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TRANSCRIPT
THE USE OF SPEECH THERAPY AND ORTHODONTIA IN THE TREATMENT
OF TONGUE THRUST DISORDER
by
Lyndi Roberts
A SENIOR THESIS
in
GENERAL STUDIES
Submitted to the General Studies Council in the College of Arts and Sciences
at Texas Tech University in Partial fulfillment of
the Requirements for the Degree of
BACHELOR OF GENERAL STUDIES
Approved
~Bob Jones Department Commumcat1on Disorders
Chairperson of Thesis Committee
Ms. Melinda Corwin Department of Communication Disorders
Dr. Joe Forsman Orthodontist
Accepted
Dr. Dale Davis Director of General Studies
AUGUST 1999
{ " ^ ^ ^ ACKNOWLEDGEMENTS Wo). ^ /
' I want to extend my appreciation to the members of my committee, Mr.
Bob Jones, Dr. Joe Forsman, and Ms. Melinda Corwin, who have been a
tremendous help and provided a wealth of information. I also would like to thank
Dr. Dale Davis, the Director of General Studies, for helping me with a paper I will
be proud offer the rest of my life. Ms. Linda Gregston, the General Studies
Advisor, has given me the confidence and assurance that I have the ability to do
anything I put my mind to. She is an incredible inspiration. I am also thankful
for the constant love and support that my parents,Beverley and Don Roberts,
and the rest of my family have given me. All of these people have readily given
their help and encouragment throughout the completion of this paper, and for
that I am profoundly grateful.
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ii
LIST OF FIGURES iv
CHAPTER
I. INTRODUCTION 1
Normal Swallow 2
Tongue Thrust Swallow 2
II. CAUSES, EFFECTS, AND TYPES OF TONGUE THRUST 3
Causes 3
Effects 4
Types of Tongue Thrust 6
Mi. ORAL MYOFUNCTIONAL THERAPY 11
First Assessment Visit 11
Speech Therapy Sample Exercises 15
Group One 15
Group Two 20
Group Three 23
IV. ORTHODONTIC TREATMENT 26
Types of Malocclusion 26
Orthodontic Treatment Appliances 29
V. CONCLUSION 31
BIBLIOGRAPHY 33
LIST OF FIGURES
2.1 Type 1: Incisor Thrust 6
2.2 Type 2: Full Thrust 7
2.3 Type 3: Mandibular Thrust 8
2.4 Type 4: Bimaxillary Protrusion 8
2.5 Type 5: Open Bite 9
2.6 Type 6: Closed Bite 10
2.7 Type 7- Unilateral Thrust 10
2.8 Type 8: Bilateral Thrust 11
3.1 Muscles of The Face 14
4.1 Landmarks of the Surface of the Tooth 26
4.2 Class 1 27
4.3 Class II, Division 1 28
4.4 Class II, Division 2 28
4.5 Class III 28
IV
CHAPTER I
INTRODUCTION
Tongue thrust, also known as oral myofunctional disorder, is defined as
"habitual resting or thrusting the tongue forward and/or sideways against or
between the teeth while swallowing, chewing, resting, and/or speaking"
(Barnes 1). It is a problem that orthodontists and speech-language
pathologists deal with frequently. Most of the population is not aware that
tongue thrust exists; however, it affects many children. The need for treatment
integration between orthodontics and speech therapy is important, because one
treatment modality is less successful without the other (Young 73). Dentists and
orthodontists routinely address the way a patient's upper and lower teeth align,
or indigitate with each other. This act is termed the occlusion (Ehrlich 40). 'This
malocclusion, or misalignment of the teeth, may be difficult, or even impossible
to correct unless an improper swallowing pattern is rectified by the speech
therapist" (Goldberger 1).
It is important to gain control of this disorder because the patient swallows
between 750 and 2,000 times per day (Goldberger 4). Patient cooperation is the
key to successful treatment. To overcome the tongue thrusting habit, one must
be prepared to work diligently with the speech-language pathologist and the
orthodontist to correct this disorder and maintain a cosmetically pleasing smile
and a healthy bite or occlusion. There are several goals that therapist Suzanne
Barnes sets for her tongue thrust patients: (1) improving the muscle tone of the
tongue, lips, and facial muscles; (2) developing correct tongue posture; (3)
synchronizing the muscles and steps associated with correct swallowing; (4)
eliminating detrimental oral habits; and (5) creating normal tongue placement
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for resting, chewing, swallowing, and speaking (Barnes 4). After these goals
have been met, the orthodontic treatment can begin improving the patient's bite
and smile.
The Normal Swallow
During a normal swallow, there are several sequential movements that
occur. First, the motion of the masseter muscles brings the molars together to
masticate, or chew the food, while the muscles of the lips and cheeks relax.
Second, the tip of the tongue is pressed up to the alveolar ridge, which is
located one-fourth to one-half of an inch behind the upper front teeth. Third, the
middle and back of the tongue are brought up to the roof of the mouth in a rolling
motion, pushing a bolus of masticated food toward the pharynx. " The elevation
of the soft palate prevents the food from entering the nasal cavity, and the
relaxation of the oral pharyngeal port allows the bolus to go from the mouth to
the pharynx" (Goldberger 2). After the food moves to the pharynx, the oral
pharyngeal muscles contract, preventing the food from entering the mouth again.
Fourth, the pharyngeal muscles are contracted to allow the food to travel to the
esophagus. Finally, the peristitial muscles allow the food to travel to the
stomach. When performed correctly, normal swallowing is a reflexive type of
movement.
The Tongue Thrust Swallow
Patients with a tongue thrust habit primarily use the orbicularis oris
muscle and the mentalis muscles, which are facial muscles, for suction while
swallowing. Instead of using the hyoglossus muscle, also known as the tongue,
to push the bolus toward the pharynx, the tongue thrusts between the upper and
the lower teeth or against the upper teeth during abnormal swallowing, making it
necessary for the facial muscles to create the suction needed to swallow. "Often
tongue thrusters must swallow several times to remove all of the food from the
mouth" (Jones). People who exhibit tongue thrust take the appropriate power
away from the tongue and therefore have to compensate for needed suction by
using the facial muscles. They differ from normal swallowers in another way as
well. Tongue thrusters do not use the masseter muscles to bring their molars
together, usually because they have a malocclusion (Ehrlich 37).
