SEASON 11 EPISODE 11

[INTRODUCTION]

[0:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by SpeechTherapyPD.com. The SLP Learning Series explores various topics of Speech-Language Pathology. Each season dives deeper into a topic with a different host and guests who are leaders in the field. me topics include stuttering, AAC, sports concussion, teletherapy, ethics and more. Each episode has an accompanying audio course on SpeechTherapypPD.com, and is available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics of Speech-Language Pathology. 

[EPISODE]

[0:01:04] MM: Hello, and welcome to another episode of Making Sense of Myo. My name is Madi Metcalf and I'll be your speechtherapypd.com host for this podcast. Before we get started, we have a few items to alert you to. This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. Dr. Marileda Cattelan Tome, PhD, CCC-SLP will be our guest tonight. She'll share about myofunctional therapy in Brazil and about treatment planning for myofunctional therapy.

Dr. Tome's financial disclosures include that she receives an honorarium for this podcast. Her non-financial disclosures include her membership in the Brazilian Scientific Society, the Brazilian Myofunctional Therapy Association and she is an ASHA member. For myself, I receive an honorarium for hosting this podcast and I do not have any relevant non-financial disclosures.

Marileda Tome is a speech-language pathologist, supervisor and professor at the School of Communication Sciences and Disorders. She graduated with her master's degree from the Federal University of Santa Maria, Brazil and her PhD from the University of Sao Paulo. She worked as an assistant professor of the Speech Pathology and Audiology department at Itaja’ Vale University, Brazil for 19 years. Also, she earned her private practice working mainly with clients with myofunctional disorders. Now, I'll thought further ado, I welcome Dr. Marileda Tome.  Hello.

[0:02:26] MCT: Hello. You said it perfect.

[0:02:30] MM: Thank you. How are you doing this evening?

[0:02:34] MCT: Good. I'm so good. How are you?

[0:02:36] MM: I'm good. Why don't we go ahead and get started? Can you tell us a little bit? Brazil is really leading the way in research for myofunctional disorders. I would love if you could share a little bit about how myofunctional disorders are perceived, the research going on, and that sort of thing in Brazil.

[0:02:55] MCT: Okay. Yeah. First, thank you for having me tonight to discuss a topic that I really love. I've been working in this effort for more than 20 years now. Brazil is one of the specializations that we have. Actually, we have 14 areas of specialization, and myofunctional therapy was one of the first one that we legalized in our Brazilian board. Since 1996, we are able to get a certification in this area. Over there, we can basically have a bachelor's degree.

Basically, you can go in a strict census, where you do research and academic focus. Basically, you can have your master's degree, or your PhD in this area. Or in a lateral sense, so you will have clinical practice in focus, which is the specialization itself. I went through all of those paths and I got my PhD back in 2006. Since the graduation, my undergrad, I started doing research in this area and helping my professors and doing some practice in the dentist clinic in my university. This is what led me to this area.

Over there, you can actually do your specialization and take the certification after taking a certain amount of hours and practicing this area. Well, you can take a test. After that, if you prove that you are able, you have your certification done.

[0:04:45] MM: That's specifically for myofunctional therapy?

[0:04:47] MCT: Yes, yes. Because I'm not sure if you know, but and the ones that are listening to this podcast, but in Brazil, we basically can do speech and audiology. We don't have this separated area, as you guys have in the United States. When we graduate, we can choose which area we can work with, but basically, we can work with both speech and audiology. In my case, I chose to work with myofunctional therapy, because I was doing this kind of work since my undergrad, and publishing research in this area.

My first research that I did was in myofunctional therapy. Basically, I continued doing this work through my master, my graduation, graduate school, master degree, and the PhD, where I worked with electromyography, mouth breathers, cleft palate clients, and so on. This is why I've been doing for a while.

[0:05:50] MM: That's so awesome.

[0:05:52] MCT: Yeah. But over there, you can choose which of those 14 areas you decide to do your certification in.

[0:06:00] MM: Oh, that's so interesting just hearing the different ways that you can get to be a practicing speech pathologist in a different country. So interesting, because with ASHA, we have the big nine. You have the 14 areas. That's also very interesting. I love that myofunctional therapy specifically is one of those.

[0:06:20] MCT: Yes. Actually, I've been out of the country for a while. I think they created two or more areas of that you were able to get your certification in, but I didn't have the time to search about. I'm not sure how in these six years that I'm here. This changed a little bit, but essentially, we have Ð myofunction as one of the first areas since the creation of the law.

[0:06:48] MM: Wow, that's so neat. Another thing that I find really interesting about Brazil is isn't there a law that all babies have to be assessed for a tongue tie at birth?

[0:06:58] MCT: Yes, there is a federal law. Dr. Roberta Martinelli is a well-known researcher in this area. Along with Dr. Irene Marchesan, another amazing scientist in that has a lot of studies in myofunctional therapy, they started a process of making this law, a project of law first in 2013. Back in 2014, the legislation accepted. Since there, we have this law where every baby needs to go through this evaluation, since they are born in the hospital. For instance, the first evaluation is this what we call, I would say, in part of this test, a linguine is tongue, little tongue test. The speech-language pathologists are the huge, I would say, representatives in this area and responsible for doing those tests.

