Dr. Baxter's Tongue-Tie Diagnosis & Treatment Keynote Lecture from ALSC 2025 in Clearwater, FL

Now I'd like to present Dr. Richard Baxter, and the title of the presentation is "Advancing Tongue Tie Treatment Protocols: Case Studies and Clinical Insights." Now, without further ado, please help me welcome Dr. Richard Baxter.

All right, thank you so much for sticking around to Sunday. I know it's, uh, it's hard away from family, away from your practice, away from, uh, kids and friends. Uh, if you guys want a copy of the slides because there's 227 of them, you go ahead and take a screenshot or take a picture, or you can get the QR code there, download the handout, and we'll get started.

So first, we'll go over the introduction, overview. Try to make this lecture good for all levels. So if you're just new to tongue tie, this should be very helpful, kind of tying it all together, pun intended, I guess. Um, and then, or if you've been treating tongue ties for a decade or more, this should still be helpful, hopefully, as interesting cases have not shown before. If you're in Atlanta a few weeks ago, you might have seen some of them, but I even have some new ones since then. So anyway, I'll go over some research, uh, briefly, uh, go over assessment, treatment, case studies, time for questions. Uh, I do have a flight at 1:45, boards at 1:10, so if you have a question, email me or find me at the break. We'll take a break about halfway through. But how many times a week are you asked about tongue, lip ties by parents? Like, a lot, right? Like, just on normal hygiene visits, normal well visits, if you're a pediatrician, uh, if you're a hygienist, all the time, right? Everyone get the QR code, okay?

A few disclosures. I'm the owner of the Alabama Tongue Tie Center. We got Jacob with us, our office manager here today. Might have seen him out in the hall. I did write the book, "Tongue Tied," with a team of specialists. Lisa is here today. Um, there's a few other people, uh, that worked on the book with us, but, um, and we donate all the royalties to charity. We have an advanced live patient course at our office, uh, that's also donated to charity. We have Tongue Tie Academy, and the update also donated to charity. I don't, I'm not paid by LightScalpel. I don't care if you buy a laser. I think they work well, but I'm not, like, connected in any way to any of these companies. Uh, there's the disclosure slide. And then we do have "Tongue Tied" in several different languages now. So if you speak another language, I know we have some people here from Switzerland. We have, uh, French, Long Tab is Danish, is Chinese, langu is Spanish, Noy, I probably said that wrong, it's Polish. We have someone from Poland here, I think. Lingu is Italian, and Zungenband is German. We're still working on Portuguese and Korean. But here's tonguetied.com. There are our new resource. All of our stuff you can find on tonguetied.com.

So I try to make it as simple as possible. We have the Academy, the advanced live patient course for attendees, uh, hands-on, but you're not treating. And as Gary would say, it's not training because I'm not like watching you do it, but it's as close as you can get to training. And then the update. This is what I worked on last year. I filmed this and released it around May of last year. It's 13 hours. It's all ADA approved CE credits. Uh, what do we do with the money? So we've, uh, sponsored several health centers in the Himalayas, lots of water projects. We just passed a 100 wells with one company and over a 100 wells with another company. So we've done another 200 wells. Not just wells, but like, one was like a whole hospital in Ethiopia didn't have water. So that's made possible by you guys, right, that are taking the course. It's really awesome. We love doing that. Human trafficking projects, both local, anti, obviously anti-human trafficking projects, local and globally. Um, so anyway, and then we sponsor a bunch of kids in South Asia monthly. So anyway, you see Tongue Tied Academy, like, written on the wells and stuff. It's cool.

All right, then there's my family. My wife, Tara, she's a nurse practitioner, but she stays home and homeschools our girls and she teaches an admin physiology. So we have Hannah right here, Noel, they're twins. That's how I got in this mess in the first place, 10 and a half years ago. And Molly will be six in a couple weeks. So it's birthday month. She's excited for February. Did the groundhog see its shadow? Yes. Yes. So does that mean like more winter? Yeah, it's okay. That's all right. Anyone else get in the ocean this morning? Cold plunge? Eric did five minutes. It was good. It was refreshing. So we're ready to go.

Here's our office in Alabama. I know a lot of you guys have been there already, just south of Birmingham. Six kids around the world, global missions theme. Each room is a different continent. You can see Antarctica there. Here's the hygiene bays. We have South America and Africa. And then here's the consult rooms. We ran out of, uh, countries, or sorry, continents, so we did the oceans. So Atlantic Ocean, Pacific Ocean. There's North America, that's where we do all the procedures.

And so, how, how do we do this? Basically, we talk to moms. They're referred to us from various, uh, places. We'll talk about that as well. Uh, and then we'll examine the baby after. Do a full assessment of the symptoms, examination, treat when indicated, not always. We don't just laser everyone that comes to see us. But basically, in dental school, we had one slide of one lecture. Right? In dental school, it was like, don't do this. This is like an oral surgeon's domain. Do not do this. One article in residency, pediatric residency at the Ohio State University. Oh, there we go. Got a cut. One, perfect. There we go. Uh, and then, so I think Gary, did he say something about Ohio State also? Okay. Anyway, uh, I think he went there too. But, uh, might interfere with speech or breastfeeding. Like, if you can stick it past your wet-dry line of the lips, it's okay. If you have a heart-shaped tongue, you can stick it past the wet-dry lips like that. That's, that's the worst test, right? The best test is elevation or lifting the tongue up. And it's a complicated procedure. Like, it requires general anesthesia, referred to oral surgery. And a lot of people still say that, like Gary said, like if they're over, like, six months old, he's going to put them to sleep. So you really do not have to put them to sleep. I'm going to show you how to do it. It's 10 seconds. Especially if you're a pediatric dentist and you're good with behavior management and you can get, like, a filling done, like a facial done on a, on a 2-year-old that's uncooperative, you can easily do a lip and tongue tie. And it's not any more traumatic.

Okay, so when our girls were born 10 and a half years ago, I thought I knew what a tongue tie was, but I didn't know what I didn't know. Couple quotes to start us off. Half of what we're going to teach you is wrong, half is right. Problem is, we don't know which half is which. This is from a Harvard Medical School Dean. Here's from the Ford of tongue tie, Reidy, who's not here. He's often at ALSC. Um, I love Reidy, but he says, "Your eyes do not see what your mind does not know." But once you've seen it, it's impossible to unsee. And then Emerson said, "The mind, once stretched by a new idea, never returns to its original dimensions."

So again, going on Sunday, you guys have been like red-pilled this whole weekend. I don't have to convince you that tongue ties are real and not a myth. But if anyone's still like straggling, hopefully at the end of this, uh, yeah, you'll be convinced.

Here's a 5-year-old male who came to see us in 2024. You can just look at this sheet. I mean, he has speech issues, eating issues, sleeping issues, history of issues as a baby, terrible time as a baby, right? Poor waking, painful nursing, reflux, milk leak out, poor milk supply, clicking noises. Uh, he's been my functional therapy with Joanne. Is Joanne in the room? Yeah, there's Joanne. She sent him to us. Thank you from Florida. Frustration with eating, choking on foods. They've had to do the Heimlich on him 12 to 15 times. Can you imagine that? Like, something is clearly wrong if you're having to do the Heimlich on your child, like, more than a dozen times, right? They've had to call 911. Like, 911 is like on the way. Like, he's choking that, that badly. Okay. These are not like, uh, his helicopter parents. Like, they were very normal, down-to-earth parents, right? Sleeps in weird positions, moves around a lot. Like, "Oh, that's just normal. That's what all kids do, right?" Grinds his teeth. That's just normal. It's common. That's not normal or optimal. Mouth open. That's normal. They all do that. Cavities on his front teeth. Trouble breathing through his nose. TMJ issues, headaches, ear tubes, hyperactivity. Look at this. He's 5 years old. No one identified and almost to the tip tongue tie, right? His lip is not bad. We did his lip for nasal breathing reasons. We'll talk about that in a second. There's obviously no diastema there. He can keep them clean, although he had some cavity starting between E and F. But look at the difference in elevation of his tongue now. It goes all the way up, right? So much higher. A week later, look at this. This is all good things that happened, right? So people like, "Oh, there's no evidence for feeding." There actually is. Robin talked about yesterday. We have an article from 2018. There's a case series. And then we have a prospective cohort study was published in 2020 showing changes in slow eating. I'll show it later, but lots of changes, okay, in eating. So we do have research on that. Say there's not, or it's like not a good study, like, whatever. It was published in Clinical Pediatrics. It's a pediatrician journal. It's not a pay-to-play journal. It's like, it's a decent journal. Um, so less constipation, less picky with textures, finishing meals better, eating more food, all these things. Sleeping better in the same position, less helicoptering, dark circles or venous pooling are going away. Don't take it from me. Hear from Mom.

"This patient has a to-the-tip tongue tie, was not identified as a baby despite lots of issues as a baby. Has speech issues, choking issues, severe choking. Mom's had to do the Heimlich. Dad had to do the Heimlich all the time on him. That's not normal. And we drove the 10-plus hours from Viera, Florida, here to eliminate this tongue tie and have it fixed once and for all. He has done a phenomenally better job. He is swallowing, when it comes to eating his meals, he's able to like chew, chew, chew and swallow. He's breaking down his food. He's able to breathe through his nose at nighttime. He's not so restless and all over the place like a helicopter in the sheets. He's staying in one position and he wakes up better rested with no purple circles under his eyes. He is less constipated, definitely better and easier for him to communicate and to not mumble or baby talk, which is something he was really doing before. He hasn't had any issues with choking on food, which has been the prior issue, which which brought us to this conclusion. Everything has been phenomenal. He's been doing great. Dr. Baxter has been absolutely excellent, both in his professionalism, his attention to detail, his patience, and answering questions. He really has been truly phenomenal."

"Easier to eat now." "Yeah, it is." And we're in New Lenny Family. Don't forget to subscribe and press the like to see some more videos. That's right. Bye.

We just asked him like what to say. He just totally said that on his own. Like, he probably watches too much YouTube. But anyway, there is a lot of myths and misinformation about tongue, lip ties. Like they don't exist, especially posterior tongue tie. So thankfully, we have Dr. Gary's article that shows that it does exist and published in a reputable journal. Um, randomized control trial. They don't cause problems or very rare. It's probably a quarter of the kids. Some people like Reidy, Dr. Agrawal, would say he's, he was looking at the kids at the Phoenix Children's Hospital, 30 to 35% is what he said. Marusan Martinelli in Brazil said 32.5% had a less obvious posterior tongue tie. Now, doesn't mean they all have symptoms, but it's extremely common. So I say a quarter to be conservative. And I'll show you where to get that number from. It's going to stretch. They'll fall and rip the lip tie. A quick snip will fix the problem. That's not true. You have to do a full release. Uh, if you just snip it, you'll see some results, like maybe less nipple pain for Mom, but it's not going to get the full results, like less colic, less gas, all that stuff. May your child, general anesthesia or sedation to treat? That's just not true. Cuz we do it all day. We never put kids to sleep for just this procedure. Maybe, maybe once, but almost always it's like if I'm doing a dental rehab and, you know, fixing much of teeth and they're asleep, then I'll, then I'll do it. But otherwise, we're not going to just put them to sleep for this. We don't even use nitrous hardly. Like, occasionally use nitrous if it's like a nine or 10-year-old that's really anxious. But mothers are told it's just their fault or give some some formula. Mom guilt is real. Or they'll say, "Wait six months." We have had a family fly to see us from Japan because it was, they wouldn't do it till they're six months old. So, oh yeah, they fall and rip it. This child fell and ripped it four times. It's still there. It's still there. It's probably 10% of kids. There's no studies. I've looked, but there's no studies on C. Often they fall and rip it. This is a full release though, and you do have to get this piece here, or else the gap will not close up. It will still sometimes close up, but not as predictably. So you got to get that piece right between the teeth. We've never seen a black triangle or anything like that.

All right, so on Monday morning tomorrow, I'm hoping that you guys will look at your patients a little bit differently for your hygiene checks or your well checks or whatever you're doing. So our goal, it's nothing earth-shattering. It's basic medicine or dentistry, right? Get a good history from the parent. If you don't get a good history, you're not going to get to where you're going. Oh, I forgot to ask you guys, what is this right here? Do you guys know what this is? Well, it's not just the school bus. What kind of bus is it? It's the struggle bus. Everyone that comes to see us is on this struggle bus. They're not like, "Hey, can you laser my child today?" It's like an endodontist. Like, I'm not going to just go to the endodontist like, "Can I have a root canal today?" Like, "Oh, which tooth's bothering you?" "None. Just pick one." You would, you would never do that, right? So they're not going to come to see us unless there is a significant problem in almost all cases. So they're on the struggle bus. We got to get a good history. Then we're going to get a proper examination. We got to check for restricted tissues, check their neck, check their lip, check everything, right? Get the proper diagnosis. Otherwise, you will veer off course. Then you have to treat it, right? Aftercare. We've talked about, so important. If they don't do that right, it's not going to work. You can do all the other four steps right, but if you don't do the aftercare stretches the right way, it will not work. We'll show you that today as well. And then follow-up. You got to follow up with them. If you don't follow up with them, you won't see what to change, what, how to get better, right? Like, we realized we can go from four stretches to three stretches a day and still have really good results if you, if you do high-quality stretches each time. If you do all that, it adds up to thriving families. And then watch this, ready? And stay on the yellow brick road. You get to thriving. That took me a long time. So I hope you really enjoyed that.

All right, so there's a lot of tongue tie terms. You've probably heard most of these, like tethered oral tissues or TOTs, or R-TOTs, restrictive tethered oral tissues, as COT says. Now, ankyloglossia, if you're searching PubMed. A frenulum is a small frenulum. Tongue tie, there's anterior, posterior, lip ties. I like oral restriction or like a tongue restriction because then it's like, "Okay, if you say tongue tie, they think they know that it has to be to the tip, right?" It's like, "No, no, the tongue is restricted along that spectrum. It could be 10% restricted, it could be 50% restricted, anywhere along there, and it can still cause an issue for some children or adults." But it's, it's very individualized. Mid-tongue restriction is the new term Zagi is using instead of posterior tie, which makes sense. Buccal ties, short wing of freedom. And then another part of the confusion is there's lots of terms for what to call it when you release it. So, frenotomy is like a snipper, a clip. In my mind, Gary calls it a frenotomy. I like to say frenectomy. Frenectomy is what they say at the hospital. Frenuloplasty is rearranging with sutures. You can do a Z-plasty or you can do a horizontal to vertical frenuloplasty. If I talk too fast, don't worry about it. It's okay. Uh, clip or snip. Those are four-letter words. Don't, don't say that. That means you're probably not, it's probably not done right. If they just clipped it or snipped it, that's what happened to our girls. Our pediatrician, no offense to the pediatrician, room. Our pediatricians clipped it, and then it didn't help. And then we're like, "Well, that's not the problem. Maybe there's two of them." They're small. They have small mouths. I don't know. Like, we were trying to figure out some other cause for the issues we were having. It turned out it just wasn't done right. So we went to see a dentist, Dr. Nordin, in Dayton, Ohio, at the time, and, uh, made a much bigger difference. Division is what they call it across the pond in Europe, right? SJ division. Uh, and then release is my preferred term. And then a revision is it has to be done again. But Gary already hit on that.

