Episode 107: Foundation First,Teeth Later: Early Intervention in Dentistry with Dr. Ben Miraglia DDS

To episode 107 of the Untethered podcast. Today we have Dr. Ben Moralia joining us. Dr. Moralia graduated from the SUNY at Buffalo School of Dental Medicine. He has 26 years of general practice experience in Mount Kisco, New York, including 17 years of interceptive orthodontic experience where his focus has been on early childhood growth and development. Dr. Moraglia lectures nationally on sleep disorder, breathing, clear aligner therapy, and craniofacial development. He holds faculty positions with Align Technology and is on the Board of Directors of the American Academy of Physiological Medicine and Dentistry. He's on the President's Council of Northern west chester Hospital in Mount Kisco, New York, and is a VP of Clinical affairs for Airway Health Solutions. Dr. Moraglia has been recognized multiple times as a leader in continuing education by Dentistry Today Magazine. 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 health care provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. Hi. I'm a certified orofacial myologist, feeding specialist, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Well, Ben, thank you so much for joining me today. I'm excited to chat about early intervention and all things you do along your path.

Oh, me too. Yeah. This is an honor. Thank you, Hallie for having me. Appreciate it.

Absolutely. So let's just jump right on in and tell us how did you get into this space? How did you start? Along the path especially? I'm really curious to know about how you got into early intervention in your space.

Yes. And so yeah, my brief background is that I'm a general dentist with 28 years of experience now and it took the first 10. So for my first 10 years in practice, I was doing reconstructive general dentistry implants, all this functional, fun dental things. But as the new doctor, way back when I was still seeing the children, we had a family care practice. So the kids were coming in and we were doing their profi and doing their brushing and counting their teeth and doing sealants. We were playing with them. It was fun. But for 10 years we didn't really do much of anything with the kids other than that. And occasionally we would send them as a referral to the orthodontist to go get braces or attention get seen. What I learned early on was that in those 10 years they don't really do anything very early. They would send back a child who was 7, 8, 9 and say it's a little early, let's wait for more permanent teeth or all the permanent teeth. We got into that pattern of nothing really happening early, but you could see there were things going on. The teeth aren't where they belong. It doesn't look right. Then 10 years in, I had a desire to pursue a little bit of education regarding non extraction therapy because at that point, 10 years of referring and watching and seeing results treatment, I had a distaste for extraction techniques. I didn't really enjoy seeing children or teens taking out permanent teeth. That was probably the direct lead into maybe I should get involved and get a little more education and figure out where we are. One thing leads to another and I start to learn about. Well, it turns out there's a whole expansive like field out there. There's such a thing as early intervention with expansive type orthodontic and orthopedic techniques. And as you start taking courses and you start learning in the expansive arena, you start learning that well there is a full non extraction technique available. It does mean starting earlier. And it turns out the foundation is really what you're focused on. So in the children that we see from three through 12 when they have a mixture of teeth, whether it's primary image, the idea there is, it's not really about the teeth at that age, it's about the foundation they have. But then you start learning more and you come across the anthropology research. When you come across the anthropology research, you start realizing that, oh boy, what a trend is going on in the industrial Western lifestyle where we have this early intervention happening with this soft diet. But what happens with the soft diet is that we end up with weaker and dysfunctional musculature and next thing you know we have a less amount of growth and development happening. So the dominoes and the puzzle pieces start getting put together. And then I learned that there is such a thing as an orofacial myofunctional therapist. So if you go back 18 years ago, when I started pursuing this line, my starting point was I didn't know that an orofacial myofunctional therapist even existed. I didn't know those words. I didn't know this was A thing. Now, if we leapfrog through 18 years, I go from not knowing it existed to oh, wow, look at the powerful collaboration I could have. If I'm doing either appliance therapy, fixed, removable, if you include frenem revision, if you include the myofunctional therapist and their efforts, all of a sudden it's a whole different outcome for the child. Then you leapfrog again to where I am today. And I understand that if, if I was faced with a decision and it was an absolute, you could only have the child see one person through all their early childhood. I would tell you the orofacial myofunctional therapist is the person who should be attending to the child if you could only have one. Now, I recognize it's a collaborative effort, not trying to exaggerate, but I am trying to make it clear that the value and the therapy and the direct treating of the cause is what the orofacial myofunctional community does. And so if you're going to have anyone involved with handling a child early to help them in their growth and development, it would be the orofacial myofunctional therapy community. Then I had the pleasure of meeting a local one in my area. I'm in the northeast, I'm in New York, and in my area I happened to meet Paula Fabi a long time ago and she's a wonderful orofacial myofunctional therapist. And I've had the opportunity to collaborate with cases on her. And so I know the value, the difference it makes, the tremendous opportunity a child has to grow and develop. So my story began with just wanting to learn about non extraction type techniques where we could grow more. That led to, okay, we're doing early intervention. How early? Well, three, it turns out you begin at three or four. You could begin starting with the children. And then that led all the way to where we are today, which is a full collaborative care opportunity to make sure the right people handle the child appropriately at the right ages to get all of the growth and development out of that child. And it works wonders on a whole host of symptoms that I know you know all about.

