SEASON 11 EPISODE 7

[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 guest, who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on SpeechTherapyPD.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.

[OVERVIEW] 

[0:01:03] MM: 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 miniseries. Before we get started, we have a few items to alert you to. This episode is 60 minutes only be offered for 0.1 ASHA CEUs.

Janine Stiene will be our guest this evening and talk about how the treatment of myofunctional disorders requires interdisciplinary care and when to refer your patients out.

[DISCLOSURES]

[0:01:30] MM: JanineÕs financial disclosures include that she receives an honorarium for this podcast. She does not have any non-financial disclosures. For myself, I receive an honorarium for hosting this podcast and not have any relevant non-financial disclosures.

[EPISODE]

[0:01:43] MM: So, as I said, our guests this evening is Janine Stiene. She is a licensed Speech-Language Pathologist, Teacher of the speech and hearing Handicap and trained myofunctional therapist with over 20 yearsÕ experience in the state of New York. JanineÕs coursework beyond her MA is comparable to her doctorate without a dissertation. Janine received her undergraduate degree from Loyola University and graduated with her MA in speech pathology from Hofstra University.

Janine is the owner and CEO of Long Island Speech and Myofunctional Therapy, in which Janine has grown her company to nine locations throughout Long Island, New York. Long Island Speech is the largest privately owned, insurance-based speech pathology practice on the East Coast, and the largest insurance-based myofunctional practice nationwide. Janine has created and trademarked her own myofunctional therapy program, Spot, which is a one of a kind and unique only to Janine practice and her clinician. Janine also has her own podcast, WHY-O-MYO, and co-host the series, Talk the Talk. Janine is the founder and CEO of the world's first tongue training appliance, Spot Pal, designed to teach proper lingual resting posture and support the elimination of a tongue thrust.

Now, without further ado, I welcome Janine Stiene to this episode of Making Sense of Myo. Hello, Janine.

[0:03:00] JS: Hello. Thank you so much for having me. I'm so excited to be part of this. And hopefully, provide some insight, answer some questions, and maybe learn a couple things myself.

[0:03:10] MM: Awesome. Well, I'm so excited. So, just a reminder for everybody. This is part of a larger series. So, if you have questions about why we're referring out for a myofunctional disorder, or what a myofunctional disorder is, you can go back and listen to some of those previous episodes. But tonight, we're really going to be diving into why myofunctional disorders require an interdisciplinary team. So, let's get started. What are some other professionals other than SLPs that may be part of the care team for an individual with a myofunctional disorder?

[0:03:42] JS: So, there's an abundance, and I think there's an absolute necessity that we work together as an interdisciplinary team. This can include from the ear, nose, and throat or an allergist who's worrying about airway and enlarged tonsils and adenoids that are affecting the tongueÕs position. We're talking about oral surgeons and their assessment of a tongue tie or a short lingual frenum, or a short labile frenum, or any buccal ties. We're making referrals to pediatric dentist and orthodontist.

Ortho looking so much at palate expansion. Is there enough room in the palate for the tongue to sit? Is their tongue pushing on the teeth because there's not enough space? And then, what type of orthodontic experience they've either had or will have, and where they are in that journey? Because a lot of times weÕre intervening in one way, but not necessarily, the ortho is not ready to intervene on their side yet. Then, of course, were working hand in hand with as many dental hygienists are also treating the myofunctional therapy. So, sometimes they're initially seeing the patients and we're seeing them as a speech pathologist and myofunctional therapist after the fact. Or they're also seeing just a speech therapist, and that speech therapist is then working on the articulation, while the myofunctional therapist is just working on any oral, facial muscle weakness or [inaudible 0:05:04].

[0:05:05] MM: So thorough. I love it, and really hit on like all those other providers that we might be working with. So, whenever you're working, do vary based on whether you're working with an infant, or a toddler, or a school age, or an older patient on who you might refer to and what that care team might look like?

[0:05:21] JS: Absolutely. Because, of course, when you're dealing with the infancy stage, oftentimes, we're not concerned about tonsils and adenoids being an issue. We're not going to make any long-term considerations or even short-term considerations with regards to palate and palate expansion. And it's really trying, we're really making the recommendation to the oral surgeon or a pediatric specialist who is able to address a frenectomy or address a short frenum if necessary, lingual, buccal, or labial. Or we're making a recommendation to a lactation consultant, because they're having difficulties secondary to having a short lingual frenum, and then going that step further and now having to address their issues as it relates to feeding and nutrition.

So, from the infancy stage, we're dealing on that side, even sometimes just dealing with a physical therapist to work on trunk support. All those things in order to substantiate what the long-term goal is. Of course, for infants, it's really swallowing nutrition and being able to thrive. 

As we get into that pediatric population, I would say, toddler till about six or seven, the orthodontist ultimately doesn't want to see our patients too young, because they know they're not going to be able to intervene. So, even though they'll say refer to us around seven for their first consult, they may be years away from palate expansion. But from the myofunctional therapy perspective, we want to know what that plan looks like, and when intervention is going to happen, because it may determine when we tried to intervene, especially if it's going to happen soon. And we may say, ÒLook, we're going to wait a little bit. Let them give them as much space in the palate that they can with expansion, and then we'll come in and do the therapy end.

But for that younger demographic, we're usually really making the recommendations to the ENT, the oral surgeon, again, for any frenum-related issues. The ENT looking at tonsils, adenoids, even some sleep-related issues. And I will say, even with that population, because the tonsils and adenoids can be developmentally enlarged. A lot of times when we're making that recommendation to the ENT, and they're even noting, yes, the tonsils are interfering, however, everybody's keeping their fingers crossed, that they're developmentally going to be reabsorbing back into the body, and they don't need to intervene.

It makes things a little challenging because we're like, ÒOkay, we're going to hold on a wish and a prayer that they're going to hit seven, and now all of a sudden, it's no longer to be an issue.Ó Or they hit seven, and nothing's changed, and now we're intervening, and we've kind of wasted or waited on valuable time we could have made a difference. And then, from the older population Ð

[0:08:00] MM: I have a question really quick, with that, I hadn't heard about the developmentally appropriate enlargement for tonsils and adenoids. I find that very interesting. So, what age is it developmentally appropriate to have that enlarged tissue?

[0:08:13] JS: So, some of the research says up till seven, some will say even as late as nine, but we usually go around the seven-year mark, just because again, early intervention is never a detriment. And we're definitely seeing so many more children, that we're referring for Ear, Nose, and Throat related to a myofunctional therapy disorder wind up having other things like sleep apnea, and parent has been dealing with ADHD diagnosis, or issues of learning disabilities, or wetting their bed. Now, all of a sudden, we're like, ÒOh, wait, we don't need all those other specialists. It all comes back to this.Ó Especially, when it's something that could be developmentally enlarged. It's important for everyone to just weigh the symptoms, right?

