Cherry Creek Orthodontics
Address:
155 Cook St. 451
Denver, CO 80206
URL: http://www.cherrycreeksmiles.com/
Phone: 303.370.0124

Foothills Pediatric Dentistry
Address:
916 S. Main, Suite 302
Longmont, CO 80501
URL: http://www.foothillspediatricdentistry.com/
Phone: 303.702.9501

Male 1: You are listening to now you know; talk radio where you get to ask the questions. Call us now at 877-NYKRADIO.That’s 8776957234. And now here are your hosts, Anne Mitchell and Bryan McCullough.

Anne: Hey, good evening, Bryan. How are you tonight?

Bryan: Anne, I am fantastic. How are you?

Anne: I am doing really well as well. I have to tell you that I have something that really is kind of flummoxing me. It’s something that you and I have talked about a bit. For the listeners out there, if anyone has any great advice for me or anything, my son is twelve and I often say that my greatest parenting challenge is that I don’t remember what it is like to be a twelve year old boy.

Bryan: (laughs) That’s right. I don’t think you ever were one, right?

Anne: I never was a twelve year old boy. I have to tell you though that I have found this book that I am reading. It has me so excited. It’s like someone took a flashlight and shown it in this dark corner where I could never really see what was there. It has illuminated it for me. It is that great a book about raising boys. So I am really excited about it. It has already really made a difference in how I am doing things and how I am relating to my son. So it is really exciting. The name of the book, and I know you are going to ask me…

Bryan: Anne?

Anne: What?

Bryan: I just want to tell you before you go too far and embarrass yourself, Harry Potter is not real.

Anne: You’re kidding. Don’t tell me that!

Bryan: Ok.

Anne: No, it’s a real book. It’s a real non-fiction book written by two guys whose therapy practices, counseling practices, are entirely adolescent and teenage boys. That’s what they specialize in independently in two different states, but they collaborated on this book. It is called Wild Things: the Art of Nurturing Boys. I so highly recommend it. I cannot highly enough recommend it. It is just really, really awesome. Because you know I don’t understand boys. You were one once, right?

Bryan: I was one several times, yes.

Anne: You were a boy several times, like in previous lives?

Bryan: Well, no I…It’s interesting because I have one boy and I have two girls. I don’t know. Maybe this is the way it is for each gender, but I don’t stress about raising my son the way I stress about raising my daughters. Since you’ve got one of each, maybe you can…Did you have the same kind of anxiety with your daughter that you do with your son? Or do you just kind of feel natural when it is the same sex?

Anne: It’s really, it is different, but you feel equally nervous and concerned and anxious about both, but in different ways. With my daughter, I actually always knew. My daughter has been a guest on the show, so you know she is an extremely competent woman. She really knows her own mind. So, I was never worried as some parents do about daughters that someone might take advantage of her unless she wanted them to. But with my son I am. From the show last week I think you’ve seen or heard that men, boys, really are very discriminated against in our culture. They grow up to be men and fathers who are also discriminated against. So, on top of the all the other things you worry about, and lord knows as a father’s rights lawyer, I worry that my son is going to get to be a teenager and some young lady wanting to get out of her own bad situation is basically going to coerce him into becoming a teenage father. On top of all that you worry about everything that we dealt with in our show last week .It’s just a different set of anxieties. Let’s face it, the moment you become a parent you wear your heart on your sleeve and in your mouth.

Bryan: You also wear your wallet in your hand.

Anne: And it’s empty. That’s right. (laughs) Anyway we have got an absolutely wonderful, wonderful guest tonight. I am so very excited about his guest. He is…

Bryan: Speaking of wearing your wallet and raising kids, right?

Anne: Hey, hey, hey, don’t you be…That’s not always the case. Before we introduce our guest and bring him on, Bryan, would you do the honors of telling everyone all of the different ways that they can call in?

Bryan: Absolutely, now we’d love for you guys to call in and talk to the amazing surprise guest that we have. Call us at 877-NYKRADIO. That’s 8776957234. That’s Now You Know Radio. You can visit us online at nowyouknowradio.com. Send us a tweet @nowyouknowradio. You can also join our chat room. Go to blogtalkradio.com/nowyouknowradio and join our chat room and pose a question there. Any of those options will get you in touch with Anne and… (pause for effect)

Anne: Anne and Bryan? No!

Bryan: Come on, I was leading you in. I was giving you the door.

Anne: I am so used to people giving me the door, showing me the door that I’m sorry it just kind of goes right over my head. Anyway, so, yeah, our guest tonight is the ever fabulous, extremely competent, and really quite pleasant Robert Rudman. He is an orthodontist who practices both in Denver and Longmont, Colorado. He has won awards for his work, and very much understandably. He is very competent. He is actually my orthodontist, so I speak from experience as one of his patients. He is also very personable. He is well published. I don’t think I could say anymore without risking inflating his head, because all I have to say about him are really good things. So, without further ado I would like to introduce to our listeners Dr. Robert Rudman.

Robert: Hi, everybody, how are you?

Anne: Hi there. Thank you so much for joining us on the show. I really, really appreciate it.

Robert: You are most welcome.

Anne: So, for our listeners out there who have not yet had the pleasure or have had the pleasure of not yet encountering or having to interact with an orthodontist, could you explain just a little bit about how orthodontics is distinguished from other branches of dentistry. Also, what is it about the training? Do you go to dental school and then additionally to orthodontics school? How does the training differ?

