SEASON 11 EPISODE 03

[INTRODUCTION]

[0:00:12] 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. 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. 

[DISCLOSURE]

[0:01:03] MM: Hi, everyone. Welcome to another episode of Making Sense of Myo. My name Maddie Metcalf. I will be your SpeechTheraphyPD.com host for the podcast, Making Sense of Myo. Before we get started, we have a few items to alert you to. This episode is 60 minute and will be offered for 0.1 ASHA CEUs. 

Our guest this evening is going to be Mary Billings. Her financial disclosures include that she receives compensation for teaching and speaking engagements through her private practice, Billings Speech Pathology Services LLC and Learning Platform Function Focus Academy. She also receives an honorarium from SpeechTherapyPD.com for this presentation. Her non-financial disclosures are that she is a member of the Board of Directors for the Oral Motor Institute and an ASHA Life Time Member. For myself, I receive an honorarium for this podcast and I do not have any relevant non-financial disclosures. 

[INTERVIEW]

[0:01:53] MM: Now without further ado, we welcome back our presenter, Mary Billings. Mary is joining SpeechTherapyPD.com again tonight. She has another 10-and-a-half-hour course on SpeechTherapyPD.com, covering orofacial myofunctional disorders. I've taken it and highly recommended it. It is fabulous. Mary Billings, MS, CCC-SLP, COM is a licensed and certified Speech-Language Pathologist through the American Speech Language and Hearing Association and the current owner of Billings Speech Pathology Services in Kansas City, Missouri. 

Her clinical focus is in orofacial myofunctional disorders, encompasses feeding and swallowing aversions, dysphagia, motor-based speech disorders, dentofacial and other craniofacial abnormalities as well as pediatric feeding. Over the years, she has developed and facilitated a multidisciplinary professional collaboration for patient care. Mary is a Certified Orofacial Myologist and is active in leadership roles within the field. 

She served as the IAOM's first mentoring chair from 2008 to 2013 and was subsequently elected President of the IAOM where she served as President-Elect and Chair of the Nonprofit Governance Committee from 2013 to 2015. She then served as president from 2015 to 2017. In 2011, she was awarded the Connie Painter Distinguished Service Award for her efforts and in 2018, she was awarded a highly prestigious IAOM President's Award for her accomplishment while in office. 

She was appointed to the Board of Directors of the Oral Motor Institute in 2016 and in 2017 was requested by ASHA to serve as a subject matter expert, reviewer and update its bibliography for their Practice Portal on OMDs. She is a current member of ASHA, IAOM, AAPMD, OMI and AAPPSPA. She is a well-known lecturer on the topic of Orofacial Myofunctional Disorders and has lectured extensively across the US, and internationally at conferences, conventions and through webinars. She is an IAOM approved instructor for their 28-hour intensive studies course for people pursuing the COM in the field. Welcome, Mary. I'm so happy to have you on the podcast tonight. 

[0:03:56] MB: Well, thank you for inviting me, Maddie. I appreciate it. 

[0:03:58] MM: Absolutely. This evening, we're going to be covering the physiology of swallowing. For a little recap, our first episode had Linda DÕOnofrio and she gave us an overview of what Myo was. Last week, we had Kristie Gatto, really give a deep dive on the craniofacial complex and why that's important is SLP's to know. So tonight, we're going to cover what is swallowing and why is it important? 

[0:04:22] MB: Well, there you go. Whenever I start a lecture anywhere, I'm always quick to remind people that what is this for? We have two primary functions for the head and that is to breathe and the other is to swallow. There are millions of people today, despite the fact that we are all specialists in communication disorders, there are millions of people today who survive in our world without saying a word, without communicating a word, but all of them are able to swallow. Okay, If we really look back at some of our neurological disorders, we look at disorders like ALS, isn't that essentially what happens is the swallowing system basically deteriorates to the point where they can no longer function and that's what causes death. 

When we look at the swallow, the swallow is just critical. Suck swallow breathe is the primary motor function that builds on the brain. It's the first motor function that builds on the brain in human anatomy and physiology. So, therefore, we know that all this swallowing stuff begins neonataly, right? In zero to six months, you've got how the rooting reflex comes, suck, swallow, breathe. Reflexes present and organizing the gag reflex begins to integrate and is present on the first third of the tongue. 

There's a lot of different motor milestones that they're all there during those first six months of life. They develop neonataly, this is true. we can go through. I think I have something here, hang on here a second. When we look at how these skills develop neonataly, I often wonder if people even realize that the butt of the tongue erupts in the fourth week of gestation. The fourth week of your pregnancy, we have a tongue bud. By the eighth week, that tongue bud is actively moving. By the 12th week of gestation, that swallow is starting to organize and it's working in conjunction with all that cranial facial growth pattern that's going on. 

At birth, all of those reflexes that have developed are moving. They're developing. Often people will say to me, how do I know that this is typical versus atypical? Well, it usually shows up pretty doggone on early, right? Even by six months, we have phasic bite and munch chew patterns that start, the phasic bite goes away. That assistive goes away and munch chew patterns begin to develop. Kids and are, they're ready to chew. The tongue can channel itself back. Between six and 12 months, you have all lateral movements of the tongue. It can go up. It can go down. It can go side to side. All of these movements integrate with one another. 

The lips are actively moving. We have dissociation of the lips and the jaw that we need for sucking and swallowing, right? There are so many milestones. So that by 12 months, the gag reflex is all the way back in the back of the mouth where it is as an adult. These are depths that we have to ensure are moving smoothly, because between 12 and 24 months, all we do is facilitate that mastery, right? Over and over and over, so that there's the basis of a completely mature swallow by two years of age. 

