Oral Dysfunction & Development from Birth to Later Years

In this episode, Jacqueline is joined by Dr. Shereen Lim, a dentist from Perth, Australia who specializes in airway health from infancy to prevent problems like snoring and sleep apnea later in life. Dr. Lim is dedicated to promoting airway health from infancy as an alternative approach to minimize the development of these problems and is the author of the book Breathe, Sleep, Thrive: Discover How Airway Health Can Unlock Your Child’s Greater Health, Learning, and Potential.

In this episode, you’ll hear:

• Key things to look for in infancy for optimal oral development
• Why tongue tie release alone is not a cure-all and still requires therapy and other interventions
• How chewing and oral exercises can help stimulate jaw muscles and correct swallowing patterns in young children.
• Ways airway & oral dysfunction negatively impacts older children and adults
  
  

A glance at this episode:

• [3:44] Dr. Lim explains how one would get sleep apnea
• [17:26] Key things to look for in infancy
• [21:57] The importance of chewing during early childhood
• [26:10] Key things to remember with swallowing and drooling
• [30:59] Oral motor patterns in infants
• [38:10] Common misconceptions about lip ties and tongue ties
• [42:00] The role of myofunctional therapy in practice
• [46:46] Tongue tie treatment for adults
• [54:19] Dr. Lim shares some tips for breathing & sleeping better
• [1:00:08] Where Dr. Lim sees herself progressing in the future

Related Links:

• Dr. Lims Website
• Dr. Lim’s Instagram
• Dr. Lim’s Facebook

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Transcript

Jacqueline Kincer  0:03  

Hello and welcome back to the Breastfeeding Talk Podcast. I'm your host Jacqueline Kincer. And I am honored to bring you a special guest today. Her name is Dr. Shereen Lim and she is a Perth-based dentist with a postgraduate diploma and Dental Sleep Medicine from the University of Western Australia. She has been involved in the team management of snoring and obstructive sleep apnea for over a decade. Dr. Lim is dedicated to promoting airway health from infancy as an alternative approach to minimize the development of these problems. And she is the author of the book, Breathe, Sleep Thrive: Discover how airway health can unlock your child's greater health, learning, and Potential. Her work in private practice is restricted to tongue time management, from infancy to adulthood, early interception, orthodontics, and myofunctional therapy. 

And we are talking about all of those amazing things today. And I have to thank Dr. Lim for being really patient with me. Originally, when she reached out to let me know about her book, I was so grateful to see that she had contributed this work to our fields, and really just put out great information that's in my mind fairly easy-to-consume format. One of the best books that I've really read on this topic that's easy for a non-medical professional to read and understand. So hats off to her. But also, I had, you know, said, Well, I would love to have you on the podcast and interview you about everything that you know, which is so much and chat about the book a bit too because there's a lot that's inside there that's really worth talking about outside of the book. And we've rescheduled our interview so many times it finally worked out. And I've got to say that trying to balance time zones in the US versus Australia can prove to be quite difficult. So it just so happens that we were able to set up a time fairly last minute that worked for both of us. And she is just wonderful. If you're in Australia, you have many great providers there, one of them being Dr. Lim. 

So if you're at all looking for some solutions related to oral ties, or oral dysfunction, you have an infant, maybe yourself, and an older child. She's an excellent resource. I know it's a very large country. So if you're ever looking for anyone else in Australia, feel free to reach out to us. Sometimes there are colleagues we can connect you to but Google Search might do just as well. So I'd love for you to grab a cup of water, grab some tea or a coffee and get ready to listen to all the wonderful things that Dr. Lim has to share with us about oral ties breathing sleep, and development throughout the lifespan. Welcome to the podcast. Dr. Lim, I'm so excited to chat with you today about your new book and what you do in your work, and all things airway and oral restrictions. And oh my goodness, some of my favorite topics. So I appreciate you being here. And I would just love for you to tell the audience a little bit more about your background and what you're currently doing.

Dr. Shereen Lim  3:44  

Fantastic. I'm really great to be here as well, Jacqueline. So with my background, I am a general dentist from Perth in Western Australia. And I first got interested in airways because of my husband snoring. So about 1213 years ago, it really frustrated me and I decided I was going to learn more about these Dental Sleep appliances and how they could help adults with snoring. And I became one of Australia's first dentists to obtain a qualification in Dental Sleep Medicine. And so I then was involved in treating and managing obstructive sleep apnea with these dental devices.

Jacqueline Kincer  4:21  

Ah, yes, I love to add sleepy snoring husbands right? Yeah,

Dr. Shereen Lim  4:26  

sure. So then really understanding Oh, it's not just a noise. This is a severe health problem. With obstructive sleep apnea. It's linked to a very poor quality of life with common symptoms like depression, anxiety, brain fog, memory concerns, and a lot of increased health risks across the lifespan. And I wanted to know how come we don't develop the jaws properly in the first place. Why are we giving these people solutions to hold their jaw forward during sleep? We're taught in dental school we can actually intervene earlier to modify facial growth. And so that's when I decide

Jacqueline Kincer  10:00  

tires. Like what about those because, you know, there's just such a, you know, I don't know exactly the climate in Australia where you are. But you know, here in the US there's these you know, quote unquote orthodontic pacifiers, which I always sort of laugh at because, you know, I'm pretty sure you know, Orthodontist would love us to pacifier because it makes them more money but like, how what can you say about pacifiers and that growth as well?

Dr. Shereen Lim  10:25  

Yeah, so a pacifier as well. If we really want that tongue up that tongue elevation and suction to the palate, that pacifier is going to interfere with that normal tongue posture. And in addition, it's going to increase with sucking pressures, which are going to distort the palate. And if we recognize that that palate is most moldable, in that first year of life, it will have an impact. And even as a dentist, it's not something that I recognized when my own child was young, like my eldest child. So it is really important to recognize that it does alter the tongue posture. And it does create persistent dysfunction or alters the sucking the swallowing pattern as well, which is obviously linked to an increased risk of Eustachian tube dysfunction, ear infections, and many other problems down the track. However, it's all related to the intensity, frequency, and duration of use. So the impacts will depend on how often a child is using it. If we can actually minimize the use seven Remove wear plus possible, that's great. But a lot of parents think, oh, they only use it during sleep. The problem is that children spend so much time during sleep. And so it's important that we promote that mechanical that yeah, what's actually happening with that dummy use as well. Oh, pacify us, it's not just about the teeth to really recognize it influences facial development.

