anna gross, ms, ccc -slp · • short upper lip • full lower lip • hypotonic facial muscles...

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4/5/19 1 Anna Gross, MS, CCC-SLP Speech-Language Pathologist Kids Therapy Made Simple OMBRE Pediatric Airway Health: The Importance of Myofunctional, ENT, and Dental Collaboration [email protected] www.kidstms.com [email protected] www.ombre-online.com Anna Gross, MS, CCC-SLP Speech-Language Pathologist Specializing 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 multidiscipliary team, 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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Page 1: Anna Gross, MS, CCC -SLP · • Short upper lip • Full lower lip • Hypotonic facial muscles Bruxism Bruxism Myofunctional therapy yielded significant results in regard to the

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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

[email protected]

[email protected]

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.