Today I am talking about orofacial myofunctional disorders and orofacial myofunctional therapy. Also called orofacial myofunctional health or just myofunctional therapy.
Orofacial refers to the mouth and face and Myo refers to muscle and function refers to the way it all works, health refers to whether the system is working as it was made to sustain our body functions. Breathing, eating, drinking, and swallowing.
Myofunctional therapy is a virtually unknown emerging field to many health professionals, parents, and children who could benefit most from it. It is a subspecialty within existing health professions like speech pathology and dental hygiene.
Myo is a therapeutic series of exercises that educate or re-educate the oral and facial muscles for optimal breathing, sucking, eating, and drinking. This is important because muscle functions influence bone and jaw growth which are the foundation for a growing airway.
We are meant to be nose-breathers. Nose breathing gives you the ideal exchange of oxygen, carbon dioxide, and nitric oxide. Breathing through our noses increases oxygen in the blood by as much as 10-18%!
Mouth breathing disrupts the exchange and decreases oxygen absorption. Which can lead to over-breathing because you need to breathe more frequently in order to replenish the oxygen that is being lost. Breathing through the nose also slows, humidifies moistens filters, and removes 98-99% of allergens, bacteria, and viruses from the air you breathe in. Mouth Breathing does none of that, the air goes right to your lungs and you breathe shallower. Mouth breathing at night can also have a negative effect on sleep. Many kids slip under the radar for sleep-disordered breathing that can be identified by a parent or allied health professional. As dental hygienists, we are perfectly positioned to call attention to myofunctional red flags and upper airway problems.
The American pediatric association released a key action statement saying all clinical practitioners should screen for sleep-disordered breathing.
Myofunctional therapy can benefit any child even before sleep-disordered breathing develops if you nip early signs in the bud. Ideally when they are 3-6 years old. This way we can use their growth and development set them up with good habits rather than having to correct bad ones. If your child’s mouth, face, or throat develops poorly or they have poor habits they can develop cavities, speech issues, and even sleep-disordered breathing. Myo is a proactive approach to training the tongue and the muscles of the face to work the correct way before they develop a disorder ideally before they get any permanent teeth.
How do we know if you or your child is a mouth breather?
As a myofunctional therapist the first thing we do is look at:
Health history and breathing. In the past and/or present. This can give us clues.
- Did you have large tonsils and adenoids as children or do you currently have our tonsils and adenoids?
- Do you have allergies?
- Did you or do you have anything that causes nasal congestion?
I don’t really have allergies now, but I did when I was younger, and now I’m an adult with these facial features I developed from all of these myofunctional problems I didn’t even know I had. They did not look at breathing in children when I was younger.
If you have sinus issues, lots of colds. If you had several septum surgeries or termination reductions.
These are all signs that a person probably doesn’t breathe well, so they more than likely mouth breathe, and if they’re not doing it during the day. They’re definitely doing it at night.
When I ask people, most people will say no, I’m not a mouth breather. Then I ask if their lips rest apart. When I am looking at them I can see the answer.
This might be a way that you recognize if you or a loved one is a mouth breather.
I think there’s a negative connotation associated with being a mouth breather. There have been several movies that use it as an insult to the other person.
So most people tend to not want to admit to it right away. Once they realize and become aware that they’re doing it, they will probably be horrified the same way I was.
When I discovered I was doing that I was like:
How did I not know this?
How did I end up here?
Why did no one ever tell me this stuff?
I have been mouth breathing since I was a child. I am a dental hygienist.
Why did I not know about this sooner? Why are they not teaching this in school? I could have helped myself thirty years ago.
Past Mouth breathing is just as important as current mouth breathing because that’s what changes the tongue posture. A child breathing through the mouth who’s learned to breathe through their nose will still have a low resting tongue so many adults can hide the fact that they used to breathe through their mouth but if you ask them about their past. Past history is one way you get some insights to start figuring out who needs myofunctional therapy. I thought I had outgrown my mouth breathing or was just doing it at night. I was just unaware and in denial.
