REPLY:

Parents often ask: "Why can't my child's tongue thrust be treated at school?" When parents discover that a tongue thrust is often treated by a Speech/Language Pathologist (SLP) they assume that the speech therapist at their child's school has been trained to do therapy with tongue thrust just as they were trained to treat other speech problems. Unfortunately, this is not true. At the present time, there are very few graduate programs of Speech Pathology that even address tongue thrust problems in their courses.

By law, a child can only be seen in the public schools by a speech therapist for an educationally handicapping condition. These conditions fall into five groups: articulation disorders, dysfluency (stuttering), hearing impairment, language, and voice disorders. The school therapist can see a child for an articulation disorder, which is often - but not always - associated with an orofacial myofunctional disorder. But the therapist may or may not have specialized training in orofacial myofunctional disorders. The consumer should be aware of this, and ask questions about the therapist suggesting therapy in the schools - Does this therapist have specialized training, and to what extent? Is this therapist certified in orofacial myology?

Most school districts wisely do not allow their therapists to treat orofacial myofunctional disorders in their schools because they understand that it is primarily a medical, not an educational, disorder. While a tongue thrust is frequently associated with an articulation disorder, your dental professional has referred you to a Certified Orofacial Myologist because your child has a medical problem that can adversely effect his/her dental, and possibly craniofacial development.

Factoids:

1. Did you know that approximately 80% of all "tongue thrusters" have an airway (respiratory) problem, and the other 20% usually have a detrimental habit, such as thumb sucking? These are clearly medical issues that are best addressed by an experienced professional who specializes in this treatment in a one-on-one therapy setting.

2. Did you know that usually children are seen in school by the speech therapist in groups of 4-6 children at a time?

Fact: the metabolic processes of the body change during sleep as compared to being awake.

Fact: the breathing process changes during sleep as compared to being awake.

Fact: moisture or dryness in the air can influence the way a person breathes either while awake or asleep. As well, allergies, medications, normal mucous flow and nasal debris accumulations can also influence the body in a different manner while asleep as compared to being awake.

Fact: many individuals who breathe adequately during the day need help to maintain a healthy exchange of oxygen during sleep, such as a CPAP.

There are many false assumptions that are associated with a decision to tape the lips together at night:

1. Assumption: All individuals are left with an ability to take in a sufficient amount of oxygen through the nose as may be needed during sleep with the lips taped together.
   

   Responses: does a MFT know the relationship between the body's increased need for oxygen during sleep and the degree of mouth opening that may be required to fulfill changing oxygen needs during sleep.
   

   Is the assumption that there is sufficient area around the tape provided as sleep needs change during the night a reasonable presumption? If so, based on what? Is there no impact on breathing when the range of mouth opening is restricted during the sleep process with lips taped together?

2. Assumption: During sleep, the configuration of the nasal airway does not change as metabolism slows down; that is, there are no changes in size of the mucous membranes of the nose, nor does nasal resistance change during sleep. Said another way, the nasal chamber remains patent during sleep.
   
   

   Responses: for most individuals, upon awakening, there is a need to clean the nasal cavity of debris that accumulates during the night. This may and will vary night-by-night, as related to a host of environmental and bodily influences and needs.The posture of lying recumbent changes the natural flow of drainage in and out of the nasal cavity during sleep, and the buildup of nasal debris differs from the self-cleansing processes while awake. As a result, there is often a need for increased oral breathing during sleep as the resistance to airflow through the nasal cavity changes during sleep.
   

   Can a MFT presume arbitrarily that whatever increased oxygen needs that may exist can be met if the range of mouth opening is restricted by taping?
   

3. Assumption: Since taping the lips shut at night provides a sufficient flow of oxygen in and out of the mouth so that there is no chance that any cardiac or other episode could occur or develop later with a patient that could possibly be linked to this intervention in the sleep process
   

   Responses: There is going to be, somewhere down the line, an instance where a patient experiences a cardiac incident or developmental problem that can, in part, be related to sleep. If taping of the lips is revealed during a physician's questioning of the individual's recent history, what defense would a MFT have if linked to the problem that has been identified.
   

Should a minimum requirement for lip taping (during day or especially night) include approval and clearance by the family physician? The answer is a resounding YES.

Attendance was by invitation only. Present were 19 specialists from around the world as well as several others who were teleconferenced into the meeting. Representatives were from as far away as Australia and Israel and their areas of expertise included a neonatal pediatric surgeon, Board Certified Lactation Consultants, medical and dental professionals, university instructors, and other related areas of interest as well as Sandra Holtzman who is both a Certified Orofacial Myologist and an ASHA Certified Speech-Language Pathologist.

