Episode 170: Does Your Child Have Enough Tongue Space with Dr. Skye Zeller, DDS

Hi and welcome to episode 170 of the Untethered podcast. Today we have Dr. Sky Zeller joining us. Sky moved to Connecticut in 2008 for grad school, completed her master's and PhD in microbiology at Yale in 2014 and then dental school at UConn in 2014-2018. Since then she's been a general dentist working in community health and as an associate at a private practice in Wolcott. She started Sleep and Airway Focused Practice Dental Sleep Experts of Connecticut in 2020 and recently became owner of the General dental office in January 2022. Outside of work interest, she has two twin 8 year old boys and they enjoy spending as much time outside together as possible, skiing, hiking, climbing and exploring. 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 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. Sky, thank you so much for joining me on the podcast today.

Thanks for having me. I'm excited.

I love having conversations with airway centric providers who just get it. So I'm excited to dive into that topic today. I would just love for you to share with our listeners. How did you get into this space?

Yeah, so honestly I dove into this just shortly before the world shut down for Covid and really I had started just by taking my very first class on sleep and airway and mandibular advancement appliances for adults. I took one class, I spent the weekend there and I was like this is really cool. Then my father in law who is approaching his 70s, has been practicing dentistry for 40 years now, has always been preaching early ortho early ortho airway to the point where he was doing it before it was a thing. He had a lot of orthodontists who would badmouth him and say that early ortho intervention is just a waste of money and he just stuck to this. And so when I took my first adult Airway course and I saw like all we're really doing is providing space and bringing the lower jaw forward. And then I kept listening to everything he was saying, like, early ortho, we need to bring that lower jaw forward. You need to expand and bring the lower jaw forward. It just kind of made sense to me that now I needed to figure out how you treat children, because if we can actually grow people out of this and fix them early, then we're not making them appliances that are band aids for the rest of their life. And I was just blessed with twin boys who were my perfect starting point. So I actually had one son who would end up in the emergency room pretty much every month, all winter long with croup. The best response we got from the ENT was that he had a floppy airway and he would probably outgrow it. I started taking more classes on that. When I went back and looked at his pictures when he was a baby, every single picture was open mouth posture, low resting, tongue position, mouth breathing. We started working on that part of it all through the beginning of the pandemic. We were training nasal breathing. We were working on expansion. And he's a completely different kid now. So exciting.

I mean, he sounds very similar to my 4 year old. So my 4 year old had croup on and off. And there was one time where we ended up in the emergency room with croup rsv. Like she was having febrile seizure. Like, it just, I was like, something's got to give, like, why can't anybody help us? And we weren't, we weren't there every month. Like you said, you are, you know, she never had a laryngomalacia diagnosis or floppy airway diagnosis per se. But I was like, like, something's up. Like, why? And now she, you know, and then they're like, oh, she's pre asthmatic. And then she was on flovent inhalers over the summers when we were living up north. And I'm going like. And we would keep dexamethasone and rescue inhaler, you know, on hand just for whenever these flare ups happen, so we could avoid going to the emergency room, especially during the pandemic. And it was like, okay, like, why are we not talking about what's causing this? Why are we just kind of. Again, like you said, like, you're just slapping a band aid on every symptom that presents repeatedly. And she. Even this year at age 4, we moved to south Florida, but she, she had croup, I think like three times in six weeks. Like it just kept coming Back. And we kept going to urgent care, and I kept being like, hey, like, we know what this is. Like, what gives? Right? And of course, like, no one helps. They're just kind of like, well, she's got a fever. Let's give her this medicine. And she's got croup. Let's give her this medicine. And so I was like, all right, that's it. I did early expansion with my older daughter, who didn't have these kinds of issues that Mia had, but she was like that picky eater, tongue tied baby, you know, all kinds of other things going on. Always jutting her jaw forward, licking her lips, and becoming, like, raw around the lips. And I'm like, she's basically putting her mandible into the position that her body needs, like, hello, people, you know, And. And so we did expand her with an ALF appliance from, like, 4 to 5. And that was, like, during the pandemic, you know, beginning part of it. And then we. She's actually going into some additional expansion starting in a couple weeks, maybe next week. I'm like, I don't even know. So I'm excited because we need to bring her mandible forward a bit more. But my youngest is starting as well because she's just got that deep bite, you know, she's got. She's got all the things, and it's really fallen, I feel, like, into the laps of dentists and orthodontists who are more airway centric and understand, like, that early intervention component, but it's so hard to find.

Yeah. And two things. One, I grew up in South Florida, so welcome to my former home. It's a lovely place to be and an awesome place to graze kids, for sure. But what I've been so excited about over the last, I would say, like, year, year and a half, is that we've created this incredible team within the central Connecticut area, consisting of myofunctional therapists and speech therapists and ENTs. We have a couple of really amazing pediatric ENTs in our area who just get it now to the point where I'll get reports over. To me, that's like, I'm not gung ho about surgery yet. Let's see what you can do with expansion first. And if you think that we really need to dive in, we will. And so, like, understanding it on that level is incredible to me. We have sleep doctors now who get it both from a pediatric and from an adult standpoint, because we do a lot. I do a lot of outreach about, like, yeah, we can actually expand adults. So when you see your patients and they're crowded and they're narrow and really the tongue is the primary obstructor, like, we can help that. We can do stuff to make more tongue space and we can train them to breathe through their nose and we can get involved at this point. And instead of having them on those band aid solutions for the rest of their life, I mean, if they're 30, that's 60, 70 years of quality lifetime that they're going to be missing. So we've been able to really just build this super cool network lately. Everyone seems to be on the same page, and it's really helpful to the patients, which I think is the most important part.

