The Jaw Growth Protocol That Heals Sleep, ADHD, and Mouth Breathing in Kids, with Dr. Ben Miraglia

Hello, I am Dr. Wendie Trubow, and our guest today is Dr. Ben Miraglia, MD. He is a dentist who has over 30 years of general dental practice experience, including over 20 years of orthodontic experience in early childhood jaw growth and Development. He lectures nationally on early childhood malocclusion, its connection to sleep-disordered breathing, and early treatment options. So Ben, welcome. I'm so excited to have this conversation with you today.

Yeah, thanks for having me. This is like my favorite thing to talk about. So I'm very happy to be here.

And the timing's perfect because I was at the dentist this morning. I have a mouthpiece to help my jaw adjust. And I was saying to him how I sucked my thumb for the first 10 years of my life. And that I was never a good breather. Like, I was never— I never breathed right. And now in my 50s, it's all of a sudden something I want to address. So I was like, where am I going to go to address this? He's like, I'll send you the referrals, but now we're having this conversation, so I'm going to pick your brain. This is, you know, it's all personal, but I'm really excited. So Ben, thanks for being here. How did you get into this topic?

Yeah, so I spent the first 10 years of my career fixing teeth, crown and bridge and implant reconstruction dentistry. But during that time, I was referring kids to the orthodontist at age 11. And so they were going at 11, and then of course having 2 and 3 years of braces, you're seeing the progress as they come back to our office for their cleanings and checkups with the hygienist. And so I'm watching this, and then you follow them a little longer after their braces are off, then they have a retainer, then they don't wear their retainer and the teeth shift. And I'm just looking at it and I'm dissatisfied. So I'm a little dissatisfied. Maybe there's a different way to do this. Is 11, 12 years old the right age? Are we starting too late? Are we missing something? I started taking classes. And fast forward, after taking classes, I started learning, oh, there's a whole world out there of treating kids earlier and even intervening at age 3. And so to get involved at age 3 and above, how— you're basically— it's a departure from the traditional model. So basically, I was a little bit dissatisfied with the traditional model of getting braces when you're 11 or 12. And over time you realize, hey, that treats the symptom, not the cause. And so if you work earlier, you get to work on the cause, which happens to be the jaw development. So the key was really working on jaw development early gets a better outcome, more stable, and has different outcomes than just straight teeth. So I started down the road, learned a lot of stuff, started treating the children earlier. Then fast forward 10 years of watching it happen in this direction. I started teaching other people how to do it too. And here we are today talking about it. 20 years later.

You're technically an airway dentist or orthodontist. What's the right term?

So, general dentist. I am a general dentist, but I think the term airway is more of a description, not an actual specialty. Dentistry doesn't have a specialty called airway, but people are saying, oh, I'm an airway dentist or airway-centered dentist or airway orthodontist. They're using these words. So I'm a general dentist, but I do practice growth and development. And so you can say orthopedics or orthodontics if we're using the kind of professional term terminology. But to be very precise, I'm just a general dentist. I'm not an orthodontist or any type of specialist, and the airway word is more of a, a description that people are using for social media and websites, but not necessarily a specialty of dentistry.

So I think we have to start with why does this matter? Like, start with why. Talk to me about what's the difference this all makes, and then we can talk about the nuts and bolts. But Why are we having this conversation? What's important about it?

Yeah, there is a big difference. So doing the traditional model of braces at 12 and above does work on the teeth and it can make your teeth straight, like that works, but it's not addressing the jaw growth or the muscles or the breathing. And so the why is that if we help the child earlier and get involved with jaw growth, as the jaws grow, we breathe better. And if we breathe better, we sleep better. And if we sleep better, we're healthier. So that's kind of the short story. But the big difference is between nose breathing and mouth breathing. So in the end, if you ask me what is the one thing I'm trying to do, believe it or not, it's not even about the teeth. The one thing we're trying to do is get back to nasal breathing. So we want a child to nasal breathe day and night. That's where you have your pathway to optimal health. But in order to nasal breathe, we need the jaws to be the right size. When our jaws are smaller, we might see crowded teeth, but when the jaws are smaller, it's hard to breathe through the nose. And when it's hard to breathe through the nose, you breathe through your mouth. Day or night mouth breathing is very unhealthy. So, yeah, the why is you can have a healthy child through jaw growth and development that leads to nasal breathing. Whereas if we waited until 12 and just get the teeth straight, all we have is straight teeth, but we might still have the same unhealthy child behind the scenes.

So are you okay? Are you saying that if you're old like me and you, because you and I are, I think, peers, if we're old, that you can't fix it? Or is it just more work than if you start young?

