Oral myofunctional therapy and frenuloplasty are not proven treatments for obstructive sleep apnea

Obstructive sleep apnea is a potentially-serious medical disorder.  Patients with obstructive sleep apnea need treatments that are based on science.  I am writing this post because over the last several months, I have seen a disturbing number of patients with obstructive sleep apnea who have tried and failed myofunctional therapy and/or frenuloplasty/frenectomy or who have seen something online about it and are asking for my opinion.  Enough is enough.  It is time for someone to speak up. There is no proven benefit to oral myofunctional therapy or frenuloplasty for the treatment of obstructive sleep apnea in adults as it is commonly practiced in the United States.  So that you do not think this is just the rant of a surgeon, I will state that I do not know of anyone respected in the sleep apnea scientific community that would disagree with this, other than one person that I will mention below.  If you are an adult and want to use exercises to treat your sleep apnea, go to Brazil for people that are using tested approaches.  Do not undergo a frenuloplasty/frenectomy for obstructive sleep apnea.  That is really all adults with sleep apnea need to know, but I will explain what I mean in the rest of the post.

What is oral myofunctional therapy for sleep apnea?

Oral myofunctional therapy includes exercises drawn from the world of speech therapy that can address speech and swallowing disorders that are felt to be related to poor function or coordination of muscles of the tongue, throat, and face.  These exercises were developed for treatment of speech and dental problems.  Practitioners of oral myofunctional therapy looked to expand to the world of obstructive sleep apnea and snoring after the 2009 research publication from the team of Geraldo Lorenzi-Filho, MD, PhD at the Heart Institute (In-Cor) at the University of Sao Paulo in Brazil.  Their randomized controlled trial showed an improvement in adults with moderate obstructive sleep apnea with performing a series of 10-20 mouth and throat exercises (depending on how you count them) that was not seen in the control group.  The improvement in the apnea-hypopnea index (number of times with blockage in breathing per hour) was from an average of 22.4 to 13.7 events/hour.  This is not that impressive by itself, but was more interesting to many in the field was the fact that the change in apnea-hypopnea index was seen in those whose neck became somewhat thinner (smaller neck circumference).  This suggests that a potential reason for an improvement in sleep apnea, namely that the exercises might tone muscles, decrease fat in the neck, or have some other effect, all of which could improve sleep apnea, based on existing and subsequent research.  This article was published in the medical journal Sleep, and an editorial from Catriona Steele, PhD, an established speech therapy researcher, expressed doubts about the value of many of these exercises for treating sleep apnea.  As an expert in the field, Dr. Steele made it clear that not all speech therapy exercises are the same and that most (even in this paper) would have absolutely no benefit in obstructive sleep apnea.

I have been fortunate to visit Brazil several times, once as President of the International Surgical Sleep Society when we organized our scientific meeting there in 2016 and on multiple occasions for a sleep surgery course at the Hospital Israelita Albert Einstein in Sao Paulo.  I have had the pleasure of getting to know Dr. Lorenzi-Filho and learning about these speech therapy exercises that were used in their study.  He really is one of the world’s leaders in sleep apnea research, and I respect him tremendously.  His group has performed another high-quality study showing that oropharyngeal exercises achieved about a 50% reduction in snoring, and another Brazilian group that I know has shown a modest benefit of these speech therapy exercises in obstructive sleep apnea.  However, the exercises that they have studied are not what is being offered to patients in most countries, including this United States.

The problem: oral myofunctional therapy offered in the United States has not been studied

Since that publication, practitioners of oral myofunctional therapy have seized on this as a business opportunity to treat a much larger group of patients than they had been.  Groups like the Academy of Orofacial Myofunctional Therapy and Academy of Applied Myofunctional Sciences were either formed or grew in membership, but the reality is that they have developed interest but done little to advance science.  They are business-savvy, charging high prices for courses in rooms that they rent on the campuses of various universities and then presenting their work as endorsed by these same universities.  My unhappiness with their work is based on my experience when giving a lecture at one of their courses.  I specifically asked their established leader in myofunctional therapy, Joy Moeller, and Marc Moeller, her son and Managing Director/co-founder of the organizations, some basic questions.  I was shocked and dismayed to learn that they were offering this course and telling practitioners (most of the course attendees were dental hygienists) to treat patients with obstructive sleep apnea but had absolutely no method to guide the selection of exercises.  This was a potentially-serious medical condition of obstructive sleep apnea, but there was no plan on how to treat these patients with anything approaching a scientific basis.  They were not recommending the same set of exercises as the Brazilian groups have and, in fact, were just letting the course attendees choose their favorites without any protocol or decision making process to follow.  I felt that this randomness in treatment planning was irresponsible and inappropriate.  I am not aware of any advances in the educational curriculum for their courses over the last couple of years.

There are some people who believe in oral myofunctional therapy.  Dr. Christian Guilleminault has recently retired after a distinguished career as an authority on obstructive sleep apnea.  For many years, he has been a proponent of approaches that target facial growth and development in children, and on this account he has advocated for orthodontic treatments like maxillary expansion and, in some cases, also for myofunctional therapy.  I know Dr. Guilleminault pretty well from my own days as a sleep surgery fellow at Stanford and in numerous interactions over the years.  Dr. Guilleminault is brilliant, but some of his strong opinions are based on his personal experience without rigorous scientific investigation.  Although he may be recommending myofunctional therapy for some adults with obstructive sleep apnea, almost everyone in the sleep community is not convinced.

What is frenuloplasty?  Why perform it for sleep apnea?

Furthering the issue is the formation of groups like The Breathe Institute, with a surgeon (Dr. Soroush Zaghi) as a co-founder.  I am extremely reluctant to criticize colleagues, and it is difficult to write this about someone who is very bright and likeable.  However, his collaboration with practitioners of oral myofunctional therapy and performance of a surgical procedure called a frenuloplasty or frenectomy (described below) is not helpful and may actually be harmful to patients.  There is no real scientific evidence supporting frenuloplasty or frenectomy in treating obstructive sleep apnea in adults.  In fact, Dr. Zaghi has admitted that the science does not really exist to support frenuloplasty in adults or myofunctional therapy as practiced in the United States, so it is especially odd that he continues to recommend them.

Frenuloplasty is basically the release of tongue-tie (ankyloglossia in medical terms) by cutting a band of tissue underneath called the frenunlum or frenum.  This procedure has generally been performed in children who have problems with speech, feeding/swallowing, or dental hygiene because of tongue tie.  There is limited evidence that having the tongue move forward to fill the space behind the upper teeth is helpful for development (mainly widening) of the upper jaw.  This would provide another reason to release tongue tie.  However, all of this relates to children.  There are certainly adults who have tongue tie (either from birth or starting later in life), but the aggressive claims about the benefits of frenuloplasty are often taking benefits seen in children and thinking the same applies to adults.  This is just not true.  For example, many patients have indicated that frenuloplasty or frenectomy is being advocated to help with jaw development in adults.  This ignores the very basic biological fact that jaw development is complete by the time someone reaches adulthood.  There is simply no way that frenuloplasty could affect jaw development in adults unless one were to undergo a surgical procedure to cut the upper jaw and allow it to grow again with the use of special mouthpieces, followed by orthodontic braces.

Is there any value in myofunctional therapy or frenuloplasty for sleep apnea?

There probably is some value in oral myofunctional therapy, but right now as practiced in the United States it is too haphazard as to what exercises are selected for different patients.  For frenuloplasty, there really is no evidence to support it as part of treatment for adults with obstructive sleep apnea.  Unfortunately, there are many surgeons, dentists, and other practitioners out there offering these completely unproven treatments for sleep apnea.  For my patients interested in oral myofunctional therapy, I tell them they have to go to Brazil to get anything close to a proven therapy.  They will need to make multiple trips for the initial evaluation and then the follow up visits, but there are worse places to visit.  Brazil is an incredible, fascinating country with wonderful people, so they can think of this as a good excuse to travel there.

 

 

0 thoughts on “Oral myofunctional therapy and frenuloplasty are not proven treatments for obstructive sleep apnea”

    • Dr. Kezirian says:

      Mandibular relocation is not a specific term I know. Moving the mandible can occur with special mouthpieces (oral appliances or mandibular repositioning appliances/devices) or surgery. Surgery often includes moving the mandible and the maxilla forward, to some extent, and is called maxillomandibular advancement or bimaxillary advancement. These can be treatments for obstructive sleep apnea. Is this what you meant?

  • Soroush Zaghi, MD says:

    “In the sciences, people quickly come to regard as their own personal property that which they have learned and had passed on to them at the universities and academies. If someone else comes along with new ideas that contradict the Credo and in fact even threaten to overturn it, then all passions are raised against this threat and no method is left untried to suppress it. People resist it in every way possible: pretending not to have heard about it; speaking disparagingly of it, as if it were not even worth the effort of looking into the matter. And so a new truth can have a long wait before finally being accepted.”–Goethe.

    I now have experience with 350+ cases to support a functional approach to treatment of sleep and breathing issues and I am honored to be identified by Dr. Kezirian as a pioneer and leader in this approach. A series of publications on our experience will be available by the end of the year. For more information:
    https://www.zaghimd.com/frenuloplasty-how-we-do-it

    • Dr. Kezirian says:

      Thank you for the quote from Goethe. As far as your research, I look forward to reading about it. Right now, the publications that are cited by many groups like the AOMT have provided no scientific basis to consider this an acceptable treatment for adults with obstructive sleep apnea. It is great that you are raising awareness about OSA and performing research on this, but we are a long way from having this be considered scientifically valid. This is not my isolated opinion, so there are apparently many of us (not just surgeons) who need convincing.

  • Steve Lamberg DDS, DABDSM says:

    Dear Dr. Kezirian,
    I can tell from your writing style that you are passionate. What is missing from your rant though is a thoughtful discussion of treatment options available to our patients. Won Moon just presented on non surgical skeletal expansion on adults in NY at a conference I hosted. Non surgical approaches will appeal to many more people. His work that shows a dec in a number of respiratory indices from increasing nasal airflow will be available sometime this summer. Additionally you mentioned that Dr. Zaghi has been supporting the importance MFT even though that data is not currently available. On this note you are absolutely correct, however, his data is coming out in the next few months so please keep your mind open when you look at this soon to be released data.
    I’m a dentist and I have the opportunity to see many more young people than you do, many of whom are still growing. I would always prefer to intervene and prevent the problems of craniofacial dystrophy than correct them later with more invasive approaches.
    When I am referred adult patients who are unable to wear CPAP I am typically asked to make an oral appliance. Successful….yes close to 90% (depending on your definition of success) but that is only a crutch and like CPAP patients have a choice to comply or not. So in my opinion it is better to offer patients a “cure”.
    What is a “cure”? My answer is…That Depends. It depends on what is causing the high AHI or RDI or ODI. These are really just symptoms. We are in the age of personalized….or I prefer the term precision medicine. So let’s get real. Where is the point of the collapse of the airway that is causing the problem. If more than one area then lets learn how to evaluate this. Does the patient have NPO? Then we need to say: What is causing the NPO? WE need to treat the cause. We need each other to move “airway” treatment (which includes sleep) to the next level.
    Please let’s not get into criticizing our colleagues so quickly. Discussion on the absence or presence of data which may be valid today could change tomorrow and if you speak so firmly against certain treatment modalities you are in some way expressing your own prejudice which as you are quick to point out is unsupportable.
    I’m sure with your passion and experience you can expand your vision to whatever can help our patients. WE need each other and no one is going to “put this all together” on his or her own.
    We need orthodontics, we need oral surgery, we need otolaryngology, we need MFT and we need to leave no stones over turned in our quest. We need to work with our colleagues in disciplines outside of our own and learn all of our options.
    There are so many pieces to the airway puzzle that in my opinion we all need to support each other…..and yes push for science….but encourage each other as there is obviously movement in this direction.

    I would love to learn from you why you do a certain procedure, when you do it, how you decide differentially which procedures to choose and more. This conversation would be nice to put in the soup. We will go further to helping many people by being more positive. Thanks for reading this and I look forward to more conversation.

    • Dr. Kezirian says:

      Thank you for your post and all that you do for promoting science and awareness. I treat all therapies critically and believe that you need some science to back up claims. I would not characterize what I wrote as a rant, as many people from various disciplines (including those experienced with oral myofunctional therapy) have written to me being very supportive. I welcome science-based arguments, but the current practice of oral myofunctional therapy in the US is not at all based on science. I am critical of people that oversell their data without any proof to back it up, and I have been very vocal with surgeons discussing their opinions as if they were based on science.