Yeah, and that's one of the things I get asked the most because I run this membership with myofunctional therapists, and they're like, where do I find the team? And do you know anybody in this area? And we're constantly trying connect people and we're like, look, you know, to some degree, you're going to have to also work with providers in your area to build that team. Because, you know, obviously everybody has to be open to learning. But sometimes learning together is so powerful too, because then you kind of sit down and look at these cases and it's like, what gives? Like, how can we stop these symptoms from recurring? Like, what is the root cause of what's going on? And so I get so excited when I hear that, like, people created teams and, you know, it's. It's so needed, but you got to put the work in for sure.

Yeah. And if I could give, like, like the smallest piece of advice in doing that. Every patient you see, write up your findings. Find out every doctor who's involved in their care, whether it be their primary care doctor, their ent, their sleep doctor, write it up with pictures and send it. Because once you see these things, as a provider, you can never unsee them. I don't think many of the providers I worked with really understood how important tongue mobility is. To be able to elevate the tongue, to be able to grow the maxilla as a child, but then also as an adult to ensure that the tongue's not being tethered down and back into the airway. So now when I point this out and I send the pictures, all of a sudden I have people coming in. They're like, my sleep doctor told me that they think my tongue's tethered. Like, can you look like things like that? That is like, so interesting. To me, because I don't. Well, I know that you don't learn that in medical school. You don't learn that in dental school.

You don't learn that in school for slps, it's like all post grad education. Yeah. So what age groups do you work with in your practice?

So we see the whole gamut. Actually, I will start looking around too, and I'll steal one of Kevin Boyd's comments. Like you treat as soon as the kid is ready to be treated. So there is no such thing as too early. It's really just when the kid is emotionally immature enough to deal with what you're doing. And I do have some three year olds that I have in expanders at this point because they need them. They need them and they're ready and we can make them look really pretty. Sometimes there's sparkles and sometimes we have dinosaurs and the kids get very excited about them and the parents buy in and then they see the difference in the symptoms and it's amazing. So we treat as young as three. And then I do treat all the way up into the 80s and 90s. You know, I do, I do a fair share of mandibular advancement appliances. We work with Medicare and we do what we can to help everybody get the treatment they need.

That's amazing. So you're basically evaluating airway in every patient that walks through your door.

Yeah, yeah. So I did. I recently bought a general dental practice in January and my father in law's practice actually.

Congratulations. Thanks.

Thanks. He had been doing this for so long, but it's interesting. Now I have his hygienist seeing things more through the lens of airway and I'll be doing something. And our hygienist Blair, who's actually training now to become a myofunctional therapist as well, she'll be like, doc, can you.

Just take a look?

Because I think I see something. And it's so interesting. Once you learn to see these things, the lens that you see every patient through and all of the problems that they're having is completely different. So we're pretty aggressive with Periel in our office. But now that we're learning that there's a huge link between periodontal disease and mouth breathing right now we know that like a lot of these patients that we've been treating for so long, let's look at them through this other lens and wow, they really don't have lip seal and they really do have low tongue posture and they really are breathing through their mouth all day. Long, drying out the periodontal tissues, allowing plaque to really stick to the teeth and causing a lot of these problems. And it's the same thing with, like, decay. Obviously, you need to investigate diet. You need to investigate all of those things. But when you see a kid with rampant decay and mouth breathing. Right. Narrow arches that they can't get into. After you rule out diet and brushing and hygiene, then what else is going on and how do we help these kids from now until they're adults so they're not losing teeth?

Yeah. I feel like I've been hearing this conversation a bit lately of, yes, it's important what we put in our mouth. And yes, oral hygiene is a very important component. But so many dentists will say, oh, you must not be flossing well enough, or, oh, you're. You're not. You're giving your kids too much sugar. Oh, this, that, and the other. And it's like, well, hold on. Has anybody looked in the child's mouth under the tongue? Is the mouth open at rest? How about when they're asleep, you know? And I feel like I'm excited to hear these conversations happening more. I feel like we're. We're, like, still at the earlier side of this, though, and we definitely need more. What sort of looking for. Not exposure. But, you know, I feel like it really. I was talking to Dr. Stacy on last week. She actually, her podcast aired, just aired, and we were talking about how, like, the gut microbiome was, like, you know, kind of a new thing 10 years ago, but now everybody knows about it. And we're, like, hopeful that the oral micro microbiome is, like, going to be where the gut microbiome is, you know, another 10 years from now where everyone's just talking about, like, is your mouth open or closed? Like, are you a mouth breather? Where's your tongue? Like, why can't your tongue go up there? What's going on? Maybe your jaw is not in the right place. You know, at least just some initial things to get the conversation started so that we normalize the conversation because we see that so many of these symptoms are common but not normal. And that's, like, one of my most favorite things to say. Common but not normal. Like, it's. You know, we see these things so frequently now that everyone's just like, oh, but everybody does it, so it's fine. Well, no, it's not.

Yeah. I gave a talk to a group of local dentists a couple months ago, and one of the big things I was saying, like, I showed Just all these pictures of kids sleeping, right? And it's like the initial reaction is, wow, that's so cute. And then you look again and these kids have open mouth posture while they're sleeping, necks up like this, trying to get air. Some of them are even like snoring. You can see struggling blue circles under their eyes, whatever it might be. And then it's like, do you see this now? Oh, yeah, now we see it, right? This is not normal, even though it's common. And this is not cute, right? Those are the two big things.

