Transcript for:
Lecture Notes: Advances in Tongue-Tie and Airway Management by Dr. Zagi

this is the moment we all been waiting for we have the Superstar Dr zagi with us and the you don't need anyu you so much thank you so much amazing amazing so great to be here with you guys this is one of my favorite conferences of the year I have so many friends in the audience who is ready to have a good time let's hear some noise yeah amazing amazing amazing I wish I could have been with you guys here all weekend but I now have two little kids at home a six-month-old and a three and a half-year-old and but I have my amazing team here in the front row you guys can stand up give stand up my breathe team they were sending me pictures videos of all your presentations and all the love and it's so great to be here uh with you my name is Dr serou zagi I'm a graduate of Harvard Medical School UC ENT residency in Stanford sleep surgery Fellowship I'm medical director of the breath Institute and one of the greatest things we love to do is research and education who here is excited to get some updates on our latest protocols yes if you would like a copy of the lecture slides which I would recommend that you grab because we have some new content new grading scales pictures and things like that go ahead and click on the QR code here I'll put it up again in a few minutes and then you'll have access to all of the pictures diagrams things like that we do want you guys to use these to help your patients and implement in your research if you use any of the content be sure to credit Dr zagi and the breath Institute all right very very very very good can you guys believe it that we are now in year seven of the breath Institute and these protocols the first presentation I gave on these topics was seven years ago is that incredible or what meanwhile I have been using the same slide over the past seven years explaining that half of what you learn will be shown to be either dead wrong or out of date within 5 years and so the most important thing is to continue learning and we do that continue learning through research studies as well as study clubs like this one I love to update all my studies and come to you guys and the input that you give today will influence the direction of research moving forward we just had our annual TBI Ambassador update who was online with me at the TBI Ambassador update amazing amazing and uh I'll be summarizing a lot of those key Concepts in the next three hours the first concept that I'm going to talk to you guys about is our surgical advancement if you guys have taken the course uh from me or studied with me more than one or two years ago I want you guys to know that the procedure is now much much less invasive we're making very very small Cuts we're no longer dissecting through the fascia into the genioglossus muscle and we're getting incredible results I want to teach you guys about the Kenalog 10 protocol who's here has heard about this okay who here has tried it okay impressive is it impressive or what okay so we do a lot of different research projects and some of them just hit and I'm so excited to share with you guys how we can improve our wound healing process through the application of catalog 10 and I'm also going to introduce a new grading scale for how we can evaluate the integration and maturation of wounds last year I introduced the nonablative laser who here has tried it in last year amazing I want to give a big shout out to Dr Sophia and Dr Cat uh L yeah amazing presentation she vide it and send it to me what's thatu Dr Dr Huffman and Dr cats sorry about that um yet uh I know that you guys didn't get the best best results in all of the patients and so I found like a little trick that it's not only getting the soft pallet area but also the posterior aspect of the soft pallette and I've got the procedure down to like two minutes like once maybe twice okay minimal pain like demonstrable changes on CT scans excited to share with you guys and finally we're going to talk about our research that I introduced last year on lip and buckle ties so I hope you guys are excited one more chance to get the link to the downloads anyone still need it and looks like we're good to go so again the biggest change from last year is that I am now now a father of two amazing boys and one more change anyone else know what's changed personally for me in the last year my my Airway Journey all right so I thought you know we guys were all friends here and I thought I'd give you an inside look on my journey how does that sound you guys excited to kind of hear about about that so seven years ago I presented you guys this case his name is Austin you can see based on his cranofacial features that he has maxillary mandibular deficiency if you studied with me you've seen his sleep oscopy where he's gasping choking and ultimately we take him for MMA and he does a lot better meanwhile there are two patients in this picture all right one of them is Austin and the second is Dr zagi because when I go back and look at my videos from 2017 2018 my mouth is always wide open oh my God I'm supposed to be an expert in sleep breathing and you know tongue posture and tongue thrust and here I am having graduated from Harvard Medical School having graduated from UCL ENT residency and it wasn't until I got to Stanford that I realized that oh my gosh I have an open bite and I'm a mouth breather imagine that graduating ENT residency and not knowing that you have these issues really a testament to the need for continued learning the need for interdisplinary multip approach so here's what my bite looked like I think it was like in the seventh grade or something like that I got hit in the face with a basketball I got hit in the face with a basketball I developed a deviated septum couldn't breathe through my nose as well I thought it was allergies and then I developed a tongue thrust my inter molar width here is maybe around 33 34 millimeters and we'll talk about how that plays a role in the decision between tongue TI versus tongue space issues in the course today so you know here's my deviated septum I had sinus issues and so you know I saw what great results my friends and my patients got from um you know sinus surgery and deviated septum surgery so I went for it so almost two years ago I had septorhinoplasty spreader graphs placed and sinus surgery and I was better and I did some orthodontic treatment in the form of you know uh crozat and invisaline and I did get some dental alveolar expansion and I was so so proud of myself and I went to a conference and Marana Evans looked at me and said your bite's not stable okay like like what are you what are you kidding yourself okay I started to get peronal root absorption and uh as soon as I took my retainers out my bite would like shift right away all right and so that's a sign that if like you know night tonight take your retainers out the next day it's tight that something's not right is it your tongue posture is it your tongue space and in my case I had a skeletal deficiency of the maxilla such that my Max which is the roof of the mouth and the floor of the nose was more narrow than we would like to see I had some transverse maxillary hypoplasia and so even though I did an orthodontic treatment I'm sure you guys can see the extensive peronal effects of that treatment over the course of three four years of constant stress on the teeth and then you know you're not wearing the retainers during the day so you're constantly having that push and the pull and so ultimately I had many patients doing marp I had contributed to the research on the Dome procedure back in 2015 2016 and you know uh the research has really really come a long way who here has heard of marpie who here has had the procedure anyone okay a couple people in the crowd okay and so basically what happens in this approach is that what you're doing is you're actually expanding the maxillary skeletal tissue and the research has come a long way in that we're not doing the Dome procedure which has a lefor one osteotomy rather we're we're expanding at the at the fulcrum of the zygomatic frontal suture and so you're getting a three-dimensional expansion of the floor of the nose the sinuses the nasal wall and uh it's been shown to be a really reliable and effective way of contributing to not only breathing but also aesthetic results so I dived in for my journey here is how I present ented with my open bite look at that tongue posture okay I got a cbct machine I sat in it and I'm like oh my gosh I did some expansion and croad and vizaline and therapy and got my nose breathing up and I got my tongue up but quite still not quite there there's different ways of expanding the palette okay we have you know light wire modalities we have removable appliances and both of these modalities work but they're limited to about 2 to 6 millim of expansion and that's what we see in the recent studies that yes these appliances do expand on average about 2.4 millim plus or minus 1.8 which means that if you have a patient who's 34 35 millim trying to go going for a goal of 38 it's an acceptable option but if you have a patient who's 28 millim less than 32 mm you could do these modalities but you're going to be limited due to you know perodontal uh resorp uh root resorption and other issues in terms of how far you can go and so what we are now doing about a year ago was Max SL skeletal expansion with surgical assist and even since that time it has become possible to expand people with less and less surgical actually cutting of the mid padle suture and so what I had was the Mind procedure it involves an amazing Appliance from Partners lab that uh you know uh you get implanted I had actually six uh mini implants into the into the maxilla and we were expanding at about six millimeter per day let me give you a little look into my [Music] journey big Airway energy good morning let's go yeah [Music] my honor to take care of you you're my brother your patients come in and out with teeth from here to here and I want the same let's do it let's do [Music] it oh yeah Dr celon locked and ready to go woo [Music] all right amazing so you know I want to show you guys so I uh had a bad gag reflex very thick bone uh even in the O was hard to place this I want to give you guys a little bit of a look of what my process looks like okay so here I am all right and uh I had nasal and tral intubation I'm sharing this with you to make the process a little bit less scary for you and your patients showing you that I walk the walk because patients with tongue ties don't have only tongue tie issues they have myofunctional issues and they also have orthodontic issues and we have to learn and be willing to you know approach this from three dimensions if we really want to help our patients so this is me Miracle M Surgery Center and um I got intubated all right is this okay for you guys to see you guys interested in seeing a little bit of this video okay uh you know numbed me up okay uh you know put the pallet in brush my teeth put the pallet expander in and here's the good stuff all right does it sound up you trying to find yeah so he makes a cut through the uh you know uh muc Ginger Junction there and uh elevates the lip until we expose the nasal spine that right there is accessing my nasal floor and my septum and so he separates the septum from the nasal floor so that's the nasal septum we like right above the maxillary spine so you separate the sub gem you make a mid pileal split and there's also a t disjunction this is him putting the screws in much more comfortable when you're asleep then awake all right giving you a sense of what it looks like the disjunction it was about what an hour hour and a half kind of a a procedure that they summarize in about 10 minutes this is fun my part's easy you just got to sit there huh doctor is split already looking they split and then they test stand now you can you can do it you can expand an adult are you guys convinced do you guys need a randomize double bonded control study to prove to you that you can split adults all right this is evidence guys okay and I'm sharing this and I'm describing this because uh you know research and evidence has become weaponized have you guys seen it have you guys seen that really this tasteful people going online saying there's no evidence there's no evidence they do all this work all this work all this research all this research is showing there's no evidence right and so I'm sharing this case with you to tell you guys that when something's self-evident like this right you don't need a double blinded randomized control trial to show that it works you have to use the level of evidence that's approprate to advance your understanding and your learning all right so this is just the first part of my journey the second part is really the recovery okay so afterwards I um I was having a little bit of swelling over my cheeks and in my jaws I'm using an ice pack for my face you know two or three times a day finding so it's about the recovery process so I used an ice pack to help with the swelling here's Dr celon going over my CT scan and he's you know verifying the placement of it uh that the tads are in the right place and making sure I'm good to go you wait for a week and then you start the expansion process so I'm become a big advocate of ice okay for my personal experience but also after frenuloplasty all right so something new that's in the protocols is applying ice to the submental area and the way that you do that is 15 minutes on 2 hours off 15 minutes on two hours off and we're moving away from giving patients benzocaine and you know tropical anesthetic and Tramadol and things like that especially with the finer technique patients are having very little pain and the ice helps to diminish pain and swelling and can be extremely helpful any anyone try icing after oral surgery tongue tie finding finding that it helps okay and little to no risk okay so 15 minutes on uh repeat every two hours the other thing that I found extremely helpful and this is a laser Symposium is um you know photobiomodulation so I had two modalities I had the 800 nanm wavelength which is a red light wavelength and the red light works for inflammation all right and I had the 1064 nomer wavelength which works on the level of fascia I also experienced shock wave therapy and so going through this journey taught me things that no textbook no research article could okay putting yourself through there is like the best way to learn the second best way to learn is through the Journey of your patience I also want to give a shout out to my friend Dr NE bu chandani amazing integrative Airway chiropractor like really taught me a lot about like what body work is like cranial sacral fashion therapy Chiropractic work this makes a huge difference huge difference because you guys know what the biggest risk of pallot expansion is what's the biggest risk asymmetric split and it doesn't look good it doesn't look good right you have this thing in there and you got to get through the turns so you turn turn turn turn turn and then it splits asymmetrically like one side of the maxilla comes forward all right the teeth are off one's up one's down anyone ever see this all right why does that happen why does that happen right the body's resisting that movement so if you integrate the body work the cranos sacral the Chiropractic adjustments and you go a little bit slower stop if you're feeling that headache sensation stop if you're having any pain go a little bit slower you're going to get a really nice smooth symmetric result any any questions or comments on that you guys agree yes doctor uh rarely rarely rarely if it's a sensitive patient this then I give them two tablets and that's it yeah so we're not finding that we need it here is uh the process you this is the expansion screw you want to make sure it's locked in all the way right so once you feel like it's locked in all the way it's always going from upper incizors to lower incizors that's activating it so boom did you feel that oh my God wa where' you feel it in my cheeks like right here just just like like that yep wo amazing huh you want to do one more do one more let's let's one more have crani sacral tomorrow so so I'll be good for good timing good timing yeah so it doesn't matter which way doesn't matter just want to make you want make sure that when you're starting you're not starting too low right cuz then you have no room to go down so you want to make sure that when you're in you might have to flip it you can flip this way sometimes you have to flip it just to get the right angle all right mhm nice oh wow feel it oh I feel it oh right here yeah right here lot of people feel it around thetical front I'm so glad I got my suure split yeah imagine if you don't right no so now now you're going to start to figure out how if you're doing enough okay so you see how this is a blank surface uhhuh you see that you do enough then no no no it's fine that's how it is so so every other surface has a marking on it okay so let's say that surface BL the what I'm trying to demonstrate to you is like it works okay but but these patients experience tightness right and the the body work the physical therapy the stretching like really helps cuz if you get stuck it's going to go asymmetrically and uh in Audrey yun's paper it showed that 51% of patients in the prior technique 