Tongue thrust may be a delayed transition stage in some children.

Therapy is not indicated in the absence

of speech or dental problems, or before puberty.

Myofunctional therapy for tongue-thrusting:

background and recommendations

There is considerable interest and confusion in

dentistry and speech pathology about the con­
William R. Proffit, DDS, PhD, Gainesville, Fla
troversial topic o f myofunctional therapy for
Robert M. Mason, PhD, Lexington, Ky tongue-thrusting. Advocates o f myofunctional
therapy contend that anterior open bite and inci­
sor protrusion are related to abnormal lingual
pressure patterns that push the anterior teeth into
malocclusion. Many dentists feel (incorrectly)
that myofunctional therapy can prevent the de­
The article reviews oral form and function inter­ velopment of malocclusions that do not yet exist.
Dentists sometimes enlist speech clinicians to
actions pertinent to tongue thrust and provides
conduct myofunctional therapy with patients
guidelines fo r patient selection fo r m yofunctional
who have no speech problems. This situation
therapy. Certain anatom ic conditions predispose
normal children to anterior tongue positioning, raises serious ethical problems for the speech
w hich disappears during puberty. In these children clinician. This paper reviews the scientific back­
the tongue thrust is a normal, if delayed, transition ground for swallowing exercises to provide den­
stage. In other children, it is a necessary adapta­ tists with guidelines about selecting patients for
tion. M yofunctional therapy is not indicated in the myofunctional swallowing therapy.
Our background in tongue thrust is a product
absence of speech or dental problems and is not
of clinical interactions between speech pathol­
indicated, in our view, before puberty. If tongue
ogy and dentistry, primarily at the University of
thrust and an associated m alocclusion persist to
Kentucky Medical Center. Our conclusions are
puberty, tongue therapy may be indicated. The
a product of research findings at Kentucky with
therapy then is more effective when combined with
o rthodontic treatm ent to reposition teeth, rather intraoral pressure measuring devices such as
than being done before orthodontics. Speech th er­ those shown in Figure 1, in combination with
data from the literature and our own clinical ex­
apy can modify speech errors in tongue-thrusters
perience.
and reposition the tongue tip posteriorly.

