Episode 263: Breathing Easy: Link Between Orthodontics, Speech & Health wi

Hi and welcome to episode 263 of the Untethered podcast. Today we have Dr. Svetlana Koval and Tiffany Zilberman joining us. Dr. Koval is a leader in airway Orthodontic treatment, being the top Marpi and MSC provider in Florida. She's a researcher with more than 30 published articles and a book chapter on T scan, digital analysis and orthodontics. She's graduated from Boston University GSDM in 2020 with Megan Cum Laude and she's received her Master of Science degree in and orthodontic specialty in 2010. Tiffany Zilberman is the owner of Little Eaters LLC and Infant and Pediatric Feeding and most recently Myofunctional Therapy Mobile Practice. She's a graduate of Feed the Peas and is now completing the MYO method and hopes to complete her CMT as she began seeing more clients since opening There is a huge need for treatment for orofacial Myofunction disorders and decided it was time to take on another amazing treatment skill with Myo. She's super excited to be joining Dr. Koval to be an in house myofunctional Therapist and improve patient outcomes and care. 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 myofunctional therapist, feeding specialist, podcaster, business owner 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, Airway tether, Dural tissue and Pediatric Feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019. Thanks for being a loyal listener as we jump into today's episode. Remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Doctor Koval and Tiffany, welcome to the podcast.

Thanks for having us.

Thank you for inviting so I would love for us to just jump right on into talking about orthodontics. There is this question that we get all the time surrounding the ages. That's appropriate because you know, we know things are changing, but we also know what traditional ortho means in the traditional ortho world so I'm going to turn this conversation over to you, Dr. Koval, but I would love for you to speak to us a bit about, you know, orthodontics, ages and even share with us, you know, what ages you treat.

As we all know, Hallie, it's the conventional approach and well accepted approach that children have to be seen starting age 6, 7 when we have early mixed dentition with a permanent teeth erupting. And this is the most common time when parents start thinking about orthodontics or at least a checkup for their children. They might not notice anything that's happening and they might not recognize any developing malocclusions. But that's just the right time to start. We have expanded that and we have moved that early timing for the checkup maybe down to three years old, sometimes even earlier. We have a lot of children in our practice that we see at the age of 3, 4, depending on their response and depending on how well they respond to our instruction. So this is the best time for us to understand if the child is ready and we can at least have an overview and we can at least guide the parents and what is happening, what is developing within the system and if any intervention is needed at that time, that's fantastic.

I always get excited to hear that expansion is starting at 3 these earlier ages because it's very hard to find somebody. And I know you're in the Boca area, but both of you practice here. And when I first moved here almost three years ago, it was impossible to find anybody who would even help my almost 6 year old. And they were like, come back in a year. And I was like, what do you mean come back in a year? She's in first grade, why would I come back in a year? She's already had some early expansion. We need to continue the process. She's a compliant kid. We're not even new to this conversation. And they were like, oh, when those front two lower teeth fallout and she had like shark teeth. It was a whole thing. So I always get very excited when I meet somebody who's nearby and who gets it and is very, you know, airway centric in that. In that regard. Isn't it true too that there are really, you know. Well, I'll let you speak to it. But what about adults? You treat adults as well. Is there any upper limit on the adult side of things?

Yeah, we are proud to say that we are one of the most experienced providers. Our practice is the most experienced provider for Marpi and MC treatment in Florida and that we're advancing our knowledge and our skills. And we do our own research based on what we see and based on the digital workflow that we have in our practice. And that sets approximately, I would say, no limits for age, no age limits for our patients in order to expand and improve their airways. So the treatment that we offer, the so called Marpi and MSC treatment, is the treatment that is focused on expanding and physically improving the space within the nasal airways. And that is usually followed by advancing the mandible and moving and I would say reconstructing the whole mid phase. There is a bonus of a very nice aesthetic outcome where the midface is becoming more prominent and when we have very nice response from the skin, from smoothing our, our natural folds on our skin and when we are achieving even beauty and aesthetic results relative related to our airway intervention. So this is the two way road and I've started a very nice book which is called Gasp by Michael Gelp. And the very first, I would say 10 pages, they say that the natural beauty to a person is the reflection of their airway health. If you see very nice symmetric proportions, if you see the face that is, that has prominent lips, that has prominent cheekbones, it means the jawline, it means that the airway dimensions are well developed in this person. So we have noticed that evolution and the way of consuming, the way for us to kind of switch to processed foods has diminished the usage of our chewing system and our facial muscles. So that has a direct contribution to the development of our bones within the face. And it's not the bones that define how muscles work. It's the muscles that define the shape to the bones, their development, their remodeling. And I am a very honest follower to the paradigm where when the bones tend to remodel within the lifetime, and especially the condyles, when we can move the mandible forward and we can actually develop and move the whole condyle, fossa relationship and this complex forward. Not even, not even using the orthogonal surgery, because that is kind of overnight approach and that also needs a lot of rehabilitation around it. In my understanding, orthodontics is a more natural approach, even though sometimes we really need orthodontic surgery. Some cases would benefit definitely from orthogonal surgery, severe cases, and some cases that have limitations. But orthodontics nowadays has developed approaches that can sometimes exceed what orthogonal surgery can do, just because it's a more elongated, more natural, more adapting approach, spread out within longer time than just one time, one day, one night intervention.

