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In this episode, Dr. Noel Ananthan shares his experience implementing short term orthodontics. Discover when short term ortho is ideal, when it is not, and other tips and tricks to add to your orthodontic arsenal!
Noel Ananthan, DDS:
Gained early acceptance at the University of Toronto Faculty of Dentistry after one year of undergraduate study at the University of Western Ontario. Currently a Clinical Instructor for Six Month Smiles short term orthodontic system teaching the Levels 1 and 2 Courses in North America and the U.K. Maintains a management company which owns and operates dental practices focused on helping young dentists how to efficiently run a successful dental practice and then purchase the practice. Has 5 children including one who will be graduating in 2016 as a dentist from his alma mater, the University of Toronto, and is then going on to graduate endodontics. Had his first grandchild this past summer.
It is a huge honor today to be podcast interviewing Noel Ananthan. You're a Canadian. You're up there. Where are you at? In Ontario, Canada?
That's right.
Well that's just outside Toronto, Howard. As I was telling Ryan, it's snowing here today, so I'm really envious of you down in the warmth of the desert.
It's so funny in Phoenix, because 10 percent of the homes are owned by Canadians. There's more Canadian flags flying in Phoenix, Arizona than American flags. I think they like to do it so they all know where each other's at to go have fun with and everything. You guys have the baseball stadium with a roof over it and we have one with a roof over it, but your roof is because it's too cold and ours is because it's too hot.
Well you do have a hockey team down there, Howard. You have the right balance. Hockey, baseball, basketball.
It is great. We're the same age, even though you look 10 years younger. I had four kids. You had five. Are you glad you went for that fifth one?
Absolutely. It was my wife wanting the little daughter at the end and that's exactly what we had.
You had four boys and then a daughter at the end?
No. Actually we have twins, a boy and a girl, and then two sons and then the daughter at the end. I actually have a grandson now as well, Howard.
How old is your grandson?
8 months.
8 months? I have my little ... I have one granddaughter, one grandchild. One granddaughter, Taylor Marie. I tell everybody she's my gift for not killing my four boys. That's nature's way of saying ...
I think there's a lot of truth to it.
That's nature's way of saying, "Aren't you glad you didn't shoot them when you should have?" All right. I called you. You didn't call me, because I wanted to talk to someone who is into this Six Month Smiles. Tell us your journey. How did you get out of dental school and end up as an instructor for Six Month Smiles?
Well it's actually a great story, Howard. I attended dental school at the University of Toronto. We had a very strong undergraduate dental program. My instructor was fantastic. He was of the mind, "Get your hands in there. Learn ortho by actually treating patients." I had a great deal of comfort and familiarity, coming out of dental school. I did treat comprehensive cases coming out of school, but as with most of us who have hygiene-based restorative practices, in very short order, comprehensive ortho lost any degree of efficiency within the flow of the workday itself. Within about three, four years, ortho was just out of my schedule altogether. That went on for quite awhile.
I came across Six Month Smiles. I looked into it and saw it made sense. It was absolutely intuitive. The ortho principles were sound and solid. I started into it. Haven't looked back since. One of the key strong elements of the Six Month Smiles system as well as the community is the support that we provide. I became very active providing support for other Six Month Smiles providers. Became involved as a mentor. Was asked to become a clinical instructor, so now I teach the both level one, the introductory course and the level two, advanced courses for Six Month Smiles.
How often are you out teaching?
I'm usually traveling about a dozen times a year, so about once a month I'm out of the office. Then we do have Six Month Smiles providers who come into my office who shadow me for days, to watch how I work in the practice itself.
Now who started Six Month Smiles?
It was Ryan Swain.
Ryan Swain? You know what? We've gotta ... I've gotta get him. I should podcast interview Ryan. A creative genius. My god. That guy.
That guy, he probably has a higher IQ than me and you combined times two.
Exactly. No, I really am grateful to Ryan, both in terms of his vision, in terms of putting Six Month Smiles together as a concept that general practitioners could use, but also his passion and the nature in which he brought everything together as well, because he's very inclusive in terms of having involved many people in a very strategic way. That's been a large part of why the Six Month Smiles system and the community has grown as profoundly as it has.
Well, spend a minute and explain that story. What do you mean, how Ryan started it? Tell them the Ryan Swain story, how he started that.
Well he started doing short-term ortho and he developed a lot of the systems, the techniques the procedures, but he also involved a lot of talented and knowledgeable people in terms of early instructors, involving people within ortho to really develop the process. Then that's grown into what the Six Month Smiles provider community is now. It's a very mutually supportive group that endeavors to not only support providers but allow all of us to learn on an ongoing basis, because really, you know as well as I do, great dentistry is a constant learning environment. It's something where we can look and be stimulated walking into the office each day, saying, "I'm going to learn something new with each and every patient."
What do you say ... This is dentistry and sometimes I like to talk about them. I don't want to talk about anything everyone agrees on, but I want to talk about the 4,000 pound elephant in the room. The 4,000 pound elephant in the room is that orthodontists are flipping patients every 15 minutes. They're doing ortho for this fee schedule for about 50 percent overhead. Then the general dentist starts doing ortho and they're doing it in half hour sequences and they're charging less money than the orthodontist. How does the math add up?
Two things actually with that, Howard. The first part is the fact that the timeline in terms of the treatment sequence and the treatment protocol for Six Month Smiles patients is just as the name implies, about six months' time. There is a time efficiency in terms of absolute chair time itself. The other key element to Six Month Smiles as a system is the degree of delegation that it does allow. It involves a huge number of team members in terms of being able to get hands on with the patients and it allows us as dentists to be free to continue to be productive in the restorative laboratory, as well. There's an interesting anecdote that one of my fellow clinical instructors tells me. He tells me that, "A bad Six Month Smiles day is when he actually has to put gloves on and get in the mouth of a patient."
I noticed you have braces on right now.
That's right. I have the Six Month Smiles on. Good eye.
Tell me [inaudible 00:06:55] what's in it for the patient, the dentist, the practice? Why are you a big believer in this and why ... [crosstalk 00:07:00] Yeah, go ahead.
Great questions, Howard. One of the key [inaudible 00:07:04] of Six Month Smiles is allowing our patients to have options. Not feeling stuck in terms of wanting ... Or cosmetic options for their teeth themselves. I was in this situation where I referred a good number of adult patients with comprehensive ortho before I started Six Month Smiles. They come back and tell me, "Nope, I'm not going to go ahead with it. I don't want braces, especially metal braces, on my teeth for two years." From a patient standpoint, they're given another option, the ability to have braces on their teeth in a cohesive timeline that allows alignment of their teeth, provide them cosmetic improvement and in a very efficient way, in an environment in which they're comfortable as well, in their general dentist practice, one that is tailored to them.
In terms of the practice itself, I can't begin to expound on the benefits to the practice. There certainly is the productivity, in terms of bringing the product of the Six Month Smiles treatment as a billing procedure itself. But it's also well beyond that, in terms of the ability to involve the team, the excitement that it brings about, both with patients and team alike. IT really does empower all of us as dental professionals, and that goes straight from the front desk staff, treatment coordinators, managers, right on to the clinical staff to feel great about what we do.
You know the old saying, "If your only tool is a hammer, everything looks like a nail."
Sometimes I'm sitting in these cosmetic dentistry cases and I ... Cosmetic courses, and I've been thinking to myself for all of 28 years that so many of these cosmetic veneer cases, and if they just would have unraveled the teeth for just three months ...
Not even six months. They could have saved so much tooth reduction and so many of these ... I just don't think you can say in 2016, "I am a cosmetic dentist," if you don't work very closely with an orthodontist or at least yourself know how to unravel these teeth.
Exactly, Howard. Could I tell you a couple quick stories? Just relating to that very specifically.
Oh, tell me all of them.
First of all, one of my patients, Jackie, she came to me years ago as a patient of record and said, "I want a better smile." Now we had already decided that veneers were part of the treatment plan, but I gave her a referral to an orthodontist. At that time, I wasn't doing Six Month Smiles. I told her what I wanted to do was see her teeth lined up a little bit better. It would allow us to be more conservative and give a better result. Now Jackie actually went through three separate consultations with great orthodontists, to whom I refer routinely. Great bedside manners, great technical skills. Each time, she came back and said, "I'm not going to have braces on my teeth for two years." We had her in the chair for the actual prep session.
