53. Breathing & Bedwetting: What’s the Connection with Dr. Piya Gandhi

Can a child’s breathing patterns be the hidden cause behind bedwetting? Join us on the Beauty of Breathing podcast as we welcome Dr. Pia Gandhi, a board-certified pediatric dentist specializing in pediatric airway and oral dysfunction. Dr. Gandhi unpacks the complex relationship between disrupted sleep, poor oxygenation, and hormone regulation necessary for bladder control in children. Learn to recognize early signs of mouth breathing, such as chapped lips and restless sleep, and understand the critical importance of early intervention to prevent primary and secondary bedwetting.

Discover the pivotal role of tongue positioning and tongue ties in the development of infants’ jaws and airways. Dr. Gandhi highlights the dangers of low-sitting tongue posture and the benefits of early interventions like treating tongue ties during infancy. We discuss practical tips for promoting healthy oral habits, such as avoiding pacifiers and soft purees. Parents will find valuable guidance on finding the right specialists, including airway dentists, myofunctional therapists, and IBCLCs, to ensure their children receive the best care.

In this episode, we also cover a holistic approach to treating bedwetting and related issues. Integrate therapies like occupational therapy, physical therapy, chiropractic care, and oral therapy to address underlying causes. We delve into the necessity of pediatric dental sleep apnea screening and the importance of recognizing early signs of sleep disturbances. Dr. Gandhi also demystifies tongue ties and offers insights into effective treatments and proper orthodontic appliances. Don’t miss this enlightening discussion as we connect the dots between breathing, sleep, and overall health in children. Share this episode to help spread critical information and support more families in need.

Chapters

• 0:02 Breathing and Bedwetting in Children
• 15:08 Early Airway Intervention and Treatment
• 22:41 Sleep, Trauma, and Oral Therapy
• 35:49 Pediatric Dental Sleep Apnea Screening
• 52:36 Tongue Ties and Pediatric Dentistry
• 57:16 Sharing Airway Information for Children

Transcript

Speaker 1: 0:02

We are live. Welcome everybody to the Beauty of Breathing podcast recording. Today I have a very special guest with us, Dr Pia Gandhi. She's a great friend of mine and an incredible practitioner. I am going to let her introduce herself to you guys, let you guys know where she practices, how to get in touch with her, and all of that Go ahead, let you guys know where she practices, how to get in touch with her and all of that Go ahead.

Speaker 2: 0:31

Hi there, I am Dr Pia Gandhi. I'm a board certified pediatric dentist that specializes in pediatric airway and oral dysfunction. I practice in Houston, texas. I have two practices Westview Pediatric Dentistry and Tanglewood Pediatric Dentistry and those are our Instagram handles as well, so you can look us up there. And we start treating for oral dysfunction at birth and even though I'm pediatric, I do treat some adults as well, but my focus is mainly children.

Speaker 1: 1:02

Awesome. So today's topic we're going to talk about breathing and bedwetting. How are those two connected? We got so many questions this last week on Instagram from parents going but hold on, my child is bedwetting and pediatricians are saying that they're fine or this is just going to. You know, it's something they're going to grow out of. How is bedwetting related to how a child is breathing during sleep?

Speaker 2: 1:30

Sure. So you know there's two types of bedwetting. One is primary bedwetting, which is normal for a young child that you know, during the potty training process and when they're little, just never was able to hold their urine through the night, but that should tend to go away by four or five years old. Then there's secondary bedwetting, which is due to an underlying medical condition or something else that's disrupting our body's ability to really hold our urine during sleep.

Speaker 2: 2:07

And when sleep is disrupted we really don't go through normal sleep cycles and so the body doesn't regulate hormones correctly, because we're constantly in this fight or flight stage of sleep, usually the beginning stages of sleep where our body is still really active, especially if we're having trouble oxygenating because of sleep apnea, you know our body is fighting to just give as much to our brain to keep breathing that it is not allowing the proper regulation of the hormones that allow our bodies to absorb more, more liquid while we're sleeping, so that our bladder doesn't get full.

Speaker 2: 2:48

And so we see this with obstructive sleep apnea, when children are struggling to get into the restful cycle of sleep, and so this can continue into the teen years sometimes, and what we see sometimes is when they're little and they're four or five, they're actually able to not bed wet and then, as their body continues to grow if the airway is not growing with them they can actually start to bed wet again Because, again, that cycle of not being able to get into a deep level of sleep where the hormones are regulated correctly.

Speaker 1: 3:28

That is perfect. So that goes back to okay. But hold on, I have a child and they are showing certain symptoms that every other healthcare professional tells me that they are normal symptoms, and I just heard Renata say on Instagram that bedwetting is related to maybe not breathing very well at night. What is the problem? What are some things that I should be looking for on a child who may be mouth breathing? A lot of times we don't even notice our child mouth breathe, but there are certain things that we can look at and we're like, and I'll give you guys one.

Speaker 1: 4:07

For example, if you're constantly telling your children close your mouth, close your mouth whenever they are chewing, a lot of times it's because they cannot breathe and chew at the same time. They could have enlarged tonsils, enlarged adenoids, and it's not because they don't want to. They know it's wrong. You know, kids are pleasers, they want to please everybody, so they're not doing because they're bad, they're doing because maybe they cannot do it any otherwise. So, besides chewing with the mouth open, what are some other signs of mouth breathing in children?

