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Howard:
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It is a huge honor today for me to be podcast interviewing Dr. Nuno Sousa Dias from Portugal and this is very brave for me to do a live interview with someone this tall, dark, and handsome I'm going to be looking extra short, fat, and bald today. You obviously had a calling on cosmetic dentistry being born this handsome would you say? So we're both lecturing today in SADA which stands for the South African Dental Association in Johannesburg. Tell everybody what your lecture was about today, you're an orthodontist ...
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Dr. Dias:
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Well hello everyone from Dental Town, I'm an orthodontist, I'm here lecturing about adult patients and how the orthodontist can be an important member when we treat patients and how can we together with the dentists work for better final results. What I'm here doing is showing the dentists how they can benefit from the orthodontist's work, so working together achieves the best results.
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Howard:
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And I know a lot of orthodontists are not too pleased with the results they see being done by general dentists, what are your views on general dentists doing orthodontics vs. the orthodontists?
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Dr. Dias:
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Well my opinion about this subject is that to the orthodontics to treat patients as an orthodontist you need to get the special training, that takes time until you get to a point until you are able to treat the patient doing proper orthodontic treatment. What I see nowadays is more and more the dentists they start to do some orthodontics and in my opinion this is wrong. I'm here giving the dentists enough knowledge to ask for an orthodontist and to benefit from his work, not for them to do orthodontics because this we cannot teach in one day so this is my opinion about that.
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Howard:
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So what would you say to general dentists who see advertisements that believe with some of these Clear liner companies that you just take the impressions, send it to them, and they'll do all the diagnosing they'll just send you the Clear liners and you don't need to know all the orthodontics ...
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Dr. Dias:
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I see it more and in my opinion many treatments with Clear liners and Invisaline and all these new systems, they are actually very easy, the difficult thing is to select the cases and for this you need an orthodontic knowledge. So the problem is not in the case, the problem is to select the case that will benefit from each system and this you cannot teach in a certification course. So even the very simple treatment, they need the eye of the orthodontist to be able to select, so this is my opinion about this subject.
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Howard:
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Because when you're a doctor 99% of the game is the correct diagnosis and treatment plan, not running off to drill fill and bill on the wrong tooth.
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Dr. Dias:
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Not in every case, especially in the cases I'm treating I am treating more adult and complex cases, the diagnosis is a very important step, but also the skills in order to treat these cases and the cooperation between the team and also the understand of the patient.
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Howard:
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Help the general dentists and we have a lot of hygienists watching our shows, help them answer questions with the patients, so let's say you're a general dentist you don't do orthodontics and a lady's siting in a chair and she says I'll go to an orthodontist but I only want the clear retainers, how should a dentist respond to that? Can you always do it in clear retainers or sometimes does it have to be fixed?
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Dr. Dias:
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The correct answer for this is the dentists they need to say this subject needs to be checked with an orthodontist, they might have the knowledge to answer some questions about this but if a patient asks or the dentist comes directly to an orthodontist and asks about this for this specific patient or the patient should search for an orthodontic opinion. This is my opinion about this.
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Howard:
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So you are from Portugal, you went to dental orthodontic school in Tel Aviv Israel, you're lecturing here in South Africa, looking around the world what percent of the ortho would you say today is clear liner vs. fixed and where do you think that will be in ten or twenty years, is it going more towards removable clear liners or is that more of a marketing phenomenon, is there still a massive place for fixed?
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Dr. Dias:
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I believe that there is a place for both, there are patients that would definitely benefit from a clear liner option and there patients that clear liner option is not an option. So we need to look at the patient individually, I know that you are asking me for the numbers, I cannot tell you about my experience because as I said I deal with more complex cases so the cases that would benefit from liners, they are not so much, we really need to go through proper orthodontic treatment with more complex mechanics. But as I see it today, more and more cases are getting treated with liners and this is also bringing some new features to the softwares and to the companies that they develop this and this would improve the systems even if I believe it will not get to the standard of treating patients with regular brackets.
