What follows is an interview with my dear friend Professor Nelson Silva, we have known each other for many years,  I remember the first time I met Nelson in New York. I don't even know if I should say how many years ago. I stayed at Nelson's house, and he took me to NYU. Nelson was a professor,  and teacher there for many years. He consults for big companies about digital dentistry and speaks all over the world. He moved back from US to Brazil recently and has a private office.

This interview was originally taken from Coffee Break With Coachman, a series of interviews with the best dental brains and the best personalities, in short, the most influential people in our dental industry today. From business to marketing to clinical to research, academics, laboratory technology and digital, each of the interviews is a conversation with a thought leader in their field, sharing their knowledge and experiences.  

We're going to talk in a very pragmatic way about the options for young new professionals. We're going to talk about how to plan your studies, your career in the US, your academic career, and how to become a researcher. We're going to talk about digital, of course, new trends in dentistry. The real meaning of comparing conventional analog with digital.

Nelson is one of the best guys to really analyze deeply this comparison. We're going to talk about the dental market with technology involved. ROI, as I mentioned, is, for me, one of the best topics. Return on investment. What can you expect when you invest in technology? What is the strategy? How do you plan your investments in technology? We're going to talk about artificial intelligence. Is this a reality? How this is going to change. What is happening right now in dentistry when it comes to artificial intelligence. Efficiency in the digital workflow. These are basically the topics.

CHRISTIAN: Nelson, since you developed a very interesting career story, I want you to explain a little bit to us how you ended up as a teacher at NYU. From Brazil, to NYU. Why do I ask this? Because I remember, I was just talking to a friend about this today, I remember when I decided to leave Brazil. When I decided that I wanted to experience life outside Brazil in 1999, 2000, at that time, there was no social media, there was very little internet. People didn't travel that much. In 2000, people didn't travel. Up to when I was 30, I left Brazil twice only. I wanted to leave Brazil. I had this dream. For me, it was so distant. I was almost impossible. 2003, I said, it's just a dream. This will never happen. So, the challenges were, how do I make money outside Brazil? How do I pursue this career? How should I study? How do I study for three years without making money? You know, what kind of investment I need to do, how to find a sponsor, how to find a company that wants to sponsor my working visa? How do I start as a teacher outside and how the university can be my sponsor?  I want you to start explain this path for you, this vision. What were your first few steps? Who helped you? How did you develop this international career?

NELSON: Several people call us asking what's the easiest pathway to do what we did. And the way you did it and the way that I did. Teaching is something that, since the beginning, I was looking for a way to be a teacher, because I had good teachers when I graduated before and even after. That was, in my mind, what I wanted to do. To go to the West is something I wanted to do since I was a kid. I wanted to go to the United States, and actually Disney World is where I was aiming for. Back then, there was no social media. There was no fast internet. If you recall ICQ was the first connection that we could do with people other than talking. Then Viber came and so on. What happened was, in 1994, the school that did the postgraduate level was University of Sao Paulo in Beru. I decided to apply and go to Beru at the University of Sao Paulo, because they had the teaching strength and the expansion that could lead people to go overseas. That's exactly what happened. I ended up applying for a Masters and then a PhD. And the PhD, I was granted support from the government to leave Brazil for one year. People who had helped me were Louise Fernando Pegorado, who you know well. And also, Ricardo Madinas, who is now in British Columbia in Canada. He's a very successful professor. They were teaching in Brazil. Louise Fernando is in Brazil still, but Ricardo left to go to British Columbia in Vancouver. Those are the two really key people. Of course there were others too.

CHRISTIAN: Let's say that the first step for you to start making your dream of going abroad and creating working outside Brazil and working in the US, a reality, was to connect to good mentors during dental school?

NELSON: That's it. To find what they call the best match. Actually, a good match, I would say, not the best. But a good match of you as a person, a good match of someone who could be a mentor. And also, it's important that your mentor is good to find you a good match overseas.

CHRISTIAN: You need to find in your school somebody that has good contacts in the good universities in the US, right?

NELSON: Yes. Good contacts. And also someone with a skill that would find you the best spot. I was lucky with Louise Pegorado and Ricardo, who found me Ben Thompson, who was the best match, not only for his capacity as a professional researcher - they had a relationship with Ben, who was one of the top researchers at NYU. They had a relationship before and it plays a significant role on your success when you are overseas, to have someone who looks like you. Ben Thompson moved to NYU to be the chair of the biomaterial department. When I came, I saw that transition and I helped him to build the lab, because it was moving, and I was the only one in the lab.

CHRISTIAN: What year you moved to New York?

NELSON: 2001, 2002.

CHRISTIAN: How old were you?

NELSON: I was 35.

CHRISTIAN: How many years were you working as a dentist in Brazil before that?

NELSON: Ten years. I shut down everything and I moved. I spent about 12 years in the US.

CHRISTIAN: What was the process? First for Ben Thompson to know you, to approve you, then university, to apply for your visa, and then for you to make the move with the family?

NELSON: It’s step-by-step. As a PhD student back then, when I decided to go, Christian, first of all, you send your intention to work with that professor. Usually, I ask people if they want to do it. That professor sends you an invitation letter.

In my case, I used that invitation letter to apply for funding for my trip, using one of the Brazilian's departments that funds people to stay overseas doing paid duty.

CHRISTIAN: When you graduated, you continued at the university and you did your Masters and you continued to study, right?

NELSON: When I graduated, if you start from the beginning, I ended up going in for residency courses, to improve my skills as a clinician. At the same time, I started working some private universities to improve my skills as a try.

CHRISTIAN: You always enjoyed teaching?

