At The 3 Day Practice, we’re all about how a dentist can differentiate their practice, be more productive, add more value and at the same time work less hours. In doing so, we look towards processes and new innovations in the profession to help us achieve this.
Today we had the opportunity to speak with Matt Everatt, Technical Director at S4S and Smilelign, leaders in technological innovation, orthodontics and custom made dental appliances. We discuss how these areas can increase profitability and add value for your patients with little detriment to your schedule. Matt also reinforces our previous descriptions of how you can utilise orthodontics in order to grow your practice.
Aalok Y Shukla: Hey Matt, thanks for doing this interview with us for The 3 Day Practice. What we wanted to talk about today was how dentists can build their practice for the future using 3D technology, digital dentistry, and custom appliances, because if they are able to do this, they are going to be able to serve more people and at the same time future-proof themselves. Tell us a little bit about some of the things that you have started to see and that your guys are now helping provide on the digital dentistry and appliance front.
Matt Everatt: Okay. The S4S lab itself is quite unique. We offer snoring and sleep apnea devices often called mandibular advancement splints. Actually, there’s a splint for all sorts of problems such as tooth wear, bruxism, headaches and migraines. The other arm to the business, which is Smilelign clear aligners, is another area where we’ve been getting lots of interest. Very popular at the minute and an area where digital dentistry has really grown, manically, within the last couple of years. Dentists can now do intraoral-oral scans and email them directly to the labs where they can 100% digitally design almost anything, from appliances to treatment plans to actually producing 3D printed models. All in house. All under one roof. Speed-wise, everything is vastly improved.
Aalok: Most practices in the UK probably don’t do anything for snoring. They probably don’t do anything for TMJ migraines, for want of a better term, and at the same time loads and loads of dentists are scared of orthodontics. If we just start off with the splints, for example, those for snoring and the NTI and things like that. From your experience, in an average practice, how many people do you reckon would benefit from something like this?
Matt: We did a survey many years ago and the figures that came out of that survey was that around 50% of the adult population snore and 100% of the adult population in the UK are affected by snoring. That would mean that either the person they’re sleeping with snores or a family member or friend does. 100% of the people that walk through your practice are at some point affected by snoring. A smaller amount are affected by sleep apnea. We see more and more doctors referring patients to practices. This is a growing thing in the UK. The U.S. is a good few years ahead of us in this area.
Aalok: Sleep medicine is quite big there, isn’t it?
Matt: Yeah, huge. It’s getting better, here. The referral process is getting better, but we’re still way off. We work with a network of dentists, we provide training courses for them to offer snoring and sleep apnea devices because the reality is, half of the people that walk through your practice, will be a snorer or will even suffer with sleep apnea. There are several devices available to dentists in the UK. The device, which is the most clinically proven for snoring and sleep apnea is the Sleepwell device, this device originally came from Australia.
Aalok: Sleep apnea is quite a problem isn’t it? What kind of risks could somebody experience in their life because they have sleep apnea?
Matt: It’s huge. First of all snoring is usually the prerequisite to sleep apnea. If you have sleep apnea, you will be a snorer as well. Snoring is more than the loud embarrassing noise that we often complain about or hear about. Sleep apnea is more, there are lots of other medical issues associated with sleep apnea, things like diabetes, hypertension, obesity, excessive daytime sleepiness, it is a big issue. The list goes on and on, headaches upon awakening, depression; severe depression is also quite common amongst these patients.
Aalok: Somebody could be generally performing sub-par and they wouldn’t be sick so to speak, but they would be consistently lethargic, tired, and there’s even instances of people falling asleep at the wheel if they are driving and things like that. This is one of the ways that you are helping dentists move just beyond tooth dentistry and further help your patients, isn’t it? If a dentist wanted to start to expand their approach, what would be the first steps for them to learn about sleep dentistry and snoring and stuff like that?
Matt: Okay, the first thing is to do a course. Defence Unions will expect their dentists to do some kind of recognized training course, if they’re offering this kind of treatment. Now, there are a couple of companies that provide training courses that are recognised by the dental unions or dental protection for instance. The one that we support and sponsor is run by Dr. Ama Johal, who’s a Consultant Orthodontist at The Royal London. We’ve been sponsoring the seminars for the last 10 years. The idea of Dr. Johal’s course is to give dentists a good overall picture of how they can screen patients that come in with the main complaint of snoring, how they can screen patients to look at things that might be associated to risks of sleep apnea. Things like large neck circumference, being overweight, excessive daytime sleepiness. We go through a questionnaire and dentists can use that tool to screen patients. That’s the place dentists would start; undertake a course or if they’ve already done a course, make sure they’re using the correct protocols to screen patients when they walk through the door.
