Episode 173 : The TMJ's Role In Facial Development & Airway

Hi and welcome to episode 173 of the Untethered podcast. Today we have Dr. Tiffany Lamberton joining us. Dr. Lamberton has dual degrees in physical therapy and dentistry, both from Loma Linda University in Southern California. She has a passion for diagnosis and treatment of temporomandibular joint disorders. Using an imaging based solution model. She's limited her general dentistry practice to TMD and airway awareness in the greater Seattle Tacoma area in Washington State. She's a creator of TMD Collective, a space to guide, educate and create community for individuals experiencing TMJD. Dr. Tiffany is a member of AOMT Spear Education, the Chicago Study Club and a board member of the Pierce County Dental Society. She loves Pilates, wake surfing, snowboarding and lives in Tacoma with her husband and two children. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified health care provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified oral 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. Tiffany, thank you so much for joining me today.

Thank you so much for having me. It's really an honor to be on the Untethered Podcast today.

Thank you. I'm excited because I know that we met through a virtual study group and when I heard about what you were doing I was like, we have to talk more. It's so hard to find professionals who have your background. So will you share with us a little bit about you and your story and how you found your niche?

Sure. I'm Dr. Tiffany Lamberton. I am in the greater Seattle Tacoma area in Washington State. I have dual degrees in physical therapy and dentistry. I was a physical therapist, first practiced mainly doing a lot of orthopedics, sports medicine. And then I got married and moved to Southern California and my husband was in medical school and I was like, oh, I think I want to go to dental school. So, so in dental school, which was an amazing, challenging experience, I just kept thinking like, when are we going to talk about the temporomandibular joints? I think we had like Two days maybe of a little bit of curriculum, a little bit of observation, but just we're just as dentists, I think we get so focused on the teeth that we don't always like back out and kind of see that big picture. And so I remember in dental school a couple rotations where it seemed like the dentist that had gone on to a residency in tmj, she's doing a lot of appliances and splints and a lot of spray and stretch. But like I said again, just as a general dentist, not a lot of instruction and hands on of what's going on, what's your thought process? What are we doing? How do we treat these patients? It was more like, okay, let's get that perfect, prep that filling just right. So, so anyway, fast forward. After dental school, I went to a big meeting in the California Dental association and I heard who's now my mentor, Jim McKee, speak in San Francisco. And it was like light bulb. I was like so riveted by kind of the way he was presenting that. And so I also heard Dr. Mark Piper speak, who is an oral surgeon and MD in St. Pete's Florida, and who's done just a ton of like joint surgeries and really like microsurgery. And so I kind of summoned up my courage to go talk to Dr. McKee afterwards. I had my cute little outfit on and I was like, hi, I'm Tiffany Lamberton. And he's like, come out to Chicago. And I was like, what? He was like, yeah, come out. And I was like, really? He's like, yeah, you should. So I went out there, I shadowed him at his office, I went to the study club and it just was like, again, it made so much sense to me from kind of like a PTS perspective that it's not just about the teeth. We really have to think about kind of that big picture. And so, you know, in the meantime, I'm kind of having my own kids and I'm starting to kind of see some of the things with airway. And that was kind of more like 2016 when I got introduced to the AOMT and started to kind of like find out a little bit more about myofunctional therapy. And so then I'm looking at my own kiddo watching him sleep, and I'm like, he's grinding his teeth, he's got dark circles, he's wetting the bed, he's mouth breathing, he's got all these things where. And then I started looking at Tongue Tied. I think he might be Tongue Tied. And So I guess just like as a parent, it's so hard to kind of navigate who do you go see. So for me it was like, you go to the pediatrician and they're like, oh, kind of kick the can down the road. Like, oh, he's going to kind of grow out of this. So like go to the pediatric dentist. Like, oh, I think he's fine. So I feel like as a professional, I really had to push hard to kind of build that inner discipline, disciplinary team. And really as a parent, I just want to like empower other moms to like be relentless in your advocacy of your kiddo. And when I was listening to one of your podcasts, you had said you were sharing kind of like your daughter's story and you said, we got to this point and I just hit this mile wall, right? So she had gone through expansion. You kind of gotten that piece in place. But then when get to sort of like that AP correction and that's where I really feel like the temporomandibular joints come into play. Because once you start to kind of see that phenotype, you start to see that profile of like, especially the kiddos that are really retrognathic or they're class two, maybe they have that anterior open bite where the front teeth won't couple together. You've got to dig a little bit deeper, right? And so, you know, in my case, I pushed hard because my brother in law's a sleep physician. And so we did the sleep study and my kiddo was having like 17 events an hour. And like, I like literally like was about to burst into tears, you know, because I'm like, here I am. This is my thing. I understand this. And like, it's happening in front of my eyes, right? So again, you know, I've been seeing a lot of, you know, I'd been taking him to different specialists, to different orthodontists, you know, kind of just trying to decide, like, how are we going to tackle this? And so we decided to do an ENT first and do tonsils and adenoids. And at that time, I was sitting out in the lobby during his surgery and he comes, the surgeon comes out and was like, do you want me just release his tongue? And I was like, no, wait, wait. We hadn't done like, you know, like, as a myofunctional therapist, you're like, you have to do like the work before surgery and after, right?

Dude, pump the brakes.

So I was like, I'm not prepared for that. No, please, like, let's like stay in our lane and just, you know, because it was, it was too overwhelming at that point.

