As the Breathe Institute has grown, one of the most amazing benefits has been the incredible people we have the opportunity to collaborate with. We could not be more grateful for all the relationships we have been able to form with so many outstanding providers, and today we want to honor our latest TBI Mini-Resident and Affiliate!
Dr. Ratti Handa, was born into a family of dentists so she is no stranger to oral health. After graduating from Tufts University Dental School in 1998, she earned her Bachelor of Dental Science degree from the ABMS Institute of Dental Sciences and completed her residency at the Safderjung Hospital’s Department of Oral Surgery in India.
As a perpetual learner, Dr. Handa has continued her education with organizations such as the Pankey Institute, The Spear Institute, The Stewart Center, and of course now with us here at TBI.
Her skills as a cosmetic dentist reinforce her passionate work as an airway specialist, which enables her to see patients in a holistic way, with a variety of schools of thought to draw from. To deepen her knowledge further, Ratti recently also graduated as an integrative health coach from the International Integrative Nutrition (IIN) Academy and continues to be an active member of the American Dental Association (ADA), the Massachusetts Dental Society (MDS), and The Indian Dental Association.
We know that our journey with Dr. Handa has only just begun, and we cannot wait to see countless more lives be improved by the work she does, and that we all do together.
TLDR?: Dr. Zaghi lectures for the International Surgical Sleep Society (ISSS) in support of Myofunctional Therapy and Functional Frenuloplasty as a safe and effective treatment methodology for certain sleep and airway issues. Video below.
Dr. Zaghi was recently invited to present and contribute to a debate about the pros and cons of myofunctional therapy and frenuloplasty as part of a series of online lectures developed for the International Surgical Sleep Society (ISSS).
For those who are not aware of the ongoing controversy, a previous blog post by Dr. Eric Kezarian claims that: “There is no proven benefit to oral myofunctional therapy or frenuloplasty for the treatment of obstructive sleep apnea in adults as it is commonly practiced in the United States. If you are an adult and want to use exercises to treat your sleep apnea, go to Brazil for people that are using tested approaches."
These attempts at debunking the results we see everyday (in well over 2000 patients in just our office alone) amounts to what we feel is little more than an expression of a biased point of view (RE: the role of oral myofunctional therapy and frenuloplasty).
What is very disheartening about the standards of care in modern medicine, is the all too common resistance to consider other perspectives. Dr. Kezirian "encourage[s] practitioners to perform research" yet subsequently tries to belittle the 3-year long research project we accomplished alongside an expert team of clinicians and researchers. The author continues by stating that “there have been no objective studies examining effects on OSA since that time.” We would like to ensure our readers that we are in the process of finalizing the data collection from our objective follow-up study, however the limitations of human research during COVID-19 caused us to experience a huge set back. We as an Institute wholeheartedly believe that studying this topic systematically will benefit everyone.
Our 2019 manuscript entitled “Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases.” was the largest most systematic reviewed research to date on this topic. Despite being recognized by the journal of Laryngoscope Investigative Otolaryngology (a peer-reviewed journal), in Dr. Kezirian’s “con” debate, he claims that our research was “nice” but should have been published as a case series, not a level-3 study. His statement implies that the numerous journal reviewers have overlooked or otherwise made an error in their decision making process. We however, as well as the reviewers, believe that the level of evidence for our study is indeed Level 3 because it was a consecutive cohort study of a very large number of patients. Level 4 studies usually correspond to nonconsecutive, hand-selected reports of a few case studies. Our Retrospective cohort study involved 348 of 420 consecutive patients who were treated with lingual frenuloplasty and myofunctional therapy.
We also would like Dr. Kezirian and anyone else who has been keeping up with this debate to know that beyond our frenuloplasty research, we have made great progress towards standardization by helping to bridge channels of communication amongst many different practitioners, offices and organizations worldwide.
These ongoing collaborations include, but are not limited to outstanding groups such as:
And many more...
Dr. Kezirian asked us to show him "something to change [his] mind" and openly challenged the entire field to deliver proof. We feel that as a community, we have been and and continually working on accomplishing this goal. A few examples include:
We would also like to highlight a particularly poignant comment by the late Dr. Christian Guilleminault on Dr. Kezarian’s blog post; “Ignorance of what is existing and published is not a good excuse”.
With that said, we would like to take this opportunity to honor all the research and work that was accomplished before. Despite Dr. Kezirian’s claim that Dr. Guilleminault’s research was mainly aimed at pediatric patients, the truth is that Dr. Guilleminault literally coined the term “sleep apnea” and first started curing the disorder by performing tracheostomies. The reason he took an interest in pediatric patients was purely to intervene early with his focus on disease prevention not disease management, since he had seen so many adult patients over his long career who could have prevented their current health challenges altogether if they were treated appropriately earlier in life. This is especially why our entire team at TBI is so committed to bringing myofunctional therapy to the forefront of healthcare.