Yes, yes, the oral phase of this swallow is part of that development. Sometimes we can see when our youngsters are going off-kilter, hence we ended up with a lot of kids by deferring that end up in feeding therapy, which is our hope. But at the same time, we know that we just cannot separate this process into smaller segments. Through my work with the oral motor institute, one of the messages that we try to send out to people today is that understanding, there are a lot of people that are using the terminology Òbaby myo.Ó 

Okay. So, I want to clarify for everyone again that myo means, muscle. That's all that term means. That's it. It refers to muscle. When people are advertising that they're doing myo therapy on infants, I would like for them to picture, I'm doing myo therapy when I take a baby who is eight weeks old, sit them up and take my hands away and expect them to sit up. They're just going to fall, right? Eight weeks old. I'm going to put you up and over and over and over until you sit up. We know that's not going to work because the system is not ready for it. 

There are phases and steps that our physiological system must move through in order to facilitate this. One of the questions that you sent me, Maddie, is how any of this has to do with cranial facial development, right? I can't speak for everyone who is here today, but I do talk to a lot of young clinicians today. I talk to therapists who have been at this for a while. I know that I get the feeling that there's not a lot of educational focus on cranial facial development today. That because there is so much to learn in grad school, the powers that we often believe this is something that you will pursue on your own. Am I wrong? 

[0:10:01] MM: I mean, I learned about the cranial facial system. We discussed it for sure, but as far as Ð I had to figure out on my own that when I'm treating speech and swallowing, I have to really know my anatomy and physiology. That was not made clear to me in school. 

[0:10:19] MB: No. It really isn't. We all Ð there is something to be said that we learn with boots on the ground. Yet, there has been a shift in perspective. What I'm going to do real quick is you cannot separate the swallow from general cranial facial development. If we go back to understanding how that develops neonataly, the most important thing that I can tell people, and this was actually taught to me by my dear friend in otolaryngologist or ENT. He was having lunch with me one day and he said, ÒMary, you do know Wolf's law, right? Wolf's law. Bone needs pressure to grow, period.Ó So many of us just perceive neonatally things are just growing. Growing. Growing. Growing. 

Well, because it happens through cellular regeneration and icon glass and icon class and how that works, but there still needs to be something that's a stabilizing pressure. So, in the head, which is my focus, all right, what we know is the emergence of that tongue early, early on provides that stability. All right. It helps to grow the roof of the mouth, to grow the jaw, to grow the bones that the teeth eventually erupt from. ThatÕs bone. That constant stabilization and movement of the tongue in its most fundamental terms, the tongue is a pump and the pumping of that tongue is what allows the basis of the cranium, the basis of the head, and the neck to grow. 

Listen, these two muscles right here, known as your masters, essentially attach the upper and the lower jaw together, okay? It's what makes them the strongest muscles in the human body. They are connected through this little disc back here, the TMJ, which allows us to shift forward, and side to side, and up and down. We're always using it. As a speech pathologist. We are always using it, because we're always, always talking. If we follow that these are the strongest muscles in the body, the tongue is the second strongest muscle in the body and that tends to blow people away. 

Unless you're a sixth-grade boy who's come in to see me who just had it in science, because his science teacher told him it was actually the strongest muscle in the body, Miss Mary, that's not actually accurate, okay? But that tongue bud and how it's working through conception allows by eight to 10 weeks the whole upper primary pallet to be formed as well as the upper lip. We have separation from the nasal cavity. Get this. The oral sensitivity, all the proprioceptive sensors for touch and pressure and temperature and pain are present by 10 weeks gestation. That's amazing when we think about it. 

The whole entire facial structure is in place by 12 weeks. The soft palate tissue has fused and the bones that develop cartilage have already formed. Now we actually have a cranial base involved and we have an actual mandible and maxilla. Now we built this whole entire system so that between 12 and 20 weeks we start getting all these sucking reflexes, right? They become more and more and more organized, so that by 27, 28 weeks all the primitive reflexes like suckling and rooting and phasic bite and the transverse term are completely present. 

The one fact that I tell parents every day that blows them away is that for a typically developing fetus, they have swallowed 50% of the fluid in their amniotic sack before they deliver in their 40th week. That's why when we talk about for years, we used to have planned deliveries or planned c-sections every week makes a difference to how those babiesÕ transition and develop healthy feeding, right? When we look at all of the mastery and all the steps that have to change, when do we finally get to a mature swallow? Well around three. 

I always do adjusted age. I have plenty of kids that have a perfect swallow by age two, but then we want to give them a little bit of time, so maybe they can get up on a bicycle, maybe they can manage it but we just feel better, because they have their training wheels on. We're going to give them a little bit more latitude. We're going to give them a little bit more time to move into it. During all of this process what's super, super interesting is, you know what's emerging at that time? Speech. Speech Ð and the movements that are needed for speech coalesce around the maturity of all these lingual movements. These jaw movements. 

One of the things that we know, if we look at a mature pattern. If we take a Maddie Metcalf and we say, ÒOkay, Maddie, I'm going to give you a glass of water. These are the movements that we would expect to see.Ó We would expect to see a coordinated intake, right, where your lips seal around the rim of the glass and you take that liquid in and your lips seal. They don't drop open, which goes back to our suck, swallow, breathe. The buccinator and the cheeks just gently contract. 

When people listen to me lecture, that's one of the biggest things that I do is I'll say, ÒJit without anything in your mouth. Just suck your cheeks in as tight as you can. When you do, figure out where this front part of your tongue goes. What does it want to do? Let's take a second, suck those cheeks in. Where did that tongue go?Ó

[0:16:18] MM: It retracted. 

