Episode #333: It Can't All Be Done With a Bur, with Dr. Jeff Rouse

Aesthetics should be the byproduct, not the driver of airway treatment. And a problem in dentistry is the pervasive camouflage treatment culture that many clinicians participate in. So, to expose the problems with this mindset, Kirk Behrendt brings in Dr. Jeff Rouse from Spear Education to teach you that not everything can be fixed with a bur; airway might be the answer. But don't just take any old course on sleep — sleep and airway are not the same thing! For more of Dr. Rouse’s advice, listen to Episode 333 of The Best Practices Show!

Main Takeaways:

Dentistry needs to go beyond the aesthetically-driven camouflage treatment culture.

Dentofacial growth problems need to be addressed, not camouflaged.

There are more than just structural and biologic issues; there's a bigger picture.

You can't solve airway issues with a bur, by cutting away and removing things.  

Comprehensive care isn't taught in dental school.

Don't just take any sleep course. Learn about airway.

Quotes:

“[Dr. Christian Coachman wrote in his post], ‘In my humble opinion, the main challenge of modern dentistry is, go beyond the aesthetically-driven camouflage treatment culture.’ And I totally agree. I wrote him and said that we need to also have ENTs and sleep physicians think the same way. . . His idea was, we need to stop just taking constricted arches and malocclusions and camouflaging it by adding veneers and crowns, that we need to get to the core problem, which is that we've got a dentofacial growth problem. And we need to address that.” (08:09—08:57)

“Dental school has a huge problem. And I don't think there's an answer to it, honestly. I can't figure an answer. If you turned a dental school over to me tomorrow, could I put a curriculum in that would advance our ability to treatment plan more ideally the way Christian was talking about? Absolutely. What would be the problem? Well, a lot of those treatment plans require multiple years, so you're not getting the hands-on. You're not actually cutting on teeth and stuff; you're doing other things. But even more important, it would require retraining all of the faculty. And every time a new faculty member came in, they'd have to be retrained all over again.” (09:52—10:36)

“At Spear, we teach that facially-generated treatment planning starts with esthetics; where do the teeth belong, like setting a denture; function, how do you put the lower denture in to get it to work right. Then, you talk about structural issues and biologic issues; do they have disease, did they break a tooth, what kind of ceramic I'm going to use. In dental school, we only talk structure and biology. There's no, ‘Where do the teeth belong?’ It is simply, get hand skills so that you're not going to hurt people when you leave. And do you need to do that? You absolutely do. The problem is, we call it “treatment plan”. They say, ‘Okay. You've met your new patient. Now, you're going to present your treatment plan to me.’ And that implies that it’s comprehensive in nature, and it’s not even close.” (10:41—11:33)

“We need to continue to spread the word that there's more than just structural and biologic issues. There's a bigger picture that needs to be taken into consideration.” (12:50—13:00)

“If the only thing a dentist knows how to do is cut with a bur, they don't understand the interdisciplinary nature of what they just put on the teeth. Then, they try to provide a solution simply by warping ceramic, building out huge bicuspids, teeth that are overlapped, ‘Well, if I prep this, it could do this and do that.’ I mean, they're always trying to figure out how to solve it with a bur. And what we’ve started to look at and look at differently is, if you take that case, and the analog or digital version of the mockup is great because it gets commitment from the patient. I want that. But I want you to then, instead of just counting the number of teeth you've covered and going, ‘That's the number of veneers I do,’ I want you to actually ask yourself, ‘If that's where I want the teeth and the bone doesn't support it, or the teeth don't support it, and I have to warp things, is that really the right treatment plan for the patient, just adding on?’” (18:08—19:13)

“What [Coachman’s article] was speaking to was the idea that we’re camouflaging a bad wax rim. And we shouldn't, because if you have a lousy maxillary wax rim, in particular, you can't breathe through your nose as well and you will have a much higher rate of sleep apnea. And actually, Christian works with an ENT down in Brazil that has just published some work on that that showed the narrowness in the premolar space, so the height of the palate in the premolar space, either one, makes you more likely to have sleep apnea. So, from an ENT perspective, they're saying if you're narrow, you also can't breathe through your nose. You can't breathe through your nose, you're going to have sleep apnea, more likely. He then went further to expand them, take the wax rim, grab it, move it out. What happens? They got better. So, camouflage needs to go away. And it also needs to go away in ENT, and it needs to go away in sleep.” (21:35—22:41)