Yeah, it's more work. Adults have options. Adults have options. But basically, the older you get, the more mature this bone is. And when the bone is more mature, it's harder to manipulate and grow. And basically, you end up with more surgical options. So yes, adults have opportunities when they learn that they have obstructive sleep apnea or things that are very bad for them, then they know, well, maybe there's a pathway through addressing my jaws. So We prefer to work on the children younger. It's easier because the bone is immature. So you can help a child easier when they're younger, but the adult— teens and adults, harder to do, but possible. And we do treat all ages. So I do treat all ages, but it's more fun to help the child out. They get the full heal, really. The adults, it's harder to work on an adult.

Okay, so you mentioned mouth breathing. Are there other signs about mouth breathing other than just mouth breathing? Is there anything else parents would look for or even people look for in themselves that would indicate Oh, this is a mouth breather.

What would you—

what do you see?

Yeah, so we throw out mouth breathing right away because it's one of the things you could see right away. My child have their lips apart? Are they mouth breathing day or night or both? But another thing a parent might recognize are— and it's kind of a long list of symptoms, but at the top of that list would be behavioral changes or issues. And that's a broad one because that is like anything that is in the attention, the hyperactivity, the sleepy or fatigued or any type of aggressive behavior. When you're talking about that ADHD diagnosis, there's a long list of symptoms that regulate, that basically regulate that diagnosis as far as what types of behavioral characteristics are we seeing in kids today. So behavioral changes are definitely related to the sleeping and breathing. So we have basically, okay, I might notice my child has their mouth open or breathing. If not, what about behavioral changes then? Bedwetting. Bedwetting is fairly common and there are lots of statistics out there, but roughly 10% of all kids bedwet up until the age of 12 today.

Wait, wait, wait, what? 10%?

Yeah, it is. It's about 10%. Now they have different age groups broken out, but generally it's about 10% of all kids will bedwet up until the age of 12, which, you know, oh, that is very bad and it's unhealthy for everyone. It makes for, you know, a disruptive lifestyle. And also it's difficult to deal with on so many levels. So behavior, bedwetting. Then we talk about ear infections because kids are getting ear infections and that is related to jaw growth and development and how our muscles are working. We talk a lot about grinding teeth because that's another one parents know right away. They can hear their child, that kind of, ooh, nails on the chalkboard kind of sound is grating, but they know their kids are grinding their teeth. So sweating at night, a lot of parents recognize their kids are sweating at night. The pillow is soaked. Restless sleep, lots of movement. Kicking and hitting, parents who have kids waking up in the middle of the night. So maybe they're not noticing or observing their kids sleeping and their mouth is open or not. They might not know. But what if your child wakes up once or twice a night and comes and disturbs you? Well, then you know that's happening. So waking up at night is one of those. So there is this long list of symptoms that are downstream from poor breathing, and a lot of parents are struggling with that list of symptoms. And then they just don't have the connection yet.

Yeah, I would say most parents don't actually have any knowledge that these symptoms indicate that there may be an issue with the jaw and the breathing, right? Like, they're not even aware.

Exactly. Okay. Exactly. And they might be treating the symptoms because any one of those things, you could go for treatment and get treatment of the symptom list, whereas we're relating that to the breathing. And the difference between nose and mouth breathing oftentimes is the jaw growth and development. When the jaws are well developed, we breathe through our nose easily. But when the jaws are not well developed, it makes it harder to breathe through the nose. And that's when the brain kind of takes over and makes a choice. Well, you're not really breathing through your nose very well. I think I'll help you. And that's when it opens your mouth. So opening the mouth is not like a conscious thing that you do, thinking it through, like, you know, my nose isn't— my nose is not open and breathing well. I will open my mouth today and walk around like this. It's an automatic thing. When your brain realizes that the air is not flowing through your nose well, it separates your lips, then your mouth breathing. And next thing you know, we're unhealthy because it affects the sleeping quality.

So you mentioned jaw development. Essentially, if you fix the breathing, does the jaw start to develop differently?

So you can work both ways. It's a little easier if you get the jaws growing better, then that fixes the breathing.

How do you do that?

Grow the jaws. And we want to grow the jaws by recruiting the muscles that are supposed to be growing them. So our jaw growth and development is dependent upon the tongue, lips, and cheeks and how they're basically functioning and resting. So when our jaw muscles, tongue, lips, and cheeks are resting and functioning properly, that produces really nice jaw growth. Through all those years. But when they're not resting and functioning properly, we'll lose the word dysfunctional. When our tongue, lips, or cheeks are dysfunctional, our jaws don't grow the same. And then of course, when the jaws are smaller, in the end we'll see crowded teeth. Like most parents are like, oh my God, my kid's teeth are all over. I know we're gonna need braces. But one step before that that a parent might see is those cute little baby teeth are perfectly together. There's no space. So that's another item on the list of an observation a parent might notice. Their 3 to 5-year-old who has all these beautiful baby teeth, but there's no gaps between them. They're together. Baby teeth that are together equals permanent teeth that are really crowded, and it's a sign of the jaws are underdeveloped. So the teeth are the symptom, the jaws are underdeveloped.

