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AUDIO - HSP #258 - Derek Mahony
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• Why treat early?
VIDEO - HSP #258 - Derek Mahony
• Oral habits: thumb, tongue, pacifier
• Correct harmful oral habits
• Improve aesthetics and self esteem
Dr Derek Mahony
BDS(Syd), MScOrth(Lon), DOrthRCS(Edin), MDOrthRCPS(Glas), MOrthRCS(Eng), FRCD(Can),
MOrth RCS (Ed), FICD, IBO, FACD, FICCDE, FADFE
Derek Mahony is a world renowned Specialist Orthodontist who has spoken to thousands of practitioners about the benefits of interceptive orthodontic treatment. Early in his career Dr Mahony learned from leading clinicians the dramatic effect functional appliance therapy can afford patients in orthodontic treatment. He has been combining the fixed and functional appliance approach ever since. His lectures are based on the positive impact such a combined treatment approach has had on his orthodontic results and the benefits this philosophy provides from a practice management viewpoint.
After completing his Dental Degree at the University of Sydney, Dr Mahony proceeded to the United Kingdom where he completed his Masters Degree in Orthodontics at the Eastman Dental Hospital, Institute of Dental Surgery, London.
Further studies led to the successful completion of a Diploma in Orthodontics at the Royal College of Surgeons, Edinburgh. Dr. Mahony has also passed the Royal College of Dentists in Canada post graduate examination in the field of orthodontics.
Dr Mahony has also passed examinations leading to a postgraduate qualification in Dentofacial Orthopaedics from the Royal College of Physicians and Surgeons in Glasgow. He has also attained his Membership in Orthodontics qualification from the Royal College of Surgeons, England and Edinburgh.
Dr Mahony has been seeing an average of 250 patients per week for the last two decades and has gained a vast amount of experience which he can pass on to clinicians so that they can come to appreciate the key elements of his combined treatment approach. He currently has over 4000 orthodontic patients in active treatment and has been a key note speaker at the International Orthodontic Summit meetings, the International Association of Orthodontics meetings, and the American Association of Functional Orthodontics meetings. He is considered by some to be the “next leading lecturer on functional/fixed orthodontics.”
Dr Mahony approaches his orthodontic diagnosis from a “facial profile” point of view. He sets his treatment goals to create not just straight teeth, but beautiful faces and healthy temporomandibular joints. He is a Visiting Clinical Professor at the City of London Dental School and is in charge of their International orthodontic programme.
Dr Mahony is a contributing editor to the Journal of Clinical Paediatric Dentistry, International Orthodontic Journal and Journal of Dentofacial Orthopaedics. A more detailed CV may be found at www.derekmahony.com
Howard: I cannot believe I have the honor today to podcast interview probably the most famous orthodontist in the world, Dr. Derek Mahony. How are you doing, Derek?
Derek M: Good thanks, Howard, how are you?
Howard: I'm sorry that it's 6am in the morning there, just early morning. You're an amazing man, Derek. You're a world renowned specialist orthodontist, has spoken to thousands of practitioners about the benefits of Interceptive Orthodontic Treatment. Early in your career Dr. Mahony learned from leading clinicians at German technology. Functional appliance therapy can afford patients in orthodontic treatment. He has been combining the fixed and functional appliance approach ever since … His lectures are based on the positive impacts such as a combined treatment approach has had on his orthodontic results and the benefits his philosophy provides from a practice management viewpoint.
After completing his doctoral degree at the University of Sydney, Dr. Mahony proceeded to the United Kingdom, where he completed his master's degree in orthodontics at the Eastman Dental Hospital Institute in Dental Surgery in London. Further studies led to the successful completion of a diploma in orthodontics at the Royal College of Surgeons Edinburgh. Dr. Mahony has also passed the Royal College of Dentist in Canada post-graduate examination in the field of orthodontics. Dr. Mahony has also passed examinations leading to a post-graduate qualification in dental-facial orthopedics from the Royal College of Physicians and Surgeons in Glasgow. He has also maintained his membership in orthodontics qualifications from the Royal College of Surgeons in England at Edinburgh.
Dr. Mahony has been seeing an average of 250 patients per week for the last two decades and has gained a vast amount of experience which he can pass on to clinicians so they can come to appreciate the key elements of his combined treatment approach. He currently has over 4000 orthodontic patients in active treatment, has been a keynote speaker at the International Orthodontic Summit Meetings, the International Association of Orthodontics Meetings, the American Association of Functional Orthodontic Meetings. He is considered by some to be the next leading lecturer on functional fixed orthodontics.
Dr. Mahony approaches his orthodontic diagnosis from a facial profile point of view. He sets his treatment goals to create not just straight teeth, but beautiful faces and healthy temporomandibular joints. He is a visiting clinical professor at the City of London Dental School and is in charge of their International Orthodontic Program. Dr. Mahony is a contributing editor of the Journal of Clinical Pediatric Dentistry, International Orthodontic Journal and Journal of Dental-Facial Orthopedics.
I could read your CV for the entire hour. By the way, I have lectured in Australia probably every five years for the last 20 years. My brother lives in Sydney. The last time I was in town, you were so nice and sweet to take me and my brother to dinner. I just think you're an amazing man. I want to start with this off the wall question, Derek and that is in the United States, if an orthodontist goes and teaches a general dentist anything about ortho, he is literally blackballed from his dental site. At the nine specialties, the endodontists want to teach you endo and they assume you will do the easy ones and they will do the hard. The oral surgeons want you to pull all the easy ones. They assume you will send them some thirds.