Speaker 2: 4:39

Yeah, A really easy one to pick up on is chapped lips. So if your child constantly has chapped lips and then they start licking their lips because they think that's going to help and it makes it worse, that is a sign that we are mouth breathing because it's just drying everything out. So that's one when they're sleeping. If you wake them up in the morning and their sheets are everywhere and their hair is a mess and you know they're sideways on the bed, that is a sign that we are not sleeping well. And a lot of it will start with mouth breathing, because when we start to mouth breathe we don't oxygenate our body as well. It also doesn't allow our jaw to grow correctly when our mouth is open because our tongue is not elevated and pushing on the upper jawbones to spread them out. So movement during sleeping is a big one.

Speaker 2: 5:32

Kids that drool when they sleep. So even when they're napping if they're napping on you or whatever and then they end up having a whole puddle of drool on you well, that's because their mouth is open the whole time. Kids that just will fall asleep on a dime anywhere inappropriately, and I think parents and the general population just knows that. If my child is asleep for X number of hours, they must be a good sleeper. But we really have to look at what that sleep looks like, which should be essentially silent and still with our mouth closed. So even if we're not hearing an actual snore sound, if you are hearing heavy breathing or anything like that, the mouth doesn't have to be gaping open. That is considered the start of what we call sleep disordered breathing, Another one that is easy to identify that I get in my office.

Speaker 2: 6:25

A lot is grinding, and because the sound of grinding teeth drives everybody crazy and parents and consent eyes hear that down the hall from their kid's bedroom, and so, again, this grinding is a sign of our body being stimulated and trying to keep us from not falling into an apneic state or stop breathing while we're sleeping. And even when they go for their regular dental checkups, when their teeth look flat or an easy one that you can see as a parent is these eye teeth or the canine teeth they're supposed to be pointy and when a child is grinding, they start to become really flat. So, looking at, these types of things are things that parents can, you know, relatively easily identify on their own child and bring up to you know a specialist in this area.

Speaker 1: 7:19

Is it common for both sibling to show these symptoms?

Speaker 2: 7:29

common for both siblings to show these symptoms. I see it very commonly and I think because there's well, there's a genetic component to some of this, and then there's an environmental component, so allergens our diet plays a role in some of this as well, in terms of causing inflammation of the body and inflammation of the tonsils and adenoids. Something that we treat and screen for in my office is tongue and lip tie, which there's also a genetic component there, and honestly, it's not just siblings. If you start to look at the parent, you'll see a very similar pattern, and sometimes that is the key to recognizing is when a parent starts dealing with their own sleep apnea, and treatment for adults is really intensive, whereas if we could pick up these chap lips moving children while they're sleeping, grinding early, the intervention is much less invasive and much simpler.

Speaker 2: 8:21

And now we know these really early signs, obviously the bedwetting, which is what we're focusing on today, and unfortunately, you know, not all of our pediatricians, but many of our pediatricians are not trained in looking at these early signs, and so I always encourage parents, you know, if you think something is off, don't ignore that feeling, go find whoever can explain what's going on, because these things a child doesn't magically grow out of.

Speaker 2: 8:52

If anything, they get worse and worse, because the more the child is growing, if the airway is not growing and supporting that body growth, we're going to see more and more of these symptoms pop up. And unfortunately, you know, bedding, bedwetting, really starts to have a psychological component on children as well, a hundred percent. So you know the fact that they feel embarrassed, they can't go for sleepovers and and as you mentioned about the chewing, it's not for lack of trying. I mean, all of these kids, they're not like choosing to bedwet, they just don't have the control and the proper function of their body to help them out. And so you know, it's a really, when you really think about it, it's like we have to help these children there, you know, and there is a way to help them.

Speaker 1: 9:38

Exactly. I tell my patients all the time. You know they feel so bad. So I tell them listen, it's not because you drink too much water, it is not because you could not wake up to go to the bathroom, it's because you can't breathe.

Speaker 1: 9:49

This is a survival mechanism. What is the one thing that you have to do in order to survive? You should take your next breath. You can stay long enough without water, long enough without food, but you cannot stay very long without breathing. So your body goes through extreme ways sometimes to make sure that you can take your next breath, and sometimes it needs to release everything that is not important. That's an easy way to explain it. He releases everything that is not important so you can take the next breath. You know, a lot of times these kids are moving around a lot why? Because as their airway closes, if you move, all of a sudden, you have these awakenings. You know that the child doesn't remember, that even an adult they don't remember. But you have this fragmentation of sleep where it kicks you back to stage. One sleep, to light sleep, so you can move around and you can take another breath. You can open up your airway, move.

Speaker 2: 10:40

Yeah, and that's another thing is, positioning can help open your airway. So you know, arching your head back while you're sleeping is a is a a way that a lot of people subconsciously open their airway while they're sleeping. So you know, again, looking at the positioning of your child while they're sleeping is really important and we see these symptoms improve with over time when we do treatment. It's you know, it doesn't happen instantaneously, but as we open up the airway, as we train children to nasally breathe, the symptoms start to get better over time.

Speaker 1: 11:16

I don't know if you guys are like me I love taking photos of my kids asleep.

Speaker 1: 11:21

They're so cute yeah you know, and whenever you start learning about these things and you go back and you start looking at the positioning, I request from all of my patients a 20 second video of the patient sleeping about 90 minutes after they've fallen asleep. And 90 minutes it gives you enough room to go through a whole sleep cycle. Sleep cycle, yeah, so I'm looking for tongue position, head position, body position and you know, as a parent, sometimes it's really funny this positions that these kids are sleeping in, and it shouldn't be like that. There's usually something going on.

