab” concept encourages dentists to narrow their focus by reducing the variety of procedures they perform and prioritizing those they genuinely enjoy. By evaluating every new skill or treatment added and strategically dropping less-loved procedures, dentists can avoid overextension and the “jack of all trades, master of none” pitfall.

Learn how to Extract Impacted 3rd Molars, don’t miss out on Third Molars Online and use the coupon code ‘protrusive’ to get 15% off!

Key Takeaways

  • Pain management is about setting realistic expectations.
  • Dexamethasone can be beneficial but must be used cautiously.
  • Dry socket is often overhyped; proper care can prevent it.
  • Effective communication can alleviate patient anxiety and prevent misunderstandings and complaints.
  • Preoperative care can help manage pain expectations.
  • Understanding the signs of infection is essential for diagnosis.
  • Chlorhexidine rinses can significantly reduce dry socket risk.
  • Patients appreciate being informed about their unique dental situations. PRF can significantly reduce the incidence of dry socket.
  • Dentists should embrace new techniques like PRF to enhance patient care.
  • Patient involvement in post-surgical care is crucial for healing.
  • Dentists should not hesitate to refer complex cases to specialists.

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

Highlights of this episode:

  • 02:54 Protrusive Dental Pearl
  • 04:05 Dr. Nekky Jamal
  • 08:39 Managing Post-Extraction Pain and Swelling
  • 21:37 Infection
  • 25:02 Identifying Dry Socket and How to Prevent it
  • 28:30 Case Selection and Communication
  • 37:13 Mitigating Dry Socket with Platelet-Rich Fibrin (PRF)
  • 39:47 The Importance of Nicheing in Dentistry
  • 43:19 Cryotherapy and Post-Surgery Care
  • 47:32 Handling Tuberosity Fractures
  • 55:08 Patient Consent
  • 57:55 Litigation and Patient Communication

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C and D.

AGD Subject Code: 310 ORAL AND MAXILLOFACIALSURGERY (Exodontia)

Dentists will be able to:

  1. Identify and differentiate common postoperative complications, and recognise the key symptoms associated
  2. Evaluate the ethical and clinical considerations of case selection for extractions
  3. Communicate effectively with patients regarding potential complications

If you loved this episode, be sure to check out another epic episode with Dr. Nekky Jamal – Wisdom Teeth Extractions – SURGICAL TOP TIPS

Click below for full episode transcript:

Teaser: Overexplain and then have them on your page, have them take ownership for their anatomy before you even start. You know what I mean? Dentistry is about talking to patients and Jaz, you've seen how I talk to my patients. I keep everything light, but after I joke around, I say, okay, but seriously, do you understand that this is a risk like this could actually happen and in this case scenario I don't want that to happen for you.

Teaser:
I’ll do everything I can for you. But there’s things that are out of our control. Do you understand? And patients have to take ownership of it? Otherwise, I’m not doing work. I hate using the word painkiller because that’s just not realistic. It’s more of like a pain reliever. Okay, and so will you be in 100% pain free even with a painkiller or analgesic?

No, you won’t, right? And so the job of an analgesic is to make you more comfortable, not to kill the pain. Patients, they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically it’s helping. But for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol.

If you’re really interested in extractions or if you’re really interested in endodontics, like, become obsessed. Like become obsessed to the point where you’ve read every single journal article out there. I want you to go home and I want you to dream of it. I want you to feel like, your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to?

Jaz’s Introduction:
In this episode, we’re one of the nicest guys in dentistry, Dr. Nekky Jamal. We’re going to revise together how to manage the common complications of extractions. There’s a bit of a bias towards third molars, but actually the advice given by Nekky and what we discuss today is pretty much applicable to any extraction or any type of dental surgery.

We’ll talk about the best strategies for post operative pain and why you should never use the term a pain killer. Nekky will also reveal why alveolar osteitis or dry socket is virtually non existent in his practice. He’ll tell you exactly what it does to prevent dry sockets. We also discuss the dreaded tuberosity fracture with golden advice on what to do if it happens to you and how to preempt it or prevent it.

Lastly, this episode is actually full of communication gems. And actually the last six minutes talk a little bit about some stuff, which isn’t really appropriate for the public eye. It’s real dentist talk, if you know what I mean. And that’s why the last six minutes will be on the Protrusive app only.

It’ll still be free, but we only on Protrusive app. It won’t be on Spotify, won’t be on Apple, and it is absolutely golden. So if you’re starting this podcast on YouTube or Spotify or Apple. And now that you know this information, you want to move over to Protrusive Guidance app, please do so now.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Some tip or advice that you can apply in your practice. This one’s about your mindset and something that we discussed in the episode. I call it Niche Kebab. The idea of niching down in dentistry and we talk about how by niching into a subspeciality or just reducing the amount of procedures you do and homing in on a few that you really enjoy.

This is what keeps the fire burning in dentistry. This is what helps you to fall in love in the details of dentistry and how to be a happy dentist. Me and Nekky truly believe that. So here’s how you apply Niche Kebab. For every new procedure that you offer or you learn, or a new skill set that you add on, which procedure or treatment will you drop?

I know that sounds a little bit scary or worrisome or maybe a bit extreme, but do you really want to keep adding procedures and adding procedures and spreading yourself out thin, becoming the jack of all trades, but the master of none? Protruserati, this is growth by subtraction. I just want to give you this idea or help you adopt this notion or this mindset that it’s okay to actually whittle down some procedures that you don’t love to give you the time and energy to focus more on things that you do love or things that you could potentially love or new skills that you can add on.

So remember, so don’t just keep adding and adding and adding. Think about what you will remove and eventually you can achieve Niche Kebab. I’m claiming that one by the way. Anyway, hope you enjoy the main podcast and I’ll catch you in the outro.

Main Episode:
One of my all time favorite dentists in the world, generally one of the nicest guys ever. Dr. Nekky Jamal, welcome back to Protrusive Dental Podcast. How are you, my friend?

[Nekky]
Jaz, this is a huge honor. Man, I listen to the podcast all the time. I’m just so proud to be a part of it, man. You’ve done some huge things across the world and help so many dentists. I’m just a fan boy over here, man.

[Jaz]
No, no, no. Look who’s talking, man. Like we all love your stuff, and it’s your charisma is the way. You very much fall into the values, which I’m going for with protrusive, right? The kind of dentist who are nice and geeky and like, you’re solely geeky. Like you love everything you do.

It’s just so clear and you’re funny and you’re very likable. And so it’s just great to build these connections, transatlantic connections with yourself. And it’s just great to have you back again. You’re messaging the way you speak. It’s all brilliant. So very excited to delve into third molar extraction complications today, following on from the previous episode that we’ve done.

Now, before we hit the record button, you told me something very interesting. You told me that you live six minutes away from where you work. So I want to know, with the amount of extractions that you do, and with the level of extractions, you’re going to get complications, right? Everyone’s going to get complications, okay? Including you, believe it or not, okay? People out there are like, no, surely Nekky doesn’t. I’m sure it does. Have you ever had that patient knocking on your door on Saturday?

[Nekky]
Yeah, unfortunately. Living in a small town, everyone knows where I live. But you know what, it’s crazy. The only time I’ll get knocks on my door is like facial trauma. Like, a kid falls off their bike and they’ve smashed their front teeth. And you know, they don’t know what to do. And so they’re like, oh, I’ll just go, I’ll go talk to Nekky. And then, we’ve had some fun times. Like, people show up to the door all bloody in their face.

And they’re like, you know, can you fix this? And you’re like, yeah, all right, let’s go, let’s do this. And that’s crazy. Man, for me, that’s the best part about being in a small community because you build relationships and it’s not like, I don’t advertise. I don’t do any of that stuff.

It’s all about building relationships with your patients. And yeah, I’ve been fortunate. I haven’t had too many knocks on my door for patients in pain. Hopefully I can keep those away forever. But, yeah, no it’s all a part of the fun of living in a small town, a little bit different than London, I would say.

[Jaz]
Well, you know, I work in Reading. I lived in Reading for a while as well. And it was like a three minute drive to work, right? And so-

[Nekky]
Oh, nice.

[Jaz]
What I would experience is, like, you’d go to KFC and you’d always bump into a patient. Or you’d go to this shop and, like, there’d always be a patient, right? And so that was interesting. But the real interesting thing is, like, I personally, I don’t have road rage. But my wife, like, bless her, she doesn’t listen to the podcast, so I can admit it. She’ll never get to know. She’s got some road rage issues, right? My wife, bless her. I love her, but she’s got some road rage issues.

And so now if ever I’m the passenger, right. And we’re in the small town, I just always have to tell, listen, this could be a patient of mine. Please just keep it down. You never know who you’re honking at. So you gotta be careful.

[Nekky]
Yeah. That’s when you put the visor down. And you’re just like, you try to hide behind the visor so no one can see you. We’ve all been there. Come on.

[Jaz]
Absolutely. My friend. Well, extractions, you are brilliant at them. I’ve done your course. I love your course. I plug your course all the time because it’s of the best piece of education I’ve ever done. But today we’re not here to talk about the course. We’re here to actually really give value to everyone spending their time, whether on the treadmill, the commuting on the train to work or whatever.

Let’s make a really impactful piece of education for complications following extractions. Now, particularly third molars, cause that’s your main domain, but a lot of, I’d say 80% of what you’re going to say will probably apply to generic extractions as well. Right?

[Nekky]
Absolutely, man. I always say they didn’t teach us enough about extractions in school, but really extraction complications. Whenever I’m talking to fellow colleagues, like my goal is always, man, stand on my shoulders. Be a better dentist than me because I’ve made more, more mistakes and caused more complications than all of us combined, but like you live in a small town. I don’t have an oral surgeon to refer to. And so patients come in.

And you do the best that you can. And unfortunately there’s not enough knowledge out there of like, hey, what to do in this scenario, what to do in this scenario. And so often the general dentist is left stuck trying to figure it out. And so I wanted to come on today to help demystify some of the complications that we get. And Jaz trust me, man, I’ve made them all. So I’m very proud to share as much as you want. And, and man, let’s just get into it.

[Jaz]
Well, let’s start with a big one, right? Let’s start with pain. Okay. Because this is so common. There’s going to be some blues in our sort of consent and in our post operative instructions, we say, look, it’s going to hurt, right?

It’s not going to be no ride in the park. It’s going to hurt. Expect it. It’s a surgical procedure. There’s going to be swelling associated with that would be some pain. Now you used the word demystify, right? And this just reminds me like this completely off script, but it reminds you of a TikTok I saw like four years ago.

I hardly have time for TikTok, but like four years ago, I saw a TikTok. I don’t know where you’re going with this. But this girl literally drinks a gallon of pineapple juice, right? Okay. And said, I’m going to go get my third molars out. Okay. I’m going to drink, watch me drink this gallon of pineapple juice. And then like three days after the wizarding, she’s like smiling, like, hey, no pain, no swelling. Cause I drank a gallon of pineapple juice. Tell me about that. Tell me about pineapple juice.

[Nekky]
Yeah, yeah, yeah. So, patients are after the bromelain in pineapple juice. And so that TikTok video is right. Like I’ve had patients they’ll come in and they’ll like have a cup of pineapple juice, like still drinking. And I’m like, man, you got to, if you want this bromelain thing to work, like you’ve got to drink like four liters of it, first of all, A, you’re probably going to become a diabetic in the process.

Cause that’s just a heck of a lot of sugar for you. But like, man, I don’t know. I don’t know. Like, yeah, bromelain can work in really high doses. And unfortunately, a lot of our patients are on TikTok and seeking those social alternatives and trying to figure out how they can beat the system.

But I tell everyone, I’m like, man, the most common complication of any extraction, whether it’s an upper first molar or your third molars, pain and swelling. So how do we tackle that?

[Jaz]
But Nekky, is it fair to call it a complication? It’s an expected outcome. Complication means that we weren’t expecting it to happen.

[Nekky]
Yeah, no, I hear what you’re saying. I hear what you’re saying, but maybe, yeah, you’re right. Let’s just call it an expectation then. Because it’s important to get our patient’s expectations on the same page. It’s shocking how many people come in and I’ll take out someone’s third molars, I’ll take out Mrs. Smith’s younger daughter’s third molars.

And the mom comes up to me, she’s like, so this is going to hurt after. Are you for real? And I’m like, man, they’re four impacted wisdom teeth. This is surgery. I’m literally removing something out of your daughter’s face. Like, yes, this is going to be sore.

And I think the best thing to do is get the expectation straight. Is it going to hurt for a day? No, it’s going to hurt for longer than a day. And so I always tell my patients, I’m like, hey, the first thing that I do is you have to tell them, yes, you will be sore, you will be in pain. And there’s no such thing is like no pain.

Like, I hate using the word pain killer. Cause that’s just not realistic. It’s more of like a pain reliever. Okay. And so will you be in a 100% pain free, even with a pain killer or analgesic? No, you won’t. Right? And so the job of an analgesic is to make you more comfortable, not to kill the pain.

So that’s a common term that we use is like, pain reliever or like we all use in dentistry analgesic. But for me, it’s almost like, what do we use? And I’ve gone through different things in my career earlier in my career. Opioids were really pushed and now we’ve steered a hundred percent away from opioids.

A lot of patients, they come in and they’re like, man, Nekky, you’re taking out these wisdom teeth. I’m going to need some codeine after. And I’m like,  codeine, you want to be constipated or you want pain relief? You know what I mean? Like is  codeine really what you’re after here? And then some people will say, I don’t know what it’s like in the UK, but they’ll be like, Nekky, I’m going to need some Percocet.

And I’ll be like, man, Percocets. I’ll only give you Percocets if you split half with me, because there’s no way I’m prescribing it with you. And so, I always make light of these situations. I’m like, but you know what, in my opinion, and according to the research is the best pain reliever. And that’s a combination of ibuprofen and acetaminophen. And in Europe, I think you guys call it a paracetamol.

[Jaz]
Yes.

[Nekky]
Or do you call it acetaminophen? Yeah. Yeah. So paracetamol, paracetamol. Yeah. So depending where you are in the world, it has a different name. But according to the research and according to my own patients, this is what I do.

So what I do for every single patient is on their post operative sheet, before the appointment even starts, I show them and I draw a clock and on that clock, I’ll say 12, 3, 6, 9, and I’ll say at 12 o’clock, you can take 600 milligrams ibuprofen, a thousand milligrams acetaminophen at six o’clock, you can take another 600 milligrams, ibuprofen thousand milligrams, acetaminophen, or if patients want to alternate every three hours, they can do ibuprofen.

Then three hours later, acetaminophen or paracetamol three hours later, ibuprofen. It depends what you want. I find sometimes patients like to split it up every three hours because that way is one’s kicking in the other one’s coming out and they feel like they’re taking an active role.