Heading the meeting of the new organization was Alison Hazelbaker, Ph.D., IBCLC, author of the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), used to determine tongue tie in infants. Hazelbaker is also author of Tongue-tie: Morphogenesis, Impact, Assessment and Treatment, which is set to be released in the very near future.

Also present and assisting at the meeting was Catherine Watson Genna, author of Supporting Sucking Skills in Breastfeeding Infants.

Discussion centered on many topics, and committees were formed to gather information to present to members via an online private blog they have created.

The topics covered included the following as well as other topics:

• Select the official name for the newly formed organization.

• How often shall we meet?

• Where shall we meet?

• Shall we also have regular teleconferences?

• Classification and Definition

• What is tongue-tie? Do we consider only function? Only appearance? Do we take into consideration length? Elasticity? Attachment location? Embeddedness into tongue?

• We need an agreement before we can create a simple screening tool to be used on infants and possibly older children and adults

• Terminology: Release vs. divide vs. clip vs. cut, etc.

• Screening

• What criteria from above do we need first in order to develop the tool?

• Who should use the screening tool? Do we consider the dyad of mother and baby? Or either one separately, if indicators are present?

• When should an infant be screened? Prior to nursing or after one or more nursing sessions? What about bottle-fed babies and timing?

• Will a tongue tied infant respond differently to the initial colostrum as opposed to mother’s milk or formula feeding?

• What part would anesthesia play in feeding difficulties related to ankyloglossia and how long should screening be delayed if anesthesia is used?

• Is it possible to develop a screening test with a wide enough net to catch the majority of ankylosed infants?

• What explanations or photos should be included with the screening test and how can we keep the screening to only about a minute or two in length?

• Can we use sections of existing assessments rather than creating an entirely new screening protocol?

• Research

• Can we put our studies together as a group in some manner?

• Can we do new research?

• Press Releases, etc.

• Where? Whom to reach?

• Can we approach well known TV personalities to consider having us on their shows?

• Country to country variations in which professionals play major roles in determining and addressing tongue tie?

• Consequences: which ones can we all agree upon?

• Surgery

• Frenotomy? Frenectomy? Frenoplasty? Other?

• Use of anesthetic? When, what ages?

• Value of not using any drugs at all vs. discomfort associated with some drugs.

• Plusses and minuses of Scissors? Scalpel? Diamond cut with silver nitrate utilized?

• Are some people “overdoing” the number of surgeries they are performing? Are others missing too many tongue tied babies?

• Should it be done in stages for infants?

• Incidence: Can we possibly know incidence unless we first have clearer definitions and classification categories?

Future Global Tongue Tie Summits were discussed and next year’s location and date is tentatively set for Tel Aviv, Israel, in June, 2010.

In summary, those who traveled half way around the world stated that it was well worth the trip, time and expense to be able to participate in this eye opening summit meeting that was the brain child of Dr. Alison Hazelbaker and paid for by the Hazelbaker Foundation, whose mission is to promote the arts and support educational projects in the U.S. and abroad.

A:

There are several differences:

1. Children’s incisor teeth are upright, while adult’s incisor edges are flared slightly toward the lips. The reason for this is that adult incisors are wider than those of children, so there is a need to create more room for them in the dental arches; thus, they flare forward and in doing so, increase the circumference of the dental arches. If adult central incisors erupt in an upright position, it is typical for the lateral incisors to be blocked out of the dental arch either toward the lips (labially or facially), or blocked palatally (toward the palate or tongue).

2. Children’s canines are smaller than those of adults; nonetheless, sometimes it is difficult to tell whether the canines are primary or adult teeth. To resolve the confusion, if you wiggle the tooth and if is moves, it is a loose primary canine. If there is wear or flattening on the canine tip, it is more likely a primary canine. Another clue: ask the patient or parent.

3. Molar teeth of children are larger than the bicuspid teeth that will replace them in the adult dentition. Some crowding can spontaneously disappear as the primary molars are replaced by the bicuspids (remember that there are no bicuspids in the primary dentition).

4. There is very little or no Curve of Spee in the dentition of children. The gentle curve downward from incisors and then back up at the molars occurs in the adult dentition, reaching a maximum of @ 2 mm at the bicuspids by age 16. Orthodontic treatment usually flattens and eliminates the Curve of Spee. This is not usually a problem.

5. Just a reminder – the full dentition in a child includes 20 teeth whereas in the adult, there are 32 teeth counting the wisdom teeth.

A:

1. One term is ectopic, which denotes a tooth that is or has erupted out of place, or in the wrong place (such as palatally).

2. Another common term is blocked out, as used above, which simply describes a tooth out of position either facially or lingually because there is insufficient room in the dental arch for the tooth.

