Episode 607
607: Redefining Early Orthodontic Intervention - Dr. Rebecca Bockow
Redefining Early Orthodontic Intervention
Episode #607 with Dr. Rebecca Bockow
Adults with dental problems weren’t always adults with dental problems, so what happened earlier that led to that point? Today Kirk Behrendt brings on Dr. Rebecca Bockow, a true rockstar of the dental industry, to discuss why you need to redefine early orthodontic intervention. Orthodontics is so much more than just straightening teeth—find out how it can make patients healthier in Episode 607 of The Best Practices Show!
Episode Resources:
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Links Mentioned in This Episode:
Check out Specialty Imaging: Temporomandibular Joint and Sleep-Disorded Breathing by Dr. Dania Tamimi
Learn more about Spear Education
Learn more about the Pankey Institute
Learn more about the Kois Center
Register for Dr. Bockow and Dr. Mike Gunsun’s course
Main Takeaways:
Orthodontics is about more than just straightening teeth.
Don’t just wait for the adult teeth to come in to deal with problems.
So much growth happens in the first few years of life.
Braces aren’t necessarily the answer for everything—use the right tool at the right time.
Keep asking questions.
Quotes:
“One of the things that really struck me as a restorative dentist was I saw a lot of breakdown that was really related to the foundation. The bones in the gums weren't in the right place, which led to a lot of the breakdown I saw as a general dentist. And I thought, ‘If I can help put the bones and the gums in the right place, and the teeth, of course, then I could partner with phenomenal restorative dentists to rehabilitate a patient.’” (02:37—03:07)
“Back in 2013, I sat through a three-day course called Airway Prosthodontics before [Dr. Jess Rouse] joined Spear Education, even. And I was blown away. Kirk, I sat in the front row and I thought to myself, ‘All of these adult patients have airway issues. They all have orthodontic problems.’ And I started talking to him about the things I learned about expansion. And really a lot of the things I learned I had to learn on my own because there wasn't a lot in the orthodontic literature, but there was a great deal in journals like Sleep and Sleep Medicine and stuff in ENT literature, and it's slowly, slowly been coming into the orthodontic literature and the general dental literature over the last ten years.” (03:32—04:17)
“And I think we're at the tip of an iceberg. And every year more and more papers are coming out and our understanding is increasing. And so I started really thinking. So I saw a lot of adult patients with the perio ortho background, and I saw a lot of adults that had a lot of issues. Generally, it's skeletal issues, underbites, overbites, crossbites, open bites, gummy smiles. And I thought ‘What happened early on in growth and development that led them to get to that point? Why? Why did we see the gummy smile? Why did we see the crossbite? And most importantly, is it preventable?’” (04:19—05:02)
“I've been really thinking a lot about growth and development, and I think we're just starting to understand even more the power of what happens early as it guides growth. And form and function are so interdependent. And we really have an opportunity to think about chewing and swallowing and speech and what's happening for these young kids that's having such a major impact on skeletal growth.” (06:12—06:48)
“If we think about a thumb sucker, I think historically we'd sort of throw our hands up and say, ‘Well, it's okay. We'll deal with it when the adult teeth come in.’ And I've even heard from families, ‘My pediatrician said “Don't worry about it until they're seven when the adult teeth come in.”’ But if we think about what's happening in growth, so much growth occurs during those first few years of life. And so a thumb pushing into the roof of the mouth creates a narrow maxilla. The roof of the mouth is the floor of the nose. So now you have a narrow upper jaw. Now you have narrow nasal passages. Ultimately that might look like crowding and that's just the upper jaw. Then you have pressure on the lower jaw, which does a few things. First, it prevents the lower jaw from growing forward and it pushes the condyle back in the fossa. So it might potentially change the way that this inner relates, whether it has to do with the disc, whether it has to do with the development of the eminence, whether it has to do with the directional growth of the lower jaw, and you train the tongue to rest low, The tongue coming up in full motion in a swallow not only during rest, but during speech, during functionality is what drives the growth of the upper jaw. And so you think about when you catch this kid at seven, let's say that's the first time they come to the orthodontist. We have to play catch up from seven years of the lower jaw not growing to its fullest potential. And we have to retrain the tongue to come up and forward. So it's not just about the teeth anymore. Orthodontics is not just about straightening the teeth. Now all of a sudden, we can reframe things. What can we do for that seven-year-old to help guide growth but also help retrain function?”
