Anna Gross, MS, CCC -SLP · • Short upper lip • Full lower lip • Hypotonic facial muscles...
Transcript of Anna Gross, MS, CCC -SLP · • Short upper lip • Full lower lip • Hypotonic facial muscles...
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Anna Gross, MS, CCC-SLP
Speech-Language Pathologist
Kids Therapy Made SimpleOMBRE
Pediatric Airway Health: The Importance of Myofunctional, ENT, and Dental Collaboration
Anna Gross, MS, CCC-SLP
Speech-Language PathologistSpecializing in motor speech disorders, phonological disorders, orofacial myofunctional disorders, and oral phase feeding disorders. Currently working in private practice in Los Angeles, CA, where I focus on the pediatric population. In addition to clinic based private practice, I am also co-founder of OMBRE, an online orofacial myofunctional therapy company, where I provide tele-health services to individuals in the pediatric and adult populations.
Speaker Disclosure
Relevant financial relationships• Employee at Kids Therapy Made Simple• Co-Founder and COO of OMBRE• Receives a fee from the CSPD for speaking at today’s conference
Relevant non-financial relationships• A member of ASHA, CSHA, AAMS, and the MSCC
Learning Objectives
• Appreciate the impact of myofunctional and airway disorders on pediatric populations.
• Be able to screen for and identify the clinical signs of myofunctional and airway disorders among patients in your practice.
• Be able to discuss the peer-reviewed research supporting the role of myofunctional therapy, tongue-tie, and lip-tie surgery in the treatment of these patients.
• Understand the importance of a multidiscipliaryteam, and how to find those professionals in your area.
WHAT DO OPTIMAL BREATHING, SWALLOWING, AND ORAL REST
POSTURES LOOK LIKE?
CORRECT RESTING POSITION
OF THE TONGUE(Illustrated by Gallay, 2014)
• Nasal Breathing• Light lingual-palatal suction
occurs so the tongue rests on the palate
• Lips close with adequate labial competency
• Absence of compensatory muscle use to maintain closure and seal
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Product of William and Julie Zickefoose(1994)
Why Pediatric Dentists?
In a study analyzing the ability of pediatricians and otolaryngologists to identify early signs of vertical facial growth among children, sensitivity was very low for both.
(Calvo-Henriquez et al., 2019)
Parent
Pediatrician Dentist
Specialist Specialist Specialist Specialist
What is an Orofacial Myofunctional Disorder?
Orofacial myofunctional disorder includes dysfunction of the lips, jaw, tongue, and/or oropharynx that interferes with normal growth, development or function or other oral structures, the consequence of a sequence of events or lack of intervention at critical periods, that result in malocclusion and suboptimal facial development (D’Onofrio, 2018).
Airway obstruction / Lingual restriction
Lips open for mouth breathing
Jaw opens to maximize airway / Oral movement is limited
Tongue position remains low & forward / Tongue thrust swallow
Hard palate narrows as face grows
Occlusal & dental changes
Sleep Disordered Breathing (SBD) / Obstructive Sleep Apnea (OSA) / Bruxing
Temporomandibular Disorder (TMD)
‘The Face as a Dynamic System’D’Onofrio, 2016
Form Follows Function
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Normalizing structure does not
automatically normalize function
Etiology of Orofacial Myofunctional Disorders
Airway obstruction
Structural issues
Oral Habits & Behaviors
What Do OMDs Look Like?OMDs include one or more of the following:
• Abnormal labial-lingual rest posture
• Poor nasal breathing
• Bruxism
• Poor saliva management, drooling
• Sleep Disordered Breathing and other sleep issues
• Tongue thrust
• Increased vertical facial growth
• Feeding difficulties (poor mastication & bolus management)
• Lisp & other atypical oral placement for speech
• Labial incompetency
• Noxious oral habits
• Poor posture
Oral Resting Posture
Oral Resting Posture
Mouth Breathing
Mouth breathers demonstrated considerable backward and downward rotation of the mandible, increased overjet, increase in the mandible plane angle, a higher palatal plane, and narrowing of both upper and lower arches at the level of canines and first molars compared to the nasal breathers group.
