Ep 74 - From Skeptic to Advocate: Dr. Daniel Grob on Embracing Early Treatment

Today on the Golden Age of Orthodontics, we’ll explore the controversial topic of early orthodontic treatment. Dr. Daniel Grob, a board-certified orthodontist with over 40 years of experience, discusses the benefits and challenges of early intervention. He emphasizes the importance of developing facial width and addressing oral habits in young patients.

Dr. Grob challenges traditional views on early treatment, arguing that cone beam X-rays have changed how orthodontists assess patients. He focuses on creating width for future development rather than just straightening teeth. Dr. Grob aims to complete phase one treatment in 15 months or less and phase two in 18 months or less.

The discussion covers the prevalence of oral habits like mouth breathing and nail biting in young patients seeking early treatment. Dr. Grob shares insights on educating parents and general dentists about the signs of maxillary deficiency and the benefits of early intervention.

The episode also addresses the marketing aspects of promoting early orthodontic treatment. Dr. Grob emphasizes the importance of building relationships with pediatric dentists and other specialists for referrals. The hosts discuss strategies for reaching parents directly through educational advertising. The conversation concludes with clinical advice for younger practitioners considering early treatment. 

IN THIS EPISODE: 

• (00:00) Intro: Early orthodontic treatment debate

• (02:28) Meet Dr. Daniel Grob

• (10:14) Cone beam X-rays changed approach to early treatment

• (14:47) Parent demand and concerns driving early ortho

• (16:49) Prevalence of oral habits in early treatment patients

• (24:42) Partnering with pediatric dentists for referrals

• (29:51) Evaluating transverse dimension and expansion needs

• (33:37) Compliance with Invisalign for young children

• (34:59) Resources to learn more about pediatric orthodontics

• (37:51) Closing thoughts and call for listener feedback

KEY TAKEAWAYS: 

• Early orthodontic treatment is about more than just straightening teeth. Dr. Grob’s focus is on developing facial width and balance, which can lead to better long-term outcomes. Using cone beam imaging has revolutionized how he approaches early treatment by allowing him to assess the transverse dimension more accurately.

• Oral habits play a significant role in malocclusions. Nearly half of the patients Dr. Grob sees for early treatment have some type of habit like mouth breathing or nail biting that impacts their dental development. Identifying and addressing these habits is crucial for successful early intervention.

• Partnering with pediatric dentists and educating parents about the benefits of early treatment has been key to Dr. Grob’s practice's success. By starting treatment between ages 6-9 when appropriate, we can often help avoid more complex interventions later on and simplify the overall orthodontic process for many patients.

EPISODE TRANSCRIPT

What follows is an AI-generated transcript. The transcript may contain errors and is not a substitute for watching the video.

Golden Age of Orthodontics Episode 74 - Dr. Daniel Grob

(00:00:00) Dr. Leon Klempner: Do you routinely offer early ortho treatment in your practice, or do you like some, consider it. A marketing tool with little or no benefit to the patients. Today's topic, early treatment. Yay or nay. Stay tuned. Our Golden Age of Orthodontics Podcast sponsors make it possible for us to bring you new episodes.

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(00:01:36) Intro-Outro: The future of orthodontics is evolving and changing every day, but although the way to achieve practice growth has changed, there's never been a better time to be an orthodontist. Let's get into the minds of industry leaders, forward-thinking, orthodontists and technology insiders to learn how they see the future of the orthodontic specialty.

(00:01:56) How will digital orthodontics, artificial intelligence, clear (00:02:00) aligner therapy, remote monitoring, in-house printing, and other innovations change the way you practice? Join your host, Dr. Leon Klempner and Amy Epstein each month as they bring you insights, tips, and guest interviews focused on helping you capitalize on the opportunities for practice growth.

(00:02:17) And now welcome to the Golden Age of Orthodontics with the co-founders of People and practice, Dr. Leon Klempner and Amy Epstein.

(00:02:28) Dr. Leon Klempner: Welcome to the Golden Age of Orthodontics. I'm Leon Klempner. Uh, if you don't know me, I am a retired board certified orthodontist, most of the director of ortho at Mount Sinai here in New York, uh, and part-time faculty at both Harvard and Montefiore. Uh, in addition, I am the proud CEO of the best marketing company in the world, people in practice.

(00:02:54) And as usual, I'm joined by my partner, by my daughter and my (00:03:00) co-host. Amy Epstein. How you doing, Amy? 

