Episode Transcript
[00:05 - 00:34] Rob: Welcome back to the Evolution of Dental Podcast, brought to you by Evolution Dental Science, where we share the stories, the people and the technology shaping the world of dentistry. I'm your host, Rob Norton. Today's guest is a pioneer in the TMJ field. She's worked on all sorts of techniques and appliances to open pathways for the airways of adults and children. And she has a fascinating story as to how she got into dentistry. Today's guest, Doctor Tracey Nguyen. Welcome to the podcast. How are you today? Thank you for being here.
[00:34 - 00:37] Tracey: Oh, I'm doing great. Thank you for having me.
[00:37 - 00:45] Rob: Thank you so much for being a part of this. And, how did you get into dentistry? You, you came here from Vietnam, is that right?
[00:45 - 01:20] Tracey: Yeah. Oh, yeah. I'm a little boat baby, hehe! I came to the States, probably at maybe, like, 15 months as a baby? Yeah. Came to the States. Military brat. Lived in, you know, Virginia, then California, Florida and then back in northern Virginia. So, yeah, it's been fun. I've been in dentistry, I think now for maybe 24 years? Something like that. So, yeah, hehe, it's been good. It's a very exciting time to be a dentist. It's a.
[01:21 - 01:26] Rob: That’s awesome! Was there something that inspired you to get into dentistry in particular? Or were you struck by an epiphany one morning?
[01:26 - 02:03] Tracey: Oh, no! I mean, dentistry kind of just fell into my lap, actually! Gosh, in college, I was trying- I really didn't have any direction. I was like, I think I came in wanting to do, like, international law. And then I was like, oh, yeah, there's way too much reading in this, hehe! And then the next year, I was into psychology. And I was like, yeah, I can do that. And then I was like, oh man, I don't want to hear problems all day. And then I jumped into like- marketing. It was funny because- and then my aunt was like, there's no money in marketing, why don't you be a dentist? And I was like, okay!
[02:03 - 02:04] [both laughing]
[02:05 - 02:07] Tracey: And I really was just like, okay!
[02:07 - 02:07] Rob: Sure!
[02:08 - 5:25] Tracey: Yeah. But it was funny because, I mean, you kind of just, you kind of just have a path and a goal and you just do it, you know? And so that I think that was where my direction was now in college and, and dental school. And you came out and you just worked, you know, and it wasn't, it really wasn't a passion until I went out on my own. You know, so I worked with a group practice for like two years, and then I was ready to buy in, but they weren't ready for that. And so then I went out on my own. I think that my true growth happened was- when I went out on my own. And then when I went onto my own, I really wanted to do more cosmetics, you know, like everybody. It’s funny, my niece is in dental school right now and she tells me I want to do cosmetics. It's like every dental student wants to do cosmetics. The problem is they don't realize how long it takes to do really good cosmetics. So then I got involved with the American Academy of Cosmetic Dentistry. That's where I got my accreditation. And then, I realized when I was with the AACD, I mean, while I was good with my hands, I didn't know why things failed and why things lasted. You know what I mean? And then you start to really start critiquing your work because you're like, you're in this for the long haul, and your stuff needs to last, and look beautiful. But if it doesn't last, you know, it's not predictable. Hence then I went on my journey at the Kois Center and sat with John Kois. And like, gosh, I was all in on day one, you know? And I realized, like, gosh, you can't learn this stuff fast enough. So I finished the whole Kois curriculum in about a year. You know, and now I think that, you know, your journey changes whatever's going on in your life, you know, whatever you feel like has a big impact in your life. And I think that then I started getting involved in airway dentistry, probably in 2016, when I met Jeff Rouse. But, you know, it's interesting because there's this misconception about sleep dentistry and airway dentistry, and people equate airway dentistry with appliances. It has nothing to do with appliances. So where sleep dentistry is about, okay, you have obstructive sleep apnea. I need a prescription from a sleep physician. I'm going to make you an oral appliance. That's not what airway dentistry is about. Airway dentistry is about really looking at a patient's mouth, comprehensively, restoratively, and looking at ways to restore the patient from a craniofacial side and a dental side that affects how the patient breathes 24/7. Not just at night. So I think what happened with the airway movement is a lot of- because sleep dentistry has been in for a while. I think what happened with the airway movement is sleep dentistry- basically they're like, oh, I like this whole airway thing. So then every sleep dentist started calling them an airway dentist because it was like a catchphrase. But we're two very different people. And I always say that because like, it's very different. I don't make a lot of oral appliances. My bread and butter, my core is restorative dentistry.
[05:25 - 05:29] Rob: So, if I could maybe ask a question to clarify.
[05:29 - 05:29] Tracey: Yeah.
[05:30 - 05:42] Rob: It sounds like a lot of folks are treating symptoms and, essentially, it's like the idea of throwing a pill at the problem, right? It's like, well, the appliance is something I can see and hold. So we'll throw that at the issue as opposed to studying the true root causes. Does that sound right?
[05:43 - 06:55] Tracey: You know. Yeah. Yes and no. I mean you're not- because I hate to use the word “root cause” because we really don't know what the root cause is. You know, and I think it's really, cause for us to say this is the root cause, then we're saying dentistry is the start and be all of everything, and we should be the number one. You know, so I'm careful not to say that. I think there is a place for appliances, when your body is so broken down and beat down. And also depending on your age. But I think as dentists, we have to take a step back and look at the bite. And before you jump to an appliance, are there any other risk factors that I can fix before we jump to an oral appliance? You know, so it's more of like getting that dentistry hat first. Whereas a sleep dentist, the first thing they have to do is an oral appliance because that's the prescription from the physician, you know. So you need a physician's blessing to make an oral appliance. We don't need a physician's blessing to do dentistry. So that's probably the big difference there.
