Orofacial Myofunctional Therapy
A stable alternative for the speech-language pathologist
By Roberta B. Pierce, MAT, CCC-SLP, COM
Recent changes in Medicare reimbursement systems have had a profound effect on the profession of speech-language pathology. Many highly trained and competent individuals have found their positions downsized or eliminated. New graduates are having difficulty finding CFY positions after having been told throughout their university training programs that speech-language pathologists are in demand. It is time to take a serious look at a delightful and stable alternative: tongue thrust therapy.
When I received my master's degree in speech pathology 30 years ago, I thought I knew all there was to know; and I was ready to take on the world. About a month into my first job at an Easter Seal-affiliated rehabilitation center, a local orthodontist referred my first tongue-thrust patient. While I hadn't been taught anything about tongue thrust, my professors did teach me how to find answers for myself. I rolled up my sleeves and started reading everything available at that time, which wasn't much.
I've had a wonderful career as a speech-language pathologist and orofacial myologist, primarily in private practice. I am grateful to my professors for teaching me what they thought I needed to know and to Dr. Robert White, the orthodontist, for challenging me to learn a whole new field of endeavor, which in the long run has been the most stable part of my caseload.
Over the years I have done traditional speech therapy with a lot of school-aged children; but when public school speech therapy became more widespread, many of those children transferred to school-based therapy because it was free, had no transportation problems, and did not have to be scheduled around after-school activities. I've worked with many preschool children, but those numbers have diminished since local education agencies were mandated to serve the preschool population. I love teaching esophageal speech to laryngectomees but have seen fewer and fewer referrals since the tracheoesophageal puncture (TEP) became widely used.
For the past 10 years home health has been a significant portion of my caseload. This year alone the number of patients and visits has decreased significantly.
Only one patient type has remained stable throughout my career--tongue thrust. Medical-dental insurance rarely pays for this type of therapy; therefore, it is a cash-based practice. Because patients pay each time they are seen, they value the service more. Cancellations and no-shows are rare. There are a predictable number of lessons, so the family and I know what to expect from the beginning. This keeps morale and motivation high for all involved.
As long ago as the early 1960s, researchers from the fields of speech pathology and dentistry reported in the literature on the high correlation between orofacial myofunctional disorders and articulation (see Table 1).
Just last year an excellent multi-variate research study by Wadsworth, Maul and Stevens (International Journal of Orofacial Myology, 1998) found that 50 percent of the children enrolled in public school speech therapy in Fresno, CA, had a tongue thrust swallow and an incorrect resting posture of the tongue and lips. These orofacial myofunctional disorders were significantly related to incorrect production of /t/, /d/, /l/, /s/ and /z/. It makes one wonder how many children have been enrolled in "speech therapy" for years, when attention to the underlying problem of resting posture and swallowing pattern might have brought about the desired changes in articulation in as few as 10 to 12 sessions.
Orofacial myofunctional therapy has clear-cut goals and objectives and a high rate of success. Many studies have confirmed the effectiveness of tongue thrust therapy in improving articulation (see Table 2 on page 16).
Nelson and Pierce (1997) reported the results of a consumer satisfaction survey conducted by members of the board of directors and the board of examiners of the International Association of Orofacial Myology (IAOM). The survey revealed 90 percent to 100 percent consumer satisfaction with all aspects of their treatment program. This therapy works!
Out of 100 patients referred by dentists and orthodontists for tongue thrust therapy, reported Pierce (1996), 51 percent had articulation errors, with the largest percentage (24 percent) being frontal lisps. Many of these children had been enrolled in speech therapy previously, some for several years, without correcting articulation or addressing resting posture or swallowing.
All of the patients in this sample were treated using a traditional tongue thrust therapy program called Swallow Right (Pierce, 1993). All were successful in correcting the resting posture of the tongue and lips and the swallowing pattern within 10 to 12 treatment sessions. Those who had articulation errors received instruction and exercises to improve their speech, superimposed on the tongue thrust therapy program, and did not require additional lessons, with the exception of one child who had a frontal lisp and three children with distorted /r/. These four patients needed to be seen for up to four additional articulation therapy sessions.
"All of the patients were successful in correcting the resting posture of the tongue and lips and in correcting the swallowing pattern within 10 to 12 treatment sessions," Pierce concluded. "This survey confirms that many speech problems self-correct as a direct result of tongue thrust therapy; sometimes it is helpful to include articulation exercises in the treatment regimen; and rarely it will be necessary to schedule additional sessions to work on articulation" (International Journal of Orofacial Myology, 1996, p. 33).