51% had asymmetric expansion more than 1 to two millimeters and that's a lot that's a lot so what are we missing we're missing that integrative like work the other thing is if they have a lateral tongue thrust okay and they keep their tongue on one side have you guys seen those patients okay oh asymmetric split asymmetry it's going to grow like that all right so what do you do first do you do tongue tie first or the tongue space first all right there's different considerations if you do the tongue tie first you're going to optimize the expansion the fascia the tongue up if you do the tongue space first well then the myofunctional and the fashion all that's easier so you know uh I think in Prior years I said look at tongue space look at tongue space look at tongue space and I'm going to qualify that in this in this seminar that most patients who have tongue tie are going to be narrow okay it's going to be unusual to find a tongue tie patient who's wider than 34 35 millimeters because they have the tongue tie the pallet hasn't expanded if you're less than 32 millimet of of pallet width if you're like 28 and the tongue tie is like not so bad okay it's like maybe like a compens form of tongue tie but not like a severe grade three grade four really bad tongue tie expand first okay if you have a very severe okay like grade three grade four thick restricted tongue tie to the tip you might consider releasing first and expanding second okay with the caveat that after you release it they may have problems such as biting the edges of their tongue and they probably will have that complication okay but that's okay because it's going to motivate them to go through they're going to understand the importance of therapy to expand and get their tongue in the right place meanwhile if the tongue's in the wrong place it's going to limit your growth another option is to expand get that space and then do the tongue typ procedure in the middle of the retention phase which means that you do all the spacing and then when you have the diasta you do it there that's like my favorite time to time it any questions about optimal timing of release tongue space versus tongue tie does this help helpful for you guys getting these like inner looks yes it's very important to have your tongue up during that process during the retention phase and even some of the expansion phase it's very important for the sense of ease around your head and the the stability because it's the swallow that's regulating it so you expand okay and then it's your swallow and your cranial sacral Rhythm that's moving everything into place and if you have an abnormal swallow you're not going to get the best best best results I was doing body work probably two or three times a week and that was helping but just getting the tongue in there once you I got to a sufficient width and I would swallow the swallow would equalize out that pressure and help me to feel better does that make sense is is it helpful insights okay other questions so you know you expand enough so the tongue space is like adequate do the tongue Tire Release maybe expand a little more maybe retain yes yeah I'm going to show more specific on all these things in the second half so around uh 11:00 or so 10:30 11:00 I'll show you the pictures of the measurements and things like that it's giving you I'm I'm going to repeat things multiple times if you guys have studied with me I introduce the concept kind of plant it there introduce it again and then hit you with it at the end sound good you guys on board all right really really really good okay so here's my pallet expander amazing okay but another thing that needs to be mentioned is the psychological effects of a diasta all right it's hard it's hard all right and it's a concern that patients have it's like what about the diasta all right and this is 4.2 I went up to you know 7 millimeters okay and you go out to like weddings and like you know your kids birthday party and people look at you like you're like off the wall like you're crazy like what happened to you okay and it's your real friends that'll point it out right it's your real friends I have a friend from high school he's like suou what did you do what's wrong with your teeth oh you know what I I love you thank you for caring about me thank you for being such a good friend right it's the ones are like oh so well what's new what's going on in life anything different with you these are people who are not that close to you right so it's important to recognize this there's two ways that we're going about this okay one is that you can expand and do invisaline at the same time to correct all right there's pros and cons to that when you have the invisaline retainer you're blocking some of the sacral symmetry like effects because as your body changes your posture changes and you lose that you lose that Mobility to reset everything else in your body uh but you can you know do that you can expand and reset expand and reset and there's some research that's being done into that and the other is that you own it right that you own it that you tell everyone hey Airway is important here's an opportunity for me to tell you guys why this is important and I wish that I had address this when I was a child when I was an infant it's a lot easier public awareness Public Service Announcement okay so if you're going to go through this go with that kind of attitude that hey this is important this is my case this is what I did breathing is valuable breathing is important my sinus is better my posture is better and that's really how you're going to get the word out there that's how you're going to beat these New York Times articles and these Asha leaders and things like that it's by showing your journey and showing that the results are really truly self-evident all right so that my journey let me show you my CT scans uh here I am in July and you can see in July it looks like I have a big gap right so the bone hasn't calcified yet uh you guys can see that I legitimately expanded my nasal cavity I'm demonstrating proving that it was actually like bone structure tissue and here I am in December I still have one more uh round of orthodontic treatment and some cosmetic denry to go but looking good feeling good I don't wear a retainer okay that's like my biggest like claim to success I don't wear retainer my teeth are settled in my posture feels good I feel balanced and I continue the amazing body work and as I do that I continue to see uh continued improvements and changes all right so let's make the diasta a little fun by sharing with you my journey on how cool it is to have this [Music] diasta baby you can me under the all right so that was that was really fun I hope you guys enjoyed that was it helpful to see kind of my personal Journey going through it very very good so okay so where's the research is there any research on it anyone want to ask that question all right so here it is this is by Audrey Yun all right a road map of cranial facial growth modification development published I think in the journal sleep all right it's published the whole protocol starting with uh tongue tie breastfeeding myofunctional therapy early on uh Habit corrector appliances removable appliances implants when to do it all of our experience published in the journal sleep okay meanwhile Audrey got viciously attacked by the orthodontic Community for publishing this is it helpful for you guys to have an article like this when you're discussing with your patients yeah amazing right you have an article publishing it like it's not just you saying something right it's actually been published it's actually been demonstrated but what we're going to learn is that the process of research always has a stage where you're first ridiculed then you're viciously attacked and then it becomes self-evident and so what I'm going to propose is that when we're in the ridicule stage you know know that you're still early and when you're being targeted and attacked you should know that you're almost there you're almost there that's the perspective we want to take okay and so these cases talk for themselves this is just tongue time my functional therapy this was novel to us in 2017 2018 look at the amazing growth and development right look at what we can do to help our kids and I'm going to show you not with research study with the decisions that I made with my own two kids okay here's my son Maxim and here's matis Maxim had a very severe restricted tongue tie okay and when we're talking about tongue ties now we're going to put them into three categories okay good Mobility you guys know what good Mobility it's grade one grade 2A no compensation that's good Mobility you guys with me there's compensated Mobility that's the floor of mouth hole the neck The Strain the submucosal and then there's restricted Mobility where it's it's just restricted are you guys good with me on kind of classifying the categories in that way and perhaps that you can see that Maxim had a tongue tie that was restricted all right you take them to anyone pediatricians you hope the parent can feel that's a tongue tie is a tongue tie is a tongue tie you guys with me all right and you can also see the the impact that had because matis also had a tongue tie but not as severe all right he had a more compensated tongue tie and so for maxim him we released his tongue tie within a week his mouth closed but matis had this open mouth posture and the best way that I like to evaluate for these borderline cases and babies is this sleeping tongue posture hold promoted by Michelle don't you ever grow up don't you ever grow up just say this little oh darling don't you all right so this is called sleeping tongue posture hold who uses this maneuver okay you guys find it helpful I find it really helpful objective is to get the tongue up to the roof of the mouth you push on the submental area you make that seal you can do it on yourself even you can feel it make that negative intraoral pressure clicking you open the mouth and you see it what point will it drop in mati's case it's not dropping okay so this is a good sign sign that you don't maybe need to do anything totally elective all right it's also important to kind of qualify whe whether it's severely restricted compensated or good so that when you tell the parents to do a tongue tie release right it's based on some objective findings right you never want to tell a patient they're probably Tongue Tied over email all right and that was the problem with the New York Times article parents that my breastfeeding issues lactation say you probably have a tongue tie go get it released that's a mistake on her part that doesn't pass a newspaper test you can't diagnose someone without examining them that's on her and she got caught all right and it affects everyone when you guys work out at a protocol so in any case in this case it's pretty good Mobility super elective doing not doing the tongue Tel isn't going to cause sleep apnea or other issues so we first started with Bodywork this is Dr uh Derek Nordstrom and his uh his physical therapist Kim and um you know amazing unwinding loosening of the tissue and as we did this two things will happen either the tissue will resolve it won't be there anymore or it will become more defined okay and we're seeing the same thing for oray and body work so uh as you do the intervention the fascia pulls away and the frenulum becomes like more tight same with Kenalog when you do the Kenalog post procedure you inject into that area first it's like a glob of scar tissue don't know where to release where not to release you hit it with Kenalog the tissue starts to dissolve either it'll be completely smooth or you will now have like a defined restriction where you can go for a stage two procedure is this helpful insights for you guys okay so in any case you know the tissue is becoming more defined we're able to do a really really small release and then amazing he's got his mouth closed okay less Lip lip blisters and things like that so for me that was a major gain meanwhile we don't want to terrify parents in the first year of life that you know it's tongue tie is going to cause mouth breathing is going to cause brain damage and you know growth development you don't want to go there all right and the second thing to mention is that often times babies have a difficult time getting that lip seal not because of tongue and lip tie issues but because their lower Jaws are recessed we have cranial strains we're using um swaddles and snooze to kind of confine the babies okay and you have a lot of fascial tension that's holding everything back releasing the tongue on the lip helps you compensate for restricted jaw Mobility because of limited body Mobility you guys see that in some other cultures like India for example all the babies out of the womb get a finger underneath the tongue and then they get oiled the grandparents great grandparents come to get oil massages move what do we do in the United States why does my baby move why isn't he growing why do you think okay you got to move the body to relax things and get things grow and as the jaw grows forward we see that a lot of the things that we think we're treating with tongue and lip ties are really covering up these jaw and fascia issues are you guys with me okay so when they say that tongue tie is being a little bit overdone it's not being thought out carefully okay that's feedback you got to you got to own that be like huh they feel very strong about this what can I learn about this how do I make this more specific how do I know there's really a tongue TI there and it's a tongue TI issue and not a jaw or fascia issue you guys with me and so that's where we're taking the research we're not doing research to prove that it works that's not that's not the way that we do research proving something we do research to learn not to prove we know that we don't know everything we know that this is investigational and uh and uh that's how we're going to continue to make progress in these areas questions comments on these topics you guys learning some stuff already just half hour into it yes okay very very very good all right so you know the premise of all this is that half of you learn what you learn in medical school be shown to be the dead wrong or out of date I have a colleague from Medical School Ashley where are you Ashley where's Ashley amazing stand up okay we went to medical school together right 2010 right it's so great to have you here do we learn about this medical school not even close right like like tongue tie breastfeeding pallet expansion was it possible to expand an adult pallet in 2010 no okay all right so when people say there's no evidence for something thank you it's great to see you there's no evidence yet yet because it's investigational and we're on the Forefront of things are you guys feeling me okay we our Clinic is on the Forefront we just got back from the alsc Symposium and we got all the updates that are going to be published in 5 years we are 5 years ahead of the Asha leader ahead of the New York Times let me show you where the research is headed that's how you're going to spin it do you guys feel me all right and so this is the process of research and research means investigating to clarify the truth to clarify to see it better it does not mean proving or disproving something you can't use a research article to disprove that pin doesn't work you can't do that I showed you with a case report that it's possible there's no research that can say it's not possible and we're already beyond that and so let us consider that all truth passes through three stages first it is ridiculed are you guys with me second it is violently opposed third it is accepted as being self evident and so as I share these concepts with you the first thing I'll say is that probably I'll come next year and there'll be some changes and I'm proud of that okay we're going to clarify things we're going to get things better so you know stay tuned but also I want to share this case with you have you guys seen this case from Karina let me share it for a second okay my name is Cina wi and my father's really Tongue Tied can't use his tongue at all and I had a frenectomy when I was seven because I was tongue tied and it didn't make much difference my tongue looked sort of normal but I've had really bad headaches my whole life I have scoliosis um a lot of jaw tension a lot of problems sleeping and um I had been told that perhaps I should go see an or my fashion specialist but I hadn't done that I actually did a uh had to do a pallet expansion because I had such bad sinus infections all the time and I didn't want to do sinus surgery and the pallet expansion helped and it helped the headache somewhat but not entirely it got rid of the sinus infections but I still have a very small pallet um and eventually after that I decided I would go see joy and I would joy Moler and I would go have um an evaluation and she suggested right away when she saw how I was swallowing that many of my issues including the not sleeping including the constant headaches and the TMJ might really change if I had a deeper frenectomy that my that my um adhesions I don't know what you call them were were deeper in and were submucosal and that they had not been uh disconnected in the first surgery so I came to see Dr zagi and he agreed that this would make a big difference and I had