Episode 320: The Impact of Oral Restrictions on Growth and Development with Dr. Annie Babb, DDS

Hi and welcome to episode 320 of the Untethered podcast. Today we have Dr. Annie Babb joining us. Dr. Annie graduated from Indiana University School.

Of Dentistry in 2011.

After working in a general dental office for almost 10 years, she became interested in oral restrictions and their impact on.

Growth and development in airway Health. In 2021, she began working in an.

Orthodontic practice and implemented a myofunctional therapy.

Program and a frenectomy program within that practice. In 2025, she decided to open her own practice focused on tongue ties, oral restrictions and myofunctional therapy.

She she treats infants and children in her free time. She loves traveling and spending time outdoors with her husband and children, Gracie and Leo.

Welcome 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 tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to 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.

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.

Dr. Annie, welcome back to the podcast.

Thanks for having me. Excited to be here.

I'm excited. I know I just randomly stumbled upon the fact that you were opening your own practice and I was like, oh, we got to have you come back. So obviously thank you for saying yes, but I, you know, I want to jump right on into this and learn a little bit about what you're going to be offering.

Yeah. So I have opened my practice. I'm at a temporary spot until my space is ready. But the name of the practice is all about function and basically it's tongue ties, lip ties, buckle ties, and then some adjunctive therapy. So I have a myofunctional therapist with me as well. But the whole kind of concept is it's not just about a quick snip of the tongue, it's all about the function so that is like the, the guidepost for everything we do. And at the forefront of, of all of it is combining function and not just myofunctional therapy. I, I'm starting to do a lot of consults too on some younger kids, kind of like the in between ages and directing them to who can help at that age, what is reasonable for that age. So that's, I love that.

I mean everything, everything is function. Right. So I love that you're really highlighting that. It really all comes back to like how are we functioning? I feel like I get a lot of, you know, people messaging me online because of my presence. And then even families that we've worked with that are kind of like they'll come to us for an eval because they've heard oh their baby might have a tongue tie or they, there's something and we're like, well what's, like what's the functional impact? And so we'll do an assessment and we'll say your child's actually feeding very well. Now. They might be compensating well right now, but to what degree do we want to disrupt that and possibly cause a larger issue when one doesn't exist right now versus like let's do some intervention to continue to support them, make sure that they really are fully functioning and monitor kind of the function and make sure that it continues and we don't start to fall apart. Right. So I love that you kind of pinpoint that.

Yeah, absolutely. There's. I've started to see a fair number of toddlers and that's typically an age that I'm not going to release. It has to be something pretty extreme to release in that age for me because I don't sedate and so then I'm not suturing. And there's as you know, a lot post operatively that the parents have to do and doing stretches in a 18 month old is, you know, good luck. So I kind of will tell them like, yeah, maybe there's some restriction like this may need to be addressed when they're older. But realistically me doing something now isn't really going to be that helpful for you. I think we need to work on tongue strength. We need to work on so a lot of myo munchy recommendations right now just because that's, I feel like that's a good kind of starting point for a lot of families to just even see like what their child is going to tolerate. And so I've been recommending that quite a lot for those kind of in between ages and then obviously early expansion if they're a little bit older.

So how old do you start early expansion?

Well, it's hard to find providers that will treat super young. There's one. Well, there's a couple that are decently close, but they're both each about an hour or so away. So some of the families who are super motivated will. Will go. One of them starts, I think, around age 2 or 3. She has that she'll start. So I haven't yet seen any of my patients go and start that young. But I would say I see even before this, like, age 5 was probably about the earliest we were really getting true expansion, which I would like it to be younger.

But yeah, I have a question for you on that. It's kind of like I'm like, developing my own theory around this. So my kids both started expansion when they were 4, so Lily. And obviously you don't know their cases, but it's just more of a general question. So I'm explaining the background. So you kind of have the context I'm coming from, and then I'll kind of ask the question. So she had an ALF appliance for about a year. We got some beautiful results with it. We had, like, before and after cbcts, more so because I wanted to see the after. And her sinuses were clear, her nasal cavity was clear. She got some good expansion. Her tongue fit in her palate. We were doing mayo. Then she went back into expansion. We moved down to Florida and she was in a hyrax with like, a forward growth component added to it because we decided she needed some more expansion. She was in that for, I don't know, six months, whatever it was. And then now we realized she needed more expansion. So now she's in another appliance. But we put her into, like, a hot. It's kind of like a. It's a customized version of a HAAS basically, and ortho that we're working with in Boca. When we did cbcts and we saw, like, she still needed more expansion. And I just kind of had this, like, thought process and, you know, because my younger one went into the high racks with forward growth component at age four. And then we knew she would need like, a second round that was more or less her, like, first round. So now she's also in the same appliance that HAAS that's been like, kind of customized to them. And they are both had these, like, gaps between their teeth in a matter of three weeks. I mean, it's definitely, like, quick expansion. I'M over here all giddy, like, whoa, this is so cool. Like, we're actually splitting the suture. Um, and so there's just so many appliances out there. Right. And part of me is like, I feel like we expanded their mouth to where it needed to be at each of those stages. Obviously, this is a very expensive process. Nothing has been covered by insurance. I haven't tried to submit the ortho work that we're doing now. Maybe part of that would be. So I'm going to give that a go because I've worked with dentists that do expansion in the other two cases and so nobody. I just couldn't get it covered. But it almost, you know, I see some providers who like, will put an elf in and they'll just keep replacing it and keeping in the kid's mouth until they're like in their teens. And so I guess where I'm kind of getting at here is do we feel like when we start younger? Because I feel like we should. I'm totally on board with that and I feel like it's given my kids so many health benefits, but I also just feel like it didn't continue to. They didn't continue to grow, as do you know what I'm saying? It's like they still need this guidance.

