Episode 189: Connecting Form and Function with Rebecca Bockow, DDS

Hi and welcome to episode 189 of the Untethered podcast. Today we have Dr. Rebecca Bacow joining us. Dr. Bacow completed her dental training at the University of Washington in 2007. After practicing as a restorative dentist for two years, she turned to the University of Pennsylvania where she earned a dual degree in both periodontics and orthodontics while simultaneously earning a Master's in oral biology. Dr. Baco is a board certified in both periodontics and orthodontics. She lectures nationally and internationally on orthodontics, airway skeletal growth and development, skeletal expansion and interdisciplinary care. She maintains a private practice in the greater Seattle area, limited to orthodontics, dentofacial, orthopedics. She has a wonderful husband and two terrific young daughters. 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. Well Becca, thank you so much for joining me today on the podcast.

Happy to be here.

So I would love to dive into your story, right. How you got into orthodontics and of course I'm always interested to know how you fell into the airway space in.

Particular or of course, yeah. So when I finished. So first I practiced as a general dentist, a restorative dentist for two years. And in restorative dentistry I saw a lot of breakdown and that's sort of what we're doing in dentistry. We repair things that are broken and a lot of what I saw that was broken had to do more with the foundation, gum recession, broken teeth wear, bruxism, things like that. And I just thought I want to learn how to fix the foundation and if I can fix the foundation, then a restorative dentist can help put the pieces back together and with the hopes it'll be more long lasting anesthetic. And so I went back to the University of Pennsylvania and I did a dual specialty training in both orthodontics and Periodontics. Periodontics is bone and gum surgery. And then of course, orthodontics is tooth movement. And my mentor, my director, Dr. Van Arsdale, was in the 60s and 70s talking about upper and lower expansion starting at age 5 and 6. And he expanded for underbites, expanded for overbites, and no one was talking about that at the time. And for him, it was to prevent gum recession and maybe with the hopes of preventing extractions. And what we saw when we followed his cases over time is they were stable, these cases. They didn't have as much relapse. There was tongue space. And at the time, I don't think we had the language to understand what that meant, just that the cases looked really good long term. Then fast forward 2013, I had an opportunity to sit through a three day course taught by Dr. Jeff Rouse called Airway Prosthodontics. And it was a course geared towards general dentists and dental specialists, talking about airway as we see it, as restorative dentists. And Haley. I sat in the front row for three days and my mind was blown because I was looking at all these adults that have sleep apnea. And I thought, these are all orthodontic patients. These are all issues that, that I treat. Underbites, overbites, cross bites, even simple things like midline shift and for sure, narrow maxillas. And so I did a deep dive into the literature, but I wasn't finding the answers in orthodontic journals. Maybe here and there, but not classically. I was reading, I was reading sleep medicine, I was reading ENT journals. I was just looking for information in so many different places, not necessarily in classic orthodontic papers, and just changed the way I practiced 100%. I have two practices. One is in downtown Seattle. We see a lot of adults, and then one is in a more suburban area. And so seeing the breakdown in adults really taught me to look at things differently in the young kids. And so now we have an opportunity to work very closely. Our practice is very interdisciplinary. We work with sleep medicine physicians, we work with ents, we work with so many feeding specialists, myofunctional therapists, pediatric dentists, restorative dentists. And we've really developed a very holistic, interdisciplinary approach to treatment. And it really spans all ages, from early kids all the way through to adulthood.

Love that it's. You know, everyone who listens to the podcast knows that we preach collaborative care, interdisciplinary, you know, really tailoring the case to the patient in front of you and that there is no child Too young and no adult too old. It can ultimately help anybody, depending on their goals. Right. At any point in the lifespan. But very passionately. I've also become a big advocate for early intervention. And as soon as that baby is born, looking even just full body, does the baby appear to have torticollis? Like, do we have a side preference with breastfeeding? Do we have, you know, reflux or really air induced reflux? Is the tongue able to do its job? Is the baby's mouth open or closed? I mean, all these little things that I wish somebody had given me a checklist when I had my first child and said, hey, do you notice any concerns with any of these items? Because I go back and look at pictures of my now 7 year old and I'm like, check, check, check, check. Yeah, we had all of those. And it's, you know, thankfully I was able to start intervening when she was 24 months old. But it would have been so much better had it been early on. And so, you know, yes, it's just that whole journey from birth. Right. If we can intervene, then we can hopefully prevent a lot of these issues that I has, many others have dealt with as an adult. You know, I just had nasal surgery earlier this year for septoplasty, turbinate reduction, nasal swell, body reduction. And I've had adult expansion after having, you know, traditional RPE and braces and also permanent retainers. And after those came out When I was 30, my teeth started to shift. I had that midline shift that you mentioned. And I was like, that's me. But even though I'm doing feeding, doing Maya with patients and literally living in that day to day, I was like, I don't have enough space for my own tongue. And that's what pushed me into, you know, the adult expansion. And, and it really just fuels me. I was like, if I can prevent this for my own children and then teach others how to prevent this for all their, you know, all their children and the kids on their caseload. It just was, it was really eye opening for me as well. Especially when I realized a high number of children on my caseload who are dealing with other issues. These issues really symptoms of a bigger problem. And that really throws us back to airway.

