We are pleased to welcome Robyn Merkel-Piccini, MA, CCC-SLP, as
our guest host for the SLP chat tonight, Monday, March 29, 2004.
She will be addressing the topic of Tongue Thrust Therapy.

Robyn Merkel-Piccini is a Licensed Speech Pathologist with  years
of experience in the state of NJ. She is employed full time by the
Ridgefield Board of Education, in addition to her private practice in
Bergen County, NJ.  Robyn specializes in oral-motor and myofunctional
disorders in children. Her private practice focuses on oral-motor
disorders in children, particularly those within the autistic spectrum.
She conducts evaluations and Program Plans for children across the tri-
state area. Her publications include "SMILE (SysteMatic Intervention
for Lingual Elevation)", "Art Talk", "Handy Handouts", and co-author
of "Sensory Stix". Robyn teaches an ASHA CE approved Tongue Thrust class.

<Robin>  Welcome!  We are chatting tonight with Robyn Merkel-Piccini, MA, CCC-SLP, about the
          topic of Tongue Thrust Therapy/Myofunctional Therapy.
<Robyn-Merkel-Piccini>  Hi! I am so happy to be here, thanks for inviting me!
<Robin>  Robyn, please define tongue thrust and give us some background about myofunctional
<Robyn-Merkel-Piccini>  Tongue thrust is also known as a reversed swallow, or myofunctional
<Robyn-Merkel-Piccini>  The International Association of Oral-Facial Myology has a journal on
          the topic.
<Robin>  Please define reversed swallow.
<Robyn-Merkel-Piccini>  The tongue pushes forward and moves in and out.
<Robyn-Merkel-Piccini>  The desirable pattern is tongue tip elevation with the midsection of
          the tongue suctioning the palate.
<Robyn-Merkel-Piccini>  I have seen this disorder commonly in the public schools.
<Robyn-Merkel-Piccini>  It also causes dental issues such as open bite and overbite.
<Robyn-Merkel-Piccini>  The tongue is moves in a horizontal plane "in and out" rather than on
          the vertical plane.
<Robyn-Merkel-Piccini>  It is also associated with mouth breathing, ear infections, thumb
<Anna>  Wow, ear infections?
<Robyn-Merkel-Piccini>  Yes, children with chronic ear and upper respiratory issues have open
          mouth posture. This leads to a forward tongue posture.
<Robyn-Merkel-Piccini>  That is some basic information
<Robin>  How do you assess tongue thrust disorders?
<Robyn-Merkel-Piccini>  I always start by looking at basic oral-motor function.
<Robyn-Merkel-Piccini>  Jaw strength, lip closure, tongue movements, and of course analyze the
          actual structure of the mouth.  Dental alignment , the frenum, and the craniofacial
          structure are also essential.
<Robyn-Merkel-Piccini>  I look at "dissociation" if the tongue and lips and have independent
          movements from the jaw.
<Robyn-Merkel-Piccini>  Oral postures at rest are also important as well as mouth vs nose
<Robyn-Merkel-Piccini>  Another part of assessment is looking at placement of t-d-n-l-s-z.
<Robyn-Merkel-Piccini>  Most often interdental, or the lateral walls of the tongue push outward.
<rarara>  At what age is tongue thrust commonly identified? Are there specific demarcations
          between commonly observed symptoms and those with syndromes (e.g Downs Syndrome)?
<Robyn-Merkel-Piccini>  The tongue thrust pattern should be resolved by 24-26 months or by
          three years the latest according to Overland/Johnson oral-motor feeding norms.
          Tongue thrust identification can occur anytime after the age of three but most
          commonly is identified either in grade school (K-6 )when the child is identified for
          articulation issues, or after age 8 when the child seeks an orthodontic consult and
          it is revealed by the dentist/orthodontist that a tongue thrust is present. Today
          orthodontic intervention starts between the ages of 8-12.
<Robin>  Robyn, please tell us, what are the defining characteristics of a myofunctional
<Robyn-Merkel-Piccini>  Normal swallow = tongue tip elevation, palatal suction, back of tongue
<Robyn-Merkel-Piccini>  Tongue thrust = tongue blade pushes forward in a flat manner with
          interdenatlization or a low tongue tip posture.
<dave-g>  Robyn-when I started doing myofunctional therapy in the dark ages-we used to talk
          tongue thrust vs. reverse swallow.  Today I'm told no one believes the later exists.
          In the OLD days a tongue thruster was said to protrude the tongue tip.
<Robyn-Merkel-Piccini>  Yes forward protrusion of the tongue OR tongue tip. I have not heard
          that the term "reversed swallow" in a long time, but it is present in the literature.