Robert: Probably the best route…This is going to take you through my journey which is what most orthodontists do. You basically go to four years of college, and then go to four years of dental school. Generally orthodontists tend to be in the top two or three percent of their class, because it is a very competitive field to get into. Then after dental school, you apply to an orthodontic residency and that’s two to three years depending on the program you go to. Basically what we focus on is two to three years of clinical training and also depending on the program, a master’s program. Where you go through the science of moving people’s teeth around, how their profiles change, and basically how to get someone looking great from an orthodontic perspective and smile perspective and also give them a healthy bite at the same time.

Anne: Ok, so how long is dental school?

Robert: Dental school is four years, and then ortho is two to three.

Anne: And then is there also like with medical school a kind of residency or an internship? Or, do you just go out and hang right up a shingle?

Robert: Well basically the orthodontic specialty is after you’ve done the four years of dental school, the three years of ortho training after that is basically your residency.

Anne: Ok. So, that sounds to me like you are basically learning and practicing on your patients, but I’m sure that’s not really exactly right is it?

Robert: It’s pretty close. Basically you have a didactic and a clinical aspect to the training so you are in a lot of lectures as well as basically learning under other orthodontists. The program I went to we had about 16 orthodontists that we basically the patients were being treated under their care but we provided the treatment for them. We were learning under the offices of a trained specialist. Basically the only way to learn how to do it, and basically the only way you really learn (that’s why they call it practice) is by practicing. We get to do it under the guidance of some really great specialists.

Anne: I didn’t mean to set you up there. I just know that I often get that question myself, being also a professional as a lawyer. All the jokes about practicing, but really how do you learn? So I get that, but I did want to let you flesh that out for the listeners as well.

Robert: Ok.

Anne: Now I am very curious about something. You are known for the non-extraction approach to orthodontic treatment. What does that mean?

Robert: Well, orthodontics has gone through an interesting history. Basically there were two arguments back in the 30’s where people thought you would have more stability if you extracted teeth. There was the argument that you shouldn’t extract teeth. Basically where things come down is if you look at someone’s face basically half their face comprises their upper and lower jaw. So, you can extract teeth and close spaces and basically push people’s upper teeth too far back which kind of prematurely ages them by giving them thinner lips. What we try to do, and I think most modern orthodontists are going to look at things, we are not only going to look at how much room do you have for teeth, but how do your teeth look in your face. If you move your teeth forward, does that give you better soft tissue support and that’s your lips, so on and so forth. Or, if someone is too full and they can’t get their lips around their teeth then that would be an indication to extract teeth. I would say about 95 percent of my patients don’t get teeth out, but there are cases where you do need to take teeth out. It’s more of how do your teeth look in your face. You can always make room for the teeth, but sometimes that is not a great thing for your face.

Anne: When I had braces the first time back when I was a teenager about a hundred years ago that is exactly what…They pulled all four of my wisdom teeth first and then they pulled all four of my bicuspids in order for me to have orthodontia. So that sounds quite different from what I went through. Although maybe I still would have had to go through that and I would have been in that five percent. Of course now I am under orthodontic treatment, or would you say in orthodontic treatment with you which goes to show that for one reason or another that orthodontic treatment back a hundred years ago didn’t actually work.

Robert: Well, I would say that there are two possible components to that. I’m not trying to second guess your orthodontist, but back in the day when they used to use bands around every tooth the bands that would fit around every single tooth took up a little bit of room and in order to get all the bands on people’s teeth you had to take teeth out to make room. Nowadays most modern orthodontists are going to use little stick on braces so there is no separating of teeth. There is no room that has to be taken to get the appliances on. Secondarily as far as stability goes I tend to be Mr. Analogy, I always tell people that your orthodontist is like your personal trainer. You are going to work out. You are going to look awesome, but you have to do something to maintain that. Just like on a diet, you have to maintain a diet the rest of your life. So, retainers are kind of a lifetime things. Back in the day they would tell you to wear your retainer for a year and you would be fine but that is like your personal trainer saying you went on the diet, you will stay that same weight, don’t worry about it. You can eat whatever you want.

Anne: Which we all know, or at least I certainly know doesn’t work. But now you have a very interesting thing when it comes to retainers. You have an interesting practice that you do. I don’t remember I have to confess what it is called. I want to say it is a lingual retainer. You actually put in a permanent retainer in some cases along the back of the teeth, right?

Robert: Correct.

Anne: Can you talk a bit about that?

Robert: Sure, absolutely. Basically where people see their teeth shifting around tends to be their front teeth. If you think about your back teeth, your back teeth have multiple cusps on them so they kind of fit together like a jigsaw puzzle. So every time you bite together these teeth tend to meet and bite together these teeth tend to meet and hold each other in the same place. Your front teeth don’t have multiple cusps on them they can twist and rotate and turn. So, what I like to do for my patients, knowing that that is where the instability of teeth tends to be what we do is a bonded lingual retainer, lingual meaning behind the teeth. The little tiny wire that is hidden from anyone’s view is basically bonded behind the first four teeth on the top arch and the bottom six teeth on the lower arch. I still give everybody a removable retainer as well. Hoping that they will wear their retainer in their sleep, but we all have New Year’s Day resolutions that we all promise we are going to do and barely keep them. So it is kind of a backup.

Anne: So, why would they need the removable retainer if they already have this permanent retainer?

Robert: I’ll give you a good situation. Kids go off to college. They have a bonded retainer. They break it for whatever reason. They chomp on something a little too hard or god forbid opens a beer bottle with their teeth. There’s not an orthodontist around. Therefore if they have this removable retainer, the removable retainer will kind of be the backup plan. I tell people life is a long journey, and it’s always good to have a spare tire on a long journey.