(Harari et al., 2010)
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Mouth Breathing
Prevalence of posterior crossbite is higher in mouth breathing children than in the general population. During mixed and permanent dentitions, anterior open bite and class II malocclusion were more likely to be present in mouth breathers.
(Souki et al., 2009)
Mouth Breathing
Open-mouth breathing is related to the growth and development of the orofacial structures, including narrowing of the maxilla, reduced development of the mandible, malocclusion, and mouth dryness.
(Bresolin et al., 1983)
Mouth Breathing
• Poor nasal breathing• Drooling / poor saliva management• Dry or chapped lips• Irritated skin around the mouth• Halitosis• Short upper lip• Full lower lip• Hypotonic facial muscles
Bruxism
Bruxism
Myofunctional therapy yielded significant results in regard to the reduction of bilateral activity of the masseter muscles during the resting position. The study found a reduction of masseter resting activity combined with the reduction of the number of bruxism episodes indicated the effectiveness of MFT for the treatment of bruxism and involuntary jaw clenching.
(Messina et al, 2017)
BruxismAll treated patients had a reduction of facial pain and reduced the number of bruxism episodes per hour, and in many cases such episodes disappeared.
(Messina et al, 2017)
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Sleep Disordered Breathing
Sleep Disordered Breathing
SnoringThe dental arch was narrower in snoring children at 4, 6, and 12 years compared to not snoring children. Cross-bites were more common among snoring children than among non-snoring children.
(Hultcrantz & Tidestrom, 2009)
Obstructive Sleep Apnea
Researchers found “a strong association between craniofacial growth and obstructive sleep apnea syndrome.” The pediatric dentist and orthodontist play a critical role in recognizing signs and symptoms that would require a referral to the otolaryngologist.
(Luzzi et al., 2019)
Tethered Oral Tissues
Tethered Oral Tissues (TOTs)
• All children with short mandibular (lingual) frenulum had an association with SDB when seen untreated between 2 and 6 years of age. They all had a narrow and high hard palate.
• While the child had orthodontic treatment for his abnormal maxillary growth, the presence of his short frenulum was not recognized. It impaired successful results of orthodontia due to its continued restriction of tongue movements.
(Guilleminault & Akhtar, 2015)
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Malocclusion
Malocclusion
Interceptive orthodontic measures to treat a narrow maxillary arch in primary and early mixed dentition should also focus on eliminating functional disturbing factors. Interdisciplinary cooperation with specialists in other fields of medicine, e.g. otorhinolaryngology and speech therapy, is essential to achieve this goal.
(Seemann, Kundt, & Stahl de Castrillon, 2011)
Orthodontic treatment with OMT was efficacious in closing and maintaining closure of dental open bites in Angle Class I and Class II malocclusions, and it dramatically reduced the relapse of open bites in patients who had forward tongue posture and tongue thrust.
(Smithpeter & Covell, Jr, 2010)
Malocclusion
Tongue Thrust
• Poor nasal breathing
Tongue Thrust
• Poor nasal breathing
TongueThrust
Significantly, higher number of children with tongue thrusting showed lip incompetency, mouth-breathing habit, hyperactive mentalis muscle activity, open-bite, and lisping when compared to children without tongue thrust.
(Dixit & Shetty, 2013)
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Chewing / Feeding
• Poor nasal breathing
Picky Eating & Feeding Issues
Significantly more chewing strokes were counted for mouth breathing compared with nose breathing. Taken together, the results indicate that mouth breathing decreases chewing activity and reduces the vertical effect upon the posterior teeth.
(Ikenaga, Yamaguchi, & Daimon, 2013)
Picky Eating & Feeding Issues
Anatomic changes associated with growth affect feeding function. This can lead to with difficulties with oral preparation or oral transit including tongue thrust swallow, poor or inefficient chewing, messy eating, and/or audible eating.
(Stevenson & Allaire, 1991)
Oral Habits
Oral Habits
Oral HabitsNon-nutritive sucking habits and tongue thrust swallowing are significant risk factors for the development of anterior open bite and posterior crossbite in pre-school children.
