Frequently Asked Questions

Swallowing and chewing are the primary functions of the mouth! Often persons with persistent speech sound disorders or orofacial myofunctional disorders present with maladaptive swallowing or chewing patterns. This is the main focus of rehabilitation here at Clarity Speech therapy.

• Wintergerst & López-Morales (2021). Masticatory Function in Children with Down Syndrome. “Children with DS have approximately 50% of the masticatory performance and maximum occlusal force of children of the same age without DS. These findings can be associated to the feeding problems reported in children with DS.”

• Borges et al. (2020). Association between dysphagia and tongue strength in patients with amyotrophic lateral sclerosis. “Forty-eight percent of the sample had dysphagia at the fiberoptic endoscopic evaluation of swallowing and 76% had an altered tongue strength test. Ninety percent of patients with dysphagia had an average tongue pressure lower than 34.2 KPa.”

• Kang et al. (2020). Muscle Tension Dysphagia: Contributing Factors and Treatment Efficacy. “Forty percent of patients had diagnosed positive gastroesophageal reflux disease” “...results suggest an association between laryngeal muscle tension and these patients’ dysphagia symptoms regardless of associated conditions. Speech-language pathology intervention showed high treatment efficacy.”
• Kim et al. (2020). Effects of chewing exercises on the occlusal force and masseter muscle thickness in community‐dwelling Koreans aged 65 years and older: A randomised assessor‐blind trial. “These results suggest that chewing exercises are effective in improving occlusal force and masseter muscle thickness in healthy elderly individuals.”

• Smith & Clayton. (2020). The Effects of Chewing Gum on Perceived Stress and Wellbeing in Students Under a High and Low Workload. “Depression and cognitive failures decreased as a result of experiencing a high workload. Perceptions of physical fatigue decreased when chewing gum under a high workload. The findings suggested that gum may be an effective way to reduce certain stress characteristics, and also reassuring students that a high workload is not necessarily detrimental to their wellbeing.”

• Suzuki et al. (2020). Effects of nasal obstruction on prefrontal cortex activities during chewing. “nasal obstruction during chewing may induce a decline in prefrontal activities, accompanied with deterioration comfort and dyspnoea, and modulated jaw movement activities.”

• Yamazaki et al. (2017). Excessive anterior cervical muscle tone affects hyoid bone kinetics during swallowing in healthy individuals. “...inappropriate posture may encourage hyoid depression and increase the extent of hyoid bone elevation, thereby increasing the risk of aspiration.”

• Choi et al. (2016). Dietary habits and gastroesophageal reflux disease in preschool children. “Dietary habits such as picky and irregular eating, snack preference, a preference of liquid foods, late night eating, and a shorter dinner-to-bedtime interval had a significant correlation with GERD.”

• Nagaiwa et al. (2016). The effect of mouth breathing on chewing efficiency. “activity of the masseter muscle were significantly (P < .05) lower during mouth breathing” “Chewing activity is disturbed while breathing through the mouth, and it takes a longer amount of time to complete enough chewing strokes to obtain higher chewing efficiency when breathing through the mouth.”
• Maspero et al. (2014). Atypical swallowing: a review. “The biunique causal relation between atypical swallowing and malocclusion suggests a multidisciplinary therapeutic approach, orthodontic and myofunctional, to temporarily solve both problems. An early diagnosis and a prompt intervention have a significantly positive influence on the therapy outcome.”
• Hsu & Yamaguchi (2012). Decreased chewing activity during mouth breathing. “Mouth breathing reduces the vertical effect on the posterior teeth, which can affect the vertical position of posterior teeth negatively, leading to malocclusion.”
• Smith (2009) Effects of chewing gum on mood, learning, memory and performance of an intelligence test. “Chewing gum increased alertness at the end of the test session in both parts of the study. This effect was in the region of a 10% increase and was highly significant (P < 0.001).”

• Robbins et al. (2008). Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity Into Clinically Oriented Evidence. “Use It or Lose It” “Use It and Improve It” “Plasticity Is Experience Specific” “Repetition Matters” “Intensity Matters” “Time Matters” “Salience Matters” “Age Matters” “Transference” & “Interference” “The motor with swallow category of techniques centers on the principles of experience-dependent neural plasticity … and warrants investigative prioritization in elucidating the translation of basic principles to the clinic. Most notable among these are the principles of Use It or Lose It, Use It and Improve It, and Repetition Matters. All of these techniques are used during the swallow with the goal of increasing the success of the swallow itself. As previously noted, this may result in the preservation of synapses and the maintenance of allocated cortical representation.” “Nonswallowing exercising of the oral, pharyngeal, laryngeal, and respiratory (i.e., swallowing) musculature holds a great deal of promise in treating individuals with severe dys- phagia. Nonswallowing exercising allows patients to progress through a training regimen safely without limitations that may be imposed if the swallowing of boluses is necessary for functional gain…behavioral plasticity of swallowing has been demonstrated from three different nonswallowing exercising techniques: lingual exercising, head lifting, and LSVT.”

• Teramoto et al. (1999). Impaired Swallowing Reflex in Patients With Obstructive Sleep Apnea Syndrome. “Patients with OSAS are likely to exhibit an impaired swallowing reflex, probably due to the perturbed neural and muscular function of the upper airways.”

The posture of the tongue and lips at rest are the foundation of myofunctional therapy. The lips should be closed, encouraging nasal breathing, and the tongue up and sealed to the roof of the mouth.

