Episode 50: Featuring Angie Lehman, RDH, COM – What subtle changes in the face tell us

Hi and welcome to episode 50 of the Untethered Podcast. Today we have Angie Lehman joining us. Angie is a registered dental hygienist and certified orofacial myologist. She is the owner of Oral Myofunctional Therapy of York in York, Pennsylvania and is currently the secretary for the International association of Orofacial Myology. In addition to private practice, Angie creates and sells OMT marketing and therapy materials and she writes and speaks regularly about the field of orofacial myology. Quick disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Angie, I am super excited to have you join us. I feel like this is way overdue. Thank you for being here.

Thank you for having me. I'm so excited that we're doing this.

I am too. And so I love to just jump right on into our topic. So I know today we're going to be talking about and that you actually write about a lot of the intricacies related to myofunctional disorders and how that impacts what we see on the face and in the mouth. So let's just take a nice nose dive into that topic.

Awesome. Let's do it. Yeah, I'm very much a detail person. It's just part of my personality. And so, you know, when I first started in this field, I feel like I could only recognize like the big things, you know, like if somebody had like an open bite a mile wide and you could see that tongue thrust, it's a no brainer. But I started seeing more patients where at the beginning when I was inexperienced, I was going, do they or don't they? Like, is there dysfunction? Isn't there dysfunction? And so of course I did what I always do and I dive into the books and I learned as much as I can. And I came across an article by Professor John Yu from Orthotropics in London and I think that the title of the chapter from A book that he wrote that was online was reading the Face, I believe is what it was. And it was really fantastic because I never really thought about it that way. I never thought about how we can read the signs. And so that was one of the first things that I read. And just through all of the books that I have, and I read every single one of them. If you've ever seen my bookshelf, I have a ton of information. I've just kind of gleaned all of this information and sort of put it all together. And now. And you probably can do this too, because you're very experienced and you can look at a patient's face and you know exactly what is going on before they ever even open their mouth. And so I'm just excited to talk today about the things that I look for. And hopefully you're going to be able to tell me things that you look for, too, that I may not have known. And we can all just kind of learn together how to decode all of those subtle signs of OMDs that a lot of us might actually be missing.

Absolutely. So where should we start? What part of the face? Or what's your favorite one to talk about?

I feel like we need to kind of get a broad picture and then we can sort of narrow it down from there. So when we think about the face and we look at our patients faces, we have to remember that the bones are a framework for the soft tissue. So anything that we see going on with the soft tissue is just going to tell us exactly what the underlying issue is.

So.

So usually one of the first things I do when my patient comes into my office is I just evaluate their face. And the easiest thing to look for at first is just symmetry. You know, Nobody has a 100% symmetrical face. All right? It actually looks odd if we do. But we don't want to see major asymmetry in a patient's face. So the first thing I look at is the eyes. Are they level? Do we have one eye that looks like it's a lot higher than the other? And then I kind of compare that to the smile line. So I may have them smile and I'll look. And sometimes you can see one side of the smile is much higher than the other. And one of the things I've learned through the years is if you have one side that's high, the eye and the smile on the same side, it often is an indicator that we've got, like, cervical vertebrae problem. And so one of the first referrals that I would make for that patient before I ever even look in their mouth would be probably a chiropractor or a PT who can address cervical vertebrae dysfunction for them. Because I know already that this case is gonna go a lot better if we address that issue too. If I see that they've got opposite issues. We've got an eye that's high on one side and the smile line that's high on the other. I might look for a cant of maxilla. All right. They may have, you know, bone structure that's kind of skewed. And there's not a lot that we can do non surgically about a canted maxilla. But I know that those muscles are not going to be functioning correctly. And so now I'm going to kind of tailor my treatment plan a little bit to what I happen to see on their face. So that's really one of the first places that I start. Another thing that I might look for is torticollis. Okay. I've actually seen patients with cross bites from severe torticollis. So, you know, that would give me another clue as to what is going on in their mouth. If I see that one SCM muscle is like really, really prominent. I'm going to look for a cross bite in their mouth because it's all connected. That might be the reason that they have the cross bite to begin with. So, you know, those are the things that I think about when I first look at every patient's face when they first come in. And then I'm going to take a look at the symmetry of their face from the perspective of do we have equal thirds? So we know that we're supposed to have equal thirds. You know, the forehead, the mid face, the lower face should all be about even. All right. That's our mesocephalic profile. That's perfection when we think about what we actually want to see on a patient's face. But is that patient brachycephalic? Do they have a shortened facial height? Are they dolichocephalic? Meaning that they've got an elongated facial height? So they've got that long, thin profile, and it's typically the lower third of the face that's elongated. That's a huge red flag for me. If I see a patient that has the lower third of their face elongated, the first thing I'm going to think about is what's their jaw posture? Because we know in our field that if we have jaws that are open beyond the normal 2 to 3 millimeters of freeway space at the molars, that patient, if they're in that position for a long period of time, they're going to get super eruption. And now we have somebody who could potentially be growing into a skeletal open bite. We definitely have somebody if that jaw is hinged open, we definitely have somebody whose tongue is not resting in the right position. Right. So it's now low, it may be forward in the mouth. And now they're kind of growing into that hyper divergent profile. They've got a steep mandibular angle. All right. That steep mandibular plane. And now we're going to have other issues later on down the road. And if it's a growing child and if they're young enough, oh, my goodness, isn't it amazing what we as therapists can do to help get them back on track? That's one of my favorite things to do.

So cool to see what we can do.