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Howard:
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I want you to help a dentist answer this question a mom and dad because we hear this question a lot not so much from mom but we hear it a lot from dads, look this is all just cosmetic, this doesn't have anything to do with health or being a doctor a third of America is overweight, okay her teeth are crowded but it's just cosmetic my daughter doesn't need ortho, is orthodontics pretty much cosmetic or do you think there's health benefits for why a teenager with crooked teeth should get orthodontics?
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Dr. Dias:
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Definitely that we should look at it as a health benefit. I believe that aesthetics will come as a benefit, but the main issue when we treat a patient, we are doctors we are not cosmeticians so we need to look at the [inaudible 00:06:44] in order to improve, in order to give better function, in order to improve all the health of the patient. And of course aesthetics comes together with this so we should look at the patient as a doctor as we are so we should be very cautious and not giving sometimes to the patient what they want because they don't remember health until they need it, so they only need aesthetics and they just want fast and everything, so it's our role to say no or we treat the way we believe is the proper way or please search for someone else, this is the way I think it should be and this is the way I try to be.
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Howard:
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Another question I'm wondering, it's 2016 so I've been doing this almost 30 years, it seems like 30 years ago there was talk about braces on the lingual inside and you always hear about it but it seems like it never really took off, it seems like I hear about it as much as I did 30 years ago, is lingual braces, some people think it's a new thing but it's not a new thing, what are your thoughts on lingual braces do you think it has a place? Is it growing in market share because a lot of the clear liner is they just don't want you to show the braces so putting them on the inside wouldn't that solve the whole deal?
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Dr. Dias:
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Well there is a problem with putting them from the inside, lingual orthodontics is a little bit different in terms of skills as well so I'm a big fan of lingual orthodontics and I believe that it will grow more and more and the patients can benefit very much from this, but the time for the orthodontist to work on the patient is much longer than to work on a patient with bacchanal brackets. This makes the price higher so if the patients are able to pay for this different I believe they can be treated with lingual orthodontics, the problem is that to treat with this customized systems, we don't have the freedom to change things in the middle. It's not so easy as with regular bacchanal brackets and in very complex cases mainly orthopario cases that we don't really know what will be the final, we will work on it until we get that, this kind of systems I don't see a benefit, I believe that regular brackets would be beneficial when we have very complex cases because let's say a patient that we have a tooth that we might lose during the treatment because of pario issue, if we have these customized systems we might not be to achieve what we were planning from before, and if we have just regular brackets we can change according to the situation at the moment.
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So there are advantages and disadvantages in every system and we just need to use our orthodontic knowledge to select the best system for the indicated patient, and sometimes in the same patient we can take advantage of two different system. So this is the reason that I believe that dentists is not able to do proper orthodontics even if in some cases they will because they are lucky because they found the system for this right patient by luck.
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Howard:
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I want to ask you another question, a lot of times the child does not want braces but mom wants braces, moms sees the malocclusion and so little Billy's going to get braces, but little Billy's not into cosmetics and he's not really into home care and then two years later when we take off the braces there's demineralization around his teeth and then mom's upset about that. Do you sometimes see the boy who's hair is matted, he's worn the same shorts three days in a row, you don't think he's got good home care, do you sometimes treat them with removable clear liners just because that might be easier for home care or do you switch him from an over the counter toothpaste of 1000 [inaudible 00:11:05] how do you handle that case?
