Orofacial Myofunctional Disorders: The Basics for SLPs

Orofacial Myofunctional Disorders: The Basics for SLPs
Marsha Lee‐White, M.S. CCC‐SLP, C.O.M.
Speech‐Language Pathologist
Certified Orofacial Myologist
copyright MLW 2010
Structure Development
Structure Development
• Tongue is adult size by the age of 8 years.
• Maxilla is adult size by age 8 with some residual growth around age 12, when growth has been completed.
(Mason, Robert, Ph.D., DMD. Orofacial Myology: Beyond Tongue Thrust, Chapter 2).
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Structure Development
Structure Development
• Mandible shows steady growth until age 8 10 years then goes through a
age 8‐10 years then goes through a prepubertal or pubertal growth spurt. Some continued growth is noted into the 20’ss.
noted into the 20
• Tonsils and adenoids are maximum size by age 9‐12 years Then they
size by age 9‐12 years. Then they begin to atrophy. At the age of 12, the tonsils are usually 2x the size that will be seen at age 20
will be seen at age 20.
(Mason, Robert, Ph.D., DMD. Orofacial Myology: Beyond Tongue Thrust, Chapter 2).
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N
Normal Dental Eruption
l D t l E ti
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T i lO l i
Typical Occlusion‐
Cl I
Class I
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N
Normal Occlusion
l O l i
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Facial Muscles
Image url:http://www.lrn.org/Graphics/figure6.11.gif Go to page:
http://www.lhwl.lhsa.com/Site2001/Courses/Adv%20Bio/muscular%20system.htm
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Facial Muscles
•
•
•
•
•
•
•
•
•
•
Levator labii: raises the upper lip Masseter: closes the jaw
Masseter: closes the jaw Obicularis oris: purses the lips Risoris: draws the lips in a smile Buccinator: pulls the lips wide and p
p
tight Depressor labii: lowers the lower lips Depressor anguli oris: lowers the bottom corner of the lips
bottom corner of the lips Levator anguli oris (not shown): raises the upper corner of the lips Pterygoid (not shown): pulls jaw back or shut Mentalis: pulls chin down http://www.yorku.ca/earmstro/journey/facial.html
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Facial Muscles
• Buccinator originates in the maxilla and mandible in the area of the molar teeth and inserts into various muscles at the corner of the mouth. – compresses the cheeks tight to the teeth and tightens and pulls the lip corners inward and somewhat laterally
pulls the lip corners inward and somewhat laterally
– It forms a large part of the lateral wall of the mouth. – It keeps food in the mouth where it can be masticated by the p
y
teeth. • Buccinator is innervated by the deep buccal branches of the facial nerve (VII) and is supplied with blood by the maxillary and facial (VII) d i
li d ith bl d b th
ill
df i l
arteries.
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Facial Muscles
• Orbicularis oris is the sphincter muscle around the mouth, forming much of the tissue of the lips. It has extensive g
p
connections to muscles that converge on the mouth. – Acts to shape and control the size of the mouth opening and i i
is important for creating the lip positions and movements t tf
ti th li
iti
d
t
during speech. • Orbicularis oris is innervated by the lower zygomatic, buccal, and mandibular branches of the facial nerve (VII) and is supplied with bl d b th f i l t
blood by the facial artery.
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Facial Muscles
•
Masseter is one of the most powerful muscles for its size in the body. It originates in the lateral part of the cheek bone (zygomatic arch) and inserts in th
the angle of the mandible. l f th
dibl
– It raises the jaw and clench the teeth. – This muscle functions to chew food and derives its name from the Greek for chewing and is associated with angry and aggressive states
for chewing, and is associated with angry and aggressive states. – When this muscle is chronically too tense, the abnormal condition called "Temporal‐Mandibular Disorder," also known as TMJ, can occur. •
Masseter is innervated by the masseteric nerve of the mandibular division of the trigeminal nerve (V) and is supplied with blood by the superficial temporal, maxillary, and facial arteries.
y,
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Facial Muscles
• Mentalis is so named because it is associated with thinking or concentration, although the justification for this view is lacking. i
lh
h h j ifi i f hi i i l ki
– It originates in the part of the mandible below the front teeth and inserts into the skin of the chin, and acts to push
teeth and inserts into the skin of the chin, and acts to push the chin boss upwards, wrinkling it and curving the lips upward in an inverted U. • Mentalis is innervated by the zygomatic branch of the facial nerve (VII) and is supplied with blood by the facial artery.