a tremendously forward neck when I came to see him I was sort of like this all the time and lo lots and lots of tension all the time in the jaw the back of the head constant headaches and um the experience of the surgery was really amazing for me because I was scared of it because I had this botched one when I was seven um and Dr zagi and his assistant were incredibly um present and and and kind and and informative so that it wasn't so scary to do the actual procedure was not painful or difficult really at all but what amazed me during it was we I had pretty deep a need to go pretty deep to cut the cords so what was amazing to me was that the first layer of cords I didn't feel much and I thought oh I'm going to be the one person this doesn't really change and then the second layer I started to feel this opening in the back in the back of my neck and particular where the neck connects to the spine and but the third layer when when he clipped them it was like everything in my head and and and back opened up and so now you can see that the way that I hold myself is completely different this would have been impossible before the surgery so in one second there was this feeling of oh everything opened up the pressure in my jaw is gone the pressure in the back of my head is gone um all kinds of possibilities are opening up I've had a little bit of a dance with my scoliosis and this is in 2017 7 years ago where something like this had never been observed never been documented had never been communicated since that time who has had a patient just like this let's see show of hands amazing right almost everyone in the room and we see this like on a daily weekly basis all right and we've really figured it out just the other day that that girl who came in and had such an amazing release we figured it out what are the essential components the preoperative Mya functional therapy body workor how deep to go to prevent any kind of bleeding or salivary gland or nerve injury the post-operative protocol and would you guys agree that it's now pretty self-evident that tongai can affect things like FAL restrictions TMJ mouth opening and so we have to really kind of consider that here she is two years later now when this research is emerging you have one of two options one is that's really interesting let me learn more right and there's a lot of you here who are like wow that's amazing let me come study with you let me come learn that's one approach the other approach is to say it's impossible this is not science and let's not do it and so that's the feedback that I got this is back in 2017 from Eric Kazarian and the first thing that he did in this process of research is what what's the first stage ridicule he ridiculed me he made fun of me he called me up and he said what are you doing what aoke joke okay you're better than this what's this testimonial get out of here go go get better research okay so that's what I did I went and got better research and then you know what happened what's the second stage violently oppos he took out paid Google ad to my name okay like a dollar per click suu zagi okay breath Institute Westwood okay to this post sleep apnea is serious don't do myofunctional therapy it's dangerous don't do a tongue tie release okay there is nobody who would recommend this except one person enough is enough it's time for someone to speak up there is no proven benefit to Mya functional therapy or tongue tie as it is practiced in the United States if you're interested in doing this go to Brazil what he literally says that he says go to Brazil well I have some exciting news for you okay time is passed and the research is there the research is here to support what we're doing okay and uh the research shows the 2019 that yes tongue tie surgery can help with mouse breathing muscle tension snoring clenching and grinding and guess what this article is top three downloaded and referenced article in the journal lingos [Applause] scope so think about what that research process has done for all of your patients and all of your communities and I'm jazzing you guys up because there's still a lot more work to do and we really have to look back and reflect on where we've come from and stand proud with our successes so we can have the energy to push forward and so there's a lot of people that go behind the scenes so I just want to give a shout out to our uh amazing clinical research team at the bre Institute thank you guys so much for working tirelessly lately and Chad we're up till like 11:30 or 12 getting the final touches on our newest research on wound healing integration and maturation which is really going to transform our results uh these this is the number of Publications that we have since 2017 okay showing you how busy we are thank you guys so much and so we're really in a new era it's a dawn it's coming and I also want to give a shout out to all my amazing Affiliates where are my Affiliates in the group and my ambassadors for replicating this for being playgrounds to retest and test these ideas because it's not it's not enough that I can do it in my clinic you have to be able to do in your clinic according to the protocols that I give you and so we give you these protocols you guys try it out you say what worked you say what didn't we come back year after year and I can't believe how much we've achieved just in the last year alone and I'm excited for what 2025 who's excited for Florida 2025 yeah you guys going to be there so no matter what people tell you words and ideas can change the world but let us remember that all truth passes through three stages say it with me first it is second it is third it is accept is being self-evident okay and I want you guys to remember that when you see challenges and controversies okay and this is the most important part I was like building up to this moment okay you were doing the work you're seeing it look at me look at my kids look at your patience it's right there all right yet people will come like there's this one girl who's stalking us Briana milock or something like that who is this girl she publish anything every time you publish something she comes out there's no evidence there's no evidence okay this is January 22 2024 and poor thing I'm so embarrassed for her she put online that tongai there's no evidence that tongue Tai causes feeding or speech issues I I feel sadness for her okay it this is not going to affect my patients and my clinic all right I I see this I'm like what what do you think think about this article I'm genuinely sad for her what a missed opportunity to really help her patient she has a platform and she missed the Target on this okay what are you saying there's no evidence okay and second of all lack of evidence is not evidence lack of evidence means yeah lack of evidence is not evidence right lack of evidence means you don't understand so you publish an article 20 it's 2024 everyone okay and I don't know about tongue ties and feating and speech issues you sound ridiculous there is no highlevel evidence yet but this is the way the research is headed we're on the Forefront when the patient what do you think about this article they're right there's no highlevel evidence yet because our Clinic is on the Forefront we invest in our continuing education we go back year after year we contribute to research at this Center you guys see how we're turning the language around okay that's the way we want to Target these things because the research and treating your patient like a puzzle some of these puzzles we figured out I get these poor patients coming in their heads forward TMJ 28 millimeter inim Moler width tongue tie so excited I can help them right we got these figured out but there are other cases we just don't know enough we just don't know enough how about these patients with connected tissue disorders okay what do you do for them how does that work okay and it comes to to pass that that these there's a lot of patients with these minor different kind of syndromes and issues that the only way we can study them is if all of the patients come together into a pool okay so the next stage of our research isn't going to be just what we can see from the top but how do we get deep deep deep in there and we've been working for the past three years on a platform called breathe insights which is going to be for everyone therapists doctors everywhere you put in your the patient puts in that they have like Marfan syndrome or they have heos downlo syndrome or that they're pregnant or they're taking this medicine or they taking that medicine and then everyone puts it into the system so I can go and query hey 50 airlo downlo patients how do they do right a 100 patients with this connected tissue disorder pregnancy narrow pallet think about the power we'll have right if we all come together in that way and so one of the biggest challenges so far has been collecting the data but I'm really really excited for this breathe insights platform because it's going to facilitate your uh op notes your procedure notes your consult notes informed consent legal medical considerations billing everything designed specifically for the work that we're doing and it's constantly updating and adjusting so this is funny Linda Denio posted this on the or my functional study group okay it's a little uh little cartoon here and the individual is doing a poster presentation and he says I have attempted science so the so the instructor says please explain I formed an idea and then I discovered I was wrong there are numerous diagrams I was wrong in numerous ways I produced a detailed tribute to my rogness lady goes that is science okay love that love that for two reasons first of all that is science okay science is saying hey I taught you guys how to go deep with scissors seven years ago you know have to go so deep you could stay more superficial okay uh we we we talked about you know Dome procedure and now we have like marpie which is easier and and and more fluid and so the most important thing to recognize is that science is about continuing to learn and we have a lot more progress to go because this is a patient that I just saw in the clinic you can see that he has the compensated for go ahead and show me your te good uh-huh and open up your mouth open big big big lift up your tongue okay and so what are they doing for your orthodontic treatment what are they doing mom what are they doing for him what are they so far they are trying to fill in the the spaces that they they pull four teeth out two on the top two on the bottom and now they're trying to to fill in the spaces got it got it got it and you guys didn't want to P the teeth not at all not at all said there's no other choice no we had no choice got it smile for me again all right we're going to thank you for some referrals okay buddy okay all right so sad right so unfortunate that in 2024 we have to have this the first thing I want is for Mobility we're describing them in three ways now good Mobility compensated and restricted okay that's just kind of globally then you can do the measurements floor of mouth hole trmr this is a Grade Three compensating a grade two are you guys with me on that we're going to go over that in a second okay go ahead all right expert consensus statement how to treat sleep apnea and kids after otonomy you know what the treatment is it's tongue based reection okay it's cmri sleep endoscopy under sedation to cut out the back of the tongue what about pallet expansion what about tongue tie surgery not mentioned on here what they're advocating for in Pediatric Sleep Apnea currently in the ENT Society is tongue based reection this is it okay if you fail to cure sleep apnea what do you do cut cut cut cut all right and we ask hey is there a better way so show people hey look at Mayo look at tongue tie it's easy it works but some people tongue up lips closed healthy breathing through the nose are you guys with me chewing and swallowing is needed to grow I made a lecture okay outlining all the long-term implication untreated Tong Tai with a balanced look at the research if an article comes out like these New York time articles instead of getting reactive you post today is a good day to share this article today is a good day to share this YouTube video okay do not repost the article do not give me can we get some you guys got it do not repost the article do not take advantage of the situation to get more followers on your account why do you feel like you have to respond today you're trying to be exciting you're trying to be novel this is a travesty these articles okay I was really affected by this because I was interviewed for this okay I made myself available like my time with my kids is precious I went through my entire presentation hour hour and a half laying out all the evidence qualifying it telling them Hey listen you have a big platform okay you can really what you're going to say is really going to make a big difference and uh ultimately everyone's seen this article right yeah you know a lot of disappointments but the biggest disappointment to me was the reactivity I saw okay was the oh did you see this article posting it getting shares people coming up with the white screen saying oh this article this article follow me follow me that's not what you want to do this is a Travis this is a sad situation so today we're going to post an article one of Dr maxter articles one of Dr zi's articles you're going to ignore it you're going to let it go down cuz if you look at it if you post it if you repost it all of your followers will see that post every time you comment on it it goes Higher and Higher and Higher and then it gets picked up by the Atlantic and it gets what are you guys doing Let It Go calm down it's behind a power it's behind a paid wall anyways no one's going to see it give them a low review pump up the investigative orology top three right your views your algorithm matter don't promote it don't share into it don't be reactive share a different perspective today is a good day to share this article someone else posted an amazing article by Dr Baxter myself whoever else Dr Agra wall with the flip post those articles this day ignore it let it go but I have is Dr Scott seagull here today is that okay but but Round of Applause for this man okay Round of Applause wow wow wow wow wow man my heart goes out to him he was subjected to the newspaper test have you guys heard of this okay and the newspaper test is something that you guys should consider every day that you do something in your patient new new intervention it's by Warren Buffett and the idea is is that if what you were doing right now was exposed by the New York Times how would you feel what would you think if a patient messages you I have these symptoms do I have a tongue tie yes you definitely have a tongue tie how would you feel they got picked up by the New York Times is that the right thing to do how would you feel if the New York Times picked up a picture of you at the tequila and tongue ties conference you guys see this so it's a not show average Dental meeting this is a real conference by bows you should be embarrassed to go to this conference right here we are new research evidence Study Club how can we prove okay this doesn't pass the newspaper test Dr back Dr seagull does pass it the article was clickbait you know I'm gonna believe to myself the person who interviewed me believed me and it was the editor that made it so nasty okay that's like my personal I don't know but the facts in here aren't bad it was the way that was spin Dr seagull's been practicing for two decades amazing that passes a newspaper test he sees up to patients a week he doesn't charge an expensive fee okay there's a lot of follow-up time energy that goes into these things he invited them to watch he's not doing it behind closed doors his open kitchen concept he's like come watch me do it before each procedure he did a complete informed consent he did a thorough exam that's what they're saying here right one mother came in and did a lot better he's being honest about the research we're looking to be proactive not scaring them he used you know protective glasses and he you know suctioned out the plume amazing amazing he acknowledged that few studies support this he has thousands hundreds of five-star reviews but not everyone's satisfied and that's true too it's 99% 97% not everyone's going to be and he has low complication rates right so round of applause okay so in a way the Artic is you know violently opposing it but the facts that they have all stand up for themselves and he passes the newspaper test so people asked me you know what do I think about this and so um you know I think that uh we have to take a more nuanced approach to these things remembering that all truth passes through three stages first it is ridiculed second is vly opposed and then it is accepted as being self-evident any questions or comments on this approach okay so that's why you guys saw me people said what do you think Dr zagi what does breathing Institute think I said we're not going to respond to this all right I'm gonna wait come in the right platform really thinking through what I want to say and and that that's what we're going to do and I'd encourage you guys to kind of reflect on that and do the same all right so now let's get to the meat of it all right tongue tie diagnosis one of the biggest problems is that people don't know