Another way is you can check the tonsils, and check the mallampati score. If you are not familiar with this, it is an interesting tongue rating scale that we use for risk assessment.
Grade One– means you can see nice and clearly into the throat, you can see the uvula and the tonsils if you have them.
Grade Two- is not too bad, you may or may not be able to see the tonsils but you can still see the uvula
Grade Three -means you really can’t see much, the tongue is blocking the view, and even when you say ahh you can’t see much at the back of the throat.
Grade Four- means that the tongue covers the whole soft palate you can’t see anything.
The patients who are in grade three and grade four are at a higher risk of developing sleep apnea and snoring. They might not have it yet, but it is something to take a look at and have a conversation about.
Kids are usually the ones with large tonsils and adenoids. If you know we can’t see the back of the throat or they have noisy breathing you might want to have screening from an EMT, especially if you see kids with grade three or grade four tonsils. If you say ahh and you see the tonsils are almost touching or they are touching that is reducing the airway even mouth breathing will be difficult.
I guarantee these kids are mouth breathing, so part of the treatment protocol when they go to get the tonsils removed is to get them to learn to keep their mouth closed and breathe through their nose.
I had my tonsil removed at 16, but did not change my habits.
This will not spontaneously happen. A lot of times we cross our fingers and hope it does, but most of the time kids can have their tonsils and adenoids taken out, still, mouth breathing.
They say it is very rare. In my case, once I had my tonsils removed it did not correct my habit of mouth breathing. Then add taking out four premolars and braces and that sealed my fate. Back then we did not know what we know now. Had I known this information it would have changed my life. Maybe I would not have TMJ issues now.
I think if kids under the age of four have their tonsils or adenoids removed they have a greater chance of becoming nose breathers without help. If they’re 5 or older they’ve been mouth breathing for many years of their life, those habits don’t spontaneously change so that’s where this therapy comes in. 12 sessions of myofunctional therapy could make a huge difference in your child’s life.
When I say mouth breathing or open mouth posture, people think of this kid literally walking around with their mouth hanging wide open and their tongue showing. Which is actually fairly uncommon. More likely, most of the kids and adults we see who breathe through their mouths don’t look like that. It is more subtle. Their lips are slightly apart or they have dark circles under their eyes like my daughter.
Most of the patients I see… their natural mouth posture at rest is slightly open when they’re not talking or eating.
It doesn’t matter if your mouth is gaping open wide like a full inch, or if your lips are just barely parted a millimeter or two. It tells me the tongue is in the wrong place, that is why the lips are apart. The tongue is usually down, yet the tongue needs to be up.
We also look for narrow palates. You can look for people with their lips apart like we discussed or you can ask patients about lips resting apart. However they usually don’t know if they’re doing it, unless they’ve really thought about it, someone points it out, or unless it really bothers them.
Most patients are going to end up having to build awareness around these habits. We have to really get good at observing and looking for lips apart and narrow palates
If someone has a really narrow palate or if they had expansion in the past that can be another good clue they may need therapy. If kids have had mouth breathing, low tongues, and palatal expanders or an appliance this too is a sign that their tongue was not where it was supposed to be and unless it was addressed they may still have issues. It is really cool to show people their tongues and the correct tongue posture.
As you’re sitting there, think about this for the rest of the day.
Where is your tongue?
Is it inside your mouth with the tip on the roof of your mouth or down against your lower teeth?
We need to talk about and start this conversation with the tongue, at rest, correct tongue posture, and correct swallowing, so what is a correct tongue posture and swallowing, what’s disordered and how can myofunctional therapy help?
What is the correct tongue posture?
Where should our tongue be?
We should have the tip of the tongue on the roof of the mouth known as the spot in myofunctional therapy. Just behind the two front teeth. Not touching the teeth. Then we have the middle of the tongue on the hard palate. The teeth are barely touching, or slightly apart, and the lips are closed. This is correct, oral tongue posture, it’s what you should be doing all day and all night. When you’re watching TV when you’re sitting and not talking to anyone. This is where the tongue needs to be at all times.
