SEASON 11 EPISODE 10

[INTRODUCTION]

[0:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by SpeechTherapyPD.com. The SLP Learning Series explores various topics of Speech-Language Pathology. Each season dives deeper into a topic with a different host and guests, who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on SpeechTherapypPD.com and is available for 0.1 ASHA CEUs. Now come along with us as we look closer into the many topics of Speech-Language Pathology.

[EPISODE]

[0:01:04] MM: Hello. Welcome to another episode of Making Sense of Myo. My name is Madi Metcalf and I'll be your speechtherapypd.com host this evening. Before we get started, we have a few items to alert you to. This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. Dr. Piya Gandhi is our guest speaker this evening. She'll be presenting on tethered oral tissues and her function first model for assessment.

Dr. Gandhi does not have any relevant non-financial disclosures. Her financial disclosures include that she'll get an honorarium from SpeechTherapyPD for presenting tonight. For myself, I receive an honorarium from speechtherapypd.com for hosting this podcast and I do not have any non-financial relationships.

We will be taking questions during the podcast this evening. I'll be watching those and asking them as they are relevant to what we were talking about, so you can put those in the chat, or the Q&A box. If I don't get your question in the pod, or during the conversation, we'll have a Q&A at the end where I'll circle back to those.

This evening, we have Dr. Piya Gandhi. She is a board-certified pediatric dentist specializing in functional pediatric dentistry. Her practice screams all patients for airway, sleep, speech, feeding, growth, and development disorders. Dr. Gandhi has done extensive training beyond her residency in airway development and the diagnosis and treatment of tethered oral tissues.

She screams all her patients for airway disorders and oral restrictions which could impact growth, development, and healthy sleep. She believes in a comprehensive team approach by using the function first model. She has worked to develop a network of practitioners in the greater Houston area, as well as in her practices. Her in-house team currently consists of a speech-language pathologist, myofunctional therapist, pediatric chiropractor, and international board-certified lactation consultant. This allows the office to provide both convenient and comprehensive care. Now, without further ado, I welcome Dr. Piya Gandhi to this episode of Making Sense of Mayo. Hello.

[0:02:56] PG: Hi. Thank you so much for having me this evening. I'm so excited to be here.

[0:03:00] MM: Yes, I'm so excited to have you on. This is a really interesting topic to me and I'm so excited to learn more. Can you tell us a little bit about what got you so interested in tethered oral tissues?

[0:03:12] PG: Yeah, absolutely. I started my practice almost seven years ago and really had no idea that it would take the journey that it's been on, which has really been driven by my need as a mother to find some answers for my older daughter, Cyrah. She's almost 11 years old. When I had her, I was a first-time mom and had a lot of goals in terms of breastfeeding and what our newborn journey was going to look like.

Similar to many patients that walk into my office, that plan went sideways very quickly and we really didn't have many answers as to why our feeding journey was not going the way we wanted it to. Ultimately, I couldn't find the answers at the time. 11 years ago, this topic was even quieter than it is today. Basically, I just plugged along, like many of our patients are told and it really caught up with us again when she was about four years old.

She ended up having a lot of signs of sleep-disordered breathing, snoring, mouth breathing, behavioral changes and a lot of it went back to the fact that she had oral restrictions that were undiagnosed and untreated as an infant. Luckily for me, I am in the dental field and I was in pediatric residency and knew some things about what sleep should look like in a child. It was really that I was sitting in a course with Dr. Zoghi in 2017, and he was talking about children with sleep-disordered breathing and tethered oral tissues, and he literally described everything about her.

[0:04:42] MM: Wow.

[0:04:44] PG: Honestly, I started crying in the course, because I was just like, ÒWow, this is my child. This is the missing piece.Ó I came back home. At the time, I was already treating some infants for TOTs, but nearly not the way I do it today. I wasn't really treating many older children or adults. She was one of my first, but I didn't know what I know about functional approach and collaboration at that time.

My first release on her was when she was four and a half, and we did no pre-work and no post-work and just did a laser release. Again, it helped a little bit, but really not what we wanted to see. Then I did more education myself with speech-language pathologists and chiros. I treated her again at seven and a half, but after doing expansion and myo and chiro, and she's now just the most beautiful, thriving child. Really, wouldn't be without the collaboration that we had and the fact that I went down this rabbit hole looking for answers as a mother.

She continues to drive my practice and really, my love and my passion for this. It took me seven and a half years to have my own child really come into her own. My mission is that parents shouldn't have to wait that long to really get to know their child. That's why we're big on education. As a mom, it's been really rewarding.

[0:06:09] MM: Oh, my gosh. I have goosebumps. That is so beautiful. I can tell, you're so passionate about that and it's so close to your heart, which, I think, makes up for a really passionate provider. What I think I heard was airway concern was really what drove you into this tethered oral tissues realm. Seeing that relationship firsthand in your daughter.

[0:06:32] PG: Yes, absolutely.

[0:06:34] MM: Well, let's jump into it. Can you tell us, what are tethered oral tissues?

[0:06:41] PG: Absolutely. Tethered oral tissues, probably the most commonly known one is a tongue tie, or a lip tie, but there can be cheek ties, or buccal ties as well. Tethered oral tissues come in all shapes and sizes. They don't always look the same. When we're defining tethered oral tissues, we really recommend looking at it from a functional approach. Everyone has a frenulum, or the attachment underneath your tongue to the floor of your mouth, or your upper lip to your maxillary bone, but that doesn't define them as a tie. Everyone needs to have a frenulum to attach these things together.

What defines them as tethered oral tissue is something causing limited range of motion and a functional deficit. This is why when we talk about diagnosis, we really have to look beyond what it looks like anatomically, and we have to do some functional screening. Movement assessment, measurements, working with a functional provider that is going to assess where the deficits may lie is really how you tethe out whether something is a frenulum or a tie. That's what we really stress when we're in our practice, but also, when I'm educating that we have to look beyond just the anatomy.

