Resources & Research — North Bay Speech

Resources

Research

Oral Rest Posture and Nasal Breathing Research

Małgorzata (2021). The role of breathing in coordination of cortical dynamics. “Induced more frequent and/or prolonged inhalation leads to better memory acquisition and reaction time improvement whereas extending the exhalation helps with memory consolidation. Breathing techniques could be used as a non-pharmaceutical treatment of neuropsychiatric disorders that originate from disrupted and reduced power of frequency bands such as gamma, alpha or delta. More research is needed to further prove breathing techniques effects on brain dynamics and their practical application.”

Zaghi et al. (2020). Assessment of Nasal Breathing Using Lip Taping: A Simple and Effective Screening Tool. “...testing whether a subject can breathe through the nose with the lips and mouth taped for three minutes can identify patients at risk of mouth breathing...”

Suzuki et al. (2020). Effects of nasal obstruction on prefrontal cortex activities during chewing. “nasal obstruction during chewing may induce a decline in prefrontal activities, accompanied with deterioration comfort and dyspnoea, and modulated jaw movement activities.”

Campaign SM, Fontes MJ, Camrgos PA, Freire LM (2010). The impact of speech therapy on asthma and allergic rhinitis control in mouth breathing children and adolescents. Jornal de Pediatria, May-Jun;86(3):202-8.doi:10.2223/JPED.1995. Epub 2010 May 6.

Level 2
Randomized control study; 24 subjects

D’Onofrio. (2019). Oral dysfunction as a cause of malocclusion. “If the impact of airway obstruction, soft tissue enlargement and/or soft tissue restriction is great enough, nasal breathing may not be adequate for muscular and cognitive functions, and a pattern of mouth breathing can develop… Mouth breathing encourages a lower jaw posture which can change directional growth over time.”

Ong et al. (2018). Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms. “Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19% in control subjects (P < .001).” “In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching—especially those with excessive SGB.” “These benefits were greater in patients with excessive SGB, and sustainable at 4 months post-treatment.”

Saitoh et al. (2018). An exploratory study of the factors related to mouth breathing syndrome in primary school children. “There is a medical consensus about the relationship between mouth breathing and allergic rhinitis.” “This suggests that incompetent lip seal or MBS was associated with the bad breath, swallowing habits and chewing, as well as the confusion of the teeth and gums.”

Nagaiwa et al. (2016). The effect of mouth breathing on chewing efficiency. “activity of the masseter muscle were significantly (P < .05) lower during mouth breathing” “Chewing activity is disturbed while breathing through the mouth, and it takes a longer amount of time to complete enough chewing strokes to obtain higher chewing efficiency when breathing through the mouth.”

Denotti et al. (2014). Oral breathing: new early treatment protocol. "Oral breathing, in children, is a very common problem. This dysfunction affects approximately 10-15% of child population.” “The rapid palatal expander is a valid appliance to solve malocclusion and oral breathing. It improves the morphology and function of the masticatory system and the upper part of the airway…. The maxilla constitutes the upper wall of the oral cavity and the floor of the nasal cavity.”

Park T, Kim Y (2016). Effects of tongue pressing effortful swallow in older healthy individuals. Archives of Gerontology and Geriatrics, Sep-Oct;66:127-33. doi: 10.1016/j.archger.2016.05.009. Epub 2016 Jun 3.

Level 4
Case series; 27 subjects

Yeampattanaporn et al. (2014). Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain. “Breathing re-education can change breathing patterns and increase chest expansion. This change leads to an improvement in [cervical range of motion] Positive consequences may result from the improvement in diaphragm contraction or reduced activity of accessory muscles.”

Byeon H (2016). Effect of orofacial myofunctional exercise on the improvement of dysphagia patients’ orofacial muscle strength and diadochokinetic rate. Journal of Physical Therapy Science, Sep; 28(9): 2611–2614. doi: 10.1589/jpts.28.2611.

Level 3
Case-controlled study; 50 subjects

Smithpeter & Covell (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. “This study demonstrated that OMT in conjunction with orthodontic treatment was highly effective in maintaining closure of anterior open bites compared with orthodontic treatment alone.”

Ono et al. (1998). Inhibition of masseteric electromyographic activity during oral respiration. “These findings suggest that masseteric electromyographic activity is inhibited during oral respiration” “This inhibition was greater during inspiration than during expiration.”

Limme. (1993). Orthognathic and orthodontic consequences of mouth breathing. “It seems that the altered postural position of the tongue and of the mandible, needed for oral ventilation, could, by soft-tissue stretching, change the growth pattern of the face.”

Swallowing and Chewing Research Links

Wintergerst & López-Morales (2021). Masticatory Function in Children with Down Syndrome. “Children with DS have approximately 50% of the masticatory performance and maximum occlusal force of children of the same age without DS. These findings can be associated to the feeding problems reported in children with DS.”