If you have a tongue tie this physically might not be possible for you to do, your tongue might not actually reach. So, this is where the frenectomy comes in. The tissue needs to be released so you can move the tongue the way it is meant to. Your tongue should be free.
If you don’t do the therapy along with a tongue-tie release. There are a couple of problems, it’s more likely to reattach and actually obstruct the airway more, so you’ve got to build up the muscles and strengthen the tone so that the tongue rests in the right place.
When you sleep you should not feel your tongue flop into your throat. You should have control of it at all times. When you have been tongue-tied your facial muscles have been compensating and may be weak and your tongue may be pushing against your teeth inst3ad of the roof of your mouth.
Ultimately, where your tongue should be hanging out is the roof of your mouth. Where the tongue is positioned right before you swallow is important. Your tongue should not push forward on the teeth when you swallow.
A typical swallow is an alveolar ridge, which it’s lined with Rue gay they are the rough tissue behind your front teeth and where we want the tip of the tongue. Not pressing against the teeth but pressing up on the roof of your mouth. I will show this to patients.
The tongue has a vertical movement, versus a forward one. It moves in a wave, but I like to use the term vertical the more helpful cue I find for patients, so let me show you. So you’ll notice there was no exertion. I wasn’t tensing any of the muscles of my mouth or my eyes, I looked really relaxed and the only way you could tell that I was swallowing was by looking down here at my throat.
So in contrast, what is an orofacial myofunctional disorder? Kids and adults that have an OMD, oftentimes are mouth breathers. The tip of the tongue will be on the low teeth. Sometimes these individuals actually go around with low oral rest time posture with their lips sealed so most of us, or you’ll see a Napoleon Dynamite. And I tell a lot of kids that he’s a great example of someone with a myofunctional disorder. You noticed that he has a forward head posture to keep his airway open his tongue is down. And he’s mouth breathing. What’s interesting is to see the muscles that are recruited when these individuals swallow.
You’ll notice an over-exertion of the muscles around the mouth and the face the chin puckers. The head goes slightly forward. You look in the teeth of these individuals you’ll see too that their dentition matched these abnormal swallowing patterns so here we have a kiddo with an anterior open bite. Let me show you.
There’s a perfect hole for the tongue to go through. This is the tongue thruster hole between the teeth. What does myofunctional therapy seek to remediate Myofunctional Therapy seeks to remediate these improper tongue movements.
Let’s talk more about tongue ties. The tongue tie is a mysterious and confusing thing so there’s a lot that you have to look at and I’m going to give you guys a crash course on how to identify a tie. Sometimes you look at this picture of the tongue.
On the far left.
This is normal, this is, this time has no problem.
This freedom looks fine to me.
If you look at the picture at the bottom here.
This is what a lot of us were trained, what a tongue tie is. It has to be full-on ankyloglossia, the tip of the tongue fully attached to the floor of the mouth. The patient can not stick it out. The problem with looking at tongue ties is that most people don’t look like that. I mean those are like the rare, rare cases. Most people who are Tongue Tied fall on a spectrum between completely attached and totally fine.
The picture with this blog is Kotlow’s Measurement not everyone agrees with this but never the less it is a great tool for a quick assessment you can do on yourself.
The two people in the middle here are also Tongue Tied but they really don’t look that bad they don’t look like they are so these are the people who get missed. So there are a few things we have to look at function versus appearance if people are pretty good functionally.
I might not always recommend a tongue-tie release. There’s also the whole discussion of anterior versus posterior. It’s kind of all the same thing if you have an anterior tongue tie or restriction, you probably also have some degree of posterior, the way we describe posterior is if there is no anterior obvious connection it’s more like the tongue is restricted but it’s not clear to see. It’s hard to describe the difference.
A tongue-tie is a restriction. So, to me, if you can’t get your tongue where it needs to rest if you can’t keep your lips together. This tells me that you need to release that tongue. The thing is, what we’re discovering more and more and we actually need more research on this but I can tell you, the people who have the most clenching grinding jaw pain and headaches that I see are always the people who are Tongue
Tied so there are a lot of cross problems here. And that has to do with a whole nother topic, you know, the airway, of course, but it has to do with tight fascia and accessory muscles compensating for the tongue not being able to function properly so there’s a lot of muscle dysfunction going on.
