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Orofacial myofunctional therapy with children ages 0-4 and Orofacial myofunctional therapy with children ages 0-4 and
individuals with special needs individuals with special needs
Robyn Merkel-Walsh
Suggested Citation
Merkel-Walsh, R. (2020). Orofacial myofunctional therapy with children ages 0-4 and individuals with special needs.
International Journal of Orofacial Myology and Myofunctional Therapy,
46(1)
, 22-36.
DOI: https://doi.org/10.52010/ijom.2020.46.1.3
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International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
22
OROFACIAL MYOFUNCTIONAL THERAPY WITH CHILDREN
AGES 0-4 AND INDIVIDUALS WITH SPECIAL NEEDS
Robyn Merkel-Walsh, MA, CCC-SLP/COM® TalkTools®
ABSTRACT
Purpose: The purposes of this paper are to 1) define variations in terminology and treatment
methodology for orofacial myofunctional disorders (OMDs) in children 0-4 years of age and in
special populations, and 2) compare and contrast service delivery models for children ages 0-4 and
individuals with special needs versus older children and children who are neurotypical. Method: A
literature review of scholarly articles, professional presentations, poster presentations, blogs, and
social media were analyzed using three tiers of evidence-based practice to include: 1) clinical
expertise/expert opinion; 2) external and internal evidence and 3) client/patient/caregiver
perspectives. Results: Professional texts and publications used consistent language when
discussing treatment of OMDs in young children and children with special needs. Terminology and
treatment approaches for young children and/or children with special needs who present with
OMDs were inconsistent in social media and professional presentations. Discussion: The
treatment modalities used in orofacial myofunctional therapy to stimulate oral motor responses
depend upon age and cognitive status. OMDs should certainly be treated in infants, young children
and individuals with special needs according to the methods of the pediatric feeding specialist.
Orofacial myofunctional therapy requires volitional control and self-monitoring; as such, it is
contraindicated for infants and toddlers as well as those individuals who cannot actively engage in
therapeutic techniques.
KEYWORDS: orofacial myofunctional disorder, orofacial myofunctional therapy, evidence-based
practice, tethered oral tissue, dysphagia, feeding, scope of practice
INTRODUCTION
It is understood that orofacial myofunctional
disorders (OMDs) can occur across the
lifespan. It is important, however, to
understand that the treatment of OMDs varies
based on the age and/or the cognitive ability of
the patient. The semantics of treatment
modalities are important. They help both
professionals and the public understand the
nature of services delivered and received. The
Oral Motor Institute, founded by Pamela
Marshalla and Diane Bahr, developed
monographs to ease the confusion regarding
these important therapy modalities (Bahr,
2008; Marshalla, 2007, 2008). Oral motor
therapy is an umbrella term with various
associated treatment methodologies including
oral sensory-motor, orofacial myofunctional
therapy (OMT/OFMT/MFT), pre-feeding and
oral placement therapies. Bahr and Rosenfeld
(2010) made an effort to define these terms
and provide clarity to differentiating evidence-
based therapy from non-speech oral motor
exercises.
Defining Orofacial Myofunctional Disorders
According to the definition by the International
Association of Orofacial Myology (IAOM), an
OMD includes one or more of the following:
abnormal labial-lingual rest posture,
bruxism (teeth grinding), poor nasal
breathing, tongue protrusion while
swallowing, poor mastication and bolus
management, atypical oral placement
for speech, lip incompetency and/or digit
habits and sucking habits (such as nail
biting). These conditions can co-occur
with speech misarticulations. In these
instances, the articulation disorder is not
developmental or phonological in
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
23
nature, but rather a result of poor oral
placement and inappropriate muscle
development. OMD may reflect the
interplay of functional behaviors,
physical/structural variables, genetic,
and environmental factors. (Billings et
al., 2018, p. 1; Doshi & Bhad-Patil,
2011; Hanson & Mason, 2003).
D’Onofrio (2019) went on to define that an
OMD includes “dysfunction of the lips, jaw,
tongue, and/or oropharynx that interferes with
normal growth, development, or function of
other oral structures, the consequence of a
sequence of events or lack of intervention at
critical periods that result in malocclusion and
suboptimal facial development” (p. 1). Both
definitions point to the fact that 1) OMDs occur
across the lifespan; 2) OMDs are the nexus of
function and structure; 3) the diagnosis
considers the interaction of how atypical
movement patterns result in structural
changes; 4) and how structural anomalies
impact functional skills. Billings and colleagues
(2018) pointed out that OMDs can be seen in
newborns, infants, and toddlers. Given that
children in the 0-4 age range may present with
OMDs, clinicians must be able to identify
symptoms of the OMD and know what
methods are appropriate to treat it. Oral motor
and feeding therapy are consistently cited as
appropriate methods as described below.
There are many citations in the literature that
reference therapeutic techniques with this
population. For example, in the text Nobody
ever told me (or my mother) that! Everything
from bottles and breathing to healthy speech
development!, Bahr (2010) describes specific,
detailed assessment measures and therapeutic
strategies for infants and children and toddlers
including those with special needs. Several
years thereafter, Overland and Merkel-Walsh
(2013) carefully outlined oral motor normative
data and a task analysis approach to feeding
assessment and remediation. The co-authors
later penned a text (2018) specifically related
to Tethered Oral Tissues (TOTs), otherwise
known as lingual, lip and buccal ties. Specific
assessment and therapeutic strategies with the
use of tactile and oral sensory-motor cues
were suggested to work from passive to active,
depending on the age and cognitive status of
the patient. Tables 1 through 4 list the many
signs and symptoms of OMDs in these
populations according to the available
literature.
