Episode 64: Early Intervention With Growth Appliances With Dr. Lenny Kundel, DMD

Hi and welcome to episode 64 of the Untethered podcast.

Today we have Dr. Leonard Kundal joining us.

Dr. Kundal is a 1999 graduate of.

Tufts University School of Dentistry. Following a year of residency at Montpierre Hospital and several associateships, he established private practices in Stanford, Connecticut in New York City. Dr. Kandel's motto is your mouth is connected to your body and so it should be treated as such. While it is not always possible to completely avoid intervention, it is certainly possible to be kind about it. Dr. Kundal feels that education of adults and children is his essential task and responsibility. He spends time helping patients decide what is right for them and wants children to have the tools necessary to grow up with a healthy mouth and body. Besides general dentistry, he addresses problems related to breastfeeding difficulties, growth and development in children, sleep disorder, breathing in children and adults, jaw joint related disorders, chronic oral inflammatory diseases known to increase risk factors for common medical problems. He's been studying the oral systemic connection for nearly two decades and his path has taken him from being the orthodontic patient turned TMJ patient to a dentist that helps people with jaw pain. He understands the connection between mouth and body and this is the foundation for his practice. 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 hi, I'm 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. Well, Dr. Kundal, thank you so much for joining me today. I'm really excited to talk about early, what I was called early expansion, but we'll dive into talking about what we can call it instead in one minute.

Yep.

So thank you. Thank you for being here with that. Let's just jump right on in. So we were chatting for a few minutes and I kept referring to it as early expansion and you actually said you like to call it growth. So can you talk a little bit about that and your preference in your choice of words?

We always think of just making the mouth bigger. We want to expand the mouth, but the mouth doesn't really exist in a vacuum. When you affect the oral cavity, when you make something bigger, you don't just expand it. You develop the head, you develop the airway, you develop indeed the entire person. So when I talk to patients and I do this myself, after I talk for five minutes, they ask me, do you mean the expander? I said, you know what, fine, think of it as an expander. But what we're really doing is we are growing and developing the small human being that we're going to talk about. So that's why I call it. It's a development appliance. It is not an expansion, but a growth appliance. It allows us to make the growing easier. That's my speech.

And no, that actually makes a lot of sense because we are working from a very holistic place when we're putting children into, you know, putting these appliances into children's mouths. And like you said, it. It affects change in the entire and the surrounding structures. It's entire cranium. It's not just the teeth, you know, it's everything. So growth, I. It feels more encompassing.

The progression is never linear. You always have global change. Always. When you do just a little bit somewhere.

That makes sense. So with that, what is the earliest age that you will start that you will put a growth appliance into a child's mouth?

The earliest I have so far is two and a half. And the reason being is the children that I started this young, they had problems. It's not like the parents didn't have anything to do. And they said, well, let's just do something because we're crunchy or because we're holistic or because we want what's better for a child. No, when people come to me, they come for a reason. And these particular children actually have moderate to severe sleep apnea, more on the severe side. And the dental arches are just very corrupt and collapsed. And obviously the child is not particularly excited about the whole thing. But if the parent is on board, it's not a difficult thing to do. And so my youngest is two and a half, and they're progressing beautifully. Beautifully. How early? I can start as early as I have teeth in the mouth. So I'm waiting for second baby molars to be fully in because we need to have good retention if we expect cooperation. So as soon as the appliance can stay without falling out and moving around, I know we'll get there.

Amazing. And I've heard of people doing it as early as in a two year old, but I've never actually spoken to somebody who has. So I'm excited to learn a little bit more about this. People who listen to the podcast know that my daughter, who will be five in August, has been in an ALS appliance since right before her fourth birthday. And she's had tremendous growth all around. We've seen lots of changes just in the overall structure of her face. She's also been in myofunctional therapy. She had a tongue tie Release at age 2, which I'm now questioning if we need to go back and revisit because she didn't actually have enough space for her tongue prior to that release. And I've now learned a lot as both a mom and a practitioner since, you know, my own child's experience. But you know, with a two year old, how long is the treatment plan generally? Is it pretty quick? Do things move pretty quickly? Do you find it's, you know, there's a certain time frame or is it very.

You should always start with an end goal in mind. And the end goal is when the child stops growing, which means 18 years old for females and 21 for males. Probably nobody in their right mind would let me do that for 20 years. But you want to come to that as close as possible. You want to keep supporting the growth for as long as you possibly can. You know how they say there is no smoke without a fire? If something wasn't developing right to begin with, don't expect it to develop right just because you did something for a year or two. It is a physiological problem, it is a systemic problem. You need to support it for as long as you can. And you can think of it as training wheels. You need to keep those training wheels for as long as possible. So my two year old patient will be in active treatment for probably two to three years or maybe two years. Then I will leave something in either the same appliance or some kind of permanent retainer. Never removable. It has to be a permanent retainer until I can develop further, let's say, let's say seven years of age. Then I'll develop some more because the big mouth has to belong to a body that is ready to accommodate it. So I can't give a 5 year old a 20 year old's mouth. So I will develop it for let's say roughly two years. Then I will place a pro permanent retainer for some years until I need to do more or I will leave it in for let's say three, four years. And if I Feel that the child is well balanced, then I can take my permanent retainer out. When we say well balanced, what do we mean? We mean lips are always closed, musculature around the mouth is quiet, there is no tongue habits. Most importantly, the nose is able to breathe without effort. If you can use your nose the way it was intended, then you can rest assured then you are on the right track. So the answer to every question is always, it depends. I'm not a lawyer, but it depends.