NELSON: Yes. Always. It's the feeling that you can share things to others. At the end of the dental school, I would say I was motivated by some good faculties that we had back then, to pursue an academic career. I would say that back then, it was very attractive to be an academic. If you see what's happening in Brazil now, which will have tons of institutions teaching dentistry, it may not be as attractive anymore, because there’s a lot of competition. You have many dentists pursuing an academic career, and they tend to ship you out. Things have become a little more dense. Unless you are really linked to good institutions, I would say, the University of Sao Paulo is a good institution, Campinas, you have some good institutions. But it's a tough time now for students to decide if academic career is something to pursue.

CHRISTIAN: What about the academic career in the US? Is that something that you would recommend to your son, for example?

NELSON: This is a very interesting question. I will give you my perception.

An academic career in the US is based on grants. If you're someone who has a huge potential of bringing grants for an institution, you have a higher value, or you become someone very important and you become someone that the institutions are looking for.

CHRISTIAN: Explain what means bringing grants to the university.

NELSON: Grants means funding and finance. When you are a full-time professor, having research as part of your contract, one of your jobs is bringing money, bringing in funding. As much as you bring in more, I would say, the stronger you are in your position as a faculty. The US, and of course all over, the national funding that comes from the government, they bring more revenue for the institution. Because that’s what's called indirect costs, it's higher than when you have companies sponsoring you on their research, or bringing you money from sponsors, from private sponsors. That's where, if you are a successful faculty or if you're not a successful faculty, that's what really puts on the pipeline if you're going to be successful in your career, and if you're going to move up positions. If you'll be asking for more salary or more money when you move ahead in your career. In the US, the institutions in general, they hire people. If you're a foreigner and you would like to go to the US, one thing you should keep in mind is, "I want to go to the US as a faculty. What's the potential I have to bring in money?" So, when you go for your interview for the position, this is something that you should show, at least attract that you have funds from private institutions.

CHRISTIAN: It means that you need to be good lobbyist.

You need to be good connecting with people.

Otherwise, you're going to depend on a simple salary. If you were to really create a good financial career as a teacher, you need to understand that your simple salary will not be amazing.

You need to be able to create great connections with companies to be able to convince companies to invest in projects, invest money in the university.

NELSON: Exactly. If you're a foreigner and you don't have, for instance, a license to practice outside the university, in my case, I have a limited license. I practice inside the institution. If you don't bring in money and just want to rely only on your salary, you become very weak and the school can fire you at any time. Then if the school fires you as a foreigner, what you're going to do? Are you going to look for a job in another institution? Well, it's not going to be successful. If you don't have your practice outside, you become very weak on that environment.

CHRISTIAN: Interesting the negotiation between the teacher and university because you don't have the clinical work to sustain you, to maintain you. So you're in their hands.  Then you need to become even better with the companies, meaning that, as you are a clinician, before you enter this path, maybe it's a good idea to, as a clinician, create great relationships, great projects, great research, great articles, great publications that make you a good speaker for companies. So when you enter the university, you have those connections. I would say that probably today, if you reentered the American academic world, you would have a much better situation than when you started. I remember, for many years, the reason why you left is because you were in that situation that you just mentioned. You couldn't practice as a clinician. Your only money was the salary as a teacher. Since you started from scratch there, your connections were not that strong with companies. You came back to Brazil. And in the last five years here in Brazil, I don't know how many years you were back in Brazil.

NELSON: Five years.

CHRISTIAN: In the last five years,  I would say you were able to build your brand, your name, and create super strong relationships that, now probably, universities in the US would value much more. You agree?

NELSON: It's just one comment that you make, I was very successful, Christian, with companies and bringing money. But what happens is, as you aim to change your academic career position, and I did, if you're in the US, you come as an assistant professor and then you become associate after six, seven years. That’s where you change, really. And if you get it, it means that you have done something right. But then there is the last step of this which is what's called tenure, which is the end of the line. For having that, especially at NYU, the requests are very hard. One thing is, you need to be smart enough to take the decision based on what your feeling is. I was successful in bringing money from private companies. I'd tried several times to bring in money from the government. I was unsuccessful in bringing money from the government. Then, that puts you in a very delicate situation. Again, it puts you in a very weak position when you were moving forward for the top, which is tenure. I could have got it, or I could not. I’ll never know, because what I did was, I left before. I felt that I was missing something here, and there was something disconnected. It was better off if I, at this point, decided to move, because I still had the strength to move and build up things again in another place, which is my country. If I came back again, it would be in a different spot, as you have said. So, you change the side of the table. Become strong in other things.

CHRISTIAN: Probably to strengthen the ones that really want to build an academic career, we know that understanding how to build research, how to be a researcher, is a completely different thing than being a clinician. It's a completely different thing than even being a good speaker. Being a researcher requires a different level of skills and a different type of skills. And probably the one way to attract grants is to be a great researcher. In the end, companies want good people on their side developing researchers that somehow can help them promote the solutions that they're selling. How can somebody become a good researcher? When did you realize you liked research? I, for example, in dental school, I realized I didn't like research. I was never into research. I didn't learn the steps to do a proper research.

NELSON: That is one component, which was in my experience that we, in the dental school, especially the dental schools in Brazil, we don't get very strong in basic sciences. In PhDs for instance, in operative dentistry, PhD in periodontics… in some of these PhDs, you don't have the very strong basic knowledge. Most of that was in the US. I got the initial steps in Sao Paulo, but then when you move into institutions where you have the infrastructure, and you have the money, and you have the equipment, things change. Then it becomes a pleasure to do what you do. It becomes a pleasure to repeat something that's needed to be repeated. It becomes a pleasure because you have structure, the physical structure of the institution. You have finances. Then you can do a lot of things that one wouldn't ever imagine that you could do.

