How Can a Good Airway Promote Good Health

In this episode I interview Caroline Smith, who is one of the co-founders of The British Society Of Myofunctional Therapy. You may not have heard of this society and nor had I until quite recently. When I did discover them I was really excited by the potential of this work and how it can help a number of our patients. 

Orofacial Myofunctional Therapy (OMT) is the “neuromuscular re-education or re-patterning of the orofacial muscles.” This therapy includes facial and tongue exercises and behavior modification techniques to promote proper tongue position, improved breathing, chewing, and swallowing. You may not be aware that most orofacial myofunctional disorders (OMD)  originate with insufficient habitual nasal breathing or with oral (mouth) breathing. 

Caroline provides lot's of tips to help both locally in the mouth and systemically for the body. This is a really important podcast for anyone who may be suffering from airway and breathing issues.

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Transcript

How Can a Good Airway Promote Good HealthMon, Oct 23, 2023 2:18PM 1:21:26SUMMARY KEYWORDSpeople, tongue, patients, breathing, mouth, breathe, teeth, muscles, nose, therapy, teach, taping, snore, sleep, dentists, nitric oxide, gum, inflammation, oxygen, pausing

SPEAKERSPeter Williams, Caroline Smith

Peter Williams 00:03
Good evening, everyone, and welcome to this Oh, new October episode of, I'm gonna call it FM bite size because I like to shorten things down these days. But welcome. And today, we are going to be with Caroline Smith, who I will introduce as one of the founding members of the British society of myofunctional therapy. Now, as you know, on my podcast, I'm only really into, I only really chat to people that I've admired their work like, what they're doing, and I had some experience with. And Caroline is definitely one of those in the last couple of years. Because obviously, I've got an interest in oral and systemic disease, and much more of an interest. And I'd say free Caroline and her group and some of the dentists that are knockabout with with regards to airway management. So good evening, thank you for taking the time to jump on this call with me Caroline.

Caroline Smith 01:01
Pleasure, thank you

Peter Williams 01:04
So you're based, teeside way, aren't you?

Caroline Smith 01:07
I'm in the northeast, just north of the time. So I'm in a little lovely little place called NorthShields, which is just on the on the coast quite close to Newcastle.

Peter Williams 01:16
Right good. Okay, so let's jump in. I suppose the best way to do this, because I'm pretty sure most people haven't heard of myofunctional therapy, and let's face it, neither did I until a few years ago. And now I'm all over it. I'm absolutely sort of well into it. Because it all makes sense to us. Because it's a it's a bit, it's a systems thinking therapy, I would say because we're always trying to not only deal with the symptoms, we're also trying to look at the sort of root root cause effect. So that fits beautifully into my sort of systems thinking medicine approach. And we're collaborating quite a lot at the moment aren't we because a lot of our other stuff that I'm doing sort of collaborates really well over to your stuff. And you're I have to say a bit of a bit of an expert in this field. So why don't you Why don't we get your story? And then maybe we can amalgamate sort of the importance of, I suppose your expertise, the job that you're doing, and the field that you're in, that'd be a great place to start.

Caroline Smith 02:18

Yes, yes, absolutely. So it has been a journey, like you say, and it's been a journey of curiosity. I'm just a naturally curious person. I'm a dental hygiene therapist. So I've been practising dental hygiene for 13 years. And I just was never quite fulfilled in my role. I used to get really frustrated, thinking, well, you know, why isn't this person responding in the way that I would expect them to respond. And as a dental therapist, I do extractions of deciduous teeth as well. And it's the most heartbreaking job taking a tooth out of a little kiddie. And every time I took that tooth out of a kid, I'd think, oh, I need to I need to know more about why you know, prevention. So, on my journey, you know, I wasn't quite fulfilled in my my daily practice, I went to teach, I was teaching at Teesside University at the time, and went back to uni to do my top up degree down at UCLAN the University of Central Lancashire and the professor that taught me the the applied clinical sciences, he's the Dean of the hospital, he's a dentist and he's a doctor. So he actually kind of because he's so knowledgeable about the human body. I kind of like understood it a little bit more. It's kind of you know, going back to basics, going back to the biochemistry and being taught by a doctor, I was like oh, gosh, this, you know, this, this totally makes sense. And there was one thing that you said that was really profound to me. He said, often, we see a rise in autoimmunity in the winter, because a lot of people get the flu and it and it triggers autoimmunity, and that not just blew my brains apart. So I was like, oh, okay, that's that's crazy. And at the time, my cousin had recently been diagnosed with rheumatoid arthritis. I went back home and said ah, you know, had you had the flu before before you were diagnosed? It's really strange because I had Quinsy quite bad before and I had to go to the hospital and get my tonsils lanced and everything. And I thought oh, wow. Oh my God, I need to all of a sudden it clicked that I was like, Oh, wow, our immune systems are primed and what and then it got me thinking like, well, what what can what can I do to understand more about the human body and of course, obviously, with the dental background and trying to prevent extractions, I was it's got to be nutrition. You know, I have to go back to uni. I have to understand the Nutrition behind it. So I found a course in York at the Northern College of Acupuncture. And I decided to do my training in nutritional science and practice. So I was sat in lectures, and I was thinking, oh my god, they these are the answers that I've been questioning the whole time, like, what is driving this? And why is that not working? And it was those co- factors. It was the vitamins, it was the minerals, it was the stress factor. It was the, you know, the, the poor sleep and things like that. And everything just made sense. So, you know, I went on this journey. And at that time, I was like, Oh, well, there must be other dentists in this in this in this field. And I started following a few functional dentists who were talking about nutrition. And one in particular, over in Australia is called Dr. Steven Lin. He'd written a book called The Dental diet. So when he was promoting his book at the time, and he came to London, he's, you know, I'm promoting my book, why don't you come down and, and, you know, he stood there,and he said, Whatever nutrient you're deficient in, oxygen is the king. Like, if you are oxygen deprived, then nothing else will really work. And then he started talking about airway health and mouth breathing, and sleep disorders. And that literally just blew everything out of the
park so that I was on this trajectory thinking, yep, nutrition. That's, that's what I'm going to do. Went back to you Uni, started asking my clients, oh, well, how do you sleep? Really, really bad. And do you breathe through your mouth? Yeah, I've got I've got really bad rhinitis, or, you know, I've, I don't know had a hockey stick bashed in my nose when I was 12. And I've never been able to breathe through it since. And I was like, oh, god, okay. In the hierarchy of needs, you know, breathing, it's got to come first. So what I decided to put my nutrition on pause, went off to America, learned, you know, about breathing, about sleep disorders. And there is this, you know, we probably say it's a new field, but actually, it's been around for a long time of this what you were saying before of myofunctional therapy. So with myofunctional therapy, we're like, okay, first and foremost, can that person breathe through their nose, you know, if there is some kind of dysfunction, you know, deviated septum nasal allergies, poor function like, is that, should that person be seeing an ENT surgeon or someone to so we can understand what's going on? Because you know, it could be anything?

Peter Williams 07:44

Why don't you expand that? Because obviously, the simple question is, as we're learning as I'm learning off you is that breathing is pretty profoundly important for being a player in increasing the risk of many chronic conditions. And of course, this is why I'm trying to get all over it because, well, I'd say most chronic conditions, but I can think about obesity, type two diabetes, I can think about cognitive decline, there's three where, you know, and of course, I think a little bit why, you know, I'm interested in, you know, the the people who go to dentist who literally are doing everything, right, and yet, they still got problems. So can you, can you expand on all of that on that simple question about why it's so important, what we're learning anyway, about why it's so important to breathe through your nose.

