Question
I have been providing speech services to a 15 year old student for articulation errors. Most of his problems are /r/ and /r/-blends; any production of the /r/ is distorted. He has been receiving speech and language services since he was 3 years old. He
Answer
On the basis of the information provided in your question, it would appear that the capabilities and deficits of this patient have not been fully evaluated with regard to use of his tongue. As a SLP, you are well equipped to evaluate whether the lingual frenum is short. Here is a simple four step method for evaluating the lingual frenum:
- LOOK AT THE ANATOMY. You may have to elevate the tongue tip with a tongue blade to get a good view. Does the connective tissue sheath of the frenum extend up to or onto the tip of the tongue? (If so, the frenum is likely to be short). Is the tissue sheath attached to the area just behind the lower incisors? (Also a sign of tongue tie, or ankyloglossia).
- EVALUATE PROTRUSION OF THE TONGUE. Some data are available if you care to measure tongue protrusion. Kotlow (1990, Qintessence International, 30:259-262) among others, established that a lingual frenum is acceptable when a completely protruded tongue measures over 16 mm from the lower incisors to the tip. Anything less than this would fall into a mild, moderate, or severe level of ankyloglossia. Is there a heart-shaped configuration of the tongue tip with maximum protrusion? This would also signal a short lingual frenum.
- EVALUATE THE ELEVATION OF THE TONGUE. Have your client touch the incisive papilla area with the tongue tip during various mouth openings. If your client cannot accomplish this task, and if all movements are restricted to the horizontal plane, this could signal a neuromotor problem. With mouth wide open, you may even note lateral connective tissue attachments that can restrict lateral elevation on one or both sides of the tongue.
- SWEEP THE VESTIBULE. Ask your client to perform a lingual sweep of the upper and lower dentition on both the labial-buccal and lingual sides of the anterior and molar teeth. The ability to perform a lingual sweep provides information about the range of movement of the tongue. As well, this movement is important for removing residue from the oral cavity. The importance of the tongue for oral hygiene is something that SLP's should address in evaluations of lingual function. If a client is unable to perform an acceptable lingual sweep, it is another indication that the frenum is short and may require surgical release and lengthening.
If this boy indeed has a short lingual frenum, "clipping" of the lingual frenum at age 15 is not the procedure of choice. While a simple clip or laser removal of tissue could be done by a general dentist on a very young child, these procedures are not employed for a 15 year old. A specialist would be needed and a referral to a surgeon may be appropriate after further evaluation. An oral-maxillofacial surgeon or plastic surgeon would perform a lengthening procedure (a Z-plasty or wedge elongation) at the base of the tongue. If your client does have surgery, it is recommended that stretching exercises for the frenum be initiated soon after. Check with the surgeon to determine if and when exercises are indicated.
You also mentioned that this boy also has "low tone" of the tongue. I'm not clear as to how this was evaluated, but I'll accept your evaluation. With reduced muscle tone, movements would be expected to predominate in the horizontal plane of space, and oral-motor stimulation to increase awareness and improve tonicity and control would be appropriate. If the lingual frenum is restricted, surgical evaluation should be accomplished prior to addressing "low tone". Traditional myofunctional exercises would then be appropriate.
Now lets talk about the /r/ and I'm going to include the /s/ here since these are the two most deviant sound productions seen in the school setting. Clinical teaching in speech-language pathology has historically contended that these sound are made with tongue tip up. As children try to master productions of /s/ and the retroflex /r/, many experience difficulties because these sound productions typically lack tactile feedback and instead, require proprioceptive or kinesthetic feedback for learning and stabilization. Speech sound learning via tactile feedback is much easier because of the large number of sensory receptors in the lips and tongue tip. As you may know, the sequence of learning speech sounds has a direct link to the distribution of sensory receptors from the lips to the palate (high level of innervation in the lips and tongue tip, low innervation of the palates and posterior tongue). Accordingly, it makes sense to tap into tactile feedback and to avoid kinesthetic feedback in learning /r/ (and /s/) where the client shows difficulty with vertical control of the tongue. Specifically, for /r/ and /s/, the target position in therapy for the tongue tip should be against the lingual surface of the lower incisors. A contact of tongue tip and lower incisors in therapy not only utilizes the horizontal plane of space, where this and almost all other children can function, but also provides a strong tactile feedback that can result in mastery of the sound productions. After this position is established, a contact against the incisors is no longer needed although the tongue tip down position is stabilized and maintained. The remaining task is to control the vertical opening at the front of the mouth. For /s/, children and even adults in therapy tend to open too wide for /s/, thus encouraging the tongue to front. Even for /r/, SLP's tend to work in therapy with a wider interdental opening than is needed. While an exaggerated opening for /r/ may be helpful, experimenting with different vertical openings for /r/ provides a strategy for change that may not have been attempted to date. It is sometimes helpful to cue the client to smile when making an /r/ sound rather than round the lips as in the production of /w/. Smiling can help to promote a less-wide open mouth position for /r/, especially when teaching a tongue tip down position.
Overall, it would appear that additional observations about the tongue of this 15 year old need to be collected, and a tongue tip down for /r/ productions might also be useful. Teaching a tongue tip down for /r/ and /s/ with a contact against the back of the lower incisors is a therapy strategy that can serve you well for selected patients, especially the 15 year old that you mention here. The oromotor therapy you have been using may be helpful as "diagnostic therapy" if you have been working on oral awareness to stimulate and elevate the tip and sides of the tongue; however, you mention using an assistive listening device. This suggests that your focus has been on acoustic feedback rather than changes in oral positioning. To me, the answers are in this teenagers mouth, as there are untold stories there that need to be further evaluated.
Robert M. Mason, DMD, Ph.D. is a speech-language pathologist (CCC-ASHA Fellow), a dentist, and orthodontist. He is a Past President of the American Cleft Palate-Craniofacial Association, a professional, interdisciplinary organization specializing in problems associated with facial and oral deformities. Dr. Mason has studied and written extensively about orofacial examination, developmental problems related to the tongue, and the anatomy and physiology of the speech and hearing mechanisms. His reports have appeared in speech, dental, medical, and plastic surgical journals and texts. He is considered to be an expert in tongue thrusting, tongue tie, and other problems related to tongue functions and speech.