CHRISTIAN: How can you explain, for example, since Brazil is really, we know, weak on forming researchers or teaching us how to be a researcher, even how to read an article, even how to write an article. We see that, even with that bad background that we have here, why we have so many great researchers. Why do we have so many great authors in Brazil? Why in so many great universities in the US, do they have Brazilians in strong positions?

NELSON: The explanation is, if you see most of those people who have that position, or are doing very great on research, first of all, they are well-connected. Second of all, they have already got an opportunity to live abroad. We have 12% of the dentists in the planet from Brazil. We have a competition among us. When you have an opportunity to leave the country and take a position, you're going to do your best. Usually, that's what happens. I did. I'm not the brightest, you know, I'm not the smartest, but I'm very good at doing things. I do things. I have attitude. I'm a believer. That attitude differentiates you from others. We have really great Brazilian guys leading this.

CHRISTIAN: So no matter how good your preparation was, your background, your studies, at the end of the day, in real life, people that really make things happen, it's much more about the energy to do the excitement and the proactiveness than your previous studies, you know. When you want to really make things happen, you become different. Not only Brazil, but people from undeveloped countries, I see that happening all the time. As we enter a first world where people are comfortable usually, and they don't feel the pressure, and they don't have problems in their economic problems like we have here, and you see that they are not with the same energy, usually, usually, of course, this is an average. As you said, it's so hard for Brazilians to even think about winning, surviving, succeeding in US, that as we enter with any opportunity, we enter with the feeling that we need to kill it. And many Brazilians, they do kill it and they do very well. You see Latins in general, we see East Europeans with the same kind of gut feeling and behavior. And that's probably the reason.

NELSON: This is the point. It's more psychological. It's an attitude. You must have an attitude and just go, believe in your dream, and you go and do it. Then, of course, even with the limitations in our country we publish tons of papers. Funds from the government now are all shut down. And really it's due to publishing. That's a combination of attitude, believing, and also your connections to other people that you have created through your career. That's why we are successful in doing that. But it's more an attitude than being the smartest. In fact, nobody wanted Einstein in their group, because this guy could be a disturbance. That could really kill the team. So as a team player, you have a leader, then you have everybody looking forward and making it. This is attitude. It's believing that you can do better every day.

CHRISTIAN: Let's summarize this part, let me know if you agree with me with these conclusions of the information you shared. Young dentists wanting to enter US, do you agree that still today, in terms of academics, the US is the best place to be?

NELSON: You know, some of European institutions are doing really good. But it's not all of them. I'm not going to name, because I have gone to some. But if you look at a lot of faculties from those European institutions, they come to the United States for a certain period of time. Still the place to be. They have a mentality of changing. They have a mentality of predicting change. They have a mentality of, let's try an experiment. And supporting ideas. And then you build that step-by-step with a very strong regulatory process. That's why we all go to the United States.

CHRISTIAN: Things are happening, that's another conclusion, things are still happening in the US. The best institutions in the US, the best opportunities in US, if you want to pursue an academic research career. How to plan the way to get there for people from undeveloped countries or growing countries like us. I think the first step you mentioned, is to create a very good relationship with great mentors at your local institution, find people that understands the international environment.

Start to feed this possibility, let them help you find a connection in the US. Then you need to impress the local US guys and you need to show this proactiveness. You need to show that, no matter what, you're going to do whatever they ask you. You're full of energy. You're humble. You're smart. I think that's a beautiful combination when you throw, you're smart and humble. You're full of energy. That's the way doors will start opening. And then, try to understand that there's a lot of politics. And you need to enjoy that. If you don't enjoy politics, I wouldn't go into academic career. Knowing the right people. It's a big game. You need to enjoy the game. You need to enjoy the game of being in politics, being in an institution and university. And you need to understand that at the end of the day, financially speaking for a teacher, it's all about connecting to the companies.

NELSON: 0.5% of dental students want to pursue an academic career. This is very little. That was done in the West. That explains why we have a lot of foreigners taking spots at American institutions. You need to have a lot of passion. There is a disconnect, because we are just seeing that the United States is still the place to go, but now the majority of the faculty, at one point, will not come from the United States. They'll come from overseas. It's intriguing. This needs to be changed somehow. I don't know the formula, but it needs to be rethought. That's my take. In fact, everything that we are seeing here is what I think, it's my perception, and my experience.

CHRISTIAN: What is your anticipated indebtedness as a US student when you finish school?

NELSON: You have $35000, with 20%. 20% of the students will have more than $350,000 US dollars to pay in debt.

CHRISTIAN: Almost 70% of the students will leave school with more than $200,000 in debt. That's the reason why they usually don't want to own their own office. They want to work for somebody else.  Since this research was developed by DSO, by group practices, by chains, this is probably the number that they wanted to see.

The final question here, we already know that education in Brazil, dental schools don't support that much research and this academic preparation. But as a clinician, do you see a lot of difference between what a student learns in Brazil and what a student learns in the US? What is the difference in quality?

NELSON: We are well prepared, Christian. I have experience in the institution that I teach, which, all the faculties are PhDs. University of Sao Paulo, all the faculties are PhDs, which means, you have a good teaching group, you get good teaching. So, the difference becomes in getting some material funding for what you're going to be using, and how, for instance, especially nowadays, one can implement technology to the teaching or to the school. It's investments.

CHRISTIAN: But don't you think that's definitely a differentiation? Institutions in the US, they have a lot of money and they have the support, access to these technologies in digital dentistry but I go to universities in the US and they're completely under-utilizing the technology. They have everything there, but they don't use it, or they don't integrate the digital technology into a decent workflow. There's no real digital dentistry teaching. Why does that happen, they have all the opportunity to change and to really bring these new things to students. The richest, best dental schools in the US are right, almost like zero, in terms of really bringing this to students.

