A day of learning with tongue tie professionals

This year has a been a year of great professional growth through education for me.   I had the opportunity today to shadow two IBCLC (board certified lactation consultants) while they worked with clients.  I have been on the receiving end in my personal life of help from professionals, but today I was viewing as a healthcare provider.  My goal is to learn more about nursing, to expand my knowledge beyond a few books read and personal experience.  Thanks to Liz and Gigi Lull with Enlightened Mama for the time.  

The second meeting of a group of healthcare providers in the Twin Cities with direct "ties" to infants with tongue tie met at Minnetonka Pediatric Therapy.  We discussed wound healing, protocols for stretches and findings of a study from Woodwinds Hospital in Woodbury.  The prevalence of tongue and lip tie appears to be increasing, necessitating greater awareness from nurses, lactation professionals, chiropractors, dentists, speech therapists, physical therapists, doulas and midwives of the problems.    

Learning everyday and loving it!

 

Interceptive orthodontics for children

Have you ever thought you got the same crowded teeth your mom or dad had?  

Or have you thought you have "too many teeth for the size of my mouth"?  

Does your child breath noisily or snore?

Who in your family grinds their teeth at night?

Is your six year old still wetting the bed?

What am I doing asking these weird questions, as if they are related to each other?  Aren't I a general dentist?  Yes,  and I am also a proponent for healthy breathing and healthy people.  I would be the first person your child would see who would ask questions like these and recognize the connection between poor sleeping, deep bite, tongue tie, grinding, gagging and ADHD.  The cause of most bad bites can be blamed for these symptoms and many more. My blog is a general article and I am not saying every health problem discussed is caused by an airway problem.  Not every person with ADHD has a bad bite and not all poor sleeping is caused by this.  However, research has been done to support how widespread breathing disorders are and how they contribute to health problems. I am learning from experts about what causes a bad bite, called a malocclusion.  Anthropologists have proven that approximately 95% of bad bites are not caused by genetics.  Wow, that was news to me!   I hear every day that "Johnie" got his dad's crowded teeth.  In the past I was guilty of evaluating a child's bite, and would suggest saving money for future orthodontics.  How little did I know that early interceptive orthodontics can not only prevent and solve malocclusions, but can improve the health of my patients. 

Anthropologists have studied thousands upon thousands of skulls of many different cultures across the world and over time and found malocclusions to be very rare except for recent times.   Has a genetic change happened that quickly from one hundred years ago?   Other than a rapid change in genetics across the world and across all cultures, what could be the cause?  The working theory of the rapid increase in malocclusion across the world is not only which foods we eat, but literally how we eat.  Different muscle strengths, or weaknesses, along with our more processed diet, do not promote strength of tongue and jaw muscles.  Tongue strength and the motion of swallowing can have an imbalance with lip strength. Our families may be at fault, but by how and what we are fed as babies and children, not because of genes passed down.

The following is a concept that may take a couple of reads to comprehend.  The proper growth of our upper and lower jaw, occurs primarily when we are very young.  Our upper jaw is supposed to grow almost entirely forward, with the help of the tongue living against the roof of our mouths.  When our tongue doesn't live there and flatten out our palate, but rather on the floor of our mouth, we develop a narrow upper arch and a high palate.  Our face looks longer when the upper jaw grows more downwards than forward.

 One consequence of this is crowded teeth, which often leads to an extraction orthodontic plan and retraction of the front teeth to close the missing teeth gaps on the side. If you are an adult, you may have had teeth removed for braces.  Others who didn't have braces live with crowded teeth.  Many people have a deep bite or big overbite.  Others have the same source of the problem but present with an open bite (front or side teeth cannot touch). In addition, an underdeveloped lower jaw decreases the space the tongue has to lift in.   The big deal about narrow dental arches is it creates a restricted airway in the nasal, oral and laryngeal (throat) airways.  What is the one thing our bodies need most urgently every single minute?  No, it's not chocolate.  The answer is air.  Did you know that it is never OK for a child to snore?  Loud noisy breathing and snoring is a sign that there is an obstruction.

The implications of a compromised airway are huge! A small nasal airway leads to mouth breathing and vice versa.  Mouth breathing doesn't filter the air we breath, doesn't humidify the air well, doesn't warm the air well and doesn't stimulate the release of a very important chemical compound called nitric oxide.  Nasal breathing does this all!  In addition, mouth breathers actually take in too much air and release too much carbon dioxide.  The driver for our breathing is interestingly not our need for oxygen, but our need to get rid of our waste gas, carbon dioxide.  When we expel more carbon dioxide than we should, we enter into a negative loop of chronic hyperventilating.   Have you woken up with a dry mouth?  You were mouth breathing.   Are your tonsils inflamed?  That may be caused by irritation by drawing in air.  Do you have dark circles under your eyes?  Venous stasis is the official term and is caused by mouth breathing.  Do you have asthma?   Mouth breathers only exchange only the top 2/3 air in the lungs, leaving one third of the air un-exchanged, leading to many cases of asthma.  An interested book I have read recently is called "Close your Mouth" by Patrick Mckeown.