It is, it is. You get that patient in your chair and just by correcting the muscle posture, we can actually change the trajectory of growth for these kids. And it is so exciting. The problem is if we miss it when they are young, they are going to grow into that teenager or adult who now is a candidate for oral surgery that could have been avoided. And they now have the perfect profile to set them up for a sleep apnea risk later on. Obstructive sleep apnea. Because all of us know that sleep apnea is, you know, it's a structural issue in a lot of cases. And so that's one of the things that I want to look at is what is their facial, you know, what is their facial profile? I want to look from the side too. Okay. I want to see that the forehead and that the maxilla and the mandible are all kind of in a straight line. That straight profile is a good, good thing that tells me that the jaws are far enough forward. That means that we're going to have a healthy airway. But if I see that those jaws are set back a little bit, then we know, okay, we've got some mid face deficiency, all right. We've got some maxillary hyperplasia, meaning that upper jaw isn't growing to its full potential like it's supposed to. And I know you've had another, you know, enough other people on here talking about what happens when we have a low tongue posture. And hopefully all of us know by now that if the tongue is not resting in the upper palate, it's not going to grow to the right size and shape. So there are ways that we can tell a patient's tongue posture before we ever even look inside of their mouth. And that's one of the big ones. Look at that patient's profile. I might look at a patient and they have that Class 2 presentation. They're retrognathic. The jaw is sitting back a little bit. And I'm going to be curious about their tongue posture. I'm going to be curious about tethered oral tissues for sure. You know, I'm going to wonder, is there a reason why that jaw is not growing forward? I'm going to wonder about their airway, going to ask them about their sleep. And I'm pretty much going to be guaranteed to find small jaws and crooked teeth as soon as I look in their mouth. But I can tell that before I ever even have them open their mouth. So those are some of the things that I look at with profile. The next thing I'm going to look at is the muscles. You know, I palpate, I feel, do we have strain on the mentalis? That might indicate that we have a short upper lip, that we've got some lip incompetence. It might mean that even if we have competent lips and the lips can stay together at rest, but they swallow. And I see strain bunching on the face. You know, the lines around the mouth, the stippling on the chin. I'm going to go, okay, we've got an issue with the tongue sealing against the palate inside of the mouth. And now they're recruiting facial muscles. And sometimes you can see that lingering strain on the facial muscles before you ever even evaluate their swallow. You know, sometimes you even see people with like the constant parentheses around the mouth. Some people think it's an aging thing or you just need a little bit more Botox. But for a lot of people, again, you know, soft tissue is supported by hard tissue. If they have retronathic jaws, if the jaws are pushed back too far, you tend to get those lines around the mouth that stay there. You can even see it around a patient's eyes when they smile. If they get really squinty and they've got lots of lines around the eyes, again, that tells me they have a mid face deficiency. So those are all kind of things that I look at just looking at the face in general. So those are some of the big things. So next thing I look at are the eyes. I did write an article about, you know, subtle things that we can tell by looking at the eyes. It was an RDH magazine a couple of months ago and I didn't Expect to get such positive feedback from it. But I really, really did. And I thought about the fact that, wow, this part of it really isn't common knowledge. We know to look at the jaws, okay, we know to look at some of those other signs. But sometimes there's a lot that you can tell by a patient's eyes again before you ever even look in the mouth. So one of the things that I look at is when I look at that patient straight on and they're staring straight ahead, I want to see if there's any visible sclera under their eyes. So basically in English, what that means is, can I see the whites of their eyes below their iris when they're looking straight ahead? Obviously if we all look up, you're going to see white under the eyes. But staring straight ahead, what do you see? We should have part of that lower eyelid covering part of our iris. So again, what does that tell us about the maxilla? It means that we have maxillary hypoplasia. It means that the jaw, the upper jaw is underdeveloped and the maxilla, remember, supports part of the orbit of the eye. It makes up part of the orbit of the eye. So if we change this structure, if we change that mid face bone, it's going to affect other areas and it will affect the orbit of the eye. Another thing that I look for is the shape of the eyes. All right, if we have a really wide and well positioned maxilla that's going to support and lift the soft tissue around the eyes and prevent that like wrinkly look that we sometimes get or that squint look. But it's also going to determine the shape of the eye too. And so the canthi, the lateral canthi, meaning the outer corners of the eye sometimes will kind of turn down a little bit in a patient that doesn't have a really wide maxilla. So that might be another thing that I look for. And you can see a combination of this in some patients. Some will have the visible sclera, some will have the downturned cant thigh. But it could be one or the other. Could be one or the other or a combination. And then obviously venous pooling allergic shiners. That is hopefully a no brainer for a lot of people. If you see that patient that has the dark circles under the eyes all of the time, that's another huge red flag. We know to look for that. For a lot of patients it could be acute. It just happens during allergy season, it happens during illness. All right, that's one of those things where it just depends on how long allergy season lasts for somebody. I get a little sniffly about two weeks out of the year and then I'm good, not a problem. But if it's for like a whole season or two whole seasons out of the year for some of these patients, then we need to get them to the allergist because again, we can't teach the mouth to stay together, the lips to stay closed if they can't breathe through their nose. So that's an indicator that we've got to refer. But the other thing that we have to think about too is for those patients that don't have allergies but still have venous pooling. Have you ever gotten one of those in your chair where mom swears up and down they're not allergic to anything and you're going, why? Why do they have such dark circles? Right. So I did a little bit of research when I was, you know, writing my article about the eyes and I found some really interesting information. And again, this should have been a no brainer for me, but it was a little bit of an aha moment for me. Again, if that maxilla is too small, it doesn't just affect the orbit of the eye, it affects all of the structures behind it. Okay? And so we've got these different fossa behind the maxilla where we've got veins running through to all the different places in the face. So basically, if you have a smaller maxilla, the space behind the maxilla is tinier. And so that pterygoid venous plexus behind the maxilla is actually going to shrink. And then the infraorbital vein comes out of there. And if that area is smaller, then there's going to be a little bit of backlog in the blood flow, hence the venous pooling for people that don't have allergies but do have a small maxilla. And so that was a little bit of a thing for me that I went, ah, that makes so much sense. Sometimes I see patients and I don't see any, you know, evidence of allergies except the allergic shiners. What in the world is going on? So that's what's going on that's so interesting.

And actually that makes me, I mean, it makes sense, right? Obviously, when things are condensed in space, they have other things also have to condense in space for everything to fit. So, you know, that would make sense that it would impact what we're seeing. And it's been pretty cool to Work with my manual physical therapist who does modern counter strain technique, because as he works on me and I have an omd and I have so many of these things that you're saying. I'm sitting here looking at myself and going, we all do.

Yeah.

I'm like, oh, yep, got those lines. I thought it was age.

Oh, yep.

Got the downturn eyes. Oh, yeah. And I also have a. I have a droopy eye on one side. I have the ptosis, and I've had surgery on it three times, and the muscle never holds. I wonder why. I wonder why. So obviously, I'm an adult who's in expansion with the DNA, and everybody who listens knows that. But it is really cool to watch my facial structure change because as my upper jaw is expanding, my lower jaw is also expanding, and they're not quite matching up just yet. My lower jaw, which you're like, yes, I see that, Holly. But it's pretty cool to see how everything else on my face is also following. So. And how I'm not really getting these. I'm not getting the pooling under the eyes. I'm not, you know, so even though I haven't slept and I'm exhausted, you know, more so just that droopy eyelid that really stands out when I'm tired at this point.

So.

But it is. It's so interesting to hear you speak about the eyes, because I have not gone down that rabbit hole of research on the eyes so much. And so that's really. That's very fascinating. It makes sense. But I mean, how cool to.

