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Tongue thrust

Tongue thrust, also known as reverse swallow or deviant swallow, is an orofacial myofunctional disorder characterized by the forward thrusting of the tongue against or between the teeth during swallowing, speech, or at rest, often persisting beyond the typical infantile reflex phase.^[1]^[2] This condition arises from a retained primitive swallowing pattern that most children naturally outgrow by age 4 to 5, but when it continues, it can result from factors such as prolonged non-nutritive sucking habits like thumb-sucking or pacifier use beyond age 3, mouth breathing due to allergies, enlarged tonsils or adenoids, anatomical issues like tongue-tie, or neurological conditions including cerebral palsy, Down syndrome, or autism spectrum disorder.^[1]^[2]^[3] Prevalence estimates among school-aged children range widely from approximately 5% to 62%, with higher rates observed in those with speech sound disorders.^[3] Key symptoms include visible tongue protrusion, difficulties with swallowing, mouth breathing, speech articulation errors—particularly interdental lisps affecting sounds like "s," "z," "sh," and "j"—and potential long-term effects such as dental malocclusions (e.g., open bite, overbite, or gaps between teeth), jaw misalignment, temporomandibular joint (TMJ) disorders, and increased risk of orthodontic relapse.^[1]^[3]^[2] Diagnosis typically involves clinical observation by speech-language pathologists, dentists, or orthodontists to assess tongue movement, swallowing mechanics, and dental alignment, often recommended between ages 8 and 12 for optimal intervention.^[1]^[2] Treatment primarily consists of orofacial myofunctional therapy (OMT), a structured program led by trained speech-language pathologists to retrain proper tongue posture, lip seal, and swallowing patterns through exercises such as tongue spotting, lip closure drills, and the 4S exercise; adjuncts may include orthodontic appliances like tongue cribs or braces to break the habit and correct alignment.^[2]^[3] With early intervention, outcomes are generally excellent, improving muscle function, speech clarity, and preventing dental complications, though untreated cases can lead to chronic issues requiring multidisciplinary care.^[1]^[2]

Overview

Definition

Tongue thrust, also known as reverse swallow or immature swallow, is an orofacial myofunctional disorder characterized by the forward thrusting of the tongue against or between the teeth during swallowing, speech, or rest, rather than the tongue resting against the palate as in mature function.^[4]^[1] This abnormal pattern persists beyond infancy, where it is a normal adaptation for feeding, and involves atypical muscle activity in the tongue, lips, and jaw that can influence oral development.^[3]^[2] The condition was first described in the mid-20th century, with early characterizations in the 1960s attributing it to adaptive responses to oral habits such as prolonged thumb-sucking or bottle-feeding, which alter tongue positioning over time.^[2] Unlike structural anomalies such as ankyloglossia (tongue-tie), which involves a shortened frenulum restricting tongue mobility, or macroglossia, characterized by an enlarged tongue, tongue thrust primarily represents a functional disorder arising from habitual muscle patterns rather than anatomical defects, though structural issues may sometimes contribute to its persistence.^[1]^[5]

Epidemiology

Tongue thrust, also known as atypical swallowing, exhibits a high prevalence in young children, with estimates of tongue thrust swallow in school-aged children ranging from 5% to 62%.^[3] This rate tends to decrease with age, dropping to 20-40% among adolescents as the swallowing pattern matures for many.^[6] In adults, estimates suggest a persistence rate of around 25%, though comprehensive data remain limited.^[6] Higher rates are observed in populations with contributing factors such as allergies, which promote mouth breathing, or habits like thumb-sucking, potentially exacerbating the condition.^[3] Demographically, tongue thrust appears more common in females, with studies reporting a ratio of approximately 1.5:1 compared to males.^[7] It is also noted at elevated levels in regions with high allergy incidence, where nasal obstruction may influence tongue positioning.^[8] In adults, the condition is often underreported due to its asymptomatic nature in many cases, leading to underdiagnosis unless associated with orthodontic issues.^[9] Current epidemiological data reveal significant gaps, with much of the foundational prevalence information derived from pre-2018 studies that may not reflect contemporary trends.^[6] Recent reviews (as of 2024) emphasize the need for more longitudinal studies to track persistence and continue to cite wide prevalence ranges without significant updates.^[6]^[9] These gaps highlight the importance of updated, population-based research to better understand distribution across diverse demographics.

Pathophysiology

Normal Swallowing Mechanism

The normal swallowing mechanism is a coordinated neuromuscular process divided into three primary phases: oral, pharyngeal, and esophageal. In the oral phase, which is voluntary, the tongue plays a central role by elevating against the hard palate to form a seal with the lips and cheeks, containing the food or liquid bolus (a soft mass prepared through mastication or minimal manipulation for liquids). The tongue then propels the bolus posteriorly toward the oropharynx through a sequential wave-like motion, without exerting anterior pressure on the teeth or lower lip, ensuring efficient containment and transport.^[10] During the pharyngeal phase, which is involuntary and triggered reflexively upon bolus entry into the oropharynx, the soft palate elevates via contraction of the tensor and levator veli palatini muscles to seal the nasopharynx and prevent nasal regurgitation. Simultaneously, the hyoid bone and larynx elevate through suprahyoid muscle contraction, protecting the airway by approximating the epiglottis over the glottis and inducing a brief swallowing apnea (lasting 0.5 to 1.5 seconds). Pharyngeal constrictor muscles (superior, middle, and inferior) generate peristaltic contractions at 20 to 40 cm/s to propel the bolus toward the upper esophageal sphincter, which relaxes via cricopharyngeus inhibition, allowing passage without residue. Lip closure maintains oral seal throughout, contributing to bolus stability.^[10] The esophageal phase follows involuntarily, with primary and secondary peristaltic waves propelling the bolus at 3 to 4 cm/s toward the stomach, facilitated by relaxation of the lower esophageal sphincter. This mature pattern, involving precise coordination among the tongue, soft palate, lips, pharyngeal muscles, and hyoid, ensures safe bolus transit and airway protection.^[10] Developmentally, swallowing begins as an infantile reflex pattern characterized by forward tongue thrusting and suckling, predominant in newborns and infants to accommodate a high laryngeal position. As the neck elongates and the larynx descends between birth and approximately 2 years, the oral cavity expands, enabling a transition to the mature pattern where the tongue contacts the palate for posterior propulsion. This shift typically completes in most children by age 4 to 6 years, with studies indicating that 90% achieve a fully mature swallow by school age, aligning with the emergence of mixed dentition and refined oral motor control.^[11]^[12]

