By Renée Cavazos Kreisner, M.S. CCC-SLP
Did your baby really dislike the car seat or tummy time? Did your child have difficulty sleeping or did they drop naps really early? Did they have difficulty breastfeeding, too? Does your child have a difficult time eating a variety of foods; foods that are different textures or they seem pickier than average? When your child is sleeping, exercising, or watching television, is their mouth open? Does your child have an oral habit like sucking on fingers and thumbs or constantly putting objects in their mouth to suck or chew on?
I just described myself as a young child. And these questions can be used as part of a screener to help diagnose Oromyofunctional Disorders (OMDs). My OMDs were not diagnosed until I was 33 years old after I went to see an Orofacial Myologist in 2021. I was diagnosed as an adult, but my symptoms actually started in utero. My entire life, my breathing, sleep, and swallow were disordered which presented as difficulty chewing, coughing and choking at meals, TMJ disorder, symptoms that resembled asthma, snoring, chronic fatigue, and chronic mouth breathing. Now, almost 8 months post Oromyofunctional therapy and medical treatment, I feel healthier, I have less body pain, and I wake up most mornings feeling rested.
What is Oromyofunctional Disorders and Oromyofunctional Therapy
Let’s break down the word “Oromyofunctional” because it is a mouthful: Oro= mouth, Myo=muscle, functional=working in a proper way. When the muscles of the mouth are not working properly, we have disorder. And disorder in the mouth directly impacts the two main functions of the body: 1. To breathe through the nose and 2. To swallow saliva, liquid and food. OMDs can impact the entire body.
Let’s talk about the beginning of the lifespan. If an infant is mouth breathing or having difficulty transferring ounces from breast or bottle, there is likely an oral-motor disorder that, if left untreated, will become an OMD. An oral motor disorder is when the muscles of the mouth are not coordinating well to feed. The oral-motor disorder will lead to other compensations in the muscles of the mouth and body as the infant tries to breathe and eat.
OMDs in Children
This is my son Jeremy. As a 2-month-old in the first picture, he is showing low, thrusted tongue posture between lips while sleeping. In the second picture, some bunny has a posterior tongue tie that’s been missed by multiple lactation consultants and one pediatric dentist that “specializes” in tongue tie releases/frenectomies. In the third picture, he looks so precious and cute. And he is displaying mouth breathing and open mouth posture/low long tongue posture.
Below are some common red flags for Oromyofunctional Disorders in pediatric populations.
In infants, OMDs red flags can look like a baby who:
- has poor latch, mom appears to have “low supply” as a result
- has a weak suck-swallow-breathe pattern and cannot transfer ounces
- mouth breathing when asleep
- cannot get back to birth weight in a typical amount of time
- shows has one-sided body preference
- can only bottle feed
- dribbles milk out of the side of their mouth consistently when bottle or breastfeeding
- is clicking on breast or bottle
- has been diagnosed with torticollis
- has head flattening, diagnosed with plagiocephaly
- has constipation and reflux issues
- seems “colicky/fussy”, cries excessively and can’t settle
- “holds” their head up early, sometimes even after birth
- rarely sleeps for long stretches and naps in 30-45-minute increments
Pictured on the left is a before and after pic of a school age child who has an open bite malocclusion from thumb sucking. The after picture is taken after Oromyofunctional therapy. Pictured on the right is a before and after of an adolescent with an open bite from oral habit and “tongue thrust” pattern. Patient was treated with an ALF palatal expander (thin wire palatal expansion) and Oromyofunctional therapy.
In toddlers, preschoolers and school age children, OMD red flags can look like children who:
- Mouth breathe when asleep and/or during the day
- Chronically are “fussy” and have tantrums more than the average toddler/preschooler
- Push out their tongue when they talk (lisp), drink, or eat. This is called tongue thrusting/anterior swallow pattern (immature swallow) or interdental/lateral lisp.
- Have speech delay and/or unintelligible speech
- Are picky eating beyond typical pickiness; eats less that 15 different food items
- Didn’t transition to solids well by 12 months
- Show overt and frequent signs of coughing, gagging, choking when eating and drinking
- Snore or grind teeth excessively
- Display excessive drooling; can soak a shirt easily
- Have poor posture, slouched, head forward
- “W” sit and who may qualify for PT or OT based on delayed motor skills
- Does not easily fall asleep, is up during the night frequently, and is chronically tired in the morning; “cranky behaviors” upon waking up
- Has ADHD or Sensory Processing Disorder (SPD) type symptoms
- Has chronic ear infections
- Needs palatal expansion for teeth fit
- Needs orthodontics/braces
- Has a gummy smile
- Needs tonsils and adenoids removed
- May have crowded teeth; shark teeth
- May suck thumb, suck pacifier, or have another oral habit that lasts beyond 2 years of age
- May still use a bottle or sippy cup after 18 months and cannot transition to other cups
Why does screening for OMDs Matter?