I know, I know. Well, I kind of. I'm one of those people. And this is kind of funny. Like, I have a really strong stomach, and obviously being in dentistry, man, I love getting in there. Blood does not bother me. Guts, gore. Like, I'm cool with all of that. But eyeballs, oh, my goodness. Like, I just can't even. And I actually have. One of my sons has a condition called retinitis pigmentosa. So he is actually losing vision. So he's losing peripheral vision, and he doesn't have any nighttime vision because the rods are dying. And so as we've kind of, like, followed this journey of eye stuff with him, I've had to go to a lot of appointments where I have to, like, talk myself through it. And I'm like, okay, Angie, you can totally do this. Even though they're putting these electrodes on his eyes, and I'm getting a little grossed out. But it's been really fascinating, and it made me really Start thinking about eyes in a different way. Just because I do have a child with a little bit of vision loss. And I actually had a really interesting thought maybe about a year and a half ago, it popped into my head. I thought, I wonder, as I was at an eye appointment with him. He also has an astigmatism and my sister has an astigmatism and my husband has one too. And I thought about the three of them and I thought, you know, they all have high narrow maxillas, all three of them. And I thought, okay, if we know that the maxilla is part of the orbit of the eye and the shape of the orbit of the eye is changing a little bit. We know that because, you know, that's what we just talked about. I wonder, this is my speculation. I wonder if an astigmatism, which is just basically, you know, the eye is a little bit more oval shaped than round, could that be a soft tissue reaction to a structural issue too? And these are the weird thoughts that I have, like late at night, the things that like pop into my head at 3am when I can't sleep. And then I was at the IOM spring training in March and I roomed with Seema Virji. And if you don't know Seema, she is just absolutely fantastic. She's a COM in Canada. And Seema and I were sitting up late at night, like way too late, talking like a bunch of college girls. And we were having a blast. And we got on this whole topic of eyes because she's got some eye stuff going on in her family history too. And we both realized that we had the exact same epiphany about astigmatisms and high narrow maxillas. And we did the old, oh my gosh, like maybe we're actually onto something. So of course I hadn't really researched and I don't even know how to go about any of that. But it's so fascinating that we both had that same thought where, okay, we know that the structure is compromised. Why couldn't it change the shape of the eye too? So it's just these are all interesting things. It would be interesting someday to see a study that compares the shape of the eye pre and post expansion. You know, pre and post, like surgery, like all of the things that we do. Does it change the eyes? And the other thing that I had happened to me was really, really fascinating. I had a patient about a year and a half, two years ago, and this is probably why I started thinking about the whole astigmatism thing, but he had amblyopia. So we had the one eye that turned inward and he had a pretty strong prescription. And every time he wore his glasses, his eye would track straight. But if I saw him without his glasses, the one eye was always turned in and he had a really significant tongue tie, like very, very significant tongue tie. So he did expansion and then we did therapy. And through the course of therapy we did the frenectomy and I was taking his final pictures when we were done. And often when I take photos of patients, I'll have them take their glasses off just because of the glare. And so I had pre pictures of him without his glasses where you could really see the eye. And then I took some post pictures of him without his glasses and all of a sudden it hit me that eye's not turning in at all. So I went back through all of my camera pictures and I take a million, I take tons of pictures to finally land on the ones that I want. And in every single post op picture that I took of him, every single one without his glasses, his eyes were tracking straight. It was the craziest thing that I've ever seen. And again, I don't have the science behind it to be able to back up what was going on, but there had to have been some sort of connection between those tethered oral tissues and the muscles in the eye. And so it's kind of a mystery to me, but it was one of the most fascinating and also one of the most rewarding things that I've ever done. Especially because he's family, you know, it's one of my cousin's children. And so to be able to have that kind of impact on patients when you don't even expect it, man, like that's. It's awesome. It's a good feeling, isn't it?

And it makes me wonder. So in our local study club, which we haven't really done in a while given the circumstances right now we have a vision therapist who joined us recently. Yeah. And she. I want to ask her about this and see what she knows because we started to pull her. And I noticed that a lot of our pediatric patients who are receiving occupational therapy, who are in feeding therapy, who have other maybe speech language delays, who have functional disorders or any combination of those, and have tethered oral tissues oftentimes too, with some of those other issues going on, a lot of them are candidates for vision therapy. And vision, I mean, vision therapy is so cool, but it's also exhausting. From what I Understand. And I have to wonder. And what I'll say is, what I notice is when you take more of a holistic approach, right. We're working on the myofunctional disorder. We're working from the vision standpoint where maybe there's an OT involved, maybe the speech. The speech pathologist or the myofunctional therapist, you know, rdh, comm, whoever is working with that child. When we see this team working together, we tend to see, like, you're talking about much faster results. And also we see things change that we weren't even directly working on because everything is now working as a cohesive whole. And it's so cool and so exciting and so rewarding when you're like, oh, my gosh, we weren't even working on that, but, like, look what happened. So I think there's something to it with the vision piece, though, because that's definitely. I've gone down that rabbit hole a teeny bit with some patients who have gone into vision therapy, but never specifically with what you're talking about with the astigmatism and, you know, the high, narrow maxilla. And so now I'm really curious about that. And I'm going to go email Amanda when we get off here. Yeah, I'm going to be like, hey, Amanda, you know anything about this?

And I'm totally going to invite myself to your study club.

Yes.

Yes. Well, actually.

This is very premature, but I am launching a MYO membership, and we're going to do like, a monthly, like, couple hours of CEUs, but it's also going to be an online study club. And so, yeah, so we're going to have, like, an online study club, and we're going to have research reviews, and we'll talk a little bit about business stuff, too, because that's my passion. And so that's all coming down the pike in a couple of months. But, yes, if we do, like, a local study club, one, I was thinking about getting everybody on Zoom. I'll talk. Totally invite you. I think you would.

I totally am. It's worth the commute for me. Well, that's interesting, because we actually have a big vision therapy center in the town next to mine. And so I actually put vision therapy as one of the little boxes to check on my health history finally, because I had so many kids that were doing vision therapy and doing myofunctional therapy that I couldn't tell is there definitely a connection or do I happen to see a higher number of kids that are in vision therapy? Because we actually have a center available to us, whereas a lot of towns don't. I know from what I've heard, our vision therapy center has people drive from all over, because sort of like us, the therapists are few and far between. And so, you know, I have noticed that correlation. So it's so cool to hear you say that, because, you know, after talking to Sima and now you like. It just kind of confirms some of these hunches that we've all had for a little while that there's such a connection between the mouth and the eyes. Oh, yeah.