          According to Dr. Robert Mason, a pioneer in oral-facial myology the correct term is
          TONGUE THRUST, reversed swallow was used but is not really a modern term.....as Mason
          puts it "the reverse of what exactly?"
<Robyn-Merkel-Piccini>  There are actually several types of tongue thrusts by orthodontic
          definition, but without pictures and dental terminology......
<dave-g>  The reverse swallower was claimed to hump the tongue.
<Robyn-Merkel-Piccini>  Yes, but the thruster can also anchor the tip and push the
          sidewalls/lateral margins against molars, still a thruster.
<dave-g>  Dental changes were different-buck teeth versus changes in lateral dentition.
<Robyn-Merkel-Piccini>  Picture the tongue of a thruster as a shovel, throwing food backward.
<Robyn-Merkel-Piccini>  Lateral thruster alters lateral dentition as opposed to frontal.
<dave-g>  Thanks for the clarification.
<Robyn-Merkel-Piccini>  The most common pattern SLPs see is a typical thrust pattern with
          overbite, overjet or openbite.
<dave-g>  Is there a difference in treatment?
<Robyn-Merkel-Piccini>  Essentially treatment is the same because you want tongue retraction
          with tip elevation and nice tight lateral wall tension.
<Robyn-Merkel-Piccini>  Frontal thrust =interdental lisp, lateral thrust = lateral lisp
<dave-g>  AHA
<Sera> How does this disorder impact eating and articulation?
<Robyn-Merkel-Piccini>  Tongue thrusters are often described by their parents as "sloppy eaters".
<Robyn-Merkel-Piccini>  Also I should mention if severe enough can suffer from oral phase
          dysphagia, not breaking the food down properly along with difficulty transferring the
<Sera>  thanks!
<Robyn-Merkel-Piccini>  A person with a myofunctional disorder has an abnormal swallowing
          pattern often associated with articulation errors and dental malocclusion.
<Robyn-Merkel-Piccini>  It is often associated with lisps, drooling, dental issues and
          r-l-s-z-t-d-n-sh-ch sounds.
<Robin>  So these sounds may be distorted?
<Robyn-Merkel-Piccini> Yes fricatives are often lateralized.
<rebecca>  Do children with frontal lisps always tongue thrust?
<Robyn-Merkel-Piccini>  Not neccesarily but most do.
<AdrienneFSU>  Is the tongue thrust a result of weakness or low muscle tone, or lack of
          coordination ?
<Robyn-Merkel-Piccini>  Absolutely ! Tongue thrust is essentially an oral-motor disorder.
<Robyn-Merkel-Piccini>  The sequence of the swallow is impacted, therefore it is a disorder
          involving motor planning.
<Robyn-Merkel-Piccini>  As for muscle tone, it is often misjudged as a hypotonia when in fact
          the wrong muscles are over/under developed.
<Robyn-Merkel-Piccini>  Many thrusters rely on jaw fixing, and use the jaw to do most of the
          work rather than the tongue.
<AdrienneFSU>  I see
<Robyn-Merkel-Piccini>  I also find overdevelopment of the muscles which push the tongue
          forward and weakness in those which help retract the tongue and help with tip elevation.
<Robin>  Robyn, tell us about therapy...how do you get started?
<AdrienneFSU>  Would you work on motor plans instead of traditional artic drills?
<Robyn-Merkel-Piccini>  I start with oral-motor exercises to develop jaw stability, lip closure,
          tongue retraction, and appropriate resting postures.
<Robyn-Merkel-Piccini>  I complement this with articulation drills which correspond to lip
          closure = m/p/b.
<Robyn-Merkel-Piccini>  I follow the Sara Johnson hierachies of bite blocks, horns, straws, etc.
<Robyn-Merkel-Piccini>  Before I work on the swallow itself, I ensure that the client has
          oral-motor capacity to be able to sequence the swallow.
<Anna>  I think the exercises are great and do work, but are certainly much more challenging
          in a group setting (ie school therapy).
<Robyn-Merkel-Piccini>  I work in a school full time.
<Robyn-Merkel-Piccini>  I take groups of 3, give an art lesson and then work with each child
          on their individual plan.
<Anna>  Okay, have yet to try because they all want to do oral motor exercises.
<rebecca>  In my school district we are not allowed to work with tongue thrusters.
<Robyn-Merkel-Piccini>  In some states dental hygienists are the primary practitioners of
          tongue thrust therapy.
<rarara>  Regarding Tx, can you tell the exact/subtle difference between orofacial
          myofunctional Tx and orofacial/oromotor Tx (is the principle of Tx same or different?)