Communication Disorders Specialist Ann Ehrlich found that the initiation of the
swallow response is partially reflex, but can be performed on command as well
(40). The progressive steps from the mouth to the pharynx and from the pharynx
to the esophagus are reflexive. Therefore, when correcting an improper tongue
thrusting pattern, the focus is on changing the habits of the initiation response
because it can be voluntarily controlled.
In exploring the problem of tongue thrust. Chapter II will proceed to
explain the phenomenonof tongue thrust; Chapter III will explain the role of
speech therapy in treating the disorder; Chapter IV will explain the potential
contribution of orthodontics; and the final chapter will offer a summary
conclusion.
(Most of the figures illustrating tongue thrust in Chapters II, III, IV are
photographs of models in the office of Don Roberts D.D.S., Abilene, Texas.)
CHAPTER II
CAUSES, EFFECTS, AND TYPES OF TONGUE THRUST
Causes
There are many causes of tongue thrust disorder. Prolonged upper
respiratory disease, which causes the patient to breathe through his/her mouth
for extended periods of time, may cause tongue thrust. Another causal factor is
the onset of allergies. Large tonsils and adenoids may contribute to the problem
as well by causing the tongue to have a low and forward posture, interfering with
normal nasal airflow. As the adenoids become enlarged, they restrict airflow
from the nasal canal and create an open mouth posture known commonly as
mouth breathing, which lowers and protrudes the posture of the tongue (Barrett
62).
As primary teeth are lost and permanent teeth take their place, large
spaces between the permanent teeth can be indicators of the disorder. Large
gaps make swallowing more difficult because they allow for tongue movement
and a lack of suction. "The Theory of Adaptive Tongue Thrust states that any
space between the dental arches not occupied by teeth will tend to be filled by
the tongue due partly to exploratory excursions of the tongue and partly to
preventing the escape of food during swallowing" (Barrett 61). A high and
narrow arch and a lack of muscle tension of the masseter muscles can be
indicative of a tongue thruster as well. A malocclusion may be created by the
constant pressure of the tongue on the front teeth. A malocclusion can also be
caused by excessive bottle feeding (Tepper 4). Along with bottle feeding,other
contributing factors may include thumb sucking, pacifier use, and/or mouthing
other objects for long periods of time. Thumb sucking has been proven to be a
major contributing factor in the tongue thrust disorder (Moyers 79). Immature
oral behavior is also a contributing factor: A prolonged diet of soft foods
discourages the tongue from developing the muscle tone needed for proper
swallowing and should be avoided. Environmental factors and genetics also add
to the tongue thrusting habit. Research shows that patients with psychological
problems and neurological disturbances tend to develop a tongue thrust disorder
as well. (Hanson 1)
Effects
There are many effects of tongue thrust that aid in a diagnosis. The first
is a recurring malocclusion after orthodontic treatment. There are different types
of tongue thrust, and they may not be identified until the orthodontic treatment
has been completed. Malocclusion may also recur due to a continued open
mouth posture. This is a permanent effect until the disorder is corrected.
Another effect observed in older patients is difficulty in denture retention. To
hold dentures in place, the suction of the facial, lip, and tongue muscles are
used. Imagine trying to swallow food and having your dentures fall out. The
tongue is a powerful muscle and dentures require constant pressure from and
movement of the tongue for stability. Speech disorders are a problem as well.
Consonant sounds such as /t/, 161, ls/,lzJ, In/, and /I/ are made by placing the tip
of the tongue on the upper alveolar ridge approximately one-quarter of an inch
behind the teeth. These sounds are difficult to make because the tongue
placement is the same as in a correct swallowing pattern (Ehrlich 50). The Is!
sound may be distorted and sound like a /th/ sound, also known as a lisp. This
lisped sound is made by placing the tongue on the posterior surface of the
maxillary incisors or in between the teeth. With a tongue thrust there may also
be difficulty in chewing and swallowing some foods. A tongue thrusters
swallowing motion is not as effective as a normal swallow. Patients with tongue
thrust have trouble chewing with their lips closed. Pill swallowing can also prove
to be a difficult task.
From an orthodontic standpoint, these cases are quite difficult to treat. It
takes longer to straighten the teeth, and the end result can be very unstable.
These patients may also contract periodontal disease. This disease is caused
by mouth breathing and drying out of the gingiva. This allows the normal oral
bacteria to create infections resulting in bone loss. Teeth that are crowded are
difficult to keep clean and may also be prone to dental decay. Tongue thrusters
may also develop Temporal Mandibular Joint (TMJ) problems. Since this is the
most used joint in the body, TMJ dysfunction can be very debilitating. A
malocclusion causes the teeth to function improperly, putting abnormal pressure
on the Temporal Mandibular Joint. Pressure is not distributed correctly;
therefore, the joint is predisposed to breakdown. (Barrett 41)
Types of Tongue Thrust
There are eight main types of tongue thrust. Each type of thrust can be
categorized as either anterior or lateral thrusting, and further categorized into
anteroposterior or vertical discrepancy. These cases of tongue thrust distort the
alignment and growth of the mandible, maxilla, and teeth.
The first type of tongue thrust is the Incisor Thrust. The occlusion is
Class I ( to be explained in Chapter IV), and the patient may also have a
crossbite. There is a definite overjet, with the lower teeth moderately retruded.
The teeth are apart with constriction of the lip and cheek muscles. The tongue
applies concentrated pressure to the incisors, which drives the upper teeth and
the lower teeth anteriorly, or forward ( Figure 2.1). There is a subtype to Incisor
Thrust which depicts the upper incisors to be relatively nomnal in position, but
the lowers are excessively retruded.
