Dr. Tif Qureshi joins us to share his ethical practices in cosmetic dentistry through the concepts of alignment, whitening, and bonding.
Dentist, educator and former president of the British Academy of Cosmetic Dentistry, Tif Qureshi shares his journey to becoming one of the successful leaders in aesthetic and cosmetic dentistry. He has transformed the field of aesthetic dentistry through the concepts of align, bleach and bond. In the Dental Leader Podcast, Dr. Qureshi explores the topic of ethical work and its importance to your long-term success in the field. Specifically, he explains the path of simple orthodontics and minimally invasive dentistry that contributes to ethical and successful work.
Payman Langroudi: I remember it was the World Aesthetic Congress, maybe 2003-2004, you were a very young member of the BACD, not even the president of the BACD. You came to me and you showed me this model. And on the bottom there was some kind of Inman device; and you said, "Hey, you know, all these veneers that we do, the upper ones, of course we're going to veneer those, but the lower ones, the veneers on the lower ones are pretty tough, aren't they? I mean, we shouldn't be doing that. So I was thinking maybe you could straighten the lower ones with..." And when did that start?
Typhoid fever: I would say that probably a few years before that, I was playing with the little mini braces with Z-springs on them.
Payman Langroudi: How? Why?
Typhoid fever: Fundamentally why, because I felt wrong doing what I was doing. Fundamentally.
Prav Solanki: Do you remember that moment when you thought, “Shit, shouldn’t I be doing this?” Was there a defining moment?
Typhoid fever: Yeah, actually, one of the veneer courses I took. The first veneer course I sat in and watched, I thought, “Mm. I’m not entirely comfortable with this.” Let’s not mention the name of that course, but I definitely sat there and thought, “Okay, there’s a lot of great stuff happening here. This is life-changing. I’m learning how to take impressions and how to do preparations. I’m learning how to handle patients in a very professional way that I’ve never learned before.” But on the other hand, I was watching and thinking: “"I wouldn't have done that.".
It made me feel uncomfortable, and it didn't mean I wasn't doing any of these things. What I usually did was send patients to the orthodontist. And typically, at that time, when only full orthodontics was offered, patients would say, "Let it go. I'll come back and do this." So, I did. And the top teeth, because you could build them up a little bit, you could try not to prepare them too much (you still had to do that occasionally), so they were easier to treat. But a lot of them, as you said, Pay, were almost a nightmare to do. And if you often didn't treat the lower parts, but only the upper ones, you created a kind of bicolor syndrome, which looked pretty damn awful. Let's face it.
Prav Solanki: And the bleaching back then wasn't very good.
Typhoid fever: The fading wasn't good, and people took it for granted. And what tended to happen was you watched TV to these extreme makeover programs, and even my patients would look at them and think, yeah, As long as you smile, you look good.. But for the rest of the 99% of the day, let's face it, when you don't smile, you'll only see the bottom teeth, which look worse and create a horrible contrast. And that made me feel quite uncomfortable. So I started looking for other ways to try, and I have to say I also used a lot of composite materials to try to mask this. But then I started thinking about minor orthopedics and the Inman Aligner came along.
That made me realize that there was a place for this. And I don't know why. Probably because everyone else was too busy with veneers at the time, and I was working in a practice where people didn't have that much money, so it made me think about alternative ways of doing things. Obviously, I've never been to central London, so maybe that was a reason.
Payman Langroudi: And then, how did it go from there? Did you start treating those lower parts, then did you start treating the upper parts?
Typhoid fever: I started treating the upper ones and then what I started doing was developing a kind of space assessment and planning protocol, where I was doing IPD (interproximal reduction).
“After eight years, when a tooth that has been aligned, whitened, bonded, breaks, and the edge breaks, there is no stress. It is simply cut and rebuilt.”
Prav Solanki: Were you talking to an orthodontist at the time?
Typhoid fever: Not really. I have to say not at that time. A little later I did. And, oddly enough, one of the first people I consulted with was Asif Chadi.
Prav Solanki: Oh, yes.
Typhoid fever: And the great thing about Asif was that he looked at what I was doing and was completely open to it and said, "Look, I see what you're doing. All you're doing is moving the front teeth, and if those patients have already come to me and said no, surely this must be the best thing to do." He played a pretty big role in making me feel at least, "Okay, this is the right thing if we do it right.".
Typhoid fever: Another person, a year or two later, who I also started to get some ideas from (and I was very lucky), and he's an extraordinary person who was my mentor for a short time, was Bjorn Zachrisson; one of the greatest orthodontists who ever lived. He's still alive.
Payman Langroudi: How do you have the confidence to go to the largest orthodontist in the world by GDP and say, "I'm doing this. What do you think?"“
Typhoid fever: I mean, again, you have to thank people like BACD here, you have the opportunity to do it and you'll always be grateful for that. So, I would have talked to one person or another. I just wanted to validate it and make sure that it's something that I'm doing to the best of my ability.
Payman Langroudi: Have you ever thought, or maybe – I've even heard you write or read about you saying this – but today it would be impossible to be the only one doing something, because you would be so afraid of the legal ramifications.
Typhoid fever: I think you're absolutely right, Pay. And I think that's a pretty sad statement, really. We've all been lucky to a certain extent for the times we've lived in. But these days, yes, you'd probably be afraid. However, I've come to the point where I'm just turning this argument around, where I used to hear and I still hear people say, "If a general dentist does orthopedics, it's dangerous." Well, I'm turning the argument around now and saying that “"A general dentist who doesn't do orthopedics is dangerous, okay?".
