Tongue thrust may be a delayed transition stage in some children.
Therapy is not indicated in the absence
of speech or dental problems, or before puberty.
Myofunctional therapy for tongue-thrusting:
background and recommendations
William R. Proffit, DDS, PhD, Gainesville, Fla
Robert M. Mason, PhD, Lexington, Ky
The article reviews oral form and function inter­
actions pertinent to tongue thrust and provides
guidelines fo r patient selection fo r m yofunctional
therapy. Certain anatom ic conditions predispose
normal children to anterior tongue positioning,
w hich disappears during puberty. In these children
the tongue thrust is a normal, if delayed, transition
stage. In other children, it is a necessary adapta­
tion. M yofunctional therapy is not indicated in the
absence of speech or dental problems and is not
indicated, in our view, before puberty. If tongue
thrust and an associated m alocclusion persist to
puberty, tongue therapy may be indicated. The
therapy then is more effective when combined with
o rthodontic treatm ent to reposition teeth, rather
than being done before orthodontics. Speech th er­
apy can modify speech errors in tongue-thrusters
and reposition the tongue tip posteriorly.
There is considerable interest and confusion in
dentistry and speech pathology about the con­
troversial topic o f myofunctional therapy for
tongue-thrusting. Advocates o f myofunctional
therapy contend that anterior open bite and inci­
sor protrusion are related to abnormal lingual
pressure patterns that push the anterior teeth into
malocclusion. Many dentists feel (incorrectly)
that myofunctional therapy can prevent the de­
velopment of malocclusions that do not yet exist.
Dentists sometimes enlist speech clinicians to
conduct myofunctional therapy with patients
who have no speech problems. This situation
raises serious ethical problems for the speech
clinician. This paper reviews the scientific back­
ground for swallowing exercises to provide den­
tists with guidelines about selecting patients for
myofunctional swallowing therapy.
Our background in tongue thrust is a product
of clinical interactions between speech pathol­
ogy and dentistry, primarily at the University of
Kentucky Medical Center. Our conclusions are
a product of research findings at Kentucky with
intraoral pressure measuring devices such as
those shown in Figure 1, in combination with
data from the literature and our own clinical ex­
perience.
Tongue thrust
At present, tongue thrust has no single title or
definition. The most frequent signs of tongue-
thrusting are said to be protrusion of the tongue
against or between the anterior dentition and ex ­
cessive circumoral muscle activity during deglu­
tition. It is variously referred to as tongue thrust,
tongue-thrust swallow, visceral swallow, infan­
tile swallow, reverse swallow, deviant swallow,
and tongue-thrust syndrome. H owever, several
workers (for example, Cleall1) have found the
presence of these “ abnormalities” in normal
JADA, Vol. 90, February 1975 ■ 403

Fig 1 ■ M in ia tu re p re ssu re -se n sin g d e v ic e s m o u n te d in th in
p la s tic p a la te -c o v e rin g d evice , as used to s tu d y th e m a g n itu d e ,
d u ra tio n , and p a tte rn o f to n g u e -p a la te co n ta c ts . P ressure tra n s ­
d u c e rs of th is ty p e ca n be m o u n te d at a lm o s t a ny in tra o ra l lo c a ­
tio n to m e a su re to n g u e o r lip pressures.
persons. The distinctions between tongue-thrust-
ing during speech and at the onset of a swallow
are often obscure in the research reported in the
literature. Many o f the issues associated with
tongue thrust have been discussed in recent re­
view papers by Weinberg,2 Moorrees, and co­
workers,3 and Christiansen.4
To us, tongue-thrusting is one or a combina­
tion of three conditions: during the initiation
phase of a swallow, a forward gesture of the
tongue between the anterior teeth so that the
tongue tip contacts the lower lip; during speech
activities, fronting of the tongue between or
against the anterior dentition with the mandible
hinged open (in phonetic contexts not intended
for such placements); and at rest, movement of
the tongue forward in the oral cavity with the
mandible hinged slightly open and the tongue tip
against or between the anterior teeth. These con­
ditions can be found in individuals with and with­
out speech or dental problems.
