46. The Transformative Effects of Integrative Orthodontic and Myofunctional Approaches with Dr. Steffen Decker

Prepare to be guided through the enigmatic nexus of orthodontics, myofunctional therapy, and airway health as we host Dr. Steffen Decker in a revelatory session. His insights illuminate the essential harmony between structural and muscular aspects of dental care, a synergy paramount for staving off orthodontic relapse and optimizing long-term outcomes. As we navigate the intricacies of tongue tie diagnoses and the impact of breathing on our dental and overall health, Dr. Decker underscores the momentous influence of proper airway function and the transformative effects it can have from infancy through adulthood.

In a candid discussion, we scrutinize the complexities of childhood sleep apnea and the role myofunctional therapy plays in its management. Dr. Decker elucidates the challenges professionals face in this nuanced field, advocating for early, comprehensive interventions. We traverse the landscape of orthodontic devices and treatments, exploring innovations like the IEP appliance and the potential of metal printing in dental alignment. By advocating for a blend of traditional and cutting-edge techniques, Dr. Decker champions a multidisciplinary approach in pediatric care, one that promises to reshape the future of dental health.

Closing with a testament to the power of collaboration, we celebrate the collective wisdom and passion that fuel advancements in our field. The excitement for future breakthroughs and the bonds forged amongst peers lend this conversation an air of optimism. Dr. Decker and I share our enthusiasm for the upcoming convergence of minds in Vienna this October, a testament to the perpetual journey of learning and discovery in the pursuit of holistic health solutions. Join us for an episode that not only informs but inspires, as we embrace the beautiful, breath-focused narrative of modern dental care.

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ABOUT THE GUEST. 

Dr. Steffen  Decker is a  Specialist Orthodontist BDS, MAS in Lingual Orthodontics, Kois Recognized Specialist, Program Director MSc in Dento-facial Orthodontics and MSc in Clear Aligner Orthodontics

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Chapters

• 0:01 Orthodontics, Myofunctional Therapy, and Airway Health
• 10:00 Tongue Tie Diagnosis and Treatment
• 22:39 Myofunctional Therapy and Childhood Sleep Apnea
• 39:13 Impact of Tongue Tie on Breathing
• 53:40 Orthodontic Treatment Options and Considerations
• 1:05:20 Importance of Collective Collaboration in Business

Transcript

Speaker 1: 0:01

Welcome everyone to the Beauty of Breathing podcast. Our guest today is Dr Stephan Decker. He is a specialist orthodontist in the UK. He has a master's in lingual orthodontics. He is COIS recognized. He's a program director in dental facial orthodontics and in clear aligner orthodontics. He says that he's fortunate and grateful to have orthodontics as a profession and finds it uniquely rewarding. A good orthodontist must possess several attributes, he says A keen eye for angles and special relationship, good listening and communication skills and the ability to balance theoretical and practical concerns. Welcome so much, dr Steffen Decker. We're so happy to have you here today. Let's jump right in.

Speaker 2: 0:56

I'm an orthodontist and myofunctional therapist. And why does nobody work in collaboration and why does nobody work in collaboration?

Speaker 1: 1:06

You tell me this is a fight that we have every day. It is so difficult. So you cannot address the structure without addressing the muscle and you cannot address the muscle without addressing the structure. I always tell my patients that the reason why my functional therapy works is because I'm not doing this alone. It's not my functional therapy by itself ever, because there is a person attached to the facial muscles and to the teeth. So we can't just look at one thing Every single time. We change something, it's going to change everything else. Change something, it's going to change everything else. So working in collaboration is key for our patients to get the best treatment possible out there. So an ENT to look at the airway, an orthodontist to look at the skeletal structure and a myofunctional therapist to adjust the muscle. If we miss one of them, the patient will relapse.

Speaker 2: 2:03

I think this is already a very crucial point which I totally agree with. Like in London or the UK, more and more dentists are actually doing orthodontics and they're using especially high technology to generate a treatment plan, for example with the Linus. And in all of this the function around the teeth is not even slightly even considered. They are just being told you need long life retention, versus someone like you would totally agree with me now if I would say your function is your retention.

Speaker 1: 2:43

A hundred percent. Your lips and your tongue is the perfect space maintainer or retainer that you can get after orthodontics. Why? If I'm talking to a parent or a patient, I explain that whenever orthodontists move teeth, they need light but constant pressure on the tooth in order for the tooth to move. So whenever somebody is swallowing, that pressure is a little bit stronger. If they're swallowing incorrectly and it's every so often, however, the pressure of your lips and your tongue at rest could impact your occlusion. So just by doing myofunctional therapy, just addressing the muscle function, the muscle tone and strength, we see teeth move. Do I claim that I move teeth a hundred percent? No, but I have seen it happen. Um, so, just addressing where your lips supposed to be, your lips are supposed to be at rest, touching lightly, without much tension.

Speaker 1: 3:56

Breathing has a lot to do with it. Also, if you think about what the wind does to mountains, over Over time it can shape mountains. What is the air? This is really nice. What is the air going in through your nose doing to your skeletal structure? Because it's a lot softer than the mountains, than the rocks, right? So if the wind can do that, can you imagine breathing incorrectly and breathing a lot faster than you're supposed to a lot more shallow than you're supposed to. Over time it does impact your structure.

Speaker 2: 4:30

So that's one interesting point If you look at this. We mentioned the resting posture. So we talk maybe for three, four, five hours in the day. We eat for two hours in the day, so that leaves us probably with 16 to 14 hours where we are at rest. So I think, if we think about from a time perspective, most of our time in the day we are at rest where these muscle structures could have impact on our T and orthodontically, when I talk to to patients they generally come for tea. They are crowded and then when they, when I tell them actually your teeth are only a symptom of a problem that is persisting there, they're first of all a bit apprehensive. But then you go a bit deeper into the topic and you talk about what you just slightly touched base on. But for me the big question is and I hope you can help this when, would you say, does it start the shaping in the wrong direction and why?