Right, Right.

Yeah. So what's the youngest age that you treat in your practice?

Well, and I think you've hinted at this, but treatment might not necessarily be orthodontic intervention. Intervention can be a whole host of things depending on how we define it. Intervention can be helping, helping get these Kids to ot, helping get these kids to feeding specialists, trying to identify allergies, whether it's environmental or food allergies, helping these kids become nose breathers. So intervention can be anything. As soon as we see an issue that we can intervene in terms of physically getting an appliance into a child's mouth really depends on the maturation of the child, we'll intervene. Four, three. So maybe a removable stock appliance like a myobrace Healthy star, something like that at 3, but considering more fixed appliances, 4, 5, 6, and then of course through the spectrum. So how we define when do we intervene? We intervene when we see a problem. How we intervene depends on the child and depends on the child's needs.

Absolutely. And so I'm just curious, like what type of appliances do you prefer in your practice when you're working with a 4 year old or a 5 year old?

Sure. And so it really comes down to skeletal maturation. We know that light wire appliances are more tooth tipping appliances, especially for more skeletally mature patients. So probably Starting at age 6, 7, we're using fixed appliances like a hyrax that really has been shown to give better orthopedic results and less orthodontic results. So the difference really is are we trying to open the suture or are we trying to tip the teeth? And in a really young kid, I think we have some flexibility. There's a lot that can happen on a suture level. But once we get into older kids, 7, 8, 9, for sure we're using more fixed appliances.

Yeah, that's. It's been interesting to be on this journey with my own kids. And you know, they're both currently in hyrax upper and lower with a forward growth component added to it that was customized to their mouths. So my daughter, who is seven actually, we were just there yesterday, she's done and going and she just turned 7 in August. And so she's going to be going into like a fixed retainer and then a myo brace as well just to kind of help continue to guide, you know, growth a little bit. But she, yeah, she's looking really good. So that was exciting. And my, my four and a half year old will be done probably in a month or so. She went into it after my, my 7 year old. But it's just, it's very exciting to see. I'm like, I can see, you know, the growth in their mouth and the widened smile and it's, I was really excited and I was sharing this yesterday with the dentist because my Daughter who has had a history of croup since infancy. She's had it nine times this year. And I turn to homeopathy because I try to avoid it when I start to hear the cough and everything. But we keep a steroid on hand from the pediatrician because that's usually the only thing that keeps us out of urgent care. And every single time she would start to get a cold, sure enough, we would hear that inkling of a barky cough, and I would know, we're going to urgent care tonight. So the last time she got a cold, which was probably like a month after she had the appliance put in, she had a cold for three days and it did not develop in a group. And I was like, huh? Okay, all right, we're on to something here. Because I noticed that Lily, when she was four and first started her expansion journey, that similarly happened with her, and she, all of a sudden, like three months into cold and flu season, was not getting sick as often. Her tonsils decrease, which I know we talked about. You guys actually have research that supports this now? At the time, I shared it in a mile group on Facebook and I said, you know, has anybody else seen this happen? You know, because my daughter's tonsils that have been chronically enlarged and unhealthy, like, veiny, red, like three plus on a good day, they're like down to a size one now. And she's been in appliance three months, and we're headed into cold and flu season. It's cold here. I'm not convinced. She's like, nasal breathing 100 of the time. So, like, has anybody else seen this as a positive side effect to expansion in a 4 year old? And I was actually told to take the post down. There was no research to support this. Like, how dare I make such, you know, such. I was like, I'm speaking as a professional, but also a parent and just asking a question, opening a conversation. So I'm really excited to see that. Yes, that can, in fact, be a really positive side effect of expansion at this age.

