Episode 149: Airway Development In Children & Across The Lifespan with Dr. Dave Singh DMD, PhD, DDSc

Hi and welcome to episode 149 of the Untethered podcast. Today we have professor and Dr. Dave Singh joining us. Dr. Singh is a US citizen who was born, educated and trained in England, UK. He holds three doctorates including Doctor of Dental Medicine, a PhD in Cleft Palate Development, and a third doctorate in Orthodontics. Dr. Singh was awarded a grant by the British Society for Developmental Biology, University of Oxford, UK and later he was appointed to the Board of Examiners, Rural College of Surgeons of England. Supported by Harvard University, the University of Michigan and the University of Hawaii. He was invited to relocate to the center for Craniofacial Disorders USA where he led an NIH funded program of clinical craniofacial research. Currently he's a Board member of the American Sleep and Breathing association, member of the World Sleep Society, Academic Fellow of the World Federation of Orthodontists, and Fellow of the International association for Orthodontics where he was awarded prizes in 2005, 2013 and 2014. He has published over 200 articles in the peer reviewed medical, dental and orthodontic literature, has published nine books and chapters and has been recently finished his new book entitled Pneumopedics and craniofacial epigenetics. Dr. Tsang was a 2019 recipient of the US Invisible Disabilities Association Award. In 2020, Dr. Singh was given a Lifetime Achievement Award for his work on sleep apnea, exemplifying leadership, excellence and entrepreneurship in service to humanity and the advancement of global health. Currently he is Founder and Chief Medical Officer, Vivos Therapeutics, Inc. And Adjunct professor in Sleep Medicine at Stanford University. Quick Disclaimer all information, content and material of this podcast are the opinions of 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 Dave, thank you so much for joining me today on the podcast. I'm really excited to have you.

Yes, good morning Hallie. It's a pleasure for me to be here. Happy New Year. New Year to you and all the listeners, thank you.

Happy New Year to you as well. So let's jump right on in and talk about how you got started in the airway world. It's a specialty, for sure. And so I'd love to hear a bit about your story.

Well, my story goes all the way back just before. Well, when I started my PhD, this is now 1988. 89. And my PhD was in cleft pallor. And one of the first things I had to do was to go back and revisit all of the anatomy and the structure and function of the. We look at the cleft palate, but really it was the airway. And so that's where my journey started. And if you fast forward, I was working in a center for craniofacial disorders, and that was looking at babies, children with cleft lip and pallor, but also teenagers who had surgery when they were younger. The new technique at that time, this is the early 2000s. Now, the new technique at that time was distraction osteogenesis, a surgical procedure. And what we were doing on these teenagers was surgically bringing the face forwards. And we found beautiful cosmetic results. Teenagers were thrilled. When I went back and looked at the MRIs, that's what we had in those days. I found this huge change in the airway. And not only that, but these kids would come back to the clinic for review and all of them would be smiling. They would all make eye contact. They were like, almost like different people. And I thought, my gosh, I think these kids are now sleeping better. They wake up feeling better, and they are refreshed and their personality starts to develop and they become mature individuals. Now remember, these kids had craniosynostosis, which means that sutures were actually fused, which is why we had to do the surgery. And then I got thinking, well, most people don't have that condition. Maybe you could use those sutures for redeveloping the mid face and therefore redeveloping the airway, and the rest is history. You know, we just got on that boat and went for it.

Yeah, I love that. I love that. It's really cool to hear how you got into it and, you know, having the imaging to look at and to kind of go, hey, the airway grew with bringing the face forward or growing the mid face. You know, it's very fascinating to me as a myofunctional therapist who looks at faces, because I'm noticing that that 3 year olds already have. We're looking and going, oh, we've got an airway problem here. And I mean we've got problems too, but I'm noticing the changes in the face as early as 3 years of age and some of these preschoolers that we treat and it's scary.

It is scary. The good thing is that we are becoming more aware of this and we are very good at screening. And of course in the last 10, 20, 30 years the technology has gone in leaps and bounds. So let's go all the way back and think about again. My area of special interest is the craniofacial anomalies, the rare cases. You don't see them very often, but when you see these cases, you'll learn a huge amount and then say, well, let me extrapolate now to say on a non complex case, what would happen? And the word I'm going to use here is neurocrystopathy, which is a funny word, but you could go all the way back to say, where did this airway develop in utero during pregnancy? And if that's a healthy airway during pregnancy, then at the early part of birth we have healthy mother baby habits. Then you get a three year old walking into your clinic who is probably going to be healthy as well. Now the reverse is also true. So neurocrystopathy is when the neural crest cells start to migrate and populate what will become the upper jaw, the lower jaw, all those parts including the airway. So if there's a deficiency of those cells, then the airway won't be big to start with, you know. And so now we're on, you know, a back burner before we even started. So that's something we screen for. Not yet, but you know, these kind of things we want to be doing in the future more often. But what I'm going to talk about here also is, apart from the genetics, is the epigenetic influences.

Yes.

You've got a three year old, comes to your office and you notice this tongue is not doing its best job. It's restricted, it's tethered, it's not doing the best thing. Now you have to question why would that term be that condition at birth? And the answer most likely is epigenetic. We don't have a huge amount of data yet, but here's my just my professional clinical kind of assessment. I just seem to see more cases, you do as well, of these kids with pretty decent freeing lingual freenae, buccal freenae. We're wondering, did we miss this a century ago or is this a relatively new phenomenon? Is it a Bit of both. And my guess is there's some epigenetic signaling going on to say that these kids are being born probably with larger or more robust frene than in the past, or we just didn't pick it up. So here's a huge amount of work we have to do to say what's going on, what can we do about it, how do we screen and then how do we treat it?