And also with Manny, my physical therapist, who does the manual counter strain I actually had, who he works with and learns from, collaborates with Brian Tuck. He was recently on the podcast. And they're just. They're fascinating human beings. They are such a wealth of information. And as I was mentioning, every time he works on me, because I get. He's in my dentist office, so not only do I see him when I go for a DNA adjustment, I get a mani adjustment, but I also go to him in between. And, I mean, I always joke. I'm like, it's like you barely touched my body. And I feel like I had a full body massage because everything is just working in unison and working together again. But it's pretty cool to see how, like, he'll go over here, and he'll do some, like, cranial stuff, and then he'll go, oh, yeah, we need to go over here. Oh, yeah, we need to go down here on your leg. And he'll go on my face, and he'll go like this, and he'll drain something. And I'm like, oh, my gosh, I can breathe better. I didn't even realize I wasn't breathing properly. And I'm a myofunctional therapist. Like, what's going on?

So it was.

It's pretty cool. I mean, because I've seen, you know, like, fatigue go away. Like, my eyes seem to be functioning better. My nose seems to be functioning better. It's full body, and it's pretty.

Exactly. That combined with the fact that as your maxilla expands, the airway is opening up, your nasal. The floor of your nasal cavity is changing. And that's such a cool thing. That has such a huge, huge impact. Yeah.

And then one awesome on that is whenever I feel like my appliance won't adjust anymore. Like, I can't crank it. It's just kind of stuck. If I have an adjustment with him, all of a sudden my appliance will allow me to crank it. And so it's definitely. And he talks a lot about how I have a Mac. We used to think that my. My mandible actually was off center. And what we realized was my maxilla was turned in on one side. He's been working to help me bring that into, you know, a point of homeostasis and more symmetrical so that I can continue my expansion properly. But it's pretty interesting what you start to learn about not just your own body, but the human body in general when you go down this rabbit hole of myo and all the related things.

Yeah. And even to think about how these subtle changes that we make, the subtle changes that somebody who's doing craniosacral therapy or another type of manual therapy can have a huge ripple effect on the homeostasis. Like you said, the health of our body just by making these small little adjustments, it really, really is a powerful thing. So it's very cool.

I know we went off the tangent here, but I love this.

Okay, that was a fun tangent. That was a good tangent to go off of, But I will get back on track.

What should we talk about next?

Let's talk about the nose next. You know, we're talking about looking at the face. We're talking about the mid face. So we have to look at the nose, because we really can tell a lot just by looking at somebody's nose. So sometimes somebody's septum is so deviated that you can see it when you look at their face. And you're not sure. You're like, okay, are the jaws kind of skewed? Is it the nose? Like, sometimes you have to almost take a photograph and look at it later to kind of determine what's going on. But sometimes you can see that deviated septum. Sometimes I can't tell on somebody until I look at their cbct. And I go, oh, yeah, we've got, like, a little bit of a deviation in the septum. But I just had a patient recently who I took a look at, and I could not tell when I looked at her face. I didn't have any films on her. But as soon as she put her head back, one nostril was much smaller than the other. And so I went, oh, I would be suspicious that she would have a deviated septum. So I can't confirm it because I don't have her films. But that's a really good clue to look at, is nostril size. And sometimes you can see really small nostrils on people. And you go, no wonder we have Issues with airway. So that would be if I'm suspicious that we've got some structural stuff going on in the nose. That's an automatic referral to the ent, just to have it checked out and see if there's anything that could be done. Another one that's kind of a subtle sign that not everybody knows to look for is that little crease right across the middle of the nose. And I know that you know what this is, but I've seen it in patients, and I've pointed it out to them, and I've said, do you know what that little line is right across your nose? And meanwhile, they're, like, sniffing and taking their hand. And I know this is a podcast so people can't see what I'm doing, but I'm basically taking either the back of my hand or the heel of my hand and brushing it up my nose because there's that constant drip for allergies. And so I tend to see this. Yeah, we call it the allergic salute in a lot of people that have just the chronic underlying stuff, like a little bit of drainage. And we often see it in kids that don't get a tissue yet when they're supposed to, and they wipe up on their nose so often that it actually creates a little tiny red crease right in the middle of the nose. And so that's always a fascinating thing to see. Another one is just a bump or that hook kind of in the bridge of the nose, because, again, nasal cartilage is supported by the maxilla. So if we don't have a big enough maxilla to support that nasal cartilage, then we're gonna get a little bit of hooking of the nose. And so people tend to end up with that little bump in the middle of the nose. I've even seen in some of my patients that have chronically enlarged adenoids and really bad allergies that they'll even get, like a little bit of an enlargement kind of up in the bridge of the nose right where your glasses would sit. So it's a good idea, when you're evaluating your patients, have them remove their glasses if they wear them and just kind of feel and look, because that might be another sign, too. Before you ever even look at their CBCT or send them to the ENT to have their adenoids checked out, sometimes you can tell just with a combination of the allergic shiners, the bump in the middle of the nose, like that sleepy, droopy, puffy appearance. We've got an airway issue. So those are other things that you can look at. And now, of course, we have to talk about lips because that's one of the big things that we do. I actually, before I started doing therapy all the time, I look back at pictures of myself, and I have a really thin upper lip, and I had a really full lower lip, and it wasn't so full that it was everted, but they definitely weren't even. And I realized, like, a few years into therapy, I looked at myself in the mirror and I was like, my lips have actually changed shape. And I never had issues with lip incompetence before. I was never a mouth breather. I always keep my lips closed daytime and nighttime. But it was amazing even for me, just doing therapy throughout the day, multiple days a week with all of my patients. Even my own lips changed a little bit through therapy. But that's one thing that is kind of common that I see is that with a lot of these people with a real subtle dysfunction, they've got the really thin upper lip and the fuller lower lip. But then, of course, you've got those patients that have the averted lip. You know, you can tell that lip is droopy. You can see the demarcation between the tissue of the lip and intraoral tissue. And so there is so much that we can do with the verted lower lips just through therapy alone. It's remarkable to see how the lips can change just once. We work on lip seal lip strength, and obviously we want to look for incompetent lips, and even competent lips can be dysfunctional. All right, again, we can look at the smile and see is it even. Is it symmetrical? Is there chapping or cracking on the lips? You know, that might indicate that somebody is either mouth breathing daytime or nighttime. If they've got, like, a little bit of angular cheilitis in the corners. That sometimes is a vitamin issue, but sometimes it's just a poor saliva handling issue. And it's constantly wet, and so it gets kind of chapped and kind of sore. And so that can be an indication that somebody's got poor saliva handling, which is orofacial myofunctional disorder in and of itself. And then for you and every other speech pathologist, you guys notice right away if somebody's bilabial sounds are not correct. You know, if you watch certain people speak, whenever they say P, B and M, they aren't doing it correctly. The lips are not meeting. I've seen people kind of like, tuck their lip in to kind of make the sound and acoustically, it sounds right, but it doesn't look right. And so that's another thing that I think, especially for the dental professionals, look for that, you know, watch people talk. Because even though we're not trained with the eye that you're trained with in speech and language pathology, boy, there's a lot that you start to see when you know what to look for. So that kind of wraps up everything that I look for extra orally or on the face. Are there any things that you look for that I haven't mentioned that I may have missed or maybe not known about?

