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Howard :
|
It is a huge honor today for me to be in Medan-did I pronounce it right?-Medan, Indonesia.
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Dr. Ronnie:
|
That's right. Medan or Medan. The Malay pronunciation would be Medan.
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Howard :
|
Malaysia would be Medan. With one of the biggest rock stars in aesthetic dentistry in Asia, Dr. Ronnie. How are you doing, Ronnie?
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Now your name, Dr. Ronnie Yap-Yiroon, Ronnie is just-you go by Dr. Ronnie because that's a name-
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Dr. Ronnie:
|
It started as a nickname, because my first name is Yiroon, but my father's friend, when I was young, he had a hard time pronouncing it. He was from the UK. So he gave me a nickname, Ronnie. And it sort of stuck from that day onwards.
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Howard :
|
You know I had the same experience when I was in Shenzhen. I was talking to a friend of mine. I said, "So, Godfrey," I said, "is that your first name or your last name? What's the rest of your name?"
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Dr. Ronnie:
|
My family name would be Yap, Y-A-P. So my first name is Ronnie. It's just easier, just call me Ronnie.
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Howard :
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That's what Godfrey said. He said, "Look," he says when we were in Hong Kong, in a British school, he goes, "We all learn by the first grade that no non-Chinese, no Americans or British will ever be able to pronounce names, so we just," he says "we stood in line, there was a basket of names and I pulled out mine and my British name given at school for first grade was Godfrey."
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Dr. Ronnie:
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Okay.
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Howard :
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I said, "Well, what's your real name?" He told me his real name, I couldn't-
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Dr. Ronnie:
|
You couldn't remember.
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Howard :
|
I couldn't repeat it for one second. But you are the president-elect of the Asian Academy of Aesthetic Dentistry. That's a huge accomplishment. You were the first Invisalign-dedicated clinic in Singapore, which I find so amazing because of all the specialties out there, the orthodontic society is a closed society, I mean no non-orthodontists are allowed-
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Dr. Ronnie:
|
Well, in Singapore, we are allowed as general practitioner, we could be associate members of the orthodontic society, it's just that we have no voting rights.
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Howard :
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Okay, so you can go to the meetings, but you can't vote.
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Dr. Ronnie:
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That's right.
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Howard :
|
In America you're not even allowed to go to the meeting. So I think that's pretty impressive, that Invisalign-you know they pick you, you don't pick them. And you were the first Invisalign-dedicated clinic in Singapore, you've done thousands of Invisalign cases.
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|
And another thing that maybe we should start talking about is this new thing. We're here in Indonesia and you're giving a hands-on course with bulk-fill posterior composites.
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Dr. Ronnie:
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That's right.
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Howard :
|
Can we start there?
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Dr. Ronnie:
|
In Asia, as you know, the countries are all quite different. Singapore, because of good governance over the years, is looked upon as a little bit more progressive, more advanced compared to the rest of Southeast Asia. But the last ten years, I think the rest of Southeast Asia has caught up very, very quickly. In terms of dentistry, I think partly due to the internet as well, the level of dentistry has changed a fair bit. So what happened was, about ten years ago-well, more than that-12 years ago, I went for some CDE in America which was unheard of then. That was when I learned a bit about amalgam, going amalgam-free and doing posterior composites. I attended a hands-on course by Rowan Jackson so when I came back I decided-
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Howard :
|
Now was that hands-on course at LVI?
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Dr. Ronnie:
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Yes, that's right.
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Howard :
|
He was an instructor at LVI for a long time.
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Dr. Ronnie:
|
He just recently retired I think last year, from LVI. So basically the lectures from [inaudible 00:03:47] really changed my life when I first heard from him. Prior to that we don't get that much exposure in Asia to the overseas speakers then. So I came back and pretty much reorganized my practice and started to be the dentist I wanted to be, because many times in Asia, you learn to conform, to do things as they are. But I think traveling opened my eyes, to see what's actually possible with dentistry. Since then it's just been continuously learning, sharing and trying to improve each time.
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Howard :
|
When you present to the Asian Academy of Aesthetic Dentistry, does Asian aesthetic dentistry, does your culture, is it any different than say, Europe, or any different than America? I hear things from dentists around the world that some countries in the Middle East want that really white, Hollywood smile. And other countries in the Middle East, "That is too white."
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Dr. Ronnie:
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I think we are somewhat between the US and the UK or Europe. I think in the European aesthetic, they tend to like natural-looking, layered ceramics, without staining, without transparency, translucency. Whereas I think America in the past, it used to be really white, the Hollywood smile. Here in Asia I think the influence from both Europe and America is pretty strong. So pretty much when the patients come in, we have both groups. Some really want whiter than white, b1 and above. Then there's those that do not want, they just want a nice, natural-looking smile. They don't want their friends to know they have veneers. So it can be quite a challenge, we really have to have a wide repertoire of techniques and we need to also have access to laboratories that support the type of dentistry that the patient wants.
