The role of tongue position, posture and the airway on the developing occlusion is hardly covered in Dental School. Let’s think BEYOND TEETH with Dr Bobby Supple, carrying on from PDP099.
Protrusive Dental Pearl: When checking someone’s occlusion after a restoration, do not just check it while they are supine (lying down), sit them up then check their occlusion again because posture does change our occlusion, even just a little.
In this episode we covered:
- Skeletal Bite vs Tooth Bite 4:45
- Trigger Points 13:28
- Myofunctional Therapy 17:14
- Dentistry and Other healthcare professionals 24:57
- Neuromuscular Dentistry 38:19
Check out the book Dr Bobby Supple recommends: New Trends in Myofunctional Therapy
If you enjoyed this episode, check out the first part Occlusion Wars: Which is the Best Occlusal Religion?
Click below for full episode transcript:Opening Snippet: Okay, so Teeth are together for long periods of time at nighttime, then the sympathetic nervous system stays on. The sympathetic is fight or flight. That's what apnea is. Squeeze, AH...
Hello, Protruserati. I am Jaz Gulati, and welcome to episode 101. It’s a continuation from Episode 99, which was Occlusion wars: Which is the best occlusal religion? And just to give you a flavor of that episode, like a quick recap, I wanted to find out, which is the best training institute for occlusion. Is it Spear? Is it Kois? Is it Dawson? Is it Pankey? Is it neuromuscular? That kind of thing, which is a common question that we all ask on our journey after dental school. And we think that, okay, we need to upskill and learn about comprehensive dentistry and how occlusion fits into it. Very often, we’ll be faced with this choice. And some people go for koiss, and some people go for Dawson. And I got someone on Bobby Supple, who continues in this episode. And he blew me away, because he’s done so much training with all these greats, he’s been in the same room, you know, Kois and spear and Dawson. And everyone’s together debating, and he’s been very much part of that. And it was great to learn from him. And essentially, it doesn’t matter who you train with, they argue and they challenge you on the different processes, the outcomes are going to be very consistent. So the answer is train with whoever you want, whoever is most convenient for you, best price for you, best mentors, maybe your principal, or your boss has also done Kois so you should do Kois. So you can speak the same language maybe, or maybe because your principal’s on Kois, you should do Dawson. So you can exchange notes about the how to, and how to get from point A to point B. But essentially, you will do your patient service. And you will do a great job, whoever you choose for your training partner, you make sure you implement it fully, and you do your best. And I think that was a really cool lesson. And going further now from that episode to this episode. The main thing I want to leave you with before we join the main interview is that sometimes, especially when it comes to occlusion, the first time you hear something from an educator, from a speaker, it doesn’t quite make sense. And sometimes you have to hear something like for the fifth time, and it’s eight years later, and then it clicks in your head because by then you’ve accumulated enough failures, you’ve got a bit more experience under your belt, you’ve got a bit more deep thought and experiences to reflect on. So if this episode is a little bit beyond you, because we do talk about higher level stuff, relevance of the airway, tongue posture, posture in general, this is all stuff that even I’m just learning, grasping more into, because very much, you know, my training was at the two teeth and the skeletal level. The teeth and bones, teeth and bones and how to make them meet together. But we’re and now I’m well versed are looking at the joint and the condyle and orthotic appliances prior to full mouth rehabs, that kind of stuff. But then looking even beyond that, and looking at airway. So this is a huge area, and even looking at children and prevention and how can we not just fix people up once they’ve destroyed that dentitions, but actually set them up at a young age so that they have a good chewing system, a good breathing pattern, and that actually has a huge influence on their anatomy. The Protrusive Dental Pearl for you is inspired by what we talked on this episode. It’s something that Kushal Gadhia taught me when I was doing some occlusion training with him. It’s basically when you’re checking someone’s bite, and they’re lying down. And we do this all the time, right? We fit a crown, we do some restorations and we get them tap tap tap while they’re lying down. We should also check it when you sit them up. Because there is a slight difference and what you might find that whilst everything is feeling okay to the patient, or is feeling okay according to your usual checks, which consists of articulating paper marks, checking for parameters with your fingers, checking for how it’s or listening to how it sounds, you know, listening to the bite and how it sounds. So once you’ve done those checks, it’s really good to check it when they’re sat up as well. And just to confirm, and every now and then you’ll realize actually, when they’re sat up, yes, the tooth is proud again. And he’s got to just adjust it there as well, because posture does change our bite. So let’s join part two of occlusion wars, and go deeper into areas where I’m exploring as well, like the book that Bobby Supple recommends in this episode is new trends in myofunctional therapy. I’ve been trying to get my hands on this book, but it’s completely unavailable everywhere. I think there’s some new ones coming in 2022, coined Amazon, and what so and stuff. So I’m looking forward to delve in deeper into this side of things, and was interested to learn about the Atlas and posture and the role of nasal breathing or things like that, which I’ve respected, but he puts it all together in terms of the occlusion. So you may find that Whoa, this is a lot more to take in because it’s stuff that we haven’t traditionally covered at dental school. But I think it’s really important to expose yourself to it, even if it’s for the first time for you. And then maybe sometime later, when you read a bit more or you shadow some mentors, who also practice this kind of stuff. It starts to make sense. So thanks so much for joining us on this journey and I’ll check you out in the outro.