Yeah, I mean, it's. Our society is basically, basically not just normalized it, but made it sexy to mouth breathe. Like models have open, parted lips and you know, it's like a sexy thing to have your lips a certain way. And you know, and so, and there's all these shirts with like lips on it, with like lips apart, you know, and so it's just what the brain sees and knows. So it's, you know, we kind of basically look at it as like, oh, well, that's how things are supposed to be. So I struggle with that. I'm like, oh, it's a cute shirt. But like, no, I can't buy that because the lips are not together.

They're putting lip tape on the shirts. There you go. Go.

That's so funny, right? In your practice, like you're using basically myofunctional orthodontics. Are there like specific appliances you use? Do you use a range of appliances? What does that look like for you?

Yeah, so we're always trying to learn more. I think as providers, we get very set on appliances and not necessarily on big picture ideas. So. So for me, I'm always like, let's start with a huge picture and then we can start to incorporate smaller aspects of that as we go. So for my big picture idea, it's every kid needs to have enough space in their mouth for their tongue. I don't really care about their teeth and their tooth mass. That's gonna come as they get older. And if we need to do some bonding on small laterals, those are all fine. It's not about the teeth ever. It's about the structure and so finding ways to increase the size of the mouth. And that depends on the kid. It depends on compliance, it depends on personality, it depends on what the parents want and are willing to get behind, then making sure that the skeletal relationships are right, that we're getting forward growth, that we're getting the mandible coming downward and forward as this kid is growing. And that all of the muscles are working to continue to promote that proper growth throughout the whole course of growth and development. If I look at a kid and the key issue is a tongue tie and they're slightly narrow, then my treatment plan looks something like myofunctional therapy, frenectomy, and let's start with myofunctional orthodontics for a while to get all of that under control. If I have a kid who's having croup every month and can't breathe, then we're pushing forced expansion, and we're doing it quickly because for me, most important is making sure that those kids are asymptomatic. And then we'll start worrying about the rest of it, like the myofunctional period piece and the myofunctional orthodontics after that. But almost every kid I have, whether they're in straight wire brackets or fixed expansion or removable expanders or myofunctional, they're always in some kind of a myofunctional program at the same time. Because I feel very strongly that no matter what, if you don't address the underlying problem, say I treat it six or seven and the kid still has a tongue thrust, well, by the time he's eight. Now we've got flared incisors and a retreated mandible again. So we need to get those habits under control. Things went wrong for a reason. They didn't just go wrong, you know, they went wrong because the muscles were out of control or the habits were out of control, or the tongue wasn't doing what it could or the kid couldn't breathe. And now if we don't address all those aspects, then it doesn't matter what I do. You know, I tell the parents I have a cool slide. I show a lot of parents. That just involves all of the members of the team. And, you know, I'm probably 25% of the overall outcome. I can make your kid look awesome, but it doesn't matter if we don't have the other 75% involved, because my 25% will only last as long as it lasts.

Right? Right. And I think that's really cool that you have, like, that visual to show parents and that you're able to also say, hey, look, we can make the teeth look pretty, but if we don't address all the root causes of why the teeth got here in the first place, we're probably going to end up back here even after. I mean, it's like we see all these Orthodontic relapse cases in the teen years into adulthood. I mean, I was one. And I think that now that I understand, like I had permanent lingual bars upper and lower. And that was after, you know, traditional RPE embraces and you know, and they're like, oh, they'll follow up by the time you're 20. And at 30 I was like, can you please take these out? Because like I, they're coming off like tooth by tooth over the past 10 years. But like it's so hard to clean. And I, you know, I love my dentist, but I don't want to come every three months because I can't seem to keep it clean enough down here with, you know. So anyways, they took them off and immediately my teeth started to shift, like within two weeks. I like the dentist, the family friend. I was like, hey, my teeth are moving. They're like, no, no, there's no way. Those things have been on for like, you know, 20 years. And I was like, no, no, they're moving. And I ended up in adult expansion. Once I got into the airway space myself and did, you know, a vivo CNA appliance, I had a tongue tie release. And anyways, all said and done, I did go into Invisalign afterwards, which actually I think retracted me a little bit in the last couple of trays. So now I'm kind of like, I think we need to go back into another appliance to bring things a little bit more forward. But all that to say, like it's, it's so powerful. I think when we can share like stories, our personal stories, experiences, but also just show everybody, hey, like, here's who makes up the team. Here's why these components are important. So I really love that because I just tell everyone, I'm like, I don't want you to end up like me. Okay, so let's avoid this.

Yeah, no, it's incredible. So I have very similar. I did expander as a kid. I had a bilateral cross bite, super flared anterior teeth. I think I'm so lucky I didn't have extraction and retraction just based on what I looked like as an 8 year old and relapsed in college obviously because I didn't wear retainers and then put brackets back on myself in dental school. I had my father in law put him on for me, took them off, relapsed again. And then finally when I started doing this, I was like, forget this, I'm not as committed as you. I couldn't commit to wearing view of lions. But I did expansive invisalign on myself and I opened spaces around my laterals which I still need to get bonded. But it stayed even when I don't wear my retainer now. So I had a tongue tie release because it turns out all this time I've been grade three tongue tie, didn't even think about it ever. And obviously like that was why I couldn't grow my maxilla, that was why I had a bilateral posterior crossbite as a kid because my tongue was not sitting where it belonged. And it's so interesting now all the time I'll just be like, tongue check.

