The Pediatric Breathing Project with Dr. Piya Gandhi, DDS

The Airway Conversation Every Parent & Provider Needs to Hear

• Dr. Piya Gandhi, DDS • Season 1 • Episode 8

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Episode 8 | The Pediatric Breathing Project | The Airway Conversation Every Parent And Provider Needs to Hear with Dr. David Alfi

In this powerful episode of The Pediatric Breathing Project, Dr. Piya Gandhi sits down with renowned oral and maxillofacial surgeon Dr. David Alfi for an honest conversation about pediatric airway health, jaw development, mouth breathing, expansion, tongue ties, sleep-disordered breathing, and why so many children are slipping through the cracks.

Together, they break down what healthy growth should actually look like in children, why crowded baby teeth are not “normal,” how modern lifestyle habits are impacting jaw development, and why early intervention matters more than most parents realize.

Dr. Piya also shares the deeply personal story that changed the trajectory of her career — her own daughter’s airway struggles — and how that journey led her into airway-focused pediatric dentistry. The episode also dives into the resistance many airway-focused providers still face, the lack of education in traditional training programs, and the growing movement toward collaborative, whole-body care.

Dr. Alfi additionally explains what happens when airway issues are missed into adulthood, including how modern airway-focused jaw surgery can dramatically improve sleep, breathing, health, and quality of life.

Whether you’re a parent, pediatric provider, dentist, orthodontist, speech therapist, IBCLC, or simply trying to better understand airway health, this episode is packed with practical insight and perspective.

In This Episode We Cover:

✔ Mouth breathing in babies and children
✔ Why crowded baby teeth are not normal
✔ Early childhood expansion and airway treatment
✔ Tongue ties, oral function and feeding
✔ The connection between jaw development and sleep
✔ Why airway issues are becoming more common
✔ Myofunctional therapy and muscle retraining
✔ The impact of modern diets and soft foods
✔ How airway problems continue into adulthood
✔ Airway-focused jaw surgery and adult treatment
✔ The resistance airway providers still face
✔ Why collaborative care matters

Connect with Dr. David Alfi
🌐 Website: https://www.drdavidalfi.com/

📱 Instagram: https://www.instagram.com/drdavidalfi/

🎙️ The Alfi Podcast
Instagram: https://www.instagram.com/thealfipodcast/
YouTube: https://www.youtube.com/@thealfipodcast

Resources from Dr. Piya Gandhi

🌿 Free Airway Checklist + Provider Resources
https://drpiyagandhi.com/

📍 Find an Airway Provider Near You
https://drpiyagandhi.com/website_4530a186/#directory

🎙️ Explore More Episodes of The Pediatric Breathing Project
https://thepediatricbreathingproject.buzzsprout.com

About The Pediatric Breathing Project

Hosted by Dr. Piya Gandhi, this podcast explores how airway health, oral development, sleep, feeding, tongue ties, and early intervention impact childhood wellness and long-term health.

If you’re passionate about pediatric airway health, collaborative care, sleep-disordered breathing, and helping children thrive, subscribe and follow along.

#PediatricAirway #MouthBreathing #TongueTie #JawDevelopment #AirwayDentistry #SleepDisorderedBreathing #PediatricDentistry #MyofunctionalTherapy

________

The Pediatric Breathing Project with Dr. Piya Gandhi explores how airway health, jaw development, and sleep impact childhood wellness. Parents and practitioners will learn to spot early signs of sleep-disordered breathing and discover practical solutions for healthier futures.

If you’re a parent, dentist, pediatrician, or healthcare professional passionate about giving children the best start in life, this podcast is your guide to better breathing, better sleep, and better development.

Piya Trehan Gandhi, DDS

BOARD CERTIFIED PEDIATRIC DENTIST, AIRWAY AND TONGUE TIE RELEASE SPECIALIST

Instagram | TikTok | LinkedIn | YouTube | Website


Resources from Dr. Piya Gandhi:



Dr. David Alfi DDS MD FACS:

Nobody knows what to do with their own children out there. We get this message all the time.

Dr. Piya Gandhi, DDS:

And I have to point out to them,"Well, what we're used to seeing is not normal."

Dr. David Alfi DDS MD FACS:

What do you do with these kids that have airway disorders? Mm-hmm.

Dr. Piya Gandhi, DDS:

My name is Dr. Piya Gandhi and welcome to my podcast, The Pediatric Breathing Project. I'm actually in the studio of Dr. Alfi here'cause we are interviewing each other. But Dr. Alfi is an amazing surgeon, airway-focused. We've known each other for 20 years or so since our days in New York. And I'm so honored to get to work with him and chat with him today about what airway treatment looks like from birth all the way through.

Dr. David Alfi DDS MD FACS:

Yeah. It's a pleasure to be here. We finally have a pediatric dentist, but not only a pediatric dentist, a pioneer in airway. Almost every time I say that you need to start with a pediatric dentist, orthodontist too, um, but you have to start early, and unfortunately, it's very difficult to find a pediatric dentist that understands and manages airway disorders. So Piya Gandhi is in the studio. You've been an airway pioneer for 10 years? Yeah. Something like that, and we'll talk about- That's true. Mm-hmm ... the journey 'cause both of us, um, came from New York. Yep. No airway background, trained in Texas, and, and this parallel path that I'll let you get into, but we're here talking about airway.

Dr. Piya Gandhi, DDS:

Yeah. So thanks so much for having me, and, um, this is actually gonna be kind of a back-and-forth interview style- Mm-hmm... because, uh, David was actually supposed to be on my podcast, and we thought, "Why not just do it at the same time?" So, you know, we're both here to kinda bring you the ends of peds to adults and what it looks like all the way through, um, but also talk about, like, the reality of where we are. Yeah. And I think for myself, this airway opportunity fell into my lap organically. Mm-hmm. You know, I came from New York as a GP, general dentist, knew nothing about airways. I ended up with a child that was tongue-tied and had all the early signs that no one ever taught us about. So I had to figure stuff out for her, and it totally not only changed her life and my life but totally changed my career as well. And- Yeah. Do you

Dr. David Alfi DDS MD FACS:

know, as you say that, I forgot that you were, you even came as a general- I was a gen-... dentist ... I was

Dr. Piya Gandhi, DDS:

a general dentist for six years.

Dr. David Alfi DDS MD FACS:

Yeah. And- Time flies... Dr. Piya Gandhi, DDS: pedes thinking,"Oh, I just wanna open, like, a cute little boutique practice- Mm-hmm ... that's personalized, do, like, your normal pediatric dentistry."

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

And, uh, we still do your everyday pediatric dentistry, but, um, we do so much more. Yeah. And it's so much more than just teeth. Mm-hmm.

Speaker:

And

Dr. Piya Gandhi, DDS:

as dentists, we need to be looking at a lot more than just teeth.

Dr. David Alfi DDS MD FACS:

Yeah. Absolutely. So stay tuned, and you don't wanna miss the rest of this episode because we're gonna drop a lot of pearls about what to do with your children. Nobody knows what to do with their own children out there. We get this message all the time. Um, if you're a provider, orthodontist, pediatric dentist, uh, or someone that's looking to refer, what do you do with these kids that have airway disorders? Mm-hmm. And I'm gonna tell you something, without... With exception, every kid has an airway disorder- Yeah nowadays, and that's a result of modern society and conveniences that we just take for granted. But- You know, we've developed in a, in, in this way, right? There's a, there's a epidemic- Yes ... of jaw size issues, so every kid- Yes... is affected, um, unless proven otherwise. Even my own son Zane, who's in the studio. Zane, come over here. So Zane- Yes... actually Zane's pediatric dentist is Dr. Gandhi right here. Yep. And he's gone through expansion. Yep.

Zane:

It was, it was... I wouldn't say it was the best while it was happening. But the result was pretty good 'cause I could breathe better and stuff. Yeah.

Dr. David Alfi DDS MD FACS:

Yeah, and was it painful? That's awesome.

Zane:

Sometimes. Taking it off, I, I could feel like the tension in my teeth being like released. Mm. And I remember the first day I had it on, um, at lunch, I couldn't really eat 'cause I had to get used to it. Yeah.

Dr. Piya Gandhi, DDS:

But your young body is super smart- Yeah ... so it got used to it pretty quickly. Yeah. Yeah.

Zane:

Then I got to eating again.

Dr. Piya Gandhi, DDS:

Yeah. That's the best part of- Yeah... doing things when you're a kid.' Speaker 4: Cause to it- Yeah... and stuff. Yeah. It's harder when you're an adult. Yeah.

Dr. David Alfi DDS MD FACS:

Yeah. A- and you've treated his sister too because- Yeah... expansion, almost every kid needs expansion.

Dr. Piya Gandhi, DDS:

It is. You know, now we commonly see kids with smaller jaws, so it's kinda become what people think is normal.

Speaker:

Yep.

Dr. Piya Gandhi, DDS:

But it's really not.

Dr. David Alfi DDS MD FACS:

Mm. And

Dr. Piya Gandhi, DDS:

so, you know, one of the things we face when we treat kids and we start creating space is parents are like, "Oh, wow, they look so different," and "Haven't you expanded enough?"

Dr. David Alfi DDS MD FACS:

Yep.

Dr. Piya Gandhi, DDS:

And I have to point out to them,"Well, what we're used to seeing is not normal."

Speaker:

Mm. Right. You know?

Dr. Piya Gandhi, DDS:

It's common, but it's not normal. And I hope one day every kid is walking around with big spaces between their baby teeth- Yeah ... 'cause that is what we're supposed to be looking like. Yeah. Um- So that's pearl number

Dr. David Alfi DDS MD FACS:

one. Yes. Right? Let's, let's... There's gonna be a lot of pearls here- Yes ... and we even take them for granted, right? I know. We say

Dr. Piya Gandhi, DDS:

them like, like everyone knows them.

Dr. David Alfi DDS MD FACS:

Yeah, so, so say that again. What... When kids... When parents see their children and there's no spacing between their teeth- Yeah... meaning that

Dr. Piya Gandhi, DDS:

their- Meaning when their baby teeth are all touching, that's considered crowded and narrow- Yeah ... and an underdeveloped jaw.