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Howard :
|
Put this in perspective for you, kids out there under 30, when I got out of school, they got the bleaching shades, but then when they came out with tooth whitening, then they had to go back to the drawing board, and make several shades whiter than anything available, they called them the bleaching shades.
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Dr. Ronnie:
|
That's right. BL-1, BL-2, three and four.
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Howard :
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That's not too white?
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Dr. Ronnie:
|
Depends. I mean, color is really a perception of the patient. Depending on what they do, their professional life, some of them are quite happy ... For example, we are the dentists for the Miss Universe-Singapore. Our practice has been the official dentist for the last six years. So typically for the winners, because they compete internationally, we have to give, if they do veneers, they have to go for at least a BL-3, if not a BL-2.
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Howard :
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But don't you think the Miss Universe pageant is rigged? Because the winners are always from planet Earth?
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Dr. Ronnie:
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(laughs) I'm not sure about that.
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Howard :
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Have you noticed? There's no one from any other planets or any other galaxies ever win. So I think it's a rigged competition when the winner's always from Earth. Let's go back to bulk fill. I think that most dentists will tell you that it's just easier to prepare a posterior MOD for a crown. A lot of them think it's easier to do a cerec inlay. A lot of dentists just don't like doing an MOD.
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Dr. Ronnie:
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That's right.
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Howard :
|
It takes a long time, there doesn't seem to be any shortcuts, contacts are an issue. The bulk fill eliminates the incremental curing.
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Dr. Ronnie:
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That's right.
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Howard :
|
Are you pretty much only doing bulk fill on posterior-
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Dr. Ronnie:
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Yes, I think for posterior composites other than maybe a simple class one, typically we use bulk fill almost all the way. Of course if it's a large restoration, the patients are given the options of inlays, onlays or even crowns if necessary.
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Howard :
|
Would you mind going through that technique, because I still talk to a lot of dentists who are not even aware of the bulk fill technique, they're not aware that there's an ultrasonic vibrator-agitator with this technique, you know?
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Dr. Ronnie:
|
So I think in bulk-fill technology, the whole idea is, if you can, just to go one increment to save time. In terms of the other difficulties in posterior composites, things like bonding sensitivities, the newer generations of bonding agents have pretty much eliminated all that. As well as the newer metric systems as well, the right wedging system, pretty much, you can get pretty nice, tight contacts. So right now I think the last part that slows things down is still the layering concept in posterior composites.
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So the new bulk-fill technologies, you basically have two different groups of bulk-fill composites. There's one which is the flowable. This is flowable bulk-fill. So you get great adaptation, but being flowable, once it's cured, it does have a bit of limitation in terms of the hardness. So the final layer, you just use a regular composite just on top.
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On the other end of bulk-fill, are those what they call high-viscosity bulk-fill, which is really nice and hard, good fracture toughness, but the problem is because it's high viscosity, it doesn't flow well. It can wet the cavity well. So you still need to use what they call flowable composite, it's a tin liner before you put on the bulk-fill. So in the end, it's still double, two increments at least.
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So what happened was, there's a company called Kerr, which came out with sort of a new composite which is delivered in a capsule that's connected to a hand piece that's made by KaVo. So the high-frequency vibration from the hand piece actually reduces the viscosity of this composite by about 70 to 80%. So when the sonic device is on, the composite actually flows. The moment you stop the device, the residual energy in the composites slowly moves away. It takes a few minutes for it to lose all its vibrational energy and during that time it's quite easy to sculpt the material to carve in the anatomy, and once you are done you just cure it.
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Howard :
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And how does light curing go? Is it dual cure or light cure?
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Dr. Ronnie:
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Most of the published evidence suggests it can be cured up to a depth of five, up to six millimeters. Of course the material is still quite new, three to four years on the market, but independent tests-and in fact some of the tests were done by the ADA, the American Dental Association-and they found the depth of cure even up to 6.5 but the manufacturers recommend not going more than five. Typically I think for most posterior composites cavity preparations, 80% of them are below five millimeters. And almost all, 80% of cases you can just go for single increment.
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Howard :
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Now see, I would think, since we were sitting in Asia when you said the ADA, you'd be referring to the Australian Dental Association.
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Dr. Ronnie:
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(laughs) I think worldwide, not many associations have their own independent laboratory.
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Howard :
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Is that right?
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Dr. Ronnie:
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That's right. I think the ADA has its own independent laboratory, that does the tests which we are told are unbiased.