Oh wow.

It's up in the maxilla, like amazing. This is awesome. And the tongue is the best retainer. It is your number one retainer, but it's also like your number one detriment if it's not doing the right thing. So yeah, I mean my kids know all the time they'll like look at each other and be like, tongue check. It's like the only 8 year old twins who will like nag each other about their resting oral postures.

I love that. That's amazing. Now you mentioned something before too about like a lisp, basically speech issues. Right? So what are your thoughts on just how you know, and I asked this because like in the speech pathology world there's definitely like a 50, 50 SPL speech pathologists. Many will say, oh, you know, Myo is not a thing. And you can just train the tongue where to go and this, that and the other. And there's no such thing as tongue ties. And then there's some who are like kind of in the middle and then there's others who are in my camp who are like, oh, hey, we've now treated, you know, thousands of patients. We see that this is the problem. We also see, at least in my experience, kids who've been in, I don't know, 10 years of speech therapy go into an appliance, if that was what was needed, have a tongue tie release with myo, you know, obviously tailored to their specific plans and then graduate six months after, like from, you know, after all that was completed, but basically only needed like another three to six months of speech and just to teach them where the tongue could go now that the tongue could go there and they had the space for the tongue to go there. And then, oh my gosh, look at that, like they're finally graduated. But when they started speech they were like highly unintelligible even as an early teenager, which is really embarrassing.

For a teen.

So, yeah, I'm just curious, like from a structural standpoint, like, do you have thoughts on this?

That's exactly. And that's exactly what it is. I think it's a structural standpoint. Right. So this doesn't mean every kid who has a speech issue needs an expander and needs a tongue tied release. Right. And I think that's what we need to be very careful about because there's no. All right. When we talk about treatment plans, there's no. Every single kid gets the same treatment. You have to tailor things specifically to what you're seeing. And that's where having a broad base of knowledge is very helpful. But I again see kids and adults who either lisp or who have had speech therapy for a very, very long time are still pretty much unintelligible. And it's hard when they walk in as a 17, 18, 19 year old with mom and you're like trying to figure out what they're saying and you're kind of giving mom the side eye, like, are you going to help me out here? Because obviously that's not working. Right. And I think that's like the big thing. Even with what I'm doing, if I have a parent who's like, we're not doing anything else, we're just doing ortho. Okay, let's try. Right? Let's try. I'll try it with you. We'll see what happens. And then when something's not working, you have to know what are the other options to fix this problem. And so if you've been doing speech therapy for a decade with somebody and they're having mild improvements, but they're still unintelligible, like, well, what else is going on? And I do get a lot of patients referred to me like that because, you know, they're. The speech pathologist will be like, I'm not comfortable in this space, help me out. So we look and I'll tell you, it's like eight or nine times out of ten they're going with ENT after that because they either had deviated septum, enlarged turbinates, adenoids are out of control. They're also seeing a myofunctional therapy group that I love to make sure that there isn't a tongue tie because even sometimes I'll be like, I don't know for sure. But you know who does know? My myofunctional therapist, because she's going to evaluate every movement of that tongue and she's going to tell me if there's Stress and strain. And I do think that you can probably train the tongue to go to the right space if there is a grade two tongue tie or compensating grade two, something like that. But what else are we sacrificing? In my case, I was a grade three compensating to a grade two. And by the time I started practicing dentistry, my neck hurts so much from all of the accessory muscles that were activating every time that I swallowed that I talked. And I talk a lot. I try to keep my patients pretty comfortable, so I talk a lot, right? And so by the end of the day, I was dying and I didn't know why. And when I started thinking about it, it's like, well, obviously that's why, because now I'm compensating. And I was like, showing my mom. I was like, mom, look. And she's like, oh, my God, her neck is like lighting up when you talk, and it lights up when you swallow. And it's like, yeah, that's why my whole back and neck hurt every day when I'm done. So just because you can get somebody to do something with more difficulty, like, what is the long term implication of that? I guess.

Yeah. Yeah. Well, I mean, and I. That's a really great point. And I think that what we do sometimes see is like, these kids can get the sounds. We can even get the sounds and words. But then when we start to string the words together, we start to lose intelligibility. It's supposed to improve over time, not decrease over time in therapy. And that's when I kind of go, like, at least, because I have a private practice and, you know, my team or anybody that I train, I'm like, hey, if we're not seeing progress over a number of months, that should be a red flag for you. It should never get to a year or two years or ten years. My goodness. We should be asking, why is this not working? And be trialing different things. When we run out of things to trial. If you're not in this space, maybe we need to be referring to someone who is. Because we need to make sure that structurally we have space for the tongue. And like you said, sometimes we can compensate. But at what expense? And why compensate, right? When we know. I always, like, use this bucket example, right, where we have like 10 buckets of energy. And for a child who's compensating, right, they may be overly compensating to speak, to eat, to keep their lips together. By the time they get to school, they're at 50% of those buckets, they have 50% energy left versus the kid who wakes up is nasal breathing, has none of this going on. And they go to school 100 buckets, you know, 100% of their buckets, 10, all 10 buckets are ready for learning, you know, and I think when you start to like connect it to some type of a visual, especially for parents, they're kind of like, oh, like I never really thought about it. And you know, I like to connect it to learning too. Because we know that these kids also have sleep issues, a lot of them. And if we're not getting restorative sleep, then this is just like, it's just that big snowball that just continues. And it's like, well, how can you expect your child to do well in school or sit still in school or attend and whatnot, you know, and even if they can, and even if they hold it together all day, they are a hot mess when they get home because they are, they're in the negatives now. They are beyond the levels of energy. I mean, I'm exhausted. Yeah, yeah.