Anne: There you go, that makes a lot of sense. I can tell you that my own true story. I did have the, I’m sure it sets your teeth on edge to hear it called this, but I had what were affectionately known at the time as railroad tracks. I had them removed slightly early to go into the service because you can’t have braces in basic training. I had my retainer. My retainer ended up getting thrown out in the mess hall. So, there is an example of you just never know what’s going to happen to your retainer. So, having a spare makes an awful lot of sense.

Robert: You gave your straight teeth for your country.

Anne: That’s right. I gave them, but now I’m getting nice new straight teeth thanks to you. We’ll talk about that in a little bit. We do have callers on hold and we have questions by e-mail as well. Also, we have questions through Twitter. Let me remind our listeners that you can call to ask a question at 877-NYKRADIO. That stands for 877 Now You Know Radio. You can also send us a message by Twitter @nowyouknowradio. You can e-mail us your questions at info@nowyouknowradio.com. Dr. Rudman, Steve from Allen, Texas is wondering. He says, “I’ve got three small kids. I’ve never had orthodontics myself. So, what can I expect with three small children. When should we bring them in? When might they actually need orthodontia?” That goes to his more general question. When is the optimum time for kids to get braces?

Robert: Sure the American Association of Orthodontists, which is kind of our oversight group for the specialty recommends that people see an orthodontist by the time they are seven. The reason why they recommend that, and that seems really early to a lot of people, but it’s much less for actually doing treatment. It’s more for screening things. Now, what tends to happen is that the canines, which are the pointy teeth three to your midline off to the left or right, they are the very last teeth to come in, and what tends to happen in about 15 percent of kids is that the canines can become impacted. A screening x-ray that is called a panoramic x-ray which basically gives an overview kind of like satellite earth, it takes a picture of everything that’s going on, it gives us an idea of whether those canines are going to be a problem. If they are there are lots of very easy things to do. Sometimes it involves maybe taking out the baby teeth to provide a path for those teeth. The problem is if that is not caught early it means potentially going up and surgically uncovering these teeth in order to bring them down, or worst case scenario is an adult tooth doesn’t know what it is eating. It eats whatever is in front of it. That’s why when a baby tooth comes out there is no root on it. Well there are many instances where permanent teeth are really damaged by the canines. So, it is just a screening mechanism. 90 percent of kids can be treated in one phase when they are twelve or thirteen, but is just a good idea to avoid a problem. That is why we do that screening x-ray around seven.

Anne: When are they most likely then to actually need to go into orthodontic treatment? Is there an optimum age for that?

Robert: Sure, as you know girls are much more mature than boys. We actually never catch up to you guys. So, for girls, 11 or 12 seems to be a good age. For boys 13 or 14 is a good age. Again, everyone is broken down into a chronological age, a skeletal age from a growth perspective, and also a dental age. Not everybody lines up on the same age. So, we might have a kid that’s 10 that has the mouth of a 14 year old. So, they might be able to be treated a little early. The opposite can goes you might have a 14 year old with the mouth of a ten year old and they might not get treated till they are 16. It’s a lot about timing. One of the good things about seeing an orthodontist early is that they can kind of monitor things, start at the ideal time, and be done within the 18 month time frame for most cases these days.

Anne: That leads us into the next question which is how long does orthodontic treatment last for a teen?

Robert: I would say that average time today is in that 18 to 20 month time frame. Depending on, some kids might have a pretty severe skeletal imbalance or a difficult growth pattern or impacted teeth. That can be more a 24 to 30 month type thing. But, overwhelming majority is 18 to 20 months.

Anne: Ok. Again to call in and ask Dr. Rudman a question, how often do you get to call and ask an orthodontist whatever you want related to orthodontia of course, the number is 877-NYKRADIO. Or you can Skype in with the link that is on the site. That site is nowyouknowradio.com. Bryan, I think we have callers waiting, don’t we?

Bryan: We do. We’ve got an old favorite on the line. Rob, you are on the line with the doc.

Anne: Hi, Rob.

Caller #1: Hi, Dr. Rudman. How are you? Hey, Anne, how’s it going? Here’s my question…

Anne: (inaudible)

Caller #1: I’m sorry? Ok, my question is do all people’s teeth move around during their lifetime or are some of us just unlucky?

Robert: I would say if you think your waistline shifts around in life, you are probably pretty correct on the teeth as well. Everything tends to move. It kind of goes back to prehistoric times when we were all roaming the earth and picking up food. We had a very abrasive diet and what would happen is our teeth would wear down. When you floss your teeth, you get in between; you get those little clicks in between the teeth. Well, we used to wear our teeth down to where they were below those clicks. Mother Nature’s answer to that was to keep everything shifting forward through life. Of course if things are shifting forward and we are not wearing our teeth down there are no sticks anymore. Therefore, things tend to crowd up. I would say for the most part most people are going to experience shifting in life just like the experience wrinkles or expanded waist lines or all the other non-exciting things that go on as we age.

Caller #1: Interesting.

Anne: So, then all the celebrities that you see that keep their beautiful smiles all the way through their third, fourth, fifth husband does that mean they are all somehow getting…Are they getting tweaked? Are they getting realigned?

Robert: I think it depends. The magic of orthodontics is that you can create really great smiles. The other magic of that is as long as things are being retained, whether that is a removable retainer or a fixed retainer, things will stay the same. Unfortunately it’s not the same as your waist. If I could come up with a retainer for the waist line I would be doing late night talk shows and advertising that.

Anne: You are doing a late night talk show.

Robert: That’s true. I still have to come up with the retainer for your waistline where you can maintain your waistline at that high school length.