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Howard :
|
So it's 100% light-cured, it's not dill-cured.
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Dr. Ronnie:
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No.
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Howard :
|
One hundred percent light cured?
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Dr. Ronnie:
|
That's right.
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Howard :
|
And you've been using them for how long?
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Dr. Ronnie:
|
Two years.
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Howard :
|
Two years? And what do you see after two years?
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Dr. Ronnie:
|
Well, we wouldn't go back.
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Howard :
|
You wouldn't go back.
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Dr. Ronnie:
|
I have about 12 associates in my practice, all of them use-
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Howard :
|
Is it faster?
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Dr. Ronnie:
|
It's a lot faster.
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Howard :
|
And you said it's by Kerr and the device is by KaVo. Both of those companies are owned by Danaher, so it would be really the same company.
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Dr. Ronnie:
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Mm-hmm (affirmative). Only not too long ago, I think.
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Howard :
|
Interesting. I've been to the KaVo factory in Germany. That was an impressive factory. So when you said you take away the sonic energy, how long do you have to carve the occlusion?
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Dr. Ronnie:
|
You have about at least two minutes.
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Howard :
|
Two minutes?
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Dr. Ronnie:
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Or more.
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Howard :
|
And I want you to talk about occlusion because you're a very great student of occlusion too. You studied with Clayton Chan out in Las Vegas. Occlusion really does seem to be one of the most-
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Dr. Ronnie:
|
It's a bit like a religion.
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Howard :
|
It is. I didn't want to say it, I didn't want to offend you, but yeah. It's like a religion, everyone has a different belief.
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Dr. Ronnie:
|
Yes, so I mean, I guess all of them kind of agree on the basic principles. I think the only slight disagreement is where to put the mandible, you know? Everyone agrees you need interior guidance, you need canine guidance, you need balance contacts, things like that. But I think the slight disagreement is where exactly do you put the mandible? Do you put it where the joints are in the anterior-superior position, or do you put it in the position where the muscles are comfortable, you know? I would say that's basically the main difference between most of the occlusive philosophies.
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Howard :
|
I want to ask you one controversial ... Some people say that TMJ, TMD, tempora-mandular, when a human around the world is stressed, they'll have five spasms: a brain spasm, headache, jaw spasm, TMJ, lower back spasm, irritable bowel, heart. Do you believe stress is a big factor in TMJ, TMD pain disorders or do you think it has more to do with mechanical forces and functions?
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Dr. Ronnie:
|
I think it's very difficult to pinpoint the single cause. It's almost always multi-factorial. I think stress can be useful to the body, and too much stress can also be harmful to the body as well. But definitely I would say stress would be a contributory factor in almost all diseases.
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Howard :
|
Interesting. I should've started also with Invisalign. I mean, my gosh you were the first Invisalign-dedicated clinic in Singapore and now there's only two, right?
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Dr. Ronnie:
|
Basically we were ... Singapore was chosen, in a way, as a test hub. So we actually had two Invisalign-dedicated clinics starting about the same time. We opened officially within a week of each other. We were the first two in Asia, and about a few months, certainly a year later there was one more in Bangkok.
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Howard :
|
In Thailand?
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Dr. Ronnie:
|
Yes, Bangkok, Thailand. In the UK now there's also Invisalign-dedicated clinics.
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We're recognized by Align-we sought permission from Align to call ourselves an Invisalign-Dedicated Center or Clinic. Of course there are lots of practices around the world that do limit themselves to Invisalign only, or clear orthodontic aligners only. Pretty much it was like a test, you could say a test hub, because Align Technology wanted to see how it would work out. It's a center for a bit of research. We have doctors from around Asia visiting our practices just to get an idea, to see whether ... It's like a prototype, to see how far Align can take this.
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Howard :
|
You know, ortho and endo, pretty much all of life is kind of like the 80-20 rule, where ... Take endo, single-rooted teeth are just so much easier than a molar.
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Dr. Ronnie:
|
That's right.
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Howard :
|
A class one is so much easier than a class 2 or a class three. Do you cherry-pick orthodontic cases and just do the easy, gravy ones with Invisalign, like with class one? Or do you use them for more complicated cases, class twos, class threes?
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Dr. Ronnie:
|
I think over the years Invisalign has been evolving, so now it's already at the G6, Generation 6 which includes an extraction protocol. So when we first started back in 2004, yes, it was basically just mouth-crowding, class one mouth occlusions. Slowly as we get more experience, we are able to then do more and more complex cases. So right now I would say probably about 80% of most mouth occlusions can be treated by Invisalign.
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Howard :
|
Eighty percent of mouth occlusions?
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Dr. Ronnie:
|
Up to 80%.