NELSON: One point of that, I believe, is the academic curriculum. That needs to be changed. You cannot implement things if there is no academic curriculum bringing up the debt in order to take place. Also, we have a component, which is the combination of the basic principles that cannot be forgotten. The basic principles, basic biology, basic occlusions and so on. And connecting that to this new era, is where things can be done in a digital environment. To make this happen, you need someone making that transition. The transition includes having faculties in it. A lot of the clinical faculties coming from some of those institutions, I would say most of them, are clinical. Some of them just retired from practice and then they take a simple position as a clinician. Most of these people who are already in the institution, they were not exposed to the technology. And so, why should they make an effort at this point? I think it's a balance of academic curriculum, development, and the faculty embracing it. Also the school getting the faculty or making the transition smooth enough that everybody can be in that spot. So, I don't see the excuse of forgetting the basic concepts. You're not forgetting it. I think you're just incorporating it to the new time we face now. That is where, I think, we are missing the point. That is something that needs to be worked on. I know some schools are trying to do it. Some schools are implementing protocols. And on some others are trying to implement protocols and see if this can be effective. Just having technology, but missing the basics, doesn't work. They need to implement and bring this to the new time we are facing. I think that's why you have all this equipment sometimes left behind. Because as you know, it's a bumpy road when we start working with technology.

CHRISTIAN: Which leads us on to technology in the industry. First question I want to ask you, new trends. When people ask me, is digital dentistry the new trend in dentistry? Usually my answer is no. Digital dentistry is not a new trend. It's already  a reality. It was yesterday. So for you, what are the new trends that you see coming into dentistry?

NELSON: Well, Christian, it's difficult to talk about new trends if we are not fully in the existing technology now. As with all of the schools in the West, which for us, is the leading place, with machines and things that are left behind. The new trend for me, Christian, is artificial intelligence that is coming, which maybe this is not new anymore, but we are implementing it.

CHRISTIAN: Artificial intelligence today, what is the stage of artificial intelligence in dentistry today? What are the companies working on for tomorrow?

NELSON: Artificial intelligence means you're going to collect a bunch of data from a computer, which means if you take photographs or you collect all the photographs that you have from the same person or different people and combine that into data, and create a way where this data will think like we humans would think. A very simple example is you brilliantly developed this digital smile design concept. If we start collecting all the designs done for people with some proportions in face and so on, and imagine that you have 500,000 scans of faces of people combined to that smile that's to develop A B or C. What'll happen to this is, you're going to come up with the data that will tell you the best possible match for a specific case. This is what artificial intelligence is.

Very simple for the dental field. If you scan patients and have all these scans, I'm talking about intraoral not CBCTs. If we start collecting those scans, because you have a stream that you can collect the data. On the diagnostic, which is now already a reality, and I see companies doing it. And then you come with your comments.

So, you have other people who are developing companies in that sense of developing data that will provide diagnostics for a specific treatment. Implant positioning, this is already happening, but not implemented yet. It's happening, but we need some proof that this is really efficient. I think that's the trend for the dental field now, getting all this data, because we are now collecting data all over, right, Christian? We are getting data. And that's what's going to happen to our profession. You're going to be more efficient and everybody will be able to be sure, at least at a certain high-end percent, maybe 90% or 95%, of what he or she is doing is correct.

CHRISTIAN: It's very simple to understand, to see the power of artificial intelligence and how realistic this is. A couple of examples, one very good example is Invisalign. You have now a computer that is moving teeth. One thing, technology today, you have a software that allows you to move people's teeth. You buy the software and you can move the teeth and you can develop appliances. That's an orthodontic software. But who is making the decision? It's you. It's a human using technology to move teeth. So this first step of technology is helping is, because it's much easier to move teeth on the computer than to move teeth on a model and set up all the models with all the movements. So, the software is helping us, because it's allowing us to move teeth better, more precise, easier.

The next step is artificial intelligence, meaning that, suddenly that software that is helping you move teeth of ten patients per month, 100 patients per year, let's say, is the same software used by a thousand different doctors doing a hundred movements per month, per year. That means already 10,000 or 100,000, maybe a million movements that are happening in the same software. Because the software is cloud-based and the company owns that information, so the company that developed the software suddenly has an example of a million cases moving teeth. Not only that, the company knows the results, because, as you make a decision as a human of going from A to Z this way and not that way, you have consequences. Sometimes you make a good decision. Sometimes you make a bad decision. Now the computer is learning the consequences of your decision. As you scan your patient, after your decision, the computer now knows your starting point, the computer knows your strategy. And the computer knows your ending point. And the computer learns. And with a million cases, the computer learns that to go from A to Z is better to go that way, not this way, according to one million cases with 96.5% result, right. So now, what the company needs to do is to take that information and bring that information back to the software and tell the software to think for us. If you helpful a situation A, you need to go this way to get to Z. If you have situation B, you have to go that way, and in 97% of the cases, you're going to go to X Y whatever.

Now, it's very easy to understand that a company like Invisalign is definitely working on artificial intelligence to help decisions, because, again, in Invisalign example, it's very interesting to realize that one new role, Invisalign created a new profession in dentistry. The ClinCheck® professional, the expert on ClinCheck®, if you're a good orthodontist, it's not enough. You need to understand ClinCheck®, you need to understand the biomechanics of aligners to make the right decisions when moving teeth on the computer. Otherwise, the aligner will not move the teeth where you want. So as you know, people are outsourcing that. Companies are being created to make decisions for you as a ClinCheck® expert for you.