[06:55 - 07:14] Rob: So, when you see a patient, when somebody comes in, what helps you identify what that is? Like, what helps you start down that path and say like, okay, what do we need to do here? What markers or identifiers do you see with patients that start you in one direction or another with these kinds of situations?
[07:14 - 08:29] Tracey: Well, you know, the most powerful tool that we have that can influence breathing is- We have to engage in that, like maxilla. And when we go into medical history, we want to look. Are there any clues that this patient can't breathe? Like whether they can't breathe at night or can't breathe during the day? That could be like nasal congestion. Obviously there's sleep issues like bruxism, things like that. And so when we look at that and then we look at the mouth, at the dental clues, we look at like oral volume space, like if it's super crowded, the scalloping of the tongue, you know. And so we look at how that influences breathing. And then your dentistry has to change that. And so the simplest thing that we can do is introduce orthodontics at some point. And I think that's the basis of dentistry in general. You know like when we do a full mouth rehabs, I think we should always have orthodontics on the table, even when we do a full mouth rehab. So I think that when you have a big case, full mouth rehab and you don't do orthodontics, the case already starts off with a little bit of a compromise, right? I mean, from a laboratory standpoint, when you guys see these crazy bites, you're just like, oh, I wish the teeth were in the wrong different position.
[08:29 - 08:30] Rob: Absolutely.
[08:30 - 08:31] Tracey: Right?!
[08:31 - 08:32] Rob: Absolutely! Yeah!
[08:32 - 08:53] Tracey: Yeah. And so, you know, it's funny because it's kind of like- and it's the same thing. It's like, oh gosh, I wish the jaws were in a different position. Maybe that's influencing how you breathe. And it makes sense because if you think about your whole face, I mean, half of that is managed by us. You know.
[08:53 - 09:41] Rob: Hehe, that's a really good point! That's one of the things I think one of our early episodes was with, Doctor Steve Glassman, and that was one of his approaches. There is, you know, take on the orthodontic aspect of it first before you start getting in and prepping teeth and really diving into what can be done whether it's esthetics or restorative. So you're saying that there are symptoms like congestion, or just airway passage blocks. What are some other things that you look for? Are there any, like, physical markers in the mouth that you see and identify? So for example, like if you have a regular GP who's looking at this or even a lab tech who's looking at a scan, like, is there things that they can see and identify to raise a red flag, be like, hey, maybe we need to take a different approach, or maybe this patient has some more going on here?
[09:41 - 11:03] Tracey: Well, you want to take a look at the wear. What I find very classic with airway problems is anterior wear, you know, I was so- and I think when I see anterior wear I start thinking that there's some kind of movement with the mandible kind of going back and forth. Now is this movement with the mandible going back and forth at night, is it a compensation or is it a byproduct of meds or something like that? And if it's a byproduct of meds, what are the meds for? You know. And so that's how you kind of go down that little rabbit hole. And then there's a lot of meds that have sleep bruxism, you know, and those patients with those diagnoses also have airway problems and sleep problems. So from a laboratory standpoint, if you're doing a case and you just see a lot of anterior wear you know that you're going to have to open up that vertical, you know, to get more relief from that construction. So that's probably like the number one thing I see that is almost always an airway problem. When you see that anterior wear. Now, the jury's out on if the whole arch has worn down, like, there's a lot of causes for sleep bruxism. I mean, some are due to meds, some are due to vitamin deficiencies, but also, it's not unrealistic to think that it could also be a compensation, you know? And so what we see now with…
[11:04 - 11:05] Rob: When you say compensation…?
[11:05 - 11:07] Tracey: Compensation to open up your airway.
[11:07 - 11:08] Rob: I see! Okay.
[11:08 - 11:18] Tracey: Yeah. So that's why like when we say like, you know, are we treating the root cause I don't want to say. I mean, because there could be many root causes, but I like to say we're treating risk factors.
[ 11:18 - 11:19] Rob: Risk factors, okay.
[11:20 - 11:37] Tracey: Like that's the thing we do at the Kois Center is we try to evaluate things from a risk standpoint, like, well, there's probably other things that are affecting you. But let me lower this risk down. And for us the risk factor that we can lower down is the anatomy.
[11:37 - 11:41] Rob: Gotcha. So it's almost like a process of eliminating variables. Sounds like that, is that right?
[11:41 - 11:44] Tracey: Yeah, absolutely. Yes. Yeah.
[11:44 - 11:44] Rob: Gotcha.
[11:45 - 12:45] Tracey: And it makes sense that anatomy is usually one of the big ones, you know, and I think the interesting thing is that we mentioned about like TMD disease, what we're seeing now with women, as women get into menopause, they start losing their hormones. Premenopause or menopause, they start losing their hormones. So their sleep gets very disrupted. Not only does their sleep get disrupted, it's very coincidental that right around menopause and premenopause, they complain more of joint issues. So it's very- you start to see this cascade of women. The women that come in with joint pain are almost always half sleep discomfort. And there's a lot of studies that show that poor sleep influences your perception of pain, you know. And so like if you have- and if you think about that, if you have bad sleep, you're going to feel miserable the next day. And so sleep and TMD tend to go hand in hand.
[12:45 - 12:51] Rob: Fascinating. Okay. So okay. You say they kind of go hand in hand. You do a lot of work with TMD and TMJ as well right?
[12:51 - 12:52] Tracey: Yes. Yes.
[12:52 - 12:55] Rob: Yeah. Can you tell us a little bit more about that?