[Bobby] Now real quickly to your point going forwards the dentist, okay. Like you look at your child, I looked at my kids. And so one of them we actually did orthognathic surgery on I mean, you’ve talked about a gut check when you have your A child and you’re looking at it and going okay, wait a second Am I going to put my child through that but it was for a lot of different reasons. He was a soccer player and concussed and had some accidents and so she so it was not just a class two even though she did have an airway thing and stuff like that, okay but that’s a gut check when you’re looking at your kids and you’re going okay, am I going to actually practice what I preach? Okay? So it’s the dentist though, it’s the dentist who sees young and old, we see male and female, we see you on a regular basis, we see you when you’re well that is radically different than if you have a strep throat and you got to go to a physician, they can only do put you on antibiotics. And we see you when you’re lying down that is just absolutely critical. Almost all therapies, chiropractor, PT, massage therapy, dentistry, we do it when you’re lying down. And that’s a concept that dentistry hasn’t really quite understood yet. So when you’re lying down in a job drops back a little bit in a closed, they’re in a tighter arc. So we’re actually doing our little crowns in our adjustments and everything is receeding, and we’re seating the condyles without really even knowing it because we’re practicing when they’re lying down. The patient sits up, let’s say you put in the crown first molar patient sits up, and then they go, Oh, Doc, no, I’m hitting it. The dentist, okay, well, fine, lay back down, or they just did some more because you got to retrofit anything. Okay. But you got to ask the question, then, if you were lying down and the bite seemed fine, when the patient was tapping and then the patient sits up and goes, no, no, Doc, it’s too high. And you know, okay, well, I’m not letting them out of the office with this, then with that feeling because you know, you’re getting the phone call tomorrow, okay. All right. So you’ll go back and adjust it. Okay. So why is that? Why is lying down just so absolutely critical? And the reason is simply because your head is supported. And so when you’re supported here, then the neck is going to want to relax. I start every exam, every single exam, hygiene checks, everything like that in the first place I go is here, go right back to the Atlas, they’re lying down, okay. And then I can figure out which is the tighter side. And then pretty much I know that that’s the side that the lateral pole is going to be a little bit tender on, that’s the side that the airway is probably going to be the least. Okay. All right. So think of the maxilla like a V, mandible wants to grow like a U shape, a U doesn’t fit inside of a V. So they pick a side. That’s what you see on the T scan at age 12, 13. You know which side is the side that they’re pushing off, okay? So just for your audience right now, just because there’s everybody has two bites. I mean, all these occlusion Wars came down to this. Everybody has. Okay. You have your skeletal by bones, ligaments, muscles, posture breathing, that’s your skeletal bite, and then you have your teeth bite. Okay. Yeah. So we’re just in dentistry, we know how to retrofit the teeth, a tooth cracks, okay, cracked crown, build it in there, we’ll get it all into it slide. That’s how we do. There’s nothing wrong with it. Okay. All right. But the skeletal bite is the general the skeletal by tells you how stable everything is and how balanced all of the system is. And we still have yet to quite figure this out. The mandible, the shoulders, the hips, the knees and the feet, there’s five planes in the body. And all five of those planes you want to be balanced. But if the mandible is growing off center, like that, then the shoulders like that the hips, the kids that grow, the girls will grow into some scoliosis, all of these sorts of things. So the fact that we can get to these kids young, when they’re healthy as a dentist, and we’re looking down the oral cavity. Dentistry is literally in the mainstream of health care, but healthcare doesn’t know it yet. Okay, we have the power to change health and wellness. But we got to get to the kids and we got to get them widened out and we got to get them to breathe through their nose. And so you were talking about your son. So here just a little thing if you’re just sitting right now, okay, if you’re sitting and slouching, okay, and one shoulders like this, because I do this way in. When I’m in a lecture hall, because everybody’s sitting there, you’re like an hour and they’re all tired. Everybody’s like, okay, yeah, they got their hands on the table like that. And they’re kind of sitting like that they go, okay, so stop right there. Now, tap your teeth. Just tap your teeth in that path. Okay. All right. Then I tell him okay, now. Take a deep breath. All right. Chest up, we’re going to roll our shoulders back, you’re going to take your hands, you’re going to stretch back, you know, you can do this if you want, but stretch all the way back, tilt your head up a little bit better get your posture, exactly all like that. Perfect. Okay? Then you get it. Okay? Now take a couple of deep, deep breaths, just breathe in, breathe out like that, okay? Now, if you take the tip of your tongue and you put it on the roof of your palate, you just put it up on the palate to the back. Okay, now the condyles will sit, the condyles will want to sit. And then you just do like, I get, don’t touch your teeth, fail, let the time relax, just go like that. Okay, they are sitting up like that perfectly straight. Now close. And just lightly close down. And I want to know what to touches first. Okay?