“The American Association of Orthodontics says you should have an orthodontic evaluation prior to age seven. And so that has become sort of the marker. ‘Okay, well, go see the orthodontist by age seven.’ I've never seen a paper, Kirk, that gives us any sort of reason why seven is a magic number. My best guess is that it's when the adult molars have erupted—they usually come in around age six to seven. So by age seven they tend to be in, and our bands fit best on first molars. And our appliances, maybe we historically didn't want to bracket baby teeth. I don't know, that's my guess. But I'd love to challenge that number because I don't know that there is any proof behind that number.” (09:14—10:09)
“And so going back to this seven-year-old that's a thumb sucker, Maybe we can reframe how we define intervention. Maybe intervention isn't putting braces on a seven-year-old or a three or four- or five-year-old, but maybe it's helping this child stop their thumb sucking habit. Maybe that's our intervention. Maybe it's helping them find a myofunctional therapist to retrain the tongue. Maybe it's looking at other ways that we can intervene and help these kids beyond braces. I don't know that braces is the answer for everything.” (10:11—10:49)
“And if we wait until growth is done, if we wait until this child is 12 and we focus on just lining up the teeth, we've lost all this opportunity of growth because so much of it is happening so early.” (12:29—12:43)
“I saw a young child a few weeks ago in the clinic. He's three and a half and his palate is so narrow, so V-shaped, that his tongue can't fit in the roof of his mouth and his lower jaw can't figure out how to fit with the top teeth. So he's sliding all over the place. When he chews food, he’s not getting a solid bite with his back teeth. He's not crisp when he speaks. He's seeing speech therapy because he doesn't know where to put his tongue, because his palate is so narrow. He's snoring at night. He's tossing and turning at night. He's constantly congested. And so, what is intervention? Is intervention putting braces on this young man? No, he's three and a half. But can we get him to speech therapy? Can we get him to ENT? Can we widen the palate? And if we're going to widen the palate on a three-year-old. How do we do that? Because maybe our traditional appliances aren't the best fit for a three-and-a-half-year-old. And so I don't know the answers. I just am excited about some of the new questions and new possibilities.” (13:03—14:22)
“The way we do things today is different than a year ago. The understanding, the depth of knowledge, and even just whether we're learning it from social media, we're learning it from our peers, or we're learning it from the literature, I feel like we're learning something new daily, weekly, monthly.” (16:46—17:05)
“So even just going back to that example—that three-and-a-half-year-old—so we got him to see ENT as the next step. We got him to get the adenoids and tonsils evaluated. We got him to see speech therapy. And so did we get started on ortho treatment? Not yet. He's not ready for us, but we got him to see new providers. Maybe he will be a candidate for expansion. But making sure that we help educate these families on growth and development, helping them find the right resources.” (18:48—19:26)
“We were trained to not intervene [on a lower lip entrapment] for some patients until they're teenagers. But if you identify a seven or an eight-year-old that's constantly biting the lower lip, what's that doing to mandibular growth and development? And so maybe intervention is something as simple as a retainer that helps reduce lower lip entrapment. And so thinking in terms of growth guidance, I think is really powerful.” (19:32—19:59)
“I think we're learning more and more. And I think with CBCT technology, we can more critically evaluate our outcomes in a very different way. I think with asking new questions and reframing questions we can ascertain new information. So if we base our conclusions today on how we practice on literature from two or three decades ago, we're missing a lot. We have new information today so we can ask new questions and therefore we have new opportunities to study new things in the literature.” (20:05—20:45)
“And to bring everyone into the same room and to really talk about what is it that we're seeing in our practices and in our patients and how can we learn from each other. And it's those ‘Aha’ moments, it's those ‘Wow, I didn't think that shifting the lower jaw forward and to the side would when in speech, would have an impact on condylar development.’ And you go, ‘Oh my gosh!’ And so thinking about the system, thinking about the importance of the system—the lips, the cheeks, the tongue, the teeth, the joint, the bite, the swallow—it's all in breathing. Of course, it's all important. (22:19—22:58)
“I would say to especially the younger dentist, but for the experienced as well, let's all keep questioning things. Let's all keep asking new questions. Dentistry is a really exciting time because it's not just about straight teeth anymore. It's about how do we make patients healthier? And that's so rewarding. It's so exciting. And it’s a great time to be a dentist.” (24:01—24:26)
Snippets:
0:00 Introduction.
01:44 Dr. Bockow’s background.
05:48 Orthodontics is about more than straightening teeth.
08:57 Why is seven (not) the magic number?
10:54 Early development is dependent on function.
14:22 Spreading the message via social media.
16:20 We learn something new every day.
18:29 Find the right tool to help the patient.
20:45 Dr. Bockow and Dr. Mike Gunson’s course.
23:53 Last thoughts.
Dr. Rebecca Bockow Bio:
Dr. Rebecca Bockow is a dual trained orthodontist and periodontist – the only dual trained provider in Seattle and one of only a handful in the country.
She grew up in the Greater Seattle area and attended University Prep for High School. She received a BS in Biology with Honors at Haverford College, where she also played Soccer, Squash, Tennis, and ran Cross Country and Track. She completed her DDS training at the University of Washington Dental School in 2007. Dr. Bockow practiced as a general dentist in Seattle for two years while simultaneously teaching at the UW dental school.
Dr. Bockow completed a highly selective dual-specialty program combining Orthodontics and Periodontics at the University of Pennsylvania. She is a board-certified orthodontist and periodontist. While simultaneously enrolled in two residency programs, she also received a Masters in Oral Biology, focusing on intranasal Ketorolac for post-operative implant pain management.
Dr. Bockow lectures nationally on periodontics, orthodontics, interdisciplinary orthodontics, airway, and skeletal growth and development. She contributes to multiple professional journals as an author and editor. Dr. Bockow is also resident faculty at Spear Education.