Well, you know, not to interrupt you, but I think another really important point, because this just came up in my membership group last week, was the opinion on, and I guess it's more of an opinion experience with children getting not adenoids, because adenoids is a much easier recovery, but tonsils removed at the same time that they have a tongue tie release. And to that, my, my question, because obviously I'm not the surgeon. It's not my decision, right. But I've seen children, I've treated these children. These children are in pain. They are recovering from tonsillectomy for a good solid two weeks. And so we like to give them that time for recovery before we resume. Myofunctional therapy, feeding therapy, anything involving the mouth, speech therapy, even, you know, we need, they need. They're swollen and it doesn't feel good to swallow water when you're that swollen in your throat. So, you know, hydrating them is our focus. We shouldn't have to worry about moving their tongue. So, you know, that's kind of my, as a mother, you know, and as a professional who has seen this, like, I'm like, even if you are prepared, like, I get it, you don't want to put a kid under anesthesia twice. And if that's your only the option, okay, fine, I'm not going to say no, don't do it. Like, again, it's not my decision. I'm just telling people what I've witnessed in my practice. You know, these kids don't want to move their tongue. So now you've got a tongue, if it does get released, we have at least asked that it be sutured so that we can hopefully avoid the wound, you know, contracting and closing on itself and becoming even more restricted than it was before. But also, they need those two weeks off. And we typically, even when they are sutured, we like, you know, when they're sutured, we give them one week at most between the procedure and their next session. And when they're not sutured, we see them within like 24 to 48 hours. And they're already educated on what to do during that time with the ability to reach out to us if they need any help sooner. So, you know, it's, it's very hands on, which I'm sure, like, you know, you're in the space, you can appreciate that. And it's like, no, as a mother, I would never want to put my kid through that understanding like, knowing what I know. And so that's where like, even with the prep, I'm just like, oh, can we please separate them out?

Like, please.

I mean, I get it. I guess a lot of ents also are only going to do it under, you know, an anesthetic. So they don't want to give it close together for two procedures when they could do it all at once. Like, I totally get the reasoning. And I know not everybody has dentists that do pediatric releases or oral surgeons that do pediatric releases in their area. So there's, there's so many variables and I just share that because I know someone's gonna be like, oh, you made me feel awful. No, that's not my goal. My goal is just to educate so you can make an informed decision. And whatever decision, like you decide for yourself or your child, like, that is your decision and I respect that. But yeah, it's.

Oh gosh, it just gives me like, like, it's like flashbacks.

Right? Like these. If only I knew then what I know now.

Yeah, yeah, well, and like I said, you know, he was kind of borderline. You know, he's kind of more like grade three. And so that was also my reasoning for like, let's just maybe wait and see if we could do it non surgically. Um, and so we did end up waiting on that and he still hasn't been released at this point. Um, just. And again, I think, you know, I may still circle back to that. Um, but I think that that's what's so hard is, you know, trying to find someone who's going to give you that big picture perspective of like, it's not just releasing the tongue, that there's other factors that are like, at play here.

When it comes down to function too. Right. Like that's, you know, I feel like every time I start to educate somebody who asks a question about tongue tied just on like a social media post, I'm like working the word function in there because I'm like, it's not a tie if there is an impaired function. It's really a tie when function becomes impaired and we have a problem. And if you can, if you can improve function without creating all other kinds of compensations and the person is, you know, healthy and happy and thriving.

If.

We can avoid a procedure, awesome. Not always the case. I think I appreciate what you're saying too because it's like, let's not just cut tissue because we see some tight tissue. Let's explore this further and make sure that that's the appropriate next Step. Even though you could very easily do this right now, Please don't do that. Thank you. Moving on. How is he doing now? How is your son functionally?