I mean, you covered it pretty well. The only other thing that I noticed when I'm looking at the face, symmetry, maybe you mentioned this and I missed it, but I look at the masseter muscle, because if you are seeing like that, and this is so common, because I do deal with a lot of kids who come in for feeding therapy issues. And when they're coming in for feeding therapy issues, you know, I'm going, what's going on?

Right.

So obviously I'm going to get in their mouth. I'm going to do everything you talked about. And I don't look at the eyes as much. I should start that. But I'm looking to see. Do the masseters just at first glance, from what I can see, are they symmetrical or does one side look more overdeveloped than the other? Because oftentimes a lot of my kiddos chew on one side of their mouth and it develops the muscle, and that's where you start to see that asymmetry. And you can actually see that masseter muscle bulging more on one side, whereas the other side looks kind of flaccid. So, you know, I would add that, but I think other than that, you pretty much, you covered it all.

I'm glad that you brought that up because it was in my notes and I totally missed it. But you can actually see that in your adult patients with TMJ issues, too. You know, somebody has inflammation on one side, that one masseter is going to look larger. And again, you know, if they're a unilateral chewer in childhood, they're going to be in adulthood, chances are, if they haven't had any type of intervention. And so that's another good one, is just palpating and looking at all the facial muscles as well.

Absolutely. Let's jump inside the mouth.

Yes. This is like one of my favorite parts. So if we dive in, there's a lot that I can tell before I ever even talk about Tongue posture with a patient. Like, I know, you know, you know where it's resting, you know? But I still like to ask them, especially the kids, because I feel like kids are so good giving you an honest answer. You know, you ask an adult, like, where does your tongue rest? What structures in your mouth do you feel your tongue touching? And they're, like, baffled, like, they can't answer it. But a little kid is like, well, my tongue tip rests behind my lower teeth, and my tongue doesn't touch anything else. Like, oh, okay. And they're always right.

Like, the best answers come from my pediatric patients. And the adults are like, hold on, let me think. I don't know.

Let me.

I'll pay attention to that. This week, it might be kids. Like, I've had kids go, oh, just kind of hanging out in the middle of my mouth, not touching anything. Or, oh, it's. I feel it touching my teeth, but only, like, on the back part of my tongue. Like, the front of my tongue is just, like, pushed. And then maybe they'll say, like, oh, it's kind of, you know, in between my teeth. Or. And I'm like, this kid is right.

Or they'll show you, like, it likes to rest here while it's, like, hanging out of their mouth. Yes, I know.

I can see.