I always say to parents, like, what's the first thing you do when you wake up and you're tired? It's like, well, I grabbed my coffee. It's like, okay, your kid can't do that. Like your kid's not drinking coffee. So they're either grabbing like high sugar carbohydrates because they're exhausted and that sugar is going to give them that boost, or they're a hot mess all day. And those are the two options. And it's not fair to these kids, I think, to like, make them compensate, to constantly treat the symptom without looking at what is the problem. Or in worst case scenario, these kids who are getting these add, adhd, behavioral issues and all these diagnoses and I look at them and I'm like, wow, this kid is narrow. Like, wow, this kid can't breathe. Like, look at the way the nose is developing. And that's the key point, is that it's developing. So we still have the time to intervene. We still have the ability to, to make a big difference. And we have the ability for a long time. I think that's also what kills me is when I talk to providers and they're like, well, the kid's already 12. That's it. I'm treating a 35 year old male right now with the strongest bone structure and guess what? He has a diastoma between his front teeth because we're opening him up and it's fine. We can do it. We just have to do it appropriately. You have to have the knowledge base, you have to have the plan in place and you have to have the team working behind you to make sure that what you're doing is going to work. Yeah.

Or on the flip side, you have a lot of providers saying, oh, well, let's just wait a year. And the child's already like six and a half. I took my daughter down here to somebody who's really well respected and that happened. And I was like, she's six and a half. She's had pre ortho, like with the alf. She's a really great patient. She sits still for, you know, cbcts. She's like, she's primed and ready, like, this kid is ready. And they're like, come back in a year. And then I took her to another one and it was like, well, she's got some shark teeth down there and, you know, this, that and the other. And she's beautiful.

I don't have her push on it with her tongue.

Yeah, that's what, that's exactly what I was told. They were like, well, we're gonna have to pull those lower central incisors, the baby teeth. And I was like, hold up. Our dentist said, she's got six months, let's see if they come out on their own. And they did. And of course, because she does have that tongue forward posture that she's in myo for that she needs the appliance for, you know, we did grow the mandible forward. She's enough. Have enough space in her mouth currently. And we're kind of debating like, do we need to redo her tongue tie release, like what? Like we're, you know, we're on the line there right now. But she did push her teeth forward with her tongue. And I was like, that's not seemed to be a good treatment plan. I'm not sure I like this very much. I mean, okay, fine, she brought him forward. But like, that should not be the answer that we get when we go to an ortho's office.

So I have never seen shark teeth or the double row come in. In a kid who has space ever. And maybe there's a provider out there who's going to prove me wrong. And I would love to see that, honestly. But in a kid who has space in their, in their lower jaw, picket fence spacing as the adult teeth are coming in, those teeth come in correctly. So like, to me, when I get, I have so many parents because My kids play a lot of, like, sports and they're in a lot of activities. And as soon as they find out I'm a dentist, oh my God, my kid has those shark teeth. I'm like, ah, can you bring them in? Can we take a look? Yeah. But then they're like, oh, my dentist said it's normal. Like, okay, normal, common. Yes. Yeah.

Well, I mean, this was how it was explained to me. So isn't it that, like, as the adult teeth come in, assuming there's enough space for them to come in where they, you know, in their proper placement, aren't they supposed to, like, isn't there that resorption process that basically starts to resorb the root or something so it makes the teeth wiggly, they fall out and then out erupt the adult teeth? Isn't that like the.

Okay, that's exactly what happens. So if, like, the spacing is correct in the mouth, what I always tell parents when we talk about guiding appliances and myofunctional orthodontics, teeth are going to follow a path of least resistance into the mouth. Right. They're not going to fight to try to come in over something else. But the tooth buds on the adult teeth come in just lingual, like just a little bit towards the tongue. If they're way back here, it's because there was nowhere for them to go. Right. So they should be coming up and they should be resorbing the root of the tooth right in front of it. But now, and I don't know that there. I have not read research on this. This is my personal opinion. But as that tooth comes in, if it's got a bang up against like four other teeth in there because there's so much crowding in the bone or in the mouth, right. Then why would it come up here? It's going to come in back here where it has space. Yeah. And it's not going to resolve the root. Right. It's not going to resolve the root and then this teeth are not going to get wiggly enough.

Yeah, yeah. So, I mean, basically it was like, all right, start wiggling those teeth. If we have any hope here, we can get them out ourselves. And I was very thankful that they came out themselves because I'm like, look, if we can avoid pulling teeth out of my child's mouth, that's a little bit more traumatic than them falling out on their own. So was very grateful for that, but I was just like, oh, man. So now we're driving an hour south to basically a functional pediatric Dentist who does. She only works really, like, with birth to 12 and likes to get them in early. And so she's seeing both of my kiddos. And we have a really great plan in place now. But I was just like, man, like, there is no, like, I can't find anybody in the Boca Raton area. Like, what gives? We have to go to North Miami, which is fine, but, no, I was spoiled up north where I came from.

