Changing the face of aesthetic dentistry

Jul 24, 2019

We talk to Tif Qureshi, one of the profession’s most pioneering minds, and most recent recipient of the Outstanding Contribution to Aesthetic Dentistry award.

Dr Tif Qureshi BDS has a special interest in simple orthodontics and minimally invasive dentistry. Tif pioneered the concept of progressive smile design thr

ough alignment, bleaching, and bonding. He is also an experienced teacher of the Dahl concept, which assists with minimally invasive, patient-centred dentistry. He lectures nationally and internationally and has articles published covering these subjects. Tif is a clinical director of IAS Academy and a past president of the British Academy of Cosmetic Dentistry. He graduated from King’s College, London in 1992 and is a partner at Dental Elegance, Sidcup. Learn more about the IAS Academy at www.iasortho.com or visit www.philips.co.uk/dentalprofessional or call 0800 0567 222 for further information on Zoom tooth whitening training.

At the Aesthetic Dentistry Awards in March, Dr Tif Qureshi was presented with the Outstanding Contribution to Aesthetic Dentistry award. Tif is in good company: this respected accolade has previously been awarded to some of the most esteemed names in UK dentistry, such as Linda Greenwall, Rahul Doshi, and Mervyn Druian.

A past president of the British Academy of Cosmetic Dentistry, Tif is a trailblazer in aesthetic restorative techniques, having developed the Inman Aligner

concept and protocols and pioneered the concept of progressive smile design through the alignment, bleaching, and bonding protocol (ABB). Tif is also an experienced teacher in the Dahl concept and a key opinion leader for Philips Oral Healthcare.

Here, Tif opens up about his award, ABB, and what’s next for him.

 

Would you like to talk about the work you have done that led to being recognised for your many achievements at the Aesthetic Dentistry Awards?

Over the last 15 years, a great deal has changed in cosmetic dentistry and orthodontics. For years, some patients refused orthodontics, instead choosing veneer preparations because they did not want to wait for the comprehensive treatment proposed to them. Many general dentists avoided orthodontics, and left it to specialists to perform the treatment, which much of the time was hardly comprehensive.

I guess it was my discovery of the Inman Aligner and its development within cosmetic dentistry that started the align, bleach, bond revolution that has led to this award. Combining cosmetic dentistry with orthodontics suddenly gave patients more of a choice.

I have had large numbers of patients who initially wanted veneers and perfect smile design parameters, but immediately after I moved their front teeth with orthodontics combined with bleaching, they completely changed their minds. And at that point would settle for composite edge bonding.

Their perceptions changed. As a result of a ‘progressive smile design’ process through align bleach, and bond, the decision-making process is made step by step as the treatment progresses. In fact, nearly 200 patients came to see me for veneers and left with no veneers. Of those patients, half would have been previously referred to an orthodontist but ended up refusing the comprehensive treatment that was offered to them. This perception change for me was a eureka moment.

But offering what I called a ‘compromise treatment’, only straightening the front teeth gave those patients a new option that many embraced, but equally, they needed to understand the benefit of comprehensive versus compromise treatment.

What set us apart was our concept of moving the teeth to improve the functionality and not just focusing on aesthetics. This disrupted the way cosmetic dentistry was being undertaken, and made peers feel almost guilty about what they were doing and needed to change.

After this, orthodontics then became more accessible to dentists and the market broadened. Lots of systems appeared, some of which tried to promote the idea that orthodontics could be carried out by just taking an impression and letting a third party plan it for you. This was, and still is, completely wrong. I felt it was crucial to ensure that if work was carried out by dentists, it had to be done correctly, which is why IAS Academy was created.

 

How have you been able to influence so many of your peers?

I suppose I had already demonstrated some ability in aesthetic dentistry and became part of the first board of directors of British Academy of Cosmetic Dentistry (BACD). At first the academy was very much focused on typical smile design and veneers being based on the American Academy of Aesthetic Dentistry methods; however, I believe the work we did within the BACD helped change its direction entirely.

The BACD gave me a unique opportunity to learn to lecture, and to have a platform from which to learn to engage the wider public. It was and is also an organisation with real passion for raising standards and being a better dentist.

On the other hand, the fact that I became the first ever president of the BACD who needed to be voted in, perhaps reflected that my work was perceived as being disruptive. I lectured, wrote articles, and provided case studies where I demonstrated that what I was doing clearly worked, and it ultimately made an impact. I also have been able to follow up on large numbers of cases, which proved the longevity of this treatment approach.

 

How has your training led to a new niche in the profession?

In the first year of teaching, we thought of it more as a hobby, offering four courses, all of which sold out immediately. In the second and third year, we had 40 courses!

The whole concept of teaching developed dramatically and we then added a support system that made so much sense and allowed us to mentor dentists through their cases. Much of this course development was down to the terrific help of the core team who I started this with – James Russell and Tim Bradstock-Smith.

IAS has gone on to develop a longer more complex programme that is now heavily restoratively focused. Our courses are also completed over a period because of mandatory case mentoring to ensure real quality assurance – normally taking three to six months at least. I am very anti one-day courses – how can you expect dentists to succeed that way?

 

Can you touch on championing ABB and how this has led to a change in mindset towards minimally invasive dentistry?