• Małgorzata (2021). The role of breathing in coordination of cortical dynamics. “Induced more frequent and/or prolonged inhalation leads to better memory acquisition and reaction time improvement whereas extending the exhalation helps with memory consolidation. Breathing techniques could be used as a non-pharmaceutical treatment of neuropsychiatric disorders that originate from disrupted and reduced power of frequency bands such as gamma, alpha or delta. More research is needed to further prove breathing techniques effects on brain dynamics and their practical application.”

• Zaghi et al. (2020). Assessment of Nasal Breathing Using Lip Taping: A Simple and Effective Screening Tool. “...testing whether a subject can breathe through the nose with the lips and mouth taped for three minutes can identify patients at risk of mouth breathing...”

• Suzuki et al. (2020). Effects of nasal obstruction on prefrontal cortex activities during chewing. “nasal obstruction during chewing may induce a decline in prefrontal activities, accompanied with deterioration comfort and dyspnoea, and modulated jaw movement activities.”

• D’Onofrio. (2019). Oral dysfunction as a cause of malocclusion. “If the impact of airway obstruction, soft tissue enlargement and/or soft tissue restriction is great enough, nasal breathing may not be adequate for muscular and cognitive functions, and a pattern of mouth breathing can develop… Mouth breathing encourages a lower jaw posture which can change directional growth over time.”
• Ong et al. (2018). Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms. “Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19% in control subjects (P < .001).” “In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching—especially those with excessive SGB.” “These benefits were greater in patients with excessive SGB, and sustainable at 4 months post-treatment.” 

• Saitoh et al. (2018). An exploratory study of the factors related to mouth breathing syndrome in primary school children. “There is a medical consensus about the relationship between mouth breathing and allergic rhinitis.” “This suggests that incompetent lip seal or MBS was associated with the bad breath, swallowing habits and chewing, as well as the confusion of the teeth and gums.” 

• Nagaiwa et al. (2016). The effect of mouth breathing on chewing efficiency. “activity of the masseter muscle were significantly (P < .05) lower during mouth breathing” “Chewing activity is disturbed while breathing through the mouth, and it takes a longer amount of time to complete enough chewing strokes to obtain higher chewing efficiency when breathing through the mouth.”

• Denotti et al. (2014). Oral breathing: new early treatment protocol. "Oral breathing, in children, is a very common problem. This dysfunction affects approximately 10-15% of child population.” “The rapid palatal expander is a valid appliance to solve malocclusion and oral breathing. It improves the morphology and function of the masticatory system and the upper part of the airway…. The maxilla constitutes the upper wall of the oral cavity and the floor of the nasal cavity.”

• Yeampattanaporn et al. (2014). Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain. “Breathing re-education can change breathing patterns and increase chest expansion. This change leads to an improvement in [cervical range of motion] Positive consequences may result from the improvement in diaphragm contraction or reduced activity of accessory muscles.”
• Smithpeter & Covell (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. “This study demonstrated that OMT in conjunction with orthodontic treatment was highly effective in maintaining closure of anterior open bites compared with orthodontic treatment alone.”
• Ono et al. (1998). Inhibition of masseteric electromyographic activity during oral respiration. “These findings suggest that masseteric electromyographic activity is inhibited during oral respiration” “This inhibition was greater during inspiration than during expiration.”  

• Limme. (1993). Orthognathic and orthodontic consequences of mouth breathing. “It seems that the altered postural position of the tongue and of the mandible, needed for oral ventilation, could, by soft-tissue stretching, change the growth pattern of the face.”

Speech and fluency (or stuttering) disorders may impact how well others can understand what your child has to say, in turn impacting their confidence and possibly their academic performance.

• de Castro Corrêa et al. (2017). Sleep quality and communication aspects in children. “A correlation was seen between the sleep quality of life and the skills related to the phonological processing, specifically in the phonological working memory in backward digits, and related to orofacial myofunctional aspects.”
• Hitos et al (2012). Oral breathing and speech disorders in children. “Mouth breathing can affect speech development, socialization, and school perfor- mance. Early detection of mouth breathing is essential to prevent and minimize its negative effects on the overall development of individuals.”

Strength and coordination training of the lips, tongue, swallowing, breathing and posture and it's application to various disorders (e.g., sleep disordered breathing) is discussed here. 

• Galvão et al. (2020). Effects of home-based inspiratory muscle training on sickle cell disease (SCD) patients. “The inspiratory muscle training at home is a strategy that can be easily applied in outpatients, providing benefits, such as increasing respiratory muscle strength, improvement in Vcap and exercise tolerance and reducing dyspnea in activities of daily living.”

• Hsu et al. (2020). Effects of respiratory muscle therapy on obstructive sleep apnea: a systematic review and meta-analysis. “Respiratory muscle therapy as an adjunct management for OSA but further studies are needed.”

• Mozzanica et al. (2020). Impact of Oral Myofunctional Therapy on Orofacial Myofunctional Status and Tongue Strength in Patients with Tongue Thrust. “OMT improves orofacial motricity and tongue strength in patients with tongue thrust regardless of the type of dentition.”

• Smith & Clayton. (2020). The Effects of Chewing Gum on Perceived Stress and Wellbeing in Students Under a High and Low Workload. “Depression and cognitive failures decreased as a result of experiencing a high workload. Perceptions of physical fatigue decreased when chewing gum under a high workload. The findings suggested that gum may be an effective way to reduce certain stress characteristics, and also reassuring students that a high workload is not necessarily detrimental to their wellbeing.”

• Ong et al. (2018). Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms.“Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19% in control subjects (P < .001).” “In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching—especially those with excessive SGB.” “These benefits were greater in patients with excessive SGB, and sustainable at 4 months post-treatment.” 