(00:03:03) Amy Epstein: Doing well, glad to be here today and especially, uh, with the guest that we have for you. Um, yes. So by way of background, I'm Amy Epstein. I am the Chief operating officer of the best marketing firm for orthodontists, uh, around and pediatric 

(00:03:21) Dr. Leon Klempner: dentists.

(00:03:21) Amy Epstein: Oh, by the way, we're an award-winning podcast now. By the way, yes, at Pediatric Dentist. We're an award-winning podcast now. Um, so we're very proud to be, um, continuing to do this podcast and providing high quality information and guests for you. Um, today, I, I'll talk a little bit about our guest, Dr. Daniel Grove in a second.

(00:03:42) Um, but we had like a little chat, um, before we, we, you know, are recording our podcast, just get to know each other, talk about topics, talk about what might be interesting for our listeners. And it was very inspiring to me because I have a 7-year-old as (00:04:00) you know, dad because she's your granddaughter. Um, and we're gonna talk about early ortho today.

(00:04:06) And you know, since that conversation, not only did I learn a lot, which is. Frankly, you know, uh, we've had people in practice for what, 15 years and my clients are all orthodontists and my father, as you know, dad are, is an orthodontist. And I basically grew up in an orthodontic practice, and yet I still learned a lot in that.

(00:04:29) Discussion that we had with Dan. Um, and yeah, it was inspiring to me and I'm, I'm bringing my daughter in for a consult, um, because, you know, I think that she could, she could benefit from being seen and at least get some more information about whether or not it's the right time for her. So. You haven't seen her in a little bit, dad, but you know, she's getting real crowded down there.

(00:04:49) No, I, I 

(00:04:50) Dr. Leon Klempner: know. And, and, and, and it's a, this is a hot topic in ortho, you know, this has been bounced around for, you know, I've been around a long time and from the beginning this (00:05:00) has been, you know, volley back and forth in terms of, uh, value, no value, do it, don't do it. And people have pretty, they're pretty set in their ways I've found.

(00:05:10) Hmm. And, and, you know, I, I. Personally did a lot of early treatment in my practice. I'm a big fan. Um, but I know that, you know, in the residency programs that I teach, uh, they get very little. I, I give a lecture on early treatment. We talk about it. But, you know, the reality is that in, in training, there's very little opportunity for early treatments.

(00:05:34) We mm-hmm. You know, we have the residents for two or three years and, you know, it's a lot to just teach 'em how to. You know, treat a case with extraction, so, 

(00:05:42) Amy Epstein: right. Well, that's why we're very lucky today that we're joined by, uh, really a pioneer in pediatric focused orthodontics, Dr. Daniel Grobe. He is a board certified orthodontist with over four decades of experience, much like you dad.

(00:05:57) Um, but Dan is still in practice. Uh, he (00:06:00) has treated tens of thousands of patients and he's built his career around delivering thoughtful. Comprehensive care with a strong emphasis on early intervention. Uh, Dan actually, oh, he has a dual specialty, um, in both prosthodontics and orthodontics. Mm-hmm. Um, and he's spent his career not only transforming little smiles, but also big smiles, um, and educating like you do dad.

(00:06:23) Um, the next generation of clinicians. He's also seen it all from founding a multi-location practice, uh, to building a thriving dual specialty pedo ortho model in partnership with the pediatric dentist, uh, from the ground up. And so, um, he at Speaking of education. Founded a Facebook group called The Pediatric Orthodontist.

(00:06:46) And for those listening today, if you're interested in early ortho, you should go check out the pediatric orthodontist on Facebook and, uh, ask to be included in the group. Um, and if you, uh, look at your. You know, a couple years back of (00:07:00) Orthotown Magazine, we'll see his name because he was the editorial director for some number of years, and his monthly columns shaped conversations throughout, uh, about phase one care for, for a good number of years.

(00:07:12) Right, Daniel, so welcome. Thank you so much for being here today. Appreciate your time so much. 

(00:07:17) Dr. Daniel Grob: Well, thank you for the nice introduction and I'm very, very happy to be here to spread, spread the word that I'm, uh, uh, working on perfecting and, and making a good experience that, that of, uh, early orthodontic care.

(00:07:31) Uh, I, I certainly didn't start out in practice doing this as, as you mentioned, I started in, in the field of prosthodontics and back in the. Eighties and nineties, it was thought that that would be a really great combination, prosthodontics and orthodontics, because in the eighties and nineties, adult orthodontics was just coming into play.

