Signs of Poor Oral Airway Health (and What to Do About Them)

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Today I spoke with Dr. Brian Hockel. Sorry, I’m a bit congested, but Dr. Brian Hockel is a really sharp dentist in the Walnut Creek area who I’ve seen personally. I think this was one of my favorite conversations on oral airway health, sleep, facial development, and the like that we’ve had. I think these conversations only get better the more that I learn because there are more insights. He really brought a lot to the table.

DrMR:

There was one thing here I want to point to that I found really encouraging, which is the approach I’m finding my way into and we are finding our way into at the clinic really seems to be represented by a larger body of data than I even realized. And that’s something that Hockel has experienced as he finds a lot of merit in, and I’ve been finding myself drifting in a direction of agreement with much of how he practices, as someone who’s been in practice now for what I’m assuming has been 20 plus years.

DrMR:

So the topic was what your teeth, your tongue, your posture, and the development of your face and oral airway has to do with breathing, respiration, and potentially things like forward head posture, non-responsive fatigue, non-responsive brain fog, poor recovery, and just a general lack of vitality, and also what can be done and how we strike this appropriate balance between imaging, lab tests, and therapies. So a very good conversation. We go quite in-depth on children. So if you have children, I really hope that you will give this a listen because this is especially an area where a bit of prevention can go a long way in not necessitating the adults to go through a long course of corrective work.

DrMR:

So if you are struggling with any type of fatigue or brain fog, this is something that you should have as a level three consideration, if you will. Not where you would start, but if you’ve done everything else and you’re still having fatigue, brain fog, or not sleeping well, then this is something to consider. And if you have children who are sucking their thumb, who have teeth crowding, who seem to be breathing through their mouths, who have forward head posture, who have behavioral issues like ADHD, then I would definitely also listen to this because it may all stem back to the same issue of something interfering with appropriate respiration and potentially sleep, and the symptoms that you’re seeing are an outgrowth of that root cause.

DrMR:

So with that, we’ll go to the conversation now with Dr. Brian Hockel. And a quick reminder, if you haven’t yet left a review for the podcast, we would really appreciate it if you would.

DrMR:

Hey everyone. Welcome back to another episode of Dr. Ruscio Radio. This is a Dr. Ruscio who’s a little bit congested. I do apologize, but the show must go on because my special guest today is Dr. Brian Hockel. I have rescheduled about a gazillion times, mostly my fault. So Brian, firstly, sorry for the reschedules, but really excited to have you on the show. I’ve mentioned on the podcast before how I was really taken aback at how meticulously organized and well-run your office is, this upper airway-friendly dental orthodontic office that you have out in my prior neck of the woods in Walnut Creek. So I’m really excited to expound more upon this topic of how the formation of the mouth is so crucial for many facets of health including breathing, sleep, and how that can tie into things like fatigue and brain fog. So welcome to the show. Happy to have you here.

DrBrianHockel:

Thank you. It’s great to be with you, Mike.

Background Information

DrMR:

It’s good to be finally talking to you also. I gave a little bit of your background, but can you give people a little bit more of a peer into your background and what you’re currently doing in your clinic?

DrBH:

Sure. I’d be happy to. I’m a general dentist and have been practicing since 1989. In about the mid-nineties, I realized after referring all my orthodontic cases to my dad, that he was not going to be around long enough to treat all my own kids. So I thought I’d better learn this myself. I was not at the time willing to be referring my own kids or my own patients to the specialists in the area just based on what we were seeing with the results that were coming back. At that time there wasn’t really an awareness of airway issues. But that was the original motivator for me learning orthodontics beginning in the late nineties.

DrBH:

So I’ve been doing orthodontics for over 20 years, and in the last five plus years or so it’s been over 90% of what I do. So what’s really energized me has been the connection between what we can do in orthodontics, orthopedics, and orthotropics, all of the things we do to help guide the growth or orientation of the jaws and teeth, and the effects of that on the airway, but also on TMJ-type symptoms and other pain symptoms, because it turns out there’s a big connection there.

DrBH:

This all started for me in large part with my exposure to Dr. Bill Hang in about 2004. I’ve studied with him, worked with him, talked with him, and just really tried to create my own sort of conglomeration of techniques and approaches to help people from a very young age, young kids, all the way up to adults in ways to either be preventive with the airway issues or actively try to treat airway issues. So that’s what’s really exciting for me. It’s not ordinary, neighborhood orthodontics. It’s something that there’s so much of a need for that I’m really on fire for teaching this too, and I’ve taught many other doctors how to do what we’re doing. It’s sort of my passion right now, how do I pass on things that I’ve been able to do that have been successful and learn with other people? I’m by no means done learning. To me, this is such a developing area that the excitement is what can I learn next to be able to do better than what I’m doing.

DrMR:

Right. And to your credit, you seem to do a really thorough job of documenting case studies and getting some of those published. I think that pre-post monitoring and ruminating over our cases really helps us to learn, especially in an area like this which is so emerging. So I think what you’re doing is really important for a number of reasons, but also because with the data that you produce, you’re hopefully going to help the field see what things are worth considering doing more of and what things maybe to pull back from.

Rethinking Orthodontic Treatments

DrMR:

And maybe that’s a good question just to launch us into some of this discussion. Are there certain things that you used to do that you don’t do so much anymore, or anything at large that you feel this newer facet of oral airway health may want to reconsider?

DrBH:

That’s a great question. Well, before I understood what I was doing to help the airway, there are things that I used to do to correct jaws that were too far back that I would never go near today. That includes treatments that are still very popular. A Class II type of a profile or bite is one where the lower jaw is further behind the upper jaw. It turns out in virtually all of those cases the upper jaw is also too far back, but that pretty much gets ignored. So I thought many years ago that I had some great tools in my bag for fixing that kind of a bite in a way that would bring the lower jaw forward. But as I learned more, I found out that I was actually pulling the upper jaw backward a lot of the time, and when I learned the risks that this posed to the tongue space and the airway, I gave that up very quickly. There’s several different ways of correcting that type of bite pattern that all tend to do the same thing, pull the upper backward. So what we call retractive mechanics is something that I’ve given up many years ago and would never go back to.

DrBH:

But in the airway realm, one thing that comes to mind is overnight sleep studies. I used to refer patients for overnight sleep studies or polysomnograms very frequently. The local sleep lab probably saw many more of my patients than the local root canal specialist, gum specialist, or oral surgeon because I had so much of a need for determining what’s going on objectively with these people’s sleep. But what I’ve found is that the way the polysomnograms are scored, a lot of times upper airway resistance gets missed. It’s not that it can’t be diagnosed from sleep study, it’s just that they’re tending to look for the bigger issues, the major obstructive sleep apnea issues. And I found that the home sleep test, the WatchPAT for example, is a better tool for diagnosing that. It’s also less expensive, more accepted by patients, and it’s very straightforward to get a diagnosis from a medical doctor that would include the upper airway resistance. So that’s something that I just really don’t do much of anymore.

DrBH:

And we were talking about kids earlier, especially for kids, you can’t use the WatchPAT home sleep study on kids, but I’ve found that referring for a polysomnogram would often undermine what we already knew, and that was that there were sleep issues going on. Even though we didn’t have an official diagnosis of it, we could tell by a lot of the symptoms and history that there was a problem, and yet the polysomnograms didn’t always correlate.

DrMR:

And you’re saying that you can or you cannot use something like the WatchPat One in children?

DrBH:

You can’t. At age 12 is when it becomes valid.

