Lip closure (also known as lip seal) is the ability to close one’s lips around a spoon, straw, cup, etc. It’s also important in order to say certain speech sounds, such as /p/b/m/, and it’s a factor in preventing drooling.
Recently I was working with a 9-year-old child who has Angelman syndrome. The mother was asking if there was anything she could do to decrease drooling. One of the first things I look for with drooling is whether or not the child has lip closure. The child was not closing her lips and could not do so on command, so I touched the Z-Vibe to her lips for about 2-3 seconds, and voila – immediately her lips closed. I waited a few minutes and repeated the stimulation, and she closed her lips again. She just needed that extra sensory input to be aware of her lips to close them.
Sometimes a simple prompt like that will elicit lip closure. Other times you may need to do extra practice until the concept “sticks,” or until they have the oral motor skill to do it. It really just depends on the child. Continue reading Lip Closure & Rounding Exercises
This young man in the video above has a jaw slide, meaning that his jaw shifts either to the left or to the right when he talks. Since the tongue is connected to the jaw, the tongue follows the jaw, also shifting to the left or right. Why is this a problem? Speech sounds are properly articulated when the jaw and tongue are midline and symmetrical. If the jaw and tongue shift to the side during speech, certain sounds may seem slushy and unclear. So in order to clearly articulate sounds, we’ll need to stabilize his jaw at center. To work on jaw stability: . .
1. Put the extension of the Grabber (or Y-Chew or Probe) in between the molars, as shown in the pictures above. Ask the child to bite down and hold for a count of 10. Repeat a total of 3 times on each side. If necessary, provide support to the chin with your free hand. .
2. As you try this exercise, check to make sure that the space between the upper front teeth is lining up with the space between the lower front teeth. If it’s not, switch to using the loop of the Grabber instead, and place it in the front of the mouth (see the picture above). This position will force the child to bite on both sides at the same side so the jaw can’t shift and will instead stay centrally aligned. .
3. You can also do this with the extension of the Grabber (or Y-Chew) placed laterally in front of the mouth (as shown above). .
4. Finally, another way to stabilize the jaw is to use two Grabbers (or Y-Chews or Probes) simultaneously – one of either side of the mouth in between the molars. This is essentially step 1, only with a tool on both sides of the mouth. .
As always, keep in mind that you may have to start with a shorter count, and work up to 10. If you only get a couple counts, that’s okay! Make a note of the progress, and try to do more in the next practice session. .
A note on counting: you’ll notice that I don’t always have the same beat to my counts in the video. If I sense that the child is losing interest, I mix things up to refocus their attention. You can change the beat, count faster or slower, say it with a deep voice or a high voice or anything in between, count backwards, use funny voices, and so forth. Just have fun .
I recently completed a Clinical Swallow Evaluation and today a Videofluoroscopic Swallow Study of a 10 yr old boy’s swallow (both revealed a safe swallow that is within normal limits) and observed that his is not an age-appropriate chew pattern. He engages in a Nonstereotypic Vertical Movement during mastication. As a result, oral prep phase is significantly extended and his mother reported that it takes him (at times) up to 1.5 to 2.0 hours to complete a meal. In one case, he informed me that he does not like powder (i.e., flour or powdered sugar) and the meal in question consisted of scrambled eggs and French Toast that had only powdered sugar on it – sans syrup. However, I have found no information regarding immature mastication patterns in older children. Any information or resources you may provide or suggest in this regard will be greatly appreciated.
In a vertical chewing pattern, the jaw moves up and down in a vertical motion. Since the tongue and jaw are connected, the tongue will follow suit, also moving up and down. This is sometimes referred to as a “tongue pump.”
On the other hand, in a mature chewing pattern, the jaw moves in a rotary (circular) motion to grind the food – imagine a cow chewing its cud as an exaggerated example. At the same time, the tongue moves from side to side in order to manipulate the ground food particles into a bolus (ball of food). Without this grinding motion and tongue lateralization, it makes sense that he’s having difficulties breaking down and manipulating his food, and why mealtimes are very long and exhausting. Try chewing your food today without moving your jaw or tongue from side to side – it’s not easy!
So your goal would be to develop a rotary chew so that he can properly chew and manage food. Once his chewing skills improve, he’ll be able to eat different kinds of foods, particularly those requiring good chewing ability. And a rotary chew will drastically decrease the time needed to properly break down food, which is typically no longer than 30 minutes.
Speech therapists have a variety of classifications / categories for speech sounds. One such category is voiced versus unvoiced phonemes. Voiced phonemes are sounds made when the vocal folds vibrate. Unvoiced phonemes are sounds that do not require the vocal folds to vibrate. As an example, say “sss” and then “zzz,” listen and feel the difference. ‘S’ requires only air, whereas for ‘Z,’ your vocal folds activate/buzz. Older children and adults can usually hear and feel the difference. For younger children, you may have to teach them how to use their voice: .
