Exodontia for Beginners – Extractions via Avocados! – PS012

Protrusive Dental Podcast

Application points, luxation vs elevation, avoiding common mistakes – this one’s an episode that I wish I had when I was at dental school!

How do you know when you’ve found the application point during extractions?

What are the key protocols that can help make your extractions more efficient?

https://youtu.be/rOBPnCTyAwM

Watch PS012 on Youtube

This week’s Protrusive Student episode is all about exodontia – and again I’m joined by Emma Hutchison, our Protrusive Student Ambassador, to discuss some tips and tricks on how to make extractions that little bit easier.

Jaz also shares a memorable analogy—could removing a stone from an avocado be the perfect way to describe an extraction?!

Key Takeaways

Tactile feedback is crucial during tooth extractions.

• Understanding application points can improve extraction techniques.
• Using the right amount of pressure is essential to avoid breaking teeth during extraction.
• Luxators are typically used to sever the PDL before extraction.
• Atraumatic extraction techniques are important for preserving bone for future implants.
• Luxators should not be used as elevators.
• Understanding the mechanics of elevators is crucial for effective extractions.
• The ‘six second rule’ helps in assessing extraction progress.
• Having a plan for extractions can prevent complications.
• Communicating with patients about the extraction process is essential.
• Avoid tunnel vision; consider the surrounding teeth during extractions.
• Breaking interproximal contacts can simplify extractions.
• Always check the patient’s medical history before procedures.
• An audible checklist can prevent mistakes during extractions.

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

Highlight of this episode:

• 00:00 Introduction
• 02:07 Catching Up with Emma
• 05:58 Teeth are like avocados!
• 11:13 Understanding Application Points in Extractions
• 17:01 Luxators vs. Elevators: Techniques and Safety
• 24:10 Extraction Technique
• 25:08 The Six-Second Rule
• 28:04 Having a plan
• 29:58 Common Mistakes and How to Avoid Them
• 38:17 Conclusion and CE Certification

This episode is eligible for 0.75 CE credit via the quiz on below.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 310 Oral and Maxillofacial Surgery (Exodontia)

Dentists will be able to –

1. Recognise essential steps to establish secure application points

2. Develop approaches for patient communication around extraction procedures, potential risks, and expected outcomes

3. Implement the “6-second rule” and other practical techniques to streamline extractions and troubleshoot common challenges

If you loved this episode, make sure to watch Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth [B2B] – PDP085

Click below for full episode transcript:

Jaz's Introduction: This episode on basics of extractions is the episode I wish I had when I was learning extractions when I was a student. But also what I've found from this Protrusive Student series is that so many dentists are listening to them and they're commenting and they're enjoying and they're liking it.

Jaz’s Introduction:
What I’ve discovered is that it’s so good to just reconnect with basics and actually by listening to these kind of episodes you do sometimes pick a few things up or it’s validation.

It helps to validate some techniques, some ideas, some protocols that you’re already using. It’s also a wonderful way to see how far you’ve come. Sometimes we move so far in our career that we forget what it’s like to have those struggles like we did when we were a student. So the reason I gave you that little preamble is because now from this episode, most Protrusive Student episodes, I think, will be eligible for CPD or CE credits.

And so this one is eligible for 0. 75 CE credits or 45 minutes, if you’re in the UK. Protrusive Education is a PACE approved education provider. So that satisfies everyone in the States and the rest of the world as well. The only place to get CE points is on our app Protrusive Guidance. So if you find yourself listening to us while you’re running or while you’re driving or watching on YouTube or on the app, you’re just literally a few clicks away from validating your learning and certifying it so you get a certificate emailed to you by our CPD Queen Mari.

Enough about certification. In this episode, we’re going to give you some real world tips with Emma Hutchison, who is the Protrusive Student. We’ve done so many great episodes just looking into the basics, the perspectives from a student, and Emma had absolutely fantastic questions today, such as, how do you know when you found an application point?

I also give my analogy, my first time I ever gave this analogy, which is how you could liken an extraction to removing a nut from an avocado. I actually think it went really well. Please comment below on what you think of that part, and I won’t take up too much time. Let’s now join the main episode. When we catch up with Emma a little bit, she’s now in her fourth year at Glasgow, and then we get into the meaty bits of the episode.

We talk about how to make your extractions better on Monday morning. The tips I share on here are absolutely timeless, and it will improve your expenditure. Catch you in the outro.

Main Episode:
Fourth BDS Emma. Welcome to the show again for the second season, if you like, of the Protrusive Student Series. Please. How’s it going? How’s fourth year?

[Emma]
Fourth year’s good. I was just saying to Jaz that I’ve not cried yet this semester, which is a good sign. Fourth year’s quite fun now. Like, you are like a little mini dentist. The difference between third and fourth year is you really need to know your stuff. So it’s stressful in that aspect. But, you do sort of have a bit more freedom on clinics and I think the clinicians like to hear what you have to say that little bit more. So it’s fun, but I’ve got my final exams this year.

[Jaz]
Give me an example of what you mean by like, having a feeling like you need to know a bit more. Have you got like a real world clinical example recently that you were preparing for or experiencing clinic?

[Emma]
I suppose, like in third year. It’s your first time seeing patients, like in Glasgow anyway, it’s your first time having your own patients. The clinicians will be a bit more lenient with you and your background knowledge and your reasoning behind why you’re doing things or what you know about your guidelines, all this sort of thing.