Yeah, way better. And a lot of the symptoms that I had seen initially are improved. And right now, my biggest thing is two weeks ago, I took them down to Albuquerque, New Mexico, to see an airway orthodontist. And so, again, I had lots of questions, like, why would you fly all the way down there? Like, aren't there good orthodontists in your area? And like, absolutely, yes. But again, I like to kind of think of, you know, it's like a triangle or like a trifecta. You have airway, you have myo, and then you have the TM joints or the temporomandibular joints. So I always say, like, you know, the TMJ kind of has, like, a bit of a branding problem, you know, because tmj, a lot of people recognize that term, but we all have tmj. We all have a left joint, and we have a right joint. And what, you know, what we're discovering now with better imaging techniques with, like, cone beam CT and mri, is that those joints aren't always healthy joints on everybody. And especially with mri, what we can visualize is the soft tissue and cbct, we can do more like the hard tissue. And what we're seeing now is that little fibrocartilaginous articular disc that sits in between the condyle of the mandible and kind of cushions the condyle against the skull base. Is a lot of times that disc is knocked out of place. In my kiddos situation, he had a fall on the chin, like, straight down in the bathtub, like, right in front of me. I'm like, you know, just right then. And then when he was in kindergarten, he had two falls on the playground, like, literally like a month apart from each other. Like concussion, lacerations, you know, so he had had some of these things. And then as I'm watching his growth and, you know, as Dennis, we really look at the bite or the occlusion of, like, how the teeth fit together, what you can start to see is that one side is not growing right. What we found with imaging is that if that little fibrocartilaginous disc is like a little gasket and it's in place there, and it's really protecting the growth center of the condyle. When that disc gets dislocated, it's almost like a fracture of the growth plate because the condyles are going to drive the growth of the mandible down and forward. What ends up happening is if you have an injury just on one side, you'll see one side that gets really short. And so you'll see the chin will point to the short side and you'll have the short ramus on that side. And then, you know, the teeth will follow, right, because the mandible, you know, the lower teeth are just going to like, follow the mandibles. So what I tell people is like, it's kind of like when you have seen a tongue tie, you can't look away from that. It's a phenotype that you start to see is that you see that really retronathic jaw that's not growing down and forward. You know, some people call it like a weak chin. Or you may see it on both sides, or you may see it on one side. And Honestly, that Class 2 or retrognathic position of the mandible really affects the oropharyngeal airway space. So I think that when we talk a lot about nose and the maxilla, but also as dentists, we need to be looking at the back of the throat. And how is the mandible growing down and forward and then how are the teeth coupled coupling together? Because, you know, orthodontically you can try to fix the teeth, but if you have a jaw that has an injury that's not, you know, that's kind of lurking beneath the surface that you're not identifying in the beginning, you know, you're not going to be able to get that, that growth. And so especially females, more than males were much more likely to have ligament tearing that. So you have kind of a medial and lateral collateral ligament that tether the disc in place. And so different types of injuries, you know, gymnastics accidents, you know, so in my, when I do my history, I call it my JPT plus T, but I do a joint history, pain history. But a lot of times, like kids may not have pain. And then I always ask about, like, previous treatment, like, have you had tonsils and adenoids removed? You know, have you had that tongue tie release? You know, have you, you know, what procedures have you had done? Have you had your wisdom teeth taken out? And then, you know, what, what previous treatment have you had? Have you had orthodontic therapy for expansion? Or have they tried to couple the teeth together? You've kind of had that relapse of where that anterior open bite opens back up again. And so, you know, we've said a lot of times it's about the tongue. But you think of all the attachments of the muscles, right? Genioglossus, hyoglossus, they're all attached to the mandible. And so if that, if that joint isn't healthy and it's not driving that mandible down and forward, you've got this like piece of the puzzle that I want to like bring into that picture, you know.

Well, and I think the injury, I mean, I don't know if we've ever talked about this. The podcast and 100 and almost 70 episodes or so now, like that we like injury to the joint. I mean, I'm just sitting here thinking, well, yeah, I mean, of course we look at like infants and toddlers maybe who have had feeding tube, like an intraoral feeding tube or, you know, I know like when I went for my nasal surgery, like they use like a donut shaped thing in the back of my throat. It was like an in office procedure, but it was like three hours. And you know, I was like, huh, like, okay. I mean, I haven't had any pain or anything, but like it's, you know, so it's just all these little things that maybe also we're not thinking about. I mean, I had a gymnastics injury when I was little and I have a maxilla that's turned it on one side up here. And it's just all these things. I'm like, oh, I wonder when like some of this could have happened. But like injury, like you're basically saying that we have these ligaments, especially females, that could essentially be causing some damage to the joint.

Yes, absolutely, absolutely. And I think that the more we start looking, the more you realize like, you know, there, there is a certain percentage of the population that doesn't have a healthy joint. And when you start putting those patients in like an appliance, maybe it's like a sleep appliance to like pull their jaw forward. I just really, my whole thing is like, let's understand what the temporomandibular joint condition is before we start doing those things. Because for me I was doing a lot of sleep appliances and I was. You start to see over time that people start to have bite changes and they start to have jaw joint pain and they start to have clicking and popping or maybe they can't couple their teeth together like they did before. And so I ended up kind of backing way away from just like, oh, yeah, let's just do a snore guard without going like, okay, we really need to just take a pause and get that really comprehensive imaging. And to me, another component is really like, the cervical spine, the upper cervical spine, like C1, C2, and how that is also really, like, a part of the picture. And so as we're starting to do more imaging, we can see that there's like a misalignment or a rotation, which is a pt. We knew all that stuff, right? Is like, you're looking at the cervical spine and like, of course that's part of the picture, but I think dentists are kind of scared to even, like, look at the cervical spine. They're like, you know, just go. Go see a physical therapist.

You know.

So one of the things I want to shoot a little video of, like, just some, like, quick and dirty little, like, tricks that you can do as a dentist or as a myofunctional therapist or OT speech, you know, just to really, like, assess that movement dysfunction in a patient and, you know, just add that to kind of like your big. Your big picture. So, yeah, so my whole thing is just really creating value for the imaging upfront. And I can tell you, with my kiddo, having him have an MRI was another barrier, right? It was really, really hard. It was really hard. So we tried it when he was younger, and he kind of freaked out in the machine. So we're like, okay, we're going to wait a year. So he just had his done about a month ago as a champion. And so basically what I wanted to work with, the airway orthodontist is, does he have disc coverage in that position where he can have healthy joints that are ready for growth? And that's the cool thing is, like, if these kiddos are still in that growth phase, that's where we can kind of catch these issues before they get bad, right? So when I, you know, I've limited my practice to TMD or. Or temporomandibular disorders or dysfunction. So a lot of times I'm getting women that are in their 30s, in their 40s, and they're like, I can't open my mouth more than 20 millimeters, or I have such severe pain, it's debilitating. You think of how many times you use your jaw to yawn, talk, to eat.

All day long, right?

