The incidence of orofacial myofunctional disorders (OMD) refers to the number of new cases identified in a specified time period. The prevalence of OMD refers to the number of individuals who exhibit OMD at any given time.

Estimates vary according to the definition and criteria used to identify OMDs, as well as the age and characteristics of the population (e.g., orthodontic problems, speech disorders, etc.).

• Tongue thrusting (protrusion of the tongue between the teeth) during swallowing is estimated to range between 33% and 50.5% of the general population of school-aged children (Fletcher, Casteel, & Bradley, 1961; Gross et al., 1990; Hale, Kellum, Nason, & Johnson, 1988; Hanson & Cohen, 1973; Wadsworth, Maul, & Stevens, 1998).
• The presence of tongue thrusting (the protrusion of the tongue between the teeth) during swallowing is significantly related to age. Prevalence estimates are highest in preschool- and young school-aged children and lowest in adolescents (Fletcher, et al., 1961; Wadsworth, et al., 1998).
• Children with articulation disorders are more likely to exhibit a tongue thrust swallow (55.3%; Wadsworth, et al., 1998).
• Approximately 31% of children diagnosed with chronic mouth breathing (a common symptom of OMD) exhibit an articulation disorder (Hitos, Arakaki, Sole, & Weckx, 2013).
• Higher estimates are reported for individuals receiving orthodontic treatment (62% to 73.3%) or with dental malocclusions (Hale, Kellum, & Bishop, 1988; Stahl, Grabowski, Gaebel, & Kundt, 2007).
• In individuals with a temporomandibular disorder (TMD), the percentage of those with orofacial myofunctional variables is estimated to be 97.92% (Ferreira, Da Silva, & de Felicio, 2009).

Signs and symptoms of orofacial myofunctional disorders may include:

• Open mouth, habitual lips-apart resting posture (in children, adolescents, and adults)
• Structural abnormalities
  • Restricted lingual frenulum
  • Dental abnormalities, such as excessive anterior overjet, anterior, bilateral, unilateral, or posterior open bite, and under bite
• Abnormal tongue rest posture, either forward, interdental, or lateral posterior (unilateral or bilateral), which does not allow for normal resting relationship between tongue, teeth, and jaws, otherwise known as the interocclusal space at rest, or the freeway space (Mason, 2011)
• Distorted productions of /s, z/ often with an interdental lisp. Abnormal lingual dental articulatory placement for /t, d, l, n, ʧ, ʤ, ʃ, ʓ/
• Drooling and poor oral control, specifically past the age of 2 years
• Nonnutritive sucking habits, including pacifier use after age of 12 months, as well as finger, thumb, or tongue sucking (Warren & Bishara, 2002; Warren, et al., 2005; Zardetto, Rodrigues & Stefani, 2002)
• Lack of a consistent linguapalatal seal during liquid, solid, and saliva swallows.
• Interdental lingual contact or linguadental contact with the anterior or lateral dentition during swallows.

No single cause of orofacial myofunctional disorders has been identified, and its causes seem to be multifactorial. Anything that causes the tongue to be misplaced at rest limits lingual excursions within the oral cavity, makes it difficult to achieve acceptable lip closure, and reduces or impedes the ability to obtain and maintain correct oral rest postures leading to an OMD. The following factors may coexist and play a role in OMDs:

• Airway incompetency, due to obstructed nasal passages, either due to nasal structural obstructions (e.g., enlarged tonsils, adenoids, hypertrophied turbinates, and/or allergies, that do not allow for effortless inspiration and expiration) (Bueno, Grechi, Trawitzki, Anselmo-Lima, Felicio & Valera, 2015). These may result in upper airway obstruction and open mouth posture (Abreu, Rocha, Lamounier, & Guerra, 2008; Vázquez-Nava, et al., 2006), as well as an incorrect swallow pattern and mouth breathing (Hanson & Mason, 2003).
• Chronic nonnutritive sucking & chewing habits past the age of 3 years of age (Sousa, et al., 2014; Poyak, 2006; Zardetto, et al., 2002)
• Orofacial muscular/structural differences that encourage tongue fronting could include: delayed neuromotor development, premature exfoliation of maxillary incisors that encourage fronting of the tongue, orofacial anomalies, and ankyloglossia.

Orofacial myofunctional interventions are conducted by appropriately trained speech-language pathologists (SLPs), as part of a collaborative team. SLPs provide these services as members of interprofessional teams that may include the individual, family/caregivers, and other relevant persons (e.g., medical, dental, orthodontic personnel).

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. Additionally, clinicians should adhere to the Scope of Practice (ASHA, 2016), as well as local laws and regulations and employer standards to guide their practice.