Definitions. You guys know what it is. I'll skip this. But it must be causing a functional issue to be a quote tie, right? So what can happen if you don't do it? This does not mean it will happen. I don't have a crystal ball, or else I would have bought Bitcoin a long time ago. Um, but speech, speech delay, shy, frustrated, embarrassed, bullying. If you don't treat as a baby, they can have trouble swallowing later on. It's more effort to swallow because their tongue does not work as well. So slow and picky eating, small appetite, underweight, poor growth and development. Airway issues, mouth breathing, poor oxygenation, snoring, poor sleep quality. So poor behavior, ADHD symptoms, right? Teeth grinding. It can affect brain development. By the time they're age three, the brain is 80% the size of adult brain. The first year of life, the brain is developing at 1% a day. That's how fast it's growing. That's remarkable, right? A tremendous amount of brain growth happens. By the time they're five, it's 90% in the size of adult brain. So if you say like, "Oh, there's no man's land between six months old and five years old. We're just going to wait till they're five because they can't do the stretches afterward." I'll show you how to do stretches on a 2-year-old or 5-year-old. It's very possible. We do it every day and get high-quality results even without putting them to sleep and without sutures, okay? Because someone else said, like, "It's better to do something." I think S is like, "Just do something. Get, get in there." Heard that. See, hear this morning, to do something, like give him some more elevation, even if it sticks back to 80%, that's still way better than they only had like 20% mobility to begin with. Um, so treat them early, please. That's, that's critical. We see so many good results in the two and three-year-olds.

All right, I'll get off my soapbox. Poor sleep quality, we talked about that. Poor dental development, reflux, and even constipation. It is true. It's, it's remarkable. From babies, we had a 20-year-old a couple weeks ago. She's like, "This is where my digestion's gotten better. Like, I'm like going to the bathroom easier." I'm like, "I know we see it in like babies to adults. It's, it's crazy." I don't have like a study, study on it, but yeah, it's, it's very, uh, it's very often.

Speech issues, trouble with alveolar sounds, vs. ENT dentals, palatal alveolar, probably others too. Speech delay. So our 2020 article is the first article to show in the literature that it can affect speech delay. Not, not every case of speech delay, certainly, but it can impact speech. Even in two-month-old babies, we'll see they'll start babbling more afterward and new sounds afterward. Has anyone else seen that in babies? You fix them for feeding reasons, put your hand up. Yeah. And then they're like, "Oh my gosh, they're talking way more now." Right? They're more expressive. They're laughing now. They're happier. Okay. Uh, trouble speaking clearly or quickly, stuttering. We've had some crazy results with stuttering. I don't have time to show all the videos today, but like, we've had adults with lifelong stutters improve afterward, and they've done every kind of imaginable, and talking like a robot and monotone, and they still stutter, and we released their tongue, which is not to the tip, it was like halfway back, and they could talk easier. They often get shy or they're bullied. It's even in the Bible. Mark 7:35: "His ears were opened, the string of his tongue was released, and he spoke plainly." They think Moses was tongue-tied. So we had Aaron and his brother speak for him. It's in the Quran. It's in the earliest Japanese writings. I mean, it's, it's pretty well established. Like, this is not a fad, whatever they want to say.

Feeding is very complex. This is from Autumn Henning. Take your TOTs course if you haven't yet. It's great. Eight tongue muscles, six cranial nerves involved. They often will gag, they'll pack their cheeks like a chipmunk, spit out food, they'll vomit, swallow whole, they can choke, like our friend Noah, refusing food, poor weight gain, very picky eating, messy eaters. It takes forever to eat. So if it's like slow eating in a typically developing child, more often than not, that's tongue tie. It's almost pathognomonic for tongue tie. Like, there's nothing else that causes that really slow eating. That should be like the top of the differential diagnosis. Instead, it's like a fifth thing down after they do swallow studies and FEES and things. It takes forever to eat, grazing on foods, and they can't consume an age-appropriate diet.

Ever heard about kids sleeping like this in a tripod position, or they throw their head back? They're trying to get the tongue out of the airway, and so they're mouth breathing. They're snoring. Sleep-disordered breathing as a continuum, right? Right. Mouth breathing starts off primary snoring, sleep-disordered breathing, and it can affect brain development, it can affect, uh, anxiety, aggressive behavior, hyperactivity, inattention. All those things can be affected by poor sleep. Bruxism, or grinding their teeth. It's not normal. It's not just psychological stress. It's physiological stress. They literally can't breathe. Okay? Restless sleeping, frequent waking, bedwetting. We've seen a lot of 9 and 10-year-olds like, "Can't spend the night with their friends or whatever." They're embarrassed about it. They don't want to talk about it because they're still wetting the bed, and they have sleep-disordered breathing. We fix the tongue tie with some therapy, and they stop wetting the bed. Like, it's literally the same night. And it's not just one or two kids. We see it pretty consistently. But basically, what it comes down to is chronic systemic inflammation. Someone mentioned the book "Outlive" by Peter Attia. I read the whole thing. It's excellent. But basically, the four leading causes of death: so heart disease, neurodegenerative diseases, cancer, and, like, diabetes, basically metabolic diseases. That's the four leading causes of death in America. All four of them, what do they have in common? Chronic systemic inflammation. And sleep apnea, obstructive sleep apnea, or SDB, sleep-disordered breathing, that leads to a state of chronic inflammation when your body is trying to repair at night. And so it's really critical that we get these kids treatment early. You treat the babies, they stop mouth breathing. No mayo, no myo need, like, they just, it's instant. Their tongue goes to the palate in many cases. Okay.

All right, here's a 19-month-old. Do you think they're on the struggle bus? How many people use the form? Like this? A lot of people. Okay. So, so you've seen this form before. Okay. So it's like that. This child needs help. Like, I can see they're probably in the right place already because they have like 25 check marks, right? There's nothing else that causes that. So speech issues. I'm not going to go through it all, but speech delay. They have seven to 10 words at 19 months. They should have like 25 to 50 words. I'm not a speech therapist. I don't pretend to be one. But it's important to like learn some of the milestones where there should be like a 100-ish words, two words together at like, at 2 years old, right? Uh, frustration with eating, slow eating, picky eating, choking, spitting out foods, reflux, restless sleeping, grinding teeth at night, really bad, almost all the time, snoring. Huge red flags here. Okay. Let's look at it. That's pretty tight. I mean, I feel like someone should have picked this up before 19 months old. Like, but at 19 months old, you see all those teeth. The pediatrician is not going to get in there. Maybe a tongue depressor, but to really get in there and challenge the tongue, like Harry talked about, like, like a forklift, like lifting you. If you do that, you will lose a finger. You will come back like this, like next time, right? You will lose a finger. And so you have to use a mouth prop. If they have teeth, buy some mouth props on eBay. They're three or four dollars and get them in bulk. We buy 180 at a time. Why do I buy so many? Because I give those to the parents to take home with them, and now they can actually do the stretches at home twice a day. It's not like forever. I tell them it's going to suck. They're not going to like it. If there was a better way, I promise we would do that, but it's, it is necessary. So we treat 19-month-olds. Full release. It was literally 10, 15 seconds. Now, his lip tie, we left alone. There's no diastema. That can keep the teeth together. It could possibly help with nasal breathing. So almost every adult we do, and even older kids, they'll say they can breathe through their nose better. Has anyone else seen that? But they say they can breathe through their nose better. I need a study on it, but it's hard to quantify that with like nasal resistance. Maybe we'll work on that. But I'm getting a little disillusioned with research. Is serious? Because you do this like great study, put hundreds of hours in, and then you submit it, and they're like, "This is a controversial topic. We're not going to even send this for peer review." Publication bias is very real, especially for like better journals. Like, if I submit this to JAMA Pediatrics, they're not going to put, like, "What? Just, you're a dentist? Go away." Right? Like, if you submit this to dental journals, they're like, "This is not really dental." Like, it's, it's very difficult. So anyway, oh yeah, you got better. Yeah. So this one got better. So completely changed his sleep, almost a new kid. When Dad is impressed, that's a good day. Be impressed, Dad. So that's good, right? Yeah. I see you right there. Yeah. Uh, easier to get words out, new words, six new words in seven days, and he only had a few to begin with, right? So that's remarkable. That's like, that's an N of one. I can, after this presentation, may end of 25, this is like a large case series here, talking more. Completely changed his sleep, less grinding, less mouth open, less snoring, less gasping for air. So if we let this kid go to, like, five or six and cooperative with stretches, that's several more years of possibly impaired brain growth and development and behavior. And then he's six or seven now. He's not sitting still in class. Now we got to think about some Ritalin. Oh, now he's not sleeping because of Ritalin. He's not eating. So we need an appetite stimulant. Oh, we need a sleeping pill. Like, it's a, it's a predictable path. How many people have seen that? Have you seen that before? Very often, sadly, right? And some of you have lived it. Has anyone lived that? Has anyone that your experience? Yep, several of you.

5-day-old. It's a great time to do it. Sooner the better. Shallow latch, falls asleep, poor weight gain, hiccuping, guming, you're chewing the nipple, pacifier falls out easily, moving on in their sleep, reflux symptoms, spits up often, gassy, milk leaks out, and frustrated. For 5 days old, this is a lot of check marks because almost always it's like a snowball going down a hill, right? The longer you wait, the more check marks you'll see. So for the first, like, you know, couple days, like milk's not even in yet, you may not even see that many issues, maybe some nipple pain, but you're not going to see all like the gassy, colic, spitting up that comes later. We ask all the moms how they're doing mentally, emotionally. We have them fill out the EPDS-10, the Edinburgh Postnatal Depression Scale, and we check them for postpartum depression every day. We have at least two or three moms score above a 10 or above a 13, which means you basically have postpartum depression. And then we have a thing at the top that says, "Is it okay if we share these with your provider?" So I modified it a little bit and added that. Um, but if you download the forms, I'll show you the QR code. It's all in there. If you can, uh, get that.

Here's the 5-day-old, to-the-tip. Very thick. Sometimes they like to write lots on Facebook. She put like the really long post on Facebook. Oh yeah, here it is. I want, we don't have time to go through the whole thing, but it was, it was really nice. And again, like, we got, we got Dad impressed. Dad was impressed. It took an hour to eat 5 milliliters. I'm not a lactation consultant, but that's too slow, right? And then the pediatrician, look, the pediatrician sent them over. Isn't that great? So we're getting more pediatrician referrals now.

Here's that exact same baby. Oh, hello. That's that exact same baby. So here's lifting up the lip. This is how we examine. Notice it's blanching, right? Just because it comes all the way down, 94% of babies have a low insertion. So that doesn't mean it's a lip tie, but it's blanching. Check the cheeks. We did not treat these cheeks. You can feel up there. If you feel like a tight restriction, feels like a speed bump or like a, a guitar string up there, you can treat the cheeks as well. We'll talk about that. But look at that tongue. Very, very tight. That's restricted. So do we need to wait like three weeks so to see the chiropractor, relactation, craniosacral therapy, the massage therapist, or should we do it at like one day old, two days old, right? They're having issues. It takes an hour to get 5 mL. Like, I'm going to do it then. We did a 12-hour-old baby. That's hard to do. So we had one day old was our previous record. But we had a baby that was born at 10 p.m. Sibling was previous patient, was like tied pretty bad, and they called us. We got him in at 10 a.m. So that's hard to do. That's their youngest. It takes the cake. And then 70 years old is our oldest. We've done. So, anyway.

Here's the procedure on Maddie. So we're going to lift up all the way. Lots of tension. Tension is the key. I wasn't here for Gary's lecture, but I did listen to it on the plane. Jacob recorded it for me. So, tension is the key, right? Lots and lots of tension. It's about 15 seconds for the lip. You could do it on a higher wattage, but it will bleed more. So we do this on three watts. I'll show you the settings in a little bit. Um, and then the tongue. I'll drop it down. So right now, I just hit the power down to two watts. Have your assistant hold the chin down. I come from 12 o'clock from behind the baby and then lift up. It'll, it'll recenter in a second, but we just filmed these with an iPhone. So it's helpful to take these videos yourself. Have your assistant get some videos for your website. Lift up all the way. Lots of tension. Look at that. Like minimal to no bleeding. And you can pick out the individual fibers. Now, I'm not getting the base of the Eiffel Tower, otherwise when you stretch, that's the only part that will open up. Has anyone else made that mistake? So what we're going to do is we're going to just get a little bit of that, uh, flapping tissue, otherwise it'll just be there forever. So there we go. That was more involved. The ones that are to the tip are typically the hardest.

4-day-old. Shallow latch, gagging, coughing, hiccuping. In utero hiccups. That's probably one of the earliest signs of a tongue tie. I don't have a study on it, but very often they'll hiccup a ton in utero, and then they'll come out, they hiccup a lot, and we do the procedure, and it stops. Has anyone else seen the hiccuping stop? It's pretty remarkable. Yep. They're gassy, sucking blisters, clicking, sleep, Mom is sleep-deprived and emotional. And that's, that's pretty standard. Seven out of 10 pain. Most of the time, if you see really bad pain, toe-curling pain, it is a less obvious posterior mid-tongue restriction, whatever you want to call it. It's a not obvious tongue tie in most cases. So in this instance, that's what it is. It's probably 50% or so to the tip. The lip is pretty tight. It's blanching. So we release that. About 10 seconds for the lip, 10 seconds for the tongue. Afterward, much less pain. Amazing. Worth the drive a thousand times. Okay, they're so happy. So more spitting up though afterward. Why are they having more spit-up? Almost always check for this check mark there. Improve breast drainage. So if they're getting more milk out, they're going to spit up more because they're just like, it's just filling up and it has to go somewhere. It just comes back up. Give them a couple weeks, it'll get, it'll get better. But was a seven out of 10 pain before, now it's a one. Look at this. She checked this one. I love to see that one checked. Mom is feeling more confident, in a better emotional state. Dr. Gary showed that with his results with the breastfeeding self-efficacy score getting above a 50, which means they're more likely to continue breastfeeding.