Abnormal Tongue Positioning

In tongue thrust, the pathophysiological process involves abnormal propulsion of the tongue, either anteriorly or laterally, during swallowing, which generates reverse pressure against the anterior dentition rather than the typical posterior elevation toward the palate. This deviant pattern contrasts with normal swallowing by producing positive pressure on the teeth, potentially leading to malocclusion, open bites, and maxillary arch narrowing over time. ^[3]^[13] The altered muscle patterns arise from this persistent forward force, which reinforces atypical orofacial habits and disrupts the coordinated sequence of tongue, jaw, and hyoid movements essential for efficient bolus propulsion. ^[3] Muscle imbalances play a central role in sustaining abnormal tongue positioning, with the genioglossus muscle contributing to protrusive forces that prevent the tongue from resting posteriorly against the hard palate. ^[13] Concurrently, weakness or underactivation of the intrinsic tongue muscles—responsible for fine adjustments in tongue shape and elevation—exacerbates the failure to achieve a stable posterior rest position, leading to reliance on compensatory anterior thrusting. ^[13] These imbalances create a cycle of orofacial musculature tension, where mouth-closing muscles exhibit extreme hyperactivity and masticatory muscles show reduced contraction during swallowing, further entrenching the deviant pattern. ^[13] Recent myofunctional research, including a 2025 systematic review of studies from 2022 onward, has examined tongue thrust in the context of orofacial myofunctional disorders (OMDs) and speech sound disorders, noting associations with atypical labial-lingual postures and challenges in tongue-jaw movement differentiation. ^[14] For instance, post-frenectomy interventions using orofacial myofunctional therapy (OMT) have shown mixed results, with limited evidence of significant improvements in speech outcomes compared to controls. ^[14] This body of evidence highlights ongoing questions regarding sensory-motor integration in OMDs, with prevalence in school-aged children ranging from 5.4% to 62.3%, often associated with speech sound disorders. ^[3]

Classification

Anterior Tongue Thrust

Anterior tongue thrust is characterized by the forward protrusion of the tongue between the anterior teeth during swallowing or speech production, often accompanied by lip incompetence where the lips fail to achieve proper closure at rest.^[1] This pattern exerts continuous pressure on the maxillary incisors, contributing to their proclination and the development of an anterior open bite.^[15] As the most common form of tongue thrust, it predominates in clinical observations among orthodontic patients, particularly in children and adolescents.^[16] Identification of anterior tongue thrust typically involves clinical examination revealing a visible forward push of the tongue against or between the front teeth, observable during deglutition or articulation of sounds such as /s/, /z/, /t/, /d/, /n/, /l/, or /sh/.^[17] This manifestation frequently leads to specific dental patterns, including an anterior open bite in approximately 52% of affected cases and associated lisping in up to 86%.^[18] Lip incompetence is a hallmark feature, present in 86% of diagnosed individuals, distinguishing it through observable mouth breathing and hyperactive mentalis muscle activity.^[18] Differentiation from other tongue thrust variants relies on its midline involvement, where the tongue's forward displacement occurs centrally rather than laterally or posteriorly.^[19] Recent case studies illustrate this distinction and the risks of untreated progression; for instance, a 2023 report described a pediatric patient with untreated anterior tongue thrust leading to worsened anterior open bite and spacing, resolved only after intervention with a modified tongue crib appliance that improved lip competence and dentition alignment over six months.^[20] Similarly, another 2023 case highlighted midline thrust progression exacerbating proclination in a child with concurrent habits, underscoring the need for early differentiation to prevent dental deterioration.^[21]

