International SYMPOSIUM on OROFACIAL MYOFUNCTIONAL Therapy roma 6,7,8 giugno 2014

1. PARADIGM SHIFT: THE NEW COMPREHENSIVE
ORAL-MOTOR/OROFACIAL MYOFUNCTIONAL EXAMINATION FOR SLPS
MICHELE L. NORMAN, PHD; GLADYS SMITH-KONYE, MS; W. FREDA WILSON, PHD; & MARC R. MOELLER, BA
Abstract
Speech-Language Pathologists conduct the oral-motor mechanism examination to
assess the structure, function, and sensation of the system as it relates to feeding
and swallowing disorders, articulation, dysarthria, voice disorders, and fluency
disorders. The current examination is considered to be comprehensive because it
views the present state of each structure at rest and in motion noting
inconsistencies in symmetry and expected range and strength of movement.
While the examination also considers respiratory support for speaking and
deglutition, it does not usually include evaluating the risks for obstructed airway.
Research has shown that children and adults with obstructed airway tend to
breathe with an open mouth which negatively effects the development of the facial
bony structures, inspiratory-expiratory cycle, and sleep cycles. Unfortunately,
these effects can manifest themselves as behavioral problems, learning
disabilities, as well as problems in speech, swallowing, and communication.
There is a need for speech-language pathologists to be able to recognize
discrepancies in the oral-motor structures that indicate signs of potential problems
beyond speech, swallowing, and communication that may impact these areas and
the ability for rehabilitation of the systems.
For example, if a child has a significant overbite, there may be other physiological
and respiratory issues to further evaluate. Also, chronic ear infections may
be related to jaw position. Finally, poor diadochokinetic rate may indicate
ankyloglossia or myofunctional disorders, not just a simple disorder of articulation.
Given the prevalence of malocclusions, open-mouth breathing, respiratory
disorders, such as asthma, and sleep disorders caused by both, speech-language
pathologists need to conduct a more comprehensive examination of the oral-
motor system and become versed in the area of oral myofunctional disorders. This
is already a common practice of clinicians around the world. Training in a more
inclusive and comprehensive examination will increase proper diagnosis and
treatment, as well as referral for appropriate care. To ensure consistency in care, a
more comprehensive oral-motor mechanism examination should become a part of
the standard education provided for speech-language pathologists in training and
in practice in the United States.
This study proposes to evaluate the current practices and protocols for oral
myofunctional and oral-motor mechanism examinations used by speech-language
pathologists and related fields to determine strengths and weakness in order to
develop a new more comprehensive tool to become the standard.
Background information
•Typical oral-motor mechanism examinations include assessing the
structures at rest and in motion to determine their symmetry, normality,
and function. While this includes a cursory look at the face, lips,
cheeks, jaw, teeth, tongue, palate, and velum, A more detailed in depth
assessment may reveal underlying deficits that cause orofacial
myofunctional disorders (ASHA, 1997). Examinations usually are
structurally-based or neurologically-based.
•Structurally-based examinations view each structure in isolation and
it’s ability to move or function as intended.
•Neurologically-based examinations assesses motor and sensory
function based on neural innervation. Cranial Nerves V, VII, IX, X, XI, &
XII are primarily targeted to assess head, neck, face, and oral-motor
muscular involved in speech and swallowing. Cranial nerves I, II, III, IV,
VI, & VIII assessed due to their supportive roles in sensation,
communication, and muscle movement.
•Both types of assessments are necessary for a comprehensive
examination of the oral-motor mechanism.
•We propose a paradigm shift from traditional oral-motor mechanism
examinations to include an exhausive orofacial myofunctional
examination in order to capture disorders that otherwise go undetected.
Tongue
•SLPs routinely check the structure, strength, and movement of the
tongue. While the tongue is thoroughly assessed, documentation
usually doesn’t indicate how it’s resting position in the oral cavity
effects overall respiration. Many make notation of chronic mouth
breathing, but do not indicate that there may be a link to obstructive
airway disorders or sleep disorders that should lead to the referral to
other professionals and a plan of orofacial myofunctional therapy
Frenulum
• Currently, when clinicians assess the structure of the tongue, they
make note of the general length of the lingual frenulum and its
adequacy; however, it’s not usually measured.
