I recently had lunch with an orthodontist who wanted to know how he could be “catching” myofunctional impairment in his practice. The lunch was a mix of emotions. Part of me was so excited that he had reached out to me and wanted to learn about what I do and how he could help. Part of me was very sad that he had been practicing nearly two decades and hadn’t ever had a discussion with a patient about a tongue-tie. Here is another example. I was practicing hygiene recently when I identified not one, but four, children in a row who had a tongue-tie (the dad said, “wow, I bet they get it from my wife because she talks funny and kisses like a parrot”). Without a doubt, the fourth child had a class 4 tie, huge open bite and obvious tongue thrust. When I suggested an orthodontic referral, the dentist said, “He is only 9 and doesn’t even have his first molars yet, he isn’t ready for ortho.” Herein lies the problem. Each piece of the “myofunctional puzzle” is an expert in their area, but a lot of their knowledge doesn’t “bleed over” into the other areas.
Hark! I have been contacted by several more specialists, notably dentists who have been asking for guidance in implementing myofunctional screening in their practice. This article is not exhaustive, but it covers the six most common areas that a dentist can start with when beginning to screen for myofunctional impairment.
DENTISTS CAN SCREEN MYOFUNCTIONAL IMPAIRMENT IN THEIR PRACTICE
6 EASY STEPS
This list is a great place to start. These six areas are probably the biggest areas that myofunctional therapists wish that dentists would be evaluating.
1. Tongue-tie
Tethered oral tissue causes a host of symptoms. While not all ties are obvious, many are and learning to look for them is important. When I am examining a mouth, I am constantly on the lookout for myofunctional red flags that might indicate impairment. This can be something as simple as noticing a scalloped tongue when I take x-rays (scalloped tongue is a dead giveaway that the tongue is most likely laying in the floor of the mouth) or evaluating the lingual frenum when I am completing my oral cancer screening. Another common issue that dentists see is clenching and grinding. The quick answer is to treatment plan an occlusal guard of some sort, but what if there was another quick check to see if they have a tongue-tie which could be contributing to the problem? Once I see a concern, I simply ask if anyone has ever mentioned the tongue-tie. I have a brief conversation about what it is, why it can be detrimental, and why it should be corrected. If it’s a child or adolescent, I get the parents involved immediately. Just like a dentist would tell a parent that a child needs to have the decay taken care of, the dentist needs to tell the parents about the tie and that it needs correction. It shouldn’t be treated like its insignificant or optional. Have somebody in mind who you can refer to and always make sure they understand the need for revision and myofunctional therapy.
This is another area that can be evaluated quickly and brought to the patients (or parents) attention. Does the child have an open bite? Does the patient have digestive issues? Are they suffering from swallowing air? Do they have a medicine on their medical history for treating heart burn? Do they have teeth that aren’t erupting due to the thrust? How about multiple times in orthodontics? These are things that I am always evaluating. A tongue-tie is usually accompanied by a tongue thrust, but not always. I, myself, had an orthodontist tell me after my second round of braces, that I needed myofunctional therapy to correct my tongue thrust or my teeth would never stay straight. Point taken. I got therapy and my teeth are beautiful to this day.
As a dental hygienist, this is an area that I saw a lot. The red, inflamed tissue scalloped along the gum line edge. There was a time in my career that I would simply note that the patient was a mouth breather and therefore had unhealthy, inflamed, sore and bleeding gum tissue. Not anymore. Identification of mouth breathing should be the beginning of the conversation. Some patients will not be receptive to hearing about how it’s important to change their breathing process and stop mouth breathing, but it’s still important to plant the seed. I just throw it out there for the patient to think about while I’m cleaning, and usually they are curious and ask how they change their breathing.
