Coulson Institute 2014 Manual

2014
Coulson Institute
Introductory Training in Orofacial Myology
The Coulson Institute offers a fully integrated process of Orofacial Myology and business
practices. In order to operate a successful Orofacial Myology practice, students need a
thorough knowledge of business and marketing essentials as well as modern, innovative
therapeutic techniques. The Coulson Institute offers courses, individual internships and
lectures on Orofacial Myology throughout the world.
Copyright 2014 – Coulson Institute of Orofacial Myology 0

Copyright 2012- Coulson Institute of Orofacial Myology
Sandra R. Coulson MS, ST, Ed, COM
Sandra is a Certified Orofacial Myologist with an MS in Health

Sciences and BA degrees in Speech Therapy and Education. She has
been in private practice in Denver, Colorado USA, since 1969 and she
was named “Woman of the Year in Orofacial Myology” by the
International Association of Female Executives. She is named in
Who’s Who Worldwide and is a member of the National Association of
Professional Female Executives. Sandra is a Past President of the
International Association of Orofacial Myology where she is currently
serving on the Board of Examiners.
Sandra can be reached via email or directly:
Email: sandra@sandracoulson.com or info@coulsoninstitute.com

Office: 2121 S Oneida St, Suite 335, Denver, Co. 80224
Phone: (303) 759-2760 or (866) 790-2466
Fax: (303) 759-2971
Website: www.coulsoninstitute.com or www.sandracoulson.com

Table of Contents
What is Orofacial Myology?_____________________________________________________________7
History of Orofacial Myology____________________________________________________________8
Scope of Practice______________________________________________________________________9
Code of Ethics_______________________________________________________________________10
ASHA / RDH Guidelines_______________________________________________________________14
What is ASHA?________________________________________________________________________14
What course content is appropriate for ASHA CEUs?__________________________________________________14
Who can offer courses for ASHA CEUs?___________________________________________________________14
Dental Hygiene and the Registered Dental Hygienist__________________________________________15
Historical Perspective___________________________________________________________________________15
I.A.O.M Certification Procedures________________________________________________________17
Anatomy and Physiology related to Orofacial Myology_______________________________________23
Muscles_______________________________________________________________________________23
Major Muscles of the Body_______________________________________________________________24
Muscle Descriptions_____________________________________________________________________25
Muscles and their Major Functions________________________________________________________28
Major Masticatory Musculature___________________________________________________________________29
Figure 1: Muscles Involved in Mastication__________________________________________________________29
Figure 2: Muscles Involved in Mastication (Continued)________________________________________________30
Figure 3: Muscles of Facial Expression: Lateral View_________________________________________________31
Figure 4: Infrahyoid and Suprahyoid Muscles________________________________________________________32
Figure 5: Inspection of Oral Cavity________________________________________________________________33
Figure 6: The Tongue___________________________________________________________________________33
Figure 7: Normal Tongue Posture….. courtesy of Joseph Zimmerman COM________________________________35
Figure 8: Abnormal Tongue Posture… courtesy of Joseph Zimmerman, COM______________________________37
Growth Changes in the Soft Tissue Profile________________________________________________39
Tooth Development_____________________________________________________________________40
Primary Eruption and Exfoliation_______________________________________________________41
The Deciduous Arch_____________________________________________________________________41
The Permanent Arch____________________________________________________________________42
Postnatal Development: Mixed and Permanent Dentition – Orthodontic Fundamentals____________43
Oral Myofunctional Therapy____________________________________________________________44
Evaluation for Myofunctional Referral_____________________________________________________45
Guidelines for Recognizing Orofacial______________________________________________________46
Muscle Imbalance______________________________________________________________________46
Symptoms of Orofacial Muscle Imbalance__________________________________________________47
What to Look For______________________________________________________________________________48
Appropriate Case Selection_______________________________________________________________54

“No Win” Therapy Cases________________________________________________________________55
How Can Patients and Their Family Assist in Treatment?_____________________________________56
Clinical Aspects of Orofacial Myofunctional Therapy_________________________________________57
The Referral__________________________________________________________________________________57
The Consultation_______________________________________________________________________________57
Medical History_______________________________________________________________________________58
Birth History__________________________________________________________________________________58
Trauma-Injury History__________________________________________________________________________58
Lifestyle Influences____________________________________________________________________________59
Nutritional Information__________________________________________________________________________59
Extraoral Symptoms____________________________________________________________________________60
Posture of the head, neck and body:________________________________________________________________62
Facial Data___________________________________________________________________________________62
Extra-oral Data________________________________________________________________________________64
Intraoral Examination___________________________________________________________________________66
How To Catch A Thruster______________________________________________________________72
Actions The Patient Can Take To Avoid A Thrust___________________________________________72
Actions An Observer Can Watch For______________________________________________________73
During A Thrust________________________________________________________________________73
Welcome Letter_______________________________________________________________________74
Clinical Questionnaires________________________________________________________________75
Initial Assessment – Referral Return Information___________________________________________78
Conducting Measurements_____________________________________________________________79
Evaluation by Parent or Patient_________________________________________________________80
Therapy Notes_______________________________________________________________________82
Patient Dismissal Report_______________________________________________________________83
Signs and Symptoms of Occlusal Disease__________________________________________________85
“Posterior Cross-Bites in the Primary Dentition”___________________________________________88
Using Photography to Promote Your Practice______________________________________________90
Software to Manage the Images___________________________________________________________95
Backing-Up Your Business Data and Photographs___________________________________________95
Learn to Present – take up Public Speaking_________________________________________________95
Tongue Thrust and Tongue Posture______________________________________________________96
Facial Muscles…Friends or Foes?_______________________________________________________97
Tongue Thrust_________________________________________________________________________99
Lesson One__________________________________________________________________________________101
Lesson Two__________________________________________________________________________________102
Lesson Three_________________________________________________________________________________103
Lesson Four_________________________________________________________________________________104
Lesson Five__________________________________________________________________________________105
Lesson Six___________________________________________________________________________________106
Lesson Seven________________________________________________________________________________107
Lesson Eight_________________________________________________________________________________108
Parent’s Participation (Tongue Thrust)___________________________________________________109

Child's Contract (Tongue Thrust)________________________________________________________110
Allergic Shiners_____________________________________________________________________111
Lateral Wall of Nasal Cavity_____________________________________________________________112
Paranasal Sinuses_________________________________________________________________112
Breathing, Posture and Myofacial Dysfunction____________________________________________115
What are Sleep Disorders?____________________________________________________________116
Dysomnias____________________________________________________________________________116
Parasomnias__________________________________________________________________________116
Sleep disorders associated with psychiatric/medical disorders_________________________________116
Who is at Risk for Sleep Disorders?_______________________________________________________118
How do sleep disorders begin?___________________________________________________________118
How Are Sleep Disorders Diagnosed?_____________________________________________________119
Oral Structures Involved in Sleep Disorders________________________________________________120
How are Sleep Disorders Treated?________________________________________________________120
What is the role of the Orofacial Myologist?________________________________________________123
The Importance of the Orofacial Muscles________________________________________________124
Ear, Nose & Throat___________________________________________________________________________129
Sounds Like Sleep Apnea by Harold Hopkins_____________________________________________131
Sleep Apnea by Arricca Elin Sansone____________________________________________________132
Snoring Program____________________________________________________________________133
How to Stop Snoring___________________________________________________________________134
Establishing Use of the Nasal Airway_____________________________________________________139
Surgical Considerations_________________________________________________________________140
Is it a Cold or an Allergy?_____________________________________________________________141
Allergy Time__________________________________________________________________________142
The best treatments____________________________________________________________________142
The Importance of Respiratory Activity in Myofunctional Therapy____________________________146
Breathing Flow Chart__________________________________________________________________150
Poor versus Correct Posture___________________________________________________________152
Information and Instructions to Patients Regarding Swallowing______________________________160
Why is it important to swallow properly?__________________________________________________160
The Best Way to Down a Pill_____________________________________________________________161
Swallowing Disorders__________________________________________________________________162
How You Swallow_____________________________________________________________________162
What Causes Swallowing Disorders?______________________________________________________162
Symptoms____________________________________________________________________________163
Who Evaluates and Treats Swallowing Disorders?__________________________________________163
Possible Treatments______________________________________________________________________163
Swallowing Problems in Adults_________________________________________________________165
Orofacial Myology for Patients with Down syndrome_______________________________________167
Oral Habits and Primary Dentition______________________________________________________168
Thumb Sucking_____________________________________________________________________170
CIOM View …. The Program (Thumb Sucking)____________________________________________172
Program to Stop Thumb Sucking_________________________________________________________________173
Pacifiers / Dummies___________________________________________________________________________174
Baby Bottles & Pacifiers_______________________________________________________________________174
Thumb Sucking, Pacifiers Affect Child's Bite_______________________________________________________175
Breastfeeding Beats Bottle Feeding for Straighter Teeth By Miranda Hitti________________________________175
Parent’s questionnaire__________________________________________________________________________176
Nail Biting: A Habit That Can Be Broken_______________________________________________177
Nail Biting____________________________________________________________________________178
CIOM View….. Fantastic Nail Factoids___________________________________________________179
Trichotillomania____________________________________________________________________180
What is Trichotillomania?______________________________________________________________180
What are the symptoms?________________________________________________________________180
CIOM View___________________________________________________________________________181
Therapy beats drugs for hair-pulling disorder______________________________________________181
Temporomandibular Joint (TMJ) Dysfunction____________________________________________183
How do you recognize this disorder?______________________________________________________183
Temporomandibular Joint______________________________________________________________184
TMJ Disorder___________________________________________________________________________184
Protocol:____________________________________________________________________________________185
Treatment:___________________________________________________________________________________185
Help in Managing Your Temporomandibular Joint Disorder___________________________________186
Avoiding Injury, Spasm and Pain_______________________________________________________188
Injury__________________________________________________________________________________188
Muscle Spasms__________________________________________________________________________188
Pain___________________________________________________________________________________189
Suggestions to Help Avoid Injury, Spasm and Pain____________________________________________190
Speech Therapy Disclaimer____________________________________________________________191
Signs of Possible Speech and Hearing Problems___________________________________________192
What the Orofacial Myologist can do for Tongue Posture and Speech Sounds___________________194
Be Aware of Apraxia of Speech_________________________________________________________194
Glossary of Dental Terms_____________________________________________________________199
Bibliography________________________________________________________________________211
Supply / Shopping List________________________________________________________________221

Useful Websites_____________________________________________________________________222
NOTES____________________________________________________________________________223

What is Orofacial Myology?
Orofacial Myology / Myofunctional Therapy is defined as treatment of the orofacial

musculature to improve muscle tonicity. It is the establishment of correct functional
activities of the tongue, lips, and mandible, so that normal growth and development
may take place or progress in a stable, homeostatic environment.
It may include the treatment of parafunctional habits to eliminate noxious oral behavior
patterns; or temporomandibular muscle dysfunction as it relates to bruxism / clenching,
range of motion activities, or postural habits of the tongue, lips and / or mandible.
The practice of orofacial myology includes the evaluation and treatment of:
1. Detrimental orofacial habits
2. Posturing problems related to the lips, tongue, jaw and respiratory system
3. Abnormal neuromuscular responses associated with inappropriate mastication and

deglutition
4. Detrimental breathing patterns
5. Hyper and hypo sensitivity of the orofacial complex
6. Swallowing patterns which may be associated with malocclusions
7. Facial and postural esthetics
The overall goals of orofacial myology therapy are to assist in the creation, re-
establishment or stabilization of a normal oral environment with regard to lingual and
labial posturing and function or to permit normal processes of growth and
development to occur. For some patients the treatment is, generally, to create, re-
establish, or stabilize appropriate normal postural and functional or orofacial muscle
patterns. In most cases, treatment goals, strategies and objectives are determined
in conjunction with primary care providers in dentistry or medicine in a team
approach.

History of Orofacial Myology
Although this field has been viable for quite a long time, it is not well-known.
There are some 300 Coulson Institute Orofacial Myologists in the USA.
This is changing. It is our mission to take this field to new heights, and the numbers are
growing.
We are excited at the prospect of extending our program -internationally.
There is a tremendous need for cooperation among Professionals to provide the

population with the most efficient means of correction of some of the problems that we
will deal with in this course.
A survey of Speech pathologists back in 1993 revealed that thirty-four percent of them
had had no exposure to the field of oral-myofunctional disorders, 63 percent had no
‘practicum experience’ and of those who had received some information, eighty-seven
percent felt that the instruction was ‘inadequate’.
In 1974 ASHA (American Speech-Language Hearing Association) issued a position

statement questioning “the validity of ‘tongue thrust’ as a diagnostic label”, and
encouraged “increased research efforts”. They recommended that speech pathologists
not “engage in clinical management procedures of Orofacial Myology with the intent of
altering functional patterns of deglutition”.
What this statement did was to stifle any clinical education about oral- myofunctional
patterns and stimulate controversy regarding the relationship between Orofacial
myofunctional disorders and articulation errors.
Now Orofacial myofunctional disorders are included in the Scope of Practice and
Preferred Practice Patterns published by ASHA.
Even today, most of the Speech Pathology programs across the country do not include
training in this field.
The Coulson Institute of Orofacial Myology provides training courses, and a Certification
process to help ensure that there is a high level of competence achieved by those who
are CERTIFIED and providing therapy.

Scope of Practice
The Orofacial Myologist is trained to evaluate and treat patients with many orofacial
dysfunctions or anomalies.
These include:
1. Abnormal, non-nutritive sucking habits

(thumb, finger, pacifier, blanket, etc.)
2. Other detrimental habits

(nail biting, clothes chewing, object chewing, trichotillomania)
3. Abnormal orofacial rest posture issues

a. neuromuscular patterns associated with
bolus formation, deglutition, and mastication
b. abnormal functional breathing patterns
c. abnormal swallowing patterns
d. abnormal speech patterns (if the orofacial myologist has the appropriate
Speech/Language credentials required by his/her State, Province, or
Country)
e. Tongue/Lip rest postures
The goal of Orofacial myofunctional therapy is to assist in the creation, restoration and
maintenance of a normal and harmonious muscular environment.

Code of Ethics
IAOM (Revised 7/24/2011)
PREAMBLE
The preservation of the highest standards of integrity and ethical principles is vital to the
professional obligations of orofacial myologist. The IAOM Code of Ethics is an evolving
document and by its very nature cannot be a complete articulation of all ethical
obligations. The Code of Ethics is derived from of the IAOM Scope of Practice, and IAOM
Board Approved Guidelines, Position Statements, and any other documents deemed
necessary by the Board of Directors. The IAOM Code of Ethics sets forth the
fundamental principles and rules essential to this purpose. All categories of IAOM
membership shall abide by this Code of Ethics. Any act that is in violation of the spirit,
purpose and rules of this Code of Ethics shall be deemed unethical and may result in
disciplinary action. A Member voluntarily agrees to abide by the IAOM Code of Ethics as
a condition of membership in the IAOM.
Section A
A member in good standing is defined as:
1) One who is current with the payment of IAOM membership dues

2) One who has fulfilled all of the appropriate membership requirements
3) One who adheres to the IAOM Code of Ethics
Section B
The ethical responsibilities of the IAOM member require that the welfare of the persons
s/he serves professionally be considered paramount.
1) The member who engages in clinical work must possess appropriate qualifications. It
is strongly recommended that the member be CERTIFIED by the International
Association of Orofacial Myology or be actively working toward receiving this
certification.
2) The member may only provide services for which s/he can provide documented
evidence of adequate training and or licensure (if applicable).
3) Results of treatment shall not be guaranteed by the member. However, a statement

of prognosis can be made.
4) If there is no documentable progress for the treatment of a patient, it is the

responsibility of the member to release the patient from treatment.
5) The member may practice by telecommunication only in accordance with the IAOM
telepractice guidelines, and where not prohibited by law. Diagnosis/evaluation may only
be administered in person. This does not preclude the member from calls, letters, or
electronic communication for therapy and/or follow-up.
6) Professional ethics prohibit the guarantee of the outcome of any therapeutic

procedure(s).
7) A patient's confidentiality must be respected by the member. No information received

professionally shall be revealed to unauthorized persons without authorization from the
patient and/or legal guardian.
8) The IAOM member is not allowed to sell or disperse a list of membership information,
with addresses, emails, and/or any other personal information.
9) The member shall use every resource available, including referral to other specialists,
as per their specific professional guidelines to provide the best service possible for the
patient.
10) The member shall maintain adequate records of professional services rendered.
11) The member shall not charge third-party payers for services not rendered, nor shall
s/he misrepresent any services rendered.
12) The member shall not discriminate in the delivery of professional services on the
basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or
disability.
13) To minimize the spread of disease organisms the member shall maintain an aseptic
environment.
Section C
The IAOM member shall honor her/his responsibility to achieve and maintain the highest
level of professional competence.
The IAOM member shall continue her/his professional development throughout her/his
professional career.
15 hours of CEU’s are required over a 3 year period. (See IAOM Bylaws Article 3:
Section A & Section B. 3)
Section D
The IAOM member shall honor her/his responsibility to the public by promoting public
understanding of orofacial myology; by supporting the development of services, and by
providing accurate information in all communications involving any aspect of this
specialty area.
1) The member shall not misrepresent her/his credentials, competence, education,

training, or expertise.
2) Members may NOT add OM (Orofacial Myologist), MFT (Myofunctional Therapists) or

OFM (Oro-Facial Myologist) after their name upon completion of IAOM approved
course(s), or upon becoming a member of IAOM, or upon approval of application for
certification. The only acceptable acronym is COM (Certified Orofacial Myologist). Only
recognized degrees, licenses, registrations or certifications and the acronym COM will be
mentioned on the directory, website and official IAOM documents.
3) The member shall not participate in professional activities that constitute a conflict of
interest.
4) The member shall not misrepresent diagnostic information, services rendered, or

engage in any scheme or artifice to defraud in connection with obtaining payment or
reimbursement for such services or products. Members shall not accept third-party
payments in excess of fees for services or for fees of services not rendered.
5) The member’s statements to the public shall not contain misrepresentations in

advertising, announcing, and marketing their professional services through oral
communication, written form and/or electronic media. They shall adhere to prevailing,
IAOM standards.
6) The member shall be active in appropriately educating the public regarding the
specialty area of orofacial myology. The member’s statements to the public shall provide
accurate information about the nature and management of orofacial myofunctional
disorders.
7) The member shall not use the name of the International Association of Orofacial
Myology to promote classes, products, and any other profit-making venture without the
approval of the Board of Directors of the IAOM. This does not preclude the member to
announce membership status or offices held in the IAOM, in a vitae or resume.
Section E
The IAOM member shall honor her/his responsibilities to the profession of orofacial
myology and maintain harmonious inter -professional and intra-professional
relationships.
1) The member shall seek professional discussion of theoretical and practical issues with
colleagues and/or members of allied professions.
2) The member shall inform other professionals regarding the therapeutic benefits of
orofacial myology.
3) The member shall be willing to share her/his knowledge, new research and
therapeutic techniques with other members of the IAOM.
• If a member is giving a lecture/course they cannot restrict attendees from sharing the
information with other members as long as the student acknowledges the source of the
information.
4) The member shall not engage in dishonesty, fraud, deceit, misrepresentation, sexual
harassment, illegal addictive behavior(s), felony, or any other form of conduct that
adversely reflects on the specialty area of orofacial myology.
5) The member shall not engage in sexual activities with clients, students, or colleagues
over whom they exercise professional authority.
6) The member shall in no way violate existing U.S., or foreign restraint of trade laws,
and/or intellectual property rights.
7) The member shall not discriminate in their relationships with colleagues, students,
patients and members of allied professions on the basis of race or ethnicity, gender,
age, religion, national origin, sexual orientation, or disability.
8) The member may not attempt to restrict the practice of another member based on
territorialism including area of practice, referral sources, location of office or clientele.
9) The member shall present products s/he has developed to her/his colleagues in a
manner consistent with high professional standards: the Code of Ethics, IAOM Scope of
Practice, IAOM Board Approved Guidelines, Position Statements, and any other
documents deemed necessary by the Board of Directors.
10) The member shall prohibit anyone under her/his supervision from engaging in any
practice that violates this Code of Ethics.
11) Any member who has reason to believe that this Code of Ethics has been violated
has an ethical responsibility to report, possible violation(s), as directed in the Procedural
Code of Ethics Violations in the IAOM Handbook.
12) The member shall fully cooperate with the IAOM President and the IAOM Ethics
Committee in the investigation into matters related to this Code of Ethics with strict
adherence to confidentiality or themselves will be in violation.

ASHA / RDH Guidelines
What is ASHA?
The American Speech-Language-Hearing Association (ASHA) is the professional

association representing more than 150,000 speech-language pathologists (SLPs),
audiologists, and speech, language, and hearing scientists.
What course content is appropriate for ASHA CEUs?
Only courses, or sessions within courses, related to one or more of the following:
 Sciences as they pertain to speech-language pathology

 Sciences as they pertain to audiology
 Speech/language/hearing sciences
 Contemporary practice of speech-language pathology
 Contemporary practice of audiology
Who can offer courses for ASHA CEUs?
Only those organizations, such as yours, that have been approved by the Continuing
Education Board (CEB) may offer courses for ASHA CEUs. These organizations are
designated as ASHA Approved CE Providers. Currently, there are more than 550 such
organizations.
Please note that the Coulson Institute, as a Provider, does not award ASHA CEUs. The
CEB awards ASHA CEUs upon receipt of the Activity Report Form and participant forms
from you. In addition, ASHA CEUs are awarded only to those participants who are active
users of the CE Registry.

Dental Hygiene and the Registered Dental Hygienist
Historical Perspective
Dental hygiene was founded by Alfred C. Fones, DDS, as a preventive dental care
specialty. Fones organized the first formal class for dental hygienists in Bridgeport,
Conn., in 1913. As more dentists began to promote the importance of educating the
public in preventive oral health care, the demand for dental hygiene services grew.
Today, there are more than 150,000 licensed dental hygienists nationwide, and more
than 300 entry-level, 60 degree completion and 18 master degree dental hygiene
educational programs.
Dental Hygiene Services

Registered dental hygienists are licensed oral health care professionals whose
preventive services limit the extent of cavities and periodontal (gum) disease. They
provide many services including cleaning teeth; taking X-rays; providing fluoride
treatments; applying sealants; examining the condition of the mouth, teeth and gums;
and educating patients to maintain optimal oral health. They are especially
knowledgeable about the preventive aspects of oral health care and view prevention as
their central focus.
Licensure Requirements
Dental hygiene is a licensed profession. A dental hygienist is eligible for licensure, which
confers the RDH or LDH designation, after graduating from a nationally accredited
educational program and successfully completing both a written national board dental
hygiene examination and a state or regional clinical examination. Registered (licensed)
dental hygienists practice according to the requirements of individual state dental
practice acts.
Educational Settings
Dental hygienists receive their education in college-level programs at colleges and
universities accredited by the American Dental Association Commission of Dental
Accreditation. Each accredited program is at least two years in length, and usually
includes general college-level class work before the dental hygiene portion of the
curriculum begins, bringing the total class time up to a total of three years.
The curriculum includes a rigorous program of basic sciences such as chemistry and
microbiology; dental sciences such as tooth development and oral pathology; and dental
hygiene theory and practice such as pain control, nutrition, oral health education,
preventive counseling and periodontology. The classroom study is complemented
throughout the program by extensive clinical instruction supervised by dental hygiene
faculty.
Practice Settings
While most registered dental hygienists practice in private dental offices, others provide
services in hospitals; managed care organizations; federal, state and municipal health
departments; primary and secondary school systems; private businesses and industries;
correctional institutions; and private and public centers for pediatric, geriatric and other
special-needs care.
Registered dental hygienists work as clinical practitioners, educators, researchers,

administrators, managers, preventive program developers and consultants.

I.A.O.M Certification Procedures
The first step in the examination process is for an ACTIVE I.A.O.M. member to submit a
written request to the Executive Coordinator. This request must include a check for
$100.00 (made payable to the I.A.O.M.) and a copy of all college/university transcripts
or professional license (if these copies are not already in the I.A.O.M. files) plus the
Application for Certification found at: www.iaom.com/_docs/iaom_certification.pdf
A person applying for CERTIFICATION must be an ACTIVE member of the I.A.O.M. and
in good standing. It is strongly recommended that the applicant belong to the I.A.O.M.
for at least one year. The applicant is required to have attended a minimum of an
approved three day course in Orofacial Myofunctional Disorders and/or completed a
minimum of a thirty-hour internship with an I.A.O.M Certified Orofacial Myologist.
Candidates are encouraged to participate in I.A.O.M. sponsored courses as they provide
a solid basis for the certification process and clinical practice in this area of specialty.
I.A.O.M. dues MUST be current in order to apply for certification.
Upon arrival of the application, a Proficiency Examination will be sent to the applicant.
It is the responsibility of the applicant to carefully read the Certification Procedures
listed in the I.A.O.M. handbook.
The applicant is given six months from the date the test is mailed to complete the
examination. If the examination is not completed within six months, the applicant may
request a 6 month extension. Any request for additional extensions must be
accompanied by the payment of an additional $50.00 application fee.
The written proficiency examination is an open-book exam, and will cove the following
areas: Anatomy, Physiology, Development, Speech, Malocclusions, Etiologies,
Incidence, Diagnosis, Treatment, Motivation, Habituation and carry-over, Musculature,
Normal and abnormal swallowing, Posturing, Principles of therapy, Prognosis, Related
orofacial problems, and Orthodontic concepts.
The applicant is asked to address each question directly. On questions requiring opinion
and judgment, the Board of Examiners (the exam readers) would like to have the writer
justify the answers in a logical and orderly manner. The applicant may consult whatever
sources he or she chooses. However, footnotes and/or references are to be used where
appropriate.
The examination should be typed or word processed neatly, and the applicant is to
include a title page with his/her name on it, but the applicant’s name is NOT to be
written in the contents of the examination. To maintain the highest level of objectivity,
the Board of Examiners must not know whose examination they are reading.
After completing the Proficiency Examination, the applicant must send two typed, or
word processed, double spaced copies to the Chairperson of the Board of Examiners. (It
is recommended that the applicant keep a copy in case the examination is lost or
destroyed in the mail.) It is recommended that the copies be bound in an appropriate
folder or notebook. The completed examination copies will be forwarded to the
appropriate members of the Board of Examiners.
It is suggested that the exam be mailed by certified mail with a signed “Return Receipt
Request.”
Mail the completed examination to:

Chairperson, Board of Examiners for the IAOM
P.O. Box 278
Georgetown, KY 40324 USA
The Chairperson of the BOE will forward the examination to two members of the BOE
who will independently read and score the examination and return their results to the
Chairperson. The applicant must receive an 80% or better on their examination from
both readers in order to pass. When there is a discrepancy between the two readers, a
third reader will independently read and score the examination based on the
recommendations of the readers and the Chairperson of the BOE. The Chairperson of
the BOE is responsible for informing the applicant of the results of the examination.
If the applicant passes the written examination, the BOE Chairperson will send a letter
explaining the procedures for the “Onsite Visit.” The BOE Chairperson will also inform
the applicant of the list of the BOE from which he or she may choose.
It is the responsibility of the applicant to keep the BOE Chairperson informed of the
onsite arrangements. THIS MUST BE DONE IN WRITING. The BOE Chairperson will be
informed in writing of the onsite arrangement BEFORE the onsite takes place.
The applicant must send a check in the amount of $100.00 to the IAOM Executive
Coordinator BEFORE the onsite takes place. The check should be made out to: IAOM
Onsite
The onsite evaluation shall be for a minimum of six hours. Special arrangements can be
made to have the onsite completed on two different days. It is possible to use up to a
maximum of three hours of videotaping from actual therapy sessions toward the onsite
visit requirements.
In the case of last minute cancellations or failed appointments at the time of the onsite
visit, the examinee shall have the option of videotaping the missing portion of the onsite
for review and scoring by the examiner. The additional videotapes must be submitted
within 30 days following the actual onsite visit.
The onsite visit shall consist of at least one initial interview or evaluation, patients in the
various stages of therapy, and patients who are in follow-up recheck visits.
It is the responsibility of the applicant to make arrangements with the members of the
BOE to reimburse the expenses incurred.
The applicant will try to complete the Onsite visit within six months after passing the
Proficiency Examination. If the Onsite is not completed within three years of passing the
Proficiency Examination, it will be necessary to start the Certification process from the
beginning.

After successfully completing the Certification Procedures, the applicant will be notified
by the chairperson of the Board of Examiners in writing.
The applicant will be sent a numbered CERTIFICATE that will be signed by the IAOM
President and the Chairperson of the Board of Examiners.
The applicant then as the IAOM sanction to list his/her certified status (C.O.M.) He or
She is thereby given all rights, privileges and honors thereto pertaining to CERTIFIED
members of the I.A.O.M.
A CERTIFIED MEMBER of the IAOM will be required to attend courses related to the
fields of Orofacial Myofunctional Disorder (O.M.D) or an I.A.O.M. Convention/Conference
for a minimum of fifteen hours within a three-year period to maintain the certified
status.
Any exceptions to these guidelines may occur only through the approval of the IAOM Board of Examiners.
Any changes to these guidelines must be approved by the I.A.O.M. Board of Examiners and the I.A.O.M
Board of Directors.

Orofacial Myology as it Relates to an Orthodontic Practice
A Personal View by:
Richard A. Coulson, D.D.S., M.S.D .
I am writing with congratulations to the members of the Coulson Institute of

Orofacial Myology on the considerable growth that has taken place in the profession in
the last few years. I have had the opportunity to use the services of several therapists
helping with myofunctional problems. It has been a valuable experience for me and my
patients. I have made a number of observations that I hope may be of some value to
you.
Problems of oral muscle posture can delay a patient in achieving a proper

relationship of various teeth during orthodontic treatment. Vertical spaces between the
upper and lower teeth can usually be forced closed one way or another; however, they
will not stay in contact if the tongue or lip is interposed.
I feel that it is imperative that the anterior teeth remain in contact following
orthodontic treatment since the incisors and cuspids function as a protective mechanism
for the posterior teeth and temporomandibular joint. The teeth function as a mutually
protective system in an ideal occlusion. Anterior teeth serve to disengage the posterior
teeth in lateral and protrusive movements, while the posterior teeth serve as vertical
stops which prevent the mandible from
closing with a force that would damage the “Advancements in technique
supporting structures of the anterior teeth.
and
Electro-myographic research by status for orofacial myology
Williamson (Brandt, 1981) has shown that
the activity of the masticatory closing
has
muscles is greatly diminished if the posterior teeth are apart. The temporomandibular
joint is protected in this mutually protected occlusion scheme since in any protrusive or
lateral movement the anterior teeth disengage the posterior teeth and prevent
contraction of the muscles. The temporomandibular joints can frequently be over-
loaded during bruxing habits occurring during the day or night if this protective
mechanism is not intact.
The facial appearance of a patient and their social graces during eating is greatly
improved when the facial muscles and tongue function appropriately. Parents are
usually very appreciative when this is accomplished.
Advancements in technique and status for orofacial myology have been delayed
by a few unfortunate circumstances, which I will discuss as one man’s opinion.
1. The terminology used in the past has been confusing, non-descriptive and
unprofessional. Terms such as tongue thrust and reverse swallow should be
eliminated entirely. “Tongue thrust” implies that the problem is an active one
only. It omits the consideration that dental anterior or posterior open bites may
be due to posturing problems of the tongue, airway issues, lip incompetence,
tongue size, skeletal discrepancies and even neurological problems. The term
“reverse swallow” deserves very little comment. It does not describe the problem
and further confuses the public since the patient is not regurgitating and the
parent or patient knows this.
2. The assessment of orofacial myofunctional disorders has been over-simplified. It

is unfortunate that therapists have been asked to correct impossible problems and
then have been subjected to criticism when the problem was not solved. A
severe skeletal open bite, for instance, is a diagnostic problem. If the
orthodontist closes the anterior open bite by over-erupting the anterior teeth, the
bite cannot be expected to stay closed regardless of therapy. If the anterior teeth
are over-erupted with orthodontic mechanics, orthodontic therapy did not treat
the real problem which is frequently over-eruption of posterior teeth. The
anterior teeth, therefore, were in a vertical position which was normal or close to
normal to begin with. The skeletal problem may involve deficient posterior facial
height or excessive anterior facial height as well as severe antero-posterior
problems. Differential diagnosis is essential to determine why the patient has
an anterior open-bite.
3. Most favorable therapeutic results are obtained when a multi-disciplinary

approach is used. Appropriate timing of therapy is another ingredient for success.
Personally, I refer to the orofacial myologist at different stages of orthodontic
treatment, depending on the problem. If an airway problem is discovered, it is
addressed prior to beginning orthodontic treatment. If an anterior open bite is
due to poor tongue posture or lip wedging, I usually refer later in treatment when
spaces are nearly closed and the oral environment is more favorable for the
therapy.
Generally speaking, if there is a space available, the tongue will fill in the space. In
the case where several
deciduous teeth are missing in
the mixed dentition stage and
“The certification program for
the permanent teeth are un- the orofacial myologist is a
erupted, I wait until the
permanent teeth are at least major step forward for the
partially erupted to reduce the
profession.”
available space for the tongue (and make the situation more favorable for the
therapist).
The certification program for the orofacial myologist is a major step forward for the
profession. It shows concern for quality care and indicates that the therapist is
willing to invest extra time and effort regarding personal study and a willingness to
be observed and assessed by their peers as they are working with patients. The
written examination should address all of the issues mentioned above and re-
certification at a specified interval would, I think, be an added major benefit.
In summary, orofacial myology is challenging work.
What are some of the ingredients to success?
 The team approach which was discussed previously. This disorder is

typically a multi-factorial problem.

 Commitment to the patient. Motivation is a key ingredient requiring a
skilled clinician. If the patient will not cooperate s/he should be dismissed
and the orthodontist should be notified of the situation in a written report.
 Understanding on the part of the patient and parents. Good visual aids
are very important, slides before, during and after therapy are helpful. Video
taping of the patient helps awareness, reinforces progress and has been
shown to be one of the best motivational aids available.
 Follow-up after the course of treatment is completed. This is critical. Too
few therapists include this in their program.
 Parental support. Patients sense a lack of support very quickly. Having
both parents present at the initial exam and spending adequate time to
demonstrate the problem effectively and answer questions is imperative. A
parent should attend as many treatment sessions as possible.
 Observing other habits is essential. The patient, parent, orthodontist and
orofacial myologist may be unaware of these through casual observation. Lip
wedging, lip sucking, digit sucking, tongue sucking and pencil biting would be
examples.
 Support by the referral source in the manner of referral, involvement
during therapy, and positive feedback to the patient and therapist.
It is well worth striving for the long-term benefits that can be provided for our
patients. This is an exciting time as all health professionals learn more about
human structures and function. By keeping comprehensive records that can be
used to teach others as well as learn oneself, the prospect for an exciting career
through a team approach is excellent.
Reference: Brandt, Sidney. (1981). Dr. Gene Williamson on occlusion and TMJ dysfunction.
Journal of Clinical Orthodontics, 15(5), 333-350 and 15(6), 393-410

Anatomy and Physiology related to Orofacial Myology
Muscles
Muscles of Mastication
Buccinator compress cheeks against teeth, so food passes between them; expels
air when it fills cheeks
Orbicularis oris compress lips against teeth, brings lips together
Masseter Elevates mandible to occlude teeth; small effect on side to side
movement
Temporalis Elevates mandible to close teeth; anterior fibres pull up, posterior fibres
pull back; aids in side to side movement
Lateral pterygoid Assists in opening mouth by pulling condyle of mandible forward;
superior belly eccentrically controls backward glide of disc during
closing; acts with medial pterygoid ipsilaterally to rotate jaw; protrudes
jaw bilaterally
Medial pterygoid Assists in elevating mandible, with lateral pterygoid protrudes jaw
bilaterally; acts with medial pterygoid ipsilaterally to rotate jaw
Suprahyoid Muscles
Digastric elevate hyoid, depress mandible

Stylohyoid elevate and draw back hyoid, elongating floor of mouth; fix hyoid for
tongue muscles
Mylohyoid elevate hyoid or depress mandible, elevate floor of mouth
Geniohyoid elevate hyoid and draw it forward; with hyoid fixed, depresses
Muscles
Hyoid depress hyoid after it is elevated; plays part in speech and mastication
Sternothyroid draw larynx down after it has been elevated, as in swallowing
Thyrohyoid depress hyoid, elevates larynx
Omohyoid depress hyoid after it is elevated; may assist in inspiration
Other muscles to consider:
 Infrahyoid  Upper trapezius

 Suboccipitals  Scalenes
 Cervical paraspinals  SCM
 Subscapularis  Pectoralis (major and minor)
 Levator scapularis

Major Muscles of the Body

Muscle Descriptions
Digastric Muscle. The digastric muscle has a double innervation. The posterior
belly is supplied by a branch of the facial nerve entering the muscle close to its
posterior end. The anterior belly is supplied by a branch of the mylohyoid nerve
of the third division of the trigeminal nerve. Variations of the digastric muscle are
frequent. They are, however, almost entirely confined to its anterior belly. The
most frequent aberration from the typical shape consists of oblique connections
between the two anterior bellies, sometimes symmetrical, more often
asymmetrical. The accessory muscle bundles may occupy the entire space
between right and left anterior digastric bellies.
Geniohyoid Muscle. The geniohyoid muscle arises above the anterior end of the
mylohyoid line from the inner surface of the mandible, close to the midline and
lateral to the mental spines, by a short and strong tendon. The muscle, in
contact with that of the other side, proceeds straight posteriorly and slightly

downward and is attached to the upper half of the hyoid body. Posteriorly the
muscle gradually widens and assumes, in cross section, a triangular shape.
The muscle is supplied by branches of the first and second cervical nerves which
reach it via the hypoglossal nerve. The geniohyoid muscle pulls the hyoid bone
upward and forward or it exerts a downward and backward pull on the mandible,
depending on the fixation, by other muscles, of either mandible or hyoid bone.
Mylohyoid Muscle. The mylohyoid muscle forms, anatomically and functionally,

the floor of the oral cavity, hence the old term “oral diaphragm.” The right and
left muscles are united in the midline between mandible and hyoid bone by a
tendonous strip, the mylohyoid raphe.
The muscle arises from the mylohyoid line on the inner surface of the mandible.
Its most posterior fibers take their origin from the region of the alveolus of the
lower third molar. The origin of the anterior fibers deviates more and to the lower
border of the mandible. The posterior fibers of the coarsely bundled muscle run
steeply downward, medially, and slightly forward, and are attached to the body of
the hyoid bone; the majority of the fibers, however, join those of the contra-
lateral muscle in the mylohyoid raphe. The muscle plate is considerably thicker in
its posterior part. Slit-like defects in the anterior part of the muscle are not rare.
The free, sharply-defined posterior border of the muscle, reaching from the third
molar socket to the body of the hyoid bone, is an important topographic and
surgical landmark. Because of the origin high up on the inner surface of the
mandible, the muscle plate of the mylohyoid and the inner surface of the
mandible bound a niche, the mylohyoid or submandibular niche. It is deepest
posteriorly and more shallow anteriorly.
The mylohyoid muscle is supplied by branches of the mylohyoid nerve of the third
division of the trigeminal nerve. The innervating branches enter the muscle
course but remain separated from each other by a variably wide strip of fascia,
sometimes referred to as the white line of the neck, linca alba colli. In its upper
part, the sternohyoid muscle becomes narrower and slightly thicker and is, finally,
attached to the inferior border of the hyoid bone close to the midline. The muscle
is, in most cases, partly divided by a narrow tendinous inscription, nearer to its
sterno-clavicular attachment. This inscription is sometimes seen only at the deep
surface of the muscle.
Omohyoid Muscle. The long, narrow, two-bellied omohyoid muscle originates at

the upper border of the scapula, medial to the suprascapular notch. The inferior
or posterior belly runs obliquely upward and forward, crossing the posterior
triangle of the neck. Deep to the sternoclydomastoid muscle the flat posterior
belly ends in a more rounded, short tendon which, in turn, continues into the
superior or anterior belly. This part of the muscle forms, with the posterior belly,
an obtuse angle which opens posteriorly and superiorly. The superior belly is
more steeply directed upward and forward until the muscle reaches the inferior
border of the hyoid bone. There it is attached just lateral to the attachment of
the sternohyoid muscle. The intermediate tendon is fixed to the clavicle by a
rather firm layer of the deep cervical fascia, the omoclavicular fascia, which
covers the internal jugular vein. The vein is firmly attached to the fascia, so that
the omohyoid muscle can widen the lumen of the vein.

Musculus Orbicularis Oris (Oral Sphincter). This muscle occupies the entire
width of the lips. It has no direct attachment to the skeleton. Its fibres can be
divided into an upper and a lower group which cross each other at acute angles
lateral to the corner of the mouth. In addition, the majority of upper and lower
fibres are confined to one side only, interlacing at the midline with the fibres of
the other side. Thus, the muscle is only functionally, but not anatomically, a unit.

Muscles and their Major Functions
M = Masseter (Superficial Belly) – Elevate mandible, clench teeth

AT = Temporalis (Ant. Belly) – Elevate mandible, retract mandible, clench teeth
MT = Temporalis (Middle Belly) – Elevate mandible, retract mandible, clench teeth
PT = Temporalis (Post. Belly) – Elevate mandible, retract mandible, clench teeth
LP = Lateral Pterygoid - (Superior Belly) –Pulls articular disc forward, assists in rotary
motion (Inferior Belly) – Protrudes mandible, assists in rotary
motion
MP = Medial Pterygoid – Protracts and elevates mandible, assists in rotary motion
DG = Digastric – Depresses mandible
SCM = Sternocleidomastoid – Opposes action of lateral pterygoid on the same side
TR = Trapezius – Opposes action of Supra and Infra hyoid muscles
IH = Infra Hyoid Muscles – Steady hyoid bone and aid in depressing mandible

Major Masticatory Musculature
Figure 1: Muscles Involved in Mastication

Figure 2: Muscles Involved in Mastication (Continued)

Figure 3: Muscles of Facial Expression: Lateral View

Figure 4: Infrahyoid and Suprahyoid Muscles

Figure 5: Inspection of Oral Cavity

Figure 6: The Tongue

Figure 6: Tongue (Continued)

Figure 7: Normal Tongue Posture….. courtesy of Joseph Zimmerman COM

Figure 8: Abnormal Tongue Posture… courtesy of Joseph Zimmerman, COM

Growth Changes in the Soft Tissue Profile
Attainment of adult size for the various soft tissue variables
and three skeletal base measurements
Growth
% growth Growth ending at completed past Growth
completed at 7 or before 15 15 and before 18 continuing at
Variable years years years 18 years
Male Female Male Female Male Female Male Female

Upper nose height 80 82 x X
Lower nose height 67 90 X x
Nose depth 63 70 X x
Nose skeletal base
at prn' – PMV 85 90 x X
Upper nose
inclination 87 90 X x
Lower nose
inclination 92 89 X x
Upper lip length 88 95 x X
Lower lip length 78 91 X x
Upper lip thickness
at A 73 76 X x
Upper lip thickness
at LS 82 93 X x
Lower lip thickness
at LI 85 89 X x
Lower lip thickness
at B 80 85 X x
Sagittal length of
mandible at B 75 84 X x
Chin thickness at
Pgs 80 83 x X
Chin thickness at
Pgs 83 88 X x
Symphyseal
thickness 92 95 X x
Skeletal base at
Pg"-PMV 66 74 X x
Inclination of
skeletal chin 44 27 X x
Inclination of chin
integument 72 66 x x

Tooth Development

Primary Eruption and Exfoliation
The Deciduous Arch
The integrity of the permanent arch depends on the care given to the deciduous teeth.
Prevention of dental disease and protective dental treatment should start with the
deciduous dentition.
ERUPTION AND SHEDDING OF THE DECIDUOUS TEETH
Eruption Shedding
Lower Upper Lower Upper
Age (months) Age (years)
Central Incisors 6 7½ 6 7½
Lateral Incisors 7 9 7 8
Cuspid 16 18 9½ 11 ½
First Molar 12 14 10 10 ½
Second Molar 20 24 11 10 ½

Permanent Eruption and Exfoliation
The Permanent Arch
The integrity of each arch depends on the normal curvilinear arrangement of the teeth,
with each tooth in contact with its adjacent neighbors. A break or irregularity in the
contact line, which is caused by the loss or displacement of a single tooth, or a part of a
tooth, results in the imbalance of the entire arch (malocclusion).
The teeth of opposing arches interdigitate in such a manner that the upper arch overlaps
and confines the lower, and each tooth is opposed by two teeth of the other arch (with
the exception of the upper third molars and lower central incisors).
ERUPTION OF THE PERMANENT TEETH
Lower Upper
Age (years)
Central Incisors 6-7 7-8
Lateral Incisors 7-8 8-9
Cuspids 9-10 11-12
First Bicuspids 10-12 10-11
Second Bicuspids 11-12 10-12
First Molars 6-7 6-7
Second Molars 11-13 12-13
Third Molars 17-21 17-21
The lower teeth erupt before the corresponding upper teeth. The teeth usually erupt
earlier in girls than boys.
Reference: Wheeler, R.C.: A Textbook of Dental Anatomy and Physiology.