Caroline Smith 08:41

Of course, of course, and I think we just have to really strip it back to basics. Mammals are supposed to breathe through their nose. If a farmer sees a cow in a field, and it's mouth breathing, that is a sign that that cow is in respiratory distress. So you know, we are designed to because the noses job is to filter the air. So you know, if we are mouth breathing, that is putting the stress on the immune system already, because the tonsils the lungs are having to do the job of that nose for filtering the air. We also create a gas in our nose called nitric oxide. And this gas was actually only discovered in the 80s I think it was 80s or 90s. And it was so profound that the guys who discovered it, they won a Nobel Prize. And basically they found that nitric oxide which is predominantly made in the paranasal sinuses, it lines your blood vessels so when you're doing exertion and you're doing cardiovascular activity, if the body needs more oxygen then nitric oxide is released and it opens the blood vessels. It's a vasal dilator it's also a bronchodilator. So every time we breathe in through our nose, we are actually supporting the bronchial dilation and the vasodilation. And what they now think is the they think that is the mechanism from what the GTN spray is used. So you know, for angina, you spray the GTN spray underneath your tongue, and it opens the blood vessels. And that's that's their belief now is it's because of the mechanism of nitric oxide. So nitric oxide opens the blood vessels. But also, when you think about breathing, just say, yes, you can breathe through your nose. But you know, it's a little bit stuffy. When you are conscious, you can override that. So you can be consciously breathing in and out through your nose. Even if you might have a slight deviation in that septum, what happens is each nostril becomes more prominent in a cycle, think it's around 20 minutes per cycle. So you can override that during the day. But when you're asleep, and each nostril is becoming more prominent, as soon as you can't breathe through one, your mouth, your body will do anything to breathe. So you know, your mouth will open, and it was to breathe through your mouth. Now, when you breathe through your mouth, of course, you're not getting the nitric oxide in the body, but when you're asleep, there is the potential that that tongue will fall back into that airway space, a, it will probably start us snoring, then it has the potential to lead to things like sleep apnea, especially when the muscles become weak if you've had alcohol or, or things like that, when they when they do become weak. So the the importance of breathing through the day, actually, we need to be thinking about breathing through the night because of the risk of the tongue falling back into that airway space and increasing the risk of apnea.

Peter Williams 11:56

So we've got two aspects of this isn't it is that anatomical, anatomically, is probably well, that we've got to think about problems that may persist with people with anatomical issues through the nose, we've also got to think about those aspects of chronic infection, sinusitis, all that sort of aspect. And, and nitric oxide, of course, as a vasodilator, reduces blood pressure. So this is why as you say that it's so interesting for me, because type two diabetics, obesity, that sort of stuff, these are all things that it's like, you know, we've got to make sure that you we can open the airways, we've got to make sure that the blood pressures down, but in particular, at night, it's for me, I really sort of, you know, if I look at not, I mean, not just type two diabetes, which is a very strong relationship. But when I'm looking at chronic fatigue syndrome, you know, these people are chronically fatigued, because they've got some degree of obstructive sleep apnea at night, and they're exhausted, they're exhausted is because, you know, they're hypoxic through the night. And then that means they got low oxygen states. And again, we'll see these huge spikes in cortisol and stress hormones and adrenaline. So those classic signs and symptoms are morning headaches, feeling sleepy through the day. There are just so many on that, obviously, they snore, but also they might wake up trying to catch their breath. And we see those chronic signs. So, so that's one of the so let's talk about because this moves in to. So when you have a have a patient that comes in to see you that you suspect so how do you I mean, do you have like a checklist that you go through, where, because it's like everything's interlinked, isn't it? Is it the gum disease is linked in. So can we talk about how poor sleeping and maybe mouth breathing has an influence on maybe these patients that come in and say, Well, I'm doing everything that you told me to do, and it's not getting any better? So can you sort of expand that area a bit more?

Caroline Smith 14:05

Yeah, of course, and, you know, as a dental hygienist, you know, teaching people how to brush their teeth is literally one of my favourite things to do, you know, explaining about, you know, the biofilm, and what if we can't get the inflammation down, and then those patients are, you know, genetically are at a higher risk of x, y and Zed then, you know, you're gonna have different people in different bigger risk categories. But when we think about the cells and the mouth, they are, you know, they are the extremities aren't they, you know, the furthest away that the oxygenated blood needs to get to so if those cells are not getting oxygen, then they are not going to survive like on a very, very basic term if we can't get the oxygen to those cells, they're gonna create more lactic acid, it's gonna cause damage. So the cells actually, they can't respire. They can't, they can't function, they can't do their job. So, you know, when I, of course, my patients when they come in to see me for a dental screen, and they're not coming for me to be, you know, screening them for sleep apnea. So I have I have to be quite mindful about

Peter Williams 15:28
and is this the point? I mean, isn't this the point where it's probably a little bit too ahead of its time for most of the people who are coming in to see you?

Caroline Smith 15:37

Yeah, yeah. But at the same time, it's like, if I say something, and that patient acts on it, and it saves their life, I'm like, it can literally save their life if they get the support. So what I tend to do is I'm in a very privileged position when I can look in the mouth. So first and foremost, I'm actually I'm sitting behind that patient, so I'm looking at them, I can see their breathing patterns without them feeling you know, that I'm judging their breathing patterns. But

Peter Williams 16:09
what are you looking for so give us some practical things are what you're looking for, to give us an understanding,

Caroline Smith 16:14

I'm literally looking is that patient breathing through the mouth or their nose, you know, at rest without, you know, when before they're, you know, feeling judged, or thinking about it, I'm also looking at that patient, are they breathing upper chest, are they breathing down to their diaphragm, because when we're nasal breathing with, with good tongue posture, that will naturally engage the diaphragm. And that's the big muscle, you know, like underneath the lungs, and that that muscle massages the internal organs, so it, you know, it helps with the mechanical movement of the intestines. But also, interestingly, the, the diaphragm actually pumps something called your lymphatic system, which is where all of the waste products go. So if we are not pumping that lymphatic system, that lymph can get quite blocked, and you can get, you know, quite stuffy, a third of that length is head and neck. So, you know, when I'm doing my manual muscle palpations, I'm also feeling for you know, is there any bulky bits of lymph around there, which can help indicate me, then it might not be like in pathology, but it's like, oh, things are a bit, you know, a bit stuffy up here that can indicate. And also, when I'm looking, I can see kind of how how straight the nose is. So if it's really off to the side, instantly, I'm like, Okay, how's he sleeping? And they're like, what? What are you talking about how to do that my sleeps really bad. I'm like, Ah, so tell me about your breathing. Tell me about your sleep. And interestingly, I've got this one patient, type two diabetic, really slim, really good diet. He was, you know, one of these patients that I said, Oh, well, you know, how's your sleeping and he was like oh my sleep is really bad. Like, I have to sleep on the sofa. Because my, my partner, my wife is like, I sound like a freight train. So I was like, well, you know, and asking them these questions, I guide people to the NICE guidelines that just came out a couple of years ago, for obstructive sleep apnea, they're a great resource, because it's got very definitive kind of like, signs that you can look out for and comorbidities that are at a higher risk. So I really like that. He acted on it. And he said, Okay, I'm going to act on this. So I give him a Berlin sleep questionnaire, which is brilliant. You can just download that PDF online. There's lots of different questions. And I think it's question number five or six. And it's like, does anyone that you sleep with, you know, say that you snore, or pause and breathe? And that should instantly make make that GP refer you to for a sleep study? And, you know, if if they don't, then that, you know, something needs to happen, because that if you're pausing in your breath, in your sleep, that needs to be addressed. So I send them with that.

Peter Williams 19:20
I mean, I think this is incredibly common. But can you just let everyone know what that's sort of telling us? Yeah, we'll do that.