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Howard :
|
Four out of five?
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Dr. Ronnie:
|
Just an anecdotal, a rough estimate. I can't give you any studies-
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Howard :
|
What cases would you not do?
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Dr. Ronnie:
|
Orthognatic surgery, for the moment, I will leave that to the specialists, although Invisalign can treat orthognatic surgical cases as well and a lot of orthodontists do that, but as a general practitioner, of course we keep to the more simple to moderate cases as well.
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Howard :
|
I've been very impressed. When I got out of school, orthognatic surgery, when you would go visit the patient in the hospital afterward, their head was so swollen you were scared, in '87. They have gotten that procedure so minimally more invasive over the last 30 years. It's really not that big a deal any more.
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Dr. Ronnie:
|
That's right.
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Howard :
|
Do you agree?
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Dr. Ronnie:
|
Yes.
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Howard :
|
That might have been one of the most advance procedures that I have seen in my lifetime. I still remember seeing one of my first patients, they got referrals when they have done-
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Dr. Ronnie:
|
Now with the mini-plates I think it has changed the surgery amazingly.
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Howard :
|
So you're talking to a lot of kids out there who have never done an Invisalign case. What are the advantages and disadvantages of Invisalign versus fixed brackets?
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|
Dr. Ronnie:
|
I think in terms of aesthetic dentistry, I think we use a lot of Invisalign in patients who are looking for veneers, looking for a new smile. Many times they need some simple alignment, so the aligners are clear so the patient who is aesthetically conscious, they don't have to go through what we call the railroad tracks. Secondly, of course they're removable, so it's actually very comfortable for the customers, for our patients, and they can take it off to clean, to brush, to floss. And pretty much in terms of treatment planning, for me as a dentist, you can actually have a visual treatment plan. You can actually show the patient the before and the after. So you have a rough idea of how [crosstalk 00:18:30]-
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Howard :
|
On the software?
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|
Dr. Ronnie:
|
On the software.
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Howard :
|
Is that free software from Invisalign?
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|
Dr. Ronnie:
|
Yes, the software is free. You need to pay to get certified, but pretty much each time you have a case, you charge a case fee, but the case fee comes with the software. The software is internet-based software. You just log on and all your cases are there, on the Cloud.
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Howard :
|
I always thought they should put an intro course, or Invisalign certification course on Dental Town, just for marketing. There's 210,000 dentists on there, they should ... I think they should put their whole program or something, just an intro, because I think more dentists would be interested to go get certified if they knew more about it firsthand. But just not knowing anything about it, and then going all the way to signing up to get certified, is a bigger jump. I think it would dis-intermediate the sales process to say "Let's just put it on your phone app so you can watch it there" and then they might learn enough about Invisalign to say "You know I think I am going to go get certified."
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Dr. Ronnie:
|
There's a new CEO, if you want to give him a call.
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Howard :
|
What's his name?
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|
Dr. Ronnie:
|
At the moment it just escapes me.
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Howard :
|
Can you email me, howard@dentaltown.com and cc him and introduce us? Because my-
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Dr. Ronnie:
|
Well, I will get to see him in May in the Invisalign Asia Summit in May in Macau.
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Howard :
|
Macau, that's the Las Vegas casino.
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|
Dr. Ronnie:
|
That's right.
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Howard :
|
You've been to Vegas several times, have you been to Macau before?
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|
Dr. Ronnie:
|
Yes, in fact the last Asian summit four years ago was in Macau as well.
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Howard :
|
So is it pretty comparable to Las Vegas?
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|
Dr. Ronnie:
|
Pretty much, just that everyone around you is Asian, rather than Westerners, in a sense. But the hotels are owned by the same companies that own the hotels in Vegas. It's pretty much, you do feel you are in Vegas when walking through the casinos. It's just that if you stop by the tables, the stakes are a lot higher. The Chinese-
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Howard :
|
There's a lot more-
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Dr. Ronnie:
|
It's in our blood, the gambling. We don't game, they gamble.
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Howard :
|
I got really close to Macau on the trip but I couldn't swing by. One of the negatives that I hear dentists worry about with Invisalign is that if I glue on brackets, I control your wearing them. I glue them onto your teeth, you can't take them off. If I give you a removable retainer-
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|
Dr. Ronnie:
|
That's right.
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|
Howard :
|
How often do you start someone on Invisalign ... Tell me this, how long does the Invisalign case last, and how long would it have lasted, if you'd gotten railroad tracks so that you had control of the patient time wearing it. Does it take a lot longer because the patients don't comply as often, or is compliance really not an issue?
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|
Dr. Ronnie:
|
I think compliance definitely is the issue. As long as it's a removable appliance, it's definitely always an issue.