Speaker 1: 5:41

in the womb explain lack, lack of oxygen. So the mom, of course, the mom's body, is producing that beautiful baby. If the mom already has a problem breathing well and breathing through the nose, the mom is always going to get the oxygen first and whatever is left over is going to go to the baby. So if the mom is already a mouth breather or is not, you know, breathing correctly, then we're already going to have an issue going with the air you know, you know foxwood and going to the baby. Of course there are different and other things that will affect the growth of the feed. As we all know, the alcohol is bad, the cigarettes is bad, the cigarettes are bad. So there are plenty of things out there that could either benefit, or, uh, not, the growth of the fetus. However, if the mom is not breathing, we know that that could be a problem. Um, oh, my goodness, there's so much we see in the womb. So babies are supposed to suck their thumb in the womb. We already see that and that's a conversation I was having with Dr Boyd. I don't know if you know Dr Boyd, yeah, as a couple of weeks ago I looked at him and I said you know what I was thinking about this. We see this baby suck the thumb in the womb. We don't know how often they do it, we don't know. We know they all do and they're supposed to. But what if that actually helped them develop? You know what? What if that was something positive in the womb? Because after babies are born and they're stuck in their thumb, usually as a as a hygienist, you know, I'm like, oh my goodness, that's awful, take it out and give a pacifier. It's easier to remove the pacifier later. However, now in the airway, as a malfunctional therapist, I'm like no, babies are supposed to suck their thumb, so let's leave that there. It's more natural. It's, you know, from your body. We're not introducing something artificial in there and from what I've learned, as if a child is being breastfed on demand and you let that be a lot of times. If they don't have an airway issue, eventually they just stop on their own. So I'm not worried about thumb sucking.

Speaker 1: 7:58

What else can happen early in life? Usually, when a baby is born, they are already born underdeveloped. Most babies are born with the mandible, the lower jaw, slightly too far back, um, we have seen, whenever they get a tongue tie, release slowly, the jaw comes forward a little bit. Um, so usually this babies are, you know, crunched up inside the womb. They have no room to move. So we also see issues when their whole body muscles torticollis you know issues moving very well because they've been inside this small confinement space, you know.

Speaker 1: 8:41

And what do we do? What do we learn? We learn to swaddle babies. It is wrong, we should not be swaddling babies. Please stop everybody. Stop swallowing your babies, because they need movement, they need massage, they need those muscles to move and to to work. And if you talk to an occupational therapist, they're going to tell you how important it is to get those muscles moving and also for reflex integration. They have to be able to feel things you know in the real world. So there are so many factors, so many things that start way when the mom is pregnant that could impact the growth of the upper and the lower jaw. So, starting with mom's breathing, and then lack of breastfeeding, and then lack of heart chewing and mouth breathing, so you mentioned two points which are interesting.

Speaker 2: 9:33

Number one sucking thumb. My opinion on that is like there's a lot of nerve endings actually ending in the palate and the palate is a soothing spot for a lot of children. So actually what you mentioned is this this thumb sucking could be a number one as a stimulus for growth of the maxilla in the womb. But number two is also soothing for the child in the womb. And then you just briefly touch base on this tongue tie, which is something in the media sometimes it's a bit controversially discussed as a money-making machine and over-treatment and everything. But if you could just explain what would you say? You need to check on children with tongue tie because there are so many parents they have. They're saying to me oh yeah, my child had a tongue tie. It has been released, but I can clearly see there's still a problem. So what? What do we parents need to look out for when it comes to tongue tie?

Speaker 1: 10:39

the first thing that we have to know about tongue ties is that it's nothing new. Back in the day you know there are books that talk about midwives they used to have a very long pinky fingernail. As soon as the babies were born, they would go underneath the tongue and cut the frenum, because back then they didn't have bottles, they didn't have formula. So if the babies could not breastfeed they would die. So it's something they've always done. And then, of course, after World War II, formula came out, gerber came out, all these extra things that offered nutrition for the babies. That's when everybody started recommending other options and the tongue tie release kind of lost, you know, its place in our field, and now it's coming back. Do we have more tongue ties? Maybe there are certain uh, you know people out there talking about the amount of folic acid. So everybody has the same amount of folic acid. Well, some moms are bigger than others. Should we be giving everybody the same amount? We don't know exactly why, but maybe, you know, we're just recognizing way more now.

Speaker 1: 11:53

I do believe that after the pandemic a lot of things changed, where people became, you know, their own advocates and they're looking for ways to do things more naturally, including breastfeeding. So the more moms that are looking to breast to do things more naturally, including breastfeeding. So the more moms that are looking to breastfeed, the more we're going to find issues with breastfeeding, and tongue ties just happen to be one of them. However, like my friend Jennifer Tell says, tongue ties are not a procedure. It's a process. Just getting the release done is not going to fix everything Because, like I mentioned earlier, these babies are being born and they were just confined in this tight, tight, tight environment. We have to address the whole body. So, just like an adult with a tongue tie, then we're not just going to go and release and expect all these benefits. We have to look at everything.

Speaker 1: 12:44

So, as soon as your baby is born, and even before your baby is born, my big recommendation is to go ahead and find an IBCLC, which is an international board certified lactation consultant and somebody who's well versed in thighs, because they don't have this training in their program either. Ask questions. You know we're not all born knowing how to breastfeed. It's a learned skill. So go ahead and find a professional who can kind of guide you. Okay, what should I expect when I have my baby? Is pain normal? What am I supposed to feel what you know, ask questions and go ahead, have an appointment set up after the baby is here.

Speaker 1: 13:24

A body worker or a body professional is another key component. So somebody who's going to give you, you know, massage and exercises for the whole body, because sometimes just a baby having torticollis or just a baby being super tight could give you symptoms of a tongue tie and then you release a tie and you don't see any benefits or you see benefits for a little bit and then it comes back because the rest was not addressed. There's an IBCLC from Texas that I interviewed one day and she was wonderful Jewel is her last name and she explained how they go with the process of releasing a baby's tongue. They treat the whole family, you know, because it's going to take the whole family, everybody's help in order to get that baby to a place where they're, you know, doing well with with breastfeeding. They got to make sure the mom is on board, the dad is on board, whoever else caretaker is on board. They explain how the stretches are going to be like.

