Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1454 Dr. Miguel Hirschhaut Talks International Orthodontics : Dentistry Uncensored with Howard Farran

1454 Dr. Miguel Hirschhaut Talks International Orthodontics : Dentistry Uncensored with Howard Farran

9/7/2020 3:00:00 AM   |   Comments: 0   |   Views: 55
Dr. Miguel Hirschhaut was born in Caracas, Venezuela in 1970. He received his DDS degree from Universidad Central de Venezuela, which he attended from 1988-1993. He then studied to become a specialist in orthodontics at the University of Pennsylvania from 1993-1995. He is an Invited Professor of Orthodontics at Universidad Central de Venezuela. Dr. Hirschhaut has given courses and lectures on surgical orthodontics, interdisciplinary treatment, and management of impacted teeth in 10 different countries. He has taught classes at 6 US universities, 1 Canadian university and 9 Latin-American universities.


VIDEO - DUwHF #1454 - Miguel Hirschhaut


AUDIO - DUwHF #1454 - Miguel Hirschhaut


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It is just a huge honor for me today to be podcast interviewing orthodontist Miguel Hirschhaut who was born in Caracas Venezuela in 1970 he's got a DDS from the university central divis d Venezuela he's a specialist and orthodontist um at university of Pennsylvania invited professor of orthodontics in Universidad central Venezuela courses and lectures given on surgical orthodontics interdisciplinary treatment management of impacted teeth he's is taught in 10 different countries classes given in six different u.s universities one Canadian university and nine Latin American universities it is beyond an honor Miguel that you came on the show today to talk orthodontics to all my homies how are you doing good the honor is all mine thank you very much for the opportunity we're doing just fine so I wonder you're in Venezuela and I’m in phoenix uh those are both hot countries mine uh we're over here 97 degrees Fahrenheit I’m sorry I don't have that in Celsius 96 96 yeah and does everybody usually talk Celsius or Fahrenheit we only use Celsius degrees it's so embarrassing to be an American it should be around 29 uh centigrade degrees yeah you know I had to compromise my mind since the uh Americans won't go Celsius and the entire planet and the galaxies on a Celsius maybe we should um negotiate and just both of us go to kelvin what would you think of that well it's a midpoint maybe [Laughter] so uh oh my gosh um so all things ortho I mean it seems like orthodontics is an um under a lot of competition I mean we have the uh do-it-yourself orthodontics miles direct club um there's um invisalign there's it seems like there's been more changes in orthodontics in the last 10 years than the first 20 years I was a dentist do you see orthodontics under a lot of change and a lot of pressure I think the problem is you have to differentiate between quality orthotics and just some of these things that are I think more commercial and are not such good quality stuff and sometimes the patients get confused and they get the wrong information so I think solid quality good orthodontics based on diagnosis and good principles is one thing and some somewhere in the middle there are these commercial inflows coming from the sides and some of the corporations coming from the sides and I think uh sometimes the general public it's in the middle and sometimes they don't get the best treatment they should because sometimes they don't have enough information and they sometimes get I think misinformed about what really a good orthodontist is and what some of these companies that are I don't think bringing the best treatment for the patients and they sometimes they cannot differentiate well you know so how do you wrap your amazing mind and I’m so lucky to be talking to you because you have a very global perspective um definitely um global perspective you know in market segmentation I could buy a Ferrari a Cadillac a chevy um a motorcycle a go-cart um housing I could buy you know an apartment a one bedroom house two bedroom three bedroom a mansion on orthodontics um do you think the consumer has the freedom to decide if they want to do it themselves or go to an orthodontist or do you think that's a place where the government um lays down the law and says no to these do-it-yourselves and no to the free market where do you draw the line between free people free markets free choice and um worried about your profession like I’m worried about I just had my sixth grandchild yesterday so I this month I turned 58 and had my sixth grandchild and I’m always thinking about what's dentistry going to look like in Arizona after I’m gone so you know so how do you how do you divide that up in your head the problem is that you know you have to go always by the bioethical principle premium no non-sharing for the first thing is do no harm and I think I think orthotics is a difficult enough profession and if you add it to the mix some of these companies that are putting people that do not have the training to treat the patients and doing treatments that are not easy you know even for a skilled orthodontist i've been in practice 25 years and sometimes I get cases that they puzzle me and sometimes I make mistakes and I have to redo things just trying to even doing things the best way you can so I think these shortcuts some of these things I look at them as shortcuts I don't think they provide the patient with the best solution and you should be comparing you shouldn't be comparing apples with oranges I think it depends what's your what's your patient uh knowledge what is their education what are their I think quality standards so you know I think the profession has gone through a lot of change and I think big corporations have come into the to take a piece of the market share it happens in your side of the world and it also happens in our in our continent and the problem is that if the public is not well informed you know you're going to get a lot of treatments that are going to be relapsing and not providing for the patient the best solution that's my intake and I’m not saying Cadillac or chevy or whatever because I don't think I don't think treatment is based so much on price as quality of care you can have an orthodontist that doesn't charge as much and he can be a fantastic organizer but you can have an expensive practice and it's not necessarily the best practice I think for it it's based on principles ethics doing the right thing being treated by somebody with a real education with a good background with good knowledge that follows the principles that's my general take on that you know when you go around the world um dentistry has a lot of differences and one of the things i've noticed the most about coming from America is that America um you know it had nine specialties when I graduated 