Long Time R Problem

Hi Sandra,

 

I am taking your /r/ e-course right now and have a question for you about a 9-year-old client who was diagnosed as an infant with a tongue tie but parents were advised not to have it clipped at the time.   As a result, he had tremendous feeding problems which mom recalls were a “nightmare.” Too bad, his pediatricians were so uninformed…sad.   His 2-year-old brother was also born with a tongue-tie but had it clipped at birth and subsequently had no feeding issues. D, I’m seeing so very often a genetic component.

This client has good range of motion with his tongue, (protrusion, retraction, elevation, etc.), Somehow, I can’t imagine that he has a good range of motion, protrusion and elevation based on what you say in the next few sentences.  Maybe the mid portion of the body of the tongue is compensating for his other difficulties and it appears that these functions are within normal range, but I truly doubt it.  however, I’ve noticed that when he retracts and elevates his tongue to produce a vocalic /r/, he raises his jaw and cannot keep his mouth open. I looked under his tongue and saw that the lingual frenum was anchored close to the floor of the mouth thus making it impossible for him to keep his mouth open while retracting and elevating the tongue. We look at several things here, D.  First of all, look at where the frenum inserts into the floor of the mouth.  Is it on or right below the lower alveolar ridge?  Or is it fairly far back on the floor?  Also, look where the frenum inserts into the tongue itself.  Is it about midway or is it closer to the tip?  Or is it far down at the base of the tongue?  Now check and see if it seems to be embedded into the tongue tissue above the place where it appears to attach to the underside of the tongue.  Look at the length of it.  And check if it is thick or thin, flexible or inflexible.  All of these are considerations and how they “come together” is important.  Get back with me, being sure to send this portion of our emails since I sometimes get so busy that I mix up one email with another.  We are also finding it common for the ankyloglossic person to have a ankylo’d labial frenum.  Look under his upper lip and see if the frenum on the underside is too close to the teeth.  It should not be tight or causing the upper lip to be pulled at all.   He also has a high, narrow palate with a long narrow face. I have found so many /r/ kiddos with high narrow palates that I don’t need a study to tell me the two often go hand in hand. 

I advised his mother to speak to an ENT about the tongue tie to see if anything could be done.  She hasn’t gone yet so I wanted to ask you if you have any research on clipping the frenum and improving production of vocalic /r/.  I don’t know of specific studies since I have worked for so many years on this type of problem that I didn’t care if someone found out that my observations and therapy was provable or not…..it only makes sense that with a restricted tongue AND a high narrow palate that one cannot obtain and maintain the ER sound.  It is impossible and a study would probably be very easy to do if you have enough clients…since it is likely that 100% would have difficulties.   Any other information you could provide would be very helpful.  I am the third SLP he has seen since he was 5 and the first one to point out the high palate and the fact that the tongue tie may be preventing progress on the vocalic /r/.  Again, a sad state of affairs that past therapists didn’t bother to look in his mouth before making him feel like he was a loser who couldn’t get the doggone /r/ sound habituated.  I truly empathize with the frustration he has experienced in not being able to change this sound error.  When I told him that the difficulty he was experiencing may not have to do with his inability to work hard and do what is asked of him but rather something structural beyond his control, he was so relieved he let out a huge sigh. I just consulted with another SLP in South Florida with a 9 year old boy; same story!  And last week I saw a 17 year old young man here in Orlando who took therapy for /r/ during his entire elementary, middle school and high school years…to no avail!!!  D, trust your “gut” about these things.  

     Here is what I would do IF he is ankyloglossic (use my criteria above and get back with me):   

I think this young man and his family are very fortunate to have found you, D…truly.  You will be able to give him the right direction and I will help you…let me know your findings and …good for you for looking deeper than the others did, for seeking  information from the online course, for emailing me….we need more SLPs like you!

My best,

Sandra Holtzman

 

 

Lip Incompetence and Over Jet, Over Bite

Posted by | Jun 15, 2015 | Tags: ,
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I wanted to get your thoughts on whether lip incompetence in an adult (in their 30’s) that has an overjet and overbite can be remediated through lip stretching exercises. Is it worth it to try?


 

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Pain during post frenectomy rehabilitation phase

In adult patients with TT, do you find less pain in the post frenectomy rehabilitation phase when a period of pre habilitation is undertaken, in essence conditioning the musculature as much as possible?


 

Importance of Proficiency Exam #1

Are there exercises in your manual that will help a child who has difficulty in lifting the middle and back of the tongue enough to suction it to the palate?


 

CVA with noted aphasia

Posted by | Apr 15, 2015 | Tags: ,
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I just screened a new resident post CVA with noted aphasia in her record and some dysarthria. On exam, her tongue had a fairly significant fissure at midline. Any recommendations for healing?


 

Could an improper oral rest postures/enlarged tonsils/inconsistent mouth breathing completely inhibit the ability to produce /k,g/?

I recently picked up a six year old boy who has been in speech therapy for years for production of velars. He consistently fronts /k,g/ and is not stimulable for the sounds.


 

Nine years old, forward tongue thrust

Posted by | Mar 15, 2015 | No Comments

I had a patient yesterday. Nine years old, forward tongue thrust. Severe allergies and asthma. These are under control as much as they are going to be. Age 9. To see orthodontist soon. So, is this one that I take as far as possible knowing it will not correct totally?


 

Swallow Right manual

Posted by | Feb 28, 2015 | Tags:
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I just ordered the Swallow Right manual. Do you think it will help with this feeling that I have that I do not know how frequent and long to have the patients work each exercise?


 

Must I wait until a palatal expander is taken out to begin therapy?

Posted by | Feb 15, 2015 | No Comments

I used to take kids who could suction flat with the expander, but there are too many other considerations.


 
ankyloglossia ASHA certified orofacial myologists decision to quit diastema Dr. Robert Mason drooling freeway space frenectomy habituation hyoid bone IAOM incisive papilla lack of expressive language lingual frenectomy lingual frenum lip licking habit lip strength lisp lower alveolar ridge malignant sleep apnea myofunctional therapy Myo Manual narrow palate open bite oral motor orofacial myofunctional disorders orofacial myology orofacial myology treatment palatal expander post frenectomy quick tongue tie assessment restricted lingual frenum sleep apnea speech language pathologist sucking habits suctioning thumb thumb sucking TMJ tongue exercises tongue thrust tongue tie tongue to spot unplugging the thumb