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Facial Muscles
Facial Muscles
• Zygomatic major originates in the cheek bone (zygomatic arch) and inserts in muscles (o. oris, depressor, etc.) near the corner of the mouth. – This muscle lifts the corner of the mouth obliquely upwards This muscle lifts the corner of the mouth obliquely upwards
and laterally and is a muscle that produces a characteristic "smiling expression.“
– Zygomatic major is innervated by zygomatic and buccal Zygomatic major is innervated by zygomatic and buccal
branches of the facial nerve (VII) and is supplied with blood by the facial artery.
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Facial Muscles
Facial Muscles
• The
The Platysma is the muscle out of which most facial muscles Platysma is the muscle out of which most facial muscles
evolved. It runs from the upper chest area through the neck to the lower cheek area.
– It lowers the lower jaw and lip, and tenses the neck to form It lowers the lower jaw and lip, and tenses the neck to form
noticeable vertical and/or horizontal ridges and depressions in the neck.
• Platysma is innervated by the deep cervical branch of the facial nerve (VII) and is supplied with blood by the suprascapular and facial arteries.
http://face‐and‐emotion.com/dataface/expression/muscle_facts.jsp
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Intrinsic Muscles of the Tongue
Intrinsic Muscles of the Tongue
Inferior and Superior Longitudinal
Muscle: go the length of the tongue
moves tip up and down
Transverse Muscle:
l go across the
th
tongue narrows and lengthens the
tongue
Vertical Muscle: go up and down in the
tongue flattens and depresses the
tongue
Voice & Speech Source; Journney of the Voice; Articulation; Facial
Muscles
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Extrinsic Muscles of the Tongue
Extrinsic Muscles of the Tongue
•
•
•
•
Genioglossus: chin to tongue; sticks g
p
g
out the tongue; presses against the teeth or alveolar ridge; pulls the tongue tip back; troughs the tongue Styloglossus: styloid process behind ear to tongue; pulls the tongue
ear to tongue; pulls the tongue upward and back Palatoglossus: palate to tongue; pulls the tongue back to grove the tongue H l
Hyoglossus: hyoid bone tongue; h id b
t
elevates the hyoid bone to tongue retracts or depresses the tongue
Voice & Speech Source; Journey of the Voice; Articulation; Facial Muscles
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Cranial Nerve Innervation
Cranial Nerve Innervation
•
Trigeminal (CN V‐3) Muscles of mastication: masseter ‐ temporalis ‐
pterygoid (lateral, medial)
(lateral medial)
•
Facial Nerve (CN VII) Mouth: levator anguli oris/depressor anguli oris ‐
levator labii superioris/depressor labii inferioris ‐ zygomaticus (major, minor) ‐ mentalis minor) mentalis ‐ buccinator buccinator ‐ orbicularis oris orbicularis oris – risorius
•
Glossopharyngeal Nerve (CN IX): Tongue and pharynx: stylopharyngeas, posterior one‐third of the tongue •
Vagus Nerve (CN X): muscles of pharynx and soft palate, vocal fold sensation
•
Hypoglossal Nerve (CN XII) Tongue: extrinsic (genioglossus, hyoglossus, chondroglossus, styloglossus) ‐ intrinsic (superior longitudinal, inferior chondroglossus, styloglossus) (superior longitudinal, inferior
longitudinal, transversus, verticalis)
http://en.wikipedia.org/wiki/Facial_muscles
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Cranial Nerve Innervation
Cranial Nerve Innervation
•
•
The Fifth Cranial Nerve, or Trigeminal Nerve, is the largest cranial nerve, The
Fifth Cranial Nerve or Trigeminal Nerve is the largest cranial nerve
and it carries fibers that give sensation to the face and motor fibers to the muscles of mastication. It exits from the brainstem through the antero‐lateral
antero
lateral surface of the Pons. surface of the Pons.
The Seventh Cranial, or Facial Nerve, consists of two parts: – The motor root, which supplies the superficial muscles of the scalp, face and neck
face, and neck – A smaller sensory root, which contains the afferent taste fibers for the anterior two thirds of the tongue and the afferent parasympathetic fibers for supply of the lacrimal and salivary glands
parasympathetic fibers for supply of the lacrimal and salivary glands
http://en.wikipedia.org/wiki/Facial_muscles
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Cranial Nerve Innervation
Cranial Nerve Innervation
•
The Glossopharyngeal, or Ninth Cranial Nerve is a mixed nerve consisting of an afferent part, which supplies the pharynx and tongue and the carotid sinus ff
hi h
li h h
d
d h
id i
and body. •
The Vagus, or Tenth Cranial Nerve is the longest of the cranial nerves. It supplies the pharynx and the soft palate. •
The Twelfth Cranial Nerve, or Hypoglossal Nerve, is a predominantly efferent nerve that supplies all the muscles of the tongue, both intrinsic and extrinsic, except the palatoglossus muscle. Source: The John Hopkins Atlas Of Human Functional Anatomy 2nd Edition 1977 by: Faculty Of John Hopkins University School Of Medicine Melvin H. Epstein, M.D. Donlin M. Long, M.D.