Speaker 6:

Yeah.

Dr. Piya Gandhi, DDS:

So we really should see nice big spaces between every single baby tooth, and it makes sense 'cause if you think about it, the adult teeth that are all forming up here are much larger.

Dr. David Alfi DDS MD FACS:

Right, so we need space for them. So we, we need

Dr. Piya Gandhi, DDS:

space for them, and a lot of that growth, especially the upper jaw, is peaking around age four or five.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So we n- we don't need to wait until they're seven or eight and we start seeing all the crowding- Yeah ... to really make a difference.

Dr. David Alfi DDS MD FACS:

Right. So that's interesting because you would think if a kid has straight teeth well-aligned with no crowding, they're good, but no.

Dr. Piya Gandhi, DDS:

No. No. They,

Dr. David Alfi DDS MD FACS:

they need space, and then the reality is that almost every kid has crowding, right? And- And they don't have room for even all their permanent teeth- Permanent teeth... to erupt normally. Well, we know that, right? Some kids don't even have room for their canines. Yep. That's a very common situation. Um, wisdom teeth is almost everybody has no room for their wisdom teeth to erupt. Some kids have no room for their second molars to erupt. Yes. But even if they have room and they're touching, that's an issue.

Dr. Piya Gandhi, DDS:

Yes. Yes, and also the earlier we can get in there and start- Mm ... expanding the bone, all those permanent teeth are sitting up there already.

Speaker 5:

Yeah. So

Dr. Piya Gandhi, DDS:

we're essentially aligning them better while they're- Mm ... in the bone. Because if they don't have room in the bone and they sit in there long enough, they are gonna start turning to get themselves in.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

And now we've just made a super complicated orthodontic case, uh, when it could be fairly easily addressed if we- Mm ... expand at three, three, four, five years old and allow those teeth to spread out while they're in the bone. Yeah. Then they just drop in where they're supposed to.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

So, you know, when I start this young and then get to see these kids through, when they're older and they need, you know, some minor Invisalign or aligners, it's easy because all of those teeth had room to come in when they were already in the bone. So it, it makes the whole process just so much simpler, and we have complicated it over time for no reason. Absolutely.

Dr. David Alfi DDS MD FACS:

I think about, now I remember-... you're a dentist. Um, we knew each other obviously.

Speaker 5:

Yeah.

Dr. David Alfi DDS MD FACS:

And then you went into pediatric residency. I was, I was at Texas Children's. Yes. I remember when you were rotating there. And y- right when you finished residency, you were talking and treating airway.

Dr. Piya Gandhi, DDS:

Uh-huh.

Dr. David Alfi DDS MD FACS:

When did it start for you? Because I know it didn't start in... They didn't teach you in residency.

Dr. Piya Gandhi, DDS:

No. So it was, um, as I was bu- I was building my practice during residency.

Speaker:

Mm-hmm. And

Dr. Piya Gandhi, DDS:

so as I was getting ready to open, I wanted to differentiate myself in the, in the market that I was in, which is a pretty saturated Houston market.

Speaker:

Mm.

Dr. Piya Gandhi, DDS:

And no one was doing anything with lasers. And I thought,"Okay, I'm gonna, I'm gonna buy a laser." So I bought an erbium laser, and I started taking tongue tie courses-

Speaker 5:

Mm... Dr. Piya Gandhi, DDS: up residency. Um, I actually had to skip a few days during residency to go take some courses. Um, and I was sitting at a course by Soroush Saghik. Mm-hmm.

Speaker:

Um,

Dr. Piya Gandhi, DDS:

anyone in the airway space knows who he is. Um, and he was talking about children with airway disorders and tongue ties, and he was describing Saira, my older daughter. And at that time, she was three. She was struggling with sleep apnea already. Um- She had venous pooling, mouth open, audibly snoring, and her dad's a physician-

Speaker:

Mm-hmm you know

Dr. Piya Gandhi, DDS:

that. And I pointed out, I said,"She should not be snoring." We at least learned that in residency.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

And he was like,"Oh, sh- she'll grow out of it." Oh, how many times do you hear that, right?

Speaker:

Right." Dr. Piya Gandhi, DDS: out of it." I'm like, "I don't, I don't know." Mm.

Dr. Piya Gandhi, DDS:

Anyway, so I was like,"Okay, you're the physician, I'll listen to you," right? Yeah. Like so many parents do. I'll listen to the doctor. Um, and then we went on a family vacation to Japan, and Saira kept Neil up snoring the entire night. And he said,"Okay, maybe we should go to..." What we knew, which was ENT, right? Mm. So we go to ENT. She is 90% deaf out of one ear-

Speaker:

Mm... Dr. Piya Gandhi, DDS: adenoids were so large- Right and her tonsils. So we did the surgery. Went fine. The audible snoring sound went away, but the behavior changes and the mouth breathing and all of that didn't. Right. So I'm sitting there in Zaghi's course and he's talking about Saira. Mm. Everything. Everything he was saying. I went home, looked in her mouth. She had a posterior tie and a lip tie. Now, at three, three and a half, if I would've known what I know n- now, I would've expanded her first. Right. But I didn't know. Yeah. We weren't big on myo like we are now, or body work or expansion. Um, so I released her. Mm-hmm.

Dr. Piya Gandhi, DDS:

And I mean, clinically, the releases look great, but functionally, we didn't really move the needle much.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

That was the point... At that time, I was treating mainly infants for tongue ties.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

And this was early on, the first six months I had opened my practice, and I was seeing these kind of results with the infants too, because there wasn't, like, a whole body approach.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So then I had to take a pause as a practitioner and say, "I'm clearly missing something here." And that's when I started hanging out with, like, the chiros here, the IVCLCs, the myos, like, people that had been in this whole body space for a while, and none of them were dentists.

Speaker:

Mm.

Dr. Piya Gandhi, DDS:

So, um, that was my biggest education, was learning about the rest of the body- Yeah ... and how it's all connected. Um, and then, you know, the conversation about tongue space started coming up and how expansion, specifically, you know, maxillary, um, anatomy really impacts upper airway resistance. Mm-hmm. And, um, that's how I got into it. I started doing stuff on my own kids, and my four children went through every iteration of-

Speaker:

Mm... Dr. Piya Gandhi, DDS: And, uh, it felt scary because we weren't taught any of this.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

But the more I saw the diff- You're also

Dr. David Alfi DDS MD FACS:

fighting a lot of resistance. Yes.

Dr. Piya Gandhi, DDS:

Oh my, oh my gosh. The more I started seeing the difference in them- Mm-hmm ... I was like, "I, I'm onto something."

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

You know? Um, but the daggers were there-

Dr. David Alfi DDS MD FACS:

For... They still are ... from the get-go. They still are. And they still are. Yeah.

Dr. Piya Gandhi, DDS:

They still are. Less so, but they still are. Um, less so. Less so. Yeah. And I- You know, I, not that I need it, but I would love s- to have some people retract some statements about me.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

Um, because now they're kind of doing what I'm doing.

Dr. David Alfi DDS MD FACS:

Yeah. Um, m- I wanna pause there'cause I had this thought. I saw a post recently about a three-year-old being expanded, and there was these comments from dentists. Mm-hmm. And they were ridiculous comments. They were like,"Oh, I've been in practice 20 years." Did you see this?

Dr. Piya Gandhi, DDS:

No." Dr. David Alfi DDS MD FACS: not a thing. Um, you guys are quacks." Yep. Uh,"You don't need to expand children. There's no evidence for this." And, and it's going on and on. There's so many daggers there, and this is today in 2026. Yeah. But we know clearly- This was, yeah, 2016, 2017- Right... it was even worse, you know? Right. Um, but the people that are doing this- Mm-hmm ... I mean, we all see the difference. Oh, yeah. And- For

Dr. David Alfi DDS MD FACS:

sure. It, it's, it's clear as day. Yeah, yeah. It... And there's evidence, and there's data. Yes, and- So those arguments are- And

Dr. Piya Gandhi, DDS:

our dental societies are telling us that we need to be looking at sleep.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So, you know, they're even recognizing this.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

The real issue, in my opinion- Mm-hmm ... is ego.

Dr. David Alfi DDS MD FACS:

Oh, yeah, 100%. You know?

Dr. Piya Gandhi, DDS:

For that doctor that's been practicing- Mm-hmm... for 20 years-

Dr. David Alfi DDS MD FACS:

Right, he missed it... Dr. Piya Gandhi, DDS: to admit, "Oh my gosh, I have let all these children suffer-

Speaker:

Mm-hmm... Dr. Piya Gandhi, DDS: didn't know." Right. And

Dr. Piya Gandhi, DDS:

the only reason you and I are where we are in our field is because we keep trying to make ourselves better- Right and learn things that we don't know. Yes, and- Mamba mentality... admit that, "You know what? I did the best I could when I knew what I did-" Yeah, and

Dr. David Alfi DDS MD FACS:

you move on and do better ... "and now I know better-" Yeah."... so I'm

Dr. Piya Gandhi, DDS:

gonna do different."

Dr. David Alfi DDS MD FACS:

Right.

Dr. Piya Gandhi, DDS:

Um, when you stop being curious, and you just continue to sit on your old laurels- Mm-hmm that's when you lose. Yeah, absolutely. And that's when patients suffer.

Speaker:

Yep.

Dr. Piya Gandhi, DDS:

You know? Absolutely. So, um, I- you just have to block out the noise.

Dr. David Alfi DDS MD FACS:

Yeah, but this is what

Dr. Piya Gandhi, DDS:

I-

Dr. David Alfi DDS MD FACS:

There, there's something about this because... And this is a message to all the dentists, physicians, orthodontists, pediatric dentists that are, are putting information out there that this is bogus, this is BS. The internet, whatever you put on the internet, it stays on there. Mm. It's forever, right? So, you know, if you're saying this stuff last year, this year, five years ago, and you're putting it out publicly, know that in five years, when everybody knows that the standard of care is expanding early- Yep ... um, that airway is a real thing, your information is on the line, and it's online. Yes. It's public, and you can't take it back, right? So just be aware that some things will not age well.