Tongue thrust

At present, tongue thrust has no single title or

definition. The most frequent signs of tongue-
thrusting are said to be protrusion of the tongue
against or between the anterior dentition and ex ­
cessive circumoral muscle activity during deglu­
tition. It is variously referred to as tongue thrust,
tongue-thrust swallow, visceral swallow, infan­
tile swallow, reverse swallow, deviant swallow,
and tongue-thrust syndrome. H owever, several
workers (for example, Cleall1) have found the
presence of these “ abnormalities” in normal
JADA, Vol. 90, February 1975 ■ 403
 tistical correlation between tongue thrust and
bottle-feeding led Straub to the inappropriate
conclusion that “ the abnormal swallowing habit
has been found to be definitely due to improper
bottle feeding.”
Causality is not revealed by correlation statis­
tics and is especially elusive when few variables
are considered. Furthermore, the data reported
on the incidence of bottle-feeding by Hanson
and Cohen6 do not support Straub’s conclusion.
Another possibility is that anterior tongue po­
sitioning in swallowing is a normal developmen­
tal stage. Some insight into this can be achieved
Fig 1 ■ M in ia tu re p re ssu re -se n sin g d e v ic e s m o u n te d in th in
by comparison of the swallow behavior in infants
p la s tic p a la te -c o v e rin g d evice , as used to s tu d y th e m a g n itu d e , with that in older children and adults. The adult
d u ra tio n , and p a tte rn o f to n g u e -p a la te co n ta c ts . P ressure tra n s ­ swallow is characterized, among other things,
d u c e rs of th is ty p e ca n be m o u n te d at a lm o s t a ny in tra o ra l lo c a ­ by contact of the teeth as the jaws are brought
tio n to m e a su re to n g u e o r lip pressures.
together, relaxation o f the lips with little or no
evident muscular activity; and placement of the
persons. The distinctions between tongue-thrust- tongue tip against the palate behind the maxil­
ing during speech and at the onset of a swallow lary central incisors where it remains during the
are often obscure in the research reported in the swallow. (By no means is this the “ normal”
literature. Many o f the issues associated with swallow in all adults.) The swallow of an infant
tongue thrust have been discussed in recent re­ contrasts sharply with that of an adult in these
view papers by Weinberg,2 Moorrees, and co­ three areas. In the infant swallow the jaws are
workers,3 and Christiansen.4 apart with the tongue filling the space between
To us, tongue-thrusting is one or a combina­ the gum pads, or later the teeth; the lips are ac­
tion of three conditions: during the initiation tive in sucking movements; and the tongue is
phase of a swallow, a forward gesture of the
placed out between the dental ridges in contact
tongue between the anterior teeth so that the
with the lower lip and beneath the nipple that is
tongue tip contacts the lower lip; during speech
being sucked. At first, lip activity is more prom­
activities, fronting of the tongue between or inent than tongue movements. Bosma7 has called
against the anterior dentition with the mandible this phenomenon a front-to-back maturation of
hinged open (in phonetic contexts not intended the oral structures, with lip “ maturation” pre­
for such placements); and at rest, movement of ceding that o f the tongue. Later in infancy, in­
the tongue forward in the oral cavity with the creasing tongue movements are seen but the
mandible hinged slightly open and the tongue tip
tongue-to-lower-lip apposition remains. Addi­
against or between the anterior teeth. These con­
tional changes in the swallow pattern occur dur­
ditions can be found in individuals with and with­
ing childhood. The typical adult swallow appears
out speech or dental problems.
some time between ages 2 and 12.
It is apparent that a child who is in a transition
stage between infantile and adult swallowing
Habit or innate behavior? would have prominent anterior tongue position­
ing. Such a child would be labeled as having a
Whether tongue-thrust swallowing is a habit has thrust swallow by all the common definitions,
been the subject of considerable debate. The including those used in this paper. But the tongue
question is important because the therapeutic thrust represents not a habit in the sense of
approach can be affected by the decision as to learned extraneous behavior, but a normal de­
whether one is dealing with a habit or with a more velopmental stage. Several transition stages ex­
innate behavior pattern. ist between infancy and adulthood. Many nor­
Placement of the tongue tip between or against mal children do not complete the transition to
the central incisors during the initiation of a swal­ adult swallowing until they approach puberty.
low was described by Straub5 as an “ abnormal Changes in the swallow pattern, with a tran­
swallowing habit.” Straub ascribed this habit to sition toward a more adult swallow, have been
bottle-feeding. His evidence consisted of rec­ observed directly in normal children studied
ords on 478 patients in his orthodontic practice, longitudinally with intraoral pressure transduc­
only two of whom were breast-fed. The high sta­ ers.8 Similar observations have been made in
404 ■ JADA, Vol. 90, February 1975
children studied with cineradiography.9 A child
with a tongue-thrust swallow, then, is most like­
ly to be an individual who has not yet learned the
adult pattern, not one who has somehow learned
the wrong thing. ------ L Y M P H O ID
Three other factors enter into this. First, a --------N E U R A L
child who sucks his thumb apparently delays his ------T O N G U E
transition toward adult swallowing, and then is + + + M A N D IB L E
more likely to be labeled a tongue-thruster in the --------G E N E R A L
early mixed dentition years. A change in the
------G E N IT A L
swallow pattern will not occur until the sucking
habit ceases, but spontaneous transition toward
adult swallowing often occurs then. If it does not,
some therapy to teach the child swallowing be­
havior he has not yet learned may be indicated. B 4 8 12 16 20
Second, neuromotor problems severe enough AGE IN Y E A R S
to prevent normal adult swallowing are rare, but
this possibility should be considered in the eval­ Fig 2 ■ M a in ty p e s o f p o s tn a ta l g ro w th o f v a rio u s p a rts a n d o r ­
g a n s o f b o d y . L y m p h o id , n e u ra l, g e n e ra l b od y, and g e n ita l ty p e s
uation of a patient. Poor muscular coordination
a fte r S c a m m o n .'0
in other movements, with or without mental re­
tardation, increases the likelihood that the
tongue will be affected neurologically. Since an adequate airway is essential for life,
Finally, it is possible that an older child, or an
respiratory demands strongly affect tongue and
adult, could revert back to a tongue thrust after
jaw position. The initial resting position of the
acquiring an adult swallow pattern. This would
tongue, from which swallowing and speaking
be a habit, in the same sense that prolonged
movements begin, is established along with the
thumb-sucking is. Such habitual tongue-thrust­
airway. Anterior tongue positioning can result
ing is seen only in older individuals and is rare.
from airway problems both in the nose and in the
pharynx.
Lymphoid tissue grows quickly in children,
Other factors influencing tongue reaches a maximum before puberty, and then re­
positioning gresses (Fig 2). Although Scammon’s 10 curve
for lymphoid growth did not consider the tonsils
A more anterior tongue position in young chil­ and adenoids, recent research indicates that the
dren is founded on several anatomic reasons. growth and involution of tonsils and adenoids
T hese factors, which relate to growth and de­ conforms generally to Scammon’s curve for thy­
velopment of the head and neck, also must be mus, lymph nodes, and intestinal lymphoid mass­
considered in evaluation o f the progress toward es. Prominent tonsils in 8- to 10-year-old chil­
adult swallowing. dren are a common finding. It may be necessary
Although it is difficult to measure tongue size, for these children to carry the tongue forward
it seems that the tongue follows the growth curve and hinge the mandible open to provide mechan­
established for the neural tissues of the body (Fig ical clearance for breathing and swallowing. This
2) in that it grows fairly steadily and approaches is the typical association with the tonsils found
maximum size at or near age 8 years. The man­ in persons with clinically identified cases of
dible grows more slowly, tapers off to a plateau mouth-breathing. If the throat is chronically in­
generally between age 8 and 12 years, and then flamed and sore, the tendency to carry the tongue
undergoes pubertal and postpubertal growth. low and forward, to reduce contact with the sore
Som e mandibular growth is seen even into and area, is reinforced.
past the 20s. The growth of the mandible more E xcessive adenoid tissue proliferation before
nearly follows the general body curve in Figure puberty is one cause of nasal respiratory ob­
2. The clinical implication of this growth differ­ struction in children. Chronic allergic condi­
ential between the tongue and mandible is a nat­ tions, nasal infections, and mechanical blockage
ural tendency for the large tongue to be posi­ by turbinates or a deviated nasal septum also
tioned relatively high and forward in the oral cav­ can lead to chronic mouth-breathing. The re­
ity in the early years o f growth. sulting respiratory obstruction syndrome, de­