Lateral Tongue Thrust

Lateral tongue thrust refers to a variant of orofacial myofunctional disorder in which the tongue exerts pressure against the lateral aspects of the teeth during swallowing or at rest, rather than the typical forward positioning seen in anterior forms. This can occur unilaterally, where the tongue deviates to one side and presses between the posterior teeth on that side, or bilaterally, affecting both sides symmetrically.^[22]^[23] Unilateral cases often stem from asymmetries in oral muscle function or habits, while bilateral forms may relate to broader issues like low tongue posture or nasal obstruction, making them distinct from the midline-focused anterior tongue thrust.^[24]^[23] Clinically, lateral tongue thrust manifests through specific dental and soft tissue changes, particularly involving the posterior dentition. Unilateral variants commonly produce asymmetric posterior open bites or crossbites on the affected side, alongside potential scalloped markings on the tongue from chronic pressure against the teeth.^[25]^[24] Bilateral forms lead to symmetric posterior open bites, where the tongue's lateral pressure impedes proper eruption and alignment of molars and premolars, often resulting in uneven occlusal wear over time.^[22]^[25] These markers are frequently identified in orofacial examinations, with reports from recent therapy cases highlighting their role in diagnostic imaging like cephalometric analysis.^[24] The bilateral subtype presents unique treatment complexities, often proving more resistant to correction due to entrenched muscle patterns and contributing factors such as allergies or poor nasal breathing. Orofacial myofunctional therapy (OMT), involving exercises for tongue repositioning and swallowing retraining, is a primary approach, but bilateral cases show higher relapse tendencies if underlying etiologies like muscle tone imbalances are not fully addressed.^[23]^[25] Adjunctive appliances like tongue cribs may enhance outcomes by mechanically discouraging lateral pressure, though comprehensive evaluation remains essential to mitigate recurrence.^[22]

Etiology

Genetic and Anatomical Factors

Tongue thrust can arise from inherent anatomical variations that alter normal tongue positioning and function during swallowing. Macroglossia, characterized by an enlarged tongue, is a key anatomical factor predisposing individuals to tongue thrust by exerting excessive pressure on the dentition, often leading to anterior open bite malocclusion.^[26] This condition is frequently associated with genetic syndromes, such as Down syndrome (trisomy 21), where macroglossia manifests in approximately 40% of cases due to hypotonia and relative tongue enlargement within a smaller oral cavity.^[27] Similarly, Beckwith-Wiedemann syndrome, caused by imprinting defects on chromosome 11, features macroglossia in up to 90% of affected individuals, contributing to tongue protrusion and compensatory thrusting patterns that disrupt occlusal development.^[28] Congenital macroglossia overall has a low prevalence of fewer than 5 per 100,000 births, with approximately 50% of cases associated with genetic syndromes.^[29]^[30] Neurological conditions can also contribute to tongue thrust through impaired muscle control or sensory processing. For instance, cerebral palsy often involves oromotor dysfunction leading to abnormal swallowing patterns, while autism spectrum disorder may present with tongue thrusting as a form of stimming or due to sensory integration issues.^[1]^[31] Another significant anatomical contributor is ankyloglossia, or tongue-tie, which restricts tongue mobility through a short lingual frenulum, potentially inducing compensatory forward thrusting during deglutition to achieve adequate seal.^[32] This congenital anomaly has a prevalence of 4.2-10.7% in newborns, with a male predominance (1.5:1 ratio), and can result in altered swallowing mechanics that favor anterior tongue positioning.^[32] Genetically, ankyloglossia often follows an autosomal dominant inheritance pattern, involving genes such as LGR5 (leucine-rich repeat-containing G-protein coupled receptor 5) and TBX22, which are implicated in lingual frenulum development and associated with syndromic forms like X-linked cleft palate.^[32] Familial patterns of tongue thrust have been observed, suggesting a heritable component influenced by neuromuscular and orofacial structural traits, as documented in early studies including those by Tulley (1969).^[33]^[13] Despite these associations, high-quality genetic research on tongue thrust remains limited, with most evidence derived from small-scale or syndromic studies rather than large genome-wide association analyses, highlighting gaps in understanding non-syndromic heritability.^[5] Current literature emphasizes the need for updated longitudinal genomic studies to clarify causal variants, as earlier claims of strong genetic determinism have been tempered by the predominant role of multifactorial interactions.^[13]

Environmental and Behavioral Influences

Behavioral habits play a significant role in the development of tongue thrust, particularly prolonged non-nutritive sucking such as thumb-sucking or pacifier use extending beyond age 3 or 4. These habits encourage a forward tongue position and immature swallowing patterns, increasing the likelihood of persistent tongue thrust into later childhood. Longitudinal studies indicate that children with ongoing digit-sucking demonstrate a statistically significant higher prevalence of tongue thrust and associated malocclusions compared to peers without these habits, with odds ratios for related dental issues reaching up to 5.6.^[34]^[35]^[3] Mouth breathing, frequently triggered by allergies or nasal obstructions, further exacerbates tongue thrust by altering resting tongue posture and swallowing mechanics. Conditions like allergic rhinitis or chronic congestion lead to habitual oral respiration, which positions the tongue low and forward, promoting interposition between the teeth during deglutition. A systematic review and meta-analysis found that mouth breathing is associated with a 3.7-fold increased risk (RR: 3.70; 95% CI: 2.06–6.66) of atypical swallowing, including tongue thrust, with one study reporting a 77.5% prevalence among mouth breathers.^[8]^[36]^[3] Environmental factors, such as prolonged exposure to soft diets or extended bottle feeding in early childhood, can delay the transition to mature swallowing and reinforce tongue thrust patterns. These feeding practices maintain reliance on liquid or semi-liquid textures, hindering the development of proper tongue elevation and posterior propulsion during swallowing. Research highlights prolonged bottle feeding as a key contributor to improper swallow habits that persist as tongue thrust.^[5]^[5] Tongue thrust typically emerges from a multifactorial interplay of these behavioral and environmental influences, often modifiable through early intervention, in contrast to inherent anatomical factors. Addressing habits like non-nutritive sucking and managing allergy-related congestion can mitigate risks, emphasizing the preventable nature of many cases.^[15]^[3]