Before I leaned her back to anesthetize her, I looked her in the eye and said, "Jackie, there's nothing that would make me happier than for you to tell me right now, 'Let's abort this appointment.' I'll have the orthodontics done. I'll line things up the way you want me to and we'll get it done right." She chuckled and she said, "I told you, there's no way I'm doing it, so let's go ahead with this." That was about eight years ago, Howard. She's still a patient of record. Each time she comes in, she's beaming from ear to ear. She loves those veneers. Every time that I look at her smile, I cringe a little bit because I see the different gingival heights. I see thicknesses of porcelain and it really irks me. Because again, in this day and age, we're looking for minimally invasive dentistry. Something that's going to be healthy for the patient and has the ability to be beneficial for them. Not only aesthetically, but periodontally as well.
Now the other story I'll tell you is actually my first Six Month Smiles case, Nathan. He actually came to me. He was in his early 20s. He had just started a job as a car salesman. No insurance benefits. His father had told him, "I'll pay you to get your teeth fixed up in order to start your adult life properly." Nathan came in. His teeth were a mess. He had caries in every single tooth, including labial caries on his anteriors, upper and lower. We took him through the hygiene sanative phase. I scheduled six one and a half hour restorative appointments to restore [inaudible 00:11:15]. When we finished that last appointment, he looked in the mirror and I thought he'd have at least a smile on his face. Didn't smile at all. He just simply asked me, "Can we put veneers on my teeth now?" That took me aback a little bit because I hadn't ever bothered to ask Nathan, "What is it that I can do for you?"
We treatment planned the veneers. It was about 12,000 dollars. His father approved it. Gave us the credit card number. Did the record, started the diagnostic workup. I took the Six Month Smiles course. Came back from it. I had my receptionist call Nathan that Monday, bring him in and I told him, "We can do the veneers, but I'm not going to. I'm going to treat you the way that I'd want a family member treated." He was a little hesitant, but went through Six Month Smiles. It transformed him completely, Howard. He went from a shy, mute, demure person ... I really thought he'd have trouble even approaching potential clients, let alone selling a car, to someone who was very confident in himself. He's actually gone back to school now because he has transformed the way he looks at himself. That's simply because he has a smile of which he can be truly proud. Really a game changer all around, and certainly as it relates to our ability to deliver cosmetic [inaudible 00:12:26] a conservative manner. Just amazing, Howard.
95 percent of all the emails I get at email@example.com for my show, they're all a couple years out of school.
I'd say five years out and younger. A good portion of them are dental students. Explain to them, what would be the difference between Six Month Smiles started by Ryan Swain ... What year was that started, about?
Let's see. It was probably about eight years ago or so.
It was only eight years ago?
Yeah. Not that long, actually.
No kidding. Okay, so there's Six Month Smiles started by Ryan Swain. There's Invisalign. There is Powerprox Six Month Braces by Rick DePaul. Is it all just three different brands of soda or what are the differences?
Okay. Well, great question. Again, for one of the things I want to applaud you with is the support that you provide. Not only dentists in general, but especially those new grads, Howard. They're looking for guidance and you are a tremendous resource for them. What I do want to say is that the Six Month Smiles system as a brand itself really sets itself apart in two ways. One is our constant endeavor to improve on the [inaudible 00:13:45]. There is currently a lot of work going on behind the scenes to move us the next step forward into the digital age with cosmetic braces. The second and one that is a little difficult to really comprehend until you get involved with Six Month Smiles is the level of support.
Six Month Smiles uses an online forum to allow the provider community to gain access to actual active support for their cases. They post photos. Clinical instructors like myself and designated mentors are on there constantly in order to provide support for providers. Not only assessing their cases, but treating them through as well. Whether it's determining, is this patient appropriate for Six Month Smiles treatment right on through to I'm at this stage in treatment, how do I go forward from here? We're on there providing that support. Not only has the system itself been designed to be efficient in a GP practice, but the nature of the confidence boost and the ability to deliver on great results for the patient is enhanced by the support that we provide for the Six Month Smiles community.
That's at www.sixmonthsmiles.com? That community?
Well the forum itself is a closed forum.
But would you find the ... How to register for that forum at sixmonthsmiles.com?
Well you register for the forum once you become a certified Six Month Smiles provider. You'll gain the information regarding the Six Month Smiles system at www.sixmonthsmiles.com and then once you ...
But it's 'six' spelled out. S-I-X.
Yeah. I think actually even if you place the number 6, you'll still log ...
Oh, really?
I'm going to check it out. Www.6monthsmiles ...
There are two pages there. One is a patient page and a dentist page. If you click on the dentist ... [crosstalk 00:15:45]
You are correct. You can get there by spelling it out or the number.
Exactly. One of the great things with the patient page is the fact that last year we did some testing, as far as direct to consumer campaigns and got a lot of great feedback from it. We're going to be looking at that in the future as well. But there's a Find a Dentist section that you'll see on the upper left hand side that allows patients, perspective patients, to actually find a dentist, a Six Month Smiles provider, in their immediate area. Again, it's a great resource. That's the nature of Six Month Smiles in and of itself as a corporation. Always looking to enhance not only our ability to deliver great results, but being supportive from the standpoint of incorporating it as an efficient aspect of a profitable practice.
How much is the course and how long is the course?
Okay. The course is a two-day course. It's about 2,800 dollars US. We carry out the course in a variety of different locations across the US. A lot of wonderful opportunities to see different cities, do a little bit of traveling as well. It's two days. It's relatively intensive. We start at 8:30 in the morning, carry on through 4:30 in the afternoon, typically a Friday and a Saturday. It's action-packed. We carry not only the theory behind short-term orthodontic treatment but the practical aspects as well, including hands on exercises that allow all of the attendees to become familiar with the procedures that they'll use day in and day out with the Six Month Smiles procedures. That includes team members as well, Howard. We encourage team members to attend because as I said, in terms of the ability to delegate duties and responsibilities, team members present at the course gain a vast amount of knowledge and experience. They really get the process going within practices.
How much does it cost to bring your assistant?
I'll have to double check that. It's a nominal fee for it. I'll double check that and get back to you with that, Howard.
Okay. Well since your name is Noel, N-O-E-L, which means Christmas, you could just say it's Christmas today and all staff are free. What do you think?
Well I'm not sure I can go that far with it. I wasn't born on Christmas, so I'm not sure I can extend that courtesy.
I love that name. I actually ... It means Christmas. I think I used to think it meant peace, too.
It may.
But you said it's a French word for Christmas?
That's right. Exactly. Noel.
I love name origination. It's so interesting. Then you said you have an advanced course, too.
That's right. We developed a level two course to allow providers who had reached a certain comfort level with Six Month Smiles to be able to treat their cases more effectively, so finish to better results, treat them more efficiently, speed up the overall length of time and then just broaden the scope of their comfort level. Take on maybe a few more challenges. Typically as with anything, we advise any new providers to crawl, walk and then run. Just get started with simpler cases. Gain that comfort and confidence level. As that confidence grows, they're able to take on more challenges. Now I do want to stress, Howard, we're not looking to supplant comprehensive ortho. With all of my patients, I made clear, the gold standard is comprehensive ortho treatment. But as I mentioned with my patient Jackie, comprehensive ortho just wasn't in the cards for her, something she wouldn't abide or tolerate at all. Now with Six Month Smiles, we're able to provide our adult patients with an appealing, attractive alternative to comprehensive ortho.
Okay. Explain the details of what Six Month Smiles is. Is it usually first molar brackets all the way around and then ...
Molar bands all the way around and then brackets across the front 10?
Okay. We use molar tubes and then brackets across the front 10 teeth. Now the beauty of the Six Month ...
When you say molar tooth, is that a bracket?
It's bonded. That's right.
It's just bonded on the buckle?