[0:08:00] MM: Oh, that is very, very neat. Again, I know that I quite awkward with this question, but would it be possible for you to share a little bit about why Brazil is leading into some of the myofunctional research, or can you just speak a little bit on the research that Brazil is doing on myofunctional therapy?

[0:08:20] MCT: Yes. Well, one of the reasons I think is because we have 11 research centers in our myofunctional therapy in the country. Basically, related with university clinics. We have centers in the north of the country, in the south of the country, across the country, actually. Those professors, those researchers, they are doing amazing work since this specialization was set in 2019, in the 90s years. It has started with Professor Irene Marchesan. I think she was one of the biggest representatives of this area in our country. She started doing research in lingo fresnel, any speech, like the relationship between them.

After that, Dr. Hilton Justino was one of the researchers that also added a lot of technology in this area. Today, they are developing research using thermography, which measures the temperature of the skin, while you are doing exercises, for instance. We have one important center that studies the base muscle activity with using electromyography. Not just those fancy evaluation, but also, basic research that measures how the muscle works, or how mouth breathers function in terms of response to the therapy.

We have groups that have developed a lot of works, like Professor Claudia de Feliz. She's a huge researcher in our country. Also, Dr. Esther Bianchini, all doctors Ð I didn't name all of them. We have a lot of researchers, but they have been publishing a lot. For instance, Dr. Bianchini, she produces a lot of research in sleep apnea and the relationship with our myofunctional therapy and how this therapy can help those clients.

We have a lot of publications since the 90s and especially in the last 10 years. They are publishing a lot regarding technology, the application of new technology to treat those kinds of disorders and also to evaluate them. Research also related with protocols, evaluation protocols. The MBGR is one of the protocols. MUF is another protocol. Those are protocols that I use today in my practice and I teach my students how to use them. Also, research related with babies. There's a lot of across the lifespan.

[0:11:08] MM: Oh, my gosh. That is so neat. I love that you mentioned that it really blew up in the 90s. Linda DÕOnofrio is one of the first people on the Making Sense of Myo Podcast. She just really emphasized that research on myofunctional disorders is not new. It's really nice just hearing that reiterated across the series, that even though it's in the States, at least, it's a little on the controversial side. People like to say, ÒOh, it's just this new fad.Ó Well, actually, it's not a new fad. It's been around. It's well-established. It's well-researched. There's more research currently being done on it.

[0:11:48] MCT: I would say, it's even before the 90s. I mentioned the 90s, because it's when we started having those schools and of course, the publication improved a lot, the number of publications. Unfortunately, some of the works are published in Portuguese, which is not a language that everybody has access to, right? But in the last 10 years, as I said, a lot of journals from this country have received publications from the Latin America and especially from Brazil. If you search those names that I mentioned, you certainly will find, for instance, GiŽdre Berretin is another researcher from our country. She published a lot in terms of a temporomandibular dysfunction, also regarding issues with evaluation. She published protocols in this area. If you Google those names, you will certainly find work in English to read.

[0:12:52] MM: Oh, excellent. Thank you for that. Well, with that, we'll jump into our questions that we discussed beforehand. I think it's really interesting. Whenever I was looking up some of the research that you've done, a lot of it was on malocclusion and structure. Did that interest come out of your time in the dental office?

[0:13:13] MCT: Yes.

[0:13:14] MM: Okay. I thought that was really interesting. I was like, ÒI wonder if that's how she got there.Ó

[0:13:19] MCT: When I was an undergrad student, actually, I attended a conference at some point, and I saw someone presenting a topic regarding electromyography. I found so interesting how the muscles and the musculature would have impact in how we produce sounds. At that point, I think I read a chapter from Travis, which is an old book. I read about that. I was like, it was my first or second year in undergrad. I was a sophomore, maybe. I didn't understand what they were talking about. But I was interested and see how well. It's not just us. It's we can have a relationship with other professions.

I was trying to find something to research, because that was my desire to be a researcher since then. None of my professors could advise me at that point, because they were so busy, whatever. Then I found a professor in the dentist department that was available to advisor me. Then I just asked him, ÒDo you have any questions that I could help you to solve?Ó ÒActually, I have.Ó Some of my clients that have opened bite, I find so difficult to solve their problems. Sometimes we have relapses in these areas. Do you think itÕs something related with the tongue?

I didn't know exactly what he was talking about. But I remember coming home with a bunch of books, and that time was hard to find something online, at least, where I used to live. We need to pay a lot of money to get one article. It's different today. But at that point, was like, it was. I had a hard time to find materials in Portuguese, but I found a lot of materials in English, because as you know, the international, or myofunctional association here is, I think, it exists since the 70s.

I started digging the material, reading everything that I found at that point. I wrote down a project, a research project. That project was approved in my state. I received fund. Fund to do the research. We studied two group of kids at that point. One of the groups was treated with appliances. The other group was treated with appliance, plus oral myofunctional therapies, like a set of sessions.

By the end of a certain period of time, we discovered that the group that was treated with myofunctional therapy had so many good results, compared to the other group. They basically closed. They fixed the occlusion and we saw these kids. I don't remember, because this work I published in Õ99. It's when the specialization was approved in Brazil. I was an undergrad student still.

Then, it was interesting to find those results. I just continued on that path, studying and analyzing how malocclusion, especially have this clinical implication on this speech and this highly prevalence in childhood in a sense that we know that there is in terms of malocclusion. How could I help my clients by adding this myofunctional treatment approach?