P ro ffit—M ason: MYOFUNCTIONAL THERAPY ■ 405

scribed well by Ricketts,11 includes tongue- positioning of the tongue in younger children.
thrusting and malocclusion. For the oral airway The richer distribution of sensory nerve endings
to be open, the tongue must be carried low and in the front of the mouth encourages fronting of
forward and the mandible held at a lower-than- the tongue tip as a means of generating tactile
normal rest position. The tongue thrust in this feedback. The universal emergence of bilabial
situation is only one of several related factors, and linguoalveolar consonant sounds at early
and the key to its resolution is correction of the ages in the speech acquisition sequence is re­
respiratory problem. lated to this.
A noticeable response in tongue position re­ Altogether, tongue-thrusting during speech or
lated to changed respiratory demands is shown swallowing or both in children in the mixed den­
by patients who have had surgical jaw reposi­ tition stage may be caused by three factors. The
tioning. These procedures almost always reduce first, adaptive behavior, is related to morpho­
the size of the oral cavity. If the lower jaw is posi­ logic variations in the mouth and pharynx. (The
tioned posteriorly, the tongue is carried posterior­ probability that the tongue adapts to tooth posi­
ly also and would tend to block the airway. This tion as well as to pharyngeal and airway dimen­
does not happen. Instead, the airway is main­ sions is discussed later.) It also may be caused
tained, and the tongue is repositioned down­ by neuromotor patterning that has its develop­
ward and forward. After such surgery, the rest­ ment in the individual’s interpretation of feed­
ing length of all the hyoid musculature is appar­ back experiences. In some children, a neuro­
ently altered, as the hyoid bone assumes a new logic abnormality contributes to the tongue
position consistent with airway maintenance.12 thrust; the prognosis for any type of therapy in
Speech quality is not changed, and lingual pres­ such children is poor. The presence of a normal,
sure patterns during articulation are maintained. if delayed, stage in the transition from infantile
Tongue pressures during swallowing usually de­ to adult swallowing is the third cause of tongue-
crease postoperatively, but in most patients they thrusting. The common definitions of tongue-
stabilize at normal levels during the year after thrusting, including those in this paper, cause
surgery.13 Speech adaptation is both quicker and this label to be applied frequently to normal de­
more complete than swallowing adaptation. Re­ velopmental stages that spontaneously change
lapse of tooth position related to failure of phys­ to adult patterns of tongue behavior.
iologic adaptation occurs in only a small percen­
tage of surgical orthodontic patients.
We have previously mentioned the tendency
for tongue-thrusters to evolve a normal adult Tongue thrust related to open bite and
swallow pattern between 8 and 12 years of age incisor protrusion
without any therapy intervention. This change
from tongue-thrust swallow to normal adult Many clinicians think that tongue-thrusting is
swallow is related to increases in the size of the associated with specific dental malocclusions,
oropharyngeal airspace. Cavity size increases especially anterior open bite and incisor protru­
are especially rapid around the time of puberty. sion. It is, therefore, valuable to examine the in­
This is caused by growth in the ramus of the man­ cidence of these conditions.
dible with an accompanying downward shift of Until very recently, no good figures were
the tongue in the oral cavity, diminution in the available for the incidence of dental malocclu­
amount of lymphoid tissue in the oropharynx as sion in children in the United States. In 1973, the
a function of normal involution of the tonsils and National Center for Health Statistics published
adenoids, and vertical growth of the bodies qf results of a large-scale study that assessed the
the cervical vertebrae, thereby increasing the dental occlusion of children in the United States.14
available space in the oropharynx. In response The sample of some 8,000 children was designed
to these morphological changes, the tongue is and selected statistically by the US Public Health
able to assume a more posterior resting position Service to permit valid inferences about the
in the oral cavity, and this results in closer ap­ health of a target population of approximately
proximation of the dental arches. 24 million children (all noninstitutionalized chil­
The pattern of sensory innervation of the dren, aged 6 to 11 years, living in the United
tongue and oral mucosa, and the earlier neuro- States). The findings of this survey are especially
physiologic maturation of anteriorly directed pertinent to the tongue-thrust controversy.
tongue movements also are factors in anterior In the sample, 5.7% of the children had an an-
406 ■ JADA, Vol. 90, February 1975
 Fig 3 ■ S p o n ta n e o u s c lo s u re o f a n te rio r o pen b ite o v e r fo u r-y e a r p e rio d , w ith o u t th e ra p y . (C o u rte s y Dr. M.
G e ilin .)