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B. Basic Assessment •
•
•
•
•
Case History
Oral‐Facial Examination
Swallowing
Articulation
Readiness for Therapy
Readiness for Therapy
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Assessment ‐ Case History
Assessment Case History
Focus Areas
Focus Areas
•
•
•
•
•
•
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Respiratory
Mi ll
Miscellaneous Medical history
M di l hi t
Dental
E ti H bit
Eating Habits
Oral Habits
P i
Previous Treatment
T t
t
Assessment Case History
Assessment ‐
Case History
• Respiratory Issues
p
y
–
–
–
–
–
–
–
–
Asthma
Allergies
Sleep apnea
Snoring
Chronic upper respiratory infections
Sinus problem
T il /Ad
Tonsils/Adenoids
id
Frequent colds
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A
Assessment ‐
t Case History
C
Hi t
Miscellaneous Medical History
– Frenectomy
– Hearing
• Frequent ear infections
• Placement of pressure equalization tubes
Pl
f
li i
b
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Assessment ‐ Case History
Assessment Case History
• Dental
D t l
– Development • Premature loss of teeth
– Orthodontics/Appliances
O th d ti /A li
• Palatal expansion
• Braces
• Retainers
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A
Assessment ‐
t Case History
C
Hi t
• Eating Habits
– Excessive liquid intake
Excessive liquid intake
– Resistance to; or excessive chewing
– Fast/slow eating
Fast/slow eating
– Digestive problems – Tongue thrusting during swallows
Tongue thrusting during swallows
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Assessment Case History
Assessment ‐
Case History
• Oral Habits
Oral Habits
–
–
–
–
–
–
–
Thumb sucking
Nail bitingg
Extended bottle/pacifier use
Lick lips excessively
Chew gum excessively
Anterior resting posture of tongue
Mouth‐breathing
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Assessment ‐ Case History
Assessment Case History
• Previous Treatment
Previous Treatment
• Speech therapy for articulation
– How long
– Which sounds were addressed
• Orthodontia
– Palatal expansion
P l t l
i
– Previous appliances
Was it successful?
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Assessment Oral‐Facial Exam
Assessment ‐
Oral Facial Exam
• Facial Features
Facial Features
– Symmetry/tone
– Observation of facial 1/3
Observation of facial 1/3’ss and 1/5
and 1/5’ss
• Lips/Tongue/Palate
p
g
– Structure, Position, Movement
– Inter‐labial gap measurement
e ab a gap easu e e
– Measurement of upper and lower lip length
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Assessment Oral‐Facial Exam
Assessment ‐
Oral Facial Exam
• Teeth
– Measurements of centric occlusion and centric relation – Measurement of maxillary arch width
• Oral‐pharyngeal
– Observation
Observation of velar structure
of velar structure and movement during
phonation
• Facial Features
Facial Features
– Symmetry
– Tone
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Assessment
• Observations and/or tactile assessment of /
orofacial muscle change from rest to g
movement during:
– Contraction of the masseter and temporalis during hard biting
– Swallowing with pureed (applesauce/pudding)
– Chewing and swallowing with cracker
g
g
– Swallowing with liquids
– Swallowing saliva
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What is an Oral‐Myofunctional Wh
i
O lM f
i
l
Disorder?
The preferred term, as this refers to all facets of this disorder:
• Abnormal tongue placement or lip movement for swallowing, but also…..
• Abnormal lip and tongue resting posture • Articulation differences or distortions • Oral/digit habits O l/di i h bi
• Structural abnormalities
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T
Tongue Thrust: A Definition Th t A D fi iti
Hanson and Barrett in 1988 define tongue thrust as follows: • Habitual resting or pushing of the tongue against at least ½ of the lingual
tongue against at least ½ of the lingual surface area of the incisors or cuspids, or protrusion between the upper and l
lower anterior teeth.
t i t th
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Tongue Thrust: A Definition
Tongue Thrust: A Definition
Hanson and Mason in 2003, define tongue thrust as Hanson
and Mason in 2003, define tongue thrust as
follows:
• When
When in resting position, the anterior or lateral portions of the in resting position, the anterior or lateral portions of the
tongue contact more than ½ of the surface of either the upper or lower incisors, cuspids, or bicuspids, or protrude between them; or • when, during the moving or swallowing of any 2 of these 3 media (liquids, solids, saliva) there is an observable increase of ( q
,
,
)
(1) force, (2) degree of protrusion, or (3) amount of surface area of the teeth contacted by the tongue
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Another definition
Another definition
The anatomical or physiological differences in the oral Th
t i l
h i l i l diff
i th
l
and facial structure are primarily related to the maxillary and mandibular muscles and to the skeletal
maxillary and mandibular muscles and to the skeletal and dental aspects of the face. These differences may be due to hereditary predisposition toward skeletal and dental differences or to environmental or d d t l diff
t
i
t l
developmental forces that occur postnatally.