[0:07:56] MM: Yes, I love that. That has been brought up across this podcast series that we can't just look at a structure and say, ÒOh, that's a tie. That's a tie.Ó It's really this marriage of what is the function and what is the structure and how is that impacting the patient. I'm super excited to hear more about that. We did have a question. What is a buccal tie? Thank you, Renee, for it is B-U-C-C-A-L for buccal.

[0:08:21] PG: Yeah. A buccal tie is in the cheek area. It can be in the upper or lower, so maxillary, or mandibular. It's usually, I'm going to now demonstrate, located along the back molars and attaches to the cheek area. Now, sometimes when they're very restricting, they can, from a dental perspective, cause gum recession and problems with oral hygiene. What we've seen is from a body, like facial perspective is that it can really cause a lot of tension in the occipital and sternocleidomastoid muscles.

On babies in particular that have torticollis, some of them may have some restricted buccal areas. By releasing them, we can really help with some of that range of motion in the neck. This is where collaboration comes in because I learned this from my chiros and my PTs. This is not something I learned in dental education about the facial tension. It's really cool to learn from these other providers how all these things are related.

[0:09:26] MM: I love that. That's another thing that's been a common theme is that myofunctional therapy is so interdisciplinary. There are so many pieces. But it makes sense because our bodies are all connected. We can't look at our one little area in isolation because it's going to be impacted, or impacting something else.

[0:09:44] PG: 100%.

[0:09:45] MM: Since we're on buccal ties right now, what are some of the functional impacts that can be seen from buccal? Well, I guess we've touched on it for the oral hygiene and range of motion and then the body tension. Are there any other functional impacts from buccal ties?

[0:09:59] PG: Not that I'm aware of. Also, this is the area where we have the least research in. A lot of it is just anecdotal, where we share cases amongst providers and see what the outcomes are like. Some lactation providers have said that it also impacts the seal of the latch for infants, so that we're not leaking out milk, or taking in too much air, so quality of latch. Really, what I've seen more consistently is more related to facial tension.

[0:10:32] MM: I have a question from something I've seen in my own practice. Have you ever seen where they have two, or three ties? Is that just a normal variation, or a variation of normal?

[0:10:42] PG: Yes. When we're procedurally releasing, personally what I do is I release some of it and then I go back and I feel the tension in there, because it can get tricky where you can just go a little too far. Again, when we're talking about releasing, you want to approach the release from a functional standpoint as well. Feeling and seeing the tension, not just getting rid of every piece of tissue that's in there.

[0:11:11] MM: What are some of the functional impacts that can be seen from ankyloglossia or a tongue tie?

[0:11:16] PG: Yeah. Starting at birth, that's the first sign that we see that a tongue is not functioning correctly. Most common things from a mother standpoint, pain while feeding, mastitis from incomplete breast drainage, blistering, or lipstick-shaped nipples. From a baby standpoint, clicking noises from that incomplete suck-swallow pattern, dissatisfied after a feeding. Jaw quivering is a big thing because we're overusing the wrong muscles in our mouth, and then just fussiness while feeding. A lot of those feeding issues. That can be, honestly, on breast or bottle. Sometimes babies do great on a breast and then they can't bottle feed, and there's some compensatory thing that's covering up their symptoms.

Then on the toddler standpoint, what we see most commonly is speech delay and difficulty with textured solid foods. Particularly, when we ask about feeding, we want to ask specific questions. I particularly ask about meat eating, because that's a very common red flag, but you have to say like, can your child eat meat that's not in a hotdog, nugget, shredded ground form because as a society, we've done a really good job of pre-chewing our food and then giving it to our kids. We see a lot of difficulty with the chewing and swallowing in that toddler, young childhood phase.

Then as we move on, really seeing issues with articulation, and depending on where the tie is, it may be harder consonants, or K's and G's if it's a posterior restriction. Then on all ages, airway dysfunction. Even on the infants, you'll see them come in with their mouth open already. That's early signs of airway disorder, breathing disorder, mouth breathing, but then it can really contribute to an underdeveloped upper jaw very quickly, because the tongue is supposed to elevate and push on your maxillary bones, specifically between zero to four years old.

We see a lot of these signs of sleep disorder, breathing, and sleep apnea pop up really early, grinding, mouth breathing, movement around the bed, snoring. Children should be silent-still sleepers. Then on our adult population, just an exacerbation of what started. Chronic TM joint pain from the overuse of the wrong muscles. Some of our adults are picky eaters still and have speech disorders. Then chronic neck tension and back pain. Most of my adult patients are sleep apnea patients. It's just a 40-year compounding, or 50-year compounding of what started during infancy.

[0:13:57] MM: Can you share a little bit more about how a tongue tie can impact airway?

[0:14:02] PG: Sure. Our tongue is the integral muscle in our mouth that dictates the growth and development of both our maxilla and our mandible. Our swallow pattern is what brings our mandible forward and dictates its forward growth, rather than it growing downward. Every time we swallow, our mandible has the ability to move forward and get out of our airway. From the maxilla standpoint, this is where early treatment is very beneficial because the maxilla growth peaks at age four and then stops growing by age eight.

If we have a tongue that is not elevating and pushing up on the two palatal bones, then we don't have that pressure to spread out our bones. What happens is with the lack of pressure, our maxillary bone becomes D-shaped, or narrowed, and very high. Well, that maxillary, the bone is also the floor of our nose. Then our nasal passages get narrowed and then we have more resistance for nasal breathing and then we open our mouth to get more air. The problem is is mouth breathing oxygenates our body less, especially when we're sleeping, it leads to a lesser quality of sleep. Then we're not falling into a deep, restful sleep. Then we just have a cascading effect on all of our things; hormone release, nervous system regulation. For our kiddos, we end up seeing them starting bouncing off the walls because they have these ADHD-type symptoms because they're just on overdrive.

That's something in our office, we screen for very early is what does the palatal development look like? We're talking a lot about not using pacifiers and using things like myo munchies and baby lead weaning because chewing is how we exercise our tongue and spread our jaw out. All these things have to happen so early because we know that gross pattern of the maxilla dies down so early in life. It's really important that we catch these things early.