But it seems the link between orthodontics in America from the orthodontists is just a black hole of information. These kids walk out of dental school and they have never done any ortho. How did you cross that bridge? How did you come down from the mountain and decide you would teach a low-life general dentist anything about orthodontics?
Derek: When I went through orthodontist school, was taught the same thing. That is don't get involved in teaching orthodontist to general practitioners. They don't know what they're doing. They'll do a short-term call course. They're going to create problems. It's not good for the patient.
What I have found out deep down, it was a turf war based on [manitree 00:04:11] goals and you're right. If you tackle a tough root canal and things go wrong, the endodonist is there to help you out. If things go wrong and it's a general practitioner and you are doing some orthodontics, wow watch out. Everything comes down at once. What I think have proven in the model I use and one of the reasons we are successful in private practice is I have an open book approach and I teach as much as I can to general practitioner. They take on board what they can utilize in their office. The bottom line is they end up becoming much better at diagnosing cases. To me, it's a win-win situation. The more they know, the more they're going to refer.
There's so much work out there in orthodontics. I'm sure it's the same in the United States. Here in Australia, we just don't have enough orthodontists to cover the territory and every orthodontist I know is busy, busy, busy. I've been teaching for nearly 23 years. What has happened in the last five years has been this whole influx of what's called "short-term orthodontics," six month braces, six month smiles, ClearCorrect, Invisalign. A lot of things that make it easier for a general dentist now to be able to do fix appliance therapy.
Howard: Do you think Invisalign and ClearCorrect, do you think these are good things for the dental profession?
Derek: For sure. I think more and more general dentists are getting involved in what's called "digital smile design." The ability to communicate to a patient and say, "You're concerned by your anterior teeth. You would like to get them straighter, but at the end of the day [ginginal margin levels 00:05:58] match up. We have to do some intrusion, some extrusion. We want to create more of a smile-like, more width. You can't do good quality prosthodontics, veneers, etc., unless you can do some minor tooth movement. Something like ClearCorrect, something like Invisalign allows a general practitioner to use CAD/CAM technology and be able to predict the movements quite accurately. I think it's a wonderful aspect for treatment planning in cosmetic general dentistry, let alone in orthodontics.
Howard: Derek, you are talking to thousands of dentist right now, most 85% are in the United States, most of them are under 30. They are coming out of schools. They had zero orthodontic training. They're sitting here and they would love to learn some of this. What pathway could you set for them? How can they go from zero to 50 miles an hour?
Derek: I think the first thing is diagnosis. Diagnosis is the key. I always say I was never a good general dentist. I think I did one root canal in my 30 years and I created a few extra canals in the process. I feel clinically what you do in orthodontics, putting a bracket on, changing a wire, activating an appliance, it's very easy chair-side. The skill and I think what makes it difficult is the diagnosis.
I think get on a program that does not push an appliance, does not push a technique but just pushes pure diagnosis. A general dentist needs to be able to understand which case he is not to touch. They need to be able to diagnose a class III jewel patent in a child that's about to undergo latent mandibular growth. They need to be able to predict a patient who is going to have increased vertical facial proportions and not extrude molars in that case. Diagnosis is number one.
Number two then is simple fix appliance therapy. There's so many courses now that work with CAD/CAM that allow accurate bracket placement positioning. I think that's the progression. Diagnosis, some simple fix appliance therapy and then as you get more experience, maybe tackling some of the more difficult cases. There's always going to be the need for a specialist as there is in every field of dentistry. There's always going to be a need to have good communications with that specialist and say to that specialist, "Hey, help me with some of these is simple cases and I'm more than happy to refer the difficult cases to you."
Howard: Are you doing any of this education online via the Internet? If someone is listening to you in Tulsa, Oklahoma, how can they learn from the man if you are not going to be in Oklahoma?
Derek M: Yeah and because I'm at the stage where I probably want to travel a lot less than I have, I put my entire two year program in orthodontics online. It's a website called ADElogin.com. It's linked with a UK-based university. What we do is we have my lectures. We have literature references. The doctors do multiple-choice questions after reading the papers they're given to them. The goal is to be able to collect grade records. They help with their diagnostic skills and then they are going to present ten completed cases at the end of these seminars, as well as in the flight to London or to Sydney, Australia, to do some clinical aspect.
I think we have put together a good package that's comprehensive and again, is not focused on one technique or one system. There is no ideal orthodontic bracket. There is no ideal aligner system. There is no ideal arch wire. I think you have got to learn how to do different techniques and use the correct techniques for the appropriate case.
Howard: Sometimes too simple is too simple. They're trying to make bonding agents just one bond. They're trying to make a root canal files just one file. Sometimes too simple is too simple. If I'm at ADElogin.com, how much money is it? How many hours is it? Tell us more about your online program?
Derek M: I'm not 100% sure on cost. That's a split deal I do with the web designers there.
I know it can be done at your own pace, meaning you start with module one. You complete that. You sit in multiple-choice exams and then you move on to module two. As a result, some people do it in super quick time. They do it full-time. Most people who do it are busy in practice and so they are allocating one-two hours a day and it takes them about a two-year period to complete that. The reason I say two years is because by that time they complete their ten cases, it's at least that time if not greater.
Howard: If we were going to start teaching someone endodontics, we'd start with a single canal incisor. Talk about if someone was going to do their first few orthodontic cases, what would be entry-level cases versus what would stay away from and you don't want to touch that unless you're an orthodontist or have been doing this for a decade?