[0:17:05] MM: Oh, that's so interesting. I love that your passion for myofunctional therapy also came out of this interdisciplinary collaboration, because as I've learned in my own practice and through the numerous conversations I've had with professionals on this podcast, interdisciplinary care is key to the treatment of myofunctional disorders. I just think that's beautiful that your interest in this area started out from that interdisciplinary collaboration. Can you explain how structural issues can impact speech in other oral functioning?

[0:17:39] MCT: Well, so we know that almost, I would say, 9% of all consonants are performed in this region, right, in few region. We have those boundaries. In order to produce them in a correct way, or in what we expect in terms of pronunciation, we need to have those basis, like structural, in terms of bond structure, in terms of muscular support. To have the teeth in the correct position will help in this balance between those forces of the tongue. I would say labial, buccinator, all those muscles together will provide those boundaries that we need in order to produce, let's say, good phonemes, or at least without distortion.

[0:18:35] MM: What other oral functions can be impacted by malocclusion?

[0:18:39] MCT: Well, this is an interesting question, because when I talk about myofunctional therapy, usually, because we're talking with a speech-language pathologist, my students itself, they say, ÒWell, are you talking about speech?Ó It's not just about speech. Why we're talking about mastication? Why we're talking about swallowing and all those different functions? Because they actually come together as a whole.

For instance, if I expected that my clients is able to pronounce a certain sound, I will also expect that the same musculature will be involved in other functions, like swallowing, like mastication. This is why to consider aspects, like occlusion classification, or those overjet, those overbites, or crowding, spacing, cross-bite during our oral motor examination is so important, because this will impact not just the speech itself, which we were talking about, but also, if the child is able, for instance, to do a bilateral mastication.

If we have a cross-bite, it is expected that the brain will try to find the side that it has less work to do, because we are trying to save energy, and our brain will try to save energy. It's important that we consider that we can't fix this stuff if we have the cross-bite. We will need to refer to someone else. This is why the interprofessional work is so important in order to have that fixed. Then we can do our work properly, or at least together. The maxillary, the mandibular arch, those are directly involved in the production of certain sounds, but also, in the way that we rest our tongue during the rest position, the way that we put our tongue to swallowing, so to swallow. This is why we need to take those aspects in consideration.

When I treat a client in myofunctional therapy, the last thing that I would be worried is like, is there weakness or is there Ð I think there's no cookbook. Again, but what I see, the professionals are so, so much worried with the exercises itself. Myofunctional therapy is not about exercise. Exercise is just a something that you have to use, but actually, we are treating a function and a function Ð that is a lot of things that you need to take in consideration when Ð to consider when you are treating a function itself.

[0:21:35] MM: Oh, I love that so much. That is such a great way to look at myofunctional therapy. You're so right. We're not just treating the strength of the lips, what the tongue is doing. My goal in myofunctional therapy is to treat the function of rest posture, to treat the function of bilateral rotary chewing, to make sure that they're collecting liquid appropriately, to work on placement of sound. That is what I'm working on. That is the function that I'm constantly striving for. I might use an exercise as a tool to get them there. Oh, that is beautiful, Dr. Tome. Thank you for that. Little nugget of wisdom.

[0:22:13] MCT: Yeah, yeah, yeah. Yeah, that is one thing that I just lectured in this Orlando conference that I went, the CURES Conference. I'm not sure if you're familiar with this conference. But the attendees were, I think some of them were speech-language pathologists working with myofunctional therapies. Some of them were hygienists. Some of them, dentist, PTs, whatever. One thing that I talked was this therapist mindset that we need to have.

I always say, it isn't about the exercise itself. It depends on knowing why the problem exists. Understand the why behind the treatment, because we always have a why behind a treatment. If my client requires extrinsic exercise, because the extrinsic musculature is failing, or the intrinsic tongue musculature, I'm talking about tongue itself, requires intrinsic approach to the intrinsic musculature. This requires clinical rationale behind treatment plan. This is why exercises are not taught in isolation, and clinicians must use their assessment.

Again, this is why protocols are such a Ð have a lot of importance, because those assessment results will help us to create this customized treatment plan. Again, not all the clients need movement, like exercise, like mobility. Some of the clients actually will need to work with the tongue inside the mouth, instead of outside of the mouth, because the intrinsic musculature requires more Ð demands more in terms of strength. Some of the clients, you will need to work with them Ð I'm talking about tongue, but it could be lips, or cheeks, whatever, is the muscle that we are addressing. If it's tongue, for instance, some of the exercises will need to be outside of the mouth, because the mobility is something that you also need to address with the strength piece.

It depends on knowing possible solutions, and when they may or not may be appropriate. This is the therapist mindset that you need to have. Functional exercise is basically the goal that we need to have. Why my client is doing this left side repetition, mobility repetition. Where do I want to get with this kind of exercise? Or why my client isn't able to keep the rest position, the tongue rest position in the roof of their mouth? Is there any reason that I need to fix first? Or how they are breathing? We need to do this rationale, this clinical rationale, and put the pieces together. This does not work for all of the clients. This is why a individualized assessment is so important.

[0:25:23] MM: I know you mentioned two protocols that you teach your students to use. Do you know if those are available in the States? If so, what are they?