Habit or innate behavior?
Whether tongue-thrust swallowing is a habit has
been the subject of considerable debate. The
question is important because the therapeutic
approach can be affected by the decision as to
whether one is dealing with a habit or with a more
innate behavior pattern.
Placement of the tongue tip between or against
the central incisors during the initiation of a swal­
low was described by Straub5 as an “ abnormal
swallowing habit.” Straub ascribed this habit to
bottle-feeding. His evidence consisted of rec­
ords on 478 patients in his orthodontic practice,
only two of whom were breast-fed. The high sta­
404 ■ JADA, Vol. 90, February 1975
tistical correlation between tongue thrust and
bottle-feeding led Straub to the inappropriate
conclusion that “ the abnormal swallowing habit
has been found to be definitely due to improper
bottle feeding.”
Causality is not revealed by correlation statis­
tics and is especially elusive when few variables
are considered. Furthermore, the data reported
on the incidence of bottle-feeding by Hanson
and Cohen6 do not support Straub’s conclusion.
Another possibility is that anterior tongue po­
sitioning in swallowing is a normal developmen­
tal stage. Some insight into this can be achieved
by comparison of the swallow behavior in infants
with that in older children and adults. The adult
swallow is characterized, among other things,
by contact of the teeth as the jaws are brought
together, relaxation o f the lips with little or no
evident muscular activity; and placement of the
tongue tip against the palate behind the maxil­
lary central incisors where it remains during the
swallow. (By no means is this the “ normal”
swallow in all adults.) The swallow of an infant
contrasts sharply with that of an adult in these
three areas. In the infant swallow the jaws are
apart with the tongue filling the space between
the gum pads, or later the teeth; the lips are ac­
tive in sucking movements; and the tongue is
placed out between the dental ridges in contact
with the lower lip and beneath the nipple that is
being sucked. At first, lip activity is more prom­
inent than tongue movements. Bosma7 has called
this phenomenon a front-to-back maturation of
the oral structures, with lip “ maturation” pre­
ceding that o f the tongue. Later in infancy, in­
creasing tongue movements are seen but the
tongue-to-lower-lip apposition remains. Addi­
tional changes in the swallow pattern occur dur­
ing childhood. The typical adult swallow appears
some time between ages 2 and 12.
It is apparent that a child who is in a transition
stage between infantile and adult swallowing
would have prominent anterior tongue position­
ing. Such a child would be labeled as having a
thrust swallow by all the common definitions,
including those used in this paper. But the tongue
thrust represents not a habit in the sense of
learned extraneous behavior, but a normal de­
velopmental stage. Several transition stages ex­
ist between infancy and adulthood. Many nor­
mal children do not complete the transition to
adult swallowing until they approach puberty.
Changes in the swallow pattern, with a tran­
sition toward a more adult swallow, have been
observed directly in normal children studied
longitudinally with intraoral pressure transduc­
ers.8 Similar observations have been made in
children studied with cineradiography.9 A child
with a tongue-thrust swallow, then, is most like­
ly to be an individual who has not yet learned the
adult pattern, not one who has somehow learned
the wrong thing.
Three other factors enter into this. First, a
child who sucks his thumb apparently delays his
transition toward adult swallowing, and then is
more likely to be labeled a tongue-thruster in the
early mixed dentition years. A change in the
swallow pattern will not occur until the sucking
habit ceases, but spontaneous transition toward
adult swallowing often occurs then. If it does not,
some therapy to teach the child swallowing be­
havior he has not yet learned may be indicated.
Second, neuromotor problems severe enough
to prevent normal adult swallowing are rare, but
this possibility should be considered in the eval­
uation of a patient. Poor muscular coordination
in other movements, with or without mental re­
tardation, increases the likelihood that the
tongue will be affected neurologically.
Finally, it is possible that an older child, or an
adult, could revert back to a tongue thrust after
acquiring an adult swallow pattern. This would
be a habit, in the same sense that prolonged
thumb-sucking is. Such habitual tongue-thrust­
ing is seen only in older individuals and is rare.