Jacqueline Kincer  11:57  

Yeah, that's, that's such a good point to say, you know, they only use during sleep. Yeah, babies do sleep a lot. So now that you've mentioned, oh, gosh, which, you know, I don't want to like jump ahead in the lifespan timeline necessarily. But, you know, there's, you know, I've seen those videos going around, right, somebody takes a picture of the baby's asleep, and they're snoring and Oh, how cute. And I'm like, though, what snoring is, is not cute. Unfortunately, you know, if it's your bulldog, you know, we expect that to happen. But you mentioned that kind of in the beginning, in terms of snoring. And I think one of the things that you do really well on your book is to define and really describe these various airway issues and impacts. But I think when people think of snoring, they think of it as sawing logs is this, you know, this very loud sound. But that's not always the case. Like maybe you could tell us a bit more about snoring and how it's caused. Why does it happen?

Dr. Shereen Lim  13:01  

Yeah, for sure. Because when I started getting involved with these Dental Sleep appliances, there was so much focus on obstructive sleep apnea. But what we don't recognize is, that's a very end-stage problem, it, it really does not often play out till the later decades of life. And snoring can be our very first warning sign of problems ahead. So snoring is really the sound made by the vibration of air, it signals that there is some sort of restriction of airflow or there's some sort of narrowing. And this is where problems begin. So it is really important that we don't overlook that snoring, because there are so many risks associated with it, especially during childhood. Because children are very vulnerable to very disturbed breathing, and sleep fragmentation that it can cause. So there is an increased risk of learning and behavioral problems. At width, there is snoring at a very young age. So yeah, I think it's one of the earliest warning signs of problems ahead. It will tend to progress simply get worse as we get older if we don't address it.

Jacqueline Kincer  14:10  

Yeah, yeah, absolutely. And there's a spectrum right of, you know, snoring and then like you're saying obstructive sleep apnea, which you do a really good job of describing some of the limitations of even like diagnosis and, and testing for it and things of that nature. I think people think, ooh, Sleep Apnea is bad, right? Like, you know, oh, I have to use a CPAP or what have you, like, maybe you could point out some of the issues with the sleep studies and get to that point of recognizing that someone has obstructive sleep apnea and some of those consequences as well because it's not just disturbed to sleep like there's so much going on in the body when we sleep as well.

Dr. Shereen Lim  14:52  

Yeah, so the progression from snoring to obstructive sleep apnea. Well, the problem with obstructive sleep apnea is really very arbitrarily defined. So to get a diagnosis of obstructive sleep apnea, you have to have a sleep study. And it has to show for instance, in an adult, you have to stop breathing for 10 seconds or more, at least five times per hour of sleep. So it's quite a high criterion. For instance, if you've stopped breathing for nine seconds, it's not really counted. And so it's by the numbers. And oftentimes, I know in the US to get treated for these problems, you have to meet the criteria to get it covered by insurance. But it's very much like diabetes, there's pre-diabetes, and we don't really want to be in that state either. Because for instance, before sleep apnea, we might have more upper airway resistance syndrome, which has very similar symptoms. And it's similarly fragmented sleep, disturbed sleep and creates chronic stress, and inflammation. So there are a lot of health risk associated with it. But it doesn't meet that criteria. Because what's actually happening is, there's a stress response in in reaction to any airflow limitation. And so the sympathetic nervous system is really more hyperactive. And it's anytime there's a restriction in airflow, there's an arousal from sleep, and the muscles are recruited, sometimes with teeth grinding to open up the airway, so it protects against those more severe collapses, you know, children may be working harder to breathe, tossing, turning, sweating, and, really, it protects against more severe collapses of the airway. But there's no oxygen deprivation, but it's totally fragmented sleep. We don't get into that deepest sleep. And this problem may play out more children, thinner individuals, and premenopausal women, and therefore these people may get underdiagnosed because they don't meet the criteria for obstructive sleep apnea. And so I think it's really important to recognize that the problems begin when mouth breathing starts, we want to promote nasal breathing, if we can promote nasal breathing from infancy, it will definitely help stave off those breathing issues down the track. And when we have nasal breathing during infancy, this is the best muscle stimulus for good forward and wide jaw development.

Jacqueline Kincer  17:26  

Hmm, yeah. And, and babies are supposed to be obligate nose breathers, right, that's what we're born to do is breathe through our nasal passages, but somewhere along the way, you know, something is interfering. And, you know, their body is saying, while I couldn't get more air through the mouth, and so I will make that kind of something. And, you know, I've, I forget who, in the airwave space kind of said this. But, you know, there are structural things that create behaviors, but then once the behaviors are created, we can correct the structure, but there's the behavior that still has to be addressed. Right. So like, I guess what I'm trying to say is that, you know, you can just say, Okay, well, I'm going to release my tongue tie and fix my mouth breathing, because I do that. And that's bad for me, and I'm learning all this stuff. Great. But if you're not used to keeping your mouth closed, and breathing through it, you know, like anybody who's ever had a head cold, I think could probably relate to this, right? You're forced to breathe through your mouth, your your nasal passages are plugged up despite your best efforts. Even when you feel better, you might notice yourself still mouth breathing, right, it becomes a habit. So what are what are some of those things that like a parent of a baby can look at? Are there are there warning signs, little progressions that, you know, ultimately lead a child to mouth breathe or snore? You know, like you said, disrupted sleep could be one, right? I'm thinking of those parents that say, my baby never sleeps more than 30 minutes at a time. Okay, well, you know, something's going on. So yeah, just some things to look for in infancy that we can recognize.