Yep. And that's something I've kind of told parents too, is you, you need to get to them young because that's when they're in their peak growth potential. So, like, you can do a lot with little at that time. You know, you don't need a lot of force, you don't need a lot of time. But then how much of that is going to last is tough because you're also relying on them as children to then be compliant with proper tongue posture, proper mouth function, proper everything. And you know, in a four year old, that's not super realistic. So it's kind of. I, I feel like everything in this field is all about timing for that specific patient. But I, yeah, I think the same things. And even, you know, I try to also educate parents that like doing a tongue release in an infant. For me, I think in anybody who does them will tell you the same thing. Very different procedure than doing it in the older kids. And so I'm always careful not to promise, like, doing this now does not mean that they're not going to have any of these things down the road. They could still have the things or they may not. You know, they may have. They may have some speech issues. They may not. They may have Some crowding they may not like. It's. This is to help them at this specific point in time. And so if there are no symptoms right now, I'm not doing anything. We're not doing something to prevent potentially issues down the road. And, you know, I'm not an orthodontist, so harder for me to speak to, like the appliance, different appliances. But I think the same thing holds true. Like, you're addressing it in that point in time. And as your child grows and develops, they may still need a little bit more. Like, you have to see, you're trying to. You're constantly trying to get them on that proper trajectory and get them on. Let's get on the right path and see where your body takes you. Intervene the best we can. But, you know, it's the human body in children, so totally, It's. It's a tough. Yeah, it's tough. And I wish there was so many times I wish I could just tell parents, like, this is gonna fix everything, you know, and do this and do it in this order and at this timing. And it's gonna work great. Because sometimes it works for some kids that way and some kids it doesn't. And I can't pinpoint what about those cases, you know, like, when is it going to be lasting and when is it not? That's tough. So, yeah, I think, I think same thing with expanders, but I'm glad that they're getting good results now. I feel like the older they get, like, they're more body aware too, so that's helpful. But your kids are always. I mean, they're good at doing palatal.

Suction and all the things you need.

To do, you know.

Yes, they're little mini me's. Yeah. No, and it's. It's interesting because I feel like every single provider we've been to has been like, so well educated in this space, and I think we've gotten the results that we needed in that moment with that appliance. Like, we met. Met our goals essentially. And with the last one, we actually had the kids in a myobrace after they came out of the hyrax to kind of hold the expansion and also supposedly guide forward continued growth. And my younger one, who's got the tiniest little mouth and wasn't like the baby size, she initially. She did great and would wear it every single night. And I feel like it really helped to hold the expansion because she also has a grinder right now. And so we knew we needed more. So that was kind of Phase one for her. And I was expecting to go into another expansion appliance. Whereas my other one, I'm like, all right, we've done this twice already. Like, now we're going into our third round. Can we. Can this be our final round? And she. Interesting thing was she could not tolerate a myo brace. Like, she would sleep in it for, like, 30 minutes, and then she would just wake up gagging it out of her mouth and coughing it out every single night. And I was like, this is ridiculous. Like, this is not good for anybody. So, anywho, long story short. Yeah, they're in expansion now. They're about three weeks in, so we'll see what happens. But just like you kind of said, like, my younger one was. Was her tongue tie was released at day five. And my older one was 24 months. Night and day two, very different procedures they both served. I mean, it was for feeding reasons. My older one was very picky, and she just was kind of like, she couldn't figure out how to drink out of an open cup. And she was kind of fixing her jaw weird. And it was, like, based a lot on her tongue position. And we were having a hard time getting, you know, function gained through therapy. So I was like, okay, I learned, you know, fell into the Maya world and was like, I think we need to work on this. And we went for a tongue tie release and. But like you said, it's very challenging, especially without sutures placed in a toddler, to get them to do anything. After a tongue tie release, the baby was easy.

Yeah. It has to be a very, very motivated parent, and it has to be a very strong reason for me to do it. There's some places I would refer if I needed to, if they. If I felt like they really needed it, needed to be sedated. I have some. Some doctors I could send to, but. But even still, it's like, let's look at the big picture here, because I think. I think tongue ties are. It's polarizing, but I also think a lot of moms are finding it, and then they're like, is this the thing? Like, is this the thing that my child needs? Is this the problem? Is this the reason for all these things? And it can be a contributor to a ton of things, but it's one piece of this whole puzzle. And so I. I spend a lot of time right now educating parents on that. And like, yeah, I. I get it. I. I see it. I can feel it. There's some restriction. But, you know, your child's feeding well they're speaking well for the most part or they're having trouble with sounds that not a speech and language pathologist but I also know their sounds that they perfect later on. Ls and Rs are always a big concern for parents. I'm like well developmentally that's a later one. But also it's a lot of mid tongue strength too. So like let's work on some mid tongue strength and like what's your space? What's your tongue space? Like it's not always the restriction that's the issue and I don't ever want to be over treating those. You know, let's look at the things we can fix non surgically first and then we can address structure if it's truly the issue. Now granted there are other ones that I see that it's obvious that structure is probably the biggest problem, you know. So it's a whole wide range of things.