[0:25:31] MCT: Yes, they are. I think there are two that were published. One was published, the MBGR, Marchesan, Berretin, G is from, I'm not sure. Gonzales. Well, it's the last name of each of the authors, MBGR. Today, they have already one for newborns. They have for different ages now. They published some screenings also, and they were published. One of them, at least, was published in the International Oro Myology Association Journal. The other one, I'm not sure. Dr. Felicio Protocol, is the AMIOF. AMIOF in Portuguese. AMIOF, there is a screening in this protocol. There is a protocol for elderlies.

Well, the baby one, I think, is the MBGR. What was recently published for Dr. Medeiros is a PhD Ð She's a researcher in the northwest of the country, and she just has a postdoc. She published this with Dr. Berretin. I'm not sure where it's published. I think, Codas. I can provide the bibliography, and you can just make it available for all that.

[0:26:58] MM: That would be fabulous. I think I found the MBGR in the International Journal of Orofacial Myology. I think I found the AMIOF, but it is not in English. I'll go ahead and share that into the chat, just so everybody can look through it.

[0:27:14] MCT: Yeah. I'm not sure even if I can share it, but I think I will. Dr. Berretin, she's coming, and she will train some of the SLP that are interested in her protocol. It will be part of a PhD study. They will come to my university here, the university where I work, and we will invite some of the special language pathologists that are interested in being trained in this protocol as part of her research, so probably will not be cost involved with the training. She will probably offer some CEUs, whatever. It will be next year. We will make the information available for all those that are interested in.

It will be a huge opportunity to be trained in this amazing protocol. It's a huge protocol, but I'm pretty sure that they are trying to summarize it and make it more friendly in terms of clinical application. Because for research, we know that's the way that we do in research more methodological. You need to go through some steps. But in clinical, sometimes it's clinical practice, you need to summarize a little bit in order to see all the clients that you need to see in your caseload.

[0:28:36] MM: Just skimming through the MBGR, it is so comprehensive though. I don't know. I think that studying this and reviewing it and maybe going through this on a few evals that I do would be so enlightening, just to get me thinking about Ð one of the things that I found really interesting on the chewing section is that it talks about the number of cycles, and so how many times on the right side, how many times on the left side and looking at not just, do they have a rotary chew? But actually, analyzing how effective the rotary chew is. It's really interesting. I'm very excited, too. We have a weekly staff meeting and I am 100% going to bust this bad boy out tomorrow.

[0:29:19] MCT: Both of the protocols, the best thing I would say about them is that they have scores. By the end of the evaluation, you can say for sure if the client has a risk to have myofunctional disorder. This is why it makes therapy easier to plan, because it's not the same for everyone. It's not one size fits all. By having those results, you can plan accordingly with what the client scored less, or more, or whatever. This validated evaluation with comparison data will make the individualized treatment plan much, much, much easier.

[0:30:01] MM: That and also, I feel like right now the myofunctional program that I was trained in, it feels very subjective. I like this, because it just seems like it's giving you more definitive information on where are they falling for Ð it just feels a little bit more like it's moving towards that standardization, which I think will be really great for the assessment of myofunctional disorders.

[0:30:27] MCT: Yes.

[MESSAGE]

[0:30:27] ANNOUNCER: Are you taking advantage of our new amazing feature? The certificate tracker. The free CE tracker allows you to keep track of all of your CEUs, whether they are earned with us at speechtherapypd.com, or through another provider. Simply upload your certificate to your registered account and you're all set. Come join the fastest-growing CE provider, speechtherapypd.com.

[EPISODE CONTINUED]

[0:30:56] MCT: I think also, Madi, this is the near future path that we may follow in terms of research, because the agencies, they will not pay us. They will not give us money to do research if we can't prove that this is the way that we need to do. Even in terms of reportability, or in terms of dosage.

[0:31:27] MM: Dosage.

[0:31:29] MCT: Dosage, yes. How many times do you need to repeat a certain exercise, or duration, frequency? We need to prove. In this area, unfortunately, we still need to show how much we can. We know from our therapy results, but we still need to prove in terms of validation, in terms of efficacy. If actually, this is something that we can spread because it's validated, it's objective. We need to still to prove a lot of things in this area. Maybe this is some of the reasons some of the speech will find subjective what we do, because we miss this piece of research.

[0:32:17] MM: I agree with what you're saying, but I do find it very hopeful that there is research like this happening though, because Ð like I said, it's a future-like possibility that this is where it may go. But even with that being a possibility, I think it's really exciting. Like you said, will just provide more validity for this type of therapy, which would be just really beneficial.

[0:32:40] MCT: Yes, yes.

[0:32:42] MM: After you do your in-depth evaluation, and you assess the myofunctional deficits in the jaw, tongue, lips, cheeks, their functional feeding and speech production skills, how do you begin to customize your treatment plan?

[0:32:55] MCT: Well, the first step after evaluating and have this individualized data with scores where you can measure what needs more help, I think the first step of treatment is awareness. I would spend a lot of time covering this awareness component of my treatment. It doesn't matter if it's related with swallowing, or with speech, or chewing, mastication, whatever, I would make sure that my client knows why he or she is there and what is going on.

We, of course, we can do a lot of different things. We can exercise to strengthen muscle. Muscle building is part of the treatment. I'm not saying that it's not. If the client really needs it. If the function is disorder, and usually it is a function disorder; for instance, if the tongue pushes forward every single time that you swallow, you will need to compensate it by working with these strength pieces, but also, making the client aware that he or she is doing what they are doing.

