Episode 128: Treating TMJ Conditions Holistically with The TMJ Doctor

Hi and welcome to episode 128 of the Untethered podcast. Today we have Dr. Priya Mistry joining us. She graduated with honors from University of the Pacific Arthur A. Dugoni School of Dentistry in 2007 and has been helping her patients smile with confidence since then. During this time, she's enjoyed working with a large variety of people, different ages, cultures and various social backgrounds. Through it all, Dr. Mistry has maintained her goal in dentistry to provide excellent dental care in a compassionate and comfortable setting. Her motivation to pursue a career in dentistry started after she had an accident as a child, leaving her front two teeth broken in half, an incident which can be quite upsetting for a nine year old child. Getting those teeth fixed painlessly and efficiently by her family dentist is what set Dr. Mistry on the path to becoming a dentist. Her dedication to patient care is apparent from the initial exam and throughout the course of treatment. Dr. Mistry's patients have said time and time again that they appreciate that she takes the time to explain each procedure and and ensure that our patient is comfortable every step of the way. More recently, Dr. Mistry has been focused on taking care of patients with tmj, TMD and head and neck pain. After seeing how debilitating it can be for people to live in chronic pain, Dr. Mistry has been attending various continuing education courses and seminars in order to provide more comprehensive care for her patients. Dr. Mistry has recently started a YouTube channel to increase some awareness among patients and providers as to what TMJ conditions are and how to treat them and how they relate to other parts of the body. She she enjoys spending time with her husband and her two lovely children and she also likes to cook, read, hike and exercise. 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 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 Priya, thank you so much for joining me today.

Thank you for having me.

So I would love for you to share with our listeners, just a little bit about how you made your shift from general dentistry into becoming the TMJ doctor.

Yeah, so I was doing general dentistry for quite a while, probably like 11, 12 years before I met my mentor, Dr. Arthur Parker. And he's amazing. And so I kind of met him on a whim. I walked into his wife's jewelry store, and her and I are both. Luckily, we're both chatty, and she ended up telling me what he's doing. And so I got his contact information. I started shadowing him in 2018, and the rest is sort of history. We just hit it off so well. I've learned so much. My first couple days of just shadowing and observing him, I was just blown away by the patients that were coming in and saying, are you taking over? We're so afraid he's going to retire. He saved me. He saved me from a life full of pain. He did this, he did that. And I thought, what's he doing that I totally didn't learn in dental school or beyond? So I started learning more and more and more and more, and he kind of took me on as his apprentice. So that was 2018. Fast forward to the beginning of 2021, and I've actually purchased the practice. We're still working together. I love working with him. I've just learned so much, and so that's kind of where I am today. I had always had interest in learning more about tmj, tmd. I just didn't really know which avenue to follow. It can be really expensive and it can be really time consuming to go to courses just around the country. And having two young children at home, that wasn't an avenue I could take. So very fortunate that Dr. Parker is here and that I was able to learn from him. So that's sort of where I am today.

That's amazing. And, yeah, I totally relate to two young children at home and not wanting to travel all over the country to specialize in expertise and. Yeah, that's so nice that you had the ability to have a mentor so, so close to you that. Literally.

Yes, literally.

Yeah, that's. That's phenomenal. I always get excited when I meet people who really start to specialize in anything related to the orofacial complex because you definitely have a deeper understanding of all the intricacies and how everything is just so interconnected. And so we have a lot of myofunctional therapists or myofunctional therapists to be speech pathologists, occupational therapists, registered dental hygienists. Even dentists, who all avidly follow the podcast. And I think it would be really interesting to take the conversation into a place where we can understand how do we even know when a patient expresses orofacial pain? And we are not quite sure where they're experiencing it, because sometimes it can be justly located to another area. You know, we don't know how to always figure that out. So when do you recommend somebody refers a patient to a TMJ TMD specialist?

Yeah, definitely. I mean, I mean, one big sign to look for that's so easy is to look for that range of motion which you guys are measuring anyways, when you're looking at how much the tongue can elevate versus just a range of motion without the tongue being up, et cetera. So that's something you're measuring anyways. And so there are some normal numbers, ideal numbers versus not so ideal. So inter incisal opening should be between 45 and 50 millimeters, ideally 35 millimeters. May indicate something's going on. Likely does 25 and below. Definitely you want to refer. So another indicator that you can look for is when they talk about facial pain, it's really about pinpointing where that pain is coming from. And that can be hard. Pain is subjective. And so what I often do a line that I often use that I learned from Dr. Jameson Spencer. He's wonderful. He's like the TMJ guy in the nation, along with my mentor, of course. And he says to say point, please point with one finger to where your pain is. Because people will go like this. They'll go like this. And really that leaves us a little bit clueless. So that one finger. And sometimes people will say one finger. It's like, yeah, one finger or maybe two. But then they'll really start pinpointing it. It's typically right in front of the ear or a little bit further forward, and then you can kind of start kind of nailing things down. I also have a video called the Muscle Palpation Exam that's so easy and simple to do. And it's so telling. It's so telling. Like if certain muscles are fired up and that's where you know the pain is coming from there. And so that's on my YouTube channel, checking that out. It even has a PDF that you can download and make part of your exam. If your patient is having pain about all them, it lists off all the muscles and the pain level the patient is reporting between 1 and 3. I feel like that's really Simple. If you have a lot of threes on that form, refer to a TMJ specialist. If you have a limited range of motion, I would say those are the top two things to look for.