So, if it's really interfering with their abilities to function, their abilities to concentrate, they're having issues in school, having issues with speech. Well, then, you know what, maybe waiting it out is not the right thing, because there's other areas that are really being affected. But of course, as a parent, you don't want to put your child through anything unnecessarily. Even frenectomies can be traumatizing. So, we don't want to make those recommendations. However, a lot of times, as the myofunctional therapist, we're working as like the intermediary person. WeÕre almost like the general contractor, especially, when airway or their tonsils are enlarged, but they also mean palate expansion. If we do palate expansion, maybe the tonsils will not be a factor anymore, because now there's more space for them to stay. But when is that happening? And can they live that long? Or can their sleep be affected for that period of time until that's completed?

It's always like weighing it out. And ironically, I feel like as the myofunctional therapist, we're the one gauging it. It's like, ÒOkay, well, if you do the frenum, and then the tongue could get in the palate, and then that can expand the palate.Ó It's like, what come first? Like a snowball effect. And then the older the patient, a lot of times, we're just dealing with prosthodontists, because they're having issues keeping their dentures in their mouth, or their muscle mass has diminished so much, and now they're having issues with swallowing and choking. Now, we're dealing with the geriatric medicine and making sure we're putting them through a whole swallow assessment so that nothing else is going on. So, yes, they vary definitely on who we're referring to dependent on age.

[0:10:39] MM: We kind of talked about a lot. Maybe we can kind of take it by like provider by provider. Maybe we can kind of go through and talk about like, how do you decide who to refer out and when to refer? What's kind of like that clinical decision-making that you go through? Why don't we start with like ENT because we've talked so much about how important that airway is, and so ENTs are going to be the ones that help us with that airway. Maybe we can start there.

[0:11:03] JS: So, the one thing that I will say when it comes to the ENT is that, in my experience, an individual that presents and that requires myofunctional therapy, their oral cavities are always small, for lack of a better word, whether it's because their palate is high and narrow. Their teeth are overcrowded. They do need palate expansion. There's not enough room in their palate for their tongue. So, when we're looking at it from the ENTs perspective, we're looking to say, ÒOkay, is there enough space in the mouth for the tongue?Ó And if the oral cavity is small to begin with, and they're on that younger side, where they're not going to start palate expansion anytime soon, now we're looking at certain symptoms.

When we're looking with or dealing with the ENT, we're looking to see if they have those dark circles under their eyes. Those dark circles are usually a sign of sleep apnea, especially in that pediatric population. Do they have any other diagnoses? Are they diagnosed with ADHD, Attention Deficit Hyperactivity Disorder? Are they diagnosed with learning disabilities? Do they have difficulty falling asleep or waking up? Are they restless sleepers? Are they snorers? Depending on how many of those answers are yes, well then, the ENT is going to be one of our first recommendations, because now, aside from just a tongue thrust and needing myofunctional therapy, we're worried about are they presenting with sleep-disordered breathing? How significant it is. And is it actually affecting the development of the matter of the brain? And is it rejuvenating itself?

So, making those recommendations are very important, and especially at any age. But when it comes to a patient that has maybe a history of seeing an ENT, maybe they've already had their tonsils removed, and their adenoids removed, people always go into that mode of like, ÒOkay, well, I've already had them done. I don't need it. It can be an issue again.Ó But that's not true. Your adenoids can always grow back. Your tonsils, depending on if they were shaved, like intracapsular tonsillectomy or they were removed, they may grow back also, depending on the procedure.

It doesn't necessarily mean, okay, just because I've had this, it's not an issue anymore. And for those patients that have had it before, they've also developed all those negative habits secondary to having that issue in the past. So, we're more inclined to say, ÒYou know what, let's send them right to the ENT.Ó We're also looking to see how they're able to breathe. Can they breathe clearly through their nasal cavity? Is there any congestion? Are they sitting with this open-mouth posture? And are they reliant on breathing through their mouth? Or is it related to the nasal cavity?

So, from an ENTÕs perspective, we're always looking at it from all different areas, and back to that airway piece, is that anything that's interfering with the airway, and especially if that oral cavity is already tight and constricted, there's no place for the tongue. So, the tongue is either going to be pushing against the teeth, or it's going to be sitting in between the teeth or outside the mouth because there's just not enough room to contain it. A lot of that is because the tonsils are enlarged, or they were enlarged, and we just never retrained the tongue where it needs to sit, and the muscle memory of maintaining lip closure. Then, just learning what your tongue needs to do in order to be able to breathe through your nose. So, a lot of it is just that retraining.

When it comes to a short lingual frenum and labial frenum, there's been so much back and forth on this front about should intervention always be done when the frenum is short? How soon do you intervene? If they've had it before, should you do a revision procedure? When should the labial frenum be addressed? So, there's always been this back and forth. And for a long time, I probably say up until the last five to seven years, there would be a lot of like pushback or we would refer for a short lingual frenum or short labial frenum, thinking that this patient is going to need frenectomy. And of course, we're deferring to the medical dental professional. Then they would reach out to us and say, ÒNope, that patient is able to mobilize their tongue.Ó And they would say, ÒThey can touch the vermilion border of their lip and that means they don't need it.Ó 

What we've found is that after speaking and educating, being able to touch the vermilion border of your lip is very different when your mouth is completely open. So, if they're approximating their jaw in order to mobilize their tongue, now the frenum Ð

[0:15:51] MM: If we can explain what we just did because there's not going to be audio whenever we have the podcast only. So, what we just modeled as though if you open your mouth as wide as you can, and then you reach up and touch the upper lip, versus keeping your jaw really, really, really, really, really closed and small, and not very open, and your tongue is just like barely sneaking out and touching that top lip. So, that's kind of the difference. Just being able to touch the upper lip, we can't just say like, ÒOkay, yes. Check. They can do it. Move on.Ó Once again, like, everything with the myofunctional disorders is looking at the quality of how they're doing it. So, that's just like another example. Yes, they can touch the lip. But can they do it with their mouth open? Or does it have to be really closed, and the jaw really supporting that tongue to move upwards?

[0:16:37] JS: That was a great Ð quality is exactly what I would say. Yes. It's the quality of it, and I do feel that in the last, like I said, five to seven years, we're starting to see that they'll say, ÒWe defer it to you. It's your decision.Ó And that's always a little nerve-wracking, and especially as a parent because you're like, ÒI listen to my doctor. I listen to my dentist, but this is just a therapist. What does she know?Ó But the other piece is that nobody's looking at the frenum and less, it's an issue.

So, if we don't look at it during infancy because it wasn't an issue with feeding, and then we don't look at it because the child has no speech issues. Then, the next time we look at it is, not until they have needs from an orthodontist in their latter part of their childhood, and nothing's been done at that point, you're only looking at it at those three times. No one's kind of taking the deep dive into frenums, which I think is changing. I think a lot of things are definitely changing. But also, in the last few years, they now want us to always do therapy before. So, they want at least five to six therapy sessions before any frenectomy, where it used to be, refer them, they would recommend or decide if the procedure is necessary. And then they would see us after for stretching and exercises post. Now, they've switched it.

