Episode 131: A Case Study: The 10-Year Old Who Was Not Appropriate For Lip Closure…Yet with Hallie

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. Okay, so on today's episode, because this was such a big hit last time, we're going to do another case study discussion. And if you're in the MYO membership, we actually just did this as part of our September 2021 case study review because it was a case I actually assessed. And so what I want to do with you all, because it's a really fascinating case, I really think that, you know, I'm not going to share the pictures on YouTube or you know, outside of my programs because I only have permission to share the images within the MYO membership and for teaching purposes in controlled containers, if you will. So I can't put them out for the general public to see. But really interesting case. I'll describe some of the things that I saw, I will discuss. We're going to go through and talk about the history, the case history and what tipped me off during that case history. You know, I don't love red flags as a term, but red flags or you know, concerns that came up that we, that I felt and the team as well, because I've reviewed this with my team. I've now, like I said, reviewed it with the MILE membership. Really just interesting case where there was quite a bit in the case history that made me go, hmm, something's going on here. Right? Then I met this individual and found additional concerns in regarding oral rest posture and the oral prep phase. Oral face swallow. Right. And so we're going to go through all of that and then we're going to talk about what my treatment recommendations were and if there was a particular order in which I would make said recommendations as well as like any referrals, do we need to refer back to anybody or to anybody new as a member of the team? So let's jump in. Okay, so our case study is a 10 year old female and what I want you to do as well is, you know, obviously if you're driving and listening to this, you're not going to take notes. But if you're not driving and you can take notes, jot down the things that jump out at you, jot down some of this information and think about what you would do if this case presented to you. Right? Think about if anything comes to mind as I'm speaking, make notes. Who would you be referring this case to? What questions do you have? What concerns do you have? If there is concerns beyond what I've shared with you based on the information I'm sharing? Because as clinicians, as myofunctional therapists, it is our job to hear continuously be asking questions, trying to put pieces of the puzzle together, working with other team members to best treat a patient. And let me tell you this, this individual, this 10 year old female, required quite a team of professionals to assist her. She had a lot going on and you know, it was definitely full body impact for this case. And she was only 10 years old, which is arguably not, I don't want to say old, but in the world of myofunctional therapy, if we're talking about early intervention, I like working with professionals who want to start treating these kiddos, expanding them at a younger age, like in preschool, okay, before kindergarten or by kindergarten. We're already in expansion. We're not starting to talk about, you know, growth appliances and expansion in kindergarten and first grade, which is typical, right? Five, six years of age, usually between six and nine years of age. That's when traditional orthodontists, we'll start to have the conversation about expansion or braces. We're talking like early intervention, like 3, 4, maybe some providers even start at the age of 2 with some of these slower growth appliances. So anyways, I backtracked to that because you can see in this case how impacted she is by her restricted airway. By the age of 10, this child was really embarrassed by the way that her mouth was, by the way her mouth looked, by the way things were operating. And you're going to hear about some of the other concerns that I noted just from her case history, before I even met her, based on what they filled out in our intake. So here's what I pulled from the intake. As I mentioned, 10 year old female, she's got seasonal allergies. She has been to an allergist. Currently, allergies are under control, not of concern at the moment. But they noted seasonal allergies, rescue inhaler, as Needed. Okay, well, maybe it's a little bit more than seasonal allergies then, because maybe there's. You know, I would be curious to ask, is there a history of asthma? Is there a history of upper respiratory issues? You know, and again, as I'm going through this, write down any questions you would have because this is how you. You evolve and start to think critically about your own cases that might present to you. There is a history of tethered oral tissues within the family. Now, this patient actually had a laser frenectomy and it reattached. The dentist referred this patient for an orofacial myofunctional evaluation. Again, I'm just telling you what I pulled from the case history in no particular order, really. Past oral habit, this child had an extended pacifier use until about two and a half years of age. And. And other than that, no oral habits reported or observed, no noxious oral habits, like no thumb sucking, no nail biting, none of that. But