Episode 190: A PTs Approach: Tongue Ties, TMD, & OMDs with Liana Sved PT, DPT, CMTPT

Hi and welcome to episode 190 of the Untethered podcast. Today we have Dr. Leanna Sped joining us. Leanna is a physical therapist, myofunctional therapist, and owner of Revive Physical Therapy in Stonington, Connecticut. She specializes in treating people with head, neck and jaw pain, including but not limited to tmj, tmd, headaches, migraines, whiplash injury, painful swallowing, concussion, vertigo and sleep apnea. Her focus is to provide individualized care with a holistic, full body approach to people both local to her and across the globe. 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. Leanna, welcome to the podcast.

Thank you so much for having me. Hallie.

I'm excited to chat today because I know we're going to focus a lot on temporomandibular joint dysfunction and MYO and all those things, but I would love to start with you telling us a bit about how you even got into this space.

It's a bit of a long road actually. So I'm a physical therapist first and I've been a physical therapist now for 10 years. So when I first graduated school I really had an interest in neurology, so working with acute stroke patients, Ms. Parkinson's, but you know, it's fairly limited growth. So I transitioned into outpatient neuro and it was presented with a place where I learned a lot about concussions and with concussions are a lot of people who have jaw issues after their concussions. And then I got into TMD and closely and then I started going into outpatient more so like outpatient orthopedics. And I took a dry needling certification and that last part of the dry needling certification is how to needle the face muscles for for cranial, facial and orofacial pain. And the person who taught the course was a physical therapist who that's her specialty is craniofacial and orofacial pain. And I didn't even know this was a specialty that I could go into. And being somebody who also has TMD and learned like maybe just one day lecture, like two hour lab tops in PT school, I was like, what? There's more to this. And at the time I was dating my husband, he was an ortho, orthodontist. And I was like, oh my gosh, did you know? And just started the whole conversation. So I started to get more into the TMD realm and I started to take more courses and myofunctional therapy kind of got sprinkled in. But it was never anything that from a PT course standpoint, they taught, they taught, you know, Rocco Battle, six by six and you know, joint mobilizations and just very more like hands on tools. And I kept hearing myofunctional therapy. Myofunctional therapy. And it wasn't until I sat in a Dr. Gelb actually came to our community and he spoke to a study group that I was invited to. And he talked about how much myofunctional therapy was so important for these people with TMD issues and airway issues. And I was like, that's it. I'm taking this coursework and I'm doing it. And that's just, that's how I got here. And it's been very successful and a very good addition to helping my, my patients and clients with tmd.

Love that. And I think it's so fascinating to see this because there, There aren't many PTs, I think, in this space, but I feel like I still have somehow stumbled across at least a few. And I find it so fascinating that, you know. Well, I don't know, maybe it's not fascinating, but it's like, how are we not being taught this in school? Like, I know that's the same for me as an slp, you know, feeding my, like all these things that are so critical to, I feel like the foundations of all of the work that we do. You know, you want to breathe properly, you want proper breath support for speech. Well, you need to have good core strength. Okay, well, what's going on in the mouth? Like, let's talk about that, right? We know that what we see and we always say we see in the lips, we see on the hips, or what we see on the trunk, we see. You know, there's all these different sayings and it's just so. I think the fascinating part to me is we know how interconnected we are from a fascist standpoint. And so the fact that it's just everything is taught in silos and not taught more holistically. And we don't even, you know, I would love to have collaboration and lectures from PTs in this space for SLPs in grad school and from OTs and from dentists and orthos and, you know, I feel like the list goes on. Obviously we'd probably be in school forever, but just of course, one semester, of course is maybe with guest lectures in this arena to at least explore, expose therapists, like therapists to be to this information. It's. It's so critical. I mean, it's really changed my practice. I know, changed my patience. I feel like when I came back, like from taking my MYO course and I assessed all these kids and like kind of tweaked what I was doing. All of a sudden there were a whole bunch of kids that were 2 years old, 3 years old, 4 years old, 5 years old who had motor speech disorders, who had feeding challenges, who had all kinds of things going on. And all of a sudden we started to make progress because we were looking at the, you know, the root cause, the underlying issue. So it just, it just baffles me. It baffles me that this is like, not more widespread, but it's. Yeah. I'm so glad you got to experience that lecture with Michael Gelb. And he's phenomenal. And I just, you know, it's great to be connected to individuals. I think also where you are in a study club setting, to even have that exposure and experience. I feel like we need, we need more of that.

Yeah, it's been a great experience to be included in the dental study clubs that are in my area. It's really has been just to kind of create like you're saying is that exposure to an interdisciplinary care versus like more blocked off professions and treatment. Yeah.

So in your practice, do you find, like, what do people typically come to you for? Like, what is your chief complaint? Is it TMJ issues or is it other things or.