  • Nora Gee says:

    Hi Dr. Kezirian,
    I would like to take the time to thank you for your incredible work. Giving patients the ability to breathe again is a gift beyond words, and I am certain you see the benefits your patients receive from your treatments each and every day. I am a pediatric dentist, and have seen first hand many patients suffer with sleep apnea. But I have also seen many patients healed over the years through various treatments, and truly can attest to the life that is brought back to these patients post-treatment.

    Ankyloglossia, sleep apnea, and myofunctional therapy are three topics that are very dense and may seem very distant from one another— but in reality are very much intertwined.
    As doctors, we are very careful when providing information to the public, whether to patients or to other providers. Most specifically, when we give advice or give recommendations.
    As a physician and researcher of your stature, I know that you would like to make statements based on fact, research, and clinical findings when making statements and suggestions to others. Thankfully, as scientists we are able to expand the field and help make these suggestions by reviewing and conducting research. Leading to the following text…
    I delved into interest of sleep apnea after I saw one too many of my patients suffering from ankyloglossia, narrow palatal vaults, and sleep apnea. I noticed all too quickly the phenomenon that occurs when a patient suffers from low-tongue posture due to ankyloglossia, and the affect it takes on the maxilla, causing high, narrow palatal vaults, crossbones, and open mouth posture. When a patient has the ability to freely move the tongue, they are more likely to keep the tongue in a natural resting position on the palatal, behind the upper incisors. I noticed that my patients with ankyloglossia develop the tendency to have open mouth posture, likely due to the low-tongue posture along with the inability to have the maxilla fully develop from the oral habit of resting the tongue in the palate as well as having proper deglutination/swallow habits. The tongue is a powerful muscle, and has been recognized in growth and development texts for years to date as key in the development of the maxilla. Imagine a child suffering from ankyloglossia, and the inability for that child to fully develop their arches. The open mouth posture just perpetuates their poor habits of breathing from the mouth, which causes pollutants and other bacteria to enter the airway with a free pass. We all know how important nasal breathing is, for our patients to filter these pathogens as well as keep the tongue in the proper resting position-which is the palate.
    Myofunctional therapy emphasizes this: keeping the lips together, breathing from the nose, and the tongue on the roof of the mouth. Simple, but so difficult for us as doctors to teach because quite simply (and sadly) we do not have the time… Orthodontists in the UK and Europe have been doing this for their patients for years. Unfortunately sometimes the U.S. catches on to things a little late..
    In your section, ”What is frenuloplasty?  Why perform it for sleep apnea?” I invite you to research this topic and further analyze the points above. To be quite frank, I understand how physicians that don’t see this problem over and over again can see this phenomenon as being far-fetched. But as a pediatric dentist that sees ankyloglossia and sleep apnea as an epidemic in the pediatric population, and how much it can worsen if untreated into adult-hood, I cannot imagine a doctor of your stature not align with others that are so willing to heal these children suffering with these issues.
    Please view the literature that follows. Doctors such as Dr. Zaghi that go so far as to provide research in the field and educate dentists draw significant attention to these problems that dentists see every day. In the study, “Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation” Zaghi along with other researchers and clinicians analyze ankyloglossia in association to the narrowing of the maxilla. A problem pediatric dentists, such as myself, have seen for years. I invite you to review the following material, and hopefully we can all work together and use some of your expertise to better heal our patients:

    Relationship between the lingual frenulum and craniofacial morphology in adults 2011
    http://www.ajodo.org/article/S0889-5406(10)00963-7/abstract
    The present study supports the hypothesis that skeletal Class III malocclusion is related to long median lingual frenulum or a tongue-tie tendency. Patients diagnosed with tongue-tie might have a tendency toward skeletal Class III malocclusion.

    In, “Ankyloglossia and its influence on maxillary and mandibular development,” 2000, this article published in The Functional Orthodontist journal recognizes the imperative role of the tongue in the development of the skeletal structures of the face. This review demonstrates how the correction of ankyloglossia may cause the tongue to change from a low-posture setting, to resting in an upward state, behind the maxillary incisors in the proper state, therefore acting as a natural expander.

    Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional – morphological study. 2017
    Restricted tongue mobility was associated with narrowing of the maxillary arch and elongation of the soft palate in this study. Restricted tongue mobility was associated with narrowing of the maxillary arch and elongation of the soft palate in this study. These findings suggest that variations in tongue mobility may affect maxillofacial development.

    https://www-ncbi-nlm-nih-gov.libproxy2.usc.edu/pubmed/25348130
    Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. 2015
    This Level 1 Evidence study demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. This is using the gold standard polysomnography to obtain these outcomes.

    Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences.2015
    https://www-ncbi-nlm-nih-gov.libproxy2.usc.edu/pubmed/23346072
    This review demonstrates abnormal oral-facial anatomy that must often be treated in order for the resolution of OSA.. Presentation of evidence supporting hypotonia as a primary element in the development of oral-facial anatomic abnormalities leading to abnormal breathing during sleep. This review indicates using myofunctional re-education along with orthodontics in order to facilitate ora-facial development.

    Thank you for your attention.

    • Dr. Kezirian says:

      Thank you for your detailed comment. First, I fully agree that ankyloglossia in children has a much more plausible link to facial development and the development of sleep disordered breathing (aka OSA). You mention some articles as the scientific support for the ideas. The first two papers and the last paper discuss ankyloglossia and facial growth, and you correctly point out that they indicate that there MIGHT be a connection. These papers report an association, but there are many, many issues to resolve before we can say that ankyloglossia in these children is the culprit in the development of OSA or that treatment prevents OSA. The systematic review is…shall we say, of very limited scientific quality. There is a single randomized trial from the Brazilian group (that I think is a fantastic study) and a few papers that are case series studies with numerous scientific flaws. The reason this is not a real systematic review is that the authors did many things that are not valid scientifically. I could bore you with details, but let’s just say you should never combine completely different exercise programs from randomized trials and case series studies. So, this systematic review basically tells me nothing more than the Brazilian randomized trial. I do look forward to getitng more scientific evaluation, but for now the science is just not there when it comes to adults. It is not.

  • Christian Guilleminault says:

    Currently i have not “retired” from the Stanford sleep clinic, and the 2 articles that we published associating oraonasofacial reeducation in Sleep Medicine were based on PSG recordings. The reeducation that we used was based on those practiced in France, where such reeducation has been established since the 1980s. Reeducators in France are part of trained personnel that have to do a 3 years university based training and pass and exam; and- as example the most well known institute is located in Paris in the 11th district has been there for over 25 years and treatment sessions are covered by social security payment. If the above author had really read our articles, he would have find the reference to a large monography written in 1991- from where our training exercise came from-, it would also have seen a large iconography, protocol, comparison between results obtained with oronaso facial reeducation and orthodontic treatment etc—[ignorance of what is existing and published ie not a good excuse…!]…
    Here, there is a specific attack on USA trials to replicate what was done in Europe (note the term “myofunctional therapy” was already used in the UK in the 1920…) The USA is very late in developing appropriate training programs in different fields and the writer may be right in indicating that there is a large educational handicap here, hopefully, there will be efforts to create university-based programs to address this gap. Such absence of developing appropriate professionals and adequate treatment protocols may be related in part to absence of a medical specialty of “stomatologist”: ENT never learn the mouth-type of problems and “stomatology” is addressed here by individuals that go through Dental School, and spending either one year in a dental school with an MD degree or one year in an ENT department with a dental school degree, will never replace a 4 years residency training in “Stomatology” that allowed development of training programs bringing specific reeducation programs. In France Professor Delaire, a well-known professor of Stomatology was behind the development of the official training programs in oro-naso facial muscle reeducation in the 1950-60s.
    The issue of “Frenectomy” is something very different, we would recommand to read the literature and to have an idea of how short frenulum is involved in the development of abnormal upper-airway recommendation is made to read a review -with a large bibliography in “sleep medicine review” a journal dedicated to publication of reviews covering a field and outlying the data on which a field developed.Here it outlined how abnormal breathing during sleep occurred in a number of young subjects ( reference: “From Oral Dysfunction to dysmorphism and onset of pediatric sleep apnea Sleep Med.Rev. DOI: 10.1016/j.smrv.2017.06.008). Finally one has to recall that many articles have emphasized that “OSA” occurs in families and may affect children and parents- such a findings lead Redline et al to investigate if one single genetic marker could be associated with OSAS- and it is not-, but without doubt OSAS runs in families…and also thatobesity as many co-morbidities, one of them been OSAS, (and not the reverse)… a better knowledge of the research and published literature is sometime helpful…

    • Dr. Kezirian says:

      Christian, thank you for the detailed comment and taking the time to write it. I apologize for thinking that you had retired, as there was an event in your honor that I obviously mistakenly understood as a retirement event. I also appreciate that ignorance of the literature is no excuse. Finally, it is great that oronasalfacial reeducation and myofunctional therapy has been practiced for many years in other countries. I will point out that being practiced for many years does not equate to scientific proof. That being said, I am not sure that you are specifically disputing what I have written. If oronasalfacial reeducation has shown a benefit in moving patients from being mouth breathers to nasal breathers, it could be very helpful in patients who do primarily mouth breathing.

      Broadly, myofunctonal therapy as practiced in the US does not have a clear basis for key elements (selection of exercises, for example), such that it is impossible for me to recommend it as a treatment for patients. The Brazilian study had a specific set of exercises, but this set of exercises is not being used. Instead, we are getting an array of exercises that are recommended by various providers without any clear rationale, with most of the exercises of the type that would be extremely unlikely to provide any benefit whatsoever (based on Dr. Steele’s editorial that I referenced). Surgery has some of these same issues, which is why surgeons have been challenged to define the selection of procedures (the primary research focus of my career) and to perform better studies (also something that many of us are trying to do). As far as frenectomy, the fact that OSA runs in families (likely not related to a single gene, as you know) is not related to ankyloglossia. As I mention in the post, I do believe that frenectomy may have a role in children due to potential effects on facial development (consistent with the paper you cite), but the idea that frenectomy in most adults with sleep apnea is valuable is pretty unlikely based on everything we know about facial development.

  • Armen Mirzayan DDS says:

    Dr. Kezirian

    I have met you personally, trusted you with a handful of patient referrals and have taken a few courses with you on sleep apnea. I admire your passion and have great respect for your demands / high standtands of care.

    I think we have a much bigger problem with apnea than is being discussed here. It is estimated that 85% of sleep apnea patients remain undiagnosed. To compound this, upper airway resistance syndrome and even mild apnea are often ignored, allowing the patient to transition to moderate / severe disease condition over time. Another alarming trend is how a significant number of apnea patients are poorly monitored long term. I meet many patients with cpaps that are a decade old and have not seen a sleep doc in that time frame.

    I appreciate what your are trying to accomplish here, but I’m sure you understand that a lot of this is patient driven. I see many patients who have had surgery and / or cpap who are still looking for a solution. We know PAP has high efficacy, but what good is that when patients have poor compliance rates? Surgery, oral appliances, and many other modalities are never a guarantee solution either.

    I think it is imparative to change all this with collaboration between all the disciplines. There is not one single approach that can address every single patient with apnea. If we could all focus on a comprehensive care, we will all be very busy managing the 100 million people in the US with sleep disordered breathing

    I’m pretty confident the people you reference in your article will rise to meet your demands- licensing and regulatory boards are always a good start for validation that is founded on sound research and reproducible results.

    The irony in all of this is how we now have hypoglosal nerve stimulation to treat apnea. I believe it was your own presentation (forgive me if I’m mistaken here) that quoted the relative cost of the procedure was in escess of $100,000. I reckon most patients will opt for tongue training / releases / exercises first, before committing to that surgery. Who knows; Myofucntional therapy just may be the exact adjunct to your surgeries that could increase your own success rates. I know I would stack all the odds in my favor if I was placing these pacemakers! Most surgeons prescribe physical therapy before / after treatment, and I don’t see how this is any different.

    With respect

    • Dr. Kezirian says:

      Dr. Mirzayan, I also respect you for the incredible work that you do and have referred patients to you as well. I am not sure I agree that this is all patient-driven. When it comes to considering treatment options, it is our responsibility as providers to counsel patients about their options, sharing what we know scientifically. I completely understand that many patients do not want to have surgery and that no approach is perfect. However, I also believe that we must present valid treatment options to patients, including oral appliances even though I do not fabricate or deliver them myself. When it comes to treating adults with obstructive sleep apnea, there is almost nobody well-respected in the sleep scientific community that would consider oral myofunctional therapy as practiced in the United States as a valid option. If this is a call for higher-quality research, then so be it. In surgery, we get the same challenges, although there is much more science to support surgery, and this has motivated us to come together to improve the quality of our evidence. You are absolutely correct that hypoglossal nerve stimulation is expensive and too expensive to use as a treatment for everyone with sleep apnea. However, it is an excellent, scientifically-proven treatment that works for the right kinds of patients.

