Episode 175: Dr Eyal Botzer, DDM. Creator of TongueGym by Liper

Hi and welcome to episode 175 of the Untethered podcast. Today we have Dr. Eyal Bazer joining us. Dr. Eyal Batzer is the DMD and founder of CTO of Liper. He has over 25 years as a doctor of dental medicine specializing in neonatal, dental and oral anomalies, specifically craniofacial defects and tongue tie. He's the Director of Pediatric Dentistry and Tongue Tie Research and Treatment center at Tel Aviv Swarovski Medical Center. He is a tongue tie medical opinion leader, co founder of the International Affiliation of Tongue Tie Professionals IATP and has over two national decades of research and.

Treatment of tongue tie.

He's also the founder and CTO of BAM Media Ltd. The inventor of Tongue Jim by Lightbar Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses.

Let's get started. Hey y'.

All.

Welcome to the podcast. I'm excited to chat today.

Good to be here. Thank you for inviting me.

Absolutely. So I want to just dive right on in because I'm curious. I want to know about the origin story behind Tongue Jim by lifer and really what it is that you're doing for the greater good.

Well, it starts with frustration. You know, when I was so frustrated with the fact that the effectiveness of my instructions to the to the parents are weren't really met by them, it was very difficult to get a good, we call it compliance. Usually it started with the parents to do the exercises, the tongue exercises on the newborns and then all their toddlers and they rather avoided it. So we can give very good recommendations. But at the end of the day they didn't really do the exercises and then we met with the, with the results that there was no real improvement in the oral function. So I was kind of looking for something which would be easy and help them both, help them kind of feeling remote from the child, yet with full control on it. And this is how I got into the Tang Jim idea. We tried it for many years. We had a lot of babies and toddlers crying, and then we got them happy. So it's.

Yeah, no, as a treating therapist in this space, I know exactly what you're talking about. We have a lot of, not just parents, not just caregivers and support, you know, and those support units, but therapists who are afraid to go into a baby's mouth and disrupt the, you know, the wound or upset the baby or cause aversions or any number of things. And we have found that there really needs to be protocols or things in place. But like you said, even with those in place, we still notice that compliance is a concern. It's an issue for us.

Dentist. It's very natural to be in the oral cavity of the child, the toddler, the adult. But for a parent or for a person himself, maybe when they brush their teeth, they feel okay, but other than that, it's kind of. It's not natural to them. And when you get something which is easier to do, something, a tool that really slips into the right spot and you can have full control over it, then it's much easier. And indeed, I do see the better results with the function.

That's great to hear because I know that, like you said, function, right. That's the key word at the end of the day. And I know we chatted before and we're on the same page. We don't want to just go in and release frenula. We want to make sure that one. We're doing it because it's disrupting function and that we plan to improve function. It's part of a larger puzzle and treatment plan. But there is a lot of important therapeutic intervention that surrounds the tethered oral tissue release, regardless of the modality in which that release happens. Right. We need to make sure that we're working towards gaining proper function and setting up the child or adult, you know, on a healthier path. So I know that, you know, you actually have like, tongue exercises and things that you target, you know, it's not just infants. My understanding, when I knew the company originally and knew about the Lifer, I always thought it was for infants. And then I, I saw your website this week and I was like, oh, wait, there's. There's an adult component here. This is the whole lifestyle. So can you share a little bit about, you know, your work and what you are addressing as far as, you know, treating or working with the entire lifespan from birth through adult?