I will spend a lot of time developing this perception about, for instance, let's say that it's a mouth breather, okay? I will make them aware of their condition. We will do the muscular training. They will need to learning about orofacial function. They will need to go over the process. Sometimes my goal would be, make them aware of those compensations while they are performing those orofacial functions disordered. Understand their condition by asking them some questions, by teaching them, because we need to teach them normal function physiology, of course, in a friendly language, in order for them to understand the consequences of this disorder that they are having.

Develop this self-observation, this self-perception. I will use a lot of videos from themselves, or from clients that allowed me to show their videos, because some of them, ÒOh, I want to show myself. Make to advocate for this, because I changed a lot,Ó so I want others, of course, attending all the hyper-compliances and all the things. This perception, for instance, asking questions, how do you breathe? From where do you breathe? Because some of the clients, they will come to therapy, because they get a referral, but they don't know why they are there. Some of the clients, for instance, I use and my students, they Ð I'm going to grab the material that I have here, so you guys that are listening will not be able to see. Basically, I'm covering my nose.

[0:36:02] MM: Dr. Tome, for those listening, just put some little cotton rolls in her nose to occlude her nasal passages.

[0:36:11] MCT: Yeah. You can ask why she's doing this, because is it the opposite? My kid came to learn how to use their nose. Now she's covering the nose, obstructing the passage. Some of my kids learn the results of this oral breathing, mouth breathing, just when I cover and ask them, what are you observing? Some of them will ask me, ÒCan I take this off of my nose?Ó I say, ÒNo, wait. Because this is the way that you breathe, usually. Wait a little bit. Stay covered there and let's talk. What are you feeling?Ó ÒOh, my mouth is dry.Ó ÒOh, yes. You're smiling. Okay.Ó ÒOh, it's not. I'm getting nauseous about this. Like, I can't.Ó

Of course, because nobody has a 100% mouth breather, breathing pattern. It makes a little bit, and those mouth breathers that have problem, they will have more oral mouth breathing than nose, but they still have a little bit of nose. Nobody's a 100% obstructed. After doing this exercise, I will ask them to make a report, like tell me, what did you feel? Because I can just come to the session and teach them, ÒOh, do you know the role that your nose has? It's humidification. It's filter. It's filtering. It filters, humidifies and warms the air.Ó I will be sure that my client will learn everything that I Ð it took me ears to learn in one session. That's impossible.

If he experiences this stuff, of course, you will remind later, ÒWow, my mouth got dry.Ó Why? I will use a lot of simple tasks, like you hold your lip now and breathe and inhale through your mouth and now touch the mucus and describe, what are you feeling? They will say, ÒWell, it's dry.Ó This is another way. I'm create a different way to make them aware. How do you breathe? From where do you breathe? What are the nose functions?

Then, now that they experienced, they will say, ÒOh, through my nose.Ó Let's try through your nose. Put your finger and feel. Do you feel it dry? No. Why? It's not dry. Because it's different. This saliva has a different pH. The lubrication is different. Let's see this anatomic picture and let's see, what do you have inside your nose? Oh, there is a lot of Ð the little kids will say, ÒThat there's a lot of bumps, and yeah.Ó What can you think about that? Some of my clients will draw and tell me, ÒWell, there's a lot of mountains.Ó So, why? Let's keep our hands this and blow air through. Do you feel any difference in terms of temperature? No. Do the same with your mouth. It's cold. Now put your hands together and blow it again. Oh, it's hot. It's warm.

This is like your nose anatomy. It's like those mountains that you saw in this picture, this anatomic textbook, whatever picture that you have. They have this function. Put things together and keep it together. Of course, we'll talk about circulation, a vascularization of the nose. It's different. This is what makes the air warmer in a way that you can breathe it through your mouth. Can you feel the difference? They will say, ÒYes, it's cold, whatever.Ó

Where is your tongue? Why are you breathing? I never thought about that. Now you need to think and tell me, or you can draw, or you can use the puppet tongue and mouth and put the tongue. Where is your tongue? Why are you breathing? Can we masticate and breathe at the same time? Those are weird questions that we never think about, but it's just important because when they go home, they will tell their mom and dad what they did, because mom and dad will always Ð well, they are supposed to ask to what they are paying for, right? What did you do?

They will, well, and my kids will come back and will say, ÒYou know, my dad keeps his mouth open all the time. My teacher.Ó ÒWhile I was in the cafeteria today, my best friend was masticating like this, with his mouth open.Ó They can be a little bit nasty. Again, this is the narrative that will show me that my client is getting better and better in terms of awareness.

To answer your question with all of this narrative is to say, first step, and I just mentioned about breathing, but I could ask the same questions in terms of chewing, in terms of swallowing, is awareness. The same thing. How do you chew? What is the role of your tongue, why do you chew? Did your tongue move or not? Let me do it again. Let me try with these, comes like the texture with this different Ð Is it the same chewing when you are chewing a cookie and when you are chewing an apple? Is it the same movement that your tongue does? Which movement does the tongue do? Do you chew hard and soft food in the same way? What is the position of your lips? Why you are chewing?

