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1361 Better Orthodontic Bonding Methods with Dr. Lisa Alvetro : Dentistry Uncensored w Howard Farran

1361 Better Orthodontic Bonding Methods with Dr. Lisa Alvetro : Dentistry Uncensored w Howard Farran

2/24/2020 3:00:00 AM   |   Comments: 0   |   Views: 76
Dr. Lisa Alvetro is a recognized orthodontist and lecturer known for delivering the highest standards of care while focusing on the entire patient experience.  She has been invited to teach not only in the United States but worldwide as well.  Dr. Lisa is well known for her passion in Class II correction and more recently as an early adopter of technology with the establishment of Alvetro Orthodontics 3D lab in 2015. Dr. Alvetro received her D.D.S. summa cum laude from Ohio State University and completed her residency at Case Western Reserve University. She currently is an Associate Clinical Professor at CWU where her most recent project was establishing their digital workflow and 3D print lab. As a firm believer in giving back, Dr. Lisa created several foundations. Smiles of Hope is working with housing, water, education, farming and nutrition in the village of Tarime, Tanzania. Her foundation St. Jude Dental Cooperative is a volunteer orthodontic clinic providing services in Vieux Fort, St. Lucia.


VIDEO - DUwHF #1361 - Lisa Alvetro


AUDIO - DUwHF #1361 - Lisa Alvetro


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Howard: it is just a huge honor for me today to be podcast interviewing Dr. Lisa Alvetro DDS MS D she's an orthodontist at L vitro orthodontics my gosh I'm so excited to get on a show she's a recognized orthodontist and lecture known for delivering the highest standards of care while focusing on the entire patient experience she has been invited to teach not only in the United States but worldwide as well dr. Lisa is well known for her passion in class - correction and most recently as an early adopter of technology with the establishment of L vitro orthodontics 3d lab in 2015 her dedication to the orthodontic profession led her to become an advocate for 3m oral care for whom she has collaborated with extensively since 2007 she also consults with three shape on various development projects and multiple 3d printer companies as a better tester and advisor she also conducts an in-office digital workshop for orthodontists and their teams entitled maximize practice efficiency with digital workflow she's received her DDS summa lotta might my homies don't even know what that means that that that means with highest praise if they knew what that meant they would listening to another podcast she comes from The Ohio State University member who say now the thud they will hurt you and completed her residency at Case Western University so she looks like she's all things Ohio she currently is an associate clinical professor at Case Western University where her most recent projects was establishing their digital workflow and 3d print lab as a firm believer in giving back dr. Lisa created several foundations smiles the hope is working with housing water education family nutrition in the valley of  Tarzana her foundation St. Jude dental co-operative is a volunteer orthodontic clinic providing services in St. Lucia my gosh we have so much in common we both have four kids and we both have done charity orphan work in a Tanzania excellent really yeah and of course you had good pure reasons do that I was just a pig I  some guy yet no seriously my buddy at the dental school asked me if I wanted to go do that and I said man I'm really  busy he goes well I was thinking after we did that we could climb Kilimanjaro and I'm like okay I'm  there and so I went there and did the orphanage thing for a week but really I just wanted to climb Mount Kilimanjaro the week after how was your climb well I'm glad I went I went with Eric Harris and I completely ran out of gas at 18,000 feet and I just couldn't do any more and he stood behind me like the sergeant Marine general from hell yelling at me for like two or three hours until I got to the top in fact I look at that picture of me standing at the top I think Eric is holding me up from the back but it was just the coolest thing cuz all the mountains in North America I mean in US are 14,000 feet and of the and it's 19,000 and I'll tell you what that that last that last 2,000 feet it was 3 dentist an oral surgeon that that last that last 2,000 feet was just a killer did you climb it 

Dr. Lisa Alvetro: I did I did and and I made it to the summit it took me a long long time and I know exactly what you're talking about that last that last bit and I should have trained I didn't I was I was leading a big dental dental team and we had I was so focused on that we saw the last patient and then I'm like okay now it's time and to Train and we were leaving the next day so I did I went really really slow and I had a phenomenal guide we had a real small guide group and it just it was amazing it was a neat experience and just getting to even know the guides God listened was our main guide and he was just so patient with me and God God listen was his first name g.od I asked him yep I was in good hands so it took me forever I made it and it was a lot of fun I'd do it again I

Howard: I was amazing and and the charity doesn't three things it turned out it really wasn't that necessary because the fluoride concentration their water I mean you know the ocean is one point three so on land we'd like at least half of that at the ocean point seven but it's like four point zero is like the low end over there I mean it was fluorosis was more than norm than decay is that what you saw you know 

Dr. Lisa Alvetro: we're more in the interior between Lake Lake Lake Victoria and the Serengeti and it depended what village you know we're kind of in a remote very remote area and saw that the areas they still they're growing sugarcane so they had a lot of decay and in some of the areas too there's not access to clean water but you can access coke so a lot of them that were drinking a lot of soft drinks it was amazing the amount of decay so we saw quite a few you know it there's realizing

Howard: this is why I it's very arrogant and narcissistic of people to make policies based on other people that they've never met or seen or whatever like like when I went over there I wondered why they drink so much coke and immediately this this MD that worked over there says well do you want her to go to the well and drink cholera and die or do you want her to get a cavity because I wanted to live and have a cavity and if you want to save her teeth you're gonna kill her and it's like it's all relative it's also it's a lot also this on this this crap about all the the child labor laws it's like well have you ever been to Cairo and seen the hundred thousand kids that live in the dump so you're telling me that they can't so for a job so you're just firearm so you know they're just gonna go survive in a landfill but but that fits their little TV narrative you know that they don't believe in child labor well okay you don't believe in child labor but do you believe in children living in a dump I mean it's complicated out there in 

Dr. Lisa Alvetro:  it really is I think that's the best way to describe it and sometimes you you just can't understand even though I go over and I've been involved for about ten years there's still things like you know even I see you know you you wear glasses I wear glasses I I thought well everybody must have really good no one wears classes and they're like where would they get them I'm like you're right there there you know so even though if you've been there you've been there a lot they're still you see things you're away and

Howard: here my dumbest foot in my mouth in Tanzania I don't know it might appear smaller I'm pretty sure as Tanzania and I'm in this school and I'm talking to the teacher and she's got this adorable class and they look like I don't know second graders little or whatever and I said so I'm so is this just a boys school and she goes no it's it's for the it's for everyone I said oh well where are the girls and show it to me and she goes there right there and I'm looking at and I didn't because they all look the same they're all in uniform but they all shaved their heads because they didn't know you walk on a tree get texty no one wants to be looking for techsan so they just save all their body hair and in fact she said in your country what is it a crab's went extinct because people start shaving the body here and she goes for diseased purposes I'm not no one wants hair anyway and that's when I first realized that half the people are looking at were girls and half boys and crazy crazy but hey I want to get you on for so many reasons not only are you a I've done two amazing articles on north of town better bonding and correcting class to malocclusions which I know is your expertise but my gosh we have to start with the smiles drug club is in the news like every single day it's in the nonmetal town every single day you talk about it so I obviously want to start with them what do you make of all this

Dr. Lisa Alvetro:  you know boy you know it's so hard I think for people to you know for consumers to understand they're being marketed to and you know the the dangers of self-directed self-directed treatment and I think it's funny because I know I had a friend that was gonna say you know I think I'm gonna do smile direct and I'm thinking don't even dye your own hair you won't even do that yourself why do you think you should be should be doing you know doing your own teeth and you know unfortunately we're starting to see people come into our office now that were gone through smile direct and you know one patient said to me is it possible that my teeth don't fit together now that I'm worse off than when I started and you know he's like I should have known better and it was interesting because I described to him why would he was doing wouldn't work he had a Bolton discrepancy with the mandibular excess with you know autumns people and they're adults and they have crowding on the bottom there's a suit that tooth size discrepancy when I explained to him as he was trying to line the bottom up he's like well I should have known that I should have been able to pick that out but I'm like but you're not a you know you're not a professional you were trying to do this yourself you were doing it online and you know being you know if our if not remotely monitored so you know I think there's a lot of dangers in it and I sometimes will tell people it's kind of like wrinkle cream you know you can try it some people may look better you'll still have my wrinkles and if it doesn't work with the cuppa tea roll saves we didn't do it right you didn't use the right wrinkle cream and then I'll try another wrinkle creep and I'll keep doing this you know over and over again but you know that is very marketed the thing it's a prod I think from an orthodontic standpoint there are people now that are more aware of their teeth than they were before because they're seeing it so much that they almost feel like I have to have straight teeth because I'm seeing it on TV I'm seeing it everywhere and so I mean I've seen your citizens walking it's like okay I'm 75 years old my straight my crooked teeth didn't bother me but now that it seems like it just it's straight and I see it everywhere now I feel like I need to do something about it so you know it's kind of interesting how it's really brought you know aligners and that type of treatment to the forefront of people but then there's the dangers of it being self-directed you know 