Tongue lateralization is the ability to move the tongue side to side inside the mouth. It’s an important skill for feeding therapy and development, as the tongue lateralizes in order to manipulate food to be chewed and formed into a ball (or bolus) before swallowing. It’s also how we go “fishing” for leftover food particles in the cheeks, around the gums and teeth, and on the lips. .
There are several ways you can “test” for this. Ask the child to imitate you “wagging” your tongue. Or, place ARK’s Probe or Z-Vibe to the corner of the mouth on each side and prompt the child to touch it with his tongue tip (in the picture above, for example, I’m doing this with the Z-Vibe Preefer Tip). Or, place the Probe in the middle of the bottom lip and ask the child to touch it with his tongue tip. Then move the Probe in increments to the corner of the mouth, prompting him to touch it with his tongue tip at each increment (this provides a tactile cue for the tongue to follow). .
Remember, one does not need to perform this oral motor task for speech sound development. Yes, the sides of the tongue need to make contact with the upper back teeth for such phonemes as r, sh, ch, etc., but no speech sounds are made with the tongue lateralizing. This movement is strictly for feeding. So observe the child eating. Really get in a position for a good view into the oral cavity. Overemphasize chewing yourself, making a “yum-yum” sound. Is the food being moved side to side? What type of food is it. Puréed? Mechanical soft? Chopped? Regular? Maybe the child isn’t progressing to eat harder-to-chew foods because he cannot lateralize. It has also been my experience (as it was just this past week), that some children may only lateralize to one side. I know this is puzzling, but every now and then this happens in therapy to me. So keep an eye out for tongue lateralization to both sides. .
Tongue pops are my faaaavorite oral motor exercise. They’re a fun and easy way to work on tongue placement, oral tone, tongue elevation and control, plus tongue and jaw dissociation. These oral motor skills are necessary for proper speech and feeding development. .
The ability to orally manage food requires a lot more skill than most people realize. Try taking a bite out of something right now, paying attention to what your tongue is doing and how it manipulates the food. Once the bite is fully chewed, your tongue will manipulate it into a ball (bolus). It will then position the food bolus on top of the middle of the tongue, raise the tongue to the palate, and then squeeze it to the back of the tongue. Once it hits the back of the tongue, it triggers a swallow. There’s a lot going on! Doing tongue pops is a great way to exercise the tongue, build oral tone, and practice controlled, coordinated movement. . Tongue pops also work on the coordination required for proper speech and articulation. For example, many speech sounds require tongue and jaw dissociation, or the ability of the tongue to work independently from the jaw. For example, try saying “la la la” right now, paying attention to what your tongue and jaw are doing. The tongue tip should be elevating to the alveolar ridge (just behind the upper front teeth), and the jaw should be stable. Tongue pop exercises will work on both elevating the tongue tip, and teaching it to work separately from the jaw. They also work the back margins of the tongue, forcing them to make contact with the upper back teeth. This contact is how we produce R, SH, CH, DZ, S, Z, and other speech sounds. .
The Y-Chew is an excellent tool to develop oral tone, practice biting and chewing skills, work on oral motor exercises, and improve jaw strength and stability. The long extensions reach all the way to the back molar area to really exercise the jaw, and two of the extensions have a textured surface for added tactile input. Check out the therapy videos below for some jaw exercises using the Y-Chew: . .
Bite and hold the Y-Chew for 10 second increments. Repeat several times on both sides. This oral motor exercise strengthens the jaw so that it doesn’t move from side to side or open too far. It also works on jaw stability and a sustained bite by keeping the jaw from sliding from side to side. . .
For example, I once worked with a child who was mouthing inappropriate objects in the classroom – her hands, pencils, rulers, etc. So during therapy, I massaged her gums every 10-15 minutes throughout the session. She completely melted as soon as I started – she enjoyed it so much! I showed her parents how to do this at home, and eventually along with other sensory strategies, her need to chew subsided.
There are many ways to massage the gums, so I’ll describe what is most comfortable for me (right-handed):
1. Place your pointer finger just above the upper middle teeth. Move it across the gums to the back right molars and back to where you began. Repeat about 3 times. Then repeat the same motion on the lower gums. .
2. Use your thumb to repeat the same movement on the other side of the mouth. Start above the upper middle teeth and move your thumb along the gums to the back left molar area. Repeat about 3 times. Then repeat the same motion on the lower gums. .
3. During each step, notice the child’s response and adjust accordingly. Is he/she relaxing? Great! Is he/she tensing? Try decreasing the number of repetitions, slowly working up to more over time. Even just a slight touch is progress. Make a note of the progress and try to go further in the next session. Repeat this exercise several times throughout the day, as often as possible. It MUST be done on a routine basis to have effect.
Instead of your fingers, you can also use the Z-Vibe with the soft Brush Tip, which has pliable bristles for a gentle massage. If turned on, the Z-Vibe’s smooth vibration provides additional sensory input and awareness.
ARK’s Grabbers, Y-Chews, Krypto-Bite, and/or Brick Stick are another safe way to provide oral stimulation. These chewies have long extensions that can reach all the way to the back molars for proprioceptive input to the jaw. The textured versions provide additional sensory feedback, and they come in three color-coded toughness levels for mild to moderate to avid chewing. To view all of the different options, click here.
If you can’t get into the mouth for gum massage, try doing it outside the mouth first (on the cheeks along where the gums are). And be sure read this article on oral defensiveness.
Do you have a tool to increase tongue protrusion and tongue lateralization?
We do! ARK’s Oro-Navigator was specifically created to help individuals “get” the concept of tongue lateralization. It’s very easy to use. Simply place the cuff on the side of the tongue and guide the tongue from one side of the mouth to the opposite side. Then repeat on the other side of the tongue. This allows the individual to feel what their tongue should be doing. Use a mirror for visual feedback so that they can see what their tongue is doing as well.
To establish the concept, you can also do trunk turning exercises. Sit on the floor with the child between your legs. Place items to the right and left side of the child (within their reach). Have the child take his right hand and reach over to the left side to get the item. Repeat to the other side. Have the parent do this with the child for home practice. .
You can also stroke the sides of the tongue with the Probe or Z-Vibe to stimulate lateralization. Stroke one side five times, then the other. Or, you can alternate sides to simulate lateralization. .
Another exercise for tongue lateralization: place the tip of the Probe or Z-Vibe inside the cheek area to one side. Have the child touch it with the tip of his tongue. Repeat to the other side. Do about 5 sets. .
For tongue protrusion: if the tongue is too far back in the mouth, stroke the tongue from front to back to relax the tongue and have it come forward slightly. .
However, the need to increase both tongue protrusion and tongue lateralization raises a red flag for me. It sounds as if there is a larger problem at hand here. Tongue protrusion and tongue lateralization difficulties are symptoms of ankyloglossia. A few factors to consider are the following:
• Can the individual extend his/her tongue OUTSIDE the mouth to lick an ice cream cone or lollipop? Or, does he/she position the food inside the oral cavity, compensating for the inability to extend the tongue for licking?
• Have the individual open his/her mouth wide and position the tongue tip up to the alveolar ridge (the piece of skin behind the upper front teeth). Can the tongue reach that spot? Is the individual closing the mouth in order to reach it?
• Is the individual speaking with a more closed mouth? Elevating the tongue to the alveolar ridge is how we produce the tongue tip sounds t/d/n/l/s/z. If an individual cannot properly elevate the tongue, his/her speech will be affected. Observe carefully, as the individual may be making these sounds with the tongue tip behind the bottom teeth instead.
Without seeing the child, it’s difficult for me to accurately assess the situation. I would refer to a medical doctor such as a dentist or ENT, who can work in conjunction with an SLP to diagnose this case. If there is ankyloglossia, the parent will ultimately decide what she/he wants for her child. I hope this information points you in the right direction. .
As a speech therapist, I don’t recommend sippy cups since many of them promote a tongue thrust and improper oral positioning, which can negatively affect a child’s speech and feeding development. So ideally, particularly for those with developmental delays, it would be best to transition them straight to cup or straw drinking. .
However, I do understand their convenience, so if you are going to buy a sippy cup, it is important that it meets several guidelines: .
• You must first consider the size of the holes where the fluid comes out. If the holes are too large, too much fluid will come out too quickly, which will make it difficult to manage swallowing. If the holes are too small, it will be too difficult to draw liquid from the cup.
• The best way to determine if the sippy cup is suitable is to try it out yourself, keeping in mind that your little one has a smaller mouth size.
• What position is your tongue in? Does your tongue go forward and under the spout? The tongue should not protrude under the spout, but rest inside the mouth.
• Is the spout too big, wide, long, and/or uncomfortable? Is it difficult to close your lips around the spout? Does the plastic taste funny? If it is, imagine what it would be like for your child.
• Is the spout too rigid? It should be soft and flexible so that the tongue can position the spout instead of vice versa.
• The next thing to do is to observe your child drinking from the cup. The child should not be biting on the spout. Check for teeth marks. The lips should also be firmly closed around the spout so that no fluid leaks out of the corners of the mouth.
The following video by Sandra Holtzmann is also helpful in understanding sippy cups and their effect on speech development. .