I know, I know. It's funny, too, because anytime I go, I'm in Fort Fort Lauderdale, where I grew up. So, like, anytime I go back to see my parents, there's a dentist on every corner. I mean, there's two dentists in certain plazas, and there's nobody in the airway space within the, like, Boca, Fort Lauderdale area at all. And I don't. Yeah, I mean, I think my neighborhood, we went to, like, four or five. There were four different orthodontists who all treated every single kid. And I don't know, I think just from a pure practice management point, like, get into this space. It's an amazing space to be in. And you treat your patients and they are grateful for a lifetime, and you change the way that their. Their whole life is going to play out for them, especially the kids when you get them young. Because if you can get a kid sleeping and. Yeah, that was another point I wanted to make. I'm terrible at this. But the idea was it's not just. It's not just sleeping. Right? So. And I think that was one of my big issues with, like, mandibular advancement appliances is that we're treating sleep and we're only treating sleep, but it's not sleep, it's airway. Right. And so a person who has a bad airway at night has a bad airway during the day. So it's not just that they can't sleep. I mean, yes, they can't sleep, but they can't breathe well. Like, maybe they're getting tired while they're playing sports or running around on the playground with their friends and, you know, mouth breathing. And then the asthma's hitting them and the allergens are all blowing up the back of their throat and all the lymphoid tissues back there. It's not just sleep. You're changing the airway of these children. You're growing their entire airway. You're growing their face. Aesthetically, they look better, obviously, because wide, broad smiles and faces that have grown to their full potential just look better. So now they sleep better, they breathe better. They can play with their friends better, they can speak better, they have more self confidence. Yeah, I just see that as a much better outcome than waiting till they're 12 and moving some teeth around.

Yeah, well, I mean, and research shows that basically the most critical period of development for our brain is birth to seven. And so why are we waiting until after that point to start giving them the ability to fully oxygenate their brain? I mean, it's like, it doesn't make sense to me when we start to actually read the research and you start to look at these cases. We're not doing any harm to these children. If anything, it's harmful to wait. Right. We're helping them. You got to get in there early. And the earlier and earlier I see this happening, the better off these children are. Because like my private practice goes and works with, you know, we work with pediatrics, but we see mostly like, say like birth to 10, maybe. Like, we do work with older kids and we do myo with all ages across the lifespan, but we work with a lot of those feeding kids, we work with a lot of those speech and language delayed children. Sure. We've had cases where after a tongue tie release, the child just starts talking. Like, we never promised that because, you know, I, there's really, there's nothing that I can really say, okay, the child can't talk because they're tongue tied. But we, have we seen it? Yes. Is it in every case? No, but it's, you know, it's just amazing to see like systemically what happens because of a child being able to sleep and get restorative sleep and have full access to their articulators and use that tongue, you know, to hold the palate shape once they've had expansion. And just all these various things that I feel like are being missed in a lot of the traditional orthodontics. Yeah.

I mean, we've seen kids hit growth spurts after expansion, you know, just all of a sudden shoot up. And I'll always say it's crazy. I'll see them and then I'll see them for like a three month follow up. And I'm like, oh my God, is that your child? It's like, yeah, well, all of the growth hormones that were supposed to be cycling appropriately, like, weren't because the sleep cycles were totally off and you know. Yeah, it's just really, it's, it's really interesting how just changing the way a kid breathes will change so many things in their life systemically.

And how young are you seeing like deviated septums.

So I think the youngest I just saw was like a four year old or a five year old. I just.

Like man four.

Yeah. And turbulence, like the turbinates are like a really big thing. And I don't know, I'm pretty sure in the, in the four year old case the ENT said like, I'd like to see what we can accomplish non surgically at this point. And that makes a lot of sense to me. But when we take a pan, I know there are a lot of providers doing cone beams of the whole airway. I'm not at this point, but I will take a pan and a stuff on pretty much every kid I see to look at skeletal relationships. I can see enlarged turbinates in so many of these cases. And a lot of the times you see the soft tissue literally touching the septum and it's like, how are you breathing out of your right nostril? Oh, I don't. Yeah, I'll be like, do you feel stuffy on either side? Yeah, yeah, my left side's always stuffy. And I'm like, well, this is why.

Yeah, yeah, that was me. And I actually think that like I hit a wall in my expansion. Now I admit I wasn't like the best patient because I was treating and like I only wore my Vivos like 8 hours a day instead of the 16 that they wanted me to wear. Took me like 2 years to get to where I got to my max on one side. I got a whole. I'm a whole mess. But I also realized, like, well, I didn't deal with my nasal cavity, I didn't deal with my ability to breathe, which is probably why I was more locked up. I was working with other providers like a PRI trained PT and a holistic dentist who was doing this with me and anybody else I was referred to. But I just had. Actually in April, I just had a septoplasty because I was straight in the front, so you wouldn't have really seen it looking at me much. But I deviated back towards the left and the back and it was completely blocking the left side. And then I had enlarged turbinates. Then I had enlarged nasal swell bodies, which I had never heard of before. So I'm like, oh, great. I've got swelling coming from the outside in, swelling from the inside off the nasal septum out. So basically my ability to breathe through my nose, especially when I lay down, is now just tanked. And so I did a home sleep test before I went in for the surgery, just for information with the goal of doing it again once we feel like all the swelling is done, because I also did a rhinoplasty. And so I'm like, maybe. Maybe six months, maybe a year. We'll see. Or maybe I'll do it at both points. Who knows? Because I'm just curious to, like. I feel like I'm breathing better, but I feel like there's still more work, like, you know, for me to do. And what it showed was that I would traditionally not have been, like, picked up as someone with sleep apnea, but definitely have uars. My body was like. Basically every time I went into REM sleep, like, in the first two thirds of the night, my body was like, yeah, no. And it would kick me out of REM sleep. So I was getting, like, no deep sleep, and I'm like, no wonder I'm always exhausted. But I wasn't really having, like, that true, like, sleep apnea. I had some apneic moments, but nothing, you know, significant enough that anybody would have diagnosed me. So it was very. It was very interesting to have that information and to have those kinds of answers. But that's also. I'm like, I hate putting kids through this kind of information or in, like, these types of tests. I'm like, no one's gonna sleep well in a. You know, in a lab. And then, like, how accurate is a home sleep test with the kid at home?