(Kellum, Gloria, Ph.D. Orofacial Myology: Beyond Tongue Thrust, Chapter 1)
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Why does an SLP need to know Why
does an SLP need to know
about OMD?
• The majority of speech sound errors for OMD patients are j y
p
p
anterior distortions
• Tongue thrust swallowing is an anterior thrusting of the tongue
• Treating the articulation errors without recognizing and treating the biological functions of the tongue (resting posture and swallowing) may frustrate the patient and the clinician with
swallowing) may frustrate the patient and the clinician with limited success in therapy. (Pierce, 1980)
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Prevalence of OMD
Prevalence of OMD
• Nearly all newborns
• About ½ of the children in first grade
• The
The prevalence decreases gradually and inconsistently prevalence decreases gradually and inconsistently
through childhood but is fairly consistent in adolescence and adulthood at the 30% level.
• In the general population 30‐40% of individuals have an orofacial myofunctional disorder
Orofacial Myology Second Edition Hanson and Mason
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Additional points to ponder
Additional points to ponder
• Orofacial myofunctional disorders are of a multi‐
faceted etiological base.
• Orofacial myofunctional disorders are common oral facial differences that may have an adverse impact on a person’ss dentofacial development, cosmetic a person
dentofacial development cosmetic
appearance, psychosocial well‐being, and/or speech.
(Kellum, Gloria, Ph.D. Orofacial Myology: Beyond Tongue Thrust, Chapter 1).
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Causes of Tongue Thrust
Causes of Tongue Thrust
• Oral habits: thumb/finger sucking, extended / g
g,
pacifier use
– Habits that push the upper front teeth outward
– This can also create an inward pressure on the lower teeth, Thi
l
t
i
d
th l
t th
in particular the molars
• Respiratory issues: tonsils/adenoids, allergies, /
mouth breathing
– Possible
Possible airway obstruction
airway obstruction
– A low and anterior positioning of the tongue on the teeth and flaccid appearance of the lips is likely
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Causes of Tongue Thrust
Causes of Tongue Thrust
• Premature loss of baby teeth
Premature loss of baby teeth
– May result in the tongue moving forward into the spaces created by the missing teeth
• Lack of lingual coordination
–C
Causes difficulty in effective tongue movements and diffi l i ff i
d
posturing
• Malocclusions/dental treatment copyright MLW 2010
Causes of Tongue Thrust
Causes of Tongue Thrust
• Tongue size: macroglossia
Tongue size: macroglossia
• Hereditary/genetic influence
yg
– Where a child inherits mouth, jaw, or tooth structure, which may encourage tongue thrust habits
• Neurological: hypotonia, oral sensory deficiencies
• Cranial and body postures
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Dental Structure Review
D
lS
R i
Class I Occlusion‐ Typical
Class I Occlusion
Normal occlusion
where the upper teeth
fit over the lower teeth
like a lid on a box.
box
The upper arch is
slightly larger than
the lower arch.
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Dental Structure Review
Cl II
Class II
Skeletal problem where the
anterior portion of the
maxilla is too far forward
forward.
The molars are in a good
relationship.
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Dental Structure Review
Class III
Class III
Skeletal problem where the
mandible is protruded.
The upper arch is inside the
lower arch.
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OMD and Pressure
OMD and Pressure
• The light, consistent pressure of the resting posture, coupled with the heavier but more intermittent pressure of deglutition
with the heavier but more intermittent pressure of deglutition, mastication, bolus formation, and the lighter intermittent pressures of speech, do affect the dental architectures. Each facet may interact with the others in unknown ways to produce the total effect of dentofacial or structural change.
Orofacial Myology: Beyond Tongue Thrust
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Dental Differences
Dental Differences
• Dental
Dental differences, such as an extreme open bite, may result in differences such as an extreme open bite may result in
lip incompetence or the inability of an individual to keep the lips in contact during rest postures. An open bite may also precipitate an interdental tongue posture for rest and for swallowing. A history of mouth breathing has been closely related to inappropriate development of dental and skeletal pp p
p
structures. Persistent mouth breathing can also contribute to dental and skeletal jaw development changes.
