EPISODE 74

[INTRODUCTION]

[0:00:05] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout the lifespan, a weekly audio course and podcast from speechtherapypd.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning.

Keys for SLPs brings you experts in the field of speech-language pathology, as well as collaborative professionals, patients, and caregivers to discuss therapy strategies, research, challenges, triumphs, and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive.

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[EPISODE]

[0:01:24] MBH: Welcome to this episode of Keys for SLPs, keys to opening your eyes and mind to orofacial myology. I am your host, Mary Beth Hines. Before we get started, we have a few items to mention. Here are the financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from speechtherapypd.com. No non-financial relationships exist. Zohara Nguyen receives compensation from speechtherapypd.com for this episode. She is the Director of Education and Training at Neo-Health Services. She is the Co-Chair of the Qualification and Orofacial Myology Examiners Committee. She receives royalties from the sale of her orofacial myology-themed products. No non-financial relationships exist.

Here are our learning objectives for this episode. One, describe steps an SLP can take to form a myo mindset. Two, explain how to incorporate orofacial myology into your current practice. And three, identify challenges specific to working with adults with orofacial myology goals.

Now, we welcome our guest today, Zohara Nguyen, CCC, SLP, CPSP, QOM. That's a lot of letters. A speech pathologist originally from Sydney, Australia. She is currently the Director of Education and Training with Neo-Health Services Incorporated. She recently presented at the Myosphere: Step Up Your Myo Game Symposium, and is a regular contributor to the quarterly Orofacial Myology News. Zohara's passion for the field is also expressed in her design of orofacial myology-themed decor and apparel that can be found in myo offices around the US.

Zohara, I have known you for a few years and I love your enthusiasm for the myo world. I'm so happy to share your story and knowledge with listeners of Keys for SLPs.

[0:03:30] ZN: Thank you so much for having me. I was almost blown out of the water, Mary Beth, when you invited me onto this podcast.

[0:03:39] MBH: Oh, my goodness. Well, thank you. Well, I am so excited to have you and honored to have you. It's funny, we were talking earlier before we were getting ready that I actually just came back from a wake of a dear friend of mine. On his card, it said, ÒIf you love what you do, you'll never work a day in your life.Ó Your enthusiasm for orofacial myology reminds me that you're one of those people. I mean, you just love what you do and you're so excited about it. I think it's so fun for me to be able to share that excitement with the listeners and participants.

[0:04:19] ZN: Thanks so much. Yeah. My friend and colleague, Becky Ellsworth, she calls me an Energizer bunny, because I have energy and enthusiasm for the things I'm into, including orofacial myology.

[0:04:32] MBH: Exactly. That's funny, because I guess that's a case of it takes one to know one because she is also an Energizer bunny. She's got a lot of energy. Yes, you might be the number one Energizer bunny in the myo world.

[0:04:49] ZN: YouÕre above me, but I'll take it.

[0:04:53] MBH: You have such an interesting story about how you came to have this expertise. Will you share your journey with us?

[0:05:02] ZN: Oh, yeah. Pretty much, when I finished speech-language pathology in university in Sydney, I got into my first job. In my first job as an SLP, my boss had said to us, ÒI want you to learn orofacial myology.Ó At the time, my face went red. I started to freak out because I thought this was a therapy that my lecturers at university had said, ÒDo not touch this with a 10-foot pole.Ó They said, ÒAnything oral-motor related, don't touch it.Ó As soon as my boss told me about it and walked me through it, I knew I had found something that really grasped my imagination, my passion.

I'd been a generalist speech pathologist for a little while. I didn't feel I was particularly good being a generalist. As soon as I learned about myo, I knew I had to dive in deep, and I did. I went off and did some trainings. I knew I was moving to the US with my future husband, who's my now husband. I thought I'm going to make the change. I'm not going to be a generalist. I'm going to go into orofacial myology. That's what I've done.

[0:06:21] MBH: Oh, that is wonderful. When did you come to the United States?

[0:06:25] ZN: Six years ago.

[0:06:27] MBH: Okay. Then from there, you decided to go into the education realm.

[0:06:33] ZN: Yes. Yes. Which is funny, because my dad was a lecturer for a long time. I thought, well, I'm a therapist, but I've gone into the education, and as much as I loved seeing clients, I really love empowering other professionals in myo, in speech pathology. It's actually worked out really nicely.

[0:06:56] MBH: Wonderful. Wonderful. Okay, so you started your myo mindset back in Australia. You've continued to grow that. I know you are up on your continuing education and the latest research in this area. Tell us, what are some of the first challenges informing that myo mindset?

[0:07:17] ZN: I think the first challenges really are challenging your belief of what you've learned previously as a speech-language pathologist. That's the hardest thing, because just like when I mentioned in university how I was told, ÒDon't touch this type of therapy. Don't touch tools,Ó I got scared and thought I should do what I'm told. But you actually in myo have to put aside what you've previously learned and come with a fresh mindset, an open mindset. Once you do that and start questioning what you've been doing all along, then you can start really understanding how myo is a perfect therapy for a speech pathologist, and how logical it is and how it will apply to a lot of your existing clients. That is a challenge.

I don't know if this is a generalization, but I feel speech-language pathologists tend to be people pleasers. We're helpers and not disruptors, and I'm not saying to be a full-on disruptor, but do challenge what you know. We will never stop learning and we have to keep learning. Myo is coming up. Myo is gaining the interest of people worldwide, especially professionals. Australia has always been behind America. But even Australian speech-language pathologists are now embracing myo slowly. That's the first thing.

[0:08:47] MBH: What do you know about how much myo is taught in the universities, in the United States, or in Australia?