Those are the questions that you can address, for instance, awareness regarding mastication. You can create your own questions, or maybe your client needs more questions related with open lip posture, because he is a mouth reader. The other maybe needs more questions regarding tongue position, because this is what you saw in your score, in your evaluation exam. After this awareness that I will check every session, at least five minutes of my session. My session is around 40, 45 minutes. This is a private session. I know that a school district, you have your own 20 minutes, maybe a group of kids. It's hard.

You can change around according to your needs. Necessarily, every session you need to recall that information regarding awareness in a different way to address this awareness, this conscious about how you function. This is so important. The other part of the session, I will build this muscle, working fits necessary inside the application. I mean, I will basically apply to the function, three maximum, two, or three exercises. I don't have a program done. I heard some of my colleagues, ÒOh, I just know how to do myofunctional therapy by using 12 sessions.Ó Why 12 sessions? Because it's a 12-week program. But is your client the same? Are your clients all the same? Do they have the same problems, the same thing to work with? Maybe your client just need four sessions, just, or eight.

I know, I'm not talking about the issues with third parties insurance, all the things. I'm talking about ideal situation, where the client will pay because it's a private service and I used to work in a private service. I also saw clients and like in the university outpatient clinic. We need to adapt it to this semester schedule. We do this work in basically eight sessions. Sometimes the client will come to reevaluation in the next semester. It's different. But I think it's not the time frame. 

I'm much more interested on working with lip-strained by watching how my patient, my client to any if he, or she keeps her lips, or his lips together while chewing, then give them a button like this. Sometimes they give, okay.

[0:45:43] MM: She's putting a button behind her Ð You go ahead and I'll do a voiceover while you show us. She's biting her teeth together, putting a button in front of her teeth, and then it's attached to a string. She's pulling it to the front and the sides. Then her lips are staying closed while she resists the pull that her hand is giving to the button.

[0:46:02] MCT: Especially, because we don't have evidence to prove how many repetitions we need to do. Of course, with the advance of technology, I have in my lab, it's a Myovos lab at Andrews University, we have ultrasonography, we have electromyography, we have equipment where we can measure tone pressure. The clinicians, the students that I'm teaching, they will not buy all these equipment, because they don't work in a research center. I need to teach them how to use simple things.

If they have clinical rational, they can apply this rational using fancy stuff and using just their hands. Like, tongue depressor, or gloves, of course, the equipment, like basic things. This is why I think, this is the difference in between a list of exercises and a clinical rational, where you address function and not the muscle itself. The muscle strength is a result of how you function in your daily life. This is also why it's so important to ask videos from home, to send videos home, to record your client, to record yourself or maybe have someone and share with them. If they are not able to do it perfectly, you can record if you are vulnerable to do this. Record yourself, or have some models that you can share with them.

Because again, I know this, because I work with these 20 years, almost 30 years, but they don't. They are just learning a different thing. Again, out of their comfortable level, because they are open mouth all time, or part of the time and they are comfortable in that way. They are comfortable sneezing and doing this, because they have the allergies, or they are comfortable by drooling. I will not say, comfortable. They are familiar between it. We need to change things by proving that those things are not good for their quality of life. Then we need to address in different ways, starting with awareness, adding a couple of exercises. Just the ones that you need and practicing, just by changing the way that they function.

[0:48:36] MM: Oh, man. Just so much goodness in that description, Dr. Tome. I love it. You're really got my wheels turning in a little bit of a different way. I've definitely been feeling this full. I was trained in a myofunctional program. It felt really limiting, because it was just like, okay, well, I have these exercises. Then I go through these exercises and well, man, they're still not doing the things that they're Ð like, the functional thing.

I've definitely been feeling that pull in my practice to start focusing more on the functional deficits a lot sooner than what my program taught me. I don't know, it's just really nice hearing that, because it's not like I learned that in a course, or anything. It was just that clinical intuition that guided me there to do that. It's really nice hearing somebody that's actively participating in research, moving the myofunctional field forward, that that's aligning with what you're finding in your research and your experience has led you to. That's so great.

I think that if there was a little bit more awareness that myofunctional therapy isn't just this cookbook of this 12 weeks, where you go through this list of exercise, then boom, Ôyou're fixed.Ó I think that it would be a little bit better accepted. I love that while you're here on this podcast tonight, we're spreading awareness about that.

[0:49:54] MCT: Yeah.

[0:49:54] MM: That's so great. The other thing I want to touch on, so is it the same result that myofunctional therapy reserve for patients that have the cognitive age of four years or older?

[0:50:05] MCT: Yeah. I would say, you need to adapt everything that you do in the speech, right? You need to adapt. I think it's the same conceptual framework that you need to have. Basically, of course, when you are talking, like low cognitive clients, you will need to change things around and make sure that, of course, if you need to adapt some tools, also, you will, and we have a plant of market addressing that stuff. Utensils, materials, whatever.

In this case, I think more than for the pattern client that we may have in this area have the team addressing the same goals and make sure that you are doing the things that the PT does, for instance, for that client and you are working, for instance, if the client leaves the PT session and goes to a myofunctional session and you are not addressing the base of their feet, you are not doing the right work, because you are basically forgetting the posture, or the Ð of course, we do this with the clients that are pattern clients. But make sure that you have the family with you and the team so tied together to help a client that is not able to maybe think for themselves all time, at least consciously.

Yeah, I had syndromic clients. I have clients, right now with, I would say, juvenile Parkinson kind of motor problems. We do the same work. What I teach my students is how Ð and this is part of the meta therapy concept.