“Camouflage is ridiculous. Classically trained ENTs are only soft tissue surgeons, for the most part. They will take a septum that is deviated, they will take away pieces, and they will re-put it together within a small box. And the research has been done at Stanford saying if you try to work within a small box, there is going to be a bunch of symptomatic patients. And the reason is, the maxilla is too small. They're going to take away a soft palate by doing surgery, when in fact the soft palate is just fine; it’s just in the wrong place. So, instead of moving the soft palate where it needed to be, they just cut it out and pretend that the skeleton is normal. They're going to cut away on the tongue or shock the tongue to make it smaller. Why? Because they're going to call it macroglossia when it’s really micromouthia — the mouth is way too small to hold it in there.” (22:43—23:31)

“Sleep physicians are the same way. Their classic articles all say, ‘This is an anatomic issue,’ but then they go find solutions through CPAP and Inspire where they shock the tongue. It’s just stupid. It is. Everyone needs to see what Coachman is talking about, which is, we’re camouflaging the real problem, which is the skeleton. And today, we’re good at moving the skeleton around. We’re way better than we’ve ever been able to do.” (23:33—23:57)

“When you start talking about health, you've got [the patient’s] attention. You absolutely have their attention. So, not only are we providing the right treatment plan by making the wax rim normal, the minute you can say, ‘Oh, and by the way, people that have upper jaws that are shaped like you, they have these things,’ and you look at their medical history, you look at their dental history, you know, reflux, bruxism, high blood pressure, AFib, I mean, just make out lists, whatever the list is, you go, ‘And these things you told me about may go away because they're probably related to the fact that you can't breathe,’ now, you get their attention.” (27:10—27:52)

“If your goal is, ‘I want to be a leader. I want to be the best. I want to have my practice as one that everyone wants to come to. I want to be able to do things that make it fun. I want to be confident in my ability to do these and render a good treatment on my patients,’ you need to start learning more about airway.” (36:42—37:03)

“Don’t go to learn how to make a sleep appliance. Yeah, you need to know how to do it. I'm not saying not to go to those courses. But do not go to a course in making appliances or any kind of sleep-based course and assume they mean airway, because they don't.” (37:11—37:27)

“[In] 2019, I made four appliances. In 2020, I made zero. And I look at airway on every single patient, and there is no need to make those appliances for the majority of the people that come to your practice. So, if you're a young dentist, please be clear, there is a huge difference between what we teach at Spear with airway and a traditional sleep course making appliances.” (37:40—38:10)

Snippets:

Dr. Rouse’s background. (03:40—07:29)

Dr. Christian Coachman’s post. (07:46—09:20)

Do dentists know the bigger picture? (09:34—13:00)

Dr. Rouse’s turning point. (14:02—17:16)

It can't all be done with a bur. (17:34—23:58)

Negotiating issues with the patient. (24:37—28:37)

Dr. Rouse’s response to, “I don't have those patients in my practice.” (29:03—33:30)

Managing patients’ expectations. (33:47—35:01)

Advice for young dentists. (35:44—38:10)

How to get involved with Spear Education. (38:27—41:41)

Reach Out to Dr. Rouse:

Dr. Rouse’s Facebook: https://www.facebook.com/jeff.rouse.58

Dr. Rouse’s Instagram: @jeffreyrouse https://www.instagram.com/jeffreyrouse/?hl=en

Spear Education website: https://www.speareducation.com/

Dr. Jeff Rouse Bio:

Dr. Rouse is recognized as a pioneer in the field of airway prosthodontics — the impact that a compromised airway has on the stomatognathic system. Along with fellow Spear Resident Faculty member, Dr. Greggory Kinzer, he developed the "Seattle Protocol" to recognize, control, and direct resolution of airway distress in a restorative dental practice.

Dr. Rouse maintains a private practice in San Antonio, Texas, and practices with Dr. Kinzer and Dr. Frank Spear in Seattle. He is also an adjunct assistant professor in the Department of Prosthodontics at The University of Texas Health Science Center at San Antonio. Among his dental accolades, he has written numerous journal articles, including a portion of the “Annual Review of Selected Dental Literature” published each summer in the Journal of Prosthetic Dentistry. Most recently, he co-wrote a textbook by Quintessence titled, Global Diagnosis: A New Vision of Dental Diagnosis and Treatment Planning.

After graduating from dental school in San Antonio, Dr. Rouse completed a two-year general practice residency at the University of Connecticut Health Science Center. He practiced family dentistry for 12 years before returning to school to earn his specialty certificate in prosthodontics from The University of Texas Health Science Center at San Antonio in 2004. He is a member of the American Academy of Restorative Dentistry and American College of Prosthodontists, and past president of the Southwest Academy of Restorative Dentistry.