[0:17:57] MM: So, you are on this way. You practice with both models. Is that correct?

[0:18:01] JS: Yes.

[0:18:02] MM: Have you noticed a difference in like patient outcomes since having more of that pre-op work versus just having it after?

[0:18:13] JS: Yes, definitely. And I went a step further and even had mine done, because I'm like, I need to understand, I was able to make the contact, I was able to do everything that a great myo patient would do. But the amount of change to my face, and like my sleeping, the tension in my face, the release in my neck muscles, it was something I just was not expecting. Then, you start to realize, and I think again, doing this for so long, I've been doing those exercises, so I can do them. But I find that our patients are that much more successful, and their success is that much more expedited when they have the ability not only to understand what the tongue should be doing, but they're already starting to do it, and doing it without those compensatory strategies.

Because if they can click their tongue great, but if they can only click it and their jaws approximated completely closed, it's completely different than what we need them to do from a swallowing perspective, or when it comes to myofunctional therapy. So, I 100% see a difference. It was always a big joke because for some patients that were on the fence about, while I always say, like try exercises for six sessions and see if you're going to get improvement. If you see improvement, then keep trying those exercises and see if you're continuing to see steady improvement. If you're not and you're still seeing that things are kind of plateauing, then at that point, make the recommendation. But you don't have to jump right to doing that. If the patient does have the ability to mobilize their tongue, and went all out these compensatory strategies.

But the second that those strategies become an issue, or they start to present with symptoms of temporomandibular joint disorder, or jaw instability, well then, we're like, ÒOkay, let's weigh it out. If the approximation is causing so many more issues, then let's just do it now and be done.Ó Then, the labial frenum, this has gone back and forth. Do it before ortho. Do it after ortho. Do it during ortho. Currently, a lot of who we're speaking with want us to make the recommendation prior to orthodontics and prior to orthodonture.

I understand both sides of it, though, because I know they worry about the scar tissue, creating that same type issue. So, I completely understand. But I also think that people are in that less invasive Ð I don't want to be as invasive in the mouth. I don't want to be in palate trials or our patients in braces for years on end. If they can make changes naturally by just releasing, I understand that, too. I think it's preference.

[0:20:51] MM: I love how you're touching so much on how this is so interdisciplinary focused, because none of these decisions, none of them are saying like, ÒOh, that's my choice. I make that.Ó It is we're making this decision with the ENT or the dentist or the oral surgeon. Then, the other thing you're really touching on is the patient and the parent. I think I forget that too, sometimes that whenever we're talking about interdisciplinary care, that also includes what our patients and our patientÕs parents want to happen in their plan of care as well. Yes, I love that.

[0:21:24] JS: That's so important what you said, and it also is huge with success. Because if you're thinking your patient is not going to be successful without a frenectomy, or without having the tonsils and adenoids addressed, well, then, the long-term success of that patient, they have to be managed, right? Because I'm not Ð we always say, we can treat the symptoms, but we're not treating the cause if we don't address these few things. We just want to set you up for that, because it's not going to be, ÒOkay, we're going to follow this myo program. Then, when they're done, they're discharged on their way.Ó We don't know, because we're not touching the cause. We're touching the symptom.

[0:22:05] MM: I think that's been really hard to kind of navigate and come to terms with as a therapist because I got into myofunctional therapy, and I was like, ÒOh, man, this is the key. I can solve the root cause. I can, like really, really help them make a difference in their lives.Ó But I live in a pretty heavy Medicaid state. So, not every single patient can afford orthodontia, and not every patient has Medicaid, so they can't get their tonsils and adenoids taken out. Or there's just lots of gray areas. So, sometimes it gets really tricky, and having to kind of acknowledge and accept that, while we might see these problems, sometimes we can only get them to the best that they can with their current structure and that's tricky sometimes.

[0:22:51] JS: I think, and I'm sure you run into it, same with health insurance, and how many visits that our patients may receive. At the end of the day, we want our patients to be better than they were when they started. That we want their goals to be met, and it's just a matter of finding a way to make those happen. But when there's something interfering with dealing with those actual causes of the problem, then it just puts you in a tough position, because I want to make a difference, but I am all of these other obstacles that are interfering with success.

[0:23:23] MM: For sure. We have a question in the chat box, but I think it might have been incomplete. Oh, okay. If you want to go ahead and finish your thought, anonymous attendee, we will go ahead and answer. Okay. So, I've seen many children who had their frenums clipped, mostly if they couldn't Ð that one might be the one Ð child 14 needs expansion. They have a high vault, mouth breather, forward head tilt with eating issues, stuffing mouth, ADHD, some snoring, tongue thrust on S, tonsils were removed. Do I wait for expansion before starting myo?

[0:24:00] JS: If that patient was presented to me in that moment, I would say I would have them go back to the ENT and have them be scoped, to make sure the adenoids or nothing is interfering with the airway. Even though the tonsils were out. ÒThey went in and did my tonsils. WouldnÕt they check my adenoids? ÒThe answer is no. We live in a reactive medicine, not a proactive medicine.

[0:24:23] MM: I love that.

[0:24:26] JS: So, we don't say, frenum, tonsils, adenoids, all those things, those are all reactive and we're not proactive. So, as myofunctional therapist, I think we can be proactive, especially that the patient is a snorer and already had their tonsils removed. I would be concerned that the adenoids are interfering with the airway. In terms of palate expansion, palate expansion will be helpful, but I wouldn't wait to start therapy until they are expanded, only because there's so much that we can do with the patient prior to that point and that all takes time, even when we have patients that get put into expansion during therapy, when I first started doing this, if it wasn't a removable expander, we were like, ÒOkay, you're on hold.Ó Or like, ÒWe can't do that anymore.Ó We need to really take advantage of the patient in that moment and make those gains.

So, we just move things around so that we're addressing things that maybe don't interfere with their palate, or don't interfere with the space. We always, when I'm working with our therapists, because there are definitely patients that come to us that have been expanded already, and maybe it's still not enough room. Or they've already had ortho, and they're not going backwards into expansion. So, we try to work with them to get their tongue to fit within the confines of the palate, and we work a lot on the lateral margins of the tongue. We work a lot with, once their tongue is suctioned to the roof of their mouth, using Q-tips and whatever we can to try to condition the tongue to stay within the palate. Over time with doing that, once you do it a lot, the tongue all of a sudden learns like, ÒOh, when I go up, I need to tense.Ó Sometimes that will help until expansion is done, or that's enough of what we can do, and they get enough from that, that they're successful regardless.