F
Figure 2.1. Type 1: Incisor Thrust
The second type of tongue thrust is called Full Thrust (Figure 2.2). The
occlusion is classified as Class II, Division I. The upper incisors protrude toward
the lips, and the lower teeth lean back toward the tongue. The lowers are
classically jumbled, but the upper and lower cuspids line up. The incisal edges
of the front teeth contact nothing when the molars are occluded. The front teeth
are apart and the mentalis muscle is hyperactive, while the lower lip rests
against the lingual, or tongue side, of the upper incisors. The tongue action is
just an exaggerated version of type one. The tongue applies constant pressure
around the dental arch from the first molar of one side to the first molar of the
other side.
Figure 2.2. Type 2: Full Thrust
Type three tongue thrust is called Mandibluar Thrust (Figure 2.3). The
occlusion is typically a functional Class III. The upper molars are usually
contained within the lower molars, resulting in a bilateral or a unilateral posterior
crossbite. The upper incisors are relatively normal, but may be laterally
constricted. Lower incisors are usually protruded and may have spaces
between them. The upper and lower front teeth may be slightly parted. The
facial grimace is a distinguishing factor. There is particular tension of the
triangularis (chin muscle) and the obicularis oris (lower lip muscle). The tongue
thrusts against the lower incisors. The subtype of Mandibular Thrust is an
anterior open bite. The front teeth are apart with strong contraction of the
buccinator muscle (mandible muscle). The tongue motion is an inversion of the
subtype of number two. The tongue is spread between the incisal edges and in
contact with the upper lip.
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Figure 2.3. Type 3: Mandibular Thrust
Type four tongue thrust is called Bimaxillary Protrusion (Figure 2.4). The
occlusion is a Class I. Both the upper and the lower incisors protrude toward the
lips. The teeth may be closed or slightly apart. Spacing of the lower front teeth
is often associated with this type of tongue thrust. The tongue puts pressure on
the lingual and incisal edges of the teeth. The subtype to a Bimaxillary
Protrusion differs in the occlusion type, usually a Class II, Division I, and the
dentoskeletal structure is superimposed. The first four types of tongue thrust are
anterior-posterior distortions.
Figure 2.4. Type 4: Bimaxillary Protrusion
The fifth type of tongue thrust is called an Open Bite (Figure 2.5). The
occlusion is usually a Class I. Patients with this type possess a normal
anteroposterior skeletal relation. The upper and the lower molars usually relate
properly to each other. The teeth are close to contacting the tongue, and the
molars are upright. In this type, the tongue thrusts to contact the lower lip before
the upper and lower molars come into contact with each other. The differences
in the subtype are that the incisors will look like a well-defined oval, molars will
be tipped toward the tongue, and the teeth are closed.
I Figure 2.5. Type 5: Open Bite
The Closed Bite is the sixth type of tongue thrust (Figure 2.6). The
skeletal relationship is usually a Class I. The dental relationship ranges from
normal to a slight overjet between the upper and lower incisors. The teeth are
apart and the mandible, or lower jaw, is moved significantly forward or down to
allow the tongue to protrude forward. There is flaccity in the lips and cheeks.
The tongue is also flaccid, but with great protrusion. The subtype of this
disorder has a Class II, Division I, occlusion. The tongue action is spread over
the constricted lower arch.
10
Figure 2.6. Type 6: Closed Bite
The Unilateral Thrust is type seven (Figure 2.7). There is usually a Class
I occlusion which may be accompanied by a crossbite opposite to the side on
which the tongue pushes. The two front teeth, known as the central incisors,
are normal while the lateral incisors, cuspids, and first bicuspids are
undererupted on one side of the mouth. The teeth on the other side are usually
closed in contact and a strong contraction of the facial muscles is seen. The
tongue action is unique; it is at a forty-five degree angle toward the involved
cuspid.
Figure 2.7. Type 7: Unilateral Thrust
11
The last type of tongue thrust is called Bilateral Thrust ( Figure 2.8). The
occlusion is Class III. The incisors may have a slight retrusion. The teeth are
apart, and the facial muscles are flaccid. The tongue action is spread bilaterally
over the entire mouth. The tongue tip is usually braced against the lower
incisors. Types five through eight are vertically disrupted patterns. As the
names imply, unilateral and bilateral thrust are both lateral thrusts. The other
thrusts are categorized as anterior thrusts. (Barrett 126-129)
Figure 2.8. Type 8: Bilateral Thrust
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CHAPTER III
ORAL MYOFUNCTIONAL THERAPY
The First Assessment Visit
On the first visit to the speech-language pathologist, a case history, an
evaluation, and an observation are completed Upon referral, the speech-
language pathologist reviews the orthodontist's notes concerning the patient and
then proceeds with his/her own observations. Communication between the
orthodontist and the speech-language pathologist is important because tongue
thrust therapy requires a team approach. After the initial referral, the speech-
language pathologist should provide the orthodontist with periodic reports of the
patient's progress. Communication and cooperation are also important between
the parents, children, and the therapist. At this time, the therapist will determine
if the patient is ready to begin treatment. The average age that patients begin
treatment is between eight and ten years (Jones). Because the mandible grows
in spurts, the growth potential must be assessed as well. Sometimes additional
growth can eliminate the need for extensive treatment. The dentition
developmental stage and space discrepancy between the teeth must be
considered. The psychological state of the patient is also important. The face,
mouth, and teeth are sensitive and emotionally important parts of the body;
therefore, the patient's readiness to undergo these appearance-altering changes
must be determined (Ehrich 70).
There are several common questions asked by patients and their families.