30 years ago now it's up to 12. oral surgery endodontist periodontist pediatric dentistry orthodontics prosthodontist dental anesthesia oral facial pain oral medicine oral path oral radiology dental public health but a lot of countries have only maybe two specialties or three specialties um what is it like in um in America the 80 you know the 80 percent of teenage children living with their parents 80 percent of that ortho is all done at an orthodontist um adult ortho is starting to drift more and more into general uh family practice what is it like in Venezuela is it um is it most of it done by orthodontist or general dentist it's not my horizons and I think uh actually with what you're saying out of the organics it's even more of a concern it should be done by an orthodontist because then you have the perio issues and if you don't have somebody with good knowledge of the biomechanics and good knowledge of the biology you can get into a lot of trouble so now in our country at least the orthodontics is done by orthodontist every now and then you get general dentists and pediatric tending you know doing some stuff that they I don't think they should be doing because they I don't think they have the best training for that but in general I think especially the the specialties is respected in this side of the world and what would you say and what do you think of um so let's say a general dentist is listening to you right now and he's saying um you know America um in Arizona we had to close down for cover 19 from uh st patrick's day to uh cinco de mayo about 50 days uh that was tough you know going to zero but now the country is only about up to 71 is what for the nation so dentists in America are still down 30 percent um how does it look in Venezuela is it about the same the same yes people are just concerned about going to the orthodontist office even though we take good control of the of the committee with the measurements but people that are not interested in going out that much or even in spending that much money because there's a lot of uncertainty still and I think by the way we're like in the early rounds of this problem I don't think we're out of the woods by any means and I think I think in the kobe crisis we probably down to the 10 or 15 of the road we have to go through so I think at least 85 long roads still ahead of us so people are just thinking over priorities and they're spending and they're and trying to stay home trying not to go out so much I haven't been to a restaurant in probably six months or so I think the world has changed and especially not only the work but the way the consumer looks at things I think from a patient stand point of view what were your concerns before going to an orthodox things might you might be looking out for different things like you know all these infection control procedures and I think everything just changed with the with the kobe 19. um I always um wonder what is a change during the pandemic versus what will take hold like you know um I got a school in 87 and hiv was the big virus of the day which went on to kill 36 million souls and um a lot of things changed and they're so reminiscent of today I remember um the older dentist being told they had to wear gloves and they were ready to you know take a gun and shoot you and they were Americans they had the freedom they you know they were still doing stand-up dentistry with no gloves uh but we changed you know we used gloves and we got rid of cuspidors and all this kind of stuff what do you think were changing now um that's not a panic during the pandemic but that dentist will still be doing 10 years after the pandemic like we're doing 10 years after hiv aids I think what's going to happen is that the large volume practice they will they will have to shrink a little bit I don't think you will be able to see that many patients and I think I think you should have like distance between people and that's going to stay that's not I don't think it's going to be an issue it's going to be gone in one year I think it's like a long-term thing I think scheduling of patients will be very different from now so and that's what um I saw right after that I mean it used to be I worked many chairs like you go into room one and numb someone up go over here do a hygiene check cement crown then come back here and do a filling you know you you're working four rooms but now with all the ppe it's kind of like you gotta get suited up to go into a room it really changes dentistry from volume treatment working several chairs to just working one chair at a time do you agree with that totally plus the reception area it's more complicated even than in the operatory because how you're going to get so a few people sitting together in the reception area and you have to have like six feet of distance and I think this is here to stay I don't think this is a problem it's going to last uh weeks or months I think it's going to it's going to be up for a while I think years and the other part uh the other part that I think is bad is that um the fear that is that's in the consumer and in general in general in the population because even though kovid is a very bad disease I think there's a lot of hysteria as well and just to get the psychology of the people back to where it was before it's going to be it's going to be a while I think not only the physical threat of the kobe but also the I think a little bit of the paranoia that it's around all the pandemic you know well you know my father was ahead of his time because when I was 10 years old he saved up his money and bought a sonic drive-in franchise do you remember uh seeing any of those when you were uh at ortho school uh in um pennsylvania sonic drive-ins no where yeah so you don't go you know you walked inside mcdonald's and wendy's and burger king but in sonic he just drove in and parked your car and you'd eat in your car so my dad I think had 20 20 vision and he could see all the way to 2020 with the pandemic and he knew uh the waiting room the restaurant would uh not be existing someday uh get it that was my joke 20 20 vision so um do you think tele dentistry is going to be a long-term changer in orthodontics um I think yes I think initial consultation is going to be done uh a lot through this way actually I think also interconsultation with other specialists and because before you would go and visit a colleague a prosthodontist or a surgeon or a periodontist I think from now on I think so this platform and all these social media platforms are going to play a role not only in first evaluations of the patient but also in communicating with your colleagues I think I think this is here to stay here and do you um I mean how are how are you using telemedicine today are you doing it with zoom or what are you doing yeah we're doing we're doing a few consultations with