Yeah, no, that's interesting. And I hadn't actually thought about it through that perspective of orthodontics, maybe being able to achieve not just different results, but maybe greater results than what you can achieve through the orthognathic surgery. You said that. I was like, oh, it is like one point in time where you're basically doing a surgical procedure and then everything's kind of locked in. So. Yeah, and it is a lot of rehabilitation, for sure. The other thing you mentioned too, about the soft food diet, the American Standard Diet, for example, and Tiffany, maybe I'll have you speak to this a little bit, because I know as a feeding therapist and a myofunctional therapist, I feel like this is such a thing that we come up against so frequently with the patients that we work with. Are you. Do you see a lot of soft foods in the patients you treat?

Totally, totally.

It's.

This is how I feel that I. I was here not too long ago on your podcast talking about feeding therapy and myofunctional therapy was in the background. And I was like, I'm gonna get there very soon. And everything just fell into place super fast. Because the more patients that I was seeing, kiddos I was seeing, it's all connected. There's so much connection. There's so much connection between the fact that they're not chewing appropriately, that they're not progressing in their foods the way that they can. They're open mouth breathers, they. They have high vaulted palates. The parents are asking me, where should I go? Like, who do I even go to? And Now I have Dr. Koval that I'm working with so closely. And this is, I feel every parent I'm speaking to is like a parent's dream come true. Where the bridge orthodontics, airway orthodontics, and myofunctional therapy and the communication between the both of us that we already have a relationship, we're already working on several cases together, and parents want what's best for their children. They want it to be that it'll be holistic and across the board, everyone's on the same page. So I'm so happy that it's. The two are merging and that the problems and the things that I'm hoping to treat through feeding is also being treated with myofunctional therapy and airway orthodontics when we're working on it on a physical plane.

Yeah, absolutely. So. So I'm curious to hear now that you started working together, because again, this is not again, but this is one of the other big questions we get this sequence of therapy or the sequence of orthodontic intervention. You know, people say, well, what comes first? Like, which one's the chicken, which one's the egg? Where do you go first?

Do you go.

Do you have the braces first? Do you do expansion first? And I know we can talk to braces. That's a whole other conversation. But that's. A lot of parents come in that specific question because that's what they know orthodontics to be. They know expansion, you know, expanders and braces. They're not as familiar with other expansion options, and they wonder, you know, well, or sometimes we get the patients that come in and say, well, we've had braces and there's relapse, and I was told I need a myofunctional therapy evaluation, which I know is a whole other conversation. So in that conversation, again, I'm going to turn this over to you all and to do with it what you will. But I'm just. I'm curious to know, you know, that sequencing, when you get these patients, do you have a general sequence in mind, or are there certain factors you're looking for?

Dr. Kowal, you could go first.

I always say that, and I always teach the parents who come into the practice and during our conversation, conversation, which is the consultation. So we usually have an hour consultation when we have a kind of a teaching environment and explaining what's going on and why this is happening and what can be done at this point and what are the best treatment approach, why we need to intervene right now at this point. And again, I would repeat myself saying that bones are defined by muscles. It's all about the musculature around the bones. Bones are moldable pieces, I would say, of a play doh. That can be shaped into what they are by the tongue, the biggest and the strongest muscle in the whole system. By saying system, I mean the head and the face that envelope. And the second strongest is the cheek muscles and the lips. So we have arches, dental arches, that are shaped by two opposing balancing groups of muscles. And how this balance works out and plays out, this is how the arches will develop. So if there is an exceeding muscle load from the tongue, then the arch would be round and nice, and it may exceed the opposing arch. But when it's the opposite, then when, for example, the cheeks and the lips, they exceed in their pressure, the pressure that is produced by the tongue, or there's no tongue pressure, like when the tongue is down on the. On the floor of the mouth, and there is Nothing on the supporting the upper arch, then the arch will develop in a V shaped, V shaped manner and it will be very narrow and we'll be seeing a lot of crowding. So going back to that sequence, for example, if we have a six year old patient and we know that the development of the head has been going on for a very long time and it's not that we just start seeing something is happening. No, it's been for a very long time. And this is the time when the maxilla has already been either underdeveloped or developed enough to to the point when it is related to the tongue. It has always been related to the tongue. And we know that the tongue is related to the airway volume and to the volume of the airways. So there is a direct two way connection between when we train the muscles, when we start training the muscles and when we start intervening with the physical, with the actual physical intervention. Intervention, which is the expansion at this. Teeth will adapt to the envelope. Teeth will erupt to where the bone allows them to erupt. If there is not too much space, the teeth will try to rotate, to twist, to erupt where not supposed to. But if there is a lot of space, what we are expecting to see, we're expecting to see a lot of tiny little spaces even between the baby teeth. If you see your child, your five year old, your four year old, with a lot of tiny little spaces between the teeth, yay. That's a huge success. That's awesome. This is something that we're really looking for because this means that the jaw is getting ready for the permanent teeth to erupt and it's getting more space for them because all the permanent teeth are always way bigger than the baby teeth. So if there is no spacing, this is the sign that you need to see either myofunctional therapist or an orthodontist as early as possible. At some point, myofunctional therapy can do its job. If there, it's not that severe. But if we already see that there is something that is affecting the size of the jaw. Yes, we need to start with the, with the orthodontic expansion. And it's not about the braces, it's about skeletal movements. We call it orthopedics. We call it orthopedic bone movement, which implies the forces that, that are directly applied to the bones, not to the teeth. There is also, this is a very long conversation about the anatomy and about the structure of the maxilla. Tiffany, please say a word.