The first question is usually about the definition of tongue thrust. This question
can be answered by telling the patient that tongue thrust is a habit of pushing
the tongue forward against or between the teeth while resting or swallowing
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(Zickefoose 1). Another question might address the effects of tongue thrust on
the individual. A reply should include the point that the pressure the tongue
places on the teeth may cause them to move even after the orthodontic
treatment has straightened them. Swallowing pills, certain foods, and even
chewing with the lips closed may be difficult. To answer questions about what
causes tongue thrust, the professional should respond that allergy problems,
tonsil or adenoid problems , or anything which inhibits breathing through the
nose can cause tongue thrust. The sublingual attachment of the tongue might
not be long enough, causing a tendency for abnormal swallowing. Thumb
sucking may contribute to the problem as well. Some patients may ask why it is
important to keep their lips together most of the time. The answer to this
question is that the lips act as a " natural retainer" for the teeth (Barnes 11).
Another concern might be that the speech therapy exercises are going to be
hard or difficult. The patient should be informed that the exercises are not hard,
but must be practiced repeatedly to retrain the tongue. Therapists William and
Julie Zickefoose tell their patients specifically,"Remember you are the star in this
program. Your therapist and Mom and Dad will help you all they can, but only
you can make it work!" (3)
Speech-language pathologist Ann Ehrtich suggests educating the patients
on which muscles they currently use and then educating them on the correct
muscles that are used in swallowing. Mirrors are very important in treatment.
They bring the incorrect swallow to the patients' attention and allow them to see
how to correct their swallow. If a patient grimaces when swallowing, he/she is
likely using the muscles of expression (orbicularis oris, buccinator, and mentalis)
to move the liquid or the food to the back of the mouth and down the throat
(Figure 3.1).
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Ehrlich then recommends demonstrating to the patient the correct use of
the muscles of mastication (temporal muscle and masseter muscles) by asking
the patient to feel these muscles as the therapist swallows. The patient places
his/her hand on the therapist's temples and then the cheeks. To help the patient
become familiar with the action of the tongue during rest and swallowing, the
therapist should tell the patient to locate the alveolar ridge with his/her tongue.
This task is accomplished by asking the patient to place the tip of the tongue
firmly on the roof of the mouth where it would be placed to make the sound of a
/t/, /d/, /n/, or / I / . This "Spot" also known as the "neutral position" is where the
tongue should be placed at rest and during the swallowing process (Barnes 16).
After the oral evaluation, a speech evaluation is performed. During free
speech and sometimes even with guided words, the speech-language
pathologist is looking for the sounds of the /t/, 161, In/, l\l, and Isl to see if they
are dentalized or spoken clearly.
After these evaluations, the therapist can begin the treatment if the
patient is motivated. If the child is reluctant, the speech-language pathologist,
the child, and parents may need to discuss the treatment further.
15
M i ron ta l io
p r o c e r u s
nasa l IS
M r i s o r u
Platy.
M- tr iangular is
M- orb icu la r i s or i i
M.zyqo-m a t i c u s
quadratuj labu 5up-
raasse ter
cc ina tor
\ M q u a d r a t u s 'labii inferioris
M-TTiczntalis
Figure 3.1. Muscles of The Face (Wheeler 1969).
Speech Therapy Sample Exercises
Group One
The following exercises presented here are used by speech-language
pathologist Suzanne Barnes in her treatment of tongue thrust patients. Most of
these exercises are considered "general knowledge" in the speech therapy field.
16
The patient must remember several key facts throughout the treatment. The tip
of the tongue should be placed on the Spot for all of the following exercises.
The molars (back teeth) should come together in a bite for the correct
swallowing pattern. Every time the swallowing motion takes place, the back of
the tongue lifts up in a rolling motion. All of the tongue muscles must be tight
when using the new swallow. All of these exercises will help shorten, narrow,
and lift the tongue muscles. Group one exercises stress oral awareness, muscle
tone, and training of the correct tongue, lip, and jaw positioning.
The first exercise uses Cheerios. The patient is instructed to place the
cereal on the tip of the tongue and position the tip of the tongue to the Spot,
making sure that his\her jaw is open, mouth is still, and lips are relaxed and
holding the Cheerio on the Spot for 30 seconds. As the patient works at the
exercise, have him\her increase the time to 100 seconds. The patient should do
three sets of the exercise once a day, resting one minute between sets. This
exercise helps create an awareness of the tongue, lip, and jaw placement. It can
be practiced without anything on the tongue, but the Cheerio cereal makes the
exercise fun. After this part has been mastered, the patient should try this
exercise with the jaw nearty closed. The molars should be approximately one-
eighth of an inch apart. It is important for the patient to remember to breathe
through the nose with the lips lightly and comfortably closed and too repeat
these exercises as instructed above. This Cheerio exercise introduces the
correct rest position.
The second exercise is called Tongue Pops. The patient presses the tip
of the tongue to the Spot and sucks the rest of the tongue up to the palate
without touching any of the front six teeth on the upper jaw. Next, the patient
pulls the tongue muscles back and down to make a crisp popping sound. The
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jaw should be still while the mouth remains open. The patient should do two
sets of five lifts twice daily and hold each for fifteen seconds, building up to one
minute when the tongue is stronger. In addition, two sets of twenty pops two
times per day should be completed, with one minute between each set. This
type of exercise emphasizes the mid-tongue placement, awareness, and
contraction.
The third exercise is called the Open and Close. The patient should
place the tongue in the same position as for the Tongue Pops exercise, slowly
open the mouth until discomfort is felt, and then release slightly and hold this
position for ten seconds. Then he/she should close the mouth, bringing the back
teeth almost together while the tongue is still on the palate of the mouth, and
holding this position for ten seconds. These steps should be repeated one time
a day with three sets of ten repetitions.
Tongue Clicks are the fourth exercise in this group. This exercise
focuses on the muscles needed for a correct swallow. The back teeth should be
placed together and the tongue positioned on the Spot. The patient then sucks
the tongue back forcefully, but slowly, using the sides of the tongue. This motion
should make a slow clicking sound, like the sound one might make while riding a
horse. Spread the lips in a wide smile and use a squirt bottle to place water over
the molars on both sides of the mouth. As the tongue squeezes in, lifts up, and
sucks back, the water will move to the back of the mouth if the exercise is
performed property. Tilting the head back slightly will encourage the water to go
toward the back of the mouth. Two sets of twenty should be repeated twice
daily. The patient is encouraged to rest for one minute between repetitions to
assure accurate practice.