Speaker 1: 14:30

You have to make sure it's not going to reattach. A baby can't do exercises, so you have to do a lot of manual stretches. And I tell everybody reattachment is healing. Everybody reattaches it. However, some people create scar tissue. That's the problem. Scar tissue is tight and sometimes even tighter than it was before and, of course, what degree of reattachment you're going to have. So we need to help these babies more manual work. A lot of dental hygienists, like myself, don't treat babies. However, if they have training in IBCLC or like dental consultant, then they can do the pre and post phrenectomy work with these babies. So parents not only look for symptoms of a tongue tie but also work with a body professional that can address other areas of tightness. Craniosacral therapy is a great thing to also do with these tight babies.

Speaker 2: 15:32

So basically I was always the opinion that below the age of four in kids you just release the tongue to let them go. A lot of industry where they release tongue ties in babies. They see them for one appointment and cut the tongue ties. They see you late because there's no myofunctional therapy needed. But what you just actually said is it's the opposite. Even kids under the age of four would need some kind of stimulus and therapy with massaging to avoid the scar tissue under the tongue. So when is it for you? Where, would you say, as myofunctional therapist, is it safe for you to start working with a child?

Speaker 1: 16:11

So in the United States it's a little bit different than everywhere else in the world whenever it comes to myofunctional therapy, because here we're mainly speech pathologists and dental hygienists that are working as my functional therapist with this treatment modality. However, what allows us to go into this training is not our license, it's our education. So my license as a dental hygienist is for me to clean teeth, not to do my functional therapy, because the dental board has no idea what myofunctional therapy is and how. To you know? Test me to make sure I'll be a good myofunctional therapist. So I want to make that clear.

Speaker 1: 16:53

Dental hygienists can, in fact, work with young children, very young children. Whenever you're practicing myofunctional therapy, my training is from Brazil. Over there there's only speech pathologists that teach you. So whenever they do myofunctional therapy with young children, it's just like myofunctional therapy with other kids. With other kids, however, they need more hands-on work, so they need a little bit more help. So it's a lot more games and a lot more fun and they will do a lot of manual therapy. So massages, kind of like myofascial release, you know, do lymphatic drainage. They do a little bit more. You know hands on work with this little kids, but you have to have the training In the United States, that hands on part training.

Speaker 1: 17:47

In the United States that hands-on part, it's called oral motor therapy and the speech pathologists separate that from myofunctional therapy. That's why it's believed that oral motor therapy can only be practiced by speech and occupational therapists. It's a gray area, Not sure if I need to go there to explain these things. However, yes, even at the hygienist, my functional therapist can treat younger children. It's just it looks a little bit different than regular myofunctional therapy because most myofunctional therapists what they're learning it is exercises that you have to copy me.

Speaker 1: 18:22

Okay, so if I do this, can you copy exactly what I'm doing and a younger child can't really so then you know it's believed that it's not true, mayo, but from my training it is from it's just a little bit different because my goals are the same. I'm trying to get, you know, these muscles to move and these muscles to work out and to increase more oxygenation and, and you know, for them to have more tone and more control. There are just different approaches that I have to have with young children. So, especially for pre and post up release, definitely, dental hygienist. My functional therapist is well trained in guiding a patient and a parent with the pre and post-tongue-tie release, or lip-tie release for a young child.

Speaker 2: 19:09

To diagnose a tongue-tie and especially give the referral for tongue-tie release? Would you say it should come from orthodontists, or should it come from myofungal therapists, or should it come from both parties at the same time? What would be your idea about that?

Speaker 1: 19:28

uh any age let's say from four onwards okay, um, I believe that it needs to be a decision that is made together. Of course, my functional therapist cannot diagnose. Only the doctor can diagnose. However, I'm able to evaluate the compensations that are happening because of the restriction. So if I see a patient and they let's call TRMR, their grade two tongue tie, and I'm asking them to do certain things, you know I'm checking for tongue mobility, I'm checking for the suction and I noticed that this patient cannot perform, for example, tongue lateralization, where the tongue goes side to side very well, because of this restriction. So what I'm going to do first I'm going to write a report. I'm going to tell you I noticed that this patient has. There it goes.

Speaker 1: 20:25

I noticed that this patient has a restriction, is a grade two restriction. However, we're going to try some therapy first. Why? Because a lot of times stretching these muscles, the muscles around the freedom the freedom never stretches because it's connective tissue, but stretching the muscles around the freedom, sometimes we have to address the structure Maybe they need expansion, just those things and then addressing the whole body, sending them to a body professional. They can address other body tightness that could be affecting the tongue. Also, we see an improvement in symptoms and we see an improvement in tongue posture, then do we really need a release? You know so, maybe not. So whenever I'm seeing a patient, I'm evaluating the compensations that this restriction is causing. After doing some therapy, it's going to become clear to me if I would recommend a release or not. However, I come to the release provider and then I'll ask you know, these are the things that I see. What do you think? It's? Ultimately is not my decision, of course.

Speaker 2: 21:35

So where this decision-making is in team, would you also involve an EMT in that decision?

Speaker 1: 21:42

It's usually the release provider and the myofunctional therapist and the patient.

Speaker 2: 21:48

Fine. And also I have a question like how much would you say can myofunctional therapy perform orthodontic treatment? Or where's the limitation? Because, like when you do, for example, as a provider, myoprase classic example you say you are myoprase provider and then you might see patients who expect that by you giving them a device, that everything will be corrected, including cross-bite, bone structure and everything else. So what is your idea about? Because it frustrates, because people need to understand what. What does myobrace do? What does myofunctional therapy do? What does an orthodontist do? So how do you feel about that?

Speaker 1: 22:39

um, at least in the united States, I cannot dispense myobrace devices. Might be in the UK, I can purchase them as a dental hygienist under a dentist or as a myofunctional therapist under a dentist, but I do not know how to measure and how to diagnose to choose a proper myobrace device and how to diagnose to choose a proper myobrace device. However, they do have some habit correctors and all of these companies do, including Myomanchi. So they do have these appliances that are a little bit softer, that promote the tongue going to the right place, promote lip closure, promote nasal breathing. Those appliances I can dispense. They also have some appliances that are helpful for the lips, for you to work on lips, so I can do those. However, the stage one, stage two, stage three, we're not allowed to do dentist only, dentists only. Yeah, it's 100%.