      We need to start with therapies that work to treat sleep apnea. CPAP and oral appliances work for many patients with obstructive sleep apnea for patients that can tolerate them. Surgery does not work as well, but there are no issues of having to wear something at night. I do not want to repeat myself, but right now there is very little evidence that oral myofunctional therapy as practiced in the United States works for obstructive sleep apnea. With some systematic approaches to defining exercise selection and, more importantly, studies of these protocols, that may absolutely change. It is just not something that is appropriate to recommend for patients outside of studies because there is such little evidence.

  • Nora Gee says:

    I’d like to chat about your comment, “…the research currently concludes associations(..in relation to sleep apnea and ankyloglossia), but there are many, many issues to resolve before we can say that ankyloglossia in these children is the culprit in the development of OSA or that treatment prevents OSA.”

    Random thought..as a researcher you know that some medications, let’s say for example those used for cancer treatments, take time to go through the various stages of testing. This process is often called from the bench to the bedside. The new drug is first studied in the laboratory. If the drug looks promising, it is studied in people. There is no typical length of time it takes for a drug to be tested, but it might take 10 to 15 years or more to complete large-scale testing in individuals before it is published as standard of care. As a clinician, would one wait 10-15 years for that treatment to be published in a level 1 evidence review to provide it as an option for patients in every single case? Let’s say, when we have evidence that our patient can benefit from the treatment, and have case/study and clinical trials in reference as being effective?
    If a clinician would say “no,” then science and research could never expand, and many patients would suffer from treatment that we would be too fearful to provide as an option.
    The point of the matter is, it takes years and years for research to be completed in order for level 1 evidence research to emerge. That is why it is imperative to align as researchers and clinicians–physicians, dentists, and therapists alike to provide ALL the options for our patients, inform the risks and benefits of treatments, and share our findings to further facilitate quality treatment for our patients. Many patients to date are thankfully benefiting immensely from the treatments provided by the physicians, dentists, and myofunctional therapists committed to this very cause.

    At this point we have evidence that shows: ankyloglossia perpetuates the behavior of low tongue posture (causation). Low tongue causes the maxilla not to fully develop from the oral habit of resting the tongue on the floor of the mouth (rather than the palate), as well as causing improper deglutination/swallow habits. Narrow palatal vaults restrict the airway, and left untreated lead to sleep disordered breathing symptoms. We are all too familiar with the dentofacial characteristics of adenoid facies once we see these into adulthood. So let’s continue this quest for more research, and help our patients heal.

    • Dr. Kezirian says:

      The analogy to cancer research is that patients get enrolled in trials that are only performed after a thorough review and approval by the FDA. A study of OMT would not have the same risks, but patients should know that what they are doing is unproven if the field is in its infancy. Most of the evidence you cite relates to children, and I agree that there really is some evidence to support this all in children. But not in adults.

  • Steve Lamberg says:

    Re adults and OMT….I know several surgeons who recommend OMT after skeletal expansion, non skeletal expansion, and surgically facilitated orthodontics….to prevent relapse. They see less relapse when employing OMT. The triad of structure, function and behavior cannot be dismissed based on lack of data. Granted it would be difficult to design a study to “prove” this. There’s plenty anecdotal evidence that supports common sense that the tongue is a formidable orthodontic appliance at any age.

    • Dr. Kezirian says:

      Thank you for your comments and your passion. I am not dismissing anything, but I am saying that we need much more science behind this and some method. I have received many e-mails from oral myofunctional therapists, sleep medicine physicians, and surgeons that have thanked me for my blog post and feel that they agree with most/almost all of what I have written.

      The bottom line is that I do not think that treating what can be a serious disorder without stronger evidence is appropriate. I would counter that treating sleep apnea without any clear plan of how this is done is at everyone’s peril. The benefits of OMT after these treatments sounds great, but I do believe that some attempts to study this systematically would benefit everyone. There are countless examples of things that were considered helpful that have been shown not to be helpful (or, in some cases, harmful). One of my mentors at UC San Francisco performed a major randomized trial (the HERS Study) showing that postmenopausal estrogen therapy did not lower cardiovascular disease and actually increased the risk of strokes, in spite of being dogma that it improved health by reducing cardiovascular events and that every postmenopausal women should be on estrogen replacement therapy unless there was a good reason not to be. This scientific study countered numerous uncontrolled trials and saved the lives of women. I am not suggesting that this is the same thing, but it does highlight the importance of scientific evaluation even when anecdotal evidence suggests a “definitive” conclusion.

  • Steve lamberg says:

    Regarding MFT in adults:
    I know surgeons who suggest MFT to prevent relapse after skeletal expansion surgery, non surgical expansion, and SFOT. Why do they all suggest this? Apparently anecdotal evidence (lowest level) supports common sense (even lower level evidence) that the tongue is a formidable orthodontic appliance…. and lack of proper function can challenge stability. Can we ignore the structure-function-behavior triad? At your own peril I think.

  • Licia Coceani Paskay says:

    Dear Dr. Kezirian,
    I always appreciate different points of view as they usually enrich a discourse, so I appreciate Dr. Kezirian’s perspective on orofacial myofunctional therapy (OMT) and sleep disorders. However, I have to question some of the terms used by Dr. Kezirian. What does it mean “There is no proven benefit to oral myofunctional therapy”? We may question the type and number of studies published so far with regards of myofunctional therapy, because the application of myofunctional therapy tn patients with sleep disorders is relatively new, but we must acknowledge that even recently published systematic reviews suggest that OMT actually significantly improves symptoms of sleep disorders. Is OMT the silver bullet. No. Is SURGERY the silver bullet? No. Is SURGERY “proven”? No. Even surgery, depending on the type, has various degrees of success. And, just like OMT, an aging body needs occasional follow-ups, so in both cases the long them effect may not be stellar. Plus, surgery is invasive, painful and leaves permanent anatomical modifications, while OMT is the opposite Myfunctional therapy is complementary with surgery, CPAP, weight loss, sleep positioning and any other OPTION to address sleep disorders.

    Myofunctional therapists understand the anatomical and physiological mechanisms that regulate the orofacial musculature, spaces and supporting structures, and implement programs, more or less sophisticated to optimize or recover those inherent mechanisms. We work based on the physiology and anatomy of the oropharyngeal complex. The tongue against the palate, in presence of lips closed and soft palate against the tongue ensures the correct position at rest of the whole orofacial complex, day time and night time. Myofunctional therapy can re-establish this mechanism, which sometimes is altered by many conditions. We have muscles in our oropharyngeal cavity, in particular the genioglossus and the palatoglossus, which are designed to keep our upper airways open in supine position, when we breathe nasally and most importantly when we sleep. We know how these muscles work and how we can train the patients taking advantage of these muscles.

    Does it work with EVERY patient? No. But again: does SURGERY work in every patient? No. Only in selected patients. Are myofunctional therapists claiming to treat sleep disorders? NO. We treat people whose morbidity or co-morbidity are sleep disorders. Are WE diagnosing sleep disorders? NO. We are privileged in our profession to be able to identify signs and symptoms of sleep disorders in children and adults, including restricted lingual frena, and make the proper referral to a professional who can make the diagnosis. Then we treat the orofacial muscle dysfunctions present in people with sleep disorders. We have a network of professionals to whom we can referred to if needed, like Dr. Zaghi. We keep our training updated and we are open to learn. We work very well in multidisciplinary teams.

    So, let’s work together, learn from one another and help the thousands of patients nation wide who need all of us, because we have different skills. Let’s FACILITATE research so we know what works and what needs to be refined. Let’s encourage universities worldwide to combine surgery and myofunctional therapy for better and lasting results and to offer an alternative to those who are not good candidate for surgery. Let’s give people more options, not fewer.

    Respectfully,
    Licia Coceani Paskay, MS, CCC-SLP
    Speech-language pathologist and myofunctional therapist
    Los Angeles, CA

    • Dr. Kezirian says:

      Thank you for your comment. First, the “systematic review” that has been published about OMT is not a scientifically-valid systematic review. Instead of delving into too many details, the paper groups various approaches to the use of exercises and OMT. These cannot be grouped scientifically. There are other scientific flaws, and I have expressed them directly to the authors of one of them without receiving a response. It is not the fault of the authors, but the problem is that you cannot call this a systematic review. It would be like saying all surgeries are the same and doing a systematic review of “surgery” (which some have mistakenly done). Second, there are hundreds of studies of surgery for sleep apnea, yet there remains an ongoing need for more research to understand even more clearly how to select procedures and also understand how well procedures (or combinations of procedures) can work in individual patients. This has been the challenge outlined for surgery and is basically the challenge I have presented to OMT practitioners. I am not alone in my thoughts, as the large, large majority of people familiar with research in sleep medicine, sleep surgery, and sleep dentistry that I know would agree with what I have written (and I have also received many supportive comments here and elsewhere). You have written a great deal about your commitment to patients and the underlying principles of OMT. I am not denying any of this. What I have said is that OMT (as practiced by most in the US) and frenectomy are not proven treatments for adults with obstructive sleep apnea. I look forward to seeing results of research that come from your colleagues and you.

  • Anonymous says:

    Dr. Kezirian, I have been to see you AND other ENT/myofunctional practitioners mentioned here. I urge you to work together. Is not your mission to help patients who are suffering? There is no success rate to spending time fighting within the medical community. Despite very narrow nasal passages, vaulted roof of the mouth, “narrowed hypopharyngeal airway” and “posterior displacement of the tongue base,” observed by you personally as well as physicians mentioned here, the practitioner who has taken me seriously has been a myofunctional therapist. Please know that myself and other patients are desperate for help, especially those whose sleep study does not show apnea because we are waking up BEFORE apnea events with UARS. I have been discouraged from getting procedures because “your insurance won’t cover it,” and have been told to go home and take SSRIs. SSRIs do not treat apnea. What does this all have to do with frenectomy/myofunctional? People are desperate and will try ANY and ALL modalities. Especially when we are already exhausted. Especially when we can’t “prove” the problem to our doctors or insurance companies unless we are evaluated under anesthesia. (Again, cost prohibitive.) I will do anything to sleep. including surgical intervention, retraining of muscles, and lifestyle approaches. We are talking about breathing here. While our health is compromised, we need you use your energy to help us make sure our medical issues are treated as legitimate. If more studies are needed to determine effectiveness, so be it, but bashing each other seems a waste of time. I would like to see more shared about what does work.

    • Dr. Kezirian says:

      Thank you for your comment. I am sorry to hear that you (may have) felt I did not take you seriously. That is certainly not the approach I take in my practice, and I do not recall a patient telling me that previously. Thank you for mentioning this, and I will work harder to make sure all of my patients are treated with the respect that they deserve.
      You mention that patients are desperate, and that is absolutely correct in many cases. The problem is that practitioners of all types have what we call asymmetric information, in that someone is coming to you looking for help and have implicit trust in their practitioner. It is extremely difficult for patients to be on equal footing with a practitioner. The result is that patients tend to accept recommendations from practitioners without questioning them. My goal is to have a solid scientific foundation for how sleep apnea is treated, as it is a potentially serious medical condition. I think it is not responsible to offer treatments that have no scientific validation. This is true for all treatments. To take my own field as an example, I am not afraid to ask difficult questions of colleagues all the time and welcome those same difficult questions from patients and colleagues about what I do. There is much we need to learn about surgery, and that is why I have focused not just on patient care but also on sleep surgery research. I have worked with many medical device companies, and it seems like my role often is to be a critical voice, pointing out what needs to be demonstrated before something can be used on patients (actually often asking tougher questions than the FDA). There are numerous examples of medical devices to treat sleep apnea that have not stood up to careful, scientific evaluation even though they seemed like brilliant ideas and that they absolutely should have worked. These companies no longer exist, even after spending tens of millions of dollars, because their device did not help patients. That is my responsibility in caring for patients.
      As for working together, I will admit that this is not my specific field. There are clearly many people with much more insight into OMT than I, so I do not want to interfere with the research that I think they should be performing before proclaiming that OMT and frenectomy are viable treatments for adults with OSA. Since my blog post, I have received many e-mails from oral myofunctional therapists, physicians, and dentists/orthodontists, thanking me for speaking up and expressing their same concerns. These are not my isolated thoughts. I look forward to seeing more proof that there is a specific approach that can be offered to patients that has been shown to help them.