Types of Sleep Studies

DrMR:

Okay. Well, right there is just so much to unpack. It’s funny that you are moving away from these in-office home sleep studies. I shouldn’t say in-office; you’d go to a clinic and you’d spend the night at the clinic to do a traditional PSG or polysomnography. I know that there’s at least one paper that has found that the home sleep tests underreport, but my experience was actually the opposite of that. I had moderate OSA, Obstructive Sleep Apnea, diagnosed by the home sleep test, which by the way, we’re now using the WatchPAT One at the clinic, but my attended PSG, the polysomnography, was actually normal.

DrBH:

Proving my point. This proves my point.

DrMR:

Yep. And so the way that we’re starting to use this at the clinic is perhaps we’ll send someone out to do the full-blown sleep study where you get a thousand wires hooked up to you, but due to cost and due to inconvenience, I don’t think we actually need that data to at least start someone down the path of trying to fix what’s thwarting their sleep and go to work on improving their airway. So it sounds like we’re kind of falling into a similar hierarchy there.

DrBH:

I think so. There was a big enthusiasm for the PSGs, and with the great variability in how they were scored, they often showed what yours did. They’re looking for the big stuff, and apparently the big stuff in the way they were scoring it wasn’t there. But you know it’s only a one night snapshot. So to be fair, there can be big variations. If it was cost-effective it would be ideal to really get multiple nights.

DrMR:

That’s why I’ve been liking the idea of doing a home sleep test like the WatchPAT One and doing a repeat after maybe six weeks, after intervention ‘XYZ,’ and also looking at that in juxtaposition to the Oura Ring, wearable, wedding band-like device. Not that it’s perfect, but I do think it gives you some information that you can use in conjunction with how they’re feeling and their home sleep tests to get a decently informed sense of if you moving the person in the right direction.

DrBH:

I see no problem with that. I’m not an expert in the Oura Ring, but there are other experts that also say the same thing, that it’s just one tool among many that can be used to get a sense for what’s going on.

Mandibular Advancement Devices

DrMR:

Now, I want to come back to something you said a moment ago, because I believe one of the lower jaw protractors would be a mandibular advancement device. Is this one of the items that you’re referring to that you’re no longer using?

DrBH:

Well, the mandibular advancement device or the MAD is typically a descriptor of an appliance that’s used to treat obstructive sleep apnea. So it’s not meant to create a permanent change. It’s meant to just hold the lower jaw forward at nighttime to temporarily open the airway. It’s like in rescue breathing, the chin tilt opens the airway. So by holding the lower jaw forward, it opens the airway just while the appliance is being worn. So it’s one type of treatment for airway problems like sleep apnea or upper airway resistance. However, Newton’s Third Law — if you’re going to pull the lower jaw forward, you’re going to have a retractive effect on the upper jaw. So yes, this is the type of mechanics that we’ve used in orthodontics on kids and even in adults which does have enough of a retractive effect on the upper jaw that I think it tends to be counterproductive.

DrBH:

When that happens, in a way it’s worsening the underlying source of the problem to begin with, which is the jaw’s being too far back. John Remmers, the Harvard-trained sleep medicine doctor who coined the term obstructive sleep apnea said it’s a structural disease. If our jaws just grew to the proper position in the face, we wouldn’t have the disease. And so if that’s true, then anything that can be pulling the jaws further backward is definitely a risk. I’m not saying it’s going to cause sleep apnea in everyone, but it’s a risk. And I’ve seen it cause sleep apnea, so if it can happen at all, then my low risk-taking temperament says just avoid it.

DrMR:

A few things I’m going to loop our audience in here to make sure that they’re tracking with us. So the mandibular advancement device is crudely described as this lower jaw mouth guard that pushes your chin forward. And there is a little exercise people can go through, at least this is what I’ve come up with. Brian, feel free to shoot this down if this is total heresy, but if you stand up really, really straight and kind of pull your neck back. If you’ve ever been given one of those tips about not having forward head posture, and then you find yourself correcting and you kind of pull your head back. If you do that and you close your jaw and you pull your head way back, I feel restriction when I do that. And then if I jut my jaw forward and kind of stick my jaw out, almost like I’m making a Frankenstein-like face, I actually have easier breathing.

DrMR:

So again, the exercise is to stand up completely straight, pull your head as far back as you can, and then breathe. You can hear that now. I’m going to put my jaw forward. That’s what the mandibular advancement device will do. It will move the jaw forward so that when you’re sleeping, the jaw isn’t occluding the airway. So that’s at least what the mandible advancement device can do to open up the airway. But Brian, it sounds like you’re saying that long-term that may be something that leads to another problem because somehow this is putting a reflexive pushback pressure on the upper jaw.

DrBH:

Exactly. So to get around that, that’s why we have forward head posture.

Forward Head Posture

DrMR:

So explain to people why that’s the cause of forward head posture, because that’s something I wanted to mention to the audience as a tie-in.

DrBH:

Well, what you just described doing, getting your head back over your shoulders, having the ears more over the shoulders, the chin will tend to be tucked back in, that’s putting the head on a more level, normal position. That’s one way of being able to tell what’s wrong with our growth, because when we do that, it’s unnatural for the jaw joint, the tongue doesn’t feel like it has enough room, and the airway pinches off as you described. So what do we do to make up for that? All we have to do is sort of tilt our head backward a little bit, which is what the chin tilt does in rescue breathing, and it opens up the airway. But then our head would be aimed upward toward the sky if all we did was tilt our head backwards. So to make up for that, we posture our head forward and that keeps the open angle of the chin being forward, but allows us to be looking straight ahead.

DrBH:

And then we’re a little off balance. So we compensate for that by rolling the shoulders forward. And now everything’s back where I was as a kid when my mom said, “Stand up straight! Put your shoulders back!” And if I stood up straight and put my shoulders back and stood the way she wanted me to it would be like, “Okay, Mom. Is that what good? Because I can’t breathe.” And so a lot of times we have to fix the position of the jaws. And of course, when we do orthognathic surgery, it’s not just the lower jaw coming forward, it’s the upper as well. And your little exercise sort of shows how if your head’s in the right position and your jaw is where it needs to be for you to be able to breathe, your upper jaw is going to be too far back to be able to meet up with your lower jaw. So it’s a good way to demonstrate how it’s really both jaws that are too far back.

DrMR:

Yep. Exactly your point. So a couple of things, this is where I think a lot of the forward head posture comes from. I think it’s really important that the chiropractic community stop criticizing people’s X-rays as if people are purposefully in forward head posture and to suggest that some sort of adjustment is going to be able to rectify that, because this understanding invalidates that hypothesis, or at least does so partially. And also for people to understand that this is primarily respiration driven, but if the upper jaw does come forward, you’ll be able to breathe more easily.

DrMR:

In fact, I notice myself when I’m doing these nasal only breathing cardio sessions, especially when I’m rowing and I can be a little more observant of my body, I will oftentimes reflexively protrude my lower jaw forward because it opens up the airway. So there’s a lot going on here, and a lot of this comes from the mouth. I don’t think it’s forward head posture that is intentional. It’s because we’re needing to do this to open up the airway. And if my upper jaw was further forward when I occluded or closed my jaws together, it would be where it should be.

DrBH:

Exactly. I do the same thing all the time too. When I’m working, I’m very aware of that my lower jaw’s forward in order to be able to breathe better. And I’m okay with that; I consciously have it forward. And the trick to that is be careful not to wear down, break, or chip your front teeth because when lower jaw comes forward, now the front teeth are edge to edge. My dream is to eventually have my upper jaw move forward and my lower jaw move forward with oral surgery in a way that would make it a more permanent thing. I’d love to have that position and not have to compensate.

DrMR:

I want to take one small step back and just remind people that, at least in my opinion, I don’t have anything against a mandibular advancement device if someone is looking at a fairly severe sleep impediment and they have no other options, because I’ve seen it really move the needle in terms of someone’s energy and their mental clarity. There may be better solutions out there, but are we in agreement on that point, Brian?

DrBH:

No, we’re in total agreement. It’s not as effective. It’s more tricky to make it effective. In the severe cases, it tends to work really well for upper area resistance or for mild and even moderate sleep apnea, but in the right hands it can work for the wide-range, depending on the person, the collapsibility of their airway, and a lot of other variables. But no, I agree. It’s a very important tool to have out there. And if your alternative is C-PAP, in a way I’d favor the mandibular advancement device because the studies showed that the cardiovascular effects of sleep apnea like heart attacks and stroke tend to be mitigated when you use the oral appliance. As opposed to when you use the C-PAP, they aren’t mitigated, and they don’t really understand why this is. So there’s something much more natural about being able to breathe and just getting the lower jaw forward but not being hooked up to the machine and the pump that you may eventually get a dependence on.

DrMR:

That’s very interesting. Okay.

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Preventative Measures for Children

DrMR:

So gosh, there are so many directions to go here. One other step back I want to take is regarding preventative strategies for children. Maybe you’re considering some of the tools like the Crozats, these retainer-like devices. Are those preventative, or if not, what are some of the hopefully lower-hanging fruit interventions that parents should be looking at their kids and saying, “Is there a potentially failure to thrive? Is there fatigue? Is there mood irritability? Is there forward head posture. And maybe I should be paying attention to and getting ahead of this because my kid may not be tired or a space cadet or whatever. Maybe we just have to make some corrections to their airway, let them breathe better, let them sleep better, and then all these things improve.” What are some of the lower-hanging fruit preventative measures, if there are any, that you feel are worth sharing?

DrBH:

Oh, sure. I mean, I could list them off for you. No spacing between the baby teeth. That’s a problem. The teeth are going to be crowded. That means the oral posture is not correct. That’s what really is behind the way our jaws and teeth develop. Certainly crowding in the baby teeth. If they’re overlapping at all, that’s a major train wreck about to happen when the permanent teeth come in. Mouth breathing is something to watch out for. The buck teeth look, where there’s there’s overjet, where the lower teeth are a considerable distance behind the upper front teeth.

DrBH:

Snoring and mouth breathing. Snoring is never normal for kids or adults. So if your kid has just a cute little snore, it’s like a nice purring sound, no, that’s probably a danger sign. If they’re sucking their thumb or keeping their finger in the mouth a lot. Obviously developing a crossbite, where the upper jaw is a lot narrower than the lower jaw.

DrBH:

Another interesting one is just ADHD-type behavior. When kids are just bouncing off the walls, have complete energy and are hard to get to sit still and pay attention or listen to you, that’s a sign that there’s likely a disruption in the sleep. And if there’s disruption in the sleep, then there’s probably something that can be done with the development of the jaws and teeth.

DrBH:

Just open mouth posture in general. The mouth should not be open all the time. It should be lips together, teeth together, and the tongue to the palate. So if a kid constantly has their mouth open, and that goes hand in hand with mouth breathing, then there’s going to be a problem with how the face develops and possibly in how the airway develops. And the other obvious ones would be like a lot of bad dreams or sleepwalking, parasomnia type stuff or bed wetting. Those are all signs there could be something going on with the airway and that some kind of early treatment is needed.

DrBH:

It’s often framed as a side-to-side orthodontic problem, and we say, “Oh, you need a palate expanded.” Actually, that’s even worse than just side-to-side, because a palate expander is only looking at one jaw. But the low-hanging fruit is widening side-to-side the amount of space that the tongue has and that the teeth have. It’s not just about whether the teeth are going to have room, it’s whether the tongue has room. But often it’s forgotten that it’s not just a side-to-side problem, it’s a front-to-back developmental issue too. So it’s where the upper jaw is developing to in space forward-backward, or where the lower jaw is developing in space forward-backward.

DrBH:

So to say, “Yeah, my kid has some issues. He needs a palate expander,” well, it doesn’t make sense to say we’re just going to make the lid of the box bigger, but not the box itself. The upper and lower jaws aren’t going to fit very well if you only expand the upper. And if you only expand the upper so far as you can that it still fits on the lower, that was a great lost opportunity when the lower could have been expanded as well. And then if you only expanded the upper and the lower, but you didn’t look at the front-to-back dimension, that’s another lost opportunity because that dimension makes a big difference as well.

DrBH:

So in short, the low-hanging fruit is to make the box bigger, side-to-side and forward-backward. And then secondly, the flip side to that coin is work toward correcting the oral posture, the rest oral posture, so that the lips are together, teeth are together, and the tongue is on the palate. Because over time, that’s what will govern the growth the most. It’s a very difficult thing to change. It’s hard to be objective about how it is now and whether it’s changed in the future, but it can be changed. And with a lot of work, the muscles of the mouth can develop tone and postures that they didn’t have before. So that’s the long answer to your question.

Myofunctional Therapy

DrMR:

No, it’s great. Now with the oral posture, are you mainly referring to having someone check in with a myofunctional therapist and do some essentially PT for the mouth?

DrBH:

Exactly, exactly. And also looking at breathing. A good myofunctional therapist may have other experts that they’re going to work with, bodyworkers maybe, that look at primitive reflexes or other types of adjunctive treatment that can work well with it.

Appliance Options

DrMR:

Now with the widening and the front-to-back alignment, is the retainer-like device, the Crozat, the method of choice? If you’re intervening earlier, are there temporary period during the day retainer-like devices that can be used instead? What are the options?

DrBH:

Every appliance has advantages and disadvantages. If I’m going to hire a guy to do a remodel in my home, I’m not going to say, “Hey, let me ask you this. Are you using a Craftsman hammer, or are you going to use some other brand of hammer? Because I really like Craftsmen, and I’d really rather that you pounded all the nails in my construction with a Craftsman hammer.” That’s kind of how it sounds to my ears when a layperson starts saying, “Hey, would you use this appliance or that appliance?” Because the amount of training it would take for you to be able to evaluate which appliance is going to be best for you would be more than you can do in a few consultations.

DrBH:

So yes, in my office and in my hands, the light wire appliance, the Crozat, is a tool I use all the time. I love it because it’s hygienic, it’s inconspicuous, it doesn’t take up a lot of room in the mouth. Some people, especially adults, might complain and say, “Well, that’s taking up way too much room in my mouth.” But you know what, in the big picture, compared to acrylic expander-type appliances or other tools that we have, it’s by comparison minimal. So for all those reasons, I like it.

DrBH:

I had a little girl with Down syndrome in today who just began treatment, and I put a Crozat on her upper teeth, put one on her lower teeth, and to be honest with you, I’m kind of knocking on wood and crossing my fingers because in special needs cases, sometimes with a lack of cooperation, or just even an intent to disrupt what we’re doing, a kid can get it out. So I actually had another special needs patient in my office today for whom we planned an appliance that is actually cemented in place. So when you need something that cannot be removed, using something that’s cemented in place with bands and has an expansion screw attached to it, even though it takes up more room in the mouth, is not as hygienic, and is more disruptive for speech, for some cases that can be the better tool to use. And this is the art form to this too, which is trying to decide what’s the best tool to accomplish what we’re after.

DrMR:

Sure. And you make a great point, which is that there are tools and then there’s how to use the tools. And I think our audience understands that I’m pretty persnickety about making sure that someone understands how to use the tools. I just want to make sure people have an idea of some of the appliances that are at one’s disposal. So there are these Crozats, there are these acrylic-like appliances, anything else that people should just be aware of that is an option?

DrBH:

Well, the general categories, if you want to understand the big picture would first be light wire appliances. And in that category would be the Crozats or the ALF appliance. And then the other category would be expansion screw appliances, which would be divided into the fixed type or removable type. The fixed expansion screw appliance would be cemented to teeth with bands, or sometimes the acrylic is cemented to teeth. We don’t usually use those for adults. Sometimes teenagers, but rarely adults. And then there would be the removable expansions screw appliances, and those are generally held on with wires that clasp on to the teeth.

DrBH:

With the expansion screws, the rate of turn of the screws is kind of a key point because it’s fashionable to do what’s called RPE, rapid palate expansion. And the goal with that has been to overcome the forces of the suture in the midline of the palate, so that you can create a gap between the two sides of the upper jaw. That’s rapid palate expansion in the classic form, but it turns out you really don’t have to expand that rapidly and apply that much force in order to get huge amounts of expansion in growing kids. Even in adults, there’s a certain amount of growth that will take place with mild forces. John Mew says that just the width of a hair, or very, very mild forces are all it takes to stimulate the growth of the bones. So even here with the same tool but applied differently, sometimes there’s a very different use depending on the rate of expansion, for example.

DrBH:

So all these are mostly focusing on side-to-side expansion. Then turn the screw 90 degrees, and you’ve got another whole category of appliances that could be used to advance the front teeth in a forward-backward direction.

DrBH:

Then there would be a third category of appliances that we call postural appliances. These are appliances that show a growing child where to hold the lower jaw in a forward position, ideally without inducing a retractive pulling back force on the upper jaw. So a postural appliance would include things like the Adapt appliance developed by Bill Hang, or the Biobloc appliance developed by John Mew.

DrBH:

These are different from what’s called functional appliances. In the past, we’ve used this thing called functional appliances, popular in Europe in the 80s, that made us think we were doing what postural appliances do. But a lot of times they have a retractive effect on the upper. That would be things like the Bionator, the Twin Block, the Herbst appliance, and any number of other orthodontic approaches that pull the lower jaw forward. So that’s kind of a quick, no pictures to illustrate it overview of different kinds of appliances that are out there.

Parental Advice for Orthodontics

DrMR:

And maybe zooming way out for a second here to make sure that parents are tracking with us. I’ll make a broad statement here, Brian, and then maybe you can clean it up a little bit, but it seems that we’re doing inadvertent harm to children with traditional orthodontics. Again, not intentional, but when we’re confining everything down that produces less room for the tongue and/or seems to move things backward as evidenced with me and headgear, can you maybe speak to the parent who is confronting this soon or now? What should they know about some of the risks? Because the person I’m really trying to reach is a person who’s a bit open-minded but says, “You know what? I’m so busy. What’s the big deal? I’ll just go the traditional route. It’s right here in town. I don’t have to worry about research or going anywhere else. Done, check it off my list. My kid will have a nice smile.” What’s the other side of this coin?

DrBH:

That’s a long answer there, but that’s a great question. That’s where the rubber hits the road and parents need to know what to look for. What are some of the things that might affect whether they would have orthodontics done? We’re trained in orthodontics to straighten teeth. I don’t mean to minimize the skill of an orthodontist, but it’s kind of all about how do we make the teeth line up straight on the jaws as they present. We talk about ways of trying to move the jaws and minimal ways here and there, but for the most part, a huge percentage of orthodontics is mainly done just to line up the teeth. And some of the pitfalls you come into with that is when you line up teeth, it often involves pulling them backward.

DrBH:

You mentioned the headgear. The headgear is not a very popular appliance to use these days. Most orthodontists know that they wouldn’t be able to get a kid to wear that. So we do the same kind of thing that a headgear does with appliances that are attached to the teeth. So I guess the first thing would be you’d want whatever is being done for the child to be taking into account not just how the teeth are going to line up, but also how the face and jaws are developing and how much room the tongue has, because those are the things that are going to make a difference with the airway and therefore with the sleep. So if there’s no discussion of what’s happening with sleep symptoms, and no sort of thought that what we do in this office could be affecting that, then they’re probably taking a “straightening the teeth only” approach.

DrBH:

With the advent of imaging technology now, many orthodontic offices have a way to image the airway in 3D. It’s sort of created this sense that “My doctor does look at the airway. He has a great image of it that he showed me on the TV screen, and he told me how big my child’s airway is.” But you know what, that really doesn’t matter. In the end, the size of the airway on the imaging is way low on the list of things that you’d want to take into account. The question I’d have would be, did they give you a questionnaire, that’s a validated questionnaire, to be able to tell whether your child has signs of sleep disturbances? That might be one thing.

DrBH:

Another might be — I asked an orthodontist this recently that I was thinking of hiring. I said, “Do you think there’s anything that we do in orthodontics that could ever make the airway worse?” And for the life of her, she couldn’t admit that there would be anything that we could do that would make it worse. So I think that might be a good screening question for an orthodontist. Is there anything we could do that would make it worse? What are those things? How do we make sure we’re avoiding those kinds of things?

DrMR:

Great question.

DrBH:

Yeah. And the other is generalized spacing between teeth. If there are gaps between the teeth and the goal of the treatment is to close all those gaps, don’t do it. It’s going the wrong way. If there’s an overbite or what we call overjet, the distance from the top to the bottom teeth, and the plan involves wearing rubber bands to pull the upper backward and the lower forward, don’t do it, because that’s pulling the upper backward. Those are very common traditional treatments that are out there, and frankly, we don’t have a good way to treat those kinds of bites that have overjet. So I don’t know, it’s such a big answer. Am I getting close to what you were asking about?

DrMR:

You are. I guess the thing I’m trying to paint for people, which you did, and I’ll just state it here, let me know if I’m misrepresenting it. There’s a fair chance that you may be impeding the development of the arch way and crowding the tongue and/or making the mouth too small and potentially setting your children up for breathing and sleep problems for the rest of their life.

DrBH:

Exactly. Unknowingly. I really don’t fault, but I’m beginning to change that. I’ve traditionally really not faulted traditional orthodontists for doing what they do because they’re trained to do that. This is where all the research has shown them this is what they should be doing, and we get good at what we’re trained to do. But there’s a different paradigm now, and there’s enough out there that I’m not so sure we can just easily write off the culpability that’s there for what’s being done. I’m starting to really feel differently about that because I think it’s best to do no harm. And when you look at things honestly, you can see that there is a possibility that some of the things we’re doing with traditional approaches does cause harm. So I think to be honest about it, we’ve got to really question that and look for ways that we can be more certain are not going to cause any harm.

DrMR:

Yep. And this is part of the conversation that I think needs to be had more broadly to help parents make better decisions for their kids, because my parents had no idea about any of this back 25-ish years ago when I was getting my braces and my headgear applied. But if we can save people from being in the situation I’m in, which is thinking about how to undo this, I think it’s an ounce of prevention here really being worth a pound of cure.

DrBH:

I was just going to say my seven guidelines for orthodontics is number one, straight teeth are great, but the airway is more important. I mean, you can have both. You can have straight teeth, but if you’re going to straighten the teeth at the expense of the airway, it’s not okay. It shouldn’t be either/or.

DrBH:

Number two, increase the tongue space. Always give it more room. Even if that means creating spacing between teeth. Sometimes someone will have no space in between the teeth, but they actually need space created.

DrBH:

Number three is a corollary to that, never decrease the tongue space by closing gaps or pulling back the front teeth. Anything that pulls teeth backward in the mouth, it’s better to avoid that.

DrBH:

Number four, the upper jaw usually needs to come forward. So start early if possible because that can be done much easier earlier on.

DrBH:

Number five, don’t wait until all the permanent teeth are in. That’s way too late for certain approaches. If the airway and the facial development are the goal, then you really need to start as early as possible. This whole idea of waiting until the permanent teeth are in or even waiting until age seven or eight, it’s missing a lot of opportunities.

DrBH:

Number six, work toward optimal breathing and oral posture. If the orthodontic office is not talking about the cause of the problem being the oral posture, then they’re still in the learning process. And you as a parent might be the one to help turn the light on for them.

DrBH:

And then my last thing is probably minimize the bulk of the appliances if you can and make them as retentive as possible, but that’s more of a practical thing.

DrMR:

Sure, sure.

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Common Orthodontic Problems

DrMR:

And what are some of the common things that you’re seeing in children, like at a high level? People come in with ‘XYZ’ and they see ‘ABC’ type of results. I know there’s probably some nuance here, but I’m sure there are probably also a few categorical buckets of things that you see walking in the door.

DrBH:

You mean like what problems might we see? Well, a real common one is that teeth have been extracted. We’ll see less room for the tongue and a patient will come in and say, “I don’t have room for my tongue in my mouth, and my wife tells me I’m snoring now. I never feel like I have room to put it on my palate. I’ve been looking on the internet and I heard that’s what I’m supposed to do, but I can’t do it.” So four bicuspid or even two bicuspid extraction is a common type of orthodontic treatment, and we’ll often deal with airway, pain, comfort, or even aesthetic problems that result from that.

DrBH:

When it comes to kids, a common thing might be something that’s called serial extraction. So when the baby teeth all come in, or when the permanent teeth are starting to come in and there isn’t enough room for them, one approach that we’re taught is to remove some of the baby to make room for the permanent teeth to come in. And then when more permanent teeth come in, you remove more baby teeth. And then eventually you end up at the end of that domino effect having to take out permanent teeth. So sometimes I’ll see kids after this process has begun and no permanent teeth have been removed yet, and we’re stuck trying to figure out how do we retrace our steps and create room for all the teeth to be able to come in. That’s really the goal, not only to make room for all of the teeth, but to make room for the teeth and the tongue.

DrMR:

Including the wisdom teeth?

DrBH:

Well, that’s a sticky thing. I mean, my dear friend John Mew and Mike Mew will talk a lot about how when our face develops the way it should there will be room for all 32 teeth, and that if there isn’t room for the wisdom teeth in a way we’ve failed because now those four teeth have to be removed. But in the world we live in right now, it’s extremely difficult to ensure that any kind of treatment is going to make sure that there’s room for all the wisdom teeth. That’s of course the goal, and my tendency is to want to leave the wisdom teeth in as long as possible.

DrBH:

I’ve noticed a lot of faces will develop bigger, even up to age 25 or 26. When we thought there wasn’t room for them at age 17, there really was later on. But sometimes it’s a bit of a hassle because teething hurts and we see babies go through it and they cry. Well, teenagers and people in their twenties cry about it too, and it can be uncomfortable. So you’ve got to put up with all that discomfort and wait and see. And it may be in the end, there may be a need to take them out anyway, especially if they come in crooked or tipped horizontally. So yeah, in the ideal world there’s room for the wisdom teeth, but we don’t live in an ideal world. In the ideal world I have a lot more hair than I do too. We do what we can.

Orthodontics and Attractiveness

DrMR:

Coming back to kids for a moment, I just want to make sure to echo this because being in your office physically and looking at these wonderful before and after photos you have all over the walls of children’s smiles, your approach, this kind of expansive approach, leaves the kids looking more attractive. I mean, they have better smiles, they have better profiles, they have more fully developed faces, and I think that’s a really important side benefit. Not only will they have better airway health and ostensibly sleep and perhaps cognition also, but there’ll be more attractive. And I think no one would turn down the prospect of being a touch more attractive if they could. So I think that’s another thing for parents just to really be aware of.

DrBH:

That’s so true. I mean, we’re meant to grow more forward and the best looking faces in the world around us have lots of forward growth. So having that as a goal is not easy to accomplish and is not predictable, but it’s a worthwhile goal to have. And if you don’t have it as a goal, then are you going to end up? But the conventional wisdom is it’s all genetic. We’re just growing the way our genes determine we’re going to grow. It doesn’t have to do with our mouth posture. We don’t have to worry about a tongue tie because we’re just going to grow the way we’re going to grow. Stuff like that.

DrBH:

But you’re right. The best looking faces have more forward growth. And John Mew’s studies that looked at this have been published in The Angle Orthodontist showing that orthotropic cases where more forward growth developed than the traditionally treated cases were all judged to look better.

DrMR:

And some of the pictures are just striking. How much better someone’s cheeks look, their nose looks, their mouth and their smile looks when they have adequate expansion and development of the jaws is remarkable.

DrBH:

Right. Right.

Orthodontics and Sleep Issues

DrMR:

Now with adults, I’m assuming you’re seeing some symptoms typically, but I’m not positive. Are you seeing people who suspect they have, or they do have sleep issues and result in fatigue and whatever else? Is this something that you’re seeing a subset of?

DrBH:

Oh, yeah. In a practice like mine, people find me that have those kinds of symptoms. I think in a typical orthodontic office, you’d have to dig a little bit to find it. When I get a neighborhood patient who wants their teeth straightened and I have to be the one to tell them, I can tell at a glance that they’ve got some sleep breathing disorder, it’s sometimes a bit of a hard conversation to have because that’s not what they came to me for. And I’m like out in left field here talking to them about stuff that they’re frankly really in denial about because the odds are they’ve been told before they have an issue.

DrBH:

With my own dad, it took many years for me to convince him to get a sleep study. I knew he had something going on, but there’s a definite aversion to sometimes just talking about it. But when somebody seeks me out because of that kind of an issue, then it’s great because they already understand the connection ahead of time.

DrMR:

I’ve given some of my story here where I didn’t really have much in the way of complaints other than my Oura Ring score not being great. I’ve learned that I was perhaps a bit in denial in terms of how important it is to be in bed by 10:30. Just a quick recap for our audience, I was in this pattern for a while of just working all day and then going to the gym at maybe 6:30 and then doing sauna after the gym. So by the time I got done working out and then did my sauna and then came home and had my protein shake and did my hour of reading on PubMed and then was ready to eat dinner, it was usually 9:00 or 9:30, and I wouldn’t go to bed until 11:30. Even if everything else was where it should be, I could not get the level of sleep quality that I should have until I changed some of those things. Went to the gym midday, ate earlier, and was in bed by 10:30. And that seems to have resolved most everything.

DrBH:

So asleep by 10:30, then what time do you wake up?

DrMR:

I’ll normally wake up between 7:00 and 8:00.

DrBH:

Great. That’s amazing.

Orthodontic Appliance Issues

DrMR:

Yeah. And when I’m doing that, everything’s clicking. Now, the PSG sleep study found no apnea and no upper airway resistance and no central apnea, I think it is. The home sleep test found mild to moderate obstructive sleep apnea. This is verified across two different tests. So that was a little bit perplexing to me. And I did come in and I tried the Crozats. Personally, I couldn’t get past the lisp that I had. For me, with all the speaking that I do, it was tough.

DrMR:

Now, there was the fly in the ointment of, “Well, you can get these silicon earbuds or wax and put it in the roof of your mouth there.” And apparently my GI is really sensitive to that sort of wax because I had loose bowels and some fatigue, and it wasn’t just mild. It was enough to where I really noticed a negative feeling. So I gave it the old college try, but that wasn’t something that worked for me. Now, does every adult have some sort of lisp when using something like the wired Crozats or is that more consolidated to me?

DrBH:

I think it’d be really unusual for an adult to say, “Oh yeah, no problem. I had no trouble at all.” It does happen, but it’s a bell curve. You get both ends of the spectrum. Some people have a hard time tolerating things in their mouth. Some people actually have a frank sensitivity to the materials, so you have to be careful with that.

DrMR:

That’s what I think I may have noticed. I still have to rerun this experiment. I got kind of busy, so I should say that this experiment is half-baked and hasn’t been concluded yet. But I may have had some reactivity to when I went to see Ted Belfor and got fit with his acrylic or plastic Homeoblock. With me knowing that I’m somewhat sensitive to plastics, apparently, that could make sense, but that was a different option.

DrMR:

And there’s also a similar system called the Vivos, which seems to be very similar to the Homeoblock, but maybe it’s just different outfit using the same Homeoblock paired with Biobloc technology in adults. Is that anything that you have any familiarity with?

DrBH:

No connection with the bio block. The Vivos is a rebranding of what was the DNA appliance that was developed by Dave Singh and that Dave Singh and Ted Belfor worked together on early on. The Homeoblock was Ted’s appliance that was kind of a precursor to the DNA appliance. So they’re kind of various generations of appliances that are all in the category of appliances that are called epigenetic. The idea is to stimulate the genome to create more bone. So that’s the idea.

DrMR:

You’re not necessarily a big fan of these? At least that’s my understanding?

DrBH:

Not really. No, not really. But I’m not saying that people can’t be helped by them because I’ve heard some great stories via. It’s just not something that I’ve found that would be a good fit either in my practice with my hands, my temperament, my desire to join a club, which is kind of what happens with that particular appliance.

DrBH:

But I’m not saying other people shouldn’t join the club and use it. It’s out there, so I think time will tell. But I think it’s in a category of its own in the sense that it sort of has set its own criteria for success, and they are not orthodontic criteria. So it’s not uncommon for issues to come up with orthodontics after treatment with the Vivos appliance that then have to be dealt with afterward. And maybe just because it’s the nature of my appliance, I’ve seen those kinds of cases. But none of us knows enough to say that appliance is no good, it should never be used, or it should be avoided, because different things work for different people. And you’re a good example of that.

Post-Appliance Teeth Straightening

DrMR:

Right. Now this brings up, I think one of the more challenging facets of corrective work for adults, meaning if you’re trying to expand the jaws. Maybe you can sharpen up some of this with numbers if you have any stats, but it seems that most people, after doing the Vivos, the Homeoblock, the Crozats, these devices that expand the arches and make enough room for the tongue, they oftentimes require re-straightening of the teeth with some type of either braces or Invisalign. That wasn’t something I was fully aware of going in. I would have liked to have had a better understanding regarding it. I mean, I was made aware of it as I went through the process, but that at least for me being in a boat of optimization changes the math a little bit. How often does that sort of thing occur where braces or Invisalign is needed post and what sort of time commitment would an adult be looking at from first visit all the way through Invisalign or braces coming off?

DrBH:

Well, there shouldn’t be a surprise. To my way of thinking, a comprehensive treatment plan should include either something like braces or Invisalign to account for the alignment of the teeth.

DrMR:

To your credit, you made me aware of that. I was spackling this together from reading a few books and doing a few podcasts interviews and it hadn’t come up. So just to clarify for people, you did a good job of disclosing that when we had our consultation.

DrBH:

But what you’re saying is true. So often people will get into, “I want to a Vivos. I want a Homeoblock. I want whatever kind of appliance.” They’re thinking one step ahead, and you have to think several steps into not only what are you going to do to make the box bigger but what are you going to do to make someone look okay after that? And maybe some people don’t care. Maybe you’re in the U.K. and all you care about is just doing the expansion and leaving crooked teeth. Hypothetically, that could be a choice for someone.

DrBH:

But then you’ve also got to deal with what’s going to happen with the extra space that was there, because there are some approaches that actually close up that extra space. And then finally, what are you going to do about the oral posture that now has to be optimized with this new physical surrounding that the muscles occupy? So thinking only one step ahead is one of the major traps of people who just dip their toes in these kinds of treatments, and it’s very dangerous. It’s not fair to the patient to do that. You’ve really got to have an overall plan.

DrMR:

Now, is it most of the time that people are gonna need some sort of corrective orthodontics after doing the expansive work? I’m assuming it would have to be, because otherwise you just have really good luck if your teeth stayed perfectly straight the entire time.

DrBH:

It depends on what’s being done. I have patients where it’s not so much a side-to-side issue as it is a front-to-back issue, and the solution might be bringing the front teeth forward maybe only two or three millimeters. You can do that in four to six months. And if you can do it without the front teeth jumbling very much, then it really might not require additional treatment with braces or Invisalign.

DrBH:

By the way, to me it’s always better to avoid Invisalign just because of how it opens the bite, takes the teeth coming together out of the picture, and can sometimes cause problems with the back teeth intruding, leaving an open bite between the back teeth. That’s kind of a footnote there, but there are treatments that can be done that can be very simple and not really involve braces or alignment of the teeth.

DrBH:

I’ve had several patients really benefit from that where the jaw joint feels compressed. It feels like the upper front teeth are holding the lower jaw back. A simple, simple thing is to just bring the upper front six or eight teeth forward a little bit. Yes, it’s going to open up a little gap between some of the side teeth, but you can fill that in with bonding resin if it’s a cosmetic problem. So it really depends on the person and what they need.

DrBH:

I do find it’s often the case that some appliances use, by their own admission, different criteria. For example, a Vivos practitioner will say, “We are not treating to orthodontic standards. We’re treating to our own standards.” The criteria for success of which are very different than the criteria for the success of orthodontic treatment.

DrMR:

Are the Vivo standards predominantly geared by airway health?

DrBH:

Function, airway, and posture, which are top of the list for me too.

Myofunctional Therapy and Sleep Quality

DrMR:

This begs a question I wanted to pose to you. The approach that we’re taking at the office is trying to find the path of least resistance to improving people’s respiration and sleep. So we’ve been starting off with doing these home sleep tests, like I said earlier, plus or minus some home tracking with an Oura Ring, getting a baseline, and then having someone do a course of myofunctional therapy and seeing what happens with the obstructive episodes or what have you. And I believe there have been now two cases where the obstructive events have been pretty much eliminated by about six weeks of myofunctional therapy.

DrMR:

It’s too soon for me to be able to say how that impacts quality of life because the sample size has just been too small. We had one person, actually a colleague, who had both central apnea and obstructive apnea, so that muddied the waters a little bit. But any thoughts on the approach of starting with just improving the musculature as much as we can if moving the structure might be a longer-term road than many people have the motivation to pursue?

DrBH:

What you’re describing is not a new concept. Look for studies out of Brazil, especially, that make the connection between myofunctional therapy and airway. I wish I could quote them just off the top of my head, but I can’t. I have them, but there are multiple studies that show for example, when somebody on a C-PAP does myofunctional therapy, the pressure can be reduced or that show that the AHI and the RDI are reduced both in kids and adults. So the studies are there, but it’s a hard thing to measure.

DrBH:

Apparently the studies that were done in Brazil were from some fairly simple myofunctional therapy exercises. So I’ve found this myself too. When the patients do myofunctional therapy and take it seriously, that in itself can make a difference in the quality of their sleep. I think there’s a great need for more research on that but controlling the variables. Because like you said, there can be differences in the type of sleep problems being treated. There can be other factors that are involved, but I think it would be great to see more.

DrBH:

And on my list of things you can do to help obstructed airway, myofunctional therapy is number one. That’s a given no matter what else is done structurally. That’s something to investigate as a conservative option that can make a big difference.

DrMR:

Well, it’s good to know that we’re not too far off. I believe every three months at the clinic we’re going to be doing quality of life assessments via the PROMIS-10 measure. How we’ll probably approach this is we’ll look at pre/post home sleep tests, Oura scores where we have it, and then a general quality of life measure like PROMIS-10 plus whatever flags from their main complaints, like I’m assuming fatigue is going to be one that almost everyone is complaining about. And then once we get an idea or hopefully a signal of benefit, then we may clean up some of the measurements around this and try to be a little bit more set up for a case series.

DrMR:

Just looking at some of the data on singers and didgeridoo players, it would make sense that if those have been shown to reduce obstructive sleep apnea, then this approach may suffice if you can’t get people to go all in for some of the expansion.

DrMR:

That being said, I think doing both is best. It is something that I want to find a way and/or the time to get correction for myself, because I think I’ll actually look better and I’m sure it will prevent me from having to do weird stuff like protrude my jaw bone when I’m aerobic. I’m sure the older I get, the more this is going to matter, and the more the limitations of how much the structural strengthening or tissue strengthening will manifest.

DrBH:

You’re in such good health and you know so much about how to take care of yourself that it probably doesn’t show as much for you as it might other people. But maybe at some point the symptoms will be worse. It’s like how the doctor told my dad his knee doesn’t hurt bad enough to replace it now, but to come back when it does. Maybe at some point in the future it’ll be, “I don’t care how I sound when I talk, I’ll do what I have to do.”

DrBH:

I was going to mention one study in 2015 in the journal Sleep. Camacho, Certal, and Zaghi are on the paper. It’s a meta-analysis of myofunctional therapy to treat OSA. It’s a good one to look at.

DrMR:

I’ll definitely make a note about that now. Thank you.

DrMR:

That’s another thing I appreciate about you, Brian, you’re a man of the literature. If the answer is already partially here for me then that makes my job so much easier.

DrBH:

If you’re doing the research, I’d love to see measurements of the inner molar width. There’s another measurement from the upper front tooth to the tip of the nose, John Mew’s indicator line. I think the right study would show a correlation between vertical growth. An increase in that length from the upper front tooth to the tip of the nose shows vertical growth, the maxilla dropping down and back. And the other dimension, the inner molar width, looking at the width of the upper molars at the gum line, it’d be great to see that data correlated with all the sleep data as well.

DrMR:

Well, plan on a follow up email from me, because I wanted to pick your brain on a few of the hallmark symptoms and historical findings that we should make sure to have in our paperwork that flag this. So I’m definitely going to follow up with you one-on-one anyway. That might be something that we can include in our measurements.

Orthognathic Surgery

DrMR:

What’s next for you? I know you said you were thinking about having the surgery one day. I believe you’ve done Crozats. I’m sure our audience would be curious to hear what you’ve done personally and what you’ve noticed from it.

DrBH:

As a kid, my dad learned on me, so I was one of the first people he put braces on. Of course I had Crozats. I’ve had them probably three different times in my life. I had a headgear at one point. He was learning the headgear. I had a Bionator. I don’t think I had a Twin Block. So I had functional appliances. Most of the treatment my dad did for me was a more traditional orientation, which was fixing the Class II by pulling the upper backward, so my growth went down and back. I was a mouth breather my whole childhood. There’s no picture of me as a kid that doesn’t show me hanging my mouth open. It’s really embarrassing. But that made a difference in how my face grew and how my head tilted back and the forehead sloped over the years.

DrBH:

So I thought, “Well, this will be fun. Let’s let’s see what happens if I bring my upper front teeth forward and create some extra space.” I have all 32 teeth. I have my wisdom teeth. No teeth were removed, but there’s still really not enough room for the tongue and both jaws are too far back. So I played around with bringing the front teeth forward and it felt great not to have the lower jaw trapped backward behind the upper front teeth. But it really became evident to me that was not really anywhere near the order of magnitude of change that really needed to happen. So to me, it’s a matter of who’s going to take over my patients while I take a few weeks of downtime to recover from the surgery. My own daughter’s going to do it in November just before Thanksgiving. So I’ll be with her during that treatment.

DrBH:

I have no fear of the surgery for myself or for my family if it’s going to make the right kind of a difference and change the things that need to be changed. In the hands of the right surgeon, it’s phenomenal. In the hands of surgeons that are not as experienced, that don’t do the same types of procedures that the top-notch surgeons would do, then I would say just avoid it. And in general, it’d be good to avoid extractions and avoid surgery unless the surgery is with the right doctor.

DrMR:

Regarding the surgery, are you referring to the surgically facilitated orthodontic treatment?

DrBH:

That’s a good question. Thanks for clarifying. SFOT, surgically facilitated orthodontic treatment, is not orthognathic surgery. That’s a type of gum surgery, essentially. It’s gum surgery that helps speed up and increase the potential for orthodontic treatment. So when you’ve had SFOT, you can expand your teeth, for example, with Invisalign or with other appliances faster, easier, and further than you would be able to otherwise. But that’s different from actually moving the jaws to where they should be.

DrBH:

So in orthognathic surgery done the right way, the angle of the bite plane or the width of the upper jaw, the width of the lower jaw, the forward backward position of both jaws, all that can be dealt with in a single, much more invasive surgery than SFOT would be. So that’s typically referred to as orthognathic surgery. Some people will call it MMA, maxillomandibular advancement surgery, but the way that it is done is very technique sensitive in how successful it is.

DrBH:

I know one doctor that teaches about orthodontics for sleep apnea. He’s had orthognathic surgery three times and he’s still on a C-PAP machine because it didn’t get rid of his sleep apnea. So nothing’s a hundred percent, but you certainly don’t want to go through it three times and still be at ground zero. So it proved my point that there are many different ways to do it, and they aren’t all equally effective.

DrMR:

And what’s the recovery time for the orthognathic surgery?

DrBH:

Well, like I said, I feel like I need someone to help me with my patients for three to four weeks. The surgeon that I work with had surgery himself. He wasn’t doing surgeries, but he was seeing patients on rounds and helping them out even a week to two weeks afterwards. But most people really need to plan to take three to four weeks of intensive recovery. And it’s a process. It takes several months before it’s going to feel a hundred percent, and there’s orthodontics both before and after the surgery. But when there’s a need for it, there’s nothing like it.

DrBH:

Almost every day I’ve got somebody in the office who is either getting ready for it or has had it and we’re finishing them up with the orthodontics afterward, so I’ve got my share of experience with it. But it’s not for everyone. It just depends on what the goals are and what somebody wants to accomplish.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly-efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our Probiotic line, and other gut supportive and health supportive supplements. Health coaching. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you’re a clinician, there is our clinicians newsletter, the Future of Functional Medicine Review, which I’m very proud to say we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter, and be able to help these patients who are otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty, back to the show.

Optimizing Sleep

DrMR:

And if you don’t mind me asking another personal question is there some sort of sleep issue that you’re trying to solve or optimize for? Is that the main driver or just trying to get more chicks when you’re driving around in your convertible?

DrBH:

It’s been a while since I’ve done a WatchPAT myself, but this is funny. I hope everybody enjoys learning about Dr. Ruscio and Dr. Hockel’s personal issues. This is where we’re the most interested and we’re good examples, but not always an analogous case for other people’s issues. In the past I’ve had airway issues. I was a lot heavier at the time. I used to be 35 pounds heavier than I am right now, so that made a big difference in itself. But to me, Mike, the big issue is when I sleep I have to be on my stomach or my side, and I have to tilt my head back. And that awkward head back position keeps my airway open fine, but I’d love to be able to just sleep on my back and still have an open airway. I know it’d be better for my whole spine and my neck and everything else. Not to mention, stand up straight with your shoulders back. I’d like to be able to do that and still breathe.

Mouth Taping

DrBH:

Those are probably my main motivations. And I’ve done lip taping for so many years. I really think that lip taping over time puts a backward pressure on teeth. My teeth have crowded tremendously during these years that I’ve been wearing lip tape when they stayed fairly straight without retainers for all the years before that. That’s something people don’t talk about, but I think that’s an issues.

DrMR:

I have a suspicion that the utility of mouth taping or lip taping is over-reported. Now, I have almost no data other than the handful of patients who’ve done this at the clinic. I think only one of six or maybe or maybe even less, maybe one of eight seems to say, “I really noticed that help.” And then on myself, I’ve gone on and off, on and off, on and off, with mouth taping. At first I thought it helped, but as a key point, I made other changes at the same time, meaning meal time and gym time.

DrMR:

When I stopped everything and then restarted the experiment isolating just for the mouth taping, my Oura Ring, and this is where I think the Oura Rings is helpful, my Oura Ring data never changed. And it does, it will change. If I go to bed 45 minutes later or if I eat too late, I will see a change in Oura, so it does seem to be a sensitive measure, but I never saw a change as far as I can discern from that mouth taping. Now take that with a grain of salt; that’s just my experience. But I wonder if it only is really helpful for people who are quite fervently nocturnally mouth breathing and for other people it may not be needed.

DrBH:

Yeah, I’m sure there are situations where it makes a big difference and others where it doesn’t. Obviously, if you are mouth breathing while you’re sleeping, then something should be done. My daughter’s doing myofunctional therapy with a great therapist and she says for the first time in her life she’s sleeping with her lips together without taping. This is from doing a lot of intensive myofunctional therapy. So that would be the goal. That’s the ideal.

DrBH:

But if somebody’s mouth is dropping open, even from a purely dental standpoint, there are benefits to having the mouth close. Drying out the gums and the tissues in the mouth is not a good thing. Not to mention all the benefits of nose breathing that Nestor talks about in breath and that we know as common sense. It filters the air, warms the air, humidifies the air, speeds up the air, limits the volume of the air, and mixes nitric oxide with the air. You don’t get that if the mouth drops open while you’re sleeping. So it’s anecdotal really what we’ve seen with our patients. A study really needs to be done. Soroush Zhagi has a study where he’s looked at the tape and has begun to investigate it, but I know a lot more is needed.

DrMR:

Well, I guess the jury is still out and we’ll see. And certainly if someone’s mouth taping, I think it’s a really low-risk intervention. Maybe there is some pressure like you’re saying Brian, but I think relative to the gain that one could potentially yield from it, it’s probably not the worst thing in the world for someone to try.

DrBH:

No, and I would never go back. If I forget to tape, I’ll wake up during the night with a dry mouth and just the worst feeling. It just does not feel good. So I’ll take the crooked teeth and I’m going to straighten them eventually, but I’d rather have crooked teeth and breathe better and sleep better.

DrMR:

I think it’s a great point for people to do a self-audit. Do you have dry mouth? Do you have receding gum? Do you notice drool on the pillow? Things like that. I noticed none of those other than I do have a bit of receding gum, but I think that’s because I used to like go on a walk and brush my teeth. I mean, I was such a notorious over-brusher. So I’ve amended that, and it seems to have halted. And actually at your office I’ll also be doing periodontal therapy, which should help halt some of the recession and hopefully get me some regrowth. But I think just doing a self-audit for some of those symptoms can give people hopefully a predictor if the mouth taping is something they should consider or not.

DrBH:

If there’s periodontal disease and somebody’s mouth breathing, that’s an easy thing that can definitely help. Or even a lot of decay, because drying the mouth out, the saliva helps neutralize the pH and help prevent decay. There’s a difference between recession and gum disease. Recession is when the gum has exposed some of the root of the tooth. That’s different from gum disease. It is a periodontal problem, but that is typically more from excess forces on the teeth, from the tongue or the bite, that kind of thing. Or like you said, the heavy-handed tooth brushing, which is what we were taught to believe was the primary cause of recession.

DrBH:

I would say typically it would more likely be from heavy forces from the bite. Clenching or grinding of the teeth, which often has its roots in the airway closing off and sleep issues. But periodontal disease, that’s different. That’s deep pockets of bleeding, and you don’t ever want that. You can have healthy gums with recession, but healthy gums with bleeding and deeper pockets is what the periodontal therapy will treat.

DrMR:

Well, I’m looking forward to getting into your office and then having that done. It’s two weeks away from my first visit, so I’m looking forward to that.

Episode Wrap-Up

DrMR:

Well, Brian, this has been a great conversation. Do you want to tell people where you hang out online and then about your office in case they were in need of some help?

DrBH:

Sure. The name of the practice is Life Dental & Orthodontics, lifedentalortho.com. If you look for my last name, Hockel.com, you’d find it there too. But a long time ago, we used to just put the tooth on the sign in front of the dental office because it was all about the teeth. And then later on, it was these smiles, the outline of the smile, because the interest in cosmetic dentistry. And then it was like jaw joint and functional stuff like that. But to me, it’s bigger than that. It’s really how it impacts our whole life. So that’s why we named the practice Life Dental & Orthodontics, because what we do in the dentistry and the orthodontics is so broad reaching if you look at it in the right way. And that’s what makes it exciting for me and it’s my passion.

DrMR:

Well, you certainly have a knack for it my friend. And again, your office is run like a well-oiled machine. It’s really impressive, the systems and the organization that you have in place from someone who is a stickler for both of those things. I really enjoyed the chat and I appreciate you taking the time. I’ll also send you an email here to pick your brain on a few of those items. Just again, I really, really enjoyed having the conversation.

DrBH:

Me too, Mike. I’m glad we were able to do it. Thanks for hanging in there, being persistent, and finding a time. It was a lot of fun.

DrMR:

You bet. Thank you again. Take care.

DrBH:

Goodbye.

Outro:

Thank you for listening to Dr. Ruscio Radio today. Check us out on iTunes and leave a review. Visit DrRuscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates.

 

Preventing airway issues in kids

Warning signs

• No spacing between baby teeth
• Crowding baby teeth
• Mouth breathing, open mouth posture 
• ADHD**
• Sleep walking, bed wetting 

Early treatment

• Widening side to side, room for tongue and teeth +  Creating more forward-backward room
• Oral posture via myofunctional therapy 
• Some options
  • Crozats (light wire appliances)
  • Expansion screw appliances 
  • Removable appliances 
  • Acrylic appliances, slightly larger 
  • Adaptive appliances – Bio Block

• Drink LMNT
• Try Elemental Heal
• Dr. Ruscio Resources