[0:51:54] MM: What was that again?

[0:51:56] MCT: Meta therapy concept. I think they talk a lot in voice therapy about meta therapy concept, but also in language, if I'm not wrong. Fluency also. But make sure that you have your client, and in this case, those local clients. I would say, the family, make sure that you have this time to conceptualize the ideas as the conversation between the clinician, the client, or the patient, whatever, guides the treatment. In order to know better your client, you need to also know, in this case, the family. Who is the team? Make sure that you use all of your tools to help the client. It's not easy. I would say, I would say, normal, like this, right?

[0:52:50] MM: In quotations.

[0:52:52] MCT: In quotations, because I don't like to use this word, but the only one that come up now. It's coming up now. You will need to address in different ways, according to what you are seeing. My clients, for instance, this client that I mentioned is a client that first day, my graduate student asked a specific food, without knowing that that client can't have any kind of sugar in her diet. That was a disruption in the beginning of the session, because mom believed that, ÒWell, when I'm not here, they will give sugar to her.Ó That would be a mess.

This is a simple thing that we need to take in consideration when we are taking history, the client history. This is how the family will rely on our work. If we ask a lot of questions, if we know what the client likes, or the client does not like, it's a good beginning, a good start point. I would never request a food that the client does not like, because my session needs to be fun and needs to be Ð the client needs to have pleasure. Because we are talking about this oral environment that is so, so private. The way that we put our hands, the way that we touch the client, it's singular. You need to make sure that you have this concept of how to approach my client in the way that it's okay for him, for her. I think I talked a lot about a lot of points to answer your question. Again, it's according to what each client needs.

[0:54:53] MM: That was fabulous. Thank you so much, Dr. Tome. We do have a couple of questions. Well, this one's about the federal law on assessing every baby for a tongue tie. If a tongue tie is found, one, do they assess for functional deficits? Two, if there are functional deficits and a tongue tie present, do they release the tongue at that assessment?

[0:55:18] MCT: Well, there is a protocol also for infants that they have over there. They will evaluate the baby and they will request a reevaluation in 30 days. They have a protocol to follow, in 30 days, in 45, six days. Then I'm not sure if it changed, but it was like that. Then they will check the need for surgery. If there is need for release, they will request. At least in babes, they will request. This, of course, will depend on how the baby is doing with breastfeeding, also how the breastfeeding is impacting money, also in terms of structure, like the breast, if there is some condition with the breast, whatever. In terms of weight gain of the baby. There's a couple of factors that they analyze together with the pediatrician. If there is need to release, they will follow up with a pediatrician, someone that's able to do the release.

It's important to mention that in our country, we have a public health system. The families, they have the right to receive this evaluation, and they will not pay for the release, which is so different in this country, right, where you guys need to have insurance, health plans, and the cost with the surgery is high. I think there is a huge thing going on right now, because of this article that was published in New York Times.

[0:56:54] MM: Yeah. Sounds very interesting article that was published in the New York Times.

[0:56:58] MCT: Yeah. I need to read the answers that some of our colleagues addressed to the authors. I didn't even have the opportunity to read the original article. Something that I need to do. Again, so we need to make sure who is evaluating the child, if this professional has competency to do the evaluation. One thing that Dr. Roberta Martinelli, again, I highly recommend to read what she writes, because she's amazing. She teaches lovely what she does, and how to fix, how to do therapy.

Sometimes how to, like don't touch the baby, because you need to give the baby the time. There is a lot of surgeries that don't need to be done. We need to also recognize. But Professor Roberta Martinelli also mentions that it's important to make sure that the baby follows his path in terms of physiology. Sometimes, the baby will be able to compensate mild problems. Sometimes not. In terms of function and speech, we are the only professionals that have the competency to evaluate that. There is a lot of, and she presents that, there is a lot of research done by other professionals. This is not a criticism, but at the same time it is. They don't know about speech.

They talk, well, there is no influencing speech, whatever. We know about speech. We are able to put apart a fricative for a different sound. We know that the fricatives, like lisping, anterior, lateral, are not the same, and the implications are different in terms of treatment. We know how alveolar sounds are affected, depending on how the tongue is attached, or how the client is compensated or not.

I presented a case now at ASHA. ASHA's convention, last November. I presented one of my cases, and also, one is from Professor Martinelli, Dr. Martinelli. This lady, this little child, she was able to produce the R sound. That's not the problem. If someone else from a different area, like a pediatrician, or a dentist, whatever, saw that client would say, ÒWell, she's producing the sound, but she's compensating, because she was producing the sound just with the back portion.Ó I think it was the right lateral back portion of her tongue. The sound was distorted, but she was producing the sound. That's not a problem. Who is listening that sound? If it was a speech-language pathologist, for sure, that's not a good sound. The problem is not now. The problem is not what we see now, but in the future, how this child will sleep with that attachment?

We have sleep apnea in 15 years from now, maybe, because we have an attachment making the tongue in a position, like rest in a position that's not properly. The muscle is aging in a position that will get less tense in years when she gets older, or there is more fat, whatever, she gains weight. We don't know how she masticated, for instance. If she's doing a lot of compensation, she does not masticate properly. This problem could be a gastroenterological problem in the future.

We have this lovely, I would say, work where we can prevent a lot of problems, because we have this knowledge. I think this is the beauty of myofunctional therapy, how we can avoid complex problems in the future by doing what we do.

