Dealing with All the Usual Suspects: Blood, Saliva, Large Muscular Tongues and the Gag Reflex

You're listening to the Phil Klein Dental Podcast. Today, we'll be talking to Dr. Ankur Gupta, a general dentist who practices with his wife in North Ridgeville, Ohio. Dr. Gupta lectures frequently on how dentists can utilize simple strategies that make the most common dental procedures easier. So we asked him to join us on our show today to see what he's doing in his operatory when it comes to direct and indirect restorations. He'll be addressing a wide range of patients, including heavy salivators, patients that seem to have an infinite source of blood all stored in their gums, patients that gag as soon as you tell them what you're about to do, patients with tongues that are more muscular and stronger than my biceps. And I assume you're getting the point here. So let's start this episode with a dentist that thinks out of the box and is always looking for a better way to do things. He also promised me that later on in the podcast, he's going to give us an invaluable tip on how to manage gaggers with a very, very interesting technique. Dr. Gupta, welcome to the show. Phil, it's such a pleasure to be back. Thanks for having me. So I really like what you talk about in a lot of your lectures and educational programs that you do. It's really for dentists that do routine procedures day in and day out. And it's important to kind of get rid of the stressors if you can, manage them so that you're happier when you work and you're more efficient and all that. We really appreciate those kinds of tips. And in fact, one of your... webinars is simple strategies that make the most common dental procedures easier. So that whole concept, that whole philosophy of getting through the day and managing things to keep things moving calmly and working through these issues so that you enjoy your career is so important to all of us. So typically, what's your biggest challenge clinically when performing restorative dentistry? So do you mind if I answer with several answers instead of just one? Not at all, however you wish. So I would say that once a week, I'll have a patient who has a pretty strong gag reflex. And for those patients, either I work stressed out or I work faster than I'm supposed to because I'm just constantly worried about their gag reflex. That's number one. Number two is patients who... have poor oral hygiene or just bad luck, their mouths are constantly bleeding or they have a real viscous saliva. That's number two. Number three is patients who are just gross. They're good people. They're decent, hardworking individuals that just for some reason, their mouths are always teeming with bacteria and inflammation. And then I would say... number four is patients whose tongues are so big or their cheeks are so strong that it's just hard to get that tissue out of the way in order to, without stress, work on teeth that are normally kind of shrouded by that tissue. When you have those patients that are coming in, I'm sure before they sit in the chair and before you go in that operatory, you know, okay, the next half hour or 45 minutes of my day is going to be kind of rough. Is that the kind of attitude you have? What's the proactive move that you make to obviate that discomfort, that stress that would kind of put a downer on that procedure? So let me start with the gross patient, the patient who, no matter how much they listen to our advice, how hard they try, how... they are in their desire to be compliant. Every time they come in, there's just bacteria everywhere. There's blood. The tissue is inflamed. It's like little red water balloons all over. Those patients, I know for sure, if I'm going to do restorative work, that's going to be predictable for me. I'm so worried, you know, just any tiny little misstep on my part. And there's going to one of those water balloons are going to explode and there's going to be blood everywhere. One particular solution that I was introduced to only about four years ago, but I wish I was introduced to earlier, is a product called Perio Protect. It's basically athletic mouth guard that people put hydrogen peroxide inside and they wear it every night. And it's just like the person who is, maybe they have limitations in their ability to be thorough with brushing and flossing. This takes away all those limitations because literally it's just wearing a tray. Anybody can do that, you know? And I've seen, it's like a magic wand. It has taken patients who are perpetually gross, visit after visit after visit, and their teeth, their mouths are just pristine. And it just allows me to do dentistry better. Right. But if these patients were on regular recare and they came in and visited your hygienist, would they not be able to be in the same state as far as the gingival health? So in some cases, yes, but I think all of us have had experiences where we're like, gosh, you're coming in every three months and you're still gross at that three month appointment. I mean, maybe if they were on such regular recare that it was like once a week or something like that. No, you don't tell them that, right? You're telling me that. No, no, but sometimes- Good, because that's- I know, I know. Not a way to build your practice, but you're basically letting them, know that you're aware that their home care is lacking because obviously their home care compliance is lacking, right? If they come in every three months and they come