De Coördinatietherapie en afwijkende mondgewoonten

Demmink-Geertman E.G. & S.J.M. Schouten (2001). De coördinatietherapie en afwijkende mondgewoonten. Logopedie en Foniatrie nr 4, p. 99-106
(Artikel in niederländischer Sprache)

Myofunktionelle Therapie bei Dysfunktion der Zungen-, Kiefer- und Gesichtsmuskulatur

Introduction
The coordination therapy, introduced by Elfriede Öcker, has originally been developed for the treatment of voice disorders and proceeds from a holistic approach. It is used on the principle that developing a favourable tone in muscles by special exercises, will influence posture, movement and breathing. Exercises and massages are used for the improvement of posture, movement, respiration and swallow functions and their interactions in order to lay a stable foundation for optimal articulation and phonation.

With organic as well with functional disorders the therapist starts with the elimination of forcing mechanisms appearing to avoid definite complaints or symptoms. Prolonged application of particular forcing behaviour effects the partly automaticaly and partly consciously controlled functions of feeding, respiration and articulation Think for instance of the consequences of increased subglottal air pressure often going with voice problems in order to enlarge audibility Only after elimination of these mechanisms it is possible to treat the dysfunction effectivily by special exercises and massages.

In case of oral myofunctional problems several symptoms and complaints are displayed, sometimes two or three together. Voice disorders and articulary disorders are often seen with these problems. It is often not clear which are causes and which are effects, as there are a lot of interactions in this scope. Disorders are seen in all ages.

Application of the coordination therapy must be considered as an extension of the regular therapies used in case of oral myofunctional problems.
Used in that way it can contribute a lot for the following reasons: – it pays special attention to posture and movement in relation to the breathing function – the very basic approach in the treatment of dysfunctions of feeding, articulation and phonation is very useful here.

Massage is applied in the orofacial region and the regions of neck, throat, sternum, flanks and diaphragm. If necessary massage on lips, chin, nasal bone cheek bone, cheeks and temporomandibular joints are executed and intraoral on the hard palate, the tongue and on the gums of the upper jaw above the incisors.
The massage applied is relaxing in case of tension and stimulating in case of hypotonus. The techniques are taught to the clients and to parents of children with orofacial problems as daily application is very important.
After this exercises are carried out by the therapist and the clients. There are a lot of exercises from which the therapist has to make a careful choice suitable for the special problems of a client.

Children

Habitual mouth breathing
Children who breathe through the mouth often display a hypotonic body posture. So we start building up optimal posture in sitting and standing with an emphasis on the head posture. In this case a deviating head posture mostly means too much flexion. It effects the dynamics of pharynx and the upper oesophageal sphincter in a negative way and sequential swallowing, breathing, articulation and phonation. In this case the swallow movement is not fluent, the breathing patterns are shallow as the diaphragmatic function is restricted, articulation is flabby and phonation lacks resonance as the resonance caves are inhibited.
The tonicity of the facial muscles must be diagnosed and if necessary relaxed or stimulated by massage. For instance the muscles of the cheeks are generally hypotonic.

Therapy (see pictures)
Exercise 1
Diagnose the tonicity of the lips by touching them only for a moment with a cold spoon. If the tonicity is right, the lips react springy.

Exercise 2
Apply stimulating massage to the often hypertonic upper lip.

Exercise 3
Move the upper lip gently together and apart.

Exercise 4
Place the forefingers just under the wings of the nose and then one cm to the left and the right and pressed gently upwards in order to make the upper lip more visible.

Exercise 5
Stimulate the tonicity of the cheek muscles by: – applying stimulating massage – practising soft pressure to different places of the cheeks with the forefingers, starting at the mouth corner and ending on the jaw joints while the mouth is slightly open. – applying soft pressure with forefinger or thumb to the inside of the cheeks.

Exercise 6
Pull up upper lip and nose, together with widening of the nose wings during an inspiration. When practised in alternation with the production of the /K/ the velum function and thus adequate velopharyngeal closure is stimulated.

Exercise 7
Apply soft massage to the chin in case of too much tension.

Exercise 8
Stimulate the shutting of the mouth by pressing the upper lip a bit upward and the lower lip a bit downward with the stem of a very cold spoon, which increases sensitivity. After this it is often possible to close the mouth without using forcing mechanisms.

When the hard palate is high and narrow, there is always a lot of tension in this region. It often goes together with deviation of the septum, because in this case the septum lacks space. The tension can be felt on the nose bridge then.

Exercise 9
Apply soft and rhythmic massage to the palate alternated with massage to the nose bridge.

The preferred place of lingual contact during rest and during swallowing is the alveolar ridge. It is located behind the upper front teeth of the maxillary dental arch. Only the tongue tip must make contact with this ridge. In habitual mouth breathing the tongue often rests on the bottom of the mouth, which has a negative influence on rate, range, precision and timing of its movements.

