Why Introduce Aligner Therapy into Your General Practice

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing how carrying out simple digitally planned orthodontics using aligners can provide safe aesthetic and functional dentistry, which is accessible to many more patients and can be delivered by every dentist. Our guest is Dr. Tif Qureshi, a clinical director of IAS Academy and an experienced teacher in the Dahl concept to assist in minimally invasive patient-centered dentistry. He pioneered the concept of alignment, bleaching, and bonding, and also progressive smile design, and teaches this widely using clear aligners. Dr. Qureshi, it's a pleasure to have you on Dental Talk. Thanks for having me, Dr. Klein. Good to talk to you today. Dr. Qureshi's in UK right now. So we're about, I guess, seven hours difference. He's winding up his day. We're kind of just before lunch. So we're going to see if we can synchronize our thoughts, even though we're in a different meal plan right now. So we'll see what happens. Absolutely. So I don't know if you know Dr. Qureshi, and again, talking to the audience, but he's done some phenomenal things using aligners. And he actually coined a procedural concept called progressive smile design, which is very interesting. So I recommend... all of you to check out his webinar. If you're, especially if you're GP, if you're interested in using aligners, I absolutely encourage you to check that out. So that is a webinar that you can find on VivaLearning.com. His name is Dr. Qureshi. It's spelled Q-U-R-E-S -H-I. Q-U-R-E-S-H-I. So just, that's all you have to do is just put that in the search field and you'll find his webinar. So to begin this one, some people say Dr. Qureshi that general dentists should not really be doing ortho what do you say to that probably the polite response to that is that i think that actually um the more general dentists do ortho the better the luck the long-term outcomes many patients will actually have and one simple question i would ask back to somebody who said that to me is well if i was your patient and i was a general dentist say you know i'm seeing a general dentist And I have a constricting envelope of function. So we know what a constricted envelope of function is, but the idea with continued tooth crowding is that it keeps moving. So if you have a constricting envelope of function, how does a general dentist who doesn't do ortho mean to fix that problem? And one of the problems globally, it's not just the US, UK, globally is there has been this kind of idea that somehow dentists shouldn't be doing ortho. There's some countries where they're not even allowed to. And actually all that happens is many patients who, have a constricting envelope of function and not everyone has that let's face it but some do many of those patients with repeatedly chipping front teeth end up with composite fillings getting bigger and bigger and eventually turning into crown veneers or crowns or god knows what and the reality is is that you know if these patients are treated early with aligners yeah they have a correct overjet overbite recreated with ortho then actually restorative treatment is so much easier so The simple fact is I think people who say that don't actually really understand long-term occlusal changes from continued tooth crowding because continued tooth crowding is a huge problem that actually the profession I don't think is really appreciated properly not just as I say not just in our countries but right the way around the world so it is something really that every dentist should be looking at every day because patients teeth change and this is the thing we've got to understand I'm a testament to that because as we talked offline, Dr. Koreshi, I have severe lower tooth crowding, which has caused my upper incisor to chip because of the incisal guidance. I'm edge to edge now. I lost some incisal guidance, lost all of it. And then if you lose incisal guidance, you're looking at molars problems and so forth. So, you know, it goes back to your first year in dental school, form and function. And, you know, they teach that to you in dental school in the first year. And then. I don't know how much they reinforce that for the rest of your academic career and then into your professional career. That's right. I think the problem is that a lot of the people that teach us, and I have huge respect for the people out there that teach dentists at a basic level, but one of the biggest problems is a lot of these people don't take pictures of patients over the long term. And unless you are taking photographs of patients, occlusal pictures, anterior shots, guidance shots of patients every year, every two years, every three years, you're not going to notice teeth have changed. And I would argue even more in the field of academia, where patients perhaps are treated in the hospital environment in teaching. I mean, are they really going to see patients over 10, 15 years? No, they're just going to see a transient population. Really, it's been general dentists who have been... fortunate and are privileged enough to be able to build relationships with their patients over years, we're the ones who are going to notice changes. We're the ones who are going to see it. And I've been lucky to be working in literally the same practice for 30 years. So from the day, almost from one year after I qualified to now. And as a result, I had a huge kind of library of patients that I treated, but also patients that you didn't treat. And it is fascinating when you look at people that you don't treat, what actually happens to their teeth, because then you can start to really build up a picture of the changes that are likely to occur. Right. Now, so when you see a patient that needs aesthetic dentistry and they're looking for a fast fix, they're looking for a veneer, they're looking for a crown, they saw their neighbor who had their teeth whitened and had veneers and they're like, I need to have this. How do you change their mindset so that they're willing to go the long haul here with something that... will be much more beneficial in the long term for