tenor open bite. There was a strong influence of strated statistically with the data from the U S ­
race— 16.3% of black children had an open bite PHS survey, we do not wish to imply that there
as opposed to only 3.9% of white children. The is no such association. We merely point out that
black children also were more likely to have a the association does not automatically reveal
clinically significant open bite that could affect cause and effect. In this instance, it is apparent
function and appearance; 9.6% of the black chil­ that tongue-thrusting and even thumb-sucking
dren had open bites measuring 2 mm or more. (with a 10% incidence found in the U SPH S sur­
Only 1.4% of the white children had an open bite vey) are much more prevalent than the open bite
of this magnitude. malocclusion they are said to cause.
The data for the incidence of tongue thrust in Open bites tend to correct spontaneously as
children are not nearly as good as those from the children become older (Fig 3). From cross-sec­
U SPH S survey. Most observers agree that tional data on 1,400 Navajo children, Worms,
tongue-thrusting is almost universal in infancy; Meskin, and Isaacson16 concluded that spon­
this, of course, reflects the prominent anterior taneous correction occurred in 80% o f simple an­
tongue position of a normal infant swallow. A terior open bites. They contend that:
relatively high percentage of children demon­
strate these characteristics at the time they begin It would be extrem ely valuable if speech therapy tech­
school, and this percentage declines with ad­ niques and interceptive cribs designed for open-bite
vancing years. Typical figures are those of Flet­ problem s would be evaluated on a percentage-of-cor-
cher, Casteel, and Bradley15 who reported that rection basis. F o r instance, if a technique corrected
about 50% of children, 6 years of age, had a open-bite in a certain percentage of the open-bite cas­
tongue-thrust swallow and that this percentage es, this percentage of correction should be greater
than that which occurs w ithout treatm ent. In the case
declined to about 25% at age 15. Hanson and
of simple open-bite in 7 to 9 year old N avajo boys,
Cohen6 show similar findings. Even if these fig­
therapy would have to produce com pletely success­
ures are discounted as being incorrectly high, it
ful results in better than 80 percent of the children with
is apparent that a clinically evident tongue thrust open-bite in order to do b etter than nature and ma­
does not necessarily coincide with an open bite turity would do w ithout therapy. O ne must be very
malocclusion and, in fact, most often does not. careful in taking credit for correction of an open-bite.
Since generations of clinicians have noted an
association between sucking habits, anterior In addition to the problem of open bite, clini­
tongue positioning, and open bite malocclusion, cians have been tempted to link the dental prob­
and since such an association can be demon­ lem of maxillary incisor protrusion to thumb-
P roffit— Mason: MYOFUNCTIONAL THERAPY ■ 407
sucking and tongue-thrusting habits. Protrusion
of maxillary incisors is strongly related to thumb-
sucking that persists after permanent incisors
erupt, and this was borne out by the USPH S sur­
vey, as well as by Hanson and Cohen.6 About
17% o f all children, however, have excessive
protrusion of maxillary incisors; this figure ex­
ceeds the percentages for thumb-sucking.
Thumb-sucking is not the major cause of this
condition in the population. Genetic determin­
ants of jaw relationship are known to be a sig­
nificant cause. The relationship (if any) of
tongue-thrusting to incisor protrusion cannot be
determined from present data.
It has been assumed in many dental textbooks LEFT LEFT CENTRAL RIGHT RIGHT
MOLAR CANINE INCISOR CANINE MOLAR
that the pressures created by the tongue, in con­
junction with balancing pressures from the mus­ R B 8I Aboriginal d - 13
CvT3 W hite n - 8
culature of the lips, strongly influence the posi­ 25
tion o f the teeth. If this were true, the pressure
by a thrusting tongue could, in itself, lead to pro­
trusion of incisors. Within the last decade, the
advent of miniature intraoral pressure measur­
ing devices has allowed this hypothesis to be dir­
ectly tested. N o balance of pressures against the
dentition has been observed. The expansive
forces of the tongue are not directly balanced
by the containing forces of the lips even when
prolonged time periods are considered. The
shape o f the dental arches and the position of
teeth within the dental arches do not seem to be
strongly influenced by the horizontally directed
pressures of the tongue and lips during functional LEFT LEFT CENTRAL RIGHT RIGHT
MOLAR CANINE INCISOR CANINE MOLAR
activity such as swallowing and speaking. For TRANSDUCER POSTTION
instance, tongue pressures decrease as the size
Fig 4 ■ T o p , c o m p a ris o n o f m a x illa ry lin g u a l p re s s u re s d u rin g
of the dental arch increases; this is the reverse
s w a llo w in g sa liva o n c o m m a n d in A u s tra lia n a b o rig in e s and
of what would be expected if tongue pressure in w h ite c h ild re n in K e n tu c k y . B o tto m , c o m p a ris o n o f m a n d ib u ­
somehow pushed the teeth into a new position. la r lin g u a l re s tin g p ressu re s in a b o rig in e s and in K e n tu c k y c h il­
This is well demonstrated by comparison of d re n . In b o th in sta n ce s, to n g u e p re ssu re s a re h ig h e r in the
tongue pressures in Australian aborigines who A m e ric a n c h ild re n , b u t th e d e n ta l a rc h e s o f th e a b o rig in e s are
la rg e r in all d im e n s io n s .
have large arches with those in North American
whites (Fig 4 ).17 Similarly, patients with pro­
