The myofunctional therapist toolkit
The measurements, assessments, photo standards, intake forms and practice systems we rely on for tethered oral tissue and myofunctional care.
Good tethered oral tissue (TOT) and myofunctional care depends on measuring function the same way every time, documenting it clearly and sharing it with the rest of the team. This toolkit summarizes the tools we use at NTX. Always review each tool's original publication, scoring instructions and permissions before using it clinically.
Tongue range of motion: TRMR
The Tongue Range of Motion Ratio (TRMR) compares how wide the mouth can open with the tongue tip on the incisive papilla to the maximum mouth opening. You only need a ruler or a disposable measuring gauge.
| Step | How to do it |
|---|---|
| 1. Maximum opening | Ask the child to open as wide as possible. Measure the distance between the upper and lower incisor edges (MIO). |
| 2. Tongue to the spot | Ask the child to place the tongue tip on the incisive papilla and open as wide as possible while keeping it there. Measure again. |
| 3. Calculate | Divide the tongue-to-spot opening by the maximum opening, and multiply by 100 for a percentage. |
| 4. Grade | Grade 1: more than 80%. Grade 2: 50 to 80%. Grade 3: less than 50%. Grade 4: less than 25%. |
Source: Yoon A, Zaghi S, Weitzman R, et al. Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep and Breathing, 2017. Repeat measurements at re-evaluation and after any release.
Standard infant tongue-tie assessments
Infant tools look at both how the frenulum looks and how the tongue functions during feeding. Function should drive decisions.
Hazelbaker ATLFF
The Hazelbaker Assessment Tool for Lingual Frenulum Function scores 5 appearance items and 7 function items. It is detailed and widely used in lactation and research, and takes practice to score reliably.
Bristol Tongue Assessment Tool (BTAT)
A quick 4-item tool scoring tongue tip appearance, frenulum attachment, tongue lift and tongue protrusion, with a total from 0 to 8. Lower scores suggest more restriction.
TABBY
An image-based version of the BTAT developed to make scoring easier for clinicians and parents to understand.
Feeding observation
No tie tool replaces watching a full feed: latch, suck rhythm, swallow, breathing, endurance and the parent's comfort.
Clinical photo and video tips
Consistent images make progress visible and make team communication much easier.
- Get written consent for photos and video, and explain how they are stored and shared
- Use the same lighting, distance and background every time
- Capture rest posture, lips at rest, maximum opening, tongue to the spot, tongue protrusion and lateralization
- Take a front and side profile view at rest for posture and lip seal
- Record a short swallow and a short feed or chewing sample when relevant
- Include a ruler or gauge in measurement photos
- Store images only in a HIPAA-compliant system, never in a personal camera roll
- Label images with date and visit type, and compare the same views over time
Intake questionnaires and screeners
Send these before the evaluation so you arrive with the history and caregiver concerns already in hand.
| Tool | What it covers | Use it for |
|---|---|---|
| Case history intake | Birth, medical, feeding, sleep, dental, speech and development history, plus family goals | Every new client |
| Feeding Flock tools (NeoEAT, PediEAT, ChOMPS) | Validated caregiver-report measures of feeding skills and behavior | Infant and pediatric feeding evaluations |
| Pediatric Sleep Questionnaire (PSQ) | Snoring, breathing during sleep, daytime sleepiness and behavior | Screening for sleep-disordered breathing |
| Nordic Orofacial Test-Screening (NOT-S) | Interview and exam screening of orofacial function | Myofunctional screening in children and adults |
| OMES | Orofacial Myofunctional Evaluation with Scores: posture, mobility and function | Scored myofunctional evaluation and progress |
See our Feeding Assessment Tools page for more on the Feeding Flock measures. Check each tool's terms before adapting or digitizing it.
Measurement tools
Ruler or gauge
A simple millimeter ruler or disposable gauge is all you need for TRMR and mouth opening.
Timers and checklists
Simple timed tasks, such as holding lip seal or tongue to the spot, give families a home baseline to track.
Practice software
The right systems save hours each week and keep documentation consistent.
EMR and scheduling
A HIPAA-compliant practice management system for scheduling, documentation, billing and secure messaging.
Secure telehealth
For virtual consults, parent coaching and progress check-ins between visits.
Home program delivery
A secure way to share exercise videos and track daily practice, so families stay consistent.
Templates
Standard evaluation, progress and discharge templates. Our Feeding, Myofunctional and Oral Motor Evaluation Templates are built for this.
Resources from NTX
Explore our Pediatric Myofunctional Evaluation Template, Myofunctional Therapy Protocol for Tethered Oral Tissues, Tiny Tongues Infant Oral Motor Protocol and the Feeding Assessment Tools page. See our favorite feeding and myofunctional tools, and grab the free Parent Handout Pack to share with the families on your caseload.
Want help building your toolkit?
Book a case consultation or join NTX mentorship to learn how we measure, document and track progress in feeding and myofunctional therapy.