Howard; I know this show is called Dentistry uncensored and I have a reputation so but I'm still trying to be protective especially where it's around sweet ladies like yourself yeah but my friends one that lives like a block this way another one block that we're both orthopedic surgeons yes with the number one broken bone is in the United in Arizona it's a big retirement community right you know we're like the Florida of the the West except we may be just a little Dumber over here a little more hillbilly than Florida but um guess what the number one broken bone is huh a broken rib why because the seniors are all down here retiring and they break their the woman breaks her rib during sex so the point being they still want to look pretty when they're 80 yeah and the science these orthopedic surgeons told me a perfect ten to a man is a woman thirteen years younger than him I'm talking about older men so here if you're 93 an 80 year old mrs. Cranston across the street is as hot as it gets and of course she wants Invisalign and of course she wants a liner therapy and and I remember when I was little on migrant my um my first great-grandma missed a hundred by like six months and this next one missed it by like four months and remember she had this uh this round thing with a powdered ale and she'd put powder on her face and she put lipstick and all this stuff on and I used to remember blowing my mind because I mean she was like 90 years old but she's still standing there putting lipstick on and powdered her and I just and and then one time about the only time she ever yelled at me is I I walked in on her and she was trying to put on her girdle and obviously she was suffering and I said what why do you wear that look good and feel good and then she struggled to pull herself into it so so yeah I mean I think I think I think beauty is it's just one of those things so yeah smiles Direct Club not that is a major deal it seems to be a very different but if we just take away take I want you to take all your orthodontic values and throw them out the window which stalk do you like better and the old-school aligned technology which owns a vis line night arrow that's partnering with the orthodontist and has been out for years or the new disrupter smiles direct Club that's trying to dissing the middleman orthodontist and go directly to the consumer who's gonna get more play who's gonna be a bigger thing  wallets boy ten years from now man

Dr. Lisa Alvetro:  that's a hard question that is really short term short term maybe smile direct because I think they're really you know 

Howard: they're in it to for the financial gain boy I don't know that you should ask me that question like yesterday so I can think about it gosh I don't know and then I want to ask another question you wrote your a you're really an international expert on class to malocclusions uh-huh and when you live in the United States which is say only 13% African American you go to Tanzania where it's a hundred percent African and then you go to Japan where there's no Africans where they have more class threes or is class two class three is

Dr. Lisa Alvetro:  it more genetics is it more is that the main crux of these class twos and class threes genetic since you see variations among the tribes I think I think you're right it's it's so much of it is genetic yeah there are some environmental factors you know airway and indifferent but so much because like we go in Tanzania where people don't even marry outside their tribe you don't see malocclusions you don't see maybe some associated with if they'd early lost the cave a lot of the skeletally you end up with the right size jaws that match your teeth and so you know particularly you start to see more people of Eastern European descent which like lives in Sydney there's a lot of similarities when I'm over in Europe and lecturing with class two and you're right then you get to Asian countries where they're where there's not so I think so much of it and you know for me I've been it added about 26 years now so there's people like I've treated their parents and they bring me their kids and I'm like yep this is exactly what I expect if you mix you know the two of you what you look like you can really see that similarity 

Howard: so yeah you know I'm I think American lose sight of the fact that like if you go to Japan they're all Japanese you go to Korea they're all Korean even Poland is ninety eight and a half percent polish you come to nice seats you're a Heinz 57 hot dog mustard ketchup thing are they getting a lot of the data from these these tribes that are like 98% or all the same people and comparing the epidemiology of occlusions and JA developments you know and I don't know the region that we're at and even there is not even a lot of health care or or dental care where we go 

Dr. Lisa Alvetro:  so I know that the areas we practice where we go and practice no because there's just not it they have a hard time even some of the government you'd go into different regions and they'd give you like the health this the statistics like how many people are maybe have you know are HIV positive I'm thinking you haven't been here in a while because you could just tell there was there was so much you know chronic illness that was underreported but if no one's there to report it or tomorrow

Howard: I mean the first thing they teach you in MBA school day is she was how all the numbers are wrong and and all the humans like but I saw it on TV I read it in the newspaper I don't care I don't care if your CPA gave it to you all numbers are wrong until proven otherwise and in fact I tell you what I am Africa changed my mind on dieting and exercising because when you're over here and you talk to PhD weight specialist they say that the that no matter how much weight you lose within a year you're gonna gain it all back in like another pound and then when I was in Africa I was talking to and I loved it because you know when you're there you're with their dentist and they're done it so dentists are always in the top one to five percent in education and income and I said I'm okay I don't understand it you know what you know we have limited electricity this that limit the economy but you have heavy overweight obese people and skinny people and he said yeah well those are all from the Tri blah blah and those are a try for that you know and this is that it's it's whether or not you baking heavy and thick is genetics and and and I've lived here my whole life and I need the same as you know but you could heat completely the whole time I was with him and I think in three countries he just say yeah those people there they're heavy and thick and these people are like little gazelles and he and he told me he says yeah I can't put a gazelle on protein shakes and have it grow into a zebra and I can't put a zebra on a diet and make it a gazelle I thought okay take me to the first McDonald's you can find and let's eat to that but so and the other thing I want to talk to you about is um AI seems to be the computer digital so how many years have you been on orthodontist

Dr. Lisa Alvetro:  26 going on 27 and how much has changed just from computer digital from 26 years ago it went to it's amazing particularly when you look at how much says it's accelerated in the past eight five years but I mean I can remember when I first opened my practice we had you had the computer with the floppy disk and we had a management system that was dog-faced that you know one person could get on at a time and you know you're moving to the now you know with everything being networked and getting rid of going paperless and you know it's amazing in my practice life and I think that's what's hard for people because so many times people kind of shut down after they graduate and to you know continue with the technology so it's you know what what it's opened up for us it was worth and honest and Dennis I think is amazing too I mean every day and we have the conversation and how different it is even even kids that I've treated a couple years ago or you know other family members now we start talking with scanning and you know digital setups and indirect bondings and it's it's amazing how quickly I think it's changed more in the past couple years and it did even maybe the first you know first 10-15 years I was in practice compared to how far it's accelerating now it seems like as soon as you get something it's it's up you know there's something better out there something no faster better in software and it's hard if you have to figure out what you really want to concentrate on because it can be so overwhelming 

Howard: so you know when I got out of school in 87 the biggest brands in dentistry were already made I mean Colgate Listerine they're the only new brand that I've seen around the world obviously is Invisalign I mean when you're I mean I got four boys I mean I don't care what country we're eating at the minute someone finds out dad's a dentist it's an Invisalign question by weight your sets you know that tall and it's just it's just it's the biggest thing and it seems like when I talked to any dentists any orthodontist that I you know well you would know that instantly that they're an alcoholic and that a bar it's about 20% of their practice most most of my friends tell me it's 80% 6 20 percent and this removable clear liner is that your is that what you see in your mix because you're in real world Ohio 

Dr. Lisa Alvetro: yeah you know and that number seems to be the percentage seems to be be climbing as far as the number of people requesting and you know I think probably one of the things that's that's really increased for us is the kind of what we call our you know a mixed case or a hybrid case where one arch can definitely be treated with a liner and the other to expedite things is treated with fixed appliances because what we thought of that because what people want is speed you know they'll come in and say one aligners a lot I must say they wanted misalign honestly I was never an Invisalign customer we always did our own in-house starting you know quite a ways to go and then now using some other you know clarity aligners but the thing is that you always ask them you know if I use aligners you know if this arches say the particularly lower arch there's a lot of crowning is gonna take so much longer and if you really want something that you can't see but you also want speed a really nice combination will do the top of the liners the bottom we can use an aesthetic bracket you can place it down low enough close to the gingiva that you're not going to see it but your bottom will go so much faster if someone's got a lot of crowding by the time you expand the arch make space with the liners sometimes I'll do a diagnostic set up and shim okay the top could be done in 20 aligners at the bottom right now we're at 85 you know and we still are not done but if you let me put fixed black it's on there I can get the bottom to go as fast as the top so that's something you know to when you're thinking about people who are trying to say do it themselves and smile direct you know you're arts you're up or your upper front teeth may look great but a lot of times it's you know obviously the bite the occlusion or getting the alignment of the lower when there's what a lot of crowding that is so difficult with with aligners you know or if I have a case where I've got to put an attachment on every tooth I'm like why don't we just put some brackets on that lower arch and get it done so that population has really grown for me because there'd be some people that just you know aligners were not going to do it so they wouldn't do anything but if I can give them a hybrid treatment like that they're definitely in and you know that works too for you know you know our teen population as well

