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Orofacial Myology Newsletter - Aug 2024

Let’s Get this Over With, Please!

I doubt there is anyone among us that has not had a client or parent who is impatient, who wants to expedite treatment, who is skeptical about possible progress.

The title of this article brings to mind a session where I was not the main therapist but rather was asked to do a consultation with a course graduate, an SLP that had recently taken her training. A parent was present in the therapy session of her 9 year old son who had been referred for an articulation disorder. The therapist was doing the right thing to set the stage for success. She was providing the basics of “myo” rather than using the “ancient” method of jumping into specific sound issues right off the bat! The young man had been seen for three sessions and was progressing nicely as was expected. The parent was adamant in her insistence that time and money were being wasted on exercises of the mouth rather than directly working on the speech problem itself.

What went wrong here, if anything? What do we do in this circumstance? Is it too late?

We don’t want to lose our client to another therapist that lacks training in myo. We don’t want to have the parent feel that money or time is being wasted. Most especially, we don’t want to “cheat the child” by skipping the steps that we know are necessary to achieve final habituation of the targeted error sounds. Unfortunately, this puts us into a position where we now are forced to try to salvage the situation:

  • We must go back to our assessment report to review with the client/parent each area where a weakness was found.
  • We must point to the steps in our treatment program that will be addressing those areas.
  • Then we must do our best to explain how specific exercises and activities will be provided to maximize the weaknesses.
  • Lastly, we have to point out how speech is affected adversely because of certain findings in our assessment.

As much as I dislike “shoulda done”, “woulda done”, and “coulda done” when looking back on something, it is necessary to do so in this case. I can’t emphasize enough the importance of that first meeting when the evaluation takes place. It is critical to practice your skills explaining each step of your assessment as you examine the client. You should be carefully tying the findings together as you proceed. This way, the patient (or parent and child where applicable), will fully understand the “why” even before you complete your exam.

Voila! Perhaps it sounds too easy? Perhaps you feel you aren’t convincing enough? That will not be the case if you have practiced your explanations for each exam step. The more confident you are in your treatment program, the easier it will be to describe in easy-to-understand words exactly what your plan of action is for their success.

By doing this, you have taken them bit by bit down the pathway from curiosity (and sometimes anxiety) to the finish line, and they feel part of that process. Now they will want to know how often treatment is recommended, how many sessions might be expected, what the cost will be, and “When can we get started?”

Can Myofunctional Therapy Help Halitosis? – Karen Wuertz, DDS, QOM

Before we can answer this question, we must look a little deeper. Halitosis, or bad breath, can stem from a variety of factors in your mouth and even beyond the mouth. Key contributors are poor oral hygiene, dry mouth, eating “ stinky” foods, smoking, alcohol, coffee, dehydration, certain medications, and mouth breathing. In some cases, halitosis can even be a sign of an underlying medical condition, such as a sinus infection, acid reflux disease (GERD), diabetes, or even liver or kidney problems.

Psychological factors such as anxiety and depression can also play a role in stimulating the nervous system, producing less saliva when a person is stressed. Saliva plays a vital role in washing away food debris and dead cells in your mouth. When your mouth is dry, this natural cleansing process is hampered, allowing bacteria to flourish. Dry mouth can stem from a reduction in the quality and quantity of saliva, thus allowing food particles and bacteria to build up on the teeth and tongue. This bacteria releases sulfur compounds and frequently is the culprit that causes the unpleasant odor.

As health care providers we play an important role in identifying signs and symptoms of dry mouth (also known as Xerostomia). As part of our oral evaluation, a thorough review of medical history, medications, risk factors and oral habits should be identified. It is also important to notice the quality, quantity and consistency of the saliva. Common presentations can be described as white, frothy, thick, ropey or stringy.

Myofunctional therapy can address halitosis (bad breath) in several ways, though it's important to note that it might not be the sole solution. Several goals of orofacial myology that are relevant include:

  1. Retraining of the muscles of the face and mouth
  2. Improving lip seal
  3. Restoring nasal breathing
  4. Improving tongue posture

Thinking about the importance of these goals, we can understand how some clients will be benefitting from therapy. When the tongue cannot adequately move around the oral cavity, it does not allow for the best oral hygiene. When there is mouth breathing or poor lip seal, these can cause saliva to leak outside of the mouth instead of remaining inside the mouth where it plays important role in the digestive process.