Borges et al. (2020). Association between dysphagia and tongue strength in patients with amyotrophic lateral sclerosis. “Forty-eight percent of the sample had dysphagia at the fiberoptic endoscopic evaluation of swallowing and 76% had an altered tongue strength test. Ninety percent of patients with dysphagia had an average tongue pressure lower than 34.2 KPa.”

Kim HD, Choi JB, Yoo SJ, Chang MY, Lee SW, Park JS (2017). Tongue-to-palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia. Journal of Oral Rehabilitation, Jan;44(1):59-64. doi: 10.1111/joor.12461.

Level 2
Prospective therapeutic controlled study

Kang JH, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI (2012). The effect of bedside exercise program on stroke patients with dysphagia. Annals of Rehabilitation Medicine, Aug;36(4):512-20. doi: 10.5535/arm.2012.36.4.512. Epub 2012 Aug 27.

Level 3
Case-controlled study; 50 subjects

Hagg M, Anniko M (2008). Lip muscle training in stroke patients with dysphagia. Acta Otolaryngoligica, Sep;128(9):1027-33. doi: 10.1080/00016480701813814.

Level 3
Retrospective Study; 30 subjects

Kang et al. (2020). Muscle Tension Dysphagia: Contributing Factors and Treatment Efficacy. “Forty percent of patients had diagnosed positive gastroesophageal reflux disease” “...results suggest an association between laryngeal muscle tension and these patients’ dysphagia symptoms regardless of associated conditions. Speech-language pathology intervention showed high treatment efficacy.”

Kim et al. (2020). Effects of chewing exercises on the occlusal force and masseter muscle thickness in community‐dwelling Koreans aged 65 years and older: A randomized assessor-blind trial. “These results suggest that chewing exercises are effective in improving occlusal force and masseter muscle thickness in healthy elderly individuals.”

Smith & Clayton. (2020). The Effects of Chewing Gum on Perceived Stress and Wellbeing in Students Under a High and Low Workload. “Depression and cognitive failures decreased as a result of experiencing a high workload. Perceptions of physical fatigue decreased when chewing gum under a high workload. The findings suggested that gum may be an effective way to reduce certain stress characteristics, and also reassuring students that a high workload is not necessarily detrimental to their wellbeing.”

Yamazaki et al. (2017). Excessive anterior cervical muscle tone affects hyoid bone kinetics during swallowing in healthy individuals. “...inappropriate posture may encourage hyoid depression and increase the extent of hyoid bone elevation, thereby increasing the risk of aspiration.”

Choi et al. (2016). Dietary habits and gastroesophageal reflux disease in preschool children. “Dietary habits such as picky and irregular eating, snack preference, a preference of liquid foods, late night eating, and a shorter dinner-to-bedtime interval had a significant correlation with GERD.”

Inal O, Serel Arslan S, Demir N, Tunca Yilmaz O, Karaduman AA (2017). Effect of Functional Chewing Training on tongue thrust and drooling in children with cerebral palsy: a randomized controlled trial. Journal of Oral Rehabilitation, Nov;44(11):843-849. doi: 10.1111/joor.12544. Epub 2017 Jul 28.

Level 3
Case-controlled study; 32 subjects

Maspero et al. (2014). Atypical swallowing: a review. “The biunique causal relation between atypical swallowing and malocclusion suggests a multidisciplinary therapeutic approach, orthodontic and myofunctional, to temporarily solve both problems. An early diagnosis and a prompt intervention have a significantly positive influence on the therapy outcome.”

Hsu & Yamaguchi (2012). Decreased chewing activity during mouth breathing. “Mouth breathing reduces the vertical effect on the posterior teeth, which can affect the vertical position of posterior teeth negatively, leading to malocclusion.”

Smith (2009) Effects of chewing gum on mood, learning, memory and performance of an intelligence test. “Chewing gum increased alertness at the end of the test session in both parts of the study. This effect was in the region of a 10% increase and was highly significant (P < 0.001).”

Robbins et al. (2008). Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity Into Clinically Oriented Evidence. “Use It or Lose It” “Use It and Improve It” “Plasticity Is Experience Specific” “Repetition Matters” “Intensity Matters” “Time Matters” “Salience Matters” “Age Matters” “Transference” & “Interference” “The motor with swallow category of techniques centers on the principles of experience-dependent neural plasticity … and warrants investigative prioritization in elucidating the translation of basic principles to the clinic. Most notable among these are the principles of Use It or Lose It, Use It and Improve It, and Repetition Matters. All of these techniques are used during the swallow with the goal of increasing the success of the swallow itself. As previously noted, this may result in the preservation of synapses and the maintenance of allocated cortical representation.” “Nonswallowing exercising of the oral, pharyngeal, laryngeal, and respiratory (i.e., swallowing) musculature holds a great deal of promise in treating individuals with severe dys- phagia. Nonswallowing exercising allows patients to progress through a training regimen safely without limitations that may be imposed if the swallowing of boluses is necessary for functional gain…behavioral plasticity of swallowing has been demonstrated from three different nonswallowing exercising techniques: lingual exercising, head lifting, and LSVT.”