here's where it got a little bit interesting to me. This patient was reportedly nervous, anxious, had difficulty concentrating, a short attention span, has nightmares, is sad, is shy, is easily upset, set, is sensitive to sounds. And then in terms of food, the parent reported that this child was picky, had strong food preferences, a low volume of food. Right. And so immediately, I might go, maybe the tethered oral tissues are impairing her ability to prepare food. Like, maybe we need to rule that out. Like, let's. Let's have our eyes open and rule these things out during the eval. Maybe it does, maybe it doesn't. We don't know yet. But that's where my brain starts to go. Maybe the mal. Maybe there's a mal occlusion. And maybe that we know. Well, we don't know. You don't know this yet, but this child was already in a ALF appliance for, I believe it was six months to a year prior to coming to me for the orofacial myofunctional evaluation. Had had some expansion, but still had a ways to go. Was really high and narrow. The palate was really high and narrow prior to the growth appliance being put in. So, okay, that's what we gathered from the case history. This is before I even meet the child, that we're gathering all of this information of a very comprehensive intake. And I do share that in my upcoming MYO method course. So, as I mentioned, no other noxious oral habits beyond the extended pacifier are used till about two and a half years of age. But here's what I found during my evaluation. So oral rest posture, if we want to break it down, right, I'm not going to go through line by line and read you everything throughout the entire eval, but I'm going to break it into oral rest posture, oral prep phase. When we prep that bolus and oral phase, swallow, because those are three of the big things that we assess for and look for. And a lot of the other items that I noted during her evaluation, they all kind of fall under these sections, which is why I'm breaking it down for you all this way. So regarding her oral rest posture, we know that in myofunctional therapy, our big goal, okay, is tongue up on the palate, teeth slightly apart, lips closed, nasal breathing, right? And we've even, like, made songs about this. We've made cute little sayings. And anyways, as long as you can remember and you visualize this, right? And try to do this yourself. If you're driving, you can do this. You don't have to take your eyes off the road. Suction your tongue to your palate, lightly put your teeth almost together but slightly apart, close your lips, and breathe through your nose. If that's challenging for you, I highly recommend an orofacial myofunctional evaluation, number one. Number two, go ahead and continue mouth breathing if that's what you need to do right now. Because if you don't have a patent airway, meaning you can't easily nasal breathe, there's obstruction or something getting in the way of that happening. You can't force it. So we need to figure out why. Right? And our body is going to put you into whichever state it needs to be in to survive, and we have to breathe to live. So if you need to mouth breathe right now because there's obstruction and that's keeping you from breathing through your nose, then that is your current situation. It can be changed, but that's currently where you're at, right? So I'm looking to see in my evaluations are these children, when they come and they sit in front of me, I don't. I don't ask them to show me, like, oh, hey, how is. How does your mouth usually look like, Is that how your mouth usually looks? They have no clue. Most often, the parents of these kids have no clue. And so I will wait until the child is, like, a little bit more relaxed with me. I mean, you can see it when they're walking back to your office or when they initially log on to a zoom or whatever the case may be. You can typically see their natural or rest posture, but if they're anxious at all, or you might not get a good read on that until they're more relaxed later in the evaluation. And you just need to be looking for it in order to really, truly, really capture their true oral rest posture. Because if they know you're watching, they may try to close their mouth because they've been told all their life, close your mouth, close your mouth, close your mouth. You know, or maybe their parents don't say that and they don't. But I've had a lot of kids who appear to have really great oral rest postures just from a distance, from afar, until they got really comfortable towards the end of the evaluation. And all of a sudden, like the jaw relaxes, the orofacial muscles relax a little bit and now they're truly in their natural resting state and they're lips are about 8 to 10 millimeters apart, right? There's that like inter labial gap between the upper and lower lip. And I'm going, okay, there it is, there's that. There's their oral rest posture, which is not what we want. Tongue is down and forward, lips are apart. Right. So anyways, what did I see with this child? Well, open mouth, mouth breathing lips were incompetent. And we often say that in a myo eval. But for this patient, she truly could not. She could bring her lips together if she tried. But, but her upper central incisors and lateral incisors, they were tipped labially, so they were tipped towards the upper lip. And then so were her