When it comes to breathing with their mouth open, so the one thing everyone has to remember is that if you put your tongue, suction your blade of your tongue to your hard palate, you cannot breathe through your mouth. So, I can stick my Ð suction my tongue up there, keep my mouth open. I have to breathe through my nose. So, once your patient has been conditioned to keep their tongue there, it's already going to naturally start nasal breathing. However, if there's something interfering with nasal breathing, like their adenoids, or a deviated septum, or something else going on, then it doesn't matter if their tonsils are removed. They are not going to be able to breathe clearly through their nose and they're going to habituate that open mouth posture.

Whereas for others, it's just a habit. And now, it's really teaching them that muscle memory of my lips need to be closed, and then my tongue in a pole or a suction, and then I can breathe through my nose.

[0:27:17] MM: I agree. I've really found a lot of success in my clinic, I refer to it as growing with our patients or expanding with our patients.

[0:27:25] JS: Okay, love it.

[0:27:25] MM: We do so much of that lingual coordination. How do we make our tongue go relax to tense, to rocks and tensor, making a bowl shape or things like that? And all that stuff can be worked on while they're in expansion. But yes, so speaking about all this palatal expansion and orthodontia, how do you determine when to refer to ortho?

[0:27:47] JS: So, when it comes to palate expansion, the easiest tool that we tell our patient, or our therapist when they're assessing, or when we're assessing is for them to click their tongue. And when they're clicking their tongue, does the tongue overlap onto the teeth? If the tongue overlaps onto the teeth, then we're assessing and saying, ÒOkay, there's not enough space in their mouth for their tongue.Ó So, we'll look at that first. Then, once we look at that, then we look to see if the frenum is then a factor. Now, that's interfering with the tongueÕs ability to make it into the palate, which is then affecting their ability to naturally expand.

So, we're looking at all of those things. Then, the other part is the type of malocclusion that they're presenting with. For some patients, if it's something that's skeletal, like an underbite, no matter how much expansion is done, how much myofunctional therapy is done, nothing is going to be fully remediated until the patient can have orthognathic surgery, and that's not until they're done growing. So, it could be upwards of 18 to 21 plus. Many of those patients are having difficulty occluding, and biting down, and chewing, or smiling, or the way their speech is resonating. So, they don't want to wait until they're 20 something years old and recovered from the surgery to start therapy.

In patients like that, when we're making the recommendation, it's so that we know what the long-term timeframe is, what the process is going to be in the interim, and then what we can do to support their symptoms until we can really work on the absolute cause.

[0:29:31] MM: Do you ever do any measuring of the palate? And if you, do you measure what norms do you use?

[0:29:35] JS: So, we do not use any objective measurement when it comes to the palate. I always, always, always defer. When I'm making the recommendation, I always will say, ÒI defer to your expertise to determine if the palate is sufficient for tongue placement or tongue habituation.Ó And we've gone back and forth with this where we were taking measurements, we were using a wafer. We were using specific tools for measurement. Then, we determined that as we were making the referral, that data was not as important to the ortho because they were looking at it not from a, does the tongue fit their perspective, but is their mouth overcrowded? And we've come a long way with palate expansion too. When I first started, the orthodontist, we're only recommending palate expansion if the patient was in crossbite. That was like the mentality. Patients in crossbite, yes, for palate expansion, where, in my opinion, most myofunctional Ð most patients that need myofunctional therapy can benefit from palate expansion.

[0:30:47] MM: Yes. And not very many of them, in my experience have had crossbites.

[0:30:50] JS: Yes, agreed. Agreed.

[0:30:52] MM: For people that don't know what a crossbite is, a crossbite is, whenever the Ð correct me if I'm wrong, Janine. But whenever the mandible out-sits the maxilla. So, we want the maxilla to slightly sit over the mandibular teeth. But with a crossbite, that mandible is outside of the maxilla. Our dental arch.

[0:31:10] JS: Yes. And when your patient smiles, I mean, this is so laymanÕs, but the center of your upper central incisors should be aligned with the center of your lower central incisors. As speech pathologists, we know that jaw instability could play a role in that. So, you need to make sure that it's, actually, their occlusion sits that way, not that they've slid their jaw to one side, and that it appears as across bite, but it's not.

We used to get a lot of kickback when we refer for palate expansion or a suspected palate expansion, and they weren't in crossbite. I don't understand what you're referring. But if you think about it, in order for you to be successful with myofunctional therapy, we need space. I always say you need space in the palate, you need space in the airway, and you need space in the oral cavity. So, if you don't have that space, then there's not room for the tongue, and you can do therapy forever. But there's just not a place for it.

[0:32:08] MM: Right. What about physical therapists? When would you make that decision with physical therapy and when to refer out for that?

[0:32:16] JS: When it comes to physical therapy, a lot of times we're seeing it specifically with infants, when they're having issues with feeding, or worried about their trunk support, their ability to hold themselves up. Especially, even for those patients that are maybe coming for multiple reasons, whether they're coming for myofunctional therapy, but they also have voice-related issues. Or they have difficulties with breath support, and we're making the recommendation to the physical therapist. We do not, and it's sad, but there's not a ton of physical therapists that are in the space for myofunctional therapy. A lot of physical therapists in our area are, for that infant, with torticollis, or the individual that needs isn't walking yet. It's not in relation to an accident injury or surgery. It's not that like building portion, which I wish, and I hope that changes. I think the hard part with physical therapy is that you need a prescription from a doctor, whereas as a speech pathologist, and that was an issue in and of itself, like what do you need a prescription for and why is that related to what you do?

So, I think that becomes a challenge. However, it has a purpose, and especially depending on what the issue is, whether it be swallowing, even in the adult population, if they don't have the proper breath support, they donÕt have the proper posture, then swallowing, it may not just be a tongue thrust. There may be an actual dysphasia that we need to assess. So, I do think it needs to be utilized more, but we don't get to use them as much as we'd like.

[BREAK]

[0:33:52] MM: 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. So, come join the fastest-growing CE provider, SpeechTherapyPD.com.

[EPISODE CONTINUES]

[0:34:19] MM: We had a podcast on the craniofacial complex with Kristie Gatto. And one of the things that Ð it was really great.

[0:34:26] JS: Of course, it had to be great.

[0:34:27] MM: It was fabulous. Go back and listen if you haven't listened yet.

[0:34:31] JS: Yes, I'm going to. IÕm going to just say that.

[0:34:34] MM: But, one thing that she said is she's really expanded her understanding of what the craniofacial complex is to including like the hips. But back on what you just said about respiration and kind of looking at that piece, I wonder about pelvic floor therapist, because pelvic floor therapists are all about pelvic positioning, diaphragmatic breathing because if you're not breathing properly, your pelvic floor is tensing. So, I wonder if like a pelvic floor PT could be a myofunctional therapist like bestie.