Yeah, so I pretty much see anybody with like complaints from like the collarbone up is essentially what people come to me for. So very basic is. Could be neck pain, chronic whiplash repercussions, concussions. But I see a lot of tmjd, so a lot of tmd. I'll use those terms interchangeably. Interchangeably. So tmd. A lot of people, it's not just popping and clicking. They're coming to me for more of the obscure symptoms too. So a lot of earfulness, tinnitus, you know, swallowing issues, you know, so maybe they're having globus or which is that feeling of a ball in your throat or difficulty swallowing. So that's really what I'm seeing people for.

Yeah, it's interesting. I had a colleague who has, she's had a lifetime of issues with her, her temporomandibular joint and bilaterally joint joints. And I know that she also I believe had. Her neck is fused. I don't remember like specifically where that was done, but she, you know, I remember I've sat next to her in conferences and I'm watching her eat like a banana off of a fork, like with like the tiniest piece that you would maybe give to like a new feeder, like a six month old who's trying banana for the first time because she could barely move her jaw and she was in so much pain. But she was like I need to get calories in and, and that I think it's interesting we were sitting in a tongue tied course together while this was happening and she's like looking at me and she's like, I think I'm tongue tied. Like do you think I'm tongue tied? And we had this whole very interesting conversation. But it again, just to see what happens and snowballs over a lifetime when a lot of these issues are not addressed or attended to or they are, but maybe not holistically or you know, we don't look at the root cause, we just hand over a bite guard or we, you know, it's band aids as I like to call them. Do you find that like a lot of your patients have been to many other professionals and a lot of treatments have failed? Is, is that common for you?

Yeah, very common. I, I see a lot of that. So people have tried everything and they're even tried physical therapy and physical therapy didn't help. And you know, the reason why physical therapy didn't help is you're really not addressing that root cause of the oral dysfunctions that are really the reason why somebody has TMJD or tmd. So yes, definitely have seen patients that have seen multitude. Sometimes I do get the patient who. I'm the first person and I feel so honored that I am the first person. So I can kind of give them this more holistic view of what's going on.

Yeah, yeah, no, that's. We find that a lot too where we're like. And it's. Some of my like team will say to me, they're like, look at the list of providers that this baby has been to. And sometimes it's you know, they're just months old and there's like 12 providers already on the list. And we're like, oh, my goodness. Right? And then sometimes we get these adults who. I've had adults who have had awful issues with temporomandibular joint dysfunction, and to the point where some of them, like, have been diagnosed with ptsd. The doctors just don't listen or believe a lot of what they say anymore. Their quality of life is really poor. Obviously, they also have an orificial myofunctional disorder. If you can't use your job properly, and I'm sure you can speak to that probably better than I can, but, you know, it's. It's such gratifying work, in a sense. When I'm like, okay, we can help you, and they're like, wait, what? Like, when I'm not used to hearing that, you don't think I'm crazy? You don't think that, like, I'm making this up and I'm sitting here going like, no, I mean, I'm sure there are people in the world or maybe things like that do happen. I'm not discounting that, however. You're telling me you're in pain. You're telling me you can't chew your food. You're telling me you don't sleep well, you're exhausted. Like, you're basically, you know, I've had grown men cry in a, you know, evaluation, and I'm like, no, I believe you. Like, you're here for a reason. Let's get to the bottom of this. And so I think it's just. That's why I think I'm so passionate about this work. Like, it just. It's incredible. And then connecting with providers like yourself, because it's just incredible. The changes and then the quality of life that you give back to people, or sometimes they've never experienced it and so they didn't know what they were missing out on. Do you have patients, like, come back to you and give you feedback along those lines?

Yeah, I mean, like, I. I have patients who are 20 plus year jaw pain. Like, I had patient, 20 plus year jaw pain, wanted to literally have all of her teeth removed because she's like, that's just the only way that this is going to get any better. And she's 95% better, right? After two months of treatment. You know, there's still things that we need to fix, you know, bite, airway issues and whatnot. But I mean, she feels better, you know, so, yeah, you know, and also Just, I feel so honored to be able to help them navigate this system. It's really. I don't know, like you said, like, I think people can get lost in the system. You know, you have a laundry list of providers. A lot of them, unfortunately, aren't giving a holistic view. So a lot of these things are quick fixes. You know, I see a lot of people with significant equilibrations where they're shaving teeth down, which is, again, like, if your bite is shifting, a lot of times it's muscular. It's not because your teeth are actually changing. So, you know, that's happened. What else? I mean, I just. Yes. I mean, I just see so many people where it's like a little bit of mismanagement, honestly, just because of the lack of giving them, or at least giving the patient the opportunity to see the bigger picture of what's going on with them in their body.

Yeah. And I've heard also from some of the dentists that I've worked with that obviously pain can radiate from different places. So even though it's maybe a temporomandibular joint issue, sometimes they'll feel it, you know, in certain teeth, in certain areas, you know, of the jaw or surrounding the jaw. And so they feel like it's like this tooth.

Right.

Or these teeth, or it's this con. Chronic issue I'm having with this tooth. And I've even heard of, you know, a lot of dentists will then, like, remove the tooth or do some kind of a procedure, and the pain doesn't go away. And so when you just said that about that patient who was like, I just want to, like, remove all my teeth, I was like, oh, my goodness. Like, I would just think. But she, like, was radiated. Like, I mean, pain had. Have been radiating from other areas. Yeah.