zoom but most of our consultations are physical you know patient comes in but some of the new patients they contact us for the first time through zoom and we talk with them and we just order them their x-rays so we probably the first appointment we're just making it um we're advancing into the first appointment so when the patient comes they already have their records ready and we're ready for treatment planning and starting treatment and just trying to avoid the unnecessary visits and making it more efficient I think you know I love this for my mother my mother's 82 and now she gets on her ipad and when she wants to talk to her doctor and a lot of times she doesn't have to drive down there and I always think about how many little old ladies uh are crashing a car on the way to a doctor that could have been a telemedicine visit um but um you're saying zoom is the most popular telemedicine in Venezuela or just what you're using we're using I don't know about other people that's what we use probably somebody everybody has a different system but some of our first appointments we're doing them by zoo but I think still you need the interaction with the patient you need to look at inside the mouth even though they can send you pictures we like to take our own clinical pictures and I don't think the I don't think the physical visit is going to be eliminated not for sure but I think maybe it's going to be optimized and you will have a you will have less appointments and more productive appointments so you think telemedicine is here to stay it's not going to be just a pandemic boom um yeah and you know what you know what I also think it's a good way of getting second opinions and I think it's a good way of even treatment planning cases interdisciplinary with other colleagues you can do like a case discussion so I think television has a lot of applications far beyond just looking at one individual patient I think it's a good teleco it's a good communication tool even for webinars for lectures for everything you know I think they said zoom and go to meeting go to webinar they have to change even continuous education and congress and everything I think from now on everything is going to be done more individually and more from the from your own space so telemedicine I think is part of the wave I think it's not something isolated I think it goes together with the zoom meetings and with the webinars and with the online lectures I think it's more of less of a personal contact and more of a of a you know contact through these platforms um you uh went to orto school at university of pennsylvania um my gosh um since then you've done seventy three hundred cases um that that's a no that's an old i've probably done like eight plus over eight thousand cases eight thousand cases um it seems like the consumer the individual um wants these clear aligners um what percent of your pr cases today are fixed arch wire versus clear aligners well my practice it's mainly fixed arch wires I would have probably like five or ten percent of aligners I think aligners have an indication uh I use invisalign which is the system we use but I think uh I’m more of a fixed orthodontist person because I think in my hands I have better control with fixed appliances even though I know they're fantastic clinicians do things with invisalign well and the cases we've had with invisalign they work out well but in my in my hands and in my view I get better control of the root of the teeth and of finishing with fix with fixed appliances compared to investment even though I think invisalign is a necessity and I think many patients want it and many patients ask of it and you have to do it otherwise you're out of the market but I think there is indications for everything and following the judgment of the originalities I know there are practices in the us that are only invisalign and I have friends only doing this but it's not my case I would say 85 to 90 percent of my cases fix appliances and 10 of my cases well I think a lot of humans are extremists I mean I always tell my uh my two older sisters are catholic nuns they went right out of high school into the nunnery and a lot of times you're saying something I always have to say hey sister ann you know you've never been married you never had kids you know this is extremist I think when dennis just say I’m not doing amalgam and I’m not doing archwire I’m only doing invisalign and composite it's like well do you tell your patients when they come to you that you're not a dentist that you're an extremist and I mean I mean are you when it does tells me they have 2 000 patients and there's never one indication where an amalgam would be better say it's an alzheimer patient class fives doesn't brush doesn't even know who their own children are you really you're telling me an inert plastic class five would last longer than amalgam because I’m pretty sure the composite class five would last six months and the amalgam would last four years or like a little boy who's not brushing not flossing and he needs an um you know you put in a mod composite number three it's going to last six and a half years compared to the research where amalgam's 38 and when these dentists tell me um I don't do any fixed arch wire I only do invisalign I say well okay well you're an extremist or I hope you're working for a line technology but you don't sound like a doctor because a doctor I mean how could you have one treatment for eight billion humans around the world I mean that didn't even make sense yeah I think I think the middle of the road is the good place to be and I think uh it depends on your skills and what you're comfortable with and what's your knowledge but I think I don't I don't believe in all or none I believe in you know in in what's right for the right patient you gotta do what the patient needs and what's correct for that patient uh I’m really honored to have you on the show I mean you've been published 30 times uh just in orthodontic journals um what are you um what are you talking about now I mean I look at a lot of you ready a lot of your articles you talk about tads you talk about non-surgical expansion in adults management of impacted teeth um I don't even know where to start with you let's start with uh with tads well I think that's change organics for good I think first explain what it is for the kids we have a lot of viewers that are still in dental school so what is a tad that is a temporary anchorage device is a it's a fixed mini screw you put in the bone and you move the teeth using it as anchorage so it's like it's like adding an anchorage that you never had before so of course it changed all the mechanics in orthodontics and it allows it allows you to do movements that you never could do before and it's just uh increasing the orthodontist capabilities of achieving things that were not