But, you know, there's other things that we can look for, especially if a patient can't quite answer that question. And obviously palate. The shape, you know, is it high? Is it narrow? I can tell you if that tongue is resting up there or not. Even if we just look at the rugae, you know, around what we call the spot or the incisive papilla. For all of the dental people listening, if you look at those rugae, those ridges on the front part of the maxilla, they're going to be super flat if that tongue lives there. But if that tongue doesn't live there, they're going to be very, very pronounced. So that's one thing that you can look for, that you can know right away how much time that tongue is actually spending in that area. And then just looking at the lateral borders of the tongue, you know, looking for scalloping. If we have small jaws, chances are we're going to get scalloping on the tongue. That could be an indication that maybe we've got some obstructive sleep apnea or even just uars, you know, just a little bit of upper airway resistance syndrome going on, a coating on the tong. You know, I know they talk about this for babies that it's not really thrush. They think it's maybe like more of an overgrowth of the filiform papilla from lack of tongue to palate contact. But you can see it in adults sometimes, too, if they have a little bit more of a coating on their tongue, and it's not because they're sick or they've got something else going on, sometimes that can be an indicator of how much time the tongue is spending on the palate. Linea alba. This is a big one. So those white lines that you get down the insides of the cheek, for some people it's just a habit from biting the cheek. For other people, you know, if they've got occlusion issues, they're going to bite one side of the cheek all of the time. I used to have linea alba all the time, and after I had my frenectomy, I don't get them ever anymore. So there must have been something about the way that I was holding my cheek, you know, cheeks against my teeth prior to my frenectomy. I thought that was really interesting. And so I don't know exactly what's going on with all of that, but it's one thing that I look for in my patients. Is it present? Is it not? And then I look at their occlusion first and see what's going on. Poor saliva handling is another one. You know, the people that have a lot of saliva kind of pooling up in the bottom of the mouth, that could be an indicator that we've got an OMD as well. And typically, those people with poor saliva handling, where it really collects, they may get a little bit more tartar buildup around those lower teeth. And of course, we have a salivary gland that opens up right in that area. And so that's why we tend to get more buildup on the lower anterior teeth and the upper buccal side or cheek side of the molars as well, just because that's the location of the salivary glands. But that's definitely one thing I think about when I look at a patient's mouth and then just inflamed gum tissue. We've got our mouth breathers that may have reduced salivary flow. Okay, so we've got that air hitting the tissue all of the time. And the tissue can become really swollen, it can become red, it can become like what we call rolled margins, where, you know, a hygienist and a dentist is going to know what rolled margins look like. The tissue is not like that knife like appearance. Where it's nice and flat against the tooth, but it's really bulbous. And so that's an indicator that we've got some drying of the tissue. And histologically, basically what's happening is it's an incomplete keratinization of the gingiva. And that's because we've got air hitting it all the time. And so that's one thing that we can kind of look at. And every hygienist who has a mouth breather in their chair is going to know, you know, sometimes I remember when I was doing clinical hygiene, sometimes that patient sits down and you look at the anterior gingiva and that stuff bleeds before you ever even get in there. Like, you look at it funny and it starts to bleed. And so I never, years ago, before I was in myofunctional therapy, I never made the connection, but now I definitely do. Another thing that we can look for is just the elongated uvula. If we've got sleep disordered breathing, or upper airway resistance syndrome, then you may have that elongation of the uvula. We've got some pressure issues when we have somebody who's snoring. And so it's going to kind of pull and elongate that uvula. And even just a red throat. You know, I look in the back of somebody's throat and I see that they've got a little bit of redness back there. It might be a case where, and usually I'll ask them, when you get up in the morning, do you cough a lot or do you have a little bit of post nasal drip? Do you feel like you have to clear your throat a lot in the morning? And so that can sometimes be an indicator of some sleep disorder breathing too. We've got a little bit of excess mucus and in the airway just because of the turbulence from the upper airway resistance syndrome. And so it kind of creates some surface tension which increases the collapsibility of the airway. And so it leads to that like, sticky, viscous coating that is kind of created because of that turbulence. And so that could be a sign that somebody's got an underlying breathing issue. And so those are all things that we can kind of look for and question our patients about before we ever even look at our next topic, which is the teeth. So the biggies, we know this, all right? Narrow jaws, crooked teeth. We know that if that tongue, again, if that tongue is not resting up in the palate, it will change the size and shape of the jaws. And so that's a huge red flag. If we've got crowding, if we have malocclusion, guys, we've got a muscle problem. It just, you can't not, you know, there's something going on and it's the old, like, you know, what happened first, the chest chicken or the egg, who knows. But if we have narrow jaws, we have poor function that we need to address. And obviously other big ones. An open bite, whether it's just a dental open bite or a true skeletal open bite, is a red flag. A cross bite in patients is a red flag. A severe overjet in a patient is something that we look at. If we look at somebody's teeth and they are a mouth breather, we might notice what's called decalcification on their teeth. They've got kind of those white spots. It's not a cavity, but the enamel is starting to break down. And so that can be a giveaway that somebody is mouth breathing, even if they are like a daytime nasal breather. But you're kind of suspicious that they mouth breathe part of the day or at nighttime. You could look at the enamel of their teeth and maybe find a couple of clues there. I actually learned something really fascinating a number of years ago. I was at a seminar. Dr. Juan Moon was talking about skeletal expansion. And he actually said that if we have somebody who has congenitally missing teeth, so as the adult teeth are growing in, they're just missing a couple of them. And it's usually the upper lateral incisors that are the most common. If you have somebody with congenitally missing teeth, you're automatically going to be thinking that there is some maxillary like hypoplasia, that they don't have enough bone structure on the maxilla, because growth of the maxilla doesn't just happen from the suture, it actually happens from the tooth follicle as well. So if somebody is missing permanent teeth, then they're not going to be growing as much bone. And so that's another thing to think about that I had never really considered before. That kind of blew my mind when I heard it. So these are all things that we can kind of observe before we ever even look at their function, before we ever even watch them swallow, before we ever even watch them chew, before we ever even watch them speak. All of these little clues that we look for can kind of tell us whether or not there's some sort of dysfunction. And again, like I was saying earlier, when you're a new therapist and you don't really Feel confident in your ability to evaluate, and you have one of those subtle cases come in. I remember the very first time I had somebody who looked like they had all of the signs but their swallow looked normal. And I was like, how is that even possible? And then I do the old, do I treat or don't I treat? And some people, it's an anomaly. But every once in a while, you see that patient that has a perfectly normal swallow, but they have poor oral rest, posture, and they have poor growth. And those patients absolutely need myofunctional therapy. Okay? It's affecting their growth, even if it gives the appearance that function is fine. So I think even beyond this whole subject of looking for signs without looking at function, we still, on the flip side of that, we have to know what good function does look like and what poor function looks like as well. Because sometimes the signs of poor function are just as subtle as these facial signs that we see, and we can't miss it. You know, I think a lot of these kids fall through the cracks if they've gone to the orthodontist and they've had beautiful expansion, and maybe they've even used a couple of, like, myofunctional appliances. And then in dentistry, we think that the job is done, and it is not. You know, sometimes I look at these cases where I go, okay, the maxilla looks beautiful now. It's a beautiful size and shape, but my goodness, if I look at the face, there is still dysfunction there. I see it. And so I think sometimes in dentistry, we think that if we just fix these structural issues, that magically the function is going to fix itself. And in some cases, that is true. It definitely improves. You know, if you give somebody great space for their tongue, it's going to start to learn to function better. But there's so many more layers to dysfunction than just that. And so it's good for us to know the ins and outs of how to really properly evaluate function after we look at all of this and know when we've actually, like, hit the mark on when that patient is fully rehabilitated.

Yeah, and I would completely agree with so many of those points. I think, one, we absolutely need to know what function looks like normally. Like, what does typical function look like? Because how do you know it is atypical if you don't know what typical is? And so, so many courses out there and, you know, therapists, I think, are they don't know what to look for because they have nothing to compare it to. Right. How do we compare what we're looking at if we don't actually know what it's supposed to look like. So I'm really glad you said that. I'm currently doing a tethered oral tissue module for my online course, and that is, like, due to everybody on Sunday. And I'm like, over here, like, I have like, three slides on form versus function, right? Obviously, form is important, but function, especially with tether neural tissues function drives everything. Like, do we not release? And obviously I don't make that decision as a speech pathologist, but I think we need to know this whole topic of form versus function. Obviously, form is very important, but what is the driving factor? Function? How do we know what dysfunction looks like if we don't know what typical function looks like? Which is why we also spent like four weeks in the beginning of this course just teaching our students what, what traditional function looks like from a feeding point for pediatrics. We spent the first third of our course on just typical development in pediatrics for feeding. So it really makes my heart sing that you said that. And then the other thing you mentioned too, that I was like, yes, yes in my evaluations and yes on my form and yes on my camera video recorded for every evaluation I do. I watch them chew, I watch them eat. I watch them swallow. I want to see them eat off a spoon and or fork. I want to see them eat something crunchy. I want to see them drink water out of an open cup or a straw or combination, whatever they typically drink out of. I ask them to show me too. And I just say, do whatever you normally do. And I sit back and I put push record on my video and I watch. But I know before I do that what I'm going to see, I 100% know absolutely. Last part of the eval. And it's sort of like this is just confirmation. So I can put photos into my eval and I can track where we started and where we're going along the way, as well as where we end up. But I can show other professionals, I can show that family, that patient what I'm seeing. And that way, actually, as I'm going through my report, I'll take other photos, as I know you do. Beautiful documentation, But I want to be able to show them and myself, really, because I also sometimes notice things in photos and videos that I don't see in person. So I fully believe in doing this part of the eval. But like you said, when you get such a good, thorough case history and you go through and you ask them these questions, that either sometimes are like, I have no clue. Nobody's ever asked me that before. But then you start to really pick it apart and ask some of those, you know, different questions, like, well, is your throat red? You know, I see some redness. Do you wake up with a dry mouth? Do you wake up with a sore throat? Do you have to clear your throat in the morning? You know, those things really give us so much of what we need to know before we ever get to that last part of the eval. But, yes, it's. So when you said that, I was like, yes, because that's the last part of the eval. I'm like, all right, snack time.