Teramoto et al. (1999). Impaired Swallowing Reflex in Patients With Obstructive Sleep Apnea Syndrome. “Patients with OSAS are likely to exhibit an impaired swallowing reflex, probably due to the perturbed neural and muscular function of the upper airways.”

Speech

de Castro Corrêa et al. (2017). Sleep quality and communication aspects in children. “A correlation was seen between the sleep quality of life and the skills related to the phonological processing, specifically in the phonological working memory in backward digits, and related to orofacial myofunctional aspects.”

Richard Baxter, DMD, MS, Robyn Merkel-Walsh, MA, CCC-SLP/COM, Barbara Stark Baxter, MD, FACP, Ashley Lashley, BS, Nicholas R. Rendell, MSc, PhD." (2020)Functional Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release: A Prospective Cohort Study"

Marchesan, I. Q. (2004). Lingual frenulum: classification and speech interference. International Journal of Orofacial Myology, 30(1), 32-39.

Hitos et al (2012). Oral breathing and speech disorders in children. “Mouth breathing can affect speech development, socialization, and school performance. Early detection of mouth breathing is essential to prevent and minimize its negative effects on the overall development of individuals.”

Bigenzahn W, Fishchman L, Mayrhofer-Krammel U (1992). Myofunctional therapy in patients with orofacial dysfunctions affecting speech. Folia Phoniatrica et Logopaedica, 44(5):238-44.

Level 4
Case series; 45 subjects

Ferreira TS, Mangilli LD, Sassi FC, Fortunato-Tavares T, Limongi SC, Andrade CR (2011). Speech and myofunctional exercise physiology: a critical review of the literature. Jornal da Sociedade Brasileira de Fonoaudiologia, Sep;23(3):288-96.

Level 3
Limited literature review 2000-2010

Kent, R. D. (2015). Nonspeech oral movements and oral motor disorders: a narrative review. American Journal of Speech-Language Pathology, 24(4), 763-789. doi: 10.1044/2015_AJSLP-14-0179

Level 5
Literature review of quasispeech, paraspeech, speechlike, and nonspeech oral movements.

Lee AS, Gibbon FE (2015). Non-speech oral motor treatment for children with developmental speech sound disorders. Cochrane Database of Systematic Reviews, Mar 25;(3):CD009383. doi: 10.1002/14651858.CD009383.pub2.

Level 3
Literature review of 3 “biased” randomized controlled studies considered

McCauley RJ, Strand E, Lof GL, Schooling T, Frymark T (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech. American Journal of Speech Language Patholology, 18(4), 343-360. doi: 10.1044/1058-0360(2009/09-0006).

Level 3
Literature review of 15 studies between 1960 and 2007

Ray, J (2002). Orofacial myofunctional therapy in dysarthria: a study on speech intelligibility. International Journal of Orofacial Myology, Nov;28:39-48.

Level 4
Case series; 12 subjects

Ray J (2003). Effects of orofacial myofunctional therapy on speech intelligibility in individuals with persistent articulatory impairments. International Journal of Orofacial Myology, Nov;29:5-14.

Level 4
Case series; 6 subjects

Ruscello DM (2008). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools Jul;39(3):380-91. doi: 10.1044/0161-1461(2008/036).

Level 5
Expert opinion

Van Lierde KM, Luyten A, D’haeseller E, Van Maele G, Becue L, Fonteyne E, Corthals P, DePauw G (2015). Articulation and oromyofunctional behavior in children seeking orthodontic treatment. Oral Diseases, May;21(4):483-92. doi: 10.1111/odi.12307. Epub 2015 Feb 2.

Level 3
Case controlled study; 56 subjects

Orofacial Myofunctional Therapy Research Links

Galvão et al. (2020). Effects of home-based inspiratory muscle training on sickle cell disease (SCD) patients. “The inspiratory muscle training at home is a strategy that can be easily applied in outpatients, providing benefits, such as increasing respiratory muscle strength, improvement in Vcap and exercise tolerance and reducing dyspnea in activities of daily living.”

Van Dyck C, Dekeyser A, Vantricht E, Manders E, Goeleven A, Fieuws S, Willems G (2016). The effect of orofacial myofunctional treatment in children with anterior open bite and tongue dysfunction: a pilot study. The European Journal of Orthodontics. June;38(3):227-234. doi:10.1093/ejo/cjv044

Level 1
Randomized controlled study; 22 subjects

Hsu et al. (2020). Effects of respiratory muscle therapy on obstructive sleep apnea: a systematic review and meta-analysis. “Respiratory muscle therapy as an adjunct management for OSA but further studies are needed.”

Mozzanica et al. (2020). Impact of Oral Myofunctional Therapy on Orofacial Myofunctional Status and Tongue Strength in Patients with Tongue Thrust. “OMT improves orofacial motricity and tongue strength in patients with tongue thrust regardless of the type of dentition.”