bottom teeth, her lower incisors. And so she actually rested her upper central incisors on, she had them impinged or resting on her lower lip at rest. And so she really physically, at this point in her orthodontic plan and her anatomy, right. Her occlusion or malocclusion, it does not allow her to close her lips. That was really interesting because this came up during the study club and I actually had some therapists reach out to me afterwards and say, you know, hey, I never would have realized that I shouldn't be working on closing the lips at rest yet. Right. I never realized that that was even something that I should consider because our goals are always close the lips, close the lips, close the lips, breathe through your nose, breathe through your nose. And like she doesn't anything that is, she has patent nasal air. You know, we've looked at her airway, we, she's got allergies under control. There's no reason why she can't currently breathe through her nose. No concerns of enlarged tonsils or adenoids. Right. So why wouldn't we work on that? Well, she physically can't achieve that with the way that her upper and lower central incisors are positioned. It's just not, it's not going to happen without a lot of tension and overworking the surrounding orofacial muscles. So, you know, she would be a case where we'd have to address that once it's appropriate, based on her orthodontic appliance and the movement that we get. Because once the bite starts to allow for the lips to properly come together at rest, then we can start to address nasal breathing, closed mouth at rest. Right. So anyways, I wanted to share that. She also had an inter labial gap, depending on the moment, somewhere between 7 to 10 millimeters, which is. It's significant. That's a pretty good size gap between her upper and lower lip at rest, especially when we really want them to be together at rest. Her masseters were strong but uneven. She had the right side protruded a little bit more. Um, the left side looked really underdeveloped. Her mentalis was overdeveloped. A lot of bunching, especially when we tried to get her to. And we'll talk about this later, but prep food, swallow food. There was a lot of. Of bunching again. She really had a hard time closing her lips. So how do you swallow easily if you can't close your lips or easily suction your tongue to the palate, which was a whole nother thing that we'll get to. Her jaw was unstable, her jaw was moving as one unit with her tongue. So they were really working together. And we know that by 18 months of age that should no longer be the case. So she's 10 years old, but still has very young tendencies or hasn't achieved certain milestones in this department, if you will, because her anatomy hasn't allowed her to keep that in mind. She's a smart child otherwise. And I do want to add that, you know, does well in school, like no concerns with general language skills or anything like that, but really struggling with some of the other things that I mentioned, which also begs the question, you know, what is. What does her nervous system look like and you know, what have we put in place to support her there? So let's go back. So lingual mandibular differentiation, right? That tongue from the mandible as I was just talking about, she was able to protrude her tongue, but she definitely needed the support of her lips and her jaw. And we, when we asked her to, when I asked her to stick her tongue out, it went straight out and down. And you saw a divot at the tip that like snake tongue, if you will, from that, you know, traditional anterior tongue tie where you get that heart shaped tongue. She was able to work with me to get it pointed. And when she did point it and it was slightly elevated above her teeth and straight out, she was able to get a nice tip. And you didn't see the divot down the center of the tongue. You didn't see that heart shape divot down the center of the tongue despite still being interiorly tied, which was interesting. Which also goes to show, just because we can stick our tongue out and make a pointy tip doesn't mean that we're not tongue tied. But I digress. Okay, so she could not elevate her tongue with her mouth open wide. She could only do it very briefly and with a very closed jaw position. Her mandible also is retracted. Oh, and I didn't talk about lateralization. So initially she lateralized and pushed into her cheeks and then she was able to lateralize to the corners of her mouth with instruction. But her jaw moved with her tongue and her tongue moved in these gross like movements of, you know, she wasn't able to make a pointed tip with her tongue to then touch the corners of her mouth. She moved things as again one large unit. Both the tongue and the, the jaw, you know, all move together and they were not, they were not fine movements, if you will. So I mentioned that her tongue can elevate, but she really couldn't get to the spot, you know, the alveolar ridge. With her mouth open wide. She was unable to hold the tongue up there for five seconds Even with her jaw closed. It came down pretty quickly. She could not do the skinny wide tongue or where you narrow your tongue. She had trouble with getting her tongue to narrow all the way back. She could get a point at the tip and then that was about it. She could do a brief click and she could