While therapy can help with bad breath caused by dry mouth as described, we must keep in mind that it might not address other underlying causes of halitosis. If bad breath persists, a dentist or doctor can help identify the cause and develop additional treatment.

When an Orofacial Myofunctional Disorder Lingers in the Shadow of Oral Apraxia – Zohara Nguyen, CCC-SLP, QOM

Introduction “He had no clue as to how his articulators worked or moved” - Rebecca, an SLP, recalls about her client, Xavier, before he began myo treatment with her. Xavier’s story is being shared to exhibit a case where orofacial myofunctional disorders (OMDs) emerged from the shadows of comorbid apraxia and articulation disorder diagnoses. Imagine a 5-year-old boy that loves nature - frogs, critters, spending time outdoors. He’s handy with scissors and paper and even makes his own little puzzles. Yet his speech can not be understood by most people. His own family can’t understand only about 60% of what he says. He has been labeled simply as “apraxic”.

The Initial Diagnoses and Background

Xavier had had a complex smorgasbord of conditions and challenges in his first years of life: difficulty breast and bottle feeding, oral phase dysphagia, failure to thrive, lingual and labial restrictions, expressive language issues, and poor lingual mobility. He had been in speech-language therapy since he was 2-years old due to delayed and unintelligible speech. He also received feeding therapy in his early years. Additionally, no improvement was observed in his lingual mobility and function following the release of his lingual and labial restrictions at 2 years, 8 months (which occurred during the height of COVID and there were no prescribed post-op aftercare/exercises).

Two years later in May, 2022, another SLP diagnosed him with Oral Motor Apraxia using the Kaufman Speech Praxis Test. He could not imitate many of the oral commands asked of him - protrusion, lateralization, or elevation of his tongue; however, he could do some of the lip movements. Interestingly, he was diagnosed only with Oral Motor Apraxia and did not meet the criteria for a Verbal Apraxia diagnosis “since his articulation errors were consistent”.

Xavier’s speech was a mechanical and auditory tangle. He was formally diagnosed with “severe articulation disorder”, which his SLP suspected was related to his Oral Motor Apraxia. The mechanics of his speech were characterized by oral groping and “constant movement” of the tongue. As he tried to navigate sounds, long pauses between speech sounds appeared as though he was “figuring out” how to articulate, and he demonstrated an inability to accurately move his oral musculature on command. Auditorily, his speech had a fast rate and was “clutter-like”, characterized by poor clarity and hypernasality of most speech sounds. As a result of the latter, he was assessed for velopharyngeal insufficiency but the exam was unremarkable. The most aberrant and curious speech errors were his vocalizing upon inhalation, the production of /n/ for /l/, and his production of /t/ with a “tongue-smacking” sound (imagine using the dorsum of your tongue to break lingual-palatal seal in the middle of your palate). Any clever person will use oral compensations to get as close as to a speech sound as they perceptually can, and considering his history of lingual restriction and oral motor apraxia, this sounds like one such compensation that he had acquired.

By 2023, speech intelligibility was significantly below age expectations and was estimated to be, shockingly, 30% intelligible to strangers, meaning only 30% of what he said could be understood by people unfamiliar to him. He was only 60% intelligible to his family - he should have been 100% intelligible to everyone. It is no surprise that a knock-on effect of his poor speech intelligibility was that he did not talk to strangers, not even to the ice cream scooper to request his favorite ice cream flavor and toppings.

Xavier received intervention from both his school SLP and a private SLP to target his articulation disorder with the goal of improving overall speech intelligibility. Childhood Apraxia of Speech interventions were not used since he did not fit this diagnosis. His progress in speech-language therapy over the years was slow and minimal.

What led to the idea of using Myo on an apraxic client like Xavier?

The purpose was to reveal and treat underlying OMDs that were buried, easily missed, or masked under his Apraxia and Articulation diagnoses.

