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VIDEO - DUwHF #294 - Fabio Savastano
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Dr. Fabio Savastano:
MD Cum Laude at University of Naples, Italy(1986). Post graduate in Orthodontics and Gnathology University of Padua, Italy (1990). Neuromuscular Orthodontist. Practice limited to Orthodontics and Gnathology in Albega, Italy. President of ICNOG, International College of Neuromuscular Orthodontics and Gnathology.
Howard: It is a huge honor today to be interviewing an orthodontist all the way from Italy, Fabio Savastano. Did I say that right? Savastano?
Howard: Perfect, and you were actually, you were born in Italy but you learned perfect English by...as a child, you moved to Washington D.C., your father was in the embassy?
Fabio: Exactly. He was also a teacher at the University of Maryland, and I grew up there. And by 1975, I had gone back to Naples.
Howard: And how old were you in 1975?
Fabio: 1975? I was 14.
Howard: So, you spoke English here for 12, 13 years. Is English very common to speak as fluently as you do among dentists in Italy?
Fabio: Absolutely not.
Howard: Absolutely not?
Fabio: Quite rare.
Howard: Quite rare. What about reading English? Lot of times you meet a dentist who can't speak English, but they read English. How common is it to be able to read English among dentists in Italy?
Fabio: That's a little bit more common because all the good publications are in English. So, if you want to make a publication, or you know, update yourself and yeah, you have to do it through the web. So, you're reading English, not speaking it.
Howard: A lot of dentists, where English is a second language, say they can read it, but they don't really like to read it in English. They say after about an hour, it gives them a headache. I don't speak a second language. Is that a common thing, where you hear where if they like, get on Dental Town, and they're reading posts, after about an hour of reading a second language, the brain is fried?
Fabio: Yeah, well it's not that easy. I mean, any second language. For example, I know a little bit of French, but I can only take it for about 40 minutes. I can't take more than that, really. So, I guess a lot of Italians get tired of English after an hour, you know? I have my son, he's going to go into university next year, I sent him a whole month in England. He came back, he can handle a little bit more than an hour, now, you know?
So, it's a question of how fluent you are with the language. How much time you've been speaking with friends, and probably how much you've had to do with other dentists, also, that speak your same language. So, if Italian dentists speak English, they don't get to meet the English speaking doctors, they won't get as fluent, you know, in the language as they should.
Howard: So is a language like riding a bicycle? I mean, do you see yourself losing your English over the years, or is it...since you spoke it fluently at 14 living in the states, will you always be able to speak English? Or, do you find yourself losing it?
Fabio: Well, actually you're supposed to lose it. I keep it up because I travel the worldwide, that I have my lectures worldwide in English. And plus, my mother lived in the states until 4 or 5 years ago when she passed away, and I used to go and see her. So, I bring my family on vacation in Las Vegas when I can, because they want to go around the parks, and you know, have fun. So I guess, you have to keep up a language.
France is right by me. I'm just about 20 minutes away from France, and I have some French friends, and I go to see them all the time. And, I keep up my French a little, but I should do more than that. I speak Greek as well, so when I see the Greek friends, I start speaking Greek with them, you know? You know, and Neapolitan is a dialect but actually, it's a language, so I speak Neapolitan as well.
Maybe you guys have heard on a TV show, it's called Galora. Now we have it in the native Neapolitan language, it's about mafia, and it has...it's written in English, so you can see what the actors are saying in English. Should be pretty cool if you can get that on the DVD.
Howard: I want to start with the most controversial question in orthodontics that I see. In the United States, the American Dental Association recognizes 9 specialties and besides orthodontists, the other 8, they pretty much all have the culture that, like endodontists, and oral surgeons. We'll help you with all the information you need, because like an endodontist, I'll help you with all the endo, I'm sure you'll do all the single canals and a lot of bicuspids, but you'll give me the hard cases. Oral surgeons, they'll help you pull any routine teeth, whatever, because they know that the difficult ones like impacted wisdom teeth, you're going to send there.
But, it seems like orthodontists, they don't like to share any information with general dentists. You almost never, ever, ever, see an orthodontist lecturing to general dentists at any convention in America, and they just only keep to themselves. It's kind of a closed club, and I was wondering. Is that a cultural thing only with orthodontists in America, or do you see that in Italy, too? Like, do your orthodontist friends not like you teaching general dentists how to do orthodontics?
Fabio: Okay, first off all, the last thing you said is true. My other friend orthodontists don't want me to teach general orthodontics to general dentists, okay? So, it is true, there is a little bit of jealousy, I'd say. We're a little closed. I tried to break that down, plus I practice a type of orthodontics that I'm not only hated by other orthodontists, I'm hated from a lot of general dentists, you know? So, that's neuromuscular dentistry. Okay? I'm hated all around, but I try my best to speak to everybody. I believe that higher the communication, the better living for everybody. I'm not for the idea that orthodontists should be you know, just kept aside and minding their own business, and being a super specialistic. That's...I feel that is quite unfair.
On the other hand, there are some...there is part of the orthodontics specialty that cannot be comprehended easily from the general dentist. I'm talking about occlusion, and TMD problems, okay? There's some problem with communication there because when a general orthodontist speaks and talks to a general dentist about occlusion and TMD problems, there is a big gap, a big [culture(?) 00:06:40] gap there. On the other hand, you have to understand that the idea of occlusion has been changing in the recent years. So, you've got a lot of dentists who still thinking occlusion the old way, and you've got newer orthodontists that are just speaking a new language. So, I think that's a cultural gap, most of all. It just takes patience.