Orofacial Myology: Beyond Tongue Thrust
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Anterior Open Bite
An opening at the front of the dental arch, while the
molars are in good occlusion.
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Anterior Open Bite
A more prominent opening in the front of the dental
structures. Molar occlusion is good.
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Bilateral Open Bite
Bilateral Open Bite
Open bite occurring on both sides of the dental arch.
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Bilateral openbite/forward tongue Bilateral
openbite/forward tongue
placement
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• Effects on oral/facial development
– Lips
– Cheeks and Chin
– Tongue
– Palate
P l t
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Low facial tone/lips parted/ Low
facial tone/lips parted/
messy eater
Cheeks show low tone,
upper lip long, lower lip
shorter
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Effects on Lips
Effects on Lips
• Anatomical changes, such as g
lip incompetence may be seen due to lack of appropriate lip closure.
• Lip closure may be obtained b i di id l ith OMD
by individuals with OMD, however muscle strain of the oral/facial muscles is noted
oral/facial muscles is noted.
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Low facial tone
Muscles
l not iin
use atrophy,
lose tone and
function
inefficiently
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Low facial tone/lips parted
f
l
/l
d
Muscles not in use atrophy, lose tone and function inefficiently
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Effects on Cheeks and Chin
• Occasionally cheeks are more floppy in appearance, rather than appearing to have good muscle tone
• Muscles of the face may not be doing their jobs appropriately or effectively
• There may be an over development of the mentalis muscle, observed by contraction during swallowing
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Open lip and mouth posture/ low Open
lip and mouth posture/ low
facial tone/tongue forward during swallow
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Eff t
Effects on Tongue and Palate
T
dP l t
• Articulation disorders
Articulation disorders
– Interdental tongue positioning for sound pattern
productions, particularly for sibilants (s, sh, ch, z, and j)
• Dental problems
– Tongue thrusting interferes with proper growth and
development of teeth
• Swallowing problems
S ll i
bl
– Ineffective chewing
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Eff t f OMD
Effects of OMD on Dentition
D titi
• Form or Function? – muscle imbalance versus structural abnormalities copyright MLW 2010
Functional activities
Functional activities
– Rest posture
– Effects on Articulation
– Effects on Swallow function
T
Tongue on the SPOT
th SPOT
• Tongue resting against the upper alveolar ridge – /n/ is the best locator
/n/ is the best locator
• Typical resting posture for the tongue
Nose versus mouth breathing
• Nose versus mouth breathing
• Lips are closed most of the time
• Some space exists between the teeth (freeway space)
• Typical tongue tip placement for swallowing
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Tongue on the SPOT
Tongue on the SPOT
• The tongue does not have to protrude between the teeth to be in an atypical position
• If the tongue is resting on the lingual surface of the teeth, this If the tongue is resting on the lingual surface of the teeth this
can also be atypical, yet not as easily detectable
• The tongue should not touch the lingual surfaces of the teeth for rest, speech, or swallowing
• An anterior tongue position in any placement can cause misalignment to dental structures
misalignment to dental structures
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Articulation
LOOK and LISTEN!!!!!!!
• Atypical tongue position may not result in acoustically incorrect speech sound
• Lingua‐alveolars that are produced with the tongue as lingua‐dentals are g
g
incorrect
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Articulation or OMD?
Articulation or OMD?
When should you look more closely at an y
y
articulation disorder or is it OMD?
• When
When the defining term is the defining term is “lisp”
lisp
• When sibilants are difficult to correct in treatment
• When the articulation diagnosis is accompanied by enlarged tonsils, open mouth posture, anterior open bite, and/or mouth breathing
g
p
g
• When single word productions are good but connected speech is difficult to master, particularly over a long period of time.
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Connection between OMD and Connection
between OMD and
Articulation
• In a study of kindergarten through 6th graders‐ 77% of those with abnormal /s/ and /z/ productions, also had an abnormal lingual g
rest posture
• And 50% of those also were tongue thrusting
(Wadsworth, et al 1981)
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OMD d S
OMD and Speech
h
• In appropriate interdental and linguadental sound productions seem to dominate the speech articulation problems found in OMD Many
articulation problems found in OMD. Many patients with OMD may have speech which is c a acte ed by o ta sp g
characterized by frontal lisping. These patients may ese pat e ts ay
also show prolonged need for traditional speech treatment services, unless the musculature issues are also addressed.
Orofacial Myology: Beyond Tongue Thrust
copyright MLW 2010
R
Research
h
Pierce (1996) found that...