TABLE 1: FEEDING AND SWALLOWING
x Aerophagia (excessive swallowing of air while feeding)
x
Deficits in oral motor development such as not integrating the rooting reflex
or failure to develop a rotary chew
x Difficulties with oral preparation or oral transit including tongue thrust
swallow, poor or inefficient chewing, messy eating, and/or audible eating
x Difficulties with suck-swallow-breathe coordination
x Difficulty nursing
x Difficulty transitioning from breast/bottle to straw/cup
x Difficulty transitioning to pureed and/or solid foods
x Failure to Thrive
x Gagging/vomiting before or after meals
x Immature or disordered swallowing patterns
x Inadequate mastication
x Picky eating habits
x Poor latch during breast- or bottle-feeding
x Prolonged hard-spout sippy cup usage
x Prolonged sucking habits
x Self-limited diet
x Tongue protrusion past the lower lip during feeds
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
24
TABLE 2: ORAL HABITS
x Bruxism (teeth grinding)
x Daytime breathing habits including open mouth posture and audible breathing
x Excessive mouthing of objects
x Low jaw posture
x Nail biting
x Open mouth posture at rest
x Prolonged non-nutritive sucking habits
x Tongue protrusion past the lower lip at rest
x Tongue suckling/sucking
TABLE 3: STRUCTURAL and MEDICAL
x Airway obstruction including sinus congestion, enlarged tonsils and adenoids and enlarged
turbinates
x Crowded teeth
x Dental malocclusion (overbite, open bite, overjet, deep bite etc.)
x Deviated septum
x Diastemas of teeth (spaces between the teeth)
x Differential dental eruption
x Dry lips
x
Genetic syndromes which are associated with dental malocclusions and/or hypotonia (such
as Down syndrome)
x High vaulted palate
x Lip blisters
x Narrow palate
x
Nighttime breathing habits including restless sleeping through the night, nocturnal bruxing,
and enuresis
x
Neurological disorders (i.e. degenerative diseases in the elderly or developmental sensory -
neural delays)
x Orofacial hypotonia
x Poor lingual range of motion
x Poor oral hygiene
x Sleep apnea
x Sleep disordered breathing
x Tethered oral tissues (TOTs, tongue, lip and /or buccal ties)
x To ng ue sc al lo pi ng
x Torticollis
x Torus palatinus
x Upper Airway Resistance Syndrome (UARS)
x Xerostomia (dry mouth)
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
25
TABLE 4: SPEECH
x Atypical speech sound elicitations with abnormal lingual dental articulatory placement for /t,
d, l, n/ due to low forward tongue position, ankyloglossia and/or atypical swallowing
x Challenges with palatal sounds which require back tongue side sprea
d such as /ʧ, ʤ, ʃ, ʓ, r/
secondary to ankyloglossia, high vaulted palate, hypotonia or inability to stabilize the
tongue blade with elongation of the lateral margins of the tongue
x Distorted productions of /s, z/ often with an interdental or lateral lisp correlated with a
tongue thrust swallowing pattern and/or ankyloglossia
x Fronted velar phonemes /k, g/ due to ankyloglossia, low forward tongue carriage and/or
weakness with lingual retraction
x Hyper- or Hypo- nasal speech
x Lateralized air emission on all fricative and affricative phonemes
x Poor overall intelligibility
x
Weakness for bilabials and labiodentals due to inadequate lip closure, open mouth posture,
lip tie and /or labial insufficiency
TREATMENT OF OROFACIAL
MYOFUNCTIONAL DISORDERS IN
INFANTS AND CHILDREN AGES 0-4
AND INDIVIDUALS WITH SPECIAL
NEEDS
Orofacial myofunctional therapy (OMT) aims to
improve facial proprioception, improve the
appearance of tone, and maximize orofacial
mobility (Homem et al., 2014). While there is
little debate that infants can present with an
OMD diagnosis such as ankyloglossia, the way
in which these infants and toddlers would be
treated is different than how older patients, or
children who are neurotypically developing
would be treated. The volitional control, ability
to follow directions and self-monitor are all
important considerations when embarking on a
treatment protocol to improve clinical
manifestations of an OMD.
According to Billings et al. (2018), OMT is
recognized as an effective treatment for a
variety of symptoms in ages 4 and up, but oral
motor/feeding strategies that apply to infants
and young children are as follows:
x To improve nasal breathing post
tonsilloadenoidectomy (Huang et al.,
2014).
x To improve infant nursing (Ferrés-
Amat et al., 2016; Steeve et al., 2008).
x To improve chewing and feeding
(Baxter et al. 2020; He et al., 2013).
x To improve the oral preparatory and
oral transit phases of swallowing and
symptoms of oral dysphagia
(Averdson, 2008; Brackett et al., 2006;
Calis et al., 2008).
x To improve articulation (Daggumati et
al., 2019; Messner & Lalaka, 2002;
Ray, 2003).
x To eliminate detrimental oral habits
(Aizenbud et al., 2014; Borrie et al.,
2015).
x To improve symptoms such as mouth
breathing, open-mouthed posture, and
muscle-based dysfunction in special
populations such as children with
cerebral palsy, Down syndrome or
dysarthria (Ray, 2001, 2002).
While these goals can be addressed in infants
and toddlers as well as in children with special
needs, the terms used to describe treatment
are controversial. To ease some of the
confusion, Merkel-Walsh (2018a) penned a
blog for Ages and Stages®, LLC, to
differentiate pediatric oral motor and feeding
therapies from orofacial myofunctional therapy.