Howard: so when you said you never use Invisalign the first thing that flashes and crossed my head is that you're that small country girl that avoids cost and they were the high-end expensive

Dr. Lisa Alvetro:  no the reason and I and I guess I'm glad that a-line there was a several reason they never became an Invisalign customer one is that I was always taught by a mentor that never do business with some with a company that you can't align with their core values and I was never sure that they were actually in it for me so what it forced me to do is to start to learn clear liner therapy before a lot of people were we were using a software that was based out of France for a while that was some of the first to be able to do some of your your aligning set up some then it started we started getting involved with reshape because I just couldn't give them money but I knew I had to learn how to do aligners so we started where does that come from it was a religion or were you raised religious or what no just I'm someone that was had led a successful company and with some of the groups and mentors I was with different women are like here's the thing only align yourself with businesses that you agree with their core values because if you give them money you're basically supporting them what they're doing so you know so we're very cautious you know who we do business 

Howard: with so aligned technologies what what were their actions and values that you couldn't with

Dr. Lisa Alvetro:  well we weren't it and I don't know that there's a lot of times we'll go back you know when it first started yes okay it's worth it honest and then it's gonna go to Dennis and then they're gonna get involved with you know they've got their hand in a lot of that do-it-yourself so I just didn't think and some of the reports that you know people were sharing with their experience I just wasn't comfortable with it but here's the other reason - from a market standpoint is that in the area that I practice the majority of dentists will all do everyone does Invisalign and they all just start competing with one another trying to you know I'll do it for this amount I'll do for that amount a lot of them do it even just as a loss leader to get people into their practice because they want to do the perio they want to do the restore it or they want to do the veneers you know as an orthodontist I don't do that so it didn't make sense for me to compete against people that had giant billboards because how do I differentiate like my Invisalign is different than your Invisalign and his is different from that so when we started doing it in-house one it helped us differentiate herself and 

Howard: I see you could do billboards I was so ugly they told me I can only do radio well I wouldn't be on that face on a billboard because car wrecks so then who is the if you're not going to use the name brand Nike Invisalign what clear aligners do you like what would what so you're just like to buy the printers and the software 

Dr. Lisa Alvetro: we do quite a bit of it in the house some of the larger cases because there gets there gets to be a point to if you're looking at when you're when you're manufacturing them yourself there really is a point where it becomes more cost-effective to outsource it looking at you know and your staff timing and manufacturing so when we do outsource now we'll outsource the clarity to clarity aligners we used to do all the cases in-house you know if you're looking at an in-house case where you do maybe eighty hundred aligners that's a lot of you know that's a lot of staff time that's a lot of your time so there really is the point where in-house is more efficient more cost effective and then when you start getting into bigger cases to outsource them but and 

Howard: what's clarity aligners yeah clarity aligners it's a 3m spread because the other one is there's a 3m three it's mostly it's a 3m product okay so talk about 3m who's gotten their stocks beat up so bad maybe maybe you'll give someone a reason to buy their stock so do you think 3m is going to be a competitor to the line technology

Dr. Lisa Alvetro:  well you know one of the advantages that they have in we just actually were doing a case today or if you do in a combination case where you're gonna do an aligner on the top you've got fixed appliances on the bottom so you know they'll be able to you'll be able to do an indirect setup where you can then determine bracket positioning and so we seated the bracket put you know indirect bonding tray that had 3m brackets and then the aligner on the top because you know if you're using a line you've got you just have to be able to use your aligners and your different attachments so you know one of the advantages of the clarity aligners if you do want to do a combination case or you can do the setup all at the same time and predict what that outcomes going to be so that I think that's one of the main advantages that they have 

Howard: so where do you think market share how far along are they

Dr. Lisa Alvetro:  honestly I don't know and it's a relatively newer product and I know particularly when it was being released or was being released and I'm limited and it just wasn't they weren't opening the floodgates or you know because they were growing getting more text training so it's continuing to grow so there are more people that that will or continue to use that take you to appear in existing with your and northen us and use a lot of brackets and wires it's easier to kind of combine all of that together 

Howard: yeah is that you find that's real I think you know for myself it is technology and technology is most of their technological gains is it in the software from the I tarot scanner the scanning and making it or is it actually in like 3m score gotta see like the actual materials of the tray the elasticity the plasticity do you think it's software or physical your

Dr. Lisa Alvetro:  a lot of it I think it's actually both and that's one thing where everyone keeps working on what is the best what is the best material to make a liner she needs something that has you know some rigidity but also needs to have some elastic memory if you compare it to like a yellow the the technology of arch wires because there actually is some given plastic and trying to figure out what is the you know the elasticity of a material do you need different types of material throughout a case you know or maybe where you've got a lot of crowding in the beginning you need something it's more flexible when you get toward the end you need something that's more ridged to do some of the fine movement so you know coming out with newer and better materials I think is really you know an important part the software to obviously the predictability of it you talk about artificial intelligence knowing how much you have to you know to move and even stage things for somebody like myself who was trained in fixed appliances moving teeth of plastic it's completely different and it's a really different mindset so even when you're looking at setups I think one of the advantages for us because we did so much of it house and still do you have an understanding of setups where sometimes of people always used to just hitting the Invisalign button and then getting back a clinch Eck and then figuring out the clinch Eck it's hard if you don't have some of that experience so a little bit of software and the software keeps obviously evolving and then materials too and then you know I think one of the biggest challenges I have with the liner therapy 2 is even patient compliance you know how long will people continue to wear their liners will they wear them as prescribed and so I think there's a lot of things that need to continue to evolve 

Howard: well whenever you say 3m I just I personally cringe and you know why that is no why is that we were talking about values where you can treat their values well first of all I'm real close to 3 M because my oldest sister is the cloister Carmelite nun in Lake Elmo Minnesota so whenever I go to Minnesota I gotta kill 4 hours 1 minute so it leaves your 3 M in Paterson and so I thought I'm all good with 3 M and I podcast interview their President James D Ingrid and I'll just tell you the date so he had his podcast with me on January 30 2018 and he was fired March 2018 and if you think there's anything correlating between those two you would be correct and so I think it's gonna be a lot harder to get CEOs to come on my show in fact the the man that we've been talking about a Joseph M Hogan whenever I ask his people when's he gonna come on my show I mean they can't quit laughing I just can't yeah yeah we're supposed to go on dentistry uncensored with Howard yeah okay we'll get back with you but yeah he was on my show and then he got to work a whole nother two months and but anyway yeah it's tough some some you know anyway enough that but so so you like clarity aligners y3m and that's the is it you're using is that more material or software 

Dr. Lisa Alvetro: probably boy that's it that probably a little bit of both the software I think software and stars quality of setup for me and again I'm comparing to some of the work put in when you're doing it yourself again you know I can compare it to Invisalign because I've never never done it isn't line setup actually I shouldn't say that I did do probably three or four cases when it first first came out but you know when you're comparing it to in-house you know we're comparing software now that we use for our in-house is three shape and so you know it takes some of the workload off of us when you can just submit it and then the the setup comes back yes I have and what did you what do you think I like there juice bar well

Howard: my theory is in Copenhagen Denmark you have three shape and in Copenhagen and then you have what's the e for D and a Helsinki Finland is a plan Mecca huh and the you know four months of the year it's like you don't even see the Sun and my all my dentist friends tell me that there there's basically only two types of people in Scandinavia in the winter for ten months you're just gonna work ten hours a day six days a week and then Sunday you're gonna go home and do all your laundry and clean your house don't stuff or you're just gonna check out and be like an alcoholic until the summer and they said that that you know the Blues the no Sun the bitter cold I mean I remember when I went to Creighton so many times we had such bad motives like we were just gonna play hooky all weekend and then you look out the window and it's like 20 below zero and freezing you know snow and Moore's law and you just I'll just stay in and do homework I think that their environment you basically just promotes working I mean I mean when I Drive past ASU I was thinking you know if I were going to issue I'd probably be a janitor right a Taco Bell because you'd be so tempted to do so many things whereas in Omaha Nebraska in the winter mother nature took all those temptations away from you and so yeah they just there's only one mode and scandanavian that's just work you know when I wasn't