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Dr. Dias:
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I handle this way, in my opinion orthodontic treatment is not treatable for every patient. If the patient doesn't want just because the mother wants I don't treat, this is how I see. In terms of not just compliance but also in the aesthetic demands I have been facing that the adolescents they want more and more clear brackets, they are aware of the aesthetics and how they look with the brackets so if there is a patient that doesn't want treatment at all as you said I don't treat this patient even if the parents want. I don't change the system according to if the patient is cooperative or not, but what I see each time more I'm using the clarity advanced brackets the clear one and the patients they can change the elastics and they like how it looks with the clear brackets. So I believe the future, the young patients, the adolescents they come with more understanding about the treatment, they request some specific things, it's not this kind of patient that I don't want I'm here because of my mom this is my experience and if we have a patient like this, I don't treat and there is no reason to have the demineralization around the brackets because if the patient is not following oral hygiene instructions and the oral hygiene is not taking care of this, I take the brackets off and the treatment is finished.
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We need to be very strict with this. We are still on command and not the patient, we need to be strict on these things.
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Howard:
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So what are you passionate about, every orthodontist is a dentist first, why did you go on to become an orthodontist and say not an endodontist or an oral surgeon, what drove you do orthodontics and what's got you passionate about that? Why do you like orthodontics?
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Dr. Dias:
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Well orthodontics for me at the moment brings me enthusiasm because we look at the patient as a whole. When the patient gets into the office we look at the face and we orthodontists have the knowledge how the face grows, what should be the correct angles and all this so we look at the face and we know what is possible to do to improve this face and after we go to the smile and only after we go to the teeth. It's important to make this sentence very strong because many dentists they still believe that the orthodontist is just looking to study models and malocclusion, this is wrong. When we look at the patient, even before we look at the teeth we are already using the knowledge that we got during our orthodontic education about growth, about development, about all this in order to give the patient the best from not only smile aesthetics but also from facial aesthetics. So this is what brought me into orthodontics as a passion and something I will be satisfied making someone looking much better and changing their whole life or improving their daily life by achieving some goals.
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Howard:
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I went to an orthodontist and he told me if I want to look better I should put a sack over my head or I should turn off the lights. Those are your two options.
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Dr. Dias:
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You look very nice.
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Howard:
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Do you think there's a place for botox and dermafillers in orthodontic practice?
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Dr. Dias:
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Definitely I'm a big fan of plastic surgery but what I see is that the plastic surgery, sometimes it becomes before the orthodontics and is wrong. Many things that we can improve with orthodontics just working with biology without any artificial things nowadays because patients want things fast, they are done with this plastic surgery. In many cases after we do the proper orthodontic treatment, in some of them of course there is a need to improve with plastic surgery, I agree, but not from before.
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Howard:
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Do you do some of the botox or ...
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Dr. Dias:
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I refer the patients but I have the understanding of the aesthetics so if I see a patient that I improve the smile by placing the teeth in the right place and I see that for example there is a non proportional size of the upper and the lower lip for example it's of course a patient that might benefit from botox or some other intervention some other surgical intervention but not before because sometimes they try to correct something and if the orthodontist comes after the plastic surgery, many times it's really unpredictable what we will get in terms of final result.
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Howard:
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What are your thoughts on using orthognathic surgery for some cases?
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Dr. Dias:
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Well I know that according to the country the mentality's very different. I don't follow numbers when I decide if the patient should go for orthognathic surgery or not, there are some patients that we look at them and they are extreme cases and straightforward no problem it's a case that will benefit from orthognathic surgery. Many of them when they are borderline cases I like to understand the patient needs, the patient desire, and if I can give the patient something very close to what we would get from orthognathic surgery I will suggest this. I'm not against orthognathic surgery, it's definitely something that's benefiting for the patient but I always try to look at the patient individual. I don't look at the [inaudible 00:17:35] and if there is two of three degrees or millimeters different we should go for orthognathic surgery, I'm not from this opinion, I look at the patient and my feeling about aesthetics will tell me if this is a patient that will really benefit or not.
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Howard:
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I hear it's funny how cultures and customs are so silly, I hear some teenage girls don't want clear lines because they want to change the color rubber bands, do you ever have that?