According to the Preferred Practice Patterns (ASHA, 2004), the SLP conducts an assessment to identify and describe:

• Underlying strengths and deficits related to orofacial myofunctional factors that affect growth and development of the dentofacial structures, communication, and swallowing performance;
• Effects of orofacial myofunctional impairments on the individual's activities (capacity and performance in everyday communication and eating contexts) and participation;
• Contextual factors that serve as barriers to or facilitators of successful communication and participation for individuals with orofacial myofunctional impairments.

The SLP conducts intervention that is designed to (ASHA, 2004)

• capitalize on strengths and address weaknesses related to underlying structures and functions affecting the individual's orofacial myofunctional and swallowing patterns, as well as related speech patterns;
• facilitate the individual's activities and participation by assisting the person to acquire new orofacial myofunctional skills and strategies;
• modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation, and to provide appropriate accommodations and other supports, as well as training in how to use them.

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 tethered oral tissue(s) (TOTs), is a medical diagnosis. The decision to perform a frenectomy, frenotomy or frenuloplasty is a medical decision made on a case-by-case basis by dentists, oral surgeons, and otolaryngologists. As members of an interdisciplinary team, SLPs may be asked to provide input on the functional implications caused by a tongue-tie or help support medical necessity for surgery. If concerns regarding the frenulum's structure or function arise during an examination of the orofacial complex, a referral to a surgeon who has experience with frenectomies should be made. There is evidence that releasing a tongue-tie may improve breastfeeding function (Ghaheri et al., 2021; Buryk et al., 2011), and preliminary evidence continues to evolve regarding speech and feeding beyond the breast (Baxter et al., 2020; Ghayoumi-Anaraki et al., 2022). See ASHA's Practice Portal pages on Pediatric Feeding and Swallowing, Adult Dysphagia and Speech Sound Disorders.

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 Feeding and Swallowing 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.

The primary purpose of orofacial myofunctional therapy is to create an oral environment in which normal processes of orofacial and dental growth and development can take place, and be maintained (Hanson & Mason, 2003).

Establish Patent Nasal Airway

When structural or physiological impediments to nasal breathing, including allergies, have been ruled out or corrected via evaluations by an allergist and otolaryngologist (ENT), achieving lip closure at rest can serve to stabilize a nasal pattern of breathing. Closed mouth posture cannot be consistently established until any airway interferences have been successfully resolved (Hanson & Mason, 2003). In addition to adenotonsillectomy by an otolaryngologist and rapid maxillary expansion by an orthodontist, orofacial myofunctional services have been utilized to promote nasal breathing.

Improve Speech Sound Articulatory Placement

An incorrect oral rest posture of the tongue and lips can result in the tongue initiating speech productions from an abnormal rest position. In such situations, correcting the OMD can positively impact the correction of speech production errors.

When an OMD is related to an abnormal lingual or labial or mouth open behavior pattern that coexists with speech production errors, the articulation errors can be expected to be corrected more easily once the behavior pattern has been corrected in therapy.

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

Eliminate Nonnutritive Sucking

Prolonged nonnutritive sucking (e.g., pacifier, finger, and object sucking) is a risk factor for increased malocclusion (Farsi & Salama, 1997; Poyak, 2006; Sousa, et al., 2014; Zardetto, Rodrigues, & Stefani, 2002). The American Academy of Pediatric Dentistry (2014) suggested dentists offer parents and caregivers guidance to help their children stop sucking habits by the age of 3 years or younger. In contrast, orthodontists do not usually make referrals to eliminate a sucking habit until close to the time that the adult incisors begin to erupt (Proffit, 2000). According to orthodontists, sucking habits that persist during the primary dentition years have little, if any, long-term negative effects on the dentition, and generally result in malocclusion only if sucking habits persist beyond the time that the permanent teeth begin to erupt.

Parents and caregivers can be taught to ignore problematic behaviors and offer praise, positive attention, and rewards as their child engages in appropriate mouth behavior to help the child break the habit.

Dental professionals have observed a limited success rate with punitive dental habit elimination appliances (e.g., a rake, crib, or thumb guard). Moreover, these punitive appliances have been associated with excessive weight loss, pain, poor sensory perception, and development of atypical lingual movement secondary to the placement of these devices (Mason & Franklin, 2009; Moore, 2008).

Modify Handling and Swallowing of Saliva, Liquids, and Solids

Individuals with known OMDs may also demonstrate oral phase dysphagia which may require intervention. See ASHA's Practice Portal pages on Pediatric Feeding and Swallowing and Adult Dysphagia.