back and they've got that mouth that you're now describing as being gross, they're not doing it much at home or there's a genetic factor involved. Some people are very not prone to periodontal disease genetically and some people literally could go to the dentist four times a year and lose their teeth by the time they're 40. That's just the way, but you're excluding those fringe cases. You're talking about those patients that do have regular appointments with you. They're not doing their home care because if they did, they wouldn't have these problems. And then you put them on this perioprotect and it's like magic. It's like magic. And I do, I don't know if I agree that they're just fringe cases, the people who come in every three months, because we can do as much as we can in those three months and really do a nice job. And I don't know when we say they don't comply with home care, I don't know if that means that they're doing it out of laziness or lack of discipline. Sometimes I think people have certain limitations just with their ability to be thorough in general. I like to be able to take a patient and say, listen, here's another option. You know, brushing and flossing haven't served you as much as they could have. Here's another option. And for me, it's just kind of been like a magic trick. It's worked out better than I had expected. And it's much easier for patients to comply with. And it's just so much easier than if they need restorative work. I'm dealing with just a pristine canvas to work on instead of one that I'm worried about bleeding. So that's my solution to the patient whose mouth is... dirty and regularly has bacteria. So what do you do in the cases where those patients come in and you're about to start a restorative treatment procedure and you touch the gums and you start to get some bleeding? What do you do? Do you postpone the restorative treatment and try to get the gingiva under control? Or do you use a laser? What's your protocol in those cases? Rarely will I postpone the procedure. And in some cases, patient's mouth is perfectly fine, but because their decay or their previous restoration is subgingival, I'm going to get bleeding no matter what. I'm going to get bleeding just because in order for me to prep a... margin, I'm going to go under the gums and create bleeding where there wasn't before. And you had mentioned the laser. And I love my laser. I think that it works really well. But there's a little bit of extra work and extra headache involved with the laser. I work out of, in my office, there's eight operatories. We don't have eight lasers. We have two. And so when it's time to create isolation, sometimes it's... It's time consuming to ask my assistant to set up the laser, bring it into the room, get the foot pedals set up and everything like that. That's one thing that makes the laser a little bit of a headache. And then number two is even though the laser is so good at incising tissue without causing bleeding, it still is incising tissue. We're still going to expect that patient to be more sore after a laser is being used. It's still cutting the tissue. It's burning it. And even though I love my laser, sometimes I just don't want to deal with those particular headaches because the amount of bleeding is not enough. But if I do nothing, then I'm not going to get a good impression or I'm not going to be able to bond well. And so I'm faced with, if I don't use the laser, I'm faced with a choice. It's either cord, which I don't particularly enjoy. I don't think many of the dentists who are listening particularly enjoy cord. Do you enjoy? Well, I'm a retired endodontist, so I didn't use a lot of it. But I did use cord. I used a double cord technique. We would dip it in a vasoconstrictor back in the day. And very effective. Very effective. Just sometimes not that enjoyable. Enjoyable for who? For you? For me and the patient. Okay. For the patient. Yeah. For cases where... was bleeding, but I still had a pretty visible margin. I could use something like viscostat or astringent X, and that was really good at erasing blood. But there were times in which, and I would say once a day, maybe once every other day, I'm doing a crown prep or I'm doing a filling, and I need actual gingival retraction. I need to push the gums out of the way, and I don't feel like using cord. Just because I know it's pretty barbaric to jam that thing in there. And then it's something that I don't enjoy. And one product that I discovered pretty recently is something called Voco Retraction Paste. It's made by Voco. And it's basically like a clay-like gel. It comes out of a thin, one of those single-use, almost like what composite comes out of, but with a very thin cannula. And you squirt that stuff under the gums. It goes under the gums really nicely. You have the patient bite on a compre cap for a couple minutes. And then when you rinse it off, my God, it's like magic. I mean, the margins are dry. The tissue is temporarily pushed out of the way. Very similar to the way it worked when you did the two-chord technique. And a lot of times I can get an incredible impression. Or if I have to use adhesive, I have to bond. I just don't have to worry about blood or gingiva getting in the way. You know, when I first learned about it, I thought, okay, I'll use it every so often. Now I would say I use it almost every day because I just enjoy it so much. So let me ask you this. You're able to extrude the material of this VOCO retraction