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AUDIO - HSP #177 - Mark Bowes
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VIDEO - HSP #177 - Mark Bowes
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Dr. Mark Bowes shares his awesome insights about the new way--the only way aesthetic dentistry should be performed.
Mark qualified from the University of Witwatersrand in 1981. He then spent 23 happy years in private practice in London before ` seeing the light` and returning to Cape Town. He was a member of the British Academy of Aesthetic Dentistry, the American Equilibration Society, and a Fellow of the International Congress of Implantologists, is a registered ITI speaker and has been involved in numerous international Study Groups. On his return to Cape Town he was approached to start the South African Academy of Aesthetic Dentistry (www.saaad.co.za), of which he is now President.
Mark’s passion and focus lies in Cosmetic and Advanced restorative dentistry and he has been involved in all aspects of Implant dentistry. He has pioneered new exciting forms aesthetic adult orthodontic treatments, which has revolutionized the way he practices Aesthetic Dentistry. He has been involved in the Digital Smile Design revolution. Mark continues to travel the world to make sure that he has the best skills available to his patients. He is committed to evidence based dentistry and the practice makes use of the most up to date, state of the art technology to provide beautiful smiles and has lectured extensively around South Africa on all aspects of Aesthetic Dentistry. He is also involved in teaching Aesthetic Dentistry for the Implant Aesthetic Academy.
Mark is the Chairman for the International Federation of Esthetic Dentistry world Congress, which will be held in Cape Town 2015. The Congress will involve world leaders in all disciplines of Aesthetic Dentistry.
Mark loves the outdoor lifestyle of Cape Town and enjoys mountain and road biking, surfing, all forms of diving, climbing mountains and golf.
mark@dwhealth.co.za
Howard: It is a huge honor today to be interviewing my bald beautiful brother, Mark Bowes from South Africa, who's a legend in cosmetic dentistry, implantology. I've heard about, our friend, Ken Sorota thinks you're just probably the smartest cosmetic dentist he's ever met in his life. How are you doing today?
Dr. Mark: I'm doing really well. I have to say, we're a couple of hours ahead of you guys in the States. I've had a full day, and a good day. A busy day actually.
Howard: It's eleven-thirty in the morning here on a Wednesday. What time is it there?
Dr. Mark: It's eight-thirty in Cape Town.
Howard: Eight-thirty pm on Wednesday?
Dr. Mark: Eight-thirty pm in Cape Town. Again, it's a pleasure to be interviewed. I'm so happy to have this opportunity just to share some of the stuff that happens down in South Africa.
Howard: You were, what, twenty years in England too? Correct?
Dr. Mark: I spent twenty-three years in private practice in London then decided that I needed to come and sample some of South Africa. I obviously qualified and grew up in South Africa, so it's been great to come back and share some of my experiences that I learned in Europe when I was living in London.
Howard: Do you ever get back to London?
Dr. Mark: Sorry, I didn't catch that.
Howard: Do you ever get back to London?
Dr. Mark: Yeah. I go back for some meetings and I've still got obviously lots of friends out there. Yeah, I get back pretty much every year. I have to say we live in the lifestyle capital of the world, Cape Town.
Howard: Why is it considered the lifestyle capital of the world? So much outdoors stuff?
Dr. Mark: Yeah. We just outdoor stuff. It's really an outdoor playground. We have mountains. We have sea. We have weather. We have everything that you could wish for if you like the outdoors. It's a great place. It's a small city. We don't have traffic and it's a great environment to work. Lots of cool people and it's got a international feel.
Howard: I shouldn't ask this. This is rude to ask but I might as well do it. What did you think of that whole international deal about the dentist from America going over to Africa, Zimbabwe and shooting a lion, Cecil the Lion?
Dr. Mark: I think that we've had a big campaign against the sort of canned hunting. Hunting in South Africa has been around for a long time but I think we've got to a point where commercially and, I think it's not acceptable on this scale. It's a fine line between what's allowed and isn't. I think lions are pretty cool things. I don't think we need to shoot them and put them on our walls anymore. I think those days are over really. I haven't got a massive opinion. It's more of a opinion on not him or the whole thing, but is it a good thing or is it a bad thing? I don't think we need to kill these things anymore to be honest.
Howard: I thought it was really gross, personally. I like the way you called it canned hunting. It's not really hunting.
Dr. Mark: They lure these guys in. There's no skill to it to be honest with you. In the good ole' days it was tough. It was an equal fight and most of the time you didn't actually pull it off. I think it needed to be brought out into the limelight. It was unfortunate for that poor guy but it was going to be someone and social media were going to jump on it big time.
Howard: Deer hunting and elk hunting is big in Arizona and I've gone several times to watch or take a picture or a camera or anything but I could kill a cow. I'm a big hamburger guy but if you're not going to eat it it doesn't make sense. I want to ask you something that probably you would have the international flare for. Is there a difference in cosmetic dentistry around the world based on customs? I've often been told by many European dentists from Russia, Poland, London, that Americans they like their teeth too white. They like their breast augmentations too big. They look more clown like in the United States. Is there a difference in what a woman finds attractive in cosmetic dentistry from Cape Town to London to the States?
