The Ultimate Guide To Tongue-Ties

 

The Ultimate Guide To Tongue-Ties is the product of years of frequently asked questions about tongue-ties.  I’ve taken the common questions and put together an ultimate guide to tongue-ties that will help reduce or eliminate the overwhelm or confusion that is often felt when trying to navigate this messy, confusing field.  Yes, the identification of some tongue-ties can be tricky.  On top of that, many providers aren’t up to speed, operate from an extremely antiquated way of thinking, or just don’t understand the long term consequences of ignoring a tongue-tie.  Do me a solid favor.  Actually read The Ultimate Guide To Tongue-Ties.  If you devour this guide, you are going to be head and shoulders above the next person who doesn’t take the time to truly understand tongue-ties and why they matter.  You can thank me later!

 

What is a tongue-tie?

Ankyloglossia (proper term), is a condition that is present at birth, although often not diagnosed. This condition restricts the range of motion due to an unusually short or tight band of tissue called the lingual frenum. The tissue anchors the tongue to the floor of the mouth. Tongue-ties vary in severity, with some having very limited movement and others only slightly reduced. This restricted movement causes poor muscle function. As a result of poor muscle function, other oral functions are also altered. Treating a tongue-tie is relatively simple with a procedure called a frenectomy.

 

What is a posterior tongue-tie?

A tie is a tie is a tie.  This is often confusing to people.  The frenum is one continuous collagen fiber.  There is an anterior portion (the part nearest the tip of the tongue) and a posterior portion (near the back of the tongue). When there is an anterior tie, there is obviously a posterior portion as well.   

Sometimes the anterior portion looks ok and doesn’t seem to be causing any problems, but the posterior portion could be the culprit.  A tongue-tie gets overlooked because many providers simply look at whether or not a person can stick the tongue out. But, this has nothing to do with the elevation of the posterior blade of the tongue, which is necessary for correct oral rest posture and correct swallowing.  Many people have adequate mobility of the anterior portion of the tongue but have a severe restriction or dysfunction of the posterior portion. This is why it is extremely important to work with an experienced myofunctional therapist to make sure a full evaluation is completed, and a posterior tongue-tie is not overlooked.  

 

What causes a tongue-tie?

A tongue-tie is a congenital issue that is present just several weeks after conception. As an embryo grows, initially the tongue and the floor of the mouth are one unit. Normally, the tongue separates from the floor of the mouth.  When this does not occur correctly or completely a tongue-tie results.  

 

How is a tongue-tie diagnosed?

Some tongue-ties are “low hanging fruit” and can be easily self-diagnosed.  Other’s require the assistance of an experienced provider. A myofunctional therapist is a great place to start.  Remember, the diagnosis of a tongue-tie is not about the appearance of the tongue, but rather the function of the tongue.  A comprehensive myofunctional evaluation will gather information about signs and symptoms, in addition to completing a functional assessment to see how the tongue functions.  All of the data is compiled to create a diagnosis.  

 

Why do tongue-ties matter in infants?

A tongue-tie can be a large problem when it comes to successful breastfeeding. The proper function of the lip and tongue are important for milk transfer. Understanding the basic mechanics of breastfeeding will help explain why this is such a concern.  When an infant feeds, the tongue creates a negative pressure, which in turn causes the nipple to open, allowing milk to flow into the infant’s mouth.  

When an infant has a tongue-tie, it simply can’t nurse properly.  The correct function requires the mobility of the full tongue (anterior and posterior) to create a vacuum.  Nursing is exhausting for an infant with a tongue-tie, often leading to “grazing” (sleeping at the breast and eating very little, but eating frequently) which quickly affects the mother’s milk supply, causes mastitis or other concerns.  Infants may also start to experience weight loss, malnourishment, and failure to thrive due to inadequate milk transfer. 

In addition to directly affecting the infant, mothers are often miserable during this nursing time as well. When an infant can’t use the tongue correctly, it may resort to using the gums to “chew” on the nipple to get the milk out.  This causes lots of pain for the mother, and it results in dysfunction of the muscles and poor craniofacial development for the infant. 

The identification of a tongue-tie in an infant is needed as soon as possible to reverse any negative effects on the mother’s milk supply and to salvage the breastfeeding relationship. It is also important to note that a tongue-tie has nothing to do with the fact that an infant can extend the tongue. It is a common misconception that if an infant can stick the tongue out that they can’t be tongue-tied. The extension of the tongue is not the same as the elevation of the tongue.  For correct breastfeeding, the infant must be able to elevate the tongue to the roof of the mouth and press to express milk. 

In my experience it can be extremely frustrating for parents of a tongue-tied infant, because the tongue-tie can get overlooked or “poo-pooed” by a doctor who doesn’t understand tongue-ties.  In addition to being comfortable with the information inside this Ultimate Guide To Tongue-Ties, I encourage you to follow your gut instinct.  Momma’s know best.  Don’t be afraid to bark up more than one tree!

