Episode 176: The Impact of Expansion on Speech, Feeding, Myo and Sleep

Hi and welcome to episode 176 of the Untethered Podcast. Today you have your host Hallie Balkan here and we are going to be talking about the impact of expansion on speech feeding myo sleep. This is not going to be a super long episode, but I want to drive home some points based on the research that is out there, including some newer research and some topics that I cover in my course course but that I haven't seen. I haven't seen it out there as a topic that is widely understood by individuals outside of the Mayo or the early expansion world. So let's jump in.

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 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.

So let's go first into early expansion and what I mean by that. If you followed my podcast for a while, then you know that I've had providers on that expand children as early as two years of age. Right. And they're generally looking for those two year molars to be in place so that those more airway focused dentists can have a place to attach brackets to and install an appliance. Right, A fixed appliance. Typically there are other appliances that are not fixed, but they require a much higher level of compliance. And my goal here is not to get into the different types of appliances, but to talk about early expansion and then expansion results in general and why I'm such a proponent for early expansion. Now, before we jump into that, I always get the question, okay, well is it too late to expand in your teen years or in your 30s? No. The answer is no. Now disclaimer. I'm not a dentist. I'm not an orthodontist. I do not have dental credentials. I am a myofunctional therapist. I'm an SLP by trade. I'm licensed as a speech language pathologist in slp. I'm a feeding specialist, a certified myofunctional therapist. Neurofacial, myologist, etc. Right. All those fun things. So this is my specialty. Right. This is what I do. I work with teams of individuals where we focus on opening the airway, getting the tongue up in the palate, nasal breathing. Right. Some of those big goals. Obviously, I'm not expanding bone. I'm working with the soft tissue, however. And when I say soft tissue, I mean the orofacial. Orofacial muscles. Right. Those surrounding the bone. Can that influence bone movement? Absolutely. But I am not in the business of moving bone. Right. I do not move bone. I do not claim to move bone, I do not claim to expand bone or anything of that sort. Anything that happens by default of the work we may do in our myofunctional therapy and or pediatric feeding programs is great, but no promises can be made there because that's out of scope. So want to put that disclaimer out there. But as I said, the earlier we can get in and start expanding, the better. And, you know, I'll give you an example. My daughter who is about to turn seven, she like, she's a week away from turning seven by the time this airs. When she. Between years four and five, ages four and five, she went into an ALF appliance. And that was something that some. That basically was an early expansion appliance that helped to grow her palate on three planes. And we'll talk about those planes in a minute. Not just laterally. Right. Most expansion treatment plans and appliances really only work on that lateral growth to widen the maxilla and doesn't look at forward growth or growth on three planes. Like I mentioned, we'll talk about those anatomical planes shortly. We're seeing some providers use things like Invisalign, and here I am. I said I wasn't going to talk about specific appliances. I'm not endorsing them. I'm just telling you what I'm seeing. Invisalign is being used to do this with toddlers and preschoolers. We are seeing other things as well. Some people are using Myobras successfully. It's not working for my own child because compliance is a major problem and arguably for both of us. But just finding the time to do it and then trying to get her to fall asleep with it in her mouth, it's just, it's not functional for her or me. There's a lot of options out there. Oh, I will say I have seen others that have claimed to have growth with the Myobrief and, you know, appears to be a good appliance. For them. So you have to know your patient, and you have to know their level of compliance. You have to know, is this child going to require something that's fixed or can it be removable? You know, there's a lot of pieces that go into deciding the best treatment plan for a patient. And that's why I don't like to go to providers who only offer my ovaries, for example, not because they don't think it's a good system, but because I think that when you pigeonhole yourself into one type of appliance, you're not actually looking at the individual child and what they need. You're looking at what you have available in your, you know, toolkit. And so I really like to look for a provider who has options in their toolkit in both the removable and fixed appliance world. Okay, so let's also remember when I'm talking about early expansion, and I'm talking about 2, 3, 4, that's even 5 and 6 in some places. Some traditional orthodontists will wait until about nine years of age or older, and they'll consider six years of age early expansion. And like, like that needs to change. There's so much neurological development that occurs in the first five years of life. Arguably, there's a lot that goes on developmentally through year seven. So we really need to give our children the best opportunity to breathe and develop properly. This is critical. And so if you have a child in this age range, it's worth figuring out who you can take them to to start