The SLP's Role in TOTS

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The Speech-Language Pathologists’ Role in TOTs
By: Robyn Merkel-Walsh MA, CCC-SLP, COM®

The first important aspect of knowing who the best provider is for your child is to know that Tethered Oral Tissues (TOTs) often requires a team approach. No one profession is more important than another. Ideally a patient will see an appropriate therapist/consultant for a functional assessment and receive some pre-operative care to optimize the release procedure. Sometimes this can be very confusing to parents as each family has their own journey and makes referrals based on their personal experience but each infant/child may present with different functional symptoms requiring their own unique plan of care.

In some cases this may warrant a Speech-Language Pathologist. (SLP). SLPs have many roles in their scope of practice ranging from feeding to language to speech clarity. In dealing with Tethered Oral Tissues (TOTs) there are specific skills an SLP has to assess and treat to assist with the care of TOTs patients.

It is important however that the SLP chosen for TOTs care, have specific training in oral motor, feeding and /or orofacial myology as these are the areas which are problematic in TOTs patients. SLPs trained in pediatric feeding should be trained from 0-3 year olds if they are going to work with an infant. SLPs trained in orofacial myology should be trained with older children 3/4 and up. Ideally an SLP working with TOTs should have both feeding and orofacial myology training.

Parents have the right to ask clinicians what their specific training(s). For example, a Certified Orofacial Myologist (COM®) has taken a 28 hour approved orofacial myology course, passed a board exam, passed a query and completed an on-site examination. There are various feeding/orofacial myology trainings that provide knowledge for SLPs.

    1. Oral Motor Development: there is a set of expected oral sensory motor milestones that infants should achieve from 0-3 years. These norms are carefully described by Bahr, Beckman, Boshart, Morris & Klein & Overland & Merkel-Walsh (to name a few) in texts and coursework. These norms are very important to assess before a frenectomy is performed to be able to establish goals. For example, the SLP needs to check of pre-requisite oral motor skills are in place to handle solid feedings. Even in older children we can assess oral motor functions and determine where the areas if deficits are to help improve feeding, oral resting posture and speech. Feeding therapy, when required, should begin pre-operatively to establish baselines and help the patient acclimate to intraoral stimulation. Oral aversion can become a problem in TOTs aftercare and pre-op oral motor training is helpful to both the patient and the parent. It should be noted that Independent Board Certified Lactation Consultants (IBCLCS) have training in infant oral motor development and Occupational Therapists (OTs) have training in oral sensory motor development across the lifespan
    2. Feeding: There is much confusion to who treats a feeding disorder. The simple answer is it depends on the age and symptoms of the patient. SLPs recognize that IBCLCs are the best professionals for treating the breastfeeding dyad; however SLPs do have feeding from 0 (newborn)-70+ (geriatrics) in their scope of practice. Many times IBCLCs refer to SLPs and vice versa based on severity of symptoms and /or clinical expertise. Feeding encompasses many stages including: breastfeeding, bottle feeding, pureed foods, solids, oral phase of feeding (chewing, bolus collection), pharyngeal phase of feeding and the esophageal phase of feeding. SLPs who are feeding specialists have the role in helping transition patients from one phase of feeding from the next, for example helping wean a bottle or introducing solids.  The SLP also treats self-limited diets and picky eating habits. All of these issues may arise from TOTs. The SLP’s clinical expertise may vary based on where they work (school vs. hospital vs. clinic) and how they trained. The American Speech-Language and Hearing Association (ASHA) has strict guidelines that SLPs must have specific training in pediatric feeding to work with babies, toddler and school aged children. Parents should discuss this training with the clinician to ensure that they have experience with these issues.
    3. Orofacial Myology: There is much confusion as to who is an “Orofacial Myofunctional Therapist”. There is no licensed profession in the United States (to date) as an “OMT”. OMT stands for orofacial myofunctional therapy which was derived between orthodontists/dentists and SLPs who understood that there was a close relationship of oral structures and the functions of the tongue. It is a modality of treatment for those who present with an Orofacial Myofunctional Disorder (OMD). The International Association of Orofacial Myology (IAOM) defines an orofacial myofunctional disorder as: “one or more of the following: abnormal labial-lingual rest posture, bruxism (teeth grinding), poor nasal breathing, tongue protrusion while swallowing, poor mastication and bolus management, atypical oral placement for speech, lip incompetency and/or digit habits and sucking habits (such as nail biting). These conditions can co-occur with speech misarticulations”. Certainly people across the lifespan with TOTs can face any of the challenges listed in this definition but the age of the patient is key in who should treat them and how to treat them. Infants and toddlers need to be treated for oral motor, speech and feeding issues (IBCLC/OT/SLP) because they cannot engage in the volitional movements and self-monitoring that OMT requires. Children four and above can be treated with orofacial myofunctional therapy (OMT). Parents seeking “OMT” should ensure the therapist has specific post-graduate training in this therapy. SLPs have OMT specifically written in their professional scope from ASHA to include ankyloglossia (tongue-tie). Dentists and Registered Dental Hygienists also have OMT in scope, so some COM®s may be an RDH. Occupational and Physical Therapists (OTs/PTs), as well as Chiropractors and Licensed massage Therapists (LMTs) help support the work of the SLP/RDH providing OMT because of the way in which TOTs impacts the whole body.
    4. Oral Habits: SLPs trained in orofacial myology learn about the causes of non-nutritive sucking habits, what causes them (possibly TOTs) and how to correct them. Generally this is addressed when children are over the age of four; however, feeding experts also address this in young children because of the impact of speech and feeding. For example, feeding specialists will use teething toys to replace a pacifier.
    5. Speech: Only SLPs should be treating speech disorders in TOTs patients. This is not to say that other professionals cannot help the underlying oral sensory motor skills for speech, such as OTs/PTs working on postural and head/neck control, but actual speech sound production is treated by SLPs. Children with tongue-tie can have issues atypical speech sound elicitations with abnormal lingual dental articulatory placement for /t/,/d/, /l/, /n/, /r/, /k/, /g/ and distorted productions of /s/,/z/ often with an interdental or lateral lisp to include /t∫/ (chip),/dʒ/ (jump), /∫/ (shop), /ʒ/ (judge). Lip ties can impact /m/, /b/, /p/, /w/ and buccal ties may impact the cheek support needed for any sound involving lip closure, rounding or protrusion such as /w/ or /∫/ (sh). TOTs patients often need a tactile approach to treatment using therapy tools and facial cues to assist in correct production such as Oral Placement Therapy (OPT) from TalkTools®. SLPs often work on feeding, oral motor and orofacial myofunctional goals preceding speech sound drills to help establish the pre-requisite placement skills required.