truding incisors have less tongue pressure against ered from a vertical or tooth eruption point of
these teeth than do normal persons. When the in­ view, the situation is somewhat different. The
cisors are retracted, tongue pressures increase forces o f eruption of teeth are very small, of a
to the normal values.18 There is no reason to be­ magnitude of 5 g, and the factors that control
lieve that incisor protrusion or arch width is re­ eruption remain essentially unknown. It is quite
lated to tongue pressure during swallowing. possible, although it has never been demonstrat­
If only resting pressures, particularly resting ed directly, that light forces produced by an an­
lip pressures, are considered, a stronger rela­ teriorly positioned tongue tip can impede erup­
tionship with dental arch form is observed. The tion of incisors. If, at the same time, there were
resting posture of the tongue and lips is certainly no impediment to posterior eruption, an open
more important in arch width and incisor protru­ bite would result as the posterior teeth erupted
sion than pressures during swallowing, speak­ and the anterior teeth did not. In a growing child,
ing, or eating.17 continuous eruption of both anterior and pos­
If the dentition of a growing child is consid- terior teeth is necessary to compensate for ver­
408 ■ JADA, Vol. 90, February 1975
tical growth of the face and jaws. meantime. Myofunctional therapy has no place
Experimental data on this recently have be­ in the techniques of preventive dentistry.
come available through the work of Wallen19 in
our laboratory. He used a new type of pressure ■ Tongue thrust with associated speech prob­
transducer to study pressures in different planes lems only: If a tongue-thrust swallow and
of space. In a comparison of patients with an­ speech problems coexist, one should not assume
terior open bite malocclusion and persons with a causal link of one to the other.
normal dentitions, vertically directed forces If tongue-thrusting is associated with lisping,
were less in the open bite group.19 This is just only a speech therapist should be encouraged
the opposite of what the “ swallowing equilibri­ to correct the speech problem using articulation
um” theory would have predicted. Therefore, it therapy techniques. Such therapy can be initi­
seems likely that the prominent tongue during ated according to the usual considerations used
swallowing in patients with open bites does not by speech clinicians. Although several speech
produce the altered vertical position of the inci­ clinicians have suggested various techniques for
sors. Resting tongue posture may be more im­ lisping tongue-thrusters, we do not think that the
portant than swallow activity in open bite also. clinical diagnosis of tongue-thrusting necessi­
The research data presented up to this point tates a special speech therapeutic approach, es­
indicate a much smaller need for tongue-thrust pecially by any individual other than a speech
therapy than its proponents currently advocate. clinician.
The swallow pattern affects the resting posture If a prepubertal child with speech errors also
of the tongue and vice versa, but the evidence exhibits a tongue-thrust swallow, it may be
indicates that changing of the resting position is tempting to work on swallowing patterns con­
more important when tongue therapy is needed current with speech therapy. Our experience
for treatment of malocclusion. The proper role has shown that this is usually unnecessary and
for myofunctional therapy is now presented in contraindicated. Articulation therapy promotes
terms of the clinical problems associated with repositioning of the tongue tip at rest and for the
tongue-thrusting. initiation of speaking and swallowing tasks in
young children. Most of the time, the tongue-
thrust swallow will correct itself with additional
maturity.
Role of myofunctional therapy in
tongue thrust ■ Tongue thrust with malocclusion but no
speech problem: If malocclusion exists in a
child who has a tongue thrust but no speech prob­
■ Tongue thrust alone: The only rationale for lem, the dentist is presented with a choice. H e
myofunctional therapy in the child with a tongue can begin the treatment of the malocclusion hop­
thrust who has neither speech problems nor a ing that the tongue posture and activity asso­
malocclusion would be that this therapy would ciated with it will disappear as the anatomic sit­
prevent development of such problems in the uation is corrected, or he can attempt to change
future. There is no evidence that speech prob­ the tongue-thrust pattern before beginning orth­
lems will develop in a child who has normal odontic treatment. Some dentists in the past
speech because he or she has a tongue-thrust have elected the second course and have called
swallow. Nor is there any evidence that an open on speech clinicians to assist with these children
bite malocclusion will develop where one does to teach them a more adult swallow pattern. The
not already exist because of a prominent tongue first course now seems to be the better clinical
during swallowing. The percentages for open approach, however.
bite and tongue-thrusting are eloquent evidence Postponement of any tongue therapy until
on this point. treatment of the malocclusion is begun has three
We, therefore, see no reason to recommend major advantages.
any treatment for children who have a tongue- First, in the absence of obvious predisposing
thrust swallow without evidence of accompany­ factors, correction of the malocclusion usually
ing problems. Such children will almost surely will result in disappearance of the tongue thrust
complete the transition to a normal adult swal­ without any particular therapy being directed at