I mean, she. Yes, for her. But I have specifically had a couple patients where I've saved them from tooth extractions because they've gone through a root canal, and the. The tooth is still painful. And all the other tests come, you know, come up negative, and they're like, well, we could just extract it. And luckily, like, this particular patient was like, I don't really want my tooth just extracted for no reason. So, sure enough, it was a master referred pain pattern, which is, you know, one of the big jaw muscles that's just causing pain in that one specific tooth. And she didn't have to get her tooth removed.

Yeah, that's the word.

I was.

The term. I was looking for referred pain. Thank you. I Was like, it's not coming to me right now. So I'm just gonna say radiating because it's an R. And that works. Yes, it's. It's so interesting. And. And, you know, like, up. I'm. I'm now in Florida, but when I lived in Maryland, I had a really great dentist who was like, a holistic dentist. And they really looked at all of this, right? And they wouldn't just, like, jump to a procedure because of. They would take an image. They would see, like, you know, that tooth looks healthy. Let's see what else might be going on. They actually have a PT in their office who's like, pri trained and who does, like, manual body work and stuff. And it's. It's just so cool, like, when you get to be in that kind of a setting and you get to work with those kinds of providers and then you move somewhere else, and it's really hard to find the same thing. It's like, I feel like I've been so spoiled and I can't find the same thing down here. But, no, it's. It's really very cool to see. And I mean, having been the patient, like, I went through expansion, have talked in the past about how, like, 50 through of the way through my expansion, I feel like I hit a wall and I could no longer, like, turn my appliance. And so when I worked with the. The PT who was in the office, he was able to do some work, which I feel like, unlocked me in a sense. And when he kind of unlocked my body, I was then able to turn my appliance and continue my expansion. And that, just like you were saying before, it really speaks to the muscular involvement. Right. It's a lot of. That really drives, you know, form first function. Right. That really drives, I think, a lot of our changes. So anyways, I just think that it's, you know, a very cool conversation when we can have providers working together. And then you also start to see how these things all support each other. But going back to temporomandibular joint dysfunction, like, as an omd, as an orofacial myofunctional disorder, are you then addressing it from, like, both a PT standpoint and a MYO standpoint? Like, how do you address that with your patients?

Yeah, so. Well, first off, it's changed my evaluation entirely in terms of how I'm evaluating somebody when they're coming into my office for. For jaw pain. I am doing a lot more basically a. My evaluation, in a sense. I do do some joint evaluation. If I feel like the joint is really a problem, but a lot of times it's not. Like, a lot of times, yes. Even the popping and clicking, like, that's not only a joint. That's because people have a muscular issue around the joint and the stability of the joint. So really, unless somebody's coming a closed lock, which is when they're not opening their jaw wide enough, like, I'm really not doing a PT evaluation. I'm doing more of a myofunctional therapy evaluation on them. So that's one way that my. It's completely changed for me. And then my treatment plans are. Are based on your findings.

Right.

So, you know, I've noticed that, you know, for a lot of people, even when they. I used to think, oh, deflection means that this particular joint is stuck. So deflection is when the jaw kind of goes off to side. You know, in the PT room, we're like, oh, the side that it's deflecting to is not working well. And the side that, you know, the other side is more mobile, essentially. And now I see it as more of like, okay, it's a muscle. Like, it's a muscle. Like, we got to build the muscles up on that side. You know, what's going on with the tongue? Like, why is the tongue bringing, you know, the jaw to that side? You know, there's just a little bit more that I'm looking at now. And so, you know, some of the myofunctional therapy exercises are. Are, like, almost better than the exercises I was given as a PT to do, because it creates a better mind, body connection, I think. But then it also teaches you, like, okay, great, you can do your exercises, but how are you incorporating those into your everyday life? Like, you swallow all the time, right? Thousands of times a day, you swallow, you know, you're eating, you're talking. Especially for somebody who's a teacher, who. Teachers, by the way, commonly have T and D because they're talking all the time. Right. So how are you. How are these patterns changing in order to really create an environment of healing and then also strengthen your. Your joint and your jaw so that way you're feeling better. So I think that's really how it's changed. It's changed from, like, okay, we're just going to do these joint mobilizations, and we're just going to, you know, give you these couple exercises to, okay, well, let's really look at what's going on with your habits.