That's phenomenal. Thank you. Because absolutely we're doing those things in our orofacial examinations. We are. We're pal, you know, unless we're virtual for the therapy, given the situation right now. We are, you know, we're trying to always do or at least the initial evaluations in person. So that because we need to get our hands on faces, we need to feel the muscles, we need to know what's, you know, overworking, what's underworking. We always have these compensations present. And anyway, so that's phenomenal. I definitely will check out that tool myself. Thank you.

Yes. Yeah.

So how do we find a reputable TMJD doctor? I mean, is that something that's challenging? Cause I know, like, in the airway centric space, it can be hard for us to find those airway centric dentists oftentimes. So do you have any tips on just how to find a specialist like yourself?

So I've joined this study club where the dentists that join it are kind of vetted. And it's not like you can just pay a fee and join. You have to kind of prove that you're very committed to TMJD and airway both. So it's like a sleep TMJ TMD study club. And that study club has a list of members that I have access to. But, I mean, I don't know if I'm allowed to share that. But I have found that if somebody contacts me from, like, I don't know, like, Houston, Texas. Right. Let's just throw something out there. I can look at that list, and then I can contact some of the dentists in Houston, Texas, and I'll say, this patient contacted me. We think their jaw might be locked closed, which is like the highest level of difficulty to treat. Do you have experience with treating this condition? And if so, would you like me to refer this patient to you? And then they typically contact me and say, yes, no, whatever it may be. And then I can kind of give a referral out, but there's no, like, listed database that I'm aware of. And so it's. It's hard. It's really, really hard. Because with TMJ tmd, a lot of the knowledge that people have is passed down through a mentorship.

Right.

So you're doing everything the way your mentor taught you. To. And so if I send somebody to somebody in Houston, I don't know that they're doing it the way I would do it. So then I can't predictably say, you're gonna get better or you're not gonna get better or it's gonna take this long. And so I wish that was an easier question to answer. That's like, something I've been working on. I just. Yeah, I wish I had a better answer for you. It's something I try to help people with. I try to do my best to refer people down, you know, send them down the right path, essentially. But it's really hard because if you go online, a lot of people will say they do TMJ TMD work, and they don't. And then the ones that really delve deep into it don't even have a spot on their website about it.

So it's like, no.

Right. So it's hard. And that's what's hard. So it's nice if you have somebody in your area, and usually the bigger cities have this that has a reputation for having treated TMJ TMD successfully. So in Portland, Oregon, that's Dr. Parker. That's my mentor. So for us, our whole referral pool is like, dentists, chiropractors, physical therapists, acupuncturists, a lot of myofunctional therapists. So we've got a lot of people referring to us. But that's because he's built his reputation over, like, 40 years.

Right.

So, yeah, a long answer. And I feel like I didn't even answer your question.

No, it's great. It's tricky because, you know, sometimes we've given, like, patients tips, and we're like. I mean, I get DM'd daily asking for, who do you know in this area? Who do you know in that area for? We have this need. That need. And so, you know, I've advised people on, like, well, you can. You can Google biological dentists and see what pops up in your area. And sometimes that helps and sometimes it doesn't. You know, it's the same thing. Like you said, some of the dentists in that space who really are the best in their practice, they don't have it on their website because they don't have to.

It's like, all word of mouth.

Exactly. Yeah. And the same thing in the pediatric feeding space. So that's. You know, my. My other specialty is pediatric feeding. Myotots, you know, it's all interconnected. And that's why I started my Course because I needed to know that people were getting the right information, that they were having the right mentorship and training. We offer this, you know, 40 and a half hour, 12 week course. It's actually like we're in the midst of like launching it for the sixth time. It ends tonight, the launch. But anyways, yeah. And so anyways, we, we've created directory because I know that at least they've gone through and they have access to us afterwards. And now I'm like, okay, now I can wholeheartedly refer some people because it's, we have the same issue. How do you find these providers all over the world? I mean, it's not even just limited to the US at this point. I get questions for people and needs all over the globe. And so, you know, I think we're headed in the right direction, but I think it is really hard to find these.

It is really hard to find and you don't want to make the wrong referral.

Right, Right.

So it's really a fine line to.

Always a disclaimer of like, I haven't been treated bi. I don't personally know. So yeah, I always say that and.

I'm like, I don't personally know them. I don't know their exact treatment methods. And then I'm like, I feel so like guilty that I just can't step in and take care of the person. I'm like, ah, so it's a conundrum.

It is, it is. Well, let's talk a little bit about some of the more unusual, at least unusual to maybe the general population symptoms that we might experience from TMD. I know that you had a YouTube video about like vision and how it can impact vision. So I'd love to just start there. Can you share with us a little bit about the impact on your vision?