You know what I mean? And we’ll talk about like taking that active role, patients they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically is helping, but for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol. And the research backs this up. In your opinion, Jaz, what works well for you guys and your patients?

[Jaz]
Yeah, absolutely. So I believe it’s the Oxford data on analgesics and it definitely shows, I think it shows at its worst point, like if you take 800 milligrams of ibuprofen and a thousand of paracetamol, that can be effective.

Now on the box in the UK, I dunno how it’s in Canada, but in the UK and the box of ibuprofen, it says 400. So we have to say that, look, if it gets really bad, it’s okay to double it. Just make sure, be careful with the gastric complications, make sure eat something.

[Nekky]
That’s right.

[Jaz]
Very important, the ulceration risk. But yeah, definitely ibuprofen, paracetamol. When I was in Singapore, there was a culture to, I guess that’s the best way to describe it. Culture of giving steroids, prednisolone, like in the UK, it’s much more difficult as a practitioner to prescribe that. And so I think most don’t, but I don’t know, does steroids have a role in anti inflammatory in terms of your active prescription of it?

[Nekky]
Oh, man, Jaz, I don’t know if I can practice without it because I feel like, so in Canada, we use dexamethasone in the States, they’ll use like  Medrol dose packs, but it for me, I regularly routinely use dexamethasone for my patients now, you can inject it at the surgical site. Okay. And it’s just four milligrams at the surgical site.

If you do an IV, you can inject it by IV, but you can also take it orally four milligrams twice a day for two days. Now you got to be careful. Like you don’t want to give it to someone who’s medically compromised. You don’t ever want to give it to a diabetic because man, I remember. I’m talking about mistakes, right?

I gave it to a patient and the patient calls me from the hospital the next day. And they’re like, Hey, Nikki, I’m in the hospital. And your heart starts pumping and you’re like, why are you in the hospital? And they’re like, well, my blood sugar is just, it’s spiked. It’s out of control.

And some dumb dentist gave me a medication that really mess with my blood sugar. And I was like, oh, who is that? You know what I mean? And you get a call from the ER doctor saying, you know Nekky, I know you’re doing your best there, but you can’t be given dexamethasone to diabetics. And I said, absolutely my fault.

That’s a hundred percent my fault. We don’t want to give dexamethasone to diabetics, but in my experience, it’s really helps with swelling. Dexamethasone has a longer half life, between 36, 54 hours. I give it for two days, or like I said, you can inject it at the surgical site. And it works really, really well for my patients. There’s a little bit of controversy, whether it helps with pain, but it definitely helps with trismus and swelling.

[Jaz]
I thought that when I was removing this teeth in Singapore and it was much easier because I think we had them in the practice to actually give to patients. So it was like an easy prescription to do and I felt as though it helped my patients when I reviewed them. And then the UK is some barriers.

So my homework will be just to figure out. Okay, how many practices in the UK are actually prescribing dexamethasone or prednisolone or some sort of steroids and how we can go about doing it because I think there is a role. Yes, anti inflammatory at least or the swelling. Sorry the swelling aspect of it definitely has a role whether it yeah makes a difference in pain I do think it does but like you said the gold standard evidence based would be ibuprofen and paracetamol.

But it’s good that we covered steroids because it’s a very important part of your regime. And we have to remember that pain is a very variable factor. I believe it’s a factor of four, right? Like someone could say something’s a 2 out of 10 and we have those patients where they come back and it was the messiest extraction ever.

And they say, yeah, it was a walk in the park. It was fine. Like it was way better than what you told me than it would be. And then we have those other patients who was like the grade three mobile perio tooth and they come back and it was like an agony and stuff. And so the whole pain internal variation needs to be respected.

[Nekky]
Oh God. Yeah. One more thing about corticosteroids or dexamethasone you don’t want to give it at night because sometimes like you don’t want a patient to take it at night. Sometimes they act like little caffeine pills and they’ll be up all night. But another complication that. I didn’t like you experience, I feel like when you’re in the thick of things, that’s when you experience your complications.

I had a patient, they’re like, Nekky, surgery is going good. I haven’t slept in two days though. And I was like, oh yeah, dexamethasone can sometimes act like caffeine pills. Let’s take it back a bit. They’re like, no, Nekky, it’s not that it’s the hiccups. And I’m like, what do you mean I’ve been hiccuping nonstop for 48 hours.

And then I’m thinking, I’m like, could you imagine like when I get the hiccups for like 20 minutes, I’m like, trying to scare myself or like swallow a bunch of peanut butter or whatever these old tricks are, could you imagine having it for 48 hours?

[Jaz]
Oh, I had no idea. This is a complication of a course.

[Nekky]
Yeah, man. It doesn’t happen often doesn’t happen often. I’ll get a patient like once every two years and they’ll be like Nekky, I cannot sleep I don’t know what to do. And I’m like, oh my god, like stop these dexamethasone. You gotta let it get out of your system. But here’s the crappy part.

It’s in your system for a long time. You got a long half life. So that’s another negative side effect. You’re not going to see it often, but if I can help one dentist out there that has that patient that’s hiccuping, yeah, it’s from your steroid. And it’s not a fun complication to have.

[Jaz]
Is there a role of how when you have a hot pulp in the endodontics and we advise that, okay, sometimes it’s more difficult to numb this patient up. And therefore we often advise, take some ibuprofen before you come in as a strategy. Is there a place, if you think it’s a particularly gory procedure, tricky one, do you ever advise taking a preoperative analgesics?

[Nekky]
Yeah, yeah, yeah. So you brought up a really good point that the research says preoperative corticosteroids. That works really well, but the research actually doesn’t support preemptive analgesics. I was reading some papers I think it was like, you know last week. I remember I was shocked I’m like because I usually give ibuprofen to patients prior like I’ll be like a start taking your ibuprofen is the morning of. But a lot of researchers saying, you know preemptive analgesia didn’t do as much as we thought it does but like it makes sense.

Like, why wouldn’t you do it? Right? Like, to me, it’s like, why wouldn’t you just have that on board ready to go? But the research is mixed on that. But like, man, these days you can find a paper to say anything you want. Hey, you’re like, on one side, it’ll work on the other side. It’ll work. So I’m often going just straight to common sense.

[Jaz]
I love that little Canadian A that you said that I was waiting for it. So thank you for blessing us with that. So Nekky, there’s so much to cover, but in terms of pain, stick to the gold standard, paracetamol, ibuprofen, don’t be afraid to go above 400 milligrams, but do check for ulceration risk. Make sure they eat something, definitely manage their expectations.

Warn them of pain, some dentists like, oh, but if I overplay the pain element so much, then they won’t have the procedure. Well, that’s all point of consent, right? You need to under promise over deliver. And so definitely yet talk about the pain. It’s going to hurt. It’s going to be really sore, but don’t worry. Eventually everything, like everything like childbirth, you’ll eventually forget about it, but it’s going to be hopefully way better than childbirth.

[Nekky]
That’s my joke for all us guys. I’m like, you know what? At least we’ll never have to give birth, man. If we have to give up four little wizened teeth, man, so be it. But that’s where it ends for us.

[Jaz]
Excellent. Now the next thing is, what would you say is the next most common complication?

[Nekky]
Oh man, you know what, the literature varies so much. I’m just going to go with my own experience. Okay. I think everyone is expecting me to say dry socket or alveolar osteitis.

[Jaz]
Everyone is, but I’ve done your course and I know your protocols and I know you openly say that. Okay. You very seldom experienced dry socket. So excited to hear about that. So we’ll talk about Nekky’s magic pineapple juice that he gives that prevents dry sockets. But okay. So for you, dry socket is not a big issue. So what is more common?

[Nekky]
Man, I don’t see too many complications. I think, the most common complication or expectation I’ll see is pain and swelling. And then maybe infection, maybe infection. Okay. Cause I don’t routinely, and I don’t know what it is about for you, or I don’t routinely provide antibiotics for my patients. Do you?

[Jaz]
No, no, no. We’re discouraged too, right? We’re discouraged too.

[Nekky]
Yeah. And so for me, if I see a patient and they’re still having pain, I would say a week later and they’re like, you know, Nekky, you told me it was going to get better. It’s getting worse. Okay. So now I want you to play this game.

Cause this is a common problem we all see. And we’re at this like decision making crossroad, right? And we’re like, okay, the patient is swollen. They’re in pain. Are they having an infection? Are they having a dry socket or is this normal? And it took me a while to like, you see enough patients and you’re like, how do you decipher between an infection, a dry socket, or if this is normal? Do you know what I mean, Jaz?

[Jaz]
Oh, totally. Totally. This is a daily experience for dentists taking out teeth. When you have that patient come in and there’s possible diagnoses and it’s important because the ramification is antibiotics indicate, can you justify it or not?

[Nekky]
Yeah. Yeah. Okay. So before we even get to this, cause I think this is the most important thing I want to talk about is like trying to delineate where we’re at here, right? Like we want to be able to diagnose our patients. The most common thing I see is actually food in the socket. Do you know what I mean?

[Jaz]
Yeah.

[Nekky]
Yeah. And so I guess the question is. And I’m kind of getting to this point here is, is do you irrigate your sockets? Like, do you irrigate your sockets? You give the patient a syringe. Are you telling them to rinse with saline or rinse with salt water that they make at home? Are you giving them a syringe to actually clean inside the socket? What do you do, Jaz?

[Jaz]
Good question. So, in Singapore, I did, actually. And you know what? In the UK, we don’t have, we had a really nice Monoject 1 in Singapore there. And in the UK, I don’t have, we should totally just get one.

[Nekky]
Yeah, the curbs are in.

[Jaz]
Yeah, and that was really good. And I think when I used to work in the hospital, we gave that as well. In practice, I’ve fallen out of habit. So, no, we just give the advice. Okay, warm water, a bit of salt, multiple times a day, especially after you’ve eaten, to make sure the food debris doesn’t get caught. But I think I know where you’re going with it. I think you’re saying that the syringe is the pineapple juice.

[Nekky]
The syringe is pineapple. Yeah. So like you’re irrigating the socket and whether you irrigate with chlorhexine or irrigate with, with saline, you need to get the debris out of the socket. And it’s so funny.

Like I had a patient yesterday, day seven, they’re like, Nekky, it’s not getting better, not getting better. And then I go to rinse the socket in like, it’s disgusting. You’re like all the food you’ve eaten is now at the bottom of your socket. No wonder you’re in pain. And I can assure you, I’m going to call her today and I’m going to be like, how do you feel?

She’s like, Oh my God, so much better. Right. So much better. But this is when the patient comes in, right? You’re like, okay, they have pain. Do they have swelling? And is it a dry socket or is it an infection? Okay. So I always want to remind everyone the three cardinal signs of infection. Okay. Pain, fever, swelling.

But everyone has pain, everyone has swelling, but do they have a fever? Okay. So that’s like a Cardinal sign. That’s how you know it’s infection and also swelling after day three, shouldn’t swelling be going down? If swelling is progressing past day three, you’re like, oh, okay. Could that be an infection?

Is there a fever? You know what I mean? That’s where my brain is thinking. However, when you look in the mouth, if they have a large dark hole, which a lot of people do, you can’t just jump and think it’s dry socket, but like how good is their oral hygiene? Is there a ton of food debris in the socket?

Does it stink? Do you know what I mean? Like, is it extreme pain in their ear down their neck? And there isn’t swelling, like swelling is subsided. There isn’t a fever. Well then I’m thinking dry socket, right? But I want to clarify one thing about dry socket and I’ll explain how to prevent it, but I found earlier in my career, and I’m sure you’ll agree with me.

When I was getting into extractions and it used to take me, a touch longer to take out a tooth and I was pulling on my flap and I was drilling bone at elevate, drill bone, elevate, drill bone, snap, snap, snap, an hour and a half later. Hey, I got the tooth out. I’m a hero, but the patient thinks I’m a bum because it took so long.

And those are the patients that end up with dry socket. So everyone talks about like, the dry socket is the like dissolution of the blood clot, but really Birns hypothesis. No one knows why dry socket occurs first of all, but Birns hypothesis is it actually starts with trauma that leads to the activation of plasminogen that breaks down the blood clot.

And so if we have less trauma on our patients. Patients heal so much faster if you can get that, if you’re in and out of that surgery quicker, well, patients heal faster with less trauma. I don’t see dry sockets anymore, but there’s one thing that, well, I guess there’s two things that really help with that, that everyone can do. Okay. So the first thing is that preoperative and postoperative chlorhexidine rinse. Okay. Do you guys use chlorhexidine?

[Jaz]
I did when I was in hospital, but you know, there was a whole phase whereby everyone was like super scared about allergy and this one person died in the UK from like corsodyl and chlorhexidine and then for some reason culturally we were like really worried about the the allergy risk. So I feel as though from that time the usage went down a bit.

[Nekky]
Really? Yeah. To use that 0. 12 percent chlorhexidine. I actually routinely give it to all of my patients. Whatever I take out a tooth, I get them to rinse with it in the office and then for third molars. I give them a bottle for a week after and it’s actually been shown to have a 40% reduction in dry socket or alveolar osteitis just from chlorhexidine alone.

[Jaz]
I read this as well, and the evidence was better than some of the other things. Like, some of the best evidence we have for preventing alveolar osteitis is the use of chlorhexidine. And I believe I read that to deliver it in the form of a gel after the extraction. Is that something that you use?

[Nekky]
Yep. I use the liquid, but 100% you can use the gel. The benefit of using the gel is when you rinse, you don’t want to rinse the first day postoperatively because you want that blood clot to settle in. You know what I mean? And so if you’re using a gel, you can start applying it right away. So that’s the benefit of a gel, but yes, you can use the liquid. You can use the gel.

I recommend it. I find in my own hands. Like it really works to be honest. I haven’t seen dry socket in years. I think it’s an overplayed overhyped complication. If you can get your patients to keep the socket clean, if you can get in and out of surgery, the best you can, as fast as you can, while maintaining as atraumatic as possible, but you got to abide by your surgical protocols.

Like you can’t be leaving a ton of bone shards and tooth fragments in there, and then like sew it up. You know, call it a day and just run out of the op because that was a fast extraction. No, you got it. You got to be efficient with your extractions, but also Jaz. I’m going to throw something out there.

Maybe we don’t have to be taking on all these cases. If you don’t feel ready to take on this case. And if you feel like this, this extraction is going to take you two hours. Why are you taking it on or you’re better off having that patient see someone else you can do other forms of dentistry. It’s much more profitable for you a much more, you know less stress because there’s one thing I teach everyone and you never lose sleep over cases. You do not. Do you know what I mean?

[Jaz]
Amen.

[Nekky]
If you’re up at night trying to get like waiting for your phone call from your patient because you know they’re gonna be in pain, man, what kind of life is that? You never lose sleep over cases you do not do. If the tooth looks ridiculous, 45 years old, distal, angular, partially, or fully impacted, you know, minimal opening.