that early expansion if it's needed. If your child is early, older than this age range, don't fear. You haven't not. There's nothing to feel guilty about. I get a lot of parents who are like, oh, my gosh, I listen to your podcast. I have so much shame, so much guilt. I feel like I've messed things up. No, you have not. You. You did the best with the information that you were given. Whether you're a provider or a parent of a child, it doesn't matter. I mean, it does matter, but what I'm saying is it doesn't. It. That's not what's We. What we want to focus on. Right? We don't want to focus on, oh, my gosh, I missed the boat. You did not miss the boat. We can always help children. We can always improve airway. And so we want to start looking at what can we do now to maximize the child's airway. And if you're an adult, what can we do now to maximize your airway. If you're noticing these same symptoms in you, and many of our parents often do. Hi, it's me. That happened to me. So why am I talking about this? Like, why is it so important that we grow the palate on three planes and not just one? Traditional ortho focuses on sagittal growth, okay? We want that plus frontal growth and transverse growth on the transverse plane as well. And what, what are those things? Like, what is, what does that mean? Like anatomically? In my course, I have a nice little chart in the, my method where I break this down because the sagitt plane is our lateral or median plane. And so when I say that traditional focuses on sagittal, they focus on, you know, basically that suture line that runs down the middle of our maxilla, our palate, right. If you want to. It's not our palate, but we're going to go with that. It. They basically want to split that, right? And then grow, grow laterally or, or the medium, you know, across the medium plane. And that is that plane that divides our bodies into left and right parts. That's where traditional ortho focuses when they talk about expansion, whether they're expanding with rapid palatal expansion, braces, whatever. Now we want to also focus on, we want that, but we also want growth on the frontal plane, okay? The coronal plane. This is that anterior, posterior, front to back part, okay. And then we want the transverse plane, which is the axial or horizontal plane. And this is superior and inferior, like upper and lower. And so we need to have this three dimensional growth in order to the growth on all planes, not just laterally. It's really important. We're noticing that our jaws are shrinking, which you've heard me talk about over time. If we pull teeth, by the way, that causes our jaws to shrink more. Extractions are a big issue now. If the tooth is unhealthy, that's a different story. My dental colleagues tell me we should never pull healthy teeth, especially not to try and achieve a straight smile, because in fact, you're causing health issues when you do that. We need to grow the palate first and then there's going to be enough room to straighten the teeth using braces or Invisalign or whatever appliance you know you want to use, okay? They also have noted that first bicuspid extractions appear to lead more to sleep disorder breathing. So adults or adults of children who have had first bicuspids extracted, please check your sleep. Please check your child's Sleep. Let's look at what's going on. Okay. We do not want to pull teeth just because we want to make room for pretty smiles. Traditional ortho typically looks at how straight our smile is. I used to have a straight smile until I decided my airway was more important. And now I've gone and jacked up my smile, but it's still there. Okay, so, so what else can we talk about here? Let's talk about some of the research. Right? So we want to grow the pallet on the three planes, not just one. Right? So we talked about that. Why am I like, why am I pushing this matter? Okay. There's a couple other results that we're seeing with expansion we are noticing. Okay. There was a, there was a study in 2016, I believe. Motro et al. Rapid maxillary expansion induced rhinological effects. A retrospective multi center study. This was published actually in April 2015 and it was in the European. It's in the European Archives of Otorino Laryngology. 273 pages 679 to 687. But this is 2016 is the, the article, the journal that it appeared in, even though it was published in 2015 initially. So you can look it up on like Springerlink, we can link it in the show notes as well. So basically what they looked at, right, is what happens in terms of nasal volume size based on skeletal expansion. Right. So you can. I'm not going to read the abstract to you, but basically they looked at what happens with this rapid and palatal expansion, rapid maxillary expansion, specifically rme. Um, and they found that it leads to a widening of the airways. Right? So they found that there was a 2.35% increase in nasal volume for every 1 millimeter of skeletal expansion. And that might not mean a lot to you, but that is huge. And that's, that's a significant. Okay. That they actually consider that. They said the total airway volume increased highly significantly, representing an average airway expansion of the plus 11.54%, which was 2.35% per millimeter of activation. The nasopharynx and oro pharynx showed highly significant expansion as well. The airway at the laryngopharynx did not change significantly. Okay, so when we say laryngo pharynx, we're talking about our larynx, which some people may refer to as the voice spots and the, the pharynx, the pharyngeal area. Right. That's her throat, basically. So up until the point of where it be, you Know, it meets with the esophagus. So what's really