So in terms of sequence, it's it's definitely, I think it's definitely nuanced, depending case by case, and definitely age. I. I've been texting Dr. Koval. What about this. This kiddo or this kiddo? And, and you know, some kiddos, it's better to start. Let's start off a little bit with even, especially if they're under 4 years old. Let me try some sensory, oral, motor therapy, which is. Falls more into the category of feeding therapy because they're not officially the appropriate age of. For myofunctional therapy. And, but the parents have all these airway concerns already and they want to meet with an orthodontist. So it's, it really, it really, really depends. There's this really awesome quote that I saw. I think it was facial physique. Myo posted it and I tagged Dr. Koval in it. Orthodontics without myofunctional therapy is like building a house on a poor foundation. So love that quote because it really explains the gap, the bridge between orthodontics and mayo and how there's definitely more room if orthodontics comes first in many cases, at least I feel so. And Hallie, I'd love to hear what you think about this, but I feel that there's definitely what to be done with mayo. But if there's not enough stuff space and there's a high vaulted palate, and if this child is a great candidate for orthodontics and for airway orthodontics, we could physically open up the space and then I come in to work on the nasal breathing and the proper tongue posture. Now we have space. We have the perfect space to do it, and everything is better aligned. So then that's where I would come in and we would work on those habits. And I feel that even therapy might even potentially be shorter in those cases because we have a really beautiful foundation to be already working from.

Yeah. Yeah. And I can definitely speak to that. Yeah. And you know, you know, I'm a big proponent of under age 4. Cognitively, we're more in the feeding world and you know, but I think what's important for people to realize too is that when you're working with a speech pathologist or an occupational therapist, for example, who has feeding in their scope, we can also adapt myo to that age group. Right. So, you know, I like to always point that out because I don't want to downplay the fact that, like, we're still addressing airway issues, we're still addressing a lot of the myofunctional things, we're just doing it in a very different way where it's not your traditional myo, but we do typically, right. A lot of these kids may end up in our practice. We evaluate them, we're going through and we're like, okay, here's all those signs of under developed facial, you know, skeletal issues. We gotta definitely need to make a referral, you know, to like Dr. Kofi Ball for example. But at the same time we're like, okay, there's things that we can also address right before expansion starts. And I think one of the things that you spoke to too is getting these kids prepared for having something in their mouth, especially if they're averse to begin with. Right. So there's definitely work to be done there. But we work a lot with just getting them used to like understanding where everything is in their mouth. Understanding maybe, oh well, our tongue, it's down here and it needs to go up on the roof. Like it's the roof of our house, right. And so education, but then awareness, sensory input, right? There's just so much to that sensory, motor experience. And so I always say, like, I like to work with them for a couple of weeks at least to just get them going and kind of get everything to the point that we probably are not going to make much progress until, you know, there's expansion because we don't have room, right. It's that I don't know who, I always forget whose example this is, but basically when you're trying to park the car in the garage, right? And there's no room like our mouth being the garage and our tongue being the car, right. There's that. There's Also, I know Dr. Felix Liao's example of six foot tiger, three foot cage. When your tongue is too big for your mouth, it's not that your tongue is too big, it's actually that your mouth is too small. And so we need to make the mouth big enough to fit the tongue because it's actually an airway issue and our jaws are just simply not large enough to accommodate the tongue. So that's where we start to, you know, work a lot with especially the little ones and just do fun little activities and trying to get their tongue up to the roof of their mouth and also clearing them for airway exercises, making sure they can actually nasal breathe. We get so many of these pediatric cases that come in that are draining, constantly draining, they're constantly sick, they're drooling, you know, it's just everything is coming out of of every crevice of their face. And that's tricky sometimes because these are also the kids who are constantly, constantly sick. And so I did find at a certain point referring them and starting expansion sooner. And some of those, I like to call them more emergent airway cases. Like my daughter who had croup nine times in one year. That's where I was like, no, no, let's not do a slow expansion. There's research to support that. Rapid, you know, maxillary expansion is going to be helpful for her. So, you know, for her, I think that getting into expansion was life changing. And I really saw firsthand how she didn't get sick anymore because now she was no longer mouth breathing right now we could teach her to nasal breathe. Now there was room for the tongue. We could get the tongue up there, even with an expander in her mouth and so on and so forth. So obviously I could talk about this all day. I'm not the orthodontist. Right. I don't know all of the, all there is to know about the, the skeletal side of things. But what I did learn was the difference between like tipping teeth and actual skeletal expansion, Which I know, Dr. Koval, you kind of like talk, you mentioned something about that briefly already. And I started to read up on what the research was saying about airway expansion and like, you know, rapid versus slow maxillary expansion. And it was very eye opening. And I know we've now had more research come out in the past couple years as well to further support some of this.