Here's that exact same baby. That's how we did it. So lots of tension. This is again, three watts, like 20 hertz, non-super pulse. We don't use super pulse. That's more for skin resurfacing, cosmetic stuff. So non-super pulse. And this is the LightScalpel. You guys probably knew that already. You can certainly do it with other, with other techniques, but this is just so much faster. We used a diode for 18 months, and it, it took about a minute per area with our, uh, little diode, and we got way more post-operative calls of nursing strikes with this. This, like the day I switched in 2016, almost, almost 10 years now, we stopped getting all those post-op calls. I still call to check on people every night, but they're like, "Okay, we're doing well." And then, like, if they haven't, almost always like, "Oh, they're not eating." I said, "Did you all do the Tylenol or the Genexa organic Tylenol?" All they're like, "No, we didn't do any yet. We tried Arnica." I'm like, "Just try the, try the Genexa. It's not forever. A few doses will make a big difference." So, here's a 5-month-old. So this was right before ALSC last year. Was anyone at ALSC last year in San Diego? Okay. So not everyone. So if you have, I'm sorry, you'll see the story again, but I have an update for you because you're like, "Oh, it only works for like a week or two." So we'll see what happens. I just got an unsolicited video sent to me to my WhatsApp a couple days ago. Um, so which I don't even check WhatsApp, but I'm glad I did.

Shallow latch, falls asleep, tried 30 different brands of bottles, hiccups all the time, pacifier. They saw the lactation consultant, pediatric dentist, admitted to the hospital, nine different professionals, ENT, right? They already had a release by a pediatric dentist, lip tie and tongue tie. Mom says, "How are you doing?" "I don't even know. I'm depressed because of lack of knowledge." Won't finish bottles, he's snoring, nose is congested all the time, spitting up on Nexium. Like, are they on the struggle bus? Yes. Yeah. Snoring, not sleeping well, all the things, hiccuping. So here's the, here's the, this is after a release already. It came back. Either insufficient stretches or insufficient release. I don't know unless you have a picture before and afterward, then you can kind of tell. But either way, it's, it's restricted again. Would you agree? Look at the cheeks. The cheeks are pretty tight with all those symptoms, with like the milk leaking out, the spitting up, the gassiness. So I think that aerophagia, like eating air, that can be related to buccal ties as well. And so watch what happens. This is just a week later. So not like that many changes because they're 5 months old. The sooner you do it, the quicker they'll see changes because they have fewer bad habits, right? So if you do it at like a week old, they're going to get better quickly. Like under a month, they get better quickly. Five-month-old, they got five months of bad habits plus four months of bad habits in utero. They start sucking about halfway through pregnancy. So he's got nine months of bad habits to overcome. But less snoring already, milk leaks out of his mouth, less babbling, more, way more blowing raspberries and squealing, less reflux, deeper latch, less falling asleep, right?

Okay, here's brother. So two boys, they came to see us. He wants his tongue fixed so his friends can understand him. Is that sad? He's on the age of a 2-year-old. They thought he had autism, but doesn't take all the boxes. These are real people, right? Like, we just, like, make this up. Could not breastfeed, woke up eight times a night as a baby. Also saw seven different providers, dentist, pediatrician, ENT. They said he can stick his tongue out. Mom says, "Dr. Baxter says that's the worst test." They're, "Who's Dr. Baxter?" And she said it was funny. So how'd she find us? She read the book. Read the book is how she found us. Just wait to see where she's from. Speech delay, like picky eating, choking, like all these things, won't eat vegetables, constipation, all the things, right? Now, his lip is fine. We don't just laser everything, right? His lip is fine. His palate, it's okay. Could use some expansion, sure, but he's four, so like, it's, it's hard. Most people like will not expand a four-year-old. Audrey Yoon, I was with her a couple weeks ago. She says like, expanding like at eight years old, that's a geriatric patient to her. She's like, "That's a geriatric patient." So she does like three and four-year-olds. But anyway, look at his tongue. It lifts halfway. He can stick his tongue out past the wet-dry line. It's fine, right? That's what they were told. He can stick his tongue out. It's fine. But was it fine? He had, he checked almost every box. Like, that's a problem for this individual child. For Jaden, that is too tight. Look at his tongue afterward.

All right, so you tell me, which kid's going to talk better? The one with 50% mobility or 100% mobility? Which one's going to eat better? Which one's going to sleep better, right? So, does every kid like that need it? No. But listen to her story. "This is my son. Up, I've got a five-month-old as well. Dr. Baxter just did Jaden's tongue tie release, and a few seconds ago, he's already speaking better after 2 and a half years of speech therapy, tongue tie taken out, seeing ENTs, dentists, feeding consultants, the whole lot, and everyone showed me away, tells me there's nothing wrong with my son. His speech is on the age of a 2-year-old. Seconds after Dr. Bax did the procedure, he said, 'Thank you to the doctor,' and he said it much better. I think we do have work and then balance, which is 5 months old, had a deep snore. He couldn't keep his milk in. He didn't, he drank now a little bit, no leaking on the corners, and he's not snoring at all. Seconds after it's a procedure. Awareness needs to be made. Thank you, Dr. Baxter. This is going to be life-changing, and I'll be forever be grateful." Where are you from? South Africa. They flew to Birmingham, Alabama, of all places, from South Africa. That's crazy. So her sister came with her, brought the two kids. You know, it's remarkable what some of these moms will go through to get help for their child, right? And so I wish there's like people close by that could help them, but they went to everyone they could in South Africa. And then two days ago, I got this video. Here you go.

"Hi, it's Lou from South Africa. Turn up a bit. January 2025. I took my two sons in January 2024 to Dr. Baxter to get their tongue tie releases after seeking several professional help in South Africa. Everyone showed me away. So Jaden, which was the four-year-old, which is turning six this year, he had, um, he's a very picky eater, and he was grinding on his teeth, sleeping with his mouth open, and, yeah, had a sleep-related apnea, and then he had a major speech delay, nearly reaching three years behind with speech. A year later, after the Taurus thing, we did speech therapy. We still have a long way to go. The result was he's not grinding on his teeth anymore. He's sleeping better, and then his speech has improved. Before the procedure, I could not understand much. He'd maybe 10% of the time. After the procedure, a year later, we had 80% of the time. We're still continuing with speech therapy and articulation exercises. So thank you, Dr. Baxter. You have changed our lives. I've got my kids back. For the little one, he was reflux-free, and then also he stopped snoring. So that was the bonus as well. So I just want to thank you. I've got my kids back. The frustration which Jaden had not communicating was a challenge, and I've got my child back. He's got his self-confidence. He's in a normal school. He's got friends. And then I also got myself back. So I just want to thank you, Dr. Baxter, for changing our lives, and thank you for what you're doing, and I hope more awareness gets made."

This is awareness right here, right? Isn't that cool? So he can, his friends understand him now. That was like his chief complaint. Isn't that sad? This is cool. I did not ask her. She just like sent the video over. She's like, "Can I share a one-year update?" So it's not just like, "Oh, one week it works." Like, we see these kids back on hygiene visits at our office, and like, it, it works for years.

Research. You guys have probably seen this at, at nauseam. So like, there's different levels of research, right? It's like randomized control trials, systematic reviews, cohort studies, case-control studies, case series. So basically, you take this lecture, it's like a large case series, right? Expert opinions. So if someone.