them. What's your pitch to them? Great question. Well, you know, we always hear this kind of argument and I used to have this conversation with patients and you'd say to the patient, you know, I can do ortho on one hand or we can maybe do veneers. And we've all heard this argument where the dentist says. I did veneers because the patient didn't want ortho. You've all heard that, okay? But listen, let's park that idea because that's not actually the question you should ask patients. If patients have crowded teeth, what you should be telling them is, okay, if you don't want ortho, that's fine. But if I do veneers on your teeth, there's one thing that you've got to understand. You're going to need to wear an orthodontic retainer. If you do veneers or crowns, on crowded teeth, they are highly likely, not always, but they are highly likely to continue to move. The funny thing is when I tell a patient that someone who wanted veneers, that actually they're going to potentially need to wear an orthodontic retainer anyway. It's amazing how many of them suddenly say to me, really? Oh, in that case, I just have the ortho. So I think part of the problem is I don't think that we are fully consenting our patients and helping them understand the truth in behind tooth movement. And as soon as they get the idea that the teeth keep moving, they're far more interested in orthodontics. So it goes back to my point that really everyone needs to be offering ortho. And you know what? Even one basic treatment that many, many patients don't even get, people who haven't even had ortho, is to give them actually an orthodontic retainer. So if you identify crowding early, you don't necessarily have to treat it. But literally there's an argument that 85% of people should be wearing orthodontic retainers. And in your patient population, what do you... seeing as the most crowded area that fits this whole situation? Typically lower anterior crowding, which is very common, you know. I think there's, obviously, there's a wide variety of malocclusions many people have. But, you know, the classic type patient who starts with class one occlusion, if their lower teeth start crowding, their lower incisors can start to move to a kind of class three edge to edge tendency. You've also got the type patients who, you know, a little bit class two, div two, and then their bites deepen. You know, I often say to people, if you see somebody with a class two, div two, even if it's a mild situation, have you ever seen that get better? You know, class two, div two is... get worse the bite always deep The fascinating thing is there's very little data or science or evidence that kind of shows or studies that have shown how, say for example, a class 2, Div 2, how the bite changes and how it actually affects the occlusion dramatically. We all know it does, but the studies just haven't been done. And again, I think this just comes from a kind of lack of perhaps the people that would be doing the studies to actually see and understand that long -term issue that occurs. So yeah, I mean, it's... a lot of it is anterior crowding. The key thing with general dentists is, and general dentists do an ortho, is that it's really, really important that the treatment, particularly if you don't have experience, the treatment is limited and that you understand what we can treat versus what we shouldn't be treating and what we should be referring. That is super, super important. Yeah, that was actually my next question, exactly what you just said. So in the beginning of this podcast, we talked about how GP should be... absolutely doing ortho. Number one, how much training do they have? Number two, how much confidence do they have? And number three, where do they decide this is beyond my scope of expertise and it's time to refer out? So those are the key things because if everything's done within someone's limitations, then the outcome is predictable and most likely would come out quite well. Absolutely. I mean, it's a great question. The fact is everyone needs some training. Everyone needs some mentoring. And what we always say is, I mean, obviously, this is something that I teach and I sort of train dentists in this. And what we always do is we take people down a kind of pathway. And most people's first experiences really should be simple cases in the anterior zone and anterior alignment from, you know, we call it five to five or premolar to premolar. That's generally suitable for most dentists. But again, within within limitations, because. The most important thing is every dentist should know how to be able to diagnose and assess at the same level as a specialist. So the point being is that we've got to be able to assess and diagnose a case. and help the patient understand the difference between an ideal treatment plan which might involve referral to the specialist versus perhaps a compromised treatment plan where maybe you know the class 3 molar half cunit class 3 molar is accepted and just left alone maybe a posterior cross spite is just left alone but all the patients interested in is just getting the anterior five to five tick the line nothing wrong with doing that as long as the patient is fully consented of what the gold standard treatment is and of course you know teaching dentists that approach is super important there's a lot of kind of learn how to scan and whatever aligner systems out there and they're not really helping doctors understand the difference between ideal you know gold standard versus compromise and they just want to take your scan and set the case up that's fine but only if you've consented the patient properly and done a full assessment Right. So obviously the dentist has to get some additional training after dental school. What kind of aligner system are you using in your practice? I use a variety. One of the main ones I'm using at the moment is SureSmile. I'm actually teaching for that system as well, which is obviously, you know, there's some SureSmile cases on my webinar as well. SureSmile from Dentist by Sirona, SureSmile aligners. and one reason i like that platform is it was originally a platform which was developed