<Robyn-Merkel-Piccini>  The principles in my research of this overlap, but you should know...
<Robyn-Merkel-Piccini>  My kids all do oral motor programs for lisps because I have found if I
          do not correct the oral-motor issues at the root of the disorder I do not make
          satisfactory progress with my kids at school.
<Robin>  Robyn, what prerequisite oral-motor skills are necessary in order to initiate
          myofunctional therapy techniques (jaw-structure)?
<Robyn-Merkel-Piccini>  "Myofunctional therapy" traditionally has a basis of working on the
          swallow to prevent dental maloclussion as is often prescribed by orthodontists.
<Robyn-Merkel-Piccini>  Jaw stability is crucial.
<Robin>  What if the client cannot sequence the swallow?
<Robyn-Merkel-Piccini>  I take them through each step to ensure that once we get to the
          swallow they can.
<Robyn-Merkel-Piccini>  My clients must master all levels of SRJ's bite blocks before I'll
          teach the "new swallow".
<Robyn-Merkel-Piccini>  Oral motor therapy encompasses speech-feeding not just "dental goals".
<rarara>  Please shed more information on this..Thanks!
<Pat>  I think myofunctional therapy entails more than oral motor, it includes all facial
<Robyn-Merkel-Piccini>  Yes tongue , lips, cheeks, etc. but most myofunctional programs
          primarily focus on the swallow itself.
<Robyn-Merkel-Piccini>  In some states dental hygienists are the primary practitioners of
          tongue thrust therapy.
<d-gross>  Robyn-then do you consider oral motor and dysphagia therapy as one and the same?
<Robyn-Merkel-Piccini>  No-oral motor is in the oral/facial phase, overlaps but dysphagia
          therapy may be in the pharyngeal phase too.
<d-gross>  Got it!
<Anna>  The same techniques work with adults though in remediation.
<Robyn-Merkel-Piccini>  sure !
<d-gross>  NDT for kids-grew out of work on adults.
<Robyn-Merkel-Piccini>  Yes NDT did, as oral-motor was taught to me in grad school for adults
          only but I use it on kids all the time.
<Robyn-Merkel-Piccini>  Getting back to myofunctional vs oral motor.....
<Robyn-Merkel-Piccini>  The IAOM clinical forum this year talked mostly about tongue, swallow,
          teeth, little on speech.
<Robyn-Merkel-Piccini>  In my opinion there is no speech therapist who does myofunctional work
          without addressing speech, but the dental hygienists who do myofunctional work can't
          address speech (out of scope of practice).
<Pat>  Yes, a speech therapist who does myofucntional work does also address speech, however,
          not all who need myofunctional work have articulation problems.
<Pat>  Myofucntional therapy does not include dysphagia.
<Robyn-Merkel-Piccini>  No, myofunctional therapy does not include dysphagia.
<Robin>  Ok, so myofunctional therapy focuses on the swallow while oral motor focuses on the
          swallow AND oral motor/artic-speech?
<Robyn-Merkel-Piccini>  Right, not often in sound but in placement (i.e. /t/ is made
<Robyn-Merkel-Piccini>  I have never seen a tongue thruster who has good placement for tongue
<Robyn-Merkel-Piccini>  I think the definitions are clearer, let's get into therapy, question
<Robin>  Robyn, do your therapy approaches differ between pre-school and elementary school-aged
<Robyn-Merkel-Piccini>  Yes, in preschool I work on everything but the swallow.  Three year
          olds can't effectively monitor their own swallow.
<Robyn-Merkel-Piccini>  I do many oral-motor and feeding tasks, straws, horns, gum, bite blocks,
<Robyn-Merkel-Piccini>  With older kids/adults I incorporate teaching not only the swallow but
          self-monitoring skills for saliva, liquids, solids, etc.
<Pat>  Approximately how long does your treatment last?
<Robyn-Merkel-Piccini>  It depends on the child, at 2x week with daily carryover at home,
          about 6-12 months.
<Robyn-Merkel-Piccini>  Homework is essential.
<AdrienneFSU>  I have found it difficult to measure progress without subjective measures. 
          What do you use to help you document the tx is working?
<Robyn-Merkel-Piccini>  I have a program that has a specific hierarchy with individual lessons.
<Robyn-Merkel-Piccini>  It has 14 lessons with data in each.
<AdrienneFSU>  Data based on what?
<Robyn-Merkel-Piccini>  Exercises, and the completion of them by set criteria, i.e "sip by sip
          swallows" must be at 90% before starting continuous straw drinking.