We do agree with Dr. Kezirian regarding the informational void when it comes to frenuloplasties and OSA, and that objective scientific evidence is needed. We also agree that we need systematic approaches for defining exercise selection and, more importantly, studies of these protocols (hence the collaborations and programs listed above). It is our hopes that with the knowledge and evidence we are gaining daily in clinical practice and our active collaboration with the International orofacial myofunctional therapy community, we can continue to collect and organize this evidence behind this functional approach to sleep and breathing. In fact, our Lingual Frenuloplasty paper was one of the top three most downloaded articles of the year in Laryngoscope Investigative Otolaryngology.
We also want to take this opportunity to remind our readers that all debates can (and should) include an element of friendship and strong collegiality. Dr. Zaghi has an open line of communication with Dr.Kezirian and has always welcomed his input and suggested research ideas. It is important for us as a community to remember the importance of open-mindedness, and willingness to hear others perspectives, especially those with whom we disagree so as to either strengthen our own convictions, or adjust them to fit new understandings whatever the case may be.
We urge our readers to consider these wise words from Goethe:
“In the sciences, people quickly come to regard as their own personal property that which they have learned and had passed on to them at the universities and academies. If someone else comes along with new ideas that contradict the Credo and in fact even threaten to overturn it, then all passions are raised against this threat and no method is left untried to suppress it. People resist it in every way possible: pretending not to have heard about it; speaking disparagingly of it, as if it were not even worth the effort of looking into the matter. And so a new truth can have a long wait before finally being accepted.”
Society needs orthodontists, oral surgeons, otolaryngologists, MFT’s, and we must leave no stones unturned in our quest. We need to work with our colleagues in disciplines outside of our own and learn all of our options.
We thank the journal reviewers from “Laryngoscope” for supporting our research. They felt that “This is an interesting manuscript and provides good information in an area where there is limited high quality scientific information,” and we hope that if you feel the same way, you will take a quick moment to share your thoughts with us in the comment thread below. Your feedback and support is essential in moving this field forward.
Finally, we leave you with one of Dr. Zaghi’s favorite quotes:
“You're never too young to learn, and never too old to change”.
--Russell M. Nelson
A Commentary by: Heather A. Vukelich, MS, CCC-SLP
It’s important for speech-language pathologists to understand the research, origins, and history behind the practice of oral sensory-motor therapy, so they may;
1) further the research,
2) practice ethically,
3) further the development of assessment and treatment, and
4) use evidence-based literature to support their work.
As a speech-language pathologist for 17 years, I have practiced oral sensory-motor assessment and treatment for 12 of those years. This has been an extremely rewarding career. The question always arises, “Is oral sensory-motor therapy evidence-based?” Therefore, it seemed necessary to evaluate this area and review the findings in order to learn and share an answer to this question with parents, colleagues, etc.
I began with a comprehensive, topical bibliography tracing the journey of oral sensory-motor assessment and treatment literature over the years (Bahr, 2008). This 50-page, peer-reviewed article cites works categorized by specific areas of content. The areas included, but were not limited to: Feeding, Oral Motor Assessment, Oral Motor Treatment, Oral Motor Function, Oral Motor Disorders, etc.
A must-read for all of the speech-language pathologists and researchers interested in this topic is the extensive academic contributions of Diane Bahr, MS, CCC-SLP, CIMI. Here are a few of the most salient contributions that would be an amazing resource to all interested in the historical context of this debate.
Another article written by Pamela Marshalla (2007) was entitled Oral Motor Techniques Are Not New. This article compiled terms used historically to describe oral motor exercises in 84 speech textbooks from 1912 until 2007. Therefore, it seemed the topic of oral sensory-motor treatment had been studied for almost 100 years. Marshalla (2011) also described the evolution of oral sensory-motor therapy from 1928 until 2009 in a blog post.
Here are a few key points in the article by Bahr (2008) worth mentioning to further the study of oral sensory-motor therapy.
Another article written by Pamela Marshalla (2007) was entitled Oral Motor Techniques Are Not New. This article compiled terms used historically to describe oral motor exercises in 84 speech textbooks from 1912 until 2007. Therefore, it seemed the topic of oral sensory-motor treatment had been studied for almost 100 years. Marshalla (2011) also described the evolution of oral sensory-motor therapy from 1928 until 2009 in a blog post.
It’s valuable to mention many early oral sensory-motor references were presentations, papers presented, and seminar handbooks. Here are some of them:
Feeding literature was found in the 1950’s and 1960’s. These included suck, swallow, and breathe, as well as mastication studies. “It is interesting to note that many of the articles were published outside of the field of speech-language pathology. There were numerous articles published in the fields of medicine, dentistry, psychology, nutrition, and occupational therapy.” (Bahr, 2008). Morris and Klein (1987) wrote one of the first literature-based, comprehensive books on feeding called Pre-Feeding Skills: A Comprehensive Resource for Feeding Development.