Other factors influencing tongue
positioning
A more anterior tongue position in young chil­
dren is founded on several anatomic reasons.
T hese factors, which relate to growth and de­
velopment of the head and neck, also must be
considered in evaluation o f the progress toward
adult swallowing.
Although it is difficult to measure tongue size,
it seems that the tongue follows the growth curve
established for the neural tissues of the body (Fig
2) in that it grows fairly steadily and approaches
maximum size at or near age 8 years. The man­
dible grows more slowly, tapers off to a plateau
generally between age 8 and 12 years, and then
undergoes pubertal and postpubertal growth.
Som e mandibular growth is seen even into and
past the 20s. The growth of the mandible more
nearly follows the general body curve in Figure
2. The clinical implication of this growth differ­
ential between the tongue and mandible is a nat­
ural tendency for the large tongue to be posi­
tioned relatively high and forward in the oral cav­
ity in the early years o f growth.
------ L Y M P H O ID
--------N E U R A L
------T O N G U E
+ + + M A N D IB L E
--------G E N E R A L
------G E N IT A L
B 4 8 12 16 20
AGE IN Y E A R S
Fig 2 ■ M a in ty p e s o f p o s tn a ta l g ro w th o f v a rio u s p a rts a n d o r ­
g a n s o f b o d y . L y m p h o id , n e u ra l, g e n e ra l b od y, and g e n ita l ty p e s
a fte r S c a m m o n .'0
Since an adequate airway is essential for life,
respiratory demands strongly affect tongue and
jaw position. The initial resting position of the
tongue, from which swallowing and speaking
movements begin, is established along with the
airway. Anterior tongue positioning can result
from airway problems both in the nose and in the
pharynx.
Lymphoid tissue grows quickly in children,
reaches a maximum before puberty, and then re­
gresses (Fig 2). Although Scammon’s 10 curve
for lymphoid growth did not consider the tonsils
and adenoids, recent research indicates that the
growth and involution of tonsils and adenoids
conforms generally to Scammon’s curve for thy­
mus, lymph nodes, and intestinal lymphoid mass­
es. Prominent tonsils in 8- to 10-year-old chil­
dren are a common finding. It may be necessary
for these children to carry the tongue forward
and hinge the mandible open to provide mechan­
ical clearance for breathing and swallowing. This
is the typical association with the tonsils found
in persons with clinically identified cases of
mouth-breathing. If the throat is chronically in­
flamed and sore, the tendency to carry the tongue
low and forward, to reduce contact with the sore
area, is reinforced.
E xcessive adenoid tissue proliferation before
puberty is one cause of nasal respiratory ob­
struction in children. Chronic allergic condi­
tions, nasal infections, and mechanical blockage
by turbinates or a deviated nasal septum also
can lead to chronic mouth-breathing. The re­
sulting respiratory obstruction syndrome, de­
P ro ffit—M ason: MYOFUNCTIONAL THERAPY ■ 405
scribed well by Ricketts,11 includes tongue-
thrusting and malocclusion. For the oral airway
to be open, the tongue must be carried low and
forward and the mandible held at a lower-than-
normal rest position. The tongue thrust in this
situation is only one of several related factors,
and the key to its resolution is correction of the
respiratory problem.
A noticeable response in tongue position re­
lated to changed respiratory demands is shown
by patients who have had surgical jaw reposi­
tioning. These procedures almost always reduce
the size of the oral cavity. If the lower jaw is posi­
tioned posteriorly, the tongue is carried posterior­
ly also and would tend to block the airway. This
does not happen. Instead, the airway is main­
tained, and the tongue is repositioned down­
ward and forward. After such surgery, the rest­
ing length of all the hyoid musculature is appar­
ently altered, as the hyoid bone assumes a new
position consistent with airway maintenance.12
Speech quality is not changed, and lingual pres­
sure patterns during articulation are maintained.
