Oral Motor Assessment and Treatment

OT 3810: OT Practice Phase I

Module IV

B.Atchison, 9/08

Context

• Cultural components• Attitudes and values• Environmental factors—home vs public • Social activities during mealtime

Client Factors Affecting Oral Motor Function

Determined in initial information gathering

Guiding Questions

• Presence of medical conditions affecting function

• Presence of seizures

• Medications

• Cognitive level

• Postural instability

Guiding Questions

• Presence of reflux

• Movement patterns that favor reflux

• Anomalies, e.g. hiatal hernia

• Non oral intake

the stomach protrudes above the diaphragm into the chest.

Guiding Questions

• Caloric and hydration intake

• Middle ear infection present

• Bruxism

• Drooling

Guiding Questions

• Variation in facial expression

• Tolerance for teeth and gum brushing

• Presence of dental caries,oral lesions, gingival hyperplasia

Dental caries

Gingival Hyperplasia

Guiding Questions

• Variety and control of movement for lips, cheeks, jaw, and tongue:

– During Speech– During Drinking – During Eating– During Chewing

Consonants and Vowels

Cookie Analysis

Applesauce Analysis

Drinking Analysis

Guiding Questions

• Hypersensitivity to touch on body, face, or within the mouth

• Are there specific oral motor interventions now?

• Sensory seeking behavior (outside of meal time

Guiding Questions

• What is reinforcing to the person?

• How does person eat at mealtimes

• How positioned

• Gagging, coughing, delayed oral transit

Guiding Questions

• Tongue thrust, tonic bite

• Refuses foods/fluids

• Consistency of techniques used

• Food texture, consistency, temperature

• Time alloted for intake

Most frequent problem in oral motor treatment is oral

hypersensitivity

Reason: Many factors can lead to hypersensitivity

Oral Hypersensitivity Scale

Positioning and Outflow

• Normal Alignment

• Poor Alignment

Indicators of Reflux

• Immediate

• Long term

Reflux Board/Wedge

Head Alignment

• Avoid hyperextension=aspiration and pharyngeal pooling

1. Quantity. Aspirating larger quantities is riskier.

2. Depth. Aspirating material into the distal airways is more dangerous than aspirating material into the trachea.

3. Physical properties of the aspirate.

• Solid food may cause fatal airway obstruction. • Acidic material is dangerous because the lungs are highly

sensitive to the caustic effects of acid. • Aspirating refluxed acidic stomach contents may cause

serious damage to the pulmonary parenchyma. • Aspirating material laden with infectious organisms or even

normal mouth flora can cause bacterial pneumonitis.4. Pulmonary clearance mechanisms. • Ciliary action and coughing. • If sensation is impaired, "silent aspiration" (without cough or

throat clearing) may occur.• Silent aspiration is likely to cause respiratory sequelae, as is

aspiration in persons with an ineffective cough or impaired level of consciousness.

Factors which influence effects of aspiration

Impact of Gravity

Sidelying Considerations

• How to determine best position

frontalis: the forehead

corrugator: the brow

nasalis: the nose

obicularis oculi: around the eye

levator labii: raises the upper lip

masseter: closes the jaw

Obicularis oris: purses the lips

risoris: draws the lips in a smile

buccinator: pulls the lips wide and tight

depressor labii: lowers the lower lips

depressor anguli oris: lowers the bottom corner of the lips

levator anguli oris (not shown): raises the upper corner of the lips

pterigoid (not shown): pulls jaw back or shut

mentalis: pulls chin down

Facial muscles around the mouth. NOTE: muscle contraction follow direction of fibers

A-m. levator labii superioris, B – m. zygomaticus minor, C - m. zygomaticus major, D - m. risorius, E - m. depressor anguli oris, F - m. labii inferioris, G - m. orbicularis oris)

Oral Motor Patterns

Normal vs Abnormal

Lip Patterns

• Normal:– Lip Rounding--ohhh– Lip Spreading-eeee– Lip Closure-mmmmm

Lip Patterns

• Abnormal Patterns– Lip tremor– Lip retraction– Lip purse string– Asymmetrical lip movement