Yeah. Oh, for sure. So we're seeing it. We're seeing it on a consistent basis. Whether or not someone can avoid adenoid tonsillectomy is to be determined. I don't know that we can say that with confidence, but we can say that they shrink. We also are seeing. This is unpublished data, but we're seeing sinusitis gets better or looks better radiographically. We see shrinkage of the turbinates. So as we widen the nasal floor Dr. Yun has published that we open the internal nasal valve. So it's not just about teeth anymore. It's about, as you know, it's about tongue space, it's about nasal breathing, it's about restoring form and function.

Yeah, well, and that you make a great point because when I looked at her CT scan from before and then a year later after her sinuses were almost full and then they were completely empty, her, you know, her nasal cavity went from looking like really unhealthy to really healthy. And just I was like, she can breathe. And that for me, that was the goal. I was like, she's four. These are baby teeth. I don't really care about, you know, what the teeth look like in terms of if they're straight, but obviously they should have space between them. We want healthy teeth. Not to downplay that, but I was really going for the airway. You know, that airway was my goal. And it's funny too, because being we moved to South Florida and I was explaining to my 4 year old teachers and pre K teachers like, yeah, I'm driving an hour back and forth from, for this, you know, specialist in North Miami. And you know, Mia's going to have an upper and lower expander. And they're like, okay. And you know, just explaining as to why she would be missing some school. And they came back to me like a couple weeks later and they're like, so, I mean, you like, are you doing this for straight tea? Like, what is it? And so I got to educate them. I'm like, all the reasons why I know this is not common. You don't see this in a lot of four year olds especially because here in Boca there really is nobody doing this. But here, like, let me lay it all out for you. And they were like, oh, okay. They're like, we were really wondering like, if you were like. I was like, if I was really shallow and just wanted my 4 year old to have really straight teeth. No, not the goal. But it was, it was fun to educate. And, and I'm just, I'm really looking forward to. My hope is that her airway also, you know, becomes much healthier. And then it was at the start of it all, that's, that's the entire goal for us. Healthy airway, tongue up in the roof of the mouth, nasal breathing. And you know, I've been laying, I lay in bed with my kids at night when they fall asleep, and sometimes I lay there and respond to emails and do other things and you know, two hours later I'm like, okay, I have to get up and actually go to bed myself. And I get to check in and see that they are truly nasal breathing and their mouth is closed. And I'm like, this makes me like the happiest person in the world.

I love it. I love it. It's perfect. It's great.

Yeah. So, you know, so I know that you're a big proponent for that early skeletal growth and development and the importance of really all things airway and really educating on that and driving that from early on. So do you ever get. So I know you said you mostly will start working around four, maybe three in terms of an actual appliance. Do you get younger patients, though? Do you refer to you or is it sometimes like a sibling and then you're referring out?

Well, it depends. We, we have, I would say when we get the younger kids, it's usually through, through a speech therapist because they are struggling for some, for a different reason. And, and as you highlighted, if there's not tongue space and, or if there's a tongue tie that's been undiagnosed, it often is manifested for the parents as an articulation issue. A lot of parents don't link poor sleep quality, poor nasal breathing with undersized jaws, even though it all goes hand in hand. So when we see the younger kids, it's often because the parents identified an articulation issue. And as you and your audience probably know, to do a tongue tie release and myofunctional therapy if there's not enough space is not as effective as if we can create the space first. So we're often tasked with expansion for some of these younger kids and older kids, kindergarten, first grade, maybe, like your daughter, because that's sometimes the first time that the teachers have identified an issue. And so we'll go in, we'll help with expansion, and then they can continue to work on tongue up, lips together, articulation speech. And the parents are often pleasantly surprised that they often are sleeping. Because we have a cbct. We take a low radiation CBCT on our new patients. And like you mentioned, we often are the first to identify inflammation in the sinuses, suspected early signs of a deviated septum, enlarged turbinates, not to mention adenoids and tonsils, because when we take that radiograph, we see things that parents haven't even. They just might say, oh, they snore or oh, they're bedwetting, but they'll grow out of it. They, they sometimes are unaware that the issues that they've identified might, might be Linked to the jaw position and. And jaw size.

