The Consequences

of Inaction:
How Soft Tissue Restriction Impacts
Facial Function
Linda D’Onofrio, MS, CCC-SLP
www.donofrioslp.com
June 5, 2017
My clinical experience & scope of
practice
• Structural & Sensory-Motor based speech disorders
• Craniofacial Disorders & Cleft Palate
• Dysarthria – childhood & adult
• Dyspraxia – childhood & adult
• Poor coordination & low tone
• Poor sensory feedback
• Fluency/Stuttering
• Feeding, Oral stage swallowing & Oromyofunctional therapy
• Social-Cognitive therapy for Autism & Aspergers
• Developmental Speech & Language
• Family Communication Support
My Contentions
• Lactation consultants & doulas are not uniformly educated
and trained.
• Soft tissue restriction is not well understood by many medical
& dental professionals, so there is little support, literature,
and multi-disciplinary treatment.
• Many infant specialists, by their nature, are non-
confrontational and struggle to counter different medical
advice or treatment.
• All action and non-actions have consequences. Patients and
parents need to be educated on current and future signs and
symptoms that may require future action.
Do No Harm (Myths)
• Scalpel, scissors, and lasers are scary.
• Maybe it’s just positioning or maybe stretching will help.
• Some birth experiences are traumatic. Don’t add more trauma
to this dyad.
• Many people do just fine with lip & tongue tie.
It’s a Baby (Myths)
• A little goes a long way. A partial lingual frenectomy is
adequate.
• You just need more time. Moms and babes will eventually
work it out.
• The lip flange is really the only important part of nursing.
• Once they figure out nursing, eating will take care of itself.
It’s Someone Else’s Problem
(Myth)
• Pediatricians, Pediatric Dentists, General Dentists, Feeding
Specialists, Speech-Language Pathologists, Orthodontists,
Otolaryngologists are well educated and trained in soft tissue
restriction and will make sure future needs are met.
Tongue Tie Correlations
• Open mouth resting posture
• Excessive drooling
• Non-nutritive sucking & chewing habits
• Poor nursing, poor chewing, avoiding hard foods
• Poor lingual-palatal contact at rest & during swallow, creating
tongue thrust swallow & increased middle ear dysfunction
• High & narrow hard palate
• Class II & Class III malocclusions
• Speech distortions of S, Z, SH, CH, J and sometimes R & L
• Pediatric & adult sleep apnea
• Open bites, posterior cross bites, repeat orthodontics
• Daytime & nightime bruxing, tooth wear & breakage
• TMD & migraines
• Forward head posture, neck & shoulder pain
A Horror Story
• The consequences of oromyofunctional disorders across a
lifetime.
• Airway-based malocclusions leading to sleep disordered
breathing in childhood, bruxing begins
• Diagnosis of ADHD, aggression, poor problem solving
• Increased risk for academic and social failure
• Poor facial aesthetics
• Jaw rotated back into airway and palate invading sinuses, bruxing
• Poor chewing and swallowing
• Poor sleeping and ability to exercise
• Tendency toward obesity leading to obstructive sleep apnea
• Increased risk of heart attack, stroke, and early death
What’s the Worst That Can Happen
(Truths)
• $30,000+ in full mouth reconstruction
• Two rounds of maxillary & mandibular jaw surgeries
• Multiple sets of braces
• Headaches, facial pain, addiction to pain medication
• Increased risk of stroke and heart attack, shorter lifespan
• Preventable craniofacial disorders
It’s Just a Fad (Truths)
• Ancient skulls and indigenous faces
• Dealing with soft tissue restriction at birth and in infancy is the
essence of early intervention for:
• Feeding
• Craniofacial development
• Breathing and sleeping patterns
• Cognitive readiness
• Industrialized Epigenetic Facial Collapse is the new normal
I’m Getting Push Back From
Pediatricians (Hard Truths)
• Much of the research for Americans providers was written
within the last 15 years.
• You may actually know more about soft tissue restriction than
other providers on your patient’s team.
• Advocating for children may require confronting another
provider.
• The best defense is a solid education in your field, keeping up
with lactation and feeding research from a number of different
fields.
• Keep data on your patients and inform the rest of that child’s
team of your goals and concerns.
• Follow up with your patients long term to check outcomes.
How To Decide What To Do
• When families do not want frenectomy
• Educate them on future signs/symptoms & the provider that can
help them.
• When families are uncertain if frenectomy will help
• Commercial articles, research articles, other parents
• Decide a trial period of behavioral, positional, or postural change,
and then a course of action if there is no improvement.
• Initiate pre-frenectomy massage and stretching exercises to
demonstrate limited range of motion & rationale for procedure
How To Decide What To Do
• When families want frenectomy, but the child will/can not
cooperate with pre- and post-procedure care
• Decision may be based on failure to thrive
• Twilight or general anesthesia may be an option
• Schedule the frenectomy around the child’s ability to participate
with after care.
How To Decide What To Do
• When frenectomy is incomplete or has healed sub-optimally
• Communicating with dentist or ENT beforehand about need for
complete release.
• Communicating beforehand revision possibility, so parents
understand that revision may be necessary and s/s to look for.
• Consider referring to ENTs for frenectomy whenever there are
other airway obstruction or sinus issues
• Consider referring to dentists for frenectomy for lip ties only or
whenever there are other oral/dental concerns.
It Takes A Village
• All pediatricians, dentists, orthodontists, PTs, OTs, SLPs, infant
specialists, medical providers, and academic specialists should
be educated on the s/s and the consequences of restricted
soft tissue.
• You are the most important part of that village. Please please
please put me out of business.
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