Artificial intelligence, for me, it's exactly to eliminate this need. Because the computer will be the best to make many of the decisions that we are making nowadays. Of course, it's a process, right. Some decisions are much more complex, intuitive, sensitive, more related to clinical experience, gut feeling, intuition. Relationship with the patient. Clinical exams. There's many things that are very hard to bring to artificial intelligence, but other things, like you mentioned Dr Kyle Stanley. It's an X ray. It's very smart. For me, if I could think of something that needs artificial intelligence yesterday, it's analyzing an X ray. It's black and white, full of color, it's very easy to identify certain issues. You throw this on the computer and the computer is analyzing a thousand, a million of these X rays and giving you the result.

NELSON: Watson has been doing that for quite a bit, even for dental. But it depends on how the precision, because this is a calculation. When you mine all this data and you have this combined, it's a calculation that needs to go behind it. Some companies are doing better than others. What they are fighting is about what they call artificial intelligence architecture, which is the engineering side of the whole process, all of these calculations and how it's done. Companies, Fiat, is doing it for their own things. Another example is, we have this place out in Brazil which is the place that goes all the way down to pull up oil from very deep down in the sea. So they have now, artificial intelligence telling them when they should change the pipes, because of the waves and so on. They have sensors collecting all this, mining all this, making that calculation. 95%, they need to change it because of risk. It's the same for us. Invisalign aligners are the good example.

This brings us to what you asked me about, changing professions in our field. Because we are now talking about, we as a dentist, what's the options I have for the future? Opening practice is one option, but as a job. So, designers now are the job of the moment. It may not be in a few years from now, because everything will be so automated. So, we have that initial step for designers. And this guy will be, maybe, as you said, the ClinCheck® person. They will change for something, because you have a computer that gives everything automated for you now. Tooth design is always there, with just one click, you have the tooth already with occlusion, all building with artificial intelligence architecture behind it.

CHRISTIAN: Many new professions in dentistry, people are worried about technology. People are worried about two things, technology taking over, and DSOs taking over. Now, we shouldn't be worried about that. First, because there's no way back. It's still going to happen if you're worried. It's still going to happen if you're not worried. So don't worry. That's not an option. Now, with technology and DSOs, new professions will be created in dentistry. For example, I see DSOs, great companies being formed in the next five to ten years. Beautiful companies to work for desperately trying to find dental managers, managers with dental experience. Trying to find treatment planners. Dentists that knows how to treatment plan and they will be coordinating treatment plan decisions. That's all they're going to do. Computer designers, as you've said, even though artificial intelligence will slowly make decisions, there's a huge opportunity for people that understand dentistry and enter the world of 3D design, 3D solutions. Even the companies that will be the hottest companies in dentistry will be the companies developing artificial intelligence solutions. All the money in the world and the smartest IT guys will not make it. They need to understand dentistry to start with, to create the algorithms, to create the solutions, they need people with a lot of experience on the decision-making process in dentistry, to start feeding the computer at the beginning with this information, to create the artificial intelligence.

So, huge opportunities all over. What I tell students today is that as you enter a dental school nowadays, don't think about being a clinician, perio, ortho, and/or implants, or endodontic only, or being a teacher at the university. Think about the new world of technology and the new world of DSOs. All the spots that these companies will have to fill in to succeed. They will go to dental schools to find these people, these young spry people that are thinking this way. So, it's a beautiful moment.

NELSON: And the DSOs in Brazil are still slow, as you know. It's gaining momentum slowly, because we have a different system and a different environment. It's not there yet, but it will come, as you know. We follow pretty much what people are doing. Definitely, they will need people to manage that. Not managing out. So, implement this new DSO concept for being successful at the end. I agree with you 100%.

CHRISTIAN: So, you mentioned the magic word, implementation. You go to a lecture. You see that beautiful lecture, Nelson Silva talking about digital dentistry. Amazing solutions. You finish the lecture. You finish the conference. Monday morning, you're back into your office and you're in trouble. You're in trouble because implementation. Next question for you. Comparing conventional to digital, financially speaking as a business model, thinking about a clinic owner, a dental office owner generating efficiency, I usually say, what we want is to work less and make more money. That's the magic. Can the digital world really help you to work less and make more money? Question number one. Question number two. How do you organize your investments, how do you understand ROI? Which is return on investment, a word that, ten years ago, I didn't even know the meaning, and I realized that many dentists didn't know it at that time as well. So, how do you create a financial strategy to translate your dental office into digital?

NELSON: It's a good question. One thing that's important, Christian this is what I believe, you need everybody. Regardless the type of clinic or business you have.

CHRISTIAN: But let's go back to the first question. First question is, can digital really help us? Because we believe in digital and we know that DSOs are investing in digital. The future is to run offices through digital technology, from management to finance, to clinical, to production, to marketing, everything will be digitalized. But today, what are your thoughts about how much more efficiency and differentiation you can achieve with digital, when comparing to conventional?

NELSON: I think the breakthrough on that is the intraoral capture scanning. This is really a big change. When it's possible for you to capture whatever you want to do and you want to make a production, whatever production that will be, it can capture intraorally. You have a significant change on the efficiency of the process. I would divide it in two models. One is, capturing information and sending over. The other one is capturing information and producing in-house. Two different investments. And two different models. Those are strictly related to the business profile. If you are alone in your practice, or if you're two guys or if you are a big DSO, of course, all of these change. We cannot, at this point, keep the conventional. We cannot. It's very simple that we still need finishing. The remaining manual process is still, most of the devices that we produce digitally, they need some kind of hand finishing. But it's down to that final little step. In most of the devices, right. Some devices require intermediate hand-made procedures. And some not. So, that is analogue. Not only this, if this is an account of time, it depends on how business is developed, it's how many hours it takes for me to get that production finished. If you have a ceramic restoration that needs to be baked, or a glaze for any reason, we're talking about 20 minutes. Furnace plus something. Which means, as much time you gain in the beginning, you have a bottleneck at the end, either polishing, baking, and so on. The other point of this is, what we are producing, for example, stone. Now, if you take an impression for a stone, it's cheaper than printing. Not only is it cheaper, it's more consistent.