Is that really a good use of your time? And as a general dentist, is that something we should be taking on? And are you ready to take on the following three weeks of phone calls and possible dry sockets and delayed healing and, hey, I’m in pain. And don’t go see that Nekky guy. Cause all he does is put me in pain.

I can’t, I can’t recommend it. Like, do you really want to do that? And that’s when you see dry socket is on the patients that you don’t want to get dry socket and it took you forever to get the tooth out. And come on, we’ve all been there. And we questioned why we got into the profession after we walk out of the operatory, because that tooth was so difficult and that’s when we see dry socket, you know what I mean?

[Jaz]
I have a lot of reflections on that because I’m a big fan of moving out of your comfort zone. But we shouldn’t move beyond our comfort zone. We should be at the edge of our comfort zone and that’s where mentorship comes in and the big C word here is case selection right? We as general dentists have the most difficult job in dentistry.

Like all the specialties, right? General dentist is the most difficult. And so we need to utilize our one trump card, our one saving grace, is that we get to be cherry pickers. We can pick the most luscious and red and nice cherries and all the rotten cherries. We can send to a specialist we don’t like, okay?

And that’s okay, right? There’s a place for that, okay? Obviously I don’t mean that, tongue in cheek, right? I always joke, send to a prosthodontist you don’t like. I always make that joke, but you know what? It’s just a point to make that, it’s really tricky to be a general dentist, so let’s enjoy the fruitfulness of being able to refer the ones, sometimes you know what?

On the Protrusive Guidance community, I posted about referring and what’s your threshold and that kind of stuff. And a lot of the experienced colleagues that said the following thing, Nekky. Often it’s not the procedure that scares them. It’s the patient that is attached to the procedure. And that’s why they’re referring.

[Nekky]
I totally agree, man. You pick and choose your patients that come with the procedures, right? So it’s the patients that you have to manage, someone comes in with their arms folded and they don’t want to be there. And I’m scared. And they’re aggressive.

They play the whole, like, if you hurt me, I’ll hurt you type card. They have a really hard tooth to come out. Like, man, do you really want to take on that case? Or would you rather take on like, someone that wants to work with you and if you ever did end up with a complication, you’ve explained it to them and they want to work with you.

They don’t want to work against you because the other thing that I’m a huge fan of, like I said, number one, you never leave sleep over cases you do not do, but patients do much better with explanations than they do with excuses. And so what I mean by that is like, if you take the time to explain to someone, Hey, Mrs. Smith, when we take this tooth out, there could be a possibility of you having a tingly feeling in your lip or chin, and that could last for a couple of days, a couple of weeks, a couple of months, a couple of years, I don’t know, I can’t control the position of your tooth in relation to your nerve.

However, if this happens, there’s some things we can do, but a lot of the times it’s variable. We don’t know. Do you understand that? And they’re like, oh yeah. And you know, Nekky, I fully understand you didn’t put the tooth there and I’m coming to you later in life to get it out. I expect those things to happen.

But if that patient came in after, you took the tooth out, you get the text three days later. Hey, Nekky, is it still normal for my lip to be numb? How long is this freezing going to last? And then your heart just starts pumping, right? And your stomach falls into the floor and you’re like, oh, here we go.

And then the patient’s mad at you and they could become litigious and they’re like calling their lawyers saying Nekky messed up my face. And I don’t want that ever to happen to any dentist because we don’t control the position of the tooth in relation to the mandibular canal.

However, sometimes patients feel that it’s something we did wrong, right? So, patients do much better with explanations than they do with excuses. Take your time, talk to your patients. I spend sometimes more time talking to my patients than the entire procedure. So, like, but patients aren’t mad at me. I pick and choose my patients, man. I refer risk and I refer patients.

Interjection:
If you want to check out Nekky Jamal’s Wisdom Tooth course, which both me and Ali have done, and we highly recommend, check out protrusive.co.uk/thirdmolarsonline. That way you get 15% off using the coupon code protrusive, and this is an affiliate link.

[Jaz]
I love how you talk to your patients. I see your videos and like, I’m in love with the, and only you can do it. Not everyone can do it. It needs to be a certain persona. And so you’re like, you’re given this ID block and like, everyone’s watching you as like, Oh man, I love you. I love you.

Like you’re good. You’re good. Like you’re so, it’s just amazing. Like only you can do that. And it’s just amazing. Honestly. Now you raise a really good point. Like we could dedicate more time to talking about numbness and stuff, but we already talked a lot about that in the previous episode, recognizing the high risk science.

So I will, signpost the previous episode that me and Nekky did where Nekky really summarizes the how to assess complexity and then the different signs you’re looking for, for a high risk of nerve damage. But the key message here is making sure that everyone has an explanation. You make them understand all the risks.

Now, one of my favorite things to do when communication is the following. You make every patient feel special. And I don’t mean like you make them feel warm and fuzzy and special. Like you’re my only patient in the world. Not like that. I mean special in the sense that you make them feel unique because they will remember that for example, if you say to a patient, okay that hey, you know what Mrs. Smith? You grind your teeth. That’s very fast. That’s very, we know it’s a common thing. It’s like, wow, your jaw is actually doing these funny things and that’s grinding and that’s a very special thing that you do, right? And so at the dinner table, like a few weeks later, it’s like, oh, yeah, you know what my dentist told me?

I grind my teeth, for example, or in the context of extractions, right? If you have a slight curve on a root, right? And I would say, look, most people, they got a normal straight root, but you have a banana root. And we know a lot of people have banana roots, but when you make them feel special, they remember that.

It’s like, oh, why? Yeah, that banana root. That’s why the tooth took a long time to come out. So when you make them feel like they’re a special case, it just heightens the, I guess, the retention of the information. It’s just something that works for me.

[Nekky]
Such a great idea. And I heard you say that before and I’ve started to do that as well. And I often say like, hey, Mrs. Smith, did you know that you have a root that’s embedded into your sinus? Like, that’s crazy. When I take out this tooth and you’re going to have a hole in your sinus. I want you to think as if I’m popping a balloon, I can’t control them. And like, they immediately think that, and they understand that.

And they’re like, so like water, when I drink water, it’s going to come out of my nose if I have a hole, right. And I’m like, yeah, we want to prevent that. And we want to explain all these things to help minimize that. So it closes, but like, that’s a crazy route. We don’t see that every day and it, boom, it almost like, it prepares them for the complication, but it also makes it almost acceptable.

Like, Jaz, you didn’t put that banana root there. You know what I mean? You didn’t control my anatomy, but this is what we’re stuck with and thank you so, so much for managing it.

[Jaz]
That’s the crux of it really. And when you highlight this issue to them, they own it, right? And it’s not like an excuse that he was later. It’s something that you can reassure the patients that and actually one of my things I like to do is yes, you tell them the complication, i. e. the curve route, but then you also tell them what you’re going to do to mitigate that. Is that okay? You’ve got a curve route. That really sucks. That’s a really bad scenario, but you know what?

I’m going to carefully split the route so that it has an easier path to come out. That’s how we’re going to navigate it. So don’t worry. We’re going to make sure you’re looked after. That’s my thing to worry about. You just relax, make sure you’re away with the fairies. You’re having a good time. Leave the trouble to me. I’m just informing you what the trouble is.

[Nekky]
Absolutely. I love that Jaz. It’s like you’re giving them a surgical game plan. Now, usually. What I do in these scenarios is I didn’t come to my second reason on how I really mitigate dry socket or alveolar osteitis, and that’s through the use of platelet rich fiber. Now-

[Jaz]
I was waiting for it.

[Nekky]
The PRF. I love it.

[Jaz]
You love it so much.

[Nekky]
I love it, man. I tell everyone like, PRF is like ketchup, it makes everything taste better and it makes your surgery just go a little bit smoother, right? And so the only thing with PRF that some dentists fall into trouble with, they’re like, Nekky, you said PRF is so good.

My patient comes back and like, it’s not good. It’s not good. What do you, like, you’re feeding me lies here. And I’m like, PRF does not change the fact that if you have a crappy surgery and if you don’t manage your tissue, if you don’t manage your bone, if you don’t stick to sound surgical protocols, PRF is not going to help you.

It’s not your superhero, okay? It is going to make your surgery heal faster with sound surgical principles. It really helps the soft tissue. It really, really reduces alveolar osteitis. So all my third molar cases, PRF, or the use of platelet rich fibrin, has actually reduced alveolar osteitis in 95% of cases, according to the research.

Just think about it, you’re putting the fibrin clot right in there. What’s dry socket? The loss of the blood clot. So you’re really helping the situation. But man, patients, they love it. And so many dentists are like, Nekky, you expect me to poke my patients? And I’m like, yeah, because you just stuck a needle this big in the back of their mouth.

What’s the point of like you already, if you can find someone’s inferior alveolar nerve in the back of their mouth while just by basic landmarks, you can feel a vein on someone’s arm. And with a little bit of training, we can show you how to get blood out of there.

You spin it down, you put it right in the socket. It’s all delegatable. Like my assistants are helping me with this. I’m doing the  venipuncture, but like it’s such a no brainer for me and it works so well. Patients love it.

[Jaz]
I guess that’s the barrier of entry, right? Being able to do the  venipuncture, but I love how you say that. Okay, if we’re getting that ID block, then you can do this. I like the way you downplay it and I think we sometimes need that encouragement that we can do it. I’ve done it. It’s been so many years I haven’t done it, but in the hospital I was training, I was doing it regularly. So if I can do it, anyone can do it.

And I think PRF has a place. I don’t use it at the moment, but my principals, they love it as well. When I used to work for implant work or that kind of stuff that they really swear by PRF and the evidence is out there to support it. And I know from your own audits, the low number of dry sockets that you experienced.

Yes, chlorhexidine is evidence based as well, but I think your PRF formula has something to do with it as well, as well as a lovely surgical care that you take, your experience, your, not speed, but efficiency.

[Nekky]
Efficiency. And have you noticed something in dentistry, Jaz? And I’m sure you’ve noticed this. It’s like when a dentist doesn’t do a certain procedure, they always downplay the effectiveness of it. Do you know what I mean? If they’re like, if they don’t know how to do PRF, they’re like, eh, that’s not doing anything anyway. But then when you honestly, when you start using it, it works really, really well as if, if we don’t understand something, we don’t recognize its massive advantage.

So I encourage dentists. Like learn how to do PRF, it’s really helped me in my surgical career. Am I any different than any other dentists out there? Absolutely not. I can’t say I have any different special skills than anyone. It’s just, you get good at something over a long period of time of doing that procedure over and over and over again.

If my patient came to see me to do a veneer or to do a root canal, man, I would butcher that because I just don’t know how to do it as well as the next guy down the street does. So like, I encourage you, if you’re really interested in extractions or if you’re really interested in endodontics, like become obsessed, like become obsessed to the point where you’ve read every single journal article out there, I want you to go home and I want you to dream of it.

I want you to feel like your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to where like you’re working eight hours a day doing clinical dentistry, and then you jump on Instagram at night and start looking through cases.

And then you’re like, I wonder how this works. You’re calling colleagues like dentists. We have such an interesting job. And I just feel so proud to be part of this obsessed profession with everyone here, but like, man, get educated. Just like you said, right?

[Jaz]
I think the sad truth Nekky, is that, what you describe that is really great and that’s what you want, right? We want dentists to be enthused. We don’t want dentists to be working and not feeling like it’s work, but unfortunately, so many of our colleagues are disengaged, they’re not in a good place, they’re struggling, and I think you hit the nail on the head that for me, what I’ve experienced and what I’ve seen from afar is that when you make it your mission or you just find a focus, a passion area to really just a rabbit hole that you can go down on niching.

When you niche down on something, right? I made an episode about finding your niche with Pav Khaira, but I want to make another one called Niche Kebab. So make a Niche Kebab episode, right? And so niche kebab, niche kebab, I know you call it niche, but anyway, Niche Kebab, right? And so basically. Really, you know, yes, when you’re a general dentist, you get to explore everything. But if you can just focus a little bit more on one area, which really, that you can really find affinity towards, and then you grow that area, then suddenly your career just takes a brand new angle.

[Nekky]
Oh, totally. And you enjoy work so much more. And it’s not work anymore. Like, it’s fun. I get to hang out with my patients. I get to do the procedures that I love. I feel like I’m actually providing a service.

[Jaz]
And this could be extractions. This could be clear aligners. This could be endodontics. Even though you’re a general dentist, this could be just endo, which is maybe like, specialist level, but you can still pick and choose what you want and create a little referral network where you are, and you can literally niche down in any discipline. This is like, we have to really appreciate the beautiful side of dentistry. And this is one of the good bits of dentistry that we can actually pick and choose, and then we can actually multiply and grow by simplifying and reducing the number of procedures that we do. And there’s a real magic about that, man.

[Nekky]
Yeah. And that’s the best part about being in general dentist, Jaz. I love it.

[Jaz]
Good old cherry picking. Now, just before we wrap up, there’s a few different points that I hadn’t covered yet. Ice. Like ice is like a standard thing that we recommend post surgery. Tell me more about ice. Like, do you guys-

[Nekky]
I got so much, so much. So, cryotherapy. Okay, ice. I want you to think about it. Okay? You put ice on the side of your face. Yeah, it’ll get the outside cold. So we’re trying to cause vasoconstriction. We’re trying to slow down nerve conduction. You know what I mean? Do you really think by putting ice at the angle of the mandible? It is going to get to your surgical site. Like, do you think it can really penetrate that far?

[Jaz]
Exactly, right? The penetration depth is ridiculous because you got a whole, you got warm blood circling everywhere, kind of counteracting the cold. But I had like, I think it was episode 27 and 28. Well, I had these two physiotherapists, one who’s now become a dentist, and we’re talking about back pain and dentistry. And they were saying when you put ice on your back or something, they said the exact same thing. Well, there’s only so much penetration microns that the very superficial skin layer that’s getting cold. Are you actually benefiting it? So tell me more.

[Nekky]
The reason I still use ice. Okay. So we both know it may not be penetrating to the site. However, the patient is taking an active role. The patient is taking an active role in their healing. And for me, that’s worth its weight in gold. So whether ice works or not, it doesn’t matter to me.

However, I really feel like if patients wants to get better, they’re icing their face. If they’re icing their face, I know that their diet is going good as well. Like they’re not eating nuts. They’re not eating seeds. They’re not sucking down raspberries and getting those little seeds in the sock.

Cause they’re taking an active role in healing. They want to heal faster. They’re listening to all your instructions. So that’s why I always give ice. Cause then people are always taking an active role. Does that make sense, Jaz?

[Jaz]
Oh, totally. Totally. I mean, same thing with analgesics, if you really explain them so well. So, and then they help do the whole thing where they’re alternating ibuprofen, paracetamol, another example, like you mentioned earlier, they’re being active, they’re doing the ice, they’re looking off their diet, and then they’re looking off themselves and that energy will heal them.