Yeah, yeah. And I like that you brought that up. I feel like, as the speech pathologist, we often get the patients calling us because there's either feeding issues, whether it's breastfeeding, bottle feeding, transition to solids. They have cut out a ton of foods as toddlers. They just been very picky their whole life, and, you know, they're dwindling down on the list of foods they'll accept and. Or articulation. And I think that it's. So. It's really changed my practice because after getting more into the myo and airway space, I started to look at. Okay, you know what? I'm teaching compensations in what I'm. What I'm doing. It's not helpful to do that, because as the jaws continue to grow in the wrong direction, we're going to have to continue to fix those compensations. Otherwise our speech is just going to fall apart again. And that's what we see. We see a lot of kids land back in speech therapy. It's like they graduate, they're okay, and then a year later, they call us back. Now we're struggling with this sound, or we seem to have gone through a growth spurt or something. A parent can't really fathom why. Like, well, we thought we were really good with the sound, but now we're not good with the sound again. And I. I've had kids who've spent years upon years upon years in speech therapy, and they had a tongue tie, they had a myofunctional disorder, they had, you know, misalignment. They needed orthodontia, or maybe they've already had their braces and things are relapsing. And, you know, it's just like the lists and the stories go on and on, and to see how interconnected everything is is really fascinating.

Yeah, well, and you mentioned compensations. What's. What's interesting to me, too, is it's not just what the sound sounds like, but how we make the sound. And I've seen adults that. Actually, I Learned this from Dr. Michael Gunson, an oral surgeon in California. And he shows a patient who, for her lifetime, shifted her jaw unilaterally to make a J sound, and she had erosion of her condylar head from that consistent movement to one side. And so we don't think about it when we see these young kids, but these early compensation patterns really can impact skeletal growth and development. And if we let it persist too long, sometimes our only option is surgery. So a big Part of our practice is trying to prevent that, but we do treat a lot of patients surgically as well.

Yeah, it's a conversation that's very interesting in the speech pathology world because I'm totally making these numbers up, but I would say there's like a 50, 50 split. Most will say, oh, it's fine, they've got the sound, it sounds good. And then there's the other half of us that are like, it doesn't matter how it sounds. Exactly what you said it was like, I've never heard more beautiful words. It doesn't matter how it sounds. It's not just about, about how we're producing it. Where is the tongue in the mouth? And that, that goes the same for feeding. How are we chewing our food? Because a lot of our myo patients chew predominantly on one side and then they have an overdeveloped masseter and an underdeveloped masseter and then they have, you know, bunching in their mentalis and other strain patterns. And we see that also impact, you know, digestion and bowel movements. And I mean, it's so far reaching that it goes way beyond just what foods they're eating. Because, you know, we, we tell parents and even adults who are really picky eaters, quote unquote, you know, we'll say, let me, let me guess. So you prefer foods that are like blander in color or they've been cooked to become like pretty soft and they'll be like, yeah, how'd you know, really? Because it's easier to break down without properly chewing it or you have to chew it less. And so that's what had also become known at what I like to call safe foods that are easy. The body feels like I can safely break this down to swallow it. Maybe not always the most nutritious, but food nonetheless, right? And so it's, especially with young kids, the brown, yellow, white, beige foods, the pouches, the, you know, where we have this epidemic of soft food diet that's really plaguing us with just further exacerbating the fact that our, our skulls are smaller, our jaws are shrinking, you know, our airways already kind of like on alert where a lot of kids are living in fight or flight. And we spend a lot of time educating families on, like, it's okay if that's where you are right now. But our goal is to help get from point A to point B so that your child feels safe and they know that they can chew and break down these foods. And then of course, a lot of the parents Recognize these issues in themselves as well.

Yep. No, for sure, for sure. Well, and you've alluded to this, too, but just the importance of the tongue filling the oral cavity as opposed to the cheeks, putting too much pressure this way, that tongue is going to drive the growth of the jaws, which drives the growth of the nasal floor. And the importance of lips together. I think, for example, open bites and open bite. As humans, we're driven to breathe. So looking at these open bites, looking for tongue ties, looking for adenoids and tonsils. Because if we're only addressing speech or food, for example, we're missing the underlying etiology. Those kids that have compensation patterns early, things like the orbicularis oris and how we recruit other muscles, it can impact in a negative way the way the jaws grow.