3. Canting is a term that you will see on some orthodontic reports and problem lists. Canting is when the teeth are slanting to the left or right from a perpendicular line when facing the patient. Either or both arches may exhibit canting. A cant of the anterior dentition may develop spontaneously in the mixed or adult dentition, or even during orthodontic treatment. The causative factors are not well known. In some patients, a cant can be linked to ankylosed and submerged (below the line of occlusion) retained primary molars, or late erupting teeth on one side that contribute to alveolar bone vertical height differences. Why the canting usually involves a left to right downward slope is not known, although a right to left cant may occur infrequently. Orthodontic leveling of a canted upper or lower dental arch usually presents a treatment challenge.

   Although the many potential reasons for the development of canting are not well documented, the rest posture or functions of the tongue have not been linked as contributing factors.

4. A Bolton discrepancy is known by all orthodontists and may be mentioned in their reports. W. A. Bolton (AJO, 1980) developed a tooth size analysis, also called a Bolton analysis, by measuring the mesiodistal widths of each permanent tooth. A table of Bolton’s data found in any orthodontic text is used to compare the summed widths of maxillary and mandibular anterior teeth, and as well, the widths of all upper and lower teeth excluding second and third molars. Where there is a discrepancy between the ratios of tooth widths between upper and lower teeth, the term Bolton discrepancy is used.

   As a quick check for tooth size discrepancies of anterior teeth, you can compare the widths of upper and lower lateral incisors. If the upper lateral incisors are not wider than the lower laterals, a discrepancy will usually exist in the form of some lower incisor crowding. As you may already know, size variations of the maxillary lateral incisors are the most common variations seen in the dentition, such as peg-shaped upper laterals.

   The suggested application of this information is as follows: if you note lower anterior crowding and, after evaluating the widths of upper and lower lateral incisors you determine that the upper laterals are small in comparison to lower laterals, it is appropriate for you to include this information as a question in your clinical report to an orthodontist. You can state that your evaluation revealed a possible Bolton (or tooth size) discrepancy with anterior teeth that may be linked to lower anterior crowding, and would the orthodontist kindly evaluate this observation?

A:
If you have high definition TV, you will note many crowded lower anterior teeth in adults. There are several reasons for this:

1. The most overused reason is that anterior crowding begins as the wisdom teeth erupt. While this may be a contributing factor for some, there are many more whose lower incisors do not become crowded with 3rd molar eruptions. Overall, dentists have blamed too much lower crowding on the eruption of posterior teeth. The reason for this overly-applied cause and effect linking eruption of wisdom teeth with anterior crowding is that dentists know that teeth tend to drift forward, or mesial (toward the midline).

2. As teeth experience wear over time in adulthood, the bite closes slightly. This tucks the lower incisors up under the cingulum of upper incisors and thus, contributes to crowding.

3. Since the cortical (covering) plate of bone on the facial and lingual surfaces of the lower incisors is thin in comparison to all other locations in the dental arches, crowding is more apt to develop. Resting tongue and lip pressure differentials also contribute to the development of the crowding at the lower incisors.

A:

There are several observations that are recommended for you to make:

1. Check the midlines. The dental midlines ideally should match the facial midline, which is judged at the middle of the soft tissue lip at the Cupid’s bow, the middle of the philtrum or the middle of the nose. If the maxillary and/or mandibular dental midline deviates from the facial midline, additional observations are suggested. Example: if the upper dental midline is deviated to the right, perhaps there is a small right lateral incisor, or a blocked out canine on the right, or a missing tooth on the right. If the upper midline is “off” and the lower midline is “on” (as orthodontist would describe the midlines), then the problem is with the upper arch only. Where both midlines deviate to the right, this may suggest some irregularity in the TMJ’s, or the ramus or body of the mandible on one side.

2. Check for the Class of occlusion (you should already know about Class I, II and III). If your patient is in mixed dentition, with some adult teeth and many remaining primary teeth, it may be difficult to evaluate the occlusion. If you are having a problem, you can make your evaluation of posterior occlusion at the canines. For Class I, the lower canine tip will fit in the space between the distal of the upper lateral incisor and the mesial of the upper canine (or the lower canine is ½ a tooth ahead of the upper canine). Make sure you evaluate both sides, since a person can be Class I on the right and either Class II or III on the left. Evaluating at the canines can work for evaluating the adult dentition as well; however, compare your observations at the canines with occlusion at the molars. With spacing or other problems, a person may be Class I at the canines but not at the molars.

3. Check for overbite and overjet. Even dentists occasionally get confused about these terms. Most patients will tell you that they have an overbite (everyone should have an overbite) when they in reality have an excessive overjet. Remember that an overbite is a vertical relationship of teeth. With front teeth a normal overbite (also called vertical overlap) should normally involve an overlap during biting of 1/3 to ½ of upper incisors covering lower incisors. For overjet (also called horizontal overlap), the upper incisors should extend facially beyond the lower incisors, whose facial surfaces should ideally contact the lingual surfaces of the upper incisors. Note: all teeth around the dental arches should normally exhibit some overjet and overbite. These are normal terms that should be qualified by “excessive” when there is a problem. A deep overbite can also be called a closed bite.