 

Why do tongue-ties matter in children?

Tongue-ties limit tongue mobility.  The movement of the tongue is important for speaking, chewing, drinking, breathing, swallowing, and more.  It is also extremely important for adequate craniofacial development. Identification of a tongue-tie in a child is beneficial so that parents can plan a release before the head and face are completely developed.   

However, it is important to consider the timing of the release.  A child who is not old enough to comprehend, comply and cooperate with adequate myofunctional therapy could experience unsuccessful rehabilitation of the oral structures.  This explanation will be listed below, in the section titled “Why is myofunctional therapy important?” 

 

Why do tongue-ties matter in adults?

Adults often experience difficulty with correct oral rest posture, swallowing, breathing, sleeping, and upper body tension when it comes to tongue-ties.  Many adults have experienced symptoms for years, having no idea that there could be a reason for the misery. As adults grow from tongue-tied infants to tongue-tied children to tongue-tied adults, compensatory patterns and habits are developed, often unbeknownst to the adult.  These adaptations aren’t viewed as abnormal, because the person just doesn’t know any different. 

Adults most often complain of poor sleep quality, digestive and swallowing problems, TMJ pain, posture issues, speech impediments, headaches, and upper body tension.  Adults tend to find out about tongue-ties when a child is born with a tongue-tie, and the parents start to understand the familial relationship. 

Tongue-tie correction is important for adults too.  Even though the frenectomy is not done for breastfeeding issues (as it is done in an infant), or to prevent insufficient craniofacial growth and airway issues (as it is done in children), adults should proceed with a release if the lingual restriction is causing difficulty with correct oral rest posture, nasal breathing, swallowing, speech, or sleeping. 

 

The Ultimate Guide to Tongue-Ties list of symptoms

As an infant, most of the symptoms are tied to breastfeeding:  messy eating, clicking, inability to latch, fussy, gassy, colicky, nursing often, spitting up, falling asleep at the breast frequently, and failure to thrive. 

Children and adults experience many different symptoms, some of which are deemed as being normal.  This happens because the person suffering from the symptoms doesn’t know any other way. “The eyes don’t see what the mind doesn’t know.”.  That means that very often, a myofunctional therapy client doesn’t know that a symptom isn’t normal until it is pointed out. Adults and children may experience some of the following symptoms. 

Digestive issues 

Many people with a tongue-tie have experienced digestive issues such as hiccuping, belching, bloating, gas, acid reflux, stomach aches, and choking.  When a person has a tongue-tie, chewing and eating may not be an enjoyable experience, and some people are “lazy eaters,” meaning they make food choices based on the ability to chew it with the least amount of effort. 

Rapid eating behaviors are common as well as inadequate chewing.  Many people with a tongue-tie just want to chew the food long enough to be able to swallow it without choking. 

Aerophagia is the condition that results from air swallowing.  This is a common symptom for people with rapid eating behaviors and myofunctional impairment.   

Food texture issues and pickiness 

As an infant transitions to solid foods, sometimes parents pick up on these issues, but it is often overlooked.  When a child has a tongue-tie, manipulating foods with the tongue can be difficult so a child may begin to develop food and texture aversions and gag on food.  Parents often respond by beginning to serve easy to chew foods, which can exacerbate the problem and lead to poor craniofacial development (because the face needs chewing to stimulate bone development).  

If a child has to poke food back into the mouth with the fingers, packs food into the cheeks, avoids certain texture and hard to chew foods, favors liquid or pureed foods, gags, or becomes very picky, it is important to consider a tongue-tie. 

Adults may have some of these same issues, but don’t relate it to the possibility of a tie.  Many adults with a tongue-tie simply avoid foods that they don’t enjoy chewing, such as meat, raw vegetables or salads. 

Chronic ear infections

When the tongue does not function properly, the swallow is affected.  This often causes a problem with the eustachian tubes draining properly.  Many children with tongue-ties end up having tubes placed to help with chronic ear infections.  

Speech issues

Many people who seek out myofunctional therapy, have had years of unsuccessful speech therapy. The problem arises when the correct movement and position of the tongue is affected by the restriction. When the tongue is restricted by a tongue-tie, it may not be possible to form the sound.  

Half of the tongue muscles are responsible for the shape of the tongue, and the other half is responsible for the placement of the tongue.  Both shape and placement are needed for successful speech therapy. Successfully treating a tongue-tie, and completing myofunctional therapy will set a person up for success when it comes to speech therapy. 

Many people who suffer from speech challenges simply tend to talk fast to cover up speech errors, or they talk quieter and fail to project the voice.  These social implications from a tongue-tie are often overlooked but have lifelong consequences. Many people who experience difficulty with speech issues tend to become “anti-social” because speaking and engaging is not an enjoyable task.