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Exercise number five. Saliva Suction, is designed to correct saliva
collection and swallowing abilities. The patient is instructed to bite the back
teeth together, place the tongue on the Spot, and suck the rest of the tongue to
the palate of the mouth. The patient should then click the tongue as in the
previous exercise while squeezing it inward and upward. The patient spreads
his/her lips in a big smile and uses the squirt bottle to shoot water over the back
molars and then closes the lips to form a vacuum. Next, the patient swallows
with the back of the tongue lifted up and rolled back. While viewing this exercise
in the mirror, the patient can open his/her lips to assure correct tongue position .
There are two important notes to this exercise: (1) there should be no facial
strain or grimace, and (2) ,while swallowing, the tongue should not slip forward
or to the sides of the mouth. When performing this exercises, the patient should
think "bite, suck, click, swallow" ( Barnes 19). The patient should do two sets of
ten twice a day with one minute rest periods between sets. The saliva swallow is
important because it is the basic swallow that one performs many times
throughout the day and the night.
The sixth exercise is called the Skinny Tongue. This exercise helps to
tone the tongue so that the patient can gain better lingual control. It also helps
the patient to feel like there is less tongue in the mouth. Skinny Tongue helps
the lateral thrusters by gaining control of the lateral muscles. To perform these
exercises, the patient should stick out his/her tongue, which in turn pulls the side
muscles toward the middle of the tongue. The patient is strengthing these
muscles and giving a thin feeling to the tongue. The patient then curls the tip of
the tongue toward the nose, remembering that the tongue should not touch the
teeth or the lips, which should be relaxed. Next, the patient performs the same
steps, except he\she brings the tongue back into the mouth. When the tongue
19
curts, it should rest on the Spot. The back teeth are then brought almost
together, and the exercise is repeated. These two variations should be
performed in two sets of ten, twice a day, with rests between sets.
Exercise number seven is called the Hissing Tongue. This exercise helps
the patient become aware of how the tongue feels in relation to the mouth. It will
help the patient to experience how the sides of the tongue feel against the upper
gums and to understand exactly what the tongue is doing. With this exercise, it
is often fun to hiss favorite tunes. To perform the Hissing Tongue, the patient
places the tongue on the Spot while the sides of the tongue are on the palate.
As the patient holds the tongue tip up, he/she begins the hissing sound, curting
the tip of the tongue slowly down and blowing a steady stream of air down the
center. At this point, the tip of the tongue is slightly off the ridge and tends to
make the sound of a tea kettle. The clinician reminds the patient to pull the
sides of the tongue up tightly against the gums. This action makes the tongue
contract laterally, pulling the sides to the center of the tongue, also reminding
the patient that the lips should not be rounded or puckered. There should be no
tension in the chin, and the tongue should not touch the front teeth. The patient
should do two sets of the Hissing Tongue for thirty seconds, twice daily, with a
one minute rest period between the sets.
The next exercise uses Cheerios cereal as in the first lesson. The name
of this exercise is Cheeno Smash. With the Cheerio on the middle of the
tongue, the patient places the tongue on the Spot and sqeezes the Cheerio
against the middle portion of the palate. The clinician should remind the patient
that the teeth are supposed to be apart. The patient is instructed to hold this
postion for thirty seconds with constant pressure on the Cheeno until it
dissolves. As the patient gets better, this exercise can be performed with a
20
sugartess mint. This lesson should be repeated two times daily each with only
one set of ten repetitions. Toning the middle portion of the tongue is extremely
important for tongue lifting, narrowing, and retracting. Successful completion of
this exercise will help achieve the middle tongue muscle strength needed to
have correct swallowing and resting habits.
"Cha-Cha-Cha"-Slurp-Swallow-Say "Choo" is the next exercise. This
exercise strengthens the swallowing muscles and helps to eliminate the use of
lip and chin muscles while swallowing. The patient should begin with the tongue
on the spot and say "cha-cha-cha" with the mouth open and the jaw still. The
patient is then instructed to slurp loudly and bite the teeth together. While biting
down, the patient should place his/her finger on the cheek, just in front of the
ears, to feel the masseter muscles contract. The patient should then suck the
tongue tightly up to the Spot. Next, the patient should swallow with the lips open
and say "choo." These steps should be repeated one time per day with one to
three sets of ten repetitions.
The rest position is very important in the treatment of tongue thrust. For
tongue thrusters, awareness of correct rest position of the tongue, lips, and jaw
is the basic knowledge that needs to be practiced. Some keys to tongue
placement are found in the following exercise. The patient should place the tip
of the tongue on the Spot with the lips relaxed and closed. The molars should
be partially separated and never clinched together. Breathing should occur
through the nose. The back sides of the tongue should touch the back molars.
To start with the correct resting position, one should consciously work on it three
times a day for fifteen minute stretches. The patient may find that writing things
down always helps one to become more aware; therefore, charting the resting
postition and the swallows allows the patient to be conscious of his/her efforts.
21
stickers are helpful in reminding children to remember their tongue placement as
well. Eventually, this new resting position will become a habit and will require
less thought.
Yawning can also be helpful in developing the muscles of the soft palate
and in stimulating the swallowing muscles. Tongue thrusters should be
encouraged to say "aaah" when they yawn. After yawning, the patient should
relax the throat, take a breath, and try it again. The development of soft palate
muscles is important because it elevates to allow swallowing without nasal
regurgitation.
Gargling is another important technique for awareness. Methods include
the following: (1) gargling with water, (2) gargling without vocal sounds, only air
bubbles; and (3) gargling without water, noticing the activity of the back of the
throat. Gargling can be done when brushing the teeth, twice daily with one set
of ten repetitions. All of these exercises must be mastered before the patient
can begin the second group of exercises.
Group Two
There are two exercises that will help to strengthen and tone the lips.
