EP 295: Beyond Braces: The Health Impact of Modern Orthodontics with Dr. Madeleine Goodman, DMD

Hi and welcome to episode 295 of the Untethered podcast. Today we have Dr. Maddie Goodman joining us. Dr. Goodman is a board certified orthodontist who co owns Harmony Pediatric Dentistry and orthodontics in Bethesda, Maryland. Dr. Goodman attended Duke University and majored in Classical Languages. She then completed dental school at the University of Pennsylvania and orthodontic residency at Tufts University. She is the past President of the Mid Atlantic Society of Orthodontists and is the founder and Chair of American association of Orthodontist Orthodontist Sustainability Committee. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered in collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Maddie, welcome to the podcast.

Thank you so much for having me. It's an honor to be here.

I'm excited to have you. I know a lot of people on the podcast know that I used to live in Bethesda, Maryland where you practice and now I'm in South Florida. But it's. You're definitely one of those providers that we're always referring to because I know that you all get it. So I'm really excited to chat with you today and dive in. Um, but I would love for our listeners to just understand a bit about your background, how you became like interested in, you know, the more mayo airway holistic space. So will you start with sharing a bit about that with us?

Yeah, sure. So I graduated my orthore residency in 2011 and soon after I moved back to Bethesda where I am from and I happened to get a job at a large pediatric, dental and orthodontic practice and that's where I met my current business partner Heather Schulander, who's a pediatric dentist. And it's also where I was introduced to myofunctional therapy. I'd never heard of myofunctional therapy before. Not in dental school, not in residency. But the orthodontist who owned that practice was very forward thinking. She did a lot of early treatment and she already had a myofunctional therapist who would come into the office once a week and they would co treat patients together. She would do screenings, and then when the patient came for their ortho visit, the myofunctional therapist would see them. And so. And that myofunctional therapist is Jennifer Triandolfoulou, who now teaches the Simon says program. But she was my first introduction to it. And I really loved that aspect of collaborative care and it made a lot of sense to me. And it was, it was just a great working relationship and she really taught me a lot. But as time went on, I still felt like there was something I was kind of missing. I would still have these cases where they had perfect tongue posture and Jennifer did a great job, but they would still kind of go wacky. And I just, it was, it was frustrating to me. And also I was sort of having like a quarter career crisis where I was like, what is the point of what I'm doing? Like, I'm just straightening teeth and most teenagers don't care about the straight teeth and then they don't wear their retainers and it relapses. And I was just kind of like, what is the bigger picture here? I was kind of searching for something. And also that's when DIY orthodontics was getting popular. And I was like, yeah, like a robot could probably do this. So anyway, this all culminated in 2018 when the AAO, or American association of Orthodontists, had their annual meeting in D.C. and I brought my staff, we went for one day and I was like, we need to go to one lecture. So they chose a lecture and. And we ended up getting lost in the lecture hall and ending up at a different lecture. But we decided to stay. And the person giving that lecture was Joy Muller, who's a myofunctional therapist. And she was talking about airway and sleep apnea and what you eat determines how you grow and that mouth breathing can be a habit and like all of these things. And I really had this moment where like literally like a light bulb went off and I was like, oh my gosh, like, this is the piece that I have been Missing. And I like, almost had chills in a lecture hall. I was like, wow, this was kind of blowing my mind. And I had a few simultaneous thoughts at once. Like, that was one. Two was, I think I ruined my nine month old son's life by not getting his tongue tie clipped when he was an infant because they told me he had one and we didn't do it. And three was like, this is what I want to do with my practice, is have a practice that's focused on function and early intervention and collaborative care. And so that Monday morning back at work, I went to Heather, the pediatric dentist, and I was like, this is the kind of practice we should have. And she had coincidentally recently been to a pediatric lecture that talked a lot about the feeding side of it and how that influences growth. And so we both, like, we were, we both got very interested in this topic and like, to say went down a rabbit hole is an understatement. Like, I have never gotten so enthusiastically into a topic like ever before or since. And so I was immediately like, read every book, read every article, went to every lecture, listened to every podcast. I listened to a lot of your podcasts. I listened to a lot of Stephen park, that ent from New York. I listened to a lot of his podcasts. I tried a lot of appliances, like myo adjacent appliances I had. Our kids were in myofunctional therapy. I went nuts with this. Really nuts. But suffice to say, it planted the seed for Heather and I. And in 2019 we started the process of setting up our own practice. So at that point, the practice that we worked at had been bought by a corporation and we just kind of knew that we weren't going to stay there long term and we really wanted to focus on this and we didn't have the freedom to do that at that office. And so we wanted to have our own thing where we could really kind of go full speed into this practice philosophy. So we ended up opening our own practice in November of 2020. And now we're about to have our four year anniversary and it's been really great and really interesting. And now we can really just practice how we want and do the things we want to do. So that's the story.

I love it. I love it. I mean, it feels very similar to like some of what I did in the past and, you know, eventually wanted to practice for myself because I wanted to be, you know, basically control, you know, how I was practicing and what I was offering. And then I actually didn't get into it for mayo, but I got into it for feeding. Although I was working with like 24 months plus, had my own kids. Came back from my first MYO course, which, by the way, I met with somebody, another speech pathologist in downtown Bethesda. One day we're having, like, coffee, and she's like, yeah, you know, I found this MYO thing, and I'm not really doing it full on, but all of my kids with, like, speech sound disorders are doing so much better. Like, I'm actually graduating them faster. And I was like, wait, now you have my attention. What do you mean? Like, those are some of my most complex cases that I can never seem to get out of therapy. And so I was like, all right, full attention. Went down the rabbit hole, you know, got into myo, and I'm like, the rest is history. Came home, realized that my then 24 month old had a tongue tie that was never identified. But we had a horrible feeding journey. Really, really challenging. Still breastfed her for, like 13 months, very painfully. And I'm like, looking in her mouth. I'm like, high, narrow palate, tongue tie, lip tie. Okay, yeah, we got. We got some work to do. And then, you know, I knew. I knew differently for my second one, but it was around 2017, 2018, where I, like, totally revamped my own practice and just dove in to everything. Airway feeding, MYO tots and. Yeah, and the rest is history. And it was so hard to find a variety of providers that we could refer patients to, even at that time. And so I remember, like, when you guys opened your office, and I remember coming to visit, I was like, oh, this is so nice to have somebody in downtown Bethesda. And then we moved, but. But, you know, we still refer patients to y'.

All. Yes, I know. We refer to you too. Yeah, no, that's great. I mean, mayo, like, it's very important for what we do in orthodontics in terms of stability and getting the results that we want. But it's, like, paramount in speech therapy. So I really don't understand that whole thing. Like, I don't understand why it's not, like, at the forefront basis of what speech therapists learn. But I'm sure that's another topic that you talk about other with other speech therapists about.

But yeah, and feeding too. I mean, feeding, basically, you know, speech and feeding. Hi. What are we using our jaw and our tongue for both activities. And there's still this massive divide amongst speech language pathologists as to, like, myo whether MYO is A real thing. And whether tetheral tissues are a real thing. And I'm like, are you guys kidding me? I mean, there are people who will argue with, you know, we teach compensation. Like, they don't really need a lot of movement for the tongue to produce speech sounds. More like what? Like, it's kind of like if you can see my face right now, people listening. What? Yeah.

That's how you make speeches with your muscles, correct?

Yes. And like, yeah, very minimal jaw movement. I will give them that. But like our orofacial muscles. Muscles. Muscles need to work together. Right. So it's, it's mind boggling to me because I've had like, I've gone over like sound by sound, like what is involved and how it can be impacted and people still want to argue with you over it. And I'm like, that's fine. If you want to keep your patients in therapy forever, that's. I guess that's on you. But ethically, for me, I would love to see my patients come in, get the help they need, work with the team of providers that's necessary, which I know you guys are also very collaborative in that sense and get you out as fast as we can. I'm. It's still going to probably take a year or two sometimes, but let's not make it take 10.