Marshalla (1995) was one of the first to use the term “oral-motor” relative to speech in her book Oral-Motor Techniques in Articulation and Phonological Therapy. Bahr (2001) wrote the first masked, peer-reviewed textbook reporting on the unique processes of feeding and motor speech (i.e., same muscles used with differing pressures and motor plans). It was titled Oral Motor Assessment and Treatment: Ages and Stages.
While not called “oral sensory-motor assessment and treatment,” the findings of this brief literature review suggest this topic has been studied throughout the past 100+ years using terms such as feeding, swallowing, motor speech, etc. Currently, much literature is evolving in many countries and a number of fields (e.g., orofacial myology, dentistry, and speech-language pathology). Therefore, further action is needed to address oral sensory-motor assessment and treatment in university programs with increasing research opportunities for speech-language pathologists.
About The Author:
Heather Vukelich, MS, CCC-SLP is a LEVEL 4 ACCOMPLISHED TalkTools instructor and owner of Happy Kids Therapy in Danville, California. Heather’s business is located inside the Down Syndrome Connection of the Bay Area where she focuses on Oral Placement, feeding and speech therapy for people of all ages. Heather’s specialty is working with people with Down Syndrome which includes in-depth knowledge and resources regarding: diet, communication programs, sign language, education, orthodontics and facial development, physical and sensory needs as well as behavioral strategies. Heather attended graduate school at Gallaudet University in Washington, DC. Heather has spoken at the National Down Syndrome Congress, as well as for Down syndrome groups across California including DSCBA, SVDSN, TBODS, and Club 21.
Written By: Cynthia Cogswell, MA, CCC-SLP
I see many patients with articulation disorders and associated orofacial myofunctional disorders. While they have knowledge of the field of speech therapy, exposure to myofunctional therapy is limited or nonexistent. This article is meant to serve as an introduction to the cultural and historical context of myofunctional therapy and its evolution as a fundamental aspect of articulation training Orofacial myofunctional disorders have been discussed in the literature for over 100 years.
In the late 1800’s, Edward Angle, D.D.S., also known as the “Father of Modern Orthodontics,” published Malocclusion of the Teeth. He recognized the influence of mouth breathing on the resting posture of the tongue and lips and viewed compromised resting posture as the primary hindrance to orthodontic treatment. In fact, he asserted that negative oral habits must be eliminated for successful orthodontic treatment to occur.
Another early pioneer, Alfred Rogers, D.D.S., became interested in the effect of function on structure and developed exercises to improve muscle function and tone. He believed that the muscles of mastication and expression had a significant impact on developing the bony structure of the face and that successful treatment of malocclusion was dependent upon developing functionality of those muscles.
In the 1950’s , Dr. Walter Straub, a California orthodontist, developed a myofunctional therapy program for patients with ”perverted swallowing,” or tongue thrust. He trained dentists and speech pathologists to become future myofunctional therapists. Two of those speech pathologists, William Zickefoose and Richard Barrett, went on to push the movement even further with their development of therapeutic lessons, training courses, and the eventual formation of The International Association of Orofacial Myology. Zickefoose expanded Straub’s original program and established a training academy for myofunctional therapists. Since that time, mouth breathing, with associated low tongue resting posture and tongue thrust swallowing, have been linked to articulation disorders.
In 1961, Fletcher, Casteel, and Bradley found that subjects with tongue-thrust swallow were much more likely to have sibilant distortions than subjects without tongue thrust patterns. Their findings led them to contend that speech pathologists should consider basic oral muscle patterns when remediating articulation deficits “since the tongue-thrust swallow is intimately related to speech production.” Information from studies such as this led to some controversy regarding the expanding role of speech pathologists. However, it was becoming clear that the swallow pattern had to be considered in its effect on speech. Training desirable resting postures of the jaw, lips and tongue have evolved into fundamental features of articulation therapy. As Char Boshart stated in her book, The Key to Carryover, “The desirable resting posture provides a pivotal epicenter, right in the heart of all the action: speaking, chewing, swallowing.” The elevated tongue eliminates mouth breathing, improves muscle tone and facilitates efficient speech and swallowing.
From my perspective, as a speech pathologist, I have observed faster progress and better carry-over of articulation skills when combining speech and myofunctional therapy techniques. The field of speech pathology has undergone significant change since the 1950’s, when a strong interest in orofacial myofunctional disorders took hold. In recent years, increasing numbers of therapists have pursued additional education in myofunctional disorders, having seen the benefits of myofunctional therapy as it relates to speech disorders. My hope is that this trend will continue.
Bibliography: Bochart, C. (2013) The Key to Carryover – Change Oral Postures to Fortify Speech Production, Speech Dynamics, Inc. Fletcher, S.G., Casteel, R.L., & Bradley, D.P. (1961). Tongue thrust swallow, speech articulation, and age. Journal of Speech and Hearing Disorders. 26. 202-208. Ray, J. (2003). Effects of orofacial myofunctional therapy on speech intelligibility in individuals with persistent articulatory impairments. International Journal of Orofacial Myology. 29, 5-14. Rogers, A.P. (1918). Exercises for the development of the muscles in the face, with a view to increasing their functional activity. Dental Cosmos. 60, 857-876. Stevens Mills, C. (2011). International Association of Orofacial Myology History: Origin-Background-Contributors. International Journal of Orofacial Myology. 37, 5-25.