• Proper measurement can determine if ankyloglossia is present
which can cause issues in feeding, swallowing, and speech. The
Hazelbaker Assessment Tool for Lingual Frenulum Function
povides general guidelines that can assist in recognizing
deviations (Ballard, Auer, & Khoury, 2002). SLPs need to be able
to recognize the variations in shapes and sizes which should not
only trigger a referral to dental professionals, but should activate a
plan for orofacial myofunctional therapy.
• SLPs in Brazil are developing protocols that will be able to assist
in the assessment of lingual frenulums in infants and children that
includes the relationship to feeding issues (Martinelli, 2013;
Marchesan, 2014).
Tonsils
• Currently, SLPs examine the oral cavity and note the presence or
absence of tonsils since they, along with adenoids can become
inflamed and infected. Most SLPs in the USA are not trained how
to assess them if they are present. Tonsil size has been linked to
airway obstruction and sleep apnea.
• Using a Mallampati (1985) scoring system can provide clinicians
with a quick means of assessing them on a classification scale of I
– IV and making a diagnostic decision to refer to other
professionals as needed.
• Children who have Class IV are at higher risk and may be
diagnosed with sleep apnea, attention deficit disorder, and/or
respiratory disorders.
References
American Speech-Language-Hearing Association. (1997). Orofacial Myofunctional Disorders. Retrieved
from http://www.asha.org
Ballard, J.L., Auer, C.E., & Khoury, J.C. (2002). Ankyloglossia: Assessment, Incidence, and Effect of
Frenuloplasty on the Breastfeeding Dyad. Pediatrics, 110 (5) p. e63. DOI: 10.1542/peds.110.5.e63.
Marchesan, I. (2014) Lingual Frenulum Protocol. Academy of Orofacial Myofunctional Therapy.
Martinelli, R. (2013). Lingual Frenulum Protocol with Scores for Infants. Academy of Orofacial Myofunctional
Therapy.
Miraglia, B. (2014). Interceptive Orthodontic Techniques for Airway and Facial Development. NYU Study
Group of the AAPMD (3/27/14)
Wilson, R. (2008). Acumeridian Tooth Acumeridian Tooth--Organ Relationships --Organ Relationships [with
Autonomic/Neuropeptide Emotion correlations]. Retrieved from http://www.NaturalWorldHealing.com
Proposed Assessment
•Our proposal is to create a comprehensive examination that bridges oral-
motor mechanism and orofacial myofunctional assessments so speech-
language pathologists can consistently identify speech, swallowing, and
orofacial myofunctional disorders. Below are examples of some structures
that should be assessed more extensively and how they impact patient care.
These are just a few to consider:
Facial Profile
•SLPs examine the facial structures for overall symmetry across midline.
However, viewing the profile of the head is not a part of the routine
assessment.
•It has been determined that normal facial structures should develop
forward, downward, and wider (Miraglia, 2014). Abnormal growth can be an
indication of underdevelopment of the maxilla and or mandible which
changes dental occlusion, narrowing of sinuses, narrowing of orppharynx
and laryngopharynx, and decreased airway.
Dentition
•Currently, clinicians make note of the absence or presence of teeth, their
general condition, and occlusion.
•We propose that clinicians note which teeth have been extracted. Research
shows that each tooth correlates with specific organ functions, emotions,
and diseases (Wilson, 2008). Therefore, the extraction of certain teeth can
trigger the emergence of problems far beyond speech and swallowing
concerns.
Future Directions
• Create a comprehensive assessment that includes neurologically-
based and structurally-based procedures that allows for the extensive
examination of structures that may indicate underlying orofacial
myofunctional disorders that manifest themselves as sleep disorders
and/or behavior disorders
• Create curriculum that becomes the standard for teaching oral-motor
mechanism examination within speech-language pathology programs in
the USA. This has been done in other countries and found to be effective
for diagnosis and treatment.
• Create an assessment that can be used by a team of professionals to
assist with referral for orofacial myofunctional disorders
Learning Outcomes
Attendees will be able to:
1. Identify weakness in current practices for evaluating oral-facial structures,
functions, and sensation
2. Recognize signs of potential deficits caused by underlying oral myofunctional
disorders
3. Comprehensively assess oral-facial structures, functions, and sensation for
proper diagnosis, treatment, and/or referral