• Toh et al. (2019). Holistic Management of Obstructive Sleep Apnea Translating Academic Research to Patient Care. “Myofunctional therapy targets the upper airway dilator muscles function pathway in the pathophysiology of OSA. It involves a set of exercises for the lip, tongue, soft palate, and lateral pharyngeal wall, aimed at training the upper airway dilator muscles to maintain the patency of upper airway during sleep.14 It is hypothesized that this set of exercises increase oral and oropharyngeal muscle tone, as well as reduce fatty deposition within the tongue, thereby reducing upper airway collapsibility. Systematic review and meta-analysis by Camacho and colleagues15 in 2015 demonstrated a statistically significant reduction of AHI from a mean of 24.5 to 12.3 per hour (P<.0001). In addition, improvement of lowest oxygen saturations, snoring, and sleepiness scale has also been shown.15 These exercises can be performed in addition to other treatment modalities.”
• Camacho et al. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. "Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments."

• Diaféria et al. (2015). Myofunctional therapy improves adherence to continuous positive airway pressure treatment. “Myofunctional exercises of local muscular endurance aim to tone the muscle groups in the oropharynx, optimizing muscle strength and mobility, and adjust the position of the soft tissues (soft palate, pharyngeal constrictor muscles, suprahyoid muscles, tip and base of the tongue, cheeks, lips) and orofacial functions of chewing, sucking, swallowing, and breathing. These exercises may therefore reduce snoring and decrease the severity of OSAS” “The myofunctional therapy and combined groups showed improvement in tongue and soft palate muscle strength when compared with the placebo group.” “Our results suggest that in patients with OSAS, myofunctional therapy may be considered as an adjuvant treatment and an intervention strategy to support adherence to CPAP.”

• Guilleminault et al. (2013). Critical role of myofascial reeducation in pediatric sleep-disordered breathing. “Despite experimental and orthodontic data supporting the connection between orofacial muscle activity and oropharyngeal development as well as the demonstration of abnormal muscle contraction of upper airway muscles during sleep in patients with SDB, myofunctional therapy rarely is considered in the treatment of pediatric SDB. Absence of myofascial treatment is associated with a recurrence of SDB.”
• Baz et al. (2012). The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea. “Myofunctional therapy can achieve subjective improvement in OSAS symptoms, as well as polysomonographic abnormalities in patients with mild to moderate OSAS and so can be considered as an alternative method of treatment.” “There was significant improvement of OSAS symptoms (snoring, excessive daytime sleepiness, morning headache) after oral myofunctional therapy as compared to before the therapy… There were significant decrease in neck circumference and ESS after oral myofunctional therapy as compared to before the therapy while there were no significant change in BMI. There were significant decrease of AHI, arousal index and % total sleep time in snoring after myofunctional therapy as compared to before myofunctional therapy. Also there were significant decrease in desaturation parameters… after myofunctional therapy as compared to before myofunctional therapy, while there was significant increase in minimum SaO2% after myofunctional therapy as compared to before myofunctional therapy…”

• Cooper (2010). Orofacial Myology and Myofunctional Therapy for Sleep Related Breathing Disorders. “An orofacial myofunctional disorder is any pattern involving the oral/orofacial musculature that may lead to abnormal facial growth and function. Myofunctional therapy involves establishing, stabilizing, and reinforcing a healthy oral environment and facilitating the use of orofacial muscles to promote normal growth and development, and proper tongue posture and breathing patterns.” “The main goal of this treatment is to develop improved tongue posture and enhanced nasal breathing.” From Schwab et al 2005. “The GG muscle has been shown to have an increase in type II fast twitch fibers in the sleep apnea patient. These fibers are more susceptible to fatigue in patients with sleep apnea when compared with normal subjects.”

• Smithpeter & Covell (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. "This study demonstrated that OMT in conjunction with orthodontic treatment was highly effective in maintaining closure of anterior open bites compared with orthodontic treatment alone."
• Guimarães et al. (2009). Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome. “This randomized controlled study is the first to investigate the effects of upper airway muscle training by a series of oropharyngeal exercises in patients with moderate OSAS. Three months of exercise training reduced by 39% the severity of OSAS evaluated by the AHI and lowest oxygen saturation determined by polysomnography. The significant OSAS improvement in the patients randomized to muscle training occurred in conjunction with a reduction in snoring, daytime sleepiness, and quality of sleep score.” “Oropharyngeal exercises significantly reduce OSAS severity and symptoms and represent a promising treatment for moderate OSAS.”

Many persons with orofacial myofunctional disorders present with “tongue ties” or “lip ties” that restrict movement and prevent ideal oral resting postures. A full evaluation is required to determine if intervention is required.

• Check out a tongue tie release video by Dr. Richard Baxter. 
• Baxter & Hughes (2018). Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. “Some improvements were observed immediately after the procedure by clinical staff and the child’s family. While these patients required continued intervention from a speech-language pathologist, their improved lingual mobility allowed for more significant and faster improvement in speech and feeding skills.”

• Guilleminault et al. (2016). A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. “A short lingual frenulum left untreated at birth is associated with OSAS at later age, and a systematic screening for the syndrome should be conducted when this anatomical abnormality is recognised.” 150 children with OSAS. “The two groups differed significantly in the anatomical description of the oral cavity (table 1), with the short frenulum group having significantly more frequent reports of a “high and narrow palatal vault” and scores of 4 on the Mallampati–Friedman scale (0–4) (p=0.0001), while the normal frenulum group had a significantly greater frequency of scoring ⩾4 on the Friedman tonsil scale (p=0.0001). The mean tonsil size score was 1.8 in the abnormal frenulum group versus 3.2 in the other children.” “speech problems were better recalled and were described as “lisp”, “stutter” or having led to speech therapy”

• Yoon et al. (2016). Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. “Functional” ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50–80%, grade 3 < 50%, grade 4 < 25%.”