[0:08:55] ZN: As far as I know, in Australia, very little. The only information I've heard is when someone's doing a clinical work and they've got a supervisor who knows about myo, and they might tell them about it. But apart from that, I don't know of any universities that actually incorporate myo into their training and into their curriculum in the US. In the dental realm, my colleague, Becky, she's taken our program, our myo program into the dental world, but speech, there might be bits taught, but I'm hoping in my lifetime we get to see orofacial myology taught in universities almost as a foundational topic and subject.

[0:09:44] MBH: When you were in school, it was still considered controversial. Now it seems to be, there's a widespread acceptance of its use and the evidence for it. Do you still feel like you're stepping into a controversial space?

[0:10:00] ZN: Absolutely. I think it's controversial, because there's been some confusion. I don't work in oral-motor work, but I have plenty of friends and colleagues who do. Oral-motor was what was controversial to speech pathologists, who thought that therapists were saying, ÒJust use horns and just use straws and that's going to fix speech problems,Ó which was totally not what they said. Then because in orofacial myology, we work on placement, we work on differentiating the oral structures and we might use tools to do this. It was brought into that vortex of controversy.

I find mainly, there are people out there on social media, who are speechies, who feel strongly that myo is controversial. But as far as I know, they haven't trained in it. I would challenge them to train in it and then see what they think. It's only controversial when people have only heard the supposed controversy, but it is so logical that I really can understand once someone is trained in it, how they would still push back against it.

[0:11:16] MBH: Mm-hmm. All right. some of the things that we talked about are learning to look around you when you're in the myo world. When you're opening your eyes, learning to look around you. What do you mean by that?

[0:11:31] ZN: What I mean is in university, when we learned about nautamine physiology, we were told what all the structures were, to look for color, shape, size, all that stuff. But we weren't taught what proper oral function looks at rest. We were taught with chewing and swallowing in parts. Once you're in myo, you learn what orofacial myofunctional disorders are. These are parts of the orofacial complex, the functions, growth and development that has been disrupted. Often, once you learn about orofacial myology, you can't help but see these disorders. I'll probably keep calling them OMDs as we go along.

You will see them everywhere. The modern person generally has some disorder, some OMD. If they don't, they've probably had excellent airway health. They've probably breastfed, had chewing experiences throughout their life. Probably, donÕt have sleep apnea. It's a blessing and a curse as we say at Neo-Health. When you learn about myo, because before myo, you didn't know this was a problem. Until you look around, you see people with their mouth open, you see long, flat faces, you see disruptions in growth and development and even function. You want to go up to everyone and just shake them and say, ÒYou need to see an orofacial myologist.Ó That's what I mean by learning to look around you. You'll see it everywhere. It is a modern disease in a way.

[0:13:12] MBH: Then what about the role of orofacial myology with our articulation? Kids who we see and adults who have articulation disorders. How are those two interrelated?

[0:13:26] ZN: There is a really nice overlap there between articulation and clients with myo disorders. There was a study, it's actually on the ASHA portal. There's a study that said, there's 31% of kids with articulation disorders, who have orofacial my functional disorders as well. I've seen other studies that go up to 80% of this. We know in that range about 30 to 80, it really depends on who is assessing and whether they've been trained to really pick up on the disorders. We know that in myo, if you have open mouth rest posture, low tongue rest posture, your mouth breathing, that is where you begin speech.

We find that those kids who lisp, who have those interdental speech sounds, and even who have those lateral speech sounds, we often see their resting posture of their tongue is low in their mouth when it really should be up on that palate. If it's far forward, we're seeing disruptions in how they speak. We also see in a lot of kids with OMDs, we see the palate is way too narrow. This is something I did not learn in speech pathology. I did not learn that the palate and the palatal width is really important to fit the tongue up into it for speech. I'll just keep using my hand.

[0:15:01] MBH: It's hard when we know that Ð but this is recorded with video, but what is recorded is only the audio. Yeah.

[0:15:08] ZN: Yes. What is not taught and completely blew my mind when I learned about this was that the tongue is up on the palate, the lateral posterior margins of the tongue are braced inside of the dental arch when we speak; when we say a lot of our consonant sounds. It braces there as the tip of the tongue moves and the rest of the tongue moves. I never learned this. This is a problem for a lot of our myo clients who have narrow dental arches, narrow palettes. They can't fit their tongue. What we see is the tongue overflows the palate. We get distortions of the sounds that come out, especially where the airflow is no longer going down a channel of the tongue. It's splaying out.

Then even with kids with myo issues who have airway problems, they might jut their jaw forward, they might pull their tongue forward to get it out of the airway. Then, of course, we hear distortions of sound. That back of the tongue is also not bracing up inside that dental arch. We see kids who have both presentation, myo issues, and articulation. Not that every articulation kid has a myo issue, but I think every articulation kid should be screened for myo issues.

[0:16:40] MBH: I agree with you there. All right, let's talk a little bit about myo and dentition and what the effect of improper oral resting posture is on dentition.

[0:16:55] ZN: Yeah. I don't claim to be an expert with the dentition and I want to stay within scope. But what I do know is oral rest postures that aren't normal, so the tongue being off the palate and being forward. You can hyper erupt the teeth, the back molars. This means that when the teeth are too far apart, it will tell the molars that they need to keep erupting. Then you get changes in the bite. When there are changes in the bite because of that, or because that tongue has been sitting between the teeth and the front teeth can't erupt the way they're meant to, because their tongue is in the way, then you form open bites.

With any of those sorts of dental issues, the tongue will often plug itself again inside of those spaces to brace itself during speech. We see it during swallowing. Then in order to achieve a correct sound, you'll often, or even just function in general, you'll find that the tongue will just accommodate. It will do whatever sounds best, or feels best, or creates negative pressure if it needs to create negative pressure. The dentition really changes a lot of our oral functions. If we think about what we call an overjet where the top teeth are a lot more forward than the lower teeth, then you'll also find the speech, the lips will have a hard time wrapping around those teeth that are coming forward. We start to see compensation. You might even see four bilabials, for instance.