Dr. Lisa Alvetro:  when I was in Copenhagen the one thing that struck me and I was just there just briefly for a day and I got to spend a day in with her three shape people but when we were out walking the street it was cold I mean it was it was snowing and there's people sitting out there there's all these outdoor cafes and like it's freezing cold and there's people like drinking their wine or drinking their beer you to swore it was summertime I'm like what's wrong with you people it's freezing out here so they were they obviously were adapting

Howard: yeah there's good research on that because we got here in Arizona when Canadians would come on down and spend the night with me of the weekend or whatever they would want to go swimming and we're like dude you don't understand the waters and then they go out there and they would swim so then I thought okay it's all in my head I'm just being a wimp and I'd get in my swimsuit and I jump in and almost have a heart attack well it turns out with that if you don't use it you lose it so when you put someone real northernly in a heat tank there's all their hairs are standing straight up and no heats given off and then you put someone from near that you know the desert like me in there and all their hairs are laying down flat and heat just pouring out so they build up smooth muscle tonicity to actually hold heat in and and if they don't have that for you know years and years and years it just it's all flaccid it goes away it was

Dr. Lisa Alvetro:  making me think of when we'd go diving in the Caribbean in Ohio when you dive in quarries in Ohio it is cold you know the Caribbean people are putting on wetsuits and you're jumping in with a t-shirt they're like what's wrong with you I'm like yeah this is this is really warm guys

Howard: so I'm gonna ask you a sensitive question a politically in an ideal I'm some dentists don't want to do any Invisalign because they're in a study club and they say I just I I don't want I don't want my orthodontist ever figure out I did or visiting Hayes and and so that peer pressure those uncomfortable around there what do you actually think I mean you have four kids right mm-hmm and I have four kids so we probably are we both equally insane then after raising four kids you just quit paying attention after a while so my question is um what would you say to a young 25 year old girl she just got out of the Ohio State University and she wants to do an Invisalign class but she wants to do it behind your back cuz she goes to your study club and she's afraid you might find out then that's what some people think so what would you what would you say to her if she if you found out she was thinking that

Dr. Lisa Alvetro:  well you know good portion of my friends who are dentists all do Invisalign and a lot of me would do fixed you know fixed appliances and I'm fine with it and I think to what's nice for them is they become more educated and what to look for and so they'll pick cases like okay I can do this one but they'll say I definitely can't do this one and or this isn't in a liner case so some of my biggest refers now are people who do their own aligners and now that they've experienced that they know this is not an aligner case or maybe this is a more difficult aligner case so even you know young doctors that are looking at doing it I think you need to become educated in and if you want to do it do it it'll also help you as you're working with orthodontist know what you know when to refer some of the people that do their own orthodontics or do their own and baseliners are really some of the best people who know when to send a kid to me and are better picking it up and someone who doesn't have any experience at all because they don't you know they're not looking at the same types of things

Howard: ok so now I'm going to ask you a question that will make make you lose friendship with half a year or third on its colleagues okay okay something's gonna make them love you more I mean it's like it's gonna say you're Republican or a Democrat approach me it's myofunctional principles I mean if you're ever with if you're ever with two or more or you have and it's it's passionate some just think man this is great stuff and we need to think holistic and the other half like man that is that a scam artist baloney no research how could you fall from that it's it's a very passionate agree with that

Dr. Lisa Alvetro:  I think it is very passion and I think sometimes what polarizes people I think like any idea is that people take it and if they apply it to this population they think they can apply it to every population where I think there's so many modalities may be looking at myofunctional that yes you know I'm just thinking of a young little girl who came to see me that I think is really gonna benefit from that would everybody benefit from it and I don't think so but I think what polarizes people when someone you know thinks that one thing can do everything for everybody and that's where people get split so are there some cases that benefit from that yes are there some that I don't think no matter what you do you know it's going to change some of those patterns or some of the skeletal patterns so you know I think in the polarization comes because people become so passionate and they're not willing to listen to what you know or look at what other people are doing

Howard: does the tongue face muscle complex have a role in facial form and development and can't attempting to manage habits have an effect on treatment planning and outcomes

Dr. Lisa Alvetro:  I know in certain cases yes you know I think of some of my patients that have you know an unusual tongue posture or tongue thrust they haven't you know and anterior open by Pro Klein maybe they have you know a trans a maxillary transverse dimension that's an issue but does it apply to everybody if I I don't think so but there are certain people that yes if you can if you can control that if you can change that and the thing is you know will that modification make a big difference and some people will make significant difference in some people it won't I mean I think it's really hard to hard to predict

Howard: I'm only trying to use controversial stuff to get in trouble okay so when I was little and got out of school the the big radiology thing was was a new pantograph right and that the coolest feature on it was that it had a are on one side and an L on the other so you knew well now they've gone to this 3d CB CT and some were that honest are saying this is standard of care dude on every case and then we have ten professions in specialties in dentistry and you're one of them orthodontics another one is maxillofacial oral radiologists and they say no that's too much radiology so what do you how do you balance between yeah I'll take more information than just the right the are in the owl but is this gonna be your standard intro stick every child in Ohio's head in this machine and zap it with that much radiation 

Dr. Lisa Alvetro: no I don't think it is I don't think it's necessary on every patient because and there are something okay like cases that are orthognathic cases yes we definitely do that even if there's an impact Anor you know it recently had a patient that it looked like there was some external root resorption from some adjacent teeth and got a limited cone beam to really see what was going on but there are so many cases that you look at that you wouldn't need that it you know you don't need that information if it's gonna affect significantly affect the treatment plan or treatment outcome yes but there are people who do it on every per I wouldn't do it to my own kids I mean and often it was so

Howard: I'm sure you do it on one of the four kids one of those moms that tells me are the favorite child I mean come on this dentistry Center which child's your favorite mmm 

Dr. Lisa Alvetro: who's ever not giving me a bad time at the time but yeah you know it was real interesting because I you know before everyone was pushing the cone beam and so much it was pushed even you know by manufacturers of film beams and what am I one of my favorite ads I saved was from a company and they were showing and it was someone's testimony like well if I wouldn't had a cone beam I never would have found these impacted cuspids and you looked at the pan there were two cuspids heading this way you look at the picture occlusal picture you could look like two marbles in the palate and I'm thinking well what else were they I mean you can yes she would have found them I mean they were right there so are you sure wasn't a hernia so you know as far as standard of care I don't think there's their place for them yes but again how can we oh we always have to pick all or nothing' people like oh I never take a comb you people like I take him on everybody how about we just do it when it's really necessary for treatment outcomes and names big words Adonis what practice software 

Howard: what CB CT you are using

Dr. Lisa Alvetro:  I don't have the CBT and  I refer I have an oral surgeon that has one so I don't use a cone beam let's see what was the rest of the question dolphin imaging and dolphin management I have been and I'm a long-term customer we started with dolphin imaging I think 25 years ago when it was just the imaging and then went into their  management soon as available actually I think we were a beta test for the management component so my son who I was pregnant with my son and he's gonna be 17 so we've had that for about 16  till 17 years 

Howard: Wow very very cool but see kids look what she just said she she's not gonna tell you but I know she's rich she's been an orthodontist for 25 years she's crushing it but in it funny how rich people drive old cars and she doesn't have a CB CT and our oral surgeon use one you just use that one and then you come out of school $400,000 in debt to schools here and I'll know their dad and I'll say you know what you're $400,000 in debt you know what you need to go move in with your dad you won't have any rent you know you eat ramen noodles in the basement and pay down this debt and I don't and they can keep the the way taxidermists knows you're a homo sapien is because you can rationalize anything well you know they come out and then next thing you know they're buying a house out in Queen Creek for $400,000 hmm and because what happened well you got used to just going a hundred thousand dollars a day like men if I bought a hundred thousand dollar car I'd have to give you a hundred thousand dollars cash that's hard to do but if you don't have a dime signing up for $1,000 a month payment for a thousand months who who cares and it's like they have no taste of cash they just they get used to pile on net and they'll buy a CB CT and they've done like three ortho cases and they'll say well I need it cuz I'm gonna get into Invisalign and it's like okay well how many how many ortho cases have you done ten thousand 