(00:07:52) Hmm. And what a, what a better dual specialty than prosthodontics and orthodontics so that you could treat all these adults. (00:08:00) And back then surgical orthodontics was coming into play. So we had a, we had a thriving practice in Wisconsin dealing with adult orthodontics oftentimes involving, uh, jaw surgery that kind of dried up when insurance benefits, uh, were cut back a little bit.

(00:08:16) So I just, um. MI migrated to Tucson and had a conventional, multiple office, uh, orthodontic practice where about 15% of my practice was spent on, uh, early treatment. Uh, I, I can still remember visiting. General dental offices saying, I'm an orthodontist, I'm in the neighborhood. Uh, don't worry. I I don't try to lock up your patients early and, and, and waste their money on early treatment.

(00:08:46) Uh, so, so Dan, let me, 

(00:08:47) Dr. Leon Klempner: let me, let me interrupt you just for a second. Sure. 'cause I'm, I'm gonna, let me, I'm gonna give you the, the pushback argument here. Um, um, and, you know, as, as. Someone teaches, (00:09:00) uh, you know, in residency programs, you know, we want to look at evidence and evidence based and, and make decisions.

(00:09:07) But, you know, if I, when I do a literature search, um, and I, I look at the studies that were done that I. All of the studies other than let's say, um, instances where they have a large overjet and there might be some trauma or maybe if there's a, you know, deviation in terms of a crossbite. Those are typically the two areas that, that everybody agrees on.

(00:09:35) And then, um, you know, if you look in at the articles that are written and the studies that I found, um, they all say that you can get the same result. This is, this is the big argument is that you can get the same result treating in one phase later on, rather than treating in two phases. Whereas two phases costs more money and takes longer.

(00:09:57) So let, let me give you a chance (00:10:00) to answer that question. So why so why, why would you choose early treatment if, according to whatever's been published, uh, you can get, uh, a similar result by doing it in one phase. 

(00:10:14) Dr. Daniel Grob: I, I think a lot of those in, in some of the writings that I did for Orthotown, I researched some of those articles also, and, uh, many of them came out of University Pacific.

(00:10:25) I think DNI had something and, and I think at, I, I think the articles that, that you and I both are familiar with are comparing early treatment. With the same end goal. And I think, I think the end goal was taking someone from class two to class one or making the teeth straight. And I, and I personally think that the evolution of early treatment has led to a different end goal where we're looking more at the face balance as opposed to the dentition.(00:11:00) 

(00:11:00) And, um, personally I think that cone beam x-rays have. Changed the way I know I look at a patient and, uh, it takes a while because, you know, we, I've only been a cone beam owner for less than 10 years, but un until you've had the opportunity to view patients as a volume rather than a linear dentition, um, you're, you're.

(00:11:29) If you're using kind of a false premise for the end goal and, um, when they say, well, you can get the same result treating later, early, well, the results they're looking for sometimes involve serial extraction, sometimes involve taking out a couple of teeth, and I don't want to say that I get up every morning and, and promise the world that I'm not going to remove permanent teeth.

(00:11:53) But I think with, with the advent of the cone b x-ray machine, you start looking at the transverse (00:12:00) dimension, uh, much more than you did in the past. And I know Ricketts talked about frontal x-rays and things, and he, I, I still credit him as being a pioneer. And I think Leon, you'll respect him also. Mm-hmm.

(00:12:12) I, I think he really got us looking at the, in, in the transverse dimension. So, um, my end goal now. Is to develop width to the face and to the smile. And I look at patients and I decide if I, if I need early treatment to create some width for the future, that's when I get involved. If I don't need early treatment.

(00:12:37) To create with, for the future. I'll pass on early treatment and, um, perhaps take care of the patient in one extended phase or in the instance of, uh, someone that like a 13 or 14-year-old that comes in with no history of habits, no transverse dimension. Uh. With problem, I'll, I'll wait for all the teeth to come (00:13:00) in so that I can get the patient done in a year, year and a half or whatever.

(00:13:03) Uh, there, there, there's no doubt about it, that early treatment does add some time and some cost, but, um, the vast majority of the patients that I get involved with in early treatment, the, the parents are very happy. Hmm. And, uh, they, you know, they bring their second child and their third child and they know that this is the way we work and.

(00:13:24) I think there's also the factor of, uh, you know, uh, society and, uh, psychosocial benefits and a lot, a lot of the parents in my neck of the woods in my neighborhood want their kids to look as best as possible for their age group. And it's not that we're putting braces on and dragging it out for five and six years.