Says, "Like, I don't believe in tongue ties. They don't exist. They'll stretch out." Posterior tongue tie is not a thing. Treating it's a fad. They're entitled to their opinion, but you know what they say about opinions. Everyone's got one. And then, just in case anyone's unclear, uh, the New York Times is below expert opinion. Right? So it's not a fad or new procedure. Here's some wood cuttings from 1620. Uh, King Louis the 13th was tongue-tied and was released by the king's surgeon, M. Gimino, in the middle of the night. Look at this. Do you recognize this right here? It's not quite as nice as our tongue tie outside there, but, um, this is from 1680. 17, 1974. So there are randomized control trials. There's five or six of them. Uh, this is where a lot of people get the 10% number from for tongue ties. So this one's from, uh, this is from England, actually, but they took 57 babies. 29 control group, 29 immediate, 28 immediate release group. One baby in the control group improved from just lactation support. It's not saying lactation is not important, but if there's a physical reason they can't nurse, like, take care of that, right? Suppose I want to like run in the Olympics and like, you know, I'm going to run the Olympics. I'm hire an Olympic coach, but my shoelaces are tied together. Like, I'm not going to run in the Olympics, right? Like you have to cut the, okay, now, now we have something for the coach to work with. You have the ability to do that, right? The release group, 96% improved overall. 95% of babies saw improvement. And this is probably just like a clip or like a division. It's, it's probably not like a full diamond shape release. They didn't mention stretches there, but they said there's no need to release all tongue ties at birth, but awareness about tongue ties and feeding problems will releasing symptomatic babies. So if they're having problems, s treated. It's not just like, okay, string cut, right? Without delay. So without delay. Uh, it also says that it's not possible to predict just by looking at the tongue tie which ones that cause problems. So this is nice because they have this is a hospital. So it's like a, a large population, right? There's 1,000 babies. They're looking at them all. I only see babies with issues most of the time. Remember, like the ended honest, okay? So 100% babies to the tip. Babies were feeding asymptomatically, which is true. We see some people come in at like five months old or even a couple months old, and they check nothing on the sheet. Like, why are you here? And they say, our pediatrician sent us. I say, great. And I look in there, and it's to the tip, and they don't have any feeding reasons. And then we'll talk about like, what's can happen in the future, what happens now. And then sometimes they don't realize because the baby's gaining weight and it doesn't hurt mom, that these other issues like reflux, gassy, spitting up, kaky, those could be related as well. But they didn't know that till they fill out the form, right? So then we have discussion with the parents, and then it's always up to the parents. Whatever they want to do. I always under promise, over deliver, right? So never promise them the moon. Never guarantee them, um, all that stuff. But look here, they mention posterior tongue tie. Basically, without knowing it, problems are found in babies with 25% tongue tie. So just a little bit there, especially breastfed. So what's important is not the length of the tie, but symptoms. Who was causing this? This is, this is a good article, right? Uh, it's if feeding was improved by the simple, safe procedure of removing the physical problems preventing at the tongue tie. So like, that's good. Uh, here's another one. This is published in Pediatrics, right? Uh, blinded. They used, uh, randomized control trial. They used validated tools for measuring. Basically, the frenotomy group, frenotomy group, it significantly decreased pain. Highly significant. Breastfeeding scores improved in the frenotomy group. All but one parent in the sham group, where they pretended to do it, asked to have it at, have it done at or before the two-week follow-up. They said clear and immediate improvement. Rapid, simple, without complications if you do it properly, right? If you just like blindly just like cut in there with like a blindfold on, it's not going to work well, right? So I'll show you how to do that. Optimal timing, two to six days after birth. Uh, it can cause postpartum latch and nipple pain. That's what's like best studied. But they've consistently shown a benefit. The studies of frenotomy, and again, in babies, there's a good bit of studies. Double-blind randomized control trial, a real immediate improvement in breastfeeding, detectable by the about, which is sustained, does not appear to be due to a placebo effect. Scott Seagull, he's not here this weekend, but often he does ALSC conferences about aerophagia induced reflux. Treat 100 babies. Half improved or weaned off their medication. 28% did not improve. 19% had improved irritability but still needed medication. So it is multifactorial, but often they're swallowing air. So let's look at this quick video. Is this colic or just a tongue tie, lip tie? So this baby had a pretty restricted lip, wouldn't you say? And the tongue is not bad. Some babies could have that and have no problems, but again, if they're coming to see me and they have 25 check marks on the form, then the tongue is likely the culprit. So what's to this mom's story? Hey, it's Dr. Backom here with our patient of the week, Kaden, and there he is. He's so cute. Tell us your story, Mom. So we came in about a week and a half ago. He was struggling with everything. We were very colicky. Couldn't put him down. Spitting up, gassy, wasn't sleeping good, wasn't eating. It was never satisfied when he was eating. I just kept telling everybody something was wrong, but I just couldn't figure it out. So we came in, same day appointment, and got his tongue and lip tie completed by Dr. Baxter, and literally could not thank him enough. It changed overnight. He's sleeping 8 hours at night. He's eating well, less gassy, less poopy, just overall a happy baby now. So we are very thankful. So thank you so much. Colic is not normal. It's common. It's not normal, right? There's a reason why they often need body work, and they probably have a lip or tongue tie. Gary, 2016. You guys have all seen this, I'm sure. Prospective cohort study, which is like in a normal office. That's about as good as you can do as a prospective cohort study. Uh, to do randomized control trials, much harder, especially if we have people traveling from like two to four hours away, which is our average distance. It's, it would be difficult to do a randomized control trial. Like, okay, flipped the coin. Sorry, Mom. It's heads. You guys have to come back like in a couple weeks, and we'll fix it. Like, that's not reasonable to do to people. Uh, but 2/3, uh, or sorry, 3/4 had posterior tongue tie. 3/4s also had upper and lower performed. The milk transfer rate increased. So they're more efficient. Again, imagine your shoelaces tied together. You're not going to walk efficiently, right? But if your shoelaces are free, okay, now you can walk easier. You can run on the beach. Self-confidence improved. Above 50, which means they're likely to continue breastfeeding. GERD went down. So reflux went down. Pain went from a 4 and a half to a 1 and a half, which is a big deal. In 2018, revision for frenotomy. So these are babies that are already clipped. They couldn't include them in the initial data set. So still had issues, and what's interesting is they had the exact same outcomes because it just doesn't, wasn't done properly. So a snipper clip, they still have issues. Do it properly. Uh, 2022. This was, uh, very smart. Uh, they used a computerized nipple because people were like, well, pain, it's subjective. Mother self-confidence, that's subjective. Like they want like hard data. It's like, I'm sorry, there's not like a lot of hard data like in babies, but they found a way to quantify it. So they use this Enfant bottle with a computerized nipple. Did he talk about this? I didn't think he talked about this. Okay, so they released posterior tongue tie. Didn't do any lip ties to not like mess with the data at all. Only a less obvious tongue tie with the CO2 laser. Statistically and clinically significant improvement in 11 objective feeding metrics. So faster tongue speed, more rhythmic, more coordinated, more adaptable. Breastfeeding scales also improved in the treatment group, but not in control. Reflux improved, but not in the control. Nipple pain improved, not in the control. This is published in Otology, Head and Neck Surgery. That's like the ENT journal. Okay. Uh, buccal freedom. So as he talked about, there's no evidence for buccal ties. I also acknowledge there's no evidence for buccal ties, but 75% of people, sorry, 87% of people are assessing buccal ties and likely treating them. So we need some kind of like data. So again, to do a randomized control trial where you flip a coin. Okay, Mom, they have lip and tongue tie, but we're only going to do the cheeks today, and then come back in two weeks, and then we'll do your lip and tongue if you still need it. Like, is that ethical to do? No, because we've seen like, no IRB is going to give you approval for that. That randomized control trial, placebo-controlled randomized control trial, that was made for drugs. Made for drugs. You can give someone a sugar pill, give them like your blood pressure pill, and compare and cross over. That's for, it's not for surgical procedures on babies. So like having holding that to a level of standard like this is, is not, not right. Um, I could say lots of other things that would not be politically correct right now, but lots of things they do in medicine, especially since COVID, were not backed up by long-term randomized control trials. You were the control group or the study group, whether you got a certain intervention or not. I'll just say that you were the largest randomized control trial, well, prospective, anyway. Uh, so 5 to 10% of infants may be affected by cheek ties. So it's not everyone. If you're doing cheek ties on every baby, that's probably overtreating. If you're not doing any, that's probably undertreating. It's, it's some. So like in a day, if we have 10 babies, think we have 10, 11 babies tomorrow, if I make my flight, then it's like maybe one or two will have cheek ties, right? Uh, so finger sweep, visual inspection, checking it. You have to combine the objective, like what you see and feel, with the subjective findings, what the parent reports to combine those together for the diagnosis. Uh, you do have to do stretches. This should be 100% recommended post-op instructions, but basically the best we could do was a survey. So thank you if you fill out the survey for us. 466 healthcare providers from various disciplines from 15 different countries. This is the largest tongue tie survey I know of. Oral restriction survey. Potential clinical symptoms. Is Robin in the room? Robin, help with this article too. There's Robin. There we go. So, um, infants, poor latch, basically seal issues. Aerophagia, children pocketing food, trouble with lip rounding, straw drinking, saliva management, pain with brushing the teeth. If you're running into that, cheek tie. Adults, trouble brushing the teeth, plaque retention. Okay, so there are four articles that even just mentioned buccal tie at all. One of them was on denture retention issues. So if you have a periodontist, or if there any periodontists in the room, general dentist, in trouble with denture retention, it could be because you can't do your border molding properly. Just having some bad flashbacks to dental school. Um, but anyway, if you know, you know. Um, but yeah, the denture retention issues, they can't blow or whistle. Facial tension. One lady, we released her left buccal tie. Tinnitus, the ringing in her ear, she'd had for a decade, went away. So there's like all this stuff. Like, we don't know. Now, what, ever guarantee that? Absolutely not, because I, I'm not God. I can't make that happen. But like, we did it, and like, it went away. So, so I don't know. There's stuff we don't know. Uh, there was no A classification scale. So we made one up. Uh, basically, instead of like the Coto or Cillos with four, here's three. That's three, which is like the Santa U Maria study. So like three is a little bit more easy, uh, a little bit easier to understand. So class one is in the mucosa. Class two is in the gingiva. Class three is like down to the ridge or close to the ridge. I also made up an acrostic. It's called BUCKL. So is it blanching the tissue? Is it uncomfortable to palpate? Is there a clinical impact, like what symptoms? Is there compensation going on? Then where's the attachment site? So it's not just like, oh, attachment site, laser. It's all these things. And then there's a limited range of motion. Uh, this article, we paid the $4,000 so you can get it open access. You can download it and read it. Uh, it's in Journal of Oral Rehabilitation. But here's like what, uh, the procedure looks like. It takes literally five or 10 seconds. Do not go too deep in the vestibule, or you will have some bleeding. There are some vessels up there. Uh, so just be careful with that. It's just like very superficial. Just get rid of the webbing. Uh, there's an child heals nicely. We put an appendix in there for treating infants and another one for treating children. Speech and feeding research. So they're like, oh, there's no research on solid feeding. And I agreed. I was writing the book, and we have, like, if you looked at the book, it says like speech, and here's the research, like sleep, and then the research, feeding, and like, where's the research? Like, there was literally not any research. There is nothing on solid feeding and on tongue ties. In fact, there's actually no valid feeding questionnaire. So even if I wanted to do a study on feeding and tongue ties, I can't, because there's, well, there's like one that's like eight pages long. It's not like reasonable to use. But I mean, we need one. Like, how fast can you eat a Ritz cracker without like spilling it everywhere? I'm like, like, there, there needs to be some kind of standardized like assessment for feeding, but there's, there's just not, right? I'm not sure what they've been doing in feeding research. Uh, but it's remarkable with dysphagia, with swallowing, all this stuff, like it does help that in many, many cases. So here's five cases, all less obvious tongue ties. It's a case series, and they all improved in speech and eating. Uh, it's a spectrum rather than a single disease state. Needs a paradigm shift. And then we try to do one better. So this is actually very difficult to do. So you have to get IRB approval, which is several thousand dollars, and then you have to go through all the trainings, and then you're prospectively treating. So meaning, before you do any treatment, you say, okay, you need a tongue tie. Do you want to join our study? And they say yes or no. They sign a consent form. We had about 50 people on the study. Uh, and then so basically, like, whatever it happens, like if it's good or bad, like we're going to report the outcomes. That's like prospective cohort study. So average age was like preschool, four years old, but age range was 1 to 12. Significantly better speech, eating, and sleep at one week and one month follow-ups. So say there's like no good studies for speech and eating. I did the best I could. All right, this is the first article. Show improvements in speech delay, picky eating, slow eating, choking, snoring, and restless sleep. Published in Clinical Pediatrics, which is a good journal. In 2020, it was one of their most downloaded articles. So it doesn't say 100% head improvement because that would be crazy. That's not believable. And it's not true. So 89% had improved speech. 83% had improved solid feeding. 83% had improved sleep. 90% like, yeah, I'll do it again. Some people like the stretches are terrible. I'm like, bro, I know. It's terrible. It's awful. Um, but they were still happy they did it in most cases. So these are kind of numbers you can take to the bank. It's like, all right, like there's a good chance, probably 80, 90% chance it'll help your child with speech, eating, or sleeping if you do it properly and do the stretches right. Uh, here's a video. Dr. Baxter, we have our patients of the week, not just one this time. We got two. We have twin girls right here. And they're identical twin. Oh, and one's hiding. And the mom's going to tell us their story. So they are 2 years old. This is Remy. That's, I mean, this is Saw. That's Remy. Before we came to see Dr. Baxter, they were, um, choking all the time. I felt like they couldn't eat well, and they had, they slept horribly. Yeah, it was just not a good time. And we're 10 days out from our tongue and lip tie release. They're sleeping better. They wake up in better moods. They're not choking at all. They're trying new foods, saying new words. I mean, it's just been, it's been a world of difference. Perfect. The real people. And here's Remy's lip beforehand, and that's afterward. Her tongue, very tight, and then afterward, lifts up all the way. So which child's going to eat or talk or sleep better, right? And then here's sisters here. Sawyer's CP. Tongue was for it, incompletely. And then, and that's afterward. So doing way better, just in 10 days. All right. Uh, here's lingual frenulum capacity with MFT. They spent hundreds of hours getting this like together and published on that stuff. And I spent 30 minutes writing a blog post on adults with tongue ties. And if you Google right now, like "tongue tied adult," see which page on Google we're talking about this at dinner because one of the guys works for Google. See which page, like my stupid blog post I wrote pops up. It's number one or number two on Google in most cases. And then this one, which is a good study, Dr. Zi did, is like page 11. So that's like, it's not even worth doing all this research anymore. So I don't know because what are people going to do? They're going to go on Google or like ask ChatGPT like, what do this? They're not going to like check PubMed and like, it's not easy to search it. So anyway, just sometimes feeling defeated, but that's okay. All right, TRQ article. The Tongue Restriction Questionnaire was like, we need a way to screen these kids because a lot of kids have a less obvious tongue tie that on a hygiene visit, I wouldn't even ask them if they had a tongue tie because it's not obvious. So we did this, just for comparison. We're supposed to screen for oral cancer, right? In adults, it's one in a thousand. So you'll probably see an adult with oral cancer if you're a general dentist, because you probably have a thousand, more than a thousand patients. Pediatric, does anyone have a million patients in their office? I'd like to shake your hand. That would be impressive. Uh, so pediatric, thankfully, it's very rare. It's one in a million have pediatric oral cancer. But how much time do we spend in residency or in dental school about these super rare, like pediatric oral cancers? Like a long time, like hours and hours, and many articles because it is significant, serious. Meanwhile, we also screen infants. So the newborn screening is done by the state. So it's not a national thing, except in Brazil. There's a national law to screen for tongue tie. But for infants, for PKU is one in 15,000. For CF, cystic fibrosis, 1 in 3500. Severe combined immunodeficiency, it's like the Bubble Boy where you don't have an immune system, that's one in 100,000. Thankfully, hearing loss is pretty common. It's one in 500. Tongue tie, not routinely performed, one in four, and that's a conservative estimate. So we really have to be checking these kids in the hospitals. But as they mentioned the other day, like most places have gag orders. If they mention my name at the hospital, they can get fired. First step of screening, the tongue range of motion ratio. How high can you lift your tongue? If you can lift over 80%, that's grade one. That's considered above average. Grade two, 50 to 80% is average, but a lot of people are compensating. Grade three, this should probably be re-grade, grade four, but they're compensating. So grade three is, uh, less than 50%. That's below average. Significantly below average is grade four, right? So that's how high can you lift. A lot of you have seen this before. So I want to keep going, but, uh, if you hold a gloved finger down here, then you get the true mobility. Okay? So you're not holding down really hard, just like normal pressure. And you can get the true mobility. So here's mine. This is before. So like, I was like pretty good. It was fine. It was adequate, but I knew I could be better because I grew back, and like, oh, my neck tension came back, and, um, my speech, like I couldn't talk as fast or as clearly. Like when I did dictation at the hospital, I was like, my time was down. It was just stupid reasons like that. So I, um, I'm competitive with stupid stuff. Like, we were doing Peloton this morning. I want to be number 16 on this, like, on this ride, you know? And Eric's like, whatever, this is dumb. But I was like, working hard. I got to number 16, I think. But, so here's before, and suction hold, that's afterward. So Zagy did it. It's on his, uh, YouTube channel. If you want to watch the whole thing. It took a long time because there's some scar tissue. And then afterward, we went to Universal Studios, as one does after getting a tongue tie release. And the lady who took the picture said, cute family. So we went there with his son, Maxim. We had a good time. Maxim got a churro. Everyone was happy. It was good. Anyway, thought you all appreciate that. So here's the tongue restriction questionnaire. This is the first version. Has the baby issues on it. You can use that if you want to. It's all in the form. So if you download our forms, tonguetie.com/professionals, or you can scan the QR code there. You can download all of our forms for free. They're Word documents. You can put your own logo on them, change them if you don't like them. I don't care. They're not like copyrighted or anything. Um, and then here's the updated version of the TRQ. So we're not going to treat anyone unless they have current issues, right? Like the history of baby issues and nothing currently. We're not going to laser them for for that. Um, so this is the greatest hits of our child symptom form. And how much does it affect quality of life? Again, if they're like slow eating and restless sleeping and like headaches, but it doesn't really affect their quality of life, we may not want to treat them. If like the parents don't see like a perceived need for it, you're just going to get yourself in trouble. We had a friend of ours, she actually came to the office like last week for hygiene check, but it was to the tip. And I was like, but she talked well and ate well and slept well. And so we did it for her. I did it for free. Side note, if you do it for free, it's like a rental car. Does everyone here take really good care of your rental cars? It's, it's a rental. Like, you know, do some donuts in it or something. I'm just kidding. But, anyway, it's like, no one takes like the best care because it's not yours. You're going to give it back or someone just gave you a car, like versus you're making payments on it, you're going to take better care of it. If there's some ownership. So if you do a tongue tie for free, they're not going to do the stretches as well. Charge them something, like $20, I don't care, like something they have some ownership in it. Because if you do it for free, they're not going to do stretches, right? And then they'll make it, didn't work. And then they'll tell your wife at the park, like, oh, Richard just ripped it back open because it stuck back together. True story. So all that to say, yeah, make sure, uh, there is some kind of quality of life issues, or else they're not going to do the stretch as well. They're not going to appreciate what you did for them, giving them more tongue mobility, because no one's ever come to us be like, oh, my TRMR was only 57. Like, they're coming for the symptom improvement, right? And then the other thing is tongue elevation. How high can they lift? Add that together. It's just a way to have a conversation with the parents, like in a hygiene visit, so you don't do a full hour-long tongue tie consult. Because if you do that, your hygienist will hate you. Is that right, hygienist? You got to keep it moving. It's like, we have like, doc, we have patients. We can't do a full tongue tie consult. So it says referral. It doesn't say treatment. It says referral. So come back, and then we'll do like a full evaluation, at a, at a different time with the doctor. So, uh, do not roll people over for same-day treatment for tongue ties. Roll them over for cavities. That's fine to fix a, you know, cavity, do a full crown, whatever you need to do. But like, if you roll them over for tongue tie, and especially if Dad is there, they come home from the dentist. Mom's like, what, what y'all do? And Dad's like, we get the tongue. What you did? What you get? Dad in trouble. So moms make all the healthcare decisions. So don't just do a tongue tie the same day from hygiene. Uh, but this is, uh, basically people ask, like, how many symptoms did it need for like a referral? So if it was grade four, they could barely lift their tongue up. They had an average of four symptoms. And I'm like, all right, we should at least come back for a consultation, right? Uh, conversely, if they could lift up great, but they had 10 check marks on that form, it's probably worth a referral for them too. Because for that individual, child, it's too tight. Got it. All right. So TRQ, basically, this, this study showed that babies with symptoms left untreated are more likely to have higher symptom counts as children. It does not go away. It just changes over time, right? Here's a study. Like, this is as good as you can get. Like, we checked all the hygiene patients, whether they had tongue tie or not, and we had them fill out the form. You can do that too. You can have everyone fill it out for six months. Now you got your whole practice. They've been checked for tongue tie. We're not doing that, like fishing for treatment, you know, which we're just trying to make sure we don't leave kids, you know, struggling when they don't have to be. Um, let's see here. So babies should be appropriately screened for common symptoms and treated if they're present. And then relatively high percentage of patients whose parents thought that a referral would be helpful. So after talking to them, parents are like, yeah, I want to get my kid back for a treatment. 26% of our hygiene patients, and that might even be low because we've already treated a lot of our hygiene patients if they had like an obvious tongue tie. So that's where I get the 25% number from. It's probably one in four patients. It's extremely common. They had significant quality of life issues. So, uh, here's a new one. So this is the cerebral palsy case series. We had four female patients with CP. They had various improvements in speech, feeding, sleep, breathing, and movement. So this was crazy. So children with special healthcare needs should be evaluated for possible tongue tie. So Robin and I wrote this up. Shout out to Robin, my research buddy. And they saw immediate improvements, and then even months later. This is always like, do I want to reach out and see how they're doing? I don't know. What if they're not doing better? I was like, screw it, I'll just send that. So I sent him an email, I called him. I'm like, how are y'all doing six months later? Right? They're still improving. They're still doing well. It didn't like grow back and like, it only worked for a week, right? So I have follow-up data. It's under review with the journal right now. But here's the table from the article. I'll do you one better. I'll show you the actual patients. So here's their forms. Three-year-old female with CP, trouble with transition solids, reflux, G-tube, not lateralizing the tongue. She's cleared to eat, but she can't eat. Wakes up easily. She's up for one to four hours. She's up half the night. As an infant, she had central sleep apnea. She won't crawl. Trouble holding her head up. She can kind of use her arms. She's non-verbal. Uses eye gaze. Right? Is this tongue restricted? If I saw them on a dental visit, didn't come see me for tongue tie, I probably would not to mention the tongue because otherwise I'm the crazy tongue tie guy. Right? If you meant to tell everyone that HS like that they have a tongue tie, like you're probably overtreating, right? They're, they're going to start leaving you one-star Google reviews saying, like, don't go to that office. They'll just tell your kid has a tongue tie. Right? The lip is pretty tight, and they could have trouble brushing that. But, but with my, our symptom checklist now, I know there is something going on. So we've released it for this child. Right? Look at this. A week later, easier with G sounds, eating faster, less choking, less spitting out foods, no coughing anymore, chewing on the right side now, actually swallowing now, can lateralize the tongue now. I mean, if you're a therapist, would you be happy with this in one week for your child with CP? If you're a parent, like it was, we did. We put this child to sleep? No, it was 10 seconds. Okay, maybe 15. Sitting up longer on knees, able to pull toys closer, using hands better, sat for 20 minutes on the couch without falling off. She's never done that before. Her balance is better. Isn't that crazy? All right, here's Mom. Hi, my name is Caitlyn. My daughter Caroline is 3 years old. When she was born, she had the cord wrapped on her neck twice with a true knot on the cord. She was diagnosed with HIE at five days old. At the time, she did not respond to painful stimuli. She did not suck, swallow, or have a gag reflex, and we were told that she would likely never move anything below the neck. She also would probably not be able to see or hear. At two weeks old, she got a G-tube. We have struggled with feeding since she was born. When our speech therapist recommended that we get her checked for a tongue tie, we went to Dr. Baxter in December of 2023, and he did a tongue, upper lip, and double cheek buccal release. Within the first day, we noticed that she was breathing better. She was able to sleep with her mouth closed. She started making more sounds. She has been able to make a G sound, which is new. She's completely off of her reflux meds for the first time in her life. She's eating her purees faster. We're able to brush her teeth. We're able to get all the way back to the back teeth that had cavities that had to be treated. She's able to eat for other people, not just myself or my husband. We are so grateful for Dr. Baxter and everything that he did for her in such a short time. It's only been less than two months, and we've seen a huge improvement. She's lateralizing her tongue. She's so less than two months, right? It's like, this is, it's, it's continuing on, and even six months later is still helpful. Um, so these kids with autism, Down syndrome, CP, pick any, everything is blamed on the primary diagnosis. Like, oh, well, they can't do that because they have autism. Like, they're sleeping crappy because they have autism. Like, I mean, they're slow eating because they have autism. I don't know, right? Cleft palate, Down syndrome, CP, any of those things. So you can have cleft palate and a tongue tie. In fact, many do. You can have CP and a tongue tie. You can have Down syndrome and a tongue tie. Autism and a tongue tie. So check all these kids with special needs for a tongue or lip tie. Here's a six-year-old, lots of issues. No babbling. She's screaming, frustrated with eating. G-tube, cleared to eat, can do thickened. She sleeps in the fetal position. She wakes up a few times at night still. She can kind of walk with a walker, a little bit. Mouth open. Trouble brushing the top teeth. Look at that. That's that's pretty tight. There's a nice diastema there. Look at now. This is a very restricted tongue. If you see that kind of tented appearance right there, that probably has some ectopic, like extra-aferent genioglossus inside of that. If it's really thick and like a tented appearance like that, I'll show you another video later. Uh, a week later, huge change. Faster eating, eating more, eating faster, trying new foods, less constipation, less mouth breathing, easier to brush the teeth, easier breathe through the nose. Here's a seven-year-old. If you guys remember, this was like two days before ALSC. I was like, I have to share this case. This is nuts. This is the day after those people from South Africa came. It was a crazy week. All right, can't lateralize the tongue. So basically, when she was six months old, she had Tetralogy of Fallot. She was born that way, but they had a repair at six months old. She had a massive cardiac arrest, 53 minutes with no pulse. They did CPR. They had to do surgery. She was on ECMO for a month, where they oxygenate your blood outside of your body. The surgeon said, like, say goodbye to her. There's less than 1% chance she survives this. She survived. They had another surgery. Less than 1% chance of survival. She survived that. And then what happens to her? So she has obstructive sleep apnea, but like, it's not worth treating. We're alive, so we're good. TMJ issues, tonsils, all day, I'm just trying to feed her and not throw up. She's always congested for seven years on Zyrtec. Has a G-tube. All these things, constipation, every, okay, every day, Mom has to give her suppositories for seven years. Can you imagine that? It's hard to imagine what these parents go through. Here's the lip and tongue. We did her cheeks too for fun. No, not really. We did them for fascial release because her face was so tight. The CP, they have lots of like contractions. And so look at her tongue though. It was pretty tight. So these kids, if she was typically developing, would she have issues with that tongue? Maybe not. But if her brain is not working 100%, then maybe that is too tight for her as an individual. Does that make sense? So here's, they came from Ohio. Here's Mom's story. Hi, my name is Katie Robinson. This is my daughter Elizabeth Robinson. We were just in today to see Dr. Baxter. The same day, it's January 31st. And, uh, my daughter was born, and at six months, had a massive cardiac arrest. And as a result, HIE, CP, all the labels came up. Followed. She since then, after six months, has been suffering with severe reflux, constipation, this snorkeling, like, like she sounds like she has a cold all the time on Zyrtec since for seven years. She's seven now. And, uh, we've done all sorts of therapies. Flew down to Orlando. A therapist quickly identified she had multiple ties. And it's a, a feeding therapist. And she goes, she will do so well releasing this. Flew in from Orlando this morning to see Dr. Baxter in Alabama. He released the upper lip, the side cheeks, the tongue. And literally, when we were in the car, she was breathing again. Not snorkeling, breathing, breathing comfortably. Coincidence? Her face looks so relaxed. She pooped, which is amazing because we've been on planes and trains and automobiles, and that would not happen. I mean, just the start of, I could see success. I am so, so grateful. Where we've been bumping into walls, we can see hope. And, um, praise God. Thank you, Dr. Baxter. And we will look forward to all the gains. Thank you. Awesome. Praise the Lord. All right, so look at this. She wrote this letter a couple days later. This is almost exactly a year ago. So thank you both for your God-given wisdom, care, expertise. So Nancy with New Jersey Pediatric Feeding, some of you guys know her. Say he's feeding intensive. But thank you both, your God-given wisdom, care, expertise. My life has changed in two days because of you both. Seven years I've been told lies. As of today, 2/1/24, I can breathe. I can eat. I can drink. I do not throw up. I can poop. My hips are loose. I do not need to take medication for quote allergies because I don't have them. I don't have to take suppositories. I poop. The list goes on. Bless you both and your families and everyone that works with you, all those you help. I showed this to Serou. Okay, okay, awesome. I showed this to Serou. She's like, she wrote all that. Said, no, Mom wrote that. It was, it was funny. He's going to kill me. All right. Part two, assessment. Again, we saw this already. Get to thriving. That's our goal. Paradigm shift. So we really need to take this old paradigm. This is what's done. Still like 90% of the time. Most pediatricians, ENTs, neonatologists at the hospital. Hey, Mom. And sorry, this works really well for like a toothache, right? Works really well for a toothache. Hey, Mom, what's going on today? Johnny's got a hot tooth. We got pain. It's waking him up. Okay, is it sensitive to hot and cold? Let me take a look. We'll take an X-ray. Maybe put a glove on, like get the mirror, look in there. All right, it's bombed out. We'll take the tooth out. There's nothing to do afterward. Like, bite on gauze. Don't suck on straws. Hopefully, they're not smoking. Our patients, anyway. So like, you're going to get good results. The toothache, right? For tongue tie, does not work so well. Hey, Mom, what's going on today? Having some trouble breastfeeding. Is it hurt when you nurse? Yes. They trouble gaining weight? No. But, and they're like, okay, bye. If so, if it's causing a problem with weight gain, they'll treat it. They'll take a peek in there, like a tongue depressor, maybe a finger. Cut. They'll do a snipper, a clip. No consent form. Just right there. Just like snipper clip. You guys know what I'm talking about. Minimal to no stretches. They're not needed. Follow up as needed. Like, just call us if you need anything. Anything. Surgeon only, maybe lactation consultant, like maybe a speech therapist if they're older. If you add all that up, guess what you get? Minimal results. It'll help a little bit. Let's throw that away. New paradigm. A comprehensive history, a 50-item questionnaire, a full exam, a full release, nice diamond shape, like you've been seeing all weekend. Stretches three times a day for babies, two times a day for 12 months and up for four weeks, about a month. Follow-up mandated. What if they're six hours away? What if they're in Orlando? Or, you know, wherever the people from South Africa. They actually did come back at week. Um, but they were not from South Africa. They just went to Disney for a couple days. But anyway, team approach. So the follow-up, they can do email follow-up. Our preference is in person. So if there's any way to get them back in person, a specialist, you're getting started. That's better. Team approach. Work with everyone. The bodywork, I don't have time to list out. If you're in this room, you're part of the team. The orthodontist, the pediatrician, the ENT, right? The sleep physician, the myofunctional therapist, lactation consultant, chiropractor. So working the team approach, you will likely get, it's not a guarantee, you will likely get impressive results. Uh, so always work with a team approach. All proper diagnoses start with a proper history. So misdiagnosis comes from either not listening or not examining fully. So most of the time, people interrupt the mom. So just don't do that. Just let them tell their story. Sometimes it's 20 minutes, often it's like five minutes. So let them tell their story. Empathize with them. All my girls had it. I had it. So I can empathize with them. Review all the symptoms systematically, one by one. Examine proper with gloves and like a mouth prop, if you need it. Symptoms and function are more important than the appearance. So it doesn't matter what it looks like as much as what symptoms they have. Image all areas of concern. No picture, not going to do the procedure. Because when they come after you, or insurance denies it, or something, you need a picture. Or they leave you a one-star Google review, which doesn't happen very often, but like, it, you want to have a picture to back up what you're doing. Uh, release fully and precisely if indicated. Or if you're a therapist, or you're not going to do it, or you don't want to do it, refer to a knowledgeable provider, right? So if they have like Pierre Robin sequence, refer them. Do not do that. Send them to the children's hospital. They can take care of it. High-quality stretches are critical. We demonstrate to the parents. We have them put on gloves and practice too. Follow up at one week minimum, or more often. So this was, uh, after I had a debate with Dr. Zi. We were on the same team. And Dr. Walsh, Jonathan Walsh, who is, uh, Mr. Dr. Anti-Tongue Tie from Johns Hopkins. He was the second author. No, no relation to Robin. She wants to make that clear. She's not related to Jonathan Walsh, even in the same area. But maybe a third cousin. Robin, I'm just kidding. I'm just kidding. He's actually a nice guy. I had lunch and dinner with him. And so afterward, I, we had this debate. If is anyone there in Michigan for that? Yeah, it was interesting. It was good. It was a good time. A couple years ago. But he's like, Richard, like, what you're doing, like, there's no like way for them to like understand like what you're like, how that works. I'm like, well, it does work. Like, should I stop treating tongue ties? Or should I keep doing it? Like, we're doing this method. He's like, well, clearly keep doing it if it's working. All right. So have your blessing, Dr. Anti-Tongue Tie, to keep doing it. So here's like the best way to describe what we're doing. So many kids, we're not just cutting a tongue tie. So releasing the restricted tongue gives extra mobility. Sometimes it's just 10% restricted and needs a little bit more for them. Normal function yields symptomatic improvement. Speech, feeding, sleeping, posture, breathing, dental development. So basically, for whatever reason, a symptomatic patient has limited tongue mobility on an individualized basis. So another patient could have the same degree of restriction, have no issues. Or those kids with CP, they couldn't compensate their way out of it. So the limited mobility, though, is variable, and symptoms are unique to each individual. Okay, here's a one-year-old. Oh, I don't know, 16-month-old. This is Dr. Trio did this one. So people say like, oh, one guy in our, fairly close to us, attended a one-hour lecture I gave at the dental school and then tells people that I trained him. It's like, please don't do that. So the only person I've actually trained is Dr. Trio, our associate there. It took me three months to train her to do it. Like, okay, she would do it on my baby, right? So no issues with speech issues, right here. Trouble transitioning solid food, spitting out foods, constipation, tripod sleeping, mouth open, snoring, trouble brushing the top teeth, and had a gap. So here's one she did. So that's pretty good. That's not bad. And then look at the tongue lifts up much higher afterward. Afterward, eight days later, easier to eat, eating faster, more food, sorry, more food, trying new foods, less spitting out foods, easier to brush, sleeping flat now, sleeping deeper. There's like nothing there. You see this one? It's barely restricted. There's not much there. And talking more, even. Okay, this is eight days later. This happened in September. Here she is. Hey there. This is Dr. Trio. We're here.

