Young Adult with lisp, narrow vaulted arch, jaw thrusting, TMD: Questions that must be addressed

Q: I’m writing with a question regarding a 22-year-old client recently evaluated; her mother sent her to me with concerns about a frontal lisp due to a “tongue thrust.”  According to mom, the young woman had had a “tongue thrust” and frontal lisp that went away around age 7 when her tonsils and adenoids were removed, but now the tongue thrust” and lisp are back.

When I evaluated Q, she did not have any tethered oral tissue but did have a slight dentalized somewhat distorted s/z on some words.  She also appeared to have a narrow maxillary and high vaulted arch, although she had a normal Class One occlusion.  What was of concern to me was her jaw thrusting forward when she produced a word with /sh/.  She indicated that she has TMJ and that she had a mouthguard for the condition, but that it keeps falling out.

I am concerned about the relationship between a jaw thrusting forward and TMJ.  Is it likely that the forward thrusting of the jaw is pulling her tongue with it, distorting her /s/ and /z/ production at times

I would greatly appreciate your help and insight with this.

A:   Since there are so many varied issues, it is important to try to get answers to as many of the following as possible prior to planning a therapy approach:

• Did the lisp really go away at one time?  Or did she learn to compensate for it by shifting her jaw and developing other facial/oral odds movements?
• Did the removal of the tonsils help a bit and make the parent think it solved the lisping problem?  Any current history of allergies or other congestion?
• Does the mandible shift because of a TMD issue or does it shift for other reasons (and possibly create more of a TMD issue)?
• Can she suction and fit her tongue within her palate with the mouth open for you to see?  If not, then that could contribute to having to move the jaw in order to get the sounds to be released the best possible way under those circumstances.  With her narrow palate and high vault, the tongue would be held over the teeth to produce some sibilants, for example.

So those are some questions I’d pose, but where to go from here?  Here are my thoughts:

1. Check if the jaw moves only for certain sounds and determine for sure which ones. You mentioned SH (which likely includes CH, J, and ZH as well).  Yet for S and Z, it is interdental?  That wasn’t quite clear to me.
2. Determine her ability to suction her tongue within her palate;

Determine her ability to maintain that suction.

Determine if the mandible is lopsided during suction with open mouth and if so, her ability to control that asymmetry.

3. Get more info why she got the TMJ mouth guard appliance, what were the reasons, is/does she have pain associated with it? (If so you have to be extra cautious with certain exercises assignments).  Have her describe why she thinks the appliance is falling out.

You have to know whether the jaw deviation is causing the speech problem or vice versa. 

Frequently it is the speech that is causing the jaw to have to move in an unnatural manner in order to produce the sounds correctly in connected speech.  That is why it is important to rule out structural reasons such as the narrow palate that won’t allow for the tongue to fit within it, thus compromising speech.

I hope this is helpful and that you will be able to clear up as many of the questions raised above.

 

 

My best,

Sandra