Tongue Position Training (Oral Myofunctional Therapy OMT)
In a world where exercise is growing in popularity, where we work out our arms and legs, where gyms are on every street, I think an exercise for your tongue is the next big thing. In my 30 years of Orthodontics Specialty practice, I’ve observed most patients have both unnatural rest position and abnormal position of their tongue during swallowing of saliva. This can be most clearly described as a “tongue-between-the-teeth” (TBT) position abnormality. This will cause tipping, rotations, and abnormal spacing of teeth as well as deep bites and open bites. Patients often ask, “how could one tooth move down or rotate differently from an adjacent tooth from the same tongue pressure”? The answer is that each tooth is different in the size and shape of their respective roots, so they react differently. I have observed that nearly all relapse cases have TBT present!
The need for an exercise to retrain resting position and swallow position of the tongue first occurred to me while treating a 13-year-old boy. His braces were not working. His lower-front teeth were resistant to straightening with braces. During an adjustment, I saw him swallow his saliva to prepare for me to put an instrument in his mouth. He showed a distinct drop of the jaw and exaggerated contraction of his lips. I recently had been taught to look for this and recognize this drop of the chin and excess contraction of lips as an obvious sign of a swallow disorder.
I was hesitant to ask him to immediately swallow again on my command because I worried that it may have been a forced/unnatural swallow. Many patients later have proven to me we must be careful how we examine a swallow. To attempt to get his most natural swallow, I decided to engage him in some conversation to build up some saliva in his mouth and take his mind off what I was doing.
I was hesitant to ask him to immediately swallow again on my command because I worried that it may have been a forced/unnatural swallow. Many patients later have proven to me we must be careful how we examine a swallow. To attempt to get his most natural swallow, I decided to engage him in some conversation to build up some saliva in his mouth and take his mind off what I was doing.
I kept my fingers near his lips waiting for the moment of a natural swallow. When he started to swallow, I managed to pull apart his tightly contracting lips, and I saw his tongue resting over the top of his lower anterior teeth in the gap created when he dropped his jaw. When in centric occlusion, it would have been impossible for him to place his tongue over the lower incisal edges so I was not surprised to see him first distinctly drop his jaw before his swallow. Keep in mind that the patient had no anterior open bite when in centric occlusion unlike a thumb sucker would show therefore, no space for the tongue. This means if the patient thinks we want them to bite first when we examine their swallow then we will not see the TBT!
The failure of his lower braces to easily straighten his teeth was despite having lower-first bicuspids extracted to make additional space. The slow improvement seen from his braces was also despite working through heavier and heavier arch wires, ligating braces tighter, and repositioning braces. As a matter of fact, his extraction spaces appeared to be closing. We had been taught in orthodontics residency that would be due to failing to prevent the second bicuspids and molars from natural mesial migration. This actually was not happening. What was happening was the patient’s anterior teeth (lower-left canine (lower-left canine to lower-right canine), as a group, were moving lingual from the abnormal tongue resting position and a retained infantile swallow exerting pressure opposite to that from his braces.
This became obvious when the boy succeeded with tongue exercises, and I observed his extraction spaces re-open simultaneously as his lower front teeth finally straightened. The exercise did the trick! I’ll never forget the terrible feeling I had when I realized that those bicuspids shouldn’t have been extracted. I was certainly motivated NOT to make this mistake ever again. The exercise and explanation I gave him has been revised from the feedback of parents, speech pathologists, and many patients through the years. The following instructions for an exercise to correct a TBT rest position and salivary swallow follows. Please keep in mind this exercise is most effective with little to no open bite malocclusion in centric relation bite. These instructions and an advised schedule of exercise have proven to be quite effective with both adults and children with adequate parental supervision and encouragement.
I always begin by educating the parents and patients (if appropriate age). This includes reviewing what TBT is and how frequently we swallow our saliva (every 2-3 minutes, day and night) as well as the concept that, ” where we place our tongue during swallows of the saliva is likely where we park it unless we have to speak.” In addition, it’s best to review that infants begin life with a tongue between the gum pads rest position and swallow which changes naturally by the age of 12 months when the child begins to swallow without protruding the tongue between the erupting teeth.
Next, it’s best to briefly review the decades-long history of success orthodontists have seen when abnormal pressures on the teeth are reduced and how this makes orthodontics easier and more predictable. It’s great to stress the benefits that will be enjoyed as a consequence of effective improvement of resting tongue position and position during salivary swallowing. This can be great motivation. Stress the benefits of faster treatment, greater improvement of the bite, better cosmetic results, and less chance of relapse.