[0:16:01] MM: Thank you for sharing that. Then the last tethered tissue that we're discussing tonight, what are some of the functional impacts that can be seen from lip ties?

[0:16:10] PG: Yeah. Lip ties, again, much more obvious to see. A lot of times, people will come in with a lip tie concern, but they're having issues that are more related to tongue tie. But we always look at all the areas. Lip ties from a dental perspective, when they're wrapping in between the maxillary teeth, or on an infant causing notching of the maxillary bone, that can impact some of the growth and development of that maxillary bone because it's putting tension on the bone while it's growing.

We do see, so there's classification gradings, one through four. One being normal, four being the ones that wrap around to the incisive papilla. We do see that some of the twos and threes that are not wrapping around will migrate and self-correct, but Ð

[0:16:56] MM: Which rating system do you use?

[0:16:58] PG: Yeah, it's a great question. It's the Kotlow classification.

[0:17:01] MM: Okay.

[0:17:03] PG: Yeah. If they are wrapping around, then they tend to cause spacing between the upper front teeth, which can be again, more of a hygiene dental issue. Then they can cause some growth impacts on the upper jawbone. Sometimes if they're really tight, they can impact bilabial sounds, and some eating patterns, like when you're trying to take a bite of an apple and need to flare that upper lip out.

From an infant perspective, it can impact the seal while feeding. We don't have a great duck lip look on the upper lip. Then those babies tend to take in more air while feeding and can also mimic reflux-y type symptoms, so it will impact the quality of the latch. In the long run, in my opinion, tongue ties are the most impactful and the ones that should be paid closest attention to. These other things can definitely contribute, like buccal ties and lip ties, but not nearly as much as a tongue tie.

[0:18:01] MM: I definitely feel like I've seen that in my practice with tongue ties being the most functionally seen. Sometimes those upper lip ties definitely have a difficult time with getting a closed mouth posture, with saying their P, Bs, and Ms, and spoon feeding. They want that upper lip to come down and clear the spoon instead of biting it. That can get in the way sometimes.

[0:18:25] PG: Absolutely.

[0:18:26] MM: Let's get into assessment and diagnosis. How do you diagnose a tongue tie, Dr. Gandhi?

[0:18:33] PG: Yeah. When I first started, as I had mentioned with my older daughter, Cyrah, is my thinking was like, ÒOh, you see a tie, you just laser it and it's good. Everyone's functioning well.Ó We know that that's really not true at all. We really have to look from a functional perspective and we have to incorporate a lot of other providers to make functional success. This is where the function first model came in. What it is, it's really a four-part model.

All of my consultations start with, how did you get here? Tell me your story. That's where we're getting the family involved. I apologize, I didn't send you an image of the function first model, but it is on my website. It is basically four little bubbles. The first bubble is a family bubble. That is where we get our family story. The reason why that's so important is there's a lot of different education out there on tongue ties. You want to know what your families are coming in with, so that you know how you need to educate them. Also, from a family support aspect, do we have a family that's all on board with ties? Do we have differing opinions? It really tells you how you're going to approach these patients, which is really important.

The second aspect of the function first model is a primary care provider. Many practitioners that are in this field shy away from primary care providers, because at least for me, most of the time, that's a pediatrician. We are still not all on the same page about tethered oral tissues. My approach is not running away from these people. It is slowly educating them, so that they can start to understand what we're doing. Because if there are any parents on this podcast tonight, you all know that when you chose your pediatrician, you chose them very carefully. Most parents are going to go back to their pediatrician and verify, or ask like, ÒHey, my dentist or my speech-language pathologist recommended this. What do you think?Ó

We can't ignore them because they're not going away. We have to acknowledge them and also, realize where they're coming from. At least in Houston, many of our pediatricians have seen bad tongue tie releases. A quick snip, or a quick clip, that doesn't work. In their opinion, tongue tie releases don't work, but they've just seen the wrong tongue tie releases. We need to step in and re-educate them. That's my stance on it. I also tell parents, ÒHey, if you go talk to your pediatrician, they may tell you the exact opposite thing. This is why.Ó I think it's really important that we incorporate them.

The third part of the model is our functional providers. Obviously, the most important, it's called the function first model. These providers for infants fall in two categories, which are mainly a body worker and an oral-motor provider. A bodyworker can be a combination of, or one of chiro, PT, or osteopath, sometimes craniosacral therapist, things like that.

Oral-motor therapy usually falls in the lactation or SLP realm. Whether they're bottle, or breastfed dictate some of that. All of my patients see a provider in each category, pre and post-procedure, for several reasons. One is we need to see if this tie really needs a procedural release. Sometimes it's so obvious that yes, we know it's going in that direction. But also, to prep them for the procedure. As you mentioned, we can't just isolate one part of the body. It's all connected. We need the entire body to be ready for the procedure and all the kinks worked out.

Then, we also need the mouth ready and the tongue attempting to do as much as possible pre-procedure. We see our functional providers. Then when they come to me for an assessment of consultation, it's really a three-part consultation. It is anatomy, functionality, and symptoms. For all ages, we have a symptom intake sheet, which they'll fill out, but I'll also get the story when I when I initially ask the family what's going on. Then we have the grading systems. For infants, we use the Kotlow for the lip. Then the curl is classification for the tongue, one through four as well. We take pictures of all areas. Then I use the Hazelbaker scoring for infants. That's our functionality testing.

We're looking at SOC, we're looking at lateralization, we're looking at elevation, we're looking at extension. Then we put all three pieces together to make a diagnosis of is this a tie, or not. To me, putting all those three pieces together, I feel really confident in my diagnosis. I don't feel like I'm over treating, or under treating. Of course, that comes with time and practice, also. The same applies for when we're treating kids and adults. The only difference is on the oral motor therapy, it's usually myofunctional therapy, or SLP, depending on whether there's a speech deficit or not. We still want them to see the body workers.

When they get to me, there's still a symptom intake form that we're looking at. From the grading system, it's a little bit different, because we use Zoghi's functional grading system, which is, we use the ROM scale. I don't know if you're familiar with that.