Yeah, so. So you work a lot or you do a lot more of like of the releases on babies from what you're saying. So kind of can you talk to us a little bit about like what your process looks like? Do you have like a local team of providers? Are, you know, I mean you've already said you pretty much do collaborate with others so talk to us a little bit about that.

Yeah, so I, right now I would say I see probably about 50% maybe it's, it might be more, it might be like 75% of babies and then the rest is older kids too. So I still see like those ortho age. So basically like 6 and above. I would do releases on or typically 1 and under depending on the case. I've done some a little bit older. I prefer to do them three, four months is like ideal anywhere really from like a month to four months is ideal. But I'll see them up until one and then if there's, if they're a little over one, it's just more of a conversation about, you know, what are we going to realistically accomplish. So with the babies, most of them come to me from a lactation group that I work with. So they've already seen the lactation consultants, they've been working with them. And that lactation group is also very good about connecting them with a body work professional as well. So I would say probably 99% of the babies I treat have lactation and bodywork. There are a few maybe who don't always have the bodywork components for different reasons. And I'm not going to, you know, force a parent to do that. I just. I can see the results are so much better with body work that I just. I really educate the parents on that, too. So I have pediatric chiropractors, a pediatric physical therapist. There's a pediatric OT, SLPs, too, but predominantly for the babies. It's IBCLC and usually pediatric chiropractic. So they've already kind of seen them by the time they come to me. And so if I feel like the baby's ready, if I feel like the parents are ready, then we'll do the procedure same day. Sometimes they'll come to me for a consult first, or maybe they've just kind of started down the path and they just want an opinion on things. And so we just have a conversation of, like, well, let's try these other things first, or yes, you're going to need a release, but your baby's. The. Their body's not ready. There'll be rare instances. While I will do it without those things, it's more typically if they're tied to the tip of the tongue, if we're at the risk of losing the breastfeeding dyad, you know, if it's. I kind of read the room, and if we're. If the mom is really, really struggling, then I'll be honest and I'll say, okay, we can do this. Like, this, this is going to help, but it's not going to be everything. And there's a higher, higher likelihood that we'll need to do a revision at six weeks, too. You know, I'll be limited with what I can accomplish, but, yeah, that's pretty much the approach with the babies.

Awesome.

Well, I mean, I love the collaboration because I. With you on that, I feel like it's so critical for these kids. And it's fascinating, too, because back way in the beginning, obviously I wasn't doing the releases, but I was referring a lot when I kind of was like, ooh, tongue ties. This could be the issue. Let's refer to a release provider. And so there was a lot of collaboration back and forth, but we weren't like, for qu. Requiring or strongly suggesting that families go to the bodywork component. When I first was kind of in this space, and then a couple years went by and I was like, I started to see some kids that I received from some of these professionals who had done all the body work with them, and I was like, feel like we're getting better results. The kids are relaxed, our nervous systems are in check. This is a whole different situation. And so we started to basically strongly suggest that they go, if nothing else, at least for a couple sessions, just to kind of get the body rely, you know. And a lot of these kids, the parents are like, it's expensive. It's out of pocket. And they would see the results wouldn't hold. And we're like, well, that's because of the tension throughout the body. So, you know. But if they could get at least like a handful of sessions and have the release and go back for a handful of sessions, such night and day, compared to children who didn't have it at all, I mean, just us being in their mouth, we could feel the difference.

Yep. I can tell the difference when I do those releases because there have been some where I've done a consult. I'm like, you really need bodywork. Have they talked to you about bodywork? Like, yeah, I don't know. Like, they're. They're nervous about it. Like, well, let me tell you what it is. You know, it's very gentle. They're not laying your baby on a table and cracking all their bones. You know, it's not like that. It's. It's really fascial release, and I can tell a big difference, especially in the nervous system regulation. You're spot on with that. But also the frenum itself, there are cases where I'm like, let's. Let's see. Could it be the neck tension? Or. I. I'm not 100% certain what is actually restrictive under that tongue. I can tell there's some restriction, but it's. It's kind of widespread. And once they have the bodywork and they relax the floor of the mouth, that frenum is much more defined. And then when I do the release, it's like just boom, goes. You know, it's just. My life is simpler. It's quicker, and it's safer for the baby, too. And so usually once I explain that to parents, if they're kind of hesitant, they'll at least go for a little bit of time. And then some parents just prefer to go to the pediatric physical therapist. And she's great, too. She's done the Gillespie approach. So it's. It's really fascia. That's like. For me, it's fascia and the nervous system regulation. Those are like the two biggest things I want to see in the babies. And I can. I can tell a huge difference. And they just. They calm so much quicker after the procedure, too. And even during, they're just calmer. Everyone's calmer.