Ed. 2. Philadelphia: W.B. Saunders Co., 1950.

Postnatal Development: Mixed and Permanent Dentition – Orthodontic
Fundamentals

The Importance of the Orofacial Muscle Complex
 Genioglossus (GG) responds to local mechanisms of upper airway negative
pressure. GG reflex is more active during wakefulness and reduced during REM
sleep, therefore more vulnerable to collapse during REM sleep ( Shea et al.1999).
 GG strength is greater in males than females and decreases with age. Fatigability
of GG is equal across genders. May explain why sleep disorders increase with age
but not the gender difference (Morlimore et al. 1999).
 GG and Geniohyoid (GH) in subjects with OSA present adaptation and muscle
injury significantly higher than in Sternohyoid and Sternothyroid muscles in OSA
subjects and control group, suggesting different involvement of the Pharyngeal
Dilator Muscles (PDMs) in sleep disorders (Scotland et al. 1999)
 GG function, structure and fatigability are different in subjects with OSA,
compared to control group, and these abnormalities are corrected by CPAP
(Carrera et al. 1999).
 GG muscles in subjects with OSA present a change in muscle fibers: increase in
fibers Type II (fast twitch) and reduction of fibers Type I (slow twitch) ( Carrera et
el. 1999).
 Daytime electro-stimulation of supra-hyoid muscles may prevent episodes of

obstructive sleep apnea (Wiltfang et al. 1999)
 Masseters in healthy subjects present low intensity and short duration activity
during sleep, greater in men than women. Facial pain may be associated with
increased activity of masseters during sleep (Gallo et al. 1999).
 Electro-myogram (EMG) of GG, masseters, and lateral pterygoid muscles showed
that there is a decrease in EMG amplitude (hypotonia) during episodes of OSA,
compared to before the episodes, and greater amplitude after the episodes of
OSA. Decrease in EMG amplitude was not observed in Central Sleep Apnea
(Yoshida,1998).
 Orofacial morphology of patients with night-time bruxism does not differ from
that of non bruxers. A further suggestion of bruxism as a central disorder rather
than peripheral (Lobbezoo et al. 2001).
 During non-REM sleep, the Superior Pharyngeal Constrictor is not activated in
subjects with OSA nor in the control group, except for airway reopening,
indicating the involvement of other muscles in obstruction of airflow ( Kuna &
Smickley, 1997).
 The metabolic and histo-chemical characteristics (glycolytic, glycogenolytic, and

anaerobic enzymes. Type I and II fibers) in the Musculus Uvula and GG muscles
are different in sleep apnea subjects, compared to snorers and control group. and
are not present in all PDMs (Series et at., 1996).

 The morphology of uvula in OSA patients contains more muscles and fat deposits
compared to the non-OSA subjects, regardless of sex or anthropometric
measures, but related to frequency of apnea- hypopnea ( Stauffer et al. 1989).
 Histo-pathologic changes in the uvula of snorers and subjects with OSA show
focal atrophy of muscle fibers, edema of the lamina propria, hypertrophy of
mucous glands, vascular dilation, and degeneration of myelinated nerve fibers.
These findings support the hypothesis of changes in the uvula secondary to
vibratory trauma and impaired pharyngeal reflexes and development of OSA
(Woodson et al. 1991)
 The palato-glossus muscle is a nasopharyngeal dilator muscle and is activated
during negative upper airway pressure in inspiration, but only the GG is activated
in supine position (Mathur et al.1995).
 The intra-pharyngeal negative pressure itself modulates the GG activity,
independent from central control, and controls the activity during and between
breaths (Malhotra et al. 2002).
 Wearing a Bionator or other appliance at night can decrease the activity of
masseters and supra-hyoid muscles, but not in a significant measure ( Hiyama et
al. 2002)
Chewing
Chewing food, even without the aid of saliva, can help the body begin to digest food.
Here are a few examples:
•Chewing well grinds food into small bites, allowing it to be more easily swallowed. Have you
ever try swallowing a poorly chewed food? It actually hurts on the way through the esophagus.
You can feel the food tear and scrape your throat.
•Well-chewed bites of food are more easily coated with digestive enzymes once in they are in
the stomach. The body uses less of its energy to digest well-chewed food than hastily chewed
and swallowed food.
•Chewing well also allows the molecules of nutrients from the chewed food to be more quickly
released and assimilated.
•Keeping a food in the mouth longer and chewing it well allows the food’s flavors to be
recognized by the tongue. When the tongue recognizes the flavor it sends a message to the
brain, which in turn sends messages to the digestive system resulting in the release of the
correct digestive enzymes needed for that particular food.
Saliva
Saliva can do a few things on its own as well:
•It moistens the molecules of dry foods so that we can taste the foods when we eat them.
We are not able to distinguish many flavors in dry food.
•It binds masticated food bits into a bolus, which can be swallowed easily.
•It lubricates the esophagus. In fact, the bolus of masticated food never really touches or
potentially damages the walls of the esophagus.
•It is important to oral hygiene. The mouth is almost constantly flushed with saliva, which flushes
away food debris and protects teeth from decay. Saliva can actually kill some bacteria.
But where does all this saliva come from?
You have 3 pairs of major salivary glands and a few minor pairs located throughout your mouth.
The salivary glands create saliva, which is then secreted into your mouth via the salivary ducts.
Sounds pretty obvious, doesn’t it? Well here are a few of the less obvious facts about the three
main salivary glands:
• The first pair of salivary glands to be considered here are the Parotid Glands. These glands,
located just under the ears, produce a serous solution. The oral serous solution i It is no wonder
that these salivary glands are the ones most associated with carbohydrate digestion. The ducts
for these glands are near your upper molars.
• The Sublingual glands are located under the tongue and produce saliva that is primarily
mucous. Mucous saliva is thick and gluey. It binds the masticated (chewed) food into a bolus as
well as lubricating the esophagus. The ducts for these glands are located on the floor of the
mouth.
• The Submaxillary glands, also known as the Submandibular glands, are located near the
jawbone and secrete both serous and mucous saliva. The saliva reaches the oral cavity via ducts
located under the tongue. The Submaxillary glands and the Sublingual glands also produce
salivary amylase.
Partners in Health
You now know what chewing well on its own can accomplish, what saliva on its own can
accomplish, and even a bit about where that liter (+) of saliva that you produce every day comes
from. Now let’s put it all together:
• Chewing well combined with saliva are partners in digestion. We all know that chewing
well and mixing your food bits with saliva leads to carbohydrate digestion but did you know
eating protein-rich meals actually decreases the amount of salivary amylase produced? Eating a
carbohydrate-rich meal leads to a slight increase in the amount of salivary amylase produced in
the mouth.
• Saliva acts as a first defense against bacterial infection. By chewing food well and
creating more surface area on which the saliva can act, more potential food-borne bacteria can
be killed.
• The bicarbonate in saliva may activate the enzyme cellulase found in raw vegetables.
The enzyme cellulase digests the fiber cellulose. Together bicarbonate and cellulase begin to
digest the raw vegetables. Chewing well also helps to break down the cellulose. However, the
combination of the saliva and chewing helps the body to fully digest raw vegetables and receive
their nutrients.
Don’t forget – even the most pureed soup or juiced veggies need to be ensalivated. Swish
nutrient-rich liquids around in your mouth before you swallow. The carbohydrates present in the
soup or juice can be partially digested by your saliva.

Chewing well and tasting food is just plain common sense. The fact that our body produces a
substance (saliva) that makes chewing, tasting, and swallowing easier is a bonus to our vitality.
Chewing well and saliva - each have their own merits. It’s when they work together that we can
really appreciate the partnership that nature has created for us.
In digestion, a bolus (from Latin bolus, ball) is a mass of food that (with animals that
can chew) has been chewed to the point of swallowing. Under normal circumstances,
the bolus then travels to the stomach for further digestion.
Three types of positive and negative pressure variations impact the bolus and control
of the swallow. These include the positive and negative pressures associated with the
muscular forces of the mouth, pharynx and esophagus; the filling and emptying of the
bolus in the tract; and the pressures of respiration, including sub-glottic pressure
variations. Swallowing occurs in three stages.
In the first stage, oral transit, (here defined as including oral prep) the tongue cups to
position the food/fluid/saliva for swallowing, and the front of the tongue elevates,
followed by elevation of the back of the tongue.
The food is propelled into the pharyngeal esophageal (P-E) segment, which is the
beginning of the second stage of swallowing, pharyngeal transit. The epiglottis comes
down to protect the trachea as the hyoid bone elevates (carrying the thyroid cartilage
and larynx upward) and then immediately returns to the pre-swallow position.
The third stage, esophageal transit, then begins, with a peristaltic wave that propels
the bolus down the esophagus into the stomach.
Dysphagia - is defined as difficulty in swallowing or the inability to swallow. This may

be due to pressure imbalances, structural changes or abnormality in innervation of the
pharyngeal or esophageal muscles. The ability to swallow may also be affected by
more readily remediated oral mechanical problems. Dysphagia due to innervation
problems or structural deviations at the second and third stages of swallowing should
be differentiated from difficulty in the first stage (oral), which may be favorable
improved through positioning, handling techniques, and techniques to control the flow
and placement of food and fluids.

Clinical Aspects of Orofacial Myofunctional Therapy
The Referral
A patient has been referred for treatment of oral-facial muscle imbalance. When they
arrange an appointment, gather information. A “telephone information slip” is helpful to
organize the date called, their name, age, the name of the referral source, address and
phone number, and details concerns. Establish a date for the consultation and confirm
that you will be sending them some information in the mail, part of which they will bring
back to the appointment with them (if your practice is to send a pre-questionnaire).
Send them informative material pertinent to their needs, i.e. tongue thrust, thumb
sucking, speech, TMJ problems, etc. Include your pre-questionnaire form, an
appointment card noting the date and a personal note such as “see you soon”. If the
patient is a child, possibly send a sticker with their name on it. Establish a rapport right
from the start.
Next, discuss the patient with the referral source. It is most helpful to know in advance
the reason for referral, what course of treatment they are presently receiving, what
treatment is proposed, what the referral source shares as concerns, and valuable
person, family, or financial data that can be shared.
Call any other clinicians who might be involved in this patient’s case if necessary, to
gather information.
The Consultation
The consultation is a time to gather information, establish rapport, diagnose symptoms,
outline recommendations, and educate the patient. It is important to remember that
you will have to teach this patient and be part of his or her life for several months. You
must be sure that you have not only the technical skills, but the motivational skills and
willingness to work with this individual. If you know you cannot, a referral to another
practitioner may be necessary.
Establish at the consultation whether this is the right timing for treatment with orofacial-
myofunctional techniques. Remember the “form determines function…function
determines form” module. If, for example, the palate is too narrow to encompass the
tongue, you can proceed with treatment with cooperation of the dentist/orthodontist.
Know your skills, know the environment necessary to perform your skills, and determine
IF you have a willing patient.
There is no hard-and-fast rule about the age limitation in orofacial-myofunctional

treatment. Education of the parents can begin pre-birth to acquaint them with skills to
prevent oral-facial muscle imbalances. Actual therapy has been performed with children
as young as two and adults in their 80’s. The program has to be modified depending on
the need, the attention span, the ability to cooperate, and the ability of the muscles to
perform.
At the consultation, we want to establish factors that could influence success.

Medical History
On a pre-questionnaire or verbally, establish a medical history. There are medical
conditions and medicines that can affect the position of the muscles and their ability to
function. Without knowing this in advance, you might assume you can “do” something
that the body will not allow?
Determine if any of the following are a concern: allergies, asthma, diabetes, epilepsy,
neurological or muscular diseases, hyperactivity, hypoglycemia, heart conditions, TMJD,
gastro-intestinal conditions, frequency of colds, ear infections, pain, dental decay, or
alcohol use, speech impediments, use of social type drugs, smoking, eating disorders,
and use of any types of medication.
Make note of areas that could affect your treatment regimen.
Birth History
Inquire of patient if there were any pre-birth problems, injuries, or drug use. What
happened during the birthing process? Was it an easy or hard labor, the extent of the
labor, were forceps utilized, was a C-section performed, were there any complications,
etc..
Pressures to the cranium pre-birth, or during the birthing process, can definitively affect
facial form, arch form, muscle position and function, and the over-all neurological
capability of the body. Cranial manipulation by a qualified clinician may be necessary
when this history is present.
Inquire as to how the baby was fed. If breast fed, ask for the duration. If bottle fed,
ask what type and duration. Was colic present and for how long? What was the
sleeping posture? Was thumb, finger, pacifier, blanket, teddy-bear, or tongue sucking
present and for how long? Were there learning disabilities, physical limitations,
coordination difficulties, speech disorders, or a history of allergies?
Proper breast feeding for two years is the feeding method of choice, but note that
“proper” breast feeding was stated. A child feeding from a breast that is engorged with
milk that squirts from the nipple will end up “drinking” and not “sucking”. The mother
should pump-off the initial heavy flow of milk first. The baby should also be held in a
more upright position rather than on its side. Using pillows is helpful for achieving this
posture.
If a bottle system is utilized, the NUK nipple and the CORRECTO bottle combination is
best. A better system is in the making at this time. Parents should be cautioned about
extensive time with any bottle. Breast feeding, if correct, continues to develop the oral
form, however, bottle feeding beyond 1-1½ years can be detrimental to arch form and
muscle function.
Trauma-Injury History
You have already determined prenatal and birthing trauma. Now determine what
injuries have occurred during childhood to the present time. You are looking for trauma
to the head and body that could have resulted in torsion patterns that could affect the
head-neck-body posture. Remember, muscles attach to bones.
Trauma
Determine the age at which the injury occurred, how it occurred, what was injured, what
treatment was necessary, and what lasting effects there were.
Lifestyle Influences
What occupies the patient’s time? Determine what their hobbies are, what do they do
during play time, what organized sports are they involved in, etc. This will help to
determine if their muscles are used to being disciplined, if they are self-motivated or
sedentary, if they are compliant, etc. It will give you better clues on which to determine
your therapy and motivational approach. Are they willing to give-up something, if
necessary, to fit therapy in? This also allows you to determine their uniqueness….what
prizes to give and what to compare therapy examples to so as to increase their
understanding.
What musical instruments do they play? Musical instruments can effect the position of
the teeth, lips and tongue, the position of the head and neck, thereby affecting therapy,
the dental arch, and body posture.
Are there siblings in their environment? If so, what ages and sexes? Competing for
attention, therapy practice time or privacy, and/or praise, observation, or rewards may
affect therapy.
Nutritional Information
Much can be gained from knowing what your patient’s diet is. The saying “You are what
you eat” may be more true than we think. A poor diet, especially one heavy in sweets
or indulgences, can affect the ability of the muscles to perform. It is important to note,
that people with oral-facial muscle issues often tend to feel a “gag” response when
taking a pill or when eating coarse types of food. Therefore, their diet will tend toward
foods easy to swallow. “Junk foods” and sweets fall into this category!
Take a survey of the food and liquids that they have for breakfast, a.m. snack, lunch,
etc. How many times a week would they have soda, candy, or alcohol?
Assess their eating habits…do they chew with their mouth open… is there noise when
chewing…are they sloppy, with food on their face, body, or table…. Is the tongue visible
while chewing… do they eat fast, slow, or in-between…do they drink often while eating
(indication of washing their food down)…do they experience gas, burping, hiccups, or
stomach aches…note specific comments made by patient or parent…do they gulp their
liquids when drinking or balloon their face while drinking, etc.?

Trauma
understanding.
affect therapy.
Generally, if several, or all of these, symptoms are present, air swallowing is likely an
issue. Not only will they be “unsightly” as they are eating, they will have gastric distress
in the form of gas, burping, indigestion, stomach aches, bloating, etc…

Extra oral Symptoms
Airway
1. Is there mouth breathing? Full-time or part of the time…visible to

you…is the patient aware of breathing through their mouth…is the parent or
spouse aware of it? A breathing mechanics and respiratory assessment can
provide a visual graphic picture of each breath – relative to optimal
breathing.
2. Is there nasal breathing…full or part time? If mouth breathing is present,

can you detect if any air is capable of being moved through the nose. Use
a mirror held under the nose. Test each nostril separately. You can also
use a pulse-oximeter to indicate blood oxygen levels and a capnogram to
indicate the body’s ability to utilize this bonded blood. (a tool to show
parents evidence of mouth breathing).
3. What is the extent of congestion? Always…only at night…only in

a.m….seasonal…most of the time…etc. Has allergy testing been done…are
they under allergy treatment … if so, what is the medication or treatment
regime? Are any medications taken for congestion…if so, what is it?
4. Do you suspect an airway blockage? Is an ENT-airway evaluation

necessary to determine the extent of allergic rhinitis, deviated septum,
enlarged turbinates, polyps, enlarged adenoid or tonsillar tissue?
Remember, if they cannot move air through the nose, it will be impossible
to correct mouth breathing, thereby, rendering treatment impossible or
greatly modified. Allergic rhinitis can often be treated in therapy with
diaphragmatic breathing techniques, nasal washing, and body posture
exercises, but be sure you anticipate nasal congestion as a real concern.
5. Is the mouth open at night? Is there snoring, drooling, night tooth

grinding (bruxism), restless sleep, and/or sleep apnea?
Determine the night sleep positions. Do they sleep on their back,
stomach (which side of face is on the pillow), hands or arms under their
face or pillow, do they hold any objects as they sleep?
Sleeping Position: There are two schools of thought in this regard, and both
have sound and valid reasons for their positions.
Snoring, drooling, night tooth grinding, restless sleep, and sleep apnea are a
result of weak oral-facial musculature, improper tongue posture, incorrect
breathing, and the inability of the oxygen which is already bonded to the
hemoglobin in the blood to break free and enter the cells. Mouth breathing
causes hypocapnia, and this low level of CO2 in arterial blood is responsible for
the tight oxy-hemoglobin bond.
Back Sleeping
When musculature is compromised and there is a lack of jaw stability, sleeping on
the back provides a more stable position for the jaw and associated muscles, as
side sleeping could tend to distort the jaw position, especially if a hand is placed
under the cheek or pillow. Sleeping on the back however promotes open mouth
breathing, obstruction of the airway due to the gravitational effect of the tongue,
soft palate and uvula falling back into the airway, and people snore and/or suffer
sleep apnea to a greater degree when in this position.
Side Sleeping
The airway remains open sleeping on the side. A suitably sized or contoured
pillow, with a stabilizing oral device will support the jaw and facilitate a good
patient airway.
The top leg should rest on the top of the other leg, not thrown over to the side…
the pillow should be on the ear, not the side of the face … no hands under the
face or pillow.
Adjustable water pillows have proved to be particularly effective in these

instances.
Habits
Determining habit patterns and correcting them is imperative to your therapy
success. This is one area often overlooked. Just as sleeping posture can
influence facial and dental arch form, so can habits influence facial-arch form,
head-neck-body posture, and the ability of muscles to function normally.
1) Thumb, finger, tongue, pacifier, blanket, object sucking:

i. Determine what is being sucked, the frequency of sucking, the
duration of sucking, and the force of sucking. Ask the patient if
he/she has ever wanted to stop … note response …. Ask, “If I have a
method that could help you stop in 1-2 days, would you be
interested?”... note response. Remember, if they truly DO NOT
DESIRE TO STOP, you should not proceed with therapy. However,
often, by the time you reach the end of the consultation, they
understand more about their problem and what can be done about it,
and are willing to proceed. Their fears and the “not knowing how to”
stop was influencing their decision originally.
2) Nail or cuticle biting

i. Did they previously bite, do they know, to what extent, and have
they tried to stop?
3) Lip, cheek, tongue, knuckle…biting or sucking?
Extra-oral Symptoms
Airway
breathing.

use a pulse-oxymeter to indicate blood oxygen levels.
a.m….seasonal…most of the time…etc. Has allergy testing been done…are


face or pillow, do they hold any objects as they sleep?
Sleeping Position: There are two schools of thought in this regard, and both
have sound and valid reasons for their positions.
Snoring, drooling, night tooth grinding, restless sleep, and sleep apnea are a
result of weak oral-facial musculature, improper tongue posture, incorrect
breathing, and the inability of the oxygen which is already bonded to the
hemoglobin in the blood to break free and enter the cells. Mouth breathing
causes hypocapnia, and this low level of CO2 in arterial blood is responsible for
the tight oxy-hemoglobin bond.
Back Sleeping

Side Sleeping
patient airway.
face or pillow.

instances.
Habits


they tried to stop?

i. Ask if they ever bite the lower lip…anterior, side, or inside… or suck.
Do they bite or suck the cheeks between their teeth…both, left, or
right. Do they bite or suck their tongue…between the teeth
anteriorly or laterally…or curled back against palate…or between the
lips. Do they hold the tongue forward or to the side when
concentrating? *Often, they are not aware they even do these
things, but you will observe them during the consultation…or the
parent will comment. *It has never been documented in writing, but
we have often observed that when there is a unilateral cross bite,
they will bite the lip, cheek, or tongue on the same side which brings
the jaw, as closely as possible, back to a centric position. It appears
it is the body’s way of attempting to stabilise the jaw function.
7) Pen, Pencil, Object Biting or Sucking:

i. Do they bite the ends of pens or pencils…or hold them crosswise
between the teeth. Does “everything” go into the mouth…hands
always by the face or mouth…?
8) Gum chewing, Smoking, Pipe biting…

i. Gum chewing is extremely injurious to the jaw joints over a period of
time. It is usually unilateral and, therefore, impacts oral-facial
musculature…the holding of a cigarette, cigar, or pipe between the
lips or teeth is also an impacting force.
9) Leaning …. Phone use:

i. Leaning on the face is damaging to the jaw joints, forces facial
muscles into abnormal positions, affects the ability to bite and
swallow, affects the bony growth of the face and influences the bite
development, and affects the head-neck and body posture… the
phone does the same. Tucking the phone between the ear and the
shoulder further distorts posture and exacerbates the problem.
Posture of the head, neck and body:
1. What is the carriage of the head relative to the body?

2. What is the carriage of the upper torso relative to the head and body?
3. Have the patient stand … back toward you…note shoulder and hip position
relative to the rest of the body. Have patient turn sideways…note head and
shoulder posture relative to the rest of the body.
4. Is the patient concerned about his/her posture?
5. Is the parent concerned? … note comments made.
6. Do they slouch in chairs? … how do they sit at the table?
Facial Data
1. Symmetry of the Face:
Is there a long-face syndrome present?

Is there a facial asymmetry?
Are there any other pertinent facial observations?
2. Lip structure:
Is there a short upper lip tendency?

Are the lips flaccid, thick, full, bottle-mouth in appearance?
Does the lower lip hang and evert?
Is there an obvious lip crease?
Do the lips chap, crack open, or appear dry?
Are there corner lip sores or mouth sores?
Do they often use a lip balm?
What is the lip strength…note # of pounds per square inch
* Normal lip strength is between 1800 – 4500 Gm.+
Is there a GRIMACE of the lips during the swallowing?
3. Mentalis Structure:
At rest, is there tension in the mentalis muscle?

During the act of swallowing, does the mentalis tighten?
In order to close the lips, does the mentalis have to tighten?
*Often there are many facial habits involving the lips and mentalis…note any you
observe during the consultation.
4. Masseter-Post-temporalis:
Palpate the masseter muscles. Note degree of strength. If the function is

symmetrical, which side is strongest, weakest, or non-functional?
Palpate the post temporalis muscles. Note the function. When the bite is correct
the post temporalis muscles will show a strong response. Otherwise, observe the
carriage of the mandible forward with little or no post temporalis function. Often
the masseter muscles will be hyper-strong.
Extra-oral Data
1. The Temporomandibular Joint:
Palpate the temporomandibular joints…have the patient open wide and

`close…note any noise-popping, cracking, crepitus…
Observe any jaw deviation during opening and closing…does the jaw shift
forward or pull to the left or right?
Palpate, with your little fingers, inside the ears…again, have the patient open and
close…note your findings.
Note the presence of pain symptoms…location, duration, treatment that the
patient administers, and the type of pain.
Ask about intervention therapy that has been performed in the past or at
present…use of splints, night-guards, injections, medications, muscle relaxants,
surgery, etc.
Does the bite appear over-closed (deep over bite)…the lower teeth will disappear
under the upper teeth in a biting position.
**In the presence of an over-closed bite, the tongue will place itself between the
teeth in an attempt to gain vertical dimension and help to keep a degree of
harmony within the joint space. It is very difficult to achieve good therapy results
in this environment without dental intervention to achieve a better occlusal
relationship.
It is felt by many TMJD clinicians that 85% of TMJD patients have oral-facial

muscle dysfunction. Which came first is always an issue, but therapy is indicated,
regardless, in order to treat the patient successfully. It is important to realize,
however, that due to pain symptoms, muscle stress and fatigue, your therapy
regimen will have to be altered to match the patients’ capabilities. Some exercises
will be contra-indicated.
2. Pain Symptoms:
Note the location of pain, the duration, and the treatment used to remedy.
Masseter, nasal sinus, forehead, eyes, temples, ears, top of head, back of head,
neck, shoulders, arms, hands, back, legs, feet….Note if any ear ringing or buzzing
is present and the duration.
3. Attrition:
Bruxing…note if any tooth wear is obvious, and to what extent. What treatment
has there been to treat the problem?
Clenching…note extent, time of day, type of activity, previous treatment.

4. Speech:
Has there been any previous therapy? … note when, duration, and for what
sounds or problem. Is the patient still in therapy and with whom? …
Communicate with that therapist.
Is there anything about the patient’s speech that the patient, parent, or spouse
would like to see changed?…note comments.
Have patient say words with these sounds…“S”, “L”, “T”, “D”, “N”, “SH”, “CH”,
“TH”, “R”, “G”, “K”, “P”, “B”, “M”, and “W” words.
While they are saying those sounds…observe:
1. Jaw movement forward or laterally.

2. Tongue placement during sounds…correct? Is there movement forward
against the teeth, forward between the teeth (normal only on a TH sound),
or laterally between the teeth, unilaterally or bilaterally?
3: Sound distortion?
4: Facial and/or lip adaptations?
5: Wetness and/or bubbles
6: Lack of clarity, poor projection of air, mumbling of words?
7: Head posture or body gesturing?
Do you feel that additional speech therapy will be necessary?…Make a referral at

the appropriate time; if you are a speech therapist, incorporate speech when
muscles are able to accommodate the intricacies of speech; or communicate with
current therapist if the patient is involved in speech therapy.
5. Orthodontic History:
Name of orthodontist? … What were his/her recommendations to the patient?

What has been the sequence of treatment: date began? palatal expansion?
Partial or full braces? Headgear, neck gear, elastics, positioner, retainers,
functional appliance, Crozats, braces removed, orthodontic relapse noted,
retreatment performed, if so, when, how many times, patient’s present concerns?
6. Pills:
Note any difficulty of patient taking a pill.
What does he/she have to do in order to “get it down”?
Do they refuse to take a pill?
*Once therapy is completed, the patient will be able to take a pill.

It may take patient instruction with some “tic-tacs”, but they will be excited once they do it and find
how easy it actually is. It is no more different than the eating-drinking process, once learned.
* In the presence of a deep-seated “fear” phobia, hypnotherapy or counseling may be required.
Intraoral Examination
Resting tongue posture:
 Determine the awareness by the patient.

“Is your tongue in the bottom, middle, or top of your mouth”?
“Where do you feel the tip of your tongue resting: is it against your upper
front teeth, your lower front teeth, between your the teeth, or against both
your upper and lower teeth?”
“Where do you feel the sides of your tongue…does it fit inside your teeth or is
it spreading between your teeth…to one side or both sides?”
 Note your visual observation of the tongue posture.

 Note the parent or spouse’s observation of the tongue.
Frenulum:
 Lingual Frenulum:
Have the patient lift the tongue to touch the palate. They should be able to open
1½ inches with the mandible dropped and the tip of the tongue against the
incisive papilla.
If there is restriction, the tongue generally is pulled down in the center causing
the tongue to appear “heart shaped”. The mandible will have to

elevate in order to allow the tongue to touch the palate.
Lingual Frenulum surgery (frenectomy or frenotomy) is indicated where there is a

definite restriction. Therapy will be difficult or impossible, otherwise.

 Mandibular labial frenulum:
Check the mandibular labial frenulum for restriction. This can cause the lip to pull
in too tight stopping correct resting lip posture. This can also effect the
periodontal tissue causing stripping. Surgery is indicated if the frenulum is too
short/tight.
 Maxillary labial frenulum:
Check the maxillary labial frenulum for restriction. If the attachment is too thick
or too low between the maxillary centrals, it can cause separation of the centrals,
restriction of the upper lip into a shortened upper lip appearance, and/or affect
the lip tone. Surgery is indicated if the frenulum is too short, thick, or tight.
Tongue Tone/Markings:
 Tongue tone or markings:

 Can the patient POINT the tongue into a “V” formation?
 Is the tongue flaccid?
 Is there scalloping along the lateral tongue borders? (Clenching)
 Is there linea alba (tongue ridge) along the lateral or anterior borders of the
tongue? … note if the ridge is thick, fibrous, or red in color.
*Cancer of the tongue is possible where trauma takes place over an extended
period of time.
 Note any other specific abnormalities.
Cheek Markings:
 Note linea alba (cheek ridge)…position, extent of, texture.

 Note any other tissue abnormalities…occasionally surgery is necessary to
remove excess pieces of tissue. Contact other professionals if you have
concerns.

Palate:
 Note width and depth of the palate.

*Be aware that a palate that is too narrow to encompass the tongue
or too vaulted to allow palatal tongue coverage, will make therapy nearly
impossible.
 Note status of the rugae.

*Rugae that are thick, deeply lined, or boggy looking, have not been
massaged by the tongue during normal swallowing and resting function.
 Note the ability of the soft palate and uvula function. Have the person say
“AHH”…do the soft palate and uvula pull posteriorly? Often there will be little or
no ability to function. This is often the patient who has snoring and/or sleep
apnea symptoms. The soft palate and uvula can be “trained” to function with
therapy techniques as you work on tongue posture.
Occasionally you will see a uvula that is too long. The need for Surgery may be
indicated.
 Determine whether you believe that palatal expansion might be necessary …

contact the referring clinician.
Tonsils:
 Observe the size of the tonsillar mass. Have they been removed? At what age?
Are they currently enlarged and to what extent?
 Are they fibrous and hard in appearance?
 Is there concern about pushing the tongue into an anterior resting posture?
 Is surgery a consideration? … contact referring clinician … discuss a possible ENT
evaluation.

* You might have to make a value consideration if
tonsils are grossly enlarged and the removal of them
is not approved. Therapy generally is affected, with
marginal results being a possibility.
* Enlarged tonsils that are red and irritated in

appearance will often begin to decrease in size as the mouth
breathing is corrected and orofacial muscle balance begins
to change.
* The diet may need modifying. Often the patient is allergic to dairy products, heavy
sweets, caffeine, and/or food additive intake, and/or other items such as wheat or corn.
Through the process of elimination-cause-and-effect, the congestive irritation process
can be influenced. Often, the patient knows what the allergies are, but discussion with
the referral source is ALWAYS the best!
 Note past and present infections, medications taken, frequency of infections, and
degree of severity.
 Note any history of adenoid tissue concern. Is referral for evaluation necessary?
Adenoid tissue mass effects airway potency. Contact the referral source. Removal
is often necessary in order to achieve nasal breathing, however, as in the tonsils,
if the enlargement is soft and inflamed, they sometimes decrease in size with the
airway techniques utilised in therapy.
 REMEMBER that the tonsils and adenoids are filters and part of the lymphatic
system. The lymphatic system is an ‘open’ system, as opposed to the circulatory
system which is ‘closed’. The only way that lymph can reach the nodes in order
to flush them is through muscle movement, and the prime muscle of lymph
movement is the DIAPHRAGM. Mouth breathers usually have minimal
diaphragmatic movement and this lack of lymph “push”, coupled with the
overloading of the filters through mouth breathing is the largest single
contributory factor to enlarged and infected tonsils and adenoids.
 Remove them and there is a strong likelihood that they will grow back.
Tori:
 Observe any bony enlargements on the palate. These are “Tori”.

* If these growths are too large, they can affect the ability of the tongue to
contact the palate in a normal resting and swallowing process.
* Surgery may be indicated…marginal therapy results would have to be otherwise
anticipated.
 Mandibular Tori:
Note the presence of tori along the lingual or labial surfaces of the mandibular
arch.
*Their presence generally will have no effect on therapy. They are difficult,
when dealing with a lower partial or denture.
Occlusion:
 Observe the dental bite…note the classification of occlusion.
Class I, Class II, Overjet, Overbite, Class III, Pseudo Class III, Crossbite,
Unilateral or Bilateral, Over-closed bite…
 Note the status of the dental arch. Missing teeth, extent of reconstruction
with crown and bridgework, if there are partial or full dentures present,
periodontal disease, gum recession, tooth wear, tendency to decay, and the
status of their oral hygiene.
 Note discussion by patient of specific dental concerns, previous treatment,

failures, etc.
Deglutition:
 Test the swallow visually…palpate the hyoid area…break the lip seal during
the swallow and observe the tongue posture…and do a squirt-swallow check
of the swallow.
Place a cheek retractor into the lips. Ask the patient to swallow as normally
as possible. Observe the tongue movement.
 Offer a cracker or… Observe the swallow during food intake and chewing.
 Offer a cup of water (a clear cup is best). Observe the tongue, lips, and
swallowing process.
 Note all observations.
Case Presentation
Benefits:
It is essential that you stress the benefits and the valuable end products of
therapy.
You have been with the patient a while…from the clues you have gathered,
present the benefits that suit the patients likes and desires… not yours! Present
benefits instead of technical data. They are most often concerned with how it will
affect their appearance, their smile, their finances in the future, the saving of
their teeth, or even being able to be better kisser!
Utilize Visual Aids. Show PHOTOGRAPHS!! Grid postural photos as well as mouth
pictures. (One picture is worth 1000 words!)
Explain briefly their involvement…how many visits, how many times a day for
practice, approximate length of therapy involvement.
Get a commitment from the patient…written is best. Use a contract for both
patient and parents.
Present the financial terms and get a signed commitment.
Arrange their therapy appointment(s).
Congratulate and thank them.
***If you document cases with photographs, we suggest taking them before you check the
swallow.
*** If you are documenting with photographs and wish to use them for lectures, advertising,
promotional purposes, or any form of visual or print, be certain to have the patient/parent sign a
“consent to use form”.

Clinical Aspects of Oral Myofunctional Therapy
We use a positive approach to eliminate such oral dysfunctions as mouth breathing,
open mouth posture with lowered tongue position, and tongue thrust by strengthening
the muscles of the facial network. This is a psycho-physiological approach which is
aimed at coordination of muscle groups as routine for normal deglutition and articulation
from a positive reinforcement exercise regimen.
Therapy is an eight-step program (not necessarily an eight-week program).
1. Therapy is directed at the tip of the tongue, establishing the placement of the
tongue to achieve a labioglossal seal.
2. Aimed at strengthening the musculature that elevates and supports anterior

tongue segments.
3. Repositioning the posterior portion of the tongue for resting and for speech.
4. Integration of new swallow with correct resting posture of the anterior

segment of the tongue.
5. Establishing new patterns of deglutition on a conscious level.
6. Establishing new patterns for subconscious control of chewing, swallowing and

tongue resting position.
7. Determination of the correct subconscious tongue position for resting posture.
8. Final concerns and evaluation of total pattern of the facial musculature.
Recheck at any change in the oral environment: Bands off, retainer, extractions, etc.,
or if the referral source desires. Patient is dismissed from therapy when at least one
recheck, after a three month lapse, demonstrates correction and proper use of
muscles to the complete satisfaction of clinician and patient.

Evaluation for Myofunctional Referral
Indications:
Any of the following may be an indicator:
 Mouth posture open, mandible dropped

 Lack of muscle tone in the lips and face
 Tight upper lip, large lower lip
 Open bite
 Chapped lips – lip licking
 Lower lip wedged under upper teeth
 Pursing of lips for swallowing
 Lack of molar contact
 Mouth breathing
 Nail biting
 Short lingual frenum
 Trichotillomania
Speech:
 Inter-dentalized articulation (L, S, Z, SH, CH, J).
 Mandibular thrust (S, Z, SH, CH, J).
 Hyper or hypo-nasality.
Therapy consists of exercising facial and tongue muscles to achieve correct tongue
position for swallowing with the molars closed and a correct tongue rest posture.
The therapy is similar for myofunctional patients, thumb or digit-suckers, denture

patients, snorers, TMJ disorders and Trichotillomania patients, in that repositioning of
the tongue and the strengthening of facial and neck muscles is essential for them all.

Guidelines for Recognizing Orofacial
Muscle Imbalance
I. GENERAL OBSERVATIONS
1. Is there a tongue protrusion and an opening of the lips when at rest?

2. Is the patient a habitual mouth breather?
3. Does the patient smoke a pipe?
4. Does the patient use a pacifier?
5. Does the patient suck his thumb, finger, knuckle, blanket or lips?
6. Does the patient chronically bite his nails?
7. Does the patient exhibit an incompetent upper lip (thick, rolled) and/or an
everted, rounded pattern to the lower lip structure?
8. Does the patient exhibit an over-developed mentalis muscle?
9. Is there a noticeable speech defect?
10. Does the patient exhibit a facial grimace during the act of swallowing?
11. Are the nares thick and rounded?
12. Does the patient have difficulties swallowing pills or firmer foods?
13. Does the patient have recurrent headaches?
14. Does the patient have stomach pains or cramps after eating (aerophasia)?
15. Does the patient pull eyelashes or hair?
II. PHYSICAL EXAMINATION
1. Is there a high and narrow palatal arch?

2. Are the rugae sharply defined?
3. Is there an ankylosed tongue or thick, foreshortened frenums (lingual,
maxillary, or mandibular)?
4. Is the tongue scalloped (indicates clenching)?
5. What is the patient’s occlusion?
6. Is there a cross bite pattern?
7. Is the tongue burning or ulcerated?
8. Are there Diastemas?
9. Is there balanced masseter function bilaterally?
10. Are there appreciable deposits of dental plaque and calculus?
11. Is there enough airway adequacy (tonsils and nasal turbinates)?
12. Is there pain in the area of the ear or TMJ?
13. Is there facial symmetry?
14. Is there a skeletal problem?
15. Is there a gag reflex? Hyper? (or No reflex)?
16. Are there wear facets on the occlusal surfaces?
17. Is the patient able to maintain suction with his / her prosthesis?
18. Does the patient wear an orthopedic or functional appliance?

Symptoms of Orofacial Muscle Imbalance
1. Mouth breathing
2. Poor posture of the tongue at rest (often visible or applying intra-oral
pressure)
3. Abnormal swallowing pattern with anterior or lateral pressures or both
4. Activation of facial muscles during the act of swallowing (grimace)
5. Lip imbalances: Weakness, puffiness, dryness, cracking, corner sores
6. Tongue, cheek and/or lip markings--scalloping or ridges
7. Narrowness of the dental arches
8. Imbalanced use of the masseter and postemporalis muscles
9. Restrictive lingual or labial frenum activity
ASSOCIATED SYMPTOMS:
1. Speech: Sound distortion, mumbling, slurring, bubbles, wetness, facial

muscle accommodation / restricted use of lips, visibility of
tongue--forward or laterally
2. Dental Arch: Poor development of dentition, orthodontic difficulty in case
completion, orthodontic relapse / surgical relapse, bruxing /
clenching tendency, mouth burning / drooling, forward carriage of
mandible at rest / during speech / when smiling, prosthetic appliance
difficulties, occlusal equilibration difficulties, poor oral hygiene /
continued periodontal breakdown
3: TMJ: (Temporomandibular joint) Jaw sounds / jaw deviation /
difficulty opening, facial – head – neck – shoulder pain, ear ringing
or buzzing / pain
4: Allergies: Mouth breathing, persistent congestion, shallow breathing,
persistently enlarged tonsils, undeveloped nasal – sinus area
5: Eating &
Digestion Open mouth chewing / noise / sloppiness / drinks often /
insufficient chewing, gulping / drooling while drinking, eats too fast /
slow, frequent gas / burping / stomach aches / and/or hiccups,
prefers soft foods
6: Face: Imbalanced facial contours, forward / side carriage of head,
facial tension / premature lining, long / flat appearance
7: Habits: Biting / sucking of lip, cheek, tongue, thumb, finger or objects;
leaning, extensive phone use, nail / cuticle biting, poor body
postures,
8: Ailments Chronic tiredness. Snoring. Sleep Apnea. Lack of stamina and
energy. Lactic acid buildup when exercising. Night-time toilet trips.
Bed wetting. Poor concentration. Irritable. Disturbed sleep pattern.
Daytime sleepiness. Breath-holding while working or concentrating.

What to Look For…
 Mouth Breathers
 Allergies – red noses, watering eyes
 Asthma, anxiety/panic attacks
 Enlarged/Irritated Adenoids / Tonsils /

Turbinates
 Nasal Congestion
 Snoring, Sleep Apnoea

 Poor Peri-Oral Habits

 Open Mouth, everted lower lip
 Chapped Lips and Face

 Calluses on Thumb or Fingers, Secondary to
Sucking
 Nail Biting

 Tongue Thrust
Clenching or Bruxing
 Difficulty with Eating and Digestion
 Anatomical Abnormalities
 Shortened Lingual Frenulum
 Protruded Lower Lip
 Short Upper Lip

 High/Narrow Palate
 Malocclusion
Ear – Nose – Throat

 Mouth Breathing and Abnormal Swallowing Patterns.
 Thumb Sucking (Relieves Eustachian tube pressure)
 Turbinates…swollen?
Prevention – Intervention
 Postural – Structural Evaluation

 Gait Analysis
 Spine and Extremity Analysis
 Muscle Balance Analysis
 Facial Muscle Evaluation
 Lingual Evaluation
 Habits – pacifiers and bottles (intensity and duration)
 Tongue – test swallowing, speech
Treatment
 Oral Myofunctional Therapy

 Postural Education
 Exercises to Improve Muscle EQUILIBRIUM
 Referrals to other Professionals
 Posture and breathing retraining

Appropriate Case Selection
It is imperative that you are aware of limitations that will compromise therapy:
1. Arch width
2. Nasal airway blockage – may need to undertake breathing retraining in the first
instance
3. Dysfunctional breathing
4. Lingual frenulum restriction
5. Severity of dental arch formation
6. Neurological and/or muscle involvement
7. Allergies or other medical conditions
8. Medications being taken
9. Hyperactivity, patient personality limitations, attitude
10. Lack of patient and/or parent commitment
11. Your “connection” with the patient…we cannot treat everyone.
Do not compromise your success!

“No Win” Therapy Cases
Limitations
a. Large tonsils *
b. Large adenoids *
c. Severe allergies *
d. Severely restricted lingual frenum
e. Severely handicapped patient
f. Extreme malocclusion
g. Severe pain
h. Chronic illness
i. Dysfunctional breathing *
Age
Schedules
Economics
Emotional Issues *
a. Personal
b. Family
c. School
Non-Compliance
Reasons not known
* Breathing Retraining has been known to help patients with these symptoms and may need to be
undertaken, prior to commencing an Orofacial Myology training program. Breathing Retraining is also ideal
for patients who exhibit anxiety related symptoms.