For me, it was my upper left premolar, on my left premolars, yeah. [Bobby]
So is this going to be one of four primary positions, it’s either going to be a second molar in the back, is going to be a pre molar in the corner. So if you think of it like a V shape and a U shape, well, it’s either going to be way back, or it’s going to be in the corner, okay? All right, and it’s going to be on one side more than the other. Now, that is your skeletal bite. So what you would see on the T scan when you were lying down, if you had the patient, close, swallow, squeeze, and then tap tap tap like three times, then the pressure would push off of your upper left premolar side. Okay, so it’s like, it’s the clue that says, Okay, wait a second, my teeth bite is a little different than my skeletal bite. For you, that’s your anterior control, that’s where you’re going to see some abfractions, that’s where you’re going to see the little pole in the gums. That’s where the lower cheese is going to start to press for it. So then you get a bicuspid drop off, and it all goes like that. Okay. Now in all fairness, if we track this and you cone beam get, then we would find that between your nose, your sinus and your ear on that side is narrower than on the other side. Because growing up your cartilage base, wasn’t perfectly symmetrical, because nobody is. So you’re sitting in first grade, you’re just sitting in first grade, and you can’t breathe perfectly like this. So literally, you tilt your head up like this and turn it in. And that’s how you sit, grow, sleep, swallow, and everything is going to grow into that. So between 6 when your first molars come in, and 12 when you have your full adult dentition then the cranium is grown and the asymmetry is in the mid face. And we call the cranium the criminal. And finally, basically now it’s, you just draw a line between the nasal airway, the cheekbone, the jaw, go back to the ear, go right back into the trigger and the neck and then drop down into the shoulder. And the epicenter is here. So I knew we would do this. [Jaz]
All right. [Jaz]
Trigger points. Lovely [Bobby]
Trigger points. [Jaz]
Janet Travell and David Simon’s. Yeah [Bobby]
Exactly. So I was probably I’m gonna say it was 1995-97, somewhere in there. And I went to California, and I’m listening to Janet Travell. Okay. Janet Travell, she was kind of eclectic. And there were some really wealthy women in New Mexico. A couple of them were my patients and they would actually fly, bring Janet Travell in, and they, she would work on them. Now Janet Travell was John F. Kennedy’s personal physician because he had back pain and so she that’s where she kind of got famous to start. Alright, but I had never heard her lecture until I went to Palm Springs. You know, one January when it’s all sunny and everything like that. You know, I just tell my wife. Hey, you want to go here? Yeah, I’ll go there. Okay. So I’m sitting in the room. Okay. And then they bring Janet Travell so they have to help her onto the podium, sees 90 some years old, she can walk but she’s not in a wheelchair or anything like that. But she can’t make it up the steps to the podium. So she’s up there and my first thought, I mean, it’s like an idiot. My first thought was, oh, I’m too late. I missed her. She’s too old. Okay, literally, she starts talking. And then I’m going okay, wait a second. This is Mother Teresa. And a lot of the audience was surgeons and stuff. They weren’t really interested in Oral Biology conference. And so they weren’t clinical dentists like I was. Okay. And literally, she’s five minutes in. And then this is what she says, she’s pointing to these two. So this trigger here, and this trigger right here. Okay, she goes, [Jaz]
So just to describe, you’re pointing to the trapezius and right side of the [Bobby]
You go to the Atlas, and then you drop down, and you can find it in a dental chair as soon as the patient lays down. So Monday, you’re going to go right to here, and you’re going to feel the tight side. And then you take your fingers and you go underneath the shoulder blades, and then you’ll find this trigger here. Okay, all right, they’ll just be tight. In the beginning, you’ll kind of think, okay, it takes a little bit of time to practice to feel the difference. But after 10-20 of them, you know, you’ll start to go oh, now I get it. And just like when you palpate here and you’re going you’re putting pressure on a lateral pole or whatever, put some pressure on it. I mean, you can literally take your finger and press into it like that, every once in a while the patient will jump or whatever, okay, but what happens is a child and these become your headache patterns. Okay, well, this is what Travell said right off, she said it two or three times in a row, because she’s talking to a dentist, and she goes, These are your dental triggers. Okay, I took a couple of deep breaths because I’m thinking late 90s. I’m thinking job teeth. I’m thinking this here. And I was all into her these all of these guts. Okay? So all of these clothes squeeze, temporal headache, jaw into the ear, pressure here. So this guy, this guy up and down here, sometimes I could get this one here. But never this one, this one, this one and this one was how totally out of my paradigm at the time. [Jaz]
Bobby about some videos in Instagram actually are patients who come in and in pain from a lateral incisor. And then I’m checking the trigger point on the temporalis and I can recreate the familiar pain. So this is when you first do it, it’s like wow, okay, this is there’s something to this. [Bobby]
Now, you’re going to take it all the way back. Because the future of dentistry. Yeah, the future of dentistry going forward in a digital world. Okay. Yeah, we know that teeth job, bite relationship because of all the philosophy wars and everything like that. But now it’s what’s below the teeth, your tongue swallow. What’s behind the teeth, the Atlas and the neck posture. What’s above the teeth, your nasal airway, and what’s in front, the face. Because we would always look at the face and then design the teeth to make it look like it all matched up into it and take a look at how pretty we’ve made these smiles. But the patient might be like this, okay? But the future going forward in dentistry is literally tongue swallow reflex. How does that tongue grow? Now we call it myofunctional therapy. I’m going to show you one book here brand new book out of Italy. Okay, so it’s called myofunctional therapy. I’ll set it up into it. You can’t I don’t know that. You can buy this on Amazon. But I might be you just gonna [Jaz]