Anne: You know I think I saw that on an infomercial actually. Anyway, Rob, thank you for the question. That was an excellent question. Actually, along those lines sort of which shows how my brain works here, Dr. Rudman, you actually said to me once…I would really love to have you talk about Invisalign as well for our listeners. I have to tell you that most people that I encounter now in person have no idea that I am wearing braces. Frankly I don’t even know if you like to call them braces, because Invisalign calls them that, but maybe you might chafe a little at the term because they are very different than the metal technology. But, a lot of people have no idea about them, so I’d really love to have you talk a little bit about those. But, first my question is you once said to me that as an orthodontist you prefer your patients to have the more traditional metal braces because you then retain, no pun intended, a lot more control over what is actually happening with their teeth. So I don’t know if you maybe want to talk about that for a minute or first explain what Invisaligns are and then go back to that. But, I found that fascinating. My experience of you, having been your patient now for several months is that you are not a control freak, so there must be something to this.

Robert: Sure. Well, let’s talk about Invisalign. Basically Invisalign is like a brand name for a car, whether it’s General Motors or Toyota. Basically orthodontists have been moving teeth with clear aligners for 30 years.

Anne: Really? Wow!

Robert: Yep. The difference with Invisalign is that Invisalign has been the first company to marry cad cam technology with these aligners. So what would happen is with the orthodontist every time you would come in I would have to take an impression, reset your teeth by hand, make this little invisible shell that fits over your teeth that would move your teeth to the desired movement, and I could only do that every maybe two or three weeks. It was very, very expensive because it was a lot of the orthodontist’s time resetting teeth. Where Invisalign came in was they basically allowed us to digitally move the teeth. Then they use Stereolithography which basically takes liquid plastic and turns it into whatever the digital technology is on the computer into a three dimensional model and then they make the aligners off of that. What it gave the orthodontist the liberty to do is do a lot of aligners with very little orthodontist time, which was great. So, it is a great technology. It is limited on what it can and can’t do for particular movements. But, it is a great technology. It has opened up a lot of treatment possibilities for adults that really want to get their teeth straight without the nuisance of having braces on. That being said, what you said about having control, I always tell people that Invisalign is like a gym membership. You can pay your membership, but unless you show up and actually do the work, nothing is going to happen. So, most adults are very motivated to do this, so there are not much compliance issues. Sometimes with kids, if they have the option to wear something or not wear it, sometimes they don’t wear it. Again, it’s really all about patient selection. I tell people that you can get from New York to LA with a lot of vehicles, a car, an airplane, a train, but you just have to pick the right vehicle for the situation.

Anne: Mm-hm.

Robert: If you want to go to Paris, it would be a whole different vehicle.

Anne: And it won’t be the Concord.

Robert: Well…

Anne: You say it is all about patient selection and I can just only imagine at this point, not at this moment, but generally, you are probably wishing that perhaps you had been a little more particular in the selection of this particular patient, because I do give you a pretty hard time.

Robert: No. No, not at all. You’ve already had braces. You know what the alternative was. You were very motivated, and your case was…basically you have a good bite and it was the little aesthetic things that could be done. I think with Invisalign, if you want to get more information go on Invisalign’s website, but they basically break providers down by experience level. If you are a premier provider you’ve done a lot of cases. So, just like anything else, you know we were talking earlier in the show, practice is a huge issue. Everyone makes a lot of promises, i.e. the product manufacturers, but until you’ve experienced what it can and can’t do you really want to try to stick with someone that has a lot of experience. They have the right tool for where you want to go.

Anne: I had actually wondered about that because I did go on the Invisalign site when I was first checking it out and I did wonder whether to get the status of a premier provider you really actually had to have done a certain number of cases or had just had to pay a certain amount of money for that placement. I’m glad to hear…

Robert: No. A premier provider is the top five percent of all Invisalign providers, so it is all about experience. There is no monetary, you can’t pay someone off to get that status. You have to…

Anne: So how did you? That’s pretty impressive. You just treat a lot of people. That’s very interesting because where I go to see you is actually a pediatric dentistry and orthodontics practice. I know you don’t give Invisalign’s to kids.

Robert: (inaudible)

Anne: So it’s interesting. This is in your Denver practice and I should mention again that Dr. Rudman practices out of both Cherry Creek and Denver, and also up in Longmont. So he is all over the place.

Robert: Cherry Creek is kind of an affluent yuppie area, so I treat a lot of adults. That’s basically where I got the premier status. What’s interesting is that I have a lot of patients in Longmont that seek me out from that area in Boulder because I am a premier provider and they know I have a lot of experience with it.

Anne: Ok. I have another question. Actually I know we are ignoring the callers that are calling in and partly that is because we are having a little problem with the switch board. We are working on that, but we also have these other questions that have been coming in from e-mail. A couple of them you’ve already seen I have to let callers know for the sake of full disclosure, but we do take them on the air. One of our listeners is wondering, she says that her daughter had two phases of braces for six years because she had an open bite. I am sure this will mean a lot more to you than it does to me. When the treatment was complete it looked really good, but now in spite of wearing her retainer faithfully her bite has completely opened up again. Her treatment used TADs, hopefully you will tell us what that is, and elastics. So, do you have a comment on the long term success rate of this procedure? She’s wondering if anything has improved in the past few years to make it worth doing it all over again. I just…Reading that makes me think oh my god her poor daughter to have to go through a treatment like this twice.

Robert: Sure.

Anne: She ends up saying she wants to avoid orthognathic surgery. What on earth is that?

Robert: Ok. Well, we’ll start off with what is an open bite. An open bite basically means that there is no overlap of the front teeth. That can mean a severe open bite would be the only teeth that you are hitting on is your very back molars and nothing hits forward. A minor open bite would be that basically your canines forward aren’t overlapping. So, it is very difficult to bite into a sandwich. If you bit in you probably wouldn’t get the meat. You would just get the bread. That being said, I am also going to explain a TAD is. Tad is an acronym for a temporary anchorage device. A temporary anchorage device is basically a titanium post that screws into the bone.

