Episode 197: Dr. Rishita Jaju: The Evolution Of A Pediatric Dental Practice Since 2020

Hi and welcome to episode 197 of the Untethered podcast. Today we have Dr. Rashida Jaju joining us. Dr. Rashida is a board certified pediatric dentist and is the founding dentist of Smile Wonders in Western Virginia. She completed her dental education at Harvard School of Dental Medicine in Boston, Massachusetts and continued to receive specialty training in pediatric dentistry at Children's National Medical center in Washington, D.C. where she was appointed as the Chief Resident. She is now the only pediatric dentist in the Mid Atlantic region who has achieved Advanced Laser Proficiency Certification from the Academy of Laser Dentistry and Breastfeeding Specialist certification. She served on the Council of Clinical affairs for the American Academy of Pediatric Dentistry and Examination Committee of the American Board of Pediatric Dentistry. Besides actively serving the profession as a private practitioner, expert laser dentistry provider, educator, speaker and published author, Dr. Rashida loves going home to her loving husband, active toddler Intuit, her Maltese doggies, Kaju and Kulfi. She is looking forward to traveling all over the world again and has visited every continent except Antarctica. 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. Rashida, welcome back to the podcast. I'm really excited to chat today.

Hi, I am so excited to be on. Thank you for having me. It is always wonderful talking with you, but I feel like this is a little more formal as well for people who don't know.

We do have some shared patience and even though you haven't been on the podcast, I guess it's been three years. We were looking at the calendar and I was like, like oh my Gosh, it's been three years. Episode 35 you were on the podcast and now we've had a whole pandemic since we last spoke, you know, on the podcast together. So I would love for you to share with us. Obviously, since three three years ago, time and a pandemic, have there been any big changes for you professionally as a provider within Your practice, You know, it's a kind of a big loaded question, but I just sit here and I'm.

Like, wow, it's been a while. Yeah. Oh, my gosh. So, you know, the last time we spoke and we were looking up a little while ago was January 2020. It was almost like exactly before the pandemic. Right. And, you know, if I was smarter about it, I would have listened to the previous one and then tried to see if things I can specifically carve out that are different now. But some of the things that come to mind, I feel, I think the pandemic has really, really affected the health care industry. And I always. I am a big believer of looking for silver linings and things. And I say, while the world has been affected in such a way, I do feel like health care has been challenged. And some parts of it, you know, some of our weaknesses came up, some of our challenges came to the surface. And as a population, we have, like, pivoted our services or figured out how to work around some of the accessibility issues and things like that, you know, and unless we are really thinking about it, we attempt to delete the two years of the pandemic out of our mind. Right. And here we are, hopefully post pandemic. And to answer your question, I think our industry has changed, and digital space and being available to our patients in a virtual way has become such a big part. Before 2020, if somebody told me that I would be speaking to my patients on video conferences or virtual consults, I'd be like, you're out of your mind. How does that happen? But since March 2020, we have had to move our, you know, sort of patient care model to incorporate virtual consults so much. Okay. So, you know, throughout the. Even the six weeks that we were all shut down, I had pediatricians, I had some lactation consultants, I had a friend from hospital, from one of the hospitals, because it's like we decided that we are going to have to shut down to control. And at that point, how naive. We thought it was going to be six weeks. Right, right. And then six weeks, my God, if you think about it, right? And so even during that time, it seemed like it was urgent enough to take care of some of the babies that. Because babies are still being born. Right. And difficulties were still there, although it made parents and providers more challenged by the feeding difficulties to find good compensations. How to help babies, how to help kids that were having feeding difficulties in your own way. Parents were home, kids were not getting other support. I'll tell you Virtual services have become so integral part of our care. So whenever, throughout the pandemic and even now, whenever a mom called us, we said, okay, let's minimize the time you have to come or number of times, or minimize the amount of time you have to come in the practice. Looking back, we were like, we want to make sure that you are in our office less than 15 minutes at a time and six feet away. And we will have the mask and everything. Of course, that's no longer our priority. But that made us focus on conversation. Discuss medical history, symptoms, what support do you have? What will you do after? Do you have someone that can help you? Are there anything else? Considerations, optimal timing, all of that discussion, now we front load all of that. We realized we don't have to have parents come out to us with the babies and you know, with their toddlers. The other thing that was really interesting is we could learn the comfort level of parents in their own space rather than sitting on our dental chair. So they were able to. We have ways of guiding them. How do you show me inside the mouth, tell me, have a second adult present. And you know, it has evolved and everything. But we found out that parents are much more capable to be able to help identify and guide if there is any issues that are, you know, they go to pediatrician sometimes. And many times our conversation starts whether they're in office or at home. My pediatrician said, everything's okay. And I'm like, I understand. That's great. That's the baseline. I want an okay baby. I don't want a completely compromised baby. So that's great news. Baby is okay. Let's see where is the trouble now? Let's move to make the quality of feeds or quality of life better. So I think virtual consoles became a big part. The second thing. That was my long answer, right?

I love it, I love it.

The second thing that I feel became a big priority is, you know, previously I feel like few years ago there was such an impact because we were all in like create awareness stage that everybody was like, early treatment right away, do this, do that. That was a priority. You know, a few years ago because we were seeing so many moms and babies not get the support and then they become disheartened and then they don't, you know, the feeding rate was becoming more burdensome. But over the pandemic especially, I feel optimal timing, the concept of optimal timing became so much more important and people realizing that just early treatment is not important, timely treatment is important. So it's not necessarily something where there are many cases where sometimes you can, you know, as providers, once you learn to see for a problem, you can't unsee it. So, you know, the consult times or the assessment is necessity. Sometimes you look at it and you're like, yes, this child's going to need the treatment. Right. But then timing is a big deal. So I feel like our, as a, as a field, most experienced providers are more focused on collaborative team, optimal timing, making sure that the mommy and baby are well supported prior to just doing those clips. Yeah. And the third thing, I guess, that has really come up lately is with more awareness is, you know, you always mature in your message. Right. So there are more people, I feel, that are more aware. There are more moms that are. We're not necessarily running into moms that are like, I've never heard of a tongue tie. Which, you know, you and I know. We've been practicing for long enough where initially when you started practicing 10 plus years ago and you were doing this, you're like, moms are like, what is that? Or dads are going, what is that? We have never heard that. We don't run into those families so much anymore. Right. Like, most people have at least heard of it. Yeah.

Especially with the babies, I feel like. And that those populations, it's, yeah, like our older kids now that maybe we still hear a bit of that. But yeah, our little ones, these moms are coming very well equipped with like, maybe my baby has a tongue tie. And how do we figure this out? And is this what's causing this? And do I need to get the tongue tie treated? And I'm like, well, are there any functional issues? That's a whole conversation.

Yeah, yeah, yeah.

So there are more.