Caroline Smith 19:30

Yeah, so that's telling us that we are basically pausing in breath and we're holding our breath. And quite often, we, you know, some people can go for like up to a minute of holding their breath before they kind of like judder or that or their body wakes them up, puts quite a lot of stress on the kidneys. So when we are oxygen deficient, the body sends a signal to your kidneys to produce EPO what they dope with in cycling because they want to produce, you know, more blood cells to get more oxygen. But actually, you know, the body's sending a signal to your kidneys to produce more red blood cells because it doesn't have enough oxygen. So that can put a bit of stress on your kidneys. And it can often then lead to, you know, you need to urinate as well. So urination in the night can be an indication, not always from that, but potentially. So, you know, when you are pausing in breath, the oxygen is not getting to those cells that we need it. And someone said to me, a while ago that made me really think, you know, so many people are having heart attacks in the middle of the night, like when our body is at its most rested, which is in the middle of the night. Why? Why are people having heart attacks in the middle of the night? Is it potentially because you know, the oxygen is not getting to the heart. So we need to be thinking about it logically and simply about these things, so yeah, so I said, get them to do the Berlin sleep questionnaire. And I also get them to download a free app called Snow lab. And that literally picks up any noise that you make, because it's often the men, the men are like, ah I don't snore, and then you do an assessment and the wife's like, oh my god, you snoring is so bad. I have to like, jig you on the side and I think you're going to not breathe. So

Peter Williams 21:34 I refuse to accept that.

Caroline Smith 21:38

So then you record it, obviously, you have to sleep alone, because it picks up any noise. But then you play that back. It's got like, it replays back the noise is like this was epic snoring. But of course, as well, if if you if you snore, and then there's a big pause, you can hear it. So I might if you go into the GP you want to go with as much ammunition as you possibly can.

Peter Williams 22:01
So just remind me on that app again, it's called Snore Lab

Caroline Smith 22:05

Yes, great. I mean, there are a few on the market, that's just personally the one that I use. But there are a few different ones. And snoring, obviously, is an indication of pauses in breathing. But you know, you can have upper airway resistance which can occur in, you know, slim females, where it's little micro pauses. So it's stopping you getting into a deep sleep, and it's just keeping you you know, gently awake the whole time. So it doesn't have to be an epic snore. It's not, you know, the middle aged overweight man with, you know, this with fat around the neck, you know, you can get this in different in different people of different sizes.

Peter Williams 22:51

Okay, so can we move that on? Because what we're What's clear on here is that, you know, this is, you know, and why I got interested in this a few years back and talking to you guys all the time is because, really, because of this is because how profound potential issues with sleeping and being in that hypoxic state has on a lot of the chronic diseases that I'm trying to deal with. Because the the numbers are pretty scary when we look at it. So can we move that on to how you deal? I mean, maybe this is carrying on with this, but how you deal with? I mean, these are signs and symptoms that maybe all is not well. But what do we do about it? I mean, obviously, there's the, you know, certainly with the type two diabetics with the the obese patients, a lot of it is just, you know, they're just too big. And the structures are getting too much too big, and there's too much fat in and around the neck. But this is where we really do get into your myofunctional therapy, isn't it? And what I love about this, this is the other thing I was attracted to, obviously, I'm an Exercise Scientist by initial background. And what's beautiful about I suppose exercise as medicine it's literally come full circle, again, and most of the literature shows that it really is the polypill for everything. I mean, maybe not the best thing for if it's the only modality for weight loss, but everything else, it's the clear leader. And there's a lot of that that sort of carries over to your work as well, doesn't it? So can we talk about the tongue? Can we talk about how that relates to obstructive sleep apnea? And this sort of reels into a lot of the other conditions that you may deal with with regards to airway management. So if we could, we could just sort of go through all of that. That'd be fantastic

Caroline Smith 24:48

Yeah, absolutely. Yeah. So you know, the, the tongue is like it's in dentistry this pink thing that gets in the way when you're trying to clean teeth, or do a filling but wow, neurologically, it's like innovated by, you know, so many nerves, we use it to taste, we use it to speak, we use it to swallow what you know, it's such an incredible organ. And if you're deficient in certain, you know, B vitamins that can present as glossitis, you know, inflammation of the tongue, that can occlude the airway. So you know, the tongues, you know, the reason that it's occluding the airway can come from lots of different reasons. But in myofunctional therapy, our goals are, okay, get this person breathing through the nose, if we can, where's my tongue? I've got a model somewhere. Oh, there it is. So we've got our teeth, we've got our tongue. And basically when the tongue is in the upper palate, and when our, breathe through our nose, when our lips are together, we should be able to breathe, you know, quite easily through that. So could you

Peter Williams 26:03

go over that, then again, the tongue naturally should I know, I know. We're on the video here. But obviously, most people will be listening to this on the podcast, what you're showing me is a diagram of the tongue that sits in that gap between the upper teeth? Absolutely. Is that where it should hang out? All of the day?

Caroline Smith 26:23

Ideally, yes. So when I discovered this, I was like, Holy Smoke, no one told me that. Because when we think about it, when we're asleep, and we're developing, when we're asleep, we are growing, we're repairing. So if you've got that tongue in that space, as as everything's growing, it's going to be a guide to support that. And when it's sat up in that space, it it really helps with the posture as well. So when when the tongue is up, it really supports and this is why when the tongue is up your nasal breathing, that really engages the diaphragm, because it really supports the posture. Now, if you're nasal breathing, if you're got nasal allergies, stuffy nose, the tongue has to go down because you have to breathe through your mouth. And it's much easier to breathe with, you know, with your mouth open with your posture. So that's one issue. And so when the tongue is low, as the upper arch is developing, it doesn't have the tongue in its space. So it can come through slightly higher, slightly narrower. And when you think about it, anatomically, the palate is the same, the palate is the same space as the base of the nasal cavity. So if you've got a high palate, you don't have as much space in that nasal space. So does that mean it is so that mean, sort of the the higher and smaller the palate, the more risk that you might have with regards to breathing? Yeah, yes. So does that mean? Does that mean, when you look at someone you sort of want to sort of, probably use Jergan Clops mouth is a really good guy, because he just seems to have a massive sort of, almost like line of teeth that go on forever. So would that be correct, then sort of the bigger the? Absolutely, because it's all it's a wider arch? And then interesting, you know, you've got oh I can't remember the other footballer, but there's a footballer that that, you know, stands out as a mouth breather and you think, okay, what is going on there? Is there a, you know, high palate, but it makes kind of sense if, if, with the anatomy, like, the, you know, the name, the nose is just there. And then I simply, you know, sometimes I asked my patients and I pull it and I pull their, their nostrils out like this is it is it easy to breathe like that, and they're like, oh, my god, yeah, I can breathe. And I was I put a breathe right strip on at night, just try anything to open your airway, or nasal dilators, or something that's going to help. But with myofunctional therapy, we're trying to use the muscles. So when you smile, you know, if you look in the mirror, and you smile, it actually helps to open up that nasal passage. So what we do in myofunctional therapy is we try and strengthen those muscles that help to support that airway and help to support that tongue posture. So basically, have I got it in here, I haven't got the bit of string, but we put like, you know, little weights on a string, and then we try and gather the string up into the mouth. And actually, when you're doing that movement, you're actually strengthen strengthening those muscles. And you also move in the fascia and you're moving the nervous system at the same time. If we think if we want the tongue to add stability, simple things like a tongue pop, just to draw the tongue away from How do you do that again. Is if you, if you click like a horse, if you playing with a kid and you

Peter Williams 29:56
Is that where you put your tongue on the top of your mouth and just click?

Caroline Smith 29:59

Yeah, just suck your tongue up and click it down. Okay? Because what happens when it's been sitting low, the muscles aren't, you know, the muscles aren't working. And what we want to do is stretch it away from the floor of the mouth. Some people do have oral ties. So they've got that connective tissue underneath the tongue that actually restricts the tongue from

Peter Williams 30:22
Is that what they call tongue tie.