Dr. Piya Gandhi, DDS:

Yes. Yeah, and- And that's gonna

Dr. David Alfi DDS MD FACS:

happen very soon.

Dr. Piya Gandhi, DDS:

And in my opinion, just don't comment on it

Dr. David Alfi DDS MD FACS:

Yeah, if you, if you don't really know If you don't

Dr. Piya Gandhi, DDS:

really know-'Cause it's gonna- ... just don't- It's, it's gonna be there just don't say

Dr. David Alfi DDS MD FACS:

anything.

Dr. Piya Gandhi, DDS:

Yeah.

Dr. David Alfi DDS MD FACS:

You know? I agree. It's really not that hard. I

Dr. Piya Gandhi, DDS:

agree. It's really not. I'm just saying

Dr. David Alfi DDS MD FACS:

this as a service to you- Yeah ... because you don't want this out there in five years. It's, it's clear as day, and there's a reason it's so much more popular now than it was- Yes ... two years ago- And I love to see the growth five years ago, seven years ago. I mean- Absolutely... Dr. Piya Gandhi, DDS: interesting because- It's very telling ... um, there- as you said, there are so many children and adults- Mm-hmm... to treat. Oh, yeah. So- It, everybody... like, one of my goals is getting more providers to do this. Yeah. For sure.

Dr. Piya Gandhi, DDS:

I am not trying to keep this information to myself.

Dr. David Alfi DDS MD FACS:

Right. No, the ma- I cannot

Dr. Piya Gandhi, DDS:

physically treat all the people that need to be treated.

Dr. David Alfi DDS MD FACS:

For sure. The more mainstream it is, it's better for everybody- Everybody ... in every single way possible. Yes.

Dr. Piya Gandhi, DDS:

Especially the parents- Mm-hmm... because they get conflicting information-

Speaker:

Yeah... Dr. Piya Gandhi, DDS: The struggle I face right now is I am, you know, expanding a child that is maybe not our general patient in our- Mm-hmm pediatric care. Right. So then

Dr. Piya Gandhi, DDS:

they're going to another pediatric dentist for their routine checkups-

Speaker:

Mm... Dr. Piya Gandhi, DDS: pediatric dentists have no idea what they're looking at. Mm-hmm.

Dr. Piya Gandhi, DDS:

I had got a call yesterday from a mom."I wanna take his expander out. Our pediatric dentist said it's not necessary." And I said,"Well, they are not really trained in this."

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

And why is the reason that you came to me first in the first place?

Speaker:

Right.

Dr. Piya Gandhi, DDS:

Like, you came here because you had a concern about something.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So it's very confusing for parents, and I don't blame them, but who ends up suffering? This child.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

You know? Mm-hmm. That is clearly struggling with an airway issue.

Dr. David Alfi DDS MD FACS:

Right, and this is a lifelong-

Dr. Piya Gandhi, DDS:

Yes ... issue. We don't treat it now, they end up in your chair-

Dr. David Alfi DDS MD FACS:

Mm-hmm... Dr. Piya Gandhi, DDS: impact of that- That's if they're become aware... Dr. Piya Gandhi, DDS: aware, and now their whole body has taken a much greater toll.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

I mean, like Zane was just saying, you know, when you're a kid, sure, you have a day where it feels weird- Yeah,

Speaker:

he tolerated it fine and then your body bounces. Mm-hmm.

Dr. Piya Gandhi, DDS:

When you're an adult, every system in your body has now been compromised by 40 whatever years- Mm-hmm... 50 years of poor sleep.

Dr. David Alfi DDS MD FACS:

And there's, there's some things that you can't take back.

Dr. Piya Gandhi, DDS:

Yes.

Dr. David Alfi DDS MD FACS:

Right?'Cause you're talking about critical years of development- Yes ... cognitive function, performance in school, years of learning- Mm-hmm focus. So for, you know, one thing is career trajectory, school, social.

Dr. Piya Gandhi, DDS:

Emotional regulation. Emotional

Dr. David Alfi DDS MD FACS:

regulation. This stuff is gonna be permanent, right?

Dr. Piya Gandhi, DDS:

Yeah.

Dr. David Alfi DDS MD FACS:

So the earlier, the better. So on that note, how early can you start expanding? Take me through a... Can you take me through- Yeah... a 0 to 10 year-

Dr. Piya Gandhi, DDS:

So-

Dr. David Alfi DDS MD FACS:

Like go 0, 1, 2, 3, 4- One thing, like, pearl for

Dr. Piya Gandhi, DDS:

parents. Yep. Newborn photo shoot, if the baby's mouth is open, they're already a mouth breather.

Speaker:

Mm.

Dr. Piya Gandhi, DDS:

That's the time. Take them to get evaluated for what their- Palate looks like.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

Um, screen them for tongue tie-

Dr. David Alfi DDS MD FACS:

All r- ... lip tie. Let's, let's stop there. Forget the photo. Should we screen every single kid for airway? If,

Dr. Piya Gandhi, DDS:

if I could get a hand on every baby that was born- There

Dr. David Alfi DDS MD FACS:

you go... Dr. Piya Gandhi, DDS: gold standard. Yep.

Dr. Piya Gandhi, DDS:

And what, who I would bring with me-

Dr. David Alfi DDS MD FACS:

Mm... Dr. Piya Gandhi, DDS: infant body worker.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Because the stress and strain from birth in itself-

Speaker:

Yeah... Dr. Piya Gandhi, DDS: feeding issues- Mm ... if we don't have those things worked out, tie or no tie. Yeah. And how does that palate start developing well? By feeding correctly. Mm-hmm.

Dr. Piya Gandhi, DDS:

And so many babies are already compensating because they don't have the right structure. Mm. They have cranial strains.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

Um, and, you know, we have now stuck a bottle in their mouth or- Yeah... a pacifier.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

When really at that age, all they need is some manual manipulation- Mm to work out some strains that were caused in utero during birth.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

And now you have c- put them on a totally different growth trajectory.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So that's step one, you know? If we could eliminate the red tape from all these hospitals- Mm ... and get well-trained providers to go in and screen, and screening is not difficult.

Speaker:

No. Yeah. It

Dr. Piya Gandhi, DDS:

really, it doesn't have to be a dental professional even- Mm ... you know? Yeah. Um, it's amazing to me, once you start recognizing these patterns, my children can identify people with airway issues. Oh, yeah.

Dr. David Alfi DDS MD FACS:

It is easy. Mike has pointed out all the time. It's

Dr. Piya Gandhi, DDS:

easy, you know? Mm-hmm. So birth, that would be great.

Dr. David Alfi DDS MD FACS:

Yep.

Dr. Piya Gandhi, DDS:

And it's not just, "Oh, there's a tongue tie. We need to-

Speaker:

Right... Dr. Piya Gandhi, DDS: laser it." Mm. That's not it. It's looking, again, at the body system. Mm. How tense is that baby? The palatal shape is already set up. You know, some of them are already high and vaulted, you know? Mm-hmm. So we gotta get some manual manipulation in there. Right.

Dr. Piya Gandhi, DDS:

Um, we do need to treat the tongue ties early. Mm-hmm. We do need to see feeding professionals, IBCLCs, to make- Mm ... sure that the mechanics of the f- the tongue are working, because every time we swallow, we expand the palate, if we're doing it correctly.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

Or if we're doing it incorrectly, every time we swallow, we overuse our cheek muscles-

Speaker:

Mm and we

Dr. Piya Gandhi, DDS:

narrow everything. Right. So it is really... And everyone knows how pliable babies are.

Dr. David Alfi DDS MD FACS:

Oh, yeah.

Dr. Piya Gandhi, DDS:

Those movements are very, very impactful.

Dr. David Alfi DDS MD FACS:

Mm. Yeah, and I would say the first year of life, the most- Ugh ... critical for jaw development. Yes.

Dr. Piya Gandhi, DDS:

Yes. So impactful. So, like, in our practice, we talk about baby-led weaning.

Speaker:

Mm-hmm. We

Dr. Piya Gandhi, DDS:

are big, big fans of early Myomunchy use, um, nasal s- hygiene- Mm... even as an infant. Um, all of these practices is setting a baby up for success for life.

Dr. David Alfi DDS MD FACS:

Yeah. Absolutely. Now, let's

Dr. Piya Gandhi, DDS:

say- Can

Dr. David Alfi DDS MD FACS:

you comment on breastfeeding versus bottle feeding?

Dr. Piya Gandhi, DDS:

So breastfeeding mechanics, totally different than bottle feeding.

Dr. David Alfi DDS MD FACS:

Mm-hmm. And

Dr. Piya Gandhi, DDS:

I will say, yes, there are situations where breastfeeding is just not possible, but that's where a well-trained professional comes in, because there are bottles that can mimic the movement- Right... of breastfeeding. So when we breastfeed, that elevation and suction that's created from the tongue, if done correctly, literally puts lateral pressure on the maxilla.

Dr. David Alfi DDS MD FACS:

Right.

Dr. Piya Gandhi, DDS:

Like an expander. Mm-hmm. That's exactly what it's doing.

Dr. David Alfi DDS MD FACS:

Yeah, the tongue is the natural expander. Yes. If we- And the best one... Dr. Piya Gandhi, DDS: The best one.

Dr. Piya Gandhi, DDS:

Mm-hmm. If we are on a bottle, on a pacie, that substance is so much more firm- Mm-hmm ... that it's actually holding the tongue down at the alveolar ridge level, and then the pressure is going down there, and we're really using our cheeks to suck.

Speaker:

Yep.

Dr. Piya Gandhi, DDS:

And what the cheeks are doing are narrowing.

Speaker:

Yep.