Tongue pressures during swallowing usually de­
crease postoperatively, but in most patients they
stabilize at normal levels during the year after
surgery.13 Speech adaptation is both quicker and
more complete than swallowing adaptation. Re­
lapse of tooth position related to failure of phys­
iologic adaptation occurs in only a small percen­
tage of surgical orthodontic patients.
We have previously mentioned the tendency
for tongue-thrusters to evolve a normal adult
swallow pattern between 8 and 12 years of age
without any therapy intervention. This change
from tongue-thrust swallow to normal adult
swallow is related to increases in the size of the
oropharyngeal airspace. Cavity size increases
are especially rapid around the time of puberty.
This is caused by growth in the ramus of the man­
dible with an accompanying downward shift of
the tongue in the oral cavity, diminution in the
amount of lymphoid tissue in the oropharynx as
a function of normal involution of the tonsils and
adenoids, and vertical growth of the bodies qf
the cervical vertebrae, thereby increasing the
available space in the oropharynx. In response
to these morphological changes, the tongue is
able to assume a more posterior resting position
in the oral cavity, and this results in closer ap­
proximation of the dental arches.
The pattern of sensory innervation of the
tongue and oral mucosa, and the earlier neuro-
physiologic maturation of anteriorly directed
tongue movements also are factors in anterior
406 ■ JADA, Vol. 90, February 1975
positioning of the tongue in younger children.
The richer distribution of sensory nerve endings
in the front of the mouth encourages fronting of
the tongue tip as a means of generating tactile
feedback. The universal emergence of bilabial
and linguoalveolar consonant sounds at early
ages in the speech acquisition sequence is re­
lated to this.
Altogether, tongue-thrusting during speech or
swallowing or both in children in the mixed den­
tition stage may be caused by three factors. The
first, adaptive behavior, is related to morpho­
logic variations in the mouth and pharynx. (The
probability that the tongue adapts to tooth posi­
tion as well as to pharyngeal and airway dimen­
sions is discussed later.) It also may be caused
by neuromotor patterning that has its develop­
ment in the individual’s interpretation of feed­
back experiences. In some children, a neuro­
logic abnormality contributes to the tongue
thrust; the prognosis for any type of therapy in
such children is poor. The presence of a normal,
if delayed, stage in the transition from infantile
to adult swallowing is the third cause of tongue-
thrusting. The common definitions of tongue-
thrusting, including those in this paper, cause
this label to be applied frequently to normal de­
velopmental stages that spontaneously change
to adult patterns of tongue behavior.
Tongue thrust related to open bite and
incisor protrusion
Many clinicians think that tongue-thrusting is
associated with specific dental malocclusions,
especially anterior open bite and incisor protru­
sion. It is, therefore, valuable to examine the in­
cidence of these conditions.
Until very recently, no good figures were
available for the incidence of dental malocclu­
sion in children in the United States. In 1973, the
National Center for Health Statistics published
results of a large-scale study that assessed the
dental occlusion of children in the United States.14
The sample of some 8,000 children was designed
and selected statistically by the US Public Health
Service to permit valid inferences about the
health of a target population of approximately
24 million children (all noninstitutionalized chil­
dren, aged 6 to 11 years, living in the United
States). The findings of this survey are especially
pertinent to the tongue-thrust controversy.
In the sample, 5.7% of the children had an an-
 Fig 3 ■ S p o n ta n e o u s c lo s u re o f a n te rio r o pen b ite o v e r fo u r-y e a r p e rio d , w ith o u t th e ra p y . (C o u rte s y Dr. M.
G e ilin .)

tenor open bite. There was a strong influence of strated statistically with the data from the U S ­
race— 16.3% of black children had an open bite PHS survey, we do not wish to imply that there
as opposed to only 3.9% of white children. The is no such association. We merely point out that
black children also were more likely to have a the association does not automatically reveal
clinically significant open bite that could affect cause and effect. In this instance, it is apparent
function and appearance; 9.6% of the black chil­ that tongue-thrusting and even thumb-sucking
dren had open bites measuring 2 mm or more. (with a 10% incidence found in the U SPH S sur­
Only 1.4% of the white children had an open bite vey) are much more prevalent than the open bite
of this magnitude. malocclusion they are said to cause.