Dr. Lisa Alvetro: well you know it's funny is that we were setting up her office and I work with residents and I was listening in to a consultant trying to convince these residents that they all had to buy a cone beam to differentiate themselves in the market and it would show them you know their patients with technology well I happened to be in my office and I was standing and I could hear that the  dad and the son talking in the new patient room and the dad goes man the technology here is just amazing this is just great do you know what they were talking about I had a trash can that was a touchless trash can and that when you when you walked by I went to throw something in it would open up he threw his paper away and hit close he goes now son that is some amazing technology and I'm thinking okay two days ago I was listening to someone try to convince people they needed to buy this very expensive piece of equipment here they could have went to touchless trash cans calm and it had been impressive too so you know it's hard when they're kind of you know pushed to try to buy things but and by the way I mean you're talking about cars I hate new cars do you know why why because I'm an awful driver my car sitting in the parking lot now all four quarter panels at the front that everything's bent dent and I like it that way I never fix it because I'm gonna hit something again anyhow I mean luckily I've never hit people so I haven't really hurt anybody I usually hit objects like poles garage things like that so I will know my car 

Howard: I bought in 2004 and it's 2020 and the animals about a year ago one of my grandchild and decides open the door and caught it and she started crying I pull it forward and I asked her why are you crying no one's hurt and then I just body slam the door back and and then when my older boy saw they punched it needed a couple more time anyway it opens and closes nice now but it's got this huge old dent on the side and every time I look at that I think of my little precious tail tells a story whenever they write on the wall I go to the the Coles Hobby Lobby uh-huh know where they buy this rain bill and I just buy the frame and then wherever they drew on the wall I just nail it around it so it kind of looks like yeah that's like and that was without Janette I would go home and I would mix up the Elgin in the pan and I put their face in it with a straw pour that in stone and put that on the wall so I got like plaster little there little plaster three year old faces on the wall and then if you ever get mad at me just go kick their plaster ahead and just mother narge but um so I'm just gonna ask guys more more and more bill questions sometimes when people get into the biggest trouble what would you would you say when a non orthodontist starts doing it in this line case and so what I want you to answer is what are the low-hanging fruit oh please do not do that I mean anything you know open buy it a long face if you know nothing you know it's it's okay to have known knowns know known as good known unknowns good not fun so she's young she wants to do Invisalign case she really doesn't know that much ortho what's the low-hanging fruit to run on this case 

Dr. Lisa Alvetro: I would say probably you know you've got a class one with obviously not an open bite but and a super-deep pipe a kind of an ideal occlusion that maybe has some spacing or some crowding and I think we owe one yes yeah those are some of the easiest ones to start with and particularly I think to when I when you look at cases ones that the arches have a similarity I think work becomes trickier if one arch has a lot of spacing and other arch has a lot of crowding if you know both arches have spacing a lot of times the mechanics is very simpler or both arches have let's have a about the same amount of chronics when you start getting mismatches is which is really hard that you know someone has an ideal occlusion and maybe he's really crowded on the lower spacing on the upper that can get you in trouble because you're closing space and decreasing arch length in one arch but then you have to increase the arch length on the other so pick class one cases that are have a very of a similarity in the alignment in both the upper and lower same thing is true and if you're even looking at like the dimensions transverse dimensions if there's a similarity in the transverse to mention those are easier cases ones that when there's a difference between the say the maxilla mandibular arch those get harder to coordinate the arches so I would look for you know class ones that have very similar arch and needs for both arches okay and then what would be the ones that they should run from one that we are harder than and they appear like they would be easy if there's a lot of spacing because a lot of times what happens is you have to really look at what type of attachment you're using as you're trying to close space or you end up with a lot of you know a lot of tipping you know cases to I think you know going back to ones for you know if a restorative dentists are looking at doing some Invisalign ones that they're going to be doing some of the restoration a lot of times I'll think of sometimes we'll be doing some touch-ups on cases that are going to be having some you know implants in the anterior may be missing laterals or you know missing teeth because as the general dentist you're going to be able to you know treatment plan exactly what size you're gonna want those pot you know that ponic or that implant space to be so those might be nice ones to start with to that you're going to be doing the restorative but I think ones that are hard to stay away from and you have to be careful I've had some friends of mine that you know when they first started doing Invisalign they would send me this clench ACK and it would be you know there definitely be a big skeletal discrepancy but they would move the teeth to try to you know in the clinch a cue could move the teeth and they would align but there was such an underlying skeletal scruff and see so I'd be cautious of ones when you look at you know if you look at a set four metric foam and there's a big discrepancy between the maxilla mandible and it's more of a skeletal problem than a dental problem I would be very careful of those as well because it's very tempting on a computer you can take that cusp in and distal eyes and you know you can move things that aren't realistic movements but if you're not used to moving teeth you don't realize that that's unrealistic so I'd stay away from skeletal discrepancies and

Howard: I've one follow-up question to the dolphin practice question that is this in 2008 Patterson bought do you think that what I mean shines bought like 60 companies since I got school do you think when Patterson bought dolphin that that was a good thing for a dolphin customers are a bad thing you know

Dr. Lisa Alvetro:  it changed some of the things because we had already been a customer for a while so we already knew quite of the people that were there obviously when Patterson bought them they have more resources so I mean we've seen it you know the software's continue to evolve and the one thing we've always we always have somebody come in from from dolphin as a as a consultant and you know teach us what's new because the thing with dolphin and so many software's there's so much in there you don't that you don't even know how to do or how to set up different templates so you know as the program continued to expand we use somebody that that comes in every year to kind of help clean up our database make sure that we're using it like we should be so I think that's where people sometimes get really frustrated as these because some of these programs can be so you know so complex but as far as that you know for us as far as support or so it was fine for us 

Howard: so Patterson owns Eagle st. Paul Effingham Illinois down here your over to the right did a lot of that dolphin imaging programming go to Effingham Illinois with the Eagle soft do you see orthodontist to use eagle soft better synced with

Dr. Lisa Alvetro:  I don't know I really don't know anything about how Eagles soft you know integrates with with the dolphin imaging of the dolphin management so but I'd have be hard to comment on that I could back to class - yeah you were obviously a huge authority on it where does that come from why were you interested in severe class - is that something more common in Ohio was that just come from yeah and part of it just came from my own patient population and you know we see a lot of a lot of patience and a lot of more class - because a lot of people who are here are generational they live you know they live here they're related to each other so I see a lot of class use compared to even different parts of it and a lot of my patients their class - is their meal mandibular retro netic so a lot of it's very simple similar and autumn is very significant so you know I was trained in removable appliances you know and you know when you get get out in private practice it's hard to know location compliance motivation treatment time so then I moved into learning fixed appliances like a Hertz type appliance and then when forces came out it just seemed like it was something simpler that I could could accomplish a lot with and part of it we just were using so many of them that's how I was asked to kind of you know what are you doing that and since we had a large patient database we were able to supply sample for researchers for residents for different university so that's how we kind of got into it just pure need so we had so many costs to kids and and now they're bringing my class to patients are starting to bring me their class to kids 

Dr. Lisa Alvetro: so it's kind of funny because they're you know some of these spend and I'm talking we've got families in this area so I'm about eight ten twelve kids and it's amazing what you can see running families so my guide one family there was four sets of Powderly impacted cuspids I mean that's that's a really high ratio and one set of kids you know people tell me okay at the family reunion all the kids are wearing some type of you know like forces or spring-like compliance because they're there's so much of it I lost you so yeah a lot of it is because of the genetic component of what I see here made me have to learn how to do this help these guys out 

Howard: again we're dentistry uncensored I don't ask anything that anyone questions until you just like get mad and walk off the stage I don't get mad gonna have a hard time cuz I really don't get mad I had a orthodontist on one time he was most controversial name was Ben Burris he thought and this happens in my pelvis has happening right now - how many of my daughter not one no two of my daughter-in-laws were there in ortho so when they go they go to the orthodontist he takes off the wires they come to me I clean their teeth they go back Ben Bertha this is ridiculous and and and we're gonna we're gonna get it orthodontist and my god so I mean a hygienist so he hired two hygienists and you would have thought he started dealing crack outside of his his office and I mean it was crazy I mean I mean they I mean he might have been safer to have a whatever but so why why was that so over-the-top or just because he had a tradition of being Hilda he was that he was the orthodontic pundit to begin what they were looking for excuse her or was really a violation of your Hippocratic oath if you were to hire a hygienist 