Yeah, we do, we do continue our research and compare the efficiency of different type of appliances, types of appliances. And you know, there are three main appliances that are out there, I would say, in the market and the, in the industry. It's the Hyrex appliance, the regular fixed metal fixed appliance that goes over the teeth. It's the Haas appliance, which has those little acrylic parts that go over the skin of the palate and also attach to the teeth. And there are some removable appliances. We have recently we have the Invisalign company has brought into the market the new appliance which is called Invisalign Palatal Expander. And the way it is pre programmed, it's pre programmed as a rapid palatal expansion, which is, which is supposed to give skeletal effects. We're currently, again, we are closely monitoring all of our cases, all of the children that undergo all these types of expansion. And we monitor with the CBCT confirming the bone separation for all those kids. I do have very, very positive results. And I do say, I must say that five years of age, four years of age, you can see immediate bone separation with almost no effort. And you can, that is, that is seen on the cbct and that is also seen just by having your child smiling. And that happens over the first three, four weeks. So the palatal expanders that we put in their mouth, this, the skeletally activated, the rapid expansion protocol produces almost around 1 millimeter of pure bone separation per week in our practice. And kids love it. I do have my kids undergoing this treatment and I can monitor them just in front of me. And we do those turns every single morning. And it's totally painless. They love it. They just come, mommy, we need to make a turn, both of them. So they bring that key and they open their mouth and they love it. And it all depends on how parents accept this. And for example, there's a mother who knows that her child is very active and they, they're very hard to, they're very hard to maybe, I don't know, calm down. And they have those drooling problems, no nose, breathing problems. And you are afraid, the mother is afraid to put something in their mouth. It's about your own attitude. And I always tell them you need to calm down, you need to understand what are the effects of treatment. And by viewing your behavior, your child understands that this is the part of a normal way of doing things. They don't stress out, the child only reacts to those, I would say 10 minutes in the chair, but once they leave the room, once you distract them, there is nothing to worry about. Absolutely. So they don't like somebody, a stranger, I would say somebody who you just saw two times in your life to put something in your mouth, kind of your intimate zone, Very, very, very something which is inside your body. And if the mother is holding their baby, their child, their three year old, four year old in their, on their lap and if she kind of tries to put that appliance in her mouth and she shows the child that it's normal, it's okay, Mommy can do that as well. And then we, we show and tell, we play, we put that appliance and we just maybe distract. And yes, there is something in the mouth, their reaction with maybe a little crying, something, it's just a reaction to something new. It's the reaction that means I don't know what to do with this thing. It doesn't necessarily mean that it's painful or it does something to their body. No, it's just Something new. And when I don't know what to do as an adult, I don't cry anymore. But this is. I have the same feeling. I feel stressed when I face something I don't know what to do with. Right. So, but the child, they just. Just express their emotions in a way of crying. So it's totally normal and it's our duty, and now I'm speaking as a parent, is just to reassure them and to tell that it's totally fine. Let's just try some new food. Maybe we will switch to a softer diet for a couple days and then we'll go back to normal. And they go back to normal.

Yeah. My kids were amazing. And they've had several different appliances in their mouth. And it's exactly as you said. It's. If the parent is in fight or flight, the child is going to be in fight or flight. Right. If that parent is in rest and digest, the child is going to be more likely to move through whatever emotions they're experiencing in the moment. That unknown, scary new thing. They're going to very quickly kind of acclimate and move into, like, being calmer because the parent is calmer. And I can't tell you how many times that. I'm sure, Tiffany, in your practice as well, like, you know, you get parents who are on very different ends of the spectrum one way or the other, and you see it play out. But. But the thing that I wanted to speak to too, as you said, like, your kids come to you and they're like, okay, let's turn it. They know it feels good and they can without being able to tell you. A lot of young kids will ask for something once they know it's safe and they know that it's actually good for them without being able to tell you, oh, this feels safe and good for me and I'm benefiting from it. Right. If it was making it harder for them to breathe, they probably would not be coming to you in the morning and being like, okay, mom, turn my appliance. Right? But it's like, without knowing it's benefiting them, it's benefiting them. And so it's really cool to see, like, my kids, after I had a nose surgery, came to me and they were like, can we do the nasal rinse? And I was like, yeah. I was like, don't have to ask me twice. And so they have every single day sit for the past two years now, they have nasal rinse at least once a day. If they're congested, we do twice a Day. And when we travel out of the country, like, it comes with us. It's my most favorite way to keep them healthy. And especially after we've been on an airplane, I'm like, okay, let's all get everything out of there. Let's nasal rinse that stuff out of here. And I think it's been a big game changer. And again, I just think kids, when they see you doing these things, as a parent, they're like, I want to do that too. And they don't know any different.

It's the same thing. I feel like in terms of feeding and that whole space, you know, a child is more motivated to eat when they're eating with you. A child is more motivated to partake in the things that you're. You're doing also. So it. All across the board, it lines, you know, it lines up that way.

It's.

It's awesome.

Yeah. And so let's talk a little bit more about the myofunctional therapy side of things. Maybe even speech therapy combined with that. Because I don't know about you, Tiffany, but I feel like unless a parent has, has been directly referred for myofunctional therapy, they're typically coming in the door going like, my kid can't say their R's and they're going to high school in the fall, or my kid has been in speech therapy for seven years, or my kid, I was told that they need to work on these sounds. Right. I'll feel like so many of them, if it's not food, it's specific sounds they come in that they just have not been able to correct at a certain age. Are you seeing a lot of that as well? What does that look like in your day to day? Sure.