Absolutely. And this is music to my ears. I love this topic of early intervention partially because before I fell into the myo space, which really I was thrown into with my own first child, I was already a pediatric feeding specialist and I was working more with the toddlers and preschool age children and I, you know, I always felt like something. And also children with severe speech sound disorders and going something is missing, like why I can't put my finger on it. Something is missing. Then I have a tongue tied baby and she just, it threw me completely down that rabbit hole of all things tots and myo, which people who listen to the podcast know all about Lilly and her journey. But it's just, it's so fascinating because being the slp, being that feeding specialist who sees even these children under the age of three, you know, I call it feeding with a twist of myo because we can take the goals. And while it's not the same type of therapy that you might be doing with a four year old on up, where they're more actively engaged, there's passive things that, you know, feeding specialists and other providers in that space can be doing with these bab and toddlers where we really want. Well, they're still developing their rotary chew, they're still developing, you know, their jaws are crucial. It's a crucial time for development in the orofacial complex. And so if we can get in there and we can truly teach that tongue living, you know, to live on the top of the mouth, live on the roof of the mouth and breathe through the nose, teeth slightly apart, once they've got teeth, lips together, all the things, you know, it's, it's just invaluable, absolutely invaluable, because we're shaping their face, you know, and how much of we all, I mean, you and I know I'm reaching to the choir. We know full body health relies on what's going on in the mouth. And this is why I always joke that dentists are going to be our pediatricians of the future. Because when you have this better understanding of what's going on intraorally here and how highly interconnected it is to so many of our issues, our diagnoses that our pediatrics are getting, you kind of start to go, whoa, I need to listen, I need to pay attention. So, you know, that's why I absolutely love this conversation. And so I guess my first question for you is then, in terms of, you know, a lot of our listeners and people in my programs have asked, how young do you start that expansion of the maxilla, you know, expansion of the mandible. Do you start at 3? What does that look like for you?

Yeah, so it's really between three and four where I get involved. But in younger, whether it's a question about an infant or one or a two year old, one of the first things I do is refer right to the orofacial myofunctional Therapy community because now that I know who is around me and we have several referrals to make and then for basically the setup for my office is that I don't have a myofunctional therapist in my office. I am in a place in Westchester County, New York, where within about 45 minutes we probably have a dozen excellent right in my. So I have a wonderful referral source I can send to. If you're talking about infant up to three, I get them right to the orofacial myofunctional therapy community because they're really good at handling that age group. My office is equipped for 3 and above. And so we make the referral under 3, but when we get to 3 or 4, all of a sudden we have a little person who can hop in the chair. They can take a ride up and down, we can observe them for a little bit. We can start talking to parents about symptoms. We can see what's happening. We're probably going to make a referral to the myofunctional therapy community because the child needs a collaboration to help them. But at three to four, what I have really gotten used to using and work really well are removable. And I call them guides, but removable guidance appliances. There are different companies that make these appliances for children in that age range and they turn out to be soft and easy to wear. A lot of the children by three or four have had experience with pacifiers and they've already had something in their mouth for a while. It's really not that difficult to have a three or four year old pop something on their teeth. And if they can start to wear one of those, it helps to redirect the breathing and the musculature a little bit. So it supports what might be happening in the orofacial myofunctional therapist's office. And those appliances are removable. And I enjoy them from three all the way through seven in that three, four category. I usually do not use things that are fixed or kind of glued in. I don't like that right there. The bones in a young child like that are so soft. I like to refer to them like a wet sponge so that when you get the breathing and musculature going, that is really the way you want it to happen as naturally as possible. Of course, the bone is maturing as we're aging and there's a difference between maturing and growing. So you and I kind of know that. Well, if we're not using the muscles appropriately, muscle weakness and muscle dysfunction, we get A lack of bone growth, but the bone's still aging. The bone is maturing, but not growing. The idea is to do whatever we can, of course, with the diagnostics. The frenum is a really big deal because a lot of these children do have a lingual frenum issue, sometimes a labial frenum or buccal frenum issue. Any type of tots, like you mentioned, if you've got a restriction. We know from that nice literature that that restrictions in tongue mobility are a risk factor for growth and development of the whole craniofacial complex. And so basically, underdevelopment in the craniofacial complex is the risk factor for sleep disorder, breathing. And you have these little dominoes start falling over, but next thing you know, you have an unhealthy child on your hands. So three to four is a wonderful age for the frenum diagnostics. Of course, nasal hygiene is good for any age to work on your nasal hygiene. Removable soft appliances is usually our entry point into helping a child. And then as the child is aging more, I tend to rely on fixed appliances more towards that 8 to 12 range.

Well, I love that you're intervening earlier on, and it's so interesting to hear you speak too, because depending on who I talk to, people have different preferences, right? Some people will do fixed earlier on some people. But I think that the overall discussion and message is that we're intervening earlier and that we're doing something that works for that child's case to help with that growth of the palate, growing it forward and laterally, not just one dimensional. So I love that. I love this topic. What do you do, though, when you have a child who won't comply with a fixed oral appliance? I'm just thinking of maybe some of my sensory kiddos who are like, nope, you're not putting that in my mouth. Or we try, and the parents been trying for weeks to get them to comply, and they're like, it's just not happening. Do you have another solution for that?

Well, you know, the idea is that we have children in every category, and there are those extremes where on one end you could do almost anything, and they are like, ready and do it. And that's, wow, that's the best patient ever. And yikes. Could everybody be like that one? The lucky one, right? But then you have children who struggle, and there are children who struggle to do these. You know, we really don't do anything in a traumatic fashion in the office. Everything is done with the child. Sitting upright, high up in the chair. At our level, we talk through a lot of stuff. If I wanted to deliver a removable appliance, we would be talking about it, touching it, show. It's a touch. Show, play with. Our goal is to get the child to put it in themselves. There's a big difference between me, the big doctor with this thing coming at them. And of course you've got on a mask and a shield and a big coat and the whole thing and the goggles and that's all the extra these days.

Yeah.