[12:55 - 14:42] Tracey: You know, so I think that is what people think. Well, what people don't realize is that this joint is no different than any joint in your body. Once it's damaged, it is forever damaged, you know, and I think many patients come in expecting, like the TMD, to kind of go away. And it's not, I mean, if anything, this joint, this tiny little joint, can get a lot of microfractures before you feel pain. And people are always like, well, how do you get microfractures? Well, as a kid, you fall down, you know? So like a kid, you fall on your face. The problem is this joint is so protected that you're not going to break your jaw as a kid, you know? So there's a lot of theories that you have a lot of these micro fractures as children or even sleep issues where you don't have growth epicondyles. But for whatever reason, you have somewhat of a compromised joint, and it doesn't express itself until you get older. And if you think about any other joint in our body, once it's damaged, in medicine, it's either like a cast, cortisone shots, or management. It's management on how to use that joint up to the point that the joint is so damaged that you need surgery. And so I think the mindset with TMD has to be the same mindset with any other joint in our body. You know. And I think that's where I try to break [it down]. It's a really sad truth that I have to have with patients about it. You know, like I’ll have a patient that goes, when I open my jaw this wide, it pops. You know, it's like, well, the answer is, don't open that wide!
[14:37 - 14:38] [both laughing]
[14:38 - 14:42] Tracey: I mean, unfortunately, there’s nothing we can do about that.
[14:42 - 14:45] Rob: Reminds me of an old joke.
[14:46 - 15:58] Tracey: People that are hypermobile, you know, it's like you're physically hypermobile. You're going to be at a high risk to damage joints, you know, and so we see that. We see more frequent joint damages with women because our bones are different, you know, and again, like with pre and post-menopause our bones- we start to lose bone too. So there's so many things that unfortunately we're more susceptible to bone fractures as a whole. So I always try to tell patients like, once you have joint damage, the popping and the clicking. My goal is to get you back into the socket, you know, and I have to look at what is housing that socket. Did you wear down that socket or did you wear down the housing in that socket? If you've worn down the housing in that socket, that's a repair. You know, like there's nothing I can do to repair that socket. But I can do things, and I always tell patients, your teeth, the positions of your teeth because they're attached to your jaw, affect your jaw position. Vice versa. If you got hit in your jaw and it went to the left, you're going to have a different bite, right? Does it make sense?
[15:58 - 15:59] Rob: Yeah! I mean, that checks out.
[15:59 - 16:53] Tracey: Right! Yeah. That's how it works. But if you change your teeth position your jaw is going to change. And so when we talk about TMD and dentistry, our goal is really to get you right in the most comfortable joint position and kind of keep you in there. But TMD management is potentially for life. Like once you have that popping and clicking and wear. I think what's happening with children is we're missing it a lot in children. One of the main reasons is because we don't know how to diagnose TMD disease. A lot of these kids have retrognathic mandibles where the mandible is set back. I mean, I would venture and say, I bet you at least 50% of those kids have some form of joint damage, but nobody's ever diagnosed the joint.
[16:53 - 16:54] Rob: 50% a big number!
[16:54 - 17:29] Tracey: I would probably venture to say that much because like we don't diagnose it, I don't know many orthodontists that would do an MRI on that joint. Look at where that joint position is, you know. So it's just we just don't diagnose it. But you see it later. And that's why I think ortho gets a bad rep, you know, when people are like oh, you know, I had ortho and I had joint pain afterwards. I don't think they had joint pain afterwards. I think they always had it, you know, and it expresses itself later on with the correction of the bite.
[17:29 - 17:43] Rob: That's very interesting. And also it's interesting you bring up the pediatric approach like it seems like if you could catch it earlier that you could probably do a lot of preventative work and you have a program I heard of ASAP. Is that right?
[17:43 - 17:45] Tracey: Yeah, it’s ASAP pathway.
[17:45 - 17:51] Rob: ASAP Pathway. Yeah. So what does that involve? What's your approach there?
[17:51 - 21:11] Tracey: Yeah. So I'm one of the partners, one of three partners. And it was interesting because when we started, we're on our sixth year, and, we met, we started to see a lot of kids with airway issues, you know, kids with, sleep deprivation, the chronic fatigue, ADHD, the bedwetting, just all these crazy things with kids. And then we started to realize that, okay, well, maybe one of the risk factors- maybe these kids are suffering from an airway dysfunction/and or sleep dysfunction. They're suffering from a 24/7 airway issue that expresses itself, and affects bone development at sleep, and brain development as they sleep. And so we're like, okay, well, what can we do? And so then we went through this rabbit hole and looked at all these treatment modalities at the time. And ten years ago, there was really no discussion of correcting, or evaluating these children's risk factors skeletally. It was really a lot of company based education, and not saying there’s anything wrong with company based education. But obviously there's a huge bias in it. You know, obviously if I only go to one course, I’m only gonna learn that. Yeah. And there's nothing wrong with that. And I think what happened was we quickly started to realize that we had outliers. You know, we're like, well, this child didn't resolve, this child didn’t resolve. And then we were getting gaslighted by companies like, well, we've never seen that happen. You know, this works 99.9% of the time. You know, and we're just like, I mean, I'm a pretty good dentist, I really am, you know? So, that's how we kind of came together. And then we decided, hey, let's develop a platform where we really focus and we look at everything and do a very thorough assessment. And I think what's happened now and what I try to do is, first and foremost, we need to be dentists. We need to make a diagnosis. And our diagnosis has to be craniofacial, skeletal, dental, you know, like mouth breathing is not a diagnosis. You know, like we have to look at what we are trying to fix and what are our dental tools that we can use to fix it. And that's how we came together. And now we have, it's actually a, it's an online educational platform. So we meet once a month, we have chat rooms where we go over cases. That's how it started in 2020. It's funny because like, that was right at Covid and we're like, okay, when are we going to record? And like, oh, so I feel like, you know, someone was looking out for us, you know, because we're like, there's no way I can practice and still record! And so the world said, well, we're shutting down for a couple months, start recording! You know, and now we have in-person courses and talking about, like, orthodontics, how to correct children and how to correct adults. I was just at Spear Education, last week, last weekend. And we spoke in front of, I think about like a thousand dentists, about dental strategies for, not dental, adult strategies, you know, and how to get adults to breathe better. So I think it's a great time.
