COVID-19 UPDATES: Find news and resources for audiologists, speech-language pathologists, and the public. 
Latest Updates | Telepractice Resources | Email Us | Chat With Action Center

Orofacial Myofunctional Disorders

See the Assessment section of the Orofacial Myfunctional Disorders evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Comprehensive Assessment

Please see ASHA's resource, Assessment Tools, Techniques, and Data Sources, for information on the elements of a comprehensive assessment, considerations, and best practices. Information specific to these practices in the comprehensive assessment of individuals with OMD is discussed below.

Interdisciplinary Team

Assessment of orofacial myofunctional disorders has many possible aspects, which often require an integrated team approach. The SLP should refer and collaborate with other professionals who may include one or more of the following:

  • Allergist
  • Certified Orofacial Myologist
  • Dentist
  • Oral surgeon
  • Orthodontist
  • Otolaryngologist
  • Physician
  • Plastic surgeon
  • Physical therapist
  • Sleep Apnea Specialist

Case History

A diagnostic written history and interview with the client or the parents/caregivers if applicable is conducted to help gather information regarding:

  • Birth and developmental history
  • Oral habits (e.g., thumb, digit, pacifier, object sucking, etc.)
  • Prior Intervention (e.g., surgery, lactation, physical therapy, occupational therapy, speech-language pathology services, etc.)
  • Respiratory habits (e.g., nasal breathing vs. mouth breathing)
  • Medical history of conditions that might affect oral function including:
    • Upper respiratory infections/allergies
    • Ear infections/myringotomy
    • Allergies – environmental and food influences
    • Injuries or trauma
    • Snoring and sleep habits
    • Use of sleep appliance such as CPAP (continuous positive airway pressure) device
    • Previous surgery history, such as (frenectomy, tonsillectomy and/or adenoidectomy, or maxillofacial orthognathic (jaw) surgery
  • Dental/Orthodontic history
    • Palatal expansion
    • Orthodontic appliances and treatment plan
    • History of temporomandibular joint dysfunction (TMD)
  • Feeding History
    • Tendency to drink liquids to assist swallows.
    • Chewing with mouth open; noisy eater; messy eater; excessively slow eater; unusually small bites;
    • belching excessively after meals
    • Dislike for foods with textures that require increased oral manipulation and chewing, such as meats, other chewy foods.
  • Speech & Language History
  • Hearing history

Assessment of the Orofacial Complex

The clinician will visually examine the client for structural differences/abnormalities (e.g., proportion and symmetry) of the orofacial complex (including face, nose, eyes, ears, mouth,-skull, and profile). Particular attention should be paid to:

  • symmetry of movement of oral structures (lips, jaw, tongue, velum)
  • abnormalities of the tongue (e.g., macroglossia, microglossia, ankyloglossia, fasciculations) (Merkel-Walsh & Overland, 2017), including asking client to lift lateral lingual edges to visually assess frenulum (Martinelli, Marchesan, Berretin-Felix, 2018)
  • size of tonsillar tissue with regard to airway (obstruction of airway will force tongue to move forward, creating an obligatory forward placement of the tongue)
  • the configuration of the hard and soft palates
  • status of the dentition, including occlusion
  • tactile sensitivity outside and inside the mouth

Ankyloglossia, also referred to as tongue-tie or short frenulum, is a medical diagnosis. The decision to clip or not clip the frenulum to treat tongue-tie is a medical decision made on a case-by-case basis by physicians and dentists. As members of an interdisciplinary team, SLPs may be asked to provide input. If concerns regarding the frenulum’s structure or function arise during an examination of the orofacial complex, a referral to a physician or other medical profession should be made. There is evidence that division procedures improve breastfeeding function (Buryk, Bloom, & Shope, 2011), but limited data indicating the link between tongue tie, division procedures (i.e. clipping), and speech sound production outcomes (Chinnadurai, et al., 2015; Meaux, Savage, & Gonsoulin, 2016; Messner & Lalakea, 2002; Queiroz Marchesan, 2004; Webb, Hao, & Hong, 2013). See ASHA’s Practice Portal pages on Pediatric Dysphagia and Adult Dysphagia.  

While awareness of a malocclusion may be useful to the clinician, please note that diagnosing malocclusion is not within the SLP’s scope of practice. Malocclusions include the following:

  • Abnormal/Excessive anterior overjet often associated with Class II Division 1 malocclusion.
  • Excessive overbite, often associated with Class II division 2 malocclusion (upright maxillary central incisors and facially blocked upper lateral incisors).
  • Excessive anterior position of the lower jaw and teeth, creating a negative anterior overjet in some individuals with Class III malocclusions.
  • An open bite (lack of normal vertical overlap of teeth) that may occur anteriorly or posteriorly, on one or both sides of the dental arches.
  • Dental cross bites may involve a single upper tooth or a segment of upper teeth being positioned lingual to lower teeth. A cross bite in the posterior dental arch may occur unilaterally or bilaterally.
Diadochokinetic Tasks

Hale and colleagues (1992) found that slower rates in diadochokinetic tasks were associated with postural differences.