[0:23:51] MM: Like the TRMR scale?

[0:23:54] PG: Yeah. TRMR and then the TIP, and the TRMR LPS. We use that. Then, of course, we correct for compensations by holding the floor of the mouth. Then we also look further in that age range because of the airway impact. We're measuring palates and making sure that we don't need to do something like expansion first on the kids and adults because it's really important on that older age that if we're going to release a tongue tie, there's enough room in the mouth for it.

On my older teens and adults, I actually take a CDCT on all of them before to make sure that our airway spaces are in a healthy place before we release a tie. Because you can really make someone worse if you release it without knowing what their airway looks like.

[0:24:41] MM: For everybody asking, so it's Kotlow, K-O-T-L-O-W. Let me double check my spelling of Ð C-O-R-R Ð

[0:24:54] PG: Y-L. I always spell it wrong.

[0:24:57] MM: Yeah. It's a tricky one. C-O-R-Y-L-L-O-S for the other. Here. I will Ð

[0:25:07] PG: ThatÕs used for the infant population. Then the Kotlow for the lip can be used for all ages, but then there's a different grading that we use for the kids and adults, which is the ZaghiÕs.

[0:25:22] MM: Yes. If you're listening to the podcast, so I've attached ZaghiÕs website. If you just scroll down, you'll see the TRMR visual there. Then the way you get that is you measure their mouth wide open and then you have them put their tongue to spot, which is the little spot right behind your upper teeth. Then you measure that. Then you have them do a lingual palatal suction and measure that. Then you divide the tip divided by the, I think, I'm not a math person, I always have to see which one gives me the percentage, but the tip divided by the max and then the section divided by the max. Then there's percentages that fall into above average, average, below average. I think, significantly above average.

Yeah, I was trying to find one for Kotlow, but I can't find a good website for Kotlow. I'm sorry for people that are in the chat. I love how interdisciplinary your clinic is. That is a dream. Whatever you're doing, I've just worked in a private practice, but a lot of my patients do go to an orthodontist or a dentist that provides CBCTs. Is there a point that you do not do a release based on what the CBC Ð so, for those who don't know, a CBCT is a 3D imaging scan that shows you what does the airway look like, and they're really cool. If it's in the red, well, does it have to be in the green for you to Ð

[0:26:46] PG: What I'm really looking at is in that space is what's called a posterior airway space, which is the space behind the soft palate and posterior tongue to the spine. If it's in the red, yeah, I won't do the release, because what will happen is the narrowest point is usually in the posterior tongue area. Sometimes all the time, but you have to be careful. When you release those tongue ties, that posterior space can close even more, because now the posterior tongue is sunk back even more.

Now, obviously we do myo and all those things to try to get that tongue to be elevated. The reality is, is when you're sleeping, that's going to close even more. When you have that red on the CT, we already know we're high risk for collapsible airway. Those go to an oral surgeon first for potential double-draw surgery. If they don't want to do it, then I tell them, you're not a candidate for a release.

Personally, I'm not comfortable with the risk. It's just I've seen other cases where it's been released and that person just got so much worse. Yeah, you have to be very careful in those instances. Obviously, also, we're looking at transverse dimension of the palate, which Zaghi has done a lot of work on this, but anything under 32 millimeters is pretty risky. Ideally, for adults, we're looking at them at 38 to 40 millimeters. The reality is, is most adults are not there. Many adults that come to me are not going to go through a full-blown expansion and orthodontics again.

I feel fairly comfortable, if their post to your airway space is good, even if they're narrow, like 30, 31, 32, and up, I'll still do the release. What I will tell them is, ÒIf your chief complaint is sleep, then you need to address your jaw size and positioning. Because just doing a tongue tie release is not going to relieve that as much.Ó What a tongue tie release will do, if you're a TM joint patient, or a chronic neck and back pain and doing their tongue tie release will help because of the facial tension. If you really want to fix your sleep, don't think that just doing a tongue tie release is going to do that, because it wonÕt. Yeah.

[0:29:08] MM: Well, number one, listening to you talk, I'm like, ÒMan, I need to move to Houston now, so I can have such a great release provider to work with.Ó We have some great release providers, but we're definitely missing that comprehensive Ð We have all these providers and we work together, but I think you have dream practice over there.

I love that you also touched on, it isn't just a magic fix. There's so many other components that we have to look at. It's not just a tongue tie. It's all of these other factors that roll into it and just clipping the tongue tie, like, unfortunately with your daughter, that wasn't the end all be all. There was more work that needed to be done.

[MESSAGE]

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[EPISODE CONTINUED]

[0:30:17] MM: That brings me, so we had a comment that this person has seen a lot of tongue tie releases that didn't help, or made things worse since she's taking this course because she's been appalled by the various providers who've been clip happy for about the last 10 years. We need to educate release providers and others. She said that she still can't make her frill, because it makes her uncomfortable because she's afraid of a botched job. She's heard about pediatricians who just clip a short front of immediately when there's breastfeeding difficulties, but there's not a clue about a bigger picture, which thankfully, we have providers like you that are going out and educating pediatricians.

To this person, I would say, reach out to the release providers. Find out their methodology. Find out what they're doing. Find out what are they looking to for release. I have a really good relationship with the release providers that I use. We have a really good back-and-forth. We talk about, I'll be like, ÒI'm sending you this patient. These are what I'm seeing. Can you check about X, Y, and Z?Ó We have a conversation about it.

If you are seeing a patient that you think needs a frenectomy, reach out and talk to your providers and see what they're doing. Hopefully, this conversation with Dr. Gandhi will give you some talking points, or questions to ask about.

[0:31:38] PG: Well, and I would say, to your point, communication is key. Anyone that you're working with as a release provider, you want to work with someone that's open to communication and honestly, open to feedback as well about what you're seeing. I have learned so much from what my therapists see. They have to be open to a conversation, I think, in order to really be a collaborative member.