[21:11 - 21:29] Rob: So. Yeah. Sorry I just.. to walk back a second. So you were saying that things like ADHD and the brain frog and, I mean brain fog, and some developmental focus issues, all go back to airway path airway issues with children.
[21:29 - 21:29] Tracey: Yeah.
[21:29 - 21:34] Rob: And it sounds like lifelong setbacks for some of these kids.
[21:34 - 22:59] Tracey: Yeah. So, like, if you think about it, like, if you think about adults, if we have a poor night's sleep, we have the cognitive ability to know that what we did affected that night's sleep. We drank too much, didn't get enough sleep, we know. We rationalize our behavior, and we know it can get better at sleep. Children don't have that cognitive ability to rationalize that behavior. So, like, if a child were to fall asleep, whether they're restless or not, they're just going to- just like a kid that doesn't have a nap, they're going to act out, you know, and so they don't know why they're acting out. They're just acting out. They can't rationalize that they didn't have good sleep because they don't really know what's good for them yet. You know, it’s just like you don't know what certain foods you like, you don't know what makes you off. The problem is because kids don't know how to communicate and they can't self evaluate themselves. We start making diagnoses and evaluate them. Then we take them through this whole rabbit hole of getting differential treatments. And then we start to label these kids. And I think that's where, you know, I think that's the struggle with some of these kids, because then it's just like- where it could have just been like, well, you know, maybe we should just sleep a little bit longer or and then the thing is like, what is it about your body or your anatomy that's affecting your sleep? And so that's another thing that we kind of look at.
[22:59 - 23:12] Rob: Gotcha. So some of these things, you know, earlier you mentioned the appliances and other paths. So what are some other treatments that you use for this? And what kind of tech and approaches do you have?
[23:12 - 23:16] Tracey: Yeah. So for children, I mean for children, it’s…
[23:16 - 23:17] Rob: Children or adults?
[23:17 - 26:56] Tracey: Yeah. So for children you're really thinking about orthodontic skeletal corrections. I mean you're really- it's funny because I think people are like, well, you know, orthodontics doesn't make the airway of my patients breathe better. Well, actually it does. We do have a lot of literature to say that, you know. And there's many things. I mean, we've been- it's funny, I did a lecture that looked about like evolution of dentistry, you know, in sleep… the first evidence of an oral appliance was like in the early 1900s, where babies with retrognathic mandibles, newborns with retrognathic mandibles that couldn't sleep, that had obstructive sleep apnea. I mean, they were basically going to die. They had surgical intervention on newborns to bring them forward and there's a syndrome called Pierre Robin. So it made sense that okay with people that were syndromic, if we advanced the mandible, they slept better. Right. And then if you look at double jaw advancement, we have tons of literature to say that that improves sleeping and breathing. Now what can we do? I mean, like for us, we're looking at, the number one thing that we have to improve nasal resistance, improve breathing is, is any kind of true skeletal expander that expands the maxilla. The beauty of expanding the maxilla is, you see a really nice change in the face, you know, because the face is attached to the maxilla, it’s attached to the nose, it’s attached to the mid-face. So a lot of these patients like really narrow, small mouths, by opening them up, they instantly feel better. And so when you're looking at some of these bites and also one of the biggest risk factors is, in the medical world, they call it macro osseo. Right. Which is a large tongue. Well, in the dental world of an even dental world, I call it small jaws, you know, because it's relative. Right? So it's like it's basically this oral volume space that holds the tongue, you know, the number one site when when we look at the data, the number one site of collapsed ability, which is means your airway collapses, which is where you have your choke point is actually at the upper is that the upper airway, which is influenced by the maxilla. The second most is the lower pharyngeal airway space that is influenced by the tongue. And what houses the tongue are the teeth and the jaws, but the tongue always gets the blame for it. But it's actually really that mid-face does that make sense? I think that's something that dentists and physicians need to understand, because the physicians, when they're looking at the airway space, they're just looking at the airway space. And they're looking at what's backing up into the airway space. Dentists, we're looking at correcting what's going to go into that airway space. Do you know I mean, so it's different different ways to treat like we basically dentistry we protect the door. We're so like we need a fix. We need to have a that we need to protect whatever. We need to give more space for the tongue. So the tongue is not in the back of the throat. We need to bring both jaws forward to open up that airway space. So a lot of people will say, oh, you know, large airway size doesn't necessarily mean that, you know, you have an air weight problem. I said, no, you're absolutely right. But a larger airway has less risks than a smaller airway, hehe.
[26:56 - 26:58] Rob: It's pretty logical to me.
[26:58 - 27:22] Tracey: Right! It's like, let's not, grasp for straws and like, like, like it just I don't. Yeah, I don't need data to tell you, like, I mean, if I want to play basketball, if I'm seven feet, I'm gonna get it better than if I was four, you know? Come on! It's like it makes sense. Granted we have some short basketball players that can make the ball, but if you're seven, it's gonna be a lot better.
[27:22 - 27:24] Rob: Yeah, they're gonna have some advantages there for sure.