Anne: Ouch!

Robert: The difference between bone…Yeah it sounds crazy, but it is a very simple procedure. It’s not a surgery. It’s really not even any anesthetic. The bone has no feeling. The periostium (?) which is the membrane that surrounds the bone has the feeling so you numb that. The little screw goes in. They are very, very tiny. I mean like pin sized. So, the way it works is, if you pull on your finger, no pun intended, for as long as you could, it wouldn’t make your finger longer. Of course the difference is a tooth has what is called a periodontal ligament and the way teeth move, and it’s kind of crazy because you think well you can move teeth around why can’t you move bone around, but it’s because a tooth has a periodontal ligament. When you put pressure on the periodontal ligament, it sends a signal to the bone to get soft and on the tension side of the force it lays bone down. So, that’s the way teeth move. A temporary anchorage device anchors to the bone which is not moveable. Reading between the lines on this woman’s question, her daughter had a fairly severe open bite. If you think about your jaw as being a wedge, the further you go back in the wedge, the more things open up. What I mean by that is if you took a really small tic tac and you put it in your front teeth, it would only open you up the size of that tic tac. If you put it in your back teeth, it would open you up quite a bit. So the way a temporary anchorage device would work is they would try to intrude the back molars, meaning taking the tic tac out of the back of the wedge. There’s a lot of complicating factors to that. Of course not seeing the kid, I can’t really comment, but I’ll give you my two cents worth. A lot of times kids that have an open bite then have airway issues. They breathe through their mouth; their mouth is open all the time. Teeth come in until they touch something. So, if your mouth is open all the time, your back teeth are going to come in and touch, and now you are going to be stuck with an open bite.

Anne: Wow.

Robert: Orthognathic surgery is where they go in and move the jaws. She was trying to avoid doing this orthognathic surgery which is fairly invasive. They go in, break your jaw, move your jaws around, and move your teeth around, but sometimes that is the only way you are going to get a lasting result. TAGs have been around in the US for about 10 years FDA approved. They have been around for about 20 years orthodontics preins(?) and the Middle East used them quite a bit. The problem is that we don’t know what the long term results are for these. We know they are safe to use for particular movements. Open bites are the hardest things for an orthodontist to try to fix. I think some advice to the lady that wrote in is I would obviously talk to the orthodontist. There really haven’t been a lot of changes in the technology. Some things to look at are do we have an airway issue where we are breathing through our mouth all the time where that is going to return? Do we have a tongue thrust? A tongue thrust is basically when you are always placing your tongue between your teeth. The tongue is a fairly good tooth mover. That could have resulted in the open bite. The best advice is to talk to the orthodontist and say if we did TAGs again would this be any more stable or is orthognathic surgery the only way to fix this permanently? I would again look at whether there are any underlying issues with the tongue thrust, mouth breathing, etc.

Anne: Are there some sorts of orthodontic issues or indicators that a child could benefit from orthodontia that sort of there is a nexus between that and you mentioned the teeth are always moving and there is no point where they become completely static and stable. So are there sorts of situations where you could really say wait and see legitimately. Some orthodontists might be much more progressive and say yeah we can treat this right now. Whereas, a more conservative orthodontist might say we could treat it but it might just resolve itself if the mouth and jaw grow.

Robert: Sure. I think that all goes back to experience level and how long someone has been practicing and what they see. There are a few components to why people have orthodontic problems. If people have a thumb sucking problem and our thumb is always wedged between our teeth and it also wedged between the roof our mouth and our tongue. As a child grows, we develop from what is called an infantile swallowing pattern, which means we are either nursing or we are sucking on a bottle. The tongue is always low. To an adult swallowing pattern, when you are hanging out your tongue is on the roof of your mouth. When kids have long term thumb habits or digit habits or blanket habits or pacifier habits, there is always something wedged between the roof of their mouth and their tongue. So, they always have a low tongue posture. They tend to want to push against their teeth. Their teeth are tongue low. If you think about it your teeth are kind of a balance between your cheeks, your lips, and your tongue. Generally most people’s teeth follow their tongue if they have a normal swallowing pattern. If your tongue is always low, what happens is the cheeks start pushing in on the teeth as they start erupt into the mouth and we wind up having a really narrow arch, which means we are probably going to have wind up having crowding. So someone who is looking for these muscle problems, because form tends to follow function, they might say well I’m going to send you to someone who is going to help you with your tongue thrust or your thumb habit and it will resolve itself on its own. There’s other times where you have to look at someone and go there is absolutely no way that we are going to be able to not extract teeth unless we do some kind of early treatment. Part of that has to do with how the craniofacial structure forms. There are particular features in the face that for girls don’t fuse till they are ten, for guys around twelve. So if you get in a little earlier, you can actually move bone around. So I tell people that doing orthodontics is like building a house. Sometimes what you want to do is work on the foundation first and if you have a four bedroom mouth with six bedrooms’ worth of teeth we need to make that foundation a six bedroom foundation. We might do that early. Otherwise, we are going to have to take some of the bedrooms off the playing field so to say. I think experience level, individual cases, looking at swallowing patterns, a huge issue is airway. It used to be that pediatricians would take tonsils out on everybody. Now they don’t take them out on anybody. Someone who is snoring at night as a kid is basically going to be a mouth breather. They are going to wind up having open bite problems, narrow arches; these are all things to look at. I don’t make the final call. I send them to an ear, nose, and throat doctor to make the final call. It’s amazing what you can find.