How Can Patients and Their Family Assist in Treatment?
Develop an awareness of the appropriate musculature. Tone the normal neuro-
musculature. Assist in making the new neuromuscular patterns habitual.
Success Factors
 Motivation, attitude and attention span of the patient
 Age and maturity of the patient – Early identification and treatment is best.
Correcting the muscle function during the growth and developmental years
encourages normal dental growth. Abnormal habits are not as ingrained as
they may later become
 Severity of the problem(s)
 Control/coordination of muscle function
 Control of other ongoing pernicious habits (thumb/finger sucking, etc.)
 Skeletal structure of patient, including the relationship of the upper and

lower jaws
 Restoration of functional breathing mechanics and balanced biochemistry

Information and Instructions to
Patients Regarding Swallowing
Swallowing is something we take for granted, yet it is a very interesting and influential
factor regarding proper function and stability of the chewing system; thus, we
constantly work to help our patients learn to swallow correctly. Besides the swallowing
of food and liquids, there is also what is called an "empty swallow" which normally
occurs several hundred times a day.
The empty swallows are part of normal. human function; for example, they drain saliva
through the mouth. Also, they are very important in stabilizing and maintaining proper
function and positions of the teeth and jaws. If a person did not swallow periodically to
move saliva that is manufactured by the saliva glands, they would drool which might be
a bit embarrassing as it does not fit the definition of proper etiquette.
The swallow is important so that proper function and stability of the teeth and jaws can
occur. In an empty swallow, the teeth come together for a very short period of time
(less than a second) and at that time, the powerful chewing muscles, for example, the
masseters, are active.
The teeth are pressed together. Although the duration of the swallow is very brief, the
force delivered to the teeth and to the system is significant, and frequent swallows
throughout the day multiply the effect. In an ideal circumstance, these empty swallows
are the only time when the teeth come together.
Why is it important to swallow properly?
When the teeth are forced to the tight position and muscles are activated, this reinforces
and stabilizes the tooth positions and the positions of the jaw joints and all functioning
parts of the chewing system. It is important for our patients to learn this empty swallow
properly; and although it is a subconscious act, if learned conscientiously, it will become
a habit.
A simple way to test for and to learn the tooth together swallow is: to place
fingers on either cheek slightly below and in front of the ear, squeeze the teeth
together… you can feel the powerful chewing muscle bulge. This muscle should
bulge for a fraction of a second.
Swallowing Disorders
Difficulty in swallowing (dysphasia) is common among all age groups, especially the
elderly. The term dysphasia refers to the feeling of difficulty passing food or liquid from
the mouth to the stomach. This may be caused by many factors, most of which are
temporary and not threatening. Difficulties in swallowing rarely represent a more serious
disease, such as a tumor or a progressive neurological disorder. When the difficulty does
not clear up by itself in a short period of time, you should see an otolaryngologist head
and neck surgeon.
How You Swallow
People normally swallow hundreds of times a day to eat solids, drink liquids, and
swallow the normal saliva and mucus that the body produces. The process of swallowing
has four stages:
1. The first is oral preparation, where food or liquid is manipulated and chewed in
preparation for swallowing.
2. During the oral stage, the tongue propels the food or liquid to the back of the
mouth, starting the swallowing response.
3. The pharyngeal stage begins as food or liquid is quickly passed through the
pharynx, the canal that connects the mouth with the esophagus, into the
esophagus or swallowing tube.
4. In the final, esophageal stage, the food or liquid passes through the esophagus
into the stomach.
Although the first and second stages have some voluntary control, stages three and four
occur by themselves, with conscious input.
What Causes Swallowing Disorders?

Any interruption in the swallowing process can cause difficulties. It may be due to
simple causes such as poor teeth, ill-fitting dentures, or a common cold. One of the
most common causes of dysphasia is GERD (gastro-esophageal reflux). This occurs
when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other
causes may include: stroke; progressive neurological disorder; the presence of a
tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat,
or esophagus; or surgery in the head, neck, or esophageal areas.
Symptoms
Symptoms of swallowing disorders may include:
 Drooling;
 A feeling that food or liquid is sticking in the throat;
 Discomfort in the throat or chest (when gastroesophageal reflux is present);
 A sensation of a foreign body or "lump" in the throat;
 Weight loss and inadequate nutrition due to prolonged or more significant
problems with swallowing; and
 Coughing or choking caused by bits of food, liquid, or saliva not passing easily
during swallowing, and being sucked into the lungs.

Who Evaluates and Treats Swallowing Disorders?
(This is ALWAYS done by a SPECIALIST MD or Speech Pathologist who is
TRAINED in this specific area. Orofacial Myologists DO NOT treat Dysphagia
unless they have the credentials to do so!)
When dysphasia is persistent and the cause is not apparent, the otolaryngologist head
and neck surgeon will discuss the history of your problem and examine your mouth and
throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope),
which provides vision of the back of the tongue, throat, and larynx (voice box). If
necessary, an examination of the esophagus, stomach, and upper small intestine
(duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These
specialists may recommend
X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is
done by a radiologist.
If special problems exist, a speech pathologist may consult with the radiologist
regarding a modified barium swallow or video-fluroscopy. These help to identify all four
stages of the swallowing process. Using different consistencies of food and liquid, and
having the patient swallow in various positions; a speech pathologist will test the ability
to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems
from the nervous system, perhaps due to stroke or other neurological disorders.
Possible Treatments
Many of these disorders can be treated with medication. Drugs that slow stomach acid
production, muscle relaxants, and antacids are a few of the many medicines available.
Treatment is tailored to the particular cause of the swallowing disorder.
Gastro esophageal reflux can often be treated by changing eating and living habits, for
example:
 Eat a bland diet with smaller, more frequent meals;

 Eliminate alcohol and caffeine;
 Reduce weight and stress;
 Avoid food within three hours of bedtime; and
 Elevate the head of the bed at night.
If these don't help, antacids between meals and at bedtime may provide relief.
Many swallowing disorders may be helped by direct swallowing therapy. A speech
pathologist can provide special exercises for coordinating the swallowing muscles or re-
stimulating the nerves that trigger the swallow reflex. Patients may also be taught
simple ways to place food in the mouth or position the body and head to help the
swallow occur successfully.
Some patients with swallowing disorders have difficulty feeding themselves. An

occupational therapist can aid the patient and family in feeding techniques.

Signs and Symptoms of Occlusal Disease
Sign: Evidence which is perceptible to the examiner as opposed to sensations

experienced by the patient.
Symptom: subjective evidence (sensations) which the patient reports.
Tooth Signs: Tooth Symptoms:

Facets Sensitivity to hot and cold
Hyper-eruption Sensitivity to biting or chewing
Cusp Fracture Spaces in front teeth
Split tooth Broken tooth
Sensitive to percussion
Splaying
Sensitivity to hot and cold
Mobility
Hyper-cementosis
Root-resorption
Pulpal Calcification
Open
Copyright 2014 –Contacts
Coulson Institute of Orofacial Myology 85
Orthodontic technology is a specialty of dental technology that is concerned with the
design and fabrication of dental appliances for the treatment of malocclusions, which
may be a result of tooth irregularity, disproportionate jaw relationships, or both.
There are three main types of orthodontic appliances: active, passive and functional. All
these types can be fixed or removable.
An active appliance is a device used to apply forces to the teeth to change the
relationship of the teeth.
Removable active appliances
 Expansion and Labial Segment Alignment Appliance (ELSAA)
Fixed active appliances
 Pin and Tube Appliances
 Ribbon Arch Appliances
 Begg Light wire Appliances
 Edgewise Appliances
 Pre-adjusted Edgewise Appliances
 Self-ligating Edgewise Appliances
 Bi Helix
 Tri Helix
 Quad Helix
 Rapid Maxillary Expansion Appliance (RME)
 Tip-Edge Appliance
Passive Appliances
Passive appliances include space maintainers and retainers
Removable passive appliances
 Hawley Retainer
 Begg Retainer
 Vacuum Formed "Essix" Retainer
Fixed passive appliances
 Bonded "Twistflex" Retainer

 Fixed Space Maintainer
Functional appliances
Also known as dentofacial orthopaedic appliances, these appliances utilize the muscle
action of the patient to produce orthodontic or orthopaedic forces.
Introduction and Definition
Definition OF Functional Appliances: A functional appliance is an appliance that produces

all or part of its effect by altering the position of the mandible/maxilla.
Indications and Timing of Treatments and Types of Malocclusion
Removable functional appliances
 Andresen Appliance- This is to reduce the overbite, making the molars over-erupt.
 Bionator — Bionators initially look like a sort of combined upper and lower Hawley
retainer, but do not fasten to the teeth and are not used for post-brace removal
treatment. Bionators are held in the mouth within the space that the teeth
surround when biting. They are used to expand the palate and create space for
incoming teeth.
 Biobloc — Biobloc is an appliance used to posture forward the lower jaw.
 Clark Twin Block — this appliance incorporates the use of upper and lower bite
blocks to position the mandible forward for skeletal Class II correction. The
appliance was first developed by Scottish Orthodontist William Clark and
Orthodontic Technician James Watt in 1977. The Twin Block has become the most
popular functional appliance in use in the United Kingdom and is gaining
popularity across Europe and the USA.
 Bass Dynamax — this appliance is similar in principle to the Twin Block. It is

based around a prefabricated modular spring, built into a maxillary (upper)
occlusal splint. Two integral vertical springs make contact with a fixed lingual arch
or removable lower appliance to posture the mandible (lower jaw) forward for
skeletal Class II correction. This appliance was developed by London Orthodontist
Neville Bass in the early twenty-first century.
 Medium Opening Activator- This is a modified version of the Andreson appliance.

Orthodontic Headgear
Orthodontic headgear
Orthodontic Headgear is a type of appliance attached to dental braces that aids in

correcting more severe bite problems.
Headgear is an orthodontic appliance for the correction of Class II correction, typically

used in growing patients to correct overbites by holding back the growth of the upper
jaw, allowing the lower jaw to catch up.
The headgear can also be used to make more space for teeth to come in. The headgear
is then attached to the molars (via molar headgear bands & tubes), and helps to push or
draw them backwards in the mouth, opening up space for the front teeth to be moved
back using braces and bands.
Headgear needs to be worn approximately 12 to 22 hours a day to be truly effective in

correcting the overbite, and treatment is usually anywhere from 6 to 18 months in
duration, depending on the severity of the overbite and how much a patient is growing.
Orthodontic facemask and reverse-pull headgear
Facemask
Orthodontic headgear
Facemask or Reverse-pull Headgear is used to control the growth of the maxillary and
mandibular bones during orthodontic treatment.

The appliance is used in growing patients to correct under bites (known as a Class III
orthodontic problem) by pulling forward and assisting the growth of the upper jaw,
allowing the upper jaw to catch up.
Facemasks or Reverse-pull Headgear needs to be worn approximately 12 to 22 hrs to be

truly effective in correcting the under bite, usually anywhere from 6 to 18 months
depending on the severity of the bite and how much a patient is growing.
The appliance normally consists of a frame or a center bars that are strapped to the
patients head during a fitting appointment. The frame has a section which is positioned
in front of the patient’s mouth, which allows for the attachment of elastic or rubber
bands directly into the mouth area. These elastics are then hooked onto the child's
braces (brackets and bands) or appliance fitted in his or her mouth. This creates a
forward 'pulling' force to pull the upper jaw forward.
Fixed functional appliances
 Herbst Appliance: A Herbst Appliance corrects overbites by holding the lower

jaw in a protrusive position.[1] It is similar to the Twin Block Appliance except that
it is fixed in place and hence non-removable. This appliance is most commonly
used in non-compliant patients. The Herbst appliance is very effective in
correcting large overbites due to small lower jaws in patients that are growing. [2]
 Fixed Twin Block Appliance: The Twin Block appliance is a removable appliance,
and its high comfort level allows you to wear it 24 hours a day. This appliance
actually is made up of two separate appliances that work together as one. The
upper plate includes an optional expansion screw to widen your upper arch, if
needed, as well as pads to cover your molars. The lower plate includes pads to
cover your lower bicuspids. These two appliances interlock at an angle, and they
move your lower jaw forward and lock it into the ideal position when you bite
together. This new position, while temporary, will eventually become the
permanent corrected position.[3]

Swallowing Problems in Adults
Swallowing disorders, also called dysphasia (dis FA Yjuh), can occur at different stages
in the swallowing process:
 Oral phase -sucking, chewing, and moving food or liquid into the throat
 Pharyngeal phase -triggering the swallowing reflex, squeezing food down the
throat, and closing off the airway to prevent food or liquid from entering the
airway (aspiration) or to prevent choking:
 Esophageal phase -relaxing and tightening the openings at the top and bottom
of the feeding tube in the throat (esophagus) and squeezing food through the
esophagus into the stomach.
Some causes of feeding and swallowing problems in adults are:
 Damage to the nervous system, such as:
o Stroke
o Brain injury
o Spinal cord injury
o Parkinson's disease
o Multiple sclerosis
o Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

o Muscular dystrophy
o Cerebral palsy
o Alzheimer's disease
Problems affecting the head and neck, including:
 Cancer in the mouth, throat or esophagus

 Injury or surgery involving the head and neck
 Decayed or missing teeth or poorly-fitting dentures
Many other diseases, conditions, or surgical interventions can result in swallowing

problems, General signs may include:
 Coughing during or right after eating or drinking

 Wet or gurgling-sounding voice during or after eating or drinking
 Extra effort or time needed to chew or swallow
 Food or liquid leaking from the mouth or getting stuck in the mouth
 Recurring pneumonia or chest congestion after eating
 Weight loss or dehydration from not being able to eat enough
As a result, adults may have:

 Poor nutrition or dehydration
 Risk of aspiration (food or liquid entering the airway) which can lead to
pneumonia and chronic lung disease
 Less enjoyment of eating or drinking
 Embarrassment or isolation in social situations involving eating
For help, consult your doctor about the possible medical cause of the swallowing
problem. An ASHA-certified speech-language pathologist can perform an evaluation of
feeding and swallowing and provide treatment if appropriate. Many medical specialists
and other health care professionals may work together to evaluate and/or treat feeding
and swallowing problems.
A speech-language pathologist:
 Will take a careful history of medical conditions and symptoms

 Will look at the strength and movement of the muscles involved in swallowing
Will observe feeding to see your posture, behavior, and oral movements
during eating and drinking
 May perform special tests to evaluate swallowing
Treatment varies greatly depending on the cause, symptoms and type of swallowing
problem. A speech-language pathologist may recommend:

 Exercises, positions or strategies to help swallow more effectively
 Specific food and liquid textures that are easier and safer to swallow
Family members or caregivers can help:
 Ask questions to understand the problem and the recommended treatment

Assist in following the treatment plan:
o Help with exercises
o Prepare the recommended textures of food and liquid, making sure that
recommendations for eating safely are followed
o

Clinical Aspects of Orofacial Myofunctional Therapy
The Referral
A patient has been referred to you for treatment of oral-facial muscle imbalance. When
they arrange an appointment, gather information. A “telephone information slip” is
helpful to organize the date called, their name, age, the name of the referral source,
address and phone number, and details concerns. Establish a date for the consultation
and confirm that you will be sending them some information in the mail, part of which
they will bring back to the appointment with them (if your practice is to send a pre-
questionnaire).
Send them informative material pertinent to their needs, i.e. tongue thrust, thumb
sucking, speech, TMJ problems, etc. Include your pre-questionnaire form, an
appointment card noting the date and a personal note such as “see you soon”. If the
patient is a child, possibly send a sticker with their name on it. Establish a rapport right
from the start.
Next, discuss the patient with the referral source. It is most helpful to know in advance
the reason for referral, what course of treatment they are presently under, what
treatment is proposed, what the referral source shares as concerns, and valuable
person, family, or financial data that can be shared.
Call any other clinicians that might be involved in this patient’s case if necessary to
gather information.
Welcome Letter
Welcome,
You may be coming to our practice for a variety of reasons. Most commonly, patients
are referred for one of these:
 evaluation and treatment of tongue thrust

 symptoms of temporomandibular joint disorder
 to end a digit sucking habit
 to end a nail biting habit
 to deal with trichotillomania
 to assist in the treatment of Down syndrome
 to achieve proper tongue position in an effort to correct articulation errors
 to minimize snoring
For many years, dentists and orthodontists have been aware that pressure exerted by
the tongue can cause changes in dental structures. Only recently has this been the
subject of therapeutic evaluation and scientific investigation. As Orofacial Myologists,
we are responsible for the evaluation and treatment of the tongue and lip equilibrium.

At your initial appointment, your therapist will begin by taking a series of measurements
and photos of your face, lips and teeth, as well as general posture photographs to show
the relationship between your mouth, teeth, jaws and the rest of your body. Your
therapy plan will be explained to you in detail, and an indication will be given if
additional treatment from other specialised therapists is required. After answering any
questions you might have, you will be given the necessary supplies to start your
program. During subsequent visits, measurements and/or photos will again be taken
and compared with the initial measurements and/or photos to evaluate your progress
throughout your therapy.
The total number of therapy sessions required for correction of your particular problem
varies considerably from patient to patient. The probable number of visits necessary will
be determined at your initial evaluation and will be re-evaluated as therapy progresses.
Once treatment has been completed, it is important that a patient be observed for
occasional check-ups to monitor the continued proper use of the facial muscles.
We look forward to meeting you on ______, ________ at ________________.
Your appointment is scheduled with __________________________________.
The Consultation
The consultation is a time to gather information, establish rapport, diagnose symptoms,
outline recommendations, and educate the patient. It is important to remember that
you will have to teach this patient and be part of his or her life for several months. You
must be sure that you have not only the technical skills, but the motivational skills and
willingness to work with this individual. If you know you cannot, a referral to another
practitioner may be necessary.
Establish at the consultation whether this is the right timing for treatment with orofacial-
myofunctional techniques. Remember the “form determines function…function
determines form” module. If, for example, the palate is too narrow to encompass the
tongue, you can proceed with treatment with cooperation of the dentist/orthodontist.
Know your skills, know the environment necessary to perform your skills, and determine
IF you have a willing patient.
There is no hard-and-fast rule about the age limitation in orofacial-myofunctional

treatment. Education of the parents can begin pre-birth to acquaint them with skills to
prevent oral-facial muscle imbalances. Actual therapy has been performed with children
as young as two and adults in their 80’s. The program has to be modified depending on
the need, the attention span, the ability to cooperate, and the ability of the muscles to
perform.
At the consultation, you want to establish factors that could influence success.
Medical History
On a pre-questionnaire or verbally, establish a medical history. There are medical
conditions and medicines that can affect the position of the muscles and their ability to
function. Without knowing this in advance, you might assume you can “do” something
that the body will not allow?
Determine if any of the following are a concern: allergies, asthma, diabetes, epilepsy,
neurological or muscular diseases, hyperactivity, hypoglycemia, heart conditions, TMJD,
gastro-intestinal conditions, frequency of colds, ear infections, pain, dental decay, or
alcohol use, speech impediments, use of social type drugs, smoking, eating disorders,
and use of any types of medication.
Make note of areas that could affect your treatment regimen.
Birth History
Inquire of patient if there were any pre-birth problems, injuries, or drug use. What
happened during the birthing process? Was it an easy or hard labor, the extent of the
labor, were forceps utilized, was a C-section performed, were there any complications,
etc..
Pressures to the cranium pre-birth, or during the birthing process, can definitively affect
facial form, arch form, muscle position and function, and the over-all neurological
capability of the body. Cranial manipulation by a qualified clinician may be necessary
when this history is present.
Inquire as to how the baby was fed. If breast fed, ask for the duration. If bottle fed,
ask what type and duration. Was colic present and for how long? What was the
sleeping posture? Was thumb, finger, pacifier, blanket, teddy-bear, or tongue sucking
present and for how long? Were there learning disabilities, physical limitations,
coordination difficulties, speech disorders, or a history of allergies?
Proper breast feeding for two years is the feeding method of choice, but note that
“proper” breast feeding was stated. A child feeding from a breast that is engorged with
milk that squirts from the nipple will end up “drinking” and not “sucking”. The mother
should pump-off the initial heavy flow of milk first. The baby should also be held in a
more upright position rather than on its side. Using pillows is helpful for achieving this
posture.
If a bottle system is utilized, the NUK nipple and the CORRECTO bottle combination is
best. A better system is in the making at this time. Parents should be cautioned about
extensive time with any bottle. Breast feeding, if correct, continues to develop the oral
form, however, bottle feeding beyond 1-1½ years can be detrimental to arch form and
muscle function.
Trauma

understanding.
affect therapy.
Generally, if several, or all of these, symptoms are present, air swallowing is likely an
issue. Not only will they be “unsightly” as they are eating, they will have gastric distress
in the form of gas, burping, indigestion, stomach aches, bloating, etc…
Extra-oral Symptoms
Airway
breathing.

use a pulse-oxymeter to indicate blood oxygen levels and a capnogram to
indicate the body’s ability to utilize this bonded blood. (a tool to show
parents evidence of mouth breathing).

a.m.….seasonal…most of the time…etc. Has allergy testing been done…are


face or pillow; do they hold any objects as they sleep?
Sleeping Position: There are two schools of thought in this regard, and
both have sound and valid reasons for their positions.
Snoring, drooling, night tooth grinding, restless sleep and sleep apnea are a result
of weak oral-facial musculature, improper tongue posture, incorrect breathing,
and the inability of the oxygen which is already bonded to the hemoglobin in the
blood to break free and enter the cells. Mouth breathing causes hypocapnia, and
this low level of CO2 in arterial blood is responsible for the tight oxy-hemoglobin
bond.
Back Sleeping

Side Sleeping
patient airway.
face or pillow.

instances.
Habits



they tried to stop?

i. Ask if they ever bite the lower lip…anterior, side, or inside… or suck.
Do they bite or suck the cheeks between their teeth…both, left, or
right. Do they bite or suck their tongue…between the teeth
anteriorly or laterally…or curled back against palate…or between the
lips. Do they hold the tongue forward or to the side when
concentrating? *Often, they are not aware they even do these
things, but you will observe them during the consultation…or the
parent will comment. *It has never been documented in writing, but
we have often observed that when there is a unilateral cross bite,
they will bite the lip, cheek, or tongue on the same side which brings
the jaw, as closely as possible, back to a centric position. It appears
it is the body’s way of attempting to stabilise the jaw function.
13) Pen, Pencil, Object Biting or Sucking:

i. Do they bite the ends of pens or pencils…or hold them crosswise
between the teeth. Does “everything” go into the mouth…hands
always by the face or mouth…?
14) Gum chewing, Smoking, Pipe biting…

i. Gum chewing is extremely injurious to the jaw joints over a period of
time. It is usually unilateral and, therefore, impacts oral-facial
musculature…the holding of a cigarette, cigar, or pipe between the
lips or teeth is also an impacting force.
15) Leaning …. Phone use:

i. Leaning on the face is damaging to the jaw joints, forces facial
muscles into abnormal positions, affects the ability to bite and
swallow, affects the bony growth of the face and influences the bite
development, and affects the head-neck and body posture… the
phone does the same. Tucking the phone between the ear and the
shoulder further distorts posture and exacerbates the problem.
Posture of the head, neck and body:
7. What is the carriage of the head relative to the body?

8. What is the carriage of the upper torso relative to the head and body?
9. Have the patient stand … back toward you…note shoulder and hip position
relative to the rest of the body. Have patient turn sideways…note head and
shoulder posture relative to the rest of the body.
10. Is the patient concerned about his/her posture?
11. Is the parent concerned? … note comments made.
12. Do they slouch in chairs? … how do they sit at the table?
Facial Data
5. Symmetry of the Face:
Is there a long-face syndrome present?

Is there a facial asymmetry?
Are there any other pertinent facial observations?
6. Lip structure:
Is there a short upper lip tendency?

Are the lips flaccid, thick, full, bottle-mouth in appearance?
Does the lower lip hang and evert?
Is there an obvious lip crease?
Do the lips chap, crack open, or appear dry?
Are there corner lip sores or mouth sores?
Do they often use a lip balm?
What is the lip strength…note # of ____ Gm.
* Normal lip strength is between 1800 – 4500 Gm.+
Is there a GRIMACE of the lips during the swallowing?
7. Mentalis Structure:
At rest, is there tension in the mentalis muscle?

During the act of swallowing, does the mentalis tighten?
In order to close the lips, does the mentalis have to tighten?
*Often there are many facial habits involving the lips and mentalis…note any you
observe during the consultation.
8. Masseter-Post-temporalis:
Palpate the masseter muscles. Note degree of strength. If the function is

symmetrical, which side is strongest, weakest, or non-functional?
Palpate the post-temporalis muscles. Note the function. When the bite is correct
the post-temporalis muscles will show a strong response. Otherwise, observe the
carriage of the mandible forward with little or no post-temporalis function. Often
the masseter muscles will be hyper-strong.
Occlusion
Normal Centric Occlusion: All teeth are in contact in a normal molar relationship.
Malocclusion: May result from the abnormal position of the teeth alone or from
abnormality in the growth of the jaws.
Classifications of Malocclusion:
Class I: Abnormal positioning of the teeth of the individual arches. The jaw
relationship is normal. The disharmony is confined to the denture alone (the
teeth and alveolar process) and is usually seen clinically as a crowding of the
teeth.
Class II: Characterized by a mandible and mandibular denture in posterior

relation to the rest of the facial skeleton: The pre-maxilla and the upper anterior
teeth may be protruded. The lips are usually flaccid with a low lip resting posture
behind the upper incisors. The upper lip appears short and drawn high over the
upper teeth.
Class III: Characterized by a mandible and/or mandibular denture in anterior

relation to the rest of the facial skeleton: The upper anterior teeth may be
retruded. The facial deformation is exaggerated. Long and “dish-shaped” face
with prominent and bulging “aggressive” jaw or lower face is markedly elongated.
Mid-face appears sunken, upper lip is usually short, lower lip is usually heavy and
projected forward.
Posture and Dental Health
To understand how posture can be related to dental health, it is important to understand

how posture develops.
Definitions.
Kyphosis: Curvature of the spine, with convexity backward.
Lordosis: Curvature of the spine, with
convexity forward.
Malleolus: A rounded bony prominence on
each side of the Ankle joint
Protraction: Forward movement or extension.
POSTURAL DEVELOPMENT
A baby is in a flexed posture in the womb, and
when born, displays one kyphotic curve.
In normal development, a child gains head

control beginning with prone on elbows allowing
the cervical lordosis to develop. Once a child
starts standing, it needs to bring its pelvis
slightly forward to maintain balance, and thereby
creating a lumbar lordosis. It is not until the child
walks unsupported that the arches of the feet
develop to maintain stability and equilibrium.
The thoracic and sacral flexion are primary

curvatures and the cervical and lumbar lordosis
are secondary curvatures.'
WHAT IS NORMAL POSTURE?
Normal physiological posture is both the task of
staying upright and balanced with a high center
of gravity and a small base of support. Ideally,
when standing from a lateral view, a plumb line
should align:
1. Slightly anterior to the lateral malleolus.
2. Slightly posterior to the knee axis.
3. Slightly posterior to the axis of the hip.
4. Through the shoulder joint.
5. Through the external auditory meatus.
In the lateral view, the spine should reveal a lordosis of the cervical (A) and lumbar (B)
regions and kyphosis of the thoracic spine (C) and sacrum (D).
In a posterior view, a plumb line should be equidistant from the midline of the heels,
knees, thighs and scapulae with no curvatures of the spine in the normal plane. Figure 2
The physiological posture attempts to maintain a balance in all three planes which all~
the least amount of wear and tear on the joints to prevent any dysfunction to the
system.
In any type of posture. it is important to understand the three dimensional orientation of

the head in space
which is dependent on four planes: the vertical plane. the bi--bipupilar line. the plane of
the vestibular system, or the otic plane. and the occlusal plane. If any of planes are not

h(bipupilar. otic. occlusal) are not horizontal, adaptive position will be made over time
by the rest of the spinal column to restore these planes to level.

Extra-oral Data
7. The Temporomandibular Joint:
Palpate the temporomandibular joints…have the patient open wide and
close … note any noise-popping, cracking, crepitus…
Observe any jaw deviation during opening and closing … does the jaw shift
forward or pull to the left or right?
Palpate, with your little fingers, inside the ears…again, have the patient open and
close…note your findings. (Note the presence of pain symptoms…location,
duration, treatment that the patient administers and the type of pain.)
Ask about intervention therapy that has been performed in the past or at present
… use of splints, night-guards, injections, medications, muscle relaxants, surgery,
etc. Does the bite appear over-closed (deep over bite)…the lower teeth will
disappear under the upper teeth in a biting position.
**In the presence of an over-closed bite, the tongue will place itself between the
teeth in an attempt to gain vertical dimension and help to keep a degree of
harmony within the joint space. It is very difficult to achieve good therapy results
in this environment without dental intervention to achieve a better occlusal
relationship.
It is felt by many TMJD clinicians that 85% of TMJD patients have oral-facial
muscle dysfunction. Which came first is always an issue, but therapy is indicated,
regardless, in order to treat the patient successfully. It is important to realize,
however, that due to pain symptoms, muscle stress and fatigue; your therapy
regimen will have to be altered to match the patients’ capabilities. Some exercises
will be contra-indicated.
8. Pain Symptoms:
Note the location of pain, the duration, and the treatment used to remedy.
Masseter, nasal sinus, forehead, eyes, temples, ears, top of head, back of head,
neck, shoulders, arms, hands, back, legs, feet….Note if any ear ringing or buzzing
is present and the duration.
9. Attrition:
Bruxing…note if any tooth wear is obvious, and to what extent. What treatment
has there been to treat the problem?
Clenching…note extent, time of day, type of activity, previous treatment.

10. Speech:
Has there been any previous therapy? … note when, duration, and for what
sounds or problem. Is the patient still in therapy and with whom? …
Communicate with that therapist.
Is there anything about the patient’s speech that the patient, parent, or spouse
would like to see changed. (note comments.)
Have patient say words with these sounds…“S”, “L”, “T”, “D”, “N”, “SH”, “CH”,
“TH”, “R”, “G”, “K”, “P”, “B”, “M”, and “W” words.
While they are saying those sounds…observe:
1. Jaw movement forward or laterally.

2. Tongue placement during sounds…correct? Is there movement forward
against the teeth, forward between the teeth (normal only on a TH sound),
or laterally between the teeth, unilaterally or bilaterally?
3: Sound distortion?
4: Facial and/or lip adaptations?
5: Wetness and/or bubbles
6: Lack of clarity, poor projection of air, mumbling of words?
7: Head posture or body gesturing?
Do you feel that additional speech therapy will be necessary?…Make a referral at

the appropriate time; if you are a speech therapist, incorporate speech when
muscles are able to accommodate the intricacies of speech; or communicate with
current therapist if the patient is involved in speech therapy.
11. Orthodontic History:
Name of orthodontist? … What were his/her recommendations to the patient?

What has been the sequence of treatment: date began? palatal expansion?
partial or full braces? Headgear, neck gear, elastics, positioner, retainers,
functional appliance, Crozats, braces removed, orthodontic relapse noted,
re-treatment performed, if so, when, how many times, patient’s present
concerns?
12. Pills:
Note any difficulty of patient taking a pill.
What does he/she have to do in order to “get it down”?
Do they refuse to take a pill?
*Once therapy is completed, the patient will be able to take a pill.

It may take patient instruction with some “tic-tacs”, but they will be excited once they do it and find
how easy it actually is. It is no more different than the eating-drinking process, once learned.
* In the presence of a deep-seated “fear” phobia, hypnotherapy or counseling may be required.

Intraoral Examination
Resting tongue posture:
 Determine the awareness by the patient.

“Is your tongue in the bottom, middle, or top of your mouth”?
“Where do you feel the tip of your tongue resting: is it against your upper
front teeth, your lower front teeth, between your the teeth, or against both
your upper and lower teeth?”
“Where do you feel the sides of your tongue…does it fit inside your teeth or is
it spreading between your teeth…to one side or both sides?”
 Note your visual observation of the tongue posture.

 Note the parent or spouse’s observation of the tongue.
Frenulum:
 Lingual Frenulum:
Have the patient lift the tongue to touch the palate. They should be able to open
1½ inches with the mandible dropped and the tip of the tongue against the
incisive papilla.
If there is restriction, the tongue generally is pulled down in the center causing
the tongue to appear “heart shaped”. The mandible will have to
elevate in order to allow the tongue to touch the palate.
Lingual Frenulum surgery (frenectomy or frenotomy) is indicated where there is

definite restriction. Therapy will be difficult or impossible otherwise.

 Mandibular labial frenulum:
Check the mandibular labial frenulum for restriction. This can cause the lip to pull
in too tight stopping correct resting lip posture. This can also effect the
periodontal tissue causing stripping. Surgery is indicated if the frenulum is too
short/tight.
 Maxillary labial frenulum:

Check the maxillary labial frenulum for restriction. If the attachment is too thick
or too low between the maxillary centrals, it can cause separation of the centrals,
restriction of the upper lip into a shortened upper lip appearance, and/or affect
the lip tone. Surgery is indicated if the frenulum is too short, thick, or tight.
Tongue Tone/Markings:
 Tongue tone or markings:
 Can the patient POINT the tongue into a “V” formation?
 Is the tongue flaccid?
 Is there scalloping along the lateral tongue borders? (Clenching)
 Is there linea alba (tongue ridge) along the lateral or anterior borders of the
tongue? … note if the ridge is thick, fibrous, or red in color.
*Cancer of the tongue is possible where trauma takes place over extended
periods of time.
 Note any other specific abnormalities.
Cheek Markings:
 Note linea alba (cheek ridge)…position, extent of, texture.
 Note any other tissue abnormalities…occasionally surgery is necessary to
remove excess pieces of tissue. Contact other professionals if you have
concerns.

Palate:
 Note width and depth of the palate.
*Be aware that a palate that is too narrow to encompass the tongue
or too vaulted to allow palatal tongue coverage, will make therapy nearly
impossible.
 Note status of the rugae.

*Rugae that are thick, deeply lined, or boggy looking, have not been
massaged by the tongue during normal swallowing and resting function.
 Note the ability of the soft palate and uvula function. Have the person say
“AHH”…do the soft palate and uvula pull posteriorly? Often there will be little or
no ability to function. This is often the patient who has snoring and/or sleep
apnea symptoms. The soft palate and uvula can be “trained” to function with
therapy techniques as you work on tongue posture.
Occasionally you will see a uvula that is too long. The need for Surgery may be
indicated.
 Determine whether you believe that palatal expansion might be necessary …

contact the referring clinician.
Tonsils:
 Observe the size of the tonsillar mass. Have they been removed? At what age?
Are they currently enlarged and to what extent?
 Are they fibrous and hard in appearance?
 Is there concern about pushing the tongue into an anterior resting posture?
 Is surgery a consideration? … contact referring clinician … discuss a possible ENT
evaluation.

* You might have to make a value consideration if tonsils are grossly enlarged and the
removal of them is not approved. Therapy generally is affected, with marginal results
being a possibility.
* Enlarged tonsils that are red and irritated in appearance will often begin to decrease in
size as the mouth breathing is corrected and orofacial muscle balance begins to change.
* The diet may need modifying. Often the patient is allergic to dairy products, heavy
sweets, caffeine, and/or food additive intake, and/or other items such as wheat or corn.
Through the process of elimination-cause-and-effect, the congestive irritation process
can be influenced. Often, the patient knows what the allergies are, but discussion with
the referral source is ALWAYS the best!
 Note past and present infections, medications taken, frequency of infections, and
degree of severity.
 Note any history of adenoid tissue concern. Is referral for evaluation necessary?
Adenoid tissue mass effects airway potency. Contact the referral source. Removal
is often necessary in order to achieve nasal breathing, however, as in the tonsils,
if the enlargement is soft and inflamed, they sometimes decrease in size with the
airway techniques utilized in therapy.
 REMEMBER that the tonsils and adenoids are filters and part of the lymphatic
system. The lymphatic system is an ‘open’ system, as opposed to the circulatory
system which is ‘closed’. The only way that lymph can reach the nodes in order
to flush them is through muscle movement, and the prime muscle of lymph
movement is the DIAPHRAGM. Mouth breathers usually have minimal
diaphragmatic movement and this lack of lymph “push”, coupled with the
overloading of the filters through mouth breathing is the largest single
contributory factor to enlarged and infected tonsils and adenoids.
 Remove them and there is a strong likelihood that they will grow back.

Tori:
 Observe any bony enlargements on the palate. These are “Tori”.

* If these growths are too large, they can affect the ability of the tongue to
contact the palate in a normal resting and swallowing process.
* Surgery may be indicated…marginal therapy results would have to be otherwise
anticipated.
 Mandibular Tori:
Note the presence of tori along the lingual or labial surfaces of the mandibular
arch.
*Their presence generally will have no effect on therapy. They are difficult,
when dealing with a lower partial or denture.
Occlusion:
 Observe the dental bite…note the classification of occlusion.
Class I, Class II, Overjet, Overbite, Class III, Pseudo Class III, Crossbite,
Unilateral or Bilateral, Over-closed bite…
 Note the status of the dental arch. Missing teeth, extent of reconstruction
with crown and bridgework, if there are partial or full dentures present,
periodontal disease, gum recession, tooth wear, tendency to decay, and the
status of their oral hygiene.
 Note discussion by patient of specific dental concerns, previous treatment,

Failures, etc.
Deglutition:
 Test the swallow visually…palpate the hyoid area…break the lip seal during
the swallow and observe the tongue posture…and do a squirt-swallow check
of the swallow.
Place a cheek retractor into the lips. Ask the patient to swallow as normally
as possible. Observe the tongue movement.
 Offer a cracker or… Observe the swallow during food intake and chewing.
 Offer a cup of water (a clear cup is best). Observe the tongue, lips, and
swallow process.
 Note all observations.
Case Presentation
Benefits:
It is essential that you stress the benefits and the valuable end products of
therapy.
You have been with the patient a while…from the clues you have gathered,
present the benefits that suit the patients likes and desires… not yours! Present
benefits instead of technical data. They are most often concerned with how it will
affect their appearance, their smile, their finances in the future, the saving of
their teeth, or even being able to be better kisser!
Utilize Visual Aids. Show PHOTOGRAPHS!! Gridded postural photos as well as

mouth pictures. (One picture is worth 1000 words!)
Explain briefly their involvement…how many visits, how many times a day for
practice, approximate length of therapy involvement.
Get a commitment from the patient…written is best. Use a contract for both
patient and parents.
Present the financial terms and get a signed commitment.
Arrange their therapy appointment(s).
Congratulate and thank them.
***If you document cases with photographs, we suggest taking them before you check the
swallow.
*** If you are documenting with photographs and wish to use them for lectures, advertising,
promotional purposes, or any form of visual or print, be certain to have the patient/parent sign a
“consent to use form”.

How to Catch a Thruster
Thrusters don’t even know it, but they make a lot of ugly faces each time they swallow.
It is easy to catch them doing it. Just observe them when they don’t know you are
watching. Why do you want to stop these people from doing something they obviously
enjoy? Thrusting delays completion of orthodontic treatment by forcing the teeth apart
or forward. After the braces are removed, thrusting will often ruin the results. It is a
habit, just like sucking the thumb. Thrusting is a negative force. Thrusting will destroy
your orthodontic investment.
Actions the Patient Can Take To Avoid a Thrust
 Don’t lick your lip prior to swallowing. Don’t separate your teeth prior to
swallowing. If you lick your lips all the time, you are thrusting!
 Place most of the tongue on the roof of your mouth (or anywhere other than
between your teeth), DURING THE ENTIRE SWALLOW!
 Another trick is to put a small orthodontic elastic on the top of your tongue,
press the elastic against the roof of your mouth behind the upper front teeth,
and swallow without swallowing or moving the tongue from the roof of the
mouth. The idea is to keep the tip of the tongue in place and not let it slip out
between the teeth. It works!!!
 Place the back teeth together (IN CONTACT) during all parts of the swallow.
 Another trick is to practice normal swallow with liquid in your mouth while
smiling (lips apart). If it is a normal swallow, no liquid squirts out while
smiling. If the whole tongue is not sealing against the roof of the mouth,
liquid will be forced out between the teeth. This can be practiced at the dinner
table.
 With your hand, feel the muscles in the throat work instead of the lips and
muscles surrounding the mouth…no puckering!

Actions an Observer Can Watch For
During A Thrust
If the teeth are apart at the initiation of a swallow, the chin will drop down while the
lips are kept together. That is the start of a thrust because the tongue will be
between the teeth at some point during the swallow.
If the lips are being pursed, and the chin is bunched up, that indicates a thrust.
If the lips are licked prior to a swallow, that indicates the initiation of a thrust.
Licking the lips is a prime indication that a thrust is going on.
Observe the lizard-like tongue, lip and chin muscle actions when the patient is not
aware you are watching. They may do a normal swallow while they are aware you
are watching, but immediately fall back to their old habit of thrusting when they are
not aware.
A cracked, swollen lower lip is often noticed on the thruster due to constant lip
licking. They will deny doing it, and say they have to lick their lips because their lips
are always dry.

Clinical Questionnaire
Sandra R. Coulson & Associates, Inc.

Patient Information Form
Patient
Last Name__________________________ First Name___________________________ Today's Date____________________________
Nick Name__________________________ Age______ Birth Day__________________ (Circle) Male Female
Address_____________________________ City_______________________ State__________ Zip Code_________________________
Home Phone(______)_________________________________Cell Phone(______)___________________________________________
Email Address (optional) _________________________________________________________________________________________
School____________________________________________ Activities____________________________________________
Who referred you to our office? ____________________________________________________________________________________
Please give a brief description of the reason for your visit _______________________________________________________________
Are you aware that some appointments may infringe on school time? (Circle) Yes No
Responsible Party
Last Name_____________________________ First Name____________________________ Home Phone (____)__________________
Address(if different from above)_______________________________ City____________________ State______ Zip _______________
Occupation_____________________________ Employer______________________________ Work Phone (____)_________________
(Circle) Single Married Divorced Separated O.K. to contact you at work? (Circle) Yes No
Spouse_________________________________________________________ Home Phone (_____)_________________
Address(if different from above)_______________________________ City____________________ State______ Zip _______________
Occupation_____________________________ Employer______________________________ Work Phone (____)_________________
O.K. to contact you at work? (Circle) Yes No
Health Care Providers

DENTIST: ORTHO:
Name_________________________________________ Name___________________________________________
Address_______________________________________ Address ________________________________________
City, State, Zip_________________________________ City, State, Zip___________________________________
Phone (_____)___________FAX____________________ Phone (_____)___________FAX____________________
MD: OTHER:
Name__________________________________________ Name___________________________________________
Address_______________________________________ Address _______________________________________
City, State, Zip__________________________________ City, State, Zip___________________________________
Phone (_____)___________FAX____________________ Phone (_____)___________FAX____________________
(OVER)
Copyright by: Sandra R. Coulson & Associates, Inc.
Health History
Please indicate with an (X) if patient has or has ever had any of the following:
YES NO YES NO
  Allergy to Latex   Arthritis
  High Blood Pressure   Asthma
  Nervous Problems   Hepatitis
  Tonsillitis   Sinus Problems
  Allergies to Medicines or Drugs   Epilepsy
List________________________________________   Heart Problems /
Murmur
Please mark with an (X) if applicable:

Does the client have a tendency toward: Colds  Sore Throats  Ear Infections  Headaches 
How often? ______________________________
YES NO
Have the tonsils and adenoids been removed?  
If so, at what age?_____________
Does the client have jaw popping and/or pain?  
Does the client have frequent headaches?  
Has there ever been an injury to the face or mouth?  
Has the client ever sucked his/her thumb or fingers?  
If so, until what age?___________
Does the client have any speech problems?  
Does the client breathe through his/her mouth while awake?  
or while asleep?  
Does the client clench or grind his/her teeth at night?  
List any drugs or medications presently being
taken:__________________________________________________
Other pertinent health information:
______________________________________________________________________________
______________________________________________________________________________

2121 S. Oneida St. Suite 633
Denver, CO 80224
303-759-2760
Permission for Exchange of Information
I give permission to exchange medical information, either written or by phone, between

my providers of medical and therapeutic services (or those of my child), as well as
insurance providers. I understand that the purpose of this exchange is to allow for
coordinated services between these providers.
Name of Patient (printed) _______________________ ___ Date _____________
Signed (responsible) _______________________________ Date _____________
Permission to Use Files for Research or Presentation
I give my permission for use of photographs and records made in the process of
examination and treatment, to be used for the purposes of research, education and
publication in professional journals.
Signed _________________________________________ Date _____________
Success of Therapeutic Program
"It must be noted that successful completion of the myofunctional therapy program is
dependent upon patient desire, good attitude and self-discipline. Parental involvement
and encouragement are important and necessary. Only the dedicated participant and
cooperation of the patient can guarantee effective swallowing and resting posture
results."
Airway Problems and Their Effects
In order to be successful in this program the patient must achieve closed mouth resting
posture. A clear airway is necessary in order to reach this goal. Patients who have
allergies or related nasal airway problems present a high risk that the goals will not be
attained or may require additional visits to do so.