Certainly, yeah. So we at our, in our practice, just to sort of prelude into it, we talk a lot about TMJ and we talk a lot about tmd. So TMJ just means temporomandibular joints. And if there's a problem inside of those joints, it will manifest as clicking or popping or episodes of the jaw locking or like crackling noises. TMD is a lot trickier to diagnose. It's not as objective because it's all about the muscles. So there are a group of muscles that surround and support the jaw. And when those muscles become dysfunctional, they get trapped in this chronic pain and spasm cycle. And when they're in that cycle, they're habitually contracted. They're edematous, they're swollen, they have a lot of lactic acid buildup. They're very painful and sore. And so there are certain muscles that attach to the sphenoid bone, which is that I think it's the most amazing bone in the human body, personally. But it's a bone that is just. We can feel it from the outside, like right here. That's kind of the only spot we can feel it from. And that bone has some plates coming off of it called the pterygoid plates. And there are some muscles, the lateral pterygoid and the medial pterygoid, that attach to those plates. And those muscles are not happy muscles in my tmj, TMD patients, all of them. And so when those muscles are contracted and dysfunctional and swollen and edematous, it can yank on that sphenoid bone and kind of pull it in different directions. And that bone is part of the orbit for the eyes. So our theory is that that's how it affects the eyes. And I've seen it cause blurry vision. Floaters, pain behind the eyes is probably the most common thing I hear. And so it can cause a lot of, it can lead to a lot of eye related issues. And so one example is I had a patient whose jaw was locked closed for, gosh, two years before she found us. Poor thing. And yeah, she was basically told by multiple people that she would not be able to open her mouth ever again. And she had to mash up all her food or blend it. And that was going to be her life. And she was 25.

Wow.

And so when we told her we could help her, we could help her regain her range of motion, she just was so emotional and it was really gratifying to be able to help her. But my point with this is as we progressed through treatment, she wore glasses all the time. But her vision started changing as treatment progressed. So we were slowly getting her unlocked. Her range of motion was increasing. She still had pain, she still had muscles that were fired up. So with tmj, TMD work, I always say it's two steps forward, one step back, two steps forward, one step back. And that's just how it is. It takes a while for the body to accept these changes as we're going through treatment. For her, she started getting blurry vision even with her glasses on. So she went to her optometrist and said, hey, I'm getting blurry vision. But I. And she said this on her own. I didn't even say this. She said, I'm going through this jaw thing. And she explained and she said, I have a hunch, my gut is telling me that it's related. And he said, no, you need a new prescription and that's that. And she said she didn't get new glasses, she didn't change her prescription. She shared all this with me. She said, I just think it's related so I'm just going to wait it out. And lo and behold, at the end of treatment, her vision went back to where it was. And so it's hard talking about these things because people say, where's the evidence? Give me the research, I want to. I don't have it. It's experience based and it's really hard to provide. How do I prove that her lock from two years ago led to her blurry vision? Now I can't, I can't. So that's the tricky part. But I can just tell you what I see in my office every day and it's really interesting. And then the pain behind the eyes that can really be traced back to the lateral pterygoid muscle does have fibers that run behind the eye and that's just anatomical. Can't argue with me about that. So I mean it's definitely something that we see.

Yeah, no, that's, it's so fascinating because I've heard from in the orofacial myology space, we have talked about the connection with vision and the impact on vision when you have just orofacial dysfunction, especially because of how just all of your muscles, the bones, things shift over time. And we know, you know, if you have a tongue tie and your tongue lives on the floor of your mouth and your palate becomes high vaulted and narrow and just things sit in different places. And so there's some been interest, some interesting discussions on that, that topic. So I was really curious about it and that, I mean it makes sense and I, we get the same thing. Where is the research? Show us the studies. And we're over here going like, you know, sure, we need more research. But again, what you see repeatedly on cases that are on your caseload and that are coming into your office, I mean that is also a part of evidence based practice. Right? Experience.

Yeah, evidence.

So anyways, it's, it's always very fascinating and I'm very much so about like, yes, the evidence has a place and it's important. But I also, my goal is to treat the patient and nothing that we're doing is harmful to this patient. You know, we're doing everything in a very, in very Safe manners and helpful manners. And if they're getting out of pain.

Or they're becoming more functional, their muscles.

Are no longer in a place of dysfunction. This works.

This works. Yeah, this works. And so. Yeah, so I think, I think, of course, evidence. We want evidence.

Right.

But, you know, the way medicine was practiced, you know, before modern medicine, the way things were done was through word of mouth, through generational stories, how things, kind of like midwives would tell the next generation of midwives how to do things, et cetera, et cetera, et cetera. And so there were reasons behind them, but there wasn't evidence. But you still did it, right? And you still knew that it benefited. And so, I mean, an example of that is that so many midwives used to have that long fingernail to help release the. The frenulum. The type. Yeah, frenulum. So. So, yes, I. A lot of what I do is experience.

Yeah, no, it's. And so you had mentioned that with that patient, you know, she was basically told, hey, purees are the way to go going forward. Like you're drinking through a straw.

Right.

I mean, what do you do with these patients do when. If the patient comes to you with a lock jaw, you know, are they going to remain on a more pureed soft food diet for a period of time before they can reintroduce other. Like, what is the protocol there usually?