Dr. Lisa Alvetro: well until recently and unfortunately our high genocide to move we had a hygienist in our office you did uh-huh doing cleanings on a limited basis yes but here's the difference we still would send them to their dentists so basically our cleanings when we needed to for certain I mean I think it's all about patient care you know and you've got some people that you know realistically are they going to go every you know three four months so their dentist when can we get them to go twice a year we even give them certificates that they can redeem for points and money if they go see their dentist and sometimes it's hard so we ran out on our own hygiene program here to her kids or even the adults who really were struggling with hygiene some of the kids that come in to see me I can't even treat them because their hygiene so bad they already have the calcification so we would dump them into our own hygiene program but the thing is we never tried to take away any of the you know I say any of the business or work for the dentist because we'd still send him to the dentist we wouldn't you know bill for any of the services it was just something for me it was more about patient care and if I can't get your hygiene under control we have to discontinue treatment I can't get your hygiene under control I can't even start treatment for you you know unfortunately we see a good percentage of patients who come into our area already have some you know some white spot lesions some you know decalcification so yeah I'm not sure at the time that he the only he did that it became so controversial part of it I don't know he may have had some you know kind of could fuel the fire anyhow and so there were people that were looking for things and and in different states have different different you know different laws Ohio has changed some in the past couple years that before I couldn't do anything once I declared my specialty unless I was thinking about my specialty now a lot of it had that has changed that you know there is some leeway there so I don't know what's that that controversial anymore I think part of its just people were afraid that we'll shoot if he's gonna see all that you know all the hygiene they're not gonna come back but I still want people to go because there's people are gonna do your dentist your hygienist they're gonna be looking more for decay you know as much as we are Dentist when she gets so focused on lining things up I mean if you become so narrow focus it's like you know oh shoot there was a hole in that one you know but but so I don't know if he'd be that controversial now I really don't you know 

Howard: it's fun listening to you the way you're thinking about this because I mean we're in Arizona we're just trying to get them not to dream out and do after they spoke math I mean that's that's just our that's our ceiling goal I I thought I saw something dying go away north adonis and by god if it didn't come back to life lingual orthodontics I remember in 87 I saw a couple of cases of that and I called it the Curious George syndrome because once your tongue started playing with the inside of it it went to hamburger and she would just say I can't quit doing this you know and they were gone why not if I didn't see a new case of it a couple months ago is it here there is it gone going you know

Dr. Lisa Alvetro:  it's not gone and there are gruesome groups that I see it more like when I'm in Europe there's more lingual orthodontist --is there's some new systems out there that the wires are pre bent and uses a lot of you know computer-aided technology to know and design the bracket but designed the wire to make it more efficient but you know to me I did some lingual probably how I was probably maybe eight ten years ago we started doing some custom lingual where the wires were bent but you know a lot of patients are write to me I don't think I could tolerate it you know in from an orthodontic standpoint it's the mechanics are so different then when you're using in a labial appliance that I think is as plastics get better and better that's why you know there's always gonna be probably some lingual but I don't think it's going to you know for a while people I go this is going to be I don't I don't think so just for what you mentioned it's a tolerated you know we found some of the patient that we did that you know there were some that tolerated it well some of them it's like no this is not gonna not going to work and they sell yeah it's there are some new companies that are kind of reinventing it and making it

Howard: you know easier and simpler for people who want to do it is the bracket that big a deal I mean like like you go on to these websites and some like no only do tip edge I mean it's only two page and then some are like Damon and summer and and sometimes I'm wondering it's like I'm sure Tiger Woods could beat me in golf regardless of what club he was using is it kind of like if you're Tiger Woods just hand me the clubs and I'll make it work or is there a reason to be brand loyal to say tip edge versus Damon versus Wonka or you know Henry Schein how brand loyal versus agnostic are you 

Dr. Lisa Alvetro:  I'm brand loyal and here's  what  else are people to do to 3m bracket and I use their self ligating bracket both the aesthetic which is the ultra a smart clip racquet and also some of their clarity advanced which is a clear bracket but what I tell people and what I wear I see people struggle is if you start mix and match like people will buy it here's the thing if you buy really if you buy like a really inexpensive bracket and the slot is not always the same you can't figure out what wire to put in there so or your friends are like why buy expensive brackets but you know like wires that are cheap and it's just you know it's not the same diameter or circumference so you have to pick a system there's usually a bracket that's designed to go with a wire and you're supposed to put it in a certain place so when people start mixing and matching their systems that's where they kind of get into trouble so I think there is there's some advantage to take a bracket pick the wire and pick where you're gonna put it and do it repetitively in that way you can see but if you don't if you don't pick something it has a quality to it it's hard to know exactly what you know what size that bracket slot is gonna be so and I think you see sometimes people will start arguing about  

Howard: you like 3m did you ever get dr. Sumitra Mitra she was there she was there I mean I love that woman so much she was she couldn't have been 2 foot right no four foot tall five foot tall just the smartest person but anyway when you when you said mixing and matching gasket because he's Dentist used the bonding agent from one the resin from another an acid that's from another and she's like did these guys learn anything in biochemistry and then she would take these quotes from the biggest names in dentistry she actually this is back when they film it and have it on a VCR tape and roll in a TV with a VCR 8-track thing and these dentists just like well you know I don't really like the acetone I prefer the alcohol or the vinegar base and and you you could walk these guys to a chalkboard with Symetra and I was there they couldn't even have passed high school organic chemistry because they learned at 10 or 20 years ago rule number one I learned from her is you don't mix and match chemistry sets and you get a damn timer when she says stir for fifteen seconds she didn't pull that number out of a hat and there was a standard deviation at one was maybe 13 seconds and 17 seconds and doctor is thinking about what time what he's gonna do after work and he started so for three seconds and my god get eight timer and stay within the chemistry set and here's why I like Europeans well you know everything's a train I was not good or bad it's just it's just different like when you go to dental conventions and Europe like cologne the largest dental meeting in the world the owners of the company are the ones lecturing about their product many Europeans don't want to they disintermediate the middleman they don't want to hear some middleman guy come in here talking about this just like in Americans we get rid of the middleman you manufacture it goes right to my house I don't want to pay it distributor remember when we got at school half these dental companies won the Arizona rap well you know what that means you mark up everything 25% can I just buy it from headquarters for 25 percent cheaper no I have the rights for the whole state of Arizona out with cars now Tesla can't sell you a car direct because you know they don't have a distributorship and errors yeah so it's all baloney but I I love the fact that the Europeans are so non-judgmental and so intellectual that if they want to hear about X Y Z's company they went well hell it's your company this named after you you you do this 18 hours a day seven days a week and the most famous middlemen on all these different deals no no I mean when you go to their scientists and you show him well they wrote this for my magazine what do you think about this half the time they'd want to just cry they didn't know if they want to cry or throw up and and but if I had the but if I but every time I did this then I put the owner of the company on the cover and ruin him a piece they say oh this this a throwaway rag I mean I had he had a the CEO of this company that sells stuff well what are you a volunteer what are you this guy has a thousand employees and you have five oh wow what an original idea and your dad was a dentist and he had five - oh yeah how could we listen to a guy that has 1,000 employees and whose dad he never met in his life I mean I mean so I don't know where all this judgmental weirdness comes from but I love Symetra and that whole rant came because it's so reminded me of her deal if your she said if you're gonna mix bonding agents why don't you just use Elmer's glue it'd be a whole lot cheaper and it's gonna work the same so after that rant I hope they didn't lose though so you're brand loyal to three M's witch bracket well 

Dr. Lisa Alvetro: it depends for aesthetic bracket we've been using their ultra s and you know I'll be honest with you too we did some of the beta testing on it and you know how I ended up so 3m brand loyal again you know starting 26 years ago people don't understand pre-internet yet a catalog and we had a rep and I had a unit AK at that time 3m was unit tech and I had a rep that really understood orthodontics and couldn't really kind of help me navigate through and so we just started using it and again I'm rural enough but a lot of people never showed up at my door to say hey maybe buy this stuff so we just got a lot of experience using their there their products and that was probably about ten years ago then they asked if I would start you know helping and doing some education for them so bracket wise their aesthetic bracket I like the self ligating bracket which is an ultra bracket and then further metal stuff like a tube bracket we've been using smart clip bracket which gosh it's priming out about ten years now I guess maybe a little bit longer so I've got a lot of longevity and again it's the system and we tend to the thing about their brackets too is they're pre coded and now they even have a flash free because here's the problem you find when you're bonding orthodontic brackets people get real precise about their prescription and where they're gonna place it but if you have an uneven amount of adhesive underneath it that really changes the values in the bracket itself so 3m right now is the only company that has a flash free bracket so that way when you put when you place that bracket to the tooth surface there's no extra adhesive so you know that you're gonna express the torque that's in in that bracket base so that's part of the reason I don't know that we could ever use anything that not only that I'd have to put adhesive on but something that's not flash free because it's just such a game-changer it makes bonding so quick and much more accurate so that's right wear that