(00:13:44) It's, um, my, my goal, and I think it was mentioned in the last. Um, editorial that I wrote for Orthotown was I'm constantly working on trying to perfect phase one in 15 months or less, and phase two and (00:14:00) 18 months or less. And if you add that up, you might have two and a half, three years of treatment. Which isn't extraordinary.

(00:14:07) I mean, I know that there are some patients that can be treated in nine months or 15, but I, uh, I think it's worthwhile and I think it's beneficial. And, um, I've got, I would 

(00:14:19) Amy Epstein: imagine, Dan, that, that, you know, there are others like me with, um. Little kids and, uh, concerns. So is, you know, how, how are you finding the sort of market in terms of the demand for early ortho?

(00:14:35) Do you see people like me coming in with like, I don't like the way this looks, or I'm having trouble with the getting, keeping the lower teeth clean. Um, is that Dr. A driving force in your focus on relief? Well, most, 

(00:14:48) Dr. Daniel Grob: most of the parents and the beauty of orthodontics is. You know, the parents can look at their kids, smile and see if there's room or not.

(00:14:55) So they see that I, I practice next to a pediatric dentist who's (00:15:00) very attuned to, you know, they, they, they have a, a standard protocol of bite wing x-rays, panorex at a certain time. And, and all day long he's explaining to parents that there's not room for the teeth. And, and in the past I think we were setting parents up for taking out first baby teeth and then perhaps some, um.

(00:15:19) Some permanent teeth. I, I can honestly say that in the six or seven years that I've been in practice with, uh, with the pediatric dentist, I have signed a letter to take out four permanent teeth in less than a dozen times, and we've had hundreds of patients treated and I feel pretty comfortable that it doesn't necessarily.

(00:15:41) Protrude the teeth. I, I remember, uh, when I first moved to the Phoenix area from Tucson, I took out a, uh, pediatric dentist to lunch. And I said, so what, what bothers you the most about the orthodontic results? Well, what can I make sure that I'm doing to keep you happy? She says, I don't wanna see teeth protruding when (00:16:00) you're done.

(00:16:01) And I, and I think. And I think in, in the world of cosmetic orthodontics, we're very aware of the fact that the upper incisors should be upright to the floor, and that that provides the best bounce of light off of the front of the teeth. So we work very hard to develop width, and we work very hard to make sure that the central incisors are standing upright and straight when we're done.

(00:16:24) And if there's flaring. That's when teeth have to be removed. Yeah. 

(00:16:28) Dr. Leon Klempner: Mm-hmm. And I know, you know, I, I've heard you speak before in a, in, in conversations I've had with you, um, because we were aligned in so many different ways. But you, you introduced a few things that were, that I, I was not aware of, which, which was the significance of oral habits in terms of the developing dentition.

(00:16:47) Could you talk a little bit about that? 

(00:16:49) Dr. Daniel Grob: Well, uh. In, in about two months, an in-office research project is going to be released in, in Orthotown, where we took three months of all (00:17:00) new patients, all recall patients, and all patients in between phase one and phase two, and we asked the parents and the patients to self-report.

(00:17:08) So from the standpoint of a, a true scientific paper, it probably won't cut. It won't pass muster, but, uh, we found that close to a half of all the patients that present for early treatment or are involved in early treatment have some type of habit. Edward Eng in 1907 in his, in his textbook, stated that of all the things that mess up people's teeth, mouth breathing's the worst.

(00:17:34) Well, we, we found that nail biting. Is even more prevalent in our practice than mouth breathing. And, and the, the, the total tabulation of the results will be available in Orthodon. But suffice it to say that almost half the patients that come in for early treatment have some type of a nasty habit, whether it be mouth breathing, nail biting, thumb sucking, uh, it goes on and on.

(00:17:59) And (00:18:00) I, I, I mentioned, uh, thumb sucking. Because when you talk about oral habits, a lot of patients say, oh yeah, thumb suckers. That was actually at the bottom of the list. In other words, the the overt. Thumb sucker really isn't the problem. The, the, the, the bigger problems are the, the hidden habits. The, the mouth breathing where the mouth is hanging open, causing the buccinator muscle to collapse, the tongue sits low, um, or the nail biting and, you know, nail biting habits cause.

(00:18:33) All kinds of muscle imbalance, and part of the article that I'm working on this weekend and need to get into the Producers by the middle of July shows adults that come in with. Crazy dentitions. And when you probe them, you find that, uh, the same light, gentle pressure that we use to straighten teeth has been used to cause their malocclusion.

