The tongue lives in our mouth, like a strange animal chained to the bones of our cranium and jaw. The three sides of the tongue guard the depths of our body, like the three heads of Cerberus keeping watch over the entry to hell in Ovid’s classic poem “Metamorpheses.” If you were to lose your tongue like Philomela, Pandion’s daughter in Greek mythology, what would happen? Would you also be changed into a bird?

Rolfing^® SI and the Floor of the Mouth

In classical Rolfing Structural Integration (SI), we relate the floor of the mouth to the floor of the pelvis by working on the mandible and by searching for alignment between the floor of the mouth, the respiratory diaphragm, the floor of the pelvis, and the feet (the Fourth Hour). Of course, by doing that, we also address the vertical axis of the body, which may influence the digestive system, thereby opening a road to the next classical session, the Fifth Hour. The activity of the genioglossus (the main tongue muscle), essentially being synchronized with respiration, suggests that when we work on the functioning of the diaphragm, we will also influence the functioning of the tongue (Onal et al. 1981). In cases of breathing difficulties, I have observed positive results when working with the tongue. Some clients with very tight tongues could only get a release in their breathing after I worked on their tongues. The way in which we use our tongues has a clear impact on our overall muscular tonus. For example, recent research has shown that if you press your tongue upwards while making a physical effort, you might be able to perform movements more strongly (DiVico et al. 2013).

General Physiology of the Tongue and Mouth

Here are only a few of the multiple functions taking place in the mouth:

• The buccal mucosa has a twenty-five-day turnover rate, which provides the body with a fast adaptive capability, even more so than the skin which turns over in fifty to seventy-five days (Auriol and Les Charpentier, 1998).
• Composed of both tonic and phasic muscle fibers, the tongue contracts during inhalation to facilitate the passage of air. It is coupled with the contraction of the diaphragm (Onal et al. 1981).
• 1 to 1.5 liters of saliva are produced each day in the mouth (Humphrey and Williamson 2001).
• The movement of the tongue during swallowing allows the mouth to become moister, the nose to drain, and the pressure on each side of the tympanic membrane to be balanced.
• Responsible for the digestion of carbohydrates, the enzyme amylase is produced by the salivary glands. For amylase to work well, it is necessary to have a good flow of saliva and to masticate long enough to let the food be completely mixed with the saliva. Therefore, when dealing with digestive dysfunction it is important to check that the person has enough saliva in his mouth and that he is patient enought to let the food be completely mixed with saliva and predigested in the mouth before swallowing.
• Immunoglobulin A (IgA) is an important component of the body’s immune response. It is secreted in saliva, tears, and the mucous membranes lining the intestines and urogenital tract, and is able to freely penetate into these mucous membranes (Trochimiak 2012).

There is a bridge between ‘abstract physiology’ and ‘living physiology’ that will emerge from our perceptions and also from clinical realities. This bridge offers a possibility for further development of our work, and I invite you to explore some of these possibilities in this article, which aims to add a few specific details and some new concepts to our work as structural integrators.

A Tour of the Mouth

I invite you on a voyage around your own tongue. We will combine a systematic tour to revise or deepen our anatomical view, a theoretical one to stimulate our brains, and a practical one more geared toward our daily practice. Some general treatment principles and techniques will be discussed as well. I have included a few diagrams of the relevant anatomy, but you may want to consult your favorite anatomy books for more detail while reading along. Techniques performed in the mouth are usually done while wearing either a hand glove or a finger cot. The ‘tools’ most commonly used are the tip, dorsum, or side of the index finger; the dorsum of the index finger when flexed; the thumb as a pincher; and the other hand working on the outside of the mouth. The client is usually lying supine, but it can be very useful to use the sidelying position when you want to use the client’s weight for a particular technique. Sitting is good for coordinative work. Standing is helpful for orientation and expression.

Muscles, Nerves, Taste Buds, and Artery

When working on the musculature of the tongue, fix a point on the place of restriction and use the client’s breathing to reestablish a normal movement pattern of the tongue. When the coordination is ‘paradoxical’, it can take some time. [Editor’s note: European Rolfers use the term ‘paradoxical’ when referring to functional patterns that are opposite to those we would normally expect]. It is necessary to let the client take breaks in order to swallow saliva and rest. I suggest you start with the tongue itself and its intrinsic musculature. Press the tongue downward and hold the tongue still while you explore its structure. Since the tongue is slippery, you will need to anchor your finger against a harder part of the oral cavity (muscle or bone), choosing the angle with care.