I can have a child walk into the room, and I can see the orofacial tension on their face just in their rest posture and how they're breathing and how, you know, people are always like, well, how do you determine, like, how big of an opening their mouth is? Because we measure that, like, on our forums, front on our assessments. And I'm like, you just. You get really good at eyeballing it. When they're following you into the, you know, the room and you're taking a good look at them, like, at rest, and they don't really know you're watching them yet. You're gonna eyeball if it's like 5 to 10 millimeters of mouth opening or if they're like, lips are almost together and, you know, like, there's a tiny little opening. I was like, that's really what you want to look for. Are they closed, or do we feel like they're somewhere between 3 to 10 millimeters wide? Is, you know, if the jaw is hanging really wide open, you're gonna know. But it's those cases in between that people get very hung up on. And, you know, I was taught it's okay if the lips are open, like, 0 to 3 millimeters. That was what I was taught. And I was like, that never sat well with me because I'm like, I'm pretty sure we want our. Not to be completely closed. We should have a seal at rest. And, you know, for all the reasons that. That you've shared with us. So that's. Yeah, it's. It's one of those things where as soon as we sort of start to fall off kilter and we're recruiting different muscles and we're compensating and just. That snowball just keeps continuing to snowball and then we run into, you know, it goes beyond asymmetrical chewing. We have a hard time, especially if there isn't tongue space, getting that bolus properly prepped, getting it to the center of the tongue versus spread all over the tongue or all over the mouth, being able to swallow properly. So many of our patients can't get their tongue to seal to the roof of their mouth and so they can't even swallow properly. And some who think they can realize they may have a posterior tie and the posterior portion of their tongue is not elevating as much as it needs to and doing its job. And so it's a very interesting conversation, especially when we pull out our mouth models and we start showing patients, we're like, this is what we should do. And they're like, oh, I don't think my tongue does that. We're like, okay, great, let's, let's talk more.

Yeah. Wow.

Yeah. And, and you know, we see this, we see this as young as infancy with breastfeeding. It's typically been there since the beginning. And the, one of the things that I educate on too is we start swallowing around 12 and a half weeks in utero. That swallow that we're born with is not, this is not day zero, day one. This is like we've already been doing this for six months. And I think that has been really eye opening too to a lot of people because it's, it's there, it's there at birth.

Right, right. No, for sure.

So, so yeah. So the importance of, I think getting in there early. I'm glad that we share that common, that common theme here. And what is your opinion though on pacifiers, thumb sucking, those kinds of, you know, non nutritive types of sucking habits? You have a, a position on, on those.

Yeah. So I get rid of them as soon as we can. I think it's so important that tongue filling the oral cavity, lips together. You talked about soft foods, you talked about pouches, pouches, straws, gums, digits, pacifiers, all this keeps the tongue low. And so even if we take it away at 2, 3, 4 years old, and you probably see this more than I see it even, but it, it just trains that muscle memory. We have low tone. So even though we took it away, and I hear that, oh, my pediatrician said don't worry about it till the adult teeth come in. No, it's not about the teeth. It's really not. It's about form and function and it's about getting that tongue up and teaching the proper Swallow. You just said it so beautifully. It happens in utero. You see those ultrasounds of the thumb in the mouth. And yes, it's about something getting in between the tongue and the palate. Yes, you're going to see a narrow palate, but you're also going to see compensation patterns, muscle memory, low tone, and that's harder to get. It's not just taking it away. I think it's unpacking and unwinding. A lot of bad habits. Thumbs are especially troublesome because of their impact on lower jaw growth. I think a pacifier, we still get some forward growth, but a thumb, you get the pressure on the lower jaw. And the conventional thought in orthodontics is to not attempt forward mandibular growth until puberty. And that. I have some question, more questions I've answered about that statement. But if we start out at age 7, let's say they've been thumb sucking till age 7 now you might have 9 millimeters of overjet. I'm making up a number. At what point are we going to get that lower jaw to grow 9 millimeters faster than the upper jaw? So we've lost seven years of mandibular growth. The mandible grows the most. It grows between years zero and two. So these things happen early.

