What is a tongue tie and what’s the big deal?
If you have a little one, chances are you’ve heard of a tongue tie and are somewhat familiar with the issues that can arise from having one, especially when it comes to feeding. That “string” under the tongue being too tight is a health concern that’s growing in awareness by a multitude of practitioners, but still is not taken seriously enough in many cases where there are obvious issues with a child. So what are the difficulties that might be the result of a tie? When is a potential tie worth getting released? Who can I reach out to do a more in-depth assessment?
What is a tethered oral tissue?
Tongue, lip, and cheek ties are all referred to as tethered oral tissues or TOTs. There is a string (frenulum) of tissue in each of these regions, and sometimes it can be too thick or too tight, meaning that it restricts oral structures from moving freely and carrying out their proper functions without compensations. A labial frenulum refers to the lip and can be upper (maxillary frenulum) or lower (mandibular frenulum). You can also have buccal ties, which is where there is an excessively tight cheek frenulum. Having a frenulum (or plural, frenula) is normal and does not mean that a person is “tied,” but rather a tie is diagnosed when these structures are not as elastic as they should be and are therefore causing functional impairments.
How do ties affect function?
This post will focus on the infant and toddler implications, though there are profound effects that adults living with TOTs may experience if they go unaddressed, which I’ll explore in a later post. So what signs might you see in your little one to suspect that there may be some kind of restriction contributing to problems with function?
Excessive reflux and gas (due to aerophagia or “swallowing air”)
Pain during nursing (due to shallow latch)
Sliding off nipple while feeding
Pacifier won’t stay in
Biting during breast/bottle feeding (bite reflex is elicited when tongue doesn’t go past gum line during feeding)
Trouble turning head to one side (tight muscles where tongue attaches further down neck)
Plagiocephaly (head flattening due to the neck restrictions)
Banana curve posture at rest (further compensations from neck tightness)
Difficulty tolerating tummy time (places tension on already-tight oral structure and their attachments in neck)
Clicking at the bottle or breast
“Colicky” after feedings (aerophagia)
Choking while nursing
Always wanting to be on the breast (greater than every 2 hours due to poor milk removal)
Excessively long feedings (20+ minutes once out of newborn phase)
Leaking during feedings (baby should not need a bib to drink milk)
Low milk supply in moms (due to poor milk removal by baby)
Persistent pacifier or thumb sucking habit (releases serotonin, which is usually elicited by the tongue when it is placed on its proper spot on the palate right behind the teeth)
Poor, short sleep, especially sleeping on back
Congested nose/recurrent ear infections (due to altered pressure and clearing during dysfunctional swallowing)
Snoring (snoring is common but is never normal!)
Pushing purees out of mouth with tongue (“tongue thrust swallow”)
Gagging or choking on purees or solids (lack of tongue placement on palate makes gag reflex hypersensitive)
Difficulty clearing spoon during feedings (this is especially indicative of a lip tie)
Perhaps you’ve experienced some of these difficulties with your infant or toddler. These things are not all specific to a tongue tie, as there can be many other reasons for several of these challenges (i.e.: underlying GI issues causing reflux symptoms, low muscle tone, etc.). However, if you’re experiencing a lot of these things, it’s probably worth getting evaluated by a qualified professional to see if feeding therapy or a release is warranted. If an oral tie is present, best-case scenario, a release provider (DMD, MD) will work closely with a bodywork provider (physical therapist, occupational therapist, or pediatric chiropractor) and a feeding therapist (usually a Speech Language Pathologist or Lactation Consultant) to make sure a baby is sufficiently prepared for a release if that’s what is needed. Sometimes, therapies are able to work through the issue and a tongue tie release is not even necessary.