You can sort of get away with it but in fourth year when you’re doing your competencies. And you’re having that discussion with the clinician. They will get on with you a bit more if you don’t know what you’re doing. I don’t know how it is in other universities. I know in Glasgow and a lot of other places down in England, they use something called LiftUpp. Have you ever heard of that, Jaz?

[Jaz]
No, never. No, I haven’t.

[Emma]
I can’t remember what it stands for but basically after every patient interaction you’re given scores by your clinician, graded one to six, like one being could cause potential harm to the patient, like not good at all, and six being that you did good whatever, independently.

So, it’ll be communication with the patient, communication with your tutor, infection control, background knowledge, like literally everything. And in 4th year you’re expected to start getting 4s and 5s, some 6s, that sort of a thing. But in 3rd year you can get away with 3s and 4s. So you just need to know a bit more of what you’re talking about, which is the scary bit. It’s fine. It’s all going okay so far.

[Jaz]
Good. I know you were worried about fourth year as being the big one. So I’m so pleased to see a smile on your face and that you said you’re enjoying it, which is really, really important. When you’re in dental school, there’s a message to those dentists out there who are reminiscing about dental school.

Or those who are looking to get into dental school or you’re in dental school at the moment. It’s so important in any phase of life you’re in, right? To stop thinking about, oh, when I qualify or when I this, it’s really important. Tomorrow’s never promised, right? So it’s important to enjoy moments of today.

And I’m so, so, so happy for you that you are looking like you’re enjoying it. So please continue. Remember that learning is a privilege. Learning is a wonderful thing. Mahatma Gandhi said, live as though you were to die tomorrow. Learn as though you’re going to live forever. Have you heard of that?

[Emma]
Yeah. Yeah. Yeah. I have.

[Jaz]
Did I say it correctly?

[Emma]
I think so. Yeah. Yeah. Makes sense anyway.

[Jaz]
Fine. Good. Well, today we’re talking about extractions and with the extractions, we’ll talk a little about the clinical side of things, but also we’ve got your student notes, which you always add to the crush your exam section.

We’ve seen Emma do a lot more on social media. So she’s had a little bit of a takeover on our Instagram and Facebook and the app and whatnot. So if you’re liking what she’s doing, come and join us on the student section of the app or check us out on Instagram. Some of your posts have been getting so much engagement.

Like they’re just basic things, but I think there’s a beauty in the basics. It’s a really nice thing about things that you do day in, day out, checking medical histories day in, day out. And to have that, that’s such an important thing. We see so much composite, beautiful composites, veneers.

We need to see some of the more daily mundane real world stuff. And it’s so great that you kind of made this like revision bit or there’s infographics and stuff. So thank you so much, Emma. With that, I think the engagement has been brilliant, but with extractions, Emma. Tell me, how many have you done?

[Emma]
I think I’ve been quite lucky. 11 or 12 over about 5 patients. I think that’s quite a lot for where I am at the moment. I have been quite lucky with patients.

[Jaz]
Okay. And so really, I mean, I’ve got a few things that I like to talk through, but more important than some of the preconceived ideas I have, I’d love to know what questions do you have? Because what your questions you have are the most valid metric. They’re the ones that the students are thinking about. You are in the midst of being this learner and extractions, a beginner, right? You haven’t have experienced that. You’ve had that glorious feeling of taking that tooth out and be like, yes, I did it. And also must’ve faced some challenges. And so let’s start with that. Have you had a moment where you just couldn’t do it? And then the tutor had to save you.

[Emma]
Oh, absolutely. On most of them, probably. I know at Glasgow when we were doing extractions, probably in fifth year as well, you’re constantly supervised, like you’re never taking a tooth out by yourself.

Well, that’s good because most of the time you need a bit of guidance in dental school, 100%. But the first thing that I wanted to ask you, Jaz, like every single time when I’m taking a tooth out, it’s such a tactile thing, extraction. So I want to talk about how important that tactile feedback is.

So application point, when the tutor is telling me that, like, do you feel that application point or they find it for me and then like, I sort of take over and they’re like, do you feel that application point? And I’m like, no, I don’t know where, I have no idea what you’re talking about. So like, what does that- it’s hard, I think it’s one of those things you need to feel, but like, what am I looking for? Like, what does it feel when you find a good application point?

[Jaz]
I’m smiling. Like those who are listening on Spotify, I’m smiling because this is such a wonderful question. I love it so much. And you know what, today I’m going to introduce an original concept that I’ve never shared before.

All right. And I was always going to like, make an episode about this or a video about this. But now is the moment. Let’s talk about it because it ties in nicely to application point. It’s how we can learn extractions through avocados. All right. So when you cut an avocado in half, okay, and then maybe you don’t do it in half, like you do it like one side is like 55%, one side is 45%, right?

So you maybe think I’m going with this, okay? So you cut the avocado almost in half, right? And you take it off. One half of the avocado will have the seed and one won’t. So the bit that was 55% will have the avocado nut. It’s a better word for it. The nut rather than the seed. Okay, so it’s got the avocado nut inside, right? Now, how do you, Emma, take out the nut of the avocado?

[Emma]
I chuck a knife into it and twist it.

[Jaz]
Aha.

[Emma]
Is that it? I don’t know.

