(Please interpret the use of “he” and “his” to represent all children and adults.)
Happy Thanksgiving, My Friend!
“If I just stim the speech sound and the child makes it, do I still need to do oral resting posture therapy?”
To make that determination, you’ll need to analyze the child’s oral resting posture! You’ll want to make sure the child’s lips, tongue, and jaw are in their optimum positions to facilitate good stabilization-mobilization for speech contacts and speech sound production.
It is wise to not settle for an acoustic result that sounds “close” to the desired speech sound. Why? Because as the child continues to practice the new incorrectly stabilized speech sound, carryover consistency may not happen.
As mentioned in last week’s ORP, Part 1 (#37, Nov. 13; click here), the ORP facilitates the oral operating zone for speaking. (It also describes the specifics of the desirable lips-tongue-jaw resting positions, if you need that information.)
To reiterate, if the tongue rests down or down and forward, it’s more likely to produce speech sounds in that region. If the tongue rests up within the dental arch, it has the greatest chance of successfully and consistently stabilizing on the insides of the top, back teeth (lateral margin stabilization) and interacting with the alveolar ridge, hard palate, and soft palate.
Wherever the lips, tongue, and jaw rest is where they work.
Two important points to remember as you analyze the ORP:
1. Investigate the cranio-facial-oral-respiratory components to determine the potential impact on his oral resting posture, as well as his ability to achieve appropriate stabilization and mobilization for speech production. In other words, all of the following information connects the cranio-facial-oral-respiratory elements to the oral system at rest as well as the oral system at work.
2. And, if we just identify one aberrant mouth-part, such as, a narrow dental arch, or an anterior open bite, or a restrictive lingual frenum and proclaim that it impacts speech without determining if that factor impacts the oral resting posture and inhibits speech sound stabilization-mobilization, we run the risk of over generalizing. Each oral mechanism is unique. We must view the cranio-facial-oral-respiratory system from a multifactorial point of view.
ORP Analysis: External
First, informally observe his mode of breathing (nose or mouth), the consistency of his mode of breathing, his facial dimensions, as well as lips and mandible.
Respiration:
Is he either nose breathing or mouth breathing close to 100% of the time, or mixed, e.g., 50%-50%, etc.?
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In general (although every person is unique), if he consistently breathes through his mouth, chances are there’s some form of nasal obstruction due to: Enflamed turbinates (chronic sinusitis, colds, etc.), adenoids in a small naso-pharyngeal space, deviated septum, or small nasal cavity, etc.
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If breathing is mixed, there may be some other reason: labial closure issues, jaw issues, tonsil issues, or even habit.
Cranio-Facial Analysis:
The size and shape of the bony cranio-facial complex is the framework of the size and shape of the mouth. Observe and measure (eye-ball) the height and width of the face.
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Cranio-facial bone growth is determined genetically. However, it can be interrupted and altered by an abnormal, self-imposed jaw resting position.
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During normal cranio-facial bone grow the face grows down and forward. However, when the jaw is lowered excessively and chronically, it can alter facial growth and grows down and back. This abnormal growth pattern potentially lengthens the maxillary bone, increasing the vertical length of the bony lower third of the face.
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Cranio-facial soft tissue is not altered. Now, there may be insufficient soft tissue to cover the redistributed facial bone and the lips may have difficulty closing and staying closed. The upper lip may be short and inflexible. And we know, when lips are open the tongue is down.
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This abnormal growth and oral position pattern is frequently seen in frontal cases.
Lips:
Make note of lip closure: closed, slightly parted, or excessively parted (indicating jaw involvement). Make note of the sufficiency of labial tissue.
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Parted lips usually indicate mouth breathing unless the oral airflow is blocked by a low forward tongue.
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Lips muscles are either competent, they close and stay closed easily, or they are incompetent and insufficient, meaning, the upper lip tissue is too short/inflexible to close and stay closed comfortably.
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Check for a labial frenum restriction.