And the child is four years old. So it's a four year old now. You look like Darth Vader coming at this kid. And so it's awful. I could see it, it's awful. But the idea is we're trying to make it playful and get to a point where the child would like to put it on themselves. Because if you're holding a mirror and if they're putting it in, it's an interesting dynamic that a child never takes that appliance and gags themselves. So it's very interesting when they go to nestle it in there, they kind of do it without gagging themselves. But when I try to do it, and I tried the hard way, believe me, when I would try to do it, if I tried to put that in there, all of a sudden wait, you're fighting the lips, the cheeks, the tongue because there's resistance, they don't know. So it's interesting how you're kind of self protective. So the little four year old who takes it and fools around with it will do a better job than me trying to jam it in there. So we basically try to make it a pleasant experience where the child puts it in themselves. That's our goal. There are three, three and a half year olds who can do it and that's terrific. But if it's not meant to be, we're not going to force it because we have other categories to work with. Of course we're going to take a look at the frenum where when you've got the significant frenum issue with the list of symptoms that's going to become maybe a little oral surgery procedure with even a little sedation if the child can't do it without being sedated. But with the myofunctional therapy, the nasal hygiene, the things that you can do, we would never have, let's say, a child where nothing could be done. It's about what can we do? And we're doing it without trauma and we're trying to make it as. And then when they're ready, we do it. So the idea is we try to see them every three months. And that child who, let's say, struggles in the first visit, we're going to play, we're going to break the ice, we're going to have a little fun. We're going to get as far as we can go without it being traumatic. So when we ask them, hey, would you come back and visit us? They say yes, they want to come back. It might be three or four months later when they come back. We've got a few other little things going on, we'll try again. And then the idea is you're just trying to have them deliver their own appliance. At the time they were ready to do it. Now you've got a happy kid and they're going to work through it. And sometimes they wear it for a few minutes at a time. Other times they can put it in for an hour. We'll take whatever we can get basically without trauma and we work with the kids. And that's that one extreme where there are children who, it's a little more difficult. But we don't give up, basically. We don't give up and we don't make it a trauma. We're just trying to help that child. They need the help. And so, you know, yeah, it breaks our heart to not treat a child. So we're trying to help them along the way as best we can without traumatizing them.

No, and that's great. I love that response because we're very play based and the work that we do and we find also when the child feels that they're in charge and when they know your sensory motor system, you take yourself out of fight or flight when you're in control. And so if they're able to put it in their mouth and you can avoid that negative experience of gagging from somebody else putting something into your mouth, you know, I can see how that would be a lot more successful. So hopefully that's a really good tip that some others can walk away from just from this episode. Because I think we say play based and I don't know that people always know what we mean by that. But we really mean being playful, making it fun, not making it super clinical because they're children and this play is how they learn. And so it sounds like you're doing exactly that, but also allowing the child to be in the driver's seat. Sort of like we're going to give you options, you can put it in an hour and five minutes. But you're going to do it.

We're going to get there.

I always say, I constantly train my husband. He's like, how do you get the kids to do what you want them to do? And I'm like, well, I gave them two options, and there are always options that I would be happy with them choosing. But they think they're in control because they're making the choice. So if we can just run with that, as long as that continues to work, I'm here for it.

Yeah, definitely. Definitely. There's an approach that can work. And part of it is meeting. Part of it is getting to know the child because they're all a little different. And not every child can do it on the first visit. And that's okay. It doesn't matter if it takes two, three or four. I don't care if it takes us six visits, because if it takes us six visits, we got started and now we're winning. The idea is to help that child grow and develop appropriately. And just because you can't get it done on the first visit doesn't mean you're done. It means, okay, a second, a third, a fourth. Let's keep working. We do the play based routine. I've never heard of the play based, but that's the right wording. Because in the end, what we're really trying to do is just establish a great relationship with that child because we know that in the future we want to do more things with that child. So we're trying to build a great relationship so that they, like you said, feel in total control but super comfortable. And if they're super comfortable coming in, they're happy. They come in happy, they do the things that we're trying to do with them, and next thing you know, they leave happy. They want to come back, they come back nicely. And each visit you get to do a little more. And the fantastic part about all of this is none of this involves the needles and the drilling like the typical dental stuff. So when the chair doesn't have to go back flat, that's a threatening position. When the chair's back and two people are hovering over you, here comes fight or flight. You can't even avoid it. Adults have that reaction. So if the chair's upright and you raise it all the way up and you're having a conversation and it's playful, next thing you know, you're basically trying to build a great relationship so that as the visits go by, you get to do more and More and more. And we have the categories of very lucky. The kids will let us do more early, but it doesn't mean we quit or give up. We're just going to keep working with that child until we kind of break through and get the things that we need to be done for them so they can grow and develop and be healthy versus unhealthy.

Absolutely. And I absolutely love that. And let's talk a little bit about the prevention of sleep disorder, breathing, or possibly maybe even treating that in some of these pediatrics that you're getting. Because if we know they already have, you know, their craniofacial structures are not developing as they should be, we can. We may highly suspect there might be some sleep disorder breathing or. Oh, yeah, airway issues going on. So are you finding that getting in there earlier is helping to treat this? I mean, I assume, yes, but I'd love to hear, you know, your perspective on that.

Yes, of course. And so, right. Over time, you learn more and more and more and you get more pieces of the puzzle. And eventually, when you feel like you've got most of the pieces of puzzle, it becomes a very clear picture that early soft tissue dysfunction is what's going to deliver the underdevelopment. Underdevelopment of the jaw structure comes with a compromise in the breathing because you have a number of things going on. But there is a bit of a linear progression of how the children deteriorate with the Western industrial lifestyle, that early soft diet. And then, of course, we always have that impact of bottle pacifier where it alters the action of the musculature. This combination of early soft food bottle pacifier leads us down that road where we're going to have this level of muscle weakness and dysfunction. It affects the growth and development. In general, we have underdevelopment. Now, the jaws, the upper and lower jaw, when they're fully grown, it produces the right amount of space for the air to flow beautifully from the nostril all the way in. These two jaws right here dictate how well you're going to breathe. So, of course, if you've got this early level of underdevelopment, you've got an early airway compromise. It doesn't necessarily have to be osa. You know, obstructive sleep apnea is a very specific diagnosis with a sleep test and you've made credentials. That's like the worst. You could be in the OSA category, but in a very simple pattern. You could just be mouth breathing. And so a little bit of mouth breathing is wildly unhealthy. And so a human being that's an obligate nasal breather. In order to have optimal human being health, you need to be nose breathing all the time. It's day and night. It's not really an option. And so I wish I could give credit for this statement I'm going to say because I know I did not invent this. Somebody else said this. I wish I knew the name to give credit, but they said you should breathe through your mouth as much as you eat through your nose. And it's a really good one.