Speaker 2: 11:56

Also, if you look at newborn photos, a lot of those newborns have their mouth open already and their heads up. So you know, when we talk about early intervention, we're not just talking about kids that are three, four, five years old, we're talking about kids that are a week old, two weeks old, because already they are having that open mouth posture and we have to ask ourselves why. Because that is not naturally what the body should be doing. And yeah, it's. Similarly, you look at all these cute newborn photos and the babies look adorable, but half of their mouths are open.

Speaker 1: 12:29

I have a patient that just came to me last week and my heart is broken for this little boy and he's so motivated, he's so excited, like are you serious, mom? Like you found somebody that can actually help me. They've tried it all and they've been ignored. Even recently went to an orthodontist and this child obviously has a small maxilla and they said let's just watch for a waiting. You know, let's wait one more year until you grow a little bit more. Well, if you're already underdeveloped, waiting is not going to push you ahead of the curve. Waiting is not going to push you ahead of the curve. Waiting is not going to do anything. So if you're underdeveloped today, you're going to be underdeveloped a year from now.

Speaker 2: 13:09

Yeah, and the body is going to still try to grow, and so that airway is going to just support it less and less.

Speaker 1: 13:16

Exactly, but it is the craziest photo that I have ever seen of a head position during sleep. It is the craziest one and I am asking them very sweetly and nicely, to let me share, because it is the craziest one I have ever seen. If you're listening to this right now and you have a photo of your child sleeping with their head all the way back, please and you don't mind me sharing on social media, because it's going to help so many other patients that, like Dr Gundy is saying, these patients, these little kids, they need us, they need us to find them out there. You know we need to be able to educate the parents. These are the things for you to look for and there's something that we can do to help this child. Somebody recently asked what is the role, and you mentioned a little bit what is the role of ankyloglossia, or tongue tie in mouth breathing.

Speaker 2: 14:07

Yeah. So ankyloglossia or tongue tie is when we have a frenulum under the tongue that is too tight or positioned in the wrong place and it is limiting the range of motion of the tongue. Particularly, the positioning of the tongue to help with nasal breathing, to help with proper growth and development, is elevated in the roof of the mouth. That is at rest. That's where it should be basically anytime we're not using our tongue for a function. You can even try it now, whoever is listening If you drop your tongue to the floor of your mouth and try to take a nice deep breath through your nose, it's a lot harder than if you elevate and suck your tongue up to the roof of your mouth and then take a nice deep breath through your nose, it's a lot easier. So if we are tongue tied and the tongue physically cannot make that elevated movement and stay elevated, we are now already prone to more resistance in our nasal passages to nasally breathe. The other problem that happens when our tongue sits low is that the tongue is not putting pressure on the maxillary bones or the palatal bones, which are two bones the palatal bones that can be separated in order to grow. Those bones also make up the floor of our nose. So if our upper jaw does not grow correctly and spread out well, then our nose does the same exact thing it stays really small. And then we have these tiny little tubes that we're trying to nasally breathe out of and there's a lot more resistance and then things like our turbinates and our adenoids seemingly take up more space because they're in a tighter area. So the really crazy part is that our maxilla, 70% or so of growth is done by age four. So if we have our tongue sitting low when we're little and we're just watching and waiting that tongue tie because it's not causing major issues, then we're missing this huge growth potential for our upper jaw and our upper airway. So this is, in my opinion, one of the biggest benefits of treating tongue ties during infancy, because we get that tongue elevated, we get that mouth closed and we get that jaw and nose growing correctly. Can it be treated later? Absolutely, but then we're already treating the other things that have been impacted. So some kids in my practice they are showing signs of sleep apnea and lots of airway disorders, really young. And if they're narrow already, I mean we are expanding as soon as they have first molar. So 12 to 18 months we're putting an expander in and these kids in three months they are totally different. And yes, we may still have to address a tongue tie and all that.

Speaker 2: 17:03

But you know some of these kids have had releases and you know, in our parenting we are also doing things that are not sometimes helping that process along. So you know, even if I treat an infant's tongue tie, just doing that is not enough to retrain the tongue and make good habits. So things like avoiding pacifier use, because that's going to hold the tongue down and train it to do the wrong thing, doing techniques like baby led weaning when we are introducing solid food is key to proper growth and development of the jaw and muscle function. So we want to skip soft, puree foods. We want to, you know, skip the little pouchy things. We want to make sure that we're promoting nasal breathing by. You can do saline rinses during infancy and all you know. So there's a lot more that has to go in, but identifying the, the underlying dysfunction early is the best thing we can do and doing that during infancy is the best. And easiest.

Speaker 1: 18:13

True, Ashley is asking where do we take our kids to get checked for this?

Speaker 2: 18:20

Yeah, so unfortunately, there it's. This is still not a universally educated specialty in dentistry, in medicine, even in pediatric dentistry. But you know, what I would do is, first of all, you can just Google, like airway dentists in your area, and look on their website anyone talking about mouth breathing, tongue ties, early airway orthodontics. You know, because it's not universally educated, there are also varying degrees of what practitioners are doing, so not all of them are treating tongue ties and doing early expansion and myofunctional therapy, so you may have to put some pieces together, but if you can identify one person, they usually have a network of people that they can refer you to. Other great resources are you know, um, airway circle has a directory. Um, you know, the breathe Institute in California has a directory. Um, uh, the chrysalis, uh, uh, what I blanking on the name, but it's autumn headings. She's a speech language pathologist. She also has a directory.