Aalok: From then on, they could start recommending, getting things checked and going from there?
Matt: Yes. Everything that you have in your dental practice is all you’ll ever need. You don’t need to buy special equipment, you have impression trays, you have impression material, you have bite registration material. Everything you need. You need a pen to fill in the questionnaire or a computer if you do the electronic version.
Aalok: Perfect. That’s one way that they can add more value and help improve the lives of the patients that they’ve got. The second thing has to do with NTIs. Can you tell us a little bit about those different kind of splints and appliances that you guys help practitioners with and what impact that can have on their patients?
Matt: Absolutely yes. The NTI is a little device that was invented by a guy called Dr James Boyd in the United States. He was the inventor of NTI. It’s since been rebranded in the UK as the SCI; Sleep Clench Inhibitor. This little device is perfect for tooth wear and separating or discluding the teeth. There are added benefits for teeth health and function. You get wider health benefits too. It helps you sleep better, it helps improve tooth wear, and the improvements on headaches and migraines are often significant. In fact, in the US the FDA gave approval for this device to be used as a frontline treatment for migraines.
Aalok: Yeah because it’s completely non-invasive. It’s a very rapid treatment, which dentists can provide. I think the clever thing about your SCI device is the fact that you get a unit which you are able to customize chair side. It literally would take you 20 minutes, if that, to be able to do it. It’s also a large number of people who suffer quite badly due to basically grinding their teeth, they don’t have canine guidance which causes the masseter and temporalis to be constantly tired. It’s like playing tennis and your arm just gets tired all the time and people can suffer quite badly from it. This is a brilliant way that you can make them feel better quite quickly. Again it’s moving beyond just being a tooth dentist and cutting and moving things, isn’t it? It’s a big thing. Okay cool. If they want to learn more about this, because migraines is a quite a broad subject. How could they do this? What would be the first steps?
Matt: We’re very fortunate, with all of the products we do because they are quite unique, and they’re not things that are in mainstream dental labs and dental surgeries so we back it up with education and the people we have doing that stuff are very educated and knowledgeable in this field. We have a general dental practitioner here in the UK who runs training sessions once a month or once every other month. There’s options there for dentists to have a play around with the materials as well. We’re very fortunate, we have a dentist from the US and he’s 100% a pain management dentist in the US. A guy called Dr. Barry Glassman. He works in Allentown and travels all over the US teaching these courses. We just put on a course in London last month where we had about 45 come along to it and had fantastic feedback.
Aalok: At The 3 Day Practice, we’re all about how a dentist can differentiate their practice and be more productive, add more value and at the same time work less time. It’s all about being as effective and as efficient as possible. One of the huge things about these types of appliances such as snoring devices, NTI devices, SCI devices or the splints is that they are a zero time procedure because this is something that somebody could easily add into a same day treatment. What’s an average cost of for example, a snoring device, for the dentist, or a splint would you say approximately?
Matt: The snoring device is around about £160 including VAT. The only thing you need to do to provide that is an upper and lower putty impressions. Really simple. Often the Assistant in a dental practice would do something like that. Also the screening process, most of that can be done online or by an assistant. The dentist can check the details. The SCIs exist in two forms. They can be chairside as we mentioned, but it can also be done by taking a couple of impressions, a couple of simple bite records, sending it to us and then get a device back that will be custom made and nicely packaged. Really that simple, not invasive. There’s no one taking preps.
Aalok: Yeah and what’s an average cost, in terms of dentist to patient, for a snoring device or an SCI?
Matt: A snoring device, the national average would now probably be around about £400, some maybe a little bit higher than that. An SCi cost to a patient I guess we’re talking about £250-300 and a lab cost of about £90.
Aalok: Okay, with both of those, your potential, if you’re doing one to two appliances a day. You can add another £200-400 of gross margin to your day for essentially zero time and at the same time, you are providing additional value. Patients might be taking headache tablets or they may be on so many different medications, or they may be groggy during the day and they might not know it. What this allows is quite a significant boost to profitability and at the same time additional value without having to take up lots of time compared to, an implant treatment or something like that.
Matt: In terms of adding patient value this is where word of mouth is absolutely crucial. The gratitude that some of these patients bestow on you is sometimes a bit embarrassing because you’ve taken a couple of very simple impressions giving them a device which they’re in control of because the sleep device itself is adjustable. The gratitude that’s bestowed upon you is incredible. I’ve worked on cases where we’re rebuilding people’s faces, but I fix a snoring problem and it can save a marriage.