Typhoid fever: And I can justify this because many dentists do not understand the concept of restrictive envelopes. Why do the envelopes tighten? Because the teeth move. And how do they fix it? Not restoratively. Yes, you can do some restoration, but you need orthopedics. And there are probably, I would estimate, millions of patients around the world who have a front tooth that is chipping repeatedly. It keeps chipping. The dentist's solution is another composite, another composite, or a splint, and many of these patients end up having crowns. The dentist understood then that they needed a little bit of orthodontics to get the overbite right, the right overbite, a little bit of bonding to improve the overbite. You would probably find that fewer people would have anterior veneers or crowns. I've seen that. It's clear, and I think that's an important part of the message now.
Payman Langroudi: Do you remember the moment you thought that rather than being a treatment modality, it could be a business?
Typhoid fever: Yes, I mean it's a business and we need to make sure it works and operates properly. But it's still largely run by dentists, so we have our ethical hats on all the time.. Sometimes we probably do things that a hardened businessman would say, “Don’t do this, do this instead.” But we can’t. We just have to do things that might hold us back in the long run. But ultimately, I have to stand up and look in the mirror, and I know that others have to do the same. That’s kind of why I took it the way I did.
“Sometimes we probably do things that a tough business would say, “Don’t do this, do this instead.” But we can’t.”
When I look back at my own cases, and this comes from my own embarrassment about what I did in certain cases, where I used to act like a typical cosmetic dentist, in the sense that I was advertising to people. You bring them in. You smile at them, you design them, you wax them, and you take pictures of them.
And you know what? It's not that different. Now, DSD is something on a much higher level. But I used to do things like that, and I would see the patients, do the treatment, finish the case, and say goodbye to the patient. They would go back to their regular dentist. And we all did that, and a lot of people still do that today. Now I realize that it's completely irresponsible, because I see patients coming back after 10 years. And I would look at the patients, and once or twice, I almost burst into tears thinking, "What the hell have I done?" Okay, the patient isn't sitting there in pain and complaining, but I look and see teeth that I veneered and now they've moved back to where they were originally. And so what I realized is that a lot of things can change.
Payman Langroudi: And it's golden, that thing that you kind of popularized, the idea of learning by watching your own patients. It's absolutely right.
Typhoid fever: Categorical.
Payman Langroudi: I mean, it's a very interesting point. And another interesting thing, the amount of knowledge that exists from people who are not necessarily famous or professors or on the international conference circuit who have had this experience of treating these same patients.
Typhoid fever: Yes, that's absolutely correct. I make these statements and I post them. Because I don't think it's being said enough. And I think one thing that's been worrying me in recent years seems to be a kind of devaluation of what it means to be a GDP.
In fact, I think the GDP is the most important person in dentistry, period, in the sense that we need specialists, and specialists do incredibly important work, obviously. But what a GDP can do is simply incomparable, because a specialist very rarely ever sees his treatment again.. He certainly doesn't see it regularly. The GDPs will do the treatment and then they will be able to monitor it and intercept it and prevent it and do everything they need to do, and that is far more valuable than perhaps anything else we could ever imagine. In addition, you can build a relationship with a patient that spans many years. And this is again something that I find quite undervalued these days. People seem to be more concerned with bringing new patients in the door than treating the ones that are already there.
“People seem to be more concerned with bringing new patients in the door than necessarily treating the ones who are already there.”
Typhoid fever: There are a couple of other things that have made me think a lot about the whole concept of cosmetic dentistry. There's this thing called the replacement event. I use that term quite a bit. And the replacement event is something that, when you go and watch a lecture on cosmetic dentistry, very rarely does anyone get up and talk about the replacement event, like in the three little fundamental factors that I'm going to give you.
- Number one, will the patient be able to afford it again? So, we would take the patient's money and they could be 30 or even 20 years old. I mean, fortunately, we haven't done many cases like that, at 20 years old. But you never know, 15, 20 years later, the patient now needs something and can't afford it. And there's no reserve for that. The moment you start doing these kinds of works, you're responsible for them.
- The second thing we've found is that patients have gotten to the point where they can actually afford to do something again. But you know what? They can't be bothered. For whatever psychological reason, they can't be bothered to go through that process again, or even part of that process.
- The third thing, and this is the real killer, which is not talked about much, is that not all the veneers fall out. What usually happens is that after 10, 15 years, one of them falls out, right? The upper central part, the upper left lateral part. No one tells you how hard it is to match a brand new veneer to a set of eight or nine that have been there for 10-15 years.
Payman Langroudi: That's a good observation.
Typhoid fever: Absolutely a nightmare. And you'll end up doing three, losing half the hair on your head, and feeling super stressed about it.
Prav Solanki: Is this something you would personally struggle with, someone with your skills, as well?
Payman Langroudi: Anyone would do it.
Typhoid fever Qureshi: Anyone, yes. You know, after eight years, when a tooth that's been aligned, whitened, bonded, and cracked, and the edge is chipped, there's no stress. I just shrug it off. I just cut it off, I rebuild it. It's a whole different ball of fish. That's the thing that people need to hear when they think about cosmetic dentistry. Now, I don't mean to say, of course, that BACD is all about veneers. It's clearly not. It's evolved a lot, but my goals are not cosmetic now; I actually have a long-term functional treatment in mind for patients.
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Source: enlightensmiles.com
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