The data for the incidence of tongue thrust in Open bites tend to correct spontaneously as
children are not nearly as good as those from the children become older (Fig 3). From cross-sec­
U SPH S survey. Most observers agree that tional data on 1,400 Navajo children, Worms,
tongue-thrusting is almost universal in infancy; Meskin, and Isaacson16 concluded that spon­
this, of course, reflects the prominent anterior taneous correction occurred in 80% o f simple an­
tongue position of a normal infant swallow. A terior open bites. They contend that:
relatively high percentage of children demon­
strate these characteristics at the time they begin It would be extrem ely valuable if speech therapy tech­
school, and this percentage declines with ad­ niques and interceptive cribs designed for open-bite
vancing years. Typical figures are those of Flet­ problem s would be evaluated on a percentage-of-cor-
cher, Casteel, and Bradley15 who reported that rection basis. F o r instance, if a technique corrected
about 50% of children, 6 years of age, had a open-bite in a certain percentage of the open-bite cas­
tongue-thrust swallow and that this percentage es, this percentage of correction should be greater
than that which occurs w ithout treatm ent. In the case
declined to about 25% at age 15. Hanson and
of simple open-bite in 7 to 9 year old N avajo boys,
Cohen6 show similar findings. Even if these fig­
therapy would have to produce com pletely success­
ures are discounted as being incorrectly high, it
ful results in better than 80 percent of the children with
is apparent that a clinically evident tongue thrust open-bite in order to do b etter than nature and ma­
does not necessarily coincide with an open bite turity would do w ithout therapy. O ne must be very
malocclusion and, in fact, most often does not. careful in taking credit for correction of an open-bite.
Since generations of clinicians have noted an
association between sucking habits, anterior In addition to the problem of open bite, clini­
tongue positioning, and open bite malocclusion, cians have been tempted to link the dental prob­
and since such an association can be demon­ lem of maxillary incisor protrusion to thumb-
P roffit— Mason: MYOFUNCTIONAL THERAPY ■ 407
sucking and tongue-thrusting habits. Protrusion
of maxillary incisors is strongly related to thumb-
sucking that persists after permanent incisors
erupt, and this was borne out by the USPH S sur­
vey, as well as by Hanson and Cohen.6 About
17% o f all children, however, have excessive
protrusion of maxillary incisors; this figure ex­
ceeds the percentages for thumb-sucking.
Thumb-sucking is not the major cause of this
condition in the population. Genetic determin­
ants of jaw relationship are known to be a sig­
nificant cause. The relationship (if any) of
tongue-thrusting to incisor protrusion cannot be
determined from present data.
It has been assumed in many dental textbooks LEFT LEFT CENTRAL RIGHT RIGHT
MOLAR CANINE INCISOR CANINE MOLAR
that the pressures created by the tongue, in con­
junction with balancing pressures from the mus­ R B 8I Aboriginal d - 13
CvT3 W hite n - 8
culature of the lips, strongly influence the posi­ 25
tion o f the teeth. If this were true, the pressure
by a thrusting tongue could, in itself, lead to pro­
trusion of incisors. Within the last decade, the
advent of miniature intraoral pressure measur­
ing devices has allowed this hypothesis to be dir­
ectly tested. N o balance of pressures against the
dentition has been observed. The expansive
forces of the tongue are not directly balanced
by the containing forces of the lips even when
prolonged time periods are considered. The
shape o f the dental arches and the position of
teeth within the dental arches do not seem to be
strongly influenced by the horizontally directed
pressures of the tongue and lips during functional LEFT LEFT CENTRAL RIGHT RIGHT
MOLAR CANINE INCISOR CANINE MOLAR
activity such as swallowing and speaking. For TRANSDUCER POSTTION
instance, tongue pressures decrease as the size
Fig 4 ■ T o p , c o m p a ris o n o f m a x illa ry lin g u a l p re s s u re s d u rin g
of the dental arch increases; this is the reverse
s w a llo w in g sa liva o n c o m m a n d in A u s tra lia n a b o rig in e s and
of what would be expected if tongue pressure in w h ite c h ild re n in K e n tu c k y . B o tto m , c o m p a ris o n o f m a n d ib u ­
somehow pushed the teeth into a new position. la r lin g u a l re s tin g p ressu re s in a b o rig in e s and in K e n tu c k y c h il­
This is well demonstrated by comparison of d re n . In b o th in sta n ce s, to n g u e p re ssu re s a re h ig h e r in the
tongue pressures in Australian aborigines who A m e ric a n c h ild re n , b u t th e d e n ta l a rc h e s o f th e a b o rig in e s are
la rg e r in all d im e n s io n s .