Conducting Measurements
1. Patient should be seated with head level.

2. Measurements are taken using a small millimeter ruler.
3. Typically, these measurements are taken:
a. Upper Lip (Philtrum)
Normal Ranges:
Ages 1-5 = 16-18 mm
Ages 6-12 = 18-20 mm
Ages 13-Adult = 20-24 mm
b. Lower Lip (Wet Line to edge of Vermillion)

Ages 1-5 = 9-11 mm
Ages 6-12 = 9-10 mm
Ages 13-Adult = 9 mm
c. Over-jet (Lower Central to Upper Central)

Ages 1-Adult = 1-2 mm
d. Under bite
An under bite is not a normal bite
Often denotes mid-face deficiency
e. Upper-Canine to Canine (tip to tip)

This will vary, depending upon heredity and facial shape as
well as breathing patterns and other habits. The typical end
result with normal growth or with a finished orthodontic case
should be 35-38 mm.
f. Inter-labial Gap
0-2 mm is normal
g. Vertical Opening
40-50 is normal

Initial Assessment – Referral Return Information
Patient: _______________________________ Date: _________________
Referring Provider: _______________________________________________________
The following observations confirm the presence of an OROFACIAL MUSCLE

DYSFUNCTION
POSTURE: Normal Forward Head Forward Shoulders
BREATHING: Nasal breathing Open Mouth Snoring Congestion/Drooling

Frequent URI Fatigue Pulse _____ Oxygen ______
ALLERGIES: NKA Allergic Shiners Seasonal Non-seasonal

Other____________________________________________
LIPS: Normal Dry Chapped Open at Rest Open to Swallow

Labial Frenum Normal Tight/Restricted
Measurements: Upper: ____mm; Lower: ____mm; Lip Strength: ____# (psi)
OCCLUSION: Overjet: ____mm; Deep Overbite: ____mm

Open Bite: Anterior Posterior Bilateral Unilateral (L/R) Deep Overbite
Cross bite (L/R/Bilateral)
TONGUE: Average Long Large Wide Geographic

Lingual frenum Normal Short Tight/Restricted Recommend Frenectomy
ORAL CAVITY : High Vault Pronounced Rugae Narrow Soft Palate Long Uvula
TONSILS: Normal Large Inflamed Removed at age____________
SWALLOWING Normal Anterior Tongue Thrust Bilateral Tongue Thrust

Unilateral (L/R) Tongue Thrust
ORAL HABITS: None Thumb Sucking (L/R/Both) Finger Sucking Pacifier

Nail Biting Lip Wedging Lip Licking Hair Chewing
Clothes Chewing Pen/Pencil/Object Chewing Clenching Bruxing
Cheek Biting Trichotillomania Nose Picking
SPEECH/ Articulation errors from poor tongue posture: None

ARTICULATION: T N S SH J P B M D L Z CH ZH TH R
Other________________________________________________
TMD: None Unilateral (L/R) Bilateral (Pain/Clicking/Popping/Locking)

Headaches Neck Pain (L/R/Bilateral) Jaw Pain (L/R/Bilateral)
Deviation L/R Bilateral Tinnitus
GOALS FOR THERAPY:

To eliminate a tongue thrust pattern To develop a nasal-breathing pattern
To increase lip competence To correct articulation error(s)
To correct rest posture of the lips and tongue To reduce mandibular stress
To eliminate noxious oral habits
Therapeutic techniques include behavior modification and passive and resistive orofacial
exercises. Estimated treatment plan will consist of ________therapy visits.
We thank you for your referral and your continued support of our practice.
_______________________________ ______________________
Signature Date

Therapy Notes
Name:
Date: Therapy #1
Upper
Lower
Overjet
Width
Button
Bottle
Pennies
Tip-pops
Lip-pops
Open-
Bite
Opening
Date: Therapy #2
Upper
Lower
Overjet
Width
Button
Bottle
Pennies
Tip-pops
Lip-pops
Open-
Bite
Opening
Date: Therapy #3
Upper
Lower
Overjet
Width
Button
Bottle
Pennies
Tip-pops
Lip-pops
Open-
Bite
Opening

Evaluation by Parent or Patient
Name____________________________________Date______________________
Please check those that apply:
1.) Usual position of the lips and teeth during the daytime
______ A) Open Wide
______ B) Open Slightly
______ C) Closed
______ D) Lips closed, but jaw position low
______ E) Lips closed, but strong contraction of the chin and lip muscle
______ F) Teeth positioned over lower lip
2.) Usual position of the tongue, lips and teeth during sleep:
______ A) Lips slightly parted
______ B) Lips apart, tongue showing
______ C) Mouth breathing
______ D) Lips Closed
3.) Chewing Patterns:

______ A) Chews with lips open
______ B) Chews with excessive lip and chin movement
______ C) Chews with lips closed
______ D) Noisy chewing, smacking
______ E) Forward-thrusting of tongue during chewing
______ F) Reaching out with the tongue to meet the food or liquid
______ G) Teeth touch utensil, cup or glass
______ H) Excessive crumbs around mouth and frequent lip licking
______ I) Mustache after drinking
______ J) Large bites
______ K) Fast chewing
______ L) Slow chewing
4.) Usual position of the tongue during the daytime:

______ A) Protruding between both teeth and lips
______ B) Protruding slightly between teeth
______ C) Low positioned, pressing against lower teeth
______ D) Unobservable, lips closed
5.) Daytime body posture

______ A) Poor
______ B) Average
______ C) Good
______ D) Face leaning
______ E) Chin leaning
______ F) Phone resting on shoulder
6.) Sleeping posture

______ A) Back
______ B) Left side
______ C) Right side
______ D) Stomach (face left/right side)
7.) Oral Habits:

______ A) Thumb or finger sucking
______ B) Tongue sucking
______ C) Lip biting
______ D) Lip licking (chapped lips)
______ E) Pencil biting
______ F) Finger nail biting
______ G) Mouth breathing
______ H) Tooth grinding (bruxing)
______ I) Drooling
______ J) Facial, tooth, head or neck pain
8.) Other Habits:

______ A) Hair Pulling
______ B) Eyelash/eyebrow pulling
______ C) Nose picking
Comments:_____________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
________________________________________

Therapy Notes
SANDRA R. COULSON & ASSOCIATES
Patient Dismissal Report

Date:
Name: Referred By:
Co-operation
Attended ___ therapy sessions
Treatment Results
Upper lip: at evaluation: ____ mm. at last visit: ____ mm.
Lower lip: at evaluation: ____ mm. at last visit: ____ mm.
Strength: at evaluation: ____ # at last visit: ____ #
Overjet: at evaluation: ____ mm. at last visit: ____ mm.
Width: at evaluation: ____ mm. at last visit: ____ mm.
Opening: at evaluation: ____ mm. at last visit: ____mm.
Oral Habits
Thumb, Finger, Lip Wedging, Lip Chewing, Nail Biting, Still Sucking, Other.________
Tongue
Patient now demonstrates better swallowing and resting pattern.
Posture
Patient now demonstrates better head and body posture to support a good tongue position.
Airway
Patient continues to have a compromised airway.
Follow-up
Dismissed therapy is complete.
Dismissed client declined further services.
Dismissed but follow-up is necessary as orthodontics proceeds.
Follow-up is necessary. Please ask your patient to call when you have completed this phase.
Comments:
I have emphasized that even though formal therapy has been completed; the patient must
continue to monitor tongue and lip postures and do the exercises which I have outlined on a
continuing, indefinite basis.
I appreciate your continued support.
Sincerely,
Sandra R. Coulson, M.S., ST., Ed., C.O.M.

2121 S. Oneida St. #335
Denver, CO 80224
303-759-2760
NOTICE TO DOCTOR
PATIENT:_____________________________________
DATE:________________
REFERRAL SOURCE:_______________________________________________
This is to inform you that your patient failed to follow-through with your
referral for services in our office.
Failed to show for initial evaluation ____________________________

________________________________________________
________________________________________________
________________________________________________
________________________________________________
______
Failed to continue therapy after _____sessions because____________
__________________________________________________________________
His/ Her dismissal report will follow.
We appreciate your referrals, enjoy working with the clients you send to our
office, and just want you to know when one fails an appointment or does not
continue therapy.
Sincerely,
________________________
Therapist

Sandra R. Coulson & Associates
Denver, CO 80224
303-759-2760
Patient Termination of Therapy
Date: _________________________
To: ___________________________
Phone: ________________________
Fax: __________________________
Message:
For your information, ___________________________________
has terminated therapy at this time.

_____________________________________________________
_____________________________________________________
_____________________________________________________
***Confidentiality Notice***
This facsimile transmission and any documents that may accompany it contain confidential information belonging to the sender. The information
contained in this facsimile is intended solely for the addressee(s) named above and is privileged and/or confidential. If the reader of this message is not
the intended recipient or the person responsible to deliver it to the intended recipient, you are prohibited from reading or disclosing the information
contained in this transmission. Any examination, use, dissemination, distribution or copying of this communication is strictly prohibited. If you have
received this communication in error, please notify us immediately at 303-759-2760 to arrange for return of the document to us. Thank you.

Denver, CO 80224
303-759-2760
Completion of Therapy
Since this is your final visit….
Please remember to:
1. Keep your lips closed and your tongue on your____________.
2. Breathe only through your ___________.
3. Chew only small bites with your lips closed!
4. Sleep on your back or side DO NOT sleep on your stomach!
5. Use your best body posture.
6. Continuing to work on the following exercises will keep your muscles working well!
 Granny Surprise Face
 Lip Pops
 Suction-Hold-Stretch
 Turtle Surprise Face
CONGRATULATIONS ON A JOB WELL DONE!

Parent Questionnaire

Denver, CO 80224
303-759-2760
Fax: 303-759-2971
We are always trying to improve, where possible, our services and programs. Please
complete this questionnaire so we may try to further improve our programs for children
with digit (thumb or finger) sucking habits. Your cooperation is sincerely appreciated.
Who referred you to our practice? ____________________________________________
What were you referred for? _________________________________________________
Were you aware of any damage to the teeth as a result of the sucking habit? ____________
_________________________________________________________________________
Had you been trying to get your child to discontinue the sucking habit prior to coming to
see us? ______ If so, what methods were employed? ______________________________
_________________________________________________________________________
How soon after beginning our program did your child discontinue the sucking habit?
_________________________________________________________________________
Do you feel your child gained in self-confidence and self-esteem as a result of being able
to 'kick the habit'? _________________________________________________________
Do you feel the program was worthwhile? ______________________________________
Would you recommend the program to other parents with a child with a digit-sucking
habit? ___________________________________________________________________
Do you have any suggestions as to how we may improve this program?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Additional comments:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Your child's name: ____________________________________________

Your Signature: ________________________________________ Date: ______________
From “In Practice”
“Posterior Cross-Bites in the Primary Dentition”

In a recent review paper, Malandris and Mahoney detail the etiology, diagnosis,
and treatment of posterior cross-bites in the primary dentition. They describe posterior
cross-bite as a transverse discrepancy in an arch relationship in which palatal cusps of
one or more upper posterior teeth do not occlude in the central fossae of the opposing
lower teeth. The prevalence of posterior cross-bites in the primary dentition varies from
1 to 16 percent depending on the population sampled. Caucasians typically exhibit
higher prevalence than Africans and Asians, partly due to cultural differences in sucking
habits. Genetic factors leading to a narrow maxilla have also been suggested.
The rapid growth occurring during childhood is a sensitive period where tongue
positions and size, mouth breathing, non-nutritive sucking (digit or pacifier), and jaw
posture can all contribute to the development of a posterior cross-bite. Studies have
demonstrated that significant maxillary constriction was associated with sucking habits
persistent after 24 months, from whom posterior cross-bites accounted for 29% of
malocclusions. Use of a pacifier after 24 months of age causes an increase in
mandibular arch width while maxillary growth remains stable. Early weaning was also
suggested to interfere with normal development due to the lower muscular activity
required by bottle-feeding. All these factors predispose children to developing posterior
cross-bites.
Posterior cross-bites may cause occlusal interference leading to a functional shift

of the mandible anteriorly or laterally. Such cases are frequently associated with
temporomandibular joint (TMJ) problems. Skeletal malocclusion may also be perceived
as non-esthetic by patients and caregivers (e.g., facial asymmetry), and may be
significant sources of distress. In addition, severe posterior cross-bites are frequently
associated with poor speech intelligibility, speech nasality, and defective articulation.
Longitudinal studies reported that the majority (between 55% and 92%) of
posterior cross-bites in the primary dentition persist into the permanent dentition.
Untreated posterior cross-bites in the primary dentition may predispose to long-term
detrimental consequences. However, due to the significant proportions of posterior
cross-bites that self-correct (up to 45%), there exists a controversy regarding the most
appropriate time to treat this condition, and whether orthodontic treatment should be
postponed until the mixed or permanent dentition stages to allow for spontaneous
correction and avoid unnecessary treatment.
Treatment should take into consideration a patient’s motivation and compliance

with the selected therapy to maximize a favorable outcome. The first line of the
intervention should aim at correcting habits that contributed to the development of the
posterior cross-bite. Orthodontic treatment during the primary dentition stare can be
advocated when the condition may predispose to the future detrimental consequences.
Such outcomes include functional displacements of the mandible that may cause TMJ
dysfunction and deviation from normal facial esthetics in the long-term.
The expected timing of eruption of the first permanent molar is also critical. In
cases where permanent molar are no longer covered by bone, orthodontic treatment
should be delayed until the mixed dentition phase. On the other hand, expansion of a
narrow maxillary arch, carried out before extensive root formation of the permanent
teeth, increases tooth spacing and may promote normal tooth eruption, in turn
preventing posterior cross-bite persistence in the permanent dentition. The efficacy of
such treatment remains to be confirmed in controlled clinical trials.
The most common detrimental effects associated with correcting posterior cross-
bites include limited cooperation of young patients, gingival irritation, and enamel
decalcification. Side effects also include changes to nasal morphology, sensations of
dizziness, tooth sensitivity following grinding, and transient diastema opening between
central incisors. Collectively, all available evidence does not support the routine
correction of posterior cross-bites in the primary dentition, as opposed to the early
mixed dentition stage.
References:
 Malandris M, Mahoney EK. Etiology, diagnosis and treatment of posterior cross-

bites in the primary dentition. Int J Ped Dent.
 Warren JJ, Bishara SE. Duration of nutritive and nonnutritive sucking behaviors
and their effects on the dental arches in the primary dentition. Am J Orthod
Dentofacial Orthop 2002; 121 (4); 347-356.
 Warren JJ Bishara SE, Steinbock , KL, Yonezu T, Nowal AJ. Effects of oral habits’
duration on dental characteristics in the primary dentition. JADA 2001;132
(12):1685-1693.
 Adair SM, Milano M, Lorenzo I, Russell C. Effects of current and former pacifier
use on the dention of 24-59 month-old-children. Pediatr Dent 1995;177(7);437-
444.
 Thilander B, Wahlund S, Lennartsson B. The effect of early interceptive treatment

in children with posterior cross-bite. Eur J Orthod 1984;6(1)25-34.
 Kurol J, Bergland L. Longitudinal study and cost-benefit analysis of the effect of

early treatment of posterior cross-bites in the primary dentition. Eur J Orthod
1992;14(3):173-179.

Using Photography to Promote Your Practice
By Dr. Richard Coulson D.D.S. M.S.D. (Orthodontist)
I am writing this section on photography because I love photography and because it was
a major factor in the success of my Orthodontic practice. It can be a major factor in
promoting YOUR practice also. I gave many presentations over the years to study clubs,
County General Dental Meetings, service clubs and one National American Association of
Orthodontist’s meeting. In all of these presentations I used photographs of patients from
my own practice. These presentations were invaluable in getting my name out there,
and it was fun.
You will probably present to small groups in private offices at first, and then present to
organizations. This is your main tool for promoting your practice. Most Doctors don’t
know what Orofacial Myology is. You have to show them. This makes the difference
between practice success and failure! Doctors have to know what you can do for their
patients before they will refer to you. You must show them what you can do.
Now is a good time to buy a digital camera, since there have been significant technical
improvements in the last year, and prices have dropped as well. There are two types of
digital cameras, and I will discuss both types and their advantages and disadvantages
below.
Features of a Point & Shoot Camera
1. Everyone likes the small size and convenience of the point and shoot cameras.
2. They do have the capability to take short video clips. Sandy has been taking video
segments on selected patients for several years.
3. Moderate cost. You can buy a good one for five hundred dollars.
4. Simpler construction usually means the smallest aperture is f8. In close-up
photography you need a very small aperture like f 22 to attain the greatest “depth
of field”. (the area of sharp focus).
5. Due to the limitation of the smallest aperture of f 8, the ones we have seen over-
expose close up photos.
Disadvantages of a Point & Shoot Camera
1. Accurate focus is difficult for several reasons. First, the small camera is difficult to
hold still especially when you hold it out in front of you to see the display. This
produces a blurry picture if you are not using flash. Some cameras have vibration
reduction, and this helps, but it can still be a problem. Second, the area that is in
sharp focus in a close-up is very shallow. In an intra-oral photo, this is around ¼
of an inch. It is therefore difficult to focus accurately at arm’s length. It is easy to
get the lips in focus and not the incisors, or the incisors and not the cuspids and
bicuspids. Focus may look fine on the LCD display or in a small print, but it is
noticeable when projected on a screen for an audience.
2. Distortion is an issue. If you are not far enough away, and using the correct focal
length on your lens, a nose can be disproportionately large relative to the ears in a
frontal face view, and the ears relative to the nose in a side view. The correct focal
length is 90 to 100 mm. Zoom lenses on a point and shoot camera is not marked
as to focal length, and it is very difficult to take the same shot from one patient to
the next, or with the same patient from one visit to the next. Size of the image will
therefore be different. Getting this correct is cumbersome and time-consuming.
3. When taking close-up photos of the teeth, you are very close to the patient, who is
likely a child, and a flash at that distance is not a good idea.
4. You have no control of flash direction, and this would be helpful in producing subtle
shadows on the face to demonstrate changes in facial tissues. If you are teaching
non-surgical face lift classes this is especially important. Shadow control is also
helpful in intra-oral photos for crisp details.
5. Most point and shoot cameras have no view finder at this time. This is a distinct
disadvantage when using the camera outdoors, or indoors for that matter. It is
very difficult to see the LCD display in sunlight. I discussed the difficulties occurring
when holding the camera at arm’s length previously; this applies when using the
camera for recreational use as well.
6. For recreational use, a wider field of view than most point and shoot camera lenses
have today would be very useful. A wider angle equivalent of 28mm is mandatory
indoors and in narrow street scenes. I know of only one model I would recommend
at this time (May 1, 2008) that has these features. It is larger than pocket size,
but smaller than an SLR. This is the Olympus SP 570. It sells for around $500.00.
Advantages of a Single Lens Reflex Digital
1. They have none of the disadvantages of a point and shoot digital camera as listed
above. The point above regarding a shallow area of sharp focus is a fact in physics,
and applies to all optical systems. This problem is mitigated with an SLR because a
Macro lens has a very small aperture available, namely f 22. This maximizes the
depth of field, which is relatively small at best.
2. Lenses are purchased separately, according to the exact purpose of the system.
The body is purchased separately. When photographing patients for intra-oral and
for portraits, a 100mm Macro lens is ideal. This is what the professional’s use, as
do as Plastic Surgeons, Orthodontists, etc. For recreational photography you can
choose a second zoom lens with the exact zoom range that you prefer. There are
many to choose from.
3. Lighting can be purchased separately. A light is attached to the front of the lens. It
can be rotated to place shadows exactly where you want them to emphasise skin
contour or to get the very best intra-oral photograph. These units are bulky. The
lens is short enough that it does not stand in the way of the light coming from the
built in flash when taking intra-oral photographs. You need to check this out in the
store to make sure this is the case with the brand you are purchasing. It is a good
idea to select Nikon, Canon, or Olympus. As a best compromise, Sandy uses an
Olympus E 500 SLR body with an Olympus 50 mm Macro lens. (Olympus does not
make a 100 mm Macro lens at this time). This functions well without an accessory
ring light.

Olympus 550 SLR with 50 mm Macro
Disadvantages of a Single Lens Reflex Digital
1. They are larger and heavier. This is not a problem inside, but some people prefer
not to have the weight when carrying the camera.
2. They are more expensive; however, prices have come down considerably. You
should be able to get a basic SLR body and a lens for around eleven hundred
dollars.
By now I am sure that you realize that there is no perfect camera. Ideally, it would be
nice to have both an SLR for clinical use, and serious recreational use, and a point and
shoot camera to have in your pocket. I have a heavy Nikon SLR that I could not get
along without. I may buy a point and shoot later that has the features that I want for
casual use.
You have to know exactly what you want when you go into the camera store. Clinical
photography is NOT their expertise, since there is such a small demand. They will sell
you whatever is on the shelf. It is important to be informed as to what the possibilities
are prior to making a purchase. I would suggest that you at least talk to two vendors
who specialize in clinical photography. These vendors have been around for several
years. You can visit with them and they will send you pamphlets on equipment and
pricing.
Many cell phones now have amazing capabilities, but the reproduction for presentations
seems to always be better with a single-lens reflex camera!

Standardization of Your Photographs Is Important
The distance from the camera to the subject should always be the same. For portraits
five feet is a good distance. For intra-orals the distance should also be consistent. It
should be at least 8-9 inches. Intra-orals should include only the area you want to
discuss. You should not include lips or cheeks. This is a very common error.
Remember that the image on the screen must be as large as possible, so the people in
the back of the room can see it. Use the largest screen possible that will fit into the
room. Kodak has booklets available explaining image size necessary for a given
audience. Images that are too small ruin a presentation. You want to be known for a
great presentation, and to be asked back for more! Remember this can be fun if you do
it correctly, and you are promoting your practice as well!
Canon 10D with 100mm macro

lens and dual point flash (MT-24
EX)
Nikon with 105mm Macro
and ring light

Camera Settings for Single Lens Reflex Cameras (SLR)
1. For Intra-orals, at an ASA of 100, and in “A” (Aperture priority mode),
not Auto or Program, set the aperture at f 22 and let the camera select
the shutter speed.
2. For portraits, use the portrait mode (symbol of a face on the dial) and the camera
will select both aperture and shutter speed. It will select an f-stop close to f8,
which is ideal.
The camera will remember the settings, so you only have to move the dial
between two settings for portraits and intra-orals.
After trial exposures are made and evaluated, (you should have an expert check them),
the settings should never be changed. (Shutter speed and f-stop). Trial exposures
should be made before taking photos of patients. Size, color saturation, and brightness
should be consistent so the audience can quickly compare before and after images. Get
these things right at the beginning. Correcting things later, if it can be done, by a
professional is expensive.
The background for portraits should be a blank off-white wall. The patients
should always face the same direction (to your right) for profile shots. The
right side of the face including only the head and neck to the shoulder is
standard. Place a mark on the floor for the five-foot distance. You do not want
a tripod. One camera store wanted to sell one to one of our students! You want
to work fast and be flexible in moving from portrait to intra-orals.

Software to Manage the Images
Patient images must be labeled and dated. They should be kept together and, ideally,
categorized by type of patient so that you can find them quickly when E-mailing or
preparing a presentation.
Sandra has spent a great amount of time and energy to develop a software program
which is designed for OROFACIAL MYOLOGY practice management which includes
cataloging and integrating your ‘before and after’ photographs into your documents
which you can use to send to referral sources for practice promotion. This is a BIG
practice-builder!
Backing-Up Your Business Data and Photographs
You must have a back-up system for your computer so that you can take the back-up
home, or lock it up at night. What would happen if your computer and/or camera were
stolen and your financial data and photographs were gone? I have a friend who lost all
of his photographs.
To store your photographs, a separate portable hard-drive is excellent. You should

consult your computer-specialist regarding the best way to back-up your financial and
other business data as well as your photographs. Be certain that you have business
insurance to cover your camera and your computer.
The following article may also be of use to you in your practice.
http://www.dentistrybydesign.com.au/pdf/Clinical%20Photography.pdf
Learn to Present – take up Public Speaking
Many people are concerned that public speaking will be difficult for them. It is easier
than you think when you have your material well-organized, and your program is in the
form of titles and photographs. You simply discuss the material on the screen and push
the button to advance to the next topic. Practice at home, time yourself, and your
program is set. Even if people interrupt and ask questions you cannot lose your place.
Having professional help to set-up your first presentation is a good idea.

Tongue Thrust and Tongue Posture
Tongue thrust is the abnormal habit of placing the tongue between the teeth before and
during the act of swallowing. During each swallow, the tongue exerts momentary
pressures of 1 to 6 pounds on the surrounding structures of the mouth.
Most people do their quiet breathing through their nose, with their lips closed and back
teeth almost touching. The tongue most often rests on the roof of the mouth and pulls
back during swallowing, which occurs an average of twice a minute when we are awake.
During a normal swallow, the mid-tongue should be placed on the roof of the mouth and
not between the teeth. The facial muscles, especially the upper lip, should rest against
the teeth to support them. The lips act as a lifetime retainer and protect the teeth.
Large tonsils / adenoids and chronic nasal inflammation are contributors to a tongue
thrust and poor tongue posture. The inability to nasal breathe can cause a person to
become a mouth-breather, which in turn can contribute to the ongoing inflammation of
the tonsils, adenoids and turbinates’.
By breathing through the mouth, the tongue must assume a low and forward position to
allow for a maximum airway. The upper lip tends to become shorter as the lower lip
tends to lengthen and internal oral tissue becomes exposed. As the lips and tongue
assume the incorrect positions, nerve and muscle differences begin to take place.
Muscles may under- or over-develop to accommodate the new habit and muscle
pressure becomes misdirected. Mouth Breathers may need to undertake a Breathing
Retraining program prior to commencing an Orofacial Myology program.
Our therapy program begins by re-training the tongue to assume the correct resting and
swallowing position on the roof of the mouth, as well as establishing a nasal-breathing
pattern. Just as importantly, we need to teach the facial muscles to support this
corrected position. This is accomplished by an exercise program designed to take 3-5
minutes 3 times per day.

Facial Muscles…Friends or Foes?
The Impact of Muscles
We cannot function without them, but depending on how they are used, they help or
harm us. In medicine, there’s a saying: “If there’s a war between bone and muscle,
muscle will always win.”
There is a therapy which deals only with the muscles of the face, neck, and tongue. It is
called Oral Myofunctional Therapy. This therapy deals with several problems, many
which dentists see that cause teeth to move.
Tongue Rest Posture is the most common problem. This is an incorrect positioning of
the tongue for resting and swallowing. It can be caused by thumb or finger sucking
habits, enlarged tonsils or adenoids, allergies or hereditary narrowness of the facial
bones.
Tongue thrust may have a negative effect on how the teeth erupt in children and may
cause movement of teeth in teenagers or adults. It is possible to correct a tongue
thrust by doing simple exercises directed at strengthening muscles in order to use them
differently. The age that therapy is done is not as important as the person’s motivation
to succeed.
Children as young as two can benefit and adults of all ages do see success. Some
tongue thrusters have an accompanying habit of pacifier, thumb or finger-sucking. Such
habits should be eliminated, and with a positive reinforcement program, this, too, is
possible.
What do you look for to determine if there is a tongue thrust?

 Mouth breathing, tongue lying down and forward
 Constantly chapped lips
 Short upper lip
 High, narrow palate
 Open-mouth chewing
 Inability to take pills
 Snoring
 Drooling
 “Moustache” on upper lip after drinking liquids
 Speech difficulties on S, Z, Sh, Ch, J or L
 Hyperactive gag reflex
 Dental malocclusion: open bite, over jet, teeth that won’t come in or together
 Constantly sore jaws
Headaches
Any combination of these can signal a tongue problem.

Tongue Thrust
The act of swallowing and the tongue’s resting posture can contribute to a disturbance
of the relationship of the teeth (Malocclusion). The habit of thrusting or resting the
tongue against or between the teeth is referred to as Tongue Thrust. This causes the
muscles of the tongue, lips and cheeks to work in disharmony with dental structures.
What Causes Tongue Thrust?
 Thumb / finger sucking habits

 Habitual mouth breathing
 Open – lips rest posture problems
 Neurological problems
 Structural problems
 Developmental problems
 Any combination of the above
If there is harmony in these muscle functions, the teeth can be guided into a more
desirable relationship during the growth and developmental years.
Proper tongue position assists the orthodontist in aligning the teeth and jaws properly
and stabilizing the teeth during / after orthodontic treatment or orthognathic surgery.
Proper tongue posture enhances overall appearance producing positive physical and
mental health.
Why Be Concerned About the Misalignment of Teeth?
Malocclusion may affect the mental health of a patient by having a negative impact on
appearance. Malocclusion may have an undesirable impact on the general health of a
patient.
 Malocclusion may cause more susceptibility to “gum disease” (periodontal

disease).
 Biting and chewing efficiently may be difficult.
 Malocclusion is thought to contribute to “jaw joint” problems (TMJ) and facial

pain.
 Malocclusion is thought to contribute to excessive grinding of teeth (bruxing).

Oral Myofunctional Therapy
We use a positive approach to eliminate such oral dysfunctions as mouth breathing,
open mouth posture with lowered tongue position, and tongue thrust by strengthening
the muscles of the facial network. This is a psycho-physiological approach which is
aimed at coordination of muscle groups as routine for normal deglutition and articulation
from a positive reinforcement exercise regimen.
Therapy is an eight-step program (not necessarily an eight-week program).
2. Therapy is directed at the tip of the tongue, establishing the placement of the
tongue to achieve a labioglossal seal.
8. Aimed at strengthening the musculature that elevates and supports anterior

tongue segments.
9. Repositioning the posterior portion of the tongue for resting and for speech.
10. Integration of new swallow with correct resting posture of the anterior
segment of the tongue.
11. Establishing new patterns of deglutition on a conscious level.
12. Establishing new patterns for subconscious control of chewing, swallowing

and tongue resting position.
13. Determination of the correct subconscious tongue position for resting

posture.
8. Final concerns and evaluation of total pattern of the facial musculature.
Recheck at any change in the oral environment: Bands off, retainer, extractions, etc.,
or if the referral source desires. Patient is dismissed from therapy when at least one
recheck, after a three month lapse, demonstrates correction and proper use of
muscles to the complete satisfaction of clinician and patient.

Asepsis and Infection Control
Every year, many lives are lost because of the spread of infections. Heath care workers
can take steps to prevent the spread of infectious diseases. These steps are part of
infection control.
Proper hand washing is the most effective way to prevent the spread of infections.
Other steps include:
 Covering coughs and sneezes
 Staying up-to-date with immunizations
 Using gloves, masks and protective clothing
 Making tissues and hand cleaners readily available
 Having CLEAN rulers, cheek retractors and mirrors
 Having a CLEAN work surface
Germicidal
One product that is recommended and is used for the cold/hospital sterilization of
instruments is:
Opti-cide by BIOTROL (800-822-8550)
Product # DDCP04-128
Kills: a) Virucidal, b) Fungicidal, c) Bactericidal and d) Tuberculocidal

What can be done to correct These Muscle Problems?
If the muscles of the tongue, cheeks and lips appear to be

contributing to a dental malocclusion, there may be a reason
for concern. A certified Orofacial Myologist is trained in the
identification, diagnosis and treatment of Tongue Thrust and
its related problems utilizing a variety of therapeutic
procedures for the correction of these problems.
Child's Contract (Tongue Thrust)

RULES FOR THERAPY
1. Exercises will be done _____ times per day.
2. Keep charts up to date and bring to every session.
3. Bring supplies required to perform exercises to every session.
4. Come to every session with a smile on your face.

Be prepared to have a good time!!
5. If things are not going smoothly, please contact our office so that we can
stay on top of things.
Please sign:____________________________

Parent’s Participation (Tongue Thrust)
Expectations after the Initial Evaluation…
 “Spots” should be worn _____ times a day. They are VERY important to the
success of this program!
 Exercises should be practiced _____ times every day.
 Mark charts only when the exercises are done.
 Be sure to have your next appointment set before you leave our office (if
possible).

 Remember that children still need your guidance and arrangement for a
successful completion of this program.
 Your therapist has made an assessment that it will take ____ visits to accomplish
the goals that have been set today. The only way that these goals can be
accomplished is to attend ALL sessions. It takes time to reeducate muscles. Our
program is designed to maximize these changes in the shortest amount of time
possible.

Lesson One DATE:___________
2 Times a Day Exercises 3 Times a Day
1. Put "Spots" in: am, pm and before bed. Remember to dry the roof of your mouth
first! Now do these exercises:
2. Tongue Exercises:
a. "Tip Pops": Do 15 loud ones
Suction your tongue tip to the roof of your mouth. Smile. Pop. Do not allow
your tongue to hit the floor of your mouth.
b. "Taco Blows": Do 15
Stretch your tongue out. Roll the sides up like a taco. Blow out and suck in air.
HARD!
3. Lip Exercises:
a. "Lip Pops": Do 20 loud ones
Roll your lips in over your teeth. Press your lips together. Pop your lips apart.
b. "Great Granny / Grandpa Surprise Face": Hold for 20 counts
Roll your lips in. over your teeth. Make an "O" shape with your lips. Raise your
eyebrows!!
4. Posture: Wall stand (like a ‘goal post’) for 30 seconds.
5. Put stickers onto your chart when you finish exercising!

Lesson Two Date:___________
1. Put "Spots" in: am, pm and before bed.

Remember to dry the roof of your mouth first!
a. "Penny Stick Hold": Hold for 15-20 counts
Tape a penny 1/3 back on a Popsicle stick. Roll your tongue around it. Hold the
stick straight. ------► Add a penny as possible.
b. "Palate Scrapes": Do 10-15
Open wide. Place the tip of your tongue on your "Spot". Scrape your tongue tip
back toward your throat. Keep your mouth open.
3. Lip Exercises:
a. "Button Pulls": Pull for 15-20 counts in each direction
Position the button in front of your teeth. Close your lips over the button, pull in
3 directions . Keep your back teeth closed.
b. "Straw Drink": 2-3 oz. of water
Close your back teeth. Place the straw against your front teeth. Pucker your lips
around the straw. Suck in. Keep your back teeth closed.
4. Posture Exercise: Wall-slide: Assume the same position as you did for “wall
stand”. Bend your knees. Slide up and down 10X
5. Mark Your Chart

Lesson Three Date:____________

a. "Tooth Cleaners": Do 10 in each direction.
Close your lips. Place your tongue between your teeth. Move your tongue in a
circle around your teeth, keeping your lips closed. Do not move your jaw.
b. "Penny Stick Hold": Hold for 20-25 counts --►

Continue to add pennies as possible.
3. Lip Exercises:
a. "Bottle hold": Hold for 20+ counts.
Put 8-10 oz. of water into a plastic bottle. Attach your button to the neck of
the bottle.
Position button in front of teeth. Close your lips around the button. Bend over
at a 90 degree angle. Place your hands on your knees. Hold for 20 counts. Add
water/ weight, as possible.
b. "Turtle Lips": Hold for 10-20 counts.
Suck your cheeks in between your teeth, stretch your upper lip down. Raise
your eyebrows!
c. "Straw Drink": Beat _______seconds.
Keep your back teeth closed. Pucker your lips. Be certain that your
tongue is UP!
4. Posture Exercises:
"Corner Wall Stands": Hold for 30 counts.
Stand facing a corner. Raise your hands in a ‘stick-up position. With wrists and
hands touching the wall and your body at an angle, move your body close to the
wall, stretching your arms and shoulders BACK. Hold for 30 seconds.
5. Mark your Chart!!!

Lesson Four Date:____________
2 Times a Day Tongue Thrust Exercises 3 Times a Day
a. "Suction - Stretch - Hold":
Suction your tongue to the roof of your mouth. Open your mouth wide to stretch.
Hold for 20 counts.
b. "Penny Stick hold": Hold for 20 counts.
Continue to add pennies as possible.
3. Lip Exercises:
a. "Bottle Hold": Hold for 30 counts
Position the button in front of your teeth. Close your lips around the button.
Bend over at a 90 degree angle, placing your hands on your knees. Add 1-2
caps of water each day.
b. "Straw Drink":
Finish 5 oz of water in less than 30 seconds. Be sure to keep your back
teeth together at all times.
c. "Cork pulls":
Hold a cork in your hand. Place it in your mouth. Close your lips around the
cork. Suck your cheeks in. Pull the cork with your hand ------► (Do not bite the
cork!.) Pop the cork out. Repeat this 5 times.
"Corner Push-ups":
Stand facing a corner, one hand on each wall. Head up. Bend your elbows to
do10 ‘push-ups’.
5. Mark your Chart!!

Lesson Five Date___________
a. "Sit ups": Do 10
Open Wide. Stretch your tongue straight out. Raise and lower the tip without
moving your jaw.
b. "Suction your tongue UP. Hold. Stretch and hold for 30 counts.
3. Lip Exercises:
a. "Bottle holds": Hold for ______ counts .
Continue to add water as possible.
b. "Turtle surprise face lip pops": Do 20X.
Make turtle lips then do a pop
"Doorway Fly-through”:
Stand 1 foot behind the center of a doorway. Stretch arms out. Hold each side
of the doorway. Lean forward. Head Up. Stretch. Hold for 20 counts.
Now do 10 “Pull-Ups”
5. Chewing Exercises:
"Bilateral chew":
Place a small cracker, cheerios, etc… on your left & right lower molars. Close
your lips. Chew up and down. Exaggerate moving your lips.
6. Put stickers onto your Chart!!

Lesson Six Date:_______________
2 Times a Day Tongue Thrust Exercises 3 Times a Day

2. Tongue exercise:
"Fat-Skinnies": Do 15.
Stretch your tongue straight out. Contract your tongue muscles to make it skinny.
Relax your muscles to make your tongue fat.
3. Lip Exercises:
a. "Bottle hold": Bend over. Hold for ______ counts .
Continue to add weight when possible.
b. "Great Granny / Grandpa Surprise Screamers": Hold for 5 counts.
Roll lips in over your teeth. Make an "O" shape with your lips. Raise your
eyebrows then open mouth wide, show teeth. Repeat 5 times.
c. Air trap: Hold for 20 counts.
Close your teeth and lips. Puff air into your upper lip.
4. Swallowing Exercise:
"Squirt Swallows": Do _____.
Squirt water once onto the back of your tongue. Place your tongue tip on the
"SPOT". Bite. Smile. Swallow.
5. Chewing Exercises:
a. "Bilateral chew": Do ____ .
Place small cracker, cheerio, etc. on left & right lower molars. Close your lips.
Chew up and down by exaggerating moving your lips and facial muscles.
b. "Place Mat":
Use as a reminder at every meal
a) Arms behind you stretch …. Hold for 20 counts.

Lesson Seven Date:_______________
1. Put "Spots" in am, pm and before bed.
a. "Fat-Skinny-Fat-Taco": Do 10.
Extend your tongue. Do ‘Fat-Skinny-Fat-Taco’ maintaining a stretch
b. Suction your tongue to the roof of your mouth.
Hold. Now, Open/Close, Bite, Smile. Swallow: Do 10.
3. Lip Exercises:
a. "Bottle": Hold for 30-40 counts.
Add weight.
b. "Lip-O-Ciser" Stretch: 30 counts.
Position it in front of your teeth.
c. "Cotton Roll": Hold for 15-20 minutes
Moisten the cotton roll first!
4. Swallowing Exercise:
Chew ↑↓, gather the food onto the back of your tongue. Check it. Suction your
tongue against the roof of your mouth. Bite, smile and swallow. Check your tongue,
it should be "clean".
5. Use your placemat at mealtime.
6. Posture Exercise:
_________________________________________________________
_________________________________________________________
7.Mark your Chart!!

Lesson Eight Date ____________
1. Put "Spots" in _________________________________________
a. __________________________________________________
b. __________________________________________________
3. Lip Exercises:
a.___________________________________________________
b.___________________________________________________
c.___________________________________________________
4. Swallowing Exercises:
_____________________________________________________
_____________________________________________________
6. Other Concerns:
_____________________________________________________
7. Mark your Chart!!

“Fun Exercises”
1. Tick Tocks: tip pop w/forward lip movement (smile/pucker) tongue tip only
2. “Smartie Melts” tip to spot, melt down by pressure – with “smartie” checks
3. Figure “8” Tooth cleaners – tongue control
4. Balloon Blows – 5x nasal breathe in to blow
5. Kiss/Pops – lateral face muscles/chin, lip strength – keep teeth closed to kiss
6. Fish Crush: tongue strength (lay laterally)
7. Palate dots: tongue awareness ↑, ↓ moving back, tip strength/stretches Frenum
8. Elastic Fat/Skinny – narrowing tongue
9. Molar Touches: works all muscles: Frenum stretch, lateral, sensory input
10. Balloon Blows
11. Molar Touches (side to side)
12. Air Trap (upper, lower, side-to-side) Hold 10 counts
13. Pin Wheel Blows: can be done with lips or ‘taco tongue’
14. Feather Blows: can be done with lips or taco tongue
15. “Raspberries” and motor boats: lip awareness
16. Pipe Blows – Nasal breath
17. Party Blowers – Blow out suck in
18. Big Ball Blows – Nasal breath in
19. Kazoo Tunes (T, D, N, L): Using spot- tip up- use for voicing
21. Clothes Pin ‘Alligator”: jaw muscle strength
22. Knotted Straw Drink – Back teeth closed
23. Sprinkle Sit-ups
24. Cotton Roll Hold
25. Sprinkle ‘Licks”
26. Elastic escapes – ‘Houdini’ move whole tongue back, move laterally
27. Big cork pops: entire network of muscles: 3 counts then pop 10x
28. Medium sized button – Pull or attach to bottle for lip stretch.
29. Horse Clicks – works well for posterior open bites right and left
30. Straw chew for proprioception – 2 minutes
31. Bilateral button pulls, teeth stay closed
32. ‘Kitty whiskers’ – teeth closed, pucker- move only pucker side to side.
Good for bilateral facial muscle control

Allergic Shiners
An additional factor in the production of oedema and

discoloration is allergic spasm of the muscle Muller.
This is the only unstriated muscle of the eyelid

musculature.
Spasm of this muscle may impede venous return from

the skin and subcutaneous tissues backward to the
marginal arcades and palpebral veins.
As a consequence, edema is produced in the soft tissue

below the lower eyelids.

Lateral Wall of Nasal Cavity

Paranasal Sinuses

Airway Obstruction
Does your child breathe with his/her mouth

open? Not everyone breathes properly.
Recent research indicates that the way your
child breathes can have a great impact on his
or her future health and physical appearance.
In normal breathing, air passes through the

nose. But many children find nasal breathing
difficult and just breathe through their mouths.
When a child breathes through his Mouth breathing is generally caused by one or
mouth, he circumvents nature's filter apparatus more of three types of problems:
and places greater strain on the heart and 1. Enlarged adenoids.
lungs. Consequently, mouth breathing has 2. Underdeveloped nasal passages.
been associated with a greater incidence of 3. Nasal blockage caused by allergies, swollen
enlarged hearts, fluid in the lungs, heart tissue, or other obstructions such as polyps.
failure, enlarged tonsils, adenoids and
turbinates, high blood pressure, digestive Recent research has given doctors more effective
problems and poor sleep – to name but a few methods of diagnosing and treating mouth
symptoms. breathing. Special standardised x-rays can
analyze, by computer, to determine the size of the
The open-mouth breathing position tends to tonsils adenoid tissue that contribute to the mouth
alter muscle function, which affects growth of breathing problem. If the tonsils and adenoids are
at fault, it may be desirable to remove them.
the face and results in an unusually long,
However, this must be weighed carefully for each
narrow appearance. In addition, the jaws tend
individual, since the tonsils and adenoids are
to grow apart rather than together, forcing the
apart of the body's immune system.
tongue to be held lower in the mouth than
normal. This can cause a narrowing of the If results indicate that the tonsils and adenoids are
upper dental arch and abnormal positions of not a problem, it can then be determined if your
all teeth, which affects the bite as well as child's breathing might be aided by myofunctional
physical appearance. therapy, Breathing Retraining and orthodontic
treatment. The problem may be corrected before it
seriously affects facial development.