Dr. Mark: I think subtle differences exist but really we speak the same language. I've been in interesting situation. I did a road show with a very good friend of mine from Budapest in Hungary. He's one of the top cosmetic surgeons, dental surgeons in Europe, no question. We prepared lectures and we hadn't exchanged notes and really what we found is that the things we were saying were absolutely the same. I think the subtle differences exist where, certainly I see on social media, some countries like bleached two and some like bleached four and some go for a one, but the principles, the protocols, the way we do it, I think there's no real difference. The materials, and the responsibility that we have to our patients I think is the same.
Howard: I don't like to talk about anything that everybody already agrees on, like two plus two equals four. That's why I like to ask the controversial ones and I don't think I could've gotten more crazy than opening with Cecil the Lion, but I want to ask you another very controversial ascetic dentistry question. It seems like when it's the doctor's own daughter it's always orthodontics, bleaching, and maybe some additional direct composite. Then when it's just some stranger off the street it's peel off the enamel on the front ten teeth and do veneers. Do you see where I'm going? Do you see any of that?
Dr. Mark: I can see where you're going. I see it everyday. It's a massive problem. This is something that this last road show that we did we really just talked minimally invasive dentistry, about another way of doing it. I have a great saying. You'll like it. You live by the bur, you die by the bur. You know? We learn to cap teeth and it's what we like doing but really we have a massive responsibility to our patients. Not only to do the different way but also to explain it to them. I think that the term, controlled failure, comes to mind. In other words, we have to be honest to ourselves and our patients that everything we do is most likely going to fail. It's only a matter of how long it's going to last or when it's going to fail.
The important thing is that if it fails there has to be another option. When I look at the dentistry that's still being done today failure is often catastrophic. That for me is a problem. It's educating not the dentist have to do it better but also the patients, what they need from us. I totally agree with you about the daughter thing.
Howard: I'm fifty-three now and my boys, I have four boys. Twenty-two, twenty-four, twenty-six, twenty-eight, and I want to tell those kids that just graduated in dental school last year that when you go to these cosmetic dental lectures they don't show any of their failures. Then don't show a case where they did ten upper veneers and twenty years later some of the teeth died and needed a root canal. They're often photo shopping these pictures and slides that you see on Facebook and all that stuff. Since they never ever show failures and you have enough high self esteem to talk about failures, if you prepped a hundred women or ten anterior veneers, like we did back in 1987, taking a millimeter and a half off. Twenty years later, if you did that to a hundred women how many of those teeth would have died and needed a root canal or a full coverage crown or a ... ?
Dr. Mark: Put it this way, there's some really cool studies out there and the one study that I looked was done by some Scottish guy Saunders and Saunders, and what they found is that they just had a look at a huge number of Panorex x-rays. They found that twenty percent of crowned teeth had periapical disease. There's a figure that we can think about.
Howard: Doesn't surprise me that the Scots published that. Did you know that they invented wire?
Dr. Mark: Yeah? No.
Howard: it was when two Scottish men were fighting over a penny.
Dr. Mark: That's a great one. that's very cool. It's a massive percentage. Even one for me is to many to be honest with you. Whether it's one or twenty, one is too many.
Howard: How many years have you been doing cosmetic dentistry? Or dentistry?
Dr. Mark: I've been doing cosmetic dentistry for more than fifteen years. My practice now is limited to ascetic dentistry. It's interesting, I suppose, that we talk cosmetic dentistry. The one thing that is different in Europe and American is in Europe and South Africa we follow the Europeans a little bit more, is we like to talk more about ascetic dentistry than cosmetic dentistry. I think it's the same thing. I don't know how you feel about that terminology.
Howard: Right.
Dr. Mark: The last ten years pretty much I've limited my practice to ascetic dentistry. Or cosmetic dentistry. Sorry.
Howard: You're probably being listened to by about seven thousand dentist, probably eight percent of the United Stated. Twenty percent that were asked. All two hundred and six countries that we track download each episode. You don't have much time. You only get an hour of these guys. What low hanging fruit do you think you could tell these guys? By you specializing and have done it for so long, what do you see day to day that you think these guys and gals should be thinking about as their commuting in to work?
Dr. Mark: As I look at my practice and i think about what's changed, the dynamics of what I do now that I do differently, the first thing that comes to mind, it's magnification. You have to work under magnification. That's not negotiable. It's not possible to do the dentistry, and my eyes are the only part of my body that still work properly. That's not negotiable. I have a joke actually when a patient's looking for a dentist, I say, if you go in to your first consultation and you notice that the guy doesn't wear loops then maybe you should think twice about the next appointment. In this day and age, you need magnification. The second thing that's changed massively for me is incorporating orthodontics into every treatment plan that I can where possible. Move a tooth rather than drill the tooth, if that's going to achieve the same result.
You need to up your orthodontic skills, no question, or your orthodontic diagnosis. Whether you do it or not it doesn't really matter. You need to understand adhesive dentistry. You need to understand the bonding protocols. You need to understand rubber dam and those sort of thing, they go hand in hand. In a nutshell magnification, orthodontics, and understanding adhesive dentistry.
Howard: One of the things that I see, my biggest critic of veneers or anterior crowns or ascetic dentistry, is ascetic the French word and cosmetic is the British English word?
Dr. Mark: Yeah. In England they've got both an ascetic academy and a cosmetic academy. I think one is a little bit more commercial. The cosmetic is a little bit more commercial but they mean the same thing. It's the same language.