Yes. Well, I started with infants. It all started with my youngest daughter with a tongue tie. Of course, we all, all of us today in this field are kind of emotionally involved because we have some personal experience, because it's still not in the medical, dental curricula. So the person that falls into this field are those that have some kind of personal experience. Mine happened to be 22 years ago with my youngest daughter. So I'm, like I said, emotionally involved. And it started with neonates. With neonates. And then started the frustration. It started with phrenotomies that I was taught that there's no need to do that. And then following our research that was done in Tel Aviv and we got amazing results that really blew our minds. And we started getting deeper and deeper into the field. We started to understand that we can improve breastfeeding. And not every child was successful following the surgery. Then we got to understand that there are many more issues to that. And you said tethered oral tissues. It's not necessarily tethered oral tissues. It's oral dysfunction, oral function. You may have a high palate and then tongue has a full range of motion. And there is an oral dysfunction in this child. We had a period of every speech pathologist, and I'm sorry, every lactation consultant would send every child that had a tongue tie to a release, that had a. Sorry, that had a breastfeeding issues, to release his tongue. And then of course, it fired back. And then we started to understand the link between proper tongue function and following. There is no real objective way to understand how is the tongue functioning in the oral cavity. We have our experience putting our finger in there and trying to feel the peristaltic like movement of the child. And it takes time to get this expertise. And you know that not every child is the same. Of course, if you see a tie that goes all the way to the tip of the tongue or just a little bit behind it, you know, and even the most offending doctors that say there is no tongue tie, maybe they can agree on that. So this is how it started. And then we moved into feeding issues and feeding issues on when babies switched to solids. And we saw that there are issues there. And good speech pathologists that understand feeding and also something that grew with time, started to understand that the tongue movement is. Has some issues there. All the work of a speech pathologist at this age is trying to teach the child both the psychological aspects of introducing food and chewing and so on, but the correct swallowing is something kind of enigmatic. From then we moved into toddlers speech issues and tongue thrust and I started to understand that it's not only a tongue tie but rather an oral dysfunction. Took me a few years, I think maybe at the maybe 12 years of releasing ties on newborns and we started to work on tongue exercises. Maybe like we say there is post surgical active wound management or post surgical physiotherapy. Something that we thought may be working is pre surgical or non surgical tongue training tongue exercises. I come from the field of cleft lift and palate and we do something which is called pre surgical orthopedics where I prepare the child for surgery, we stretch their soft tissues, we align them, we get better surgery. And this in mind, I started to try to have the tongue function correctly and get maybe better, I would say craniofacial growth and started to do those exercises on newborns and then on bit older kids and started to work. Not every child needed surgery and it was kind of mind blowing. And from there it moved into the understanding that breathing has anything to do with that. I never thought of airway or breathing. This is something that evolved with time. Then one of the doctors in Israel, Roy Fuerer, passed away and he was the person who was treating adults. He with me was one of the co founders of the IATP and he would talk about the palatal size. We never understood that at the very early ages days. And when Ray passed away I was the person left to treat the older kids and the adults. So I was drawing into this field and gained some experience with that. And again it's so frustrating to see the tongue is not moving, the child is being referred from a speech pathologist. And I tried to measure the tongue range of motion ratio. Now that we have some kind of tool which was developed by Surush in his group and the child cannot even lift the tongue. So what do you do? You work in a team. And this team has a lot to do with training tongue exercises, teaching the brain re education of the, of the proper movement, sealing the lips. And this team led me to get this way of training exercises, get good function where surgery is really a minor part of it.

That's fantastic. I mean you said so many things on there that we could talk about everything from not every child, you know, you alluded to not every child needs a tongue tie release. Have we done any? We call it like pre op therapy but essentially we're going in and doing feeding therapy, we're addressing the surrounding tissues, we're working intraorally. We're also referring to different forms of body workers, whether that's cranial sacral therapy or osteopath or a pri trained physical therapist in our area or something where they understand the full body fascial connection, that deep frontal line and how, you know, sometimes if we release those surrounding tissues, other tension also releases and maybe the tank, the tongue can gain function in a way that we don't have to head towards a surgical release. But the child still, you know, or adult even in some cases still requires that therapeutic intervention and possibly much more so. I really like that you, you touched on that as well as palate size and TRMR and you know, does the tongue fit in the palette? Aside from the fact of whether or not we can get the tongue up there? If we release this tongue, does it have a place to live? Can we then behaviorally train it through neuromuscular re education to live in the palate? So we have teeth slightly apart, lips closed, tongue up in the palate, breathing through our nose. Can we achieve that or are there other obstacles in our way? Which has become the great big discussion and debate of working with anyone from birth through adulthood. Because we're basically saying, yes, there's always something that can be done. What that looks like might look different depending on where you are in your journey.

But yeah, and everybody knows now that the earlier you intervene, the better the results. Breastfeeding is the best orthodontic treatment that you can get. And when you have breastfeeding issues, it means something is wrong there. The child is not on the right tracks for the best craniofacial growth. So we all know that. We all. I'm talking about us guys.

In the zoom squares here.