That's 10 years is not a practice builder. And same with ortho. Like the goal is to get in and get out. Like, no one likes you that much that they want to keep coming for six years.

Yes.

That's not a good story.

Yeah. And I use this, like I have this one story that I tell all the time of this kid who came to me. He was going into high school and mom had said they had seven other speech language pathologists over the course of his lifetime. Like since he was 2. And I did a myo eval on him. I looked under his tongue and I was like, holy cow. Like there was like webbing. I was like, this is one of the worst, like most obvious, like most severe cases I've ever seen. Squirt is like a two year old on our speech testing, which is very heavily rooted in like the R. So he, he could not make R for his life, but he also couldn't do other sounds. Sended him. I said, I can't talk today. I don't know what is going on. It's Monday morning and I'm making up new words. Sent him to an oral surgeon who did do the release. And he, and he said, this is one of the most involved, like cases I've seen on a, on a child. Anyways, long story short, you know, we did all the therapy leading up to it. We did all therapy afterwards. We had a whole team approach and he was graduated within like six months and went to high school speaking the way he wanted to, which for him. I mean, then you start getting into like having thoughts about yourself and your, you know, just how, how you identify and how good you feel about yourself. And he clearly just, he flourished. It was really, really cool to see like, how quickly, you know, he was able to move with the right intervention. And I'm not like writing off all the other treatment he ever had, but to come to me still presenting as like a 2 year old on speech testing tells me that was not very effective. The other interventions that they had attempted and how quickly we were able to move him through with the right team approach was like, just so, you know, mind boggling to me, but at the same time just like, wow, like this really, this really is something. Like we really need to kind of dig our heels in a bit further and really like promote this because, you know, when you share cases like that, I think people like really start to wake up and start to realize, like, no kid should be in speech therapy for 10 years. That's absurd.

There's something else going on at that point.

Yes. Yeah.

Yeah. And I do think that, you know, we, we have relationships with a lot of speech therapists and a lot of patients that are in speech therapy and various, you know, with various providers. And I do think that speech therapists have become a lot more aware of tongue tie.

Yeah.

What it is and what it looks like, I think it's almost, almost over, over diagnosed now. But I think overall though, I do think it's, it's, it's, it's better that they are more aware of it than less. And I think like people like you with podcasts and getting messages out there, I think it's really resonated with a lot of speech therapists that maybe don't learn about it in school.

Yeah, I mean, none of us really learn about it. If anything, we learn that it's not a thing. It's so rare that you get someone who comes out of a program that even knows about MYO or tongue ties. So that's, it's mind boggling to me. And it's interesting too that you say that you feel like it's even over diagnosed now, which I completely agree with. And I try, like in my courses that I teach, I Try to really drive home the point that, like, if we're going to diagnose a tongue tie, there needs to be a functional impact and there needs to be a physical impact. We need to see that tight tissue and we also need to be able to list all of the symptoms that we're observing and how it's impacting them on a daily basis. And then we need to also intervene in other means. So I think it's really important the work that obviously I do and other speech therapists do, and obviously the expansion and the growth that you're doing. But I also feel like we oftentimes need like body work. We need to address tension throughout the body. And I'll tell you, we've seen kids where we're like, so sure they're tied and three to four weeks in working with us, maybe starting expansion with a, or working with body work, they look totally different and like the anatomy kind things kind of shift and they don't seem to carry as much, much tension. And I'm not saying it's not a tongue tie necessarily, but I really try to caution people these days to like running right into a tongue tie release because sometimes we don't need that. And less is more, in my opinion, like if we do all the things and we feel like it's still impacting and we need to do a release, 100%, I'm on board. Obviously we work with patients, all the times getting released, they come to us because they need that pre and post op work, you know, but not every case needs to be released. And like I say that and now there's people like on the other side, they're like, oh my gosh, you're gonna make people run away from releases? And I'm like, no. My goal is to hopefully give people like the information so they have, they can go have a conversation with providers, they get informed consent, they know like what the benefits are, what maybe risks there are, which there aren't a ton of risks per se. It's a minor procedure. But if you're not going to do the work, if you're not going to expand the palate and grow the jaws forward when that's needed, you know, it's like. And you can speak more to that. You know, I feel like it's got to be kind of like a holistic approach, not just like piecemealed things here and there.

And it's a lot and an individualized approach because we have some kids who present looking like super tongue tied and they've totally compensated for it and have very minimal issues. And then you have kids that don't look that tied but have not had any progress with speech and all of that. So, you know, we get patients asking all the time, like, you know, do they need the release? Do they not? And we always say like, again, try all the things first. That should be kind of like last resort. Yeah. The last thing that you try is because the other part of it is there aren't that many risks, but it's not. It can kind of turn into a thing because there aren't a ton of providers. You don't want to. You don't want to put a kid under general to have a tongue tie release. They can do it later. You know, there's. There's other factors at play. So we really try to be conservative about us recommending it as well. But we never, we never. Unless it's something like blatant. Blatant, which is very rare. That you have like an anterior tie where like the tip of the tongue is tethered. In that case, like. Sure. But otherwise we rely on the myofunctional therapist to make the final call. Like, we don't do all the screenings and measurements and everything. We refer.

Yeah.

But we like to be in on the conversation just so we kind of, kind of keep things conservative for the patient. Yeah.

How do you feel about a kid where we're pretty sure they may need a release, but they have a really high narrow palate? Right. Because my thought process is you can release a tongue, but if it doesn't have the proper space to exist in, how are we rehabbing it properly?

Yeah, we almost always will recommend expansion first and then do the release second. So we do a lot. I do a lot of early treatment, definitely more than the average orthodontist. I have one because I have like a special interest in it and I believe in it a lot. But two, like, because I work with a pediatric dentist and we share a lot of patients, I'm able to. She's able to kind of flag issues very early and kind of plant the seed. Like you can kind of tell in a two or three year old if they have a high and narrow palate and the baby teeth are coming in crowded. In a three year old, you kind of know. So she's like kind of priming them for some more early ortho. So yes, again, it's on an individual basis, but if there's a kid who we feel like needs a release but they're not having any sort of Major issues with feeding and speech from it. We'll wait until they're ready to do the phase one, we'll do the expansion and then we'll have them go for the release afterwards.

I love that. Yeah, that's kind of aligned with like how we approach things. And we try to explain to parents that. Because a lot of times parents will come to us for like they'll say we're calling for a tongue tie evaluation. And we're like what are the symptoms? Like there's no such thing as a tongue tie evaluation. It's a feeding evaluation, it's a myo evaluation. That's a part of, part of like what we look at and what we assess and what we kind of figure out, you know, is there a functional impact or not? But we get called for that so often and then it's really, we feel like there's a big part that falls on us to kind of start educating and saying okay, we know you came to us and yes, we agree that we need to intervene and we're going to start doing that. We would also love for you to go and see another provider to assess the hard tissue. Like we do soft tissue, they do heart tissue, the bone. Want to make sure the teeth are coming in, you know and, and we see a ton of these kiddos with like those high and or narrow pal. And so that's, you know, how early do you start intervening with expansion?

So it depends in I, I've done expansion on kids as young as four but they have to have a special circumstance for me to go in on a four year old. One number one, they have to be a good patient. Like I don't want this, I want this to be like a fun and a good experience. I don't want them to be traumatized. They have to be a patient who's going to like lay in the chair and they're. And you'd be surprised. There's some four year olds who are very good patients.

Yeah.