Howard: Ryan, could you check that? I think ascetic might have a French word. One of the things I see, what you said about orthodontics is a principle often abused in ascetic cosmetic dentistry is what we were taught. The bmw, the biological minimum width. A lot of times you have crowded teeth on the front that you're shaving down for veneers. If those roots almost touch there's not enough bone there to be healthy to have a defense against periodontal disease and pathogens and you need about a millimeter and a half bone in-between those anterior teeth so that they can survive when the patient is going to be fifty, sixty, seventy, eighty, ninety. Unraveling it is better long term. I love what you started with as dentistry is controlled failure. Live by the bur die by the bur.
Dr. Mark: That's the way it is. In simple terms.
Howard: I want to get specific on adhesive dentistry because I still think the biggest mistake I see in adhesive dentistry is dentists are smarter than these billion dollar companies. They mix and match materials. They use a bonding agent from this company and an adhesive, they mix and match and I always humility, the number one trait among successful dentists. They listen. They listen to the manufactures. They listen to their patients. They listen to their staff. So many dentists are arrogant. It's like, so this was admitted by 3m and they have sixty phd researchers that have phd's in organic chemistry, but you know more than them. You're mixing and matching the deals and you just know everything. What exactly do you use in adhesive dentistry. What product? What bonding agent, and why?
Dr. Mark: I tell you, are we now going to talk about cements or we going to talk about adhesive? If we're talking about cementation and we're talking about, because when we're chatting up about now, veneers, porcelain and bonding, I'll mention one other thing that is key to controlled successes rather than controlled failures, is enamel. There's no question.
Howard: Is it what?
Dr. Mark: Enamel. The enamel of the tooth. We have to preserve it. Whether we move the teeth and then prep it, there's so much research out there. There was a great paper that was done by a very good friend of mine, [inaudible 00:15:22], and Christian Coachman, and Kelly Marta. They showed absolutely beyond doubt that the longevity of these restorations depends on the enamel that we're bonding to. It is the most predictable bonding substrate to bond to. We need enamel. That's for sure. My preference these days is the universal bonding systems because it allows us to make a decision whether we go down the total etch, whether we go selective etch, or whether we use the self etching adhesive system. It gives you great flexibility. It's taken a lot of the confusion out of all the bottles and the bond strengths are without doubt as strong as they need to be, particularly if you're preserving enamel. That's the key to the bonding systems that I like to use.
Howard: Which brand are you using?
Dr. Mark: At the moment, for my cementation I love the new Ivoclar products, I have to say. The prime etching bond and the ascetic [inaudible 00:16:35] dual care, light care. It's such a simple process. When I used to bond veneers, you know what it's like. We had umpteen bottles all over the place and you had to really get your mind in gear about whether you put this liquid on for this long and then you had to rinse it, dry it, put it in an ultrasonic bath, then clean it, then wipe it, then blow it, then spray it. It was really almost impossible to get this whole process right. They've simplified it and again you're right. I trust the r and d from these companies. You can't look at something and say, it looks too simple or it's not going to work.
Obviously a lot of these products we need to wait five or six years down the line to see what is going to pan out but their r and d departments of the likes of Ivoclar and 3m are going to do good research for us. These days, I had to say I used to use the 3m products. It's a fabulous product. Again, the universal bond, the scotch bond universal and the RelyX Ultimate but I've switched because I'm a big UMEX fan. If I'm doing indirect restorations I'm a UMEX fan. I'm not getting paid by them, sadly but it's a great product. There's no question.
Howard: You graduated from dental school in '81, right?
Dr. Mark: Yeah.
Howard: In University of, how do you pronounce that? Witwatersrand?
Dr. Mark: Witwatersrand.
Howard: What country was that?
Dr. Mark: It's in Johannesburg, in South Africa. Yeah?
Howard: A lot of the listeners weren't born then, I'm sorry to say. When you go into these dental school classes, every time I go into to lecture to a dental school class I'm always thinking it before I get in there. I'm always going to think, don't be shocked when you see how young they are. Every time you walk in there ... oh, my God. I walk in there like, oh my God. You guys are going to be doctors in a year? You look like you should be on a swing set on a playground, but walk these kids back through that journey because when we started doing cosmetic dentistry in the 80's there was a lot of sensitivity from bonding, and a lot of these instructors were saying that it was all our fault.
We didn't have the rubber dam on right. We put too much or too little. We dried it too much. We didn't dry it enough. It was always our fault and we all believed it and what I did is I started going to these dental lecturers who never had any sensitivity. I started going to their dental office and then while they were in the middle of procedure I'd walk up front to the receptionist and I'd say, show me. I'd start looking up records and I'd start asking the receptionist and calling patients, did you ever have any sensitivity? They'd be like, oh my God. I was eating ibuprofen for six weeks and I quite taking ibuprofen because my diarrhea from the ibuprofen was so bad I had to decide what hurt more, my mouth or my butt.
Then I'm going back and say, that's amazing. You just lectured to three hundred people and you never get any sensitivity and every single person I call, and some of these people had got refills on Vicodin three times. It really changed. The chair side chemistry set changed. The sensitivity went away. To me, I'll always believe it was a manufacture problem in the 80's and the 90's and then they solved it. Do you agree or disagree with that assessment?
Dr. Mark: Listen, I agree. If I just think back over the last two years that I can think clearly about, there's no question. I wouldn't say I don't sensitivity but I literally can't remember the last time I had sensitivity. For sure the bonding systems are much better. We conceal the dentin in a much better way. We understand the process. There's no question our products have improved dramatically.