Portions of this work were presented at the
2018 IAOM Convention and this information
was also shared via webinar (Merkel-Walsh,
2018b). The following is extracted from the
article (Merkel-Walsh, 2018a) and presentation
with additional information included to reflect
more recent data.
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
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Pediatric Feeding
Feeding is a function of daily living that starts
at birth. In order to understand abnormal
development that occurs with OMDs that
impact feeding, one must understand normal
development (Bahr, 2017) and how feeding
and swallowing are a part of the OMD puzzle.
An infant is born with hard–wired synergies, or
central neural pathways (Singh et al.,2018),
which affect infantile reflexes that support
feeding. For example, a baby innately is able to
root their head to turn to the mother’s breast at
birth and draw the nipple into the oral cavity
(Overland, 2010; Overland & Merkel-Walsh,
2013). When a structural anomaly or muscular
imbalance interrupts the oral sensory-motor
system or when atypical reflexes are present,
feeding problems often occur. There are four
modern texts that thoroughly describe infantile
reflexes, pre-feeding, and feeding:
1) Pre-Feeding Skills (Morris and Klein, 2000);
2) Nobody Ever Taught me (or my Mother)
That! Everything from Bottles and Breathing to
Healthy Speech Development! (Bahr, 2010);
3) A Sensory Motor Approach to Feeding
(Overland & Merkel-Walsh, 2013);
4) Feed Your Baby and Toddler Right: Early
Eating and Drinking Skills Encourage the Best
Development (Bahr, 2018).
The American Speech Language and Hearing
Association (ASHA, 2018) describes
feeding/swallowing as having four stages: 1)
Oral Preparation Stage — preparing the food
or liquid in the oral cavity to form a bolus
including: sucking liquids, manipulating soft
boluses, and chewing solid food; 2) Oral
Transit Phase — moving or propelling the
bolus posteriorly through the oral cavity; 3)
Pharyngeal Phase — initiating the swallow and
moving the bolus through the pharynx and 4)
Esophageal Phase — moving the bolus
through the cervical and thoracic esophagus
and into the stomach via esophageal
peristalsis (Logemann, 1998).
It is within the scope of practice (SOP) for a
speech-language pathologist (SLP) to assess
and treat all four stages of swallowing. When
SLPs consider feeding across the lifespan,
they also look to International Board-Certified
Lactation Consultants (IBCLCs), nurses,
respiratory therapists, occupational therapists
(OTs) and physical therapists (PTs) for their
roles in the four stages. Pediatric dysphagia
often requires a team and it is important for
each member to know the others’ roles for
referral purposes. The oral preparatory and
transit stages of swallowing are also targeted
by as part of OMT, however, feeding therapy is
not within the orofacial myologist’s SOP
(Holtzman, 2018). Unless of course, it is
delivered by an SLP who has specialized
training in OMT and pediatric dysphagia.
Pediatric feeding therapy differs from OMT.
Features specific to pediatric feeding therapy
include:
x Pediatric feeding therapy is based on
normal oral sensory-motor
development and a task analysis of the
pre-feeding skills needed for safe,
effective nutritive feeding (Overland &
Merkel-Walsh, 2013).
x Pediatric feeding therapy can be
passive, requiring no volitional
execution of motor skills by the client,
but rather motor responses that occur
when the therapist uses sensory-motor
mapping techniques to elicit a
response. For example, by stimulating
the lateral borders of the tongue the
SLP can elicit lingual lateralization
required for maintaining a lateral chew.
Or, by providing adaptive equipment,
such as a therapeutic recessed-lid cup,
the therapist can facilitate improved
motor skills for drinking and swallowing
(Bahr, 2010 & 2018; Morris & Klein,
2000; Overland & Merkel-Walsh,
2013).
x Pediatric feeding therapy often has
nutritional targets and considers
optimal weight gain and the child’s
growth curve. This is coordinated with
the medical team (ASHA, 2018).
x Pediatric feeding therapy may involve
all four phases of swallowing, which
requires a specific skill set through
post-graduate training in pediatric
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
27
dysphagia which is not the same as
adult dysphagia training (ASHA, 2018).
x Pediatric feeding therapy can occur
from 0-18 years of age to include the
four stages of handling liquids, purees
and solids.
x Pediatric feeding therapy involves
facilitating the oral motor skills required
to safely handle various utensils and
/or modifies utensils to improve
feedings such as nipple shields,
therapeutic cups, adaptive forks and
straws with lip blocks (Overland &
Merkel-Walsh, 2013).
x A pediatric feeding team may include
the: IBCLC, gastroenterologist,
endocrinologist, allergist,
otolaryngologist,
pulmonologist/respiratory therapist,
dietician, speech-language pathologist,
home health aide, nurse, occupational
therapist and /or a physical therapist as
well as the educational specialists and
caregivers.
x Pediatric feeding therapists must pay
attention to medical considerations
(e.g., nasogastric tube, tracheostomy,
etc.) and complex medical
complications (neonatal intensive care
unit stay, traumatic brain injury etc.) in
addition to coordinating with a medical
team for cardiac and respiratory
concerns.
x Feeding therapy involves learning
adaptive strategies to compensate for
oral sensory-motor deficits or
delays/disorders in pre-feeding skills.
x Pediatric feeding involves collaborating
with a gastroenterologist and/or
dietician to establish calorie targets,
safe textures, and diet expansion.
x It also includes working with
occupational and physical therapists
for optimum posture, alignment, and
sensory regulation to maximize
progress in feeding sessions.
x Pediatric feeding therapists coordinate
with IBCLCs to assist with transitions
from breast/bottle to pureed/solid foods
and /or as a part of a tethered oral
tissue team.
x Pediatric feeding disorders are often
treated concurrently with speech sound
disorders, specifically those that are
organic in nature and impacted by
structural and/or muscle-based
disorders. While there is not a 1:1
correlation between feeding and
speech sound production, the two
systems overlap (Overland & Merkel-
Walsh, 2013; Bahr & Rosenfeld-
Johnson, 2010).