All day long. And so when you have, like, pain and limited range of motion, and then it can start to get into the sympathetic nervous system, and you can end up getting into a lot of complex regional pain syndrome. And it's very debilitating. And my whole thing is, my passion is, let's recognize who those patients Are. My mentor used to call it the deep end of the pool. So who are that small category of. Of kiddos, like, before they even start their orthodontia, to correct that AP shift, Like, let's make sure their joints are healthy enough to withstand these treatments. Because I just think with the disc and the ligament system, it's like micro trauma becomes macro trauma. So maybe I have patients that say, oh, yeah, I used to. Like, my jaw used to click all the time. And then it stopped, and they're like, like, it's better. And I'm like, oh, actually, probably not. Because what. Probably what was happening is, like, your disc was kind of hanging on, and now it's all the way off. And now you're on your retrodiscal tissue, which may thin and perforate, you know, and so that's the crazy thing is, like, with cbct, now that we have better imaging techniques, it's lower radiation than even a panoramic plus a lateral ceph. If you have kind of those new machines, you can start to see all of this stuff in the skeletal where you're just like, whoa, okay, this is like, it all makes sense because the skeleton is not going to lie, and you can try to fit the teeth, but if those joints are not stable or they're actively breaking down, it's going to continue to do that and the teeth are going to suffer. So I just think a lot of symptoms with grinding, clicking, and popping, we can't ignore those or normalize those because those are our little, like, warning flags, like, you know, something wrong.

Can you get more information now, like, on these newer CBCT machines? I'm asking because my kids have had imaging through cbct. Mia just had her first. Lily has had it three times. She had before expansion, after expansion. The dentist was very holistic, was like, we don't need to do it after. I'm like, no, I need her case study. So I need to. I need to talk about her case. So I'm okay with it.

Let's do it.

And then I had it done recently at an ortho consult down here in South Florida at two different places, actually, for both kids. And so we had. We sent off for the beam reader reports, too, because I'm a nerd.

I make you beam reader.

I'm like, yes, I'll pay for that.

Just get me.

Yes.

No, they're. They're absolutely fantastic. The CPCT without the beam reader report.

So, you know, it was interesting because on one of the cbcts with Lily, we had. Had seen what we were kind of like questioning is. We were like, is something going on with their TM joint? Like, is there, like, let's monitor this? And then the last one came back and, you know, with reviewing everything, we're like, okay, no, it looks to be very healthy. Like, we think we're good. And so anyways. But do you feel like those newers, like you were saying, the new cbcts can give us more imaging, but can it give us, like, the full amount of information we need about, like, the health of a joint for, like, a child, a pediatric case?

I think it's a really important piece. I honestly feel like you've got to combine that with the MRI as well, especially in a growing child. Because what you want to make sure, especially is with that class 2 anterior open bite patient, or maybe a cross bite patient, is if the orthodontist is saying, hey, I want to put them into a herbs or Maybe a Class 2 correction to bring their mandible forward. I want to know that they have that disc coverage, especially on the medial pole where they're. They're going to be able to, like, have that growth happen. And so I really, like, I definitely believe in cbct, but I think it's important to do the MRI cuts with it as well. So for my kiddo, I kind of did. So Dr. Piper has an MRI protocol and I. I did more of kind of like an abbreviated scan with him. So what we did was a bite registration that brought him into a Class 1 canine position and had the tech do like, a proton density scan to be able to see the fibrocartilaginous disc. And so now I'm going to be working with my airway orthodontist on how do we work and kind of plan that case because again, he needs expansion. He's going to need that Class 2 correction. But we wanted to make sure because his disc is kind of squirted out to the side laterally. It's been laterally displaced as we want to make sure he's in that place where he can get that growth. And what's so cool about. So the airway orthodontist that I'm working with is Dr. Drew McDonald. He is like a ninja of like, cone beam CT and like, all the stuff he's doing. And I'm like. I thought I was like, doing it comprehensively, and then I was like, I was at his office. I'm like, mind blown, you know, just like. I mean, he's doing all the things that I am, but just he's Looking at everything so comprehensively, and I just think we need to have orthodontists that are like that, that really can look at the airway space, look at how is the maxilla growing, how is the mandible growing, how is the tongue functioning? So he does all of that in his exam weekend. Talked about his tongue. We talked about should we revisit that? And that's why I said we were going to probably circle back to that. But just really planning and planning that out, I think in a thoughtful way is going to be the key to really preventing, you know, because, like, there's like 10 million people in the country and globally that have like, TMJ problems, you know, it's a massive problem, you know, and like I said, why are we waiting until it's like all you have is surgery or like a joint replacement. Like, why are we waiting until it gets to that point? You know, I have a good friend, you know, I like, just looked at her panoramic X ray and I was like, your condyles, instead of looking like an nice, like ice cream cone shape, it's like a stiletto heel, you know, it's like you have no bone. You have like a little bird beak, you know. And so honestly, like, that's what I would say is like, even, you know, the dentists that are just looking at a panoramic X ray, pay attention. If you see one side that's shorter than the other, and you, you know, you're looking so closely at like, the tongue and like the, the posture of the, you know, cervical spine. But if you see like this whole shift to that short side there, there's that there's been an injury to that joint, and that joint's not growing. So it basically becomes like an osteochondral growth defect where one or both joints aren't growing like they're supposed to.