paste under the gums rather easily. So it's basically pretty effortless and easygoing on your hands and wrist. But at the same time, it's strong enough to hold the tissue back. So how does that all work? So it's a two phase. So actually, there's a lot of competitors that are out there that claim to do the same thing. What this is interesting is it's two phase. So upon dispensing, it's in the low viscosity phase. And so it dispenses really easily. I mean, it dispenses almost like flowable composite would dispense. But then when it's and so it goes under the tissue really nicely because it's more it's lower. It's not viscous. And so it's more liquidy. It goes under the tissue pretty nicely. Then during those couple of minutes that the patient is biting on a copper cap, it hardens. I don't know. It dries up or something. But it goes into a high viscosity phase. And so it's more like clay at the time that I come back to rinse it off. How long is that period? About the amount of time that it takes me to go into another room to do a hygiene check or to go into another room to get a patient numb, to remove a temporary crown or something like that. My guess is two to three minutes. I'm sure the manufacturer has an exact amount of time that they recommend. What I would say is realistic in my experience, though, is anywhere between two and five minutes. And they're biting on the copper cap that whole time? They're biting on a copper cap, yeah. OK, and then you come back and what happens then? I remove the copper cap, use, you know, where you put your thumb on the air and water on the air water syringe so that it's like a real high pressure blast of water. I use that to rinse off all of the all of this material, this blue clay like material until it's gone. And then usually I'm like high fiving myself inside because then when I look at my margins, they're just they're beautiful. They're kind of like, you know, the type of margins you see. at ce courses you know where it's just so nice and there's this really really nice uh moat of sulcus around them i know that my scan or my impression is going to look real nice now is okay so you're using uh intro scanning you're not taking you're not using impression material every so often i'll do an impression but most of the time it's a scan right and that's really critical for digital scans If you can't see that margin, then you really can't get a good scan of it. Yeah, yeah. It ends up being really visible, very nice, and the crowns become more predictable this way. And as far as the bleeding, is there something in the formulation of that retraction paste that acts as an astringent? Yeah, so there's this two-phase clay-like material, which is responsible for the retraction, but then it also has an astringent. like kind of mixed in with it. So 98% of the time, when I come back and I rinse it off, it's completely dry. There's no blood. So when you were prepping a crown, talking about indirect restorations, tell us about some of the techniques that you use most often in order to minimize that stress that we talked about in the introduction of this podcast. Actually, I want to tell you about a little trick that I learned. And I learned this just on social media, but I've been using it now for about... About six weeks. And it's been like a complete practice changer. And that's for patients who gag. I saw this just on a social media video. It's not like I learned it at a CE course or anything like that. Gaggy patients. So they're going to give me a hard time with x-rays. They're going to give me a hard time with impressions. They're going to give me a hard time just with me holding a suction. Sometimes like that. They're tough. And it's very difficult for those patients to tolerate and isolate. or any type of isolation mechanism. And Isolite, I love for, I wish gaggy patients could wear an Isolite because they're the ones who create all that saliva who aren't tough to work on. If you take a K-file, just an endophile, oh, you know these. Yes, I know a K-file. Now I open, I just open my eyes. It goes, wow, he's talking my language. So just a size 10 K-file. So a purple K-file or a white size 15. And that, you know, there's like a little line. right between where your chin is and where your lip starts, okay? There's this little line. I'm pointing to it, but I know this is a podcast. So I wipe that little area with alcohol, and then I stretch it out with my thumb and forefinger, and then I pop a K-file right into the skin. maybe five or six millimeters deep. And I'm telling you, it's a total magic trick. So I can... That's an ouch though. That's like a... It hurts. It's about a one out of 10 because I ask all my patients afterwards. I'm like, so how much did that hurt? And they're like, oh, about a one or maybe a two. I'm surprised actually because it sounds like... I mean, it should feel like a little bit like a bee sting without all the allergic reaction pain afterwards. Yeah. I would say so. I would say so. And then once I remove it after the procedure is done, patients are like, oh, that wasn't really too bad. Oh, so you leave it in there? In there the whole time. So what's supporting the five millimeters of the tip of the instrument that's in the skin is not going to hold, that thing's going to be swinging around in the breeze. Yeah. So I have tried to put a rubber dam on a person before, and the frame of the rubber dam knocked it off. So nothing's holding it on. Um, but let's say