Episode 279: Navigating Different Orthodontic/Dental Approaches and Appliances with Hallie Bulkin

Hi and welcome to episode 279 of the Untethered Podcast. Today we're going to dive into a topic that came up when I asked y' all what you wanted to hear about on the podcast. So let's dive in. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational.

Purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider.

Foreign to the Untethered Podcast.

I am your host, Holly 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, tetradural 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 coral rest posture.

Tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Okay, so what is this elusive topic? I'm hoping not to ruffle too many feathers today, but this was something I wanted to have a conversation about when I saw this pop up. A friend and colleague, Emily, actually posed this conversational topic when I asked what you what you all wanted to hear about on the podcast. So what is the topic? Basically? How do we approach? And I don't. I'd have to go back and like see her wording. Exactly. But how do we deal with or approach different orthodontists? Right? Like, how do you deal with different orthodontists when they have different approaches? And how do we keep up with their approaches like as feeding therapists or as myofunctional therapists. How do we deal with that? Right? And so I was like, this is a really good question. And I'm actually chatting with her right now to see, to like just get more feedback, more information from her. But you know, some of my questions were are they airway focused, you know, orthodontist? And she said 3r1 is not really looking at airway as others are based on like her experience. And I think this is interesting information and I think it's important to think about because not all dental providers, orthodontists are taking the same approach. Right. Even within the airway Space. And so what do I mean by that? I think that it really falls on us as therapists, right, to have a certain pathway, if you will, to referring to these providers and then also to continuing therapy while a child is either in an appliance or not in an appliance. Like, what does that look like, right? Like what comes first, the chicken or the egg? What comes first, the therapy or the expansion? And I've talked about this before. I've talked about my pathway to how I basically determine what to recommend for different patients. Because honestly, it's not the same for everybody. We. There's no one size fits all approach. And so I think that's the first tip is that if you are interacting with a provider and they're basically trying to tell you that there is a one size fits all approach, like that is the first sign to go running the opposite direction, because there isn't. No two kids are the same, no two adults are the same, right? So we have to look individually. I always recommend starting with like an. Whether it's a pediatric feeding evaluation or it's an orofacial myofunctional evaluation. I recommend starting with that functional eval because that's going to give us our baseline that is going to tell us what we're dealing with, and then we can refer potentially onward to a expansion provider if we feel that that is a good next, you know, best up referral, if you will. So how do we determine if we should refer to them? Well, for one, if a child appears to have a very high or narrow palate, you know, and your eye is really well trained and you know what that looks like, that's probably a good time to refer. If a child is sleeping with their mouth open and you're like, you know, or just their mouth is hinged up and their tongue is down. And let's say that you try to teach them to have their tongue up in the roof of their mouth and the tongue just doesn't actually rest there like it should. And you're looking and you're like, you know, this car's not fitting in the garage, right? The tongue is not fitting in the palate. Well, that tongue not fitting in the palate is a sure tell sign that we don't have enough space for the tongue. And it's not that the palate is too, is the right size and the tongue is too large, because sometimes you'll hear like, oh, the tongue is too big for their mouth. No, I mean, is macroglossia a real thing? Yes, sure. It is. It's rare. It's very rare compared to how commonly we have palates, right. Dental arches that are not wide enough for our tongue. So that's one way to know if we should refer. How do we know if we should continue therapy when a child is in an oral appliance? Well, can they, can they function with the appliance in their mouth? Can they work on their skills that you're teaching them with their appliance in their mouth? Or does the appliance. Is the appliance, is the appliance removable? Can we work on it then? But if it's removable and then they put the appliance back in and let's say they have an appliance that they're supposed to wear 24, 7 or 16 hours a day or whatever, they're not going to generalize the habits you are teaching them because the appliance is in the way. So you can work on skills all day long. But if that skill is, let's say you're teaching them how to rest with their tongue in their palate, but they have something blocking that from happening and getting that neurofeedback from the tongue up against like the skin of the palate. It's not going to become a habit, a healthy habit, if you will be. They're just going to continue to keep their tongue low and forward