[27:24 - 27:26] Tracey: Yeah.
[27:26 - 27:27] Rob: Absolutely.
[27:27 - 28:04] Tracey: It's a fun time. It really is. I think more and more dentists are starting to be aware. And I think what's happening is and from a laboratory standpoint and I, it's how quickly are patients breaking things. You know, it's like in dentistry where it breaks. I'm gonna make something stronger. You know, if it breaks, I'm gonna make something stronger. We always think of it as a material failure. And, and sometimes I think, like, it's probably not a material failure, you know, maybe where it's, biomechanics. Maybe. Maybe it's something that we can't control.
[28:04 - 28:37] Rob: That's a pretty interesting point there about the material failures. I literally was working on a case yesterday for a five unit bridge. And it broke to number two after ten months. And so the doctor comes back to me because we need stronger zirconia for this, for this case. And I'm like, okay, yeah, maybe, but what else is going on here? So, for example, at a city, I mean, obviously you're not looking at the case, but like in a situation, how would you initiate that conversation? Because I don't I don't think airways or anywhere in his purview on this now.
[28:37 - 31:49] Tracey: So it's interesting because like, I think, you know, the, the second molar is always going to take I always tell people, like, if you think about this jaw, think about like a nutcracker, if you're going to crack the nut, you're going to put it all the way in the center. That's the most pressure, right? So as you up, as you bite, as you close that, like The Nutcracker. Or, you know, like the second molar will always break first. So, sure, you could use a stronger material, but the force is going to be distributed somewhere, you know? And the reality is I tell patients like if and I, it's interesting you say that because I just had that with a patient. We did it with tooth number 18. And I looked at like before when we prepped it like 18 was kind of like hollowed out, you know, and I really needed to open up the vertical because there's no tooth left, you know, and so, you know, like we did an Imax and three years later that Imax broke. And I told him, I said, look, this is the reality I can put I'm going to put something stronger, but I don't know how long that's going to last. That might give you six years, you know, like this one gave you three. Maybe a buster may give you six. You know, every time I take away the structure, I get a weaker tooth structure going on. Really, what I need to do is I need to recreate what you lost, you know, so, like, I, we might need to open up the vertical. Another thing you have to do is you have to look at the overall bite. Forces, you know, like redistributing the base forces are the first point of contact, the second molars. Maybe it needs to be redistributed to the whole world. And that's actually something that we even talk about the quoi center with like occlusal dysfunction, something in the back. This, you know, this includes everything else. But yeah, I mean, a lot of times it isn't. It's funny, at Speer, the guy was. There's one lecture, he goes, one of the biggest failures of restoration is like adhesion, you know, in materials. And I was like, I would argue and say one of the biggest failures is the lack of diagnosis of an airway problem, you know, and, and just putting a, and a night guard, like, if the patient is there, some people can't tolerate a night guard, right? You know, like if there's a certain thickness, like, and if they're bite, if they're, they're mandibles a certain way, they can't tolerate a night guard. If they end the massive tongue, you throw a night guard in there, you know, so, but I do think that we, as dental professionals, have to make patients aware of the risk factors and have them accountable for the failure. Also, you know. Yeah, like patients got to own it, too. And I mean, I think it's not like, hey, we're going to do this, but like, because at the moment you, you say like, well, I'm just gonna have my lab make a bigger, stronger crown. You put the liability on the technician and the material, you know, and just feel like, hey, there's something really going on with your bite. And if we don't fix that, no matter what I do it is going to break, you know, like, I mean, it's crazy, like you, if you have a really expensive car, I don't care if you paid 50,000 or 200,000. You drive the tires and glass, you're going to pop a tire. Doesn't matter how much you paid for it. You know, I always tell people that.
[31:49 - 31:55] Rob: Yeah, you have to be accountable for what you do with that. And also, on the other side, it's not a car, it's not an inanimate object. You're making these choices.
[31:55 - 31:56] Tracey: Yeah.
[31:56 - 32:09] Rob: And, you have to, say, you do have to educate the patients on what they're looking at. Exactly. And speaking of. So you do some educational stuff yourself, is that correct?
[32:09 - 33:18] Tracey: Yep! Yeah. You know, so this airway journey has been interesting. So obviously I have my ASAP Pathways where we teach how to identify the patient, children and adults with airway issues, and how to correct them. I have another program with Dr. Victor Khatchaturian, he's a cosmetic dentist in Beverly Hills. And basically what we came up with, what we call this Airway Smile Design. And so our philosophy is more of like, okay, you know, we look at the face and we look at the teeth and we look at how we can- How to do dentistry differently now with an airway lens. So that's really exciting because I think most restorative dentists get that. Some restorative dentists don't want to go in and do appliances. They don't want to go and put expanders, you know, like, what else can I do? And so what we teach there is all the different things to look for and different things- We teach you how to rehabilitate that bite with an airway hat. So the restorative part is really fun.
[33:18 - 33:29] Rob: What kind of technology do you use for all this? Like, do you use 3D printers? Do you use CAD software, like exocad? What are some of your key tools that you approach this with?
[33:29 - 33:58] Tracey: So, you know, Victor's playing a lot with MODJAW. I use a lot of exocad. Aligners, I do a lot of aligners with, you know, Invisalign and Angel. Yeah, I mean, you use that for, you use the aligners for, to develop the simulation, you know, then you have like exocad to kind of design what the teeth are gonna look like. You have MODJAW to look at where the bite is going to be when they're, awake, and then you just put it all together.
[33:58 - 34:00] Rob: Put it all together!
[34:01 - 34:03] Tracey: It sounds very simple, right? Hehe.
[34:03 - 34:05] Rob: When you put it that way, it sure does.