Yeah, we definitely have seen a major uptick in my practice, but we also, I always tell everybody we see a lot of it because we specialize in that. So everybody comes to us with that concern generally. But yeah, it's also an interesting conversation and I have talked a lot about epigenetics in having this conversation. Why the major uptick in, you know, tethered oral tissues and such thing as a posterior tie and you know, all these big questions. But I think it's a very fascinating conversation. We know that it's been, they've been documented for thousands of years, but in terms of the incidence, the prevalence, you know, we don't have data to compare, you know, back then now. So it's a very interesting conversation. But and it's also one that I actually have with a lot of parents and professionals because we know that swallow develops about 12 and a half weeks in utero. And so we are developing our swallow pattern that we're basically going to have for life or at least in the early infancy years, at the end of trimester. And already swallowing, we're compensating when swallowing, right, because we may have a restricted tether tissue, we may have a high narrow palate already developing. You know, these things are, these things are unfortunately already there in utero. And I think a lot of it gives moms a little bit of a, they can take a deep breath because they know something that they caused after birth. But then they sit back and they go, but hold on. I mean.

Yes, what happened exactly. Now remember that two major things to think about here in terms of a parent is that the tongue is a very complex organ. We see it as one piece of the mouth there. But actually the tongue itself in terms of development and evolution is highly, highly complex. And so when you go that degree of complexity, there's more chance that something might possibly go wrong. That's just from a structural point of view. But the thing to think about when the in utero swallow, this is a very important phenomenon. If that kid is not swallowing, the amount of amniotic fluid will actually increase. And so, you know, the obgyn all these great pediatricians already know that. I can look at the amnion to find out how this kid is behaving in utero and what makes the kid swallow. These are primitive reflexes. So we already have a reflex and mom can say, I can feel a baby kicking. Well, these are the primitive reflexes to say eventually this kid will be crawling and then walking and then biking and running. So what happens with swallowing is that you develop these very primitive reflexes. Then when you're actually born, you start to refine them and make them more sophisticated based on the environmental input that you get. And so most people will have a regular swallow reflex when they're born. But then if the reflex is used in a different way, it will produce different result like a reverse swallow or a tank thrust and all those great things that we know about, right? So that's kind of interesting. Not only that, is we know that some of these babies, preterm babies, they thumb suck, they sometimes they suck their big toe in uterine. Okay? Again, these are reflexes. When a baby or the, you know, the fetus at the time is sucking their finger or thumb or even the toe, they are going to develop that habit in utero because it makes them feel good. This is a reflex saying when you get contact between the palate and what they think is the tongue, do more of that. It's a survival reflex. And then what happens when they're born if they are not, let's say, breastfed sufficiently, that kid may develop a thumb sucking, digit sucking habit or something else. Now I know this from my own experience as a parent, my son, okay, so what I noticed is that he started to suck his thumb and I thought, well, what do I do here? Right? So he's in college now and all that great stuff. But so what do I do here? And I think to myself, you know, we know all the theory and all that kind of stuff, but here we are as a parent, what do I do? I'm thinking, why is he sucking this thumb? Well, he gets a feel good factor. Endorphin release, it's a sense of security when you have this contact with the palate. So I thought, but at the same time, it's not doing his orofacial development the best that he could get. What I did is a little in house experiment. When I saw him sucking his thumb, I would go over to him and hug him. And then when he stopped sucking the thumb and whilst he was sucking it, I would gently just remove the thumb from his mouth and I did that. Continuously to the point where when he wants to suck his thumb, he just came to dad and got a hug instead.

Oh, he knew that feel good input. That's amazing.

Kids learn, you can teach them stuff. And this is the beauty of this orofacial system is we have motor control here and we can go back, do some neuroplasticity and actually get these pathways moving and use them to our advantage. And this is not rocket science. We've been doing this forever. And so there's so many options that we have to realize, well, what I'm going to do with this particular case, it may be something different in a different case, but we have options.

Yeah, no. And I think I always say you can take away a pacifier but you can't take away a thumb. Right. So it's challenging when we have these kids who suck their thumbs. And I been on my own interesting journey just as a myofunctional therapist with myself, with both of my kids. You know, my both of my kids had their tongue ties released. I had mine as well. My first daughter had hers at 24 months when we discovered it because I'd been turned away so much saying nope, she's fine, she's fine. That threw me into the rabbit hole of all things tethered oral tissues and airway. And I looked back at my second one was released day five when we noticed the same symptoms. So she was then they both their own journeys following that. And for my now 6 year old, you know, she's gone into an early expansion appliance. Her tonsils decreased as a result of being in that appliance. She's a very healthy kiddo. But when I look back at her baby photos, she was that kid who threw herself onto her belly to sleep airway. She threw her bottom up in the air and tripod slept because airway her mouth wasn't open in a lot more photos than I realized. When I go back and look at it now, now being in this space and I was like, oh my goodness, if I then what I know now and just treat after that with my second daughter, I was like, okay, we're doing things differently. Here we go.