because that's where it's forced. That's a position it's forced to be in with such an appliance. Right. But there are also appliances that do open the palate up or that leave the palate open, I should say. And so that's a very different conversation. Right. There are times though, when we have a child who has a palate that is partially blocking their, their, I'm sorry, a appliance that's partially blocking their palate and will still do therapy with them because they're able to work on isolated skills that they need to work on at the moment and their palate's not interfer fearing. Right. And then there's children where once we get close to the expansion being done and the appliance coming out of their mouth, we'll start to do therapy with them because now we can start to work on the skills and we know that appliance is coming out soon and so we want those skills in place. And so once the appliance is out, we can then generalize those skills. Right. So there's, there's a lot of nuances and I'm just giving Some examples, some of the more common ones. But this really isn't every single possibility of how things can go. I do think that despite many of us not, you know, I know there's orthos and dentists that listen to us, listen to this podcast. But despite us not being, most of us not being providers who can actually move bone, right? We work with muscle and sometimes that influences bone, but we don't move bone for a living as myofunctional therapists or feeding therapists, right. Slp, ot, pt, rdh, et cetera. Right. If we are not actually moving bone, we can't make certain promises, right. But we can still learn about the different approaches and what's behind the approaches. And, you know, then we can recognize why a provider may choose to use this certain approach or have a preferred method, Right. Due to the type of training they've had or the experiences they've had and even updated technology, which is constantly changing. Right. So I do think that we have a due diligence. Like, we need to do our due diligence. We need to educate ourselves and stay informed on, like, the latest developments when it comes to different orthodontic techniques or dental techniques and appliances and technology and all that fun stuff. And one of the easiest ways to do that, outside of actually taking courses, which could be challenging if you're not an ortho or a dentist, to even access some of those. One of the ways that we can become privy to that information is through the relationships that we develop with providers that we refer to or that refer to us. And I do think it also falls on us to have these conversations with the referring provider, the provider we're referring to for dental, you know, ortho expansion, because we need to communicate what our goals are, and we need to be very clear in articulating, you know, what we are working on and why their current palatal shape or the high narrow shape of the palate or, you know, the whatever is going on. Right. We need to be very clear on why that is impacting our ability to move forward in our myofunctional therapy program or how that is going to impact our ability to proceed. I think when we make it clear as to why we're referring now and then have a conversation about, like, timeline for a specific patient, our clarity helps to breed a conversation with the other provider that ultimately allows us to all be on the same page and figure out the next best steps for a patient. Right. I also encourage second opinions. So I sometimes get people who will message me on Social media, and I don't know the cases, and they'll share a little bit about their child's case. And look, I don't. Guys, honestly, as much as I'd love to help everybody, like, I can't do that. I can't really give you medical. Well, it's illegal. I can't give you medical advice on a case that I want to have no jurisdiction over. Like, I don't live where you live, I'm not licensed where you are. We haven't done anything short of a consult. Right. And so I can't actually give you medical advice. I can create these podcast episodes, and if you wanted a consult, we could set you up with somebody on my, my therapy team. But that's neither here nor there. The point is, I think second opinions can be very powerful because if there are disagreements between professionals or approaches and they're not matching up because, you know, talking to professionals in this space, they're telling me that they're frustrated by all the different approaches and how one orthodontist and another orthodontist, you know, in the same town, both airway centric, are saying different things. I think it really then falls on the patient to do a consult with both and to figure out who they feel most aligned with and which approach feels best for them. We can't determine that for you, unfortunately. And so I'll have people ask me all the time, well, what do you think about this appliance and what do you think about this approach? I, if I've used that appliance, if I've experienced that approach as a mom of a patient or the patient myself, you know, if I was the patient, I'll share my story with you, but I don't have the licensure to advise on getting expanded or not technically, even though I can tell you you're an error, I can't say you have to get expanded or you should get expanded. And I also can't advise on the best appliance for you or your child's case. Right. And so I just wanted to make that very clear that myofunctional therapists do, do not have