Caroline Smith 30:24

So that's what they call a tongue tie. So myofunctional therapy, you know, a lot of people are fixated that, oh, gotta get a tongue tie release. And it's all about the tongue tie, but it's not, it's about integrating all of the muscles, and getting the tongue function. And you can actually get quite a lot of movement in the fascia from just that, that that distraction and the exercises, but some people are so restricted, that you know, a little bit of release of the fascia can be can be really profound. It's a bit like a webbed foot. You know, if you've got webbed fingers or web toes, you know, you would just want to release that little bit of connective tissue in between your fingers so that you could take that function, but myofunctional therapy if you don't have the therapy before and after you release that tissue. But those muscles have never worked in your fingers before. So you have to then build up those muscles, and then you have to teach the tongue.

Peter Williams 31:23

I'm assuming I'm assuming that? Well, as I say, it's very much when you're when you're dealing with someone who who needs to take exercise is that the reality is the results are only going to come from consistent effort. Yeah, so what would be what would be? Let's imagine someone comes in? And how do you determine? I mean, is it just on? Is it just on they snore? They may be showing signs of sleep apnea? Is there a way that you can physically look at them? And go? Yeah, we need to do something about this. And how does that? Again, how does the if you could explain how maybe poor tongue posture at night, mouth breathing actually starts to influence gum disease? That would be great if we could get into that as well.

Caroline Smith 32:10

Yeah, of course. So a lot of people reach out because they're having, because they're having issues. So you know, the goal of myofunctional therapy is to nasal breathe, lip seal, tongue posture, and, you know, working on correcting the swallow. So a lot of patients who are tied or for whatever reason might have a reverse swallow, so they kind of have a thrusted swallow so that they push their teeth every time they swallow. So you can get a bit of an open bite. So those

Peter Williams 32:51
people what you're saying, there, is that some people maybe so what would be a perfect swallow.

Caroline Smith 32:58

So a perfect swallow is starting from the tip, and then backwards. And this is the progression of myofunctional therapy. So we, we want to teach the tongue to sit up in the palate, but we can't just expect the tongue to be able to do that straightaway. So we, we practice kind of like tip of the tongue on the spot. So the spot is just this bit behind the upper front teeth. Interestingly, that is, you know, connected to the vagus nerve. And when the Yeah, the tongue tip is there, it helps really control that autonomic nervous system. So we want to teach the tongue on the spot, we want to then teach the middle of the tongue to sit up there. And as we build up the strength of the tongue, and those tongue muscles, we've got eight muscles inside of our tongue. So we've got a midline got four muscles, each side of the tongue, it's got so much going on there. So we build up that strength of the tongue. And then we do a lot of exercises with swallow so that the ideal swallow would be from the tip back, but you can understand if you try and do it now. You can probably do it but imagine if your tongue is being pulled to the floor of the mouth. You tongue will thrust forwards. Yeah, just can't move. It's so restricted. Okay? Your muscles will compensate. Because the tongue can do its job and the tongue is super, super, super strong, so everything else can compensate. So we're

Peter Williams 34:31
very basic, what are the fundamental jobs of the tongue?

Caroline Smith 34:38

So it's to protect the airway. We it's got, you know, tastebuds on it so we can use it for taste. We use it for speech and sound and swallowing is part of that oral phase of digestion. Okay, so you know if we can't move the tongue and You know, and we can't get that correct swallow sometimes we can swallow air and it can, you know, present as reflux. But actually, it's just because we're not actually, you know, we're swallowing air at the same time. If for example, you've got stuffy nose, and you're trying to eat your food, you will eat really fast because you're trying to breathe at the same time. Foods. So these people who are like, I've got gut issues. And I've tried this, that and the other and you know, a lot of practitioners and yeah, but you need to slow down eat, and these people actually can't because they just can't breathe if they try and slow it down. So it's kind of like thinking, Alright, okay, let's start thinking about food and nutrition, mechanically, chemically, of course, but actually mechanically, can people actually chew their food, move their tongue to support that chewing, create that bolus of food and then swallow it? That's what we're trying to do with myofunctional therapy. It's actually supporting from a nutritional stance, the oral phase of digestion. And so

Peter Williams 36:08
if I can go to that question, then that question was, if people are mouth breathers, how does that how does that accelerate that sort of periodontal disease?

Caroline Smith 36:23

Okay, so, yeah, it's not going to be kind of one thing, it's going to be having to think about the how the mouth breathing impacts the oxygenation around the body, how much oxidative stress, it's causing, you know, on a cellular level, how it's impacting the sleep quality. And if your sleep quality is poor, and I know we've had this conversation before, it upsets hormones like leptin and ghrelin, which make you crave sugar, because, you know, leptin and ghrelin, help to balance how satiated you are. If you're not sleeping properly, you know, you'll go for the the easy, digestible sugars just to give you that boost of energy. So I think it's, it probably drives, you know, different behaviour changes, because the body's just trying to basically stay awake. So

Peter Williams 37:19
would it? I'm assuming mouth breathing also dries the mouth?

Caroline Smith 37:25

It does. Yeah. So the saliva you know, I think a lot of people don't think about saliva and how, how wonderful it is, it's 98% Water, though, and it gives that lubrication, it acts as a buffer. So what happens, you know, your plaque will get sticky, I put disclosing solution on my my patients. So it's like a purple dye. And it shows me where the plaque builds up. And quite often, when I've got, you know, a darker stain, it means you've got a thicker biofilm. And as you know, with your research with with periodontal disease, it's all about the biofilm. And those pathogenic bacteria is can you know, stick on that late stage. So quite often in mouth breathers, it's quite, it's quite distinctive, that they've got staining at the front. So that's another conversation that can start like, oh, you know, are you breathing through your mouth, it seems to be you know, build up here and then that can lead on to the conversation about about breathing. But um, you know, those pathogenic bacteria, we know, they survive without oxygen, you know, the big the big pathogenic bacteria like the new P gingivitis, which is associated with Alzheimer's, we know that it's an anaerobic bacteria. So, you know, we're creating an internal environment for these kinds of bacteria to live. So what can we do to reduce oxidative stress? What can we do to get more oxygen in the body? What can we do to support sleep? What can we do to just teach the patients that the simplicity of how the human body is actually supposed to function? And, you know, for me, the simple stuff is literally the most profound.

Peter Williams 39:14

What about what about? So what about tools to help? So, I think we've had a couple of conversations on this actually, you know, we, we've just, we were talking just before we started about a group of German chaps who have developed a really sort of really chewing gum, which sort of stimulates the jaw muscles better than and it was that other one, which was, I think, an American one where you bite down straight on it. I'm not so sure whether that one. I mean, the German guys are saying that the toothpaste replicates more natural chewing because it's a side to side rather than the straight down so it reduces your risk of TMJ dysfunction, which I find quite interesting. But you guys must have loads of little tools and taping is big, isn't it? So what's your I think this is where I've been schooled a little bit by you and your group. So, I mean, everyone seems to be taping these days. Can we have the pros and cons of taping? And why people take? Yeah, so