In a survey of 100 patients, 50 who were diagnosed with tongue thrust, had articulation errors as well.
Therapy to retrain the muscle for swallowing can result in improvements in articulation
in articulation
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Dynamic function of the tongue
Dynamic function of the tongue
• If
If oral mechanism l
h i
examination indicates some possible OMD behaviors….
ibl OMD b h i
….then clinical observations of the then clinical observations of the
placement and function of the tongue and oral structures during chewing and swallowing are h i
d
ll i
necessary
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OMD l t d t
OMD related to swallowing
ll i
• An area of OMD also relates to dysphagia, as orofacial myofunctional differences may have a negative impact on the y
y
g
p
oral‐preparatory or the oral phase of swallowing. These difficulties may manifest themselves in poor bolus formation, poor or uncoordinated posterior transfer of a bolus through the
poor or uncoordinated posterior transfer of a bolus through the oral cavity, use of extraneous facial muscles for the process of initiating a swallow, and/or in the forward tongue movement during or immediately following the swallow.
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Swallowing Swallowing
• Normal
Normal vs. Abnormal vs Abnormal
Functioning
• FFocus is primarily on the i i
il
h
preparatory and oral phase of the swallow
h
f h
ll
– Assessing both solids and liquids
– Various severity levels of disorder
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Ab
Abnormal swallowing
l
ll i
• Abnormal Findings
•
•
•
•
•
•
Mentalis contraction
Mentalis
contraction
Lack of masseter contraction
Anterior loss of the bolus
Excessive or forced swallowing
Tongue Pumping
Poor bolus formation
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Abnormal swallowing findings from Abnormal
swallowing findings from
OMD evaluation
Inappropriate bite size
Use of liquids to clear foods from the mouth
fl
d
l
f d f
h
h
Chewing with the mouth open
Difficulty in isolating the tongue to manipulate the food
• Tongue forward or interdentalized during the swallow
•
•
•
•
copyright MLW 2010
Teaching the characteristics of the Teaching
the characteristics of the
“normal” swallow
• Educate patient of appropriate chewing patterns ‐practice gathering food into a bolus.
• Increase awareness of the masseter/“chewing muscles” – clenching, tension, biting to “pop” the muscle
• Teach correct placement of tongue for swallowing
– sequential positioning of the tip, mid‐portion, and back of the tongue
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Habituate the Normal Swallow
• Establishing habitual awareness and behavior by following a hierarchical level of skill
by following a hierarchical level of skill development:
–
–
–
–
Individual to consecutive swallows
Crackers to more typical diet
Sips of liquids to continuous drinking
fl
d
d k
Charting meals and monitoring progress of carryover
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Th
Therapy Goals
G l
Therapy goals should include: •Habituating a typical rest posture
•Habituating a typical rest posture
•Habituating a typical swallow function
•Habituating appropriate tongue movements for speech sounds.
p
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Contra indications for Treatment
Contra‐indications for Treatment
• Age
A
• Upper airway
• Cognitive level
• Motivation/Family involvement
Motivation/Family involvement
• Severe malocclusion
• Co‐existing neurological disorders i.e. hypotonia, CP
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What Approach To Treatment Is What
Approach To Treatment Is
Most Appropriate? Generalized remediation programs are available p g
that include specific, structured exercises and y
or lessons but ultimately……. …..the clinician must determine which interventions would best meet the specific needs of each patient!
ld b
h
ifi
d f
h
i !
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I t
Intervention
ti
• Treating the articulation errors without recognizing and treating the biological functions of the tongue (resting posture and swallowing) may frustrate the patient and the clinician with limited success in therapy. (Pierce, 1980)
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T t
Treatment Goals
tG l
• Build
Build better awareness and habituation of oral behaviors better awareness and habituation of oral behaviors
including correct resting posture
• Reinforce and establish appropriate muscle movements
R i f
d t bli h
i t
l
t
• Teach typical tongue function for swallowing and chewing
• Modify tongue positioning for accurate speech sound productions
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B
Beyond the Basics
d h B i
•When to Refer
•OMD Specialists/Team
i li /
•Treatment considerations
•Efficacy research
•Resources and references
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To Refer or Not to Refer???
To Refer or Not to Refer??? Clinical knowledge needs to be the guide
Cli
i lk
l d
d t b th
id
• I think there is a problem, now what???
• Need to decide what works best in your setting
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IAOM
• An Orofacial Myologist
• History of the IAOM
f h
• ASHA Position
ASHA Position
• ASHA
ASHA knowledge and knowledge and
skills
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A O f i lM l i ti
An Orofacial Myologist is…….