Parents may not realize it at the time, but it is common for a child with a tongue-tie to have a delay in speech development  Simply put, it is exhausting to use the tongue for speech, so a child simply doesn’t. Or perhaps, the child will simply avoid the difficult sounds, choosing instead to create their own version of an “easy” language.

Crowded teeth

Tongue-ties and crowded, crooked teeth are directly related to each other.  When the tongue has proper mobility, it can live on the roof of the mouth like it is supposed to (correct oral rest posture).  A tongue in the correct resting position becomes “natures expander”, causing the mouth to expand laterally, which allows for proper space for all of the adult teeth.    

When the upper arch grows properly, the lower arch follows suit.  The maxilla acts like a lid on a box and should be a bit larger than the mandible. While many people look at crowded teeth as a cosmetic issue, the concern really is a structural issue.   If the bones don’t grow big enough, the teeth won’t be able to erupt correctly. Parents tend to look at a child’s crowded teeth as a genetic issue, but parents should be concerned about early tooth crowding rather than just passing it off as “the father’s mouth”. 

Dental problems

The tongue is meant to be a tool, not only for speaking and chewing but also for oral cleansing.  When there is a tongue-tie, the tongue cannot reach to clean the teeth, and a decay problem can result.

Overbite

In addition to growing the maxilla laterally, the tongue also helps the growth of the face forward.  When a child has tongue-tie there is often an overbite where the mandible is recessed, or “sloped backward”. This alters the attractiveness of the face as well as causes other health concerns, such as insufficient development of the airway.  When there is any difficulty getting air, often the head and chin are pushed forward creating “forward head posture”, which afters the structural alignment and growth of the body. Early intervention is key.   

Jaw pain

TMJ pain is common in people with a tongue-tie because of how the muscles pull on each other, in addition to the tongue being held in an incorrect resting position.  The tongue is released and can learn the correct oral rest posture, many complaints of TMJ pain are alleviated. 

Another reason that so many people complain of jaw pain is that there is a repetitive strain on the joints and muscles because the joint often does the job of the tongue.  When the chin and tongue “operate together” because of a tongue-tie, the joint is overused. 

Lastly, the styloglossus muscle of the tongue is the muscle that retracts and elevates the tongue.  This muscle runs from the tip of the tongue to an area near the temporomandibular joint. A tongue-tie makes the movement of this muscle difficult and it very often causes jaw pain. 

Chronic head and neck pain

A tongue-tie is a structural issue, which means that the effects of it are far-reaching throughout the body. The tongue is connected to so many muscles throughout the head, neck and upper body that it’s impossible for correct alignment and comfort.   Adults tend to suffer from constant tension, discomfort, pain, muscle tightness, and headaches. 

 

Why is myofunctional therapy important to a successful tongue-tie release?

Myofunctional therapy has three distinct roles that help improve the success of tongue-tie surgery. 

First, adequate myofunctional therapy before the procedure helps to build strength, coordination, awareness, and behavior modifications as the client and the therapist starts to address oral resting posture and breathing habits.  In addition, good muscle tone and control make the procedure easier on the provider, often resulting in a better release with a smaller wound. 

Second, myofunctional therapy helps the client heal correctly from the procedure.  Learning post-procedure exercises, stretches and active wound management will aid in this process. 

Third, myofunctional therapy following the procedure is needed to rehabilitate the oral structures and to restore or improve correct oral function. Similar to physical therapy following a surgical procedure, myofunctional therapy fills the same role to help improve the success of a frenectomy.  

Read: The Ultimate Guide To Orofacial Myofunctional Therapy

 

Is tongue-tie surgery necessary?

If a tongue-tie is affecting correct oral function, it should be released.  Not all tongue-ties are significant. It is important to remember that the concern is not with the appearance of the tongue-tie.  The concern is how the oral function is affected and the long term consequences of decreased oral function. 

 

What happens if I don’t release my tongue-tie?

When making the conscious decision not to release a tongue-tie, a person needs to understand the long term consequences of that decision.  It depends upon the severity of the tie and the symptoms associated with the tongue-tie. As a person ages, the body’s adaptations and compensations will give way, resulting in an increase in symptoms.  When this happens many adults end up choosing to have the frenectomy completed. 

 

What are the tongue-tie recovery and healing process?

Everyone is a little bit different but the goal is to heal correctly.  Some providers place sutures to prevent reattachment of the tissue, and others leave the wound open.  It will depend upon the method used by the doctor. Recovery and healing can take 2-4 weeks.   

If someone has an open wound, it will look something like a diamond at the beginning. The goal is to facilitate healing by secondary intention, causing the wound to heal slowly, from the outside edges inward, instead of top and bottom healing together.  The top and bottom triangles should not attach to each other. When there is correct healing, the sides of the diamond heal together, creating a new frenum. The goal is that the new frenum is long, lean, and limber allowing for adequate mobility. 