even think of before because not even that these are also evolving to mini plates which is like it's like a play that connects three tags and you have better 3d control so I think fix this total anchorage fix devices like that uh change the whole landscape of orthotics just uh open the envelope of the possibilities and we used to go always by the envelope of the discrepancy in orthodontics which is you could move teeth certain amount of millimeters this way or this way I think with that it all changed it's now a new ballgame did tads um extinct headgear to the age of the dinosaurs or not really and what do you mean can you repeat um well when I was little um a lot of cases needed headgear and uh it was um traumatizing for a lot of uh kids to have to wear and comply with headgear does tads eliminate a lot of uh need for headgear well I think here still has an indication every now and then I use it every now and then and uh I think that just takes away a lot of the compliance you know because the orthodontist is in control of the movement and you don't need as much compliance from the patient you don't need them to wear like some of these appliances you're mentioning or so much rubber bands and stuff because you can do a lot of things in charge by using them as anchorage and you don't you don't need as much compliance from the patient and also you can move teeth in a wider in a wider range if you want if you want to say you were mentioning before a non-surgical expansion with that that's a that's a total game change that's a game changer because many of these adults that they used to be very narrow in their maxillas we used to send them for surgical assisted rapid pattern expansion we still do them when they're narrow and the in their skeleton mature but sometimes with the touch we can make their upper jaws wider and achieve parallel expansion using the thousand anchorage without the surgery for the patient so it's a less invasive treatment also as well um if you did 100 orthodontic cases how many of them would use tads probably nowadays I would say I would say absolute anchorage probably 30 of my cases percent of your cases and is that um is that normal do you think for uh orthodontists that you know or is that uh more than uh I don't know I don't know but I know that of ten patients 2.5 to 3 of them get that in my practice I don't know what the other people do say that number again from 10 patients at least three get that so it's between two and three at that so I think yeah I would say 30 I think it just makes your life so much easier and uh allows you to work more control and I think more precise because uh you are you also eliminate the cold effects you know the adverse effects because every movement of a tooth has a co effect so if you use the thought you just move the teeth that you want to move but the ones you don't want to move they don't move so it also accounts I think for a more precise treatment as well yeah um what do you what has got you um excited and the most passionate about today what is uh I mean you've been an orthodontist for a long time uh what's uh the latest hottest thing that got you excited or passionate about well I don't think I don't go by fashion or other things but what I really like what's coming out is the new the new technologies for 3d imaging I think uh I think uh all these diagnosis we're getting better at it because of the 3d imaging and also I think long term uh all the 2d imaging is going to be gone uh we want we will have to change even our cephalometrics we will have to change many of the diagnosis that we carry out today it's going to be totally changed and I think in the next five years you will not see more headplates everything will be done through 3d and you I don't think you will see more cephalic x-rays and stuff like that also photography I think it's a big game changer clinical photography because now you can document your cases better good for presenting your lectures and good for explaining the patient is good for communication and if you ask me what's the boom I see ahead is better diagnosis measures with better 3d imaging and better photography so same question if you saw 100 new patients how many of those would get three-dimensional cbct radiography as opposed to two-dimensional I would say now we're switching I would say probably 30 25 to 30 of my patients are getting that and what determines the 25 the one in four that gets cbct 3d imaging uh which has um versus uh the other way uh 2d well you know the problem is I don't know how it is there but down here sometimes we get the patients already with their x-rays taken so if they have their exercise we're not going to do new x-rays and also it's a it's a cost problem it's more expensive to get the cbct where you can extract all the images from the cvct and also still some people are a bit concerned about radiation even though that's not a concern because the new machines are so well calibrated and the amount of radiation is so small I still I think there's a lot of myths there and the people have there are afraid about these things and which uh which uh they always want to know which one you bought which one uh which 3d cbct did you get well we're using a I use one that it's not mine but we we're using a lamecha one I don't know the brands in the us this is one called plameka is a very good one yeah plan mecca is in a helsinki finland and uh three shapes and uh copenhaven denmark and um when I visited those places I always thought they were so high quality because unlike venezuelan phoenix which is so nice to go outside it's so cold there and for four months a year it's almost dark everyone that worked at plan mecca and three shape and the companies I visited they said man in the winter you either going to work six days a week ten hours a day and just work as hard as you can or you're just going to sleep in your basement and stay drunk for four months and they say the healthiest thing you can do through a long cold hard winter is work really hard every single day so I uh I think all the universities should be in antarctica because then the kids uh won't be attempted uh to go out and play um there's always um my gosh um one of the longest oldest debate in fact I hate to even ask you about this because it's so old you're probably sick and hearing of it but there's just a lot of general dentists in America you know people just they believe what they want to believe they're not interested in debate and if their orthodontist pulls four bicuspids uh that they're done and they think you butchered the face you made a concave is that an extremist position to say eight billion humans none of them need four bicuspid extraction as an orthodontist who's done 8 000 cases would you say indeed in fact there are cases where you have to pull four bicuspids of course there's many cases