I've heard that before. I love it.

Yeah, I don't know where that originated, but somebody deserves credit for that. That and one day they should stand up and say, it was me. I said it first because I did not. I heard it somewhere and I love it. These children that get on this track, all of a sudden, the category of sleep disorder breathing, that's a good way to describe it because if you're mouth breathing, or worse, mouth breathing, snoring, or whether you get all the way to osa, mouth breathing itself is wildly unhealthy. So it's probably the most unhealthy thing a child could do is breathe through their mouth at any point during their day or night. So while it's very unhealthy 24 hours a day, it tends to be. It's a little worse overnight because you're supposed to be having this nice sleep cycle where your brain is working to clean and reset you for the next day. And all of that goes well, you wake up ready for the day. But if that gets interrupted, we're going to have some trouble. And so we have that very nice research from Dr. Karen Bonnick. And Dr. Karen Bonick in 2012 published an article. She had looked at 11,000 children over six years. The idea was that the children in the sleep disorder breathing category did have a relationship with their behavior. The next day she went down the road of researching does the breathing and sleeping affect the behavior. Her research outlined pretty well that there is a connection poor breathing, sleeping to behavior the next day. If we know this child is going to have a poor airway because we've got the. We got the early muscle dysfunction and weakness. We've got the lack of growth and development. That underdevelopment does lead to an airway compromise because you really can only have that, let's say, 100% airway if you've got 100% of the facial growth. If you've got your maxilla and mandible where they belong. At the right ages, you're going to breathe great. But we don't have that in most kids because the early position in an industrial Western society is set for them. So here comes that start. So what it turns out to be is most. It's overwhelmingly most. And I know it's never appropriate for anyone to say it's 100%, it's 100%. But I got to tell you, I'm looking at kids for a long time, treating a lot of kids for a long time. It's probably 99 point something because I only get to meet one child in a few hundred that doesn't really need early attention because they've got the whole thing right where it belongs and everything's in place and there are no symptoms. When we think about these kids who have this pathway, the symptoms are there early. The symptoms that we're finding. If you had to think about the top list of symptoms, it's a very long list. But when you're thinking about behavior, that's at the top of the list. Behavior, bedwetting, nightmares, night sweats, clenching and grinding of the teeth. There's a handful of symptoms that are right at the top. Gastrointestinal issues, whether it's constipation or diarrhea or upset stomachs, headaches. The things that go into being healthy or unhealthy. A lot of it goes back to how well are you breathing and sleeping? Because it does affect every system in the body. And like you mentioned earlier, how the jaws grow really dictate how healthy a human being you're going to be. And it should almost be common sense, because the way a human being basically takes fuel to run and there's air because you have to breathe, and then there's nutrition. So we've got stuff to put in the nose and we've got stuff to put in the mouth. Well, how you fuel a human being really dictates how healthy you're going to be. And so the breathing needs to be through the nose without obstruction or resistance. So when these children come in with this list of symptoms, the idea is we basically work in reverse. So to be honest, I don't really treat sleep disorder breathing. I don't really treat osa. I treat the underdevelopment because I'm just a dentist. So since I'm just a dentist, I have to work with what I can diagnose. I don't diagnose a breathing or sleeping disorder. I don't diagnose osa, but I can Diagnose. And every dentist can diagnose underdeveloped jaws. So I treat what we call malocclusion. Malocclusion is that underdeveloped jaw structure. It's basically a bad bite, an underdeveloped bite. So if a child has an underdeveloped set of jaws, you're treating that, and then, like the dominoes fell over. You're basically working your way back. So if we could treat that underdeveloped malocclusion, then you're looking at doing it through the cause. Meaning what can we do to redirect the breathing and musculature? Because if you can get the nose breathing back and you can get the muscle function and strength appropriately balanced, guess what happens? The human being starts growing appropriately again. So the appliances we use aren't really the miracle. What? The appliances, they're just supportive of getting your breathing and your musculature back. None of them is like a light switch where put this in your mouth and you're going to be perfect. It's a combination of a lot of things. But again, that the orofacial myofunctional therapy is, like, at the top of the list. Because when you start to treat the underdevelopment and you're doing it through the breathing and the musculature, you get to see the jaw growth. But what you really get to see is the symptoms disappear. So the behavior changes, it improves. The bedwetting stops, the nightmares stop. Kids start dreaming. They talk about dreams. Then, of course, you can work your way down. The headaches will disappear, the gastrointestinal issues start to disappear. Basically, you start to heal the child. And it's through treating the cause. Because if I just put stuff in the mouth and pushed it where it belongs, there's a really good chance it's going to go back, because I haven't really treated the cause. We might get to that topic a little later. But the idea is you read.

I was like, well, this is those orthodontic relapse cases, because when you're just treating the structures, but you're not treating the remaining underlying cause of the issue. Getting down root breathing. Where's our tongue? Resting. How are we swallowing? What's going on? Full picture. I think we need every piece of this puzzle in place or you're going to have orthodontic relapse like I did and like many of my patients do.

Yeah, me too.

Me too.