You're not doing a band? [crosstalk 00:19:56]
We don't need bands. That's right. Now the beauty of the Six Month Smiles system is actually the fact that it takes the inefficiency of hand placing brackets and converts that to custom bonding trays. Once the impressions are taken, they're sent to the Six Month Smiles lab with the lab requisition. The lab pours up the models and the bracket specialist actually precisely positions the brackets to the prescription. Then the lab specialist will create custom trays and they're essentially sucked down trays and inner soft layered to hold the bracket in position with the custom bonding pad, a more rigid outer tray that maintains the positioning of the brackets themselves. Those are used to efficiently place the brackets in one step. One step seating means that we're able to place the brackets very quickly, very efficiently and in the general dental practice, that makes all the difference in the world.
That is really, really slick. What is the lab bill on that and then what are you charging for ... What is the lab bill on that and then what are they charging the patient for Six Month Smiles? We don't want this in Canadian dollars. We want this in real money that you can spend at the store.
Well especially with the value of the Canadian dollar right now, Howard, you're absolutely right. The lab fees for Six Month Smiles are about 7 to 800 dollars US. The range of fees charged for Six Month Smiles are anywhere from about 3,500 to 5,500 dollars US. Again, it's a comfort level based on the provider themselves.
I'm sorry. I keep interrupting. Is that one arch or two arches? Is that upper and lower?
Two arches. That's right. That's for upper and lower arches. The Six Month Smiles lab will also fabricate the fixed retainers. They're inserted in exactly the same manner as the brackets and that's using a custom bonding tray.
That's a lingual bar on the mandibular lingual ...
Exactly. That's right. It's a canine to canine retainer.
That 7 to 800 dollar lab fee is for upper and lower, 10 bracket instant seating for the upper and lower ...
... and a mandibular retainer?
Well we actually use mandibular and maxillary retainers to hold the teeth in position. The philosophy that we used is actually fixed and removable retention, Howard. The fixed retainer ensures that the social six stay in position just beautifully. The removable retainer is a nice backup, as well.
Okay. I'm sorry, so you're ... That [inaudible 00:22:34] a mandibular lingual bar retainer with two wings on the ...
But the upper is a removable retainer?
No. The upper is a fixed retainer, as well.
Just all [crosstalk 00:22:48] just lingual pads on canines and then a bar connecting?
Well we actually use pads on each of the incisors as well. That insurances [crosstalk 00:22:55] That's right. The teeth are locked in just beautifully. We also provide other alternatives in terms of the fixed retainer. For instance, the chain material, Ortho-FlexTech works really nicely as well.
Explain that. What's that?
Well it's a chain link material that's bonded directly chair side to the teeth. It's cut from a role. It's bonded directly to the lingual of the teeth using a flowable material and locks the teeth into position just beautifully.
I just heard back from Ryan Swain. The answer was yes. That'll be awesome. When you're doing Six Month Smiles, do you also ... I mean patients, you say you're building a brand name. They come in and ask for Six Month Smiles.
Patients are coming in and asking also for Invisalign. There's now an Invisalign lower cost alternative, ClearCorrect. There's Inman Aligners. What do you think about all those? In your practice, do you only do Six Month Smiles or do you sometimes use Invisalign? Do you sometimes use the new ... The one, ClearCorrect?
Yes. Absolutely, Howard.
Do you ever use other stuff?
Yes, I do. It comes down to the fact that we don't have one catch-all solution for every single patient in every situation. I always tell my patients that there's no ... Rarely one absolute correct or incorrect answer. What we try to do is provide them with options. Now typically, I find that the use of brackets and wires is not only more efficient but also more effective, in terms of being able to move teeth into alignment quickly and efficiently. My preference is always to use brackets and wires, to move the teeth and have greater control as opposed to aligners. But once again, in terms of aligners, they have their place as well. There are patients who will be very specific, that they will not have brackets and wires on their teeth. Aligners are a great option for them, as well.
You call Invisalign, ClearCorrect, Inman Align ... You call all those aligners?
That's right. Exactly.
That's the correct term for that?
You just can't make generalizations. It comes off bad. You can't say all Irish people like me are drunks when only 38 percent are. That'll piss off the other 62 percent. But in my 28 years, the bottom line is when I bond on the brackets, I am in control. When I hand you removable retainers, now you're carrying the ball and what I've noticed is that girls will do anything to look better and they're so compliant. But I have had so many cases where boys, they go into it motivated ... Well if their mom wants it and they're not motivated, they're sitting there in the chair with their hair matted up and a booger hanging out of their nose, you just know it's not going to ... They're not going to be compliant.
I tell people this. They say, "I just don't have that problem." I just think to myself, "Well I'm in Phoenix. It's not like I'm in Scottsdale or Beverly Hills." I'm in a normal cross section of America and young boys, if they don't want ... They have a look. If they look well-groomed and they just look GQ, they'll do everything I say. But if they look sloppy like me, they always ... They just don't comply. It just takes so long. You know what I mean? Sometimes they don't even finish.
Exactly. Well you hit on a really key point, Howard, and that's compliance. I actually have a fair number of patients who come in looking for Six Month Smiles who are in the midst of aligner treatment. They simply say, "It's been going on too long. I'm not seeing the results that I want to see. I want to switch over. I want something that's going to be effective, that will straighten my teeth, that will give me the smile that I want. I don't want to be using these aligners for another six months, 12 months, year and a half." Providing that option is a wonderful alternative. As you said, typically females are great with compliance. Males need that little nudging. It's a key element in terms of assessing, how long is this treatment going to stretch out? Am I going to have someone who is going to comply? Am I going to work through the aligner series in a staged and controlled way?
That's key to making aligners productive and profitable and efficient within general practice, as well. Not having those surprises, where we need to make mid-course corrections at all.
Talk about the lab bills. What's the difference in lab bills between Six Month Smiles and Invisalign?
We're probably about a half to a third, in most cases.
It's a dramatic difference, and one that resonates with most providers who start up. The key thing though is there's that enticement, that lure in terms of, lower lab fees, I have a little more control of it. The real eye-opener for new providers is seeing just how efficiently the teeth move, Howard. Again, once you place brackets and wires on the teeth, there is no compliance issue. They're moving 24/7. We see those dramatic changes in a very quick time. In fact, if you think about patients who are undergoing comprehensive ortho in your practice, they come in at about 4 to 6 month point, seeing the orthodontist. You see most of the [inaudible 00:28:19] unravel already. A lot of the alignment is already in place and that's where we're focused. Cosmetically aligning the teeth, giving the patient a smile of which they can be proud in a very efficient timeline.
Now is this all round wire or do you finish in a rectangular wire?
Yeah. We do have rectangular wires in the Six Month Smiles Lucid-Lok system, but the typical series that we use is all round wire. Light wires, light forces. That incidentally allows not only efficient movement of the teeth, but great comfort for the patient as well. It's rare actually that within the context of the goals of Six Month Smiles short term ortho, that we need to finish or use rectangular wires at all.
Okay. Can you explain ... My job is to guestimate questions on these users. Some kid's driving to work and he don't know the difference between a round wire and a rectangular wire. Can you talk about the difference between a round wire and a rectangular wire?
Absolutely. A round wire is as it sounds, round. If you think about the cross section of a bracket, Howard, it's essentially a rectangular space. A rectangular wire fitting into that rectangular slot will allow more control over the movement of the teeth. That relates primarily to torquing of the teeth. When we talk about torquing, we're looking at moving the roots of the teeth labiolingually and rectangular wires work very efficiently in that context. Round wires, because they don't engage the squared slot walls, will not have that torquing ability. That's one of the key differentiators between short-term orthodontics and comprehensive ortho, the fact that we're not looking to torque teeth labiolingually.
I know some people are afraid of ortho because what you need mostly on ortho is a diagnosis. Like I say, the assistants can help you do all the technical stuff, but you've got to get in there with the right diagnosis and treatment plan. Talk about what are ideal ... Because these people driving to work, they've got a bunch of patients already. They've seen a bunch of patients. What's an ideal candidate for short ... Six Month Smiles and what is the red flag where you don't want to ... Stay out of trouble, don't do that?
