#66 Spotlight on Tools 'n Techniques: The Toothette

Greetings, SLP!

Most of us speech-language pathologists (SLPs) have uttered the following frustrating phrase, “This child has no clue where his/her tongue is—so what do I do?”  We use mirrors, verbal descriptions (multiple times in multiple ways), even show the child our own mouth, but sometimes even that isn’t enough. 

That’s where, quite literally, intra-oral therapy tools come in.  

A speech therapy-tool is the extension of a therapist’s hand that implements and fulfills a pre-determined objective.  

In other words, when wielding a therapy-tool you know why you’re using it, what you hope to accomplish, and where and in what manner you’ll apply it. 

The judicious and thoughtful use of speech therapy-tools can be extremely beneficial.  After all, the mouth is unique from all other body parts.  The facts are: 

1. The mouth is “inside” and we are unable to automatically view our mouth as it functions, unlike viewing our hands when we use them, for example. And, 

2. Quite literally the mouth is a sensing “machine.” We sense intra-oral surface stimulation (side-tongue on side-teeth anchorage, for example), deep proprioceptive awareness (for awareness of lingual movement, for example), taste and temperature differences, and levels of pain.  

Speech therapy is all about providing sensory input to generate the desired motor output—no matter what type of sensations you use.  For SLPs that adhere entirely to an auditory therapy approach, you might consider adding another highly effective form of sensory input—intra-oral tactile sensory input. 

Many children benefit from specifying and localizing mouth-parts.  The Toothette is an excellent facilitator.  For example, if your objective is to stim an /s/ speech sound, you know that the front-tongue must spatially interact with the alveolar ridge.  What better way to “inform” the child of that fact that to directly touch the front-tongue and the alveolar ridge.  

In addition, it’s helpful for the child to learn that the mouth is not a “whole” (no pun intended!) but consists of several parts that move and interact.  Of course, how deep you get into this awareness depends on the age and cognitive abilities of the child. 

Today spotlights a specific and pretty well-known therapy tool:  The Toothette. 

About the Toothette 

If you’re unfamiliar with this tool, the Toothette is a single-use, disposable therapy tool that’s used intra-orally.  Following are a few particulars you need to know when purchasing them. 

• There are a variety of names for the “toothette:” Toothette, Den Tips, Ora-Swabs, Oral-Swabs, oral foam swab stick, disposable oral care swabs, and TalkTools’ Toothies.  I’m sure there are others.  We’ll refer to it as Toothette.  They all pretty much do the same thing.  However… 

• There are a variety of textures and shapes. The original was/is pink and looks like a star-shaped piece of bubble-gum on a lollypop stick.  But there are, also, blue ones and green ones.  The stick is either plastic (does not soak up saliva), or a tightly wrapped paper stick (like a lollipop).  They range in length from 3 to 5 inches long and the sponge is either shaped like an elongated star, a rounded clover leaf, or a rectangle.  Personally, I have found the blue ones to be scratchier than the pink ones.  Although the pink ones are not totally smooth, they’re just not as scratchy as the blues.  The green rectangular ones (that have a long, plastic stick) seem to be a little smoother and tend to cost more. 

• Also, do be aware, there is the “untreated” Toothette and the “treated” Toothette. The untreated Toothette has no flavoring or taste.  I recommend the untreated type for oral therapy tasks as you’re free to add any flavoring you want.  The “treated” Toothette contains a toothpaste-like substance, called dentifrice that foams when in the mouth.  The treated ones are typically used as a toothbrush for those unable to use a conventional toothbrush. 

• You’ll find many retailers online (in addition to Amazon) that carry the Toothette. Just Google “untreated toothettes” and several options will come up.  As previously mentioned, the untreated Toothette can be flavored with any flavoring you choose to make the device more inviting.  My favorite flavored spray is by Tootarts.  It’s sugar free spray candy and comes in three (not too tart, not too sweet) flavors: apple, berry, and strawberry.  As you have probably found, some flavored sprays are excessively tart; some children love the tartness, but many don’t.  

Ages and Precautions 

In speech therapy, Toothettes can be used with pre-school age children and older, including adults.  They can also be used with even younger children for feeding therapy. 

Do exercise precaution, however, with very young children, children with lower cognitive skills, and physically active children.  The child is at risk to bite, rip, chew, swallow or aspirate the sponge.  The sponge is secured tightly to the stick but is no match for an active little one whose goal is to pull it apart.  In its place, you may wish to use something sturdier such as an ARK Probe or Nuk Massage Brush, etc. 

Acclimate the Child to the Toothette First 

Some children see a Toothette with a spritz of flavored spray on it and they open their mouth right up.  Others aren’t so willing to put something new, like a Toothette, in their mouth.  I do recommend introducing and acclimating the Toothette to all children to one degree or another. 

There are a range of things you can do, from, “This a Toothette!  The sponge end has strawberry on it and I’m going to touch the front part of your tongue then take it out; let’s see how you like the taste,” to, several minutes of examining it, figuring out what it is, and getting used to the ideas of it going intra-orally.  

Following are a few acclimating options: 

• Show the child a Toothette. Feel it, compress it, make note of how fun and squishy it is; let the child touch and investigate it with their fingers.  

• Get another one, add flavoring and put it in your own mouth. Respond appropriately of how fun it feels and tastes, etc.  Frequently, flavored tools open mouths, but not always. 

• Get another one and use it with a puppet. If you have a puppet that has a “mouth” encourage the child to put the Toothette in the puppets mouth; add intriguing positive commentary. 

• When you do venture the Toothette into the child mouth, consider sitting in front of a mirror so the child can see. Once the Toothette is close to his/her mouth, the child loses visual field of the Toothette.  The mirror may help to squelch uncertainty. 

