The Appliance Trap: Why “One-Size-Fits-All” Myo Solutions Fail

sleep disordered breathing is part of it. We kind of need a quicker thing that moves, and therapy is a dance and a back and forth and a tweaking things and a providing cues and supports and then fading those out and, you know, looking towards the big goals. I think just kind of defining what those are.

Hi, and welcome back to the Untethered Podcast. Today we have Autumn Henning joining us. Autumn is a founder of Chrysalis Orofacial and a distinguished speech pathologist Certified orofacial myologist and international board-certified lactation consultant with a master's in communication disorders from the University of Kentucky. Autumn has extensive experience and expertise in orofacial function and myofunctional therapy. She's currently appointed and in good standing as an assistant professor within the voluntary faculty series in the Department of Communication Sciences and Disorders at the University of Kentucky College of Health Sciences and was founding board member for the ICAP, the International Consortium for Oral and Cranial Professionals. She's a sought-after speaker and author and has trained thousands of professionals through her courses like TOTS training and the Stones Approach. She resides in Greer, South Carolina with her family and enjoys travel, reading, and her cats. Welcome to the Untethered Podcast.

I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, temporal tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture: tongue up, lips closed, teeth apart.

Breathe through your nose. Let's get started. Autumn, welcome back to the podcast.

Thanks, Hallie. I know we talk like all the time, but this is our formal, more formal chatting, even though it's more of a conversation. 100%. But yeah, here I am. I'm back. I'm not going away.

You're not going away. I know. I think you're the most frequented podcast guest at this point on the podcast. Been here 4 times. And listen, like, the podcast has been around since summer of 2019, so that's not even once per year. So like, clearly you've got like time to make up for it. Okay.

Yeah, yeah, totally, totally. And we, we always have good things to say and hot topics and not afraid to shy away from those.

Yes. And that is why we're going to dive into some hot topics today. All right, so I know we're going to chat a little bit about like how myo fits into the bigger clinical picture in terms of like the, you know, for SLPs, OTs, PTs. But there's a couple different, you know, we'll dive into that. I also want to dive into the pre-formed appliances because I know you and I have very shared opinions, maybe experiences and things to discuss when it comes to some of those appliances. Anywhere you want to start?

Yeah, I think just kind of defining what those are. So there are— it's sort of like tissues, right? Tissues. There's Puffs, there's Kleenex, there's whatever else, right? Different brands. And so the full umbrella is preformed appliances. And there are several different brand names that these go by. Y'all probably know what they are and you're probably aware, but they're all very similar in design. So they can be typically silicone. For more harder acrylic, plastic, whatnot. But they're all very similar. They come in different colors and yeah, they're all pretty similar. So here's a general look of what one looks like. Sort of like a little sports mouthguard, honestly. So if you can see, there's a shelf for the tongue and then there's this little tag right there that promotes the tip of the tongue to rest up. So it encourages lip closure, has these little bumps there.

So all of that.

and can they work? Yes. Do they always? No. And it's just like anything else. It's case selection of who is the ideal patient for these? Why would it be successful or not? And how that is carried out. So many of these are sold as like packages and programs, and you start with this one and then you move up to that one. And yeah. So I think that's pretty misleading and it's actually pretty expensive for what it is. It's a child that is grinding. I have seen them grind through these multiple times.

Huh.

And some of these programs are thousands of dollars. So that's really tough on parents, right? So anyhow, they're all pretty much similar and the same. And the caveat with them is A, The kid has to be able to wear it and keep it in, right? And even if they can, do they want to? Are they motivated to? Yeah, you're supposed to wear them. This is kind of across the board from all the different brands and programs. One hour awake and then all night. So yeah, that can be a big issue if they have nasal breathing issues. And so those that are not nasal breathing, this is never going to work. It's never going to stay in their mouth. And it actually, I mean, if their only good airway is their oral airway, now we're adding resistance and blocking that. So those are the ones that I feel would not be good candidates for that. The other type of case that is not a good candidate would be ones that are older and are kind of past that point of really malleable fast growth, and then the other ones that are like so severe, right? They have, you know, a 14mm overjet or something like that that really needs a little more oomph. And especially if sleep disordered breathing is part of it, we kind of need a quicker thing that moves. And this is great because it is slow, right? There's positives to faster and slower. So faster is like, hey, we get there, we open up that airway, we're making space, hoorah, right? We're taking advantage of the time that they're growing if they're kind of on the tail end too. The good thing with, you know, slower is that our body has time to like acclimate to the new positions, the new alignment. So it's really a balance of those two. And like I said, it's, it's all about case selection of, you who's going to do well with that and who isn't.