[Jaz]
No, you’re living by the edge. That’s a good way to do it. But have you ever put a knife in it and like, it can slip sometimes? Or when you twist it, are you trying to break the nut? Or are you trying to just take it out whole?

[Emma]
Well, I do it like you chuck the knife in and then it sticks with the knife once you twist it. And then it’s stuck to your knife when you take it away.

[Jaz]
Okay. Amazing. Let’s go with this. Right. So you put the knife in. It’s the knife is now on the nut. Now then you twist it and what do you hope will happen?

[Emma]
That it comes away on all in one piece.

[Jaz]
Okay. Has it ever gone wrong for you?

[Emma]
Yeah, it doesn’t always.

[Jaz]
This is really good where this is going because we can learn so much about extraction. I promise you it’s linked to extractions. Okay. So tell me about what could happen when you’ve twisted it and it hasn’t gone to the right. Just try and remember, what kind of stuff happens.

[Emma]
Like it can start to split, it can start to crack, and then it just falls away.

[Jaz]
Excellent, just like teeth, just like teeth, you try and take it out, you put some pressure, you put some force, it’s a force transfer from your arm to the tooth, essentially, okay?

[Emma]
Yeah.

[Jaz]
Instead of the PDL, we have the avocado itself, the green bits, the soft bits, okay? But now we have, obviously, the nut and the tooth, basically, analogy, and sometimes you put force, but the force transfer, okay? It actually breaks the nut. Why does that happen? Why does sometimes the nut break and it’s not the soft avocado that breaks? Because surely the soft avocado should be mushing away, but it isn’t. So what’s happened there? Why has that happened?

[Emma]
Too much force?

[Jaz]
That’s a good one actually. If you put more force, like if you are using a giant hammer to break a nut, it’s overkill. So maybe, and already lesson number one of the podcast is sometimes when you have a fragile tooth, like a fragile lower premolar with a huge MOD amalgam and extracting it, if you, and it’ll happen to you, it’s happened to me many times.

I remember I was taking a tooth out and I broke it and my consultant was very upset with me. He said, when you’ve got a fragile tooth, you have to grip it. You still put the force transfer. You have to grip it lighter. And then try and sort of twist it basically until you feel as though if you twist any more, the tooth will break.

So you kind of have to respect the tooth basically. So that’s lesson number one, basically the appropriate amount of force. So maybe you put too much pressure and it broke the nut. Basically, what else could it be?

[Emma]
That you didn’t have a good enough grip on the-

[Jaz]
Yes. And it slipped away and it slipped away. So that is akin kind of tooth not having an application point. So an application point, like if you put the spoon, for example, right. Or a knife. Where the nut meets the avocado. Where the nut meets the flesh of the avocado. And what you’re trying to recreate that in terms of tooth analogy is you’re trying to put the luxator in push push push or you get the elevator.

Right and then you do the twist. If you get a nice application point what you should feel is the tooth that you are extracting, you kind of see under loops like lifting up a bit at the same time your instrument is not slipping. And the adjacent teeth, tooth behind it, for example, is not having too much pressure.

They are not seeing that one move as well. That is the ideal application point. So feeling an application point is that you are moving your wrist, moving your hand. And the instrument is not rotating. Like the instrument is sturdy. Because that force transfer is going from your arm, to the instrument, to the tooth.

So that is an application point. You’re feeling that actually, if you were to really go for it, all the energy would get transferred for the tooth, but sometimes you don’t want to put all your might into it because the scenario one will happen again, whereby the nut breaks. And so what you want to do in that scenario, the elevator, is like, gentle, a little bit, you’re kind of getting that tactile feedback, just like you said, you’re really learning a lot from that tactile, and you feel as though that if you’re putting too much, that is, nothing’s really happening, you want to go the other way, and then you see the tooth become more mobile, in the same way that an avocado nut goes mobile.

I’m going to just go with this avocado nut analogy and just say one more thing that extractions actually very easy if you think about it. Okay, fundamentally, there is only two ways to extract the tooth. That’s it. And the same way to remove the nut basically from avocado. Either you break the nut. You make the nut smaller. If you make the nut smaller, you can take it out. Or you remove the avocado flesh. If you literally get a spoon and you gouge out and you sacrifice avocado flesh, you can take the nut out in the same way.

Taking a tooth out is, either you make the hole bigger, i. e. you remove the bone, okay, or you make the nut smaller, i. e. you section the tooth, or you drill into the tooth, basically. And when we think of it that way, you kind of get an idea. Does that help in any way, with this nut analogy, and actually figuring out what an application, does that answer what an application point can feel like?

[Emma]
Yeah, so in my head, I thought an application point was like, I don’t know a specific thing, but from what you’re saying, it’s like a situation. I don’t know if that makes sense.

[Jaz]
It’s a situation. It’s a position that you find, right? Whereby this is sometimes to understand what something is, we have to appreciate what it isn’t. It isn’t when you put your instrument and you’re moving it and your entire instruments moving left and right, and nothing’s actually happened to the tooth. That is not that. It’s not when you’re put your elevator and the tooth and the wrong tooth is moving. It’s not that basically you’re in the exact right place.

In the PDL, where you’re putting that energy force transfer and the tooth that you want to take out is starting to get some energy, is starting to move a bit and your instrument is not moving because if the instrument is not moving, that means actually it’s in the right place to put the force into the tooth you’re moving without significantly damaging the adjacent teeth.