Clinical Manifestations

Oral and Dental Impacts

Tongue thrust exerts significant pressure on dental structures during swallowing and at rest, leading to characteristic malocclusions. The most prevalent is anterior open bite, where the front teeth fail to meet, often resulting from the tongue's interposition between the dental arches; improper tongue posture is observed in 81.3% of such cases.^[15] This condition is particularly associated with anterior tongue thrust, though lateral variants can contribute similarly.^[15] Proclination of the incisors occurs due to the forward thrust applying uneven forces, tilting the maxillary incisors labially and exacerbating spacing between teeth.^[15] Posterior crossbites may also develop, as the low tongue position widens the lower arch while constricting the upper, disrupting normal transverse occlusion.^[15] Untreated progression can lead to increased interdental spacing or orthodontic relapse, with persistent tongue forces causing previously corrected alignments to revert, as evidenced in longitudinal evaluations of swallowing patterns.^[37] Chronic tongue contact contributes to long-term dental wear through enamel erosion, where repetitive mechanical abrasion accelerates substance loss on acid-softened surfaces. In vitro studies demonstrate that tongue licking after acid exposure significantly heightens enamel and dentin wear compared to non-abrasive controls, potentially compounding erosive damage over time.^[38] Tongue thrust is implicated in a substantial portion of adolescent malocclusions, with seminal research indicating associations in cases involving open bite and related discrepancies.^[39] The resulting occlusal irregularities hinder effective plaque removal, elevating caries risk in affected children through impaired oral hygiene and associated mouth breathing that reduces salivary protection.^[40]

Speech and Functional Consequences

Tongue thrust often results in speech distortions, most notably lisping or frontal lisps characterized by the production of /s/ and /z/ sounds with the tongue protruding between the teeth, due to aberrant tongue positioning during articulation. This improper placement disrupts the precise alveolar ridge contact required for sibilant sounds, leading to interdental or lateral emissions. In a study of children with tongue thrust, 86% exhibited lisping during speech, highlighting the high co-occurrence of this functional impairment.^[41] Beyond speech, tongue thrust contributes to functional challenges in eating and daily activities, including inefficient chewing and swallowing patterns that fail to properly propel food boluses, potentially causing digestive discomfort from inadequate breakdown and increased air ingestion. These inefficiencies arise from the forward tongue thrust exerting pressure against the teeth rather than the palate, compromising bolus formation and esophageal transit. Additionally, the associated low tongue posture frequently leads to lip incompetence, where the lips remain parted at rest, resulting in aesthetic concerns such as a strained facial appearance and chronic mouth breathing.^[3] Tongue thrust has potential links to sleep-disordered breathing in pediatric populations, with atypical deglutition observed in 74% of children aged 6–12 years diagnosed with moderate to severe obstructive sleep apnea syndrome, suggesting a bidirectional relationship influenced by altered airway dynamics and pharyngeal collapsibility. This association underscores broader functional risks, including disrupted sleep quality and daytime fatigue, particularly in cases involving mixed dentition.^[42]

Diagnosis

History and Physical Examination

The diagnosis of tongue thrust begins with a thorough history taking to identify contributing factors and rule out underlying issues. Clinicians conduct structured interviews with patients or, in the case of children, their parents or guardians, focusing on developmental milestones, oral habits such as the duration and intensity of thumb-sucking or pacifier use, and respiratory patterns including persistent mouth breathing, which may signal allergies or nasal obstructions.^[36]^[3] Additional inquiries cover medical and dental history, such as allergies leading to chronic nasal congestion, family history of orthodontic issues or orofacial structural anomalies, and any reported feeding or swallowing difficulties from infancy.^[1]^[43] Red flags like prolonged mouth breathing beyond early childhood or a family predisposition to open bites prompt further evaluation to distinguish tongue thrust from related conditions.^[36]^[3] Physical examination involves non-invasive clinical observations to assess orofacial function and confirm tongue thrust patterns. Intraoral inspection evaluates the tongue's rest position, noting if it protrudes forward against or between the teeth, which deviates from the ideal palatal posture.^[3]^[36] Clinicians observe a swallow demonstration, where patients sip water or saliva to reveal forward tongue thrusting or lack of lingual-palatal contact, often accompanied by facial grimacing or head tilting.^[3] Lip seal and competence are assessed during speech tasks, checking for incomplete closure or compensatory movements that indicate weak orbicularis oris function; symmetry, tone, and range of motion in the lips, jaw, and tongue are also examined for abnormalities like ankyloglossia.^[3]^[36] These techniques help identify associated dentition changes, such as anterior open bites, without requiring instrumentation.^[36] Age-specific considerations guide the approach to ensure appropriateness and accuracy. In children, parental reports are essential for detailing early habits, developmental delays, and observed symptoms like noisy breathing or speech distortions, as young patients may lack self-awareness; tongue thrust is considered atypical if persisting beyond age 4–5, when mature swallowing typically emerges.^[3]^[36] For adults, self-reported concerns often center on speech impediments, such as lisping on sibilants, or swallowing inefficiencies, with history emphasizing lifelong patterns or recent exacerbations from allergies.^[3] These protocols align with the American Speech-Language-Hearing Association's (ASHA) evidence-based practice guidelines, updated as of 2025, which emphasize interprofessional collaboration and comprehensive orofacial assessment starting from age 4 for intervention readiness.^[3]