[Nekky]
Absolutely. So that’s why I use ice. Now, the question is, is ice better in the mouth or is it better outside the mouth? This really came to a head for me when I took out, I was giving someone a lower denture with a couple implants and I removed six lower teeth and they texted me the next day. I always give everyone my cell phone number.

I know some people don’t, I always do. And I always encourage patients. And I know I’m one of the few ones. However, it really makes patients feel better. I’m a family member. Okay. My patients call me Nekky. They don’t call me Dr. Jamal, I’m a friend. Okay. I’m here to help you with your surgery.

I know there’s a lot of controversy about this and I don’t care. This is just how I do things. And so they’ll text me and they’ll be like, Nekky, I got a problem. And I was like, what? And she’s just like, it looks like I’m wearing a necklace. I’m like, just send me a photo. What are you talking about? And she’s just red, bruising, like purple all the way down here.

[Jaz]
Yeah. I’ve experienced this from just anesthetic. I’ve just on one side, just from getting a buccal infiltration and then to come down and there’s all that bruising.

[Nekky]
Totally.

[Jaz]
Very thin lady, very thin lady by any chance?

[Nekky]
Yep. Yeah. Very, very thin lady. Very loose skin, right? And you’ll see that. And I’m like, okay, well, have you been icing it? And they’re like, well, yeah, I’ve been icing. It hasn’t done anything, but I’ve been eating really hot soup. And I was like, interesting, interesting. So like, are we increasing vasodilation causing bruising, causing bleeding by really hot fluids?

And so I found when I got my patients, I’m like, man, just eat cool stuff for the next two days. Like just eat cool food. Do you really need a hot coffee? No, have an ice coffee, man. Like, do you really need soup right now? No, I have some ice cream. Like, just keep it cool in your mouth.

And that’s another thing patients like they, it feels like they’re healing, man. Like just like when you get your tonsils out, are you giving someone hot soup? You’re giving them popsicles. You know what I mean? Like I find that it all relates together. I try to keep everything cool where it can. If cold is getting to the surgical site, I just think it’s better. And whether ice externally or internally does anything, it just makes my patients feel better.

[Jaz]
Okay. Wonderful. Final thing then. Cause again, we can go on for like three hours talking about everything, but we’re being selective.

[Nekky]
Let’s do it, man. I’m canceling my day. Let’s just do this.

[Jaz]
Oh, I wish Nekky. I wish I’ve got to take my little one swimming, but tuberosity fractures. Okay. So, upper wisdom tooth, like literally two months ago, I experienced my first tuberosity fracture, this big gaping cavity in the maxilla. That I was suturing up, but you know what?

They heal amazingly. Well, the human body is marvelous, right? But at the time you’re like, you’re really bummed out and stuff. But you know what? I really don’t think I could have avoided it because you know how teeth, sometimes teeth are very difficult to remove because they have this like patchy areas of ankylosis.

And so any force that you put because of that ankylosis will go through the bone. And sometimes it’s very difficult to section, especially if it’s like not clearly like divergent roots. So tell me what your strategy, what’s your mind, where’s your mind at in terms of preventing tuberosity fracture. Have you experienced one?

[Nekky]
Oh man, come on, Jaz. We’ve all experienced tuberosity. I’m surprised this far in your career. You’ve only had like one, like you just had, like that blows my mind away. Now I’m questioning. Yeah. Now I’m questioning. I’m like, I can’t even count [overlapping audio] it’s, it’s poor case selection.

That’s what it is. And so, okay. So whenever I see divergent roots on an upper posterior tooth, so like. The very loud, the penultimate, the last tooth in the arch. I’m always nervous. And I’m looking at the tuberosity, man. Can you always tell how dense the bone is from your x ray? No, because it depends, the angle of the x ray.

It depends how strong the x ray beam was going through it. It depends how fat the patient’s face is. There’s so many other factors going on, right? So I’m looking at divergent roots. And I find when I just stick a straight elevator between the second and third molar and turn, and I hear a crack and you’re like, oh, shoot, here we go.

You know what I mean? I want to give everyone a tip. The problem with the tuberosity fracture isn’t always the small chunk of bone that comes with it, because a lot of times it’s small. If you use a lot of force, you can really create some serious damage there. But the biggest problem is when you go to remove the tooth, all the soft tissue is still stuck to it.

And so you just, you’re like, okay, well the tooth’s out. I’m just going to pull it out of here and I’ll suture it up. But then as you pull, you’re going to notice something tear and it tears on the palate. And as you pull more of that tooth coming out, it tears further and further. And now you’re in the soft palate and you’re like, Oh crap, I just need this tooth out of here. It’s literally waving in the wind. He’s either going to choke on the tooth or he’s going to choke on the blood coming out of there profusely. And then you pull more and now you’ve created this huge tear right down the soft palate. And let me tell you, suturing that tear is absolutely brutal. Man.

[Jaz]
I think everyone just held their breath for like the last 10 seconds. Everyone just held their breath as you were saying that.

[Nekky]
You put a mirror back there and they start gagging. So now you’re expected to suture that. Oh my Lord. Okay. So the first thing I do whenever I hear the crack, cause I’ll be honest, I’ve broken my fair share of tuberosities and if you haven’t go look in the mirror and be honest with yourself.

[Jaz]
Remember Nekky, just like in endodontics, we never break a file. We separate the file separated. You never broke a tuberosity. The tuberosity decided to separate.

[Nekky]
Yeah. It broke itself, man. The patient came in like that. What am I supposed to do? Yeah. So like when you have a divergent roots, I’m always nervous. If that bone behind it, man, if the bone is really soft, it’s going to come with it. If the bone is really hard, well, it’s going to come with it too. I want you to be careful of a couple of things. So when you first hear that crack, if you were putting a lot of force, which I don’t recommend, but let’s be honest, some people it’ll happen.

Okay. You put it in a lot of force. If there’s any other piece moving, like if you’re trying to take out the third molar and now the second molar is moving, let’s just back off. Okay, put an arch wire on there. Do not take out the tooth and I want you to refer it to your maxillofacial surgeon.

[Jaz]
By an arch wire, you mean like a rigid, like a trauma splint kind of thing?

[Nekky]
A rigid wire, yeah.

[Jaz]
Yep.

[Nekky]
Yes, absolutely. Just splint it, take it out. The patient isn’t going to be worse off. However, I want you to refer it to that surgeon at that point. As a general dentist, like, there’s obviously a fracture somewhere else going on and I don’t want that to happen too.

Okay, if you can see like the tuberosity moving and you see like nothing else is moving around there, I want you to start separating that lingual gingiva from the tooth. Okay, and do it very gently. This isn’t a race. Okay, take your time, use your periosteal, start to separate that tooth from that gingiva.

So as you start to remove the tooth, that the gingiva is not going to rip at the same time. Okay. Now, something theoretically that sounds so great but is a lot harder to do is what if you thought there was a large piece of bone there, if you tried to use a bur and go behind your tooth and try to actually separate the tuberosity bone from the tooth so you can cleanly remove it.

[Jaz]
So you’re kind of sacrificing the tooth, you’re like drilling into the tooth basically so that you’re not leaning against the bone so much.

[Nekky]
Yeah, and you’re trying to keep that bone there, depending on how large that tuberosity you think it is. As long as the tuberosity is still connected to the periosteum, it’ll heal. Like, it’ll, you can leave it in place. However, in practice, when a patient can open this wide, and you’re trying to get your bur distal to that third molar, good luck, my friend. You know what I mean? Like it sounds so good and you see it in textbooks and you’re like, oh, this is just so simple. And then you feel like a dork when you’re trying to do it and you’re like, I can’t do this.

Like what is going on here? So, do your best. If you hear a large crack and you feel something moving. I’m not like, be careful, but also if you hear a crack and you’re trying to like loosen up that tooth, you remove the lingual gingiva and there’s a lot of pain distal to that tooth.

I’d recommend you stop as well. And if you have the ability to take a CBCT, do it and see exactly where that crack is. Cause if it’s far posterior, you may just want to put an archwire on there and send it to the surgeon as well.

[Jaz]
Could you also put an Essix retainer on that? Like an arch wire followed by an Essix retainer on top as well. What’d you think?

[Nekky]
I’ve never had to try an Essex retainer. I guess you could, like there’s no problem with that at all, but you just want to stabilize it and get it to the surgeon. Cause if it is a far posterior crack, you can cause some damage as well. And I don’t want that to happen to you.

Knock on wood. Luckily. All of my tuberosity fractures, and I’ve taken out some big chunks of tuberosity, none of them have been too far distal. I’ve never had a first or a second molar moving when I was taking out a third molar. In most cases, it’s going to be a small piece of bone distal to that third molar.

I just want you to be careful, and don’t just start ripping out third molars without sufficiently elevating. If you have divergent roots and if the patient has good opening and you’re able to section, or you can try that. I find sectioning upper third molar is really difficult. However, if you need to make a buccal trough to kind of loosen up the tooth, so you’re not putting as much force on the tooth and the tooth needs to come out, then you can do that.

Like say there’s an infection on the tooth and the tooth needs to go. You can make a small buccal trough. You know, when I make my buccal troughs, it’s half on tooth, half on bone. So I’m not removing a ton of bone. I just feel like we can be a little bit kinder to the tissue and I always teach in all my courses when you use the grip and rip technique, you grab onto a tooth and you just wanna rip it out of there, it often leads to a lot of problems.

And one of those problems can be a tubes fracture. So be gentle to your patients because if it happened to you or if you were taken out a tooth on your dad, you wouldn’t want that to happen, right? So why would you let it happen to a patient?

[Jaz]
It goes back to everything we discussed before, you know? Assess the radiograph, tell the patient that, wow, your tooth has got this funky root. Sometimes a bit of bone comes with it. Don’t worry. We got some techniques to manage it, but sometimes they can be quite nasty. And then we need to sort of put a wire there, but listen, this may or may not happen.

I’m just giving you an idea of it. I mean, how far do you go with the consenting for the rarer things, right? And you don’t want to overplay some of the rarer things. So it’s a difficult thing to warn about tuberosity fracture sometimes.

[Nekky]
It is, it is. But the best part about a tuberosity fracture is when a patient’s like, hey Nekky, can you show me your tooth? And you’re like behind the patient with your elevator, trying to chip off the bone and you’re like, oh man, I got it. I don’t want them to see there’s a chunk of bone there. And so. Yeah, no. I stick to the main ones. I stick to pain. I stick to swelling. On the lower, if there’s close proximity to the mandibular canal, I know we could do an entire episode on just that, right?

I tell the patients, oral antral communications, if I’m taking out like an upper second molar, I tell the patients, it’s the common ones. But am I telling patients about like, do you know, Mrs. Smith, I could fracture your jaw here, unless it’s a high risk scenario, which I don’t recommend you take on anyway, like I’m not breaking patient’s jaw.

And so like bleeding. Yes. I talk about bleeding. I just talk about, I stick to the main ones. And if I think, a more serious complication is on the table. I’m not doing the case because I don’t take on cases that where I lose sleep, you know what I mean? And I don’t want you to either. That’s why we have specialists.

That’s why we have people that we can refer to. Remember we refer risk and like we talked about earlier some angry patients. We can refer those to right? But like never take on cases where you lose sleep. You never lose sleep over cases. You do not do. Keep your life simple. Keep your life easy. Live on the edge of comfort. I get it. But don’t push the envelope because you’re not helping yourself or your patient.

[Jaz]
And when you are at the edge, make sure you have enough education, experience, mentorship nearby. That could be virtually through like some of the wonderful stuff you put out there or someone holding your hand is great.

But always, micro steps and growth at a time. Don’t know giant leaps. It’s always one small step for man and keep it one. Don’t know giant leaps of mankind. Yeah, we’re not doing that in the surgical specialty, right? We’re not doing the Neil Armstrong. Okay. Almost said Lance Armstrong, Neil Armstrong.

Listen, so what for the tuberosity, watch out, look at the radiograph, really think, is this a fight that you need to fight? And then the soft tissue is what saved me, right? So I had Chris Waith a long time ago. We talked about tuberosity fracture. It’s And the whole thing about he’s brilliant, right? Moving away that soft tissue lately that saved me. That saved me.

Cause I was able to, I had something to stick the suture back and it healed wonderfully. So that is a real top tip. I’m going to ask you a personal question, Nekky, feel free not to answer this personal question. If you don’t mind. Have you had like a complaint that’s gone litigious? Have you had like someone try to sue you before?

Jaz’s Outro:
Well, there we have it, guys. Thank you for listening all the way to the end. So, this is what we’re going to cut off for those on YouTube, Spotify, Apple. If you want to listen for free, you can. Just head over to Protrusive Guidance. This is the nicest and geekiest community of dentists in the world. And it’s a safe space.

It’s a safe space. You have to be a verified dentist to come on there. And I’ve got all the free content there. It’s also paid content on there if you’d like to. If you want to get CE credits for these episodes, we are a PACE approved provider. So the website for that is www. protrusive. app, that will take you to our landing page, make an account, and then use those login credentials on the iOS app or the Android app.

Thank you though, for those on YouTube, Spotify, Apple for making it to the end. Really appreciate your listenership. I’m really hoping you enjoy this one. I really enjoyed speaking to him. He’s just a breath of fresh air and he’s like just the nicest guy. You can just sense it in his voice. Very knowledgeable and I always learn from him and I hope you did too as well.

Do check out his Third Molar’s online course. For me, it’s the best online course I’ve ever done and I’m pretty sure the Protrusive discount code is valid. It gets you, I think, 15% off. I’ll put that in the show notes. We are an affiliate but if you’d rather pay full price, be my guest, but if you want the coupon code, it is Protrusive.

The website to automatically apply the discount is protrusive.co.uk/thirdmolarsonline. That’s /thirdmolarsonline. And you can see the reviews on other websites. This course is just packed full of videos after videos after videos. Every time I’m doing a third molar, I will go in the video library, find a similar x ray, a similar case what I have, and I’ll just like revise it before I do the surgery.

It’s that good. Anyway, thanks to team Protrusive for helping this together. I’ll catch you same time, same place next week. Bye for now.

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เนื้อหาจัดทำโดย Jaz Gulati เนื้อหาพอดแคสต์ทั้งหมด รวมถึงตอน กราฟิก และคำอธิบายพอดแคสต์ได้รับการอัปโหลดและจัดหาให้โดยตรงจาก Jaz Gulati หรือพันธมิตรแพลตฟอร์มพอดแคสต์ของพวกเขา หากคุณเชื่อว่ามีบุคคลอื่นใช้งานที่มีลิขสิทธิ์ของคุณโดยไม่ได้รับอนุญาต คุณสามารถปฏิบัติตามขั้นตอนที่แสดงไว้ที่นี่ https://th.player.fm/legal

What’s the best way to reduce post-op pain after extractions? And why should we never use the term “painkiller” with patients? What to do when you hear the dreaded *crack* of a tuberosity?