So. Oh my gosh, there's so many different cases jumping in my head right now. I have, I've had a few cases of kiddos around 5, 6 years old where the parent says, oh, we did speech therapy for X amounts of years and we got nowhere. And I'm like, oh, really? Tell me more. And then, and then I explained to them, I basically like pop their bubbles of how the reason I'm here is that we're going to get to the root cause and the reason that your child still has a tongue thrust and the reason that your child still can't pronounce potentially their Rs or, you know, any. Anything like that. It's actually a structural issue. It's because they have. They're placing their tongue in the incorrect place in their mouth. They're, you know, their lip seal is not, is not in the right way. And all the different things that I could help with, with myo and potentially depending on how severe it is, then referral. An airway ortho. A lot of parents are so concerned about so many, all the airway issues a child is having. A lot of parents are telling me, open mouth breathers, the child's not sleeping through the night, the child can focus in class. You know, all red flags, it all lines up together. And I explained to them, you know, there's this concept of a CBCD scan where we could see the entire airway and we could get a better idea of what's going on, you know, behind, behind closed doors. And they're like, what? No way. This is amazing. I never knew this existed. So then it's nice because I could get started treating, which I have been already with a few kiddos and knowing in a week or two weeks or three weeks or whenever they're comfortable, they'll be going and seeing an Airway Ortho. Dr. Koval. And then we collaborate and review notes and seeing. Okay, are they, are they a good fit for, for airway expansion or not? Maybe we'll wait off a little bit. Sometimes the parents are a little bit, you know, resistant as to what Dr. Koval was saying that they really need to be confident in this, this decision, which, which is huge. And, and if they're not ready yet, you know, I'm here to already at least set a good foundation so that maybe in a few months, as they read up more information, as they do their own research, they get more confident in that decision. They could reach out to Dr. Koval. And we didn't waste two months because I was doing something, I was doing already. Myofunctional therapy, already working on building better habits, already working on better, better airway breathing and, you know, all the different things that we could be working on. So, yeah, it's, it's so much. There's so many kiddos and every. And, and not only that, I'm seeing it also across the board with feeding. Like, it's all, it's all together. It's all together. So a lot of times, that's what I'm saying. I started doing feeding therapy and now I'm like, totally doing feeding in mayo all the time. Exactly. And, and I was like, how fast can I swallow up as much information as possible, you know, And I'm so grateful to now be a graduate of Feed the peds. Now I'm MYO method. And I'm hoping to go for my, you know, CMT to really just be really confident in everything and hone all my skills. But I'm just eating up information. Like, as I'm watching your, you know, the MYO method, I'm like, oh, screenshotting this. Screenshot that I'm like, I need to save all these little bits of information for that. If, if a parent asks me something, I have an answer. You know, for example, my favorite one that I screenshot that I've already been sharing and like explaining this to several parents, including my sister who went to Dr. Koval for, for her children, also for my niece and nephew. But one of my favorite questions that parents always ask, and I would love for Dr. Koval to speak about this more in detail because I feel like this is a huge question by all parents. The difference between typical ortho versus airway orthodontics. What the difference is? The one takeaway I got from the MYO method was that typical orthodontics only grows on one plane, like left to right, right. And that airway orthodontics is focusing on frontal and up and down, right front and back and up and down, whereas they're just focusing more on maybe the, the, the look of the teeth and aligning, all of that. And that was a huge, like, you know, clarification for me and that I've been explaining to parents because there are some parents who are calling, oh, my child already had braces, or oh, we already did orthodontics. And then I'm like, wait, wait, the.

Difference between growing on like one plane versus three and really going for straight teeth versus a healthy airway, which then in turn makes room for your teeth to be straightened once we have enough space. But doctor, you're the expert, doctor, please let me speak to that.

So, yeah, going to into details, what, what is airway orthodontics built around is? If you imagine the airways, there are actually three dimensions to the airways. And I would start from there. So the air, in the ideal case scenario, air has to enter the body through the nostrils and go and follow the nasal passages, then go down and go down through the nasopharynx, oropharynx. So nasopharynx is the part that has limitation in such as that there are structure. There might be structural limitations because we all know that the palate, the palatal bone, is the same bone that builds the base of the nose. So there are actually, it's not a single bone. There are several bones. But we just to simplify, just to simplify it, we will accept that notion that there is one single bone, just to understand that there are no other walls between the nose and the mouth other than the pouch. And by understanding that there is a straight connection, there is a direct connection between the dimension of the nasal passages and the dimension and the width to the palate. So once the air has less room and the turbinates occupy the most of that space, the air will no longer be able to pass through those passages. So the body will try to open another plan B, through the mouth to get the air into the body, because that is the most important part of the body, to have it survive through breathing. And we have several functions. We cannot deny that we are still, we are Homo sapiens and that we still have our basic reflexes besides of our intellectual abilities. And those basic reflexes are, are intended to keep our bodies alive. And one of them is breathing. And it's the most important part of our surviving mechanism. So if the air cannot pass through the nostrils and if the turbinates are too big, or if the adenoids, which is the lymphatic tissue within the nasopharynx, if it's enlarged, then there is a physical obstacle on the way of air to pass through. So the mouth will start being opened, the tongue will go down to the floor of the mouth just to open it up to separate from the soft palate. And this is when we're having issue with the another part of the airway, which is the oropharynx, and this little tube, which kind of reminds me of a garden horse, which has to have a circular dimension to it. But in case, when the tongue is pressing against the airway, when the tongue and the mandible are positioned too far backwards, this horse has become collapsed. So instead of having a circular dissection, we are having a collapsed, very thin, narrow dimension to the airway. So, so the notion of the tongue collapsing the airway is a very big idea around the airway. And we need to understand that the position of the tongue has a direct relationship to where, to the dimension of the airway, because there are no other walls to the airway, rather than the neck from the back and then the tongue from the front and the actual muscular walls around it. So the tongue position is directly related to the mandibular position because the muscles of the tongue are attached to the, the mandibular bone from the inside. There is a special little spot which is called genial tubercle. And the muscles of the tongue are attached to that. So if the mandible is positioned too far backwards, the tongue will press against the airway. And this is how all the snoring habits, mouth breathing, open mouth and all the sequences, all the consequences of that arrive. And with the pharyngeal tonsils being super large and almost kissing each other and the adenoids being super large, it's just because the body is not adapted to having, having that deoxygenized airflow or less oxygen, less airflow, less airification that it's supposed to have. That's why this idea behind airway orthodontics, it's all built around improving the dimensions to the airways. And we're not looking at the teeth, the first thing, we're looking at the airways and then the teeth and their arrangement and their lining, they come into play. And this is a bonus. Like in all inclusive hotels, we are focusing on the airway and we have a bonus of the well developed mid face of the straight aligned teeth and the perfect bite at the end of the treatment.