Be prepared to care for the wound around the clock.  This means during the night too. A person with a frenectomy wound should not go longer than 6 hours before doing stretches.  This will help make sure that the wound heals correctly. During healing, granulation tissue will fill in the middle space of the diamond, as it heals from the outside edges inward.   

Do the minimum amount of stretching necessary to get maximum results.  If a person stretches too vigorously or is too rough with the wound, the body may respond with extra inflammation.   

It is also common to experience “wound contracture” where the frenum area suddenly feels tight and restricted again.  This is a common experience that happens anywhere between weeks 1 and 4. This is normal, and it is important to continue with wound care, stretches, and myofunctional therapy.  The tightness normally goes away.  

 

How long does it take for a tongue-tie surgery to heal?

Most people heal from the frenectomy procedure in 2-4 weeks. 

Read: Tongue-Tie Surgery Tips

 

How do I find a tongue-tie release provider?

Ask questions and be willing to travel to see the right person. One of the most important decisions is choosing the right provider.  Dentists and physicians are not created equal and some are not up to date on the proper diagnosis and treatment of tongue-ties. This makes it difficult because everyone is not on the same page.  Tongue-ties and the need for essential myofunctional therapy is not understood by everyone in the medical or dental profession.  

Here are some great questions to ask: 

1. How many releases do you perform each week?
2. What ages do you work with?
3. What method do you use and why?
4. Do you give instructions for wound management?
5. What are your thoughts on myofunctional therapy?

Choosing to work with an experienced provider, regardless of cost and location, will improve the success of the procedure.  The method doesn’t matter as much as the level of experience behind the method. It is important that a provider be able to explain what their method is and why they find it to be the best for their patients.  It is also important to choose someone who has experience with the age that corresponds to the patient. It is not recommended for an adult to see a provider who mostly works with infants. The process will be different and it would be a better idea to seek out a provider who has adequate experience with adults. 

The best provider will also have a complete understanding of adequate wound management and the importance of pre-and-post procedure myofunctional therapy.   In addition to feeling confident with the information found in this Ultimate Guide To Tongue-Ties, you could also learn more about questions to ask, or things to keep in mind when searching for a provider. 

Read: Considerations When Choosing a Frenectomy Provider

Read: Questions To Ask Your Doctor About a Tongue-Tie

 

What if I need to have a second tongue-tie release?

Sometimes this is necessary.  If a person originally had a frenectomy without completing adequate pre-and-post procedure myofunctional therapy, the need for an enhancement is common.  The good news is that with the correct myofunctional therapy beforehand, the procedure is usually successful the second time around. 

Another reason that a person might need a second release is simply that the tongue-tie was pretty significant.  This two-stage release is actually pretty common, and most myofunctional therapists will have this planned into the therapy framework. 

 

Building your comprehensive health care team

Tongue-ties are a “connective tissue issue”, impacting the whole body. It is important that you assemble your comprehensive health team to make sure you have all the people lined up who will help improve the experience. In addition to a myofunctional therapist, you may need to seek out a craniosacral therapist, chiropractor, cranio-osteopath, physical or massage therapist, or myofascial release specialist.

Read: Myofunctional Impairment?  Who You Should Have On Your Comprehensive Health Team

In my new video, The Ultimate Guide To Tongue-Ties, I introduce you to this incredible guide. Remember 90% of what I see is not easily identifiable. If you’ve grabbed your Getting Started Guide, you can use it while watching this video or reading The Ultimate Guide To Tongue-Ties!

 

What Should You Do First?

#1.  Read the Ultimate Guide To Tongue-Ties. Get a solid understanding that it’s not about tongue-tie appearance, it’s about oral function.  Regardless of what your doctor may be telling you, it doesn’t mean it is correct! 

#2.  Once you’ve read the Ultimate Guide To Tongue-Ties, find your myo person.  Getting an experienced myofunctional therapist to help educate you.  I’m not worried about the tip of the tongue as much as I’m worried about the back of the tongue.  The posterior blade of the tongue needs to function properly for a correct swallow.  In many, if not most of my clients the back of the tongue doesn’t move during a swallow.  This becomes a huge problem in my older population of clients because they are starting to choke, and it’s extremely difficult to relearn a new habit when you’ve been doing it wrong for decades.

#3.  Understand that it is a process.  I encourage you to read Tongue-Ties and Myofunctional Therapy: 2 Pieces of the Puzzle to help you further understand why this is so important.

#4.  Download the Getting Started Guide.

#5.  Read The Ultimate Guide To OMT.

#6.  Make an appointment with me so we can visit face-to-face and talk about your situation.  I give everyone 30 minutes of my time to help get you on the right path!  You can make a complimentary appointment here.