Well, the great thing about kids is that they learn how to cope and how to compensate if they're given that opportunity. Some kids are not. And again, there are some pretty serious topics here. I got involved in sids, Sudden infant death Syndrome. And the conclusion we reached going back a few years now was that we don't have sufficient craniofacial information to say what's going on with these kids. And so part of it is reflex, part of it is sleep apnea, part of it is airway collapse, so on and so forth. Part of it is, you know, the arousal threshold. Some kids have a very high threshold. In other words, you can't wake them up easily. Other kids are the reverse. And they just, you know, a little sound or something, they suddenly wake up. The funny thing about the airway is that we're talking about the upper airway here. So let's make a distinction between we say airway, we're talking about the upper part of the airway. The lower part of the airway, of course, is the lungs and all that great stuff. So we're talking just the upper part. It has a pretty nice developmental pathway. Like every other organ of the body, it doesn't grow in a straight line. And so what we know now is that when the child is born, the airway starts to increase in volume. As this child grows, there's a certain peak that it reaches in, I'll call mid childhood, this is pre adolescent kids, and then goes a little bit flat. And then right around the age of puberty, it grows again. And by the time it reached, let's say, 25, 30 years old, you've got a stable, mature adult airway which should keep its volume structure. And then at the age of about 60, maybe 65, you start to see the slight decline in the volume of the airway. So the airway itself is. The upper airway is an organ. It's got its own behavior. The question is, what made it change its volume during this time of growth and development? Well, a big part of it is the adenoids, the tonsils on all of those tissues which surround the airway. And the tonsils and tissues, they have their own temporal spatial patterning. At a certain time, at a certain place, they grow and develop, and then they're supposed to go away. Classically, by the age of about 15, 16, all your tonsils should have regressed and your airway volume increases. But we're seeing that less and less often in our modern kids. There are adults out there who still have pretty decent tonsils. And of course, that's the immune system. And we have changed our environment so much that our natural immune patterns have been changed quite a lot. So we have the tubal tonsils, which go around the ears, we've got the adenoids, we've got the palatine tonsils, and then we've got tonsils in the tank. The whole of the upper airway is surrounded by a circle of lymph nodes. That job is to prevent infections coming in into the airway, but because they're still there, they end up with a side effect, which is upper airway obstruction. This is where the oral myofunctional therapist comes in, looks at the tongue. The ENT comes in, looks at tubal tonsils. The dentist can come and look at the palatine tonsils. And between us, we've going to say this child may need an intervention to say that this is how we're going to allow that airway to get back onto its developmental pathway at a certain age.

Yeah, that's another interesting topic with the tonsils, because it's been challenging to find a collaborative approach in the D.C. metro area. And we obviously can look in the mouth and see if there's some enlarged tissue in the back and then make an appropriate referral further. But oftentimes these kids are getting turned away. And that happened to my own daughter. And I said, you know, I don't necessarily want a surgery. I don't necessarily want, you know, to put a steroid spray up her nose every day either. I'm just trying to figure out, what do we do to open her airway. And thankfully, a good friend of mine I learned was an airway centric dentist who was using a variety of growth appliances. That's where I did my vivos DNA appliance with her. And my daughter went into an ALS at the age of four. And, you know, it was. It was incredible to see what happens when there was some support and, you know, opening the suture lines and growing the palate forward, you know, laterally, and to see the tonsils decrease and stay, you know, minimal with an open airway during cold and flu season. Nonetheless, three months into, having this appliance in her mouth was just phenomenal. It was very, very exciting. I wasn't anticipating that, but it was a really great side effect.

Absolutely. Well, you know, the great thing is that some of these kids respond really well and really fast. But it's a bit of a coin flip because what the studies show is approximately half these cases respond really well and the other half don't. And reverse is also true. What I mean BY that is 50% of the kids who get the tonsils and adenoids removed, the airway doesn't improve much. Now they will need a device after the surgery to say, let's see what we can do to recover the airway. The other side of it is some of the kids, you give them a device to begin with, and the tonsils regress and you don't need the surgery. And so the question is, well, why would the airway not get bigger after the surgery's been done, you remove all that tissue. And the answer is, you know, healing, scarring, fibrosis, you know, is that the tissues came back together and they actually shrunk a little bit. They didn't actually shrink. They just didn't grow. Okay. And so this is where it becomes very important to say which protocol for which patient and why. Patient selection is very, very high on the list of things to do. And so I actually spoke at an ENT meeting. It was last year. Hold on. What year are we in? We're in 2022, right? Yes, it was last year. And there was half the group of the ents were very traditional, conventional, saying, here's our rules for removing tonsils. And the other group was thinking, well, apart from the infectious disease, we've got to think about obstructive disease. And so there was a very healthy discussion about, with the ENT saying, who is going to do what and when and how. And the answer is, there has to be much more collaboration to say, we'll do this procedure on this child. And here's the reasons why.

Absolutely, absolutely. And that's the collaboration that I know we're all seeking in the myofunctional therapy world. So we look forward to more of that because that really, it brings the best outcomes for our patients, and we get very excited. I know a lot of the therapists in my membership and my program, they're seeking that. That team, and they get very excited when they find it, because it really, truly is incredible when we can come to these results for our patients together. So I have a question for you. Does vivos have an appliance you can use with young children? Is there something available right now? Or how young do the appliances generally begin?