Same thing. And it turns out to be the combination of a focus on treating the teeth versus the foundation, that's a big difference. Just to treat the teeth alone, offer straight teeth, but it doesn't really improve symptoms. Now, it's nice to have a good smile. Everybody wants to feel good and confident and positive about having a nice smile because we share it. We look at people, we're smiling. We're social human beings. But the idea is if you just line up the teeth and you don't really treat the cause of the trouble, you still have your muscle imbalance. Then there is that relapse issue, meaning braces from 12 to 15 make teeth straight, but they don't really affect the foundation and they don't treat the cause. Anyone can force teeth into a lineup that looks nice, but if we don't have permanent retention, locking it in place, you know what happens? Relapse to a majority, overwhelming majority. And I know there was some research a while ago where they showed if you take away the retainers, the relapse rate is above 90%. So a lot of relapse. And it does stand to reason, because if you think about. Look at today with adults, what's available for adults for their teeth? Clear aligners. Well, the clear aligner industry is endless because everybody who had braces has crooked teeth again. And so it seems like it matches. Yeah. Who could have clear aligners? Well, pretty much every adult. If you ask an adult, did you have braces? Yeah. Did you have clear aligners? I either did or I'm going to get them because that's what's out there. So, yeah, the braces I find very effective at lining up teeth, but they don't really treat a cause of anything. And if you're not going to balance the musculature and the breathing, you're going to get relapse at a very high rate. And what we end up with is we still have an unhealthy child. And so I don't see that as option number one anymore. It's like the last thing. So when you have a focus on foundation first based on breathing and musculature, that's a winning combination because here you're going to help that child grow naturally where they should be, and maintain it, because the child who does grow naturally and gets to where they're supposed to be, they don't even need retainers because the musculature imbalance is your body's natural retainer. So that's the ultimate goal, is you treat the foundation through the cause and you're winning. If you're just going to try to force the Teeth straight. Everybody's getting clear aligners when they're 30, you know.

Absolutely. And I'm curious to know too. Do you see issues with TMD in some of your younger patients? Are you seeing, like, how early do you see that? Or is it more your teens, adults.

It's less common in the younger kids. So there, there are statistics that show what is like a TMJ or TMD rate in adults and children. And the child rate is much lower. And I forget, I forget the actual numbers, but in children it's much less. But again, it is the same philosophy. In other words, when I think about the patient who comes in and has TMD symptoms, well, I automatically think underdevelopment because you've got this relationship of these jaws. Well, the upper jaw is connected to everything. It's attached, but the lower one can wobble around and move all over. So right now my lower jaw is moving because I'm yapping at you. But the idea is my lower jaw gets to move around. But here's an interesting thing to consider. The lower jaw can only land where the upper jaw allows it to. So when you close your mouth and your teeth are connected, my lower jaw only has permission to go where the upper says it can go. It can't go somewhere different. It can just land where the upper allows it to. Well, what that does is it sets up a bit of a philosophy that I have where, okay, well, if the lower is put in a position, it doesn't really belong. Well, that's going to throw off the rest of the mechanism because the lower jaw is one piece. And then you have these condyles. Fancy word, but there's a little disc in there and then there's a whole eminence. This is all connected. How can any of the musculature or the disc or the condyle or this connection be correct? If the teeth are landing inappropriately, so then you think about common sense. If the upper jaw grows fully exactly where it should be, well, then the lower is landing appropriately. But if the upper jaw is underdeveloped, no matter where the lower jaw connects to the upper jaw, it's not in the right place. Because your upper jaw, fully grown, produces a different. You have two different places. Well, that's my pathway to seeing my TMD patients. Is that, okay, you've got trouble here, or head, neck, whatever their symptom might be. It could be all of it. Right? Your upper jaw is the criminal. Your lower jaw is the victim. So I don't treat the lower. I treat the upper. So if we can grow the upper back where it belongs. And of course, with the adults, it's still related to the breathing and the musculature, because adults benefit from the OMT or facial myofunction just as much as the kids do. So when you combine my techniques plus the myofunctional therapist techniques, all of a sudden you get all of this balance coming with jaw growth. If the upper grows better, more appropriately, the lower gets to land more appropriately, and it kind of resets the muscles and the condyle and the disc and all the parts of the tmd. We do the same thing through childhood or adult. No matter who we see, when we see TMD symptoms, it's upper jaw growth is the key. And so where does that land for me? Well, I've been doing that for eight years, so for the last eight years, I've been treating TMD with upper jaw growth, foundation first, teeth second. Because usually when you grow the foundation, whether you're a child or an adult, you got to coordinate the teeth second. So foundation first, teeth second. Always with the nasal breathing, the myofunctional therapy, that solves the TMD issues. So I no longer make night guards and splints. The idea is, if we take our TMD population, whether they're young or old, and grow the maxilla, the lower jaw gets to come and be where it belongs. The TMD symptoms go away because basically you're providing a system back in balance. So it's rare, but we do see kids with jaw pain or trouble or headaches and things like that. And when we treat them with growth and development, those symptoms go away.

Fantastic. Yeah. And it's really an interesting topic too, because, you know, we know that everything is so interconnected. But I, as a feeding therapist, even before I was in this space, I would look at some of my kids, and there was such great asymmetry that you could just see when you looked straight on at their face. You could see the overdeveloped masseter on one side of their face.

Yes.

I mean, I know the child clearly only chews over there, but I really wonder why. Like, what is going on that's forcing that? And as I got into the myo world and really fell down that rabbit hole, you know, back in 2017 or so, I was like, oh, well, it all makes sense now, because if their teeth, if they can't occlude and they can't actually break the food down on their back molars, well, it would make sense why they're Only able to chew on that side. And I will tell you, these kids are amazing. And adults, too, but definitely the kids. You know, I've seen kids with almost complete malocclusion where they barely make any contact on maybe four total teeth in their mouth. And they still have figured out how to break that food down, but their oral musculature has paid a price, and it is not.

Oh, yeah.