Orofacial Myofunctional Therapy
OMT differs from pediatric oral motor/feeding
therapy. Those differences include:
x OMT is typically an active approach
and often requires volitional execution
of a motor plan by the client, such as
practicing lingual positioning for
isolated swallows (Merkel-Walsh,
2018c; Boshart, 2017).
x OMT requires the patient to know the
“why” of the program and the patient
has to “work” at their goals (Holtzman,
2018). An infant or toddler would not
know the “why” of an OMT program.
x OMT is based on abnormal structure,
tone, oral resting posture, habits and
swallowing patterns (AOMT, 2018).
x While early signs of OMD can be
recognized in infants and toddlers, the
initiation of OMT varies in the literature
from as early as 4 years to as old as 8
years of age (Holtzman, 2018). Other
treatment modalities are available for
younger populations.
x An OMD team may include the:
pediatrician, physician, SLP,
Registered Dental Hygienist (RDH),
Certified Orofacial Myologist® (COM®:
RDH-COM® or SLP-COM®), dentist,
orthodontist, allergist, otolaryngologist,
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
28
breathing specialist, sleep specialist,
bodyworker (osteopath, chiropractor,
licensed massage therapist, physical
therapist, occupational therapist) and
/or oral maxillofacial surgeon.
x OMT requires volitional imitation of oral
postures such as “tongue to the spot”
or practicing oral resting posture and
the lingual palatal seal with a
conscience effort to self-monitor.
x OMT involves repetitive practicing of
phonemes, articulation drills and/or
oral placements of lingual alveolar and
palatal phonemes to ensure that not
only acoustics are correct, but also the
phonetic placements are correct as
well (Merkel-Walsh & Overland, 2018).
x OMT targets oral habits such as thumb
sucking and mouth breathing (e.g.,
Sandra Holtzman’s online Unplugging
the Thumb, n.d. or Pam Marshalla’s
How to Stop Thumbsucking (and Other
Oral Habits): Practical Solutions for
Home and Therapy (2001) with
positive reinforcement schedules and
self-monitoring.
x OMT addresses respiratory control
with the dentist, otolaryngologist (ENT)
and other appropriate medical
professionals when the airway is not
patent (de Felicio et al., 2018).
x OMT involves developing self-
awareness of saliva management.
x The OMD team coordinates with
dentists and orthodontists regarding
appliances and management (e.g.,
Myobrace, Advanced Lightwire
Functional Appliance (ALF), palatal
expanders).
x OMT can alleviate the symptoms of
temporo-mandibular dysfunction (TMD)
and facial pain (de Felício et al., 2010;
Machado et al., 2016).
x OMT is used to improve symptoms of
sleep disordered breathing and
obstructive sleep apnea (de Felicio et
al., 2016; Diaferia et al., 2013; Huang
& Guilleminault, 2013).
x OMT involves coordination with a
medical team to rule out and or treat
airway problems/ sleep disordered
breathing (Archambault, 2018).
x An OMT program can be used to
improve lingual range of motion post-
frenectomy (Ferrés-Amat et al., 2016).
x OMT is a part of a dental and
orthodontic team, to assist in the
prevention of orthodontic relapse.
A COMPARISON OF ORAL
MOTOR/FEEDING AND OROFACIAL
MYOFUNCTIONAL THERAPIES
When clinicians can differentiate diagnoses
and treatment plans, they are empowered to
better serve their patients, clients and students.
The distinctions between oral-motor/feeding
and OMT does not imply that we ignore, or fail
to treat OMDs in infants, young children and/or
special populations.
Despite variations between pediatric oral
motor/feeding and OMT, there are definite
overlaps in diagnosis and treatment. For
example, an OMT program works on tongue tip
swallows and self-monitoring of the swallow, as
mentioned previously. These types of tasks
would make this treatment modality difficult for
infants, toddlers, and preschoolers as well as
patients/clients with motor-planning disorders
(childhood apraxia of speech), motor-execution
disorders (dysarthria) and/or special needs.
These individuals require the assistance of
tactile tools, manual manipulation and oral-
motor techniques such as The Beckman Oral
Motor Protocol (Beckman, 2020) or tactile and
proprioceptive input through the motor-
kinesthetic approach (Marshalla, 2020).
Many SLPs who have interest and specialized
training in pediatric oral motor/feeding also
have training in OMDs and vice versa. For
example, SLPs who are trained in pediatric
feeding and orofacial myology may combine
tactile oral sensory motor strategies and pre-
feeding therapy to target goals in an OMT
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
29
program. Most experienced clinicians who are
trained in these therapeutic modalities know
how to recognize the early signs and
symptoms of OMDs in babies, toddlers, and
individuals with complex diagnoses. The
similarities and differences between pediatric
oral motor/feeding and OMT can be confusing
to professionals and the public.
For example, therapy that is recommended for
pre- and post- frenectomy is often considered
OMT, but when it is with an infant or toddler,
the term may be contraindicated based on the
target age group for OMT. Merkel-Walsh and
Overland (2018) call pre- and post-operative
therapy with infants and toddlers
“neuromuscular re-education” and describe the
importance of a multi-disciplinary team.