What does this all have to do with dentistry?  Great question, I am so glad you are wondering!  I used to recommend all children see a dentist by the age of 1.  That is still the case, except for when I see babies to do a laser tongue tie release.    I am connecting all the dots of airway, sleep disordered breathing, malocclusion and general health.  Let's say for example, that you were born with a tongue tie.  Your mom likely couldn't nurse you for long and switched to a bottle.  I have nothing against bottles since both of my children had them since I work outside the home.  However, the significance of a tongue tie, is that the tongue cannot live on the roof of the mouth, creating a wide and normal height of the palate.  When a pacifier (I have used them for my children so no judging here) or a bottle is introduced, something foreign is between the tongue and it's natural habitat, the palate. When the tongue is tied, the upper arch becomes narrow, and since the roof of the mouth is also the floor of the nose, the nasal space is reduced.  The palate can often be so high as to deviate a septum in the future.  So this child grows up breathing through their mouth.  Fast forward to age 2 or 3 or 4 when they are getting so many ear infections and their tonsils/adenoids are so large that they need surgery.  Perhaps the ear infections were contributed to by inflammation of adenoids which blocks the drainage of the ears, the Eustachian tubes.  Also the posterior part of the tongue is supposed to make a seal with the palate when swallowing.  This proper swallow creates a small vacuum which can open the Eustachian tubes.   Eating slowly, having difficulty swallowing, grinding teeth, hyperactivity, difficulty waking in the morning, night terrors, a gag reflex, snoring, sleepiness during the day are a few of the many symptoms that may point to a mouth breathing problem.  A current theory of why people grind their teeth at night is that our brain wants to improve the air quality while we sleep.  When grinding the jaw around, our airway is opened by the jaw moving forward.

And what do you do about it?  My job is not only to give you information on the current health of your mouth, but also suggestions for optimum health.  It is possible to train your mouth to be closed, and become nose breathers.  How is that possible when a nose is always stuffy?  I recommend people see an ENT and an allergist to diagnose contributing problems to nose breathing.  Many people will have a referral to a sleep doctor and an Oral Facial Myologist.  We recommend nasal strips, nasal sprays, breathing exercises and sometimes bite splints or orthodontics.  Chiropractors are often a part of the team by releasing restrictions that interfere with your bodies natural ability to heal and function optimally. Each person is an individual and a plan is made that makes sense for the patient (and their family if a child).    There is no formula that fits all, so careful thought is given to each person.  Some children are really good candidates for a system called Myobrace

The big picture for me as a general dentist, is that I am in a great position to spot health problems.  There is a saying that goes like this "the more you know, the more you see."  A great reward for me is really seeing my patients, and being able to help in ways that are above expectations for a dentist.  Being a dentist is not about being a "tooth doctor" for me, but a doctor who really wants to improve your health.

What is a posterior tongue tie?

As a laser dentist who sees a lot of babies, I get asked about posterior tongue ties every day.  I thought explaining what this is would answer a lot of questions.  Here I go...

We all have seven frenums in our mouths.  Our tongue only has one frenum, and it is the midline under the tongue.  When a person is "tongue-tied" it means that tissue is restricting their function.  We gather a thorough health history and ask a lot of questions, not just evaluating the child's weight gain. So, to determine if a frenulectomy is recommended, we discuss symptoms and physical findings.  For babies, I evaluate what they are doing with their tongue by having them suck on my gloved finger and watching their mouth and tongue move.  For children and adults, I ask they to go through some range of motion exercises.

An anterior tongue tie is tethered tissue that can be more readily seen.  Oftentimes, the frenum creates a fence-like barrier to prevent a finger from sweeping the floor of the mouth from one side to the other.  Many people can see the tight tie when the baby is crying.  These restrictions often insert towards the tip of the tongue and may create a "cute" little heart-shaped tongue.  Anterior tongue ties can be very thin like a guitar string or very thick like a Twizzler stick.  Many of these ties prevent the tip of the tongue from normal movement up, to the sides and out of the mouth.  All anterior ties have a posterior component.  Even if the front part of the tongue is "clipped" and the tongue tip is free, the deeper (or further in) part remains.  The significance of this is that a deeper frenum attachment restricts the upward movement of the mid and back portion of the tongue.  A posterior tie is problematic by interfering with normal suck, swallow and breathing functions.  Often times it leads to gagging, gulping of milk, spitting up, symptoms similar to reflux, excessive gas, nasal congestion upon waking, chomping on the breast and a tongue thrust motion.  There are many other complications including but not limited to improper rest position of tongue, which leads to a narrow maxillary arch, which leads to poor facial growth.  A future consequence is often malocclusion, mouth breathing and sleep disturbances.