Yeah, I would ask them about treatment philosophy, how they diagnose. If someone is just looking, I would question that, because they're going to miss some ties and then they're going to overdiagnose other things as ties that are not. You definitely want there to be some aspect of functionality basis. The other thing I would say is know what tool they're using. Not every tool is created equal. There are lots of different types of lasers out there. Of course, the practitioner skill is very important, but know what tool they're using, not just as a screening for you, but also, that's going to dictate some of the aftercare that's needed and what the wound looks like. Just so you know how to support your patients as well.

The other thing I would ask them about is what's their aftercare protocol. I would be very skeptical of any provider that does not see their patients for a post op. You'd be surprised how many people don't do that, because I see so many patients in my office that got it done somewhere else and theyÕre now having post-op visits with me, because they're lost. I think it's just about having conversations. Unfortunately, that's very time consuming. You do have to invest a lot of your own time in building these networks. Then once you find your people, it works like magic, but it takes time.

[0:33:28] MM: Thank you for some of those tips for collaborating and getting this going, if people don't have a team quite yet. Speaking about the different lasers that can be used, that gives us a great segue into, what does the frenectomy look like?

[0:33:43] PG: Yeah. I will talk about the infant population first, because the techniques are different and providers really should take clinical courses if they're going to treat everybody in all the arenas, because you can't interchange the techniques in my opinion. An infant release is quick. I mean, I personally, I use a CO2 laser. I use the LightScalpel laser, which is extremely precise and gentle. Our infants are awake. They're in a swaddle. They wear little safety glasses. We are using just a little bit of topical numbing gel and we're lasering for about 15 seconds. That's a lip and a tongue together, about 15 seconds.

This laser in particular is we don't really see any heat inflammation around the surrounding tissues, because again, it's not Ð there's another laser called a diode laser that is very hot. That's a little bit different. Overall, procedure is quick. Minimal to no bleeding. Again, some of that is dictated by the fact that all of my babies do bodywork. Everything is really nice and loose. All of the veins and blood supply is all out of that frenulum. It's a very clean procedure.

What's different, which you're probably are not going to find in most of your areas because as far as I know, I'm the only practitioner doing this, but I suture infants. After I'm done with my release, most practitioners are just going to take some pictures, baby is done. They feed right after. We have a nursing room, where they can bottle, or breastfeed right afterwards. They don't need to put anything on the wound, or anything like that. I will put a dissolvable suture, too, in each area that I release. Only adds about anywhere from a minute to a minute and 20 seconds to the procedure. The reason we do that is because it minimizes the amount of stretching that the parents need to do. It also makes wound healing more predictable, just like it does on kids and adults.

When we are treating an infant tie, we are releasing just the frenulum. We are not releasing into the muscle, or anything like that. You really want to release until you don't feel any tension under the tongue. Hopefully, that tongue starts lifting up right away. From a lip perspective, when we release, we release all the way up into the vestibule. But really, you want to check again. It's about functionality. Can that lip cover the nostrils? The minute it can, you're done releasing.

Then similarly, like I said, about the buccal ties, we'll release just the ties that we need to to feel that the tension is gone. Like I said, baby feeds right after. Does need pain medication for about 24 to 48 hours. We offer homeopathic options, such as Arnica, or a weight-based dose of infant Tylenol. We let parents decide what they want. There is no restriction on feeding, but we do restrict pacifier use after the procedure. Because we want to teach these tongues to lift up and move around, not be held down. Then we see our patients for three post-op visits, a few days after the procedure to teach them stretches. Because of the stitches, they do no stretches for about three days. Then we teach them stretches that need to happen four times a day, every four hours approximately. Then we see them at two weeks and four weeks for visits.

During that duration, they're also seeing their body workers and their oral motor therapist, so that we get everything moving the way it's supposed to. Then from the kid and adult perspective, I do a functional frenulopasty technique, which is taught by Dr. Zoghi. I'm an affiliate of The Breathe Institute, so I'm closely related to all their training and what they do. Functional frenulopasty technique, by definition, is myofunctional therapy before and after and placing sutures. Any other type of release is not called a frenuloplasty, it's called a frenectomy, because if there are no sutures, then it is not a frenuloplasty technique.

Also, something to know about if you're asking providers what they do, in my opinion, placing sutures is the gold standard. For the kids and adults, a little bit different, same laser. We do offer all types of sedation as well. Nitrous, oral sedation, IV sedation, just no sedation, depending on the patient. We do locally numb with an injectable local for those patients. Then again, we're releasing to where we need to to get functionality.

It's really important that they work with myo first, because during the procedure, I'm asking them to the spot, they're holding their suction while I'm lasering, so I can see how much I need to release. Then we're measuring that ROM scale during the release to see, have we released enough. Because again, you don't want to go overboard. The more you release, the more likely that scarring and healing that's not optimized. You want to be as conservative as possible while getting functionality.

Similarly, those procedures recovery-wise, most of my kiddos go to school and normal activity that day, pain medication as needed, and then they're following up with their therapist as well. Similarly, they'll see me for post-ops, but just two post-ops, a week and three weeks out.

[0:39:09] MM: You talked so much about the work before and the post-op. Can you give us a little bit of what does pre-work look like, and then what you recommend for that post-op care?

[0:39:19] PG: Yeah. Pre-work-wise with myo, most of the time, they're doing, average I would say is about four to six sessions before. Obviously, this is dependent on how dedicated they are to home exercising and things like that. TheyÕre usually seeing their therapist weekly. Main things that we're working on are minimizing compensations. A lot of good job lateralization that happens, or the neck engagement. When they're elevating the floor of their mouth, things like that.

Then we're really working on strengthening the tongue muscle as much as possible. Because the more defined that muscle is, the more I know where I'm going. A huge part of that is the lingual palatal section. I mean, I want my patients to be able to hold that suction for two minutes straight. Because I'm having them hold it approximately 30 seconds at a time, while I'm working on them, while they're numb. If they know it like that, they can be numb and their tongue still does it. That's a minimal requirement for me.

