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Questionable Clinical Practices in Orofacial Myology: An Editorial

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Questionable Clinical Practices in Orofacial Myology: An Editorial

Questionable Clinical Practices in
Orofacial Myology: An Editorial

ABSTRACT Some selected questionable clinical practices in orofacial myology will be discussed.
These include: intervention in sleep-related problems; nasal irrigation (lavage); the evaluation and
treatment of temporomandibular disorders (TMJ/TMD); and facial rejuvenation.

INTRODUCTION
Current concerns and questions about the future of the field of orofacial myology relate in part to
selected clinical practices and advocacies of a few clinicians who perceive orofacial myofunctional
therapy to be a magic pill for almost everything, including selling pillows intended to maintain a
particular posture during sleeping, claiming to be sleep apnea specialists, TMJ specialists,
specialists for special needs patients, diaphragmatic breathing specialists, posture professionals,
cosmetic face reshaping experts, and nasal irrigators of unwanted bacteria. Although those clinicians
involved with such practices are few in numbers, their impact can potentially harm the entire field by
advocacy of such practices.

PURPOSE
The purpose of this communication is to identify and discuss questionable clinical pursuits currently
advocated and practiced by a few orofacial myologists and to offer guidelines for appropriate clinical
practice or orofacial myofunctional therapy. Such guidelines can serve to clarify the scope of practice
for orofacial myologists.

Rather than become all-inclusive, this communication will focus on selected clinical procedures that
are considered to be not in keeping with the goals of the field of orofacial myology. If all orofacial
myologists can embrace and adhere to a clear set of clinical standards, the reputation and the future
of the field should be enhanced, strengthened, and insured.

SUPPORTING DOCUMENTS

Since many orofacial myologists are speech-language pathologists certified by the American Speech-Language Hearing Association
(ASHA), and since many procedures and principles of conduct are derived from the ASHA scope of practice and ethical guidelines, two
ASHA documents are specifically applicable to clinical activities in orofacial myology as provided by ASHA certified clinicians. One
document is: Orofacial Myofunctional Disorders: Knowledge and Skills, (ASHA, 1993). It will be referred to in the dialogue to follow. The
second reference document is: Preferred Practice Patterns for the profession of Speech-Language Pathology, (ASHA, 2004). Subsets #
38 and 39 are specific to the work of ASHA members who provide diagnostic and therapeutic services with orofacial myological
disorders.

CLINICAL PURSUITS OF CONCERN:
INTERVENTION IN THE SLEEP PROCESS. It is not well documented how some orofacial myologists have become involved in
evaluating and participating in the treatment of sleep disorders. There is a history of some orofacial myologists recommending and
using lip taping as a reminder for patients to maintain a closed-lips posture during the day, and especially during sleep.  A document
available on this website details the assumptions and issues related to the use of lip taping. This intervention has apparently expanded
into some clinicians recommending a particular type of pillow or particular sleep position. Some have also contended that sleeping on
one’s side can account for the development of a unilateral dental crossbite. The association of sleeping position and dental problem
has no solid basis in research in dentistry and, therefore, this unfounded contention by some orofacial myologists should not continue.

The key perspective for the orofacial myologist regarding sleep disorders is that any sleep issues are medical problems that should
be evaluated and treated by physicians, preferably, those physicians associated with sleep labs or clinics.
Further, it should be
recognized that orofacial myologists, by virtue of education or experience, cannot claim any expertise in the evaluation or
treatment of sleep disorders.
These perspectives are in keeping with the ASHA Knowledge and Skills document that specifically
states: …"the practice of orofacial myology does not include:  Practices related to the reduction of medical conditions, such as
sleep apnea”
(page 23). For the non-speech pathologist orofacial myologist, this same exclusion should apply due to a lack of
appropriate medical credentialing.

At the present time, no recommendations or procedures related to sleep are appropriate clinical activities for orofacial myologists,
including any counseling or recommendations regarding the type of pillow or sleep posture that a person should use. Nighttime lip
taping is not an appropriate clinical technique to use under any circumstance. The potential for harm from any restriction of breathing is
applicable to lip taping. If a patient is ever identified as having a previously undisclosed cardiac condition where there is a history of lip
taping, the orofacial myologist involved would have no defensible way to show that the lip taping had not contributed to or caused the
cardiac problem. For the protection of the orofacial myologist and patients, lip taping is not appropriate as a therapy technique,
whether as implemented in the daytime or during nighttime sleep.

In the future, there may be a role for the orofacial myologist to participate in an exercise program that may be developed to help remedy
problems of sleep apnea. At present, however, orofacial myologists can claim no expertise in muscle exercises related to the palates
and pharynx, except for those speech-language pathologists working in the area of dysphagia who have had extensive background with
palatal and pharyngeal muscle functions and exercises. At present, any therapy to “tone” or otherwise influence the rest posture of the
tongue in relation to sleep should be determined and prescribed by a physician associated with a sleep lab. There is no current
justification for an orofacial myologist to diagnose or undertake any muscle exercise program designed to remedy any sleep related
disorder.

In summary, orofacial myologists cannot claim expertise with sleep related problems and should only participate in experimental
therapy procedure as prescribed by a physician associated with a sleep lab. Such therapy interventions should be clearly stated to
patients as being experimental.

NASAL LAVAGE (WASHING/IRRIGATING). While self-cleansing and self-medication of the nasal cavity is practiced routinely
among the general public, there is a difference between the self-administration of nasal sprays and cleansing agents, and the
administration of such agents to a patient by an orofacial myologist. Orofacial myologists cannot claim expertise in the area of the
health and maintenance of the nasal cavity.
The reason for this is that the health of the nasal cavity represents a medical issue that is
not part of orofacial myology. Furthermore, the insertion of any fluid or spray into the nasal cavity is considered to be an invasive
procedure, and as such, is not an appropriate role for the orofacial myologist.

The nature of the bacteria in the nasal cavity, the size and shape of turbinates, and the presence of swelling of the mucous membranes
of the nasal cavity, are not appropriate diagnostic or therapy concerns or activities of the orofacial myologist. Any intrusion/insertion of
any substance into the nasal cavity is not appropriate to the clinical pursuits of the orofacial myologist.

TEMPOROMANDIBULAR DISORDERS.  Many orofacial myologists participate in the treatment of temporomandibular joint and
associated disorders. Any therapists who are members of the American Speech-Language Hearing Association (ASHA) are subject to
following the ASHA guideline in the Knowledge and Skills document: “…the practice of orofacial myology does not include:
Treatment of parafunctional problems related to temporomandibular joint disorders and myofascial pain dysfunction”
(page 23).
Those orofacial myologists who are dental hygienists should not evaluate and provide therapy services without the approval and
supervision by the dentists involved in the care of such patients. For orofacial myologists who are neither speech-language
pathologists nor dental hygienists, there should be no participation in the therapy of any TMJ-related problem.

Dental hygienists who provide therapy for TMJ problems should not physically manipulate the mandible during therapy.  Any procedure
to reposition the mandible or guide the mandible to a centric relation should be accomplished by a dentist.  The following ASHA
guideline for speech-language pathologists should also apply to dental hygienists: …”the practice of orofacial myology does not
include:  Craniosacral manipulation or practices within the scope of physical therapy”
(page 23). The risks to a dental hygienist of
further exacerbating the TMJ problem, rupturing the meniscus (disc in the temporomandibular joint apparatus), or contributing to the
worsening of pain and functions by manual manipulations of the mandible, should remind hygienists that they are legally obliged to
work on TMJ problems only under the direction and supervision of a dentist. TMJ treatment is not physical therapy, so the role of the
dental hygienist, and others within orofacial myology, should be restricted to the elimination of noxious habits that are involved, such as
bruxism, while also normalizing an excessive freeway space resting dimension of the mandible at rest.

FACIAL REJUVENATION.  Some orofacial myologists who engage in facial rejuvenation procedures contend that sagging skin is
related to toxins in the skin. Research to support this view is scant.

Nutritional or trophic changes form an important part of the symptomology in many neurologic disorders. They may appear in the skin,
nails, subcutaneous tissues, muscles, bones, and joints. Although a neurologic basis has usually been stressed as a prime factor in
the causation of trophic changes, other factors also play a role. These include physical activity, blood supply, nutritional elements
(vitamins), lymph drainage, and endocrine activities. Orofacial myologists have no credentials or expertise to make the decision as
to why skin sags, or what procedures should be undertaken to treat such conditions.
 Orofacial myologists who participate in facial
rejuvenation can only harm the reputation of the field of orofacial myology, as this area of public concern has nothing to do with orofacial
myology.

The procedures involved in facial rejuvenation by some orofacial myologists involve facial muscle exercises. There is no solid research
support for a cause and effect relationship between facial exercises and skin tone, or that facial exercises increase muscle “tone”. In
the primary areas of the face and neck where skin sagging occurs, there is no direct connection of muscles with skin, making the claim
of a therapeutic link between exercise and skin toning highly questionable. Physicians who are experts in the skin and its problems
(dermatologists) do not endorse facial muscle exercises as a means of alleviating sagging skin. The reason is that there is no
evidence that they work.

Orofacial myologists cannot claim any expertise in the area of skin, its disorders and the aging process. None of the therapies
designed to firm skin or “tone” muscles for purposes of improving cosmesis are a part of orofacial myology.

SUMMARY
Fortunately, the questionable clinical practices discussed above are being implemented by only a few orofacial myologists.  The
majority of orofacial myologists continue to provide traditional procedures of orofacial myofunctional therapy that have a long and well-
established history of successful use and outcome. The discussion here of peripheral therapies which are outside of the boundaries of
orofacial myology serves to alert the public to procedures and claims that merit concern.

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