I'm laughing because we're teaching a 12 week course right now on how to become a pediatric feeding therapist and just how to get into that space for OTs and SLPs. And you know, there's so many questions every week and a lot of the mentors in the group start with, we're going to tell you it depends and you're going to hate us for it, but it depends. And then we can talk about some scenarios. But yeah, it's that it makes complete sense to me because I get it, I get that. Yeah. And I actually had more traditional orthodontia myself followed by a permanent retainer that they said, oh, this will fall out of your mouth by the time you're 20 or something. Like it'll come off your teeth at top and bottom. Permanent retainers and the wires. And that was probably placed when I was 13, maybe even 12, I want to say after, you know, so many years of orthodontic work. And then I think when I was 30, I finally had my dentist take it out because I was having issues with buildup and plaque and you know, they were like, oh, you don't need this in here anymore. As it's come off one tooth at a time, they basically would cut it off and like, you know, make sure it wasn't sharp on the end. And it just finally they took it out and then everything started to shift. And I think for me, I obviously had an orofacial myofunctional disorder and I did need more of that anterior, posterior and lateral growth still, even as an adult. So I've actually been in the DNA appliance myself for, oh, has it been two years now? I don't even remember, but it's been a couple of years and I've had a lot of growth and a lot of improvements. There's enough space for my tongue now. I also had a tongue tie release done. And so I've been, I've been through it as the patient, but it makes a lot of sense what you're saying just in terms of having some type of permanent support even after the expansion's done. I know I'm an adult and I don't have the same growth my child will since she's only five come August. But that's very, that's interesting. You're the first person I've heard say, you know, we need to make sure that with the early, you know, growth appliances that we continue to support them beyond what we're doing right now. We're not just going to put it in and then take it out and kind of hope that we don't need future work. I've almost heard it as sales pitch to if you do it now and you set them up now like, you know, we might be able to avoid braces down the line because we'll give them the space their teeth need to grow in their permanent teeth. So it's fascinating, it's actually very interesting.

What I find and you know this, I'm sure somebody will ask that question at some point is, does that mean that if I develop my child now, my child will not need braces? And the answer is, it depends. I certainly have that goal in mind. And even though I tell people, give me two years to develop your child, I will tell them, please let me develop some more, please let me develop some more. Because yes, the teeth, rather the jaw will have a greater chance to develop, which means the teeth will have a greater chance to un crook themselves or unwind themselves, whatever word you want to use. But really, yes, and if you leave the child alone long enough, you have a much greater chance of their body just sort of finding its way. Today I had a 10 year old girl who just lost baby canines and the orthodontist says she'll soon be ready. And I told the mother, leave her alone, give her at least two years, let that face grow because it will be so much easier to correct what you need to correct without creating problems. Interesting, because once you put braces on this 10 year old, you will retard the growth forward. Do you understand?

Yeah, 100%. I get a lot of these kids right on my caseload and some of them come to me in braces, some come to me at the end of they're done with their braces, but yet their tongue is still shifting their teeth. Or I've got some kids who come with a, a crib in their mouth and they figured out how to get that tongue under, around in front of that crib and they're still pushing their teeth out of alignment and the dentist is going you know, 85% of my cases like this work, but there's always that 15% that I just can't figure out. So, you know, I've seen, but I've seen a lot of kids who come to me in braces and I'm going, their jaw is just so small, I don't even. There's no growth here. There's no room for the tongue. So yes, they have beautifully straight teeth for whatever that gets them, but their jaw itself can accommodate their tongue. So we can't do anything at the moment if there's no space. So that's interesting.

I tell parents, the hardest thing for you as a parent is to wait because you want your child looking perfectly. What you really end up getting is six teeth in the front that are straight. That's all you understand. You don't understand anything else. So if you hurry up, you will get your teeth straight, the six of them. But the entire head is not going to be where it needs to be. And so I tell parents and you know, you think about it. To us, it's something that we don't think about anymore. But we need to step back and remind ourselves that we need to educate parents about what normal is. And normal is, your child needs to look goofy. They need to go through ugly duckling stage. That is how you know that your child is growing correctly. If you slap braces on your nine year old, yes, you will have straight teeth, but you won't have the right growth.