Well, age is not really the factor. The main deal is what is the diagnosis, what is a treatment plan, what's the prognosis kind of thing. So if you say to me, what's the youngest child that you would consider treating with a vivo type of device? You know, the youngest kid that I can remember that we did way back when was about 4 years old. And so the bottom line is if all the deciduous teeth are fully erupted and in occlusion, so you can get a device, you know, to be retentive there, then there's no contraindication per se, in terms of age. So, you know, for the youngest kid, I remember the first kid that we did was like 4 years old, and she did extremely well. Now, remember that the device, what it's really doing is retaining space. And so you're thinking, I need oral volume. The oral volume has to be done in correlation to the facial structure. So basically, you put the device in the patient's mouth. If that kid can keep their lips together, they will automatically suck air through their nose and become a nasal breather. And we've got videos showing that all you do is give the kid the device they put in the mouth. The lips come together, now you've got an oral seal, which means the oral volume is bigger than the nasal volume. And because those two parts communicate behind the palate, you're sucking air through. It's simple physics. You suck air through your nose. That's called nasal breathing. So we did seven kids in a. It wasn't a. It was a training seminar that we had. And we had seven brand new little kids in the waiting room. And I always kind of quiz the kid because I'm going to see how good they are. Compliance and variance. And so I gave them a device, and first question to say is, do you know which way around it is? You know, 99% of kids get it the right way around on the first thing, on the first girl, it's not my device, it's your device. So which way? Then I said, can you pop this in your mouth? Because they know which way it goes, they pop it in. And then we watch them. And if they conceal their lips, they're gonna automatically breathe through their nose. And then I say, it's mom and dad next, you know, because this kid knows what to do. Now we just got to get the protocol going, get them wearing the device like any other device, you know, for several hours, prolonged wear. We did all six kids, and they were perfect. Kid number seven comes in, we do the same routine. We pop the device in his mouth. Ten seconds later, the device is on the floor. What it is, is preformed devices work in most cases, most of the time. But the exception proves the rule. Because when these devices were designed, they used a whole bunch of American kids from the Midwest and said, this is the kind of device that probably will work. Well, that demographic has changed. We have kids of African American descent, we have kids of Asian descent, we have kids of Latino descent. And it might work, and we hope it does, but it don't say that. Don't make the assumption it's going to work. So this is why we have to customize the device for that particular child if the generic versions don't work, and either way, we're good to go.

That makes sense. That's phenomenal. And thank you for that, because I know that's one of the big questions we often get is, is there a certain age that we can start? What do we need to look for? What are the certain markers? And so I think that's very helpful. The other question I know that we get quite a bit is, what about all this pushback? I know we're focused on kids and airway, but adults, right? Well, you know, can you actually get skeletal expansion using like the vivos DNA appliance, or are we teeth? Do you have a response for that?

Oh, absolutely. You know, as you know, I've been a professor of orthodontics for several years. I'm getting old, okay? And so the way I was taught was that when you become an adult, your sutures are completely closed and fused together. And I believed it. Well, that information came from the previous century where we did not have even X ray technology. And so the way we were told was using a dried skull and they would show you that the suture is completely fused. And we said, great, we're good to go. Then we came along with X rays and we looked at the sutures again and said, it looks a little bit different from the dried skull, but it's only an X ray, it's only in 2D, so we just can let it go. And then we came with 3D CAL beam, the 3D scans, and we look at the suture again in 3D. And in those cases, that suture is, quote, wide open. You know, now I say wide open again, talking biological opening. Okay? So what we can do is actually measure how wide is a suture, because a suture is not like a dried skull. It's got all the organic components, it's got fluid, extracellular matrix, it's got collagen. And the big thing is it's got cells. So we went back and said, well, what cells do we find inside the suture? And the answer is stem cells. It's like, what? Yes. Yeah. So what we know now is that the sutures are a niche or a niche for the stem cells. And what that means is when you're growing and developing, you need more cells. The stem cells are going to differentiate, make bone cells. The bone cells will then lay down bone. As long as you got stem cells, you can keep on making bone. So two examples is, let's say you get a jaw fracture, okay? You break your jaw or you get a jaw surgery. Okay. How is that bone going to heal? But it's going to heal by recruiting stem cells both from the periosteum, from the sutures, and some other kind of sources as well. Cell recruitment, okay? And so we know that for all of your life, you have the ability to heal bound using the stem cell differentiation. Okay? So now we're not going to break the bowel, we're just going to gently stretch that suture. What the studies have shown is if you stretch the suture, the suture thinks it's growing. Tensile stress. There are stretch sensitive genes, and those genes switch on and they make proteins, including enzymes, which say stem cell become a osteoblast, a bone forming cell, and make new bone to resist the tensile striatus. And it's a slow procedure. You know, it's a biological procedure. You know, when the kid is sleeping, that's when they're growing, that's when the growth hormone is produced. Okay. And so with these cells, you get this very gentle stretch and the body will respond. Okay. Now we did a study, okay? So we do all this stuff, right? Then we go back and let's do the study. We compared the sutures in regular patient, adult patients and adult patients with Ms. Multiple sclerosis. Okay. And what did we find? We measured the sutral width, and in the regular patients, the suture width was, as predicted, about a quarter of a millimeter. That's 250 microns. It's a pretty small amount, but it's typically what we find in the Ms. Patients. It was almost double. And so we know that they have suture mobility in Ms. Cases, and maybe that's why they get some of the neuronal kind of trauma and, and pathological effects. But going back to the control case, 20 0.25 millimeters is 250 microns. So when we turn the little screw on this device, how much do we turn it by? 0.25 millimeters. So the dental profession, the orthodontists, historically by trial and error, realize that a quarter of a millimeter seems to work. And now we know why. So when the information starts to converge, you're probably on the right track. And we haven't got 100%, but clinically, you know, it's making a lot of sense. Most studies have to be done, and they are being done. But I can say that based on our own clinical experience, even in adults, we can get some pretty decent responses.