In this episode we talk about all things post-operative extraction complications! And I’m joined by one of the nicest guys in dentistry – Dr. Nekky Jamal

Complications are something we ALL experience, so this episode is great for any dentist. Whether you’re brushing up on dry socket prevention, mastering post-op communication, or just curious about advanced healing hacks, tune in for real-world advice to make extractions smoother – for both you and your patients

Watch PDP210 on Youtube

Protrusive Dental Pearl: The “Niche Kebab” concept encourages dentists to narrow their focus by reducing the variety of procedures they perform and prioritizing those they genuinely enjoy. By evaluating every new skill or treatment added and strategically dropping less-loved procedures, dentists can avoid overextension and the “jack of all trades, master of none” pitfall.

Learn how to Extract Impacted 3rd Molars, don’t miss out on Third Molars Online and use the coupon code ‘protrusive’ to get 15% off!

Key Takeaways

  • Pain management is about setting realistic expectations.
  • Dexamethasone can be beneficial but must be used cautiously.
  • Dry socket is often overhyped; proper care can prevent it.
  • Effective communication can alleviate patient anxiety and prevent misunderstandings and complaints.
  • Preoperative care can help manage pain expectations.
  • Understanding the signs of infection is essential for diagnosis.
  • Chlorhexidine rinses can significantly reduce dry socket risk.
  • Patients appreciate being informed about their unique dental situations. PRF can significantly reduce the incidence of dry socket.
  • Dentists should embrace new techniques like PRF to enhance patient care.
  • Patient involvement in post-surgical care is crucial for healing.
  • Dentists should not hesitate to refer complex cases to specialists.

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

Highlights of this episode:

  • 02:54 Protrusive Dental Pearl
  • 04:05 Dr. Nekky Jamal
  • 08:39 Managing Post-Extraction Pain and Swelling
  • 21:37 Infection
  • 25:02 Identifying Dry Socket and How to Prevent it
  • 28:30 Case Selection and Communication
  • 37:13 Mitigating Dry Socket with Platelet-Rich Fibrin (PRF)
  • 39:47 The Importance of Nicheing in Dentistry
  • 43:19 Cryotherapy and Post-Surgery Care
  • 47:32 Handling Tuberosity Fractures
  • 55:08 Patient Consent
  • 57:55 Litigation and Patient Communication

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C and D.

AGD Subject Code: 310 ORAL AND MAXILLOFACIALSURGERY (Exodontia)

Dentists will be able to:

  1. Identify and differentiate common postoperative complications, and recognise the key symptoms associated
  2. Evaluate the ethical and clinical considerations of case selection for extractions
  3. Communicate effectively with patients regarding potential complications

If you loved this episode, be sure to check out another epic episode with Dr. Nekky Jamal – Wisdom Teeth Extractions – SURGICAL TOP TIPS

Click below for full episode transcript:

Teaser: Overexplain and then have them on your page, have them take ownership for their anatomy before you even start. You know what I mean? Dentistry is about talking to patients and Jaz, you've seen how I talk to my patients. I keep everything light, but after I joke around, I say, okay, but seriously, do you understand that this is a risk like this could actually happen and in this case scenario I don't want that to happen for you.

Teaser:
I’ll do everything I can for you. But there’s things that are out of our control. Do you understand? And patients have to take ownership of it? Otherwise, I’m not doing work. I hate using the word painkiller because that’s just not realistic. It’s more of like a pain reliever. Okay, and so will you be in 100% pain free even with a painkiller or analgesic?

No, you won’t, right? And so the job of an analgesic is to make you more comfortable, not to kill the pain. Patients, they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically it’s helping. But for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol.

If you’re really interested in extractions or if you’re really interested in endodontics, like, become obsessed. Like become obsessed to the point where you’ve read every single journal article out there. I want you to go home and I want you to dream of it. I want you to feel like, your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to?

Jaz’s Introduction:
In this episode, we’re one of the nicest guys in dentistry, Dr. Nekky Jamal. We’re going to revise together how to manage the common complications of extractions. There’s a bit of a bias towards third molars, but actually the advice given by Nekky and what we discuss today is pretty much applicable to any extraction or any type of dental surgery.

We’ll talk about the best strategies for post operative pain and why you should never use the term a pain killer. Nekky will also reveal why alveolar osteitis or dry socket is virtually non existent in his practice. He’ll tell you exactly what it does to prevent dry sockets. We also discuss the dreaded tuberosity fracture with golden advice on what to do if it happens to you and how to preempt it or prevent it.

Lastly, this episode is actually full of communication gems. And actually the last six minutes talk a little bit about some stuff, which isn’t really appropriate for the public eye. It’s real dentist talk, if you know what I mean. And that’s why the last six minutes will be on the Protrusive app only.

It’ll still be free, but we only on Protrusive app. It won’t be on Spotify, won’t be on Apple, and it is absolutely golden. So if you’re starting this podcast on YouTube or Spotify or Apple. And now that you know this information, you want to move over to Protrusive Guidance app, please do so now.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Some tip or advice that you can apply in your practice. This one’s about your mindset and something that we discussed in the episode. I call it Niche Kebab. The idea of niching down in dentistry and we talk about how by niching into a subspeciality or just reducing the amount of procedures you do and homing in on a few that you really enjoy.

This is what keeps the fire burning in dentistry. This is what helps you to fall in love in the details of dentistry and how to be a happy dentist. Me and Nekky truly believe that. So here’s how you apply Niche Kebab. For every new procedure that you offer or you learn, or a new skill set that you add on, which procedure or treatment will you drop?

I know that sounds a little bit scary or worrisome or maybe a bit extreme, but do you really want to keep adding procedures and adding procedures and spreading yourself out thin, becoming the jack of all trades, but the master of none? Protruserati, this is growth by subtraction. I just want to give you this idea or help you adopt this notion or this mindset that it’s okay to actually whittle down some procedures that you don’t love to give you the time and energy to focus more on things that you do love or things that you could potentially love or new skills that you can add on.

So remember, so don’t just keep adding and adding and adding. Think about what you will remove and eventually you can achieve Niche Kebab. I’m claiming that one by the way. Anyway, hope you enjoy the main podcast and I’ll catch you in the outro.

Main Episode:
One of my all time favorite dentists in the world, generally one of the nicest guys ever. Dr. Nekky Jamal, welcome back to Protrusive Dental Podcast. How are you, my friend?

[Nekky]
Jaz, this is a huge honor. Man, I listen to the podcast all the time. I’m just so proud to be a part of it, man. You’ve done some huge things across the world and help so many dentists. I’m just a fan boy over here, man.

[Jaz]
No, no, no. Look who’s talking, man. Like we all love your stuff, and it’s your charisma is the way. You very much fall into the values, which I’m going for with protrusive, right? The kind of dentist who are nice and geeky and like, you’re solely geeky. Like you love everything you do.

It’s just so clear and you’re funny and you’re very likable. And so it’s just great to build these connections, transatlantic connections with yourself. And it’s just great to have you back again. You’re messaging the way you speak. It’s all brilliant. So very excited to delve into third molar extraction complications today, following on from the previous episode that we’ve done.

Now, before we hit the record button, you told me something very interesting. You told me that you live six minutes away from where you work. So I want to know, with the amount of extractions that you do, and with the level of extractions, you’re going to get complications, right? Everyone’s going to get complications, okay? Including you, believe it or not, okay? People out there are like, no, surely Nekky doesn’t. I’m sure it does. Have you ever had that patient knocking on your door on Saturday?

[Nekky]
Yeah, unfortunately. Living in a small town, everyone knows where I live. But you know what, it’s crazy. The only time I’ll get knocks on my door is like facial trauma. Like, a kid falls off their bike and they’ve smashed their front teeth. And you know, they don’t know what to do. And so they’re like, oh, I’ll just go, I’ll go talk to Nekky. And then, we’ve had some fun times. Like, people show up to the door all bloody in their face.

And they’re like, you know, can you fix this? And you’re like, yeah, all right, let’s go, let’s do this. And that’s crazy. Man, for me, that’s the best part about being in a small community because you build relationships and it’s not like, I don’t advertise. I don’t do any of that stuff.

It’s all about building relationships with your patients. And yeah, I’ve been fortunate. I haven’t had too many knocks on my door for patients in pain. Hopefully I can keep those away forever. But, yeah, no it’s all a part of the fun of living in a small town, a little bit different than London, I would say.

[Jaz]
Well, you know, I work in Reading. I lived in Reading for a while as well. And it was like a three minute drive to work, right? And so-

[Nekky]
Oh, nice.

[Jaz]
What I would experience is, like, you’d go to KFC and you’d always bump into a patient. Or you’d go to this shop and, like, there’d always be a patient, right? And so that was interesting. But the real interesting thing is, like, I personally, I don’t have road rage. But my wife, like, bless her, she doesn’t listen to the podcast, so I can admit it. She’ll never get to know. She’s got some road rage issues, right? My wife, bless her. I love her, but she’s got some road rage issues.

And so now if ever I’m the passenger, right. And we’re in the small town, I just always have to tell, listen, this could be a patient of mine. Please just keep it down. You never know who you’re honking at. So you gotta be careful.

[Nekky]
Yeah. That’s when you put the visor down. And you’re just like, you try to hide behind the visor so no one can see you. We’ve all been there. Come on.

[Jaz]
Absolutely. My friend. Well, extractions, you are brilliant at them. I’ve done your course. I love your course. I plug your course all the time because it’s of the best piece of education I’ve ever done. But today we’re not here to talk about the course. We’re here to actually really give value to everyone spending their time, whether on the treadmill, the commuting on the train to work or whatever.

Let’s make a really impactful piece of education for complications following extractions. Now, particularly third molars, cause that’s your main domain, but a lot of, I’d say 80% of what you’re going to say will probably apply to generic extractions as well. Right?

[Nekky]
Absolutely, man. I always say they didn’t teach us enough about extractions in school, but really extraction complications. Whenever I’m talking to fellow colleagues, like my goal is always, man, stand on my shoulders. Be a better dentist than me because I’ve made more, more mistakes and caused more complications than all of us combined, but like you live in a small town. I don’t have an oral surgeon to refer to. And so patients come in.

And you do the best that you can. And unfortunately there’s not enough knowledge out there of like, hey, what to do in this scenario, what to do in this scenario. And so often the general dentist is left stuck trying to figure it out. And so I wanted to come on today to help demystify some of the complications that we get. And Jaz trust me, man, I’ve made them all. So I’m very proud to share as much as you want. And, and man, let’s just get into it.

[Jaz]
Well, let’s start with a big one, right? Let’s start with pain. Okay. Because this is so common. There’s going to be some blues in our sort of consent and in our post operative instructions, we say, look, it’s going to hurt, right?

It’s not going to be no ride in the park. It’s going to hurt. Expect it. It’s a surgical procedure. There’s going to be swelling associated with that would be some pain. Now you used the word demystify, right? And this just reminds me like this completely off script, but it reminds you of a TikTok I saw like four years ago.

I hardly have time for TikTok, but like four years ago, I saw a TikTok. I don’t know where you’re going with this. But this girl literally drinks a gallon of pineapple juice, right? Okay. And said, I’m going to go get my third molars out. Okay. I’m going to drink, watch me drink this gallon of pineapple juice. And then like three days after the wizarding, she’s like smiling, like, hey, no pain, no swelling. Cause I drank a gallon of pineapple juice. Tell me about that. Tell me about pineapple juice.

[Nekky]
Yeah, yeah, yeah. So, patients are after the bromelain in pineapple juice. And so that TikTok video is right. Like I’ve had patients they’ll come in and they’ll like have a cup of pineapple juice, like still drinking. And I’m like, man, you got to, if you want this bromelain thing to work, like you’ve got to drink like four liters of it, first of all, A, you’re probably going to become a diabetic in the process.

Cause that’s just a heck of a lot of sugar for you. But like, man, I don’t know. I don’t know. Like, yeah, bromelain can work in really high doses. And unfortunately, a lot of our patients are on TikTok and seeking those social alternatives and trying to figure out how they can beat the system.

But I tell everyone, I’m like, man, the most common complication of any extraction, whether it’s an upper first molar or your third molars, pain and swelling. So how do we tackle that?

[Jaz]
But Nekky, is it fair to call it a complication? It’s an expected outcome. Complication means that we weren’t expecting it to happen.

[Nekky]
Yeah, no, I hear what you’re saying. I hear what you’re saying, but maybe, yeah, you’re right. Let’s just call it an expectation then. Because it’s important to get our patient’s expectations on the same page. It’s shocking how many people come in and I’ll take out someone’s third molars, I’ll take out Mrs. Smith’s younger daughter’s third molars.

And the mom comes up to me, she’s like, so this is going to hurt after. Are you for real? And I’m like, man, they’re four impacted wisdom teeth. This is surgery. I’m literally removing something out of your daughter’s face. Like, yes, this is going to be sore.

And I think the best thing to do is get the expectation straight. Is it going to hurt for a day? No, it’s going to hurt for longer than a day. And so I always tell my patients, I’m like, hey, the first thing that I do is you have to tell them, yes, you will be sore, you will be in pain. And there’s no such thing is like no pain.

Like, I hate using the word pain killer. Cause that’s just not realistic. It’s more of like a pain reliever. Okay. And so will you be in a 100% pain free, even with a pain killer or analgesic? No, you won’t. Right? And so the job of an analgesic is to make you more comfortable, not to kill the pain.

So that’s a common term that we use is like, pain reliever or like we all use in dentistry analgesic. But for me, it’s almost like, what do we use? And I’ve gone through different things in my career earlier in my career. Opioids were really pushed and now we’ve steered a hundred percent away from opioids.

A lot of patients, they come in and they’re like, man, Nekky, you’re taking out these wisdom teeth. I’m going to need some codeine after. And I’m like,  codeine, you want to be constipated or you want pain relief? You know what I mean? Like is  codeine really what you’re after here? And then some people will say, I don’t know what it’s like in the UK, but they’ll be like, Nekky, I’m going to need some Percocet.

And I’ll be like, man, Percocets. I’ll only give you Percocets if you split half with me, because there’s no way I’m prescribing it with you. And so, I always make light of these situations. I’m like, but you know what, in my opinion, and according to the research is the best pain reliever. And that’s a combination of ibuprofen and acetaminophen. And in Europe, I think you guys call it a paracetamol.

[Jaz]
Yes.

[Nekky]
Or do you call it acetaminophen? Yeah. Yeah. So paracetamol, paracetamol. Yeah. So depending where you are in the world, it has a different name. But according to the research and according to my own patients, this is what I do.