Dr. Shereen Lim  19:13  

Yeah, definitely. I think we all many people might be familiar with the sleeping tongue posture hold. Michelle presser Manuel posted a lot of videos on that. If we can actually notice that the baby has their mouth open, we can actually try to close their jaw and see if we can seal their lips to promote that habit. And we really want to see the tongue resting in the roof of the mouth. Because when the tongue is sufficiently turned to rest in the roof of the mouth, it is naturally easier to close your mouth. And it's actually really easy to breathe through the nose and there's just a smoother airflow because that that tongue ceiling to the roof of the mouth and the soft palate, it just blocks off that mouth breathing route. So I think one of the things that we can look out for is just if there is that habit to really try to reinforce that closed mouth posture, I do find that it's not always easy sometimes that some children have these allergies and nasal congestion. So we can definitely use the nasal sprays the Ceylon rinses their non medicated just to help clear the nasal passages. The other thing that I'm really interested in is Tasha chosen to work with the low tongue posture or the low lying tongue. Because often that can be related to cranial nerve dysfunction from compression. During the birth of that sort of bases cowl neck area, it can impinge nerves that are involved with sucking, swallowing, breathing, as well as the motor nerve of the tongue. And so some of the our body workers or chiropractors and Austria's they can release that area to allow greater mobility of the tongue. And so that can be helpful to get that tongue lifting better towards getting that tongue to Palace seal. But I also do think a lot of babies are born with a narrow, high arch palate. And this is usually a reflection of outward sucking and swallowing in utero. So that tongue hasn't been able to stimulate proper development. And sometimes it can be related to tongue ties, or even prematurity. So this is a structural problem where we have a narrow nasal passage that can contribute to these issues and play out as a child gets older. So I do think when parents see this, sometimes that structural limitation can be very difficult to manage until a child is, say, three or four years old, there's more and more dentist that are involved with expanding or widening those palettes. So being able to recognize this as a risk factor, we can't do anything right now. But you don't have to wait till the child is 12 You might be able to see these dentists and help with that, because it will help significantly improve nasal airflow. If we can widen that palate. Right.

Jacqueline Kincer  21:57  

Now, it's such a good point. And, you know, there's so many issues that can come up in those early childhood years, whether, you know, if there's this cycle of, you know, not getting enough sleep and having difficulty, you know, academically and maintaining focus and even hyperactivity, and, you know, we're seeing like these the way these things play out picky eaters, or, you know, a number, a number of things that that can be consequences. And it's so great that, you know, there are more and more dentists like yourself learning how to treat these issues earlier. But yeah, like, like, you're saying, it's that tricky age where, you know, I, every now and again, there's a parent, you know, well, my kid is, you know, almost two, and, you know, what can I do? Well, you know, there's limitations there, right? Probably, we're not going to do a ton of oral exercises, they have to be like, a kind of willing participant, if you will, to do myofunctional therapy, or, you know, it'd be hard to do some of those more dentistry things. But it made me think about something you touched on in your book, which was chewing, right. So you know, we have a baby that is drinking just a purely liquid diet in the beginning, but then they advanced to solid foods. And I think that's like you're talking about, it's these patterns of things that we do all the time. So we can keep the mouth closed, and breathe through the nose. But chewing is really important. And I'd love to get your take on that. And kind of what are the things that really helped to optimize jaw growth foods, you know, ways of ways of eating ways of drinking things that are helpful?

Dr. Shereen Lim  23:39  

Yeah, for sure. So when we chew and utilize all those jaw muscles fully, that stimulates really good jaw development. And in fact, one of the reasons that's been proposed for the increase of crooked teeth over the last few 100 years is industrialization, and the more processing of foods and the purees that we're offering children as well, which are not really allowing them to actually utilize those jaw muscles. So yes, chewing. A lot of parents now are interested in baby led weaning. So rather than offering babies purees, hips skipping straight to the finger foods, so I think that can be a good option to actually stimulate those muscles further and get things working the way that they're really supposed to. Also the BB manchi. Do you use that at all? The it's a maya machi for babies?

Jacqueline Kincer  24:29  

Yeah, every every now and again, something I'll recommend for somebody, but it's probably more popular. Where you are, I would say that it is in the US.

Dr. Shereen Lim  24:40  

Yeah, so I, I think that's a fantastic tool to offer to especially to babies, like, I think it's really impactful. I mean, sometimes you have to use it to get it to work, but even just last week, I had a two year old last year that I offered one, two, and she had a very reshaped palate, and some of her teeth were in crossfire and her face was deviating to one side. So it was a bit of a facial asymmetry because of the nature narrowness of the palate, but their parents offered it to her, her parents offered it to her and she used it super well used it super well. And her whole symmetry is corrected her, her whole upper teeth are fitting much better over the top teeth. So I think when we have really young children, I'm really convinced of the benefits of this chewing and also correcting that swallow pattern. So when the mailman she goes in the lips or close your eyes, it's impossible to thrust the tongue forward, it disengages all those facial muscles, the lips and cheek muscles during the swallowing. So by intervening really early and trying to block those patterns, I think that it's very possible to get some nice changes that can minimize the the intervention that is going to be required later on. Yeah, so so that would be the key for chewing I think, trying to get more hard foods introduced texture quickly. And then the added benefit of your exercise with a tool like Maya munchy.

Jacqueline Kincer  26:15  

Yeah, no, that's a great point. And you've mentioned swallowing a few times, which I think actually gets overlooked a lot. You know, I'm assessing for that when I work with babies, I used to do myofunctional therapy with all ages, but just found babies were more exciting for me. So because breastfeeding, you get to work with both and just you know, that's my area of passion. But I would assess adults for swallow. And it was so crazy to me to see how many of them had really incorrect swallows really dysfunctional swallows, and you know, obviously a baby who's drinking milk. They're doing lots of swallowing. But it also makes me think about babies who drool all the time. I mean, if I'm out and about and I see somebody with a baby, or there's, you know, there's always one that's got the drool bib, and that's just pouring out like, These babies are not swallowing the saliva that is just pulling in their mouths. But then it's this idea. It's become so normalized, right? Whether teething or they're just a big drooler. And I'm like, I feel like you know, they kind of all make the same amount of saliva just some swallow this and others are not so yeah, I think it's hard sometimes for parents to conceive of, oh, you know, that there's a there's either a swallow is like a yes or no, for a layperson, I think right? You either swallow or you don't, you're choking or you're not. But there's more to it than that. And there's so much going on in the tongue and in the whole oral cavity. I'd love for you to walk us through like what's what's a functional swallow? What's what's dysfunction when it comes to swallowing? Because I bet you there's someone listening right now that goes, that's, you know, thinking to themselves, like, oh, do I? I don't know, maybe I don't swallow correctly, you know, how do we know?