Yeah, no, I. I love that. And that's so Interesting, because I think when, like, even for me, I noticed that I was, like, a clencher when I was sitting traffic. And that was back more in the D.C. metro area when I was, like, driving to go treat every day. Pre pandemic, really. And what I noticed was, like, I had to stop and think and, like, recognize that this was a pattern for me. And because I was doing it throughout the day, because I was between kids, homes or schools, like, when we travel to the patients, like, it was all day, every day, during my work hours. And I feel like that obviously caused a lot of tension right, in the surrounding muscles. And when I was expanded, Becky, I feel like I could start to breathe a little bit better and I had more room for my tongue. It wasn't until I actually. I had nasal surgery earlier this year, and they fixed my septum. They fixed. You know, I've had reduction in nasal swell bodies and turbinates. And now I'm like, oh, I can actually breathe through both sides of my nose. Like, this is so much easier. And I find myself, like, not having to think about where my tongue is, because my tongue typically is up on my palate, and my teeth are not touching or, like, slightly apart at rest. And if I find myself, like, clenching, I'm like, all right, what's going on? Why am I stressed? Like, what is happening right now? Like, this is not my. My usual, you know, rest position. And that's one of the biggest things that I feel like everybody needs to know about. Like, everybody, regardless of who you are, what you do, if you do not have correct oral rest posture. Why? Right? Like, if your tongue is not up in the roof of your mouth, full tongue. Everyone's like, well, is it just the front of the tongue or half the tongue? I'm like, no, really? You're like, entire tongue, including the posterior portion, should be resting up in the top of your palate. Teeth apart, lips together, breathing through your nose. And, you know, people are like, we.

Don'T think I do that.

How do I do that? And easier said than done, right? It's like, you have to create a new habit, but you also have to have a patent airway and enough space for your tongue to rest in your palate. So it's. It's definitely one of those things where you're exactly right. You know, in addition to where our tongue is resting, where is it when we're swallowing? Because we swallow, we swallow saliva all day long. We chew food and swallow food. And I think there's been a sidebar. I think there's been so much focus on people saying like, oh, myo is like not research based or which it is, but that's a whole other conversation for another day. Or, you know, why is everybody so focused on correcting a tongue thrust? Thrusting your tongue doesn't move your teeth. And we're over here going, we're not saying that swallowing like, you know, all day long is necessarily what's, you know, that's not necessarily the force that's like moving your teeth. However, it is perpetuating dysfunction and oftentimes incorrect use of the surrounding oral musculature, which then has a obviously full body effect, as we know, but it's really where your tongue is resting and the force of your tongue, like if your tongue is resting between your lips, between your teeth, against your teeth, that's going to start to shift teeth. And that's what I think a lot of people like at least have come to us or some of our dentists for and have said like, I don't necessarily want expansion. I don't necessarily want this, that or the other. I just don't want to be in pain and I don't want my, my teeth to shift any further. Can you help me? And you know, we'll do our best in myo, given the anatomy and airway that we're presented with. But I think that it's really an interesting conversation because I like how you brought up like, well, well, yes, maybe we want to correct the tongue thrust regardless. We also want to focus on oral rest, posture, tongue thrust. I feel like gets a bad rap and is like so highly the focus of why mayo is like bogus. And we're like, it's, again, it's not. But I think that goes back to what you're saying about just what muscles are you recruiting and how are you using them? Same thing for speech. If we're not, if we don't have full access or we have tension or we're compensating, that's going to carry over to other areas of our life. It's not just going to impact speech, it's going to impact how we breathe, it's going to impact how we chew, how we swallow. Right? It's, it's all interconnected. And so anyways, I could go off on this like sidebar, like all day long, but it just drives me a little crazy that people, people teach compensations and they advocate for teaching compensations. And I'm like, in an adult, if that's their choice, by all means go for it in a Child who has their whole life ahead of them, educate the parent and then let the parent decide. And if they choose compensations and you're okay doing that, fine. If they, if they don't like, that should not be your. The main purpose of the therapy you do.

Right. I am all for, like, I guess, informed consent, essentially, you know, making sure that the person that you're treating understands, like, everything that's going on. You know, what are, okay, this is what I'm recommending and this is what's going to happen if you don't do it and then, and then allow them to, or give them all the other recommendations that are out there. Right. And then this is what's going to happen and let them make the decision for themselves, you know.

But yeah, well, and I think that's part of it because, you know, with social media, for example, there are all these influencer accounts in, at least in the SLP space where in some of its, you know, feeding account, a motor speech account, you know, big names, where there's these discussions around. Well, yeah, sure. If there's an older child who's been in therapy for a while and they have. They present with a tongue tie, like, then, okay, like, let's address it. But like, no, we don't see it being a problem for like, our younger kids. Disagree, 100 disagree. If it's a true tongue tie, the definition of a tie is that it's impairing function. Right. And so there's that physical presentation plus the impairment on, on function or, you know, it's.

Yeah, this is, and this is why, like, I mean, and this is like the people I'm seeing at the later stage, you know what I mean? I'm seeing them after years and years of dysfunction. So almost like 95% of my clients with TMD have a tongue tie. It's a matter of, you know, like, where, how and is it going to. Working through these compensations, is that going to get you the relief you need? Like, how much relief do you want? Like, what symptoms are we working with? Like, that kind of thing. We're that discussion. I mean, not everybody wants to go through a tongue tie release, but essentially, if the tongue is tied, your jaw joints are going to move too much. End of discussion. You know, your tongue needs to have the range of motion, mobility and function in order to stabilize those jaw joints just as much as your other muscles. So, you know, I'm having that conversation a lot, you know, and people are, I, you know, I have kids that are coming in that have had speech for, you know, years. And I'm like, they're. They're tied, you know, and they're like, well, why hasn't it's been brought up before? And I'm like, I'm like, I. I.