Yeah, we. All of us. Yeah. So sad. So we know that the earlier you intervene, the better you get the results. You don't have so many compensations and so on, but unfortunately we have a lot of patients coming in with so many myofunctional issues that should be addressed at older ages. And like I said, the teamwork you mentioned, the bodyworkers so important, all the facial manipulation, that is something rather new in our intimate world that we talk about. So for me, like I said, as the surgeon, I have the least amount of work to do and then I need a lot of preparation before and a lot of work after my intervention. And I hope most of the patients will not even come to my place. They should work at home and not have the surgery done. I'm just one part of the team. And if you've seen some of my lectures at the tongue tied meetings, when I'M talking about the teamwork. The surgeon is the last person on the team.

But I think it's really important, as you do, to highlight the necessity of the team collaboration, the entire treatment plan, because unfortunately, and I'm sure this goes on everywhere, but in the US we have a big, big problem with. We just call them happy releasers. They just kind of release any tongue tie that appears to come their way without confirming that the infant, toddler, teen, adult has the proper team and therapeutic intervention surrounding that procedure. And really, you know, green lighting, we call it like a green light system, whether or not they're ready to proceed with a release if that's the direction that they're headed. So, you know, thankfully, we do have providers who are wonderful, that do have certain, you know, operating procedures in place and checks and balances in a green light system. But we receive a lot of patients that, you know, call us and say, oh, I just had my tongue tie released today. I was told to call you. Like, what? And when do you want us to squeeze you in? Like, okay, you know, it's like, we need to see you within 24 hours. Really? Where. Where is this happening? So that's part of the passion behind education, too, is that it's not that. It's not that we don't want to see you, but, yeah, there's a lot more that happens before, you know, the procedure itself, if that's even the direction that we're heading in. So I like how you spoke to what's needed, you know, from a team and collaboration approach as well.

Let me tell you, this is a very easy problem. What you just described, because I work in the hospital and we have kids that need to have undergo bone marrow transplantation. And as a dentist, they should have it examined and treated way before tomorrow is the bone marrow transplantation. When can you fix their teeth? So it's. So we are in a kind of good situation. The worst thing that can happen will reattach.

Yes, yes. And hopefully not multiple times, because we get those too. And then we go, all right, let's hit pause here and, you know, let's reevaluate the situation and see what else we can do, because it's. It's an interesting conversation to have. And I am always thankful when patients make it to a practice, whether it's mine or another that can say, okay, like, let's take 10 steps back and evaluate the current situation. What does function look like? Now, obviously, you're here because it's. We're having issues with oral function. Whether that be feeding, speech, breathing, which is impacting sleep, attention, and behavior at school. I mean. Right. The list goes on and then into adulthood, adult ADHD and OSA and all the things. So it's always a very interesting conversation to take that deep, dive back into history. And it's one of my passions that kind of threw me into teaching in this space because I was like, they're not teaching this to SLPs or OTS in grad school, and we're all going out and trying to source this information. And there really isn't a. You know, at the time when I created my feeding course, there wasn't a course that dove into tethered oral tissues, myofunctional, you know, therapy, and just crowfacial development in that way. And while that's only like two modules out of 12 modules in the course, it's truly a feeding course. I think it's very, very eye opening to therapists who go through it and start to realize, oh, we develop our swallow at 12 and a half weeks in utero. So that baby's been swallowing dysfunctionally since, like, you know, the end of the first trimester. This wasn't just like, oh, we had a baby and baby can't latch. Well, yes, that's happening, but here's why, right? Because at that point, you and I know that there's also a lot of other development that's occurred in those last couple of trimesters. And the palate is high and narrow. We're seeing bubble palates or channel palates and other things that are making it very challenging for these babies to feed, even if they can gain lingual function just based on their anatomy. Anatomy. So it's. It's really a big discussion surrounding that because, you know, I look at family members and friends and colleagues, and I go, omd. Omd. Okay, everybody's got a myofunctional disorder, and you don't want jaw surgery. So what's your solution? You know, it's like, what do we do now? Which I know there are other answers besides jaw surgery in many cases, but not always. But I think that it's, you know, behaviorally, what can we do? And can we improve function? I've also had adults come to my practice and say, hey, I'm not having jaw surgery. I don't want an appliance. I don't want a tongue tie release. I just don't want the problem to get worse. Like, can you help me? Like, I know I'm compensating. Can you just help Me prevent it from getting worse. And I'm like, well, I can teach you certain things and we can see what kind of function you can gain. We can see what kind of compensations we can reduce and behaviorally what you're able to maintain with the current anatomy in place. Right, and so it's always an interesting conversation.