for orthodontists quite a high-end quite highly technical platform actually and it's been sort of slimmed down a little bit and still some of the cool features are there for general dentists so it's quite a you know it's quite a lot of control with that particular system i'm running a program for them which basically does take dentists through that pathway where again we give some education And then very importantly, we have some mentoring kind of built into the courses. So before the doctor actually even can submit a case, they'll have the opportunity to speak to our trainers and say, is this case suitable? Is my plan correct? Are my records defensible? I mean, that's quite a scary term, but it's important. Are my records defensible? And is my plan correct? And then at that point, we can then help sort of submit the case. help refine the case so we can look at the digital setup is really important because you know the plan is as good as they are they're not dentists and it's important to understand that when you get a digital setup back as a dentist you can always improve on it you can always ask to change this change that and refine it so we'll help do that and then mentor the mentor those cases all the way through to completion we found doing that um and we've been teaching this sort of approach for for many years in europe really gives doctors the confidence and the guidance so they can get going with cases and know you know they're not going to make mistakes along the way right so they have help from the company to help support their whole treatment plan and guide them through the process which is really important absolutely you talk about the lifetime patient in your practice you mentioned that you've been following and treating the same patients throughout your career from the time you got qualified in UK. So tell us about that concept. Yeah, I mean, you know, the idea of this really is I am going to do an examination a little bit different perhaps to the standard dental examination because there's a couple of extra facets that we add in and we add in ortho-restorative parameters. And what I want my patients to understand are several things as well as, you know, what their periostatus is or what their caries, which is hopefully zero. I want them to understand what direction their teeth are likely to move, how that's going to change their bite, is it going to contribute to anywhere. I actually want my patients to understand what an envelope of function is. I know it sounds crazy, but it's a five-minute conversation with a patient. Once they understand, what I do is I call it tooth sat nav, and we sit down and we look at the photographs, we play tooth sat nav, so it can help, we sort of work together to understand what direction the teeth are likely to move. We'll do a fremitus check and just see, are we getting more contact pressure on certain teeth under loading? And all of these things, I'm not trying to panic the patient. It's all about gently guiding them and helping them understand what's going to happen. And ultimately, I reassure them. And then I say to them, look, we can monitor it. We can retain it. And whenever you're ready, we can treat it. And you know what happens? Pretty much once a week, several patients will walk in and they'll say, hey, Tiff, you know that? tooth you were talking about that was drifting and it was knocking my upper one you know i'm sure it's going darker and i said yeah you know that's because that's dentine on the surface of your tooth and it's going to absorb stain blah blah blah and the point being is most of the treatment most of the patients that i treat for big treatments are patients that i know already they are not patients that i've had to market and you know i've got you know got nothing against doing evening opening, open surgery sessions and getting people in and scanning them, that's fine. But I believe it's much safer to treat patients that you know and you have a relationship with already. And if these patients become also restoratively aware and functionally aware, you get your own patients asking you for treatment. And what's better than that? you know how many patients who you know are likely to turn around and make a complaint and blah blah blah you know what i mean it's kind of like no it's actually it's shifting the risk basically it's a great philosophy and it's a service of the patient i mean you're you're thinking this as more of a medical approach um long term at least for those good physicians out there that look long term and look at the whole body health system like you are um so Before we wrap up this podcast, can you briefly tell us about something that you actually coined Align, Bleach, and Bond? Just real briefly, and what you call the progressive smile design approach. Back in, you know, 98, 99, 2000, I was a big-time cosmetic dentist, but I was a big-time cosmetic dentist in a general practice in a rural community. So actually, I had to see these people again. And although I wanted to do, and I did a lot of veneers, I loved doing veneers at the time. there were times when i felt uncomfortable and it was really the only option as soon as some ortho came along what was really interested in i started doing a little bit of limited ortho And all of a sudden, I would sort of straighten someone's teeth who wanted veneers because I wanted to do less preps, basically, or do known preps. And as soon as I started whitening their teeth, the patients who had these really profound kind of smile design goals, all of a sudden, as soon as I straighten and whiten their teeth, they just wanted a wedge bond. They just said to me, hey, what can you do about the edge of my teeth? And I said, well, I can put some bonding. But, you know, I said, but you know what? I haven't really widened your buckle corridors very much. I haven't reduced your gummy smile, et cetera, et cetera. You wanted all that stuff done. And all these people who thought they wanted one thing with ideal smile design parameters all said, not interested in that, just fix the bonding. And this is what progressive smile design is. It really allows people