Caroline Smith 40:26

Do not tape your mouth if you can't breathe through your nose. Yeah. So taping is is yes, of course it's it's, you know tennis players taping during the training and it's become you know people are talking about taping now and I think from James nesters book 'Breathe' Yeah. You know, a lot of people are thinking about this, but the reason behind taping is just to keep the lips together while you're asleep, some people just have low, low tone. And you know, it's a bit like kinesiology tape, you put a Kinesiology tape on your body to keep that that muscle in place. So you've got the likes of Patrick McEwen from the Butako or breathing. So he's created a myotape, which is a bit like kinesiology tape, it goes around the mouth, and it gives you your chance to keep your mouth open. People with you know hyperventilation syndrome and stuff like that you ask them to put like just don't even go there because it makes them feel like they're going to, you know, the hyperventilate. So for me taping is not something that I advise straightaway. It's something that I might integrate at some point. But for me, I tend to, you know, talk about, you know, nasal strips first or nasal dilators, anything to open up that airway space. And then we do breathing exercises first. And once my patients get to a certain point, I'm like, Okay, try this tape while you're cooking your tea, okay, so it's going to keep your lips together, you're going to be breathing, you know, you're going to be smelling your food. As as your lips are together, that's going to start off that digestive process that you know that horse a phallic stage, if you can keep that on for you know, for half an hour without any issues. You know, try it, try it, try it at night, I will get them to do the unblock the nose exercise that I think I sent the link to you. Sometime again, just google Buteyko breathing unblocking nose. And it helps to unblock the sinuses. So I'll get them to do as much as they can before taping but yeah, taping is not for everybody. And you have to be very, very, very careful with it. But yeah, you fundamentally you've got to be able to breathe through your nose without any distress. Before you tape

Peter Williams 42:54

take sounds good. But obviously, it's not for everyone. I think about sinus infections, I think about people, you know, overweight people who've maybe had too much to drink, it's probably not a good time to probably think about taping. But it's sort of it's like everything, isn't it? It's all over social media with regards to you know, everyone seems to be taping. And I suppose for me, at least with the mayotape, there is some safety built into the fact that you it doesn't shut your mouth. Yeah, it sort of brings your lips together, but you do have the capacity to breathe on that one. So would that be your choice? If you were going to

Caroline Smith 43:35

yeah. And, you know, I even take it a step back. So I get the myotape and I cut it so it's just strips and then you know, just put it up the sides of the mouth. So it's basically putting your, you know, pulling your cheeks open to into a gentle smile. And it's just, you know, elevating the lower jaw just that little bit. So you can you know, please, please, please do not go straight into taping if you haven't done any breath work or, you know, haven't been screened appropriately, or you really struggle with breathing. I think people think, oh, you know, I'm snoring and I'm going to tape it's going to solve the world. Please don't do it. If if if it's not safe. Okay.

Peter Williams 44:20

Where else do you think? Where else? Do you think that the sort of the myofunctional therapy has real therapeutic value? I mean, I think we've talked about I mean, I don't think there's any chronic disease where restricted breathing can't be a problem, but where else do you see it been so beneficial? Oh, gosh. Tell us about some of your patients because they must run from kids. I mean, I think about you know, I think about kids and mouth breathing all the time, you know, because I know, Jess, our 11 year old he's, he's definitely sort of suspect for that because he always seems to have some kind of sinus infection. So what would be what would be? And I'm sure there's loads people listen to this whose kids are the same? I mean, is it quite normal for kids to mouth breathe?

Caroline Smith 45:08

Um, I think it's common, and I think it's become more normal. This is just my own kind of thinking, but I think mask wearing, COVID, stress, allergies, I think we're just generally a stressed world now. And I think, you know, when we're stressed, the immune system doesn't function properly, you know, we're more prone to x, y, and Z and, and I just think it's become the norm. But I do think masks have made a big impact for adults, because we've been wearing the masks and, you know, to wear a mask. Quite often people are just mouth breathing underneath there. And that's just become so habitual that they've turned into mouth breathers

Peter Williams 45:59
almost like they've they've been wearing masks for such a long time, they've almost trained themselves to breathe in a slightly different way. Yeah, because, of course, most of the, I themselves to breathe in a slightly different way. Yeah, because, of course, most of the, I suppose when we're looking at root causes for us, I mean, I can think about so many patients where the sympathetic nervous, so that sort of fight or flight aspect of the nervous system is so switched on. I mean, it's a sort of root of all evil, really, until you start to sort of create a programme that helps them to do that, which, of course, is what the breathing can do for us, doesn't it?

Caroline Smith 46:30

Yeah, absolutely. But thinking about the muscles like, especially that I think, you know, the little kids who babies, you know, when, especially during COVID, who, if everybody's been wearing a mask, and this lower part of the mouth is such an influential part, you know, your smiling with them, and you're cooing with them, and you're making them giggle, and they've not actually seen that, and we're not laughing as much, or we're not using these, these muscles, I think, I just think it's had such a detrimental effect on the lower part of the, you know, the muscles in the lower part of the face, which are so profound in helping for correct oral posture. Because when your lips are back, and you're smiling your tongue, but naturally, you know, you don't want to actually be elevated. So myofunctional therapy is basically helping people smile, and breathe and do the stuff that we should be just naturally doing.

Peter Williams 47:36

Which is gold dust really, isn't it? I suppose, you know, I think it comes down to a lot of really what we do. So people aren't the fancy tests all the time. And the reality is, is that they're not really going to give them the sort of outcomes that they want. But something such as simple as, you know, you smile a bit more than you're probably more or less more parasympathetic state, you're probably sort of more oxygen rich, you're probably producing more nitric oxide obviously brings the BP down. And it's sort of like a golden cascade, isn't it?

Caroline Smith 48:05 
Absolutely, yeah.

Peter Williams 48:07
But again, the root cause is will you know, how shit is your life at the moment?

Caroline Smith 48:11

Well, exactly. And this is the thing. So you've gone back to a question that I didn't answer earlier. It's like, you've got to do it to see the difference? And if that person doesn't like looking in front of the mirror, or if that person because it's neuromuscular, you're teaching the muscle, you're teaching the muscles of the face to do something that not used to it's like trying to learn to write with your other hand with blindfolded do not, you've got to look in the mirror. Some people don't want to look at themselves in the mirror, they don't actually like themselves. And actually, that's, that's been a massive revelation. Like, why are some patients just doing it? And others are? Like, no, I just didn't have time to do my exercise that just not invested because they don't want to and some people are just not ready for that. And that's why with my clinic, I've realised that some people are so stressed that any therapy is going to be another stress on them even to help them what I do I offer just single massage therapy. You know, some people are so stressed out, they've got this going on they're going through a divorce, the kids are a nightmare. And they're like, I just I just, you know, I just want to be you know, I just want a massage and I was like, totally cool. That's fine. And I know that you know, you can get referred pain patterns in you can get headaches, you can get migraines, because when you're not using that muscle, that diaphragm muscle that we're talking about before. These are your accessory muscles to breathing. And if you get pain in the knees that can refer to headaches, migraines, neck tension. So we're talking

Peter Williams 49:51
about the sternocleidomastoids -the sort of strappy muscles at the side of the neck

Caroline Smith 49:56

absolutely so you can get you know these primary primary areas are trigger points. And then you can get referred period, like up here, you can even get referred pain from the temporalis in your teeth. So people go to the dentist with phantom tooth pain, get their teeth out, and it's like, Ah, this is neuromuscular. This is not to tooth pain, like some people have had, you know, the whole quadrant of the mouth, you know teeth removed and actually say, okay, these pain patterns that actually when you look at the pain patterns, they are reproducible, and it's actually quite beautiful the way that you know, the body is trying to protect itself. So yeah, I do single session massage to, okay, these people are in pain, let's do you know, three to six sessions of manual therapy to get them out of pain. And then if that patient is ready to go on that journey of, you know, healing, then, of course, then I'm there for that as well as

Peter Williams 50:56
a question for you, then. I'm assuming you do online consultations, where you can teach people how to breathe correctly. Is that something that you would do?