More parents and providers who are at least in the space of is there something. And being more proactive. Right. Like, is there something in the way let me not have my baby or myself struggle instead of having the mindset of, you know, it hurts to breastfeed. This is just a part of being a mom. And I didn't know why I was struggling so much. You know those stories, the.

That was me. That was me. Yeah, that was me eight years ago almost, you know, so.

Yep. So. So I do. And I remember you mentioning that. Right. And I feel like, yes, we hear those, but not that often. We hear definitely more of moms going, I had heard of this, but I never thought it would be me.

Yeah.

You know, and then the whole part about my providers, everybody thought it was a fine baby suck is okay. And then the Impact like the importance of functionality assessment. I think in the last. Don't you agree? Like in the last two, three years we all have become more like adamant about are we doing functional assessments and are we doing this optimally? Are we doing this thoroughly? Because I will tell you some of the numbers that actually, you know, we did a multidisciplinary conference and we had a lactation consultant, an occupational therapist and myself, like present the concept of collaborative team. And why it's not just a procedure, it's a process that the functional assessment became a big part of. You know, don't just say baby is okay. Define okay, baby is fine. Well, baby is fine. Because they are healthy, neurologically sound in their development, they know to adapt. We as humanity adapt. So they are working around something, right?

But how much energy are they putting into compensating and how long can we sustain this as they continue to grow and evolve and things further, things have to compensate now to make up for those initial compensations that had to. I mean, it's a snowball effect, right? And we see that symptoms that it might seem kind of minor now tend to snowball over time into other much larger issues. And maybe not for everybody, but we don't, nobody, I would say no one has a crystal ball and knows what the future is going to hold. And if there are functional impact, there are symptoms now with that mother infant dyad, or just that toddler or baby who's bottle feeding or whatever, then we should be intervening. What that intervention looks like depends on the individual child and family. But yeah, I mean, why wait? Why wait when there's a functional impact now.

Yeah, and I agree with that. And then I think you brought up a great point of how we intervene. So. So there are therapeutic approaches, surgical approaches, medical management versus procedural management. But you know, keeping that eyes on the prize of do we have good quality of life and good growth and development. So yeah, your question was what has changed in the last three years? These three things, my friend. I love it.

I love it.

Yeah.

You know, it's so interesting too because in my practice, like speaking to your first point of really going virtual, right? Tele therapy, telemedicine, assessing over virtual means. We had done a little bit with our older MYO patients and I typically would require they come for an in person evaluation and then we could create a treatment plan and because they were older, we could move to virtual therapy and then we would maybe have them come like once or twice during their therapeutic process to do check ins. And also at the end before we officially like dismissed them from the therap. And parents love that like this again, pre pandemic, they loved it because traffic in our area, in the dmv, you know, back then, it's awful. It's not something anybody wants to have to drive their kid to on a weekly basis. And you know, something that should take you 20, make it 20 minutes, takes you an hour and 15 and you're, it's, it's not feasible. And I think part of it was like we were trying to make it more accessible and more consistent for some families. And I just, I found, I was like, I love it. I feel like the child is not exhausted and they're more on and by the time they drive in the traffic and get to you, my gosh, everybody's just like toast. Like, they're done. And so, you know, when this, when this started to happen with the pandemic and everything, we quickly shifted to, to offering virtual. And I tell people, I'm like, I counted the numbers. We lost 50% of our patients overnight. Because think about who we're working with. We have a lot of children who have different diagnoses and who are medically complex and maybe whose parents work full time and they can't sit next to their child, who can't sit alone at a computer. And then there was kids trying to navigate sleep school and I mean, there was just a lot going on. And so we, but we found with the families who did do it. And then we started to have families call us for virtual who hadn't worked with us previously. I started to really fall in love with it because I noticed a trend of more commitment, more responsibility on the side of the family, really taking on the responsibility of being that therapeutic partner to the child across the screen from us because we were, you know, we're here to guide. And you know, I didn't really consider it parent coaching so much. Like we always have that component in our therapy process. But I was like, this is real therapy, like what we're doing here. Even some of the children took on the onus of doing on their own faces or, you know, interacting and doing things that we maybe would have done before. And I was like, you know what? This has grown us and stretched us as providers because we had to get really creative. And that whole dance of art and science really came together to figure out how to be a effective therapists over a screen. And I know there's research that supports that it's absolutely effective. But I'm like, until you're Living in it. And you're doing it, you're like, oh gosh, like where is this? But what's going to happen?

And you know, one of the, the first questions that we would get is how will she see? How will she see? And the thing is, I trained my team members, I was like, you will show her. Yeah, yeah. You know, empowering the parents and you know, I think, I think their recognition of oh, this is a concern is so much real to them because they are hands are in their baby's mouth or their kid's mouth trying to say, see how difficult it was for, you know, elevating the lip. See how easy it is to do the lower lip even though the jaw is moving and then see how hard it is to get that tongue up away from the floor of the mouth and them seeing it. And then of course we do have the in office assessment. So I'm like, you know, when you come in the office, we will confirm it. I will be doing the digit assessment, I will check their swallow, I will see if there's anything else, if there are any cheek ties, any other parts. But let's make sure that we have done all the pre work before we have you come and you know what has been amazing is being able to do the pre work and feeling by the time, because I always say by the time you come for the procedure, we should be all on the same page. We should have a plan of how we're going to support this baby afterwards or child afterwards. We're not doing considerations. It's not like you're having to make a decision about a procedure in front of the doctor. Yeah. You know about this. I have told you, you have done your part. I have had. So in our office we have our. One of my team members kind of goes through like some educational intake, all of that and then she kind of walks them through. This is how you're going to do. One person becomes the camera person. One person becomes a demonstrator, flat surface, this, that. So she does a little setup. So by the time I am talking to them, parents know where to position themselves, where to sit, where to show me. And then if it is truly a concern, that tells me these parents are going to have a hard time with aftercare. Yes.

Yeah. And we've had parents send us videos, which we were doing even before the pandemic because to your point with getting them ready for a procedure, we don't want anybody obviously going in who's not ready, number one. But we also want to make sure the Parent feels like very confident and not fearful over doing the active wound care. And so based on the provider we were working with once a provider would say, okay, here's the, you know, here's your pre op instruction. Like, here is the act of wound care we want you to do. We would then kind of help step in because we were seeing them weekly and go, all right, I want you to show me. And you know, and when we would notice that they were very apprehensive or they're like, I just don't want to hurt my, my child or the child's not letting them get in their mouth. That also helped us shape our therapy so that we could work towards that goal. Like, we can prep the child all day long to get their tongue ready for release. But if you're not going to let someone in your mouth afterwards, why are we even doing this? You know? Or do we consider sutures? You. It's like that's a different conversation that we need to go back to the release provider to talk to, you know.