Gallerano G, Ruoppolo G, Silvestri A (2012). Myofunctional and speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia. Progress in Orthodontics, May;13(1):57-68. doi: 10.1016/j.pio.2011.08.002. Epub 2012 Jan 25.

Level 4
Case series; 19 subjects

Prado DG de A, Berretin-Felix G, Migliorucci RR, Beuno M da RS, Rosa RR, Polizel M, Teixeira IF, Gaviao MBD (2018). Effects of orofacial myofunctional therapy on masticatory function in individuals submitted to orthognathic surgery: a randomized trial. Journal of Applied Oral Science, 26:e20170164. doi:10.1590/1678-7757-2017-0164.

Level 1
Randomized control study; 48 subjects

Ray J(2001). Functional outcomes of orofacial myofunctional therapy in children with cerebral palsy. International Journal of Orofacial Myology, Nov;27:5-17.

Level 4
Case series, 16 subjects

Ong et al. (2018). Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms.“Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19% in control subjects (P < .001).” “In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching—especially those with excessive SGB.” “These benefits were greater in patients with excessive SGB, and sustainable at 4 months post-treatment.”

Toh et al. (2019). Holistic Management of Obstructive Sleep Apnea Translating Academic Research to Patient Care. “Myofunctional therapy targets the upper airway dilator muscles function pathway in the pathophysiology of OSA. It involves a set of exercises for the lip, tongue, soft palate, and lateral pharyngeal wall, aimed at training the upper airway dilator muscles to maintain the patency of upper airway during sleep.14 It is hypothesized that this set of exercises increase oral and oropharyngeal muscle tone, as well as reduce fatty deposition within the tongue, thereby reducing upper airway collapsibility. Systematic review and meta-analysis by Camacho and colleagues15 in 2015 demonstrated a statistically significant reduction of AHI from a mean of 24.5 to 12.3 per hour (P<.0001). In addition, improvement of lowest oxygen saturations, snoring, and sleepiness scale has also been shown.15 These exercises can be performed in addition to other treatment modalities.”

Camacho et al. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. "Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments."

Diaféria et al. (2015). Myofunctional therapy improves adherence to continuous positive airway pressure treatment. “Myofunctional exercises of local muscular endurance aim to tone the muscle groups in the oropharynx, optimizing muscle strength and mobility, and adjust the position of the soft tissues (soft palate, pharyngeal constrictor muscles, suprahyoid muscles, tip and base of the tongue, cheeks, lips) and orofacial functions of chewing, sucking, swallowing, and breathing. These exercises may therefore reduce snoring and decrease the severity of OSAS” “The myofunctional therapy and combined groups showed improvement in tongue and soft palate muscle strength when compared with the placebo group.” “Our results suggest that in patients with OSAS, myofunctional therapy may be considered as an adjuvant treatment and an intervention strategy to support adherence to CPAP.”

Guilleminault et al. (2013). Critical role of myofascial reeducation in pediatric sleep-disordered breathing. “Despite experimental and orthodontic data supporting the connection between orofacial muscle activity and oropharyngeal development as well as the demonstration of abnormal muscle contraction of upper airway muscles during sleep in patients with SDB, myofunctional therapy rarely is considered in the treatment of pediatric SDB. Absence of myofascial treatment is associated with a recurrence of SDB.”

Baz et al. (2012). The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea. “Myofunctional therapy can achieve subjective improvement in OSAS symptoms, as well as polysomonographic abnormalities in patients with mild to moderate OSAS and so can be considered as an alternative method of treatment.” “There was significant improvement of OSAS symptoms (snoring, excessive daytime sleepiness, morning headache) after oral myofunctional therapy as compared to before the therapy… There were significant decrease in neck circumference and ESS after oral myofunctional therapy as compared to before the therapy while there were no significant change in BMI. There were significant decrease of AHI, arousal index and % total sleep time in snoring after myofunctional therapy as compared to before myofunctional therapy. Also there were significant decrease in desaturation parameters… after myofunctional therapy as compared to before myofunctional therapy, while there was significant increase in minimum SaO2% after myofunctional therapy as compared to before myofunctional therapy…”

Cooper (2010). Orofacial Myology and Myofunctional Therapy for Sleep Related Breathing Disorders. “An orofacial myofunctional disorder is any pattern involving the oral/orofacial musculature that may lead to abnormal facial growth and function. Myofunctional therapy involves establishing, stabilizing, and reinforcing a healthy oral environment and facilitating the use of orofacial muscles to promote normal growth and development, and proper tongue posture and breathing patterns.” “The main goal of this treatment is to develop improved tongue posture and enhanced nasal breathing.” From Schwab et al 2005. “The GG muscle has been shown to have an increase in type II fast twitch fibers in the sleep apnea patient. These fibers are more susceptible to fatigue in patients with sleep apnea when compared with normal subjects.”