Derek M: Good question. Simple cases would be class one and crowning. There is no a doubt about that. Basically, buckle segments aren't change. It's correcting anterior crowning problems. Then you move on to the class II cases, particularly class II that have deep bite. The younger the child, the easier they are to treat because the low angle case is what we called "brachycephalic class II," self-correct as the child gets older because that mandible grows forward.
The cases you want to stay away from are the high angle, what's called "increase vertical cases." They typically will have large open bites. They'll have long faces. They are always difficult to treat, even for the orthodontist. The other case I think a general practitioner should stay away from, unless he has a lot of experience is the class III jewel, where the problem is the large mandible. We encourage in our program getting in early for kids who are class III mid-faced deficient, whose problem is not the big mandible, but whose maxilla is underdeveloped, retronathic. They are easy cases to six. You expand the upper jewel. You use reverse pull face mask therapy and you get a good outcome.
The cases that are very difficult are those where the mandible is the problem and the mandible is still growing. You have no end in sight and no matter what you do that mandible keeps growing. Class III cases with big mandibles on high angle vertical growers, large open bites, these are the cases I think a general practitioner should refer out.
Howard: I noticed humans by their nature are extremists. Everything is black, white, yes, no, up, down. I remember when I got out of school in 1987 if you sent 100 kids to the orthodontist, 100 got their four first bicuspids pulled and that was ortho. It seemed 20 years later, then there's a lot of general dentists who would not even refer to an orthodontist who did any four bicuspid. The pendulum swang to the other way. Is there a place for four bicuspid extraction?
Derek: Yeah, I think there is, but here's the thing. When I went to orthodontics school, we would extract to relieve crowding. I distinctly remember we used to do a study model analysis, any crowding greater than 5 mm, we'd take out four bicuspids.
We now realize you can resolve crowding with neuro-techniques on a non-extraction basis. When I would extract is not so much crowding, but when the face is full. Typical profile of a Chinese patient who is lip incompetent, has what we call bi-dental protrusion, which in the old days was called bimax. Those cases, you need to extract because you need to retract the incisors to get a better lip seal. I use the adage nowadays "I extract for the face. I don't need to extract for space." That's the big paradigm shift in orthodontics, whereas traditionally, I would look at the facial profile. I would just look at the study models. I'd see if I needed the room and I would work out how to get that room.
Now with techniques like [pasosofligation 00:14:16], earlier treatment with dentafix orthopedics, we can make the room and not have to extract teeth. But if a patient has what we call the division three incisor relationship, where their upper and lower incisor teeth are proclined, it's very unstable to treat the non-extraction and in fact it worsens the profile. In those cases, I would recommend extraction.
Howard: What was the that crime again? "Extract for face, not for space?"
Derek M: Correct.
Howard: "Extract for face, not for space." I love that. Do you care if I put in fact saying on your picture and make a meme out of it?
Derek M: It's actually something Dr. Dwight Daymond pushes a lot in his philosophy. The way I practice now has been heavily influenced by what he has done and that is to teach specialists that when a child walks in, you look at their profile. If their face is deficient, if they're flat-lipped, you don't want to extract. You want to support that profile, particularly as that patient ages.
Conversely, if you have a patient who is very full and that is in my term to simple, but it works. You do what's called "a soft tissue profile." If you take a photo of the patient from side on, you draw a line from the soft tissue chin to their lower lip, by and large if that line goes behind their nose that's a non-extraction profile. If that line goes ahead of their nose that would be someone I would consider extracting teeth in. Yes, there's thousands of cephlinetric analyses, but unfortunately their downfall is they're all looking at heart tissue factors.
What patients look at our soft tissue. There's such a resurrection these days in doing the fullers and Botox and things that help a patient look younger and more youthful. I think the best way to keep someone's face looking younger, more youthful is to support their lip, improve their nose at a label angle and that involves a non-extraction-based techniques.
Howard: Derek, I always felt and tell me if you agree or disagree, I always felt the reason so many adults needed orthognathic surgery is because so many of them, when they could have been intercepted, their general dentist had no orthodontic training. They did not know what they were looking for and basically, the general dentist, family dentist was asleep at the wheel between the ages of 6 and 12. Then this girl shows up at 21 and when she smiles, it's all messed up. Do you believe if all the general dentists took your program and they all knew the mind part of the game that there would be a lot more interception and a lot less orthognathic surgery?
Derek M: Absolutely. This is the thing. The term "orthodontics" means tooth movement. Where you have got a problem that's a skeletal imbalance, you have got to do what's called dentofacial orthopedics. Orthopedics is bone changes. At the appropriate age, you can expand a maxilla. At the appropriate age, you can advance a mandible. At the appropriate age, you can advance a maxilla. The only cases that probably would still be orthognathic surgery are those class three, high angle, large mandible cases because no orthopedics is going to help those. In the olden days we would try chink-up therapy. All that did was to rotate the mandible backward. You can't stop a large mandible from getting larger.
Certainly, in the cases of patients who have an auxiliary deficiency, then dentofacial orthopedics will reduce orthognathic surgery. On top of that, we now have techniques combining braces with what's called "tads" or temporary anchorage devices. They also allow us to reduce the percentage chance of orthognathic surgery.
Howard: When I got out of school in 1987, everybody was afraid to refer to an orthodontist for oral surgery and orthognathic surgery because there was so much paresthesias. A lot of them back in the 80s if you said to your patients, "If you had to do it all over again, would you do it over again?" 90% would just say, "Oh my God, never, never, I can't feel …" How has orthognathic changed from the 80s to 2015? What percentage of these people do you see now where they say, "If I had to do it over again, I would not do it. It made me numb. I wouldn't do it again," versus what percentage say, "Oh man, that was a great decision. I look better, feel better."