And you know, what is interesting is how much we as a dentist, I think we always talk about dental phobia and how parents, emotions kids get. So if you think about pediatric dentistry, you always think about managing the parent perceptions and parents and this and that, because that's how children. Because children don't know to be afraid, but parents are off the energy. If the parents go three times, is it hurting? Is it hurting? They're gonna be like, man, this is about to hurt me. You know, so but in infants or in a soft tissue type thing, we don't, I think we didn't make that as much of a priority of like that getting that parent phobia down of going into your child's mouth. Is he gonna bite my finger? No, your child is not going to bite your finger on purpose, but you have to figure out how to. But. And when parents say, is he gonna bite my finger? How do you brush their teeth?

Like, right.

Is this happening? Like, I, I get it. I get a very good, you know, insight on how they are stabilizing for normal oral hygiene things and then how that is going to translate to management or access. Is the child not even allowing parents. Oh, no, no, he doesn't like lifting that lip up. So we try to stay away from it. Oh, why don't we lift it up? Because there might be cavity there, you know, so those are the types of, types of things that kind of came up more, which used to happen in our office. But it's like us Guiding it now. It's like parents being able to tell us. So, you know, you mentioned something about how, you know, you would do a few sessions, have them come one time, and then before they graduate or before they move on, you have them like a final thing, which is a great, I think, hybrid model, Right? Yeah.

And we offer it still. You know, it's one of those.

That's what I was gonna say. Do you still do it, right? Yes.

I mean, some families are very adamant. They're like, we are over a virtual. We only want an in person therapist. You have some. Somebody available. And I'm like, yes, the team is back. Like, we are fully and we have been for a while. But, like, then you get on the flip side. You have families who are like, I don't want anybody in my house. Or they're like, I have a heated garage. Are you willing to sit outside in my garage with a mask on and work with my child? And I'm like, well, I can ask my team, but no promises. Like, it's winter, you know, it just, you know, we really tried to work with families. We had a lot of families where we were working in, like, external, like outside or heated garage classroom setup type situations because we wanted to bring care to the family still and do in the way that made everybody feel comfortable, whether that was the therapist and. Or the family. Most people, I think, have moved beyond that and are happy to have us, you know, back in the preschools and daycares and homes again. But then just convenience, like, germs aside. Right? Convenience and consistency. Even if a child or parent is sick or somebody, you know, we. We can still offer if it works with a schedule. Since our therapists do travel, we can still offer, you know, a virtual session that week, possibly. Or, you know, we do try and, like, it's a great sol that we really did not take advantage of as much before the pandemic. And I think myself and maybe two other therapists who were doing myofunctional therapy were the ones who did a little bit of this here and there pre pandemic. And then it was like, overnight I had a whole team of like, 22 therapists that were like, oh, my gosh, like, I don't even know how to do this right.

Like, teach me.

Teach me your ways. And I was like, I am not the one who's going to do, like, fun games on a computer. Let me have one of the other therapists on the team teach about that.

I was like, but I can teach.

You how to assess Feeding. I can teach you how to assess for, you know, tethered oral tissues and how to like, you know, work with the families on myo stuff and all.

I was like that.

That we can do. But the rest of it I'm gonna pass on to someone else.

That's true. Sometimes I also now incorporate, you know, how to do an assessment, how to guide parents. What are you looking for? What are the signs? Functional things on virtual as well. And then, you know, what was also interesting, and I don't know if that happens for you, is moving some of these parents and patients to virtual. Opened up office space now for parents and patients that needed to be seen in person. So during the pandemic and, you know, most of 2020, what we would do is my healthy patients, we were seeing them virtually first and then having them come for shorter appointments and things like that. So now that opened up my schedule for some of my special needs patients who lost all their services. Right. So the, the at school they used to brush, but they don't allow me to brush. I had kids coming monthly for cleanings because they were not. And, and I would think is this since last month? Is this the first time?

Yeah, that's a long time.

Yeah. Doing that like, you know, but so we routinely have my special needs patients now are able to come more frequently for services or patient. I shouldn't say special needs. Any patient that need us to be able to see them more frequently for things that we have to be present for are able to come more often because we have this side where the patients that actually, and you know, patients were driving three and four hours before I would, you know, before the pandemic, we would have patients that would come stay overnight because Weston's right across from our office do the consult and I'm telling them, you need to do this, this and this. Or they hadn't done a lactation visit or they needed mom supply was not at the. A place where we could move on. Or they had some asymmetries, some other extra oral things. Now they've driven three hours.

Right.

We are telling them these things. So now they have to go back. I give them, you know, resources and then they have to drive back up. Yeah, that has been eliminated with the virtual part. And then instead of using that time for these type of almost like hard on our heart type discussion, we were able to open up our hours to patients that needed to be in the office to get service. So in a way it has helped both. So the in, in person side of the services have been also benefited because the virtual has supported the.

That's amazing.

That's really amazing.

Yeah, I love that. I mean, I feel like it's. It's really shaped and changed. It kind of made everybody pause for a second and become really creative and like, how do we deliver the best quality care to everybody?

Yeah.

Given all of these very. Given this pandemic and just all these things being thrown our way and so I do feel like there are so many beautiful things that have, like, come out of it and ways that, you know, people's lives have shifted but for the better, where we've all kind of woken up and been like, you know what? It's like it was like this big shakeup in our status quo of just like daily go, go, go. And I think there was a lot of resistance to it just because people don't like, change people. I mean, I don'. But I moved since the pandemic. I mean, here I am. Whoever thought, you know, it's like all these things that, you know, never, I think were on any of our radars and then we kind of were forced in a sense. It was either like, well, we can either stop working altogether and that's probably not an option for most of us, or we, we adapt and we adjust and. And it's really cool to see what's. What's been born out of it. Have you like, changed your. Any methods in regards to like sedation dentistry or, you know, any of the releases even has that. Have you seen anything evolve?

Yeah, you know, you brought up sedation dentistry, which is an interesting topic as well. In. And because we are trying to keep this theme of changes since my last time talking to you or since the pandemic in. During the 2020. During the pandemic time, many providers that were just like, what I would say is like casual providers. I see adults, but I will see sometimes stop seeing children mainly because of, you know, the risk masks and the things that come with taking care of a child. You, you know, the pandemic itself was very anti pediatric, I feel. Right. So the other providers who were my casual, I will sometimes do a frenectomy here and there or I will sometimes see a child here and there. They started referring patients to us.

Us.

We were also in the mindset of reducing the number of times parents and patients have to come in. We didn't know how use of nitrous was going to be okay or not with not being in the, you know, being so close to the child's mouth and all that. So that really brought up a really good part where IV sedation became a good option for many of the patients. And you know, previously we would do sedation only for the most complex patients patients only for this and that. And then, you know, one of the things early on that one of the parents had brought up is nitrous oxide use or laughing gas use is somewhat contraindicated for kids that have MTHFR gene mutation. And MTHFR gene mutation is correlated to tongue tie liptide findings.