have large arches with those in North American
whites (Fig 4 ).17 Similarly, patients with pro­
truding incisors have less tongue pressure against ered from a vertical or tooth eruption point of
these teeth than do normal persons. When the in­ view, the situation is somewhat different. The
cisors are retracted, tongue pressures increase forces o f eruption of teeth are very small, of a
to the normal values.18 There is no reason to be­ magnitude of 5 g, and the factors that control
lieve that incisor protrusion or arch width is re­ eruption remain essentially unknown. It is quite
lated to tongue pressure during swallowing. possible, although it has never been demonstrat­
If only resting pressures, particularly resting ed directly, that light forces produced by an an­
lip pressures, are considered, a stronger rela­ teriorly positioned tongue tip can impede erup­
tionship with dental arch form is observed. The tion of incisors. If, at the same time, there were
resting posture of the tongue and lips is certainly no impediment to posterior eruption, an open
more important in arch width and incisor protru­ bite would result as the posterior teeth erupted
sion than pressures during swallowing, speak­ and the anterior teeth did not. In a growing child,
ing, or eating.17 continuous eruption of both anterior and pos­
If the dentition of a growing child is consid- terior teeth is necessary to compensate for ver­
408 ■ JADA, Vol. 90, February 1975
tical growth of the face and jaws.
Experimental data on this recently have be­
come available through the work of Wallen19 in
our laboratory. He used a new type of pressure
transducer to study pressures in different planes
of space. In a comparison of patients with an­
terior open bite malocclusion and persons with
normal dentitions, vertically directed forces
were less in the open bite group.19 This is just
the opposite of what the “ swallowing equilibri­
um” theory would have predicted. Therefore, it
seems likely that the prominent tongue during
swallowing in patients with open bites does not
produce the altered vertical position of the inci­
sors. Resting tongue posture may be more im­
portant than swallow activity in open bite also.
The research data presented up to this point
indicate a much smaller need for tongue-thrust
therapy than its proponents currently advocate.
The swallow pattern affects the resting posture
of the tongue and vice versa, but the evidence
indicates that changing of the resting position is
more important when tongue therapy is needed
for treatment of malocclusion. The proper role
for myofunctional therapy is now presented in
terms of the clinical problems associated with
tongue-thrusting.
Role of myofunctional therapy in
tongue thrust
■ Tongue thrust alone: The only rationale for
myofunctional therapy in the child with a tongue
thrust who has neither speech problems nor a
malocclusion would be that this therapy would
prevent development of such problems in the
future. There is no evidence that speech prob­
lems will develop in a child who has normal
speech because he or she has a tongue-thrust
swallow. Nor is there any evidence that an open
bite malocclusion will develop where one does
not already exist because of a prominent tongue
during swallowing. The percentages for open
bite and tongue-thrusting are eloquent evidence
on this point.
We, therefore, see no reason to recommend
any treatment for children who have a tongue-
thrust swallow without evidence of accompany­
ing problems. Such children will almost surely
complete the transition to a normal adult swal­
low on their own and dental or speech problems
attributed to the tongue will not develop in the
meantime. Myofunctional therapy has no place
in the techniques of preventive dentistry.
■ Tongue thrust with associated speech prob­
lems only: If a tongue-thrust swallow and
speech problems coexist, one should not assume
a causal link of one to the other.