About The Author: Cynthia Cogswell is a Speech/Language Pathologist and Orofacial Myofunctional Therapist, with a highly respected private practice in Northern California. Cynthia’s extensive background encompasses private schools, public schools, hospitals, rehabilitation units, participation on a cleft palate panel, consulting to local orthodontists, and providing staff development in-services in a school setting. She works with all ages, and has specialized training in a variety of areas, including articulation, oral-motor deficits, orofacial myofunctional disorders, receptive/expressive language skills, phonological awareness, voice disorders, social language needs, and central auditory processing disorders.
Originally Posted at: https://www.goinmeditations.com/post/how-to-get-sleep-during-these-uncertain-covid-times
Are you noticing its more difficult to fall asleep since this time of COVID 19 hit?
Do you have difficulty falling back asleep if you wake up during the night?
Stress, Anxiety & SleeP
As many of you know, stress and poor sleep go hand-in-hand. The research is clear on this bidirectional relationship and Dr Matthew Walker outlines it clearly in his important book Why We Sleep "The two most common triggers of chronic insomnia are psychological: 1) emotional concerns, or worry, and 2) emotional distress, or anxiety."
The two most common triggers of chronic insomnia are psychological:
1) emotional concerns, or worry, and
2) emotional distress, or anxiety.
So it makes sense why more of us are having difficulty getting quality sleep at night. These times are bringing a heightened sense of anxiety, stress and uncertainty, which are contributing to poor sleep.
In addition to the anxiety and stress that is present during these times, there is also a range of things that are coming from this time of COVID 19 that further disrupt sleep.
Getting to Sleep
So what can we do about it?
While sleep issues are multifaceted and often require a thorough assessment through a sleep clinic (I can't recommend The Breathe Institute highly enough for this), here are some things that you can incorporate into your routine this evening that will help counterbalance the added stress from the COVID pandemic.
Create a routine and schedule for sleep and wake.
Also, give yourself a “wind-down” window before bedtime. Just like it takes time too cool down after 30 minutes of vigorous cardio exercise, give yourself a chance to wind down before bed. Lower the lights, turn down the music, don’t look at screens, and put your to-do list away.
...particularly in the afternoon. Caffeine has a half-life of 5-7 hours for most people, meaning that it takes that long for half of the caffeine to work its way through the system. Implement a caffeine curfew for yourself, so you have had your last cup of java by 11am or 12pm, giving yourself a chance to metabolize as much of the caffeine before bedtime as possible. For more on caffeine, watch a video I posted recently on IGTV.
Use guided meditation for sleep...
...to help combat “bedtime thoughts” and allow your body to reach a relaxed state. In times of increased stress and uncertainty, two things that can disrupt sleep happen. One, when you close your eyes at bedtime, suddenly “bedtime thoughts” and worries have a longer list of things to think about.
Second, the body is in a stressed state - the "fight or flight” sympathetic nervous system state, where the primary goal is to keep us safe and alive by being attentive (alert) to our surroundings. To fall asleep, the body ideally is in a relaxed state, and be able to relax its “guard”. Guided meditation for sleep helps by giving your attention something to focus on, other than the worry list, such as the breath or sensation.
Guided meditation for sleep helps by giving your attention something to focus on, other than the worry list, such as the breath or sensation.
Moreover, meditation can help shift the body from the stress state to a calm state, thereby creating the conditions in which your body can ease into sleep.
There are many options for guided meditations for sleep...
Go In - Calm Down & Sleep
Aura & Insight Timer
Spotify and YouTube.
May you sleep well.
Cassandra Carlopio is the founder of Go In Meditations, a mindfulness and sleep expert, collaborative provider at The Breathe Institute, and thousands of people fall asleep to her meditations each night.
She also offers individual and corporate sessions, using mindfulness and meditation to improve performance.
Go In meditations- guided meditation app with a range of meditations for sleep and calm, as well as breathing exercises and more exploratory meditations
Spotify for guided meditations for sleep
Youtube for a range of guided meditations for sleep and calm and presence.
Insight Timer & Aura - meditation and mindfulness apps
Our autonomic nervous system can alert every cell in our bodies in times of stress, however ‘sounding the alarm’ can sometimes result in shortness of breath or anxiety and such symptoms. The autonomic nervous system receives information about the body and its external environment, and then responds by stimulating body processes through its two main divisions: the sympathetic and parasympathetic nerve pathways.
Balance between the sympathetic and parasympathetic states is vital to overall health and well-being. An imbalance or dominance of one state over the other can divert vital resources away from their most efficient and optimal utilizations.