I have it. Check all those boxes.

Yeah.

As I was.

Yeah. And as I was going through my, you know, the IVF journey, you know about that. You get yourself also evaluated. I'm like MTHFR gene mutation carrier. I mean, sort of heterozygous, but. But I am. So laughing gas is not as well supported in the literature with risks and benefits of a child that may have an MTHFR mutation gene mutation. But then IV sedation is an option. They can be 100% oxygen support, they can get sedation. They have an anesthesiologist in the office. And slowly it has become a bigger part of my practice because now when I'm seeing my toddlers and when I'm seeing my older patients, we know that why put them through multiple. And I'm usually the one that actually also sees patients that have already had a release before and we want a second opinion or we wanted you to find out. And I'm dealing with, with scar tissue. I'm dealing with compensatory gag reflex, like high, high sensitive gag reflex and things. So being able to offer IV sedation has been a big, big game changer for the population of above 2. But still younger than your 12, 13, 14 year olds. Right?

Yeah.

So kids. So before the pandemic, we would offer sedation. Our anesthesiologist would come to our office once a month during the pandemic. He started coming about twice a month. Mostly because people were not even going to their dentist for regular checkups. Right. So by the time they actually did go, it's like multiple cavities.

Yeah, it's a lot.

Parents also found out that kids were hiding candy or lollipops inside their masks. Oh, how interesting is that?

I haven't heard that.

Oh, my gosh. Oh, yes. So, you know, more cavities and more. All of a sudden I was like, what is sneaky? Yeah, what a side effect. So more. More rampant decay, Definitely. In pediatric dental world, higher levels of decay. Rampant decay, along with, you know, delayed preventive care has been A big part. So the anesthesiologist used to come twice a month. Now he comes three times a month. Okay. Between 2020 and you know, soon approaching 2023, we have figured out ways and benefits of being able to serve more patients in a. Fewer appointments, more reliably rather than. There were many practices. We never did oral sedation, but there are some practices that used to do oral sedation. And then the kids would kind of just cry through it, but they won't remember. We would, we would think. But now parents are more or more providers are recognizing, you know, if a board certified anesthesiologist is present. Dr. Rashida is doing the procedure. I'm not focused on their vitals and things, just focused on administering and monitoring the medication. I have a more stable, safe, thorough environment. So sedation has one of the other bigger things that I feel like more toddlers and more children that may have had a difficult time previously to be able to tolerate a procedure. And you know, you were talking about do we need to go sutures or do we need to do this? All of that is much easier.

Yeah. Well, and so I guess explain for our listeners. I don't know if we really ever dove into this, but like when we talk about like oral sedation, like, like Versed. Right. Because that's what my daughter had at 24 months.

Oh, got it. Okay.

And then I had a local anesthetic. I had shots like into my, my mouth. Right. And then I don't know, I don't think I had additional sedation beyond that for mine. But then there's the IV sedation and then there's also general anesthesia. So I mean, I know that's like probably a whole day course, but like just a very.

You're right, it is a whole day course. But I will tell you that if you go to like Dr. Stanley Malamed, he offers a whole day course on these things.

But I'll give you like, it is.

Like a little bit of a control continuum.

Okay.

So local anesthetic by itself, just numbing the area locally is one way and that is still something that may be required even though other things might be needed. But local anesthetic is utilized usually if you're doing excissor release scalpel. Because the local anesthetic works to reduce bleeding by it's. It's called a vasoconstrictor. It closes some of the capillaries and blood vessels, it shrinks them. So the bleeding control is better if the patient is numb, they're are paralyzed that area is paralyzed. Then their movement is a little less. So local anesthetic, is that. So that's what you had? That's what you were talking about?

I believe that's what I had. Right. And the expectation is, yeah, I could still suction my tongue to the roof of my mouth, but I didn't feel the procedure. And I was not like, you know, I wasn't on nitrous, and I was not, not. There was no IV sedation or intentional anesthesia.

So you were a classic. Otherwise not my completely dental phobic patient. You were okay to sit in the chair. You were not worried about managing gag reflex. You talk about suctioning your tongue to the roof of the mouth. So you were orally aware and you were very, I would say, like an advanced patient that had worked on motorcycle planning and holding my tongue, still being able to position it so that the doctor can release it. For children, sometimes gag reflex management itself is hard. So even if the area is numb and they don't feel it, the fact that they are feeling as if they have to protect their airway makes it hard for them to move. So local anesthetic by itself is okay, but not the most comfortable thing for children. Okay, then we get to oral sedation, or let's actually, before we get oral surgeon, let's talk about nitrous. So nitrous is great option for just my slightly anxious, but otherwise really well. You know, my 11, 12 year olds that are really great, they've done so well with myofunctional therapy. I get very detailed notes from my therapist. We can do this, this, this, and this, this. But jaw dissociation is hard. They cannot click. They cannot do that. And then you ask the child, and child goes, yeah, doing this, this, and this is hard, but that miss so and so would tell me to do this. And I can do this well, but you can hear that lisp in their voice. Those kids, beautiful. They just need some help. It's called anxiolytic, meaning it brings the anxiety down or anxiousness under control. It's not sedative. It doesn't make them fall asleep. It doesn't change the reflexes. It just helps with anxiety management, which gives them better oral control. So with nitrous, you do some topical anesthetic if you have to, because with the water laser, I don't have to worry about shrinking or injectable local anesthetics and stuff or, or bleeding. So I can do topical and nitrous. Great. For my younger ones, you know, when we Call them pre cooperative or you know, between, especially between three and eight or something. The kids that are just going to be threatened by somebody being in their mouth and obviously anything that is more than slightly uncomfortable. Yeah, those are the kiddos that would benefit from sedation. Especially the kids that need to be in our lapse to do a good exam. Yes, sedation. So then we go into the types of sedation. Right. So the oral, oral sedation is where you give a child something to drink and you dose it based on their weight and how long you expect that the sedation should last. And it has to go through your digestive system, go through your liver, then cross the blood brain barrier and then the sedative comes. So there is a little bit of a on time. So that's why you start checking for vitals early on. You go a little bit earlier and then the therapeutic window or the therapeutic time is a little bit also based on how well your body metabolizes because you can't really give another dose because we have to worry about therapeutic dosage and you have to worry about making sure that we are not overdosing with the oral sedation. So you will also notice that the providers that do oral sedation also use a papoose or something to stabilize the child because they don't know whether that oral sedative is going to be as effective throughout the time that we need to work on. It also is not as strong to eliminate reflexes to pain stimuli. So that's oral and usually with oral most providers also use mitrosun. Top what we offer in our office is anesthesiologist that comes for IV sedation. So IV is, IV sedation is similar to what we would do if you go for wisdom teeth extraction or you know, if you get any gynecologic procedures done, colonoscopy, things like that, where it's twilight sleep, you are breathing on your own, there's still not a tube or anything. Sometimes depending on your on your health of for adults they do some oxygen support. For kids we always do 100% oxygen support so they have that additional way of managing their airway. Initially, many people, many providers would start with a little intramuscular just to get the child sleepy enough. And then they look for IV so the child doesn't have to cooperate to look for an IV site. They're already asleep by the time and then the doctor has, has control over titrating the medicine up or down. So that's where the safety comes in. Because if there is, you know, Oh, I thought I needed to do this much work, but I saw X rays needed more work to be done. The doctor has the ability to continue to manage the flow. It's not like, you know, we gave her once and done. We were expecting only 30 minutes of sleepy time. We have to do another visit it. So with IV we can manage. It's intravenous. That's what IV stands for. So intravenous. And it goes up and down. You can manage. And then I feel like that is the most like kindest, safest, thoroughest way, especially if it's two different providers that are focusing on the child. The, the. I guess the last form of sedation slash anesthesia is what we call general anesthesia. Usually it can be offered in some, some places in an in office setting as well. But more and more providers are getting away from that just because general anesthesia is either done in a surgical center or a hospital. My kids that have history of epilepsy, bleeding disorders, breathing disorders, cardiac conditions, those are the kids that I have, I recommend that they get general anesthesia in a hospital setting with a tube through their, through their throat. Who is managing their breathing? The machine's breathing for them. They are not anymore. So that's paralyzing and anesthetizing, not sedating. And so gel anesthesia is cleft of impellate patients sometimes whose airway is going to be compromised. Anybody that we think is not healthy enough to metabolize or their drug reaction, reaction, you know, managing the drug impact is then general anesthesia patient. So iv, There you go. You got a course on the different sedatives or different versions of getting some cooperation or making it comfortable for the kids.

