Question

I have a 9 year old girl on my caseload with an open mouth posture  She presents with normal cognitive abilities and is compliant towards sustaining a closed mouth posture .  However, the day is long and memory is short.  Therefore, I would like to provide her with strategies to remind herself during the day in order to maintain this position    Any suggestions are welcome

Answer

The biggest question for me is why, what else could be going on? I would look to solve the etiology before trialing treatments that may not be applicable given what the etiology actually s.

Oral-motor problems can exist in and of themselves but, in my experience,  they are part of a bigger picture that must be considered. Considering the potential impact of the postural mechanism, the sensory system and the feeding/swallowing pathway in its entirety, often helps to solve a clinical puzzle such as the one you pose.

Some questions I have to help problem-solve:

Does she and/or do  parents report this is new onset behavior? Was it observed in infancy? Is it longstanding? If not, what prompted the referral  at age 9?

Are there any past co-morbidities from which  this may be part of the sequelae? These may be from birth, or alterations along her developmental trajectory that may not be so obvious now. You will need to ask parents and look beyond the obvious. If there are past co-morbidities, for example if there is even mild postural hypotonia in infancy, the sequelae we would see at 9 may be more subtle but affect function as you report.

Does she appear otherwise grossly normally developing in her sensory, gross-motor, and fine-motor and perceptual motor skills? I ask because I have learned from some fabulous OTs that sensory integration skills that underlie all these systems and can lead to what can look like “isolated” aberrations but are not.

An open mouth posture may be compensatory/purposeful (i.e., it is being used for a purpose, and does not reflect  a “mandibular” or muscle problem in and of itself) OR  it may be pathologic (related to alteration in the muscle synergies that stabilize and provide the dynamic synergies for suprahyoid/infrahyoid function)  OR it could be purely habitual which is very unlikely, given what you have told us.

Is her breathing quiet or is there some audible turbulence in airflow whether on inhalation or exhalation, suggestive of potential obstruction to/alteration in nasal airflow?

When she establishes a closed mouth posture, does that maneuver provoke any changes in her work of breathing (i.e., breathing effort) or her RR?

Tell us about her oral-motor skills, both for speech/conversation and during eating/drinking. Do you see the full ROM and strength and coordination that underpin both those functional skills? Is her voice or swallow altered in ways that are suggestive of tonsillar or adenoidal hypertrophy?

What about her saliva swallows? If the open mouth posture is predominant, she would likely have anterior loss of saliva bolus. Does she actually establish an anterior seal at the moment of the swallow and is it effective? Does she have other sensory challenges that may not be readily apparent but might be a part of the differential.

I would request an ENT consult to assure integrity of the nasopharyngeal airway, rule out any other structural etiologies and assure patent nasal airway, while you are sorting out the pieces that are or are not in your clinical differential.

Its ok to be in the “gray” zone for a while and not have the answers right away,  and take time for reflective thinking to sort this out. I suspect it is not that simple, but more comple.x