Is it a Cold or an Allergy?
When is a cold not a cold? When it is a nasal allergy? Since the reason you're sniffling
and sneezing makes a difference in choosing the best treatment, we asked Bry
Benjamin, M.D., assistant clinical professor of medicine at Cornell University Medical
College, how to read common symptoms.
Cold Allergy
Runny nose and sneezing last 1-3 days; Persistent watering of nose and eyes
lasts anywhere from a few weeks to
if cold symptoms persist for more than a
several months, depending on the
week, see a doctor - you may have allergen
complications such
Itchiness of the nose, eyes and roof of
as bronchitis or sinusitis
the mouth or back of throat
Sore throat and / or coughing General feeling of well-being, except for

areas experiencing allergic symptoms;
General malaise -fever, muscle aches, appetite usually is not diminished
chills, sweats, loss of appetite, fatigue -
which indicate an infection In most cases, sinuses are not painful or
tender
Burning sensation in nose, often
accompanied by nasal/sinus tenderness Mucus is watery and clear
Mucus can become yellow, green, thick,

foul-smelling or bloody
Allergy Time
How to help your child cope
By Loraine Stern, M.D.
When a hot wind starts to blow or construction begins in a neighborhood near my

office, I know I'll be seeing a bunch of children with allergy problems. Disturbances of
soil and air can trigger a bout of allergic rhinitis, otherwise known as hay fever.
The term is really a misnomer, as allergic rhinitis has nothing to do with hay and
there's no accompanying fever. It's caused by allergy to materials in the air. Pollen
allergy is worst in spring, grass allergies flare up in late spring and summer, and
ragweed is mainly an early fall allergy. Mold allergy often occurs after a rainy or foggy
spell is followed by a dry, warm wind. Furry pets also can cause problems (though
children born into a home with a pet are actually at less risk of being allergic to it).
Childhood allergies usually begin in the early school years but can start as young
as 2 years of age. One recent study revealed that umbilical cord blood cells showed
sensitivity to pollen, meaning allergies may begin even before birth. As many as 40
percent of children suffer from seasonal allergies and in only 10 to 20 percent do the
symptoms completely disappear over time. They often run in families, and most children
with asthma also have allergies.
The most common signs are cold-like symptoms such as itchy, runny eyes and
nose that don't clear up after a week or two. Some children also experience bouts of
rapid “'machine-gun" sneezing. Sleep problems may occur because nasal obstruction
leads to snoring, which may wake a child during the night. This can cause sleep
deprivation, fatigue and missed school days. Discomfort during the day can cause
irritability and difficulty concentrating. Ear and sinus infections are also common.
The best treatments

While over-the-counter allergy medicines can help, they may also cause
drowsiness. Prescription antihistamines such as Claratyne, Zyrtec and Allegra don't have
this side effect, and some can be used on children as young as 2. Your pediatrician may
try several before finding the one that works best.
Saline nose drops thin mucus and wash away irritants as well as moisturize
tender sinus passages. Available without a prescription, the product can be used CIS
often as you like because it has no side effects. Prescription nasal sprays can also be
helpful, but I've found that many children simply refuse to allow their noses to be
sprayed.
If simple measures don't work, you may need a referral to an allergist to

determine what is causing the problem. Skin testing has become easier than the painful
multi- needle procedure used to be. The current device applies all the suspected
allergens at once so discomfort is minimal.
For a child who suffers persistent problems, it may be worth the trouble and
expense of allergy shots, which can often bring significant relief.
Teaching a child to breathe through their nose can help to prevent allergy
symptoms.
Prevention tips
Knowing what triggers your child's symptoms can help you cut down on exposure.
Keep windows closed during pollen season, especially on windy days and in the early
morning. If your child is sensitive to dust, replace carpeting with linoleum or wood
flooring; encase mat- tresses and pillows in allergy-proof zip-up casings, use synthetic
bedding and keep a minimum of books and stuffed animals. For mold allergies, remove
wallpaper and old carpeting.
Keeping furry friends out of your child's room can help with pet allergies. Also,
bathing cats about once a month can significantly cut down on the amount of dander
they release into the air. WD

Breathing, Posture and Myofascial Dysfunction
The Hardware – Software concept.
Adjusting the Hardware Retraining the Software
Irrespective of what has caused “hardware” problems, be it to the teeth, jaw, neck, spine,
musculature or posture, the body will ALWAYS rely on its instinctive survival mechanisms and
alter whatever has to be altered in order to maintain the airway and keep us alive.
If dysfunctional physical conditions persist for any length of time there is usually – in fact almost
universally – a change to the breathing “software” as the body learns to adapt to the new
postural, myofunctional or physical state.
This change to the breathing pattern then becomes the new “software” which drives the
biochemistry and physiology, and a new habit or pattern is installed.
This pattern becomes “NORMAL” for that person but is in fact dysfunctional in terms of body
balance.
The reason that so many hardware treatments, adjustments and devices do not bring about the
desired results, be it in implementation or retention, is that the old version of the software is still
running and will bring the body back to the original state – unless ‘upgraded’.
Breathing Retraining, together with postural correction and behavioral modification tends to
support the hardware systems and bring about a far better and longer lasting outcome.
The Importance of Respiratory Activity in Myofunctional

Therapy
By Irene QUeirO2 Marchesan, MA &
Lilian Ruth Huberman Krakauer, MA
For many years, the speech-language pathologist's work related to the orofacial
myology was basically restricted to the swallowing function. Currently, we are becoming
more aware that two other functions, respiration and mastication, are extremely
important for the growth and development of the Stomagnathic System. In this paper,
we will limit ourselves only to breathing, specifically mouth-breathing. In our speech-
language-hearing clinic, we have been treating a great variety of patients, referred by
orthodontists, with a diagnosis of tongue thrust. In general, this condition appears to be
highly correlated with mouth-breathing. Actually, most patients present with a
combination of respiration (oral and nasal). One question arises, why this enormous
amount of oral breathers?
The reasons are many, and some of them are:

 Organic problems, like: rhinitis, sinusitis, hypertrophy of pharyngeal or palatine
tonsils
 Hypotonicity of the mandibular elevator muscles, because of pasty food resulting
in open mouth with incorrectly positioned tongue
 No discernible reason for poor posture: the patient (child or adult) simply sits with
mouth open, sometimes even without being aware of it, with no mechanical or
functional barriers to nasal respiration.
In general, the mouth-breather may present a variety of symptoms, characteristic of the
condition known as Oral Breather Syndrome or Dysfunctional Breather. These symptoms
are:
1. Craniofacial and Cranio-dental Disorders

 Predominantly vertical craniofacial growth
 Steep gonial angle-elongation of the face
 Narrower facial dimension
 Maxillary hypo-development
 Narrower or inclined nostrils
 Micro-rhinia with less space in nasal cavity
 Deviation of the nasal Septum
 Class II, over jet, cross bite or open bite
 Upper incisal protrusion
2. Disorders of Phono-articulatory Organs

 Hypotrophy, hypotonia, and hypo-function of the mandibular muscles
 Tonus changes with hypo-function of lips and cheeks
 Short or retracted upper lip, and lower lip everted or interposed between teeth
 Dry, chapped, or bruised lips with changes in color
 Hypertrophy of gums with changes in color and frequent bleeding
 Tongue-forward posture or dorsum elevation to regulate air flow
 Oral proprioception
3. Body Disorders

 Thoracic deformities
 Distended or flaccid abdominal muscles
 Shadows around the eyes with ocular hypotelorism or hypertelorism, weary-eyed
 Ill-positioned head in relation to the neck causing changes in the spinal column as an attempt
to compensate for this ill-positioning
 Shoulders forward compressing the thorax
 Alteration of the tympanic membranes, diminished hearing -visible facial asymmetry, mainly in
the buccinator muscles
 Very lean individual, sometimes obese and lacking normal color
4. Disorders of the Oral Functions
 Ineffective chewing causing digestive problems and choking because of in-coordination

between breathing and mastication
 Tongue thrust with noise, anterior protrusion of tongue, exaggerated orbicularis oris
contraction, compensatory head movements, over contraction of the mentalis muscle.
 Imprecise and inaccurate speech, with excess of saliva, without full resonance because of
frequent otitis with high incidence of anterior or lateral lisping
 De-nasal, nasal or hoarse voice
5. Other Possible Disorders
 Frequent sinusitis, recurrent otitis-pharyngeal and palatine tonsils growth (adenoids and
tonsils) -halitosis and diminished perception of taste and smell
 Greater incidence of caries -sleep alterations, snoring, nocturnal drooling, insomnia, vague
facial expression
 Appetite reduction, gastric alterations, constant thirst, choking, pallor, loss of appetite, loss of
weight with less physical development or obesity
 Less physical activity, global un-coordination with frequent weariness
 Agitation, anxiety, impatience, impulsivity, despondency
 Difficulty with attention and concentration, causing school problems
It is important to point out that all symptoms mentioned above will not necessarily be present at the
diagnosis of the oral breather syndrome.
Why is the respiration so important?
Babies do not breathe through the mouth because their oral cavity is small and totally
occupied by the tongue. When a baby is suffering from a cold, he becomes very annoyed, for mouth-
breathing is almost impossible for him. As the babies grow up, they learn that the mouth can be used
as a respiratory channel when nasal breathing is impaired.
When we breathe through the nose, with proper functioning of chewing, swallowing, and
resting postures of the tongue and lips, the muscle actions stimulate the bones correctly for optimal
facial growth and development.
If mouth-breathing is present, that stimulation may occur improperly, resulting in a

disharmonious growth and development.

Genetic conditions must be considered. If the individual has a tendency toward a class III
malocclusion, mouth-breathing, a low tongue resting position, and an open mouth resting posture,
this will certainly aggravate the class III malocclusion. Orthodontics and oral myofunctional therapy
can redirect growth and minimize the possibility of pragmatism, by correcting the breathing patterns
and the oral muscle functions and postures.
Orofacial myofunctional therapy with young children (4 to 5 years of age), who are mouth-
breathers without unfavorable genetic heritage and without organic problems impairing nasal
breathing, is highly successful because once good lip and tongue posture have been established and
habituated, a more harmonious growth is facilitated.
With allergic patients, the oral myofunctional therapy goal is to give the patient better nasal
breathing conditions outside crisis. If the individual can be trained to use nose-breathing whenever
possible, episodes of allergy crises are diminished, since the air flowing through the nose is
submitted to cleansing, heating and humidifying processes.
However, we must emphasize to the family that this therapy will not cure the allergy; it will
only improve breathing conditions of the patients outside crisis.
Therapy with the oral-breather is not limited to the oral myofunctional therapy. On the'
contrary, usually the therapist works together with an otorhinolaryngologist and an orthodontist in a
team approach.
It will always be necessary to ask for an otorhinolaryngologic evaluation to determine whether

or not the mouth breathing is caused by organic disorders. If the disorder is organic, it will frequently
be best to delay treatment. It might be necessary to proceed at first with medical or surgical
treatments, before myofunctional therapy is began, in order to install or reinstall nasal breathing.
With regard to the orthodontist, as mentioned above, mouth-breathing can cause alterations in
occlusion and/or facial growth.
We must not forget that there are also adult mouth-breathers. These are two types:
 Those who became mouth-breathers as adults;

 Those who were mouth-breathers since childhood but only sought treatment as adults
The first type present muscle but not bone disorders, since the facial growth was already
completed when they became oral breathers. 90% of the face grows until the age of 13 to 14 years
and the remaining 10% until the age of 20 years. In these cases, because of muscle alterations only,
the changes are swifter and the therapeutic success is higher. As for the second type, attention must
be directed to the choice of appliances and also the lack of a 100% success in treatment, since the
craniofacial growth ended and the muscles will have accommodated over the bones.
Before beginning the myofunctional therapy, the patient must be aware that the therapy itself
will be limited to muscle functions and will not be able to change occlusion and bony structures.
In relation to mouth-breathers' characteristics, some associated problems can develop, as:

 Articulatory imprecision: because of tongue hypo-tonis, sometimes incorrect articulation of
phonemes is present in spontaneous speech, despite the patient being able to articulate each
phoneme individually.
 Anterior lisp: because of tongue hypotonia associated with anterior open bite, common in
mouth-breathers.
 Lateral lisp: because of tongue hypotonia, the tongue occupies the oral cavity, interposing
itself in the posterior part of the dental arches.
 Tongue thrust: because of poor resting posture of the tongue or as a compensation for
anterior open bite or other malocclusion.
 Atypical mastication: because of hypotonia of mandibular elevator muscles and poor
coordination of respiration with mastication/deglutition.
In summary, we would like to alert professionals who are working with the Oral-Motor-
Sensory System that "tongue thrust" swallowing may not be the "key point," but may actually result
from ill-functioning of breathing and even chewing.
Working accordingly with respiration as well as with chewing, swallowing can adapt by itself
without the training of "tongue on papilla." Also, it is important to note that simultaneous therapy with
tongue, lip, and cheek tonicity, and mandibular elevator muscles must be carried out if necessary.
In London in 1870, George Catlin Wrote a book entitled Shut Your Mouth and Save Your ~
Today; we can plagiarize him and write: "Without a closed mouth there is minimal nasal breathing,
and without nasal breathing, because of all the alterations it causes, there is poor quality of life."

Coventry 2000 & Guyton 1982 noted that
“Occlusion abnormalities occur predominantly during childhood as a result of:
 Breathing through the mouth

 Thumb sucking or sucking of the lower lip
 Muscle function defects – placement of tongue between the teeth and incorrect
swallowing.
Resulting in:
 Narrowing of the arches within the jaw resulting in overcrowding and and
 unattractive “gummy” smiles
 Forward head posture which can lead to neck muscle pain, stiffness and
 fatigue
 Headache
 V-shaped upper jaw and high palate
 Malocclusion - anterior bite
 TMJ dysfunction - complain of pain where the lower jaw hinges to the skull,
 may have trouble chewing, may have earache
 Under developed nasal passages and / or underdeveloped jaw and
 cheekbones
 Gum disease or Dental decay
 Dry mouth / throat or Bad breath
 Increased allergen / airborne infection entry to lungs
 Chronic swelling of the tonsils
 Enlarged adenoids, polyps
 Noisy breathing / noisy eating
 Excessive snoring at night
 Orthodontic treatment
 Increased mucous production
 Hypocapnia - a low level of CO2
 Reduced lip tone and/or tongue tone
 Diaphragmatic spasm
 Shallow upper chest breathing
 Poor posture and Reduced strength in core muscles”


 Regardless of the amount of orthodontics, if the patient is not taught to breathe
correctly and myofascial therapy is not instigated as part of the orthodontic
treatment…there is greater potential for relapse of orthodontic correction.

 According to the British Snoring & Sleep Apnea Association, ‘During sleep
we are designed to breathe through the nose. If for any reason nasal
breathing is not possible our body's self-preservation mechanism forces
us to breathe through the mouth.
What are Sleep Disorders?
Dysomnias
Disorders associated with difficulty in initiating or maintaining sleep or with excessive
sleepiness.
Insomnia
Narcolepsy
Periodic limb movement or restless leg syndromes
Nocturnal eating
Circadian rhythms-related sleep disorders (jet-lag, shift work, etc.)
Parasomnias
Disorders of arousal or sleep stage transition.

Sleepwalking.
Rhythmic movement disorders.
Nightmares.
REM sleep behavior disorders
Sleep bruxism
Sleep-related abnormal swallowing syndrome
Primary snoring
Sleep apnea
Infant sleep apnea/ sudden death
Sleep disorders associated with psychiatric/medical disorders

Not primarily sleep disorders, rather manifestations inducing sleep disturbance or
excessive sleepiness.
Mental disorders (panic, anxiety, overuse of drugs and alcohol)
Neurologic and/or movement disorders-related

(Parkinsonism, epilepsy, headaches)
Sleep-related gastro-esophageal reflux disorder (GERD).
Fibromyalgia
Fragmentary myo-clonus (associated with severe sleep bruxism).
Sleep choking syndrome
(Thorpy, M.G. ,1990)
Definitions of Sleep Disorders
Snoring (with and without apnea)
 Loud noise
 No arousal
 Normal sleep and respiration patterns
 No 02 desaturation or cardiac arrhythmia
 Worse in supine position
 Complaints from bedroom partners
 Dry mouth at wake time
Obstructive Sleep Apnea
 >5 episodes and > 10 seconds’ duration per hour

 Accompanied respiratory effort
 Frequent arousals
 Brady tachycardia
 Arterial O2 de-saturation
 Short sleep latency(<10 min with 10-20 min normal)
 Happens during daytime sleep as well
 Not due to gastro-esophageal reflux disorder (GERD), asthma, choking etc.
 Excessive sleepiness by self and others report
 Morning headache
 Dry mouth
 Sexual dysfunction
 Intellectual performance deterioration
Central Sleep Apnea
 Apneas > 10 sec. each

 No accompanied respiratory effort
 Respiratory efforts after 10-30 sec of apnea-hypopnea
 10-60 sec hyperventilation after apneic episode
 O2 desaturation
 Not due to physical obstruction as in OSA, GERD, asthma, choking etc.
 Complaints of insomnia or hyper-somnia by self and other report
 Frequent napping during the day
 Driving somnolence
 Headache at wake time
 Depressive reactions
 Reports of hypertension
Nose versus Mouth Breathing

Published-western-clinical evidence clearly proved that mouth breathing is one of 2 immediate
leading causes of mortality in the severely sick patients with chronic diseases. Early morning hours
(from about 4 When seeing modern people on Western streets and in public places, one may easily
notice that up to 30-40% of them breathe through their mouths when walking or even while standing
or sitting. Most people these days are mouth breathers. The same can be easily observed during night
sleep. Some decades ago mouth breathing was socially abnormal and unacceptable. For example, one
dictionary suggests that a "mouth-breather = n. a stupid person; a moron, dolt, imbecile". What
are the confirmed mouth-breathing effects?
CO2-related biochemical effects of mouth breathing

CO2 is not a toxic waste gas (see links to studies below). Research
articles on respiration often mention dead space, a physiological
parameter, which is about 150-200 ml in an average adult person.
Dead space is inside the nose, throat, and bronchi. This space helps to
preserve additional CO2 for the human body to invest elsewhere.
During inhalations we take CO2 enriched air from our dead space
back into the alveoli of the lungs. When the mouth is used for
respiration, the dead
space volume
decreases, since nasal passages are no longer a part
of the breathing route. Consequently, air exchange
for mouth breathing is stronger since air goes
directly from the outside air to the alveoli. This
reduces alveolar CO2 and arterial blood CO2
concentrations. Such an effect does not take place
with nose breathing.

Furthermore, the nasal-breathing route provides more resistance for respiratory muscles as compared
to oral breathing (the route for mouth breathing is shorter and it has a greater cross sectional area).
In their study "An assessment of nasal functions in control of breathing" (Tanaka et al, 1988),
Japanese researchers discovered that end-tidal-CO2 concentrations were higher during nose breathing
than during oral breathing. This research study revealed that a group of healthy volunteers had an
average CO2 of about 43.7 mm Hg for nose breathing and only around 40.6 mm Hg for oral breathing.
In practice, in terms of body oxygenation or the CP, this corresponds to 45 s and 37 s at sea level.
Hence, mouth breathing reduces oxygenation of the whole body.
Each mouth breather needs to know this short summary

of immediate negative biochemical effects of mouth
breathing related to CO2:
- Reduced CO2 content in alveoli of the lungs (hypocapnia)
- Hypocapnic vasoconstriction (constrictions of blood
vessels due to CO2 deficiency)
- Suppressed Bohr effect
- Reduced oxygenation of cells and tissues of all vital
organs of the human body
- Anxiety, stress, addictions, sleeping problems and
negative emotions
- Slouching and muscular tension
- Biochemical stress due to cold, dry air entering into the
lungs
- Biochemical stress due to dirty air (viruses, bacteria, toxic
and harmful chemicals) entering into the lungs
- Possible infections due to absence of the autoimmunization effect
- Pathological effects due to suppressed nitric oxide utilization, including vasoconstriction, decreased
destruction of parasitic organisms, viruses, and malignant cells (by inactivating their respiratory chain
enzymes) in alveoli of the lungs, inflammation in blood vessels, disruption of normal
neurotransmission, hormonal effects.
Nose breathing delivers nitric oxide to lungs, blood and cells
Normal nose breathing helps us to use our own nitric oxide that is
generated in the sinuses. The main roles of NO and its effects have
been discovered quite recently (in the last 20 years). Three scientists
even received a Nobel Prize for their discovery that a common drug,
nitroglycerin (used by heart patients for almost a century), is
transformed into nitric oxide. NO dilates blood vessels of heart
patients, reducing their blood pressure and heart rate. Hence, they can
survive a heart attack.
This substance or gas is produced in

various body tissues, including nasal
passages. As a gas, it is routinely measured
in exhaled air coming from nasal passages. Therefore, we can't utilize our
own nitric oxide, an important hormone, when we start mouth breathing.
The confirmed functions of nitric oxide are:

1. Destruction of viruses, parasitic organisms, and malignant cells in the airways and lungs by
inactivating their respiratory chain enzymes.
2. Regulation of binding - release of O2 to hemoglobin. This effect is similar to the CO2 function (the
Bohr effect).
3. Vasodilation of arteries and arterioles (regulation of blood flow or perfusion of tissues).
4. Inhibitory effects of inflammation in blood vessels.
5. Hormonal effects. NO influences secretion of hormones from several glands (adrenaline, pancreatic
enzymes, and gonadotropin-releasing hormone)
6. Neurotransmission. Memory, sleeping, learning, feeling pain, and many other processes are possible
only with NO present (for transmission of neuronal signals).
Obviously, during mouth breathing it is not possible to utilize one's own nitric oxide which is
produced in the sinuses. The mouth, according to Doctor Buteyko, is created by Nature for eating,
drinking, and speaking. At all other times, it should be closed.
Cleaning, humidification and warming of air flow due to nose

breathing
Our nasal passages are created to humidify, clean and warm the incoming
flow of air due to the layers of protective mucus. This thin layer of mucus can
trap about 98-99 percent of bacteria, viruses, dust particles, and other
airborne objects.
If you are an endurance athlete and an asthmatic, you must train mostly, or
even better, only, with nasal breathing. For really important competitions,
you can use the mouth for breathing, but only if you have no current
problems with your asthma. Sport training is useful due to its aerobic training
effect. This is achievable while breathing only through the nose, as one
Australian study confirmed (Morton et al, 1995; see the abstract in the references).
A group of US doctors from the Department of Surgery, University of Chicago even wrote an article
with the title "Observations on the ability of the nose to warm and humidify inspired air".
Mouth breathing influences on the autoimmunization effect
This is another advantage of nasal breathing over mouth breathing. The thin layer of mucus moves as
a long carpet from sinuses, bronchi and other internal surfaces towards the stomach. Therefore, objects
trapped by the mucus are discharged into the stomach, where GI enzymes and hydrochloric acid make
bacteria, viruses and fungi either dead or weak. Later, along the digestive conveyor, some of these
pathogens (dead or weak) can penetrate from the small intestine into the blood (due to the intestinal
permeability effect). Since these pathogens are either dead or weakened, they can not do much harm
(cannot cause infections). Moreover, they can provide a lesson for the immune system. This is exactly
how natural auto-immunization can work with success. Medical doctors and nurses inject vaccines
with dead or weakened bacteria or viruses so as to teach and strengthen our immune response to these
pathogens, but not to bed bugs NYC. Therefore, nasal breathing creates conditions for natural
autoimmunization.
Practically, when a household member is sick (as with the flu or cold), the still-healthy people could
breathe either through their nose, teaching the own immune system how to deal with the pathogenic
bacteria or viruses, or through their mouth, as in mouth breathing, allowing these pathogens to gain
access, settle and reproduce themselves in various parts of the body, causing the infection.
Which medical therapy provides techniques and methods to get rid of mouth
breathing?
It is one the key goals of the Buteyko breathing method

to stop mouth breathing and ensure nose breathing 24/7,
to prevent all these mouth breathing effects. Over 150
Soviet and Russian MDs have been using this system.
For many mouth breathers and sick people, quick health

improvement (the initial stage of breathing
normalization) is accomplished by one change only:
learning how to breathe through the nose 24/7. Just this
step alone can make a big difference in the health of
many people so that the main symptoms are reduced
and less medication is required.

(Lavigne et al.,1999)
Who is at Risk for Sleep Disorders?

Obese, middle-aged males with small mandibles, short or thick neck, who sleep on their
backs
Children with enlarged tonsils and adenoid pads, with nasal allergies
Post-menopausal obese women
Stroke and TBI patients
How do sleep disorders begin?
Gravity.
Age.
Gender.
Sleep position.
Body weight.
Small retrognathic mandible.
Elongated uvula.
Hypotonic soft palate.
Hypotonic or un-coordinated tongue.
Debilitating illnesses.
Neurological disorders.
Drugs, alcohol, tobacco.
Dis-coordination between breathing and swallowing patterns
Forward Tongue Rest Posture

How Are Sleep Disorders Diagnosed?
Sleep clinics
Overnight polysomnography in a sleep clinic

Ambulatory polysomnography at home
Portable pulse oximetry
RDI (Respiratory Disturbance Index) or AHI (Apnea- Hypopnea Index)
<5 episodes and >10 seconds duration per hour

<5 is normal
10-20 is mild
21-40 is moderate
>40 is severe

Oral Structures Involved in Sleep Disorders
Pharyngeal Dilator Muscles
1) Genioglossus
2) Geniohyoid
3) Musculus uvulae
4) Palatoglossus
5) Sternothyroid
6) Sternohyoid
7) Suprahyoid muscles (Digastric muscles, Mylohyoid, Stylohyoid)
Also involved:
8) Orbicularis oris
9) Masseters
How are Sleep Disorders Treated?
Low-tech devices
 Breathe-Right strips
 Soft foam ear plugs for others
 Household remedies
 Chewing gum for sleepy patients
 Nosovent
Nasal Continuous Positive Airway Pressure (CPAP)
 Good therapy, but scarce compliance unless well motivated.
Behavioral changes
 Changes in sleep position

 Reduction or elimination of drugs & alcohol
 Weight loss programs
 Physical exercise programs.
Dental devices
 More than 35 dental devices are available for sleep disorders.

 Activate mastication and tongue muscles.
 Tongue Retaining Devices (TAD): can be used by edentulous patients.
 Mandibular Advancement Devices (MAD) or Prosthetic Mandibular Advancement
 (PMA): TMJ limitations

Surgery
The American Sleep Disorders Association indicates the following surgical procedures for
OSA :
 Laser-assisted uvulopalatoplasty (LAUP)

 Uvulopalatopharyngoplasty (UPPP)
 Tonsillectomy and adenoidectomy
 Nasal septal surgery
 Mandibular surgery
 Inferior mandibular osteotomy
 Maxillomandibular advancement osteotomy (MMO)
 Hyoid bone suspension
 Genioglossal advancement with hyoid myotomy and suspension (MOHM)
 Partial tongue resection
 Linguoplasty
 Tracheostomy
 Radio Frequency Ablation (RFA)
 Cautery Assisted Palatal Stiffening (CAPS)
Long term success for surgery varies from 46% to 73% (LAUP and UPPP)
What is the role of the Orofacial Myologist?
 Assessing orofacial structures

 Screening patients with OSA characteristics
 Form a network between orthodontists, pediatricians, physicians
to refer and care for children and adults with OSA
 Research functional therapy for OSA
 Does tongue repositioning reduce OSA?
 Is reduction in OSA episodes a bonus of myofunctional therapy?
 Can it be applied to adults or works only with children?


The Importance of the Orofacial Muscles in OSA
 Genioglossus (GG) responds to local mechanisms of upper airway negative
pressure. GG reflex is more active during wakefulness and reduced during REM
sleep, therefore more vulnerable to collapse during REM sleep ( Shea et al.1999).
 GG strength is greater in males than females and decreases with age.
Fatiguability of GG is equal across genders. May explain why sleep disorders
increase with age but not the gender difference (Morlimore et al. 1999).
 GG and Geniohyoid (GH) in subjects with OSA present adaptation and muscle
injury significantly higher than in Sternohyoid and Sternothyroid muscles in OSA
subjects and control group, suggesting different involvement of the Pharyngeal
Dilator Muscles (PDMs) in sleep disorders (Scotland et al. 1999)
 GG function, structure and fatigability are different in subjects with OSA,
compared to control group, and these abnormalities are corrected by CPAP
(Carrera et al. 1999).
 GG muscles in subjects with OSA present a change in muscle fibres: increase in
fibres Type II (fast twitch) and reduction of fibres Type I (slow twitch) ( Carrera et
el. 1999).
 Daytime electro-stimulation of supra-hyoid muscles may prevent episodes of

obstructive sleep apnea (Wiltfang et al. 1999)
 Masseters in healthy subjects present low intensity and short duration activity
during sleep, greater in men than women. Facial pain may be associated with
increased activity of masseters during sleep (Gallo et al. 1999).
 Electro-myogram (EMG) of GG, masseters, and lateral pterygoid muscles showed
that there is a decrease in EMG amplitude (hypolonia) during episodes of OSA,
compared to before the episodes, and a greater amplitude after the episodes of
OSA. Decrease in EMG amplitude was not observed in Central Sleep Apnea
(Yoshida,1998).
 Orofacial morphology of patients with night-time bruxism does not differ from
that of non bruxers. A further suggestion of bruxism as a central disorder rather
than peripheral (Lobbezoo et al. 2001).
 During non-REM sleep, the Superior Pharyngeal Constrictor is not activated in
subjects with OSA nor in the control group, except for airway reopening,
indicating the involvement of other muscles in obstruction of airflow ( Kuna &
Smickley, 1997).
 The metabolic and histo-chemical characteristics (glycolytic, glycogenolytic, and

anaerobic enzymes. Type I and II fibres) in the Musculus Uvula and GG muscles
are different in sleep apnea subjects, compared to snorers and control group. and
are not present in all PDMs (Series et at., 1996).

 The morphology of uvula in OSA patients contains more muscles and fat deposits
compared to the non-OSA subjects, regardless of sex or anthropometric
measures, but related to frequency of apnea- hypopnea ( Stauffer et al. 1989).
 Histo-pathologic changes in the uvula of snorers and subjects with OSA show
focal atrophy of muscle fibres, edema of the lamina propria, hypertrophy of
mucous glands, vascular dilation, degeneration of myelinated nerve fibres. These
findings support the hypothesis of changes in the uvula secondary to vibratory
trauma and impaired pharyngeal reflexes and development of OSA ( Woodson et al.
1991)
 The palato-glossus muscle is a nasopharyngeal dilator muscle and is activated

during negative upper airway pressure in inspiration, but only the GG is activated
in supine position (Mathur et al.1995).
 The intra-pharyngeal negative pressure itself modulates the GG activity,
independent from central control, and controls the activity during and between
breaths (Malhotra et al. 2002).
 Wearing a Bionator at night decreases the activity of masseters and supra-hyoid
muscles, but not in a significant measure (Hiyama et al. 2002)

How OSD affects Children
by Bharatha Malawaraarachchi
Obstructive Sleep Disorders (OSD) in children was a less talked-about issue until a
recent study conducted by research team in the USA made the shocking revelation that
children suffering from OSD do not perform as well as normal children in their studies.
"For decades OSD did not concern people, but now with new researches like this and
medical practitioners getting absorbed in its details, it is becoming a common issue
worldwide". Prof. Christian Guilleminault from Stanford University, USA told an annual
seminar organized by the Mount Elizabeth Hospital, Singapore last week with special
focus on OSD in Children.
Chronic snoring in a child is a sign that should concern parents, pediatrician and
educators." Chronic, noisy breathing in a child is abnormal and it is very commonly
associated with mouth breathing that is also abnormal," added Prof. Guilleminault who
has been researching this subject for well over three decades.
The professor said that the research conducted by Dr. Gosal, Head of Sleep Medicine
Unit, Louisiana, USA, confirmed that after undergoing a four-year period of treatment, a
group of children who were earlier suffering from OSD, improved significantly and
performed much better in their studies.
“Children who did not undergo the treatment prescribed by the research team remained
under-performing as they were earlier,” said Prof. Guilleminault. This is clear example
that although children do not complain about OSD, it really affects them, the professor
added.
What is OSD
Sleep Disordered Breathing is a concept that has evolved over the past 25 years in
children.
Obstructive Sleep Apnea Syndrome was first described, but it became quickly obvious
that many children had clinical symptoms related to abnormal breathing during sleep
without presenting typical "apneas" at nocturnal polygraphic recording," Prof.
Guilleminault said.
According to the Professor, abnormal breathing during sleep leads to many non- specific
behavioral difficulties such as hyperactivity, irritability, bed-wetting, sleep terrors and
sleep walking, morning headache and also increase in total sleep.
"In worse cases, failure to thrive occurs with abnormal respiratory efforts visible during
sleep with nasal flaring and supra-sternal or inter-costal retraction”, he explained.
More commonly, agitated sleep, sweating during sleep and chronic, noisy breathing are
the nocturnal indicators of the problem.
According to Prof. Guilleminault, there are three types of sleep disorders:
a) OSD where the sleep disorder is due to an obstruction causing a narrowing or

blockage of the upper airway(from the nose/throat).
(b). Central sleep disorder is where the reduction of oxygen flow to the brain causes the
breathing to stop. In order to allow the buildup of CO 2 to adjust arterial pH.
(c). Mixed obstructive and central sleep disorder.
Excerpts from an interview Prof. Guilleminault had with the Daily News.

What are the Causes of OSD?
Common causes of OSD are; anatomical obstruction such as large tonsils and adenoids
or a large and posteriorly-set soft palate, narrow nasal airways, allergic rhinitis, sinusitis
etc.
What are the telltale signs of a child who may be suffering from OSD?
(a) Mouth breathing, especially at night (mouth breathing is not normal in children)
(b) Snoring (is also not common in children)
(c) Apnea (when the person actually stops breathing during sleep for periods of more
than 10 seconds at a time)
(d) Restless sleep with tossing and turning, sitting up or arching the head back while
sleeping
(e) Excessive perspiration during sleep, etc.
At what age do children begin to display signs of OSD?
A child may develop OSD at any time from birth to puberty.
Does it affect a particular race or group of children?
(a). It has been noticed that OSD is more common in the Southern Chinese (including
the Cantonese, Hokkiens, Teochews and Hainanese) as it is basically related to the
anatomy of the Southern Chinese cheekbone, jaw bone and relatively narrow upper
airway.
(b). Children of parents who have the same "adenoid faces" or who have OSD are more
likely to have OSD.
What can be done to correct OSD in children? Is surgery the only option?
Surgery is one, but not the sole option to correct OSD. The treatment depends entirely
on the cause of the OSD.
Unlike in adults, the majority of OSD in children is due to large tonsils and adenoids
which are easy to treat surgically. Removal of enlarged tonsils and adenoids (if these are
the causes of the OSD) usually has very dramatic and immediate results.
If the OSD is caused by allergic rhinitis or sinusitis, these are usually treated medically
with appropriate medication or nasal steroid sprays.
Obese children with no other upper airway obstructions would benefit greatly from loss
of weight.

What can parents do about the home environment to lessen the risk for their
children?
If the OSD is caused by allergic rhinitis, sinusitis or obesity, the home environment is
very important.
If so, the home should be made as dust-free and smoke-free as possible.
It should also be made as free as possible from tempting fatty and high-calorie snacks
and food.
Parents need to give their children counseling and encouragement to lose weight and to
teach their children good eating and healthy habits.
What are the effects of OSD on children -both short and long-term?
What are the most common effects, and what is the worst that can happen?
Because of the sleep disorder, the sleeping child takes in less airflow and less oxygen.
As the heart and brain need a constant supply of oxygen, the body begins to work
overtime, trying to get more air and more oxygen.
This leads to a number of problems such as noisy and labored breathing, mouth
breathing or snoring, excessive perspiration, sleep-walking, nightmares, bed-wetting
and/or drooling.
It also causes excessive daytime sleeping, stunted growth, learning impairment or

inattentiveness in school and a permanently sunken ribcage.

Ear, Nose & Throat

1. Nasal Cavity
2. Turbinate Bones
3. Opening of Eustachian Tube
4. Naso-pharynx
5. Adenoids
6. Tonsils
7. Oro-pharynx
8. Laryngo-pharynx
9. Esophagus
10. Epiglottis
11. Larynx
12. Trachea
13. Cilia
14. Dust
15. Eustachian Tube
The cilia are very important to nasal

function. Delicate, rapidly beating
(1,000 times per minute) hair-like
projections, the cilia work constantly to
move liquid mucus and trapped debris to
the back of the throat at a rate of a
quarter inch per minute. From there,
drainage into the digestive tract takes
place. Impairment of cilial function can
be caused by smoking, allergies,
infections, nasal sprays, and dry air.
The nose can be divided into two internal triangular spaces called nasal cavities.
The septum is composed of cartilage and bone and serves to separate the interior of
the nose into two roughly equal triangular spaces. See following page for example.
The three turbinates, located on the lateral sides of the nasal cavity, are composed of
bone, which is fixed, and soft tissues; which can swell or shrink with various conditions.
The sinuses are cavities within the facial skeleton that open to the nasal cavity. They
include the ethmoid, frontal, sphenoid, and maxillary sinuses.
The maxillary sinus, the largest and most potentially troublesome of the four sinuses,
is located under the eye. Because the opening to the nasal cavity is high off its floor,
drainage of the maxillary sinus can be a problem.
Mucous membrane lines the nose, sinuses, throat, Eustachian tube, and the rest of
the respiratory tract like a carpet. This mucosa secretes about two quarts of liquid each
day, which moistens the surface of the respiratory tract and the air flowing over it.
Mucus aids in keeping the entire respiratory tract clean and moist.

Sounds Like Sleep Apnea by Harold Hopkins
Abstracted by Patricia J. McLoughlin. M.A.
Mr. Hopkins details the sleep apnea syndrome which affects at least 2.5
million Americans (Reference: Guide to Better Sleep, American Medical Association).
During sleep, victims stop breathing for periods of 10 seconds to three minutes.
Families are disturbed by the loud and persistent snoring, snorts and gasping for
breath. The sufferer typically faces days of fatigue due to lack of restful sleep.
The condition was first known as the Pickwickian Syndrome resulting from
Charles Dickens description in The Pickwick Papers (1836) of a sleepy red-faced
character called Fat Boy. Dickens considered the traits of daytime sleepiness a
subject for fun. Only since 1966 have the daytime symptoms been connected to the
potentially life-threatening sleep disorder. Alcohol, sleeping pills, and tranquilizers
taken when the condition is misdiagnosed as insomnia can worsen the symptoms.
Centers for the study of sleep disorders have proliferated, enabling accurate
diagnosis of sleep apnea and other disorders. Hopkins describes three types of sleep
apnea syndrome:
Central Apnea; Obstructive, or Upper-airway Apnea; and Mixed Apnea.
Central apnea, in which the brain "forgets" to breathe until the oxygen-
starved brain cells reactivate the breathing cycle, is extremely rare. More common
are the obstructive or combined central and obstructive syndromes. Typically the
musculature of the soft palate, uvula, and sometimes the tongue, are drawn inwards
with air intake and block the upper airway during sleep.
Treatment may be as simple as changing the sleeper's position. Elevating the
head to allow gravity to keep the tongue forward, or side sleeping (encouraged by
sewing an object into the back of the sleeping garment), can solve the problem.
Most treatments have been developed for obstructive sleep apnea. The article
describes diet regimens, medications, surgeries, and a variety of devices that have
been employed. Some severe cases require tracheostomy which is a drastic but
unfailing solution to the problem. Other surgeries include: Tonsillectomy and
adenoidectomy; removal of nasal polyps; correction of deviated septum; and uvulo-
palatolast procedure is helpful in 50-60% of obstructive sleep apnea cases. Of the
devices, one gaining popularity is a system called Continuous Positive Airway
Pressure, reported1y effective in about 85% of sleep apnea cases. The mechanism
drives air through a nose mask with sufficient force to overcome the obstruction.
Sleep apnea is more common in males, and is associated with obesity and a
short neck. Children with the condition often function poorly in school. In infants, it
has been connected with Sudden Infant Death syndrome. Loud snoring usually
signals the onset of an episode of obstructive apnea. The snoring stops when the
soft tissues block the airway. Eventually, the muscles of the respiration build up
sufficient pressure to blow open the airway. This stage is signaled by gasping noise
and partial wakening. The victim falls asleep again and the cycle repeats itself.
Serious health, personality, and intellectual deficits are associated with its
progression.
Mr. Hopkins emphasizes that persons with serious sleep problems of any kind
should see a physician. Referral may then be made to a Sleep Disorders Center. For
a list of accredited centers, write to the Association of Sleep Disorders Centers, 604
Second Street SW, Rochester, MN 55902,
Sleep Apnea by Arricca Elin Sansone
What it is:
A condition that causes people to momentarily stop breathing in their sleep, repeatedly
during the night. An estimated 12 million adults have sleep apnea, the most common
form of which is obstructive sleep apnea (OSA). It occurs when the tongue and soft
tissues in the back of the throat collapse and block the airway, which causes snoring.
For some, the airway closes completely and breathing ceases. Once the brain stops
getting oxygen, the person briefly awakens, then the cycle repeats. The result is poor,
fragmented sleep. Left untreated, sleep apnea can cause high blood pressure,
cardiovascular disease, memory problems and headaches.
Symptoms:
If you or your partner experiences any signs of sleep apnea, see your doctor for a
complete evaluation.
: Loud snoring, which may be punctuated by choking or gasping
: Falling asleep during the day
: Memory and concentration problems
: Morning headaches
: Irritability and moodiness
: Frequent nighttime urination
What you can do:

: Lose weight, if necessary
: Avoid alcohol, which relaxes upper airway muscles
: Consult your doctor about the use of sleeping pills, anti-anxiety drugs, muscle
relaxants antihistamines (both over-the-counter and prescription) and cough syrup
containing dextromethorphan. All of the above may have a sedating effect, making
apnea worse.
Treatment:
CPAP (continuous positive airway pressure) The most common solution is the use
of a small mask that delivers pressured air to the nose and/or mouth during sleep.
When the mask is worn nightly, symptoms improve for most adults within a month.
Nighttime mouthpiece A protective plastic or acrylic guard worn over the lower
and upper teeth can keep the airway open by moving the lower jaw forward and/or by
preventing the tongue from falling backward. A dentist trained to treat sleep apnea can
fit the mouthpiece and , monitor your progress. Oral appliances are effective for about
half of OSA patients.
Surgery In a small number of OSA cases, the airway is blocked by large tonsils or
nasal polyps, which can be removed by surgery. Those who cannot tolerate CPAP or a
mouthpiece may also be candidates for surgery. The most common procedure is
uvulopalatopharyngoplasty, in which the tonsils and/or adenoids are removed and the
uvula is shortened or taken out; excess tissue in the airway also may be removed.
Surgery success rates hover around 40 percent. Another option is radiofrequency, a new
procedure that uses a needle electrode to deliver energy to the area, which helps
eliminated excess tissue blocking the airway.

Snoring Program
Wake Up! Snoring can be Dangerous!
By Lois Rosenthal
Snoring is, the subject of many jokes, but it's no laughing matter: Its health
consequences can be much more significant than the embarrassment of keeping others
awake. Here's how to tell if your -or your spouse's -snoring merits medical attention.
Anatomy of a Snore:
During sleep, the muscles and tissue that line the air passage at the back of the
mouth and nose normally relax and flutter as you breathe. However, the presence of
excess tissue (from being overweight; for example), poor muscle tone or blocked nasal
airways may obstruct the flow of air, producing the noise we call snores. The greater the
obstruction, the mightier the snore.
Older people, who are more likely to be overweight and have poor muscle tone,
snore more often than younger people: At age 60, 40% of women and 60% of men
snore, versus 5% of women and 20% of men between the ages of 30 and 35.
The severest forms of snoring, which afflicts about 3 million people and also
produces the loudest snores, is called obstructive sleep apnea. This occurs when tissues
in the back of the throat, such as tonsils, adenoids or the uvula (the fleshy structure
that hangs from the roof of the mouth), block the upper portion of the airway
temporarily, causing total interruptions of breathing, sometimes even waking the
individual from sleep.
The Toll Snoring Takes:

As a snoring person tries with labored breathing to supply his or her body with
oxygen, the cardiovascular system is taxed. Of people who snore loudly, blood pressure
rises with every snore, and if this occurs night after night, blood pressure can remain
high during waking hours. In fact, a recent study done in Finland found that snorers
developed high blood pressure - one of the leading causes of stroke - almost three times
more often than silent sleepers.
In the case of obstructive sleep apnea, irregular heartbeat frequently

accompanies the labored breathing that deprives the body of oxygen. This may have
potentially fatal results. According to Dr. Michael J. Thorpy, director of the Sleep-Wake
Disorders Center of Montefiore Hospital in New York City, "We suspect that many people
who have died in their sleep of a heart attack or a stroke may have had apnea-related
complications."