The upper teeth are touching the lower lip. For those B sounds, you might see, Òthe, the, the,Ó the top teeth hitting the lower lip, rather than the lips coming together. The kids who are doing this are actually pretty clever. They're trying to get an approximation of the sounds they're meant to using the dysfunctional structure that had developed. I could go more into it, but that is the general idea behind dentition and how it can affect speech and oral functions.

[0:19:16] MBH: Well, thank you. Then one more little point, so we're talking about in the development, but I worked in a private practice with a lot of OM clients. We got a lot of referrals from orthodontists. The reason for those referrals was the orthodontist did not want to put the braces on the teeth with the OM disorder, because after the braces came off, the tongue would just move the teeth back to where they were, or in the direction where they were. Do you, in your experience, do you get a lot of referrals from orthodontists?

[0:19:55] ZN: This is probably one of the top reasons for referrals to an orofacial myologist, because of what they call orthodontic relapse. We have heard of clients who've had two, three sets of braces in their life. The orthodontist is pulling out their hair, because it's not working. The teeth are moving. The orthodontists have clued in that there is an issue here, probably with the tongue, and it's out of their hands. They can't work anymore. They work with the teeth, and they ask us to step in.

Usually, those referrals say that there's orthodontic relapse and that there is Òa tongue thrust.Ó Tongue thrust is a super vague term, but we know what it means pretty much when it's referred to us. It means, there is an OMD there. There's a myofunctional disorder. It often means that resting posture of the tongue is between the teeth, or against the braces, or against the teeth for long periods of time. Those constant pressures of the tongue against the teeth, or between the teeth, even though they're light pressures, will move the teeth. That's the problem.

Orthodontics constraining your teeth, even make them more functional by lining them up, but they won't teach the tongue where to go. That's where OMDs come to light once orthodontics are off. We see it looks beautiful, but it's not functioning correctly as a system.

[0:21:35] MBH: Right. Right. Well, you had these beautiful straight teeth, and your braces are off. If your tongue is not in the right place, if your tongue is putting constant light pressure against the teeth, that's the exact same thing that the braces just did.

[0:21:51] ZN: Absolutely. That is how it works. Yeah, that is the idea behind the movement of the teeth. It's the same with orthodontics. It's consistent. It's a light pressure. There is still talk all over social media, all over dental and even speech websites saying, a tongue thrust swallow is four to six pounds of pressure. We swallow 2,000 times a day, and this moves teeth. It's not the swallow. This drives me crazy, and I will advocate till the end that this was debunked long ago. It's the tongue rest posture that moves the teeth.

[0:22:32] MBH: Well, when I took my 28-hour course, that was my first surprise. I thought that was the problem. But no, it makes sense. It's not the problem. If you think about it, orthodontists don't put braces on that are moving to move the teeth. The braces are fixed, which is what the tongue is in the resting posture.

[0:22:53] ZN: Yeah. To add to that about the pressures, we have buckle pressures. We have our cheek pressures that are always pressing lightly against our teeth. We also have our lip pressures, pressing with the orbicularis oris, always pushing lightly against our teeth. We need that tongue up against the palate to counteract those pressures. It's a harmonizing of all of those intraoral pressures that work together to maintain that dental arch, to maintain that palatal arch.

As soon as that is out of whack, the tongue is down. It's not counteracting. We see the movement. That's what the orthodontists want us to do is get that tongue backwards, meant to behaving the way it should to allow their work to look beautiful and to not move anymore.

[0:23:46] MBH: Exactly, exactly. All right, so if someone is interested in working in this area and they need to take a 28-hour course, what should one expect to learn in an introduction to orofacial myology course?

[0:24:01] ZN: Off the bat, anatomy, physiology, absolutely. I don't think you have to learn intricately every single muscle. Some people will say yes, and that's fine, but you generally need to understand the system and how it works the way it does. Through anatomy and physiology and knowing what looks normal versus disordered in the myo world will help a lot. That's generally what you should expect from the basics of a course is how to identify myofunctional disorders based on structures and what they look like and how they behave.

You'll also learn how form affects function and then how function even affects form. It goes both ways. You should also learn about barriers to myofunctional progress. There are all sorts of factors that can inhibit a client's progress and even their ability to start a myo program. We shouldn't take anyone and everyone. That should be on the table in one of the courses that you do.

[0:25:12] MBH: Can you give an example of that?

[0:25:14] ZN: Yeah. Yeah. An example would be an airway issue. Just say, a client comes in, theyÕre mouth breathing. You've done an evaluation and they're clearly mouth breathing. They cannot nose breathe. You are not going to begin a program in orofacial myology, because they're forced to mouth breathe, what we call obligatory mouth breathing. When we're trying to get that tongue up to the palate, if you suck your tongue up to the palate, you can't mouth breathe at the same time. All of our goals that we have won't be achievable until we refer the client on to an ENT, get their airway assessed, and probably intervened to achieve nasal breathing, then we can do our job.

[0:26:01] MBH: Thank you. Okay. What else? What else should one expect from a 28-hour course?

[0:26:08] ZN: You should also learn evaluation, how to look at clients. As I mentioned, we should know what normal structures look like in an abnormal structures, or dysfunctional structures, and then understand how we're going to treat those issues. That's where we need a treatment program that is systematic. It's not just a random assortment of exercises and we close our eyes and point at one and grab it. There really has to be a structure and a plan in place to the exercises if the client doesn't have any barriers in the way.

For treatment, you really want to make sure you can individualize the program to the specific client. We all know when we go to the doctor, we don't want to be just given a script for a drug that everyone's taking for the symptoms they've got. We want to make sure everything's individualized to our needs and that we're not wasting time and money. That's what we want in the program, whatever program you end up learning is knowing how to choose what is important and assigning those exercises to the client, eventually working towards habituation. 