    In summary, there are many members of a TOTs team that may be needed to assist with functional skills pre- and post-operatively. SLPs who have specific training for TOTs patients can assist with patient care across the lifespan to include: oral motor skills, feeding, oral habits, orofacial myology and speech. It is important for parents to discuss the SLPs experience and training with TOTs, and preferably seek an evaluation and start therapy prior to a release procedure.


    REFERENCES:

    American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

    American Speech-Language-Hearing Association. (2019). Orofacial myofunctional disorders practice portal. Retrieved from: https://www.asha.org/Practice-Portal/Clinical-Topics/Orofacial-Myofunctional-Disorders/

    Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World.

    Baxter, R. (2018). Tongue tied: how a tiny string under the tongue impacts nursing, speech, feeding, and more. Alabama, GA: Alabama Tongue-Tie Center.

    Baxter, R. & Hughes, L. (2018). Speech and feeding improvements in children after posterior tongue-tie release: A case series. International Journal of Clinical Pediatrics, 7(3), 29-35.

    Billings, M., Gatto, K. D’Onofrio, L., Merkel-Walsh, R. & Archaumbault, N. (2018) Orofacial myofunctional disorders. Retrieved from: http://iaom.com/wp-content/uploads/2018/10/OMD-Overview-IAOM.pdf

    Boshart, C. (2015). Demystifying the tongue tie. Ellijay, GA: Speech Dynamics.  

    Meaux, A., Savage, M., & Gonsoulin, C. (2016).  Tongue ties and speech sound disorders; what are we overlooking?  Poster session at The American Speech and Hearing Association, Philadelphia, PA.

    Merdad H. & Mascarenhas, A,K. (2013). Ankyloglossia may cause breastfeeding, tongue mobility, and speech difficulties, with inconclusive results on treatment choices. Journal of Evidence-Based Dental Practice, 10(3):152-3.

    Merkel-Walsh, R. & Overland  L. (2018). Functional assessment and remediation of tethered oral tissues (TOTs). Charleston, SC: TalkTools.

    Merkel-Walsh, R. & Overland  L. (2017) Functional assessment of feeding challenges in children with a diagnosis of ankyloglossia. Poster presentation at The American Speech and Hearing Association, Los Angeles, CA.

    Merkel-Walsh, R. (2018). Orofacial myofunctional disorders vs.  pediatric feeding disorders: what’s the buzz about. Retrieved from: http://www.agesandstages.net/ or:  https://talktools.com/blogs/from-the-experts/orofacial-myofunctional-disorders-omd-pediatric-feeding-disorder

    Merkel-Walsh, R. (2018). Oral placement therapy: a practical solution for articulation issues in children with orofacial myofunctional disorders. Poster Presentation at the Annual Convention of the IAOM: Charlotte, NC.

    Messner, A.H. & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otoloaryngology Head and Neck Surgery, 127(5):539-545.

    Mills, N., Pransky, S.M., Geddes, O.T.& Mirjalili, S.A. (2019). What is tongue-tie: defining the anatomy of the in-situ lingual frenulum. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30701608

    Morris, S. & Klein, M. (2000). Pre-feeding skills (2nd Ed). San Antonio TX: Therapy Skill Builders.  

    Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

    Pine, P. (2018). Please Release Me: The Tethered Oral Tissue Puzzle. NY, NY: MiniBuk.

    Potock, M. (2015). Tip back that tongue! The posterior tongue tie and feeding challenges. The Asha Leader Blog. Retrieved From: https://blog.asha.org/2015/05/26/tip-back-that-tongue/

    Potock, M. (2017). Three structures in a child’s mouth that can cause picky eating habits. The ASHA Leader. Retrieved from : https://blog.asha.org/2017/08/22/three-structures-in-a-childs-mouth-that-can-cause-picky-eating/

    Siegel,S.,  Calasuma,N.,  Emanuel, M., Fabbie,P. ,   Watson-Genna,C., Merkel-Walsh, R.  & Overland, L. (2017). Connecting the Dots in TOTs. Oral Presentation, NY, NY.

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