Yeah, yeah. No, we encourage everything out by six months at the latest. And if we can work on it earlier, we do, obviously, when they're really young, it's. It's really tricky. But we encourage, you know, chewy tubes or things that they can chew on that you can give them for a few minutes and then we can take them away. Because that also, we feel that it helps to build jaw strength and development if they're chewing, you know, on those back molars or where the future molars will be. But then hopefully also it's also filling some of that void of the tongue not being in the palate while we work on getting the tongue up in the palate through and, you know, those early interventions. But it's. Yeah, it's. It's tricky. It is tricky. And I think what you mentioned, a straw. And I think the issue is especially. I don't know if this is an issue outside of the US but a lot of our straws are really long. And so they do pull the tongue down. And so what we do is we often will cut the straw down so that it can't go past the lips. So they have to use their lips and it can't go beyond where the teeth are, and they can still use those Straws, but it's like a short angled straw. So they still have like that head neutral position. They can bring it to their lips, use their lips, but that tongue has room to elevate during the process. Versus, like you're saying, holding that tongue down where it kind of bunches back, it retracts, it just not a healthy way to drink. So, yes, 100% on board with all of that, you know, getting those things out early. And it's so interesting too, because I think it, we're just so ingrained that, oh, you're not supposed to start a pacifier until a baby has established breastfeeding. So wait a couple weeks, but then, you know, then give your baby a pacifier. That's fine. Like, who made that rule? You know, it's. I've had conversations with other colleagues in the dental space and along the lines of, you know, they, they said to me, they're like, do you think we should recommend pacifiers? Like, do you think pass. I was like, no, I don't think a pacifier should ever be needed. In fact, if a tongue is doing its job at birth and it's up in the palate and the lips are closed and the baby is nasal breathing, there will never be a need for a, for anything really to go in the mouth as long as, you know, development continues accordingly. I said, I think that it becomes a thing. That pacifier is needed when the tongue is not doing its job either. It doesn't fit. We're seeing a lot of babies born with these, like, high channel palates, bubble palates, where the tongue really can't get up there. Even if it's not tied, it really can't get up to the palate. And so, you know, parents are falling back on something that soothes their child, which then is often a pacifier. So it's, it's a very interesting conversation. And parents will say, well, they just go cold turkey and take it away. And I'm like, hold on. Yes, I want to remove it. But first we need to figure out what the root cause of it is. Why do they even need it in the first place? Because if you take it away, guess what's going to happen? The thumb is probably going to go in and that's going to be much harder to take away. So, like, let's, let's take a few steps back and work together to eliminate the need for any of these things.

Yeah, yeah, I know. I think you brought up a great point. I don't. I want to make sure all parents feel Supported and to make some of these decisions, breaking free from these non nutritive sucking habits should be done with, with control and intention. Absolutely. And supporting the kid.

Yeah. And there, there are some nice like, you know, systems out there I think like Frida baby or one of those has something where you can like wean the pacifier. It's a little bit more gentle. But I still, everyone just says to me, well how do you do it and what do you use? And I'm like, can you set up an evaluation with somebody in your area, let me know where you live, I'll make a recommendation. Because yeah, it just goes back to really needing that support. And I think that's one of the biggest things that's lacking honestly is even one, knowing that we should be looking for that support. And then two, finding somebody who is even trained in this and who can actually support you in what you're trying to do. That's, that's become the biggest hurdle I think number two. So we, I always invite everybody to, you know, DM me, I tell me where you live, what your child's age is, what your concern is and I will do my best to, you know, find somebody from a network of providers that I have access to and just, you know, connect because that's like information is power and it's so hard to know where to go and what to trust. And you go three different places and get three different, you know, sets of instructions and guidance. It's a lot.

Yeah, so.

So you mentioned you're in Seattle. Are. If someone's looking for you, how can they find you?

Our website is inspiredortho.com and we have two practices we have really jumped on. Virtual appoint. What's the word? Virtual monitoring. Really Virtual consults. Virtual monitoring. So we do have families that travel from all over the region and as long as we can see them in person a few times, we can get a lot done virtually. And that's been really exciting, especially for early and late, late expansion. We have adults that come find us for TAD expansion. I don't know if your listeners have heard much about TAD expansion, but that's been a game changer for our late teenagers and adult patients. So really doing everything we can to open things up predictably and to be able to provide services for a greater population. So Covid, I guess that's a silver lining for us is it forced us to really implement those systems efficiently.

Yeah, no, it made us all go a little bit more online and yeah, become a little bit more efficient and it's Great. I mean, sometimes I send images to my daughter's, you know, dentist and they can assess whether or not we are ready to come back for our appointment or if we can cancel that appointment and move it because it's, you know, it could take an hour and a half to get there and get back in traffic. And that kills a whole school day for my kids, so.

Right, right.

You know, I'm always happy to see them and go, but I'm like, if we don't have to come yet, that's great too. So it's you. I've seen the evolution too and, you know, being able to get patients that more greater access to this type of care. For patients who are, or anybody listening who's not familiar with tads, can you give us like a little brief explanation of what you're doing with them and the idea behind?

