The Use of Speech Therapy and Orthodontia in the Treatment

THE USE OF SPEECH THERAPY AND ORTHODONTIA IN THE TREATMENT

OF TONGUE THRUST DISORDER

Lyndi Roberts

A SENIOR THESIS

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

1 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.

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.

8 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

12 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

13 (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).

14 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 procerus irontalio

M.zyqo- maticus

quadratuj labu 5up-

raasseter nasal IS Mrisoru ccinator Platy. M- triangularis \ Mquadratus M- orbicularis orii '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

17 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.

18 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.