Yeah, you're like, how long of an explanation do you want?

I'm like, well, I don't know, but. But, yeah, so it's not, you know, like, I see it all the time, and it's, you know, like, you and I. You know, you brought it up. It's all about function. Like. Like, I. Like, I have tmd. I don't look like I have a tongue tie. But when you take the compensations for the floor of my mouth out of the equation, I have a pretty significant posterior tongue tie. Like, I can't get the last half of my tongue up to the roof of my mouth very comfortably. You know, really, all I have are TMD symptoms. Like, I don't have any issues or painful swallowing. I don't have a tongue thrust. I don't have, you know, headaches or migraines or anything like that. But I do have a lot of jaw discomfort. So I think it's something. At some point, I'll explore getting a release done. But like I said, it's function, like, yeah, yeah.

And that's. And that's the beautiful thing, right? As an adult, you get to make that choice. And I think that that goes right along with informed consent. We have to educate and provide all options. And, you know, I think when some people hear me, like, teach on this, and they hear me podcast on this, and they see me post on this or kind of like, oh, Halle's probably, like, you know, hardcore, like, skewed one way. No, like, I. I want what's best for my patients. I've worked with patients. Like I was saying, like, we're like, I don't want the tongue tie release. I don't want expansion. I just want to work on my current habits, see if I can get to this, like, point of homeostasis for me so that it doesn't get worse. And I'm like, okay, great. And I did, like, five sessions with that person over several months, and they had. They had improved their rest posture. It wasn't perfect. It wasn't, you know, 100% functional, but it was. They were happy, and that's what they wanted for themselves. And so that's the beauty of doing the work that we do is, like, we get to educate. We get to give the patients the different options. We get to Tell them, like, okay, in best case scenario, imperfect world, here's what we may want for you now. What would you like to do? Right? And it's, you know, we get parents who are like, well, what would you do if it was your kid? And I'm like, well, go listen to my podcast. You can hear everything I've done for my own kids in this space. But, you know, it's. I think there's so many parents who also, you know, because we do work with a lot more. We work with across the lifespan, but definitely a lot more pediatrics. Through my practice, a lot of parents are, you know, very like, gung ho. Like, let's do it. Let's do it all now. We're like, okay, pump the brakes. Like, yes, there's a time and a place, but maybe we don't have to do everything that you've heard about. Maybe we start here, see what happens, and then we, you know, go to the next step if we feel like we hit a wall. Because we do get, like, for example, lots of cases who are borderline tongue tie. Like, we're like, will you appear to present with or your child appears to present with one? Let's see what happens. Let's see if therapy addressing the oral musculature. Let's see if we can address that. If there's improvement in the next three to four weeks while we see you once a week and you continue to work at home a bit. And, you know, if we're like, hitting a wall and we're not seeing any progress, we're going to have a different conversation if we feel like we're progressing and there are not all these compensations happening at play to make progress. Like, we're not. That's the whole thing that I look at is are we snowballing compensations? Like, are we just adding more compensation and more compensation to the pile to achieve our goal, or do we feel like we're actually achieving that goal without having to compensate? And maybe it's just. Maybe it appeared to be a tie and it wasn't. Because we do see that. We see, like, tension patterns that make someone appear as though they're more tied than they actually are. And so we'd like to give, you know, and that's also part of the reason why I'm such a big proponent of, like, preoperative intervention body work. You know, we're a facial work. We really need to do all the things so that we can determine if this patient really does need to go for that consult to see if they're a candidate for a release. But yeah, it's, it, the whole conversation is just so fascinating because you know, seeing these adults who are completely miserable, to be honest with you, so many of them, it's, they're in pain, they don't sleep well, they don't breathe well, they just. And then when you don't feel well, you don't really want to take care of yourself either. So it's kind of like this like downward spiral for a lot of patients. It's like when we feel better, we do better. We want to, you know, do more for ourselves and take better care of ourselves. It's kind of like that catch 22, right? So yeah, it's, it's definitely something that I wish there wasn't so much I keep saying it's ego of providers not being able to get out of their own heads and their move away from their own beliefs. To see the multitude of patients, whether it's pediatric or adult, who are greatly benefiting and have majorly improved their quality of life. Adults getting off medications, getting off CPAPs, there's all kinds of stories that you just hear. It's not like one case study here and there. Like we're talking about thousands and thousands of patients. So yeah, I'm like, you know, when, Maybe it'll be 10 years from now, but one day, one day I hope this is more like the norm versus, you know, this. Anybody told me this kind of conversation.

Yeah, I mean I do too. And I honestly don't know if it'll be the norm until there's something that drastically changes in our, either like the literature and, or like the insurance based world. You know, the fact that, you know, insurance isn't, is an obstacle. You know, the fact that the dental world is a lot of out of pocket, you know, I don't know what will, how that'll change. I know a lot of people spend thousands of dollars, thousands upon thousands of dollars in the dental field, you know, work, you know, fixing their tmd, you know, and then on top of that sometimes when they come in I'm like, well you've gonna probably have to spend thousands of dollars to get where you want to be. Unfortunately, because of the, just the issues that have developed from all of those like closed minded or non communicating, like they don't communicate with the patient, you know, about what's going on or their options or whatnot. So I do, I do hope something changes though in the future because I think this is really beneficial work for people who are in so much pain.