So walk me back to what are you doing to develop the jaw and the tongue lift, to develop— what, what do you do? Like, now I'm like, what do I— my kids are— my youngest is 13, so I think the horse is out of the barn on this, but what do we do to develop that jaw?

So if we recognize like the signs and symptoms along the way and we have whatever age it is, 3, 4, 5, et cetera, mostly we can work between 3 and 12 easily. So we'll talk about that age range, 3 to 12. So let's say we meet a child who has some symptoms because we would ask some questions and then we look and we see, oh yeah, the baby teeth are together or the permanent teeth are crowded. So backing up to the cause, meaning if it was our muscles that weren't resting and behaving properly, gave us these jaws that are too small. Let's get the muscles back on track. So the analogy I like to give parents is like, you know, if you haven't been to the gym in years, maybe things have shifted a little bit, and we don't want that.

Sagged a little bit.

They might have shifted a little bit. So we don't look— if we don't go to the gym for years and we watch a lot of TV on the couch, we might not look our best come springtime for our bathing suit. Now meanwhile, the answer is, oh, let's go to the gym. We're going to work the muscles, we're going to do a beautiful routine, and you know what we're going to do in a year? We're going to come out looking great. It'll change how we look, right? Well, the jaw muscles do the same thing. So when we haven't used our muscles properly, so our jaws are not growing well, to get the muscles to work, we have different things we can do. Now, one of them is myofunctional therapy. So myofunctional therapy is specifically working with jaw muscles, the entire head and neck, to train and educate those muscles so they rest and function properly. It also develops proper strength of those muscles because a lot of the dysfunctional musculature, it's not resting properly, it's not functioning properly. There's also weakness in there too. So if we work with myofunctional therapists and have a child do therapy for the jaws, we can help those muscles to grow the jaws. But then the second component are what we call guidance appliances. So guides, we loosely call them guides, but basically between 3 and 12, there exist guidance appliances that at a glance, if you held one, you would look at it and say, hey, this looks like a football mouthguard. I would put it in and run around on a football field. And it has that look to it. But what the guide does when a child wears it— we ask them to wear it 1 hour a day plus overnight, and it is a trainer. Basically, when the child pops the guide in, it's designed to guide that tongue to function properly, meaning the tongue's going to go to the roof of the mouth. And when the tongue gets to the roof of the mouth and exerts pressure, that's how we start growing outward. But then that guide also redirects the lips and cheeks. So the dysfunctional pattern is that the tongue is not doing enough The lips and cheeks are doing too much. They compensate to help the tongue. But when the inside is weak, like the tongue not doing its job, and the lips and cheeks are strong, we kind of grow inwards or shrink. That's what makes the teeth crowded. So we don't want our lips and cheeks doing too much. We need them doing less. So the guide gets the tongue doing its job and takes away the lip and cheek function, redirect the balance, redirect the growth. So guides plus myofunctional therapy help a lot in those younger ages because the bones are mature. Next thing you know, the child, an hour a day plus overnight with some exercises. And then you can watch as the weeks turn into months. Oh, we start seeing the changes now. When the jaws are growing, they start to breathe better. When they start to breathe better, they start to sleep better. That's when the symptoms start fading away. So guides and myofunctional therapy are the two main components. We do sprinkle in a little nasal hygiene because that is the lost art. Like, nobody is doing any nasal hygiene anymore, especially the kids. So we teach them how to blow their nose and use nasal sprays that are natural.

Okay, say more about this. Like, blow your nose, how? Just blow your nose, or there's— it sounds like there's an art to the science.

Like, yeah, learning how to blow your nose is nice. There are other tools too that, you know, for older children, maybe you could use a Neti Pot or a little irrigation system for the older ones. But for the little ones, it really is just beginning with proper nasal hygiene, meaning let's blow our nose right, let's learn how to blow our nose, you know, close one side, blow out a little bit, do the other side. And then getting some natural nasal sprays in there. If you use a natural product, it can help to kind of shrink the passages a little bit. Clear out some of the excess junk they've got in there. And sure enough, if we can loosen things up and clear that stuffy nose, get a little airflow through there, that helps too. 'Cause we're looking for that combination of really good muscle rest and function with the air flowing in and outta the nose. And a lot of kids today, even if it's not allergy season or, you know, the cold and flu season, they come in a little stuffy and always sounding a little congested. And a lot of that is just stuff that's not getting pushed out. So there's no filters, you've got to clean it.