Whatever program you do for treatment should have very clear steps, usually in some form of sequence that builds the skills upon one another and work towards habituation of the skills involved in the program.

[0:27:36] MBH: Habituation is important in any therapy, but why does it play such an integral role in orofacial myology?

[0:27:45] ZN: I think one of the most important, if not the most important part of living is breathing. If we're not breathing correctly and we lapse back into our old habits, then we're going to start compensating again. Just like with speech, we always want to Ð articulation. We always want to take clients to the end where they will do it without even thinking it's automatic. It's the same with orofacial myology. Our main goals are proper oral rest postures. Lips together, tongue up on that palate, nasal breathing.

As soon as the client has not habituated and even coordinating their orofacial structures and functions. If they have not habituated, they're going to find breakdowns in chewing, in a bolus collection, in speech, in all sorts of orofacial functions, and those are probably the reasons they came in the first place. They will even see the body adapt to those compensations. Teeth might move, they might start snoring, whatever it is. We want to get them into habituation, so they form new habits and it's all automatic.

[0:29:03] MBH: Okay. All right, so let's say, an SLP just took a 28-hour course and is excited to get started with OM. How do you suggest incorporating orofacial myology into an SLP practice?

[0:29:17] ZN: First off, they'll probably go skipping into their practice with their newfound information and sit down and think, ÒOh, my gosh. My mind is blown. How am I going to introduce this to my clients?Ó First off, they should probably think about new clients that are coming in and how they're going to implement everything they've learned and then figure out, what are the first thoughts of call that we need to make? Can I see this client, or do I need to refer them on?

In myo, we are incredibly interdisciplinary. We make sure that we're not stepping out of scope. When we see a barrier to our therapy, just like enlarged tonsils, airway issues, ankyloglossia, we need to refer on. They need referrals. They need people to refer to and people who will refer to them. If they don't have an ENT to refer to, a surgeon who will do the frenulum release, they need to set up those networks, connect with people in their area who they can refer to and who will refer back to them. That's probably the first step.

[0:30:32] MBH: The number one, get a referral network.

[0:30:34] ZN: Yes, get a referral network. One of the major pieces of advice is if you've shared information with potential referrals and they're really pushing back and you feel you need to convince them, they're probably not the referral source for you. It's difficult in smaller towns where there's very few professionals, but finding like-minded people, or people who even have that myo mindset, they're open to hearing what you have to say, they trust you as a professional, they're the people to set up as your referral sources.

[0:31:09] MBH: I know with your organization, you have some materials to present to dentist, orthodontist, ENTs, other professionals. What's your recommendation besides going in and talking to the people? What's your recommendation on resources, bringing resources to them?

[0:31:25] ZN: One of the resources that usually helps is a screener. I'm pretty sure we have one for our graduates on our orofacialmyology.com website. But a quick screener. What we often suggest is to create some referral pad and have on there main myofunctional disorders that the referral source might see. This could be mouth breathing. This could be, if it's a dental person, that the teeth are shifting, or there's orthodontic relapse. You can have a bunch of symptoms that the referral source can easily identify.

When that referral source sees a client and realizes they've got these symptoms, they check them off, they write the client's name on it, give it to the client and the client will call you. That referral pad should have your name, your business name, and your phone number and contact details. That's one thing that a lot of people use in our world because it's a quick way to do it. That's in a way, a quick screener to some little symptoms for the referral source to acknowledge and identify.

[0:32:38] MBH: That's great because even if they don't totally buy in at the time when you talk to them, you leave that with them, they have a client who's demonstrating these different disorders and then all they have to do is check it off.

[0:32:50] ZN: Absolutely. They don't have to pretend that they know a lot. They don't have time to do a full-on assessment for you. Just a few really recognizable symptoms helps a lot.

[0:33:05] MBH: All right. Once you have set up your referral network, or started to do that because that's really an ongoing process of networking. Tell us a little bit about the evaluation.

[0:33:17] ZN: With the evaluation, as I said about the myo mindset, you've got to put aside some of your old speech-language pathology glasses and put on your myo glasses, because you're going to be looking at the disorders, the myofunctional disorders that present to you. They're so, so obvious, once you know what they are. Sometimes people get really good at identifying them but don't know what to do about it. The thing is once you have all the tools you need, you've got the referral sources, you know what program to use and how to individualize, then it's pretty simple.

The evaluation is usually about an hour to an hour and a half. You take the client through looking at their orofacial structures. You start from the outside of the mouth, go inside, look at function, look at structure, you watch, you observe them, eat something, like a pop tart, something that's not too hard to manage. Then you watch them drink.

Even if you are a feeding therapist, you can also do a separate feeding therapy assessment. But when we do a myo assessment, we are specifically looking at behaviors that we see in myo clients that indicate that there is dysfunction there and that there are present compensations occurring. Anyone who's ever been scared of becoming a feeding therapist, in myo, you're not becoming one. But we have a lot of feeding therapists who do myo to add it to their skill base. Yeah, it's really interesting how many myo clients are textbook with their presentations in the evaluation.

[0:35:01] MBH: That's very true. Yes. One key part of the evaluation is taking all those measurements but also taking a video recording and pictures.

[0:35:12] ZN: Absolutely. Yes. We do take measurements and the measurements are not only just a baseline. They allow us to have data for our clients to show progress over time. We don't really take measurements and go, ÒOkay, that's just the way they are.Ó We often hone in on those measurements and then set a goal to improve those measurements, whether it's lip resistance, whether there's a short philtrum and we know that philtrum needs to be longer for lip compression and lip competence, we will then use that data to then help with referrals to professionals who can help us with things outside of our scope for insurance purposes and even for post-therapy data.