Dr. Piya Gandhi, DDS:

So we're going high and narrow versus wide and flat. Mm-hmm. So that's it. I mean, your tongue is your, supposed to be your natural- Mm-hmm ... growth guidance, palatal expander. That's why we gotta get those babies' lips closed-

Speaker 5:

Yep... Dr. Piya Gandhi, DDS: tongue can be up. Let's say zero to one, we kind of missed that mark, right? Yeah. We were told by whoever we went to, "Just give them a bottle," whatever, whatever. Um, and now we're already mouth breathing. Some of these one-year-olds are already... Like, children should be silent and still, lips closed- Right... tongue up- Not noisy breathing while sleeping. The, some of these one-year-olds are already heavy breathing. You can hear them. Mm-hmm. So if, if an infant, or I should say if a toddler, has first molars, I, I can put an expander in them. Before then, we're doing more therapeutic things, munchie, uh, working with an SLP for oral motor through feeding, chewing. But once we can get an expander in, then we'll go that route. Now, do I commonly expand 18 months old?

Speaker:

No. Mm.

Dr. Piya Gandhi, DDS:

It is a, you know, it is patients where we're already struggling with sleep, and it's very obvious, and we've tried other things- Mm-hmm ... and we're not moving the needle.

Dr. David Alfi DDS MD FACS:

Yeah, these kids are struggling.

Dr. Piya Gandhi, DDS:

Yes, these kids are already struggling. We also know that if they mouth breathe, those tonsils and adenoids are gonna start going crazy. Mm-hmm.

Speaker:

And

Dr. Piya Gandhi, DDS:

even, let's say they need to be removed. If they are removed under two-ish, the rate of recurrence is insane.

Speaker:

Oh, yeah.

Dr. Piya Gandhi, DDS:

You're basically, like, going to be doing that over again.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

So it's a waste of time. Yeah. Mm-hmm. And again, putting a kid under GA when they're that little, that's detrimental to their brain. Mm-hmm. You know? So, um, expansion, even at that age, very simple. I don't need a kid to be cooperative. They can sit on their- Mm-hmm... parent's lap.

Dr. David Alfi DDS MD FACS:

All right, I'm gonna comment on the tonsils and, and adenoids- Yeah ... for a sec because, you know, most... not most people, but many people will buy an air purifier, for example, from Costco or Target, right? And you're buying an air purifier because the air is dirty, and you want it to trap and filter bad stuff- Yeah before it gets into your lungs, right? Just like the tongue is an expander, we have this natural air- Air

Dr. Piya Gandhi, DDS:

filtration... Dr. David Alfi DDS MD FACS: air purifier, and it's called our nose, right? Mm-hmm. And the nose has nasal mucosa, turbinates, these epithelium that's different than other epithelium, pseudostratified ciliated epithelium, something like that. And, but- Don't take me back to dental school. Yeah, but you remember that. But essentially, we have this miraculous, organic- Yes ... air filtration system. For the same reason that you buy a Costco filter, we have this system so it traps bad air before it gets into our lungs, because the lungs have this capillary- Mm-hmm network of, of blood vessels, um, that now has access to that air. So if you have dirty air and it, and it encounters this rich capillary network in your lungs, you're gonna have to fight all these- Yeah... pathogens and, and upregulate all these inflammatory markers and, you know, hence why people have so much inflammation. Yes. So the first line of defense, if you think about, you know, an army fighting a war on the battlefield, that first line is your nose. Mm-hmm. Right? If your opponent is dirt in the air. Your second line is your adenoids- Yes ... and your tonsils, because that's lymphatic tissue. Yep. So it would make all the sense in the world, the way our bodies are designed to compensate, that if you're not breathing through your nose, which means that your air filtration system, which you bought from Costco- Is gone. Yeah ... you didn't plug it in. Yeah, yeah. Right? You forgot to plug it in. It's sitting in the room, but it's not plugged in. It has no electricity. So now you get air through your mouth, not filtered- Yep... so the adenoids and tonsils are now working o- Overdrive... overdrive. Yeah. Overtime. Yep. And they, something happens where they're called, they hypertrophy.

Speaker 5:

Mm-hmm.

Dr. David Alfi DDS MD FACS:

Because they have to work harder to catch all this-

Speaker:

Yeah... Dr. David Alfi DDS MD FACS: So now your second line of defense is working hard to protect your lungs and the blood, and your systemic capillary network, your bloodstream from getting dirt into it, so your body doesn't have to fight and, and, you know, get sick and all these things. But what we've done in medicine is say- All right, the first line of defense is out. That's gone. Yeah. Now the second line is working hard. We're gonna take that out. Take those out. Yeah. Right? So that's what happens, right? Yep. We're taking out the second line of defense. So what did we actually do for these, for everybody that's had their tonsils and adenoids out, if we didn't really recognize that, that concept right there? Yes. So now people are getting air straight into their lungs that's unfiltered, dirty. Hopefully- Completely unfiltered now... hopefully you have the Costco purifier at least. Yeah, completely unfiltered. Right? Uh, so you have some kind of defense. Um, so do get a filtration system in the house, right? Yeah. Uh, but completely unfiltered air. Nasal breathe. Yeah, you're right, nasal breathing.

Dr. Piya Gandhi, DDS:

Yes. But it's, you know, the number of kids that don't even know how to- Mm ... blow their nose or breathe through their nose- Yeah ... is incredible, you know? Mm-hmm. Because, yeah. Because if you don't use it, they, the nose basically becomes useless. It has to- Is

Speaker 4:

this some kind of joke?

Dr. David Alfi DDS MD FACS:

No, man. No. Kids don't know

Speaker 4:

how to use their nose. How many

Dr. David Alfi DDS MD FACS:

kids do you see mouth breathe instead of nasal breathe?

Speaker 4:

Yeah.

Dr. Piya Gandhi, DDS:

Yeah. Oh, I guess a lot. And when you're mouth breathing, you're not using your nose. Mm-hmm. That's

Dr. David Alfi DDS MD FACS:

true.

Dr. Piya Gandhi, DDS:

It's just kinda sitting there.

Dr. David Alfi DDS MD FACS:

Yeah, so more people use their mouth to breathe than their nose nowadays.

Dr. Piya Gandhi, DDS:

That's insane. You

Dr. David Alfi DDS MD FACS:

know? Yeah, but without thinking the consequences about that.

Dr. Piya Gandhi, DDS:

Well, I would say- And that's

Dr. David Alfi DDS MD FACS:

your goal ... hmm?

Dr. Piya Gandhi, DDS:

And that's your

Speaker 4:

goal,

Dr. Piya Gandhi, DDS:

trying to fix it, right? Yeah. Yeah. That's what we're trying to fix,

Dr. David Alfi DDS MD FACS:

exactly.

Dr. Piya Gandhi, DDS:

I would say I don't, I don't know that we knew the consequences so much- Mm-hmm... until relatively recently. Right. You know? All of

Speaker 4:

this new technology

Dr. Piya Gandhi, DDS:

and different- Yeah, and just people are talking about it. It's now become-

Speaker:

Mm-hmm... Dr. Piya Gandhi, DDS: you know- Yeah ... normal conversation, not just- I love it ... academic. I love

Dr. David Alfi DDS MD FACS:

it. This year- I love it ... has been an explosion. I, you know- Oh, I love it ... I remember being, going on in Instagram seven, five, seven years ago and talking about this stuff. Yeah. And people would shoot it down and call me crazy. Yes. Now I put my For You page, and I see every-

Speaker:

Yep... Dr. David Alfi DDS MD FACS: see many dentists, many surgeons, many, many orthodontists- Yes ... pediatric dentists saying these things, and it's awesome. And I love that,

Dr. Piya Gandhi, DDS:

like, Amazon has a million types of, like, mouth tape.

Dr. David Alfi DDS MD FACS:

Yeah. It's great.

Dr. Piya Gandhi, DDS:

It is. It's, it's- That's great ... it is giving access to every person- Mm, mm ... to address some of

Dr. David Alfi DDS MD FACS:

this. All of a sudden, airway has become the trendiest subject in the world.

Dr. Piya Gandhi, DDS:

Yes.

Dr. David Alfi DDS MD FACS:

And we're not even close to mainstream. We're not even

Dr. Piya Gandhi, DDS:

close, and what's so interesting- Mm ... is that there's still so much resistance about it.

Dr. David Alfi DDS MD FACS:

Yeah, even with even- Even when... with all the public awareness. Even when. So that's the interesting part. We have all this public awareness. But the profession- The professional awareness- ... is not ... has not, has not matched the public awareness. Yeah,

Dr. Piya Gandhi, DDS:

yes, which is... You know, it's funny. Uh, initially, obviously the airway revolution, you know- Mm-hmm their initial goal was to change curriculum and teach. Mm-hmm. Now it's like,"Well, screw that. We're going straight to the people." Straight to the public. Yeah, and that makes sense.

Dr. David Alfi DDS MD FACS:

Yeah. You know? Eventually the providers will be forced- Yes, because patients are coming in- Patients are smarter... saying," Dr. Piya Gandhi, DDS: course"- Mm-hmm ortho, you know, the, the airway intervention under six years old. And o- one of the dentists sitting in there said,"I need to get some of these answers because people- Patients are asking ... are coming in asking me to do this treatment- Mm... and I don't know what I'm doing." 100%. So if you're a dentist out there or any professional and your patients are asking you airway stuff, you know you don't know. Yes. Like, you know. Yeah. We don't have to say. You don't have to comment below. You know. But sign up to the- Yeah ... Custom Orthognathic Surgery Airway Conference in Miami June 5th, 6th, and 7th. Yeah. Because for two days, after two days of lectures from this expert panel, you'll go back home and you'll know- Yes what to say.

Speaker 4:

And you could teach more people, expanding- Yeah ... and yeah.

Dr. David Alfi DDS MD FACS:

Yeah. Spread awareness, right?

Speaker 4:

Yeah.

Dr. Piya Gandhi, DDS:

Yes. You can talk to your friends about mouth breathing.

Dr. David Alfi DDS MD FACS:

Mm-hmm. Yeah. Yeah, call them out. Lips closed. And then

Speaker 4:

my friends could tell their friends. Exactly. That's how it works. Branching out. Mm-hmm. Uh, exactly. Eventually the whole world will be

Dr. David Alfi DDS MD FACS:

aware. Exactly. That, that's exactly what this is about.

Dr. Piya Gandhi, DDS:

Yeah. Yeah. All

Dr. David Alfi DDS MD FACS:

right. So- Back on it, we're, we're at age one to two.