Yeah. And it's so, it's very interesting. I've been watching this a bit too and obviously I think our health care system is just a whole. Yeah.

Right.

We'll just leave it at that. You know, I think the nice thing for speech pathologists is because we are addressing like oral phase prep, you know, bolus prep and oral face swallow with myofunctional we can bill it under that, which is beautiful because we can bill it under feeding and swallowing. And so if we have patients that are insured that can access those benefits they have included, we have been pretty successful in getting our little patients coverage. Now obviously some families will prefer to go in network. They may have a high deductible. So it still goes back to your whole conversation on you're going to spend thousands upon thousands of dollars before you start to get anything covered. In some cases, unless it's an in network provider, then maybe that changes. You know, my practice is out of network. We are private pay and we do provide a super bill. We actually have like a whole guide that basically walks them through before they even fill out our intake. We send it to them so they can call and ask the questions and find out if their plan even provides that out of network coverage for their child or themselves as an adult. And you know, it's. We have had a lot of families who've been very successful submitting super bills and getting reimbursement. And typically it's either at the level of what it costs in the same amount as going in work and or some cases they've gotten reimbursed more for the out of network service than they would have gotten reimbursed if they had gone in network. And there's definitely no shortage of therapists doing this around my practice in the D.C. maryland, Virginia area. So people have options. But they love that my team is highly trained, they love that we get results, they love that we travel to them or provide virtual therapy. Right. They love that there's all these benefits. And so sometimes they'll leave because they want to go in network and then they come back to us and we're like, welcome back, we're glad to have you. But it's, you know, it is a full time job sometimes fighting with insurance, which is just simply why we don't take insurance. In my practice I always tell parents to squeaky wheel. The third time's a charm. Keep going, keep fighting. You will get it. And once you kind of get the process down, then it's just a matter of like, wash, rinse, repeat. But it does take time and advocacy for sure, which is a major barrier for a lot.

A lot it is. I mean, I don't. I don't take insurance in my practice either, just because from the PT side of things, in TMD codes, those are sometimes very tricky for some insurances. But like you said, a lot of times the squeaky wheel will get it. So. Yeah, yeah.

And I know, I mean, there's definitely some research out there that talks about also the positive impact. Right. The effect of myofunctional therapy on temporomandibular disorders. So I, you know, I want people to realize, like, and it's not necessarily new research. I think, like, there's. I know there's an article from like 2010 that talks about the. The difference in that. How there was like, you know, reduction in pain and.

Yeah, it was a. I think I know what article you're talking about. It was an article in 2010 that really looked at separate therapy. So looked at myofunctional therapy compared to your normal flat plane appliance, which is a very common appliance to be given for tmd. So what that appliance is is it just covers all of your either upper or lower teeth, flat, flat out, you know, and they looked at those two therapies and compared to control groups, and what they found is that those people with TMD that were treated with myofunctional therapy actually had better outcomes, less pain, than those who were just treated with an orthotic splint. So, you know, it is very beneficial. And like, one of the things that they brought up in the discussion with this particular article was that although the splint may be putting your teeth or your joint in a better alignment, it doesn't account for what's moving that joint. It doesn't account for the muscular components.

Right.

It's only accounting for the very finite structures. Right. Versus the things that move and are holding those structures in place. So that's why they said that, you know, the conclusion was, you know, myofunctional therapy is definitely a much better way to go than an orthotic splint. Yeah.

And we can definitely link that article. I know there's other ones too. So I always encourage people, if you go to Google Scholar and you just type in, you know, myotherapy, you can do, like, even abbreviated, you don't have to spell the whole thing out and temporomandibular or TMJ and just put those words in, it'll Pop up all kind of, you know, a whole bunch of different articles for you to read. But it's, it is very interesting. I think the more and more that we look at this, it just, it makes sense, right? We are more than just hard tissue. We have soft tissue. We have. And everything works together and everything influences everything else. And so I always say, like, while I'm not in the business of moving, moving teeth and dealing with bone because that's not in my scope, muscle influences what happens right. To the bone, which is exactly what you're saying. And you know, I've gotten some of these patients who come, adults with these occlusal splints and they're great. I mean, they tell me that they really do help and ultimately sometimes they've ground their teeth down so far that like the occlusal splint is just so necessary to avoid like pain at the root of the tooth from the grinding. But we then, you know, have to combine that with myofunctional therapy and other interventions potentially to get the full benefit of trying to address the root issue. Right?

Yeah, definitely. Like, I mean, occlusal splints can be very helpful, but again, not addressing the root cause of what's going on and why that person is clenching or grinding their teeth. So yeah, educating the person that there's something else that they could be doing is, is great. Yeah.