Caroline Smith 51:08

Yeah, I do like to see people for the first time in the flesh, because I can feel the muscles, I can look at the tongue function, we can talk about pain patterns, and I can, you know, do some manual therapy as well. It does make it I mean, I do do it online. And I have done it, it just, it puts me at a bit of a disadvantage. I work a lot with well, not a lot, but I work with some dentists, for example when they're doing some early intervention work. And then I will, you know, support that. And basically, I'm just learning as I'm going and trying to integrate everything that I know, given the patient, the best support, try not to overwhelm them. But I think it's more so about supporting people to get into a routine. Because if you're in a routine, you can you're brushing your teeth every morning and evening, hopefully, can you add these little bits of exercises every time you brush your teeth, or, you know what every time you go to the loo and you gotta wash your hands, and there's a mirror there, I'm going to give you this one exercise that's going to help to you know, to strengthen that tone. And if that's all we do, that's all we do. Some people like, right, great, I'm on it and ready, I can give them five exercises, they do it three times a day, like 15 minutes a time. And I'm like, Whoa, that's that I couldn't do that. But some people are totally ready for that. So I've realised that I have to really adapt it to that person, and what their goals are and what their needs are.

Peter Williams 52:41

So where do you think you're? I mean, your society is growing quite quickly, isn't it? So where do you think the sort of next five years are? Because you know, I was I was just sort of running through it before we came out. You've been this is not there's not poopoo stuff, is it? You've got some quite serious ENT surgeons, you've got some some, some sleep consultants on this as well. So clearly, everyone is trying to well, the right people are trying to integrate and get a deeper understanding as I'm trying to do. I mean, I think what's pretty clear to me that airway management really matters. So oral disease, of course, and they're all beautifully interlinked. Where do you think they're Where do you think the future is? Do you think sort of dentistry is going to be sort of moving a little bit now, isn't it from a point of view with a us as far as I've always said, you can't ignore the science with regards to is dentistry just going to become part of part of medicine rather than being separate? And there would be a sort of, you know, Dentist, Dental Hygienist myofunctional therapist and nutritionist, which is essentially what your your journey has been hasn't it to pull it all together? So where has it been then for you? I mean, obviously, you guys were right at the beginning of this, obviously, one of the founding members, how far is it coming to think? And how far does it need to go?

Caroline Smith 54:13

I mean, for me, because I've literally spent hours learning. I've spent my life saving every on the courses. And I'm like, this is the future. This is the future of medicine. How could it not be if people can't breathe? Then how on earth and like I was saying to you earlier, I just did a lecture at the dentistry show. And I was like, How can I actually get this across to dentists in a way that it's not going to be seen as pseudoscience, like, it's like, okay, how does the body shows like that it's sick when it's when it's not oxygenated. And when and I think we need to go back to basics and we need to look at how cells take in oxygen if they don't get oxygen, how can how can that present? How you know? And using the science, of course, but the, the, you know, the pure anatomy, it's just, it's just anatomy. So I feel it's the future because I'm like, well, it just makes so much sense. And you know what the patients get it the ones who are struggling. They're like, Oh, my God, I feel like you've just looked into my soul. Like, how did you know that was like, well, it's just the way that the body works like this is what's happening. And like you say, we've got some great members, some, you know, a variety of different clinicians, because who is actually screen in the airway? You know, you go and you get blood pressure checked, you get your eyes tested, you get your ears tested, who is actually asking you Do you breathe through your nose? Or do you breathe through your mouth? Nobody is asking that question. We all think that somebody else is looking for that. And I don't, I can't remember. But I don't think I was even told to look at the tonsil size when I was doing my like over screen and now get the tongue I put a push it down. I get everyone to say, ah, somebody's tonsils are massive. I'm like, that's going to occlude, you know, the airway space. This, you need to get to ENT and they need to be screening for this and they need to, you know, I'm not, obviously I want to do everything before surgery. But if they are atrophied because you've had multiple bouts of tonsillitis, and they are literally boulders in there. So, you know, you're gonna breathe better if there's not big boulders in the back. Yes. Okay.

Peter Williams 56:46

So let's, what would be what would be sort of trying to sort of conclude here? What would be some of the warning signs that you would look for immediately that anyone who's listening to this podcast could go? sort of sounds like me? I mean, most of what you said, that's like, what's going on with me, but

Caroline Smith 57:04
I did. Yeah. And you know, what, I fell down this rabbit hole because of me as well, you know, so, yeah, so I feel it as well. So for me, it would be fatigue. Um,

Peter Williams 57:18
so daytime sleepiness is, is definitely it's almost like a red flag.

Caroline Smith 57:22

daytime sleepiness in adults, in children can present as hyperactivity, they're trying to keep themselves awake. So, you know, I'm not saying that sleep disorders cause ADHD but, potentially that lack of oxygen, you know, if you're not getting oxygen to your brain, it's not going to function. So you know, I, if if people are tossing and turning, obviously snoring, pausing to get up to go to the loo, nasal allergies, nasal dysfunction. I think that the NICE guidelines for obstructive sleep apnea are a great resource. Because if you cannot tolerate a CPAP, which is gold standard for you know, positive air pressure, then the other options are mandibular advancement devices. So they are a dental device, therefore, this screening really should, we should have more knowledge on this as a dental professional. As a whole, we should have more knowledge on this. And you can, there are the British society of Dental Sleep Medicine, I think it's called. And again, there's another cohort of amazing practitioners who support with mandibular, the mandible, it's the lower jaw brings it forward. So opens it airway slightly, so you can get specific devices for you that can open the airway. And that can be enough for some people who don't want to go through myofunctional therapy, who don't have that, you know, that capacity to put in the energy and the effort to do that. Sometimes just pulled in that you're into a more stable ordinary. I mean, it's not great for the TMJ long term. But for some people, that's that's what they want. And that's enough for them. So yeah, there aren't there is that option of a bubble, Donna forgotten what question?

Peter Williams 59:18
The question was really sort of, you know, what are the simple warning signs that the general public can sort of go and think Okay. I suppose you have a question on this, though, if they do public can sort of go and think Okay. I suppose you have a question on this, though, if they do see these warning signs, who they go to? Because to be fair, I mean, I've reasonably I've had enough years now speaking to dentists. And obviously, you know, I've developed quite a bit of stuff in this area, a lot of whom have no idea what I'm talking about. So I'm assuming that's not dissimilar for you, is it? There are some dentists that are really clued up there are others who aren't interested. Yeah. And what why do you think that is? Do you think it's just because it's another rabbit hole that they've got to jump down and it's just well I get it. It's too much for some people.

Caroline Smith 1:00:03

Yeah. I don't know. I don't know. Because when when you're learning, you just think, oh my god, that makes so much sense. And I think I was so naive at the beginning, I was just gonna tell people in the beginning Oh, yeah, that makes sense. We'll just do it a different way. I think I think there's, there's a multitude of different reasons. But I think it is because it is multi multifaceted. And you know, what, we're taught in a way. And that's, that's, that's fine. But I don't know why more people aren't aware of it. And quite often it takes for a family member to be ill, and natural, I mean, the normal route of medicine to not do the job. So they're looking at alternatives. But there are a few. So you know, they can come to the British society of myofunctional therapy, that's, you know, maybe a good start. We can, our goal is really to get a directory up as well, just of practitioners who might not all be dental related, but are aware of these issues. And we can work within that interdisciplinary team, if you think that you are pausing and breathing with, you know, and have got sleep apnea that needs to go by the GP for a sleep study, again, like I say, The Snore lab and the Berlin sleep questionnaire, just go with as much ammunition as possible and being really forceful.

Peter Williams 1:01:33

is to be fair, it's probably going to be pretty difficult with the state of the NHS at the moment. I just thinking just speed of therapy with this one. Yeah. And sleep studies aren't aren't cheap. That No, no, so Yeah, unfortunately, again, that's something to think about. But of course, you know, that's where you think about the bigger picture, like if you're quite considerably overweight, you know, you probably want to do something about that. You mentioned the nasal the nasal strips are good. You're quite happy, I used ot remember Robbie Fowler used to when he was a top lad for those. Oh, Robbie, he loves them. Yeah.