  • On single-syllable /pʌ/ measure, slower rates were associated with open-mouth postures
  • During trisyllabic /pʌtʌkʌ/ measure, slower rates were correlated with dentalized postures of the tongue

Many clients with OMD may have difficulty disassociating the tongue from the mandible, leading to imprecise speech. They may be able to easily pass the diadochokinetic assessment task compensating with the mandible rather than the tongue.

Oral Rest Posture

The typical rest posture consists of the lips closed, nasal breathing, teeth slightly apart, and the tongue tip resting against the anterior hard palate, at the lower incisors, or overlying gingiva. A forward tongue resting position or tongue tip protruding between anterior teeth can impede normal teeth eruption and result in anterior open bite (Mason and Proffit, 1984; Mason, 1988).

Difficulty achieving lip closure, or closure with accompanying muscle strain, could be related to the presence of lip incompetence -- abnormal lips-apart rest posture in children, adolescents, and adults (Mason, n.d.B). This is often due to unresolved airway interferences (e.g., allergic rhinitis, enlarged tonsils, etc.) and is associated with mouth breathing, dental changes, and speech production errors.

Lips-apart mouth posture is normal and age-appropriate before the lips are fully grown (Mason, n.d.B). The child’s oral mechanism, including the lips, tongue, and jaw, continues to grow and change into the teenage years (Vig & Cohen, 1979), with most individuals able to achieve lips-together resting posture around approximately 12-13 years (Mason, n.d.B; Vig & Cohen, 1979). However, some clinicians may address lip closure before this age, to avoid possible structural changes to the orofacial complex (Harari, Redlich, Miri, Hamud, & Gross, 2010;  Hitos, Arakaki, Sole, & Weckx, 2013;  Ovsenik, 2009).

Swallowing

Observe the client’s tongue and lip movements in the handling and swallowing of saliva, liquids, and foods. During the initiation phase of a client’s swallow, watch for the presence of an abnormal forward or interdental protrusion of the tongue tip. Tongue tip pressures exerted against the anterior teeth during swallowing are insufficient in duration to move teeth (Mason & Proffit, 1984; Proffit, 2000). Impaired chewing and anterior bolus loss are additional swallowing problems commonly associated with OMDs (Ray, 2006). The clinician may also note if the mentalis muscle or lower lip are being used to retain liquid contents, lack of hyoid excursion during the swallow, and lack of movement of masseters on palpation during swallowing.

See ASHA’s Practice Portal pages on Pediatric Dysphagia and Adult Dysphagia for more information.

Speaking/Articulation

Differentiation between developmental speech sound disorders (i.e., phonological processing), disorders of motor planning (i.e., Childhood Apraxia of Speech) and muscle-based speech sound disorders often present in OMD is critical. Assessment should focus on the placement of the articulators and the rest postures of the tongue, lips, and mandible when evaluating the speech of OMD clients. Differential diagnosis of a speech sound disorder should drive treatment methodology (Ray, 2003).

Imprecise articulation may be related to the inability to separate/differentiate the mandibular and lingual excursions within the oral cavity and the incorrect resting posture of the tongue and mandible. This incorrect resting posture becomes the location from which speech production begins and ends. Unless addressed prior to initiating traditional speech therapy approaches, the habitual resting pattern will continue to interfere with habituation of the desired sounds.

The SLP evaluates:

  • the resting position of the tongue, mandible and lips during pauses in conversation.
  • the placement of tongue for /t/, /d/, /n/, and /l/. Imprecise articulation may be noted for these phonemes, and are sometimes erroneously referred to as mumbling or lazy speech.   
  • any deviations of the jaw during connected speech.
  • specific errors of articulation: /s/, /z/, / ʃ /, / t ʃ /, / ʒ /, /dʒ/. Note if they are produced interdentally, produced with lateralization, or noticeably against the upper or lower anterior dentition.
  • /r/ distortion.
  • distortion of velar sounds /k/ /g/, and /ŋ/.
  • lack of posterior retraction of tongue on production of /r/, /k/, /g/, and /ŋ/.
  • weak bilabial productions, including vowels and diphthongs.
  • nasal quality of vowels (i.e., hypernasal or hyponasal). A chronic hyponasal voice quality suggests the presence of an upper airway interference and the need for ENT and allergy workup.

See ASHA’s Practice Portal page on Speech Sound Disorders-Articulation and Phonology for more information.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.