[34:05 - 36:48] Tracey: Yeah! It's like you do your standard photos, you import everything in. I mean, it's interesting because I think we're just reevaluating how we do dentistry and can we do it better. You know, I think that, the initial thought process, even when I was doing it was like, okay, this is the anatomy that I have, and I'm just going to fill everything with porcelain to make it fit, you know? And what we're realizing is that porcelain could widen that smile/bite so much when you have a skeletal issue… And even an anatomical issue and a breathing issue. So we look at it like, well, we can change it a little bit more. And the side benefit is you'd actually breathe better. Is that something you would like to do? I mean, because we're already going to be doing a full mouth rehab. So that's been really fun. I mean, I just posted a case, I think, on Instagram where if I didn't know airway, I would just open up the vertical and then restore the patient. And I'm not saying it's wrong to do that. But I'm saying that there's so much joy in doing airway dentistry when a patient says, oh my gosh, I feel so much better. My sleep is better, my breathing is better. Right around this time I used to get a bunch of sinus infections. I don't have any. You know, it's a different joy. I think when I used to do cosmetics, people would, you know, don't get me wrong, I loved it. I used to joke around and say, like, I promote self-esteem, you know, everyone was happy with their smile, you know? And some patients cried when their smile was great, you know, that they could smile more now. Now it's different because I still get that. But then I get the parents and the kids, and the parents say, my child is so different. Thank you for saving my life. My husband, he feels so much better. You know, it's so rewarding once you dive into it, you know why because it’s very different. And then patients like once they realize that you really care like yeah like oh well you actually really you know, you're not just looking about what's in my mouth. You're looking at my overall health. I mean, wellness. This is how we're going to change dentistry. I mean, this is how we need to act like real doctors. You know, it's funny I have this joke with my boyfriend because he's an oncologist. He goes, you know, because he's like a “real” doctor. I was like, we'll get there. I'll be a “real” doctor one day! I was like, my patients breathe better! Like, I'm a doctor! But I think I would like to see dentistry get there, you know, versus just changing smiles.
[36:48 - 37:02] Rob: Yeah. It sounds like it comes back to educating the patient. And like you're saying earlier, you have them be a little bit accountable for it. And as you said, like you're already doing all this work to improve their smile, why not make it more functional?
[37:03 - 37:03] Tracey: Yeah.
[37:03 - 37:21] Rob: And treating the patients again, taking a whole whole patient. whole personal doctor approach to this. It’s a whole person with a real life that's beyond just what we see for the cosmetic aspects of their restoration here.
[37:21 - 37:33] Tracey: Yeah, totally.
[37:34 - 37:30] Rob: Yeah. That's a good approach. That sounds widely underappreciated.
[37:31 - 38:55] Tracey: Yeah. You know, I think like where dentistry is going. I mean I feel like there's no middle class. It's going to be like the corporate, you know, which is going to be- there's a lot of patients that want the fast, that want cheap dentistry. And the problem is the middle class can't compete with that. You know, like, we don't, we don't get the same pricing. So if you're just doing like, bread and butter dentistry, you can't compete with corporate because they're getting everything for less, you know. But the ones that are specializing in different types of care and you see that now in medicine. People will pay for concierge service. I mean you have people like Dr. Mark Hyman that are like functional medicine. People want to feel better and they will pay for things that their insurance doesn't cover because they want to feel better. And that's going to be how dentistry has to be like, you know, we can, we need to find a way for patients to be like, you know what? I want that service. This other dentist doesn't really care about me. I'm just a number. This person actually does. I mean, so I think it's going to take some time, but the more dentists, the more we start talking about salivary testing. The oral system, the connection, you know, like, you know, more people are going to be like, you know, I want a dentist that does that.
[38:56 - 39:01] Rob: How do you think we can reach these patients and get the conversation started more?
[39:02 - 40:34] Tracey: Well, I think this podcast is great! You know, and I think social media is what's going to drive patient awareness. I think podcasts that are public that patients can listen to. I mean, we have a podcast for ASAP Pathway. I mean, I actually started through social media. It's funny because like most of the people I know who started asking me to speak knew me on social media. And the reason why I started to do it is I started to read a lot of articles, and then I started to blog on them. You know, so I will read a scientific journal like an EMT journal. And then I was like, oh, wow! You know, there's an airway component here. And the more people started to follow me, I just made my page public, you know, I was like, well, you know, I don't really care. Like everyone could read it. And so the more we talk about it in public and the more platforms that talk about it, the more patient awareness is going to be. I mean, that's just where that's how medicine is going and that's where dentistry needs to go, too. So the more podcasts that talk about wellness, the more social media platforms that do it, that's where it's going to be. I think patients drive the service. You know, they'll come asking for it. I mean, my average new patient commute is probably four hours. And I have people flying in, you know.
[40:34 - 40:34] Rob: Four hours?!
[40:34 - 40:36] Tracey: Yeah!
[40:36 - 40:37] Rob: Wow!
[40:37 - 40:55] Tracey: Yeah, that's my average. Yeah. So like, I have quite a bit of patients that drive down from New York. I have some people that fly up from Florida, you know, so I have another one like in, gosh, I think I have a dentist coming in from Seattle, like, so, I mean, yeah! Hehe!
[40:55 - 41:09] Rob: Hehe, that's pretty wild! I know some people complain about 40 minutes, much less four hours. That’s crazy. I mean crazy in a good way! Good that you have that kind of reach and that people are coming to you for proper treatment!