that jurisdiction. Right. We don't have the licensure that has to come from the dentist or the orthodontist themselves. I do think that, you know, everything we do should be patient centered and you as the patient, or if you're the provider who's trying to advise the patient, I think that we need to be asking questions about the patient. What, what does their daily life look like, what are they going to be able to feel successful with? What feels most aligned for them? Which appliance feel feels like it is doable? Be right. Sometimes we give people these appliances that are removable and they lose them or they break them or they don't use them. Um, whereas we have fixed appliances that sometimes we put in and that leads to some greater success. Even though it may get in the way of myofunctional therapy right now, it ends up leading to more success with the actual expansion journey because it is a fixed appliance. And now we just have to remember to turn the appliance or whatever the case may be. Right. So I just wanted to pop on here and share a bit about that because I do think that it's not our job to police other medical professionals. Right. But it is our job as a professional to guide our patients to the right providers and to answer questions that we're able to answer, you know, based on our own licensure and certifications and experience and everything. But I think that it's. I'm just hearing that it's becoming like, increasingly more confusing because there are so many different providers using different approaches and different appliances and yeah, that can be, that can be challenging. Now, on the flip side, the one other thing I will say about this is that you need to be very clear in like, what your process is and you need to communicate that. I kind of talked about this a little bit at the beginning of today's episode, but you need to say, okay, here is the checklist. Here's what we need to see in place. One, we need to have an evaluation done. Two, we need to attempt to do, you know, some early therapy and see how the patient responds. Three, you know, I'm just giving examples, right? Maybe you tell your patient when you are at a certain point, that is when I will refer you because then you will be ready for it if they determine that's the next best step. And if you decide that's what you want to do. Right, because both of those things have to happen too. So I don't know, you know, how helpful this is, but I wanted to shed some light on this because I heard this pop up and I was like, oh, this is a really good conversation. And again, it's not to ruffle feathers, although I may have ruffled some. But I do like to believe that most orthodontists and dentists in this airway space are very patient centered. They are doing what they're doing because they truly want to help. But I think that we need to be asking questions and we need to be comparing our options. We need to be seeking out different options. I personally prefer referring patients to a provider that has an arsenal of expansion tools, right? Meaning they have different appliances that they can recommend. They're not using a one size fits all approach for everybody because we know that you cannot use one appliance on every single person that might walk in your door. That's, that's just not individualized care. And there are practices that do do specialize in one specific type of appliance. And I'm not saying don't go to them, but if you get to the point where like, well, that's the appliance that I've been told my child needs, that's the appliance that we want, sure, great, go to them. But in your journey of trying to seek out the best route for you or your child or your patients, you know, my recommendation is to find providers who have at least a couple different appliances that they offer for dental or orthodontic expansion in their arsenal of appliances so that they can really, truly pick the one that's better best for their patient. And they do have different options, like, what if something doesn't work? Right. Well, then we're out of luck. So we need to have options. And I just think it's a major red flag for those who claim a one size fits all solution. Right. Or, you know, I also don't love when people get pressured to make immediate decisions. Like the first time you go in, I think that it's really good to get information, take it home with you, think it over. It's a big investment in both your time and energy and finances to put in dental appliances. And so I do think that anybody who is like into high pressure sales tactics, you know, unless you like that kind of thing, I just don't think that that needs to apply when it comes to dental appliances. I think that the initial consult should be a informational gathering type of process. And unless you're like 100% sure that this is the right path for you not saying don't sign on with them, what I'm saying is don't feel pressured. Because I've had people say, oh, well, I went to this person and I ended up signing and making the down payment. I just felt so pressured when I was in their office. Well, that's not fun. Like, nobody wants to be seen by you if you know, or go to you as a provider, if you're going to be pressuring them into something that they then may later regret. You don't want buyer's remorse when it comes to your dental expansion. You don't want it, period. But especially not with dental expansion, something that's going to live in your mouth for a while. That to me is just a major