suction. But her suction was only 42% of her mouth open wide measurement. And we want it somewhere between 50 to 60%. Definitely appeared restricted during the evaluation. Her palate, like I mentioned, already high vaulted, narrow. We went over that. Then I also mentioned that her upper central incisors impinged on her lower lip. Just meaning that those upper two central teeth rested on the lower lip. That was her oral rest posture when her lips were closed. Now regarding the oral Prep phase I've mentioned she had a malocclusion and she had both a lateral and posterior open bite bilaterally. And so she was in a upper and lower alf elf, as I call it, appliance. She was a year in. She was a year in. Okay, So I couldn't remember before if she was six months in or a year. And she was a year in and still was relatively narrow. Now, keep in mind what I just said. She had both. She had a posterior open bite bilaterally. How do you chew food on your molars if they don't come together? The only two teeth, the only four teeth, I'm sorry, that touched were her upper and lower central incisors. That's it. Prior to this, she primarily chewed on one side. And so she was still trying to chew on one side. But that really messes up her jaw in order to try and accomplish this chewing motion. Because her teeth don't come together in her natural occlusion, in the natural posture that her jaws are, she really has to jut the jaw over and bring it back in a very funky way to try and break down any foods with her back teeth. Drinking. She definitely brought her tongue forward to greet the cup, as I like to say. And the same thing with using a spoon or a fork. The tongue would come forward and greet that spoon. The spoon then scraped against the upper teeth to clear upper central incisors and lateral incisors. And then she would bring it all, bring her mouth together, her lips up to the bottom of the spoon. But she would have to use her upper, central and lateral incisors against her lower lip to swallow. And there's that a lot of mentalis bunching noted when this happens. So regarding that oral face swallow, moving into that, it was interdental. We took a look at it in several different ways, but we saw that she had an interdental swallow and scattered food bolus. She still had food particles remaining on, you know, on her teeth, on her tongue and her mouth. Just in general, post a few cleanup swallows. And I share this because, you know, well, not I share this. This is not a surprise simply because this poor child, 1, has a restricted tongue and is having a hard time clearing things with her tongue. Two, is having a hard time suctioning her tongue to her palate to swallow and create that negative pressure that she could potentially do even with her mouth not so sealed. Right. If you're able to seal your tongue to the palate, you could potentially swallow that way. But when she showed us her bolus, it Also was not well prepared. It wasn't well broken down because again, she's not chewing very well. She's really mashing and she's doing a lot of the mashing with her tongue. And you could see the intense focus, the effort and the time it took her to eat something like a single goldfish cracker, for example, that was extremely effortful. So, you know, if we go back and we talk about what I saw on the intake where the parent wrote, strong food preferences, low volume of food, picky eater, doesn't like things like meat or cooked veggies. Well, I mean, even when veggies are cooked, they don't just fall apart in your mouth. Most a lot of veggies, I mean, maybe a cooked carrot, right? But think of a cooked green bean or a cooked piece of broccoli. You know, these foods still need to be chewed even if they are well steamed. Okay? So it's no wonder. And meat, forget about meat. There's no way this child could eat meat if it was not pureed for her. So yeah, it's no wonder that she doesn't like these things. And it's no wonder she has a low volume of food. It takes so much effort to mash a goldfish between her tongue and her palate that, you know, this is not a case where I necessarily would work on trying to introduce a variety of foods to her at this moment. You know, we might want to, we'll talk about referrals in a minute. But one of the referrals we might make is to a nutritionist who can help them figure out how to get more calories in, in maybe lower volume and in a way where she's getting her nutritional needs met. But we're not going to do like, I'm not going to refer for traditional feeding therapy in this 10 year old because she's got low volume of food, strong, strong food preferences and she's picky and doesn't like certain things. A lot of what we're seeing is a direct result of her orofacial myofunctional disorder, that malocclusion, the inability to properly prep and swallow these foods. She's really overexerting herself in so many different ways. So I really wanted to highlight that because, you know, as a feeding specialist, I do see young kiddos where there we do have similar issues, but they're at least able to make contact with their back molars or they, you know, they're able to break down certain foods but they, you know, really, they've restricted their food repertoire to like five foods or 10 foods. And we're really worried that they're going to keep food jagging as we call it, and start cutting out