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Dr. Dias:
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As I told you many patients they ask for the clarity advanced brackets, they want invisible brackets because the colors they look nice when the brackets are like this. So sometimes we think that if we eliminate the elastics with self-ligating brackets we are doing some big things and on the contrary we see children asking for this.
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Howard:
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So self-ligating brackets there would be no rubber band so then these teenage girls would not like that. Do you think that three dimensional CVCT radiographs have changed orthodontics or do you think most orthodontics is fine with two dimensional or do you think three dimensional CVCT was a game changer?
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Dr. Dias:
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Well you know orthodontics is a specialty that has many years and we see beautiful cases without any of this technology, this is a fact. In my opinion, the CVCT they came to stay and we will definitely benefit from the information that they are bringing us so we cannot use the excuse that we don't have a CVCT to do orthodontics because we have two dimensional because it's possible to do very nice work with two dimensional but the CVCT is definitely bringing a lot more to the profession and I believe that if we have the chance to have a CVCT from before the patient will benefit even if it's a little more radiation all this I believe if the patient is not such a straightforward case we should do it.
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Howard:
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I want you to help the general dentists with a diagnosing question, sometimes you see a child come in and there's no permanent tooth behind a baby second molar, some dentists believe that that tooth is going to fall out anyway so you should pull it and go forward, some people believe that if you don't pull the tooth it will stay in there forever, how do you think when you see a 14 year old kid with no permanent tooth behind a second baby tooth?
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Dr. Dias:
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We have to look at each case individually but when I discuss this with the parents I first make sure that the parents understand what we have at the moment, we have a patient that has a missing tooth, missing permanent tooth, if they ask me for how long will this tooth stay there, we have to be honest we say maybe in two weeks it will fall maybe it will stay very long, we don't know, what we know is that we should take advantage of the age and if we need to for example to bring the molar forward in order to close the space, in my opinion we should extract the tooth with the right mechanics start this correction. If we see that for this patient it's beneficial to leave the space for a future implant we can also do the same we leave the space and when the patient has enough age to get the implant there it's also another option. But every decision it depends on the patient individually so what makes me decide sometimes is the way that the parents look at it, I have cases that parents say I don't want an implant in my child even if I tell them this is the best option and I explain okay so let's maybe drag this molar forward, the treatment will take longer but this is also possible.
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So everything's possible if we have the parents or patient with us and they understand what we do sometimes it takes longer, sometimes it's faster, but we just need to be serious with them and we should do proper work and that's it.
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Howard:
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You're so fun and informative to talk to is there anything else that you're passionate about, anything else you want to talk about, anything new in ortho?
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Dr. Dias:
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I'm excited about everything in orthodontics, I don't see something new coming that will make a big difference. They change they come with new systems, they come with Sure Smile, they come with this and that, I see this world of potential for the profession but the main passion doesn't come from the systems or appliances that we use. My patient comes from the ability that we have working with biology to change function and to improve function and to change aesthetics for the best. Doesn't matter if it's with a regular bracket or with a self-ligating or with a lingual customized bracket, what matters is what we can get as a final result.
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Howard:
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Everybody in their room was ranting and raving about the cases and slides that you were showing, I was wondering do you think that Dental Town or Ortho Town would ever be graced with having an online course from you?
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Dr. Dias:
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Yeah sure why not I will according to what you will tell me or whatever you need I will try to set a presentation that will be beneficial for the dentists in order to understand how they can benefit from the orthodontic work. Again I'm not teaching dentists to do orthodontics.
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Howard:
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And then if you want to you could create a different course for the orthodontists on Ortho Town is you ever want to create a course for those guys they would love that. And I also firmly believe that dentistry's done a little differently as you go around the world so I would love to see a course from someone from Europe, I know Japan does things very differently than the United States and I think it's always so fun to have courses with different flavors from around the world because everyone has a little spin and you're definitely an international man so we would love to have it.
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Dr. Dias:
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It would be my pleasure to do that.
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Howard:
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Well thanks for spending a half hour with me at the SADA meeting.
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