[0:16:20] MB: It should have gone up to that alveolar bone, right, that maxillary alveolar bone. For people that think a little bit more about it, they should also feel that when we suck in the cheeks, the sides of the tongue gently come up. We feel it. That's that term that we use loosely called cupping, right, or making a bowl. All right. The buccinators must gently contract. The buccinators hold that food product to collect in the middle, so that when that tip elevates up to that central papilla, then we gently push off of that spot and engage a whole system of muscles which everybody can learn on my lecture. The palatoglossus, the transverse, the styloglossus to create a seal. 

When we walk our way through social media today, everybody talks about a suction. A suction and how long they need to be able to hold a suction and whatever, but the suction is what escorts that fluid back to the oral pharynx and then actually allows us to engage the rest of the swallow, once it hits that pharyngeal wall, right? When we talk about developing and understanding myofunctional disorders, the biggest question is asking me is it the oral phase of the swallow? Well, in most cases, it definitely is, because that tongue placement is out of place. 

What happens predominantly and what we tend to see more is that the swallow is impacted through the chewing phase. I find this repeatedly, I have the great pleasure of knowing a lot of the people who have presented on SpeechTherapyPD, and elsewhere. Some really, really wonderful people. I often talk to them about why we are not doing a better job in terms of educating people. How do you chew? What do we know about the chew, right? 

Suzanne Evans Morris did a great job or trying to highlight it. Lori Overland has done what she can. I think that that is most often, if I'm doing an assessment for an Oro myofunctional disorder, one of the components that's most missing. There is just a complete breakdown on how we do it, okay? what I want to do, if you'll bear with me. You can feel free to ask a question. If you want to, is I'm going to take a few minutes and I'm just really going to review it in a very simplified manner. 

If anybody who's listening to us, it's dinner time and you happen to have something that you aren't munching on, you might want to think about it, while we're talking about it. One of the lectures who made one of the greatest impressions on me was Pam Marshala. I regret her loss every day. She would have made quite an impression on our younger generation of speech pathologists that are out there. Among the last lecture that I heard Pam give before she passed away, she was doing a literature review. Her quote was, ÒChewing is neuromuscular. It's a neuromuscular pattern.Ó The research has identified there are 22 neuromuscular movements involved in producing one effective swallow. 

[0:19:49] MM: Wow. That's a lot going on during a chew.

[0:19:52] MB: 22. It is. That is when we think about Òno muscle works in isolation.Ó We talk about the eight muscles of the tongue, right? The intrinsic, the extrinsic, but we're really not addressing all of the hyoid, the infrahyoid, the super hyoid, and all system that works right along with it, right? We're not really looking at the lip seal as part of that, because we're so focused. We're tongue people, okay? 

What I believe is in order for people to truly understand if this is dysfunctional, that they have to have some understanding of the function of the teeth, right? Every tooth in our mouth has a role. the primary function that humans, the reason they have teeth is for mastication. When I have teenagers that they come in and they're orthodontists standing there, because they have this tongue-thrust thing that's going on. I will often tell them, ÒYou know what? You are not an orthodontia to be good looking. Your parents already gave you that care. You are an orthodontia to align your teeth, so their mechanics work, because every tooth has a separate shape, okay?Ó 

The purpose of the teeth is to cut and mix and grind and move the food around. Your tongue is your spatula when you are making brownies. That's how it serves its purpose intraorally when we are chewing, right? Every tooth, every shape of the tooth, it's crown and its arch mechanics and how it meets itself within the position of the mouth determines how chewing occurs. What happens when our babies are losing their teeth? We think about that, because that's often the age that we are working with. 

Obviously, we have our incisors. Those are our front teeth that we are also sensitive about and they are called incisors, because they mean cut. That's what it means. Your canines, some people call those your, what? Your vampire teeth. Some people call it your eye teeth, whatever, but your canines are actually the cornerstone of the entire dental arch and they help provide stability for where the attachment of the upper and the lower goes and they are critical for jaw dynamic, okay? They help control how one tooth slides on and off another, all right? 

They actually have the longest roots of any teeth and they are tightly, tightly fastened to the bone. We don't ever want to lose a canine. We don't ever want to hear about a dentist extracting a canine. We would rather have him move something back behind so that the canines can come down, but in chewing, they tear. Let's think about a piece of beef jerky, all right? If somebody has too sensitivity, they will often you'll see little kids. They're going to bite over on their canine. 

Behind the canine are what we call the premolars or the bicuspids. There are four, right? Two on the upper, two on the lower on each side for a total of eight. These things, they're flat, but they have little ridges. What happens once we've done that and breaking it down in the canines is we move the food further back. It's an assembly, right? Then we're crushing it and we're mixing it and we're crushing it until we can move it further back and then we go to our molars. 

In most cases we have six-year molars. We have 12-year molars. I'm going to stick with six-year molars, because what we know is kids, if we're looking at how we go off course, kids only have 20 teeth. You as an adult have or did have 32, right? Because 32 includes our wisdom teeth. Do you still have your wisdom teeth? 

[0:24:00] MM: I do not. 

[0:24:01] MB: Okay. Sometimes orthodontists get really excited and they're looking at, ÒOh, we just got to do the orch.Ó They get a little over-exuberant and they take out not just the wisdom, but they take out some of the bicuspids and then they try to pull it all together. That's called extraction orthodontics, right, to align those teeth. I mean, I'm not a big fan of that, because that shrinks the bone. The most important thing that speech pathologists need to get over is that Ð and there are many people, because I deal with the public every day. There is this notion that people cannot chew if they don't have teeth. That's completely flawed, right? Because the actual masticatory process within human physiology begins in the sixth month of life. 