Another example is that of open-mouth posture
at rest. Infants with open-mouth posture should
be treated, but cannot self-monitor. A well-
trained pediatric feeding therapist (IBCLC,
SLP, OT) can recognize and assist improved
resting posture in patients who do not have
volitional control. An OT or PT, or other
bodyworker such as a chiropractor, can assist
with posture and alignment to support the
head, neck and jaw to assist with resting
posture (Merkel-Walsh & Overland, 2018).
Techniques that help superimpose lip closure
through pre-feeding therapy may be used.
There are some additional strategies that could
also be helpful and are long-standing muscle-
based and neuromotor treatment modalities,
long before myofunctional therapy with infants
and toddlers was suggested. For example, The
Beckman Oral Motor Protocol was developed
in 1975 by Debra Beckman, a speech-
language pathologist. Her techniques were
developed for those individuals who could not
volitionally control the orofacial muscles on
command. Her protocol provides “assisted
movement to activate muscle contraction and
provide movement against resistance to build
muscle strength” (Beckman, 2020; Beckman et
al., 2004).
Other methods could include Neuro-
Developmental Treatment (NDT) or pre-
feeding techniques as aforementioned when
discussing pediatric oral motor/ feeding.
This varies in comparison to working with a
teenage or adult patient, where the COM®
teaches the patient to position the jaw, lips and
tongue at rest. OMT has a strong focus on
habitualization and therefore actively engages
the patient in the self-monitoring process such
as practicing the new resting posture during
common daily activities (exercise, watching
television etc.). In both age groups the
therapist will be working with the medical team
to determine the underlying causes of the open
mouth posture to rule out structural concerns
such as adenoidal hypertrophy; however, the
way the resting posture is treated varies from
passive to active based on the volitional
control, cognition, motor-planning abilities and
neurological status of the patient.
While SLPs and OTs can work with feeding
across the lifespan, only therapists who have
been specifically trained to work with the infant
population should do so, and therapists from
related fields who work with older patients
should receive specialized instruction before
attempting to work with infants. Confusion
occurs because pediatric feeding and OMT
often target some similar goals such as
improving: bolus mobility; labial seal on a straw
or cup; lingual palatal seal; lingual protrusion,
retraction, lateralization, and elevation; lip
closure; mastication; oral transit time; range of
motion of the jaw, lips, cheeks, and tongue;
sequencing of the oral phase of swallowing;
tongue tip dissociation from the jaw to the
incisive papilla.
Scope of Practice
OMT is a treatment modality that should be
performed by a licensed professional who has
this modality in their SOP. To date, there is no
license in the United States of America for an
Orofacial Myofunctional Therapist, although the
IAOM offers a formal certification process
(COM®). The COM® is legally trademarked and
recognized by the United States Patent and
Trademark Organization (USPTO). Historically,
the IAOM has only certified SLPs and RDHs
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
30
because they are the only professions that
specifically list OMDs in their SOPs (ASHA,
2016b; ADHA, 2018). The COM® process
trains RDHs and SLPs side by side through a
28-hour course, written examination, on-site
clinical examination and with success,
continuing education requirements (IAOM,
2020). The IAOM also has a fellowship
program for physicians and dentists.
Often similar goals could be targeted by
multiple professionals. Several professionals
may encourage and manipulate the placement
of a bolus, using massage, myofascial release,
pre-feeding activities, oral tools, strengthening
exercises, and/or oral sensory-motor cues to
facilitate progress. It is up to professionals to
rely on their own professional association and
state licensing board to define their roles with
pediatric dysphagia and/or OMDs.
Treating OMDs in infants and young children
requires a team approach (Billings et al.,
2018). Although SLPs and RDHS have scope
to deliver OMT, the supportive services from a
team of professionals is critical. For example,
according to The American Dental Association,
babies should have early oral screenings
around the age of 1 year. This would help
identify and treat an OMD early in life. Children
with developmental disabilities who receive
early intervention may be identified by
occupational or physical therapists due to their
knowledge of feeding disorders, small and
large muscle groups and sensory-motor
integration. Table 5 provides examples of
pediatric OMD teams.
Table 5. Potential Members of Pediatric OMD Teams
OMD Infant and Toddler Team
Pre-feeding, Oral Motor and Feeding
Therapies, Bodywork and Medical Team
OMD Pediatric Team
Orofacial Myofunctional and Feeding Therapies,
Bodywork and Medical Team
x Allergist
x Body worker – osteopath,
chiropractor, licensed massage
therapist, physical therapist,
occupational therapist
x CranioSacral therapist
x Dentist
x Early Interventionists
x Feeding specialist (OT/SLP)
x Lactation consultant (IBCLC)
x Nutritionist
x Occupational therapist
x Oromaxillofacial surgeon
x Osteopathic medical physician
x Otolaryngologist
x Pediatrician
x Physical therapist
x Registered Dental Hygienist
x Respiratory Therapist
x Speech-Language Pathologist
x Allergist
x Body worker –
osteopath, chiropractor,
licensed massage therapist, physical
therapist, occupational therapist
x Certified Orofacial Myologist™
x CranioSacral therapist
x Dentist
x Educational Professionals
x Feeding specialist (OT/SLP)
x Nutritionist
x Occupational Therapist
x Oromaxillofacial surgeon
x Osteopathic medical physician
x Orthodontist
x Otolaryngologist
x Pediatric dentist
x Pediatrician
x Psychologist/Neuropsychologist
x Registered Dental Hygienist
x Respiratory Therapist
x Speech-Language Pathologist
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With the team model in mind, it is important to
consider ethical issues for best practices in
interprofessional collaboration. Examples
include:
x RDHs practicing OMT may target jaw
strength for mastication purposes but will
refer patients with signs and symptoms
of dysphagia to the SLP/OT.
x OTs may be working on feeding goals
with a patient but will not work on the
placement of the articulators for speech.