Howard: So, yeah. The reason it concerns me is, you know, America, everybody thinks of New York, and Vegas, and D.C., but there's actually 19,000 small rural towns, and about 10% of them don't even have a general dentist. And, another 10,000 don't even have a single specialist. So, when you're sending these kids back to a rural town and there's only 1800 people, and nobody wants to teach them specialty work, then it really harms rural small town Americans.
Fabio: I agree 100%.
Fabio: That's...the same here in Europe. When we think of Europe, or Italy, we're thinking of Rome, and Milano, and the big cities, and there's a lot of rural here also. And, a lot of general dentists would like to treat a little bit of orthodontics to you know, their patients, and deliver good treatments. And, it's the same here. It's a little big problem in the sense that, you have certainly 50 or 60 percent of children that could go to the general dentist to have, you know, the big problems relieved and probably you need a specialist to have the more refined treatment, and bigger problems treated for the child.
So, we're losing, general dentists, for this reason, are losing a big 50%, a big chunk, of an easy practice on the orthodontics on their children. So, what I would suggest is that, and there are associations who do this, there is a general orthodontic teaching for them. For example, the International Association of Orthodontics is open not only to specialists in orthodontics, but also to general practitioners. I believe that they organize very good courses on about orthodontics.
Howard: Well you know, Dental Town has put up 350 courses, and they've been viewed over half a million times, and I still have not been able to get an orthodontist to put an orthodontic course, or curriculum, on Dental Town. And, I've been trying since 1998. It's just a no-show. And I mean, you would think on Dental Town with 205,000 dentists, that I could find one orthodontist to put like a ten part course on diagnosing, treatment planning, you know a curriculum of how to do orthodontics and I've never been able to find it.
Fabio: Okay, let me say this. There is one big difference the orthodontics that most of us do here in Europe, in respect to that is done in the United States. For example, a lot of orthodontists here use functional appliances, and it's not the same in the states. I don't know if it's for legal reasons, but you have also had an association for functional orthodontics in the United States that was absorbed by the International Association of Orthodontics, I believe. And, this means that we're treating very economically, from one point of view, a lot of children that maybe don't have the money to go into fix brace wear orthodontics in the second part of the treatment. But, we reduce a lot of class 2 occlusions and class 1 malocclusions simply with a functional appliance.
What I'm saying is that I believe probably the first course that should be set up by Dental Town, or Ortho Town, should be a course on general functional orthodontics, which is inexpensive. It's very easy for rural doctors, and it can deliver an immediate benefit to children. And, it has also a very important significance for interceptive therapy and it seem the worldwide now, even more as days pass, a very, very good type of treatment.
Howard: So is this something Fabio might do?
Fabio: Oh yeah, I could do that. It's-
Howard: Would you really do that?
Fabio: Sure, why not? I'll sign up for that, and I'll get another 100,000 orthodontists who hate me, but it's okay because it's fun to show orthodontics. It's okay.
Howard: Dental Town will get you hated around the world. There'll be dentists watching that from China to Brazil. I want to ask you the next most controversial question, I hope it doesn't offend you. There's a lot of dentists on Dental Town who say "you know what, Fabio? Occlusion, it's all voodoo. When these people are chewing, their teeth don't even touch. How can you tell me occlusion matters when the teeth almost never touch, and when they're chewing, they're just chewing on a bowl of some food, their teeth don't touch. And, furthermore, the occlusion theory, every 5 years, it's a different theory." What would you say to those guys?
Fabio: Okay, first of all, centric occlusion only happens when you swallow, and it should happen only when you swallow, not when you chew. So, we talk of occlusion because we talk of that full contact, that centric occlusion, as the moment in which one of the most, and one of the least functional, automatic functional reflexes happen, that is swallow. Swallow is an automatic reflex that is, it's sort of like zeros and resets all function. So, it is very important that this reflex, swallowing, happens at the lowest possible usage of energy.
Whenever there's a malocclusion, the energy you need to swallow is higher than normal, and you don't get a chance to reset easily, all the system. So, that's why occlusion is important, because if the mandible is in a relaxed position and it slowly moves into a centric occlusion that will not strain muscles and TMJ, the swallow will use up very little energy and you can probably swallow 2 times, one easily after another.
If you can ask a patient if he's having TMD problems to swallow 2 times consequently, and he won't be able. He'll just swallow once, and then he'll take some time to swallow again. His system is using up a lot of energy.
Now, this type of a balance, the muscular occlusion, it has been demonstrated to be the best idea, the best system you can have to have a functional temporal mandibular joint. That means we do not have any accommodation from the joint and the muscles. Everything is relaxed.
And now, I'm going to surprise you. There's a French professor of anatomy who studied a thousand cadavers and demonstrated that on the...in the joint, and on the ligament, the [pyterygoids, 00:14:51] the [masseter, and temporalis 00:14:51] all 3 muscles are on this ligament, and not only the [pytergoids(?) 00:14:58] as we thought until, you know, we learned at university. Now, if these muscles are all relaxed, don't you believe that the temporomandibular joint also is relaxed?
So, every type of occlusion must be a functional occlusion. That means these muscles must start their movement in a relaxed fashion. That's why electromyography has been used by a lot of dentists to prove that their occlusion was working fine, okay.
Then, mandibular tracking systems came on in the last 15 or 20 years, and they started demonstrating how fluid these movements could be. And then, from there, we also have neuromuscular dentistry, which is nothing I'm going to talk about today, because it's quite complicated.