I mean, these poor kids. And so, you know, I just. I love this conversation. It makes. It makes so much sense that our maxilla is really. It's fixed. And that's really what's driving. You know, I say fixed meaning it's. It's the fixed part of the jaw. If we're looking between the two, I know we can make changes to it, but it's just really fascinating to think. Yeah, that's. The mandible has to just reach up. Lower jaw reaches up to meet the top jaw, and that can throw everything out of alignment. And that's. That's what happened for me. You know, I was that kid who went into palatal expansion into braces. Then they put me into a permanent retainer, which then came out. When I did, I think I had clear aligners, went back into permanent fixed retainers. They said they would fall out by the time I was 20. At the age of 30, I said, hey, can you take these out? This is really hard to clean my lower back and lower. You know, incisors are just a nightmare to clean. And they finally took it out and my teeth started shifting. And I said, I remember saying to my dentist at the time, who has since retired, but I said, I'm like. And he was a family friend. And I was like, my teeth are moving. And he was like, you're crazy. I was like, no, look, my teeth are turning. I am not crazy. I like, look what's happening to my lower incisors. And he was like, they're fine, you're fine. And I was like, okay, whatever. And then now obviously fell into this space and have since gone through a DNA vivos appliance myself and did that for a couple of years, did my own myo and now am in invisalign to help just kind of close up some of those spaces. But for me, that clear aligner was really more so just a cosmetic thing. After we attained, were able to obtain the open airway. And I've also had my cbcts to demonstrate how we throw my airway, which was absolutely incredible to see the before.

Yeah, it's nice to have that change Happen where you can see, oh boy, here I was before, here I am after. And then a little bit of alignment with the clear aligners to kind of coordinate connection of the teeth. But foundation first, teeth second, that's a winning thing at any age. And yeah, the relapse like you experienced, I experienced the teeth were starting to overlap or get crowded again and it goes right back to what was the muscle doing? Well, if the tongue is weak and dysfunctional, the outside compensates. So like you were mentioning, one side will usually be more active than the other because the bite is so terrible. So you get this asymmetry going on, but you do have hyperactivity. Outside usually just tipped one way or the other. So if the inside is weak and the outside is compensating, you're going to collapse. Of course, when you try to force it all straight and you take away retainers, we collapse again. It's amazing how the relapse is usually in the collapse department because we haven't attended to the muscles and the inside's weak, the outside strong in general. But yeah, you have. The compensation is significant because a human being is built to survive. And so once something is off a little bit, the body compensates right away. It involves everything. As soon as you do a little bit of mouth breathing, next thing you know, your posture changes, then the musculature changes, then the musculature changes in two directions. Some get weaker, some get stronger, some become active when they're supposed to be inactive. Some become inactive when they're supposed to be active. And this whole compensation that occurs just kind of keeps the child getting through each day and night. And if nobody resets that, you go from being an unhealthy child with a list of symptoms to being an unhealthy adult with a bigger list of symptoms. And now your medical crisis grows as you're aging, you're basically with underdeveloped jaws and no appropriate treatment. You're basically deteriorating ahead of schedule. That's all you're doing. You're not aging because there's a big difference. Human beings are really supposed to age in a healthy fashion. We're built to be healthy. We should be aging healthy. Meanwhile, because of this underdeveloped jaw and the breathing, sleeping combination, all of this is a premature deterioration. We're basically aging a whole lot faster than we should. But really not even the aging is the right word. It's a deterioration that's occurring. Then we get to fall into the statistics. Oh, the average 50 year old takes three medications and the average 60 year old takes five medications and the average 65 year old has had two surgeries or three surgeries or oh my goodness, those are staggering numbers. How basically unhealthy we become. And you can trace it all back. A lot of this stuff is a chronic and slow process that begins with, in the early stages, we were not growing well.

Yeah.

And getting it all back in line is a huge benefit to any human being.

Yeah. And I mean, it's, you know, obviously I'm not an airway, I'm not an ENT or an airway specialist in that regard, but I do understand airway, I think, in a very different way than maybe some of my SLPs who are not in this space. And so one of the things that I have really focused on and preached on is, you know, how often do you go to the doctor and they say to you, well, you're stressed. You know, if you could just, if you could just eliminate some stress out of your life, I think you would do, you know, these migraines might go away or you maybe wouldn't have so much tension in your neck or, you know, basically listing out all the symptoms that we know could be connected to an omd, tetheral tissues malocclusion, mouth breathing, you know, sleep disorder, breathing, all of the above. And, you know, I have to laugh at that to an extent because I go, well, stress is not the cause. The stress to the body is from an underlying root cause that nobody is taking the time to identify. And that for me has been the biggest thing that I've gotten out of this space. Being in the myofunctional therapy space. Working with professionals like yourself and collaborating and really having these discussions has just shed so much light on how much healthier we could be if we were all truly in a. If we didn't exist in malocclusion, if we didn't have. If we didn't, you know, if we were able to truly exist with tongue on the palate, you know, tongue up, lips together, teeth apart, breathe through your nose, and our jaws were where they were supposed to be, how much healthier would we be as a nation? And I even look outside of the US because arguably there's other countries who've got it together much more than we do. And that's because of our food supply here. And that's, you know, we've mentioned this a couple times. You brought this up today. So, yeah, it's one of those interesting topics and one that I also talk a lot to early moms, early on in their child's life. And with my daughter, we saw very early on that she was tied. And everyone said, well, she's fine. She was never over the first percentile, but she was on her own growth curve. She was that infant. Horrible, painful breastfeeding, feeding her around the clock. Had to make sure no matter where we went, there was a nursery, nursing room, I could sit down and feed her. And as soon as we got there, because she never could pull enough in a feeding session. And these are the kinds of things that we need to go back and look at. How did they feed infant? You know, and I know that we've got some parents who are, you know, it was cloudy. Those days are cloudy. So we remember as much as we can and we try to even educate now from that standpoint of, hey, if you're having a child, if you're having a baby, if you're in the first year of life, these are the things we need to be looking for. An interesting thing that my daughter did too, that comes up quite a bit that I've got no research to support, but it makes complete sense in my brain. Is she tripod slept, Right? She slept with her elbows down below her, her tush up in the air, and her head was, you know, to one side. And in my opinion, she was trying to keep her airway open. And, you know, I look at this and I look at SIDS and how concerned we are about having these babies with sudden, you know, unexpected death and their sleep. Well, how many of them have airway issues? Why are we not looking at that? Why do we require a pacifier for six months to decrease sids? What does that tell us? Why is nobody doing research on that? And so, you know, when you saying this is like early intervention, this goes back early on, it's there at birth, it is present when these babies pop out. I know that goes beyond the phase one and phase two orthodontics. A little bit younger there, but, you know, it's sort of my big psa. Like, look at your child. What is their mouth doing? That's. That's step number one. What is their mouth doing? Is their head or neck an extension when they're sleeping? Yeah, so many of these kids are.