how to diagnose baby tongue ties it's a major problem if you rely only on symptoms if you can't show them it's a tongue tie what are you doing that's a major problem in our society in our in our current platform so for adults we've done a lot of research and we've shown that you know the cutof free tongue measurement is good but there are individuals that fall through the gaps on these the cillos classification is not going to tell you if they have a tongue tie or not it tells you where it is and the chances of it but this doesn't tell you how bad the tongue tie is it really doesn't tell you anything it's just describing it to you trmr is helpful but also limited and I we've lectured on this in Prior years all right what we're finding to be the most helpful is and so this is showing you that first of all trmr is not applicable to under age 12 so those measurements the average is 50% for 3 to 11 all right the most useful tool to diagnose these things is a finger in the floor of the mouth so we're changing the assessment to three categories great Mobility you put your finger there it doesn't I mean the tongue goes up nice and easy it's clearly a grade three or four or compensated Mobility you guys got that those that's that's kind of where we're moving and this floor of mouth hold Works in adults and in babies all right in addition to the sleeping tongue posture hold you're going to demonstrate that there's a posterior tongue tie and what is a posterior tongue tie we're going to change that at this meeting okay and we're going to talk about mid tongue elevation okay because the term posterior is it's a little confusing for ENT doctors because the posterior tongue is supposed to be down the back of the tongue the base of the tongue is down so when you guys are talking about getting the back of the tongue up up they're like do you even know Anatomy the back of the tongue is down and we're going to spend a minute talking about that let me guys show you guys who here has used this maneuver who here finds it helpful more helpful than trmr are you guys with us okay it's like 99% sensitive in specific for uh your tongue for us we're going to publish it this year lift up your tongue okay lift up the tongue to the front two teeth okay so you can see that it looks like a grade two uh tongue Mobility but really she's bringing up her entire floor of the mouth and if we hold her floor of mouth down or it should be and ask her to lift up you can see she can't get it up she just cannot get up her tongue and you see the dimple right here that reflects the side of the frenulum attachment point okay so we're seeing where the Restriction is and it's been published by one Moon and we're going to publish again this year and this is where the posterior tongue tie is but this is not the posterior tongue the posterior tongue is back here these tongue ties are affecting the posterior part of the anterior 2/3 of the tongue let's clarify that all right the posterior onethird of the tongue based on ENT literature surgical Anatomy Dentistry is behind the circum Villa Pell it's that little ring of tissue that part is attached to the hyoid and it's down the part that we're talking about is the anterior 2/3 tongue are you guys following me and a posterior tongue tie is just behind the first 16 mm so really it's more like mid tongue elevation are you guys with me so you have a problem with mid tongue elevation now it's difficult because the literature already has the term posterior tongue tie but it's kind of a misnomer so for the next few years we're going to carry them together and then we're going to let go of posterior and talk about mid tongue elevation are you guys with me all right so why is it mid Tong so here is a 5-year-old eight-year-old boy and you can see that the front he just drank some Gatorade and he's swallowing right and the tip of the tongue is clearing it off but what about that mid tongue is that going up no it's not clearing it up this is done with Gatorade I uh also sometimes use uh fluorescent die by to to kind of show it you can put Opthalmic fluorescent diey on the tongue we saw it together uh doctor uh and you ask them to swallow and you can see if the tongue is going up in the middle of the pet and if the food is being cleared but so let's take a look open up your mouth for me good lift up your tongue all right and let your tongue go down and stick out your tongue very very very good lift up your tongue one more time for me good rest your tongue good lift up your tongue fantastic and stick out your tongue one more time excellent excellent so good okay and then just just for like the description of it just we on the same page what would you guys say good Mobility compensated or restricted restricted okay this is this is restricted category and it's going to be important to classify it in that way for our future research okay um all right so we we've I've shown you guys this case okay where the tongue isn't getting up here it is before and after this is again emphasizing you know the mid tongue just right behind the anterior onethird of the tongue so I just want to take a pause here what should we call this any any thoughts questions should we call it it will take a couple minutes posterior tongue tie does anyone else have any any other ideas that they like better mid restri mid tongue restriction we'll put that out there mid tongue t you want to just go for it huh mid mid tongue restriction give give ideas we're taking notes we're gonna take notes and we're going to practice these things out other ideas sub sometimes this is not submucosal though so this is not this one these are are not submucosal right so submucosal doesn't work cuz this is he's compensated he's compensating and it's affecting the the you know lift up your tongue see it's it's that mid tongue elevation lift it up even though it's not sub so that are you with me on that lift up any other any other suggestions for what this could be called mid tongue restriction what else mid blade who who's who's who's commenting I can't see okay yes mid mid blade restriction with low tongue posture okay but we're we're kind of going we're kind of getting on the same page right and we're understanding that it's just just behind the tongue tip in the body of the tongue and the uh I think the blades the isn't it the tip yeah I think it's right behind it right so it's more it's the body so not not not so you have the the Apex you have the tip and the Apex that makes up the blade is the side and then you have the body so it's midbody restriction again let's take a look at this Anatomy figure make sure we're on the same page all right so you have the apex of the tongue right then you have the body of the tongue and it's really like in the middle of the body of the tongue the Apex is just the first like little like you know 12 to 16 millimeters all right it's right behind there what is it apical yeah we write it down hey we're going to this is where new ideas come from right yeah all right very very good right if you have other ideas feel free to email me or let's have a discussion about it yes please what's that yeah so I so so ventral dorsal so we have ventral coming up I I like that and we have it coming up okay so the way this this this this modality of assessing for the posterior tongue tie all right so now is this one good Mobility compensated or restricted so if you have a positive floor of mouth hold maneuver we're calling it compensated Mobility okay uh so in this case all right um first of all we're calling it depression on the dorsal surface of the tongue the ventrals on the on the inside of it okay so you're seeing a DDT depression on the dorsal surface of the tongue and should you treat it all right if you're like a significantly restricted then you say you're high risk of what's up no it's not the tie is in the middle so yeah yeah um so if if it's like this and it's compensated you want to be nuanced with your treatment recommendations if it's restricted you can say yeah these typical tongue ties affect chewing swelling clenching grounding mouth breathing the ones that are compensated are very common 50% of the population may have these kinds of tongue tie all right uh meanwhile only some patients are symptomatic so if it's grade three four civil restricted encourage release recommend I Am the Doctor I went to a conference based on my expert opinion I recommend treatment okay the second option it's elective the third option is you could but I don't know maybe recommend not all right yeah please that's a little dangerous though so you can't you can't diagnose a tongue TI based on the effects it had because tongue tie is only one cause of low tongue posture it's only one cause so mouth breathing adids tonsils will cause the same okay and so I appreciate that comment but that's the kind of thing that gets in the New York Times yeah we we'll we'll talk okay but I but I'm glad you mentioned it but you cannot diagnose a tongue type based on the fact of a high a pallette you can't do that the tongue tie has to be in the tongue in the tongue function not in the results you can't diagnose it based on symptoms symptoms might suggest it look a little bit deeper because tongue tie is only one cause of low tongue posture you can also if you're not sure you can exclude the other ones I did a CT for tongue space there's no tonsils adenoids I did the myofunctional still restricted I feel a little something it might be a tongue tie you can also make it a diagnosis of exclusion telling the parents we tried everything else you might as well try this but not your first thing to go to yes so we know that develop what else High fashion issues swaddle bottle feeding allergies milk protein allergies for sure much more 90% of the baby that will come to you will have a tongue tie you'll release it if if you're in that kind of modality if if you're in that kind of mindset and a lot of them don't have tongue ties you have to tell yourself you have to admit to yourself that you've released some kids who weren't really Tongue Tied if you've done 10,000 1% of the time you were wrong I'm wrong probably 5 10% of the time if you think you're 100% correct 100% of the time you're not learning anything you're not growing you're not developing how can you get more sensitive how can you get more specific in your approach all right um all right so you're going to tell them to relax hold the floor of mouth and lift you're going to look for Visible depression the surface of the tongue you're going to see is there a physical restriction affecting mid tongue elevation it's not enough that they can't get it up if it's weak and it can't get it up doesn't qualify it has to be a tightness that you feel that's not getting better with their y or or body work all right let's take a look at this case so this is a compensated form good you got a good video mhm uh lift up your tongue good and um do a suction hold good drop your tongue down open up your mouth lift up your tongue lift up your tongue [Applause] uh-huh all right so you guys are seeing that we're good on this topic right the depression ad also surface of the tongue uh you know you tell them again let's go back to it you guys have the slides too relax hold the floor of mouth lift look for that cupping dimple or depression all right DDT depression dorsal tongue okay all right so I'll remind you guys about this case open up for me very very good lift up your he has a narrow palette good show me your suction hold good and then uh put your tongue uh into the back of your throat like you just did it's amazing okay well done bring it up do it again he has a narrow palette no narrow palette SP his palette yes section H hi how all right and uh you want to push sublingual care Uncle so if if I did it that way it's cuz I'm was trying to take a picture you're going to push on the sublingual care uncle and also knowing that is going to affect your surgery because you'll do your surgery in a way that is separating the tongue from the floor of mouth which is the goal of the intervention good it works but it's hard to really assess yeah so at the time of surgery it's a little bit hard the baby's crying you're not getting the best uh but in an assessment if you're assessing you're not sure you hold it down and you see a tight restriction you shown the tongue tie you show the Mom hey look when they stick out their tongue they have the milk tongue in the back of the tongue it's right where the Restriction is you're proving to the mom that there's a restriction you got to prove that there's a restriction New York Times won't come after you often email go get released because you have these symptoms that doesn't cut it that doesn't pass the newspaper test and and the more successful you get the more scrutinized they're waiting for you to slip up right all right good good good all right so uh what about tongue space issues all right so we said that you want to be more than uh you know most people are 34 to 36 mm if you're less than 32 if you're really narrow you can get worse especially if you have a diminished posterior Airway space uh after the break we're going to talk about how to assess tongue space if you know you do these procedures and they have a narrow pallet they can bite and clench on the sides of their tongue and um we you know we're using the LPS palal overflow because you know you can get complications like this one this patient didn't have enough tongue space you go in there to do a deep release it swells up a little bit and then you get more and more complications es schema diminished blood flow return so let's remember it's tongue tie tongue tone and tongue space and if you identify the tongue tie and the tongue tone okay you're good but if you miss the tongue tone in the tongue space and only focus on the tongue tie you're not you're not going to be in a good place all right so let's take a you know 10 15 minute break we'll be back at 10:30 when we come back I'm going to show you the new technique I'm going to show you Kenalog we're going to go over soft pallet and tongue space research thank you guys so much for coming we're going to come back at 10:30 welcome back everyone welcome back very very good thanks for all right so hope you guys enjoyed the the first uh you know hour and a half of the lecture thanks so much for uh giving me this platform and U I think on the break where where we're headed is a mid tongue restriction okay you guys feel good about that mid mid tongue restriction okay so what's that yeah it's clean so that so so every year we come here we get your little two cents we're going to get your two cents on some things here but we're moving away from posterior tongue tii and introducing mid tongue restriction which equals poster your tongue tie and then in four or five years we used to call it posterior tongue tie now mid- tongue restriction or mid tongue restriction AKA posterior tongue tie not submucosal because submucosal refers to where it's attached rather there's a restriction like a physical restriction not a weakness not a tongue space issue affecting mid tongue elevation very very good all right so you know we showed you this article and the amazing results we got right it's it's it's incredible to see this reproduce that I think we have like 2500 ambassadors over 60 Affiliates uh who are doing this work and you know it's one of the top 10 downloaded articles from the journal lingos scope investigative oology having you guys download our work and cite the work makes it more likely that we can continue to published in those journals meanwhile the prior way that we were doing this was associated with a lot of complications pain bleeding 133% of my patients would bleed for more than 24 hours for would have some bleeding and 2% for more than 24 hours okay the prior version was with just scissors approach I had some numbness of the tongue tip for 2 weeks about 5% 3% were numb for more than two weeks that those are some complications guys okay some salivary gland injury and uh so we decided hey what can we do to make things even better all right uh since that time I've moved to an approach where we're using exclusive we're using like laser and more refined examination techniques including the floor of mouth hold to guide the depth of the release so if I were to ask you in What proportion of cases of mid tongue restriction okay that's the compensated one the posterior tongue tie all right is the muscle involved what do you guys think 100% 50% yeah comes out it's about 50% okay and the muscle can be involved to different extents often times just a little bit of fascia other times you have to go quite deep but in my hands the muscles involved about 50% of the time and I'm not stripping the muscle and getting every little bit uh the more you go into the muscle the more contraction you get and I had some questions about what's the best stretching protocol okay how do we show that Kenalog Works what about sarapeptase what about Vitamin E oil all right and the common denominator to all of these the common denominator is that we don't have a way of assessing our wound healing results you guys see that so today we're going to demonstrate to you guys the wound healing integration and maturation scale and then what we're going to do is we're going to try different stretching protocols and we're going to rate the patients according to these scores at two to six months