interesting is that there are positive rhinological effects that were comparable across age groups using different expansion appliances. And so one of the things that they did look at too was a conventional dental borne rapid maxillary expansion and combined skeletal dental appliances. And so what was kind of interesting about it is, you know, and you can again dive into this a bit deeper is there's so many appliances on the market that we really kind of need to do our research and know what appliance group does the appliance being recommended to us fall into? Does it expand on the three planes? If we need three planes of expansion? Right. We talked about sagittal frontal transverse and is this one of those that would potentially, you know, grow my airway? Right. So for example, some patients used high racks rapid maxillary expansion, some had a hybrid rapid maxillary expansion and then some had this acrylic cap rapid maxillary expansion. But they noticed that there was increased airway across all appliances. So again, does matter which appliance you're using, but they notice that the hybrid actually might be an advisable procedure in patients who have nasal maxillary impairment and pronounced patients age, meaning like some of the older kids. So that hybrid rapid maxillary expansion they talked about in their study might be beneficial for that population based on their findings. So again, really great article. Again, we will link it if you want to read about a bit about it. I'm not sure if it's available to general public, but I know I want to say we have a copy somewhere anyways. Sometimes you can reach out to if you don't have access and request a copy of an article, just FYI from the original authors if you're in the medical space. All right, now the other, the other one I want to mention, which was in review at the time that I was creating my Mayo course, was a article in our research that's I believe, officially published. Let me see. Because I have it here. Yes, Audrey Yoon. Okay, so Audrey Yoon, Rebecca Baco and others published this in June of this year, June 22, 2022 and sleep med impact a rapid palatal expansion on the size of adenoids and tonsils in children. And one of the really interesting things they found was that there was a 43% reduction in tonsil size with expansion. So what's really cool about that is I actually saw this happen with, with my now 7, almost 7 year old when she was in her appliance between ages 4 to 5 years of age, within 3 months during cold and flu season. If again, if you've listen to this podcast, you've heard me talk about this, I noticed that she that her tonsils reduced from like a three plus to basically like one to two. Okay, they were visible, but they, they're visible but healthy looking. They were no longer inflamed and enlarged and getting close to touching, which is really exciting one because I was actually, I posted this in a study group back in. It would have been three years ago, so 2019, and asked if anybody else, you know, or yeah, I think fall of 2019, asked if anybody else had seen this, like if anybody seeing in early expansion patients a reduction in tonsil size. Like, here are the pictures, right? I shared the pictures. I was told by the group moderator and that this is one of those large MYO groups that I'm no longer in. But I was told by the moderator in a private message to immediately take it down. Like, how dare I suggest that expansion could possibly impact soft tissue? And there was absolutely no research to support that. And I'm over here going like, well, this could be a case study. I have documentation, I have cbct. I have all these different things that demonstrate the changes. And it was just, it was very. I just ended up taking it down because I just didn't want to, you know, get into a back and forth. But I was thinking like, huh, I wonder if other people are seeing this. And now we are noticing that, yes. In fact, there are others who are seeing this part of the issue here. Right? And I told you when I basically this episode would be the impact of expansion on speech and feeding and myo and sleep. Bottom line, is this right? If we have a child who does not have a patent airway because their adenoids or their tonsils are enlarged, and we cannot possibly expect them to put their tongue in the correct place to produce their speech correctly. We can't expect them to put their tongue in the correct place to prep a bolus and chew their food or receive a spoon or water without maybe their tongue coming forward. Depending on how much space they have in their mouth, based on the size of their, their tonsils and if anything, maybe their uvula is inflamed, maybe they have other inflammation in the back of their mouth, right? So then it starts to impact feeding and if they are inflamed back there, it may not feel good to swallow certain things, especially if they're not breaking that bolus down properly with enough saliva, chewing it enough, then it's definitely not going to feel good to Swallow that. And we're going to see them cut out foods that are not easy to prep and swallow. It may not be that they don't taste good or that they're really a super picky eater or a selective eater, but they start to become one because of their anatomy, because of their inflammation, because of what's going on internally in their mouth and their throat and their nose. And so we see that impact speech, we see that impact on feeding, we see the impact on their ability to achieve goals in myofunctional therapy, feeding therapy, speech therapy. Because again, we cannot expect a child to put their tongue in the roof of their mouth and seal off their mouth, even with their