Then, of course, we're working on nasal breathing and lip closure. None of my therapist will clear a patient. What we do in our office is on every age, we reach out to the functional providers and get clearance before the procedure. If they're not cleared by their functional provider, I won't do the procedure. What we're looking for is we have minimized compensations as much as we can. We have strengthened, particularly the posterior aspect of the tongue by being able to hold that suction. We also have been consistent and dedicated to our pre-therapy appointments, because if we are not committed pre to coming into our appointments, there's no way they're doing it after. The after is just as important for healing and function. It doesn't stop. It doesn't stop at the procedure. I always try to say, the procedure is this much. Everything else has to happen also. Those are the things we're looking for.

On babies, we're looking for relief of tension as much as possible, resolve toward a call us as much as possible, like cranial work so that we don't have a lot of plagiocephaly. Or again, babies are a little more time-sensitive, so we don't want to wait a long time. I'm doing as much of the compensations as possible.

[0:41:53] MM: You talked a little bit about aftercare and finding out the providerÕs aftercare of their procedures. What kind of aftercare do you prescribe?

[0:42:04] PG: Yeah. Yeah, sure. All ages need stretches, even with stitches being placed. For all ages, they generally start manual stretches about 72 hours after the procedure. For babies, it's a simple lift and stretch and hold for four seconds.

[0:42:26] MM: Hold on. 72 hours after the procedure, but that's with your sutures, right?
 
[0:42:30] PG: Yes. ThatÕs with sutures. If there were no sutures, you start day of.

[0:42:35] MM: You do sutures in, I'm sorry if I missed this, but you do sutures in all of your patients?

[0:42:39] PG: Yeah.

[0:42:40] MM: Okay.

[0:42:42] PG: Yeah, birth through adults. Unless, something goes unplanned, which in pediatrics can always happen. But I would say, 99% of them get sutures. That's where the 72 hours comes in. For babies, it's a simple lift of the lip, hold for four seconds, covering the nostrils and then the tongue, it's either a forklift with two fingers, or a single, horizontal lift with one finger, just depending on how they can get in there. That has to happen every four hours during the daytime.

Pretty similar with the older population, even though their myo will give them other exercises to do, I have parents, or the patient themselves do a manual stretch on themselves, by doing that same tongue-lifting technique.

[0:43:31] MM: Not just doing the suction, but actually going in and still doing that manual on themselves. Okay.

[0:43:37] PG: Yeah. I actually like the manual. I know you guys, a lot of our providers also do the forklift-type thing. I actually like a straight stretch back towards the throat. Yes. The reason why Ð

[0:43:50] MM: Just pulling the tongue back.

[0:43:52] PG: Yes. Almost, I saw parents look like you're choking them with their tongue. It's terrible, but itÕs the right visual. The reason I like that is I find that reattachment happens most often at the junction of the base of the tongue and the floor of the mouth. That little spot is where I see reattachment happen. I find that by doing that straight stretch back, it really opens up that area.

[0:44:21] MM: Yeah. I could feel that on myself, the forklift versus pushing back. It was definitely a much more intense stretch.

[0:44:29] PG: I mean, the kids hate it, but I'm like, ÒDo you want to do this again? Nobody wants to do this again.Ó That is what I instruct. Then other than that, I leave the movement and the functional exercises to my other providers. I'm also lucky that I have amazing providers in the office and outside the office that have great instruction. I don't need to give more to my patients. I'm more take care of the wound healing and they take care of the function.

[0:45:00] MM: Yes. I love that. I always tell my friends, I'm like, ÒPlease, give them what you want them to do for wound healing and I work on the neuromuscular reeducation and the functional improvements.Ó

[0:45:11] PG: Exactly. Exactly.

[0:45:13] MM: Oh, man. That is fabulous. Learned some new things that I'm going to go talk to my frenectomy provider about.

[0:45:18] PG: Amazing. 

[0:45:20] MM: You've touched on it a lot throughout, but what are some of your providers that you collaborate with for patients who you do frenectomies on?

[0:45:28] PG: Yeah. Definitely, heavily in the infant population, the bodyworkers. Sometimes more so than the lactation and SLPs, because I find that that makes a huge impact on procedural outcomes and procedural readiness. In the Houston area, it's the chiros know most about frenectomies and ties. We have a couple of PTs and a couple of osteopaths, but it's really the chiros. There is a certification from the ICPA. If you're looking for a pediatric chiropractor in your area, you could look up the ICPA website. It's the International Chiropractic Pediatric Association, something along those lines. Oh, you got it. Okay.

[0:46:14] MM: I did. Yup. Then for people listening, I'll just say really quick, let me see if I can find the full name. I'll come back to it.

[0:46:23] PG: Okay. That's a good resource. Those are the people that have had more pediatric training and have had more exposure to talks. Technically, any chiropractor can treat a baby, but you really want to vet out. A couple of questions that I ask when a provider approaches me, or I'm thinking of collaborating with them is, do they work in the mouth? If they don't work in the mouth, then they don't really do this. That's not to say they can't be trained to work in the mouth.

Now, some things to note is there are some state regulations as to whether a chiro can work in the mouth. If they can't, then they usually instruct the parents on how to do it. That's one thing to note. I see a question about craniosacral therapist. I don't know if you want me to Ð

[0:47:07] MM: Yeah. Jump on it.

[0:47:09] PG: Craniosacral therapist. Yes, some of them are chiros, some of them are massage therapists. One thing to note is craniosacral therapists are great. The advantage to doing a chiropractor that does craniosacral therapy is they can do manual adjustment as well, so you are going to get better spinal alignment. That's also where when we talk about PTs, PTs are great, but a muscle is attached to a bone. If a bone is out of alignment, then that muscle is only going to be able to be corrected so far. That's why I like the chiros. I think it's also dependent on where you're located and what you have available.

I teach a course with a chiro and a myo and an IVCLC. We all talk about ideal versus real, because we are all living in reality and not all of us have access to all these providers. My philosophy is some is always better than none. Use what you have. If you have a provider that's open to more training, then work on that. At least getting them some body work is going to benefit them more than nothing. Yeah.