The tongue is composed of extrinsic and intrinsic musculature. That means that as Rolfers we want to check that their functioning is differentiated, i.e., the functioning of the extrinsic muscles is separate from that of the intrinsics. You want to see if there is a spot where the intrinsic muscles are ‘glued’ together with the extrinsic musculature. Functionally, you want to make sure that the tongue is mobile and the muscular insertions in the mouth are the fixed points and not the contrary. If an athlete performs better while having his tongue pressed upwards, it seems clear that his tongue cannot have the ‘paradoxical’ situation of reversed fixed points while at the same time the trigeminal nerve fibers are being activated by the pressure of the tongue against the palate.

In working on the tongue there are five layers of intrinsic musculature you have to feel through. While holding the tongue still, you will work on the place of most stress. It is a little bit like searching for hard spots in a sponge. Start with the superior longitudinal muscle, then the transverse muscle, then the verticalis and septum, and finally the inferior longitudinal muscle (see Figures 1 and 2). The superior longitudinal and verticalis muscles actually interweave, with the former running along the length of the tongue and latter vertically. This intrinsic musculature protrudes and elongates the tongue, while the extrinsic musculature – genioglossus, styloglossus, and hyoglossus – controls the movement of the tip ot the tongue (Takemoto 2001).

Now, with your index finger, using either the tip or the side, touch the following extrinsic muscles in succession: styloglossus, genioglossus, hyoglossus (see Figure 3). You can also use a finger on the outside of the mouth to work the geniohyoid and mylohyoid muscles. Move up the styloglossus to find your way back down along the stylohyoid muscle, and then hook the root of the tongue (Figure 2). Continue with the deep palatoglossus muscles and the superior constrictor (Figure 3). The palatoglossus muscles, which can be difficult to palpate, form the palatoglossal arch and and are in close relationship with the tonsils. Together with the palatopharyngeal arch they close the oropharyngeal isthmus. Scar tissue can often be found in this area, and it can be useful to work on this, despite the discomfort it may cause the client.

Repeat this sequence on the opposite side of the mouth. Which muscles are the most tense within these areas? You now have a three-dimensional image of the tongue and you can work on the specific restrictions in order to reestablish proper tracking of the tongue.

As an aid in learning the names of these muscles, I suggest memorizing the origins and insertions of the structures – which determine their names: ‘genio-’ comes from the Greek geneion, meaning chin; ‘stylo-’ relates to the styloid process of the temporal bone; ‘hyo-’ relates to the hyoid bone; ‘glossus’ comes from the Greek glossa and means tongue; ‘mylo-’ comes from the Greek myle, meaning grinder (a reference to teeth).

Between the hyoglossus and genioglossus muscles, feel for the lingual artery branching off from the carotid artery, which brings blood to the sublingual glands, the gums, and mucosa of the oral floor. Feel if this artery is unobstructed or if some tension might be inhibiting its proper function. The hypoglossal and lingual nerves enter the tongue on the external side of the hyoglossus. The first is higher than the lingual artery, the second is lower. Because of this situation, it is most efficient to hook your finger as deep as comfort allows on or along – depending on what restriction you find – the course of the artery and then pull towards the outside the mouth in

order to let the nerves find their maximum length. (Note: apart from specific medical conditions, there is no concern in touching the intra-oral arteries as long as your touch stays light and smooth – no pressing. Take breaks often to let the client breathe and give feedback.) The glossopharyngeal nerve lies in between the two nerves you just worked on. You can find it by localizing the deep root of the lingual artery medial to which the nerve should lie. Is the flow of blood in the lingual artery unimpeded and are the nerves unimpinged?

A clear and precise diagnostic assessment at this time is important if you want to get a good understanding of how the tongue moves. A little deviation to one side or in one plane will often occur during the course of a day and will have a strong influence not only on the temporomandibular joint (TMJ) and posture, but on physiology as well. For testing the muscular structures of the tongue, you can gently grasp the tongue and pull outward. In this way you can feel if the tongue tracks well or if tension is making it deviate. This maneuver will also allow you to stretch the tensest muscular fibers. Actively tracking the tongue in this manner needs a careful touch because of the risk of pressing against the nerves mentioned above.