Many people who have problematic tongue ties don't have an attachment in the front (anterior part).  Unfortunately, they are often much more difficult to see.  As a trained laser dentist who releases posterior tongue ties, I examine the baby from the 12 o'clock position with the baby laying flat.  My pointer fingers go under the left and right sides of the tongue and the tongue is elevated.  My finger tips are nearly touching.  Examining this way allows me to see if a posterior tie exists.  I take a photo and also feel for a restriction by sweeping across the floor of the mouth.  That area should feel soft, without a hard cord of tissue in the midline.  After practicing dentistry for 15 years (seeing thousands upon thousands of people) and going through continuing education on restricted oral tissues, I am able to give an accurate diagnosis of a tethered oral tissues.  I am a general dentist, which means I treat all ages.

Many health care providers are not trained in what to ask of parents regarding the symptoms that may be caused by a problematic frenulum attachment.  Often a tongue depressor is quickly used while the parent holds the baby upright or is in a car seat.   An absent or poor examination combined with myths regarding tongue-ties (that is passed down through educational system) leads to people hearing that oral tethered tissues do not affect suck, swallow, breathing for infants.  Personally, I remember being taught in dental school that if they have a tongue tie, a surgeon needs to sedate the person and do an extensive procedure called a z-plasty.  Also, I was told that a thick or low labial frenum,  will eventually trip and tear it when the child falls on their face.  Really?  Thankfully lasers can easily treat these problems without sedation, without sutures and a long healing time.   I am amazed that we were taught to tell parents that a potential trauma will solve an anatomic and functional problem.   My blood pressure is raising as I continue to write.  I am upset with the lack of knowledge in general for health care practitioners and moms being told it's a problem with a lazy baby, too heavy of a let down, or that the child just needs to "get it eventually."  I also hear that a tongue tie is "a little tight" but will probably be ok if the child is gaining.   Breast feeding success is so much more than just a measure of weight gain.    I know what you are going through if you are a nursing mother reading this, because I have been there.  The problems are not in your imagination.

Twin cities professionals discussing tongue ties

Dr. Geisler is pleased to be hosting a lunch today with the discussion surrounding infant tongue and lip ties.  Lactation specialists, cranial sacral therapists, chiropractors, pediatricians, orthodontists, speech pathologists and oral facial myologists will gather for the first time.  There will be learning from everyone and an opportunity to meet the other professionals in the west metro of Minneapolis who are invested in helping moms and babies breastfeed.  

How much radiation am I getting?

Dental Radiation from X-rays

                Dental radiographs (X-rays) are a useful and necessary technology to educate your dental professional on your oral health that cannot be viewed clinically (visually).  We examine the films for evidence of decay, periodontal disease, infected teeth and other pathologies.  The frequency and type of films needed is up to your dentist, with your approval of course.  No two people are alike, so films are recommended on an individual basis.

                Radiation exposure is typically measured in units called millirem (mrem).  The average person receives about 620 mrem of radiation, a year, from natural and manmade sources combined.

                Here is an example of different types of radiation and the amounts they give out:

0.1   mrem from a single digital x-ray

5 mrem from a round trip, coast to coast, plane ride

35 mrem from sunlight and other cosmic radiation for 1 year

40 mrem food and water for 1 year due to radioactive trace elements

228 mrem breathing normally for 1 year due to the radon in the air

1,000 mrem for a full body CT scan

10,000 mrem when the first clinical signs of radiation injury appear.

                Radiation is cumulative; however, with digital dental radiographs (X-rays), the dose is minimal. When Dr. Geisler prescribes dental X-rays for accurate assessment and diagnosis, you can feel relieved and assured that you are in a safe range of exposure.

Why do my teeth feel fuzzy?

If you've ever been bothered by the rough or fuzzy feeling of your teeth, you are feeling plaque.  When that soft matrix of plaque sticks to your teeth, sugars and bacteria have contact with your teeth and gums.  When it hardens, it turns into calculus (aka tartar).  The smooth feeling you have after your cleaning can happen every day with proper brushing and interdental cleaning.

My tooth hurts when I bite on it!

When you bite just right on that one tooth, you get a shooting pain.  What is going on with the intermittent biting pain?   If you ignore it, will it get better and just go away?

The pain on biting is called "cracked tooth syndrome."   It is caused by a micro-fracture that is getting deeper every time you bite.  The pain is your nerve letting you know the fracture is getting near the center of the tooth where the main nerve lives.  That area is called the pulp of your tooth.  Treatment is best earlier than later.  Consequences of a cracked tooth are possible need for a root canal or an extraction.  A crown often solves the problem if treated early in the symptoms.