Thank you. Yeah, that was helpful because I think that a lot of not just parents, but therapists are like, I'm not really even clear on what's being done. And I'm like, well, this is a conversation like I know you and I recently, like not so many months ago. It's like, okay, what's the latest and greatest? Like, what are we doing in office? What are we offering parents? Just because we're not going to educate the parents on that. But I'm like, we should know because the therapists will come to me and we do a lot of collaboration in our practice, even amongst the team. And so we'll, we'll talk about cases and next steps and a therapist will come to me and say, oh, you know, Dr. Rashida, you know, their office referred this patient and we're going to, you know, we're Getting them ready for their. Their release and everything. And I'm like, okay, well, what are we working towards? Like, are we thinking, like, what a doctor. Like, what did her office say? Do they say that we're thinking they may need a certain type of an anesthetic? Do. Are we talking sutures or no sutures? Like what? Like, I don't. What are. We don't know what to work towards or help the family with if we don't have all the information. And that's why I was like, let me get on the phone. I feel like things have changed. You know, even though I'm not treating this patient, let's, like, let me chat with you and find out, like, what's the latest and so that, you know. But that's so helpful to have those conversations and obviously to have a provider like yourself who's so, you know, collaborative and who really does want to communicate with every single team member to the extent needed so that we can make sure we're providing the best for these. These families. I know that's not always the easiest thing to, one, find a provider who does what you do, and two, who is willing to collaborate even though they do what you do. So, first of all, thank you for that, because I think that really, it brings the best outcomes for everybody.

Thank you. And, you know, I know you thank me, but I have to thank the team because like I said, I think it's a procedure that I can perform, and it is my responsibility to do it completely safely, thoroughly. But then how that procedure translates to proper function, because they have been adapting all this time, and now we have to train them to really, you can do this better. You have to do that. So when you or your team reaches out to say, how can we help prepare towards a procedure? I'm like, thank you, you. Because now the procedure is going to be more successful, because what I do can be successful anatomically. There was a restriction. There is no longer a restriction. But then is it successful functionally will come only by working with skilled therapists who help kids translate the abilities to skill. Right. You know, how many times do we see kids that parents go, well, if you ask him to say say R, he can say are okay, but he cannot say the words that have the ra sound in it.

Okay. You're like, well, how is that functional? Right? Like, let's. Let's discuss this a little bit.

Yeah, but he can say R just fine. Okay, so what is the problem? You know, like, I. So sometimes the difference is, is the child able to do Something, or can they do it without having to put their thought process some things. If we are constantly thinking about all the involuntary things that we are doing, how compromised are we and how can we do function the other way? So breathing, eating, sleeping should be parts of life that we shouldn't have to put resources towards doing Those things are restorative. Breathing, sleeping, eating should be helping us, us function better. But if we are having to work to breathe, sleep and eat and can help and I. You guys can make that possible. I can provide. Excuse me, I can provide the abilities. But I do know that a skilled therapist is going to make that child now use their lip, tongue, mouths better. Yeah, no, it's both ways. We can have a mutual, mutual admiration. It's fine.

Absolutely. Absolutely. I'm so appreciative of that because it's like, it's one of those things that I preach so often on this podcast. Like, everyone comes on and I feel like a lot of the conversation tends to cycle back to best patient care, collaborative team approach. What is the optimal time of a release if we're headed there for this patient? And, you know, I'm like, one of the things that I stand by is families who are like, well, why are we going to do this therapy if we don't know if we need the release? And I'm like, because this therapy is necessary whether we're having a release or not. A little bit if we're headed towards a release to help you prep for that procedure. But we're also, especially for, like, the borderline cases and like, sometimes things appear to be a tie, but there's other things going on that kind of mimic a tie. And we're not, you know, we don't want to do a procedure if we don't have to, but also if it's necessary and, you know, recommended after we spend some time together therapeutically and we're not really making progress. That's a different. That's. That's that conversation. Okay, let's. Let's have that consult or, you know, you know, move forward having followed that initial consult. And I love that you brought up the speech side of things, because these kids who have been in speech their whole life, when I say whole life, I mean, like, you know, they're 12.

Their whole life, they don't know life outside of having to go to therapy.

And I'm like, has any. I mean, and. And the parent says to me, nobody's ever looked in their mouth like that. Nobody's ever asked them to move their tongue like, that or maybe they had them, like, wiggle their tongue around and stick it out. But, like, nobody's had spent an hour with them asking me about all these things and reviewing this intake. You had this very thorough intake you had to spell out before we ever saw you. And, you know, now I came for a speech eval, and you spent maybe 10 minutes on speech and 50 minutes on all functions. Right? And I'm like, well, yeah. I mean, I'm also gonna probably venture to guess that you may not be chewing and swallowing your food properly. You don't know that you. That's a problem for you. And that doesn't have to be like, our initial conversation right now, But I'm gonna tell you, we see a lot of consistencies and patterns amongst children who have oral anatomy that presents a certain way. And it's. You know, I think the biggest struggle for me is that my profession seems so split down the middle on this topic. And to me, I'm like, don't you want to help the child sitting in front of you? Do we want to keep them in therapy for the rest of their life, coming back on and off for 12, 15 years? And then even as adults, they come back. Because then it's like, if you have to speak for your job and you have a lisp, and, you know, it blows my mind to see how our approach can help these children and how quickly it helps them be done with therapy. Right.