[0:35:05] JS: That actually Ð yes. Right. And they release so much too. They're releasing that tension on top of it, like in the inappropriate place where you shouldn't have tension. Yes, that's actually Ð

[0:35:16] MM: And I feel like they're also a little bit more, like you were kind of talking about that proactive versus reactive. I feel like pelvic floor PTs are kind of moving towards that proactive space versus that reactive space.

[0:35:30] JS: Which we think we all need to get there, right?

[0:35:32] MM: Absolutely.

[0:35:34] JS: I think itÕs all important even what the pediatrician asks at when youÕre a baby, when you're an infant, you go, you bring your child, they give you like, are they crawling? Are they babbling? I feel like sleep needs to be part of that. I think frenum needs to be part of that. I think tonsils and adenoids need to be part of that. I do think there's a lot Ð or how are they breathing? Are they breathing with their mouth open, mouth closed?

I do think too, there's been a lot of emphasis placed on frenum lately, and I do think we're like our eyes are open, but they were talking about how, a lot of times those patients that have short frenums, because they're often sitting with their mouth open, it's what's causing the tonsils to be enlarged, because they're not filtering the bacteria through their nasal cavity. So, it's like what came first, the chicken or the egg? It's what do we address first?

[0:36:27] MM: I was just looking, I saw this morning, Sweden has come out and saying that we have to start looking at sleep-disordered breathing in childhood. I'm just going to read this really quick because I think it's really interesting. The main reasons for the course of care for obstructive sleep-disordered breathing and children is that there is a great deal of ignorance and ignorance among both guardians and healthcare staff, that these simple questions should be part of every child assessment. Now, Sweden is making them a requirement, not an optional extra. There's no wait-and-see. It's early referral for assessment by an ENT, and I think that is so awesome. Then, like the dentists are having to screen for sleep now also, which is I think that we're gradually moving into this proactive state.

[0:37:12] JS: I could not agree more. I hope that it gets to a point that myofunctional therapist can recommend those at-home sleep kits, because we're not diagnosing, just to get that information so that when you go to the ENT, you're like, ÒOkay, I've already done this, and/or, n, I haven't, and this was what we need to doÓ, kind of thing. I'm glad to hear that, and I think we're going to start here. They're always way ahead of us. Brazil is always like Ð we're always behind the eight ball when it comes to myo. A little delayed. But maybe if it's happening there, that means we're not that far behind here.

[0:37:46] MM: Right. Hopefully, we're moving in that direction.

[0:37:49] JS: Yes, exactly.

[0:37:51] MM: So, we had a question. Do you see a correlation between a tongue tie and a deep overbite? Just for clarification, overjet is whenever the teeth stick out past. When the upper teeth stick out past the lower teeth and a deep bite is whenever, or an overbite is whenever the teeth go really far out, the upper teeth go really far over the lower teeth. So just making sure because I called an overbite the wrong thing for a really long time. So, is there a correlation between a tongue tie and a deep overbite?

[0:38:22] JS: I wouldn't say that I would specifically say there's this absolute correlation that every time I see this, I see a deep bite, it's a short frenum, and vice versa, because I think so much of it is where the tongue is resting, how restricted their frenum is. If it's interfering with the growth of the mandible, or growth of the maxilla because of where the tongue is sitting, which is all going to have an adverse effect on their bite.

So, I will say that, when I do see it, those patients are also the ones that typically have temporomandibular joint disorder, or symptoms associated with that. A lot of that is just a lack of usage. Once they're not engaging those masseters, even back to the forward head posture. When you're thrusting your tongue, you're never utilizing your masseters, and thatÕs what actually holds everything back. So, I find that most of, that's what's pulling your head back and keeping you aligned. I feel so many times the orthodontic issues that are occurring may not have a one-to-one correlation with something so specific.

[0:39:30] MM: Another question. If the typical myo program. ItÕs supposed to take about 12 sessions, not including articulation with the above example, so maybe the patient with the palate expansion. What kind of timeframe do you give the client. And two, if it's going to take longer, do you charge for a package program or a session at that time? I find the parents get overwhelmed with all the different providers needed to correct the problem. Absolutely.

[0:39:58] JS: So, okay, so this is a tricky question. So, when I first trained, I was trained in Daniel Garliner's approach to myofunctional therapy, which was back in the seventies. And then, since then, I've gone and been trained by all the other organizations, and when I did Garliner's approach, it was a nine-month to a year program. So, when I would go for some of the subsequent trainings, when they had these short programs, I wasn't understanding how are you accomplishing all of that?

It wasn't until I realized that, depending on the program, and this professional. So, if you're a dental hygienist doing myofunctional therapy, then a 12-week program or a 12-session program is sufficient. But if you're a dental hygienist doing a myofunctional therapy program, and that patient has articulation issues, or also has feeding, or texture consistency, aversion issues, or other things that they need addressed, that's all done within and encompassed by a speech pathologist. Whereas when a dental dentist is doing it, they do their portion, and then they'll make that recommendation to the speech therapist, or they'll make that recommendation to the myofunctional therapist who's also a speech therapist now that can work on the tongue placement for bolus control or chewing, rotary chewing, and lateralization.

So, our programs as a myofunctional speech pathologist is a year-long program, and we say nine months to a year, but it's about a year. And that includes everything from tongue and jaw association. I always tell our patients, like we're turning back the hands of time to where the development stopped, and where you should have developed your adult swallow and you didn't. So, we're always starting with everything from tongue and jaw association to jaw stability, to stabilizing and swallowing the just your tongue tip, stabilizing and swallowing saliva with just your tongue tip, engaging your tongue bleed, and then working on chewing, bolus control, texture inconsistency, residue. With certain textures, then weÕll move on to meals, all while working on articulation and everything else, and then going to a subconscious swallow.

So, working on sleeping, swallowing correctly in their sleep, training the parents on how to do that. Yes, it's so overwhelming when we do an evaluation and we hand out all these referrals. You could just see like the shear panic. The question that always gets asked is why did my pediatrician, my dentist ever say anything? The answer is, I don't know. We are looking for it. They weren't looking for it unless something presented itself.

But I also find that the latter generation of medical dental professionals, they may not know much about myo. I mean, there was a time when myo was completely denounced, and when I started this, you would have thought I was like proposing voodoo. It was just Ð what do you mean? What does that mean? Put a habit breaker in and call it a day. That's all changed. So, that was that. CanÕt we do not do packages. We do everything over we try to do as much as we can through their health insurance. And one thing that I promote in my practice is that I don't believe that any therapy is the end all be all.

So, every one of our therapists, I send to every single therapist for prompt training. I send and train everyone in infant, pediatric, and adult feeding, as well as voice, or oral motor, artic. Because not every patient fits into that myo box, and sometimes, we need the whistling horn, [inaudible 0:44:04], or we need the straw hierarchy, or we need a bite block or a Chewy Tube. 