Howard: What is the microscope behind you we see right now?
Dr. Mark: This one here?
Howard: Yes.
Dr. Mark: It's just a little toy of mine for seeing better. It's the magnification we talked about.
Howard: What system is that? I can't read the blue.
Dr. Mark: It's a microscope called Zumax.
Howard: Zoomax? Z-o-o-m-a-x?
Dr. Mark: No. Z-u-m-a-x.
Howard: What magnification do you like with that?
Dr. Mark: I have to say, I don't do any endodontics because I do such good minimally invasive dentistry that my need for endodontics is almost gone. Interesting, there was a conference just recently in Europe. I think it was done by Pascal Manya and the whole theme of the conference was a world without root canal treatments. Now we're talking about minimally invasive dentistry. I like to work between five and eight, times.
Howard: That is just amazing to be able to see something five or eight times larger.
Dr. Mark: It's another world. I said, you cannot do this without these things. It's not possible.
Howard: How much did that cost?
Dr. Mark: This cost? This is a great system, I have to say. This one cost about twenty thousand dollars.
Howard: Twenty thousand dollars? What would be the website. Www. What?
Dr. Mark: Zu.
Howard: Zeg u? You mean, z?
Dr. Mark: Yes, I'm sorry. You guys say z, we say zed.
Howard: You say zed?
Dr. Mark: Zed? Yeah. In England they say zed.
Howard: Z ...
Dr. Mark: Zumax.
Howard: Zumax?
Dr. Mark: Yeah. Zumax.
Howard: The British call the letter z a zed?
Dr. Mark: Zed. Yeah.
Howard: Zed. Is that where Led Zeppelin comes from? That is just amazing to to look to.
Dr. Mark: That's full HD. That's got full HD capacity. We have a feed onto a HD screen. This is the full package. That's twenty thousand dollars for the full monty.
Howard: What country makes that?
Dr. Mark: Would you be surprised if I said China?
Howard: The Chinese are making those?
Dr. Mark: Yeah.
Howard: Fantastic.
Dr. Mark: I'm pretty sure it's China. Put it this way, it's somewhere in that region. I'm pretty sure it's from China.
Howard: Actually when I go into dental manufacturing companies you really can't say it's made in that country. When you talk to any country, anybody making anything, they say, yeah, we assemble this bonding agent but this chemical is from Switzerland, and this chemical's from Sweden and this chemical from Japan. They saw thirty thousand components are assembled in a car and they come from literally fifty countries when they assemble a car. A lot of dentists I know, in fact the closest friends I know in just my neighborhood, my zip code, 8504, who actually bought a microscope like that actually did it for their neck first. They just couldn't lean their head over anymore. They had so much back pain and shoulder pain. They did it for ergonomic reasons.
Dr. Mark: A hundred percent. If you look at the posture and your position we have to look after ourselves, us guys who are getting old. It's amazing how much better you feel after a day of microscopic dentistry but I have to be honest, with the restorative dentistry that I do I still have my loops. I work between the two. I wouldn't say that I do absolutely everything with a microscope. Maybe I haven't been using it long enough. It's quite new in my kind of work, per se, but yeah, it's a great tool.
Howard: I'm always thinking of what is the most controversial I can ask you? This is the next one.
Dr. Mark: Gone ahead. You're fine.
Howard: What I like about it is the whole mission of Dentaltown, when I saw the internet come out, in 1998 for me, I said, no one ever has to practice solo again. The reason podcasts are so popular as opposed to a lecture is because they're multitasking. They're listening while they're driving to work. They're listening while they're commuting on the plane to work.
Dr. Mark: That's the idea, I have to say. You've done some great ones and I've listened to a lot of them. Well done.
Howard: You were a member of the American Equilibration Society and I can't think of anything more controversial in dentistry than occlusion.
Dr. Mark: [crosstalk 00:25:31] me that.
Howard: Many dentists say that occlusion is the religion of a dentistry. Everybody has a different guide. everybody just believes things and they can't prove what they're saying. Why were you a member of The American Equilibration Society and what are your thoughts about occlusion from 1981 to 2015?
Dr. Mark: I've simplified the whole idea of occlusion over my time that I've been working as a dentist. We used to look for problems in occlusion that often weren't there, is my first thing I would say, is we really tried to make it difficult for ourselves. These days, there are certain things that if we're doing rehabilitations for patients that we do a relatively large amount because of all the wear cases that we see. Certain fundamentals that we need to look at are, that we need guidance. We need some kind of guidance system. Canine guidance is the greatest and anterior guidance needs to be established when we are providing any anterior restorations and posterior restorations for that matter.
A lot of cases failed because the guidance issues haven't been dealt with. The big debate about centric relation, centric occlusion, I have to say that I have restored a lot of cases in centric occlusion. Of course you have to look at centric relation and see where it is in relationship interferences, eliminate interferences. Obviously you have to do a full tmj work up and see is there any pathology. If ever I've made a mistake with occlusion it's because I've tried to look too deep into it and to find problems that maybe necessarily weren't there. If we stick to the rules, things like vertical dimension have always been controversial.
There was a great paper that was written by Frank Spear. There are few people over my time that I have respect for and he is one. His feeling was that, for instance, there are multiple vertical dimensions that patients can function at. There is not one vertical dimension. Just you change it because you want to change it isn't a good thing either. Use it if we need it, and we do often in wear cases where we don't have space for restorations. Keep it simple. One hundred percent we need guidance. You need good anterior guidance if your cases are going to last. There's no question.