In practice it is also possible to proceed as follows, with the client lying either on his side or supine. Work with the weight of the tongue as much as possible or use a counterpressure against a nearby muscle or bone. Go from posterior to anterior and from lateral to medial. When the tongue starts to relax you can access its upper side more easily and feel if the taste buds need some work. They respond well to a slow circular touch. The root of the tongue is easy to access first (Figure 2), then the base of the tongue. Scrape the root upwards (i.e., elongate the fibers distally to give length) and medially, separating the extrinsic muscles from the intrinsics in a sweeping movement that stops at the sites of any abnormal tension. In this way, you have quickly tested all of the structures discussed and you can then ascertain the most demanding sites. For clarification, the root of the tongue is the attachment between the front and back of the mouth, while the base of the tongue is the deeper part (Fang et al. 2011).

The Salivary Glands

In the oral cavity, fluid production and exchange are of major importance; for example, the quantity and quality of saliva in the mouth affects taste sensitivity (Matsuo 2000; Mese and Matsuo 2007). Saliva carries information to the taste buds, it prepares the bolus by predigesting it, it protects the teeth and mucosa from infections, and it allows the salivary glands to produce and transport the right quantity of saliva to the oral cavity. Saliva not only has an antibacterial function, it also supports a selective growth of non-cariogenic microflora (cariogenic refers to tooth decay). In a breakdown, 20% of saliva comes from the parotid glands, 65% from the submandibular glands, and 8% from the sublingual glands. The remaining saliva comes from other minor glands. When you eat, the parotid glands increase their production to 50% of the total flow (Humphrey and Williamson 2001).

Palpate the submandibular glands and their execretory ducts; palpate the sublingual glands and their ducts; then palpate the parotid glands that lie close to the ear. The parotid gland ducts are close to the second lower molar. Palpate the oral cavity entirely, searching for tension in the individual glandular structures embedded in the soft tissue. In working on the sublingual, submandibular, and parotid glands and their associated duct work, try to form an image in your mind of how well they are functioning. Are they tight or smooth feeling? Normally, when they are free and unrestricted you can barely feel them, but any fixation is easy to assess with a gentle touch. When a gland is tight, it feels a little crunchy. The surface of the mucosa should feel smooth and glide easily without encountering any interruption in the movement of your finger. When the gland is free, you should feel the saliva spray against your finger. For this kind of technique, it is necessary to take some time because the glandular structures do not react immediately – it can take a few minutes of work for the parotid gland to work well again. Also be aware that the facial nerve (cranial nerve VII) passes through the parotid gland. If a client has a complaint in this area around this nerve, you will want to check the passage of the nerve through the parotid gland.

The parotid gland is situated inside a division of the fascial layer in the cheek (Drake et al. 2004). Make sure that the two layers on each side of the gland are free from the gland itself and from the surrounding structures. You have to be aware of the presence of glandular stones, so you should never use a hard touch. Also be aware of the presence of the carotid artery and vein embedded with the parotid gland.

Different types of bacteria are present in different areas of the mouth and have specific roles in the balance of oral health. When this balance is disrupted, there is the production of biofilm on the surface of the mucous membrane. A mucous cell will react differently in the presence or absence of biofilm, and the energetic feeding of the mucous cells can be disturbed. Mucous cells use musclular contractions to expel their secretions. We need to be sure then that the cell itself is well-connected to physiological pathways if we want it to function correctly. In the presence of biofilm in the oral cavity, bacteria compete and interact in a protected environment, similar to crowded cities with many people jostling each other (Jakubovics 2010). Our manipulations act not only on mechanical stresses, but also may help to simply clean up some of this oral biofilm, facilitating cellular access. It has been demonstrated that tongue scraping, in addition to brushing the teeth, is efficient in reducing bacterial populations (Bordas et al. 2008). Following a mouth-work session and for a few days afterward, you can suggest to a client to brush all around the inside of his mouth, including the three sides of the tongue and the inside surface of the jaw. (The outside of the tongue is like a triangle: there are three sides to it. One is the upper surface, called the “dorsum,” and the two other sides are separated by the lingual septum, forming the right side and the left side of the tongue.)This will help to ensure that the pathways stay as clear as possible from biofilm buildup.

Lamina propria is the name of the loose fascial layer of the mucous membrane, and you will find it throughout the oral cavity. If you pinch the skin from inside and outside the mouth, you can easily evaluate its freedom. Localized strong restrictions can often be found and worked on.