[1:01:15] MM: Yes, absolutely. Well, I'm going to see if we have any questions that come in. The one other question we had throughout the conversation we had was if you could spell the names of the key researchers that you talked about. Would you be able to do that really quick?

[1:01:31] MCT: Yeah. Maybe I can use the chat.

[1:01:34] MM: That would be excellent. Absolutely. If you just make sure and change that little to button to everyone, and then everybody will be able to see them pop up. As you put them in, I will spell them on audio for people who are just listening.

[1:01:49] MCT: Okay, some of them. Well, one important is this one. Everything related with the speech, she produced a lot of work. She is the mother of oromyofunctional therapy in Brazil, Dr. Marchesan, regarding a frenulum Ð

[1:02:06] MM: Marchesan is M-A-R-C-H-E-S-A-N.

[1:02:11] MCT: Irene. Irene Marchesan. Okay, she's not working now. As right now, she's retired, but what she produced is a treasure, at least for the Brazilian speech language. She is well-known around the world. I was in France in the beginning of this year, and we were discussing in a panel. Everyone was mentioning her name. The other name is, I'm not sure if it's double L, sorry, Roberta. But it's Dr. Roberta Martinelli. She's published a lot in terms of tongue tie and [inaudible 1:02:49] tissues. Claudia Felicio, she published a lot in terms of Ð I have a lot of her books. She recently published a book. I don't have it here. Well, those that are listening will not be able to. She published an amazing textbook. She also talks a lot about trauma, facial trauma, and all those disorders.

We have Berretin-FŽlix, that I hope she comes to visit me in my university, in my lab. Berretin- FŽlix, Dr. GiŽdre. She's from the University of Sao Paulo, Bauru, and she works with those protocols, evaluation, also swallowing. She also has worked with dysphagia. In this area of dysphagia, she published. She also got a recent award in this area. She was in the European Congress of Dysphagia. There is a Hilton Justino. Sometimes Silva is the first one, but sometimes the first one is Justino da Silva. Silva Justino, or Justino da Silva. He has a lot of work.

This is one important researcher. Also, Bianchini Esther, she does a lot of sleep apnea work. She recently published a work with her collaborators, her students, where she was advisor. I think she was advisor from the works. She published a work testing a bunch of exercises for sleep apnea. She just found out that some of them are not a good exercise. Just take them out of your list. The research showed this. Yeah. I think, Motta Andrea, she works with basic physiology of muscles. I'm not sure how much she's publishing, but some of the names are there.

[1:04:56] MM: I'm just going to run through this list really quick and spell them. We have Marchesan, M-A-R-C-H-E-S-A-N. I, for the first initial. Martinelli M-A-R-T-I-N-E-L-L-I, first initial is R. Felicio F-E-L-I-C-I-O, first initial C. Berretin- FŽlix, B-E-R-R-E-T-I-N-F-E-L-I-X, first initial G. Justino da Silva, J-U-S-T-I-N-O, D-A-S-I-L-V-A, first initial H. B-I-A-N-C-H-I--N-C-H-I-N-I, first initial E. And Motta, M-O-T-T-A, first initial A. Thank you so much for those researchers. I have them saved and can't wait to look up some of them.

Dr. Tome, you were the concluding guest to be on Making Sense of Myo for this first season, and I can't think of a better way that we could have wrapped this up. I loved your emphasis on function in the myofunctional therapy, and I know, it was so great listening to you speak, sharing what Brazil is doing for myofunctional therapy, and your just emphasis on function just really hit home for me. I really enjoyed that, and I can't wait to go and look at my patients with a new functional lens on. Thank you so much for your time this evening.

[1:06:33] MCT: Yes, I thank you, Mandi, for leading me in this task. We didn't have the opportunity to talk about the goals, but maybe another time.

[1:06:45] MM: If you'd be willing, I would love to have you on for another episode. I think we might have a second season in the works, so there might be some more to come. I just want to say, for everybody that's listening, thank you so much for tuning in. I recognize a lot of the same names every week. It's been so great getting to learn with you all, and I thoroughly enjoyed hosting this podcast.

[1:07:08] MCT: Thank you so much.

[1:07:09] MM: Yes. Thank you, Dr. Tome. I hope you have a wonderful evening.

[END OF EPISODE]

[1:07:19] ANNOUNCER: Thank you for joining us for today's course. To complete the course, you must log into your account and complete the quiz and the survey. If you have indicated that you are part of the ASHA registry and entered both your ASHA number and a complete mailing address in your account profile prior to course completion, we will submit earned CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to reflect on your ASHA transcript. Please note that if this information is missing, we cannot submit to ASHA on your behalf. Thanks again for joining us. We hope to see you next time.

[OUTRO]

[1:07:58] ANNOUNCER: Thanks for joining us at SLP Learning Series. Remember to go to SpeechTherapyPD.com to learn more about earning ASHA CEUs. We appreciate your positive reviews and support and would love for you to write a quick review and subscribe. If you like this and want to hear more, we are offering an audio course subscription special coupon code to listeners of this podcast. Type the word SLPLearn for $20 off. With hundreds of audio courses on demand and new courses released weekly, it's only $59 per year with the code. Visit SpeechTherapyPD.com and start earning ASHA CEUs today.

[END]
SLPL S11E11		Transcript

	©Ê2023 SLP Learning Series	1