The scope of this page is the identification and treatment of orofacial myofunctional disorders.
See the Orofacial Myofunctional Disorders Evidence Map for summaries of the available research on this topic.
Orofacial myofunctional disorders (OMDs) are patterns involving oral and orofacial musculature that interfere with normal growth, development, or function of orofacial structures, or call attention to themselves (Mason, n.d.A). OMDs can be found in children, adolescents, and adults. OMDs can co-occur with a variety of speech and swallowing disorders. OMD may reflect the interplay of learned behaviors, physical/structural variables, genetic and environmental factors (Maspero, Prevedello, Giannini, Galbiati, & Farronato, 2014).
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.).
Signs and symptoms of orofacial myofunctional disorders may include:
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:
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, 2016a), 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, 2016b), 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:
The SLP conducts intervention that is designed to (ASHA, 2004)
See the Assessment section of the Orofacial Myfunctional Disorders evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
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.
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:
A diagnostic written history and interview with the client or the parents/caregivers if applicable is conducted to help gather information regarding:
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:
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 Feeding and Swallowing 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:
Hale and colleagues (1992) found that slower rates in diadochokinetic tasks were associated with postural differences.
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.
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).
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.
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:
See ASHA's Practice Portal page on Speech Sound Disorders-Articulation and Phonology for more information.
See the Treatment section of the Orofacial Myofunctional Disorders evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
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).
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.
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.
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).
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.
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).
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.
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.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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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:
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/.