I put an isolate in, it's just stays in. I mean, there's, I guess I have to be a little bit cognizant with my hands. Um, if I'm putting a fulcrum on the patient's, uh, tooth or something like that to drill on it. But other than that rubber dam experience, it's just stayed in for the duration. So, so this is like an acupuncture concept. I think so. I mean, I don't know enough about it to know the history behind it. So you have, you have this file. sticking out of the patients below the lip in the midline above the chin five millimeters into the tissue um a sterile file and then you you go ahead and cut a crown prep on number 30 and you take an impression with the scanner and do what you do the retraction and do everything you need to take your impression and that file still dangling off their chin yes and they don't gag because of that i'm telling you the gaggiest patient I've ever had, I was able to take a full arch PVS upper impression on her. I needed to. I was doing the type of procedure where that was my only option. And I was able to take a beautiful impression. And it was the type of thing where some of that was kind of oozing down the back of the throat. It was definitely catching some of the soft palate. And she couldn't believe it. I couldn't believe it. My assistant couldn't believe it. It's truly, it's a magic trick. That's why I'm so excited to talk about it. How often have you used this technique since you saw it on? I've done it probably about 30 times in the past two months. And what's your success rate? 100. Wow. I'm not kidding. So I want to make sure that everybody who's listening to this podcast, read our disclaimer about... our liabilities about doing these things we're strictly we're strictly a platform ladies and gentlemen we are a platform an open platform for ideas and innovation so we love dr gupta and we love his idea but we are obviously not endorsing this because i don't know but uh it sounds like a very cool concept but again you know i understand i understand well from from the endodontic standpoint from my profession Not having a rubber dam on and having a file near the mouth, that concerns me. If they do gag and they lift their hand up and whatever happens and that file comes out, they're gagging and there's no rubber dam. But again, the file's outside of their mouth. So it shouldn't be a problem, but you got to keep an eye on that. Yeah, yeah. And it's something that I'm sure that there's going to be a point. Maybe somebody, their hand will come up and they'll push it in further and injure themselves a little bit. And so I understand that. At the same time, I mean, we're using scalpels. We're using matrix bands. We're using a lot of sharp stuff when we're dealing with patients. And this is, compared to those things, much less invasive. The only thing that's different, it's extra oral as opposed to intraoral. And I feel like that's where the hesitation comes. But I've been able to do dentistry that I wasn't able to do before as a result. I've been able to put in isolates on patients that I've never been able to before. And so the quality of the dentistry I've been able to offer is just higher. And so that's why I want people to know about it. That's amazing. That's it sounds like a game changer for you. It's been it's been a game changer. Yeah, that's wow. All right. So we got by that one. Any other techniques? And don't scare us here on these other ones. How about some stuff they teach in dental school? That was the weirdest one. I did want to mention the isolate because I love it so much. But I feel like I talked about it and I feel like isolate their marketing is very strong. I feel like every dentist at least knows about it. For sure. And so that has been that's been a game changer in my office. And again, the same way you were talking about a rubber dam. You know, I do a rubber dam every time I do endo, but I don't do a rubber dam. Sometimes if I'm just doing a class two composite or a crown or something, but we're still dealing. with small bits and pieces when we do those things. And so let's talk about a class two. If we drop a wedge or we drop a sectional matrix band or the shank, the cutting part of our drill breaks off, the cutting part of our burr, having some type of protection for that patient so it doesn't go down their throat, that's something that I, that's a fear I feel like every dentist possesses. we all possess that tiny little fear. Like, well, I'm using a lot of really, really small stuff. Some of this stuff is so small, I'm not going to be able to tie a piece of floss around it. Being able to know that I can protect the back of the patient's throat, especially on a gagger, especially on a person who has a big tongue, strong cheeks, knowing that that back of the throat is protected, that's really liberating for me. And so I think the reason most people don't use an isolate is A, It's sometimes expensive. You know, not everybody is in a position where they can just purchase an ice light for every one of their operatories. That's number one. But number two is sometimes the patient can't tolerate it because their gag reflex is so strong. And that's why I wanted to at least introduce that other weird acupuncture thing, because it has allowed me to place it on patients I've never been able to place it on before. Are there any things that you use to actually control salivary flow, like those kind of pads that go in the inside of the... cheek against the glands, the