The masticatory process activates within the pons of the brain stem. That's when it starts to kick in. Not too many babies have all their teeth at six months, right? Typically, what we find is all of this chewing process is mastered before all of the primary dentition are even in place. What's that do for our older adults? The ones who are losing their teeth, because they didn't take care of them, right? Well, I've done that too. Working for years in nursing homes and trying to clean up dentures, right? But most of my patients opted not to eat with their dentures. They left them on their table side, because they were uncomfortable. They still ate. They still chose to chew. Those motor patterns were still really, really there. So, yeah.

[0:25:36] MM: Did you use a myofunctional approach when you were in the nursing home? 

[0:25:39] MB: Yes. Without even realizing it. I often tell people. I had this conversation with a young woman the other day that I started in my dysphagia journey in the opposite direction. I worked with stroke. So, a lot of my people were vent-dependent, peg tube-dependent, and then trying to work through pharyngeal swallow issues and moving through all of that. So, yeah. I think that a lot of the therapeutic techniques that we use therapeutically in skilled care came with that underlying motor skill approach. I will tell you one of my favorite stories that I tell people is, I have a dear friend who, when she was a young speech pathologist, trained directly under Jeri Logemann, do you know that name? 

[0:26:28] MM: I do. 

[0:26:29] MB: Jerry Logemann, obviously, is iconic in our profession.

[0:26:32] MM: Absolutely.

[0:26:33] MB: There are people who say she saved our profession in the 1980s, because of her work in working with dysphagia. My friend worked side by side with her. She's still working today. She ran a hospital where I worked PRN. This young woman taught me everything I needed to know about modified barium swallow and videofluoroscopy. We remained very good friends. As the years went by and my practice grew, she knew I always worked with myofunctional disorders, so she would never accept them on the hospital caseload and she would send people over to me. 

Eventually, I got too busy to come and work with her. After I'd done my training, she asked me to, if she could come and watch. She goes, ÒI just want to see what you're doing. I need to get this piece of the puzzle.Ó She did. She came in and watched a colleague and I do an orofacial, myofunctional assessment on a probably, I don't know, a 12-year-old. We're just going to say it was a 12-year-old. She sat very quietly during the whole thing. When it was over and the people left for the day and we walked the door and I turned to her and I said, ÒSo, what do you think?Ó She said, ÒOh, my God.Ó I was like, ÒWhat?Ó She said, ÒWhere has this been? Where has this piece of the puzzle been? Why haven't we as speech pathologists working in hospitals acute care everywhere been looking at the oral phase of the swallow to help our patients transition back to a solid diet instead of leaving them on thick and liquids and purees?Ó Yeah. 

[MESSAGE]

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[INTERVIEW CONTINUED]

[0:28:36] MM: I did a rotation in a sniff and I was a little bit blown away Ð well, I didn't realize how complex the oral phase of the swallow was until I got into my myofunctional trainings. I was like, ÒOh, man.Ó It's not just, like prepares it. It goes down. Then the pharyngeal phase is where the magic happens. There's a lot of magic that happens in the oral phase, but we never touched how they were chewing or how they were collecting the bolus or any of that stuff when I was in my rotation there. We focused so much on the pharyngeal phase. I just think back to that time. I wonder how different with some of those patientsÕ diets been with their Oro functioning have been, if we would have taken a step back and looked at that oral phase a little bit more. 

[0:29:20] MB: If we had looked at the oral phase, there's a better than even chance that the pharyngeal phase, the modification would have been slight to assist. Obviously, there are always, always, always unfortunate cases where they've suffered a significant neurological impairment of the epiglottis. That makes it difficult for us or their esophageal reflex is so bad that we can't keep it contained down within the esophagus, but for the most part, I still carry the faces of those patients in my memory of those that I can think about that it would have really made a difference for. 

To review, I want everybody to just think about how do we take a bite and think about every movement that needs to go through. We take a bite, sometimes we take a big bite, like a big burger. So, we've separated our lips, so our labial system is involved, okay? Then what do we do? We're going to take a bite of whatever it is, we bite into it. Now we're moving it to the canines and it's mushing it down and it's mixing and moving with the saliva and then it moves back to the bite cuspids and it breaks down a little bit and the jaw starts to shift it a little diagonal side to side back and forth. There goes that spatula in the bowl, bringing it closer to closer and it continues to move back and forth and back and forth, but it's really back in the molars. 

This is why that chew can take up to age three, where the molars really start to rotate. That's where that term rotary chew comes from and the upper and the lower begins to go like this. The mortar and the pestle. The cheeks have to be tight, because the buccinators, it's like your core. It's your belly, right? It keeps the food on the surfaces, the occlusal surfaces of the teeth. Then it helps it move on to the tongue. 

First it stabilizes, then when we want to collect it, those cheeks will just slightly retract, all right? That pulls it to the tongue. Then the tongue tip elevates up to that central papilla to create what we refer to this as a term that came out of my class called tip anchorage. We need to anchor that tongue on that bone. Once that happens and it, what we do is we push on that bone. Did you know this bone is designed to take pressure? It's designed to take pressure. So, our tongue pushes against that bone. That's what allows us to have a safe onset and create lingual palatal seal. We just squeeze that food product back. That's how it works. 

We're not talking gummy worms here. We need a bolus. ItÕs a round block. Instead, what I see in most of my patients is the food collects in their cheeks, like a chipmunk or a pelican, right? I have seen people where particles collect underneath their tongues. That can't always feel good. Typically, what happens is people are chewing, storing in their cheeks, and then they're rolling, they're overcompensating, because they can't flex those cheek muscles. They're rolling those lips inward, all right? 

