This may be a controversial topic I’m writing about today, but my intention with this blog is to foster cooperation and education not defensive territorialism. There are many reasons that children and teens get braces and I am not an orthodontist so I am referring only to those who I have extensive experience with and where I have the privilege of collaborating with orthodontists…tongue thrusters!
More often than not, tongue thrusters require orthodontic braces at some point to make up for what the tongue did not do naturally during development. Teeth are often misaligned due to a narrow palate that doesn’t have enough room for the teeth as well as an overbite or overjet because the tongue is pushing on or through the teeth.
I have never seen a tongue thruster that does not have a high narrow palate. Why? Because the tongue didn’t learn to rest on the palate and spread it naturally during development. There can be a myriad of reasons why: pacifier, thumb sucking and mouth breathing are common influences.
If you look at an infant their face is very small and round with a prominent tongue as they are nursing and sucking as the primary feeding pattern. As an infant develops and begins erupting teeth the natural transition is to easy to swallow “baby food” which is usually a pureed consistency. Any parent can tell you that initially as much of it comes out as goes in! This is because the baby is transitioning from a sucking pattern to a more advanced swallow pattern in which the tongue learns to move backward to swallow instead of forward.
Still developing and having more space in the mouth as the face elongates and more teeth erupt the toddler begins simple chewables such as soft fruit, cereal or crackers that are manipulated with the synchrony of the tongue and the teeth. It is around this time that the posterior swallow becomes dominant and the reverse swallow is left behind, unless it isn’t.
For any number of reasons, tongue thrusters continue to demonstrate the forward, tongue dominant swallow pattern often using the molars to bite and tear food rather than the front teeth. The tongue posture remains forward in the mouth both at rest and when in motion.
So what does this have to do with braces? Well just about everything because if the tongue hasn’t spread the palate and the jaw by resting and hinging properly the end result is the need for restructuring the mouth by external means to align the teeth for effective alignment for chewing, articulation and aesthetics. This is where palate spreader, braces, and retainers of all sorts come in.
I will leave the orthodontic details to the orthodontic experts but will address when, why and how tongue thrust therapy should be integrated into any orthodontic treatment plan for an individual that demonstrates tongue thrust.
In my opinion, tongue thrust elimination should precede orthodontic appliances. I am seeing appliances earlier and earlier on kiddos. I understand that the reason is to facilitate space for the eruption of the teeth but too often the tongue is not considered in the early intervention program of the orthodontist. It should be!
As children begin to lose the “baby teeth” and have permanent teeth emerging is the perfect time to eliminate the tongue thrust, around age 8. Tongue thrust can be eliminated at any age and it’s never “too late” however, just as with any early intervention the process is often easier when younger because they learn so quickly and honestly schedules are a bit more flexible before they hit those full on teenage years!
Why not have development on your side? Clearly the need for orthodontics is the result of something gone wrong in the development of the mouth, so why not train the tongue to do what it is supposed to do naturally to facilitate optimal oral development and function?
The reasons that many orthodontists don’t consider tongue thrust therapy is because they don’t know about it or haven’t had a good experience working with a speech therapist that specializes in tongue thrust. Just like most general dentists refer to an orthodontist specialist most orthodontists should refer to a tongue thrust specialist.
The tongue is a dynamic and complex group of 8 muscles! No other muscle group in your body is as specialized as the tongue with much of the function being automatic yet still having voluntary control as well! Understanding the anatomy, physiology, form and function of the tongue requires specialized training to effectively and permanently retrain.
Even within the field of Speech Language Pathology, specialized training is necessary to understand tongue thrust. Yes, all SLPs have training in the anatomy and physiology of the tongue but not all understand the form and function of tongue thrust and how to effectively retrain both the voluntary and automatic, resting and active nature of a tongue thrust.
Do your homework! Just like you seek out a competent doctor that meets your needs you should seek out an orthodontist that meets your needs. If any of these “red flags” seem familiar to you or your dental provider has mentioned tongue thrust, the next question to ask is “Who do you recommend I see to eliminate the tongue thrust?”
If you are told that they address it in the office through placement exercises or appliances, they are not addressing the tongue thrust and it will eventually resurface and unfortunately often with undesirable compensatory posture that result in a disorder swallow instead of just a reverse swallow.
If you are told the braces will address it and the tongue thrust will go away, you may want to ask for references from other individuals who had tongue thrust and what their experience was. These are the situations with multiple rounds of braces and permanent retainers that “just keep moving”.
If they refer to an SLP find out if they have specialized training in tongue thrust. What does the program look like? How long does it take and what are the outcomes? A comprehensive program should address not only the “spot” but generalized habituated resting posture of the blade on the palate. It should also address training of a generalized habituated posterior swallow. It should collaborate with other professionals who may support optimal structure and function of the oral and nasal areas such as an ENT and orthodontists.
It’s important that the SLP and orthodontist work together to achieve optimal long term outcomes. The tongue and the teeth can be working on separate programs simultaneously as long as they are in communication and not conflicting with each other. For example, orthodontic spikes would not be helpful for tongue placement if an SLP is retraining the correct tongue posture, however a palate spreader (although uncomfortable and awkward) does not interfere with correct tongue posture and even swallow training.
The elephant in the room is the stigma around tongue thrust therapy. I’m not sure if it’s because it has “therapy” in the referral or if it is just the unfamiliarity of the process, but I can tell you that more often than not clients don’t want to say that they are receiving “tongue thrust therapy”.
It’s interesting to me that it has become a “cool social status” to have braces (younger and younger) but to address the underlying cause of the braces (for many but not all) is completely ignored and even avoided. I’m sure it’s because this is my world and my clients are thrilled with the elimination of the tongue thrust and the fact that it is more cost effective and permanent than repeated orthodontics and braces, but I just don’t understand why people are embarrassed to have “tongue thrust therapy”.
Maybe we should change the terminology and refer for “tongue thrust elimination”. Yes! Let’s do that! Call it what it is and maybe we can educate the masses and reduce the stigma.
Instead of putting braces on 10 year olds, let’s eliminate the tongue thrust that is contributing to the problem so that the tongue can support the correct structure and function of the mouth while the child’s mouth is changing at a crazy rapid rate! Let’s work together to create the best outcomes for 16 year olds instead of putting on a second or third set of braces. Let’s facilitate the correct growth patterns instead of altering them. Let’s look at eliminating tongue thrust as the first line of defense instead of the last!