and we're going to say hey when you do the stretching when you don't do the stretching when you do the Kenalog it's objectively improving the quality integration and maturation of the wound does that make sense that's how we're contributing to that research all right so um you know I want to save some time but basically you have the patient lift up their tongue or do a limal padle suction or you assist them in doing so the prior version was with scissors but basically you make a small uh opening and you can see that the small opening is now uh you know a lot smaller and more confined as compared to before so this is like the kind of depth of release that I get now as compar compared to you know Katarina win where I was going in there deep releasing all the muscle fibers most my incisions are very very very small the smaller the wound the smaller the scar okay if they have myofunctional issues it's a struggle so doing the myofunctional therapy beforehand can certainly certainly help all right um let me go let me you how I used to do it and how things have changed a little bit all right so before I would do like a hemat I still do I now curve the hemat a little bit lower because the objective is to separate the sublingual Carles down and the tongue up all right so I'm going a little bit lower but don't go so low that you cut through the sublingual Carle all right if you go too high well then it's still going to be attached to the sublingual Carle and your floor of mouth hold will still be positive are you guys with me all right I know this is kind of fast we only have an hour and a half but I'll give you everything I have we have the lecture slides if you want to take the annual breathe update course it's about an8 hour video on demand that you guys can can learn or you guys can come and Shadow spend more time all right so before I would go in there and I would pick out fibers okay I would pick them out until it was all clear not doing that as much the end point now is what floor of mouth hold tongue getting up that's it all right you're not going to strip every piece of mucosa and fiber and every last strand because not necessary for the outcomes the less deep you go the better result you'll get so you'll see before I had like a lot of sutures here and here's the new updated approach okay we start by determining is this good Mobility compensated or restricted which one is this going to be okay it's compensated all right and you can see that on the floor of mouth hoold it's like mildly compensated all right it's not terrible we give the injection to that area Okay hemat clamp you'll notice that I'm kind of pointing downward trying to separate the sublingual Carles uh from the freom pushing the sublingual Carle towards the floor of the mouth I do a little bit of a push back see how small my incision is all right I get a qtip in there that's it okay I'll lift it up in butterfly make sure the muscle is like kind of deep to the vental surface the muscle's not sticking out when I lift it up check the floor of mouth hold much better all right and that's it it that's my release I'm not digging in there trying to get that fascia out there is a fascia band in there you guys see it right here okay I'm not fishing out the medi lingual septum like before you've reached your objective all right then then you take it a little bit and just the fascia at the bottom and the muscle will release you're trying to preserve as much muscle as you can okay so as little fascia towards the bottom towards a sublingual Carle as you can all right and a couple sutures fewer sutures than before and between the sutures I'm using percal glue the sutures introduce inflammation all right and they also cause a little bit of wound dehance as the tension can sometimes tear so a couple of sutures in perac glue we get great healing all right let me show you then we can take the dog out either with scissors or we can ablade it on the Ben freom setting okay so that's where the freom was attached before all right so much more minimal than before okay uh here's how you do the pararal glue in between the sutures you guys seeing that just a little bit the littlest littlest bit okay then you use a dry Q-tip this this this works very very very good in their practice finding it helpful okay few fure a little bit of drops of Paracel you guys saw that look again how little I'm using it's like not even a drop you guys see that so you're like 0.1 MLS 05 MLS like throughout the whole thing if you do too much it gets crusty and it's not so nice okay here's what the final result looks like we confirm it with the floor of mouth hold maneuver the floor of mouth hold maneuver is like the most important to me even when I check them afterwards floor of mouth hold if you're good then you don't have a mid- tongue restriction all right and then we ask him how he's doing all right Ethan thanks so much for participating and allowing everyone to learn from your case tell us what you experienced during the procedure it was very um stressfree um didn't feel any pain um I notice a lot more mobility in my tongue after it was procedure was done I was able to actually touch my tongue to the roof of my mouth comfortably and um yeah that was everything amazing okay so he's getting his tongue up swallowing back you get the same cathartic changes everything you get the same outcomes less complications less bleeding less pain uh better wound healing has anyone tried the more minimally evasive approach yet any comments yeah amazing same same great results any other comments so much less than amazing so better patient selection right more minimal technique better results passes a newspaper test right amazing any other comments anyone yes please it takes getting used to to be to kind of back off a little bit right yeah good good good good good all right so I'm using the scissors more the um laser more and more here are my settings that I like okay I added an upper lip dense Freedom setting um if you know it's you have the lecture slides also if you go to my website zagi MD and you go to educational resources you can also get the PF there if you ever forget the settings but these are my most updated settings my favorite setting is the fascia setting the fascia setting has the least contraction okay if there's a blood vessel something like that fine use the muscle or Freedom vascular setting it's all good if you're not sure settle for the mucosa setting um in babies I probably do mucosa setting unless it's bloody I'll do Muscle fascia you may get some bleeding because it's not drying it up that much okay but it slices through the fascia layers and doesn't dry it up if you put too much heat the fascia dries up and then later on you get a more contracted thicker wound all right and it delays the integration and maturation process are you guys with me good do I like to use sutures yes okay the smaller the wound the smaller the scar um but I'm using fewer sutures but yeah for sure still suturing I don't like PTFE anymore I don't like it the reason is is that it tears the tissue so you put it in there they lift up their tongue and then it tears through okay now you have a big wound the chromic at least you put a couple if they stretch their tongue first of all the peral glue is helping to keep it together and also they fall off after a few days so with the mobility like you're going to be um all square away I have to acknowledge Jenny Chang for teaching me about the surgical glue is she in the room here today no okay um the initial way was just to squirt it in there that's not the best way to do it the best way is actually to push the wound together this is Paracel glue where you get it from again just a little bit okay if you get too much excess that spills around you can you can wipe it away with a wet but if you got precise you just dab it with a little dry and you should be good all right you don't want to squirt it in there you want to get the wound edges together I you can use it on babies all right upper lip tie tongue just a drop like like almost nothing okay like you feel B pet it's just like a little bit of a drop if you put too much it gets crusty and then the crust falls off and then it bleeds and then it's like it's all over the place you dry it up real good you dry it up with a gauze a drop dry Q-tip you're done okay any questions about that yes no I'm s there is Dr Pia Gandhi who uses sutures the technique is very challenging okay it's it's technically difficult to do okay uh so I'm not advocating for sutures I'm advocating for if you're thinking about it and are interested in in doing it I'm not saying definitely do it but you can safely use perac gr infants is what I'm telling you I I have done it on infants and it's been safe if I take them to the O I use I use sutures and and glue in a baby uh so you want to keep doing as small as possible okay and in a baby you're you're keeping the wound small uh you're you're pinching it together and then putting just a drop just a drop like where the muscle is where that little opening is so you're just kind of laying it in there okay just to drop it just helps everything not contract down because where that thing is it's not going to stick down to each to itself it's going to heal from the bottom up because that's how that's how secondary wound healing works right so you're protecting the top while the bottom comes out and then it comes off my pleasure if you use Vitamin E oil v o will dissolve it so you can't use vitamin oil if you use this yes you're going to get less bleeding so if you if you use it so same no vitamin oil that's the only thing unless it's getting crusting vitamin oil will come off yeah so if you want it to come off it's getting crusty vitamin oil it'll come right off uh but if you have like those wounds that are a little bit bloody or you know you're not so happy with it or whatever a drop peral glue goes goes a long way no it'll actually be nice and soft you're just using a drop it's like over like the muscle layer it's just a drop if you put too much yes it'll come off try it on your own hand okay you put just a drop kind of smooth it over just so it's like smooth and continuous if you have rough f as you push too much it's not going to work better not to do it start with the lips okay if you're looking to do it put it just a drop see what happens um you know kind of push it down if it gets too thick and crusty uh you put too much or you you don't want it to be wet good all right okay so let's talk about wound healing all right all wounds go through these stages of inflammation granulation tissue and wound contraction and then from two to six months from two to six months we have a very important stage it's called maturation and remodeling okay and today we're going to talk about this phase of maturation and remodeling which happens in all patients between two and 6 months the most tight when will it be the most contracted one to two months okay that's the most contracted after that it automatically loosens up there are some things that we can do to accelerate the healing all right so the first few days you're dealing with you know inflammation the inflammation brings granulation tissue through the first week by about day 10 the granulation tissue starts to contract when it contracts you're getting typ three collagen type three collagen pulls the wound in from all directions okay pulls the wound in from all directions tight then from 2 to 6 months the type three based on the movement that you're doing changes to type one which is more linear okay it's not pulling in from all directions the type three collagen resorbs and you get type one collagen which is more stronger and finer and more elastic okay uh so here we have a patient preop one week posttop one month and 9 months you can see from 1 to 9 month months what an improvement we have just based on natural wound healing and remodeling all right in order for us to be successful in rating hey is it good to use suas it good to use Paracel what about vitamin E what about cepes what about wound stretching protocol the first step is we need to have a good grading scale do you guys agree okay so let's develop this grading scale together here and your input will count just like mid tongue restriction all right so first of all first of all which stage of healing do we have here can you guess how long after surgery this case is exactly this is two weeks posttop okay so if you want to get good the first thing you want to do is learn to recognize which stage of wound healing you're at you're at two weeks this is the granulation into the contraction phase are you guys with me on this all right this point you can't really assess what's what but what we say when we're evaluating them is saying you know minimal granulation tissue or a lot of granulation tissue and is the wound open or closed those are the things that you want to kind of evaluate for if the wound is open still it's going to delay the integration and maturation if the wound is closed and small you're going to have more advanced quicker integration and maturation yesing at two weeks if the wound still open death probably recover suure uh maybe yeah maybe it's hard to say yeah maybe the Su just popped out yeah all right how about okay here's another case all right which time frame are we in now okay that's pretty good so this is I think closer to uh maybe maybe like a couple months I think okay maybe two months but four weeks is a good guess the wound is closed and then how's the mobility is it good restricted or still compensated what do you guys think still compensated you have that floor of mouth involvement all right the next thing we want say is how thick is the wound is it 1 to 3 mm 3 to 5 or more than 5 millim 3 to 5 millimeters okay this is going to be helpful because you're not just saying oh it looks good what do you guys put on your notes the wound looks good the wound looks bad like how like like who had good healing I had good healing who had bad healing I had bad healing like how do you even describe that right but this way you're like all right the wound is three to five millimeters there's some compensated Mobility okay uh the next thing we're going to look at is the color all right is it well integrated is it totally pink we're going to go through some cases so take some notes on the grading scale or we'll we'll you also have the the the sheet there is the color is it totally pink well integrated is it integrating I'll show you examples or is it distinct it's like white okay if it's white it's you know a little delayed healing okay if it's pink it's really good well integrated healing the smoothness is it totally smooth well integrated slightly raised or rough in texture and the mobility those are the five different categories okay so this is two months posttop fully healed a little thick a little contracted and so we develop this grading scale okay either either look on the sheet or take some notes because we're going to go through it together okay this is the new newest uh you know way so next year I love the presentation this year on the cbct keep that up next year come and rate some tongue Mobility you know how are things healing based on different protocols hey I tried you know this kind of product or that kind of product look I got a better whims score wound healing integration and maturation scale first of all what do you guys think of the name whims you guys like it okay so because that's what we're trying to describe it's about wound healing it's about the integration and it's about the maturation and it kind of sounds good right whims but we went through many different uh variations we're going to call it lfw anyone like that one lingual frenulum wound healing assess like Ella doesn't have a ring to it okay so we're calling it The whim scale all right and there is going to be three categories nice and simple okay F five categories three options the first one is the thickness you're eyeballing these you're not taking out calipers and measuring it okay in the first one you have like 1 to three millimet you get two points the middle option is you know 3 to 5 millimet and the third option is 5 millimet so you get two one or zero points 10 out of 10 is incredible healing okay zero is terrible healing but it's not terrible because it changes it matures so it's like in progress It's like delayed healing okay so where are you with the healing oh you're advanced healing you're delayed healing the next one is the color discrepancy can you guys see on the first option how it's well integrated and matching yes can you see in the second that it's in progress the pink the melanocytes are coming in right the the color is coming in and the other one's just white it's distinct color this is going to be important it's going to help help you decide are you a candidate for catalog or not all right if it's well matching well integrated all that I don't know if you need to do anything it looks good if you're like white thick means you have a lot of type three collagen and you want to help it become more type one collagen you have an indication to something does that make sense so all right uh wound texture do you guys agree the first one is really smooth right the second one is slightly raised and the third one is like really rough and irregular the next one is contraction the first one is flexible good when you put your finger in