So with that, do you have certain criteria? I know you mentioned with the 2 year old, for example, you're not going to obviously put a growth appliance in their mouth unless there are symptoms. There's something larger going on like obstructive sleep apnea, for example. Are there certain times where you will start to, you'll put a growth appliance into a child who is in that awkward growth phase. Right. It might be earlier than we would like. Are there certain symptoms that you're looking for or certain symptoms that you say, well, you know what, it's okay, why don't we wait until they've gone through this phase? Does that make sense?

Yeah. I'm going as a parent would let me be because I look at every child as my own child. My 9 year old asked me recently, is there ever going to be a time when I don't have an appliance in my mouth? I told them, not for a while, not for a while. So I will gladly treat a 2 year old without any symptoms because we can look at the face, we can look at the X ray and we already know where their child is going. Even though the child may not have symptoms at 2, I don't want to meet the delinquent teenager who is under slept, who is always tired, who is belligerent. That's not the person I want to treat. I would much rather treat a crying 2 year old with a confident parent who understands that she is doing what needs to be done for this child now because it's so much easier because I would rather have the child sleep well from two years on than from 15 because the damage by 15 is done.

Yeah, absolutely.

To answer your question, I'm going to be as proactive as the parent will let me. The reason I didn't suggest anything for a 10 year old that I saw today because it is a parent that I just met and even though she drove for an hour and a half to get my opinion about this, that and the other, she didn't really ask me about. Do you think we should go ahead and do something? I told her, you know what, she's growing. Well, let her grow. For the other child who is eight year old, I showed her on the X ray what needs to be done. I explained why it needs to be done and that was it. And then she went home to think about it. But she is new to me, she doesn't know me. There is no trust yet. So that's it. But if it's somebody who knows me and I know that person, absolutely, I'll tell them. Start now.

Well, I think that's so important because we preach a lot in the speech pathology world, you know, about other areas that we treat and how important early intervention is. But you know, I think that the work that you're doing in combination with the habit elimination and airway, you know, the benefits that you get from growth as far as airway goes and then overall cognitive development absolutely plays into that child's future. And so you know, how they, how they can attend in school or on Zoom classes, how they can, you know, just really how, what are their social emotional abilities, what you know, because I don't think people realize how far reaching, not being able to sleep. Right. How far reaching these issues actually impact a child and even an adult in their everyday life. Not being able to sleep is huge. And we've, I know, I've had conversations with others about, you know, we'll try not sleeping for 72 hours and see how you feel. Because some of these kids are operating from feeling like an adult who hasn't slept in three days. So, you know, when you. When we start to understand what these kids are actually existing, like on a daily basis, you know, and how important it is to do the more early types of intervention. I think it's amazing to hear about the work you're doing because I know as a myofunctional therapist, a certified orofacial myofunctional therapist, a speech pathologist, a mom, a patient to all the above, I've seen it firsthand in my own child, But I've also seen it in myself as an adult who's been throughout a lifetime and got an ADHD diagnosis. When I was in college, despite having straight A grades all through high school and really having a tough time my freshman year, they threw me on medications, which helped. And nobody looked at my airway, nobody looked at my mouth, nobody. That was not even a discussion that anybody had at the age of 19. So I think we've come far from that point, but it's just a very fascinating topic for me. Is there. So I know people listening will also wonder, well, how the heck do we find somebody who's willing to do this with a younger child? A child, you know, I know it's hard enough to find somebody who doesn't want to wait until a child, you know, in that magical age of 6 to 9 years old for traditional orthodontia, are there groups of you unicorns that exist somewhere that people can tap into? Or is it really, would you consider it a newer area doing the growth in younger kiddos?

There are people that talk the talk and there are people that walk the walk. And there are, obviously there are organizations where people like me get together. But whether everyone in those organizations does the same that I do, it's not even does the same that I do because we all take the same classes. But it's what kind of results do you get? What is your philosophy? What do you believe in? Because you can give the same appliance to them, to 10 different people, and you'll get different results, Right? How do you find a practitioner? You ask around. You ask around and you try and what I tell parents because sometimes people move away and so they ask me, can you refer me to somebody? And I go online myself and I look and I Google and I do this and that. But at the end, I tell people, you know what, Ask them to show you what they've done, because you can have a beautiful website and you can take somebody else's photos and you can claim whatever. I don't know People who do that. But I imagine that it's not hard to do. And so what I tell people is when you go to a practitioner, ask them to show their results, that's your best shot, I guess.