Imbalance or disruption to a healthy lifestyle, diet and even negative thinking can trigger the sympathetic stress response and prime the body for action through an intimate association with the adrenal glands. This known as the sympathoadrenal system. Within the brain, reception of a stress signal leads increased activity of the sympathoadrenal system. This is done through a complex internal signal cascade that releases a number of neurotransmitters.
A neurotransmitter called acetylcholine causes excitation of the nerves that signal to our skeletal muscles, along with the muscles surrounding certain bodily systems such as the cardiovascular system and respiratory system. This is what can cause increases in strength and speed during times of stress, as well as accelerating our heart rate and breathing.
The sympathetic nervous system response is protective on the scale of seconds to minutes to hours, but chronic levels of increased sympathetic stress on the scale of hours to days may actually interfere with the body’s allocation of energy, resources, and immune reserves to sustain an efficient host defense in the long term.
But it does not stop there; stress disrupts deep sleep by heightening our awareness to external stimuli, which in term suppresses the release of growth hormone and immune modulators. Growth hormone is released during deep stage-3 sleep, and it has been shown that any source of sleep disruption can impair the release of growth hormone, which is important not only for growth and healing, but also for immunoregulation and adaptive immunity.
Moreover, chronic stress may predispose one to mouth breathing (an attempt to keep up with increased respiratory demands) and negatively impact the body’s innate nasal immunity defense mechanism against infectious microbes.
The human immune system has two arms: Innate immunity, and adaptive immunity. Innate immunity is the body’s first line of defense and includes mechanisms that activate immediately or within hours of detecting an unwelcome microbe or antigen in the body.
The adaptive immune response is a secondary response, and is more complex. The microbiological invader first must be processed and recognized. Once the enemy has been recognized, the adaptive immune system creates an army of immune cells specifically designed to attack that antigen specifically.
Coronavirus enters the body and infects alveolar epithelial cells of the upper respiratory tract. Once the virus has penetrated the cell it invades the cells’ biology machinery to replicate new viral particles. In that process, the virus constantly evolves to evade the adaptive immune response, until either the virus or the immune system dominates the fight. The viral particles are potent inducers of inflammatory cytokines
The best way to prevent the infection is to limit direct transmission through taking social distancing measures, committing to vigilant and thorough hand-washing, and to avoid touching the mucosal surfaces of the face (eyes, nose, and mouth) as much as possible.
If the virus does somehow find its way into the body, the primary line of defense will be the innate immune response of the sinonasal tract. The innate immunity of the nose is our first line of defense against pathogens, but our immune-system will never get the chance to say “shields up” and fight for us, if those pathogens are invited directly into our lungs through the oral breathing route.
Chronic mouth breathing bypasses the well armed nasal defenses, and as a result our inflammatory and immune pathways must attempt to fight the virus and infection in a much more delicate territory (our lungs). Mouth breathing also drops the temperature in the sinonasal cavity, which further impairs nasal mucociliary function, and can cause the stagnation of mucous, which further impairs nasal breathing and nasal immunity.
So, besides washing our hands what can we do as we temporarily physically distance ourselves from others...
(4) Relax and meditate.
If you are experiencing a challenge with any one of those four goals, get in touch with us at The Breathe Institute so we can help. We have case managers available for remote telemedicine evaluations to review your case and direct you to the proper resources, as well as Zoom online medical evaluations.
Our team of doctors and healthcare professionals is available to provide you with individualized medical advice. We look forward to the deep breath of relief we will all experience when we pass though the other side of this interesting time, but for now: keep calm, wash your hands, and Breathe on!
Your Friends at The Breathe Institute
Dr. Soroush Zaghi, Chad Knutsen, Leyli Norouz-Knutsen
“Tongue up, lips closed, healthy breathing through the nose.”
Dr. Kevin Coppelson (MD, DDS), an Oral and Maxillofacial surgeon, has joined the team at The Breathe Institute to treat a myriad of oral, jaw, and airway related issues. He will also be focusing with TBI on researching ways to improve surgical outcomes by incorporating myofunctional therapy, craniosacral and body work among other multidisciplinary collaborations.
Dr. Coppelson is a fellowship trained Oral & Maxillofacial Surgeon from Los Angeles, California. He pursued his undergraduate studies at the University of California, Los Angeles. He went on to graduate from the University of Southern California with a D.D.S. and received his M.D. from the University of Maryland.
At TBI, Dr. Coppelson will be working closely with ENT/Sleep Surgeon Dr. Soroush Zaghi, and Myofunctional Therapist Sanda Valcu-Pinkerton to advance the standards of care and overall patient experiences in relation to orthognathic jaw surgery and less invasive modalities.
Studies* have found the surgical success and cure rates of Maxillomandibular Advancement (MMA Surgery) were 86.0 ± 30.9% and 43.2 ± 11.7% respectively. Exploring innovative and less invasive ways to reduce this discrepancy is one area of interest for Dr. Coppelson, as well as potentially reducing the extent of advancement required to achieve optimal results through collaboration with providers from other disciplines such as Myofunctional Therapy and Body Work.