So what I do for every single patient is on their post operative sheet, before the appointment even starts, I show them and I draw a clock and on that clock, I’ll say 12, 3, 6, 9, and I’ll say at 12 o’clock, you can take 600 milligrams ibuprofen, a thousand milligrams acetaminophen at six o’clock, you can take another 600 milligrams, ibuprofen thousand milligrams, acetaminophen, or if patients want to alternate every three hours, they can do ibuprofen.

Then three hours later, acetaminophen or paracetamol three hours later, ibuprofen. It depends what you want. I find sometimes patients like to split it up every three hours because that way is one’s kicking in the other one’s coming out and they feel like they’re taking an active role.

You know what I mean? And we’ll talk about like taking that active role, patients they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically is helping, but for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol. And the research backs this up. In your opinion, Jaz, what works well for you guys and your patients?

[Jaz]
Yeah, absolutely. So I believe it’s the Oxford data on analgesics and it definitely shows, I think it shows at its worst point, like if you take 800 milligrams of ibuprofen and a thousand of paracetamol, that can be effective.

Now on the box in the UK, I dunno how it’s in Canada, but in the UK and the box of ibuprofen, it says 400. So we have to say that, look, if it gets really bad, it’s okay to double it. Just make sure, be careful with the gastric complications, make sure eat something.

[Nekky]
That’s right.

[Jaz]
Very important, the ulceration risk. But yeah, definitely ibuprofen, paracetamol. When I was in Singapore, there was a culture to, I guess that’s the best way to describe it. Culture of giving steroids, prednisolone, like in the UK, it’s much more difficult as a practitioner to prescribe that. And so I think most don’t, but I don’t know, does steroids have a role in anti inflammatory in terms of your active prescription of it?

[Nekky]
Oh, man, Jaz, I don’t know if I can practice without it because I feel like, so in Canada, we use dexamethasone in the States, they’ll use like  Medrol dose packs, but it for me, I regularly routinely use dexamethasone for my patients now, you can inject it at the surgical site. Okay. And it’s just four milligrams at the surgical site.

If you do an IV, you can inject it by IV, but you can also take it orally four milligrams twice a day for two days. Now you got to be careful. Like you don’t want to give it to someone who’s medically compromised. You don’t ever want to give it to a diabetic because man, I remember. I’m talking about mistakes, right?

I gave it to a patient and the patient calls me from the hospital the next day. And they’re like, Hey, Nikki, I’m in the hospital. And your heart starts pumping and you’re like, why are you in the hospital? And they’re like, well, my blood sugar is just, it’s spiked. It’s out of control.

And some dumb dentist gave me a medication that really mess with my blood sugar. And I was like, oh, who is that? You know what I mean? And you get a call from the ER doctor saying, you know Nekky, I know you’re doing your best there, but you can’t be given dexamethasone to diabetics. And I said, absolutely my fault.

That’s a hundred percent my fault. We don’t want to give dexamethasone to diabetics, but in my experience, it’s really helps with swelling. Dexamethasone has a longer half life, between 36, 54 hours. I give it for two days, or like I said, you can inject it at the surgical site. And it works really, really well for my patients. There’s a little bit of controversy, whether it helps with pain, but it definitely helps with trismus and swelling.

[Jaz]
I thought that when I was removing this teeth in Singapore and it was much easier because I think we had them in the practice to actually give to patients. So it was like an easy prescription to do and I felt as though it helped my patients when I reviewed them. And then the UK is some barriers.

So my homework will be just to figure out. Okay, how many practices in the UK are actually prescribing dexamethasone or prednisolone or some sort of steroids and how we can go about doing it because I think there is a role. Yes, anti inflammatory at least or the swelling. Sorry the swelling aspect of it definitely has a role whether it yeah makes a difference in pain I do think it does but like you said the gold standard evidence based would be ibuprofen and paracetamol.

But it’s good that we covered steroids because it’s a very important part of your regime. And we have to remember that pain is a very variable factor. I believe it’s a factor of four, right? Like someone could say something’s a 2 out of 10 and we have those patients where they come back and it was the messiest extraction ever.

And they say, yeah, it was a walk in the park. It was fine. Like it was way better than what you told me than it would be. And then we have those other patients who was like the grade three mobile perio tooth and they come back and it was like an agony and stuff. And so the whole pain internal variation needs to be respected.

[Nekky]
Oh God. Yeah. One more thing about corticosteroids or dexamethasone you don’t want to give it at night because sometimes like you don’t want a patient to take it at night. Sometimes they act like little caffeine pills and they’ll be up all night. But another complication that. I didn’t like you experience, I feel like when you’re in the thick of things, that’s when you experience your complications.

I had a patient, they’re like, Nekky, surgery is going good. I haven’t slept in two days though. And I was like, oh yeah, dexamethasone can sometimes act like caffeine pills. Let’s take it back a bit. They’re like, no, Nekky, it’s not that it’s the hiccups. And I’m like, what do you mean I’ve been hiccuping nonstop for 48 hours.

And then I’m thinking, I’m like, could you imagine like when I get the hiccups for like 20 minutes, I’m like, trying to scare myself or like swallow a bunch of peanut butter or whatever these old tricks are, could you imagine having it for 48 hours?

[Jaz]
Oh, I had no idea. This is a complication of a course.

[Nekky]
Yeah, man. It doesn’t happen often doesn’t happen often. I’ll get a patient like once every two years and they’ll be like Nekky, I cannot sleep I don’t know what to do. And I’m like, oh my god, like stop these dexamethasone. You gotta let it get out of your system. But here’s the crappy part.

It’s in your system for a long time. You got a long half life. So that’s another negative side effect. You’re not going to see it often, but if I can help one dentist out there that has that patient that’s hiccuping, yeah, it’s from your steroid. And it’s not a fun complication to have.

[Jaz]
Is there a role of how when you have a hot pulp in the endodontics and we advise that, okay, sometimes it’s more difficult to numb this patient up. And therefore we often advise, take some ibuprofen before you come in as a strategy. Is there a place, if you think it’s a particularly gory procedure, tricky one, do you ever advise taking a preoperative analgesics?

[Nekky]
Yeah, yeah, yeah. So you brought up a really good point that the research says preoperative corticosteroids. That works really well, but the research actually doesn’t support preemptive analgesics. I was reading some papers I think it was like, you know last week. I remember I was shocked I’m like because I usually give ibuprofen to patients prior like I’ll be like a start taking your ibuprofen is the morning of. But a lot of researchers saying, you know preemptive analgesia didn’t do as much as we thought it does but like it makes sense.

Like, why wouldn’t you do it? Right? Like, to me, it’s like, why wouldn’t you just have that on board ready to go? But the research is mixed on that. But like, man, these days you can find a paper to say anything you want. Hey, you’re like, on one side, it’ll work on the other side. It’ll work. So I’m often going just straight to common sense.

[Jaz]
I love that little Canadian A that you said that I was waiting for it. So thank you for blessing us with that. So Nekky, there’s so much to cover, but in terms of pain, stick to the gold standard, paracetamol, ibuprofen, don’t be afraid to go above 400 milligrams, but do check for ulceration risk. Make sure they eat something, definitely manage their expectations.

Warn them of pain, some dentists like, oh, but if I overplay the pain element so much, then they won’t have the procedure. Well, that’s all point of consent, right? You need to under promise over deliver. And so definitely yet talk about the pain. It’s going to hurt. It’s going to be really sore, but don’t worry. Eventually everything, like everything like childbirth, you’ll eventually forget about it, but it’s going to be hopefully way better than childbirth.

[Nekky]
That’s my joke for all us guys. I’m like, you know what? At least we’ll never have to give birth, man. If we have to give up four little wizened teeth, man, so be it. But that’s where it ends for us.

[Jaz]
Excellent. Now the next thing is, what would you say is the next most common complication?

[Nekky]
Oh man, you know what, the literature varies so much. I’m just going to go with my own experience. Okay. I think everyone is expecting me to say dry socket or alveolar osteitis.

[Jaz]
Everyone is, but I’ve done your course and I know your protocols and I know you openly say that. Okay. You very seldom experienced dry socket. So excited to hear about that. So we’ll talk about Nekky’s magic pineapple juice that he gives that prevents dry sockets. But okay. So for you, dry socket is not a big issue. So what is more common?

[Nekky]
Man, I don’t see too many complications. I think, the most common complication or expectation I’ll see is pain and swelling. And then maybe infection, maybe infection. Okay. Cause I don’t routinely, and I don’t know what it is about for you, or I don’t routinely provide antibiotics for my patients. Do you?

[Jaz]
No, no, no. We’re discouraged too, right? We’re discouraged too.

[Nekky]
Yeah. And so for me, if I see a patient and they’re still having pain, I would say a week later and they’re like, you know, Nekky, you told me it was going to get better. It’s getting worse. Okay. So now I want you to play this game.

Cause this is a common problem we all see. And we’re at this like decision making crossroad, right? And we’re like, okay, the patient is swollen. They’re in pain. Are they having an infection? Are they having a dry socket or is this normal? And it took me a while to like, you see enough patients and you’re like, how do you decipher between an infection, a dry socket, or if this is normal? Do you know what I mean, Jaz?

[Jaz]
Oh, totally. Totally. This is a daily experience for dentists taking out teeth. When you have that patient come in and there’s possible diagnoses and it’s important because the ramification is antibiotics indicate, can you justify it or not?

[Nekky]
Yeah. Yeah. Okay. So before we even get to this, cause I think this is the most important thing I want to talk about is like trying to delineate where we’re at here, right? Like we want to be able to diagnose our patients. The most common thing I see is actually food in the socket. Do you know what I mean?

[Jaz]
Yeah.

[Nekky]
Yeah. And so I guess the question is. And I’m kind of getting to this point here is, is do you irrigate your sockets? Like, do you irrigate your sockets? You give the patient a syringe. Are you telling them to rinse with saline or rinse with salt water that they make at home? Are you giving them a syringe to actually clean inside the socket? What do you do, Jaz?

[Jaz]
Good question. So, in Singapore, I did, actually. And you know what? In the UK, we don’t have, we had a really nice Monoject 1 in Singapore there. And in the UK, I don’t have, we should totally just get one.

[Nekky]
Yeah, the curbs are in.

[Jaz]
Yeah, and that was really good. And I think when I used to work in the hospital, we gave that as well. In practice, I’ve fallen out of habit. So, no, we just give the advice. Okay, warm water, a bit of salt, multiple times a day, especially after you’ve eaten, to make sure the food debris doesn’t get caught. But I think I know where you’re going with it. I think you’re saying that the syringe is the pineapple juice.

[Nekky]
The syringe is pineapple. Yeah. So like you’re irrigating the socket and whether you irrigate with chlorhexine or irrigate with, with saline, you need to get the debris out of the socket. And it’s so funny.

Like I had a patient yesterday, day seven, they’re like, Nekky, it’s not getting better, not getting better. And then I go to rinse the socket in like, it’s disgusting. You’re like all the food you’ve eaten is now at the bottom of your socket. No wonder you’re in pain. And I can assure you, I’m going to call her today and I’m going to be like, how do you feel?

She’s like, Oh my God, so much better. Right. So much better. But this is when the patient comes in, right? You’re like, okay, they have pain. Do they have swelling? And is it a dry socket or is it an infection? Okay. So I always want to remind everyone the three cardinal signs of infection. Okay. Pain, fever, swelling.

But everyone has pain, everyone has swelling, but do they have a fever? Okay. So that’s like a Cardinal sign. That’s how you know it’s infection and also swelling after day three, shouldn’t swelling be going down? If swelling is progressing past day three, you’re like, oh, okay. Could that be an infection?

Is there a fever? You know what I mean? That’s where my brain is thinking. However, when you look in the mouth, if they have a large dark hole, which a lot of people do, you can’t just jump and think it’s dry socket, but like how good is their oral hygiene? Is there a ton of food debris in the socket?

Does it stink? Do you know what I mean? Like, is it extreme pain in their ear down their neck? And there isn’t swelling, like swelling is subsided. There isn’t a fever. Well then I’m thinking dry socket, right? But I want to clarify one thing about dry socket and I’ll explain how to prevent it, but I found earlier in my career, and I’m sure you’ll agree with me.

When I was getting into extractions and it used to take me, a touch longer to take out a tooth and I was pulling on my flap and I was drilling bone at elevate, drill bone, elevate, drill bone, snap, snap, snap, an hour and a half later. Hey, I got the tooth out. I’m a hero, but the patient thinks I’m a bum because it took so long.

And those are the patients that end up with dry socket. So everyone talks about like, the dry socket is the like dissolution of the blood clot, but really Birns hypothesis. No one knows why dry socket occurs first of all, but Birns hypothesis is it actually starts with trauma that leads to the activation of plasminogen that breaks down the blood clot.

And so if we have less trauma on our patients. Patients heal so much faster if you can get that, if you’re in and out of that surgery quicker, well, patients heal faster with less trauma. I don’t see dry sockets anymore, but there’s one thing that, well, I guess there’s two things that really help with that, that everyone can do. Okay. So the first thing is that preoperative and postoperative chlorhexidine rinse. Okay. Do you guys use chlorhexidine?

[Jaz]
I did when I was in hospital, but you know, there was a whole phase whereby everyone was like super scared about allergy and this one person died in the UK from like corsodyl and chlorhexidine and then for some reason culturally we were like really worried about the the allergy risk. So I feel as though from that time the usage went down a bit.

[Nekky]
Really? Yeah. To use that 0. 12 percent chlorhexidine. I actually routinely give it to all of my patients. Whatever I take out a tooth, I get them to rinse with it in the office and then for third molars. I give them a bottle for a week after and it’s actually been shown to have a 40% reduction in dry socket or alveolar osteitis just from chlorhexidine alone.

[Jaz]
I read this as well, and the evidence was better than some of the other things. Like, some of the best evidence we have for preventing alveolar osteitis is the use of chlorhexidine. And I believe I read that to deliver it in the form of a gel after the extraction. Is that something that you use?

[Nekky]
Yep. I use the liquid, but 100% you can use the gel. The benefit of using the gel is when you rinse, you don’t want to rinse the first day postoperatively because you want that blood clot to settle in. You know what I mean? And so if you’re using a gel, you can start applying it right away. So that’s the benefit of a gel, but yes, you can use the liquid. You can use the gel.

I recommend it. I find in my own hands. Like it really works to be honest. I haven’t seen dry socket in years. I think it’s an overplayed overhyped complication. If you can get your patients to keep the socket clean, if you can get in and out of surgery, the best you can, as fast as you can, while maintaining as atraumatic as possible, but you got to abide by your surgical protocols.

Like you can’t be leaving a ton of bone shards and tooth fragments in there, and then like sew it up. You know, call it a day and just run out of the op because that was a fast extraction. No, you got it. You got to be efficient with your extractions, but also Jaz. I’m going to throw something out there.