Imaging and Specialized Assessments

Diagnosis of tongue thrust is primarily clinical, led by speech-language pathologists for functional assessment, with referrals to dentists or orthodontists for structural evaluation of associated issues like malocclusions. Radiographic methods may be used adjunctively in multidisciplinary settings to evaluate anatomical relationships and positional abnormalities related to tongue thrust. Cephalometric X-rays provide lateral views to measure tongue position relative to the maxilla and mandible, as well as bite angles, particularly in cases of open bite or atypical deglutition.^[44]^[45] Cone-beam computed tomography (CBCT) enables three-dimensional visualization of tongue volume, oral cavity capacity, and spatial relationships, aiding in orthodontic assessments of muscle positioning.^[46]^[47] Functional tests can provide dynamic evaluation of swallowing mechanics in specific cases, such as suspected dysphagia. Videofluoroscopy visualizes tongue movement during swallowing and may identify anterior protrusion in certain populations.^[48] Electromyography (EMG) can assess electrical activity in tongue and circumoral muscles for research or complex neuromuscular evaluations, detecting patterns in individuals with tongue thrust.^[49] Low-radiation approaches, including digital imaging and optimized fluoroscopy, are prioritized in protocols as of 2023 to minimize exposure.^[50] In differential diagnosis, clinical history and observation help identify when to refer for neurological evaluation to distinguish tongue thrust from conditions like dystonias or neuromuscular disorders.^[51]^[52] For instance, absence of organic lesions in myofunctional cases can rule out entities like pantothenate kinase-associated neurodegeneration.^[53]

Treatment Approaches

Myofunctional and Speech Therapies

Myofunctional therapy involves a series of targeted exercises designed to strengthen the tongue and orofacial muscles while retraining proper tongue posture and swallowing patterns to address tongue thrust.^[2] Common exercises include the "spot hold," where the tongue tip is pressed against the alveolar ridge behind the upper front teeth for 10 seconds and repeated 10 times, and tongue push-ups, which involve elevating the tongue to contact the hard palate with resistance.^[2] Another key technique is the 4S exercise—spot the tongue position, salivate, squeeze the tongue against the palate, and swallow—performed up to 40 times daily to promote a mature swallow without anterior tongue protrusion.^[2] These interventions typically occur in programs lasting 4-6 months, with 10-20 sessions of 30-60 minutes each, starting weekly and tapering to biweekly or monthly, supplemented by daily home practice.^[54] Speech therapy is often integrated with myofunctional therapy to correct articulation errors associated with tongue thrust, particularly for sibilant sounds like /s/ and /z/, which are distorted by improper tongue positioning.^[3] Techniques include articulation drills, such as practicing /s/ sounds with the tongue tip elevated to the alveolar ridge, combined with swallow retraining to ensure posterior tongue movement during deglutition.^[36] This combined approach emphasizes consistent daily practice and may extend over 6-12 months to establish habitual changes, depending on patient age and compliance.^[36] Recent evidence from randomized controlled trials and scoping reviews supports the efficacy of these non-invasive therapies, particularly in children. A 2016 pilot RCT involving children aged 7-11 with anterior open bite and tongue dysfunction found that myofunctional therapy achieved physiological tongue posture at rest in 60% of participants and normalized swallowing patterns in 50-60% after 4-6 months.^[54] A 2020 study reported significant improvements in tongue strength and orofacial function following myofunctional exercises in patients with tongue thrust.^[55] A 2024 scoping review of nine studies, including children, indicated that 47% achieved normal swallowing after 8 weekly sessions of myofunctional therapy, with success rates up to 58% in group settings and long-term stability observed over 3 years.^[56] These findings highlight resolution rates of 47-60% for key outcomes like swallowing correction in pediatric populations, underscoring the value of behavioral retraining without mechanical aids.^[56]

Orthodontic and Appliance Interventions

Orthodontic and appliance interventions for tongue thrust focus on mechanically addressing the resulting malocclusions, such as anterior open bite, by repositioning the tongue and stabilizing dental alignment. These approaches are typically recommended when the habit has caused structural changes in the dentition, providing physical barriers or corrective forces to interrupt thrusting patterns and support long-term bite correction.^[16] Tongue cribs and spurs represent foundational appliance types designed to directly block tongue thrusting, particularly in cases involving anterior dental interference. A tongue crib is a fixed intraoral device, often bonded to the posterior teeth and extending across the palate, that creates a mechanical barrier preventing the tongue from pressing against the anterior teeth during swallowing or rest. This retrains associated orofacial muscles and has been described as extremely effective for habit cessation by disrupting the thrusting action and promoting proper tongue posture.^[57] Bonded spurs, consisting of small stainless steel projections attached to the lingual surfaces of the maxillary incisors, serve a similar function by physically deterring forward tongue movement and are commonly used in early orthodontic phases for patients with associated open bites. Clinical comparisons indicate that fixed palatal cribs may outperform bonded spurs in correcting anterior open bite in growing patients, primarily through greater dentoalveolar effects.^[58] These appliances are applied selectively, with spurs showing success in restraining anterior tongue posture and aiding bite closure.^[59] Palatal expanders address tongue thrust-related issues when the habit contributes to a constricted maxillary arch, which limits proper tongue positioning and perpetuates dysfunctional swallowing. These devices, activated by the patient to gradually widen the upper jaw, alleviate crowding or crossbites that may reinforce thrusting tendencies, thereby facilitating improved tongue space and functional adaptation. Orthodontic protocols emphasize their role in comprehensive treatment for malocclusions influenced by tongue thrust.^[16] Integration of these appliances with conventional orthodontics, such as fixed braces, follows updated clinical recommendations that pair mechanical correction with adjunctive therapy to minimize post-treatment instability. Recent evidence supports combining braces with myofunctional exercises during active orthodontic phases, which significantly reduced mean relapse to 0.5 mm compared to 3.4 mm with orthodontics alone.^[60] Advancements in appliance design have introduced 3D-printed options, enabling customized fabrication of tongue cribs or guards with enhanced precision to patient anatomy, which improves fit, reduces discomfort, and optimizes habit interruption. Clear aligners, adapted for tongue thrust management through built-in attachments or programmed movements, offer a less invasive alternative to traditional braces, guiding dental alignment while incorporating myofunctional elements for sustained tongue retraining and stable outcomes.^[61]^[62]^[63]