So it's so fascinating. I mean, we see all the time where just the masseter, right, is clearly being overused on one side and underutilized on the other side. And you can just see that by.

Looking at that imbalance.

Like it's, you know, and sometimes it's very often obvious, sometimes it's a little bit more borderline. And you kind of really have to put your hands on and do some open, close posture to feel it. But we see that frequently. And I know from creating a MYO course and going through research, and I remember the first time I read that it was something like 99.7% of all TMD cases have a myofunctional disorder. I was like, well, yeah, that makes sense. I mean, how can you use your muscles properly if your bones aren't okay?

Yeah.

So it really kind of just opened my eyes to all. I'm like, there's so many people walking around, like you were saying, with issues with their TM joint. And it's so imperative in how we sleep, where our tongue rests, how we chew, swallow, speak. I mean, like, you were listing it off before. It is a really important joint to pay attention to, but I think it gets, like, the least bit of attention, really, in the medical community. I'm like, we really need to pay more attention to it. And I know, like, so, like, I've gone through adult expansion, too, and, you know, I did get some growth, and then my teeth also tipped a little bit. And so then we kind of, like, brought them back. We stopped and, like, brought them back. But, you know, it just made me so much more aware of, like, this airway, myo expansion, you know, space and everything. And I just, you know, I'm like, for the longest time, I've never had pain, but I am somebody who at night, like, well, clench, grind, but I clench. I'm like. And I can wake up in the morning and feel like some tension carried throughout here. And so I just had my nasal surgery three months ago. And so, you know, I'm still. Swelling is a lot more. It's a lot less than it was. But, you know, I know it's like, I've still got another three to six months or so of true swelling to go down. So I'm just kind of, like, waiting it out to see what happens. But it's something I keep going back to. To myself, because I'm like, I feel like I have enough space for my tongue. I can fit it up there, but for some reason, it doesn't naturally want to go there. And I know, like I was saying before, like, my max was turned in on one side. I'm like, obviously, my journey's not done, but I'm like, you know, I'm like, one step at a time. Like. Like you're saying, too. I think it's. It's so important to kind of have a plan, an individualized plan that makes sense for the patient based on, like, what you're seeing, what their symptoms are, their profile, their imaging, that whole comprehensive approach. And, you know, I admittedly, like, got my tongue tie released, and then I was like, oh, maybe I should have waited till I had more room for my tongue to get my Tongue tie release. You know, it's like that was the beginning of my journey. Right?

Live and learn.

But you know, it's like sometimes we're really passionate about these things because we've experienced them firsthand, you know. Yeah, but it's, it's, you know, one of those things too that all I'm, all the time, I'm just constantly going like, okay, I know that they've said that my joint is healthy, but I'm like, what am I feeling on my face? And like, where is the tension? And where, like someone asked me today on one of my posts, like, well, like what's the significance of a, like an upper lip tie? Or like what kind of impact is that going to have? Like, why would that cause mouth breathing? And I'm just like, well let's back it up and think about like what's happening here. Right? If, if the lips lip is tight and it curls under and it's tense and you're constantly carrying tension. Right. Well now it's not doing its job. So now other areas have to compensate and if the lower lip can't come up to meet it, maybe it does. But now it starts to cause tension in the mentalis muscle and then we've got like, then we have to think about the other perioral muscles and then we have to think about the impact up, you know, like it, it causes this whole big snowball effect. And like even though your neck is here and your TM joint is here.

And your chin is here, they're all connected.

Like it's just, it's all interconnected. And so when we start to like realize how interconnected fascia truly is and then the impact that has on our bone structure, that's when I start to see people go like, oh my gosh. Like, you know, and obviously what you're talking about is even beyond me. Like I'm no TMJ expert by any stretch of the imagination. But you know, it's, I'm like, it's just, it's so fascinating. And I'm constantly just going like, wow, this is really like, maybe that's why I feel this on the right side today. Okay, all right, well, document and continue.

Well, and I always tell people, if your 12 year old child had a ski accident and they injured their knee and they tore their medial meniscus, you wouldn't think twice about if the orthopedist was like, okay, they need to have an MRI before you decide, are you going to do PT and a brace or are you going to have arthroscopic surgery. I don't understand why there's such pushback against getting an MRI of the TM joints. Because to me, that gives you an understanding of, like, you know, what your anatomy is, and then you can decide, am I going to do conservative things, you know, am I going to maybe try to do nerve blocks or Botox or PT exercises or, you know, chiro or, you know, or am I going to maybe consider surgical options or, you know, am I going to consider those orthodontic options? But I just think you have to have that value, you know, you really have to create value for people. And I think that that TMJ kind of is sort of that gray area between medicine and dentistry and dentists kind of don't really want to touch it. You know, we try to, like, build medical and, like, they don't cover it, you know. So, yeah, it's really, you know, kind of been unfortunate because it is a very complex, complex joints. And, you know, I really feel like that connection, if you have that disc coverage and you have that connection, that. That that's going to influence your maxilla, the growth of the maxilla as well, in our young, growing children, it's going to. They really need to have that connection, you know, that synovial joint be, like, functioning properly. And I think with kiddos, you know, they don't always have pain, but you start to see those little subtle signs, you know, you start to see that little S thing as they're, like, opening and closing. You know, maybe they'll get, like, a little deviation, you know, as they're opening and closing. Or like I said, you look at the bite and you start to see that anterior open bite where the teeth don't couple. And you're thinking, like, maybe, you know, that's why I said I loved on the podcast, you said, I hit a mile wall with my daughter where she'd had a release. I have her where, you know, but she's still not quite where I want her to be, right? And kind of like that sagittal plane, you know, when you're looking at kind of the growth and development and, you know, medical modeling tells that even that little shift from a Class 1 to a Class 2 bite decreases the oral volume to 92% from 100%. So already those little Class 2 kiddos that have that retrognathic presentation, they're already not getting as much oxygen, even if they've had the tonsils and adenoids out. So that's my whole thing is just like, I want people to think about kind of that other piece of the puzzle. Like, let's not leave the journey joints behind. So, you know, kind of my thing was I started TMD Collective because I had had so many clients, you know, kind of like crying in my chair. Like, why didn't anyone ever explain this to me? I, you know, like, I, you know, I just, I want to know, like, why did I have to wait till it got so bad that I can't open my mouth or like I have this closed lock I can't open. And so I just really feel like in order to make it better for the individual, we have to make it better for, for the collective. And so I feel extremely passionate about just getting my message out there that we have to really take that comprehensive look. It's part of myo. It's part of the cervical spine. We all, you know, it's like we all have to collaborate. I'm like, let's all get along.