[Emma]
Yeah, no, that makes sense. So like the things that you’re looking for, that’s your application point rather than like one specifically, this is what I was thinking in my head anyway, but no, that definitely clears it up 100%.

[Jaz]
In the same way, like the another scenario for application point is imagine you’re removing a lower molar, two roots, okay? And then what happens is that one root and the crown comes out leaving behind, just one root in there, right? And so in this scenario, have you ever used cryers? Those ones that look like a flag?

[Emma]
I’ve never used them. No.

[Jaz]
So let’s imagine you get a cryer in, right? It’s curved. And then you try to like get the pointy bit. You want it to almost engage in the pulp chamber or something. Or in some piece of anatomy of that remaining root. And sometimes what you can do is you can create an application point yourself. You can get a bur. You can sink it into the root basically. And now what you find is when you put the pointy bit, the cryer, and it will lock inside the tooth.

So before the instrument was slipping, now, because you burred into the tooth a bit, okay. You’re now able to find that the tip of your cry is actually just sits in there. And then that’s an application point because now what you’ve done now, when you twist, okay, the energy transfer will now go from your hand.

To the cryer, to the tooth. Whereas before it was hand to the cryer, but it was slipping. The tooth wasn’t getting that energy. And now that application point allows you to retrieve it. It’s a cool little trick, basically, that allows you to get out a little hole. Basically sometimes having cryer when you’re moving roots is a, is a really good way to do it.

[Emma]
Yeah. So in that situation, you’ve created your application point. Yeah.

[Jaz]
Yes. You’ve leveraged, you create a leverage point, create an application point. So that’s a really, really lovely question. Just to go with the avocado analogy a little bit more, by the way, sometimes, okay, because the initial avocado cut was more like 55%, 45%, okay, the reason why the nut stayed in the one with the 55% cut, basically, is because the avocado was above the maximum bulbosity of the avocado nut.

It’s like the undercut. And so let’s just go around with a knife and you just loosen up that bit of avocado near the top. Then the nut comes off very easily. And sometimes we see the same thing in teeth. Basically, we literally, we just need to just get down a little bit more beyond the applicator, beyond the maximum bulbosity.

And then it can come out. Now, if you see a bulbosity on the root, like you see a root and then out of nowhere has like a bulbosity.

[Emma]
Yeah.

[Jaz]
Have you experienced that yet, Emma?

[Emma]
I haven’t. No, not clinically.

[Jaz]
Massive red flag, okay? They are really, really tough because you can’t get that out, because it’s just like the nut, there’s too much flesh above, right, the undercut. And so what typically happens, that literally the whole tooth, your forceps, your hand is spinning around. The tooth is like feeling like it’s going to come any second and you’re there for minutes, just try and take it out. It’s because of that maximum bulbosity because of that sort of bulbosity. So this is what you can learn from the avocado nut analogy. I’ll stop with the analogy there, but I’m hoping it was useful. I’ve always wanted to bust it out and I’m glad you gave me the platform to use. Thank you.

[Emma]
No, a hundred percent. The next thing I was going to ask you Jaz was the difference between using a luxator and using an elevator. Am I right in saying you would always go for luxation first?

[Jaz]
Yes. So I’m going to ask you, what do you think, what do you think we should be using it for? And if you’re wrong, it’s okay, I’ll correct you. If you’re right, I’ll root for you. Go for it.

[Emma]
I think for, would you usually go for luxation first to sort of tear that PDL and that’s when you’re going down the long axis of the tooth. Is that right?

[Jaz]
Well done.

[Emma]
And then-

[Jaz]
And do you think we’re going buccally and lingually or do you think we’re going interproximally?

[Emma]
I don’t, I know in Glasgow we don’t, well, the students aren’t allowed to use them sort of lingually anyway. I don’t know if normal dentists would use them lingually, but we’re not allowed to.

[Jaz]
Excellent. So good. Anatomical considerations, okay. Lingually, lower is a dangerous area. Why is it a dangerous area? Have you thought about that?

[Emma]
I suppose if you slip, you’re at risk of damaging the lingual nerve.

[Jaz]
Absolutely. If you slip, you can damage the lingual nerve. You can go through the floor of the mouth, you can cause a major bleed, it’s a very vascular area. Absolutely. So, lingual luxation, not really gaining so much, right? Sometimes the bone, right, it’s approximately so thin anyway, okay? And so, it’s just a risky area. And again, buccally, like, what are you achieving? And if you’re a bit too aggressive, you kind of chip away at the most coronal portion of that bone basically.

And so it’s safer, the interproximal bone is more sacrificial. So if you are luxating, you get down and little bits of a granules of bone are breaking away, it’s more forgiving. So yes, you typically go interproximally with a, let’s say to A, it’s safer and B the kind of application point, even for luxation where you’re trying to get down is much easier to get.

[Emma]
Okay. And then-

[Jaz]
Yes, it’s severing PDL.

[Emma]
Yeah. Severing the PDL and that will mobilize your shifts.

[Jaz]
Yes, it will. And it’s kind of in a way that whole term of dilating the socket, right? Like getting some sort of flex basically, it’s kind of doing that as well. We want to be careful with that. Cause we want to make our extractions as a traumatic or least traumatic as possible, basically.