Versus that's the whole thing. It's like the definition of impediment is not there. It's only if you are diagnosed at speech delay, then you feel like some people will be like, okay, let's try to help. And then also, I think I have heard mostly people try to, like, provide diagnosis, and I'm like, apraxia, when that comes up, I go, okay, I think that might be there. But I also see that the mouth is just not functional.

You know, one of the cornerstones. One of the cornerstones of being a speech language pathologist. Okay, is that we are supposed to differentially diagnose and to see how overly prescribed the term of childhood apraxia of speech is. I'm not downplaying it. It is real. It is a real thing.

I agree.

But I have seen a lot of kids come in with autism. I've seen a lot of kids come in with apraxia. I've seen a lot of kids come in with a whole host of different diagnoses that, guess what, a year later, after working with us, they no longer present as a child. With any of these diagnoses. And I'm going, huh? You know, I just feel like they didn't have that differential diagnosis with anybody prior to coming to see my team. And that's, that's the thing that just gets me, because parents, parents like dying a slow death when your child gets a diagnosis and trying to make sense of that. And, you know, I'm not, I don't look at children who are diagnosed with something as having anything wrong with them. I look at every child and I've always said this to parents, regardless of what title diagnosis, anything you receive for your child, I'm going to tell you something that looks different in every single child. It does not mean anything. Please stay off the Internet. Like, we will help you navigate the resources that you and your child need to help you move forward, but there's also, in my opinion, nothing wrong with the child. It's our job as adults to figure out how to get down on their level, how to communicate with this child. And it's not our job to make them verbal communicators if that's not where they're headed. It's not our job to, you know, say they need to have social skills if that's not where we're headed. And there's a whole, this whole, you know, movement right now with looking at neurodiversity very differently than we did even five years ago. How to get down on their level, how to communicate with this child. And it's not our job to make them verbal communicators if that's not where they're headed. It's not our job to say they need to have social skills if that's not where we're headed. This whole movement right now with looking at neurodiversity very differently than we did even five years ago. And being a neurodivergent adult with ADHD who was, who's had a whole host of my own, you know, history and everything.

Very well compensated, right? So very well compensated, Very well compensated. And a lot of times you will find that more of us are going to then have, you know, I think I have those symptoms or I think I have had to work around those, which makes us even more empathetic with our patient population. Right?

And I tell parents, I'm like, a diagnosis can be great because it can help you get insurance, benefits, benefits. So let's not, but let's not let it, like, take over our life.

Let's, let's use it to get the resources right.

Let's use it for that.

Not use that as a barrier to getting out of it, you know, like outside of that box. Yeah, yeah.

And I know I'm not downplaying either how a parent feels or the journey they go on because I've talked to a lot of parents, friends of kids who have different diagnoses and it is a life changing thing that they never anticipated or expected. And so I'm definitely not downplaying that from the parent side of things. But I think that the way that our medical system approaches a diagnosis, like you hear a child has autism and.

Someone doesn't want to see the kid.

And I'm like, wait a second. That doesn't tell you anything about this child. Like that's where I'm going with this. I don't want to be like misconstrue what I'm saying. It's that we really need to look at who the child is, how, you know, and maybe they're not the right provider for them.

But that's exactly what I was going to say.

Can we meet the child? Can we see if this child is someone that is going to walk into our office and connect with us and that maybe we can work with them because there's such a range of neurodiverse individuals out there, we don't know who the person is based on a label.

You are so right. And I think that that can apply to more than one field. Because you know how you said if somebody doesn't deal with autistic children. Great. That you know that because. Yeah. You shouldn't be. Yeah. You know, because you will have recognized that you don't have the skill set to be able to cater to those but to be able to say I don't work with them. But here are. It is incumbent upon us to have resources to send them somewhere. You see what I mean? I don't do orthodontics in my office. Yeah. Because I am busy with. My skill level is. Yeah. Ask me my specialty. Right. But parents ask me, I, I take n number of hours of continuing education and things like that for providing comprehensive feedback. Right. So I will say I don't do that. But I can give you some names of providers that we have mutual patients with or I, that I have met in a CE event or that you know. So saying that if acknowledging that this is not my specialty is. I give you that. Right. I give you as a colleague, I give you respect to say yes. However, I do. And I think both of our alarms are going off. They've been talking for A while. But I do think that one of the things is I don't want to step in and just do something. And I hear this a lot and some of my ENT friends, I have friends that are ENTs that I debate date with. Yeah, this mom really wanted me to do it, so I took care of it. But I think, Rashida, you. I might have to send them to you because they have to. I feel like there might be something else going on. Why did you do it?

That's. Yeah. How about like we're not doing this today. That's.

Don't we have an ethical place where I don't feel so that's where I, I feel like it's a double edged sword some sometimes you dismissing that I don't see a problem is different from I don't see a problem. But I know you're having a hard time. Let me send you somewhere or I don't take care of kids that have autism. Kids that have autism. Yeah, Right. Versus saying yeah, you can't come here or you know, I don't see that.

It also goes back to the collaborative care model and being a provider who knows where to refer, who to refer to, which patients are in your realm, which patient patients or not. Because, you know, yes, I were, you know, let's say I work with kids with tethered oral tissues and myo and I do infant feeding, but not everybody on my team does. And so we do. I'm even seeing this in my profession where people are like wanting to get into it but not taking the proper courses or getting mentorship and they think they're just treating tongue ties and babies. And I'm going to second, like if there is one population you should not put your hands on if you don't have experience, that is tots babies. Like let's, let's just put that out there, you know, and, and now we're seeing a lot of hygienists start to step into treating, you know, tether or tissue babies and calling it active wound care and pre op and post op. And I'm going, okay, pump the brakes again. Because that is feeding therapy and like that's a whole nother episode. But it's, you know, I've talked about that before, but it's, you know, it's definitely prevalent across certain populations. And I just think, you know, I'm like, as a provider, I hold myself responsible for my choices and I also feel that I have an ethical responsibility to, to my patients, myself, my profession, you know, it's And I'm like, where do we get? I just felt, not we, but, like, so many people have moved so far away from that just in. Under the guise of trying to be helpful or. Or help that patient or parent that's sitting in front of them. In that moment, I'm like, you are doing more harm to them than you. That is. You know, that's kind of like the.