Yeah, exactly. If we, we can improve as much as we can on this, on a certain conditions, like if someone doesn't have any legs, he will not be able to walk. If somebody has two legs, it doesn't necessarily says he can walk. It's one thing is the anatomy and function is totally different. And again, the clinicians today need to look for the, for this, to look for sources of education. And what you're doing is a great source of information. I have a good friend in Israel, a speech pathologist, Dorit Mais, who says she watches religiously what you're talking about. And it is a, it is an educational source like other Facebook groups and so on. And we need to dig our data from. And a lot of data comes from personal experiences of patients, also from people and patients and the meetings where we meet our own kinds and we discuss things and this is how we get the information grown research is way behind and we've started a research center of Tangta at my hospital where we try to get the research. It's so difficult to do. There's no resources. It's so difficult to get. We sit on a gold mine of a lot of babies and even toddlers and adults. But to turn it into research is something that I will do maybe in the next, not maybe I will do in the next few years, but maybe this way we can educate the world much better.

Absolutely. So going back to the tongue exercises, right, I know that we established that they are for the, you know, any age really, infant, infant through adult, and we are working towards like, function. But can you speak to like the types of exercises that you have on your program and even share with us? Like, where can you know our listeners learn more about them or even see an example of what you're talking about?

Okay, so every, every clinician has their own. The things that works in their own hands. For example, if you look for active wound management protocols on releases, post releases, and you go to our top clinicians like Bobby Gihari, Rajiv Agrawal, they all have great websites with great protocols and nothing has been proven scientifically. So it's all what works in your hands. And what I've seen, I can share only my experience. And this is what we do. And I usually like the parents to start exercises way before they come and see me. If they see a lactation consultant, let her educate the parents how to do the exercises. And by the time they come to me, whether breastfeeding is improved or not and the exercises are changing on my protocol, my private protocol where I'm not, I'm not. It's not evidence based. Something that every physician would say, oh, it's not evidence based and forget about it, let's give the child some PPI to prevent his reflux and which is not evidence based by the way, and.

Can be harmful per the research. But hey, you know, these kids are at more risk of breaking bones at the age of three. But that's not important right now, so just keep on.

So what I instruct the parents before they come to the office and after do try to work into lifting the posterior part of the tongue for about 30 times a day. When you don't start with a single the first time and jump into the baby's oral cavity and start lifting and stretching and interfering it, we call it TG time. Let's have some fun. You put and play with the, with the instrument with the tang Jim on the lips and you go under the tongue a little bit and it's kind of bonding experience. And then you try to move into 30 repetitions a day either throughout the day following the surgery. However, when people are talking about very immense tongue stretching, I'm not into re tearing the wound and opening it because I think when you aggravate a wound, it will try to do all its best in order to heal and will get a much thicker scar tissue. So it's kind of a gentle separation between the floor of the mouth and the tongue and that I recommend three times a day. There is one research that was done in 2012, I think by a group in Montreal and they showed that once they started doing post surgical exercises, they saw that they had less returns of patients for redo during that year. It wasn't really published. It was presented at the IATP meeting in 2014. And this is something that really opened my mind to it. So this is the protocol that I'm using. So gentle separation of the floor of the mouth from the tongue. The tongue from the floor of the mouth. When you are going to kids or toddlers that let's say, have issues with, they don't know how to lift the tip of the tongue. They just have no idea the brain doesn't know how to lift the tip of the tongue. And they have speech issues. Then my protocol is almost as with the newborns, lift, go with the tool, etc. Now fingers are too difficult to use. This is where the tongue gym has a lot of advantages. It slips under the tongue and you let either the parent is doing the exercises or getting the child itself. I would say a three or four old child can go under the tongue, stand in front of the mirror, lift the tongue and see how the tongue tip gets up. And then when they see that, you can really feel like an electric circuit is being closed. And the child knows the brain knows what to do next. And then you keep reinforcing this movement. And I get a lot, lot of experience, good experience with that. With children that did not know how to do the tongue lift, starting to lift the tongue. And usually what I tell them if they are referred for a tongue release, I tell the parents, take a month, a month and a half of exercises and reevaluate it after that. And boom, most of these kids are speaking much better in six weeks. Now we have the question of where the frenulum is. If we have a type 1 Coriolis or type 2 Coriolis, I would go and release it. And I have a child that knows how the tongue training can be. The tongue exercises can be done and I do the release. The parents are doing the exercises and everybody's happy. Sometimes it's difficult for them and we have reattachment, but really very, very rarely, when we get to older patients where they can do it by themselves, let's say adults, we have other exercises rather than lifting the tip of the tongue, they can go all the way to the back of the tongue as much as they can go under the tongue and lift that other area. You get different sensation, you get other education of the tongue. And you can also do some isometric exercises, like putting the tool under the tongue, try to lower the tongue and resist it with the finger, or can put it on the tongue and try to lift the tongue. So we have several exercises that can be done on older, on adults. These are the protocols. I would say 30 repetitions. Addition to that, I would add the exercises that the speech pathologist would give them. Of course, close your mouth and et cetera, et cetera, and move your tongue from side to side. But these are the exercises that I recommend, and I don't want to recommend too many exercises because they won't do anything. We have to keep it the most effective exercises that they can do.