OMDs are important to identify because they can interfere with normal growth and development of the muscles and bones of the face and mouth. The bones of the face and cranium are around 70-80% done growing by 8 years old and 98+% done growing by 12 years of age. OMDs can also interfere with how the muscles of the face and mouth are used for eating, drinking and talking. Did you know that the tongue is a muscle that grows and expands the palate so their adult teeth have room to come in? That means that muscle builds bone.
Who Can Treat OMDs?
Now that we know more about symptoms, that brings us to therapy. Who can treat OMDs, how can OMDs be treated and when is the best time for treatment to be most preventative? A highly skilled Orofacial Myologist (COM certification) or Speech Language Pathologist (SLP) with Orofacial Myology Training can conduct an evaluation and make medical recommendations and referrals and create an individualized treatment plan for their patient to address the disorder. COM certified individuals are certified through the International Association of Orofacial Myology (IAOM) and they can be dental hygienists, orthodontists, speech therapists, ENTs, etc.
How can OMDs be treated? That completely depends on your child’s age and specific OMDs. There is not a one size fits all or most model to therapy. Evaluation should consider multiple areas of function and therapy should be highly individualized to meet the specific individual’s needs. No two patients with similar OMDs should have the same exact treatment plan.
When is the best time to be getting evaluated and treated? In my opinion, as soon as possible. As soon as there are red flags for oral motor delay in infants and OMDs in older children, evaluation can happen and a treatment plan can be made. It is never too early to start early intervention.
Let’s Talk about the Controversial Elephant in the room: Tongue Ties and Tethered Oral Tissue
Left: pictured is one example of a posterior tie Right: picture is one example of an anterior tie. There is no way to tell by the descriptive words of anterior/posterior which child has what symptoms or impaired function. There are children that can breastfeed really well with either tie for various reasons. There are also children who cannot adequately breastfeed with tongue tie.
Tongue Tie soap box. It has taken me dozens of hours of professional development to correctly assess tongue ties and other oral ties. I have heard the frustrating phrase or some variation of: “My pediatrician said there isn’t a tongue tie. They can stick their tongue out; the pediatrician said it’s not a tongue tie. My pediatrician says tongue tie is a fad; it doesn’t impact feeding, breastfeeding or speech.” This is ill informed advice and bias being passed off as medical fact.
There can be two ways to simply generalize tongue ties: Anterior and Posterior tongue ties. Anterior tongue ties are more of the “traditional” looking tongue ties/string under the tongue is visible and closer to the tongue tip, tie creates a heart-shaped tip if insertion point is close to the tip of tongue. Posterior tongue ties can be extremely difficult to identify, and sticking one’s tongue out is not a functional measurement of tongue tie. Unfortunately, pediatricians and many, many other professionals are not trained to be able to correctly identify tongue tie.
Someone must be highly trained to assess tongue tie as it relates to airway and feeding. This someone could be an IBCLC, a dentist, an ENT, a nurse, a SLP, an OT or PT, a pediatrician, a birth worker, a chiropractor etc. (the list goes on; it’s not the person’s job or title that makes them the expert in identifying tongue tie, it’s the additional training and specialized coursework). Visually looking at a tongue tie is not an accurate way to identify tongue tie. Function has to be assessed. I will have an upcoming blog that goes more in-depth on tongue ties later this summer.
Picture far left: Family picture from May 2022. Guess who has a tongue tie in this picture? If you guessed my husband and my son, you’d be correct! It’s a trick question really because you cannot accurately say who has a tongue tie by asking them to stick out their tongues. If you guessed correctly, it was either blind luck or you’re a psychic. All tongue tie psychics can submit me their resumes ASAP! Pictured in the middle and far right: Rolling Stones’ iconic tongue sticking out logo to always remind us tongues are out for Rock n’ Roll but not for assessing tongue tie.
I am always happy to provide tongue tie resources to families and other medical professionals, so that one day I can stop hearing “But they said there isn’t a tongue tie” because if they just asked your child to stick out their tongue, then they just told you “I don’t really know what I’m doing here and here is my best opinion human to human not doctor to patient based on little to no evidence” without having to say it. Tell me you don’t understand the function of the tongue and how it relates to breathing, sleep, drinking, swallowing food, and speech without telling me. Ok, coming down from the soap box, y’all.