Absolutely. So taking a big step back, thinking about the maxillary suture in a really young kid, it's pretty wide open. That's why breastfeeding in the tongue is so important and why non nutritive sucking really plays such a negative role in terms of growth of the palate. When we start getting into early adolescence, 6, 7, 8, 9, 10. We can really predictably use a tooth borne appliance. That's our hyrax expander. And then once we get into the full complement of permanent dentition into late teen years, all the way through adulthood, that suture is pretty rock solid. So to truly open up the suture, to truly widen the nasal floor, we have to use something stronger. So we use a special expander that's anchored to the bone itself. A TAD stands for temporary anchorage device. It's these usually anywhere from 2, 4, up to 6 small titanium pins that are placed in conjunction with the expander. And so we're getting true sutural expansion, really opening up that suture, which is a really predictable way to once again open the internal nasal valve, widen the nasal floor and widen the palate. And it's been a game changer for us and our patients, of course.

That's amazing. Yeah, we've seen some cases and it's really seemed to do some amazing things, especially for adults that I've seen try other interventions that really were not so super successful for them. So there's a lot of appliances and approaches out there and everyone always says, what's the best? And I'm like, first of all, I am not licensed to give you that information. I can't help you on that. I can help you with mayo. I can help you with the feeding side of things, speech. But it's, I think it's nice to, to hear that there are a lot of successful cases using tads. And I know a lot of our listeners are going to go and like Google where they can find somebody to help them with that, but we'll have them reach out to you.

Sure. Well, so yeah, I'm trained as a periodontist, so we want to keep the teeth in the bone. If we use an appliance that pushes the teeth and doesn't open the suture, we can create bone loss, gum recession and tooth loss. And I've seen 30 year olds that are going to lose their teeth because they tried something less invasive. And at the end of the day, if you don't move the bone, it's not stable. You can't just move the teeth in the absence of the bone. So there's a lot of appliances out there that don't take the biology into consideration.

Yeah, we've, we, we've heard, I mean, I've heard all kinds of things and it's, you know, definitely throw me down that rabbit hole of doing my own types of research and listening to patient experiences and just reading different stories. And like I said, there's, there's so much out there, it can be hard to know what to trust, who to trust. And so it's always nice to hear it from, you know, your perspective and your expertise because, you know, you do have that specialty behind your training. To know what we're doing, why we're doing it, what we want to avoid doing, I think is not, I don't know that many people ask about, like, well, what could happen if I do this? What are the downsides, you know, aside from it maybe not working, you know, what else I'd be looking at in the future? And I think there's more information coming out on that now being shared by patients who unfortunately have had some bad experiences. So. But I, I do also love to hear about, you know, the ability to open the suture lines in adults because I know that, you know, how I guess when you were in school, was that something you were told just could not be done?

Is that our program was pretty unique.

We.

Are. So there's a surgery called a sarpy where you use a hyrax expander and then a surgeon makes, in the grand scheme of things, some relatively low invasive cuts. It's still surgery. And then we can widen the palate. And that was a very popular option for patients in our training that were skeletally mature. We were exposed to TAD expanders pretty early on. I think there were a lot of papers being published out of Japan, Korea long before and some in the United States. So it had been catching on. During our residency we had some, I had some wonderful peers like Dr. Mariana Evans, who is in residency with me, who were really working with a lot of TAT expanders early on. So it was a big part of our training. We did a lot in our program and then coming into private practice, working with a lot of different TAD expander designs. There's a lot of advances that have happened in the last 10 to 15 years in terms of design. And now we can even use CBCT and optical scan guided surgical placement of the tads to make it custom for every patient to avoid things like the septum. And it's pretty exciting. Just the advances in the last five years.