With our patient of the week, this is Amelia. Um, so we saw her last week, and she's had some great improvements. Yeah, she had difficulty, um, eating, sleeping with her bottom in the air, snoring a lot. And literally overnight, she is eating more foods, trying new things, and sleeping so much better. Awesome. I'll show the pictures.

All right, so proper examination technique. Come from behind. This is a pediatric dentist from Germany. She translated "Zungenband" for us. Um, I say that right? Well, yeah, Zungenband. Okay. And her son, she didn't realize, had almost to the tip tongue tie. They don't teach us in dental school worldwide. It's a worldwide problem, right? Look at that. But I use this because this is the tooth chair. You can get on eBay. MT Mouth Prop, 3.5 inch.

Here's our exam form. It's Marty Kaplan had the original version of this form. I added some stuff on there. Added buckle ties on there. Added functional grading, compensation, and palate things on the form. Here's a baby. It's kind of loud. I don't have time for that one. But, uh, this is milk tongue. This is thrush. What's interesting is you can still like wipe the thrush off, uh, often. So look at this baby. Came in like this. This is the same day. I just wiped it with a 2x2 and like, we kind of debulked it a little bit. Now, they still need some obviously some Nystatin or Gentian violet or something. But, uh, that's a lot better. It's better to debulk it a little bit. Um, so anyway, they had lots of issues. Came to see us. They, they were taking Nystatin, but it still looked like that. So I just wiped it off. I just thought that was cool. I was like, "Oh, look, this looks a lot better. Let me take a picture."