low on their own and dental or speech problems it. A distillation of orthodontic experience sug­
attributed to the tongue will not develop in the gests that 80% of children with malocclusion and
P ro ffit— Mason: MYOFUNCTIONAL THERAPY ■ 409
tongue thrust fall into this category. tive in producing this.13,20 (Well-controlled
Second, postponement of tongue therapy gives clinical studies indicate that myofunctional ther­
the child a maximum opportunity to complete apy does not significantly change the swallow
the swallow pattern transition on his own. In our pattern.9) Simpler exercises aimed primarily at
opinion, the usefulness of swallowing therapies correcting resting position may be equally effec­
with elementary school children is unsupported. tive in treating open bite malocclusion.
Experience with electromyography, cinefluor-
oscopy, and lingual pressure transducers indi­ ■ Tongue thrust with malocclusion and a speech
cates that children are much more variable in problem: If speech therapy and orthodontic
their swallow patterns than is the adult popula­ treatment for open bite are carried out concur­
tion. Variability seems to be a primary attribute rently in pubertal and postpubertal patients, it
of school-age swallowing patterns. As a child often is desirable to modify the resting posture
becomes older, variability decreases concurrent of the tongue. The tongue positioning exercises
with the normal transition to adult swallowing. used in classic myofunctional therapy may be
We already have pointed out that at this same helpful. Articulation therapy techniques involv­
time in the growth pattern of the child, spon­ ing adaptive phonetic placements also are use­
taneous remission of open bite is also seen as a ful in repositioning the tongue tip posteriorly in
consequence of developmental progression into these individuals. Speech therapy certainly
adolescence. should not be delayed until treatment of the mal­
Third, for those older children who do not occlusion is begun. In some instances, ortho­
show spontaneous progress toward adult swal­ dontic treatment at an earlier age may be recom­
lowing and for whom therapy is indicated to pro­ mended to make it easier for the child to achieve
mote changes in resting tongue position and swal­ proper tongue placement for speech.
low pattern, the therapy seems most effective if Orthodontic treatment procedures may create
it is carried out along with tooth movement. This a temporary relapse of some speech skills that
takes advantage of the natural tendency of func­ have been developed previously. We have found
tion to adapt to changing form. that the orthodontist need not fear creating long-
Even in older children, it is important to eval­ range speech problems by orthodontic treat­
uate anatomic or physiologic predisposing fac­ ment nor should the speech clinician be discour­
tors before any tongue therapy is started. When aged from continuing with therapy procedures
tongue-thrusting is related to airway problems, during orthodontic treatment. Most children
the tongue is expected to adapt with a forward adapt quickly to the reduction in articulatory
gesture to initiate a swallow so that the bolus of proficiency sometimes brought about by orth­
food can be accommodated through the faucial odontics. In those instances in which the child
isthmus. This is a natural adaptation rather than does not adapt readily, it is logical to provide aid
an abnormal behavior for such a child. There­ in the form of speech therapy. It makes little
fore, swallowing exercises should be avoided in sense to us to wait for the completion of orth­
those children in whom the faucial isthmus size odontic work to start therapy on any associated
is reduced. Tongue-thrusting associated with speech problems.
airway maintenance problems may be etiologi-
cally related to hypertrophied tonsils and aden­
oids. Any decision for adenotonsillectomy
should be made by a physician on the basis of Summary and recommendations
physical complaints rather than speech or
tongue-thrusting variations. In the event that The controversy surrounding tongue-thrusting
the tonsils and adenoids are removed for medical focuses on whether this behavior has a deleter­
reasons, we suggest giving the child time to de­ ious effect on dental occlusion or whether it
velop a normal adult swallow before tongue ther­ merely represents an adaptation to the malocclu­
apy is recommended. sion. The weight of the evidence is that, most of
It is helpful in an evaluation of the various ex­ the time, the tongue-thrust behavior does not
ercises for improving tongue position and cor­ cause malocclusion. The dentition is relatively
recting tongue-thrust swallowing to reflect on insensitive to pressures of tongue and lips dur­
the probability that the resting tongue position is ing swallowing. Any effect that the tongue has in
more important for malocclusion. The published contributing to malocclusions seems related to
step-wise exercises for swallowing may be effec­ resting posture as it affects the eruption of teeth.
410 ■ JADA, Vol. 90, February 1975
 A constellation of morphologic findings can R e s e a rc h s u p p o r t w a s p r o v id e d b y t h e N a tio n a l I n s t it u t e o f
D e n ta l R e s e a rc h , g r a n t D E -0 2 1 8 2 .
explain the presence of tongue-thrusting in nor­
T h e a s s is ta n c e o f R o b e r t L. P a te r s o n w ith p r e s s u r e t r a n s d u c e r
mal school-age children. Of particular impor­ s t u d ie s is a c k n o w le d g e d .
tance is the airway space at the faucial isthmus
and in the pharynx. Reduction in airway space D r. P r o f f it is p r o f e s s o r o f o r t h o d o n t ic s a n d c h a ir m a n o f t h e

