Running head: MYOFUNCTIONAL THERAPY INTERNSHIP 1

Myofunctional Therapy Internship

Denise Landon, RDH

Georgia Highlands College

DHYG 4080 Internship

Dr. Michelle Boyce

First Draft

April 23, 2017

MYOFUNCTIONAL THERAPY INTERNSHIP 2

Abstract

This is an account of the learning experience of the author regarding her internship with a

myofunctional therapist. A total of 60 hours spent observing and discussing the methods used to

correct the parafunctional deviated swallow, also known as a tongue thrust. The author found

this experience extremely rewarding and directly applicable to her clinical practice as a dental

hygienist as well as an option should she wish to branch away from clinical practice at some

point.

Keywords: Myofunctional therapy, tongue thrust, deviated swallow, internship.

MYOFUNCTIONAL THERAPY INTERNSHIP 3

Myofunctional Therapy Internship

Chapter 1

Introduction

Statement of the Problem

Dental hygienists have a high incidence of musculoskeletal disorders due to the awkward

positions and repetitive motions involved with patient care (Gallon, 2014). With this in mind,

the author is seeking possible alternative work positions she could move into if, at some point,

practicing clinically is no longer an option for her. Ideally, such a position would utilize the

knowledge and skill of an RDH and hopefully feedback to enhance her current clinical practice.

During her practice of dental hygiene, the author has encountered many cases of

temporomandibular joint dysfunction (TMJ) and bruxism and is dissatisfied with the standard

practice of treating these conditions with an occlusal guard. This method only helps to prevent

damage to the dentition itself but it does not stop the root of the disorders. She has also spoken

with several worried parents of pediatric patients who have parafunctional habits such as thumb

sucking that the parent has not been able to break with traditional methods.

Purpose of the Internship

Myofunctional therapy is a lesser known practice that runs parallel to the practice of

dentistry. It may be helpful when other methods, such as bite guards and orthodontics, fail. It

addresses many of the issues of concern that the author has seen in her patients yet been unable

to fully address. The author believes that knowledge of myofunctional therapy will play well

into her clinical practice by widening and enhancing her individual skill set and will enable her

to better assist with her patients oral health. The purpose of this internship is to explore the

practice of oral myofunctional therapy (OMT) to determine (1) if it is a field that the author
MYOFUNCTIONAL THERAPY INTERNSHIP 4

would like to become proficient in as an alternative to clinical hygiene practice, (2) to learn to

recognize when her patients have a condition that would benefit from an OMT referral, and (3) if

there are techniques from myofunctional therapy that she can implement in her clinical practice.
MYOFUNCTIONAL THERAPY INTERNSHIP 5

Chapter 2

Review of Literature

Myofunctional Therapy

Orofacial myofunctional therapy (OMT) is a unique practice that combines the attentions

of several professions including dental, speech pathology, pediatrician, and sleep specialists. Its

very name describes its focus to be involved with the function of the muscles of the mouth and

face. These muscles include the masseters (cheek), mentalis (chin), orbicularis oris (lips) and the

tongue (Garliner, 1971). Abnormal strength and function of these muscles can cause several

different problems including, malocclusion, relapse of orthodontic treatment, speech impairment,

sleep apnea, snoring, temporomandibular joint dysfunction, postural changes, mouth breathing

and behavioral problems (Fabbie, 2015; Garliner, 1971). Myofunctional therapy seeks to retrain

and properly strengthen and balance these muscles so that they correctly perform their given

functions of chewing, swallowing, and breathing. It also addresses parafunctional habits such as

nail biting and finger sucking (Fabbie, 2015). Most myofunctional therapy centers around

disorder known as a tongue thrust, also called a deviated swallow. This is the most common

myofunctional disorder. It occurs when the tongue pushes forward against or through the teeth

when swallowing, instead of pushing up against the hard palate (Fabbie, 2015; Garliner, 1971).