Yeah, no, it's something that I've come up against myself. I'm very fortunate to be in the D.C. metro area where we treat across D.C. maryland and Virginia. And it's not far for people to travel to one of the few providers who might be out here. But there are also. There's the main provider that I work with. There's also a big name who's down in Virginia that people can go to that do the ALF appliance specifically. The reason why I love working with the practice that I work with, aside from knowing them really well and they treat us, myself and my daughter and my husband, is simply that they have a variety of appliances that they use and they don't just put the same appliance in everybody's mouth. They really look at. Like you said, you have to know your end goal. You have to know what we're up against here. We have to know what, what we think is going to achieve that end goal, the best for this patient. And so because the two of them, one of them has orthodontic credentials as well and on top of her dental credentials. But, you know, they both do the growth appliances. And it's just been amazing to learn from them and to see, you know, while they put me in one, they put my daughter in another one, but then they put another adult in an alf, whereas I was put in the DNA because that's what they thought would be best for me. So, you know, I think that's another interesting conversation. Do you offer different appliances in your office? Are you more inclined to use like one on a certain age group or how does that work?

I think it's all a matter of personal experience and honesty. You need to be able to deliver a certain result.

Right.

If you are not happy with a certain result, then move to something else or get better at whatever you're doing. Because I also have a history and you will read that history in a book that's coming up. It's a plug.

Plug away, plug away.

There's going to be. I'm actually writing a book on how to treat children.

Fantastic.

And it's not about a particular appliance at all. The book is much more conceptual than detail oriented because what we need to do is we need to educate each other and we need to educate, most importantly, public. And so the Book really is dedicated to parents, more specifically to mothers, because they are the ones who are pushing the progress. I forgot what question I was answering.

I was curious, aside from plugging the book, because I do want to hear about that. I wanted, I was just curious to know, like, do you use a particular appliance? Do you use a variety? What does that look like in your practice?

You know, I use different appliances. I'm very fortunate that I was able to learn from really good practitioners about different things. And there are different philosophies, there are different practices. I use different things. I have three or four different things that I use right now that I use. Depending on many different things. You have to take into account expectation of the parent, willingness of the parent, how hard, how easy, how far are they coming from, how much time do I have? There are many, many different things. There is no one appliance. There are some people that use only one particular appliance. And you know what, if they're getting great results, whatever that means to them or to their patients, I don't have a problem with it because when people ask me, I always would say, in my hands, this is what works. There is never black and white. You have to be able to deliver the result that the patient deserves to have. So that's my answer.

I think that makes sense. Thank you. And so one other question too in regards to then the results that we get from, from any of these appliances. Do you find that I know we talked about already, earlier versus later and symptoms and even if they're not present and we know looking at a child, they would really benefit it too. You'll go ahead if the family's willing to let you expand early on so we can prevent those issues that we know are coming down the pike. But do you find that there are any other benefits to putting a growth appliance in earlier versus waiting till later, beyond, you know, obstruct beyond airway. Like, what other benefits are you seeing or looking to achieve by growing that face? Oh man, loaded question. I know this one. I mean, I could answer that myself. But I'll let you answer it too, because this came from one of our listeners who was like, I'm curious to know about the different, you know, early versus waiting till later. Like what other benefits are we?

What we want to give our patients is we want to give them peace. That's what the families are lacking who are coming to us. I have a 6 year old with a police record. I have a number of teenagers in mental institutions with sleep apnea so when I look at a 2 year old, I'm looking to deliver peace to that family that they might not get otherwise. I never know. I never know which child would develop which symptoms. I have children with tiny mouths and they are perfectly agreeable even though they have sleep apnea. They're the easiest kids to work on right now. They're the easiest kids to work on. And then I have other children that have very, very mild symptoms, but they're a nightmare, they're a nightmare at home, they're a nightmare in school. So I think the broad answer is we want to give them peace. We want to make sure that they're able to sleep through the night. And not only that they're able to sleep through the night. I don't mean that the parents shouldn't be bothered. What I mean is the child's brain should rest at night. And that's why I'm so adamant about doing sleep studies for children as early as possible. Because without sleep studies, we simply don't know what's going on with that person. And so you really want to surround yourself with knowledgeable sleep specialists that know how to assess sleep in children because it is a separate knowledge base from adults. We want to make sure that the child is able to sleep through the night. We want to make sure that their cognitive development is on par with their age. We want to make sure that they get the growth hormone that they need to get. We want to make sure they're able to eat. We want to make sure that they don't have violent outbursts so they can have the social life that they should be having, that they're not considered a public enemy in school. We want to make sure that the parent is able to send her son on a play date without being afraid of a meltdown. So peace is what we're looking to give.

Yeah, no, that's a great answer. I haven't heard anybody else say it from that perspective, so I think. But that it's a beautiful answer, really, because what do we all want our kids to be? Happy, healthy, thrive. We want them to enjoy being with friends and family and going to school and just enjoy life in general. And how much harder is it to do that if you're not getting adequate sleep, like we've talked about throughout this podcast? So I think that's really, really important. And on that note, you know, a lot of dental insurances don't cover this type of work. So, you know, I know I get a ton of questions about, well, these families can't really even afford the myofunctional therapy unless it's, you know, somebody who's in network who can provide it. And they definitely can't afford like a growth appliance because that typically is not covered by insurance. Is it ever covered by insurance or is it typically out of pocket?