Point there, because it's that false, false sense of, I took care of it. Now my still. My baby's still having a problem.

It's like, we didn't really take care of it. And I'm so sorry to be the one to tell you that we're kind of starting from ground zero here. So.

Yeah, and those are the conversations that have actually also increased in the last three to four years, honestly, because, you know, during the pandemic, many of us and many providers did take some of these CE courses and did take some of this. You know, you'll hear many providers go, during the pandemic, I had my team get trained for, blah, blah, and you'll see, you'll hear that. So now there is more of that going on. But then. Did you really.

Yeah, yeah.

Well.

And also to that point, I'm hearing a lot of, oh, but they're teaching feeding in dental courses, and they're teaching this. And I'm going, okay, one, who taught it? Because if it's not being taught by an actual feeding therapist, like an SLP and OT or maybe a PT who's highly qualified to do feeding, okay, fine, basic information can be shared, but who's teaching it? And two, just because you learn something does not mean it's covered under your licensure or scope of practice. And so, you know, like, I've had dentists take Feed the Pete's because they are on my collaborative care team, and they want to. And I love that, because they want to learn and they want the education, but they're not turning around and doing feeding therapy by any stretch. I'm like, these are two very different. You're one of them. Yes. You are one. There's been a couple others. Yeah. So, you know, I'm like, I highly value professionals who want to learn and I don't want to stop them. And I think we all can value learning other professions, you know, so that we know who to refer to and we understand the conversations that we're all having with each other as professionals even, but also realizing, like, let's stick in our. Let's stay in our own lanes. Like, like, you do like I do like or scope.

Yeah, yeah, yeah, yeah.

In our own scope and yeah. So anyways, was there anything else that I think the only other question that I feel like I have to ask you because it's like one of the questions that just always comes up and everybody wants to hear everybody's opinion on is, has anything changed regarding your perspective on like using scissors versus like laser? For what? Is it patient based? Is it that you prefer your waterlase to scissors, you know, sutures versus not like is. Is there a preferred method that you have?

Great question. So I think the preferred method is a very provider skill level specific. Are there really good providers that have used scissors for years before the lasers were around here? Really? Even. Yes.

Yeah.

However, in my hands, in my experience, if my laser is down, I'm rescheduling patients. Okay. Because that is my expertise. I personally think the. So the biggest difference between how scissors or scissors work versus laser is say for example, this is the site. Right. This is the tongue. This is with scissors, you have to child's moving, you're estimating how far to go. There are things around things, meaning blood vessels and. Yeah. Anatomy things, all the things with the laser. The great thing is, and especially with the water laser, it has a penetration depth of 3 to 5 microns. So it's cutting or removing or ablating. Rather my water laser colleagues would be like she said, cutting, but it's ablating few cells at a time. Right. And everything else is an air, water, mist. So it's almost like it is cutting, removing, ablating this way. And I can sense and check where the, how the tongue movement is if the child's moving. It's almost safer for a moving child to have a water laser or a laser procedure because the laser beam penetration depth or surgical depth is few cells at a time. Yeah. Versus a scissors or scalpel cutting. Yeah.

I mean, and it seems, I mean from what I've heard too, just, you know, once there's also a lot of blood, it can be hard to visualize exactly that component. There's more control with the laser. And I will tell you, I'm not going to throw any names out there, but I have a number of adult colleagues who have had functional frenuloplasty is done by highly, highly qualified individuals who are like within a year they are back to where they were when they started.

And so that's another thing. So with the laser, you know, it has that. So the penetration depth of a blading is the surgical part, but then the laser Effect is going further, deeper. So it coagulates, desensitizes, and then releases. So, you know, if you're teaching, when I teach laser, laser dentistry courses, I show like little circles of effects. And so it's first circles cutting. It's like almost like looking at like a hair follicle, like the first layer, then the second layer, then the deeper layer. So it's cutting or ablating, fuse microns. But then it is coagulating and desensitizing. And so that's where the laser analgesia or the laser. And it's not called anesthesia because it is not numbing, but it's called laser analgesia because it's desensitizing and taking away the pain. In my mind, a laser release seals the little capillaries before it releases the connective tissue. And when it releases the connective tissue and at the end it seals that tissue as well. So the chances of the dreaded reattachment are so much less. Right. The sutures you brought up, I know we talked about sutures a couple of times and there is a different thought process about it too. With the laser release, we are looking for healing with secondary intention. We want the site open. We want it to heal where we leave the tissue sometimes. And the reason we want to make sure that it remains very mobile and functional is because we want those epithelial cells and connective tissue to come at the right time in the right layer, rather than come back to what it is. If you leave, if you do a very biologically friendly release, your body is going to feel like, I want to go back to what it was, goes right back. When it comes to sutures. Sometimes for my toddlers that I have to do sedation for, I actually also place resorbable sutures there just to kind of help them further hold where it is. Just knowing that their level of wound management is sometimes challenging by, you know, because there is another adult doing in the mouth, right. So. But I tell parents, you still do as if it was laser release done and as if it was no sutures there, because my laser benefits, benefits are still there. I'm still using all the benefits of doing that release and holding and putting that tissue where I need it to be. So do the functional part right away. Next day onwards, start doing those exercises because we want that tissue to start healing right away with a scissor or scalpel release and then us putting sutures. Sometimes I have my therapist go, but my other doctor said, if it sutures a place, then don't touch the it for a while. It's because they didn't have any of those sealed tissue, their blood vessels and things like that. And they're worried that if you manipulate that area, it's going to open up those capillaries or the sutures are going to fall out or the, the bleeding is going to ensue. So that's where some providers will say, don't touch the site that has sutures because they're worried about he management or bleeding management. And that's why they say, don't touch it it. But in our release, I don't, I tell parents to do right away because I know that the laser effects have helped with managing the biological field around the site. So that's the difference in my mind. And honestly, I do feel like there are so many different ways of getting to that one spot. But we are in a modern world. We have the best technology available. I don't want to say there are things that we used to do so many years ago that were like, oh, man, I can't believe they did that. Do we want to be a part of that ancient history or do you want to be a part of the modern world with the modern technology to help it?

Yeah, well, what, and what about scar tissue? Like, because people come to me, yeah, like scar tissue. Isn't that a concern? If we use a laser versus, you know, scalpel? Is not my scalpel better? And I'm like, I'm not a doctor. Go ask your doctor. I don't know.

They think it's the scalpel is better.

I'm starting to hear. Starting to hear that? No, they're starting to hear that the other, the scalpel is better. And I was like, I thought it was the opposite. I was always taught, oh, I see.