That's amazing. I'm so happy to hear that. I know it's not always the traditional exposure in a program, which is the same to be said for professionals in my space. We didn't learn a lot of what we do now in our program, but we are seeing that, especially in the past couple years, that some programs are starting to talk more about airway and myo and it's becoming more of a thing, which is just so fascinating because Myo's been around for 115 plus years. It's not new, but here we are. It's been that back and forth of like, is it real? Is it not? Is it? But anyways, yeah, no, I, I love to hear about that. And I think that all of this is just absolute incredible. And to know that, you know, we should not be waiting, as you mentioned, for those like all the permanent teeth to grow in before intervening. I think it's just such a, such a powerful message because I had taken my daughter to a, an ortho, a couple orthos for just to see what I could find closer to me. And you know, one was like, come back in six months. And I was like, that or a year. And I was like, well, she's about to turn seven. Like, why would I come back when she's eight? Okay, no, that's not for me. The next one I went to said they were airway centric. They did like all the things they took. They did the CBCT on the spot and pulled it up to show me they had a whole nice airway intake. I was very impressed and then said that, sat there in front of my daughter and said like, her face is beautiful. Why would you want to mess that up right now? She's already had expansion. You're going to fatigue her. I was like, she had expansion between 4 to 5. It was like 6. Slow expansion because she was young and little and, like, she's about to turn seven. I want, like, let's get the show on the road here. Like, one of my colleagues said her mandible needs to be brought forward a little bit. Like, we don't have a lot of time. And, yeah, they just didn't want to. I said, I'm. I don't think she's going to fatigue. Both my kids are actually really great patients and very compliant, and they have a mother who's, like, very compliant as well with the work I do. And, you know, I was like, but I got it. If you don't want to do it, that's fine. And, you know, they even called me after I left to make sure, like, I wasn't upset. I was like, I'm not upset. I just felt like, you know, from one colleague together, I wanted you to understand, like, my passion behind doing it now and not waiting 6 months, 12 months. But now I just was like, I'm going to go find somebody who truly is on the same wavelength as me. And that's why we drive to North Miami. And it's just been incredible to see, you know, she's now at the end of her expansion journey at 7 and so much healthier for it. And my youngest, you know, four and a half now, and she's almost. She'll be done before she turns 5. And I'm like, this is. Makes me the happiest mom in the world. Like, it's just incredible because I've already seen so many health benefits for both of them. And I'm like, you can't deny that.

Yeah. Awesome. That's great.

So. So, yeah. And I'm sure you see a lot of this in your practice, too, but. Yeah, if there was any last words of wisdom or encouragement for any parents who are like, do I do it now? Do I wait? You know, based on. I think one of the biggest issues is they. They do take their child for a consult and they're basically told to come back in two years or come back in a year. Any, like, words of wisdom or, you know, you could pass along to parents if they're thinking it should be done sooner and they're kind of up against the wall with that.

Yeah, well, I guess just globally, thinking about, like, we mentioned, what does intervention mean? Intervention can be a lot of different things. I think the biggest things to look for in these kids are what are the compensation patterns and how do we get away from the compensation patterns? So the diagnosis will be different for every child. It might be dealing with a tethered oral tissue, it might be diet, it might be breathing, might be adenoids, tonsils, turbinates, allergies. They might need expansion, they might need protraction, getting upper and lower joint and so tailoring it to the needs of the child. If they're struggling, why wait?

Right.

Yes. There's no. There's no need to wait. What are we waiting for? If the child is at a maturity level where they can't sit in the chair, then maybe we find another way to intervene. And maybe it's not expansion for that child. Right. Then that doesn't mean we can't revisit it. But to ignore a problem because of chronologic age does. Doesn't. We don't need to do that anymore. Yeah.

Yeah. Well, thank you. That's very helpful and amazing. And I think also just the SLP in me thinks about all of the cognitive development that also happens in the first seven years of life. And if we're not sleeping well because we're mouth breathing and our tongue is not up and we're not, you know, we're also not supporting that cognitive development, which I know we could go on all day about, we won't. But ADHD and IQ, actually, you know, there's research shows the IQ can be 10 to 16 points lower in these kids compared to same age, typically developing peers that are not mouth breathers. And, you know, it's. It's very interesting to be on both the parent side of things and the professional side of things. I'm sure I make myself a little crazy, but I was like, if. I was like, man, if I can get my children healthy and nasal breathing asap, not waiting until, you know, then I will. I will do whatever it takes. And so, you know, I'm. I'm a big proponent of encouraging parents like, follow your gut. And if you feel like your child has an issue that you want to address now, like you said, what the intervention looks like needs to be tailored to that child. And there are different ways to intervene now. I mean, we've even worked with kids on, you know, creating little molds that the dentist gave us to practice, like having, you know, we don't have to do that as much anymore. Now we have different ways to scan the mouth for appliances, but just sometimes that's a barrier. Getting like one of those molds into the mouth for a child who has sensory issues. And there's, there's usually always a way that we can help, but you have to have a team that also has that desire to, to figure out how we're going to best help the patient in front of us. So.

Yeah, so.

Yeah, yeah, yeah. So.

So.

Thank you. Thank you for joining me. This has been so much fun. I always enjoy talking to providers who I would love to have on my team. Thank you for the work you do. And we'll make sure to put your, your contact info of your website in the show notes so they know how to, to find you.

Amazing. Thank you for the work you do. You're helping a lot of families and you as well. Well, thanks. Thanks for inviting me.

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