Dr. Shereen Lim  28:05  

So the ideal swallow is when we swallow, and there's no movement of our facial muscles. Yeah, and, and all the activity should look like it's in our throat. And we should look pretty relaxed, like our head shouldn't really bump up and down. So I think, for me, when I'm looking at whether a swallow is functional, or a little bit altered, is just looking at the facial muscle activity, we don't want to see the lips and cheeks overly purse. And so we do and we see this a lot all the way into adulthood. And because if we use those increased pressures of the lips and cheeks, that is actually going to distort our palate inwards over time, and it's going to affect the way that their jaw structures grow. And, yeah, I do see these problems, you know, play out with ear infections and the jeweling. So I think it's really important to recognize that whether we feed a child from the bottle or the breath breasts, it does affect the way that they swallow throughout the lifespan. And we really want those throat muscles to be working really well, because those throat muscles need to be really well toned during sleep to keep the airway open. And I'm with you, you know, we see these children with jeweling. And a lot of parents assume it's cheating, even if it's babies three months or four months, but yes, it is I consider jeweling to be a dead myofunctional disorder, whether the tongue is not raising and going backwards. Just swallow it's going forwards instead. And I do think dueling often goes hand in hand that all that lower tongue posture goes hand in hand with the babies that really want to now they want to mouth and put everything in their mouth.

Jacqueline Kincer  29:50  

Yeah, like they need that stimulation. Is that it?

Dr. Shereen Lim  29:53  

Yes, that's correct. You know, so I do think that it is important that that tongue in He's sitting in the roof of the mouth and having the mouth closed, because there's a lot of sensory receptors, or sensory information that gets processed through the mouth. And we know one of the highest areas of concentration of sensory receptors is on the end spot where we say in, and it shouldn't really touch the teeth. And that's where the tongue should be during the swallow. And when the tongue is not there at rest, what happens when the tongue is there at rest, it's involved in neurotransmission. So it sends signals to the brain, and the brain releases dopamine and serotonin. And it's very calming, it helps people feel relaxed. And so I do think when we see these children with these open mouth, and they're mouthing all the time, they're really trying to, to get that same sensation, it's a compensation I feel, to actually stimulate those receptors. And, and, and get some of those benefits. They're missing out on.

Jacqueline Kincer  31:01  

Right, right. Yeah. And, and I can think of, you know, adults who have, like oral habits, right, they just constantly need to be chewing on a pen or something, or, you know, biting nails and that sort of thing. They're that, you know, they're like you're saying there's so much sensory input and activity that's going on there. And yeah, everybody who's listening, just, you know, stop, where's your tongue? Right? Is it up against your palate? Is it's against your lower teeth? Like, I just, that's always a good check in to do right. And just think, okay, and it's, I think it's hard to because it's just something that's so involuntary for most of us. And, you know, with with babies, too. So I know, in your book, you talked about some of the research that had been done on children, where it showed they were issues later in life that, you know, going back, these could be observed in infancy. So kind of the inverse of that if we are able to treat infants with correct, you know, oral motor patterns. It's a tongue tie that's holding them back, and we're able to correct that. What does that trajectory then look like for them throughout the lifespan? You know, because I think a lot of parents sometimes will say, Well, you know, I don't know putting my baby through a procedure that sounds scary, and I don't want them to be in pain, and I can manage breastfeeding. You know, it's okay. But then oftentimes, the thing that ultimately gets them to make that decision is considering well, but what about later on in life if I don't? And that's all the things we're talking about. So what can we, you know, there's no crystal ball, everybody's different, but what can we reasonably expect if these things are corrected and infancy for going forward in the life?

Dr. Shereen Lim  32:47  

Yeah, I think, well, one of the things we don't want to do is suggest that if we release a tongue tie, it's actually going to prevent future speech issues and future solids and snoring and sleep apnea, because not really, this is, if there is also second swallowing, even in utero. I don't expect that things will be absolutely perfect, after we do the release. And sometimes there's a structural problem with the palate that will still need to be addressed. What I'm really trying to do most of the time is improve mobility to address the current dysfunction with the feeding, although symptoms and reflux like symptoms, but what I'm trying to do is trying to get things more back on track, so that we can break those patterns early, especially for instance, like the swallowing, if we've been using a dummy or a bottle, and we get in something like the BB manchi. And we can break that pattern early. I'm trying to get things more on track. But I know that I'm going to have to follow up children quite often do I need to do a little bit of pellet expansion? Can I get that back up tongue lifting better. So I think it's not always easy. It's not like it's a magic bullet to kind of cure all future problems. But we want to get in early where we can to not let these dysfunctions compounds, because then it becomes more problematic. If a child is a picky eater, or they're not chewing and swallowing correctly. Now, that could be a red flag that their muscles aren't working well. So you know, going in to see the speech and feeding therapist and getting things optimized and working better. If we can correct those patterns early, it just becomes much, much harder to break. So I think that's the main take home message from that is just treating early and reversing that quickly. But it's not necessarily going to be a quick fix. There's so many other things that we have to look at when children are growing. We've got to address both the structure and the function along the way.

