How to Handle Certain Situations: 1. You are meeting tomorrow with an orthodontist who refers patients to you. The most recent referral arrived for your orofacial myology examination wearing a tongue guard. What can you say to the very adamant orthodontist who strongly believes in the tongue guard even if therapy cannot be initiated with it in place.
1) The tongue guard does not serve to teach a normal rest position for the tongue – which is the main goal. 2) While a tongue thrust can be temporarily discouraged with a tongue guard, kids can push their tongue forward under the guard – and quickly learn to do so. Direct the orthodontist to the position paper about appliances for habit problems. https://orofacialmyology.com/wp-content/uploads/2018/10/orofacial-myology-position-statement-regarding-appliance-use-for-oral-habit-patterns.pdf 3) And most important, the tongue guard encourages the freeway space to be opened beyond the normal range. This is the opposite of what we want since a freeway space open beyond the normal range leads to continued eruption of posterior teeth and an opening of the bite anteriorly. 4) Also, orofacial myology can correct problems without an appliance and you are within your rights to insist that the guard be removed or else you cannot establish a proper rest posture of the tongue and retrain the tongue during swallows. 2. Palatal expander. An orthodontist recommended a palatal expansion after myofunctional therapy for an 8 year old. You explained that the palatal expansion should take place before orofacial myology treatment. The orthodontist said she felt that therapy should go first so the tongue would widen the palate. Will the tongue widen that palate at 8 years of age? Can you help me to understand why the tongue is not going to widen it. Is it because of the patient’s age? Is there an age at which the tongue will naturally widen a narrow palate? Actually, no. The palate naturally widens by a process of apposition (adding) bone on the oral surface and resorbing bone on the nasal surface of the palate. You can mention the work of Enlow and Hans here whose book Essentials of Facial Growth. The role of the tongue at rest is useful but not a major contributor. Expecting the tongue to naturally widen the palate at any age, especially 8, is not a reasonable goal. The point is that if the orthodontist can widen the palate and then allow you to adapt the tongue rest posture and functions to that expanded position, this is the recommended protocol; the house needs to be fixed before the tongue can properly function in the environment in which it resides. With a narrow palate, the tongue is encouraged to thrust forward at rest and during function to adapt to the narrow maxilla. Here again, I would decline treating this kid if OMT is mandated by the orthodontist first. 3. Slide: I have a slide of a very narrow palate. Would this better be filed under my section on ‘consequences’ or under the section for ’causes’ of OMDs? A narrow palate can be either 4. Tongue guards – I looked in the literature and could not find any articles to tell me why orthodontists use these. Is it because they believe it is the best way to close the bite? Do they feel it is a more convenient and easy way to address open bites? Why do they opt for this….is it based on research and training? Orthodontists and other dentists use such appliances because they do not know any different — and it up to the therapist to educate them to the advantages of therapy and the disadvantages of appliance use. There are studies they cite – Greg Huang and colleagues at the University of Washington; however, such studies do not report on the characteristics of patients being treated with appliances (such as the status of the airway) nor whether they have an anterior rest posture. They only focus on the thrusting, and show no data about whether the habit returns following the cessation of appliance use. You should point out that, with good intentions, orthodontists focus on tongue thrusting rather than rest posture, and few even note if there is a forward rest posture of the tongue when they do record that a thrust is there. This can be your primary message here — the importance of the rest posture and that thrusting itself does not move teeth, as eloquently reported by Proffit and colleagues in many oral transducer studies (and the references are all on the For Dentists and Physicians document on the website https://orofacialmyology.com/files/FOR_DENTISTS_AND_PHYSICIANS.pdf — as is the position statement on appliance use. Anytime you get stuck, just refer to that article and position statement — written by an orthodontist who has studied such issues and written more than anyone else. Dr. Robert Mason