Speech, eating and drinking. This really refers to chewing and swallowing. We don’t only swallow when we eat and drink – most of us swallow our saliva over 1000 times a day (probably somewhere in the region of 1200-2000 times!).
 
We also look at the resting posture of those muscles – this means thinking about what the tongue, lips, cheeks and facial muscles are doing when we’re not talking, chewing or swallowing. When we’re watching TV, playing, reading or working, or even just waiting for our turn in a conversation, is our mouth open or closed? And where is our tongue?  
 
Those who have an Orofacial Myofunctional Disorder or OMD, often have an open mouth posture at rest, and will benefit from OMT. When we have optimal function, we observe closed lips, the tongue resting up in contact with the palate, and nasal breathing.
 

It could be due to low muscle tone. This is seen in both children and adults. Some adults present with a history of Occupational Therapy that targeted fine or gross motor skills to address low muscle tone.
 
It could be an issue with the nasal passage. If we can’t breathe through our nose, we must breathe through our mouth.
 
There could be tethered oral tissues, such as tongue and lip ties. These tethered oral tissues may not be as obvious as you would imagine. There can be restrictions at the back of the tongue which can significantly affect functional speech, swallowing and the ability to maintain an optimal resting position (tongue resting at the top of the palate).
 
It could be habitual. That means that there may have been a history of nasal obstruction which has now been resolved but mouth breathing has remained habitual. In this situation, we can launch straight into breathing re-training to habituate a closed mouth posture with nasal breathing.
 
When we have our mouth open at rest, we cannot achieve proper posture of our whole body. As we open our mouth and jaw, it causes the hyoid bone to swing down and compress the airway. That is why we always see a flexed (or forward) head posture in people who are mouth breathing. It is also the reason why it is very common for people with Occupational Therapy goals such as posture, handwriting and pencil grip, to also have OMD issues, even if these two areas don’t appear related at first.
 
So back to function: what are we looking at? We are looking at oral rest posture when awake, and when sleeping.
 
We are looking at speech, and chewing and swallowing patterns.

When we see a low resting and anterior tongue rest posture, we often see speech errors that involve anterior placement of the tongue. Commonly, this is a lisp on ‘s’ and ‘z’ sounds. It may also be on the palatal sounds – ‘sh’ ‘zh’ ‘ch’ and ‘j’. Also, quite often on the alveolar sounds, the ones that are produced by elevating the tongue tip to the spot on the palate, just behind the top front teeth – ‘t’, ‘d’, ‘l’ and ‘n’ sounds. The sounds are incorrectly produced with the tongue either pushing against the teeth, or even protruding beyond them.
 
Sometimes – functional changes are even more subtle. Do you know any kids or adults who move their jaw or lips in a unique way when speaking? They might be compensating for tethered oral tissues! We often see jaw sliding, jaw fixing and excessive lip movement. This is something that I see a lot in kids who have already had speech therapy following a traditional approach – they find a way to make the sound, but through compensatory motor patterns. Over time, asymmetrical use of muscles can also impact craniofacial growth. We meet adults who have TMJ syndrome and chronic migraines all the time (I must say, I’m a textbook case as well…!). So, while we don’t have a crystal ball, striving for speech outcomes that are acoustically accurate, and without compensation, is a worthwhile goal as we know this is a population at risk of TMJ issues, migraines and in more severe cases, sleep apnoea.

In my job as an OT, I meet a lot of fussy eaters – kids who have been referred for an evaluation of their sensory preferences as the root cause of those feeding issues. Of course, sensory based intervention can be helpful for some kids, but I firmly believe that this should not ever be prescribed until a thorough structural and oral motor assessment has been completed. 
 
I meet children for example, who won’t eat popcorn, or whole strawberries, and when we look inside their mouth, we find – an extremely high, vaulted palate, and a very restricted tongue that does not have the range of motion to reach the top of their palate. This means they are unable to fish a bit of popcorn stuck in the corner of their mouth or they can’t stop a chunk of strawberry from falling into the pharyngeal space at the back of their throat. These children have reduced chewing abilities where they cannot easily push a bolus onto their molars for chewing.
 
These kids aren’t just fussy…they are keeping themselves safe!
 
They might have low muscle tone and reduced sensory awareness on top of all this too, or maybe even an obstructed nasal airway so they have to pause chewing every few seconds to breathe. That is why a thorough function and structural assessment is critical at the beginning of therapy. At some point they may need a sensory based approach but it is important to address all the factors contributing to fussy eating.
 

 
Swallowing – this is a big area because we don’t just swallow when drinking, we swallow our own saliva up to 2000 times a day! When I assess children, I can often see signs of a tongue thrust swallow as they swallow their own saliva at rest. Their lips tighten and flex – and there is dimpling in the chin muscles as a restricted tongue pulls on the mentalis muscle. When we get to cup drinking, we may see the tongue greeting the cup, the child gulping the liquid down and often a final tongue thrust is observed as the cup is lowered. Other times, children hold water in their cheeks for a moment after bringing the cup down, before they ‘trigger’ their swallow, or they might even tilt or jerk their head. This is quite effortful as they need to activate all the muscles around their lips to counter the force of the tongue pushing from inside.
 
In a typical swallow, the orbicularis oris muscle (lip msucles) should remain relaxed. The tongue tip goes up to the special spot behind the front teeth and there is then a backward, wave-like movement of the tongue to propel food or drink backwards. It is a relaxed and natural process.

A quick recap, optimal resting posture is:

• Lips closed
• Tongue on the palate
• Nasal breathing

 Humble goals, but a very high proportion of the kids I see in my practice, for a range of reasons, present with an open mouth posture and mouth breathe.
 
This is huge, because obviously we can’t work on lip closure if you can’t breathe through your nose!
 
This is also huge because mouth breathing, is in fact, over breathing. I could talk about this point all day (quite literally- I have a one day course called ‘The Breathing Link’). But in a nutshell – Breathing through our nose is important because the air is filtered and warmed, and the volume of air that is both inhaled and exhaled, supports optimal biochemistry. When we mouth breathe, we exhale too much CO2 – and contrary to what most people understand about CO2 being a waste product to be expelled – we need to learn that exhaling too much does harm!
 
CO2 helps oxygen to hop off our red blood cells and enter the tissues to give us energy. Low CO2 means low oxygenation – even when we are breathing a lot. This can be seen in children with big dark bags under their eyes due to low levels of oxygenation. Big breaths don’t mean more oxygen, they are inefficient and are effectively hyperventilation. Not in an acute sense, but at low and chronic levels which is often not identified when other physical, mental health or learning issues arise. But this is important as low CO2 triggers our sympathetic nervous system, meaning we’re in fight or flight all the time. This affects energy levels, digestion, sleep, executive functioning (including working memory and attention), emotional regulation, anxiety and low mood including depression.
 
At SPOT Therapy Hub, if we treat kids, or adults, for any goal at all, without treating dysfunctional breathing, we are doing them a disservice.
 
This may not be what a family has bargained for when they first see us for support with gross motor skills, dressing, handwriting, emotional regulation strategies, speech and language therapy, stuttering etc., as breathing may seem distant to all these goals.
It can be a bit to take in and it requires commitment because management is often multidisciplinary- that means we have to work together with other airway specialists – ENTs, airway-oriented dentists and sleep specialists, to get to the bottom of these issues.
 
But trust me, it is worth it.

Oral habits include thumb sucking, nail biting, finger sucking, tongue sucking and putting things in your mouth to suck or chew, when it is no longer developmentally appropriate. We view these habits as symptoms of Orofacial Myofunctional Disorder. We have a cranial nerve in the roof of our mouth that should be stimulated by the tongue at rest. When the tongue doesn’t do its job because the mouth is open so you can breathe, or because the tongue is tethered down, it seeks that stimulation elsewhere.
 
We love helping our clients with habit elimination because it usually that means sorting out some underlying health issues and setting them up to succeed using positive functional retraining – not just a behavioural program that leaves them at high risk for developing substitute habits. We know that a lot of the children we treat for oral habits have an inflammatory condition such as eczema, asthma and food allergies. These are things we want to be mindful of when planning to give up oral habits. We also consider emotional trauma, so timing is crucial. We gather all this information to support families to make informed choices so that success happens the first time we give up the oral habit.
 
So – if this has got your brain ticking…if you’re wondering about yourself, your partner, another family member, your child, a child you’re treating, a child in your class…speak up! You could be helping them access care that will have lifelong benefits to their physical and mental well-being. We are talking about happiness and quality of life.
 
Please feel free to get in touch and we are more than happy to help! Contact us on spottherapyhub@gmail.com or 9389 3322. Also check out our podcasts and blogs on a variety of topics at www.spottherapyhub.com.au