Yeah, good question. So when they come in and they're locked, the main thing is to increase their range of motion so that we can at least get impressions to make the orthotics that we make to treat with. Right. And so for these patients, to help increase their range of motion or get them unlocked, we use a combination of TENS therapy. So it's a muscle stimulator. It gets the muscles in the head, neck and jaw nice and relaxed. So we use that for about 45 minutes. And what it's really effective in doing that, tens, is it flushes out toxins that are built up in these dysfunctional muscles. It brings fresh blood flow, oxygen to these muscles that are angry and contracted constantly. So 45 minutes of tens is sort of the sweet spot where we found, okay, the muscles get some sort of break. We Also, in that 45 minutes, have them wear an aqualizer, which is a really ingenious device. I wish I'd invented it. But it has two pads that are filled with sterile water. And those pads, when they rest in between your teeth, they serve as a waterbed for the muscles of the head, neck and jaw. So that TENS therapy and the Aqualizer together already start getting the muscles relaxed after that, 45 minutes, then we come in and we do an extra oral massage and then intraoral myofascial release and massage. And then we do some very specific jaw manipulation. So the jaw manipulation is like an osteopathic technique that my mentor sort of developed over time. So he was around before Google was around, and so he actually traveled the world. He worked with Mariana Rocabado, who's like a famed TMJ physical therapist. He trained with osteopaths. He trained, I mean, he studied clinical nutrition. He's really done it all. And so he's kind of come up with this technique of jaw manipulation that can be really effective for these patients that are locked. Sometimes we can get them a little bit more open on that first appointment, but it typically takes four or five appointments to get to increase their range of motion enough so that we can get impressions. Well, maybe two or three appointments, maybe I'm exaggerating that a bit. But then once we can increase their range of motion a little bit and get those impressions, then we make these orthotics. These orthotics, what they are. I keep saying orthotics, not nico, because there's a big difference. So we measure where the muscles are relaxed and where the joints are aligned and we actually build the orthotic to a very specific position. So it's holding the patient's mandible in a very specific position in three dimensional space to allow for the muscles to remain in their relaxed position and to give the disc that's displaced in the locked jaw chance to get back in alignment. So once they're on these orthotics, there's a daytime one and a nighttime one. Then we see the patient weekly, we do that therapy all over again, sometimes with the tens, sometimes without the tens unit. And each week, typically, we see the range of motion increase a little bit. So it's not like a quick thing. It's not like you can quickly relocate the jaw that's basically dislocated at this point. With the locked jaw, it's a slow process. And we typically tell patients it'll take four to six months of coming in weekly or bi weekly to get everything back in alignment, to get stable, to get out of pain. And so that's sort of the treatment protocol that we use. There's also an injection that we can do into the joint that can help with the locked jaw as well. And so we don't jump right into that. We give it some time because no one likes an injection. Yeah. But also we need to have the orthotics able to put in right after the injection. So we have to do it a certain way till a certain point. So we have a couple different tools in our toolbox, I suppose, but that's typically the protocol and I think it's really helpful.

Thank you for explaining all of that. I've worked with some of these adult patients in myofunctional therapy who are in the orthotics and they're more challenging cases. I always say this is not for like a brand new clinician to navigate on their own simply because this patient is typically in pain. And everything that we are doing needs to. We need to make sure that we're supporting their current capabilities and we're not going to over. We don't want them to overexert themselves, especially when we're trying to get them out of pain. We don't want to put them back in pain. Sometimes we recommend pausing and waiting till they're at a certain point before we continue on with the therapy because they are in treatment with the tmj. Tmjd, Doc. But you know, but then in other times, depending on the patient, we've worked very closely and I have one patient who just stands out in my mind. And you know, this patient had had just a history of drug abuse and a history, just very interesting case and was compliant most of the time with wearing, you know, her, her orthotics.

And.

Yeah, thank you. What was the word I'm looking for? Yeah, orthotics. And you know, we were able to make a lot of progress. It was slow, it took time. And I think that that's one of the biggest conversations and, and I say this because some people in the myofunctional therapy world teach people that, well, you can do a myofunctional therapy, you know, in 12 sessions, in 12 weeks, you'll be done. And that's our program. And you know, we're very much about. No, there's no set number of sessions for a patient. It is highly individualized to their needs. And when you are talking about a patient with pain or facial pain, especially if it's at the tmj, you know, that's where it can take a lot more time and it can take a lot more time. Yeah, I mean, it's a journey. So I appreciate you explaining that and, you know, sharing what you're doing on your end because it's, you know, thankfully we do, we do have some good sponsors, specialists in, you know, I'm now in Florida, but when I was. My team is still in Maryland, D.C. virginia. So in that region, there's definitely some great specialists who are. That we're able to collaborate with in this space. And the other thing you mentioned, too, were the. The osteopathic technique that's used. So we often send them out to an osteopath as well, because we want them to. You know, we're not just working on their mouth where it's full body.

It is body.

You know, we see. It was so interesting to me the first time that I went to an osteopath. And then actually the physical therapist that I work with who was treating me when I was living in Maryland was trained through the Postural Restoration Institute. And yes, yes, they're my favorite people.

I love pr.

Oh, my gosh. So he had me, like, stand against the wall, and he's looking at my posture and he's looking at my feet. And he's the first one who said to me, he goes, your legs aren't different lengths. Your left leg is not shorter than your right leg. He's like, your hips are off. And then, you know, my max low was turned in on the left side, which it still is a little bit. And I have a. I've actually been an expansion myself. I went through two years of DNA vivos. I just finished up a year of Invisalign and my daughters. Thank you. My daughters. And I was an orthodontic relapse case. I have a.

My gosh.

I'm like, not with the words today. Goodness, Hallie. Septum. I'm like, what am I thinking of? That I need to fix my deviated septum, which probably should have been done a while ago, but that's, you know, that's next on the list because it has. It did resolve a bit with some of the osteopathic and the expansion, and. But I still need to address it. So. But anyways, I mean, I share all of this because I'm that patient who. I haven't had pain, but I definitely have a little bit of deviation. I have had some issues where, like, we've monitored it very closely, and because my maxilla is turned in a little bit on the left side, you know, I don't. My. My jaws don't line up. And we used to think it was my mandible. It's actually my maxilla.