They're flattening out that tongue. That's one example. We're going to talk a little bit more about some others. They're swallowing that way. It's not a cohesive bolus. It's a mixed bolus everywhere. You will see scatter. That's why we have people open their mouth after they swallow, because we can see scatter all over the tongue. They're residual is still there, so it can often tell us. One of the biggest questions that you had for me was what kind of an impact does swallow have on dental-facial development? We've clearly already covered how that happens neonataly, right? That constant pumping of the tongue up and down and the moving. 

One of my favorite stories I tell people is that thumb sucking gets such a bad rack, any time we see any noxious habits. I have a speech pathologist that worked for me for about 14 years. When she was expecting her first baby. She brought the baby son, Graham in and she was so disturbed and said, ÒWhat? This is so exciting. It's a baby.Ó She goes, ÒDon't you see it? Don't you see it? Don't you see it?Ó Her dad is a dentist, by the way. Okay. I said, ÒWhat?Ó She said, ÒMary, he's sucking his thumb. My dad is going to kill me. I'm having a thumb sucker.Ó 

Well, what we know is all babies suck their thumb in utero. That's normal healthy development. What we know is that babies, if they lack that coordination, if their body is positioned in such a position, such a way that they can't easily move and manipulate and put their fingers or their toes in their mouth to suck on, their suck does not fully develop. Those reflexes do not fully develop or integrate through the birthing process. Sucking in utero is important. It's just when we come out into the real world that we don't really need to. That sucking helps facilitate bone growth, because bone responds to load, okay? 

A lot of people ask me about different shapes and babies' mouths about how come it's so high, how come it's so this? A lot of times that's just a neonatal anomaly. I had a little girl who came in, who was perfectly normal, but when she opened her mouth, we were checking her, because her brother was tongue tied. I saw a pallet I had never seen before. I swear to you. It was so high, it was so narrow, it looked like this kid was walking around with a cleft. I took a picture of it and I sent it to my ear, nose and throat physician. Then I'm like, ÒWhat am I looking at here, Doc?Ó His response was, ÒWell, that's interesting.Ó ÒOkay. Yes. I thought so too.Ó 

[0:35:31] MM: I did it too.

[0:35:33] MB: Yeah. ÒI need a little bit more than that, Doc.Ó He said, ÒIt looks like it could Ð there's some chance. It's probably a normal midline defect.Ó Is that a term that speech pathologists in this group would normally think of? Because when we hear midline defect, we're thinking something is wrong, but they are all different in cranial facial. Bone growth, there are all different types of midline normal. His perception was, she doesn't have this, she doesn't have this, he goes, ÒIt's interesting. It's challenging. It's midline normal.Ó He said, ÒThere's some small possibility she might have a cleft of the nasal floor.Ó Again, understanding that the roof of the mouth is not the floor of the nose. They are two separate bones that bump up to each other. It's possible to have a cleft within the nasal floor as well. This is Ð 

[0:36:33] MM: I did not know that.

[0:36:34] MB: Yeah. There's a lot of interesting things that we learn about when we start looking at the cranial impact. Okay. I'm more focused on dental-facial and that's because it's super important to understand that we all have 32 teeth, kids end up with 20 primary teeth, but they lose them. Then we move into what we call mixed dentition. 

If we're missing parts of our engine, how is it going to function correctly? Right? Because remember, we said every tooth has a job, right? If we're missing teeth, how does that come into play? I think the important part here is it's usually when we talk about significant dental-facial changes, it's not something that they were born with. It's something that occurs a compensation that they have developed for another weakness within our systems. 

[0:37:37] MM: Does that include class three or malocclusions or underbites? 

[0:37:41] MB: I believe so. I've seen plenty of them that we call functional, right? Dental facial development is this age that we are working on. People become super hyper-focate Ð parents in particular, because we want our children to look perfect and be perfect and think perfect. Often, they become fixated on the little spaces in teeth. In a little kid in primary teeth, we typically don't mind seeing space. That means the bone is big. That means as the other teeth start to erupt, there's going to be plenty of room. 

For me, the dental-facial development happens in the jaw growth and the changes in the facial jaw. That's exactly what you are talking about right now. When we ask if somebody has an OMD, what type of swallow deficit would they present with? I want to preface this comment by saying, you know what, there's a whole lot of information that has been written and not written about an Oromyofunctional disorder. I have an old rare book collection. It drives my husband crazy, because another book comes, but they are all rare books. Most of them are not in print. I'd like to think that I have read more than 90% of the works that have been produced. 

What I have seen historically in the written literature, and I know this is certainly true for our friends at ASHA, is that they are hyper-focused on the thrusting pattern of the tongue. Okay. But in reality, Oromyofunctional disorders are much broader than that and are defined as disorders of the jaw, the lips, the tongue, and even general body posture that negatively impact the developing or existing orofacial structures. Okay. I can take a 22-year-old in this group who's a grad student who's listening, who just got involved in an automobile accident where she was broadsided, who ends up with a TMJ problem, where she's got a lot. She's going to end up with an Oromyofunctional disorder. 

They can develop neonatally, they can be present, but sometimes they're caused by other things. In order to figure that out, that's why oromyofunctional disorders, I will often teach in my courses as a 5,000-piece jigsaw puzzle. Just we know, we get the frame together and we have a pretty good idea. Now we've got a whole section, look how much progress we're making. I've got this part, I've got this part, but what's going on over here? There's always something. The way we pull these pieces together is to understand that oromyofunctional disorders can stem from deficits in airway, whether it's the structure of the airway or a breathing pattern. 