<Anna>  Once jaw strength and stability are developed, have you ever seen regression?
<Robyn-Merkel-Piccini>  Yes, some kids need maintenance especially those having orthodontic
          work or appliances.
<Robyn-Merkel-Piccini>  Kids with crossbites are the most challenging.
<Robyn-Merkel-Piccini>  Let me outline my therapy steps.
<Robin>  Great....thanks!
<Pat>  Would love to hear your therapy steps.
<Robyn-Merkel-Piccini>  Jaw, cheeks, lips, tongue protrusion, tongue retraction, tongue
          lateralization, tongue tip depression/elevation.
<Robyn-Merkel-Piccini>  Chewing, oral habits/rest, liquid swallows with straw, liquid swallows
          with cup, purees, solids, carryover.
<Robyn-Merkel-Piccini>  See above for hierrachy steps.
<Robyn-Merkel-Piccini>  This is obviously a condensed format.
<Robyn-Merkel-Piccini>  I work on oral-motor exercises first to estabilsh that placement and
          strength for each sequence of the swallow is intact first..........
<Robyn-Merkel-Piccini>  I like to use visual reminders, charting meals, charting saliva
          swallows, bedtime rituals.
<Pat>  Do you use tapes?
<Robyn-Merkel-Piccini>  Roberta Pierce recommended tapes, and they work nicely, but are not a
          part of my program.
<Pat>  What suggestions do you have for carryover?
<Robyn-Merkel-Piccini>  For example, I have my clients choose a color of the week and every
          time they see this color they must concentrate on the next 10 swallows.
<Robin>  great idea
<Anna>  great idea!
<Robyn-Merkel-Piccini>  Older kids love to pair swallows with favorite songs.
<Robyn-Merkel-Piccini>  I also use maintenece programs such as every day they have a series of
          exercises to do in the morning and in the evening to maintain motor planning,
                    strength and stability.
<Robyn-Merkel-Piccini>  Once the new swallow is learned and mastered in isolation I start to
          work on slowly transitioning this.
<Robyn-Merkel-Piccini>  Think of traditional artic, we do not do initial position of CV words
          and jump to phrases.
<Pat>  How long does your carryover phase last?
<Robyn-Merkel-Piccini>  It can last up to 6 months, especially if braces are in place and
          teeth shift.
<Robyn-Merkel-Piccini>  Also I require that the 2 top permanent teeth are grown down before
          teaching a swallow otherwise when they fall out major regression can occur.
<Robin>  good point
<Robin>  Robyn, you have been busy giving us information for an hour!  Is there anything else
          you'd like to share with us?
<Robyn-Merkel-Piccini>  Also I want you all to know that I have concerns about sippy cups and
<Anna>  What are rakes/cages?
<Robyn-Merkel-Piccini>  Orthodontic appliances cemented to the alveolar ridge which "prohibit"
          tongue thrusts.
<Robyn-Merkel-Piccini>  With the rake for example, kids are "supposed" to stop thumb sucking
          but they will just put the thumb elsewhere.
<Robyn-Merkel-Piccini>  Sippy cups provoke tongue thrusting, and I find rakes/cages to be
          obtrusive and they often do not correct a tongue thrust, just displace the contact
          points of teeth/tongue.
<rebecca>  Is that because kids suck from the sippy cups rather than drink from them?
<Robyn-Merkel-Piccini>  Sippy cups do provoke sucking rather than lip draw with tongue
          retraction for swallowing.
<Robyn-Merkel-Piccini>  Only really used in USA.
<Robyn-Merkel-Piccini>  Every SLP should have some basic knowledge on these things they are
          essential in tongue thrust is so imporatnt for SLPs.
<Robyn-Merkel-Piccini>  When I teach my tongue thrust class I spend much time on dentition.
<AdrienneFSU>  I believe ASHA says any work on myofunctional disorders should be done in
          consultation with a dentist.
<Robyn-Merkel-Piccini>  Interesting point on ASHA, but they do not say this with oral-motor
          issues and most tongue thrusters have OM issues as well.
<Robin>  Robyn, thank you for sharing your expertise with us!
<AdrienneFSU>  Thanks Robyn!!
<dave-g>  Thanks Robyn
<Sera>  thanks everyone, it has been very informative! Good NIght!
<Pat>  Thanks robyn
<rebecca>  Thank You Robyn
<Anna>  Thanks Robyn
<Robyn-Merkel-Piccini>  My pleasure, any time.
<Robin>  Robyn, thanks again....and thanks to all of you for joining us tonight.
<Robyn-Merkel-Piccini>  Good night !