Then adults and kids can also really benefit from chiro and PT. I mean, it's all connected, and honestly, they have more effects from the ties, because it's been years and years. We do highly encourage that as well. Really, on the older kids and adults, it's myo all the way. I mean, that's what we stress. That's what I will not negotiate on a procedure is myo first. Does everyone do the bodywork? No, on that population. Yeah.

Again, when I am choosing myos, I want to know what their protocol is. I want to know where they trained. I love that here in Houston, I collaborate with a lot of SLPs that are also myofunctional therapists, so we get both in one. That's ideal for our kiddos that have speech dysfunction, but we need them to do myo. Yeah, I want to know where you training is. I also want to know your philosophy on TOTs, because it's all over the place. We need people that are on the same page that are diagnosing correctly, so that we don't miss them, or over diagnose.

[0:49:31] MM: The ICPA is the International Chiropractic Pediatric Association, if you want to look into that. Caroline asked you, fine that some patients complete the myofunction therapy and then they do not need a release.

[0:49:44] PG: Yes, it does happen. Some of those cases when they come for a consult, I will say, ÒI don't know if you need a release.Ó Most of those are posterior ties, where we just may be lacking some muscle tone. Also, sometimes, it's a space issue. If we have a narrow upper jaw, our tongue just can't get in there. Absolutely, yes. This is where working with great providers that you are not intimidated, or feel like you can't say like, ÒHey, I don't think they need a release.Ó Having a provider that's open to that conversation. But yes, it happens even on babies, it happens, where they're having feeding difficulty. I mean, if they're walking into your office like this, they're going to have feeding difficulty. Sometimes if we just straighten them out with some body work, they do great.

[0:50:42] MM: For those that are just listening, what Ð

[0:50:44] PG: I'm sorry, I'm making a gesture.

[0:50:46] MM: Yeah. She was modeling what a torticollic baby would look like. Then saying like, ÒNo, if we straighten them out,Ó and then she straightened her head back up to midline. Yeah.

[0:50:57] PG: Yeah. I mean, definitely, again, this is why we use something like the function first model because we don't want to be over-treating.

[0:51:06] MM: Mm-hmm. Jumping on to this over-treating, I know we touched on at the beginning, but we did have another question to clarify. I think it is a really important point. Is there a difference between a tie and a frenulum?

[0:51:18] PG: Yes. A frenulum is a piece of connective tissue that is not restricting the movement of the tongue, or the lip, or causing functional symptoms. That's just a frenulum. That's an anatomical piece of tissue that we're supposed to have. Frenulum is considered a tie if it is restricting range of motion and causing functional symptoms. This is why when we do our diagnosis, we have to put all the pieces together.

[0:51:52] MM: At your practice, do you have people mostly coming in for suspecting ties, or is it bouncing around, like your PT that works with you as like, ÒHey, go see this person and have them assess you for a tongue tie?Ó How does that work?

[0:52:08] PG: Yeah. It's a combination. I have people that seek me out that, I mean, parents are the best advocates for their children. I mean, the parent education connection sends a lot of parents to me, even if they've been told otherwise from other providers. Then I do get a lot of referrals from functional providers. Then we are a full-fledged pediatric dental practice. We screen every single patient for ties. I have two other pediatric dentists that work for me. They're screening all the patients they see. Then if there's a functional concern, meaning parents are reporting symptoms, all of our patients fill out a screening form, all of our patients fill out a sleep questionnaire, then my pediatric dentists who do not do any of this will refer them to me for a consult.

It's a multi-factorial referral source if you will. Most of my adults come from adult dentists here in Houston that don't treat ties but know about airway. I have a couple of oral surgeons and sleep medicine docs that refer to me. Then a couple of orthodontists. That's literally two in the entire city of Houston.

[0:53:26] MM: Wow.

[0:53:26] PG: They're probably the most resistant right now is our orthodontist. Yeah.

[0:53:31] MM: That is so interesting. This is not on our question list, then you might not want to tackle it, but why do you think that tethered oral tissues is such a hot topic? Do you have any ideas about how we can get a little bit more of a standardized cohesive approach among providers?

[0:53:49] PG: Yeah. It's funny that you bring this up. Last week, I had a patient that came in for routine care. She didn't shouldn't come in last week, but a while ago. We screened her kid for ties like we do for everyone. I brought it up to her. Actually, recommended therapy. I didn't even recommend a release. Well, she went on Facebook and just went crazy about me over diagnosing. There were over a 100 comments. Not good comments. There were pediatricians, they were other, you know. It just brought up how much of a controversial topic this still is.

My perspective on it is it starts from our education system in all of our fields, SLP, dentistry, medicine. We are not universally educated on this. Because our research is still relatively new, and we know that education systems take forever to catch up, I don't anticipate that this is going to change anytime soon. I think from a physician's standpoint, when they are not trained in something, they just don't believe it's a thing.

As I had touched on earlier, they've also seen some bad releases. Their view on it is skewed, right? Some of them you can't blame because they're taking from what their experience is. I wish they would be more open to the changes that have been made in the field. From my perspective, yeah, what we're doing is by sending them completion letters of their patients that are now thriving, maybe we're starting to change their perspective and they can see what their patients look like post-procedure.

[0:55:35] MM: I love that idea of completion letters.

[0:55:36] PG: Yeah. We do it on all of our patients.

[0:55:38] MM: Oh, my gosh. I love that.

[0:55:40] PG: It's a backdoor way of saying, ÒLook, see.Ó Without saying like, ÒHey, we did a good job.Ó

[0:55:46] MM: Right.

[0:55:48] PG: Then, I think continuing to do what we do, things like this, educating within your own field. Because I know from a pediatric dental standpoint, there are not a lot of functional pediatric dentists. I think what happens is sometimes when you're a provider in your field, you get worried about things like competition. ÒOh, I don't want to share this, because what if I lose patients? What if my next-door SLP becomes an expert in TOTs?Ó There are so many people that need help that honestly, the more awareness we bring to it, the more people that are treating it, the more we're going to have a chance to universally educate on it.