Great question. The ideal Six Month Smiles patient has mild to moderate crowding or spacing. Mild to moderate, anywhere from 4 to 6 millimeters of crowding or spacing in each arch. They treat beautifully with Six Month Smiles, especially the crowding cases. They unravel just beautifully. The results show very quickly. Patients come into their adjustment appointments excited. They want to be in because they see these results occurring. Similarly with space cases, that 4 to 6 to 8 millimeters of spacing closes up just beautifully using Six Month Smiles protocols.
There are some red flags for short-term orthodontic treatment. Those can include overjet. If the patient is looking to address the overjet, whether it's a large positive overjet with a class two situation or a negative overjet with a class three underbite situation, those are potential red flags. If the patient is looking for changes in the mid-line, we can affect changes of 2 to 3 millimeters with Six Month Smiles treatment fairly routinely. But beyond that, when we're looking for precise mid-line coincidence, that is a typical red flag as well. That's better suited to comprehensive orthodontic treatment. Then anything relating specifically to the bite, Howard, is in the realm of comprehensive ortho. If the patient presents asking for an ideal bite, then we typically will send them to the orthodontist for the consultation there. It doesn't mean that the patient won't return. Very often, once the patient understands what's involved, if they are looking for cosmetic improvement in their smiles, almost invariably they're back asking, "Okay, can we get started on Six Month Smiles treatment?"
I don't think they should even treat class threes, because then your children might grow up to be a comedian, have their own television show, be the next Jay Leno. I think that's his whole stick is that big old [inaudible 00:32:28]. Hey, I gotta tell you my thoughts on mid-line. You're more qualified to talk about it than me, but you know what? At least when I was learning ortho back in the day and everything, at least 100 times, when you're sitting there at a conference, a lunch or dinner or whatever, and I'm talking to some dentist. He's there with his spouse. Then I say, "Look me in the eyes right now. Only look at my eyes. Is your spouse's mid-line straight on or is it to the left of a millimeter, to the right? Describe your spouse's mid-line." Oh my god. They never knew.
I'm sitting here thinking, why are we torturing all these people to correct the mid-line when the orthodontist don't know if their wife's mid-line is off? It just doesn't ... When you're talking to people, your jaws are moving. Your teeth are moving. I don't think there is a dentist in America who has five kids like you or four kids like me who could even tell me where their own children's mid-line is. Why do we care about mid-line if the dentist don't even know the mid-line is? They're kissing this person.
Howard, you're making such a great point. The Six Month Smiles philosophy is that children should be treated idealistically. Adults should be treated realistically. As with my patient, Jackie, she wasn't willing to go through two years of treatment for that marginal improvement. Having said that again, I'll tell you a couple things. One is in the introductory course. There's a segment in which we show photos of Penelope Cruz and Michael Jordan. Their mid-lines are heavily [inaudible 00:34:09], still have great smiles, still extremely attractive people. The other story that I'll tell you is a very personal one: me. You asked me about the braces that I'm wearing. Back when my parents first came to Canada, typical immigrant story, we had five children in my family.
We went to see a dentist. I had crowding. The dentist's thought was, "Let's take a tooth out to try and relieve that crowding." Took out my upper right lateral incisor. It eased everything up, but certainly not straight teeth. When I was going through dental school, one of the grad ortho students, a friend of the family, actually put brackets and wires on. About a year and a half with painful rectangular wires, just aligned everything. Got everything to the point where at least they were straight. Now after I graduated, the orthodontist, a great one in my area who is treating my children ... I thought, "You know what? Let's get things sorted out once and for all." I went to him and I said, "Okay, do me." I sat down in the chair and I said, "I want the mid-line shifted back. I want space opened up for an implant at that lateral incisor."
He laid me back. Took a good hard look for about 10 minutes. Sat me back up, Howard, washed his hands. Rubbed his hands together and said, "I'm not touching you with a 10-foot pole." I asked him, "Why not?" He said, "Because I'll never be able to achieve the results that I'd want to achieve for you. It's really going to be unrealistic. I'm not even going to delve into whether we can get a good aesthetic result with an implant at that upper lateral." You're absolutely right. The fact that we have ideals are absolutely equated. That's why I'm proud to be a dentist, because uniformally, we're all striving to provide our patients with the best possible results that we can. Incorporating the scientific, the health aspects of it.
But one of the elements that we do have to realize ... One of my sons is graduating from dental school this spring. One of the key things that I instill in him as well as all my associates is always remember, there's a person attached to the teeth that we're treating. We have to be aware of that, provide them with options that will allow them to satisfy their treatment objectives in a realistic manner. Certainly one that holds true to our ideals in terms of providing them with sound dental care, but one that serves them well as people.
I think the other thing you have to realize about ortho, it is the law of diminishing returns. When you start someone in ortho, then next month they come in. The patient is like, "Oh my god, there's so much movement. There's so much movement." But as you get into month 12 and month 18 and month 24, as a dentist, you can't even tell what's moved at the very end.
Ortho starts off with just a bang and then slowly goes down to nothing. What you're saying is that in Six Month Smiles, let's get the 80/20. We're not going to twerk all the roots. We're not going to line it up like it's an anatomy textbook. We're just going to make your teeth whiter, brighter and sexier and love an align and just unravel everything. You can get 80 percent of it done in six months. Is that kind of ...
That's it in a nutshell, Howard. Actually it's kind of interesting because when we are providing support on the Six Month Smiles forum, we'll have those dentists. Again, we as dentists tend to be the anal retendant types, aren't we? We want everything just so, exactly according to the textbooks. Very often, we'll have providers saying, "The patient is over the moon with the results, ready to get the braces off, but I want to tweak this one tooth just a tiny little bit more." The reality is in many of those situations, it doesn't even show aesthetically. It has no functional impact at all. It's just our mindset to say, "I want everything as perfect as possible." Again, you're absolutely right. As we reach that point where we've achieved all of the treatment objectives, we're actually doing the patient and ourselves a disservice, thinking that we have any benefit carrying onto ... Comprehensive orthodontic ideals.
They also do that with restorative dentistry. They're working on some hillbilly that hasn't brushed their teeth or that hasn't even flossed one time in the last 10 years. They come in with plaque and tartar all over their teeth. They're fixing a filling and they're already five minutes late. They realize that some thing is just not quite right with it, so they drill it out and re-do it. They're running 30 minutes late, trying to go from a B+ to an A- and they stress out all the staff. They stress out everyone. I know it's very controversial to say this, but I do A dentistry on A patients. I try to do A dentistry on B, C, D, F, but I'm not going to run 30 minutes late on a D or an F patient who is a ... You know what I mean?
If this filling is a B, it's good enough. I'm not going to stress out my assistant and stress out everybody, trying to get these anally retendant results on customers who don't even care. A lot of these dentists are working on patients that only came to them because they take the discounted PPO fee, so they're not even willing to pay fee-for-service premium and then they don't even have enough [inaudible 00:39:17] to floss. They don't have enough [inaudible 00:39:20] to get their teeth cleaned every six months. You're redoing your work three times because it's not perfect?
[crosstalk 00:39:28] [inaudible 00:39:26]
Yeah. That's the practical side of it, the fact that ... Again, we do have that desire as dentists at the core to deliver as ideal of a result as possible. But the reality is, we have to recognize whether we own our own practices or our associates, that dentistry is a business. It has to be run efficiently, productively and at the end of that is being sensitive to not only the timeline efficiencies with scheduling but also the patients that are receiving the work, as well.
You said you immigrated to outside of ... Streetsville is a suburb of Toronto, right?
How old were you when you immigrated?
Three years old.
Where were you from?
Burma, which is now Myanmar, Howard.
Burma, which is now ... Wow.
The other side of the world.
You were three, so you probably don't know anybody back there, do you? Or do you still have family back there?
No. We still have family there. I haven't had a chance to go back and visit, but they come regularly to visit here.
Well my goal, my fantasy goal, is to do a podcast interview with someone from every country on Earth. I just think that would really make an international community. The smartphone is international. iTunes and YouTube is international. If you know anybody back there, if you know of anybody ... They have a dental school instructor, whatever, whatever, if you can think of someone who would be fun ...
Absolutely. I'll reach out and then keep ... Connect you.