you have to you have to pull forward speeds and uh like before I don't believe in all or none I think you there are indications for extracting teeth by the way there's many research being done and extractions do not damage the profile if they're done properly uh and the this has been published in the ajo for many times so I think I think extractions are part of therapy and they have indications and if they're well indicated they're just the correct treatment for that patient so a lot of people say that um a rapid palatal expander is something you could have to do on a child but once you know a girl is you know once children are 16 17 years old certainly by time during adults that there's no way to expand the maxillary arch in adults and that if you try to do it you're just going to tip the teeth out you're not going to expand the arch how would you explain expansion uh needs in children versus adults and just talk expansion yeah have you written so much about it I think expansion if you do the earlier you do it the better I think if you do it in the primary dentition or even in the early mixed dentition you you're better off because the palette is more it's simpler have in mind that the limit to expansion is not the midline suture but all the circum maxillary and terego palatine sutures but I think if the earlier you do it the better off you are but there are options nowadays with mini screws you can do them even in adults and always if the minuscule assisted rapid pattern expansion doesn't work you still have the resource of going to a surgical assisted rapid paradigm expansion so you can do father expansion in anybody in any eight range from four or five years old till whatever you know I don't think there's a limit for that so you can expand the arch at any age more than the arch to the bone we're talking about we do the expansion for the patients that are maxillary transverse deficient it's not a it's not a dental arch treatment but a skeletal treatment for somebody that has a narrow maxilla compared to their man it's a it's a concept you know and I don't think we should expand who doesn't need it you should expand whoever has that discrepancy and I don't think expansion is a way out of extractions either if there are indications for extractions you need to extract so you have to know what your treatment is and who should receive it based on diagnosis you know just like we were talking before in the beginning I think um if you have solid diagnosis uh you can do whatever procedure needs to be done and I don't I don't believe in all or none good or bad proper or proper I think everything has an indication yeah and um I i'll take it one step further I don't think you know that something could be good if it couldn't be bad I mean everything is uh I mean it's up down left right it's um you know um an extremist doesn't work I want to talk about variances because one of the gifts I got I had no idea um this month on august 4th was the 30-year anniversary of me lecturing and when I get my first lecture in new york city I had no idea that someday i'd be in 50 countries and what I love the most is seeing the variants I mean you got 8 billion people in 200 plus countries and they're all reading the same books and journals and they do things differently and the one thing I noticed a lot was that in scandinavia um if there was an extraction case they were more likely to do a second molar than a bicuspid and um I was going to ask you um you've lectured around the world what kind of variances have you seen where like japan does you know goes left and germany goes right or what kind of variances do you see among orthodontists not general dentists doing ortho but intelligent highly educated orthodontists seeing the same humans uh but arriving at a different treatment where do you see the variances well I think I think uh just like before any tooth that has an indication for extraction can be extracted if you're a good orthodontist you can do wood ortho with secondary molars or with first premolars extraction always second moral extractions i've done second molar cases i've done first three more cases i've done secondary bond cases I don't think uh there also there's a known role I think everything has an indication the advantage of extracting first premolars is if you have a lot of crawling or a lot of unit of change in the profile and you're close to where the problem is by extracting first three molars then those are the things that should be extracted but some cases let's say you have broken down totally broken down second molars with a lot of carries and the teeth are hopeless and why not take those out digitalize the first molar and treat the case uh just like without pre taking out the pre balance making out the teeth are in bad shape allowing the third molars to drop in and having a you know a full dentition pretty much because the wisdom teeth will not be gone and you would have used the space of the second molars and you would have solved the crowding so I think everything has an indication you know one of the most controversial things I ever said or wrote about um actually the top two are both about endo I am the owner of the publisher of dental town magazine way back in the day when we had this guy write an article on the 15-minute root canal and of course all the endodontists went insane because they didn't even read it and what he was saying is that in time mechanics like an endodontist will use a rotary 15 file but then he takes it out and he spends a minute or two changing the file and go to the next whereas dr scott perkins in el paso texas he had four slow speeds and when he walked in the room it was already loaded with a 15 a 20 a 25 a 30 and he was just so efficient he had no wasted movements he literally could do a molar root canal in 15 minutes and the other one was um again the endodontism in fact the endodontics got so mad uh one of them banned me to some place in canada but um I said I see I don't understand all the second molar endo because um to do a root canal build up and crown on a second molar for two thousand dollars and wipe out this person's money for the year while they have five other cavities i'd rather pull that tooth and do the five other cavities and my and my evidence this was that when I was in scandinavia a lot of orthodontists routinely pull second molars and a lot of the occlusion research i've read is that um a second molar it's like one sixth chewing on the first premolar uh one third on our on the second period one third on the first molar and only 1 6 on the second molar that it's hardly functional and if someone has a budget for their whole mouth I wouldn't blow it all on a second molar do you think second molars are overrated compared to the first molar and the second bicuspid I think probably yes and I think [Music] to extract a second