Speaker 2: 19:31

So a simple Google search will probably be a good start and, honestly, even if you find somebody that is not fully into this, anyone that's even interested wants to help kids. So they will usually tell you. You know, I'm not the person, but I have a person and so it may take a little bit of time to find your network. But again, everyone's super passionate about helping children thrive in this arena and so generally you will get hooked up with someone that can help you out. So I'm sure Renata and myself we're happy to also start that search with you so you can message us and we know people kind of all over the country that is, that are doing this.

Speaker 1: 20:18

A hundred percent.

Speaker 2: 20:19

So just let us know One thing I will sorry not to interrupt, but one thing I will say is if you go to a practitioner that is not specialized in this and ask them to screen for it, you're likely going to get the answer that everything is fine. So don't make that mistake of just trying to go to any pediatric dentist or any you know, because you're going to get misinformation. I'm sorry, renata, I didn't mean to interrupt you.

Speaker 1: 20:43

No, it's fine. One of the best things to do is also contact a myofunctional therapist around you, because they usually already know which dentist to go to, which dentist to avoid. They usually already know which dentist to go to, which dentist to avoid, or orthodontist. We have our own little local network. What I do when I'm seeing my patients I always open up the ARA circle directory and I go ahead and I search who's around them to be able to do the proper referrals On the first appointment. I do all my referrals already.

Speaker 1: 21:12

But if you start with a myofunctional therapist, first they have area knowledge and two they're kind of already going to know. So if you're going to just any ENT or any dentist that's around you, like Dr Gandhi was saying, you might not get a person who is actually trained on this. For infants, of course, if you're having any issues breastfeeding, always look for an IBCLC which is an international board certified lactation consultant. I always recommend two appointments for a baby an IBCLC and a pediatric dentist who is trained in releasing ties in babies, because they are also able to evaluate the tie. Actually, they are the ones that can diagnose if the patient has the baby has a tongue tie or a lip tie.

Speaker 2: 22:01

Yeah, and you know the therapy, like the myofunctional therapy and IBCLC, is a great place to start because we always need to incorporate that in our treatment model and it's those appointments are very informative as well, so they give you a great like base knowledge of what's going on and also can get your child especially if it's myofunctional used to being more aware before going to a dentist or before any other intervention. So I think I agree that's a great place to start.

Speaker 1: 22:32

Perfect, do you recommend? I think I agree that's a great place to start. Perfect, do you recommend, do you? I'm going to leave that one for later. Do you recommend occupational therapy assessment for?

Speaker 2: 22:43

bedwetting.

Speaker 2: 22:43

Yes, I think occupational therapy is is helpful, um more so, not just for the bedwetting, but even like any body treatment OT, pt, chiro we have to incorporate those therapies because the mouth and the airway is not isolated, it's affecting everything from head to toe, and that is from a breathing airway perspective, from a tongue tie perspective.

Speaker 2: 23:13

And so those other therapies can certainly help, and in fact in my practice we require that you do body therapy in conjunction with oral therapy because there's such a connection. But doing that in itself is not going to address the root cause as to why the bedwetting is happening, why we have more body tension, why we're missing gross motor milestones in babies, why we're gassy, why we're colicky, why we're tense, why we have torticollis. All of that is related to breathing and airway dysfunction. So I have many patients that have done OT for years and years and years, and it's not that it hasn't helped at all, but we still have the major problems going on. And that's because we have not addressed what the root cause is, which is airway dysfunction and oral dysfunction and breathing dysfunction.

Speaker 1: 24:09

Yeah, and these things are very complex. So if you go and get a release, you're not going to get all of the results.

Speaker 1: 24:15

If you go and just do myofunctional therapy, you're not going to get all the results. You're going to get some benefit from every single one, but you have to do all of them together. You have to. Of course, not every patient is going to need everything, but it's very important for us to be able to pinpoint exactly what that patient needs and in most cases you're going to have to see different professionals. You know we are very complex individuals. That is another reason why not everybody is going to present exactly the same symptoms. You know even siblings sometimes will have different symptoms. You know one likes to wake up early, the other one. You cannot wake that child up for the life of you and they both, you know, may have issues.

Speaker 2: 24:59

So that's because the body will try to compensate and it's just going to do whatever it needs to to try to make it function best. And every person does that differently. Every body does that differently. Every body does that differently, and so you know the moment for your child. But the longer they do it, the more trouble it's going to be in the future.

Speaker 1: 25:41

Perfect Ahead of time. We always get questions on Instagram, so you guys keep an eye out for our stories. Right before we go live with the beauty of reading podcast, I post a question box and Maya moves Instagram, so you're not following us yet. Please go over there, share this with your mom, friends and anybody who you think that may benefit for some of this information. So I have some questions over here from Instagram that came in earlier. So a mom said I have a one-year-old and they were recommended general anesthesia for tongue tie and lip tie release as she won't be compliant in a chair. Is general anesthesia okay for this age?

Speaker 2: 26:30

So in my opinion it really depends on the child. Sometimes we do have to use we don't use as deep as general anesthesia. We do do like a 15 minute sedation if needed on that age but honestly, most of the kids that are under two years old I do them awake. To the kids that are under two years old I do them awake, and it depends on what tool they're using. I use a carbon dioxide laser. It's called a light scalpel laser. It's extremely gentle and precise. It doesn't even require me giving the child a shot to do the procedure. We just use some topical numbing gel. So as long as the parents okay, you know, we put them in a big kid swaddle or burrito or whatever you want to call it, give them a nice big hug and then the release takes me under a minute. So in my opinion, I don't know that it's necessary to go through the risk of anesthesia for such a quick procedure. And I think a lot of it does depend on the tool the practitioner is using, because if you're using something like a scissor or a scalpel, that is very hard to control in a moving child, something like the CO2 laser that I use the child does not need to be perfectly still. Also, it depends on the skill level.