(00:18:59) So we, (00:19:00) uh, I, I almost never let a, an early patient leave the office after an exam without determining why they need early treatment. And almost always, there's some type of an oral habit. 

(00:19:12) Amy Epstein: Hmm. Yeah, that makes sense. You know. Our, um, so people in practice, something that we do at the start of any engagement with an OR orthodontist to try to help them market their practice is to understand what makes them different in their community, what their strong suit is, something that patients value that they can do consistently.

(00:19:36) Um, and that's, you know, relevant in the marketplace. And, and also that the. Their competitors are not doing to help find that, um, almost like single source of truth, north Star message that we build all of our marketing around to present to the community so that. People like me who are looking to bring their kid somewhere.

(00:19:58) I have, I have a treatment age, (00:20:00) a 10-year-old, and I have a 7-year-old. But no matter what I'm looking for, I know that this practice is good at this and this practice is good at, this seems to me that you have a very strong handle on what your differentiated positioning is in, in your market. First of all, I mean, it's.

(00:20:17) It's a, a different, uh, angle, certainly than most orthodontists Talk about. Um, how, how do you, how do you talk about the practice? Um, you know, there's, I guess there are two parts to the question. One is a little bit about, um, how do you educate parents about phase one and the other is like, how do you use this differentiation to attract more of the patients that you wanna see?

(00:20:47) Dr. Daniel Grob: Well, we're very fortunate for one to have a pediatric dentist that we've worked with in a pediatric dental office staff that we've educated to, to explain to them the transverse dimension in habits. Hmm. When, (00:21:00) when the pediatric dentist staff goes out to the grade schools and talks about brushing teeth and fluoride and don't, don't eat candy, we follow up and, and we step in.

(00:21:11) Work with educating the parents and the kids about oral habits. Just a very simple message. Uh, thumb sucking, mouth breathing, things like that. Um, our marketing collateral has been designed to highlight that. Where we talk about the stages of eruption, my, my first article with Orthotown was on, uh, treatment by twelves.

(00:21:32) In other words, early treatment is taking care of the first 12 permanent teeth that erupt. Uh, comprehensive treatment is taking care of the next 12 permanent teeth that erupt, you know, the buccal, the buccal segments. And then after the 12 year molars erupt, you're basically in into the adult dentition. I haven't really.

(00:21:50) Expanded that to include a whole lot of primary only, although I do have some pediatric dentists now that are reaching out to me and we're meeting and talking about how we can do (00:22:00) that effectively. Uh, and, and. Scientifically, like you said, Leon, to, to make sure that we're doing, using evidence-based things.

(00:22:10) 'cause I, I don't want to create a firestorm of, of early treatment and, and, and be known as someone that's wasting parents and kids' times. But, but I, I think, I think there are situations where, uh. We, we can start treating the six year olds and, uh, just getting a, a few teeth and start, start to expand. Like I said, I've, I've been very, I've never been an early adopter on pretty much anything, uh, in orthodontics.

(00:22:38) And this, this realization of the benefit of early treatment is, like I said, is kind of an epiphany that came to me five or six years ago. And I just said this, the, the best thing is it makes the practice of orthodontics easier. Not only are you delivering an an attractive looking kid with all of their teeth, but.

(00:22:59) Every (00:23:00) day in my office is just so much simpler than the transverse deficient patient that shows up at 14 or 15 where the parent says, we've been waiting for all the teeth to come in. And you know the look of this patient, Leon. It's a narrow upper jaw flared incisors. Class two and you're, you're left with, okay, are we gonna do this surgically or are we gonna do this or that?

(00:23:23) And we just don't have that. And, and when we, when we have a 13 to 15-year-old with all of their teeth and that. That, that, um, protrusion and the narrowness, it's almost always a patient that just showed up at the pediatric dentist for the first time, or someone that was referred to us by someone that said, oh, they do a great job.

(00:23:44) And then I, then I'm left to explain to them that, well, we've, I have to start with width. So, you know, you're a little old for the conventional expander, so we might have to do. A Sarpy or, or like a surgically assisted type, uh, uh, expansion. Mm-hmm. And then (00:24:00) we're left with the protrusion. Uh mm-hmm. I, I feel pretty comfortable using herps appliances in, uh, when, when people reach double digits mm-hmm.