Caroline Smith 1:02:10
And you know what some patients are like that works an absolute treat during the sleep. I'm not mouth breathing anymore. I'm not clenching my teeth anymore. That is enough for me.

Peter Williams 1:02:21

Is there? Is there a make of those mouth strips that you like? We know the mayo tape if you're thinking about taping the mouth, and I know you've had some sort of precautions around there, but that seems to be the one that doesn't tape the mouth does it it closes the mouth but doesn't tape it out. So it's probably the safest choice. Yeah. What about the what about the nasal strips?

Caroline Smith 1:02:46
Just Breathe Right strips. So you can get them from boots or breathe?

Peter Williams 1:02:49 
Right? Okay.

Caroline Smith 1:02:50

Yeah, that's what I've got some good feedback, you can get a little nasal dilators. So the little kind of, you know, little bits of plastic that pushes the nostrils out. See? So I often ask my patients to just pull the nostrils out like this and just say, Is that easier to breathe? And they are like yeah. Okay. So you can get a little bit of plastic thing, it pushes your nostrils out. So would

Peter Williams 1:03:14
that be something that you'd use at night again? Because obviously, okay, and they're fine. I mean, where would you get them from?

Caroline Smith 1:03:21

You can get them from boots, or you can get them online. You can get here, I should get like a discount for boots. You can get ones which are different sizes. So they've got like a trial pack. They're quite good, because we've got a small, medium and large so you can try the different sizes. Yeah, so like those ones, they actually do a sports version which might interest you. So Chris, Chris Froome. The cyclist? Yeah. He is sponsored. Well, he used to be sponsored by them. What are they called? I can't remember now. But they're pretty much like the mute snore guard. But they're a sports version. I don't know if I don't know what the difference is. Whether it you know, stays up there better when you're doing sport. But again, if you can do sport, as you nasal breathing, we know that the nitric oxide is a is a vasal dilator. So you know, it's gonna get more oxygen to the body.

Peter Williams 1:04:22

There are lots of breathing techniques out there. So is there anyone in particular that you feel as though that you know anyone listening to this? Because obviously, it's something that is clearly super important. I don't do enough of it. What techniques would you prefer? If you're going to say, you know, go onto the internet and look at this or look at that, what would what would be your choices? Well, I

Caroline Smith 1:04:52

suppose it would depend if you've got a stuffy nose and you've got you know, sinus issues or then I would say right There's a Buteyko, unblock your nose exercise. Had someone in my clinic the other day, lower back pain. All of these issues, as I said have a bit of a stuffy nose is that yep, yep, yep, had a bit of a cold. So anyway, did the did the massage released the tissues? And I was like, Can I kind of show you how to unblock you knows we did three rounds of the Buteyko - cleared its nose was clear. So if you've got an unblocked know, if you've got a stuffy nose, then I would suggest that

Peter Williams 1:05:28
one. Yeah. And that one's not just online isn't on YouTube

Caroline Smith 1:05:31

online it's a free app called the Buteyko Clinic app. So all of these little exercises or a little videos on the website, actually Patrick has, you can go and download the kiddies Buteyko or breathing clinic protocol for free, it gives out free so you can go on there and you can do it yourself. So for me, again, I probably don't do as much as I should either. I like the headspace app, and they do the you know, in four or five out for six or kind of general box breathing that can really just, you know, sometimes you over breathe. And just because you know,

Peter Williams 1:06:18

isn't it interesting that this breathing strategy is also the strategy that you'd be using to to induce increased vagal tone, which of course is the sort of the wandering nerve that controls the central nervous system. And so so as you say, how interrelated that everything is on

Caroline Smith 1:06:38

interest. And you should say that because the back of the mouth. So if you when you go brush your teeth tonight, have a little look in your mouth. And when the tongue is down, and at the back, you should be able to see the dangly bit. Yeah, yeah, so it's a bit like, so you've got your dangly bit. And then you've got the muscle that that keeps it in place that's innovated by the vagus nerve. So you know, when in functional medicine and supportive therapies, we say gargling is really good. Yeah. Because it stimulates the vagus nerve, because you're actually vibrating that that muscle and that interest in the vagus nerve legs, short, sharp stimulation. So vigorous gargling is really, really good. But you can imagine when you're asleep, and you've

got sleep apnea, or upper airway resistance, and that tongue is just, you know, oh, all of a sudden, just just gently, you know, touching that vagus, and that, that, that's a chronic stress in that area. So what I often find, and again, this is just anecdotal. When I'm looking in the mouths of my my dental patients, and I'm looking at the tongue function and the airway space, I'm like, Oh, do you gag your teeth when you do gag when you brush your teeth? Like, yeah, how did you know that? I'm like, Oh, well, you know, your body is presenting in a certain way. And this is a great little tip. In acupuncture. There's an acupressure point here, CV 24. So if you've got a gag reflex, and you push your thumb right here, so it's just on the crease of your chin,

Peter Williams 1:08:19
right, okay, so Okay, in the crease of YouTube, in the crease of your changes,

Caroline Smith 1:08:24

nice and firm that can disengage your gag reflex. So if you've got if you're a gagger, when you brush your teeth, try this use a dry toothbrush. So there's not kind of gloopiness or water, especially if you're a mouth breather. Because imagine putting the toothbrush in your mouth. When you can't breathe through your nose. Yeah, you're gonna feel claustrophobic. If you've got a gag reflex, put your thumb on there. And again, it's like it's like magic, the patient's like oh my god, I can actually put my toothbrush in the correct place. And interestingly, I had a patient once and I had to do certain kind of X ray in the mouth it's called a Peri apical and it has to go kind of down underneath so you can you can get on the X ray the apex of the tooth so it has to go quite down soon. As I put it in. Gag gag gag. Got him to press on this point I managed to get the X ray. Soon as I finished I was like Okay, tell me about your sleep. Like what How did you know that I had poor sleep because because of that as well. Because you know your body's telling me that your tongue is trying to protect the airway. It's telling me that the you know the potentially you know there's some kind of like micro arousals going on back there that are compromising that that vagal tone

Peter Williams 1:09:45

any other cool tips like that? Because I'm way over time a reminder will get the most will get the gold as well. We can any any other tips which would just be classical - do this, it might be this

Caroline Smith 1:10:00 
But for for exercise wise you

Peter Williams 1:10:02
think for anything really? I think anything that is someone go wow, I didn't even realise that.

Caroline Smith 1:10:08

Um, I think if there was my golden my golden nugget that if you know, I think the unblocking always exercises just absolute winner. Yeah. And you know, the gag reflex point. Yeah. But I think as well because when I don't think people know how to brush their teeth properly, they're

Peter Williams 1:10:30
That's true. So why don't you? Why don't you? Let's conclude with with that because I'm

probably doing it wrong myself.