salivary glands? So because I want to make sure that anybody who's listening to this is learning about stuff that they didn't already know about. I think everybody knows about cotton products, like sticking a cotton roll under the tongue and then something like putting a triangle up against the cheek. But there is a product that I feel like not a lot of people know about. I know one of them is made by a company called Zerk. And then the other one is made by Ultradent. The Ultradent product is called the Umbrella. And I don't remember what the one from Zerk is called. But these are, you know, an Isolite can be cost prohibitive for a lot of people. You know, it's a piece of equipment. And sometimes a person's not ready to equip all of their offices. But the Umbrella by Ultradent. That is it pushes the tongue and pushes the cheek and pushes the lips out of the way. It's a one piece kind of goofy looking thing that is it's rubbery, but it's slightly rigid. So you can you can squeeze it to fit it into the patient's mouth. But then when you unsqueeze it, it kind of pops open and it pushes all of that tissue out of the way. And what's really nice about that is you can still fit a triangle. between the umbrella and the cheek, and you can still fit an umbrella, I mean, a cotton roll between the tongue part and the tongue. And what those do is now they're held in place. Because have you ever noticed, Dr. Klein, with... materials, once they get saturated, they're more of a hustle. They become problematic. Well, you have to change them up. Then you change them up. They have no value once they're saturated. But yeah, you're saying that this technique with this Ultradem product actually stabilizes the cotton product. It holds it in place. And true, you're right. You got to change it once it's saturated. However, sometimes the timing is all bad. You know, it's at the exact moment where you need it to be in place. That's when you have to replace it. Yeah. And replacing it can also throw a whole gulp of saliva on your restoration as you're replacing it, just because the patients. may swallow and the whole works. Yeah, we deal with that all the time. What I like about this is that you put it in the patient's mouth, the patient can still bite down within it. You can't do that with a rubber dam. You can't do that with an isolate. Something like this patient still can bite down. You can check occlusion. You can check to see if you've reduced enough from the occlusal surface. I find this to be really helpful and it's not cost prohibitive. It's something. Kind of like that K-file to make gagging go away. This is something that, you know, most of us can just add to our armamentarium to make things easier. To wrap up this podcast, what is your typical armamentarium in your office when you're doing a restorative procedure for the middle level patient, the patient that falls right in the middle of the spectrum as far as bleeding, salivary flow, gagging? You know, they're not the best. They're far from the worst. What's your go-to stuff? You know, a couple of years ago, it was cord. There was a there was the zero zero cord and then there was the two cord and they were sitting there soaked in the astringent. And that's how it always was. That's no longer the case because I don't particularly like using the cord. Now it's there's vocal retraction paste 100 percent of the time. I don't use Isolite 100 percent of the time because, you know, the mouthpieces are actually quite expensive. But I will use them with a patient that's difficult. And I would say the other thing that I like to have available 100% of the time is an astringent-like viscostat or astringent X. Because there's times in which I don't really need retraction, but I just got to erase the blood. I got to just, you know, it's time for me to bond or it's time for me to take an impression. And I just need to scrub something in there to get the blood under control. The next five minutes, then I'll use something like astringent, but that doesn't do anything to retract. It just erases the blood. And so those two things I would say are, they are part of my normal armamentarium. And I feel myself a little annoyed when they're not there, when they're not available. Right. So for the bulk of your cases, you can do quite well with that armamentarium that you just described. Okay. Yeah. Awesome. All right. Well, listen, Dr. Gupta was a great visit here on this podcast. You covered a lot of stuff. The whole thing with the K file, especially as an endodontist blows my mind, but it sounds like an acupuncture kind of thing. You know, I mean, it's doing something, diverting the neurological system away from the gag reflex and moving it over towards that little tiny nerve response that is being generated from that. sharp little file that's going into their chin again uh it sounds punitive but it's working for you you've done what 30 of them yeah i would say 30 probably between 30 and 40 and you're saying if the patient says it's a one yeah that's a winner no doubt that's a winner yeah the most i've gotten so far is a three a three out of ten Okay. And the patient was still happy because it was one of my gaggiest patients. And so we were able, it was still a win. Again, Dr. Gupta, it's always great to have you as a guest. Always, you always have surprises for us, which we love. And talk to you next time on the next program. We really enjoyed it. Thank you so much. Thanks for having me, Dr. Klein.