Even though we have been focusing mainly on the oral cavity, we also have been affecting the muscular structures that enwrap it. The masseter, buccinator, and multiple little muscles and fascial sheets around the mouth can be evaluated by using a hand outside of the mouth while the gloved finger is concentrating on the mucous membranes and glandular structures inside the mouth.

The Hypoglossal Nerve

Cranial nerve XII, the hypoglossal nerve, is located beneath the tongue (‘hypoglossal’ means ‘under the tongue’), and this nerve innervates the tongue. Gently pinch the tongue and carefully stretch it, putting your attention on the slow and precise stretching of the hypoglossal nerve. Have the client breathe deeply to help relax the tongue. Stretch the tongue at different angles and feel for any abnormal tensional patterns. Continue stretching until the tongue can stay relaxed in every position. Be aware that tongues sometimes need tonus: please do not stretch tongues in directions in which the fibers are already hypotonic. A recent study has shown that hypoglossal stimulation could reduce respiratory apnea (Kezirian et al. 2014). It’s easy to see how this could stimulate future explorations into our work.

The Lips, Mouth, and Gums

Now that the area close to the tongue has been carefully and systematically checked, let’s take a look at the lips and the inside surface of the lips. Your aim is to affect muscular tension in this area in order to stimulate the excretion of fluids, much like a spongey pump that needs to be able to contract and release. If the tissue is hypertoned or hypotoned, the effect will be the same in that serous or mucous fluids will not move freely into and out of these tissues. Use your fingers as you usually would in the classical Rolfing ‘Recipe’ to find the places of most restriction. These specific places in the soft tissue can be worked with more precision by being attentive to the fact that there are individual glandular structures located throughout the mucosa of this area and especially close to the lips. This is one reason this area is a good site for biopsies to check for any tissue pathologies.

Evaluate any soft-tissue restrictions that you find and work with them. By applying a subtle ‘listening’ touch, you can feel for a slight spray of fluids, much like that of the parotid glands, but on a smaller scale. In order to do this we need to do more ‘listening’ with our hands, allowing more time for a release, because the glands need a little more time to respond.

Besides our usual shearing fascial touch, it is useful to gently pinch the soft tissue and to elongate it in the direction in which you find a restriction. Normally you should be able to move this pinched tissue all around. If one direction is missing, including rotation, you have found a restriction. There are more directions to check than on other parts of the body, because we are also working on the inside of the mouth.

Next we will evaluate and work on the gums as in the classical Recipe. The gums are an anchorage site for the teeth and are unique because they have no submucousal tissue. The mucous membrane is directly attached to the bone and the teeth by the mucoperiosteum (Auriol and Les Charpentier 1998). To work with the gums you will need to use a slightly different touch. It is not the same as you use for bones, and not the same as you use for soft tissue, but something in between. Slowly palpate the perimeter of the gums, searching for places of microrestrictions. This feels like a lack of springiness, a hard spot, or a dryer spot. Release the localized tension by staying in contact with the bone under the gums and by imagining you are reestablishing a springiness in the gums.

The Teeth

In this part of the skeleton, there is a permanent remodeling taking place in reaction to changes in pressure. In the classical Recipe, the cranium will be addressed before we proceed to inside the mouth. If this cranial work has proceeded well, we should be able to achieve a durable balance with the intraoral work.

Palpate the tip of each individual tooth. You can feel when the density of the alveolar bone under the tooth is too strong or too weak. Feel if a tooth has lost its micromobility or if, on the contrary, it has gained too much mobility. Simply remobilize the tooth and alveolar bed, as well as the structures directly underlying each tooth that transmit pressure at each bite that’s taken. Mobilize a lower tooth first, then check the corresponding upper tooth and the transmission into the maxillary bone. Make sure there is no strong repetitive pressure directed to the tooth you want to reinforce. It is useful to pinch the tooth between the thumb and a finger. Pinching the tooth with your other hand at the same time will allow you to have even more leverage on the gums and implantation of the tooth.

Now you can address the structures of the mandible and maxilla by ‘listening’ to how the bone is being influenced by mastication forces. As you want to create a new balance, you need to check each side of the mandible and each side of the maxillary bone to find if there is a twist or a fixation that would inhibit the proper functioning of the jaw. Release any adhesions between the bone and the soft tissue, often present around the TMJ, to free the movement of the mandible. Free the attachment of the medial pterygoid on the inside of the mandible. In our work, this is often an important step to freeing the TMJ itself. We will not review all the structures attached to the mandible at this time as the focus of this article is on the inside of the oral cavity as close to the tongue as possible.