other foods that they eat regularly. And we're worried about nutrition and we're, you know, not able to reason with this three year old or this four year old the same as you might be able to with a 10 year old. Bottom line, again, hers appeared to be her. Her feeding concerns appeared to be directly related to everything that we were going to address through the MYO program. So she was not a kid who required like an oral motor feeding plan in place of a MYO program. Like I like I call it feeding with a twist of myo. So I wanted to go over that because if I got this case and she was like four or under, I probably would be taking a very different approach. But because she's older, she's cognitively intact and, and I feel that her food repertoire will increase when she has the ability to properly enjoy these foods, chew them, taste them, manage them. You know, we can work on turning them into proper food bolus and swallowing them properly. I really do feel like that will change as a result. And if it doesn't at that point then it might be worth recommending a feeding therapist and doing feeding therapy beyond the MYO program. So, so I hope that that's helpful. But in terms of treatment recommendations that I would make, I would definitely send her back to the referring dentist for a tethered oral tissue consult because we know that she had a release and it reattached. We know that it is restricted, we know that it's impairing her. Now I would send her for the consult, but I would want to work together to get her ready for a follow up release. If that was the plan, I'd want to discuss why there was reattachment. Did she not have proper pre and post op last time? Is her body just heal a certain way and we need sutures in place to help it heal properly? You know what, what could have happened? Were they given instructions but the patient was non compliant? They didn't do post op protocol. You didn't do any active wound care. What, what happened? We don't know. You know, I don't know. I don't know that without having a conversation with both the family and the release provider that did the initial release. But, so this referring dentist was not the one who did the initial release. So I would want them to, to consult with this referring provider who we work very closely with. And who basically explain what is necessary if that is one of the next steps in the treatment plan. The same provider was doing the expansion the ALF appliance. And so that was already underway. So you know, once we gain a bit and there was okay space for the tongue, but I really would want her to gain a little bit more space if we were going to do a frenectomy. And then again, like I said, you know, pre op frenectomy, you know, therapy which is really just myo before release and making sure we can get her to the point where she is really truly maximized her skills until the, you know, up to the point of going for that release followed by the release itself and then the post op therapy plan. And then, you know, obviously number three is an orofacial, is orofacial myofunctional therapy. Now this kind of overlaps with, with part two, right? Number one was that tot consult with the referring dentist. Number two was the experience expansion is already underway. So once we have enough space for the tongue, let's do this. Let's discuss doing the frenectomy and what our plan is. And then number three is just the general orofacial myofunctional therapy plan targeting, you know, for her, I want to target oral rest posture once appropriate. We want to maximize that lingual coordination. So getting that tongue to lateralize and elevate and protrude and work independently of the jaw especially and the lips and the cheeks also in her case, we want to also help her better shape that tongue so that they're not these gross movements, but they're these more fine movements and more controlled movements. And we want to make sure, like I said, the dissociation is in place. We want to get that lingual palatal suction going, make sure that's really addressed because that was not easy for her. And and then overall during the course of treatment we're going to work on improving, you know, her chew once she's able to bolus collection, you know, we have to help her. She needs to be able to eat. So we need to work with her to figure out what foods are easier to eat. You know. And this again is where we might go into the referrals next, where we might refer to a nutritionist to pull in, you know, some help with, hey, why don't you meet with this, this kiddo, find out what they like to eat, find out what they are willing to experiment with and then let's see how we could possibly get this kiddo, you know, on A nice healthy diet despite her limited ability to chew right now. And you know, so once the, once the occlusion is, is once the malocclusion, I should say is fully treated or to the ability where she can at least chew. We want to definitely work on helping her with collecting the bolus, that oral prep phase and then the swallow, you know, the swallow is something. We could start to work on that part already because if she is able to eat certain foods that are appropriate, given her current situation, she still was thrusting her tongue forward when she swallowed. She was making a lot of compensatory movements with her orofacial structures. We