I’ll throw a link. If it’s wherever it’s available from I’ll throw a link on there. So yeah, new trends in myofunctional therapy occlusion muscles and posture. It’s a very similar to the Carlson books? [Bobby]
Yeah, exactly. Exactly. It’s just, it’s out of Italy. And during COVID What happened was, there was six or eight weeks when the whole world was shut down. Every single dentist in the world was furlough. Okay. And then dentists just their social so they were going online. Okay, and then they had this occlusion confusions things like that. So, Javier out of Florida was putting in and he was interviewing people about occlusion, but what he literally did is he was zipping around the world. And so every single day, I would have a podcast, it’d be like two o’clock. And I could just dial in, I’ve just go right on the internet and go oh, which podcasts are happening today and they were coming from all over the world. You had Chirodontics, you had you know, orthodontists, you had the airway Doc’s, you had the surgeons, you had the cosmetic dentists and everything like that, but they were after a couple of days on my first thinking was, you know what, we’re all on the same page. I can’t even believe this. Dentistry around the world, we’re like on it. And everybody was coming at it and, and they were all kind of coming around it. And so then this one group out of Italy, Sacred Heart Hospital next to the Vatican in Rome. It was like the pope blessed him, you know, literally across the street from the Vatican in this big hospital and 20 years of research, but they’re looking at Oral oncology, and they’re looking at anything to do with swallowing and breathing with the kids. And then they just developed into it and they going, okay, the tongue swallow reflex, that’s the maxilla and the maxilla is offset by cause of the airway. And then the head has to hold into that. And so the epicenter is that tongue swallow reflex in the kids. And it’s age 7 through 10, that that tongue should break and you should lose the infantile swallow into being an adult chewing swallow. Any person who at age 10, still exhibits an infantile swallow means that the tongue swallow is over protecting the airway. And it’s all because of post nasal drip, and then they swallow it. And then they grew into that pattern. So now, you know, the sockets aren’t symmetrical. The sockets aren’t symmetrical, the atlases aren’t symmetrical, and then you made the comment at the beginning and then I’ll be done. You made the comment. Oh, yeah, we’ll see our doesn’t talk about the disc. That doesn’t end the definition, doesn’t talk about the disc. Well, guess what, you have a lower compartment that has to do with more rotation, you have an upper compartment above the disc that has to do more with translation. And then you have another condyle back here, which is the Atlas, which is all off center, too. So in to have six joints, you’ve got three on each side, like that, and all of them grew into this, have and now you can systematically just pick it apart as a dentist, if you start with the triggers, then you’ll kind of get the idea, then you’ll start looking at your panels, and going oh, one condyle’s up here, the other ones down here, oh, one palate goes this way. And then it stairsteps up and, and you’ll start looking at it, this side and this side skeletally. And then you’ll quickly start going, Oh, the abfractions match this, the forest patterns on the T scan match it, the gum recession, the cracks, the wear facettes, they all start to match up. Because it was one shoe at a time like one leg shorter than another over decades. So it goes into an asymmetry. Everybody has two bites. It’s when the skeletal bite and the airway and then posture bite are overpowering the teeth, that a dentist will have a problem. Those are the ones where you prep a second molar, and then the joint seats. And then they come back and then you put the crown on and the crown’s too high. And you go No, I know I gave myself enough space. Well, what happened? The condyles, you know, and the posture went better. And their headaches are less. And then now you go put the crown in. And now the crown’s too high. Well, guess what? It wasn’t your lap. It was like you have two bites and so dentists are good. We know how to get around problems, because you don’t want the patient complaining or you don’t want the too sensitive so we can retrofit it. And I’m just telling you, there’s nothing wrong with that. Dentists are Awesome. [Jaz]
Well, I just want to just say that mean, I like the term retrofit that you used because I think it really makes it tangible who are listening that okay, what we’re essentially doing is we are retrofitting teeth to an ignoring the underlying, and I think what you’ve done is brought lighter fact that, okay, it all starts at a very young age with the swallowing, and how things compensate. And what we’re dealing with here is a much bigger issue. But before I let you just talk about the direction about how in dentistry, we can be more unified in this front, because one of the challenges is A) lack of education on this at Dental school and acceptance amongst perhaps some prosthodontics societies who are very much still focused on the teeth and jaw and not at the bigger picture. So that’s a big challenge. And B) you know, it’d be great if the health care professionals are more allied, you know, as a general, we are almost sometimes dentistry as if the mouth is not part of the body. You know, it’s sometimes we need to have more open conversations with our other healthcare professionals to be able to do a more holistic diagnosis. So those are some of the challenges but I was just pose you this one question could have so many different directions we can go in, if you can go back 10, 15, 20 years to those cases, when you were doing these beautiful Empress restorations. And you had these teeth setup, how you were trained to set them up and for many patients at work, but then you know, it’s obvious, some chipping and cracking, which you now can look back and think, Okay, it’s because at a higher level you are retrofitting. How would you manage that case today? And then if and I’ll let you answer that. And then I might just give you another sort of challenge to what I think you might say. So how would you manage those same cases today? [Bobby]