Aalok: Yeah, and this is a very high impact thing which people want, and makes you feel good as a practitioner. Moving from those high impact activities into another high impact activity, a beautiful smile, everybody wants a beautiful smile these days. There’s been an explosion in the last four years in orthodontics. Particularly in adults and obviously everybody nowadays, they want a nice smile. They don’t want the hassle of having anything visible. What technological improvements have occurred in that space, and where do you see the opportunity, and the growth in that?
Matt: The growth in the last four years has been absolutely incredible. My background in orthodontics, predominantly in teaching hospitals and now coming out into a commercial environment, the growth in the last four years has been amazing. So many more adults that come into dental practices seeking orthodontic treatment because they were either refused in the past or they’ve had some kind of braces in the past, now want the more aesthetic option. They’re hearing about it on TV, radio, all sorts of things. The biggest thing more recently has been clear aligners.
Aalok: Yeah, because lots of people, even if it is clear, they just don’t want anything on the outside. I think nowadays if you go to any department store for say beauty, if you look at the cost of make-up packages etc, people have no limit to what they will spend on things they want to make them feel and look better. People are also used to wearing contact lenses and things like this so aligners seem like a very natural fit in that department?
Matt: Absolutely, It’s been a huge area for growth and again, it’s something that general dentists, and orthodontists, obviously, can deliver very easy, low cost. There’s no special brackets, equipment, glue, adhesive, anything like that that you’re going to need, it’s all stuff that you already have in practice. At the very worst, additional composite, but usually it’s impressions and all the tools you’ve already got in your practice.
Aalok: Technology has moved on a lot in aligners. I think many people have heard about aligners a long time ago and there were lots of limitations at that time because of technology, but what people aren’t necessarily aware of is the exponential growth and improvement in technology. What kind of cases can be treated these days with aligners, would you say?
Matt: Well if you’re really bold and brash about this we could easily say every case is doable. However, what we would say is, general dental practitioners want to keep it very safe and within sensible limits. We want patients to complete their treatment in a timely manner. Now, if we’re going to do an extremely complex, severely crowded case, where there are multiple extractions and attachments and IPR required then that would push treatment onto two, three, four years with aligners. We personally feel, that the compliance might become an issue. We like to see cases finished, usually between six and 12 months, at the very worst 18 months. It’s very rare that we get a treatment plan that goes beyond that.
Aalok: Okay, that gives a good window because the key thing, you said, is compliance, isn’t it? People have to be sufficiently motivated to see their improvement. What kind of movements can you do? Can you do vertical movements? Can you do rotations and stuff like that?
Matt: Absolutely yeah, and because of the digital innovations that we’ve had with 3D scanning and treatment planning. You can do extrusions, intrusions, rotations, you can even do torquing, which was something that we never thought we’d do with removable appliances. All of these can be controlled by using attachments. Basically, we can control the force through a tooth. All these things are doable with clear aligners. Sometimes we would often recommend, in really severe cases, that the specialist would be the best option. However, in a majority of cases that walk through your door are often very easily treatable with clear aligners.
Aalok: The beauty of clear aligners is, there’s nothing that could suddenly snap and cut their cheek or something couldn’t suddenly break and go wrong that could cause a problem. Lets just say you were doing lingual braces or a different type of brace and suddenly a bracket fell off and they couldn’t come to see you. Everything is pretty much reversible, but an inexperienced dentist might panic and not be able to do something. With aligners, nothing like that is going to happen, because the worst they could do is lose the aligner.
Matt: Absolutely. Good example, yesterday I took a phone call. A patient from London was overseas. He travels overseas quite a lot and had broken his aligner. We could identify, from the number on the aligner, which one it is. The dentist said he would be back to London on Friday and asked what we could do. I said, “Well, we’ve got digital records, we simply print off another 3D model of the aligner and the guys in the lab will make another one and post it out -it will be with him on Thursday’.
Aalok: This is highly productive. A highly desirable treatment and there’s no complexity. You have taken the complexity out of it. With these cases, let’s say someone wasn’t comfortable with IPR, could they still straighten their teeth?
Matt: Yeah there’s often compromises to be had and it’s something we would expect the dentist to discuss with patients. There are cases where you’re looking at treatment and often the conversation will be that a specialist will be ideal. Although the patient doesn’t want brackets. Or a patient who doesn’t want to have three years of treatment.
Aalok: The point is, they want what makes them feel happy at the end of the day. This is all about adding increased value. This is not reactive health stuff. There is a space for that, but what we are talking about is as our standard of living improves, so do our aspirations. We want to feel even better about ourselves. We want to be even healthier. We want to be our best version of ourselves and this is where these sort of appliances come in. Many people might think, okay for a simple tooth movement, traditional braces are way over the top. However, aligners could be acceptable. Is it about two weeks per aligner would you say?