Our colleagues throughout the world have been more receptive to tongue thrust therapy than speech pathologists in the United States. Through many years of serving on the editorial staff of the International Journal of Orofacial Myology and traveling extensively to present programs on this specialty area, I have had the opportunity to meet dental and speech professionals from Argentina, Austria, Belgium, Brazil, England, France, Germany, Italy, Japan, Sweden and Switzerland. In most of these countries, oral myofunctional training is included in the curriculum and clinical practicum experience at the universities.
Umberger and Van Reenen (1993) surveyed speech-language pathologists from a variety of job settings. Thirty-four percent of the speech pathologists surveyed reported that they had received no classroom instruction in oral myofunctional disorders, and 63 percent had no practicum experience. Of those who received classroom instruction, 87 percent viewed their instruction as "inadequate." The majority (92 percent) of practicing, experienced clinicians believed that academic and clinical training in orofacial myology is necessary.
In 1974 the American Speech-Language-Hearing Association (ASHA) issued a position statement questioning "the validity of the diagnostic label tongue thrust" and encouraged "increased research efforts." However, the association indicated that it could not recommend that speech pathologists "engage in clinical management procedures with the intent of altering functional patterns of deglutition."
The intent of the statement was to encourage further research into this specialty area of practice; the effect of the statement was that most speech pathologists receive no training or clinical practicum experience with this type of patient.
For many years there was controversy regarding the relationship between orofacial myofunctional disorders and articulation problems. Members of the International Association of Orofacial Myology (IAOM) continued to conduct research, to publish articles in professional journals, and to provide and perfect treatment techniques (Zickefoose, 1976; Barrett & Hanson, 1978; Pierce, 1978; Hanson & Barrett, 1988; and Pierce, 1993).
Fortunately, ASHA replaced its original position statement with a positive one (Position Statement by the Ad Hoc Committee on Labial-Lingual Posturing Function, 1990). Unfortunately, too many speech-language pathologists entered the field during the "dark ages" and received no training in orofacial myology.
Orofacial myofunctional disorders are included in both the scope of practice and the Preferred Practice Patterns (12.10 for orofacial myofunctional assessment and 15.4 for orofacial myofunctional treatment) published by ASHA.
The preamble to the scope of practice states that "levels of experience, skill, and proficiency with respect to the activities identified within this scope of practice vary among the individual providers. It may not be possible for speech-language pathologists to practice in all areas of the field. As the ASHA Code of Ethics specifies, individuals may only practice in areas where they are competent based on their education, training, and experience (ASHA, 1994). However, nothing limits speech-language pathologists from expanding their current level of expertise. Certain clients or practice settings may necessitate that speech-language pathologists pursue additional education or training to expand their personal scope of practice."
Later in this document, ASHA states, "The practice of speech-language pathology includes [p]roviding screening, identification, assessment, diagnosis, treatment, intervention (i.e., prevention, restoration, amelioration, compensation) and follow-up services for disorders of speech: articulation, fluency, voice (including respiration, phonation, and resonance); language (involving the parameters of phonology, morphology, syntax, semantics, and pragmatics and including disorders or receptive and expressive communication in oral, written, graphic, and manual modalities); oral, pharyngeal, cervical esophageal, and related functions (e.g. dysphagia, including disorders of swallowing and oral functioning for feeding: orofacial myofunctional disorders); cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment); and social aspects of communication (including challenging behavior, ineffective social skills, lack of communication opportunities)."
The ASHA Code of Ethics specifically addresses the requirement for individual practitioners to "hold paramount the welfare of persons they serve professionally" and to "provide all services competently." Specifically, the Principles of Ethics are as follows:
* "Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence.
* Individuals shall engage in only those aspects of the profession that are within the scope of their competence, considering their level of education, training, and experience.
* Individuals shall continue their professional development throughout their careers."
Research studies for the past 30 years have indicated a strong correlation between oral myofunctional disorders and articulation. Studies also have determined the effectiveness of tongue thrust therapy on improving articulation. Most speech-language pathology training programs do not include orofacial myofunctional training in their curriculum.
The scope of practice includes orofacial myofunctional disorders among the disorders that can and should be treated by speech-language pathologists. The code of ethics mandates that speech pathologists should practice within the scope of their competence based on their level of education, training and experience.
The ad hoc committee recommended the development of continuing education activities designed to promote competency in treating oral myofunctional disorders. The IAOM provides training courses, a yearly convention, a yearly clinical conference, a professional journal, and a certification process that includes a written examination and an on-site evaluation.