Smithpeter & Covell (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. "This study demonstrated that OMT in conjunction with orthodontic treatment was highly effective in maintaining closure of anterior open bites compared with orthodontic treatment alone."

Guimarães et al. (2009). Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome. “This randomized controlled study is the first to investigate the effects of upper airway muscle training by a series of oropharyngeal exercises in patients with moderate OSAS. Three months of exercise training reduced by 39% the severity of OSAS evaluated by the AHI and lowest oxygen saturation determined by polysomnography. The significant OSAS improvement in the patients randomized to muscle training occurred in conjunction with a reduction in snoring, daytime sleepiness, and quality of sleep score.” “Oropharyngeal exercises significantly reduce OSAS severity and symptoms and represent a promising treatment for moderate OSAS.”

Tethered Oral Tissues Research Links

Baxter & Hughes (2018). Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. “Some improvements were observed immediately after the procedure by clinical staff and the child’s family. While these patients required continued intervention from a speech-language pathologist, their improved lingual mobility allowed for more significant and faster improvement in speech and feeding skills.”

Guilleminault et al. (2016). A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. “A short lingual frenulum left untreated at birth is associated with OSAS at later age, and a systematic screening for the syndrome should be conducted when this anatomical abnormality is recognised.” 150 children with OSAS. “The two groups differed significantly in the anatomical description of the oral cavity (table 1), with the short frenulum group having significantly more frequent reports of a “high and narrow palatal vault” and scores of 4 on the Mallampati–Friedman scale (0–4) (p=0.0001), while the normal frenulum group had a significantly greater frequency of scoring ⩾4 on the Friedman tonsil scale (p=0.0001). The mean tonsil size score was 1.8 in the abnormal frenulum group versus 3.2 in the other children.” “speech problems were better recalled and were described as “lisp”, “stutter” or having led to speech therapy”

Yoon et al. (2016). Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. “Functional” ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50–80%, grade 3 < 50%, grade 4 < 25%.”

Bruderer et al. (2015). Sensorimotor influences on speech perception in infancy. “Our results provide striking evidence that even before infants speak their first words and without specific listening experience, sensorimotor information from the articulators influences speech perception… Moreover, an experimentally induced “impairment” in articulator movement can compromise speech perception performance, raising the question of whether long-term oral–motor impairments may impact perceptual development.”

Huang et al. (2015). Short Lingual Frenulum and Obstructive Sleep Apnea in Children. “One fact is clear: frenectomy for short lingual frenulum in isolation or following T&A helps but is commonly insufficient to resolve all abnormal breathing patterns during sleep when SDB is present. Myofunctional therapy, which has been previously demonstrated to allow return to normal nasal breathing may be needed post surgery.” “The existence of familial cases and the association with genetic syndrome suggest that presence of a short lingual frenulum may be part of a specific genetic predisposition, but no genetic study has been performed on familial cases of short lingual frenulum.” “In conclusion: children with SDB should be evaluated for a short lingual frenulum, and conversely, children with an abnormally short frenulum should be investigated for the presence of SDB. Frenectomy should be performed as early as possible but it may not be sufficient to restore normal nasal breathing function during sleep [28], particularly if the frenulum-related problem has lingered over years, and nasal breathing reeducation may be needed in these cases.”

Ito et al. (2015). Effectiveness of tongue-tie division for speech disorder in children. “Substitution and omission improved relatively early after tongue-tie division and progressed to distortion, which is a less-impaired form of articulation disorder. Thus, distortion required more time for improvement and remained a defective speaking habit in some patients.” “Speech sounds that may be adversely affected by impaired mobility of the tip of the tongue include lingual sounds and sibilants, such as t, d, n, l, s, r, z, and th.”

Marchesan (2004). Lingual frenulum: classification and speech interference. “An altered frenulum may predispose the individual to exhibit an accompanying speech disorder.” “The more frequent speech disorders were: omission and substitution of /r/; {R}, and consonant clusters with /r/, and of /s/ and /z/.”

Sleep Apnea Research Links

de Felício et al. (2018). Obstructive sleep apnea: focus on myofunctional therapy. “OMT is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure.” https://www.dovepress.com/obstructive-sleep-apnea-focus-on-myofunctional-therapy-peer-reviewed-fulltext-article-NSS de Felício et al. (2016). Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy. “The OSA group had lower scores in breathing and deglutition, more unbalanced masticatory muscle activities than PS group”

Ieto V, Kayamori F, Montes MI, Hirata RP, Gregorio MG, Alencar AM, Drager LF, Genta PR, Lorenzi-Filho G (2015). Effects of oropharyngeal exercises on snoring: a randomized trial. Chest, Sep;148(3):683-691. doi: 10.1378/chest.14-2953.