Matt: I would say three weeks. If you go much longer than three weeks, the aligners are pretty much shot and worn out. Two weeks would be a minimum. There has been some research thrown out there that suggests that two weeks is where most of the movement is happening and then the third week it tails off. We do simultaneous tooth movement, about 0.3 millimeters per aligner. We find that three weeks is the ideal, beyond that it’s not doing much else.
Aalok: 0.3 millimeter per aligner, that’s a lot, isn’t it?
Matt: Approximately, yeah. 0.3mm would be the maximum movement. It usually is somewhere between 0.2 and 0.25. Sometimes with very simple movements it will be around about 0.3. Never above that.
Aalok: Sure. Over 12 months, if they are wearing each one for about three weeks or so, is that what you’re saying? So what they are going to be having is about 18 aligners or something like that, over the course of a year essentially. In that kind of thing you are saying about 0.3, so we are looking at four to five millimeters, a movement, which is quite a big transformation which you could achieve. That could be simultaneously top and bottom? Loads of people have crooked lower teeth and lots of people might have small things that they want to improve at the top and then they want to get some whitening afterwards, that could be a big thing? I can definitely see how in an 18 month time period you could pretty much do most things.
Are you finding that once people start providing these aligners, that after a couple of months, suddenly there will be a lot of people who start spiking because as they get more confident and more people see it, it just becomes a virtuous cycle doesn’t it?
Matt: Absolutely, yeah. That’s a good point. Back 20 years ago, when I started my career in the hospitals there was a lot of GDPs doing orthodontics which tailed off. Now GDPs are seeing that there’s a real interest and that patients are asking for this. What we see is GDPs trying it out in practice and realising this is really easy and it was a pleasurable experience. The benefits that the patient got from it made me feel good about being a dentist again.
Aalok: It’s a huge growth area, isn’t it? There’s very little time required for it, but high impact for the patient . One thing that you guys are real experts in and really progressive is in staying ahead of the technology curve and helping dentists take advantage of these new technologies that help add more value. Where do you see for the future in the next two years? What advantages/new areas do you see for the most cutting edge practices?
Matt: It would be intraoral scanning. I think that’s the biggest area for growth. The patient demand is really high and these patients are aesthetically driven patients, so they may want something quicker. Quicker than you could possibly imagine. Digital dentistry is going to allow us to do the old photo express thing, where you send your snaps in and in an hour you can get your photographs back. The dentist can do your intraoral scans, email it to us, we can get a treatment plan done within an hour. The patient can be in aligners treatment with 24 hours. That will be the goal. The dream. What I see that will be happening in the next two years, is, I think intraoral scanners will become cheaper. They’ve certainly become a lot better and quicker.
Aalok: They are about £10-12K right now, aren’t they?
Matt: Yeah, I think so. So you’ve got records of patient’s teeth easily. You don’t have models stored in garage or your attic. We have everything under one roof, so we have desktop scanners, we have CADCAM technology for appliance design, some online treatment planning. We see that there will be 100% digital process. We’ll design it, we’ll articulate it with all the things dentists need on the screen. Models will be printed, the actual appliance will be even printed. The material’s almost ready and been passed for approval for temporary use in the mouth.
Aalok: Actually printing the aligners? At the moment you print the models, don’t you? I think there were some criticisms about the rigidity of the material, but now you’re saying that that’s actually doable!
Matt: The aligners are a bit trickier because the aligners do a lot more, so at the minute the vacuum form or pressure form is the best type of material to use. Certainly for some splints or for the dental appliances, being able to print the actual splint themselves it’s very common for us to print things like surgical guides, other things that go in the mouth temporarily. The next step for us is where we’re producing 100% digital appliances.
Aalok: By embracing this and embracing the fact that as a dentist you have the ability to impact just beyond the teeth, you can obviously help them improve their breathing potentially and help them with snoring and different aspects. You can also help relieve pains and headaches and all that sort of stuff. You can also transform smiles. All of these things are without having to add extra clinical hours to your week. You’ve got the ability to help these sort of high impact things. If we are going to learn more about how to get involved in some of these things, where is the best place to look?
Matt: We run courses regularly, so we do advertise quite a lot in journals for the different courses. We are involved as sponsors, we go there to support courses like the European Society of Aesthetic Orthodontics. On our website we have all the information about courses we run. We do dental practice visits if need be. There’s a lot information on the website that will allow dentists to find out more about what we do.
Aalok: Perfect. Thank you very much, Matt, for doing this interview with us. We are excited about all of these innovations and that you are helping practices help their patients.
Matt: No problem, an absolute pleasure.
To find out more information about the course’s Matt runs and the two businesses discussed here, please visit S4S and Smilelign.
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