Jacqueline Kincer  34:56  

Yes, right. It's so important. You know, I I never want a parent, especially to think that it's a magic bullet, like, we're just gonna get this done, all my problems will be fixed. Sometimes when it comes to nursing, you know, right after the tongue ties released, yes, the latches a lot better. That doesn't mean that there's not still work to do. But you know, I, it makes me think of my kids with what you're saying. So my son, I didn't have the luxury of learning about tongue tie with him. But that's why I do what I do now. Because I just never, I don't know, I couldn't give up and stop looking for answers. So here I am. But, you know, I didn't get his tongue tie corrected. When until he was six years old. Now, I realized that he had a tongue tie. Gosh, I don't know if sometime closer to him being three years old, but three years old is tough. Right? We did. I'm trying to think if we attempted to do anything with the tongue tie, then I think I was trying to do some stuff with him to see if he would be, you know, willing to do it. And it was a no, but we started myofunctional therapy. So we did that and focused on like, you're saying his swallow some speech, articulation things? Chewing those were a lot of the exercises. Nasal Breathing, right. So he, he he really he had sleep apnea. He would I mean, I remember this, we went on a trip, my husband and I, you know, we had like, we shared one of the queen beds in the room. And then the kids were in the other queen bed. And like, I mean, we would hear him stop breathing and hold his breath. And you know, and he just was a terrible sleeper. And my husband's like, he totally has sleep apnea. And I'm like, Yeah, I'm telling you. So we do this myofunctional therapy, we get huge improvement. He's sleeping better. He's just, you know, all around a better kid and whatever. Finally got his tongue tie released when he was undergoing some other dental work at six years old. He's now 10. Even at six, his palate was so much better. Because we had done the myofunctional therapy, we used to do munchie as well, right? All of that. We see an airway dentist now, of course, right? Why would we not. And he's like, he will. I mean, he's like, might need braces just to kind of straighten out some teeth. But he's not going to need expansion, you know, is everything looks great. Every teeth are coming Great can see where they're positioned. The arches are, are nice and broad. And it's like, Ah, yes, because we did all that other stuff. So like, releasing the tongue tie was sort of the cherry on top that was going to reinforce all of the other work that we did, and not keep it from backsliding or make us have to keep doing that he doesn't do myofunctional therapy now, you know. But then like with my daughter, I got her tongue lip and buckle ties treated when she was an infant. And she still has a super narrow palate, she'll totally need expansion one day, she has tiny little nasal passages. And she snores at nights. And it's just what it is, I did more work with her as an infant to correct those patterns and structure than I ever did with my son. So I was illustrating that example to people to go you could do all the quote unquote, right things. But you know, there's just some things like you're saying in utero? Or maybe it's genetics, right, that we have to just consider other than releasing a tongue tie, right?

Dr. Shereen Lim  38:10  

Yeah, absolutely. Because I think a common misconception from parents is really that if we release it sometime, that we can promote better power development, which, in principle, the more we can get that tongue lifting. Yes, it will stimulate the palate more wide. But one of the critical areas that needs to be stimulated is the mid palate suture, the growth center right in the middle of the palate. And sometimes if that has developed too high, it is really hard then for the tongue to create that really good suction, and to really stimulate that development. So yes, I think we mustn't overlook that a child may need to have palate expansion. And there's that can actually be really key to optimize their breathing for life if we do it early. But yes, not always. Is everything going to correct with the tongue tie? Sometimes it's a structural limitation to allow up that that's a very optimal function,

Jacqueline Kincer  39:07  

right? No, I absolutely agree. And, you know, I'm curious what you can say about lip ties, as well. And usually it's the upper lip that we're talking about, but it's still a thing. It is absolutely still a thing where I hear from people, and they're like, my baby has a lip tie. And I'm going What about the tongue, though? So there's this conception, I think that you know, lip ties cause a lot of problems and I'm not saying they don't cause problems but where does that come into play with any of what we're talking about?

Dr. Shereen Lim  39:39  

Yeah, it's quite common that some people particularly here in where I am, there's a lot of child health nurses that may refer their children in for assessment equipped, I think it's the most obvious thing you can see it quite easily. There's a bit of flesh you know, touching the upper lip to the gum but we We all have that there has been a research study that has photographed 100 babies in a row. And the majority of them will have some sort of attachment that's quite fleshy. So what we really need to be doing is lifting up the lip and seeing how easily does that upper lip move how mobile is it, if there's blanching or tension, that's a tie. And yes, it can impact the latch, it can impact how deep the latch can be. Because if it's too tight, we can't get that nice, big mouthful. And if it doesn't allow proper sealing during the latch, we're going to get sucking and swallowing your ear. So sometimes it can be very important to release that to allow a better seal. So we're not going to suck and swallow air and have those reflux like symptoms. And then something I'm looking at more closely now is as well, how does the lip wrist because sometimes if that lip sort of doesn't seal down properly, that release, or it doesn't close all the way or it's sort of that rule inverted look, sometimes when we release it, it just allows that to seal or the lip can sit more long, it looks like the upper lip is longer. And so I think that may be another reason I want to just have a look at how is the lip resting and how tight it is. And sometimes yes, I think it can be helpful to release.

Jacqueline Kincer  41:20  

Yes, yes, yeah, I see, I see the same things. And, you know, one of the exercises I would teach people to do with, you know, tight lips or upper lip ties would be where I would have them stretch their lip to lengthen it, whether it was kind of rolling the lip under the teeth and holding it there or manually pulling out doing various exercises to release that tension in the muscle and, and create a different shape to it. And it's amazing what that can do for honestly, just making you look less tense and stressed and worn and tired, right? Like, these things contribute so much to that. And they think there's you know, kind of these trendy things about like face yoga, and this and that. And I'm going it's just myofunctional therapy. Right? And it's so important, really important. The role of myofunctional therapy Do you Do you have? Is that something that you teach patients that you see in your practice? Or do you have therapists that you refer to or include? I'm curious, you know, kind of how you go about doing things in your in your world?

