Mastering the Myo Merge: The Importance and Essentials in Implementation in the Dental Office

by Karese Laguerre, RDH

Sleep and airway focused dentistry have been estimated to be a $6 billion global industry and has seen rapid growth since COVID-19.While airway is comprised of much more than just sleep, this is outstanding news for the profession. Piqued interest and awareness mean that there are new options for growth in one’s professional life and in practices of collaborative care amongst professionals.

Having a trusted network of professionals is essential

The soft tissues of the cranium have the all-important job of supporting facial growth and impacting the trajectory of dental arch development.¹ The function of these muscles is often overlooked unless a patient presents with orofacial pain or discomfort. Yet, they have a direct impact on the services one provides and the oral appliances prescribed. At the convergence of frustration and discovery lies an underutilized service that can be incorporated into the sleep dentistry practice to meet the needs of both the patient and the provider.

Orofacial myofunctional therapy is an individualized program of exercise and re-training for muscles of the orofacial complex. Strengthening these muscles reduces the collapsibility of the upper respiratory tract that allows the obstruction that leads to an apnea. This century old field of specialty has been studied and shown to improve CPAP and oral appliance tolerance, decrease obstructive sleep apnea symptoms and in some rare instances eliminate the need for the CPAP. A 2018 comprehensive review of 11 separate studies concluded: “OMT [orofacial myofunctional therapy] is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure.”²

The addition of this specialty in the dental office requires much planning and several essential considerations to ensure a consistent patient experience, effective treatment coordination, and successful collaboration.

Team Considerations

Incorporating orofacial myofunctional therapy into the dental office is not just treating the teeth as a structure, rather the individual person with teeth. It’s the piece that connects the ability to address what can be done about identified oral problems with specified questions about why deficits have occurred. However, it takes more than just myofunctional therapy or sleep dentistry, it takes strong team collaboration as well.

The dental office is made up of a team of players, ranging from the front desk managing the schedule to the dentist performing treatment with the assistant. In airway dentistry it is no different – the influence of the team is critical to one’s success. Whether one is referring out for orofacial myofunctional therapy or establishing an in-office adjunctive service, collaboration is the key to success.

Many patients with orofacial myofunctional disorders will need other care. Some may even need to see a specialist for diagnosis and treatment before they are able to start other treatments. Myofunctional therapy is not effective when there are structural deficits, such as insignificant palatal width for the tongue to rest, physical obstructions to nasal breathing present, or the presence of significant sleep apnea. In dental screenings, some of these are readily notable, for others a referral is necessary.

Having a trusted network of professionals whose values are aligned to provide patients with quality service is essential. Treating airway centered disorders can be expensive and most often is out of pocket. Patient trust in their providers facilitates greater acceptance to a prescribed program or suggested treatment plan.

The following are providers you should seek out in your area:

Orofacial Myofunctional Therapist/Orofacial Myologist – Helps to resolve functional issues and compensatory patterns in orofacial musculature. Always best to have a professional that provides this treatment modality for most cases with appliance therapy, sleep breathing disorders, and tethered oral tissues

Speech Language Pathologist – Can help with patients with oromyofunctional disorders, as well as speech, speech sounds, and feeding disorders. RDHs and SLPs have specialized training in oral anatomy, health, and function, and with training, can include myofunctional therapy in their practice. OMT is only included in licensure definitions in three states for SLP (PA, CT, NJ) and none for RDH, however.

Occupational or Physical Therapist – Can also be trained in oromyofunctional intervention. An occupational therapist can help with sensory disruptions and sensory integration; whereas, the physical therapist can help with postural alignment, breathing, and temporomandibular dysfunction disorders.

Sleep Physician – May be a pulmonologist, neurologist, or other physician with a specialty in sleep medicine. As per the ADA recommendations any patients screened that have a high risk for sleep disordered breathing should be referred to a sleep physician.

Manual Therapist (a.k.a. Bodywork Professional) – Physical manipulation of the facial system and strains that may present within are under the scope and capabilities of a body worker. This all-encompassing title can refer to an osteopathic physician, chiropractor, craniosacral therapist, physical therapist, or massage therapist. Osteopathic physicians are trained to use gentle pressure and stretching to manipulate soft tissue to treat or prevent illness or injury.

Otolaryngologist (ENT) – Are critical in providing medical clearance and intervention for the patency of the airway. When a patient exhibits at risk or in need of diagnosis and treatment of upper respiratory blockages, airway disorders, and physiological anomalies, a referral to an ENT is necessary.

Lactation Consultant – Can be a LC, CLC, or an IBCLC to treat the breastfeeding dyad (mother and baby) to facilitate proper latch, position, milk supply, and global feeding intervention as it relates to breastfeeding.

While this is not an exhaustive list of team members, they are essential collaborators in the care your patients will need to address the multi-faceted manifestations of sleep and  airway disorders.

Out of Office Team Building, Networking, and Referral

There are 5 steps in successful team building and development covered here: forming, storming, norming, performing, and adjourning. Each step comprises one piece of the well-oiled machine a collaborative relationship needs to flourish and grow.

1. Forming

Forming is the most critical step for implementation. As mentioned previously, a strong team of multi-disciplinary providers is required to address the many manifestations of airway centered disorders. Attaining this complete team within a single office is a challenging task, therefore working relationships with professionals in your region are required.

The referral orofacial myofunctional therapist may be a dental hygienist or speech-language pathologist who practices as an independent practitioner. There are other healthcare professionals who can obtain training and certify in orofacial myology, such as RNs, PTs, and OTs. However, the gold standard of care remains with the RDH and SLP who have specialized knowledge of oral anatomy, function, and physiology of the oral phases of the swallow.

Seeking out independent practitioners may consist of completing an online search for therapists in the area or searching the directories of professional associations. The International Association of Orofacial Myology (IAOM), Academy of Orofacial Myofunctional Therapy (AOMT), International Association of Airway Hygienists (IAAH), Breathe Institute Ambassadors (TBI) and American Academy of Physiological Medicine and Dentistry (AAPMD) all have robust directories one can search. A Google search or social media search using the terms “myofunctional therapist near me” may also provide a listing of nearby professionals.

Contacting a new prospective collaborator is no different than meeting a new friend. Get to know them personally and lead with a face-to-face public social meeting, such as a breakfast gathering at a local coffee shop. This enables an interpersonal relationship to best meet the needs of the patients. Get to know how these professionals started their interest in dental sleep medicine, became airway focused, and incorporated orofacial function. Establish the types of patients to focus therapy on, how a typical program is developed and carried out, how much growth is hoped for one to achieve, and the expected length of time of the program. Full disclosure should be provided by both entities. These questions will guide interactions with outside professionals, manage expectations, and form a foundation of effective communication for collaborative patient care.

2. Storming

The second stage is how this team weathers the uncomfortable presence of unavoidable conflict. Conflict is the nourishment one’s team needs to grow. Most conflicts in professional relationships are based on misunderstandings. Face to face communication is preferable to handle conflict with all providers, regardless of if they are in or out of the dental office. E-mail and texts may lead to misunderstandings as intended messages get lost in translation. Compromise and split difference in resolution may be the solution to meeting the needs of the patient.

3. Norming

Our third stage is one’s ability to maintain the relationship. This is crucial for optimal ongoing patient care in collaboration. One must establish the team relationships either within the office or externally and be prepared to educate other professionals about one’s expertise. Some questions may be familiar, but some may not. Orofacial myofunctional therapy is a specialty about compensatory orofacial muscle patterns and the associated neuromuscular re-education of the dysfunctional muscle movements for appropriate functional swallowing. Like any outside professional, be it a periodontist, sleep specialist or oromyofunctional interventionalist, additional education presents a grounded knowledge of their specialization. Myofunctional therapy can be shrouded in mystery as neuromuscular repatterning is considered a highly specialized skill that is rarely introduced in educational settings during traditional trainings (dental, hygiene, speech, or others).

It is also imperative to understand that refining the collaboration process is continual. With the introduction of newer research, techniques, education, and integrations into the practice, changes will be expected as the information related to dental sleep and orofacial myofunctional therapy intervention is surging. Staying current with these changes with all members of the team is integral during the norming stage.

When approaching team members about changes to routines or techniques, a 3 T’s approach is preferred. This begins with translating respect, then transferring the issue from a problem to a solution and implementing trust for all parties to make informed decisions. For example: Dr. Nicole is having an issue conveying myofunctional therapy to her patients. This has been frustrating for her, and she would like better wording or understanding from the therapist, Joanne. Using the 3 T’s Dr. Nicole calls Joanne and states, “Hi Joanne. I want you to know that I am very happy to have the referral relationship we have. The work I’ve observed with my patients has improved the overall orthodontic outcome and promoted retention. I would like to handout or summary defining myofunctional therapy to share with patients. This would help to reduce chair time explaining while increasing patient understanding and promote increased follow through. I would like your guidance on the matter as I trust you know best how to explain it in the most effective way possible.”

The therapist now feels valued and trusted as the specialty provider and is more likely to address it promptly. By offering a solution, it presents Joanne the choice to either agree or propose an alternative. This exchange becomes mutually beneficial and overall meets the needs of the patients at large.

4. Performing,

Stage four brings us to the bottom line. This should be a relaxing stage where one steps back and appreciates the well-oiled machine. A mutually respectful, didactic referral relationship continues to enhance learning from both parties. There are five important improvements that can be observed. They are improvement in the office differentiation, overall patient satisfaction, promotion of patient loyalty, increased patient load, and potential sales of related services. As one works through cycle of team building and maintenance one should find improvement in several areas. Occasionally one may have a relationship that does not serve the office well and may be detrimental in certain areas. In those cases, it is important to consider and properly implement the final stage, adjourning.