Risk Factors. While each of us is born with a deviated swallow, several factors can

contribute to retaining it into adolescence and adulthood. A foreshortened frenum or

ankyloglossia (tongue tied) can physiologically keep the tongue from moving in a natural

manner by binding it into a forward and downward position. Thumb or finger sucking can force

the tongue down and away from its normal resting place against the roof of the mouth (Garliner,

1971; Hanson & Mason, 2003). No two things can occupy the same space at the same time.
MYOFUNCTIONAL THERAPY INTERNSHIP 6

Bottle feeding also contribute to a deviated swallow because the plastic nipple enters the babys

mouth further and has a higher flow rate than a womans breast (Garliner, 1971). This forces the

child to use his tongue to slow a too rapid flow of the milk instead of working his jaws to

stimulate milk production (Hanson & Mason, 2003). Issues that cause oral breathing (breathing

through the mouth instead of the nose) such as allergies or enlarged tonsils may contribute to a

deviated swallow as well. When the mouth is open the tongue naturally falls to the floor of the

mouth (Garliner, 1971). When this happens so much that the tongue learns to stay there is when

a problem develops. Difficulties breathing at night can lead to poor sleep; poor sleep can lead to

behavioral problems in children. Low oxygen can lead to poor academic performance (Besson,

2015).

Myofunctional Disorders. Originally myofunctional therapy was develop because

orthodontists found their work relapsing because of the improper pressures exerted on the

dentition by the patients own tongue and lips. Teeth moved because the pressures on them were

unbalanced and misdirected between the extra-oral forces of the facial muscles and the intraoral

forces of the tongue (Hanson & Mason, 2003). Myofunctional therapy can improve the

prolonged outcome of orthodontic treatment and possibly reduce the amount or length of

orthodontic treatment needed. About 30% of the general population has a tongue thrust (Hanson

& Mason, 2003). Hanson and Mason report on multiple studies that found a very high rate of

relationship between tongue thrusting and malocclusions (2003). One study found the lowest

incident of tongue thrusting in children with a class I occlusion, 18.2%. This percentage then

jumps to 50.7% in participants with a class II, division I malocclusion. In participants with an

open bite the percentage of tongue thrusting skyrockets to 98.5% (Hanson & Mason, 2003).

Other studies reported on by Hanson and Mason agree that tongue thrusting and malocclusions
MYOFUNCTIONAL THERAPY INTERNSHIP 7

have a high correlation (2003). These reported studies also note that tongue thrusting can be also

found (to a lesser degree) in those with normal molar relationship. It has also been observed as a

temporary condition in children that have lost their primary maxillary central incisors, until their

permanent centrals erupt, and the tongue is no longer curious about this strange new space in the

mouth.

Although it is possible to have a deviated swallow and normal speech sounds (and in fact

most do), there is a higher rate of dentalized speech in individuals with a tongue thrust. In the

English language six sounds are produced by raising the tip of the tongue against the area around

the incisive papilla. These sounds are s, z, t, d, n and l. It is difficult to make these sounds

clearly if the tongue is not raised to the proper place, leading to the development of an anterior

lisp, and an unattractive appearance when speaking as the tongue pushes forward (Hanson &

Mason, 2003).

Sleep apnea is a condition that is gaining more and more interest in the dental

community. It is a condition when the upper airway closes during sleep, which can be caused by

poor muscle tone in the oral, nasal and throat areas. This can cause waking up frequently at

night and sleepiness during the day. Poor sleep then can lead to other health issues (Guimaraes,

Genta, & Lorenzi-Filho, 2009). Typically sleep apnea is treated with a continuous positive

airway pressure machine (CPAP). However, several studies are now showing success in treating

sleep apnea with myofunctional therapy and resulting in a reduction or elimination of airway

obstruction during sleep for both children and adults (Guimaraes, Genta, & Lorenzi-Filho, 2009;

Macario, et al., 2015).

