Question
Do you have any suggestions for remediating tongue thrust?
Answer
Tongue thrust, otherwise known as an infantile or reverse swallow pattern, refers to a swallowing movement where the tongue moves forward to approximate the lower lip. It also refers to labial and lingual resting postures. The resting tongue posture is characterized by a forward carriage of the tongue with the tongue tip pressed against, or carried between, the anterior teeth. The lips maintain an open resting posture, or an open mouth posture, which facilitates the forward tongue carriage. Often other myofunctional variables are associated with the tongue thrust, all of which may lead to dentofacial developmental differences that could have negative dental, speech, and psychosocial consequences. Management of the tongue thrust, therefore, requires a team approach and may include a dentist, orthodontist, physician, and a speech pathologist. Variables that must be addressed by the team sometimes include: (a) anatomical differences (high narrow palatal vaults, malocclusions, restricted frenulums, and lip incompetencies), (b) oral behaviors (thumb/finger/pacifier sucking, licking the lips, teeth grinding, and mouth breathing), (c) medical conditions (obstructions to the airway, and upper respiratory complications), and (d) associated speech problems (lalling and lisping behaviors).
With the understanding that a tongue thrust may be accompanied by many complicating factors that need to be addressed by a team, some specific behavioral activities designed to remediate the above defined tongue thrust often addressed by the speech language pathologist, may include the following: (a) education regarding the importance of proper tongue and lip postures when at rest and when swallowing, (b) awareness training to establish appropriate resting postures for the lips and tongue, and (c) exercises to develop an appropriate swallow movement. A few of my favorite procedures are explained below.
- Education: Tell the student and the parent that proper tongue placement and lip closure at rest is very important for proper dental-facial growth and development. Our tongue is a very strong muscle, and if carried against or between the teeth, it can easily alter our dentition over time. Our lips are also muscles that help hold the teeth in their proper position and must remain closed when at rest in order to do their job effectively. Correcting the constant resting posture of the tongue between or against the teeth is probably the most important objective of tongue thrust therapy.
- Awareness training: The student must become aware of proper placement of the tongue tip when a rest and when initiating the swallow pattern. The following exercises may be helpful in achieving this objective:
a.) The clinician touches the anterior portion of the alveolar ridge (right behind the upper central incisors) using a cotton swab or a tongue depressor. The student is asked to locate and hold the tongue depressor or cotton swab on the "spot" 5-10 times for several seconds at a time. Another similar activity involves the student holding a tiny dental rubber band between his/her tongue tip and alveolar "spot" for several minutes, rest, and then repeat the holding procedure several times in order to insure awareness for the tongue tip's correct resting position.
b.) Homework: The student is encouraged to continue heightening his/her awareness of proper tongue placement using the dental rubber-band exercise periodically during the day.
c.) The student must become aware of proper lip closure when at rest. Remind the student to keep his/her lips closed (within their structural limitations) when at rest. Catch the student "being good". A good reinforcement schedule is identifying 5 good behaviors to every 1 correction. Use age appropriate cues to help remind the student to keep his/her lips closed when at rest.
d.) Homework: Carry reminders, chart closed-lip behaviors. - Establishing a swallow pattern: My favorite procedure, perhaps a little messy but very effective, is "trapping the tiny sip" exercise.
a.) Educate the student by explaining the correct swallow pattern. Explain that the food or water to be swallowed should be tightly trapped between the tongue and the roof of the mouth. The tongue tip is placed on the "spot" with the sides of the tongue lifted to approximate the roof of the mouth. When we swallow, the tongue slightly moves back pushing the food posteriorly into the esophagus. The lips should remain closed and relaxed during the swallow.
b.) Demonstrate what happens with an incorrect swallow. Have paper towels ready and a small basin to catch water spillage. Tell the student that you are going to show them what happens when the tongue moves forward instead of back as it should during the swallow. Take a very tiny (and I mean tiny) sip of water, trap the water between your tongue and alveolar ridge, then pull you lower lip down with your gloved index finger so the student can view the swallow behavior. Swallow letting your tongue come forward such that the trap is slightly released. Water should drip out the corners of your mouth (remember you have your lips apart so they can see the swallow). The student will quickly see that the forward movement of the tongue pushes the tongue and water forward rather than back.
c.) Demonstrate the correct swallow, holding the lower lip down but keep the lips relaxed. Show that no water spills from the corner of the mouth. In addition, alert the student to the fact that the lips are relaxed with little or no movement (no lip pursing) during the swallowing behavior. Tell the student that performing this exercise helps them to establish the correct tongue placement for the swallow movement.
d.) Homework: Since this exercise may be embarrassing to practice in front of the clinician the first time due to water spillage, especially for the older student, you might ask them to try it in the privacy of their home, in front of their bathroom mirror following the initial demonstration. Most students learn to trap the water correctly very quickly in order to prevent the spillage. Let them show you their success the next time you see them. Sometimes younger students are very willing to make their first attempt in your presence. If they are, find the success in their attempt. Tell them you are sure they will be able to accomplish the task very quickly.
e.) Continued practice: Once the student can demonstrate "trapping the tiny sip", there is no longer any need to pull the lip down during the swallow to see proper tongue placement. Instead, they now need practice keeping the lips closed and relaxed during the swallow. Once sufficient success is achieved, ask the student to perform the swallow movement with other foods beginning with soft foods like pudding, and then on to more solid foods that require chewing.
f.) Homework: Chart meals. Ask the student to begin to identify which meals they intend to make conscious attempts at using the correct swallow pattern. Request reports of his/her success.
g.) Alternative procedure: Practice the following sequence. Trap the liquid or food as instructed above, bite down on the back of the teeth, smile, and push the substance back to complete the swallow. Request feedback from the student. Make a list of the sequence above. Chart or check-off the sequence of steps as they are completed correctly with each swallow.
There are numerous Internet sites on tongue thrust providing information, exercises, and available programs. There is also a published program The Tongue Thrust Book, which contains exercises for correcting the tongue thrust. Below are a few sources that contain lists of exercises for tongue thrusts.
Hanson, M. L., & Barrett, R. H. (1988). Fundamentals of Orofacial Myology. Springfield, Il: Charles C. Thomas.
Pierce, R. B. (1982). Swallowing right: A program for the corrections of the deviate swallowing pattern in young children (3rd ed.). Huntsville, Al: Swallow Right.
Richardson, M. (2003). The Tongue Thrust Book (2nd ed.). Austin, TX: Pro-Ed.
Zante, S. M. (1994). Treatment and compliance methods. In Michelle Ferketic and Kirsten Gardner (Eds.). Orofacial Myology: Beyond Tongue Thrust (pp. 41-44). Rockville, MD: American Speech-Language-Hearing Association.
Zickefoose, Wickefoose (1989). Techniques of oral myofunctional treatment. Sacramento, CA: O.T.M. Materials.
Bibliography
Kellum, G. D., (1994). Overview of Orofacial Myology. In Michelle Ferketic and Kirsten Gardner (Eds.), Orofacial Myology: Beyond Tongue Thrust (pp.1-10), Rockville, MD: American Speech-Language-Hearing Association.
Zante, S. M. (1994). Treatment and compliance methods. In Michelle Ferketic and Kirsten Gardner (Eds.). Orofacial Myology: Beyond Tongue Thrust (pp. 41-44). Rockville, MD: American Speech-Language-Hearing Association.
BIO:
Michelle G. Harmon, Ph.D. CCC-SLP
Associate Professor
Mississippi University for Women
P.O. Box W-1340
Columbus, MS 39701
Office: 662-329-7265
mharmon@muw.edu