Derek M: I think orthognathic surgery has changed drastically and the advent has been the small fixation screws. When I was in dental school, the orthognathic cases used to leave the operating theater with halo frames around them. We had two stage surgeries: One stage surgery to place these large bone plates and another surgery to remove them. Nowadays with the small titanium screws, it's a one surgery procedure. It's one - two days in the hospital. Recovery is quick. The chances of paresthesia, although they are still there, are greatly reduced. I have a very positive feedback from the patient's because the one I sent to orthognathic surgery have major facial problems. When you see their facial balance improve, they are so happy.
Also, the cases that I sent for orthognathic surgery are patients who are suffering from severe obstructive sleep apnea. Those who can't cope with the cpap. I must say more that more cases that I diagnose with OSA are those who have the older style retractive orthodontics. Rather than develop the upper jaw, bring it forward, they had teeth out and the upper jaw was pulled back, so now they have no room for their tongue and they have a lot more [t and joe 00:20:13] problems. They have a lot more airway problems, etc. Unfortunately, those we missed the boat for in general orthodontist orthopedics, are those that go to the orthognathic surgeon for what we call a "bimax advancement procedure" to improve their airway.
It's chalk and cheese compared to what I saw 30 years ago in orthognathic surgery to what I see now. It's a much simpler surgery. The advent of numerous surgical techniques, the advent of semi-rigid fixation has made it a procedure in patients where they recover quickly and their chance of the problems you said are greatly reduced.
Howard: Do you have any percentages or anything about what percent of obstructive sleep apnea could be corrected orthodontically or orthognathic surgery? Is this rare or common?
Derek M: Depending on who you read, up to 70% in some of the figures they are quoting. What I am saying is a general orthodontist needs to be on the ball with a CBCT. CBC technology is such you can look at 3-D airwave. A general orthodontist needs to ask the right questions to parents and their kids, "Does your child to snore? Does your child wet the bed? What's your child's sleep cycle like?"
I think one of the big epidemics in America is suddenly kids being randomly diagnosed with attention deficit disorder without a sleep study. There's been landmark research to show many children who were incorrectly diagnosed with ADHD, put on medication that actually disrupts their sleep, where those who have what's called "sleep disordered breathing." What it involved was either removal of tonsils and adenoids if they were the cause. What it involved was arch expansion. All these things actually improved their airway because the young child you don't treat dentofacially orthopedically for mid-face the efficiency is going to be a future apnea patients. There's no doubt about that.
Howard: How much of your curriculum these days involves sleep apnea?
Derek M: A huge amount. Every year we have more add more and more modules because to me, in the days of John [Wichsead 00:22:29] if you remember, it was all about facial profile. It was all about don't take teeth out because you're going to age the patient. Don't take teeth out because you're going to put pressure on the jaw joint. Some of those things are true, but I think the bigger thing is getting early to improve the child's airway. We as general dentists are actually gatekeepers of the kid's airway. We are looking at the kids' mouth a lot more thoroughly than their general physician would. I say to my students, "Look, don't just look at the teeth, push the tongue down, look at the back of the throat, look at the size of the tonsils. Ask the patient to say, 'Ah,' see if the soft palate elevates. If it doesn't, maybe the adenoids are increased."
You can hear these kids. Rather than say, "Banana," they will say, "Banana." You ask the parent to take a photo of their child while they're sleeping and you see these kids have these weird posture with their mouth open, with their head back like that. These are the kids that need a combined approach with a general dentist who does dentofacial orthopedics with a respiratory physician and most importantly, with the ear, nose and throat doctor.
Howard: What age are you starting to intervene on these children, five, six, 12?
Derek M: Yeah, absolutely when it comes to airway, the earlier the better, absolutely. We have some kids who have such severe obstructive sleep apnea, even as babies. This is the thing. We know and the medical profession knows large adenoids and tonsils will naturally shrink in most kids by age 12. But the problem is 90% of facial growth is finished by age 10. If you have a child who has large adenoids and tonsils, non-infected but just large and it's affecting their sleep. It's affecting their breathing, it's actually also affecting their facial development. I think one of the big things we're looking at now is to take a CBCT, do a 3-D measurement of the airway, ask the right questions as far as the child's sleep is concerned and then institute the appropriate therapy.
Howard: Is there any CBCT brand name you like or prefer that's easier for everything you do?
Derek M: Yeah, 100%. The market leaders are I-CAT. They have come up with technology in their new flex machines where one head CBCT is less radiation exposure than one panoramic radiograph, which is amazing. Why would you expose a kid to a panoramic radiograph that only gives you two dimensional data when you can do a whole 3-D scan, use that for cephlinetric analysis, use that to check the airway and there's many orthodontists who lecture specifically for that the company, who like me, are passionate on looking at kids' airways. Juan Quintero was one who is out of Florida. If anyone has not listened to that guy speak, it's an absolute must because he …
Howard: What's his name?
Derek M: His name is Juan Quintero. He is an orthodontist in, if I'm not wrong in Miami, Florida, and he does a lot of lecturing on early screening, early diagnosis using this new technology and it's truly amazing. He, again, is focusing on the kids.
He, again, is focusing on the airway. That's the important issues.
Howard: You are exclusively using the I-CAT then?
Derek M: Correct, yeah.
Howard: Is that a Danaher product?
Derek M: It is.
Howard: They're probably the largest dental company in the world, aren't they?
Derek M: I think of them and Henry Shine taken in turns to one larger than the other.