Yeah, they feed better too. You know, I feel like babies will latch to rest or bottle so much easier if their body is calm, their nervous systems are regulated. And so like you said, it's like you're seeing. It's just easier. Like, we see such a huge difference. And obviously, you know, that dyad, it's important too. So I feel like if baby's a little bit more relaxed, mom is a little more relaxed, mom's a little relaxed, babies rely. It's like this whole, like, you know, 100, 100.

And that's something I. That's something I read the room on too, with the infants. You know, it's like, how is mom doing? How is dad? If. If dad's there? Like, what's. How is everybody? Are we like in this super stressed out state? Because if that's the case, the majority of the time, that's not the time to do the release. Like, we need everybody working towards peace before the release. Unless, like I said, if we're really at risk of losing that dyad. Like, if I've had some. Where they. The moms have stopped nursing and that's not their goal. Like, they just can't do it. They can't. They're in so much pain or there's. They have infection or, you know, whatever is going on. And so then those ones I will be more aggressive about because again, you're just weighing pros and cons all the time.

Yeah, definitely. No, I. And I like that. I like that you have a very individualized approach to sort of what that dyad needs. And sometimes, you know, it's not perfect, textbook, you know, scenario ever.

Everyone was just black and white. And I've said that to parents. I'm like, I would love for it to just be black and white. I would love to give you an absolute, like, yes, this is gonna work and now is the time. But that's not real life.

There's so much nuance in human, you know, interaction and treatment.

Yes.

Yeah, yeah, yeah. So, okay, so you. Are you doing then like a frenectomy on these little ones and not like a functional frenuloplasty, obviously, right?

Yeah, yeah. Frenectomy on the babies. So I use a light scalpel. It's very quick. I. I would say probably 10 seconds or so, maybe at each site. Less if I do buckles. It's. It's even less than that. Those release pretty quickly. Tongue, maybe 10 seconds. I don't know, I don't count. But it's very fast. And so usually I'll do like my main incision and then I just use my finger to kind of open everything else up. And so it's, I try to be as conservative and as gentle as I can be. I don't, you know, I'll stop sooner than I would on older kids too. I'm not going to be nearly as aggressive in infants. And I find most of the time you don't really need to be the more conservative you are. I think they heal better. It's a more approachable thing for the parents too, the smaller you can keep the wound. So that's always the goal. And then I see them for a one week post op and typically I want them to see lactation somewhere between the release and that one week post op, just so that they have support in the stretching. And it doesn't matter how much you prepare the parents to stretch. It doesn't matter how prepared the parent is, how familiar they are with the body. I think they all have moments of doubt when they're doing the stretches. And so if they can see lactation within those first couple days, that kind of gives them the extra boost. If they can't, I always tell them like they can reach out to me if anything comes up. I get them my personal number so they have direct access to me if they, you know, need it, which most of the time they don't. But I think it's with the infants, a lot of it is really supporting the parents. A lot of them are first time parents and so, you know, they're already anxious and things aren't probably going quite the way that they planned. And so it's a lot of things. Emotional support too, not just like the surgical part of things. Yeah, yeah.

Question for you. So because you're mentioning the stretching, do you have a thought process on? I feel like this has just come up lately. So it's like on the tip of my tongue, like rubbing on the wound. Like do you guide parents to do that or do you guide them to like do more of like a forklift kind of maneuver to help?

So I have them do like the scoop technique. I follow a lot of doctor, Dr. Chelsea Pinto's kind of protocol. I just took her most recent course too actually, and so I kind of do more of her protocol. I will say lactation has them do more of the forklift. So we kind of land somewhere in the middle, which I love. I want all the different options. So I'll show parents a few different options and say, do what works best for you. Do what feels best for you. I like just the quick, like, scoop on the wound because for me I can feel the tension. So some parents, I think if you're. If you're scooping right on the wound just once, you can feel if it's starting to tighten in there. But I don't want a lot of back and forth rubbing. And my stretches are very quick. I. I say it should take about 10 to 15 seconds to stretch everything. So I don't want the baby to be really stressed. I don't want the parents to be really stressed. I always kind of explain they're going to be. They're probably going to cry a little bit because you're in their mouth and they're protective of their mouth and they have a wound and like, you wouldn't want anyone doing that either. But they should settle very quickly and so get in, get out. Be effective. Really work on keeping that tongue up. So a lot of education about like that sleeping tongue posture hold. So pushing the tongue up to the roof of the mouth when the baby's asleep, that's a passive stretch. And I've found that that works pretty well. I think I've always kind of had that approach, but I've changed a little bit of like, the way I present it to parents. And I think lately the wounds have been better. You know, when I'm like, don't stress too much about this. Don't push too hard. Like you. It's a. It's gotta be effective but efficient. You know, you need to push hard enough that you're doing something. But I don't want everybody stressed out because, like, that's not good, you know, that's not.

That doesn't help healing, right?