Like better than 13 year olds. So that's one, two is they have to have something like pretty just disfiguring. I don't know if that's the right word. But anyway something pretty major going on like a very large mandibular shift posterior cross bite like or an underbite. So the four year olds I've done expanders on are. I did, I corrected an underbite. The. It really bothered the parent and so the parent was very motivated to help him with that. So we corrected his cross his underbite in like Four months in and out, like little. The younger the kid is, the more easily things move. And again, I go very slow with everything. But you know, there I try to make these younger kids only in something for like six months or less. So anyway, I'd say an underbite, a major asymmetry or shift crossbite. And then otherwise I'm gonna probably wait until a kid's older and like a five year old who has super narrow, super crowded, all the sleep problems, already had tonsils and adenoids out. Then I would go in and do some upper lower expansion if they need it. I've only done that a couple of times. Six is where I would probably start with that. I'd probably rather start with that. And then by the time they're seven or eight, then you're getting into the more traditional phase one. I put an expander in my son when he was four, but again, I wouldn't just do that on anyone. So they have to have a pretty significant issue for me to go in on a four year old.

Yeah, when we moved down here, so Lily had had intervention, my older one, who's now nine when she was starting at four and we moved down here and she had ended up having another phase of expansion when she was, I want to six, sixish. But my other one, my younger daughter who is now six, started at four as well when we moved down here. But she had had croup nine times as a three year old. And both my girls are like, they're the good patients. Like they will just lay in a chair and let you do anything. They're like so easy. I'm so grateful for that. But I will tell you, her croup cleared up. Like she maybe got it once the following year and then, I mean you could sneeze around her, she would get a cold on like the next day and the day after that, like we'd be in croupville. And they were constantly putting her on steroids. And I was like, there's got to be another way to like there's something, something's got to give. And she had had like chronic croup even before she was three as an infant and you know, enter into toddlerhood, into the preschool years. And so I was very, very grateful for the expansion because I. What I think it did was it opened her airway enough that if she did get sick and she got inflamed, it just didn't get as severe as croup. And you know, I was like, thank goodness for that. So and it's also interesting too, because both kids were, like, delayed getting their teeth, and then they were delayed starting to lose teeth. But with the expansion, it was like we started to expand and all of a sudden teeth got wiggly and teeth started to come out in my older one. And same with my younger one. I feel like she's been more on track now, even though she was like, later to cut teeth because we were able to experience. So that's been very cool to see. And like, we did cbcts on. On both of them, so it was very cool. I didn't do an after. Did I do an after? I think we did an after on Mia. Maybe we didn't. I don't remember.

Lily.

I have a before and after, which is just they're like two years apart, but like four and six. And it's incredible to see how much, like, her airway opened, her sinuses were no longer full. Her, like, you could see her turbinates, like, on the CBCT where you, like, things were very obviously very fluid filled and inflamed when she initially had her CBCT at 4. And so it was like, so eye opening to me to, you know, to start this conversation of, like, early expansion. So I love that you get in there earlier than. Than most because it's so hard to find someone who will expand that young.

Yeah, it really is incredible. Yeah. I call it phase 1a and phase 1b. Like, phase 1a is like if they have this problem or if we want to make space. And then phase 1B will be when they get their front four incisors. But it is incredible how. How much, like, if you go in before the. All the permanent incisors start to come in and you make the space, they come in pretty straight.

Yeah.

Whereas you're right. Like, if they're really crowded, teeth take a long time to come in because they don't have room. So they try to come into, like a funky space. Space either come in mind or they come in really high or they get impacted, worst case. Or they pop out the baby canine early, which is also not a great situation because most people shouldn't be losing their baby canine at 7 or 8. They should be losing it at 10 or 11. So anyway. And then you lose that space. So suffice to say, I mean, it's. It's really incredible. I have a number of patients, like either of my staff members or of other dentists who are like, let's just do whatever you want to do. And I'm like, okay, I'll put in expanders at 6 or 5. And it is just incredible what we see with these kids. Like, you really change a lot of things about the trajectory of their growth. But that being said, it's not a super popular treatment philosophy amongst orthodontists. So I kind of try to tread the line and be careful with regular patients. I always give them the option like, you could do nothing. Now this is what that path looks like. You could wait and. Or we do something and this is what that looks like. So I never tell people they need to do it except if they have something really off. But yeah, I mean, I think that it is very hard to find orthodontists who are one comfortable treating young kids because we don't learn about this in residency either. Like, the way programs are structured. And it's not the program's fault per se. It's just like that's how the patient flow is. In residencies, you see a lot of, like, older kids, and in older kids with severe crowding, you're looking at taking out a lot of teeth. Like in my residency, we took out teeth on 75% of the patients that we saw because a. That's the philosophy of the people who were teaching us. That's how they learned and that's how they practiced. But also we were seeing older kids and you have to, you have to make concessions when they're too old to grow the bone, if you will. But, you know, I think it's. In the end, it is kind of confusing. It's confusing for patients because when they're told by the pediatric dentist, go get an evaluation when they're seven or eight and they go for a couple opinions, they're going to get three different opinions. Yes. Because every orthodontist has a different philosophy, uses different things, is coming from a different place. Like in orthodontics, there's a million different ways to treat everything.

Yeah.

And especially early when there is always also the option to wait. So. Yeah, again, I think that's why it's. It's been really great having this growth and awareness amongst speech therapists who also have a lot of access to kids and parents to kind of educate them on how one, like how important it is to have enough space for the tongue and having us. Because having space for the tongue and having a pal, I mean, to me, like, that helps them form the sounds for words. Like if your mouth isn't the right shape, you can't speak clearly, I guess. And, but also, like doing it young because the other Part of it is that expansion is really only predictable non invasively in my opinion, like nine and a half and below. When they reach 10, 11, 12, you can't really change the shape of the palate. You can change the shape of the, you can straighten teeth until you're 100. You can change the, the alveolus, the dental housing, like that, the housing of the teeth, but you cannot change the shape of the palate unless you do something more invasive, which. Who wants to do that? Nobody. Yeah. So I'd say like 8 or younger is like ideal deal.

Yeah.

To start.

Yeah. Now that's, you know. I know. It's just, I think so important that you. We keep talking about collaborative care and I know that you guys work very closely with myofunctional therapists, speech pathologists. So are there other people that you find yourself like referring to regularly? Who and who, who is that?

Yes. So we work a lot also with a physical therapist for TMJ issues. TMJ issues are largely not dental related or occlusion related. They're muscle and ligament related. So, so we work with a physical therapist. He's awesome. He's part of an office called the center for Facial Recovery in Rockville. And we just tell our patients like the myofunctional therapists are for the muscles inside the mouth and he's for the muscles outside the mouth. So actually they collaborate a lot on some of the adult cases and people with pretty severe pain. But we refer to him and work with him a lot. And they're great. They look at the whole body and they look at your posture, the patient's posture and like what you were mentioning with like fascial release and tension release. He's, he's really great at that. He's helped me a lot. Not on with my jaw, but because I have a lot of like overuse injuries and so does my husband who's an orthodontist. So Carl Chua. Shout out. He's. He's great. So them. We do refer a lot to ENTs. I always tell my patients to get, ideally get two opinions because ENT is also lots of variety and variability. But we have a lot in our area who are very good and who I, my patients are very happy with. Again, like ENT is another thing. Like no one wants their kid to have surgery. Like, but it's, it's, it's. They, they're the ones who diagnose the sleep apnea. They do the sleep studies. You know, I think tonsils and adenoids out are still the frontline therapy for a kid with diagnosed sleep apnea or who checks a number of boxes on the pediatric sleep questionnaire. We don't routinely do the pediatric sleep questionnaire. If in our evaluation a lot of things kind of come up, I will give that to the patient along with an ENT referral and say, fill this out, take videos of your kid, take sleeping and go to the ent. So I'd say ENT physical therapist. I don't do a lot with feeding, but my partner does because she's seeing kids starting at like one and a half or two. So she refers a lot to feeding therapists, which I know is like with speech and myo, we work with a dentist who does. Who does a lot of TMJ and does more of the imaging side of things like CBCT and mri. And if they need like a splint, like, she deals with that. We do, you know, we do. We refer a lot to oral surgeons, but not for like, Maya related. We don't have a CBCT machine in our office. We're very X ray conservative, I would say. So I don't really ever use CBCT to diagnose airway problems or to help diagnose them, but I do take a lateral ceph, like all orthodontists do. And I always look at the adenoids in the lateral ceph. And if the adenoids look large to me, I will email them to email to the patient and say, you should have an ENT take a look at this. But usually that also goes. Usually there are other things that the kid has by that point that I've already said. You should probably talk to an ent.