You know what it's like. These companies now acquired laterally. Danaher has a market share in Sybron, in Ormco, Nobel Biocare implants now, etc., etc. These are massive con, rich companies. I guess the benefit there is there's a lot of interaction between their sales reps and one of the bigger interactions with Ormco in the orthodontic market is with i-CAT and the technology associated with that.
Howard: One of the litmus tests in economics is when you come out with a new product, it should solve a problem faster, easier, higher in quality, but lowering in costs, it seems when it went from fix braces to removables like Invisalign, they did not get that lower-cost thing. It was actually $1000 penalty to do that more. Now some people are saying the patents are expiring. That there's going to be more competitors. Do you think someday soon the price of an Invisalign-like product will be the same cost as traditional, hardwire or do you think it's just inherently a higher cost way to do ortho?
Derek: No, no, no, Invisalign had and I take my hat off to Invisalign. They have done magnificent marketing directly to the public, which is putting patients in the offices of dentists and orthodontists around the world. Unfortunately, their patent does end and it ends next year. What's going to happen? You will have a conglomerate of companies using CAD/CAM technology using orthodontic softwares to reset the teeth to make it quite already other than ClearCorrect. Ormco have a product, which again uses CAD/CAM technologies, uses a software that resets the teeth and then from that produces a series of aligners. Whether you want to call it red, white and blue, magic aligner, there's so many companies on the market.
Here's the thing. I think with any of the bigger companies what tends to happen is they make the whole aligners in one go. If you have a complex case you might need 35 aligners and things start going off the track around about aligner ten over 11, either compliance-based or the fact you haven't done enough stripping or you haven't done the stripping in the right position. I think the future lies in technology where the patient is given a set of six aligners. They are then re-scanned for accuracy and another six.
What makes it easier nowadays is intra-oral scanners. Back in the day when I started doing Invisalign, I had to learn how to do a PVS impression because as an orthodontist, that's not a normal thing we did. Now it's so simple the scanners on the market, you can do an upper-oral scan in under three minutes and there's no gagging. That technology goes straight to the lab you're working with to reset the teeth. That's the future of orthodontics. It really is the Holy Grail.
Howard: What scanner are you using? You're using an I-CAT for a CBCT, but what scanner?
Derek M: To me, the number one scanner in the market is by 3Shape. It's a scanner that works very quickly, but it's also the most expensive. I think there's a lot of mid-range scanners on the market. There is a scanner called Lythos, which I started with which is great. I think what a general dentist needs to understand is if they're going to get into intra-oral scanning, make sure you get or work with a company that gives you an open file, an STO. Then you can share that data for your crown and bridge. You can share that data for your aligners, etc., etc.
Fortunately, I think when the first scanners came on the market, they were linked with certain products like Invisalign I think had the … I'm not sure the name of the company, but it was a scanner-specific just from Invisalign and you could only use it for that. Nowadays with these open files, you can scan for a number of properties. For instance, I get all my lab work done in the United States, even though I am here in Australia. After I've scanned a case, literally one minute later, the lab is printing out the 3-D custom model and fabricating the appliance. It's amazing to see what these labs can do nowadays.
Howard: What lab are you using in the United States?
Derek M: I use Allesee Orthodontic Appliances, AOA and I use …
Derek M: Yeah, I'm sure they are called AOAlab.com. They are again a subsidiary of Ormco. They make a number of appliances, including clear aligners very accurately and at very good cost.
Howard: Oh, AOAaccess.com.
Derek M: That's it. Access is their portal. Access is the ability for you to upload the 3-D file to design the appliance and to interact with the technician on the other side, yeah.
Howard: That's owned by Ormco?
Derek M: Correct.
Howard: Which is owned by Kerr, which is owned by Danaher, is that right?
Derek M: Exactly.
Howard: Ormco, Kerr, Daneher. They will make all your aligners at that lab, AOA access?
Derek M: Yeah, not all the aligners. If I have a simple case where I'd need six aligners to finish a kid I had to pull the braces off early because their oral hygiene was not good, the bride to be that needs their braces off in time. I do a lot of case finishing with their aligners. For the complex cases, I love ClearCorrect. I think their technology is as good as Invisalign, but their cost is 35% cheaper. Again, you need to shop around and …
Howard: ClearCorrect is out of Dallas, Texas, is it?
Derek M: They started in Dallas. Now they're still in Texas, but it's something rock. I was going to say …
Howard: Wasn't the founder of ClearCorrect, wasn't he also the founder of Invisalign?
Derek M: One of the founders. The history goes that when that company first launched, it was launched by a general practitioner who was left with 200 cases he could not finish because the previous company he was using was successfully sued by Align Technology and had to be shut down. Here was this guy who was mid-treatment in all these cases and wanted to finish them, but was not allowed to basically. Lawsuit after lawsuit, he decided, "Look, I'm going to set up my own company." He got the guy who set up Invisalign to begin with, who was also upset and they worked together and they set up ClearCorrect and then the rest was history. They have launched. They have now launched in Canada, a very successful model.
Howard: That is amazing. You call things like Invisalign, ClearCorrect, you call those aligners. That would be the generic term?
Derek M: Correct.
Howard: Versus what? Fixed ortho? Is it fixed ortho versus aligners.
Derek M: Yeah, as I always tell my patients you can have clear aligners. You can have invisible braces. By that I mean lingual technology, which again is 3-D customized. Or you can have braces on the outside, which may or may not be visible. Nowadays you have self-legating ceramic brackets, which are very aesthetic. They all get the job done, but it's gotten to the stage with the predictability of aligners and the predictability of lingual is as good as [laybill 00:34:03]. More and more my patients are going for that technology.