You know, they're actually not FDA cleared for kids, or at least in my knowledge. I don't think there are any.

Yeah, most of my providers don't require them. Sometimes insurance will require them. And we have had some cases where, like, an ENT was like, this is emergent. I want this kid to go for a sleep study immediately. And then, like, the next week, consults and adenoids came out, and I'm like, okay, that's. You know, that's a specific situation. But I'm like, we can see behaviorally and structurally enough to know why the child's acting the way they are. And if you're. I was actually in my daughter's bed last night. She fell asleep. And this is the one who has the history of croup who's getting ready to go into expansion. And she's, like, flailing all over the bed. And, like, you know, I. Her mouth was closed, but she was flailing and kicking and making noises sitting up, but, like, not. Not responsive. If I was like, hey, Mia, you okay? You okay? Like, not responding to me, like, clearly, you know, not really having a night terror, but, like, also just Totally out of, like, totally out of it. But that's not normal. And this was going on like, I was. I just stayed there for a while to watch her. And I even recorded it because I was like, what is going on? Like, this is not normal, even for her. So I'm like, these are the kinds of things where, like, parents, like, well, sometimes my kid kicks around a little bit, but I don't think it's anything abnormal. I'm like, no, we should be quiet breathing, mouth closed, you know, you should not, like, no audible breathing. Body should be relaxed and still while we're sleeping. We should not be flipping all over the place in our bed. So it's. I do feel like it's one of those things if, like, we watch long enough, we can usually see on our own kids. But it's. Yeah, a lot of parents are like, I think they sleep great. I'm like, let's look into that a bit more.

Yeah, yeah. And I think, like, sometimes those baby monitors that you totally got rid of when your kid was, like, old enough, those are amazing to pull out because for one night, just, like, put it in the room. Even if it's just like, so my kids are 8. I feel like everything changed in, like, the baby world as soon as I had them. There were like, camera monitors and, like, links to your cell phone. And so the technology changes quickly. But even if all you have is like the Volume 1, you'll be amazed at the amount of noise that comes out of their room at night. Like, whether it's snoring or just breathing or speaking or tossing and turning. Like, you can hear that on one of those monitors if you turn it up. And then you won't sleep all night because you'll hear it all night long. And yeah, it's not normal. It's not normal. And I always have parents, I'll be like, well, how do they sleep? Oh, my God. They go to bed at 7 o', clock, they're exhausted, they go right to sleep, and they don't wake up until 8 o' clock the next morning. I'm like, okay, how are they sleeping in between 7 o' clock at night and 8 o' clock in the morning? Well, I don't hear from them at all. It's like, okay, maybe let's take a look at this, because I have a feeling that maybe those hours of sleep are not as productive as we think they might be. And maybe we can come up with some strategies to help that. And honestly, in the case of your daughter, if that was something that's happening, like, all the time. That's one of the kids I might send for a sleep study, an in lab sleep study, because I want to know what else is going on. As a dental provider, I can certainly treat any apneic events, and I'll have the sleep doctor send things to me all the time. He'll be like, I think there's more going on here, but this kid has apnea. And let's get rid of that first before we can figure out what else is going on. Because I've spoken to a couple pediatric sleep doctors lately, and it's like the number of diagnoses that they deal with with the limited amount of data that they get from an in lab sleep study, Being able to parse all that together with the parent history, that is not my job. And that's just an honest statement. I don't want to be doing that. I want to deal with what I know is going to help these kids. So if there are frequent things that are popping up that sound like a REM disorder, I want them to be seeing somebody who may be able to.

Fix that or help with that.

And yes, I'll help with whatever part it is that's mine. But I don't think every kid needs a sleep test. I truly don't. I think some of the kids, you look and you see very obviously what's going on. So now say we fix that. And this goes back to the idea of having a lot of tools in the toolbox. Right? We expand these kids, we make them nice and wide. We send them to the ent. The ENT takes out the adenoids and the tonsils and does the termectomy. And, you know, make sure that this kid has no structural issues, and I make sure the kid has no structural issues. And the myofunctional therapist is working with them, and the kid is still waking up in the middle of the night talking and walking. Okay, we got to get them to a sleep doctor at this point, because we're not just going to say, that's fine. Like, oh, well, we already dealt with all the problems, so they're fine. No, they're not. They're still not fine. So now we've dealt with many of the problems, and let's see what else is going on. And that's where having that collaborative team is just, like, the most important part of treatment.