“There are many modalities being used worldwide to address sleep disordered breathing, apnea, and other airway conditions. Although the success rates of some of these procedures is high across the field, the actual cure rate is shockingly low so and I could not be more excited to now be a part of such an amazing team at TBI to improve the outcomes and innovate new, safe and effective solutions for our patients." said Dr. Kevin Coppelson.
We look forward to many years working with Dr. Coppeson to continue to make The Breathe Institute the place Where Goodness Meets Wellness!
Learn more about Dr. Coppelson at:
* Giarda M, Brucoli M, Arcuri F, Benech R, Braghiroli A, Benech A. Efficacy and safety of maxillomandibular advancement in treatment of obstructive sleep apnoea syndrome. Acta Otorhinolaryngol Ital. 2013;33(1):43–46.
Written By: Kathy Soto
One of the first things most of us notice about a person is their smile. Smiling has been linked to an improved mood for only the person smiling, but others around them as well. Still many people may feel shy or embarrassed when smiling, which could be due to having crooked or misaligned teeth. Many patients end up seeking the help of an orthodontist (a dental professional who specializes in early detection and correction of malpositioned teeth and jaws). If done right, orthodontics can improve a person's quality of life, bolster self esteem and just feel better in general by smiling more often. Straight teeth are also easier to keep clean, which helps them look their best, and you feel your best. The effects of misaligned teeth reach far beyond the mouth however, and can even contribute to malformations of the jaw and mandibular arch, resulting in airway and sleep issues for example. On the other hand, improperly applied, orthodontics can lead to similar restrictions as well, by limiting the body’s natural growth or driving the development of poor oral habits. A patient may go on to suffer from airway issues for years without knowing that the suffering was caused by the orthodontic work they had years ago, with symptoms not rearing their heads for many years in some cases. Let’s examine the benefits of a straighter smile, the causes of malalignment and possible consequences of extracting teeth to make room for that beautiful straight smile.
“So, why did you decide to get braces at the age of 28?” I casually asked one of my new dental hygiene patients during an initial dental cleaning visit. At this point in my career I had been a dental hygienist for 10 years and I could see that he had a significant amount of gumline recession (likely due to orthodontic extractions of the first bi cuspids). He simply stated that he “wanted to do something nice for himself”, to improve his health and have a better smile. Jacob had been a mouth breather for as long as he could remember. He had suffered from allergies since he was a young child, which made it difficult to breathe through his nose which was always stuffy (even with the use of over the counter medications). His mouth breathing was not addressed as a child, leaving Jacob with a high narrow arch, lips that could not close fully at rest, and crowding of his anterior teeth. Living in Los Angeles, Jacob wanted to have that straight smile that he saw many people have and he decided to explore braces. He wanted to look better and perhaps more importantly, feel more attractive.
In Jacob’s case, like many who grow up with allergies or chronically stuffy noses, he always found it difficult to breathe through his nose and as a child, developed the compensatory habit of mouth breathing. His allergies were not addressed, leaving Jacob’s upper arch to develop in a high, narrow V shape, rather than a healthy U shaped arch (more like that of a horseshoe).
When the tongue rests at the palate or top of mouth it acts as a natural retainer for the maxilla development, and the body develops with straighter teeth as a result. Jacob, due to having his mouth open for breathing, developed with his tongue resting low on the floor of the mouth. Imagine pulling the scaffolding out from under a dome while it’s still being built. This certainly did not help much in the development of a healthy airway or upper arch. This also led to dental crowding, for which he sought out 3 orthodontic opinions as an adult. Two of the orthodontists suggested 4 first bicuspids be removed prior to orthodontics to make room for the other teeth to straighten due to the narrow maxillary upper arch. One orthodontist who was primarily trained outside of the US suggested Mandibular advancement jaw surgery - he was addressing the functional airway issue and was concerned about the actual physical airway space, suggesting he could widen the maxilla with orthodontics, but that Jacob would need jaw surgery. The thought of that surgery seemed extreme to him at the time so he decided to simply remove 4 teeth to avoid surgery and get straight teeth. Although he expressed to me that in the back of his own mind it didn't make sense to him to remove 4 perfectly healthy teeth to straighten his smile, but he ignored his gut feeling, and that seemed to be the standard practice so he decided to trust the US trained orthodontist and go that route.
Ultimately, Jacob had his 4 healthy bicuspids extracted, and additional 4 healthy wisdom teeth extracted at the request of his orthodontist who had apparently explained that he couldn’t keep those teeth clean, and down the line they would need to come out anyways. During the treatment, things seemed to be going good. He could see that his teeth were becoming straight, just like he’d always wanted.
Fast forward 18 months or so into his orthodontic treatment, and around the time elastics were being used to close the bite, Jacob started having trouble sleeping. He would wake up gasping for air. He had no idea that one had anything to do with the other. Due to his mouth breathing habit he was unconsciously gasping for air during the night, but the elastics were preventing him from opening his mouth enough to get a breath, which was of course reducing the air he was intaking. Shortly after orthodontics being removed, Jacob started developing symptoms of obstructive sleep apnea.