4. Referring to the orthodontist
Another biggie that gives me heartburn. The field of orthodontics has changed and there are many experts in the field teaching why traditional, functional orthodontics is no longer the way to go. There are gobs of research and articles out there talking about orthodontics and the importance of the airway. Extracting teeth from a small mouth, only creates a smaller mouth and compromises the airway. Pulling the face “backwards” compromises the airway, the temporomandibular joint and affects facial/skeletal growth. Waiting until a patient is 12 and “has all of the permanent teeth” is an antiquated practice. Most of the facial growth is completed by age 10. Let’s start getting these kiddos to the orthodontist much, much younger! I encourage you to learn more about orthotropic orthodontics and seek out someone in your area who specializes in it. Don’t be afraid to encourage a paradigm shift. Many dentists that I work with just refer to the local orthodontist who did their kids teeth. This is not because they are bad dentists. It’s just what they’ve done for years. It’s all they know. Let’s change this thinking…one person at a time.
Snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA) are very concerning and should warrant a serious discussion with patients. Every single person I am in contact with who have indicators of sleep apnea are referred for identification and treatment of it. No wiggle room here. When I was a hygienist in a private practice, I knew that the dentist(s) were not “additionally trained” in sleep medicine but were making hundreds of snoring appliances every year for patients. There was never a conversation about the effects of snoring and sleep apnea on the body. There was never a conversation about seeing their doctor to get a sleep study ordered. In fact, in one staff meeting the office manager was identifying more ways to make money and pushing “snore guards” was near the top of her list!
Another topic here is tonsils. If there are these huge obstacles in the throat how can air be effectively and efficiently moving past? How can this person not be snoring? Usually, chronically enlarged tonsils are a red flag for mouth breathing. You don’t have to diagnose the need to have them out or not, you need to simply refer to an ENT so they can be evaluated.
6. Toxic habits
Please! Do not tell parents that the child needs to stop sucking their thumb by the time all the permanent teeth are in! I’ve heard this again and again and I just cringe. The child needs to stop all toxic habits before the baby teeth start to fall out and the permanent teeth start to erupt. The sooner the better. I always talk to the parents about how the “palate is like putty” and the child constantly pulling on it is reshaping it. I like to use “laymen” terms so the parents understand. I feel that looking into a child’s mouth and telling the parent “that Johnny is going to need braces anyhow so don’t sweat it” is doing a big disservice to Johnny and his parents. The parents don’t know any better and they are looking to their dental professionals to guide them.
NOW WHAT?
When I am helping others learn how to screen for myofunctional impairment in their practice, I always encouraged them to remember that we are all experts in our little world. No one is expected to “know it all.” Being comfortable to have a basic conversation with the patient can make all the difference. Then refer. Tell the patient that you are not an expert in that particular area but you are getting them to the right person who can answer their questions.
WHY IS IT IMPORTANT TO BUILD “A TEAM”?
Once we all learn that we are just a piece of the puzzle and that we need other specialties to help treat the whole person, our patients will be better served. I spend a lot of time educating and I always encourage surrounding yourself with people who are smarter than you. Never underestimate the power of knowledge and how we each learn from others. Learn about building an “integrative” team here.
WHEN SHOULD THERAPY TAKE PLACE?
Ideally, the sooner the better. At least have the conversation with the patient and make sure it gets noted in the chart. It may take a couple visits to get the patient on board, but you can be reminding them of the importance every time you see them.
You can read my blog here that talks more about when to do myofunctional therapy.
HOW IS THERAPY COMPLETED?
All of my therapy programs are completed via video conference. This type of delivery makes therapy available to people in all geographic locations with a good internet connection and computer. Working online allows me to offer programs to fit many different budgets, because my overhead costs are low.
WHERE TO LEARN MORE?
You can browse my website for more information. I also offer, free 30-minute phone consultations to introduce myself and help answer questions. This free consult can help people decide if they want to move forward to the comprehensive exam. I have lots of reference materials and articles to read if you’re so inclined! Just drop me an email and I’d be happy to give you more direction for information.
In addition, if you have (or know of) an office that wants to start screening myofunctional impairment, consider Myo On Location. I come to your office and help get the process going. From questionnaires to conversations, we cover it all.