(00:24:10) In age and things. But once you start getting into the teenage years, uh, you gotta start making some decisions, is how you're gonna deal with that. So, uh, my practice. As a rule of thumb, does not have to deal with that occurrence too often. Yeah. Just because we're, we're blessed with having the referrals at age six to nine for the early treatment.

(00:24:31) Right. And there, and there are plenty of young kids that I pass on. It's, it's when they have enough maxillary with. And I feel that I can get it done in, in one, in one phase. Right. 

(00:24:42) Amy Epstein: So you have the benefit of, uh, partnering up with a pediatric dentist who it sounds like is doing the education and making the referral and saying, you know, this is, uh, you know, your, your child has a couple of things that we are gonna make it easier later on, and even perhaps make it better for them (00:25:00) from the self-esteem point of view in their younger years, even before all the permanent teeth erupt.

(00:25:06) Um. And we, we work with a lot of practices that, you know, are not PETA ortho practices. And so, you know what, just as a, a thought for those listening, um, about. How to solve for, well, I waited, this is the parent talking. Well, I waited until all their permanent teeth came in, and now I'm, I'm in front of you.

(00:25:26) Right? And so the problem to solve is if you don't have that education coming from a pediatric dentist, how do you insert yourself in there? Um, and there are plenty of, um, you know, a a o tool, tools and, and resources with seven and up type stuff. But our perspective is that this is a job for. Educational advertising, uh, where you, you ice.

(00:25:51) If you want to do, have those kids come early, like Dan's saying, and be able to make space younger to make it easier later, then you have (00:26:00) to reach those parents when their kids are seven and eight and or, or younger, and reach them with things that they can understand and identify about their children and give them a call to action that.

(00:26:15) If these things are going on, then perhaps it's time to come in and see. Our practice. We specialize in early ortho and we're wonderful with kids, and we make it, uh, life easier when, when all the permanent teeth are up and come in to learn more or click to our website to learn, you know, see this article and, and read more.

(00:26:35) So, um, from, from my perspective, I can see, or, and I can imagine many of our listeners are thinking, you know, I'd like to be able to do more of this, but how do I, how do I solve this issue? 

(00:26:47) Dr. Daniel Grob: I'm sure you know, and Amy, you know from your marketing experience that. Practicing is almost constant marketing. And I know we, we are very big and focused in our practice on intraoral photography and (00:27:00) photography and creating presentations.

(00:27:03) Um, so, you know, I'm, I, I don't visit the general dentists so much anymore because I have mm-hmm. Uh, access to the pediatric dentist. Right. And then sometimes those patients refer. And then we'll, we'll get a, a referral with a different general dentist, and then I will go out and visit like a lunch and learn.

(00:27:22) Yep. Um, the other general dentist with a, with a small slideshow, couple of tools. Uh, you know, a cotton, a cotton roll is 36 millimeters wide, and a, and a and a cotton roll held up on the roof of the mouth should fit between the upper molars. And if it doesn't. Uh, that patient is maxillary deficient. Now, if it's only a couple of millimeters that can be picked up later if it's significant.

(00:27:49) That's something to look for. So I, I show the, I show the general dentist and the staff that, you know, this is, this is your, you've got a box of disposable rulers that you can put (00:28:00) on your, uh, exam tray and take a tweezers and hold it up to the molars and see how, how wide the, the molar are. And that's, that's research, uh, from James McNamara, who is legendary.

(00:28:12) I mean, I grew, I grew up with McNamara in the Frankel Appliance. And I'm heading into my sunset years with McNamara and his transitional dentition treatment. Mm-hmm. So I think he's, he's probably been the biggest influence in my practices mm-hmm. Is McNamara. Uh, but, uh, we, we, we have, we've got a couple of, uh, lunch and learns scheduled with ear, nose and throat practices.

(00:28:36) Mm-hmm. My first exam that I'm doing today after this podcast is on the, the child of an ear, nose, and throat surgeon who's been doing. Tonsil and adenoid work for me for the patients that we refer. So. Uh, it's, it's just, yeah, I mean, that's a 

(00:28:50) Amy Epstein: good point is that, you know, you, you raise a really good point, which is that the, um, ref expanding your referral base to all of those (00:29:00) specialists who are treating the kids for these different habits and, and, uh, anatomical challenges, those are also opportunities to build relationships for referrals and coupling that with.

(00:29:12) You know, reaching out, this is what we do. But coupling that with reaching out to consumers, patients, parents directly, is the other side of that coin. So that they're seeing, they're hearing it from their doctors, their specialists, that seeing an orthodontist at this time is a good idea and they're doing their own research on their side confirming that this is a good decision for their.