4. Check the esthetic line. The esthetic (or E-line) of Ricketts indicates the relationship of the dentition with the facial profile. Remember that where the teeth are located (positioned) determines the position of the lips in the horizontal plane. The E-line is constructed by drawing an imaginary line between the tip of the nose and the chin. In a well-balanced face and profile, the lower lip will be at or near the E-line, while the upper lip will be positioned slightly behind the line. Example: if both lips are well behind the E-line, extraction of teeth for orthodontic treatment is contraindicated since the profile will become even more retruded or dished-in at the lips following closure of the extraction spaces. Lips positioned far behind the esthetic line are a clear indication that extractions are not indicated, but remember that it is the dental provider’s role to make the decision to extract or not. Conversely, if the lips are positioned ahead of the esthetic line and if there is lip incompetence, extraction of teeth would be an expected part of the treatment protocol. The spaces providedby extractions are then closed by retracting the anterior dentition into the extraction spaces and thus, improving the facial profile and lip posture.

5. Check for the presence of open bites and cross bites: anterior, posterior, unilateral; bilateral. Where the lower incisors project ahead of upper incisors, the anterior crossbite is also referred to as a negative overjet, while the public may call this an underbite. You will recall that you can have a crossbite at a single tooth location or at multiple locations, such as involving an entire posterior segment from canine or first bicuspid on back.

6. Where you have questions about the dentition, remember to count teeth. Many patients have a malocclusion because of a missing incisor or canine or bicuspid. If a canine is missing, the dental midline will be expected to deviate to that side. Also remember that a rule in orthodontics is to avoid, wherever possible, extracting a canine.

A:
In most extraction cases, it is the first bicuspids that are extracted; then the canines are moved distally into the extraction spaces. Where retraction of anterior teeth is indicated, teeth closest to the area to be extracted are removed. To close extraction spaces from front to back, the posterior teeth are used as anchors to pull the anterior teeth posteriorly (or distally – away from the midline) during orthodontic treatment.

For esthetic purposes, it is unwise to extract incisors or canines. Orthodontists always avoid removing canines. Why? Because the canines are located at the greatest curve of the arch and have very long roots. As such, they stabilize the dental arches and also contribute to opening and closing gestures of the jaws during chewing referred to as canine rise in dentistry; a chewing relationship that dentists like to achieve. Where this is impossible or impractical and where the posterior teeth control opening and closing activities, this chewing pattern is referred to as group function of the dentition. Group function is a normal functional behavior.

A:
A space between adjacent adult teeth, a diastema (pronounced die-ass-tuh-muh), is a common occurrence, especially between the adult upper central incisors. By contrast, the spaces seen between primary anterior teeth are not termed diastemas. Spacing in the primary dentition is a normal and positive indication that the adult incisors have enough room to erupt normally since primary incisors are smaller than their adult counterparts.

A central diastema is common in the mixed dentition, especially where the lateral incisors have not yet erupted. In many individuals, the diastema will close spontaneously after the lateral incisors erupt, so resist the temptation to conclude inappropriately that the patient will need frenum surgery. In other instances, a diastema can be linked to a tooth-size discrepancy.

Orthodontic treatment for spacing typically involves braces rather than a retainer with springs. The reason for this is that retainer springs will only tip the teeth toward the midline to close the space. This leaves a window open just below the gingiva. Braces close the space by bodily moving the teeth together. The roots remain upright, which is desired for long-term dental stability.

In many patients, the cause of the diastema is the presence of extra connective tissue strands that continue from the frenum in the labial sulcus across the dental arch between the upper incisors and ending on the palatal side of the anterior alveolar ridge. In some cases, this connective tissue band will have to be surgically removed or altered. However, there is a universally accepted rule in orthodontics that you would never recommend surgery on the frenum until after the diastema is closed orthodontically. If surgery is done before orthodontics, a window will be seen at the gingival margin. In contrast, if surgery on the frenum is needed after closure of the diastema, the procedure would involve sculpting the gingival so as to preserve the natural curve of the gingiva interproximally.

Interestingly, only about 5% (10% at the most) of thick labial frenums (or frenulae) will need surgical correction following orthodontic space closure of a central diastema. In most cases, the tissue remodels sufficiently following orthodontics so that no surgery is needed. Orthodontists monitor the situation following space closure and make a referral for surgery only after it is demonstrated over time that the space will not remain closed without some surgical assistance in connective tissue sculpting.

A central diastema has a genetic link in some families. A diastema can occur anywhere in the dental arches, but the central diastema is the most recognizable example.