Yeah.

Do you feel you can visualize. Visualize them pretty well.

Do you find that some of those tissues calm down with expansion, like that noise or the tonsils or you're not really tracking it so much, so it's hard to say.

I don't track it that much. I do kind of eyeball the tonsils during an exam. If there are other, like an initial exam, especially if there are other, like, things that the parent has already said yes to, like snoring and problems breathing through the nose and whatnot. It's very hard to say because one, like the child. Over the course of like a year, a child's gonna look different. They're, you know, I don't know what the age is, where the, where they, the tissues start to recede a bit. Another thing is like, I, I actually, when I put the expander in my son at 4, he didn't have a crossbite, but he had a lot of issues with, like, mouth breathing and snoring. And it did help his snoring. The problem was that once they took the expander out, he refused to wear a retainer. So there was not really a great way to retain it. But. But anyway, and so he's gonna get another one, but suffice to say when, before and after. I took a video of his tonsils, and I actually showed the video to this ENT who's in our study club. And I was like, look, his tonsils look smaller. And the ENT goes, well, I don't know if his tonsils look smaller or his mouth. His oral cavity just looks bigger because of the expansion. He's like, it might just be all relative. But then I was like, well, does it even matter? They're taking up less of his right airway. So I don't know. I don't track that. But I think if it's. If it's a thing, I think that's a great, you know, a great outcome. Yeah, yeah, yeah.

Audrey, I don't know if you're familiar with Dr. Yoon. Audrey Yoon. Yeah. So she had spoken to our MYO membership and presented this data. I think it was before it was even published, and now it's been published. Sometime I don't have it in front of me, but sometime in the past couple of years where she talked about how expansion does open up the airway, like, you know, several millimeters or what it was like for every millimeter of expansion, it's a certain percentage that the airway becomes more open. And so I feel like that definitely helps. And I think that's what I saw with, like, my own daughter with her whole croup story. And why, you know, if there is inflammation, like, it's just not having the same negative impact to the same degree. And then my. My first daughter, we had done a slower expansion route with her, like using an ALF appliance when she was four. She's since has gone into rapid palatal expansion, but her tonsils were almost touching. And within, like, a couple months, because I was crazily taking pictures and documenting everything because I was just, you know, kind of curious. Her tonsils went down to. I couldn't even see them anymore in her airway. They were like a one. And I was like, they were like a three and a. Like, almost four to a one in a couple of months. And I was just like, okay. I mean, that's fascinating. And that's where I started asking people like, what are you seeing? Because like you said, is it. I mean she had maybe had a couple, like a couple millimeters of expansion at that point. It wasn't anything like huge. But she did start to expand and I was like all of a sudden her like tissues just seem to be like calming down. And I was like, this is so cool.

Yeah, no, it's great. And Audrey Yoon is just, I think she's so awesome because she not only like helps champion these things, but she also does it in a way where she's doing research at Stanford and like publishing these very high quality papers. She's really making a difference. I think she's great actually. When, when I was president of the Mid Atlantic Society of Orthodontist, we get to organize a full day lecture for the society. And she spoke at our meeting. Like I got to choose.

Oh, amazing. That's amazing.

As did then in the, in the afternoon it was Stanley liu, who's the ENT, she worked with. And yes, Dr. Zabi spoke for a little bit too.

So amazing.

It was amazing. Yes.

I know, it's so fun to hear and I know that like they're all involved in this ongoing research, which is so very cool because, you know, I feel like we're seeing things happen, but it's nice to have like some data to back up what we're seeing because it just, it doesn't exist to the same degree that I feel like it needs to. And I'm always, I've always been someone who's like, if I'm seeing something clinically and I'm seeing it repeated, like I clearly know it works, we're going to keep doing what's working. But yeah, it's still nice to have just a little bit of, you know, data to show when you expand the palate, like it does grow the airway.

Yes. Orthodontists are very big on, on studies and data. And as you know, it takes studies and data a long time to catch up to what people are doing clinically. And there's so many naysayers in orthodontics about all of this. So this data is very, it's very necessary for anything to ever change. Yeah, were taught so.

Yeah, and I know that she had referenced, I think it was at a Boston University. It's coming back to me. But it was something like if you like for every millimeter of skeletal expansion, I think it was like 2.3% of airway growth for every millimeter of expansion. And I was Like, I don't know what that looks like clinically, other than my kids. My kids benefited, but I'm like, it was just really cool. I mean, there's the other thing, too, where we were talking about tmj, and this is something that I reference on. Oftentimes. We're like 97.92, if my brain serves me correctly. Said it enough, hopefully, I'm saying the right number of patients. This is like pediatrics, and adults with TMJ issues have a myofunctional disorder. And it's, you know. And you had mentioned that a lot of the TMJ stems from, like, the soft tissue dysfunction, the muscles. And it's not necessarily, you know, always hard tissue. That's. I mean, I know there could be, obviously, issues with the joint. I'm not the expert here, but we do see a ton of people come to us, adults alike, because we work with PEDs and adults in Mayo that have jaw issues. And I feel like we're seeing more of it in young children now than we were seeing even five years ago that are having, like, issues with their jaw. Do you see that? I mean, you guys are pediatric, and you mentioned you do refer to a PT who specializes in facial pain and jaw and everything. But is that something that you all see?

Yeah. So when I. When I said hard tissue, I meant, like, with your. With their bite and their occlusion.

Yes, yes.

So, like, like, their bite, it definitely has a lot to do with hard tissue bone.

Right. And like, in the junk, in the joint. Right? Yeah.

Again, like, kids with, like, rheumatoid arthritis and whatnot, like, they're all much more prone to having TMJ problems. But, like, the average kid and young, I feel like I've always seen it. Usually, most TMJ problems start to crop up around the time of puberty. They're more common in girls. But I think, again, it goes hand in hand, because when you have someone with the short. With a short ramus because of, like, if they're mouth breathing or have their mouth open all the time, and they have that very vertical pattern with a short ramus and the mandible set back, those are the patients, again, who are a little bit more prone to having TMJ problems because every time they bite, they're also in, like, a posterior occlusionist, like, the Class 2 patients, where that's when you have more of that tendency of the disc to slip and for them to get the clicking. So I'd say, like, those kind of patients, again, also Maybe with more of, like, a weak musculature. Then you have the patients with a really strong musculature who clench and grind, and they're more prone to having muscular pain as well. I definitely see a clinical correlation between people with tethered. Tethered tissue, tethered tongue, and, well, again, they have a myofunctional disorder, and then that translates into. Into disc dysfunction. Yeah, but. Yeah, I mean, I think they've. I've always seen in teenagers, especially girls, some TMJ issues, but where it really starts to manifest and. And become detrimental to the person's life is when they're an adult. So a lot of teenagers will have a lot of clicking and crepitus that's like that. When it's like. Like the bone scraping bone. Like, that'll crop up in teenage years, but not. It's not that common that teenagers will actually exhibit symptoms. The symptoms start to come when you're older, and I guess when this has been going on for longer and longer. And I don't treat a ton of adults, so I don't see it. I don't. But a lot of my adult patients, like. And I will get patients that come and say, hi, I have tmj. What can you do? I'm like, I can't. I can give you Carl's car. I mean, there's not a ton, but I have some, like, patients in their 20s who've come back and who've come in. And there is one girl recently who came in. She has a little bit of an open bite, and I just saw the whole time, her tongue's just like. And I was like, where does your tongue rest? And tons of TMJ issues. And so again, that's a myo. PT referral.