(Kasparaviciene et al., 2014)
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An investigation into the effects of conventional and orthodontic pacifiers on the prevalence of malocclusion considering frequency, duration, and intensity of sucking habit. The study concluded the prevalence of malocclusion was higher among children who used pacifiers.
(Lima et al., 2017)
Oral Habits
Speech Production
Speech Production
SpeechOcclusal alterations may be factors of influence, allowing distortions and frontal lisp in phonemes /s/ and /z/ and inappropriate tongue protrusion in phonemes /t/, /d/, /n/, /l/.
(Pizolato, Fernandes, & Gavião, 2011)
Posture Posture
A study looking at changes in head position one year after rapid maxillary expansion suggested an ongoing change in head posture possibly due to a change in the mode of breathing from oral to nasal as a result of rapid maxillary expansion, thereby contributing to a change in craniofacial development.
(McGuinness & McDonald, 2006)
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What is Orofacial Myofunctional Therapy?“Therapeutic exercise-based techniques to stabilize, tone, strengthen, or improve the range of motion of the skeletal muscles of the face and internal muscles of the face and neck used to treat orofacial myofunctional disorders.” (D’Onofrio, 2018)
What is Orofacial Myofunctional Therapy?“…the treatment of dysfunctions of the muscles of the face and mouth, with the purpose of correcting orofacial functions, such as chewing and swallowing, and promoting nasal breathing.” (Moeller, Paskay, & Gelb, 2014)
Exercises vs. Goal Oriented Tasks
Does the child understand what they’re working on?
Does the child know what the end goals of therapy are?
Tools
Myo Munchee
Lingual Resting Posture
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Swallowing
• Poor nasal breathing
Myofunctional Exercises
Breathing Retraining
The impact of orofacial
myofunctional disorders across a
lifetime. (D’Onofrio, 2016)
Airway-based malocclusions leading
to sleep disordered breathing in childhood
BruxingDiagnosis of ADHD,
aggression, poor problem solving
Increased risk for academic and social
failure
Poor facial aestheticsJaw rotated back into
airway and palate invading sinuses
Poor chewing and swallowing
Poor sleep and sleep related disorders
Increased risk of heart attach, stroke, and
early death
The “Interdisciplinary Orofacial Examination Protocol For Children And Adolescents” (Bottini et al, 2008)
The “Interdisciplinary Orofacial Examination Protocol For Children And Adolescents” (Bottini et al, 2008)
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Building Your Team
Pediatrician Otolaryngologist AllergistFeeding Specialist
(SLP, OT)
Speech-Language Pathologist
Orofacial Myofunctional
Therapist / Orofacial Myologist
Pediatric Dentist / Orthodontist
Body Worker (e.g. Physical Therapist,
Chiropractor, Occupational Therapist)
Finding Providers & Resources
Oromyofunctional Study GroupThe Oromyofunctional Study Group is a professional-only forum for those who evaluate, treat, and provide support for patients with oromyofunctional disorders and their families. This group is for SLPs, RDHs, orthodontists, ENTs, OMF surgeons, general dentists, pediatric dentists, neuromuscular and functional dentists, PTs, osteophaths, OTs, IBCLCs, and pediatricians that specialize in the orofacial complex and in craniofacial development and disorders.
Educational Organizations & Associations
Academy of Orofacial Myofunctional Therapy (AOMT) www.aomtinfo.org
Academy of Applied Myofunctional Sciences (AAMS) www.aamsinfo.org
International Association of Orofacial Myology (IAOM) www.iaom.com
Final Thoughts
Form follows function Treat the cause, not the symptom
It takes a village
References
1. Calvo-Henriquez, C., Martins-Neves, S., Faraldo-Garzia, A., Ruano-Ravina, A., Rocha, S., Mayo-Yañez, M., Martinez-Capoccini, G. (2019) Are pediatricians and otolaryngologists well prepared to identify early signs of vertical facial growth? International Journal of Pediatric Otorhinolaryngology, Apr; 119: 161-165. doi: 10.1016/j.ijporl.2019.01.035
2. Dixit, UB., Shetty, RM. (2013). Comparison of soft-tissue, dental, and skeletal characteristics in children with and without tongue thrusting habit, Contemporary Clinical Dentistry.