Now palpate the mandibular nerve. This nerve divides into two branches: 1) the inferior alveolar nerve, which pierces the bone of the mandible to emerge at the mental foramen; and 2) the lingual nerve, which is close to the tongue. If there is a restriction, it will be sensitive. To release it, gently elongate the nerve distally with minimal pressure and by ‘listening’ to the attachments of the soft tissue around it that could be pulling or narrowing it.

We can also look at facial expressions and how they might be affected by tension in the oral cavity. It can be meaningful to use this aspect together with the new proprioception that our work brings in order to anchor the functional goals that have been set.

The Oral Cavity and Aging

In older people, there is a natural reduction in olfactory sensitivity altering taste and, to a lesser degree, causing difficulties in chewing and swallowing. On the other hand, salivary output and food enjoyment are normally unaltered. Therefore, other discomforts, such as dry mouth, are related to functional disorders. Nevertheless, this concerns up to 39% of older adults (Ship 1999). Dental, mucosal, and salivary dysfunctions are frequent in older people and often are related to medication, chemotherapy, and radiation therapy. It is very possible that older people could benefit greatly from our work in the mouth.

Saliva and Sports

It has been established that a moderate amount of physical training elevates the level of Immunoglobulin A in saliva. With intensive training, however, the salivary level of IgA is reduced. The conlusion is that too much physical training will decrease the immune response in the oral cavity, while a moderate amount of training will increase it (Trochimiak 2012). This means that when the flow of saliva decreases, when our oral health worsens, or when we see a reduced immune response, we should engage in a reasonable amount of exercice – not too much, not too little. On the other hand, in the presence of autoimmune diseases like ankylosing spondylitis, we should understand that as the level of IgA in the mucosa and the blood is elevated, moderate physical training could possibly enhance inflammation (Nathan 2002; Montenegro and Monteiro 1999). What I then wonder about is whether either extremely moderate exercise or intensive training (in order to reduce the immune response) could be useful to individuals with autoimmune conditions.

Conclusion

In my opinion, our capacity to build bridges with professionals from other fields – namely doctors, dentists, nutritionists, biologists, psychologists, scientists, etc. – is a keystone in the further development of our work as manual therapists. We need to feed our curiosity and creativity in order to meet our clients with fresh enthusiasm. Whatever new fields we want to discover, whatever new theory we might build, I believe that the quality of our touch will always be our most valuable tool. The most simple empathetic touch by someone who is aware of what he does not know, along with the most simple ‘listening’ touch of someone truly curious about what is happening under his hands, are the two biggest strengths we want to refine.

I hope you enjoyed this little exploration, and I hope it inspires your practice, enhances the quality of your touch, and motivates your own explorations.

After intensive involvement in rock climbing, and after having done many different jobs including the founding of a rope access company, Mathias Avigdor was certified as a Rolfer in Munich in 2006. Together with Esther Rehacek DO and Mathias Berovalis DO, he leads a multidisciplinary center offering Rolfing SI and osteopathy in Yverdon les Bains, Switzerland. His twenty-six-minute documentary on Rolfing SI from 2012 is available in the original French at http://tinyurl.com/AvigdorRolfDoc and with English subtitles at http://tinyurl.com/Avigdor-doc-English (where you can also find links to versions subtitled in German, Italian, Japanese, Spanish, Czech, and Slovak under the heading “Vidéos Toutes Versions”). Avigdor invites all of his colleagues to freely use these videos on their websites, in presentations, etc.

Intensive further education in Rolfing SI and osteopathy was a major focus for Avigdor until 2013, when he turned his attention to teaching adults, offering further education for manual therapists in the fields of postural, cranial, visceral, and articular approaches. He is a member of the board of the Swiss Association for Rolfing and Structural integration and a founding member of the Académie Francophone de Rolfing® Intégration Structurale (aka ‘afris’; the academy of Rolfing SI for French speakers), in which he is currently active in Geneva as a Rolfing teacher-in-training. He likes to share a passion for precision and delicacy of touch and of relationship. He nourishes a creative drive for whatever feeds his need to bring meaning into his work.

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