Speaker 2: 23:47

But now we have a problem, because how many orthodontists or dentists in your area are giving children these devices? Many, wow, because, because in the uk it's completely different. Number one children from the age of 12 years old are being seen. So the age group below 12 is not being seen. They have been told there's nothing we can do for you. So this topic of myofunctional therapy, myoprase, is not even on the radar for most parents, even so that parents are concerned, looking out for help, and they are getting it.

Speaker 2: 24:39

And now for me, as an orthodontist, my hands are a bit tied by my environment, because if I would go in now and would say I start expanding arches at the age of two, three, four, I will be going on very thin ice and I might break into the ice if I do that. So for me, that's why it's so important for me to talk to someone like you, because I need somebody like you in my team, because you can actually, in a very gentle approach with exercises, achieve a certain result. But this is what I want to know from you what would you say when we have talked about crossbite, high pellets, for example? What would you say could you achieve by myofunctional exercises alone?

Speaker 1: 25:34

whoa. So it depends on the case, um, because if this patient cannot breathe, nothing that I do is going to work.

Speaker 2: 25:50

So because I think of one kid, now four years old, high pellet cross bite. She has sleep apnea and she's already on a CPAP machine.

Speaker 1: 26:02

For me that's expansion. Immediately, tonsils and anenoids taken out.

Speaker 2: 26:07

So you say tonsils, adenoids taken out, because you see, the main reason for the sleep apnea is the adenoids and tonsils. At this age right, both.

Speaker 1: 26:18

Transverse deficiency of the maxilla and tonsils or adenoids? I'm not sure. I haven't seen the patient, but there's something obstructing, there's something in the way. There's a few reasons why children's tonsils and adenoids can be enlarged. We don't really know exactly what causes every single child. Of course we would just address. So it could be allergies, it could be dairy, it could be sugar, it could be processed foods. And then Dr Christian Gimeno had a hypothesis back in the day in the 80s he was talking about this in the 80s that it could be just the transverse deficiency of the maxilla by itself could cause enlargement of tonsils and adenoids. And then, of course, dr stanley liu and dr yun did a study where they expanded these children with an rpe and their tonsils and adenoids shrunk. We see that. You know dentists that I work with see that often happening. Um, oh, yes, somebody is saying that my voice is doubling. Let me see if I can mute myself here. There it goes. Let me know if you guys can hear me, because you're going to hear me from the computer over here on Instagram. So of course it's going to depend on the specific case, on the specific child.

Speaker 1: 27:47

I am the patient's advocate. I am going to be there to guide the patient. Based on the experience, based on the cases that I've seen, based on the providers that I've worked with and what I've seen, ultimately it's the parent's decision, the doctor's decision. However, if a small child comes to me and they have sleep apnea, especially if they're on a CPAP, we got to act fast. So none of these functional appliances, a myobrace, would not work, or any of those other habit correctors, because this patient can't breathe. You can't force them, I can't force them to keep their tongue up because they can't breathe. So we have to address the structure immediately. Is that tonsils and adenoids? Not sure. Maybe they have a polyp in the nose, I don't know. Maybe they have a cyst, maybe they have something else blocking their nasal passages. We have to find out why. So usually I send every patient to get a sleep study and a CBCT. So the CBCT is a 3D x-ray that's going to give us a really good image of the structures of, you know, upper jaw, lower jaw, the airway volume, back here where the tongue position is, if there's anything in the nose. Cmj is going to give us a picture of everything structurally and we can kind of see our tonsils and adenoids, turbinates, anything swollen, deviated septum. Based on that, with the collaboration of our team, we can make a decision for that child. So if they have sleep apnea, we have to act fast, whatever it is. If it's tonsils, adenoids, that's going to be my first choice, of course, because that's the golden standard right now.

Speaker 1: 29:31

However, we need to find orthodontists that are willing to get trained in seeing younger children, because traditional orthodontics know they don't teach you to see somebody under 12. So that is why I believe that pediatric dentists now are getting this training, because they are trained in treating younger children and orthodontists do not want to touch a crying child. You know it's harder. How are you going to do the impression of that? Thankfully, now we have the scans that are much easier that Thankfully, now we have the scans that are much easier. So I feel like we're lacking in the orthodontic community the willingness to get extra training, to learn how to see these younger children and to look at these other devices.

Speaker 1: 30:15

You know how much is too much when you're expanding somebody. When can you do slower expansion versus rapid expansion? What even makes something a fast expansion? How many turns a week? So those are things that we as a community need to talk and we need to learn from people who are doing it and we're getting successful cases, because all of those providers who are getting successful cases, they've had plenty of failures and that's why they're succeeding right now. But we don't know. We have to ask them, we have to find out what they're doing.

Speaker 2: 30:47

I agree with you because what I find really interesting, what my personal feelings on this, is when I have a kid with a sleeping disorder and it's quite severe, I go quickly in. So I don't think twice of going rep palatal expansion versus maybe performing something with an aligner and do a slow movement expansion, because the more severe the sleeping disorder, the more quickly I need to act in opening the palatal suture. So but again, like, for me, the biggest thing is the fear of the community around me that I might get attacked for actually doing this kind of procedure. I even struggle to say now I do it now this week on a four-year-old kid the only kid I just mentioned because she literally doesn't sleep, she's on a machine. Because she literally doesn't sleep, she's on a machine.

Speaker 2: 31:46

So me, my personal heart tells me okay, I don't care, I need to do this because I hope that, combined with the ENT and all the other things we just mentioned, I'm pretty confident I could at least improve the situation of this child, and I couldn't agree more. I do courses, and I do orthodontic courses, but I do also courses for pediatric dentists. I get much better positive feedback from pediatric dentists because they see it every day in their chair, but they have a problem. They refer on to an orthodontist and they're getting told there's nothing they can help you them with. So this is, for me, exactly the frustrating part is there's so much need out there that we need as educators you and me, we need to join, venture and make these people where there is somebody, you can do something.