So you mentioned dentistry relationship with health care. So in my community, I have never ever seen this at all. In my community, the chiropractors, the massage therapists, the physical therapists, even the neurologists, they’re all starting to get on board, we’re all starting to talk about the same thing. We’re all in the same camp. So just 10 years ago, now a chiropractor was a quack, a massage therapist, you know, was just likes surface stuff, they weren’t really helping so much. And even anything to do with dry needling and stuff like that, it was just No, it was not in the consciousness of even dentistry or medicine. And then, because medicine so cracked, and there is not a family physician anymore, and things like that, that’s why the dentist is going to become the family physician. And now in my community, a neurologist will say, hey, I can solve this part of the migraine, I want you to go see Bobby, and he can help you with the rest of it. So you’re watching it change. Now every community is going to be a little bit different in that sort of thing. But I have never ever seen everybody on the same page. Because posture and nutrition and things like that are really at the forefront. And post COVID I mean, literally dentistry is going to be pre COVID, post COVID. With everything starts all over, everybody’s got a clean, fresh slate, everything in the past is fine. I’m just going to tell every single dentist young or old, you’re fine. You’re brilliant. You know how to fix teeth, you can get rid of abscesses, the younger dentists know all about pathology, way better than I did in school. They know the legal part of it. So they have to deal with that. So that’s fine, because you got to basically stay out of trouble. Okay, but we’re good. We’re really good at what we do. So going forward, what you were trained to do you keep on doing. So yes, you build in MIP. Okay, because that was always the thing about the philosophies is Oh, MIP is not right, well, it is right, it’s the best that we can do at that time. Okay. Now, if you’re going to go forward, and you’re going to do more comprehensive dentistry, now, you have to start thinking on a little different hat because your teeth bite and your skeletal bite now start to come into play. So now you’re going to have to get better at orthotics and literally center this thing up, and you got to get these condyles. But mostly, you got to get the condyle in the neck in harmony with each other before you’re going to do a full mouth reconstruction. Okay? So you’re going to pick your poison, alright, if you want to go in that direction and do more and more comprehensive. So pretty much what happens to the average dentist is you practice for about 10 years, and you go, you know, I am just good enough to be dangerous. It’s like, I want to do all this sort of stuff. And then there’s more money or there’s more, you know, satisfaction into doing this. And my patients are asking me to do all of this sort of thing. And so it’s like, then the question is, how can I do this? Where can I go? Where can I learn? So now we have people like you podcasts and internet and stuff like that. I mean, you’re not paying attention, then that’s your problem. And the way I look at it right now because it’s everywhere you can think okay, but now you go back Monday morning, your first patient and after you watch like videos all weekend, you’re like, Okay, I see the end result, I can see all these beautiful smiles involved because they show the before then they show the after and all of that. It’s like, how do I get from A to B, you’re gonna have to go back to the basic definitions and the basic definitions is condyles have to go into socket. Literally, they put them in a socket, even if it’s an adaptive position and all that sort of thing. Find your skeletal bite, find that first point where you’re touching. Okay, so I’ll straighten out the neck, stretch them all out, palpate their joint, a lightly lightly do my little bite thing like Dawson taught me not hold it tight. All of that sort of thing, tongue to the roof of the mouth. I’ll let them find that position naturally close down. And then I make sure it matches the T scan. So then I know Okay, a duck is a duck. But we don’t do models anymore. We don’t. I don’t take impressions and go in. I don’t know is about 15 years ago, one of my assistants goes Dr Supple it’s like you make us take these models and we do it all that and we get it all nice and healthy. And then you go to the consultation and you don’t even look at the models. I go well you’re right I’m looking at the photographs. So if you’re going to get into any kind adapt, the number one thing you have to do and you have to get good at is photography. If you’re not taking pictures, if you’re not taking pictures of the palate, and you’re not looking at Tori, or you’re looking at a lower arch and how the teeth are going, you’re never going to get the 3d concept of how the teeth are fitting into the skeleton. Okay, so you got to almost blank out the teeth and look at the bone structure. I’ll leave you with one last little pearl, I don’t know where we are time it but, but if you breathe perfectly neutral through your nose like this, and everything’s nice and wide, your palate should be dead flat, you should have room for all 16 teeth on the top, relatively flat, lips and tongue seal breathe through your nose. Okay? Now if only one in 100 Kids have that. Okay? So instead of the palate growing like that, if this airway grows like this, and then they’re in this pattern like that, then literally the cartilage, what happens is the cartilage is going to grow. So instead of growing flat, the cartilage in a nasal downdrafts. So then it drops like that. So we look at an upper Tori and go, How the hell would that happen? I don’t know, well, what Guess what? It’s because of their nasal airway, it grew like that. So literally, you’re going to look at it differently. And when you see a Tori and you see it downdrafted, and you see it pushed off to the side, or you take your finger, and it’s high vaulted, right here and my friend, can you rub it back, and then you’ll feel the tori line up and stuff like that. And then you look at the picture. So what happened is it got downdrafted, there was so much cartilage compression into here, and the patient’s swallowing, and they’re holding it like that. They’re squeezing their teeth, that’s that sleep disorder breathing, you know, the kids and in their teeth, and all that sort of thing, okay? All it means is the tongue is in the way of their airway. And the back of their tongue is a muscle and it’s not relaxing at nighttime. It’s literally simply every time you swallow, it’s compressing so then you drop into it, then the mandible would love to grow forward the mandible, but it’s being trapped. So you got like, the mandible wants to come forward. And then you start to see the Tori on the lower on the lingual and you’ll see like two bumps on one side and one on the other. Well, literally the mandible is trying to grow forward and in throughout life, it’s trapped. It’s like a shoe that’s on that’s too tight, and