No, it doesn't. Exactly. And like, you're. Then they're just mad. And what do we do when we're mad? We just scrunch up. Like we're doing the exact opposite of what we want. So I think that that's resonated pretty well with parents. So, yeah, not a lot of, not a lot of rubbing, but the forklift stretch. And I will say that also depends on the baby. It depends on what their initial presentation was. It depends on what their compensations are. I recommend like a pretty firm floor of mouth push. So, like, if this was the front of them, I have them push right here because I would say a lot of the babies I see have more of like the clenching type. And so that floor of mouth just wants to keep coming up with the tongue. So I try to emphasize that. So I do have them Kind of push at the floor of the mouth and then do the scoop and then kind of hold. So you're getting kind of both points. I've explained it too, as like a. If you have a cut rubber band and it's stretched between, you know, two things, you can stretch it even further if you were to pull both ends, but you can't get in there and pull both ends. But if you push and scoop at the opposite ends, you'll get a stretch. So that's kind of my way of explaining it to the parents. And that seems to click for them.

Yeah, no, and I mean, I like that. So we've seen a lot of recommendations out there for rubbing back and forth on the wound. And I'm like, that just feels very traumatic to a lot of our families. So, you know, we can't give active wound care where we're not licensed to do that. So we can really kind of help carry it out if it's been prescribed by somebody else. But we can't really physically say, change the care plan. We can do all the other stretches, but we can't do that one, like active wound care stretch or really advise, you know, advise on it differently. So we've had this, like. We're like kind of between a rock and a hard place. And we'll say, well, some of our providers say this, and some of our providers say this. So you do whatever you feel is best for you. We can't tell you what to do there. But I like what you're explaining because, you know, I think the floor of the mouth, like you said, we always feel so much tension in the floor of the mouth. So to kind of start there sounds. I mean, to me, I don't know that there's any provider that we work with that really uses that as a starting point. And I really like that a lot of them either do the forklift or recommend, like, just rubbing back and forth on the wound. And I'm like, these parents cannot tolerate.

Yeah. And I think the forklift, like, I know from a. From a lactation perspective, they've used. They use that as like a preoperative stretch. Like, they're working everything. And so they'll kind of have them follow up with that after. From a wound stretch perspective, I think it all depends on how you're doing it. Like, you can get a great stretch that way if you're doing it just right. But, like, that's hard on a baby. And the majority of the time, you know, you're trying to, like, hold their jaw down, do this. Like, it's just. It's so much. And if you're not holding the jaw down, you're not getting that great of a stretch. And so what are some ways that we can kind of hold the jaw steady where it's at? I mean, you're not forcing it open, but you're just not letting it rise up with the tongue. And I think that the floor of the mouth push has probably been like, the most pivotal thing that I've really started focusing on. That I think, has changed the healing of it.

Yeah, no, I love that. I really. I can't think of anybody else who's mentioned that on the podcast anytime recently. So thank you for sharing that because I think some parents will go like, oh, there's another option. Or I can maybe, you know, they can ask their provider about that or even have a provider show them how to do that. So that's amazing.

It was Dr. Baxter. He lectured on at the Light Scalpel, one of their CE courses, one of their big Breathe and Thrive. And he was talking about just when he sees them postoperatively at a week, if you. If you push down at the floor of the mouth, typically if the wound has started to reattach, it'll open. And so I kind of started. I'm like, okay, that works really well. Like, well, if we're doing it post op, why don't we just start having them do it? You know, focus their attention on that during the stretching, just like I do in the older kids. I have them do floor of mouth hold. So why would it be, you know, different for babies?

So, yeah, no, I love that. That's fantastic. Okay, so I know we're talking lots about lip ties. I feel like I've also seen quite a bit of discussion around tongue and lip ties also. It's probably just because of some of the accounts that I pop into and kind of check on what the discussion is. But, you know, there's a lot of people who talk about, like, oh, it's over diagnosed. Oh, it's over treated. And then there's some people who are like, it's the opposite. It's under treated. We feel like there's more kids who might be able to benefit from it. Do you have. I know you use function, right? Like we talked about that, but do you have any, like, perspective or opinion on this whole discussion?