Dr. Piya Gandhi, DDS:

One to two. And, uh, yeah, we're still, you know, we- So you said expand as early as- We wanna treat it as early as we catch it.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

So, um, I would say the average age that I treat is three to four years old.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Um, and that is when symptoms start to really uptick.

Speaker:

Right. So more- Is it easier then at three? More parents

Dr. Piya Gandhi, DDS:

are noticing. In terms of appliance design- Mm-hmm ... it's always easier when we have more teeth to anchor to.

Speaker:

Sure.

Dr. Piya Gandhi, DDS:

So that's why I really only reserve the when they have just a first set of molars to the cases that really need it right now and we cannot wait.

Dr. David Alfi DDS MD FACS:

Yeah. But you're talking about pediatric molars.

Dr. Piya Gandhi, DDS:

Pediatric molars. Because- Oh, all the way... Dr. David Alfi DDS MD FACS: orthodontists- Oh, 'cause orthodontists are waiting for permanent molars... Dr. David Alfi DDS MD FACS: start treatment I don't really care what teeth are in the mouth- Mm-hmm ... because honestly, I'm not treating the teeth. I am treating the jaw.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

So that's a common question I get. Well, they haven't gotten these teeth, or what if they're losing teeth? Mm. I don't care. Right. The teeth that I'm putting this expander on, they're not going anywhere. Mm-hmm. Everything else is free to do what we want. Mm. And we know, especially if they're in the five, six, seven-year-old range- Mm-hmm once we start expanding and making that room, they are going to start losing teeth- Yeah ... because now the teeth have somewhere good to go. Right. So they're gonna start dropping in the bone like they're supposed to naturally.

Speaker:

Mm-hmm. Right. So

Dr. Piya Gandhi, DDS:

I would say like three, four, and up-

Speaker:

Mm... Dr. Piya Gandhi, DDS: I personally love fixed expanders, meaning ones that are glued in the mouth. Mm-hmm. And

Dr. Piya Gandhi, DDS:

I just wanna put a little caveat here about rapid palatal expansion. Mm-hmm. Uh, an expander with a screw does not mean it's a rapid palatal expander.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

The s- the screw expander has gotten a very bad name- The only thing that makes something a rapid palatal expander is if you are expanding rapidly with it.

Speaker:

Right. So we do not do- So just your rate of expansion... we, it's the rate

Dr. Piya Gandhi, DDS:

of expansion. It's not the actual device.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So we do not do rapid expansion because we try to work with the whole body system- Mm-hmm ... and the nervous system, so we do slow to semi-rapid, but it, most of our appliances do have a screw.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

Now, if we have a kiddo that is super uncooperative-

Speaker:

Mm-hmm ... I can

Dr. Piya Gandhi, DDS:

get a expander in any kid. Mm-hmm. I mean, most of my kids do not do what I want them to anyway.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

And the process of getting one made is really easy because they're 3D printed, and they're custom.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

So we just have to try them in, even if it's on a parent's lap.

Dr. David Alfi DDS MD FACS:

Mm-hmm. And

Dr. Piya Gandhi, DDS:

then we fix them in permanently.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

Or semi-permanently, I should say. Um-

Dr. David Alfi DDS MD FACS:

And the kids are tolerating.

Dr. Piya Gandhi, DDS:

Tolerating it? Totally fine. Yeah. Kids are so adaptable. Like Zane said- Yeah ... it feels weird for about a day.

Speaker 4:

And then you get- And then you get used to it. Um- And then you, like, have it there for a few months. Yeah. And then-

Dr. Piya Gandhi, DDS:

And then it becomes part of your body.

Speaker 4:

And then, yeah, it feels like one of you. Yes. And then you get it taken off.

Dr. David Alfi DDS MD FACS:

And then it feels better, right? Well-

Speaker 4:

And then you have to get used to it again. You feel, like, all the space- Yes ... where your tongue used to be. I've had some

Dr. Piya Gandhi, DDS:

kids- Mm ... not want me to take it out because they feel like now it's part of them.

Speaker:

Mm-hmm. Yeah.

Dr. Piya Gandhi, DDS:

But average time of expansion takes about a year, and that includes six months of retention.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So we're in these things for approximately a year.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

Um, no real pain associated with it, kind of very easy visits. We have some patients that live out of state, so we'll do hybrid virtual. They come in about four times during that yearly process.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Um, so really manageable and easy and, um, like I said, not painful. Mm-hmm. So, you know, a year goes by like that, and it's a year that's gonna make a huge

Dr. David Alfi DDS MD FACS:

difference. 100%. Yeah.

Dr. Piya Gandhi, DDS:

But, you know, it doesn't end there, right? It doesn't end with the appliance. Right. We then have to retrain our musculature.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

So tie or no tie, we have to do some myo oral motor therapy-

Dr. David Alfi DDS MD FACS:

100% ... because

Dr. Piya Gandhi, DDS:

those muscles are either gonna help us- Mm ... or they're gonna work against us.

Dr. David Alfi DDS MD FACS:

Yeah, and that's the same for adults. That's the same- Yeah. Oh, yeah ... same for my- Oh, yeah... the patients in my- And I...

Dr. Piya Gandhi, DDS:

If, if there are any orthodontists out there, if I could implement one thing in your practice, it's get a myofunctional therapist.

Dr. David Alfi DDS MD FACS:

100%. It

Dr. Piya Gandhi, DDS:

will change your outcomes. We have just become accustomed to this, "You just need orthodontics three times." Mm-hmm. Well, why does that happen?

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

Because we have not trained the muscles-

Speaker:

Mm-hmm

Dr. Piya Gandhi, DDS:

to help support the movement.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

So just like in babies- Mm ... that tongue muscle was either gonna help us or hurt us.

Dr. David Alfi DDS MD FACS:

Yeah, same thing with adults. Same thing. And we see it. Same

Dr. Piya Gandhi, DDS:

exact thing. I don't

Dr. David Alfi DDS MD FACS:

know how many patients I have, 30s, 40s, and they say that, you know, even between their age of 30 to 50, 50 to 60, that their jaws are growing backwards- Yeah down. Their arches are becoming more narrow. They're becoming more crowded. We see this all the time.

Dr. Piya Gandhi, DDS:

Yes. Well, my... The thing that shocks me most is, like, our benchmark for a four-year-old is 30 millimeters- Yeah... intermolar, right? I, when I've s- I don't see many adults anymore, but when I did- Yeah ... a lot of them were hovering- A lot of my patients don't have 30 millimeters a lot of them are hovering around that 30, 32. Third- Yeah,

Speaker:

exactly. And I'm like," Dr. Piya Gandhi, DDS: your natural growth peaked at age four." Mm-hmm.

Dr. Piya Gandhi, DDS:

And then that was it. Your muscle function didn't help you. So, um, yeah, it, these things- Mm... don't magically fix themselves. Right. Yeah.

Dr. David Alfi DDS MD FACS:

So expand as early as possible.

Dr. Piya Gandhi, DDS:

You got it.

Dr. David Alfi DDS MD FACS:

So basically then from age 1 to 12, it's all the same. Yeah. It- It's expansion- It's expansion... myofunctional therapy.

Dr. Piya Gandhi, DDS:

Myofunctional therapy. Lots of coaching on, like- Right... how we eat, what we eat- Mm... nasal hygiene. Correct. Because it's not just here.

Dr. David Alfi DDS MD FACS:

Yeah. It's here. It's everything. It's

Dr. Piya Gandhi, DDS:

everything. Yeah, it's

Dr. David Alfi DDS MD FACS:

posture. So you

Dr. Piya Gandhi, DDS:

have to, like, clean house.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

You know? And I, I would say that's the biggest struggle.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

We live in a society where the, uh, you know, American diet is not helping us in- Right ... any sort of way. Yeah. We're not chewing like we should.

Speaker:

Mm-hmm. Our

Dr. Piya Gandhi, DDS:

nutrition is not what it should be, and that is starting at a very young age.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

You know?

Speaker:

Yeah. The

Dr. Piya Gandhi, DDS:

pouchy things, the vessels we drink out of.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Hence, the Myo Munchy. Yeah. And why it comes in all sizes.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Because everybody needs to chew more.

Dr. David Alfi DDS MD FACS:

Yeah. You think about, you know, a lot of the things that are affecting our development and, and growth is just con- it's laziness. Yeah. It's convenience. Convenience. Like, how- Convenience... lazy did we get that we got Vitamixes- Yeah ... to blend our foods? Yeah. Like, I remember in the '90s, the first Jamba Juice that came out- Yes ... in our neighborhood. It's like we can't even- But it's also like-... chew food anymore... Dr. Piya Gandhi, DDS: like, mealtime used to be, uh, significant. Mm. You'd sit. You'd connect with people. Right. Now it's like,"What can I have on the go?" On the run. Right? Yeah. I'm running here. I'm running there. Mm. I need my Jamba Juice or whatever.

Speaker:

Mm.

Dr. Piya Gandhi, DDS:

And so we, we've not only lost our physical capabilities-

Speaker:

Mm... Dr. Piya Gandhi, DDS: lost the human connection- Yeah... of what mealtime used to look like. Yeah.

Dr. Piya Gandhi, DDS:

Um, so it's just a whole-

Speaker:

Mm-hmm... Dr. Piya Gandhi, DDS: That's what... You know, when I talk about baby-led weaning with parents, I'm like, "One benefit is the chewing." Yeah. But the other benefit is also having this child learn to feed themselves and self-regulate. Mm. We're

Dr. Piya Gandhi, DDS:

not shoving food in their face.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

They are learning hunger and satiety. Yeah. They're, like, learning good cues that are good- Mm-hmm ... for their whole body at a very young age.