Lip Patterns

• Abnormal Lip Patterns– Hyptonic lips– Dystonic lip movement– Lip Fasiculations

Normal Tongue Patterns

• Suckling (retraction/protraction) Infancy

• Simple tongue protrusion

• Sucking (elevation/depression) Later childhood and adulthood

Normal Tongue Patterns

• Tongue tip elevation

• Munching

• Lateral tongue movement

Abnormal Tongue Patterns

• Tongue tremor

• Exaggerated tongue protrusion

• Tongue thrust

• Tongue retraction

Abnormal Tongue Patterns

• Asymmetrical tongue placement/mvmt

• Hyptonic tongue

• Macroglossia

• Dystonic tongue movement

Abnormal Tongue Movements

• Tongue fasiculations

• Ankyloglossia

• Pseudo-Anklyoglossia

The tongue is restricted in its movements by a strand of mucosa (lingual frenum) that attaches the anterior third of the tongue to the floor of the mouth and the lingual gingival mucosa. Persons with this condition are commonly called "tongue-tied." Treatment is surgical.

Normal Jaw Patterns

• Close and hold (normal bite reflex)

• Wide jaw excursion

• Phasic Biting

• Nonstereotypic vertical movement

• MunchingNO lateral movement with these five patterns. Would result in not being able to grind fibrous

foods

Normal Jaw Patterns

• Lateral jaw shift

• Diagonal movement

• Diagonal rotary movement

• Circular rotary movement

Abnormal Jaw Pattern

• Micrognathia

• Dystonic jaw movement

• Bruxism

Abnormal Jaw Pattern

• Jaw clonus

• Tonic bite reflex

• Jaw thrust

• Jaw retraction

Normal Cheek Pattern

• Protrusion

• Retraction

Abnormal Cheek Patterns

• Hyptonicity

• Hypertonicity

• Fluctuating Tone

• Atrophy

Abnormal Cheek Pattern

• Anterior hypertonicity and Posterior hypotonicity is common cheek problem

Swallowing Patterns

• Pressure variations (both + and -) impact– In mouth– Pharynx– Esophogus– Filling and empyting of bolus in tract– Pressures of respiration

Swallowing Patterns

• Stage One: Oral Transit

• Stage Two: Pharyngeal Transit

• Stage Three: Esophogeal Transit

Oral Phase of Swallowing

Food is held within the mouth A bolus is formed in the central portion of the tongue

At same time, the base of the tongue and the soft palate close the oral cavity to prevent food spilling into the open larynx and trachea.

Tongue pushes bolus posteriorly toward the pharynx with an anterior-to-posterior tongue elevation.

As the bolus enters the pharynx the actual swallow or pharyngeal reflex is triggered.

B

Pharyngeal Phase

This phase is a reflex action. The bolus passes through the pharynx quickly and then enters the esophagus.This takes place in less than a second.

The initiation of this process starts when the bolus passes the anterior faucial arch and reaches the posterior pharyngeal wall. Elevation of the soft palate prevents material from entering the nasal cavity.

This stage is followed by the pharyngeal constrictor muscles pushing the bolus further into the pharynx, toward the cricopharyngeal sphincter. The larynx prevents material from entering the trachea by respectively closing the true vocal cords, false vocal folds, and aryepiglottic folds. Contraction of the lower pharyngeal constrictor is followed by relaxation of the cricopharyngeal muscle, allowing the bolus to pass into the esophagus.

Esophogeal Phase

Due to insufficient closure of the larynx

Oral cavity doesn’t close well in preparatory phase

or swallow reflex not intitated when bolus

enters pharnx

When larynx opens, bolus enters into trachea

Esophogeal Phase

Peristaltic muscle action pushes food through espophagus to stomach OR aspiration occurs

Excellent Videoflouroscopic View of Swallowing Phases

Abnormal Swallowing Patterns

• No Active Swallowing

• Poor Suck/Swallow/Breathe Pattern

• Drooling

• Gagging

Positions for Facilitating Suck

Facilitating Suck

Shoulders & Trunk

Hips

Choosing the Right Nipple

• Size

• Shape

• Stiffness

• Nipple Hole

Transitioning from Nipple Feeding to strained foods…

The feeder has to gently scrape the food off on the baby’s upper lip, & the food usually has to be put back in several times after the baby has spit it out. When would this be a real problem?