[0:56:26] MM: I love that.

[0:56:27] PG: The more we keep it in the dark and try to keep it to ourselves and make it our specialty only, we're still going to have this controversial some people know about it, some people don't. My perspective is, if you know about this, if you're passionate about it, spread the word to whoever will listen. Just spread the word. That's how I think, we'll make strides. Be prepared to get resistance. I mean, I had a hundred-plus comments about how awful I am. You need to really love this stuff and really believe in it. I think the message will start to spread. You can already see the difference. It's happening. It's just going to happen slowly.

[0:57:12] MM: Big change does happen slowly, so we just got to embrace it.

[0:57:17] PG: I hope I answered your question. I kind of Ð

[0:57:18] MM: No. I think that was a really great answer. I think that it Ð yeah, no. I think that was an excellent answer. It motivated me to keep trucking along. We did have a question and you touched on it again. What does a bad release look like? What do you mean by a bad release?

[0:57:38] PG: Yeah. It's not just about the release. It's about doing the pre and post work, right?

[0:57:43] MM: Yeah.

[0:57:44] PG: Because a release can clinically look beautiful and not a over Ð not aggressive and not under-released. If you haven't addressed any of the muscle tone and the functionality, then you're not going to see much of a change. Part of it is a bad approach to treatment, maybe, is not incorporating functional providers, in my opinion. Honestly, most of those releases look really messy, too, because the muscle is not defined.

I mean, for lack of better words, some of these releases look like chopped meat. There's no defined muscle. There's no defined start and stop point. They're really wide. I mean, I have some pictures that are just Ð I mean, they're scary to look at. You really want to keep that release as narrow as possible. We should not have, again, pointing is not going to suffice here. When I see a super aggressive release, where they're really wide, they're taking up like Ð I would say, when I do a release, we are maybe a quarter width of the tongue. I don't know. I just, again, the visuals are hard when you're on a podcast, but you want to keep it as conservative as possible. The wound should look pretty vertical. We don't want horizontal looking wounds.

[0:59:03] MM: It should make a little diamond shape, right?

[0:59:04] PG: Diamond, exactly. Little diamond. I also tell practitioners like, don't aim for the diamond. If it's done without a diamond, then it's done. Don't keep going so it looks like a diamond. The diamond is a good guide, but it's not the end all be all. The other thing that we see is that people will go too deep far into the muscle. Sometimes you have to release a little bit of the muscle, but again, not on babies. That is mainly on older kids and adults where the muscle itself is restricting. Again, that's a millimeter or two. You're not diving into that. It should not look like a black hole. Then in my opinion, there should really be sutures placed. Yeah.

[0:59:47] MM: That has not been my experience with infants. All of the providers in our area just do a Ð I think they have a water laser.

[0:59:54] PG: Yeah, yeah. Sure.

[0:59:55] MM: Then they don't put the sutures in. But I really like that idea because those aftercare stretches are a doozy for a fresh mama.

[1:00:04] PG: Yeah. Well, especially what's nice is they get to go home that day and for the first three days, just comfort their baby and feed them and donÕt have to stick their fingers in there. It's funny because I started doing the sutures in babies a little over a year ago. I am now treating younger siblings and things like that. When I tell the parents like, ÒOh, this is a change we've made, because ÐÓ They're like, ÒOh, my God. Yes, we don't have to get back in there right away.Ó I mean, for them, it's the most amazing thing.

[1:00:35] MM: Yeah. Oh, my gosh. That's so neat. Then, Beth, you mentioned that your dentist is a laser without sutures. That's what my dental provider does. We see really good results with that. I will say, I'll let Dr. Gandhi speak on to this, but the aftercare is very different with a laser release and no sutures, versus a frenectomy that has sutures placed.

[1:00:58] PG: Yeah, totally. Well, first of all, the wounds heal faster and more predictably. We see a lot more of the vertical wound healing because it's already started once the three days are in and they have to start the stretches. It's also nice, because we're not Ð we used to instruct on infants, a stretch in the middle of the night, too. Those parents were having to stretch in the middle of the night, whereas when we placed the suture because that primary healings already happen, they only need to do daytime, especially on the older infants where they're sleeping through the night, we're not disrupting their sleep by having to do a stretch.

[1:01:36] MM: Have you noticed a difference in the healing process in putting the sutures on the infants versus not?

[1:01:41] PG: Just that the wounds are healing quicker. I mean, they all look really good. Yeah, they all look really good.

[1:01:50] MM: That is so awesome. I'll give everybody a couple more questions, or a couple more minutes to see if anybody has any more questions. Oh, my gosh. Dr. Gandhi, this was amazing. I learned so much from you. It was so great.

[1:02:05] PG: Thank you so much for having me.

[1:02:06] MM: Oh, yeah. I'm so excited to go share with my frenectomy provider about pushing back, versus a forklift. I think that's so interesting. Yeah, this was great. I do just want to put a little disclaimer out there, because we are predominantly speech pathologists that are watching this. Once again, tethered oral tissues is part of differential diagnosis. As Dr. Gandhi shared, not every patient that comes in and gets an assessment needs a frenectomy after they've had therapy.

My practice even goes for infants. Sometimes we need to work on strengthening, or improving their latch, or their stuck and we can do that without a frenectomy. Not every single patient you see is going to fall into this category, but we can use this. We can use frenectomy providers as a way to form that differential diagnosis and determine if there is a structural deficit that's impacting their function. Would you agree with that, Dr. Gandhi?

[1:02:55] PG: Exactly. Exactly. Well said. Well said.

[1:02:58] MM: Perfect. I didn't see any other questions come in. We're getting lots of, ÒIt was informative. You are amazing, Dr. Gandhi.Ó Thank you so much, Dr. Gandhi. This was so great. You have me super excited about all that is to come.

[1:03:12] PG: Anytime. Thanks so much for having me again. This was awesome.

[1:03:15] MM: Absolutely.

[END OF EPISODE]

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SLPL S11E10		Transcript

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