And it's just.

It's so interesting when you work with the. With the team, right? And you dive into, actually Looking at a patient holistically, what you start to recognize on a deeper level. So I, you know, really have appreciation for the whole team when it comes to treating patients with myself. So.

Yeah, well, I mean, one of the first things I noticed when I started working here, and I barely knew what a tongue tie was, I didn't know a lot before I started working with Dr. Parker. But one of the first things I noticed, we take a CBCT scan, the 3D imaging, and we go through and we analyze it a very specific way and always look at tongue posture, always. That's probably one of the first things my eye goes to. Now, for the vast majority of our patients, it's low and posterior, and it's totally just getting in the way of the airway, obviously. And most of my TMJD patients are tongue tied and they have some sort of sleep disordered breathing. And I've made videos about this as well. And so what I did is I went and got trained in myofunctional therapy, and I got trained by Corinne Jarvis, who's an SLP here in Portland. She's well known. She has Breathworks. Her company is amazing. And so I started incorporating. I started trying to incorporate myofunctional therapy. What I realized quickly is I am seeing all the extreme cases in this area, and I was aggravating symptoms big time. So I did it with two patients, a third patient who was not locked. So those two were locked, and I should not have done that. And we basically stopped because their symptoms, as you mentioned, can get worse. Because what we're trying to do with our orthotics is put the muscles in their most relaxed position. Then I'm asking them to do all these exercises. And I wasn't connecting the dots because I was like, I'll just make them better. Like, I'll fix everything all at once. And I was so excited. And then I realized, wait a minute, it's too much. It's too much on the muscles. There was another patient who was not locked. She had just mild pain and some clicking and popping. And we sent her to Breathworks because at that point I was a little gun shy. I was like, I don't want to rush in with my MYO training, because obviously I haven't done it and practiced it as much. So we sent her to Corinne Jarvis office, and she really thrived. I mean, she just did amazing. So I definitely think for our cases that are not as severe, the myofunctional therapy can be done in conjunction. And then for our Patients that I recognize are going to be severe from the start. I tell them, phase one is stabilizing the joints and getting the muscles to a healthy and functional state. Phase two is orthodontia or full mouth reconstruction if you want to move the teeth to that stable position. Phase 1 and a half is myofunctional therapy. And I say, you cannot skip that phase if you want to have a successful phase two. And so then we get into it. And so, you know, it's been a learning curve for me too. And I felt horrible with those two patients. And luckily it was just like a week of aggravated pain for them. And then I figured it out pretty quickly. But it's, again, a fine line.

Yeah, no, and we all learn through experience. I mean, it was the same thing for me.

We.

I started my practice also. I took my course in 2017 and got certified right before having my second daughter in 2018, in February 2018. And I remember as soon as I came back and started treating again after, I mean, already been treating for that year, but I started to notice changes in patients that were coming back to me and just we had done things different ways. And so now, you know, it's obviously very individualized for us. And when we will treat, not treat, but we have a lot of patients that go through some form of expansion. We have growth appliances in place. We're growing the jaws laterally, we're growing them forward. You know, we need to be cognizant of what space do they have available in their mouth and can the tongue fit in the palate right now? And so typically, you know, all things aside, if there is no pain or a facial pain, they're not, you know, a tmj TMD patient. We are. We generally, sometimes we take a break and we wait until the tongue has enough space in the palate through expansion to continue our program. Because what good is it if we teach? And I learned this from my own daughter, right? We had her release when she was 24 months old, and her palate was okay, but it wasn't fabulous. At four years of age, I put her into an ALF appliance and she gave so much growth between 8. And this was, of course, during the pandemic, right. We put it in in August and she would have been done in about nine months, but we left it in for about a total of a year just because we're like, why not? It's not hurting anything. Oh my gosh. Her airway, her. Her U shaped palette. It's beautiful now.

I mean, so great.

She just turned six and so I'm monitoring her still because, you know, I'm not convinced she won't need anything in the future. But she's that kiddo who we released her tongue to a palate that was too, too small. And it was helpful. There was some dysfunction, it was helpful. She's improved some. But it wasn't until we could really get her expanded and then do the myo that I noticed she had the most benefit from an orofacial standpoint, being able to chew and swallow properly, her oral rest, posture, not sick as often, all those things.

That's wonderful. Was her ALF fixed in there then? Did they cement it in or was it removable?

So it was fixed in. Yeah, it was fixed. And I think that's important for our little ones who compliance reasons. Obviously they were able to easily take it out to adjust it between appointments. And we had a couple cases like where when it was first put in, it was coming out and it was actually a lab issue that we had to send one of them back and. But no, she did great. She did last with it. I think she was my sensory kiddo, a little picky eater and was great. Horrible with breastfeeding. You know, that was painful for both of us. I didn't have great support, which is really what threw me into, threw me from doing toddler on up feeding to infant feeding. That was that journey because I was that mom.

It's not good that you had that experience.

Right, right.

But you learned.

But good because I also got to know firsthand. I went to some of the specialists in the area for tongue tie and I got turned away by two ents and these are supposed to be the two who are doing all the releases. And I was like what is going on here? And I landed with the oral surgeon who became my go to person in the area. And we do have a handful of really great release providers between dc, Maryland, mostly Maryland and northern Virginia. But either way I was like, you know what it was, it was not nice, but nice to have that experience as a parent and the professional in this space because now I know where to refer so I can hopefully save some for my patients.