Then we can show what work we've done because it's a little hard at times to the untrained eye to show what clients look like before and now what they look like. It's not like dentistry, where you can show the teeth earlier and the teeth now. It's much more about function. But some of those measurements can help us show the improvement over time.

[0:36:24] MBH: Absolutely. Let's talk about the frenulum. That is a very important little piece of tissue, isn't it?

[0:36:33] ZN: Absolutely. Talking about controversy, the frenulum is this little structure that is very controversial.

[0:36:42] MBH: For being so little, it sure has a big debate, right?

[0:36:46] ZN: There's a big debate where the tongue ties exist. It's not the tooth fairy. It is a structure and people really worry about it. I think they overthink it and it's easy to do. But the main thing to know about the frenulum in myo is when it hasn't developed properly, or it hasn't receded throughout development, how it can impede progress. It can impede oral function. There's a swinging of the pendulum from no one getting released to everyone getting released.

But as orofacial myofunctional professionals, we don't advocate for everyone to get released, because we all have a frenulum. It's only if it's really affecting function. In Myo, it is considered a barrier to beginning our goals, because we'll see the clients only can advance so far in their retraining of their oral and facial muscles before they begin to compensate. Some of you, if you open your mouth really wide and try to touch the incisive papilla behind your top teeth if you look in the mirror, you might see that floor of mouth is coming up. Floor of the mouth is coming up along with your tongue and that's a compensation. We're really good at compensating only to a certain point.

We even see with articulation clients, some might have distortions on their T, D, N, L sound. They might actually be hitting the incisive papilla with the middle of their tongue, with their tip tucked under the bottom teeth. We see compensations. It depends how much function is inhibited here as to whether you do something about it or not. It's those nuances that get confusing for people, I think.

You can observe a frenulum. You measure it. You look at it. But we don't say, ÒOh, it needs releasing, because it's there.Ó I think most speech pathologists need more training in it. They really need to understand it. I would encourage them, if you have any release providers in your area, ask if you can shadow them. A lot are very happy for you to shadow them, to see what they do. Once you understand the process, you can communicate that to your clients and then they know that you will also refer to them when your clients need releases, and it's a win-win.

[0:39:19] MBH: There are really two ways that the release is done. One is a laser, right? Then the other is with a scalpel. Is that still there?

[0:39:28] ZN: Yeah. They call them scissor releases. Laser is pretty popular. Dr. Zaghi in LA, he is very famous for being the ankyloglossia expert. As far as I believe, he uses a combination of laser and scissor. With the different methods of release, it gets a bit complicated. It's really up to the surgeon how far they want to go with the release, which tool they feel is appropriate, because there are so many blood vessels there. It can be different for everyone based on their structure and their anatomy.

[0:40:11] MBH: That could be a topic of a podcast, or a webinar in and of itself, but I did want to touch upon it.

[0:40:17] ZN: Oh, yeah. People get pretty freaked out when they hear that people use scissors, or use scalpels. Even with lasers, people get a bit worried. They think, will it burn, and will it go really deep? My colleague, Dr. Karen Wuertz, she presents amazing information on the nuances of laser releases, since she mainly does laser. I mean, there's a whole range of lasers. People really worry about it. Most clients do fine if it's in the right hand. As long as the surgeon has proper training, they know what they're doing. Once again, they individualize to the client and their structure and their needs.

Yeah, back in Australia, it's very controversial still to identify ankyloglossia and to release. I mean, there are even professionals out there who get a laser and aren't really trained. That's where we ask you if you are referring to a new release provider, ask them how often they do releases. If they say, a couple of times a month. Yeah, they should be doing it more than that.

[0:41:34] MBH: Yes. Another important part of Ð a lot of times, we'll see a client who was released, but it grew back, or it didn't really work right. There are exercises that should be done after the release to keep those tissues stretched and to prevent adhesion. Can you tell us a little bit about that?

[0:41:52] ZN: Yeah. I think the main thing to understand about ankyloglossia releases, just like myo, is no one is promising, or they shouldn't be promising that that is all. You do the release, or you do myo on its own and it fixes everything. There's always that follow up, just like you talked about, Mary Beth. Sometimes people will say, it regrew, and/or it just grew back, or it didn't work.

Karen Wuertz talks about poor healing. Sometimes what I've learned from her is sometimes people aggravate the wound. They rub it, and then it won't heal properly. Sometimes people don't do the exercises post-frenectomy. In myo, we look at kids and work with anyone from four-plus. They should be doing exercises that require them to move their tongue at their own will. Most of these exercises, you get them to use range of motion. As they're doing that, they're stretching that wound to open it up, so it will heal well.

If the client doesn't follow up, there's going to be poor healing and then it looks bad for the surgeon. Not saying that surgeons don't always do a good job either, but it's really a trust between the two, between the therapist, the surgeon and even the client. In our program, in our myo manual program, we don't have specific exercises post-release. We say, to begin with what we call phase one, which is pre-treatment conditioning. What you're doing is getting the tongue to move in various planes. You're getting the tongue to move inside of the oral cavity, as it should, independently of the mandible, which is a skill.

A lot of clients who've had ankyloglossia, they move that tongue and the mandible together. They've never been able to separate. Some surgeons have their own exercises and you can use those. Most orofacial myologists should have a set as well. Then it's an agreement between the surgeon and the orofacial myologist which exercises they're going to do.

[0:44:10] MBH: Thank you. Very good explanation. All right, so let's talk about articulation. We're going to have a lot of clients who have articulation issues and myo issues. What is your philosophy on continuing the articulation therapy, or holding off on articulation therapy while you're doing myo?

[0:44:32] ZN: It's tricky if you've already got a client who you've been doing articulation with for a while and you suddenly learn this new skill set to then say to them, ÒWe're going to throw everything out of the window and begin with myo.Ó You can do that, especially if you hit a roadblock. Then the parent, or the client is even more likely to say, ÒYou know, yeah, we've been trying this for a while and we're not getting the progress we expect.Ó They might be up for a new therapy.Ó If not, then you will have to integrate the two.