[41:10 - 41:50] Tracey: Yeah. I mean, that's it, like I said, I mean, you'll have some people that complain for the 15-20 minute [drive] and they'll find someone. And so I think that, you know, as professionals, we have to kind of decide, it's like, you know, where do you want to be? You know, I think it's going to be more than just cosmetics. I think that the wellness component is going to be taking off. I mean, the wellness component in medicine is like a billion-dollar industry. You know, like supplements right now is a billion-dollar industry, you know. So I think that it'll be interesting to see where dentistry lands on all of that. But, you know, you can't have a healthy body and have an unhealthy mouth, you know, like, you can't.
[41:50 - 41:52] Rob: Turns out they're all a part of the same mechanism.
[41:52 - 41:54] Tracey: Exactly, exactly.
[41:54 - 41:55] Rob: Who would have thought right? Hehe.
[41:55 - 41:56] Tracey: Exactly.
[41:57 - 42:01] Rob: Do you have any interests outside of dentistry? Like, what do you do with your free time?
[42:02 - 42:06] Tracey: Oh, I'm a crazy biohacker crazy biohacker. Hahaha!
[42:06 - 42:11] Rob: Crazy biohacker?! Haha! What does that entail? Hahaha!
[42:11 - 42:17] Tracey: It means for longevity. I think it's so funny to be like, I look great for 95, right? Hahaha!
[42:17 - 42:19] Rob: Never would have guessed!
[42:19 - 43:06] Tracey: No, I mean, like, I'm really big into, like, fitness. So, I do like yoga. You know, I think, like everybody else, I love to travel. I mean, but yeah, if anything, my time is spent on just feeling and being better. And then now, I mean, gosh, I don't even know if I have that much free time because I'm spread so thin with all these different programs, you know? So I always like reading material. So, like one thing at the Kois Center, I'm a scientific advisor. So, like, it's my job to read, you know? So I just got a little notice, like. All right, where are your articles for June 1st? It’s like, okay, hehe! I like to put some articles out there.
[43:06 - 43:19] Rob: Well it sounds like it kind of all feeds back into the same thing though. It sounds like you’re focused on wellness, it just kind of feeds right back into your approach to dentistry and then to airway restorations.
[43:19 - 43:51] Tracey: You know, and I think what young dentists, I mean, as they start doing these cases, you know, they'll start to see their stuff fail you know. And then they'll, just like your doctor, the first thing you do is you blame it on the materials, you know, and so you'll look for better materials. And when you and you get something that's supposedly a better material and that fails, you start to reevaluate what's going on. You know, the whole system that's there.
[43:51 - 44:07] Rob: Yeah. And like just I mean, not to not to drag that case too hard, but it's one of those situations where, it's a five-unit bridge, but it's a quadrant intraoral scan. So you have maybe a scan from number nine over, you know.
[44:07 - 44:09] Tracey: Oh, so you don't have bilateral contact.
[44:09 - 44:13] Rob: I didn’t even have the whole bite to go with it. And it's like, well, how do we properly diagnose what's going on with this?
[44:13 - 44:15] Tracey: Yeah. Yeah.
[44:15 - 44:41] Rob: And I love this guy. And if he's listening I'm not dragging your case here. It is just a situation where like you were saying you can't really diagnose without seeing the full picture. And, is it really a failure of the material or is it something greater at play there? And like you're saying, it's really difficult to identify if you're not gathering the proper information or enough information, rather, to really assess that.
[44:41 - 45:57] Tracey: Yeah. You know, and I think that's one of the reasons why I joined the Kois Center, like, John Kois like, he really… What resonated with me a lot was, you know, like, if we have things in dentistry that fail because I think, dentists are really, we're so meticulous about things like, if you got a cavity or something broke, it's always my fault. You know, like, we're so hard on ourselves about things. But what John taught me was it's not you. It's really your failure to diagnose the risk factors, you know? And at some point, you have to bring the patient in on that accountability, you know? And so that for me was really like eye opening. So like, if I, if I do a case, I mean, I was doing another case on a patient and I said just like that, that one crown that broke as like, I don't know if it's going to last. I can use a stronger material that might buy us, you know, another maybe five years? But we have a functional problem here. And once you say that the onus and the liability is out of your way, you know, because if you think about medicine, they don't guarantee anything!
[45:57 - 45:58] Rob: Right.
[45:48 - 46:46] Tracey: You have a pacemaker? There's no guarantee that that's going to last. You know, like you you said you have a certain- but in dentistry we like and I think our patients think that everything has to last, you know, and somehow we validated that, you know, like somehow when the patient comes in with a broken crown and they say your crown broke, we've validated that statement and said, sure, I'll do it different, I'll do a new crown and I'll even do it for free! You know, and we need to stop doing that. We need to be like, well, this could potentially last you X amount of years. This is your bite, you know, blah blah. We have to take that liability off of us because they do that in medicine all the time. They don't give you any guarantees and they tell right off the bat.
[46:46 - 46:53] Rob: Entropy is a thing. Things wear out. Your roof doesn't last forever. The tires that you were talking about, especially if you're driving them through a pit of nails, are not going to last forever!
[46:54 - 48:28] Tracey: Yeah. I mean, like, it's funny when, you know, when I gave that little, elevator speech about TMD, like, I learned that from my orthopedic surgeons, you know, like, when they do an ortho, even when they do a surgical, or when they do a knee replacement, they tell you this knee replacement is gonna last X amount of years before you even decide to do a knee replacement. They'll give you cortisone shots, they'll give you a brace, you know, like things like that. But they take the liability off of the surgeon and onto the patient and say, this is your risk factor, you know, and we need to do that more with dentistry. It's been like, oh my gosh, you broke this tooth? You know, if you broke this tooth, you most likely might break a crown, you know, and I think, like I tell them, that right off the bat is like you've managed to destroy the strongest thing in your mouth, which is enamel, like, so anything I put in there is going to break. And it's funny because we talk about like, you know, you have those are fraction lesions on teeth? And so some people are like oh it's toothbrush abrasion. And most are like, no, it's bruxism because that's like the weakest point. So I always tell patients I was like, well, you know, you're wearing your front teeth down. Let's put a bonding there so you can- I'd rather have you wear down the bonding than your natural teeth, you know, like I'm letting you know that the bonding is going to fail, but it's what's happening to you. And I think we need to do more of that, and just maybe give ourselves a little grace about those things.