They will refer to an SLP if they notice
speech clarity problems.
x SLPs may strive for ideal posture and
positioning during OMT sessions but will
refer to OT/PT when signs and
symptoms of muscle dysfunction are
noted beyond the orofacial complex.
x PTs treating torticollis will refer a baby for
a feeding evaluation to an IBCLC, OT or
SLP, as well as for a medical evaluation,
if they suspect that tethered oral tissue is
possible and may be impacting an
infant’s feeding.
x An orthodontist who has a plan of care
for palatal expansion in a young child will
refer the patient for OMT if atypical
speech or swallowing is observed.
x An oral surgeon, who plans to perform a
frenectomy on a 3-year-old patient with a
diagnosis of autism, will refer the patient
for pre-operative therapy/ies in order to
ensure that post-operative stretches and
intraoral massage will be tolerated post-
operatively.
x An SLP or OT without pediatric feeding
or myofunctional training who is working
in the educational setting will refer a
preschooler for a medical consult if they
suspect issues with the orofacial
complex.
It is also important to note that taking a class
on a topic to learn information does not
necessarily mean it is ethical to practice that
method. Interprofessional training helps us
understand how varied professionals can
assist us with patient care, but we may not be
able to practice what is learned in a course if
we do not have the license to do so. For
example, many IBCLCs and RDHs have taken
courses on the management of tethered oral
tissues. Pediatric feeding, speech, and OMT
are often covered in this coursework; however,
these professionals should not implement
certain aspects of care when it is not within
their SOP. For example, the IBCLC will learn to
adapt strategies to support breastfeeding and
the infant-mother dyad, whereas the SLP
learns articulation strategies. Goals of pediatric
feeding and OMT are illustrated in Appendix A.
CONCLUSION
Semantics are important. Semantics and
choice of words help the professional seek the
proper training and will help the public
understand what services they need to seek
from the right professional. Pediatric oral
motor/feeding therapy and orofacial
myofunctional therapy may overlap; however,
each requires a very specific skill set in training
and each have different aspects that make
them unique. Both pediatric oral motor/feeding
and OMT involve an interdisciplinary team that
ranges from physicians to bodyworkers and
crosses the lifespan starting with IBCLC’s all
the way up to COMs® with specialized training
in tongue thrust, airway dysfunction, and
orthodontia in adults. Infants, babies, toddlers
and children with special needs require special
considerations due to their fragility and
complex medical profiles in addition to their
decreased ability to imitate or initiate self-
monitoring.
SLPs are unique in that they have both oral
motor/pediatric feeding and OMT within their
scope of practice while other fields may have
one or the other. Proper training in both skill
sets are needed to diagnose and treat, and
while overlap may occur, it is important not to
transfer the methods used for older patients to
babies and toddlers. It is up to each
professional who treat these patients to ensure
safety and consider ethics (ASHA, 2016a) in
order to implement a proper plan of care. This
could mean providing appropriate referrals to
the professional with the experience and
proper professional scope when needed.
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
32
In summary, OMDs in infants and young
children (0-4) and children with special needs
should not be ignored; however, in an effort to
“do no harm” we must refer these patients to
the most highly trained, licensed professionals
that can best serve this population with
evidence-based treatment strategies within
their scopes of practice. Patients who are 4
and over and/or can follow directions,
understand therapeutic goals and self-monitor
are more appropriate candidates for OMT.
These patients should also be referred to the
most highly trained professionals within
licensure scope. Oral motor/feeding and OMT
treatment methodologies help improve the
signs and symptoms of OMDs across varying
ages and population.
CONTACT AUTHOR
Robyn Merkel-Walsh, MA, CCC-SLP/COM®
480 Bergen Blvd. Ridgefield, NJ 07657
201-741-1918
Robynslp95@aol.com
Acknowledgments and Disclaimer
Special thanks to Mary Billings, Kristie Gatto, Linda D’Onofrio and Nicole Archambault who worked
together on the reference list and defining OMDs, and again to Mary, Linda and Kristie for allowing
this publication to share our infographic. Thanks to Diane Bahr for featuring me on her blog to
discuss this topic which resulted in this paper. Thanks to my mentor and friend Lori Overland for
teaching me and to Pat Taylor for her tireless efforts to the IJOM.
The author of this article is the Board Chair of the Oral Motor Institute and is a consultant, product
developer and lecturer for TalkTools®.
Additional references and resources on this topic can be found at
http://oralmotorinstitute.org/resources/Orofacial-Myofunctional-Disorders-RefList.pdf
REFERENCES
Academy of Orofacial Myofunctional Therapy (AOMT). (2018) Retrieved from:
https://aomtinfo.org/
Aizenbud, D., Gutmacher, Z., Teich, S. T., Oved-Peleg, E., & Hazan-Molina, H. (2014). Lip
buccal mucosa traumatic overgrowth due to sucking habit - a 10-year follow-up of a non-
surgical approach: a combination of behavioural and myofunctional therapy. Acta odontologica
Scandinavica, 72(8), 1079–1083. https://doi.org/10.3109/00016357.2014.913308
American Dental Hygienist Association (ADHA). (2018). Policy manual. Retrieved from:
https://www.adha.org/resources-docs/7614_Policy_Manual.pdf
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available
from www.asha.org/policy
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-
language pathology [Scope of Practice]. Available from www.asha.org/policy/
American Speech-Language-Hearing Association (ASHA). (2018). Retrieved from:
https://www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia/
Archambault, N. (2018). Healthy breathing round the clock. The ASHA Leader, 23: 48-54.
http://dx.doi.org/10.1044/leader.FTR1.23022018.48
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
33
Arvedson, J. C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and
instrumental approaches. Developmental Disabilities Research Reviews, 14, 118–127.
http://dx.doi.org/10.1002/ddrr.17
Bahr, D. (2008). A Topical Bibliography on Oral Motor Assessment and Treatment. Oral Motor
Institute, 2(1). Available from www.oralmotorinstitute.org
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to
healthy speech development! Arlington, TX: Sensory World.
https://doi.org/10.1177/1525740109350217
Bahr, D. (2017). Best practices in pediatric feeding, motor speech and mouth development. Live
Presentation. Clifton, NJ.