What kind of sprays do you recommend?

Simple saline is wonderful. And then there are the— I'll say X-Clear, but it's the Clear products. They spell it with an X for xylitol. The Clear products are very nice. They're over the counter. They're in any pharmacy. You can find those. Amazon sells them too. I don't receive anything for people buying that stuff. So disclaimer, no money being made here. Just that's what I've used in my practice for the last 20 years. Asking patients to do nasal hygiene multiple times a day until we get the jaw growth going. So we ask them for morning, middle, and night. And some kids, if they're really stuffy, 3 to 5 times a day to get that nose kind of open and clear again. Then we can reduce. The goal is to do nasal hygiene twice a day like you brush your teeth, morning and night. Let's keep the nose clean and clear. We wanna keep that air flowing through there.

So I actually had heard of XClear like 4 years ago and used it. And got nosebleeds and had to stop using it. I was like, okay, am I doing something wrong here? Because it made it so like cracked and uncomfortable, I had to stop using it.

Oh, oh yeah, I'm sorry to hear that. Um, but me too. I'm sure it's like everything else where it's not for 100% of the people. So I'm guessing that, okay, it didn't agree with you, but then you probably shifted to a different product, maybe something, a simple saline solution maybe, or—

I've never used that. With simple saline, just Saline and a nasal spray.

Yeah, that's all it is. And so there are some basic, very basic products out there that you can use that don't have the xylitol in it if you were getting a reaction like that. Yeah. Oh, yeah. Sorry to hear that.

Yeah, I was so bummed. I was like, this is going to be the thing to clear out the sinus passages. Okay, what about allergy remedies or Flonase or anything like that? Are those things that you include in the treatment regimen?

I do try to avoid the ones that include medications. And so in the Flonase and other ones like it, there are steroids in there. So I try to avoid those. I wouldn't fight someone if they said, look, in the springtime when the allergies are so bad, we use it for a couple of weeks. Sure, I get that.

Go ahead.

I'm not trying to take anything away from you, but I don't like to use those long-term in kids because now if you were to do that on a daily basis, now you're getting a dose of steroid every day for a long period of time. I don't know if that's a good choice, you know?

Right. And what do parents do? Like, what kind of evaluations are there for parents who are worried about their kids who mouth breathe? Like, what should— where should they go?

Yeah, now it would be wonderful if their local dentist or orthodontist was practicing early treatment for growth and development. So you can go locally and try, and you start asking some questions and you see if you're in the right place. Because, you know, if they tell you, oh, we don't do early treatment, or we wait until 7 or 12, or we do things later, you know, you'll learn when you ask questions. But meanwhile, if you have someone local, terrific. And then you would hear things like, yeah, we start at age 3 or above, we do guidance appliances, we do expanders, we do, um, myofunctional therapy, we'll look at your tongue, lip, or cheek ties, because some people have tongue ties, and we'll get into that later. But if they're saying all these things, then you know, like, okay, they are concerned with the jaw growth and they have tools and techniques to work at this age to improve my child. You're in the right place. But We do recognize that there are few of us around. So while there's a lot of dentists and a lot of orthodontists around, not everybody's doing early treatment. And so because of the shortage of people doing early treatment, that's kind of where this led. After about 10 years of doing this in my own practice and seeing the benefits to the kids, I started to teach it. So I was teaching other dentists around the country, and that led to a few hundred other dentists joining the cause. And but spread out in 50 states, that's not a lot. So then fast forward a few more years, and basically what we did was a group of us who were doing this decided to get together and talk about access and how— so there's so few of us, how are parents going to be learning about these opportunities but then not have anywhere to go? So that kind of fast forwarded to the creation of Toothpillow, a new company. And that Toothpillow company, new name, basically is providing care remotely. Because there is a percentage of children who could be treated remotely, monitored through an app, where we could evaluate them, send them what they need, and then monitor them remotely. So we created Toothpillow to provide access to care for growth and development early, where maybe your local dental or orthodontic offices don't offer it. And no parent really should need to travel 3 states away or 5 states away or hours away to have this. It's just inconvenient. It's impossible to do that with multiple kids in a household, in a family. So Basically, we created a new company that provides techniques that have been around for decades. None of the techniques are really new, they're just kind of the, the minority of the dental community does growth and development early. So we provide it through Toothpillow. So what a parent would do is visit our website just to then learn, is their child a candidate? Because that would be step one. And we ask them a questionnaire because there's kind of like two components to are you a good candidate for early treatment. One would be We ask all those questions about the sleeping and the breathing and the symptom list. So we ask everything there because then we want to learn about the child. Is the child struggling in all the things we started talking about? And if they have those struggles, that's one thing. Then we ask the parent to submit some photographs, and we have a little app that's designed to take the images we need. So they get like a format, take a picture of the face and the profile and the teeth and the upper and the lower and all that stuff. Because from the photos and the questionnaire, we know, oh, we have symptoms. And we can see from the teeth and the bite and the facial development, the jaws are smaller. So we know, okay, we have a reason to treat earlier, your child's a candidate, or it's too severe and I can't do it remotely, then we would try to refer you to an office. So generally, I can probably be approving about 75% of kids for treatment remotely, but 25% do need to go in office for things like expanders and things that are needed to be done hands-on.

