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‘How to reverse medical tourism through local invisalign adoption’  

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Bunmi Tokede is the promoter of The SmileHub in Nigeria and an associate professor of informatics and orthodontics at the University of Texas Health Science Centre at Houston, TX, where he also practices as an attending (consultant) orthodontist. He trained at Harvard University, where he also taught for years as an assistant professor. He acquired his Master’s, PhD degree and orthodontics residency education from the Harvard School of Public Health, Harvard Medical School and the Harvard School of Dental Medicine/Boston Children’s Hospital, respectively. In this interview with FEMI ADEKOYA, he talks about setting up a practice that proposes Invisalign as an alternative option to metal braces in the country.
 
Can you give an insight into the specialised solution you are offering to Nigerians and why now?
Yes, we are planning to improve smiles and transform lives by using aligners. Aligners are one of the most consequential innovations in dentistry in the last decade. Aligners are a tool used in the orthodontic care of patients. Orthodontics is that branch of dentistry that deals with the diagnosis, prevention, and correction of mal-positioned (crooked) teeth and jaws, and misaligned bite patterns. In younger patients, it also focuses on modifying facial growth, known as dento-facial orthopedics. Abnormal alignment of the teeth and jaws is common in all races/nationalities and Nigeria is no exception. Orthodontists use many tools in the treatment of patients, ranging from fixed appliances (braces) to removable ones (clear aligners).

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Almost all orthodontic treatment in Nigeria is currently performed using braces (fixed to the teeth). Removable appliances (clear aligners) represent an almost non-existent market, driven by few educated and well-informed patients who are aware of the availability and advantages of clear aligners but lack easy access to it through certified service providers (we are not aware of any certified aligner provider in Nigeria). As a result, the aligner market remains informal and grey. Many in Africa often travel abroad to undergo aligner care.
  
To be clear, I know of one or two clinics in Lagos who say they are able to provide this service, but many Nigerians do not even know about aligners, not to talk of knowing that they can benefit from aligner therapy.

What informed the choice of this solution/business?
I am an orthodontist, so naturally, I was interested in sharing my expertise with Nigerians. I underwent my specialty orthodontics residency training at Harvard University. During this training, we were formally educated with various tools and techniques, including the science behind aligner care and how to use it efficiently in the provision of orthodontic care. The more I learned about aligner care, the more I thought Nigerians would absolutely benefit from this incredible innovation. There is no tool in dentistry that leverages the power of data and artificial intelligence (AI) in the provision of care to the extent the aligners do. At the moment, I am also an associate professor of orthodontics and informatics in the US. You can begin to see how aligners are the perfect melting pot for my interests and qualifications.

Many people are familiar with the use of metal braces. You are proposing Invisalign as an alternative option. What makes the option different and a value proposition for adoption?
A major benefit of Invisalign is that the aligners are virtually invisible. It reduces social awkwardness. Patients also love that colleagues and clients can’t see they are undergoing orthodontic treatment. Many who are interested in orthodontic care are usually discouraged by the fact that they have to get braces. For this section of the population, aligners are a game changer.
  
Also, fewer consultations are required. Regular braces require monthly visits to the dental clinic. With Invisalign, much of the orthodontist’s work happens before you receive your aligners. A 3D scan of your teeth is used for making all the customized aligners in a laboratory. There is no need to visit the orthodontist for adjustments, so visits are kept to a minimum to check on progress. Few visits to the orthodontist mean less time off work for parents, and off school for kids.

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With braces, there are restrictions on the types of food you/your kids can eat. With Invisalign, you can continue your diet as usual. You remove the aligners, eat, brush/rinse, and re-insert the aligners. Braces are not removable.
   
As with eating and drinking, you can also remove your Invisalign to brush your teeth. With braces, patients usually have cavities and unsightly decalcifications (white spots on teeth) at the end of treatment. This is due to the inability to brush properly over the duration of treatment.
 
It is also comfortable to wear. You may be wondering “which is more painful?” Moving teeth around with Invisalign can be uncomfortable, however, much less than traditional braces. Additionally, there are significantly fewer mouth and gum problems with Invisalign. Invisalign aligners are made of a special material and fitted to each patient’s mouth, so – unlike braces – there are typically no cuts on the inside cheeks or warm salt washes to deal with.
 