    • Anonymous says:

      Thank you for your reply, above, doctor. This was not meant as a criticism of you personally, you did a thorough examination and referred me to a colleague of yours due to the specificities of potential surgery. Over the course of several years, I have seen 3 ENTs as well as other professionals including dentists and myofunctional, and frankly, the suggestions for treatment vary wildly. I may have gone down some unhelpful paths and I don’t know where to go from here. This is hard to navigate.

      • Dr. Kezirian says:

        Thank you for clarifying. I appreciate this. Please let me know if there is anything I can do. You can respond directly to me via e-mail instead of as a public post here.

  • sandra says:

    Dr. Kezirian,
    This is a fantastic debate, thank you so much for bringing it up. As an orthodontists I have used OMT for more than 2 decades and I certainly have not seen consistent results or consistent prescription of activities. For the last 5 years I have implemented a postural and functional program designed by Dr. Simon Wong that has 8 very specific and clear everyday activities. This is proven to have spectacular results, but we still need to conduct serious research to understand what will be helpful. We are in the process of selecting cases and looking at results in collaboration with the Technion University in Israel. We are focusing in children only but as was pointed out by CG, working in a setting with well trained stomatologists is critical when we want to recommend therapies to our patients.

    • Dr. Kezirian says:

      Thank you for your comment. It is great that you have had spectacular results, but more importantly I look forward to the publication of these results going forward.

  • Erik Heger says:

    I struggled with TMD and difficulty breathing/sleeping for years. I have seen countless doctors and spent tens of thousands of dollars chasing after what the “experts” told me they could do for me. Several famous doctors have delivered their “Magic Bullet” to me and all I got out of it was worse health (and a maxed out credit card.)

    I was chronic pain. It was ruining my life.

    If I could do it all over again I would have gone to Saroush Zaghi first and forgotten about all the rest of them…

    I received a Lingual Frenectomy from Dr. Zaghi about 2 years ago.

    From the moment my “tongue tie” was released my life has been significantly better. My jaw pain, neck pain, and the many years of back pain are remarkably improved. And I mean: FROM THE MOMENT I GOT OUT OF THAT CHAIR… I felt like I was freed from a prison that I had come to assume was normal.

    About 9 months after my Frenectomy, I received a Septoplasty from Dr. Zaghi. Again: FROM THE MOMENT THE SPLINTS WERE REMOVED FROM MY NOSE I have been a different person. I sleep better, I breathe better, I eat better, I exercise better. I was under the assumption that everyone had trouble breathing. That, apparently, is not true. And now I am one of the people who doesn’t have trouble breathing through my nose. It feels like nothing short of a miracle, but I am learning that it is actually simple, safe, and possible.

    Furthermore, in concert with these procedures I have done Myofunctional Therapy.

    I no longer take pills for my headaches — in fact: I no longer experience headaches! The myofunctional therapy has helped tremendously with my TMD where appliances and braces have made things worse. I have had doctors offer to do all sorts of crazy things (such as remake all of my teeth to find a “better bite.”) By far the most consistent and most helpful thing has been Myofunctional therapy. It’s not easy. It’s not a quick fix. It can be remarkably frustrating. But it has been worth it for me and I suspect that I will be doing the exercises for the rest of my life… just like I will exercise and eat well for the rest of my life. Myofunctional therapy has become part of my healthy living routine. And it helps. Period.

    I spent a decade of life — A DECADE! — chasing after a way to make my headaches go away, a way to release the chronic jaw and neck pain, and a way to sleep better. I’ve had appliances, I’ve had braces, I’ve had neuromuscular dentistry.

    Oh — and did I mention that I have spent tens of thousands of dollars on doctors and dentists and orthodontists who have all seen my problem as the nail that’s the perfect for their particular hammer.

    If I could do it all over again (and lord knows I wish I could) I would go to Dr. Zaghi FIRST and then I would go straight from his office to see Joy Moeller, my myofunctional therapist.

    My experience with them has been nothing short of life changing.

    I could go on and on….

    Erik

    • Dr. Kezirian says:

      Thank you for your commments. I am so glad you are feeling better, and I am sorry it took so long for you to achieve some relief. I hope it continues forever.

      Your experience highlights the importance of scientific evaluation of myofunctional therapy and frenectomy–which is almost nonexistent–as there may be a potential to treat many more patients. As a clinician treating patients with a potentially-serious medical disorder like obstructive sleep apnea, it is irresponsible to advocate treatments that have not been scientifically evaluated. Septoplasty and other treatments of nasal obstruction have undergone evaluation, but myofunctional therapy (as practiced in the United States) and frenuloplasty have not. I have many patients who have undergone unsuccessful myofunctional therapy and frenectomy by these same providers, and their experiences do not prove that these have no role. It is just that we need to understand how much benefit any treatment offers and in what patients there may be benefits. Even with the kinds of surgical procedures I do, there are no guaranteed results. However, I use all of the available scientific research (including my own) into consideration when developing a treatment plan that makes sense for patients. I encourage you to ask your providers to perform scientific research on these approaches.

    • Anonymous says:

      I have gone to Dr Zaghi and have done myofunctional therapy and seen zero improvement in my sleep. Every patient’s situation is different. Whatever works is valid. That said, yes, we need more research and documentation. The issue for me is the compartmentalization of medicine and the following of pre-determined protocols. One doctor will see the tongue as the main issue ignoring the rest of the system. One will only recommend surgery and ignore the role of the tongue in apnea. One will tell you to take meds, and completely ignore the anatomy. The patient suffers. Especially the female patient who often does not get taken seriously because of bias. Then there is the issue of cost. May doctors do not take insurance at all because they don’t want the inconvenience of dealing with it, which makes them impossible to work with for all but the wealthy. I will not give up on my health and am noting some of the other names on this thread. Thank you to those who are interested in solving the unique challenges that some of our bodies present.

  • Bob Mason, DMD, PhD says:

    Dr. Eric: Many responding to your excellent and much-needed commentary on the lack of scientific research to support myofunctional therapy for individuals with sleep apnea, make the claim that a tongue tip-up rest position at the rugae is THE natural position for the tongue at rest, while a tongue-down rest position leads to narrowing of the maxillary arch. These claims being made almost universally among orofacial myologists, represent an example of why your commentary is so pertinent, challenging and truthful.
    A disclosure: I have a tongue-down rest posture with my tongue tip resting against the lower incisors. My entire orthodontic staff also reports having the same rest posture. In a pilot study that I did with an adult orthodontic group, the split between having a tongue-up or down-down rest posture was about 50/50. None of us with a tongue-down rest posture have reported any collapse of the maxilla or having developed any changes in dental alignment due to a tongue-down rest posture. I will also disclose that during swallows of food and/or liquid, my tongue tip never elevates or moves away from the rest position at the lower incisors. I find this to be a very efficient swallow pattern.
    It is a significant and sad reality that there has, to date, not been an epidemiological study of children, adolescents and adults to determine how many have one of four rest posture choices for the tongue, and the tongue tip. These potential rest positions include: a tongue up with the tip at the rugae; a tongue tip rest position at the distal surface of upper incisors; an interdental tongue rest position; and a tongue-tip at the lower incisors (or overlying gingiva on the distal side of the lower dentition).
    It is a poor reflection on those clinicians advocating for OMT with individuals with sleep apnea, that the assumption that the tongue-up rest position is natural, and preferred has no research support. Further, it is a shame that the assumption that a tongue-down rest posture is a dysfunctional position that will lead to maxillary narrowing and other perceived problems has not been confirmed in research studies. Those of us with normal occlusions who share the experience of having a tongue-down rest posture, are forgotten when the assumption of a tongue down rest posture being in need of change is discussed.
    The claim made that a tongue-up rest posture is the natural rest position for the tongue has been challenged by Schmidt, Carlson, Usery, and Quedevo, in their article: Effects of tongue position on mandibular muscle activity and heart rate function, in http://www.ooooe.net/article/S1079-2104(09)00532-0/abstractOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Volume 108, issue 6, pages 881-888, December 2009. The abstract is worth including here: “Objectives: A primary goal of pain management for muscle-related pain is to reduce masticatory muscle activity. This study aimed to investigate masticatory muscle group activity and heart rate variability change when the tongue was placed on the palate or the floor of the mouth in a healthy pain-free sample. Study design: Participants were 23 females and 18 males with a mean age of 19.6 years (standard deviation = 1.5). Muscle activity was measured using surface electromyography and heart period were measured using electrocardiography. The experimental protocol consisted of 3 periods: baseline, tongue placement on the floor of mouth, and tongue placement on palate. Results: Results indicated significantly more activity in the temporalis and suprahyoid muscle regions as well as a significant reduction in heart rate variability when the tongue was positioned on the palate compared with tongue position on the floor of the mouth. Conclusions: Instructions to place the tongue on the roof of the mouth are not instructions that will promote reduced physiological functioning (i.e., relaxation) but rather promote small, but potentially important increases in overall activity as indexed by muscle tone and cardiac function”.
    A noteworthy conclusion by these authors from surface EMG data is that a tongue-down rest position results in a more relaxed, more physiologic rest posture than a tongue-up rest position.

    In a study by Takahashi, Kuribayashi, Ono, Ishiwata, and Kuroda, titled: Modulation of Masticatory Muscle Activity by Tongue Position, in Angle Orthodontist, Vol 75, No 1, 2005, pages 35-39, their conclusions support the research of Schmidt et al as follows: “Furthermore, it has been emphasized that a patient with TMJ dysfunction should avoid lifting the tongue against the palate because this may lead to pain in the masticatory muscle or TMJ region”. Both studies advise against a tongue-up rest posture in the treatment of patients with TMJ dysfunction and orofacial muscle pain.

    The claims made by several colleagues responding to your honest and astute commentary, Eric, ignore several pertinent facts that challenge the view of unwanted changes in the dentition, and maxillary archform from a tongue-down rest posture: 1) One concept important for the stability of the dentition is the vertical rest position of the jaws (or freeway space). I first introduced this important concept to the literature in 2003 in the text by Hanson and Mason, Orofacial Myology: International Perspectives, Charles C. Thomas Publishers, Springfield, Il., 2003. A tongue-down rest posture, with a normal resting freeway space (2-3 mm at the molars, and 2-5 mm at the incisors) will not lead to any changes in the dentition; 2) It is a false assumption that a tongue-down rest position, with a normal vertical rest dimension (or freeway space), results in a loss of the resisting and balancing force of the posterior margins of the tongue against the competing pressures of the muscles of the cheeks. Even with an increase in the freeway space with the mandible being hinged open beyond the normal vertical rest dimension, it would take a very wide opening of the mandible to lose the tongue-cheeks maintenance of the position of the posterior maxillary dentition; and 3) A primary goal of MFT should be to establish or recapture a freeway space open at rest beyond the normal range, to one that is within the normal range of 2-3 mm at the molars. A clinical caveat: When an orthodontist makes a referral to an OMT for post-orthodontic relapse, a clinician should evaluate three rest postures: the freeway space, the rest posture of the tongue (either up or down, but not interdental), and whether there is lip competence. If there is lip incompetence, and the patient is over age 13 when lip competence should have been achieved through the natural vertical growth of the lips, then there may be some unresolved airway interference that the orthodontist had not addressed via referral to an ENT specialist or allergist. If, however, all three compoents are normal, with the patient having the ability to breathe nasally with lips together, then the orthodontist should be advised to look for other causes for the relapse.
    By the way, the tongue is not a prime “molder” of the hard palatal vault, as is often claimed. The research of Enlow and Hans in their classic text Essentials of Facial Growth, W.B. Saunders, Philadelphia, 1996, details how and why growth events above the hard palate account for the configuration of hard palatal vault and width, rather than a “molding” effect of the tongue.
    In summary, I applaud your commentary, Eric, on why myofunctional therapy does not have a solid scientific base – especially related to the medical condition of sleep apnea, and your call for research to support the many presumptions of myofunctional clinicians that remain untested. The almost-universal presumption that a tongue-up rest posture is the preferred rest position for the tongue is challenged here. As one with a tongue-down rest posture, this challenge includes the many other normal individuals who share this tongue position at rest.
    I remain hopeful that, following the much needed-research that should include establishing and testing evaluation and treatment protocols for individuals with sleep apnea, that there may eventually be a well-defined role for orofacial myofunctional clinicians with this medical condition. Until then, however, I remain skeptical of the premature advocacy for orofacial myologists to parti
    Dr. Eric: Many responding to your excellent and much-needed commentary on the lack of scientific research to support myofunctional therapy for individuals with sleep apnea, make the claim that a tongue tip-up rest position at the rugae is THE natural position for the tongue at rest, while a tongue-down rest position leads to narrowing of the maxillary arch. These claims being made almost universally among orofacial myologists, represent an example of why your commentary is so pertinent, challenging and truthful.
    A disclosure: I have a tongue-down rest posture with my tongue tip resting against the lower incisors. My entire orthodontic staff also reports having the same rest posture. In a pilot study that I did with an adult orthodontic group, the split between having a tongue-up or down-down rest posture was about 50/50. None of us with a tongue-down rest posture have reported any collapse of the maxilla or having developed any changes in dental alignment due to a tongue-down rest posture. I will also disclose that during swallows of food and/or liquid, my tongue tip never elevates or moves away from the rest position at the lower incisors. I find this to be a very efficient swallow pattern.
    It is a significant and sad reality that there has, to date, not been an epidemiological study of children, adolescents and adults to determine how many have one of four rest posture choices for the tongue, and the tongue tip. These potential rest positions include: a tongue up with the tip at the rugae; a tongue tip rest position at the distal surface of upper incisors; an interdental tongue rest position; and a tongue-tip at the lower incisors (or overlying gingiva on the distal side of the lower dentition).
    It is a poor reflection on those clinicians advocating for OMT with individuals with sleep apnea, that the assumption that the tongue-up rest position is natural, and preferred has no research support. Further, it is a shame that the assumption that a tongue-down rest posture is a dysfunctional position that will lead to maxillary narrowing and other perceived problems has not been confirmed in research studies. Those of us with normal occlusions who share the experience of having a tongue-down rest posture, are forgotten when the assumption of a tongue down rest posture being in need of change is discussed.
    The claim made that a tongue-up rest posture is the natural rest position for the tongue has been challenged by Schmidt, Carlson, Usery, and Quedevo, in their article: Effects of tongue position on mandibular muscle activity and heart rate function, in http://www.ooooe.net/article/S1079-2104(09)00532-0/abstractOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Volume 108, issue 6, pages 881-888, December 2009. The abstract is worth including here: “Objectives: A primary goal of pain management for muscle-related pain is to reduce masticatory muscle activity. This study aimed to investigate masticatory muscle group activity and heart rate variability change when the tongue was placed on the palate or the floor of the mouth in a healthy pain-free sample. Study design: Participants were 23 females and 18 males with a mean age of 19.6 years (standard deviation = 1.5). Muscle activity was measured using surface electromyography and heart period were measured using electrocardiography. The experimental protocol consisted of 3 periods: baseline, tongue placement on the floor of mouth, and tongue placement on palate. Results: Results indicated significantly more activity in the temporalis and suprahyoid muscle regions as well as a significant reduction in heart rate variability when the tongue was positioned on the palate compared with tongue position on the floor of the mouth. Conclusions: Instructions to place the tongue on the roof of the mouth are not instructions that will promote reduced physiological functioning (i.e., relaxation) but rather promote small, but potentially important increases in overall activity as indexed by muscle tone and cardiac function”.
    A noteworthy conclusion by these authors from surface EMG data is that a tongue-down rest position results in a more relaxed, more physiologic rest posture than a tongue-up rest position.

    In a study by Takahashi, Kuribayashi, Ono, Ishiwata, and Kuroda, titled: Modulation of Masticatory Muscle Activity by Tongue Position, in Angle Orthodontist, Vol 75, No 1, 2005, pages 35-39, their conclusions support the research of Schmidt et al as follows: “Furthermore, it has been emphasized that a patient with TMJ dysfunction should avoid lifting the tongue against the palate because this may lead to pain in the masticatory muscle or TMJ region”. Both studies advise against a tongue-up rest posture in the treatment of patients with TMJ dysfunction and orofacial muscle pain.

    The claims made by several colleagues responding to your honest and astute commentary, Eric, ignore several pertinent facts that challenge the view of unwanted changes in the dentition, and maxillary archform from a tongue-down rest posture: 1) One concept important for the stability of the dentition is the vertical rest position of the jaws (or freeway space). I first introduced this important concept to the literature in 2003 in the text by Hanson and Mason, Orofacial Myology: International Perspectives, Charles C. Thomas Publishers, Springfield, Il., 2003. A tongue-down rest posture, with a normal resting freeway space (2-3 mm at the molars, and 2-5 mm at the incisors) will not lead to any changes in the dentition; 2) It is a false assumption that a tongue-down rest position, with a normal vertical rest dimension (or freeway space), results in a loss of the resisting and balancing force of the posterior margins of the tongue against the competing pressures of the muscles of the cheeks. Even with an increase in the freeway space with the mandible being hinged open beyond the normal vertical rest dimension, it would take a very wide opening of the mandible to lose the tongue-cheeks maintenance of the position of the posterior maxillary dentition; and 3) A primary goal of MFT should be to establish or recapture a freeway space open at rest beyond the normal range, to one that is within the normal range of 2-3 mm at the molars. A clinical caveat: When an orthodontist makes a referral to an OMT for post-orthodontic relapse, a clinician should evaluate three rest postures: the freeway space, the rest posture of the tongue (either up or down, but not interdental), and whether there is lip competence. If there is lip incompetence, and the patient is over age 13 when lip competence should have been achieved through the natural vertical growth of the lips, then there may be some unresolved airway interference that the orthodontist had not addressed via referral to an ENT specialist or allergist. If, however, all three compoents are normal, with the patient having the ability to breathe nasally with lips together, then the orthodontist should be advised to look for other causes for the relapse.
    By the way, the tongue is not a prime “molder” of the hard palatal vault, as is often claimed. The research of Enlow and Hans in their classic text Essentials of Facial Growth, W.B. Saunders, Philadelphia, 1996, details how and why growth events above the hard palate account for the configuration of hard palatal vault and width, rather than a “molding” effect of the tongue.
    In summary, I applaud your commentary, Eric, on why myofunctional therapy does not have a solid scientific base – especially related to the medical condition of sleep apnea, and your call for research to support the many presumptions of myofunctional clinicians that remain untested. The almost-universal presumption that a tongue-up rest posture is the preferred rest position for the tongue is challenged here. As one with a tongue-down rest posture, this challenge includes the many other normal individuals who share this tongue position at rest.
    I remain hopeful that, following the much needed-research that should include establishing and testing evaluation and treatment protocols for individuals with sleep apnea, that there may eventually be a well-defined role for orofacial myofunctional clinicians with this medical condition. Until then, however, I remain skeptical of the premature advocacy for orofacial myologists to participate in the treatment of individuals with sleep apnea when so many referrals lack sufficient documentation of the morphological characteristics of those patients with sleep apnea that are presumed to have some problem with the rest position of the tongue, or have other problems in the oral cavity that would require MFT.

    • Dr. Kezirian says:

      Thank you for your detailed thoughts. Many of the comments to my post have clearly come from people with greater knowledge of the literature and experience in considering questions related to myofunctional therapy, skeletal growth, dental/orthodontic considerations, and many other topics. I thank everyone for raising my awareness of the real debate about myofunctional therapy and its potential role in treating obstructive sleep apnea. I share your hope that we will be able to learn more from careful scientific evaluation of many of these questions, and my sentiment that there is no clear evidence supporting a role for myofunctional therapy (at least as practiced by most/all in the United States) and frenuloplasty/frenectomy in the treatment of obstructive sleep apnea.

    • Meghan Wallblom, CCC-SLP says:

      Dr. Mason,

      Thank you for your comment and information. What about function? You have mentioned “2) It is a false assumption that a tongue-down rest position with a normal vertical rest demension (or freeway space), results in a loss of the resisting balancing force of the posterior margins of the tongue….”

      What about restricted oral tissue that could be contributing to the low tongue posture? As a pediatric SLP and mother of 5 children (4 with diagnosed ankyloglossia) I have observed in my son and in many pediatric clients with restricted lingual frenulums and low tongue resting posture the following functional deficits: 1.) an inability to bilaterally stabilize the posterior margins of the tongue in order to produce /r/ and or sibilants. This is evidenced by their switching back and forth unilaterally when instructed to try and “brace” the lateral margines of the tongue bilaterally and simultaneously on the insides of the upper molars as necessary to produce central airflow for sibilants. Electropalatography has shown that merely making contact with the upper molars for certain speech sounds such as /r/ and sibilants is not sufficient. When bilateral “anchoring” is not achieved lateral air escape on sibilants for example occurs, resulting in a “lisp”.

      Along with a low tongue resting posture, my son who is almost 8 and just had an anterior/posterior lingual frenulum release last year (by the 4th professional I took him to) has a dysfunctional oral phase of the swallow with his tongue moving anteriorly and down rather then posteriorly and back. He has a lateral /s/ and “sh”, distortion on “ch” and “j”. I have been working with him for years and noticed his posterior tongue is more flaccid then it should be. His /r/ is almost completely remediated now. Since his release he is able to stabilize bilaterally with the posterior margines of his tongue in a way he would shift from one side to the other when instructed prior.
      The difficulty he had with bilateral anchoring is consistent with what I have observed in my pediatric clients with the same speech errors, and swallowing patterns. I should add many, including my son, have difficulty forming a bolus due to difficulty lateralizing the tongue.

      I realize your post is regarding low vs. high resting posture of the tongue as it relates to the development of the boney structure of the oropharyngeal cavity. Because none of us spend all day in a rest posture, this can only be viewed like a “home row” as in typing and how our tongue functions the rest of the day when we eat, speak, and breath must play a role in form?

      It sounds like you have done your own research when it comes to tongue resting posture which I appreciate.

      I share my experience only to emphasize that where the tongue rests is perhaps one piece to a larger puzzle and to leave “function” out of the conversation would be amiss.

      Respectfully,

    • Robert Murdocco P.T.,CFC says:

      Dr. Mason
      In order to say the “tongue up position” caused increased muscle activity in the temporalis you would have to make sure your subject had a ” Normal” craniovertebral angle of 96-106 degrees. If your subjects had posterior cranial rotation from a forward head position( very possible for your entire staff to have this as I have seen it in many dental offices) this would cause elevated temporalis activity. Posterior head rotation and forward head posture would also encourage lower tongue position to open airway. I am curious to know if your have forward head posture( zyogomatic arch infront of sternal angle).

  • Daniele Merkov says:

    The problem is, when I go to sleep earlier I don’t get that full eight or nine hours; I usually wake up at 5 or 6 AM so I’m still getting the same amount of sleep I would if I was closing my eyes at 1 or 2 AM.I am aware that sleeping regimens need time to kick in with the cycle, but it’s been months now and I have no reprieve. Should I see a doctor? Take medication? Should i try taking medicinal cannabis like this one https://www.bonzaseeds.com/blog/cat-piss/ ??
    Sucks, man. By like 3 or 4 PM I start dozing off again, and I come home and I just want to take a nap. Lack of energy, which impacts my gym regimen and general welfare. I don’t want to do chores, or work, or even play video games in my down time because staring at the screen tires me out.

    • Dr. Kezirian says:

      You should see a doctor and discuss this. Medicinal cannabis can have many uses but would not be a first-line treatment for any sleep disorder. There is some limited evidence about cannabinoids (some of the chemicals in cannabis or synthetic chemicals that are similar to those found naturally) and improving sleep apnea in a very selected group of people with sleep apnea, but this research is very early and not something to recommend yet.

  • Bob Mason, DMD, PhD says:

    Meghan – I was, of course, referring to myself and the many others who have a tongue-down rest posture without a tethered lingual frenum. I appreciate that what you describe in your child is a much different situation that “obligates” your son to have a low tongue rest posture. We should not presume, however, that a low tongue posture without an accompanying restricted lingual frenum will always create the problem claimed by many.

    I appreciate your details report of your son’s difficulties and I am glad to know that his short lingual frenum has been released. I hope that he will continue to improve.

    Some additional comments: Even though your son swallows, with the tongue moving anteriorly and down, and if this movement pattern does not result in excess burping or aspiration of food, he has a physiologically normal swallow. I see this, and other similar swallow patterns, including an interdental tongue protrusion, in individuals with a small oral isthmus. To get food past the oral isthmus, some have to enlarge the area by protruding the tongue. As orthodontist/physiologist William Proffit has pointed out, there are up to 11 stages of swallowing from infancy to adulthood, and these changes in swallowing patterns are related to morphological changes in the oropharyngeal structures. (Examples are a short ramus of the mandible, spontaneous resorption/involution of faucial tonsils and adenoids, and increased vertical growth of the pharynx. By the way, Proffit and colleagues, using miniature oral pressure transducers, found that the posterior margin of the tongue contacts the lateral margin of the maxillary alveolus at the molars – on one side, but not both, during swallows. Also, a contact of the lateral posterior tongue on one side of the posterior maxilla is seen on many speech sound productions, such as /s/; thus, the posterior tongue – on one side only, acts as a hinge to stabilize the elevation of the tip during some speech sound productions.

    Another point related to your comment about the teeth being apart during the day – our teeth are in contact only 5% of the time, including all of the moments during eating, and during the rest of the 95% of each day and night, and, as you point out, the teeth are slightly parted (the interocclusal rest position, or the freeway space). While dentists and orthodontists evaluate the dentition with teeth together, orofacial myologists evaluate and focus on the 95% of the time when the teeth are apart. This distinguishes orofacial myofunctional clinicians from dentists and orthodontists. (This distinction should be marketed by OMTs).

    I appreciate your comments and agree that there can be other issues involved in various oral functions with a down rest position – for some individuals. For me, I continue to function well in speaking, chewing and swallowing starting from a tongue down rest position.

    • Meghan Wallblom, CCC-SLP says:

      Dr. Mason,

      Thank you very much for taking the time to respond.

      In terms of my son’s swallowing, he does not have excess burping and has no penetration or aspiration of liquids or solids. However, as an infant he had severe reflux (aerophagia) that was first treated with Zantac and when that didn’t help, Prevacid. At this point, no provider, including myself, assessed his lingual frenulum. That aeorphagia could be due to an interruption in the peristaltic wave like motion of the tongue needed for breast feeding (sucking) as described by ENT, Bobbi Gaheri, Portland OR, was not a concept I gleaned from my graduate training here in the U.S., nor was it a part of my undergraduate training here or in Australia.

      It is interesting that you noticed a co-morbidity in some of your patients with a small oral isthamus and an interdental tongue protrusion or anterior and down motion of the tongue when swallowing. I have noticed in many of my patients with this swallow pattern that they will also have a Mallampati III or IV of the oropharyngeal opening. After reviewing your article “The tongue thrust controversy background and recommendations”, Feb. 26, 2013 in the Journal of Speech and Hearing Disorders, I will pay more attention to the age of the client when I notice this phenomenon.

      Thank you for bringing the research and your collaboration with William Proffit to my attention. I am fascinated by the findings, “Whether the clinically defined tongue thrust swallow represents a detour in the normal road to adult swallowing or whether it represents a normal transition stage remains unclear (xxxix, 2)”.

      It was also interesting to read “If only resting pressures of tongue and lips are considered, a stronger relationship with dental arch form is observed, but it still appears the function adapts to form much more than form adapts to function (Subtenly, 1970).

      This is a varied assumption in the literature. For example, current research by Yoon, Zaghi, et.al note a short lingual frenulum as a phenotype for a high vaulted palate. This would imply the reverse (limited function, in this case affected form).

      Also, “a contact of the lateral margin of the maxillary alveolus at the molars on one side but not both during swallows” is interesting.

      You mentioned using miniature oral pressure transducers showed “Also, a contact of the lateral posterior tongue on one side of the posterior maxilla is seen on many speech sounds such as /s/, thus the posterior tongue on one side only, acts as a hinge to stabilize the elevation of the tip during some speech sound productions.”

      It would be interesting to combine your findings with the acoustical analysis research “In a separate lingual pressure study, it was found that for speakers with frontal lisps, the “th” sound appears to be an “s” substitution physiologically and acoustically (McGlove, Profitt 1973 b).

      Research conducted by Irene Marchesan (Brazilian, SLP) using acoustical analyses showed variations in the formants on /s/ production and other sibilants produced with the placement you’ve described. This could be because bilateral stabilization permits central airflow where unilateral stabilization would, by basic physics, cause lateral air escape on the opposing side. This would account for distortion of /s/ on lateral productions where a “th” replacement is not observed as in a “thrusted” or interdental production of /s/.

      On this note, it was news to me that there was a difference in what orthodontists refer to as a tongue thrust and what SLP’s define as a tongue thrust. From your article, “…That is the pressure patterns by frontal lispers on “th” for “s” substitutions were closer to the lingual pressures used by many tongue thrusters do not represent unnatural or excessive forces applied to the maxillary alveolus or anterior teeth but rather, an apparently simple substitution of one sound for another. On the basis of these data, cataloguing speech behavior as tongue thrusting by observing “th” for “s” substitution in a typical frontal lisp is questionable”.

      In my training as an SLP, an interdental production of /s/ would be described as a tongue thrust. Is this different to your training in 1965?

      In the case of my son, having had a restricted lingual frenulum most of his life, because it was missed by myself, the head of pediatrics at a local hospital, a general dentist, and a pediatric dentist has contributed to a co-morbidity with a “reverse” swallow and a lateral production (distortion not substitution) of sibilants. This distortion significantly impacts his overall speech intelligibility to the unfamiliar listener without contextual cues.

      The article “The tongue thrust controversy background and recommendations “, Journal of Speech and Hearing Disorders surmises, “Articulation therapy techniques involving phonetic placement may be particularly helpful in modifying speech errors in tongue thrusters while also re-positioning the tongue tip posteriorly”. This is how I was trained.

      The traditional way that I was trained and other SLP’s are trained in this country to catch a tongue-tie (attached on the tip of the tongue..limits protrusion and touching the left and right comissura) would never have and didn’t catch my son’s ankyloglossia. Apparently, this is true of other disciplines as well.

      In the case of a short lingual frenulum or posterior tongue-tie, as in my son, I tried the fore mentioned articulation therapy techniques until I was blue in the face and my son felt defeated. These techniques were never going to truly help him with his soft tissue restriction.

      I appreciate that you have clarified that you are referring to a low tongue posture in the absence of a tongue-tie.

      It is my humble opinion that as a profession, when it comes to “tongue-thrust” and or associated dysfunctional swallow, and a low tongue rest posture, we should be automatically screening for not just an anterior tongue tie, but a short lingual frenulum, and a posterior tongue tie.

      Myofunctional Sciences should be a mandatory course of learning in our graduate programs.

      These patients are ending up in the chairs of Myofunctional therapists after years of failed speech therapy both from the schools and privately.

      It is unacceptable to dismiss a child’s/patient’s concerns about their distorted speech because the “therapist” feels this is inconsequential or because it doesn’t overtly affect academics.

      In this particular area, I challenge any SLP reading this to complete further training in the screening of restricted oral tissues and study in Myofunctional Sciences if you have ever had a child on your case load that you wished would just move because you didn’t know what to do about his/her persistent lateral /s/, distortion on sibilants, or even not being stimulable for /r/.

      We must be patient-centered. Without this, what good is our therapy? Unfortunately, it took me as a mother trying to help my child to see this very real gap in our training as SLP’s in this country.

      I am very excited about and very hopeful for our profession in this area which is ripe for further research, collaboration, and most importantly higher standards of care for the individuals we serve with oromyofunctional disorders.

      Thank you again Dr. Mason for your information and for your kind thoughts for my son.

      Sincerely,

  • Suffering & Frustrated in Chicago says:

    Dr. Kezirian (or others),

    I’m in my late 30s. A few months ago I began and seeking treatment for TMJD and bruxism which led me down a journey of learning I have a tongue tie, am a mouth breather, and very likely have UARS. I personally feel my UARS could be the underlying cause of my bruxism and TMJD. The problem is I really don’t know what my team of specialists should be, which discipline should be the lead, and how to find and vet all of them. As a patient it feels like on one side you have people that just want to throw you in a CPAP or dental appliance, on another side it’s myo/cranio sacral/buteyko, on another side are surgeons, and maybe someplace in there are LVI dentists. I’d love to take the most natural, non-invasive approach possible but I also want to balance that with getting better, not allowing this to progress even further, and not being tied to doing myofunctional exercises 3x per day or a CPAP the rest of my life.

    What’s your advice to a patient trying to get a diagnosis and treatment?

    • Dr. Kezirian says:

      As my blog post indicates, myo/craniosacral/buteyko all are NOT proven for the treatment of obstructive sleep apnea. I would start with examinations by an ear, nose, and throat physician (ideally one with a focus in sleep surgery) as well as a dentist who has expertise in not only UARS/sleep apnea but also TMD/bruxism. Obviously, you can consider a sleep medicine evaluation and sleep study, although there may be some things that they could do before a sleep study. I understand your desire to avoid invasive treatments, and you should share this with everyone on your treatment team.

  • Brian Bivens says:

    Dr. Kezirian-

    I am a patient of Dr. Zaghi and Joy Moeller. My primary symptoms were throat pain, dry mouth in the morning, and vocal fatigue. I am almost finished with my MFT exercises and I received a frenuloplasty from Dr. Zaghi. I was not aware that I could also be suffering from sleep apnea, although my father has the condition as well. Since the surgery and exercises, I have improved significantly. My throat pain is gone and I have less vocal fatigue. I am no longer a mouth breather and now solely breathe through my nose. My wife says I no longer snore at night and she has not heard me hold my breathe or cease breathing at night. Perhaps I will do a sleep study to document my results. Therapists may vary in their implementation of MFT exercises, but I believe Joy Moeller seeks to create a unified approach and set of exercises throughout the entire MFT community. My exercises were pre-planned a year in advance and included postural retraining, tongue and mouth exercises, and a plan to maintain anatomical changes for the rest of my life. It is my hope that more studies will be done to validate this important work.

    • Dr. Kezirian says:

      It is great to hear that you have had a good result and relief of your symptoms. I am also so glad your snoring has improved, but it seems like you may not have had a sleep study before treatment to show that you had sleep apnea in the first place. I have seen many patients with sleep apnea with no benefit from treatment by these providers, and I am sure there are other people like you who have. I echo your desire for studies to validate this approach, and this is precisely the problem and the challenge I have put out there. Oral myofunctional therapy and frenuloplasty are unvalidated and without any research showing them to be viable options for adults with obstructive sleep apnea. Until there is some structure to the selection of exercises (pre-planned exercises are not a structured approach to treating patients) and some scientific evaluation, oral myofunctional therapy and frenuloplasty cannot be considered real options for adults with sleep apnea.

      • J says:

        I have had no benefit from frenuloplasty that I was strongly urged to have when I was in a vulnerable condition. It was not an appropriate procedure for me based on my symptoms. Despite doing the exercises, I now have pain daily. This is very upsetting. I don’t think myofunctional therapists are different than other doctors. Doctors have a protocol, and are blinded by it despite whomever is sitting in front of them. I was in a vulnerable condition and was basically told that getting my tongue cut (I did not have a tongue tie) would solve many of my problems. If more doctors were willing to say “I don’t know” “let me think about it” and “I encourage you research other solutions that feel right to you” the world would be a better place. For patients – based on my experience, DO NOT start with myofunctional therapy. Start with a qualified ENT. It might work for you as an adjunct to treatement, but it’s not a starting place.

  • Bennett Mui says:

    Dr Kezirian,
    Thank you for your scholarly comment. As a matter of fact, I really don’t see any problem with you comment. As doctors, our patients depend on us to recommend treatment that works for them. We own it to the patients to be critical to any new treatment modalities until they have proven themselves. The burden of proof is on the people who provide the treatment. There is nothing unfair about it that you point out some of these “new trends” can be seen as standard of care. In the meantime, I am looking forward to Dr Zaghi’s upcoming publication.

  • Elizabeth Dooher-Anthony says:

    Hi Dr.Kezerian-
    I am but a lowly dental hygienist, working in my field for 30 years. I recently took the introductory course from AOMT. There was a great deal of valuable information. As a clinician I can guarantee you that patients are much more interested in anecdotal evidence than science. They base their decisions on opinions/experiences from their family, friends and coworkers, and of course, Google.
    I am looking for more options to help my patients. Why should I not recommend and try a non-invasive, less costly treatment before getting into more expensive, surgical treatments and appliances?
    I get weary of feeling less-than because I want to help people.

    • Dr. Kezirian says:

      You are not a lowly dental hygienist. Do not dismiss your training and qualifications. Patients come to you for your advice and guidance. With a potentially-serious medical disorder like sleep apnea, we do not try things that have absolutely no scientific support. This is a challenge for everyone to come together and perform a real, proper evaluation of whether this is something that should be recommended. There are comments here and on the Facebook page (and in direct e-mails) from expert oral myofunctional therapists who have applauded me for writing my blog post and challenging colleagues to determine if something is useful before just recommending it. I could cite so many examples of cases where anecdotal evidence was not harmless and actually probably lead to deaths (post-menopausal estrogen therapy for all women as a way to “protect” against cardiovascular disease when it turns out that it actually increased the risk is one excellent example).

  • Renata Nehme says:

    Hello Dr. Kezirian!
    As a Brazilian citizen, it warms my heart to see the good of Brazil being portrayed by so many incredible physicians/dentists/professionals. Thank you for recognizing that. I do agree with you that we all need to follow what has been scientifically proven to work.
    I also cannot wait for a Masters Program in Orofacial Myofunctional Therapy, it will change the view of our profession drastically. Research studies are coming out of several countries in the world to aid in the credibility of myofunctional therapy. Hopefully more professionals will become interested to study the benefits of this therapy.
    With that being said, there aren’t any good scientific studies proving that flossing is beneficial to prevent decay. Am I a careless dental hygienist for recommending that to my patients?
    Warm regards,
    Renata Nehme, RDH, BSDH
    trained in Orofacial Myofunctional Therapy

    • Dr. Kezirian says:

      I appreciate your sarcasm, as I do have a sarcastic sense of humor too. There are no studies showing that wearing a parachute when jumping out of an airplane saves lives, either. Let us agree not to look for every absurd example. This is completely different. There is no (NO!) scientific study showing that OMT as practiced in the US has any benefit in treating adults with obstructive sleep apnea, a potentially-serious medical problem. I do not know the OMT literature, but I assume there is evidence to support treatment of many other conditions. If not, at least flossing does not take people away from performing other treatments that have been shown to prevent tooth decay (for example, brushing your teeth).

      Keep up the wonderful work in Brazil, and I wish you the best of luck in development of the Master’s program.

  • Linda D'Onofrio says:

    Hi Dr. K, I haven’t thought about this post in a while but a colleague just sent it to me and I was wondering if you’re still trashing American OMT practitioners. It looks like you are. I sure wish you’d stop lumping folks together because many of us provide evidence-based high quality services to our patients with great outcomes and have for years. I could say that American ENTs don’t understand oral function, but I don’t think it’s fair to lump all ENTs into the same group. I hope you had a chance to look at any of the 388 studies I sent your way and maybe one day we can continue our email conversation on this topic. Take care. You can reach me for further discussion if you like. Hope that Munich Sleep Conference went well and I didn’t ruin your sleep!

    • Dr. Kezirian says:

      We have communicated many times. This is obviously the same post from earlier this year, so I am not sure what you mean in your comment. I never trashed OMT practitioners and have highlighted the numerous areas where OMT has shown benefits (although I do not know your literature). What I have challenged your field to do (in a much gentler way than people of all backgrounds have challenged surgeons over the years) is to provide some evidence that OMT as practiced in the United States has any benefit for the treatment of adults with obstructive sleep anea. Right now, there is absolutely no evidence. I think it is not responsible to treat a potentially-serious medical condition with something that has absolutely no evidence. I fully believe that American (and all) OMT practitioners are good people. In fact, you hae indicated that you agree that treatment of obstructive sleep apnea without a clear protocol is not responsible. I actually think we agree on this.

      • Linda says:

        Just because you say there is no evidence doesn’t make your statement true. Just because you say something doesn’t work doesn’t make it true. I showed you research. You said it was low level. I showed you high level research. You didn’t like the studies. Waiting for a Level 1 Study to help a patient when I know that normalizing oral function reduces s/s is unethical. I’m letting this go because I can’t make a difference here. Good luck to you sir. You can reach me directly any time.

        • Dr. Kezirian says:

          I do not comment on anything about OMT other than the claims about treatment of OSA. This is not for oral function in general or the numerous areas where you sent me citations of research publications. I am also not waiting for a Level 1 study related to OSA. There simply are no studies at all about adults with OSA and use of OMT as practiced in the US. I think you are misunderstanding what I have written. Please feel free to reach out to me directly, as you have before. I do need to respond here on my blog because I want to be very clear here.

  • Marginne says:

    How do you feel when frenectomies and myofunctional therapies are only recommended as an adjunct to oral appliance therapy? I agree a tongue tie release alone won’t help with OSA, but I can see it totally enhancing any dental appliance that already helps to bring the mandible forward.

    • Dr. Kezirian says:

      There is no reason to believe that they would help with benefits from an oral appliance. To me, it seems that a frenectomy might actually reduce the benefit.

  • Peggy Hinkle says:

    Others have addressed issues with your post – I would only be echoing them.

    You seem to be firmly in the space of “contempt prior to investigation”, as well as relying on only one of the three legs of evidence based practice – “relevant research”. “Evidence Based Practice (EBP), as proposed by Sackett, involves the consideration of 3 equally weighted factors, the “pillars of EBP”, namely: Patient Values, Clinical Expertise and Relevant Research. Practicing true EBP requires clinicians to understand the interplay of these 3 factors, and to make judicious clinical decisions regarding the care of an individual patient based upon this knowledge.” “…[Sackett] is perhaps most appreciated by doctors for repeating his residency in medicine some 20 years after first training because, although a professor in the medical school, he “wasn’t a good enough doctor.”

    All I can say is thank heavens we now have the internet and social media so we as patients are not confined to opinions of physicians who choose not to learn.

    • Dr. Kezirian says:

      I believe that there should be some scientific basis to doing something, even if there is not the gold standard of a randomized trial supporting it. Let me just repeat that there is no scientific evidence supporting the use of OMT in treating obstructive sleep apnea in adults. If there were clinical experience showing benefit, then there should be some basic studies (even case reports) showing benefit. There are none. I am very familiar with evidence-based medicine. Evidence-based practice would indicate that OMT is not an appropriate treatment for adults with obstructive sleep apnea at this time. I assure you that I have the same skepticism with everything I do (including my own research areas). This is why we take clinical experience and observation and publish initial results, followed by more-rigorous investigation.

      In all the e-mails from those who have been unhappy with my issuing a challenge to the OMT field, there remains no evidence to support OMT in this specific area. I believe OMT is important and valuable in many areas, but obstructive sleep apnea in adults is not one of those areas at the present time.

  • Jason A Anderson says:

    As a practicing orthodontist, I find it absurd that myofunctional therapy has now become the new “en vogue” treatment for open bite malocclusions. The quality of evidence is very low to support this type of treatment. Even so, there has been an explosion of orthodontics and dentists (who practice orthodontics who are not orthodontists) who have been pushing this treatment on patients, while trashing the rest of the professionals who base their patients treatments on high quality research. This has been very frustrating. The motivation to treat in this manner is often financial. In addition, I believe that most graduates of medical and dental school today do not have the knowledge to be able to critically evaluate scientific research. Very sad.

  • Terri says:

    Dr. K,

    There are many of us who do NOT suffer from obstructive sleep apnea (OSA), but rather upper airway resistance while sleeping that could possibly be caused by the position of the tongue in those of us who have tongue ties. You state in one of your responses that your expertise is only in OSA. So it may be best if you don’t make conclusions about upper airway resistance that is NOT OSA. Not being able to sleep well is also a serious condition for those of us with upper airway resistance — it can still greatly reduce our quality of life and our health. It would be very helpful if, when someone writes to you about tongue ties and muscle exercises, if you could refer us to experts in the field of treating ***upper airway resistance while sleeping***. Thank you.

    • Dr. Kezirian says:

      Upper airway resistance syndrome is a variant of obstructive sleep apnea. My expertise is in sleep disordered breathing, ranging from snoring to obstructive sleep apnea and including upper airway resistance. There continues to be no evidence supporting the release of tongue ties as a treatment for any form of sleep disordered breathing, including upper airway resistance syndrome. Also, my post outlines the differences between the specific set of exercises studied in a Brazilian center and the completely different approaches to exercises used by those who advance myofunctional therapy. As I mention in my post, I believe that this approach is interesting but absolutely needs to be studied properly.

  • Matt says:

    Hi Dr. Kerizian,

    Thank you for your thoughts. I realize you wrote this article in 2018, but as always, it’s critical to have a dissenting opinion in any discussion so it can move forward towards truth and clearer understanding. I’m thankful you’ve provided this voice.

    With that said, I feel like you could’ve chosen better words here in the spirit of science. Specifically, in my opinion, you should say something along the lines of “there is *currently not yet enough* evidence to support OMT and frenuloplasty.” Phrasing it as an absolute, ie. “there is no evidence to support OMT and frenuloplasty” conveys that you are shutting down the whole field before the research has even been given the chance to progress.

    I agree with you that the evidence is currently lacking, but the cause for this is due to the fact that not enough studies have been done – not that sufficient studies have been done and found that these treatments make no difference.

    This is a critical distinction if we want to see the science play out in this emerging field of study. I strongly believe you ought to clarify this so you don’t risk closing the book on what has yet to be fully studied.

    • Dr. Kezirian says:

      Thank you for your comment. I have written another post in the last couple of months with exactly the same conclusion. I am sorry to say this, but I do not agree with you – and neither do other international leaders in the sleep community (from sleep medicine, dentistry, oral surgery, and otolaryngology – head and neck surgery). We have written an editorial on this in one of the top lung-related medical journals in the world (American Journal of Respiratory and Critical Care Medicine).
      It is absolutely correct to say that these are not proven treatments. There is absolutely no study supporting frenuloplasty as a treatment for sleep apnea, so I am amazed that people offer this to patients. As for myofunctional therapy, there are two studies with conflicting findings (one shows some benefit and the other shows none). As such, these are not proven treatments for sleep apnea. My feeling is that people are very eager to publish results for innovative treatments that work, so the absence of publications suggests that they do not work. I wrote this post in 2018 and was supported by many others within and outside my own field (including many myofunctional therapists), yet the only response from those who offer myofunctional therapy to patients with sleep apnea was mainly complaining without actually providing any evidence. In short, there has been lots of marketing of myofunctional therapy but no proof of benefit. I think it is not responsible to treat patients with a potentially-serious medical disorder using a treatment that is not proven at all.

  • Patrick says:

    Dr. Kezirian,

    Thank you for this article and your thoughtful replies throughout the comments. I find this entire discussion enlightening and about as true today as it was when it was written in 2018. It is unfortunate to admit that not much has changed as we are still seriously lacking in understanding of how to treat obstructive sleep apnea effectively and appropriately, and our knowledge of frenuloplasty or myofunctional therapy in this regard continues to be very lacking.

    I noticed that Dr. Zaghi chose to reply and allude to a forthcoming study of his while carefully choosing his words to say that frenuloplasty and myofunctional therapy improve “sleep and breathing issues”, and not specifically “sleep apnea”. And yet the above article he is responding to is solely about these treatments in relation to sleep apnea.

    With the benefit of now being able to read the work that he alluded to, (“Lingual Frenuloplasty With Myofunctional Therapy: Exploring Safety and Efficacy in 348 Cases”, 2019 DOI: 10.1002/lio2.297) he may have used such overly vague wording because the study did not objectively measure efficacy of either treatment. In fact, it did not measure their effects in a sleep apnea patient population at all. To be included in the study, a potential subject had to simply complain of one or more of the following: mouth breathing, snoring, dysfunctional swallow pattern, clenching, and/or myofascial pain or tension. No effort to select patients suffering from sleep problems was apparently made. The data collected was a simple questionnaire of self-reported satisfaction with the procedures, quality of life, and a binary improvement or failure to improve in various facets. How one could read these findings as supportive of oral myofunctional therapy or frenuloplasty’s usefulness in adult sleep apnea patients is unclear.

    As in the conclusion section: “…it should be emphasized that testimonials are not a scientific result and that long-term studies with objective findings are necessary to corroborate the findings of this preliminary report.” The aforementioned study and several others he has published have been performed within the purview of Stanford University. Given his extensive experience treating patients with these procedures, one would think that Dr. Zaghi is in a unique position to gather polysomnographic metrics from his patients and extend this preliminary report with objective findings specifically for sleep apnea patients.

    I am not being facetious when I say that I look forward to Dr. Zaghi’s research, as well as that of other investigators so that we may determine the truth about such treatments and their usefulness in sleep apnea patients. As you say, sleep apnea is a potentially serious medical condition. We have an incomplete scientific understanding of the disease and perhaps an even more incomplete understanding of how to properly treat it. Should novel treatments be demonstrated as reasonable and effective, they could be added to the list of sorely needed treatments for an undertreated sleep apnea population. We need more treatments.

    I have read numerous accounts of medical professionals in the replies on here, many of them who offer OMT or frenuloplasty and clearly have a vested interest in it being a scientifically valid treatment option. I would like to offer a different perspective. I have sleep disordered breathing and it has radically interrupted my life, with PAP therapy not giving me the relief I had hoped for. I, like many others in my situation, have limited time and resources, and I will be the first to admit that I am reasonably desperate for relief from my symptoms. I am aware that there are treatments available for adult sleep apnea patients that are demonstrably no better than placebo, such as buteyko breathing and tooth-borne rapid palatal expanders. I think it is incredibly important that we actively raise awareness of the uselessness (and in some cases the harm) that such “treatments” can do.

    However, regarding frenuloplasty and myofunctional therapy for adult sleep apnea patients, I agree with your assessment in that it is not proven, as opposed to provably useless. There have been some interesting investigations involving children, their development, and the frenulum linguae, but even there I have not seen anything resembling more than a correlation. And while it is true that children are in a unique position to influence the development of their craniofacial structures before their sutures fuse, adults are typically far beyond that part where only extreme mechanical interventions may prove useful. Given what we know about all these mechanics, it is only prudent to adopt the null hypothesis about the usefulness of these treatments in adults with heavy skepticism against it being rejected. I believe there does exist the possibility that some form of either of these treatments could be efficacious. However, I think there is a greater possibility that they are not very helpful, or not at all helpful, or that a very specific protocol is required to see any efficacy. I believe that the odds increase against their viability given that much time has passed since these procedures have entered the clinical research realm and we have not seen convincing evidence of efficacy.

    It is because of these serious doubts that I disagree with clinicians who encourage patients to undergo such procedures with the implication that it will improve their adult sleep apnea. While I am sure there are patients who are content to try a little bit of everything in the hopes that their situation will improve, I assume most are instead like me and want the best treatments offered up front so that progress can be made as quickly as possible to return to normal life. I think one of the unfortunate consequences of sleep apnea being a multifactorial disorder is that one must consult with a wide variety of types of doctors. Often, they are not too experienced and/or knowledgeable enough to recognize when the patient should be referred to another type of specialty, or they are unwilling to do so because they are overly confident, to a fault, in their own specialty’s ability to treat. If such treatments are to be offered by providers, I should hope they are forthright and explicit in how and risky it is to assume that an unproven treatment should work on adult sleep apnea patients. Yet something tells me this is often not the case.

    In fact, I personally know a few sleep apnea sufferers who were given reassurances about unviable or untested treatments that ended up costing them significant time and money with no improvement in their very serious disease to show for it. While not specifically about the aforementioned procedures, this is what one sleep apnea sufferer had to say about being sold on an unproven treatment by a provider: “Drained my account […] out of desperation. Now I don’t have the money to pursue anything else.” I hope this underscores the seriousness of directing patients towards provably efficacious treatments instead of the experimental and unknown. I have personally encountered providers who simply lacked expertise to point me in the right direction and found that to be frustrating. I cannot imagine how I would feel if a provider instead actively steered me towards a dead end.

    • Dr. Kezirian says:

      Patrick, thank you for your thoughtful comments. I also was disappointed in the publication that was advertised by Dr. Zaghi as showing so much yet showed nothing of any scientific value. We need to expect more before treatments (not just myofunctional therapy and frenuloplasty) are offered for a potentially serious medical disorder like obstructive sleep apnea.

  • Eric says:

    Not sleep apnea related but related to tongue ties and zaghis methods. 2 months ago I had a tongue tie release with the promise I would heal my tmj through the release and myofunctional therapy. I have been experiencing extreme jaw pain tmjd for 2 years now. I have been grinding my teeth so bad at night that my teeth have the wear down of a 70 year old at the age of 33. My tmjd has cause me a whole host of symptoms from fainting and lightheadedness, dizziness, heart arrhythmia and palpitations, panic attacks anxiety, fibromyalgia and chronic pain, head aches, confusion, degenerative disc disease in my neck;my c3 and c5 are smashed on top of each other.

    About 3 weeks after my release I felt amazing like a whole new person. The symptoms all mostly subsided. At week 5 they slowly started coming back, and here I am at 2 months post surgery and most of my symptoms have returned. My jaw hurts more than ever and I notice the tongue up position causes more jaw pain. The dr and therapist say my jaw hurts still and my symptoms returned because my upper jaw is severely under developed from the severe tongue tie I had. And since I have a new longer stronger tongue that it’s like fitting a semi truck in a single car parking garage. They want me to spend 10000$ to get an ALF appliance to expand my upper jaw and invisalign at the end.

    Before the myofunctional therapy route I went to a tmjd specialist and all he did was make me a custom night guard that held my mouth open at night. This only made this worse as my jaw fell backwards and I grind even harder on the appliance. His words were, “I don’t think you will get any better but I can help you not get worse.”

    My thing is.. I partly agree with what your saying that this is financially motivated. But what are we to do as a patient? I’d do anything to get rid of my fainting issues and chronic debilitating pain. Ive been down every road and every specialist, the best answers I found were that from the myofunctional therapist. But now 2 months after the release I’m having my doubts. I’m about 20% better if that after the surgery. Though for 2 weeks I truly did feel relief of all my symptoms. Why would I relapse back so quickly to how I felt before?

    Where do I go from here? Pay 10k for a what if? or accept the answer I’ll never get better and will keep fainting and feeling dizzy ect for the rest of my life?

    It seems there are no clear answers on tmjd. Myofunctional Therapy taught me it was my tongue tie and improper tongue resting position and function that is causing these symptoms and my under developed maxilla. Was told my tongue is supposed to support my jaw and that’s why I grind my teeth at night because my tongue wasn’t able to do it’s job. A part of me feels foolish for believing this.. but again I’ve had no answers from any other drs and specialists other than all tests come back normal, we cant find anything wrong, just reduce stress and here’s a night guard…

    I did find a recent article describing all the symptoms I am going through about the neck being a culprit in causing fainting and that prolotherapy has greatly helped in resolving the matter. Do you have any insight on prolotherapy and what drs do that kind of treatment?

    Sorry it’s a little off topic from sleep apnea, but I’m in desperate need of help and answers. Tha k you for any advice.

    • Dr. Kezirian says:

      I have seen a number of patients with some initial benefit. Just as can occur when surgery offers only short-term benefit like this, I would worry about a placebo effect rather than a real benefit. I would not recommend an ALF for sleep apnea, and it is unclear how this actually expands your upper jaw (it pulls on the teeth, and the studies mention tooth separation but not generally true growth of the jaw). I am not sure the myofunctional therapist provided “answers”, as you have not had relief. The ideas about tongue tie and tongue position are not proven, and trying to address that has not really offered much benefit for you. You should continue your search but remain skeptical, searching for real proof of what is being proposed to treat you.

  • Ali says:

    This article and the ensuing discussion are chock full of good information! Mainly that nobody, not even specialists like yourself, have any idea how to cure OSA in adult patients! That’s relieving to know because it means I’m looking in the right places. I wonder if the cropping up of a lucrative OMT market was the inevitable result of a dearth of research toward finding such a cure?

    What I’m saying, in no uncertain terms, is that if anybody can be reasonably expected to be at the forefront of scientific research in this field, it should be specialists like yourself. Yet sufferers of OSA, like Eric above, are told “You should continue your search”. Patients are neither doctors nor scientists and cannot be reasonably expected to determine what treatments will work best for them. They come to doctors like yourself to answer that question.

    Telling a sufferer of OSA to continue searching is not an acceptable answer for any professional to give. Instead, the current state of the research, that you are no-doubt leading, should be presented and recommendations made, if available. I saw a distinct lack of recommendations throughout this whole discussion. This could either mean there are no recommendations, or making such recommendations is not your priority. Both present us with grim outlooks.

    • Dr. Kezirian says:

      The challenge is that no treatment works well for everyone. This is why it would be absurd to make recommendations on a blog. I need to examine patients to see what might make the most sense for them. We are leading research to try to make everything more straightforward and effective. If you consider where things stood about 20 years ago when I started in this field, I would argue that we have had much greater advances in science and treatment than most other fields of medicine, especially when you consider that we are such a small group of people who focus in this area! We hear your concerns and will continue our work to use science to improve the health of our patients.

  • Dr Brenner says:

    Dr Kezirian et al,

    As I was previewing my patients for the coming week, I was reading a consult for an adult pt being referred for frenotomy to address his OSA. Being passionate about OSA, I was curious to find out more because this was the first referral I’ve gotten in 15 years for frenotomy in relation to OSA. This thread popped up as one of the top hits and I will say it had been a real pleasure reading through it and seeing some of the prominent names in the sleep medicine / surgery field. When reviewing other searches, a similarity stood out to me which I have seen before and wanted to discuss.

    Frenotomy procedures have been on the rise over the past decade prompting consensus statements form AAO and several articles addressing frenotomy and lip tie in pediatric patients. I have discussed the surge of frenotomy procedures with several leaders in the ENT community and all share a similar view. One of the driving forces behind this surge is peds dentistry and laser dentistry. If you google “frenotomy” or “tongue tie” the top hits will mostly be peds dentist offices or laser dentistry sites. I really feel that these industries are driving the numbers of frenotomies up.

    When reading about adult OSA and frenotomy, I see the same trend with most sites being laser dentistry offices.

    I have no doubt that frenotomy is effective for select infants having difficulty with breast feeding or toddlers having speech and articulation issues, but treating adults for OSA is a stretch and not supported by any peer reviewed research. The same goes for releasing upper lip ties or buccal ties in peds pts – there is no supporting research to suggest these procedures are helpful but they are done everyday.

    As dental offices look to expand uses for laser procedures, I would expect to see more referrals for frenotomy in OSA pts. The science is not there to support this procedure which is why there is a lack of research. Citing personal experience or a case series only published on La Leche website does not rise to the level of peer reviewed research. The intersection of medicine and money remains one of the most dangerous crossroads and we need to proceed with caution letting research, science, and experience guide us safely across.

    Again, thank you for all who have posted above, it was a real pleasure to read!

  • Anonymous Patient says:

    Hello Dr. Kezirian,

    I watched your lectures on your YouTube channel that summarized your sentiment in this blog post.

    I am a young adult patient with OSA and I have MMA planned for early next year. I have been recommended to do myofunctional therapy in tandem with MMA (pre-op and post-op). I also have a tongue tie and have been recommended to have a frenectomy in order to release it.

    I understand the sentiment that MFT + frenectomy is being provided haphazardly as a treatment option for OSA.

    However, what are your thoughts regarding MFT’s effectiveness when coordinated with other treatment modalities? Such as with my treatment plan of MMA?

    • Dr. Kezirian says:

      MFT may help with swallowing issues after MMA, but I do not know of any reason to do it in advance for improving sleep apnea outcomes. I am not an expert in MFT, and I would simply ask what evidence there is in support of it. I would be apprehensive if someone just tells you to rely on their own experience without a solid rationale and, ideally, some studies showing benefit. MFT has been studied for other conditions besides sleep apnea and snoring, and there are higher-quality studies than the the conjectures being “sold” to patients as evidence of benefit in sleep apnea and snoring.

  • Patient Patient says:

    Thank you for this open dialogue with prominent researchers and physicians in this field.

    I hope this blog thread is still active, as I have a scheduled laser frenotomy to cut my tongue tie (tied to the bone) and am having serious doubts.

    I’m in my twenties and do not have speech issues or sleep apnea per my sleep study results. I also don’t mouth-breath (at least while awake). I do have mild to moderate TMJ, which causes pain and stiffness in the jaw some days, and I have some stiffness/frequent popping of the neck.

    My MFT (my dentist referred me) is advising I get the frenotomy despite my normal sleep study results because of longer term issues that could arise (pain, dental problems, etc.) as well as the few current issues I mentioned.

    My question is: what are the downsides to a frenotomy besides the monetary cost? I understand there is a very small chance of permanent nerve damage, but are there any other serious risks to consider? Could the physiological changes due to a frenotomy actually cause sleep disordered breathing (if the frenum is holding the tongue, it seems that its release could cause the tongue to collapse into the airway)?

    The frenotomy is not very expensive, so my cost-benefit analysis is mostly focused on the presence and probabilities of the health benefits/costs. I would appreciate any input on the serious/long-term risks of a frenotomy.

    Thank you!

    • Dr. Kezirian says:

      Like myofunctional therapy itself, frenotomy is not studied in adults with obstructive sleep apnea (or at least results are not reported). Possible risks could include scarring, nerve injury, and worsening sleep apnea (if the tongue can now fall more easily to block breathing). Overall, patients need to know the real risks and benefits of any treatment for a potentially-serious medical problem like obstructive sleep apnea.

  • Lisa says:

    Hello,
    My now 14 year old had a frenectomy 2 years ago by a dentist to help with her nighttime bruxism. She was diagnosed with a tongue tie. After doing myofunctional therapy the ability of her tongue to reach the palate improved to the point that the SLP felt it was no longer indicated. The dentist preferred to do the least invasive approach which was to perform the frenectomy vs orthotics. He felt that there was minimal risk to doing a frenectomy. I seriously regret having him do it. Her bruxism and sleep worsened significantly so she now has terrible mood swings during the day. She is unable to sleep well and this has affected her quality of life terribly. I wish there was a way to reverse the procedure.

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