Uh, so here's the lip and tongue release afterward. Look how tight that tongue was. And they did better. Less spitting up, less gassy, fewer hiccups. So this is like, you know, at one week. Um, often, well, sometimes the angels are saying it's perfect. Often it's like, "Eh, some's better, some things maybe worse, something's the same." And then like, maybe 10, 20% of the time, I like, "Eh, not that much is better." That's not common, but it does happen. So just reassure them. Make sure they've seen lactation. Make sure they've done some body work. Make sure they're doing the stretches right. If they haven't done those things, like, that's going to delay your progress. They're not going to get better faster. Um, it's a spectrum of lip restriction. This is like the tightest we've ever seen. This is minimal. Don't treat that. Even this one might be fine. It's not blanching. Depends on what symptoms there are, right? Tongue restriction. This is very tight, thick. And so the pH say, "Okay, that's this is mild." I just wrote a blog post. It's called "Respectfully, Your Scale Needs Calibrated." Why to the tip tongue tie is not mild. Um, it's on our blog. Uh, but anyway, um, and if I try to get that published, it would, no one ever published that. So I publish it myself. And it shows up at the top of Google. So I don't even need them, right? It's like alternative media now, you know? Joe Rogan and Sean Ryan showing stuff.

All right, so this one's like, this is not a tongue tie, according to most pediatricians. This is not a tongue tie. This is not a tongue tie. These ones are clipped. So those ones are treated. Those are fine. No, look how restricted those are, right? So the two to the tip ones are called mild. Not to rag on the pediatricians. I know there's several in the room. But this is like true, like the unenlightened pediatricians. They'd say these are not tongue ties. And this one's mild. Uh, but even these ones, even this one's barely there. We treated that one. They still got better. That's like, it's crazy sometimes. It's like, "There's no way they're going to help." And Mom's like, "Please, if there's a 2% chance that's helping, I want to try it." I'm like, "All right, it's minimal risk." Uh, so we did it, and they got better.

This is the same patient, uh, just more tension. So if you pull up on it and check it the right way, you'll see that's how you see the restriction. If you just peek in there with a tongue depressor, you're not going to see it. Uh, this is a child on hygiene visit. Again, not obvious right here. O.N.P. Well, O was, uh, geminated. But so, okay, teeth are turning inward. That's normal. But what's pulling them inward, right? But this child had no symptoms. So I say, "Here's what you say." Ready? On a hygiene visit, "Hey Mom, does Johnny have any speech, eating, or sleeping concerns?" And they're like, "Nope." "All right, well, no cavity. See you in six months." Now, sometimes if I really want to like be a little bit nosier, I'll be like, "Okay, so sleep concerns would be like tossing and turning, mouth breathing, grinding teeth." "Oh, yeah, he does do that." So sometimes they don't even know those are not abnormal, right? So you have to sometimes be like, "Okay, like speech would be like speech delay, like clarity issues, slow eating, picky eating." "Yeah, he's like always been the pickiest eater. He takes an hour to eat a hamburger." "Like, okay, well, that come back and see us for a full consultation." But this child didn't. So we did nothing to do.

Seven-month-old, 11 pounds, lots of issues here. 0.2 percentile for weight. Okay. Did y'all, sorry, I said that too fast. A seven-month-old weighing 11 pounds. They called me on my personal cell phone on Thanksgiving morning. We're like watching the parade. And I was like, "How did you get this number?" You know, like they said the other day, like, "How she called and pressed like for the emergency line?" I'm like, "She must be desperate." Um, so they came in from Memphis to see us. Look at this to the tip. They couldn't find anyone to help them for seven months. They're going to give this baby a G-tube. Like, what? Treat the problem. Right? Treat it. They got better. Uh, so imagine if your child had the shoelaces tied together and they're like, "You don't know what's wrong with Johnny. Here's a wheelchair." No, like treat the problem. Untie the shoelaces. I asked Grok, the AI, to do that for me. That's cool.

We recently had a baby that had a to the tip tongue tie. The parents were told there was nothing wrong with their baby. They just couldn't eat very well. Meanwhile, seven months later, they only weigh 11 pounds and are still struggling. So they had to come see us from four hours away. We quickly identified they had a pretty significant lip tie and also a to the tip tongue tie that they were not told about. And they were about to do a feeding tube on this baby because of their failure to thrive and not gaining weight. Meanwhile, to the tip tongue tie, it's like if someone tied their shoelaces together and they said, "I don't know why you can't walk. Here's a wheelchair." Right? Just like, "Take, take this wheelchair because your kid can't walk." No, untie the shoelaces. So we fixed it. And guess what? They're feeding better.

We've had tons of babies this week, even and last week, that had to the tip tongue ties. They were told they're mild, they'll stretch out, they'll go away, they won't cause problems. All those are not true. So if your baby has a to the tip tongue tie or close to it, that is not mild, it's severe, it's significant. You need to get a second opinion by someone who knows what they're talking about. With fant tongue top, there we go. I was like, I can spend a lot this time doing an article, or I could just put on Instagram and then people will watch it and we'll get way more. Because if you write an article, maybe a thousand people read it. 20,000 people saw that reel. If I was Dr. Eric with 180,000 followers, we'd get more. But sorry, buddy. Follow, follow Dr. Eric, Pediatra. It's all in Spanish, but it's good.

All right, buckle ties. We talked about this already. No charge. Don't charge for buckle ties. Like minimal risk, possible benefit. Downplay it because there is, there's no like good evidence on it. Like I wrote the article, and I'm telling you, there's not good evidence on it. It was a survey, and we're not going to have any evidence on it because you can't do a randomized control trial on buckle ties. He said it's like the easiest study to do. It's not the easiest study to do.

All right, max or lip tie. When to do it? For those reasons: labial issues, BPM, and W trouble, nasal breathing, poor oral hygiene, they fight with brushing. That's one of the most common reasons we do it. They can't keep the teeth clean. Uh, diastema. Uh, before the primary canines are up, 18 months. When the, uh, we'll take a break in just a few minutes. I know it's getting close. Uh, when permanent central incisors erupt, when causing a problem, it's shared decision-making. Everything in dentistry, like when you do SDF or a Hall crown or leave it or just diet and hygiene, it's all shared decision-making, right? We're not just going to like tell them like, "This is your treatment. You need to go to the hospital."

So, eight-year-old. This one's cute. Slow eater, constipation issues as a baby, but they just change over time, right? They didn't go away. Sleeps restlessly, mouth open. And then gap between her teeth and trouble breathing through her nose. So this, that's pretty tight, right? Look at this tongue. Lifts like halfway. But look how much. Which one's going to talk better? And then, then when you release this fascia, it's like a cuddle maneuver. It feels like you have some Afrin or like a Breathe Right strip on. It's remarkable. I'd like to do a study on. Probably would get. We had a tongue tie and a lip tie release done seven days ago. Uh, she had a lot of difficulty with sleeping, very restless. Was sleeping with her mouth open, wide open, head thrown back. Having a little bit of issues with eating slowly. And ever since we had things released, she says that her stuffy nose cleared up immediately. She can breathe a lot better. She's sleeping with her mouth closed now. There's not so much mouth breathing during the day. And she even said that she can move better. And has said really good results. Very little bit of pain, just immediately after the procedure, but really nonsense doing wonderful.

What do you think? Well, I think that I, that it's so hard to explain, but I can do everything a whole lot better. I, I can turn my head like this, and I can do this, and I can do this, and I can do this, and I can even do this. Lift your tongue up now. Perfect. Good. And then what else did you notice when you left the office? What did you say about your nose? I can breathe through my nose. Like the second guy in the car. I think it was. It, it was like the best relief ever. That's amazing. Thank you so much. So this is a case series. There's no evidence.

All right, well, here's like five patients. They can breathe through the nose. Boom. Case series. Like it's not my opinion. I would not have guessed that. Like constipation. I'm like, "What?" And then after like 10 people told me, I was like, "Okay, well, I put on the list." And like people would check it their initial visit and check it at the follow-up that it got better. So symptoms and function more important than appearance. Elevation more important than protrusion. I got to hurry up. A lot of you guys know this already, but like lip tie is this lip tie. But notice this distributed spacing. We left that alone. There's no reason to treat that. We treated the tongue because they had symptoms. Oh, here's the symptoms they had. They had like tongue symptoms. But down here, this is the lip tie symptoms. And they didn't have anything down there. Oh, just let it fall down and rip it. This is what happens when they fall and rip it. It's not like that much. Although I did see one patient. Did a really good job. It was a bike trauma. Fell and de-gloved the gingiva. How's that melon? That's a pero is right there. But it actually healed nicely. So look at that. And then I used to think it was impossible to fall and rip your tongue tie. Anyone else seen someone fall and rip their tongue tie? It's very difficult. The way you do it is they have to have like, walking around with a plastic baseball bat in their mouth like this that's cut off and fall and rip the lip tie that way or the tie that way. Had a nice diamond under there. I was, it was remarkable. But yeah, I would not advocate that.

Uh, they say wait till after orthodontics to prevent scar tissue. But nothing in this, this is the article that's cited for that, right? Nothing in the article even mentions scar tissue. It's not based on science. It's only in the opinion. But he's a famous orthodontist. So that was published. American Journal of Orthodontics. Seems preferable. So no data to close the space is orthodontically as early as possible, then perform the surgical procedure, the frenectomy. Reason for such sequence to allow the healing of tissues to occur. I agree with that. If they're in braces like already, that's fine. Like you can close it and then do the procedure. I don't have anything with that. But look at this later in the article. Remember, this is like the article saying don't do it because of scar tissue. Watch this. "To avoid retreatment of many cases with all the associated discomfort, both the patient and orthodontist, every effort should be made to diagnose properly, remove the cause of the diastema, or to avoid its occurrence whenever it is predictable and possible." I'm here to tell you, it's predictable and possible to remove the cause. Right? C.L. 2004. I was finishing high school. Optimal time is between 8 and 18 months of age. The greatest chance for spontaneous closure. That holds up. I see that. Does everyone else see that too? Do it before 18 months, before the primary canines come in. That closes up. Optimal time if it's not done then is when the central and incisor is erupting. It's like seven, eight years old or so. Uh, there's a diastema systematic review. Max frenulum is highly associated with midline diastema wider than 2 millimeters rarely closes spontaneously. We have an article from 2022. Uh, basically had 200 patients. 109 we got them follow up. We got pictures. And so we were to use our X-ray software to measure before and afterward. You can standardize it based on the width of a central incisor. Half width CO2, half width diode. 13 permanent teeth, 96 with primary teeth. Published in International Orthodontics. That's the European Orthodontic Society's journal.

Look at this. So this one's with diode. Look how thick that is. This is the diode laser. That's what it looks like afterward. It's still healed very nicely. But you really have to get this tissue right here, or else it doesn't close up as well as often. Even in babies, make sure to get this tissue in babies so they don't get a gap later. And then, uh, look at that. It's like, that's nice healing. That's probably like one year later. And that's probably two years later. Here's another one with CO2 laser. This is a light scalpel. See, it looks cleaner. Uh, it's much quicker. And then it closed up. No braces. Here's the article. It was the most downloaded article for the last two years in this journal. People like, they do want this information. But, uh, here's a bunch more cases. It closes up like almost always. So the study, as Gary correctly showed, does not cause scar tissue, right? It's like if you say like, "All swans are white," and then I find a black swan, well, then like I've negated your hypothesis. So it does not cause scar tissue. So it's safe to do. But to say it closes up, we'd have to have like a prospective randomized control trial. But like, this is the next best thing. And I'm not doing that. So I don't have time for that. Look at this. No need for braces here. Saved him $6,000. There's still kind of narrow, but it's okay. This one was done in March of 2016. This is right after diode laser. September of 2016. Is there scar tissue there? Ah, the scar tissue. It didn't close. And then 2023, 7-year follow-up. Was pretty good to me. That's a lot better than this picture.

Not just tongue tie. So often we lecture together. Zagy will go first. Might say he R pills. Some already. So, tongue tie. This lecture. But there's also tongue tone. So M functional exercises, like the resting posture. And then tongue space. You have to have enough room for the tongue, otherwise it falls back and chokes you there. So max mandibular expansion or uprighting, if you want to be technical, in the mandible because there's no suture to expand. Um, and also it's not just tongue lip ties. There's tongue space and airway volume. Retain primitive reflexes. Jenna's in the room. I think somewhere. I heard about this from Jenna. And Phoenix. Quality sleep. Screen time. Like the average screen time for kids, like five or seven hours. There's something unbelievable. Like, is that even possible? I think it's 7 hours average screen time for a child. It's like, that's not possible. Exercise. If our girls were getting antsy, like my wife will make them go run the hill. They're on a cross country team. Like, don't call Child Protective Services. Um, and we live across the street from a track. So they'll go run the track. They like it, though. But they like, they feel better. Like, "I need to run." So if it's cold, they run on the treadmill. Like, they love it. But eating healthy, chiropractic, body work, outdoor play. We were grounding this morning outside on the sand. Cold plunge after doing the Peloton. So like, just takes the whole picture to get to thriving families, right? So if you just fix their tongue tie, like that's not going to fix like drinking Mountain Dew and eating Cheetos all day and like on Coco Melon for four hours a day. Like, they're still going to have issues, right?

Uh, the palate for the nasal cavity. So the wider palate, increased airflow. It's to the fourth power. Poiseuille's law. Those people are going to have issues on the left. These people are going to breathe better. You can see the low tongue posture, deviated septum, inferior turbinate hypertrophy, all kinds of issues. But look where the tongue is in all these CTs. If they have a midline defect, extra level suspicion for tongue tie. Uh, so here's the one from yesterday that I talked about. AHI was 70 in a baby. That's high. That's severe sleep apnea. G-tube. They had a jaw distraction. Level two palate. They have all these issues. They came to see us for a tongue tie. "Please fix this tongue tie." Oh, Pierre Robin sequence. Sorry. Look at this, though. The lip is actually not bad. Like, that's fine. That's probably fine. But look at his tongue. The tongue is restricted. Do y'all see that? It's very restricted. Where's it going to go? Like, there's nowhere for to suction cup up. It's going to fall back in the airway. It's going to make their problem worse. Even though he had a jaw distraction already, the palate's not fixed. I said, "If the palate is totally fixed, maybe I said, just like have them do it at the hospital." Like, I value my dental license. I don't want to have any issues.

Here's the infant symptom sheet. You guys have seen this before. Cot Llo created the initial version of it. I changed it a little bit. So these are more tongue tie issues. These are more lip tie issues. It's not perfect. But in general, the seal issues or like buckle tie issues, lip tie down here. These are Mom's issues. Check how Mom's doing mentally, emotionally. Seven out of 10 pain. If it's high pain, what is it? Most likely a less obvious tongue tie. So what happens? These babies, they have colic. They're given Gripe Water. They have reflux. They're given Zantac. Oh, sorry, Zantac causes cancer. Let's do Pepcid instead. And then, "Oh, that's not working. Here's Sium." They're gassy. Here's that didn't work. That's a bad arrow. All right, there's gas. See? Here's some gas drops. Right? It hurts. If there's a nipple shield, it really hurts. Here's a bottle. What have you done? A family pack of Band-Aids instead of what's the root cause? Not always, but often a lip tongue tie.