Our mouth-breathing kids. It's impacted by body posture. So, when we have kids that are disabled, we have a body posture problem. Can they hold their head and their neck up? Do they have shoulder girdles? Do they have head-neck strength? What's going on with their core stability? If they're not and they don't have it, how does that affect your ability to swallow? It includes the jaw. What's going on with the jaw? Some Ñ there are people who have skeletal class three, Maddie, which is where this ramus bone starts to extend and grow longer than the maxillary bone. That is a real thing. It's rare. 

I've lost count, but I can tell you, like about two years ago, I was going through records and I stopped in the year 2018 because I was up to over 5,000 evaluations that I had done. I think I probably superseded that. I've seen thousands and thousands and thousands of patients. I can tell you that most of the class threes most likely started on a functional basis when the child was small. The ones that were truly genetic, the bone is just growing long, are rare. That's not to say I haven't seen them, because I have, and I've actually seen them in toddlers. 

[0:42:01] MM: Oh, wow.

[0:42:01] MB: It's pretty obvious, all right? But these malfunctional disorders can cause by weaknesses in the lips and the cheeks. From there, we move from the tongue and what kind of deficits are going on there? What anomalies? Until we finally get to the swallow. That's what my lecture that you were talking about when I do my 10 and a half hour here on SpeechTherapy, is it takes you through all of those modalities until you finally get to the crux of, this is what I need to treat, right? 

[0:42:30] MM: Yes.

[0:42:31] MB: It's like the top of the iceberg. We can't do that. We can't stop and I see this consistently with people, because of how we bill, right? They feel obligated to put food or liquid in someone's mouth because they're working on swallowing and that is incorrect. You are working on a system that is not yet ready to do that, right? Having the correct development of the entire complex is what prepares the space. 

Also, for the ongoing development of speech and speech sound placement. The tongue only has so much room to work. If we have this little tiny narrow space, there's no room for the tongue to position itself. You're going to modify. I have a friend who's a physical therapist and she says, ÒMan is the most adaptive species on the planet.Ó I think that she is right. Second to cockroaches. 

So, where there's a will, there's a way. If you think about this with your kiddos that you're over and over and over trying to work with and repeat the same thing over and over, especially with an S, but his structure won't let that happen or his physiology. Where are we going? Okay. What I'm going to do, because I know we've only got a few minutes left, is I'm going to summarize this, because you asked me what's a tongue thrust and a horizontal swallow pattern. 

[0:44:06] MM: Right. 

[0:44:07] MB: Here's something that you may not know. I have never read the term horizontal swallow pattern. Don't know where it came from. That was a new one on me, because I've read a lot of them. But I want to say to everybody, I hate the word tongue thrust. I don't like it. I've been working and specializing in this field, specifically from this stage for over 15 years. The reason I don't like it is because it only identifies one single issue from a disorder that has many, many, many, many symptoms. I don't just treat a swallow. I treat the entire disorder. 

My tongue thrust is based on decades-old terminology. It is something we want to correct, but historically in the literature, Hansen and Barrett were two men who founded the IOM that were both academically based SLPs and they were fascinated. They identified eight different types of tongue-thrusting pattern. Do you know why? Because the only people who would talk to them back then were orthodontists. They wanted. They were seeing the impact of this frontal swallow. All right. Just like reverse swallow is another one. There's no such thing as a reverse swallow. What's reversing is the mandible is moving backwards, right? That's only one type of atypical swallow. 

When Hansen and Barrett wrote their book, they showed the classic one with the tongue coming between the teeth. They discussed the dispersing where the tongue spreads itself around the dentition. They discussed the lower dentition where the tongue purchased down here. Now if you're always putting the pressure of your tongue tip down here, what is this right here? This is the junction of the mandible. That's bone pressure over and over. That's where we talk about functional class three, right? 

They identified another one as Bimaxillary protrusion, which is sometimes we're going to see these incisors are slightly reclined. The canines are slightly forward. So, the tongue is right there, but it spreads wide. They talked about open bited swallow where it basically comes all the way through to the lips, like this like a cork. We just seal it, closed by a unilateral bite where the tongue is pushing to one side and coming between the dentition. You notice I keep using the word bite, bite, bite. I'm using bite, because they're referring to the malocclusion and how the malocclusion develops itself. 

[0:46:41] MM: This goes back to, if your dentition doesn't support what the tongue needs to do, then you're going to have dysfunction. 

[0:46:48] MB: Yeah. Understanding the dentition gives you the clues to know what the tongue is doing. Unless you are doing this, even I know people who actually got sent in to have a modified barium swallow to identify a tongue thrust. That's when my friend kept saying, ÒNo, you need to go see Mary, because we don't do that here.Ó Why would we do that? Because a modified barium swallow, unless you're doing an anterior posture of you instead of a sagittal, it's not going to show you anything. We don't really give people anything to masticate in a modified barium swallow. We don't do it that way. That's where that whole term tongue thrust came about. 

When we do this with our assessment, it's like the last five minutes of our assessment to see how these atypical movements that we're seeing and how that coordination manifests itself. So, in a good therapy program, are we going to work with the oral phase? Of course, we are. Believe it or not, we introduce these concepts for oral coordination in kids as young as two and a half. If we think they need it in therapy, but always it's a side-by-side approach when we're working with kids that are three and up. Do they have language? Uh huh. Do they have speech issues? Uh huh. They have all of it, but we're doing all of it, because we know the oral phase is under volitional control. 