• Bruderer et al. (2015). Sensorimotor influences on speech perception in infancy. “Our results provide striking evidence that even before infants speak their first words and without specific listening experience, sensorimotor information from the articulators influences speech perception… Moreover, an experimentally induced “impairment” in articulator movement can compromise speech perception performance, raising the question of whether long-term oral–motor impairments may impact perceptual development.”

• Huang et al. (2015). Short Lingual Frenulum and Obstructive Sleep Apnea in Children. “One fact is clear: frenectomy for short lingual frenulum in isolation or following T&A helps but is commonly insufficient to resolve all abnormal breathing patterns during sleep when SDB is present. Myofunctional therapy, which has been previously demonstrated to allow return to normal nasal breathing may be needed post surgery.” “The existence of familial cases and the association with genetic syndrome suggest that presence of a short lingual frenulum may be part of a specific genetic predisposition, but no genetic study has been performed on familial cases of short lingual frenulum.” “In conclusion: children with SDB should be evaluated for a short lingual frenulum, and conversely, children with an abnormally short frenulum should be investigated for the presence of SDB. Frenectomy should be performed as early as possible but it may not be sufficient to restore normal nasal breathing function during sleep [28], particularly if the frenulum-related problem has lingered over years, and nasal breathing reeducation may be needed in these cases.”

• Ito et al. (2015). Effectiveness of tongue-tie division for speech disorder in children. “Substitution and omission improved relatively early after tongue-tie division and progressed to distortion, which is a less-impaired form of articulation disorder. Thus, distortion required more time for improvement and remained a defective speaking habit in some patients.” “Speech sounds that may be adversely affected by impaired mobility of the tip of the tongue include lingual sounds and sibilants, such as t, d, n, l, s, r, z, and th.”
• Marchesan (2004). Lingual frenulum: classification and speech interference. “An altered frenulum may predispose the individual to exhibit an accompanying speech disorder.” “The more frequent speech disorders were: omission and substitution of /r/; {R}, and consonant clusters with /r/, and of /s/ and /z/.”

OSA occurs when the soft tissue of the airway collapses completely (apnea) or partially (hypopnea) throughout the night. UARS It is very similar to OSA; however, it is when the tissues of the airway are reduced due to structure or inflammation. Both conditions result in lowered oxygen levels, disturbed sleep quality, daytime impairments, excessive daytime sleepiness and there are other often health conditions may occur. There is research to show that myofunctional therapy (i.e., treatment of swallowing, chewing, breathing and oral resting patterns) may be used as an adjunct treatment for OSA and URAS.

REHABILITATION 

• de Felício et al. (2018). Obstructive sleep apnea: focus on myofunctional therapy. “OMT is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure.” https://www.dovepress.com/obstructive-sleep-apnea-focus-on-myofunctional-therapy-peer-reviewed-fulltext-article-NSS de Felício et al. (2016). Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy. “The OSA group had lower scores in breathing and deglutition, more unbalanced masticatory muscle activities than PS group”
• Kuo et al. (2017). Short-term expiratory muscle strength training attenuates sleep apnea and improves sleep quality in patients with obstructive sleep apnea. “EMST improved the scores for AHI (-40%), PEmax (+68%), and PSQI (-28%) and reduced the PSQI scores of the moderate OSA subgroup but not the mild OSA subgroup.”
• Camacho et al. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. “Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments.”
• Ieto et al (2015). Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial. “Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring.”

• Guilleminault & Sullivan (2014). Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. “Elimination of oral breathing, i.e., restoration of nasal breathing during wake and sleep, may be the only valid end point when treating OSA. Preventive measures in at-risk groups, such as premature infants, and usage of myofunctional therapy as part of the treatment of OSA are proposed to be important approaches to treat appropriately SDB and its multiple co-morbidities.” “In all of the baseline PSGs of the 64 children with SDB, there was evidence of excessive mouth breathing (defined as at least one third of total sleep time) on baseline diagnostic PSG.” “The interaction between orofacial structural growth and muscle activity starts early in development, and the physiological functions of suction, mastication, swallowing, and nasal breathing in infancy play an important role in stimulating subsequent growth.” 

• Valbuza et al. (2011). Swallowing dysfunction related to obstructive sleep apnea: a nasal fibroscopy pilot study. “OSA patients presented subclinical manifestations of abnormal swallowing, when analyzed using nasal fibroscopy, possibly associated with neuromuscular injury caused by snoring.”
• Jäghagen et al. (2000). Swallowing dysfunction related to snoring: a videoradiographic study. “snoring is associated with subclinical pharyngeal swallowing dysfunction.”

• Toh et al. (2019). Holistic Management of Obstructive Sleep Apnea Translating Academic Research to Patient Care. “Myofunctional therapy targets the upper airway dilator muscles function pathway in the pathophysiology of OSA. It involves a set of exercises for the lip, tongue, soft palate, and lateral pharyngeal wall, aimed at training the upper airway dilator muscles to maintain the patency of upper airway during sleep.14 It is hypothesized that this set of exercises increase oral and oropharyngeal muscle tone, as well as reduce fatty deposition within the tongue, thereby reducing upper airway collapsibility. Systematic review and meta-analysis by Camacho and colleagues15 in 2015 demonstrated a statistically significant reduction of AHI from a mean of 24.5 to 12.3 per hour (P<.0001). In addition, improvement of lowest oxygen saturations, snoring, and sleepiness scale has also been shown.15 These exercises can be performed in addition to other treatment modalities.”