Mandible:
Observe the jaw at rest. Is it elevated, slightly lowered, or excessively lowered? Is it elevated and postured centrally or skewed anteriorly or off to one side? Is it closed? Is it clenched?
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If the jaw juts forward or off to the side, the tongue’s positioning in relationship to the roof of the mouth is influenced. Lingual stabilization becomes logistically difficult and the roof of the mouth becomes a moving target.
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The position and movement of the lower jaw can make or break your therapy: Wherever the jaw goes, so goes the tongue.
ORP Analysis: Tongue Resting Posture
Say, “Where do you keep your tongue when you’re not using it; when you’re not speaking or swallowing? Does it sit on the bottom, in the middle, or on the top? Now, close your eyes and send a spy down to your tongue.”
When the tongue is down, determine if it’s “just down” or “down and forward” (touching teeth). There’s a difference. When resting forward, the back-tongue vacates the pharynx. Try to determine why:
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Are there large tonsils in a small pharyngeal space?
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Is there an open bite and the tongue moves forward to fill the space?
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Is there is a narrow upper dental arch and the tongue is unable to comfortably elevate and fit?
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Is there or has there ever been thumb/digit sucking or excessive use of the pacifier?
There’s also the element of the tongue’s direction of pressure while at rest. A tongue that rests behind maxillary anterior teeth and directs its resting-pressure vertically, will not adversely affect teeth. A tongue that rests behind the same teeth but directs its resting-pressure against the teeth may move them.
A low tongue or a low-forward tongue is postured at the “horizontal midline,” not up within the dental arch to easily access lateral margin stabilization.
Also, ask his parents to check his sleeping habits for possible sleep apnea (intermittent obstructed breathing during sleep due to a constricted airway). A relaxed, non-elevated tongue runs the risk of collapsing back to the pharynx and blocking the airway. Sleep apnea can present its own set of negative consequences: sleep deprivation, extreme fatigue, behavior issues, learning difficulties, etc.
ORP Analysis: Potential Causes
The causes and consequences of altered the ORP are layered and most often connected. Any one component can influence other components. For example, a lowered jaw may be the consequence of an obstructed nose. But the lowered jaw maybe the cause of abnormal facial bone growth that, in turn, makes it difficult to close lips during resting posture and functions. That causes a low-forward tongue posture that may influence the positioning and consistency of stabilization-mobilization and thus, be associated with speech errors. You get the picture. Pull the thread and determine where it goes.
Also, determine if there is something you can do, or if the expertise of related professionals is warranted.
The following information is condensed and presented in no specific order.
Tonsils:
A low-forward tongue posture is a probable indicator of large tonsils in a small pharyngeal space. If there is a low-forward tongue posture investigate the back of mouth first.
View your analysis as a “space-availability” issue. If there are large tonsils in a larger pharynx, there may be ample room for the base of the tongue to reside in the pharynx. If there are large tonsils in an average to small pharyngeal space, there may not be space for the tongue to inhabit and either the tongue displaces forward, or the jaw postures forward to help displace the tongue.
Hard Palate and Dental Arch:
During oral functions the hard palate is lightly touched, firmly compressed, and used as an interactive source for the production of fricatives. Therefore, we are concerned about the tongue’s reach- and interactive-ability.
The dental arch contains the teeth. Therefore, we are concerned about the sides of the tongue resting and anchoring against the side teeth and light-interaction with the front teeth.
Analysis: Visual scrutiny of the hard palate and dental arch is not enough to tell if it’s too high, too narrow, or too wide. You have to actually get the tongue up in there. Do tongue pops to see if it’s able to reach, apply ample pressure so as to interact up within the hard palate and dental arch. If he is unable to do that, have him bite on a small tongue depressor with side teeth and attempt the tongue pops again. This keeps the jaw still, centralized, and the tongue in close proximity to the top. Listen for the sound (a clear pop? a “sloppy” imprecise pop? no pop? etc.), and also observe his effort as he does the task. Does the tongue fit and reach, or not? Also, ask him to place the tongue up in the desirable resting position. Does the tongue reach and fit effortlessly and comfortably?