Howard: Frank is actually about thirty minutes up the street from me. He has done some of the most stunning ...
Dr. Mark: He's a great guy. He's a smart guy. He's a great teacher. There are few people who I look at and I think, those guys I'll listen to anytime. He's really probably on the top of the list. As an educator and just a good mind, someone who actually sees things in quite a clear way. The other thing when it comes to occlusion, the occlusion and the wear and the bruxism and all these things come hand in hand in managing these problems. I can personally say that I've destroyed my teeth over a period of time. Whatever it was but I didn't feel like I had interferences. Yes I lost my guidance.
There's certainly an element of a psychogenic nature to bruxism. We have to, as I said, as a result build in good guidance patterns for our rehabilitations. Otherwise they're going to fail. I have to say that sadly, or not sadly, we have to educate our patients that night guards and wearing of night guards is really a smart thing as well. Whether we like it not.
Howard: What would you say to some of these non dental groups out there in the world, evidence based people, evidence based epidemiology, things like that, that are saying that they thing there's a stress psychosomatic component to five things? Migraine headaches, tmj, lower back pain, irritable bowel, and heart beating irregularities? Do you think there's a psychosomatic stress association to grinding your teeth or do you think it's purely mechanical engineering occlusion?
Dr. Mark: No. I have to be honest. My feeling is that it's multi-factorial. There's a number of different factors that come into play with it when we look at bruxism as a problem in patients. One hundred percent there's a psychogenic element that's involved there, and a habitual element. Whether it's psychogenic, but it's an habitual thing. It's not a mechanical problem that your teeth don't fit together properly. I don't believe that.
Howard: My teeth are worn down.
Dr. Mark: It's made worse by your teeth not fitting together properly but I don't believe that it's purely because your teeth aren't fitting that you grind them. I don't believe that.
Howard: I don't know when I grinded my teeth. I spent the first half of my life drinking beer and chasing women and then I wasted the other half. I don't know which half I did it. Small attempt at a joke. You're a man who wears many hats. That's probably an under statement if I ever said one. You were also a fellow of the International Congress Implantology.
Dr. Mark: That's right.
Howard: You're a registered ITI speaker. Are you just doing cosmetic dentistry or are you placing implants? Are you only restoring them? Where are you at with implants right now in your journey?
Dr. Mark: Listen, I started placing implants back in '97, which makes me pretty old. What I've learned as I've got older is stick to what you know best. If you look at dentistry and you're going to embrace it and other aspects like the orthodontics, we do a lot of small design cases. I can't keep up to date with the implant side of ascetic dentistry. That's moving so fast. I work with, as far as I'm concerned, and you know what? You got to try to get him own because he's hilarious and he's so smart this guy, was probably the best implantology in the world. Hoey Glackman. He's a magician. When it comes to soft tissue and bone regeneration, which most of our cases need.
I absolutely, I can't do it like he can do it. We have high ascetic demand cases. Our patients are smart. They know exactly what they want. You have to surround yourself with people like that if you're going to achieve the right results. Otherwise there's a compromise somewhere. Yes I used to place them but not anymore. I placed the really easy ones. Put it that way.
Howard: In just the United States for anybody working on another human body in healthcare. Just doctors only work on the human body, there are forty thousand different monthly journals.
Dr. Mark: Oh, my God.
Howard: I know that because I have a dental magazine, Dentaltown, so I've seen this list. I would go back even further into implants. Just to keep up on bone grafting would be a full time job. Just bone grafting alone is ...
Dr. Mark: We've been doing some amazing work. For instance like partial extraction therapy, where [inaudible 00:33:44] we're leaving roots behind in edentulous places. We're preserving bone like we never used to preserve bone before. There's no question that our ascetic cases are going to be much more sustainable long term than ever before. It's moving so fast that you have to focus on one area of dentistry. I chose more the restorative side, not the surgical side. We have a great partnership. I do the design. Hyde does the surgery and then I follow up with the restorative work at the end. It's a team. There's no question that these cases can't be solved by one person. It's not possible.
Howard: We would love to interview him on a podcast. We'd also be beyond honored to get an online CE course from you guys.
Dr. Mark: We'll make it happen. I've got this big conference. I'm running a big conference in six weeks time. When I get that out the way, I'm all yours.
Howard: We put up, i forget the number, I think it's three hundred and forty-seven one hour courses and they've been viewed over half a million times. Five hundred and fifty thousand times.
Dr. Mark: That's fantastic.
Howard: I want to go into this still. Bottom line is you're talking to a lot of dentists who might think they do cosmetic dentistry, they're ascetic dentistry, because they do [inaudible 00:35:08] but they've never ever used a digital smile design. Talk about a digital smile design and what exactly are you using? What software and how does that help you be an ascetic cosmetic dentist [crosstalk 00:35:24] ?
Dr. Mark: Again, if I think about the things that have changed the way I work and the one thing for sure is digital smile design. Came about five years ago. Four or five years ago I met up with Christian Coachman. In fact I was first exposed to it by Philip Gruell at his practice in Istanbul. I have to be honest. The first time I saw it I thought, this is pretty cool but it looks like a gimmicky thing and I'm not sure that it's going to stick around, but wow, I must say that I'm absolutely a hundred percent convinced. We do it for every case. Whether it's a two teeth full mouth rehabilitation.