I was also wondering, on this Six Month Smiles, how many people are on that community?
We have well over 7,000. I think we may be up to about 8,000 worldwide right now.
Oh my god. That is amazing.
It is. Again, I can't stress enough just how supportive that community is. Once providers are on the Six Month Smiles forum, they're absolutely shocked at how supportive, how positive it is. Again, we all learn from each other, Howard. That's part of great dentistry, as well. One aspect with dentistry in general, whether you're in a solo practice or a group practice, is it is a very isolating type profession. We're centered on a small area of space, focused on that area. Opening up with a Six Month Smiles community allows us to gain input as well as interaction, not only for our Six Month Smiles but understanding ... Dentistry is a great career, a great profession. We're very privileged and fortunate to not only be able to provide our patients with a great service, but earn a great living and have fun doing so as well.
I want to always stay on the controversial stuff and avoid everything [inaudible 00:41:56]. You remember when back in the day ... Because we're the exact same age. We're both 53. Remember back in the day, in the 80s, where orthodontists said that ... You mentioned Michael Jordan earlier, that they were saying something like 90 percent of African Americans were bimaxillary protrusive. There were all these old school orthodontists that every time they got an African American, they would pull his four [inaudible 00:42:16] to pull it back.
I'm sitting there ... Well, damn. If they're already damn good looking and 95 percent are bimaxillary protrusive, then that's normal. How could that be abnormal? But why would you try to correct a face to European measurements or something like that?
Is that all dead and extinct now in 2016? Are there still old school people that think things like that?
Yeah. Unfortunately, there is still that old school. I still have my core of orthodontists to whom I refer, and some of them are of the mind that for instance, if there is crowding, I'm going to extract straight out and then deal with aligning the teeth after. Similarly, achieving those ideals of the angle classifications, the canines, the first molars, overbite and overjet. Sometimes they can be blinded to how those teeth actually interact with the individual. One of my classmates in dental school, Howard, just a beautiful woman. Always perfectly dressed. One day we were waiting in one of the clinics and she turned to me and she said, "I hate the way that I look." I was taken aback. I said, "You're beautiful. Why would you say that?" She turns sideways and she said, "Look at my profile. They took four [inaudible 00:43:27] out. Now I'm concave and I just can't stand the way that I look."
That was with a view to reaching that textbook ideal at the expense of the practicality of how these teeth actually interacted with the patient's lips, the cheeks, the bone support.
When women tell me I'm unattractive, I just turn out the lights and it's instantly solved. You just used two terms that someone might not understand. You said overbite, overjet. Now you've gotta explain that.
Okay, sure. The overbite is the horizontal overlap between the teeth. It's the way that the upper incisors overlap the lower incisors. How much of the lower incisors are covered by the upper incisors? The overjet is the vertical ... Oh, sorry. That's the vertical separation. The overjet is the horizontal separation. How far forward or behind the upper incisors are from the lower incisors. That's an important thing as well, Howard. As I mentioned, overjet can be a prohibitive aspect of a patient's chief complaint. If they're a class two patient with a skeletal class two jaw type and they have a lot of overjet and they're looking to correct that, short term ortho and even conventional orthodontic treatment isn't going to correct that. Very often, that's a surgical intervention. We help our patients to understand the scope of the treatment objectives that we're looking to correct.
It's amazing. When I got out of school in '87, whoever was doing implants was just called the butcher. A lot of them end up having their license taken away. Some of the most famous implantologists, their first big case has failed. They got their license taken away. I thought that was sad. Orthonathic surgery was pretty crazy in the 80s.
It's amazing how much more of a minor surgery that's become, how much more sophisticated it's become. I remember walking into the hospital in '87, just to visit a patient, and their head was so swollen. Even me as a dentist, I gasped. In the 80s, I would say 80s til '95, 100 percent of everybody I met that got orthonathic surgery said that if they had to do it over again, they wouldn't do it.
Now it's a lot more minimally invasive. I want to say one other thing that I think is the biggest advantage of Six Month Smiles, and that is back to this crowding thing. A lot of times, the orthodontists ... I don't understand why we don't work better together, but the orthodontist will say, "Oh, there's this much crowding. We need to extract four teeth," or whatever, whatever. Or, "It's going to take this long to unravel." I'm a general dentist and I'm looking at this mouth and obviously cosmetics and want whiter, brighter, sexier teeth. I'm looking at a bunch of MOD amalgums and I'm looking at an ugly PFM. I just sit there and I'll just take that arch and I'll just take all the dentistry out of that arch and then replace the MOD amalgums with MOD composites with open contacts and you can pretty much get all your space just by ... You can take out the over bulbous PFM and put on an [inaudible 00:46:37] crown or whatever, but ...
If they've got an arch full of dentistry, I can almost always create all that space.
That's right. Well actually, you hit on a key point. One of the other elements of Six Month Smiles, whether it's in the planning stage or during the process of treatment, a co-discovery process for the patient themselves, Howard, is the adjunctive treatment that can occur. I mentioned that a large overjet isn't going to be corrected with Six Month Smiles, but deep bites are. We've all seen those class two cases with the deep bite. 100 percent over bite. The lower incisors actually either worn down or traumatically cluding on the palette. Six Month Smiles short-term ortho opens up those teeth bites just beautifully. But it's also a great starting point, in terms of any cosmetic procedures. I spoke at the AACD meeting in May in San Francisco last year, and I'll be there in Toronto this year as well. I do a lot of Six Month Smiles treatment as a spring board to cosmetic or reconstructive cases.
Again, as you mentioned, getting those teeth into better positions so that I can deliver better restorative results for the patient. It really is an eye-opening process in terms of seeing the scope of what we can provide for our patients, whether it is simply straightening the teeth, closing spaces, giving them nicer smiles, or allowing us to do better dentistry overall.
Well I think the purpose of the American Academy of Cosmetic Dentistry and the purpose of cosmetic dentistry is the simple phenomenon. When you're dealing with a human, every day they need information but they mostly need motivation. They either haven't been bowling in 10 years or they own their own bowling ball. They either haven't gone to the lake in 10 years or they own their own boat. When humans don't like the way their teeth look, they don't take care of them. They're not into their teeth.
They don't brush, they don't floss, they don't get cleans. I first noticed that in bleaching back in 1987 when everybody was saying, "Oh, there's no research. No one has said anything. This is crazy." You would bleach this person's tooth and they would wake up to dentistry. They would wake up to getting into their mouth. As soon as they were looking, then they were brushing, flossing. Then they wanted this plaque thing removed. They wanted this fixed. The most important thing of bleaching and bonding and Six Month Smiles and all that is you need this little monkey to like their teeth.
If the monkey likes their teeth, they'll have oral teeth. If the monkey doesn't like their teeth, then they're not going to take care of them. They don't care. They just ... Forget it. That leads to disease and all kinds of things.
Well just yesterday, Howard, we finished up all of the restorative on a patient who had undergone Six Month Smiles treatment. He had amalgum throughout his mouth. Teeth were crowded. We undertook Six Month Smiles and aligned them just beautifully. All of a sudden, he loved his smile and he wanted to do more to enhance it. That led to progressively carrying through all the amalgums, replacing some crowns, some onlays in there, which is completely transformed his mouth, his smile. But more importantly, how he feels about himself. I couldn't agree with you more, Howard. I always say a great smile is like a great outfit. You don't need a designer label on it. You don't need a price tag. Everyone notices. It sits well. The material may be nice. But the most important element of it is how it makes you feel. You walk into a room with a great outfit or a great smile, you own that room. You know that you feel like a million dollars and that confidence just soars. It doesn't matter whether it's a social or a work setting. It just has that profound influence on you.
Oh my god. Now you see it in bikes, too. I do a lot of biking and somebody ... They've never biked ever and they think they're going to do the 70-mile Mesa bicycle deal and everything. They go in there and if they see some pretty bike that's cool and jazzy and they just love their bike, then they want to go jump on their bike and ride it. A lot of people ask me, "What type of bike do you recommend?" Or this or that. I just say, "Get one that you just want to get on, that makes biking fun." It's all about self ... I want to talk about something else that's controversial, and that is slenderizing. Sometimes when you got crowding, some people like to go the incisors and slenderize. There's some automatic slow-speed attachments that do it. Some do it with fine diamond. Some don't believe in it. What's your thoughts on slenderizing?