Temporomandibular joint dysfunction (TMD) is a common and painful condition. A

study done in Brazil compared treatments for participants who suffered with TMD. Data was
MYOFUNCTIONAL THERAPY INTERNSHIP 8

gathered from four groups, those with TMD using an occlusal guard, those with TMD using

myofunctional therapy, those with TMD receiving no therapy, and those without TMD.

Participants receiving myofunctional therapy reported statistically better results than those using

only the occlusal guard, to the point that there was no longer any statistical difference between

the myofunctional therapy group and the group without TMD (de Felicio, Melchior, & da Silva,

2010). Myofunctional therapy could prove a useful treatment for those suffering from frequent

jaw pain.
MYOFUNCTIONAL THERAPY INTERNSHIP 9

Chapter 3

Methods and Procedures

Site Specifics

Mentor. Ryan Wexler earned his Bachelors of Science in Communications from

Kennesaw University. He is a myofunctional therapist, and licensed speech aide with over 15

years of experience. Ryan works primarily with dental clients of all ages addressing orthodontic

conditions, TMJ disorders, sleep apnea, reflux, and eating difficulties (The Institute of

Myofunctional Therapy, 2016). He is passionate about his field and enjoys teaching others about

this type of therapy.

Facility. The Institute of Myofunctional Studies (TIMS) partners with orthodontists,

dentists, speech pathologists, occupational and physical therapists or physicians to address oral

motor needs. These may include speech and swallowing abnormalities, tongue thrust, and

language delays. The Institute of Myofunctional Studies was founded by Sharon Wexler, a

speech-language pathologist. She works with her son Ryan Wexler and speech pathologist Jenny

Hearring (TIMS, 2016).

Population served. Most myofunctional clients are between the ages of four and

eighteen, although some adults received treatment as well. Most of them are referred to this type

of therapy by an orthodontist who recognizes a deviated swallow or facial muscle imbalance and

knows that this will affect the outcome of any orthodontic treatment. Frequently these clients

have had orthodontic treatment that has relapsed or are currently in braces. Others have been

referred by schools or brought in by parents who have noticed their children having difficulties

pronouncing some words. Myofunctional disorders also tend to run in families. Several clients

have siblings who have also received therapy.

MYOFUNCTIONAL THERAPY INTERNSHIP 10

Learning Objectives

The learning objectives include the following:

1. Learn the certification/licensure requirements for an orofacial myofuctional therapist.

2. Learn to recognize conditions in dental hygiene patients that could benefit from

myofunctional therapy.

3. Learn at least 2 techniques that can transfer over into dental hygiene practice.

4. Learn to recognize the risk factors and signs of a tongue thrust/deviated swallow.

5. Learn how the body and dentition can be affected by a deviated swallow.

Schedule of Activities

Table 1

Schedule of Activities

Week Activities Hours

Week 1 Researched myofunctional therapist in area and set up internship 0
Week 2 Shadowed Ryan. Crash course in myofunctional therapy 7
Week 3 Shadowed Ryan. Observed new patient evaluation 7
Week 4 Shadowed Sharon and Ryan. Observed 3 speech pathology sessions 6.5
Week 5 Reviewed Literature. Dental Hygiene Lobby Day at GA Capitol 4
Week 6 Reviewed Literature 0
Week 7 Shadowed Ryan. Observed end of stage 1 therapy patients 6
Week 8 Shadowed Ryan and Sharon. Discussed Down's children 6
Week 9 Shadowed Ryan. Observed bruxism therapy reginmen. 7
Week 10 No observation. Worked on Chapter 4 of paper 0
Week 11 Shadowed Ryan. Discussed bruxims and oral muscle balance. 4.5
Week 12 Shadowed Ryan. 6
Week 13 No observation 0
Week 14 Shadowed Ryan. 6
Week 15 No observation. 60 hours complete.
Total 60
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Learning Benefit

Exploring other career options outside of clinical dental hygiene was the goal of the author. This

internship allowed the other to explore a lesser known field that works closely with some aspects

of dentistry. It improved her awareness of the tongue and its role in structure of and functions of

the oral environment, thus improving her clinical knowledge while allowing her a deeper

knowledge of possible avenues to branch into.