Speaker 1: 32:40

If the orthodontist is not joining, that they're churning together, we need to do it ourselves yeah, and if a child is transverse efficiently or AP deficiently at four, do you think they're going to be at 12? I've had an orthodontist tell me I'm not touching your child as my daughter right now I can do everything I need to do in 12 months. So come back. I'm like I don't care about her teeth, I care about her. What is an extra year of hypoxia going to do to her? It's 18% less oxygen that goes into the brain. If they're mouth breathing at night, why are we waiting?

Speaker 2: 33:18

And what was their response?

Speaker 1: 33:22

Because they don't have the training they don know it's. You know, I can't blame them completely because that's what they were trained in and they believe that they're gonna have a beautiful smile afterwards. But if you don't know it, you're not gonna see it. That's why we need to keep doing these talks and and podcasts and lives and get together your community. Let's do a study club. You know, area Circle helps you guys. Put study clubs together.

Speaker 1: 33:49

You have to grow your local community. You have to find like-minded professionals to collaborate with, because we can't do what we are doing alone. And, yes, there are plenty of people that are going to come and throw rocks because we're doing something different that they are not. And it is okay if you're feeling in your heart that it's part of your purpose to help these children who are not breathing well, who are not learning well in school, who are being bullied, who feel awful, who are irritable, who have tantrums because they can't breathe. And you have the tools in your hand and you can do something about it. We can't be afraid of what everybody else is going to say, because it's going to come.

Speaker 2: 34:31

You just have to be ready for it and actually, and also like in the UK, there is a famous blog, mainly managed by professors in the UK, and there was recently an article who compared a rapid maxillary expander compared to watchful weighting and the conclusion was that there's no clear evidence that maxillary expansion is beneficial to just weighting it out.

Speaker 2: 34:57

But the problem in general is what we mentioned at the beginning, is it's so multifactorial that when you look at the studies that are being done purely by expanding the bone structure, yes, might not help the child in the breathing, but we need to have a multidisciplinary approach and then eventually we could start a research study on it. But all the research that is out there is not being done like this. So we cannot go there and say, oh, watchful, waiting is the same as winding a pellet. And also we have to ask about the ethical responsibility we have. Who is responsible for this child you just said couldn't breathe properly for another six, seven years, and now the struggling at school can't concentrate, adhd, anxiety and all of these other issues which eventually can be linked. We have to be careful what we say to the breathing. So who is responsible for these things later?

Speaker 1: 36:04

Mm-hmm. 100%. Hypoxia is brain damage. Everybody it's damage. What are you going to do afterwards, after it's all said and done?

Speaker 1: 36:13

But the more these professionals hear our call and I feel like it really takes a personal experience so having a child or having a grandchild with an airway issue, or not being able to breastfeed, or tongue tie or CPAP machine if they have apnea.

Speaker 1: 36:31

You know it usually takes something personal for these professionals to go like whoa, there's so much more out there and then they can go research because they are so busy as it is. I know that around me over here it's difficult to get an appointment with an orthodontist. They are so busy as it is. I know that around me over here it's difficult to get an appointment with an orthodontist. They're so busy and they're so successful and they're making plenty of money. Why are they going to change what they're doing? They're going to have to slow down, they're going to have to make a little bit less money in the beginning until they can figure things out. But you know, airway it is more complex, it is more comprehensive, it is more taking a step back, waiting for my functional therapy to be done. Working with my functional therapy, you know it's a little bit harder for professionals to to understand everything that's that goes into what we do and working in a team.

Speaker 2: 37:20

I want to share something from my personal experience. Like I moved to london nine years ago, like I moved to London nine years ago and when I moved to London from Switzerland where I treated mainly kids, I treated only adults. I treated them with lingual braces and the market in London is very competitive, everyone doing the same. But then you deal with adults all the time. But then you deal with adults all the time and, treating adults, you sometimes deal with the psychology of the adults as well, which you, as an orthodontist, you can't treat. But financial interest aside, as an orthodontist, me focusing on prevention and children changed my life to a positive massively, because when you have this impact on a child's life and you make the changes in their life, you help them breathe and getting confident and getting the love from them when you change their life. It's so much more rewarding than any dollar you ever made in an adult. And if an orthodontist is purely financially driven to make money, everyone needs to earn a living. That's absolutely fine, but for me, helping children gives me so much more value to my life that I can't even put any value of money on it. And this is what people need and the reason why I do all these podcasts and these teaching and education is. I realize the need is so big that we can't do it alone. We have to spread this word. We need to educate other people because the need is so high that these children are crying out for help. But I want to give you one example. I want your opinion on that.

Speaker 2: 39:13

I recently had a 45 year old gentleman in the chair and he came for a consultation and the first thing he said to me is can I record this consultation, which I already find bizarre and adult because you have to be careful nowadays. But anyway, he had a at last three malocclusion, like the lower jaw was overdeveloped. So I looked in his mouth. I immediately spotted a severe anterior tongue tie. I already knew it. So you knew it because you know already the impact a tongue tie has on jaw development.

Speaker 2: 39:53

But then when you looked at the medical history, this gentleman was on ADHD medication, was on antidepressants and he was an alcoholic Wow. So he was drinking every night so he can get some sleep. So when I basically mentioned that his problem are actually not his teeth, the problem is the way he's breathing at night and the way it has an impact on his health, this gentleman became very emotional because for the last probably 40 years he's seen professionals all over the world and not one of the professionals ever linked his tongue tie to the way he is feeling. So what is your experience? What would you say to that? Am I right to think that this is linked?

Speaker 1: 40:48

A hundred percent. A hundred percent. It's all about development. We already know that if you plug the nose of monkeys that their teeth get crooked, and then if you open the noses up they start getting straight again. We know that lack of nasal breathing causes malocclusion.

Speaker 2: 41:09

And how do you think about the mental health side of things? What is it?