Slenderizing ... Most of the orthodontists to whom I refer slenderize for their comprehensive cases without any concern at all. It is part of the Six Month Smiles system. But one of the interesting things, Howard, is that especially for those new providers who have used aligners and with the prescriptive amounts of slenderizing or reprox to be carried out, one of the biggest things that we need to do is stress to them the very, very conservative with slenderizing. Within the Six Month Smiles system, we provide three elements to carry out slenderizing. A diamond dyst, diamond strips and diamond [inaudible 00:51:40]. They come with each of the patient tray kids, the set up for each patient.
Strips, burs and what?
That's right. Each of those is used in very strategic positions, locations and we show and teach that in the introductory course. But we stress the fact that slenderizing should be a conservative and a progressive process, one which doesn't place the tooth at a greater risk of carry susceptibility, doesn't compromise the aesthetics of their the tooth form itself or the contact form. It is a very integral part of helping us to create space in order to align the teeth. Now one of the great benefits of fixed brackets and wires is that the arches round out. That's simply the teeth moving out into the shape, the form of the archwire itself. That in and of itself creates a fair bit of space, Howard. That's one of the reasons that we stress, don't be aggressive with slenderizing teeth.
Well tell me if this is right or wrong. I think slenderizing adds to long-term retained stability, because if I held a softball in each hand and tried to hold a softball in the middle, it would be a balancing trick. But if I held a brick in each hand and tried to hold a brick in the middle, it would be very, very easy.
Yep. That's true.
Do you think when you're slenderizing, you can go from a very rounded [inaudible 00:53:05] tooth to just putting a little bit of a flatness on it, just a little bit, that that just kind of locks in and it's a lot more stable and less crowding?
Well rounded contours aren't prohibited to positional stability in and of itself. There are other factors that impact on the potential for relapse to occur. Everything from the gingible fibers themselves to outside forces, such as a soft tissue, seclusion forces as well. That's why we stress dual retention, both fixed and removable retention, to hold the teeth in place. One of the greatest sources of Six Month Smiles patients are individuals who have gone through comprehensive ortho as teenagers, come in saying, "Look, I had two two and a half years of orthodontic treatment. Look where my teeth are now. I want that nice smile back." It's a little more involved than that.
However, having said that, two approximated flat surfaces will tend to stay a little more stable than two rounded surfaces coming together.
But you think that's pretty low on the totem pole as far as what's causing the relapse?
That's right. It's not a primary factor in the relapse, but ... [crosstalk 00:54:11]
Talk about ... Go through the most primary to the least primary factors. Are you doing any soft tissue releasing sometimes for stability?
No. No pericision whatsoever.
Is that theory gone now or ...
For the most part. I don't think I've come across an orthodontist in the last 15 years who has used pericision at all. There are a lot of factors ... [crosstalk 00:54:33]
Man, you know you're old when you've lived so long that now some of the stuff you learned in school hasn't even been ... No one has done it for 15 years. I should probably go to a vet and be put down. That's extinct. No more.
That's extinct.
What do they call that?
It's simply cutting the circumferential fibers holding the tooth into place, allowing them to release potentially and then allow the fibers to reattach, reform without that shape memory. Although there are no conclusive studies that show that it is effective. That's why it's fallen by the wayside, Howard. But in terms of the relapse itself or the potential for relapse, different factors at work. Everything from the periodontal ... The attachment fibers themselves to [inaudible 00:55:22] forces, mandibular growth can continue well into adulthood. We can see vertical growth of the mandible changing the relationship between the particularly the anterior teeth. [inaudible 00:55:36] can come into play. Habits, soft tissue, forces, the lips, the cheek and the tongue. It is very multi-factorial in terms of potential for relapse.
It is always there, regardless of whether it is comprehensive or short-term ortho. That's the necessity of retention. Once we get a patient having a great smile that they love, we want to keep them loving that smile.
I want to ask you another very controversial ... I'm down to only four minutes. But there is a lot of freaks who just ... They quote the research like the bible.
That's all good, but that can be bad too. Because you know 100 years from now, a lot of the things we believe now are going to look silly.
The orthodontic research is telling us that when the mandibular wisdom teeth erupt, that's not causing the lower anterior. They say research-wise, that's not true. But god dang, it sure seems like that. I see patients every day for 28 years and it just seems like those teeth are coming in and those lower incisors are just folding. Do you believe it has no relation to the wisdom teeth or not?
My personal belief based on the studies I've read is that there is no relationship at all. It tends to be a coincidental timing with the eruption of the wisdom teeth, the changes that are occurring in mandibular positioning and growth. It tends to be an overlap of timelines. But having said that, I still know a lot of dentists and oral surgeons and orthodontists who still subscribe to the wisdom teeth are going to cause crowding, so let's get them out as soon as we see any sight of them at all.
Yeah. I noticed that in more advanced civilizations ... I always think of the United States as kind of a redneck hillbilly country. I still think Canada, Scandinavia, Germany ... I've been to so many countries. It just seems like they're more of an advanced, civilized country. I noticed the Germans are pulling a third less wisdom teeth than they did 10 years ago and about two thirds less wisdom teeth than they did 25 years ago. Have you noticed that?
Same thing here, Howard.
There's still that prevalence of old school dentists who will say, "If I see wisdom teeth, they're coming out all together."
But more and more, we're leaving them in tact and I think most of the research shows that the potential for the [inaudible 00:58:00] effects of the surgery itself outweigh any potential risks of leaving the wisdom teeth in place. Typically, I always advise unless there is the potential of a problem, either periodontal pockets, the potential for cystic formation, then the wisdom teeth can stay in place.
Hey, you know, my job is to do these podcasts for free because I know they're going to listen to them on their smartphone. I've noticed that my 28 years at the ... The 20 percent of the dentists in my neighborhood that went to the monthly study club once a month, they just learned something to keep them fired up and motivated and over the decades, they just were more ... They just were happier and they were more successfully than ever. I know at the end of the day, I know it's tough to drive across town and go to the study club and eat the rubber chicken and all this stuff. I'm trying to bring this study club into their car on the way to work. But you know, a great marketing thing for you to do, you should create a Six Month Smiles course on Dental Town. We put up 350 courses. They've been viewed half a million times.
You've got 8,000 people on that, on your site. Dental Town has 205,000. I'm sure you'd find a couple thousand more people on Dental Town and to go over there and talk ortho. That might be a great marketing thing.
No, I'll bring that up. One of the aspects with Six Month Smiles in terms of the support, Howard, is that we run regular webinars as well for the Six Month Smiles provider community. That as with the forum is very focused to the existing community, where we bring out advanced topics, tips, techniques, case reviews. But I will bring that up, because ...
The reach is ...
You could put a couple of those webinars already done onto a series on Dental Town. You can have ... You've probably already got the webinars to do a one-hour or a two-part or a three-part ... I'm sure you have to ... I'm sure 10 people have to see it before that one person is just turned on.
That's right. It clicks.
Hey. Another thing I was wondering, can you email me that picture of Michael Jordan and Penelope Cruz?
I'm dying to see it. That is just ... You know what a bald man thinks of Michael Jordan? Seriously, because we're the same age. You want to know what a bald guy thinks of him?
What's he think of him?
Well it's a fact. I mean, I lived through it. I am a bald guy. Before it ever ... When you were in college or high school or whatever and losing your hair, people would always say, "Oh man, that's bad. Are you going to get a toupe? Are you going to wear a wig?" It was this big negative thing. I'm like, "Whatever." Then the Phoenix Suns played the Chicago Bulls in that basketball series to the final deal. For seven games, the whole country is watching these two teams with the two most handsome bald men that ever lived, Charles Barkley from the Phoenix Suns and Michael Jordan from the Chicago Bulls, and I swear to god ... I'll swear on my father's grave, the next day, bald was cool. The next day, the combover stopped. The next day, people with hair like you start shaving their head. Michael Jordan and Charles Barkley single-handedly took bald to a disability to the in thing and there they were with their Nikes and flying around. They did. They made bald cool.