Prognosis and Prevention

Long-Term Outcomes

Early intervention in children with tongue thrust, particularly through orofacial myofunctional therapy (OMT), yields high resolution rates, with studies reporting effectiveness in correcting resting tongue posture and swallowing patterns. In one cohort of children treated for open bite associated with tongue thrust, 90.3% achieved proper lip seal after 12 months of OMT combined with orthodontic management.^[64] These outcomes underscore the importance of addressing the condition before permanent dentition, where success rates can reach up to 90% for normalizing orofacial functions when therapy begins in early childhood.^[64] In adults, relapse risks following tongue thrust treatment are notable without ongoing maintenance, often linked to persistent low tongue posture. Long-term stability improves with adjunctive appliances like tongue elevators. Untreated persistence into adulthood heightens the likelihood of chronic complications, including temporomandibular joint (TMJ) disorders, with atypical swallowing patterns correlating to a 67.7% prevalence of TMD compared to 46.7% in those without such habits.^[65] Prognosis is significantly influenced by the timing of diagnosis and intervention; early detection in children enhances outcomes through prevention of entrenched malocclusions and associated habits.^[64] Factors such as airway competency and resolution of underlying contributors like allergies further bolster long-term success, reducing relapse by promoting stable orofacial muscle balance.^[3]

Strategies for Prevention

Early interventions play a crucial role in reducing the risk of tongue thrust by addressing common contributors such as prolonged nonnutritive sucking habits and impaired nasal breathing. Discouraging extended pacifier use is a primary strategy, as long-term reliance beyond age 3 is associated with increased likelihood of anterior open bite and posterior crossbite, which often stem from altered tongue positioning. The American Academy of Pediatric Dentistry (AAPD) recommends anticipatory guidance during early dental visits to wean children from pacifiers by 36 months, noting that discontinuation before this age substantially lowers malocclusion rates, including those linked to tongue thrust patterns. Similarly, promoting nasal breathing through effective allergy management helps prevent mouth breathing, a key factor in tongue thrust development; allergic rhinitis can cause nasal obstruction, leading to a 3.7-fold increased risk of atypical swallowing when mouth breathing predominates.^[66]^[8] Educational approaches empower parents and caregivers to foster proper oral habits from infancy. Parental training on appropriate feeding practices, such as transitioning from bottles to open cups by 12-18 months and selecting orthodontic pacifiers if needed, supports normal tongue posture and swallowing development. The American Speech-Language-Hearing Association (ASHA) emphasizes educating families on behavior modification techniques, like using praise and rewards to eliminate nonnutritive sucking, during routine health visits starting at age 1. These strategies help mitigate environmental influences on risk factors, such as thumb sucking or improper bottle propping, without requiring invasive measures.^[3]^[67] School-age screening programs enhance early detection in at-risk populations, allowing for timely preventive counseling. Pediatric myofunctional screenings, integrated into school health or dental check-ups, assess for signs like low tongue posture or mouth breathing in children aged 7 and older, where tongue thrust prevalence ranges from 5.4% to 62.3%. The AAPD's 2024 guidelines advocate routine clinical examinations during well-child visits to identify habits contributing to unfavorable dentofacial growth, with referrals to interdisciplinary teams if nasal airway issues are suspected. Recent public health updates from dental associations, including the 2024 AAPD policy on developing dentition, stress enhanced screening for high-risk groups—such as those with allergies or family history of malocclusions—to promote nasal breathing and habit cessation, updating prior recommendations with a focus on interprofessional care.^[3]^[66]