The Myo Diagnosis:

Myo crossed paths with Xavier just at the right time. Rebecca had previously worked with him in a preschool program for a year while he was 3 years old. She couldn’t shake the feeling there was a “missing link” in his case. “Why hadn’t he gained progress in prior therapies?” and “Was there something else co-occuring with the Oral-Motor Apraxia and Articulation Disorder Diagnoses”? After years of wanting to learn more about myo and no longer working in the schools, she trained with Neo-Health, and then reached out to Xavier’s family to offer him a therapy that had not yet been explored. His mother, an OT, had already been researching Myo and had wondered if it could help her son. He was also at the perfect age to begin Myo - the stars had aligned! There were no promises that it would help, but desperate times called for innovative measures…

In April 2023, Xavier began a journey that unearthed and treated a previously undiagnosed orofacial myofunctional disorder (OMD) that subsequently improved his speech, confidence, and orofacial function forever. Rebecca conducted an Orofacial Myology evaluation on Xavier, revealing that he presented with an Orofacial Myofunctional Disorder characterized by the following: open mouth posture and mouth breathing, dry lips, low tongue rest posture, inability to elevate or shape the tongue as requested, disordered movements of the tongue, lingual-mandibular differentiation difficulties, inability to suction tongue to the palate, hyperactive gag, munch-chewing pattern, pocketing of food in the buccal cavity, inability to create and propel a bolus correctly, and excessive liquid intake with food swallows. He did not appear to have any neuromuscular deficits such as paralysis or weakness. He had no history of noxious oral habits.

Feeding and swallowing issues remained significant. The case history intake and examination revealed that he overstuffed his mouth with food and had difficulty coordinating his oral structures when eating. He dropped food on its way to his mouth. He open-mouth chewed and was observed to facial grimace when eating. He experienced previous coughing and choking episodes and had previously required the Heimlich maneuver during one such choking episode. This meant his mother had to cut up his food into small pieces for safety and keep a “close watch” on him during meals.

The Journey

In April 2023, one year of Myo treatment began with his mother as an active participant in his weekly sessions. Rebecca used the Orofacial Myology: From Basics to Habituation Program, tailoring and pacing treatment to Xavier’s individual needs. Within the first session, Xavier experienced a monumental breakthrough. With his mandible stabilized, Xavier was able for the first time to briefly isolate his tongue from his mandible to elevate it! Rebecca believes it was this oral motor skill that paved his path to progress. He and his mother worked hard every day as he sat on the bathroom counter, practicing in the mirror. Over the course of the next few months, Xavier made impressive gains in his lingual coordination and accuracy, especially with lingual-mandibular differentiation and tongue elevation. Though oral fatigue remained a challenge, within 3 months working on myo with some articulation work carefully integrated, his tongue clicking on /t/ in isolation and in single words was resolved!

By mid-December, 2023, Xavier had achieved amazing progress considering his oral-motor apraxia diagnosis. He had mastered numerous lingual-basic training skills, lingual-mandibular differentiation across all planes, lingual-palatal suction, shaping of his tongue… the skills and criteria usually expected of his peers who only have OMDs and not apraxia. It was an impressive feat after years of essentially being at a therapeutic plateau. In myo he completed the lingual skills with accuracy and consistency. He eased nicely into more sophisticated motor tasks for Chewing and Swallowing Mechanics. Like a duck to water, he learned to suction, trap and swallow liquid.

Throughout treatment his apraxic tendencies remained. In February 2024, he demonstrated difficulty coordinating the steps for suctioning water on command and instead was blowing the water. When prompted to “suck like from a straw”, it was still a challenge for him and for the therapist. Like many children with complex cases, Xavier was sometimes behaviorally challenging. He became frustrated when some tasks were too hard. Rebecca managed to creatively navigate his behavior to set him up for success.

The Light at the End of the Tunnel

One year into myo therapy, Xavier’s progress was astounding. He was surprised at the leaps and bounds he had accomplished during the past year. Whereas he previously could not coordinate even one oral skill on command, he was now able to perform multi-step oral skills .