• Cooper (2010). Orofacial Myology and Myofunctional Therapy for Sleep Related Breathing Disorders. “An orofacial myofunctional disorder is any pattern involving the oral/orofacial musculature that may lead to abnormal facial growth and function. Myofunctional therapy involves establishing, stabilizing, and reinforcing a healthy oral environment and facilitating the use of orofacial muscles to promote normal growth and development, and proper tongue posture and breathing patterns.” “The main goal of this treatment is to develop improved tongue posture and enhanced nasal breathing.” From Schwab et al 2005. “The GG muscle has been shown to have an increase in type II fast twitch fibers in the sleep apnea patient. These fibers are more susceptible to fatigue in patients with sleep apnea when compared with normal subjects.”

ANXIETY

• Ben Simon et al. (2020). Overanxious and underslept. “Sleep disruption is a recognized feature of all anxiety disorders. Here, we investigate the basic brain mechanisms underlying the anxiogenic impact of sleep loss.” “patients suffering from anxiety disorders express reductions in non-rapid eye movement (NREM) sleep.” “these sleep-stage changes also co-occur with reductions in subjec- tive sleep quality3 as well as objective sleep efficiency… Such cross-sectional (between subjects) evidence demonstrates that poor sleep quality positively correlates with higher anxiety.”

ATTENTION & HYPERACTIVITY

• Sedky et al. (2013). Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. “Pediatric populations suffering from SDB are at increased risk of presenting with symptoms of ADHD, including inattention and hyperactivity.” “There are several possible explanations for the relationship between SDB and ADHD symptoms. SDB syndrome is associated with lower oxygen saturations and hypercapnia overnight, oxidative stress, increased free radicals, and/or release of inflammatory cytokines (e.g., proinflammatory cytokines interleukin-6 and tumor necrotizing factor alpha) leading to neurological dysfunction particularly involving certain brain areas (e.g., prefrontal cortex). Cortical dysfunction is associated with cognitive and behavior dyscontrol and can consequently lead to inattention, hyperactivity or impulsivity symptoms.”

• Bonuck et al. (2012). Pediatric Sleep Disorders and Special Educational Need at 8 Years: A Population-Based Cohort Study. “Children with a history of behavioral sleep problems (BSPs) and of sleep disordered breathing (SDB) in the first 5 years of life were more likely to have a special educational need (SEN) at 8 years of age; even controlling for 16 putative confounders, BSPs were associated with a 7% increased odds of SEN, for each ∼1- year interval. Thus, for example, children with a BSP in at least 2 of the 4 intervals (∼1 of 5 children) had a 15% increased likelihood of special educational need SEN.(SDB), overall, was as- sociated with a near 40% increased odds of SEN. Children with the worst SDB symptoms were 60% more likely to have an SEN. Sleep problem effects remained significant, even after controlling for IQ, which itself was associated with five- to sixfold increased odds of SEN for both BSPs and SDB”

• Bonuck et al. (2012). Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. “The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the "Worst Case" cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity, and conduct and peer difficulties. The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years. … Findings suggest that SDB symptoms may require attention as early as the first year of life.”

• Macey et al. (2010). Relationship between Obstructive Sleep Apnea Severity and Sleep, Depression and Anxiety Symptoms in Newly-Diagnosed Patients. “Consistent with other studies, a strong link between OSA severity and psychological symptoms did not appear in these newly diagnosed patients, suggesting that mechanisms additional to the number and frequency of hypoxic events and arousals occurring with apneas contribute to adverse health effects in OSA.” “The findings support the hypothesis that AHI is not the most appropriate polysomnographic measure of clinical impact of OSA… Symptoms like poor sleep quality and daytime sleepiness may be more closely related to number and extent of arousals… The frequency of arousals is a better predictor of fatigue…blood oxygen desaturation appears to be a better predictor than AHI of daytime sleepiness.

• Huang et al. (2007). Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. “A low AHI score of >1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake”

• Chervin et al. (2002). Inattention, hyperactivity, and symptoms of sleep-disordered breathing. “Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and---especially in young boys---snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.”

CRANIOFACIAL GROWTH & TONGUE TIE 

• Guilleminault et al. (2019). Sleep-Disordered Breathing, Orofacial Growth, and Prevention of Obstructive Sleep Apnea. “During the last trimester of pregnancy there is a continuous training of the suck-swallow reflex” “During fetal lide, training of diaphragm and respiratory accessory muscles must also occur.” “The absence of the normal development of the orofacial growth also has secondary consequences of the maxillo-mandibular position. Such changes have a negative feedback impact on the insertion of the muscles forming the upper airway.” “The only valid treatment goal is restoration of nasal breathing, not only during wakefulness but also during sleep.” “Snoring develops and there are both disuse of normal reflexes and impairment of reflexes caused by inflammation and perhaps local vibration related to snoring, the beginning of the slow progression toward OSA with comorbidities.”