5. Adjourning

Collaboration starts, and also ends. As much as all parties would desire to enjoy long term referral relationships, when they cease to serve the founding purpose, a choice point arises. Sometimes, a decision is necessary to part ways. One must remember that how this separation occurs, matters.

Referral relationships end for any number of reasons. A provider may move or leave a practice, priorities change, performance declines, or chronic conflict in the working relationship are some examples. Don’t ghost the other provider – always contact them to explore what has changed. Express the 3 T’s and make a final attempt to resolve any issues. When the relationship cannot be salvaged, complete any open cases and wish them well. Every failed endeavor is an opportunity to learn and pivot going forward.

OMT is a beneficial inclusion in any dental practice.

In Office Implementation

Many providers seek out the situation where a staff member potentially takes on the role of orofacial myofunctional therapist. The thought is that the service becomes more convenient for patients and the dentist. This, however, can be the trickiest of situations, as who you pick matters and training does not mean competence.

The ideal dental hygienist must be eager to learn and equally invested in making this transition. That investment may be financial or a vested interest in advancing their career. There is considerable information to learn, education to obtain to establish a solid understanding of the information in the field. Whether or not the dentist decides to invest in a staff member’s education, it is always encouraged that the dentist and hygienist pursue ample education to be effective providers to the patients.

Prior to transitions or education, formulate a contract. Confirm that person reflects qualities and characteristics reflective of your practice. Speaking, personality, and salesmanship are crucial as a brand is being built. One must have the ability to effectively communicate the message, the understanding, and overall basic need for appropriate intervention.  Many professionals have made mistakes regarding educational funding of others, only to have the individual become trained and seek new opportunities outside of the office for which they were trained. Avoid this undue stress, and ensure all terms are decided prior to any education or money put out by the dentist or the professional office. A contract should include a mutually beneficial set of terms regarding compensation, expenses, length of service, continuing education, and expectations. This agreement begins the relationship on a positive note without hesitation.

Compensation is a delicate topic and can be managed in one of two ways in the dental practice. Most frequently the therapist is provided either an hourly rate or a commission based on fees collected for the services rendered. Hourly wages can be aligned with office rates for services typically provided by the professional. When this option is considered, the dental office would provide treatment space, accounting, supplies, and scheduling. These are overhead charges that save the therapist from having to pay for rent, purchase their own supplies, and spend time doing administrative tasks. This is a more typical compensation schedule for providing the therapeutic service. Another option would be the negotiation of specialty wages. This would entail a negotiated rate and the professional would be responsible for acquiring business resources. In this instance the therapist would be charged for the space in the form of rent. It has also been observed that when hourly compensation or a percentage is negotiated, a growth period should be expected and is slower. When considering this type of fee arrangement, one must consider the potential loss while a schedule is being developed. Percentage wages are beneficial initially and incentivizes growth, so this option is an acceptable alternative. The industry average is to have 30-40% of collections as a compensation reserved for the therapist.

Initial training courses can cost anywhere from $2,300 to $3,500 and will vary from exclusively online to in person. One must be mindful that a single introductory course usually does not suffice, and multiple trainings should be expected. It is also a fair expectation for the professional office to have to pay for additional advance training within the first year. Introductory training options can be with the International Association of Orofacial Myology (IAOM), Academy of Orofacial Myofunctional Therapy (AOMT), Graduate School for Behavioral Sciences, Neo-Health Services, MyoMentor, Airway Health Solutions, or Dental Sleep Toolbox. One must do their due diligence and review the programs available to verify if they will meet the needs of the office and what one is seeking.  Also, be mindful that not all programs offer the same content, structure, timeframe, or expectation.

State legislation is unclear and most dental practice acts pertain strictly to clinical dental hygiene services without mention of orofacial myofunctional therapy. Maryland, Iowa, Nebraska, New Jersey, and Texas have current and/or pending state board rulings that myofunctional therapy is not part of the dental practice and must occur separately. What this means for the dental practice is that orofacial myofunctional services should reflect a distinction from clinical dental hygiene. The myofunctional therapy business can be within one’s office and may in many ways resemble the practice, but it is NOT the dental practice and should be presented as such. Depending upon the negotiated pay structure, billing practices will evolve. It is strongly suggested that a separate business entity is created with an EIN, payroll, billing, accounting, tax filing, and so forth. This will enable the business to evolve with changes in legislation. Seek appropriate guidance for the actual payment process – W-2, 1099, separate company, etc.

Be prepared to give the new therapist time to develop all the separate and appropriate forms for registration, patient onboarding, evaluation, treatment planning, referrals, and progress reports. There will also need to be implementation workflows and staff acclimation and training on new patient management software for scheduling, billing, and tele-therapy when applicable.

Conclusion

Orofacial myofunctional therapy is a beneficial inclusion in any airway focused dental practice. Patients will enjoy the convenience of having multiple services available in one location and it differentiates the practice as one that amplifies oral wellness to overall wellness. There are multiple challenges and rewards to establishing this practice in the dental office successfully, but when has anything worth doing been easy?