If you have medical insurance, you should be able to do sleep study. If sleep study says your child has sleep apnea. Sometimes we get 100% covered, sometimes we get 80% covered, sometimes we get 60% covered. It depends not only on the insurance, but it depends on who picks up the phone in their insurance. It is such a game. Sometimes we lose our appeals, sometimes we win on a third appeal. So we try really hard for our patients to get the money. But it is a game that's not predictable. Sometimes they say, yes, we will pay, then they don't pay. Sometimes they say we will pay a full amount and they will send you a little bit. And sometimes it works. But I think overall it's a pretty positive. It's a pretty positive experience. It's unpleasant to deal with them and I feel really bad for the people on the other end because they're just following the directives that they're given. So we never try to give them a hard time, but we're just trying to play the game and we ask them the questions that we need to ask. And don't ask me what those questions are. I'm not the one who does it. But we can always tell you what to do. In adults, it's much easier to get some money for medical insurance for sleep apnea because a dental appliance is already an approved service for a child. The approved, the number one approved service actually, unfortunately is a sex change, not dental sleep treatment. They might approve tonsils and adenoids, but not dental. Dental appliances for children is still in the air. It's a soft yes. Yeah, they look for, they, they will tell you you need to look for a professional in your area who does it and takes our insurance. If you don't have, then you can apply for out of network exception.

Yeah.

So it's a complicated game.

Yeah. No, and it's. We are out of network, actually my private practice and we do speech ot feeding myo, all that stuff. So we have a little guide that we've created for our parents because they pay us in full on a monthly basis and then, you know, they take the super bills and submit them to, to their insurance on their own. And we basically have created, you know, a pre authorization guide here's what you call your insurance and ask. We don't actually make the phone calls for them, they do it themselves. But once it gets to the point that you mentioned before of, you know, they've been denied and then either a peer to peer is required or whatever it is you know, before we move into an actual appeal, then we generally, we come in, we write the letter of medical necessity, we do the peer to peer, you know, phone call and usually we can get them the benefits at that point if not. But we often will have them start with that out of network gap exception if they don't have somebody in network that does exactly what we do because of some of our credentials. But yeah, it's, you made the biggest, the best point there was. It's a game. It is definitely a game with insurance. They are banking on people giving up and we tell all of our families.

Be the squeaky wheel, just keep calling.

Because don't be that family who gives up. If you keep calling, they will, eventually you will get something even if you have to go through the appeals process and it's not fun. It's a major waste of time for everybody involved.

I'll tell you something. Some people were able to get Medicaid to pay for out of network. Wow. So talk about squeaky wheel.

Yeah, that's impressive. That's very impressive. Especially with all their hard and fast rules that they have in place. But yeah, no, I always tell people it's definitely worth a try. You never know what's going to happen. But that's also really interesting that having the sleep study done kind of pulls it into the medical insurance versus going through dental insurance. And so that, that's a really great tip. And so I think we're going to get a lot of people who start contacting me and go, okay, well how do I find a pediatric sleep expert in my area? And that's going to be my next. Yeah, so yeah, no, I, I've been very fortunate to be able to afford these things for my family and to not really have to worry about it. But I know that it is a legitimate concern of a lot of our families. So that's actually something that I'm sitting here going, hmm, I wonder who in my area. Because to be completely honest with you, unless they appear to have obstructive sleep apnea or they're awful snoring, you know, they've got awful snoring at night or when napping oftentimes, even the ents don't always refer for a sleep study unless it's absolutely needed for insurance to cover a procedure that they're recommending. So it's. You know, they seem to not want to send young kids and put them through that if we can avoid it and want to put them on medications first to see if we can, you know, shrink some tonsils or whatever. And that's definitely not my area of expertise, so I won't. I don't want to speak out of. Turn on that, but it seems to be more. More avoided in this area, if you will. It's been hard to find ents that are even on board with some of what we're doing.

Do you know why? Because sleep as a discipline is not being taught as a priority. So when people come to me for different reasons, and they come with a list of symptoms, and what I tell them is, I don't understand complicated things. I understand simple things. Before we try and fix or cure or address esoteric problems that your child might have, let's try to fix things that are basic. What are the two basic needs that your child has? Sleep and breathing. That's it. There is nothing else that's more basic than that. You do not survive without those two things. Yeah. Before we start treatment, we need to get a baseline. What are we starting with? Who are we treating? We need to understand the quality of your sleep. Unfortunately, sleep studies for children and sometimes for adults are done incorrectly. They're carried out incorrectly, they're interpreted incorrectly. But that's the world we live in. We can lament it, or we can try to make it better. So we want. You have to have a system in your head to help somebody.

Mm.

So what that means is you need to get a baseline. Where are you starting, and where do you want to go? Because after two, three, whatever, five years of treatment, you need to repeat that sleep study. Did your treatment make a difference? Is the sleep apnea gone? Is it less? What did you actually do? Because if all we do is use dental expanders to expand the mouth, then you're not really helping anybody. You just make the mouth bigger. So these two basic things is what we need to worry about, because really, a lot of everything else will just resolve in time.

