SECOND ARTICLE (On oral exercises)
This article has been taken from an explanatory leaflet given on the First International Speech Therapy Congress of Guadalupe (French Caribbean) on March 96, with extracts from the Author's talk on this Congress.MYOFUNCTIONAL OROFACIAL THERAPY - PADOVAN METHOD
(NEUROFUNCTIONAL REORGANIZATION)
A system of therapy for improving nasal breathing, sucking ability, chewing, swallowing, speech and orofacial muscle function is described. The therapeutic exercises do not require conscious co-operation therefore they can be used with very young or handicapped Patients. New strategies for helping Patients overcome negative oral habits are detailed.
Human beings use their mouth for different functions:
FUNCTIONS OF NUTRITION - Respiration, Suction, Mastication and Deglutition. These functions are vital to human beings and are called Vegetative-Reflex Functions (VRF).
FUNCTIONS OF RELATIONSHIP or OF COMMUNICATION- these functions include:
Significant mimic
Speech
FUNCTIONS OF RELATIONSHIP or OF COMMUNICATION- Let's begin our analysis by the production of the speech. Speech is the articulate oral language and it consists in the emission of the voice and in the articulation of the word. We know that, although the articulate and codified word is peculiar to the human being, man has not developed any special organ for this activity.
The speech is a function that was originated from an adaptation of two vital systems:
the Respiratory System and
the Digestive System
The human voice is produced by the Respiratory System. An air current comes from the lungs and, when it reaches the larynx, it produces the voice by vibrating the vocal folds.
In the initial part of the Digestive System - mouth and its structures - the sound is either modified by a larger or smaller opening of the mouth, forming the vowels, or that sound is interrupted at different points, forming the consonants. These are the points of articulation of the phonemes. They are the same points as the ones that are used in the process of feeding. The bilabials at the point of apprehension of the food and the other phonemes at the points the tongue touches during the act of deglutition.
The mechanisms used for eating and speaking are one and the same. The VRF are prelinguistic in that they prepare the phonatory organs by adapting them to the production of speech.
MORPHOGENETIC FUNCTION - On the other hand, these very functions adequately developed and functioning within their correct patterns are going to influence beneficially the form of the dental arches.
The teeth are maintained in balance and in harmony by two antagonistic muscular forces:
an internal restraining force, which is the tongue
an external force, formed by the BUCCINATOR MECHANISM, which is the muscular band formed mainly by the orbicular of the lips (orbicularis oris) and the buccinator muscles that hold the teeth, surrounding them externally.
These two forces have to be balanced. And the moulding action of these muscles is exerted while in repose as well as while in function.
During the reposing posture there should be a soft labial contact, the tip of the tongue must stay in the incisive papilla and there has to be an approximation of the dorsum of the tongue towards the palate, holding internal and external muscular components in balance.
The balance of the muscles in function concerns the VRF of RESPIRATION, SUCTION, MASTICATION and DEGLUTITION.
We must remember that what we call NEGATIVE ORAL HABITS (described as functional etiology of some odontic-facial deformities) are deviations of those functions:
Respiration - MOUTHBREATHING
Suction - SUCKING OF FINGER and/or PACIFIER
Mastication - BRUXISM, ONICOPHAGY, UNILATERAL CHEWING, BITING
OF OBJECTS (the most different ones)
Deglutition - TONGUE THRUST SWALLOWING (Atypical Deglutition)
Here we can see very clearly the link between Odontology and Speech Therapy. This link is represented by the VRF. They are considered prelinguistic functions in Speech Therapy while in Odontology they are considered functions that are responsible for the stability of the teeth in their correct axial angles of inclination.
THE METHOD
During 6 years (1969-1975) I worked at the University of São Paulo (USP), where I used to give classes to Post-Graduate students in Orthodontia. There I developed my method of Neurofunctional Myotherapy and I have been applying it since then, with excellent results, even with comatose Patients, because their participation is reflexive, not volitional. The method was initially published in the orthodontic journal "Revista de Ortodontia", São Paulo, in 1976.
Researchers, since the beginning of the century, have noticed that relapses sometimes occur in orthodontically treated cases. Angle (1907) noticed that the habit of letting the tongue rest between the teeth or letting it project itself, led to difficulties in completing orthodontic treatment.
Other authors have shown interest in this subject. It was, nevertheless, from the researches done by Straub, Garliner, Hanson and others, in the United States, and by Cauhépé, in France, during the 1960 decade, that this matter has become more important.
Many methods have been developed and published since. Most of the methods in myofunctional treatment are directed to the reeducation of atypical deglutition (tongue thrust swallowing) and the establishment of normal oral rest posture.
Some programs take respiration into consideration as well. There are even some "strategical practices" proposed in order to "close the Patient's mouth".
As far as I know, there are no methods that use chewing as therapy, besides recommending Patients to chew well during meals.
Concerning suction, there is much importance given to breast-feeding. Often a harmful sucking habit is addressed by treatment only to eliminate that habit. I haven't found any reference as to the use of the pacifier suction as a therapeutic exercise. Yet, in the Padovan approach, the orthodontic pacifier has been used as an effective therapy tool since 1972.
It is of great importance that we bear in mind that all of the VRF use just the same muscles and just the same nervous impulses.
It was surprising that the authors only addressed reeducation of the tongue thrust swallowing. It was also surprising that the authors would affirm that the reeducation of the atypical deglutition should begin only after the age of 7, when the Patient would already be able to co-operate.
A seven year old child who is tongue thrusting would certainly have developed dentofacial deformity, or malocclusion, by this point. Why not administer preventative therapy?
Besides thinking of that preventive work, I also considered other Patients carriers of different pathologies, like the Down Syndrome, cerebral palsy, developmental disabilities and even mental disease, who exhibit atypical deglutition, and, generally speaking, who also had all VRF altered. Some of these children are unable to blow or to suck, have difficulty chewing, disordered speech and various types of malocclusion. So, how would they possibly be able to co-operate, repeating the exercises recommended for the training of deglutition?!...
Considering carefully all these facts the Padovan Method was developed as a treatment approach in which all these functions are undertaken and that may be applied to any type of Patient, with any kind of pathology and at any age.
In the Padovan Method, all of the VRF are exercised in each therapeutic session. Never only one of these functions is isolated for specific intervention, for all of these functions are dependent on the same muscles and the same nerve impulses. If one function is altered, the others are likely to show related pathologies. And the good functioning of one will already be a help to the other ones.
When using this method, it is important that the Clinician does not allow the Patient to become aware of his own difficulties. Rather, the Clinician should use the Patient's own reflexes to establish adequate function.
SOME EXERCISES OF THE METHOD
Here we are going to describe only some of the exercises. There are many others, of course. The materials used in the Padovan training are very simple and can be found everywhere - party blowers, orthodontic pacifiers, flexible rubber tubing of different sizes and diameters, spatulas, small pieces of holy bread, catheters, orthodontic elastics, drinking straws, a small massage vibrator and wooden whistles.
RESPIRATION: - The Clinician must take the entire respiratory tract into account, from the diaphragm up to the nose and mouth. The Patient does not need to become aware of the breathing patterns nor of the Clinician's purpose when conducting the exercises.
The patient leans back comfortably on a special easy chair and is asked to phonate vowels one by one while the Clinician applies gentle pressures on the region of the diaphragm. These light pressures interrupts the sound and stimulates the vocal folds through tapping on the abdomen below the sternum. The diaphragm and vocal folds are addressed simultaneously.
The blower is used in exercises to increase lung capacity. Exercises to re-establish nasal airflow are done with the blower in the nostrils. The Patient closes the lips, occludes one nostril with a finger and inserts the blower into the other nostril. The Patient blows nasally to unfurl the blower and keep it inflated as long as possible. When the blower deflates it is immediately removed, so the Patient will automatically breathe deeply through the open nostril. The exercise is repeated a varying number of times, depending on the Patient.
SUCKING: - A special orthodontic pacifier is used to stimulate sucking. The orthodontic pacifier elicits sucking but does not deform the dental arches.
These exercises involve all of the facial muscles and those which support the head. The sucking mechanism is synergistic. In order to have an efficient suction, it must be continuous and rhythmic. Muscle tonus is improved through the synergy and rhythm of alternating contraction and relaxation. The exercises are performed to the accompaniment of rhythmical poems, recited by the Clinician, so that the rhythm will be incorporated into the Patient's movement patterns. Never should a pacifier be offered to a Patient, nor should a Patient be given an exercise to do, without the guidance of the Clinician. The suction should be monitored to make sure that the movements are being adequately performed. The pacifier is slightly pulled out to make the suction more vigorous.
MASTICATION: - Surgical rubber tubing is used to exercise the masticatory muscles. The tubing is placed transversely in the mouth so that molars on both sides are in contact with it. After the bilateral chewing exercise, the Patient chews unilaterally, with the tubing bent. The bent tube is inserted between the molars on one side, then on the other, and then on the anterior teeth. The effect of the tube ends, during mastication, is to pinch the tongue slightly, which is a beneficial stimulus. More time is given to mastication with the posterior teeth than with the anterior teeth.
DEGLUTITION: - The Reflexive Swallowing Exercise stimulates the supra (upper) and the infra (lower) hyoid muscles and those of the posterior tongue. At the moment of deglutition, the supra and the infra-hyoid muscles elevate the hyoid (...and we know just how important the elevation of the hyoid is for the evagination of the pharynx during the normal act of deglutition!...).
Water is injected into the Patient's mouth, while the tongue is held and pushed with a tongue depressor (spatula). The Patient is asked first to gargle quickly, in order to move the water into position where it will trigger the swallow reflex, then to swallow. The exercise is repeated many times during the session. After this procedure, the Patient becomes capable of pulling the tongue back without the aid of the tongue depressor and triggering the swallowing reflex. From that moment on, the position of the Patient's tongue tip becomes irrelevant to the initial swallowing. Next, correct tip positioning (on the incisal papilla) is addressed. With this exercise, the mechanics of normal deglutition are quickly established. We may say that this exercise works as a facilitator for any other kind of swallowing exercises.
SPECIFIC EXERCISES: - There are many specific exercises to stimulate and to strengthen the bucco-facial musculature.
One of them is very important to improve proprioception of the tongue as well as its propulsion and retraction. An orthodontic elastic is placed around the tongue. The Patient begins retracting the tongue, sliding the elastic forward until it comes off. If the Patient needs assistance initially to establish this movement pattern, a straw can be placed under the elastic, bent and pulled gently forward by the Clinician, to aid in the transit of the elastic.
NEGATIVE ORAL HABITS: - Now let's talk about how to eliminate, with this method, the negative oral habits.
According to my conception, if a person shows a harmful sucking or chewing habit it is because the respective functions have not been completely fulfilled and matured at the appropriate age.
Therefore, to eliminate any negative habit at first all functions should be exercised (we, should not forget that they are mutually dependent...). Then it is beneficial to focus mainly on those functions which failed to mature properly.
So, more sucking exercises will be assigned to the patient who sucks a finger or a pacifier. Exercises for mastication will be stressed with patients with chewing habits (e.g. bruxing, finger nail biting, and so on).
But always all functions are exercised. By exercising the functions by the functions themselves, naturally all the muscles are being activated in their own way. The response, the results, sometimes surprises us.
In summary, each exercise addresses all functions. As the muscles are activated naturally neurological memory is established or re-established. "And the sooner therapeutic measures are taken and the correct function is being used, the stronger its fixation in the CNS will be, and the later, the more difficult it will be to restore a normal function of chewing and swallowing" (Moyers). Therefore it is preferable to work with the Patients as early as possible.
We should not forget that muscles constitute the best and safest constraining appliance for teeth "No orthodontic correction can be adequately maintained unless optimal occlusion obtained at the end harmonises with the patient's musculature" (Moyers).
FINALLY, I would like to point out that my intention here is not to present just one more research method, but to let the philosophy of this method remain with you as my message.
Two points to remark on:
FIRST- to consider the human being as a totality.
The musculature is interlinked throughout the body; the muscles of she head are related to the whole body, even with the ones of the feet. For example, we know that mouth-breathers presents postural alterations and may have a tendency toward flat feet and halux valgus.
Therefore, all the Patients in treatment get exercises not only for the mouth and its functions. Patients always get exercises for the whole body through Neurofunctional Reorganisation, that consists of the recapitulation of the phases of normal neurological development: rolling, creeping, walking, and so on.
SECOND - this Method follows a line according to nature.
Body exercises consist of movements from the genetically programmed sequence of the normal human development.
The oral exercises are done following the same philosophy, that is, training the functions by the functions themselves, because their movements are also part of the human genetical program.
I would like to conclude saying that THE ONE WHO FOLLOWS WHATEVER THE WISE NATURE SHOWS AND TEACHES US IS LESS PRONE TO ERROR.
BIBLIOGRAPHY
1. ANGLE, E. H. Treatment of malocclusion of the teeth; Angle's System. Phila-delphia, 7ª ed., S.S. White Dental, .(1907).
2. BRADLEY, R. M. Fisiologia oral básica. Ed. Panamericana, Brasil. (1981).
3. CAUHÉPÉ, J. Étude experimentale de la musculature et de la position des dents. Acta Stomatologica, Belgique, 57(4):585-591, (1960).
4. CAUHÉPÉ, J.. Thérapeutique des anomalies dento-maxillaires. Rev. Portu-guesa de Estomatologia e Cirurgia Maxilo-Facial, III (4): 349-362, Out/Dez, (1962).
5. DELACATO, Carl H. . Neurological Organization and Reading. Illinois, Char-les C. Thomas Publisher, (1966).
6. GARLINER, D. Myofunctional Therapy in Dental Practice. New York, Bartel Dental Book Co.Inc, (1971).
7. HANSON, M. L. Some suggestions for more effective therapy for tongue thrust. Journal of Speech and Hearing Disorders, XXXII(1): 75-79, (1967).
8. HOVELL, J. Modernas Correntes da Ortodôncia em Inglaterra. Revista Portuguesa de Estomatologia e Cirurgia Maxilo-Facial, III(4): 363-377, Out./Dez, . (1962).
9. LE WINN, Edward B. Human Neurological Organization. Illinois, Charles C. Thomas Publisher, (1969).
10. LINO, A. P. Ortodontia Preventiva Básica. São Paulo, Artes Médicas.
11. MOYERS, Robert E. (1958). Handbook of Orthodontics. Chicago, The Year Book Publishers, Inc., (1990).
12. STRAUB, W. J. Malfunction of the tongue. Amer. J. of Orthodontics,
46(6): 404-424, Part I, June, (1960).
47(8): 596-617, Part II, August, (1961).
48(7): 486-503, Part III, July, (1962).
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