Exercise 10
Apply massage to the surface of the tongue to improve its function. During the massage the mouth is opened and the tongue is lying broad on the bottom. Brush across the tongue blade with the stem of a cold spoon from posterior to anterior on the left and the right side just beside the centre line.

Exercise 11
To activate mobility and strength of the tongue have the patient practise exercises such the patient exercises as repeating sounds in rapid succession, or making movements with the tongue as pointing, protruding, lateralizing and pushing against the cheeks, or elevating the tongue.

Exercise 12
To reach the right rest posture of the tongue touch the tongue tip and the alveolar ridge with the stem of a cold spoon. The touching makes these two places very sensitive. When the patient shuts his mouth after this, the two places make contact naturally.

Additional aspects that should be noted include the often present deviation of the functions of drinking, biting, chewing and swallowing.
The lower jaw must be lowered vertically downwards with drinking and biting, but good chewing needs also lateral and forward movements. With drinking the lower lip is moved slightly forward and the upper lip is pulled up. In that way the liquid touches the inner site of the upper lip and its temperature is checked before sucking the liquid further in the oral cave. With biting the upper lip is also slightly pulled up. Just chewing is only possible when the lips are closed. Just swallowing also requests closed lips together with the right tongue movement for the transport of the bolus in the direction of the pharynx.
An effective swallow stimulates ventilation of the middle ear by the Eustachian tube, thus decreasing the occurrence of otitis media. If the swallow is executed with too little strength, the ventilation is insufficient. Requiring optimal velum function is also important as it prevents the reaching of liquids in the nasal cave during swallowing and too much nasal resonance in speaking. So checking the functions of drinking, biting, chewing , swallowing, articulation and phonation is necessary.
Together with application of the preceding massages and exercises described we can create an optimal basis for the common and well- known exercises for stimulating nose breathing.

Aberrations of the swallowing movement
This can be assessed by having the client swallow solids and by noting, by parting the lips while swallowing, if the tongue is thrusting against or between the front teeth. It should also be noted if there is contraction of the chewing muscles during swallowing and if there is excessive use of the lips during chewing and swallowing. The swallow must be followed by a small expiration in order to stimulate the decent of the larynx into his natural rest position.

Therapy
The total orofacial area is observed and any irregularities are treated as described for the habitual mouth breathing. Tongue tip and alveolar ridge are touched with the stem of a cold spoon. Next the correct rest posture of the tongue (tip of the tongue on the alveolar ridge ) is reached easily. After this the right upward movement of the tongue is taught and practised with careful indications.

Tongue thrust
In this case there is a display of too much tension of the muscles of tongue, cheeks, lips, palate and throat. The tongue is protruded. Often the tongue blade is pressed against the palate and the upper teeth, which brings about dental and jaw irregularities and too much tension of bone, muscles and tissues of the hard palate. Besides the hyoid muscles become too tense and stimulate too high a rest position of larynx and hyoid.

Therapy
Massage of tongue, cheeks, lips, palate and throat is necessary. Next the right rest position of the tongue can be achieved in the same way as already described.

Malocclusion
Malocclusion is a condition where the teeth in the upper and lower jaws do not meet properly setting one’s teeth.

Therapy
After and together with dental treatment the therapist can apply massage to the tense places of the hard palate. Often the configuration of the hard palate is high and narrow as a result of sucking habits, pacifier sucking or mouth breathing caused by atopic and allergic diseases. After some training it is very easy to trace the tense places. Also massage of the gums with the index finger is very useful particularly above the front teeth but also lateral in case of asymmetry. Any other displayed disorders in the orofacial region such as mouth breathing, tongue thrust or aberrations of the swallow function must be treated. So a stable basis is created, which is very favourable for a natural development of palate, upper jaw and denture.

Sucking habits
In general sucking has a relaxing function with babies during feeding. However persisting need of sucking, often going together with pressing the thumb or two fingers on the hard palate is also possible. It causes an increase of tension of the palate bone, tissue and muscles, certainly when it is done with force. Besides a high and narrow palate can cause excessive tension in the region of the septum and create deviation of the septum position with obstruction in air flow and so inhibition for normal articulation resonance.

Therapy
Regular massage of the hard palate and the nose bridge must be applied in order to relax the muscles in these regions. Massage of lips, cheeks, chin and throat is often needed. With young children this treatment is very successful, with older children the massage is also useful, but improvement comes more slowly and addition of a frame placed by the dentist is often needed as the habit has already been engrained.
In a later phase the practice of the methods normally used to unlearn the habit has much more effect because the child has less need of sucking.

Habits as nail, cheek, tongue and lip biting
These parafunctions can achieve an imbalance of several muscles in the orofacial region. Especially too tense chewing muscles are seen, which leads to problems of the mandibular joints.

Therapy
Here advice and explanation of the consequences of these habits are needed, together with massage of the muscles in the region of the mandibular joints (m. masseter) and behind the ears (m. temporalis) and if necessary of cheeks, chin and lips.

Adults

The orofacial deviations can be the result of hereditary factors as well of habits applied in childhood as already described in the previous chapter. They can also arise later on by problems of the airways, dentition, jaw, mandibular joints and articulation.
Often a vicious circle can be seen in which case particular influences reinforce each other. So giving explanation and advice about the symptoms and complaints is important.
As with children the therapy starts with the correction of posture and movement. Especially stimulation of right muscle tone of head, throat and sternum by massage is important. The client must learn the massage techniques to make daily appliclation possible The elimination of particular tensions, caused by forcing mechanisms, is- compared with children- much more difficult as in general they have been applied during a longer period and does result in more symptoms and complaints which can be much more serious. Besides there are more lasting causative factors.
In case of too tense hyoid muscles the rest position of the larynx is too high, the swallow reflex is initiated too soon and the mastication phase is shortened, grinding and mixing with saliva of solids is incomplete. Dysphagia, aspiration, reflux and other problems of the digestive system and/or globus sensation are displayed. Another possibility is unilateral tension of the head, in the region of the ear, as a result of a tense m. temporalis. People complain then of ear ache, buzzing and dizziness without existence of significant organic diseases. Other arising problems are bruxism and TMD.
Further misarticulation as addental, interdental or lateral lisps, flabby articulation, or articulation with too much subglottic air pressure are seen as well as hypo- or hyperkinetic dysphonia.
Stress can play a role in causing or reinforcing the symptoms. In several studies chronic tension is associated with irregularities on the autonomic level. So the following disorders described are often displayed together with other irregulaties which need treatment as well.

Tongue thrust
Adults also display the phenomenon of thrusting the tongue on the hard palate and/or the front teeth, sometimes together with teeth clinching. There can be several causes, for instance a badly fitting set of denture or Parkinson disease, but chronic stress can also play a role. Here the tonicity of the muscles of palate, the velopharyngeal and hyoid muscles and the muscles in the region of chin, cheeks, neck, shoulders and /or sternum is increased.
The swallow movement is not fluent and/or not complete. The last thing means omission of the small expiration after the swallow in order to stimulate the lowering of the larynx to its natural rest position. The tension of hyoid muscles and muscles in the region of the sternum, occurring in this case can stimulate symptoms as a shallow breathing pattern, inhibition of the resonance caves, insufficient closing of the upper oesophageal sphincter and globus sensation.

Therapy
Explanation of cause and possible consequences in the context of tongue thrust is needed and can form an eye opener for the client. Next massage is applied to the muscles of all the strained regions and the massage techniques are taught to the client in order to make possible daily application. The correct tongue position in rest is learned and trained to make it a habit. If necessary the swallow and breathing functions are treated.

Bruxisme / clenching
In this case the temporomandibular joints are overburdened and often painful. Related symptoms are tooth wear, headache, neuralgic facial pains, facial asymmetry and deviating tonicity of head, neck and shoulders especially the chewing muscles. Sjöholm et al (1995) examined the hypothesis that bruxism is accompanied by disturbed autonomic function, particularly in the sympathetic function of vasoconstriction. Tests were performed on 11 sleep bruxists in the waking state who confirmed this statement. Other studies mention nocturnal measurements that show symptoms such as altered respiratory rate, skin potential changes, peripheral vasoconstriction and tachycardia; also apneu and snoring often go together with bruxism..

Therapy
Explanation about possible origin of the habit (for example stress) and the effects of it is important. Next massage is applied to face, joints, backside ears (m. temporalis) and neck. After reaching some relaxation in these areas the correct rest position of the mandibular joint is taught. By training this in the waking state the client contracts the habit. After some time this reduces the periods of nocturnal bruxism. In case of articulation accompanied with restricted mandibular movements by clenching, a more relaxed articulation should be learned and practised.

Malocclusion
Problems in this area can be due to a deviating development, but can also be the result of absence of dental elements or set of denture, badly fitting set of denture, all with negative effects on biting and chewing of solids.Tension of orofacial muscles as the result of chronic stress can also cause problems in this scope.
Malocclusions also affect the TMJ; both the ball and socket function and its movements can deviate. Mastication can be too powerful (aggression) or too flabby (fatigue). Misarticulation for instance in the form of speaking with clenched teeth is seen.

Therapy
After intervention of a dental specialist the elimination of forcing mechanisms is very important. Often massage must be applied to the muscles in the region of the mandibular joints and to other facial muscles. The functions of biting, chewing and swallowing must be checked and if necessary treated.

TMD
Temperomandibular pain and dysfunction syndrome can be the effect of a development disorder in youth or of a bodily trauma for instance as a result of an accident. Long term dedication of forcing mechanisms as mastication on one side in case of tooth pain is another possibility. Often such a habit persists after elimination of the pain and the used joint is overburdened. Bruxism, teeth grinding, tongue thrust and nail biting, badly fitting set of denture also cause TMD.
TMD shows symptoms and complaints of the mobility of the mandible as crackling, painful jaw and joint, orofacial phantom pain, tooth pain, headache, fatigue of chewing muscles, pain in the ear area, ringing in the ears, dizziness, visual problems, neck pain and concentration difficulties. The functional deviation of the cervical vertebras influences the position of the shoulders and the hyoid. The latter can cause a sore throat and globus sensation. The rest position of the tongue can deviate, which then influences the rest position of the mandible, the tonicity of the muscles of the palatine arches, velopharyngeal muscles and the chewing muscles. If the mouth is opened too far as in case of excessive yawning, luxation of the yaw is possible and intervention of a dental specialist is needed.

Therapy
It is important to start with eliminating the possible cause of the complaints.Organic disorders must be treated first. Intervention of other disciplines is always needed.
It is also in the interest of the client to get a clear insight into his problem. Origin and following effects of implying certain forcing mechanisms must be known.
Practising chewing on either side of the mouth, avoiding chewing tough materials, breaking habits as nail biting or using chewing gum are factors which can release the jaw joints. Next massage is applied to the muscles in the region of the joints and on other tense orofacial muscles. A decrease of the tonicity of tense muscles and an increase of the tonicity of flabby muscles can be reached by massage.
Particularly the mm. masseter, temporalis, orbicularis oculi and the m. zygomaticus major are often hyperactive. After this massage in the oral cave is often needed. Apart from the described massage on the hard palate, direct massage of the joint is possible. Move the index finger in the mouth of a client on the painful side till you feel the jaw bone. By pressing softly on this place and by massaging a lot of strain in this area can be released.
In a later stage of the therapy opening and closing the mouth is practised very carefully. Just before opening the mouth the mandible must move a fraction in posterior direction and next downwards. The movements made during biting, chewing and swallowing must be checked and if necessary corrected.

Burning mouth syndrome or BMS
BMS is characterized by a burning sensation of the oral cavity although the oral mucosa are clinically normal. The syndrome affects especially middle-aged women. Its aetiology is not fully understood. Various types of oral complaints are possible. Subjective oral dryness, but also higher salivary flow, taste disturbances, hyperactivity of the tongue, lips and lower jaw, muscle pain in the orofacial region, but also depression and anxiety are reported.
It can be the result of initiating forcing mechanisms in case of dental problems or problems with set of denture. Vitamin deficiency, use of medicine, allergy for definite toothpastes, too spicy food, too hot or too cold food, nicotine and alcohol can also lead to BMS. Further globus sensation and tongue thrust are also associated with burning sensation of the mouth. As speech therapist we should be very alert with clients who have these complaints and search for the underlying cause of the problem. Intervention of medical specialists is always necessary.

Therapy
First we must get a clear insight into the problem of the client and explain it to him and give him advice. Abstention of bad habits, elimination of forcing habits, creatinon of balance in the orofacial cave form the next step. After this we can start with exercises in order to improve the functions of respiration, feeding, articulation and phonation.

Conclusion
The coordination therapy has proved to be very helpful in the scope of treating oral myofunctional diseases and can help people overcome a lot of problems.
The massages and exercises of the coordination therapy can be used here to improve the functions needed for feeding (biting, chewing, swallowing) and the functions for breathing, articulation and voice. Next a more natural development of the organs active in this scope is possible It is not our goal to avoid orthodontic intervention, but to make it more effective. With adults it leads to regaining of a better and more natural behaviour and the elimination of a lot of symptoms and complaints and so it benefits the personal well-being of the clients.

Summary
The logopedic coordination therapy, originally introduced by Elfriede Öcker for the treating of voice disorders, is used on the principle that developing a favourable tone in muscles by special exercises and massages, will influence posture, movement and breathing. In case of oral myofunctional problems a lot of muscles do not have the right tone. The massages and exercises of the coordination therapy can be used in this scope to improve the functions needed for feeding (biting, chewing and swallowing) and breathing, articulation and voice.

Keywords
Oral myofunctional diseases, posture, movement, lipclosing, breathing, biting, chewing, swallowing, articulation, voice.

Authors
Lize Demmink-Geertman, speech therapist
Simone Schouten, speech therapist
E-mail: Demman@planet.nl
Schoutensjm@zonnet.nl

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