I want to show you guys the main signs and symptoms to look for:
- Is it a heart-shaped tongue or a heart-shaped tip of the tongue?
If someone sticks out their tongue, they’ve got a notch, a cleft, or depression if it looks like an indent to the tip of their tongue. That’s a sign, they probably have a tongue tie.
We have to look at this stuff as a collection of symptoms.
Not just one thing so this one’s kind of an obvious one, but not everyone who has Tongue Tied has this so you have to keep digging.
- A really prominent midline down the tongue
Is there a deep groove or kind of depression, almost like a valley or like a trench running down the center of the tongue
If yes, that tells me there’s some restriction from the underside or internally so that’s one thing you can look for.
Again, you know not everyone has a restriction with just this sign. I can stick out my tongue and make it look like that, the midline groove like the one in the picture is a lot more obvious, but depending on how a patient’s holding their tongue. This one might not be 100% true all the time.
- The elevation shape
When a patient opens wide, and they lift their tongue up, what shape does the tongue make it able to make a point?
Like this picture, it should not make this heart-shaped V shape or this oblong shape so patients should be able to maximum opening reach up to their tongue and it should form a point.
The other thing they should be able to do is to reach the roof of the mouth at the maximum opening, so if you open wide, and your tongue goes about you know 50% up towards your incisive papilla, you’ve got a tongue tie.
If it’s like, you know, 90%
You might be on the borderline again. I’m not really into just saying everyone should have their frenum released. I think these three examples for sure need an evaluation.
This person’s fine. This is normal.
The other thing we can look for is a web attachment or a fanning shape so the frenum should drop straight down to the floor of the mouth and it should attach without any webbing. It shouldn’t have this thing called an Eiffel Tower frenum.
It should not attach to the alveolar ridge and it should not have this wide, and out base. This is a sign of midline developmental issues so that’s really what a tongue tie is it’s a genetic mutation it comes from the MTHFR gene mutation, and it’s a midline issue so that same gene mutation is responsible for congenital heart disease, spina bifida scoliosis, and tongue ties, of course, are like a minor thing associated with it but it’s still I mean in my world a pretty big deal.
The other thing that’s associated with that defect is cleft palate or cleft lip and all that so it tells me that the apoptosis if you guys remember back to studying embryo changes and fetal development, stuff like that. We’re supposed to have that planned cell death in the midline as the cells change and grow. But sometimes, sometimes the cells don’t fully die out so that’s really what this webbing is showing me the attachment did not complete the way it should have.
We also have to look at the fascia. So I’ll talk about this really quickly but basically, this is a cadaver diagram of all the fascia connected to the tongue. The tip of the tongue is up here and throughout the whole body all the way down to the feet. We are connected through fascia so fascia holds our muscles together, ultra muscles through the skin, and fascia is so overlooked it’s so important though and the fascia is the main reason why people who are Tongue Tied have a lot of head and neck and shoulder issues, you know clenching grinding.
All the compensations that happened to the muscles and the head and neck and the TMJ area are pretty crazy when it comes to having a tongue tie. This to me is a big missing piece of the puzzle we have not been talking about. We’re still just at the tip of the iceberg. We’ve only been getting good research on Tongue ties and adults in the past like three years so we don’t have a lot to really say yes here’s what’s going on but when you talk to people on a clinical level who deal with this every day. We are seeing it so clearly. So that’s the tough part about not having the research to fully say here’s the problem.
Let’s put it into dental schools and dental hygiene schools. I think we’re working on it. We’re getting there and we’ve got some great people doing research now, and I think it’s going to change how we talk about Tongue ties, headaches, TMJ pain, and problems with clenching and grinding and the airway.
Healthy habits start when you are a baby. Yet, It is never too early or too late to start myofunctional therapy. This information is practical your whole life. Since tongue ties run in the family the ideal scenario is for the whole family get involved. Our kids learn from us. Make it fun so it is not a chore and it becomes a natural activity for the whole family.