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|
Howard :
|
Whenever you're dealing with a human it's an issue (laughs).
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|
Dr. Ronnie:
|
(laughs) Yes, that's right. In Invisalign, in our practice, it's mainly adults, adult orthodontics. The interesting thing, or what's a bit different about Invisalign is that you can actually sort of program the tooth movements. You can actually decide which teeth you want to move. Sometimes when the occlusion is pretty good and settled, and the patient is just looking for some improvement and not for full correction to a class one, because some of them might be 40 and they are in class two all of their lives, and all they want is to maybe align the front four incisors and maybe just correct the lower imbrication, so using Invisalign you can actually control the teeth movement and just give the patient what they want without making the malocclusion worse. So in that case, the treatment time is a lot shorter. Whereas if you were to put the full braces on, obviously the time taken would be longer. So it varies from case to case.
|
|
|
But generally we find our patients don't mind if the Invisalign case takes longer than braces, because what happens is, Invisalign is obviously not very obvious. No one really knows they are on Invisalign. Normally by about the sixth to ninth month period, the smile has improved pretty dramatically. Even if the treatment drags on another year or two, they are already so used to the aligners and they are invisible, they don't really complain. But that said, I think most cases in terms of treatment time is comparable to fixed braces. Sometimes it's faster, sometimes it's slower.
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|
Howard :
|
Is the common Asian orthodontic bi maxillary protrusive, is it usually all non-extraction or do you ever need-
|
|
Dr. Ronnie:
|
It depends a lot on our patient as well. How much their side profile bothers them. So of course in Asia, most of the movie stars are still very much influenced by what we see in the west and we know the western profile is quite different from the Asian profile.
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|
Howard :
|
Explain that more in detail. How does the Asian profile look different from a western profile?
|
|
Dr. Ronnie:
|
Typically, one parameter of aesthetic facial line is what we call the aesthetic line or the E line, where you draw a line from the nose to the chin in the lateral view, and typically the lip should basically be on the line. But Asians, we have a shorter cranial base, sometimes the nose is a bit underdeveloped or a bit short, and the chin can be smaller. So as a result, the E line is further back and the lips are beyond the E line and that gives the protrusive look.
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|
Howard :
|
Interesting.
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|
Dr. Ronnie:
|
Some of our patients are bothered by it, then in that case we may have to extract if we cannot create enough space through expansion. Some patients are very happy with the way they look, because pronactic look, you tend to look, especially for the ladies, you always look young. As you grow older, the soft tissue will start to droop and you show less of your teeth. But if you have slightly bi-max appearance, you're always smiling and you always have a young-looking look. Which is why when sometimes western tourists come to Asia, they find it a bit hard to tell the Asian ladies, how old they are. Because even in their 50s and 60s when they smile, because of the bi-max appearance, they show a lot of teeth.
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|
|
Some of our patients, they like the bi-max appearance. So for those cases, we can just align the teeth, straighten it without having to extract.
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|
Howard :
|
Every time I am completely off on someone's age by a decade or more, they're always Asian or African.
|
|
Dr. Ronnie:
|
Yes, exactly. Even Africans as well tend to be bi-maxillary as well. So when they smile, you always see the full smile, you see some gums, even when they are past 40.
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|
Howard :
|
So you're seeing these Western women who are getting all this botox, and dermafill, they're trying to look Asian.
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|
Dr. Ronnie:
|
Not really, I think they're just trying to look-
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|
Howard :
|
They're trying to put their lips past that line.
|
|
Dr. Ronnie:
|
(laughs) They're trying to compensate maybe for the loss of soft tissue volume as we age.
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|
Howard :
|
Well the one thing about beauty, it's interesting if you go back through history. The parameters are always changing. So what's beautiful today wasn't beautiful a hundred years ago or a thousand years ago. Look at all the Greek paintings, what they thought was beautiful. Interesting.
|
|
|
So when you're worried about compliance, are there any things you've picked up, are girls more compliant than guys, are young guys less compliant than older guys? Is there anything you've picked up, any red flags-
|
|
Dr. Ronnie:
|
Probably the group that is slightly less compliant is the teenage boys. We don't do that many teenagers, but I think that's beginning to pick up. In fact in the US as well as in Asia, we are seeing more teenagers asking for Invisalign, but we find that the boys are the ones that tend to be more active, they tend to be a bit less compliant.
|
|
Howard :
|
They seem to be a lot less beauty-driven.
|
|
Dr. Ronnie:
|
That's right.
|
|
Howard :
|
I noticed with my four boys, they get a shirt they like, they want to wear it four days in a row. (laughs) Now he's flipping me off behind the camera.
|
|
|
So now do you do any fixed ortho, or is it all removable?