It's the starting point of the treatment planning. The key thing about treatment planning if facial integration, is that, I can remember the times where you were given models and x-rays and you were told to treatment plan. I cannot do a treatment plan without looking at the face. The face will control the rest of the diagnosis or the rest of the planning situations. It's a facially driven treatment process rather than a tooth driven treatment process. We integrate really the teeth with the face and then we move it forward. What it does is it allows us to work out so many different parameters that need to be thought about during the planning process. The workflow I think that we all know it is the DSD or the digital smile design, eventually takes us to a wax up.
It's a very detailed wax up that we have not just asked any ole' lad to make six teeth with wax on them. This is a wax up that's been driven by the face. We've determined where the teeth need to go. From there you can start to answer all the other questions about bone grafting, about periodontal, about orthodontics. Then it provides us with a communication tool to speak to the other members of maybe a multi-disciplinary treatment case. There is huge number of benefits from using DSD or digital smile design in a treatment planning case. Case presentation, there's so much that we take from it. Once we have the outline or the markup or whatever you want to call it and you're happy with everything then it makes the rest of the treatment process quite simple because really you're taking a design that you've agreed upon, maybe the team, you and the patient and you're just moving it through from the beginning to the end. It's a simplified process of treatment protocol .
Howard: My mother told me I had a face for radio, not TV.
Dr. Mark: You look pretty good to me I must say.
Howard: What brand of this digital smile do you use? Which software?
Dr. Mark: I'm not affiliated but I am about to become affiliated with Christian Coachman. I go down their school. I use their philosophy and their methodology and their software. Those guys are really unbelievable thinkers and yeah, they've done a great job for this process.
Howard: Tell about your meeting coming up. What type of speakers are you bringing in and why are you bringing them in? Are you bringing in implant people? Is it smile design? Is it cosmetic dentists? What's hot and what's not right now?
Dr. Mark: From my side, we've probably been exposed to a lot more implant dentistry over the last five to ten years than other aspects of dentistry. Some of the orthodontics, that's been left out. We're trying to bring that in for sure. Ascetic dentistry is multi-disciplinary. I don't know if you know about South Africa, but the theme of our meeting is the big five. Really that means the big five. Not the animals but restorative dentistry, surgical dentistry, perio, and even endodontics. We're bringing in all the disciplines.
Howard: For our viewers that have never gone to, I went to the Serengeti last year. Explain what the big five is. That's a lion, elephant ...
Dr. Mark: Buffalo.
Howard: Buffalo.
Dr. Mark: Leopard.
Howard: Leopard.
Dr. Mark: Rhino.
Howard: Rhino. I'll tell you what. I thought the Serengeti, I literally was speechless for two days.
Dr. Mark: You know what? When I talk to people about going to the bush I say, I'm not even going to try to explain it to you because I won't do it justice. You got to get there and you got to sample it. It's the noises. It's the smell. It's just something you have to there to ...
Howard: I swear, I'm fifty three now. I've lived half a century on this planet earth. I had no idea there were places like that that still existed. You hear about it. You hear about it. Until you get there you're like, oh my God. I can't believe it.
Dr. Mark: Yeah, that's unbelievable.
Howard: I still remember the weirdest thing ever. We were doing something and I was looking at a tree and then I realized camouflaged in that tree was a giraffe that was about twenty feet tall. Just looking at me. I was staring at that tree probably for a full couple of minutes before I realized it was a giraffe in there looking at me.
Dr. Mark: No, It's amazing. It's something that if you had a bucket list that's got to be at the top of the list to go to the bush, to the real bush, African bush. Serengeti's right up there. It's great.
Howard: What would be the best safari to see in South Africa?
Dr. Mark: What's the best safari?
Howard: Yeah. Or best park to go?
Dr. Mark: We have a place called the Kruger Park which is a huge, it's a government run park. It's for the people. It doesn't cost a lot, but bordering on that area are private parks. We have options really for all budgets which is really a cool thing about the game reserves in South Africa. They're not just for the exclusive people who have got a lot of cash. It depends what your budget is. If you tell me what the budget is I'll tell you where you need to go. We have so many options, I have to say. There's no shortage of really good game reserves in South Africa. Then of course we have Botswana, Namibia, and Zambia. We have so many other places which have also pretty cool places to visit.
Howard: Let's switch gears completely for international viewers around the world. What is it like being a dentist in South Africa meaning things like do you have water fluoridation or not? Do your children drink a lot of soda? Do you have a lot of pediatric decay or not? What's public dental health like in South Africa?
Dr. Mark: Put it this way. I'll have to be a little bit careful. It's two things that really, I'm in a very small niche of dentistry. I'm not really exposed to run of the mill dentistry we're talking about. One thing's for sure. I know if you think about the population of South Africa, it's over fifty million. We have only three and a half thousand registered or just under four thousand registered dentists. You can do the math quickly. We have a huge shortage of dentists in this country. The areas that get effected most are the lower socioeconomic areas. For sure we have a lot of poverty in the country and the basic dental needs of people is neglected to a degree. Dentistry in this country, we have such a big spectrum. We have the best dentists in the world but equally we have a need for basic dentistry which I think I stretched, to be honest.