Anne: That actually leads right into another caller who is writing in and wrote in earlier today. She is asking…you were talking about thumb sucking and nursing and I actually want to ask you about that in specific, but first callers and listeners always come first. She says, “My daughter is three and sucks her fingers for comfort. Do you have recommendations on stopping that habit? How to replace the comfort she gets with something else? It is apparent that the fingers are making her teeth move. When she does stop the behavior, what is the likelihood that she will need braces?

Robert: Ok. We will start with the habit first. Usually a thumb habit, a digit habit, a pacifier habit, a binky habit, whatever it is that is in your mouth, as long as it is resolved by the time you are two, you are probably fine. So, this gal is three so from most conservative to most aggressive is going to be obviously a positive reward system. There is a product called Mavala, you can look that up on the internet and order it. What it is is a nail polish that tastes really, really bad. So, if you paint it on your kid’s fingers, it is not going to taste very good and they are going to not put their fingers in their mouth. Some kids are very pernicious about their habits. You can see someone called an orofacial myologist which is a very fancy name for a speech therapist that has gone on for further training that helps kids with where should they rest their tongue, how do we get rid of the thumb habit or finger habit. The most aggressive one is an orthodontist can place what is called a tongue crib. What it basically is that most kids get their endorphin rush when they have a habit from pressing on the roof of their mouth. So, what we do is we kind of put this little appliance in that doesn’t allow you to touch the roof of your mouth. It kind of gets boring for the kids and they quit the habit. The big issue with the habit is again if your tongue is always low and you are kind of sucking on the thumb it’s making it worse because your tongue is not supporting the inside of your teeth and your cheeks are pushing on the outside of your teeth all of the sudden we get a very, very narrow upper jaw and the teeth start to flare forward. So, if you think about if you stuck your finger between your upper and lower teeth, it is acting like a wedge. So, it will do a couple of things. It will make your teeth flare on the top forward. It will make your lower teeth flare backwards. It will retard the growth of your lower jaw. These are all important habits to get rid of early on.

Anne: That is actually very interesting in as much as we all know that having kids that suck their thumbs for too long. It can make them have what many people call buck teeth. I had not realized that it could actually reform or retard the proper formation of the jaw. Why don’t we as parents know? Why isn’t that out there? Why did I know that before? I think I am a pretty conscientious parent, and I’ve never heard that.

Robert: I think that you would probably have heard it from your dentist if that was kind of an issue. Today we have a lot more choices. There are pediatric dentists for kids and the pediatric specialty of dentistry recommends that we see the kids as soon as we see teeth, which is generally a year and a half. They are much more apt to look at these habits and see why things are flaring. I think that most modern, trained dentists are looking for those things now. I assuming if your daughter or son had that habit, they probably would have brought it up and hopefully sent you in the right direction. I get a lot of referrals from the dentists that refer to me on what do we do with this kid. Do we send him to an orthofacial myologist for some training or a habit appliance? The worst case scenario I had was a girl that was quite a bit older past high school that they actually had to put a cast on her hand in order for her to quit.

Anne: Wow! That’s extreme.

Robert: That is extreme.

Anne: That’s extreme.

Robert: What’s amazing is once that habit was removed there were a lot of huge changes in her teeth just alone. She had to go through orthodontic treatment anyway. I don’t think, getting back to your caller’s question, that her daughter absolutely needs treatment. But, I do think that she absolutely needs to get rid of the habit.

Anne: That makes sense. So, now let’s back track up a little bit. Because you mentioned among other things, thumb sucking, a bottle, a pacifier, and you mentioned nursing. You may or may not have known this about me, I don’t think we’ve had this discussion, no reason we would have, but I was very active in what is called the attachment parenting community. I was pretty well versed in things related to nursing and at one time acted sort of as a peer counselor for that. One of the things in my studies that I learned was that the average age of weaning around the world is between five and seven years old. So in the United States and in some of the other “civilized, industrialized, first-world countries” now we sort of rush kids off the breast interestingly not so much the bottle. But, in other countries it’s extremely common for kids to still be nursing when they are three, four, five, even six or seven years old. The conventional wisdom in the attachment parenting community and among breastfeeding advocates is that nursing actually facilitates the proper development of the jaw. It’s kind of well known, and maybe it’s kind of hypocrisal. It seems to hold true that babies who are solely breastfed tend to teeth earlier. The supposition is because they are working their jaw muscles, etc. So, is there a point, because you did mention nursing, where extended nursing can actually be detrimental to the shape of the jaw and the dentition?

Robert: To go to Bryan, I would say 30 is definitely a cut off.

Anne: (laughs)

Robert: I’m going to totally agree with you, because if you think about the mechanics of nursing, the lower jaw has to come forward in order to get the mouth around the nipple. The difference is…When I had mentioned nursing, I meant infantile swallowing pattern, where the tongue is kind of low to do that, which is fine, because the lower jaw is coming forward versus a bottle. With a bottle, it is something stuck in between the roof of your mouth and your lower jaw for very extended amounts of time. Most nursing is not going to go on for hours and hours and hours. Where a lot of parents send their kids to bed with a bottle, and again you have something wedged between your upper and lower jaw. So I totally agree with you that natural nursing brings the lower jaw forward and helps with jaw development.

Anne: That’s awesome.

Robert: We are on the same page there. Bryan needs to cut it out.

Anne: (laughs) Yeah. I wasn’t challenging you. I was clarifying. So I can be sure, everyone heard this now. We have our expert orthodontist saying that nursing regardless of how extended (to a point) is not bad for the development of the jaw and in fact can be good for it.

Robert: Correct.

Anne: That’s very nice to hear, because that is what we have always kind of assumed. Bryan is sending me frantic messages saying who is he talking about? Your son’s name isn’t Bryan. He’s talking about you, Bryan. He’s on to you and that extended nursing.