Yeah.

Because in a person that age, like, there's not a ton you can do orthodontically to help that. So anyway, it's a little harder to explain in a kid. Like, okay, that's not something I usually lead with in a consult. Like, oh, if we do this, like, you could prevent TMJ issues because prevention is. It's a little harder of a sell. It shouldn't be, but it is.

Yeah.

But again, I think just being aware that TMJ issues are, again, very multifactorial.

Yeah, yeah, no, I totally agree that it's harder to sell prevention unless, like, we've once in a while, we'll get a parent who comes to us and be like, I suffered from this, this, and this, and I want my kid not to what do we do? Right. It's like, unless they come to us with that. I'm like, okay, why are you here? What's the chief complaint? Let's circle back to that and focus on that, and then maybe down the road, we can, like, talk about how the work that we've done is also hopefully prevented these other things. Yeah, but you. Okay, you mentioned your interdisciplinary study club, which, when I was living there pre pandemic, I had started one, and then I feel like it kind of fell off because of the pandemic, and then I move. I love that there is still one in the area. So will you talk about that a little bit?

Yeah. So this actually started before COVID A different myofunctional therapist started it, but it was just like, five of us. And it was like, me, the physical therapist, the pediatric dentist, and then one ent and then a couple other speech therapists, and we would just, like, go out to dinner and talk about stuff, which was. Which was honestly great. It was really fun. And then Covid hit, and that ended. Then we started our own. Our new practice, and we were like, let's revive this. So we have it. We had it in our office, and we just, like, invited whomever. And then now, like, four years later, we have, like, 30 people on the invite list. And whenever anyone, like, expresses interest or wants to come, we just. Whoever wants to come, you're welcome to come. Yeah, just let us know you want to come. And we have it at our office, and we've actually, like, kind of outgrown our office's space. We were actually talking about, for the spring, having it at a restaurant because we just don't have the space anymore. But, you know, I kind of. Kind of just took aspects of other study clubs and other, like, lectures that I've been to, and we kind of took all those things that we liked and didn't like about them and put it into ours. So, like, I'm always like, oh, I wish we had more time to, like, talk to other people. And so we have always built in, like, a lot of time for, like, sitting around and networking first. And we have dinner for everyone. And then we always. Every time, like, everyone goes around and introduces themselves and says, where's they. Where they practice and what their area of interest is. Because I think that's great, because also then people bring their cards, and someone's dentist in D.C. is like, I've been looking for a therapist in D.C. and, you know, it's been really great for, like, inter referrals. Yeah. And then also we very rarely have a lecturer come in. We've had a lecturer come in once and we're going to do another one in the spring. But most of the time we just pick a topic and Heather and I will get literature. We'll get like, we'll try to get literature from different specialties, like an article, like a study from orthodontic and from pediatric and from ent. And then we circulate it ahead of time and we talk about it. We've done that a few times. We've done like, we've done. People watch that like open Wide documentary on Netflix and we talked about that. We have a lot. It's more like a discussion instead of just like a lecture. So it's been really great. It's been very fun. It's been really great in terms of getting to know other practitioners who think the same way in the area. So I would encourage anyone out there who wants to start one. I totally would if I were you. It's been great for everyone in it, I think.

Yeah, I love that. I love that at the time that I was doing it in person, I also was just like, it's hard because not everybody has access to the professionals in their immediate area or they know who they are yet. And so we're always encouraging therapists to go and find them in their area. But we started like, we started our online study club which is mostly for like speech therapists and OTS and like RDHs and some dentists that are doing myO specifically. So I always love hearing about more collaborative like study clubs out there because it's so important. And I will tell you like some of my most favorite times. We're sitting around a table with like a laptop open. We had like a case that actually I think, you know, because a lot of it was like, There may be 10 people around the table, but we were all sharing cases. And so we would like pass that, that case. Like the images, you know, CBCT images around and the, like, the, the addition of information from every specialty was so different, but still so eye opening sometimes. And we were like, this is what we need to do more of. Like, we really need to be collaborating so much on cases because we all have our own specialty and like lens through which we see things. And it's so helpful to have those conversations. And I know it's like challenging. We, we, we can't all just sit around a table and discuss every single patient case all the time. But I think when we do discuss certain cases, I Think it opens our eyes in ways that we then see something in another patient. Right. That it's like, oh, okay, this would be a really great referral for the pt. Or this is a great referral for, you know, it's kind. Helps you figure out who needs to even be on the team and then we can more easily collaborate and send the patient out. And like we were talking in the beginning of the episode, get them in and out as, you know, as fast as we can. Because no one wants to be in therapy and seeing a bazillion providers all the time for the rest of their life, right?

Yeah, yeah, yeah. No, it's. It's really been great and very eye opening. Like, as an orthodontist, like, we see studies and articles that come out in the orthodontic literature, but we don't know what ents are being told. One and two, a lot of orthodontists only like once a patient's done, when they're like 13 or 14, you never see them again. You know, at our practice, Heather sees the patient until they're like graduate college. So I do see cases long term, but not that long term. So it's very beneficial to talk to general dentists. And I love asking them, like, like, what do you.

What.

What do you see? Like, what are you seeing down the line in terms of like, periodontal health and teeth health? And what do you, what do you wish your patients would have gotten out of orthodontics when they were younger? And all of them are like, they need more expansion, like, expansion, boom. Because everything collapses over time regardless. So talking to general dentists who kind of see it way down the line is very beneficial. And also the ent, like, the ENT in our study club, I think we've really opened his eyes to a lot of things. But also from his perspective, there's one thing he said that just sticks in my mind all the time. He's like, if you have a kid who then turns into an adult with a very high vaulted palate, very narrow, that means that their entire sinus apparatus is also very narrow. So if they ever need to have a sinus surgery or anything, like, it's going to be very hard for the ENT to ever do what they need to do. And he's like, there's very little you can do about that. Once a child's finished developing or a person's finished developing, when everything's kind of squished together. And like, that's what you were talking about. If all the Tissues, the soft tissues of the sinus and the nose are all squinched into a small space. Any hint of inflammation, there goes the airway. And so like hearing that, like it just when, when I start to think twice about like, oh, does like every patient need expansion and blah, blah. No, I don't think every patient needs expansion. But I'm like, you're really doing them a service because what if something happens when they're an adult and they can't fix it? At least you're opening up the space and giving them the best anatomy they could possibly have, given their genetic predisposition for whatever. So, you know, I think that that really has helped me like, justify things when I hear a lot of like naysaying orthodontists who don't, you know, believe in doing much.