Current Employment

Currently, the author is working two part time clinical dental hygiene positions. On

Mondays, Wednesdays and Fridays she works in Midtown Atlanta in a small private practice that

has a focus on implants and cosmetic dentistry. She also works Saturdays at a corporate office in

Douglasville GA. This leaves her with Tuesdays and Thursdays to perform her internship hours.

She hopes to complete all program courses and core credit hours to achieve her BSDH by fall of

2017.
MYOFUNCTIONAL THERAPY INTERNSHIP 12

Chapter 4

Results

Analysis of Strengths, Weaknesses, Opportunities, and Threats

Strengths. The Institutive of Myofunctional Therapy has several strengths. The first is

that its founder, Sharon Wexler, has been practicing speech pathology and myofunctional

therapy for over 42 years (The Institute of Myofunctional Therapy, 2016). She was originally

trained in myofunctional therapy by Danial Garliner, who was one of the leading developers of

this form of therapy. She retains the rights to Garliners work. The authors mentor, Ryan

Wexler, has been practicing myofunctional therapy for 15 years (The Institute of Myofunctional

Therapy, 2016). Unlike many myofunctional therapists who perform this therapy as an adjunct

to another main practice (such as speech pathology or orthodontics), Ryan only practices

myofunctional therapy. Along with his many years in the field this gives him a very focused and

targeted expertise in correcting deviated swallows.

One of the main focus Garliners method of myofunctional therapy is the systematic and

objective measurement of progress for each patient. This allows for the patients progress to be

tracked and for the exercises to be customized for each individuals specific needs. Ryan is

currently working to improve these measurement techniques to reduce the incidence of operator

errors.

Both Ryan and Sharon were excited to share their knowledge about myofunctional

therapy and speech pathology with the author. They were very gracious in opening up their

facility to the author, answering any questions she had, and discussing how the deviated swallow

could be affecting her own patients. Because of this all of the authors learning objectives were

accomplished.
MYOFUNCTIONAL THERAPY INTERNSHIP 13

Weaknesses. The main weakness of myofunctional therapy is how relatively unknown it

is. It holds a very close relationship to the fields of dentistry and speech pathology. However,

relatively few people in those adjoining professions are aware of its existence, or are able to

recognize a patient that would benefit from myofunctional therapy. There are also very few

myofunctional therapists in the Atlanta area. As mentioned before, most of those who practice

myofunctional therapy do so as an adjunct to another field. This risks not having enough clients

for a practitioner to really be able to develop a good foundation of knowledge and experience in

order to be able to individualize and adapt treatment for each patient. It also leaves many without

a support system of other myofunctional therapist who can advise and assist a therapist who is

new to the field (Wexler, 2017).

A second weakness is that this field is relatively unregulated. There are no across-the-

board standards for training or practicing myofunctional therapy. In the U.S.A no licensing is

required. Myofunctional therapy falls into a gray area under the American Speech Language

Hearing Association (ASHA). It is recognized but not really regulated (Wexler, 2017). The

Academy of Orofacial Myofunctional Therapy is an organization that seeks to support the

practice of myofunctional therapy and offers four day training courses in myofunctional therapy

(Academy of Orofacial Myofunctional Therapy, 2015). The International Association of

Orofacial Myology (IAOM) is another similar organization. They are the only U.S organization

that offers certification in myofunctional therapy for dentists, dental hygienists or speech

pathologists that complete a 28 hour course (International Association of Orofacial Myology,

2016).