My Tongue Tie
Pictured far Left: Tongue tie measurement position of tongue tip anchorage/tongue on the spot before frenectomy/release. Middle: Tongue Tie measurement position of lingual palatal suction/cave before frenectomy/release. Pictured far Right: tongue tip anchorage 5 minutes post frenectomy/release with sutures by Dr. Poplin, DDS.
Renée’s Case Study (Look Ma, no more tongue tie!)
Pictured left: A candid of my wedding day showing mouth breathing, low tongue posture and forward jaw to better open up my airway. Pictured far right: Me having to consciously put in effort to close my mouth, smile and nasally breathe.
Here’s a very simplified version of what part of my individualized Oromyofunctional treatment plan looked like. *DISCLAIMER* This is not a treatment plan. This is NOT medical advice. It is for educational purposes only. Please call a speech therapist with Oromyofunctional therapy experience like myself at Prism Speech ATX or a COM certified Orofacial Myologist like Tracey Brizendine at Myo4All if you are interested in assessment and treatment of OMDs:
Pictured far left: Before and after of me in 2021 before Oromyofunctional therapy and after therapy in 2022. There are subtle changes in my face due to retraining, strengthening and coordinating the muscles of my face. Middle picture: Me in April 2022 after my first Myo Talk Tools training. Probably thinking about where my tongue should be resting in my mouth. And pictured far right: Me happy as a clam having finished a myo program for myself, taken more myo trainings and taking a picture for my business website.
-I scheduled an initial evaluation with an Orofacial Myologist Tracey Brizendine, RDH COM. She evaluated me, recommended OMT and referred me to these two doctors as first steps in treatment.
-I was referred to Dr. Poplin, a dentist, to assess tongue tie/lip tie. I was diagnosed with tongue tie and lip ties. I had my releases/frenectomies done in the middle of my OMT.
-I was referred to an ENT Dr. Wassmuth to assess nasal passages and sinuses. I was a candidate for a balloon sinuplasty because 50% of my nose wasn’t working.
-I’m 8 months post my last orofacial myology therapy appointment. The positive changes that have come post treatment have been substantial and have improved my mental and physical health.
Prism Speech ATX was born conceptually in 2021. It started as an idea and grew into a mission of providing a different type of speech therapy than traditional speech therapy. Prism Speech ATX is therapy that is integrative and collaborative to target root cause and etiology of Oromyofunctional, Feeding and Speech delays.
Prism Speech ATX is Born
I opened Prism Speech ATX in Spring 2022 because I decided to specialize as a speech therapist that provides Oromyofunctional Therapy (OMT) to all, ages 0-99 years+. Early intervention is so close to my heart, and I strive to provide the best care possible for my patients at any age. I believe that the more parents who are empowered by education and information of OMDs, the more people we will have in the community that can identify red flags and refer. This creates the ability to offer preventative therapy earlier.
Prism Speech ATX is a private Speech, Feeding & Oromyofunctional therapy business that serves the central Texas area. As of August 2022, we will move from in-home therapy model to clinic space in south Austin around Menchaca and Ben White area (5 minutes south of Radio Coffee). We are excited to serve the community by offering exceptional speech therapy services that are integrative and collaborative in approach and address root cause and etiology of delays.
If you have any questions or would like to schedule a free 15 minute phone consultation, you can contact us at via email at [email protected] or via text or phone call at (512) 387-0332.
Pictured Far Left: Learning kinesio taping at the IAOM conference. I tell people all the time, Oromyofunctional therapist/Orofacial Myologists are the physical therapists of the mouth. Pictured Middle: Me with Dianah Davidson, RDH COM & Mary Billings, SLP COM. They are absolute rock stars in the Orofacial myology world. They teach and empower other therapists to be master diagnosticians and therapists in treatment of OMDs. The kindest people in the field I’ve ever met & I strive to make them proud as their former student. Pictured Far Right: Me treating a patient with OMDs with oral motor therapy and Oromyofunctional therapy techniques.
Meet Renée Cavazos Kreisner, CCC-SLP
Renée Cavazos Kreisner is an ASHA certified and Texas state certified SLP with over 7 years of experience as a pediatric speech therapist. She has taken the IAOM’s intro 40-hour coursework to begin the process of becoming a COM certified orofacial Myologist in addition to many additional hours of continuing education and coursework in oral motor therapy, TOTs tethered oral tissue, feeding therapy, and apraxia (severe speech delay). She is also a mother to a 4-year-old that struggled with breastfeeding immensely due to his oral motor delays that went unrecognized by many providers in the infant feeding space. She strives every day to be the therapist she would have wanted to have when her son, Jeremy, was struggling with sleep, airway issues, swallowing and breastfeeding issues.