Yeah. I mean, we've only had, so I'm trying to think, we haven't had experience with all of them. Mia had Myobrace, and if anyone's listened to the podcast, they know this, that, you know, we were recommended Myobrace and I said, no, no, this child has had, she's been in, she's in an airway crisis. She's been in an airway crisis for years. Like she's 4, let's get her out of airway crisis. And the dentist completely agreed once she did her assessment. And she did not immediately, she said, usually because of her age, I might've put her right into the Myobrace first. First and worked her up towards having like a fixed palatal expander. So in that clinic, you know, the— that's not the end-all be-all. It's basically a step one, phase one, and then we go into phase one of fixed expansion with the Myobrace as kind of a growth holder, if you will, between phase one and phase two of a fixed appliance. And I was like, okay, I could get on board with that because we're not looking at this as the primary device, right? My kid needs more than that in my opinion, and I'm not the dentist, but I see what's going on. So anyway, she said, no, no, no, we cannot put a kid in airway crisis right into a Myobrace. That's not going to work for her. It's not healthy. Plus, we really want the rapid expansion to get her inflamed airway under control. And I was like, thank you so much. Okay, so she goes into expansion, we put her into that Myobrace in between. And so she had great expansion initially. That kid, like you said, she bit through it, she ground through it, she had mold growing in it. And it happened in a matter of 24 hours because like, we brush that thing every morning. And I I'm looking at it, it's fine. And the next morning she wakes up and I'm like, what's that black dot? Like, what is that black stuff? It was mold growing because she had broke the plastic and you can't get into the area to clean it well enough in some of these appliances because the Myobrace that she had had like the white— I don't know, whatever it was, like, you know, feeding through it to kind of hold the shape of the pre-molded plastic. And so it's a little bit more of like an active appliance maybe than a passive one in that sense. But Anyways, for her it was really like continue to guide the growth, not be the primary driver of said growth. But I was like, okay, we're done. Meanwhile, Lily was also using it between expansion appliances and the girl like would choke on it an hour into sleeping. We would find it all over her room in different places when she would wake up in the morning and she's like, I don't know why that happened. So I would like stay in her bedroom for a couple hours after she'd go to sleep so I could capture this happening. And sure enough, every single night, like it was like that 60-minute mark, like right around there, give or take a few minutes, cough, gag, exits the mouth, and she's without it for the rest of the night. So I was like, this is not functional. And this is a kid who had already been expanded, who did not have overt airway issues. So I'm like, what is happening in her mouth that this is like— this should not happen in a child who has enough, quote unquote, space for the myobrace to just hold growth and guide continued growth. So it just made me really like— it gave me pause and made me really skeptical of all of these systems because I was like, okay, I have two cases here in my own household that I know very well, and I'm not very pleased with what I'm seeing with either one of them. I don't know. So that's just my little personal— yeah.

And I've seen that clinically as well. They are nice for kind of like a, you know, pseudo retainer while they're growing and whatever after, you know, they've done some orthodontics. But exactly what you said, like, once you've like perforated that silicone, acrylic, plastic, whatever, there is no way to like clean that out. The bacteria, the mold, the fungus, any of that.

Yeah.

And so a lot of parents have been worried about that. The other thing that was a big scandal, if you will, was the dyes. There were dyes in the colorations of these appliances. And so parents, you know, a lot of these Children are very reactive to dyes. You know, they're not sleeping. They have some ADHD type symptoms and dyes just set them off. Can you imagine it like sitting in their mouth, mixing with saliva, they're swallowing it and whatever. So I'm not saying that it's like as horrible as like ingesting red dye, but, but you're still swallowing it.

If it's mixing with saliva, it's, it can still get into your system. You know, I'm like Lily. I cut food dyes from her when she was a toddler because she would be next level meltdown city. I mean, she was a toddler, so you couldn't really have conversation with her anyways when she was at that level, right? She was kind of way gone. But I'm like, it was Exorcist. The child's head was spinning, and I could not forget reasoning. You couldn't say anything to her because it just escalated. And that was every single time she had food dyes at a birthday party. And so I tested it at home, and she reacted, and we completely pulled dyes out of her system, and it never happened again. So if I had known that, right, like as a parent, and that wasn't disclosed, that would have been a hard— like, that would have been game changer for me. Like, no, we're not using that. That's not happening. Not interested. Prove to me that this is, you know— and there's a lot of holistic, health-minded parents who have been sold on these systems that I know were up in arms over a lot of that. But I also don't know they all know because I, I only saw it like circle small circles on the internet. I didn't really see it go too big.