Speaker 1: 41:15

Oh my gosh. Like I said, it's hypoxia, it's brain damage. If you have lack of oxygen to the brain, what do you think is going to happen? I have somebody really really close to me who had dyslexia growing up but she had, you know, buck teeth. She was overweight, just this, you know young child and teenager full of bullying and tons of issues in school. Even though she tried hard, it was difficult for her, several other issues and then finally, when she was a young teenager, they did braces and then beautiful white smile. She lost weight. Because then you're able to, because you're able to breathe well at night. She no longer has dyslexia. There's no you know no issues.

Speaker 1: 41:55

Why do we have to wait for this child to go through elementary school, middle school, with these issues? And what is the long, what are the long term consequences of that on a 40-year-old adult who has spent so many years not breathing correctly? We also know the lack of deep sleep is now connected with Alzheimer's disease. You know, if you're not getting enough deep sleep, you're not getting the glymphatic system to work in the brain that clears all of the debris that accumulates throughout the day. What is that happening? That happening increases beta amyloid and tau protein in the brain which is directly linked to alzheimer's. There's a hundred percent of connection. A hundred percent of connection, and it's it's all about. It starts with breathing. It's the first thing we do whenever we're born, the last thing we do before we die. We have to address breathing first.

Speaker 2: 42:46

So I want to ask you a personal question. I know your intermolar distance was 30.4 millimeters, sure, and you have palatal expansion by my dear friend Ilya Lipkin. How do you feel, how? What would you say from personal experience changed for you?

Speaker 1: 43:10

oh, my goodness. So I was an airway kid and that's why I'm so passionate about this. I was bullied in school. My nose was running constantly, allergic rhinitis. I couldn't breathe well. I needed to sleep with two big pillows in order to be able to breathe a little bit. I I slept with my mouth open, I snored, I drooled. I never had a sleep study as a child. I bet I had some form of sleep disorder, breathing. And as I got older and I was introduced into this field, I did my functional therapy on myself for a while and just my functional therapy by itself did help me sleep with my mouth closed, breathe through my nose. So it did reduce, you know, brain fog. It did reduce irritability.

Speaker 1: 43:55

I still have a hard time, or had a hard time, working out, you know. I couldn't run because I couldn't get enough airflow in my nose. Allergies were still kind of bad. And then I had palatal extension and I remember when my nose all of a sudden opened up and I could take a full breath in without effort. Working out became so much easier. Clear thoughts became so much better. Sleep is more deeply. Now. If I have a good night of sleep, I go to sleep and I wake up and it's like nothing happened. I don't wake up throughout the night anymore and I used to. Very, very often I also used to have insomnia. None of that Nasal breathing is undervalued. I wish that we talked a little bit more about it. But now also, I have more room for my tongue. I still have the appliance in my mouth. It's called the Marpe M-A-R-P-E, meaning implant assistive rapid palatal expansion. I have six screws. For those who want to know. A lot of times for my age, four is not enough. No, a lot of times. For my age, four is not enough. I didn't have a PSO cut, so it was just the device and in three days, turning about twice a day, I split, the suture is split. I had a light headache, didn't have pain at all, the whole process. I'm seeing him next week again to find out where we're going to go now. But it's one of the best things that I have ever done for my health, not only now but for the future. You know my father has full blown sleep apnea.

Speaker 1: 45:35

I look, my structure is very much like his or was. You know I'm. I'm changing. My nose is so much wider Now. My upper lip looks better. Everything has changed. My cheekbones are so much higher, but I feel better. I like the way that I look. I used to hate my side profile because I am retuded. Top and lower jaw are too far back. I do have a huge bump on my nose. Why do people have bumps on their nose and other people don't? Could that be related to a small maxilla and not having enough room? I don't know, but these are questions that we have to ask. So even my nose looks better. The tip of my nose went up after my expansion. So not only looking at myself, my skin looks better because now I have more oxygen. It's, it's insane. It has changed my whole life.

Speaker 2: 46:18

I cannot wait to get it out, to really feel what that tongue space feels like now so you had the luxury, obviously, that the orthodontist as a kid didn't take four teeth out, right?

Speaker 1: 46:30

Thank goodness. So I always had straight teeth, beautiful straight teeth, but very narrow and very high-vaulted palate, very high. So whenever I was 14, I begged my mom to take me to the orthodontist because I thought it was cool to have braces. And they gave me a palatal extender and it made me talk super funny and I had, you know, the little wire on the top. Oh, I felt like I was the coolest kid ever. I loved it.

Speaker 1: 46:56

And that's when I moved to the United States and I forgot my expander in Brazil. So I remember going back six months later and it didn't fit anymore. So I know I relapsed some. I don't think I fully relapsed because I remember there was this piece of candy that I could fit after I did my expansion and it couldn't fit before. So I was probably a 27, 28, I would guess, before.

Speaker 1: 47:20

So it did change a little bit. You know what? That time my breathing got better. I started looking better right around that time during the expansion, so it already improved some. However, I didn't continue. I didn't do my functional therapy either. So I relapsed and after you know all these years of learning more things about airway and going through the MARPI, I mean we gotta start early. We gotta get you. Start getting these kids, because I know what I went through and if I can't, you know, help any child not have to go through the bullying, the allergies, not sleeping. Well, you know, studying super hard but you're still not making great grades in school because you can't breathe, you don't have the energy. You don't have the energy to play sports, to work out, it's not fun.

Speaker 2: 48:11

So when you have the device in your mouth now and you are supposed to do myofunctional exercises, how would you say, can you do it? Should you wait until the device is out? What is now your personal fit? Because we're doing kids with these devices I I don't do so many adults because I like the kids too much but what? To which degree can I tell kids now? You should start already your exercises, or now you have it in your mouth? You are the best reference for me. What can kids do and what they can't do when their device is in?

Speaker 1: 48:48

So it depends on the issue. If a child has an overbite, they have reduced intraoral space. When they get an appliance in there, if you think about it, it's going to reduce the amount of room for the tongue even more. So a lot of times those children will have worse sleep until the appliance comes out. So a lot of times those children will have worse sleep until the appliance comes out. So we have to keep that in mind.