Yeah. And, you know, there is a little bit of research out there on sids.

And, yes, the tripod sleeping. That's the piece where I. Yeah, when.

You start to dig a little bit, you do find. And there were countries that had looked at some sort of volume. And the one study I remember was they had looked at over 2,100 SIDS deaths. And one of the common differences that they found to be significant was that in those 2,100 SIDS deaths, 90% of them had histories with bottles and pacifiers, but only 10% of the SIDS were in the exclusive breastfeeding category with no bottle or pacifier. So 90 to 10 is a very big difference.

Yeah.

And so if you have. Yeah, that's an interesting. That. That should lead to more research is what that should.

There's definitely some out there on upper airway and sids, but it's. It's one of those kind of like. Well, we don't have enough research to support this, and we're just going to keep recommending sounds like these.

Sounds like we need more, right? Yeah. The bottle pacifier changes the muscle activity, and so it produces more extra oral activity. It gets between the tongue and the palate, which is really a no no today, knowing what we know now. And so if you're going to depress the tongue with a bottle or pacifier and then work the outside muscles inside weakness, take the tongue away from the palate and make the outside stronger at an age where the bone is so soft, that becomes an orthopedic process of shrinkage. Now we're going the other way. So there's definitely a relationship. The part about the piece that they talk about. Pacifiers are not. The problem is because the infant doesn't pass away with the pacifier in their mouth.

Right.

Because technically, when you put it in, it'll open the lower jaw a little bit. But that doesn't make it protective because the muscle activity that's going on during the time it's being used in the early infancy is actually helping the bone to shrink versus grow, because we're setting up a pattern of inside weakness and push the tongue away from the palate and outside hyperactivity. Think about the amount of time an infant uses a pacifier. That's a lot of physical therapy, but in the wrong direction. So we have this kind of shrinkage happening. And yeah, there's a need for more looking into that because the pacifier is not a helpful device. I have a pretty strong opinion on that. I don't believe those are helping.

I do, too. I will tell the moms. They'll say, look, I'm never going to shame you for whatever choice you make for your child and your baby.

Oh, yeah. And just to. I want to make it clear, too, My three children had them. So, yeah, I don't want to be Here pretending I did anything right, because that's absolutely the case. No way. So not only did my three children had the mush blended diet, we stuffed everything in that magic bullet. We used that thing till it burned on fire. And then we gave them pacifiers. And if one pacifier didn't do it, I was jamming two at a time in there because I figured if one's good, two is better. So, yeah, I did everything wrong early. And now my 20, my 19, and my 14, we started them at 5. At the time, you go back 15 years. We started working on them early with the guides and stuff. And then one thing leads to another. So, yeah, I had the same pattern of the symptoms. Were there the underdevelopment, was there digital wrong, blah, blah, blah. Then learning from it, figuring out, yeah, there's a better way. And then there's this whole idea of orofacial myofunctional therapy out there. My goodness, who would have known?

Yeah, it was interesting. With my first, she was so tongue tied, she could barely keep a pacifier in her mouth. And, you know, of course, here I am and I tell everybody I use those wubba nubs with little animal hanging off the pacifier, which is the worst thing that you could do once the child is mobile and they're not just laying flat on their back. And, you know, thankfully she didn't really take it. I tried to push it on her again at four months, thinking, like, maybe now she'll take it. She wouldn't take it before, and maybe she used it for like a week. And then she just was disinterested because it was too much work to keep it in. So blessing in disguise. With my second one, she used it a little bit, but didn't seem to take to it much. And so again, I just got lucky. I got lucky with my kids. And that's why I always say I will never pass judgment on any mother who needs this for their humanity or needs it for sleep. But I think it's definitely something that needs to be discussed. And I've had some very strong statements and opinions on my social media. One of my colleagues had said using a mam pacifier like the flat orthodontic as a qualified orthotic pacifier is the same thing as trying to dance with your shoes tied or something like that. Or dance with your. What she say? Dance with your foot stapled to the floor or something. It basically was like, you just can't. You can't. You know, you're stuck. And that's exactly what it does to the tongue. And I thought, that's such a great example of what we're doing when we force these pacifiers in. And the whole concept of these orthodontic pacifiers drives me up a wall. It's all marketing, but, yeah, that's marketing. Class action lawsuits against, you know, one of the companies. But anyways, you know, we know, when we know better, we do better. And there's definitely a lot of other opportunities, I think, for these discussions to lead to education, which is really the avenue that, you know, we're trying to take. But, you know, I just. It goes back to that whole conversation of, what did your child look like as an infant? What was their sleep like? What was their feeding like? You know, could they nurse? Did you have to give a bottle despite the fact that you really wanted a nurse to. That killed you to have to, you know, either formula feed or pump and feed through in a bottle. Because that also is just not discussed enough. But when I. We ask our patients, even our adults will say, do you know anything about your feeding history as a infant or toddler or young child? It's always so fascinating to hear the stories that some of them share when they. When they can recall it or when they have a parent, they can ask and, you know, the parent can shed some light on that. So they're at birth.