Child symptom sheet. You've seen this a bunch already. If they're over 12 months, adult symptom sheet. If their teenagers are up. Uh, it talks about kissing on there. So like, I don't do it to the teenagers. Like 18 and up, maybe. Yeah, sometimes if the teenager's on the fence, I'm like, "You're about to kiss your wife better one day." Trying to. I don't say girlfriend, but anyway. Uh, so screening tool. We talked about this already.

Here's an opera singer we saw. I was going too slow, so I'm going a little bit faster now. Sorry. Here's an opera singer we saw, uh, that had a lot of issues and issues with singing. We've done several opera singers now. Her tongue doesn't look that bad, but if that's your instrument, that's important, right? If you hold down the floor of the mouth, look at her true mobility. That's very restricted. Uh, here's afterward, and there's some sutures. So we, we do suture adults, teens, kids. If they're asleep, singing better, singing is easier, less moving at night, awe is easier, less neck tension, posture's improved. TRQ. We talked about that. Someone said, like, "Just make it easy." Here we go. Easy symptoms and appearance, right? Okay. If it's obvious, like to the tip, and they have lots of symptoms, that's a slam dunk. Like, you're going to get something. They're going to be happy afterward, even with the terrible stretches, right? Also, if it's obvious, like to the tip, and there's a few symptoms, right? That's also worth treating. That's low-hanging fruit. Our poor peach tree. There's a moth called a peach tree borer that I didn't know existed, and it bored into our peach tree and destroyed it from the inside out. That's terrible.

All right, also, if it's minimal, just a little bit tight, a little bit restricted, and lots of symptoms. This one's the one that tricks people up. They're like, "Oh, there's not that much there. Just do it anyway, right? Treat it anyway." And they'll likely have a lot of improvements. The only time you're really waiting is like, just a little bit there, and there's just a few symptoms. Here's one. There. Would you say that's a tongue tie? If I saw this patient on a hygiene, I would never say that's a tongue tie. But they came to see us. Packing food, spitting out food, sleeps in weird positions, trouble with top teeth. So we did the lip. I'm like, "Mom, if you're doing the lip, and you're doing the stretches for the lip anyway, might as well do the tongue." Uh, no, we didn't do the tongue on that one. I don't even know. Sorry. Go back. Go back. So, okay, this one's not that bad. So we didn't treat that one. If they had like 20 check marks, I would have treated that one. So we're, they haven't done it yet, but we're just going to do the lip on them. Got it. So this is when we did not treat the tongue on 'cause it's minimal and like minimal symptoms. It's like, but if they had like terrible speech and terrible eating and terrible sleeping, then I would treat that tongue. If they had like 25 check marks. Got it.

All right, 2-year-old. Here's another one. They came to see us for cheek tie releases. Cheeks are pretty tight. The tongue is tight. So if you're going to do one in this child, you're going to do the tongue. But look at their symptoms. Grinding teeth sometimes. And they got a gap. That's like a quarter of a millimeter gap. I'm not going to treat it for that. That's going to close up on its own, right? That's like, that's not a reason to do it. The lip is fine. The cheeks are tight. I wrote the article on cheek ties. I acknowledge their existence, but I'm not going to do that on a 2-year-old because what symptoms am I going to improve? There's like maybe some fascial tension, but like that's not even their chief complaint. But they were referred to us for cheek tie release. If you're going to do anything else, this child would be the tongue. But there's no speech, eating, sleeping issues. So what are we going to do? We're going to wait. We're not going to treat it right then. So we don't just L everything. And there we are, Grand Rapids, after it snowed half a foot. That's Tom, my father-in-law. The mind can only absorb what the ass can endure. So we're going to take a break.

All right, so a lot of the questions we're actually going to get into in part two. So that was just the appetizer. Here's part two. We'll go till 12. We got an hour and five minutes. Just 100 slides. It's okay. All right, so here's our team. There's Dr. Trio. I said, "Please don't say like I trained you to do this. Like, don't just laser a baby just after like this conference. Like, get additional training." Technique sensitive, though. So if you don't do it right, it won't work right. So if you do a composite filling, it's like prep, rinse, dry, etch, rinse, dry, not too much, bond, air dry, not too much, cure, fill, cure, polish. Like, there's a lot of steps to do like a simple like dental filling, right? And your restoration will not work or as well if it's done out of order or if you skip steps or if you don't do it right. Does that make sense? With tongue tie, it's history, your assessment, or exam, diagnosis, treatment, aftercare, follow-up. Tongue tie treatment will not work as well if it's done out of order or if you skip steps. So it's really, it's silly to say, "Oh, I'm doing a filling. Like it doesn't work if you do it wrong." And it's silly to say, "Treating tongue ties don't work if you do it incompletely or incorrectly."

So five keys for a proper release. This is taken out of Tongue Tie Academy. Anesthesia, precision, she cut in the right place, tension, look and feel for fascia, and then size and shape. So you want to make sure they're comfortable. We're not trying to like, uh, damage anyone's psyche. We're not trying to traumatize these kids. So that's why we don't put them to sleep. But we do it in a way that doesn't traumatize them. We have a TV in the ceiling. You'll see in just a second. But we also want to cause the least amount of pain. So scissors versus cautery versus diode versus CO2 laser. We want a controlled, efficient cutting. So I would say 10, 15 seconds or less. If it's taking you a minute, that's way too long. Especially I'm a screaming baby. That feels like an eternity. A minute. That's a long time. Strong topical versus injected lidocaine. And I'm always changing it. So we use like 2% viscous lidocaine. Under 12 months, after hearing Gary talk about it, like I'm going to have our compounding pharmacy find a good one. I'm going to have them mix up some 3% lidocaine, 3% tetracaine. We'll try that out. Like a thick paste is what you recommend? Like, um, like petroleum jelly, right? But then for over 12 months, or if it's like a huge, like 11-month-old, uh, we'll do 10% lidocaine, 10% prilocaine, 4% tetracaine. And we've been have had some phenylephrine in there too, so it stays. And you can tell 'cause it blanches the tissue with the phenylephrine. But they, well, some three-year-olds don't even, doesn't, they don't feel anything on the lip. They'll still often feel the tongue because the saliva washes it away pretty quickly. But a lot of three-year-olds, they just sit there and don't even move for the lip tie. So like, we know the jelly works. The strong jelly, the less strong jelly for the little babies. Like, they're going to cry. I'm pulling up really tight on it with tension. Like, they're going to feel that, and they're going to cry. So if they're over four years old, a cooperative five-year-old, we'll consider adding some 2% lidocaine with epinephrine. I always say injected lidocaine instead of shot because if you say shot, you know what happens? You don't let them see it. If you're a pediatric dentist, you know how to do that. Well, don't like come up with a shot like that over their eyes. You're not going to get any treatment done.

Precision. Not too high. So this one was cut into the body of the tongue. This one was cut, I don't even know where, but they said it was cut as a baby. Now they have braces on. And there's, so a very tight tongue tie. This one was clipped by a, a pediatric ENT, a great guy. We've referred to him for tonsils and adenoids, just not tongue ties. And it's St. About. I don't even see where they cut on the tongue, but it was done previously. And just that little snip right there. That's not enough, right? You got to get a full release, like a teardrop shape typically. And that diamond release on bottom. Here's another one. Uh, lit pretty tight. This one, they cut into the salivary duct, actually. This patient came back to see us on hygiene visit, like a week or two ago. Oh, your fa Miss. I show your picture in, uh, lectures. So we have to come up here and then come down to release that because you're always trying to come between the Wharton's ducts and like the body of the tongue.

All right, let me see here. Too many animations. All right, all these have been previously clipped before. So this one, very tight, still restricted, very restricted here. Uh, look at this lip tie, not addressed. Very tight, still very restricted. It does not stretch out or go away. Here's a 36-year-old, clipped as a baby. Look at the difference now. I would have sutured that up. That's from like 2016, 2017. That's a long time ago. I would have sutured that today. Um, and probably done myo. I just like, "Bro, hop in the chair." We just released it. So like, we've come a long way, you know? Uh, we're always getting better. So if you're not getting better, you're going backward. And then look at this huge lip tie. And then very, uh, messed up, mangled Wharton's ducts. They cut directly into the ducts. You'll see that one on the bottom right. So the child survived. That's a joke. People think like it's, they're not going to die if you cut the ducts. Uh, but like, it's not ideal. And it can cause issues. They might have to like re-superiorization or something. Um, and so you had to come from up here above it and then come down. So it was pretty tricky. But this child, we saw in the back years later, recently. One of the neonatologists in our area has started cutting near the ridge. This huge gaping hole. I don't know why it is. I think, uh, took a course or something. I don't know where this came from. They did a little cut here. And this huge cut. It doesn't heal well. The babies don't eat afterward. We've seen it multiple times.

Here's another one from just a few days ago. This is again from from December of '24. Again, they cut down here and here. If you do that, so we've released it here. But now when you stretch it, it only wants to open up in the base of the Eiffel Tower. You want the spire of the Eiffel Tower, the tower part to open. When you see this picture, you see it's tight. You see the nostrils. Afterward, flips up easily. Like, no problem. Up over the nostrils. And they're doing better afterward.

Here's a two-month-old female. Lots of issues. Spitting up almost every feeding. Nose is congested. Nine out of 10 pain. Look at this one. That's very tight. So less obvious tongue tie, right? Oh, let's cut right here. No. Do not cut the base of the Eiffel Tower. Only cut. Ah, so the lip is very tight too, obviously. So we release that. But cut right here. That's all you need to do, right? Like halfway between like where it inserts into the tongue and the Wharton's ducts. Okay. Do not cut down here. Look how high this lifts. And look where did that tension go? It disappeared. Okay. So you do not have to cut into the base of the Eiffel Tower. If you do that, they will not do the stretches right. It won't heal nicely.

Anatomy. Avoid the lingual nerve. Avoid the deep lingual vein. Avoid the deep lingual artery. That's always a good option. Here's the deep lingual nerve. This is fascia, the connective tissue, all that clear stuff. And then the white ribbon right here. That's the lingual nerve. Okay. There's a deep lingual vein. It's deep to here. Can't see the artery most of the time, thankfully. Here's another one. This is deep lingual vein right here. And it's on both sides. That's why you don't take it too wide, or else you hit that. Uh, it can cause, it can make a mess. If you hold good pressure on it, I'll show you in just a second. But, um, hold good pressure.

Here's tension. This is a four-week-old baby. Lots of tension. This is the 3-second tongue tie release. So the lip, we'll do first. It's about 15 seconds or so. Kind of hover around. Keep a tight tip to tissue distance, about 2 millimeters. Slow hand speed. The slower you move it, the faster it will release the tissue. I don't need an aiming beam because I want to see what's happening with the tissue. If I have a bright green aiming beam, no offense, then like, you can't see what's like, you might hit something you don't want to hit, especially under the tongue, 'cause you're a centimeter away with other other lasers. It's like, you know, another CO2 laser that has an aiming beam. So lots and lots of tension. Pull it up really tight. And then it's literally 3 seconds. Right in the middle, just horizontal passes. You get that diamond shape to open up. We're not taking muscle, just exposing it. The genio-glossus. And that's it. And the baby ate better.

Okay, here's another one. So lots of tension on the lip. Start low. Get all the way down, or else they could have a gap later on. It's still possible to have a gap, but it's less likely. It's like, you know, their speech can be perfect. I don't know. Like, it's less likely if they have more mobility of their tongue. More likely to have good speech, eating, sleeping. But never guarantee it, or they will come back to you and say, "You promised my kid's not going to have speech issues."

So sometimes you get a little bit of bleeding. If you linger too long on, you hit the periosteum on the lip. Just dab it off. That one's going to stop on its own. You can defocus a little bit. So scoot back and try to get it to stop a little bit. But that's, that's not a concern. Just let it go. It'll stop in a few minutes. Under the tongue. Lift up all the way. Lots of tension. The assistant holding the chin down. That's important, otherwise they'll try to bite you. So if you can't figure out why you can't do it, hold the chin down. If they're six months though and very strong, put a mouth prop in there. They don't have to have teeth to use a mouth prop. So these seven-month-olds, they're like, like very strong. Put a mouth prop in. And then now you can, uh, you're not fighting that to get the, um, the tongue released. I used to think like, "Oh, they have to have teeth to use it." But you can use on the gums here.

Here's a two-week-old male. Lots of symptoms. Seven out of 10 pain. Oh, it's to the tip. So occasionally you see ones that are to the tip have a lot of pain like that. Uh, they got better. Here's that video. Kind of circle around. Lots of tension. Uh, move a little slower. Probably that's a little bit fast. This one's a few years old. And then you don't need to go like really wide. You're not trying to do a vestibuloplasty here. Just like release the tissue. Should be like a teardrop shape. Look how tight that was though. Mom and dad are both physicians. Very nice people. But like, my, my kid's tongue is to the tip. And so you can get a little bit of that tissue there. You're not going to get much functional benefit from that, but just like a cosmetic benefit. And then that little piece that's on the ridge will get just that little bit, but not go down into like the base of the tower. Got it. Okay. There we go. It's very quick and easy.

Two-month-old male. This is the very next patient after that one. This always makes me sad. Uh, it's difficult to bottle feed. So are you presently breastfeeding? Yes. Oh, no, sorry. No, they stopped. How long since you stopped? A month and a half. They tried for a couple weeks. It was painful. It was not working. The baby wasn't gaining weight, wasn't transferring well. They have all these symptoms. Short sleeping, colic, reflux, gassy. Switching to a bottle does not magically solve the problem. They still had issues. They still had to come see us. If it was identified sooner, do you think this one should have been identified at the hospital or within the first two weeks when Mom was still trying to breastfeed? I think so. I mean, that's like, that's pretty obvious. Like, it's hard to justify like how they can miss that one. A lot of these though, I'm like, "Okay, I can see how they missed that. It's just a little bit there." But that's pretty tight to me. Uh, afterward, much better. They gained 10 ounces and a, let's see here. No, this one's like almost a pound. So 14 ounces in a week. Less falling asleep, less reflux, less clicking, less hiccups, less gumming, sleeping longer, less snoring, less moving and sleep. So airway improvements. Here's the tongue. This is the video on that, uh, baby. It improves like almost always. It's high, 90% chance. You never say 100%. Say 100% it won't work, right? But like high 90% chance. Babies are obviously awake. Just some numbing jelly. No injections. Always cry. I'm sure even with a stronger jelly, they're going to cry. So I try to minimize the risk of methemoglobinemia. That's why we usually like the 2% lidocaine.