Speaker 1: 49:14

However, myofunctional therapy is not only tongue position. Is tongue position the most important thing? Absolutely? Because without the tongue position you can't breathe, you can't keep your lips closed and all that stuff. So, as a myofunctional therapist, I'm also working on nasal breathing, I'm working on awareness. I am working on the cheeks, the lips, the oral pharynx. There is a lot that I can do while they have the appliance in their mouth Increasing tone, increasing strength in their mouth, increasing tone, increasing strength.

Speaker 1: 49:51

I don't do chewing and swallowing until they're completely done, until after an expansion, after tongue tie release, because why am I going to train somebody to swallow a certain way? As soon as the structure changes, the function changes. This is very important for people to understand. The function is always going to follow the form. So, depending on what the structure looks like, your body is always going to compensate and find a way to do function, because you have to function right we have to swallow, we have to chew, we have to breathe.

Speaker 1: 50:16

But it's my turn as a myofunctional therapist to check to see how that function is working and if I can do anything to help improve, based on the structure of the patient. So yes, 100%, there's plenty that they can do with myofunctional therapy. A lot of times I will see these patients once a month while they're going through expansion. So if it's a six month, eight month process, sometimes a year, I'm still keeping up with them and I'm not giving them major things to do, but I'm giving them one or two exercises to do during that time. So they get used to me and we. You know there's so much already that we can do with those muscles and that by itself makes a big difference already.

Speaker 2: 51:02

So in your experience. What is the best friend for you in terms of palatal expansion when you see orthodontic patients? What is, for you, the best expansion device as a myofunctional therapist?

Speaker 1: 51:17

Not everybody agrees with me. I am a lover of an RPE. There are several different types out there that you can use. Recently I heard the Hyrex is not great. I've always liked the, the appliances that have the acrylic up there, because I feel like it gives a little bit more support to the palate.

Speaker 1: 51:34

However, I am not an orthodontist. I don't know exactly how things work in your world. I do like them fixed better than removable. I feel like it's easier. You don't't have a choice. You got to keep it in there. At the same time we have to make sure that the child is okay. You know, sensory wise to having something in their mouth. So a lot of times we have to desensitize the patient before they can allow an appliance in there. I also like the fixed appliances because they tend to be a little bit more rigid. So I feel like putting more pressure and, you know, making sure that suture is going to open a little bit more than a removable appliance. My child has had three. Zoe has had three different appliances and she's lost all three, 100% fixed.

Speaker 1: 52:20

Oh, something I forgot to say about Marpie in adults and myofunctional therapy very important to do myofunctional therapy whenever you're doing palatal expansion as an adult, whenever you're working with something like the MARPI, because when the suture splits, everything is a little unstable there. If you're a patient that's used to eating on the right side only let's say, and all of a sudden everything is a little unstable and kind of growing, it's going to get worse. So my functional therapist will be able to tell you two more on this side. While you're going through the expansion, let's work on the side a lot more to see if we can kind of help a little tiny bit with asymmetries. We're all asymmetrical. There's barely anybody out in the world that's perfect, okay, or left and right side. So those asymmetries, we're all asymmetrical. There's barely anybody out in the world that's perfect, okay, or left and right side. So those asymmetries are always going to get worse, especially in adults, and especially if they don't have any myofunctional therapy work as they're going through that expansion process.

Speaker 2: 53:26

So if I would say to you that the new Invisalign palatal expansion device that is already launched in the US and Canada is not your best friend, which one is that?

Speaker 1: 53:35

the Invisalign. I recently, last week, had two patients. They're siblings. The boy doesn't have a lot of crowding, the girl has a lot of crowding and they are, you know, 13, 10, 13, 16, 15, around the age 10 to 15 years old. No, 13 to 15 years old. I want to get something in there fast and I want to get something in there to open that suture, especially with a girl that's so crowded, um, and with him, because he has sleep issues. So everybody's you know different case. You would look at one person looks like they're going to have a worse airway. It was the other way around for us with these patients. So immediately the orthodontist said Marpie, and I was like hell, yeah, let's do Marpie. But they didn't agree.

Speaker 2: 54:38

So she offered the other option, which was the.

Speaker 1: 54:40

IEP. And immediately I'm like what that just came out like last week no, we do not have enough studies, we do not have enough. You know it's going to be probably, you know, tooth dipping, like we can't do it. And then, of course, I got in touch with the orthodontist. I was like what's going on? These patients really need you know something aggressive. And she explained that the patients didn't want to do it, it was their choice and that she was one of the trials for the IEP. She and that she was one of the trials for the IEP.

Speaker 1: 55:08

She did it for two years and she did see plenty of sutures open up. They have CBCTs and everything. So I asked her to send me some of that info and it makes me super happy and comfortable knowing that she has already used it for two years. She has seen plenty of patients. Of course, I want to know the age of those patients. I want to know the age of those patients. I want to know the symptoms of those patients. I want to know the tongue position of those patients. I want to know if the palate is going to hurt, like I don't really know how. You know how tight it is, how close it is. I don't have enough info, but I have two patients right now that are about to go through it, so I will let you know in five to six months how everything is going with that.

Speaker 2: 55:51

I think the biggest problem for me as an orthodontist is the compliance point of view, because, obviously, when we treat children, we have only limited time as orthodontists. Where we have a compliant child, and in that time we have, we need to achieve the maximum outcome, and when we have in terms of airway, when it's an absolute need and urgency. My personal opinion is we cannot trust a child to do the job for us with none of the research present right now, and so I'm also still on the fence with this device because it's removable. I agree with you, I prefer a fixed device for that, because on the four-year-old girl I'm just treating, I would never, ever, consider a removal because I need to be quick. So and I know which orthodontist you're speaking to so we need to be a bit critical and have a look.

Speaker 2: 56:58

What's the age group? Because we don't know yet, and certainly when we talk about teenagers, it's a different ballgame anyway. So it's interesting. Is it the future? I'm not sure it. It to be found out, but the thing is from a company perspective, we need to have also a company who focus on the children's side as well, and a company you're talking about is mainly focused on adult treatment. So, as an orthodontist who is focused on prevention, it's sometimes questionable is that the right approach or is it another thing time being? So what I do now nowadays a lot is I combine metal printing device like Armys, with an aligner on top of it, so because I can maintain the bone structure while I still align the teeth. So that is something which I find works really well and it's super important. So at the end, do you have any questions? You always wanted to ask an orthodontist at your disposal that you don't know the answer to.