you never take the shoe. So every time you go to eat and chew, you’re compressing like that. I’m just, I’m just going to tell you photograph everything you want to see abfractions and you want to see the gum poles, you want to see the wear facets in the teeth. But mostly you want to look at the architectural of the bone. Once you have the digital pictures. Okay, so I just got lucky 1980s were photographing, so I don’t ever do an exam or I mean a records appointment without the photograph. So I have a photograph of every patient from their initial exam full set, just like an orthodontist would do the photograph. So you have to the first digital technology is the cheapest it’s a good it’s a camera. Okay. Number one. All right. So I would then say okay, now scanners are the future. So since we don’t take impressions and I don’t take bottles and I don’t put them articulators to do that console, literally, we just take the scanners and go all the way around in and off the scanner, then I can teach the patient if I need to, but the scanners are the future. Hey, there’s different kinds of prices for scanners, okay, I use an iTero. But iTero I do that because of Invisalign. iTero has the best software, they have the most bells and whistles in the software. They showed the pictures. So I’m addicted to the iTero software. And so that’s why I use that scanner. Okay. The other ones find they’re good. It’s just that they’re not tied to Invisalign. Why probably 15 years into Invisalign, and then you going okay, so most of my practice is TMJ bite issues. I do do some dentistry now, but not so much. I have a partner who’s an implantologist so he can handle all the perio and the implants and then I have Bethany who’s just this brilliant she’s 10 years out of school so she can do the dental work and things like that. I see literally 10 new TM patients a week, [Jaz]
You pretty much niche down into TM patients who are suffering with a temporomandibular disorders. [Bobby]
I generally the patient, when I see him, they’ve already seen at least three docs, it might be a dentist, but it also might be a neurologist or they’re chasing some kind of other medical issue. For sure they’ve been going to physical therapists, chiropractors, stuff like that. But I have a network in my community where you know, I have 20 chiropractors who know who I am, all the PTs. At the university, I was actually teaching the physical therapy students in school whenever it came up, because the instructors were my patients, you know, so Bobby, come here, can you talk to my class and things like that, we would go into the PT class when they were learning about their jaw, and sit them up, put them on the T scan and show him they’re fitting up by on the T scan, lay them all down, then go back in there, close it. And so then you can put on the screen they’re sitting up bite and they’re lying down bite and then I would just simply go, you guys are the heroes here, you have to understand the PTs because they’re going after all of this and they’re lining up neck and shoulder and they’re helping us a lot. So going forwards if if you’re going to do a comprehensive case, and you have a lot of wear, okay, and you know you got this airway and neck issue and posture, you have to kind of clean this up, and then use the scanner. Now the scanners will then now you can mail your orthotics. So we’re a couple years into that scan, then I just send the study models to the lab. And then we use the lab software now to then articulate it. Because I can pick five different articulators on there, you know, I can do a hand our Sam or whatever, okay? You just pick your articulator and then all adapt, I’ll just take the pan out, and then literally, I can change the condylar thing just a little bit, whether there, it’s just three things, okay? Are they flat? Are they medium or is it curved? Okay, because that’s going to make a little bit of a difference. Okay, so then you can just set it because sometimes you’ll have one eminent saddle flat and the other one that will be much more steeper, because they grew compressed. Okay. All right. So then I can quickly make a little thing, the lab guy does it now I don’t. Ralph and I been together for 20 years, so he knows what I want. Okay, so he just looks at it changes the condylar inclination. And then we just open up the vertical a little bit, just three millimeters to five millimeters on the front, because I know there’s [Jaz]
Using the neuromuscular background that you also got so at all the schools that it all tied up at the end, you know, although all these wars and really, you know, occlusal religions arguing each other, ultimately, they tied up in this very comprehensive era. Now, as we’re looking at the bigger picture there, like you told me in the emails, we’re all friends now. They’re all the religions our friends. [Bobby]
Yeah. So this book you can still buy, if you kind of want to go back out away. This is the one I’m saving in my archives, but this book is called posture airway and tongue [Jaz]
By Jenkinson, right, [Bobby]
Jenkinson. So this is the father of neuromuscular dentistry. But before LBI and with before we started doing full mouth reconstructions to match this, though this just right off in the beginning it goes okay, these are the things you’re looking for upper narrow arch, inflamed adenoids and tonsils history of throats and stuff like that. So the dentist now is the oral physician. It’s called integrative dental medicine. So the Dawson Academy this is what’s new book, it’s called The Shift is literally the entire Dawson curriculum is in here with the whole concept of Wait a second, start with the nasal airway, understand how it’s kind of grew that way. Then if you’re gonna do more comprehensive dentistry, you have to make sure the neuromuscular is correct, but you do that within orthotic, okay? And then the whole idea that if you’re just adjusting teeth, and then that’s called mutilation, you have to get that out of your mind. The word equilibration and the word CR, they were so bastardized that everybody just had the bail on, So originally it was the American Equilibration Society. Okay, well, when I was on the board, when with put me on it. 10 years back, then you could see, okay, the word equilibration isn’t fitting. And then society is a fitting, and Americans not fit. Okay? Cuz it’s international. And a equilibration is a bad word. Okay? And so then now we just kept the word A, so we kept this, basically the brand and then dropped all the words. So now it’s just known as the AES. Nobody in the world really notice that it used to be the American Equilibration Society, but we dropped all the words because the world were pathology, in a sense, because if you didn’t understand what true CR or the epigenetics of a equilibration, okay, where all that came from, then it was all fake news. And so then you threw it out. And so then you were well, where do I start? Okay. But in all fairness, the thing that I learned most from Peter Dawson, and all of the early Pankey guys, was that the master teachers, then they definitely stayed on topic to the definitions. They didn’t bastardize the definitions. Okay. So, the biggest one is anterior. Anterior, that word right away, in dental school, you thought it was anterior guidance, canine disclusion, when in fact, anterior means in front of the condyles [Jaz]