(00:29:34) Their child. So, and, but we don't want to ever forget that the referral stream is still there and they're important and it's good to be building relationships with them and, um, you know, continuing to, to pay attention to that, uh, stream of, of referrals. 

(00:29:50) Dr. Leon Klempner: So, so Dan, I want to, I want to, in the short amount of time we have left, I'm looking at the clock and I wanna flip it back to some clinical stuff quickly towards the end.

(00:29:59) Yes. (00:30:00) Um, a couple of things that come to mind for me when I, when I'm lecturing to, to, uh, both petto and ortho residents when, when evaluating the transverse, which is so critical, um, the, the under. Uh, the, the less understood aspect of transverse in the maxilla, in my opinion, has to do with. What's going on in the mandible, and if the mandible is not in a normal axial inclination, the curve of curve of Wilson, uh, Wilson.

(00:30:31) Yep. Um, then I remember it well. Yeah. That oftentimes we end up under, under expanding, so we need to expand to a normal lower arch. So that's just one thing that I, I find you don't need a cone beam in order to. To, you know, evaluate that. The other thing is that if I'm measuring the upper incisor and it's like 10 millimeters, 11 millimeters, or I have a bi maxillary protrusion, then I'm really questioning am I dealing, am I gonna try to treat (00:31:00) this, you know, non extraction.

(00:31:02) That's just like a simple thing. You don't need a lot of records in order to do that. No, you don't. So, I, I'm just curious, like, what advice would you give to, uh, to our listeners? A lot of them are residents, uh, younger. Practitioners that are just starting out, that are struggling with, you know, should I do early treatment?

(00:31:21) I don't know. I, I haven't been taught a lot. You know, how, how, how would you suggest that they get, get more knowledge or, um, advice that you might give them in terms of making those types of decisions? 

(00:31:34) Dr. Daniel Grob: Well, there, you know, MC McNamara has. Made available to the public, A PDF on, on Google search, uh, showing his, I believe, 2015 lecture on transitional dentition, where he brings up the 10 millimeter central incisor, where he brings up the 36 millimeter maxillary width, where he also shows devices.

(00:31:56) Uh, and, and he does, he treats the mandible first to (00:32:00) upright the lower and the lower buccal segment so that, uh, the curve of Wilson is not accentuated. I will agree that, uh, my failures in, in phase one early treatment have been because I have not paid enough attention to the mandible and parents. I, I have, I have never taken the approach of treating the mandible first just because.

(00:32:21) Doing early treatment is enough of a shock to some parents, but when you tell them that they don't have their, their patients are coming in because there's no room for the front teeth and you, you say, okay, well we're gonna start by putting a Schwartz appliance on the lower. That's a little much for them to understand.

(00:32:36) So, so we start with expanding and then when we, when we get to a point where the, the lingual cusps are almost on the buccal cusp of the lower, we either put brackets on the lower, or we do a removable device, or Invisalign, of course, really makes it easy. I mean, we've really, we've embraced Invisalign early treatment to a great extent.

(00:32:56) And the beauty is that the, it, it's treated (00:33:00) in a, in a pretty. Short time period. And because you can, because you can put the teeth where you want them and you're not dealing with open coil springs and brackets, you can really position the front. Permanent teeth to look nice. Uh, and, and, and that, and that's great, right?

(00:33:18) Uh, but, but you, I need to just 

(00:33:19) Amy Epstein: interject and ask one, one personal follow up question on that is yes, is how do you, what about compliance in a 7-year-old or 8-year-old with an aligner that needs to be worn, however, 20. Three hours a day. I hear, I hear 

(00:33:33) Dr. Daniel Grob: Kayla. I hear Kayla. Yeah. I'm just curious. I mean, I have, I 

(00:33:36) Amy Epstein: have the expert on the line here, so I'm gonna 

(00:33:38) Dr. Daniel Grob: invisalign's own scientific research and, you know, they measure everything, including how much they Sure do.

(00:33:44) How much time it takes each one of your assistants to scan a patient. I mean, they know everything. Mm-hmm. But their, their own proprietary research has shown, at least that's what my rep has told me, that the kids. Are better at compliance than adults. And I (00:34:00) think if you asked my staff, they would agree.

(00:34:02) Mm-hmm. Because the amount of time that we spend with adults, um, trying to cover their tracks for, oh, I was, you know, I was in Vegas or Nashville this weekend, I forgot my aligners. Versus the kids that are really enthusiastic about making their smiles look great. Um, I, I, I think, uh, we've had a great result with, with, uh, even as young as, as the littles.