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Somatosensory innervation of the tongue is supplied by the lingual nerve (mandibular branch of the trigeminal nerve (CN V); anterior two thirds of the tongue), ...<|separator|>
[18]
Effectiveness of Orofacial Myofunctional Therapy for Speech Sound ...
Green [30] found that 41% of parents reported speech concerns in children with ongoing digit sucking, a form of OMD. The high percentage of parents who ...
[19]
Tongue Thrust Treatment | Textbook Orthodontics
The most common form is anterior (or middle) tongue thrust, where the tongue pushes forward against the front teeth. This pressure can lead to spacing between ...Missing: 70-80% | Show results with:70-80%
[20]
Tongue Thrust and Treatment of Subsequent Articulation Disorders
Feb 25, 2011 · Tongue thrust (also called "reverse" or "immature" swallow) is the common name given to orofacial muscular imbalance, a human behavioral pattern ...
[21]
Comparison of soft-tissue, dental, and skeletal characteristics in ...
Aug 7, 2025 · Significantly, higher number of children with tongue thrusting showed lip incompetency (86% vs. 14%), mouth-breathing habit (38% vs. none), ...
[22]
Tongue Thrust - an overview | ScienceDirect Topics
A patient with an anterior tongue thrust is not able to create the vacuum needed to swallow when the lower lip is retracted because the seal and vacuum for the ...
[23]
[PDF] A Modified Tongue Crib Appliance for Correction of Tongue Thrusting
Jun 16, 2023 · A modified tongue crib was used for six months resulting in significant improvement in maxillary anterior dentition position, lip competence, ...
[24]
https://pmc.ncbi.nlm.nih.gov/articles/PMC7323810/
[25]
(PDF) TONGUE THRUSTING ORAL HABIT - A REVIEW
Aug 6, 2025 · There was a significant difference in the age-wise prevalence of oral habits with older children showing greater prevalence of oral habits than ...
[26]
Bi-Lateral Tongue Thrust - aomtinfo
The tongue moves forward or laterally, called anterior, bi-lateral, uni- lateral or bi-maxillary tongue thrust (dynamic).Missing: subtypes unilateral prevalence<|control11|><|separator|>
[27]
Review of Etiology of Posterior Open Bite: Is There a Possible ... - NIH
Jun 25, 2020 · Lateral tongue thrust was detected among all three patients with clear scalloped dental marks on both sides of the tongue. The size of the ...Missing: wear | Show results with:wear
[28]
[PDF] Tongue Thrust: A Review
Also it is a source of relief in passion and anxiety in both children and adults. It gives a soothing feeling when the region is stimulated with tongue, finger.
[29]
Diagnosis of macroglossia and indications for reduction glossectomy
Macroglossia may contribute to anterior open bite malocclusion with prognathism, speech articulation disturbances, drooling and the perception of intellectual ...
[30]
prevalence of tongue alterations in a group of patients with down ...
Results: DS had a high prevalence of macroglossia (40%) and fissure tongue (65.7%). Conversely, geographic tongue and irritation fibroma were found in 5.7% and ...
[31]
Beckwith-Wiedemann Syndrome: Open bite evolution after tongue ...
Macroglossia causes functional deficits such as airway obstruction, drooling, phonation difficulties, and leads to protrusion of dentoalveolar structures ...
[32]
Macroglossia - DermNet
Macroglossia is most often diagnosed in infants and children [1]. The prevalence of congenital macroglossia was reported to be fewer than 5 per 100,000 births, ...
[33]
Skeletal and dental characteristics in subjects with ankyloglossia
Nov 7, 2013 · Ankyloglossia, commonly known as tongue tie, has a prevalence of 4.2% to 10.7% in the population [2]. There is a mild male predilection with a ...
[34]
[PDF] Operant Control of Pathological Tongue Thrust
Tongue thrust is natural and normal behavior in suckling and swallowing and in the acquisition of speech in early life . Sometime between five and ten years of ...Missing: history | Show results with:history
[35]
Polymorphisms of genes encoding P2X7R, IL-1B, OPG and RANK in ...
Age, overjet, tongue thrust, skeletal class II and the other polymorphisms made minor contributions. Conclusion: This study highlights the P2RX7 gene as a ...
[36]
A longitudinal study of the effects of digit- and dummy-sucking
Children in whom digit-sucking persisted revealed a statistically significant increased proportion of Skeletal II dental base relationships, tongue-thrust ...
[37]
printer-friendly
Apr 28, 2011 · ... thumb sucking had the smallest odd ratio of 5.6, compared to other oral habits related to malocclusion (pacifier sucking and tongue thrusting).<|separator|>
[38]
[PDF] Speech - Tongue Thrust - Cincinnati Children's Hospital
Tongue thrust is a forward position of the tongue during rest, and a thrust against or between the teeth during swallowing and speech. A tongue thrust condition ...Missing: definition | Show results with:definition
[39]
Effect of Tongue Thrust Swallowing on Position of Anterior Teeth - NIH
Many research studies have pointed out that a significant percentage of relapse after orthodontic treatment might be related to orofacial muscle imbalance and ...Missing: challenges | Show results with:challenges
[40]
A study in vitro of the abrasive effect of the tongue on enamel and ...
The results suggest that the tongue could exert an abrasive effect on dental tissues softened by erosion, thereby increasing the overall loss of tooth substance ...
[41]
Common dental diseases in children and malocclusion - Nature
Mar 13, 2018 · Disintegration of the primary tooth crown from severe caries may lead to malnutrition since dental status can affect masticatory function, food ...Missing: erosion | Show results with:erosion
[42]
Comparison of soft-tissue, dental, and skeletal characteristics in ...
[3] Various epidemiological studies have reported prevalence of tongue thrusting to be 40-80% in children between age 4 and 6 years,[1,4] and 3-25% for children ...
[43]
The role of atypical deglutition in children and adolescents with ...
Feb 19, 2024 · This cross-sectional study aimed to assess the prevalence of atypical deglutition (tongue thrust) in children diagnosed with moderate to severe obstructive ...
[44]
Understanding Tongue Thrust: Causes, Symptoms, and Treatment ...
Apr 6, 2024 · Tongue thrust, also known as an orofacial myofunctional disorder (OMD), is a condition characterized by the abnormal forward positioning of the tongue during ...