The anterior determinants of occlusion. [Bobby]
Your anterior guidance is your occlusion. And so if you go back to the basic definitions as how the master teachers taught them, how Pete originally talked about center in the sockets, and you didn’t get into all these other philosophies that were brought into it for basically economic reasons, okay, there’s a lot of this was because, oh, I’ll do it this way, because I can make more money or whatever, okay, there was that part of the whole thing. Okay. But in all fairness, it comes down now to a couple of basic definitions, understand what the tongue swallows doing, understand how the postures going, think about the nasal airway, and Invisalign, what it does is literally you take all these old orthodontic cases that have all collapsed, and then I just basically I stand them back up. So in a sense, instead of doing a lot of prepping on the teeth, we’re just we move the teeth back and then the amount of dentistry is less. And so I’m going to finish my career as more of a orthotic orthodontist that deals with medical issues that mostly migraine, things like that. So teeth come from the nerve family. So in embryology, they literally come from the second brachial arch. So teeth are neurotransmitters. So Nick Yana , he’s taught me over and over Kirstine all those guys, we’re into the neuro part of it. Okay, so it’s just called sensory neuro overload. So if the teeth at nighttime, if you’re swallowing, you’re kind of squeezing your teeth a little bit, or you’re squeezing and pressing off and then Apneic and things like that. Okay, so Teeth are together for long periods of time at nighttime, then the sympathetic nervous system stays on. The sympathetic is fight or flight. That’s what apnea is. Squeeze, ah, save your life. Okay. But the teeth are resting, it takes years before the Apneic comes in, where they stop breathing, they just literally close down, swallow and adjust and squeeze a little bit, okay. But through all that time, and especially with young teenagers, females, especially when they’re hormone, so what will happen is their teeth will be together and then they’re squeezing down a little bit in their sympathetics are on, that’s anxiety, that’s depression. That’s this building where they’re not in REM sleep, that’s where they think that they’re waking up, but they’re not. Okay? One last Pearl, because everything’s cartilage base, and cartilage grows by cell division, then the girls get their hormones quicker and sooner. So there’s some times age 10 years old, and that estrogen starts to hit those periods start, and then literally, the girls will turn, they’ll twist. So this gets off center more, and the guys we compress and so we’ll hold more tension and neck and shoulder and snore more Hold on all the way back, but we have bigger round or stronger condyles, the female’s not so much. So if they really get into trouble here, and when they get off center, and this is growing, and their hormones are hitting, and they’re growing into the spurts like that, that’s why you see 7, 8, 9, 10 Girls, for every guy for TM issues, aged 18 and say 25. And those hormones have in and out of pregnancy, messes with them, you know, so we’re getting the concepts better, you just have to start younger than older and understand how all of this stuff grows. But when the teeth are together, because they’re neuro, they’re literally neuro systems. They’re telling the trigeminal cervical nucleus, okay, squeeze and grow, and all of that sort of thing. So the neuro network will become more and more part of dentistry, that’s the migraine anxiety and things like that. But it’s the dentist to pick it out in the kids. And once that takes over across the world, then look out because people love their dentist. [Jaz]
And that’s where the prevention comes in. And that’s we can pick up things earlier. And one of my favorite quotes here, Bobby, which I did accompany them, and said here is the mouth is like a window to the health of the body. So the mouth is a window to health of the body. And I think, you know, just like going to be very much allied with the like you are in your community, I wish that upon all dentists listening, that you have this support network of healthcare professionals, who are all singing from the same hymn sheet with airway principles in mind, Bobby, you’ve been absolutely amazing. Thank you so much for giving so much of your time here to really cover what we started off with the teeth and bite and why everyone’s fighting about that. And we evolved into the bigger picture, which I think a lot of them, especially in the UK are going to find very fascinating. I do believe that our colleagues in the US where you are a little bit more switched on in this, I hope and I’d certainly seems that way to me. But please tell us how you can educate more of us dentists. I know obviously, with AES mean, I’ve been wanting to come to AES every year and I’ve got a small child, but 2025 is a really cool date that I can earmark to my wife and and really just build this what is 2021 now I’m gonna keep whispering every few nights, every few weeks, okay, 2025 AES, 2025 AES. So when it comes, there will be no objection to be able to make it a very successful trip when you are president. Please tell us what else, you know, because this knowledge needs to get out there. What else do you teach? How can we learn from you, from the AES and from yourself? [Bobby]
Well, I would go back to a book like this now. [Jaz]
So that’s new trends in myofunctional therapy for those who are driving or listening to this book. [Bobby]
This book is two years old, all comes out in Italy. So and it’s not really tied to philosophies. It’s tied to basically the growth and development of the kid. So any younger dentists, any dentist, if you’ve been practicing for 2030 years, okay, and is thinking okay, now Whoa, I really want to put this oral physician model into my practice and I gotta tell you, it just grows the practice so fast, you know, you have a mom there and then you see how this grew and then you’re going okay, how old are your kids, you know, and then do they have allergies and things like that. The mom’s all over it, that child has an appointment, you know, set up before she leaves [Jaz]