Dr. David Alfi DDS MD FACS:

Yeah. Now, now here's a reality issue, is that, you know, it's better now than it was two years ago or three years ago, but even me, I'm in this space. Yeah. I'm all airway. Yeah. That's all I treat. My practice, everyone gets a sleep study. We're always opening up airways. It's all I think about. It's all I talk about. It's what the Alfi podcast- Yeah ... is about. I'll get these parents c- And I have a lot of patients that come from out of state, right? And they all say, "What do I do with my, what, my child?" Yeah."What do I do with my kid? They're one, they're three, they're four." And I say what we just talked about, and they're like,"Who do I go to?" And I don't know. I know Piya Gandhi. Mm-hmm. I know a few other people. I know my friends out there, if I didn't mention your name, don't... But I know a few of you. Yeah, yeah. Right? Yeah. But I really don't know more than a few. Well,

Dr. Piya Gandhi, DDS:

you can direct them, so drpiyagandhi.com-

Dr. David Alfi DDS MD FACS:

Mm-hmm... Dr. Piya Gandhi, DDS: been- It is a work in progress... working on curating a list of providers- Yeah... pediatrics providers all over the country. Let's be realistic. How many are there in the country?

Dr. Piya Gandhi, DDS:

Not- Not a lot not a lot. Uh, under 100-

Dr. David Alfi DDS MD FACS:

Yeah. Th- that's-... would be my guess. Yeah, th- Good ones.

Dr. Piya Gandhi, DDS:

Right. Good ones.

Dr. David Alfi DDS MD FACS:

I mean, it should be every single pediatric dentist. Yeah. Yes. It should be every single orthodontist. It's...

Dr. Piya Gandhi, DDS:

Someone reached out to me on Instagram the other day in the Massachusetts area- Mm-hmm... Dr. David Alfi DDS MD FACS: sent her a name, and she said, "Oh my God, they're two hours away." I said,"That's pretty good." Yeah,

Speaker 5:

that's really good.

Dr. Piya Gandhi, DDS:

I was like- That's great ... "Two hours is great." And, and that is- That is pretty good ... is sometimes where the problem lies- Mm ... is people will reach out saying,"I want help. I wanna do this." Yeah."I will do anything." Mm-hmm. And then you give them a provider that's a little bit too far- Mm-hmm and they say,"Well, can't I just go to a traditional orthodontist?" No, you can't. No.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

The answer is no.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

Sure, you could, and I've had people say, "Well, can't you talk to them and tell them how much they need to expand?" Mm-hmm.

Dr. David Alfi DDS MD FACS:

And I

Dr. Piya Gandhi, DDS:

said, "You don't wa- They don't know what they're looking at."

Dr. David Alfi DDS MD FACS:

Right. They have no idea. I can't... No. Unless they come to our courses, so. Yes. Miami, June 5th, 6th, and 7th, you wanna be there.

Dr. Piya Gandhi, DDS:

Yes. And then in September, if you're pedes and wanna do kids under six-

Dr. David Alfi DDS MD FACS:

Mm-hmm... Dr. Piya Gandhi, DDS: Texas, which is not the sexiest location- ... like Miami, but it's a two-day intense course. Yeah, but you gotta do these courses. You gotta do these courses. And you gotta go to every single one of them.

Dr. Piya Gandhi, DDS:

Yes. Yeah, I mean, I- You know, if you've been to one, you, it's not enough ... I still go to courses. Yeah,

Dr. David Alfi DDS MD FACS:

absolutely. Uh, constantly. We learn, we're learning something every day. Yeah.

Dr. Piya Gandhi, DDS:

So-

Dr. David Alfi DDS MD FACS:

For sure.

Dr. Piya Gandhi, DDS:

Yeah, so if you see... I mean, that's the other thing with kids. Chewing is a big- Mm ... fa- sign of oral function.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

And so, you know, when we're talking about, we've also normalized toddler picky eating.

Speaker:

Mm-hmm. That's not

Dr. Piya Gandhi, DDS:

a thing, okay? Kids should be able to eat everything an adult should be able to eat. Right. So when I ask parents- They have allergies... "Does your kid, is your kid picky, or are they selective about what they eat?" That's true. I ask them, "Do they eat meat that's not in a hot dog, nugget, shredded, or ground form?" Mm. Do you know why? We've already pre-chewed all that stuff for them.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

Can they handle a piece of steak and chew it and swallow

Speaker:

it? Mm-hmm.

Dr. Piya Gandhi, DDS:

You know?

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

That is a huge sign, and that's something parents c- can test their kids on easily at home.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

So if you're a parent out there, give your kid whole foods- Mm ... and see what happens.

Dr. David Alfi DDS MD FACS:

Yeah, don't buy these pureed pouch- Yeah.

Dr. Piya Gandhi, DDS:

No. Mm-mm And don't give them- Give them real food... chicken nuggets.

Dr. David Alfi DDS MD FACS:

Yeah. I agree. Yeah, I always say- So-... Dr. Piya Gandhi, DDS: food, not the- Mm... pureed form of it. Yeah. So I know, and, you know, throw your daggers, I know most orthodontists are not on board yet. Oh, yeah. I know it. I know the American Association of Orthodontists is- is dabbling now. Did you see that white paper? I did. Yeah, exactly. Come at me. So I know where their stance is, and I- I- I've- I haven't been up to date with the pediatric dentistry board. Where are they?

Dr. Piya Gandhi, DDS:

They are also lagging. Throw- throw your

Dr. David Alfi DDS MD FACS:

daggers. They are

Dr. Piya Gandhi, DDS:

lagging. Right. And I'm gonna- I'm gonna say something about, you know, our, the AAPD, for example. Yep. Uh, the conference is every Memorial Day.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

For a few years, I lectured on tongue-tie. Yeah. They had a whole pre-course day on tongue-tie that sold out. Mm. Over 1,000 people. Well, obviously there are politics playing a role in this-

Speaker:

Mm

Dr. Piya Gandhi, DDS:

but, like, they have no one talking about this anymore.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

And I- Audrey Yoon will be there, and I love her-

Speaker:

Mm-hmm ... but I

Dr. Piya Gandhi, DDS:

feel like they have her there rather than a pediatric dentist because they feel like it's safer.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Well, guess what? We need pediatric dentists doing this.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

Audrey Yoon's a badass, and I love her-

Speaker:

Mm-hmm

Dr. Piya Gandhi, DDS:

but this conference is not orthodontists. Right. It's pediatric dentists.

Dr. David Alfi DDS MD FACS:

Yeah, I mean, this is a- So you need a

Dr. Piya Gandhi, DDS:

pediatric dentist teaching pediatric dentists how to do this. 100%. I

Dr. David Alfi DDS MD FACS:

mean, this is the biggest opportunity.

Dr. Piya Gandhi, DDS:

And the reality is, is people are gonna stop going to these conferences-

Dr. David Alfi DDS MD FACS:

Mm-hmm... Dr. Piya Gandhi, DDS: not talking about- Yeah the current events- For sure ... and the relevance of it. You go to Miami instead- Yeah ... and stay at the one hotel. Well, that's why

Dr. Piya Gandhi, DDS:

all these specialized conferences- You can just do the same ... are coming up. You're... For sure. So, I mean, come on, like, back us up here. Yeah,

Dr. David Alfi DDS MD FACS:

agreed. You know? Someone's gotta

Dr. Piya Gandhi, DDS:

go to bat. It's, yeah, and it's not gonna age- Someone's gotta go to bat for this... Dr. David Alfi DDS MD FACS: gonna age well. And again, like, even when we talk about our state boards-

Dr. David Alfi DDS MD FACS:

Mm... Dr. Piya Gandhi, DDS: people sitting on state boards and reviewing cases- Yeah... Dr. Piya Gandhi, DDS: even know what we're doing. Hmm. No, it's true. You

Dr. Piya Gandhi, DDS:

know? So it's just, it's, there's gotta be a full turnover- Mm is what, you know, you gotta... We really, we really do. Yeah. Yeah. We gotta get some-

Dr. David Alfi DDS MD FACS:

And the data is there. I'm tired of hearing- But now-... there's no data... it is there. Mm. It is

Dr. Piya Gandhi, DDS:

there, you know? And, uh, no one's looking though. Yeah. No one wants to look.

Dr. David Alfi DDS MD FACS:

They don't wanna. There's a lot of resistance. No one wants to look. Yeah. Humans do not like change. I will also

Dr. Piya Gandhi, DDS:

say, again, not trying to throw daggers- Mm ... but I also feel like some of the information that's out there that might be creating some of these statements coming back out from the AAO and- Sure ... AAPD are things that are supposed to be growth guidance appliances- That are being portrayed as expanders-

Dr. David Alfi DDS MD FACS:

Yeah and being- I mean, that's, that's the issue... Dr. Piya Gandhi, DDS: Yeah.

Dr. Piya Gandhi, DDS:

So it's like the tongue-tie thing. Right. I understand why pediatricians think tongue-tie releases don't work-

Dr. David Alfi DDS MD FACS:

Right... Dr. Piya Gandhi, DDS: were done in a poor fashion for a long time. Yeah, and without myofunctional therapy. With no collaborative

Dr. Piya Gandhi, DDS:

care.

Dr. David Alfi DDS MD FACS:

Right.

Dr. Piya Gandhi, DDS:

With a blade or a scissor.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

And then no functional change. Well, obviously there was no functional change. Right. We weren't doing any functional training.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

The same thing with these growth guidance appliances.

Speaker:

Mm-hmm.

Dr. Piya Gandhi, DDS:

We're saying do a, call it whatever you want, Myobrace, HealthyStart, Vivos, tooth pillow- Mm-hmm

Speaker:

and

Dr. Piya Gandhi, DDS:

you're gonna get expansion. No, you're not.

Speaker:

Mm.

Dr. Piya Gandhi, DDS:

You're gonna get better muscle function, you're gonna get better lip closure- Right ... you're gonna get better nasal breathing, and yes, it will definitely improve sleep quality if you can get that- Mm-hmm ... but if you don't have the underlying structure to support that-

Speaker:

Mm-hmm

Dr. Piya Gandhi, DDS:

that, you're not gonna be able to tolerate that appliance.

Speaker:

Right.

Dr. Piya Gandhi, DDS:

And so, like, we use a tr- a myo trainer-

Speaker:

Mm... Dr. Piya Gandhi, DDS: to get those muscles on board- Right ... but not as an expander. But I think that's part of the problem- Mm ... is, like, there's too much information floating around- Yeah ... that is inaccurate.