I feel like I have a pretty decent perspective because I was in an orthodontic practice for four years, so I had the benefit of staying seeing patients, older patients and kind of saying, okay, how many times am I releasing the buccal frenum on these older patients? How many times is that an issue? How many times is the lip an issue? And I, you know, I wouldn't do those. I would say in an orthodontic practice, I was doing lip releases pretty frequently. Buckles, not buckles aren't as frequent, but I'm, I was doing them and they were problematic for some of these older kids. And they're kids who can articulate how their mouth feels and how things feel. So obviously a baby can't articulate that. But I, I do think that in general, in the infant population probably especially there is over treatment just across the board by some providers. Because if you're, if you think that that is the thing that's going to fix everything, you're wrong. And so if that's what your mindset is, you're probably over treating because you're thinking this is going to fix all these issues. And I don't think that the majority of the time it's just one thing. Very rarely have I seen one thing fix anything in the body. It's usually a component of lots of different treatment modalities. So the upper lip, I do have babies that come from their ob, maybe or pd. Like when they just take, when the baby's born, they'll be like, I think they might have a lip tie. All of them have a low lip attachment that is normal anatomy. It's like 96%, some very high. 96, 97% of babies have a labial, maxillary labial attachment that's low. So if you just look at the location, you can over treat very easily. If you're not looking at symptoms too, I will say also babies will use their upper lip to compensate. If the tongue can't move, they'll hold on with their lips. So you kind of have to watch and make sure that you're not thinking it's the frenum of the upper lip when really it's the tongue and they're just compensating. However, I've done some where I'm like, I think it's, it's just the tongue. You know, I don't think we need to do the lip. And then they come back for the one week post op and they're still having some of the same symptoms. And I reassess the lip and I'm like, okay, I think we should do it. So I, the lip, if they're having symptoms, I don't know, I struggle to not do it. There have been rare instances where I haven't. Maybe I'm too aggressive with the lip, but I feel like when I've been conservative, it's. I've ended up having to do it. The buckles, I don't do those real frequently in the babies, but I see them where they're very tight. You know, they're attached low on the ridge, which, again, everything is going to migrate. The upper jaw is going to grow down and forward, so those attachment points are not where it's going to be always. So if you're just looking at attachment point, you can get kind of swayed. But they're tight and their whole cheek is tight and their whole face is tight. And that's what I would see in the older ortho kids too, is so much facial tension. And in my opinion, that's got to impact expansion. It's got an impact position of the teeth with the upper lip. You know, the practice I was at was doing a lot of protection, as I think you should. I think that that is an essential part of everything where the jaws just aren't. They're not growing wide enough, but they're not growing far enough forward either. So that's kind of a missing piece. So for protracting, I felt like I would release the upper lip to aid that process as well. Because in my mind, if you have anything that's kind of holding the lip up against those teeth and you're trying to move everything forward. And same thing with the buckles. You know, that's more of. The buckles are going to be more of a width thing. But I've had, you know, kids that I've done releases, older kids, and their whole face is just relaxed and they're. They can feel it. Like they. They can tell.

I did do.

I did a lip release. I can't remember if I did buckles on this child or not, but the mom was a craniosacral therapist and so she. It was cool. She kind of did her things beforehand. And then I did the lip release. I think I did upper and lower lip. And so. So we did the probably lower lip first, and she could kind of feel some changes. And then I did the upper lip and she, you know, words I don't even know, but she was basically saying like, everything could just glide so much smoother. And so the way I kind of have explained it to the older parents is we don't really know what all that impacts, but it's a point of tension and a point of Tension that it shouldn't be that tight. And so, yes, it impacts lip position, but everything. There's so many cranial bones and so much movement right in that area that I think we underappreciate how important a missing piece that that can be. So my short answer is do some over treat, yes. But do some under treat, yes. And I don't have the magic answer for. For it either. I just try to guide based on symptoms and the individual patient.

So, yeah, no. And I can. I can really appreciate that because I did go into, like, a DNA vivos appliance myself a number of years ago. And I just remember, I mean, and I had all the traditional expansion and ortho as a kid, too, but I remember getting about halfway through and, like, I couldn't crank my appliance and put it back in anymore. Like, I was literally locked up and I was work. They had somebody in our. In the office who I was seeing in between my appointments even there. And he was a PT who was trained in, like, postural restoration and, you know, all but a whole bunch of other things, too. And I don't know, I'm like, whatever magic he worked, like, he would go, like, you know, map things on my head and then go somewhere on my body and be like, does that. Does that hurt? Or do you feel tension there? And I'm like, how did you do that? But he would release the tension, and all of a sudden everything was kind of like you said, it was like everything was gliding again and things were kind of smooth moving, and I could turn the appliance, put it back in my mouth. I was no longer locked up. And it was like all these tension patterns, and it kind of opened my eyes to this whole concept because I really had not. I had no education in that, you know, prior to going through this experience. And I just think it was fascinating. And so is that something? Like, do you feel like that's a big kind of lesson that you learned, like, working in that ortho office?

For sure. Yeah, for sure. How much it can affect the movement and. And just the, like, facial relaxation, too. I. I would love for the older kids to go and do bodywork. They don't do as much body work usually as the babies. I feel like those families are always, like, on it. But to convince some of the older parents, granted, I mean, they're an ortho, they're doing myo. They're doing, like, they have so much going on and their kids are in a bunch of activities. But I've tried To explain, like, sometimes. Yeah, when kids are locked up like that from expansion. Not that that was ever my focus, but, like, this could help. And it's very gentle. And it seems like, how could this do anything? But it does.

Like, it's magic.

Yeah. We don't need to always be so aggressive and forceful for things to change in our bodies. And I think that's, like, hard for people to understand. You know, it doesn't always have to be a surgery. It doesn't always have to be some, like, aggressive massaging or cracking of the bones or, you know, like, it can be very gentle to get a lot of changes, and those changes can help a lot of things. Like, it just. I think we have kind of moved away from, like, listening to our bodies a bit, and I think that that specifically, like, craniosacral kind of pulls back in that mentality.

Absolutely. I would totally agree. I mean, it was. It was wild having. What does he call it? He calls it, like, modern counter strain technique. So it's like, not your traditional counter strain. It's like, more modern version. And he's got, like. He's done so many courses and ceus, and he even, like, is teaching stuff now. And so it's like, to see everything pull together and then experience it. Like, I would tell people, I'm like, I feel like I went. I feel like I. He didn't give me a whole body massage, but I left feeling like I had a whole body massage. And everything just felt, like, so relaxed and so, like, everything was functioning in a very different way. Like, when I walked in, I didn't even know that I needed that, and I walked out, and I was like, oh, wow.