I mean, I feel like I've never seen anything negative come out of expansion. I feel like if anything, it's always been very positive just in terms of general health, like holistic health. And then, you know, you're talking about kind of like even sustaining that over lifetime. Like things are going to kind of collapse over the course of lifetime, just, I guess from natural growth. But I feel like we have this like epidemic right now of just like very narrow faces, right, Very narrow orofacial complexes. And you know, so that collapse that normally happens, it almost seems like it's happening on a more drastic level. And you know, I was that 20 something year old who was constantly on meds for sinus infections. And I kind of was just like, I've had expansion, I had braces, you know, as a kid. I ended up going into adult expansion, which, you know, they say that. I mean, I was in it for two years, so it was like slow and it was, it sometimes did not feel so good. I did not go into like a Murphy or anything, which I know, I think to kind of break the suture line is really like what a lot of people are talking about these days. But that kind of scared me at the time, to be honest with you. And it seemed very, very invasive. So I do have more room for my tongue now. But even after all of that, I was like, something is up with like my nose. And ended up having no surgery two years ago because the septum was almost like fully blocking the left side of my nose. And I was like, you couldn't really even see it that well because it was more posterior. The anterior portion of my septum was actually like relatively straight, like a little turn, but like nothing that warranted like surgery Per se. And because of that, I then had, like, very inflamed, like, turbinates. I also had inflamed nasal swell bodies, which I had never heard of before. So I was like, oh. So basically, there's things growing inward from the outside wall of my nose and things growing outward from the inside wall of my nose. So not only am I blocked on the left, I also am having a hard time. Like, it's very turbulent. Like, it's hard to breathe through my nose. And my entire body was inflamed as a result. And so I ended up having the surgery, and my body, like, just, like, dropped 10 pounds after that. It's like, all this inflammation just, like, cleared up when I could breathe again. And so that's why I think I've also become such a big proponent of, like, early intervention myself and, like, referring out when we can, because I'm like, I mean, honestly, the surgery wasn't the worst thing in the world, but it's really uncomfortable to have that surgery and not be able to breathe through your nose for a couple weeks. And no one wants to have to go through that if you don't have to.

Did you feel like you couldn't breathe well through your nose before? Like, when you'd be like. Or could you not really tell?

It's funny, because I couldn't really tell. And I think there's a lot of adults that I. We've worked with that they'll go to ENT and ENT will do the skin, and they'll say, like, you really can't breathe out of one side of your nose very well, can you? And they're like. Then, you know, they'll kind of like. I mean, I guess when I plug it and you ask me and I'm cognizant about it, like, okay, now I can kind of see a little bit of a difference. But it's so fascinating to me how many adults will say to me, I had no idea what I was missing out on until after, like, that invasive procedure. So it's, you know, I feel like, as adults, like, I feel like we should know, but at the same. And I'm high. I'm in this specialty. I'm in the specialty. Like, I feel like me more than anyone should know. Like, I would do, like, a mirror test and blow, and, like, the circle on the left will be smaller than the circle on the right. But I was like, I can't feel it that differently because I feel like my body was just compensating to the best that it could, who knows? Yeah, yeah. It was kind of wild with an ante after this.

Look at that checked out.

It was wild. It was wild. I mean, and I also feel like pregnancy for me made like I had like a bump that developed on my nose I didn't have before. So that was also kind of a sign for me that, like carrying that extra weight, the extra inflammation in my body when I was pregnant, you know, I know a lot of pregnant women tend to have like greater levels of sleep disordered breathing, even upwards of maybe obstructive sleep apnea. And so I think that was kind of eye opening for me too. And I was like, why do I have a bump here? Like, things must be like, something must be collapsing, like something is off. So I did have that like shaved down as well when I had the surgery. And I ended up just having a complete rhinoplasty because I was like, if you're going to put me under, we might as well just fix the whole thing. So just go for it. But, but no, I will say that I can now, like, I, I feel the difference and I can breathe a lot easier. And if I get a cold or something, it's not as debilitating in a sense as it was before. Yeah, yeah. And I don't, I don't get sinus infections anymore either. I haven't had sinus infections in years. Years. Yeah. So definitely some benefits there. But it was invasive. Yeah, it was invasive. Now you, I know, have also had articles in like, there's some involvement with Medium.com and Parent magazine articles. Will you share a little bit about that with us?

Yes. So when back at my old job in like 2018, 2019, when I was like full on into this, I had a patient whose mom is an author and journalist and she had recently come out with a best selling book about parenting and behavior and children's behavior. And so she gave me a copy and I read it and I noticed that there was only a very small part about sleep. And so once she was in with her daughter and I started talking to her about the importance of sleep and how it's tied to behavioral problems and ADHD and about the mouths and how they're shrinking. And I really gave her an earful and my assistants were all laughing. They were like, there goes Dr. Goodman talking about tongues again. But it really caught her interest. And a couple months later when she was back, she was like. So I decided to research an article about what we were talking about. So I was so excited and we kind of Kept in touch, I'd answer some questions for her. And then several months later, she told me that it had been picked up by medium.com and they were going to have like a. Turn it into like a feature article and promote it a lot. And so she came out with the article I sent you. The link to was very good article, very well written and very well researched. And I think it's had like over 20,000 views, like in the first few weeks that it was out. I think I shared it or someone shared it on the myofunctional Facebook group. This was like years ago, but it got a lot of positive feedback and of course I was like super excited about it. And then after that, she was asked to do a spin off article for Parents magazine. And so I actually had a quote in that article which was very exciting. And we, we have that article up like on a plaque in our waiting room and parents read it like all the time and they ask us about it all the time. That article in your waiting room with a. I think my kid has, blah.

Blah, blah, blah, blah.

You know, it's, it's, it's been great. And at that point, I was also very big on promoting people to like, stop using the pacifier. So I think that's a bit, that's a big part of that article on parents.com. i think she included that.

Yeah.

And you can't access that article anymore online. I looked before this, but I have a hard copy of it if you want me to.

Yeah, I'd love it. I'd love it. And we'll definitely link the one that's linkable. We might be able to link the one that's not the PDF, but we'll, we'll stay tuned on that. But no, I love, I, I love that. So thank you for sharing that because that's awesome that it's in the waiting room and parents are actually reading it and then they're asking you about it. Like, that's so cool.

Yeah, like every week they ask about it.

It's amazing. That is amazing.

So that whole thing was very fun. And, and she's, she's really a great author. She's moved on to other things now, but, but it was, it was a fun project.

Yeah. And now you've, I know you mentioned you've treated like your own kids too. So how is, how is that all going with whatever you want to share with us?