A:

This question reveals a common and potential problem in communicating information to professionals from other disciplines, especially dentists and orthodontists: the vocabulary of the OFM and SLP often differs from those in other disciplines. Here are some examples of things to remember in writing reports:

1. The alveolar ridge encompasses all teeth in both dental arches, or from” ear to ear”. That is, all teeth are housed in alveolar bone. It can be confusing to dentists when reports discuss lingual-alveolar tongue contacts, What is really meant is a tongue tip to incisive papilla contact, or, alternately, a tongue tip to anterior maxillary alveolus contact.

2. An articulator in dentistry is a metal apparatus on which dental study models are attached (mounted) for purposes of evaluating occlusion and movements of the mandible. In mentioning the articulators, it is recommended that you qualify your statement by identifying that you are discussing the speech articulators.

3. Many in speech-language pathology report that they conducted an oral-peripheral evaluation. Other medical personnel would wonder “Peripheral to what? Were the peripheral nerves evaluated? Where is that report?” More clearly, what you are reporting on is an orofacial evaluation, so that is what should be stated.

4. When reporting on oral diadochokinetic testing, remember to include the word oral. The use of diadochokinetic testing to assess the tongue and lips is derived from medical testing of rapid and repeated finger movements to grossly assess cerebellar competence. The term diadochokinesis was coined from this medical assessment.

5. Many terms are seldom used in dentistry, such as distocclusion and mesiocclusion. (Class I, II and III are sufficient). Also, frenum is preferred to frenulum (acceptable but more anatomical) and the same for nasal turbinate rather than concha (which is actually the correct anatomical name). Please remember that orthodontists prefer the name of their discipline as orthodontics rather than orthodontia, a term that smacks of the olden days of orthodontics.

A:

There is nothing wrong with making observations about the status of the dentition and including your findings in reports to dentists. However, there is a way to pass on your observations. It is recommended that you include your observations as: “It appears that the patient exhibits…” or “The patient appears to exhibit…” and request that the dentist or orthodontist verify your impressions with a definitive evaluation. In our opinion, any in dentistry would welcome your observations if you defer to them for the diagnosis. In this way, you cannot be accused of diagnosing dental conditions, which you legally cannot do as a myofunctional clinician.

Personally, I begin to become concerned at age 4-5. Between ages 4 and prior to the eruption of the permanent teeth, much of the damage that occurs to the palatal structure can be reversed. Prolonged and vigorous sucking can act as a deterrent to the normal growth and development of skeletal, facial, nasal cavity, tooth alignment, lip structure, tooth eruption, palate, finger growth, speech, breathing and swallowing functions. That little thumb can do an awful amount of damage that many parents are not aware of.

The more vigorous the sucking habit and the more fingers sucked, the greater the degree of damage likely. Two-finger sucking is considered the most damaging, and a thumbsucker who hooks the index finger above the nose will develop finger, nasal, and palatal damage simultaneously. The longer the sucking habit continues, the greater the chance of the negative effects of finger sucking (especially palatal narrowing), becoming resistant to spontaneous reversal.

As the mouth is propped open from the front teeth contacting a finger, the back teeth may begin to erupt excessively to fill that open space in back forcing the bite to become permanently open. In addition, when a child keeps a finger in the mouth, the tongue is forced into a downward and forward position. The roof of the mouth, the hard palate, depends on the tongue resting and molding it's shape for proper width and development. When the palate does not have a tongue resting within it during the early formative years, it is at risk for narrowed development. In addition, the muscles utilized in a normal adult swallow, which encourage the tongue to lift to the palate for the swallow, are weakened and fail to engage at the proper time. Additional forward and downward movement of the tongue occurs against teeth and beyond teeth influencing the child's palate and facial development further. In addition, the mere suction and pressure of the sucking act can create pressure against the upper arch forming a v-shaped arch, instead of a nice round arch, narrowing the palate even further. What are the effects of a narrow palate?

First that comes to mind, is that many teeth will not be able to erupt fully, on schedule, or straight, due to limited space in which to contain them. In addition, once the bite has been affected through crowded or abnormally erupted teeth, the lower jaw or teeth may shift as a result, to attempt to find a comfortable biting surface, forming an overlap situation on the back teeth, often referred to as a crossbite. Without enough room for the tongue to fit in during rest and swallows, the tongue, with already altered muscular patterns, will be perpetually forced into a situation where it has nowhere to go but out. A tongue which habitually thrusts forward, is termed a "tongue thrust". The entire facial muscular complex can often be affected, as children attempt to seal their mouth from the extruding tongue to avoid an embarrassing moment of food or saliva falling forward from the force of the tongue. Muscles are said to exhibit an "imbalance" situation, i.e., the muscles we normally use for facial expression are being called upon to do the work of chewing and swallowing, in a compensatory action.