But, I'd say that centric occlusion in a balance function with relaxed muscles gets you to start that swallow. That swallow with low energy and easy to do is a reset of all your [posture(?) 00:16:04], [craniofacial(?) posture 00:16:05] and then probably also body posture. If you don't have that coming in easily, if you do not swallow with your teeth in centric occlusion, but you put your tongue in the middle, you know, you're not swallowing correctly. That's when effect of the [craniofacial(?) 00:16:22] system.
Howard: So, could you summarize? What are the main international occlusion camps called and why did you pick neuromuscular? And, could you describe the basic different theories of occlusion, and then hone in on why you picked neuromuscular?
Fabio: Okay, first of all, I picked neuromuscular because in the specialty where I was in [Padua(?) 00:16:47] I was friends with Dr. [Balanchine 00:16:54]. His father was a friend of professor Jankelson in Seattle. So, he imported neuromuscular dentistry in Italy, and so, I knew him, and I was very influenced by him. Second, and most important of all, I like anything that was...that had to do with physiology, with just reasoning. And, most of all, I like the idea of measuring something, like measuring the activity of the muscle with the electromyography and seeing the movements of the mandible. Nothing could give me this that had not been neuromuscular dentistry.
On the other hand, I understand that occlusion was seen very mechanically. At least when I was at school, everything was with orthodontics was very mechanical like, you know, we do [cephalometric 00:17:53] tracing like everybody does, and we calculate the millimeters, and then we look at the casts, and then we look at where the cuspids were used up and then we were talking about the teeth should be in a class 1 dental position. And, this was all very mechanical. But, it did not tell us for what reason the mandible should be in that position and how function was delivered once that occlusion was obtained. That's why I was interested in neuromuscular dentistry.
And, there are a lot of occlusion theories. The more or less, that have more or less different ideas, but the concept that is the coming out in these years is that there must be a conservation of function. Now, that means you have to swallow correctly. Your muscles have be relaxed, and your TMJ has to work correctly. If these 3 basic functions are not preserved, the occlusion you have gained is not a functional occlusion. It won't work properly, and you're just creating a stress to the system.
And, you'll see that in a lot of, in the changes we've had in orthodontics where once there was a lot of extraction orthodontics, there was a lot of flattening of the mouth, and pulling back the teeth in class 2. And now, we're trying to move face forward, coming forward with the mandible and not flattening the profiles as it was done once. So, there has been a change in orthodontics as well as in gnathology where dentists were very mechanical at the beginning, and now research has demonstrated certain very important principles about the mastication cycles, centric occlusion, that have changed the idea and views of the general and the specialist, the dentists of specialty in orthodontics, and [anthology(?). 00:20:01]
Howard: So, how much of your practice is orthodontics versus TMJ, and TMD?
Fabio: It's usually about 70/30.
Howard: 70% regular orthodontics and 30% TMJ? Would you say yes?
Fabio: Yes, yes.
Howard: Yeah, and how are you diagnosing TMJ and what is your standard there? They're coming in with symptoms, and then what are you doing from there?
Fabio: Well, symptoms are usually headache, and jaw pain, and ear problems sometimes, and neck pain. And, first of all, diagnostics is clinical, and once you have an idea the patient has temporal mandibular disorder. And, first thing you want to do is treat pain, and to do that, according to the level of pain, if the pain is tolerable, you can start doing a functional analysis. That means complete mandibular scan, electromyography, and creating a bite for this person, which is called orthotic in neuromuscular dentistry.
On the other hand, sometimes pain is very. And, you can't just start treating it, taking casts, and trying to find a problem occlusion. So, probably the first thing you want to do there is treat very strong pain. So, you'll go into pharmacological pain side and there are little tricks that whoever treats TMD knows, and so, you'll probably want to treat pain first.
But, diagnostics for neuromuscular dentist would be to use mandibular scanning and then electromyography, and creating a proper bite. Usually, in about 90-95% of the cases, pain is gone like that (snaps fingers,) in about 1 or 2 days. So, that's no big deal. I mean, whoever does neuromuscular dentistry knows this, but nobody believes us. It's a fact, it's not an opinion.
Howard: So, what equipment are you using for this?
Fabio: Oh, I'll show you.
Howard: The brand name, and the equipment.
Fabio: I got it here. I'll show you right away. I don't know if you can see this. This would be my Myotronics K7.
Howard: K7 Evaluation System.
Fabio: Exactly, there you go.
Howard: Who makes that?
Fabio: Myotronics, Seattle. That's my laptop, and then we have...this is a TENS machine, which we relax muscles with.
Howard: And that's the Myomonitor? Is that also made by Myotronics in Seattle?
Fabio: Yes sir, and then we have the pre-amplifier of the EMG, that's also made from Myotronics. The whole system is fantastic. The only problem is, you have to study to get the know how to work properly all this type of machinery, and not all dentists are willing to do that; and that's a part of the refusal. We're measuring things here, and we can just print out the whole case and we know what's going on with the patient 100%.
Howard: And does Dr. Jankelson still run the company?
Fabio: His son, Bob Jankelson runs the company now, yeah.
Howard: His son, Bob Jankelson? What's his father do?
Fabio: His father is not with us anymore, I believe. His son now runs the company, but most of all, lectures around the world. And, Dr. Frey Adib, I believe he's the head now of Myotronics, the CEO.
Howard: Wow, and back to pharmacological pain, what are you perscribing for pharmacological pain for that acute patient?
Fabio: Well, first of all, I'm a medical doctor, so I can use...I don't know how it is in the States, but I can order some types of pain relief pills that probably dentists could not. But, in severe cases, I've used some [inaudible 00:24:49] morphine, and in severe cases, and an [amitriptyline. 00:24:53]
Howard: And what?