The exercises allow the lips to act as a natural retainer for the teeth, the job for
which they were designed. These exercises promote lip closure as well as nose
breathing. Pucker Power, or the Button Pull, should only be used with children
over the age of six or seven. In preparation, the speech-language pathologist
should thread a smooth one-inch button with a twelve-inch piece of string or
dental floss. Next, the therapist instructs the patient to place the button between
his/her front teeth and the center of the lips. This isometric exercise encourages
the lips to increase in competency (come together properly). As instructed by
22
the therapist, the patient should pull gently so that the lips have to provide
resistance, but not hard enough to pull the button out of the mouth. After
exercising the center of the lips, these steps should be repeated with the button
placed to the left side of the lips. It is important to make sure that the button is
pulling on the lips and not on the cheek. After one minute in the center and one
minute on the left side, the button is positioned on the right side for one minute,
and the steps are repeated. These exercises should be performed three times
per day with four sets at each position. The second of the lip exercises involves
the therapist placing a straw between the patient's lips and instructing him\her to
relax the lips. The patient should do this activity twice a day for fifteen minutes.
After these activities, the patient should massage the lips with the finger tips.
The next activity used to correct tongue thrust disorder is the Kick-Kick-
Kick exercise. This exercise helps the patient feel comfortable with the correct
placement of the back of the tongue. It also helps reinforce the lifting of the
tongue to close the airway dunng swallowing. The therapist should instruct the
patient to say "kuh-kuh-kuh" while holding a mirror and watching the back of the
tongue in motion as these sounds are made. The therapist should remind the
patient to keep the lips relaxed. Next, the patient should say "kuh" and follow
that by "kick-kick-kick". The mouth should still be open and the chin should be
still. The "kuh" sound stresses the forcefulness of the back of the tongue. The
patient should do two sets of ten Kick-Kick-Kick exercises twice daily. At this
point in the treatment, Suzanne Barns instructs her patients as follows:" Your
tongue thrust did not occur overnight, and it will take time and effort to correct it.
Be patient and remember: Practice makes perfect when you practice perfectly."
(Barnes 31)
23
Liquid management is another important aspect of treatment, because
many liquids are swallowed daily. The Water Seals exercise will help the
tongue thruster to master the liquid stage of swallowing. The therapist should
instruct the patient to take a small sip of water while keeping the tongue inside of
the mouth and slightly cupped to hold the water. Then, the patient sucks the
tongue into the pop position. The tongue tip is on the Spot and the middle and
back of the tongue are pressed to the roof of the mouth. The water is now
sealed between the tongue and the palate. The lips and cheeks should be
relaxed and the mouth open, allowing the patient to check the tongue position in
the mirror. The sides of the tongue should be placed on the gums, not on the
teeth, to create the proper seal. The exercise is being performed successfully if
the patient can move his\her head from side to side without the leakage of water.
Lastly, the patient should release the water into the sink and repeat this
procedure twice daily with two sets of ten Water Seals. The therapist should
remind the patient to rest for one minute between sets. If this exercise proves to
be difficult, the patient may need to return to the group one exercises to
strengthen the tongue muscles and develop the correct swallowing patterns.
The next exercise uses what the patient learned from the Water Seal
exercise and adds the swallow. After a seal has been made and checked with
the previous steps, the teeth should come together in a bite using the masseter
muscles. The patient should manually feel these muscles once again to
reinforce the awareness. The next step is to close the lips and suck the tongue
back into a swallowing position. The patient should check this position in the
mirror by making a wide smile so the tongue may be seen. Swallowing is the
next step. The patient should remember to suck the tongue up and lift the back
of the tongue in a rolling motion. The lips should not be tight. They should
24
remain relaxed throughout the swallow. This type of swallowing should be
practiced twice daily with two sets of ten repetitions. At this point, the tongue
should be comfortable at the Spot. With practice, the liquid swallowing will
become easy. In the beginning stages of this exercise, it might be helpful for the
patient to tilt his/her head slightly backwards.
Squirt Bottle Swallows are a fun way to practice the liquid swallowing
technique. The patient should bite bringing the molars together, suck the tongue
into position, and open the lips in a big smile. With the squirt bottle, the
therapist should shoot water over the molars. Next, the lips should close to form
a vacuum. Water is brought over the sides of the tongue with suction to form the
water seal. After these steps are completed, the water may be swallowed using
the methods in the previous lesson.
The last step in the group two exercises is to learning to drink
continuously. This exercise uses the same swallow that has been learned, but
in different way. Continuous drinking can be achieved by placing the tongue tip
on the Spot, biting the molars together, and bringing the cup of water to the lips.
This exercise works best with water at room temperature. The temperature of
the water is important because the patient is going to pull the liquid through the
teeth. If the patient has sensitive teeth, the cold water could be uncomfortable.
The tongue should be kept on the Spot and in the swallowing position
throughout the exercise. The patient should continue using this new swallow
until all of the water is gone. In the beginning it may be easier if there is only a
small amount of water in the glass. Drinking from a straw is another great way to
practice this form of swallowing. When drinking, only one-forth of an inch of the
straw should enter the mouth. The exact same swallow is used. When drinking
from a water fountain, the patient must remember to keep his/her molars
25
together and swallow in the correct manner. The only skill remaining is to learn
proper food management swallowing.
Group Three
Reminders should be given to the patient to continuously practice the
exercises in groups one and two. The first step in swallowing food correctly
begins with soft food. These soft foods can consist of applesauce, mashed
banana, yogurt, or pudding, depending upon the patient's preference. The
therapist instructs the patient to place a small amount of the food on the middle
of the tongue. The patient must keep the tongue in the mouth as the spoon is
inserted. Then, the patient should let the spoon come to the mouth rather than
the tongue meeting the spoon. Once the food is on the tongue, the lips should
close to form the vacuum. The patient should form the tongue into a bowl shape
to hold the food, just as he/she did with the liquid. Then the patient should bite
the molars together and suck the tongue into the swallowing position. The
analogy of lifting the back of the tongue like a dump truck provides a visual
picture of what the tongue should be doing as the swallow takes place. The
patient should practice these exercises twice a day.