Right. And so there is an art to it. I know many dentists use something called periotomes, okay, for this purpose to really work on that PDL, like, they’re really working on it, working on it, working on it, so the tooth almost just comes out, like, completely clean, basically, like, it just wants to just come out without very minimal force, because you want to not damage the bone, think about it, if you’re putting lots of force with an elevator or a luxator, basically, there’s like micro cracks appearing in the bone.

And so some people are very, very anal about that because they want this very nice environment for their future implant. And so what we can learn from that is always think about excessive force. Always think about, okay, do I need to really do any more? Is this actually benefiting me or am I crossing the barrier of excess force?

Interjection:
Hey guys, just Jaz interfering. If you are a student and you’ve come this far, you need to check out the Protrusive Student section. It’s a student forum on our app, Protrusive Guidance. You can get free access to it. All you have to do is email [e-mail] with some proof that you are a student.

And when you join this community, you’ll get added to that space, but also a bonus space called Protrusive Vault. We have all our Premium notes, infographics, all the goodies that we have to help improve your practice and help improve your learning, as well as that, you get access to the crush your exams section.

I wish I had this when I was a student, it’s all those revision notes that Emma’s been working hard on. The best place to start is www.protrusive.app. And once you made an account, you can actually download us on iOS or Android as well. And of course, if you’re a qualified dentist, this is the place to get your CE credits.

As well as being the nicest and geekiest community of dentists in the world. I don’t put any Facebook ads out there. I don’t market. I only talk about the app to those who listen to the podcast because I find that you are the nicest and geekiest tribe of dentists in the world. And you deserve to be surrounded by really lovely dentists who love to learn, which is what we found on Protrusive Guidance. Back to the main episode.

[Emma]
So taking your time with luxation, and I’ve never used a peritome myself, but I’ve seen other dentists, implant dentists, use it for their atraumatic extractions and things. So it takes a lot of time.

[Jaz]
And they’re taking a lot of time, right? They’re going all the way around. They try and get to that PDL, and they’re trying to really loosen it. The dream for the implant surgeon is to take out the tooth with just a peritome, as much as possible, basically, to loosen it, and that is a very atraumatic extraction. So with the luxator, by the way. Like you don’t want to do typically. And here’s some real world advice. We don’t want to use a Luxator and you want to put in and then start twisting and starting to lift and tooth up.

But in the real world, when you’re in with the luxator and you start to see some movement, okay, you get a little bit carried away. You just flick it and it comes out sometimes. And so it’s not how we should be using it. We’re kind of damaging luxator basically. That’s what the elevators are for.

But in the real world, I think we’re all guilty of doing it. You put the luxator in, you try and get some mobility and you do the other side, get some mobility, and at that point you can either get some forceps or sometimes just do a bit of a twist with the luxator and the tooth just pops out. Cause that’s the only way it can go.

[Emma]
Yeah. And I’ll send you a picture of it. In our introduction to oral surgery, there is a slides that big bold letters that just said luxators are not elevators.

[Jaz]
Yes, yes, it’s true.

[Emma]
Big red writing, so that was drilled into us from day one.

[Jaz]
So tell me about elevators then, how you’ve been taught to use elevators.

[Emma]
So in Glasgow, we were taught your sort of three different ways of using elevators, like your wheel and axle, lever, and a wedge action, those are the three.

[Jaz]
Listen, you’re saying all these things, right? And I don’t remember any of this, okay? So, I’m so far away from dental school now that I’ve got, like I say, the elevator in my hand. I’m just doing my thing from tactile, from muscle memory experience of taking out, thousands of teeth now. And so it’s great. I mean, I don’t expect you to, if you know any of those and you want to talk more about it, go for it. If even you’re like, I’m not really sure what they’re saying. That’s totally cool. That’s a safe place to be. Tell me more about elevators.

[Emma]
So I suppose, would it be right in saying the most common elevator would be a Coupland’s?

[Jaz]
Yes. Yeah. Coupland’s one, two, and three. They get progressively bigger from one to three, three being the largest.

[Emma]
Yeah. So if you’re starting with your luxator and you’re going down that, like the long axis of the tooth, then when you come on to use your Coupland’s elevator, you’re more likely to go at a different angle, like 90 degrees to that, and like towards the tooth. I think you’re more likely to use Coupland’s sort of mesially and distally, is that right? Would you say?

[Jaz]
Absolutely. Yeah. Yep. Yep.

[Emma]
And you’re going to try and get that sort of application point that we were talking about when you go down in between the bone and the tooth and you’re trying to find that good application point and then you’re going to sort of do your rotation and things with your Coupland’s.

[Jaz]
And you start to see if you’re in the right place and it’s a tooth with good anatomy that the tooth will get increasingly more mobility and it just starts to lift up in an ideal world, right? It just starts to lift up and then you can go for forceps to deliver the tooth. Whereas when I was learning extractions, they were so, cause this was second year we were learning doing extractions in Sheffield, right?

And so they were so worried about us using elevators and luxators and causing damage, that we were just forceps only. It’s like, you learn the hard way, just do forceps only, which really is not ideal because the amount of force transfer, you’re more likely to break a tooth. And so luxators definitely are the way to go in the real world. Luxators, elevation, and then delivery with forceps.

[Emma]
Yeah. So how do you know when you have sufficiently loosened a tooth enough that you’re ready to move on to forceps? Like, are you listening for something? Feeling for something? Like, what are you looking for?