Well, it's so important because both my kiddos, so they're just turned three and soon to be five, but I had them in 2016 and 2018 before I met my mentor and I had no knowledge of anything. I couldn't nurse either of them. I mean pain, everything that comes along with that and I just couldn't figure out why. And Then as I started working with Dr. Parker and learning more and more and more, I realized. I started talking to my mom. She couldn't nurse us.

Yeah.

I realized I still have a tongue tie that I haven't gotten released yet. Yeah, right.

Mine was released, but. Yeah, me too.

Yeah. I just. I can't commit to myofunctional therapy right now. I'm just too scattered. But someday I'll get there. But both my children have a ton of time. My son's is very obvious. And I just was devastated when I found out all of this, because you learn it after the fact, after you've learned. Missed that window. And I'm one of those people where it's like, I. If I set out to do something, I'm gonna do it. And I've never failed so catastrophically at anything besides nursing. And I just couldn't figure it out. Like, I was going to lactation consultants. I was going to lactation support groups. I was bringing my babies everywhere trying to do this, and I was like, why is this so hard? And now I realize this is why.

Yeah.

Yeah. So when my daughter was almost three, we had her seen by Dr. Dahari, who's like, the ENT here, the airway guy that everything. And he's like, yep, she's tongue tied. Yep. She needs her adenoids out. She didn't need her tonsils out, but he took care of the adenoids. And her breathing changed overnight. Her sleeping changed overnight. I mean, these are real things. But it's like, how did my. Not to point fingers. But how was this not pointed out by any other practitioner up to this point? When I'm saying I'm struggling, when I'm crying, every time I'm trying to nurse, when I'm.

That's a famous question.

Yeah.

Nobody else found this yet. I can't tell you how many patients ask us that.

Yeah. Yeah. And, you know, I recently had my children. They had a well check, and the pediatricians are like, nope, this isn't a thing. And I'm just sitting there, like, I don't know what to say. I didn't go there to argue with anybody, so I just kind of kept my mouth shut for once. I don't usually do that, but I just thought it's. It's like. Just like everything else in the United States. It's so polarized. Like, you guys like, yeah, yeah, yeah.

No, it's. It's so frustrating. You know, I had Dale Tyler on who's an ENT who has written the rebuttal with Dr. Gihari and, you know, to their organization. And it's. It's so frustrating because it can be such a minor thing, but it becomes such a big issue when it's not addressed. And children get sent from one provider to the next to try to deal with issues and nobody is looking in the mouth or under the tongue. And of course, it's not the end all be all for everybody, but it's a big piece of the puzzle, you know? Yeah. Yeah. And my first one, we had very painful breastfeeding for the first 13 months. I was stubborn. I was like, oh, I am going to breastfeed this baby. I know what I'm supposed to do as a feeding therapist. You know, this is happening and I can't even tell you. I thought it was normal. And I was until a certain point where I realized it wasn't. But I was just too stubborn to stop. And so I was only treating two days a week for six hours at a time because my baby would not take a bottle from my nanny either. And so even though I was pumped, I was either like pumping or the baby was with me. And we were going to places like Nordstrom or places where I knew they had comfortable nursing rooms. Yeah, she would nurse for 45 minutes and then I could maybe if we were out of the house, I could get like a three hour stretch where she would sleep in her car seat while I was like moving her around. And then we would nurse again. Otherwise it was just nursing around the clock at home. So that was like my seat. It was just. And then my second one, I remember. And also with my first one, she was a kid who was marked failure to thrive. She lost too much weight in the hospital and we had to go over weight checks. And I was seen by the ibclc and it was like, I joke. I'm like, it's take like taking your car to the shop. She nursed beautifully with the IBCLC present. And then I went home and it didn't work. It just didn't transfer. Every single, you know, it's like every single time. But of course it was my fault, right? I was holding her wrong, positioning her wrong, not doing this right. Get her naked, blow on her face, face, you know, spritz water at her. And I was like, I'm not doing that to my baby. Oh, I did it all because I.

Was literally going crazy. So I did all that.

Admittedly. I tried to strip her down naked. I did like, try to blow in her face. I'm like, I'm not throwing water at a baby's face. I'm like, that's where I draw the line.

That's where I draw the line. We're not doing that.

But no, after a while was like, this doesn't work either. So I don't know. I'm at a loss. But with my second, she was tongue tied. And I remember being in the hospital and they had gag orders there. They were not allowed to look inside the mouth, you know, of course, I pulled in the IBCLC immediately. It was a very friendly room in mother baby hospital, you know, and everything else was great, except I was like, I kind of know what to expect. So I was like, I'm not looking in her mouth for the first 24 hours. I'm just going to, you know, in this bliss of childbirth and exhaustion, I'm just going to pretend like there's nothing there if there is. And the sec. The second she latched, I was like, oh, no, this is the same all over again. I was like, I knew it immediately. And so I ended up looking in her mouth. I did wait till the second day I looked at her mouth.

Good job.

There it is. And they, you know, the hospital is just like, oh, oh, that's interesting. And then when my outside pediatrician came in, she agreed with me, which was interesting because they're not really like a pro tots practice by any stretch of the imagination, but this pediatrician was like, yeah, I see that. And I was like. And then the hospital goes, oh, yeah, we see that too. Do you want our doctor to release that or, you know, our doctor here to release that or surgeon? I was like, don't touch my baby.