mouth open. We put our tongue up there and we suction our tongue to the top of our mouth, or we ask them to rest their entire tongue up on their palate. Guess what you've just done? You've cut off their ability to breathe through their mouth. And what if they can't breathe through their nose? Not a fair thing to ask. Which is why we always need to make sure that the nasal airway is patent. This is also a reason why I never recommend lip taping in pediatric patients, because. And once they're of adult age or you're an adult, you can do it yourself. Children fluctuate so much based on the season. They. They may have, you know, different allergies to external environmental factors outside of what they're eating, outside of what's going on inside the house that we can't control. And we don't have a snapshot every single day of what their airway looks like today. So to cut off their air supply by taping their mouth, in my opinion, is highly problematic. A child needs to have the ability to breathe through their mouth if absolutely medically necessary. And sometimes it is medically necessary. As I just explained, children also are developing their immune systems and they also need the ability to. They're going to get colds. They're going to get sick. Sick. We should not be taping their mouth. If they're sick and their nose is stuffed up right. It can change in the middle of the night. They could go from having one nostril patent to having that one feel stuffy and the other nostril feel patent. We don't know how things are moving around in an adult. We may either wake up and remove the tape, or maybe we're using something like a myo tape or something that goes around the lips. You're an adult, okay? You can make your own choices. But I Really, I do not feel that it is good advice to recommend lip taping for pediatric patients because of how and as once you become a parent and you see this in action, you have a good grasp on children and their ever changing airways. Now, what we love them to be mouth breathers. What we love to be nasal breathers 100% of the time. Yes. I never met a child who has never had a cold, never had a stuffy nose, never had like any form of, you know. Yes. Or certainly there's kids who don't appear to have allergies and they're, you know, primarily nasal breeders. But at some point or another, a child is going to get sick. It's part of, again, developing your immune system. So we need to be cognizant of what we're recommending and to whom. Okay, I'm just going to throw that out there. You know, this is something that a while ago I basically said lip taping, in my opinion, is literally putting a band aid on the problem. Right. And then I know Autumn and I discussed that as well when she and I recorded an episode. Autumn read Henning. You're literally putting a band aid on the problem. Now, again, if you're an adult and you want to use that as a crutch until you can solve the problem and, you know, breathe effectively through your nose without having to tape your mouth all the time, great. If you want to tape your mouth for the rest of your life and you're an adult, by all means, go for it. Children should not need to tape their mouths for life. Children should be able to be taught how to nasal breathe. But first, again, we need to make sure that their anatomy allows for that, whether that's bone or soft tissue structure. Okay? So I know I'm like beating a dead horse here. Let's just leave it at that. But back to, back to the reduction in tonsil size with expansion. Because I think it's like, that's just, it's one of my most favorite things to have seen hit the research. What I think is really cool about this is that. So, okay, let's back up. Not what I think is really cool, but the adenoids and tonsils, the enlargement right. Hypertrophy of adenoids and or tonsils often leads to mouth breathing, often leads to respiratory issues, often leads to obstructive sleep apnea, especially when we have enlarged tonsils and adenoids and they're, you know, sometimes we see like 80% enlarged adenoids, like they're blocking 80% of the nasal airway. And then we see, you know, the tonsils are a three plus. Sometimes they're touching that. How is that child breathing? Okay, they're not. And when they sleep, they're not breathing while they're really going to struggle. And then we're going to see all the other symptoms that come along with that. And, you know, reference my episode on ADHD and all that fun stuff, because that's who I'm talking about. There are some clinical guidelines from the American Academy of Pediatrics and American Academy of Otolaryngology Head and Neck Surgery, and they recommend tonsillectomy as the first line of treatment for pediatric obstructive sleep apnea patients. What's interesting is that rapid palatal expansion that is performed by either dentists or orthodontists in the airway space is improving obstructive sleep apnea in children by reducing that airway resistance in the nasal cavity and increasing the nasal volume. Right. So we talked about. I've talked about increasing nasal volume. How that's really important. We know that that 1 millimeter skeletal expansion increases nasal volume 2.35%. Right, 2.35% for every 1 millimeter of skeletal expansion or the other article we just talked about. It also allows us to work on elevating the tongue posture and enlarging the pharyngeal airway as well. So. So I know that the pharyngeal airway had mixed results in that other study, but obviously more research needs to be done. But we are seeing this. We are seeing this in children in pediatrics, and I think that it is, especially if they're going to need expansion anyway. Expansion anyways, and