Normally, infants use these same patterns of chewing and swallowing up until ages 4-6, and then a transition begins to take place, and proper patterns of swallowing develop as part of the maturation process. However, in over 80% of children who continue thumbsucking beyond the early years, a proper swallow transition does not occur, and the swallow pattern remains infantile in nature. Children who develop these problems are said to have "Orofacial Muscular Imbalances".

Development of other hard structures may also become altered. In these children, the roof of the mouth grows vertically, instead of horizontally, narrows, and becomes vaulted, often taking on the shape of the finger. The nasal cavity floor is also associated with the growth of the roof of the mouth. If the palate is narrow, the nasal cavity and sinus may also develop with a narrow and shallow anatomy. In addition, speech can be effected because the tongue has difficulty raising to the palate, or with tongue tip placement, due to structural and muscular changes, to articulate various sounds, especially n,t,d,s,l,z, and ch. R, formed with the back of the tongue raised, may also be problematic. Incompetent lips may affect letters p, b, and m.

Oftentimes, the area where the finger sits in the mouth has provided a nice gaping open area for the tongue to thrust out of during rest and swallow function. The more the tongue continues to exert pressure by resting against teeth, or through them, the more at risk teeth are to continued movement. If this tongue thrust issue is not addressed during orthodontic treatment, orthodontic movement of teeth may be slowed, as the tongue pushes forward, exerting pressure in a continuous slow manner in the opposite direction the orthodontist is attempting to move the teeth into. When the orthodontia is completed, continued movement of the teeth may occur as a result of the tongue continuing to exert pressure at rest and swallows against those beautifully straightened teeth. This can lessen the possibility of a beautifully maintained and retained orthodontic correction.

Lips may assume a flaccid appearance, with little muscle tone, when at rest and not actively sucking. The lips are unable to remain together easily. Lips that remain closed at rest act as a natural retainer to the front teeth, and help keep them from drifting forward in the mouth. Average normal lip strength is aprox 4-6 lbs. of pressure. This is measured using a spring tension gauge. Most of the children with orofacial myofunctional disorders, have lip strengths of only 1-2 1/2 lbs. of pressure. Luckily, this is easily reversed. I personally use a custom molded exercise device to work with the children on improving lip strength, and more importantly, closure. I am usually able to increase lip strength significantly in a few weeks, and improve lip closure after the sucking behavior has been discontinued.

In preschoolers, it is believed that 1/3 to 1/2 of 3-5 year olds suck fingers and thumbs when tired, although there is a decline in overall time of fingers in the mouth. Some quit sucking entirely once they begin preschool and peer pressure kicks in. However, even though most daytime sucking decreases during this time period, often nighttime sucking continues. Many preschoolers will return home from a finger-free day, snuggle up to a blankie, t.v. or other familiar object in a comfortable spot, and automatically, the thumb goes in.

Aprox. 13% of children who are entering kindergarten suck a finger, and in 7-11 year olds, aprox 6%, with the most finger sucking occurring at night. Many children begin other oral habits as a substitute, however, such as pen chewing, a more socially acceptable form of oral stimulation than a thumb. (These other oral habits may also be harmful to the oral structure, and are less commonly addressed.) If thumbsucking continues much past this age group, often orthodontic and orofacial muscular therapy are not enough to help these children. In addition, surgical intervention may become necessary to address jaw discrepancies.

There are currently 2 methods commonly employed to address non-nutritive sucking behavior and tongue thrust. The first is Appliance therapy, and the second is Orofacial Myology Therapy.

1. Appliance Therapy: For this form of therapy, a General, Pediatric Dentist, or Orthodontist is consulted. A metal appliance is bonded directly to the teeth, which house various extensions. These extensions act as a deterrent to placing a thumb into the mouth, or conditioning a tongue to position forward. They cannot be used successfully in all types of tongue thrusts, and with all patients.

2. Digit Sucking Habit Elimination Therapy: Using behavior modifications, specialists such as myself provide counseling to children and families on thumbsucking issues. O.M.'s are licensed professionals in the medical, dental, or speech communities that receive specialized training and are expected to complete an internship program and testing to qualify for certified status in the profession. O.M.'s are overseen by the International Assn. Of Orofacial Myology, an association dedicated to quality education and training, assuring standards of excellence in care. Children are treated with respect and given encouragement, love, and support in their desire to stop their sucking habit. Positive reinforcement techniques and parental participation are instrumental to success. One on one, orofacial myologists help plan rewards for the children, act as a resource person for parents, and provide daily contact to the children, monitoring success and offering encouragement. Nighttime sucking issues are addressed with gentle "proprioceptive" (thought-stimulating/physical) reminders that are geared for that particular child on an individual basis (finger splints, custom gloves, etc). Most parents state they have tried many of these things before with no success, yet the therapy works. A special relationship of support and guidance from an outside source that attains a 3rd party intervention status is often the reason for such a positive outcome. Most patients with no psychological problems will overcome their finger habit after the first visit! The key is that THE CHILD MUST WANT TO STOP!