Yeah, so. So after I heard Joy Muller's lecture and my son was nine months old and I was like having A panic, because when he was born, the pediatrician in the hospital actually was like, he has a tongue tie, and he has a narrow palate. And my husband and I thought that was, like, of kind hilarious. We were like, oh, like, I guess he's gonna need an expander. But he was able to latch right away. First of all, I didn't know that they. That they, like, even diagnosed narrow palates in infants. But anyway, he lashed right away. And my daughter, who has no hint of a tongue tie, who's older, she was three and a half at the time, like, she had a terrible time latching, and I had to use that guard for two months, and finally she got it, but she had a really hard time. And I was like, well, my son is, like, one day old, and he can already latch, so he's fine. But I didn't. Because I didn't know. Yeah, I didn't know any of this. So, anyway, fast forward to when he's nine months old. Now's hanging open all the time. He can't breathe through his nose. He is, like. He has, like, all the things. So I took him immediately to an ENT because that's who our pediatrician referred us to for the tongue tie. Our current pediatrician and ENT was like, he's nine months. Like, he's passed the window for doing it as an infant. So you. And, like, you don't want to, like, put him under for this. So we didn't do it. Then it turned out he had an abdominal hernia, so he was gonna have to get it repaired when he was 2, so. And he did that at Children's Hospital. And so I went to the. To an ENT at Children's Hospital, and I convinced them to do the tongue tie release at the same time as he was getting his hernia repair. So the ENT that he saw there was great. She said that she felt like it would be too much to take out his tonsils, which are huge, to take out his tonsils at the same time. So she took out his adenoids and did his tongue tie release. And he had a very, very thick lip tie. So I was like, yeah, sure, just do that too. And he was 2. So we did that at 2. We did no exercises before, no exercises after. He's 2. Like, he's all over, you know, it just wasn't happening. But almost immediately, he had a really bad, like, lisp, I guess. You know, he, like, his speech improved somewhat immediately after the tongue tie release. Then when he was 4, still had a lot with the snoring, I shoved an expander in him. He's not a good patient. I had to like hold him down. I wouldn't, I don't do this to other patients. But. But he didn't have a crossbite or anything, so there's only so much we could explain. Stand on the top. But I definitely noticed his snoring got better. It resolved pretty much, but it came out when he was maybe like four and a half. And then again when you have like a cross bite or an underbite and you expand it and correct it, it holds pretty well because it's held by the occlusion. When you don't and you just expand, you need to do something to retain it. So I think he lost some of it. And he's now seven and a half and he's about to get his full face one with like upper and lower expansion. But anyway, fast forward about a year ago, he still can't say R. So he went into speech therapy. Well, first we tried myo and he just. We were terrible. Like, we just never do the exercises and he would just fail. So he now, he now for the past year has seen a speech therapist who they're kind of model is that they do three zoom zooms a week for 15 minutes each so that we don't have to do the exercises. It's like just built in. So she does kind of like a combination of my own speech. And his speech has gotten better, but he still just struggles with the, with the R, like just saying it properly. And so very recently she was like, hey, like he still just has this little bit under his tongue. And I looked, I'm like, yeah. I was like, we just need to have that re release. So we're going to do that on the horizon as well. But that's kind of the story with him is that he's headed towards some more expansion and a rerelease and continue with the speech therapy. Yeah, my daughter, when she. She doesn't have any of the speech or ties or anything, her teeth just came in like funky, like just. She just looked real. Her incisors are down here, her laterals are up here. She had a really gummy smile. This is when she was like seven. She got her teeth pretty early. So when she was 7, put her into upper and lower expanders. I can explain a little bit more about that, about my like phase one protocol in a minute if you want. But upper lower expansion and upper braces. And she had everything for about a year. Came off. She Went into an upper retainer. Now she's ten and a half, has lost almost all of her baby teeth. I'm not planning on doing braces on her again. She'll probably just need, like six months of aligners when she has all her teeth, like, things have retained pretty well. And I have on my dresser her before 3D printed model and her after. And I look at it all the time because her palette just. I mean, it's. It's incredible the difference you get in a seven year old. But if they don't have a crossbite, which majority of patients don't have cross bites. They just have constriction and crowding. Upper and lower. If you don't do anything on the bottom, you're not going to get very much out of the expander. You need to do something on the bottom as well.

Yeah.

So. And if you do and you're there in the year, and the change in the shape and the anatomy of the palette's incredible. Yeah, but they have to be young.

Yeah. Both my girls had upper and lower already, but I feel like we're headed to more upper and lower for both of them too. So I would love for you to explain your phase one. Cause I almost feel like what we did, even though they were young, was phase one, but it wasn't. And they put him in a myobrace afterwards to help guide continued growth. And I was kind of like, I don't know if I buy this, but we'll do it. To be completely Honest, my now 9 year old at the time, this was like a year, year and a half ago. She could not keep it in her mouth more than an hour. She would gag on it and spit it out. So I was like, that's a waste. We're clearly going to go into more expansion. But then my, what, she was 4, 5 at the time. She would actually keep it in all night. And so I was like, okay, we see. And then she leveled up to, like, the next level because she had a tiny little mouth and so leveled up to the next level. And so I was like, okay. And then I guess you're supposed to like kind of chomp down on it and chew on it. And that's like, supposed to be normal. Which. Okay, whatever popped a piece of it out, it became moldy. I was like, that's it. We're done. I'm not ever putting one of these back in your mouth again. Because that's just another whole health issue that we're going to create. So anyways, now There is somebody in Boca who actually is like, an orthodontist who's doing expansion work that I found recently. And I was like, okay, in the next phase, because we used to drive to North Miami, who. I love our dentist there. But it's just so hard. Like, they can't miss so much school, and, like, they miss a day of school every time we go. So I'm like, we need somebody who's, like, 10 minutes away from us. So we thankfully have somebody now. But. But, yeah, I would love for you to, like, share, like, what that phase one looks like.

Yeah. So the majority of patients who come in seven and a half. Eight. Eight and a half. Average patient is crowded maybe a little bit. Class two, like, lower jaw, kind of back, but very narrow. Upper teeth crowded, Lower teeth really crowded. So you always want the upper to fit kind of like a hat or like the lid of a box over the bottom. And so there's a limit to how much you can expand if you just put in an upper expander, because the top will start to sit outside the bottom, and then you've created a worse problem. So you need the bottom to kind of follow along the top. And there's. In orthodontic school, there's, like, a major article that you. And a big principle that you learn that you, like, cannot expand the intercanine width. Like, you can't expand where the canines are for stability reasons or periodontal. I'm not sure. It's been a long time since I was there. But suffice to say, this is when they still have their baby canines. And so when I talk about lower expander, lower expansion, we're not actually expanding the base of the mandible. You're just expanding the dental arch, like the housing of the teeth. And you're really just uprighting things. So the cause of the lower crowding is because the body always wants to have that relationship where the top fits over the bottom. So when. If the palate is narrow, when the bottom teeth start to erupt, they erupt kind of tilted in and, like, squinched in. And so that's like where. When the prominent incisors, which are large, start to come in, they have a smaller circumference of a circle to erupt into. So they come in crowded. So basically, what we're doing on the bottom is uprighting. There's three different ways you can do that that I do. That one is with braces. Like, braces on every tooth. And the wires, they get stiffer and stiffer. Every time you come in. And they are really great at creating like that nice big U shape. And in a younger kid. Yes. Where the tooth goes, the bone goes with it. So I put a brace on every tooth and looks great. That's 1, 2 is with aligners like Invisalign. If you want a big change with aligners you need to wear them all the time even in a kid. And not every kid is going to do that. So I'm very hesitant to get into like the full time removable appliance with any kid that's 7 or 8 years old. But if they just need. If the upper super narrow or they have a hint of a cross frostbite and they just need a little bit of expansion on the bottom. I will do 12 hour wear of aligners just to get a little bit of it depends on the case. So aligners are second third is that I'll use. It's like a. It's like a spring jet uprighting appliance. I call it a lower expander but it's like an operating appliance. This is great for when they're still in full primary dentition or the six year molars are in all the way and you can't. I'll do it off of the baby molars but basically it's. It's similar to like a lower. I forget the name of it but it's like a kind of like the lower hyrax with the key but there's no key. It's a spring, it's a night high coil. So the parent doesn't do anything. I compress it every six weeks and it very slowly goes to its shape, to its like original shape. And it will expand over. Over time the lower arch. And I can. If you want I can like. I know it's hard to explain and visualize it. I can send you a picture you want. So that's for the bottom on the top. I've tried everything. I've tried all sorts of expanders and whatnot. And I really settled on for the most part something called a. A HOS expander. It's a tooth and tissue borne expander. So there's an acrylic pad that sits up on the roof of the mouth. It has a high rack screw. But it's really great especially for the people who have a very high narrow arched palate. Because if you just have something on the six year molars and you're expanding back there, you get really wide in the sixer molars but you don't do much for the anterior palate and the interior of the mouth, which is a majority of crowding and constriction is at the front of the mouth. And so this appliance I found is really, really incredible at changing the shape of the palate because you have that acrylic pad, like, pushing on the anterior palate. So I can send you a picture of what this looks like, too. The only time I don't use a HAAS is if I'm also using a face mask appliance, which is a headgear that's used for underbites. For class three, because you attach it. I use a more traditional hyrax, like a single bar hyrax expander to attach the face mask to. But that's for the kids that have. Have underbite.

So.