Yes. Wouldn't that be so great? So the TMD Collective, who is the that for? Like, where can they tell us where you can find it?

Yeah, so I do have a website. It's www.tmdcollective.com and that's mainly for people, you know, kind of in the, in the greater Seattle Tacoma area if they want to see me in person. I'm taking new clients, but, you know, kind of staying, staying tuned. I'm hoping to do, like I said, you know, maybe a masterclass for kind of like myofunctional therapists or I'm going to be speaking at the pndc, which is like the Pacific Northwest Dental Convention in November, which is like our big dental meeting. And it's going to be airway and myo and TM joints. So if anybody wants to come see me November 10, I think 10 to 12 is in Seattle, our big meeting there. But I'd be happy to do any, like, small group study clubs. You can email me if you want more information. I am also an Instagram @TMD Collective because like TMD Collective was taken. So. But that's the platform I'm probably like the most active on at this point. Like I said, I'm just kind of getting started. But love to hear feedback from your community. If they want to like hear more information or you know, reach out to.

Us, we can bring you into the MYOME membership and have you functional therapists in there. We have a. For like 450 monthly members right now, and we're about to reopen doors. I don't know when this will air, but July 18th, week of July 18th, doors will be open so that they can join us too. So we'll have to see. I know. I'm pretty sure we have like, maybe at least one month still open this year, but we'll confirm with Jess. But yeah, I think this would be so informative because, you know, we are constantly looking for, like, airway forward providers who, you know, even if you don't even, I mean, you have an understanding of mile, but like, even, even if providers don't have an understanding of myo, but they collaborate with MYO and they understand airway, I'm like, we can all come together, learn from each other, and it's just going to benefit our patients. And one of the most exciting, I think, discoveries for me in this space. And I was very spoiled when I lived in Maryland with my team up there. My practice is still in that D.C. metro area primarily. So I have a lot of. We still have a lot of collaboration with those teams. But having my airway centric dentist had a PT, a PRI trained PT in the office, two different PTs, like twice a week, so that their patients going through expansion or, you know, having any kinds of issues were able to see the PT when they were there for their appointment. And so every time I went in for like an appliance adjustment, I also got to see the pt. I did see him between as well, because I only went in, you know, every so often. But it was incredible. It was absolutely incredible. And that's also one of the arenas that kind of really pinpointed for me that whole, like, tip of the tongue to toe connection. Like how just from a fascist standpoint, we're so interconnected. And I would be like, I don't know what he did. I mean, I do know. I don't really. I'm like, I can't explain it, but, like, I feel like I got a full body massage. He barely, like, did, you know, barely touched me. And I just feel.

Did you do some of, like, the intraoral massage?

Like, like the pterygoid stuff in my palate. But, like, he did a lot like cranial and, you know, he'd go to, like, other points on the body too. And he called it modern counter strain technique was like, part of what he did. He's like, yeah, yeah, it's not the traditional counter strain, it's modern counter strain. And I know he works. Manny, who I was, who was treating me, works closely with Brian Tuckey, who's out of Frederick, Maryland, who's like, just phenomenal as well. And the two of them are just these brilliant minds with amazing application for patients. And, like, they get you out of pain so quickly, but it's, you know, then looking at, well, what's the root cause of this, what's causing this, and what is our, our team approach to make sure that we keep you in relief and not back, you know, sending.

You back into pain mode.

And I know for me, right, like, I'm low tone. I've always been low tone. That's a lifelong thing, right? I have a dowager's hump on the back of my neck from being, you know, sitting forward. So, like, my spine. Forward head. Yeah, my spine is lovely. You know, I've had all these airway issues and orthodontic relapse and, you know, so on and so forth. I feel like I've had to check all the boxes at some point or another, but I feel like finding a PT who got it was just absolutely life changing. I mean, yes, the dentist too, but like, the PT component, I was like, oh, my gosh, like, this is incredible. Like, how do we clone you and just like, put one of you in every single dentist office? Like, how do we.

How do we do that?