Absolutely. Yeah. And, you know, similar experience. My wife had to go back to work, and so while she would have liked to have breastfed longer, it was, I have to go back to my job. So it was the pumping, the bottles, the formula, the pacifiers. You know, I did my part as best I could. You know, we did. We did the routine that, you know, kind of society lays out for you, and then kind of catching the symptoms later on, you start to get involved with trying to make the corrections. And so, yeah, there's definitely those two pathways of we don't pass judgment because I live the same thing. No one's here to judge anyone. We're trying to recognize unhealthy children and figure out how do we help them to become a healthy child, to become a healthy adult. And then on a small level, it's about education, like you mentioned, where maybe there is a pathway to educate. And then people have choices because a lot of people don't know there are choices. And then learning gives opportunity to make different choices along the way, and then that can make us another difference. And anywhere you're learning is helpful.

Absolutely. So do you work also with a lot of adults, or are you mostly Pediatric?

Yeah. It's a pretty good mix. So kids and adults, any age three, all the way through, and we basically live in the breathing, musculature, growth and development categories. And then depending upon that age group, what are we choosing to support our techniques to get that patient to grow and do better with their breathing and sleeping?

That's fantastic. So if there are other dentists who are listening, who are like, hey, I really want to get in this space, do you have any advice for them or where they could start to enter into this world?

Yeah, certainly there are a lot of pathways for education. When I started 18 years ago, it was like a piece at a time. I didn't have this full program to go and take, and it was all there in one spot. So I took this course and that course and this. And then when I started figuring things out, I learned. Well, that's helpful. Let me put that here. No, that's helpful. Oh, that's not helpful. I'm going to avoid that. So then you put it all together, and then you treat people for a decade, and then you start putting it together. And basically, I have a partner in crime, and Lauren Gates and I have an educational platform, Airway Health Solutions, and that's a place where you could learn about the opportunities for collaborative care to treat a child or an adult. And so we have a pediatric course, we have an adult course, and that would be a great place for a general dentist to start. And we offer the training for not just the dentist, but the team. And it's a why and how. Why are we here? Here's what's going on. And then if you have a philosophy that understands. So, wow, this is a really big why, then you want to know how to be involved, to fix it. And then the next thing is teaching doctors how you help these kids. What are the techniques that are involved for children, teens, and adults? Airway Health Solutions is a wonderful first step. What I've done is I've taken the last 15 years of my puzzle and boiled it down to here's what's been most effective for me. In the end, the overall theme is about collaborative care. And it's everything from the nose breathing through the musculature, through the frenum, through the diagnostics, through the different things that are available, you put it all together, and you can make a really big difference in a child, a teen, or an adult's life.

That's fantastic. Awesome. So we will make sure that we link airwayhealthsolutions.com in, because I know Sometimes we've got people driving. Don't drive off the road. We'll put in. It'll be in the show notes, but airwayhealthsolutions.com and we'll make sure that that's in the show notes so they know where to find you. Is there any last pieces that we didn't touch on that you want to share with us today?

Just the philosophy. The shift in what I was doing my first 10 years was tooth focused and I fixed a lot of teeth and that made for some happy patients. Because if you come in and you got bad teeth and blah, blah, blah, there was a certain level of satisfaction fixing teeth right then. That was where my transition all of a sudden towards, wait a minute, I might be able to have a bigger impact than just fixing the teeth. How about fixing the human? How about transitioning unhealthy to healthy person? That's really what the biggest transition has been for myself, my team, my practice. Then once we realized that, okay, bigger things are happening here when we address the foundation first, teeth second. And then at a younger age, there's a whole different level of satisfaction in helping an unhealthy child become a healthy child. That I can only treat so many people in my physical office location. And then, of course, joining forces with Lauren to be able to build an education that we can teach other people to have an effect in their community. I can make a tiny difference, but if I could teach 10 doctors, that's all of a sudden, here comes the compounded effect of other communities anywhere in the country. And to date, we're pretty proud. I think we've trained well over 100 different offices to be doing things like this, to get involved with. Let's work on the foundation and let's do it with all the collaboration we need. Most importantly, the orofacial myofunctional therapy community. And next thing you know, yeah. You get to experience what it means to help an unhealthy child become a healthy child.

That's fantastic. And I love the whole the philosophy of where you started, you know, what you've evolved into and now how you're really looking. I call it the one to one versus the one to many. Right. And so I've done the same thing where, like I told you before, working with these pediatric feeding cases and these speech sound disorders and really starting to realize, hey, there's a root cause behind all of this that nobody really taught me in grad school. It's all been post grad. And, you know, so I always tell Everyone, don't be me, don't go down, don't go through 10 years of lots of thousands of dollars of you know, expensive CEUs. Like we're kind of pulling it to together for you over here. And so we do that for pediatric feeding actually where I've created that course and for me it was the same thing. If I can help get this information out to other therapists who can go out and assess and treat from this modality and really look at that holistic child and not just the silo of what they think is going on, but really how this impacting them full body. I'm like we can impact so many more children and we can really put them on the right path. And and so I love the work that you're doing. I'm really excited whenever I learn about businesses like yours. And so thank you for the work that you're doing. Like I said, we'll include that in the show notes and make sure everybody knows where to find you.

Thank you very much. Thank you. It was great talking to you today. This was excellent. I appreciate the time.

You too. Thanks for listening to this podcast. If you want to hear more of these Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @hallebulcanbiz, on Instagram Alibulcan and you can head over to theuntetheredpodcast.com to grab a copy of the show notes where you can also also subscribe to be kept up to date on the latest podcast episodes.