Howard: What do you say the old guys like me that are 50-70 that back in the day when Lingual came out, everyone came in with a chewed up hamburger tongue. Do you think Linguals are making a comeback? Is the tongue playing with them less and not getting chewed up like it was in the 80s?
Derek M: With Lingual now, the 3-D custom bracket has such a low profile and it does zero effect on speech. I have patients who within a day are back to jobs such as lawyers or TV news readers and it doesn't affect their speech. Back in the day when Craven Kurst was developing the Lingual technology with Ormco, the Series 7 bracket, which was the latest bracket back then, it's mesiodistal dimensions and its logo lingual dimensions were nearly four times the current bracket size just to give you an idea. People who knock Lingual used to knock it because it was hard work wire bending. It was bulky for the patient. It affected their tongue and their speech. Those days are gone. I always say, "Get behind the science, get behind the tooth." That's the new Lingual catch-cry nowadays.
Howard: "Get behind the science, get behind the tooth." I love your catchphrases. Derek, what are the red flags for when you treat a patient and say, "No, I want Derek to be in charge of this. I want fixed. I want to take all the variables out of your hand. I am worried that you are not compliance." Maybe it's more a boy or a girl or a boy that had not combed his hair and he comes in and he's not cleaned up. What red flags do you look for when you say, "I trust the patient to wear aligners, clear aligners versus you are looking at this patient and you say, "No, I want it all control?"
Derek M: That's a hard thing to pick. You'd say in the past look at the kid. If he is shabby in his dress sense and he is always the kid who is losing his glasses and things, but some of those kids become your best compliers. I think it's trying to get down to the level of the child. There's no doubt in my mind that female patients are a lot more compliant than males, particularly at their teenage years. There is no doubt about that. I always say girls mature three to four years ahead of guys of that age, if guys mature at all at that age. That would be one of the predictors.
I always give the patient the first chance. I set it right, "If you don't want braces, we can do this with aligners, but if you don't wear the aligners it ain't going to work." Nowadays, there's more and more compliance indicators. With a lot of my retainers nowadays, we have a compliance indicator chip we put in the retainer. That means when the kid comes in for their retainer check, I can scan it and I can tell how many hours the kid's been wearing it.
Howard: Are you serious?
Derek M: Yeah and the kid knowing that becomes a better complier.
Howard: They say if you put a security camera over a cash register, stealing from a cash register plummets. Tell me more about when did a chip come out that you could put in an aligner?
Derek M: This came out about three years ago. Again, came out because of the OSA market. Here were companies that you realized oral appliances were sometimes as effective as cpap for the mild to moderate cases. But a lot of the physicians were saying, "The good thing about cpap with the card reader, we can tell how often the guys used it and what his sleep was like when he did and didn't use it." What we have done now with oral appliances, there is a microchip that goes in the acrylic so you can see how often the patient wore that. Then that technology then led to what's the biggest compliance issue around the world? It's kids after braces not wearing their retainers. Putting these compliance chips in there has made a huge difference in that regard.
Howard: Is there just one company doing that or is there more than one?
Derek M: Well, there's the main one is … I'm trying to think of the name. They are out of Germany. I think Braybon. I can get back to you with the exact details. It's a simple system. You literally just buy a little scanner. You work with your lab and the lab buys the little chip directly. They embed it in their acrylic and then away you go. When the kid comes in, you just get that retainer, give it a scan and you can check the hours of where. It's really that simple.
Howard: What was the other lab? You were talking about AOA access. What was the other lab you are talking about?
Derek M: The other lab was Pro-Tech. They are out of Vancouver in Canada. They are one of the market leaders in 3-D technology. Again, when it comes to I make some appliances with AOA, mainly my fixed functionals, my maras, my hoops that sort of thing. With removal appliances, twin the box, retainers, Pro-Tech does a fantastic job.
Howard: Do either of those labs do just traditional crown and bridge, too, if you had the oral scanner and all that?
Derek M: Not AOA. They are dedicated for orthodontics, but Pro-Tech is a full-service lab. Again, they're doing milling technology. I'm not a general dentist, but I'm amazed at how they make these zirconium crowns using CAD/CAM technology. Then the crown is made 30% bigger and then it just shrinks to this perfect vacuum. That technology blows your head away.
I make it my pilgrimage every two years to go to Cologne to the biggest dental show in the world at the IDX and that's the show place for German technology. Every time I go, I see it's becoming more and more automated. I think, we as orthodontists, have lagged behind you as general dentists when it comes to CAD/CAM technology. You guys had the cert machines, years ahead. We are just slowly catching up with things like sure smile, the newer Lingual braces that are 3-D customized. Insignia is another product where the brackets are cast specific for the patient's mal inclusion. The wires are bent by a robot. The brackets are put on with indirect bonding. It's truly amazing.
Howard: Derek, is it overly simplistic for meto ask you if all your patience were adults, what percentage would be clear aligners versus Lingual braces versus fixed appliance?
Derek M: Literally with adults, I would say more than 80% would be clear aligners and Lingual. 20% are Labial just simply because at their age they don't want to go through that whole experience they went through as teenagers. Most of the adults are relapse cases. In the past I used to balk at offering aligner type technology or Lingual because I knew my case finishing would be difficult. Now, the case finishes are as good as Labial, so why not give the patient what they want? That's a huge market builder.