Dr. Shereen Lim  42:31  

Yeah, myofunctional therapy is generally more suitable for children that are age four and up to be able to, to do, there's definitely exercises that you can do with younger children. But a lot of myofunctional therapist, you know, may be able to work like for instance, in our own practice, we work more successfully with children that are foreign up. And yes, I will do that every time I'm doing a tongue tie release, it needs to be done in conjunction with my functional therapy, because we really need to retrain proper movements of the tongue proper tone, proper isolation. And the ultimate goal for me, when I do a tongue tie release in an older child is going to be to get that tongue and palate suction that tongue and palate needs to rest and connect together well for proper breathing. And Toronto released on its own will not do that. It is the myofunctional therapy or exercises that will help work towards that and that Toronto release is really just the adjunct to improve the mobility and, and help that that last missing link to get things working better. So yes, I think myofunctional therapy is really important. And in fact, even in infants, over the last couple of years, I've worked the lactation consultant that really does a lot of our work. She gives a lot of our exercises to children, even before we do the tongue tie release. And wow, it's so nice to hear that children can get suction improvements before they even do the release. Yesterday, I saw this mum and I said I wasn't ready to do the release, I think they needed to do a little bit more exercises. Because the baby was thrusting. You put the finger in the mouth, she had a totally highly sensitive gag reflex. And she kept coming on my fingers. And we sent her away for two weeks where she just did it so religiously. And baby was so much more comfortable with me in the mouth, was able to touch her tongue. She's not thrusting all the time. And I just know that if what we're really trying to do is get better tongue suction that are there that are latch, we really need to set it up well, so baby's not going to be gagging. And they're going to be able to move their tongue better that they've already got an idea of what to do so that we can get a more optimal result.

Jacqueline Kincer  44:47  

Yeah, I'm really, really glad that you mentioned that and I'm so glad that you have someone there that does that because that's to me the most important piece of work that I ever do with clients and that that anybody that, you know, sees clients on my team is those oral exercises, because, you know, all the other stuff for us is easy. The milk supply the the, you know, the positioning the latching like the, you know, mastitis club dunks, whatever, like, we've got all that down, Pat, it's the oral exercises, because, like, you're saying, we kind of want to deliver this baby to you as the dentist on a silver platter, meaning that it's easy for you to lift up the tongue because there isn't all of this tension there. Or the tongue isn't weak and shaky, because it hasn't, you know, gotten some good training and like that thrusting and, you know, I tell parents, like, you've got to do some, you know, they're always individualized, depending on what the baby needs. But to your point about the gag reflex, right? If we don't desensitize that, and the baby, you know, they get their tongue and lip tie release, they're able to open wider, they're able to get more breast tissue in the mouth, what happens when the breast actually touches the palette and they gag, they're not, they're going to instantly go back to a shallow latch because they can't tolerate a deep latch. So we've got to do things ahead of time. And that's a piece that we need more folks like you that reinforce that right to say, I need this baby to do more work, you know, some babies are going to need that tie release sooner than others. But like you're saying, if there's time to go back and do these exercises, and create those patterns ahead of time, and I've absolutely seen cases where, you know, those oral exercises are not a replacement for for doing a frenectomy at all. But you can sometimes get enough improvement that you're going well, I don't know that we would get some significantly greater amount of improvement, just because we released this front, um, you know, if your symptoms are resolved, and things are going, Okay, let's see how it goes. You know, let's check back in in a month or two. And, you know, maybe this is just something that you keep in your back pocket for later when your child is a bit older, right? Like, let's not just go release ties, because they're there. And I think you take that approach and really look at the whole picture, which is so important. Are you seeing that that's like a niche thing for you where you are in Australia are more doctors and other providers catching on and doing similar work there?

Dr. Shereen Lim  47:13  

Yeah, I have a cool group of colleagues around Australia that we have a pretty similar approach, for sure. Yeah, that's awesome. And I think, you know, as a dentist that is actually involved with a lot of Le interceptive, orthodontics and just seeing the babies again, as they get older, I think it's a very valuable perspective to really understand what are some of the limitations of tongue tie release, and how much work we still have to put in for some of these children. And how much benefit there is when we spend that little bit of time upfront, even pre release to optimize that outcome? It's valuable, because we want to improve that function. And the release itself may not necessarily do that.

Jacqueline Kincer  48:05  

Yeah, yeah. And it just I think, you know, it takes a team most of the time, right? There's things that you're gonna do, and, you know, maybe other things, and it's, you know, the parents at home, you know, encouraging their child to chew and not eat, you know, purees as much or what have you. Right, so, what are some of the, the biggest effects of of all of this, you know, kind of going unnoticed and untreated in adults? You know, what are what are the things that? You know, I think so many people just, you know, we're talking about sleep apnea, and we're talking about the jaw growth and the need for orthodontics or palate expansion. Are there other things that you're seeing in the adult population that have to do with, you know, not getting things corrected earlier in life? Yeah, for

Dr. Shereen Lim  48:55  

sure. The The two most common problems that adults will present with me is either disturbed breathing during sleep, or chronic head and neck tension. And so in terms of how those problems develop, well, the breathing, if we have a tongue tie, we can still actually compensate it is still possible to breastfeed, it's still possible to speak, it's still possible to, to do a lot of things and get on with life, however, we actually incorporate a lot of compensations. So we use muscles that we shouldn't really be using, whether it's our lips and cheeks, our jaw, our neck muscles, as well. And so what this means is that the tongue is not developing its proper tone. And it may not necessarily rest correctly during sleep when all our muscles are relaxed. And so when our tongue rests low, we're going to have increased risk of mouth breathing, and obstructed breathing. And so a lot of adults now our understanding all Tongue Tied could be implicated. So they they come to me With those disturbed breathing problems, but the other thing is that when we overuse our neck muscles, what actually happens is we can develop these tight bands or trigger points. And we get this chronic tension in our neck and shoulders. But it can also refer pain to our head. And so there's a lot of patients with these chronic tension headaches or chronic headaches, and even migraine like symptoms that can be attributed to this dysfunction. And if we can get the tongue working better, quite often, we will actually see improvements or alleviation of these headaches, where people have gone for decades, you know, getting acupuncture and physio, or Chiro, and all these other treatments, it can be related to oldest function, and the increased compensation by other muscles. So I, I really enjoy seeing those, being able to not seeing them, it's quite despairing To be honest, it can make life miserable, but to be able to help them towards the myofunctional therapy and getting their tongue to work better and the release to be able to free them up with some of this chronic tension. I think that is one of my most rewarding aspects of being involved in this.