Mm. Yeah. Well, and that's. That's a really great point, too. I had. I don't know if you're familiar with Ken Hooks, who's a respiratory therapist.

Yes.

Yeah. So I had him on the podcast a while back, and he really opened up my eyes to a lot of the markers that we should be looking at and why things like Upper airway resistance syndrome gets missed so often, or, you know, people who don't have obstructive sleep apnea but have UARs, you know, just things going on that are not being people are not reading the correct things. So you made that point that, you know, we definitely need people to be doing the studies correctly, but also interpreting the right factors, the right measures on those studies. I know there's been discussion around the obstructive sleep apnea Scale and how mild sleep apnea is not something that should be, you know, kind of like, oh, it's fine, it's just mild. No, it's still sleep apnea. That's not okay. You should have absolutely no incidences of apneic moments. So, you know, I think there's. Like you said, there's a lot more to be done in this area, but I think it's. It's an area that I'm even exploring more myself, trying to learn more about myself and looking for providers in my area who can do sleep studies across the lifespan, both pediatric and adult, who are reading them correctly, who are performing them correctly, who can. You know, I think that you're making a very valid point with. You need that baseline. And I know that, you know, a CBCT can give us a good baseline just in terms of what the airway might look like, like, and in relation to other things. But, you know, the measure of the sleep measure, that's. I'm adding it to my list of things to, you know, begin working on a little bit faster at this point.

Absolutely, absolutely. Because, again, you can get a benefit.

Yeah.

If you can prove that you have a problem, then medical insurance is likely to help you. Yeah, absolutely.

Well, thank you. This has been very informative. Is there anything else that you would like to add on this topic? Anything about your book that you want to plug or share with us?

I will. I mean, as far as the book know, the only thing I can tell you is nothing that we do is easy. All of this is really hard. It's hard for parents, it's hard for children. It's hard for practitioners. My hat comes off for parents that make this drive 2 hours, 3 hours each way, who have these children, who struggle, who look for solutions. None of this is easy. Whoever is listening to this podcast should understand. Some people are maybe listening to this, thinking, I want to get into this because it has meaning and I want to add more meaning to my life. I just want you to know that you will be getting yourself into not only treating children, because guess who is Gonna bring those children, the parents who.

Have the same issues or more advanced versions of those issues.

Yeah, yeah. And it's.

As soon as the parents realize what's going on with their child, they go, holy cow, I think I have this. And then you, you know, can you look in my mouth? And I'm like, well, we need to set up a whole separate assessment.

It's challenging. It's really. We. I, you know, I can only, I can only tell you my personal experience, but I think we live right now in a pretty negative environment for various reasons. Even before March, it was pretty not nice. And people forget they get lost. That we are human beings too, and we try our best to help these little people to have a better life. And we just need, I think, to have a little more compassion towards each other, to realize that we are not just doing a filling, we're helping rebuild a human being. And you are going to have challenges and you either pay now or pay later. And paying later is far more expensive.

Yeah, absolutely. Absolutely. I would agree with that, having been on both ends of that experience. So, yeah, it's.

Yeah, I'm a patient too, so I know.

Yeah. I mean, and I think you make a good point because we always say in the myo world and in the feeding world, you know, it's not, there's no cookie cutter approach. There's not one plan. Because everybody comes to me and says, hallie, what is like, how do I do the pre frenectomy, pre op work followed by the post op work? What does that look like? And what is, what does this look like? I'm like, I could give you 5,000 different scenarios depending on what, who the patient is. I mean, there is no cookie cutter answer or approach. You know, are there underlying goals that are similar across the board? Sure. But how we get there based on this patient's history and what they're presenting with now versus the next patient who walks through the door could be completely different. Which is why it depends. Like you were saying, it's my favorite phrase, it depends. So, you know, we do our best to educate and give, give examples based on cases and scenarios and try to teach people to think critically, which is what I try to do in my courses. But yeah, no, you make a really good point though. I mean, there's a lot of baggage surrounding this and it's not always so pretty. It is work. And the patients have to be willing to put in the time, put in the effort, put in the work. We really need to have their buy in before we Ever start something like this, otherwise we're all going to be hitting our heads against the wall. Absolutely. But I think the other thing that you mentioned, too, with remembering that we're working with human beings and that we need to be both passionate about what we do and have compassion for our patients and their families and truly understand, you know, who's on the other side of this, you know, what we're looking at as a provider.

But what I mean is I think we need to remind our patients to be compassionate towards us. I don't know exactly how to do that.

Yeah.

But what I find is people forget that they are not being treated by robots. And we have our days, too. And if you see 20 screaming kids in your day, give you a break.

I'm taking the rest of the week off. I'll see you next week. Yeah, absolutely. Well, for what it's worth, I started my career really specializing in working with children with autism.