Speaker 2: 27:52

I'm a pediatric dentist. I never work on a still patient ever, so my tolerance for movement is much higher than, let's say, an ENT or who does most of their work under general anesthesia. They're used to a very still patient, an adult dentist or a general dentist, that a lot of general dentists do infant phrenectomies and kid phrenectomies and that's great. Also, their population is generally more cooperative than if you're a pediatric dentist doing work on children all the time. So I you know some of it is a tool, some of it is a practitioner. The short answer is no, I don't think it's necessary. The short answer is no, I don't think it's necessary.

Speaker 1: 28:33

Perfect. Oh, want to know if you think that having trouble with sleep also can happen if you have trauma. I love this topic.

Speaker 2: 28:48

Yes, yes, absolutely. There's definitely a psychological component to sleep, but I will say those that don't sleep well, sleep is a traumatic process in itself. So, even besides the outside trauma, that's probably the poor sleep is compounding that trauma, because the act of sleeping in itself is traumatizing to your body, because it's trying to literally survive the entire time. Also, you know, when we get to our deeper level of sleep cycle is when our body really starts to let go and process a lot of that trauma. And if we're having poor sleep and constantly being in the level one and one sleep cycle, then we are not allowing our body to process those deep traumas and so we hang on to them a lot longer. So absolutely go hand in hand with each other.

Speaker 2: 29:51

And poor sleep is going to lead to more anxiety. So those those experiences that are traumatizing are compounded by the anxiety that you already have. So even if you're trying to process them awake, it's going to be much more difficult. So it's. I mean, sleep is just the key to everything. Everything I always say, like so many medical specialties would be eliminated if we can just get our sleep right.

Speaker 1: 30:23

Yes, I always say that sleep is more important than nutrition and exercise, and every single time you go to a physician, they're telling you about nutrition and exercise, but nobody asks about your sleep. And if you don't sleep well, you're more likely to eat like crap and you're more likely to not want to go work out because you're exhausted.

Speaker 2: 30:44

So and your body's going to hang on to things that it doesn't detox correctly.

Speaker 1: 30:49

Exactly, there's so much. Somebody has a question about these habit correctors. There's so many of them out there, we don't have to name anybody, but are habit correctors a good option for young kids?

Speaker 2: 31:05

We're talking, like for thumb sucking and those types of things.

Speaker 1: 31:12

Like my embrace, I'll say one.

Speaker 2: 31:14

OK, like those. Okay, so I you know I've had experience as a practitioner with several of these and I think they can work well in terms of retraining tongue positioning and promoting nasal breathing. In my opinion, I don't think they do an adequate job of expansion If we need true bony movement of the maxilla and the mandible. I don't think you get it from something like those types of appliances and I've seen it firsthand with my patients All of them that I tried to do those with I ended up putting in other appliances. In theory, I think they would work well on a really young population that is super pliable, like under four, under three. The problem is you need such good compliance and that population is not going to give us that compliance. It also takes a long time, Even in that population, if you're going to get significant movement 18, 24 months For me, if I make a custom-made expander on those little ones, you're looking at four months, maybe six, and then we're getting better sleep in four to six months, not 18 to 24 months. So I I basically don't use those.

Speaker 2: 32:45

What I do use are things like my own munchies, which are great tools in conjunction with therapy to help with nasal breathing, to help with strengthening the tongue for chewing mouth closure, especially on the little ones, because they are very difficult to teach exercises to. So this is a natural way to have them exercise. The other thing it works really well for is teething if you stick it in the freezer. Other thing it works really well for is teething if you stick it in the freezer, um. And the other thing that I love using it for is pacifier replacement, um. You can actually the baby ones have a little passy clip hole on on them so we tell them just swap it out, just swap it out and have them go to town on that I actually love that idea because they can still hold the pacifier.

Speaker 2: 33:33

Yes.

Speaker 1: 33:33

It's still there.

Speaker 2: 33:35

And some of that is a comfort thing. Yes, I will also touch on I know this was more myobrace related or myo that sort of thing. Yeah, but I will also touch on things like the need for a pacifier or a thumb sucking habit, Because, you know, traditionally in pediatric dentistry we are taught to make an appliance that has little spiky things on it so that they can't suck their thumb. But what we're missing there is the reason kids need those things is because something else is dysregulated in their body. Their nervous system is dysregulated, which is very much driven by breathing and sleep. Their nervous system is dysregulated, which is very much driven by breathing and sleep, but it's also driven by alignment and cranial nerve function, which has to do with what we call fascial tension, and fascial tension can be caused by a tongue tie and poor sleep.

Speaker 2: 34:29

And so by just sticking something in there where they physically can't do that, we're almost torturing a child, in my opinion, Because we're taking away the way that they sued themselves without giving them any sort of tool to replace it with or fixing the reason why, and that's why kids start to go berserk when you just stick an appliance in there. So our recommendation at the practice is doing craniosacral work or chiropractic care to help regulate the nervous system and our body's ability to soothe themselves by regulating the vagus nerve, which does a lot of that. Doing things at home like grounding with your child you just go outside barefoot, you can do ear massage, you can do head presses all these things really help your child regulate their nervous system and then you work with them about getting rid of this habit. You don't just take it away and put something in there and say you can't't do it because they're again. It comes back to these. Children are not choosing to be defiant. They are trying to regulate their bodies.