Definitions of Sleep Disorders
Snoring (with and without apnea)
 Loud noise
 No arousal
 Normal sleep and respiration patterns
 No 02 desaturation or cardiac arrhythmia
 Worse in supine position
 Complaints from bedroom partners
 Dry mouth at wake time
Obstructive Sleep Apnea
 >5 episodes and > 10 seconds’ duration per hour

 Accompanied respiratory effort
 Arterial O2 de-saturation
 Short sleep latency(<10 min with 10-20 min normal)
 Happens during daytime sleep as well
 Possibly due to gastro-esophageal reflux disorder (GERD), asthma, choking
etc.
 Excessive sleepiness by self and others report
 Morning headache
 Dry mouth
 Intellectual performance deterioration
 Sinus drainage
Central Sleep Apnea
 Apneas > 10 sec. each

 No accompanied respiratory effort
 Respiratory efforts after 10-30 sec of apnea-hyperpnoea
 10-60 sec hyperventilation after apneic episode
 O2 desaturation
 Not due to physical obstruction as in OSA, GERD, asthma, choking etc.
 Complaints of insomnia or hyper-somnia by self and other report
 Frequent napping during the day
 Driving somnolence
 Headache at wake time
 Depressive reactions

Sleep Disordered Breathing
If you snore loudly and often, you may be accustomed to middle of the night elbow
thrusts and lots of bad jokes. But snoring is no laughing matter. That log-sawing noise
that keeps everyone awake comes from efforts to force air through an airway that is not
fully open.
Perhaps 10% of adults snore. Although for most people snoring has no serious medical
consequences; however, for an estimated 80% of snorers, habitual snoring is the first
indication of a potentially life threatening disorder called “Obstructive Sleep Apnea.”
It has been estimated that the indirect costs of sleep disorders are:
 41 billion dollars a year from lost productivity

 17 to 27 billion dollars a year from motor vehicle accidents
 2 to 4 billion dollars a year in home and public accidents.
Clearly, this is a major national problem that needs to be dealt with in an appropriate
fashion. Dr. Stagg has extensive training in the recognition and treatment of Snoring
and Obstructive Sleep Apnea.
DEFINITIONS:
“Apnea” is defined as the absence of breathing or the want of breath. When there is a
cessation of airflow at the mouth and nose for more than 10 seconds an apnea episode
has occurred. If a person experiences 30 or more apnea episodes during a seven hour
period, then they are believed to be suffering from Sleep Apnea.
Apnea severity is usually categorized by the frequency of apnea episodes:
 5-15 episodes per hour is mild

 15-25 episodes per hour is moderate
 More than 30 episodes per hour are considered severe.
These episodes can last anywhere between 10 to 20 seconds each, terminating with at
least a partial wakening. Typically, a patient may have as many as 300 episodes per
night. There are three basic classifications of sleep apnea: central, obstructive, and
mixed.
Central Apnea – Airflow stops because inspiratory efforts temporarily cease. Although
the airway remains open, the chest wall muscles make no effort to create airflow. The
etiology frequently is encephalitis, brain stem neoplasm, brainstem infarction,
poliomyelitis, spinal cord injury, and cervical cordotomy.
Obstructive Apnea - The cessation of airflow due to a total airway collapse, despite a
persistent effort to breathe. An obstruction in the upper airway can occur in three areas.
They are the nasopharyngeal, oropharyngeal, and hypo-pharyngeal regions.
Regardless of the level, an obstruction causes the breathing to become labored and
noisy. As pressure to breathe builds, muscles of the diaphragm and chest work harder.
The effort is akin to sipping a drink through a floppy straw, the more the collapse the
greater the effort. Collapse of the airway walls will eventually block breathing entirely.
When breathing stops, a listener hears the snoring broken by a pause until the sleeper
gasps for air and awakens, but so briefly and incompletely that he/she usually does not
remember doing it the next morning.
Mixed Apnea - A combination of central and obstructive apnea usually beginning with
a central episode being immediately followed by an obstructive one.
What is Snoring?
Many people think that snoring and apnea is the same thing. This is not true -
Snoring, which is caused by a change in airflow through the nasal and pharyngeal
tissues, is only a sign that a patient may be suffering from apnea. It’s basically like
water running through a pipe. If the water runs abnormally through the pipe it will
vibrate. The same thing happens with airflow when it is partially obstructed.
Snoring can be categorized by its severity -
 On one side of the spectrum, you have the benign snorer, who snores but
experiences no physical problems
 On the other side of the spectrum, you have the snorer who suffers from apnea
 In the middle you have the snorer who suffers from what we call Upper Airway
Resistance Syndrome.
In these people, though they may not actually experience apnea episodes, their snoring
is so loud and their breathing is so labored, that it still wakes them up numerous times
throughout the night. This leaves them un-refreshed and tired in the morning.
THE ROLE OF THE DENTIST:

Pre -2006, the gold standard of care for treatment of Sleep Apnea was the C-Pap
machine (Continuous - Positive Air Pressure). However, the compliance rate after one
year with the C-Pap machine is so low (estimated to be less than 20%) that there have
been some changes to help more apneic patients. As of January 2006, the American
Academy of Dental Sleep Medicine has stated that mild to moderate Sleep Apnea can be
treated with Oral Appliance therapy.
Because the etiology of obstructive Sleep Apnea is multifactorial and the treatment
options are varied, proper diagnosis and treatment are best handled by a team
approach. Dentists may include in their team the patient’s primary care physician, a
sleep specialist, an ENT or an Internist and CERTAINLY an Orofacial Myofunctional
Therapist!
SCREENING for ADULTS:

Patients will need to be evaluated for the presence of any physiologic and behavioral
predisposing factors. A complete evaluation will reveal some of the physiologic factors.
It should include the following:
 Complete medical and dental histories

 Soft tissue / Intra-oral assessment
 Periodontal evaluation
 Orthopedic / TMJ / Occlusal examination
 Intraoral habit assessment
 Examination of teeth and restorations
 Initial dental radiographic survey (panoramic and/or full mouth Series and a
baseline lateral cephalometric survey)
 Diagnostic models
While doing the soft tissue / Intraoral assessment part of the examination, Dr. Stagg will
evaluate all three regions of the upper airway.
An obstruction in the naso-pharyngeal area is usually caused by turbinate hypertrophy,

a deviated septum, or an abnormal growth like a polyp. Although documenting a
problem in this region is the job of an ENT, you can work with patients after the
diagnosis has been made and the patient has been referred to you.
When evaluating the oropharyngeal region, You must first check for hypertrophy in the
tonsils. Then check the size and position of the tongue as it relates to the soft palate.
Finally look at the size and drape of the soft palate and the uvula. When the soft palate
is excessive or drops down immediately, there is a good chance that this patient will
suffer from an oropharyngeal blockage.
An obstruction in a hypopharyngeal airway space is a lot harder to detect through

observation alone. We do know that when motor nerve activity stops during REM sleep,
the tongue can drop back against the posterior pharyngeal wall and block the airway.
Cephalometric films can give us some information on whether an airway is blocked.
Although it is a two dimensional view of a three dimensional space, we can get an idea
of the relative size of the airway, the posterior airway space, the length of the soft
palate and the position of the mandible, maxilla and the hyoid bone.
SIGNS & SYMPTOMS:
Adults
 Heavy snoring
 Gasping or choking during the night
 Excessive day time sleepiness
 Frequent arousals during sleep (fragmented sleep)
 Non-refreshed sleep
 Restless sleep
 Morning headaches
 Nausea
 Personality changes such as becoming irritable or temperamental
 Severe anxiety or depression
 Poor job performance
 Clouded memory
 Intellectual deterioration
 Occupational accidents
 Impotence
 Decreased sex drive
 Bruxing
 Dry mouth when you awake
 Scratchy throat
Children
 Hyperactivity
 Poor concentration
 Developmental delay
 Hypo-nasal quality to their voice
 Noisy breathers
 Obesity
 Frequent upper airway infections
 Ear aches
 Bed wetting
 Nocturnal mouth breathing
 Snoring
 Restless sleep
 Nightmares
 Night terrors
 Headaches
 Chronic nose running
Typically these children suffer from growth and development problems. A lot of them
have under-developed maxilla, narrow upper arches, and retruded mandibles. Often
they are highly allergic with their airway completely blocked due to tonsillar
hypertrophy. If they are already having snoring and breathing problems, do not ignore
them.
DIAGNOSIS:
An ENT, a sleep specialist, and Internist can work with you to make sure you get a
complete medical work-up and sleep test.
A proper medical work-up by a physician can detect physiologic changes as well.

Typically, these patients will:
 exhibit a fragmented sleep pattern

 experience excessive daytime sleepiness
 have a change in their C02/02 ratio, causing acidosis
 have a change in their C02/02 ratio, causing acidosis
You will also find that these patients tend to have hypertension

 Some will show signs of altered heart function like cardiac dysrhythmias and
premature ventricular contractions
 Someone suffering from apnea episodes can also end up having anoxic seizures,
cardiopulmonary arrest and even experience sudden death
Even after a thorough evaluation by a physician, a definitive diagnosis of OSA can only
be accomplished by a sleep test. There are two types of studies:
1. POLYSOMNOGRAM (PSG), an attended sleep study done in a hospital or sleep

clinic. During sleep, the Polysomnogram measures ventilation, gas exchange,
cardiac rhythm, the number and length of apneic episodes, assesses oxygen
saturation, determines sleep stages, and detects arousals.
2. Mobile sleep technology which allows you to take a similar test in the comfort of
your own home also known as an unattended sleep study. Dr. Stagg uses the
Watch-Pat 100 from Itamar, an ambulatory sleep study device. It uses a
proprietary system to monitor the Sympathetic Nervous System. Studies have
shown a relatively high correlation with a PGS test and the respective device.
Most major medical insurers will require patients to undergo a full blown PSG
(Polysomnography) study in a sleep lab for primary diagnosis prior to paying for any
treatment. However, in recent years, ambulatory sleep study devices have entered the
dental market and are beginning to play an important role in proper treatment protocol.
Patients with a high insurance may prefer the low cost of diagnosis with an ambulatory
study as opposed to the relatively higher cost of a PSG. An ambulatory study, with a
physician’s signature, is a legal diagnosis that Dr. Stagg can use to justify treatment.
TREATMENT PROCEDURES:
Once you understand some of the basics in sleep medicine, it becomes clear that Dr.
Stagg, as a dentist, can play a significant role in both the prevention and treatment of
snoring and OSA.
Early detection of structural abnormalities in the developing child affords us the

opportunity to intervene with FUNCTIONAL THERAPY possibly preventing another
eventual OSA casualty. For example, after a thorough orthopedic evaluation, Stagg may
then decide to use orthopedic appliances to direct and control a child’s growth. Arch
development, mandibular repositioning, and controlling vertical dimensions can create
the intraoral volume needed to accommodate the tongue and prevent its compaction
into the hypo-pharynx.
Many treatment methods have been tried over the years to treat snoring and obstructive
sleep apnea. To date, three approaches seem to be most effective.
 Continuous Positive Airway Pressure (C-PAP)

 Surgical techniques
 And the use of intra-oral appliances.
Regardless of the technique used, most people benefit by following a few general
measures.

A. GENERAL MEASURES:
 Lose weight – People with severe sleep apnea are almost always over weight
 Side-sleep
 Avoid alcohol within two to three hours of bedtime
 Avoid certain pharmacological agents.
B. SPECIFIC MEASURES:
Continuous Positive Airway Pressure (CPAP):

This technique involves wearing a mask tightly over the nose during sleep. Pressure
from an air compressor is used to force air though the nasal passages into the airway.
The forced air creates a pneumatic splint, keeping the airway open and allowing the
person to sleep normally. When accepted by the patient, this treatment is highly
effective and is considered the “Gold Standard” on which all other treatments are
compared. To increase patient acceptance, many improvements have been made over
the last few years. Even with all the improvements that have been made, this treatment
modality is still not for everybody. In fact, daily compliance by patients using CPAP is
less than 50%.
Besides being uncomfortable, the other negatives to this treatment are that it is
inconvenient, and it dries out the airway mucosa. There is also real concern of having
reduced cardiac output and renal function.
C. SURGICAL APPROACHES:
NASAL RECONSTRUCTION: Surgical procedures to clear the nasal airway are done to
correct turbinate hypertrophy, Septal deformities, alar collapse and the removal of
tumors or polyps.
UPPP: Uvulopalatopharyngoplasty was first introduced by Ikematsu in 1964 and later

by Fujita in 1981. This surgical procedure enlarges the air space by excising redundant
soft tissue of the palate, uvula, tonsils, posterior and lateral pharyngeal walls. Most
clinical investigations indicate that the success rate of this surgical approach to correct
OSA is less than 50%. This is due to the level and cause of the obstruction often being
misdiagnosed. Removing some of the vibrating tissue may resolve snoring, but it does
not prevent an obstruction by the base of the tongue. This is a serious surgery that is
not without its complications.
LAUP: A laser Assisted Uvulectomy is a modification of UPPP surgery. It is accomplished

using lasers and is considered a less invasive procedure. It is commonly being used to
remove the redundant soft tissue of the palate believed to be causing snoring.
SOMNOPLASTY: This procedure uses a radio frequency to heat the tissue to a very
precise temperature creating a finely controlled lesion of coagulation within the tissue.
Over a period of four to six weeks, the injured tissue heals and in the process the tissue
shrinks and tightens. This technique can be used to reduce the excess tissue in the soft
palate, the nasal turbinates and the tongue. This procedure generally takes two to three
treatments to shrink the tissue sufficiently to have a clinical effect.

ORTHOGNATHIC PROCEDURES:
Patients with a mandibular deficiency, surgical advancement to a normal occlusal
relationship can bring the base of the tongue away from the posterior pharyngeal wall.
When both a maxillary and mandibular deficiency exists, a bi-maxillary surgery will
provide more physical room for the tongue as well as increase anterior tension on the
tongue musculature. Waite et. al. has shown 96% improvement when bi-maxillary
advancement surgery was the primary surgical procedure.
In patients with a normal dental tongue space, a procedure called an anterior inferior
genial osteotomy can be done.
DENTAL APPLIANCES:
Numerous appliances are available to treat snoring and obstructive sleep apnea.
Research has shown that many appliances are quite effective and can now be
considered an alternative when choosing a treatment modality. In fact, sleep appliances
offer several advantages over other therapy choices. They are inexpensive, non-
invasive, easy to fabricate, reversible, and quite well accepted by patients.
BASIC INDICATIONS for sleep appliances:
 Are to treat primary snoring and mild to moderate obstructive sleep apnea.
 Attempting to make an appliance is particularly appropriate for those patients
who cannot handle CPAP.
 When surgery is contraindicated or the patient is unwilling to go through a
surgical procedure, then appliance therapy may be the way to go.
TREATMENT OBJECTIVES for appliance therapy:
 To reduce snoring to an acceptable level

 Resolve the patients’ OSA problems
 Get a higher amount of oxygen into their systems
 To eliminate excessive daytime sleepiness allowing them to function normally.
Sleep appliances seem to work in one or a combination of several ways.

 Appliances can reposition the soft palate
 Bring the tongue forward
 Lift the hyoid bone
 As they reposition, they also act to stabilize these tissues, preventing airway
collapse
 Lastly, appliances seem to increase muscle tone. Specifically, there seems to be
an increase in pharyngeal and genioglossus muscle activity.
Variations in design range from the method of retention, the type of material being
used, the method and ease of adjustability, the ability to control the vertical dimension,
differences in mandibular movement and whether is it lab-fabricated or made in the
office.

The appliance design that you choose will be dependent upon Dr.Stagg's knowledge of
these variations and the oral conditions of the patient. In our office, when selecting an
appliance, we will also evaluate the health of the TMJs, the periodontal structures and
the number and health of teeth.
DIFFERENT EXAMPLES OF APPLIANCES:
 Palate Lifters: The soft palatal lift appliance

 Tongue retainers: - Tongue retaining device
 Snor-X
 Non-adjustable Mandibular Re-positioners
 The clasp retained mandibular Re-positioner
 The mandibular inclined repositioning splint ( MIRS)
 The dorsal appliance
 The snore free Appliance
 Adjustable/ titratable appliances
 The Herbst Appliance and variations
 The Klearway appliance
 The EMA: Elastic Mandibular Advancement Appliance
 The TAP and variations
 The Silencer
 The Oasys Oral/Nasal Airway System ( has a nasal dilator too)
CONTRAINDICATIONS AND CONCERNS:

As a therapist, it is essential that you work as part of a team of health care
professionals. This is particularly important because many other medical
conditions can be associated with OSA. Some of these are:
 Increased hypertension
 Elevated protein levels (Proteinuria)
 Angina pectoris – more likely to develop
 Initiation of gastro-esophageal reflex
 Frequent nocturnal voiding
 Hypoxema
 Hypercapnia (high blood level of CO2)
 Cardiac changes – bradycardia, tachycardia, and right heart failure, possible
leading to sudden death
 Susceptibility to atherosclerosis
 Hypothyroidism – causing polythycemia and bicarbonate retention
Orofacial Myofunctional Therapy:
Exercises to change tongue rest posture, lip posture, jaw stability and to increase nasal
breathing are being used more to allow the patient more involvement in their treatment.

The Science behind these statements:
Exar E. Collop N. The Upper Airway Resistance Syndrome

Chest 1999; 115 (4): 1127-1139
Urschitz M et al. Snoring, intermittent hypoxia and academic performance in primary schoolchildren.
America Journal of Respiratory and Crititcal Care Medicine 2003: 168: 464-468
Wiggins CL et al. Comparison of Self and Spouse Reports of Snoring and other Symptoms Associated with
Sleep Apnea
Sleep 1990: 13: 245-252
Hoffstien V. Mateika S. and Anderson D. Snoring; Is It in the Ear or the Beholder?

Sleep 1994: 17: 522-526
Scott S et al. A Comparison of Physician and Patient Perception of the Problems of Habitual Snoring
Clinical Otolaryngology 2003: 28 (1): 18-21.
Douglas S et al. Development of Snoring Symptoms Inventory

Otolaryngology, Head and Neck Surgery 2003: 129:20.
Effect of Orofacial Myofunctional Exercise Using

an Oral Rehabilitation Tool on Labial Closure
Strength, Tongue Elevation Strength and Skin
Elasticity
Fatimah Ibrahim1), Nooranida Arifin1), Zubaidah H A Rahim2)
1) Medical
Informatics and Biological Micro-electro-mechanical systems (MIMEMS) Specialized
Laboratory, Department of Biomedical Engineering, Faculty of Engineering, University of Malaya:
Kuala Lumpur, 50603, Malaysia. E-mail: fatimah@um.edu.my
2) Department of Oral Biology, Faculty of Dentis
How to Help Snoring
Does snoring need treatment? If you snore only occasionally and not too loudly
and only when you've consumed alcohol, are exhausted, have a stuffy nose or sleep on
your back (a position in which airways are more likely to be obstructed), you probably
don't have to worry.
Preventative measures include weight loss and exercise, which reduce bulky
tissues and tone muscles in the throat that may otherwise vibrate and produce snores.
Also, snorers should avoid alcohol, sleeping pills and antihistamines, all of which relax
tissues in the throat excessively, obstructing airways. And be sure to treat allergies that
cause nasal blockage and breathing through the mouth, both of which contribute to
snoring.
If however, you snore loudly every night, regardless of the position in which you
sleep, you should see a physician.
 Lastly, appliances seem to increase muscle tone. Specifically, there seems to be
an increase in pharyngeal and genioglossus muscle activity.
Variations in design range from the method of retention, the type of material being
used, the method and ease of adjustability, the ability to control the vertical dimension,
differences in mandibular movement and whether is it lab-fabricated or made in the
office.
The appliance design that you choose will be dependent upon Dr.Stagg's knowledge of
these variations and the oral conditions of the patient. In our office, when selecting an
appliance, we will also evaluate the health of the TMJs, the periodontal structures and
the number and health of teeth.
DIFFERENT EXAMPLES OF APPLIANCES:
 Palate Lifters: The soft palatal lift appliance

 Tongue retainers: - Tongue retaining device
 Snor-X
 Non-adjustable Mandibular Re-positioners
 The clasp retained mandibular Re-positioner
 The mandibular inclined repositioning splint ( MIRS)
 The dorsal appliance
 The snore free Appliance
 Adjustable/ titratable appliances
 The Herbst Appliance and variations
 The Klearway appliance
 The EMA: Elastic Mandibular Advancement Appliance
 The TAP and variations
 The Silencer
 The Oasys Oral/Nasal Airway System ( has a nasal dilator too)
CONTRAINDICATIONS AND CONCERNS:

As a therapist, it is essential that you work as part of a team of health care
professionals. This is particularly important because many other medical
conditions can be associated with OSA. Some of these are:
 Increased hypertension
 Elevated protein levels (Proteinuria)
 Angina pectoris – more likely to develop
 Initiation of gastro-esophageal reflex
 Frequent nocturnal voiding
 Hypoxema
 Hypercapnia (high blood level of CO2)

 Cardiac changes – bradycardia, tachycardia, and right heart failure, possible
leading to sudden death
 Susceptibility to atherosclerosis
 Hypothyroidism – causing polythycemia and bicarbonate retention
Orofacial Myofunctional Therapy:
Exercises to change tongue rest posture, lip posture, jaw stability and to increase nasal
breathing are being used more to allow the patient more involvement in their treatment.
The Science behind these statements:
Exar E. Collop N. The Upper Airway Resistance Syndrome

Chest 1999; 115 (4): 1127-1139
Urschitz M et al. Snoring, intermittent hypoxia and academic performance in primary schoolchildren.
America Journal of Respiratory and Crititcal Care Medicine 2003: 168: 464-468
Wiggins CL et al. Comparison of Self and Spouse Reports of Snoring and other Symptoms Associated with
Sleep Apnea
Sleep 1990: 13: 245-252
Hoffstien V. Mateika S. and Anderson D. Snoring; Is It in the Ear or the Beholder?

Sleep 1994: 17: 522-526
Scott S et al. A Comparison of Physician and Patient Perception of the Problems of Habitual Snoring
Clinical Otolaryngology 2003: 28 (1): 18-21.
Douglas S et al. Development of Snoring Symptoms Inventory

Otolaryngology, Head and Neck Surgery 2003: 129:20.
Effect of Orofacial Myofunctional Exercise Using

an Oral Rehabilitation Tool on Labial Closure
Strength, Tongue Elevation Strength and Skin
Elasticity
Fatimah Ibrahim1), Nooranida Arifin1), Zubaidah H A Rahim2)
1) Medical
Informatics and Biological Micro-electro-mechanical systems (MIMEMS) Specialized
Laboratory, Department of Biomedical Engineering, Faculty of Engineering, University of Malaya:
Kuala Lumpur, 50603, Malaysia. E-mail: fatimah@um.edu.my
2) Department of Oral Biology, Faculty of Dentis

Snoring

Sounds like Sleep Apnea by Harold Hopkins
Mr. Hopkins details the sleep apnea syndrome which affects at least 2.5 million
Americans (Reference: Guide to Better Sleep, American Medical Association). During
sleep, victims stop breathing for periods of 10 seconds to three minutes. Families are
disturbed by the loud and persistent snoring, snorts and gasping for breath. The sufferer
typically faces days of fatigue due to lack of restful sleep.
The condition was first known as the Pickwickian Syndrome resulting from Charles
Dickens description in The Pickwick Papers (1836) of a sleepy red-faced character called
Fat Boy. Dickens considered the traits of daytime sleepiness a subject for fun. Only since
1966 have the daytime symptoms been connected to the potentially life-threatening
sleep disorder. Alcohol, sleeping pills, and tranquilizers taken when the condition is
misdiagnosed as insomnia can worsen the symptoms.
Centers for the study of sleep disorders have proliferated, enabling accurate
diagnosis of sleep apnea and other disorders. Hopkins describes three types of sleep
apnea syndrome:
Central Apnea; Obstructive, or Upper-airway Apnea; and Mixed Apnea.
Central apnea, in which the brain "forgets" to breathe until the oxygen-starved
brain cells reactivate the breathing cycle, is extremely rare. More common are the
obstructive or combined central and obstructive syndromes. Typically the musculature of
the soft palate, uvula, and sometimes the tongue, are drawn inwards with air intake and
block the upper airway during sleep.
Treatment may be as simple as changing the sleeper's position. Elevating the

head to allow gravity to keep the tongue forward, or side sleeping (encouraged by
sewing an object into the back of the sleeping garment), can solve the problem. Most
treatments have been developed for obstructive sleep apnea. The article describes diet
regimens, medications, surgeries, and a variety of devices that have been employed.
Some severe cases require tracheostomy which is a drastic but unfailing solution to the
problem. Other surgeries include: Tonsillectomy and adenoidectomy; removal of nasal
polyps; correction of deviated septum; and uvulo-palatoplasty procedure is helpful in
50-60% of obstructive sleep apnea cases. Of the devices, gaining popularity is a system
called Continuous Positive Airway Pressure, reported1y effective in about 85% of sleep
apnea cases. The mechanism drives air through a nose mask with sufficient force to
overcome the obstruction. Sleep apnea is more common in males, and is associated with
obesity and a short neck. Children with the condition often function poorly in school. In
infants, it has been connected with Sudden Infant Death syndrome. Loud snoring usually
signals the onset of an episode of obstructive apnea. The snoring stops when the soft
tissues block the airway. Eventually, the muscles of the respiration build up sufficient
pressure to blow open the airway. This stage is signaled by gasping noise and partial
wakening. The victim falls asleep again and the cycle repeats itself. Serious health,
personality, and intellectual deficits are associated with its progression.
Association of Sleep Disorders Centers, 604 Second Street SW, Rochester, MN

55902,

Establishing Use of the Nasal Airway
A. Determine Etiological Factors which would prevent the success of the therapy
program.
1. Deviated Septum
2. Enlarged Turbinates
3. Polyps
4. Enlarged Adenoids and / or Tonsils
5. Allergic Rhinitis and / or Sinusitis
6. Vaulted -Narrow Palatal Arch Formation
B Make Appropriate Referrals... The Team Approach

C. Teach Diaphragmatic Breathing Technique
D. Teach Nasal Washing Techniques
E. Accomplish Lip Closure (if possible)
F. Achieve Back Sleeping Posture
G Achieve Correct Head -Neck -Body Posture

Surgical Considerations
Both the appearance and function of your nose must be considered together. When you
reduce the size of your nose for aesthetic reasons, the size of the breathing passages
will also be reduced. Whether or not this will affect your breathing depends on the
internal structure of your nose.
Best Case: The nose on the left is too large, but it has no internal problems and has
ample room for breathing. Therefore, when its size is reduced by aesthetic surgery,
there is still sufficient breathing space. In this case, functional nasal surgery is not
required, nor will nasal function be impaired by aesthetic alterations. The goal of a
good-looking and functioning nose can be accomplished with aesthetic surgery alone.
Worst Case: The nose above (left) is not only too large and broad to be attractive; it
also has a deviated septum and enlarged turbinates. If aesthetic surgery were done
alone (right), breathing space -already reduced by the internal problems -would be
cramped even further. In this case, functional surgery is also needed and may be done
before, along with, or after aesthetic surgery.

Allergy Time
How to help your child cope
By Loraine Stern, M.D.
When a hot wind starts to blow or construction begins in a neighborhood near my

office, I know I'll be seeing a bunch of children with allergy problems. Disturbances of
soil and air can trigger a bout of allergic rhinitis, otherwise known as hay fever.
The term is really a misnomer, as allergic rhinitis has nothing to do with hay and
there's no accompanying fever. It's caused by allergy to materials in the air. Pollen
allergy is worst in spring, grass allergies flare up in late spring and summer, and
ragweed is mainly an early fall allergy. Mold allergy often occurs after a rainy or foggy
spell is followed by a dry, warm wind. Furry pets also can cause problems (though
children born into a home with a pet are actually at less risk of being allergic to it).
Childhood allergies usually begin in the early school years but can start as young
as 2 years of age. One recent study revealed that umbilical cord blood cells showed
sensitivity to pollen, meaning allergies may begin even before birth. As many as 40
percent of children suffer from seasonal allergies and in only 10 to 20 percent do the
symptoms completely disappear over time. They often run in families, and most children
with asthma also have allergies.
The most common signs are cold-like symptoms such as itchy, runny eyes and
nose that don't clear up after a week or two. Some children also experience bouts of
rapid “'machine-gun" sneezing. Sleep problems may occur because nasal obstruction
leads to snoring, which may wake a child during the night. This can cause sleep
deprivation, fatigue and missed school days. Discomfort during the day can cause
irritability and difficulty concentrating. Ear and sinus infections are also common.
The best treatments

While over-the-counter allergy medicines can help, they may also cause
drowsiness. Prescription antihistamines such as Claratyne, Zyrtec and Allegra don't have
this side effect, and some can be used on children as young as 2. Your pediatrician may
try several before finding the one that works best.
Saline nose drops thin mucus and wash away irritants as well as moisturize
tender sinus passages. Available without a prescription, the product can be used CIS
often as you like because it has no side effects. Prescription nasal sprays can also be
helpful, but I've found that many children simply refuse to allow their noses to be
sprayed.
If simple measures don't work, you may need a referral to an allergist to

determine what is causing the problem. Skin testing has become easier than the painful
multi- needle procedure used to be. The current device applies all the suspected
allergens at once so discomfort is minimal.
For a child who suffers persistent problems, it may be worth the trouble and
expense of allergy shots, which can often bring significant relief.
Teaching a child to breathe through their nose can help to prevent allergy
symptoms.

Prevention tips
Knowing what triggers your child's symptoms can help you cut down on exposure.
Keep windows closed during pollen season, especially on windy days and in the early
morning. If your child is sensitive to dust, replace carpeting with linoleum or wood
flooring; encase mat- tresses and pillows in allergy-proof zip-up casings, use synthetic
bedding and keep a minimum of books and stuffed animals. For mold allergies, remove
wallpaper and old carpeting.
Keeping furry friends out of your child's room can help with pet allergies. Also,
bathing cats about once a month can significantly cut down on the amount of dander
they release into the air. WD
Coventry 2000 & Guyton 1982 noted that

“Occlusion abnormalities occur predominantly during childhood as a result of:
 Breathing through the mouth

 Thumb sucking or sucking of the lower lip
 Muscle function defects – placement of tongue between the teeth and
incorrect swallowing.
Resulting in:
 Narrowing of the arches within the jaw resulting in overcrowding and and
 unattractive “gummy” smiles
 Forward head posture which can lead to neck muscle pain, stiffness and
 fatigue
 Headache
 V-shaped upper jaw and high palate
 Malocclusion - anterior bite
 TMJ dysfunction - complain of pain where the lower jaw hinges to the
skull,
 may have trouble chewing, may have earache
 Under developed nasal passages and / or underdeveloped jaw and
 cheekbones
 Gum disease or Dental decay
 Dry mouth / throat or Bad breath
 Increased allergen / airborne infection entry to lungs
 Chronic swelling of the tonsils
 Enlarged adenoids, polyps
 Noisy breathing / noisy eating
 Excessive snoring at night
Copyright 2014 – Coulsontreatment
 Orthodontic Institute of Orofacial Myology 207
 Increased mucous production

Regardless of the amount of orthodontic work carried out, if the patient is not taught to
breathe correctly and myofascial therapy is not instigated as part of the orthodontic
treatment…there is greater potential for relapse of orthodontic correction.
According to the British Snoring & Sleep Apnea Association, ‘During sleep we are
designed to breathe through the nose. If for any reason nasal breathing is not possible
our body's self-preservation mechanism forces us to breathe through the mouth.’

The Importance of Respiratory Activity in Myofunctional
Therapy
By Irene QUeirO2 Marchesan, MA &
Lilian Ruth Huberman Krakauer, MA
For many years, the speech-language pathologist's work related to the orofacial
myology was basically restricted to the swallowing function. Currently, we are becoming
more aware that two other functions, respiration and mastication, are extremely
important for the growth and development of the Stomagnathic System. In this paper,
we will limit ourselves only to breathing, specifically mouth-breathing. In our speech-
language-hearing clinic, we have been treating a great variety of patients, referred by
orthodontists, with a diagnosis of tongue thrust. In general, this condition appears to be
highly correlated with mouth-breathing. Actually, most patients present with a
combination of respiration (oral and nasal). One question arises, why this enormous
amount of oral breathers?
The reasons are many, and some of them are:

 Organic problems, like: rhinitis, sinusitis, hypertrophy of pharyngeal or palatine
tonsils
 Hypotonicity of the mandibular elevator muscles, because of pasty food resulting
in open mouth with incorrectly positioned tongue
 No discernible reason for poor posture: the patient (child or adult) simply sits with
mouth open, sometimes even without being aware of it, with no mechanical or
functional barriers to nasal respiration.
In general, the mouth-breather may present a variety of symptoms, characteristic of the
condition known as Oral Breather Syndrome or Dysfunctional Breather. These symptoms
are:
6. Craniofacial and Cranio-dental Disorders

 Predominantly vertical craniofacial growth
 Steep gonial angle-elongation of the face
 Narrower facial dimension
 Maxillary hypo-development
 Narrower or inclined nostrils
 Micro rhinia with less space in nasal cavity
 Deviation of the nasal Septum
 Class II, over jet, cross bite or open bite
 Upper incisal protrusion
7. Disorders of Phono-articulatory Organs

 Hypotrophy, hypotonia, and hypo-function of the mandibular muscles
 Tonus changes with hypo-function of lips and cheeks
 Short or retracted upper lip, and lower lip everted or interposed between teeth
 Dry, chapped, or bruised lips with changes in color
 Hypertrophy of gums with changes in color and frequent bleeding
 Tongue-forward posture or dorsum elevation to regulate air flow
 Oral proprioception
8. Body Disorders
 Thoracic deformities
 Distended or flaccid abdominal muscles
 Shadows around the eyes with ocular hypotelorism or hypertelorism, weary-eyed
 Ill-positioned head in relation to the neck causing changes in the spinal column as an attempt
to compensate for this ill-positioning
 Shoulders forward compressing the thorax
 Alteration of the tympanic membranes, diminished hearing -visible facial asymmetry, mainly in
the buccinator muscles
 Very lean individual, sometimes obese and lacking normal color
9. Disorders of the Oral Functions
 Ineffective chewing causing digestive problems and choking because of in-coordination

between breathing and mastication
 Tongue thrust with noise, anterior protrusion of tongue, exaggerated orbicularis oris
contraction, compensatory head movements, over contraction of the mentalis muscle.
 Imprecise and inaccurate speech, with excess of saliva, without full resonance because of
frequent otitis with high incidence of anterior or lateral lisping
 De-nasal, nasal or hoarse voice
10. Other Possible Disorders
 Frequent sinusitis, recurrent otitis-pharyngeal and palatine tonsils growth (adenoids and
tonsils) -halitosis and diminished perception of taste and smell
 Greater incidence of caries -sleep alterations, snoring, nocturnal drooling, insomnia, vague
facial expression
 Appetite reduction, gastric alterations, constant thirst, choking, pallor, loss of appetite, loss of
weight with less physical development or obesity
 Less physical activity, global un-coordination with frequent weariness
 Agitation, anxiety, impatience, impulsivity, despondency
 Difficulty with attention and concentration, causing school problems
It is important to point out that all symptoms mentioned above will not necessarily be present at the
diagnosis of the oral breather syndrome.
Why is the respiration so important?
Babies do not breathe through the mouth because their oral cavity is small and totally
occupied by the tongue. When a baby is suffering from a cold, he becomes very annoyed, for mouth-
breathing is almost impossible for him. As the babies grow up, they learn that the mouth can be used
as a respiratory channel when nasal breathing is impaired.
When we breathe through the nose, with proper functioning of chewing, swallowing, and
resting postures of the tongue and lips, the muscle actions stimulate the bones correctly for optimal
facial growth and development.

If mouth-breathing is present, that stimulation may occur improperly, resulting in a
disharmonious growth and development.
Genetic conditions must be considered. If the individual has a tendency toward a class III
malocclusion, mouth-breathing, a low tongue resting position, and an open mouth resting posture,
this will certainly aggravate the class III malocclusion. Orthodontics and oral myofunctional therapy
can redirect growth and minimize the possibility of prognathism, by correcting the breathing patterns
and the oral muscle functions and postures.
Orofacial myofunctional therapy with young children (4 to 5 years of age), who are mouth-
breathers without unfavorable genetic heritage and without organic problems impairing nasal
breathing, is highly successful because once good lip and tongue posture have been established and
habituated, a more harmonious growth is facilitated.
With allergic patients, the oral myofunctional therapy goal is to give the patient better nasal
breathing conditions outside crisis. If the individual can be trained to use nose-breathing whenever
possible, episodes of allergy crises are diminished, since the air flowing through the nose is
submitted to cleansing, heating and humidifying processes.
However, we must emphasize to the family that this therapy will not cure the allergy; it will
only improve breathing conditions of the patients outside crisis.
Therapy with the oral-breather is not limited to the oral myofunctional therapy. On the'
contrary, usually the therapist works together with an otorhinolaryngologist and an orthodontist in a
team approach.
It will always be necessary to ask for an otorhinolaryngologic evaluation to determine whether

or not the mouth breathing is caused by organic disorders. If the disorder is organic, it will frequently
be best to delay treatment. It might be necessary to proceed at first with medical or surgical
treatments, before myofunctional therapy is began, in order to install or reinstall nasal breathing.
With regard to the orthodontist, as mentioned above, mouth-breathing can cause alterations in
occlusion and/or facial growth.
We must not forget that there are also adult mouth-breathers. These are two types:
 Those who became mouth-breathers as adults;

 Those who were mouth-breathers since childhood but only sought treatment as adults
The first type present muscle but not bone disorders, since the facial growth was already
completed when they became oral breathers. 90% of the face grows until the age of 13 to 14 years
and the remaining 10% until the age of 20 years. In these cases, because of muscle alterations only,
the changes are swifter and the therapeutic success is higher. As for the second type, attention must
be directed to the choice of appliances and also the lack of a 100% success in treatment, since the
craniofacial growth ended and the muscles will have accommodated over the bones.
Before beginning the myofunctional therapy, the patient must be aware that the therapy itself
will be limited to muscle functions and will not be able to change occlusion and bony structures.

In relation to mouth-breathers' characteristics, some associated problems can develop, as:
 Articulatory imprecision: because of tongue hypo-tonus, sometimes incorrect articulation of

phonemes is present in spontaneous speech, despite the patient being able to articulate each
phoneme individually.
 Anterior lisp: because of tongue hypotonia associated with anterior open bite, common in
mouth-breathers.
 Lateral lisp: because of tongue hypotonia, the tongue occupies the oral cavity, interposing
itself in the posterior part of the dental arches.
 Tongue thrust: because of poor resting posture of the tongue or as a compensation for
anterior open bite or other malocclusion.
 Atypical mastication: because of hypotonia of mandibular elevator muscles and poor
coordination of respiration with mastication/deglutition.
In summary, we would like to alert professionals who are working with the Oral-Motor-
Sensory System that "tongue thrust" swallowing may not be the "key point," but may actually result
from ill-functioning of breathing and even chewing.
Working accordingly with respiration as well as with chewing, swallowing can adapt by itself
without the training of "tongue on papilla." Also, it is important to note that simultaneous therapy with
tongue, lip, and cheek tonicity, and mandibular elevator muscles must be carried out if necessary.
In London in 1870, George Catlin Wrote a book entitled Shut Your Mouth and Save Your ~
Today; we can plagiarize him and write: "Without a closed mouth there is minimal nasal breathing,
and without nasal breathing, because of all the alterations it causes, there is poor quality of life."
Breathing Flow Chart

Did you know... that treating all US drivers
suffering from sleep apnea would save $11.1
Billion in collision costs and 980 lives
annually…
75% of severe Sleep Disordered Breathing

cases remain undiagnosed…
9% of middle-aged women and 25% of

middle-aged men suffer from OSA?

-Treating all US drivers suffering from sleep apnea would save $11.1 billion in collision costs and save 980 livlly.

-75% of severe Sleep Disordered Breathing cases remain undiagnosed.

-9% of middle-aged women and 25% of middle-aged men suffer from OSA.

I-Cat Scans Before and After ONLY OM Therapy…

THE RELATIONSHIP BETWEEN HEAD
POSTURE AND OCCLUSION
The occlusion determines the position of the jaw
which then determines the position of the cranium
on the cervical spine. and so on. .This is easily
demonstrated by tapping your teeth lightly
together or using occlusive wax or bite paper.
When the head is flexed, the occlusal contact is
more anterior. When the head is extended. the
occlusal contact is more posterior. When the head
is side bent and rotated. the occlusal contact is
stronger on the side to which the head is hp.nl 4
POSTURAL DYSFUNCTIONS
The most common postural dysfunction relating
to dental health is forward head posture. In a
forward head posture it is common to find
posterior rotation of the cranium, reversal of the
cervical lordosis, or protracted scapulae,
increased thoracic kyphosis and decreased lumbar
lordosis. (Figure 4) Children and adult mouth
breathers obtain this posture to increase their
airway space. As many as seventy percent (70%)
of those exhibiting forward head posture will also
exhibit a Class II Occlusion. Some of the
symptoms found as a result of this posture are:
facial pain, fatigue and spasm of the facial
musculature, headaches (sub-occipital or cranio- SUMMARY
facial). neck pain, arm pain and in some advanced Poor posture is not thought of as an injury or
cases, Allergenic pain. health problem. However, over time, the
dysfunction can lead to degeneration and its net
In a forward head posture patient, it is possible effect can be as damaging as an injury.
to have maximal contraction of the masseter, When the occlusion is misaligned, a
temporal is digastric and upper trapezius muscles compensating effect takes place through the
with resultant muscle hypertrophy and muscle postural chain and the body must adjust. This can
imbalance. Normal physiological balance requires often affect the work of dental professionals,
the least amount of muscle activity. joint pressure possibly causing a failure in their procedures if not
and connective tissue tension. Normal addressed. Early postural screening by a physical
physiological posture is imperative to provide therapist can aid in the prevention of postural
normal function. A poor posture can lead to dysfunctions. Physical therapists should be an
dysfunction and eventual degeneration. integral part of the program for dental
professionals.
Rocabado and Tapia state, "The loss of the

physiological curvature of the spine at an early
age is a fundamental process of interception that
all dental specialists must know about in order to
prevent early regeneration of the cervical spine

Information and Instructions to Patients Regarding
Swallowing
Swallowing is something we take for granted, yet it is a very interesting and influential
factor regarding proper function and stability of the chewing system; thus, we
constantly work to help our patients learn to swallow correctly. Besides the swallowing
of food and liquids, there is also what is called an "empty swallow" which normally
occurs several hundred times a day.
The empty swallows are part of normal. human function; for example, they drain saliva
through the mouth. Also, they are very important in stabilizing and maintaining proper
function and positions of the teeth and jaws. If a person did not swallow periodically to
move saliva that is manufactured by the saliva glands, they would drool which might be
a bit embarrassing as it does not fit the definition of proper etiquette.
The swallow is important so that proper function and stability of the teeth and jaws can
occur. In an empty swallow, the teeth come together for a very short period of time
(less than a second) and at that time, the powerful chewing muscles, for example, the
masseters, are active.
The teeth are pressed together. Although the duration of the swallow is very brief, the
force delivered to the teeth and to the system is significant, and frequent swallows
throughout the day multiply the effect. In an ideal circumstance, these empty swallows
are the only time when the teeth come together.
Why is it important to swallow properly?
When the teeth are forced to the tight position and muscles are activated, this
reinforces and stabilizes the tooth positions and the positions of the jaw joints and all
functioning parts of the chewing system. It is important for our patients to learn this
empty swallow properly; and although it is a subconscious act, if learned
conscientiously, it will become a habit.
A simple way to test for and to learn the tooth together swallow is: to place fingers on
either cheek slightly below and in front of the ear, squeeze the teeth together… you can
feel the powerful chewing muscle bulge. This muscle should bulge for a fraction of a
second in a tooth together swallow. It is that simple.