Yeah. Now that I remember my dentist saying to me, how does your tongue feel? Does your tongue feel like. If it's. I'm a myofunctional therapist, she can ask me, and I can give her an accurate response here. Does your tongue fit in your palate? And I remember saying to her, she's like, do you think you're, like, close to being done? Like, I'm happy with how things are looking, but what does it feel like to you? And I was like, no, the back of my fit yet. We need to keep going. I was in for about 24 months, and I noticed for me, about halfway through, it slowed down. But I also have an airway that I'm still dealing with and I probably should have dealt with, you know, before or during expansion. I don't think I'm done with expansion yet, but my deviated septum. I know I've got enlarged turbinates. I am now seeking my ENT down here in Florida to basically fix my nose and fix my airway at the entry point of my nose.

Well, I think that's a very relevant point because we have to look at all of this upper airway, at least in two ways. One of it is structural, which we've talked about. The second is functional. And so, again, we have a very complex biological system here. And what this system will do is it will regress to homeostasis. And what that means is it wants to be in balance. So let's take an example. Let's take your blood pressure. The blood pressure is. If you've got exercising, you're working out, blood pressure goes up. When you start to relax, it goes down again. It gets a kind of basal rate. You know, now it can get out of control. Hypertension means you've got high blood pressure all the time, which is not good. It's pathologic. Let's take body temperature. When you go to sleep, body says, this is my time to conserve energy. And your core body temperature decreases during sleep, okay? And then when you wake up in the morning, your metabolism is going to rewake and you're going to warm up the body again. But what if you didn't get good sleep? If you didn't get good sleep, you didn't save the energy during nighttime. And during the daytime, your body's saying, well, I need to conserve energy. And if you check your fingers and your toes, you feel cold, okay? You feel sleepy. During the day, you might have some chronic pain, such as tmj, headaches or back pain. And so what I'm trying to say here is that all of These structural elements are in biological balance, homeostasis, including the nasal airway. I can go in, or my ENT colleague can go in and give you a huge, big nasal cavity, but there's no guarantee that you will become a nasal breather. We've just written a new book. I wrote a chapter. All my ENT colleagues got together and said, let's write a book on this thing. So they invited me to write a chapter on, would you believe it, nasal maxillary, you know, parts of things. The conclusion after doing all this review is that again, it's about 50, 50, when you do a nasal surgery, about 50% of those mouth breathers become nasal breathers and the other 50% don't. So what is the conclusion is that before you do the nasal surgery, how about doing some nasal exercises? Now, here's a very interesting point, because everyone knows this, that we need oxygen to breathe and oxygen to live and so on and so forth. The way the body does it, it does it the other way around. Yes, I need oxygen for all of these metabolic processes, but my control system is not going to be based on oxygen. My control system is going to be based on carbon dioxide. And so what we want to do is very carefully control how much carbon dioxide is coming into our body through our nasal airway, and that's going to regulate our breathing. So that's a very big topic. Nasal breathing. And the controlled nasal breathing is a huge topic. It brings you straight into neurology and the neurologic controls. But the bottom line here is that nasal breathing, oral myofunctional therapy, all of this is in the hands of clinicians like yourselves. This is not rocket science. We can teach, train, show patients how to nasal breathe prior to surgery. I think that's a very important step.

Absolutely. And I love that you brought that up, because that is something that we do. And our goal, right, in our practice, we treat holistically, we look for the root cause. But our goal is to avoid a procedure if we don't need one, whether that's on a restricted tissue, if that's, you know, on the nose, if that's, you know, tonsils, adenoids, whatever, really, you know, obviously we're going to do it if it's necessary, and if the team feels like that's what this patient needs and the, you know, child is on board, or the adult in some cases. But it's one of those things where we do try to exhaust all options from a therapeutic, you know, a behavioral therapeutic standpoint and intervention through myofunctional. Therapy and breathing re education. And I always say, you know, I'm, I'm that perfect example of. I've, I've been in myo, it feels like for six years now because I treat patients right and so myself into my. I know I can breathe through my nose during the day, but I know that it's not the past of least, of least resistance. And being that it's challenging. I know now and it's gotten worse. I know now mouth breathing at night. I have woken up with headaches, you know, recently, which is a new symptom for me. And I'm, you know, I'm aware that I'm not getting restful sleep. I am not. Right, not healthy sleep, right. So that's really pushed me over the edge to do go look into the consult with the ENT at this point because I also have my maxilla turned in on one side. And with working with an osteopath and a physical therapist who used what he called modern counter strain technique and doing the bodywork and the myo and the vivos DNA appliance and just needs hygiene and then also focusing on what is my mouth doing, what is my nose doing, what is my tongue doing. I've really done a lot on the front end. And so for me I'm like, well, this is unfortunately my next step.