This spitting out is usually a result of immaturity rather than a dislike for the food. This is messy time!

Presenting strained foods before a baby is physically just gives them more practice taking strained foods in an immature way

When strained or pureed foods are first presented, babies usually try to suckle.

The suckling tongue action begins as soon as the spoon touches the lips. Doesn’t move downward on the spoon to remove the food.

The closer the baby is developmentally to 6 months, the shorter the messy period, and the sooner the baby gains more control

Transitioning…

When children have muscles that are too floppy or weak, they may need to have their faces “wakened up” with a brisk washcloth rub before the presentation of the food.

Can also use Rood technique: quick ms. stretch and ice as last resort

Inhibition Facilitation

Muscle tightness interferes with the child’s ability to close lips on the spoon.

Incorporate facial massage in direction of protraction prior to the feeding to inhibit tight ms.

Facilitating Spoon Feeding…

With the spoon resting on the lower lip. This facilitates upper lip closure.

• When the food is presented, close the jaw while giving it stability support.

• This also facilitates lip approximation.

Pause! Help close the jaw

Transitioning to Spoon…

• Bring the upper lip down to meet the spoon when it is resting on the lower lip

• Present the spoon laterally, then tip first.

• First, rest as much of the side of the spoon as possible along the lower lip

• and pause to see if the child responds by bringing the upper lip down.

Help close the Lip Lateral Presentation

Special Straw- Drinking Techniques

Tongue Lateralization

• Tongue lateralization is necessary for placing food over the teeth and keeping it there during the whole chewing process. Without good sideways tongue movement, food falls off the teeth and isn’t well-chewed.

• You can use the NUK brush with the child, or let the child use it while you supervise. But a child should NEVER be left alone with the brush because choking can occur.

• Infa-Dent Finger Toothbrush

Choosing a Cup for Independent Cup Drinking

• Developmental Skills• Size• Shape & Design• Safety• Lid Cover• Handles• Weight• Training System• Straw Possibilities

Mealtime Sensory Challenges

• Tactile

• Proprioceptive

• Gustatory

• Olfactory

• Visual

• Auditory

Oral Aversion

• Put child on a sensory diet—Which modalities?

• This is the “back door” to the mouth

• 50% or more of O.T time spent on sensory diet before food is presented.

Oral Aversion

• Modify the mealtime environment

• Dim lights

• Create an ambience “ candlelight dinner”

• Play rhythmical, soft music

Oral Aversion

• Slow and steady• Break into small steps • Short sessions• Structure the treatment session for success • Work outside the mouth, gradually leading up to

the mouth them inside the mouth• Reinforce positive responses, even

approximations• Include/ train the caregiver

Oral Aversion

Example of a “typical” session for an oral aversive child

• Proprioceptive tasks such a HOT DOG game crawling over pillows/ crash pad

• Wearing a weighted vest • Play dough, beans/rice scooping, pouring

(tactile)• Blow bubbles• Tastes of familiar • Slowly introduce challenges

Transition from strained foods to soft, lumpy foods

• Children with physical and sensory problems can have a hard time moving from strained foods to soft, lumpy foods.

• Gradually, children learn to like thicker purees or ground foods. Tiny, soft, unnoticeable lumps usually are accepted.

• Children may carefully spit out a lump or two to play with it on the tongue. But with more experience, ground, mashed, or chopped table foods with noticeable lumps are readily taken.

• Most of the time moving to new textures is done naturally with an eager interest in the new foods presented.

Strategies for Acquisition of Physical Skills

• Physical issues

• Postural alignment head/neck and trunk alignment

• Capital flexion (chin tuck) and symmetry

• Head/trunk stability

• Airway stability

Strategies for Acquisition of Physical Skills

• Address limiting areas such as hypo/hypertonia• Change or break up total patterns of flexion or extension• Oral control arena• Tongue• Jaw control• Lip control• Cheek control

• l

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