Tongue-Ties and “Tethered Oral Tissues” 101


Tongue-ties have become a hot topic over the past decade. From dentists to lactation consultants to celebrities and YouTubers, everyone seems to be talking about them. Many question the sudden increase in tongue-tie prevalence, arguing that some diagnoses are fictitious, while other researchers argue that there may be a genetic correlation, specifically with mothers who exhibit the MTHFR gene mutation and low folate levels during pregnancy. There are also debates between surgeons who prefer a laser and others who prefer a scalpel.

The topic of tongue-ties is often emotionally charged and filled with a variety of nuanced perspectives and experiences. Each patient’s story is unique and the team involved in effective diagnosis and treatment is diverse. The decision to proceed with or without corrective procedures is a choice reserved for the patient and their family. My job as a clinician is educate my patients, make necessary referrals and provide neuromuscular re-education intervention.

Before discussing this topic further, it’s important to define some terms.

Frenulum: a small fold or ridge of tissue; often refers to the connective tissue between the tongue and floor of the mouth or between the lips and gums.

“Tongue-tie”: medically termed “ankyloglossia” refers to the ridge of tissue between the tongue and floor of the mouth being too thick and/or stiff. Tongue-ties restrict the tongue from full range of motion and are often associated with breastfeeding problems, sometimes speech sound disorder and normal oral development. Recent research from Stanford Sleep Medicine has also shown noteworthy correlations between untreated tongue-tie and Obstructive Sleep Apnea, Pediatric Obstructive Sleep Apnea and Disordered Sleep Breathing.

“Lip-tie”: medically termed “lip adhesion” refers to the small ridge of tissue between the lips and gums being too thick and/or stiff and restricting the lips from typical closure and/or movement. Lip-ties can interfere with breastfeeding, oral and dental development and breathing behaviors (as patient with difficulty sealing their lips often mouth breath or over-recruit facial muscles to compensate)

“Buccal-tie” or “cheek-tie”: refers to abnormal mucosal adhesion stretching from the gums to the cheeks and can interfere with breastfeeding and normal oral development.

Tethered Oral Tissues (TOTs): a category that encompasses all restricted oral tissues including tongue-ties, buccal-ties and lip-ties.

What is the role of a speech and language pathologist in regards to Tethered Oral Tissues?

Speech language pathologists are specialists in the areas of feeding, swallowing and speech and language development. Tethered oral tissues (TOTs) interfere with each of these skill sets. Speech language pathologists diagnose TOTs and evaluate their impacts on feeding, swallowing and speech skills. After evaluation, a speech language pathologist will make necessary referral to a specialized physician (e.g. ENT), dentist and/or oral surgeon for further evaluation. Speech language pathologists can also provide pre and post surgery intervention. For infant patients, this may include tissue stretches, feeding positions and strategies, etc. For school age children and adult patients, this includes pre surgery and post surgery exercises to decrease scar tissue and increase/maintain mobility.

How TOTs Can Impact Feeding and Swallowing

Tongue-ties can significantly impact the lateral, anterior and posterior movements of the tongue. Many babies who have issues latching and/or establishing a fluid suck-swallow-breath pattern, who make a clicking sounds during breastfeeding, tongue hump and who causes their mothers nipple pain and trauma may have a tongue-tie. Impeded tongue movement continues to negatively impact feeding skills later in life and can result in issues clearing the molars of residue, moving a bolus from side to side in the mouth during feeding, maintaining correct tongue posture during swallowing and correct oral test tongue posture throughout the day.

Lip-Ties can significantly impact an infant’s ability to establish a latch during breastfeeding. Later in life, lip-ties impact a patient’s ability to seal their lips during feeding and swallowing and when the mouth is at rest. They can contribute to mouth breathing habits.

Buccal-ties can significantly impede a baby’s ability to establish a latch during breastfeeding. They can also impair food clearance in the cheeks.

How TOTs Can Impact Speech

Of all the TOTs, tongue-ties have the greatest impact on speech and articulation skills. Patients with significant restriction may struggle with a variety of speech sounds including /t/, /d/, /n/, /r/ and/l/ productions.

How TOTs Can Impact Facial, Airway and Dental Development

As mentioned in previous clinical topics, the movement of the tongue, oral and facial muscles can have a significant impact on orofacial growth. When the tongue, lips and cheeks are restricted from typical movement patterns, it can result in significant changes to facial, oral, jaw, dental and airway development. Research from Stanford Sleep Medicine has shown correlations between tongue-ties and the development of a high, narrow palate. As mentioned in previous clinical topics, research has also showed correlations between a high, narrow palate and an increased risk of pediatric obstructive sleep apnea (POSA).

Tethered oral tissues are most often remediated with a frenectomy.

Frenectomy: refers to the cutting of frenula tissue to increase structural mobility, often in regards to tongue-ties, lip-ties and/or buccal-ties. Other terms include “frenuloplasty,” “tongue-tie release,” “lip-tie release” and/or “buccal-tie release.” This procedure is most often performed by a specialized physician (e.g. neonatologist, ENT), dentist and/or dental surgeon. The procedure can be performed with a laser or scalpel, depending on the surgeon’s preference.

As noted above, a frenectomy for school-age and adult patients is often followed with a stretch and exercise protocol to ensure that adhesions/restrictions do not redevelop and that mobility is maintained during the healing process. For these older patients, orofacial myofunctional disorder is often comorbid (also occurring). Some doctors and dentists recommend Orofacial Myofunctional Therapy (OMT). OMT increases the mobility of the tongue before the procedure and helps maintain structural remediation and mobility afterward.

TOTs can significantly impact a child’s feeding, swallowing and speech skills. TOTs can also impact the healthy oral, facial and airway development of children in a variety of ways. I am passionate about thoroughly educating patients throughout the process, so they feel empowered with information to take the best steps for themselves and their family.