I don't know how you do it.

And then I got to the point where I was like, I'm burnt out. And I became very interested in the feeding side of working with that population and why they had such stringent rules around what they would eat and what they wouldn't. And then I realized many other things as I started to dive deeper into the feeding world and then found the MYO world and the tots world and had my own children and they had all these, you know, my firstborn has all these issues with MYO and tots and airway. And so, yeah, you know, I think that it definitely goes both ways and that it's exhausting. It's exhausting to be that practitioner, especially because so many of us. I'm what many people would call an empath. I take on a lot of what my patients, you know, their emotions. And so I have to, like, cut that off sometimes and like, decompress and just kind of release that stuff. This gets very woo woo. But it's like, release that stuff back into the world and away from me because it can be so hard to be that provider who is constantly taking on everything that's coming your way while also trying to figure out what is the best for my patients and just dealing with the intricacies of treating those children or adults on a daily basis and all the baggage that comes along with that, too. So, yeah, 100%.

Yeah.

So are you able to announce the title of your book or is that still a secret?

It's still a secret.

Okay. All right.

We're still working on it.

Okay. So I was going to say because we can put some information in there in the show notes. But what we'll do is we'll link to. To your website. I assume you'll probably have it connected to your website somehow once it's out there. Maybe. Sure. Okay. All right, so we'll link to your website and I think, you know, you're definitely a name that I think people also follow in the myotots and airways space. You know, your names come up a few times talking to colleagues and you know, I even had was mentioned before. I've got a family that's close to you that I want to refer to you as well as, as we've been talking. I've got a speech pathologist who just graduated who works for me now and she is on her own journey and I'm actually, we're going to do an assessment, but she's up in the New Jersey area and I think she might be relatively close to you. So I'm going to have to tell her to come your way as well. But yeah, I'm excited for your book whenever that comes, whenever that comes along and to read it, get my hands on that once it's out in the public. Keep us posted on your work. Is there anything else you want to today?

Yeah, I do, as a matter of fact.

Please do.

Did I mention the book yet? One of the things that gets overlooked in treatment of small children is their nose. When you go to an ent, they look for the most part and tonsils and adenoids, they are either big or they're small. Unfortunately, oftentimes decisions are insurance driven because insurance pays peanuts for removal of tonsils and adenoids. When you make somebody's mouth more developed, notice how I didn't say it bigger, more developed, the tonsils and adenoids can actually shrink.

Thank you for saying that.

I have X rays to prove it. So if the child is not really unwell, I would tell parents, why don't we wait? Let's grow the person. We'll take another X ray in a year or two and we'll reassess. If nothing changed, then perhaps we need to consider that intervention. Perhaps tonsils need to be taken out. Perhaps they need to be shaved or removed. And you know, it depends on whoever you work with. Sometimes tonsils are full of scar tissue and no matter what I do, they won't shrink. So you have to understand that as well. But what I find is no matter how big, no matter how developed that face gets, the nose remains compromised. It may be less compromised, but it is a compromised nose. Nevertheless. Very few ENTs address nasal passages of children because they are taught in medical school that if you touch inside of the child's nose, you affect growth of the face. Many of them believe that and do not touch the nose. Plus, don't forget working in the nose of a three year old, like, whatever, it's very small. Yeah, it's very difficult. You have to be a jeweler to work inside of a child's nose. Not everybody wants the responsibility, not everybody wants to do that. But I will tell you, it can make a world difference. You can literally have a different child in front of you overnight. No matter how small the mouth is, no matter how swollen those tonsils are, you can have a different child. If the operation is done well, it is a minimal, minimally invasive operation. It's not difficult. Recovery is practically uneventful. But you have to find that person.

Who would do that and what procedure specifically are they doing in the nose.

Sometimes it's turbinate reductions. Sometimes there are literally defects inside of the nose. Some of us are malformed. Sometimes the bones are crooked, sometimes the bones are misshapen. So things have to be done that the air needs to flow. So the ent. I'm not an ent. I don't diagnose these problems. But I've seen enough X rays where I tell the people, yeah, you need to go. I refer to the ENT on a daily basis. Literally on a daily basis. Yeah, because I tell. And again, I give the option, I tell parents, you decide. Here's my opinion, you can go now or you can go in a year. But here's my experience, here's my opinion, take it under consideration. But this is one thing where I feel our children are being misdiagnosed and under treated. And if you want to save money somewhere, I would even go as far as telling you if you can't afford an appliance, if your grandparents can help you, if whatever, now is not the time. I would rather you have your sanity and not feeling bad about yourself. Then put your house in a second mortgage, find an ENT that would address the no's. Because if the nose is addressed, at least you will be closer. You will be much closer to having that piece that we are looking to give you. So that's something that's not easy to find. Those people are unicorns also. But they're out there. They are out there and I wish I knew more of them because there is definitely need. There's definitely a need. So that would be my 2 cents.