|
|
Dr. Ronnie:
|
Now I think our practice is about 95% clear aligners. So if the patient needs a fixed case we refer them to the orthodontist.
|
|
Howard :
|
Is the Invisalign-Dedicated practice, is that office only doing Invisalign or do you do-
|
|
Dr. Ronnie:
|
We do hygiene, we do some whitening as well. Teeth whitening. Our practices are just next door to each other, we have two practices. So the one next door is the one that does general dentistry, the implants, the aesthetics and the veneers. Then the next door is just the Invisalign-dedicated practice.
|
|
Howard :
|
Do Asian dentists use hygienists to the same ratio as the Americans?
|
|
Dr. Ronnie:
|
Definitely I think the short answer will be no. Most countries in Southeast Asia do not really have hygienists. Most dentists in this part of the world do the hygiene themselves.
|
|
Howard :
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Do you see the hygiene profession growing, or not really? Do you see the dentists just doing it?
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Dr. Ronnie:
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I think it depends which country you go to. In some Southeast Asian countries, there are quite a lot of dentists. In some other countries, there's a real need for more dental personnel. But specifically I can comment in Singapore, I think we definitely need more hygienists going forward.
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Howard :
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How many dental schools are in Singapore?
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Dr. Ronnie:
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There's only one dental school in Singapore.
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Howard :
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Does it have a hygiene department?
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Dr. Ronnie:
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Hygiene department is under the polytechnic roster. Dental school is under the university.
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Howard :
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So Singapore's about, what, seven million people?
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Dr. Ronnie:
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Yes, about six, coming to six million people.
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Howard :
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Six million? How many dental students does it graduate a year?
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Dr. Ronnie:
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Per year, typically it's about close to 50. But we are in the process of building a new dental school, so once that's completed we should be able to bump up to about 80.
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Howard :
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How many hygienists do you graduate a year?
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Dr. Ronnie:
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Exact numbers, I'm not too sure because I'm not involved. I teach part time in the university but I'm not involved with the Polytechnic. If I'm not wrong, about 30 hygienists a year.
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Howard :
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What we've seen in the United States, it's about 125,000 general dentists, 30,000 specialists, so you're talking about 155,000. But you have to graduate almost 400,000 hygienists because they are in and out of the work force with babies and things like that. They try to aim for about two hygienists for every dentist. Interesting.
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I want to go back to that bulk-fill just because I think that's a really hot thing. You talked about SonicFill by Kerr, which is owned by, what did I just say-
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Dr. Ronnie:
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Danaher?
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Howard :
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Danaher.
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Dr. Ronnie:
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I think so, I'm not too sure.
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Howard :
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Yes, Kerr's owned by Danaher, which also owns KaVo. But there's also the DentSupply which just merged with Sirona. DentSupply-Sirona. DentSupply has Sure-fill?
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Dr. Ronnie:
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Yes, I think they do have ... I think almost every major dental company now has some form of bulk-fill composite, 3M has its own.
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Howard :
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Do you want to comment on any of the others, do you like any others, or you're just really sold on SonicFill?
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Dr. Ronnie:
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As I mentioned earlier, some of them are just high-viscosity and some are lower. Each of course has its own advantages and disadvantages. But when we started with SonicFill, we found that the unique properties of SonicFill is something that solves[crosstalk 00:30:26]-
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Howard :
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You really like SonicFill, that's the main takeaway there.
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Dr. Ronnie:
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That's right.
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Howard :
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I want to get to other issues. In America, we've heard that the Asian diet over the last decade or two has increased a lot of sugars, carbohydrates. Do you think your country, Singapore, you were born in Malaysia. Do you think a six-year old child in Malaysia or Singapore today has more cavities than they did say a generation ago?
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Dr. Ronnie:
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Actually, at one point Singapore had the lowest decay rate in the world, actually. That was because of active fluoridation, in the water.
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Howard :
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Fluoride in the water.
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Dr. Ronnie:
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Yes, that's right. But again, with the change of diet I think sugar consumption has gone up, so the decay rate has definitely gone up. With fluoride therapy, we do find the incidence of what you call the blow-out lesion has increased, but that's kind of anecdotal among my dental friends. We're seeing more kids with pretty pristine teeth, but sometimes you just find a little dot on the occlusial or the molar, and further exploration you see a pretty big lesion and we suspect that although fluoride has its advantages in protecting the teeth, but it can also cause of the these blow-out lesions if the dentist is not so vigilant in looking out for it.
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Howard :
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So all of Singapore's water is fluoridation?
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Dr. Ronnie:
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Yes.
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Howard :
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Explain the blow-out lesion one more time.