If an orofacial muscular imbalance/retained infantile swallow/tongue thrust is detected during visits to the office, muscular therapy sessions can be initiated once the thumb habit is under control, or if the tongue thrust is allergy or airway related, a properly maintained airway is established. If your orthodontist has suggested tongue thrust therapy for your child, orthodontic visits are coordinated to work together with therapy for the best possible comprehensive outcome. This therapy consists of various individualized exercises designed to retrain, improve, and correct muscle pattern usage (I often refer to it as physical therapy for the mouth) to a more harmonious form, and address open lips and mouth posture. (Lips should not be apart at rest, and this is a big tip-off that a problem exists.) Again, this therapy is not for everyone. It requires active participation on the part of the child. In a cooperative patient, therapy is proven in the literature to be over 83% effective in altering long-term swallowing behavior.

By discussing both options with your orthodontist, the correct method of addressing your child's orofacial myofunctional disorder can be determined.

Why is Treatment Necessary?

A tongue thrust which is not corrected can often threaten the stability of any long term orthodontic correction. A tongue which exerts steady constant pressure on teeth during swallows and rest, or lips that do not seal with a jaw that postures habitually open, will not readily provide the proper environment functionally to best retain recently moved teeth in their new position. In addition, orthodontia in progress will take longer, as the orthodontist battles the tongue posturing itself and exerting continuous pressure in the opposite direction the teeth are attempting to be moved. A tongue thrust which has not been corrected during orthodontia is believed by many researchers to be the number one cause of orthodontic relapse in retained patients. Frequently, as this lowered postured jaw and tongue continues during adulthood, the muscles which support the TMJ (jaw joint), can become easily irritated. The normal position of the jaw should be elevated, with a gentle 1-2 mm. of open space in between the two arches, and the tongue resting up in the palate. Years of straining the musculature and joint downward from incorrect posturing of the tongue can take it's toll, possibly contributing to TMJ discomfort. Do this simple test yourself. Place your tongue on the floor of your mouth and see what happens with your jaw. Down and forward it goes. Twenty years of this - Ouch!

1. Habitual mouth breathing.

2. Lips apart at rest or during swallows.

3. Tongue visibly forward during eating or at rest.

4. Facial smirk or grimace during a swallow, or using a lower lip squeeze to seal off the mouth.

5. Open spaces where teeth should be in which a tongue comes through during a swallow or at rest.

6. A tongue which comes forward into a cup when you take a drink.

7. Golf ball appearance to the chin when swallowing.

8. Washing food down with copious amounts of water.

9. Speech difficulties.

10. Messy eating, excessive drooling, and crumbs that frequent the corners of the mouth.

11. Loose, flaccid lip tone, or teeth that are visible in the presence of an arched upper lip.

12. Improperly chewed food yielding stomach pains and gas frequently.

13. Excessive elongated facial growth.

14. A head which seems to bob forward when a swallow completes.

I have been so fortunate to be part of this entire process. There is nothing more joyful than seeing the positive changes that occur from working with these children, as their little mouths change, grow and develop. The best rewards are the smiles and special friendships that result. I am so thankful for the opportunity to work with so many wonderful parents and children, and for all they have taught me, and for all the medical and dental professionals who have been instrumental in recognizing the need for this treatment, and insuring that these children get the care that they need.

Acknowledgements

Zickfoose, B. (1989) Techniques of Oral Myofunctional Therapy, Sacramento, California: OMT Materials.

Hanson, M. , Barrett, R. (1988) Fundamentals of Orofacial Myology, Springfield, Illinois: Charles C. Thomas.

Pierce, Roberta (1978) Tongue Thrust/ A Look at Oral Myofunctional Disorders, Lincoln, Nebraska: Cliff Notes, Inc.

Gelesko, A., Wilder, T., (1991) The Breath of Life, The International Journal of Orofacial Myology, 17-3, 18

Umberger, F., Van Reenen, J. (1995) Thumb Sucking Management: A Review, The International Journal of Orofacial Myology, 21, 41-45.

Heitler, S. (1996) David Decides About Thumbsucking, Denver, Colorado: Reading Matters. 

Roe, S. (1998) Treatment Recommendations for Nonnutritive Sucking Habits, Journal of Practical Hygiene, 7, 11-15.

Van Norman, R. (1997) Digit Sucking: A Review of the Literature, Clinical Observations and Treatment Recommendations, The International Journal of Orofacial Myology, 22, 14-33.