there the second one has like mild to moderate tension when you run your finger on it and the last one is really tight and contracted and then Mobility we already learned this one good Mobility compensated or limited okay there's five categories the best score is 10 10 out of 10 means that you have like good like you're all set you're done zero means it's like really bad okay it's not really bad it's like early on in the healing or there's complicated healing or things like that a seven to eight is going to be a good score all right don't just put 10 out of 10 most of them are going to be seven out of eight the tool has to be sensitive so a seven eight is considered good if you have all tens then you can't really measure anything that's why the scale like you know like six seven8 kind of range if you're below low five it's kind of like really not good you're going to need like more attention like multiple rounds of calog oras like more attention if you're like a 78 you could consider it but you don't have to if you're ATT 10 like honestly the patients don't get that much benefit from it all right so assess this wound based on the whim scale are you guys with me all right so the first option is what thickness is this raise your hand is this 1 to 3 millim good 3 to five or more than five okay so we see that there's some kind of debate 1 to three 3 to five and that's fine okay there is going to be some variations in um in uh in the scale and that's okay so you know write down whatever score you did if you said one to three you get two points if you said three to five you get one point if you said more than five you get zero points how is the color is it well matching integrating or distinct integrating one Point okay is the texture smooth slightly raised or uh or you know significantly irregular slightly rais one point is the wound tense is this smooth tense mildly tense or or you know significantly restricted mildly tense okay and how's the mobility good Mobility compensated or restricted compensated Okay so so I gave this a six out of 10 healing okay so I give it a six out of 10 now we're going to observe in two months maybe it's still a six out of 10 seven out of 10 we give calog oh it's a 10 out of 10 that's how we're showing the calog works all right I want you guys to try the calog this year I want you guys to try different stretching protocols and come back and say hey the whim score was this at two months here it is at four months here's it at 6 months and the timing matters okay because doing nothing will also change these measurements how about this is this fun for you guys is this helpful like to study the wounds right you because when you study it you start to see things differently you know all right so how thick is this wound more than F it's pretty thick right it's pretty thick how's the color okay not no color right it's like zero color all right how's the smoothness it's smooth okay how's the mobility it's good okay is there one that we missed so okay so 3 to 5 millimet colors distinct flat and smooth uh so you know it's not bad overall even though it's a little bit white it's not bad if you just wait with time it should improve if you want to give it a l kog you can but it's really not that bad whereas this one looks a little bit more significant five out of 10 six out of 10 all right uh this one how's this one how how's the how is the thickness what score do you give two okay how's the uh color two how's the smoothness two how's the tension two how's the mobility two okay so you could say like a nine out of 10 or 10 out of 10 uh healing all right so if this patient has a complaint unlikely that Kenalog is really going to help you that much you can try it it's safe but you know don't pump it up so much does that make sense all right let's take a look at this case all right that was a really tight tongue tie you know big wound I use the sutures percal glue here he is at two months I would say that's pretty good okay but instead of writing pretty good on my Note right how's the wound healing wound looks pretty good right do you guys do that that's what I do honestly right looks bad looks good all right now we say all right all right so who who wants to take this one anyone want to take it go for it 3 to 5 millimet okay color white uhhuh texture yeah yeah slightly raised and then flexible I think I said eight out of 10 let see this maybe maybe maybe a little off so eight out of 10 or you could say if I said 1 to three millimeters if you say 3 to five it would be a seven I mean it's not it's not like 100% the scale between people it's just a picture it's on Zoom so it's not the best but kind of gives you a sense all right uh you want to ask you know why these things happened all right how does this won look okay it's thick irregular textured limitting inability like like a zero right probably um and so we revise it and then this is zero out of 10 healing all right and then we this is how it heals after the first stage of release it's better but it's still not great okay it's still a little too thick a little white a little tense restricted so then we can consider her for stage two or Kenalog these patients would be very good for Kenalog the ones with lower scores on the whim scale all right here's a case by Dr Milton GIS that he contributed I thought it was an interesting case all right so you know there's the frenulum band all right um he did a really nice release okay based on what I would do now differently I would put per acal glue between the sutures all right because when there's so much tension on this wound and the wound is so big this patient bit their tongue the tongue swoll up and then as it swells up what happens to the sutures po po the peral glue kind of helps it the smaller you keep your wound the less chances that the wounds going to separate does that make sense all right what are you going to do in this scenario you're going to decide is a stable or unstable hematoma stable means there's no bleeding it's just a blood clot unstable means it's still bleeding if it's stable you watch it if it's unstable you got to clean it out laser pacal glue things like that decide if you're going to resure probably not resure leave it open to heal by secondary intention so here it's healing okay wide wound how's the healing okay so let's rate it not too bad right how is the healing not too bad right you guys want want to rate this all right so what F more than five millimeters okay irregular raised textured colors distinct okay so now we're able to describe what we're seeing was that a fun experience yeah we put a lot of work into it thanks to L and Chad and Dr Lauria and Dr Baxter and all of you guys for contributing it's a work in progress so come back and help us with the language say hey instead of this word here put that word we put the tool available to you guys you guys have it uh and uh you guys excited to try it out okay good good good all right so this introduces Kenalog 10 so Kenalog 10 is a steroid that uh you know affects wound healing first of all in terms of wound healing is a great paper here it's open access download this article if you want to learn about the stage of wound healing it's really really really good article okay it talks about the different phases and basically just to simplify it you have type three collagen and type one collagen type three collagen pulls in all different ways it's like a thick glue like velcro straps grabbing the wound in type one is like a nice elastic silk like rubber band that's keeping the tongue together at first when the tongue is healing you need that velcro coming in from all ways like tying it down when it's better just a little bit of like a little elastic you know rubber band will do to keep the wound together and that's how wound healing Works depend in on how you're moving the tongue the environment the inflammation other things like that Kenalog has been described in the fields of plastic surgery since like the 1960s 1970s all right dermatologists cosmetic surgeons feel very comfortable extraoral it has never been performed intraoral before we did it okay people were who who said someone was scared and then they did it who who was that who came up to me was who did I walk in with this morning okay what did you say Dr Robel so you had you had like a little lip issue or mouth issue and the dermatologist felt comfortable injecting on the outside but didn't feel comfortable on the inside because it's never been described okay so just telling you about like the research process and what we do in our clinics and the risks that we take right because you can have complications and I did have a complication it was a really bad complication all right but I just want you guys to know like what we do the the pain of it in order to to succeed and so you know even though it was described um you know I decided to try it for the tongue and uh I use the same syringe the plastic surgeons use it's like a little Botox syringe one cc tuberculin syringe okay uh this is what it is uh and the way that you get it is either Kenalog 10 which is previously diluted or Kenalog 40 and then dilute it down okay if you get Kenalog 40 then you put one parts of this to three parts of saline all right so basically uh you could like get the whole calog 40 I think it comes like in a little uh syringe of like one two or three MLS for every 1 ml of the product you put three MLS of of saline or buffer or whatever and now you have calog 10 is that does that make sense Kenalog 40 is less expensive than calog 10 and easier to get I like calog 10 cuz it's clean it's ready to go it's like ready like it's all good calog 10 like this cost about $20 you can use it four times um you could use it four or five times the calog 40 same cost you could use it like 20 times or something okay uh uh what else do I want to say uh you want to shake it up okay I you don't have to refrigerate it you keep it out if you refrigerated it precipitates so you want it to be warm all right you want to shake it up if it precipitates then it doesn't look so good so just to tell you about the research protocol the first patient we do all right we tell them straight up I have never done this before you are the first patient doing this this is these are my options we can either do this this or this I'm really interested in trying this I'm very hopeful but newspaper test it's investigational we don't know but the patients who are coming to you are coming because you're on the Forefront of research and you'll find the patients that are open to it meanwhile don't pretend to your patients that you that you know you have a lot of experience when you don't if you don't have doing experience you say you don't they'll still do the treatment with you believe me you're transparent about it say hey we're on the Forefront I just got back from a conference here's the protocol here's what it is let's give it a shot I have mentors to support me if I have an issue okay so here's the patient here's how it healed at two months all right and here it is one month after Kenalog do you guys see that that's pretty good pretty good all right can I publish a paper and say okay the patient presented with all right healing and then it went to very good no so we have to come with a grading scale so we have these pictures and the grading scale that we're using is the whim scale and based on the whim scale you can see it's maybe 3 to 5 millimeters thick textured tense restricted Mobility maybe like a five out of 10 I I marked it as a three out of 10 okay and then afterwards is 10 out of 10 are you guys with me on that okay and so that's how we're demonstrating that the wound healing is improved you can see that it's improved but having like an objective way of assessing it that everyone agrees on is superior here here's another case all right um I won't spend too much time on the grading scale but I scored it as a four out of 10 and then a 8 out of 10 and here is um a patient here hello my friend welcome back it's great to see you we're here to follow up after the Kenalog injection that we did for you I think it was maybe what two to four weeks ago is that right uh three weeks ago right before three weeks ago three weeks ago how is it going fantastic it's just right after that it was still feeling a little tight and then like over time in the last three weeks I don't feel any tightness or pain when I tried to touch the spot and open the mouth as wide as I can you don't you amazing so you have much much improved range of motion and Improvement and the tightness uh all went away amazing did you have any complications or side effects from it no nothing it's just you didn't even great on a scale of to 10 you injected on a scale of one to 10 how satisfied would you or would you be with the injection and would you 10 out of 10 and would you recommend it to others 10 out of 10 yes amazing amazing so so so so good did you do your myofunctional therapy exercise what's that you should do it as standard practice do it as standard practice amazing did you do anything else like myofunctional therapy or stretches what else did you do uh after the surgery uh did myofunctional therapy on a weekly basis till the calog injection right and then after the calog injection I didn't actually do the exercises at all so so he's being honest about it that's probably probably didn't do it after the therapy either after the proced which is why he got tight but it's all good and so you don't have to do any therapy if you want to do it you can but you don't have to do the therapy yes you can give it once the wound is closed okay because at first you need the type three collagen and so if it's open you're not going to get type three collagen you're gonna have a bigger wound so you want to wait for sure until it's closed you don't do the same time of surgery you get delayed wound healing once it's closed you're in the one to two months you're you're like still Contracting maybe you still need the type three okay because if you didn't have it maybe the wound will open again on you so do you want to riskk it at one month or do you want to wait till two months where you're out of that contraction phase and you're in the mattress remodeling phase so two months for sure one month if it's like it's closed is that helpful yes uh yes multiple times you do it once maybe twice yeah one to two months yeah it works for about two or three weeks and then it's out okay um more pictures just for the sake of time patients love it we try a lot of different things and the things some some things hit some things don't we're transparent about it you draw it up I'm not going to you know I'll kind of go quickly on this um you know we show the floor of mouth hold improves after this okay that's a good thing let me just show you how to do it stick your tongue out of your mouth excellent excellent this is a calog 10 we've already put uh Carli on there right so we put topical first you can see it's thick regular 35 mm you go directly into the wound directly into the scar tissue and you and you and you you open it up okay it's kind of like micro needling the very action of going in there breaks up some of the scar tissue and it releases it so you're doing drops few drops halfway there okay you see how it's spilling a little bit you want to wipe that away you don't want to go in there and spill a bunch into the mouth and that's like a like a novice novice move you're going in there and then you inject inject inject and it starts to spill out and then they start to swallow it those patients will get throat pain if you give too much too quickly or when it's open you can get cadaa fungal infection esophagitis and it and it's pretty not not fun okay um so you guys saw that show you one more just for the sake of time okay good you see how thick that wound is directly into the scar tissue okay not into the muscle you're trying to break up the scar tissue right any questions about it like two months yeah yes great I feel safe doing up to one cc or you know 10 milligrams in adults and uh I have at three easily on a child okay I have done up to seven on a on a baby it depends on how much Scar Tissue you have okay so if you have like a lot of scar tissue you can go more but I don't know if I feel comfortable uh too much there yes what's that uhhuh you'd have to do it all the time right like multiple just one Administration or multiple administrations like multiple times that introduces more trauma stress contraction this is a onetime deal so it's a onetime boom boom done like you're set you don't need to do anything else so yeah you could try the topical CL I think someone said that they used it um but every day and they're for sure swallowing it okay and then Canada risk I think goes up I don't know uh over time these things can resolve we're taking pictures and measurements patients are really happy uh most patients experience improvements uh some don't okay some people experience Improvement right away some it takes about 3 weeks okay but there are some patients who don't improve and we're using the whim scale to identify the patients that may improve the most patients experience less tightness less Scar Tissue greater range of motion uh but there are complications all right and the major complication is that of fungal infections there was a patient who had probably four tongue Tates before she came in Som me um I said let me do