A person who has undergone specialized training
• to
to identify dental abnormalities and the impact of these identify dental abnormalities and the impact of these
abnormalities on functions of teeth and oral facial musculature
• can provide a more complete habilitative program than any other professional
• a resource for elimination of digit habits
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A O f i lM l i ti
An Orofacial Myologist is…….
• OMD specialists may be speech‐language pathologists, dental hygienists, dental assistants, dentists, orthodontists, or professionals in other related areas
f i
l i
h
l d
• Each
Each professionals has additional training or experience in at professionals has additional training or experience in at
least one of the areas related to OMD
• A
A certified OMD specialist has completed a written tifi d OMD
i li t h
l t d
itt
examination and site visit, per the by‐laws of the IAOM
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OMD Team
OMD Team
• As
As in many other facets of speech pathology, this in many other facets of speech pathology, this
disorder is treated most efficiently by a team, which may contain the following professionals or individuals:
‐
‐
‐
‐
‐
‐
General/Pediatric dentists
Speech Pathologist
Speech Pathologist
Oral & Maxillofacial surgeon General physician Certified Orofacial Myologist Parents/family copyright MLW 2010
‐ Allergist
‐ Otolaryngologist
‐ Periodontist
‐ Orthodontist
‐ Patient ASHA‐ Scope of Practice 1991
ASHA
Scope of Practice 1991
• Assessment and treatment of oral myofunctional y
disorders are within the practice of speech language pathology
• Published research indicates that oral myofunctional therapy is effective in modifying tongue and lip postures and movement
d
• SLPs who desire to perform oral myofunctional services must have the required knowledge and skills to provide high quality treatment
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ASHA‐Scope
ASHA
Scope of Practice
of Practice
• Appropriate goals should include retraining of labial and lingual resting and functional patterns
• Evaluation and treatment should be interdisciplinary and tailored to the individual
interdisciplinary and tailored to the individual
• Further research is needed regarding evaluation g
g
and treatment or oral myofunctional disorders.
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Orofacial Myofunctional Disorders: Orofacial
Myofunctional Disorders:
Knowledge and Skills
ASHA guidelines developed in 1993:
• Understanding dentofacial patterns and applied physiology pertinent to orofacial myology
• Understanding basic orthodontic concepts
• Recognition of the dynamics of etiological factors (airway, thumb sucking, anterior malocclusion)
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Orofacial Myofunctional Disorders: y
Knowledge and Skills
• Understanding interrelationships between speech and orofacial myofunctional disorders.
f
l
f
ld d
g
p
y g
• Demonstrating competence in identifying factors affecting prognosis
• C
Coordination of the treatment program with other di ti
f th t t
t
ith th
medical and dental procedures
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Orofacial Myofunctional Disorders: Orofacial
Myofunctional Disorders:
Knowledge and Skills
• Demonstrate a clinical environment appropriate to pp p
the provision of services
Demonstrate appropriate documentation of all appropriate documentation of all
• Demonstrate
clinical services
• Demonstrate
Demonstrate professional conduct within the professional conduct within the
scope of practice for speech language pathology
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International Association of International
Association of
Orofacial Myology (IAOM)
• Began in 1972, pioneered by a small group of speech‐
l
language pathologists; later joined by other dental h l i
l
j i db
h d
l
professionals
• "set standards for qualification as an oral myo‐therapist and to create a profession“
• IAOM publishes an annual journal; articles published are from dental professionals as well as SLPs
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C
Current IAOM Initiatives
t IAOM I iti ti
• Increasing certification
• Continuing education and training
C i i
d
i
d i i
y
• Efficacy research
• Standardization measurements
• IAOM website
copyright MLW 2010
How to get more training?
• IAOM website (www.iaom.com)
– continuing education courses
g
– contact information for orofacial myologists in your area
– publications and research
bli ti
d
h
• ASHA website
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Efficacy Research
Efficacy Research
Through a retrospective analysis of over 100 subjects g
p
y
j
(predominately ages 5‐20) dental measurements were used to show that myofunctional therapy can..
• improve dental occlusion, decrease dental open bite, and decrease dental overjet;
• age was not necessarily a factor in predicting success of age was not necessarily a factor in predicting success of
a therapy program;
• improvement of open bite and overjet can result from OMT without prior or concurrent orthodontic (Benkert 1997)
intervention.