In spite of some lingering articulation errors, he was now remarkably 100% intelligible to strangers and family with spontaneous speech in conversation. He was passing the proficiency exams in therapy and breezing through all the therapy stop points. As he worked towards incorporating and habituating his skills into his daily life, his mother found that Xavier no longer was at risk of choking, and he did not need monitoring at school during mealtimes by the school nurse. His mother no longer had to cut up his food into small pieces and no longer had to supervise him. He no longer pocketed food and he swallowed without using water to assist bolus propulsion. His oral kinesthesia improved and he now had awareness of where his tongue was in his mouth.

Xavier’s speech, confidence, and orofacial function were almost unrecognizable from one year prior. His tootbrushing and hyperactive gag during dental examination had normalized. Family members whom he hadn’t seen often were remarking that they could understand him, much to the relief of his mother who had been acting as his “translator”. He was able to attend school and no long had the fear of not being understood. He was pleased that he could eat alongside his peers in the cafeteria. When he was asked “Who do you like to talk to?” he responded “everyone”. When his mother reminded him that in the past he did not talk to everyone, he agreed and said “but now I like to!” His confidence blossomed over the past year, and he gained control and agency over his oral-motor coordination. His mother admitted that she had been prepared for him to be in therapy until he was 20 just to be understood by others. Recently, Xavier’s mother and Rebecca spoke on the phone, and it was reported that Xavier is now a confident child that talks to new people and is independently ordering his own favorite toppings for his ice cream at the ice cream parlor. What a sweet resolution for a boy who seemed entangled in a web of comorbid diagnoses.

When Patience is a Virtue: Therapist worried about oral habit of her 19‑month‑old son

Q: A: My son is 19 months. He sucks his two fingers (middle and ring finger). He does it quite often (before sleeping, in car, when watching tv). I obviously am concerned and worried for the future. I brought him to a pediatric dentist and he informed me that as of right now there is no damage. He hasn’t shifted anything in his mouth yet. I guess my questions are “Is he too young to stop? If no, how can I get him to stop?” Are there any devices to help assist with this like an orthodontic pacifier or something?

A: Regarding your son, unfortunately there is no acceptable method to eliminate the habit at his age based on my prior experience, both as a therapist, mother, and grandmother. If you are able to substitute an orthodontic pacifier on occasion, it might be somewhat helpful since it will be easier to eliminate it in the future. I have had success introducing habit elimination with a few children that were 3 ½ to 4 years old. When he reaches that age, if you feel he has the reasoning ability to present the program, you might consider addressing it at that slightly earlier age than the recommended 4 years. I know it is hard to ignore this habit because of everything you have learned in your training but approaching it in a relaxed manner is the best advice I can offer. It is probably wise to set your mind to accept it for the time being. On a personal level, I had to practice my patience for my own son and eventually for a granddaughter with oral habits. Both of them have lovely dentition today and excellent speech. I hope this brings you some peace of mind.

In December 2023, I had a couple of days off and my knowledge-seeking mind brought me to AGD’s website where I found the course on orofacial myology by Neo-Health Services. It was an intense 3-day event packed with information and hands on training which blew up my mind and changed forever the way how I diagnose and treat patients. It is amazing that in my 16 year dental career I never thought about this different orofacial myology aspect of the diagnosis and treatment of dental patients.

I did not know anything about orofacial myology prior to taking the class and felt ashamed that all the SLPs attending my training already knew so much more. I realized that I had been stuck in one place with my treatment protocols, and the course opened a new horizon for me and my dental office.

Prior to my myo training, I was not fully considering soft tissues and muscles as primary reasons for certain malocclusions. After my training course, I am following a protocol to consider function first before anatomy. I had been working on multiple orthodontic cases and was always puzzled by the high relapse chance with certain cases. Solving the soft tissue and muscles memory missing parts during the training has helped me reduce the relapse cases. Dealing with happy patients after a comprehensive orthodontic treatment is our priority.

My plan is to get my hygienists and associate doctors qualified in orofacial myology so we all have the same view on oral conditions. Also having a specific area in the office designed to myo will be ideal. Diagnosing and treating dental patients after I took the myo course will never be the same. Having a more broad and complex view on procedures incorporating not just anatomy but function will be my go to approach.