Maybe we don’t have to be taking on all these cases. If you don’t feel ready to take on this case. And if you feel like this, this extraction is going to take you two hours. Why are you taking it on or you’re better off having that patient see someone else you can do other forms of dentistry. It’s much more profitable for you a much more, you know less stress because there’s one thing I teach everyone and you never lose sleep over cases. You do not. Do you know what I mean?

[Jaz]
Amen.

[Nekky]
If you’re up at night trying to get like waiting for your phone call from your patient because you know they’re gonna be in pain, man, what kind of life is that? You never lose sleep over cases you do not do. If the tooth looks ridiculous, 45 years old, distal, angular, partially, or fully impacted, you know, minimal opening.

Is that really a good use of your time? And as a general dentist, is that something we should be taking on? And are you ready to take on the following three weeks of phone calls and possible dry sockets and delayed healing and, hey, I’m in pain. And don’t go see that Nekky guy. Cause all he does is put me in pain.

I can’t, I can’t recommend it. Like, do you really want to do that? And that’s when you see dry socket is on the patients that you don’t want to get dry socket and it took you forever to get the tooth out. And come on, we’ve all been there. And we questioned why we got into the profession after we walk out of the operatory, because that tooth was so difficult and that’s when we see dry socket, you know what I mean?

[Jaz]
I have a lot of reflections on that because I’m a big fan of moving out of your comfort zone. But we shouldn’t move beyond our comfort zone. We should be at the edge of our comfort zone and that’s where mentorship comes in and the big C word here is case selection right? We as general dentists have the most difficult job in dentistry.

Like all the specialties, right? General dentist is the most difficult. And so we need to utilize our one trump card, our one saving grace, is that we get to be cherry pickers. We can pick the most luscious and red and nice cherries and all the rotten cherries. We can send to a specialist we don’t like, okay?

And that’s okay, right? There’s a place for that, okay? Obviously I don’t mean that, tongue in cheek, right? I always joke, send to a prosthodontist you don’t like. I always make that joke, but you know what? It’s just a point to make that, it’s really tricky to be a general dentist, so let’s enjoy the fruitfulness of being able to refer the ones, sometimes you know what?

On the Protrusive Guidance community, I posted about referring and what’s your threshold and that kind of stuff. And a lot of the experienced colleagues that said the following thing, Nekky. Often it’s not the procedure that scares them. It’s the patient that is attached to the procedure. And that’s why they’re referring.

[Nekky]
I totally agree, man. You pick and choose your patients that come with the procedures, right? So it’s the patients that you have to manage, someone comes in with their arms folded and they don’t want to be there. And I’m scared. And they’re aggressive.

They play the whole, like, if you hurt me, I’ll hurt you type card. They have a really hard tooth to come out. Like, man, do you really want to take on that case? Or would you rather take on like, someone that wants to work with you and if you ever did end up with a complication, you’ve explained it to them and they want to work with you.

They don’t want to work against you because the other thing that I’m a huge fan of, like I said, number one, you never leave sleep over cases you do not do, but patients do much better with explanations than they do with excuses. And so what I mean by that is like, if you take the time to explain to someone, Hey, Mrs. Smith, when we take this tooth out, there could be a possibility of you having a tingly feeling in your lip or chin, and that could last for a couple of days, a couple of weeks, a couple of months, a couple of years, I don’t know, I can’t control the position of your tooth in relation to your nerve.

However, if this happens, there’s some things we can do, but a lot of the times it’s variable. We don’t know. Do you understand that? And they’re like, oh yeah. And you know, Nekky, I fully understand you didn’t put the tooth there and I’m coming to you later in life to get it out. I expect those things to happen.

But if that patient came in after, you took the tooth out, you get the text three days later. Hey, Nekky, is it still normal for my lip to be numb? How long is this freezing going to last? And then your heart just starts pumping, right? And your stomach falls into the floor and you’re like, oh, here we go.

And then the patient’s mad at you and they could become litigious and they’re like calling their lawyers saying Nekky messed up my face. And I don’t want that ever to happen to any dentist because we don’t control the position of the tooth in relation to the mandibular canal.

However, sometimes patients feel that it’s something we did wrong, right? So, patients do much better with explanations than they do with excuses. Take your time, talk to your patients. I spend sometimes more time talking to my patients than the entire procedure. So, like, but patients aren’t mad at me. I pick and choose my patients, man. I refer risk and I refer patients.

Interjection:
If you want to check out Nekky Jamal’s Wisdom Tooth course, which both me and Ali have done, and we highly recommend, check out protrusive.co.uk/thirdmolarsonline. That way you get 15% off using the coupon code protrusive, and this is an affiliate link.

[Jaz]
I love how you talk to your patients. I see your videos and like, I’m in love with the, and only you can do it. Not everyone can do it. It needs to be a certain persona. And so you’re like, you’re given this ID block and like, everyone’s watching you as like, Oh man, I love you. I love you.

Like you’re good. You’re good. Like you’re so, it’s just amazing. Like only you can do that. And it’s just amazing. Honestly. Now you raise a really good point. Like we could dedicate more time to talking about numbness and stuff, but we already talked a lot about that in the previous episode, recognizing the high risk science.

So I will, signpost the previous episode that me and Nekky did where Nekky really summarizes the how to assess complexity and then the different signs you’re looking for, for a high risk of nerve damage. But the key message here is making sure that everyone has an explanation. You make them understand all the risks.

Now, one of my favorite things to do when communication is the following. You make every patient feel special. And I don’t mean like you make them feel warm and fuzzy and special. Like you’re my only patient in the world. Not like that. I mean special in the sense that you make them feel unique because they will remember that for example, if you say to a patient, okay that hey, you know what Mrs. Smith? You grind your teeth. That’s very fast. That’s very, we know it’s a common thing. It’s like, wow, your jaw is actually doing these funny things and that’s grinding and that’s a very special thing that you do, right? And so at the dinner table, like a few weeks later, it’s like, oh, yeah, you know what my dentist told me?

I grind my teeth, for example, or in the context of extractions, right? If you have a slight curve on a root, right? And I would say, look, most people, they got a normal straight root, but you have a banana root. And we know a lot of people have banana roots, but when you make them feel special, they remember that.

It’s like, oh, why? Yeah, that banana root. That’s why the tooth took a long time to come out. So when you make them feel like they’re a special case, it just heightens the, I guess, the retention of the information. It’s just something that works for me.

[Nekky]
Such a great idea. And I heard you say that before and I’ve started to do that as well. And I often say like, hey, Mrs. Smith, did you know that you have a root that’s embedded into your sinus? Like, that’s crazy. When I take out this tooth and you’re going to have a hole in your sinus. I want you to think as if I’m popping a balloon, I can’t control them. And like, they immediately think that, and they understand that.

And they’re like, so like water, when I drink water, it’s going to come out of my nose if I have a hole, right. And I’m like, yeah, we want to prevent that. And we want to explain all these things to help minimize that. So it closes, but like, that’s a crazy route. We don’t see that every day and it, boom, it almost like, it prepares them for the complication, but it also makes it almost acceptable.

Like, Jaz, you didn’t put that banana root there. You know what I mean? You didn’t control my anatomy, but this is what we’re stuck with and thank you so, so much for managing it.

[Jaz]
That’s the crux of it really. And when you highlight this issue to them, they own it, right? And it’s not like an excuse that he was later. It’s something that you can reassure the patients that and actually one of my things I like to do is yes, you tell them the complication, i. e. the curve route, but then you also tell them what you’re going to do to mitigate that. Is that okay? You’ve got a curve route. That really sucks. That’s a really bad scenario, but you know what?

I’m going to carefully split the route so that it has an easier path to come out. That’s how we’re going to navigate it. So don’t worry. We’re going to make sure you’re looked after. That’s my thing to worry about. You just relax, make sure you’re away with the fairies. You’re having a good time. Leave the trouble to me. I’m just informing you what the trouble is.

[Nekky]
Absolutely. I love that Jaz. It’s like you’re giving them a surgical game plan. Now, usually. What I do in these scenarios is I didn’t come to my second reason on how I really mitigate dry socket or alveolar osteitis, and that’s through the use of platelet rich fiber. Now-

[Jaz]
I was waiting for it.

[Nekky]
The PRF. I love it.

[Jaz]
You love it so much.

[Nekky]
I love it, man. I tell everyone like, PRF is like ketchup, it makes everything taste better and it makes your surgery just go a little bit smoother, right? And so the only thing with PRF that some dentists fall into trouble with, they’re like, Nekky, you said PRF is so good.

My patient comes back and like, it’s not good. It’s not good. What do you, like, you’re feeding me lies here. And I’m like, PRF does not change the fact that if you have a crappy surgery and if you don’t manage your tissue, if you don’t manage your bone, if you don’t stick to sound surgical protocols, PRF is not going to help you.

It’s not your superhero, okay? It is going to make your surgery heal faster with sound surgical principles. It really helps the soft tissue. It really, really reduces alveolar osteitis. So all my third molar cases, PRF, or the use of platelet rich fibrin, has actually reduced alveolar osteitis in 95% of cases, according to the research.

Just think about it, you’re putting the fibrin clot right in there. What’s dry socket? The loss of the blood clot. So you’re really helping the situation. But man, patients, they love it. And so many dentists are like, Nekky, you expect me to poke my patients? And I’m like, yeah, because you just stuck a needle this big in the back of their mouth.

What’s the point of like you already, if you can find someone’s inferior alveolar nerve in the back of their mouth while just by basic landmarks, you can feel a vein on someone’s arm. And with a little bit of training, we can show you how to get blood out of there.

You spin it down, you put it right in the socket. It’s all delegatable. Like my assistants are helping me with this. I’m doing the  venipuncture, but like it’s such a no brainer for me and it works so well. Patients love it.

[Jaz]
I guess that’s the barrier of entry, right? Being able to do the  venipuncture, but I love how you say that. Okay, if we’re getting that ID block, then you can do this. I like the way you downplay it and I think we sometimes need that encouragement that we can do it. I’ve done it. It’s been so many years I haven’t done it, but in the hospital I was training, I was doing it regularly. So if I can do it, anyone can do it.

And I think PRF has a place. I don’t use it at the moment, but my principals, they love it as well. When I used to work for implant work or that kind of stuff that they really swear by PRF and the evidence is out there to support it. And I know from your own audits, the low number of dry sockets that you experienced.

Yes, chlorhexidine is evidence based as well, but I think your PRF formula has something to do with it as well, as well as a lovely surgical care that you take, your experience, your, not speed, but efficiency.

[Nekky]
Efficiency. And have you noticed something in dentistry, Jaz? And I’m sure you’ve noticed this. It’s like when a dentist doesn’t do a certain procedure, they always downplay the effectiveness of it. Do you know what I mean? If they’re like, if they don’t know how to do PRF, they’re like, eh, that’s not doing anything anyway. But then when you honestly, when you start using it, it works really, really well as if, if we don’t understand something, we don’t recognize its massive advantage.

So I encourage dentists. Like learn how to do PRF, it’s really helped me in my surgical career. Am I any different than any other dentists out there? Absolutely not. I can’t say I have any different special skills than anyone. It’s just, you get good at something over a long period of time of doing that procedure over and over and over again.

If my patient came to see me to do a veneer or to do a root canal, man, I would butcher that because I just don’t know how to do it as well as the next guy down the street does. So like, I encourage you, if you’re really interested in extractions or if you’re really interested in endodontics, like become obsessed, like become obsessed to the point where you’ve read every single journal article out there, I want you to go home and I want you to dream of it.

I want you to feel like your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to where like you’re working eight hours a day doing clinical dentistry, and then you jump on Instagram at night and start looking through cases.

And then you’re like, I wonder how this works. You’re calling colleagues like dentists. We have such an interesting job. And I just feel so proud to be part of this obsessed profession with everyone here, but like, man, get educated. Just like you said, right?

[Jaz]
I think the sad truth Nekky, is that, what you describe that is really great and that’s what you want, right? We want dentists to be enthused. We don’t want dentists to be working and not feeling like it’s work, but unfortunately, so many of our colleagues are disengaged, they’re not in a good place, they’re struggling, and I think you hit the nail on the head that for me, what I’ve experienced and what I’ve seen from afar is that when you make it your mission or you just find a focus, a passion area to really just a rabbit hole that you can go down on niching.

When you niche down on something, right? I made an episode about finding your niche with Pav Khaira, but I want to make another one called Niche Kebab. So make a Niche Kebab episode, right? And so niche kebab, niche kebab, I know you call it niche, but anyway, Niche Kebab, right? And so basically. Really, you know, yes, when you’re a general dentist, you get to explore everything. But if you can just focus a little bit more on one area, which really, that you can really find affinity towards, and then you grow that area, then suddenly your career just takes a brand new angle.

[Nekky]
Oh, totally. And you enjoy work so much more. And it’s not work anymore. Like, it’s fun. I get to hang out with my patients. I get to do the procedures that I love. I feel like I’m actually providing a service.

[Jaz]
And this could be extractions. This could be clear aligners. This could be endodontics. Even though you’re a general dentist, this could be just endo, which is maybe like, specialist level, but you can still pick and choose what you want and create a little referral network where you are, and you can literally niche down in any discipline. This is like, we have to really appreciate the beautiful side of dentistry. And this is one of the good bits of dentistry that we can actually pick and choose, and then we can actually multiply and grow by simplifying and reducing the number of procedures that we do. And there’s a real magic about that, man.

[Nekky]
Yeah. And that’s the best part about being in general dentist, Jaz. I love it.

[Jaz]
Good old cherry picking. Now, just before we wrap up, there’s a few different points that I hadn’t covered yet. Ice. Like ice is like a standard thing that we recommend post surgery. Tell me more about ice. Like, do you guys-

[Nekky]
I got so much, so much. So, cryotherapy. Okay, ice. I want you to think about it. Okay? You put ice on the side of your face. Yeah, it’ll get the outside cold. So we’re trying to cause vasoconstriction. We’re trying to slow down nerve conduction. You know what I mean? Do you really think by putting ice at the angle of the mandible? It is going to get to your surgical site. Like, do you think it can really penetrate that far?

[Jaz]
Exactly, right? The penetration depth is ridiculous because you got a whole, you got warm blood circling everywhere, kind of counteracting the cold. But I had like, I think it was episode 27 and 28. Well, I had these two physiotherapists, one who’s now become a dentist, and we’re talking about back pain and dentistry. And they were saying when you put ice on your back or something, they said the exact same thing. Well, there’s only so much penetration microns that the very superficial skin layer that’s getting cold. Are you actually benefiting it? So tell me more.

[Nekky]
The reason I still use ice. Okay. So we both know it may not be penetrating to the site. However, the patient is taking an active role. The patient is taking an active role in their healing. And for me, that’s worth its weight in gold. So whether ice works or not, it doesn’t matter to me.