Yeah, you feel like fluid. My. My friend, the pediatric pt, who does. She's done some of that jealousy training. She'll ask me. She's like, can I practice on you? Because you're really, like, in tune with your body. And so. And she knows. I'll tell her, like, oh, I'm feeling this, or, oh, I noticed this. And I always love when she does sessions with me because I'm like, how did you fix that? Like, you didn't have to touch that area hardly at all. Like, I had. I think it was my knee with her, but I've had, like, my shoulder before. Like, just different things, and all of a sudden it's better, and it's even hard for me to comprehend, but it's. I think a lot of it is just, like, the fascial system adhesions, all that kind of moving the Lymph through the body is huge. So, yeah, that's a big component of everything I do. If I could just get everybody on board in a perfect world. Yeah.

And kind of on that same token. So do you feel like there's insurance, like, barriers that present even for your patients? I mean, obviously these, all these alternative therapies, sometimes you can get them covered, but a lot of times they may not be. So is that an issue?

I do. I, I think that often that's a question that patients ask, and maybe it's, maybe it's going to happen a little bit less now because they're specifically seeking out, you know, me separate from ortho. But that's a question that we've gotten a lot was, is my insurance going to cover it or I'm going to go to a provider who my insurance will cover? And I completely understand that. I have encountered that even myself, like, with trying to find, you know, just a primary care physician. I'm like, well, do I have to go to somebody who's in network? And I think it's a little bit confusing. Depending on what policy you have, and then dental versus medical and dental will still oftentimes cover a fair amount, even if you don't go to a network provider, depending on what type of policy you have. But that's, that's always a hard thing because we're like, well, okay, I get it, but make sure you're going to a provider who is doing a functional approach. Make sure you're going to a provider who is requiring myofunctional therapy along with treatment for the older kids. And sometimes you can go to. I mean, I've seen patients who go to providers who are maybe in their network, and then it didn't go great. And, you know, I'm not, I don't want to act like every result I get is perfect. That's not the case. It's the human body. But, you know, you can't let insurance dictate everything. You need to go to a provider who does these all the time, who understands really, like, the goals and understands the importance of collaboration. And I think, you know, if you find somebody who's in network who is doing all those things, awesome. But, you know, don't let insurance be the, the thing that guides the decision. But that's tough. And, and there's, I think we need better education about, like, what insurance actually does and what they cover versus what they don't and when they cover versus when they don't, because a lot of people don't know, even my, like I said, even myself with my own medical insurance, I'm like, okay, who can I go to? Like, I want to go to this person. It's okay to me if they're not in network. But I, they don't accept anybody who's adamant. You know, it's.

So there's a lot of different policies.

With insurance that are tough to navigate. Yeah, I think in dentistry the pendulum might be swinging a bit. I don't know. Do you, do you have that with speech like, do you have a lot of insurance issues?

So yes and no. Like we are a private pay practice, but we give a super bill so families can submit. So even though we're out of network, most insurances will still reimburse the families directly. Like they'll pay us, you know, and then reimburse the families. It's more of just the process of getting families to agree to that process because it takes a lot to submit, to track, to argue sometimes to get it covered. Some insurances require that you have pre authorization, others don't. And so, you know, thankfully none of our patients need like a script from a doctor are basically us doing an eval and saying, yes, you have this diagnosis and we are recommending therapy is enough if their insurance is going to accept an out of network provider. But because we're not, like, there's some insurances that want you to be in their system as an out of network provider and we don't do that. So you know, we're like, no, we know this is not legally required you if they have out of network services. So it's just a lot of advocacy and also explaining to families. And so like we have an insurance guide that we've created for our families so they can call and ask questions before they start with us. And then we, you know, how to then submit, you know, your claim after the fact if you're working with our team. So I will say the fascinating thing is that some families get better reimbursement out of network than they were getting like in network or it's exactly the same because at the end of the day they're paying a high copay or. And when you can kind of compare the money, it's like they're either paying this higher copay and so it ends up being about the same as what insurance is reimbursing them as an out of network setup. So it's, it's. And I've actually had situations also where my out of network parents were getting reimbursed. More than they would have if they had gone somewhere in network. Which was bizarre. But also doesn't surprise me because like you're talking about, we just had this conversation in my house last night. We were like, we pay an arm and a leg because I own a business, my husband's a partner in a law firm. Like, so it's cheaper for me as a business owner than it is through his firm for us to have it because he basically subsidizes the rest of the firm. Right. So there is that. So we're in a very unique situation in that sense. But to that extent, like it's still astronomically expensive and our deductible is astronomically high. And even though we go to in network providers, if I go for a sick visit for my kid or I do a telehealth appointment, $125 is the copay. Well, why do I even have this insurance? Because if I didn't have would actually be cheaper for me with all these out of. Because the cash pays are all rates are always. Are usually lower than the in network rates. And so then, you know, but then we look at it and we're like. Well, because catastrophic. If something catastrophic happens.

Yep.