Fabio: Amitriptyline? Is that how you call in the States? Amitriptyline?
Howard: Uh huh.
Fabio: Okay, that's an anti-depressive that in low doses can, 10-20 milligrams, is probably also very effective in highering the tolerance for pain.
Howard: So this Myotronics has been very successful for you? How long have you been using this?
Fabio: Oh, I started with a K5AR, which is an oscilloscope. I started in 1987 working on a K5, and then I bought a K5AR that's big oscilloscope, it was very complicated to do, but we were tracking then. And, then I moved to the computerized systems, the one that you see now, is very compacted, quite easy to use. It's quite easy to use.
Howard: And right now, you're the president of the International College of Neuromuscular Orthodontics and Gnathology, congratulations on that.
Fabio: Well, I've founded this association more or less about 10 years ago, and it was part of an older association. It's a non-profit association, and to deliver the ideas of neuromuscular orthodontics. Myself and a very good colleague of mine in [Chenowa(?), 00:26:27], Dr. [Piero Silvestrini 00:26:28] we lectured around the world, and we lectured over 750 doctors only in India.
Howard: Wow, wow. And so, what is the website for the International College of Neuromuscular Orthodontics and Gnathology? Is it-
Howard: ICNOG.com, and how many members you have on there now?
Fabio: The members are automatically set up in my mailing list, and I have a global mailing list is about 7,000. But, I believe about 2,800 are members that applied directly because they had the direct application to the website.
Howard: And why do you think neuromuscular is controversial for you? Why do you think it's so controversial?
Fabio: Well, that's a big question. Well, one of the first controversies that was said some years ago was that the...was about the use of this machine, the older o frequency TENS, a lot of doctors said that whenever you use the TENS, you always have the mandible coming forward and that was no really rest position. Well, I think that was kind of...we've kind of went over that, and that was demonstrated from a lot of publication that this is not true.
And then, the other big problem we have in neuromuscular dentistry is that there are some doctors that still continue to state that the TMD problems are mainly psychological, and do not come from occlusion. And, I don't know what to say about this. There are so many publications, and that demonstrate obviously the opposite. But, there are still some doctors that fight forcefully that want to continue to state that TMD problems do not come from occlusion or in any way that occlusion is only responsible for a very small part of the TMD problem.
Now, this is the big debate we have. Then, there's another big problem that if you want to be a good neuromuscular dentist, you have to buy the equipment, okay? Not all dentists can afford to buy the equipment. It's not that it's that expensive, but there are a lot of dentists who are not willing to spend extra money, you know? Why? I'll show you. Because, when you start buying a CBT, and you go into [milling your old 00:29:28] things in your office, and working on 100 computers, and you're spending 200k for all this stuff, you don't want to spend another 30 or 40k for anything else. You're getting tired, you want to buy your Porsche, right? You want to buy your Ferrari, and you're taking away money from that.
And, you probably think you can treat TMD just by putting something, any sort of bite in the mouth, and make it very economical for you. And, to use this system takes time, you have to do courses, you have to study. There's confrontation with other doctors, and the courses sometimes can be expensive, and not everybody wants to go through this. So, that's why we have this small community. It's getting larger, though. Small community of neuromuscular dentists around the world.
Howard: And there's also...do you think there also has to be a hormonal element to TMD because women get it so much more than men? Do you agree that women get it more than man? And, why do you think that is?
Fabio: Yeah, well absolutely, women get it more than men. There are different reasons. Okay, one is probably hormones have something to do with this. We know that during the women's cycle, monthly cycle, there is an aggravation of TMD symptoms. So, probably hormones do have an influence.
There are some publications, on the other hand, that demonstrated that very strong headaches that are typically vascular and not from muscular tension do behave better if there have been a proper occlusion settled, that means if you put an orthotic in a patient who has migraine headaches, sometimes they'll feel better. So, I think there is an interconnection between anything that is vascular and has to do with orthotic, the treatment of the neuromuscular dentist.
There also are publications that demonstrate that [a good orthotic(?) 00:31:48] when well done, the neuromuscular concepts, it increases blood flow to the central nervous system. So, there are big discoveries coming out which demonstrate that there is a link, and hormones, of course, play an important role.
On the other hands, men tend to tolerate more pain. So, their level of tolerance is higher, and so, they come less to the office. But, there are a lot of men who have TMD and just support it, just go over it. A woman will probably be alarmed easier, and will not tolerate that sort of pain.
And, I think maybe the third concept that makes us all agree that woman have TMD problems, and they suffer from TMD problems more, is that probably the level of stress sometimes for women with children and a job, and a husband, is that level of stress lowers their tolerance and therefore, there are more symptoms.
Howard: Yeah, my ex-wife said divorcing me was the best thing she did for her TMJ. I just cracked up my son. Is there an age perimeter with women when they seem to seek treatment for TMJ more? Do you see most of the women falling between certain age perimeters?
Fabio: Yes, it depends also in the country you are. I'll tell you the truth, because I was talking to a doctor from Saudi Arabia, and women get married there at 16 sometimes, at 17, so they have children when they're 17, or 18, and we don't see that anymore in our countries. So, very rare, and they get into a lot of stress, a lot of work and they see patients, women patients with TMD around 25, 26, 27, maximum age, okay.
And, in my office, women with TMD are usually from about 25 to 35 in age, maximum 40. I've talked with other doctors in the United States, and they say they have different ranges, sometimes from 30 to 40. So, obviously there is a difference but that's why I link it a lot to the level of stress when you have family and kids.