I think Michael Jordan has got to be probably the most handsome guy that ever lived. I'm dying to see his mid-line. I have never, ever noticed.
I definitely will send you those photos, Howard.
Who is Penelope Cruz? That's a movie star, I take it?
That's a movie star. Actually I think she was dating Tom Cruise for a little while.
She's not right in the head.
Let's see. I think her newest movie is Zoolander 2 with ...
Oh, I love that show. Zoolander.
She's in the new one, as well. You'll have a chance to see her there.
All right. She's a pretty girl but her mid-line is off.
Yeah. Okay. I'll still never forget the most amazing cosmetic study I ever saw back in dental school. It was done in Scandinavia and it was totally randomizing college universities. They took this broad sample of boys and girls college-aged, and they had them sit down for pictures. They said, "Okay, think of something sad." Then they said ... They took a picture. Then they said, "Okay, think of the happiest thing in your life." Then they mixed those photos around and just being happy bumped you up about two and a half ... On a 1 to 10, the bump was like two and a half.
If people are just radiating happiness, they just ... They look good. The best cosmetic dentistry you could ever get is a smile on your face.
Exactly. You know, Howard, I can't tell you the number of times I've had those big strapping 6'4" guys who never want to show their smiles. They walk in during the course of treatment. This is before they're even finished. They tell me, "You know, my co-workers, my wife, my girlfriend, my family say they've never seen me smile so much. I don't really notice it, but I guess I just like my smile now." That's absolutely right. If you feel good about your smile, you're going to smile. If you're smiling, you're going to look pretty to the world.
We're in three minutes overtime. I've gotta wrap this up. But here's the thing that it took me forever to develop, but if you can develop this straight out of school, you can do a thousand more cosmetic cases. That is when you're talking to a patient, the ones that hate their smile, especially girls, have really fast hand movements to cover their smile.
Whenever they laugh, they just ... You don't even see it, it's so fast. They've just got these lightening fast, cover the mouth with the hand ... If you spot that one time, she hates her smile, and you can just go there. You know what I mean? That's the hottest lead you can get, is a woman that covers her mouth when she smiles.
That's exactly it. I always ask my patients at the consultation appointment, "Think about photos, videos that are shot. How do you feel about your smile?" When someone says, "Okay, everyone set up for a photo, are you shy? Do you turn one way or the other because you think you have a good side or a bad side?" Very often, that relates to the smile itself. What we can do for our patients, not just giving them aesthetically pleasing looking teeth, but actually impacting on their lives, is profound. That's why I would encourage anyone listening, take a look at sixmonthsmiles.com. As I said, it's a rewarding process being able to align teeth in a very efficient way, but really the joy of seeing the impact that we have on our patients and then the effect that it has on our practices, both in terms of productivity absolutely but also how the entire team feels about what we're doing for our patients is truly profound.
What if one of my homies wants to contact you? Can they email or can they contact you?
Absolutely. You're welcome to give out my email address. It's email@example.com.
Now did you also get ... With Six Month Smiles, you can do the numeral or spell out 'six'.
For Noel, can they also just type it email@example.com?
No, that's taking it a little bit further. But those emails ...
How about x-mas?
At the North Pole and Santa will be answering those, Howard. It'll be out of my hands there. But again, if anyone has questions, by all means, feel free to contact me.
No, seriously dude. Thank you so much for spending an hour with me here today. I thought this was extremely fun and informative. Thank you so much for doing this.
Howard, it's been my absolute pleasure. I will send you those photos, as well.
Yeah, do. Send it to email@example.com. I can't wait to see what the most handsome man on the Earth, Michael Jordan's midline is.
Okay. Thank you very much.


text:
Bhagavad Gita As It Is
Srila Prabhupada
Radha Kund
Chapter 16
asatyam apratiṣṭhaṁ te
jagad āhur anīśvaram
kim anyat kāma-haitukam
asatyam—unreal; apratiṣṭham—without foundation; te—they; jagat—the cosmic manifestation; āhuḥ—is said; anīśvaram—with no controller; aparaspara—by mutual lust; sambhūtam—caused; kim anyat—there is no other cause; kāma-haitukam—it is due to lust only.
They say that this world is unreal, that there is no foundation and that there is no God in control. It is produced of sex desire, and has no cause other than lust.
The demoniac conclude that the world is phantasmagoria. There is no cause, no effect, no controller, no purpose: everything is unreal. They say that this cosmic manifestation arises due to chance material actions and reactions. They do not think that the world was created by God for a certain purpose. They have their own theory: that the world has come about in its own way and that there is no reason to believe that there is a God behind it. For them there is no difference between spirit and matter, and they do not accept the Supreme Spirit. Everything is matter only, and the whole cosmos is supposed to be a mass of ignorance. According to them, everything is void, and whatever manifestation exists is due to our ignorance in perception. They take it for granted that all manifestation of diversity is a display of ignorance. Just as in a dream we may create so many things, which actually have no existence, so when we are awake we shall see that everything is simply a dream. But factually, although the demons say that life is a dream, they are very expert in enjoying this dream. And so, instead of acquiring knowledge, they become more and more implicated in their dreamland. They conclude that as a child is simply the result of sexual intercourse between man and woman, this world is born without any soul. For them it is only a combination of matter that has produced the living entities, and there is no question of the existence of the soul. As many living creatures come out from perspiration and from a dead body without any cause, similarly, the whole living world has come out of the material combinations of the cosmic manifestation. Therefore material nature is the cause of this manifestation, and there is no other cause. They do not believe in the words of Kṛṣṇa in Bhagavad-gītā: mayādhyakṣeṇa prakṛtiḥ sūyate sa-carācaram. "Under My direction the whole material world is moving." In other words, amongst the demons there is no perfect knowledge of the creation of this world; every one of them has some particular theory of his own. According to them, one interpretation of the scriptures is as good as another, for they do not believe in a standard understanding of the scriptural injunctions.
etāṁ dṛṣṭim avaṣṭabhya
naṣṭātmāno 'lpa-buddhayaḥ
prabhavanty ugra-karmāṇaḥ
kṣayāya jagato 'hitāḥ
etām—thus; dṛṣṭim—vision; avaṣṭabhya—accepting; naṣṭa—lost; ātmānaḥ—self; alpa-buddhayaḥ—less intelligent; prabhavanti—flourish; ugra-karmāṇaḥ—in painful activities; kṣayāya—for destruction; jagataḥ—of the world; ahitāḥ—unbeneficial.
Following such conclusions, the demoniac, who are lost to themselves and who have no intelligence, engage in unbeneficial, horrible works meant to destroy the world.
The demoniac are engaged in activities that will lead the world to destruction. The Lord states here that they are less intelligent. The materialists, who have no concept of God, think that they are advancing. But, according to Bhagavad-gītā, they are unintelligent and devoid of all sense. They try to enjoy this material world to the utmost limit and therefore always engage in inventing something for sense gratification. Such materialistic inventions are considered to be advancement of human civilization, but the result is that people grow more and more violent and more and more cruel, cruel to animals and cruel to other human beings. They have no idea how to behave toward one another. Animal killing is very prominent amongst demoniac people. Such people are considered the enemies of the world because ultimately they will invent or create something which will bring destruction to all. Indirectly, this verse anticipates the invention of nuclear weapons, of which the whole world is today very proud. At any moment war may take place, and these atomic weapons may create havoc. Such things are created solely for the destruction of the world, and this is indicated here. Due to godlessness, such weapons are invented in human society; they are not meant for the peace and prosperity of the world.

subset: commoncrawl


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BNF – Webinar update
|We have two new webinars planned for May – why not pop these dates in your diary?
22 May (4pm) – The dairy farm visit – Primary schools
Using the story of a dairy farm visit as context, this webinar explores how work in 'food' can support numeracy and literacy. The full resource includes seven stories, all of which have food themes and link to the curriculum. Resources are editable, allowing you to fine-tune activities for your class. Join us and find out about the free resources available to support your teaching!