I appreciate that in terms of not, not overwhelming the family or they're just not going to do it. I mean we, we find that in the speech world, we find that, you know, if you give them too much homework, they're not going to do it at all. I'd rather give them one thing that they're going to reinforce and get really good at so we can move forward the next week versus give them seven things. Because we did all seven things in the session and you know, let's carry it all out at home. No, first of all, I'm a mom. I have a private practice. My children have been in feeding slash myofunctional therapy and I am the worst parent when it comes to carrying out homework. So if you don't make it easy for me as a professional, it's not happening. And my kids are like, mom, we didn't do my own. I was like, oh my gosh, your session's tomorrow, let's go. Come on, crack it out. So I can appreciate, you know, the need to really simplify, reduce and be very, what's the word I'm looking for? Intentional. With what we're giving, there should be a purpose behind it. And what drives me crazy is that whole ebp, that whole evidence based practice debate, because it's a triangle. And we, yes, empirical evidence, research studies are definitely an important part of that. But so is our experience as clinicians, as doctors, you know, as professionals working with these children day in and day out. Right? And then on the third part of that totem pole is the family. And we need the input from them as well, from the patient and their experience and their goals. And at least in the SLP circle in the US a lot of that is constantly debated. If it's not, you know, level one, level two, they just basically say research doesn't exist. This is not evidence based. This, that and the other. And I'm going, okay. But this 13 year old who's been in seven years of speech therapy, nobody ever looked under his tongue. He scored on a standardized assessment at the level of a two year old with his speech sounds. And we prepped him, he had therapy, he did go for a, he actually had a final plastic, he had extra skin under his tongue. It was a different type of case. And what do you know? Six months later he was graduated from speech and entering high school, which was his goal, with the ability to sound like a high schooler who could produce all of his sounds, including his R's because he didn't want to sound immature. And so I'm going, we're, we're here going. We have case after case after case like this. I've had realtors who say, I just want to make it through my wedding vows so that without getting tired. It's 10am I've had a cup of coffee. I spoke to one client. I'm here with you. I'm physically exhausted. Right. And so I think people, hopefully, the more they start to hear and learn about this, because they start to realize the functional impact on their daily life when they didn't know any different. Right. And when you start to understand that, oh, it could be different, it could be better, it sort of changes the conversation. And I'm like, the general public seems to be getting more on board with that than my own profession, which is unfortunate. It's a constant. You know, it's a 50, 50 split, if you will, right now. So it's a work in progress.

Yeah, exactly.

And I know it's the same way in other medical spaces as well. So we all just keep saying onward and upward. I was talking to a dentist a couple weeks ago, and she said, you know, gut health was like, not a thing 10 years ago. Like, if you were talking about gut health, you were at least in the U.S. like, you had three alien heads and, you know, who are you now? Everybody's talking about the connection between the, you know, the gut and the brain, your second brain and all this, you know, stuff. And she said, so really hoping that the oral microbiome also becomes that same conversation in the next 10 years that we get to a point where we realize so much of our health holistically starts in the mouth. And if we can address function here and then work on the rest of the body as well, like, we can start to heal ourselves without, you know, we don't have to get into a big conversation of what goes on in the US but with all that put aside politics, big pharma and everything else, you know, it's like we have the tools to heal ourself and we have the professional who understand how to address this, and hopefully that just continues to evolve.