We know that we have to break it down in little pieces. When you are an iitty-bitty and your dad wanted you to learn how to play basketball, first he put the ball in your hands, so that you were not afraid and would teach you how to go up and down. Then he would teach you how to run with it going up and down. Then he would teach you how to stop and catch the ball. Then throw. Those are the little tiny components that we have to break things down in order to build successful neuromuscular patterns. 

Those good programs don't just jump into swallowing. We work on swallowing, but usually it's when more three quarters of the way through our program. It's a very, very short period of time that they can show through mastery. We achieve coordination, always rest posture, variances and food products and ensure that we have patient compliance and habituation. That's what resolves an oromyofunctional disorder. 

[0:49:10] MM: For that disordered transit of the swallow, if you don't like tongue thrust or horizontal swallow pattern as I was taught by someone. Well, if you're like classification for that and you're Ð 

[0:49:24] MB: I always, always, always first and foremost refer to what I am treating as an oromyofunctional disorder. Then within that, I'm addressing the oral phase of the swallow. 

[0:49:38] MM: Okay. 

[0:49:39] MB: Does that make sense to you? But I don't call it. I'm not treating a tongue a thrust. I don't diagnose it as a tongue thrust. When I talk to parents, I take them back and take them through every single system and delineate it. Guess how we got here? This is what we're seeing. Now, because it's been happening, we did a 24-year-old athlete today who has so much facial pain, right, and head and neck and shoulder pain and her hyoid is sitting all the way up here, way too high. 

The strain builds up and that's why oromyofunctional disorders are so important, because for every age, they lead to a cascade of dysfunction. We can deal with it for a really, really long time, but eventually if we're moving atypically, it's going to show up in the body. Sometimes it shows up as speech, sometimes it shows up as open bite. Sometimes it shows up when people just stop eating because they feel pain. Sometimes it shows up in voice disorders because their hyoid is so high. There's so much strain that they're putting on their vocal cords. Many, many layers to this onion that people have to unwrap. 

[0:50:52] MM: I guess, like my specific question was. So, whenever I'm like writing my summary section on my reports. I'll say this patient exhibits a severity level orofacial myofunctional disorder. Then I list, like the signs and symptoms. What led me to think that? Then I also have to refer it back to speech and swallowing, because a lot of my patients are Medicaid patients and I have to like get it under that speech or swallowing. So, I list out, they lacked all tongue dissociation, lingual coordination, lingual shaping. Then I get into the, if they have any respiration issues or signs of sleep disorder or anything. Then I go into the characteristics of their swallows. They have poor section on a cup, they have poor collection. They have a lack of rotary chew or bolus collection. 

[0:51:35] MB: Exactly.

[0:51:36] MM: Then that's whenever I would put in that tongue thrust swallow as part of that. Is it okay to use it in that context of describing the disorder in that phase of the oral swallow? 

[0:51:47] MB: This is me. I'm skeptical and I'm really careful. I don't ever use the word tongue thrust and care planning, mostly because I work with health insurance companies and they look for it as a red flag. The minute they see it, they kick it out. Sadly, to date, because it's so broad, there's no definitive diagnosis for oromyofunctional disorders and myofunctional disorders have been clumped into a field where they are considered cosmetic, because tongue thrust meant dentition, but we're not working with dentition. So, there are certain ICD-10 codes and I have dialogues. 

My good friend Linda DÕOnofrio and I sat for a whole night one time at a conference arguing. You know, she's not quiet. We argued this over and over that the codes that she's using are dental based codes and people at insurance companies don't know the difference. They just know that this is delineated, so they're not going to cover it. I tend not to use the word tongue thrusting ever. I tend to describe the pattern, right? Where they're stabilizing or mostly, I tend to describe what's missing. There's no TIP, Anchorage. There's no lingual stabilization. There's no suction that's occurring. There's no rotary chew, right? 

Those are things that health plans can wrap their heads around, because swallowing is a fundamental. It's a major medical. It's a fundamental to human survival and human success. When IÕve certainly seen this when we have Ð I have a 25-year-old I'm working with right now, who has stopped eating, literally, because it hurts to swallow. He's 25 and down to 80 pounds. 

[0:53:24] MM: Oh, my God. 

[0:53:25] MB: Are we waiting until we put him on a G-tube? Wouldn't it have been better if he had come to see me six months before when this pain started, right? So that's my personal choice. I saw a post from someone recently on Facebook just a week or so ago, who said that her boss refused to allow her to use the code 92526 for dealing with oral phase dysphagia, because they were not feeding the child. My response to that is it's unfortunate that this is your boss, because she clearly is not educated in what's involved within that coding. It's been oversimplified. 

[0:54:03] MM: Right. We do have a couple of questions. Kate M. says that she works with over 25 school-based SLPs and none of them know how to do a quality orofacial myofunctional assessment. Hello, that was me a couple of years ago. She says that she's been struggling with improving this aspect of her practice. She's found scattered PD courses but still doesn't feel confident in documenting her observations and interpretations. Mary, do you have any recommendations or books, protocols, trainings to help us conduct consistent high-quality orofacial myofunctional assessments? 

[0:54:34] MB: Okay. That's a Ð 

[0:54:35] MM: Big one. 

[0:54:35] MB: That's a tough one. I'm going to be releasing a new course on my Function Focus Academy that deals specifically with diagnostics and walking people through a better diagnostic assessment. I feel like a lot of times when people take our class, they want to see a hands-on evaluation. Then we've done that before, but unfortunately, again, this is an onion. So, sometimes the patients that we see the signs are very, very subtle. I would as a school-based SLP, I would go back and look at every single one of the systems that are identified in my lecture here on SpeechTherapyPD. Yeah, they're obviously a member, all right, go back and review that for what constitutes airway. Where's the jaw problem? Focusing airway and jaw are the two biggest ones for kids in schools right now that actually got you to their caseload. 