Because the printing a strategy is a learning curve. If I buy a printer and you buy the same printer, I bet we're going to produce two different models using even the same resin, using the same setup recommended by the company, which means, an analogical environment is there.

There is no disputing one against another. It is that one compliments another at this point. I believe that we're going to go to a certain level, that the analogical will get reduced. But we still have some types at the end, until things are finished.

So now, how you create your business model on that, that's a challenge. Because it depends on, for instance, in my case, I have everything here in my office. But if I write down step-by-step how much money I make out of it, I would never would have the production in my office, because it's just myself and a colleague, my wife and that's it. However, for me to teach and to learn all of this process, I needed to go into it in the field, because things break, the bulb doesn't work, machines stop, maintenance and so on. We can talk about that for hours and hours. I have spreadsheets all over about it.

And then, at the end, you feel, why should I invest all that amount of money if everything that I do is still needs a lot of analogical components here? Of course, this varies between the different business models. It's just a general thinking process. So, for me, if anyone would like to start, it's getting a data capturer, regardless the size of the office, then you decide which route you go. That's the best business model for beginners. And not buying everything, because there is no magic. As you said, we still need to see it and design things, because artificial intelligence is not there to give you, in just a click. We need to wait a little bit for that to happen. How you do it, do it smart. Do it step-by-step. But my understanding is, everybody should have a way to capture data in their practice, because this will mean something at some point. An Intraoral scanner or big scanner.

CHRISTIAN: You believe that investing on a scanner is definitely something that, financially, is a good move?

NELSON: It's a good move to start with. Then you go for the other processes.

CHRISTIAN: You started talking about digital breaking down into two different models. When we talk about digital workflow, you can talk about acquisition of information and outsourcing everything, and enjoying the results. Or, bringing manufacturing into your business, right? We can actually break down, even in more pieces, the digital workflow is made out of three moments, acquisition, manipulation of the information, and manufacturing. And initially, when dentists talk about digital, they see everything together and they want to do everything. We know that acquisition, here in Brazil, it's still outsourced. So, we send the patient out, usually to an imaging center. And the imaging center will scan and do the CBCT and the digital part of it.  So, I usually say that the first step into the digital world is to bring in-house acquisition. An intraoral scanner, and the digital camera, and nowadays even a facial scanner app. That, in probably six months to one year, will become something extremely realistic to work with. And extremely cheap. So, acquisition is the first step. And the beauty of investing on acquisition equipment, scanners, and digital facial scanners, is that the learning curve is short.

The problem with digital is not only the investment, but the learning curve as well.

The other point is that we cannot analyze digital only with time and money. When you have this over-simplification of the analysis, I believe you end up having unrealistic analysis of the comparison between analog and digital. You're comparing analog and digital because of the time you're spending, and because of the money you're investing to have that to happen. But you're forgetting one very important factor, that is probably the most important, it's consistency on the results. It's standardizing the quality. It's replicating the result. Because when you can replicate a result, and the only way to do it is through digital, you can press buttons and get similar quality on key procedures that, when it's hand-made, it creates a lot of stress. It creates unpredictable outcomes. This is probably one of the reasons why dentistry is so stressful, because it depends in your hands, and it's unpredictable. So technology, for me, before we talk about time and investment, technology brings a workflow that will slowly bring predictability into your life. This will reduce stress. The quality is this, it's not more, it's not less, this is the quality to your patient. This is what I'm gonna give you. If you're happy with this, I'm fine to treat you. If you're not happy, you can find another doctor. But this is the quality I will deliver. I can guarantee to you, because I use a digital workflow. So the chances are, I'm going to end up with this result. I believe this is a factor that people need to explore more. That's when the digital believers will start benefiting.

NELSON: There is one component, Christian, that goes for it. That's why I believe on data being acquired in the office, regardless of the office. If it's DSO, regardless, that's why. One thing is, the investment that we did in the past is not the same investment that we do now. This is one thing that people need to understand. Before, we just bought a light cure unit, some other things. Now, you need to buy a data acquisition process, which would be the intraoral scanning. Because it also can scan models with intraoral scan. When you can have predictability of things, when you make a complete denture that you scanned, and you have the file of the denture was printed or milled, whatever, which is not conventional, if that denture breaks, you just make another one when the patient comes back. So, you give not only a quality control, but you can give a warranty.

CHRISTIAN: Yes. But look at this, what you're saying. Look how powerful this is, because then, smart dentists that are really investing into digital, they will start to create services that you cannot provide without digital. This is related to marketing. If you can do a denture and you can tell your patient that if he's on vacation in Paris and his denture breaks, you can press a button and ship an identical denture in three days. You have a network of people that you never lose a connection, that you can reach through your digital company that can print or mill whatever you need there and deliver it at the hotel.