For more information, contact the International Association of Orofacial Myology on-line at www.iaom.com.
Roberta Pierce is a speech-language pathologist in Alabama. She can be reached at P.O. Box 7166, Huntsville, AL 35807 or via e-mail: firstname.lastname@example.org.
Studies Showing Correlation Between Swallowing and Speech
Bell, D. & Hale, A. (1963). Observations of tongue thrust swallow in preschool children. Journal of Speech and Hearing Disorders. 28.
Bigenzahn, W., Fischman, L., & Maryhofer-Krammel U. (1992). Myofunctional therapy in patients with orofacial dysfunctions affecting speech. Folia Phoniatrica. 44 (5).
Blythe, P. (1959). The relationship between speech, tongue behavior, and occlusal abnormalities. The Dental Practitioner. 10 (1).
D'Asaro, M., Shapiro, S., Baum, A.. & Jacoby, M. (1961). Incidence and relationship of abnormal swallow, open bite, absence of gag reflex, lisping and lip posture in children from 8 to 10 years. Asha. 3.
Fletcher, S., Casteel, R. & Bradley, D. (1961). Tongue thrust swallow, speech articulation, and age. Journal of Speech and Hearing Disorders. 26.
Gross, A., Kellum, G., Hale, S., Messer, S., Benson, B., Sisakun, S. & Bishop, F. (1990). Myofunctional and dentofacial relationships in second grade children. The Angle Orthodontist. 60.
Hale, S., Kellum, G., Nason, V. & Johnson, M. (1988). Analysis of orofacial myofunctional factors in kindergarten subjects. International Journal of Orofacial Myology. 14.
Hale, S., Kellum, G., Richardson, J., Messer, S., Gross, A. & Sisakun, S. (1992). Oral motor control, posturing, and myofunctional variables in 8-year-olds. Journal of Speech and Hearing Research. 35.
Hale, S., Kellum, G. & Bishop, F. (1988). Prevalence of oral muscle and speech differences in orthodontic patients. The International Journal of Orofacial Myology. 14.
Hanson, M. (1988). Orofacial myofunctional therapy: Historical and philosophical considerations. International Journal of Orofacial Myology. 14.
Hanson, M. (1994). Oral myofunctional disorders and articulatory patterns. In Child Phonology: Characteristics, Assessment and Intervention with Special Populations by J.E. Bernthal & N.W. Bankson, (29-53). New York: Thieme Medical Publishers, Inc.
Hanson, M. & Peachey, G. (1991). Current issues in orofacial myology: Part I. The International Journal of Orofacial Myology. 16 (2).
Jan, G., Ward, M. & Jann, H. (1964). A longitudinal study of articulation, deglutition, and malocclusion. Journal of Speech and Hearing Disorders. 29.
Kellum, G., Hale, S., Sisakun, S., Messer, S., Benson, B., Gross, A. & Bishop, F. (1989). Orofacial myofunctional factors at ages 6 and 8. International Journal of Orofacial Myology. Vol. 15, (3).
Mason, R. (1980). Principles and procedures of orofacial examination. International Journal of Orofacial Myology, 6 (2).
Mason, R. (1994). Basic medical-dental considerations. In Orofacial Myology: Beyond Tongue Thrust by M. Ferketic and K. Gardner (eds.). Rockville, MD: ASHA.
Pierce, R. (1996). Age and articulation characteristics: A survey of patient records on 100 patients referred for tongue thrust therapy. International Journal of Orofacial Myology. 22.
Ronson, I. (1965). Incidence of visceral swallowing among lispers. Journal of Speech and Hearing Disorders. 30.
Straub, W. (1960). Malfunction of the tongue. Part I. The abnormal swallowing habit: Its cause, effects, and results in relation to orthodontic treatment and speech therapy. American Journal of Orthodontics. 46.
Subtelney, J. & Subtelney, Joanne. (1962). Malocclusion, speech, and deglutition. American Journal of Orthodontics. 48.
Wadsworth, S., Maul C. & Stevens, E. (1998). The prevalence of orofacial myofunctional disorders among children identified with speech and language disorders in grades kindergarten through six. International Journal of Orofacial Myology. 24.
Ward, M., Malone, H., Jann, G. & Jann, H. (1961). Articulation variations associated with visceral swallowing and malocclusion. Journal of Speech and Hearing Disorders. 26.
Zimmerman, J. (1994). Speech articulation problems in orofacial myofunctional disorders. In Orofacial Myology: Beyond Tongue Thrust by M. Ferketic and K. Gardner (eds.). Rockville, MD: ASHA.