Teach us your ways. And I did link up with the, with PRI and learned about a lot of, you know, their. They gave me. They had me go through one of their trainings virtually during. During pandemic times. I watched it online and I was just like, this is so fascinating. Like, this is such a missing piece of the puzzle. So as a pt, I'm like, you have such a really unique perspective on the joints and the full body impact that I think a lot of dentists may not. And so I'm like, I can get why people would avoid the tmj, TMD thing. It's kind of like what people avoid MYO in general, as if our muscles don't exist. It's not something they teach us in grad school. Tongue tie. What's that? Like, we had to basically learn all of this, you know, post grad. And in my opinion, like, the things that are most important in life are things that we're all having to spend, like, you know, thousands of dollars and hours learning ourselves and now trying to impart on others, because it's not simple, but it doesn't have to be this complex either. You know what I mean? Like, it's just like, I feel like there's. If more of us come together, we can help more people. And so I love your Whole, you know, let's all work together. And I. And I'm like, yes, all come together. Like, we can all make such a big change. So I'm excited for, you know, the future.

Yes, I know. And I use, like, a lot of, like, muscle energy techniques, too, which, you know, I think can be, like, really incredible, especially, like, for C1 too, because, you know, I think there's, like, a lot of incredible, like, AO chiropractors that are awesome at, like, fixing the alignment. But then patients are coming back and they're like, it's not staying or like, I'm unstable and stuck. So you've got to be able to find ways to really, like, help retrain posturally what's going on. And, you know, muscle movement pat, you know, recruitment patterns. I like, I love to geek out on that, you know, And I love Pilates too, because, like, it's also, you know, about, like, alignment and, like, specific, you know, like, let's try to fire multiple and, you know, and like, stabilize your spine and, you know, so I don't know, maybe I could start like a Pilates for tmj.

Yeah, so that's basically manual was like, please don't do yoga. Please do Pilates. He was like, I want you to do Pilates Reformer. He's like, that's where you need to start. You need to build some core strength. You need to get your lower back strength going. Like, he, you know, being a pt, like, he looks at this stuff, and I was just like, oh, okay. Like that. That was why. Nobody ever told me that before. Like, why did I have to be 30, whatever, mid-30s before someone said, hey, do some Pilates. That's what your body needs. Because nothing else was helping. So I love that.

Yeah, start.

Start some kind of, like, you know, a Pilates thing for all of us in our MYOC functional crises.

Yeah, I know, I know. That's why I just like, to me, like, I love just, like, collaborating with other people. I just feel like that makes you stronger as a clinician and, you know, it's like, I'm just like an addict to, like, lifelong learning, you know, like, continuing, like, study clubs and like, continuing education and like you said, like, paying for, you know, a masterclass that is really, like, worthwhile and is going to. To take you to the next level. But I just really think that is going to be the standard of care is where you're looking at all of those things. And we're not just so siloed into our one thing of just the teeth.

Yes. Yes, yes. I cannot wait for the day. I was just having a conversation with another dentist in the airway space, and we were talking about how the gut microbiome 10 years ago was what people were like, what's that? And those of us who were paying attention to it were crazy, right? And then it's all of a sudden, like, now everybody is paying attention to the gut microbiome. And her whole thing was like, the oral microbiome, like, airway health, like how all of this impacts our overall health. Like maybe 10 years from now, that's, you know, that's what everybody will be talking about. And I'm like, we can only hope, like that that is the goal, that the TMJ airway, myo, all the things that would be one wonderful.

Right, right. Well, and hopefully, you know, we're in a world where dentists aren't just like, fixing like cracked teeth from, like, you know, clenching and grinding that we've gotten to kind of, like you said, the root cause of it is that we've like sorted all of those things out. And, you know, I really feel like, you know, you talk about, like, forward head posture, you know, the muscles have that ideal length, tension relationship, and if they're not there. And I think the same thing happens with the masseter is like, if you lose that dip and all of a sudden your condyles are seating further up into the, you know, the joint socket, all of a sudden that masseter is scrunched closer together, the medial pterygoid, you know, there. Those are those elevator muscles and they're not happy. You know, you try to get under there and try to release that and you're like, ah, oh, yeah.

Now we have like, certain things in place where we're like, okay, if you see this on a patient pause, don't ask them to repeat that. Make a note and a referral. You know, it's, you know, we never want to upset the joint. That's one of the things I think that is really beautifully discussed in the myo world is like to very. To protect that joint and to make sure we're not making it angry. And so there may be some dysfunction. There may be some, you know, there'd be an imbalance and whatnot. But if you have any concerns at all or the patient complains, not just of clicking or pain, but if you notice something that makes you kind of go, hmm, you know, like, like you're saying we need to have more information before we just jump into a plan where we start addressing the muscles and that's, you know, one of the things, like you said, lifelong learner. That's one of the reasons why I created my membership. I was like, there really isn't a place right now where, you know. And again, this was before the pandemic, but I was like, you know, or kind of like in the beginning of it, I was kind of like, there really isn't a place where people can easily do this if they're not. If they don't do local study clubs, which I was doing with my team, but everyone was complaining that they couldn't source one, they couldn't find one. And I was like, well, why don't we all just kind of get together and learn together and, you know, being a lifelong learner, right. I'm constantly learning from colleagues in my space, outside of my space. And I think that's the beauty of all of this and the inner connection between everything that we're doing. Because, like, you're sitting here talking about injury today, and I'm going, oh, wow. Yeah, that's new. That's new for me. I've been doing this for a while now. And I, you know, I mean, injury direction to the joint. Yes, but, like, injury not directly to the joint, that could still impact the joint. I was sitting here, like, why didn't.