So, yeah. Oh, one more thing. So I usually. And then if the front teeth come in kind of wacky, I will do braces as well with the HAAS expander. So typical phase one upper HAAS expander, upper braces, lower full braces or lower expansion appliance or lower aligners. I'll use Class 2 elastics to help with the. With the overbite. I like the phase one to not last any longer than a year. So they're in it for a year. You take it out, they go into. Usually they go into a removable, like, Holly retainer for nighttime wear. I don't have them take the retainer to school. On the bottom, I'll use a clear, like, Invisalign style retainer. I'll monitor the kids at their cleanings if they're a dental patient. If not, like, every five, six months while they're getting the rest of their teeth. And then most patients require a second phase later to kind of finish things up if they have a deep overbite. That's something that's ultimately corrected when they have all their permanent teeth. So I tell all patients to expect something later. But now with aligners, like, I'd say, more than half my teenage patients are in aligners. Aligners are great. They can be faster than braces. Like a lot of these. A lot of these phase one patients, I try to get the phase ones as far ahead in the orthotic process as possible. So their time in phase two is less complicated, less invasive, shorter. I rarely take out permanent teeth because we do so much expansion. I think a lot of crowding is just an expansion, a width issue. But there are some kids that are so crowded that they also have a length issue. It's more Rare. But in those cases, I can really tell the parents, like, I can see it a mile away if I think they're going to be a 4 by extraction case. And I tell them, like, you can either just have the extractions later and not do phase one, or we could develop their anatomy. There's still a good chance you're going to need extractions because they just don't have the arch length to fit all their teeth. Like you can. You can expand all day, but if they've lost length in the primary dentition for whatever reason, you might not have room for all the teeth. So anyway, that's my long ship.

Thank you. Thank you. So I have one question, because I've looked at the Haas before, and I know that I think it depends what lab is making it, because I've seen, like, different variations of what it looks like, but it almost looks similar to, like, a. The DNA Vivos appliance, but without, like, the front load springs on it. Is that accurate or is it completely different? And it's just like the images I'm seeing are confusing.

I'm not totally familiar with the. Is the Vivos, the removable appliance?

It's removable and it has the acrylic on the palette and it goes like. So this is. Yours is fixed, right? The Vivos is removable. Okay.

So you know what a high rack. Yes.

So my kids had the Hyrax.

Yeah, it's a Hyrax, but the spring is embedded in. In. In acrylic. And the acrylic go. You know what a nance is? It's like the acrylic button. Anyway, anyway, it's fixed. It's glued around the sixes. It's a hyrax. Same thing with the key, but instead of it just being metal, that screw, the one that sits up by the palette is encased in acrylic, and the acrylic goes up and rests against the palette.

Okay, thank you. Thank you for explaining that. Yeah, yeah.

You might even be thinking of a Holly is like a removable retainer. A Holly is like what you're talking about.

Okay.

What you're talking about is like a Holly with, like, springs on it. Like, a Holly is like the one that comes in and out with clasp. And there's acrylic on the couch.

Yeah, I mean, I guess. But the Holley doesn't have, like, the adjustable component down the center. Right. Because, like, the DNA Vivo sets removal has like, what the Hyrex has in terms of, like, turning the key in the center and the acrylic. But I think. I think a big difference is, like, sometimes they'll have springs, especially towards the front, not necessarily on the sides, but, like for the central incisors. And then it will have. But it is removable. It's removable.

Yes. I. I call that a removable expander. I don't use those, but I have at my old practice, and the kids just don't wear them. And they don't. Right.

I feel like there's such a compliance.

Issue that's like a Holly with an expansion screw.

Okay, cool. Thank you. Thank you for explaining that. Yeah. Because I'm like. I know I've seen pictures of them in the past, and I just was like, Googling too. I was like, let me pull up a few pictures while we're talking. And then I was like, okay, now I remember. And I think there was a big difference between the Holly doesn't have the. You're not turning a key anymore. Right. Doesn't have the metal down the center.

Right.

Okay, cool. Awesome. Thank you. Well, this has been amazing. Is there anything that we haven't touched on that you want to cover before we wrap up?

Well, I just want to throw out one thing about what I've been working on now with the aao, and that's that I do a lot with their sustainability committee, actually started it for them. And so I just. That's been my main extracurricular for the last year. So one of the things that we've been doing is we're hoping to flesh this out even more, but have a collaboration with a company called TerraCycle, which is a very well established private recycling company. They have operations in lots of different countries, but a very robust one here. And they're the only company that's recycling class two medical devices. So they recycle, for instance, used toothbrushes, used gloves, used dental aligners. So one thing that we've been working with them on is kind of offering their dental aligner recycling program to the public, and they just released it. So basically, I know for. For all the dentists and orthodontists out there, but also for people in your profession who go through a lot of gloves, you can order off the TerraCycle website, terracycle.com boxes that are like recycling receptacles that then you send back to them and they recycle for gloves. Even if they have saliva on them, as long as they don't have blood on them, you can recycle them. They have a box for use toothbrushes, and they have A box for any brand of dental aligner and aligner packaging. So you can order those off of that website. So that's just. I think it's. Our profession in the health field creates a lot of waste, a lot of plastic waste, and a lot of it's unavoidable because of OSHA and because of the tools we use. But I think it's super important for us to recognize that and be conscious of that and do little things. Like any little amount helps, like whether it's recycling or not getting out plastic bags in your practice or not mailing out a bunch of stuff, whatever it is, every little bit helps. So just wanted to put that psa.

No, I love that. And I. There's a bunch of I call a scrunchie, but, you know, semi crunchy moms who are also practitioners that both moms and practitioners who listen to this podcast that, you know, even in our day to day, we're wearing gloves. You know, a lot of times if we're working in the mouth or using tools or anything. And I know a lot of us have, like, tried to figure out ways that we can use tools that are, you know, able to be used across patients. But for many of us who are like, on the go during the day, you know, it's like you either have a big arsenal of tools, you know, or patients bring their own, but either way, there's still so much waste. And that's always been in the back of my mind, like, how can we eliminate a lot of that waste? And I think, like, in my practice, one of the things that we've done is we will use those tools that can be, you know, sterilized to the extent that that's possible. But gloves, like, I feel like the one thing that we have not been able to get away from because we used to, like, mail out kits or we would, you know, have a same.

Kit for every kid.

And then when I was like, enough, we're not doing anymore. Not everybody needs the same tools. Let's figure out what they need and then we'll get, you know, those tools. Let's try and buy tools that are not disposable, number one. But you know, again, sometimes there are things that are, that are not made in, you know, in things that can be reused. And just in the medical in our space, like you said, there are certain laws and certain regulations that really do hold us to a very high standard. But man, I've always thought about like, gloves, because sometimes we'll put on a pair of gloves and take them off and have to put on a new pair of gloves just in a single session and. Or you, oops, you pick something up and you're like, ah, I have to take that glove off and like re.

Glove.

So, yes, I, I love hearing about things like this. Like, I'm very excited. I had never heard of that before. But we will definitely. You link to it. I'll make sure people are aware of it. So thank you for sharing that and then tell us where can everybody find you? Harmony Bethesda.

So we are on Instagram. I think we're at Harmony Bethesda and I guess Facebook too. I gave Hallie my email address. So if anyone has any questions about any of the things that I talked about, I'm happy to help. So. And if anyone's in Maryland, I'm happy to see them. Yes, I'm in Bethesda, Maryland. Yeah.

Well, amazing. Well, thank you so much, Maddie, for joining me today. This has been so informational. I know our listeners are going to love this. And because again, like my practice is in that area and you all are in that area, I'm hoping this also just kind of kicks up some more, you know, people finding you through the podcast.

Great. And you too. And thank you so much for having me. I've been listening to your podcast, as you know, for four years, so it's a very big honor to be here.

Oh, well, thank you. Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halbalkin.com or pop over to Hollybulcin on Instagram to get all the latest updates.