So yes, yeah, yeah, definitely. What was the other thing I was gonna say? Yeah, with the grinding, grinding through it, having to buy multiple ones. And then something you said about Lily. I know Lily's kind of a little more of your sensitive sensory kid.

This is a whole mouthful.

Oh my gosh, like therapists, I urge you to like try it out, put one in. And just like I tell you to drink from, you know, whatever sippy cup you're recommending or straw or whatever, try that, see how it feels, see what muscles you're using. So oftentimes I'll see a lot of difficulty closing lips and a lot of clamping and mentalis and lip closure fixing. Many times the lips can't close. I also sometimes I feel like these limit growth. Right. Because they don't move with you. I mean, yeah.

Yeah. So Mia went through like she went through a couple of different sizes of them. And yes, I had to spend $1,500 to get the new one that we then never wore again. So that was super fun. So I was like, it gets really pricey really fast, especially when you're also doing fixed appliances in addition to them. And I really— I've talked to a number of parents who really jumped on to like the early bandwagon with some of these appliances, and I won't start naming names and everything, but they were pretty pissed when they had to turn around and go get fixed rapid palate expansion after the fact because it got their kid to a certain point, but it couldn't take them any further. And I think, like, right, you know, to your point, how old is the kid? What is our goal with this appliance, you know, or mouthguard? I don't know. I don't even want to call it an appliance because I feel like it's, you know, they're promising growth, they're promising support, they're promising Sometimes they're promising habit correction or whatever. I think it actually creates compensations when you have a big old appliance or device in your mouth that, like you're talking about, like you put it in your mouth and you feel it, you can't get your lips closed around it. So what do we do? We compensate. We can't get the tongue where it naturally should rest all the way up on the palate. It's kind of going front into that pocket. It's still trying to press forward. So what are we doing? We're just egging on the compensations that they already have. Right. And so it made me think of my DNAVivos appliance, which got me growth, but it was huge. It was uncomfortable. There was no space for my tongue. It was like— I mean, thankfully, I will say when I took it out during the day, my tongue was going to the palate. So it was promoting that. And so I'm not pooping all over that appliance or anything. It just didn't do enough for me. I needed more. But it was a really great, like, phase one as an adult for me, if you will. I just think that a lot of parents go into these appliances based on all these marketing ploys. That are sold to them, not realizing that it actually may not do that and may cause you to have to undo some other things, like other compensations that are built. Yeah.

And that's so true. And you know, I'll have patients ask about them because maybe they've been recommended, maybe a friend is using this, but not having any sort of, you know, true dental guidance and not in person. Some of them are virtual.

Yeah.

Which, I mean, it's really hard to get imaging when you can't also like palpate and have them do different movements and whatnot. I think that's a little rogue. You know, it's hard enough to do a therapy, you know, virtual evaluation, much less like something more, I guess, invasive, if you will. I do, there's a lot of claims out there of like, hey, you use this and you won't need orthodontics.

We don't know that.

The other thing I hear is people lose 'em.

Well, yeah. Yeah.

I mean, right? Like so expensive, you lose 'em. Yeah. It's a fix-all. Many of them have their own Myo programs and it's pretty much a set of videos. It's a cookie cutter set of exercises. You do. Right. And so here's the thing. What if that child doesn't need that exercise? Now we're doing it meaninglessly. What if they're doing it wrong and they're creating more problem?

Yeah. Right. Tracking that, right? Like who's tracking the quality of the exercise? Yes.

And if you're just doing exercises, like that doesn't translate to functional outcome and task, right? Like with therapy, we do this exercise, do this exercise. There are pieces of the sequence that we need for like swallowing or something, right? So it's always tied to that functional goal. So yeah, you know, if, if parents ask me about it, I just tend to say like, hey, I would get, go get an opinion. Now I'm not saying it's wrong. I'm not saying it's bad.

Can it help?

Yes. But I urge them to like go get another opinion just so you can compare and parents Parents have to decide what's right for their kid. I'm not here to tell you that. I'm here to give you information.