Outside the Mouthbox: Catherine's Story – Becky Ellsworth, BS, QOM

The impetus for writing this article stems from a long talk I recently had with a trained Orofacial Myologist about her traumatic childhood experience involving fixed oral habit appliances. Her story was painful to listen to but not as painful as what she had to live through…

Imagine that you have been a committedly intense thumb sucker all day and all night long, starting from birth. It comforts and soothes you like nothing else. Because they care, your parents repeatedly discourage you verbally and have started applying a vile tasting polish to deter the habit. If any wet polish remains on your nails, it burns your eyes when you wipe them. By trial and error, you figure out by sucking it all off when first applied, you can resume your sucking without care. As years pass, you develop an anterior open bite. Since you suck your thumb at school or wherever you are, not surprisingly, you are considered “different” and you are a loner with no friends. At the age of seven, not knowing what else to do, your parents take you to a local orthodontist for help. His “help” is cementing an oral habit appliance (a crib/cage, rake/spurs or other) into your palate with the goal of ‘stopping the dreaded habit’. You have no say in the matter, but you emotionally and vehemently reject allowing it to “help”. You continue to thumb suck over and around it, causing pain and blistering of your thumb. Over the next three years, you endure three other types of fixed appliances with the last one being modified two times within a week! Your teeth have become very sensitive and your tongue blistered by trying to help maneuver soft foods, which is all you can eat at this point. You have had enough! By using chewing gum and one of your mom’s expensive dinner forks, you pry the device out of your mouth. Now you can suck your thumb whenever you want to but can pop the device back in when others are around! You told your parents that if they tried to have anything put back in, you would destroy fork after fork to remove it!

This was Catherine’s story. I’m sure you felt her lack of control over herself as well as her physical and emotional pain. As an adult, she has TMD issues, which she believes were caused by years of habit appliances and four years of braces. She has a fear of dentistry, as well. She confided to me that if someone had been there to talk with her about her habit and given her information in an honest, caring way, she probably would have jumped at the chance to stop! And she was sure that her parents would have definitely moved in that direction had they known of such a program.

As Orofacial Myologists, we are called to change the approach from “doing to”(habit appliances) and instead “drawing from” (habit control therapy) our patients/clients. If we can help others from having to go through this, even if the circumstances are less traumatic, we have changed a life for the better. As Catherine said to me when I asked her to share her story, “Thank you for doing this. I am very grateful you are speaking up for these kids.” Let’s be sure we all speak up for these kids!!

Till next time,
Becky

The Sister Program: Growing the Nails

Most of our readers have heard of Unplugging The Thumb (UTT), the highly successful program that has helped many children stop thumb sucking and other digit habits. Not everyone is aware of Growing The Nails (GTN), the “sister program” that was released in 2011.

The years of providing treatment prior to the creation of these helpful “kits” offered us a magnitude of communication that served to give us a deeper understanding of the habits themselves as well as the underlying forces behind them. By meeting the emotional and social needs of parents and children, we were able to design methods that really work.

We found that therapists and parents seemed to be more tolerant of nail biting behavior than they were of thumb sucking…why was this? When questioned, they often stated that thumb/finger sucking habits can damage teeth and the palate as well as make their child look “babyish” when they were well beyond that stage. They felt that nail biting might be socially unacceptable in public but did not realize it was also harmful to the oral cavity.

As therapists, it is incumbent upon us to explain that nail biting should be taken with the same seriousness as other oral habits. The intensity of this habit can have consequences beyond the oral cavity itself. The health of the nails and the image projected by those who maintain this habit is frequently interpreted by observers as demonstrating nervousness, being upset about situations or people, and being careless about appearance. Additionally, the visible damage on the hands is unpleasant to look at and embarrassing for the nail biter.

We found from our exchanges that even though there are certain differences (ie., sucking the thumb creates a pleasant and calming sensation while biting nails responds to moments of insecurity and nervousness), the approach to combating both habits in younger children was applicable to both types of oral habits.

Hence, the idea of creating a program designed to help kids stop biting their nails. The kit is easy to use, has all the necessary elements to generate productive sessions and leads to a positive self esteem. For years this approach has proven successful in combating the habit, and we encourage therapists to keep GTN within their toolkit to be ready for use when needed.

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