Ryan points out that a weekend course such as these cannot possibly provide an adequate

foundation of hands on experience or training to fully enable someone to be able to practice

MYOFUNCTIONAL THERAPY INTERNSHIP 14

myofunctional therapy (Wexler, 2017). These weaknesses caused some initial difficulty for the

author because she found very limited options for internships in a drivable range from her home.

However, since she was able to contact The Institute of Myofunctional Studies it did not keep

her from accomplishing her learning objectives.

Opportunities. Very soon The Institute of Myofunctional Therapy is going to convert

itself to a non-profit organization with the goal of teaching and expanding knowledge of

myofunctional therapy. As well as establishing a regulating and supportive body for

myofunctional therapists. Sharon Wexler is in the process of developing a textbook for

myofunctional therapy. Ryan is in the process of developing and patenting more accurate

measurement tools for tracking patient progress.

This provides a potential for training for the author if she decides to pursue further

education in this field. This internship itself also provided a huge opportunity for the author to

increase her knowledge of a field closely related to her own. In addition to providing her with

tools to be able to (a) recognize a tongue trust or deviated swallow in her own patients, (b) be

able to refer those patients to someone who can address that condition, and (c) to explain the

basics of what the therapy will entail.

Threats. Current cultural mentality demands a quick fix for many problem or goals. It

often does not want to recognize the investment of time and dedication needed to perform the

exercises involved with myofunctional therapy. If the exercises are not performed with

consistency then the therapy will not be successful. Many individuals would rather pay for an

appliance or take medication to solve problems than take the time to train their own bodies to

solve the problem itself. Threats did not hinder the author from accomplishing her goals.
MYOFUNCTIONAL THERAPY INTERNSHIP 15

Chapter 5

Discussion, Conclusions, Implications, and Recommendations

Discussion

The author spent 60 hours observing Myofunctional Therapist, Ryan Wexler, or speech

pathologist, Sharon Wexler. During this time the author was able to accomplish all her

internship goals. For the most part, the days spent shadowing included only observation and

discussion. Occasionally her input as a dental hygienist was asked for but she did not participate

in administering or demonstrating any of the exercises. The author found most interesting the

times when she could simply discuss with Ryan or Sharon about Myofunctional therapy in

general, reasons and methodology for specific exercises, and observations regarding patients.

Both mentors were extremely open to discussing concepts and answering any questions the

author had.

Conclusions

This internship was a great learning experience for the author. The author knows that

clinical dental hygiene is a difficult field to sustain full time for many years. Previous to this she

knew of only public health (which appeals little to her), or teaching, that would allow her to

leave clinical practice yet still utilize her dental skills and education. This internship has

increased her knowledge of other career options as well as enhanced her clinical practice by

teaching her how to recognize and address a specific parafunctional habit that can cause oral

concerns for her patients.

Implications

This experience has greatly changed how the author practices clinically, specifically

regarding her oral assessments of her patients. She has started evaluating for signs and
MYOFUNCTIONAL THERAPY INTERNSHIP 16

symptoms that could indicate a deviated swallow such as (a) a high palate, (b) clenching or

grinding, (c) tongue thrust, and (d) specific malocclusions. If these issues are noted she discusses

the findings with the patient and recommends a referral for them. Although she has utilized

some of the stress management techniques used by the myofunctional therapist she does not

attempt to treat a deviated swallow as that is still well outside of her scope of practice. However,

formal training and certification is something that she would like to pursue in the future. The

author has also found that she is less likely to get aggravated with a patient who cannot control

his or her tongue during hygiene treatment because she understands why it is difficult for them.

Recommendations

The author highly recommends that this form of therapy be introduced to dental and

dental hygiene students at some point during their schooling and introduce assessing for a

deviated swallow as part of standard oral assessments. This would enable those in the dental

field to be more aware of the implications of oral muscle imbalances and parafunctional habits,

as well as foster a sense of interdisciplinary collaboration between the dental field and

myofunctional therapists.
MYOFUNCTIONAL THERAPY INTERNSHIP 17

References

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