Yeah, but I think it's also, you know, if you had to put it into a framework for a parent to try and simplify it, like, I think a lot of parents come to us and we're like, this is out of our scope, but they'll be like, what, what appliance is best for my kid, right? And I'm like, okay, here's the thing, like, is your child's nasal airway patent? Is there a skeletal restriction? Is this a growth case, or is there like a structural deficit here, right? Is your child compliant? Is there a professional collaboration that you can have? Look, Are we going to be training function like you mentioned, you know, alongside changing the structure? Because like you said, structure without function, that's going to lead to relapse if we even get any gains. And then function without structure stalls, right? And so the magic here is kind of integrating everything. And that's where it's like we need to go to the medical professional in person who can do the evaluation and take the imaging and have their eyes on everything going on. And like, is there a time and a place where virtual can come in handy? Yes, but I wholeheartedly believe you— if you don't have it locally, you better be getting in the car and traveling to someone who's got like some CBCT imaging or something where— or they can do an iTero scan. Like, how are they planning this for you without actual imaging? Just giving everybody the same thing, in my opinion, is a waste of time and money. I'm just going to throw that out there. Yeah, I feel very strongly about this. Yes, definitely.

And what you said about, you know, just that team that works together, you know, I always say orthodontics is the hardware and myo is the software. So they put the structure together and then we, you know, help operate and make it work. And you're right, every— so many patients, which appliance is the best for me? And I'm like, I can't tell you that. I can tell you, you know, some of the properties of each one of these, some of the questions you might want to ask, things like that. You know, potential pitfalls and struggles other patients have had or successes or whatnot, just to give them things to think about and be able to advocate for their child. I think so often as you know, it just society in general, we go into a dental or medical provider's office and we're the recipient, right? We take what they say in without feeling empowered enough to challenge them and to ask questions and to say, well, what's the research behind that? Or tell me about cases like my child that have been successful. I personally love those patients. It, I love them like challenging me, you know, makes me look at myself and Do I have all the information that I need to help this patient? Am I missing things in my knowledge base? And that's the kind of person I am too, is asking the hard questions. But I do feel like A, patients don't always know what to ask, and B, they're nervous and afraid to ask, right? So many providers unfortunately tell you all the things, but they don't say like, hey, How are you feeling about this? What questions do you have? Whatever. And so I always tell parents and patients like, hey, they work for you. You are paying them, right? So, you know, take that opportunity and, you know, yeah, ask, ask the things.

Love that. I love that. 'Cause parents, you know, and I think parents, it's not your job to know all the questions to ask or to know, like that's why you're going to this specialist, right? That's— they're supposed to guide you, and if they're not doing that, that's more of a them issue than a you issue. And so I love this, I love this conversation because I really like to encourage parents, like, you know, and even if you're a therapist who's a parent who is like, I feel like I should know this— no, not necessarily. If you're not educated on it, how are you going to know this information? I have learned it because I've now been in 2 appliances. My kids have now been in 3, 2, 3 plus appliances. You know, like I have poured thousands and thousands and thousands of dollars and time and energy into Mayo, into various appliances, into working with 3 different providers because of where we've lived. And, you know, everybody has their own approach and everybody has their own education and experiences. And so there isn't always even necessarily one approach that's better than the next. It's really what is the best approach for your child in this moment with the knowledge that we have and what's available in your area? And does that feel like a good fit for you? Right. But like, you can't know that unless you actually have the conversation. and I've been known to challenge an ortho who's local to me. They, the ortho called me after I left, like at the end of their workday being like, are we okay? And I was like, no, you're not okay. Because I'm like, I have the information and I'm challenging someone who thinks they know better than everybody else. And listen, that's fine. And if your patients are happy with that, by all means, I hope you have a thriving practice. However, don't do an, you know, an airway eval and not offer an airway treatment plan. And so that was what, but I knew what to look for going in, right? And so that's another reason why I even created this podcast. Like, I want you all to feel equipped with enough knowledge to know what to ask. And that's why I'm like, this is here. It's a free resource. Listen to it, ask questions, and challenge your professionals. Like, keep them on their toes. Keep them on their toes.

Otherwise, how would they know? How would they know something else is out there? And I do feel like it's getting more known, mainstream, if you will. The orthodontists that we work with mainly worked next to me for 5 years.

Mm-hmm.

And really, like, I tried a few times and they were so nice, but nothing came of it. Right. And then I had a case that just hit it out of the park, helped her open bite close, and they were like, wait, they talked to the patient. What did you do? And she was like, well, I researched and I went to myofunctional therapy. And so I got a cake the next week. So this was 5 years ago and they took their whole orthodontic team to, I forget what conference, but it was in Florida somewhere. And they texted me like on our group chat and they were like, there was a lot of talk about myo. And I was like, see, you're an early adopter.