red flag. So I know that business is a big part of running a practice. And you do have. You should absolutely be presented with the cost of the appliance and, you know, a payment plan or any options or discussion around that that you continue to, that you choose to discuss with the provider, the provider chooses to discuss with you. But nobody should be forced or pushed into investing in something until they're absolutely sure about it when it comes to dental appliances. Okay, so those are just a few of my tips, really. You know, educating yourself, being super clear and communicating with the providers that you do refer to understanding what tools and like, what appliances they have in their arsenal of tools, like in their tool belt. Right. If you will, and making sure that you understand what they're recommending for your patient or for yourself and why. Right. They should be able to tell you why they're recommending the appliance that they're recommending and what they foresee the treatment plan looking like, how they, how long they expect you to be in this appliance, what you have to do during the course of the appliance. You know, those are all really great questions to ask so that it can be very patient centered and truly be a, a patient centered decision that is made at the end of the day. And also, you know, the last thing I will say, because I think egos run high sometimes in these fields, is that second opinions are not a, it's not a shot to somebody's ego. Like, it's not, it's not necessarily about you personally. It's about the patient doing their due diligence and figuring out are there other appliances that feel more aligned? For me, I do believe everybody should go with the provider and the appliance that feels aligned for them. And the only way that you can figure that out as a patient is not being told by a dentist or an ortho, you know, or even being told by your myofunctional or feeding therapist. You have to experience for yourself a consult to find out who you want to work with and which appliance feels best. So hopefully this is helpful. I know this started off more as me answering a question that kind of came through from a colleague about, like, how do we even, like, deal with these different orthodontists who have different approaches. Well, I think we need to be really solid as therapists in our approach and understanding how to adapt. And I think it also falls on us to be super clear which with each patient, as I mentioned before, about like what our goal is for this patient and then have a conversation around like the best treatment plan and timeline for each given patient with the provider we're referring to. Now, providers typically make a, you know, a decent amount of money off of appliance work, so they should be willing to speak with you. If they're not, that is a red flag for me. So anyways, I feel like I'm starting to repeat myself here, but I know there are varying philosophies out there and a lot of them are contradictory to the next. And so it definitely makes it more challenging for us as even medical professionals, but you as a parent or a patient to determine like who the best fit may be. So trust your gut, right? That that parental instinct does not typically lead you awry. It's typically going to point you in the right direction. And you know, it can be so confusing when you have providers who are disagreeing with each other. And so I fall back on my intuition and on what feels best at this moment in time for that patient. Of course we want to look at research too. I don't think I mentioned that. But is there research to back what we are seeing, what we're discussing? Maybe there isn't great research. Who knows, Maybe that's not important to you. Maybe there's case studies and that's the level of research that you're happy with accepting. Because I'll tell you, there are some appliances where it is more case study based than research based in terms of the actual appliances, appliance itself. But the, the background behind what that appliance is doing is what's been researched. And so the airway expansion, right, is what we're looking for. The you get so much airway expansion with every millimeter of dental expansion, like in your actual bone. So that's where we want to be looking. What are what appliances are going to give us the best results for the goals that we've set and for what we're seeking for ourself. And that again is not something that anybody can answer for you per se. It really depends on doing your due diligence as either the professional referring the patient or the parent of the patient. So hope that helps. I know it's still a bit of a confusing topic. If you all have questions, I'm happy to answer them. You can always DM me at halibalkin on Instagram.com if there are other topics you want me to talk about or you want me to elaborate on this more and you have further questions, I'd be happy to chat further but that's all I've got for you today. Do your due diligence, be super clear in your in your treatment plan and what you're like. Look looking for whether again whether you're a professional or a parent and just kind of stick your heels in until you find the thing that feels best suited for you or your child. Thanks for listening to this podcast.

If you found value in this episode and want to hear more of these Myotots, 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@halliebalkin.com or pop over to Hollybulcken on Instagram to get all the latest updates.