Howard: you and I have lived through a lot of fads uh-huh lots of things come and went from micro air abrasion to whatever some people some people are thinking that I'm that this um sleep medicine stuff his is it it's either being applied to way too many people how was sleep medicine and affected your wartime practice I mean are you now five person sleep ten percent of sleep a lot of people call everything's a crisis now they you know we're supposed to be having an opioid crisis when the British got to Hong Kong two hundred years ago they said one third of the people were stoned on opium I don't know what Ohio looks like but I don't see one third of Arizonans smoking opium they they always say it were in a health care crisis their herd is dropping three hundred thousand newborn babies a day if you ever meet a rancher and he says my hogs are dropping three hundred thousand babies a day I don't think anybody would say it's a health care crisis but is sleep apnea is it is it is it real is it overdone is it dramatic as it as it impacted you a lot we're yet with that

Dr. Lisa Alvetro:  oh you know and I think it's kind of like like we talked about before is that sometimes someone takes one principle and it tries to apply it to everybody you know and I'll have people come in for a consultation that they're you know sit thinking that their sleep apnea is due to their you know their dental relationship and there are some you know if you're if your retro ethic if you've been actually transverse deficiency you know but if you really have an idea you know skeletal relationship of your face but your way 450 pounds I mean but oh but you know and I'm thinking sometimes they're focusing on the wrong part of the story because sometimes what you need to do - it's not a quick it's not a quick fix it's not a goal fight you know I've had people that sometimes even their dentists say oh if you you know if you fix your teeth your sleep apnea you know that's not true it's not that's not your problem you know do we see some patients particularly kids that are really men you know max we transverse mandibular deficient to help increase Airways that going to help yeah but I mean obviously you're gonna have to coordinate that with with a true you know someone who specializes in sleep medicine and you can do the appropriate studies or so again it hasn't impacted my practice I think what's kind of funny is when you hear so much a push it like airway friendly orthodontics I I just kind of laugh cuz I'm thinking what we never really tried to some other people smothering people I I don't get it so you know and so much of orthodontics in the past you know in the past 15-20 years has been more of expansion you know trying to increase mandibular projection as far as you know trying to make things more retrieve I think that's probably more people who were treated and you know that are now maybe in their 50s or 60s so that kind of when everyone starts talking about you know do you do airway friendly orthodontic I just want to kind of lap them like well no I'm gonna try to smother your kid instead it was much more fun just the kid yeah think of all the money you saved on food by not having to ever feed that that guy again one more thing you know we've come in the house and has also has sleep has is it impacted my practice to is sometimes what people don't realize if they're wearing a sleep appliance long-term and they had maybe a class-3 tendency to start with and there really there was a woman who came to see me who really was held so far for it and she was a very she was a very large woman and it held her so far forward she got to a point after and she had been wearing this appliance for about five years and I know there's some exercises to try to reseat things but she had a really significant malocclusion and she's like I hate this now you know she described have an underbite that's an inch and a half and the problem is she was so used to being held forward the only really option would be probably an orthognathic procedure to move the maxilla for but that would have looked awful so I think sometimes with what I'm seeing is people come in that are wearing you know sleep appliances a long term and don't realize there can be some changes in their bite or and you know in their occlusion and then all of a sudden they're not happy about that so you know that of see seen some in becoming a little bit more prevalent - as more and more people are practicing you know sleep dentistry 

Howard: so you know from smiles direct Club and visit Ryan - more orthodontic residents what would you say to someone who's in dental school at the Ohio State University and said they wanted to go on to be an orthodontist which I mean compared to when you became a ward that I was 25 years ago well you know I even think back to

Dr. Lisa Alvetro:  when I was in dental school they actually were telling us in dental school they really wouldn't be a need for dentist because all the decay was going to be gone there wouldn't be anything to do you'd have to all do aesthetics and the interesting thing too like when you're talking about the Mountain Dew and all the habits you know in our area here there's more decaying kids and there probably has been in from the generation before you know as far as orthodontics what I still encourage people to if that's something they want to do yes but I think it's going to continue to evolve you know has you know have all these things influenced our practices as being an orthodontist I still still think the greatest job in the world yes I do will continue to be that way I think so not for everybody though because there's just certain things people don't want to change you know one of the things that with all the aligners and even the smile direct and all his made orthodontists realize is that we have to be maybe more accommodating to patients and what patients want and come up with different treatment modalities and continue to evolve so that we can serve patients because you know you know 15 20 years ago if you went to North us this is what you got this I was gonna long was going to take and that might have been your only option so yeah I would I would still you know my own son thinking that this is something he'd wanted is it gonna look like what I'm doing today probably not I mean is it going to change I think you know it will continue to change but I think the change has been good 

Howard: so far or am I just an optimist and in - profession in the world that's because when we go home we we had four kids and I think I think that the young kid should realize well remember they had four kids let's not do that mistake let's let's have four dogs then maybe I will want to go home nah but I know four kids out that was a commitment that was the hardest job I ever loved I mean did you ever have a what was harder becoming always successful worth it honest or for kids mm-hmm I thought the kids are pretty easy but again maybe I wasn't paying attention well depends on the population I mean if you weren't raising Irish might have been totally different I don't know what I don't know what you're raising um but um one last thing I want to tell the kids a lot because I because when you've been doing this 32 years you stuck your tongue in a lot of light sockets and a lot of your friends have done it and I always tell you and it sounds so obvious and everyone knows it but they don't think about it I mean I want you to get a a on the diagnosis and treatment plan I don't care we get a C on the work that's a lot better than getting an a-plus Dental case and you got a C on the treatment plan the diagnosis and I see a lot of these people they run to these these six month worth of courses these weekend were no courses and I'm like okay well you know Richard Litt is a board-certified orthodontist and he was the he taught the program University of California San Francisco he taught it at Detroit so this is the guy that taught the orthodontist and a lot of you know it's too long it's wrong you know I mean the course is the cost of one ortho case and then another one is Harry green out here in Arizona you know I mean I just think if you're gonna learn ortho remember if you cut Alaska in half each half is bigger than Texas so in Texas are telling you how they're all that in a bag of chips they're not even a half of an Alaska and orthodontist if I cut the 10,800 orthodontist that we mail ortho tau Magazine to every month and I cut that in half each half is bigger than the number two which is oral surgeons and the number three which is para nós I mean the orthodontist they're the Jupiter of the specialists you know Jupiter's like what is it like ninety four percent of the mass of all the planets in the solar system or whatever and if you're gonna learn ortho you need to learn from a board-certified orthodontist and and I would really recommend that when you start that you you know that you go meet the words on on us up the street and say hey I took this course from a real orthodontist board-certified whatever whatever and here's the case I'm gonna do when I started my first course I told Harry green I said okay I'm gonna start this this case but the first one's gonna be a freebie it's gonna be my aunt sue and you're gonna come watch me present the treatment and go over her questions can we agree on that and I'll pay for that or whatever whatever he doesn't absolutely and to this day my aunt's who thinks he's like the sexiest man alive seems he's like the Brad Pitt whatever but I was taught by board-certified I had a relationship and then one last thing I'll notice about the doing ortho you know number one just get a good course if you're gonna try but it seems like all my friends that learned ortho they they played with it for maybe five years interest and what went away from it and I'd say half my friends that learned or implants mid the Dominican Republic got the Machine God they did the whole nine yards and after about a hundred implants said I just don't like it and so but I think that's a good thing because then you have the more diagnostic in your head so you're not doing ortho you're not placing implants but my god a lot better yeah I think it's really true I mean when you have that kind of knowledge base you know 