NELSON: Which means, you have your patients secured, what you're providing and offering, you can guarantee that you can rescue him in a hard time. The other point is, never in our career as a dentist, could we monitor our patients properly. If my patient comes today, I did the treatment, I scanned the patient, it will come very soon, my friend, that you can just immediately get one scan, which is happening, and monitoring a gradient timeline of that patient, that is something that we never had that easily done before. How many times you have a patient come from orthodontist that you don't know if the occlusion is good? Then, in the old times, what'd we do? We’d nod and articulate, and everything's messed up because you have braces and so on. Now you can scan and check it. Not only you can scan, very soon, you're going to scan and the scan will be getting thinking movements. While it is scanning, you have displacement of the jaw. Never, could we monitor our patients, giving them a warranty, quality control.

CHRISTIAN: A dentist that is investing in digital and exposed to this technology, he can tell stories to his patients that are real, that can directly benefit his patients right now, today. Not tomorrow. We could be talking about, we just mentioned sending a denture at the hotel in 24 hours. Monitoring the bite and the occlusion of an orthodontic patient remotely and schedule an appointment with artificial intelligence, and detecting the problem, recording the jaw, creating a time lapse, a time frame, of the 3D information and forecasting what is gonna happen. What is the value? How can you put a price on that? To be able to tell your patient that you can forecast things, that you can diagnose faster, that you can interact and you can intervene before things happened, because you use digital to understand the probably. I usually say, when people talk about digital, they usually talk about digital dentistry, how to use technology, with CAD Cam, or guided, implement, how to fabricate a restoration. To see things better, to make better decisions, to treatment plan better, to diagnose better, through technology. If you don't want to do CAD CAM, if you don't want to do guided surgery, I tell, don't do it. But don't miss the opportunity to deliver a better service to your patient by diagnosing better, seeing the probably beforehand better, through technology.

NELSON: That's the key. We have techniques, Christian, that everybody has created by grafting. How people follow that up, if you scan today, scan tomorrow, scan in one year. A lot of the techniques we use now may be different because now you have something that give you a number. Change the dynamic.

CHRISTIAN: We see a patient with a soft tissue defect, old school, you do that beautiful graft, you take photographs. We know that we can angle the photography to change the perception of how much tissue you grow. And then you put on a lecture and say, look how good I am. I did this graft and I fixed the problem. Now, with technology, there's no more bullshit, because you scan your patient with the defect. You do the grafting. You scan your patient, and then you scan your patient every month or every six months or every year. And in five years, you're gonna know exactly how much you gain, volumetrically. And this is going to improve techniques, because then, we're gonna start realizing what techniques really work. Every single specialty will evolve in a much different speed because of what I call digital dental quality control. Overlapping images. Overlapping 3D files. And understanding exactly the impact of your decision and the impact of your procedure. This will put pressure on companies to develop better materials, on researchers to develop better solutions, on clinicians to develop better procedures. Because patients will require that. They will say, I wanna see my 3D initial file. I wanna see what you promise. I want to see the 3D consequence of what you did. I want to match everything and I want you to tell me the comparison here.

NELSON: Health insurance are looking for that to reduce the cost of paying for services that were not done properly. If you cannot do a procedure, you just monitor the procedure, any healthy student would smile for the rest of their life. You as a dentist, because you're being paid with a very minimum cost from that consultation that was given, because what you're doing, you're monitoring the patient. If something is controversial, you can give your take on what I'm going to say, forever, dentistry is not a discussion any more. Because as you said, I do forecast in a percentage when something that I do will fail. When I forecast something that I do will fail, I will prepare my patient at that time, I will redo your work, but with a certain cost, because I have all your files. I will just replace what I have done, and I will put a new part on you.

CHRISTIAN: I always mentioned copy/paste dentistry. Keeping the predictability between steps by copy and paste files, changing what you want to change, keeping what you want to keep. And making the procedures more reliable, more predictable. Of course, you know, the basics of dentistry will be still the key factor to deliver good dentistry. That's not a matter, it's not a question. We're not here, not even arguing about that. Understanding dentistry is the key. It's the way to use technology to facilitate the process. And I don't know if you agree with me, we are on a transition moment, where these procedures and technologies are being developed. But I believe that, and I hope, and that's the reason why I put all my energy on this, is that technology will help more dentists to treat more people with better quality. Because today, good quality dentistry is a luxury. Good quality dentistry belongs to super good dentists. The only way to deliver good dentistry is to be super good dentist. And to work with an even better technician. These professionals are super expensive. That's the reason why the only way you can have a good treatment today in the whole world, is to pay a lot of money for it. There's no other option. Right?

You don't have money, I'm sorry. Either you have a relative that is a good dentist, or you're probably going to suffer. That's the reason why we have research proving that areas in the world that are so poor, that don't have dental care at all, people have better oral conditions than areas of the world with dentists. And that's actually sad for our profession. I believe that we need to push technology to make quality a little bit more democratic, right? We need to believe in that, otherwise, nothing makes sense.

NELSON: I agree with you 100%. Here's the point, technology is for everybody, all of us dentists. I would say just as technology is for all of us dentists and not for a few. Technology is for every patient, not for some. That would be, you know, a statement that would fit, because I agree with you, things can be done in a good quality for everybody. It's interesting, you said about the good oral health condition of some poor places, because if you see, we have talked about using fluoride to keep the teeth. But in fact, complete dentures, implants, business, is growing. Which means everything that we have learned in the past about keeping fluorides because when you have all these massive dentists treating people, we're producing tons of complete dentures, hybrids, and so on. Which should be the opposite. Don't you agree? It's one question that I ask one of the guys that talk about fluoride and so on, because when I show that the numbers on the growth of prosthetic component, the growth of the implant business, every year, it's more and more implants being sold. More implant companies coming by. It could be the opposite.

So then, we need to find the technology will bring us that perception. And just before you go for any other comments, it's about, we're not here saying that the best concept needs to be forgotten, that's not our job here. We're saying that the best concepts need to be dealt differently with the tools we have nowadays. It's a misconception of forgetting things and changing how things are handled with the tools that we have now.