I think of that?

That's. Yeah.

I mean, it's funny, too, is, like, if you ask the question, like, have you had any. You know, have you had any injuries to, like, the head and neck? And people are like, oh, no. And then you'll be like, well, what about this scar on your chin? Oh, yeah, I fell and I busted my chin open and blood was everywhere, and I had to get stitches. And, you know, like, sometimes you have to ask very, like, specific questions, like, have you ever been intubated? You know, like surgery with a breathing tube, you know, have your wisdom teeth removed? You know, all of those things. Like, have you been in a car accident? You know, in my case, I was in three car accidents, you know, and, you know, it. Like I said that micro trauma becomes macro trauma to the joints. And we really need to understand that before we start fixing the teeth or putting in appliances or, you know, and to me, like, once I discovered how to image correctly and to, like, really read those images. And again, I love beam readers. I think, you know, I absolutely use them, too. But I had to also learn how to read mri, right? Which is. That was a whole new skill. And so, you know, that was really comprehensive curriculum to. To read that. But once I had that information. It took all of the mystery out of it, right? You know, and it was like, I think as Dennis, we would be like, you just put in like a night guard and like, hope for the best, you know, and like, hope that patient doesn't ever come back. Or like, they come back and they're like, oh, it's making me worse. And like, you kind of just grind on it and like, give it back to them and like, hope that they don't, you know, come back again, you know, but like, if their joints are actively breaking down, that's when you see bite changes. And like, you know, the biggest complaints are like, something's in pain or something doesn't fit, right? And so if you're, if your bite is changing or if you're starting to have pain, you're having limited range of motion, those are all like, kind of those little, like, warning signs. And like I said, you know, with our kiddos, I think that those are the things that we need to be like, really, like, just popping up in front of our eyes is like seeing those little subtle changes where, you know, we might think like, oh, it's no big deal that they have a cross bite. Or, oh, it's no big deal that they have, you know, that their front teeth don't couple together. They have an anterior open bite. No, it is a big deal.

And I think one of the things to look at too is sometimes you tell a child to smile, like, like my own, my 4 year old. And she put. She brings her teeth bite to bite, like edge to edge, and she smiles, but that's not. And into someone who's not trained, they're gonna go like, oh, her bite's fine. And then we go, no, no, put your jaw where it's supposed to be. And she moves that lower jaw back and it's trapped by her Mac. Her mandible's trapped by her maxilla. And you know, it's like, it's scary. It's. She's such a deep bite. She's grinding in her sleep, she's waking herself up, She's. She's crying, she's, you know, like, she's not getting deep restorative sleep, which is a whole nother topic for another day. But, you know, it's like one of those things where I'm like, oh, gosh, like her joint. I mean, her joint. And she's going into treatment. But it's one. You know, that's where I completely agree with you. Like having the ability to do more early intervention instead of even waiting until 7, 8, 9, if we can. It's just critical because they're developing and we need to, to catch these things when we can and try to implement what we can as early as possible. I always say to everybody, it's never too late to do something, but what that something might be, like you said you might be at the point of surgery or something more involved. So usually it gets more involved, more costly, and takes longer to address the longer you wait. So I always say, get in early and see what you can do now.

Well, and what's so cool is on the cbct, you can see in a growing kiddo that the cortex of the condy is fuzzy because that it's still growing. And so, you know, there's like norms, if you're looking at the literature of like, you know, if you have a 9 year old boy, he should have like a 48 millimeter ramus height, you know. And so then like you start looking at females and their growth center is completed by 15. So you've got this like little window, you know, of time of where you can really change, you know, the, the amount of bone and the amount of growth that's happening with the mandible before it's too late, you know. So I think that's where, you know, CBCT and mri, you know, I think CBCT is great for really looking at the skeletal parts, but you've got to also put it together with the MRI and have those done in a bite with the bite registration so that you can correlate, you know, is the joint healthy enough to support. Now I'm going to change the bite to that healthy position. And then, you know, what ends up happening is like if that disc is covering the growth center, then you, you take a repeat imaging, you know, nine to 12 months later and you've gotten growth, you've gotten bone growing. I mean, that is what's so incredible. It's like you can grow like 4 millimeters of bone. You know, it's like, imagine that, right, if you didn't have to do that with like a surgery or you know, if you could do that orthodontically with the functional appliance or, you know, anything like that. But you just, to me again, you have to know the whole picture. You can't like miss those things because it can just, you know, then that's, Those are the cases. You know, when I talked to my orthodontist, I was like, I want you to think about those cases that relapsed, you know, what does that even mean, you know, why did it go sideways? Like, why did you have kind of this like subpar outcome or even orthognathic surgery where you had like an MMA and you had an advancement and then it relapsed, Right, because the joint wasn't stable, it was actively breaking down. So then they started start relapsing and maybe they do like some chin augmentation and some things like that. But really nobody's like paying attention to the fact that the joint wasn't stable or healthy to begin with. So that's kind of my whole thing is like, let's create value for that diagnostic imaging early and comprehensively and then like let's all work together.

I love it. Well, thank you so much. This is has been absolutely amazing. I can't wait to have you come join us in the MYO membership and thank you for sharing. Also your your son's journey and you know, everything you've learned.

Thank you. Thank you for having me.

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