Howard: It's amazing how the continent of Africa now has a billion people, which is over on this side [inaudible 00:45:03] North and South America combined have one billion but Africa has as many people as North and South America. It's a huge country. Just amazing. It's amazing to see a map when you can see the United States of America and you can set it down in the Sahara.
Dr. Mark: If you worked out how many dentists were in Africa you would be absolutely shocked. This is the population for each dentist and it's not manageable on that scale. That's for sure. I can't give you the figures but I look at South Africa's model and we have way more dentists per capita than any other country. The universities, there aren't enough dentists qualified. [inaudible 00:45:51] left the country, I have to say, that's another issue.
Howard: You're also president of the Ascetic Dentistry Society?
Dr. Mark: That's right. I'm actually just become the first president two weekend ago. As the president I was the founder and the president for the last three years.
Howard: Of The South African Academy of Ascetic Dentistry?
Dr. Mark: That's right. I founded the academy in 2010. We've done really well. We're responsible for a lot of post graduate education. We've held a lot of courses. We hold a lot of study groups. We run a lot of meetings. Yeah, it's a big gap that we've filled.
Howard: Are you using or do you like cad cam?
Dr. Mark: Cad cam is great. I'm not using it at the moment. I use it indirectly through my laboratory and through the orthodontic process where we use digital work flow but I don't have a cad cam machine in my practice. I had one for about four months and a hundred percent we will be using cad cam in the near future. I certainly will scanning it in the future. Whether I'm the person who's going to be doing the milling and staining and glazing I'm not sure yet, but for sure cad cam dentistry [inaudible 00:47:24] here to stay. It's the future of dentistry, there's no question.
Howard: I started in '87 with CEREC one, then I went to CEREC two, then I went to CEREC three. Then it was 3d, then it was bluetooth. I find myself more and more just using the scanning portion of it and sending the image to the lab.
Dr. Mark: If I look at it where it is now a hundred percent I want to scan, I'm not sure that I want to be the guy doing the laboratory side. There are a couple of reasons is that I don't have the time at the moment. My book is [inaudible 00:48:03]. I'm good at what I do. I have to be honest. My technician can do work that I can't do. He's been doing it for twenty years and he knows more than I do from a technical point of view. I'm not going to learn his skills in one month, or in two weekends, or whatever it takes. It's going to take me so long to get as good as he is.
I love the scanning idea and I love the ability to integrate the DSD, the concept now of DSD of taking a scan, taking a photograph, all the photographs, and taking a cone beam a CBCT and integrating all these assets into one and from that doing a design and working out a treatment plan and out the other end comes the orthodontic appliances, the surgical stent for the implants, and the prosthetics for the patient. It's another world. It's just so exciting, I have to say.
Howard: Yeah. You just have to have a lot of extra operatories to be able to give up an assistant for an hour or two to go finish milling, designing, staining, glazing, whatever and so many times I need that assistant for an emergency, a tooth ache, another deal. If I say to a guy like you, a typical business man person in the office and say, Mark, you can either stay here today. I'll just keep you one hour. We'll numb you up, prep the tooth, take an impression, and you'll leave in one hour, then you'll come back in two weeks for thirty minutes or we can do it all today but you'll stay for two hours. Do you want an hour today or two hours today and be done with it? Nine out of people tell me, they're busy.
They're like, an hour? I'd rather come back for the other half. They're looking at their calender. They're looking at their work flow and they just don't want to spend two hours in there and I don't want to have one of my four pillar assistants tied up in a room for two hours. You know what I mean?
Dr. Mark: There's pros and cons. It's not the clear argument. Each person has to look at their own skills and their own practice and the sorts of patients they're treating. I do a lot of anterior cases which are highly demanding and saying that, we do a lot of restorations which are full press, in other words monolithic that aren't glad, which are just stain and glaze because I'm a big fan on the staining, glazing, monolithic portion from UMEX. I can't do what my technician can do. That's what it comes down to. He understands the laboratory side of work in a way that I don't I don't see myself having the time available to learn his skills.
Howard: Correct.
Dr. Mark: I see that as a waste of time. If you had a practice where you were doing lots of single unit posterior restorations, partial coverage, that's a great option.
Howard: Right. Like everything, I notice, on guys our age when you're young everything's black and white. Yes, no, right and left, up, down. One of the first questions I asked you about TMJ, is there a stress related you said it's multi-factorial. As you get older and older nothing's black and white. Everything fifty shades of grey. Everything's multi-factorial. When you're young you're looking for an answer. You're like, am I supposed to go right or left? When you're half a century old you're like, there's a lot of paths you can take here. There might be twenty different paths you can take here. About lab, do you use a lab in South Africa or do you ship it international?
Dr. Mark: I use a lab in South Africa. I have a great technician that I work with pretty much on all my cases. I have one technician that he understands my language and I understand his language. We communicate well. We have a great understanding in how we manage our cases. There's no need for me to ship them out, to be honest with you. The skill level in South Africa is high. For sure.
Howard: On orthodontics are you using any clear trays, like Invisalign or Clear Correct or any of that stuff?
Dr. Mark: Yeah. We use clear aligners in South Africa.
Howard: Do you do that yourself since you're a cosmetic guy or do you have your orthodontist do that?