Another thing Israel has pioneered in is also the gut health. The whole issue of the microbiome. Some of the pioneers in that are Iran and INAV and Iran Segal, which are based in Israel and did a lot of work and really pioneer work about the gut flora. Amazing things that we were never taught about them, and we are learning every day, and it affects each and every one of us.

Absolutely, absolutely. So if someone wants to look further into Tung Jim, where can they find it?

Well, we have. Well, Tangjing is by Liper. And you can look on the website for Lipr Device and look for Tangjing both on the Facebook and Instagram. I guess I don't have Instagram. I'm too old.

I will tell you. Honan. Well, I'll pick it up because I know the website is liper-devidence.com and we'll put that in the show notes. So everybody has it. And I want to see if I can find your Instagram because I had it pulled up.

One thing I wanted to add. You said that people, you don't have the time. Well, if you're an adult and we have those breathing issues and so on, and you are on your car, you're doing the tongue exercise that you were taught by your myofunctional therapist in order to strengthen your tongue muscles. You can do it while driving, while sitting, whenever. Nobody sees that. And you can do and do those isotonic exercises and stretches. It's on the go. You can do it.

Yes. And that's amazing. I think it really needs to be. To be so easily implemented into the day in order to make it functional for people, for people to truly carry it out. So I like that. That's, you know, part of what you focus on. How can we make this more easily accessible? How can we. How can we partner with our patients? Whether it's the parent of the child or the parent is the patient or the adult is the patient themselves? And how do we partner with them to set them up for success versus handing them? Like, when I had my nasal surgery, they sent me home with no joke, like, 20 pages of printed material and instructions. Some of it was repetitive for different procedures. And I'm sitting here like, okay, like, I'm adhd. Like, this is. I like lists, but, like, this is really overwhelming. And it took me an hour to sort everything out. And most people won't do that. My ENT was like, you are crazy. Nobody follows all of our instructions, but you're healing great. And I was like, that's just my personality. But I know that's not true for most human beings, so we have to streamline this.

Tldr. Too long. Didn't treat.

I love it. Okay, so on your website, liper-device.com we will, like I said, we will link that to the show notes. I was just going there to see if there was anything else popping up that I could share. I do have an Instagram under Liper underscore device for at least one of your Instagram accounts. I Don't know if you have many, but there's one there where you can go and order the Libra device. It takes you to the webpage, but we'll make sure to link Instagram, Facebook and the website. Like I said in the show notes, is there anything else that you want to share with us that we haven't discussed or covered so well, it's so.

Good to be in a place where people understand you and you're not preaching like preaching to the choir. And it's very good. And always add a little bit more information to your audience. Yeah, I think people should try and like, if you go to a gym and you find a new device there that can work on certain muscles to strengthen very, very specifically, this is the thing that you should try and see how it works. And now it's rebranded as the Tongue Gym. So go to the gym.

I love it. I love it. Yeah, that's. That is one of the things that we often say, you know, there's so much pushback around recommending pre and post op therapy. With one, you know, I always tell our patients, regardless of what happens in this therapy leading up to a potential consult or even release procedure, it's the same type of therapy we're going to do. Whether you're having the procedure or not. We are trying to gain function. We are looking at your individual, you know, plan and trying to help the child, the adult, gain function. If we hit a wall and we truly think there's an anatomical restriction, okay, now we're going to move towards that release. We're going to have a different conversation. Things are going to switch a little, but we're still going to continue those functional goals. Because like you said, when you work on the surrounding tissues and you release, when you were talking about cleft lip and palate patients and you know, those soft tissues and you work with them, we see a world of difference in our patients in terms of ability to function post op when they've been properly prepped. And it makes no sense why there's pushback. When in every single other part of the body and every other piece of the medical world, there's always pre op therapy, post op therapy for other surgical procedures. Why the pushback?

Well, you hit the nerve here. Like I said, I'm a surgeon and I love doing the surgery. Don't take me wrong, I love doing the surgery because they do change. Well, surgery is something that is very instant and changes stuff. But I can tell during surgery, especially on older kids and adults, whether he was prepped well, or not, when I released the mucosa and then I see the fascia. If the fascia is kind of unveiling like so easily, then this kid or person is very, very well prepared. And sometimes you get a fascia which is adhered to the, to the mucosa and is at the herd to the muscle. And you know, well, we do the surgery, but this one was not prepared well and probably will reattach or not. I don't know. But you can see who was prepared or not. And the fascia is amazing.