Plus, you know, there are countries where women have like 7 or 8 kids, we don't see that in Italy, I don't know in the United States, but you know. 7 or 8 kids, then you're running to a job, you're running back, and if you have a little bit of...you probably don't chew your teeth as well as you should, you know? And you probably have a little bit of mild occlusion, it all starts, and then it just won't go away, and you can't sleep well at night.
One of the first questions I ask my TMD patients is how many hours they sleep? I want to be sure they sleep 8 hours, and I'm going to put them to sleep 8 hours. No matter what, okay? To cure a TMD patient, first of all you have to have all the basics there, you know?
Howard: I was talking to a Dr. Silvana Beraj from Tirana, Albania and she goes to Cairo, Egypt, and she was telling me how exactly what you said, that there's just so much more TMJ in Egypt than there is, just like in Albania among the women there in Egypt.
Fabio: I've met a lot of Egyptian doctors, and there are now many doctors in Cairo, several doctors in Cairo I've met that treat only TMD problems. And, their TMD problems come a lot from missing teeth. There are a lot of young people who miss a lot of teeth, and so they have a lot of jaw problems, and that brings them TMD problems.
And, it's quite different from what we're seeing in our countries in which maximum you get is 1 or 2 missing teeth. They have sometimes large missing in young people, and with no occlusion, TMD strain is easy. And, they're treating a lot of people there, there's big numbers, big numbers.
Howard: Just for, I'd like to get your explanation on your International College of Neuromuscular Orthodontics and Gnathology, explain the difference in orthodontics and gnathology.
Fabio: Oh, great. Orthotics is, I move crooked teeth, okay? With one objective, that is good functional occlusion. Gnathology is the whole study of the occlusion on the individual when he has a TMD problem. Because, when he has a TMD problem, if his level of tolerance is very small, that means you have to be very precise, and that's when all your gnathological study comes in. And, gnathology deals a lot with obtaining and fixing, fine fixing, an occlusion, and fixing an orthotic that is very precise to the prescription.
Howard: And these word originations, you know, I grew up, I went to Catholic high school, Catholic college, all that, and so, I take Latin, and all that. And, I once had a Latin priest say, 'all these words originate from Latin or Greece,' but he said, 'most of Latin was, you know, back to Greece, Sparta, and Athens.' Would you say almost all Latin comes originally from Greece? I mean, would you say gnathology is a Greek word or a Latin word?
Fabio: Gnathos. Gnathos is Greek word, okay, and when we specialize in orthodontics in Italy, it's a specialization in [foreign language 00:38:12]. 'Ortho' means straight. ['Gnato' 00:38:17] is mandible bones, and [foreign language 00:38:24] comes from teeth, 'dontic,' when you say 'dontic,' okay. [foreign language 00:38:32] is also origins in [inaudible/possible foreign language 00:38:36]. So, the big word of our specialty is 'ortho,' 'gnathology,' and 'teeth,' okay. So, yes, it comes all from Greek.
Howard: All Greek.
Howard: Interesting. So, let's switch gears back from neuromuscular back to orthodontics. Talk to...you're talking to thousands of American dentists, at least half in small rural areas. What could they be doing more with removable appliance in their office with children, as you were talking about?
Fabio: Okay. First of all, there are a lot of class 2 occlusions we see. Easily a general dentist, when there's no opportunity for this child to go to a someone who does only orthodontics, or a specialist, you know? First thing he can do is just probably expand the upper arch and use a functional appliance. He doesn't have to put on brackets, you know braces. He doesn't have to use all the complicated things that come with fixed appliances. So, we're talking of a removable appliance and a fixed appliance, only if we want to use a rapid palette expander, which is very simple. After rapid palettal expansion, a functional appliance will change the aspect, the face of the child, and will solve the big overjet.
Once that is done, you've done 80% of what you're supposed to do in orthodontics. That other 20% is probably your fixed appliance to straighten teeth to a perfect occlusion. But, if that doesn't happen, you've treated already 80% and that's a lot you can do in a rural area.
Howard: And what age range would this child be?
Fabio: Oh, from 7 to 13, 14, no problem.
Howard: And do you think you might build us an online course on this on Dental Town?
Fabio: Sure, why not?
Howard: I would love that, because so many of them... Plus, in rural communities, a lot of times when you tell your patient, "you really need to drive an hour to the big city and get this done."
And then, the parent's like, "I don't have time for this."
Howard: And then the schools graduate this kid, he doesn't have any experience in it. The parents aren't motivated enough to drive an hour into town, and so I think this is something that online continued education can really help these dentists treat their patients better.
Fabio: Sure. I think that's a great idea. I just like to remind what the general dentist can do. Like, when he's done that 78% of bringing the mandible forward and expanding the upper arch, the time that is needed for the fixed appliance, the specialty thing, the driving one hour to the city, is only done for a lot less time, and with a lot less expense. So, that means that that part of sacrifice, that probably the parents wouldn't do for 3 years, would probably do it for 6 months or a year. So, that changes the whole aspect of treatment. Absolutely.
Howard: So your 70% orthodontics, 30% TMJ, or TMD. On your 70% orthodontics, what percent of that is fixed hardwire braces, bands, brackets, versus removable appliances?
Fabio: Okay. My daughter is in dental school in Valencia, in Spain, okay? I can't wait to have her in my office, because the day she's in my office, I won't want to touch anymore, any fixed appliance like brackets, and braces, and wires. That'd be great for me. All I have to do is functional appliances. I can use them all, change the faces of my children, and then my daughter comes and does the fixed alignment at the end, okay?