A lot of myo programs have nothing built in for jaw issues, nothing built in for jaw instability and how to target those things. And all of those areas, we have to start adding in. Same with drinking and resting posture, and all of those areas. So, that makes the difference in terms of therapy. Then, the parents it's still overwhelming. But we do reevaluate very often at different milestone points so that the parent can see the progress from I can't keep my tongue off my bottom lip and it's shaking all over the place, to I can mobilize my tongue without moving my jaw, or my mouth, or my teeth, and those things can be rewarding.

[0:44:54] MM: I love how you touched on, it's not just myofunctional therapy that you're doing as a speech pathologist. You're treating their articulation and swallowing and feeding disorders using an orofacial myofunctional lens. All that means is you're looking at the structure and the function of the mechanism that we're working within. So, that's one of my goals with this podcast is that I wanted to show SLPs that myofunctional therapy isn't this special shiny thing, that is its own separate thing. But it's something that we are all already doing a little bit of already, and just increasing that knowledge bases will just help us further our patients even more. It's not the only tool. You can use all your other tools that you've learned and gathered and the courses that you've took, and you can use this as another means to help get your patient where they need to go. Because that's what it is.

[0:45:54] JS: Absolutely. I think it's important that people realize, and I don't think the community, the medical and dental community know this as a rule. But you can buy The Tongue Thrust Book. ItÕs a tool on, I don't know, maybe super-duper lingo systems. You can buy Swallow Right. There's definitely approaches, but not every person that knows how to target a tongue thrust is a myofunctional therapist. And not every myofunctional therapist is a speech pathologist. So, it's not mutually exclusive, and I think the other part, which is definitely coming around is that myofunctional therapy is not done in school.

So, the pediatrician that used to say, like, ÒWell ask your school therapistÓ, and the school, they will barely touch articulation here in New York. There's just too many other kids with needs, that unless it's negatively impacting the academic performance, they're not touching it in school. So, it's just that knowledge base. I hope I answered that okay.

[0:46:57] MM: Yes. I think that was great. I mean, I answered it. If we didn't answer your question, let us know. So, whenever you're working with all these other providers, what does that care model look like? That collaboration piece?

[0:47:10] JS: So, first, obviously, when their patients are in the office, and we're making the recommendations, we give Ð so our recommendation list, or our referral list, I should say, has been cultivated over the last 20 years with professionals that I have gone and spoken to, worked with, to make sure that we are on the same, have the same mindset. Some ENTs won't do anything with tonsils and adenoids unless you've had nine bouts of strep throat, and 19 ear infections, and a myo kid may not be that patient. I need someone that's going to look at it from a different lens.

So, I think, when they come in, we give them our referral list and say, these are all doctors that are on this list that understand what our purpose is, and what our concerns are. Then we give everyone a script that they bring with them and outlines what our concerns are. So, there's different ones for the orthodontist, or anything frenum related, pediatrician, dentists, what have you, ENT, and we'll say, these are what our concerns are, these are the symptoms that were reported why we're concerned. That gets shared with, obviously, the parents take it home with them, but then itÕs shared with the provider.

Then, if a parent does not follow up with a recommendation, despite our persistence, we have them sign something called the compliance form. Especially, when you're dealing with insurance, and your patient is not making the progress that they need to be, or it's taking them forever to finish therapy, we try to document on this compliance form that the parents signs and sees that says, you know, the following recommendations were made, however, you've chosen not to fall through, and that can interfere with the quality of care, or their successful discontinuation of therapy.

Just because we never want it to go back, like I never knew, or no one instituted how important this is to the success in therapy, and I just find Ð we're always in that like CYA moment, or CYB, cover your butt moment where you want to make sure that you've done everything for your patient that's going to make them the most successful. And if there's anything that you can help support them with doing that. If there are specific or even something different about a case then we will reach out to that doctor directly and say, ÒI really want you to look at this. Sometimes it's velopharyngeal insufficiency or concerned about resonance, or concerned about the nasal cavity, or is there more of a Ð is it DiGeorge syndrome? Is it something syndrome related? To when it's something really specific, then we are reaching out to them directly. But otherwise, they get a script and the doctor gets it, the parent gets it, and we stay on top of it.

The other part, obviously, is that a report is sent to us after every evaluation that they go for so that we can review and see what the recommendations are. Then, with each reevaluate those medical professionals that are involved in the case, get a copy of their reevaluation to see how they're progressing.

[0:50:24] MM: You request those reports? Or are they just automatically sent to your clinic, because of that's the relationship you've established?

[0:50:30] JS: Yes, that's the second one. But it's taken time, and I definitely find that when we have new people that join our list, making that second nature takes a little bit of time. But after our office has to call over a few times, like okay, we get it, you want a copy of this each time. And it's helpful. It really is, even just as a clinician to read what it says. Okay, the tonsils are enlarged, but they're not big enough to intervene, or they're big, but the oral cavity is really small. So, we know that this will change with A, B, and C. In that situation, anytime you hear something's wrong, you want to figure out how to fix it. But not everything has to be fixed right in that moment.

[0:51:15] MM: Anne said, ÒI loved hearing the tools that you use to support your practice. I want to invest in some instrumentation to support improving position, stability, and function. What are your top five products that every clinic should have?Ó ThatÕs a good one.

[0:51:28] JS: That's a really good one. So, in terms of tools for myofunctional therapy, we always use, obviously, flashlights are tremendous, huge.

[0:51:38] MM: I also love the throat scope. Throat scope is a great one.

[0:51:42] JS: Yes, obsessed. And just because it contains everything without needing to have four hands. So, we're using a flashlight, throat scope, we use a lip for scale to assess lip strength, lip resistance. So, from a myofunctional therapy perspective, there is nothing that I would say other than that for lips, when it comes, like I said to checking out the oral cavity, where they use a lot of [inaudible 0:52:12], and sour sprays, or even like lemonade or something super sweet to help build and stimulate the oral cavity to facilitate a swallow, to build their overall intraoral awareness and decrease hypersensitivity.

Then, a lot of what I would go back to, is using your knowledge of everything else, and it doesn't necessarily have to be a tool. Lip retractors are great, but they're not great with every patient. Bite blocks, awesome, but not great with every patient. So, everything has a little niche. But when it comes t, if I had to say like, what are things for myo, it's always a flashlight or a throat scope. It's always a lip scale. Using dry animal crackers and goldfish crackers in order to help work on bolus and chewing. Having different variations of cups and straws. So, when we're teaching them how to swallow with liquids, we're utilizing every type of outlet, or however they use or get liquid. Is it a straw? It is an open cup? Is it a water bottle? Is it a squeeze bottle? Then, other than that, it's just being hyper-vigilant with understanding what's happening and making sure we're treating it and addressing it in the proper way.

[0:53:31] MM: Also, to add, if you are looking for like jaw stability tools, you can get the fancy bite blocks, there's so many options. But I find a lot of my patients can't tolerate a bite block in their mouth without gagging or getting really annoyed with how their tongue wants to go find it. And so, if you just take a tongue depressor and turn it on the side, it works as a great way to give you a little bit of space in that jaw, provide some of that stability, and then super easy to remove whenever they get it. Because we want to wean off all those tools. The goal is to get them doing it without any supports. So, you can probably find a lot just hanging out in your clinic.