Yeah.

You can't diagnose it, but you're willing to build my insurance to release it? I don't think so. No. I got my oral surgeon on. On a text message right here. We're going on Friday. Yeah.

Man, I wish I had known to Harry then, like, I would have just been texting him up a storm. We would have fixed it. I'm just. I still am. Like, it's.

It's just so sad that. That moms are still to this day having to deal with this. I mean, and that's where I created the platform, because I decided, you know what? I can only reach so many children myself. I can only do so many evals with me and my team, we travel all over, dc, Maryland, Virginia, to these families, but there's still so many more that need us. And there's just not enough feeding therapists to even identify this so because you know ibclcs can find it, but they're not supposed to diagnose. You know, they should be then referring, but then it depends if you go refer to the ENT because that's who's in network. And they say, oh no, there's no tie, the baby's fine. Well that's the end of the road. And it's like dead end. Hold on, what just happened? So, you know, that's where I decided I need to create this course. I need to have a feeding course that also talks about tots and myo from birth. Because you know that it happens in utero. We know that the baby starts swallowing by 12 weeks in utero. And that swallow that develops utero is a swallow that you're born with. And if they don't have the proper oral rest, posture, arguably issues with the jaw, you know, aside from injury like that, that starts at birth, I mean it's like all starts at birth. And when I think I started to open up some providers eyes to this, you know, even within my space in the SLP OT space, they were like, whoa, why has nobody ever taught us this? And I'm like, exactly, let's go help these children before it becomes like a major issue. Because it just snowballs into other health issues.

Well, my problem is not only is it not taught, but there's like a movement against it.

Yes, of course, I know even, even in my industry there is like a split down the middle and some people think we are absolutely insane and they think that we just diagnose everybody with tots and that's not the case. But there is, you know, I think it's a combination of things, you know, epigenetics, awareness, There's a whole bunch of things going on here either way. You know, we also are big proponents of just because a tot is present, you know, tetherball tissues are present. Like we're not just referring. Right. For a release, there needs to be pre op, post op surrounding this care to make sure that we gain function. Because you just release a tongue, you still have a dysfunctional mouth. So you do.

Your tongue isn't just naturally going to go where it's supposed to go. It needs to. There's some work involved.

Yeah. So it's all so fascinating. Do you now do you ever see children with these, these jaw issues and lock jaw or is it primarily adults.

That it typically comes on? The youngest I've probably seen is like 12 or 13.

Wow.

And it's very much female. All these TMJ TMD issues are really. The majority of our patients are female. And the reason for that is that they're the connective tissue in the temporomandibular joint. First off, there's a ton of connective tissue, and it's highly under the influence of hormones, particularly beta estradiol and relaxin, which are found in much higher levels in women than in men. So relaxin goes in there and loosens things up. Right. That's why we can birth our babies. Loosens up our hips, but it also loosens the ligaments that hold the disc in place. Got it. And so a lot of our patients are female, especially with the locked jaws. So one thing I say in some of my videos is, gosh, since 2018, I've seen, like, hundreds of lock jaws. It's really unfortunate. I don't love to see that condition. It's not a comfortable one. Four have been men.

Wow.

That's it.

Oh, my gosh.

Yes. So it is predominantly a woman's disorder. Tmj, tmd.

Yeah, that's. I was actually going to say to you when you mentioned relax, and I was like, oh, do you get a lot of pregnant patients? I mean, do you?

Shockingly, no.

Oh, okay. Well, that's good.

Yeah. You think that I would. So I almost think that there's other factors that are underlying. And then the relaxant and beta estradiol, if they're there with that other factor. So the other factor being like, hypermobility. So a lot of my patients whose jaws have locked, their previous range of motion was really big, maybe too big, or they have hypermobility in their other jaw, and that's going to contribute more to dysfunction if it's going to happen. So I almost think, because I'm like, why aren't we seeing more pregnant patients then? It doesn't really make sense. And we're really not. So I think there's some underlying factors. Yeah.

Thank goodness. Because pregnant women need another thing to deal with. Right, right.

They already have it.

Well, this is amazing. Now, is there anything else that you would like to share with us before we start to wrap up today?

Just lastly, that we also believe really strongly in craniosacral therapy. Yes. So. Yes. So fascia, I mean, there's a direct connection to our whole body with the fascia. And when that's too tight or restricted because of a tongue tie, sometimes it can be. Or other things, like people have injuries they have, et cetera. Just, you know, keeping in mind that everything is connected, keeping an open mind to different types of therapies, because for some of our patients, it's all of these things combined. The osteopathic techniques, the craniosacral therapy, our knowledge of dentistry and tmj, tmd. And that's what brings the patients back to function and back to health. Not just one size fits all kind of thing. It has to be an individualized approach where you are willing to incorporate other treatment modalities as well. That's all.