Dr. David Alfi DDS MD FACS:

Yeah. And a lot of that is because of the resistance from the organizations themselves. Yeah. You know, it's like you have the Wild West out there because the bigger, the bigger authorities are poo-pooing it- Yeah ... right, so that you have to have... It creates the Wild West. Yes. And then when you have a Wild West- There's no guidance

Dr. Piya Gandhi, DDS:

from them there

Dr. David Alfi DDS MD FACS:

is, there's no guidance from them, and then you're gonna have some bad actors, or not even intentional bad actors- Right... you're just gonna have some things that, that fail, and then instead of saying, "Hey, let's, let's figure out- Yeah... the st- how to standardize these things," there's the best way- Yeah ... to do it.

Dr. Piya Gandhi, DDS:

I mean, the smarter thing is for them to control the narrative.

Dr. David Alfi DDS MD FACS:

Correct.

Dr. Piya Gandhi, DDS:

But they're not. They're

Dr. David Alfi DDS MD FACS:

not. They're, they're, they're anti. And so to your point,

Dr. Piya Gandhi, DDS:

like some of these, you know, growth guidance appliances have just taken a journey of their own- Mm... because you can't control the, all the conversation that's happening out there, you know? Right. So to your point is it maybe wasn't even intentional-

Speaker:

Mm-hmm ... but

Dr. Piya Gandhi, DDS:

there is no one telling the actual story- Mm-hmm ... and giving providers a framework.

Speaker 6:

Yeah.

Dr. Piya Gandhi, DDS:

So it's making it a lot more complicated for not only providers, but for the people trying to seek this care.

Dr. David Alfi DDS MD FACS:

Yeah, for sure. It's very difficult. Yeah. It's very difficult- Yes... to find the right information, the right provider.

Dr. Piya Gandhi, DDS:

Yeah. Exactly. So, um, we've obviously heard how simple this can be- Mm ... on the pediatric side.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

You know, therapy, some appliances, really no pain, no surgery.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

But let's talk about what happens in your chair. Yeah. So if

Dr. David Alfi DDS MD FACS:

you miss that boat...

Dr. Piya Gandhi, DDS:

And that boat is relatively, I mean- It's long ... you become surgical-

Speaker 6:

Yeah ... fairly

Dr. Piya Gandhi, DDS:

early.

Speaker 6:

Right.

Dr. Piya Gandhi, DDS:

It's true. So let's talk about what, what age- That's true... does it transition from I can do a more traditional expander versus now we gotta do-

Dr. David Alfi DDS MD FACS:

Yeah... Dr. Piya Gandhi, DDS: interventions. Yeah. I think- Once you get to 12, 13, you're looking at surgery. Mm-hmm. Or sur- some, some type of surgical- Some type of surgical intervention... intervention. Maybe a little more conservative at 12. Mm-hmm. Some myofunctional therapy and expansion can go a very long way- Mm-hmm ... for, for someone like Zane. Yeah. Yeah. Right? And, and it has- Awesome ... done a lot for you, Zane. Yeah. Um, but yeah, certainly at, at 12 a lot of the growth is there, right? A lot of that potential has happened. Um, so we, you know, early expansion again. Early expansion means expansion as early as possible. Yes. That's what I mean by early expansion. Yes. Whether that's at one, two, three, 12, 13, or 40. Yeah. Right? That's early expansion in my mind. Um, and then orth- you know, custom orthognathic surgery. Jaw surgery is completely different than it was when I learned how to do it.

Speaker:

Yeah.

Dr. David Alfi DDS MD FACS:

And, you know, I have to be careful because still most of the world does it the way I learned how to do it 20 years ago. Yes. Um, so it's not the same everywhere, but the way we can do jaw surgery the way we do it here, and there are other... I'm not the only one that does it this way- Mm-hmm... with custom guides, custom plates, airway centric, airway focused, it's a predictable, stable operation. People are back at work in one to two weeks. They're-

Dr. Piya Gandhi, DDS:

Would you say if someone only had access to a provider that was doing it the traditional way, it's still worth it?

Dr. David Alfi DDS MD FACS:

Not necessarily, actually. Really? Yeah. Okay. Not necessarily. And the, the reason I say that is the traditional way of doing jaw surgery, very unpredictable. Mm. It's imprecise, and, um, higher rate of complications, but also the, the tools in traditional jaw surgery influence the treatment planning and philosophy of how to do the surgery. So what happens is because it's not as precise or accurate, and the larger the movements, the more issues- Yes... you're gonna have. Yeah. What happens is, and this is the way I learned how to do it too, traditional jaw surgeons are limiting their treatment plan and not really treating airways.

Dr. Piya Gandhi, DDS:

Because they cannot make those big movements. Yeah. Yeah.' Dr. David Alfi DDS MD FACS: big moves poses way more- Yeah... issues, right? Um, but if you use custom or custom guides and plates like we can, and you use the tools that we have, and understand the tools, which are very powerful. I mean, to plan something 3D in a computer- It's amazing... Dr. David Alfi DDS MD FACS: And then take that information on a custom titanium plate, which not only provides stable fixation co- especially compared to the older hardware- Yeah but also puts you in that exact planned position. So what the plates are doing, they're dual purpose. They're providing the stability of, of the position, or what we call it fixation, but they're also providing the GPS for where to go, uh, very accurately. So that, that allows, those two things together allow us to make these larger movements- Um, and, and have them stable without relapse, but also provide, um, uh, you know, the ability to treat airway- Yeah which needs these larger movements. Larger movements. So the issue... I say that f- because the issue of traditional is they're not making the right movements. Yeah. And even if they're planning 10 millimeters, they're not getting- Getting it ... 10 millimeters. Yeah. They're getting five. Mm. And I know that because I've done this surgery for 14 years. Yeah. I've gone through that transition- Progression... and progression and growing pains, and once you see what's happening, once y- you have that information from that GPS, you become very aware- Yeah ... that if that information's not there, you're not getting what you planned. What was the catalyst for you to try to change the way you did it?

Dr. David Alfi DDS MD FACS:

Yeah. So the- I'll try to summarize that,'cause there's a couple parts to it, and this is, this is true. I think there's a problem of putting anyone on a pedestal, right? Yes. There's a problem putting your partner on a pedestal, your children on a pedestal, because you- you'll become disappointed, right?'Cause nobody is, is perfect, right? Yeah. And, and I'm, I'm bringing this in. Oh, no. I, I'm following. I'm bringing this in. But what happened was when I was a resident at Columbia University, I put attending oral surgeons- Of course ... you know, my heroes, my mentors, on a pedestal. Yeah. They're... You know, I grew up loving Magic Johnson, Michael Jordan, Kobe Bryant. These guys were my heroes, and then when I went into dentistry and medicine and surgery, my heroes were the guys in these books. Yeah. Like, I looked at them the way- Yes ... I looked at Magic Johnson, and I put them on a pedestal. And what happened is as I, you know, went up the ranks to become a sixth-year resident, and I realized at some point that they were asking me, as a sixth-year resident, you know, "Oh, how do you do this?" or, "Why do you do it that way?" or, "Can you do this procedure? I'm just gonna hold the retractors." You realize at some point that, man, that was very disappointing. Mm. Like, I looked... I put these guys on a pedestal. I looked at them, and now I'm looking down at them. Mm. Right? And it was, like, a 180 thing when I was leaving residency. It was such a disappointment, and it was my fault. I put them there, you know? But it was a disappointment for me, and I looked at a- many of them this way that, man, they're stuck in their old ways. They're doing- Mm ... the same thing they learned 40 years ago from, from this guy that taught, from that guy that taught them, from... Nothing's changed. They're not up to date with anything. Yeah. They're not changing, and it was like, I left residency and I, I- Made this vow to myself that I will never be that person- Mm ... because it, it almost disgusted me. Mm. But I think it was because of that flip- Yeah... of I looked at them at so much light- Yeah and then felt disappointed in once I learned more how much, how little they cared, um, to progress and learn and change. Um, so I think that coming out, I had this thing where every day I'm questioning why do we do what we do? How do we, how can we do it better? Yeah. I still do that today. Yeah. I've done over 1,000 jaw surgery patients- Yes. Yes ... and every case- You're my mentor. Thank you

Speaker:

so much. Aw.

Dr. David Alfi DDS MD FACS:

Every, every case today, I learn something from it. Yeah. You know? And my surgeries now are better than they were five years ago, and five years ago they were better than- Of course... they were five years- Yeah... um, before then. Um, so that goes into... I started just looking at why are we doing this procedure the way we're doing it, and then started to make tweaks and- Mm you know, now it's a one-hour operation. Yeah. Way more predictable. The way I... Treatment plan's completely different, the philosophy's different. It's this entire 14-year evolution, but it came from a day-to-day-

Dr. Piya Gandhi, DDS:

Yeah, yeah... Dr. David Alfi DDS MD FACS: I love that. I love that. Um, it's funny, I was actually teaching at a conference and one of my attendings- Mm was there. And he said,"This is so funny. I'm now learning from you." Yeah. And I was like,"Yeah, it's, you know..."

Dr. David Alfi DDS MD FACS:

As, as it should be. As, as we all are- Yeah ... learning from each other. Right, from each other.

Dr. Piya Gandhi, DDS:

Yeah.

Dr. David Alfi DDS MD FACS:

Yeah.

Dr. Piya Gandhi, DDS:

Um, it's, I mean, it's amazing the work that you do.

Speaker:

Yeah, appreciate that. Um, I

Dr. Piya Gandhi, DDS:

get this question a lot from parents of my patients-

Speaker:

Mm-hmm

Dr. Piya Gandhi, DDS:

that are, that are struggling with sleep and airway. Right. I mean, that's one of their biggest drivers to start treating their children. Mm-hmm. Uh, what

Dr. David Alfi DDS MD FACS:

is- And we see that vice versa. We, we, we see- Yes. Yeah ... we see, you know, parents that come to us- Yes ... after they've discovered it for their children, and we see, you know, the people that come to us that have children and then we say- Yeah"Hey, how about, how do we get our children?" Yeah. And- And so it's a bi-directional thing... Dr. Piya Gandhi, DDS: thing I- they always ask me. Okay."Well, what does the process look like?" Yeah.