If you've got a client fresh, it is in my philosophy, best to begin with myo first, and then articulation. The reason being with myo, as I said in phase one of our program, the myo manual, what you're doing is teaching that tongue to move independently. It's differentiating from the mandible and even from the lips. Because with myo disorders, you see them all work together, trying to help one another because there's limited function there. That's one of the first things we do. We get the lips working.

In a lot of our clients, they have short upper lips, short philtrums, and we can see their teeth when at rest. What we want is to make sure there's no lip tie. There's nothing structural there, preventing them from closing their lips. No excessive overjet, or malocclusion there. If all is good, then we want the lips working as they should, differentiating from the mandible as well. We get all those muscles coordinating well and freely and we get that tongue shaping because a lot of our myo clients have this big lobby tongue that can't narrow. It can't curl. It can't move in all the different directions it should and it drags along the oral cavity, hitting everything in its way as it tries to talk or swallow.

We get the tongue and the oral structures into shape, and then we can move on into our second phase, which really deals with suctioning. Our clients often don't suction. They have really never suctioned very well. They might scoop their food with their tongue, or fluid, pocket the food or fluid in their cheeks, and then suck it back. They're not really trapping food as you should, or fluid on your tongue up to your palate. Now, when you do this, when you learn to do this, you're putting your lateral edges of your tongue inside of your dental arch, when taught correctly.

As I mentioned earlier, we need to have our tongue inside of that dental arch for many functions. When you learn to suction, you're doing this constantly. You're also learning to put your tongue tip to the incisive pillar, what we call the spot. Throughout this program of exercises, you're constantly getting to the spot, you're constantly suctioning the tongue inside that palate. We need all those individual movements and bracing of the tongue for speech. This is where the controversy sometimes comes in where people think, ÒYou're saying you do these exercises, they're non-speech exercises, and you're going to automatically improve speech.Ó Not necessarily.

We're getting the oral structures in the right placement. We're getting them moving as they should, and then we can move into speech once the groundwork is done. I'm sure you're familiar with Pamela Marshalla's work, Mary Beth?

[0:48:12] MBH: Yes.

[0:48:13] ZN: I just want to say something that she says. One of her phrases was, therapists should not be using oral motor activities to improve phonemes. They should be using oral motor activities to improve oral movement. Then those improved oral movements can be used to teach improved phoneme production. She's saying, we need to improve our oral movement coordination and shaping before we move into sounds, and that's all it is. That's what we do with myo, and then we can move into working on sounds once our tongues are able to move the way they should and the oral structures, including the jaw, because that's often off-kilter as well.

[0:48:54] MBH: Exactly. Okay, one of the things that you said was, look at yourself. What did you mean by that?

[0:49:02] ZN: You are going to find when you learn about myo, you will evaluate yourself.

[0:49:07] MBH: Yeah.

[0:49:08] ZN: Yes. How many species are type A types? You want to be perfection, and you're going to find your tongue maybe it doesn't sit up on the palate. Maybe your tongue tip does, but the rest doesn't. Maybe you've got a high-vaulted palate, and you wonder why. We just trained a class over the weekend, and we had speech pathologists getting frustrated because they couldn't do some of the exercises because they knew there were some issues. They had some OMDs. You are your first client, really. Most of us have something. It doesn't mean we need to run off to an orofacial myologist. We do very well with orofacial functions as speech-language pathologists, but we can work on ourselves.

I was my own client, first and foremost. Long story short, I'm a triplet. I was born premature, seven weeks premature. From an early age, I can see from photos, I had airway issues. I'm more of a class three presentation, prognathic. My lower jaw tends to sit more forward than my upper teeth, which means my teeth don't line up. Speechies would know that that affects chewing. Our teeth surfaces should be lined up so we can chew well.

My palate was narrow and I managed to compensate around those structural issues. I knew doing myo that I had to change my bite in order to improve my chewing because I've always compensated. There were certain foods I avoided because my teeth just could not bite them. I also knew that my tongue would not rest well in my palate because my tongue was low for a long time. I actually had really large tonsils, up until 29. Beyond your teenage years, you should not have enlarged tonsils. I advocated for mine to get removed. Since then, to improve the amount of space I've got, I've had palatal expansion.

[0:51:12] MBH: I did not realize that you could have palatal expansion as an adult.

[0:51:16] ZN: Yes, and this is something you learn in myo.

[0:51:19] MBH: I must have fallen asleep during that part of the class.

[0:51:22] ZN: Look, well, it's still something that people say, you can't expand adults. But there are plenty of dental professionals out there expanding adults, and it is possible. It's not as effective as when you're younger, but it is still possible. It helps a lot of people. There are people undergoing expansion older than me. I've seen some of my colleagues in their 50s undergo it, often because they want more airway. They also want more oral space. They recognize the disorder in themselves as orofacial myologists, and they want to do better. They want to improve their health, their nasal breathing, their oral postures because, as I mentioned, if you are mouth breathing, there's actually a cascade of problems that can occur from that. Yeah, you're the best client around.

[0:52:18] MBH: Right, right. That is good to tell anyone who's listening tonight, or in the future who is interested in taking that 28-hour course, be prepared to find something wrong with yourself and not to panic.

[0:52:32] MBH: Absolutely. That's it. You have to, in a way, let yourself mourn what you didn't know before you do the course. That's something that can haunt you is what you could have done for yourself, but even more, what you could have done for your clients that you saw for two years working on S sound, and they're still in therapy. We can't take back what we didn't know. With the knowledge we have after learning, we can then take it to improve our life and our clientÕs life.

[0:53:05] MBH: Absolutely. Absolutely. You only know what you know. All right, so then look at your clients and talk about acceptance and maximization.