Yes, because of that, they have a lingual and a lingual coordination problem. It is definitely there, but kids that are sitting and mouth breathing constantly are doing it, because we're living in a world full of allergies, and food allergies that have been undiagnosed and allergies that parents just flat out refuse to treat. I have so much empathy for my colleagues who work in the schools right now, because they're so overwhelmed and so overloaded. We're dealing with a different generation of parents who just don't really want to hear it. 

We become a generation, we're frankly afraid of entering our medical system, because there's always another horror story. I can empathize with that, but at the same time, we can't ignore it and expect that we're just going to work on this sound and it's just going to go away because this parent will pay attention. We have to work on some of those issues. 

[0:56:28] MM: Then just from my own training, I've found SpeechTherapyPD to be so great. I took Mary's 10-and-a-half-hour course on here and learned so much. It was fabulous. It doesn't necessarily walk you through how to do a craniofacial exam or a myofunctional exam, but from what I found, there's not a specific protocol that gives you all the answers. It's really like building your knowledge base Ð what is typical? 

[0:56:54] MB: There are intensive study. We cover every bit of this in our intensive studies course. It's 40 hours, where there's 12 hours online and then there's a four-day live. We take everybody through every single component, but we also understand that not everybody can get that time and not everybody can afford to do that learning opportunity. I think that Char Boshart, she also has a podcast on TherapyPD. I don't know if she's still selling her product, but years ago, Char wrote a basic book that was extremely helpful. It was like oral motor analysis. I'm not quite sure if she has it. 

It wasn't something that was tongue thrust. It was specific to orofacial myofunctional disorders and it talked about how your craniofacial development goes, how all of these patterns move alongside speech sound, because that's where Char's focus was, as well. Sometimes you can still find those types of guides on Amazon. They might be a little pricey, because they're mostly out of print, but I know that she's done some good work worth reading. 

[0:58:08] MM: I did take a 28-hour myofunctional course and it was super great. It definitely gave me my foundation. Then I've just done a lot of things to supplement it. But I just Ð Char's booked, The Myofunctional Evaluation. I just shared that link. That was a really great tool that I use starting off. ItÕs so helpful. It really does like walk you through it. 

[0:58:25] MB: She has a great way of writing that brings it down into simplistic terms for sure. I think that there are those of us who teach are not necessarily putting out shortcuts to how to do an evaluation just predominantly, because there's so much information that you need to have in order to make sure it's a proper assessment. You can use this even just what you have with mine and make it part of your screening rather than a complete thorough assessment. But this work from Char is a good way to fill in some of those gaps. 

Certainly, a colleague who have reached out to me have told me that they've read that and it would be a good resource. But yes, it is a rabbit hole, isn't it, Maddie? Once you take the class, it opens your brain and you're like, but what about this? This is where, when people, like somebody said, I seen this in my kiddo, it with Soto syndrome. Yes. In my practice, we tend to get the kids that nobody else wants to work with anymore, because they don't even know where to start. But we can, as long as we understand the anatomy and the physiology and how it works together. 

[0:59:35] MM: We have another question that's a little bit bigger, but where you work if the OT involved in the oral phase? I've heard that many OTs own the oral phase and then SLPs own the rest of the phases. I know it's a ton of collaboration, but curious how it's split for the most part. 

[0:59:47] MB: Okay. That's a really tough question, because I know some really fantastic OTs and I happen to have two in my family. Here's what I know, occupational therapy has changed, just like speech pathology has changed. When I was working for years side by side with OTs, OTs were in functional ADLs. Feeding came from hand to mouth and working with adaptive equipment, so that people could self-feed. Somewhere in the interim, OTs and Marsha Dunn Klein was really involved with this in early EI where OTs began to see, well, it's sensory feeding and poor feeding and lack of feeding and picky eating is a sensory issue. I'm not going to disagree with that. 

What I find though, and what's often overlooked, and I've had this discussion with some really great OTs, by the way, is that they're so hyper fixated on the sensory that they don't know anything about the motor and how the motor system is supposed to work. I don't care how the grass feels. I need to know that the blade on the lawnmower is going to cut the grass to the length I need, before I can get the feel that I need with my feet, right? I have never heard that OTs own the oral phase. I don't agree with it. I don't believe it. 

I think that in my city at my children's hospital, OTs are the only ones that do the modified barium swallows. So, if that's the case. How is it possible that they are not allowed to look at the pharyngeal phase? If they're the ones that are being recruited to do all the modified barium swallows. I just think that there's been a lot of cross-pollination between the fields and I have a colleague actually, who has been accepted to Northwestern for her Ph.D., and that's one of her programs that she's going to do for her dissertation is to lay out the background training and what qualifies someone to work in the field versus someone else. 

I'm not picking on OTs by any means. It's just that there are lactation specialists, dental assistants, psychologists, social workers, and many, many, many other allied professionals working with swallow who have no education or groundedness in being able to work within the field. That should be a concern for the next generations of SLPs. 

[1:02:11] MM: Mary, this is fabulous. After taking so many of your courses and learning from you. Thank you so much for your time this evening. This was great. I hope you have a wonderful night. 

[1:02:22] MB: Thank you all for hanging around and listening to us tonight. 

[1:02:26] MM: Absolutely. Thank you all so much. 

[OUTRO]

[1:02:35] 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  S11E03		Transcript

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