So, whenever I can use a functional appliance, I'm going to use it in my patient, okay? At the moment, out of 100 patients, I'd say about 60 or 65% all have used a functional appliance. Okay, obviously not 100%. Not all patients need a functional appliance, but a lot can do with, and the results are amazing. And, a lot of orthodontists hate me for this, too.
Howard: And what do you think is actually causing class 2s and class 3s? Would you say it's just simple genetics? They were just born for this to happen?
Fabio: Well, genetics of course play a role. You know, you see a lot of class 2 mothers with big upper, tight maxilla breathing problems, and you'll probably have the child that is the same. So, I think one of the main reasons we see a lot of class 2 is about thumb sucking and respiratory problems. And, thumb sucking will just keep the mandible back and push the upper maxilla forward, and will not deliver the proper physiological ambiance for the tongue to move, probably will not expand the upper maxilla. And, this has been demonstrated from a lot of publications, that in order to have a good function, you have to breathe correctly.
So, what we do now is that we look a lot of how the child is breathing. I usually, the first thing a class 2 occlusion, I do with a class 2 occlusion is I assess the quality of breathing of the child, obviously. And then of course, the [palette 00:44:45] functions. So, if the child is chewing his thumb, or is thumb sucking, you know that's a big problem we have to deal with. There's a lot of psychological work also for the orthodontist. He's got a lot things to work on.
Howard: And a lot of these dentists listening to you right now, I mean, they have children of their own, you know? I raised 4 boys, I had a thumb sucker. When do you think thumb sucking has to stop before it's going to cause an orthodontic...an issue?
Fabio: You know, did you ever see the little baby on the scan, mother is about 8 or 9 months, and he's already thumb sucking? So, that's when it starts, sometimes. And, I believe in order not to risk, okay, before 24 months.
Howard: So at age 2, they got to stop. Yeah, I've seen these, you're talking about ultrasounds.
Howard: Where they're showing these babies in the womb, sucking their thumb.
Fabio: So, if you can get them to stop before 24 months, of course the ideal is much earlier, or to have them not suck at all. But, having them suck to age 3, 4, 5, can start create some problems. On the other hand, something very interesting is that these thumb suckers, when they're very small and I get to see them, you know, of course I don't treat a child of 24 or 48 months. But, what I do is, if the parents can get the stopping sucking on the thumb, I'll send the babies to an osteopath. And, he'll do some cranial manipulation, and believe it or not, I've seen big differences after osteopathic intervention on these small children. And, it's getting very interesting now, and how osteopathy, how a cure practor can help re-equilibrate this equilibrium of the cranio that is going on at that age, and that interests us in orthodontics a lot.
Howard: You know, it's funny because dentists in America are very against alternative health care, holistic medicine, all these things like that. And, I think they have blinders on because you know, a businessman should always be listening to the market. And in my 53 years, I have sensed a growing distrust of the American medical system where you know, they're always trying to make you take a pharmaceutical pill, and doing some surgery.
Like you know I had, my mom took me to the doctor, I was sick. So what'd they do? They ripped out my tonsils and adenoids, you know? And now, that probably wouldn't happen in 2015. And, it's funny that the market is growing alternative medicine, holistic, naturopath. It just seems like every smart old man I talk to will exhaust every natural alternative before they'll go to the doctor because they know he's just going to want to write him a prescription for a pill and, or do a surgery and cut something off. I mean, it almost goes back to the ancient medicine man where you went to the medicine man, and he made you a lotion, or a potion, did a dance, and then pulled out his knife, and cut something off.
You have a very unique alternative that you're extremely familiar with both the United States and the Italian dental communities. What would you say, are there any real differences between the Italian dental community and American, as far as like insurance reimbursement, water fluoridation, types of treatments, specialties. Any differences that might be unique or interesting?
Fabio: Yes, there are some differences. You know, we're all a big family when we're talking about dentistry. You know, we're more or less, we're all the same. When I speak to other dentists, they like cars like I like, and they want to show them off. I don't show off my car anyway, but, you know. A lot of dentists are golfers, I'm a golfer. I go golfing, and there are a lot of dentists, because we have sometimes we can get our free time when we want, you know? So, we have a lot of things in common.
What the big difference between us Europeans and you Americans as a job, is that you have a lot of legal things. You have a lot of things, like whatever procedure you do, has to be a standardized procedure that is very legal, and you can get stuck with it. You can get a lawyer right after, okay? For us, it's a little different.
When a dentist or a medical doctor is in Europe is an artist. It's an art. It's a profession of art, and that means that a lot has to come from our personal judgement. And, treatment of [tentatives 00:49:53] most of all, and I'll give you something about it here, have to be [foreign language. 00:50:00] That means, first of all you're not supposed to harm the patient.
That's why we are very open to holistic medicine, and that's why we've had some fantastic orthodontics, orthodontists, and European doctors write fantastic books like Professor [foreign last name 00:50:18], she's French. And, she started treating skeletal problems of orthodontics and [maxival 00:50:28] facial interests using the help, with the help of an osteopath and cure practor. And, she's become very famous, and there are a lot of doctors that have come from the United States for her courses, and this happens every day in Europe. We try to be very open to alternatives that do not harm the patient, that can only do some good.
I mean, this is one of the reasons why the procedure of functional appliances in America doesn't work that well. Why? Because when I deliver a functional appliance, if I don't have the kid bring it, carry their appliance in his mouth, for at least 15 or 16 hours, I'm getting no results. And I can get sued for that, and nobody wants that. So, the no-compliance therapy, which was born in the states, it's getting worldwide because you know, it's very easy for the orthodontist to just deliver a fixed appliance where there's no compliance. So, patient doesn't have to do anything and he gets the results. That's very mechanical. It's not very muscle function, that's what functional orthodontics is.