Yeah, that reminds me. Sorry, go ahead.

I was going to say just speaks to also like that speech, conversation and the feeding conversation, right. If your mandible is too far back and that impacts the position of your tongue, right. You can't hit the articulatory targets, you can't chew and swallow your food properly. And I don't think that parents really grasp this until they start to, you know, you show them a visual or you start to show them the difference, the physical difference between what it looks like to make that S sound or that S sound, right. Or that the R or whatever or you know, hey, this is how we should chew and swallow. And when I started to educate more parents on that, they go, oh well that makes sense. Like why has nobody ever told me that? And I'm like, well, because 50% of my profession still argues about this and thinks that as long as it sounds good, it's okay. And you know, we're over here going, that's not a very holistic root cause based type of medicine way of approaching this. So if you, you know, and that's a whole other conversation for another day. But you know, you know, Tiffany, you had spoken earlier and you said like positioning anatomy, right? Like this all matters and it does. And so often it's ignored. And so I really hope that we're moving and continuing, continuing to move in a direction where the airway is first and foremost at the center of this discussion. I tend to say things that I always say. This is very Morbid. But if you can't breathe, you're dead. Because I think it catches people's attention and then they go, wait, why is Hallie saying that? Well, because we have two main biological needs. We need to be able to breathe and we need to be able to eat, and we deal with both of those in feeding and myo and hopefully with teams that also understand what we do. But it's just. It's been an uphill battle, hopefully one that seems like it's becoming a little bit more normed in terms of discussions. But again, I'm in a very nuanced space on the Internet, so who knows? Maybe it's just the people who find me and follow me where airway is really, truly at the epicenter of everything that we're talking about. And if we can keep bringing it back to that airway discussion and really honing in on, hey, if we address the airway, all of these other things are so much easier to treat because, hi, we're no longer in fight or flight and high. Our anatomy is. Everything's in the proper place. So now we can teach you how to do it, and you might actually make progress and it might actually stick, and then maybe you won't spend the rest of your life in therapy. Maybe, just maybe. I don't know. It's not like we don't see that in our practice all the time, but. Sorry, Tiffany, go ahead.

Yeah, no, totally based. I was just. Lots of things were popping what Dr. Koval was saying. I. Like I said when I was. As I'm finishing up with the MYO method, there were a few good liners that, Hallie, that you said that I was like, I need to write this down. So one of them being similar to what Dr. Koval was saying, that having, like, the teeth lined up at the end of all of this and just looking aesthetically pleasing. Right. And really that it was something that you said, that the teeth are the victim of the problem. I don't know where you had sourced that from, but. But when I heard that, I was, wow, that. That makes so much sense. Because what we see on the outside, what parents notice first is the teeth. They're not necessarily thinking past the doorway. The doorway is the teeth. And the teeth are just showing to us that there's something going on on a deeper level that isn't lining up. Airway connected. Very likely. And, you know, depending on what it is, it's all together, you know, based on. Yeah. And that the mouth. Another thing that you said that I loved that the mouth is quite literally a door to our body. And when we see it that way, everything lines up, especially for a lot of parents. I'm. I've been speaking to so many parents. I'm getting so many calls now, thank God. And they're all so concerned for their kids, and they have so many symptoms and they're not able to put it together. And then when I start looping it together for them, that this leads to this, leads to this. And then they're like, wow, this is all connected. And I. And I say, yeah, that it is. Our bodies are holistic. Everything is connected. And once we start an our job and this why I love doing this. I love working in the mayo and feeding space now, because I really feel like I'm helping so many parents get to the root of the issue. And then we're really treating, we're really working through a lot of symptoms. And more than one thing starts going away just from doing myofunctional therapy or just by doing early expansion, all of a sudden the tonsils are getting smaller. Whereas other, you know, other physicians and doctors, oh, it's fine. Or here's flonase. Or, you know, they're. They're just giving us band aids. But we're trying to do, especially as a team, we're getting to the root of the issue, which is huge.

But no, Tiffany, I think that, you know, it's funny because I'm not treating right now, but at a certain point, I would have conversations with parents and I would say, okay, I'm gonna go out on a limb here, but is your child experiencing, like, X, Y and Z? And they're like, how did you know? I'm like, okay, well, what about this? And they're like, yeah, why are you asking me these questions? And then they'd be like, how is this related? Like, I called you for speech, and I'm like, I know, but this is my specialty. This is what I do. Like, just give me two minutes here, and I'll make it all make sense.

Sense.