[45]
Cephalometric Appraisal of Tongue and Related Soft Tissues ... - NIH
Aim: To compare the tongue position of normal and open bite subjects at rest and to study if there is any difference in the hyoid bone and posterior ...
[46]
A cephalometric evaluation of tongue from the rest position to centric ...
This study for the evaluation of the tongue position from the rest position to the centric occlusion showed no statistically significant changes in both groups.
[47]
Volumetric measurement of the tongue and oral cavity with cone ...
CBCT has been used in the evaluation of tongue and oral cavity volumes to assess correlations between those volumes and with the upper airway.Missing: thrust | Show results with:thrust
[48]
Preliminary study: evaluating the reliability of CBCT images for ...
May 3, 2020 · This study was intended to estimate the reliability of using cone-beam computed tomography (CBCT) to measure tongue space, which includes tongue ...
[49]
Tongue thrust swallowing in severely physically disabled children
In five patients with severe physical and mental disabilities, a feeding pattern with tongue thrust was assessed videofluoroscopically.
[50]
Electromyographic investigations of the tongue and circumoral ...
The electromyographic (EMG) examination of 11 normal individuals in whom bipolar fine-wire indwelling electrodes were placed showed no EMG activity during rest ...
[51]
Electromyographic features and efficacy of orofacial myofunctional ...
May 7, 2021 · Recent research has demonstrated the high prevalence of harmful oral habits, such as thumb or dummy sucking, mouth breathing, and tongue-thrust ...
[52]
[PDF] Optimizing radiation safety in dentistry - Willamette Dental
1.1. Digital rather than film-based imaging should be used because digital imaging allows for lower patient radiation exposure. 3.1.1.2. If film is used, only ...<|separator|>
[53]
Severe tongue protrusion dystonia: clinical syndromes and possible ...
The pathophysiology of intermittent severe tongue protrusion remains unknown. Tongue protrusion dystonia is often unresponsive to oral drugs but may benefit ...
[54]
Tongue dysfunction in neurological and neuromuscular disorders
Parkinsonian patients exhibit tongue movement problems, and patients with muscular disorders show tongue weakness. These symptoms can cause aspiration or ...
[55]
Severe tongue protrusion dystonia - Neurology.org
Sep 25, 2006 · Tongue protrusion dystonia is often unresponsive to oral drugs but may benefit from botulinum toxin injections into the genioglossus muscle.
[56]
The effect of orofacial myofunctional treatment in children with ...
Jul 1, 2015 · This prospective pilot study investigates the effects of OMT on tongue behaviour in children with AOB and a visceral swallowing pattern.
[57]
https://onlinelibrary.wiley.com/doi/10.1155/2013/647649
[58]
Habit Breaking Appliance for Multiple Corrections - Abraham - 2013
Oct 3, 2013 · Tongue crib appliances are extremely effective in breaking the tongue thrust habit [4, 5, 10, 11]. They create a mechanical barrier and prevent ...Missing: efficacy | Show results with:efficacy
[59]
Comparing skeletal and dentoalveolar effects of fixed palatal crib ...
Aug 1, 2025 · Conclusion. The fixed palatal crib appliance was more effective than bonded spurs in managing anterior open bite in growing patients, mainly ...
[60]
Effects of tongue tamers and customized bonded spurs as an early ...
Jan 16, 2025 · This study aimed to evaluate the effects of prefabricated metal-bonded tongue tamers and customized bonded spurs in the early treatment of anterior open bite.
[61]
How Myofunctional Therapy Supports Orthodontic Success—Before ...
“Relapse rates in patients who completed myofunctional therapy during orthodontic treatment were reduced by as much as 62% compared to those who received ...
[62]
3D Printer-Assisted Layered Fabrication of a Novel Appliance ... - NIH
Apr 28, 2024 · Tongue thrust, or low tongue, is a typical myofunctional disorder (MFD) that causes occlusal abnormalities, and the tongue thrust habit has long ...
[63]
Resolving Tongue Habits Using Clear Aligners - LearnDentistry™
Dr. Shotell describes techniques using special adjustments made to clear aligners aimed at decreasing tongue thrusting habits.
[64]
Clear Aligners and Tongue Thrust: Managing Abnormal Swallowing ...
Oct 28, 2024 · This article explores the latest insights on clear aligners for managing tongue thrust and how a holistic approach can create stable, lasting results.
[65]
Oral Myofunctional Disorders - Speak Easy Therapy
These studies have shown that Orofacial Myofunctional Therapy can be 80-90% effective in correcting rest posture, swallowing and other oral functions, and that ...<|control11|><|separator|>
[66]
Impact of myofunctional therapy on orthodontic management and ...
Apr 16, 2025 · This study found improvements in tongue position and function, increased tongue/palate contact, enhanced lip tension and function, and better ...
[67]
(PDF) Treatment and retention of relapsed anterior open-bite with ...
Aug 6, 2025 · Relapse rates are high, with relapse estimated at about 20-30%, with slightly more stability for a surgical approach. Read more. Article ...
[68]
The correlation between temporomandibular disorders, atypical ...
The prevalence of TMD among subjects with or without atypical swallowing is equal to 67.7% and 46.7%, respectively, being statistically significant (p<0.05), as ...Missing: untreated | Show results with:untreated
[69]
[PDF] Management of the Developing Dentition and Occlusion in Pediatric ...
Abstract. This best practice asserts that the management of developing dentition and occlusion is an essential part of comprehensive oral health care.Missing: 2025 | Show results with:2025
[70]
Pacifier Use and Its Influence on Pediatric Malocclusion - MDPI
Pacifier use was consistently associated with an increased prevalence of malocclusions, including anterior open bite, posterior crossbite, and overjet. The risk ...
[71]
[PDF] Policy on Pacifiers - AAPD
Based on good-quality patient-oriented evidence, the AAP recommends offering a pacifier when an infant is placed to sleep due to its protective effect on the ...
[72]
Understanding Pediatric Myofunctional Screening
Nov 28, 2023 · Pediatric myofunctional screening is a vital tool to detect orofacial myofunctional disorders (OMDs), such as tongue thrust or mouth breathing, in children.