• Guilleminault et al. (2016). A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. “A short lingual frenulum left untreated at birth is associated with OSAS at later age, and a systematic screening for the syndrome should be conducted when this anatomical abnormality is recognised.” 150 children with OSAS. “The two groups differed significantly in the anatomical description of the oral cavity (table 1), with the short frenulum group having significantly more frequent reports of a “high and narrow palatal vault” and scores of 4 on the Mallampati–Friedman scale (0–4) (p=0.0001), while the normal frenulum group had a significantly greater frequency of scoring ⩾4 on the Friedman tonsil scale (p=0.0001). The mean tonsil size score was 1.8 in the abnormal frenulum group versus 3.2 in the other children.” “speech problems were better recalled and were described as “lisp”, “stutter” or having led to speech therapy”

• Huang et al. (2015). Short Lingual Frenulum and Obstructive Sleep Apnea in Children.“One fact is clear: frenectomy for short lingual frenulum in isolation or following T&A helps but is commonly insufficient to resolve all abnormal breathing patterns during sleep when SDB is present. Myofunctional therapy, which has been previously demonstrated to allow return to normal nasal breathing may be needed post surgery.” “The existence of familial cases and the association with genetic syndrome suggest that presence of a short lingual frenulum may be part of a specific genetic predisposition, but no genetic study has been performed on familial cases of short lingual frenulum.” “In conclusion: children with SDB should be evaluated for a short lingual frenulum, and conversely, children with an abnormally short frenulum should be investigated for the presence of SDB. Frenectomy should be performed as early as possible but it may not be sufficient to restore normal nasal breathing function during sleep [28], particularly if the frenulum-related problem has lingered over years, and nasal breathing reeducation may be needed in these cases.”

• Huang & Guilleminault. (2013). Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. “Pediatric OSA in non-obese children is a disorder of oral-facial growth.”

NOCTURNAL ENURESIS (BEDWETTING)

• Choudhary et al. (2016). Association of Sleep Disordered Breathing with Mono-Symptomatic Nocturnal Enuresis: A Study among School Children of Central India. “findings suggest that it is imperative to rule out SDB in PMNE patients as they may require different therapeutic interventions.” “In this study, children with inappropriate toilet training, family history of enuresis in father and SRBD score >0.33 were found to have higher odds for developing PMNE” “ In the present study there is a threefold association between PMNE in the children and positive SRBD. The 22 item SRBD scale has been validated for use in research studies for the assessment of obstructive sleep apnea (OSA) and the instrument has shown good internal consistency and test retest reliability”

FERTILITY & GENDER DIFFERENCES 

• Tasali et al. (2008). Polycystic Ovary Syndrome and Obstructive Sleep Apnea. “PCOS women were 30 times more likely to have OSA than controls and that the difference between the two groups remained significant even after controlling for BMI.”… “About two third of these PCOS women had poor sleep quality as assessed by the Pittsburgh Sleep Quality questionnaire and 45% had chronic daytime sleepiness as defined by the Epworth Sleepiness Scale. Remarkably, less than 8% of this cohort of 40 women with PCOS were free of sleep complaints.”
• O’Brien et al. (2012). Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study. “New-onset snoring during pregnancy is a strong risk factor for gestational hypertension and preeclampsia.” “Snorers in general, as well as those with pregnancy-onset snoring specifically, were more likely to have chronic hypertension, gestational hyper-tension, and preeclampsia, than non- snorers. In contrast, although snorers were more likely to have gestational diabetes compared to nonsnorers, further analysis revealed that it was the chronic, not pregnancy-onset, snorers who appeared to drive this relationship”

• Tantrakul et al. (2012). Sleep-disordered breathing in premenopausal women: Differences between younger (less than 30 years old) and older women. “The younger premeonopausal women has less severe SDB with a trend towards upper-airway resistance syndrome.” “As a group, these premenopausal women often presented with non-classical symptoms of SDB such as insomnia and depression, and had a high percentage of cranio- facial findings on exam, mainly small and retrusive mandible and high, arched, and narrow palate. Abnormalities of the nose were common, particularly inferior nasal turbinate hypertrophy, and usually associated with a history of nasal allergies.” “Snoring or witnessed apnea are considered the hallmarks of SDB, but were often absent in this group, particularly in the younger age group…may be more frequently undiagnosed"

POSTURE 

• Pirilä-Parkkinen et al. (2011). Pharyngeal airway in children with sleep-disordered breathing in relation to head posture. “Head posture is an important factor in maintaining airway patency.” “When the head was in neutral posture children with sleep disordered breathing (SDB) had significantly narrower oropharyngeal airway space than control children.” “In SDB children, head flexion significantly decreased retroglossal airway area (RGCA) in relation to neutral and extended postures. In control children, intra-group differences between the RGCA measurements in different head postures were all significant.”
• Piccin et al. (2015). Craniocervical Posture in Patients with Obstructive Sleep Apnea. “In OSA subjects, the greater the severity of OSA, the greater the head hyperextension and anteriorization.” “The subjects in the group of mild and moderate OSA feature changes in craniofacial morphology, with shorter intermedi- ate pharyngeal space and greater distance from the hyoid bone to the mandibular plane, as compared with healthy subjects, suggesting a relationship between craniocervical posture and OSA.”
• Solow et al. (1984). Airway adequacy, head posture, and craniofacial morphology. “Obstructed nasopharyngeal airways… were, on the average, seen in connection with a large craniocervical angle and with small mandibular dimensions, mandibular retrognathism, a large mandibular inclination, and retroclination of the upper incisors."

OTHER

• Bista & Barkoukis (2012). Medical Disorders Impacted by Obstructive Sleep Apnea. “Research has shown a higher risk for several medical disorders, most ominous being a myocardial infarction or stroke. This article serves as an overview to the cardiovascular, cerebrovascular, metabolic, and gastroesophageal effects of OSA.” The list includes disorders such as: Systemic Hypertension, Myocardial Ischemia and Infarction, Cardiac Arrhythmias, Pulmonary Hypertension, Stroke, Diabetes Mellitus, Metabolic syndrome (abdominal obesity, triglycerides, high-density lipoprotein cholesterol, blood pressure, and fasting glucose), Gastroesophageal Reflux Disease.