Level 1
Randomized control study; 39 subjects

Kuo et al. (2017). Short-term expiratory muscle strength training attenuates sleep apnea and improves sleep quality in patients with obstructive sleep apnea. “EMST improved the scores for AHI (-40%), PEmax (+68%), and PSQI (-28%) and reduced the PSQI scores of the moderate OSA subgroup but not the mild OSA subgroup.”

Camacho et al. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. “Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments.”

Guimaraes KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G (2009). Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. American Journal of Respiratory and Critical Care Medicine, May 15;179(10):962-6. doi: 10.1164/rccm.200806-981OC. Epub 2009 Feb 20.

Level 1
Randomized control study; 31 subjects

Ieto et al (2015). Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial. “Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring.”

Guilleminault & Sullivan (2014). Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. “Elimination of oral breathing, i.e., restoration of nasal breathing during wake and sleep, may be the only valid end point when treating OSA. Preventive measures in at-risk groups, such as premature infants, and usage of myofunctional therapy as part of the treatment of OSA are proposed to be important approaches to treat appropriately SDB and its multiple co-morbidities.” “In all of the baseline PSGs of the 64 children with SDB, there was evidence of excessive mouth breathing (defined as at least one third of total sleep time) on baseline diagnostic PSG.” “The interaction between orofacial structural growth and muscle activity starts early in development, and the physiological functions of suction, mastication, swallowing, and nasal breathing in infancy play an important role in stimulating subsequent growth.”

Valbuza et al. (2011). Swallowing dysfunction related to obstructive sleep apnea: a nasal fibroscopy pilot study. “OSA patients presented subclinical manifestations of abnormal swallowing, when analyzed using nasal fibroscopy, possibly associated with neuromuscular injury caused by snoring.”

Jäghagen et al. (2000). Swallowing dysfunction related to snoring: a videoradiographic study. “snoring is associated with subclinical pharyngeal swallowing dysfunction.”

Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA (2015). Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep. 2015;38(5):669-675. doi:10.5665/sleep.4652.

Level 1
Meta-analysis of 9 studies

Sedky et al. (2013). Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. “Pediatric populations suffering from SDB are at increased risk of presenting with symptoms of ADHD, including inattention and hyperactivity.” “There are several possible explanations for the relationship between SDB and ADHD symptoms. SDB syndrome is associated with lower oxygen saturations and hypercapnia overnight, oxidative stress, increased free radicals, and/or release of inflammatory cytokines (e.g., proinflammatory cytokines interleukin-6 and tumor necrotizing factor alpha) leading to neurological dysfunction particularly involving certain brain areas (e.g., prefrontal cortex). Cortical dysfunction is associated with cognitive and behavior dyscontrol and can consequently lead to inattention, hyperactivity or impulsivity symptoms.”

de Felicio CM, da Silva Dias FV, Trawitzki LVV (2018). Obstructive sleep apnea: focus on myofunctional therapy. Nature and Science of Sleep, Sep 6;10:271-286. doi: 10.2147/NSS.S141132. eCollection 2018.

Level 3
Literature review; 11 studies

Frey L, Green S, Fabbie P, Hockenbury D, Foran M, Elder K (2014). The essential role of the COM in the management of sleep-disordered breathing: a literature review and discussion. International Journal of Orofacial Myology, Nov;40:42-55.

Level 3
Literature review

Diaferia G, Badke L, Santos-Silva R, Bommarito S, Tufik S, Bittencourt L (2013). Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the quality of life of patients with obstructive sleep apnea. Sleep Medicine, Jul;14(7):628-35. doi: 10.1016/j.sleep.2013.03.016. Epub 2013 May 20.

Level 1
Randomized control study; 100 subjects

Diaferia G, Santos-Silva R, Truksinas E, Haddad FLM, Santos R, Bommarito S, Gregorio LC, Tufik S, Bittencourt L (2017). Myofunctional therapy improves adherence to continuous positive airway pressure treatment. Sleep and Breathing, May;21(2):387-395. doi: 10.1007/s11325-016-1429-6. Epub 2016 Dec 2.

Level 1
Randomized control study; 100 subjects

Villa MP, Brasili L, Ferretti A, Vitelli O, Rabasco J, Mazzotta AR, Pietropaoli N, Martella S (2015). Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep and Breathing, Mar;19(1):281-9. doi: 10.1007/s11325-014-1011-z. Epub 2014 May 26.

Level 4
Case series; 14 subjects

Villa MP, Evangelisti M, Martella S, Barreto M, Del Pozzo M (2017). Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing? Sleep and Breathing, Dec;21(4):1025-1032. doi: 10.1007/s11325-017-1489-2. Epub 2017 Mar 18.