Mm-hmm.

So I think, you know, challenging those doctors in an obviously respectful way. Helps them think differently. You know, like obviously we didn't know all these things and someone influenced us and challenged us, or even a patient that we saw or our own children, something happened to make us go and learn and think out of the box and shift our thinking and, and how we manage patients. So, yep, it's good. I know you and I are both Enneagram 8s. Ironically called the Challenger.

So yeah, it totally fits. Totally fits. And I think it really is a kind of a good bridge into the other side of this conversation where like how myo fits into the bigger clinical picture, because as you shared, you know, earlier in our conversation, myo, it's not just tongue exercises, right? It's a nervous system plus airway plus like the musculoskeletal. It's a conversation amongst all of these components, right? We've got the neuromuscular repatterning. We've got to optimize the airway. We've got— we're working on craniofacial, you know, growth and supporting that. Like, I know we're not moving the bones, but we're dealing with the muscles which influence the bones, right? We're working on maybe restoring functional breathing patterns. There's full body postural integration. As I sit here slouched over, you know, it's like, you know, it's across disciplines, but also there's so much within our scope that we address through that myo lens and then collaboratively that, like you said, some of these programs just were like, here's your exercises. Like, you're missing the mark, y'all. Like, this is not myo. Like, you can call it myo if you want, but it's not myo. And honestly, you're failing your patients.

Right, right. And it's not therapy. Therapy is a dance and a back and forth and a tweaking things and a providing cues and supports and then fading those out and looking towards the big goals. But yeah, you're right. As far as, you know, we're SLPs here, but I know you have listeners that are all different professions and the trend that we're seeing in the myo world is that, you know, occupational therapists and physical therapists are really getting involved in the myo world. And it's really interesting because physical therapists, they deal with muscles, so Why not muscles of the face, right? When we're talking about full body impact and the whole fascial line with the tongue throughout the whole body, looking at that as far as posture, rolled shoulders, forward head posture that opens the airway, even pelvic floor issues. So pelvic floor is related to breathing and OTs and PTs, particularly OTs, work on constipation and incontinence. And bedwetting stuff. Traditionally, they work on it from like a pelvic floor muscular situation and sensory, right? But those are often related to breathing and airway, especially bedwetting. So I did a talk for the, what is it, Pediatric Pelvic Floor Summit a couple years ago. And it was just so interesting to see, to put together how all of that impacts together. Let's see, as far as PT goes. We, yeah, we talked about that and just general coordination. And we know that stability in the body affects the mouth and vice versa. So there's a really cool—

those tips you see on the lips, you know, right?

There's two really cool studies that relate to PT and myo that I can think of right now offhand. But one of them is basically they're doing like a leg extension, or maybe it's flexion, I can't remember. Basically moving your leg like this, right? Bending at the knee. And they had patients do it 3 different times, and they randomized the order. They had patients do it with their tongue on the roof of the mouth, their tongue kind of hanging out in the middle, and their tongue low in the floor of the mouth. And what they found was like the excursion, the strength and force, the weight they were able to lift, all of that was better with the tongue on the roof of the mouth. So it's very interesting. And when we're also talking about myo, nasal breathing, and you know, nitric oxide that we make in our nose is a vasodilator. It gives us more oxygen to our muscles. So, you know, Olympics just finished up and you see all of them are nasal breathers. So that's really interesting. The other specific PT study that I found is more related to adults, but TMJ issues. So what they did, they had a group that had cervical neck pain and headaches that just were treated regular PT, like ice, range of motion exercises, postural stuff, you know, the usual, maybe even dry needling, right? The typical PT go-tos with that. Well, what they found was they did a group that did traditional treatment with PT plus myofunctional therapy, and they found that those two together had a way better effect on their neck pain, their headaches, and their TMJ, which, you know, if, if you're working on working with a PT, that's so powerful just because, you know, the function matters and You keep misusing that function and PT keeps loosening it and helping, you know, to move things, but you're kind of undoing it. So those are two studies that I love in relation to PT. Yeah. OTs with pediatric feeding, you know, feeding is different than myo, right? We've, you and I know this. Feeding is more like, okay, I can't eat all the food groups. I have texture issues. I'm gagging and choking. I don't chew my food all the way. I'm spitting out, whatever it is, right? Aspiration. Whereas Mayo is more like the correctness of the chew and swallow.