What— talk to me about the— it's myofascial, or what did you call it? The—

oh yeah, myofunctional therapy.

Myofunctional. Is it— is there a national database or a national referral system? Because I've actually never heard of that.

So, yeah, so the long words are orofacial myofunctional therapist, OMT. And so, yeah, that is basically a specialty where they work on all of the muscles of the head and neck related to breathing, posture, and jaw development. And so I think if you went and Googled, you could just Google orofacial myofunctional therapist near me and it'll start to populate. I know there's a couple of companies out there that do all the trainings. And so it would probably bring you to those companies where they probably have doctor locators. We also have a locator within ToothPillow. So ToothPillow built out a referral system where if people are not finding local people near them, they could reach out to us and we could guide them to who, who's the closest to me who does early treatment for kids or who does myofunctional therapy. Then one step past that is myofunctional therapy. Let's say in the worst case scenario, you don't have anyone near you, they're hours away. It can be done remotely. So we can connect you to someone one-on-one who can do it remotely.

How long do these treatment processes generally take for kids who are not in the severe range but who are even able to do it online? How long does it take?

We usually run a 24-month course of treatment. And so for 2 years' time, regulating nasal hygiene, the guidance appliance wear, the myofunctional therapy one-on-one through Zoom. When a child goes through 2 years of that, and then of course the parent is submitting information along the way, we do check-ins. By 2 years later, we should have a child that is now nose breathing, sleeping through the night, have reduced symptoms, and a better view of their teeth and bite. They should be kind of moving to the right direction. So basically it's like reversing poor growth. So here we have a child who's got crowded teeth and a bad bite and poor breathing and poor sleeping. We just have to redirect the muscles and redirect. And it is like going to the gym because I know I threw that analogy out before, but it's not a quick fix. It is not a light switch. I wish it was. Believe me, everybody does. Because when you go to the gym and you haven't been in years, you know, oh boy, I'm in for it because I can't fix this in a week. I can't fix it in a week. I can't fix it in a month. This is going to take me 12 months of effort to get back where I used to be. That's what this is. It's a growing process, but it's natural. This is as natural as it gets.

Yeah. I mean, it's not for the faint of heart, though. Like, when I think back to when my kids were younger, I might have been hard pressed to do that. Although even recognizing the benefit, I would be like, oh my God, I'm so overwhelmed. So how often is this? Yeah, twice. It's an everyday thing with the nasal therapy and the mouthpiece. And then how, how frequent do you have visits?

Yes. So the daily commitment is nasal hygiene 2 to 3 times a day would be great. And that could be a minute really. But the guidance appliance, we want to wear that for at least 1 hour a day plus to bed. So we have an hour commitment there. When you're doing myofunctional therapy, you might have like 10 sessions over many weeks, but they do give you homework to do some little exercises every day. So we're looking at an hour plus some minutes, 10 minutes where you're doing these things daily. Then we check in in the app. So weekly we have a support team doing reminders to parents. How's it going? Like, are you doing your checklist like for each day? And then weekly and monthly we're asking for a couple of photos, like let's get some updates coming. So there's a little commitment to, to send back information. Quarterly, we take a new survey to say, like, okay, it's been 3 months. How are we doing with our symptoms? Also upload more photographs because we want to check. And then the doctor checks in too. So then the doctor checks in to see everything, to know, all right, we've got good compliance and we're showing signs of improvement in both directions. This is wonderful. Please keep it going because it's like the gym. If we stop going, we lose it. We have to keep it going for the 2 years to really get back on track. It is a commitment. You're right.

Yeah. It is, but on the other— so it's not for the faint of heart, but the benefits that you see for kids in terms of behavior, sleep, attention, focus, and then the long-term issues with heart disease and sleep apnea and longevity. So it really is important. It's just, I can imagine that it would be challenging to do for some parents. All right, are you— do you feel comfortable, Ben, talking to me about what can adults do? Because I can guarantee you that there's an adult listening who's like, I'm a mouth breather, What can I do? What, what? Are you comfortable with that at all?