encourages anterior tongue positioning as an d e p a r t m e n t o f p e d ia t r ic d e n tis tr y , U n iv e r s it y o f F lo r id a C o lle g e

o f D e n tis tr y , G a in e s v ille , 3 2 6 0 1 . D r. M a s o n , f o r m e r ly a c a d e m ic
adaptation to the airway maintenance problem. p r o g r a m d i r e c t o r o f s p e e c h p a t h o lo g y a n d a u d io lo g y a t t h e U n i­
Since involution of lymphoid tissue at puberty v e r s ity o f K e n tu c k y , is w it h t h e d e p a r t m e n t o f o r t h o d o n t ic s , U n i­
helps to relieve airway problems, there are mor­ v e r s it y o f K e n tu c k y C o lle g e o f D e n tis tr y , L e x in g t o n , 4 0 5 0 6 .

phologic as well as physiologic reasons to anti­

1. C le a ll, J .F . D e g lu t it io n : a s t u d y o f f o r m a n d f u n c t i o n . A m J
cipate changes in tongue positioning in early O r t h o d 5 1 :5 6 6 A u g 1 9 6 5 .
adolescence. Up to 80% of children who have a 2. W e in b e r g , B. D e g lu t it io n : a r e v ie w o f s e le c te d t o p ic s in
tongue thrust and anterior open bite at age 8 show “ S p e e c h a n d t h e d e n to - fa c ia l c o m p le x : t h e s t a te o f t h e a r t . ” A m
S p e e c h H e a r A s s o c re p . n o . 5, 1 9 7 0 , p 116.
improvement without therapy by age 12. 3. M o o r re e s , C .F ., a n d o th e r s . R e s e a r c h r e la te d t o m a lo c c lu ­
On the basis of our view of tongue-thrusting, s io n . A “ s t a te - o f - t h e - a r t ” w o r k s h o p c o n d u c te d b y t h e O r a l- F a c ia l
these recommendations are offered as an aid to G r o w th a n d D e v e lo p m e n t P r o g r a m , t h e N a tio n a l I n s t it u t e o f
D e n ta l R e s e a rc h . A m J O r t h o d 5 9:1 J a n 1971.
clinicians for making decisions about myofunc­ 4 . C h r is tia n s e n , R .L . S o m e b io lo g ic c o n s id e r a t io n s in o r th ­
tional therapy. o d o n t ic r e s e a r c h . A m J O r t h o d 6 0 :3 2 9 O c t 1 9 7 1 .
First, such therapy is not indicated for chil­ 5. S tr a u b , W .J . M a lf u n c t io n o f t h e t o n g u e . P a r t 1. T h e a b n o r ­
m a l s w a llo w in g h a b it : its C a use, e ffe c ts , a n d r e s u lts in r e la t io n
dren who do not have a malocclusion or a speech t o o r t h o d o n t ic t r e a tm e n t a n d s p e e c h th e r a p y . A m J O r t h o d 4 6 :
problem. Because no problem will arise, there is 4 0 4 J u n e 1960.
no need for preventive treatment. 6. H a n s o n , M .L ., a n d C o h e n , M .S . E f fe c ts o f f o r m a n d fu n c ­
t io n o n s w a llo w in g a n d t h e d e v e lo p in g d e n t it io n . A m J O r t h o d
Second, even in the presence of malocclusion, 6 4 :6 3 J u ly 1 97 3.
therapeutic intervention for swallowing varia­ 7. B o s m a , J .F . H u m a n in f a n t o r a l f u n c t io n . In B o s m a , J .F ., e d .
tions is not indicated before puberty. (Matura- S y m p o s iu m on o r a l s e n s a tio n a n d p e r c e p t io n . S p r in g f ie ld , III,
C h a rle s C T h o m a s , 1 9 6 7 , p 98.
tional age is more important than chronological 8. P r o f fit, W .R . L in g u a l p r e s s u r e p a t te r n s in th e t r a n s it io n
age.) In the event that the transition from tongue- fro m t o n g u e t h r u s t t o a d u lt s w a llo w in g . A r c h O ra l B io l 1 7 :5 5 5

thrust swallow to a normal adult swallow does M a rc h 1972.