And I think that's the whole. That goes back to like the whole conversation on not treating in silos and not thinking that like a one off appliance or a one off procedure is going to solve all your problems. Right. If you. So if, if I had just had my expansion appliance and I didn't address my tongue tie and I didn't address my nose, quite honestly, I would not be where I am today. I was holding on to a lot of like water weight. I was holding on to a lot of inflammation. People who have seen me since I had my nose procedure done almost, well, it's about like, like six and a half months now that I had it done. They're like, wow, like, you look different. Like, not just my face because I also had a rhinoplasty, but they're like your body, like, you look like you lost weight. And I'm like, yeah, my clothes fit me better. Like, I feel like I just dropped like 10 pounds of like water weight and inflammation that my body was holding on to because my sleep study showed that I was constantly waking up at before I went into REM sleep or I would Go into that, like, deep sleep, and then, boom, my body would just immediately wake up. So I was never truly getting, like, restorative quality sleep, regardless of how long I slept for, which is completely debilitating when you realize that and you have something to compare it to on the flip side.

So it's like, honestly, because, like, you know, unfortunately, I feel like I'm the person and I think maybe you feel this way too, but I'm, like, the bearer of bad news sometimes. Like, I'm the one that's opening the can of worms. Like, oh, great, you're coming to me for job pain. But you've got all these other things that are causing the job pain that we also have to address potentially at some point. And I have to. But I mean, obviously it's their choice, but that you should address it.

And they address.

Yeah, you know, it's a very hard conversation. I feel like for me to be like, well, all of this is because you have sleep apnea, you know, and it's because your jaws, you know, you're. The arches of your teeth are too narrow or your, you know, your retrognathic, so your jaws are set back, or because you, you know, that deviated septum that you've been putting off, like, taken care of for years, like, probably should take care of it. So, yeah, sometimes I feel like I'm a bear of bad news. But, you know, like you said, it's not. You can't just get a result with one thing. Like some. For some people, like, you know, you're going to come in, you're going to think, oh, physical therapy is going to help. Myofunctional therapy is going to help, but really, it's. There's quite a few things, quite a few moving pieces, and it really does need to be treated in a more holistic fashion than just a little silos.

Yeah, absolutely. Absolutely. And I think that's, you know, having seen that as the patient and provider, I find it. It was even overwhelming for me, right. For me to realize, like, oh, I have a tongue tie. Oh, I have an omd. Oh, wait, I had braces. And, you know, all this expansion and everything as a kid, like, then they took off my permanent retainers because I asked them to when I turned 30 and everything started to shift. And then I was like, okay, okay, now what? Like, why? Why is that happening? And I think it just kind of having gone through all of that, it really also makes me appreciate how overwhelming the process is and how, you know, how we need to approach our patients Because I tell my team all the time, they come to me and they're like, okay, like, this parent is going to go screaming in the other direction if I, like, lay it all down for them. I'm like, so don't. Yeah, let's start with what did they come in for? Let's, like, focus on that, right? And I always tell them, I'm like, what was their chief complaint for themselves or the chief concern for their child? Focus on that now. Let's also tell them, okay, while assessing, we also found some other things that we would like to discuss. And, like, let's focus on, like, three things max. And if we're going to send them for. And we can even. I tell people, I'm like, you can say there may be other referrals that I'm going to make and other conversations that we may have. However, I want to start here, and I think this is going to be the best starting place. You know how, like, what do you, like, how does that sound?

Right?

And I, like, try to get feedback because I want to know is this parent. Has this parent. Maybe they've been to three ents already. Maybe three ents have turned their kid away and that's why they're sitting in my office. Maybe they didn't put that all in the intake paperwork or answer all of those questions to the full extent during the eval because they were just trying to get. Some parents come to us, like, trying to get another perspective without us being, like, influenced, right. By where they've other reports who they've already seen. They just. They want a true, separate opinion without giving us too much history. And then sometimes that history obviously unravels a bit more during the eval or after we say, okay, this is what we're seeing. And then they go, okay, yeah. So let me fill you in on. On some other things. So that happens sometimes, but it's. It is completely overwhelming. And I don't think it's healthy for a parent who's already concerned, especially a parent or even an adult, to feel like they have to go make five appointments at, like, five other specialists or even three. So we usually try to, like, reel it in, and we're like, let's. Let's start therapy here. Let's start to work on some, you know, some function. Let's see if we can gain some function. In the meantime, I do want to know if you. If we can. But usually my first line of referral is either like, ent or allergist, because I want to make sure they can breathe through their nose, especially if there's certain symptoms. But that's tricky because we don't really have many in the D.C. metro area who are on, you know, on board. It's actually a pediatric dentist sometimes who gets these kids in for sleep studies in the children's hospitals because they have rights at the hospital and they can order a study.

Yeah.

So it's. We've like found ways like to go around and then sometimes when we have either the c. The CBCT or regular CT scan or sleep study, then we can go like, okay, this kid clearly needs to see any. Who is going to be willing to look at this information. But yeah, it's. It shouldn't have to be that way. But it is, unfortunately.