[Jaz]
A lot of times with teeth with favorable root anatomy, right? That conical roots without any curvatures, without any bulbosities, maybe they’ve got an apical infection already, therefore the bone quality isn’t very good there, therefore it’s softer. In those scenarios, by the time you’ve luxated, by the time you’ve done a bit of elevation, the tooth is quite mobile now, right?

And then you just know, okay, I’m ready for my forceps and then it’s a nice day at the office. You get to have a coffee afterwards. Sometimes you’re there luxating and the bone is like marble. And then you’re elevating and the bone is like, you’re not getting very much basically, and then you’ve got to think about, okay, can I get my forceps on and start to like twist and try to traumatize that PDL is trying to do.

And so it all comes with experience, but I would say that when you feel as though the tooth is ready to deliver, forceps a good point, or you’re not really making that much progress on elevator. All in all, the best tip I learned, and something that perhaps it’s not easy to relate to as a student, but one thing I can say is the six second rule.

It was never taught to me directly. It was like someone shattered someone and they learned it and then they told me and now I’m sharing it with everyone else. But essentially it’s a six second rule. Have you heard of my, not my six second rule, have you heard of the six second rule?

[Emma]
No, I don’t think so.

[Jaz]
So the six second rule, and actually when, when you join Protrusive Guidance, our app, and then first question in the checklist is, what’s the number one thing that you’ve learned from the podcast? And a few people have said the six second rule actually is the number one thing that they learned.

Essentially, imagine you stick a luxator in. And then you put luxator in, and you’re kind of putting that long axis, and you’re doing tiny little rotations, not twisting so much, but you’re trying to sort of wiggle a tiny bit to try and traumatize that PDL, right? And you’re trying to hopefully get a little bit more apical, half a millimeter, half a millimeter, that’s a good day.

And as you’re doing that, you’re seeing that you’re making progress. And if you’re making progress, that’s good, you continue, okay? And then you go the other side. The six second rule pertains to that if you’re using an instrument or you’re using a technique and you tried it correctly for six seconds Okay, And nothing’s happening.

Literally like nothing’s happening, right? You’re doing it as nothing’s happening. You have to change It doesn’t mean you change the instrument doesn’t mean you change technique, but something needs to change So for example, if I’m using a luxator and nothing’s happening, if it’s been six seconds, I’m going to change my angle, my position, because maybe I’m not there at the ideal application point, okay?

Because I’ve done it before, I learned this rule, and you’ll be there for ages doing the same thing, and nothing’s real. It’s like the definition of insanity, right? I think it was Einstein, right? Definition of insanity is doing the same thing over and over again, expecting a different result, and you apply that to extractions, and you’re there.

Like, you’re there with forceps, right? And you’re there for ages, and nothing’s happening, and your wrist is hurting, your arm’s hurting. You’ve got to change something, either change your forceps or reintroduce a different size of elevator, or in my world, you’ve got to be sectioning, you’ll be raising a flap or whatever it could be basically.

So the six second rule means that if something’s not happening, if you’re not seeing a visible change in six seconds, do something about it. Don’t just continue to do what you’re doing.

[Emma]
Yeah. And I’ve had a situation where tooth wasn’t moving, couldn’t find that application point. And the tutors watched me and he’s like, are you making any progress? Now I’m, no. And he went, well, why are you still doing that?

[Jaz]
Great. It’s great. You’ve got taught that. Very good.

[Emma]
Yeah. It’s like change it up. You’ve got to try something different is what one of those clinicians that are quite, in a good way, quite cutthroat. I was like, yeah, why am I still doing that?

[Jaz]
It’s amazing that you learned that lesson early. Like, so many of us, I’m not going to name drop anyone, but, a dentist that I know very well, he or she is just, refuses to take my advice to start sectioning teeth for whatever reason. And they break teeth and they struggle and very much they’re just doing the same thing over and again.

I’m like, just change it up. Okay. And it’s constantly just be dynamic. And be confident about it. We’re getting some movement here, but actually I’m going to now change technique and it’s going back to one thing we haven’t talked about, which is having a plan for extraction. When I’m doing a crown prep, I have a plan.

I never thought that an extraction would have a plan. I thought the plan was extract the tooth, tick, right? Well, actually, you should have a plan. If this doesn’t work, you’re next going to do sectioning. If that doesn’t work, you’re next going to do this. That was taught to me as a DCT. And that’s the trickier the tooth is, it’s really nice to have like a checklist plan.

[Emma]
Yeah. And I think that’s good for your patient as well. Like not even in terms of consent obviously, but just so that they know what’s going on. That would mean ease my mind a little bit as a patient as well. Having a bit of a plan.

[Jaz]
And I love that you said that because in me to involve our patient that, we tell them, okay, so you’ve got a really tricky tooth here. It’s not going to come out in like five seconds. Don’t worry. As long as it’s not feeling anything. As long as you are comfortable, leave it to our space deep. We’ve got little tricks and tips up our sleeve to get this out. First, we’re going to try it one way and then we may have to just cut the tooth in half, basically.

Don’t worry. You won’t feel a single thing. It’ll sound like you’re having a filling done. And at some stage, the top of the tooth might break off and don’t worry. This happens very commonly because the tooth is very weak. And you just tell them, look, you’re in the driver’s seat. You’ve got everything under control, right? You just put the seatbelt on and leave the rest of me.