model what you're saying you have to also look at the panel and look at the position of the third molar look how the roots are a it's a complex decision it's not just that but I do really I do understand what you're saying and uh yeah I think it's the last tooth uh in the arch and it can be substituted by it's by a third model that is in good shape and with good root form and with angulation so I think probably yeah it's worth it's worth considering I think the scandinavians are correct in that it's worth considering for extraction in the indicated case i've done it i've done it a few times yeah I just um you know I mean I just can't believe how many people i've seen in 32 years that spend their whole budget on one tooth and they've got 10 other cavities that don't get fixed because they spent all their money so then what happens is now um one of those other cavities goes to the nerve then they come back and now they need another 2 000 root canal boat and they never get ahead of the curve and I’m just like who is doing this and endodontist about half their business is second molars that that's the tooth that all the general dentists don't want to be uh have a root canal done on it and that's why America has 4 000 full-time endodontist and mostly what they're doing is second molars because general dentists can't do that and I look at half the second molars that I see have endo on and I’m just saying did you tell that guy that he doesn't really even need that tooth I think they're highly overrated I think it's one of the most overrated things in a uh dentistry what do you see done in ortho uh where you think it's success or uh where you wha what gets under your skin the most when in orthodontics think in my in my view some of the dental alveolar expansion I see I see that many people are trying with just with large wires to expand teeth and they're pushing them beyond their periodontal limits and they're causing a lot of problems so that's an area sometimes especially a few techniques that use specific type of races I think they're not respecting the biological limits I want you to weigh in on another issue because uh um Germans German oral surgeons and American oral surgeons do not see eye to eye I mean most American oral surgeons recommending removing a wisdom tooth a third molar if it exists if it exists they're coming out a lot of the Germans they want epidemiological evidence of why this wisdom teeth needs to be removed and they remove at least one less wisdom teeth than the Americans so there's europe versus north America you're in south America how do you how do you weigh in and see this well I think I lean more towards the north American side I tend to I tend to send for extraction a lot of the third motors because I see sometimes potential problems and when I see that the arch is very crowded you can even look at it in the panoramics it's very it's a very simple evaluation uh and you don't see it doesn't have space uh I think you're better off just sending for that for removal of that because I think posterior crowding is the less diagnosed problem in Arizona so I probably lean towards the north American side there um let's switch to advertising on ortho town you know we have dental town for the general dentist we have orto town um of all the 12 specialties orthodontists are the only ones who ask for their own website and we um whenever a group wants their own website like dentaltown we always make it and um but um but I uh I’m not allowed to post on there because it's only for orthodontist uh so I uh own the site but it's not mine it's for the orthodontist um but a lot of them are talking about um competition advertising the lowest price the one guy was saying this month an orthodontist in town is offering braces for 1999 which includes a laptop free laptop with 1999 will get you braces only good until the end of the month do you see a lot of aggressive advertising in venezuela for orthodontics we don't have that unfortunately no so you would say it's a difference in culture between uh venezuela yes I think I think the united states has this 999 culture a lot I see it because i've been going through the us forever you go to a store and instead of saying ten dollars it says 9.99 and I think people just want to get free things and in general I don't think there's a free lunch and some of this advertising I think is I think a little bit misleading I don't think it's very ethical either and I don't think in the long term this advertisement is they hold up to their end of the of their deal you know what I mean um and the other um the other thing about that the 1999 or the 999 or whatever is um you need to know where it came from where it came from had nothing a lot of people believed to this day that if I say it cost 9.99 a lot of people think it won't be as expensive as 1 000 and that's not where it came from where it came from was uh internal control over peculation uh you'd put you had a cash register and you didn't know if the person was stealing from you so what you did is by charging everything 99 cents they would go in the morning they'd break open 100 pennies and then at the end of the day the manager come back and if you only had 70 pennies he knows you made 30 transactions so then he could look at the number of uh revenue and divide it by the transactions to get an average price and it gives them a data point to know if you're stealing so it all came out of an accounting metric to measure transactions and a lot of people think it's a psychological thing and it's not I want to ask you another thing um there's um you know business in three words is supply and demand and uh that's um you know that that's in three words well the same guy um who started the orthodontic centers of America now do you remember orthodontic centers of America when you were back in pennsylvania I remember seeing it but I don't know much about it but I remember it was the past your time I think i've seen their advertising they're like massive clinics right well they're bankrupt now but back in the day um I’m older than you um and they were the only company that made it to the new york stock exchange ipo worth a billion dollars and then it went under uh like a lot of the dsos did in that especially in that first round all the ones that went into public markets like oca and they're about a dozen on nasdaq uh they all they all end up going under and were delisted and wall street has no interest in any of these dsos right now that's what they tell me but anyway that same guy um I am he is now at gastro deserts at the georgia school of orthodontics and he has received approval to double its enrollment to enable the school to train more residents um resident dentists and especially orthodontists and dentofacial orthopedics at its two atlantic campuses with the commission on dental accreditation