Absolutely. Yeah. No, she's. We had done a cbct. I took her to the ent. We've done a number of things with her and she's been to an allergist and pulmonologist and all, you know, all the things. And it's, it's so interesting too, because I started back when she was like two. I remember the first time I took her to the allergist and they did the whole test and they're like, well, everything looks negative, but, you know, it's not really reliable with a two year old. And I was like, okay, then why did we just put her through that? Like, I know, I know. What is that all about? You know, it's like, so that's where I start to like, pull back as a parent. And I'm like, okay, like, what is the priority here? Like, you're saying, like, if a child is flailing like that when they're sleeping, we go, whoa, this is screaming airway. Like something is going on. Like, let's address this and what is the right treatment plan for this child? So I love that you're like, you're very individualized in terms of like, okay, we want to be. It's hard to be like, least invasive, right? We don't want to send every child for a surgery. It's like, what can we do behaviorally, what can we do structurally without having to like, send them for something surgically? And then if we feel like, okay, this child needs more, like, let's. Let's talk about what's next. So that's very similar to like, the approach that like, my team and I take. And so I always appreciate that because I'm like, it's a lot. And like, as a parent of a child or two children going through this, you know, it's. It's overwhelming even for me being in this space. And, you know, I think that like, one of the plans was we is to put both my kids obviously into their. We're doing rapid palatal expansion for them, but we're using a hyrax that also does forward growth. So. And it's going to be upper and lower. And in the meantime, the dentist wants to like, build up their. My youngest bite. Right? So the plan or track. So we're going to build up her bite a little. We've been using myo brace with her a little bit just to kind of get some more space because she's such a deep bite and she's just, you know, obviously grinding away at those teeth, but she just won't sleep in it yet. And I'm like, we could just get you to sleep in this so that your jaw is better positioned. I feel like that would be like a good band aid for the moment until we can get you into like the rapid palatal expansion. We're just waiting. I think we're going like in the next week or two to actually get things moving along. But yeah, it's, it's just so interesting. And it's also very interesting to see like, different dentists in this space taking like different approaches. And I'm like, I don't care what approach is taken as long as it works, as long as we get my child healthy. Like, you tell me what you recommend. And I think that's something also that we don't talk about enough because people get really stuck on a single appliance because they've heard it works.

Yep. Yeah. So, like right now I don't do like an elf. It's just not in my toolkit. And I am very happy to send anybody who is like dead set on that to somebody else. But for me, like an alpha, it's very slow. It's like a very slow expander. And a lot of the kids I'm getting, again, they're very symptomatic and I want a 4, 3, 45 year old out of symptoms and I want them out of them quickly. I don't want to take the time to slowly develop the arch if they need to do it quicker. And if I am slowly developing the arch, then I'm doing it with myofunctional orthodontics. So again, I think there's too much on the exact appliance I and not enough on the overall treatment plan, the final goals and like where these kids need to be. So, yeah, I think having like a really strong background in orthodontics period is very important. So a lot of these, like weekend courses that you take and you learn an appliance, it's great. But until you have like that whole background to understand growth and development, to understand like what you're actually seeing on the ceph, the cone beam, the like, all of these things need to come together. And so, you know, one of the major courses I'm taking is through the International association of Orthodontics and it's a two year fellowship. We meet four times a year, we review all our cases. Like we go through every single aspect of it. And I thought that was super important if I was going to be doing this because you need to have that basic understanding they're not treating or they're not teaching as much of this early intervention. But I get that from everything else I see. I just, I Think everybody should have a good basis in. In all of it if you're going to be doing it.

Yeah, no, that's. I definitely can appreciate that. One of my dental colleague friends went back to school. He's up north, but he went back to school for orthodontics, like midlife. And so I've sent him the kids cases and I'm like, okay, like, what do you think? What is. What about this? And this is what this person said. He's like, okay, this person thinks she looks great. No, like, her mandible needs to come forward. Her width is. She got some great expansion with the alf, but it didn't bring her mandible forward enough. And we really need the jaws coming together and so on and so forth. And so it's nice, like you said, it's nice to have somebody with that background and understanding who gets it from various levels, because he was a restorative dentist before and basically sold practice and went back to orchestra school for ortho and is now completely practicing in a different space. And so it's really exciting to see this. And, you know, I'm like, I'm sure people think I'm crazy because my kids are like, you know, ortho at the age of like 4. But I'm like, I don't care. Like, I want my kids to have the best lease on life. And this is, you know, it's like, like you said, when you see it, you can't unsee it. When you know it, you can't unknow it. And, you know, I'm like, I just. I'm like, I wish I could have started them even earlier, but. But here we are. At least we're doing what we can do now. And. And that's what I try to tell everybody, too. I'm like, there's so many appliances out there. There's so many is to helping the airway. And I think the most important thing is that you figure out what provider you dive with. You know, hopefully there's somebody close to you and see what they use, see what they recommend and just don't. Because everyone would get so focused on, like, the ALF when they would talk to me, because Lily had that. And I'm like, that was step one. Look, she needs another step. Like, maybe. Maybe Mia going into this appliance first, maybe she won't need an initial step, but who knows? I don't know that we won't know until later. So every kid is different. Yeah, right.

It's like some of them, like, you fix the one problem and that's it. They're, like, free. They're flying. They're good. Other ones, like, there's a lot more going on and the growth just doesn't quite hit it and you still have to go back and do things. So.

Yeah. Well, I love everything you're doing and appreciate, you know, all of the teamwork and the collaboration with Mayo. And I think it's, it's, it's just, it's so fun to meet providers who are in this space. So thank you.

Yeah, thank you. Thank you for having me on. It was really cool, cool to talk, to get to know you.

Glad that we got to chat. Yeah. Thanks for listening to this podcast. If you want to hear more of these Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook, on my Facebook page at Halibulcan Biz, on Instagram at Alibulcan. 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.