Well, you know, you touched on a very, very big topic there, which is, you know, the sleep hygiene. And you know, if you want to have a good night's sleep, you need to have a good day before it to have a good night's sleep. This is, you know, circadian rhythm. You know, we can't have a crazy weird day and then expect to have a decent night's sleep. It doesn't work that way. You have to set yourself up for success. You have to set yourself up for successful sleep. And let's talk about kids now, okay? And kids are in a learning mode, okay? They're going to say, this is how I go to sleep. This is my personal childhood experience. When we were kids, it was nine o' clock and it's bedtime and you know, that's it, you're going to bed. You know, now we would kind of sneak down the stairs and try to watch TV or whatever. But 9 o' clock was bedtime. So we got into this very good sleep routine. And it's simple things that we have to do now. We have to think about what did we eat during the day and when did we eat in. So if you have this very nice big Heavy meal right before bedtime, you know, it's going to be difficult to sleep. You might get some reflux and stuff going on. So you need to plan ahead, saying, this is what I eat, you know, this is what I'll drink. Because if you want to sleep and you had a really big drink before bedtime, you're going to wake up halfway through the night and go to the bathroom. Okay, so part of it is saying, let me plan for a success, successful night's sleep. What did I eat during the day? Did I have my, you know, standard American diet, the SAD diet, which is an inflammatory diet? Is that what I had? I had a lot of soda, a lot of junk food, a lot of fast food. This is what the studies are showing, saying the child ate a bunch of junk food during the day and then they didn't get good sleep at night. What they did in these studies is done in actually in Asia, China, I think, and different places, and Korea. And I'm sorry, I just got distracted. The beautiful hawk just went by my window. So I just saw it going there. Anyway, so these studies were done in Asia and they were comparing kids on a traditional Asian diet. Healthy fruit, veg, all great stuff. And kids on a modern diet in Asia, you know, soda pop, you know, the burgers, the whole works. And what they found is the kids on the junk food diet had worse sleep than the kids on the traditional diet. And then what it did is said, okay, so what? Well, the deal is that those kids on the traditional diet also got higher scores in their sleep and their school tests compared to the kids on the gen diet. So if you're successful sleep, get ready for successful sleep during the day. So diet is a big part of it. Number two is what we've done with our environment is that we have totally, you know, changed it. Right, right. So part of it is we have a TV in the bedroom. And so the TV with the blue screen is like, no, what we need is we don't want blue light. Blue light is going to suppress milit. What we want to do is have a room which is free of any light, artificial light, if you want, like we do, we have blackout screens. So it's very, very dark. Okay. And the room temperature is a little bit below the living room temperature. Okay, so what are we doing here? Well, this is a thing called biomimetics. We're copying nature. Human sleep is a microform of hibernation. So here's our little cuddly black bear. It's going to hibernate for the winter before it does. So it eats a ton of food. Okay? And very specific food, at least traditionally. The kind of foods that bears eat classically would be, you know, things like fish, which are high in fat, and berries and fruit, which are high in fructose. The fructose gets converted to fat, then they make themselves a dentist. The den is very dark, okay? They're gonna make it snug because they're going to decrease their body temperature, but they're going to get peripheral vasodilation. The outside of the body is going to be warm. And so the den heats up. It's very quiet. It's cold and it's dark. And they sleep for three months. Now take that and make a microphone, okay? We'll do it for eight hours. Slightly colder, nice and dark, you had the right food, and you sleep like a baby. Okay? So that is if you want to have successful sleep. And if we're not doing that, if we've got a device with a computer, with a cell phone, with a TV screen in the bedroom, that's the wrong signal for the body. Okay? So talk about diet, you talk about lifestyle. What about exercise? Okay. Or keep fit. We want to have to the point where you are physically a little bit tired and your body wants to sleep. Because when you get into stage three sleep and REM sleep, you have muscle paralysis. All the recovery, all the growth, all the repair, all the regeneration happens in deep sleep. If you're not getting that, then you're not going to age very well. So how do you know that you had really good sleep? Well, a couple of things happen. Number one is you bounce out of bed and you can remember all your dreams. If you know your last dream, when you woke up, you are in REM sleep, which is the perfect time to wake up right after rem, okay? And your body wants to get up out of bed and, you know, what's it called? Carpe diem. You know, grab the day, go for it. You know, that is the feeling that we want to get. I don't mind how you do it, but you want to bounce out of bed and grab that day and go for it. You know, and there's other things that we can talk about as well in terms of how you'd achieve that. But again, you train yourself. You can't do that overnight. Gradually, you train yourself how to get very good, decent sleep. And no one's perfect. You're gonna have a bad night's sleep. You got. Maybe something's worrying you, you get some stress but generally speaking, you want to have good, deep, sound sleep, both for children and for adults.

Yeah, no, that's. Sleep is a big topic in our house. And I always joke with my husband, I say, well, the reason why our children are so smart is because, you know, I was always eating organic, but I got really strict before getting pregnant. I was really strict in pregnancy. And we are really strict now where we eat. You know, they're children, so I allow some things occasionally. But we're a household where I don't allow red dyes or any dyes at all. You know, everything is organic, cashew raised, you know, yes, they have sugar. They're children. But we try to, you know, within reason. My kids have never had soda. They've never had fast food. To my daughter last week, oh, well, they have chicken nuggets. They're kind of like McDonald's chicken nuggets. And she was like, what's McDonald's? Chicken nuggets. And some other. Well, Dune said that they're. It's fake chicken. And so she comes home and tells us this story. And I was like, this is a very interesting conversation amongst six year olds. And then I. I was laughing because my child had no idea what McDonald's was. So I was like, I feel. I feel like I did something right as a parent.