Some of the most powerful moments I’ve had in the last few years as I’m learning more about this field as well Bobby is having those conversations about Bedwetting, having those conversations about children who are making sounds when they’re sleeping when they really shouldn’t be, children who are having behavioral issues at school and then just suggesting to have a look at these massive tonsils that these children have and the parents have no idea and to encourage them to get investigated and the kind of engagement and interest you get from the parents and like the the warm do you get for liking, thank you for almost they think that is beyond our remit and thank you for looking after the health of my child and I completely agree with you [Bobby]
No, it’s that they leave and they’re going okay, it’s not really about costs. It’s about health and wellness. And once that brand is in your practice once you’re known as a not a dentist but you’re basically a wellness person, then it’s all over. I mean, I say this in a really humble way but it takes three months to get an appointment with me. So if somebody calls the office and they go okay, yeah, and then I’m seeing 10 TM patient Well imagine how many phone calls that is and stuff like that and some of them are like in an acute situation I can’t really get to them [Jaz]
Probably from out of state as well who probably heard about you want to travel and come and see usually when you know people with TM niches they do attract patients from all over. [Bobby]
No every single day they travel three, four hours, I mean, my community is the state of New Mexico. So we have a big territory. And I’m not going to apologize, I built that. But that wasn’t the intention in the beginning. That’s just what happens when you start to put all these little puzzle parts together. And it started as a dentist who did a lot of prosthodontics. I mean, so you, you’re gonna learn it, and I’m just saying, learn it, but, but we kind of learned it backwards a little bit. And then you’re gonna have failures, it’s like my coaches growing up, every single workout was okay, we’re going to warm you up, we’re going to do a couple sets. And then I’m going to give you a set that you’re going to fail that, though I do that with my staff, when we sit down every single day, it’s not like you’re going to win the Olympics every day, basically, you come in every day. And we’re gonna fail, we’re gonna fail either through a phone call or a communication, or we didn’t do the temporary right or something like that. Just know that every single day you’re going to fail. But the problem there is, if you don’t learn from those mistakes, and then you just keep repeating it, now you’re locked in. And then generally, that’s when your career path is going to seem like it’s a little bit of a dead end. So it starts on Monday morning. And it starts with an attitude of okay, yeah, come in, I’m gonna start off with the best I can, come in, rested, ready to go. And then as things start to fail around you during the day, you can absorb it, you just cannot absorb it, you got to let it be Teflon person bounce off of you. Because patients come at you hard these days. If something doesn’t come, right, the patient’s calling and they’re blaming you. It’s like my tooth didn’t hurt before you prepped it. So now it’s sensitive. Now what are you going to do? And so then or a temporary will pop off I call it the refactor. So anytime you’re redoing something or reappointing or recementing, or anytime you’re backtracking, it feels like pain to the dentist. It feels like Okay, wait a second, where did I fail. And literally once you get everybody in the your group and your team to know Okay, recognize the failure right off the bat, the phone call that’s coming, deal with it as quick as you can. And then just in the future, just try not to make that mistake again. Because we do learn it backwards. You have to learn it by experience, you have to learn, you have to make the mistakes, okay, you literally the only way you learn. But if you want to advance the envelope into wellness and comprehensive and put it all together, then literally you just have to go back to the kids. The only way you’re going to learn it. [Jaz]
And it starts with a sound understanding of anatomy physiology, as it’s being presented to us in those textbooks, which I’m going to totally buy so and share it with everyone. Bobby, thank you so much for giving your time and your knowledge and your generosity and all these lovely things. I look forward to hopefully meeting you one day 2025 AES it’s going to happen. Who knows? Maybe someone listen to this in 2025. And think I wonder if Jaz made it I think I really do want to. So let’s see. [Bobby]
Let me congratulate you too. Because it’s different now is because of people like you can you imagine it used to be okay, I would jump off and jump on a plane on a Thursday, go to a lecture, you know, lecture the podium. Now I missed the happy hours, I miss all of that sort of thing unto itself like that, but then go, then I’m back on Monday morning and I’m tired. Okay, and fine. On advanced, I taught I did it, you know, my career path, all of that sort of thing. But I gotta tell you, in this hour and a half, I’m probably going to reach 10 times more people because of people like you, because of the way we teach now. Okay. And you got to know that Dentistry has never been in a better place absolutely never been [Jaz]
100%. And we need to hear that. I think our young colleagues, we need to hear that there’s so much doom and gloom. But I always emphasize that message. I’m so glad you echo it as well. Thank you. [Bobby]
You’re very welcome.
Well, there we have it guys. Thanks so much. Again, as always listening all the way to the end. I really, really appreciate it. It was a little bit more complex than that. I appreciate that. But massive kudos to Bobby Supple for giving his time, giving his knowledge, sharing his experiences, sharing his failures. You know, the whole occlusion was part one. We talked about all these full mouth rehabs, which are breaking down and sharing that information with us and letting us consider that actually is more to it. There’s a skeletal bite. There’s a skeletal difference. And it’s not just about the teeth At the dental level is high level, skeletal bite level. So I hope that gave you some food for thought and I’ll catch you in the next episode. Same time, same place