Of course. Yeah, certainly. So now adults, we don't really have remote care available. It would be we have to find you like someone who would refer to themselves as an airway dentist or an airway orthodontist. Now if we can locate one, um, that's great because now hopefully there's someone in your area. If not, you're going to travel a little bit to find, to get to one. But Toothpillow is not a bad place to reach out to because we have a doctor locator and we have 70 doctors around the country that do monitor all of the kids treatment. But most of them treat adults in their own practices. So we've got a little bit of a database going at Toothpillow. That's one way to learn where should I go? I'm in Minnesota, or where should I go? I'm in Kansas. So Toothpillow can give you a referral. Adults, what can they do? There's a long list. And so anyone benefits from nasal hygiene. So we'll begin with the least invasive, easiest things and work our way to the most. Nasal hygiene is for everyone. So everyone can do better nasal hygiene to keep the nose clean and clear. Then Myofunctional therapy is for everyone because at any age you can help your musculature be resting and functioning properly. Now, it might not make the adult's jaws grow because we pass the window of growth, but the tongue, lips, and cheeks, when they're properly resting and functioning, it does improve airflow. So the myofunctional therapy community does have nice research that shows the adults that have obstructive sleep apnea, if they do myofunctional therapy, it improves their scores. Not a cure. Like, we can't say cure. It doesn't say, oh, I'm always say I'm going to get cured. But when your score is a number that's, let's say, bad, you can reduce it. And that's nice to go from, let's say, moderate to mild OSA or severe to mild or severe to moderate. So myofunctional therapy, very helpful. Then there are things that adults can do in the expander category. So I'm saying loosely the expander category, but it is slow going because it's mature bone. So are there expanders that adults can use? Yes, very slow. So I can give you examples from my own office. Some of the older patients I'll treat are in their 60s. And it can take 2 to 3 years because it's very slow going to kind of nudge things to give the tongue more space. So yes, there's that. That's like what we would call the non-surgical category. Appliances that can be used, they're removable, but they do get turned like once a month just to get a little pressure to get some growth. Well, slow going, very slow going. Then there's the surgical category. Okay, now we can do things like put expanders in and do little bits of surgery. They're referred to as MARPI or SARPI. You know, assisted RPE or rapid palatal expansion where there are some surgical procedures done as well. Those are on the less invasive side. Then going even further, more invasive would be like jaw surgeries. And jaw surgeries do exist for people with maybe severe obstructive sleep apnea where the CPAP is not helping them. They don't feel any benefit from that. If you're in that category, I've got medical issues I'm struggling with, I have severe apnea, my CPAP is failing me, that's a patient who might consider a jaw surgery to help them out. So anything from nasal hygiene all the way to, you know, jaw surgery, there are things adults can do.

Can I ask a dumb question, Ben? You know, if you think about— So I treat women with osteopenia and osteoporosis, which is bone loss, and you can see that the bones improve over time with proper treatment. So I would imagine that— and again, not for the faint of heart and not a quick fix— but I would imagine that you could see some growth in the jaw over time with repeated, concerted, sustained work on the tongue, lips, and cheek. Is that not— I mean, because you could make it grow.

Yeah, it's— and so I'm a believer in bone dynamics, and the basics of bone dynamics is that cycles of pressure and tension induce bone growth. Bone grows by cycling pressure and tension. That's the premise behind using like removable expanders for adults where when they wear an expander and once a month you turn it, it exerts a little pressure. So, but we have them take it out. So during the day it's in and out, it's in some of the hours, it's out some of the hours. So when your expander's in, it puts a little pressure. When it's out of your mouth, there's relaxation. That's the tension, pressure tension, back and forth, get some bone growth. Well, that's what the musculature too, but it would be challenging for the muscles alone with mature bone. You'd have to be very dedicated to doing myofunctional therapy over a very long time. To show changes in the bone. So that's the slowest way with an adult would be getting bone growth from just muscle activity. I believe it's possible. I just think it's going to take a long time and you have to be very dedicated to it because it's like a two steps forward, one step back if you take a day off. But the removable expanders do work in that fashion, cycling pressure and tension to get some bone growth.

So why remove them? If you leave it in, wouldn't that be a better better progress?