Disorders of the TMJ or TMD can be caused by multiple factors, such as joint degeneration/damage, genetics, clenching and grinding (bruxism), problems with occlusion, and more. If you have been referred by your dentist/orthodontist and the cause of your pain is muscular we may be able to help.

• Le Kuex & Frapier (2021). Lingual treatment of an adult patient with an iatrogenic class II anterior open bite: Report of a case with a non-surgical orthodontic approach. A single case presentation “where a regrettable unsuitable splint for bruxism treatment forced an open bite to appear” In the end, "the occlusal balance with physiotherapy and patient compliance maintained the closure. … the iatrogenic effects of the poorly designed bite splint were repaired.”

• Fassicollo et al. (2020). Jaw and neck muscle changes in patients with chronic painful temporomandibular disorder disc displacement with reduction during chewing: Changes in jaw and neck muscle coactivation and coordination in patients with chronic painful TMD disc displacement with reduction during chewing. “Patients with chronic painful TMD-DDR during chewing presented changes in the jaw and neck muscles, with more compromised function of the former, which are specific to chewing.”
• Zharova et al. (2020). Rehabilitation of patients with facial nerve injuries after neurosurgical treatment. “Psychological conse- quences of facial muscles paresis are more important to the patient than physical damage. Paresis of the facial muscles cannot be hidden and often leads to social maladjustment, isolation and a marked decrease in the quality of life. Facial neuropathy in most cases is not a life-threatening condition, but it is definitely life changing. Motor defect in facial nerve neuropathy leads to cosmetic a defect that not only has a psychotraumatic effect on the patient, but also violates acts of chewing, swallowing, changes the phonation” “The combined use of physiotherapy, massage, therapeutic gymnastics, including posture treatment with taping, during the early period of the disease, allows restoring nerve function and maintaining mimic muscles, as well as avoiding undesirable complications.”
• Ferreira et al. (2014). Impaired orofacial motor functions on chronic temporomandibular disorders. “Impaired oro-facial functions and increased activity of the muscles of balancing sides during unilateral chewing characterized the altered orofacial motor control in patients with moderate-severe chronic TMD.
• Sanders et al. (2013) Sleep Apnea Symptoms and Risk of Temporomandibular Disorder: OPPERA Cohort. “a significant association of OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first-onset TMD.”
• Weber et al. (2013). Chewing and swallowing in young women with temporomandibular disorder. “TMD subjects showed a significant difference on tongue (p=0.03) and lip (p=0.04) posture during swallowing function, and a more frequent adoption of a chronic unilateral chewing pattern as well (p=0.03)... presented a lower position of the hyoid bone in relation to the mandible (p=0,00).”
• de Felício et al. (2010). Effects of Orofacial Myofunctional Therapy on Temporomandibular Disorders. “OMT had the following positive effects in treated patients: (a) a significant reduction of pain sensitivity to palpation of all muscles studied but not for the TMJs; (b) increased measures of mandibular range of motion; (c) reduced Helkimo’s Di and Ai scores, (d) reduced frequency and severity of signs and symptoms; and (e) increased scores for orofacial myofunctional conditions.”
• Masumoto & Fujumoto (2009). Daily chewing gum exercise for stabilizing the vertical occlusion. Volunteers “chew gum for 10-15 min before or after three meals daily for four weeks.” “after four weeks of exercise, anterior and posterior occlusal contact areas and forces were significantly (P < 0.05) increased and the increments were significantly (P < 0.05) higher in the anterior occlusal contact area and force than in the posterior occlusal contact area and force”

• Perkiömäki & Alvesalo (2008). Palatine ridges and tongue position in Turner syndrome subjects. This paper explored the relationship between tongue position and palate height in Turner syndrome (TS). “35% of persons with TS will likely have a high arched palate.” The study concluded, “the tongue position in TS females is low. The presence of prominent lateral palatine ridges is associated with a reduced palatal width.” Meaning, the tongue was down, the ridges were prominent, and the arch was high.  

• Grabowski et al. (2007). Interrelation between occlusal findings and orofacial myofunctional status in primary and mixed dentition: Part III: Interrelation between malocclusions and orofacial dysfunctions. “Lateral crossbite in mixed dentition, as well as increased overjet and frontal open bite in primary and early mixed dentitions appeared significantly more frequently in children with orofacial dysfunctions”

Picky eating is not uncommon, but children who struggle to eat may have weakness or discoordination of the muscles of the mouth or sensory concerns that are preventing them from eating easily. Your child may also have reflux symptoms that are worsened by their oral breathing pattern. If your infant or child has challenges with sucking, chewing, swallowing, or the sensory experience of eating, meal times might be unpleasant. This might look like “picky eating” or refusing food/bottles. The goal of feeding therapy is healthy habits and happy meal times! Want to learn more, check out Melanie Potock, a speech pathologist and amazing feeding coach. We are happy to consult with your current speech/feeding therapist to develop and refine an oral motor program or we can provide concurrent myofunctional therapy services focused on breathing, oral resting postures, and oral motor development.

• McCue et al. (2017). Gastrointestinal dysfunctions as a risk factor for sleep disorders in children with idiopathic autism spectrum disorder: A retrospective cohort study. “...children with GI dysfunctions had nearly twice the odds of having multiple sleep disorder symptoms … compared to children without GI dysfunctions.”