I think there's two things that precludes adults from orthodontics and it's not cost. Everyone thinks its cost. It's absolutely not cost. It's time in braces and the convenience factor of how many visits they have to come in and the second is aesthetics. They just want something that is not visible. That's why Align Technology has done so well. If you look at their figures in profit, their profit last year was bigger than the to the orthodontic companies combine, which is Ormco and Unitech, which shows you there's a huge demand for aligners.
Howard: Ormco and Unitech combined did not make as much as Invisalign?
Derek M: Correct.
Howard: These Lingual braces, are you doing a lot more of them in 2015 than you were in 2010? Is this a relatively new, hot explosive growth part, Lingual braces?
Derek M: Yeah because there is a guy out of Germany, an orthodontist, Dirk Wieschman, who developed a technique known as Incognito and it was the first technique where everything was automated and German precision and you got the end results and that opened this whole market in Lingual.
Nowadays the top Lingual braces would be braces that are self-legating, so they are easy for the clinician to change the wires. They are very low in profile, so they are comfortable for the patient and they are very, very accurate because of the fact that they are just like aligners, they work from the in product backwards. You do an intra-oral scan. The teeth are reset into an ideal inclusion. From that ideal inclusion, the brackets are manufactured and then put back on the original mal inclusion model and then the wires are customized for first, second, third order of bends. That technology is now available in [Truer Force 00:43:31] systems, but the market leader has been Incognito, which eventually was bought by 3M-Unitech now and is still I think one of the most popular Lingual braces.
Howard: One of the things about air travel since you and I have traveled to way too many cities for way too many decades, I got to leave tomorrow to Calgary, then New York, then Tennessee, it seems the planes gets nicer and nicer and nicer, but they still fly 500 mph. They haven't got any faster. For me to visit you and my brother in Sydney that's still a 16 hour flight. Is braces the same way? Are braces getting any faster? Do you see braces from 20 years ago to today, is the length of time in braces shortening any or is it like an airplane it will get nicer, but it's not going to go any faster?
Derek M: No, no, no, I think it's not the braces that are becoming smarter in any way to reduce time. It's the technology of teeth movement. The two biggies on the market now our Micro Vibration that speeds up tooth with movement and the other thing is a company called Propel. What Propel is, it's doing a micro perforation near the tooth you want to move be quicker, which takes advantage of a phenomenon known as rapid [excellery 00:44:58] phenomenon, rap effect. That rap affect releases more cytokines and we know cytokines are important for tooth movement, regardless of which braces you use.
If I offer a patient clear aligners, all Lingual, all Labial, I also offer them an ability to speed up the treatment. With aligners, I like using a product called Exceldent, which allows me to change my aligners a lot quicker than the average ten days. With braces Labial or Lingual, I like using a product called Propel. Those two has been shown in clinical studies to speed tooth movement up to 40%. I can say to an adult, "Look, I can get you out of braces maybe six months to nine months sooner if you are willing to undergo these techniques." Of course, adults jump at that. There's no doubt about that.
It's not the braces that have gotten more intelligent and quicker like Concorde did back in the day. You're talking about flights to Sydney, I know there's problems with Concorde, but wow that was well ahead of its time in doing long, haul flights. To me, it's not the braces so much these days that's speeding up the treatment. It's the ability to use added technologies such as micro perforations, such as vibration, nowadays even ultra sound to speed up the biology of tooth movement.
Howard: Do you know the CEOs of Propel and Exceldent?
Derek M: Look, I don't, but both those companies are based in the United States, both have good literature support what they do. Propel, all the studies came out of NYU. Exceldent, out of Texas as far as the initial trials and both have shown promising results. Again, if you look at Exceldent, the compliance indicator chip that's in there, again allows me to check whether the patient is using it. It's 20 minutes a day, but for some patients that's a hard call. Now they have got their new model, which is waterproof, so the patients can use it in the shower every morning. I can then check how many times they have done that an absolutely, I have seen a huge improvement in the way teeth move because of that.
Howard: That is truly amazing. How much extra to you have to charge for your ortho case to use these new technologies, Propel and Exceldent?
Derek M: The magic figure though matter what technology comes out seems to be about $1000 United States dollars. That seems to be the cost to the consumer and the cost of the orthodontist is a little bit less than that. If a patient can get out of their treatment nine months sooner, they are quite willing to pay that extra premium of $1000. It's a bit like people flew Concorde knowing it was five- six times the cost, but it got there a lot quicker.
Howard: What would you think of all these general dentists around the world, their introductory to ortho is like a short-term ortho course and not a full curriculum. Do you think that's a bad idea? Do you think it would be smarter to learn a two year curriculum first before you start playing with short term? Or do you think short term is a good introduction to learning ortho?
Derek M: I think short-term is a great introduction provided someone is helping that dentist who has zero experience with diagnosis in picking the right case. If you are doing anterior cosmetic alignment and not disrupting the [buckhold segment 00:48:29], short-term ortho is great. But if you have a case that has a class II, a class III, a deep bite, an open bite and you are doing more than just anterior alignment, then definitely, I think the longer haul courses are the way to go.
I guess it's a hard mindset for a general dentist who has done no ortho to then have a two-year commitment to incorporate orthodontics into their practice. Where it's alluring to do a weekend course on one of these short term ortho and then try one or two simple cases, get the confidence level and then if you like it and you see it's a good mix for your practice, progress on to the more complex cases. I think there's a market for both. What I'm saying is, I don't think a general dentist can say, "Yeah, I do orthodontics in my office," if all he does is short-term ortho.
Howard: Have you noticed when you go around the world that some countries, like in the United States and the Middle East, like their teeth really white and really straight, then in some other countries, the people think that looks goofy, almost like you look like a clown? Do you see more ortho in some cultures versus others and does ortho seem to be correlated with super-clorox bleach white teeth?