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A d th
And the research says.....
h
Hahn and Hahn (1992)
• Subjects: 98 children
Subjects: 98 children
• Ages 6‐18 years • Approx. 5 years after discharge from myofunctional therapy..70‐80% were still swallowing correctly, maintaining correct lingual resting posture day and night and had
correct lingual resting posture day and night, and had habituated consistent nasal breathing. copyright MLW 2010
A d th
And the research says, continued
h
ti
d
In a survey of 100 patients enrolled in a program of traditional tongue thrust therapy, all of the patients were successful in correcting the resting posture of the tongue and lips and in correcting
posture of the tongue and lips and in correcting the swallowing pattern in 10‐12 treatment sessions.
sessions
Pierce, R. (1996)
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Resources and References
Resources and References
• Ackerman, R.L. & Klapper, L. (1981). Tongue Position and Open‐
bite: the Key Roles for Growth and the Nasopharyngeal Cavity. Journal of Dentistry for Children, 48, 339‐345. • American Speech‐Language‐Hearing: Position Statement and Guidelines on Myofunctional Therapy. www.asha.org
• American Speech‐Language‐Hearing Association, Ad Hoc Committee on Labial‐Lingual Posturing Function. (1989). American g
g
(
)
Speech‐Language and Hearing Association. 31, 92‐94.
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R
Resources and References
dR f
• American Speech‐Language‐Hearing Association, Ad Hoc Joint Committee with the International Association of Orofacial Myology. (1993). Orofacial myofunctional disorders: knowledge and skills. American Speech‐Language‐Hearing Association. ASHA Suppl. 35(3 Suppl 10), 21‐3.
• American Speech‐Language‐Hearing Association. (1991). The role of the speech‐language pathologist in assessment and management of oral myofunctional disorders ASHA 33 (Suppl
management of oral myofunctional disorders. ASHA. 33 (Suppl. 5), 7.
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R
Resources and References
dR f
• Barrett, R.H., & Hanson, M.L. (1978). Oral Myofunctional &
(
)
l
f
l
Disorders. St. Louis: The Mosby Company.
• Benkert, K. (1997). The effectiveness of orofacial myofunctional therapy in improving dental occlusion. International Journal of O o ac a yo ogy o 3
Orofacial Myology. Vol. 23.
• Christensen, M. & Hanson, M. (1981). An investigation of the efficacy of oral myofunctional therapy as a precursor to
efficacy of oral myofunctional therapy as a precursor to articulation therapy for pre‐first grade children. Journal of Speech and Hearing Disorders. 46, 160‐167.
copyright MLW 2010
Resources and References
Resources and References
• Hahn
Hahn, V., and Hahn, H. (1992). Efficacy of oral myofunctional V and Hahn H (1992) Efficacy of oral myofunctional
therapy. IJOM, 18.
• Hanson
Hanson, T.E. & Hanson, M.L. (1975). A follow‐up study of T E & Hanson M L (1975) A follow up study of
longitudinal research on malocclusions and tongue thrust. International Association of Orofacial Myology. 1, 21‐‐28.
• Hanson, M.L. & Mason, R.M. (2003). Orofacial Myology: International Perspectives. Springfield, IL: Charles C. Thomas • International Journal of Orofacial Myology (IJOM) www.iaom.com
copyright MLW 2010
Resources and References
Resources and References
• Nelson, M. (2001). http://www.southwestoralmyo.com/omdinfo.htm
• Pierce, R. (1980). The role of myofunctional therapy in speech pathology. IJOM, 6.
• Pierce, R. (1996). Age and articulation characteristics: A survey of patient records on 100 patients referred for “tongue thrust f ti t
d
100 ti t f
d f “t
th t
therapy”. IJOM, Vol. 22. • Pierce
Pierce, R. (2002) Swallow Right: An Exercise Program to R (2002) Swallow Right: An Exercise Program to
Correct Resting Posture and Swallowing Patterns. Austin, Texas. Pro‐Ed
copyright MLW 2010
Resources and References
• Umberger, F.G., Johnston, R. (1997). The efficacy of oral g ,
,
, (
)
y
myofunctional and coarticulation therapy. IJOM, 23, 3‐10.
• Van
Van Norman, Rosemarie: Digit
Norman, Rosemarie: Digit‐sucking:
sucking: A review of the A review of the
literature, clinical observations and treatment recommendations (1997). IJOM, 23, 14‐35
• Warren, J.J., Bishara, S.E., Steinbock, K.L., & Nowak, A.J. (2001). Effects of oral habits’ duration on dental characteristics in the primary dentition. Journal of the American Dental Association. i
d ii
J
l f h A
i
D
lA
i i
132, 1685‐1693.
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R
Resources and References
dR f
• Wilder, T. and Gelesko, A. (1997). Lingual Frenums and Frenectomies. IJOM, 23, 47‐49. • Zickefoose, W. (1990). Techniques of Oral Myofunctional Therapy, Sacramento, CA: OMT Materials
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