That's amazing. Yeah, that's the first for me, you know, because the marketing is so good, it's so subtle, it's so successful that it's a rite of passage, you know, that's what you do. But I think you're right. Wholesome discipline is what it's about. You don't want to be hard or harsh on yourself. It's like, have a healthy degree of, you know, discipline. And, hey, you can lay your head down and do something, you know, once in a while. Nothing wrong with that, you know. And so I think kids are very smart and you give them guides and hints and they'll figure it out. You know, it's like, these are very smart little kids that we have. You know, we are by definition Homo sapiens. We're supposed to be the smart people, you know, so come on, let's. Let's see your smarts. You know, and so, yeah, there's a lot of things going on there. You know, the environment has changed dramatically. We have changed artificial lighting dramatically. And we're trying to do things at super speed. It's like, slow down a second, you know, just take a breath, you know, and there is a balance that we have to achieve in our Lives. And I think what the trend is, have a slightly shorter working week and, you know, let's live a little bit, you know, because you can work and do studies and whatever, but at the same time, you have to balance it out with, you know, it's like day and night, male and female, black and white. Everything is in balance, you know, and that's what we have to achieve in our lives, if you possibly can, from every aspect. So we talk about lifestyle, we talked about diet, we talked about sleep. You've got to think about relaxation, you've got to think about, you know, yoga, massage, meditation, unwind. Let's just get that out of your system. Allow your brain to say, okay, I can take some time out and just relax. Okay. There are several things like that that we tend to take for granted. But we're humans, you know, we've got these certain biological limitations. Whether we like it or not, there's so many things we can do. We can send people to outer space. That is becoming a big deal now where people are going into outer space as a space tourist. Excellent. So here's an interesting thing. And two identical screens. One of them is a military guy and the other guy's, you know, a regular guy, right? So the military guy said, and these are both famous people. And I forgot the name of hand, but they're very famous people. And so the military guy says, I'm going to take a space flight, okay. And see how it works out for me. Great. So he went out into outer space, okay. Came back, landed safe, everything. Then what they did is compared his DNA versus his identical twin brother. There was a 7% change in his DNA structure.

Wow.

Just by changing the environment, you change the way the genes are expressed. We control our environment. We can put light, heat, humidity, so many things. And so just be aware of that, that you're not an island. You live in context and try to be the best one that you can.

Yeah. That's so fascinating. That's really cool to see, you know, to hear about that. I had no idea. And I'm a big believer in epigenetics and environment and controlling what we have the ability to control to a certain extent, like these things that you've talked about. Because we see it firsthand. We see it when patients make these changes. When I've made these changes in my own family, it's like I worry about everybody else and get them all going. I'm like, the kids are good now. We still need an appliance for my 4 year old. We need to maybe put my 6 year old into a lip bumper to bring her mandible forward a little bit, but otherwise she's doing really well, you know, And I'm over here going, okay, I need to really finish my own treatment plan to, you know, put yourself last. But it's fascinating though, when we really sit down and we look at all the pieces and we listen to what's being found in the research because it's, it's very exciting, it's very interesting.

Well, it's interesting that you mentioned all the bits because the other bit that we really haven't mentioned yet is the sinuses. And that comes in big time with breathing, mouth breathing, allergies, you name it, ENT collaboration, so on and so forth. Now, why is it so important? The big question we were always asked as students was we don't really know what we have. Sinuses, you know, we're not really sure why we have them. If you go back now, because research just moves on, studies keep moving on. They went all the way back in the fossil record to find out when did sinuses first appear? And the answer is theropod. Dinosaurs. Long story real short, there's two groups of dinosaurs, ones that have the sinuses and ones that don't. Long story real short. The dinosaurs that had sinuses eventually became birds, because what the scientists do is they lighten the skull and they lighten the bones, and therefore it's easier to fly. Now we've got to think about breathing during flight. And breathing during flight is very different from breathing on the land and breathing underwater like mammals, like whales and dolphins, all the great things. How do they breathe in the water? And so the long story real short is that the sinuses, human sinuses, are probably vestigial organs of breathing. So how do we use them today? Well, what happens is that the body is producing nitric oxide. Nitric oxide is your friend. It's the molecule that protects against tissue damage, inflammation, aging, all of that great stuff. And so the body wants to produce large amounts of nitric oxide. So where do you think it puts it? It puts it in sinuses. So your cells that are in your sinuses, their job now is to produce nitric oxide. Now, if you're not nasal breathing, what happens to the nitric oxide? It's sitting there not doing its job. It can't do anything because it's a storage place. So when you breathe in through your nose, the air passes by the sinus, picks up the nitric oxide, takes it all the way down to the pulmonary alveoli the lungs, and you get excellent gas exchange, you get good oxygenation. And that nitric oxide is produced in other parts of the body. It's good for joint health, for blood vessels. You know, the whole metabolic system of the body is based on nitric oxide. And so there's an upside here. So if our kids have well developed orofacial structures, it's probably going to include their sinuses. And then what's behind that? You got your ears. Right now we're thinking, well, what are ears got to do? I've got. The kids got ear, you know, grommets in the ears and all that kind of stuff. What is going on with these children's ears? Because as an oral myofunctional therapist, you see this every day. The kids got ear stuff, they've got nasal stuff, they've got oral stuff going on. This is not a coincidence, because this craniofacial system all works together. And remember, one thing is that when the child's ears are developing, the ear tubes are surrounded by tonsillar tissue. And if that tonsilla tissue is hypertrophic because of allergies, they're going to get ears that are blocked, ear tubes that are blocked. And so this is where we're going to go from first principles and saying, how does the body normally develop? Which directions are going in right now? And who is a therapist is going to help us to get past these issues that we face? And so there's a lot of stuff here that's coming together. And this is why I like to talk about craniofacial sleep medicine, for example. It's not just the mouth, it's not the nose, it's not the sinuses. All of this actually works together. It's a complete, you know, craniofacial system here is pretty complex. But we have people specialize, like oral myoflex therapists. They specialize and say, we can do this part of it, the ENT can do this part of it, the dentist can do this part of it, so on and so forth. And between us, we can get a high rate of success. That's my belief.