were seeing eye and then eye movements and she was blinking and she was grimacing and the lips and the cheeks and the mentalis and it was, there was a lot going on. She actually changed her head position, her neck position. You could see it. The, the top one third of her body was overworking to swallow. It was pretty incredible. So anyhow, so that's what I would do with her in therapy. And I wonder what you would do. Is this what you would do? Based on what I, what I shared, what order would you recommend certain treatments in? And then as far as referrals go, other than a nutritionist potentially, and referring back to the dentist, as I mentioned, are there any other referrals that you would make? Right. So for her, I definitely want her to be followed by the allergist. And she does have a rescue inhaler. I think that that's important. If she just had seasonal allergies and they were managing them, you know, with over the counter meds and they felt like it was under control, I would be less likely to say, hey, go see the allergist. Because you already, you already do that. But because she's got the rescue inhaler, it's definitely one of those things that's really good for her just to be monitored, even if it's just once in the fall and spring to make sure that her, her nasal airway remains patent because we can't achieve nasal breathing if we've got other things going on up there that's preventing it. And then the other thing too, just so that you're aware, is she already had other members on her team. So she was already being seen by an osteopathic doctor. She was also being seen by a physical therapist who's trained through the Postural Restoration Institute and doing, you know, that body work with her because she had, I didn't mention this, but her posture was just, it was very interesting. She already had that neck, that head and neck forward posture with the shoulders hunched over. One shoulder sat higher than the other shoulder. I mean, this poor girl was a mess. And so that is something that was being addressed as well because we were really trying to gain some symmetry for her throughout her whole, whole body, which was a work in progress. So anyways, you know, I know that some of you have given me feedback and you have said that you love, love, love these case study discussions. So if anybody has an interesting case that you want to share and that you want to talk through, I welcome you to email clientcare@feedthepedes. No, yeah, you can email Client Care. That's fine. Email clientcareadhepedes.com and let me know that you want to let team know that you would love to come on the podcast. You'd love to share a case. I think it really helps for our listeners to understand what we see in case histories and what we see during an evaluation and what things really stand out as needing to be addressed. And then what are recommended treatment, you know, treatment plans and is there a certain order to this treatment plan? And are there other people on the team that we need to consider? I think that the more that we have these conversations and we normalize these conversations, the more patients will understand themselves. Because we do have patients, parents of patients, we do have both providers and non providers listening to this podcast. And so my goal is for you to become well equipped with information so that you are able to better discuss this, whether you're a provider in this space, a provider looking to get into the space, or you're a patient or a parent of a patient. Because this is really important information we're discussing and I really want, you know, early intervention is key. Now I do get the question a lot. Is it too late? I'm an adult who has X, Y and z going on, or my child is 13. Is it too late? No, it's never too late. It becomes harder, arguably, especially in the adult years, it becomes harder to expand an adult palate. But it is possible. I am living proof of that. If you have symptoms of myofunctional disorder, or it's really hard for you to, you know, chew and swallow food, or you get really fatigued talking, or you have sleep issues, or you've got neck and back pain and you have this like hunched over posture to you, or, or, or, or, or. Right. We could go through a whole bunch of other things. Highly, highly, highly recommend orofacial myofunctional evaluation. And we are working to train more providers that are in this space so that it becomes a more readily available assessment that can be done and also treatment that can be completed as well so that patients don't have to go searching all over for it. Because currently it's still pretty challenging to find providers, especially out in some rural areas, that can assess and treat for myofunctional disorders. Anyways, I hope you guys enjoyed this case of this 10 year old female really cool case. And again, email clientcareadthepedes.com and let me know if you would like to come discuss your case one of your patient cases. Of course you have to get permission to do that and or let me know what other types of cases you want to hear about on the podcast. I'll talk to you guys soon. 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 untetheredpodcast 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 @HALLIEBLCAN BIZ, on Instagram at Alibulcin, 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.