And when you can, like, bring it back around to, like, the reason why they called you and their main concern, and you can go. And by the way, all these other things you said you're concerned about, it's all interconnected. And we can, you know, from a team approach, like, we can all tackle this together. They're like, holy cow, I had no idea that sleep had anything to do with my kids speech or, you know, or. Yeah, right. Like, you're shaking your head. You get it. But it's, it's so interesting to see that long list of symptoms. And it just, it's like that snowball. It just keeps snowballing and snowballing and snowballing. And so I get really excited when parents do call and you get to have that educational conversation or they're there for an evaluation and you get to explain to them. Yes, and, and, and by the way, we can also address this now because then again, so many of them. And you know, Dr. Koval, I don't know if this is a lot of what you get in your office or people come educated already, but so many parents are like, well, what do you mean? I should call an orthodontist or a dentist for my kid? Like, they're for four, they're three, they're what? Like my kid, my other child's embraces now they're nine, they just got them. I'm like, I understand what you're saying, I hear you, I do. But, but let's not go that route again. Let's change it and deal with it now. Like, at the end of the day, I think, you know, people say to me, well, how do you get parents on board? I'm like, well, every parent wants the best for their child. So if you just kind of show them that this is the healthiest option and that it's available to them, most parents are not going to turn it down. And they might need, they all take their own time, right? Like you said, there's certain parents who are on their own timeline, they may need to do their own research, totally fine. That's human nature, right? You've got the people, the different types of personalities, the people who are like, fast, they jump on right away. You got the people who are like, well, jump on in three months. You've got the people who might take a year and you've got the people who may never do it. And that's fine, everybody's prerogative. But yeah, at the end of the day, I found that when we speak to like, don't we just want to make your kids life easier? Like, don't you just want your child to basically experience like optimal health, like full access to everything put in front of them on a daily basis and as parents are like, well, yeah, I mean, what parent would say no to that? Like, okay, this is that, this is that.

Let's go.

It's true. Parents are parents bringing 34 year olds. They're just happy that there is such, such a new opportunity and a new approach when we can start earlier and we can address those problems that they're not getting worse over and we're not wasting that valuable time. When the child is growing, actively growing. And we know that the final size to the head, the cranium, the size that embraces the brain, the final size is achieved by the age of six to seven. I don't know if you knew that, but the facial skeleton keeps growing and we know that the transverse growth, it stops at the age of 10 to 11. And we still have the growth, the forward growth, which stops at the age of 13, 15. And we still have a vertical growth that continues until the age of 18. But it does not mean that we have to wait until 18 or 14 or 13. It's just that we have certain periods of time when this the most important, the. I would say that the transfers growth is the most restricting, the most limiting growth because that growth stops the first. And that has several increments to that. And the best time to actually intervene, and I'm again repeating myself, is the age somewhere age of four or five, which we have the, the fastest results, the most obvious results with the least effort. And the child really, they, they feel it. And we can see that those allergic shiners, the black circles under the eyes, they vanish, they go away, they start. No, they don't bed wet anymore, Even these kind of things. How can one imagine that this type of thing is related to breathing, to expanding? Yes, it is because this is just something that follows the abnormal obstructed nasal breathing. The child is tossing and turning during the night. They don't have a very nurturing sleep, they don't have a quality sleep. So this just accompanies, it's a consequence of not having a good sleep overnight. I think the best thing we can do is to restore their sleep by redeveloping this mid facial region, by redeveloping those bones and, and putting them back on track with their growth, which was lost at some point because of the poor tongue posture. So redeveloping that habit for the tongue to rest where it's supposed to be at the roof of the mouth, being suctioned to the roof of the mouth. And this is where Tiffany and I'm happy that we started this fruitful collaboration because we can do it starting 3, 4, 5 years old and we can continue through the adolescence and we can do it in adult patients because very limited number of patients, patients, even adult patients who come and seek their MARPI MSC treatment, restorative breathing treatment, they don't know that they have a Tongue tie. They never knew that their tongue is not positioned correctly against the palate. And what we always say and what we always repeat is that what is the best retainer? The tongue is the best retainer. Right. So my functional therapy has to follow orthodontic treatment through the whole sequence of events, maintenance, treatment, just to hold everything in place where. Where it's supposed to be.

Thank you. And I'm glad you spoke to Sleep because my last question for you is going to be surrounding, you know, children who snore. And really, that really speaks to any type of sleep disordered breathing. It doesn't have to be snoring. It could be. I always tell parents, if you can hear your child breathing, we need to look into this further. Breathing should be silent. And you know, to the point where we've had babies, we've had toddlers, we've had children have like tongue tie releases and also, you know, the proper therapy surrounding it. And then, you know, the parents, like, I thought my child was not breathing anymore because they were so quiet for the first time in their life. I was so scared, I kept going in to check on them. I decided just to sleep on the floor because I thought my child wasn't breathing. They were. And I was like, nope, that's what normal breathing sounds like. Not, maybe not normal, but like, that's what breathing should sound like. Right? It's become. Seems like it's become the norm to snore to. They even like, you know, make it very child friendly in a sense and shows. They have like, oh, it's so cute, he's snoring. I'm like, it's not just nor that is a major health issue. Let's stop glorifying the snore and noisy breathing. But anyways, it's one of those big signs that I tell parents all the time. And they'll say, oh, no, they only do that, like when they're sick. And then, you know, we go into this kid's preschool, we see them napping, and the kid's mouth is wide open and they're like, all right, well, maybe the parent defines snoring differently, but this child needs some help, you know. And so I think again, that conversation of snoring, it's really sleep disorder breathing. And any type, any mouth that is not closed, any breathing that you can hear, you know, if your mouth is open, you can hear the breathing. We should be examining that further. If it's, you know, outside of the child maybe being sick and the child does not return to mouth you know, together, tongue up, breathing through our nose. Because it just seems like we have a major epidemic of that, especially in our, our preschool and elementary school population these days.