We were referring to Ents pretty much daily as well. But we just found these kids kept getting sent back to us. And so now it's been a larger mission to go out there and try and find a few Ents in our D.C. maryland or Virginia area who are willing to basically sit down at a table with us and have some discussions around what we're seeing, what they're seeing, and see if we can educate each other on just seeing if we can create this together. Because if there's just one unicorn out there amongst one of these three areas. I do know some great dentists. I do know some great. I really think the dentist have come really far in this area and there's some nice options out here. But ents have been harder, harder to find. And the other thing you mentioned about when you have the growth right, and you see that the tissues shrink and the tonsils or even the adenoids. I had said that this happened with my child. I could see that her almost kissing tonsils shrunk down and they weren't veiny anymore. They weren't enlarged like they looked enlarged, but because they weren't infected. Infected. And she wasn't a kid who. She actually had a closed mouth posture. Her tongue was not up, but her mouth was closed and she appeared to be nasal breathing. The ENT literally said to me, and this is supposed to be the ENT in our area who is airway centric, said, her tonsils are unimpressive. And I was like, I am very impressed by her tonsils. I know I'm not an ent, but they're almost touching. I mean, how the heck can this child breathe? I guess she's got, she's got a closed mouth right now in front of you and she's not snoring at night. But I mean, come on, what gives? So anyways, I.

Insurance and the bottom line.

So I put her on Exley. We started using xlear with her, but we also began the growth. We put her in an ALS and she. Within months she wasn't sick anymore. Over the course of that winter, her tonsils shrunk and they fluctuated a little bit, especially with cold and flu season, but they're significantly smaller than they were. And I mentioned this in a very big group on Facebook. And would you not believe that the leader of that group basically cut my head off and said, you know, delete this post. You have absolutely no evidence to support the basis of this. And I said, I'm not saying that this happens for all children. I'M not a dentist, nor am I an ent. I'm just sharing what happens for my child. And I have pictures to show you if you'd like to see, but, you know, whatever. I deleted the post because it was almost like it's not worth going there, but. So I was really happy to hear you say that because here. Here I am thinking, like, I've seen this in my patients, and I've seen it in my own child.

You know what? If you have the pictures, if you can write an article, I'll gladly post on my website.

Okay. I'd have to. Yeah. I have to go back and see how good the pictures are. But, yeah, I'll definitely look at what I've got from her. I know we've got pictures from the dentist, so I'll see what they've got too.

See, the problem is we have our patients for a long haul, and int does not.

Yeah.

It really takes a progressive person to think outside of the box to realize that your actions actually have consequences.

Yeah.

And that's the bottom line. We have to understand that our actions or inactions have consequences.

Mm.

I have a patient for life. You have a patient for, I don't know what, the lifetime of your patient, but let's say it's five years. That's a long time. And you can't dilly dally. You can't string them alone. You have to solve the problem as quickly, efficiently as possible. And that's the problem that sometimes non dentists have with dentists. Because as a dentist, my philosophy as a dentist is get in, get out. If you come to me with a toothache, it is not acceptable for me to nurse your toothache for two years.

Mm.

I'll tell you. Let's try different toothpaste. Why don't we try some coconut oil swishes. Why don't you do some cod liver oil? You're gonna tell me, doctor, I'm in pain. Fix my tooth today. Today. Today. I don't care that you have a patient waiting. My tooth hurts. Now, the dentist philosophy is get in, get out, and don't forget, it has to be hundred percent successful. You don't want me to fix your tooth a little bit. I have to fix it hundred percent. Right. So that is what we're trying to do, or at least that's what I'm trying to do. When it comes to these problems, we have to get in and we have to get out because our patients, if you treat them for too long, will burn out. And then you can't get them better. And so when that ENT doesn't want to do a sleep study, that's just because the person has never been taught to think this way. And plus, a lot of doctors are in group practices. They have agreements between each other. They have to produce.

Yeah.

That's another game that we have to respect and live in. And we have to try the people that look at it like we do. We want to solve these problems.

Absolutely. Absolutely. Well, thank you. This has been amazing. Any other last words you want to add in?

Stay safe and most importantly, stay sane.

Yes, I love it. Stay safe and stay sane. Well, thank you so much, Dr. Kundal. It's been an absolute pleasure talking with you and having you on the podcast. And I'm going to go back and see if I can pull together those photos of Lily's tonsils and see what, what the dentist took as well in her initial photos from, you know, we've got scans of her too, the CBCT from when she before we we did her growth appliance before we started it. So I'll see what pictures we can pull together because I'm, I'm curious just to see, even as a practitioner, let alone her mother, what, what results we have on that front. And I'll be gladly, I'll gladly share them.

Yeah, absolutely. Absolutely.

Well, thank you. Thank you. Thank you.

You're welcome. Bye.

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 screen social media platforms and join us over on Facebook, on my Facebook page at Haliebulcan, Biz, on Instagram at Alibulin, 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.