One of the most controversial considerations in occlusion is the importance of the surrounding musculature in forming the occlusion. Certified orofacial myologists have been trained to identify, diagnose, and treat myofunctional problems. Many dental professionals are beginning to endorse those findings or support any treatment performed by orofacial myologists. Orofacial myologists work with speech therapists and dental professionals, especially orthodontists, who agree with the basis for this specially.

A specific treatment plan for each patient involves making the patient aware of the problem, producing new muscle functions, toning appropriate musculature, and helping in making the new patterns habitual.

Before	Before
	;
After	After

Orofacial myologists believe that early identification is an advantage but that young adults and older adults can benefit from therapy. Many dental professionals are expanding into this field. Further studies are necessary to ascertain whether myofunctional considerations are important in malocclusion and whether such therapy has a long term benefit.

The most common myofunctional problem cited by many orofacial myologists in regard to occlusion is a tongue thrust. During the act of swallowing and rest posture, the tongue is believed to contribute to the formation of malocclusion by the infantile habit of thrusting the tongue and resting it against or between the anterior teeth to form an oral seal. Many orofacial myologists believe that a tongue thrust may result in an anterior open bite, deformation of the jaws, an abnormal function.

Another myofunctional problem cited by orofacial myologists is an incorrect resting position of the lips, which can affect the position of the anterior teeth and facial aesthetics. The competency of the lips to make to maintain lip seal when at rest can affect the position of the maxillary incisors. Competent lips allow these tooth tips to lie below the lower lip boarder, helping to maintain normal inclination. Incompetent lips that fail to provide a lip a seal do not control this inclination and may even allow the maxillary incisors to lie in front of the lower lip, exaggerating already buccally inclined teeth. A tongue thrust may be associated with this problem, complicating the treatment. In comparison, overactive and tight lips can cause the maxillary incisors to become linqually inclined.

Orofacial myologists believe that the tongue thrust and negative tongue and lip resting positions are due to disharmony between tongue, lips, cheeks, and teeth. Etiological factors cited by orofacial myologists include nonnutritive sucking habits, habitual mouth breathing, open lip position, structural problems, developmental problems, or a combination of any of these factors. Speech problems may be associated with these noted myofunctional disorders. The most important of these seems to be the rest posture of the lips and tongue. Habitual open-mouth rest posture does not allow the tongue to provide the valuable pressure into the palate that helps to widen the maxillary arch. Another issue is the length of the lingual frenulum. If it is restricted, it also limits the possibility for the maxillary arch to expand and increase speech and articulation problems. Allergies are an issue for all orofacial myologists. They seem to be increasing in all ages of the population and present a challenge in achieving proper tongue-resting posture.

1. Get a better understanding of the typical SLP's knowledge of orofacial myology components, concerns, methods, etc.

2. Find out what "terms" SLPs commonly use to describe oral myofunctional disorders.

3. Disperse information about orofacial myology.

4. Determine attendees' interest in furthering their information base.

Let's address our "non" data-based finding to the above:

1. The knowledge base is almost non-existent among those who have not taken at the very least some oral motor workshops. Many looked at the large sign depicted in this article, shrugged their shoulders, and said "I don't see any clients with these symptoms" or "I don't see 'tongue thrust' students." When we reviewed the various symptoms more in depth, nearly all of them said that, "Yes, my clients do have these symptoms. Is that Tongue Thrust?" Of the hundreds of visitors to our Neo-Health Services booth, there were approximately 15 who had any knowledge of our speciality area, and of those 15, over half had attended a course by Sandra Holtzman or had corresponded with her website, www.neohealthservices.com; two had attended a Zickefoose course, and the rest had attended a Garliner course many years ago.

2. Most of the speech pathologists were not familiar with terms "oral myofunctional" or "myofunctional" therapy, although ASHA officially uses these terms in some literature and a booklet that was created by some of our own IAOM members.

3. Well, we certainly did disperse information! And we encouraged as many booth visitors as possible to attend the superb presentation by Licia and Dianne Fonnsagrives, as well as the poster sessions by Jayanti Ray. Fortunately, Licia's and Dianne's presentation was early enough that we were able to attend it and still be in our booth in a timely manner. It was very,very well received.

4. Once attendees entered our booth, read our literature, watched our DVD, or spoke with us, the great majority of expressed interest in learning more. We determined this interest to be genuine, rather than just obligatory. Many stayed long periods of time, asking questions and expressing interest in learning more.

In summary, all of our goals were met satisfactorily. We wish that the IAOM were able to exhibit next year at ASHA, which is being held in Miami, Florida. The expense, however, runs into thousands of dollars. Although it might not be possible next year, it is something we might want to consider. Perhaps an ongoing fund raising for this purpose could be established.