The Best Way to Down a Pill
For some people, the idea of swallowing a pill is enough to make them gag-especially
when it comes to giant-size antibiotics or calcium supplements. To help you overcome
your pill problem, Jon Schommer, Ph.D., an associate professor at the College of
Pharmacy at the University of Minnesota in Minneapolis, recommends these grown-up
tactics:
 Drink something before you take your medication. This will lubricate your tongue,
throat, and esophagus and help keep the pill from sticking.
 Place the pill as far back on your tongue as you can, and take a large sip of water
(or even OJ or milk). Then swallow it and the pill in a single gulp. You can tilt your
head neck slightly to nudge the pill along. If it lodges in your throat, swallow
again or drink lukewarm water to dissolve it.
 Try coated capsules if available. Their smooth texture and cylindrical shape make
them easier to get down. (Beware: Gel capsules may become sticky when wet,
making them tougher to swallow.) Some medications are also available in liquid
or powder form, so talk to your pharmacist.
 Practice, practice, practice. Put an M&M on your tongue, drink some water, and
swallow the candy whole. It tastes better than a pill, and since it's small and
coated, it will slide down easily.

Difficulty in swallowing (dysphasia) is common among all age groups, especially the
elderly. The term dysphasia refers to the feeling of difficulty passing food or liquid from
the mouth to the stomach. This may be caused by many factors, most of which are
temporary and not threatening. Difficulties in swallowing rarely represent a more serious
disease, such as a tumor or a progressive neurological disorder. When the difficulty does
not clear up by itself in a short period of time, you should see an otolaryngologist head
and neck surgeon.
How You Swallow
People normally swallow hundreds of times a day to eat solids, drink liquids, and
swallow the normal saliva and mucus that the body produces. The process of swallowing
has four stages:
5. The first is oral preparation, where food or liquid is manipulated and chewed in
preparation for swallowing.
6. During the oral stage, the tongue propels the food or liquid to the back of the
mouth, starting the swallowing response.
7. The pharyngeal stage begins as food or liquid is quickly passed through the
pharynx, the canal that connects the mouth with the esophagus, into the
esophagus or swallowing tube.
8. In the final, esophageal stage, the food or liquid passes through the esophagus
into the stomach.
Although the first and second stages have some voluntary control, stages three and four
occur by themselves, with conscious input.
What Causes Swallowing Disorders?
Any interruption in the swallowing process can cause difficulties. It may be due to
simple causes such as poor teeth, ill-fitting dentures, or a common cold. One of the
most common causes of dysphasia is GERD (gastroesophageal reflux). This occurs when
stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes
may include: stroke; progressive neurological disorder; the presence of a tracheostomy
tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus;
or surgery in the head, neck, or esophageal areas.

Symptoms
Symptoms of swallowing disorders may include:
 Drooling;
 A feeling that food or liquid is sticking in the throat;
 Discomfort in the throat or chest (when gastroesophageal reflux is present);
 A sensation of a foreign body or "lump" in the throat;
 Weight loss and inadequate nutrition due to prolonged or more significant
problems with swallowing; and
 Coughing or choking caused by bits of food, liquid, or saliva not passing easily
during swallowing, and being sucked into the lungs.
Who Evaluates and Treats Swallowing Disorders?
(This is ALWAYS done by a SPECIALIST MD or Speech Pathologist who is

TRAINED in this specific area. Orofacial Myologists DO NOT treat Dysphagia
unless they have the credentials to do so!)
When dysphasia is persistent and the cause is not apparent, the otolaryngologist head
and neck surgeon will discuss the history of your problem and examine your mouth and
throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope),
which provides vision of the back of the tongue, throat, and larynx (voice box). If
necessary, an examination of the esophagus, stomach, and upper small intestine
(duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These
specialists may recommend
X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is
done by a radiologist.
If special problems exist, a speech pathologist may consult with the radiologist
regarding a modified barium swallow or video-fluroscopy. These help to identify all four
stages of the swallowing process. Using different consistencies of food and liquid, and
having the patient swallow in various positions; a speech pathologist will test the ability
to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems
from the nervous system, perhaps due to stroke or other neurological disorders.
Possible Treatments
Many of these disorders can be treated with medication. Drugs that slow stomach acid
production, muscle relaxants, and antacids are a few of the many medicines available.
Treatment is tailored to the particular cause of the swallowing disorder.
Gastro esophageal reflux can often be treated by changing eating and living habits, for
example:
 Eat a bland diet with smaller, more frequent meals;

 Eliminate alcohol and caffeine;
 Reduce weight and stress;
 Avoid food within three hours of bedtime; and
 Elevate the head of the bed at night.
If these don't help, antacids between meals and at bedtime may provide relief.
Many swallowing disorders may be helped by direct swallowing therapy. A speech

pathologist can provide special exercises for coordinating the swallowing muscles or re-
stimulating the nerves that trigger the swallow reflex. Patients may also be taught
simple ways to place food in the mouth or position the body and head to help the
swallow occur successfully.
Some patients with swallowing disorders have difficulty feeding themselves. An

occupational therapist can aid the patient and family in feeding techniques. These
techniques make the patient.

Swallowing Problems in Adults
Swallowing disorders, also called dysphasia (dis FA Yjuh), can occur at different stages
in the swallowing process:
 Oral phase -sucking, chewing, and moving food or liquid into the throat
 Pharyngeal phase -triggering the swallowing reflex, squeezing food down the
throat, and closing off the airway to prevent food or liquid from entering the
airway (aspiration) or to prevent choking:
 Esophageal phase -relaxing and tightening the openings at the top and bottom
of the feeding tube in the throat (esophagus) and squeezing food through the
esophagus into the stomach.
Some causes of feeding and swallowing problems in adults are:
 Damage to the nervous system, such as:
o Stroke
o Brain injury
o Spinal cord injury
o Parkinson's disease
o Multiple sclerosis
o Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)
o Muscular dystrophy
o Cerebral palsy
o Alzheimer's disease
Problems affecting the head and neck, including:
 Cancer in the mouth, throat or esophagus

 Injury or surgery involving the head and neck
 Decayed or missing teeth or poorly-fitting dentures
Many other diseases, conditions, or surgical interventions can result in swallowing

problems, General signs may include:
 Coughing during or right after eating or drinking

 Wet or gurgling-sounding voice during or after eating or drinking
 Extra effort or time needed to chew or swallow
 Food or liquid leaking from the mouth or getting stuck in the mouth
 Recurring pneumonia or chest congestion after eating
 Weight loss or dehydration from not being able to eat enough

As a result, adults may have:
 Poor nutrition or dehydration
 Risk of aspiration (food or liquid entering the airway) which can lead to
pneumonia and chronic lung disease
 Less enjoyment of eating or drinking
 Embarrassment or isolation in social situations involving eating
For help, consult your doctor about the possible medical cause of the swallowing
problem. An ASHA-certified speech-language pathologist can perform an evaluation of
feeding and swallowing and provide treatment if appropriate. Many medical specialists
and other health care professionals may work together to evaluate and/or treat feeding
and swallowing problems.
A speech-language pathologist:
 Will take a careful history of medical conditions and symptoms

 Will look at the strength and movement of the muscles involved in swallowing
Will observe feeding to see your posture, behavior, and oral movements
during eating and drinking
 May perform special tests to evaluate swallowing
Treatment varies greatly depending on the cause, symptoms and type of swallowing
problem. A speech-language pathologist may recommend:
 Exercises, positions or strategies to help chew more effectively

 Specific food and liquid textures that are easier and safer to swallow
Orofacial Myofunctional Therapy can help in conjunction with Speech Pathology:

 Ask questions to understand the problem and the recommended treatment
Assist in following the treatment plan:
o Help with exercises
o Family support

Orofacial Myology for Patients with Down syndrome
Oral Motor Exercises for:
 Drooling….Blowing exercises
 Lip Closure….Lip pops, kisses
 Pre-Speech….M-m-m-m-m, chewing exercises
 Speech….Tongue placement
Parent Education for:
 Feeding….Clearing the spoon
 Posturing….Seated body posture
 Tongue Posture Activities
Generalized Therapy for:
 Tongue Posture…."SPOTS"
 Lip Strength….All lip exercises
 Chewing….Small bites, encourage lip closure
 Head and Body Posture
Orofacial Myology is therapy which facilitates facial, tongue and lip movements to
improve chewing, swallowing, speech and posture. It focuses on tongue and lip
exercises to increase control of the facial muscles. Head, neck and body posture are
also addressed, which aid in the proper head carriage and the development of good
tooth alignment.
Orofacial Myology cannot and does not treat Down syndrome; however OM treats tongue, lips
and the mouth posture to improve those areas in patients with Down syndrome.

Down syndrome is a genetic condition caused by abnormal cell division in the egg, sperm, or fertilized
egg. This results in an extra or irregular chromosome in some or all of the body's cells, causing
varying levels of intellectual disability and physical problems.
Down syndrome is also called trisomy 21, for the specific chromosome that has the abnormality. A
person with Down syndrome has three copies of chromosome 21. Normally, a person has two copies.
Down syndrome usually can be detected during pregnancy or soon after birth. Chromosome
(karyotype) tests and how a baby looks can help make a diagnosis.
Babies usually have distinctive facial characteristics, such as upward-sloping eyes and a flattened
nose. People with Down syndrome have an increased risk of being born with or developing health
problems. For example, some babies with Down syndrome are born with heart, intestinal, ear, or
respiratory defects. These health conditions often lead to other problems, such as respiratory
infections, sleep apnea, or hearing problems. Other health issues, such as vision trouble or problems
with thyroid function, can also develop.
Children with Down syndrome grow and develop more slowly than other children. But most are able
to attend school, play sports, socialize, and enjoy active lifestyles. Unless their disabilities are severe,
adults with Down syndrome can care for most of their own needs. Many people who have Down
syndrome live into their 50’s and some into their 60’s or older.

Oral Habits and Primary Dentition
 While continuous nonnutritive sucking habits of 48 months or longer
produced the greatest changes in dental arch and occlusal characteristics, children
with shorter sucking duration also had detectable differences from those with
minimal habit duration.
 It may be prudent to revisit suggestions that sucking habits continued to as

late as 5-8 years of age are of little concern.
Warren J et al. Effects of oral habits’ duration on dental characteristics in the primary
dentition. JADA 2001 (Dec): 132: 1685-93
Pacifier, digit sucking and ‘sippy cups’ are strongly associated with malocclusion.
o Malocclusions found in 35% of 3-year-olds
o Anterior open bites in 27%
o Unilateral cross bites in 8%
Paunio P. Rautava P. Sillanpaa M. The Finnish family competence study: The effects of living
conditions on sucking habits in 3-year-old Finnish children and association between these
habits and dental occlusion. Acta Odontal Scand 1991:53:23-29.
 Pacifier and digit sucking resulted in increased tendency to tongue thrust.
 Tongue thrust is related to: open bite, cross bite, overjet, Class II
malocclusion.
 Sucking habits influence the etiology of malocclusion.
Melsen B. Stensgaard K. Pedersen J.

Sucking habits and their influence on swallowing pattern and prevalence of malocclusion. Euro
J. Orthodont 1979; 1(4): 271-280.
 Digit and pacifier-sucking was the lowest among children who had good
opportunity for breastfeeding.
 A significant relationship was found between sucking habits and malocclusion

such as: Class II malocclusion, increased overjet, anterior open bite, crossbite
and underbite.
Farsi. N. Salama F. Pedro C. Sucking habits in Saudi children: prevalence, contributing factors and
effects on the primary dentition. Pediatric Dentistry 1997: 19(1): 28-33.
 There is a strong association (p = 0.0006) between exclusive bottle-feeding

and malocclusion.

 This mal-relationship does not diminish as the child grows from the primary
to permanent dentition.
Davis D. Bell P. Infant feeding practices and occlusal outcomes:

A longitudinal study. J Can Dent Assoc. 1991: 57(7): 593-94
 Data support cup-feeding as an alternative to bottle-feeding for supplying

supplements to breastfed infants. Administration times, amounts ingested,
and infant physiologic stability do not differ with cup- or bottle-feeding.
Howard CR, et al.

Physiologic stability of newborns during cup- and bottle-feeding
1999; Pediatric (104)(5): 1204-7.

Thumb Sucking
 Thumb presses against the rugae, pushing the palate up
 Teeth narrow laterally, causing the upper teeth to protrude
 Thumb pulls the upper teeth forward, which protrudes the upper teeth
causing the upper lip to curl up
 Tongue presses to the floor of the mouth putting pressure on the lower
teeth, which protrudes the lower teeth causing the lower lip to curl
downward
 Upper lip curls up, the lower lip is pulled down, which stretches the lips and
labial frenulum
 This impacts lip closure, which impairs respiration causing mouth breathing
 Pressure of the hand against the mandible retards forward growth and may
cause the mandible to retract
 The index finger over the nose deviates the nasal septum which obstructs
air passage causing mouth breathing
 Mouth breathing causes reflex changes in the respiratory system
 The result is high costal breathing which uses the SCM and Scalenus Medius
to elevate the ribs
 This pulls the cranium into extension which increases the cervical curve
 Inefficient respiratory pattern reduces capacity for exercises. This reduces
the ability to increase activity levels, which can cause an “inferiority
complex.”
At about 4½ months of prenatal development, the fetus is

about 10 inches long and weighs approximately 9 ounces.
As shown in this photograph, the fetus shows the reflexive
movement of sucking its thumb. This activity appears
remarkably similar to thumb-sucking in neonates.
Photo courtesy of “The Developing Fetus”

www.dushkin.com
Open Bite created by a Thumb Habit

Adult Thumb Suckers….. www.thumbsuckingadults.com
Why do we suck our thumbs or fingers?
For most ATS it comes down to habit. When we were children, tsing gave us a lot of pleasure,
satisfying the sucking instinct and even possibly compensating for less nurturance than we may have
needed but, as we got older, this satisfying behavior became a habit. As such, we learned to associate
it with certain comforting needs that we all share. These associations help to relieve psychological
stress. We also retained its usefulness in helping us go to sleep under a variety of conditions and
moods. We’ve also found that, by relaxing us, it helps us to concentrate better. All these benefits, over
a lifetime, only encouraged us to continue.
Other factors that may have enabled us to continue concern our ability to hide it. Additionally, for
most ATS, its benefits outweighed any dental affects. In other words, the cost/benefit ratio was
weighted towards the benefit end of the spectrum. In some rare cases, the benefits combined with a
confident personality and this combination enabled the ATS to indulge, even in public or in front of
trusted friends or family members.
There have been a good number of cases where large percentages of siblings are ATSers. A major
tying theme in these families has been alcoholism on the part of the parents, particularly the father.
Some cases mentioned drug dependency among one or more of the siblings and so this, too, may play
a part in certain situations. Another aspect which may serve to further cement the habit, in these kinds
of cases, involve issues of emotional neglect on the part of the parent(s) when the ATS was a child.
Tsing may have provided feelings of safety and/or security for these individuals. These same
adaptations carried into adulthood.
Why haven't I stopped like so many others have?
Usually people who have been able to withstand the demands to stop have continued because they
were very good at hiding it from others and thereby being able to derive the benefits without having
any associated negative reinforcements from others. In some cases the habit ceased due to braces that,
once fitted, removed the pleasurable sensations the tser felt without them. Others never felt the need to
stop because their families tolerated the habit well. Still, some, the confident ones, have had the
attitude that they have a right to ts, especially since they weren't hurting anyone. In fact, with these
kinds of individuals, if anyone suggested that they stop, they’ve felt that that decision was solely up to
them and that other's should, "mind their own business." With others, the need to continue was so
powerful, due perhaps to psychological dependency, that stopping was out of the question. Some
continued because they’ve felt it to be a part of who they are or were uneasy, even ill, without it.
Basically, though, it’s another case of benefits outweighing costs.

I thought I was the only one. How many adult thumb suckers are there?
There are no known, scientifically determined, answers to this question, only educated guesses but the
numbers must be higher than anyone would have guessed.
Immediately after this site was featured on the nationally televised program “Extra” for only 8
minutes, four times in May of 1999, it was deluged with thousands of “hits”. Prior to the show the site
averaged 300 or so hits a week, immediately afterward the site averaged from 800 to 900 hits per
week, peaking one week at over 2,300. (It now averages 1100-1300 hits per week, as of 12/25/00.) Of
these hits, about 140 surveys were filled out where the survey participant indicated that they’ve heard
of the site from that show. The producer of Extra wouldn’t tell me the exact number of viewers during
those particular shows, but indicated that, during prime time, there are upwards of 3 million people
watching, typically. I’d guess that one in four ATS visiting the site take the time to fill out and
successfully send the survey. One should also realize that there are still many homes without access to
the Internet. Based on this limited experience, I’d guess there are 200,000 or more ATS in the United
States and millions worldwide. But there may be more, a lot more.
It is interesting to note that the United Kingdom seems to have a much more tolerant attitude about
ATS. In much correspondence with those living or visiting there, as well as other English speaking
countries like New Zealand and Australia, public ATS is far more common than anywhere else I know
of. As such, I’d guess that there is a higher percentage of ATS there than anywhere else. But I think
you should have at least one more reason to move to any of those places, don’t you?
http://www.thumbsuckingadults.com/Indexphotoscroll.gif

COULSON INSTITUTE VIEW …. The Program (Thumb Sucking)
THUMB AND FINGER HABITS are so subconscious that reminders in
positive ways are helpful. Please stay positive, even if there might
be an occasional time with finger or thumb are in the mouth. We
WILL work through it!!!!
(It is rare that a child will slip and suck the thumb or finger. When
this does occur, it is usually because the sock/glove was not placed
at bedtime or the Band-Aid was not on the thumb or finger).
If there should be a slip and the digit is sucked, IT IS VERY

IMPORTANT THAT THE PARENTS DO NOT GET UPSET.
As long as the child is willing to keep trying, THIS IS THE MOST

IMPORTANT THING. And the phone calls help to keep this program
structured.
It is of course VERY IMPORTANT to offer a lot of praise and

encouragement for effort.
This program is based on building self-esteem. I hope that you will

be part of what is usually a positive experience!

Program to Stop Thumb Sucking
1.) PUT CONTROL-IT ON 3 TIMES PER DAY.
2.) WEAR A BAND-AID ON YOUR THUMB OR FINGERS 24/7.
3.) WEAR A GLOVE OR SOCK TO BED. TAPE IT ON SO IT DOES

NOT COME OFF DURING THE NIGHT.
4.) WEAR A GLOVE OR SOCK IN THE CAR AND WHILE

WATCHING T.V.
5.) PUT 2 STICKERS (ONE FOR DAY AND ONE FOR NIGHT) ONTO
YOUR CHART FOR NOT SUCKING.
6.) PUT IN A “SPOT” 3 TIMES A DAY:
-AFTER BREAKFAST
-IN THE AFTERNOON
-AND AT BEDTIME
(REMEMBER TO DRY YOUR PALATE FIRST)
7.) CALL YOUR THERAPIST ON THE NUMBER PROVIDED. IF

LEAVING A MESSAGE PLEASE LEAVE YOUR NAME AND YOUR
PHONE NUMBER!
8.) SPECIAL INSTRUCTIONS:
REMEMBER TO DO YOUR BEST!!!!!!

Pacifiers / Dummies
 There is a positive association between pacifier use and posterior cross bite
and reduced upper arch width.
 The mechanism of sucking activity in the cheeks reduced palatal tongue

support as the tongue takes a lower position in the floor of the mouth.
Ogaard B, Larsson, and E, Lindsten R. The effect of sucking habits, cohort, sex, intercanine arch
widths, and breast or bottle feeding on posterior crossbite in Norwegian and Swedish 3-year-old
children. American Journal of Dentofacial Orthopedics 1994; 106: 161-6.
 75-85% of all children in western countries use pacifiers. Children weaned

from breastfeeding early use a pacifier more often than those who are
breastfed longer.
Victoria CG, et al. Pacifier use and short breastfeeding duration: case, consequence, or
coincidence? 1994, Pediatric Dentistry; 99: 445-53.
Baby Bottles & Pacifiers
A strong association has been found between

exclusive bottle-feeding and malocclusion.
(SOURCE: The Journal of the Canadian Dental Association--1991)

Your Jaws ~ Your Life (page 46)
Backward forces of bottle and pacifier sucking constrict dental arches and jaws,
dramatically increasing malocclusions. Sucking forces constrict the palatal bone that
holds the teeth, especially in the upper front roof of the mouth area. The forces of
sucking oppose normal directions of growth for the upper and lower jaws. This prevents
the upper and lower jaws from growing to their full potential during what should be one
of the fastest periods of growth. Small upper jaws then prevent the lower jaws from
growing and moving forward. The longer and stronger an infant sucks, the more
damage is done.
Current baby bottle and pacifier designs do NOT place forces on the jaws (sucking), the
same way as breastfeeding (suckling). There is presently no bottle or pacifier nipple like
a mother's breast. Breast suckling helps upper and lower jaws form in 3-dimensional
ways that sucking on bottles and pacifiers cannot. Research shows there are lifelong
benefits for an infant and a nursing mother from at least 3-6 months of exclusive
breastfeeding, including a greater chance for straighter teeth and jaws for the child.
David C. Page, D.D.S.

Thumb Sucking, Pacifiers Affect Child's Bite
Breastfeeding Beats Bottle Feeding for Straighter Teeth

By Miranda Hitti
WebMD Medical News
Nov. 17, 2004 - Babies who suck their thumbs or use pacifiers are more likely to grow
up with crooked teeth. But breastfed babies may be more likely to develop a nicer smile.
Domenico Viggiano, MD, and colleagues studied about 1,000 preschool children aged 3-
5 in the southern Italian town of Cava de' Tirreni. The kids had all participated in an oral
health study organized by the local school.
Data included how the children were fed during their first three months of life and
whether any children had used pacifiers or sucked their thumbs for more than one year,
which the researchers call "non-nutritive sucking."
A dentist examined all the children's teeth to flag any flaws in their mouths.
The researchers found that breastfeeding appeared to have a "protective effect" against
posterior cross-bite, which occurs when the top back teeth bite inside the bottom back
teeth.
Bottle-fed children accounted for 11% of cross-bite cases, compared with 4% of

breastfed kids.
Non-nutritive sucking may have exaggerated the problem.
Bottle-fed children who had also sucked their thumbs or used pacifiers made up 13% of
posterior cross-bite cases. Five percent of kids with posterior cross-bite were breastfed
children who had sucked their thumbs or used pacifiers.
Pacifiers and thumb sucking were linked to two other baby teeth problems.
A third of all participants had malocclusion, meaning the teeth are not lined up properly.
Those who had used pacifiers or sucked their thumbs were twice as likely to have
malocclusion as those who did not.
In addition, 89% of children with anterior open bite (when the front teeth do not touch)
had been thumb suckers or pacifier users, write the researchers in the December issue
of the journal Archives of Disease in Childhood.
The type of feeding didn't affect open bite and was less important in malocclusion, say
Viggiano and colleagues.

Baby teeth eventually fall out, but it's believed they set the pattern for adult teeth. The
different actions required for breastfeeding and bottle use could affect development of
the mouth and face, say the researchers.

Parent’s questionnaire

Denver, CO 80224
303-759-2760
Fax: 303-759-2971
We are always trying to improve, where possible, our services and programs. Please
complete this questionnaire so we may try to further improve our programs for children
with digit (thumb or finger) sucking habits. Your cooperation is sincerely appreciated.
Who referred you to our practice? ____________________________________________
What were you referred for? _________________________________________________
Were you aware of any damage to the teeth as a result of the sucking habit? ____________
_________________________________________________________________________
Had you been trying to get your child to discontinue the sucking habit prior to coming to
see us? ______ If so, what methods were employed? ______________________________
_________________________________________________________________________
How soon after beginning our program did your child discontinue the sucking habit?
_________________________________________________________________________
Do you feel your child gained in self-confidence and self-esteem as a result of being able
to 'kick the habit'? _________________________________________________________
Do you feel the program was worthwhile? ______________________________________
Would you recommend the program to other parents with a child with a digit-sucking
habit? ___________________________________________________________________
Do you have any suggestions as to how we may improve this program?

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Additional comments:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Your child's name: ____________________________________________

Your Signature: ________________________________________ Date: ______________

Nail Biting: A Habit That Can Be Broken
Habits that are acquired over a lifetime can sometimes
produce regret.
Research shows that human beings’ ability to develop habits

begins even before birth. Often, sonograms show a thumb
in the mouth!
Some repetitive behaviors are annoying to others and can

be harmful to us. It is proven that the ‘germ factor’ is a
major consideration, since a possible two million germs can
be harbored under one thumbnail!
Sometimes we exchange one bad habit for another. Adults

are occasionally defined by their habits, both good and bad.
OROFACIAL MYOLOGY is a therapy which deals with

changing behaviors such as thumb and finger sucking,
pacifier sucking, tongue thrust, tongue sucking, open-mouth
resting, hair pulling (trichotillomania), and NAIL BITING.
This therapy is proven. It is performed by therapists who

are trained in the areas of muscle function and behavioral
change. It is POSITIVE and usually takes only a few visits.
The goals established are attainable. Measurements and

photos are taken so that the patient can compare changes.
RESULTS are often LIFE CHANGING!!

Nail Biting
It is my opinion that one of the primary reasons people bite their nails is because they
spend most of their time breathing through their mouths. The ages of these patients
vary from young children to mature adults.
Since the facial muscles are being primed to function throughout the day and night, if
they are not used, the body figures out a way to relieve the stress of the muscles, and
nail biting becomes a habit pattern.
Nail biting can be detrimental for a number of reasons:
 Research shows that there can be approximately 2 million germs under one
fingernail
 Nail biting can cause TMJ damage by stressing the muscles as the mandible
is thrust forward to achieve an edge-to-edge position of the teeth.
 Nail biting can damage teeth as they “crunch” together in the edge-to-edge
position, much like “bruxing.”
Nail biting is treated much the same as thumb sucking.
 A full history is taken and an evaluation with measurements, facial

muscular function, photos (including photos of the nails), and assessment
of body posture is done on the first visit.
 A behavior modification program is begun with the goal being to establish

proper tongue and lip resting positions. Progress charts, praise and
rewards are used as motivators.
 The patient is expected to call daily to report on progress.
This therapy usually takes six to eight visits.

CIOM View….. Fantastic Nail Factoids
As early as 400 BC, Hippocrates

taught that nails reflect the
inner
body’s condition. It is true that
nails can often give early clues
to
common medical and even
more
severe systemic diseases.
There are a number of variables

that may affect nail growth;
1.) Nail growth is different from person to person and from finger to finger. The nail
on the middle finger grows the fastest and the nail on the little finger grows the
slowest.
2.) Nails grow from 0.05 to 1.25 millimeters per week. If a nail is lost, it may take
seven months to grow out fully again.
3.) A healthy fingernail takes about six months to grow out completely.
4.) Nails grow faster on the hand you use the most.
5.) As a rule, the nails of babies and older folks grow more slowly than teenagers.
6.) The length of the finger and the size of the lunula or moon suggest the speed of
growth of the nail. The shorter the finger and the less of its visible lunula, the
more slowly the nail will grow. (The thumb is the exception.)
7.) Fingernails grow faster than toenails and all nails grow more quickly in the
summer than in winter or cold weather. Heat increases the rate of all metabolic
processes.

Trichotillomania
What is Trichotillomania?
Currently, trichotillomania is classified in psychiatry as a disorder of impulse control,

along the lines of pyromania, kleptomania and pathologic gambling. According to the
current psychiatric diagnostic manual (DSMIII-R)* the definition is:
A. Recurrent failure to resist impulses to pull out one’s own hair, resulting in
noticeable hair loss.
B. Increasing sense of tension immediately before pulling out the hair.
C. Gratification or a sense of relief when pulling out the hair.
D. No association with a preexisting inflammation of the skin, and not a response
to a delusion or hallucination.
As more is known about all these disorders, each one may eventually be reclassified as
compulsive disorders in the future. The supposed difference is the “enjoyment” of the
act and lack of desire to change except for the long-term consequences. Impulses as
defined in the DSM-IIIR could be viewed as the other side of the same coin as
compulsive, rather than as opposites.
What are the symptoms?
There is virtually always some anxiety or tension associated with the disorder. Many
describe the hair pulling as decreasing this tension. On the other hand, after an episode
of hair pulling, the fear of losing control and becoming completely bald can cause an
extreme heightening of their anxiety.
Many people may have the habit of playing with the hair in some manner after pulling it
out. They may touch the root to their lips or pull it through their mouth or hands. Many
bite the root off and a few will eat the whole hair (called trichophagy) which in rare
cases has resulted in the need for surgical removal of the indigestible hair ball from the
stomach.
Some describe pulling out hairs that “feel wrong” and may spend much of their time
searching for the right hair to pull out. Others select a “favorite” are of the scalp (or
elsewhere) to pull from which may change in location over the years. Any are of hair
growth such as the eyelashes, eyebrows, beard, chest hair, leg hair, or pubic hair may
be involved.

The hair pulling is generally not painful. It may be engaged in from minutes to hours a
day and usually is done when alone. The preponderance of people requesting help with
this disorder are women, although there is no proof it is more common in women.
CIOM View
It is my opinion that trichotillomania results from the “pain/pleasure” response of the

brain to the pulling. We know that endorphins and serotonin are emitted when there is
pain (pulling) and a calmness results after the pain chemicals have subsided (pleasure.)
The protocol for treating trichotillomania is similar to that used for thumb and finger
habit control.
Therapy beats drugs for hair-pulling disorder
NEW YORK, Mar 10 (Reuters Health) -- Trichotillomania -- compulsively

pulling out one's own hair -- is a difficult disorder to treat. A recent
study comparing the only two effective treatments -- a drug, and behavioral
therapy -- found that behavioral therapy gets the best results.
The disorder is more common in women. It usually begins before puberty, and often
causes a great deal of stress.
Researchers at Emory University School of Medicine in Atlanta, Georgia, led

by Dr. Philip T. Ninan, compared cognitive-behavioral therapy, the
anti-depressant drug clomipramine, and placebo (inactive) pills in 16
patients who had been pulling out their hair for an average of 20 years. The
patients,13 of whom were female, had an average age of 33.
During the 9-week study, patients who received clomipramine or placebo also
met weekly with a psychiatrist, while those receiving behavioral therapy had
weekly sessions with a behavioral psychologist. Behavioral therapy included
awareness training, practicing alternative responses, and stress management
techniques.
Behavioral therapy “had a dramatic effect'' in these patients, the authors

write. It proved to be significantly more effective than either clomipramine
or placebo. All five of the patients in this group showed significant
improvement, and four had completely stopped pulling out their hair by the
end of the study. Among the six patients taking clomipramine, four showed
significant improvement, but none were symptom free. The placebo group
showed no significant improvement at all. However, patients taking clomipramine
reported more side effects than most patients taking this drug, the researchers note,
including tremor, drowsiness, and dry mouth. Four of the 10 patients that started the
study in this group dropped out. Ninan and colleagues suggest that other
anti-depressant drugs should be tried with trichotillomania patients.
Writing in the January issue of the Journal of Clinical Pharmacology, the

authors add that larger studies comparing behavioral therapy to drug
treatment should be done, as well as research on how to maintain the
improvement achieved with short-term therapy. SOURCE: Journal of Clinical
Psychiatry 2000;61:47-50.
Drs. Chow, Mailloux, Lauretti & Goldberg provide behavior therapy for individuals with
Trichotillomania.
The Coulson Institute
PROGRAM TO STOP HAIR PULLING
1.Put in a SPOT after breakfast, after lunch and before bed.
2.Place a glove on your hand that does the pulling.
3.Place a sticker on your chart if you did not pull at all.
4.Do these exercises morning and night and place a sticker on

your chart.
a. Tip Pops…do 25 ‘snappy’ ones.
b. Tip ‘sit-ups’…do 25 keeping your tongue straight.
c. Lip Pops…do 25 as loudly as possible.
d. ‘Great Granny Surprise Face’…Raise your eyebrows
as you stretch your lips over your teeth, rolling your lips
in…Hold this position for 25 counts.
5.Recite this ‘promise’ every morning…

I will wear my ‘spots’ and my glove/s, put on stickers, do
my exercises, and call my Therapist EVERY morning to
check-in.

.
Temporomandibular Joint (TMJ) Dysfunction
How do you recognize this disorder?
Differential Diagnosis:
Symptoms: Pain or tenderness in either or both jaws, headaches, neck pain, shoulder,
earache, or tooth pain are possible symptoms. The diagnosis should be determined by a
professional/specialist in the area of dentistry, neurology, general practice,
otolaryngology or orthopedics. Upon referral the questions you may ask include:
Pain on opening or closing the jaw? The entire movement might be painful, or it
can be restricted.
Inability to open the mouth in a straight vertical pattern? Observation of the

patient while seated in front of him/her. If the jaw slips noticeably to one side or the
other on opening or closing, it might be a left or right TMJ disorder.
Tenderness of the TMJ on one or both sides? The joint is located directly in front of
the ear. You can feel it easily by pressing your fingertips onto this area, then having the
patient open and close their mouth. If it is painful, the joint/joints might be inflamed.
Pain or tenderness in any of the muscles of chewing? You can easily feel the thick
masseter muscle which extends diagonally from the angle of the jaw to the cheekbone,
and the temporalis muscle which is fan-shaped above and in front of the ear. The
pterygoid muscles can be assessed by tests of resistance.
With the mouth open slightly, press three gloved-fingers against the top of the lower
front teeth. Ask the patient to close the teeth against the pressure, then, with the jaw
closed, press a fist against the chin and ask the patient to open against the resistance.
Finally, press an open palm against each side of the lower jaw sideways against the
resistance. If any of these tests cause noticeable pain, one or more of the muscles
might be fatigued or inflamed.
Noticeable clicking or popping on opening or closing of the mouth? This, by

itself, with none of the other symptoms present, is not necessarily evidence of a serious
TMJ disorder. This could be a classic symptom of an internal derangement.

Temporomandibular Joint

TMJ Disorder
Orofacial Myology plays an important role in the treatment of this disorder. It is
especially useful with myofascial pain. It has two main goals: the relief of pain and the
restoration of function, particularly the function of movement. It helps patients to
develop weak or underused muscles and improve tongue posture and other physical
habits.
Protocol:
 Take a complete medical history

 Review medical records
 Discuss case with other treating professionals
 Perform a thorough physical examination
 Create an individualized treatment plan
Treatment:
Treatment concentrates on reducing pain and inflammation and restoring mobility using
a typical orofacial myofunctional treatment regimen. The patients are normally ‘pain-
free’ in just a few days with improved tongue posture and lip closure.
You should be a part of a TMJD ‘TEAM” that has records and knows the patient’s
specific issues so that all treatment can be coordinated.

Managing Your Temporomandibular Joint Disorder
Self Care:
 Put in a 'spot' A.M., P.M. and at bedtime.
 Rest your jaw

 Keep your tongue up.
 Keep your teeth apart slightly.
 Close your lips.
 Work on body posture

 Avoid leaning on your hands.
 Sit up straight at your desk, table, etc...
 When driving, be certain your head touches the headrest.
 Eat soft foods
 Apply ice/heat to reduce swelling…

 Put ice on your jaw, until the area is ‘numb’, for 2 minutes each hour, for 2
hours.
 Apply moist heat to your face to relax your muscles. Do this at bedtime.
 Exercise your jaw three times a day.

 Do these exercises to help restore normal range of motion by improving
flexibility and creating greater strength.
1) Tip pops- do 10 snappy ones- SMILE!
2) Palate scrapes- do 10.
3) 'Granny face'- hold 20 counts- look surprised.
4) Lip pops- do 20.
 Massage your face twice a day.

Intra-oral stretch-- do while showering or just massage your cheeks,
externally.
Rules:
1) Yawn with your lips closed.
2) Take only small bites.
3) Do not chew gum or eat raw carrots, whole apples, bagels, etc...
4) Hold the phone in your hand (do not cradle it on shoulder).
5) Drink room temperature liquids with your teeth closed so that you do not
thrust your jaw forward, or just drink from a straw.
6) Be sure to nasal breathe so that you do not rest with your mouth open.
7) Back sleep as much as possible or side sleep (not on your stomach).
8) Get a body massage when possible to relax the rest of your muscles.

World Health Statistics Relating to the T.M.D. Population
According to Dr. Mariano Rocabado
 70% of the pediatric population needs some type of

orthopedic or orthodontic care.
 37% of digit suckers under age 10 have moderate to

severe symptoms.
 60% of all teenagers have symptoms and 15% of those

need treatment.
 58% of all T.M.D. patients have an abnormal cranio-

vertebral position (Atlas / Axis)
 88% have abnormal cervical thoracic function.
 54% have a malocclusion – 48% have a class II.
 86% have an abnormal clavicular position.
 78% have an abnormal scapular position.
 86% of mouth breathers have blood oxygen levels which
are 10-40% low and an increased possibility of T.M.D
symptoms because of head and tongue posture.

Avoiding Injury, Spasm and Pain
We have all seen the amazing strength, flexibility and grace in the body movements of a
highly-trained gymnast. But we rarely stop to appreciate that this movement is only
possible when bones and muscles work together and are held in place by healthy
ligaments, tendons and cartilage. Without healthy muscle ligaments, tendons and
cartilage, even the simplest everyday movement can result in debilitating pain or injury.
Consider an example of a man bending down to pick up his briefcase. He suddenly
experiences excruciating pain in his lower back. What caused this unexpected event?
What we learn from this example may help us avoid: Injury, Muscle Spasm and Pain.
Injury
A close examination of his lower spine reveals a variety of ways that injury may occur:
1) Herniated disk: A chronic weakening of the outer sheath of the disk allows the softer
center portion of the disk to bulge through, pressing on a nerve exiting the spine and
causing severe pain. 2) Degenerated Disk: Over time the entire structure of the disk
has become so weak and thin that it no longer provides the proper separation and
shock-absorbing effect between the vertebrae. As a result, the vertebrae develop
micro-fractures and bone spurs and are susceptible to improper movement that may
result in painful misalignment. 3) Weakness of Spinal Ligaments and Tendons: A
chronic weakening of ligaments and tendons may contribute to overall structural
instability, making a person susceptible to improper bone movement and painful
misalignment. Laxity of ligaments and tendons may also occur in any other joint such
as the shoulder, elbow, knee, etc.
These injuries may actually result from a long series of painless micro-injuries that
progressively weaken the tissue to the point where a simple, everyday movement
becomes disastrous. While injury to connective tissue was once believed to be
irreparable, there is now strong evidence to the contrary. When properly nourished, the
cells found in cartilage may multiply and manufacture new, healthy collagen, the
material that cartilage is made of.
The degree of repair and regeneration is greatly dependent on a person’s biomechanical

function; i.e., proper bone alignment, joint movement and the availability of important
nutrients. Effective therapy addresses these concerns.
Muscle Spasms
Millions of muscle fibres (also called muscle cells) are connected together to form
skeletal muscles. A close examination of the muscle fibres reveals a graphic
enlargement of microscopic muscle fibres. The spastic, malnourished muscle fibre
(lower) is contrasted with a relaxed, nourished muscle fibre (upper). The well-nourished
muscle fibre is less likely to develop a painful spasm or cramp. When injured, we may
adjust our posture into a position that will help relieve the pain and compensate for our
poor mechanical function. This along with poor muscle nourishment may create
muscular stress that triggers spasm, cramping and muscle pain. It may also cause a
worsening of the original injury and greater pain. As with connective tissue healing,
when dealing with muscle spasm and cramping the degree of therapeutic success is
greatly dependent on a person’s biomechanical function; i.e., proper bone alignment,
joint movement and specific muscle cell nourishment. Effective therapy addresses all
these concerns.
Pain
Prolonged or excessive pain and inflammation, or total elimination of inflammation by

drug treatment, may both result in delayed healing. The greatest benefit to healing
comes when balance between these two extremes is achieved.
A common and painful shoulder injury, known as “impingement syndrome,” is caused

when connective tissue cells are torn open as a bone impinges on a tendon in the
shoulder. The cells then release certain fatty acids that are changed by specific
enzymes into substances that create pain and inflammation. Inhibiting the action of
these enzymes may serve to reduce the excessive production of these pain-causing
substances. In addition, certain other dietary fatty acids may lead to the production of
substances that relieve pain. Also, the cellular fragments and other debris resulting
from the injury must be dissolved or removed to set the stage for healing and repair.
Specific nutrients may be successfully applied in an effort to accomplish these goals.

Suggestions to Help Avoid Injury, Spasm and Pain
1. Take care to achieve and maintain your body’s optimal biomechanical

function, focusing on accurate bone alignment and proper joint movement.
2. Nourish your various tissues (cartilage, ligaments, tendons and muscles)

with nutrients which may support their ability to heal and their prolonged
health and vitality.
3. Exercise regularly, even if it is only a simple range of motion. Movement is

essential to accomplish the delivery of nutrients to – and the removal of
waste products from – the cells found in the cartilage of the inter-vertebral
disk.
4. Reduce stress as much as possible. Adequate rest following exercise may

help promote thorough delivery of nourishment to the cells of the
connective tissues.

Speech Therapy Disclaimer
In this practice we do not use traditional methods of speech

therapy.
Orofacial Myology applies techniques, which bring the

muscles of the face, tongue and lips into balance so that
they produce improved articulation. In some cases, a
referral will be made for traditional therapy after the
muscles respond to our methods of exercise.
The optimal treatment plan is based on differential diagnosis

and personal wants and needs of the client and the referral
source.
When necessary we refer patients to other professionals

where we find that there are external factors which
compromise our treatment regimen.

Signs of Possible Speech and Hearing Problems
Parents and physicians alike should consult professional help when any of the following
conditions exist:
1. If the infant seems unaware or does not localize the source of sound by the age of
6 months.
2. If the infant does not babble, coo, or play with sound by the age of 9 months.
3. If the child has no words at all by the age of 20 months.
4. If speech largely is unintelligible after age 3.
5. If the child is not forming simple sentences of two or more words by age 3.
6. If the child uses primarily vowel sounds in speech at age 3.
7. If there are many omissions of initial consonant sounds after age 3.
8. If sentence structure or grammar noticeable is faulty at age 5.
9. If there are many easy sounds substituted for difficult sounds by age 5.
10. If the ends of words consistently are dropped after age 5.
11. If the child appears to hesitate excessively or “stutter” after age 5.
12. If the child is embarrassed or quite disturbed by his speech at any age.
13. If individual consonant sounds are mispronounced after age 6.
14. If the pitch of the voice is excessively high or low, or if the quality of the voice
is excessively unpleasant at any age.
15. If the voice is noticeably nasal at any age.
16. If the child breathes through his mouth for prolonged periods of time at any
age.

What the Orofacial Myologist can do for Tongue Posture
and Speech Sounds
Be Aware of Apraxia of Speech

Definitions
- Oral apraxia; patient cannot move the muscles of the throat, soft palate,
tongue, and cheek for non-speech purpose
- Verbal apraxia; a difficulty in initiating and executing the movement patterns
necessary to produce speech when there is no paralysis, weakness, or
dis-coordination of speech muscles.
1. Differentiation from dysarthria

Dysarthria Apraxia Aphasia
- No impairment of muscle
function
- Slowness, weakness,
incoordination, or change in
- Continuing impairment of
tone of the speech
articulation, with prosodic - Impaired in comprehension,
musculature
alterations at times following formulation, and expression of
as compensatory phenomena language
- Respiration, phonation,
resonance, articulation, and
- Have difficulty in initiating
prosody-variably involved
phonation at will (usually in a
few days)
- Problem involves the
processing not-meaning
bearing units
- Problems lies in the
- - Problems in articulating processing of the meaning-
given word, not in word- bearing units of language
finding difficulty
- May be able to write it

- Few simplification errors, but
substitution or addition of
phonemes, repetition of
phonemes, and prolongations
- Imprecise production of
of phonemes.
consonants, usually in the -
form of distortion
- Answers correctly when
asked to choose from a group
of words that he is trying to
say.