• For the first time inside the mouth, consider touching the cheeks. The mucosa on the cheeks are the least sensitive area of the mouth.  The roof of the mouth is typically the most sensitive.  Do fairly firm press-release actions then remove the Toothette.  Let them taste the flavoring.  Then go back in and touch the oral area(s) you want to localize, i.e., front-tongue, sides of the tongue, etc. 

• Also, keep in mind, do not stroke the mucosa. A stroking action can be over stimulating and aversive.  If the child is hypo-sensitive intra-orally, however, he/she may like it. 

Not every child requires all of the above steps.  If you are working with a cognitively aware elementary-aged child or older, chances are you can go right in.  Otherwise, acclimate. 

Using the Toothette in Speech Therapy; Why, How & Where 

In none of my writings or seminars have I ever supported doing haphazard isolated oral tasks then expecting a correct speech sound to magically emerge.  And, you won’t read it here.  

From my perspective, as an experienced therapist, no matter what methods we use in therapy to facilitate correct speech sound productions, we apply techniques (and sometimes use tools) to facilitate the developmental process of improving the capability of the child to say the speech sound.  This is something that happens over time, like “normal” development.  

Use as a General Oral Indicator 

I’m convinced that some children have no clue that the mouth is a distinctly separate functional mechanism from their head.  Developmental oral-facial differentiation takes place over the first six years of life.  Mouthing (peeks during the 5^th to 7^th months) helps to initiate that head/mouth distinction.  Some kids we work with continue to have oral differentiation issues, for whatever reason. 

What is recommended?  Any form of sensory input that you can do to help localize the mouth is a good start.  Sit in front of a mirror (visual input), stimulate lots of vocal play (tactile/auditory), add oral (tactile) input with a tool of your choice, e.g., a mouthing tool, an Ark Probe, a Z-Vibe (Ark Therapeutic), a Sensi (TalkTools), a Toothette in a “spinner” (TalkTools), or just a Toothette, flavored and controlled by you.  

An alternative to a Toothette held and positioned by you, is a “hand over hand” maneuver, i.e. the child holds the Toothette in his/her hand as you firmly place your hand on the child’s and guide and control the device.  This techniques is also known as “full physical prompting.” 

Use as a Specific Tactile Indicator 

The surface of the Toothette has a slightly coarse, almost grainy texture that’s much different from oral skin/mucosa.  Therefore, when a Toothette touches the lips, cheeks, tongue, palate, or alveolar ridge it’s readily noticeable.  

As part of your systematic approach, always know where you are heading intra-orally (lips, cheeks, front/mid/back/sides of tongue, palate, perimeter of the palate, or alveolar ridge) and in what manner i.e. firm press-release, light press-release, tapping, stroking (typically only on the tongue-sides), or even tickling.  Tickling the palate may persuade the tongue to elevate and contact the palate to assuage the tickle sensation. 

The Toothette is an excellent Intra-oral mouth-parts localizer. 

• To accentuate the lingual-palatal resting position, touch (apply a fairly firm press-release action) the front portion of the palate and alveolar ridge with the Toothette, then touch the tip-blade area of the tongue. Ask the child to “match” and put the two articulators that you just touched together.  (See Therapy Matters #37-40, for info on the oral resting posture.) 

• To identify the sides of the tongue and the insides of the top, back teeth and perimeter of the palate (since the teeth have no surface touch reception). This is the only time I recommend “stroking” or sliding the Toothette.  Stroke each side of the tongue, but then press-release the side-teeth and perimeter of the palate; match.  (See Therapy Matters #7, for side-tongue bracing for speech.) 

• To isolate the mid-tongue to facilitate mid-tongue contraction to help elevate the front tongue. (See Therapy Matters #6, for working with the front-tongue.) 

• To locate the “back-tongue.” I’m talking about the specific area of the tongue that lifts for /k/, /g/, /ng/, and /r/.  In most individuals, this area is semi-sensitive to initiating a gag response.  Technically, the actual “gag territory” is behind the back-tongue that elevates for back sounds.  With that said, typically one of the only times a Toothette is palpated on that back area is when trying to generate back-tongue elevation for back-tongue vertical speech sounds.  (See Therapy Matters #29, to get the back-tongue moving.) 

Use as a tactile indicator/resistance tool to generate lingual movement 

Unlike a flat surface (like a tongue depressor) the Toothette requires “muscle energy” to compress it. 

Lips:  Place the Toothette between the lips (handle to the side like a toothbrush) and squeeze the lips “into” the Toothette.  Do repeatedly, increasing the number of repetitions according to the child’s capability.  This compressive action, overtime can aid in labial movement differentiation to build capability toward producing bilabials.  Please note that the “corners” of the lips contract and stabilize while the mid-lips, if you will, move. 

Front-tongue and back-tongue elevation:  Place the Toothette on the front-tongue (tip and blade), bite on the stick (to help keep the jaw still and squeeze the tongue up “into” the sponge.  Same thing for the back-tongue.  If you are able to see the juncture of the hard and soft palates, you can use that as a visual indicator for the back area of the tongue.  Place the Toothette directly below the juncture. 

While the child does these activities, watch for possible extra undifferentiated movements and posturings.  Make note of what is and isn’t moving and watch for changes/progress over time.  For example, if you see jaw movement that shouldn’t be happening, make note.  Call this to the attention of the child (of course this recognition depends on the child).  Touch the part that is moving abnormally, show the child in a mirror; stabilize the jaw, stabilize their head; demonstrate the desired movement with your own mouth. 

As you know, speech production boils down to appropriate stabilization and mobilization.  Using a variety of forms of sensory input can help immensely to build the necessary oral capability for speech sound production. 

Thanks for reading and for all you do with your speech kids. 

All the best to you, 

Char Boshart