Speaker 1: 35:42

I love that Somebody's asking what is the easiest way to assess a six-year-old for airway dysfunction. I think we touched a lot on the symptoms already. What does it look like when they come to your office?

Speaker 2: 35:55

Sure. So even if children are presenting to our office for just a routine dental checkup, we are using a screening tool called the Ferris 6, which is six different components that put a child in a risk for developing sleep apnea, and many of them we've touched on. But mouth breathing is a big one. So mouth breathing versus nasal breathing, dental wear, which would be a sign of grinding, so flattening of the teeth, what their tonsils look like, so enlarged tonsils, something called mentalis strain. So yeah, if a kid is kind of like puckering their chin to try to close their mouth, that means they're straining a lot and that is usually kind of a positional discrepancy. And then the other one is a narrow palate. So a way a parent can tell that on a six-year-old is are there spaces between the teeth? If there are no spaces between your child's teeth, that's considered underdeveloped. So we don't need teeth overlapping or crooked, we just need to see if there are spaces or not. So no spaces, intervention is needed. Spaces you're in better shape. So just look at, have your kids smile.

Speaker 1: 37:21

I know all of us parents are so proud. Oh, my goodness, my child has perfect teeth. You know they're touching and it's a perfect smile and it's not.

Speaker 2: 37:29

I always say in two years, like if they're six in two years, that's going to look like a disaster because they're going to get their permanent teeth and it's going to be, you know.

Speaker 1: 37:38

so I always say, like a picket fan A tooth yeah.

Speaker 2: 37:42

That's great. But it's funny because when I do early intervention and I make all the spaces so many parents are like they look crazy. I'm like you will thank me in a few years.

Speaker 1: 37:53

Exactly Should we be lip taping children?

Speaker 2: 38:00

Carefully and with guidance. I don't recommend that parents just buy lip tape and start lip taping their child because we don't know what's going on. I lost an air pump.

Speaker 1: 38:11

Hang on, you're fine, yeah, so lip taping and I never recommend taping the lips shut, don't ever tape the lips shut. We usually start during the day until they get used to it. And then I have a very specific way that I teach parents how to lip tape. Not many people do it like me, but it's a more therapeutic way. It's with kinesiology taping, which is a tape used, you know, by physical therapists to really work on actually muscles. So it's not a physical way that you were just closing the lips because they have to. You're actually contracting the muscle. So that's what we're doing.

Speaker 2: 38:53

Is that similar to the myotape that goes around or a similar concept? Yeah, okay, yeah, that is the one that I recommend. But I always tell them similar to what you say is start during the day. But also, we do a three minute breathing test in the office with just a tongue depressor. We do a three minute breathing test in the office with just a tongue depressor, and if they can't handle that they then they're not a good candidate for attempting anything like that.

Speaker 1: 39:22

And I like to compare this. As you know, growing up my mom was always like, shoulders back or not, I should tap on my shoulder all the time, shoulders back or not. I should do that Because I always had this awful posture, which I I still do, I'm still working on it. That's why I've been going through expansion, tongue tie release, and now I have to do some body work to address everything else, to make sure I can have better posture. But she always, you know, would tap me and say we're not our shoulders back. Of course I don't want to look like I have bad posture, I want to have good posture and sit up straight. Like that I can also breathe better.

Speaker 1: 40:00

But if I and I got a brace when I was about 10 years old, you know, and the brace is just, it's mechanical, it's physically pushing you in the right position. So that's the same thing that just taping somebody's lips shut is doing. It's a mechanical and physical way of you just closing it shut, but it's not addressing the habit, it's not addressing why this patient can't keep their lips closed. So, yes, not lip taping unless you've been evaluated by a pediatric dentist, a myofunctional therapist, sometimes an ENT, to make sure that it's the right thing for that patient. Is there a correlation between consistent talking or yelling in sleep, always about one and a half to two hours after the eight-year-old falls asleep. This morning he not only had the mouth wide open but the head also tilted back. Send me a photo.

Speaker 2: 40:52

Yes, there is. That usually happens in like the second stage of sleep is when that talking and yelling, but it is a sign of sleep disturbance as well.

Speaker 1: 41:06

Yeah, gotta get it checked out. Love the podcast. Thank you very much. What is the path of correction for class two, division two? What is that? First of all, what is a class two division?

Speaker 2: 41:17

Yeah, so class two, division two, is. Class two refers to how the molars first molars line up, top molar in. You know when you're biting down on your bottom first molar yes, thank you, a model would be fantastic. Usually the layman's terms that people say is that's an overbite. It's actually when you have your top jaw much farther in front of your bottom jaw, like Renata is showing. Really that in the dental term is called an overjet. The dental term is called an overjet how far your top jaw is in front of your bottom jaw. When it's division two, the front teeth are actually tipped in and tilted back. Do your teeth move on that thing? No, okay, I was like that would be impressive. And so you know the teeth are almost inclined backwards, if you will not sticking out like this.

Speaker 2: 42:20

So in this case we were traditionally taught that we need to bring the maxilla back to meet the mandible to make that discrepancy less. Actually, what this is is a underdevelopment of the lower jaw. Many times, which is surprising that when I tell patients this, the upper jaw is still also too far back. So we want to move everything still forward, even though there's such a pronounced discrepancy already. So the last thing we want to do is take that maxilla and pull it back, because then we are making the airway even smaller. We need to use sometimes appliances, but a lot of myofunctional therapy and breathing and tongue tie release to bring that mandible forward.