3. D’Onofrio L.I. Oral dysfunction as a cause of malocclusion. Orthodontics & Craniofacial Research. 2019;00:1-6. https://doi.org/10.1111/ocr.12277
4. D'Onofrio, L. (2018, October 7). Publication Trends and Levels of Evidence in Orofacial Myofunctional Therapy Literature. Lecture presented at International Association of Orofacial Myology.
5. D'Onofrio, L. (2016). The Face as a Dynamic System. Lecture.
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References
6. Grandi, Diana. (2012). The "Interdisciplinary orofacial examination protocol for children and adolescents": a resource for the interdisciplinary assessment of the stomatognatic system. The International journal of orofacial myology : official publication of the International Association of Orofacial Myology. 38. 15-26.
7. Guilleminault, C., Akhtar, F. (2015). Pediatric sleep disordered breathing: new evidences on its development, Sleep Medicine Reviews, Dec;24, 46-56. doi: 10.1016/j.smrv.2014.11.008
8. Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope. 2010;120:2089-2093.
9. Hultcrantz, E., Lofstrand Tidestrom B. (2009) The development of sleep disordered breathing from 4-12 years and dental arch morphology. International Journal Pediatric Otorhinolaryngology.;73(9), 1234-41.
References
10. Ikenaga, N., Yamaguchi, K., Daimon, S. (2013). Effect of mouth breathing on masticatory muscle activity during chewing food. Journal of Oral Rehabiliation, 40(6), 429-35.
11. Kasparaviciene, K., Sidlauskas, A., Zasciurinskiene, E., Vasiliauskas, A., Juodzbalys, G., Sidlauskas, M., Marmaite, U. (2014). The prevalence of malocclusion and oral habits among 5-7-year-old children. Medical Science Monitor, Oct;20: 2036-42.
12. Lima, A.A., Alves, C.M., Ribeiro, C.C., Pereira, A.L., da Silva, A.A., Silva L.F., Thomaz E.B. (2017) Effects of conventional and orthodontic pacifiers on the dental occlusion of children aged 24-36 months old. International Journal of Pediatric Dentistry, Mar;27(2), 108-119. doi: 10.1111/ipd.12227
13. McGuinness, N.J., McDonald, J.P. (2006). Changes in natural head position observed immediately and one year after rapid maxillary expansion. European Journal of Orthodontics, 28(2), 126-34. doi: 10.1093/ejo/cji064
References
14. Messina, G., Martines, F., Thomas, E., Salvago, P., Fabris, G.B.M., Poli, L., Iovane, A. (2017). Treatment of chronic pain associated with bruxism through Myofunctional therapy. European Journal of Translational Myology, 27(3), 6759. doi: https://dx.doi.org/10.4081%2Fejtm.2017.6759
15. Moeller, J.L., Paskay, L.C., and Gelb, M.L., “Myofunctional therapy: a novel treatment of pediatric sleep-disordered breathing,” Sleep Medicine Clinics, vol. 9, no. 2, pp. 235–243, 2014.
16. Seeman, J., Kundt, G., Stahl de Castrillon, F. (2011). Relationship between occlusal findings and orofacial myofunctional status in primary and mixed dentition: Part IV: Interrelation between space conditions and orofacial dysfunctions. Journal of Orofacial Orthopedics, Mar;72(1): 21-32. doi: 10.1007/s00056-010-0004-1
References
17. Smithpeter, J., Covell, D. (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. American Journal of Orthodontics. 137(5), 605-14. doi: 10.1016/j.ajodo.2008.07.016
18. Souki, B.Q., Pimenta, G.B., Souki, M.Q., Franco, L.P., Becker, H.M., Pinto, J.A. (2009). Prevalence of malocclusion among mouth breathing children: Do expectations meet reality? International Journal of Pediatric Otorhinolaryngology. May;73(5), 767-73.
19. Stevenson, R.D., & Allaire, J.H. (1991). The development of normal feeding andswallowing. Pediatric Clinics of North America, 38(6), 1439-1453.