[0:54:04] JS: Agreed. Agreed. So much of what we've implemented over time is like okay, what do we have in our presence right now, and what can I use in this moment to address what I'm seeing? Oh, I should say Q-tips. WeÕre huge with Q-tips. Q-cute tips for underneath the tongue to keep their suction tight, to stabilize, or to push one side of the tongue that's maybe a unilateral Ð showing some unilateral weakness and that's not making good contact, and just stimulating, and kind of giving that tactile cue is what we rely on as well.

[0:54:37] MM: Okay. I haven't read this through, so I'm going to read this one really quick. I'm a little Ð so anonymous attendee. I don't know if we have more than one, but some of these were kind of a little confusing on where they went. But I think this is one on its own. So, ÒI also worked with a seasoned SLP who had just passionately finished myo training education, making it her specialty. I was appalled by how she urgently told parents of any child with a shortened frenum to have it clipped. I was especially stunned because these kids had no breathing issues, no artic issues, no sleep issues, et cetera. She said that it was best to do this prophylactically rather than wait until issues did arise. She even told me that she could tell that my frenum was shortened, never asked me to open my mouth even, and she really pushed for me to have it clipped. I have no issues either. But she felt that it was a good preventative measure for me too. She also recommended that a little girl who spoke nasally have her adenoids removed and that child was actually worse after the surgery. Her clients just really liked her and trusted her and do whatever she said. I give these examples of her because they're representative of so many other very similar stories clients, parents have.Ó That's kind of a big one.

[0:55:44] JS: It is. That's so disheartening. But I will say that there's no standard of care when it comes to myo, and there's no standard of care Ð and it sounds crazy. But when it comes to frenums, there's no standard of care when it comes to palate expansion. There's no standard of care when it comes to identify a tongue thrust, what do I do? We tell every patient just get three opinions.

So, if you go for one opinion, and you get this answer, and then you go for a second, and it's completely different, to go for a third. If you don't find two people's opinions that are somewhat similar, then go for a fourth. Because I can't tell you how many people like, yes, palate expansion, start immediately. No, palate expansion, not necessary. Yes, palate expansion. But wait until you know another two years. It's so varied. When it comes to the frenum, I think I've had said earlier, I had my frenum done, and I didn't think I had Ð I mean, definitely have like TMJ type stuff and I'm not the best sleeper. But I would never have associated that with my frenum. And then once I released it, it was like the world of difference, but not even something that I would consider doing in the past.

The one thing about the frenum that everyone has to keep in mind, that if your frenum is short, your tongue is what shapes your palate. So, your tongue should fit within your hard palate like a puzzle piece. If, for either a prolonged thrusting habit, or a prolonged sucking habit, you've been pushing against that palate, the hard palate is malleable, and it's an open suture until you're done growing. So, when you expand, it's really just Ð and for me, I always wanted them to expand as soon as possible because the palatal suture is the most open. So, they would only have to make that little bit of a change. Whereas, if you wait long enough, and it's almost closed, and now you need this big amount of growth, you have a lot to fill in at that point.

But if your tongue frenum is short, and it cannot make calm, your tongue can't make contact with your palate, then it can't naturally shape your palate. So, that's when we often find that the tonsils get enlarged because it's out there in their breathing with their mouth open, or their mouth is open all the time, as an open mouth posture. They're not utilizing nasal breathing, which is causing their tonsils to be enlarged. Their palate is high and narrow because even once I work with them, and they're cognizant that they're thrusting their swallow, it's not habituated long-term, because they can't do it. They can't make contact without utilizing a compensatory strategy. And therefore, that palatal suture is not going to be able to maintain itself or grow naturally.

So, I'm giving a little props to the therapist only because I think that it can go multiple ways where you're looking at a patient and you're like, ÒTheir frenum is not affecting anythingÓ, but sometimes what it's affecting is nothing that you're looking at in the moment. Like their articulation or their sleeping. We can't, even as an SLP or an ENT, without scoping a patient, you're not going to see their adenoids. Even if they say, if they didn't put a camera in their nose, they didn't see them. Sometimes they'll X-ray them but even the X-ray is one dimensional. So, you really want them to be scoped, and they have no way of telling if they have sleep-disordered breathing unless you do a sleep study.

A lot of what the visual is may not necessarily be that. With regards to having everyone clipped, I don't necessarily agree with that because it has to Ð if they can make contact with their hard palate and they're able to naturally shape Ð actually, expand their palate and they can breathe clearly Ð habituate breathing clearly through their nasal cavity with their lips closed. Then, no, there's no reason. But I think it's like you said, it's symptom specific.

[1:00:02] JS: With the adenoids question, with regards to the individual that had the resonance issues, this can go both ways too because sometimes the VPI or the velopharyngeal insufficiency is being Ð if they have it, the adenoids are what was bridging that space, especially if it's a patient that their adenoids may naturally regress. Well, now the resonance is going to get worse on its own, because of natural growth and development. And the same thing with the tonsils. So, even though it may have made the situation worse situation worse, which it definitely can, for a period of time, it doesn't necessarily mean the issue wasn't there. Chances are it was there, and that was just Ð it was like a compensatory strategy. So, doing the intervention is a positive, because there's so many other things that can happen when there is VPI, right? Things can come at your nose. You don't have good control. So, I do think there's pros and cons to everything. But I can understand feeling, being a little apprehensive if you're hearing like an all-or-nothing mentality.

[1:01:10] MM: Yes. I agree with all that you said and I think that's really great. And then the other thing that I want to point out is that the SLP might have made the referral to the ENT, but like we talked about earlier, that wasn't the SLPs decision to remove the adenoids. The adenoids were removed by the ENT who made the decision that they were enlarged based on their evidence-based practice as well.

The question you just answered, they just followed it up, and this person's question is like one of the reasons that we want to do this myo podcast because it is a tricky hot subject area. I wanted to bring a lot of light to a lot of these controversies. But she said that she truly did not mean any disrespect, and that's why she was asking that question was to learn more and figure it out for herself. And that she's had a lot of big feelings about this. And she wanted to get more clarification. She loves the three-opinion idea, which I also love that. Go on and get some more. And she thinks that creating a myo standard of care is critical to get in place as soon as possible because it would help to create trust and respect and I completely agree. I think that as much standardization as we can get is really awesome. 

[1:02:22] JS: I am actually appreciative that you brought that question and that opinion to light because a lot of people will not say it, but they think it. And I think it gives myofunctional therapist a bad name because too many people get into the field and become these all-or-nothing therapist. I've created my own myo program that we use just in our office, and our therapist training is a yearlong. And they learn each stage of the program, while their patients are in it as well.