if they're not at risk of like severe obstructive sleep apnea and, you know, possibly having an issue that ends not well. You know, we want to see if we can get expansion in there, like some rapid PAL expansion and start expanding them quickly so that we can reduce the tonsil size and open that airway. So in the study that Yoon and that team did, they looked at changes in alloy and the adenoid and palatine tossel tonsil sizes following rapid paddle expansion. And they use 3D volumetric analysis of cone beam computational tomography or CBCT imaging. And that's also what we've used, like with my children as well. And it's amazing. That's actually what my ENT use with me before and after my or before my surgery. I want to do another one after to see the results once my solving is all down. So definitely worth looking at they noticed that compared to their control group, the expansion group experienced a statistically significant decrease in both adenoid and tonsil volume. And they also noticed for the expansion group that 90% and 97.5% of patients experienced significant reduction in adenoid and tonsil volume respectively. So sorry, that was the the percentage for that group. The average volume decrease of adenoids was 16.8% and tonsils was 38 point. And let's see, patients had up to 51.6% and 75.4% reduction in adenoid and tonsil size respectively following the rapid paddle expansion orthodontic treatment. So what? Again, there was a significant reduction in their pediatric sleep questionnaire scores, PSQ scores in the expansion group. And so we are seeing stat typically statistically significant differences, improvements that tell us yes, we are onto something here. What we're seeing on our cbcts is not just a, you know, random image in time. It's actually representative of these changes and what early expansion or expansion in general can do for a growing child. So I know that they want to do more long term studies on this and that this is really the first time that this type of information has been published. However, they do consider it to be valid and effective as far as treatment options go for treating pediatric OSA patients and especially when they present with like a high arch palette and adenoids and tonsils that appear enlarged. So all that said, back to the purpose of the topic today. Right. I wanted to talk about the impact of expansion on speech, feeding, myo and sleep. Okay. And I think we have established that we are seeing very positive results from an expansion standpoint. We also, based on what I shared with you briefly understand that we cannot. There is a reason why children, for example, spend years and years and years and years in speech therapy, work or feeding therapy or now we're even seeing patients kind of get stuck in the myotherapy realm. Why? This is why anatomy, anatomy matters. Bone and soft tissue anatomically need to be addressed and that is something that we are unfortunately seeing be ignored, which makes absolutely no sense. So if you have a child who's been in speech therapy, feeding therapy or myofunctional therapy for 2, 3, 4, 5, 6 years. And look, disclaimer Again, if you have a child who has significant disabilities, I'm not referencing those children who need ongoing support and therapy. I'm talking about otherwise typically developing children who appear to be a little picky or selective in their eating, who just can't seem to get those that set of speech sounds that they've been working on for years who started MYO but have, like, hit a wall and you can't really figure out why. Right. Or those children who are typically developing but seem to have sleep issues. Or maybe you don't know if they have sleep issues but they are bouncing off the wall at school or they have been diagnosed with ad. You know, I. We have a patient that we recently received who is between the age of 5 and 6 and is on two stimulant medications for their ADHD diagnosis and an antidepressant. This should be illegal. The child has never had a CBCT done. A child has never had a sleep study done, but somebody felt it in their power to put this child on three medications. And when we. The child actually came to us for a certain type of evaluation and then we went, we need to look at some other things because that evaluation that they came for, they were fine. They were fine. And these are the kind of kids who slip between the cracks because they perform well on standardized tests and or their language skills appear to be okay. You know, you test them for auditory processing, it appears to be okay, but yet they've got this ADHD diagnosis and they're on all these meds and nobody's ever looked in their mouth or at their sleep. So I'm gonna wrap it up there and leave you all with that. I hope that this information is helpful if you want to learn more about it. I do go into all of this and more inside the myomethod course. So if you're an slp, OTRDH or somebody with dental credentials, you are welcome to join me or a PT. You're welcome to join me in there. Themyomethod.com if you're looking for monthly CEUs, Themiomembership.com is where that's at, but I hope this was helpful. If you're a parent and you're seeking a provider in this space, I do not know all the providers in this space, but I'm happy to help you try and find one. So you can always message me on Instagram at Hallie Balkan and I will do my best to try and connect you with a provider in your area who is thought to be more airway focused in this regard. All right, everybody. I hope this was a helpful episode and I look forward to talking to you next week. Thanks for listening to this podcast.

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