Dr. Mark: No, I do it. I will say that I only treat adult cases. I don't treat any children for orthodontics. The fundamentals are quite different in terms of what we are trying to achieve and what we're not trying to achieve. That you have to understand. Yes, we do a lot of aligner cases. Whether it's a spring aligner, a inland aligner, or clear aligner, I'm a big fan of these. Just even pre-orthodontic movement for restorative cases. For wear cases it's also, when you have no space for restorations. I don't want to cut teeth. I'll move them to make space for the restoration. I'm a big fan of integrating orthodontics into the [inaudible 00:53:48]. For sure.
Howard: That has really been the biggest change I've seen. I started dental school in '84 and I'm just like, everything with these big monster burs and how fast could you prep down a teeth and there was just people out there that they would brag about how fast they could prepare a tooth but basically hitting it with a chainsaw. Now, twenty-eight years later we realize it's just minimally invasive. It's like that, saving the enamel, saving the tooth structure. Anything you could do.
Dr. Mark: It's not another way, it's the only way. It is the only way. There is no other way. That's the mindset. I'm not sure. I might get into some hot water here but I'm not sure what the approach is at dental schools these days, the education process, is it on a minimally invasive or is it still old school? I'm sure that really the attention needs to be on teaching these guys from day one that this is the way it needs to be done. I'm not sure that's [inaudible 00:54:59]
Howard: It's funny because I get so many viewer fan mail and emails from these podcasts and so many of them tell me that they, listening to the podcasts or they're on their iPhone reading Dentaltown in the back row of a boring lecture in dental school. They go, when I'm not learning anything in the lecture I just go to Dentaltown and read during class.
Dr. Mark: What I really enjoy when I do cases like this like the ones I do is really educating the patients, giving them the information. I learned this concept about raising a patient's IQ. I think I got it from one of my American mates, that if you can raise a patients IQ for dentistry anything is possible. I can't tell you the number of times where I see something, we did it like this because the patient refused x y z. I don't buy into that I have to say. If you give an intelligent person all the right options I don't believe that they will refuse something to have their teeth cut down. That's my opinion.
Howard: Bottom line, is this digital smile design, is that more to help you do your ascetic dentistry or is it more a patient communication of getting the patient on the same page. Do you think it's a more patient focused technology or a dentist focused technology?
Dr. Mark: The benefit is for myself massively. It's for the patent also in a big way and it's also a communication tool to any other the clinicians that I'm working with. For instance if Hoey Glackmman [inaudible 00:56:49], the periodontist has a case and he's going to plant some implants he wants to know where the implants need to go. He'll send the patient to me and I'll do a digital smile design. That will then determine that we put in now the teeth in the correct place. From a functional and an ascetic point of view. Once we know where the teeth are going to go then we can decide where the implants are going to go. That's the order that it has to be done.
Then you can explain to the patient why maybe they need some periodontal surgery or they need a bone block or whatever it may be. If they want their teeth in the right place we have to put the implant here. We can't put it over there because if we put it over there which is the easy option possibly the teeth are going to be in the wrong place. There's going to be a functional problem and there's going to be an ascetic problem. It's the driving force behind the treatment planning that goes on. I can't imagine doing a case without it anymore. I've done two or three hundred cases now. Some of them are quite simple. There are some cases you can eyeball and you can see what needs to be done but then there are some complex cases that come into our surgeries where there are a multitude of problems.
You need a starting point. If you start to think about too many things all at once you get confused. This simplifies the process of where you start and where you finish. The thing that comes to my mind is we've become more predictable in our treatments that we provide patients. We understand where we're headed. The end result is already decided before we start. That's the way to make it so much easier for me.
Howard: Like they say, if you don't know where you're going you'll probably get there.
Dr. Mark: Might be painful though. Might cost a lot of money as well.
Howard: It's now nine-thirty at night there and you're a legend and it's just so dang nice of you to stay up for an hour after a long day at work to spend talking to me. I just think you're a hell of a guy, you're a hell of a legend. So many of my dentist friends just think you're the absolute bomb. I think you are. I just want to say from the bottom of my heart thank you so much for spending an hour with me.
Dr. Mark: We're going to be sharing a podium in South Africa I believe possibly next year. Is that right?
Howard: That's right. Yeah, and what I was also thinking is we have an annual townie meetings for the townies. There's two hundred and two thousand townies. I think some day we should put on our thinking cap and try the mix of a clinical dental continual education while they can get out there and see some of these game parks and reserves.
Dr. Mark: They would love that.
Howard: Yeah. Make it a business expense trip or you can go and learn from legends like you and then get out there and see some big five game.
Dr. Mark: Are you going to get a chance to go the game reserve when you come out to South Africa next year?
Howard: Absolutely.
Dr. Mark: All right. If you need some recommendations, you send me an email and I'll tell you where you need to go if you want. That's no problem.
Howard: Absolutely. Africa absolutely has to be the most beautiful continent on earth.
Dr. Mark: It's extraordinary. You know what? I'm so lucky that we live in the most beautiful city in the world. Cape Town and I'm not biased because I live here. I promise you, you come here, and everyday I drive past the mountains and I look it up and I think oh my goodness, it's just the most beautiful place.
Howard: I climbed Kilimanjaro last year.
Dr. Mark: Okay.
Howard: Just to go out there with no cell phone, no work, no phone, just completely unplug from the world and then go out there.
Dr. Mark: That's a great experience. I did it about six years ago.
Howard: Yeah. That's always amazing. Thank you so much for your time.
Dr. Mark: You too. Thank you so much.
Howard: All right. Have a good evening.