• Choi et al. (2016). Dietary habits and gastroesophageal reflux disease in preschool children. “Dietary habits such as picky and irregular eating, snack preference, a preference of liquid foods, late night eating, and a shorter dinner-to-bedtime interval had a significant correlation with GERD.”

• Merkel-Walsh & Overland (2016). Self-Limited Diets in Children with a diagnosis of Autism Spectrum Disorders. “The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD.”
• da Silveira et al. (2013). Influence of breastfeeding on children's oral skills. “It was found that breastfeeding contributed to mature orofacial as it improved the ability of oral suction.” “Pacifier use was shown to affect the functioning of the stomatognathic system. This should be made clear to parents and the use of pacifiers during infancy should be avoided.”
• Montgomery-Downs et al. (2007). Infant-feeding methods and childhood sleep-disordered breathing. “...breastfeeding may provide long-term protection against the severity of childhood sleep-disordered breathing.”

There are many diseases that commonly co-occur with speech, swallowing and myofunctional disorders, allergies and acid reflux are the most common. 

• Kung et al. (2019). Allergic rhinitis is a risk factor of gastro-esophageal reflux disease regardless of the presence of asthma. “We analyzed the data of 193,810 allergic rhinitis (AR) patients aged 18 years or older and being free of allergic rhinitis at baseline. The allergic rhinitis cohort had a significantly increased risk of GERD over a non-AR cohort AR may have stronger correlation with GERD than does asthma, although asthma might increase GERD risk by means of certain pathways shared with AR.”
• Choi et al. (2016). Dietary habits and gastroesophageal reflux disease in preschool children. “Dietary habits such as picky and irregular eating, snack preference, a preference of liquid foods, late night eating, and a shorter dinner-to-bedtime interval had a significant correlation with GERD."
• Fujiwara et al. (2012). Gastroesophageal reflux disease and sleep disturbances. “Clinical evidence strongly suggests that GERD is associated with sleep disturbances such as shorter sleep duration, difficulty falling asleep, arousals during sleep, poor sleep quality, and awakening early in the morning. New mechanisms on how GERD affects sleep have been recently identified by using actigraphy, and sleep deprivation was found to induce esophageal hyperalgesia to acid perfusion. Thus, the relationship between GERD and sleep disturbances is bidirectional.” “GERD patients with sleep disturbances report more severe symptoms and poorer quality of life as compared to those without sleep disturbances. Consequently, GERD should also be classified as GERD with sleep disturbance and GERD without sleep disturbance.”
• Farahmand et al. (2011). Cow’s Milk Allergy among Children with Gastroesophageal Reflux Disease. “A diagnosis of CMA was considered in one third of the pediatric cases with signs and symptoms of GERD. This finding shows that CMA can mimic or aggravate all signs and symptoms of severe GERD during infancy.” “In the present study, it has been shown that elimination of cow’s milk product in the patients with diagnosis of refractory GERD resolved the problems. It seems that cow’s milk product can either aggravate GERD symptoms (via dysmotility of gastrointestinal tract) or explain nonresponsive GERD to appropriate pharmacologic treatment.”
• Katle et al. (2011). Nose- and sinus-related quality of life and GERD. “Patients with GERD have a reduced nose- and sinus-related quality of life compared to a control group…” “Accordingly, this study indicates that there is a causal relationship between GERD and (CRS) chronic rhinosinusitis.”
• Bredenoord. (2010). Excessive belching and aerophagia: two different disorders. “Excessive and bothersome belching is a common symptom, which is often seen in patients with functional dyspepsia and gastroesophageal reflux disease.” “Excessive belching can be treated by speech therapy” “The most common symptoms in the patients with true aerophagia are bloating, abdominal distension, and constipation, while only a minority complains of excessive belching. A logical treatment for these patients would be speech therapy, with a different approach compared to the patients with excessive supragastric belching.”

REFLUX & AUTISM

• Yang et al. (2018). Are gastrointestinal and sleep problems associated with behavioral symptoms of autism spectrum disorder? “ASD children with GI symptoms reported more severe ASD core symptoms than others. Autistic children's GI symptoms were associated with maternal sleep problems during pregnancy, child's 0–6 month food sources and picky eating. ASD children with sleep disturbances had lower performance in daily living skills, social cognition, social communication and intellectual development than ASD children without sleep dis- turbances. Sleep disturbances were associated with extra nutrient supply during lactation and feeding, and child's picky eating. Autistic children with GI or/and sleep problems may represent clinically relevant subtypes of ASD, for which targeted treatments may be needed.”
• McCue et al. (2017). Gastrointestinal dysfunctions as a risk factor for sleep disorders in children with idiopathic autism spectrum disorder: A retrospective cohort study. “Our study found that GI dysfunctions increase the odds of reporting sleep disorders in children with idiopathic ASD, independent of age and gender. This study provides key evidence for clinicians as well as parents of children with ASD that suggests higher risk of sleep disorders among children with ASD who have GI dysfunctions. Sleep disorders further exacerbate autism symptomatology. Therefore, early intervention would be expected to result in significant improvement in long-term developmental outcomes in children with ASD.”

Want to learn more about anatomy and physiology, check out the following resources

• Sanders & Hu (2013) A Three-Dimensional Atlas of Human Tongue Muscles. This paper provides amazing images of the tongue musculature!
• SketchFab has an amazing color coded model of the muscles of the orofacial complex!
• The Neurosurgical Atlas A wonderful website with animated 3D models of the cranial and cervical structures, actual images of the neuroanatomy,  Grand Rounds and more.