Do you think there is a connection there?
Derek M: Yeah, definitely. I think with my patients finish orthodontics and have straight teeth, the next thing they want is white teeth. There's no doubt about that. Some of my teenage patients, their expectations of white is the porcelain in the toilet bowl. Vito has come out with new shade guys specifically for this whitening market.
You are right. I did my training in the UK and let me tell you if you look at horrible teeth, you have always associated England with that, don't you? You look at some of the English actors, you think they would never make it in Hollywood just on their teeth, let alone anything else. That culture is slowly changing. In Australia, we follow more the American market. People want that Hollywood smile. There's no doubt about that. America is still the big market for straight teeth, white teeth, but that's slowly changing. Again, the Internet, travel, access to information, people realizing straight teeth is not just about how it looks. It's about better hygiene. It's about better where on the teeth, etc.
I think one of the biggest things we look at now is the impact on problem vertical dimension when it comes to aging. If you can get in early and do some orthodontics not just to make the teeth look better, but to improve the facial balance, definitely that patient is going to age more gracefully. I think that's becoming a big market.
Even in the UK, my alumnis in London, I teach in the UK a lot, I see that slowly changing where the younger generation absolutely want to have straight teeth. Whereas back in the days of the National Health Service 30 years ago, the really severe class II's were the only ones that had treatment. Nowadays more and more people have access to that.
Howard: Derek, I have also noticed, I wonder if you believe this true or false, but when
I go around the country's it seems like the dentist that didn't do cosmetic, whether it be bleaching, tooth color fillings, veneers or ortho, short-term for ortho, it seems when they walk the talk by doing it to themselves, their assistants, their hygienists, it takes off in the office. It's almost like the culture brand is the whole office. But I still see so many dentists trying to sell bleaching, bonding, veneers and their own teeth are crooked and they are crowded. Their dentals assistant looks like she could eat corn on the cob through a chain link fence.
Then I meet guys like you, you are gorgeous, you are polished, your teeth are perfect. Do you think to your listeners out there, you could not be an aerobics instructor if you weighed 300 pounds and had a cigar in your hand that maybe one of the first persons that should get ortho, bleaching, bonding is the dentist themselves and their staff?
Derek M: 100%. When I employ my front desk staff, the first thing I looked at is their teeth. I am here trying to convince an adult or convince a parent that their kid would benefit from orthodontics and if I have horrible teeth, I can't justify … I had bad orthodontics as a kid, so I retreated myself with braces when I was an orthodontist and I would tell you my productivity that year when I had braces on, was 30% over and above and I could never figure it out. Then it finally clicked, people were walking out and saying, "I know Dr. Mahony has braces.
I didn't realize you could get braces as an adult. Not only do I want a consult, but I want the braces he is using because clearly he knows what he's doing." The same thing when it comes to front desk staff. We insist those girls have nice teeth and white teeth because that's what we're selling at the end of the day.
You know what's funny how every general dentist calls themselves a cosmetic dentist. Where is the non-cosmetic, general dentist? There isn't one. But the thing is they need to have a good look in the mirror themselves if they are trying to sell veneers, if they are trying to sell whitening and they have these horrible teeth. Again, technology is available where they can get simple treatment. I always believe no one should become a midwife unless they have had a kid themselves. The same thing, before you start doing orthodontics, go through the experience yourself and you are going to relate to the patients much easier.
Howard: I agree. It seems all the people are crushing in on ortho and cosmetics, they all walk the talk. They all do themselves. That was the first thing I noticed with you when we met for dinner. You have a million dollar smile. I am just about out of time and I can't believe you got up at 6:00 in the morning to meet me. Dental Town has 205,000 members from all over the world. I wish you would put some of those ortho courses on Dental Town, even if it was just a teaser section for each one, it might be a good marketing thing to lead them back to your other site.
One of the big pet peeves I have for wanting general dentists around the world to listen to this and on my podcast, every single country that iTunes match is downloads every single episode on these podcasts is that if they don't understand the knowledge and they are a sleep behind the wheel from this child from age six to twelve, so many things could be prevented. I just wish that general dentists knew how to diagnose and treatment plan, especially in the critical interceptive ages between six and ten.
Then the other reason I love orthodontics most is I have noticed with humans in America, you are either all in or you are out. You have never gone bowling for five years or you own your own bowling ball. You haven't been to the lake once in ten years or you own your own boat. It seems everybody that gets their teeth straightened and bleaching, they start brushing and flossing and coming in every six months. It's like their mind gets turned on to their mouth. If they look in the mirror and they don't like what they see, they don't pay any attention to it and that turns into gum disease and decay and oral systemic health issues.
I think what every American needs is a look in the mirror and to fall in love with their teeth and their smiled. If that means they have to be straighter with indirect, direct, Labial, Lingual, I don't even care. I just want humans to fall in love with their mouth because they will only take care of things they like.
Derek M: I totally agree with you. That's absolutely well said.
Howard: I applaud you for having the guts to talk to low life people like me. I can't believe I'm talking to an orthodontist as a low life in general dentist. You have lectured in every country I can think of. I have seen your name there at all the major meetings. I think you are the number one, most sought after speaker in orthodontics. You are an amazing man. I sure had fun having dinner with you and my brother. Thank you, Derek, so much for all that you do for dentistry all around the world.
Derek M: Thank you, Howard. I look forward to catching up again when you come and visit your brother.
Howard: All right, thanks a lot, have a great day and tell your lovely wife I said hello.
Derek M: Will do, thank you.