Occasionally, the dental arch is too narrow to accommodate the tongue, therefore, the tongue may rest low or low-forward. A narrow dental arch may be due to: genetics, a self-imposed dental arch collapse via thumb sucking, or long-term lack of lingua-palatal contact due to a lowered tongue (possibly due to chronic mouth breathing).
Also, sometimes, the dental arch is too wide to access bilateral stabilization. Therefore, the jaw and tongue shift from side to side in an attempt to acquire stabilization; lateralized speech productions typically, but not always, result.
Lingual-Frenum:
If his tongue rests in a lowered position it’s important to determine why. A restrictive lingual-frenum is a potential cause.
The lingual frenum is the tongue’s tether. It determines the tongue’s range of movement, i.e., how far the tongue can elevate, curl, extend forward, retract back, move laterally, and circumrotate.
Analysis: Is the tongue comfortably able to reach the adjacent mouth-parts to potentially acquire consistent lingual stabilization and mobilization? If not, there’s a problem. For analysis, at the very least ask him to do the above tongue directional movements and make a judgement. Ask him to talk or specifically count to 10 and observe his tongue’s visibility, reachability, and range of motion. If you frequently see the surface of the tongue during talking, vertical reachability may be impaired. (Keep in mind, speech sounds are “vertical.”)
Dentition:
“Teeth tell.” Teeth are the primary indicators of long-term adverse tongue and jaw positions, and habits.
When he chronically rests his tongue anywhere but on top, it is not unusual to see a dental malocclusion: an anterior open bite, a unilateral or bilateral open bite, an overjet, or a class III under bite.
Once you’ve identified the malocclusion, do your best to determine why there’s a malocclusion. There isn’t always an answer, but most of the time there is; teeth rarely move on their own. They give way to pressure: Tongue pressure during tongue sucking, during resting posture, during swallowing, chewing, or speaking, pressure from a thumb or finger, or a long-term pacifier. Find out why, and take care of the culprit if possible.
(Dental malocclusions are covered in The Myofunctional Evaluation book and the Oral-Facial Illustrations and Reference Guide.)
Thumb/Digit Sucking:
Thumb or digit sucking is not an all or nothing habit. We must consider the variables: frequency, duration, force, and position (where it’s placed in the mouth).
Chronic thumb/digit sucking can initiate a consistently low-tongue posture, perpetuate horizontal (anterior-posterior) tongue movements, and deter vertical tongue placements and movements.
Early and chronic low-tongue posturing has been known to influence upper dental arch collapse and narrowing due to lack of lingua-palatal contact, as well as dental malocclusions.
All of these elements can negatively influence tongue resting position and stabilization placements.
Whew! Thanks for your interest and thanks for reading! I hope it’s helpful for you and your kids.
Over the following weeks Parts 3 and 4, ORP Therapy.
Have a terrific Thanksgiving,
Char
Resources
Bishara, S.E., Warren, J.J., Broffitt, B., & Levy, S.M. (2006). Changes in the prevalence of nonnutritive sucking patterns in the first 8 years of life. Am J Orthod Dentofacial Orthop, 130(1), 31-36.
Bonuck, K.A., Chervin, R.D, Cole, T.J., Emond, A., Henderson, J., Xu, L., & Freeman, K. (2011). Prevalence and persistence of sleep disordered breathing symptoms in young children: A 6-year population-based cohort study. SLEEP, 34(7), 875-884.
Harari, D., Redlich, M., Miri, S., Hamud, T., & Gross, M. (2010). The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope, 120(10), 2089-2093.
Messner, A.H., & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology Head and Neck Surg, 127(6), 539-545.
Yang, K., Xianglong, Z., Mengsun, Y., A study on the difference of craniofacial morphology between oral and nasal breathing children. Chinese journal of stomatology, 37(5); 385-387.