[Emma]
Yeah. Yeah. I mean, I’ve never had a tooth taken out. I wouldn’t like to, but I know that if I was a patient, like I would want to know, I’m that kind of person. I would want to know what’s going on. So-

[Jaz]
The worst thing you can do is if you don’t tell the patient all these things, right, and then now you’re like, nurse, can you pass me this? Can you pass me that? And you’re there for ages and you’re like, hmm, I’m now going to start sectioning. Just spend that one minute at the beginning, just telling someone, hey, yours is a tricky one. We’re going to try all sorts. At some stage, you’ll be laying down. Don’t worry. It’s part of the plan. Okay. But the most important thing is you are comfortable and you don’t feel a thing that just that one minute, giving that confidence that, okay, you know what? It’s not going to be just like tape tooth comes out. It’s going to be a bit of a journey with ebbs and flows and that’s okay.

[Emma]
Yeah, I suppose related to that is my last sort of question, which was about common mistakes that I suppose dental students or younger dentists, dentists, whoever, like common mistakes maybe that you’ve come across that are new graduates that they do during extractions and how they can be avoided. Like what advice do you have for students when they encounter a challenging or a difficult extraction?

[Jaz]
Okay, I think the most common mistake you make, which I’ve made before as well, is you just get tunnel vision on the tooth but you really need to take a step back and look at the teeth around, okay. And very often you see these huge MOD amalgams and really fragile teeth, teeth that should have had a cram but they don’t and whatnot.

And you just need to have a plan of how you’re going to mitigate that force going transferred into those adjacent teeth, but also telling the patient, showing the x ray, saying, look, I’m taking this one out. But it’s actually impossible to take this one out without the other teeth feeding a little bit of a bump.

It’s a bit like you’re trying to eat some food and you’re only going to eat on one tooth. No, a bit of collateral force will go on all the adjacent teeth. When I’m taking this tooth out, as I’m twisting it, it’s going to be pushing a little bit on the adjacent teeth. Okay, and that’s okay. But if your tooth has got some decay inside that we can’t see on the x ray, or your tooth is just very fragile, Okay, sometimes a filling comes away.

Okay, if it comes away, we will put a temporary dressing and then we will deal with it. Good strong teeth don’t break, but teeth that already have an issue usually do, it can break. And if that happens, we will sort you out in the future and it can sometimes can alert us to issues that could happen. So just have that conversation beforehand that yeah, this could happen.

Okay, and if you encounter a scenario whereby the adjacent teeth are heavily restored. A really great thing you could do is, now me and you Emma have been working on a breaking contact series basically, which we’ll come to soon basically, but actually just breaking the contact. So imagine you’re taking out a lower right molar, as you would do for a crown prep, you break the contacts, mesial and distal, right?

Except this time you have the luxury that you’re actually removing this tooth, so you can use the big bur and really just go for it. Mow the tooth. Obviously do not touch the adjacent teeth, obviously, but you can actually just get some good practice and just being very, very, practice a crown prep, crown margin, wherever you want, basically just get rid of those mesial and distal contacts.

Okay. You’ve done now two things. At the point of luxating, elevating, and forceps, those interproximal contacts are no longer pushing on the adjacent teeth and transferring the force of the adjacent teeth. And two, the other wonderful thing that you’ve done here is now, because you created space for that tooth, it can actually wiggle around, mesial distal, and rotate without colliding with the adjacent teeth.

And actually you can twist and torque the PDL more because now it’s able, you can imagine the tooth moving about more in a socket compared to when it’s got really tight contacts and it’s jammed. Is that making, can you visualize that?

[Emma]
Yeah, 100%. I’ve never seen anyone do that, actually, but that makes so much sense. Like the tooth is going anyway, so yeah.

[Jaz]
It’s one of those things that I’ve got on my sleeve that if I’m applying the six second rule and a tooth and someone’s got like a bone, like marble, and it’s just not budging, then I know the tooth’s going to break. If I just put more and more pressure, tooth’s going to break.

If you just break the contacts, not only do you protect the adjacent teeth, your extraction becomes simpler. So that’s the number one thing. Number two thing, like I said, is to communicate to that patient as well. And number three, like, I mean, we can dedicate a whole episode to medical history and stuff, right?

And this is not what this episode is about. It’s about actually tips that young dentists and colleagues who struggle with instructions can use tomorrow. And then hopefully everything we’ve said from the avocado to all these tips is usable basically, but just medical history wise, a basic thing is just asking, have you had your breakfast today or have you had some food today?

Because a lot of people, they think that, oh, I’m having a toothache, I better fast or something. People think that, right? And then when you give them the local, and the adrenaline is going, and what are they going to do? They’re going to faint. So it’s always important to check. Okay, have you eaten? Okay, and if they say no, the next question to ask is, is that normal for you?

If it’s normal for them, then that’s cool. But if it’s unusual for them not to have eaten, okay, I’m just going to give him a sugary drink. I make a joke about it. Don’t tell anyone else I gave you a Fanta or get a sugary drink or whatever. But you’re going to have it kind of thing. By the way, I don’t have Fanta in the practice.

I just give them like a glucose mix. Okay. It’s really important. I don’t know why I got a Fanta. So that was my other tip basically to do check the medical history in terms of, that’s fine. And then the last thing is throughout your career, Emma, you will remove potentially if you do the GDP life, thousands of teeth, right?

