Untying Tongue-Ties: A Brief Introduction to Tethered Oral Tissue

The tongue is a small muscle within the body that is often underestimated for its big impact. The tongue plays a critical role in one’s speech, feeding skills, breathing, and dental development. Sometimes the ability to efficiently complete these tasks or to develop appropriately is interrupted or inhibited by a “tongue-tie”. A tongue-tie is when the tissue under the tongue, which connects the tongue to the floor of the mouth, is tight, short, or abnormally attached. This tissue, also known as the lingual frenum, leads to issues with normal tongue mobility and function. The lingual frenum can be visible and towards the front of the mouth (anterior tongue-tie) or difficult to see and hard to identify (posterior tongue-tie). When restriction of the tongue is present, whether the restriction is anterior or posterior, problems often arise that are brushed aside or misdiagnosed, leaving parents, children, and adults confused and lost.

Protrusion of the tongue and adequate weight gain should not be the only factors in determining whether a tongue tie is present or not. The evaluation and diagnosis of a tongue-tie requires a thorough examination of the tongue's range of motion, strength, and coordination. Besides evaluating the tongue's mobility, the following should also be addressed: a suck assessment (if applicable), a cranial nerve assessment, a feeding evaluation, and a body assessment. These should all be performed in conjunction with a detailed birth and medical history.

What are the symptoms of a tongue-tie?

Tongue-ties can present as early as an infant’s first attempt to breast or bottle feed. What should be an easy, pain free experience becomes both stressful and painful for mother and baby. Common symptoms for breastfeeding mothers include: pain with latching or breastfeeding, blistered/bleeding nipples, mastitis, plugged ducts, and reduction in milk supply. Common symptoms for breast or bottle-fed infants include: a shallow latch, unsatisfied nursing attempts, sliding down or popping on and off the nipple, gumming or chomping on nipple, prolonged feedings, fatigue, clicking, poor weight gain, loss of milk during feeds, and reflux.

During the first few years of life, a tongue-tie can present as a concern during speech and feeding development. Symptoms include: inability to tolerate textured foods or to advance in textures, gagging or vomiting with food, frequent episodes of choking or coughing, difficulty chewing or swallowing, selective food intake, picky eating, limited babbling or vocal play, delayed first words, limited word repertoire, and consistent articulation errors with little success in therapy.

Lingual restriction of the tongue not only causes issues with appropriate tongue movement for speech and feeding but can also affect breathing and dentition. These issues often begin during infancy and extend throughout adulthood. Obstructive sleep apnea can occur from the tongue’s restricted resting position entering the airways and preventing adequate oxygen to the brain. Dental concerns include: high arched palate due to inability for palate to form around the tongue, dental carries due to the tongue’s limited mobility to clear residue, a deviated swallow impacting teeth alignment, and drooling.

Concomitant Issues

A tongue-tie often does not occur alone, and other oral tissue and body tightness should also be assessed. Lip ties (tissue connecting upper or lower lip to gums) and buccal ties (tissue connecting cheek to gums) may also be present and can impact feeding, specifically, when breastfeeding. Also, when restriction under the tongue is present, tension within the neck and shoulders may also be present. Issues, such as torticollis and positional plagiocephaly (flattening of one side of the head) can occur from pressure on the sternocleidomastoid muscle within the neck. This can cause issues such as: pain or difficulty with breastfeeding on one side of the body, head tilts, head preference to one side, difficulty visually tracking to both sides, and decreased tolerance of tummy-time.

What can be done?

If concerned that a tongue-tie is present, discuss the issue with your pediatrician and with a trained provider in the area. Providers will conduct a thorough assessment and determine if the tongues ability to function efficiently is impeded. If so, then trial therapy to work on language, feeding, or oral motor skills is recommended with a speech-language pathologist or occupational therapist. If progress is limited or the breastfeeding relationship is in jeopardy, then a revision may be warranted to release the frenum and provide increased lingual movement. Therapy post revision is recommended to assist with retraining the tongue on appropriate placement and movement during both speech and feeding.

From infancy to old age, the tongue is a powerful muscle that we depended on for functions of daily living. Without it, our ability to eat, drink, talk, and breathe could all be disrupted.

By: Kelsey S. Brasseaux, M.A., CCC-SLP

Kelsey Brasseaux has been a pediatric speech-language pathologist for 3 years. She received both her bachelor's and master's degrees at Louisiana State University, where she focused her studies on pediatric feeding and swallowing disorders. Since graduating, she has devoted her work experience to pediatric feeding disorders including experience with the following: behavioral/sensory feeding concerns, oral motor feeding issues, tongue-tie therapy pre and post revision, and complex medical feeding disorders.

She recently joined Ochsner Therapy and Wellness' team in February of 2018 and is excited about her new career. She looks forward to expanding the pediatric feeding program within Ochsner and is thankful for the opportunity to provide feeding services within the New Orleans area.