[0:53:17] ZN: That acceptance is a bit of what I just mentioned. Accept that you didn't know better earlier. For some of them, especially for adults, they're coming to you for a reason. Some of them have to accept that they couldn't change their history and what happened. Sometimes people had dental procedures that left them with some issues and they have to accept that things are the way they are and now you need to commit. You need to put in the hard work to change for you.

Some clients will try to change for the therapist and that's not the way it works. You won't habituate that way. As to maximization, we use that term at Neo-Health to talk about taking clients as far as they can go. We don't close the door on people who aren't typical myo client. A typical myo client is someone with orthodontic relapse, who has been in therapy, speech therapy for a long time working on the same speech sounds and traditional therapy is not working.

We see people with Down syndrome. We see people with all sorts of atypical presentations and we maximize them. We take them through parts of the program to improve their orofacial structure and function. When we hit a wall, that's as far as we tend to go. We don't promise to get them to habituation, but we improve their orofacial function the best we can. That's part of maximization.

Sometimes it's not even a structural thing. Sometimes it's a circumstantial thing. Maybe the parents, if it's a kid, maybe the parents aren't committed, or maybe there's something happening in their life and we can only take the clients so far before services have to cease. That's just the reality of therapy.

[0:55:07] MBH: ItÕs definitely a therapy that has to Ð you have to be committed to the home program. Sometimes if a family is not able to participate in a home program for articulation, for example, that's okay. You can still get to where you need to go. With orofacial myology, because it's habituation and because you're retraining the muscles, it can't just happen in a half an hour a week.

[0:55:31] ZN: Yeah. It really won't. If they're doing their exercises in the car on the way to see you, it's not going to stick. You're trying to lay down new motor patterns and they need to practice daily, really, especially since we're trying to override old habits. Yeah, commitment is a big one.

[0:55:51] MBH: What else would you say, as far as adults go, what are some of the treatment approaches and challenges with adults?

[0:55:58] ZN: Often, with adults who come to us, sometimes they've been sent by another professional. Maybe the orthodontist, or a dentist. Sometimes they've also been sent by their spouse. If they don't truly understand why they're coming, it's a massive challenge. No matter what approach you've got, they might quit pretty early, because they're not invested in it. They don't understand it. That is always a challenge because they just won't do their homework and you see them taper off.

The other challenge with adults is many are impatient. They want results quickly. Our modern world, we're used to popping a pill and the pain going away, or whatever function, dysfunction we have, we're used to an app helping us. This is pretty old school doing therapy every week, every day and it being a responsibility. Having the time, especially if adults have a family, or a busy schedule, that is definitely a challenge.

They also have habits that are decades long. Figuring out how to rewrite those habits can be difficult if they're just not committed. They also have to understand the benefits of moving away from those habits. again, they need to be motivated. They need to know why they're coming. part of our job is to educate them from the get-go of what the expectations are throughout therapy and what the goals are. It should be their goal as well.

The other challenge are personalities. Some adults think they know better than the therapist. Some have access to Google and YouTube and have seen exercises on YouTube that say they're myo exercises and why don't you do this and why don't you do that? I think as therapists, we know how to handle people, but definitely personalities and a clash of personalities can come into it, especially if you're a younger therapist telling someone twice your age, or 20 years older than you what to do.

On the flip side, I really love adults. When they're committed, when they're motivated, often, they will progress really quickly compared to the kid, because they put it all into plan. Sometimes they will overdo the exercises. But often, they want it to be over, but they're willing to throw the full yards to do it.

[0:58:28] MBH: Exactly.

[0:58:30] ZN: We see pretty quick adjustments to their lifestyle to improve. There are facial functions and yeah, they're pretty good at it, actually. The treatment approach will have to change at times with adults to suit their lifestyle, to suit their personality and attitudes and to suit their progress. Some, frankly, just get bored with one exercise or two, so you might have to change that up and stimulate them a little bit more.

[0:59:00] MBH: Mm-hmm. Give them more exercises at a time. Yeah.

[0:59:03] ZN: Yeah. If it's appropriate. That's where you as a therapist has to know how to adjust your exercises to the client and their needs.

[0:59:11] MBH: Mm-hmm. Well, thank you. All right. Well, we have just Ð we're almost at time. Just want to remind our participants, if you have any questions, you can put them in the chat, or the Q and A, and we can answer them now. I will be looking up for those. Just a couple more questions for you, Zohara. You're a native of Australia and you've worked with a variety of clinicians. We've talked a little bit about what's happening in Australia but what does orofacial myology look like globally?

[0:59:40] ZN: It is spreading globally. As someone who's an instructor who does it virtually, I've met people all over the world who are signing in from Tunisia, from China. We have a bunch from Hong Kong lately, who are working for hospitals with really complex cases and they're looking to myo to help maximize their clients. We've had people from Jamaica. It looks like the word is getting out. Sometimes we don't even know how they found it. I guess the internet. They've heard whispers.

I know Brazil is doing a lot of myo. Even though we don't really call it myo, they're screening babies at birth for Ankyloglossia. It's in what I call myo-adjacent. It's in our interests. As for the UK, I don't hear a lot coming out of the UK about myo, but I do know that it is gaining traction in Australia, as I said. It's becoming more of a therapy that's becoming accepted. Pretty much on every continent. We've trained people on every continent, except Antarctica.

[1:00:51] MBH: Wow, that's really exciting. ThatÕs great.

[1:00:54] ZN: The wordÕs getting out.

[1:00:56] MBH: All right, so in the last couple of minutes, if you could give us one case study, whether it's someone you trained or someone you worked with clinically.