(00:34:26) Yes. 

(00:34:26) Amy Epstein: Okay. Yes. Good to know. 

(00:34:27) Dr. Daniel Grob: We, we've had, we've had good result with Invisalign. Okay. 

(00:34:30) Amy Epstein: Very good. 

(00:34:31) Dr. Daniel Grob: So, 

(00:34:31) Amy Epstein: okay. Well, listen, thank you so much for taking the time to talk with us today for answering all my personal questions about my daughter, Kayla. Uh, if there any, well, it sounds like you, 

(00:34:41) Dr. Daniel Grob: you'll be in good hands from what I understand.

(00:34:44) Amy Epstein: Yes. Well, I mean, yes, definitely. Yeah. Um. If our listeners are interested in learning more about early ortho, have questions for you, follow ups, can they reach out to you and if so, what's the best way? 

(00:34:59) Dr. Daniel Grob: Well. (00:35:00) About six months ago, I created a Facebook group called The Pediatric Orthodontist. There's a Facebook page open to everyone called the Pediatric Orthodontist, and then there's an associated website, although it's kind of small right now, but there's a pediatric orthodontist.com website and my intention is to start filling it up.

(00:35:21) With all the, the case reports that, uh, that are sent in from other orthodontists that follow the, the page and myself, so that it's a resource for, uh, like you said, residents, uh, orthodontists patients, the, the. The website is available to anyone, the Facebook group, or is available only to members, and we're encouraging people on the Facebook group, the pediatric orthodontist, to upload photos, uh, before and after cases discuss the cases that I'm showing.

(00:35:55) I get, I put one case up about every two weeks. Uh, I try to limit it to a (00:36:00) two minute video so that, uh. Um, people can get in, see what's going on, and easily digestible and move on with their, with their life. Mm-hmm. And my intention is to make it, um, a a growing, live, living site mm-hmm. That continues to show the goods and the bads of, of early treatment.

(00:36:19) That's great. Uh, what, what I do at the end of the cases that I show. Is I, I critique myself. Here's a case where, uh, we, we, we got our maxillary width to 34 millimeters. Our ultimate goal is 36. I think I could have upright the lower molars more, uh, things like that. Yeah, I mean, so, okay, great. 

(00:36:37) Amy Epstein: So we're gonna encourage our listeners to visit that Facebook page and ans you can, uh, interface with you there.

(00:36:43) You'll answer questions, things like that to visit the website. We know it's a work in progress, but they can learn more there. Um, and you know. That's one thing. So thank you again. 

(00:36:54) Dr. Daniel Grob: Yes. 

(00:36:54) Amy Epstein: Really appreciate your time. Looking forward to hearing more, um, and hope to have you on again in the (00:37:00) future. 

(00:37:01) Dr. Daniel Grob: This is enjoyable.

(00:37:02) I, I love spreading the word. 

(00:37:04) Amy Epstein: You do it well, we, we appreciate it. Okay. Thank you. You can subscribe or download other episodes of the Golden Age of Orthodontics podcast on Apple Podcast, Spotify, SoundCloud, YouTube, if you wanna see us, uh, or wherever you got your podcast. And if you enjoyed it, we would appreciate very much if you would tell a colleague, especially with this episode, if you know that they're interested in early intervention for more information about people in practice.

(00:37:31) And about how we can help you bring that younger set to the practice for their exam and, uh, you know, educate those adults, the parents, uh, about early ortho. Visit our [email protected] 

(00:37:48) Dr. Leon Klempner: Dan, thanks a lot. We really appreciate it. Thanks. And, and for our listeners out there, I'm interested in what you think, you know, shoot me an email at Leon at PPL practice.

(00:37:59) Uh, do you do early (00:38:00) treatment? Um, if not, why not? If you do, what resources do you have? We can open up a, a discussion and, and share some information. I think it, it can only help all of us. And if you're looking for the best marketing company in the world, shoot me an email there as well and, and let's talk.

(00:38:18) And most importantly, remember. It's. Never been a better time to be an orthodontist. We are in the golden age, so please take advantage of it now. Till next time, see ya.

(00:38:36) Intro-Outro: Thank you for tuning in to the Golden Age of Orthodontics. Subscribe now on Apple Podcasts, Spotify. Or visit our website at the golden age of orthodontics.com for direct links to both the audio and video versions of this episode.