Level 1
Randomized control study; 54 subjects

Bonuck et al. (2012). Pediatric Sleep Disorders and Special Educational Need at 8 Years: A Population-Based Cohort Study. “Children with a history of behavioral sleep problems (BSPs) and of sleep disordered breathing (SDB) in the first 5 years of life were more likely to have a special educational need (SEN) at 8 years of age; even controlling for 16 putative confounders, BSPs were associated with a 7% increased odds of SEN, for each ∼1- year interval. Thus, for example, children with a BSP in at least 2 of the 4 intervals (∼1 of 5 children) had a 15% increased likelihood of special educational need SEN.(SDB), overall, was associated with a near 40% increased odds of SEN. Children with the worst SDB symptoms were 60% more likely to have an SEN. Sleep problem effects remained significant, even after controlling for IQ, which itself was associated with five- to sixfold increased odds of SEN for both BSPs and SDB”

Bonuck et al. (2012). Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. “The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the "Worst Case" cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity, and conduct and peer difficulties. The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years. … Findings suggest that SDB symptoms may require attention as early as the first year of life.”

Macey et al. (2010). Relationship between Obstructive Sleep Apnea Severity and Sleep, Depression and Anxiety Symptoms in Newly-Diagnosed Patients. “Consistent with other studies, a strong link between OSA severity and psychological symptoms did not appear in these newly diagnosed patients, suggesting that mechanisms additional to the number and frequency of hypoxic events and arousals occurring with apneas contribute to adverse health effects in OSA.” “The findings support the hypothesis that AHI is not the most appropriate polysomnographic measure of clinical impact of OSA… Symptoms like poor sleep quality and daytime sleepiness may be more closely related to number and extent of arousals… The frequency of arousals is a better predictor of fatigue…blood oxygen desaturation appears to be a better predictor than AHI of daytime sleepiness.

Huang et al. (2007). Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. “A low AHI score of >1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake”

Chervin et al. (2002). Inattention, hyperactivity, and symptoms of sleep-disordered breathing. “Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and---especially in young boys---snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.”

Guilleminault et al. (2019). Sleep-Disordered Breathing, Orofacial Growth, and Prevention of Obstructive Sleep Apnea. “During the last trimester of pregnancy there is a continuous training of the suck-swallow reflex” “During fetal lide, training of diaphragm and respiratory accessory muscles must also occur.” “The absence of the normal development of the orofacial growth also has secondary consequences of the maxillo-mandibular position. Such changes have a negative feedback impact on the insertion of the muscles forming the upper airway.” “The only valid treatment goal is restoration of nasal breathing, not only during wakefulness but also during sleep.” “Snoring develops and there are both disuse of normal reflexes and impairment of reflexes caused by inflammation and perhaps local vibration related to snoring, the beginning of the slow progression toward OSA with comorbidities.”

Huang et al. (2015). Short Lingual Frenulum and Obstructive Sleep Apnea in Children.“One fact is clear: frenectomy for short lingual frenulum in isolation or following T&A helps but is commonly insufficient to resolve all abnormal breathing patterns during sleep when SDB is present. Myofunctional therapy, which has been previously demonstrated to allow return to normal nasal breathing may be needed post surgery.” “The existence of familial cases and the association with genetic syndrome suggest that presence of a short lingual frenulum may be part of a specific genetic predisposition, but no genetic study has been performed on familial cases of short lingual frenulum.” “In conclusion: children with SDB should be evaluated for a short lingual frenulum, and conversely, children with an abnormally short frenulum should be investigated for the presence of SDB. Frenectomy should be performed as early as possible but it may not be sufficient to restore normal nasal breathing function during sleep [28], particularly if the frenulum-related problem has lingered over years, and nasal breathing reeducation may be needed in these cases.”

Huang & Guilleminault. (2013). Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. “Pediatric OSA in non-obese children is a disorder of oral-facial growth.”

Choudhary et al. (2016). Association of Sleep Disordered Breathing with Mono-Symptomatic Nocturnal Enuresis: A Study among School Children of Central India. “findings suggest that it is imperative to rule out SDB in PMNE patients as they may require different therapeutic interventions.” “In this study, children with inappropriate toilet training, family history of enuresis in father and SRBD score >0.33 were found to have higher odds for developing PMNE” “ In the present study there is a threefold association between PMNE in the children and positive SRBD. The 22 item SRBD scale has been validated for use in research studies for the assessment of obstructive sleep apnea (OSA) and the instrument has shown good internal consistency and test retest reliability”

Pirilä-Parkkinen et al. (2011). Pharyngeal airway in children with sleep-disordered breathing in relation to head posture. “Head posture is an important factor in maintaining airway patency.” “When the head was in neutral posture children with sleep disordered breathing (SDB) had significantly narrower oropharyngeal airway space than control children.” “In SDB children, head flexion significantly decreased retroglossal airway area (RGCA) in relation to neutral and extended postures. In control children, intra-group differences between the RGCA measurements in different head postures were all significant.”

Suzuki H, Watanabe A, Akihiro Y, Takao M, Ikematsu T, Kimoto S, Asano T, Kawara M (2013). Pilot study to assess the potential of oral myofunctional therapy for improving respiration during sleep. Journal of Prosthodontic Research, Jul;57(3):195-9. doi: 10.1016/j.jpor.2013.02.001. Epub 2013 Mar 20.