Yeah, no, I. I love that. I love that. And the last thing I'll add is that, you know, I had taken. I always share this because I feel like it really speaks volumes. Everyone says me, well, what is craniosacral therapy? And I'm like, I am not that person who can really answer that in a great. You know, I can't really sum that up for you very well. And now that I've experienced it, as a mother of a child, I tell people I took my second daughter to post an. Both an osteopath and a cranial sacral therapist ever have, after having her in traditional pt, really to keep her on track with her gross motor milestones because she was tongue tied and she. Both my babies had very strong necks at birth, and they were holding their necks up and everyone's like, wow, they're so strong. I'm like, no, that's not normal. They should not be holding their necks up. That's right. Meanwhile, my first daughter was ahead of her gross motor milestones and has always had great fine motor skills. And then my second daughter is pretty average with her skills, but she was starting to fall a little bit behind. And then she was dragging her leg when she started crawling. And she did this all through her first year. And I was like, something is not quite aligned here. So I did the traditional PT thing because everyone said, oh, that should be fine. It kept her going and hitting milestones, but it did not fix the root of the problem. I took her to an osteopath. They did their adjustment. They said, you know, she's a very healthy child. And then I actually took her to CST the next week. And with. With those two appointments, you know, I told the CST too. I said, look, she's, you know, really. I mentioned she's a really sweaty kid and she's always, you know, sweating through her clothes in her car seat and just, you know, just runs hot. And they were like, oh, that's interesting. And so they use some Chinese medicine as well. And they showed me this thing I could do on her back since that day that, that disappeared, never again was she not my, my sweaty kid. I mean, she still runs a little hot, but like nothing like, like she was before. But I tell people, like within 10 days of those two appointments, the child got up, was walking like no big thing. And then that following week she was on the couch and she just crawled across the couch normally without dragging her leg, like it was no big thing. And I was like, oh my gosh. And my husband was like, but she can walk now. What's like, what does it matter? I'm like, no, no, no, no, no, no, no, no. There's so many reflexes that integrate when you crawl properly. I'm like, this is important. You have no idea how interconnected our bodies are. So, you know, I'm like. That grew my personal appreciation for, for both. You know, I already had it for osteopathic medicine, but I didn't really fully understand cst. And I'm actually bringing in an OT next month in my MYO membership to train, you know, to teach everybody more about it because it's so important. I think it's so misunderstood or just not understood at all. Right, So I love that you brought that up because it's such an important modality that we need to be considering.

It is. I think I, again, I wish I had known this with my kiddos because same thing, my daughter was like pushing us away and looking around at birth and I'm like, what are you? And I realize now there's so many cranial strain patterns. Right? Yep. And she, she'll be five soon. And she used to, this is really tapered off. But when she, she spoke very early. So a couple years ago even she would come to me and say, mommy, I have a headache. Can I have a head massage? Because I'm actually trained in craniosacral therapy. So I would sit with her and kind of straighten out her cranial strains and headache would go away. And it's. But you know, I, how do I. Again, I go back to, how do I prove that? I can't prove anything. I can just tell you what I see. And for her to come to me and say, mommy, I want a head massage. I mean, that's telling for a young child to recognize. Yeah. And so there's, there's a lot to it. And I even, I used to hesitate to say I'm trained in craniosacral therapy because I think dentists are notoriously close minded. Yes, we are. And so I'll be the first one to say It. So I just kind of shied away from saying that. But I've just seen it benefit so many people that I'm just like, you know what? I'm just gonna say it. Yeah.

And I love it.

Yeah. And I treat my patients with that here, too. So that's part of all of our treatment. Yeah, I love it.

Well, and they should be very grateful that they can get that from you in office and not, you know, have to go out to another provider. Because it's such a powerful tool to have in the tool belt for these patients who are in pain.

It is.

It is.

It's always interesting because I did have a patient on the table the other day. She was. She was locked, and I was releasing her scm, this big muscle here. Right.

Favorite muscle.

Oh, it's an amazing muscle. And as I was doing it, she's like, this is so interesting. I'm getting a neck massage from a dentist. And I said, yeah, it is interesting. It was just. It was just funny. We started cracking up when she said that. But, yeah, I really am a big believer in lots of different. Just keep learning. Lots of different treatment modalities. And I think you can only benefit your patients that way.

Absolutely. Well, thank you. This has been phenomenal. I have had such a great time chatting with you. Where can everybody find you? I know you've got your Instagram account, your YouTube channel. Tell us where to find you.

Yeah, yeah.

Instagram and YouTube.

Those are the main ones I'm active on. I'm not so much on Twitter. I'm going to try to do TikTok, but I feel like I'm too old, so we'll see where that goes.

I'm with you on that one.

I don't know if I can do this, but YouTube is like my main one, and there's so many informational videos. And I've had a lot of myofunctional therapists reach out to me once they found my videos and say, I use this as a course and they go through and they take notes. So I'm not trying to toot my own horn, but there's just a lot of information on there. And I tried to. I made my YouTube channel for patients, so I tried to make it very simple and easy to understand with diagrams, videos, etc. So I know that you guys are very, very trained, but this is like the TMJD aspect of it. So give it a go if you have some time, because I think that the information in there is valuable and especially the muscle palpation. Exam. Check that out if you want to incorporate it.

Amazing. Thank you so much. And we will link that to the Show Notes so that everybody has easy access to your Instagram and your YouTube account.

Yes.

Yes.

Awesome. I love it.

Thank you. Thank you.

Yes. It was so fun talking to you and learning about you and your kiddos.

And I just love it. You as well.

Thanks for listening to this podcast.

If you want to hear more of.

These Myo Tots, 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 to share this.

Episode on your social media platforms and.

Join us over on Facebook on my Facebook page at halliebulcan biz, on Instagram.

@Hallybulkin and you can head over to.

Theuntetheredpodcast.Com to grab a copy of the Show Notes where you can also subscribe to be kept up to date on the latest podcast episodes.