I'm right now one of the schools that I'm treating. Just one kiddo in. I had spoken to the teacher of the class, and I was explaining to her what I'm doing and all his symptoms and basically all the things that I'm hoping to work through. And he was assessed by Dr. Kowal as well. And, and I was telling a teacher about this, and she says, you know, he snores during nap time. And I said, yeah, we're not supposed to hear kids breathing. Not awake or sleeping, breathing. It should be silent. And she said, there's. There's two other kids in class that snore. She's like, she. I was like, I'm happy to connect to the parents. You know, maybe I was like, I'm happy to screen them for my, you know, for myofunctional therapy. They'd probably be great candidates. But all of a sudden, teachers are. They. She had no idea that this is what I do. What am I doing? I'm not typical speech therapist, because he has one already. And I'm not a typical. I'm not an ot, you know, I explained to her that I'm a feeding and myofunctional therapist and what I'm doing. And then all of a sudden, her light bulbs start going off. And then she. She said to me that, you know, it's interesting, the kids that, that I mentioned that are snores, they have a harder time with specific subjects in the classroom and, like, focusing. I say to her, you bought it. Yeah, exactly. It's like you connected the dots, you know, that it's not a coincidence. And she was really interested. She was like, wow, that's amazing. And that's so good to know.

It's so important that we, like, educate teachers, especially because the ones that have children sleeping in their classrooms, you know, I was doing a lot of that when I still lived up in the D.C. metro area. We were doing like, you know, the. In services every year before the school year started and talking to them about, like, what to look for, you know, airway and feeding myo and just kind of, you know, sensory stuff. My OT would do it too. And it was really eye opening to a lot of the teachers. And we got to a point where, like, we really didn't have to do it anymore at certain schools. And I was like, oh, wow, that's really cool. Like, how do we like more of that, please? Right. And, you know, and we would integrate, like, the screenings in the airway screenings into the screenings that we were doing for speech or OT feeding. Right. Like that. Basically, myo and feeding should be part of every pediatric screening. And so that's like a big push, too. Like, we should be catching these kids early. And that's always been one of my big pleas here on the podcast is, like, if you are working with young children and you go into a preschool setting or you're in a daycare setting, you need to be educating, and you should be, you know, offer the screenings for free. I don't care. Take one day out of your life for every school that you go into and do this out of the goodness of your heart, because you are literally going to change your. Change a lot of lives, or at least educate. And then the parents can choose what they do with the information. It's. It's so critical and it's so needed.

So, yeah, following August, I'm already gonna be. I already set up that I'll be doing screeners, Airway and feeding screeners. Yeah, because they already give to the parents in the beginning of the school year, you know, to check off if you want a speech screener, an OT screener. But I spoke to the speech therapist who has no experience in my own feeding. She's the one who called me to come and see this kid because she heard about my own feeding, but she doesn't do it. So I came in. So another speech pathologist, technically. And I. And I spoke to the other team in the school, and they said, yeah, we'll add on to checkbox for feeding screening and to check box for myofunctional therapy for, you know, airway and all that stuff. So I'm really excited because that's like my first in with the school and helping so many kiddos. So I came in for one kid, and now hopefully I'll be helping a lot more. Yeah.

Yay. Well, congratulations. So as we start to wrap up Dr. Koval, Tiffany, is there anything else that you want to speak to that we have not covered today?

There's just a huge amount of information that we can potentially share, and I'm happy that you hosted us today, and thank you for this opportunity to speak up and to just create that awareness around this, the airway and the relationship between the breathing, the dimensions, the myofunctional therapy, and the approaches that we can offer to our community.

Absolutely. And where can they find you, Dr. Koval?

We're located in Boca Raton and it's called Dr. Koval Orthodontics. It's an airway designated airway practice and we're building out big, very nice big office with the the digital workflow and that's going to be 3020 Military Trail. We have our website and we have a lot of information on Instagram and YouTube and I hope I will be able to share that here somewhere in comments just to have to take a look for those of you who are interested and Tiffany is our dedicated, my functional therapist and I'm super happy to meet her and and to have her contribute to our workflow. And this is essential that we have built this collaboration together and that Tiffany, as you mentioned, there is no way orthodontics and airway orthodontics can survive alone. It's always a two way road and it's always a collaboration throughout the whole sequence.

Yeah, absolutely. Thanks so much Hallie for setting us up.

Absolutely, absolutely. And we will link both of you your contact information and everything in the notes and so everybody can find you very easily. Tiffany, just real quick plug where they can find you if they want to reach out to you directly.

My handle on Instagram is Little Little Eaters FL. My website is www.little eatersfl.com. i'm doing feeding and myofunctional therapy throughout all of the South Florida area. I'm a mobile private practice. I come to you and now I will be very soon starting up in VOCA as part of Dr. Koval's office and her team. So I'm really excited to be joining forces.

I'm just excited to be able to refer everybody to you guys.

Yay.

Well, thank you both for joining me today. This has been amazing and again we'll link everything in the show notes and they'll know exactly where to find you.

Thank you Hallie.

Thank you Jessica.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots and Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halibalkin.com or pop over to at Hollybulcan on Instagram to get all the latest updates.