[1:01:07] ZN: I love this. I saw a woman in her, I think it was mid to late 20s, and she was getting married soon. She had a nail-biting habit. She had some jaw issues, some TMJ issues. She came to me. She was assessed by someone else, but she came to me, and I had to do the program on her. She was a good candidate, actually. First and foremost, we worked on oral habits. I said to her, ÒOkay. We're going to do a nail-biting program.Ó

Before we did that, we noticed she had ankyloglossia. Off she went to get that handled. She got that released. When she came back, she said, ÒAs soon as I got that done, my tongue just lifted to my palate.Ó She said, ÒAnd I didn't feel the need to bite anymore.Ó Whether she'd be biting her nails Ð

[1:02:01] MBH: Oh, itÕs so interesting.

[1:02:03] ZN: SheÕd been biting her nails her entire life. Perhaps, the nail biting was a mandible advancement intervention to open the airway. I don't know. Either way, she maybe felt really glad after the frenectomy and stopped biting her nails, but she stopped biting, and instantly, we began myo. Because she was getting married, her goal was, she wanted to get married and have her nails long, natural, and painted. That's what she envisioned. She also wanted to just not have discomfort and pain.

I never say that we will prevent TMJ pain with myo, but sometimes it can happen just through the program. She was a health fanatic. She did so well with her exercises. She followed up constantly. She made every appointment and she was out pretty quickly. She got married, had full nails, didn't bite them again. As you can see Ð

[1:03:05] MBH: That is a beautiful story. That's so fun. Fascinating that she didn't feel the need to bite them anymore. That's really interesting.

[1:03:13] ZN: Yeah. IÕm not saying that everyone who gets a lingual release will stop nail biting, but there's a cascade of problems there, and we got to one of the root causes, which was ankyloglossia. After that, she did feel a change. She felt a change in her body and a change in her tongue posture. Definitely addressing the barriers in her case were a massive advantage.

[1:03:36] MBH: Absolutely. What are your current and future projects, or plans? What do you have going on?

[1:03:44] ZN: I have some exercise cards for our program, for our myo manual. You can see, I illustrate here. I illustrate. I've been illustrating exercise cards for us to release, to go along with our exercise program, because kids need visuals. As speech pathologists, we know this, and photos of mouths are often quite complicated. I've gone ahead and have drawn little exercise cards, and they'll be released, hopefully soon.

[1:04:16] MBH: Oh, that's great. Those would be very helpful.

[1:04:19] ZN: Yeah. I mean, nice and colorful. They can play games with them. Yeah, use it as a visual timetable.

[1:04:26] MBH: Excellent, excellent. Well, I look forward to seeing those. Oh, we have one question here. Let's see. From Eleanor K. Do you base your decision to release on function, or viewing the length of the frenulum, or the color, which I've heard, too?

[1:04:41] ZN: Aha. I know what she's referring to. Usually, function. You do, as an orofacial myologist note Ð you don't have to note the length, but you can note where the frenulum inserts into, which can give an indication of function at times. What she means by color is the blanching. Is the frenulum so tight that it's actually pulling hard and blanching the tissue around it? That can be another indicator that the frenulum might be tight, but usually, function. There are measurements out there.

We use a QTT scale, a quick tongue tie assessment tool, and scale to help us, but there's also Dr. Zaghi's methods as well to help with the measurements, and then you look at function. It's a combination. Mainly, function.

[1:05:31] MBH: Okay, thank you. All right, well, here's another one. What are your thoughts on providing this service via teletherapy?

[1:05:39] ZN: Myo is very good over teletherapy. But I would say, evaluation should be done in person. It's not impossible over teletherapy, but it's much easier to see what's going on and to be in person with someone. I train this virtually. I've seen clients virtually. Not really the younger ones. Older clients, school age adults. Teletherapy works really well. As long as you've got good lighting, they've got their tools, they can follow instructions well. It works very well.

[1:06:11] MBH: Sometimes with good lighting, you can actually see inside the mouth better than you could in person.

[1:06:16] ZN: You can. You can. Because in person, even for a class, if you've got 20 people trying to look inside one mouth, it's hard. But then on the screen, with the right lighting, you can see a lot.

[1:06:30] MBH: Yes, yes. Exactly. All right, and then here's another question. What is the website for you and do you have any recommended resources?

[1:06:40] ZN: The website is orofacialmyology, O-R-O-F-A-C-I-A-L, myology, M-Y-O-L-O-G-Y.com. That's our website for Neo-Health. Recommended resources, there's a lot. There's a whole bunch of resources on orofacialmyology.com, articles by my team, by Dr. Robert Mason. This is one of my favorite resources, the book by Dr. Diane Bahr, Nobody Ever Told Me (or My Mother) That! That's for the more the younger populations that might pose myo risks later on. I think, that one's a good one for younger populations.

There's also Orofacial Myology: International Perspectives by Robert Mason and Marvin Hanson. That has a lot of good information as well in it. There's individual articles as well. I would have to reference them separately.

[1:07:42] MBH: Well, that's a good start though. Thank you very much. All right, what do you use to measure pressure inside the mouth?

[1:07:50] ZN: The only thing we use is the myo lip meter. It's actually our product on orofacialmyology.com. What it is, it's a measuring tool that measures resistance of the lips. We don't measure pressures of the tongue. It's only the lips. To ensure lip closure, lip compression. That's the myo lip meter.

[1:08:17] MBH: Excellent. Okay. All right. Well, thank you so much, Zohara. We really appreciate all of your information and your perspective. Of course, I have to say, I love your accent. I love talking with you. I love your enthusiasm, for what you do. It's really appreciated and great to hear. As we said, if you love what you do, you'll never work a day in your life, right?

[1:08:45] ZN: Absolutely. Thank you so much, Mary Beth. It's been an honor.

[1:08:49] MBH: It has been an honor to be with you. All right. Thank you very much, everyone. Have a great night.

[END OF EPISODE]

[1:08:55] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]
KFSP 74		Transcript

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