Level 4
Case series; 92 subjects

Piccin et al. (2015). Craniocervical Posture in Patients with Obstructive Sleep Apnea. “In OSA subjects, the greater the severity of OSA, the greater the head hyperextension and anteriorization.” “The subjects in the group of mild and moderate OSA feature changes in craniofacial morphology, with shorter intermediate pharyngeal space and greater distance from the hyoid bone to the mandibular plane, as compared with healthy subjects, suggesting a relationship between craniocervical posture and OSA.”

Solow et al. (1984). Airway adequacy, head posture, and craniofacial morphology. “Obstructed nasopharyngeal airways… were, on the average, seen in connection with a large craniocervical angle and with small mandibular dimensions, mandibular retrognathism, a large mandibular inclination, and retroclination of the upper incisors."

TMD Research Links

Le Kuex & Frapier (2021). Lingual treatment of an adult patient with an iatrogenic class II anterior open bite: Report of a case with a non-surgical orthodontic approach. A single case presentation “where a regrettable unsuitable splint for bruxism treatment forced an open bite to appear” In the end, "the occlusal balance with physiotherapy and patient compliance maintained the closure. … the iatrogenic effects of the poorly designed bite splint were repaired.”

Fassicollo et al. (2020). Jaw and neck muscle changes in patients with chronic painful temporomandibular disorder disc displacement with reduction during chewing: Changes in jaw and neck muscle coactivation and coordination in patients with chronic painful TMD disc displacement with reduction during chewing. “Patients with chronic painful TMD-DDR during chewing presented changes in the jaw and neck muscles, with more compromised function of the former, which are specific to chewing.”

Zharova et al. (2020). Rehabilitation of patients with facial nerve injuries after neurosurgical treatment. “Psychological conse- quences of facial muscles paresis are more important to the patient than physical damage. Paresis of the facial muscles cannot be hidden and often leads to social maladjustment, isolation and a marked decrease in the quality of life. Facial neuropathy in most cases is not a life-threatening condition, but it is definitely life changing. Motor defect in facial nerve neuropathy leads to cosmetic a defect that not only has a psychotraumatic effect on the patient, but also violates acts of chewing, swallowing, changes the phonation” “The combined use of physiotherapy, massage, therapeutic gymnastics, including posture treatment with taping, during the early period of the disease, allows restoring nerve function and maintaining mimic muscles, as well as avoiding undesirable complications.”

Ferreira et al. (2014). Impaired orofacial motor functions on chronic temporomandibular disorders. “Impaired oro-facial functions and increased activity of the muscles of balancing sides during unilateral chewing characterized the altered orofacial motor control in patients with moderate-severe chronic TMD.

Sanders et al. (2013) Sleep Apnea Symptoms and Risk of Temporomandibular Disorder: OPPERA Cohort. “a significant association of OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first-onset TMD.”

Weber et al. (2013). Chewing and swallowing in young women with temporomandibular disorder. “TMD subjects showed a significant difference on tongue (p=0.03) and lip (p=0.04) posture during swallowing function, and a more frequent adoption of a chronic unilateral chewing pattern as well (p=0.03)... presented a lower position of the hyoid bone in relation to the mandible (p=0,00).”

de Felício et al. (2010). Effects of Orofacial Myofunctional Therapy on Temporomandibular Disorders. “OMT had the following positive effects in treated patients: (a) a significant reduction of pain sensitivity to palpation of all muscles studied but not for the TMJs; (b) increased measures of mandibular range of motion; (c) reduced Helkimo’s Di and Ai scores, (d) reduced frequency and severity of signs and symptoms; and (e) increased scores for orofacial myofunctional conditions.”

Masumoto & Fujumoto (2009). Daily chewing gum exercise for stabilizing the vertical occlusion. Volunteers “chew gum for 10-15 min before or after three meals daily for four weeks.” “after four weeks of exercise, anterior and posterior occlusal contact areas and forces were significantly (P < 0.05) increased and the increments were significantly (P < 0.05) higher in the anterior occlusal contact area and force than in the posterior occlusal contact area and force”

Perkiömäki & Alvesalo (2008). Palatine ridges and tongue position in Turner syndrome subjects. This paper explored the relationship between tongue position and palate height in Turner syndrome (TS). “35% of persons with TS will likely have a high arched palate.” The study concluded, “the tongue position in TS females is low. The presence of prominent lateral palatine ridges is associated with a reduced palatal width.” Meaning, the tongue was down, the ridges were prominent, and the arch was high.

Grabowski et al. (2007). Interrelation between occlusal findings and orofacial myofunctional status in primary and mixed dentition: Part III: Interrelation between malocclusions and orofacial dysfunctions. “Lateral crossbite in mixed dentition, as well as increased overjet and frontal open bite in primary and early mixed dentitions appeared significantly more frequently in children with orofacial dysfunctions”