However, I really feel like if patients wants to get better, they’re icing their face. If they’re icing their face, I know that their diet is going good as well. Like they’re not eating nuts. They’re not eating seeds. They’re not sucking down raspberries and getting those little seeds in the sock.

Cause they’re taking an active role in healing. They want to heal faster. They’re listening to all your instructions. So that’s why I always give ice. Cause then people are always taking an active role. Does that make sense, Jaz?

[Jaz]
Oh, totally. Totally. I mean, same thing with analgesics, if you really explain them so well. So, and then they help do the whole thing where they’re alternating ibuprofen, paracetamol, another example, like you mentioned earlier, they’re being active, they’re doing the ice, they’re looking off their diet, and then they’re looking off themselves and that energy will heal them.

[Nekky]
Absolutely. So that’s why I use ice. Now, the question is, is ice better in the mouth or is it better outside the mouth? This really came to a head for me when I took out, I was giving someone a lower denture with a couple implants and I removed six lower teeth and they texted me the next day. I always give everyone my cell phone number.

I know some people don’t, I always do. And I always encourage patients. And I know I’m one of the few ones. However, it really makes patients feel better. I’m a family member. Okay. My patients call me Nekky. They don’t call me Dr. Jamal, I’m a friend. Okay. I’m here to help you with your surgery.

I know there’s a lot of controversy about this and I don’t care. This is just how I do things. And so they’ll text me and they’ll be like, Nekky, I got a problem. And I was like, what? And she’s just like, it looks like I’m wearing a necklace. I’m like, just send me a photo. What are you talking about? And she’s just red, bruising, like purple all the way down here.

[Jaz]
Yeah. I’ve experienced this from just anesthetic. I’ve just on one side, just from getting a buccal infiltration and then to come down and there’s all that bruising.

[Nekky]
Totally.

[Jaz]
Very thin lady, very thin lady by any chance?

[Nekky]
Yep. Yeah. Very, very thin lady. Very loose skin, right? And you’ll see that. And I’m like, okay, well, have you been icing it? And they’re like, well, yeah, I’ve been icing. It hasn’t done anything, but I’ve been eating really hot soup. And I was like, interesting, interesting. So like, are we increasing vasodilation causing bruising, causing bleeding by really hot fluids?

And so I found when I got my patients, I’m like, man, just eat cool stuff for the next two days. Like just eat cool food. Do you really need a hot coffee? No, have an ice coffee, man. Like, do you really need soup right now? No, I have some ice cream. Like, just keep it cool in your mouth.

And that’s another thing patients like they, it feels like they’re healing, man. Like just like when you get your tonsils out, are you giving someone hot soup? You’re giving them popsicles. You know what I mean? Like I find that it all relates together. I try to keep everything cool where it can. If cold is getting to the surgical site, I just think it’s better. And whether ice externally or internally does anything, it just makes my patients feel better.

[Jaz]
Okay. Wonderful. Final thing then. Cause again, we can go on for like three hours talking about everything, but we’re being selective.

[Nekky]
Let’s do it, man. I’m canceling my day. Let’s just do this.

[Jaz]
Oh, I wish Nekky. I wish I’ve got to take my little one swimming, but tuberosity fractures. Okay. So, upper wisdom tooth, like literally two months ago, I experienced my first tuberosity fracture, this big gaping cavity in the maxilla. That I was suturing up, but you know what?

They heal amazingly. Well, the human body is marvelous, right? But at the time you’re like, you’re really bummed out and stuff. But you know what? I really don’t think I could have avoided it because you know how teeth, sometimes teeth are very difficult to remove because they have this like patchy areas of ankylosis.

And so any force that you put because of that ankylosis will go through the bone. And sometimes it’s very difficult to section, especially if it’s like not clearly like divergent roots. So tell me what your strategy, what’s your mind, where’s your mind at in terms of preventing tuberosity fracture. Have you experienced one?

[Nekky]
Oh man, come on, Jaz. We’ve all experienced tuberosity. I’m surprised this far in your career. You’ve only had like one, like you just had, like that blows my mind away. Now I’m questioning. Yeah. Now I’m questioning. I’m like, I can’t even count [overlapping audio] it’s, it’s poor case selection.

That’s what it is. And so, okay. So whenever I see divergent roots on an upper posterior tooth, so like. The very loud, the penultimate, the last tooth in the arch. I’m always nervous. And I’m looking at the tuberosity, man. Can you always tell how dense the bone is from your x ray? No, because it depends, the angle of the x ray.

It depends how strong the x ray beam was going through it. It depends how fat the patient’s face is. There’s so many other factors going on, right? So I’m looking at divergent roots. And I find when I just stick a straight elevator between the second and third molar and turn, and I hear a crack and you’re like, oh, shoot, here we go.

You know what I mean? I want to give everyone a tip. The problem with the tuberosity fracture isn’t always the small chunk of bone that comes with it, because a lot of times it’s small. If you use a lot of force, you can really create some serious damage there. But the biggest problem is when you go to remove the tooth, all the soft tissue is still stuck to it.

And so you just, you’re like, okay, well the tooth’s out. I’m just going to pull it out of here and I’ll suture it up. But then as you pull, you’re going to notice something tear and it tears on the palate. And as you pull more of that tooth coming out, it tears further and further. And now you’re in the soft palate and you’re like, Oh crap, I just need this tooth out of here. It’s literally waving in the wind. He’s either going to choke on the tooth or he’s going to choke on the blood coming out of there profusely. And then you pull more and now you’ve created this huge tear right down the soft palate. And let me tell you, suturing that tear is absolutely brutal. Man.

[Jaz]
I think everyone just held their breath for like the last 10 seconds. Everyone just held their breath as you were saying that.

[Nekky]
You put a mirror back there and they start gagging. So now you’re expected to suture that. Oh my Lord. Okay. So the first thing I do whenever I hear the crack, cause I’ll be honest, I’ve broken my fair share of tuberosities and if you haven’t go look in the mirror and be honest with yourself.

[Jaz]
Remember Nekky, just like in endodontics, we never break a file. We separate the file separated. You never broke a tuberosity. The tuberosity decided to separate.

[Nekky]
Yeah. It broke itself, man. The patient came in like that. What am I supposed to do? Yeah. So like when you have a divergent roots, I’m always nervous. If that bone behind it, man, if the bone is really soft, it’s going to come with it. If the bone is really hard, well, it’s going to come with it too. I want you to be careful of a couple of things. So when you first hear that crack, if you were putting a lot of force, which I don’t recommend, but let’s be honest, some people it’ll happen.

Okay. You put it in a lot of force. If there’s any other piece moving, like if you’re trying to take out the third molar and now the second molar is moving, let’s just back off. Okay, put an arch wire on there. Do not take out the tooth and I want you to refer it to your maxillofacial surgeon.

[Jaz]
By an arch wire, you mean like a rigid, like a trauma splint kind of thing?

[Nekky]
A rigid wire, yeah.

[Jaz]
Yep.

[Nekky]
Yes, absolutely. Just splint it, take it out. The patient isn’t going to be worse off. However, I want you to refer it to that surgeon at that point. As a general dentist, like, there’s obviously a fracture somewhere else going on and I don’t want that to happen too.

Okay, if you can see like the tuberosity moving and you see like nothing else is moving around there, I want you to start separating that lingual gingiva from the tooth. Okay, and do it very gently. This isn’t a race. Okay, take your time, use your periosteal, start to separate that tooth from that gingiva.

So as you start to remove the tooth, that the gingiva is not going to rip at the same time. Okay. Now, something theoretically that sounds so great but is a lot harder to do is what if you thought there was a large piece of bone there, if you tried to use a bur and go behind your tooth and try to actually separate the tuberosity bone from the tooth so you can cleanly remove it.

[Jaz]
So you’re kind of sacrificing the tooth, you’re like drilling into the tooth basically so that you’re not leaning against the bone so much.

[Nekky]
Yeah, and you’re trying to keep that bone there, depending on how large that tuberosity you think it is. As long as the tuberosity is still connected to the periosteum, it’ll heal. Like, it’ll, you can leave it in place. However, in practice, when a patient can open this wide, and you’re trying to get your bur distal to that third molar, good luck, my friend. You know what I mean? Like it sounds so good and you see it in textbooks and you’re like, oh, this is just so simple. And then you feel like a dork when you’re trying to do it and you’re like, I can’t do this.

Like what is going on here? So, do your best. If you hear a large crack and you feel something moving. I’m not like, be careful, but also if you hear a crack and you’re trying to like loosen up that tooth, you remove the lingual gingiva and there’s a lot of pain distal to that tooth.

I’d recommend you stop as well. And if you have the ability to take a CBCT, do it and see exactly where that crack is. Cause if it’s far posterior, you may just want to put an archwire on there and send it to the surgeon as well.

[Jaz]
Could you also put an Essix retainer on that? Like an arch wire followed by an Essix retainer on top as well. What’d you think?

[Nekky]
I’ve never had to try an Essex retainer. I guess you could, like there’s no problem with that at all, but you just want to stabilize it and get it to the surgeon. Cause if it is a far posterior crack, you can cause some damage as well. And I don’t want that to happen to you.

Knock on wood. Luckily. All of my tuberosity fractures, and I’ve taken out some big chunks of tuberosity, none of them have been too far distal. I’ve never had a first or a second molar moving when I was taking out a third molar. In most cases, it’s going to be a small piece of bone distal to that third molar.

I just want you to be careful, and don’t just start ripping out third molars without sufficiently elevating. If you have divergent roots and if the patient has good opening and you’re able to section, or you can try that. I find sectioning upper third molar is really difficult. However, if you need to make a buccal trough to kind of loosen up the tooth, so you’re not putting as much force on the tooth and the tooth needs to come out, then you can do that.

Like say there’s an infection on the tooth and the tooth needs to go. You can make a small buccal trough. You know, when I make my buccal troughs, it’s half on tooth, half on bone. So I’m not removing a ton of bone. I just feel like we can be a little bit kinder to the tissue and I always teach in all my courses when you use the grip and rip technique, you grab onto a tooth and you just wanna rip it out of there, it often leads to a lot of problems.

And one of those problems can be a tubes fracture. So be gentle to your patients because if it happened to you or if you were taken out a tooth on your dad, you wouldn’t want that to happen, right? So why would you let it happen to a patient?

[Jaz]
It goes back to everything we discussed before, you know? Assess the radiograph, tell the patient that, wow, your tooth has got this funky root. Sometimes a bit of bone comes with it. Don’t worry. We got some techniques to manage it, but sometimes they can be quite nasty. And then we need to sort of put a wire there, but listen, this may or may not happen.

I’m just giving you an idea of it. I mean, how far do you go with the consenting for the rarer things, right? And you don’t want to overplay some of the rarer things. So it’s a difficult thing to warn about tuberosity fracture sometimes.

[Nekky]
It is, it is. But the best part about a tuberosity fracture is when a patient’s like, hey Nekky, can you show me your tooth? And you’re like behind the patient with your elevator, trying to chip off the bone and you’re like, oh man, I got it. I don’t want them to see there’s a chunk of bone there. And so. Yeah, no. I stick to the main ones. I stick to pain. I stick to swelling. On the lower, if there’s close proximity to the mandibular canal, I know we could do an entire episode on just that, right?

I tell the patients, oral antral communications, if I’m taking out like an upper second molar, I tell the patients, it’s the common ones. But am I telling patients about like, do you know, Mrs. Smith, I could fracture your jaw here, unless it’s a high risk scenario, which I don’t recommend you take on anyway, like I’m not breaking patient’s jaw.

And so like bleeding. Yes. I talk about bleeding. I just talk about, I stick to the main ones. And if I think, a more serious complication is on the table. I’m not doing the case because I don’t take on cases that where I lose sleep, you know what I mean? And I don’t want you to either. That’s why we have specialists.

That’s why we have people that we can refer to. Remember we refer risk and like we talked about earlier some angry patients. We can refer those to right? But like never take on cases where you lose sleep. You never lose sleep over cases. You do not do. Keep your life simple. Keep your life easy. Live on the edge of comfort. I get it. But don’t push the envelope because you’re not helping yourself or your patient.

[Jaz]
And when you are at the edge, make sure you have enough education, experience, mentorship nearby. That could be virtually through like some of the wonderful stuff you put out there or someone holding your hand is great.

But always, micro steps and growth at a time. Don’t know giant leaps. It’s always one small step for man and keep it one. Don’t know giant leaps of mankind. Yeah, we’re not doing that in the surgical specialty, right? We’re not doing the Neil Armstrong. Okay. Almost said Lance Armstrong, Neil Armstrong.

Listen, so what for the tuberosity, watch out, look at the radiograph, really think, is this a fight that you need to fight? And then the soft tissue is what saved me, right? So I had Chris Waith a long time ago. We talked about tuberosity fracture. It’s And the whole thing about he’s brilliant, right? Moving away that soft tissue lately that saved me. That saved me.

Cause I was able to, I had something to stick the suture back and it healed wonderfully. So that is a real top tip. I’m going to ask you a personal question, Nekky, feel free not to answer this personal question. If you don’t mind. Have you had like a complaint that’s gone litigious? Have you had like someone try to sue you before?

Jaz’s Outro:
Well, there we have it, guys. Thank you for listening all the way to the end. So, this is what we’re going to cut off for those on YouTube, Spotify, Apple. If you want to listen for free, you can. Just head over to Protrusive Guidance. This is the nicest and geekiest community of dentists in the world. And it’s a safe space.

It’s a safe space. You have to be a verified dentist to come on there. And I’ve got all the free content there. It’s also paid content on there if you’d like to. If you want to get CE credits for these episodes, we are a PACE approved provider. So the website for that is www. protrusive. app, that will take you to our landing page, make an account, and then use those login credentials on the iOS app or the Android app.

Thank you though, for those on YouTube, Spotify, Apple for making it to the end. Really appreciate your listenership. I’m really hoping you enjoy this one. I really enjoyed speaking to him. He’s just a breath of fresh air and he’s like just the nicest guy. You can just sense it in his voice. Very knowledgeable and I always learn from him and I hope you did too as well.

Do check out his Third Molar’s online course. For me, it’s the best online course I’ve ever done and I’m pretty sure the Protrusive discount code is valid. It gets you, I think, 15% off. I’ll put that in the show notes. We are an affiliate but if you’d rather pay full price, be my guest, but if you want the coupon code, it is Protrusive.

The website to automatically apply the discount is protrusive.co.uk/thirdmolarsonline. That’s /thirdmolarsonline. And you can see the reviews on other websites. This course is just packed full of videos after videos after videos. Every time I’m doing a third molar, I will go in the video library, find a similar x ray, a similar case what I have, and I’ll just like revise it before I do the surgery.

It’s that good. Anyway, thanks to team Protrusive for helping this together. I’ll catch you same time, same place next week. Bye for now.

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