Bahr, D. (2018). Feed your baby and toddler right: early eating and drinking skills encourage the
best development. Arlington, TX: Future Horizons Inc.
Bahr, D., & Rosenfeld-Johnson, S. (2010). Treatment of Children with Speech Oral Placement
Disorders (OPDs): A Paradigm Emerges. Communication Disorders Quarterly, 31(3), 131–138.
https://doi.org/10.1177/1525740109350217
Baxter, R., Merkel-Walsh, R., Baxter, B. S., Lashley, A., & Rendell, N. R. (2020). Functional
Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release:
A Prospective Cohort Study. Clinical pediatrics, 59(9-10), 885–892.
https://doi.org/10.1177/0009922820928055
Beckman, D. (2020). About Beckman oral motor intervention. Retrieved from
www.beckmanoralmotor.com
Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D. (2004). Range
of movement and strength in oral motor therapy: A retrospective study. Florida Journal of
Communication Disorders, 21, 7-14.
Billings, M., Gatto, K., D’Onofrio, L., Merkel-Walsh, R., & Archambault, N. (2018). Orofacial
Myofunctional Disorders. International Association of Orofacial Myology. Retrieved from:
http://iaom.com/wp-content/uploads/2018/10/OMD-Overview-IAOM.pdf
Borrie, F. R., Bearn, D. R., Innes, N. P., & Iheozor-Ejiofor, Z. (2015). Interventions for the
cessation of non-nutritive sucking habits in children. The Cochrane database of systematic
reviews, (3), CD008694. https://doi.org/10.1002/14651858.CD008694.pub2
Boshart, C. (2017). Swalloworks Therapy Program. Eligay, GA: Speech Dynamics Inc.
Brackett, K., Arvedson, J. C., & Manno, C. J. (2006). Pediatric feeding and swallowing disorders:
General assessment and intervention. Perspectives on Swallowing and Swallowing Disorders
(Dysphagia), 15, 10–14. http://dx.doi.org/10.1044/sasd15.3.10
Calis, E. A. C., Veuglers, R., Sheppard, J. J., Tibboel, D., Evenhuis, H. M., & Penning, C.
(2008). Dysphagia in children with severe generalized cerebral palsy and intellectual
disability. Developmental Medicine & Child Neurology, 50, 625–630.
http://dx.doi.org/10.1111/j.1469-8749.2008.03047.x
Daggumati, S., Cohn, J. E., Brennan, M. J., Evarts, M., McKinnon, B. J., & Terk, A. R. (2019).
Speech and Language Outcomes in Patients with Ankyloglossia Undergoing Frenulectomy: A
Retrospective Pilot Study. OTO Open, 3:2473974X19826943.
http://dx.doi.org/10.1177/2473974X19826943
de Felício, C. M., de Oliveira, M. M., & da Silva, M. A. (2010). Effects of orofacial myofunctional
therapy on temporomandibular disorders. Cranio : the journal of craniomandibular
practice, 28(4), 249–259. https://doi.org/10.1179/crn.2010.033
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
34
de Felício, C. M., da Silva Dias, F. V., & Trawitzki, L. (2018). Obstructive sleep apnea: focus on
myofunctional therapy. Nature and science of sleep, 10, 271–286.
https://doi.org/10.2147/NSS.S141132
Diaferia, G., Badke, L., Santos-Silva, R., Bommarito, S., Tufik, S., & Bittencourt, L. (2013).
Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the
quality of life of patients with obstructive sleep apnea. Sleep medicine, 14(7), 628–635.
https://doi.org/10.1016/j.sleep.2013.03.016
D’Onofrio, L. (2019). Oral dysfunction as a cause of malocclusion. Orthod Craniof Res.22, (Suppl.
1): 43-48.
Doshi, U. H., & Bhad-Patil, W. A. (2011). Speech defect and orthodontics: a contemporary
review. Orthodontics: the art and practice of dentofacial enhancement, 12(4), 340–353.
Ferrés-Amat, E., Pastor-Vera, T., Ferrés-Amat, E., Mareque-Bueno, J., Prats-Armengol, J., &
Ferrés-Padró, E. (2016). Multidisciplinary management of ankyloglossia in childhood.
Treatment of 101 cases. A protocol. Medicina oral, patologia oral y cirugia bucal, 21(1), e39–
e47. https://doi.org/10.4317/medoral.20736
Hanson, M.L. & Mason, R. M. (2003). Orofacial Myology International Perspectives. Springfield,
IL: Charles C. Thomas publisher Ltd.
He, T., Stavropoulos, D., Hagberg, C., Hakeberg, M., & Mohlin, B. (2013). Effects of masticatory
muscle training on maximum bite force and muscular endurance. Acta odontologica
Scandinavica, 71(3-4), 863–869. https://doi.org/10.3109/00016357.2012.734411
Holtzman, S. (n.d.) Unplugging the thumb. Retrieved from:
http://www.orofacialmyology.com/unpluggingthethumb/ForTherapist.html
Holtzman, S. (2018). What age is appropriate for OM treatment? Orofacial Myology News.