Kenalog before I even start all right so I did Kenalog and then I did more Kenalog and more and I probably put like 1.5 milligrams and then when I released it I I put some and then like afterwards I put some and put put a lot more anyways she got really bad drush right uh painful swallow that lasted like a couple months so there is a rate limiting factor all right being transparent with you guys telling you that it's good but also like be careful don't do too much it's good to kind of you know test the boundaries of things if you know this has been reported in monkeys uh we want to consent them for the possibility of it so you basically don't want to do it if if you're worried it's going to open or if they're like immunosuppressed not healthy they already get thrush they have like fungus and other parts of their body um if you do get it the what you're going to treat it with is um clotrimazol troes it's 10 milligrams it's a little antifungal that they suck on and um you know you do it like five times a day for a couple weeks and uh that should kick the infection okay any questions about that finally there's a Sarah pep taste protocol yes yes so if we do a tongue tie release and it's like a three-month old six-month old whatever it is it I didn't like the way it heal it looks thick okay mom's still complaining you see improvements okay in addition to that we are also doing oralay which is a 1064 nmet wavelength uh treatment that also really helps okay so I really think there like two categories of patients I do the calog on some people and they're really happy but then some I do calog and it doesn't hit they feel tense everywhere these are usually the ones that on the whim scale it doesn't look so bad on those patients when they're feeling tight everywhere I send them for the oral a procedure by my wife and these people have like fascia releases and it's like incredible it's like a 5 minute little laser procedure it opens up so I feel like it's like a different kind of a indication any questions comments on that good all right sarapeptase works by eating away at the tissue all right it eats away at the granulation tissue who here uses it okay good results so so results so so so so the problem yes good result of serapeptase so how do you use it Mom scrubs it in there it dissolves away the grain tissue huh okay so uh the way it works is you have all this type three collagen you have too much type three collagen in there right too much granulation tissue so it it eats it away like you spray it on there and so you have less type three collagen is is the wound healing longer or shorter probably longer wound healing huh okay so it's more flexible but it delays the wound healing a little bit um I I don't personally use it in my clinic the reason is is newspaper tests okay for the Kenalog it's been used since 1970 in plastic surgery and dermatology and I'm using the same doses indications as you would in plastic Dermatology that passes for me this product specifically says don't open it and it's never been used on babies it's an anti-inflammatory so it's a little bit rough for us to experiment on it although you do get the results like you're saying it's just a little bit like hard or to like Implement in that context of high scrutiny does that make sense you try yourself what you think okay yeah it worked amazing it just it away tissue and didn't cause any bleeding or complications like that five weeks later amazing okay so something to look into if you want to do a presentation on it next year I'm interested to kind of hear what people have to say uh that's where the research come do the whim scale compare this to that you know let's see so we have Kenalog cream we have sarap pepase we have ores we have anything else people use people like Vitamin E oil okay so whatever you like you know try it measure it kind of see but also kind of know where you stand so if you're going to use this you say it's an off label indication for this product it's an off label indication it's not FDA approv for this the Kenalog is FDA approved for Scar Tissue that's that that's that's the difference all right so functional tongue space analysis um we're doing the LPS palal overflow we've described this in in the past who here finds like a helpful tool okay good who here finds it helpful to look for uh scalloping to decide on tongue space issues the Freedman tongue position okay um and so the final one that we want to talk about is the LPS palal flutter sign this is something that's often confused so let me take a minute and spend that second on it basically what you're going to do for this assessment is you're going to have the patient open up their mouth and make the snoring sound try it with me you're making the pallet flutter now you're going to close close your mouth put your tongue up to the roof of the mouth and then try to snore try to make that pal flutter if you can't do it that's a positive sign that myofunctional ENT things like that are going to help your condition soft pallet are going to help it's positive indication if you can snore mouth open mouth closed no matter what you can make like that deep deep sound that's a tongue space issue it's negative for what we're going to offer okay even for soft pallet for soft pallet if you can make that snoring sound with mouth open but not mouth closed you have a good chance of getting it okay if you can make it with your mouth closed you might improve it but they're for sure still going to snore afterwards okay for sure gonna snore afterwards so that's how you're going to use that one all right who here is use the palet of flutter you guys find it helpful to prognosticate yeah you guys like it okay uh and so you know the P flutter comes from the Ping rotenberg sign which has been validated in ENT and we've been working on this study for a few years now so we are proud to introduce you guys know about the feris 6 we now have the feris 6 plus four for adults all right who's excited about this one all right and so the difference in kids and adults is in kids if you have a myofunctional issue you're going to treat it you're going to treat the soft tissue okay the the tonsils the Mayo the tongue tie you're going to do everything in adults you really have to weigh the tongue space issues you really have to like think about that more and so the plus four are directed at managing is it more on the first side like an ENT tongue tie issue or is it more of a tongue space issue depending on uh how many scores you get on this and the cbct so you know give it a shot let us know what you think anyone already seen this or implemented it you guys like it you guys hopeful for it okay very very very good if you want a copy of the instrument see our team and they'll make sure to get it to you so we have the original feris 6 but then we have fredman tongue position LPS palal overflow tongue scalloping and our pal sound positive or negative now push your tongue up make the section hold now try to do it I can't okay so is she positive or negative for the indicator positive she can't do what her tongue is up she can't do what her tongue is down that's more favorable all right uh here's your CT scan o 29 mm all right so what are you going to do first you gonna do tongue tipe first or you tongue space first for her is this good Mobility compensated or restricted is compensated if that right so are you going to tongue typ releas on ER tongue space okay the tongue space you see it based on the feris 6 plus 4 okay she has three out of four factors fredman tongue position is four she has severe pallet overflow she has tongue scalloping she doesn't have the petal flutter so she has three out of four on that she has 29 millimeters but her posterior Airway space is wide Dr zagi 1.6 what a wide Airway well that measurement isn't the measurement you want to look for what's the measurement you want to look for the nbc3 all right and her nbc3 is 125 do you guys know about this naason bason C3 so when you're assessing CT scans the finding is the posture that is the finding if you put them in a headrest chin rest stabilizer posture you can't measure changes in posture when you do an intervention the outcome is better posture first then Airway size the airway size is dynamic as is the posture but we're what what we care more for are those posture changes and the posture changes come from the pet expansion but also from Body Work strength strengthening and things like that does that make sense because when your head is forward this is what's causing your TMJ issues back pain neck pain shoulder pain you want to get the head back the reduced Airway size is a sign of postural compensations and things like that questions comments so it's not to say that cbct is not a valid measure the first thing you want to look for is the nbc3 and the second thing you want to look for is the airway measurements okay and you don't want to isolate the nbc3 because they'll do funny things that will alter their Airway because breathing is first all right here are the widths for the me uh for the adults and Pediatrics we're short on time so you have the references so you can see it uh for kids we go 24 plus Age based on the bo index graciously offered to us by Dr Kevin Boyd again for the posterior Airway space you can see the restriction retromaxillary retrop palal retrolingual and head posture makes a big difference this is the same patient one with the head slightly down one with the head slightly up in the first example is 6.3 examples like 1.3 so twice as big again when the head is down the airway closes when the head is up all right the airway opens up posture is integral to tongue posture we now published Open Access in the Journal of oral maxilla Facial Surgery the anason bason C3 angle a five degree change changes the airway by 25% a 10 degree change changes by 80% 15° is 1 .5 all right so if you have a patient like this who is 15° more than average it's like a 150% compensated okay it's 1.5 times so after you treat her with pallet expansion her Airway will not get bigger it'll probably get smaller this patient you do p p expend her air will get smaller what now okay because she doesn't have to try as hard her head will go back her nbc3 will go from 125 to 110 and her Airway will go from 1.6 to 1.2 have you guys noticed that yourselves too in your practices anyone else noticed that okay all right so keep that in mind let's look at the posture how many physical therapists do we have in the group body workers professionals more of you guys okay Neil's made me a Believer thank this guy yeah when you experience it yourself okay uh it can be really really incredible all right so any other questions about tongue space just want to make sure we addressed all that and then we'll hit soft pallet here's here's oh here's the protocol you you know you don't want to be swallowing during it again I wish I had more time uh to spend with you guys when about half hour left questions on the protocol you guys using this protocol what happens if you use a chin rest where does the tongue go it goes up you can't evaluate tongue position anymore even chin rest you affect the tongue posture okay this is one patient he was swallowing here he is like this if you push this up uh it'll it'll probably look something like this okay anytime you have the chin rest the tongue is going to be pushed up you don't want to use bite registrations um trying to give you guys as much as I can a limited time okay um let's now talk about okay let's see this case all right 74y old male all right he has the bite registration in there okay his tongue is down they use a chin rest all good you don't have to repeat the scan you can see a lot here he's 74 years old has severe sleep apnea unrefreshing sleep RDI of 12.6 worse with CPAP does anyone want to offer him tongue tie surgery doesn't even matter what the tongue tie looks like I'm telling you if the tongue looks if the situation looks like this T is probably not going to help you can start my functional therapy first um uh he's not that healthy but you still want to help him there's a Target here where you can help this guy do you guys see it what's the target the soft pallet how do you know it's elongated below the accusal surface are you guys seeing that so for this patient I wouldn't mess I mean I think he had a little of dementia too and things like that for this patient you're not going to mess with therapy like no offense to the therapist okay so what I offer him is excite Osa it's a device that goes inside the mouth it's neuromuscular education it goes in there and it stimulates the tongue for you works on on uh on people who've had Strokes it works really low tone as an adjunct to Mya functional therapy uh really really really good okay uh this has been shown to really help with sleep apnea any tongue weakness it will help so this patient I'm going to give them an excite Osa and hey we have this new intervention the soft pallet elongation it's not going to cure all your issues but it is going to reduce that soft pallet length all right so this is the nonablative CO2 tissue Remodeling and the this procedure is not a snoring treatment it's a treatment for soft pallet elongation does that make sense okay tongue tie release is a treatment for ankal glossia it's not a treatment for sleep apnea okay so you got to be like kind of specific in terms of what you're going to do questions comments okay so but it works really well I want to congratulate Dr Sophia Catz and Dr Huffman who listened to the presentation yesterday okay amazing amazing okay so so so so good putting it out there sharing your experience your experience whether it's successful or not informs us so I did hear that some of the results were equivocal okay sometimes the soft pile went up sometimes it went down like what's going on and that's very helpful feedback because whatever we do has to be reproducible first of all shout out to Dr Katz's uh son okay I would love to get a copy the laser on the left is an ablative laser the laser on the right is a nonablative laser the nonablative laser just makes the cells go closer together the ablative laser destroys the cells by vaporizing them okay amazing yeah I'm going to ask you for the whole video but that was like an amazing explanation okay and the reason this becomes relevant is will this non-ablated laser work for tonsils all right let's think about that I'll tell you my personal experience but we'll also get it from the physiology this laser tightens tissue it doesn't remove tissue is it going to remove the tonsil tissue no it's going to tighten it what happens when you tighten the tonsil tissue it gets more compacted in there the cryson valleys are now smaller the food and bacteria are more trapped okay it doesn't work for tonsils in my experience I understand that the that the photon way of doing it works for tonsils it's all good if you guys want to try it on the tonsils go ahead I'm just telling you I really really tried hard on this and I couldn't get it to work for the tonsils it works really well for the soft palette really well two minutes predictable reliable we got it down two different settings I prefer this setting all right this is if they're really slow uh you know if you want to be slower here are my fomy settings the blade of laser settings here's what the procedure technically looks like this is the kind of hand speed that you need okay very very good so basically you make one pass horizontal vertical complete the treatment and I probably do it three times total okay um how do we set it up I give them 4% I know you had an amazing presentation on U the different kinds of topicals that you can put you can put back there uh and uh you know amazing the way that I'm doing it nice and easy 4% lidocaine I have them gargle it I fill up about 30 MLS of it and 15 MLS they gargle for like 15 to 30 seconds have do it for 30 seconds you know and then spit it out out wait don't wash out do it one more time okay they'll be num they're they're they're they're going to be good in them at that point um you don't want to use benzocaine if you use benzocaine like the hurricane spray and all that do you know which is what like you would think to use right how long of a spray is is recommended half a second that's it if you're that's methemoglobinemia all right so this can be overdone but this works legit works okay so when I was doing the tonsils I was using some hurricane spray because the tonsils it does it does hurt when you get in there all right uh so these are the settings Peter gave you guys these you have the slides here's what it looks like okay you're going back and forth along the soft pallet and you're going for that white chocolate chip look all right see the the white little dots dot dot dott dot dot dot dot dot dot dot dot you're going to go until you see like a little bit of white if it's still pink maybe you didn't get you didn't you didn't get like that's not the way I'm doing it maybe that's the way your guys are doing it are you going do to white chocolate chip or to pink white chocolate chip how white chocolate chip okay so you don't want it to be black black means you bladed it this is nonablative so you want to just a little white just so you got under the mucosa are you guys with me does that make sense all right um and the other key F and then you know uh this is this patient we're about to do okay the other key finding