There are many aligners in the market, outside of Nigeria. But we have chosen Invisalign because it is the market leader – a tested, trusted and efficacious product that makes us confident in the types of results we can deliver.
 
How affordable is this option, considering that many don’t even take dental health seriously?
There are multiple things to get at with this question. Stepping back, a huge issue generally in dentistry in Nigeria has more to do with education/information, than with affordability. The issue of the importance of dental health has been dealt with ad nauseum, so I wouldn’t belabor the point. Other than to say we need to continue to proactively engage the Nigerian population on helping them understand the critical importance of paying attention to their oral health. As with general health, prevention is better than cure. Delay charges interest. Not having regular cleanings lead to needing an expensive filling tomorrow. Not getting the filling in time leads to needing a more expensive root canal treatment in the future. And not getting the root canal treatment in time can lead to loss of the teeth. Many Nigerians have an experiential relationship with this narrative.
   
To hone in on orthodontics, you are correct in noting affordability as a potential concern. I’m just not sure that is the right question. You are your own best investment. Look around you, Nigerians pay for what they believe is of value to them. Orthodontic treatment usually takes place over a period of months to years. As a result, patients are able to spread the cost over a long period of time. This makes it an affordable service for a huge swathe of the population, if they’re made to understand that it is an investment in themselves.
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Competition across many sectors is increasing. How do you hope to tackle this, considering the share of market, alternatives and disposable incomes?
The psychologist, Maslow, in his popular paper, talked about hierarchy of needs. Broadly speaking, at the base of this hierarchy, we have the basic needs and then we gradually go all the way up to esteem, and self-actualization needs. Inasmuch as Nigeria continues to struggle with many of the basic needs, a significant section of the population has proceeded on to esteem and fulfillment needs. Nigerians are expecting more of themselves and demanding more from their government, and service providers.
 
If you consider the proportion of middle to upper class Nigerians, and the prevalence of moderate to severe malocclusion in the population, the initial market for Invisalign in Nigeria could easily be as high as over a million patients. If and when Nigerians become aware of this product/service and its potentially transformative power, they would embrace it. Part of our job at The SmileHub is to help them become aware.

Dental healthcare is often considered as secondary and not given immediate attention as other cases. How can this be addressed considering its impact on the physical and psychological well-being of many people?
This has a lot to do with advocacy. You are absolutely on point to talk about some connection between oral and psychological well-being, especially with children. Many undergo bullying and experience a lack of self-esteem that usually lingers through adulthood. We do talk about oral health a lot but these discussions are usually fitful, and are not followed up with some sort of actionable plan. Even many of my highly educated physician friends are usually surprised by how much they do not know about dentistry. At every level of schooling, we need to integrate an appropriate level of education about oral health.  
  
Our legislation/spending should also reflect our values. If we care about oral health, we need to spend on improving outreach, education and access to oral health care. The existing structure for training dental professionals also needs to be strengthened.
Those are some of the conventional ways to approach the intractable issue of poor attention to oral health.

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More creative solutions involve enlisting the help of young, educated opinion-leaders. Understanding where Nigerians get their information is critical to being able to effectively get information across to them. Regular blogs, targeted advocacy will organically motivate Nigerians to seek more information about their oral health.

Lastly, one of the reasons why we brought The SmileHub to Nigeria is because we wanted to reinvent how oral health care is delivered in Nigeria. We want to change some of the negative stereotypes about dentistry.

Dentistry doesn’t have to be painful or boring. We are bringing in technology, highly skilled and relatable specialists, and delivering service in a relaxed and beautiful boutique. Nigerians will see and hear about The SmileHub and want to be part of what we do. The change will be incremental, but it is one step in the right direction.

What is the value of investment the business would be bringing into the economy? Will it help to address FX costs due to medical tourism?
The African economic world still revolves around Nigeria, even if it does so in increasingly wider orbits. Align Technology (the multibillion-dollar company that produces Invisalign) announced late last year that they will be coming to sub-Saharan Africa. Because Nigeria must continue to be the leaders in Africa, The SmileHub is partnering with Align Technology to provide this care to Nigerians way ahead of the rest of the pack. Africans who are aware of this product/technology frequently travel to Europe or America to obtain treatment. Consequently, one of our goals is to reverse this trend. And with reduced overhead costs, we would be able to provide care at a cost that is less than the US or UK, as such, this can open up the market to interested parties traveling in the opposite direction in order to obtain care.

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