Ah, so that's where we get that cycle from. In other words, if the expander is always in, then it's always pushing, but that's always pressure. And so if I'd like to entertain like pressure and tension or relaxation, I want that bone to recover. So it's kind of like when, um, when you get your braces off and you wear your retainer, it keeps everything in place, but when you don't wear your retainer, things shift back. So that's what the removable expander does. When it's in, it puts a little pressure so things are growing, but when you take it away, everything wants to collapse. So you have the bone expanding and contracting, expanding and contracting. Basically, you're pressurizing it and then you're taking it away. So I want to have that bone feel a pressure cycle and a relaxation cycle, and that kind of tells the cells that, oh, this is a cycle of pressure and tension, we're supposed to be growing. So I ask my patients to wear it for 2 hours and then take it out for 1, wear it for 2 hours, take it out for 1. And if they can do that all day long, it exerts a little force, but then they get an hour break for it to relax. and then it goes back in and it feels tight. Like when you take out an appliance for 1 hour, things shift back. It feels a little tight again. So the body is kind of spongy, but just with mature bone, it's a slow process. That's why it can take anywhere from 12 to 24 months to help gain with enough to change the breathing, which our goal is really to change the breathing.

Do you ever work with ENTs or osteopaths to help with the sinuses and the bone structure of the head?

Yes, and it's a long list of collaborative care. So the ENTs involved, osteopath, chiropractors, craniosacral people, body workers. I know I'm going to leave some out, but it's everybody, everybody who can work with musculature and posture and body and breathing experts. The myofunctional therapy community, speech language pathology is included in this. Anyone who works with the body. Can help any age. And so we do refer people to others. I'll say in the ENT category, I don't mind the referral and I don't mind learning about tonsils and adenoids, but I'm very hesitant to take them out. I'm not a fan of removing body parts. So I don't mind learning that, oh, they're big. Okay, we got a little nasal scope and they're big. But I would like the opportunity to get that child back to nasal breathing. And so it has been my experience that while the tonsils and adenoids oftentimes are larger than they should be, if we can get the child back to nasal breathing, they will shrink and heal. And so I prefer that pathway and then reserve tonsil adenoidectomy for last resort, meaning we've done everything we can. We've got your jaws at the right size, you're breathing through your nose, you're doing better, but they're still big and they still have some residual symptoms. We would offer the parent the opportunity to pursue that, and it's up to them really. We, we don't force anybody to make any choices. We just say, You want the last of it, we probably got to think about this.

This is fascinating, Ben. I'm really glad we're having this conversation. Is there anything I didn't ask you about that you're like, you should know this, or the listeners should know this?

Yes. And for parents, it's like a public service announcement. I would say, please don't let anyone extract any of your child's teeth. Tooth extractions are subtractive. We're going to be making you smaller then. So I'm not a fan of taking out teeth. So I would ask a parent, look, if someone suggests, oh, we should take out baby teeth to make room for permanent teeth, we need another opinion. Don't take out baby teeth to make room for permanent teeth because that's not exactly what's happening. When you take out baby teeth, the permanent teeth that you see will spread out. It's not making room for the permanent teeth coming for those baby teeth, it's the ones that are already in. So it's kind of a deceiving approach in that, hey, I've got 4 baby— I've got 4 permanent teeth in the front and they're really crowded. But my next baby teeth in line are the canines. If I take out the baby canines at age 7 or 8, the 4 permanent teeth are gonna spread out, and then my canine underneath, which isn't coming till 11, is blocked. So it only makes the teeth there look better. It doesn't make room for the actual baby tooth replacing it. So the short story is, I would ask parents, look for other opinions when people suggest taking out baby teeth. And definitely, I would say, do not allow anyone to take out permanent teeth. Removing permanent teeth is a bad choice today, and there was a time where it was done a lot of, but knowing what we know now and how you can help earlier, you're better off with early intervention to get the jaw size bigger to keep all your teeth. We don't want less teeth in there, we want a bigger jaw because the teeth are the symptom. Let's find a different place that will give you jaw growth to keep all the teeth. We shouldn't be taking teeth out anymore.

Interesting. I'm thinking about my youngest who had the most crowded mouth. And we've finally gotten her to a place where she doesn't look snaggly. She had, uh, yeah, her canine was like pointing off into South Pole. But what the orthodontist said was there's actually a baby, uh, an extra baby tooth that was here in between the, in between the roots of her two teeth, her two, these two teeth. So one tooth was twisted and they couldn't untwist it. He said you got to take out this it's like a remnant of a tooth. And I was like, okay, what? But we took it out and we were finally able to move her teeth back into place. So I'm thinking like, there have to be exceptions. Like, obviously my youngest is an exception, but I totally resonate with don't, don't just make the teeth look better, fix the jaw.

Yes, that is an exception, and it is a fraction of a percent of people actually have an extra tooth. So yeah, not 1 out of 100, it's like, that's one in— I don't know the number, but it's a fraction.

It's like a unicorn, like I'll tell her, I'll tell her she's a unicorn tonight. I met with the dentist, he said you were a unicorn.