Caroline Smith 1:10:39

No, no, that's absolutely fine. And like I said before, it's, it's literally my favourite thing to teach people and you know, in periodontal therapy, we and we have this discussion at the weekend when I was done at the dentist, for sure we've got phases of perio. So we've got the gingivitis phase, so that's inflammation of the gums only completely reversible. And then you've got the later stages where you know the bone is involved or the periodontal ligament, you get bone loss, you get pockets. Now, inflammation is the absolute key, because without inflammation, you cannot get progressive gum disease. So healthy gums do not bleed. So actually, and this is where dentistry is evolving, because they're, they're saying, we have to work on the inflammation first, like, well, to

Peter Williams 1:11:34

be fair, this this was this was all part of me building that genetic panel, which fundamentally is about innate immunity, which really has a an inflammatory, inflammatory aspect to it. So yeah, that's why

Caroline Smith 1:11:49

we should talk about this because I've got this idea of kind of like, okay, what can we screen? What can we what can we teach people do the genetics, do the saliva panel, and then do the lifestyle, you know, get the lifestyle history, and then you can create this beautiful package for your patients

Peter Williams 1:12:06

I mean, I think this is, I mean, funny. I had a conversation with two new clients this week. And the reality I said to then, I said look, you give me six months, you let me do a load of data collection, you let me get some genetics, this wasn't associated with gum disease. They said, Yeah, let me get some genetics. And I will give you your booklet in six months. And that booklet won't be 100%. But it'll be as close as we can probably get currently to giving you your sort of your personalised, you know, book of book of template. And I think that's something that, you know, I look at that periodontal genetics panel, and it really is that it's like, if you've got, you know, a strong family history, and you do that test, you have a better idea. I mean, it's such it's preventative. I mean, if I'd have done it, I mean, same for me. I mean, I mean, I've managed to pull my periodontal disease back massively, and it's probably better now at 54. than it was 10 years ago. Much better. So I've managed to keep my teeth in a family where you know, I grew

up with getting shit scared when I went the bathroom because Grandma and granddad's false teeth always used to used to scare me and same with my mom, my mom's got false teeth. I look back and think, you know, maybe maybe the having this information is putting that disease process back 20/30 years. So that's the plan for me. But yeah, I think that's what that's where we should be going because we've got the technology to be able to do it. Yeah, it's a question of putting it all altogether.

Caroline Smith 1:13:36

You're right. And imagine if you were taught at an early age, about inflammation. And if you were taught literally how to brush, I am flabbergasted at new patients who come in and I'm like, has anyone ever told you how to brush your teeth, and

Peter Williams 1:13:54
So do you want to share, shall we close on on how to brush, brush your teeth. Given that most

people won't see your won't see your video. So try and be as sort of,

Caroline Smith 1:14:04

I will, okay, so I won't patient like, if you can imagine, just see you wearing a t shirt. Okay, so your you've got your arm, and then you've got your T shirt, just imagine your arm as your tooth, and your T shirt as your gum. So where your arm meets your T shirt right at that edge. That is a bit like where the gum meets the tooth. And that little bit of gum is not attached to the tooth. So you have a little sulcus where the tooth meets the gum, and what happens is bacteria stick because you've got that watery environment, sticks to the teeth. Especially you know, if you're a mouth breather it's going to be more sticky fuel. If you're fueling the bacteria if you're constantly given them, you know, sugars, they're going to multiply and the bacteria are very sneaky. They'll get underneath that gum margin. And when they're underneath that gum margin then your immune system very cleverly wants to protect you and your immune system is is in your blood so your gums start to bleed because your body is in that protective mode. So what you need to do with your toothbrush, you need to get those bristles underneath the gum margin. Now the surface area of the gum margin, you know, it goes around the edge, but 50% of that gum margin 40 to 50% of that gum margin is in between your teeth as well. This is why dental hygiene has forgotten about those little brushes in between the teeth all the time, because we want to get as much of that plaque biofilm removed as possible. So with a manual toothbrush, if you just use the manual toothbrush, angle, the toothbrush, so it's going underneath the gums kind of 45 degree angle underneath the gums, and then you're gently kind of massaging underneath those gums. Personally, I see much bigger benefits from an electric toothbrush. The new Oral B IO is fantastic. I absolutely love it because it's got Sonic and rotating. I'll send you a little link to a to a discount code if you want Pete you put the toothbrush on the tooth, you gently pulsate, pushing the the bristles up underneath the gum, and as it's rotating and vibrating, you're just guiding the bristles underneath the gum margin. So like driving a car, you are the function of that toothbrush is to get underneath the gums and disrupt the biofilm. So I advise I advise with a dry brush to start with, so people can actually see what they're doing, you got to have a magnifying mirror, I've got a magnifying mirror that with the light so I can see what I'm doing. And pushing those bristles and, and moving it around the

contour of the gum margin. Now the gum margin equates surface area wise to the palm of your hand. Now, you can imagine that if you if I do a bleeding score, and you got 50% bleed in your mouth. That's like, that's like an open wound. Yeah. Yeah,

Peter Williams 1:17:10

again, can totally goes back to some of the some of the newer, say some of the concepts with regards to bacterial translocation, you've just got to glue wound where bacteria that shouldn't go into that wound do go into that wound. And that cause that causes a whole host of systemic issues.

Caroline Smith 1:17:28 
Absolutely. So really is

Peter Williams 1:17:31 
Bleeding is not a great sign.

Caroline Smith 1:17:33

Bleeding is not a great sign. But you know what, and so why I phase my therapy. So I put that in kind of a hygiene phase therapy. So the patient's got like 60% bleeding, I tell them all of this, I give them the skills, I teach them, you know, but do gentle biofilm disruption, I'm not going underneath the gums, I want that patient to go away and heal themselves. I get them back, so the healing process takes between seven to 10 days. Once you know those, those fibroblasts at the base of the pocket, they can, you know, produce more collagen in that in that in that third week. So I get them to come back like two or three weeks after and I'm like if you do this consistently, every single night, every single day, the science tells us if this inflammation is plaque induced that will go within 10 days.

Peter Williams 1:18:26
Which really says you need to clean your teeth consistently well, every single day, twice a day.

Caroline Smith 1:18:33

Yes, especially before bed. Because you know, when you're not producing as much saliva or your mouth breathing at night, the bacteria will take that food that you've eaten, and it's stuck in between your teeth, and they will just feed on it. Yeah, so nighttime brushing is the king. And you know, there's patients who just always forget I'm tired, I'm like, Well, if you're not going to eat anything after your dinner, like you know, give it a half an hour to balance your pH and then just go and do it before you're gonna sit down and watch TV. It doesn't have to be directly just before bed. You know, you've got to adapt to your lifestyle, but I think it's just ingrained in

us all you've got to do with just before bed. You don't you can, you know, change your system to for whatever works for you. So yeah, if patients are inflamed, what I normally see is that generally and again it you won't find it in a paper, but this is just what I'm seeing. I'll get that patient back after two weeks and and normally see the inflammation has come down about 50%. So if they had 60% bleeding, it normally comes down to about 30. And our goal is for less than 10%. So normally if they're about 60% I get them in for two sessions. And I give them the incentive you know if you if the bleeding has gone down and within the first session, I'll cancel the second session. I don't need it. I'm not just going to get you back for getting you back sake. This is our goal. And this is our primary goal. Some patients like well, I can't really afford it. I'm like, Okay, well, you go in, do your homework. And you email me. When that when that bleeding stops, you just send me an email and just say, yeah, it was 10 days, it was nine days, it was seven days, my bleeding stopped. I'm quite happy. I'm like, That's great. Like, whatever the patient is ready for, you've just got to adapt for, for what they are ready for?

Peter Williams 1:20:29

Well, we've been going for quite a while, haven't we? I think we better stop it. I'm bloody starving. Where are we, we're an hour in 25 minutes? Well, at least at least we're sort of into the subject hey. It's nice when we bring people on and they're so into their subjects. Caroline it has been a real pleasure. Thank you so much. I think everyone will sort of look at myofunctional therapy, or even at least its put it on put it on a marker out there for them to say, Well, what the hell is that? And that's usually where it starts, doesn't it? There are going to be so many people who've got so many of these problems. And a lot of it can be sort of sorted out or helped pretty quickly with some with some some of your techniques. So thank you so much for taking the time to to come on and speak to us it's been a real pleasure.

Caroline Smith 1:21:22
Thank you so much for having me. Thank you