Yeah. No, absolutely. And that's exactly what we see. We see that when the team really works together and figures out what that individual needs, because we all really preach individualized treatment plans, even within the MYO paradigm. You know, we have to look at that individual patient. And that's where I love. I love looking at a scan with a team sitting around a table together and all talking about the different things that we see. And this is something that my study club did pre pandemic. They'd come sit at my kitchen table, we would bring some cases together. We had the pt, who was also an osteopath. We had his, you know, osteopath wife with him. We had the airway centric dentist, we had, you know, myself, the myotherapist, and some of my colleagues. We had a vision therapist as well, who join us amongst other colleagues. And we would all sit at the table. And it was so fascinating to have a conversation from everybody's different training and perspective, because what they saw was a little bit different than what I was seeing. But together it all made that, it all made sense. It was a cohesive, truly holistic viewpoint at that patient. And then we had the best treatment plan in place possible. And I know that not everybody can sit around each other's kitchen tables doing this all the time, but we can definitely share scans, share reports, share findings about what the next steps are.

Well, we know we did some studies with our chiropractic colleagues because posture is a very big topic of discussion. The way the body developed is from the top down, head down, but functionally it's from the feet up. What I mean by that is you got a little baby learns how to crawl. Now when it starts to crawl, it's going to have horizontal gaze. And so it tilts its head up whilst it's crawling, looks straight ahead, and that's how you get the curvature in the back of the neck. Then this kid learns how to stand. And to prevent them from falling over, they develop lordosis in the back. So that's how you get your spinal curvature. Okay, now what happens is the craniofacial is developing from the top down. The body is developing from the feet up. They have to meet somewhere. Those gradients meet at C1, C2, which is the first one or two cervical vertebrae. Well, what if those vertebrae aren't well aligned? It means everything's going to have to compensate. The head is going to compensate. You're going to have head forwarded posture, you're going to have head tilt. The shoulders will be asymmetric. It goes all the way down to the feet. And so what I usually say generically is align the body, align the jaws and then align the teeth in that sequence. Great. But what is your stability factor when you've done that? Well, that's called the soft tissues, that's called the tongue, that's called function, that's called breathing. So once you've got the structural elements in place. Now we have to build instability and we have to build in a support system. And that's why you don't have a single tissue, like skeletal tissue, dental tissue. You have the soft tissues, such as the tongue, the muscles, and so on and so forth. And the big thing that you have are the functional spaces, such as the upper airway for breathing. Right. So none of this comes as a surprise to us, but we're all coming together to converge, to say, everybody. It's like a big mosaic. The big picture is a big jigsaw. Everyone plays their part, the pieces start to fit, and you see the beautiful picture starting to emerge.

Yeah, absolutely. This has been phenomenal, and I'm glad we, you know, it's almost like a crash course in all things hard, soft tissue, myo, sleep, airway. Thank you. This has been so, so good. Are there any last things that we haven't talked about that you want to add in before we start to wrap up today?

Well, I think, you know, prevention is better than cure. And so let's have some awareness, education, information. You don't know what you don't know. So let's share this. There's so much information out there. And then once you've got a little bit of information, you can start thinking about screening and prevention. And that's when the story really starts. And so, you know, if you have a healthy baby, you got to think what happens prior to pregnancy, the folate, supplementation, so on and so forth, to say, let's prepare. And so, you know, it's never too late, you know, can always pick up where something wasn't done. But my big deal is to get the message out there, create awareness, share information, and let's see how we can work together as a network and, you know, reach a success globally, you know, as individuals and as parents, as a community, so on and so forth. It's a small world. You know, you'd be surprised how good our connections are now compared to pre pandemic. Everyone is doing everything virtually. And so, you know, we get people from China, from Brazil. It's like Panama. It's like, how did you find out about this stuff? You know, so that's my message, is let's share this and, you know, let's see how we can go.

Absolutely. I absolutely love that. I recently launched a course, a MYO course, online. And we have online support communities and everything. Because like you're saying, it's. Everybody's starting to hear about this. They want more education, which I think is phenomenal. And you know, and so I think the more that we do, you know, I know you're very involved in the research side of things. So thank you for all of the work that you've done and what you've put out and all of your education because you are a wealth of information. This has been so much fun. I learned a few things today. I've got my little sticky notes over here. I was taking some notes as you were talking about things going, yes, that makes so much sense. I need to research this further. This has been so thank you.

Very welcome. Absolutely. It's been a real pleasure, Hallie. Anything I can do in the future, just let me know. Great work with you and our fellow professionals and thank you everyone for being on the podcast today.

Yes, thank you. 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 forward/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 at Halle Balkan Biz, on Instagram at Hallebulcken. 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.