The next step in the progression of learning to property swallow is to add
chewing. Snacks and small meals are preferred for this exercise. The patient
should take moderate sized bites. As the food enters the mouth, the tongue
should be resting at a low position behind the bottom teeth. Chewing can be
done several ways. One way involves chewing simultaneously on both sides
with the tongue tip on the Spot. Another way involves chewing on one side for a
while and then switch sides. As the patient chews, he/she should move the food
26
toward the back molars with the lips closed and the tongue away from the upper
six front teeth. As the patient gets ready to swallow, the tongue sweeps from
side to side in an upward motion. The lips and the chin should be relaxed. As
the food is formed into a bolus, it should be moved to the center of the tongue.
The patient should lift the tongue to the Spot, bite, suck the tongue up and back,
and swallow. All of the food should go down the throat. While watching in the
mirror, the patient should notice how his/her lips do not pucker and the tongue
does not protrude during a properly executed exercise. It often helps the patient
to have a mirror at the table while eating. Another helpful tip is to set the fork
down between bites. This habit encourages the patient to chew slowly and be
aware of the swallowing process.
Through therapy and every swallow that is performed correctly, the
patient is forming correct swallow habits. This habituation stage is the stage of
treatment that allows the patient to take the knowledge that he/she has obtained
from the therapy session and apply it to his/her life, changing old habits into
newer and better actions. These lessons typicaly take from six to twelve weeks
to learn and master. To help these habits form, therapists stress practice in the
patients' sleep as well by having them practice twenty correct swallows before
bed and telling themselves several messages. Some suggested messages are
"I will keep my tongue on the Spot all night; I will breathe through my nose all
night long; My lips will stay together all night long; and My back teeth will stay
separated all night long" (Barnes 44). These messages reinforce the exercises
that the therapist and the patient have worked on over the previous weeks.
Charting continues to be imperative to incorporate into the exercises during the
last stages of therapy. As Suzanne Barnes recommends, there should be
several sections to the chart, which include: (1) resting posture, 2) collecting and
27
swallowing saliva, (3) swallowing liquids, (4) chewing and swallowing food, (5)
swallowing when active, and (6) sleeping and waking position of the tongue.
These categories are tailored to the type of therapy that Suzanne Barnes
recommends. When charting, the patient or parents will mark a (+) for the
correct position or movement and (0) for an incorrect attempt at the postition or
movement when practicing the sets of repetitions. Charts are simply used for
awareness. An even simpler charting idea is to wnte the day and time of
practice. Anything written down is easier to remember. With pediatric patients,
parents play a large role in the treatment of tongue thrust. Good oral habits
(including swallowing, resting, speaking, and brushing) should be encouraged
and praised by the parents of the patient. Cooperation and persistence with this
treatment will increase the chances of successfully ending the tongue thrust
disorder and making the new swallow a habit.
28
CHAPTER IV
ORTHODONTIC TREATMENT
Types of Malocclusions
Malocclusion is defined as the deviation from the normal way that the
maxillary teeth and the mandibular teeth relate (Goldberger 10). In tongue thrust
patients, the tongue can exert as much as six pounds of pressure on the teeth
up to 2,000 times per day (Ehrtich 97). This pressure is enough to move the
teeth into undesirable positions. There are three main classes of malocclusions
that occur. These three types of malocclusions correlate with the eight different
types of tongue thrust. A diagram of the landmarks of the mandibular first molar
can be used to aid understanding and onentation (Wheeler 353) (Figure 4.1).
Figure 4.1. Landmarks of the Surface of the Tooth (Littman 1968)
The first type and most common type of malocclusion is a Class I (Figure
4.2). These malocclusions have a characteristic normal mesiodistal relationship
29
malocclusion occurs when the antehor segments of one or many teeth are
mispositioned and\or are deflected from their normal, natural course. The types
of tongue thrust that have a Class I malocclusion are incisor thrust, bimaxillary
protrustion, open bite, closed bite, and unilateral thrust. (Barrett 42)
Figure 4.2. Class I.
The second class of malocclusion is termed Class II. It suggests a
retrusion of the mandible; therefore, the lower arch of teeth are distal from a
normal relationship to the upper arch. The mesiobuccal cusps of the lower first
molar articulates postenorty with the buccal groove of the upper first molar. Full
thrust and the subtype of bimaxillary protrusion tongue thrust have a Class II
malocclusion. There are two divisions of this malocclusion. Division I, including
primarily mouth breathers, shows the maxillary incisors protruding anteriorly
toward the lips (Figure 4.3). Division II is a bilateral distocclusion where the
maxillary central incisors are almost normal to slightly retruded (Figure 4.4). The
maxillary lateral incisors are flaired toward the lips (Barrett 42).
The third category. Class III, is where the mandibular teeth protrude in
relation to the maxillary teeth (Figure 4.5). The mesiobuccal cusp of the
mandibular first molar is articulated anteriorty to its normal mesiobuccal
30
The third category, Class HI, is where the mandibular teeth protrude in
relation to the maxillary teeth (Figure 4.5). The mesiobuccal cusp of the
mandibular first molar is articulated anteriorty to its normal mesiobuccal
relationship to the maxillary first molar. This type of malocclusion is seen in
mandibular thrust and bilateral thrust (Barrett 43-44).
Figure 4.3. Class II, Division 1 Figure 4.4. Class II, Division 2
Figure 4.5. Class
31
discussed the oral myofunctional (speech therapy) approach. However, there
are also methods that some orthodontists use to attempt to retrain the tongue.
Fixed appliances are used to discourage incorrect placement of the tongue.
These appliances may deter the problem only temporarily because when the
appliance is removed, the tongue usually reverts back to its initial trusting habit.
One appliance is called the Hay Rake. This appliance consists of a metal
bar or wire placed to the lingual side of the maxillary incisors. The hay rake is
usually attached to two metal crowns that are fitted to the maxillary first molars.