the real like secret to the success the secret sauce is not only doing the uh interior soft palette you guys see my mouse here but right here this is the money you guys see this the posterior pallette that's the real money that pulls it forward in fact I think that's more important than up here so go a little bit up here all right you're good but as long as you miss this it's still going to look low on your CT skin and you want to get the UA too because that's still going to be low are you guys with me is that interesting okay it's right here white chocolate chip white chocolate chip pulls everything forward you can see it patient breathes it's like it's good okay let me show you all right right hi everyone we are here with Sven who's going to uh allow us to learn about the new uh technique for the soft pallet uh laser application all right so we have our laser uh set up here okay we're going to go to go to zagi MD uh laser educational resources this video is on YouTube it's on my website okay so if you want to show your patience this we have a a web soft palette setting all right good take a look inside his mouth all right go ahead and open up for me good say ah good go ahead and make the snoring sound good one more time you can see that nice vibration of the soft palette that nice p a little flutter one more time go ahead good let's get a little bit closer there more time good again great love it okay so now we're going to go ahead with the treatment let's get the laser ready going to open up for me very good all right so we're going to get at different targets okay the first one is going to be the soft pallet now we're going to the anterior tons pillar that's right there now we're going to the posterior tons pillar okay close and swallow open up your mouth say ah now I'm aiming for the back there okay swallow good open so this is the back area here that's the posterior tonsillar pillar see that there we're going to tighten up the back very very good okay you can already see a little bit of lift there to the pet now the opposite side very very good you can see it's treating a little bit white where we're treating it very very good next we're going to go to the uila close and swallow open good okay we're going to do the uula up and down okay then side to side little lattice shape lies good now we're going to go to the if you're an anti or if you're adventurous I'm going to show you how to do the tonsils here so no tonsil on that side okay on this side this tonsil looks a little bit enlarge say ah say ah ah again okay just getting the tonsil there really really good close and swallow open say a little bit conso there say again any questions or comments uh what's that and that's the protocol go ahead not intentionally yeah it'll work better if if it's a little dry try again uh very very good that be our first cons St it'll close up the cryp but now you close up the Crypt easy you know yeah uh all right so very very good uh amazing Case by Dr Sutter is he in the room today okay I really enjoyed seeing this after uh after you know the seminar uh you know putting into action great result okay you can see the lifting again the pictures doesn't really tell you the whole story the CT scan um is is you know preferable for assessing that uh you know how to measure the soft pallet length um here's another case where the soft pallet got got bigger again the pictures it could be you know like optical illusion so here's an amazing Case by Dr Merchant Merchant and um we can see that the soft pal is really long and then and then it's shorter right so it legitimately I I believe if you do the right protocol right patient elong get it soft pallet will reduce it and I think that this is the main outcome I'm looking for did the soft palette decrease the secondary issues of snoring breathing and things like that are secondary to the shrinking of the selft pallet uh we're looking to do more studies on this um uh if there's anyone who's really I have a lot of different in interests all right this is is uh we think we got it figured out but it's not like a like a dying burning interest of mine to be honest with you because there are other people who are doing it there's not this is already FDA approved for this indication so no one's asking where's the research for this Dr shiffman's pushing the research on that front so it's not like a big need for it other than to show that perhaps the CO2 is more effective at doing it than the phana but you know we have a lot of things on our plate if there's someone who wants to push this research if you guys want to push it I think I think Hal Huffman and cats I would love to uh get a little group anyone else interested in being a little cohort and taking over the project Dr Merchant anyone else okay yeah email ly thanks Ley uh if you're interested we'll get a little cohort together I'll set up the design for you it's not like an like super interesting it works but it's like self-evident it's like obvious that it works so I'm more interested in like the debate and like you know like all the juicy stuff does that make sense any questions on the soft palette anything guys you go Wonder yes long lasting I get I get it like one or two your husband did it right no no he hasn't done it yet got it got it um it's longlasting I'll do it once I don't want to overdo it maybe have them come back another time it lasts yeah like a year at least maybe two yeah yes can it come back can it be overdone it can be overdone so if you overdo it um you can get you can get issues and problems I described a case last year where it just went too high if it goes too high the tongue base won't reach the roof of the mouth you have difficulty swallowing Dr Schmidt here so Dr Schmidt had it done he had like a tongue tie issue like myof functional issues to swallow you got to get that mid tongue up to touch the pallet if there's no pallet it affects your voice and then the mucus as it's coming down postnasal drip sits there you can't swallow as much you get more redness in the back of the throat so you're not trying to destroy the soft pallet you need to cover it there to protect the back of the throat uh so you know you want to do it up to the Cal surface but you don't want to like remove it other questions yes uh me adults yeah yeah I I don't know the answer to that question yeah I just I just I'm not involved in that to be honest with you yeah other questions so what questions do you guys have like research questions about this is this like I'm interested to know I think I got we got it figured out but are there any research questions on this or you guys convinced that it shink it yeah the tongue um like to shrink the sides of the tongue it hurts a little bit when you do it with the CO2 and I tried it a little bit on the sides of the tongue I don't really enjoy doing it like I like to do something like Kenalog and like boom wow thank you doctor or like this like it like really worked um they have you do it underneath the tongue they're tightening the fascia tissue there it's kind of like opposite what we're trying to do to loosen up the tissue with things like ores you know um I would defer to them okay they have some great protocols going on I know this uh you know in terms of you know photobiomodulation uh you know the light scalpel is one way of doing things nonablative laser there is the 1064 nanometer wavelength there is 800 nanometer wavelength there's a laser for everything I'm not sure the CO2 is the right treatment for those indications um you know they people say that the you know the the photon can shrink tonsils and decrease inflammation and improve wound healing I'm all that's all good like you know try it in the nose you know all good I don't think in my hands I'm getting these results with the CO2 okay but I'm getting really good results with a soft pallette so every tool has this indication the indication for the su2 non nonablative is soft pallet also if you have any bleeding anywhere if you have like bleeding in the nose or bleeding on the side of the throat or bleeding from a tooth or ulcers works really nice works really nice so those are the cas I'm using it for thank you all right Dr Stewart had a case okay I would want to get him up but I'm a little short on time uh basically showing like right left okay he did one side and not the other and demonstrated on a couple patients that when you do it it legitimately lifts it up amazing how right wow we have these case studies I'm not sure it makes sense to do like too much more research because we expect it and we know it to work uh and he did it like on a couple patients he did one more patient where he did like one side not the other and when we do one side not the other soft pallet you know lifts up asymmetrically so it's been shown again I just want to know are there any like research questions about this is anything you wonder okay we'll still do the study on the soft pallet elongation okay if you guys are up for it uh you know it could be useful we'll get Peter I know Peter's interested in it but I think we got it squared away all right continue but nevertheless you want to continue to uh you know observe and improve how do we get it better and more effective um here's how's case showing that the Sleep appne improved this is fantastic research we're so so proud all right the final thing I want to touch on before I bring up L and Chad to talk about uh how we're going to push the field forward is our research on lip ties and so last year I introduced some of this research it's now being considered for Journal of pediatric dentistry and so this is like a major uh accomplishment to kind of you know discuss lipti more formal in literature this picture will be uh published in the journal and uh it's showing you you know what is it what is a Max labal Freedom where is the anatomy a lot of P pediatricians don't know these things pregnant don't know these things so we hope these images are helpful uh the attachments can be mucosal gingival papillary or papillary penetrating all babies are born like most of them with papillary and papillary penetrating attachments that by ages 3 to six naturally remodels all babies have class three and four so if you're doing a lot of lips you may be overdiagnosing them not to say it doesn't help if they're having issues but it's probably helping because the lower Jaws recess they have oral incom competence and releasing the lip is helping the oral incompetence so I'm not saying don't do it if you're getting good results with it go ahead but it's not a problem because it naturally regresses over time whereas the lower lip it does not all right so again even things like tension I feel tension in the lip well there supposed to be some tension all right all babies have tension in the lip like 92% okay up until Age 3 to 6 and then it gets less and less there is a possibility that above age six to 12 or 3 to 12 it's tearing and we're looking at our Affiliates at looking at how often does it tear versus naturally uh recede let me share with you the case of my son my son had a very low attachment at 2 and a half years old difficulty brushing his teeth in that area uh we didn't do the lip tie release at the time of the tongue tie release it was really difficult to brush his teeth there a year later we see epical migration of the of the attachment going up naturally much easier to treat so the truth the matter is between ages three and six there's a chance it can resolve on its own don't scare patients in doing lip tie releases I know you're seeing good results it's all good continue doing if you want but also consider that the reason that you're getting the good results is the fact that the problem is not the upper lip it's the jaw is back okay and when you release the upper lip you're helping compensate for that but the problem is the jaw's back so if you're going to do lip tie release to help them because you're so good at it and things like that well are you going to miss the underlying issue which is the body work Physical Therapy jaw growth if you really want to help the patient you'll first put them through the bodyw cranos cyal therapy get that jaw growth if you really want to help them if you're just trying to do a procedure and you miss that and you're just trying to do a procedure don't kid yourself all right is that fair yeah all right so these procedures do help okay they have tension difficulty with lip seal they have vertical grow growth because of mouth breathing and other issues this child his problem is not lip tie all right his problem is vertical jaw growth because of mouth breathing tongue my functional issues but he's having difficulty getting his lips together I can release that tissue lengthen his lower lip and improve oral competence improve that seal uh Sandra Khan is doing some amazing work on lip seal with her up locker system uh to to you know get the lips together if you don't get the lips together you don't get that suction okay so the lips have to come together if the upper jaw is going too down lower jaw is too back lip tie releases can help even though it's not like a problematic lip tie all right this girl you know we do these lip tie relases it has cosmetic benefits for sure people like it we offer the treatment but we don't scare people into it all right um really good aesthetic results okay uh but it's really a lower it's like a lip lowering lip lengthening procedure um so last little bit that I'll talk to you guys about is Buckle ties okay uh Buckle ties we just came up with this with this paper kind of assessing what different people think the classification system can be mucosal gingival or alveolar and uh you know we described what it is who here has seen this paper yes Dr BX maybe talked about it a little bit as well um it can cause various issues so the benefit of this paper that is defining something it's interesting to see the wide variation in different providers okay different people are doing different things there's no real consensus highly experienced providers tend to treat it more people who have been doing this for a long time whereas more novice providers don't see as much into the Buckle ties the way that you want to assess it is based on palpation and symptoms most people agree on that just based on symptoms is not a valid way of assessing it okay you have to feel and have symptoms many people rely on lactation Consultants body professionals or feeding therapists I think that's a good thing okay because if you have these Buckle ties it could be because of symmetries and strains in other parts of the body um if you do it most people will do it on both sides which I think is an interesting thing um 5 to 10% of infants may have Buckle ties some people are diagnosing it like never some people are diagnosing it in over 50% of Tongue Tied patients all right some people say the incident is less than 5% some people say 80% of you have tongue ties so that's like a like we're all over the place on that you know which is it is it 5% or is it 80% um so you know to the extent of buckle ties if it's tense if it's causing a problem you're going to advocate for you know first Body Work physical therapy all that and then bilateral release if you do asymmetric release you can get you know Scar Tissue up more on one side than the other when I do these for adult patients I go from the midline so I do a lip tie release and I Buckle through I um I um I you know dissect through to get all the attachments it can help it can loosen up the tissue um you know people respond well to it uh but um you know we don't want to scare patients into this again it's super it's super elective investigational all right let me give you a pop quiz on a diagnosis and then we'll get l in chat if you want to get your computer up what's the assessment here what's the problem here yep lip Liquors dermatitis this is an individual who is licking their lips probably because they have open mouth posture nasal obstruction and when you when the air is going through it's drying out the lips what's the diagnosis in this case you guys see the problem something that's becoming what's that let's say it again so this is actually associated with chronic mouth tape yeah people like mouth tape hostage tape somnifix like you know all those serious tapes over time every because I'm interested in saying that everything has a risk and when you talk to your talk about the benefits talk about the risk so a risk of long-term uh mouth tape use is uh adhesive related traction alopecia so every day you're ripping ripping ripping ripping just something to be aware of not trying to scare you guys too much all right so did you guys have fun all right very very good hope you guys learned some stuff I got it in there in two and a half hours okay if you guys are interested to really go in depth on all these different topics we'd love to see you at the breathe course in person we also uh do live stream of the breathe course now uh we go through everyone's cases floor of mouth holds CT scans really dive deep and um more than anything I want you guys all to recognize that we need more research who's here who's with me on that on that concept that we need to keep pushing the research forward okay we need to be more resilient because we understand that all truth passes through three stages first it is ridiculed secondly is violently opposed and third is accepted as being self-evident