So, there's the big difference, okay? You guys have to deliver in that time table, that result, or he gets sued. In our country, you get sued if you do something really bad, and really bad, and really wrong. So, we have more space to deliver treatment options.
Howard: You know, the United States has one million attorneys, and I want to get a law passed that every time we take refugees from a country, we send them the exact same number of our attorneys. So, if you want to send us 200,000 Syrians, we'll give you 200,000 of our attorneys. We'll just make it an even trade.
And yeah, I see so much more alternative healthcare in Europe. Like, [Marchin Delecia(?) 00:52:31], a dentist in Warsaw, Poland, I mean he calls himself a chiro-dentist, and, chiro-dentics. He considers himself half chiropractor, half dentist, and he calls it chrio-dontics, and been just extremely successful in Warsaw, Poland. And he's like, "there's not a chance this would ever take place in the United States."
I've been in his practice, and I've watched him treat patients all day long, and I mean, just amazing, I love...and this is what the internet can do. I can't believe I'm sitting here on a Friday at 11:15, and what time is it in Italy right now? 7:15?
Fabio: Yeah, 7:15.
Howard: Yeah, I just think that's so neat that I'm sitting here in the United States at 11:15 in the afternoon on a Friday, talking to you in Europe. That's just, the internet is so darn cool. So, I only got you for 6 more minutes. We're already 53 minutes into this. Anything else you want to talk about? The last 6 minutes? Any other subjects you think you can shed light on?
Fabio: Well, probably the last thing I wanted to talk about is that dental school. Dental schools in Europe. There are a lot of private dental schools in Europe coming up, they're very good. Beautiful places, beautiful cities to visit also. And actually, if you want to go into dental school and you don't get into dental school in the states, or you just want to experience coming abroad, we have some fantastic dental schools in Europe that are now private and very good, like in Valencia, Madrid, Spain, or [Entora(?) 00:54:11], or there's one in France also that I know of.
And, all these dental schools are very high quality, with since they're private run, they can have the big professors, they choose coming from all over the world for lectures, and it's fantastic. And, you'll be very surprised, if you go and check how they're doing in Hungary, and [Bulgaria(?) 00:54:33] which were countries that we were not even thinking of 10 years ago that have fantastic dental schools now, and medical schools also running. And of course, England.
Howard: I want to go, going back to changes between the United States and Europe, specifically to Italy. In America, 80% of the patients that come to the dentist have insurance, private from their employer. Is that the way it is in Italy, or is 80% of your patients coming to you and having insurance paid for by where they work to pay for part of the treatment? What is the insurance mechanisms like in Italy?
Fabio: Okay, let's say that out of my patients, about 90%, 95% would not have any type of insurance. So, I only have 5% of patients in which the insurance comes in and pays the part. In my office, I work with my wife, she's a dentist, she does all the bloody job thing. She works with about 30% of insurance, so her job is 70/30 with insurance. Mine would be 95/5.
Howard: So why do you think that is? Why do you think Americans go to the dentist only if their employer is paying for part of it? And, why do you see...like, you go to Brazil and China, they don't even know what insurance is. So, why do you think American dentists think they have to do everything the insurance company says, and just be totally insurance-driven? When you go to some of the greatest civilizations on Earth, and they don't even have dental insurance, and people just pay for dentistry like they do their cars, houses, TVs, radios, iPhones. Why do you think that is? You think it's just cultural?
Fabio: Well, sometimes it's not wise to work with an insurance company. For example, I'll give you an idea of how it works here. Some people come in with their insurance and their insurance is willing to pay that fixed amount for the treatment, and they don't want to add anything for the treatment. If I'm willing to work with that insurance, I have to accept their policy, okay? For me, it's not convenience. It's not worth it. So, I will refuse to have any contract with any of these insurance companies.
On the other hand, there are insurance companies that work in a more elastic way, in which I do have confidence, and I work with. I believe it's probably the same in the United States. I mean, if a doctor will not accept insurance, you expect the payment from the patient, and then the patient can do whatever he wants. I mean, I think there is still this liberty or, am I saying something wrong?
Howard: No, I think you're on it. I have 2 more differences. A lot of patients, or you hear people on the internet say that Europe is banning mercury amalgams. Do you think that's true? Do you see a lot less mercury than when you came out of dental school? Are there any specific European countries that have outlawed and illegalized the use of an amalgam filling that has mercury in it?
Fabio: No, it's not outlawed in Europe that I know of. Maybe, in a country. I don't remember, to tell you the truth. I can just tell you what my wife has been doing. It's been 28 years, she's been not using mercury. 28 years, and whenever she's taking away the old fillings, she has...it's like a, she looks like a neurosurgeon, you know? Because the fumes, when you take out the old amalgam, they say can harm you. And yes, I believe they can harm you, and I believe that also sushi with tuna harms you, because the amount of mercury in tuna is over 1 milligram per kilogram. So, that is very, very high amount. That's over any limit of any country in the world, but nobody talks about that.
So, we have mercury all over, and we want to reduce any way the quantity of mercury coming in contact with. So, the old amalgams had mercury, and we want to get rid of that stuff, and it's not banned. But, I know that at least 90% of the dentists I know, do not use mercury at all anymore.
Howard: 90% of the dentists that you know do not use silver fillings with mercury anymore.
Howard: Okay, and then my last question, I only got you for 1 more minute. What is the status of what community water fluoridation in Italy? Do they add fluoride in the community drinking water to reduce decay, or not so much?