approval class sizes increased from 18 orthodontic residents per class to 36. and basically this is what um this you the georgia school of orthodontics is saying and this is what the dsos want that well if he trained twice as many orthodontists I could get more of them for less money I mean obviously if you increase the supply and hold the demand constant the price will fall do you see that happening in venezuela too where I don't have an opinion on that I think I think orthodontics is a specialty that needs to be taught and I think large classes is difficult to control and to teach everybody but I don't have an opinion on that because back in the oco days um I mean he was um when he was raising money to do his ipo he was actually I think he started three schools and um and uh so it's a big uh supply and demand when you talk to um orthodontist um what percent of you are you if you did 100 cases how many of those cases would you need a lab and how many of those cases do you do the lab work in your office uh completely and don't need a lab well so there are cases where you need labs if you need appliances let's say you need expanders you need nances you need retainers you need I think you always need a lab you can have an in-house lab which we used to do long time ago but I think you will never get out of the lab I think every now and then you will need a lot and do you tend to do more of your lab work or um do you send a little more we send down we don't do it you send it out and um also um when you say you are you agnostic uh to the brackets and wires I mean um you know dense fly sirona I mean all the big companies have an orthodontic line I mean whether it's a danaher which is uh you know densefly um do you feel strongly that one set of brackets and wires brand works better for you or are you more agnostic and would um not really focus on one company I think I think their tools and I think what's most important is the knowledge of the orthodontics so I don't have any finance financial agreements with any company and I I’m not married to any company I would use what I think is best in each situation so I’m more agnostic in that you can say so on august 17 2020 did you read the letter for our um from dentsply uh sirona about I said uh did you did you hear about that dense fly serrano orthodontics customer it says um it basically informed me that we are going to uh it says dear dentsply sirona orthodontics customer dated august 17 2020. we're reaching out to you our value customer to inform you that we intend to exit the traditional orthodontic business the market shifts towards clear aligners and digital solutions requires dense fly sirona to adjust its business to meet customer demand in this growing area we are fully committed to building our digital orthodontics solution leveraging the investments and expertise of orometric suresmile and its state-of-the-art digital treatment planning platform operations please note the following uh we will but anyway what do you think about that shift I really don't have an opinion uh I don't know what to say I think uh I can tell you what I do is I use what is best for me and I don't judge big companies and their market strategies I do I’m an orthodox I really don't know much about that and I don't want to talk about something I don't know all right fair enough um so um what do you um one of the things that concerns me about the young generation is you go back to the united states I only have data on the united states I don't have for the world or venezuela but in 1900 health care was 1 of the gdp and there were no specialties in dentistry or medicine and by 2000 it was 14 percent of gdp the mds had 58 specialties dennis had nine now it's 20 20 and now there's 12 specialties and you just see kids coming out and they um they would have learned it all they want to learn how to place implants do ortho muller endo everything and this clear aligner usually it's debate should I go into clear aligners or should I go into placing implants and a lot of the young kids coming out of dental school they're so ambitious and they're so excited they want to learn all 12 specialties and I tell them you're not going to go back in time and we're not going back to 1900 where one person treats the whole damn body I mean it's very specialized as you learn more and more knowledge you don't have time to learn the other knowledge but what would you say to a kid who just graduated this year in 2020 that says well I’m a general dentist but I’m going to learn how to place implants and I’m going to learn how to do clear liners what would you say what advice would you give them as an orthodontist my advice is go if you want to do a specialty going into a specialist program and learn everything about the specialty and once you have knowledge you decide what you do and I and I’m a strong believer in specialties I don't think you can do everything and know about everything because even in your own specialty there are many things you won't know so I think if you wanna don't buy it more than you can chew that's that would be my advice and are you um are you doing a lot have you are you moving towards a digital solution where someday you know that between oral scans and computers and printers are you using a printer anything we're starting to move diagnostically to digital and I think eventually everything is going to be moved that way I think yes so actually many of our patients that go through orthognatic surgery the aura maxillofacial surgery surgeon one of the ones we work with is doing all the planning with the computer and all the digital so I think I think every specialty is going to be influenced by this not only orthotics um one of the fun things about getting old is you've uh you see something that went out of style and then it's back and you're like oh I saw that rodeo 20 30 years ago but I’m seeing a resurgence of lingual orthodontics I think so many people realize they didn't want fixed so they're going to clear aligners but obviously there's you know a lot of people there's a lot of indications for fix do you see lingual orthodontics making a comeback so that the nobody can see the wires and brackets or do you think it died appropriately the first time I think it has a place I don't do lingual but I think it has a place it's I think it's for me in my hands it's complex to do it and I don't do it but I yeah there's people that do it well I know a couple of them all the towns that do it well and I think it has a place I don't do it but I think it has a place yes it has a market for sure um do you mind I know it's been one hour we went over the hour can I still ask you a few more questions going to some overtime yeah we can do ten five ten more minutes okay a couple more questions um there was a big article in a big magazine called the atlantic that got