Yeah. I have a question. So on that, because we've talked about this with other providers, is there a concern from a release standpoint, as the surgeon, that a tongue that is not prepped well may then fall back into the airway during sleep, for example, and become, you know, actually an extraction?

Absolutely, yes. In my opinion. Not in my experience and things that were shown by Surush and others. If you have a very narrow palate and you do someone who is retrognotic and you're going to release the tongue without any preparation, you may experience worsening of the sleep issues. You may. Well, the. There have been two case reports at least on babies on children that had retrognatic jaw, that had their tongue released and they had moved into sleep issue and breathing issues. I don't know about older patients, but we know that if the tongue does. Is not strong enough to sit on the palate, maybe it can go up there, but it's, it is resting at the bottom of the mouth. Logically, it may go back and even worsen the sleep issues.

Yeah, it's one of those topics that I'm glad I wasn't questioning with my first child yet, because she was that tripod sleeper who slept with her bottom up in the air and she had her neck hyperextended with her and she flipped herself over at a couple months of age. Both of my kids could hold their head up at her birth. I mean, it was, I was like, wow, they're so strong. Well, my first one, she's so strong. And then I had my second one. I was like, oh, no, not this again. Like, now I know what's happening and I know too much. But it's, it's just very fascinating, especially when you follow these infant cases because, you know, like you had mentioned, sometimes it goes beyond breastfeeding and bottle feeding and transition into solids can be really challenging for these babies. Sometimes we see that they, they get by okay. And we get phone calls somewhere between 3, 4, 5 months of age and all of a sudden they're not feeding well and we know that there are. The swallow reflex starts to integrate and it becomes, goes from automatic to volitional at that point and there's just so much change happening that things start to fall apart. And you know, it's, it's just very eye opening to follow these children and look at their overall developmental patterns. Are they crawling? They drag the leg behind them like one of my kids did do, you know, did they stop doing that after they had the right bodywork and tongue tie release and you know, oral, you know, therapy and all the pieces of the puzzle put together that basically finally put her on the right track. But having a child who wasn't released until two years of age and went into early expansion at four and now having my second daughter who was released at five days of age, very different feeding experience but gross motor challenges, and now is going into early expansion at 4. You know, it's even amongst my own children and all of our patients, very different profiles, but also a lot of commonalities and things that, you know, I'm very passionate about educating on so that we can start addressing this now so they don't become me, the adult who had orthodontic relapse retainers, a permanent retainer is removed at age 30 to then have to go into expansion and other things and nasal surgery and all the things. Right. I mean, it's just, it snowballs UARS because I don't present like a typical sleep apnea patient and all that fun stuff. You know, my goal is, yes, we can treat you if you're an adult, but what can we do to prevent that happening down the line? How early can we intervene and get that orofacial growth on track? Which I know is a big, you know, goal of yours as well. So. So thank you for all of this. I'm going to ask you again because I feel like we went down a whole new rabbit hole. Is there anything else that we didn't cover that you want to add to that?

There's a lot to talk about. Again, nothing that I think of now. No. It's just that like you said, one thing leads to the other. Those vicious cascades or let's say magic circles that you can put the child on the right tracks as early as possible and hopefully prevent. Like I said, there is no data supporting the fact that if you do that, they will prevent sleep apnea.

Right, right, absolutely. That's. Yeah. One last thing and then we'll wrap up one of the dentists. I talked to recently also, she pointed out we're doing everything right. We're doing all this early intervention. We're, we're seemingly getting function on track. Feeding is improving, sleep is improving. Why do these children still have high palates when we're intervening in the first, let's say, six months of life? And so that's something I know that is a passion project of some dentists here in the US like, what el can we do to help direct the craniofacial growth on a skeletal structure, which is outside my scope, but, you know, we were to get the tongue in the palate, but that doesn't seem to be enough for all these children.

So like you said, it's a passion of a lot of dentists. And one of them is here. Yeah.

Yeah. Well. And thank you. Thank you so much for your time. Thank you for sharing. You know, Tang Jim by Lifer with us. This has been something.

I didn't show you how it looks like.

Oh, yes.

Where is it? I cannot.

There it is. Yeah. So if they're watching on YouTube, they can see it, and if not, they can definitely go to the site and check it out. But thank you. This is.

Thank you very much.

Yes. Thank you for joining me and I look forward to further collaborations.

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