This metal bar is equipped with a row of four to six prongs. These prongs are
welded at right angles to the bar and project posteriorly and downward. The
prongs may be sharpened to irritate the tongue as it thrusts fonvard. Another
version of the hay rake points the sharpened prongs toward the gums with a light
loop of wire positioned to catch the thrusting tongue. As the tongue thrusts, the
sharpened prongs stab into the gum tissue. The idea behind this appliance is to
make tongue thrusting so painful that eventually the patient would stop the habit.
However, the Hay Rake usually does not teach the patient to swallow property
and often inhibits the normal motion of a the tongue.
Another appliance is the Cage. The Cage is a version of the Hay Rake;
however, the Cage does not have sharpened prongs. Instead, the rounded wire
projections are more numerous and longer. Numbenng between ten to twelve,
the inch long wires hang from the palate. The tongue fits into the Cage to keep
it from pushing the teeth. This appliance impairs speech and normal articulation
of the teeth . As the tongue is held back, the lingual muscles are increasing in
strength to protrude again when the cage is removed. Once again, this is an
example of an appliance that in some cases may do more harm than good.
32
The Cnb is another appliance that is used. This appliance is fitted to the
maxillary arch. A heavy arch wire is placed on crowns that are fitted to the upper
molars as with the Hay Rake. A wire screen is suspended down from the arch
wire. Attached to the screen is another piece of wire or acrylic arranged in
crisscrossing, broad "V" shapes. This appliance causes no pain; it contains the
tongue before it reaches the teeth. The problem with this appliance is that it
provides resistance for the tongue and, therefore, strengthens the thrusting
muscles. " In combating tongue thrust, it restrains; it does not retrain" (Barrett
147).
Another restraining method is called the Curtain. It is a "U" shaped piece
of acrylic that is suspended from the palate around the cuspid region. This
appliance may drop down somewhat into the lower mouth. It is held in place
with continuous looping wire around the buccal surfaces of the molars. The only
way the Curtain will restrain is if the patient bites down before swallowing. This
appliance will interfere with the molar occlusion because the teeth cannot
articulate property with the curtain in the mouth.
Efforts have been made to create reminder appliances rather than the
torturous appliances such as the Hay Rake or the Cnb. Walker and Collins
suggest anchonng a wire that extends across the palate. The patient is then
instructed to keep the tongue behind the wire while he or she eats, drinks, or
swallows ( 771). A second reminder appliance devised by Littman is a hawley
retainer with a pear-shaped opening in the acrylic. The tip of the tongue rests in
the opening positioned at the alveolar ndge. This particular appliance is worn at
all times. The patient is instructed to practice swallowing by placing the tongue
in the opening, with the molars together, and swallow. The patient should
practice this exercise three times per day with twenty-five repetitions. This
33
approach is the only technique that helps to train the tongue. It is usually worn
for approximately three months (138).
The above appliances are a broad overview of the techniques that
orthodontists have used. Today most patients are instead referred to the oral
myofunctional therapists for treatment. In some cases, the orthodontists will
begin correction of the teeth prior to speech therapy. In other cases, the
orthodontist's job begins when the control of the tongue is regained and the
thrusting has ceased
34
CHAPTER V
CONCLUSION
Tongue thrust is a difficult habit to correct. One should conclude from this
thesis that speech therapists and orthodontists, each with various methods, have
individually tned to alleviate this disorder. The most successful approach is
ideally one in which the orthodontists and the speech therapists work together to
change the thrusting habit. Significant improvement can be made in the
patient's confidence, appearance, and quality of life with diligent effort and
cooperation. It is a fact that habits can be corrected. It is not an easy task by
any means. This is especially true when the patient does not believe the tongue
placement is incorrect and does not cooperate. There have been many
successful cases of corrected tongue thrust. With hard work, repetition of
swallowing exercises, and cooperation with the speech-language pathologist
and orthodontist, the patient can be on his/her way to better swallowing habits,
improved speech and beautiful and stable straight teeth.
35
BIBLIOGRAPHY
Barnes, Suzanne M. Taming Tongue Thrust Mantjal Arcadia: Suzanne Barnes Enterprises Company, 1995.
Barrett, Richard H., and Marvin L. Hanson. Fundamentals of Orofacial Myology. Springfield: Chartes C. Thomas Company, 1988.
Barrett, Richard H., and Marvin L. Hanson. Oral Myofunctional Disorders. Saint Louis: The C.V. Mosby Company, 1974.
Collins, T.A. and R. V. Walker. "Surgery or Orthodontics - A Philosophy of Approach" Dental Clinicians 15 (1971): 771.
Ehrtich, Anne B. Training Therapists For Tongue Thrust Correction. Spnngfield: Charles C. Thomas Company, 1973.
Goldberger, Jeanne M. Tongue Thrust Correction . Danville: The Interstate Printers and Publishers Inc., 1976.
Jones, Bob. 19 May 1999. Personal Communication. Communication Disorders, Texas Tech University, Lubbock, Tx.
Littman, J.Y." A Practical Approach to Tongue Thrust Problem" Journal of Practicing Orthodontists. (March 1968): 138.
Moyers, Robert E. Handbook of Orthodontics. Chicago: Yearbook Medical Publishers, 1973.
Tepper, Harry W. " Tongue Thrust Correction in One Easy Lesson" The Journal-(December 1986): 4-5.
Wheeler, Russell C. A Textbook of Dental Anatomy and Physiology. Philadelphia: W. B. Saunders Company, 1969.
Young, L.D. "The Use of Cueing and Positive Practice in the Treatment of Tongue Thrust Swallowing" Journal of Behavior Therapy and Psychiatry. 14 (Marchi 983): 73-77.
Zickenfoost, Julie and William E. Zickenfoost. A Childs Guide to Tongue Thrust. Sacramento: OTM Matenals, 1989.
Zickenfoost William E. What Do These Terms Mean To You?. Sacramento: OTM Materials, 1989.
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