You know what I mean? Yeah. It's, it's basically like the oral phase, right? Up until the point of triggering the swallow. So it has that little overlap with pediatric feeding if you wanna call it that, but that's like, right, right.

And so, you know, oftentimes what I'll do. You know, depending on the issue, the severity, the age of the, the kid, oftentimes what I'll do is I'll teach them correct chewing and swallowing with things they do well with. And then we start working on the actual feeding stuff. You know, we've worked on the mechanics side. They feel confident with the steps and patterns of chewing and swallowing. And then we kind of, especially picky eaters, we kind of branch out from that for their variety. So OTs do pediatric feeding as well. You know, traditionally, really hand-to-mouth was traditional and a sensory base, but really I don't feel like feeding is— you can't separate sensory out from motor, from behavior, from the medical diagnoses. So it really all comes together and, you know, you, you can't identify that it's it's one thing, cuz 99% of the time it's multiple things. But, um, yeah, we're seeing such a, a shift and OT and PT kind of coming in on all of that, which is really cool just to have different perspectives. And you know, it's in their scope of practice, so go for it. Just as long as, you know, you have the confidence and training specifically for that. None of the, none of us learned this in school. So that's the big key.

Yeah, we like for SLPs, like I would even say, you know, I know we're SLPs and we have a lot of SLPs listening here, but there's that articulation component that people like to ignore, especially with your, you know, your, your S, your Z, your T, D, N, L. Like, I feel like it's easier to say the letter names than the sounds because we're on a podcast. But when you start to think about how these kids are presenting, right, with like their open mouth posturing, their tongue thrust, that is oftentimes present when they swallow saliva, and it's present when they speak, and it's present when they try to swallow a bolus, right? You know, it's not just present for one, it's present across the board. And then there's, oh, the drooling that's lasting too long and the swallow dysfunction. And, you know, a lot of these kids across the board, regardless if it's SLP, OT, PT, right, these kids have sleep disorder breathing oftentimes. And so that's a whole nother aspect because then we see those behaviors that you were mentioning, right? We've got these poor kids who not sleeping. Now, they might appear to be sleeping through the night. They might be like— the parents like, what do you mean? They sleep 12, 13 hours a night. But like, what is the quality of that sleep? Are they constantly arousing? Are they awake, asleep, awake, asleep, awake, asleep? Are they actually ever getting into deep sleep and getting that fully restful, restorative sleep, right? Because if not, they can appear to be sleeping all night, but then they have these ADHD-like behaviors during the day, and it's like there's this mismatch. Well, not really, because something's happening when they're sleeping, right? Plus, then tethered oral tissue is like the whole form in addition to, you know, I know that's tissue versus hard tissue with the bone and everything, but it's like there's all of this stuff that overlaps. You know, I think the most obvious one is just that chronic mouth breather that comes in. Like, if you're seeing that, SLP, OT, PT, whoever you are, that is your open window into everything else that we just discussed, you know. We're seeing these 3-year-olds now with longer growing faces, like long narrow faces at 3. That's insane. And we're seeing these kids hunched over PTs, like that posture is, it's impacted in an early age now. And so I just think, you know, we are really having to kind of reframe the lens through which we all look at these patients. I was just talking to a clinic owner who opened a clinic recently in New Jersey, and she was like, she's multidiscipline in that clinic. And she was like, listen, even if the feeding cases are not our initial referrals, I know that the kids that the PTs or the OTs or even the speech cases coming in, we're going to flag those kids with those feeding and those myo issues. You've seen them when they walk in the door, it's on their face. Like, we can see what's going on. And so I just think that the myo stuff really shows up in so many more ways than anybody actually realizes, and there's such an integration. But I love what you shared too about how you know, it really— you can't really separate them. I was just giving this chat, this talk this morning to a group of SLPs and OTs, but really talking about like the three driving— like, who's driving the bus, right? So you've got the skill or the motor, like you were talking about. You've got the systemic or the medical complexity side of things. And then you've got sensory. And for so long we've been taught like, oh, it's sensory, oh, it's sensory, oh, it's sensory, or it's motor, oh, it's motor, oh, it's motor. And then it's like finally these two camps kind sort of started to come together. And I'm like, we might teach in silos, but we really shouldn't. And we can't treat in silos because human-wise, like, we have an integrated sensory-oral-motor system or a sensory-motor system in general. And so I love that you highlighted that because I'm starting to see a shift. Now admittedly, it is a little bit more in my own population of individuals coming out of my programs, but we're seeing a shift in the language and what people are saying. And they're saying like, I'm holistically looking at the child. I see the integration of sensory and motor. Like, we cannot be teasing these apart necessarily. Like, yes, there's probably a root cause driver here, right? And it might be one of those three arenas. It's hard to figure out what it is, but also, if you even can, does it even really matter? You kind of have to figure out what you think the driver is and treat that. But really, we're treating the whole system regardless, right? So I think, you know, going back to the whole thing, kind of pull this full circle, like, myo is not just tongue exercises. It's not just a cookie-cutter program built in with some of these pre-formed appliances, if you will. Or I hate calling them appliances, but anyways, like an appliance to me is like my Marpee or my kids' Arpees.