Exercise to improve tongue resting and salivary swallow position should be done for 3 months. This same exercise encourages and trains nasal breathing which has been proven to be very beneficial for overall health.
Month 1 DAYTIME
The exercise should only be done while the patient is awake. Trying to do it while sleeping is not advised until success is achieved completely in month 1. The exercise is simply to bite naturally and place a small piece of tape over the closed lips. The best tape patients have found is blue painters tape. It doesn’t come off too easily from the wetness of the lips but comes off easily when it’s time to remove it. The tape will “tug” on the lips if the patient begins to separate his/her teeth by dropping the jaw so it alerts the patient of creating an anterior open-bite space where he/she is accustomed to placing the tongue. This gentle tug provides sensory feedback helping both consciously and unconsciously to break the habit. Patients should not attempt the exercise with a head cold or nasal congestion. If congestion is present, they must clear the nasal air passages and then start the exercise again. Remember that our internal upper airway passages expand on their own with deliberate practice breathing through the nose.
The effectiveness of training will be greater with more exercise sessions each day. Depending on the age of the patient, once or twice for only 5 minutes may be the most in the first week. Rewarding children is very effective. Increasing the number of times per day to 3 or 4 and 10 to 15 minutes is a good goal. A clear sign of successful completion of month 1 training is when patients “forget” the tape is on repeatedly go beyond their time goal with tape. If this is observed day after day then it’s okay to proceed to Month 2 Daytime & Nighttime training.
Month 2 DAYTIME & NIGHTTIME
The tape should be attempted every night unless the patient has congestion. Again, clear any congestion and resume night-tape after the congestion is cleared. Remember that our internal upper airway passages expand on their own with repeated use. Congestion will be less severe and less often with nasal breathing practice which tape creates. Success is defined in month 2 when a patient can sleep through nights consistently without removing tape. At this point it is okay to move to month 3.
Month 3 NIGHT TIME
It’s advisable to continue the exercise for an additional 4 weeks. This abnormal TBT swallow has been called a “reverse swallow” as well as an “infantile swallow.” Researchers have described it as a normal swallow (at birth) characterized by the tongue being between the upper- and lower-anterior gum pads. They believe that everyone begins life with this (tongue between the gum pads) swallow, and by about 12 months of age, we retract the tongue while swallowing saliva so it is not between the erupting anterior teeth. Through 30 years of practice, I have observed this retained infantile swallow (TBT swallow) and rest position in virtually all orthodontic relapse cases. I first tested the boy to see if he could swallow while keeping his teeth together. He struggled at first but quickly succeeded. To break the habit, I suggested that the patient bite together and not allow his teeth to separate while swallowing, 3-4 times a day for 15 minutes. He could practice this new skill any time he would not be required to speak, like during class or while doing homework. I told him that he would not get his teeth straight unless he stopped this habit.
Initially, I advised patients to place a small piece of tape over the lips to encourage “passive lips” during swallowing as well as lip competency at rest. The tugging of the tape also made the patient aware as to whether they are dropping their jaw preceding the swallow. Eventually the “tape-over-the-lips” approach was incorporated into the exercise, which led to greater understanding with patients and thus greater success rates. I changed the name to “MFT/tape.”
This exercise was designed to stop the patient from dropping the jaw and creating a gap between upper and lower teeth as a first step in the patient’s swallow. I also explained to patients that they didn’t have to be concerned with their tongue placement while drinking and eating.
The time to begin the exercise varies by patient. Sometimes patients start this before they go into Phase 1 treatment or full treatment. In other cases, it will start after they have been in treatment for a few months. The delay is only to avoid throwing too much information at patients at once, as I discovered that if I explained the impact of a retained infantile swallow, the parents wanted to start exercises right away.
I try to incorporate checking for a TBT and abnormal swallow in the new patient exam. I’ve also found an abnormal swallow of saliva/abnormal rest position of the tongue to be the predominant cause of most relapse cases. In the consultation exam, patients are reassured that the cause of the relapse appears to be from retained infantile swallow and that they can do something about it.
How To
Staff can be trained to give all explanations and handouts to parents and patients as well as refer them to online instructions and background information. The staff members do have to be “great motivators” and highlight that the use of this technique will make teeth move faster, more comfortably, and be more stable. For patients who struggle with the exercises, I invented and patented an appliance to retrain the tongue, called the DOT (DeLuke Oral Trainer).