Though it may seem excessive, these other disciplines are quite crucial in the whole process, as the tongue is intricately connected to the entire rest of the body. This means that relieving tension and removing compensations for inadequate tongue/lip function in the face, neck, shoulders, and trunk is especially important for priming the proper muscle groups to take over once the tongue is released. Otherwise, the same compensatory patterns will simply continue to exist and cause oral dysfunction. Furthermore, these providers may be facilitating additional exercises post-release to continue to increase tongue function (lateralizing and elevating tongue, appropriate stretches to wound, monitoring wound healing, etc.). And speaking of best-practice, a tongue tie is evaluated by conducting a full oral-motor exam, which requires that the provider lays down the child on an exam table or on the parent’s lap, and then places both index fingers underneath the tongue to elevate it and assess its elasticity and range of motion. Having a child stick their tongue out does not tell you if someone has a tongue tie!
Orofacial development
While some will argue that babies will grow out of many of these issues related to TOTs, there are several other factors to consider when it comes to setting them up for optimal development. The tongue is a powerful force, placing many pounds of pressure on the roof of our mouths whenever our mouths are closed. This is optimal oral rest posture: lips closed, nasal breathing (not audible or turbulent breathing), teeth gently touching in the back, and tongue resting in the roof of the mouth just behind the top row of teeth. In a baby, this is incredibly important because all of that pressure really forms how a skull takes shape. The sutures (gaps of connective tissue between the bones of the skull) are soft in the head, and the pressure of the tongue in its proper place facilitates a nice wide development of the floor of the nasal passage, ensuring plenty of width for free nasal breathing. When the tongue is anchored to the floor of the mouth, it makes little (if any) contact with the roof of the mouth, and as a result the baby will likely develop a high arched palate. These pressure dynamics raise the floor of the nasal passage over time. This narrowing of nasal structures has a profound effect on breathing and therefore sleep is significantly impacted as well. The link between tongue tie (which when unadressed can exacerbate a high palate) and sleep apnea is significant, and recent research has just drawn a link to high palate and SIDS. All of this to say, if a baby is having significant functional issues now, there’s a good chance that as they grow, the issues might seemingly resolve, but will likely manifest as new issues. For example, adults and even older kids with functionally significant tongue ties that were not sufficiently addressed experience a different symptomology (because of course they are no longer on the bottle or nursing), and include things like:
Frequent headaches
Night terrors/bedwetting long past when daytime potty trained
Excessive snoring
Frequent night wakings
ADHD symptoms or foggy mind
Waking in the morning never feeling rested
Constant sinus/ear infections/congestion
Turbulent nasal breathing
Narrow facial development
Recessed jaw (when looking at a person’s profile, forehead and chin should be a plumb line) or jaw pain
TMD (Temporomandibular Dysfunction)
Who do I call to get help?
Not every provider is educated on the latest research with TOTs, as this is seldom included in any kind of detail in the curriculum for major professional programs. That being said, only doctors and dentists can diagnose a tie, so it would be best to do some homework on whether your doctor or pediatric dentist has had any additional trainings on TOTs. The TOTs training by Chrysalis Orofacial is one of the leading courses in the field, and Talk Tools also has a reputable and comprehensive training course as well. In fact, Chrysalis has a directory where you can search providers in your region who have taken the two-day intensive training. This would be a good place to start when trying to find providers who will be in the know about tongue tie and the whole-body effects of this and other types of oral dysfunction.
As with any evidence-based research, it takes years to actually translate those findings into mainstream practice. For this reason, I’d recommend looking for yourself at the body of evidence in the research databases, and to be critical of any provider who makes light of your struggles. Not everything is a tongue tie, and not every tongue tie needs released, but you and your little one deserve access to a provider who hears your struggles and collaborates with you and other professionals to find solutions, whatever the cause!
These books were also very helpful along the way on tongue tie and other related topics:
Airway and sleep: Gasp! Airway Health-The Hidden Path to Wellness by Dr Michael Gelb &, Dr Howard Hindin
Tongue Tie: Tongue Tied by Richard Baxter, DMD, MS
Breastfeeding: Breastfeeding Doesn’t Need to Suck by Dr. Kathleen Kendall-Tackett PhD