Jacqueline Kincer  51:14  

Yeah, yeah. I, I had an opportunity to sort of see for myself earlier in my career, and a colleague of mine was, you know, had just kind of, you know, finished her training on how to do, you know, releases of ties, and she was looking for some guinea pigs. And I was like, let's do it. You know, pretty sure I have one. I mean, I've, you know, learned enough about this that, you know, I didn't have sleep apnea wasn't really a snore. But I definitely had some, you know, crowding, right narrow palate, things of that nature. And yeah, she released my tongue tie, I sat up, and I felt like my shoulders were so low, like, it was uncomfortable, like, as if I had dropped them. And I needed to, like, hold on to them. It was it was that's the only way I could describe it was like, they just felt so loose and unstable, really. And I was going, Oh, my goodness, I just, you know, a lot of people will say, Oh, it's it's stress. You know, I grind my teeth because it's stress. Well, maybe you'd be less stressed if you breathe better, right, like, and I just felt like, oh, and then I remember the next thing. You know, my shoulders were so low. Like, it was weird for me to drive home after that, like, I just remember going oh, this is so I feel so relaxed. Like I just had somebody I don't know is magic.

Dr. Shereen Lim  52:39  

Had you done a lot of body work and preparation? Men? Well, I

Jacqueline Kincer  52:43  

you know, I had because I I've gotten you know, I'd referred for bodywork. I worked with a body worker. And so yeah, I was getting my own body work done pretty consistently. Yeah. So I'm sure that's probably why I had like a really good, you know, kind of instant result. And I followed up with lots of body work to his attention wants to come back, right? My muscles were like, Oh, wait, no, no, we're used to being in this position. But then I also just felt like I took the first deep breath I had ever taken in my life. I just remember that just going. Wow, everything was just so open and easy. And air flowed so freely. And it just was like, wow, it was unnecessarily hard for me. Those years, and that's me, as you know, somebody in their early 30s going through that and just going oh, my goodness, it was to experience that myself. You know, I had seen the results with infants, right, I had been working with them. But to go through that and really feel what a difference it made in my own body. Yeah, it's just full circle. I understood everything that you're talking about. And I'm not saying everybody should go get a tongue tie release. And then, you know, go experiences for yourself. But like, if it's impacting you go do it. But like, it was, it was really crazy to me just, I had no idea, right. And I think we go through life. And it's just how it's always been since we were in utero. And you do this work that is life changing for people. I mean, they must be like, wow, you know, thank you so much. Because I've been suffering all this time. And like you're saying, I've tried acupuncture, I've tried medications, I've tried all these things, and nothing is really kind of helped. And here, here you are going well, here's why. And we can fix that. That's so cool.

Dr. Shereen Lim  54:19  

It is cool. It's like a literal release of a person. And for instance, I I had this one lady, one of my favorite ones to think of she she'd been seeing a psychologist every week for 10 years for depression. And as soon as she had that, she just said, I feel so free. She didn't even have to see anyone they discharged her. So it isn't we shouldn't really underestimate the impact that it has. I don't want to over promise anything either. But yeah, for sure. I think it's a tiny piece of string. But yes, it can create do lots of things that we don't even recognize could be better.

Jacqueline Kincer  55:04  

Yes, it's so true. And God, you know all of this knowledge in more and the way you've explained it is, in this wonderful book that you've written, which I just love. I've read so many books on tongue tie, I think I've hopefully been caught up and read them all. I've gotten some obscure things off of eBay, like it's anything I could find good or bad. And it's called breathe, sleep thrive. And just what I love about your book is that one, it's not too crazy long. So for people that are like, Oh, I don't like to read, you know, while there's, you know, organizing chapters and sections and headings, and you can skip to the part that you want to read about, which is really nice. But you do a really good job of just explaining all of this tying it all together, going way more in depth than what we're talking about here. But it's easy to understand. I'm curious, what really prompted you to even write the book, because obviously, you're like a dentist, by trade, you're not an author by trade. So something there sparks that in you.

Dr. Shereen Lim  56:12  

Yeah, there are so many things that get missed or dismissed. And it's really hard to connect the dots for people like as a general dentist. So you know, before I got more restricted in my practice, to this type of area, seeing people and seeing all these things, and not being able to share that information in a very succinct way, it's not really a quick conversation. But I did want people to recognize that the way that Jaws develop is really important. It affects the way that we breathe, and our whole mood, emotional regulation, our health, and there are things that we can do early to actually help develop the job as well, or get things back on track. And how do we have this conversation? It's much easier to just do it in a book, so that they can actually take it home and process it.

Jacqueline Kincer  57:06  

Is it like a prerequisite to book an appointment with you just like, hey, read my book first, and then

Dr. Shereen Lim  57:10  

we'll talk? I want to make it but But nowadays, you know, a lot of people come in specifically for this. So yeah, I do think that people can take a lot of things, and they can recognize these patterns and see how things are integrated and see how it's multifactorial, we cannot just see one person, we often require a whole team approach.

Jacqueline Kincer  57:33  

Yes, I love that. And what I find refreshing about what you wrote is that, you know, it talks about, you know, breastfeeding talks about speech and talks about obstructive sleep apnea talks about all ages, various circumstances of things. And what I also really appreciate about it is that, all of that I was worried because I've read enough books on this, that some of these things are, are presented as, like, it's, it's good information, it's a lot of information. I'm not saying that other people haven't written about this, and, you know, they're not wrong, what they're saying, but sometimes I come away from these, these works, and go, that's a lot like that is a lot for the average person, you're like, if you're gonna do if you're gonna address everything this person is saying in this book, it's a lot and it's overwhelming, and I can see how many people would go, yeah, that's not going to happen, like I can't commit to doing all of the things are completely, you know, I'm not going to do breath work for the rest of my life, or I'm not going to do whatever right like, and what you do is really present these things and all of the nuances and, you know, like what you're saying, we're trying to get improvement, right? It doesn't have to be perfection. And sometimes, when there's books about various health concepts, it's like we're trying to present like, what's the ideal, optimal, you know, state of perfection. And I think that that just leads so many people to disappointment. And I don't, I don't like that. So I was so glad when I started reading your book that you don't do that in it, because it's like, okay, maybe don't have to do every single thing. Like, so many people will chase these, you know, every solution. I've seen 10 Different people to address this. And I'm not saying you don't need that many people, but like, it's rare, right? Like, let's, let's try to get you the best improvement we can without going crazy. And doing like all these other things. And so I really have to say thank you for doing that. Because that's a big thing for me as a lactation consultant when I work with a breastfeeding family. You know, this mom, she's postpartum. She's, you know, transitioning into motherhood. She's struggling with breastfeeding, she's probably sleep deprived. She doesn't need to have this massive checklist of things to do to make sure that her baby is you know, okay. Right, like, so anyway, it was a breath of fresh air because yeah, I would encourage people to read it and go, Oh, yeah, this makes stance. And here's the things I need to know, as opposed to kind of like, you must do all of these things if you want to be healthy.