Speaker 2: 43:12

The way the mandible grows forward is by proper swallow pattern and lip closure. So that is what we need to work on. So this is why we can't do orthodontics without therapy and looking at muscles, because it's not just about moving things with appliances. The way we really move things is with function and muscle movement. So in my opinion, the treatment for class two, division two, is not bringing things back or extracting upper teeth and closing spaces. It is bringing the mandible forward, so figuring out why that mandible is receded. The division two part you can put on aligners to align the teeth. I'm not that concerned about the tooth alignment. To me that's just the jaw. Discrepancy is what I'm most concerned about.

Speaker 1: 44:00

Perfect. Thank you. I know that was a little bit off topic, but very, very important for everybody listening in. Next question does removing enlarged tonsils actually help with bedwetting?

Speaker 2: 44:12

It can. Again, this goes back to not one thing is going to fix everything. It so a it depends on how large they are. Okay, also, if we remove and why they're enlarged, why they're enlarged and how large they are, if they are enlarged because we're chronic mouth breather and all we do is remove tonsils and continue to mouth breathe, they will actually come back and we are not addressing the fact that we're still not oxygenating our body correctly because we're continuing to mouth breathe. If they are so large that they are encroaching and we physically just, even if we expand and everything and start to close our mouth, we still are struggling because there's so much resistance.

Speaker 2: 45:02

Same with adenoids. Sometimes we do have to take them out, but if they're borderline, I try other things first. Daily nasal hygiene can help calm things down. Looking at the diet to remove as much inflammatory nutrition that we're putting in our bodies dairy gluten, those types of things. If there is an underdeveloped jaw, can we expand first. So we are going to try those things first, generally, unless they're three plus tonsils, like kissing, you know so enlarged that we just can't get around them, and then we're going to reevaluate because we also know that those tissues are naturally going to shrink as the child gets older. So can we get there, can we? Can we get them there and have them naturally shrink some? Or are we so enlarged that it is actually going to get in the way of our therapies and, um, you know, procedures?

Speaker 1: 46:03

Perfect Um. Ent says no tongue tie, tiny tonsils and no deviated septum. Although my daughter says she cannot keep her tongue to the roof of her mouth, it resists or rests below. Orthodontics says no expander needed.

Speaker 2: 46:20

So I would go to a myofunctional therapist because what they're going to assess is is that tongue not elevated because it's not strong enough? Does it just need some training? Um, is it because there's a tongue tie, is it? You know so, and also I will caution and say the orthodontists, when they are looking at need for expansion, their lens is can fit teeth? Can teeth fit in? Can they fit in? And then can we just straighten them? They are not looking at an airway.

Speaker 2: 46:55

So going to an orthodontist that focuses on airway or a pediatric dentist that focuses on airway, we're going to have a much different lens of what we're looking at. I actually don't really care about straight teeth and I'm not saying I want to make kids look crazy, I'm just saying that is not my primary goal. My primary goal is a large enough jaw to support proper nasal breathing and an airway. So I'm going to be looking at something totally different. Our measurements are different, our screening is different. So, again, this is where, unfortunately, if we land up with the wrong practitioner, we're going to think that we can check the box and now this is not an issue, when really we just haven't had the proper screening. Similarly, there are four types of tongue ties. Some are super obvious to see, some are not. So, depending on what that ENT's assessment was, there may be a tongue tie there that is just not easy to see. You're only going to pick it up on looking at movement and function. So my recommendation at this point would be to go to myofunctional therapist.

Speaker 1: 48:05

Perfect. Is 0.5 grams children's melatonin a bad idea if the breathing is challenged?

Speaker 2: 48:15

I think melatonin can help, but I think it's a bandaid, so I'm not a proponent of long-term anything being used. I think we need to ask ourselves why A child should not need an aid to sleep. If it's a one-off here and there, not a problem, but if it's something that we're having to utilize, that's not a long-term solution.

Speaker 1: 48:39

Very good, we have so many good questions y'all, but we have reached our time. How do I do the tongue depressor test?

Speaker 2: 48:48

Oh, you, just take a tongue depressor or popsicle stick that you know we've eaten the popsicle off of, and you just have the child hold it between their lips for three minutes and what you're looking for is even if they can keep it in. Is there a lot of fidgeting, like are they panicking Because then at least then we know they can do it, but there's some still some resistance. Or are they taking it out and they can't? They can't do it? Then maybe we need to look for some more obstructions or there's more of an issue. It's very simple, but put on a timer for three minutes, because three minutes is a long time.

Speaker 1: 49:24

Perfect, and some of the signs that they fail the test is if you see mentalis strain. Yes, not only if they can hold it, but do you see mentalis strain? Do they get fidgety All of a sudden? They start moving around. Get fidgety all of a sudden, they start moving around. That just you know, do they?

Speaker 2: 49:38

look uncomfortable. Uh, they might do their eyes.

Speaker 1: 49:39

Do their eyes get really big you know I've had somebody hyperventilating 10 seconds before crazy. Let's see. Please discuss cleft lip and palate and what to do if nasal cavity is occluded and ent this, not guess to address until rhinoplasty. In the teenage years there's a typo, does not want to Too late as the facial changes. Can you expand a child with a cleft palate?

Speaker 2: 50:09

You can. Those are very complex cases. Honestly, I don't do it myself.

Speaker 1: 50:16

They need a craniofacial team.

Speaker 2: 50:18

They need a craniofacial team just because everything is so closely connected. Those are not straightforward expansion cases. I wish I had more to comment on or share with that, but it is honestly just not my area of expertise.

Speaker 1: 50:35

Perfect. Would myofunctional therapy prevent the need for an expander from an orthodontist?