Bryan: I would have jumped in earlier had I known I was the topic of conversation. In fact I couldn’t figure out if he was telling me that I needed to stop breast feeding or I needed to stop my kids’ breastfeeding. I don’t know what is going on here.

Anne: (laughs)

Robert: Bryan, I would say you have a really great jaw development. I don’t know what that means.

Anne: (laughs)

Bryan: (laughs)

Anne: Ok, Dr. Rudman, Dena calling from St. Paul would like to know how do you tell if you’ve got a good orthodontist from a bad orthodontist. Should you just always accept the referral that your dentist gives you? What are the indicators of a good orthodontist? While you are thinking about how to answer that, because I’m sure you are going to have to think about that for a minute, because, I am going to take this minute. I just want to tell you a story which I told your staff actually. I think I may or may not have told you. In fact, I will tell a two part story. I know I told you the first part. You were actually, and I know this is maybe going to hurt your feelings, but not my first. I did have a consultation with another Invisalign orthodontist in the area before going to you. Actually if anything I should thank him because he made me want to run in the other direction. It was then that I looked elsewhere and found you. Part of it was the way he talked to me. One of the things he told me was, “Oh yes, Invisalign will help you and we are going to make your mouth more feminine.” Well I’ve never thought of myself as having a masculine mouth and certainly none of the men I’ve date have ever complained about my mouth being unfeminine. So I just thought that was a very odd remark. The other thing about this particular orthodontist which really put me off and now that you know about my involvement with attachment parenting, etc., it will make sense to you. I walked into the waiting room and there was a huge sign saying, “Parents not allowed beyond this point.” It wasn’t even a pediatric practice. My thought was you are telling me that under no circumstance can I accompany my child back to the treatment room even for the first time? That just so put me off. That doesn’t mean that he is necessarily a bad orthodontist, but certainly it wasn’t a good fit. I’m often asked as a lawyer, what is the best way to know if a lawyer is good or bad. I tell people one of the things that you really have to think about is is it a good fit. Because you are going to place your case in the case of a lawyer or your treatment in the case of an orthodontist in their hands, you have to have faith. So, even if they might be competent technically, if it is not a good fit then it is kind of like the retainer thing. You are going to be less likely to go back. You are going to be less likely to do what they tell you. That’s just my story, but please riff on that.

Robert: Sure. I think that going through the filter of decisions obviously you want to be sure that they are a specialist. That’s what they do, and they are a university trained specialist. I think secondarily you get your referral from your dentist and you also ask your friends on whom they are going to and what their experience level is and I will totally agree with you that people will do better when they actually understand what is going on. That is makes sense to them. I think the only way that you can do that if it’s your child that you are involved in the care. We always like to give any instructions, if we are giving instructions, to both the parent and the patient. If it’s just you, obviously we are giving instructions to you. It is very important that everyone is involved and everyone is on the same page. I definitely agree that you have to have a comfort level, you have to understand what is going on, and I think not only do you get your referral from your dentist if that is who referring you but you also go ask in your community and what parents’ experiences are. You have to be a good fit. You have to feel comfortable.

Anne: Is there something? You mentioned university trained in the specialty. Is there sort of a baseline? Something that you should always look for? I know that also with lawyers, doctors, whatever, you go in the office and they have all these diplomas on the wall and you don’t know if they printed them out from the internet. I get spam all the time offering me a university diploma. What do you look for to screen to make sure they really are university trained as you say? What do you look for?

Robert: I think the United States in order to call yourself an orthodontist you have to be a university trained orthodontist. There are dentists that will say they do orthodontics or some dentists will call themselves orthodontists, but they are not. They’ve just basically taken a few courses here and there, which is not saying that one is better than the other it’s just that I feel like if you are going to go for a kidney operation you want to see a kidney specialist. You don’t want to see your family doctor.

Anne: Or your orthodontist.

Robert: Right. You want an orthodontist to treat you from an orthodontic perspective. They have a lot of experience. I would also try to look for someone that has a few years under their belt, because when you think about orthodontics, orthodontics is an 18 to 24 month process. You are general training is anywhere from two to three years, so you really don’t see that many cases. The more experience you have, the more you’ve seen, the more decisions that you can make from experience. Then again I think it is really important to ask your friends, and as you did if you don’t feel comfortable get another opinion. I think if you are questioning the actual recommendation I think it is always good to go to a second opinion whether you get along with the first orthodontist or not.

Anne: We have another question coming in through our Twitter account. Jenny says she is in Eerie. She is wondering if you have a child and it is pretty clear that they need orthodontic treatment but they are extremely resistant to it, and she doesn’t say why or even how old the child is. But, I can imagine any number of scenarios, whether it is peer pressure or the child is young and scared. What do you recommend in terms of assisting the child to get over that? I would also add is there a point at which you feel like maybe they so badly need treatment you should coerce them? Or can you pretty much always wait until they are more accepting. Given that you have a pediatric practice, that’s a great question for you. How do you recommend parents handle that?