Speaker 1: 58:13

My friend Sam over here just mentioned awareness of AP. I think that all of us are very aware of transverse deficiency, but we don't talk enough about AP deficiency. What to do, when to treat. What do we do with the mandible? You know how do you bring the mandible forward and address the TMJ at the same time. I'm not an orthodontist, I don't understand enough about that, and usually when I meet a new orthodontist that I'm trying to get them, you know, into our airway world to help me with these patients, because I don't have anybody else around. Those are usually the questions that they ask me. Well, you know, if they're not a class three, why am I going to bring the maxilla forward?

Speaker 2: 58:58

So basically like we know that the reason for deficient lower jaw is quite frequently the deficient upper jaw, so that the lower jaw is trapped Like when I do my consultation I always compare it with high heels of ladies I love that they have these beautiful high heels on and the foot will never be able to slide forward. So what I see? Because we see that in adults as well. In adults, john Coyce and Seckierra will call it constricted envelope of function. So the upper jaw is trapping the lower jaw. As soon as you release the upper jaw, the lower jaw naturally will posture more forward until what age?

Speaker 2: 59:41

well at any age, because in others you see destruction, you see wear on front teeth, you see open bites and so on, but that's a complete different topic. This is truncated function. So in children, when you give them the platform early in life like a wide upper jaw, the lower jaw has a lot of potential to grow naturally forward. When the jaw is trapped it will never do that. And then it's super important. When we look at growth itself, the lower jaw has its main growth at growth peak in puberty. That's true. But before the growth peak we have tiny little waves of growth of the lower jaw and that starts at 5, 2, 9, 10. We have tiny little waves of growth of the lower jaw and that starts at 5, 2, 9, 10. We have tiny little waves of growth and these small little waves we should encourage to use to bring the jaw forward. So when we do early interceptive orthodontics I use a lot of advancement devices like mandibular advancement or angel liner. We'll call it A6. So it's a twin block device that brings the jaw forward, like mandibular advancement or angel liner, we'll call it A6. So it's a twin-block device that brings the jaw forward while you're widening the structure of the upper jaw. So it's super important. And actually I'll give you one example just now. Today I had a kid. I widened the upper jaw it's a complete lower deficient jaw and I gave her a her class two elastics at the age of eight. She was so compliant that she came in in a class three, wow. So I actually got scared to think, oh, my goodness, from an overjet of seven, eight millimeter to a negative overjet of 7, 8 millimeter, to a negative overjet where I had said, oh, we have to stop, you know. And it of course relapsed a bit so it was no problem. But I document that case because what I try to say with that is the earlier we start developing arches and bringing lower jaw forward, the more we will get the airway open up. We're not creating these class four cases David Boyd is talking about.

Speaker 2: 1:01:54

Yeah, we bring the A and B point, we call them in the forward. So the lower jaw is important. We catch it just as early as we do the upper jaw. But the upper jaw, we know the palliative suture is fusing a bit earlier than the lower jaw. But the upper jaw, we know the palatal suture is fusing a bit earlier than the lower jaw.

Speaker 2: 1:02:12

And also, what people forget is everyone's talking about treatment of teenagers. But you cannot bring a jaw forward in teenagers. They're maybe not growing so much anymore or they're not wearing the device as instructed because they are full of hormones. They do whatever they want to do at that time. So it's a time period which is really hard for an orthodontist to have control over a patient versus young children below 10. They're super keen, especially when they're getting bullied because of protruding teeth.

Speaker 2: 1:02:49

So this girl I was just talking about, she was so concerned about her appearance that she did exactly what I wanted to do and she did it so well that I got scared because it went the opposite direction. So again, it's super important to get in early rather than late in developing the jaw up or in the transverse, but sometimes ap. And to finish that off, when I do, I like face masks, yeah, like rapid maxillary expander with face mask and combination of grommets's mask. The younger the children, the quicker we have this corrected, and in speed I mean weeks. So it's so powerful that within a few weeks of wearing a mask you can completely change their whole profile. And when you see that and you see that what it does to a child, you get emotional and I get sometimes messages from the mom saying my child looks so different. You know, like you mentioned yourself in yourself, the cheekbones getting high, the skin getting more oxygen, and you see in their eyes they are more shine, more spark in their eyes. Their whole personality changes, their behavior changes, and that's not just teeth, there's so much more that changes in these young, growing children.

Speaker 2: 1:04:20

So we need to intercept early and you know so much and you, unfortunately, you can't do it.

Speaker 2: 1:04:28

You, you need orthodontists, which I'm happy to help with, to be able to do this early and on a professional side as well. With prevention you can just as much run a business that you can do on adults, because when I did my business, start my business two and a half years ago, we only focused on children. The whole marketing was for children, and now we are growing so quickly that we can't even keep up with getting new stuff in because we have too much demand. So if you think there's no business in children, you're wrong. And the beauty of it is a beautiful business because you help children every day and you can then choose if you want to treat the parents or if you don't want to treat the parents. So by this AP correction I totally agree and hopefully in the future what I want from companies is yes, we have now within this line, a brand that gives us the transverse correction, but it will not give us the AP correction. So hopefully in future we will have companies who give us both.

Speaker 1: 1:05:47

Yes, that's my wish, yes, I love it, I love it, and together we can keep keep working, keep treating, keep keep finding out. You know better ways of doing things, what works, what does not work. So spaces like this are very, very important for us all to grow. So thank you, thank you for having me and inviting me to chat.

Speaker 2: 1:06:09

It was amazing and it's so nice to have your vibe and your smile. Your smile is amazing. I hope we could help to create more awareness of the importance of working together in a collaborative community. But it takes more than just the two of us. It takes a whole team. Thank you so much. Have a lovely day. Have a nice evening everyone, and I hope we meet in vienna latest in october. Have a nice evening thank you take care.