And that, that is evidence, that one piece, that is evidence that you have, you know, connection to unicorn. But the, um, the extra baby tooth, I get it. As long as it has been double-checked, it is an extra tooth. I don't mind taking away an extra tooth. And even more rare than that is having extra permanent teeth. Like, having an extra permanent tooth is rare. We're supposed to have all 32. We would like to have all 32 teeth fit in. But we need the right size parking garage for those cars that are coming to the party. So just get the garage size right and all the cars are welcome.

That's great. Is there anything else you want to share with the audience that I haven't asked you?

Yeah, one more thing. And it has to do with the difference between nose and mouth breathing because a lot of parents out there, until they go down the rabbit hole and do all the digging, they're not aware of how severe the difference is. And so nose breathing is healthy for us. That's how all of our physiology works great. We're basically bringing in the proper fuel and we're doing so through the nose, which prepares the air for the lung. The nose has all those functions in place on purpose, but the mouth does not. So now we bring the air in the mouth and our body is still going to work, but it's going to function differently. So the words that people do hear are obstructive sleep apnea. That's the worst breathing you could be. So that we're going to assign like stage 4 disease. Is obstructive sleep apnea. And then in the continuum, mouth breathing is stage 1. So we don't want to wait until we're obstructive sleep apnea to treat when mouth breathing is unhealthy, because no one in their right mind goes to the doctor and then they say, oh, you have a stage 1 of this particular disease, but why don't you wait and come back to when you're stage 4? Because that's not okay. Well, that's where mouth breathing to OSA is. So we don't need our child to be obstructive sleep apnea. We're trying to avoid that at all costs. When you notice some mouth breathing day or night, we have unhealthy right there. So mouth breathing is basically bringing that air through the mouth. It gets in the lung, and then the lung can't do its job well. So the exchange is not the same. We're getting less of the good in and less of the bad out. And that creates that imbalance, which leads to dysregulation. So I try to teach parents about fuel. So we're going to fuel. Well, your child is a Ferrari. And if you have a Ferrari, it requires a specialized gasoline to have the best performance, peak performance, and so-called win the race. When a Ferrari gets the right gasoline, we get proper function. Well, that's nose breathing for a child. Nose breathing is proper fuel going. Mouth breathing is taking that Ferrari and then going to the lowest watered-down gasoline you could get that a regular car might run okay on, but a Ferrari can't win a race like that. So you can't put regular gasoline in a Ferrari and expect it to do well on the track. It's gonna slowly malfunction. It won't have peak performance and it will break down. That's mouth breathing. Mouth breathing is the bad gasoline. Mouth breathing is very bad for kids, really anyone. It's unhealthy for everyone, but it does change our entire physiology. So at mouth breathing, kids need attention, not waiting until they have obstructive sleep apnea. That's worse. That's fair.

Where does mouth taping fall in all of this?

Yeah, it can be very helpful. So I am a fan, but the way I'll describe it is I don't like it first or early. And here's why I'm a believer in, okay, if I see the teeth are crowded or the baby teeth are together, I know the jaws are small. Now, if the jaws are small, it makes it difficult to breathe through the nose. So when the jaws are small, basically the tongue doesn't have a lot of room. So when we close our mouth, the tongue is back a bit, and that's what blocks the airflow. It's the reason the brain is opening the mouth. So here's what happens when we just say, oh, well, let's tape the mouth closed as step number 1. If we tape our mouth closed, we are forcing bad nasal breathing. So that's not necessarily a win if your jaws are small and your tongue doesn't have enough room. You might be now forcing bad nose breathing because it's not going in and out very well. So I'm a fan of the taping a little bit later in treatment, meaning let's get the nose hygiene going so we have clear passage. Let's get a little bit of jaw growth, some myofunctional therapy, check on the frenum, like tongue tie, lip tie, cheek tie, because sometimes those are there. If we can get a little growth and improve the breathing, But let's say the lips are not remaining sealed. Then that's when you can introduce tape, when you've got an improvement in nasal breathing. So we're not locking down bad nasal breathing. I'm not a fan of doing it first or early, but a little later on it can help retrain lips to stay together.

Okay, cool. Where can people find out more about you, Ben?

Toothpillow.com. Toothpillow.com is a place where parents can go. We built it for their education. There's a lot of material in there. They can kind of dig through all of the connections that we've been talking about. And then if you would like to know if your child's a candidate, there's a tab to submit. And then I do all the screenings so I can check to see if the child would work with remote care. And if so, we're happy to help you.

That's great. Ben, thank you so much for being here because this is personal to me. I mean, I was sharing, like, I was at the dentist today talking about this. So this is perfect timing. So really, thank you for being here and sharing your expertise with the listeners. And for the listeners, thanks for being with us for another episode. So thank you, Ben.

My pleasure. Thanks for having me.

My pleasure.