big wide circulation says Americans are spending billions on unnecessary dental treatments the evidence that braces make you healthy is shaky at best and it wasn't even out for a day and patients are coming into your office and asking about that and I lived through this just recently in America the new york times ran an article that said there's no evidence on flossing and I don't know how you would make a double-blind study would you have to run in the hospital when two identical twins were born and kidnap one of them as the control and let the other one grow up in caracas I mean I but what do you what do you say um this article went to link says the evidence that braces make you healthier is shaky at best and basically the article's saying dude it's all cosmetics you're not doing anything you're not doing orthodontics for your health uh you're doing them to look as pretty as a peacock for your uh for mating or self-esteem or whatever I think it's wrong I think orthonyx it has a lot of functional to it and I think just from the base just from the basics think of somebody with a lot of lower crowding and being able to brush your teeth and the same person with the theta line uh I do believe in bite stability that it also holds up better all the all the systems the muscles the joints everything so I’m not going to I’m not a good customer for that for that idea well see I thought you would uh read that article because uh um guess who was quoted in that is uh peter greco uh from uh university of pennsylvania um it says um expert peter greco a clinical professor orthodontics at the university of pennsylvania an associate editor of the American journal orthopedic and dental facial orthopedics points out that orthodontic treatments are uniquely difficult to experimentally test and so treatment decisions are often based on traditional knowledge and orthodontics clinical experience rather than on scientific evidence and I couldn't agree more I wish the guy who wrote the article on flossing um I would love to be able to uh take two of his family members uh for the long term on flossing I mean some of these experiment experiments to prove this stuff I don't even know how you'd set up the experiment yeah I didn't read it but dr Gregory all emailed to you dr greco is one of the best orthodontists in the world he's a very smart orthodontist and a great clinician but I didn't read it so I cannot comment on that you know okay no worries i'll send it to you so last night I will always comment on what I know and what I read I will not you know tell you an opinion or something I don't know yeah um last but not least um let's end on this um I know everyone that listens to me they want to know the most about what's going on with the pandemic um nobody can predict the future um it's the first day of September is that um you live in between two hot spots I mean brazil and America I think are the top two uh countries with cases um what and I know that you're not an expert in the future because the future doesn't even exist yet but where do you think final question where do you think we are in the pandemic and what are you expecting to see uh this September October November December the rest of 2020 and then what do you think is going to happen in 2021 and when do you when do you think you go on I think we're in the early stages I think we're like in the if it's a nine inning ball game I think we're in number two or something like that and I think uh because even if you look at the declaration that the German government gave I think was Angela Merkle she said that 70 of the German population is going to get contact with the kobe with the coronavirus and uh she said it's a two-year problem so I think we're in we're on this for a long run I think we're not we just I don't I don't think we still have the grasp of the how long this situation is going to it's going to last I think this is this is a long problem not only that but look at the report just came in CNN where it said that a patient in Hong Kong tested positive 140 days after testing positive the first time so they're suggesting reinfection with they call it so I think we're in the long we're in this for a long battle we're not it's this is a long problem this is not a short problem well the dentists are emailing me they um your questions I um my only email is Howard dentaltown.com and I love the questions in the comments on YouTube that really helps me a lot but they're always saying they want to know if a vaccine comes out are you Miguel are you going to take the vaccine yeah I would are you are you close to that I mean is there anything that's going to be released you think in the next four months in 2020 that you'll be taking no I don't think so I think I think of a good serious vaccine you they may come out you know strange vaccines their vaccines coming out in you know rare places and I think a good vaccine with good clinical trials and with the approval of us European community or FDA I think we're still in a long this is a long battle I don't think we're ready in the next few months I don't I don't see it coming maybe I’m wrong and uh last but not least my final um thought is I know humans are crazy humans aren't crazy they're wild animals I mean they always say you know um even my mom if I say she's a homo sapien she says Howie I’m not a homo sapien I’m a human being uh she denies being uh homo sapien but uh um they're wild I don't think they're crazy I mean most the things of what people do is like yeah that's what wild animals do but yesterday um was the uh happy 101st birthday to dr maurice ralph hillman phd who was born on august 30th 1919 died 2005 who developed eight of the 14 vaccines routinely scheduled uh measles mumps hepatitis a hepatitis b chickenpox meningitis ammonia haemophilus influenza and um everybody's an anti-vaxxer everybody's trash in the sky but every scientist and epidemiology says that um that is the number one scientist that has saved the most lives and in history and dr hellman you're my hero um I’m so sorry that you uh spent your whole life making eight of the 14 regularly routinely scheduled vaccines and a quarter of Americans think uh your nuts are a conspiracy but uh I cannot wait till they get a new vaccine for this one um it was just an honor uh to get you on there uh when I asked you to come on the show I was so honored that you uh come on uh thank you so much for taking an hour out of your life to come on the show and talk to my friends and homies about all things orthodontics it was truly an honor to podcast you thank you very much an honor for me and send me a copy of the of the conversation we have thank you absolutely have a great day thank you and when the pandemic's over I want to visit Caracas I would love it okay all right have a good day
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