Really shouldn't. I mean, my, my first usual referral is either to a sleep study or to an orthodontist in our area who has a cbt. Yeah. Am I saying that like cbct.

How.

Many letters are there? CBT scan to at least like get some sort of airway assessment and then work from there, essentially, because most of the time I'm already seeing people with airway concerns at that magnitude.

Absolutely, absolutely. Yeah. So, I mean, it's great that you have people in your area. I feel like, like I was saying, the pediatric dentists are like really showing up in the DMV up in D.C. maryland and Virginia and which is great because at least we have like a line of referral where we know someone's going to be looking into airway and if they truly are concerned, they're going to recommend that next step and can oftentimes help with getting that next step completed versus kind of hunting to another provide writer who might then say, no, you're fine, you don't need that. I looked into the child's mouth. They look fine. We're like, you can't see the adenoids from the mouth. Like, can't really even see them up the nose. You kind of have to scope or scan them like that. We had a parent come to us last week and they're like, oh, they looked in my kid's mouth and they said the adenoids and tonsils were fine. We're like, so did they do this? No. Did they do this? No. We're like, there's absolutely no way they could have seen the ad noise. Then let's get another opinion.

Just can't make this stuff up. No, you really can't. And I mean, I think it's turning around in my area, honestly, like the, the ents have been the hardest in our area. You know, my husband being an orthodontist, he actually was diagnosed with sleep apnea when he was 20. He had his orthognastic surgery. You know, so he's pretty pro airway and he's been working with the ents for a while and it's still like, yeah, yeah. But luckily some of the other dentists that we have a. Some family dentists in the area who are starting to like, understand and there's a, you know, we're going to be starting a study group and things like that, so hopefully it'll turn around in our area. I'm just so hopeful.

Yeah. And that's the biggest piece of advice. It's like study groups. If you can get a study group going, whether it's virtual or in person, like, that was one of the reasons why I created my MYO membership way back when was because I was like, people want access to study clubs that they don't have access to. So, like, let's at least create that for the myotherapists. Invite in guest speakers and we can like all learn from each other. It's just, it's been such a beautiful thing because it's like, okay, like, we get it. How do we get this in front of more eyes now? But it's. It's very cool to be surrounded by that. I almost like, forget sometimes until, like, we're like in front of our patients and then we're like, oh, yeah, okay. We still have a lot more work to do.

Yeah. There's still other people we need to, to educate and talk to. Yeah.

Oh, yeah. So do you work with people, like, only in person? Do you do virtual work? Like, how do you operate?

I do a combination of things. So I do work with people in my office, which is where I'm at right now. So I do see people in person. I see people virtually as well. And then I also work with people digitally and these are for people who are more or less looking for coaching ways to navigate their healthcare system in their area. Maybe in an area that doesn't have access to myofunctional therapy as. As easily as other areas and really specifically around jaw pain. So helping them through that process. So that is also an option for working with me. Nice.

So how do people access you then, if they are interested in that?

Yeah, so you can always message me on Instagram. I love connecting with anybody who has questions. So my account is at Healthy Healthy Underscore Heads Underscore pt and which I hope you'll put in the notes somewhere.

Yes, we'll put that in the show notes and we'll tag you when we share it on Instagram and all those fun things.

Yeah. And also you can go to my website and you can book straight from my website, which is reviveptct.com so you should be able to book a free. I do free in person consultations. I think it's really important for people to understand and know what's going on with their body. So I do offer free 30 minute consultations and then I also do a free discovery phone call where we can kind of talk things out as well. So I just, like I said, I stand behind knowing what's going on with your body. I think education is power, so I do offer those services.

Amazing. Well, thank you so much. Is there anything that we didn't cover today that you want to share? I feel like we talked about a ton of things.

I think we covered a lot of things. No, I really think that this was very conclusive for, you know, at least the MYOPT blend for the TMD world. So that was great.

Yes. And thank you for sharing that with us. I think it's a fascinating topic, one that just makes so much sense and one that I really hope, you know, people like listen to this and they kind of go like, oh yeah, that's me. I have that problem. Like, okay, now I know where to start. Because I think at the end of the day, like that was the whole reason why I even launched this like way back when was just to bring more information. And initially it was to have conversations with providers and educate providers or get providers on who are in this space or a related space. And now we found there's like a ton of just patients and parents of, you know, patients who listen to these podcasts and who have said like, it's really equipped them with like the questions to ask the providers to look for. And I'm like, okay, my, my job here is done. Not really, but I feel like, you know, like we can keep sharing that info and actually directing people to the providers that can actually help like that. That's the best.

It is. It's the best feeling in the world when I can help somebody or educate them on the questions to ask, you know, people to see like things to even like kind of like look on, you know, their, their website and kind of pick a provider before getting a consult. Yeah, all that stuff. Just so it kind of streamlines things a little bit better. Awesome.

Well, thank you so much for joining me today, Liana. This was a blast.

Thank you so much for having me. I really appreciate I really appreciate the invite.

Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com forward/the untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page page @hallebulkin biz, on Instagram at at Halle Balkan. And you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes where you can also subscribe to be kept up to date on the latest podcast episode.