Unknown to him, when the dentist, at the request of the orthodontist, took out those healthy 8 teeth they inadvertently made his airway smaller. The tongue remained the same size, and using ortho elastics to push the lower jaw back further impinged on his airway. When I met Jacob he mentioned talking to many doctors and medical specialists explaining his symptoms of increased tiredness, unusual dependency on coffee and sugary substances, and weight gain even though he was an avid gym goer (2 hrs daily average 6 days a week). Thinking back on my training in orofacial myofunctional therapy, I suggested that he be evaluated by a specialist in the area of sleep medicine and airway health.
He had a consultation with Dr. Soroush Zaghi at the Breathe Institute, who was sympathetic and understood what was going on with his health condition. He suggested a sleep study which revealed moderate to severe obstructive sleep apnea. This condition can lead to high blood pressure, sleep deprivation, heart attacks and stroke among others. This diagnosis made sense to Jacob because he was already diagnosed with high blood pressure and had woken up many evenings choking on his tongue with rapid heat rate. He was then referred to Dr. William Hang, a functional orthodontist based out of Agoura Hills, CA. A cone beam CT scan was used to evaluate his airway and the decision was made that Jacob indeed had his lower jaw pushed into his airway and there was no room for his tongue to rest properly in mouth due to lack of space. With a new plan of action, crafted for him by a multidisciplinary team, Jacob underwent a year of ortho in preparation to see Dr. Reza Movahed for MMA surgery (a procedure in which both jaws are moved forward to create a more open airway), used a CPAP machine and underwent myofunctional therapy training to teach him benefits of nasal breathing, toning the tongue and keeping it up resting at the palate.
Jacob has since had his MMA surgery and is already experiencing the benefits of a wider maxilla and larger airway. His nostrils are a normal shape whereas before they were very narrow due to not being used for many years. He no longer suffers from sleep apnea, and states that his tongue naturally rests at the upper palate and now he breathes through his nose. He also reports that he now dreams again, and is not dependent on coffee or sugary sweets to keep his energy levels up. He, like many others wishes he knew about this sooner in life, because if he had simply learned to breathe through his nose and keep the tongue up to the palate as a child, he could have developed optimally and probably avoided years of health struggles that he experienced as an adult.
I am grateful that there are indeed many dental and health professionals acting as detectives, asking the right questions to optimize their patients paths to better health. Even something as simple as asking “why” when deciding on ortho as an adult, opened a conversation on this patient as a whole.
A minor surgical intervention can be a life changing experience. “There’s nothing I can say enough, do enough, or give back enough that explains my gratitude to her,” was Dalan Motz’ heartfelt response to Dr. Amy Luedemann-Lazar. The experience a father and mother shared when their son, Mason, who was finally able to speak clearly and articulate his words without difficulty for the first time in his life, after a tongue-tie release surgery, should serve as a testament to that fact.
Mason Motz is a 6 year old boy who until recently lacked the ability to fully enunciate words despite years of speech therapy. The Motz family emphasized that the combination of Mason’s sleep disordered breathing and inability to chew and swallow food without choking was the source of numerous behavioral problems in his life. Mason was diagnosed with Sotos syndrome, a genetic disorder identified by a long, narrow face, overgrowth in childhood, and learning disabilities. Seeking remediation from numerous clinicians, including pediatricians, geneticists, neurologists, and speech pathologists, proved personally frustrating and ineffective in alleviating these symptoms.
Enter Dr. Amy Luedemann-Lazar, a dentist specializing in tongue-tie release who recognizes the virtues of holistic treatment and interdisciplinary treatment modalities. While performing routine dental work, she observed Mason’s tongue-tie. After consulting with his parents, she performed a simple, non-invasive surgical release that permanently changed the course of the entire Motz family. The results were astonishing! Upon returning home, Mason began to speak in full sentences. He is presently not afflicted by obstructive sleep apnea and snoring. Chewing and swallowing food no longer present a daily choking hazard for him. In short, his quality of life has drastically improved.
Points worth considering…
Detecting the presence of tongue-tie should be a priority for our child(ren)! Dr. Luedemann-Lazar advocates, as do I and virtually all the myofunctional therapists I know, for mandatory tongue-tie screening as part of a comprehensive health treatment assessment.
Tongue-tie, medically termed ankyloglossia, which is defined as a short or thickened frenulum restricting the tongue’s range of motion has multiple sequela which even experienced medical professionals may dismiss or overlook. Tongue-tie affects the natural resting posture of the tongue inside the mouth, inhibiting one’s ability to speak, eat, practice nasal breathing, and/or sleep soundly. An aberrant oral resting position can develop multiple pathologies, anatomical, physiological, and behavioral: including malocclusion, mouthbreathing, and altered facial development (such as “long face syndrome”).