CHRISTIAN: I want to make two final remarks, and I want your opinion on this so we can conclude this great, great conversation, I think we shared a lot of useful information. The first remark is this, we all, even people that don't like digital or don't see the need for digital right now, or that are not using digital right now, they all agree that at one point in time, digital will take over. Right? Five years, ten years, at one point, digital will take over. If digital will take over, I usually suggest if we all conclude here that digital will take over, and today, digital is already helping us in so many ways, why not jump in right now while things are still in development? Be part of this journey, because then, when digital becomes the obvious way, you're going to be ahead of the others. That's remark number one.

Its first mover advantage, becoming an authority, going through the learning curve, and as soon as, one by one, digital solutions because by far the best way to go. You will take the advantage much more than the others that are waiting for digital to become perfect here and there.

The other remark, usually when I lecture in conferences, you have speakers before and after, and usually, after I speak comes another speaker. And usually this speaker after me is not going to speak about digital. He's going to speak about whatever. One thing that I noticed is that usually the guy speaking after me becomes very defensive. I give a full lecture about what we've been doing with all this technology and usually this new speaker after me comes up on stage, and usually either starts with a joke, or they try to minimize the lack of technology in their lectures as if they needed to give an excuse for not using digital, and they don't.

But, what I want to say is that usually, it happened a couple times with me, that the speaker speaking after me, with no digital in his lecture, he ends up with the message trying to give the feeling that non-digital is the humble way of doing dentistry, you know. This is daily. This is normal. This is easy. This is what I do everyday, this is what I've been doing for 20, 30 years. And I have to be honest, that pisses me off. Because, these speakers are coming and showing amazing hand work, beautiful direct composite, amazing ceramics, magical surgeries, you know, really delicate procedures.

After 20 years of training, and having a natural gift with artistic hands, and then they show that hand work and they finish saying, this is my humble daily work.

What Christian just showed is super cool, super fancy, super sophisticated, but that is not for everybody. This is for everybody. I'm looking at that and saying, this is not true. He's not telling the truth. He's not saying that he's an artist, that he's an amazing unique professional, that worked really hard for 20 years, that took 2000 pictures of that case and did a thousand times that restoration until he got to that quality.

He's in front of everybody saying that that is the normal. That this is the easy, and my digital workflow, that after six months of learning curve, anybody in the world can do it, gifted or not, artistic or not, amazing professional or not. When you have a digital workflow working for you, anybody can do it with very similar quality. And that, for me, is why we need to create a partnership. People need to start thinking that hand-made is the easy, available for everybody, and that technology is exclusive, expensive, sophisticated, and difficult. When I strongly believe that today is not at all. What do you think about that?

NELSON: I'm with you 100%, Christian. I cannot agree more. I just came from the Czech Republic, where they're trying to change that mentality of people understanding, and this was exactly the same. We talk the same. It's a belief that things that can be for a lot of people, give us much more pleasure than things that only few can do. So, the population on the planet is poor and gets poorer. So, it's a misconception that technology is there for few. Technology is there to save those guys, to get them something that is distant and good, to, as you said, replicate it in any part of the planet, rich or poor, and the cost of that is actually not that expensive. If the government really does the math, and sees how much this can be really used, they will feel this makes sense. I will witness, be able to provide good service to the population, regardless of where. Because you can quality control what you're doing. And the government will be able to track down what was before and what was done. The same concept on health insurance. As you mentioned, people must go for it understanding that three steps, as you said, is real, design, and some manipulation, and production. But you don't need to produce anything. You can also use it for other things. You're absolutely right with your remarks, and I think people need to get into it somehow, very fast. That's my recommendation. Institutions, they must stop doing it internally.

CHRISTIAN: I mentioned recently that in the near future, there will be no space for amateur dental offices management. The main reason is because when you see a professional manager, when you see a business guy, and you talk about these trends, they embrace it immediately.

Even if it's not perfect now, if it's not ready here and there, they know that every solution that is developed in a digital process can be replicated. In absolution. That is beautiful, but depends on human hands, and sophisticated training in exclusive skills, you cannot replicate. They will invest in digital. They will find the solutions, companies and corporations, DSOs, that's the main reason why I say that in five to ten years, 90% of the clinics will belong to corporations.

NELSON: I agree. I'll just give you mine, blocks of ceramics recreated for that, right. Why should I have all these ceramics being hand-made if I can create a block? Which is industrially produced, and I have quality control off that block, and then a machine will melt. It's not going to break. Whether it's going to fit or not is another story, based on the way that the professionals are handling it. And this is getting better and better with the technology, of course. But, it's a way that the industry really changed the concept of creating already quality controlled products that a machine will be doing instead of a hand-made guy. I am 100% agree with you, we need to think more on the majority of the people, not on the very tiny tip of the pyramid. We need to think in a broad way, in a broader way, and to embrace more people. That's, I believe it's your job, and you do it beautifully, and that's, I believe it's my job, and I, as you said, I'm a true believer. We are here to help, we're human, so as much as you can help, of course, we all would like to have a better life, some financial benefits, we all need that, to pay your bills, to have kids in the school. But if you can help people and you can get it, helping people, that is the main, most fantastic that we all can give to people, Christian. That would be my closing remarks. Thanking people.

I hope you enjoyed this interview with Dr Nelson Silva and were inspired by his journey and the choice he has made. We also hope you enjoyed the discussion about where we see this industry of ours heading.

If you would like to know more about Digital Smile Design, the DSD Planning Center and the courses we offer, including our four day residency to take the first step to becoming a DSD Master, find out more here: