Sep 21 / Dennis Hartlieb

The Dental Journey Toward Specialization with Dr. Jeff Rouse Part 2

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What do you do when you are a pioneer in your field and you face opposition from other professionals?

In the second part of Dr. Dennis Hartlieb's discussion with Dr. Jeffrey Rouse, Dennis and Jeff talk about all things airway! Get your brain buzzing during part 2 of this 2 part Q&A with Dr. Rouse on the importance of understanding airway in your dental practice and its role in overall patient health. Jeff shares his experiences as an airway prosthodontist, and explains his fascination with bruxism, reviewing the role it plays in dental health and the longevity of your dentistry. Jeff also talks frankly about the difficulties of being a pioneer in this field and the ways he's dealt with opposition along his journey.

In the episode, Dr. Rouse mentions his 2010 article, "The Bruxism Triad." You can find that article and more of Dr. Rouse's published work here. Dr. Rouse also mentions his more recent publication, "Autonomic Nervous System Trial: Control and Resolve for Sleep Breathing Disorders," which can be viewed upon logging in here.

Dr. Jeffrey Rouse works with the Spear Institute, and you can learn more about them at speareducation.com. You can also learn more about Dr. Rouse's practice here.
Do you want to learn about Dr. Rouse and airway prosthodontics but don't have time to listen?

Read the Full Interview Below

Dennis 0:06  
Hello, Dental Online Trainers. 

Welcome back to our conversation with Dr. Jeffrey Rouse, airway prosthodontist. If you missed the first episode in our Sharecast, I'd recommend that you go back and listen to really get a sort of a good understanding of Dr. Rouse's history, sort of his background, sort of what's led him up to where we're going to talk about this afternoon, which is this airway information. Jeff, I remember seeing you back... you came and spoke to our study club. First you had spoken to our study club on the core stuff. You and Bill came out and you did a three part program, which was awesome. And for those of you who have an opportunity to get a part of that -- I know Bill is still teaching that stuff, Bill Robbins, and it was super valuable information, super helpful for me in my practice and our study club. And then I met up with you with airway stuff. We went out and... you may have introduced us to Jim Metz. I'm not quite remembering how we first met up with Jim in Columbus. It might have just through Brian Vence and his relationship with Jim. And then we started sort of following your tracks, and I remember Inside Dentistry: The Bruxism Triad that you presented. So the first question is like, how did it start for you what the airway? Was it like this little drip and drab? Like you'd just see a little bit, hear a little bit, start to get introduced a little bit? Or was it like you opened a door and there was a bright light and there was airway, just like just giving you a big old hug? And, Jeff, just welcomed you into airway?
 
Jeff 1:45  
So we kind of have to go backwards a little bit in my history, because we were talking the other the other session about where I came from, and what I did, but I got into debate in high school. And I actually was on scholarship to debate for A&M, so nationally. And what debate teaches you is to be able to take a topic, research the topic and then present the research and a cogent way to make an argument. In the last session, I mentioned that Bill Robbins allowed me to do lit reviews with his group. I wasn't one of the outstanding students, but they let me do that. And the reason I even mentioned or even asked about it, was I heard about it through a friend, and I was like, well, that's debate and I love doing the research stuff. Can I do that? Can I learn about this? 

Because of that, I got this way of thinking through problems that I've carried on since then, which is, if I have an issue in the practice, then I'm going to go research it, I'm going to read all available literature, and then I'm also going to view it with a critical eye because in debate, I have to be able to argue both sides. And so I'm always... I'm never really satisfied with what I've been presented by people. I'm always asking why? Why would that be? I mean, there's just lots of things in dentistry that just don't make sense. And we just accept it because we didn't... we either don't think about it, or we don't have a better answer, or I don't know why... Or our mentor, you know, somebody we trusted told us that. 

Dennis 3:44  
Right, it becomes dogma. 
I'm never really satisfied with what I've been presented by people. I'm always asking why? Why would that be?
Dr. Jeff Rouse
Jeff 3:42  
So I always had a fascination with bruxism as just something that I always wanted to know more about. And so in 2004, I graduated from my prosth program. Bill and I had been teaching global diagnosis from that for a while, but the piece to global diagnosis that was missing is okay; we've got the teeth set up where we want them. How do you do the next thing? So we started teaching the next thing, and part of that was occlusion. And so Bill said, "All right, you're the prosthodontist. You get to teach occlusion, and I sucked at it. I was horrible at it because I was teaching it the way I taught, and they taught me in grad school, and no one wants to know all that stuff. Honestly, occlusion -- what you want to know is how do I keep from hurting someone? Which is pretty rare. To be honest, it's fairly rare that you're going to dink with someone's occlusion to the point where you've created some dysfunction or pain, right? So that's fairly rare; you've got to really mess something up. But what really is important in occlusion is how do you keep my dentistry from breaking? I don't care about your dentistry. I don't want my dentistry to break. In fact, if your dentistry breaks, it is a bonus. 

So I started looking into why does stuff break. That was really what I was going to, how I was going to teach occlusion. Why does stuff break? What do we do to avoid that from happening? And then a little bit about how do people get in pain, but it was mostly why does stuff break. With the why does stuff break, I was taught that it was all about bruxism. That's the key. If you could somehow get to whatever bruxism, what the culprit is, what the trigger is, then we could start protecting our dentistry. 2005, 2006, 2007 I'm doing research on bruxism. Now I've got notebooks full of stuff on occlusion and all those topics but mostly focused about bruxism.

Dennis 5:33  
And what what were you taught in your program about why people brux?

Jeff 6:10  
I was taught three things: stress, neurochemical, and occlusion.

Dennis 6:15  
Yep, a bad bite can cause people to brux.

Jeff 6:17  
Yes, yep. So I was taught if you're stressed, if you're just got piss poor luck, and you happen to have a neurochemical imbalance that creates an environment for bruxing. You know, you're just a grinder, right? And if you have a second molar interference, basically.

Dennis 6:36  
Yep. Okay, same. That is the same as I was taught back at back at Michigan.

Jeff 6:41  
I was also taught that bruxism was an incredibly aggressive phenomenon that caused you to break crowns and teeth, right? So I'm working under that premise. But I'm always skeptical, I'm always questioning. And I had already spent a fair amount of time by this point, looking at daytime bruxing. Because I was extremely interested in bruxism in general. And I started getting a real fascination with what we do with our teeth during the day. So I was already focused on that, and things had started to change in my mind by that point.

In December of 2007, there was an article written by a guy named Undero, in Cranium, and Undero was using an ultra thin piece of vinyl -- it was point one millimeter thin, before heating, so it gets even thinner. And he painted it with an ink. And he watched people grind on that.

Dennis 7:45  
Yep. I remember you sharing this with us during your early meetings with us in the study club. Continue, though; this is really interesting stuff.

Jeff 7:52  
So Undero goes through and watches people grind. And one of the things that hit me; well, there are a handful of different things that hit me, but one of the main things was people don't grind forward at all at night, they only grind laterally. And then I was like, okay, that's really interesting. So I started doing this myself. And I've done over 300, I think 350 or something like that now, of nights... of multiple nights with people grinding on these pieces of plastic that we've created.

Dennis 8:32  
And did you paint the surfaces of them? Is that what I remember, Jeff? You would paint the surfaces with polish material, right?

Jeff 8:39  
Yeah, I changed it from one... Undero's stuff was kind of toxic. So, I changed it up a little. But yeah. So they would, they would grind, and sure enough, they would grind lateral. And no one really moved forward. So I made some during the day to watch what people did during the day. And they had some pretty standardized patterns during the day. And so that's where it started was 2007, the end of 2007, saying, okay, there's something going on here. There's a pattern of grinding that's happening. By the way, I never put one... if anyone had wear facettes on their teeth, I never ever placed a device in their mouth, and they didn't grind. So they're always grinding.

Dennis 9:31  
They're grinders. If they're going to grind, they're going to grind.

Jeff 9:34  
The interesting part there is that now the sleep literature tells you only 5% of people grind their teeth at night, which is just wrong. 

Dennis 9:41  
Right. 

Jeff 9:43  
The data, the reason they established that, is they set a really high standard for how many times, how hard, all these [parameters], you know... it has to make noise. So the data is between the research data and what's out there. The message from dentists and the message from researchers just do not jive at all.

Dennis 10:06  
This is one of the biggest challenges, isn't it?

Jeff 10:09  
Yeah. So anyway, that got me. That got me going, and really got me excited about the topic. And so, what I started finding was that what we have been told about nighttime bruxing was wrong. The forces generated at night are really low; they're not high. People rarely ever have an event that even reaches near 100% of what they can do while they're awake. And yet I was taught it was five to six times, you can somehow generate five to six times more strength at night when you're asleep. The forces are very mild, about same amount of force when your teeth come together when you're swallowing.

Dennis 10:53  
So then, our patients, then, are they exhibiting these higher wear patterns from daytime bruxism?

Jeff 11:02  
So the wear patterns? Well, let me let me finish the thought. It's not about... at night, it's not about breaking anything. So if you think about your practice, patients don't call you at eight o'clock in the morning, having been asleep the night before and broke a tooth off in the middle of the night.

Dennis 11:21  
Occasionally, I do. Occasionally, I'll do that. Because we'll have like kids in Essix appliances after we do some bonding in the wake up with the bonding broken off in the Essix appliance.

Jeff 11:33  
Okay, I can't... I'll just give you my history then. And I'll give you what I think is the answer for that. 

Dennis 11:44  
Okay. 
I was also taught that bruxism was an incredibly aggressive phenomenon that caused you to break crowns and teeth, right? So I'm working under that premise. But I'm always skeptical, I'm always questioning.
Dr. Jeff Rouse
Jeff 11:44  
My history is I've never had anyone break a tooth off when they were asleep. Ever. A tooth. I've had people... I've had two people break little bits of ceramic, but never shearing big pieces of ceramic off. They broke, and they would complain of it feeling like sand. So they've broken these little pieces off. I'm going to suggest to you that people that break things in the middle of the night were actually awake when they broke it.

Dennis 12:16  
Oh, interesting.

Jeff 12:18  
And that's the difference. They weren't fully asleep. And I will do that occasionally. Since I've been in ortho, I'm more aware of my teeth. And so I will find myself as I'm waking up, moving my jaw and clenching down in a different position, in an unusual position. So if you were to monitor when the impact really happened, I'm guessing that the ones that you're highlighting probably were awake, moving to a side, changing sleep position, whatever... And they were gridding down at that point because they had this thing in their mouth, retainer in their mouth. They had discomfort in their mouth; their teeth were sore from it, something to that effect. I know when I was in Invisalign, and I put a new tray in, I would also... the teeth would be sore, and I'd want to clench against the retainer when I would [put in the tray], but I was awake. So I think what we've been taught about what happens at night is not... is incorrect. What happens at night is you wear the teeth down. And the reason you wear the teeth down... so you're talking about wear patterns. The reason you wear the teeth down is because you're breathing through your mouth, and you may have reflux, and you have the stimulation to grind because of airway events. Now you've got dry, acidic, you know, demineralized teeth; they're going to wear faster.
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Dennis 13:48  
Right. How much relationship there is there with grinding and with acid reflux? 

Jeff 13:57  
A fair amount. A couple of studies... unfortunately, it hasn't been studied very well. But there have been a couple of studies where they compared people that grind and people that don't grind and monitored for reflux, for pH levels in the oral pharynx. And found that the ones that grind had moments where the pH was dropping low, like four, three, in that range. And it would elicit a grinding response and the grinding response would be associated with a swallow. Because it's it's the way you buffer, right? 

If your mouth is completely dry at night, which is what happens, salivary flow is circadian. So you're only swallowing 2, 3, 4 times an hour at night. Now let your pH drop to three. You've got to swallow; you've got to milk up some saliva somehow.

Dennis 14:57  
So because I've seen reports were research where they've suggested I've seen it both ways where the bruxism instigates the reflux, but I've also seen where it says reflux instigates the bruxism. So based on what you're describing, it would be the latter.

Jeff 15:17  
I don't think the bruxism causes the reflux, I think that both of them... Bruxism, I think, is due to negative pressure events, that would be an easy way of saying it, alright? So bruxism can be (and there are other reasons why), but can be caused by a negative pressure event. So what are negative pressure events? Well, there are respiratory events where the airway shuts down. So the body's saying, "I need to breathe." But a negative pressure event also can milk up acid from the stomach, so it's an acidic event. So if we think of bruxism as being a reaction to negative pressure, then you say, when my airway is closing, I'm going to grind, and when I get reflux up, I'm going to grind. One is to buffer; one is to breathe.

Dennis 16:09  
Gotcha. It seems like... I mean, I didn't create the system, but it seems like nature would have created a system where if we were going to be grinding while we're sleeping, and we needed to reduce this negative pressure, that we would be grinding forward to be able to maximize the opening of the airway.

Jeff 16:29  
That is... you would assume, but think about the muscles involved in making you grind protrusively; it's just these tiny little lateral terrigal. The lateral movement is bigger muscles, easier to instigate, easier to activate, and it involves a tongue. I mean, the tongue can be involved in that. The other thing... and I'm just... You know, I have no proof of this, but what we're finding more and more in the ENT literature is that when they do surgical interventions, the AP dimension of the airway is not their key; it's the lateral component of it, so moving laterally may actually be the most advantageous. We as dentists think protrusion because that our device does, so we just assume what we do is what the right thing to do. And it may not be that at all; it may be that the perfect oral appliance would move you laterally, you know?

Dennis 17:29  
During the nights, switch you left to right, move you all around, keep you guessing! 

Jeff 17:35  
There you go. 
We as dentists think protrusion because that our device does, so we just assume what we do is what the right thing to do is. And it may not be that at all; it may be that the perfect oral appliance would move you laterally, you know?
Dr. Jeff Rouse
Dennis 17:36  
Alright, so tell me this, Jeff. So, you know, you are a pioneer in this field. And in my practice, I was practicing with Buddy Mopper, who for those who don't know, was a real pioneer in cosmetics, but especially with composite and composite bonding. And Buddy would share stories about as a pioneer in that field, a lot of the... I don't know. A lot of the pushback that he would get from other dentists. I know Pete Dawson, when he came out with his principles of sort of joint-related occlusion stuff, he had a lot of pushback. He spoke openly about that. Are you comfortable talking about that? About sort of your experiences in this sort of airway world, and being being the person sort of... you're sort of like Don Quixote... you're out there with your sword, and you're running at windmills, sometimes, it might seem. What's been your experience?

Jeff 18:33  
You know, it's gotten better. Because in 2000... And you know, the story, the end of the the first story was in 2008, I started that study in my own office. It led to in 2010, I wrote the bruxism triad article. And in that two year period, and Jim Metz was one the ones... you mentioned, Jim was one of the ones that introduced me to the airway literature and its relationship to bruxing. And so, it was a two year period where I was just fully invested in finding these answers. But in 2010, when I write this article, saying, you know, there's a there's a relationship out there between bruxism, reflux, and apnea, and that you need to be looking. If you see a bruxer, start asking other questions. If you see reflux... I mean, always ask other questions because these are the same people. And then I went off and wrote two more articles in the next year or so, linking it (the airway) to TMD patients, where I said, I think that the run of the mill TMD, headache, morning headache, muscle pain, that patient... I think that's an airway patient and then went on into into kids. I wrote an article about kids and all the issues that kids have, especially ADHD, which is what my son had. I said I think this is just an airway issue. At that point in time, though, I had to make... I had to take this piece of literature and this piece; I had to do a pretty sophisticated debate presentation, where I just had to piece things together, and then fill in the logic between them. 

This is where... and I was following a lot of the stuff that Christian Dimanau out in Stanford was doing. And I know his, I almost... Like I was around him a couple of times. And it was like, "I think like you." I mean, he's doing it, but my mind was thinking the way his mind was thinking. He's a physician, I'm a dentist, but he would tell his residents, you go in the room and you and you are given two minutes to find all the anatomic problems that could be leading to this because he was on the track of it being anatomy the whole time. So I kept thinking the way he was doing, and he was publishing stuff. So my mind was saying, this is what's going to happen and Dimanau would come along, and a year or two later, and I'd have a publication to prove it. So at that point in time, I was having... I mean, I was fighting every time I spoke, and I mean, just on this topic of bruxism. There was a meeting of the American Oral Facial Pain. And there were three mics after... there were three speakers. All three of us took q&a for 30 minutes after all three of us had finished. So it was like these little sessions. And Jeff Okeson was one of them. I mean, he's freaking famous as all get out, right?

And we sat down, and there were three mics in the audience. And this group of like fanatics about... like followers of this one cult, essentially, dominated the three mics and for 25 minutes, we yelled at each other. Finally, the guy running the program said, "We're going to have to take a question for Okeson!" And Honest to God, it was... the first guy stood up and said something, and then I just, I didn't answer. I just sat there and went, "Okay, that was a statement, I guess." And then the second guy goes off and asks a question, and I answered it. And the third question, I could feel my heart start beating hard and I'd get flushed. And I was like, All right, here we go. And literally, we yelled at each other... yelled at each other! -- for the next 20 something minutes. It was crazy. So yes, I had Oral Facial Pain people yell at me about bruxism. And today, the research is now continuing to evolve to show that what I was saying is true. If I was dogmatically believing in the things they believed in at the time, I could absolutely make the argument; "Jeff, hey, you're having to make leaps here!"

Dennis 23:21  
Sure.

Jeff 23:22  
Yeah, I am! And I would have totally understood that. I would have totally said it. You're right. "It's an explanation. I think we ought to start looking at it." But I didn't get that I got, "BLAAHHHH." Right? So I get that. Interestingly, I have rarely had arguments with physicians. Sleep physicians would be the exception; they tend to want to dominate everything. "If you find somebody that you think has a problem, you send them to me." Well, no, I don't think so. Then we would go back and forth, because they want total control of the case. And I'm like, I'll send them to you. But I'm still gonna do my stuff because all I'm doing is dentistry.
So at that point in time... I was fighting every time I spoke... just on this topic of bruxism. 
Dr. Jeff Rouse
Dennis 24:06  
Right. And you're seeing the first line failure where they're seeing endline failure. Right?

Jeff 24:14  
Right. So I have very... ENT. I had an ENT that worked in my office for five years. And because of that, I get along really well, typically, with ENTs...
 
Dennis 24:25  
Sure. You speak their language.

Jeff 24:26  
Because I've got a guy in my office, they know him because he's published. It's kind of like, "Well, if he trusted him, in all trust him." And I'm a big fan of ENTs, so... and I know their... I do. I speak their language, and I read their literature. The one that's funny to me, though, is I am probably the biggest proponent of orthodontics making a change in patients of anyone out there. I mean, I... For me, this is all structural. If we can get to it early, we fix people for a lifetime. If we miss it, we have to play catch up and see what we get out of it.

Dennis 25:09  
That's been your message from the very beginning. 

Jeff 25:12  
And orthodontists argue with me all the time. It's crazy. 

Dennis 25:17  
I see it in my community. I see it firsthand. Anyone who's done any airway stuff, sleep dentistry, and they've tried to communicate with their orthodontist and collaborate with the orthodontist. If you're like me, you've run into a lot of dead ends and a lot of walls. And it's crazy, that you're trying to provide not only better outcomes for the patient, but you're actually trying to give the orthodontist more treatment. 

Jeff 25:45  
Oh, yeah. A ton more! 

Dennis 25:47  
And they will just fight you tooth and nail it. It's bizarre to me; it's incredible.

Jeff 25:53  
So here's what I think they can't get out of their head. Their metric has always been aesthetics and function. Like, you know, the end of all their studies is aesthetics and function. And I don't care about that. I care about health. I care about volume. I care about... And, that's one thing is aesthetics and function. And the other is, and the way I word it today is I show an example of a denture that's totally off, and I say, the wax rim is off. And I and I asked everyone in the audience, what's the matter with the wax rim. And the wax? They go, "Well, it's, you know, it's canted. And it's not supported. And it's not wide enough." And I go, "Okay, well, what would you do?" "Well, I'd warm the wax, I'd move the wax, I'd move it here, I'd add wax, I'd do whatever..." Right? And I then ask, "Would anyone set teeth on that wax rim and try to manipulate the teeth in such a way as to camouflage the fact that the wax rim is off? And everyone's like, "No, I'd just fix the wax rim." And I'm like, "Why do we do that in ortho, then? Why do we do that in restorative dentistry? Why don't we... Why don't we just fix the wax rim? Because if the wax rim is correct, then the aesthetics and function are way better. But more importantly, lousy wax rims are telling you a story about the health of the patient.

For me, this is all structural. If we can get to it early, we fix people for a lifetime. If we miss it, we have to play catch up and see what we get out of it.
Dr. Jeff Rouse
Dennis 27:26  
Right. Well, let me let me ask you a question. So first of all, for those of you out there who have not read Jeff's information from Inside Dentistry 2010 - The Bruxism Triad. You should Google that, and read that because for me, that was just a seminal article, Jeff, that that article really opened up my eyes and gave me an awareness that I had not had before. And then secondly, I think the issue with dentists and with orthodontists on this topic is, and especially with orthodontists, but maybe dentists also, is the whole idea of upsetting the applecart. You know, orthodontists, their practices, they're kind of a machine, right? They have a number of, in most orthodontic practices, certainly not all, but many and most... they have a team of skilled assistants that are going to be doing the heavy labor, they're going to come in and just, you know, change the wire, or whatever they're doing, but they have a system that works. And I think that they're very nervous of putting a word out in the community, because orthodontists are like the most community-established professionals out there. I mean, orthodontists are in the community, they're they're like, they're like clergy, I think, right? I mean, they really are. I mean, people are so dedicated to their orthodontists that they don't want to be seen as someone who is sort of outside, thinking outside of the box or thinking out [of] the norm. And I think it scares them to put themselves in a situation like that. So I think that's why orthodontists are so fearful of losing that grip on their community by going out into this this airway thing, though it's so critical and so important that we're treating this at a young age, because...

Jeff 29:18  
So, I can see that. And I think that's community dependent. In fact, I know, that's community dependent. Your community that you practice in and work in. That's a an older established, right? Conservative kind of community, yes?

Dennis 29:41  
Second and third generation orthodontists. Right.

Jeff 29:44  
You now go to Santa Barbara. I mean, why wouldn't you want to be the holistic orthodontist? Everyone wants that. And so there's a study that in one of the ortho journals that came out in 2011. So it's an older study, but it's still one that I think is valuable for orthodontists to know and utilize. And it said at the end in looking at heart rate variability, which is an incredible marker for overall health, that people that have malocclusions are unhealthy in comparison to people that have normal occlusions. So working to a crappy wax rim rather than going in early and in developing it, and... I mean, you can make this whole case, this entire change, of we're going to be looking at health. So I have two different orthodontic practices in town, one in the in your community, your style of community, and he is more reticent to do this type of really be out there. But I get him to do it. Because that's, it's like, "Jay, I'm sending you this to do this." The other one is in a newer, younger community. And the guy's wife is a physician that is dealing with holistic types of things as well, and his practice is just killing it. It's crazy. I mean, this guy, he works four weeks takes off one, and he's off, you know, doing incredible... I mean, it's like, it's... I don't know, you asked in the other segment that we did, what's your, you know, what message do you have? Well, if you're a young orthodontist, good lord, focus on early intervention. And I mean, be that guy. Be the airway guy. Be different.

Dennis
31:45  
Yeah, I agree. Because if you're trying to compete with the other orthodontists that are doing traditional dental, and there is this phenomenal opportunity...

Jeff
31:54  
And now there's research! I mean, there's a tons of research! It's crazy. So the orthodontists will bad mouth the other orthodontists. It's crazy. I mean, they're like, "Oh, well, he does this, and he he does that, and he's wanting tonsils out on everyone." Well, now there's data that says we ought to be doing this. And so they can turn it right around and say, "If you're not doing it, you're doing X, Y, and Z to these kids. And I don't want to be that guy. So if you're willing to be the old guy looking at just bites and function, and you don't realize the impact that orthodontists can have, you be that. But that's not going to be me."
You asked in the other segment that we did, what message do you have [for young practitioners]? Well, if you're a young orthodontist, good lord, focus on early intervention. And I mean, be that guy. Be the airway guy. Be different.
Dr. Jeff Rouse
Dennis 32:32  
When you're talking about...

Jeff 32:32  
Sometimes, by the way, you were talking about... you know, sometimes you've just got to stand up to stuff and just say that, you know, this is wrong. And nowadays, there's enough science that... it was cloudy when I began arguing with people, it is no longer. It's not as it's not set, you know? But it's pretty darn close. 

Dennis 33:00  
So you don't think this whole airway thing is just a fad? Like, it's just going to go away, like mythology? 

Jeff 33:07  
It's isn't going away.

Dennis 33:08  
If we lived for 20 more years, we won't be talking about remember those days when we talk about airway?

Jeff 33:12  
It ain't going away. It's not... you know, here's the evolution that's happened. And we need to get you up to the course sometime, sometime soon, because it's changed. I spend very little time -- you mentioned Seattle protocol -- I spend very little time talking about the protocol anymore. It used to be about what appliance do you make and that kind of thing... making the appropriate appliance, which I think is still a great idea, and we do it. I mean, I still do it in the practice, but it's very infrequent. Today, it's about just different treatment planning. It's just a treatment plan. In fact, you mentioned airway prosth, and it almost hits me wrong now to think of the course as anything but advanced treatment planning. That's all it is. Frank Spear introduced facially generated treatment planning, Bill and I went in and said, "You know, the problem with that is that it's not systematic enough. We need to make it five questions. And the answers tell you what to do next." So that's all we did was systematize it so that it can be easier to utilize. But both of those systems really only dealt with the vertical component of where the teeth belong. They did a... there's a little bit of a discussion about the horizontal, but not much, the transverse. And there's no discussion of AP, right? I mean, we, you mentioned some markers, but you rarely talk about... it normally is if you look at a case that Bill and I would do or Frank would do, it's like where did the teeth belong in this dimension? And how do I get them there?

Dennis 34:56  
Right. And the only exception to that is we had a VME case and then you would talk correcting... 

Jeff 35:00  
The entire maxilla, right. So, airway adds the other pieces to it. That's it. Because the transverse dimension is the nasal volume, the ability to breathe through your nose and the AP dimension is the back of the throat and where the soft palate sits. So incorrect positioning of the maxilla has an impact on aesthetics and function, but most importantly, health. And so that's why airway isn't going away because it's just going to become part of dentistry. It's just how I see cases now. When I put them... when I used to put them on the articulator, it's like, "Okay, there's the maxilla. What do we... you know, how are we going to deal with that?" Well, we could do veneers that are really fat and bulk them out, and we could kind of give the illusion that we fixed the wax rim, or we could now fix the wax rim. And ortho has progressed at such a rapid pace that I mean, I'm doing MARPE and DOME, and I'm doing... There is sophisticated ortho being done on almost all the rehabilitations I'm doing, and it makes my life easy.
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Dennis 36:09  
So, I'm glad you brought that up. So for those who aren't familiar with MARPE and DOME, those are essentially maxillary expansion, surgical and non surgical, using some sort of retention to place into the palate to expand the palate. So I have a couple questions. I'm glad you brought that up. So one of the challenges, I think, when I'm talking to patients, is what is the predictability with being able to improve airway if you have a successful expansion? How many millimeters do we have to expand? And I know this is different for every patient, obviously, because of what their needs are when they start out. But number one, like, for instance, I have a patient I'm having consult with and I... it's funny enough, this is one I wanted to ask you about: so he's 60 years old, he's very narrow arches, end to end close to cross bite in the posteriors. You know, several millimeters, several millimeters of recession on the posteriors, sort of a classic narrow arch guy. Incredibly healthy. Like, you know, triathlete, super healthy. We did a high res pulse ox [high resolution pulse oximeter] on him; things were fine. He has zero health complaints. Zero health complaints. Number one, it's hard to sell health to people when they're healthy, right? Especially from a dentist's perspective, you know. But number two, what would I expect to achieve besides being able to give... perhaps give him more stable occlusion if I got him expanded. If you have a patient that is healthy, and they are beyond say, being a younger, I'm talking about in sort of a mature adult? Are those patients that you still look to have these conversations? And what I guess I don't know what to tell him to expect? What would be the positive outcome of going through an expansion procedure? And, you know, the procedures that are involved with that?

Jeff 38:15  
So I guess the first thing I would say is that that; you're giving me the exception.

Dennis 38:23  
Okay. Fair enough. That's fine.

Jeff 38:25  
That's a very rare patient. And I would bet that if we set long enough with him, we could find the things that are being impacted, because I've not found people that are your he's having to adapt somehow. He's having to overdo, like you said he's a triathlete. And I mean, there's something that's allowing him to get past the structural issues that he that he has, so he's just trained his way out of it.

So that could be a possibility, but a very rare exception. The rule is that person is going to be sick. So if it's if it is a patient like that, the discussion becomes more difficult in that we go back to old school, it's aesthetics and function that you're going to have to sell. Yeah, well, that's what we did most of our career, right. We need your teeth out here. Here's, you know, we can do a mock up we can. So it's just old school stuff. Today we have for the recession, we could do SFOT surgery where we could cover the tissue, get quicker expansion. You could do what we did in my mouth, right? What the... to answer your question, though, what to expect. Let's do it a different way. If you do an orthodontic procedure to just add bone, so surgically facilitated ortho. Yep. All you can expect is a gain in oral cavity volume.

Dennis 40:07  
Okay, sure. Yep.

Jeff 40:09  
The gain in oral cavity volume typically is met with the tongue coming out of the airway more, and you being able to breathe better.

Dennis 40:21  
You've just opened up, you've opened up the space for the tongue to set more forward.

Jeff 40:26  
However, that's not a guarantee. You may have to train them through myofunctional therapy. A large percentage of old men that have had apnea for a long period of time don't tend to activate their tongue during episodes; they tend to be just lay there and let the tongue... so no matter how much room you create, you aren't going to help them.

Dennis 40:48  
Does myofascial therapy help with those people while they're sleeping to regain tongue function?

Jeff 40:56  
I don't know the answer to that, but it will create more tone, and therefore the airway won't be as collapsible, so it's not necessarily that they're going to move the tongue up or keep the lips close, but they do... their airway will be more toned, so the collapsibility is less.

Dennis 41:14
Does that also support the new position of the teeth? If they go through the myofunctional therapy, get the tongue to be in a better position?

Jeff 41:22  
Yeah, if they can get them there. So, you can do that. And it's basically adding baseplate wax, to a wax rim. Alright. If, however, instead of adding baseplate wax, you actually grab the wax rims and move them out where you want them and put them along, with more sticky wax, right? That's MARPE or DOME, which is where we're actually putting a jack screw essentially in the middle of the pallet and separating an adult the way that you would kid. You can add a little surgical release as well. If you do that, you will absolutely gain nasal volume, you will absolutely gain a lower resistance nasal breathing, you will absolutely get less nasal valve collapse. So, you will breathe better through your nose. Typically, when you get that expansion, you know, and do all the things, you're also getting oral cavity volume, so you're doubling up. So the difference between just doing perio along with ortho and doing the split is the nose, and the nose is the key to everything.
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Dennis 42:30  
I've heard from those who have gone through it, they immediately feel it. I mean, it's like almost instantaneous that they...

Jeff 42:37  
A lot of them, even before the split happens, they'll go, "Oh my God, I'm breathing better!" I'm like, "Well, nothing's happened yet." And they're like, "I don't know. It's just, it's amazing." 

And then when that split occurs, they say it's just like crazy. Like, it's like they just have this whole volume of air coming in. 

Yeah, that's, it is an amazing change. The huge advantage comes if you can do it with MARPE, as opposed to having to make the surgical cuts. 

Dennis 43:04  
The advantage is?

Jeff 43:06  
The nasal volume growth, the nasal breathing; the best changes you can possibly get is if you do it with MARPE because it's like a Le Fort 3. The whole face changes. 

Dennis 43:18  
Got it.

Jeff
43:18  
Volumetrically. And most of the people that need it need, you know, they're they're deficient here. So you get bigger volume changes, better changes for the nose; everything's better if MARPE is done as opposed to DOME. The moment you make the cuts, you don't release a lot of the sutures, and so you don't get as much of a change, so good, but not...

Dennis
43:40  
But with MARPE, isn't it very age limited? Like once you get into like, into your 30s, you're pretty much... you're on the fringe.

Jeff
43:50  
Yeah, guys in their 20s, we're rather... we're questioning whether it's going to work or not. Women in their 30s. But we've had a 68 year old woman and a 48 year old guy. So you never know. You can always try. They're developing some protocols now and it's based on palatal thickness and thickness at the zygomatic buttress and... to try to figure out who's going to split and who isn't. But as of now, we don't have it. You just kind of have to put it in and give it a shot, and see what happens. Now that that brings up another point, which is, I mean, there are a ton of orthodontists don't have that in their arsenal yet, 

Dennis
44:33  
Right. For sure.

Jeff
44:35  
Just like, I mean, how many years did it take us to get orthodontists to start using temporary anchorage devices?

Dennis
44:40  
I still can't! In my community, I still can't get a bunch of orthodontists to use them. It's crazy.

Jeff 44:45  
So there are... we discussed earlier. There are a group of dentists that just want to go to work and do dentistry. They want to get a paycheck. And orthodontists are going to do fine. They're not many orthodontists that go broke, right? 

Dennis
45:05  
No, not around here! 

Jeff
45:08  
You know, I don't see them all of a sudden going, "Well, we're having to going out of business sale this month," right? They don't have that. they're going to do fine. But you have to you have to find, you know, we said that the general dentist that wants to progress has to own their own practice. I mean, we set up a criteria for that. And the orthodontists are the same way. There's got to be a drive for them to be better than the person down the street, and to be one of the leaders in their community and leaders in in dentistry. And it may not be the guy next to you. That might not... And in fact, it isn't, I've got close to me, and I've got a person 20 miles from me, and my patients make that drive. And so I think the restorative dentists that are thinking through how am I going to be better than, you know, how am I going to grow my practice? How am I going to be better? A very important part in the future is you have to work with a progressive orthodontist. If you're not, you can't do the case. I mean, you've gone to Spear, you've gotten the education, you've set your practice up, you've got the patients that you want, you practice case presentations, you do all this stuff, then you send it to the orthodontist down the street, and they don't do what you need to do? You're screwed at that point in time. So, you have to be willing to say, you know, the 10 year old with, everything in the right place, it just needs some tweaking of a couple teeth, you need to go down the street to the guy next to the school. But this person, they need to drive 20 miles, and go see somebody else.

Dennis
46:59  
Jimmy Key had some great advice when we had him in on one of our Sharecasts. He, when talking to young dentists about how to be successful, he said, "Don't compete with people who are doing bread and butter dentistry," right? Get there and learn how to manage joints, manage airway; you do all this stuff, and you're going to automatically separate yourself from... You're not going to be competing with all these others. So for all the young dentists out there who are listening, or even other dentists, who are sort of midstream dentists, and they want to, you know, give a little boost to their career, look at doing the stuff that is going to take more intervention, more time, more consideration, more conversation with patients, to ultimately get them healthier, and get them in a position that a lot of dentists won't spend the time to do. And then collaborate. Find your orthodontist. Find the orthodontist that wants to go to Spear. Learn this information. You know, build study clubs around this stuff, and be the person in your community who's the Jeff Rouse, or the Jimmy Key who does the TMJ stuff out by us, or Buddy Mopper who did all the bonding. You know, be that person, and you will not be short of patients! Because there are so many people out there. 

Jeff 48:15  
And it's fun, too! To be stimulated in your, in every day, to be stimulated about some new thing that you're doing is incredibly fun to do. I mean, it's the reason I still really love going in and doing stuff. It's a blast. So yeah, I don't... dentistry has got to be. I mean, I think it's just got to be intellectually challenging, or it just... I couldn't do the mechanical part over and over again. I think I have to be challenged somehow.

Dennis 48:50  
I think we do it too long, that if you sat there and just kept on, for me, kept on just doing, like you said, the mechanical stuff without the I don't know... the, I don't know, something that's going to make it, that's going to make it more engaging. It's got to be more engaging for me, right. And I think that's it.

Jeff 49:10  
Oh, one other thing I was going to say about if you want to get involved in more complex dentistry, the other thing for young dentists to know is that it is a two year process, I think. And the two year process is you have to feed the specialists the cases, and you can't stop along the way. So I remember when Bill came and joined my practice, I told him, "It's two years. Just be patient." Because you look at the case and you go, "You know what? I could do this case we're just doing a bunch of veneers." And that's what the digital smile design stuff is all is kind of unfortunately leading a lot of people to think, which is I'm covering all these teeth. I make the smile look better. How about I just do veneers and all the teeth I cover?
Well, you know, I've talked to Coachman, and he's not... that's not what he's saying at all. He's just painting a picture. He's not saying that's the treatment plan. And so you need to then say, "Okay, how do I change the wax rim?" And then you put together a plan to go to the orthodontist, periodontist, whatever it is... it's going to take two years for that case to come back when you would have started cutting on teeth. When you get the cycle going, though, and you can't break the cycle, you have to keep it you have to keep pumping...

Dennis 50:25
You keep on planting! You keep on planting, and wait for your harvest.
When it comes back, it's great. But it's two years. But once it gets going, then you are constantly refilled with this new case coming in. So, you'll get a restorative one. And then you'll get another restorative one. And then all of a sudden you get one back from ortho. And it's like, "Wow, that was an incredible month." And you didn't see it coming. But you have to be willing to put up with the beginning where the cases that are going out that you would have ordinarily been able to treat? I'm not treating that one yet! I'm treating when it's in a better situation. And you also have to be willing to accept that more than likely you're going to do, on many of the cases, you're going to do less dentistry. 

Dennis 51:21  
You're going to do less dentistry, yep.

Jeff 51:23  
You're going to bleach and do four front teeth, as opposed to doing 10 or 12 teeth.

Dennis 51:28  
But I tell you that builds your tribe, right? These are people who now are just so grateful for their changes in their health, their life, and you've saved them a crapload of restorative money and not grounded down their teeth. 

Jeff 51:39  
And you don't have to deal with all the problems. I mean, you and I've been doing it a long time. The more dentistry you do, the more problems you have to deal with down the road, right? The less... the more you can keep them in natural teeth, the better. 

Dennis 51:51  
Yeah, I agree. The less dentistry that you can do on a patient, the better off you are. And I tell patients, the biggest downside to dentistry, I think, is that it doesn't last forever. Because any patient could sit down and say I'm gonna do your teeth and you're 25 years old, it's gonna last you until you die; it'll last 75 years. Fine. Sign me up! I think everyone would sign up for that. But that's not our reality. Not in my world, at least. And so...
But you have to be willing to put up with the beginning where the cases that are going out that you would have ordinarily been able to treat. "I'm not treating that one yet! I'm treating when it's in a better situation." And you also have to be willing to accept that more than likely you're going to do, in many of the cases, you're going to do less dentistry. 
Dr. Jeff Rouse
Jeff 52:16  
You know, the good part, though, is, and it's another learning lesson, is when you start doing predictable dentistry and use, that the world becomes a better place for me. I mean, I don't have... I don't go into my office constantly dealing with emergencies anymore. And I've gotten to enough of a point in my career, and the lessons that I've learned have gotten me to say, "That's not predictable. I'm not doing it. You know, this is what we've got to do." Which is, you know, just treatment planning. I don't, I was going to say that I don't let people talk me into stuff... I let people talk me into stuff I shouldn't do all the time, but I try to do it less than I used to.

Dennis 52:58  
That's the advantage of growing old, right? It's like people will push you a little bit less. And you'll stand up a little bit more. Because you've gone down the path they're asking you to go down, and you'd be like, "I've gone down there. I don't want to do this again."

Jeff 53:11  
A lady the other day came in and she said, "I think we need to redo these front two crowns." And she looked at me and said, "And you don't want to do it, do you?" And I go, "No." She said, "Well, will you do it?" "Nope! I'm not gonna do it."

Dennis 53:29  
It's funny at our age when we turn down dentistry because you know, you're just wiser. You know what... you can know what's going to happen. You've read this book before! You know the outcome. 

I want to ask you one more clinical question before we finish up because this is a subject that I'm really confused about. It's about tongue tied. So for for kids, I totally get it. For infants and kids, I understand that the tongue is going to help develop the maxilla, it's going to, for infants, it's with breastfeeding, and all that. And I understand as the maxilla develops that helps the nasal floor develops. What are your thoughts on adults with tongue ties? When do you... When do you recommend releases? What's... Any thoughts on this? I truly, I don't have any information on this. I'm curious what you can give me in about 60 seconds.

Jeff 54:23  
I find that the cases that I look at, and I say the wax rim is messed up in some dimension, a very large percentage of those cases have an associated tongue tie.

Dennis 54:39  
So the tongue isn't going up into the palate and helping spread it out.

Jeff 54:43  
Right, so they either had big tonsils and adenoids as a kid or a tongue tie, or both. And my take on it at this at the moment is if I do the correction to the wax rim, then I want to take care of the tongue tie when that correction is done. If they're not willing to do the correction, I'm very reticent to do the tongue tie. Because I don't know where the tongue is going to go. Now myofunctional therapists will theoretically tell me, "Oh, no, we can get the tongue to go and do this." And I'm like, "But where is it going to go? I mean, the arch is already too narrow, and the tongue is really big." Where? I know it doesn't make sense. To me. It's like ENTs that do tongue procedures to drag the tongue forward, you know, genioglossus advancement, something like that, right? Those... if you run the data right up front, the data looks pretty good. If you run it, you know, three, or four or five years down the road, it's horrible. Because it goes, it drops back to the position was at before, and now they've been through this big procedure. If there's no room, there's no room. 

So my take is that I want to create space before I start dealing with tongue ties, but I'm recommending it at the end of my therapy on a vast majority of the cases because I don't... I think I'm going to create room and then they're not going to put their tongue up there, and either they're not going to get the full advantage of the space, or they're not going to maintain the space as well.

Dennis 56:20  
Is that why you think there's the relapse on these cases is because the tongue is not doing its part to support it? 

Jeff 56:26  
Yes, I do.
So my take is that I want to create space before I start dealing with tongue ties, but I'm recommending it at the end of my therapy on a vast majority of the cases because... I think I'm going to create room, and then they're not going to put their tongue up there, and either they're not going to get the full advantage of the space, or they're not going to maintain the space as well.
Dr. Jeff Rouse
Dennis 56:28  
What do you think, with... this is not inexpensive to go through these procedures. Access to care issues... and so, where do you think we'll get with medical insurance, getting more support for these dental procedures? You think not at all?

Jeff 56:44  
I was shaking my head. Maybe. Because I talked to Stanley Liu out at Stanford. Stanley is an oral surgeon and works in the ENT department. He developed the DOME procedure, and they're getting coverage for that. Medical coverage. I've also talked to Sam Bobek who's a an oral surgeon at Swedish Hospital in Seattle, the one that I used when I was working in Seattle with Greg, and he's getting coverage for upper airway resistance, doing maxilla mandibular advancement. Oh, yeah, we had one patient that had, she had bilateral crossbite, an anterior open bite, and UARS documented through a sleep study, and they got coverage for the ortho and the surgery. So, I know it exists. I think the problem that we're going to have is that MARPE, DOME... Let's just say MARPE because it's a purely orthodontic procedure.
 
Dennis 57:53  
Right? No, no surgeon involved other than a periodontist putting in some tabs or appliances. 

Jeff 57:57  
We don't do big enough studies in dentistry. We won't have, here 10,000 people that went through MARPE, and we did sleep studies before and after. We don't have funding for that kind of information. We're going to get, we had 20 people that had MARPE and this is what happened. And there's no control, and there's no this and there's no that... And then there's you know, 32 people had blah, blah, blah and 12 people did this. We're going to have a bunch of studies that we're going to try to sell as a big unit and the science, the people in the medical world, they're going to go, "Yeah, that doesn't... that isn't going to work."

Dennis 58:40  
Right.

Jeff 58:40  
Now. It's the same... I mean, we've got, you know, rapid palatial expansion literature out the wazoo, but we have 20, 30, 50 and 100. And we've got... we never did a big multi center with controls and this and that and the other and proving that the airway got better. You know, using a real marker and stuff. And all we would look at is, "Oh, look on the set that got wider" or whatever, right? "The the nasal volume got bigger on a comb beam." So what? So, the reason we're probably never going to get medical coverage is because we don't generate science to the level that the insurance company is going to go, "Oh, well, of course, that makes sense. We need to do that." MMA they do. Right? 

Dennis 59:30  
Because there's so much data to support it.

Jeff 59:33  
It's in a hospital, they usually have sleep studies associated with it, it was being done by both ENT and sleep labs and OMS. And I mean, so they created a decent set of literature. But MMA...

Dennis 59:52  
For those who aren't aware, that (MMA) is a maxilla mandibular advancement, so bringing both jaws forward.

Jeff 59:58  
So I think that... Oh, one of the questions you asked was how do we know how wide and such... I think that our protocol is now where we do the periodontal, the SFOT, on the lower, we actually expand the arch as wider than the basal bone allows; we go wide on the lower, and then we expand the upper beyond that. So we start on the lower, get as much expansion as we possibly can to the lower arch, just within a housing of bone. And then the upper is expanded beyond that. Now, so we've maximized the amount of expansion we can possibly get. I think that, along with myofunctional therapy, can be, for many patients, just as good as the full two jaw procedure. How do I know that? Because I've got one patient. No, I've got one in particular that went from an AHI of 28 to an AHI of 1. And having already had UPPP surgery, but you know, all kinds of different ENT, deviated septum -- she had everybody intervene. And when we finally just created the room, she took advantage of it and everything got better. 

So I think that we can be as effective as a full blown surgery. For many of our patients that are not that far off anatomic, you know... like not the ones McGue looks at whose jaws are way set back due to joint degeneration, stuff like that, you have to move those jaws. But the ones that are just a little off the wax rim, we need a little wider, a little farther forward, a little this, a little that... Those patients I think we've got a good chance without full blown surgery of making them feel better. It's just are we ever going to take the time to research it well enough to prove it? Probably not. We just probably aren't. It's never been a strength of dentistry because we aren't funded to do it.

Dennis 1:02:06  
Yep, exactly. And the system in dentistry, the dental schools are not set up like medical schools are to do the clinical research that they are in medical schools. It's just a such a different system. So if we can get Pfizer to, to be in charge of making a MARPE. 

I think they got a little cash laying around right now. They can probably afford to do that for us. So, but who am I to say? I don't know. Jeff, there's so much more to know. And really, it's just, spending this time with you shows even more why I need to spend some time out at the Spear educational facility. There's... here's here's the challenge, I think, with this stuff. And here's, actually, here's a question for you. The information is growing so much. I look back at 10 or 12 years ago when you first came to our study club, and it was just like a little pinprick, right? Do you do you foresee that at some point, that this will be like a subspecialty in dentistry -- sleep dentistry, airway dentistry?

Jeff 1:03:13  
I hope not.

Dennis 1:03:14  
You hope not because?

Jeff 1:03:17  
Because the people in sleep dentistry are taking it the wrong way.

Dennis 1:03:20  
What do you mean by that?

Jeff 1:03:21  
I mean, it's... for them it's: find a sick, fat man with, you know, a fat old guy with apnea, and make a mandibular advancement appliance. That's their only tool. They don't think through... I think it's doing our patients a huge disservice. And I think it actually is delaying our ability to move this where we need it to, which is: we need to be looking at four year old kids and trying to keep them from becoming the fat old man with apnea. 

That's the ultimate goal. 

Yeah. And if we get people... we need to find them at four and then we need to find them at 12 and 18. I mean, we need to find them along the way and we've got these orthodontic tools now that are so much better at intervening earlier to give people beautiful smiles, good function, and good airways that we ought to be using them earlier. We shouldn't... my goal would be to hopefully eliminate the need to ever have sleep dentistry. Sleep dentistry, C-Paps, all that crap. I hope goes away, not in my lifetime... Oh! There's a bonus! A cat!

Dennis 1:04:32  
Right, I brought a friend. I have a friend who needs some attention. This my cat, everybody. So those who can't see this, this is Chip the cat, that just needed a little attention. He was biting my ankles, so I brought him up.

Jeff 1:04:41  
So no, I hope that sleep never becomes a sub specialty because all they're going to do is make these appliances and mess up people's bites. So I think I think we ought to be able to solve it rather than think keep band-aiding it.

Dennis 1:05:02  
At the Spear Institute, you obviously have presentations and stuff. Is there hands-on workshops also with the stuff? What do you learn in the in the hands-on workshops? 

Jeff 1:05:14  
Hands-on workshop -- we have three, I mean, they are obviously lectures. So we have three days worth of lecture material. There are three hands-on components, though. Day one, we do an exam, so we go through what an airway exam looks like. And honestly, it's just a dental exam; it's just looking at the same stuff we always look at. It's just seeing it with new eyes. So it doesn't change your exam and your practice at all. Second day, we do steps two and three of the protocol. Step four, or five and six are done day three; every night that you're there, you go home and sleep with screening devices, so you learn what that's all about. And we evaluate your sleep screening.

Dennis 1:05:15  
Would you mind talking about the six steps since we since we brought a couple times just for those who are like, what the heck are they talking about?

Jeff 1:05:40  
So, we call it the Seattle protocol because I came up with it while I was up with Greg up in Seattle. And the idea was that, that I had been making sleep appliances. So I was talking bad a second ago about sleep dentistry. Well, that's what I did. I made sleep appliances. But I also started learning about the idea of being able to breathe through your nose as being a critical component. And so I said, "Okay, I've got sleep appliances that I made, but I also need you to breathe through your nose." So I came up... I actually wrote an article about it, which was called the Autonomic Nervous System Trial. And it was saying, I'm going to... a person that comes to see me for a sleep appliance, I'm going to make them prove to me that they can't fix themselves before I try to fix them. So it make them go through a nasal breathing protocol first. And if that didn't fix them, then I would make them a sleep appliance. But I would never make them a final sleep appliance. Because too many times people come in and you make them final sleep appliances, and they go, "I don't like this," or "I don't want to wear it," or "It doesn't work." So I made a temporary version. And then I would... if they said, "Okay, I like this," And we proved that it was good, then we make the final plans. So that was the foundation that I went to Seattle with. 

And I was using, you know, as temporary appliance, a thing called a myTAP, which is just a thermoplastic mandibular advancement appliance. And when I went up there, I said to Greg, I said, "You know, the the thing we're missing is that a bunch of my patients tell me 'I can't sleep without my night guard.'" And I used to believe it was because I fix their second molar interference, right? And the flat plane and we prefer I remember being in a room with a really famous dentist and him saying, "The night guard works when you perfect the occlusion on it." And I'm like, "No, I know who you are. But what you just said is not true. And I know you believe it because you perfect the occlusion." But it's not true because night guards work, and people come in to me, and they're crap. I mean, they're just... they barely fit. The occlusion is totally off on them. And yet the person says, "I can't sleep without this thing." And you look at it, you're like "God, it barely even covers any of the teeth and, I mean, it's just a total disaster." "Oh, no, I love it. Don't touch it." Okay, right? So I know that night guards do something. And when you now get into the world of airway, you realize all it does is create more oral volume, more oral volume means the tongue can leave the airway. And so you may breathe through your nose better, sleep better all night long. And if you do, you're going to heal yourself, you're going to feel better. And then I also looked at the research on anterior repositioning appliances, so we move people forward three millimeters on a Ferrara appliance or Gelbe appliance or many, many different varieties, right? Aspirin appliance, some of the common names... And those all seem to do the same thing. You look at the data and read it, and you're like, "Oh, crap! Those work, too. Why would those work?" Well, maybe because they opened the vertical dimension and move people forward a little bit, both very positive things for the airway. So we took -- Greg and I figured out a way to actually take this myTAP and make five different night guards from it. 

So, step one of the protocol, prove to me you can't heal yourself by just learning to breathe through your nose. So we use myotaping, which is a Buteyko protocol. So we teach people to breathe through their nose for two weeks. If that doesn't fix them, we make them a manibular night guard, but it's a temporary version. It's provisional. It's from the myTAP. So we deconstruct the myTAP, make a lower night guard, that doesn't work after a few days, then we add some beads, move them forward three millimeters. If that doesn't work, then we add the upper to it, take the beads off, put the lower in; now you've got an upper and lower night guard, which doubles the vertical dimension. If that doesn't work, we stay at the doubled vertical dimension and move them forward three millimeters, and that doesn't work, then we move them out until they finally feel better. So five different night guards; one way of healing yourself. And wherever the patient feels better, we know that's their sweet spot. That's the night guard they deserve, whereas I was, before, always making them mandibular advancement appliances and messing their bite up. So five different opportunities rather than one to find the right appliance for you. And if I can do anything... in fact, last year, I didn't make a single mandibular advancement appliance, not one. Year before, four. Year before, four. 
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Dennis 1:11:03  
Because once you got to that point, then you would be having conversations all along with the patient about this is a structural issue. And this is what we would want to... this would be our goal with the surgical intervention is what this appliance is doing for you. Is that the basis?

Jeff 1:11:20  
So the protocol does two things, or is used in my practice for two reasons. One is a patient says, "I'm not doing anything to fix me." Or, you know, basically, that's what comes out of a discussion. You know that they aren't doing anything, in which case, you've got to make them something to make them better. Okay? So I make them something. The second is, they're reticent to believe that what you're saying is true. Right? That you need this and that and the other. I mean, you're 60 year old guy? Right? Why would I want to do that? I'm healthy. Well, if we walk through this protocol, and we can get rid of and remember I said, if we search enough, I bet we can find something. 

Dennis 1:12:08  
I don't doubt that. Yep.

Jeff 1:12:09  
If we searched enough and said, "Oh, well, it could actually be that..". If I can make you something, and that goes away, now I've got your attention. Then you can say, in order to be like this piece of plastic all day long, and all night long, you need this. So it's proof of concept. So the two uses I have for the protocol now are I'm going to control your disease, and you're not going to do anything else, or I'm going to prove to you that it makes you better. But what I'm finding now is that by having done enough cases and been using this for a few years is an I just do dentistry. Yeah, it's like, where do I really want the teeth? Oh, and by the way, that's going to be the healthy place. Or you can work the discussion backwards. You know, in order to be healthy, the teeth need to be here. Here's the reason why. Oh, and by the way, you're going to look better and feel and function is going to be better. Whatever gets the patient's attention more, you know, be a dentistry with a bonus health, or the other way around lady the other day goes, "I'm 58 years old and have been married for 35 years. I don't care what I look like." and I said, "I don't care what you look like either." She was like, "What?" Like, "No, I could care less. All I want is your to be healthy." "So this will make me healthy?" "Yes, this is gonna make you healthy." "How do you know that?" "Well, we did your... we went through the protocol. We're just simulating what the protocol did." And finally I went, "Oh, and by the way, you're going to look better! I'm sorry. I mean, we'll work on keeping you this way, but I think you're going look better."
So before you get into any of the airway stuff, I don't want say, for all cases, but are you typically then going through your Seattle protocol as you're trying to get a better understanding? Or no? 
No, not now. Used to be. 

Dennis 1:13:59  
But now you have enough confidence that you can talk to patients, because this is your experience. This is what I've seen. "We could go through this protocol, but I can tell you based on patients like you, this is what I've found." Is that sort of how the conversation goes?

Jeff 1:14:12  
Yes, I'm comfortable enough in my presentation to have that discussion. Today. And what I'm finding is we've been doing the workshop now for four years, and so I've got a group of mentors that started... my kind of best group of mentors went to my first course, and a ton of my mentors came from that group. And so they come back once or twice a year that I get to see them, and the vast majority of mentors. In fact, probably all of them, actually, when they come back. They say the same thing. "I used to do the protocol all the time. It was kind of essentially my crutch to getting into these conversations. The more I've done, though, I don't do it very often. I just present the case; I have the conversation about the case. If they don't want to do it, then I do the protocol to find the right appliance. If they don't want to do it because they're a little reticent about the, you know, how am I going to react? Are you sure this is going to be the case that I do the protocol to prove it." The rest of the time, all they do is dentistry. It's advanced treatment planning. That's all it is.

Dennis 1:15:27  
Yeah. And it's certainly for patients who are, they're stating right from beginning they're not going to do surgery, it gives you a much more predictable way to figure out where their appliance... what type of appliance they should be having and where the appliance should be set.

Jeff 1:15:39  
Yeah. You know, the... So, it's funny you say that, because "I'm not going to do surgery" goes away sometimes. 

Dennis 1:15:52  
Yeah, for sure. 

Jeff 1:15:52  
Just like, I'm not going to do ortho. Oh, I'm not doing ortho. Well, okay. Then you have to, you know... When you say no to that, you're saying yes to something else. 

Dennis 1:16:04  
Correct. 

Jeff 1:16:05  
So here's what you're saying yes to. You're not going to get the advantage of this, this and this. "Well, is there another way we can do it?" No. Do the ortho, or you can not get the advantages that we've been talking about. "But I want to do the advantages." Okay. Well, then let's have a conversation. So what's... you know, then you have the conversation about what's the limiting factor of ortho? "Well, I don't want to be in three years." "All right. Well, you give me two." I mean, you just start negotiating time, or cost, or whatever it is. It's... but you've got them for the ortho. Because they...

The change in my world happened, when, first of all, when I started believing more in ortho. And that came when I did a little bit of ortho for a while, and then I could... and then I found the right guys to help me, and so I was... I'm a big believer in ortho and in restorative care. So I've always been able to sell it. I'm also a big believer in gold. And I've always been able to sell gold. I mean, everybody has gold in my practice. I actually have a technician in my office that just does gold. So I mean, it's what you really believe in. But the added part, the added element of the protocol allowed them to believe it as much as me. Right? And so they're like, "Well, I feel better with whatever..." and I go, "Okay, well, in order to be whatever, in order to be that thing..." because the moment you take it out, you're you again. You're not that. And it also... I mean the more sleep appliances you do and the more bites you mess up, you also start believing it a little bit more, too.

Dennis 1:17:52  
Yeah, I think that's absolutely true. I think the more you do it the more you see that there's going to be some changes not for everybody but there's are going to be people whose bites change, and then how do you manage that, and conversations with that become really complicated.

Jeff 1:18:03  
Yeah, you know, the interesting thing... I have a new one for that, which is people go, "Well, I want my bite back. I want to get my bite back." And I... My line to them is "No, no, no. The new bite... the new bite is actually better!" And we screen them with their new bite, and 100% of the time, their airway is better because their jaw is held, is right more forward, right? So... and it's more open, so their tongue goes out through their teeth, right? So my line now is "old bite bad; new bite good." And they're like, "But I want my bite back!" "No, no, no! Old bite bad! New bite good!"

Dennis 1:18:44  
Can I use that? A little Jeff Rouse Confusionism.

Jeff 1:18:50  
I need a t-shirt!

Dennis 1:18:51  
You do! You need to brand that! Make sure you get that copyrighted!

Jeff 1:18:56  
"Old bite bad; new bite good!" Because it's... that's I remember having a friend that that that happened, and he took out lower buys and retracted them. Like Oh my God! What are you doing? And sure shit he ended up back on C pap and the whole thing! And I'm like, "NO! Old bite bad; new bite good!"
[When patients say they want their old bite back,] my line to them is "No, no, no. The new bite... the new bite is actually better!" And we screen them with their new bite, and 100% of the time, their airway is better because their jaw is held, is [positioned] more forward, right? So... and it's more open, so their tongue goes out through their teeth, right? So my line now is "old bite bad; new bite good." 
Dr. Jeff Rouse
Dennis 1:19:17  
When do you finish with your ortho?

Jeff 1:19:20  
I've decided I'm going to be cremated. And so I've always wondered if this nickel titanium stuff melts and what temperature? So, I wondered about that if you'd see this ashes with this... this orthodonic... 

Dennis 1:19:38  
Yeah, but with your better airway, you're going to live forever! 

Jeff 1:19:41  
My devanding will be cremation! You know the story ends if I ever finish. So I have been told the first of the year but I'm not holding out for that... 

Dennis 1:19:58  
We've heard that before from orthodontists. 

Jeff 1:20:01  
So I'm actually...I'm turning 60 in May. And so I want them off. And I'd love to have the restorations on, but I doubt... I mean that timing would be really difficult. But yeah, I'd like them off. That would be really cool. Before for my 60th birthday, so...

Dennis 1:20:25  
Some people say 16TH; Jeff Rouse says 60. Just to be clear, 

Jeff 1:20:30  
Well, yeah. I'm breathing better, though. 

Dennis 1:20:33  
Well, ultimately that's the whole thing, right?

Jeff 1:20:35  
When we go out, I still don't have bad apnea at the end of the evening. I may slur more.

My apnea... I actually I got to do a beta test for a device on a phone. And to show you how weird I am, I did it with like... I would keep a diary. Okay, "two drinks at seven o'clock."

Dennis 1:20:59  
That's a Friday.

Jeff 1:21:01  
And so I never got over HI of 5. I mean, I could drink right up to the minute I go to sleep, and five was my max. So that's pretty good.

Dennis 1:21:10  
And you've had SFOT, you've heard surgically facilitated orthodontic treatment. Was that once or twice? 

Jeff 1:21:15  
Twice. 

Dennis 1:21:16  
Twice. 

Jeff 1:21:16  
I would have... I didn't have the option of DOME. I would have done it that way. 

Dennis 1:21:21  
You would have done DOME to begin with? 

Jeff 1:21:23  
Mmm hmm. I would have been done.

Dennis 1:21:25  
Would you have considered SFOT as an adjunct to the DOME? 

Jeff 1:21:29  
Yes.

Dennis 1:21:29  
Okay.

Jeff 1:21:30  
Yeah, because I've got better tissue and bone support from my teeth now.

Dennis 1:21:34  
So just quickly, for those who aren't familiar with SFOT, it's also called local dontics, or there's other descriptions for it. But essentially, there's incisions that are... the tissue is flapped, the tissue is released, there's cuts that are made in the bone. There's something called a RAP phenomenon, which allows the teeth to move faster. There's typically some bone grafting that's done before the tissue is put back into place. And then you can get up to maybe 10 millimeters of expansion. That's what Mandalar says, but I think that might be pushing it a little bit. So maybe 6 to 8 millimeters? 

You can get a bunch. You can get as much as you need. 

Yeah. So it allows you to move, to upright the roots, and you can then move the roots into this new bone, into this particular matter that you've done. 

Jeff 1:22:19  
I've got eight; I had got eight millimeters more inner molar width. 

Dennis 1:22:22  
Okay, so that's first molar, first molar palatal first molar palatal.

Jeff 1:22:26  
Yeah. And we didn't measure it on cone beam. We'll eventually do it when I'm finished to see true movement, but... 

Dennis 1:22:33  
And then you did a maxillary expansion? You did MARPE? Is that what you did? What did you do for you?

Jeff 1:22:38  
No, I'm too old. No, I did that in the upper. I did SFOT in the upper, and I did a little bit, a little bit on the lower right. 

My lower jaw is big; my lower arch is big. My upper, I have bilateral crossbite and anterior... So, my problem is all upper arch.

Dennis 1:22:56  
So you just did two rounds of SFOT. You did not have any expansion surgery. 

Jeff 1:23:00  
No. I would have, I would have done DOME.

Dennis 1:23:03  
To do it again?

Jeff 1:23:04  
I actually entertained the thought of later on... Every so often when I'm not getting done, I'm like, you know, I could just move that whole segment...

Dennis 1:23:16  
Yeah, and just make it get done faster. You're done. 

Jeff 1:23:19  
But anyway, we'll see. 

Dennis 1:23:23  
Alright, buddy. You know what I was thinking -- there's gonna be... Someday there'll be a dentistry Hall of Fame. And I was thinking, you know, so you will for certain be one of those key members in the Hall of Fame and Jeff is a Kansas City Royals fan, a baseball fan. And so I was trying to like equate it, and I was like, Alright, so who would he be from the Kansas City Royals? And who's your favorite Hall of Famer? I'm curious. 

Jeff 1:23:53  
My favorite Hall of Famer or my favorite Royal? 

Dennis 1:23:55  
From the Royals.

Jeff 1:23:58  
You know, I... so, I played second base, so Frank White was always a big deal. But, George Brett, that's if you're a Royals fan, you have to think George Brett, that's...

Dennis 1:24:11  
Probably the greatest Royal ever is George Brett. But I said that can't be Jeff Rouse because he's an infielder. So Jeff Rouse, he's the kind of guy that needs to be holding the ball all the time. He needs to be a pitcher. No, no, no, I don't think so! So I think there's a guy named Quisenberry. Remember Dan Quisenberry? 

Jeff 1:24:31  
Oh, yeah, Submarine.

Dennis 1:24:33  
Yeah, he had the little sort of side arm, underneath arm, submarine pitch right hander. And that's sort of Jeff Rouse. Jeff Ross is going to be... he's not; he's unorthodox in his style. 

So to me, even though I think George Brett is the greatest of the Royals, I think you're more Dan Quisenberry because you've got to have the ball in your hand, and you're going to come at people a little bit submarine, a little bit under arm, a little side arm, and it's goint to be a little bit a little bit harder for them to appreciate some of the stuff you've done. 

Jeff 1:25:02  
I like it, I like it. Thanks. 

Dennis 1:25:05  
Alright buddy, I can't thank you enough. I mean truly the amount of time that you've spent with us. You're so generous. How do people want to... if they want to reach out and they... And I can't encourage people enough to go learn from from Jeff. Get out to Spear. How did how do they do that?

Jeff 1:25:20  
They can look up SpearEducation.com. Speareducation.com is a website. All the workshops are going; they're all back at full capacity. We still through 2021 are doing the seminars online. And 2022 is still... we're hoping because the auditoriums a little over 300 people. So we're hoping to start doing them back there because I love having that much energy in the room. That's fun. But the definitive time for when that's going to happen hasn't been set. But the workshop is out there. Really, and the workshop is... while I would love for everyone to have a background in airway before you take the workshop, and treatment planning the way that we teach it out there. We've, since COVID and the kind of restrictions on travel and how hard it is to do, we've eliminated those entry points. And so you can come straight into the workshop, the airway workshop, and visit. And you don't have to mess with the other things right now. So if you want to just catch that, if you've gone to some other outstanding places for treatment planning and occlusion and all the rest, and you just want to skip to airway, this is the time to do it because we're gonna allow that for a while.

Dennis 1:26:48  
The nice thing is you can do like a two for one. Go out and see Rouse and then go see Jimmy Key, and then you get the TMJ occlusion and the airway, and then you can get them together and you can hear them debate which came first, airway or joints, and the chicken or the egg.

Jeff 1:27:00  
We're actually, yeah. We're doing that AES this year. At Society, we will have McKee, Piper, and myself on a... like three lectures in a row, and then a panel, so we may be back to screaming for twenty minutes!

Dennis 1:27:16  
We saw that at the Restorative Academy a few years ago, so they got the band back together! That'll be awesome. 

Jeff 1:27:24  
So, should be fun. 

Dennis 1:27:26  
Jeff, truly, thank you for your time, your sharing of your knowledge, your experience. This is so valuable, for all dentists, but especially I think about the young dentists as they're finally finding their path and stuff. The amount of courage that you show, and I appreciate it, and maybe I appreciate it more because I saw, learning from Mopper and sort of some of the obstacles he had to overcome in his pioneering. But we are a better professionals because of you. I can certainly tell you, I'm a better dentist because of you. I appreciate your friendship. And I appreciate your guidance with all this stuff on airway. So thank you so much for your time.

Jeff 1:28:02  
That's very nice of you. Thanks. I really... you know, one of the great things that has come to me is I grew up in a little bitty small town in Texas and to think that I get to know famous people like you is pretty amazing. And that I know, right? To get to know who you really are and what an incredible person you are is just such a treat. So thank you for having me on. I appreciate that.

Dennis 1:28:29  
Thanks so much. All right, everybody. I'm in my fancy Panama hat. That's it for now. Thank you for joining us for our DOT Sharecast. And always yours for better dentistry. I'm Dr. Dennis Hartlieb. We'll see you next time.
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Exploring Nighttime Bruxism

Listen in to hear Dr. Rouse's thoughts about nighttime bruxism.

Timestamp 11:44 in the interview.
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Explanation of Role of Airway

Dr. Rouse examines the role of airway in today's world and the way that it's an integral part of dentistry.
Timestamp 35:01 in the interview.
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The Impact of Using MARPE and DOME

Dr. Rouse explains the potential impact of using MARPE and DOME with patients. 
Timestamp 41:14 in the interview.
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The Role of The Seattle Protocol

Hear about the steps of the Seattle Protocol and how it works in practice with patients.
Timestamp 01:09:36 in the interview.



Dennis Hartlieb, DDS, AAACD

DOT Founder

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