2. Unique features of apraxia
 Contrast between voluntary and involuntary performances.
1866 Hughlings Jackson; automatic vs volitional performance of simple

speech and non-speech tasks
o classical example: could not protrude his tongue on command or by

imitation, but could protrude it to lick a crumb from his lips
Liepmann; inability to use parts of the body in a purposeful manner,

despite intact power of movement and complete understanding of what is
required ~ apraxia
 Variability of error
Errors in articulation are not evenly distributed throughout the target words,
initial sounds being more formidable than final sounds, and consonants
causing more difficulty than vowels.
Speech is Highly variable from patient to patient and from trial to trial within a
given patient's performance.
i.e, /spl/
1st; insert schwa

2nd; unequivocally say /spl/' correctly
3rd; (a stuttering like response)
4th; a totally unrelated substitution (sukpltweeing/spleen)
5th; substitutive simplification (speen or pleen for spleen)
6th; with the precision of a normal speaker
In apraxic patients -grossly abnormal in form; repeated utterance with great

variability; vowel were prolonged and variable in length.
3. Clinical features
 Behavioral characteristics
Deviations from normal in apraxia of speech are primarily articulatory.
1. The apraxic patient effort fully gropes to find the correct articulatory
postures and sequences of them.
2. Such articulatory difficulty involves consonant phonemes more often
than vowel phonemes.
3. The articulation errors are inconsistent and highly variable, not
referable to specific muscle dysfunction.
4. The articulatory errors are primarily substitutions, additions,
repetitions, and prolongations-essentially complications of the act of

articulation. Errors of simplification, such as distortions and omissions,
are relatively much less frequent.
5. Analysis of substitution errors by distinctive features (place, manner,
voicing. and oral-nasal characteristics) indicates that the majority of
errors are close approximations of the target sounds.
88% - one or two feature errors, most of the remaining l2% being
three-feature errors. Place-61%, manner - 53%, voicing-36%
6. Articulatory errors appear to be at times perseverative, with

recurrence of phonemes recently articulated, and at times
anticipatory, with the premature introduction of a phoneme
that appears in a subsequent word.
7. In attempting to produce a difficult cluster of consonants, the patient

may simplify his task by inserting a schwa between the elements, as
in pronouncing "stuh-rike" for strike.
8. Patients with apraxia of speech can recognize their articulatory errors

beyond random guess.
 Factors influencing apraxic speech behavior
1. Articulatory errors increase as the complexity of motor

adjustment required of the articulators increases.
Vowel < Singleton consonant, fricative and affricate phonemes evoke

the most error.
/puh/,/tuh/,/kuh/ vs /puh-tuh-kuh/
2. Initial consonant phonemes tend to be misarticulated more often than

final consonant phonemes.
3. Phonemes occurring with relatively high frequency in spoken English
tend to be more accurately articulated than phonemes occurring less
frequently.
4. Apraxic patients display marked discrepancy between their relatively
good performance on automatic and reactive speech productions and
their relatively poor volitional-purposive speech performance.
“Words and phrases highly organized by practice and usage tend to
sound normal".
5. Imitative responses tend to be characterized by more articulatory

errors than spontaneous speech production.
6. Articulation errors increase with increase in length of word. (thick,
thicker, thickening; cat, catnip, catapult, catastrophe). Errors typically
occur in the syllable common to all of the words, not just in the added
syllables. 7. In oral reading of contextual material, articulatory errors
do not occur at random.
8. Correctness of articulation is influenced by mode of stimulus
presentation.
9. Attainment of the correct articulatory target is facilitated more by
repeated trials on a word than by increase in the number of stimuli
presentation.
 Factors not influencing apraxic speech behavior
1. When patients perform a task under two conditions, one while

observing themselves in the mirror and the other without visual
monitoring, the difference in the number of errors produced is not
statistically significant.
2. Introduction of masking noise so the patient cannot hear his own
speech does not significantly alter the number of articulation errors he
makes.
3. Articulatory performance is not improved when the patient is given an
opportunity to delay his imitative response.
4. Articulatory accuracy is not influenced by the instructional set created
in the patient.
 Associated features
1. Many patients exhibit oral apraxia.
2. Some apraxic patients demonstrate difficulty in auditory perception.
3. Some apraxic patients display impairment of oral sensation and

perception as measured by tests of oral form identification, two-point
discrimination, and mandibular kinesthesia.

Summary – Apraxia of Speech
All of these need to be with initial assessment:
 Apraxia of speech is a distinct motor speech disorder distinguishable from

dysarthria and aphasia
 A disorder of motor speech programming manifested primarily by errors in

articulation and secondarily by compensatory alteration of prosody
 High variable articulation errors embedded in a pattern of speech made

slow and effortful by trial-and-error gropings for the desired articulatory
postures
 Substitution, additions, repetitions, and prolongations, less frequently

simplifications(distortion and omissions)
 Errors are most often on consonants occurring initially in words,

predominantly on those phonemes and clusters of phonemes requiring
more complex muscular adjustment. (i.e.,/dr/ in drinking or /str/ in streets,
for example; strategy = “statir.. tatar…strkeg...stratipy….satirigy...I can't
do it.")
 Not significantly influenced by auditory, visual, or instructional set

variables.
 As patients struggle to avoid articulatory error by careful programming of

muscle movements, they slow down, space their words arid syllables
evenly, and stress them equally.
 Makes many errors of articulation, recognizes errors, and makes repeated

attempts to correct the errors.
 Phonemes and words that are used more frequently are produced with
greater accuracy.
 Speech sound of a word may be produced out of sequence. (i.e., California

= "lala…hala…uh…calfa…calanor…calforfa…halfnora…calfrona…I can’t get it.”
 Complex or longer words are more difficult than simpler or shorter words.
 The person who cannot say a word can write it.

Glossary of Dental Terms
Aberrant.
Wandering or deviating from the usual or normal course.
Abrasion.
The wearing away of tooth substance by mechanical means.
Abutment.
A tooth used for the support or anchorage of a fixed or removable prosthesis.
Alignment.
The line of adjustment of the teeth.
Alveolar process.
The ridge projecting from the lower surface of the body of the maxilla or the upper
surface of the mandible containing the alveoli of the teeth.
Alveolar septum.
The bony wall that separates individual alveoli.
Alveolus; pl., alveoli.

A tooth socket. A cavity in the jawbone that envelops the root of the tooth.
Anatomical crown.
The portion of the tooth that is covered by enamel.
Anatomical landmark.
A readily recognizable anatomical structure used as a point of reference in establishing
the location of another structure or in determining certain measurements.
Angle.
A sharp bend formed by two borders or surfaces. A point. The angle of a tooth is the
line or point where to surfaces meet.
Ankyloglossia (tongue-tie).
Partial or complete fusion of the tongue with the floor of the mouth or the alveolar crest;
caused by lingual frenum being abnormally short or abnormally attached.
Ankylosis.
Abnormal immobility and consolidation of a joint. Stiffened; held by adhesions. An
ankylosed tooth is fused to alveolar bone, with obliteration of the periodontal
membrane.
Anodontia.
Total congenital lack of teeth, often combined with lack of sweat glands,
persistence of fetal hair (lanugo), and defects of the nails. See also Oligodontia.
Antagonist.
A tooth in one jaw that articulates with a tooth in the other jaw.

Anterior tooth.
Any one of the incisors or cuspids in either jaw.
Apex; pl., apices.

The pointed extremity of any conical part. The terminal end of the root of a tooth.
Apical base.
The basal bone portion of maxilla and mandible; that immediately adjoining portion
upon which the teeth and alveolar process rest.
Apical foramen.
The opening of the pulp canal at the apex of the root of a tooth.
Aplastic.
Having imperfect development.
Aptyalia.
Deficiency or absence of saliva.
Articulation (of teeth).

The contact relationship of maxillary and mandibular teeth as they move against each
other.
Attrition.
The wearing away of the incisal edges and occlusal surfaces of the teeth in the act of
mastication or by the opposing teeth of the opposite jaw in the course of normal use.
Axial surface.
Any surface of a tooth that is parallel with its long axis. The labial, buccal, mesial,
distal, and lingual surfaces are axial surfaces.
Balanced occlusion.
An ideal relationship of the mandibular and maxillary teeth to one another in centric
position and throughout all the movements of the mandible.
Balancing occlusion.
The dynamic relationship of the mandibular and maxillary teeth to one another during
the excursion of the mandible from balancing position to centric position.
Balancing position.
The static relationship of the mandibular and maxillary teeth to one another on one side
of the dental arch when closure is made with mandible moved laterally to the opposite
side.
Basal bone.
The bone of the maxilla and mandible, excepting the alveolar processes.
Bicuspid.
A tooth having two cusps or points. Man has eight bicuspids, also called premolars.
They are situated between the cuspids and the molars, two on each side in both jaws.
They are named from the median line distally as maxillary or mandibular first and
second bicuspids.
Bifid.
Separated into two parts.
Bifurcation. Division into branches. The division of a root into two parts.
The division of a groove into two branches. The anatomic area where roots
divide in a two-rooted tooth.
Bruxism. Grinding of the teeth, especially during sleep. Also called
stridor dentium.
Buccal.
Pertaining to the cheek. The buccal surface of the tooth is the surface next to the
cheek.
Buccal e.
The embrasure opening from the contact toward the cheek in the posterior teeth.
Calculus (tartar).
A hard, mineralized deposit attached to the teeth.
Canine.
(1) Of, pertaining to, or like that which belongs to a dog.
(2) The third tooth from the medial line. See also cuspid.
Carabelli cusp.
The cusp located on the lingual surface of many maxillary first permanent molars; it is
also known as the Carabelli tubercle and as the fifth cusp. (Named after Georg C.
Carbelli, Vienna dentist from 1787-1842).
Caries.
A localized progressive disintegration of a tooth, beginning with the solution of the
enamel and followed by bacterial invasion; a “cavity.”
Cementoenamel junction.
The line on the surface of a tooth that marks the meeting of the cementum and enamel.
The cervical line.
Cementum.
The layer of bonelike tissue covering the root of a tooth. It differs in structure from
ordinary bone in containing a greater number of Sharpey’s fibres.
Central fossa.
The depressed area in the occlusal surface of the molars that surrounds the central pit.
Central incisor.
The first tooth on either side of the median line in either jaw. Also call the central pit.
Central lobe.
The middle portion of enamel when the surface or part has three lobes.

Centric occlusion.
(1) The relationship of the teeth to each other when the jaws are closed so that the
lingual cusps of the maxillary bicuspids and molars, and the buccal cusps of the
mandibular bicuspids and molars, rest in the deepest parts of the sulci of the maxillary
bicuspids and molars. (2) The relationship of the upper and lower teeth to one another
when the jaws are completely closed and at rest.
Cervical border.
The extreme margin toward the root of any axial surface of the anatomical crown of a
tooth. It is located at the cervical line.
Cervical ledge.
The slight elevation of enamel around the periphery of the crown immediately above the
cervical line.
Cervical line.
(1) The line of the anatomical neck of the tooth; to be distinguished from the gingival
line. (2) The line around the surface of a tooth where the enamel and cementum meet.
Cervix.
The neck or any neckline part. The cervix of a tooth is the portion of the tooth surface
adjacent to the junction of the crown and root.
Cicatrix.
A scar left by a healed wound.
Cingulum; pl., cingula.

The lingual lobe of anterior teeth which is located mostly in the cervical third of the
lingual surface.
Clicking (TMJ articulation).

A snapping or cracking noise evident on excursion of the mandibular condyle. See also
crepitus.
Clinical crown.
(1) The portion of the tooth that projects from the tissues in which the root is fixed. (2)
The portion of the tooth that is visible in the mouth.
Comminution.
The act of breaking, or the condition of being broken into small fragments.
Condyle.
The rounded eminence at the articular end of a bone. That portion of the mandible that
articulates with the temporal bone of the skull to form the temporomandibular joint.
Contact area.
The portion on the surface of a tooth that touches the adjacent tooth in the same arch.
Crepitus.
(1) A grating sound heard on movement of ends of a broken bone. (2) The cracking
sound emitted by a dysfunctioning temporomandibular joint.

Crypt.
A follicle or tubule; a small glandular sac or pit.
Curet (curette).
An instrument having a sharp, spoon-shaped blade, used for debridement of periodontal
pocket, tooth root, and bone.
Curettement.
Scraping or cleaning the walls of a cavity or surface by means of a curet.
Cusp.
A pronounced elevation or point on the crown of a tooth.
Cuspid.
The third tooth from the median line, lying between the lateral incisor and the first
bicuspid, the incisal edge of cuspids is raised to form a single point or cusp. There are
four cuspids in all. They are named maxillary right and left and mandibular left and
right cuspids. Also called canine.
Cutting edge.
Same as incisal edge.
Debridement.
Slitting a constricting band of tissue, the surgical removal of lacerated, devitalized, or
contaminated tissue.
Deciduous tooth.
One of the teeth of the first dentition, so called because they are shed to give place to
the permanent teeth. Also called temporary or milk teeth.
Dental dysplasia.
Abnormal development of bone, resulting in insufficient space to accommodate all teeth.
Dentin, dentine.
The hard tissue that forms the main body of the tooth. It surrounds the pulp and is
covered by the enamel and cementum.
Dentinocemental junction.
The line of meeting of the dentin and enamel.
Dentition.
The kind, number, and arrangement of the teeth.
Diastema; pl., diastemata.

A space between two teeth, commonly between the central incisors. Also called trema.
Distal.
Away from the medial line following the curve of the dental arch.
Dorsum.
(1) The back or posterior surface of any organ or part. (2) The upper surface and back
of the tongue.
Dysphagia.
Inability or difficulty in swallowing; may result from hysteria, paralysis, muscle spasm,
narrowing of pharynx or esophagus, etc.
Ectopic eruption.
In an abnormal position; a tooth erupted out of its normal sequence in the dental arch.
Edentulous.
Absence of teeth due to loss, as contrasted to anodontia, in which teeth never existed.
Edentulous space: site of tooth loss either through trauma, extraction, or natural
exfoliation of deciduous tooth.
Embrasure.
An opening with sloping sides; the sloping space adjacent to the contact.
Enamel.
The hard, mineralized tissue that cover the dentin of the crown of a tooth.
Endodontics.
The specialty of dental science concerned with the diagnosis and treatment of diseases
of the dental pulp.
Endodontium.
The dental pulp.
Endogenous.
Growing from within; developing or originating within the organism, or arising from
causes within the organism.
Epithelium.
The epidermis of the skin; the surface layer of mucous membranes, consisting of one or
more layers of cells varying in form and arrangement.
Erosion.
The loss of tooth substance due to a combination of chemical action and abrasion.
Eruption.
The emergence of a tooth through the soft tissues to appear in the oral cavity.
Exogenous.
Originating or deriving from outside the organism; being produced or growing from
without.
Extrusion.
The hypereruption or migration of a tooth out of its normal plane of occlusion.
Facet.
A small abraded spot on a tooth.
Facial surface.
The surface of a tooth that is next to the lip or cheek; the vestibular or outer surface.
Fissure.
A fault in the surface of a tooth caused by imperfect joining of the enamel of the
different lobes. Fissures occur along the lines of developmental grooves.
Fossa; pl., fossae.

A round or angular depression in the surface of a tooth. Fossae occur mostly in the
lingual surface of incisors and the occlusal surface of posterior teeth.
Freeway space.
The space between maxillary and mandibular antagonist teeth when the mandible is
suspended in postural rest position.
Frenulum; pl., frenula.

A small frenum. Sometimes applied to lingual frenum.
Frenum; pl., frena.

A fold of mucous membrane that serves to check the
movement of a part or organ.
Gingiva.
The gum; the fibrous tissue covered by mucous membrane that covers the alveolar
processes of the jaws and surrounds the necks of the teeth.
Gingival e.
The embrasure opening from the contact toward the alveolar process. The
interproximal space.
Gingival line.
The line of contact of the extreme border of the gingival to the tooth; to be
distinguished from the cervical line.
Gingival papilla.
The part of the gingival that lies in the gingival embrasure.
Gingival sulcus.
The space that develops in the soft tissues surrounding the tooth, bounded by the tooth
surface on one side and the epithelial lining of the gingival on the other.
Gingivally.
A direction from any part of the tooth toward the gingival line.
Gnathic.
Pertaining to or affecting the jaw or cheek.
Gnathology.
(1) The science of the masticatory system, including physiology, functional disturbances,
and treatment. (2) A specialised field of dentistry concerned primarily with positioning
the teeth in healthy relationship with the temporomandibular joint; also called
orthognathics.
Groove.
A linear depression in the surface of the tooth.
Hyper plasia.
The abnormal multiplication or increase in the number of cells in a tissue; an increase in
size of a tissue or organ resulting from proliferation of cells.
Hypertrophy.
The enlargement or overgrowth of an organ or structure due to an increase in size of its
constituent cells, but not resulting from an increase in the number of cells.
Hypoplasia.
Defective or imcomplete development.
Iatrogenic.
Any adverse condition in a patient occurring as the result of treatment; a detrimental
condition induced or caused by a doctor.
Idiopathic.
Of unknown causation.
Incisal edge.
The sharp angle formed by the union of labial and lingual surfaces of anterior teeth. The
cutting edge of the anterior teeth.
Incisal papilla.
An oval or pear-shaped nipple-like prominence of the gingival immediately behind the
upper central incisors. Also called palatine papilla.
Incisal e.
The embrasure opening from the contact toward the incisal edges of anterior teeth.
Incisor.
Any one of the four front teeth on either jaw.
Inclined plane.
A sloping area found on the occlusal surfaces of bicuspids and molars. It is bounded by
the primary grooves and the crests of the ridges. Each normal cusp has two inclined
planes named for the direction in which they face, that is, the lingual cusp have
mesiobuccal and distobuccal inclined planes, and the buccal cusps have mesiolingual
and distolingual inclined planes.
Intercuspation.
The cusp-to-fossa relationship of the maxillary and mandibular posterior teeth to each
other.
Interdigitation.
The interlocking or fitting of opposite parts, as the cusps of the maxillary and
mandibular teeth; intercuspation.
Interproximate space.
The V-shaped space between the proximal surfaces of adjoining teeth; it extends from
the contact to the crest of the alveolar process.

Keratin.
A protein that forms from the basis of hair, nails, and any horny tissue, including the
organic matrix of tooth enamel.
Labial e.
The embrasure opening from the contact toward the lips in anterior teeth.
Labial f.
Folds at the midline that attach the upper and lower lip to alveolar tissue.
Labial surface.
The surface of an anterior tooth that lies closest to the lips.
Lamina propria.
Alveolar bone proper, or cribriform plate. It lines the inner surface of the alveolus and
offers attachment for the fibres of the periodontal membrane.
Lateral incisor.
The second tooth from the medial line on each side in either jaw. Also called the
second incisor.
Leukoplakia (smoker’s tongue).

Formation of white thickened patches on the mucous membrane of the tongue or cheek.
These cannot be rubbed off, show a tendency to fissure, and may become malignant.
Lingual e.
The embrasure opening from the contact toward the tongue.
Lingual f.
Fold along midline of inferior surface of tongue extending to floor of mouth.
Lingual surface.
The tooth surface that is next to the tongue.
Lobe.
One of the main morphological divisions of the crown of a tooth.
Long axis.
An imaginary line passing lengthwise through the center of the tooth.
Luxation.
Dislocation of a joint, as the temporomandibular articulation, or displacement of organs.
Malar.
Pertaining to or affecting the cheek.
Malocclusion.
Imperfect or irregular position of the teeth.
Mamelon.
One of the three rounded prominences on the incisal edge of the anterior teeth when
they first erupt.
Mesial.
Toward the median line following the curve of the dental arch.
Molar.
One of the large grinding teeth of which there are three on either side in both jaws.
They are situated distal to the bicuspids and named from before backward as maxillary
or mandibular first, second, and third molars. The first molar is also called the six-
year molar; the second molar, the twelve-year molar; and the third molar, the
wisdom tooth.
Occlusal e.
The embrasure opening occlusally from the contact in posterior teeth.
Occlusal surface.
The surface of a bicuspid or molar that makes contact with a tooth of the opposite jaw
when the mouth is closed.
Occlusion.
The contact of the teeth of both jaws when closed or during those excursive movements
of the mandible that are essential to the function of mastication.
Oligodontia.
Congenital absence of one or a few teeth.
Operculum.
(1) Any covering.
(2) The hood or flap of mucosa over an unerupted or partially erupted tooth.
Orthodontics.
The profession or science of straightening teeth.
Papilla.
Any small, nipple-shaped elevation.
Incisive p. The elevation of soft tissue covering the foramen of the incisive
canal; crosses upper gingival along midline behind maxillary central incisors.
Interdental p. Gingiva filling the interproximal spaces between adjacent teeth.
Lingual p. Any one of the tiny eminences covering anterior two-thirds of tongue,
including circumvallate, fungiform, and conical papillae.
Pedodontics.
Specialised care of children’s teeth.
Periodontal membrane.
The fibrous tissue that is attached to the cementum of the tooth and to the surrounding
structures.
Periodontics.
Phase of dentistry dealing with treatment of diseases of the tissues around the teeth.
Periodontium.
The investing and supporting tissues surrounding the tooth – the periodontal membrane,
the gingival, and the alveolar bone.
Periosteum.
Tissue that covers the external surface of a bone.
Pit.
A sharp pointed depression in the enamel.
Posterior tooth.
One of the teeth situated distal to the cuspids. Bicuspids and molars are posterior teeth.
Primary groove.
A sharp V-shaped groove that is a constant and developmental part of the tooth. Marks
the union of the lobes.
Prosthodontics.
The branch of dentistry pertaining to the replacement of missing teeth by artificial
devices, whether with dentures, or fixed or removable bridges.
Proximal surface.
One of the surfaces of a tooth, either mesial or distal, that lies next to an adjacent
tooth.
Pulp.
The soft tissue containing blood vessels and nerve tissue occupying the central cavity of
a tooth.
Pulp canal.
The part of a pulp cavity that traverses the root of the tooth.
Pulp cavity.
The entire central cavity in a tooth; it contains the dental pulp.
Resorption.
The gradual loss of the tooth structure or of bone resulting from an altered biochemical
state in a localized area.
Ridge.
A long, elevated portion of the tooth surface.
Root.
The portion of a tooth that is covered with cementum.
Root canal.
Same as pulp canal.
Ruga; pl., rugae.

Irregular, sometimes branching ridges across the hard palate, radiating from the incisal
papilla and the palatine raphe.

Secondary groove.
A groove of lesser importance. Secondary grooves differ from primary grooves in that
they are usually rounded, or U-shaped, at the bottom, and they do no mark the
boundaries of the lobes.
Septum.
A dividing wall or partition. One of the thin plates of bone separating the alveoli of the
jaw.
Stomatognathic.
Pertaining to the unified structure and function of mouth and jaw with all appurtenant
tissues and organs as a cohesive system.
Subluxation.
Imcomplete or partial dislocation.
Succedaneous tooth.
Permanent tooth that succeeds or takes the place of a corresponding deciduous tooth.
Sulcus; pl., sulci.

A well-defined, long-shaped depression in the surface of a tooth, the inclines of which
meet at an angle.
Supernumerary.
Exceeding the regular number. An extra tooth, often peg-shaped.
Supplemental lobe.
An additional lobe. A lobe that is not usually associated with the typical form of a tooth.
Trismus.
Inability to open the mouth due to spasms of the muscles of mastication.
Trunk.
The main body of the root of a multiple-rooted tooth. That portion of the root from the
cervical line to the division of the root.
Tubercle.
A small, rounded, or pointed elevation of enamel. Tubercles occur frequently on the
cingula of anterior teeth and occasionally on various parts of other teeth.
Working occlusion.
The dynamic relationship of the mandibular and maxillary teeth to one another during
the excursion of the mandible from working position to centric position.
Working position.
The static relationship of the mandibular and maxillary teeth to one another on one side
of the dental arch when the mandible is moved laterally to that side.

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Umberger, F., Van Reenen, J. (1995). Thumb Sucking Management: A Review, The International
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Vaiman, M., Eviatar, E., & Segal, S. (2004). Evaluation of normal deglutition with the help of
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positive approach. Brochure.
Van Norman, R.A. (1997). Digit Sucking: A Review of the Literature, Clinical Observations and
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Van Norman, R.A. (1999). Helping the Thumb-Sucking Child. Avery Publishing Group, Garden
City Park, NY.
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Werlich, E.P. (1962). The prevalence of variant swallowing patterns in a group of Seattle school
children. Unpublished thesis, University of Washington, Seattle, W A.
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Orofacial Myology. 15(2), 14-18.
Yashiro, K. & Takada, K. (1999). Tongue muscle activity after orthodontic treatment of anterior
open bite: a case report. American Journal of Orthodontics and Dentofacial Orthopedics. 115(6),
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tongue thrust swallowing. Journal of Behavior Therapy and Experimental Psychiatry. 14, 73-77.
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Materials.
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tongue thrust associated with open bite: a case report. International Journal of Orofacial Myology
15(1), 5-9.
Efficacy Studies for Orofacial Myology Concerns

(STUDIES FROM 1995 – Present)
Barlow SM. Central pattern generation involved in oral and respiratory control for feeding in the term
infant. Curr Opin Otolaryngol Head Neck Surg.2009 Jun;17(3):187-93.
Kelly BN, Huckabee ML, Jones RD, Frampton CM. The first year of human life: coordinating
respiration and nutritive swallowing. Dysphagia.2007 Jan;22(1):37-43. Epub 2007 Jan 13.
Eugene C Goldfield, Michael J Richardson, Kimberly G Lee, and Stacey Margetts Coordination of
Sucking, Swallowing, and Breathing and Oxygen Saturation During Early Infant Breast-feeding and
Bottle-feeding Pediatric Research(2006) 60, 450–455; doi:10.1203/01.pdr.0000238378.24238.9d
Garretto, A.L. (2001). Orofacial myofunctional disorders related to malocclusion. International Journal
of Orofacial Myology. 27, 44-54.
Smithpeter, J., and Covell, D. JR. (2010): Relapse of anterior open bites treated with
orthodontic appliances with and without orofacial myofunctional therapy. American Journal of
Orthodontics and Dentofacial Orthopedics, 137, 5, 605-614, 2010.
Lateral open bite: Treatment and Stablility, Cabrera, M.
The Interrelationship of wind instrument technic, orthodontic treatment and orofacial myology, Green, S.
IAOM, 1999
Hale, S.T., Kellum, G.D., & Bishop, F.W. (1998). Prevalence of oral muscle and speech differences in
orthodontic patients. The International J. of Orofacial Myology.14(2), 6-10.
Hale, S.T., Kellum, G.D., Nason, V.M., & Johnson, M.A. (1988). Analysis of orofacial myofunctional
factors in kindergarten subjects. The International Journal of Orofacial Myology. 14(3), 12-15.
Hale, S.T., Kellum, G.D., Richardson, J.F., (1992). Oral motor control, posturing, and myofunctional
variables in 8-year-olds. Journal of Speech and Hearing Research. 35, 1203-1208.
Mayer, C. & Brown, B.E. (2000). My Thumb and I: A Proven Approach to Stop a Thumb or Finger
Sucking Habit for Ages 5-10. Speech Dynamics, Temecula, CA.
Meyer, P.G. (2000). Tongue lip and jaw differentiation and its relationship to orofacial myofunctional
treatment. International Journal of Orofacial Myology. 26, 44-52.
Moore, M.B & McDonald, J.P. (1997). A cephalometric evaluation of patients presenting with
persistent digit sucking habits. British Journal of Orthodontics. 24(1), 17-23.
Moore, N.L. (2002). Suffer the little children: fixed intraoral habit appliances for treating childhood
thumbsucking habits: a critical review of the literature.International Journal of Orofacial Myology.
28:3-4.
Neiva, F.C. & Wertzner, H.F. (1996). A protocol for oral myofunctional assessment: for application
with children. International Journal of Orofacial Myology. 22:8-19.
Oulis, C.J., Vadiakas, G.P., Ekonomides, J., & Dratsa, J. (1994). The effect of hypertrophic adenoids
and tonsils on the development of posterior crossbite and oral habits. Journal of
ClinicalPediatricDentistry.18(3):197201.
Proffit, W.R. (1999). The Development of Orthodontic Problems. Mosby.
Ray, J. (2001). Functional outcomes of orofacial myofunctional therapy in children with cerebral
palsy. International Journal of Orofacial Myology. 27, 5-17.
Ray J. (2002). Orofacial myofunctional therapy in dysarthria: a study on speech intelligibility.

Ray, J. (2003). Effects of orofacial myofunctional therapy on speech intelligibility in individuals with
persistent articulatory impairments. International Journal of Orofacial Myology. 29, 5-11.
Shapiro, P.A. (2002). Stability of open bite treatment. American Journal of Orthodontics and
Dentofacial Orthopedics. 121(6), 566-568.
Stone, M., Davis, E.P., Douglas, A.S., Aiver, M.N., Gullapalli, R., Levine, W.S.,&Lundberg, A.J.
(2001). Modeling tongue surface contours from cine-MRI images. Journal of Speech, Language, and
Hearing Research. 44, 1026-1040.
Vaiman, M., Eviatar, E., & Segal, S. (2004). Evaluation of normal deglutition with the help of rectified
surface electromyography records. Dysphagia. 19(2), 125-32.
Van Norman, R.A. (1997). Digit Sucking: A Review of the Literature, Clinical Observations and
Treatment Recommendations. The International Journal of Orofacial Myology. 22, 14-33.
Van Norman, R.A. (1999). Helping the Thumb-Sucking Child. Avery Publishing Group, Garden City

Park, NY.
Van Norman, R.A. (2001). Why we can't afford to ignore prolonged digit sucking. Contemporary
Pediatrics. June
Wadsworth, S.D., Maul, C.A., & Stevens, E.J. (1998). The prevalence of orofacial myofunctional
disorders among children identified with speech and language disorders in grade kindergarten
through six. International Journal of Orofacial Myology. 24, 1-19.
Wilder, T. & Gelesko, A. (1997). Lingual frenums and frenectomies. International Journal of Orofacial
Myology. 23, 47-49.
Yashiro, K. & Takada, K. (1999). Tongue muscle activity after orthodontic treatment of anterior open
bite: a case report. American Journal of Orthodontics and Dentofacial Orthopedics. 115(6), 660-666.
"Suck Predicts Neuromotor Integrity and Development Outcomes" by Steven Barlow and Meredith
Poore
Sayin, M; Akin, E. (2006). Initial Effects of the Tongue Crib on Tongue Movements During Deglutition:
A Cine-Magnetic Resonance Imaging Study
Connaghan, K. & Moore, CA. (2013). Indirect Estimates of Jaw Muscle Tension in Children with
Suspected Hypertonia, Children with Suspected Hypotonia, and Matched Controls. Journal of
Speech, Language, and Hearing Research, 56, 123-136.
Rudy, K & Yunusova, Y. (2013) “The Effect of Anatomic Factors on Tongue Position Variability
During Consonants” Journal of Speech, Language, and Hearing Research, 56, 137-149.
Huang, Y & Guilleminault, C (2013) “Pediatric obstructive sleep apnea and the critical role of oral-
facial growth: evidences” Frontiers in Neurology. Vol 3, Article 184.
Arvedson, J. “Swallowing and feeding in infants and young children”. GI Motility online. 16 May 2006
Rossetti, L., Rossett, P., Conti, P, Pereira de Araujo, C. (2008) “Association Between Sleep Bruxism
and Temporomandibular Disorders: A Polysomnographic Pilot Study”. Journal of Craniomandibular
Practice, 16.
Gastaldo, E. et al. (2006). “The Excitablity of the Trigeminal Motor System in Sleep Bruxism: A
Transcranial Magnetic Stimulation and Brainstem Reflex Study” Journal of Orofacial Pain, 20: 145-
155.
Coryllos, E., Watson-Genna, C., Salloum, A. “Congential Tongue-Tie and its Impact on
Breastfeeding”. Breastfeeding: Best for Baby and Mother, Summer 2004.
Mew, J. “The aetiology of temporomandibular disorders: a philosophical overview”. European Journal

of Orthodontics 19 (1997) 249-258.
Jang, S., et. All. “Relationship between the lingual frenulum and craniofacial morphology in adults”
AM J Orthod Dentofacial Orthop 2011; 139:e361-e367).
Marchesan, IQ. Lingual Frenulum: quantitative evaluation proposal. The International Journal of
Orofacial Myology, 2005:V. 31, P. 39-48.
Soylu, A., Irmak, R, Baltaci, G. “Acute effects of Kinesiotaping on muscular endurance and fatigue by
using surface electromyography signals of masseter muscle”. Med Sport 15 (1): 13-16, 2011.

Sexton S, Natale R. “Risks and benefits of Pacifiers” Am Fam Physician. 2009; 79; (8):681-685.
Gommerman, S., Hodge, M (1995). Effects of oral myofunctional therapy on swallowing and sibilant
production. The International Journal of Orofacial Myology. Vol. XXI, 9-22.
Scavone-Junior, H., Ferreira, R., Ferreira, F., “Prevalence of posterior crossbite among pacifier users:
a study in the deciduous dentition”. Braz Oral Res 2007; 21 (2): 153-8.
Cheng, HY, Murdock, B., Goozee, J., Scott, D. “Physiologic Development of Tongue-Jaw
Coordination From Childhood to Adulthood” J Speech Lang Hear Res 2007; 50; 352-360.
Cooper-Brown L, Copeland S, Dailey S, Downey D, Petersen MC, Stimson C, Van Dyke, DC.
“Feeding and swallowing dysfunction in genetic syndromes”. Dev Disabil Res Rev. 2008; 14 (2): 147-
57.
Trier E, Thomas, AG. Feeding the disabled child. Nutrition, 1998 Oct; 14 (10): 801-5.
Tamura F, Kikutani T, Machida R, Takahashi N, Nishiwaki K, Yaegaki K. “Feeding therapy for

children with food refusal”. Int J Orofacial Myology. 2011 Nov; 37: 57-68.
Giseal EG, Birnbaum R, Schwartz S. “Feeding impairments in children: diagnosis and effective
intervention.” Int J Orofacial Myology. 1998; 24: 27-33.
Bishara SE, Warren JJ, Broffitt B, Levy SM. “Changes in the prevalence of nonnutritive sucking
patterns in the first 8 years of life.” Am J Orthod Dentofacial Orthop. 2006 Jul: 130 (1): 31-6.
Sheppard JJ. “Using Motor Learning Approaches for Treating Swallowing and Feeding Disorders: A
Review” LSHSS. 2008 Vol 39; 227-236.
Clark H, Henson P, Barber W, Stierwalt J, Sherrill M. “Relationships Among Subjective and Objective
measures of Tongue Strength and Oral Phase Swallowing Impairments.” Amer J of Sp-Lang Path,
2003, Vol 12: 40-50.
Stierwalt J, Youmans S. “Tongue Measures in Individuals with Normal and Impaired Swallowing”. Am
J of Sp-Lang Path, 2007, Vol 16: 148-156.
Arvedson, J. “Evaluation of Children with Feeding and Swallowing Problems” LSHSS. (2000) Vol
31:28-41.
Ruscello, D. “Nonspeech Oral Motor Treatment Issues Related to Children with Developmental
Speech Sound Disorders”. LSHSS (2008): Vol 39:380-391.
Lass N, Pannbacker M. “The Application of Evidence-Based Practice to Nonspeech Oral Motor

Treatments”. LSHSS (2008): Vol 39: 408-421.
Paskay L. “Orofacial Myofunctional Disorders: Assessment, Prevention and Treatment”. JAOS

(2012): March/April.
Barlow S, Poore M. “Suck Predicts Neuromotor Integrity and Developmental Outcomes” Perspectives
Barlow, S (2009a) Current pattern generation involved in oral and respiratory control for feeding in
the term infant. Current Opinion in Otolaryngology & Head and Neck Surgery, 17, 187-93.

Barlow S, Estep M. (2006). Cetneral pattern generation and the motor infrastructure for suck,
respiration, and speech. Journal of Communication Disorders, 39, 366-380.
De Costa, SP, van den Engle-Hoek, L & Bos, AF (2008). Sucking and Swallowing in infants and
diagnostic tools. Journal of Perinatology, 28, 247-57.

Supply / Shopping List
Contact Order
Product Supplier Information Number
Band-Aids www.drugstore.com
Biocide Henry Schein 1-800-372-4346 247-4699
Bite Therapy Wafers OIS 1-800-441-7700
Bulk Elastics Glenroe 1-800-237-4060 UNLN553B
Technologies
Buttons Blumenthal 1-563-538-4211
Lansing
Company
Cheek Expanders OIS 1-800-959-9505
Control-It Next Step 1-888-850-8216

Enterprises
Cotton Rolls Henry Schein 1-800-372-4346 100-5897
Flavored Tongue O.M.T. Materials 1-530-642-0323
Depressors
Gloves (Exam) Plak Smacker 1-800-558-6684
Gloves (Therapy) Dollar Tree In Store
High Chair Kettler 757-427-2400 H4832-0000
International Fax: 757-427-0183
PO Box 2747
Virginia Beach,
VA 23453
Metal Harmonicas Henry Schein 1-800-372-4346 366-0344
Tongue Guards Coulson Institute 303-759-2760
Mouth Mirrors Henry Schein 1-800-372-4346 100-5067
Pacifiers Concord 1-323-588-8888 40704
Enterprises
- Regent Baby 182-20 Liberty Ave., BK-44Z (3 pk)
Products Corp. Jamaica, NY 11412
Prizes Oriental Trading 1-800-526-9300

Prizes Smile Makers 1-800-825-8085
Rulers Dentsply 1-800-877-0020 Promotional Items
Socks/Gloves Dollar Tree In-Store

Stickers Trend Enterprises 1-800-328-0818
Stomahesive Wafers Byram 1-800-873-8385 SQ21712
Healthcare
Trigger Pull Brownelle www.brownelle.com 174-025-250
Water Pik Flossers Water Pik 1-877-597-8674
(Hummingbird) Technologies
Zulauf Metal Cover Zulauf 1-800-972-7607 400-50M
Ups for Braces

Useful Websites
Sandra R Coulson & Associates
http://www.srcoulson.com or http://www.sandracoulson.com
Coulson Institute of Orofacial Myology

http://www.coulsoninstitute.com
International Association of Orofacial Myology

http;//www.iaom.com
American Speech-Language-Hearing Association

http://www.asha.org
National Maternal and Child Oral Health Association

http://www.mchoralhealth.org/contact.html
Myofunctional Research
http://www.myoresearch.com/cms/index.php?english
Practice Management
www.practicefusion.com

NOTES

Additional Items – Helpful Hints and Forms
Gum Chewing Found to Boost Brainpower, Memory
Reuters Health via Yahoo – Jeremuy Laurence
Posted on Wednesday, March 13, 2002 @ 5:53:49 PM by Pharmboy
LONDON (Reuters) – The often-miligned act of chewing gum could in fact make us
smarter, according to British research.
A joint study carried out by the University of Northumbria and the Cognitive Research
unit, Reading, has found that chewing gum has a positive effect on thinking, memory
and other cognitive tasks.
“The results were extremely clear and specifically we found that chewing gum targeted
memory”, Andrew Scholey of the university’s Human Cognitivve Neuroscience Unit said.
“People recalled more words and performed better in tests on working memory”.
Peppermint gum, menthol or spearmint – it makes no difference. The key is the

repetitive chewing motion.
Scholey, who was to present his findings to a symposium at the British Psychologgical
Society’s annual conference in Blackpool Wednesday, said the improved performance in
a range of memory tests could be attributed to an increase in heart rate coupled with a
surge in insulin to the brain.
The experiments involved 75 people split into groups of non-chewers, real chewers and
“sham” chewers.
Prior to undergoing the 25-minute test, the two chewing groups spent 3 minutes
working their real or imaginary gum around their mouths.
Scholey said the tests included questions relating to short-term memory, such as
recalling words and pictures, and so-called working memory, for example the ability to
retain a person’s telephone number. He said the heart rate of the real chewers after the
tests was three beats per minute faster than the non-chewers and 1.5 beats per minute
faster than the sham chewers.
“What we think is that the mild increase in heart rate may improve the delivery of
oxygen and glucose to the brain, enough to improve cognitive functions,” he told
Reuters.
Scholey added the other possibility was that chewing gum induced a surge of insulin due
to the mouthwatering in anticipation of a meal.
“It is known that there are insulin receptors in areas of the brain which are important for
learning and memory,” he said.

Before and After Therapy…
Turn the page upside down!

Motivation… PRIZES>>>
For a chance to win a prize you must do the

Following:
1. Bring your bag.
2. Bring your chart.
3. Bring all of your supplies.
4. Have Better Measurements.
5. You CANNOT have been a
“GROUCH”!
You may put your name on a ticket for a chance to

win!

Press On…
Press On
Nothing in the world can take the place of persistence.
Talent will not; nothing is more common than unsuccessful

people with talent.
Genius will not; unrewarded genius is almost a proverb.
Education alone will not; the world is full of educated

derelicts.
Persistence and determination alone are omnipotent.

Denver, CO 80224
303-759-2760
After Your Frenotomy…

1. Tip-Pops…place your tongue tip on the ‘spot’. Suction.
Hold. POP. Do 15X
2. Windshield Wipers…Open wide. Stretch tongue out.

Move from corner to corner of your mouth. Do 15x
3. Roof Scrapes…Open wide. Place tongue tip on the ‘spot’.

Scrape the tip BACK toward your throat. Do 15x
4. Lip Pops…Roll lips in over teeth. Press together firmly.

Pop apart. Do 15x
How to unblock a “STUFFY” Nose…

1. Sit up straight.
2. Close your lips, take a small breath in through your nose, then a small
breathe out through your nose.
3. Pinch your nose with your fingers and hold your breath, keeping your lips
closed.
4. Gently nod your head (forward and back) until you cannot hold your
breath any longer.
5. When you need to breathe, let go of your nose and breathe gently
through it, keeping your mouth closed.
6. Continue to breathe gently for several seconds.
You can repeat this exercise several times until your nose is unblocked.
Wait 30 seconds between each exercise.
Now close your lips and continue to nasal

Breathe!


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Copyright 2014 – Coulson Institute of Orofacial Myology 0

Sandra is a Certified Orofacial Myologist with an MS in Health

Sandra can be reached via email or directly:

Email: sandra@sandracoulson.com or info@coulsoninstitute.com

Copyright 2014 – Coulson Institute of Orofacial Myology 1

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Orofacial Myology / Myofunctional Therapy is defined as treatment of the orofacial

1. Detrimental orofacial habits

3. Abnormal neuromuscular responses associated with inappropriate mastication and

4. Detrimental breathing patterns

5. Hyper and hypo sensitivity of the orofacial complex

6. Swallowing patterns which may be associated with malocclusions

7. Facial and postural esthetics

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We are excited at the prospect of extending our program -internationally.

There is a tremendous need for cooperation among Professionals to provide the

In 1974 ASHA (American Speech-Language Hearing Association) issued a position

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1. Abnormal, non-nutritive sucking habits

2. Other detrimental habits

3. Abnormal orofacial rest posture issues

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A member in good standing is defined as:

1) One who is current with the payment of IAOM membership dues

3) Results of treatment shall not be guaranteed by the member. However, a statement

4) If there is no documentable progress for the treatment of a patient, it is the

6) Professional ethics prohibit the guarantee of the outcome of any therapeutic

7) A patient's confidentiality must be respected by the member. No information received

1) The member shall not misrepresent her/his credentials, competence, education,

2) Members may NOT add OM (Orofacial Myologist), MFT (Myofunctional Therapists) or

4) The member shall not misrepresent diagnostic information, services rendered, or

5) The member’s statements to the public shall not contain misrepresentations in

Copyright 2014 – Coulson Institute of Orofacial Myology 13

The American Speech-Language-Hearing Association (ASHA) is the professional

What course content is appropriate for ASHA CEUs?

 Sciences as they pertain to speech-language pathology

Who can offer courses for ASHA CEUs?

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Dental Hygiene Services

Registered dental hygienists work as clinical practitioners, educators, researchers,

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I.A.O.M. dues MUST be current in order to apply for certification.

Mail the completed examination to:

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I am writing with congratulations to the members of the Coulson Institute of

Problems of oral muscle posture can delay a patient in achieving a proper

2. The assessment of orofacial myofunctional disorders has been over-simplified. It

3. Most favorable therapeutic results are obtained when a multi-disciplinary

In summary, orofacial myology is challenging work.

What are some of the ingredients to success?

 The team approach which was discussed previously. This disorder is

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Digastric elevate hyoid, depress mandible

Other muscles to consider:

 Infrahyoid  Upper trapezius

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