Dr. Lisa Alvetro: you're right a lot of times people will start and I think some of my friends that used to do a lot of were have you know had gotten trained in it but they found you know what I like it but I really get a kick out of some of you know my Curtain my crown and bridge or my implants or my complex restorative cases that may the kind of you know fade away you know and the thing I think what's hard to once when if you're starting orthodontist and as a general it says it was a general just a lot of your procedures are more compact like you know you're may be prepping something where they're like man I didn't know it was gonna take this long to get to the end I'm used to more instantaneous gratification where you know some of these cases can go a long period of time and if you're trying to do maybe some early expansion and then you're going in to fix the punch you might not see your work completed for a long period of time and then you're watching people and retention and you know something like this goes on forever so it's almost a different it's a different mindset that if you're not used to DIF your used to things don't quick and C in there you know cases be done in six months or even you know quicker some of your restorative cases that's I think the hardest part is to pace yourself and I think too trying to when you if you're slipping back and forth you know what you're doing during a day a lot of times people will block and just do their ortho at a certain time because I think it'd be really hard to go from one mindset to the other you know one patient right after the other

Howard: so the average overhead is for an orthodontist in America right overhead 

Dr. Lisa Alvetro: you're probably looking around 65 orthodontist is chargin say 6,500 for a case what do you say the average class 1 molar adult ortho is probably I would say you're probably hang on yeah and how long would you say that average appointment time is when they come in once a month for the appointment depends on if you're looking an adult versus a kid if you're looking at don't I mean a dolphin yeah sure don't don't it could be forever you probably look at least half hour okay kids maybe 20 minutes adults half hour 45 minutes it's $20 off our yeah and 1% of your practices kids versus adults we're about 15 to 18 percent adults right

Howard: so it's 80/20 kids those points are 15 minutes mm-hmm right depends what we're doing you're looking at 15 20 minutes for our changes kids 15 minutes then bozo my buddy learned ortho and that there's an hour mm-hmm and I'm like okay well the orthodontist has got two-thirds overhead dude and she's doing it in 15 to 30 minutes you're doing it for an hour it's the same same thing with the wisdom tooth you know you impacted wisdom teeth your oral surgeon would have pulled two peoples for wisdom teeth in one hour and so if this is what they charge and this is what they overhead since they don't know their math they don't know their math because their software isn't hooked up to their r accounting so I mean I I can walk into any dentists in America with my you know when people say Americans don't know metric that's because they don't shoot a nine millimeter and buy drugs but if you walk into the ovens with a nine millimeter and Dennis walks out of the hygiene check you put into his head and say hey your hygienist of ten years just to the same old cleaning exam to buy twing x-rays did you make five dollars and twelve cents after taxes or do you lose twelve bucks and I say okay well let me tell you let me explain it this way your orthodontist is charging sixty five hundred she's 80 percent kids and the average time the kids they'll do three kids an hour and you're doing one kid an hour

Dr. Lisa Alvetro:  yeah and I think that's why sometimes people will get out of it yeah part of the whole key is just repetition I mean I can do it faster because that's all I do all day long and you know it's you know it's years of repetition doing the same thing so you know we should get quicker that's where you know that difference is and it's you know it's harder if you're not doing it all you know all the time or your staff too I mean that's a big difference to if you've got staff that you are also you know doing further start helping with restorative procedures and then all of a sudden they have to switch to earth and that makes you know that makes a big difference too and even what they can accomplish for you you know what you have to do is you have to get really good help and that that was the advantage because sometimes you know young women ask me well how do you how do you have kids and work what if have your own practice it's easier because if you're kidding you know sometimes my kids would be with me in the office carrying around running around screaming have really good help you know at home that can help so you're not worrying about your kids so I think that's you know I always consider the person who helped me with my children was like it's as important or not more important than one of my staff members so if you can you know pay them like you would pay a staff member make it an important job it'll make someone like so much easier so that's one thing I always encourage young people it's in your personal life delegate what you don't like or delegate what needs to be done but the really good good people and then you can you know you can have both a great career and great kids and and all that goes with it so 

Howard: I feel like I'm a man because I grew up with five sisters so I was very aware of sexism just from my own family we lived right by the Arkansas River well I could swim but my sisters had to be 10 feet from the edge you know and I remember at 10 years old begging my sisters this one with me in there and  then my mom would iron patches on the outside of my knee jeans and she put them in dresses and if they soiled their dresses they were in trouble but she prepared me with patches on outside and so that sex isn't a lot of it's gone away but it's still there and I still have a lot of women Dentist tell me I'm just afraid that even though I'm a woman and I'm a doctor that if I you know I'm marrying my classmate he's a man and a doctor I'm probably still gonna have to be the mom at home and if she's sitting there like I want to own my own practice but I want to get an A and being a mom so my question clearly is looking back at raising your four kids would you have been a better mom if you were to given up ownership and went and got a job at Heartland or a DSO so you could just do the 8 to 5 thing and then go home and be mom would you better better balm or was owning your own business allowed you to be a better mom

Dr. Lisa Alvetro:  owning my own business has allowed me to be a better mom because if they you could control if you're working for someone and you de can't come in or you want to be there something special to your kids school it's your own business all you do is you plan ahead and you mark that out like we're not seeing patients that day I'm gonna be at the school or I'm doing this but if you're if you're not the boss you don't get to call that shot and a lot of times women that I know are you know they maybe will do less days but longer days or but it's I think it's so much easier to have your own your own business and even being a woman and owning your own practice I think is easier and I really feel for some of my male colleagues right now because there's so much pressure on men to be conscious of not saying the wrong thing or being you know inappropriate to kids and there were there was and it made me think yes it was last week there was a little kid who was obviously very upset and as a woman I could take this little girl give her a hug hold her tell it was gonna be okay but you know if some of my male colleagues would do that people might have looked sideways at him where you know the parents like oh that was so nice she really needed nurtured but right now I think one is a woman if you own your own practice you can control when you work you also control who works for you how much time you put in and then also it's so much easier I think as a woman to deal with patients even if you know if you're a dentist or you're you're an orthodontist it so many of our patients are women and so many the men that come to see us I think are very comfortable with a woman to take care of them and nurture them through the hard times then they would be with a man so there may be some still you know even from maybe colleagues or or you know some people in in dentistry but honestly I think being a woman and being I think women is in dentistry is fantastic young women have such an opportunity and a lot of times you go to different countries men are the minority dentistry is a woman's profession in a lot of the countries that's yeah you know fewer if you're a communist country a socialist company and X communist country there are women and

Howard: there's just you know a few men now getting into it my well in a centrally planned economy I would have been an army ant so since boys of 27% muscle we do mining manufacture we do all the dangerous jobs military and dentistry was put in with accounting and bookkeeping you don't yeah biceps and so I've gone to I've given lectures in old civilian countries st. Petersburg Poland where the whole although they're all women and so that's the East versus West that does essentially plant economy that says you don't need to be the muscles of man and then there's poverty here's where I wish I would not have been a man when you go around the world if there's money involved all the men are there with suits and dice there's no money there it's always like in the United States there's no money in teaching so it's all women and all never forgot the only time I had to step out of a dental office and take a knee because I started to cry I was in Katmandu Nepal and this and I'm trying to grasp this dinars cuz when I'm in a deal I don't want to go buy a purse or a you know or clothes or whatever I just go to dental offices yeah and I'm trying to figure out this dental office I'm trying to figure it out but I couldn't figure out the economics of it so finally I said her I said I'm um well in u.s. dollars I mean how much money does this make a month and she says why I'm very lucky my husband has a job in the military knees high ranking and he subsidized my office runs at a loss of a hundred US a week and I'm in Katmandu Nepal where a hundred of Benjamin Tobiah the nicest dinner for four and wine at a restaurant and I looked I said well why do you do this she goes well if I wasn't doing this who would treat all these people no man are you a woman a woman a woman a man would have closed this thing down and taking a job you know and the military blowing people up or we know whatever the hell and wherever there's no money involved but someone has to do it it's always a mother Teresa Calcutta just doing it because someone's got to do it then she knows the man ain't gonna do it unless he gets a big gold medal a big bronze car and a big paycheck and everybody you know everybody gives him Adelaide's and those women just show it up because someone's got to do it and this woman her hours to lose $100 a week was was six days a week she worked Monday through Saturday says I can't stay home because I know there's gonna be a half-a-dozen people sitting here in severe pain if I don't come down here and get them out of pain they're not gonna get out of pain I just thought my god yeah but it's not my fault I don't think that way because I was born a man I can't help but Lisa thanks for all that you do you got four lucky kids a lucky town Tanzania maybe oh god baby we'll run into each other next time in Tanzania it's a big place it's a bit come to our farm come come to your farm it's a 5:03 charity mm-hmm

Dr. Lisa Alvetro:  yep it is and actually we're a recognized NGO in Tanzania is well an NGO 

Howard:nice thanks for all you do thanks so much for coming.


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