You know, you can't just buy catastrophic insurance if you make money. So it's, you know, we kind of are cornered into having this insurance that we constantly go. We feel like we're just pouring money away every year into something that we're not actually using just in case we need it for something big, you know?

Yeah, yeah, that's exactly, that's exactly it. I feel like there's. You have to have it because if something big happens, you need it. Like my son broke his arm a couple years ago and I'm like, okay, well thank God, you know, but the.

Crazy part was like we. My daughter fell on her head and was vomiting 10 hours later. And so I took her for a CT scan. And this was two, three years ago at this point. And they charged our insurance $12,000 for that CT scan in the emergency room. Because we had insurance. Our negotiated rate was like 4K.

Yeah.

For that freaking evening. And that was. I'm sorry, that was just for the ct. That didn't include any of the other, you know, doctors, met, whatever.

Fine.

Okay. Had I been a cash pay person, I would have paid maybe 1500 dollars all in for everything. And I was like, okay, this is, this is where things start to get really confusing. Because I know that not extremely catastrophic, but still, you know, I just was like, it's Such a racket.

Well and I think for like the physicians it's so much, it's such a administrative burden on them to file with insurance, to, to talk to insurance, get things reimbursed to get the, the chase pre auth get the all the things. It's so much that they like they have to even charge more to basically handle that burden. Which yeah, it's, which is why we don't take it.

And I tell our families, I'm like, it would require me hiring a full time person just to manage insurance and there's no guarantee that we would be able to even continue seeing you based on whatever insurance decides. So you know, it's just. Yeah. So anyways it's really, it falls on the families and I get it because I haven't even submitted or even asked for a super bill for the two appliances I just paid for for my K. And the past few times we went to dentists and so I didn't even try because I was like, I just don't think it's going to be covered. And the this current time it's an orthodontist. So I'm like, we have ortho coverage in our policy. I might as well submit for each kid and see if we at least get something back since this is our third round for one of them or a second round for another. But again, just time wise I just haven't done it because I know it takes time.

We do, we give the baby families the super bill which will have like, you know, all the, all the parts filled out that we need to fill out. Then they just, we give them instructions and you know, I don't know, sometimes they cover. We'll usually tell them like here are the codes. You can call your insurance before you ever even come in and kind of get an idea of what they would cover. The older kids, we will send a dental claim for them as a courtesy but we do still have them pay up front and then if they get reimbursed it goes to the families directly. But yeah, it's. Insurance is just tough. I, I wish it was better. Yeah. But it's not. It's.

It's a whole business and it's a whole. Yeah, the model is not great. I know it's not great for the doctors either. And that's, that's the whole thing. It's.

Right.

It's a little tricky there. So I don't know. I, you know, I'm kind of part of me is like I hope it improves. I don't even know what that would look like, honestly, aside from just families actually being able to easily submit to their policies. I joke with my husband. I'm like, it is easier for me to submit the dog's insurance claims, and we actually get paid 80 to 100% back.

And this is.

I'm like, he was a frequent flyer last year, he just turned 12. So I'm like, he's getting older. We had a whole bunch of health things going on with him. And I'm telling you, I sat down, like, and spent an hour submitting claims, like maybe a month ago from the last six months, and got like, I don't know, it's a dog too. So there was nothing major medical major there, but it was maybe like $5,000 all in. And I got almost all of it back. And it was. It was easy to submit. It was like the check came a week later. I was like, gosh, this could just.

Be the experience like that. Right?

How do we get this on the human side of things? Got it down for the dogs. What about the humans? Great. Oh, man. And the other thing too, that I try to tell parents is, you know, I know IBCLCs, I think, can submit, you know, or not. Well, they can submit if they're in Niharc, but they can also give super bills, which is great. And then as like a speech pathologist, if you're going for like, MYO or feeding, oral motor speech, any of that, that's all billable on a super bill. And MYO for us is build under feeding. So parents should be able to get reimbursed for that. And so I just like parents to know, like, even if you're going to someone out of network, they, you know, ask for a super bill because, you know, the diagnostic codes and the CPT codes and what you paid and all that in one place works very well if you have that right page to submit to your insurance and to hopefully get some form of, you know, money back in your pocket.

Yeah, yeah, sure. Yeah.

Well, this has been amazing. Is there anything else? I mean, aside from telling us where you're located so everyone can find you? Is there anything else we want to talk about that we haven't covered?

I don't think so. I think we've covered a lot of ground.

Yeah.

So, yeah, my office is in Portage, Indiana. So that's where I've been actually, always. I've always practiced in Portage as when I did general dentistry and then when I was with orthodontist, and then I'll be actually right next door to where I was when I did general dentistry. So hopefully opening in July, maybe. Fingers crossed, I'm hoping. And right now I am at a temporary spot in Valparaiso and so if go to our website, it has the temporary location on there and if you book an appointment, it's very clear about where to go. And you know, we'll get that all changed when I'm in my, my final spot. So that's exciting.

Congratulations again. And we'll make sure that we link your Instagram handle and your both of your Instagram handles and your website so everybody can find you. And, and yeah, thank you so much for joining me.

Yeah, thanks for having me.

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@halim balkan.com or pop over to at Holly Balkan on Instagram to get.

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