Fabio: Okay, yes they do. Every little community, okay, can run their own tests on the water, and decide if chemicals, any type of chemicals that are added to the water are safe for the population or not. Now, in preventive medicine, we've seen that adding fluoride reduces cavity, and we also know that in order for this to work, people have to come in contact with a certain amount of fluoride during the year. Many towns and many cities now do not have fluoridation of the water, but some still do.
Now, the problem is that we've had a big problem if you can remember [Chernobyl 01:00:28] in Russia, when you know, we had the nuclear problem over there in Russia. And, the problem was that with that the fluoride that was being delivered was thought to have a contamination from the spill out, the fall out, nuclear fall out. So, in that period, everything ended, you know? Fluoride treatment, home fluoride treatment, and a lot of fluoride added to the waters. And, as of now, any doctor knows that if you do not take your pill, fluoride pill, for at least 250 days out of a year, it won't change the outlook of cavity, and that's the same if you put fluoride in the water. If you do not have that contact, drink enough of that water, that will not provide any preservation of your beautiful teeth.
Howard: And so, we are out of time, but I just got to ask you, you know everyone's supposed to talk about religion, sex, or politics, or violence. But, since I went to Catholic school, my 2 older sisters, Mary Kay and [Jean Marie 01:01:40] went straight into the Catholic nunnery, right out of high school. My older sister's been a cloistered carmelite monk for longer than I've been a dentist. I have to ask you, what do you think of the new pope? Pope Francis? I mean, I just didn't see it coming. I mean, he is an international rock star, wouldn't you say? Would you agree?
Fabio: Yes, he's very cool. Italians love him! He's really cool, I mean he's funny at times, you know? And, he's very close to the population. I'm no type of religion, okay, so I'm not...I don't go to church as much as I should. And, okay, and I cuss sometimes, okay? So, and I get mad at my child, so I'm not that good of a guy, you know I can believe that.
But, Pope Francis is changing something. We're going into a change, and we still don't know what's going on. I mean, we know there's a big change coming, he's working it undercover, okay? Like an undercover agent in the Vatican, and like an undercover agent around the world. And, we'll have to just wait and see what this big change is about. I think finally, we have a person who has the courage to a change, because, that was the whole point. Nobody had the courage to change.
Howard: And then I gotta ask you, 1 more politically incorrect question. Americans are always wondering if the Euro will stay together, and it seems like half the articles are like, 'when it's Greece, or this, that it's going to fall apart.' Then, the other half of the articles say, 'it'll never fall apart, they love the common currency.' Some people are saying that Europe doesn't even need a common currency anymore, because we're now in a cashless society that just uses credit cards and the credit cards have no problem converting currencies or whatever.
So, I gotta ask you, the takeaway. 20 years from now, will the Euro zone still be together? Common currency, [brussels 01:03:41] they had, or do you see it crumbling apart and going back to individual nations?
Fabio: Well, that's a big question.
Howard: I know, I know, and I'm sorry I asked it. But, I couldn't resist.
Fabio: Okay. I think it still be there. I think it will still be there for one simple reason, anything away from the situation, going back to the old era, or old currency for any country, would not be something 100% positive. It would be another big change. We already had the change with the Euro, okay? And, [owning(?) 01:04:21] together, Europe together, can start having a currency that can work with China, and United States properly. There were too many differences before. So, I think, yes. Everything is electronic, you know, you don't need all that currency. But, if you have 3 or 4 currencies around the world, without all the little small ones? You know, Italy was a small country. Spain was a small country. Our currency was devaluated every year. So, what was the use of it?
On the other hand, the problem of the European Union, maybe the currency is the last problem. We got bigger problems than currency.
Howard: Well, I'll just leave on one note that I think is kind of humorous. You know, they're always talking about the Greek bail out, or the Greek debt, or whatever. I think it's kind of funny, because the United States is like a Euro zone. We have states, like Kentucky, that have lost money every single month. I mean, so the United States, we just know that richer states like California and Connecticut are going bail out states like Kentucky every year, forever. I mean, some countries, they run at a loss, and Greece just might be your Kentucky. Some day you might just have to eat that bill.
But hey, I tell you what, it is such an honor that you spent time with me and I can't believe I got an orthodontist to talk to a low life general dentist like me. And, if you could ever put an online course on Dental Town, it'd be such an honor to have someone of your statue, from Italy, putting a course on Dental Town. That would just be really, really neat.
Howard: All right, yeah. There's 2 Howards at Dental Town. I'm Howard@DentalTown.com, Howard Goldstein, he's the online CE, so his email is HoGo@DentalTown.com. But, if you ever have time to put up in any course you want on neuromuscular, or orthodontics, interceptive for children in the rural practice, or whatever you want to do. Thank you so much again, for spending an hour with me.
Fabio: Thank you, you've been great. It's been fantastic to speak with you.
Howard: Thank you, have a great day. Or, good night!
Fabio: Wait, if you ever come over, I'm waiting for you here. We go out to dinner, and show you around a bit, okay?
Howard: Well you know what, I got 4 boys, and so we did tons of family vacations and all that stuff. But, on my lecturing, I like to take one with me at a time for just an individual father-son trip, and my oldest son Eric says his favorite vacation of all time was when I took him to Venice. When I lectured in Venice, and I took Eric with me. He still talks about how he thought that was the coolest city he's ever seen, and that kid's seen a dozen countries.
Fabio: Okay, fantastic.
Howard: All right, well have a good day! Okay, bye.
Fabio: Bye bye, thank you.