Dr. Shereen Lim  1:00:08  

Absolutely, Jacqueline. And that also brings me to this point about breastfeeding. Because I think the people that feel particularly guilty about not breast feeding, because people that didn't get the right support, they wanted to breastfeed, but they couldn't get the right answers. And so really, the book is also about explaining that these are the factors. This is why breastfeeding matters. But if we miss that boat, how do we reverse that? How do we actually get things back on track? To know that there's, like lots of different opportunities if we actually know what to look for? And and what else we can do?

Jacqueline Kincer  1:00:42  

Yes. Oh, it's such a valid point. And also, just I'm curious, because you're so involved in this work, and you're really a leader in this field? Where do you see things progressing in the future? Because I think there's a lot of changes to be made, we obviously need more people to to learn the things that you've taken it upon yourself to learn and get educated and trained on, you know, yeah, any any predictions or hopes or things that you would like to see change in healthcare in general, or just related to these issues?

Dr. Shereen Lim  1:01:17  

Well, I do think we're seeing a lot of integration between specialties, like my colleague at colleague, just on the weekend, organize a meeting with the EMTs that had many, many dentists come along. So 360 People in Malaysia, just all having these great conversations about how can we integrate together to develop better airways and, and pay attention to nasal breathing as a key pillar of health rather than having to manage these problems down the track. So I think, number one is integration. But number two, what I'd really love to see is an approach to orthodontics where we're actually focusing, not so much on the teeth, but to develop those jaws early because when we develop the jaws early, we're going to get better breathing and sleep. And it's particularly important for young children to, to do this. So I don't think we need to set a an age limit of that start treatment at seven to eight, we are seeing more and more people interested in having their child treated while they still have their baby teeth. So I think what needs to happen is we need more and more professionals becoming confident in dealing with this issue, because it's very impactful. It's something as a professional I was quite scared to do. Six years ago, I think it was or seven years ago, I did my youngest daughter at age six. And even that was a big scary thing, because we're taught you don't start till seven to eight. And now I do three and a half, four year olds. So I think I'd like to see that shift, because it's very impactful. The breathing, even speech for sleep, just helping children get their most restorative sleep, rather than if they have these ADHD or behavioral problems. Really, what else can we offer them to help them get a better night's sleep? I think that's a really impactful pinion and a change that slowly happening as well.

Jacqueline Kincer  1:03:05  

Yes. Oh, I agree. And, you know, as I'm listening to you say that it occurred to me that I've never once had a pediatrician. Now, it's not like I've seen a million of them, but I certainly know a lot of them and have worked with them. They don't seem to ask the question of the parents, like, Hey, have you seen a pediatric dentist yet? Like, there's so there's still such disconnected professions, right? And I'm going I've absolutely encountered people in the wild, as I like to say, where they're like, oh, yeah, you know, all of a sudden, my kids three, and I just realized, I've never taken them to the dentist, because it didn't occur. They didn't have to early on, right. Although we could argue they might, you know, be a good idea. But they're thinking, oh, yeah, well, you know, now I need to get my kid, you know, cleaning, regular cleanings and all of this, you know, and that's what it becomes about, but I'm going, but why didn't the pediatrician make sure that you were going as soon as the baby's first tooth erupted? You know, at least, or asking, you know, have you scheduled that? Because if we did that even I think it would be great, right? And I'm not saying all dentists are you know, gonna know all these issues that you're describing. But, you know, we probably get things caught a lot earlier, especially when I mean, it's I don't know if it's like that in Australia, but absolutely us. I've heard many people say that, or they're, they're somehow being told that you don't need to take your child to a dentist until age three. Well, there's a lot that's happened by the time they're three like you're saying, so I would, I would love to see more people doing that. So if you're listening and you haven't brought your little one to the dentist, it might be a good idea. That's what I would say. Preferably an airway focused one if you can, because that would be wonderful. So Well, you're in Australia, and I know we have a fair amount of Australians. Listen, the podcast you're in Perth, you said, Where can people find you connect with you if they want to see you? Yeah, we'll link up you know you're in for me. Shouldn't our show notes to make it handy and accessible as well, but you could just give us a quick overview.

Dr. Shereen Lim  1:05:06  

Okay, my website is Dr. Shireen limb.com.au. And in terms of social media, I am more active on Facebook. So I've got a page Dr. sharing them, and I try to post a lot of different cases and, and, and patients stories as well.

Jacqueline Kincer  1:05:20  

Oh, that's wonderful. I love that. Thank you so much for sharing your wisdom, your expertise with us today. And thank you for writing this excellent book. So for anyone who wants to get her book, it's available on Amazon, you can do a paperback Kindle, and maybe one day coming soon an audio book? I don't know.

Dr. Shereen Lim  1:05:43  

We'll have to look at it. It's getting more and more difficult to ignore those requests.

Jacqueline Kincer  1:05:48  

I love it. Well, you're just such a wealth of knowledge and expertise. And you're doing great work. I appreciate you being here with us today.

Dr. Shereen Lim  1:05:55  

Thank you so much for having me. It's great to reconnect again. Thank you, Jacqueline.

Jacqueline Kincer  1:05:59  

Yes, you're welcome.