23 May (4:30pm) – Food provenance – Secondary schools
To support food provenance work, especially highlighted in the new GCSE, this webinar uses the production and processing of milk as a case study. The presentation will review the different resources available to support learning, including presentations, worksheets (with marking sheet), data facts and videos. In addition, it will highlight key facts and figures about dairy farming in the UK today.
Details on how to join will be circulated in the next newsletter!


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Timber Creek Leather Back Quiver Big Bear Delux Tan
The big bear deluxe quiver is made from heavy duty quality suede and decorated with feathers. It's three point harness makes it very comfortable and secure to wear. It can hold up to 24 arrows in its faux fur lined opening which makes for reduced arrow noise, this with its large zip fronted pocket can hold all manner of accessories. Making this quiver perfect for long archery adventures.
I like this quiver a lot and I recommend it. I'm 6.2 and quite skinny and this fit me great after adjusting the straps
Almost perfect overall - Less suitable for archers +6'1" height
The quiver arrived well ahed of time and I am very impressed with it's functionality as a quiver and the quality of leather. It can easily hold 24 31" arrows (Possibly more) and the front pocket is a must for carrying around small items, such as a finger tab and stringer. The only letdown was the harness not quite being big enough for a taller archer as it is. Other than that small fault, an amazing product!
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DHL Western Province U19 will go up against EP Elephants U19 at Boland Landbou near Paarl on Friday as an opener for the SA Schools clash with Wales U18.
DHL Western Province U19 will be looking for their third win of the campaign, when they take on the Eastern Cape side in an early game which kicks off at 12h30 on Friday.
Head Coach Nazeem Adams said that DHL Western Province U19 are determined to get back to winning ways on Friday following their defeat to the unbeaten Cell C Sharks U19 last week.
"We have identified a number of areas where we can make a step up, so the players are looking forward to the next challenge and proving themselves on Friday," he said.
That match will be followed by Aon Under-18 International Series matches between England U18 and France U18 before SA Schools take on Wales U18.
DHL Western Province U18 Coca-Cola Craven Week skipper Adrian Alberts has been named as captain of the SA Schools side for the forthcoming Aon Under-18 International Series.
Alberts, of Paarl Boys' High, captained the unbeaten DHL Western Province U18 side at the recent Coca-Cola Under-18 Craven Week in Paarl. He plays lock and in his second season with the SA Schools side.
The second match is against France at Stellenberg High School in Durbanville on Tuesday, 14 August, when Wales and England will square off.
The series concludes on Saturday, 18 August at SACS in Newlands, when the SA Schools side face England, while France and Wales will face each other.


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Amaju Pinnick, President of Nigeria Football Federation (NFF), on Thursday won a place on the CAF Executive Committee for the 2017 to 2021 cycle. Pinnick won 32-17 to beat the President of the Football Association of Benin Republic, Anjorin Moucharafou, to the West B Zone seat.
It was reported that Pinnick's federation was given a matching order by the federal government of Nigeria through the minister of Sports to support the candidancy of Isa Hayatu on compassionate ground. However, Pinnick team up with Ahmad to end Hayatu leadership. The election of Pinnick makes him the third Nigerian ever to sit on the CAF Executive Committee.
Earlier at the elections, Madagascar's Ahmad Ahmad had beaten incumbent Issa Hayatou of Cameroon 34-20 to emerge new CAF President. Both elections were part of the elections held in the Nelson Mandela Hall of the African Union (AU) building in Addis Ababa, Ethiopia.
NAN reports that the elections were held at the 39th CAF Ordinary General Assembly. The elections were witnessed by FIFA President Gianni Infantino and Secretary General, Fatma Samoura, and were declared open by President Mulatu Teshome of Ethiopia.
Also elected into the CAF Exco was Fouzi Lekjaa of Morocco who thumped incumbent Mohamed Raouraoua of Algeria 41-7 for North Zone.
Musa Bility of Liberia defeated Amadou Diakite of Mali 26-22 for West A Zone, while Adoum Djibrine of Chad was elected unopposed from the Central Zone.
For the Central-East Zone which had four candidates, Suleiman Hassan Waberi of Djibouti polled 20 votes to win after Sudanese Magdi Shams El Din withdrew before the second round of voting. In the first round, the incumbent El Din had got 12 votes, while Juneido Basha Tilmo of Ethiopia got nine and Moses Magogo of Uganda got seven.
After the Southern Zone election, Ahmad and Suketu Patel of Seychelles were replaced by Danny Jordaan of South Africa (35 votes) and Rui Eduardo Da Costa of Angola (25 votes). Frans Mbidi of Namibia could not make it in spite of getting 24 votes, while Patel withdrew from the election.
In the election for the female slot, Isha Johansen of Sierra Leone got 35 votes to beat Lydia Nsekera of Burundi who had 12. In the election of the African representative for the FIFA Council for the cycle 2017 – 2021 (Arabic, Portuguese, Spanish Category), Tarek Bouchamoui of Tunisia was successful.
This was after Hani Abo Rida of Egypt had withdrawn from the contest. In the Francophone Category, Omari Constant Selemani of DR Congo got 35 votes to beat Augustin Sidy Diallo of Cote d'Ivoire who had 19 votes.
The Anglophone Category election saw Kwesi Nyantakyi of Ghana polling 33 votes to beat Leodegar Tenga of Tanzania who had 20 votes. In the Open Category, where there were three positions to fill, Almamy Kabele Camara of Guinea and Nsekera were elected


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We must provide plastic surgery for all sub7 men, or suffer the consequences. Think the government can't afford it? Think again. That's only a tiny fraction of what our greedy leaders have already spent in the last 5 years. Give every ugly and average man a $10,000 cosmetic surgery voucher. The cost of an Ugly Men's Bailout ranges from 500 billion to 1.5 trillion. We stand to lose MUCH, MUCH MORE if we don't! More and more men are waking up to the truth about female sexuality, and that's potentially VERY dangerous. If we're serious about improving the economy, gender relations and crime rates, even a highest-cost-scenerio "ugly man's bailout" would be the best investment we ever made.
Looks matter. Female "attraction" has 2 faces - an authentic one and a pragmatic/businesslike one. Most average looking men are being settled for, and her sexual desire for him is lukewarm at best. She might whore herself and put up an act in order to "catch" him, but she eventually reveals her true colors. Hot guys get the best sex for free, while average looking men must pay through the nose for mediocre/infrequent sex. This is a double standard, and it isn't sustainable. Also, average looking men are deceived by society into believing women are "less visual". Female settling is behind high divorce rates, sexless marriages, cheating on both sides, mind games, long checklists of demands, and even bad dating advice. As more and more men wake up to the game that is being played, and HOW MUCH looks truly matter, I believe the backlash is inevitable - potentially even catastrophic. Also, much of current society iself relies on a Pay-For-Play sexual marketplace, so men's awakening to the Big Lie would really shake things up.
Being sexually attracted to your long-term partner was traditionally a luxury only afforded to men. Now that we are transitioning away from a Pay-For-Play sexual marketplace, women are starting to place more and more importance on a man's looks. I am doubtful that western civilization will survive this transition. Not unless we work to fascilitate GENUINE sexual attraction between partners via government subsidized plastic surgery and hair replacement. Many men simply cannot become sexually attractive through diet and exercise alone.
The Big Lie is what kept the "not-hots" docile, productive and obedient. If women think they live in fear of their lives now, they could be in for a nasty suprise! Rape gangs could rise up, roaming the streets. "Beta Male" terrorist organizations could spring up. They could find themselves pushed back into the kitchen, having to marry just to survive. More likely scenarios include a dramatic drop in male ambition/productivity, a sharp rise in all crime rates, and a rapid, nightmarish rise in misogyny - of a level never before seen in human history. The media's attempts to brainwash men back into submission will not save them from society's decline. Some men simply cannot handle the truth, and they would be in large enough numbers to bring western civilization itself down to its knees. A healthy sexual marketplace is necessary for the very survival of western civilization itself. If we don't subsidize cosmetic surgery, we WILL learn that lesson the hard way!!
Pandora's Box: The Men's Sexual Revolution. Free ebook here:
Stop Living The Big Lie. Download it here:
Stop Living The Big Lie. Download it here: