JSHD 3902 115-1

THE TONGUE THRUST CONTROVERSY:
BACKGROUND AND RECOMMENDATIONS
Robert M. Mason and William R. Proffit

University of Kentucky Medical Center, Lexington, Kentucky
This article reviews oral form and function interactions pertinent to tongue thrust
and provides guidelines for selecting cases and planning treatment. Anterior tongue
positioning during speech and swallowing, commonly called tongue thrusting, is
seen in about 50% of normal eight-year-old children. Open bite malocclusion, the
most frequent related dental problem, occurs in about 4%. Both percentages decline
with advancing years. Certain anatomical conditions, particularly related to
pharyngeal airway dimensions, predispose normal children to anterior tongue posi-
tioning which disappears during puberty. In these children, the tongue thrust is a
normal, if delayed, transition stage. In other children, it is a necessary adaptation.
Swallowing therapy is not indicated in the absence of speech or dental problems,
and, in our view, is not indicated before puberty. If tongue thrust and an associated
malocclusion persist to puberty, swallowing therapy may be indicated. The therapy
then is most effective when combined with orthodontic treatment to reposition
teeth, rather than preceding orthodontic treatment. Articulation therapy tech-
niques involvifig phonetic placement may be particularly helpful in modifying
speech errors in tongue thrusters while also repositioning the tongue tip posteriorly.
Speech pathologists and dentists frequently interact regarding clinical prob-

lems related to the controversial and ill-defined subject of "tongue thrusting."
There are a variety of opinions as to the effect of tongue thrusting on the
development of dental occlusion. Some individuals, advocates of "myofunc-
tional therapy," feel that uncorrected tongue thrusting during speech or
swallowing causes dental malocclusion in adults and children. Particularly,
they call it a primary etiologic factor in open bite and incisor protrusion
(Straub, 1951; Garliner, 1964; Hanson, 1967). Others doubt that tongue
thrusting in most cases is anything more than a normal developmental stage
(Ward et al., 1961; Brodie, 1952, 1962; Shelton, 1963; Bell and Hale, 1963;
Hoffman and Hotfman, 1965). Many speech clinicians are confused by a
lack of basic information they can use as a framework for making clinical
decisions (Shelton, 1970; Weinberg, 1970). In this paper, we review oral
form and function interactions pertinent to tongue thrust and provide guide-
lines the speech clinician can use in selecting cases and planning treatment.
115
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116 JOURNAL OF SPEECH A N D HEARING DISORDERS -- XXXlX, 2
A morphological reference point is essential in considering variables in oral

function. These functional variables are difficult to measure, and we have
used miniature pressure transducers to obtain physiologic measures pertinent
to mutual clinical problems. T h e data included in this report are a product
of our research findings using pressure transducers, in combination with data
from the literature and clinical experience.
WHAT IS T O N G U E THRUST?
At present, tongue thrust has no single title or definition. It is variously

referred to as tongue thrust (Hanson, 1967), tongue thrust swallow (Fletcher,
Casteel, and Bradley, 1961), visceral swallow (Ward et al., 1961), infantile
swallow (Leighton, 1960), reverse swallow (Barrett, 1961), deviant swallow
(Garliner, 1964), and tongue thrust syndrome (Palmer, 1962; Jann, Ward, and
Jann, 1964). The distinctions between tongue thrusting during speech and at
the onset of a swallow are often obscure in the research reported in the litera-
ture. Definitions of tongue thrust seem to vary according to the researcher
(Winitz, 1969).
The most frequent signs of tongue thrusting are said to be protrusion of
the tongue against or between the anterior teeth and excessive circumoral
muscle activity during deglutition (Weinberg, 1970). However, Rosenblum
(1963), Ardran and Kemp (1955), and Cleall (1965) have found these "ab-
normalities" in normal subjects. With such confusion surrounding the be-
haviors attributed to this condition, one can appreciate the dimculty re-
searchers encounter in defining and studying tongue thrust. Many of the
issues associated with tongue thrust have been discussed in recent review
papers by Weinberg (1970), Moorrees et al. (1971), and Christiansen (1971).
T o us, tongue thrusting is one or a combination of three conditions: (1)
during the initiation phase of a swallow, a forward gesture of the tongue
between the anterior teeth so that the tongue tip contacts the lower lip; (2)
during speech activities, fronting of the tongue between or against the
anterior teeth with the mandible hinged open (in phonetic contexts not in-
tended for such placements); and (3) at rest, the tongue carried forward in
the oral cavity with the mandible hinged slightly open and the tongue tip
against or between the anterior teeth. All of these conditions can be found
in individuals who have no speech or dental problems.
WHAT PROBLEMS ARE ASSOCIATED WITH TONGUE THRUST?
Dental Problems. Many clinicians identiEy tongue thrusting as associated

with specific dental malocclusions, especially incisor protrusion (as in Angle's
Class II, Division I malocclusion) and anterior open bite. It is therefore
valuable to examine the prevalence of these conditions.
Until recently, there were no accurate figures for the prevalence of dental
MASON, PROFFIT: THE TONGUE THRUST CONTROVERSY 117
malocclusion in children in the United States. T h e National Center for

Health Statistics is publishing a large-scale study assessing the dental occlusion
of children in the United States (in press). T h e U.S. Public Health Service
statistically designed and selected the sample of some 8000 children to allow
valid inferences about the health of a target population of approximately 24
million children, defined as noninstitutionalized children aged six to 11 years
living in the United States. T h e findings of this survey are especially pertinent
to the tongue thrust controversy.
In the USPHS survey, an open bite is judged to be present when the leading
edges of the upper incisors lie above those of the lowers so that there is no
overlap. In the sample, 5.7% of the children had an anterior open bite. There
was a strong influence of race in the survey-16.3% of black children had an
open bite, as opposed to only 3.9% of white children. T h e black children also
were more likely to have a clinically significant open bite that could affect
function and appearance. Of the black children, 9.6% had open bites measur-
ing 2 mm or more. Only 1.4% of the white children had an open bite of this
magnitude.
T h e data for the incidence of tongue thrust in children are not nearly as
good as those from the USPHS survey. Most observers agree, however, that
tongue thrusting is almost universal in infancy (Lewis and Counihan, 1965).
Also a relatively high percentage of children demonstrate these characteristics
when they begin school, and this percentage declines with advancing years.
Typical figures are those of Fletcher, Casteel, and Bradley (1961), who re-
ported that approximately 50% of children six years of age had a tongue
thrust, with this percentage declining to approximately 25% at age 15. Han-
son and Cohen (1973) showed similar findings. Even if these figures are dis-
counted as being incorrectly high, a clinically evident tongue thrust does not
necessarily coincide with an open bite malocclusion, and in fact most often
does not.
Since generations of clinicians have noted an association between sucking
habits, anterior tongue positioning, and open bite malocclusion, and since
such an association can be demonstrated statistically using data from the
USPHS survey, we do not mean to infer that there is no such association.
Rather we merely point out that the association does not automatically reveal
cause and effect. In this instance, it is apparent that tongue thrusting and
even thumb sucking (with a 10% prevalence found in the USPHS survey)
are much more prevalent than the open bite malocclusion they are said to
cause.
T h e fact that there may be a relationship between tongue thrusting, thumb
sucking, and open bites is reflected in the finding that most open bites are
self correcting when thumb sucking and tongue thrusting disappear. A
perspective about open bite self correction and tongue thrust is provided in a
report in the American Journal of Orthodontics by Worms, Meskin, and
Issacson (1971). These dentists studied the prevalence of open bite in 1408
118 JOURNAL OF SPEECH AND HEARING DISORDERS -- XXXlX, 2
Navajo children and inferred from cross-sectional data that there is ap-
parently a spontaneous correction of 80~o in anterior or simple open bite.
They contend that:
it would be extremely valuable if speech therapy techniques and interceptive cribs

designed for open-bite problems would be evaluated on a percentage-of-correction
basis. For instance, if a technique corrected open-bite in a certain percentage of the
open-bite cases, this percentage of correction should be greater than that which
occurs without treatment. In the case of simple open-bite in 7- to 9-year-old Navajo
boys, therapy would have to produce completely successful results in better than 80
percent of the children with open-bite in order to do better than nature and
maturity would do without therapy. One must be very careffil in taking credit for
correction of an open-bite. (1971, p. 594)
Clinicians also have been tempted to link the dental problem of maxillary
incisor protrusion to thumb-sucking and tongue-thrusting habits. Protrusion
of maxillary incisors is strongly related to t h u m b sucking that persists after
permanent incisors erupt, and this-was borne out by the USPHS survey as
well as by the research of Hanson and Cohen (1973). Approximately 17%
of all children, however, have excessive protrusion of upper incisors, a n u m b e r
which exceeds the percentages for t h u m b sucking and indicates that t h u m b
sucking is not the major cause of this condition. Genetic determinants of
jaw relationship are known to be a significant cause. T h e relationship, if any,
of tongue thrusting to incisor protrusion cannot be determined from present
data.
Speech Problems. Research reporting on tongue thrust and coincident
speech problems has been reviewed in several recent publications (Weinberg,
1970; Moorrees et al., 1971; Christiansen, 1971). Lisping and tongue thrusting
have been linked by some authors and w i t h o u t question do occur simultaneous-
ly in some children. These reviews of pertinent articles resulted in the con-
clusion, shared by Winitz (1969), that at present there are no definite or
predictable links between tongue thrusting and lisping.
We have conducted longitudinal lingual pressure studies of normal and
lisping subjects during swallowing and speaking tasks in our laboratory at
the University of Kentucky Medical Center. T h e design of the intraoral pres-
sure transducers used in much of this research is shown in Figure 1. Ex-
tremely small foil strain gages, carefully matched to the temperature co-
efficient of the beam on which they are mounted, have replaced the bulkier
wire strain gages of earlier days. T h e pressure transducers are designed to be
m o u n t e d in a thin plastic carrier, as shown in Figures 1 a n d 2.
Analogue pressure waves are produced by tongue or lip contacts with a
transducer. Pressures, duration of contact, area under the pressure curves
(time-pressure integral), and time relationships between pressure curves at
multiple recording locations may all be retrieved from the IBM 1800 computer
which is connected directly to the pressure-recording instruments. Develop-
ments in electronics in the late 1960s leading to improved stability of the
MASON, PROFFIT. THE TONGUE THRUST CONTROVERSY 119
Figure 1. Strain gage transducers mounted in a palatal appliance,

internal view. (A) foil strain gage at end of cantilever beam; (B)
calibration guide. (From Profflt, 1972.)
Figure 2. Palatal appliance containing five transducers, in a child's

mouth. (From ProMt, 1972.)
transducers and the amplifying system were necessary before this computer
application was possible. Only in the last few years has the instrumentation
itself reached a satisfactory stage of reliability and accuracy.
A sample of data obtained from pressure transducer studies is shown in
Figure 3. These data compare the pressure patterns of normal speakers and
two groups of lispers during production of the utterance/isi/ (McGlone and
Proffit, 1973b). The data reveal distinct differences between the subjects
40
tM
/isi /
D, nNORMAL
E
U O - - - - - - - .-O FRONTAL
:52 ~'- . . . . . - & L A T E R A L
r
o
v
24
.... "~'- ._.,//"
0 - "~ ~'"~ ~
I I i t t
RIGHT RIGHT CENTRAL LEFT LEFT
MOLAR CANINE INCISOR CANINE MOLAR
TRANSDUCER POSITION
Figure 3. Comparison of mean time-pressure integrals distributed around

the maxillary arch for utterances of /isi/ in three groups of subjects.
Statistically significant differences are indicated. (From McGIone and
Promt, 1973b.)
according to speech classification, as summarized in Figure 3. Some differences

in pressures during swallowing have also been noted. Frontal lispers are
much more similar to normal speakers in their speech utterances than are
lateral lispers (McGlone and Proffit, 1973b).
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
as well as acoustically (McGlone and Proftit, 1973a). T h a t is, the pressure
patterns used by frontal lispers on "th" for "s" substitutions were closer to
the lingual pressures used by normal subjects on "s" than "th." Thus, lingual
pressures used by many tongue thrusters do not represent unnatural or ex-
cessive 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 a
"th" for "s" substitution in a typical frontal lisp is questionable.
HOW DOES TONGUE THRUST LEAD TO DENTAL PROBLEMS?

Tongue thrust, as usually defined, does not typically lead to dental maloc-
clusion in the form of anterior open bite or protruding maxillary incisors.
MASON, PROFFIT:THE TONGUE THRUSTCONTROVERSY 121
Many clinicians have assumed that the pressures created by the tongue, in
conjunction with balancing pressures from the musculature of the lips,
strongly influence the position of the teeth (Weinstein et al., 1963). If this
were true, the pressure by a thrusting tongue could in itself lead to pro-
trusion of incisors.
Horizontal Pressure Components. Within the last decade, the advent of
miniature intraoral pressure measuring devices, such as shown in Figures 1
and 2, has allowed intraoral muscle pressures to be directly tested. It has been
observed that there is no balance of pressures against the teeth (Gould and
Picton, 1964; Lear and Moorrees, 1969; Proffit, Chastain, and Norton, 1969).
The expansive forces of the tongue are never balanced by the containing
forces of the lips, even when prolonged periods of time are considered (Lear
and Moorrees, 1969). T h e shape of the dental arches and the position of the
teeth within the dental arches seem to be little influenced by the horizontally
directed pressures of tongue and lips during functional activity such as
swallowing and speaking. If only resting pressures of tongue and lips are con-
sidered, a stronger relationship with dental arch form is observed, but it still
appears that function adapts to form much more than form adapts to func-
tion (Subtelny, 1970). We do not believe that the degree of protrusion of
incisors, for instance, is related to the amount of tongue pressure behind these
teeth pushing them forward. This belief is based on studies of North American
whites and Australian aboriginals. T h e teeth seem remarkably insensitive to
the tongue pressures of the type shown in Figure 3.
Vertical Growth and Adjustment Considerations. If the dentition of a
growing child is considered from a vertical or "tooth eruption" point of
view, the situation is somewhat different. Continuing eruption of teeth is
required to compensate for vertical growth of the face. T h e forces of eruption
of teeth are small, of a magnitude of 5 grams, and the factors that control
eruption remain essentially unknown. It is quite possible, though it has never
been demonstrated directly, that light forces produced by an anteriorly posi-
tioned tongue tip can impede eruption of incisors. If at the same time there
is no impediment to posterior eruption, an open bite would result. In this
sense, then, open bite malocclusion develops slowly as the posterior teeth,
without the tongue in their way, are freer to erupt than anterior teeth
(Protfit, 1973a). Accordingly, open bite malocclusion develops in a sequence
involving primarily the vertical, not the horizontal planes of space.
IS T O N G U E THRUST A HABIT?
Straub (1960) has described the presence of tongue tip activity between or
against the central incisors during the initiation of a swallow as an "abnormal
swallowing habit." Straub ascribes the etiology of this habit to bottle feeding
(1951, 1960). His evidence consists of records on 478 patients in his orthodontic
practice, only two of whom were breast-fed. T h e high statistical correlation
122 JOURNAL OF SPEECH A N D HEARING DISORDERS -- XXXIX, 2
between tongue thrust and the presence of bottle feeding led Straub to the
conclusion that "the abnormal swallowing habit has been found to be definitely
due to improper bottle feeding" (1960, p. 421). This conclusion appears to be
inappropriate. Many investigators have pointed out the problems associated
with assuming cause-effect relationships on the basis of correlation statistics
(Perkins and Curlee, 1969; Weinberg, 1970; Shelton, 1970). Furthermore, the
data reported on the incidence of bottle feeding in a recent study by Hanson
and Cohen (1973) do not support Straub's conclusion.
Whether tongue thrusting is a habit in the same sense that thumb sucking is,
has been the subject of considerable debate (Lewis and Counihan, 1965). T h e
question is important, because the therapeutic approach can be affected by the
decision as to whether one is dealing with a habit or with a more innate be-
havior pattern. Some insight into this can be achieved by examining the
swallowing pattern in infancy and comparing this pattern with the pattern in
older children and adults. The adult swallow is characterized, among other
things, by contact of the teeth as the jaws are brought together; relaxation of
the lips with little or no evident muscular activity; and placement of the tongue
tip against the palate behind the maxillary central incisors, where it remains
during the swallowing act. By no means do all "normal" adults swallow this
way (Subtelny, 1970). T h e swallow of an infant contrasts sharply with that of
an adult in these three areas. In the infant swallow, the jaws are apart with the
tongue filling the space between the gum pads or, later, the teeth; the lips are
active in sucking movements; and the tongue is placed out between the dental
ridges in contact with the lower lip and beneath the nipple which is being
sucked (Moyers, 1958, 1971). At first, lip activity is more prominent than
tongue movements. Bosma (1967) has called this phenomenon a front-to-back
maturation of the oral structures, with lip "maturation" preceding that of the
tongue. Later in infancy, increasing tongue movements are seen but the
tongue-to-lower-lip apposition remains.
Without doubt, there are many transition stages between the initial infantile
type of swallow and the adult pattern (Proffit and Norton, 1970). 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.
If an open bite is to be created (or at least facilitated) by anterior tongue
positioning, as mentioned by Tulley (1969), the posterior teeth would have
to be brought closer together during a swallow while the tongue tip remains
between the incisor teeth. A transition swallow of this type, which resembles
the traditional description of tongue-thrust swallowing, has in fact been
observed in children who are developing normally (Proffit, 1972). T h e transi-
tion from an infant-like swallow toward an adult swallow appears to be
delayed, however, by a thumb-sucking habit. As long as a child sucks his
thumb he is almost certain to have a tongue-thrust swallow. Given the high
percentage of tongue-thrust swallowers in groups of young children, it seems
likely that most of these children are in a normal transition stage. Some chil-
dren who suck their thumb, and create an open bite in doing so, may maintain
that open bite with the tongue as puberty approaches. In these individuals,
the tongue positioning may in fact be a classic habit.
WHAT ANATOMICAL AND DEVELOPMENTAL FACTORS

P R E D I S P O S E TO T O N G U E THRUSTING?
With a few exceptions (Hoffman and Hoffman, 1965; Subtelny, 1970;

Moorrees et al., 1971; Christiansen, 1971; Speidel, Isaacson, and Worms, 1972;
Mason, 1973), little attention has been focused on the growth and development
of the head and neck in relation to tongue thrust. Most researchers have treated
anterior movements of the tongue as the main offender, failing to take into
account that this is but a small part of the dynamic orofacial complex.
Anatomical factors in some cases can account for the tongue positioning
(Weinberg, 1970).
Growth Differential Between Tongue and Jaws. The tongue follows the
growth curve established for the neural tissues of the body (Figure 4) in that
it grows fairly'steadily and approaches maximum size at or near age eight
years (Brodie, I952, 1962). The mandible grows more slowly, tapers off to a
plateau generally between age eight and 12 years, and then undergoes pubertal
and postpubertal growth. Some mandibular growth is seen even into and past
the twenties. The growth of the mandible follows the general body curve as
seen in Figure 4. The clinical implication of the growth differential between
the tongue and mandible is a natural tendency for the tongue to be positioned
relatively high and forward in the oral cavity in the early years of growth
(Subtelny, 1970).
Adequacy o[ Airway. Since an adequate airway is essential for life, respira-
tory demands strongly affect tongue and jaw position. The initial resting
position of the tongue, from which swallowing and speaking movements
begin, is established along with the airway (Bosma, 1967). Anterior tongue
position can result from airway problems both in the nose and in the pharynx.
Lymphoid tissue grows quickly in children, reaches a maximum before
puberty, and then regresses (Figure 4). Although Scammon's (1930) curve for
lymphoid growth did not consider the tonsils and adenoids, recent research
indicates that the growth and involution of tonsils and adenoids conforms
generally to Scammon's curve for thymus lymph nodes and intestinal lymphoid
masses (Handelman, Pruzansky, and Mason, 1966). Parenthetically, it should
also be noted that the inception of puberty, as represented by the growth spurt
for genital tissues seen in Figure 4, occurs two years earlier than it did in 1930.
Scammon's curve for genital tissue growth shown in Figure 4 should be
corrected for this.
Prominent tonsils in eight- to 10-year-old children are a common finding.
These children may have to carry the tongue forward and hinge the mandible
124 JOURNAL OF SPEECH AND HEARING DISORDERS -- XXXIX, 2
200
f'x
I
150 I \ --- LYMPHOID
/ \ -- --NEURAL
w /
o \ " - - TONGUE
< I X
F-z 100 / ....C._.._..~, , . . _ ..f_
. ~ .. ~
,,_
§ + + MANDIBLE
Q: / L; _§ ; I----GENITAL
"" 50 "-~" ++++~" / I
I
o -".-:---',-- . .
B 4 8 12 16 20
AGE IN YEARS
Figure 4. Main types of postnatal growth of the various parts and organs
of the body. Lymphoid, neural, general body, and genital types a~ter
$cammon (1930). Growth of the mandible and tongue extrapolated from
data by Brodie (1952, 1961, 1962), Bjork (1963), and D. G. Woodside
(unpublished materials from the Burlington Research Centre, Toronto,
Canada, 1970).
open to provide mechanical clearance for breathing and swallowing. This is

the typical association with the tonsils found in clinically identified cases of
mouth breathing. If the throat is chronically inflamed and sore, the tendency
to carry the tongue low and forward, to reduce contact with the sore area, is
reinforced.
Excessive adenoid tissue proliferation before puberty is one cause of nasal
respiratory obstruction in children. Chronic allergic conditions, nasal infec-
tions, and mechanical blockage by turbinates or a deviated nasal septum also
can lead to chronic mouth breathing. The resulting respiratory obstruction
syndrome (Ricketts, 1968) includes tongue thrusting and malocclusion. To
open the oral airway, it is necessary to carry the tongue low and forward
and the mandible at a lower-than-normal rest position. The tongue thrust in
this situation is only one of several related factors, and the key to its resolution
is correction of the respiratory problem.
Adaptation o[ Function to Form. That tongue position does adapt dra-
matically to changed respiratory demands is shown by experience with patients
who have had surgical jaw repositioning. These procedures almost always
reduce the volume of the oral cavity.
If the lower jaw is positioned posteriorly, the tongue is carried posteriorly
also, and might be expected to block the airway. This does not happen. In-
stead, the airway is maintained and the tongue is repositioned downward and
forward as necessary to accomplish this. After such surgery, the resting length
of all the hyoid musculature is apparently altered, as the hyoid bone assumes
a new position consistent with airway maintenance (Wickwire, White, and
Proffit, 1972). Speech quality is not changed and lingual pressure patterns
during articulation are maintained (Mason et al., 1972). Pressures during
swallowing are often increased postoperatively, but in most patients they
stabilize at normal levels during the year following surgery (Proffit, 1973b).
Speech adaptation is both quicker and more complete than swallowing, but
relapse of tooth position related to failure of physiologic adaptation occurs
in only a small percentage of patients. T h e changes in oral morphology with
conventional orthodontic treatment are slower, but similar adaptations of
tongue position usually occur (Subtelny, 1970).
Developmental Sequence of Swallow Patterns, Related to Growth. Many
tongue thrusters evolve into a normal adult swallow pattern between eight
and 12 years of age without therapy (Tulley, 1961; Proffit, 1972). This is shown
clearly by the declining percentage of children reported to have a tongue
thrust. T h e transition has been observed directly in children whose pressure
patterns were being studied longitudinally (Proffit, 1979).
The adaptation from tongue-thrust swallow to normal adult swallow appears
to be related to increases in the size of the oropharyngeal air space. Cavity
size increases during puberty can be linked to growth in the ramus of the
mandible with accompanying downward shift of the tongue in the oral cavity;
diminution in the amount of lymphoid tissue in the pharynx as a function
of normal involution of the tonsils and adenoids; and vertical growth of the
bodies of the cervical vertebrae, thereby increasing the available space in the
oropharynx (Brodie, 1952, 1961, 1962; Bench, 1963, Ricketts, 1968; Mason,
1973). In response to these morphological changes, the tongue is able to assume
a more posterior resting position in the oral cavity, resulting in closer approxi-
mation of the dental arches.
Innervation Patterns of Tongue and Oral Gavity. The pattern of sensory
innervation of the tongue and oral mucosa, and the earlier neurophysiologic
maturation of anteriorly directed tongue movements, also explain why fronting
of the tongue is more prominent in younger than older children. T h e richer
distribution of sensory nerve endings in the front of the mouth (Dixon, 1969;
Grossman and Hattis, 1967) encourages fronting of the tongue tip as a means
of generating tactile feedback. The universal emergency of bilabial and
lingual-alveolar consonant sounds at early ages in the speech acquisition
sequence lends credence to this association. Also it is well known that the
primitive neuromotor pattern of the tongue is an anteriorly directed gesture.
Even a child with a neuromotor deficit can usually protrude his tongue to
some degree, whereas he may not be able to elevate the tongue tip with any
control or effectiveness (Shelton, Haskins, and Bosma, 1959). Consequently,
fronting activity of the tongue in infants is a normal, rudimentary gesture
which may be further encouraged or habituated by the sensory feedback
systems involved or by a small airway space. This reasoning appears consistent

with the discussion and research reported by Hardy (1970), Fletcher (1970),
and Moyers (1971).
Altogether, tongue thrusting during speech or swallowing in some children
can be viewed as an adaptive behavior related to morphologic variations in
the mouth and pharynx. It can also be tied in with neuromotor patterning
rooted in the individual's interpretation of feedback experiences, especially
related to the sensory receptors in the tongue. The common definitions of
tongue thrusting, including those in this article, almost surely cause this label
to be applied to normal developmental stages which spontaneously change to
adult patterns o[ tongue behavior. It becomes important, there[ore, to evaluate
possible predisposing factors which may require a child under 12 to carry the
tongue anteriorly but which will allow spontaneous remission of the anterior
tongue positioning with further growth and development. This is highlighted
by the finding of a de.velopmental factor which produced spontaneous correc-
tion of 80% of the simple open bites in a large sample of children.
WHAT IS T H E ROLE OF THE SPEECH CLINICIAN IN

"MYOFUNCTONAL THERAPY" FOR TONGUE THRUST?
Tongue Thrust with Associated Speech Problems Only. When tongue-thrust
swallow and speech problems coexist, one should not assume a causal link
one to the other (Subtelny, Mestre, and Subtelny, 1964; Weinberg, 1970). The
neural control of speech and nonspeech activities in the central nervous
system appears to be different; hence, swallowing is probably not neurologically
related to speech, or vice versa. Differences between speech and nonspeech
movements of the articulators have been demonstrated by a number of investi-
gators (Hixon and Hardy, 1964; Murphy, 1966; Shelton et al., 1966).
When tongue thrusting is associated with lisping, the speech clinician should
be encouraged to correct the speech problem in the elementary school years,
using articulation therapy techniques. Such therapy can be initiated according
to the regular considerations employed by speech clinicians, and without
regard for whether the child will eventually require orthodontic treatment.
Although several clinicians have suggested specific techniques for lisping
tongue thrusters (Barrett, 1961; Hanson, 1967; Lewis, 1971), we do not feel
that the clinical diagnosis of tongue thrusting necessitates a special speech
therapeutic approach. Tongue thrusters have lisps associated with production
errors rather than discrimination errors. Accordingly, a speech therapy empha-
sis on adapti'ce phonetic placement techniques is recommended as especially
appropriate for such patients.
Where the prepubertal child with speech errors also exhibits a tongue-thrust
swallow, it may be tempting to work on swallowing patterns concurrent with
speech therapy. It has been our experience that this is usually unnecessary and
contraindicated. Articulation therapy promotes repositioning of the tongue
tip at rest and for the initiation of speaking and swallowing tasks in young
children. Most of the time, the tongue-thrust swallow will correct itself with
additional maturity.
Tongue Thrust with Malocclusion But No Speech Problem. If malocclusion
exists in a child who has a tongue thrust but no speech problem, the orthodon-
tist has a choice: He can begin the treatment of the malocclusion hoping that
the tongue activity associated with it will disappear as the anatomical situation
is corrected, or he can attempt to change the tongue-thrust pattern before
beginning orthodontic treatment. Some orthodontists in the past have elected
the second course and have called upon speech clinicians to assist with these
children to teach them a more adult swallow pattern. T h e first course now
seems to have been demonstrated to be the better clinical orthodontic ap-
proach, however. Correction of the malocclusion usually will result in disap-
pearance of the tongue-thrust swallowing pattern without any particular
therapy being directed at the tongue thrust. If any therapy aimed at altering
the swallowing pattern is employed in these patients, it is better that it be
done in conjunction with orthodontic treatment rather than preceding it
(Reitan, 1969; Graber, 1969; Begg and,Kessling, 1971; Hamilton1). This takes
advantage of the natural tendency of function to adapt to form.
Tongue Thrust with Malocclusion and a Speech Problem. When speech
therapy and orthodontic treatment for open bites are carried out concurrently
in pubertal and postpubertal cases, it may be desirable to modify the resting
posture of the tongue. The tongue positioning exercises employed in classic
"myofunctional therapy" can be helpful. Articulation therapy techniques
involving adaptive phonetic placements are also useful in repositioning the
tongue tip posteriorward in these individuals.
When tongue thrusting is related to airway problems, the tongue is expected
to adapt with a forward gesture to initiate a swallow so that the bolus of food
can be accommodated through the faucial isthmus (Moyers, 1958). This is a
natural adaptation rather than an abnormal behavior for such a child (Brodie,
1962; Hoffman and Hoffman, 1965). Therefore, swallowing exercises should be
especially avoided in cases where faucial isthmus size is reduced.
With or without a concurrent speech problem, tongue thrusting associated
with airway maintenance problems might be etiologically related to hyper-
trophied tonsils and adenoids. Any decision for adenotonsillectomy should be
made by a physician for physical complaints rather than for speech or tongue-
thrusting variations. Our view is to permit growth and development to run
its course when tonsils and'-adenoids are intact. If the tonsils and adenoids
are removed for medical reasons, we suggest giving the child time to adapt to
a normal adult swallow up through the puberty range before recommending
swallowing therapy.
1E. H. Hamilton, Jr., personal communication regarding longitudinal records from Knox.
ville, Tennessee, and Lexington, Kentucky (1973).
In our opinion, the utility of swallowing therapies with elementary school-

age children is questionable. This view is shared by many others (Tulley, 1961;
Shriner, 1966; Speidel, Isaacson, and Worms, 1972). Experience with electro-
myography, cinefluoroscopy, and lingual pressure transducers indicates that
children are much more variable in their swallowing patterns than the adult
population. Variability appears to be a primary attribute of school-age
swallowing patterns. As a child becomes older, variability decreases concurrent
with the normal transition to adult swallowing. We have already pointed out
that at this same time in the growth pattern of the child, spontaneous remission
of open bite is also seen as a consequence of developmental progression into
adolescence. Accordingly, we do not recommend swallowing therapy before
puberty, even if speech therapy or orthodontics is begun.
Orthodontic treatment procedures may create temporary relapse of some
speech skills that have been developed previously. T h e orthodontist need not
fear creating long-range speech problems by orthodontic treatment, nor should
the speech clinician be discouraged from continuing with therapy while the
child is receiving orthodontic treatment. Most children adapt quickly to the
reduction in articulatory proficiency sometimes brought about by orthodontics.
In those instances where the child does not adapt as readily, it is logical to
provide speech therapy to aid in this adaptation necessitated by changes in
tooth position. It makes little sense to wait for the completion of orthodontic
work to start therapy on any associated speech problems.
Tongue Thrust Alone, No Other Problems. T h e only rationale for myo-
functional therapy for the child with a tongue thrust who has neither speech
problems nor a malocclusion would be that this therapy would prevent
development of such problems in the future. There is no evidence that speech
problems will develop in a child who has normal speech because he or she
has a tongue-thrust swallow. Nor is there evidence that an open bite malocclu-
sion will develop where one does not already exist because of a prominent
tongue during swallowing (Subtelny, 1965). T h e percentages for open bite
and tongue thrusting are eloquent evidence on this point. Therefore, there
is no reason to recommend any treatment for children who have a tongue-thrust
swallow without evidence of accompanying problems. Such children will almost
surely complete the transition to a normal adult swallow on their own and
will not develop any dental or speech problems in the meantime (Brodie, 1961;
Proffit, 1972).
SUMMARY AND RECOMMENDATIONS
T h e controversy surrounding tongue thrust focuses on whether tongue

thrusting behavior has a deleterious effect on dental occlusion or whether it
is a normal developmental stage requiring no therapeutic intervention. Our
view is that in most cases the latter situation is involved. T h e dentition is
relatively insensitive to the pressure imbalance between the tongue and lips
as documented in normal subjects and various classes of lispers and tongue

thrusters. Instead, malocclusions related to the tongue develop as tooth erup-
tion is influenced differently for anterior and posterior teeth. There is a
constellation of morphologic findings which can explain the presence of tongue
thrusting in school-age children. Of particular importance is the airway space
in the pharynx and at the level of the faucial isthmus. Reduction in airway
space encourages anterior tongue positioning as an adaptation to the airway
maintenance problem. Since involution of lymphoid tissue starting in puberty
helps to relieve airway problems, there are morphologic as well as physiologic
reasons to anticipate changes in swallowing pattern in early adolescence. Ap-
proximately 80% of children who have a tongue thrust and anterior open bite
at age eight show improvement without therapy by age 12.
We offer the following recommendations as aids to speech clinicians for
making decisions about myofunctional therapy:
1. Such therapy is not indicated for children who do not have a malocclusion
or a speech problem.
2. Even in the presence of malocclusion, therapeutic intervention for
swallowing variations is not indicated prior to puberty (maturational age is
more important than chronological age). In the event that the transition from
tongue-thrust swallow to a normal adult swallow does not take place by the
beginning of puberty, swallowing therapy is probably indicated.
3. When swallowing therapy is indicated, it is most effective when combined
with orthodontic treatment to reposition teeth. The lack of effectiveness of
swallowing therapy without supportive dental treatment should discourage
speech clinicians from assuming sole responsibility for the swallowing problem.
4. When lisping and tongue thrusting or malocclusion coexist before
puberty, we recommend initiating speech therapy in spite of concurrent prob-
lems. Adaptive articulation therapy techniques emphasizing phonetic place-
ments are especially recommended as a means of correcting speech errors and
modifying resting tongue position in prepubertal children. Classic myofunc-
tional therapy techniques are of little additional help and are contraindicated
if airway size at the faucial isthmus is reduced.
5. For those older children with speech problems for whom orthodontic
treatment for open bite is carried out, and in whom it is desirable to modify
anterior resting posture of the tongue, the techniques of myofunctional, therapy
are useful. Articulation therapy techniques involving phonetic placement may
also be particularly helpful in repositioning the tongue tip posteriorward.
ACKNOWLEDGMENT
At the time this article was submitted for publication, Robert M. Mason was an associate
professor in the Departments of Special Education and Orthodontics and academic program
director of speech pathology and audiology at the University of Kentucky.
William R. Profllt
was chairman of the Department of Orthodontics at the University of Kentucky. Currently,
Mason teaches part time in the Department of Orthodontics and is a dental student at the
130 JOURNAL OF SPEECH AND HEARING DISORDERS -- XXXIX, 2
University of Kentucky College of Dentistry. Proflit is chairman of pediatric dentistry and

professor of orthodontics at the University of Florida in Gainesville. Requests for reprints
should be addressed to Robert M. Mason, Department of Orthodontics, University of Kentucky
Medical Center, Lexington, Kentucky 40506.
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Received August 2, 1973.

Accepted September 12, 1973.

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THE TONGUE THRUST CONTROVERSY:

BACKGROUND AND RECOMMENDATIONS

Robert M. Mason and William R. Proffit

Speech pathologists and dentists frequently interact regarding clinical prob-

A morphological reference point is essential in considering variables in oral

At present, tongue thrust has no single title or definition. It is variously

WHAT PROBLEMS ARE ASSOCIATED WITH TONGUE THRUST?

Dental Problems. Many clinicians identiEy tongue thrusting as associated

malocclusion in children in the United States. T h e National Center for

it would be extremely valuable if speech therapy techniques and interceptive cribs

Figure 1. Strain gage transducers mounted in a palatal appliance,

Figure 2. Palatal appliance containing five transducers, in a child's

.... "~'- ._.,//"

Figure 3. Comparison of mean time-pressure integrals distributed around

according to speech classification, as summarized in Figure 3. Some differences

HOW DOES TONGUE THRUST LEAD TO DENTAL PROBLEMS?

WHAT ANATOMICAL AND DEVELOPMENTAL FACTORS

With a few exceptions (Hoffman and Hoffman, 1965; Subtelny, 1970;

open to provide mechanical clearance for breathing and swallowing. This is

systems involved or by a small airway space. This reasoning appears consistent

WHAT IS T H E ROLE OF THE SPEECH CLINICIAN IN

In our opinion, the utility of swallowing therapies with elementary school-

SUMMARY AND RECOMMENDATIONS

T h e controversy surrounding tongue thrust focuses on whether tongue

as documented in normal subjects and various classes of lispers and tongue

University of Kentucky College of Dentistry. Proflit is chairman of pediatric dentistry and

J. Speech Hearing Dis., 29, 293-306 (1964).

Received August 2, 1973.

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