But all right, so lifting up lots of tension, right in the middle. See that little piece that's still sticking off the ridge there? So I'm going to go back and get that in a second. So I'm going to get that right here. You can't quite see it. So I'm just getting that little piece on the ridge. Otherwise, I just like flapping. There we go.

Here's a three-week-old. Lots of symptoms. Projectile every feeding. Three weeks to regain birth weight. Ideally, it's like a week. If ideally, they should regain the birth weight at a week. They give them two weeks before they're concerned. Three weeks is definitely a red flag if they're not back to birth weight. Pumping since the last three weeks. Nine out of 10 pain. Worst thing ever. People say it's worse than unmedicated labor. I've never experienced that, but like, that's, that's bad. It sounds like. And then every time they nurse, they're like, "I'd rather be in labor." The worst case of mastitis or surge care has ever seen. Postpartum depression. I can see how this one was missed. Like, there's nothing there for whatever reason for this child. They've done body work too. For whatever reason for this child, even that amount is too tight. I don't know why. I don't know how. We could just treat the lip tie. But again, if you're do putting them through the procedure for the lip tie, they have lots of tongue symptoms. Like the lip's not going to cause hiccups. The lip's not going to cause the gumming or chewing. The lip's not going to affect the pacifier as much, maybe nasal breathing. But like all of the stuff, these are more tongue issues. But reflux, spitting up, gassy, milk leaking out of the mouth, those are more lip symptoms. So we treat both. And magically, they got better. Six days later, now they're up like 11 and a 12 ounces. Was projectile feeding before eight times a day. Now they've only spit up four times in the last six days. Much better. Fewer hiccups. Better weight gain. Less reflux. Nine out of 10 pain. I'm not making these up. These are real people. Now it's a one. It was barely there for that baby. For whatever reason, it was too tight. Better milk supply.

So where do you start? Make it really simple. Ready? Start here. Start here. Not here. Not here. Definitely not down here. Teardrop shape up top. Diamond. Skinny diamond below. You get too wide, it'll grow back together easier. You more risk of hitting a nerve, more risk of hitting a blood vessel. You're not making a diamond. It's just when you make a horizontal cut through through a triangular prism, two triangles form, you get a diamond. Okay. So this one was sent to us. Please don't send me like all the pictures. I can only respond to so many emails. But this one was sent to us from someone taking our course. And I was like, "That's not the, that's not the right information." This is before they took the course, they said. But that's not enough. And like they're right on the ducts. And that's not. This patient does not have any. Can you see that? Appreciate that. They do not have any extra like elevation. That's a problem. Too wide. That's like way too wide. So the yellow I drew on my phone to like where it should be. And that's where it was too wide. Look at this. Like it should look like this. They went way too wide there. Can you all appreciate that?

All right, here's another one. Too deep. I was like, "There's the nerve right there, buddy." Uh, too wide. And part of it's like the picture taking too. So. And like maximum elevation. It should be a narrow diamond. It's like they're lifting. Okay. But this is why I don't use a groove director because you can't get like that great of elevation with it. I haven't used one in several years. I just use my fingers. I use my left index finger, right middle finger to retract. And then I'm holding the laser with my, uh, thumb and index finger and resting it on my middle finger like this.

All right, so here's another one. This is during, uh, GA case 'cause they're asleep. But the suture saved it. So it was like pretty wide and pretty deep. But like with the sutures, like it's going to be okay. Not quite enough on this one. I would have expected like where the yellow is. And then the, the lip is fine. It's not terrible. I they could have gone a little bit skinnier. But I, I like to get this area right down here. This is a water lace release. It looked like, um, like like explosions, like little, you know, little explosions under there and shooting water. Um, I don't, I've never used the water lace before, but I don't think you can turn the water off.

Here's a lip tie. They didn't get this tissue as well. Sometimes if you don't get this, the parents will come back and like, "You missed the spot, and I want you to re-laser it." So it's better to get it the first time. So here's our consult room. We have five consult rooms now. Originally, it was my office. We use this sensitive baby scale, the Tanita BD 585, for weighted feeds at the office. We use a swaddle and lap board. If you download the forms, this is all in the forms. So all this, it says like our materials list. It's all in there. Use a lap board. Little donut. There's our diode setup. No one here has a diode anymore. So here's the CO2. I'm just kidding. It's okay if you have a diode. Uh, but yeah, we started with the pen, the Eyce. They went bankrupt though. So like, I wouldn't buy a Bas right now. They literally went bankrupt. But I would inject because it was so painful, right? I was like, "This is taking forever, and I can tell they're hurting." Like, "I'm just going to inject some lidocaine." So they're screaming, but I know they're not in pain. So if you have a diode, I would consider that. I'd almost rather do scissors at this point. Like for a tongue, hematoma and scissors. I did that in Nepal because they didn't bring my laser. And, um, I would do that. 3.5 inch MT Mouth Prop. And this is called a

plamp. So, if you a, you know, now you only need one assistant. Tada! You can hold on to the side, and then you can have one assistant instead of one to suction and one to hold the head. Now, I just have one holding the head during procedure. We used to have two like that, hold from the front. It works better if they hold from the back, then the doctor has to like worm their, like their arm through the other arm of the assistant, and it's a little too close. So I like this better.

Uh, diode lasers. It's a hot tip. 700 to 1,000° C. It's white hot, and it literally burns the crap out of the tissue. Uh, CO2, you can do cut from a distance because it's actually using the laser as a laser. Uh, here's the diode. Max myectomy. We don't have time for this 'cause it's so slow, but you can see I, it's, it's like cut, cut, cut. This is lots of tension. Cut, like, just like, please cut. Now, this, this, this child is cooperative. I think at some point I just use my fingers and grab like the little piece off.

But all right, for comparison, uh, here's Nd:YAG. More for stuff, and like, it's debatable whether it works or not, right, Dr. G? Like, all right. Here's the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the,

I think for one of the other kids, like this is holding down. Look how tight that is. So here's before. This is holding down, uh, same patient, and that's afterward. Even holding down, see how much higher it goes. So you really have to check for compensations, check for floor of mouth elevation.

So I, I do know how to suture. Uh, these are PDS. These are PDS2 sutures. They cost a lot more. We switched back to chromic gut. They work the same. They don't stay any longer. Uh, there's another one. So we've done like all these patients, family of seven, and we have had 9-year-olds up to 52-year-olds. And, um, my 9-year-old sleeps more soundly at night. He doesn't move around and, um, he, his lisp has improved quite a bit. Um, we have a daughter that's a cheerleader, and she noticed she could cheer louder, but she also noticed immediately that her nasal breathing was much better after time. Um, she just felt more air coming in. The thing, um, the range of motion for all of us is incredible. Um, myself, I notice at night that I sleep with my tongue coming forward between my teeth and pressing up against my teeth, and that was really bothering me. And now I can sleep and know my tongue is up on the top of my mouth. I can feel it, and it just, it's much more comfortable at night when I sleep. Um, my husband and I snore a lot less, which is wonderful for both of us. Um, so anyway, lots of good improvements.

But here's, like, I think was on Friday. Here's on Monday. Uh, two-month-old, lots of issues to the tip. They got better. Hey, I'm India. Um, I'm here with Parker. Um, he had a lip tie and a tongue tie, and both cheeks tied. Um, we had the revision done a little over a week ago. Um, babbling more too, and now he has a lot less spit up, a lot less, um, fussiness, colic symptoms, gagging, choking. He's not chewing on the nipple anymore. Um, they're just bottle feeding too. He can hold his PA in his mouth by itself. Um, look at his bottle. Look how deep it is. That's what you want. All the way in the collar. Yeah, he's talking a lot more. He actually started doing that a couple days ago. Um, and anytime he's awake, all he's doing is talking. He's talking all the time. Overall, you want that deep latch on the bottle. Typically, the Dr. Brown's, the narrow ones are the best bottles. Um, here's a six-year-old, lots of issues, medium restriction. The lip was kind of tied to do the lip, though. This is my wife, Laura, and this is our son, Banks. He's six years old. Saw Dr. Baxter 10 days ago. This video is kind. We're running out of time, but anyway.

Two-week-old. Okay, to the tip. You got better. Hey, I'm Bailey, and this, this is all the follow-ups that day. This is not like picking and choosing. Before we came here, we had struggle. Uh, 10-day-old. This is on the 8th. Uh, was stressed. All these issues, not obvious tongue tie, pretty tight lip tie. A week later, 7 oz up. So an ounce a day is normal weight gain. Doing better. Here's Mom. Hi, this is Jackson. He, um, before his tongue and lip tie, he wasn't latching very well. He was popping on and off whenever he would nurse. He really wasn't gaining weight very well. Um, was sleeping a lot. And now since then, we've noticed he's been awake a lot more. He's latching better. Um, he's a lot more alert, and he's starting to gain weight. Per less pain for you if you do it right. It's almost every patient. If you do it right with the team approach, get a full exam, a full release, good stretches.

3-month-old. Again, the same day. IBCLC, feeding therapist, GI pediatrician, five different formulas tried, all the bottles, syringe feeding. Not obvious tongue tie. A week later, daytime sleep is worse, but all this other stuff's better. Babbling more and new sounds. How many of these babies have you seen doing that? This is Argie. Um, we had a couple issues with him eating, not being a couple minutes. So, uh, here's a 16-month-old, lots of issues, good gap in the teeth, not obvious tongue tie. We did it anyway because of symptoms, and he's eating better and sleeping better.

Please help. The one-year-olds, don't tell them it'll just get better at six. Don't tell them you have to put them to sleep. If you, at least inform them, like, I'm not going to do it. I want to put him to sleep. If you want to, there's this crazy guy down in Alabama. He'll do it if you really want it done. Like, tell them that someone else, like near you or wherever, like, will provide it if they do want that. Because a lot of people are like, we have people drive from Wisconsin because they didn't want to put their kid to sleep, like a 2-year-old, and on the way home, she was eating better, sleeping better, and talking better.

So here's. All right. Hello, my name is Kiari Knox, and this is my husband, Curtis Knox, and our son, England Knox. Um, he's currently 16 months old. Um, we came in back in October of 2024, and we're here for a follow-up appointment. Um, some of the concerns and issues we had earlier were, um, not really eating well, speech was a little bit delayed, um, and as far as his sleeping, he was not sleeping through the night. However, we have made progress on all three of those areas. He's sleeping better, um, sleeping through the night. He is eating way more foods. He's less of a picky eater. Texture is not a thing anymore. And then lastly, um, he has been saying a lot of new words, even trying to word, um, sentences, I guess, or syllables together.

So we're not asking them to, like, they ask the parents to put a helmet on these kids. They do way more like invasive things in medicine, um, and in dentistry, even than like a tongue lift tie procedure. It's 10 seconds. Stretches. They're terrible. Just like, level with the parents. It's four weeks. It's quick. Just get in, get out, move on with your day. But you got to be on mission. So what's your vision? What's your why? We want to live for something bigger than ourselves. So educating others. I also like to substitute teach for our girls' class at school, which is fun. Training others. Family.

Here's Molly. Molly was born with a tongue tie. She's our youngest. She's, she'll be six in a couple weeks. Pretty tight was to the tip, and then the lip was medium. But my wife said, you have one chance, do whatever you want to do the first time. I said, okay, that's fine. No cheek ties. I didn't do those. Um, the power was out, so I had to do it in the hygiene bay, and I hadn't slept at all, but we did it at two days old. I plugged into a battery backup. So if you don't have a generator, we have a full generator at our office now that runs the entire office after we got hit by a tornado. Got one of those. It's a long story. But anyway, get a full office generator, or if you don't have one, get a battery backup off your computer. Mouth breathing, tongue up afterward, gaining weight, a pound a week for seven weeks. Chunky. She, if her tongue was still to the tip, she would not be thriving like she is today. Here she was, Daddy, Daddy, Daddy, the best daddy in the world. Daddy, you're the best daddy. Daddy, just made this the best daddy in the world. Daddy, so sweet. Loves me. So I love daddy. He's the best daddy in the world. That's her old microphone. Give it for Molly.

And then here's Nepal. Uh, if you think that doing tongue ties is controversial, what about training non-dentists to take out teeth? Hah, that's controversial. So, uh, we go to places like Nepal or Ghana. Middle of nowhere, Ghana, 3 million people, one dentist. There's not access to care there, and they see 10 patients a day. So in this area, there's no doctors, there's no dentists, there's no lawyers either. So we're training them, uh, how to do extractions. They get a certificate. One guy took out 57 teeth in one day. How many did you take out in dental school? 10, 20, 30. 57 in one day. They get a lot of experience. We teach them how to give antibiotics, injections, blocks, everything. They pray first. They pray first, which is important. Uh, they pray afterward, and they said, Brother Richard, help us baptize this man. He was a gang member. He had all these stab wounds on him. Um, yeah, it was, it was intense. Uh, that was before I did cold plunges. This is very cold Himalayan runoff. That was interesting. Uh, and then by the end, we could just sip tea, and then they're doing the work. So that's a.

Ow approach or itch. Uh, they're in Florida, actually, in Ocala, but itch USA, I think it's their website. But so proper assessment and evaluation is critical. Ask them to lift the tongue, not stick it out. Symptoms and function are more important than appearance. Common does not mean normal. Screening should be conducted at hygiene well visits, and the sooner it's addressed, please do it sooner. If you're going to wait for therapy, I wouldn't wait like more than like a couple weeks or whatever, but like, don't wait five years. The sooner it's addressed, the more team members, the better. Restrictions must be assessed, diagnosed, treated, follow up properly. Tongue tie issues do change over time and can last a lifetime, and they just place, they do place significant limitations in a patient family's quality of life. So don't ask, stick out your tongue, but lift up your tongue. Assess with glove fingers and challenge the tongue and ask them at the hygiene visits any speech, feeding, or sleeping issues. If you see a tight tongue, then you make a plan for referral or comprehensive treatment.

So if you do want to contact us because I don't have time to stick around for questions, um, info@tonguetie.com. Easy as pie. Uh, I guess that rhymed. Download the forms. Tonguetie.com professionals. There's the QR code if you need it. And then through next Friday, you can use the course, the code ALSC2025. That's on all the courses. So it's our live course, which almost never goes on sale, as well as the Tongue Tie Academy Lite for therapists, and then the update or the full course for doctors or dentists. So anyway, thank you so much for your time. It's been a pleasure talking to you.

[Applause] Guys, we all want you to be here. I mean, in, in, in Las Vegas next year, ballpark the same time, first week of February. Thank you. Thank you. Thank you. Thank you, everyone. Happy birthday, Peter. Thank you.