When you do enough of anything. Imagine the chance of you extracting the wrong tooth is 1 in 5, 000. If you take out 5, 000 teeth, it might happen once. So how can we mitigate that is before I take out any tooth, before I put my probe to check if it’s numb enough or my luxator on any tooth, I will always count.

I will always check the chart. Okay. Upper right six, and I will do upper right four, upper right five, upper right six. And I will just say it out loud, before I do it. Those are my quick wins. That’s sort of like audible checklist, yeah. Yes!

[Emma]
Yeah, the checklist manifesto. Yeah.

[Jaz]
Absolutely.

[Emma]
I mean, it wasn’t anyone that I knew, but I remember speaking to a nurse a wee while ago, and it was a VT’s, like, first day doing treatment in the practice, and it went for the wrong tooth. But it was lucky enough that the nurse spotted it. But it does, I think it can happen, especially under pressure. Like you just get flustered or you don’t know what you’re doing. So just having that other person there.

[Jaz]
And it’s so great for that nurse. But a lot of times nurses are thinking about other things. They think about suction. They think about lunch. They think about whatever, right? So the onus is on you. Responsibility is on you. So if it’s one thing people take away from this episode, it’s just have that audible checklist, upper right 5, upper right 6, upper right 7, here’s my tooth, here’s my target tooth. And that little just automatic thing that you do might just save you one day.

[Emma]
Yeah, for sure. And I mean, I know it’s not really a thing in general practice, but I know in the hospital, like in the oral surgery department, we do the whole, is it the WHO, like the surgical checklist and all your sharps and all that sort of a thing as well, which is good. So it just saves your back as well.

[Jaz]
That’s a really good way to do it. And a lot of this practice I learned from time in hospital, whereby the patient walks in and on the whiteboard, You have like a chart, and then you wrote, you write them the teeth that are actually being removed that day.

And then you took them off as you do it, obviously in hospitals more complex, more teeth being extracted, et cetera. But it’s such a great way to do it. Having the radiograph up, being prepared, having a mental sort of checklist of all things, just foundational.

[Emma]
Yeah. And like you were saying, I know you said at the start, a lot of it’s muscle memory. So I think students can get really quite frustrated with extractions but then when it starts to come I think a lot of students really really like oral surgery and extractions and things they think they’re quite satisfying, quite fun and a good thing to do when it goes well. But yeah, so I just need to tell myself not to get too bogged down over it because like I said I’ve done just over maybe 10 extractions but I’ve not had to do, like, I’ve not been able to do any of them without help, so.

[Jaz]
I think, hopefully, some of the tips I gave today will help you find that application point. Or help you just communicate with your patient those important aspects. What you might struggle to do as a student is say to your tutor, Oh, I think I’m in a section of contacts. They’ll be like, what? We don’t even have hand pieces here.

I don’t know how it works, you know what I mean? So there are some things that you apply in the real world and have up your sleeve, and some things that you just have to oblige in dental school. I’m just putting myself in your shoes, that’s all.

[Emma]
Yeah, yeah, no, 100%.

[Jaz]
Emma, excellent questions as always. It’s great to have you back for another season here. What notes have you prepared for the dental students in the crush your exam section of the Protrusive Guidance app?

[Emma]
So to link in with this theme, obviously, I’m going to go for extractions. There’s bits and bobs in there about anesthetic, your instruments, lots about instruments. I know that’s big for competencies, especially in second, third years, knowing your instruments, as well as your techniques on how to use them as well.

I know we spoke about it briefly in here, but it does go quite into depth about the movements that you’re using with your wrists and your arms. your surgical checklist that we were talking about as well. So loads of bits and bobs about extractions there, just lots of good tips and study notes.

[Jaz]
And there’s a whole plethora of every previous episode that we’ve done so far in the Protrusive Student series. All those have got wonderful from dental materials, which is the very exhaustive they did, crown preps, everything is wonderful, anatomy. So thanks so much for doing all those. And it’s great to see you and it’s great to see you smiling and enjoying your fourth year.

It will get tough, right? Especially when exam season comes around and whatnot, but you can do this Emma, the whole community is rooting for you. And please keep up the wonderful work you’re doing in spreading good, good vibes and good knowledge on social media.

[Emma]
Perfect. Thank you so much.

Jaz’s Outro:
There we have it guys. Thank you so much for listening all the way to the end. Please tell me in the comments, what was your tip that you took away? What was a validation points for you? Or maybe you just want to comment to wish Emma all the best with her fourth year.

As I said, this episode is unusually eligible for CE. When I look back at all the feedback we’ve had from the Protrusive Student series, so many dentists are watching and enjoying, so I thought, okay, let’s certify. So we’ve done the whole quality assurance protocol on the CE, we’ve got aims and objectives, and we’ve got questions. So you have to actually get a high score to be able to show that you learned something, reflect on it, and you get a wonderful certificate sent to you every week.

And then every quarter, Mari will send you your certificates and tally up all the hours that you’ve got with us. So thank you, Mari, for doing that. Thank you to my team. The team is ever expansive. We’ve grown yet again. So thanks so much to all of Team Protrusive for all that you do.

For all the Protruserati out there, we’ve just celebrated recently 300 episodes of Protrusive. So again, I’m so, so thankful for your listenership and watchership, if that’s a word, over all those years. Thank you so much. And please, if you haven’t already told your friends about us, why not? This is how we grow and we really appreciate your referral. Thanks so much and catch you same time, same place next week. Bye for now.