Collaborative interdisciplinary treatment modalities are beneficial in diagnosis, assessment, and remediation. Mason’s case teaches us that the more clinical professionals we incorporate in our treatment plans, the higher the odds of achieving optimal health. Mason’s team included pediatricians, geneticists, neurologists, speech therapists, and a caring, attentive dentist who was able to properly diagnose and release his tongue-tie.
Successfully treating orofacial myofunctional disorders (OMDs) through the combination of surgery and myofunctional therapy greatly enhances the patient’s quality of life. Clinical research has demonstrated the effectiveness of myofunctional therapy, both alone and as an adjunct treatment modality to surgical intervention. Repatterning dysfunctional orofacial behaviors (ie. tongue thrust, mouth breathing, etc.) and eliminating harmful habits (ie. finger sucking, nail biting, etc.) are examples of integral behavior modification techniques applied by myofunctional therapists.
In this month’s professional profile, I would like to bring attention to an individual who embodies these traits. Kristie Gatto is not only a successful SLP (speech language pathologist), but she is also a lifelong student, a business owner, and an accomplished author. Ms. Gatto’s career delineates a deliberate and methodical approach to improving oneself. To better understand the nature of the pathological elements that the orofacial myologist must address, Ms. Gatto devoted thousands of hours to reading research materials which identified exactly how dysfunction develops throughout the orofacial region from a physiological and anatomical perspective. She is driven to know, explain, and illustrate the relationships that disparate units of the orofacial complex can have when they are underdeveloped and/or when deleterious behavior negatively impacts anatomical function
The pursuit of continuous education and professional excellence are important pillars, but the foundational stone of orofacial myology is the desire to be prolific in addressing clinical issues that patients bring one’s way. Ultimately, the orofacial myologist’s purpose is to incapacitate the patient’s pain and discomfort by teaching them how to overcome potentially debilitating behaviors/habits which frequently inhibit the execution of vital functions! Maladaptive orofacial behaviors (including non-nutritive sucking, mouth breathing, tongue thrusting, etc.) can significantly alter the musculature, structure, and function of the orofacial complex. A myofunctional therapist must be aware of exactly how to address a patient’s unique condition as there is no universal treatment solution.
With an ever growing spotlight on orofacial myofunctional disorders (OMDs) and their impact on overall well being, the orofacial myologist must be committed to continuous education. Research demonstrates that focusing on an isolated behavior, such as tongue thrust, is not nearly as effective a treatment plan as addressing the multiple interrelated factors which arise from and/or precipitate the behavior. Additionally, there are concepts, such as compensation, dissociation, impact of motor reflexes, and congenital neurological conditions that have slowly, but steadily received increasing attention from research in an attempt to illustrate a comprehensive view of the cause and effects behind (OMDs). A successful myofunctional therapist is aware of these advances. Awareness is not circumscribed to the orofacial myologist by any means!
In this day and age, parents are increasingly coming into offices with questions, having done some preliminary investigative work. Iit is incumbent upon the myofunctional therapist to stride over some of the comfortable boundaries he/she may have in respect to being researchers and lifelong students. One of Ms. Gatto’s contributions to the field of orofacial myology is The Orofacial Complex The Evolution of dysfunction. This insightful tool effectively illustrates the various muscles, structures, and co-relational functions of the orofacial complex. With over 170 pages, The Orofacial Complex outlines everything from terminology to the interconnections between the facial/cranial nerves and the specific muscles of each orofacial structure. Detailed pictures of muscles and bones add color and stunning visual cues, in addition to functional significance assessments, and real life implications of abnormalities. This manual is comprehensive in tying together the phenomenon of various organs/muscles and how dysfunction within each potentially leads to OMDs.
After obtaining her certification in Orofacial Myology, administered through the IAOM (International Association of Orofacial Myology), Ms. Gatto dedicated her professional life to improving people’s quality of life. She has been a strong promoter of interdisciplinary relationships ranging between hospital based teams, oral and maxillofacial surgeons, neurologists, otolaryngologists, orthodontists, pediatric dentists, pediatricians, and myofunctional therapists . Orofacial myology encourages a collaborative atmosphere of professionals as a means of addressing not only the noxious habits people have come to practice, but also the anatomical etiologies behind those behaviors. Often times, the habits are merely an individual’s attempt to achieve an acceptable degree of function. Compensation is the result of an individual’s desire to achieve function to the very best of their ability!
The logic behind having a team approach is to ensure that each aspect of pathology is appropriately addressed. Myofunctional therapists for habituation and behavior modification, surgeons for surgical interventions, psychologists for the process of transition and healing, nutritionists for implementation of a balanced and healthy diet, and pharmacists to ameliorate any pain or discomfort after a surgical intervention. The more facets that are covered by the team, the more successful the outcome. The orofacial myologist’s goal is to assist the patients transition into a healed, healthy, and vibrant human being. This is the benchmark of care and what each service provider must strive for.