Speaker 2: 50:43

It really depends on the situation, it depends how underdeveloped we are. The general rule I will say is no. I don't think that that in itself is going to be sufficient. I agree, the only time and this wouldn't be myofunctional therapy, because myofunctional therapy starts a little bit older, but the only time I sometimes I will see a two-year-old that is slightly narrow and they have a tongue tie and they're mouth breathing and I will say let's address the tongue tie, let's address the mouth breathing and because we're under four, we may be able to self-correct. That's the only. That's the only instance. Other than that, anytime I see a narrow arch and a tongue tie, we are addressing the narrow arch first, with expansion, then we're addressing the myo and the tongue tie.

Speaker 1: 51:38

All right. Last question y'all Is a severe tongue tie in a five-year-old. Could a severe tongue tie in a five-year-old be a cause of behavioral issues?

Speaker 2: 51:54

100%, and the reason I say that is several things is we now have talked quite a bit about how the tongue plays a role in breathing and sleep. Poor sleep in children presents as behavioral issues ADHD, hyperactivity, defiance. Again, these kids are, they're not functioning well, they're not resting well, they're not getting to recharge, and so the tongue tie at this point in that age has probably led to some underdevelopment of other structures that are compounding this issue. But the root cause could have been just that tongue tie from birth. The other thing that happens that I see with kids with tongue ties is they are extremely they are sensory kids. They are, if you think about it, if you have a normal moving tongue, it is stimulating so much of your mouth and your nerves, especially that vagus nerve when you are tied. Nothing has ever really touched those areas as much, and so they are hypersensitive to those areas and it makes them very uncomfortable and it almost feels violating. It becomes sort of a private part area of your body because it is not being stimulated.

Speaker 2: 53:13

These kids also tend to have a more processed diet because they can't handle the chewing and swallowing of more whole foods. So now we are compounding our poor sleep with not the best nutrition, which again, I'm not. I have you know, these parents are really going through it. They're just trying to survive and get their kids to eat things. So there's no judgment there, but these things all compound each other. So I would say, if you're having those behavior issues and there is a tongue tie that you know about or that you suspect, find a practitioner. I'm happy to help. I see children from all over the country, all over the world. I do virtual consults, but if I can help you, find someone locally happy to do that as well.

Speaker 1: 54:03

Okay, so how do again? How do I make an appointment with you? Do I go through your website?

Speaker 2: 54:07

Yeah, so either so westupediatricdentistrycom or tanglewoodpediatricdentistrycom or Tanglewood pediatric dentistrycom, and we are located in Houston, texas. You can give us a call 832-767-2227. You can find us on Instagram. We check our messages daily. You can contact us through there. Um, and you know, happy to help your kiddos in any way that we can.

Speaker 1: 54:36

I will also make sure that all of this information about Dr Pia Gandhi is in our show notes. We have some extra questions which I'm going to go in our Instagram stories right now and I'll answer them. One of them is the difference between Marpie and MSC. This is off topic. I will talk to you guys over there. We do have an ENT over here. Thank you, dr Colleen.

Speaker 1: 54:58

She said there's no contraindication to nasal surgery in younger kids if needed. So maybe a second opinion got to find the right ENT, got to make sure it's a pediatric ENT. What do you think about Toothpillow? We just literally talked about tooth pillow, myobrace and healthy start they are all the same thing. They're habit correctors. They're not expanders. They're great for really young kids if they can breathe through their nose, If they are done with myofunctional therapy. You cannot shove this thing inside a child's mouth. If they can't breathe it is not going to work. And I'm going to say this because I've been seeing way too many children be prescribed these habit correctors. That is not the right prescription. So please go to somebody who doesn't do only these appliances. Go to somebody who has a more general or even more thorough, comprehensive knowledge of airway and does different things. Go to my functional therapist and they are going to guide you. Go to somebody who's not attached to some of these companies.

Speaker 1: 56:11

Yes.

Speaker 1: 56:11

Because, sometimes, if they are that provider, guess what? You're never going to walk into a dental office of somebody who only does alpha appliances and they're going to recommend MRP. It's not going to happen. So make sure that you go to somebody who offers different appliances and they're going to be able to find the right one for your child. What is the expansion device used for lower jaw? Dr Gundy was saying that we're going to make sure the tongue is not tied. We're going to make sure swallowing is correct. That's going to help lower jaw come forward.

Speaker 2: 56:42

Anything else? Yeah, you know. I mean traditionally there are things like Herbst appliances and things like that. I'm not. If you catch it early, you don't have to use those types of things. It's really about muscle function. You always have to be careful when you're using an appliance that attaches the upper and lower jaw together, because you will have some retraction of that upper jaw.

Speaker 1: 57:01

So I see so many kids do the harps appliance and they end up with a much worse gummy smile.

Speaker 2: 57:07

Exactly, exactly. So really, the key is early identification and muscle function and myofunctional therapy and nasal breathing 100 hundred percent.

Speaker 1: 57:16

Well, thank you so much Thanks so much for having me yes Hanging out with me on a Friday at noon. I hope everybody enjoyed, if you like this information. Guys, please help us out, share this. There is a mom out there praying for some information to help their child and you guys can be the bridge to that, so please share this. This is going to come out on Beauty of Breathing podcast next Tuesday, so go over there, follow our show. We're on Spotify, apple podcast, all of the podcast platforms that you can think of, whatever is of your choice. Please share this with your community so we can get airway to more kids. Thank you, everybody. Have a wonderful day.

Speaker 2: 57:58

Thanks guys, have a great one, Renata.