If tongue-thrusting is associated with lisping,
only a speech therapist should be encouraged
to correct the speech problem using articulation
therapy techniques. Such therapy can be initi­
ated according to the usual considerations used
by speech clinicians. Although several speech
clinicians have suggested various techniques for
lisping tongue-thrusters, we do not think that the
clinical diagnosis of tongue-thrusting necessi­
tates a special speech therapeutic approach, es­
pecially by any individual other than a speech
clinician.
If a prepubertal child with speech errors also
exhibits a tongue-thrust swallow, it may be
tempting to work on swallowing patterns con­
current with speech therapy. Our experience
has shown that this is usually unnecessary and
contraindicated. Articulation therapy promotes
repositioning of the tongue tip at rest and for the
initiation of speaking and swallowing tasks in
young children. Most of the time, the tongue-
thrust swallow will correct itself with additional
maturity.
■ Tongue thrust with malocclusion but no
speech problem: If malocclusion exists in a
child who has a tongue thrust but no speech prob­
lem, the dentist is presented with a choice. H e
can begin the treatment of the malocclusion hop­
ing that the tongue posture and activity asso­
ciated with it will disappear as the anatomic sit­
uation is corrected, or he can attempt to change
the tongue-thrust pattern before beginning orth­
odontic treatment. Some dentists in the past
have elected the second course and have called
on speech clinicians to assist with these children
to teach them a more adult swallow pattern. The
first course now seems to be the better clinical
approach, however.
Postponement of any tongue therapy until
treatment of the malocclusion is begun has three
major advantages.
First, in the absence of obvious predisposing
factors, correction of the malocclusion usually
will result in disappearance of the tongue thrust
without any particular therapy being directed at
it. A distillation of orthodontic experience sug­
gests that 80% of children with malocclusion and
P ro ffit— Mason: MYOFUNCTIONAL THERAPY ■ 409
tongue thrust fall into this category.
Second, postponement of tongue therapy gives
the child a maximum opportunity to complete
the swallow pattern transition on his own. In our
opinion, the usefulness of swallowing therapies
with elementary school children is unsupported.
Experience with electromyography, cinefluor-
oscopy, and lingual pressure transducers indi­
cates that children are much more variable in
their swallow patterns than is the adult popula­
tion. Variability seems to be a primary attribute
of school-age swallowing patterns. As a child
becomes older, variability decreases concurrent
with the normal transition to adult swallowing.
We already have pointed out that at this same
time in the growth pattern of the child, spon­
taneous remission of open bite is also seen as a
consequence of developmental progression into
adolescence.
Third, for those older children who do not
show spontaneous progress toward adult swal­
lowing and for whom therapy is indicated to pro­
mote changes in resting tongue position and swal­
low pattern, the therapy seems most effective if
it is carried out along with tooth movement. This
takes advantage of the natural tendency of func­
tion to adapt to changing form.
Even in older children, it is important to eval­
uate anatomic or physiologic predisposing fac­
tors before any tongue therapy is started. When
tongue-thrusting is related to airway problems,
the tongue is expected to adapt with a forward
gesture to initiate a swallow so that the bolus of
food can be accommodated through the faucial
isthmus. This is a natural adaptation rather than
an abnormal behavior for such a child. There­
fore, swallowing exercises should be avoided in
those children in whom the faucial isthmus size
is reduced. Tongue-thrusting associated with
airway maintenance problems may be etiologi-
cally related to hypertrophied tonsils and aden­
oids. Any decision for adenotonsillectomy
should be made by a physician on the basis of
physical complaints rather than speech or
tongue-thrusting variations. In the event that
the tonsils and adenoids are removed for medical
reasons, we suggest giving the child time to de­
velop a normal adult swallow before tongue ther­
apy is recommended.
It is helpful in an evaluation of the various ex­
ercises for improving tongue position and cor­
recting tongue-thrust swallowing to reflect on
the probability that the resting tongue position is
more important for malocclusion. The published
step-wise exercises for swallowing may be effec­
410 ■ JADA, Vol. 90, February 1975
tive in producing this.13,20 (Well-controlled
clinical studies indicate that myofunctional ther­
apy does not significantly change the swallow
pattern.9) Simpler exercises aimed primarily at
correcting resting position may be equally effec­
tive in treating open bite malocclusion.