I have always felt it was right to put yourself in the shoes of your patients and wonder whether you are doing the right thing. I ask myself the question: ‘Would I have veneers myself, especially on virgin teeth?’ Quite simply, no. So, I only offered the treatment to those who refused or rejected orthodontics, and when there was no alternative route.

Trying to do things in a different way was my goal, and ABB proved to be the perfect solution. It doesn’t leave a big footprint on a patient’s dentition, which means that in 10 years’ time at the ‘replacement event’, the dentist has an easier job without the stress of patients having to deal with treatment failures, both psychologically or financially.

I expect one of the reasons why I won the Outstanding Contribution to Aesthetic Dentistry award is the fact that I have had the same practice for 25 years, which has allowed me to see my patients on a long-term basis. This has given me a chance to witness both the positive and negative effects treatment and no treatment have had on occlusion, function, and aesthetics.

I can confidently say that ABB has a much lower emotional, financial, and psychological impact over the years than more aggressive treatments. My view is that if you don’t need to put ceramics on teeth, simply don’t: they seem to lead to more complex issues down the line.

 

How do patients react to ABB and what kind of obstacles do you typically face?

Patients often don’t realise they have this option. They commonly think they need veneers, but when you go through the details involved with ABB, they embrace the idea of having their own teeth, but looking better.

One recurrent obstacle is the perception that the aligning aspect of the procedure – the orthodontics – takes a long time. However, 1mm movement per month is actually very possible for most orthodontic appliances.

Another obstacle is the concept of ‘retainer for life’ needed in orthodontics. The simple fact is that so many patients and dentists do not appreciate that crowded teeth will continue to move, regardless of orthodontics.

How often do you hear dentists say, ‘the patient did not want orthodontics, so they used veneers’? I can tell you on the lecture circuit this is common. They should instead be asking their patients, ‘do you want a retainer?’ Once patients hear this, most choose orthodontics. I believe there is an enormous consenting issue currently going on within cosmetic dentistry. There are thousands of patients walking round now who had veneers to treat crowding, but have no idea their teeth will still crowd regardless.

I believe the continual movement of teeth is the biggest blind spot in dentistry today and I would confidently say that 99% of dentists around the world are unaware of this, mainly because orthodontics and restorative dentistry have traditionally been kept apart when they are actually so intertwined.

 

What are the main benefits of your ABB approach?

With ABB, patients are given a chance to see their smile evolve instead of jumping to the end result. The improvement is progressive and patients end up more involved in the decision-making and the next steps forward.

From a financial point of view, ABB is much more affordable by a larger demographic. But the most important benefit is the fact that ABB is non-invasive and in the long run, patients have a better health outcome.

It is notable that very few lecturers are yet focusing on the replacement of veneers, their ongoing cost implications, the socioeconomic and psychological impact on patients, how difficult it is to match replacement veneers, and all the complications associated with them. ABB is unarguably a far more ethical approach; it is best for everyone and more patients would have it done if they knew about it.

 

What has been your experience of Philips Zoom tooth whitening for the first B element in ABB?

I have been using the Philips Zoom Daywhite take-home system for the last 15 years. My initial draw was its hydrogen peroxide content, and being able to undertake tooth whitening simultaneously with orthodontics.

The thickness of the gel is spot on, it has the right consistency and definitely not too runny, which means it sits well in the aligners. From the start my patients had virtually no sensitivity issues either and it was very simple to use,  and patient compliance was great.

Whitening during orthodontics was also critical. Interestingly, without the whitening, after they finished orthodontics, many patients would start demanding porcelain veneers. However, if I combined whitening in the last stages of orthodontics nearly 100% of the time the patient changed their minds and simply settled for edge bonding.

In terms of the whitening itself, it always occurs about three quarters of the way through the orthodontics treatment. The beauty of this is that patients are already in a routine with orthodontics and the use of aligners, so adding tray-based daytime whitening is really simple, as well as effective.

 

You recently raised the question of what was more important: aesthetic perfection at the cost of heavy tooth preparation, or minor aesthetic imperfection with real patient consent, and no invasion at all. Can you expand on this?

The concept of smile design has been recognised as a major advancement: the teeth look technically perfect, and if you are doing veneers and are picking up a drill, smile design will help.

However, when you align and bleach the teeth, patients then move away from the concept, as it is no longer of any relevance. What they had pictured in their mind when thinking of veneers is actually achieved when whitening shows how good their teeth look. This in my opinion is far better consenting than going straight to veneers, as you can allow a patient to see their own teeth looking better and then make a choice.

What’s next for you?

We are taking IAS Academy in a different direction. We are not just about orthodontics – restorative dentistry is just as important. We already teach fixed orthodontics, clear aligners, Inman Aligners, and comprehensive treatments, but an orthodontics case on its own is never enough – there is often heavy restorative element and long-term retention is critical to understand.

With this in mind, we are helping dentists understand how to move away from single-tooth dentistry and static examinations, to learn different ways of diagnosing patients and go beyond the cosmetic assessment.

We are also going ‘open source’ in that we teach anyone using any system how to improve the orthodontic and restorative dentistry they do. Pretty much any appliance can move teeth. What is critical is to know how to assess diagnose and plan properly, how to plan position and restore for function and aesthetics, and critically how to hold them there for life.

I know we can change the way dentistry can be done – not just for individuals but for large groups, which ultimately means more dentists can carry out this kind of treatment on many more patients.

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