Dr. Piya Gandhi, DDS:

So if you could briefly just take me through. Yeah. Someone has an airway concern.

Dr. David Alfi DDS MD FACS:

Mm-hmm.

Dr. Piya Gandhi, DDS:

Now, now what?

Dr. David Alfi DDS MD FACS:

Yeah. So what we're gonna do is, uh, it takes one consultation, and that consultation, it's a 3D CBCT which gives us a lot of anatomical information. Yeah. History, physical. We're so trained at seeing the airway stuff, um, signs and symptoms, and then getting a sleep study on every single patient. Yeah. With exception. You know, almost... I can't think of anybody... You know, I see 1,000 consults a year. I might get one or two that don't have an airway issue.

Speaker:

Right.

Dr. David Alfi DDS MD FACS:

I, I don't even know if that's true. That doesn't surprise me. Right. Um, so then it's a, then we, we identify that there's an issue. We have a diagnosis. The patient's- You usually have so much relief in finding that there's an explanation- Mm-hmm ... for the headache, migraines- Yes ... neck pain, shoulder pain, anxiety, brain fog, all these- Everything. Everything. Early hypertension. Yes. Yes. Autoimmune flare-ups. Yes. You know, stubborn belly fat. Infertility. Infertility. It- the list goes on and on, right? And then, um, and then it's just a matter of everyone's, it's customized care. Everybody's a little different, but we always get a myofunctional therapist on board 'cause that's always gonna be help. Mm-hmm. And it's do we expand and do ortho, or is it expansion, ortho, and then jaw surgery? Mm. Or some people just jaw surgery.

Dr. Piya Gandhi, DDS:

So what would be, like, the range of timeline of the whole process? Yeah. Obviously depending on how complex, but-

Dr. David Alfi DDS MD FACS:

Yeah. So it can range. So I think on the, let's start with the easiest ones. They're, they're, they have good width. Yeah. Um, their teeth are pretty aligned, and a lot of these have had premolars removed. Right. Right? Yeah. So they've had premolars removed. They've had ortho, so their molar width is okay. Um, their bites are match, but they're obviously recessed. Recessed. Yeah. They're eight teeth behind. They've had the four premolars removed. Yeah. I know. Yeah. They had four wisdom teeth removed- Yeah... so they're lacking the depth of eight teeth. Yeah. Um, so for those, it's like, okay, we can go to surgery six weeks from that visit- Mm. Wow ... from the first time I meet them. Take impressions, make the custom guides and plates. They do surgery. Some of them don't even need ortho post-op because- That's amazing... if their bites are perfect. That's the- That's like a dream scenario... that's the easiest. But I see that. Yeah. That, that may be 5%, 5 to 10% of my patients.

Speaker:

Okay.

Dr. David Alfi DDS MD FACS:

Okay. Um, so six weeks and you're done. Yeah. That, that's a possibility. Yeah, and then back to work in two weeks. Yeah. No chew for two to three months, but you're not wired shut, anything like that. Yes. Yes,

Speaker:

yes,

Dr. David Alfi DDS MD FACS:

yes. And then on the other extreme is the ones that are so narrow, so crowded, that we're gonna wanna do it in two stages. The first stage is get an expander in- Yeah whether it's a MARPE or a surgical MARPE or- Yeah ... some kind of variation in that. Expand their upper jaw, expand their lower jaw- Mm-hmm... with ortho, sometimes SFOT. Yes. Um, that c- that will take a year. Okay. So it's a year for expansion. After a year, they're much wider, their teeth are straighter and aligned. They're probably already functionally better. They're already so much better. Yeah. And then they become that patient I just described. Yes. We go to jaw surgery, bring them forward. So it becomes a- And then they do

Dr. Piya Gandhi, DDS:

ortho after. And then- Chew aligners... finish

Dr. David Alfi DDS MD FACS:

with ortho after. Okay. So that becomes a one to two-year process. Yeah. Okay. So those are the two.

Speaker:

Yeah.

Dr. Piya Gandhi, DDS:

Yeah. Okay. The two walls. So I've been telling people, yeah, about two years.

Dr. David Alfi DDS MD FACS:

Yeah. But that's, that's the- The upper end ... that's the upper end. Okay. That's, those are the difficult-

Dr. Piya Gandhi, DDS:

The more, the com- More-... more complex... Dr. David Alfi DDS MD FACS: I wouldn't say difficult. I would say more involved treatment plans is a two year. Um, but we've had, we've had patients that, uh, you know, it's r- not all obviously, it'd be nice if it was all of them, but I meet them, they're in surgery six weeks later. That's amazing. They're back at work in two weeks, and they- Yeah... wear a retainer and that's it. What is the most common complication you see?

Dr. David Alfi DDS MD FACS:

So, so pa- paresthesia. Uh-huh. Numbness. Yeah. That's... And I wouldn't even call it... People will say consider it a complication. I actually don't consider it a complication. I would consider it an expectation.

Dr. Piya Gandhi, DDS:

Okay.

Dr. David Alfi DDS MD FACS:

Because you're gonna be numb after jaw surgery.

Dr. Piya Gandhi, DDS:

Yeah.

Dr. David Alfi DDS MD FACS:

Right? And it's not that the nerves are being cut, just the stretching and manipulation. Yes. Yeah. Nerves are very sensitive. Yes. And we have amazing tools now that make things better, like the guides and Piezo. Um, but even in the best case scenario, there's gonna be some numbness. Thankfully, most of it will come back. Yeah, almost all of it will come back in most patients. Yeah. But I would expect that to take a year to happen. Okay. Um, in that subset, not subset, in that set, uh, of, of nerve function, a few of them will have painful nerve recovery. Mm. The, that's, that's the worst ones really. Okay. And then again, that's usually temporary, but it has to be managed, um, with some pain medication, sometimes a, a, a pain specialist, but those are rare. And then things like non-union, traditional complications, non-union infection. Sure. Extremely rare. Okay. Extremely rare.

Dr. Piya Gandhi, DDS:

That's so, that's amazing. Yeah. I mean, I always tell when the parents are like,"What about me?" I say this, and maybe you'll echo this, but it's never too late.

Dr. David Alfi DDS MD FACS:

No. Yeah. You know?

Dr. Piya Gandhi, DDS:

Just-

Dr. David Alfi DDS MD FACS:

It's never too late to identify- Yeah and treat. The- Yeah ... the treatment plan may change- Of course... but there's always something to do, and it doesn't have to be surgery. But the number

Dr. Piya Gandhi, DDS:

of like mid 30-year-old parents that are in my office that are like, "Oh, I'm too old." Oh, no. Like, what are you talking about? We have patients in their 50s and 60s. Like, you have so much life to live- Totally... first of all. Yeah.

Dr. David Alfi DDS MD FACS:

Some of my- Yeah... most grateful, uh, patients are in their 60s.

Dr. Piya Gandhi, DDS:

Yeah, yeah. I mean- I- in, in general ... it is... I still have yet to meet someone that has regretted going through that. Yeah. Um, and similarly on the pedes side, like I have yet a parent to come in that say, "Oh, I wish I never did that on my kid." Correct.

Dr. David Alfi DDS MD FACS:

You know? Yeah. Oh, yeah. It's life changing. And,

Dr. Piya Gandhi, DDS:

and essentially, and this happens with your surgeries- Mm-hmm... but I am giving that child a face.

Dr. David Alfi DDS MD FACS:

Yeah. You know? Yeah. Oh, it's life changing. Cheekbones- An entire- ... jaw structure ... an entirely different trajectory- Yes ... for their life in every way imaginable. Yeah. I just had a patient... I know we're, we're running on time. Yeah. I had a patient today who's 18 months out of, um, surgery. You know who you are 'cause I saw you today. And pre-surgery, you know, POTS, dysautonomia, fibromyalgia, hypertension, anxiety- Ehlers-Danlos, all these things, 43 pills a day

Dr. Piya Gandhi, DDS:

Holy ... Whoa She took

Dr. David Alfi DDS MD FACS:

43 pills a day as her medicine routine. Today, I asked her, "How many pills are you on today?" Today, she says, "I'm on six pills a day."

Dr. Piya Gandhi, DDS:

Wow. Yeah

Dr. David Alfi DDS MD FACS:

Life-changing Life-changing Truly life-changing Yeah, so It's amazing It was cool. That, those make me the happiest. Yeah Like, I wanna get people off medicine You, you've truly changed... Yes Yeah

Dr. Piya Gandhi, DDS:

Truly changed a life That, that's awesome Um, yeah. I mean, I 100% believe in this work Yeah I wouldn't be... I wouldn't do anything else

Dr. David Alfi DDS MD FACS:

No, for sure I mean- Same here I would just- For sure, same here. It's- And, and once you see it, you can't unsee it You can't unsee it Yeah It's rewarding I guess It's changing lives And we're helping people It's- It is ... not just changing teeth And we're here to share it- Yes and help other people provide this thing Yes Um, so comment below, message us- Yeah... share this. That's the most important thing because we gotta get the word- Yeah, reach out about your kids, reach out about yourself Reach out. Yep Um- And then Zane, come here'cause I'm gonna ask my question to end this. I know we're running out of time Okay For Dr. Gandhi, NP, the greatest basketball player of all time in your opinions

Dr. Piya Gandhi, DDS:

I mean, I know your answer I, you know my answer Kobe Bryant But your answer Kobe Bryant That's my answer

Zane:

Zane? My answer would be I, I... K- Kobe?

Speaker:

All right I, I have

Dr. Piya Gandhi, DDS:

one more

Speaker:

Okay

Dr. Piya Gandhi, DDS:

Okay. Your dad? Your dad? Oh,

Dr. David Alfi DDS MD FACS:

nice. I love it Um-

Dr. Piya Gandhi, DDS:

Well, thanks so much for having me

Dr. David Alfi DDS MD FACS:

Th- thank you for having me Yeah He's a good basketball player Yeah, I know. I've seen him play He's awesome Thank you for having me on your podcast. Yeah. It's a pleasure to be here.

Head Shot

Dr. Piya Gandhi, DDS

Host
Contributor

Dr. David Alfi DDS MD FACS

Guest