[48:28 - 49:22] Rob: Yeah, I think that's a really good point, to involve the patients in their own care. It's not like they're not an inanimate object that you're servicing. And they just sit there, you know, working day in and day out like a blender or a toaster, like they're involved in the process. It kind of reminds me of when I broke one of my fingers again a couple years ago, and, this time it was a knuckle joint, and the orthopedist is sitting there saying, "Look, we can only do so much with this. You have to do this physical therapy stuff on your own at home, or this is never going to work right again”. And, it's not if it doesn't if it doesn't work right, it's not the orthopedist that's on me for not taking responsibility for the care. And I think that's a really good point that you bring up with the dentist educating the patients and having that communication to bring the patients into the conversation as, hey, you have to be responsible for this, too. Don't go chewing on bricks.
[49:22 - 49:22] Tracey: Yeah.
[49:23 - 49:40] Rob: Yeah, this is going to break again if you at least don't take some care or thought into it. What are you excited about with what's coming down the pipeline with dentistry? Like is there any kind of tech or new techniques that you see coming up on the horizon that has you excited or looking forward to the future?
[49:40 - 50:24] Tracey: You know, I want to play around a little bit with MODJAW. You know, Victor is obviously playing around with that, you know, just getting an understanding of how the jaw functions, like, throughout the day. I’d love to see that at night, too, you know, with sleep bruxism, because I'm looking at ways to make our dentistry last longer. I do think that the airway for us to evaluate risk factors of every dentistry is not going to go away. You know, I think that there's a lot of associations that are trying to say it's a fad. And I definitely don't see that happening. We are finding-
[50:24 - 50:25] Rob: We are. Breathing is a fad. Haha!
[50:25 - 52:05] Tracey: Yeah. We're getting more and more evidence, to prove that what we do, is positive and it's crazy because it's like, why would we, as a profession, just shoot ourselves in the foot? You know, it's like you have physicians that want the want to know your opinion and then just say like, oh, no, you know, I'm just, the dentist, you know, like, I was reading one article, and it was, it was a really disappointing, article and it was, it was an editorial article and basically it was saying how you know, dentists need to stay in their own lane. And if they wanted to go to med school, they wanted to treat medical conditions. They should have gone to med school. I was like well, thanks for making us feel like crap. Like what? Like, wow, if I didn't feel like a real doctor now, I do, you know, and it's a crazy mindset to have. It's a crazy mindset to be like, my only job is to fix your teeth. My only job is to make your teeth straight. Make sure that you don't have any cavities and just fix your teeth. And that I think that we're not mechanics. That's not why I went into this field, you know? So I do. I'm excited and I'm going to keep on pushing for our involvement in the medical field. Because, like I said, you can't have a healthy body with a home with an unhealthy mouth. You know.
[52:05 - 52:35] Rob: It's one of my favorite jokes because it turns out your mouth is part of your body. You know, it's where most things come in and out. Like, it's where your thoughts come out and everything that goes in, goes in. Yeah, an important factor there. I'd love to see that, that, the author of that article gets a cavity and has that same approach, you know. Not that I'm not going to wish that on anybody! Okay. Just a funny situation, but yeah. Thank you so much for being a part of this. Your work is absolutely fascinating..
[52:35 - 52:37] Tracey: Thank you for having me!
[52:37 - 52:44] Rob: Where, where can people find you online? Where can they find your courses? Like your social media stuff? Where can they follow you and learn more about your work?
[52:44 - 53:24] Tracey: Yeah. My handle is, @drtraveynguyen, super simple! Yeah. I mean, I'm on social Instagram, Facebook, things like that. Yeah. And all our online courses, our educational platform is asappathways.com. Airway Smile Design is something that I do with Dr. Victor Khatchaturian. If you're a hardcore restorative doctor, I mean that is like one of my favorite courses because we really do look at full mouth rehabs with an airway hat. And you'd be really surprised how we do it a lot differently now, knowing what we know.
[53:24 - 53:28] Rob: What's something you do a little differently now than you did before?
[53:28 - 54:11] Tracey: Well, because now, like before I had the airway hat, like, I would just design with what was given to me, you know, like, now I'll make suggestions based on, you know, what I see as like, you know, the face in your smile would look so much prettier if I was able to put your teeth here, you know? But the only way I could put your teeth here is through some form of skeletal advancements, skeletal modifications. And the good thing is, that's actually in my wheelhouse, you know? So there's things that we can do now to make the patients actually look better skeletally, versus just dentally. That's really nice.
[54:12 - 54:20] Rob: That's so cool. Thank you so much for being a part of this. We really appreciate you being here. And thank you for sharing your experience and your knowledge of this.
[54:20 - 54:24] Tracey: Yeah. Thank you for having me. It was fun. Good times!
[54:24 - 54:41] Rob: Good times. And thank you, everyone for joining us for this episode of The Evolution of Dental Podcast. Please look for our new episodes every Friday on Apple Podcasts, Spotify, YouTube, and wherever you find your favorite podcast. Remember to like, subscribe, share these videos and remember, never stop evolving.