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Dr. Ronnie:
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Well basically what happens is, because of the fluoridation, the enamel is more resistant to tooth decay, but sometimes in the right depressed grooves, the area is still vulnerable, and when the caries start, they can't spread laterally, they spread inwards. Once it's below past the enamel into the dentin, it spreads sideways along the enamel, the internal junction, but because the enamel is still pretty hard, it's not easily detectable. Perversely, because of the lower fluoride you could actually see the decay from the occlusal surface more easily. Now it's sort of hidden until it's actually quite big.
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Howard :
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And how do the Singapore people react to the government putting fluoride in the water? In the United States, there's about 19,000 towns and on any given day 25 or 30% of towns have voted it out of the water because they thing it's bad for you. So the United States has averaged, about seven out of ten cities have had it because there's no national policy on it. It's a city-by-city referendum.
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So do the people of Singapore-what percentage of the peiople of Singapore say, "We trust the dentists, we trust the science, we like this." Or they're upset that it's in their water and they want it out.
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Dr. Ronnie:
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I think-we are developed now, but during the developing times, the population is generally more preoccupied with other things. Of course there are pockets of ... My patients are against fluoride but you can always buy filtered water or distilled water, depending. No one really forces you to drink the water if you don't want to, but pretty much I think in Asia the population I think tends to be quite compliant with whatever the government is doing, unless of course there's really strong evidence. But I think the Minister of Health in Singapore is very pro-active around this. Even as dentists we were very aware of this fluoride issue for a while. Then they've been looking at the evidence as well but so far from what we see, the evidence of fluoridations seems to outweigh some of the disadvantages. There's talk of increased hip fractures, cancer and things like that, but I think it takes a while to really verify the evidence. So if patients as me, I say "topical fluoride works pretty well, as long as you are using topical fluoride toothpaste, then if you feel the fluoride in the water is harmful, just go for distilled water.
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Howard :
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And what is the most popular toothpaste in Asia?
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Dr. Ronnie:
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Again it varies from country to country. I think in Singapore it's probably a good fight between-probably Colgate will be number one, Oral B is also trying pretty hard.
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Howard :
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Oral B toothpaste?
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Dr. Ronnie:
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Oral B toothpaste. Recently in the last few years, even Sensodyne has been picking up market share.
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Howard :
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Interesting. That is interesting.
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You're in the aesthetic dentistry arena. There's a lot of over-the-counter aesthetic products, toothpastes that claim they white, now there's a lot of mouthwashes that claim they whiten. Do you recommend any of those to your patients? Do you buys into that or do you-
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Dr. Ronnie:
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I think the only mouthwash we tend to recommend would be Chlorhexidine, in patients who are either post-surgery or kind of active periodontal disease. Patients wearing braces, we do recommend fluoride mouthwashes as well. But generally we just tell our patients, "The most important is to brush and to floss well. If you brush and floss well, there's' really no need for any mouthwash. Of course if you belong to the minority that really has very bad halitosis or bad breath issues, there are some mouthwashes that we do recommend to them.
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Howard :
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I want to go back to something that they used to teach when I was at dental school. Tell me if it's misinformation or information. They told us that ... I was formally taught at school that Asians have more peridontal disease because they have a constrictive cervical neck, it's a very constriction and plaque and tartar precipitate, forming tartar more, and that Africans had the least amount of peridontal disease because they had the most bulbous cervical neck that didn't mechanically precipitate plaque and tartars, and Europeans around the middle. True, false?
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Dr. Ronnie:
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I've not really heard of that.
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Howard :
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You've not heard of that? Do you believe Asians have a more constrictive cervical neck around their teeth?
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Dr. Ronnie:
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I think in Asians the soft tissue is definitely thinner.
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Howard :
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Do you think there's more gum disease in Asia?
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Dr. Ronnie:
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In day to day practice, it's hard for me to tell because not every patient is Asian, so you can't really tell the difference. I am not aware of any research in the area. I really can't comment on that. But what I do know is when it comes to implants for Asian patients, typically once they lose the teeth, we don't have much bone left for the implants and grafting is usually difficult because the soft tissue tends to be a lot thinner.
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Howard :
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I know you're headed for ... How much more time to I get him for? I get five more minutes? My last subject and this is a selfish question for me since I've always had a weight problem.
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You recently just were telling me that you changed your diet? Four years ago?
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Dr. Ronnie:
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It started more than four to five years ago. I think it started back in 2004. I remember mentioning I went to LVI, basically the causes that really changed the way we look at malocclusions, and then we continued with Caton as you mentioned. So that set me off on a journey of why malocclusions happen. You dig up ancient skulls, 10,000 years ago, everybody pretty much had straight teeth. Even in Asia if you travel to Nepal or areas where there's clean air, clean food, natural things, everyone has a nice, broad smile. So genetically we are meant to have a nice, beautiful smile. But we find that nowadays malocclusion is more common and many times it's due to allergies, rhinitis, runny nose that cause young kids to breath through the mouth. Then the tongue position is altered and you get a narrow arch and you get crooked teeth.