But myo is really like, it's in, it's that nervous system, right? It's the airway.

It's that musculoskeletal integration that's happening, right? It's not just the tongue exercises. So I'm going to hop off my soapbox in case you want to add anything, but Everything you were saying, I was like, yes, yes, yes.

Yeah. And you know, back to that sleep disorder breathing stuff, that changes the brain when you're not getting into that deep sleep and those, the cerebrospinal fluid doesn't like wash and get all the toxins out of your brain and stuff. There are studies that talk about if a child snores for more than 3 months, 60% increase for ADHD. And so here's the thing, how do you diagnose ADHD? It's like a checklist. Like there isn't like a blood test or anything like that where sleep disorder breathing, like you have numbers on a sleep study. And so many times these, these kids are just getting these diagnoses and now here's some stimulants to medicate you when that's not truly where it came from or what they needed. And, you know, I've seen a few times that, you know, we get a patient sleeping better because we're addressing all the things, right? And they no longer like meet criteria for ADHD at that point. So it's really interesting and, you know, that's another thing with, with OT, you know, you know, working on sensory and regulation. And, you know, we all have those kids that we can't, you know, get them to sit down. And, you know, they're here, there, and everywhere and having a hard time paying attention, or they're labeled as behavior kids, or, you know, just inattentive, or, you know, not motivated, or whatnot. And I do think people see those characteristics and just chalk it up to that. I also think this happens in the autism population, especially with, you know, the eating, like, okay, they're autistic, they're gonna be picky eaters, right? Okay, they're autistic, they're gonna have, you know, articulation issues or whatever. There's a lot of preconceived notions with that that, you know, could be potentially helped with some myofunctional therapy, right? And you know, we're not gonna cure anybody or change any of that, right? But it's one thing that we can help control, one way to improve function, to help them in school and their daily life and all of that stuff socially. Even just how, how we look, there are judgments made. You know, if you have a longer face or you have your teeth are way out there, or you know, you're all the time. Not saying that's right, but that's reality. And so we can really make a difference in that as well, that oftentimes we don't even think about, you know.

Well, and I love that you share that because it just makes me think to like one of my little kiddos, right? So he's a child with Down syndrome, and he was 2 when I started working with him, and we were prepping him for his tongue tie release. And this kid could like click his tongue better than his 6-year-old typically developing brother. And I became the tongue click lady. Like, that was like my claim to fame because every time he saw me, that was how he greeted me. He would just click his tongue and he'd be like— and they'd be like, oh, he would start smiling and clicking his tongue. And I was like, okay, I can get on board with this. But let me tell you, his face changes, his facial changes after release. He went from that very typical, like, Down syndrome profile to having a very not so typical Down syndrome profile. Like, his face had more curves to it and his jaw, his lower jaw came forward and his face didn't look so flat. And it was— he got a little bit of like wider, you know, it was like his face started to develop. Had we not released the tongue, had we not taken more of an adapted Mayo approach because he was 2 when we started, keep that in mind, right? So it was like pediatric feeding with a twist of TOTS and Mayo, Mayo goals in mind. He would have never looked like this. And I have the pictures of him side by side. And I teach this in my course because I show people like, Look, like, look at the difference it makes. And it's— yes, the aesthetics are a bonus. That's not why we did this, right? Right. We did it for his airway support. We did it for his functional abilities to chew and swallow. We did it for his ability to have clearer speech because his tongue can actually move and hit certain articulatory targets now that it couldn't when it was tied and when it was living on the floor of his mouth, you know. And now there's not as much drooling. And now it's like he has better control, he can breathe nasally, the tongue is up on the roof of his mouth. Like, that's the ultimate goal. So like, if— not saying that that's going to be the case for every single child, especially with, you know, structural anomalies or things going on where you might be working against anatomy that maybe you can't really shift much. But in this kiddo's case, because we got in there so early and he was so into his tongue clicks, like, let me tell you— and this is a kid who still does not love to eat. Like, he is still in feeding therapy, okay? But like, he's Beautiful. Okay. It looks good.