to see their teeth improve incrementally. a bit at a time to make a better more informed consented decision and rather than just jump straight into ceramic porcelain ceramic composite veneers and yeah i know for some people that's still going to be the right option but honestly I can say for most patients, if you straighten and whiten their teeth, they will not end up having veneers. And let's face it, that's got to be the best thing when you think about the whole concept of the replacement event long term. So that's what Align Bleach and Bond is. I kind of created that term many years ago, and then it kind of turned into progressive smile design. Right. And on the edge bonding that you do, that's obviously much quicker. and very easy to repair compared to a veneer right the last thing you want to do is have a veneer fail when you get up in the morning yeah that's going to ruin your day so with the edge bond though how durable is that where it's not this edge bond is not popping off great question great question well the first thing to say is we've moved the tooth out of that constricting envelope of function there's that so one reason a lot of composites fail is because they're placed within a constricted envelope that's changing and continuing to change So that's one thing. The second thing is I kind of developed this technique using a couple of certain types of material where basically I'm just I'm layering the material using a kind of dentine and then an enamel but really fundamentally only using two increments and it's hard to explain in a podcast it's kind of something that we teach but but basically by using this particular method it actually blends really well so you don't see a join so you don't need a bevel and it has great strength because I'm not making, using like 15 different increments. The reality is on the edge of the tooth, you want as few increments as possible. Otherwise, you're going to start building air layers into the teeth. In boxes and in cavities, yeah, you want increments to try and distribute the stress. But on the edge of the tooth, I want the biggest, most solid, strongest piece of composite that I can get that is, when I've taken it out of the tube, hasn't been ripped. torn and air layers put inside it so there's a certain method of edge bonding that we use that really does give good strength and i've got you know good 12 13 years now of cases that you would imagine would have broken by now uh but they haven't so that's fundamentally the reason why they're not breaking is because the occlusion is set up with the alignment process that you do prior to that and then you do the bleaching which is the bulk of the tooth and then you've got the edge taken care of with the bonding and those edges aren't really under the crazy abnormal forces because the occlusion is set up properly the occlusion is better but on top of that the layering is it is there's very little layering so it's literally just two increments of material a dentine increment and then an enamel increment rather than having an i don't use like enamel shells and colors and tints don't use any of that stuff you just it just keeps it super simple and it makes the whole and i cure literally the whole dentine in one go and then the whole enamel kind of window so to speak in one go and that actually then reduces um stress layers in between the teeth in between the the layers composite the aligners that we're using today and the aligner technology that you're using with dense glycerona or the material um which i know is a tremendous company and they lead the way in this both in the actual materials and the science and the education that's really the setup then the vp really has to appreciate what they could do within the realm of their office using aligners to get these teeth set up so that you can minimize the amount of tooth structure that you have to remove which often in veneers is it could be excessive definitely definitely and the one thing i really like about the the software is is it gives you the ability to look at some of these ortho restorative parameters in a way which i think is better than a lot of the other kind of systems out there in that you can take a almost like a cross-sectional view through the teeth as you spin through the arch so you can actually check where the kind of the constriction would be versus the correct envelope function might be overjet overbite all these things are easy to measure contact pressures all easy to measure as well so it's really smart system and I found it highly reliable the other thing that I think is quite cool is that and a lot of learner doctors don't really understand this is that you can vary the trim line a lot of people kind of assume that a line on an aligner is the gold standard no it's not that's actually fine for some cases but if you've got patients you've got you know short clinical crown heights and and basically I've got tipping well then you might what you may want a higher finish line in fact in most cases you want a higher finish line towards the end of the treatment you don't want to scallop so I found that actually it's far more customizable than some of the other systems out there And so I can look at the case, decide on the tooth anatomy and what type of movement's going on, and I can then choose my trim line according to what I need. So there's some quite cool things like that within the system and software. Great discussion, Dr. Qureshi. We really appreciate it. I think it's absolutely wonderful to have dentists in this world that think along the philosophy that you do, which is a longer-term approach. You're looking to minimize tooth structure removal. You're getting much more success and patient satisfaction out of a much more intelligent approach to solving the problem because by doing these restorative procedures without understanding the occlusion, you're setting yourself up to fail. So it was really a pleasure to talk to you. We hope to have you on more educational programs with Viva Learning in the future. So Dr. Qureshi, have a great weekend and thank you very much. Thanks very much, Phil. Nice to meet you.