Robert: Sure. I think a lot of times, a lot of kids are very resistant. It’s funny. Nowadays I get kids mad at me because I tell them that they are not ready for orthodontics. It seems like all of the kids want braces now. It’s a funny phenomenon. So I think a lot of times if you as a parent have a concern I think that if you pick the right person to go to and you let the orthodontist know that they are a little apprehensive. Then, it may not be an issue of saying let’s start right now. Let’s talk about it. Let’s see what is going on. A lot of times, if you haven’t been to the orthodontist, the orthodontist might say, “Hey, you know what you’re fine. Don’t worry about it. We can wait.” Then, we can wait for maturity to set in and the kid can make the right decision. If it is something where it really needs to be done then I think it is just like any other medical or dental decision. You as a parent have to make that decision. I think waiting and delaying it just because the child is resistant to it probably isn’t the best bet. Especially because probably the news that you are going to hear is we don’t have to do something now, the kid can get used to the practice. They can see that it is fun. They can see all the other kids having fun in the practice. The one thing I’ll tell you about orthodontics is that I’ve always said it’s happy dollars being spent, meaning you are not going in for a root canal and paying for a root canal. You are actually getting this really beautiful result and it is good for your kids. They might see that this is really not a painful place to be.

Anne: Ok. Now, speaking of painful things, this is one of the things that I…This is a question from me, because I’m very curious about it. I don’t think it was the practice back when I was having orthodontia. It’s to me relatively new, but maybe you could just abuse me of that notion, just as you did with Invisible aligners, and that is the concept….And, maybe I even have it wrong, but here is how I understand it, that currently there is a procedure by which if the teeth are going to be too crowded rather than extracting the teeth you actually spread the palate and increase the size of the upper palate. I think that is the palate, the roof of your mouth.

Robert: Correct.

Anne: As it was explained to me by people whose children were going through it, it is literally stretching the roof of the mouth while it is still kind of soft and pliable to make it larger. I’ve got to tell you I cringe at the very thought of that. It almost makes me think, well that’s kind of us interfering with what the natural development of what the shape of that mouth would be. So, first of all, do I have it right? If so can you convince me that it is a good thing?

Robert: Sure. Well basically if you are correcting something. If you have a narrow upper jaw it tends to be issues with airways or habits. The way an expander works is it just like in any child’s skeletal structure there are varying sutures. You can have growth sutures and growth plates, etc. That’s why little kids as their brain grows the bones are not fused together. That accommodates the growth of brain, that’s why our heads get bigger from infancy through about six or seven. So, with what is called the midpalatal suture, it is the suture where the tow halves of the upper jaw meet. They are not fused together yet. So, the way an expander works is the weak link in the system is that suture. The expander goes in and we turn this thing. Actually, the parents do it at home. It basically puts pressure on either side of the teeth. What happens is the whole upper jaw expands. You are actually moving bone. So, why that is good is if you can do that early on what kids generally report is that it is a lot easier to breathe through their nose, because when you have a constricted jaw the roof of your mouth is very constricted. Which means that your airway is very constricted, which means that your nasal pages are very constricted and they always say oxygen is a good thing.

Anne: (laughs)

Robert: Yeah. So again just like building a house, if you want to have a house that is going to accommodate all the bedrooms and right now you have a six bedroom house on a four bedroom foundation, if you can make that foundation the right width early on you have a much more stable house that you are building. Versus, if you have a very, very narrow arch that you try to push the teeth out too far when you are an adult, you basically wind up pushing the teeth through the bone and you wind up getting recession around the teeth.

Anne: But doesn’t that…Isn’t that somehow us playing god with the shape of that’s child’s face?

Robert: Well if you have one leg that is shorter than the other leg, you could just say well we should just let that play out.

Anne: (laughs)

Robert: But basically what you have is a skeletal imbalance and thank goodness for modern technology you can change that skeletal imbalance. I’m not saying it has to be done to everybody. But, generally if you have a very, very narrow upper jaw there are reasons for that. It is usually some type of habit that has played itself out like I said earlier. Form tends to follow function. If you have an issue with the function you are going to wind up having kind of a narrow jaw and we need to kind of change that to get the right form.

Anne: So what you are saying is that in most of those cases using that expander is actually correcting something. It’s not modifying what nature intended. It’s actually correcting something to bring it back to what nature intended.

Robert: Correct.

Anne: Oh. Well I feel much better about that.

Robert: Good.

Anne: Thank you for clarifying that.

Robert: That’s why no one in your house is walking around with one leg shorter than the other.

Anne: Well actually I am, but that is a whole other show. We only have a couple of minutes left and I really wanted to reserve those couple minutes to let you tell people about the two practices. I think you only have two. Maybe you have three. I don’t know, but to tell them where they can find you and to give out the phone numbers if you would like and the website addresses and tell people how to find you/

Robert: Sure. Well the easiest way to find me is on the web, and the web address is toadvanceorthodoniccare.com (?) or cherrycreeksmiles.com. They will both link you to my website. Practice in Longmont with Dr. Ed Christianson, he is a pediatric dentist and that is primarily a kids practice, but we treat a lot of adults as well. I also practice in Cherry Creek which is right outside of downtown Denver. The practice there is probably 50 percent adults and 50 percent kids. I’m not a toot your own horn kind of person, so you can look me up if you have questions and you write to our web address. I am happy to answer them for you whether you are in my geographic area or not.

Anne: Well I will certainly toot your horn if you want, because I think you are fabulous and you have a great manner and you just treat your patients (at least your adult patients) very well. I have to assume you are wonderful with the kids too. I would like to just say thank you so much for coming on the show. I learned so much in this hour. It is amazing.

Robert: Good. It was fun doing it.

Anne: Thank you so much.

Robert: You’re welcome.

Anne: Everybody tune in next week and Bryan is going to tell you who our guest is next week. I am going to put him on the spot because I don’t have it in front of me right now. Bryan, who is our guest next week?

Bryan: Well that is a very good question, Anne. I have got no idea who our guest is next week.

Anne: (laughs) Ok, well I’m going to tell you. Next week we are going to be talking about anti-aging technology with anti-aging expert Ellen Wood who is going to tell us how to grow younger. Talk to you next week. Now you know.

Dr. Robert Rudman’s Website

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