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TIMED AGENDA : The Functional ASSESSMENT and REMEDIATION of TOTs (Tethered Oral Tissues)™ - 2 DAYS

DAY 1: Functional ASSESSMENT of TOTs (Tethered Oral Tissues)

Robyn Merkel-Walsh MA, CCC-SLP/COM® | Lori Overland MS, CCC-SLP, C/NDT, CLC, FOM

Course Description

Tethered Oral Tissues (TOTs) is the restriction of the frena or frenulum, which are small folds of tissue that connect bone to tissue and support or limit movement. While not a new condition, the term TOTs was coined by Kimberly Benkert, RDH and later by Dr. Kevin Boyd in 2014 to describe restriction of the frenula in the tongue (ankyloglossia), lip (lip-tie) or buccal frena. While there are respected assessment protocols that look at the structure of the tissues, there is yet to be a detailed functional assessment that looks at the impact of TOTs on oral motor, feeding and speech skills. Lori and Robyn have done extensive literature review on TOTs and have collected several years’ worth of clinical data in preparation of this course.
This course provides participants with a “Task Analysis” of a TOTs assessment. Robyn and Lori have created case history forms for infants, children and adults that will reveal pertinent developmental and medical histories that look for red flags of both structural and functional TOTs issues. Then they will walk you through craniofacial /structural assessment of TOTs including what tools and cues will help assess structure. For the second part of the course, participants will be taught the functional markers of TOTs, with:  breast, bottle, cup, and spoon, solid and straw feeding (s). Oral placements required for speech clarity will also be covered on how to assess errors that are typically associated with TOTs. Finally ethics, scope of practice and creating a “TOTs Team” will be explored. 

Timed Agenda

9:00-9:30  Introduction
  • About the speakers
  • What are TOTs?
  • Theoretical Foundations
9:30-10:00  Case History/Assessment Forms
  • Structural red flags of TOTs
  • Functional red Flags of TOTs
  • Pertinent birth history
  • Pertinent medical history
  • Pertinent developmental history
10:00 – 10:30 Assessment
  • Current protocols and assessment tools
  • The Merkel-Walsh Overland TOTs Protocol
10:30-10:45: Break
10:45-12:00  Structural Assessment
  • Craniofacial analysis
  • Hard tissue
  • Soft tissue
  • Frena
  • TOTs assessment techniques and tools

Structural Quiz

12:00-12:45: Lunch

12:45- 2:45 Functional Assessments of Pre-Feeding and Feeding Skills

  • Breast
  • Bottle
  • Spoon
  • Cup
  • Solids
  • Straw

2:45 – 3:00 Break

3:00- 3:30:  Functional Assessment of Speech Clarity

  • Acoustics vs. placement
  • Bilabials
  • Alveolars
  • Back Tongue Side Spread
  • Velars
  • Labiodentals
  • Linguadentals

3:30: 4:00: Additional TOTs Topics and Conclusions

  • TOTs team
  • Referrals
  • Therapeutic Considerations

4:00-4:15 Q and A

Learner Outcomes

 Participants will be able to list at least 2 assessment protocols for TOTs.

  1. Participants will be able to identify at least 3 ways in which TOTs can impact feeding and /or speech.
  2. Participants will be able to describe at least 3 techniques to assess structural and/or functional implications of TOTs.
_______________________________________

 

DAY 2: Functional REMEDIATION of TOTs (Tethered Oral Tissues)

Robyn Merkel-Walsh MA, CCC-SLP/COM® | Lori Overland MS, CCC-SLP, C/NDT, CLC, FOM

Course Description

Tethered Oral Tissues (TOTs) is the restriction of the frena or frenulum, which are small folds of tissue that connect bone to tissue and support or limit movement. While not a new condition, the term TOTs was coined by Kimberly Benkert, RDH and later by Dr. Kevin Boyd in 2014 to describe restriction of the frenula in the tongue (ankyloglossia), lip (lip-tie) or buccal  frena. There are many “hot topics” about treating TOTs ranging from the need for surgery to whether or not pre- and post-op care is necessary.  Lori and Robyn have done extensive literature review on TOTs and have collected several years’ worth of clinical data in preparation of this course to explore these controversies and focus on an evidence-based approach to treatment.

This course provides participants with a “task analysis” of TOTs interventions, based on Robyn and Lori’s theoretical foundation that the oral sensory-motor system cannot be separated, and therefore when TOTs is diagnosed the impact on movement impedes the way the person processes sensory information for feeding and speech. Any movement in the body can be broken down into smaller motor units, and Robyn and Lori have created a series of neuromuscular re-education techniques ranging from passive to active to work with patients across the life span with a range of cognitive skills.

This class will walk through interventions for both pre-feeding and feeding for: breast, bottle, cup, spoon, solid and straw feeding(s) in addition to the oral placements required for speech clarity.  Pre and post- operative considerations as well as surgical procedures will be discussed. Neuromuscular re-education of the cheeks, lips and tongue will be presented and numerous demonstrations, practicums and video slides will teach participants to execute a functional remediation program. Exercises may be executed in the school, hospital or clinic-based settings based on the impact on education or activities of daily living. Finally, Robyn and Lori have added a new section on toddlers and strategies for success with this challenging population.

Timed Agenda

9:00-9:30  Introduction

  • About the speakers
  • What is TOTS?
  • Theoretical Foundations
  • Brief review of assessment and functional impact of TOTs

9:30-10:00 Hot Topics

  • TOTs team
  • Scope of Practice
  • Ethics

10:00: 10:30 TOTs Remediation

  • Pre-feeding/Oral Motor
  • Feeding
  • Orofacial Myofunctional Therapy
  • Oral Placement Therapy
  • Active Wound Management

10:30-10:45  Break

10:45-11:15  Frenectomy

  • Scissor/Scalpel
  • Laser
  • Risks and Complications
  • Aftercare comparisons

11:15-12:00 Neuromuscular Re-education for Pre-Feeding

  • Buccal TOTs
  • Labial TOTs
  • Lingual TOTs

12:00-12:45: Lunch

12:45-1:30:  Neuromuscular Re-education for Pre-feeding Cont.

1:30-2:45: Neuromuscular Re-education for Feeding

  • Buccal TOTs
  • Labial TOTs
  • Lingual TOTs

2:45-3:00 Break

3:00-3:50:  Neuromuscular Re-education for Speech

  • Bilabials
  • Alveolars
  • Back Tongue Side Spread
  • Velars
  • Labiodentals
  • Linguadentals

3:50-4:00 PM TOTs and The Terrible Twos

4:00-4:15 : Q and A

Learner Outcomes

Participants will be able to:

  1. list at least 2 surgical techniques for TOTs.
  2. identify at least 2 goals of a pre-op TOTs plan of care.
  3. execute at least 3 neuromuscular education activities for pre and post op TOTs (1 buccal, 1 labial, 1 lingual).