Retrieved from: http://orofacialmyology.online/wp-content/uploads/2018/06/2018-may-orofacial-
myology-online-news.pdf
Homem, M. A., Vieira-Andrade, R. G., Falci, S. G., Ramos-Jorge, M. L., & Marques, L. S.
(2014). Effectiveness of orofacial myofunctional therapy in orthodontic patients: a systematic
review. Dental press journal of orthodontics, 19(4), 94–99. https://doi.org/10.1590/2176-
9451.19.4.094-099.oar
Huang, Y. S., Guilleminault, C., Lee, L. A., Lin, C. H., & Hwang, F. M. (2014). Treatment
outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective
longitudinal study. Sleep, 37(1), 71–76. https://doi.org/10.5665/sleep.3310
Huang, Y. S., & Guilleminault, C. (2013). Pediatric obstructive sleep apnea and the critical role of
oral-facial growth: evidences. Frontiers in neurology, 3, 184.
https://doi.org/10.3389/fneur.2012.00184
International Association of Orofacial Myology (IAOM). (2020). Certified Orofacial Myologist®.
Retrieved from: http://iaom.com/certification/
Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: Pro-Ed.
Machado, B. C., Mazzetto, M. O., Da Silva, M. A., & de Felício, C. M. (2016). Effects of oral
motor exercises and laser therapy on chronic temporomandibular disorders: a randomized
study with follow-up. Lasers in medical science, 31(5), 945–954.
https://doi.org/10.1007/s10103-016-1935-6
Marshalla, P. (2001) . How to Stop Thumbsucking (and Other Oral Habits): Practical Solutions for
Home and Therapy. Ashland, OR: Marshalla Speech and Language.
International Journal of Orofacial Myology & Myofunctional Therapy 2020 V46
35
Marshalla, P. (2007). Oral Motor Techniques Are Not New. Oral Motor Institute, 1(1). Available
from www.oralmotorinstitute.org.
Marshalla, P. (2008). Oral Motor Treatment vs. Non-speech Oral Motor Exercises. Oral Motor
Institute, 2(2). Available from www.oralmotorinstitute.org.
Marshalla, P. (2020). The Marshalla Guide: A Topical Anthology of Speech Movement
Techniques. Ashland, OR: Marshalla Speech and Language.
Merkel-Walsh, R. (2018a). Orofacial myofunctional disorder or pediatric feeding disorder-what is
the buzz about? Blog written for Ages and Stages®, LLC. Retrieved from:
http://www.agesandstages.net/blog.php?link=Ym9JJUUyJTgyJTExJUI5JUFETiUyMyVFQiU1Q
nAlMUEyJUE4JUI2JTJGJUIxJUYzJTkwJTI1JThBJUREJTg0JTA0JThCJTI1JTFDJTEyJUMzJU
Qw
Merkel-Walsh, R. (2018b). Orofacial myofunctional disorder or pediatric feeding disorder-what is
the buzz about? Webinar presentation. Charleston, SC: TalkTools®.
Merkel-Walsh, R. (2018c) Systematic Intervention for Lingual Elevation (SMILE). Charleston, SC:
TalkTools®.
Merkel-Walsh, R., & Overland, L. (2018). The functional assessment and remediation of tethered
oral tissue. Charleston, SC: TalkTools®.
Messner, A.H., & Lalaka, M.L. (2002). The effect of ankyloglossia on speech in children.
Otolaryngology Head & Neck, 127(5), 539-545. http://dx.doi.org/10.1067/mhn.2002.1298231
Morris, S., & Klein, M. (2000). Pre-feeding skills (2nd ed). San Antonio TX: Therapy Skill Builders.
Overland, L. (2010). A sensory-motor approach to feeding. Perspectives on Swallowing and
Swallowing Disorders (Dysphagia), 20, 3, 60-64.
Overland, L., & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC:
TalkTools.
Ray J. (2001). Functional outcomes of orofacial myofunctional therapy in children with cerebral
palsy. The International Journal of Orofacial Myology: official publication of the International
Association of Orofacial Myology, 27, 5–17. https://doi.org/10.52010/ijom.2001.27.1.1
Ray J. (2002). Orofacial myofunctional therapy in dysarthria: a study on speech intelligibility. The
International Journal of Orofacial Myology: official publication of the International Association of
Orofacial Myology, 28, 39–48. https://doi.org/10.52010/ijom.2002.28.1.3
Ray J. (2003). Effects of orofacial myofunctional therapy on speech intelligibility in individuals with
persistent articulatory impairments. The International Journal of Orofacial Myology: official
publication of the International Association of Orofacial Myology, 29:5-14.
https://doi.org/10.52010/ijom.2003.29.1.1
Singh, R. E., Iqbal, K., White, G., & Hutchinson, T. E. (2018). A Systematic Review on Muscle
Synergies: From Building Blocks of Motor Behavior to a Neurorehabilitation Tool. Applied
bionics and biomechanics, 2018, 3615368. https://doi.org/10.1155/2018/3615368
Steeve, R. W., Moore, C. A., Green, J. R., Reilly, K. J., & McMurtrey, J. R. (2008). Babbling,
chewing, and sucking: Oromandibular coordination at 9 months. Journal of Speech, Language,
and Hearing Research, 51(6), 1390–1404. https://doi.org/10.1044/1092-4388(2008/07-0046)
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APPENDIX A
Unique and overlapping symptoms and goals specific to orofacial myofunctional therapy (OMT) and
pediatric feeding therapy. (Reprinted with permission by Billings, D’Onofrio, Gatto, and Merkel-
Walsh, 2017)