Absolutely. And by the time you get through that entire evaluation, like, I don't know how long yours take, but, like, we're there for a while, and, like, we all need a little bit of a snack after we're done, you know, like, it's been a long time. And those kids sit there so well, so they totally need to be rewarded with a little snack. And I get to see so much when they're in action, because still, photos can only tell us so much. You know, it tells us a lot. It's only part of the puzzle. And so we absolutely have to see it in action. And I will say, you know, and hopefully I can say this and not get in too much trouble, because I am a dental professional, but dental professionals don't know what the heck they're looking at when it comes to chewing and swallowing. I know I didn't, you know, when I first took my first MYO class, and we were supposed to be looking at, like, bolus collection, and I'm like, I don't even know what the heck a bolus is. Like, I had to, like, look up some of those terms because we don't. You know, I know that the math inside and out, but I didn't know the function side of it. And so, again, you know, I was cracking books, and I was watching webinars, and I was going to as many courses as I could until I felt really comfortable with the information. And there's probably still so much more that I haven't learned that I need to. But I feel like if we are working at changing structure in dentistry, this is information that we need to know. You know, we can't say that we have fixed a patient's function by changing their occlusion or by giving them something to chew on a couple of times a day. That's not fixing function. That's helping, but it's not fixing the problem in so many of these cases. But if we don't know what to look for, how do we know that? How are we supposed to know that? So I feel like every. Every orthodontist who considers themselves an airway or a myofunctional orthodontist needs to take some classes in what to actually look for. Like, if you're not actually asking your patient in the dental chair to, like, chew some food and watch them drink some liquid, how do you know if their function is good? We can't say that we fixed function just because we've altered form. There's so much more to it than that. And I think it's a little bit of a scary thing that we don't understand that. And I know, like, after I say this, there's gonna be a lot of people, like, you know, boiling the tar and, like, plucking the feathers for me. But this is why people have to have a good, solid background before they go into this field. This is why when I hear that some of these people, some of these dentists and orthodontists are having their dental assistants do a couple of chewing and swallowing exercise or a couple chewing exercises and facial exercises with patients and calling it myofunctional therapy, it makes me nervous. Because even with our background knowledge, yours as a speech pathologist and mine as a dental hygienist, and the amount of anatomy and physiology that we had to have just to go into our fields, and then I still felt like there was so much that I didn't know when I started in myofunctional therapy that I had to learn. If we have people that don't even have the underlying anatomy background to be able to look at these structures and know what we're looking for, then it's a disservice to the patients that just go through a tiny little one size fits all program. Where do these couple of lip exercises chew on this product and then, boom, we fixed the problem. We haven't, you know, we haven't. And we're missing it because we don't know what to actually look for. So I feel like we have now come up with a whole other topic that you can build a whole other podcast off of, a really important thing. You know, it's something that I feel passionate about, and I know that a lot of other people do, but, you know, just a couple chewing exercises is not myofunctional therapy. You know, just a couple of, like, lip pops is not myofunctional Therapy, it's so much deeper and so much more involved than that.

Well, and we'll finish up in a minute, but I want to kind of do that. The flip side of that is, as speech pathologists, most speech pathologists got no education on the feeding and swallowing. Or maybe like, for me, I had education on the adult population, but no peds. And so I had to do all of this work on my own after graduation with my master's. After I graduated with my master's, I should say. And that's why I created my feeding course, because there are. I actually have a lot of grad students in it right now, entering the workforce in the upcoming months, and they're like, I didn't get this either. And I'm going, wow. Grad students want to pay for an online course right now and, you know, learn extra information when they have all this other stuff to worry about. I mean, that just goes to show how much of a lap there is, even for speech pathologists. And so I'm really happy that they're doing this because I think that my background as a feeding therapist is what actually gave me a one up and is what propelled me. Like, I literally left Sandra and Becky's course, and I was back in my, you know, back treating, and I just offered a free myo eval to all of my patients that would accept it that week. And I started with like 8 myo evals right away. And I had just taking that nosedive in really helped me also to start looking at, okay, what's going on? Let me feel different faces. The more faces you can feel, and the faster you can feel them, and the more, you know that's how you're going to learn, the bigger you're gonna learn.

Yeah, absolutely.

Hands on. But you also need, like, you're saying you need to have that right background. And as a speech pathologist, I had no. When Becky was going over, like, the different bites and malocclusions and what proper occlusion looks like, and I was sitting here like, this is foreign language to me. Like, I have got some stuff to learn. And even to this, like, I am not a dentist. I am not an rdh. I don't know that. I mean, I know the basics, but I definitely am not the person who speaks on teeth. Right. And I always tell my patients, I am not in the business of moving teeth. So you need to go talk to the dentist or the orthodontist about that, because that is. That's out of scope for me. I can look and I Can say, oh, they have a cross bite, or oh, they have an open bite, or oh, there's an overjet, or, you know, but beyond that, I'm not touching that stuff. And so, you know, that's why it's so important to have a team. And I talk about that a lot on the podcast because you definitely need that team approach.

Absolutely.

And you know, on the flip side of that too, like you mentioned, I see so many courses popping up, so many, you know, become a myofunctional therapist online today. Do this, do that. You know, look, nobody can learn in a couple of hours how to be a myofunctional therapist. It's not happening. As you mentioned, we have so much medical background in the anatomy and physiology that goes into just normal human full body development. And I think that anybody who is in this space also, like we've talked about, this is a full connection. This is not just what's going on in the mouth. What goes on in the mouth impacts the entire body. So that's why one, we need that team of professionals. But two, you need that background. You can't just jump into mayo without that background and actually do right by your patients.

Absolutely.

It does drive me up a wall a little bit. And I love others. So, you know, I always joke, I'm like, I'm gonna get hate mail for this one. And still we're like 50 something podcast episodes in. And I've never gotten any hate mail 50 plus podcast episodes in. So clearly they don't hate me enough to email me.