9. S u b te ln y , J .D ., a n d S u b te ln y , J .D . O ra l h a b its — s t u d ie s in
not take place by the beginning of puberty, ther­
fo r m , f u n c t io n a n d th e r a p y . A n g le O r t h o d 4 3 :3 4 9 O c t 1 9 7 3 .
apy to promote a changed tongue position is 10. S c a m m o n , R .E . T h e m e a s u r e m e n t o f th e b o d y in c h i ld ­
probably indicated. The techniques of myofunc­ h o o d . In H a rr is , J .A ., e d . T h e m e a s u r e m e n t o f m a n . M in n e a p o lis ,
U n iv e r s ity o f M in n e s o ta , 1 9 3 0 , p 50.
tional therapy may be helpful for this purpose. 11. R ic k e tts , R .M . R e s p ir a t o r y o b s t r u c t io n s y n d ro m e . A m J
Third, if tongue therapy is indicated, it is most O r t h o d 5 2 :4 9 5 J u ly 1 96 8.
effective when combined with orthodontic treat­ 12. W ic k w ir e , N .A .; W h ite , R .P ., J r .; a n d P r o f f it , W .R . T h e e f fe c t
o f m a n d ib u la r o s t e o t o m y o n t o n g u e p o s itio n . J O ra l S u r g 3 0 :1 8 4
ment to reposition teeth. M a r c h 1 97 2.
Fourth, if lisping and tongue-thrusting or mal­ 13. H a n s o n , M .L . S o m e s u g g e s tio n s f o r m o r e e f fe c t iv e t h e r a p y
occlusion, or both, coexist before puberty, we f o r t o n g u e t h r u s t. J S p e e c h H e a r D is o r d 3 2 :7 5 F e b 1 9 6 7 .
14. K e lly , J .E .; S a n c h e z , M .; a n d V a n K ir k , L .E . A n a s s e s s m e n t
recommend that a speech clinician initiate o f th e o c c lu s io n o f te e th o f c h ild r e n . N a tio n a l C e n te r f o r H e a lth
speech therapy procedures in spite of concur­ S t a t is t ic s , U S P u b lic H e a lth S e rv ic e , 1 9 7 3 . D H E W P u b l n o . H R A
rent problems. Classic myofunctional therapy 7 4 -1 6 1 2 .
15. F le tc h e r , S .G .; C a s te e l, R .L .; a n d B r a d le y , D .P . T o n g u e -
techniques are of little additional help and are t h r u s t s w a llo w , s p e e c h a r t ic u la t io n , a n d a g e . J S p e e c h H e a r D is ­
contraindicated if airway size at the faucial isth­ o r d 2 6 :2 0 1 A u g 1961.
mus is reduced. 16. W o r m s , F .W .; M e s k in , L .H .; a n d Is a a c s o n , R .J. O p e n - b ite .
A m J O r t h o d 5 9 :5 8 9 J u n e 197 1.
Fifth, in those older children with speech 17. P r o f fit, W .R . M u s c le p r e s s u r e s a n d t o o th p o s it io n : f in d ­
problems in which orthodontic treatment for in g s f r o m s t u d ie s o f N o r t h A m e r ic a n w h it e s a n d A u s tr a lia n a b o r ­
open bite is carried out, and if it is desirable to ig in e s . A n g le O r th o d , in p re s s .
18. P r o f f it , W .R . D ia g n o s is a n d t r e a tm e n t p la n n in g f o r a lv e o ­
modify the anterior resting posture of the tongue, la r s u r g e r y , w ith s p e c ia l r e fe r e n c e t o s o f t tis s u e c o n s id e r a t io n s .
the techniques of myofunctional therapy may In P r o c e e d in g s o f t h e T h ir d In te r n a t io n a l O r t h o d o n t ic C o n g r e s s .
be useful. Articulation therapy techniques are L o n d o n , 1 9 7 3 , in p re s s .
19. W a lle n , T .R . V e r t ic a lly d ir e c t e d f o r c e s a n d m a lo c c lu s io n : a
also particularly helpful in repositioning the n e w a p p r o a c h . J D e n t R e s 5 3 :1 0 1 5 S e p t- O c t 1 97 4.
tongue tip posteriorly. 2 0 . B a r r e t t, R .H . O n e a p p r o a c h t o d e v ia te s w a llo w in g . A m J
O r t h o d 4 7 :7 2 6 O c t 196 1.

P ro ffit— M ason: MYOFUNCTIONAL THERAPY ■ 411