Where that might be coming from. So within lasers also, there are multiple different types of lasers. So the scar tissue comes with, if it is a trauma to the site or heat buildup or therm, what we call thermal damage. So sometimes if there are providers that are using diode lasers and they haven't really managed the site as well with like thermal, what we call thermal relaxation or allowing the site to kind of not build up that much heat energy, then the scar tissue might be something because then your body is in overdrive trying to protect that tissue. However, a laser or a CO2 laser or water laser and things like that that are actually protective against scar tissue. So a laser release is less likely to have scar tissue compared to a diode or scissors or a couple Release with sutures. So I am surprised that you heard, but that I can. I'm not that surprised. Now that I think about diodes. I don't think about diodes as lasers. That's why.

Well, and I think, you know, you get into like Facebook and Instagram and people start throwing things around. And while there's so many variables that you're not telling me with this question that I don't really like, and it's first of all not in my scope to even answer, but I'm like, I don't know where you're getting this from, but I've heard this. And I'm just like, where is this stemming from it? So that really does make a lot of sense. So thank you for clarifying because I know our listeners are gonna be like, oh, my gosh, that's so helpful.

Diode lasers don't have the air, water, mist and the, you know, that the CO2 and the water laser has. And I think even with CO2 lasers, some models have it, some models don't. So sometimes. But I honestly think that as patients, shouldn't we be able to trust the provider? Yes, we should. We should be able to trust the provider. And as provider. So I'm a mommy, I have to get things done for my child too. And sometimes, you know, there are a number of things that you'll find on the Internet and it's great. Do I Google search everything that I get for myself and my son? Yes, obviously. Or my husband, honestly.

But.

But at the end of the day, should I feel like I can ask my providers the question and they should be able to give me clear answers that I can understand? Yes. If my provider cannot answer that question or you feel like you have to go on Facebook to answer that question, we have failed as providers because Facebook does not know the comprehensive reason why a particular diagnosis is going to be there. Yeah, you know, there was a joke where, you know, you can talk about backache and this and that, and the first question, first thing that will come on Google search is muscular dystrophy. Yeah.

Yeah. I mean, it's like you Google one thing and all of a sudden you.

Have like your mind, like, you know, the most invasive, most global something comes up, up, and in your search and then you are worried about, oh, my God, does my child have that? Wouldn't you be able to, shouldn't you be able to ask your provider, do you know about your laser? What did you do? How have you, have you done a two day course that a sales rep gave you to be able to run this or did the little trial or versus you have done your research and you have done your training and how many years of experience do you have? I don't ask somebody else that. That. We all, as providers either should have this information readily available for you or be able to defend our experience and expertise. If you ask us the question. Nicely.

Yeah, nicely. Exactly. Exactly. That's a whole other conversation. Yeah, yeah. Oh my gosh.

It's really funny because a lot of the times I will have dads or I say dads. I love dads also. My husband is one of those interesting dads. Right. But anyway, they'll be like, yeah, yeah, whatever you say. I. I walked in the office, I saw you went to Harvard. And so great. Let me tell you, I didn't learn anything about this during my Harvard education. You know what I mean? Like, okay, I am. And I make that joke. I tell them, I said, I always say it's great that that helps you build trust and confidence in my capabilities. But they taught me none of this. I learned all of this after my Harvard education. You know, what I got from Harvard is probably an open mind to learn to continue to be, you know, give back to your community and, you know, don't just like have a private practice and do this, be in academia, teach, organize dentistry and all that. Yes, I got that mindset from there. But I learned more about like cusps on a dental like a model while I was at Harvard. Overall medical like health and all of that because medical school and dental school are together at Harvard, like the class size was small, so I got all that. Infant oral health. Learned a lot after.

So this is infant feeding period, pediatric feeding zero. Adult dysphagia. Yes, got lots of that, that whole course. But pediatric, like any pediatric, none. I mean, no tongue tie, no. Oral motor was kind of like, here's all the articles that oral motors like, you know, and so it's non speech. Oral motor exercises don't work. And I'm like, well, that's not what we're talking about here. This is. Okay, all right, forget it. All right, move on.

Just as like a little aside, you know, one of the things that I did, did learn about freedoms in my dental school is that freedoms become a problem when you are trying to make a denture for a patient because they don't allow for good retention. When there is all these freedom tissues or freedoms are a problem because they cause recession of the gum tissue. So mandibular frenum releases were actually something that I learned about during my periodontal studies in dental school. Interesting. Mandibular is actually such a small part of my day to day everyday impact on feeding mandibular labial freedom. I don't see that often that I have to treat those usually. And that's why, you know, in the. When they say old school, they think freedom is so rare. I don't understand why all this. Because mandibular labial freedom causing recession is still that rare. It's not common to see that. You see it, but you don't see it commonly. So unless they're looking at the other parts for other things, they're like, I don't know why they're looking about all this. Because they're thinking, yes, that makes sense.

I mean, you know what? You know, right. So. Oh my gosh, that's so interesting. But yeah, you're absolutely right. I mean, we see more. So the tongue and the maxillary.

Maxillary. You don't see as much of the mandibular labial freedom. So much it does. I do end up having to see a handful of them, obviously every year. I do notice those, but. And we always look for and diagnose and I want to make sure I'm doing comprehensive. So if there is anything else, I'm.

Taking care of it.

But at the same time, the percentage of times I have to take care of the child cheek ones or the buccal ones is even higher than the mandibular ones.

Wow.

You talk to any prosthodontist that sees older patients that are going to get implants or dentures, they'll know all about cheek freedoms and buckles and all of that. You know, there's so many.

They do releases in order to like accommodate dentures. Oh my gosh.

Yeah.

Just Open up a whole new world for me. Oh, fascinated by this.

Yeah. You have all these ents and all the, you know, medical providers that are not dental in the dental world who are like, well, cheek freedoms and buccal ties should not be released and blah, blah, blah. And I was like, what makes you say that?

Yeah.

What is your thought process on this? Like, why are you even chiming in? It's like me saying something about. About larynx. No. So, you know, those are. And I just look at that and I just go, okay. You know, everybody has their perspective, I'll do mine. And this is my way of giving back, of helping spread the word helping. Because when I hear parents have heard this misinformation or lack of disinformation already, then I'M like, well, I didn't do a good job of providing good information.

We know you do a great job of providing good information, but you know, you can't help them all. So sometimes we just get. And sometimes that's the patient side too. There are sometimes patients where it doesn't matter what you say, what I say, what the next person says, they're looking for something specific or they have their own agenda and we all do the best we can.

True, true, true. So I feel like we chatted.

I know we could chat all day. This has been so much fun. So much fun to come see you when I'm back in the D.C. area.

You have to. And we have to definitely. We have to do something that makes it more professionally relevant and then just hang out. Exactly.

Well, thank you so much for joining me today. It's been so much fun.

You're welcome. So good to catch up and so good to share the Cannot believe this is still happening.

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 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 at Halle Balkan Biz on Instagram @hallebulcan. 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 episodes.