They might send it to me. But it's okay, people to understand. It's nothing against dental assistants. I tell you what, some of the smartest people that I've ever worked with have been fabulous dental assistance. But we have to have a dividing line between what is appropriate treatment and what isn't appropriate treatment. And it's not appropriate treatment to have somebody who doesn't have the background knowledge to be able to try to put together some sort of sequential and systematic treatment plan for these patients when they don't even know what structures they're supposed to be looking at. And so there is a huge delineation between these one size fits all quick programs and true, in depth customized myofunctional therapy. And I think it's important to make that distinction because our field is becoming more popular, which is awesome. Like, that's a fabulous thing that there's more awareness, there's more understanding. But just like with anything, as it grows, as it gets bigger, we need to make sure. That we're spending still treating what we're supposed to be treating and that the people that are supposed to be treating it are the ones actually doing it. And we're not kind of passing it along just to say that we can add it in to our, you know, things that we offer out of our offices. So it's, you know, it's an important thing. It's an important distinction to make.

Yeah. And so the last thing I'll say about that is I think that while some of us may have like an arsenal of exercises that we typically use, as you mentioned, the of type treatment plan is individualized. It is that patient based on their history, their current needs, their structures, their function, what we're trying to change, what the end goal is. And so while we might have like three general end goals in myofunctional therapy, how you get there and what you do from point A to point B is completely different from one patient to the next. And how you modify those exercises for that patient versus another is completely different. So I might have my exercises for recorded that I send a patient so they can do it, but how we might have to modify that for them is very different from one patient to the next. And if you don't understand that and you, you know, it's not a 12 week program with 20 exercises that everybody gets and then everybody, you know. No. So it's not a cookbook recipe. I know that that's kind of the term that gets thrown around a lot is not a cookbook recipe. No, it is not. And obviously we could go on about this for a whole other podcast episode because, yeah, we'll kind of like leave it there for today. But you know, I think it's a really great discussion for people to hear because I think that there also is a beautiful relationship between RDHs and speech pathologists who have the background. And I think we need each other. I think that we really each other. And I love having you guys in my back pocket, as I'm sure you do for your SLPs too, because I like to be like, hey guys, this is what I'm seeing. And I don't have the dental background. Like, what do you think? Versus, you know, coming over to a feeding therapist and saying, hey guys, I'm not a feeding therapist, but I'm seeing this. What do you think? And so, you know, I definitely think there's a time and a place and a space for that, but.

To learn to speak each other's language and to learn a little bit like you've had to learn a little bit about dentistry in order to fully help your patients. I've had to learn a little bit about feeding and speech pathology to be able to, like, fully help my patients. And it doesn't mean that either of us are treating anything outside of our scope. It means that we're doing what we need to do to be able to understand the bigger picture. This field is such a beautiful blend of both of our backgrounds. And so to be able to have that and to be able to communicate and to be able to have those friends that we can call and be like, hallie, I have no idea what to do with this kid. Like, where do I send them? That's an awesome thing. You know, that's at the heart of collaboration. That's what we're supposed to be doing, is having people that we can call when something is a little bit unfamiliar and we're uncertain about it. I want to be able to send them to the right people. So I love how this field is such a beautiful blend of so many different people. You know, it's a team approach. I never treat a patient in isolation. There's always other people with eyes on that patient, maybe even with hands on that patient who are treating them. You know, I'm working with the orthodontist, I'm working with the ent, I'm working with the chiropractor, I'm working with a speech pathologist. I'm working with, like all of these other professionals. And isn't it so rewarding to see that when we treat every single person from that holistic approach, they get real results in a fast amount of time, and it is truly life changing for these patients. And so this, this field has been the best thing that I never knew that I needed it.

Yeah.

And I'm like, this is like, this is it. Like, this is what I'm passionate about. This is what I'm gonna do for the rest of my life in one capacity or another. It's such a great thing.

Yeah. Well, I know that. Is there anything that you want to share with us? I know that you guys have an upcoming course coming up, but I know that in the current state of affairs, I'm not sure.

I could have told you about all these amazing things that I'm gonna be doing soon. I had a big trip planned to Australia to do lectures in two cities there upcoming course with Mary Frances Gonzalez. And that one we're really breaking down. I mean, when you were talking about how nobody really understands what normal looks like, that's the epiphany that we had a year ago and said we've got to put a course together so people can understand what good function looks like before we can start talking about poor function. And so we were slated to teach that this summer. But again, with all of the shutdowns with COVID 19, we're looking at maybe kind of scooting it back a little bit. So people can watch my website, omtofyork.com or they can look at teachspeechtherapy.com at Mary Frances website just to kind of keep tabs on upcoming dates for classes. And I always have some stuff online. I've got like, an online course with dentaltoasters.com that's just kind of a brief overview of myofunctional therapy. That one's really geared toward dental professionals, and they do get dental credits with it. So that's always available that people can kind of go on at any time and look. And I have a couple other little things going on. I just had a great interview with Sarah beach and Tim King from Fast and Functional, just talking about TMJ stuff. And I just finished up taking their online course, which totally blew my mind. It was fabulous. So, you know, just little teaching things here and there. I'm going to do a little bit more writing in the future, but I feel like with not seeing the full amount of patients right now just because I can't see them in person, I feel like I'm busier than ever. But it's all these projects I'm creating, my website, I'm writing, I'm speaking, I'm doing courses. How is it that for somebody who really doesn't have a whole lot of patience in the past couple of weeks, how am I so doggone busy?

Yeah, I've been dismissing patients because they've been making so much quick progress over teletherapy, which is amazing. And I have not been filling the spots because I'm so busy creating courses. And just our membership we're creating and all these different things right now that I'm like, it must be really nice for all those people who are just, you know, eating ice cream and watching Netflix. But I'm over here, like, trying to remember to sleep right now.

We're, like, crying because we're so exhausted and we don't know which end is up.

I totally resonate, and I do want to say I love both you and Mary Frances. So whenever you guys have that course, everybody who's listening should definitely look into that because I thank you. Fabulous course. This has been such a fun, jam packed episode with like you went through so much information in such a short time. So I'm sure we will have show notes. Everything that you mentioned will be in the show notes, including John, you article. I know you shared another one with me and the, the one you mentioned, we can, we can link to that too.

Perfect website.

But we'll, we'll link to omtofyork.com as well so you guys can see where Angie has her account seminars and all that information about upcoming course change dates and all that fun stuff. And when you go to Australia, I want to come with you.

So. Okay. I will put you in my suitcase. You're coming along.

All right, Angie. Well, thank you so much. It's been an absolute pleasure.

This was so much fun. It was. Thank you so much, Hallie. This was like the highlight of my week. I loved it.

Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and feeding related episodes, be sure to leave a review on Apple podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @halliebulcan biz, on Instagram @hallebulcan and you can head over to theuntetheredpodcast.com to grab a copy of the show notes where you can also subscribe to be kept up to date on the latest podcast episodes.