Therapeutic intervention can involve the selection of appropriate oral tools such as straws, lip or bite blocks, appropriate food items, etc. for jaw-lip-tongue dissociation needed for eating and drinking.

Oral Rest Posture

A primary goal of orofacial myofunctional therapy is to create, recapture or stabilize a normal resting relationship between the tongue, lips, teeth, and jaws. Individuals who demonstrate difficulties with the patency of their nasal airway often remain mouth breathers, and this further affects normal resting postures of the tongue, jaw, and lips (Harari, Redlich, Miri, Hamud, & Gross, 2010). When the resting dimension (freeway space) has been achieved and stabilized in therapy, dental stability should follow (Mason, 2011).

Achieving a lips-together rest posture is another goal of orofacial myofunctional therapy. Therapy to achieve lip competence helps to stabilize the vertical rest position of the teeth and jaws, and may also positively influence tongue rest posture (Mason, 2011). Exercises to improve lip closure may include holding a tongue depressor between the lips (Ray, 2003), use of a lip gauge (Paskay, 2006), smiling widely and then rounding lips alternately (Meyer, 2000), and lip resistance activities (Satomi, 2001).

Labial-Lingual-Pharyngeal Muscle Resistance Exercises

Exercises to improve tongue, lip, and jaw differentiation include oral tactile stimulation and tongue movements without assistance from the jaw, such as tongue tip to alveolar ridge or tongue clicks against the palate (Meyer, 2000). Isotonic and isometric exercises target the lips and tongue, in order to teach closed mouth resting posture and nasal breathing.

Service Delivery

Format refers to the structure of the treatment session (e.g., group vs. individual) provided.

Provider refers to the person offering the treatment (e.g., SLP, trained volunteer, caregiver).

Dosage refers to the frequency, intensity, and duration of service.

Setting refers to the location of treatment (e.g., home, community-based). OMDs are usually treated in a private practice, clinics or hospital settings. OMDs are not typically treated in public school settings. See ASHA's resource on Eligibility and Dismissal in Schools.

ASHA Resources

• Orofacial Myofunctional Disorders public page
• Assessment Tools, Techniques, and Data Sources

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• Ages and Stages
• International Association of Orofacial Myology (IAOM)
• Oral Motor Institute - OMI
• Orofacial Myology
• Speech Dynamics

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American Academy of Pediatric Dentistry. (2014). Guideline on management of the developing dentition and occlusion in pediatric dentistry. Clinical Practice Guidelines, 37(6), 253-265. Retrieved from http://www.aapd.org/media/policies_guidelines/g_developdentition.pdf

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Hanson, M. L., & Cohen, M. S. (1973). Effects of form and function on swallowing and the developing dentition. American Journal of Orthodontics, 64(1), 63-82.

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Martinelli,R.L.d.C., Marchesan, I. & Berretin-Felix,G. (2018). Posterior lingual frenulum in infants: occurrence and maneuver for visual inspection. Revista CEFAC, 20(4):478-483.

Mason, R. M., & Franklin, H. (2009). Position statement of the International Association of Orofacial Myology regarding: Appliance use for oral habit patterns. The International Journal of Orofacial Myology: Official Publication of the International Association of Orofacial Myology, 35, 74-76. Retrieved from http://www.suburbanmft.com/_pdf/Position%20on%20Oral%20Habit%20Appliances.pdf

Mason, R., & Proffit, W. (1984) The tongue thrust controversy: Background and recommendations. Journal of Speech and Hearing Disorders, 39, 115-132.

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Mason, R. (2011). Myths that persist about orofacial myology. International Journal of Orofacial Myology, 37, 27-38.

Mason, R. (n.d.A). For Dentists and Physicians. Retrieved from http://www.orofacialmyology.com/files/FOR_DENTISTS_AND_PHYSICIANS.pdf

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Messner, A.H., & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology Head and Neck Surg, 127(6), 539-545.

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Acknowledgements

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Orofacial Myofunctional Disorders page:

• Mary Billings, MS, CCC-SLP, COM
• Dianne Fonssagrives, MS, CCC-SLP, COM
• Honor Franklin, PhD, CCC-SLP, COM
• Patricia Grant, MA, CCC-SLP, COM
• Sandra Holtzman, MS, CCC-SLP, COM
• Gloria Kellum, PhD, CCC-SLP
• Robert Mason, DMD, PhD
• Patricia Taylor, MEd, CCC-SLP
• Elaine Wolkoff, MS, CCC-SLP, COM

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Orofacial Myofunctional Disorders. (Practice Portal). Retrieved month, day, year, from  www.asha.org/Practice-Portal/Clinical-Topics/Orofacial-Myofunctional-Disorders/.