So, they're learning it, or I should say, in advance of that patient, but we're not teaching them what's happening six months from now in therapy and right now. We're waiting, getting them comfortable with what they're doing, and then moving on. Because I believe this as a therapist in every facet. But when I go to a therapy, I mean, a training and then on Monday, I'm supposed to be trained and that Ð I only saw three days of lectures. And now Monday, I'm supposed to go out and be like this stellar [inaudible 1:03:27] therapist. How much did I learn in three days, that now all of a sudden, I'm like the specialist in this area? I feel like you need to learn over time and see a bunch of different cases. Because I don't know if I'm doing it right, wrong. Who knows? I do think what happens with our field too, without the standard of care.

[1:03:47] MM: For sure. Yes, thank you so much for letting us or bringing that question so that we could discuss that. Okay, we have another one that's kind of similar field. And so, I see many children who had their frenums clipped mostly if they couldn't breastfeed easily. And without consulting a lactation counselor or any other methods, I really feel that many medical practitioners including myo SLPs are cavalierly clip happy. It seems it started about 10 years ago.

[1:04:17] JS: We've started training our speech therapist myofunctional therapist sending them for lactation training, because there is a disconnect between, I think, lactation, speech, oral surgeons, myofunctional therapist who takes over when. So, we've started training because I think it allows us to have this comprehensive understanding, and then be comprehensive in our treatment approach.

When it comes to, I think it's Ð so back a million years ago, every child that was in the nursery at the hospital, a nurse would have a very long-time pinky fingernail. I swear this is true. And they would just go through the nursery with their pinky fingernail and sever every frenum. So, it went from that eons ago, to, ÒOh, my God, we're never cutting the Frenum everÓ, to people being a little more open and cavalier to doing them. But I feel like the people that are cavalier in making the recommendation, they're not always as well versed in knowing why they're making the recommendation, they just know the frenum is short, I cut it. Or the frenum is short, the child has issues with latching, I cut it. Instead of saying, ÒOkay, what else could be going on? And can I resolve this issue without cutting the frenum or without lasering?Ó

I don't know if this is common knowledge, but I always advocate for the laser frenectomy versus the physical cutting of the frenum, more so from a healing perspective, and being able to get into therapy, and a scar tissue perspective. I think the laser is so much better. But I will tell you that most of the infants that come to us now that had frenectomies during infancy, they wind up needing them again, because they're very conservative when they're releasing the frenum, especially as a baby, because they're so close to the blood supply on the base of the mouth. But also, we're just a little more conservative, because we can't assess function except for them what they're doing naturally. So, it's not uncommon for us to make that recommendation.

But I also think, as the world becomes more knowledgeable and we start to understand what we can do to limit chances of reattachment or the intensity we should be utilizing post frenectomy, in order to limit reattachment and increase and maximize mobilization. I think with that, we'll start to see a change, hopefully.

[1:07:06] MM: The other thing is that I just kind of want to reiterate, is that we never recommend a tongue tie Ð well, in my clinic, we don't just look at a tongue tie and say, ÒOh, thatÕs short. Go get a frenectomy.Ó Or, ÒOh, well, you can't do X, Y, or you can't stick your tongue out or make an S sound or say an L. So, you need a frenectomy too.Ó It's really about this marriage of what does the structure look like? What is their function? Can we do some therapy beforehand and see improvement? And do we hit a wall that we can't get past? Do we plateau when we shouldn't be plateauing? Then, that's kind of, in my practice, whenever I'm like, ÒOkay, I think that we need to refer it.Ó Once again, it's not my decision. I say, ÒOkay, we're hitting this roadblock. I see that your frenum is short. It's attached really close to the tip. It's on the mandibular alveolar bone.Ó And then, we have these functional deficits. You can't keep a single palatal suction for an extended period of time. You're reporting tension on that. You can't generalize your vertical swallow pattern. You're having a lot of gulping whenever you're swallowing.

So, we sit down and we're like, ÒWe cannot overcome these things. You do have the structure. Let's refer out.Ó In my area, we have some great dentists that do laser frenectomies, and so, that's usually who we refer to. And then we say, ÒHere's what we're seeing. Can you do an assessment and see what you think from your expertise, and they make the decision to release?Ó But it really is like, once again, interdisciplinary care. It's not just the SLP making that decision. It's not just the dentist. The parents are also included and their values. So yes, but definitely, so great that we got to kind of hash through that chunk, because it is a big thing.

[1:08:45] JS: I had said earlier, like, one of the ways we assess is if they can make contact with their palate. But there's even like, there's a condition to everything. Because if they can make that Ð if they can click their tongue or make the contact with their palate, but their click is very hollow sounding. Well then, we know that even though they can make the click, and we think, ÒOkay, they don't need the frenectomy.Ó That hollow sound is because they're not getting that tight enough contact. So, that patient, even though they can make it and you would think, ÒOkay, well, she said, if they can do that, they don't need itÓ, they still may need it because they can't make the best contact or they can't contain things. So, there's definitely rules to everything. It's not just black and white, unfortunately.

[1:09:31] MM: Right. Which, like we've also been talking about throughout this series, is taking the time to learn about anatomy and physiology. Taking the time to learn about what the tongue should be doing. What is the anatomical physiological processes that we need for speech and swallowing. And then, you can make that decision for your patients and help talk to your parents in your care team, and figure out the best plan of care for them. But always about just filling those gaps.

[1:09:56] JS: Yes, exactly. Exactly.

[1:09:58] MM: Well, this has been so great. I love getting to meet and talk with you tonight, Janine. It was so great. You gave me some really good things. I love your three provider or go get your three recommend Ð or referrals, recommendations, opinions, hearing your tools that you like to use in therapy and just your referral process, how you build your team, and that sort of thing. We'll have to jump back on and catch us on another episode of Making Sense of Myo. Thank you so much, Janine.

[1:10:24] JS: Oh, it was such a pleasure. I don't know if I'm allowed to do this. But can I give my email if anyone has questions?

[1:10:32] MM: Please do. Yes. And I'll put it here in the chat as you say it out.

[1:10:35] JS: So, it's my first name, janine.s@lispeech.com. If you have any questions, patient-related questions, anything you didn't ask tonight or you think of later, knowledge is power. So, I am Ð this is like my baby. I love myo. It sounds crazy, but I do. It's nice for my brain to be thinking of things that you guys are coming up with, and if I can provide any support or insight, I'm happy to do so.

[1:11:07] MM: Thank you so much. This was so great.

[1:11:10] JS: Thank you for allowing me to be part of this. It was amazing and I look forward to seeing some of the more of these in the future.

[1:11:18] MM: Yes, thank you so much. I hope you have a wonderful night.

[1:11:22] JS: You too. Goodnight, everyone.

[OUTRO]

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[END OF EPISODE]

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[END]
SLPL S11E7		Transcript

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