■ Tongue thrust with malocclusion and a speech
problem: If speech therapy and orthodontic
treatment for open bite are carried out concur­
rently in pubertal and postpubertal patients, it
often is desirable to modify the resting posture
of the tongue. The tongue positioning exercises
used in classic myofunctional therapy may be
helpful. Articulation therapy techniques involv­
ing adaptive phonetic placements also are use­
ful in repositioning the tongue tip posteriorly in
these individuals. Speech therapy certainly
should not be delayed until treatment of the mal­
occlusion is begun. In some instances, ortho­
dontic treatment at an earlier age may be recom­
mended to make it easier for the child to achieve
proper tongue placement for speech.
Orthodontic treatment procedures may create
a temporary relapse of some speech skills that
have been developed previously. We have found
that the orthodontist need not fear creating long-
range speech problems by orthodontic treat­
ment nor should the speech clinician be discour­
aged from continuing with therapy procedures
during orthodontic treatment. Most children
adapt quickly to the reduction in articulatory
proficiency sometimes brought about by orth­
odontics. In those instances in which the child
does not adapt readily, it is logical to provide aid
in the form of speech therapy. It makes little
sense to us to wait for the completion of orth­
odontic work to start therapy on any associated
speech problems.
Summary and recommendations
The controversy surrounding tongue-thrusting
focuses on whether this behavior has a deleter­
ious effect on dental occlusion or whether it
merely represents an adaptation to the malocclu­
sion. The weight of the evidence is that, most of
the time, the tongue-thrust behavior does not
cause malocclusion. The dentition is relatively
insensitive to pressures of tongue and lips dur­
ing swallowing. Any effect that the tongue has in
contributing to malocclusions seems related to
resting posture as it affects the eruption of teeth.
 A constellation of morphologic findings can
explain the presence of tongue-thrusting in nor­
mal school-age children. Of particular impor­
tance is the airway space at the faucial isthmus
and in the pharynx. Reduction in airway space
encourages anterior tongue positioning as an
adaptation to the airway maintenance problem.
Since involution of lymphoid tissue at puberty
helps to relieve airway problems, there are mor­
phologic as well as physiologic reasons to anti­
cipate changes in tongue positioning in early
adolescence. Up to 80% of children who have a
tongue thrust and anterior open bite at age 8 show
improvement without therapy by age 12.
On the basis of our view of tongue-thrusting,
these recommendations are offered as an aid to
clinicians for making decisions about myofunc­
tional therapy.
First, such therapy is not indicated for chil­
dren who do not have a malocclusion or a speech
problem. Because no problem will arise, there is
no need for preventive treatment.
Second, even in the presence of malocclusion,
therapeutic intervention for swallowing varia­
tions is not indicated before puberty. (Matura-
tional age is more important than chronological
age.) In the event that the transition from tongue-
thrust swallow to a normal adult swallow does
not take place by the beginning of puberty, ther­
apy to promote a changed tongue position is
probably indicated. The techniques of myofunc­
tional therapy may be helpful for this purpose.
Third, if tongue therapy is indicated, it is most
effective when combined with orthodontic treat­
ment to reposition teeth.
Fourth, if lisping and tongue-thrusting or mal­
occlusion, or both, coexist before puberty, we
recommend that a speech clinician initiate
speech therapy procedures in spite of concur­
rent problems. Classic myofunctional therapy
techniques are of little additional help and are
contraindicated if airway size at the faucial isth­
mus is reduced.
Fifth, in those older children with speech
problems in which orthodontic treatment for
open bite is carried out, and if it is desirable to
modify the anterior resting posture of the tongue,
the techniques of myofunctional therapy may
be useful. Articulation therapy techniques are
also particularly helpful in repositioning the
tongue tip posteriorly.
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P ro ffit— M ason: MYOFUNCTIONAL THERAPY ■ 411