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Going further back, what causes this rhinitis? It's actually allergies and you can trace it a lot of times to diet, it could be processed food. Some people who are sensitive to wheat, it could be germinated wheat, it could be the gluten wheat, we are not exactly sure. Also, if you have a very high carbohydrate diet or a high sugar diet, that causes inflammation as well and that will again create more mucus and large tonsils and things like that.
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So there's a lot of evidence showing that if you sort of move away from a modern day diet, more toward a natural diet or what we used to eat 10,000 years ago, when it was difficult to get simple carbohydrates, you couldn't get wheat that easily, you had to grind it manually and all that ... I think it started mainly in the States and Australia, what they call a paleo-like diet, something that our ancestors ate.
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There's quite a bit of evidence that shows that diet actually helps, because by avoiding simple carbohydrates and sugar, we can actually control our insulin level. By keeping our insulin level low, we signal to our body not to store fat. By not storing fat, we naturally lose weight. So by going on a low-carbohydrate diet that helps to actually lose weight quite easily. By taking more healthy fats, you don't feel hungry, most of the time. After a while, as you get less dependent on carbohydrates, the enzymes and hormones in you body change. You start to be be able to burn more fat. As long as you insulin level remains low, your body after a while, you adapt and we call it fat adaptation. You start to use the fat and you naturally lose weight. It may not work for everyone, we are all different, but generally all of us have insulin, so as long as you don't trigger insulin spikes in the body, it makes sense that you can actually lose weight by controlling your insulin level.
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Howard :
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Be more specific. What would you eat on an average day? Do you eat breakfast, lunch, dinner?
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Dr. Ronnie:
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Eggs in the morning, I fry eggs in butter, the butter itself is from cows that feed on grass, not on corn, because cows that feed on corn have too much omega-6, too much inflammation. For lunch it could be a salad, or it could be we go for Chinese food, we order a soup with some vegetables and meat. Dinner at home could be fried vegetables, a bit of meat. Sometimes a bit of carbohydrates would be all right, but not too much.
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So when I was actively losing weight or losing fat, I avoided simple carbohydrates altogether. Once you reach your ideal BMI, you can start to increase a bit of carbohydrate consumption.
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The interesting thing about starting on this diet, we realized that our whole family was actually sensitive to wheat. By avoiding wheat we could remove all the bloat. We used to feel bloated, we thought that maybe it was because we ate too much, but it's actually from the wheat. We're not sure why. If you eat pizza made from ancient grains, the reaction from the body is quite different than pizza made from mass-produced grains like wheat.
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Howard :
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My brother has celiac's brew and my sister, one of her children has celiac's brew.
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Dr. Ronnie:
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Celiac disease?
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Howard :
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Celiac disease. I'm sorry, they used to call it celiac's brew in Kansas. I don't know if that was a Kansas term [crosstalk 00:41:50].
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Dr. Ronnie:
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I think the celiac part, there's a wide range, some of us which are [inaudible 00:41:52] you don't really show the symptoms. But my wife, she used to get ulcers in the mouth maybe every month-
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Howard :
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Canker sores?
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Dr. Ronnie:
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For many years. Small aphthous ulcers almost every month. When we discovered that our son was actually sensitive to wheat, then the whole family stopped taking wheat to support him, she realized that she stopped getting ulcers. For the whole year. Sometimes she would cheat and have a bowl of noodles, the next week the ulcers come back.
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Howard :
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Because everyone always thought those were autoimmune ulcers.
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Dr. Ronnie:
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Yes, that's right.
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Howard :
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Aphthous ulcers. Well, seriously it was a huge honor that you would meet with me today and I was sitting in on your lecture, I wish you'd give that at a town meeting some year. You're just amazing. Any chance we could ever get an online course from you on Dental Town?
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Dr. Ronnie:
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Definitely, I mean let's keep the option open.
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Howard :
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That would just be ... We would just love it. It would be a huge honor. Thank you for all you've done for dentistry and thank you for spending time-
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Dr. Ronnie:
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Thank you. I remember joining Dental Town back in 2005.
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Howard :
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It's been a long time, hasn't it? Back in the day. Well hey I don't want to be the guy who makes you miss your plane back from Indonesia back home to Singapore, so thank you again for all that you do.
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Dr. Ronnie:
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Thank you. A pleasure.
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Howard :
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Okay, bye bye.
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