Blame me.

Love it. Love it.

Yeah, I, I always say, you know, particularly in the Down syndrome population, you can really tell the patients that have had oral motor work early on and the patients that haven't. And I do think back to that is, you know, many times I think people look at the diagnosis and they make assumptions and this is what it's gonna be. Okay. You know, this kid with Down syndrome's gonna have a tongue thrust forever and ever, right? And that's just not the case. Like, you know, there's genetics and we have a syndrome, but then there's epigenetics and that includes therapy and all the environment stuff. But I always say like, hey, like let's do anything we can to make a difference, right?

Incompetence. Like let's give them a chance. And if it doesn't work, if we're not making progress, we're not going to keep you on therapy forever. But like, how are you ever going to know if you don't try? It's not going to hurt anything. If anything, it's just going to help like exponentially. Like it's going to improve this child's health and well-being. Why wouldn't we try that? And that, that's what drives me up a wall. I'm like, we need to be having more of those conversations versus like just writing kids off because they have a diagnosis.

So, and especially since, you know, the treatments are, you know, surgeries and invasiveness and things like that, whereas You know, her therapy, you know, very low risk. I don't even know what the risks are really. I mean, to be honest. So yeah, why not give it a shot? And like you said, if it's not going, it's not going and we switch gears, but.

Amazing. Well, I know we could talk about this all day, but I won't keep you because I know we're both busy, but thank you so much. This has been amazing. I know you also, I want to give you a chance to share what you've been working on because I know you also have a little update. Update on one of your programs. And anybody who's taken like Feed the Peas or has been in our membership, like, you know Autumn, you know she's got TOTS training, you know that was my original TOTS course that I attended that like sent me down this rabbit hole of like, holy cow, my whole family's tied. So Autumn, give us a little update on what you got going on, man.

So yeah, this year it's been 10 years since I launched TOTS training in 2016.

Girl.

And yeah, Hallie was one of the early adopters. So anyway, yeah, you know, you evolve over time and your training should too. So even if you've taken TOTS training, you know how powerful and robust it has been. And so we're just kind of kicking it up a notch. So, you know, updated and new research. We have a fully overhauled healing protocol. We have new clinical pathways that things we want to consider and which ways we want to go. A ton of exercises that you get to keep.

Yeah.

So lots of new things in there. So we're calling it TOTS Training Gold Edition. So if you've already taken it, you need updates, right? And if you are just, you know, wondering and getting into the world of tongue ties, seeing symptoms in your patients and you're like, okay, what is this? What's next? What do I do with that? How can I help? This is for you as well. So definitely hop on there. This is the most complete version we've ever done. And honestly, you know, I feel like when something's good, I'm like super proud of it. And so I'm very proud of this because it's been years in the making. Yeah, there you go.

I'd love to see you there. First and foremost, understand the blood, sweat, and tears that go into creating it. From the get-go, but then updating it. Like, let me tell you, people think like, oh, that's the easy part. No, it's probably harder and takes you 3 times as long because not only do you have to go through all of your own content and decide what's still relevant, but then you've gotta go update everything. And like that alone, like we're revamping Feed the Peeps right now and just kind of doing like Feed the Peeps 2.0. And we've released some of it already, but we're like full on in the thick of it. And I'm just like fetal position, like, oh, is it done yet? Have we updated it? I love it. I love it. And I want y'all to have like all this information, right? But at the same time, it is, it takes heart to do the work that you do, right? So anyways, all that to say, I'm sure this is amazing. I love the gold edition. I saw your seal and it is beautiful. So everybody needs to go check that out. But yeah, that's, you know, if you've taken any of my things, you know that TOTS, the TOTS training is the definition that I referenced from Autumn. And, you know, I learned like all of my initial TOTS info from Autumn. She is the OG in this space, y'all. So that is who— you're like, who do I learn TOTS from in a comprehensive TOTS course? That's the one. That is the only one that you need to be learning from because she's the OG. So everybody else took her course and then went and created one. There, I said it. All right, so true. Hey, flattered. All right, well, thank you, Autumn, so much for coming back on the podcast for the 500th time. I'm kidding, 4th time. Love you, love all that you do for this space. And I just thank you again for joining us.

Thank you, dear. So much love to you too, and all the impact you're making.

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