Like many of you, when I finished dental school, I had some idea of what a tongue-tie is and how it can impact speech and possibly gum recession. But in four years of dental school, we had only one slide on tongue-tie treatment, and in pediatric residency, we read only one article on tongue-ties, which was already ten years old and outdated. It wasn’t until our twin girls were born and the lactation consultant told us they had a tongue-tie that I dove headfirst into the rabbit hole to learn more about this condition.
It turns out that a restricted tongue or tongue-tie is quite common, with traditional estimates in the 4-10% range, but that estimate is mainly for one that is to-the-tip or close to it. So if you have ten patients a day, one patient is likely significantly tied. This statistic does not include less obvious or posterior tongue-ties, which can just as easily impact tongue mobility and function and therefore cause symptoms in many individuals, from babies to adults. A recent study from Brazil found that when properly assessing for tongue-tie, 32.5% of infants had a tongue restriction. In our office, in recently published research regarding our screening tool, we found that 26% of hygiene patients had significant symptoms and appearance that warranted a closer evaluation. So the number of patients affected is likely much closer to 20-25% in our dental offices. It’s extremely common, but just because something is common does not mean it’s normal. In the next few moments, I’ll give you the basics of tongue-tie assessment and symptoms, and point you to some resources if you want to learn more.
“Sticking the tongue out is the least specific test for tongue mobility. That’s one reason why so many patients go undiagnosed.”
Most medical providers will ask a patient to stick their tongue out to check the tonsils, and many also think that protrusion is a good test for tongue mobility. However, sticking the tongue out is the least specific test for tongue mobility. That’s one reason so many patients go undiagnosed. A better test is to check the elevation of the tongue. Ask the patient to open wide (without pain or discomfort) and lift their tongue to the incisive papilla behind the maxillary incisors. If they can lift less than halfway, they are significantly restricted. Some patients will “cheat” and not fully open their mouth when lifting, or without realizing it, the floor of the mouth will lift up to try to get the tongue higher. You can use a gloved finger to hold the floor of the mouth down when they lift to get an accurate picture of their true mobility. The functional grading system by Zaghi and Yoon says that if the patient lifts less than 25% of the way, it’s a grade 4 tongue restriction. Between 25%-50% is grade 3, 50-80% is grade 2, and over 80% is grade 1. To assess babies or children who are pre-cooperative, we use the knee-to-knee position and come from behind the head. Then use two fingers to lift under the tongue and isolate the frenum. This test is also useful during exams on adults to assess mobility during a hygiene check. You should check for a tongue restriction and assess mobility just like we screen for oral cancer. Oral cancer affects 1 in 10,000 adults. While obviously a very different diagnosis, tongue-tie affects an estimated 1 in 4 patients of all ages and can cause life-altering symptoms.[2,3]
Tongue elevation alone does not give us the full picture, and we have to marry symptoms and a patient’s quality of life with this clinical sign of tongue mobility. Now, if a patient is tied to the tip and can lift less than 25% of the way, it doesn’t take much imagination to see that they will have significant limitations and, therefore, many symptoms of a restricted tongue. What is interesting, though, is that some patients who can lift 75% also have significant symptoms that stem from restricted tongue mobility. So we use a screening tool, the TRQ, which includes fifteen of the most common symptoms and also asks the patient how significant these issues impact quality of life. If there is no impact on quality of life, then very likely no treatment would be recommended. With several symptoms and significant quality of life struggles, then it would likely benefit the patient to have the tongue-tie released properly.
The most common symptoms starting with babies are difficulty with nursing or bottle-feeding, painful nursing, choking or coughing, not getting full, slow weight gain, reflux, colic, gassiness, and excessive spitup or hiccups. They can have any combination of those symptoms, so nursing a tongue-tied baby doesn’t always hurt, and many tongue-tied babies do gain weight well. We use our infant assessment form that parents fill out with over 35 common symptoms, and we look at the general number of symptoms. Most of our patients have 10- 20 check marks on the form of significant struggles. We always recommend parents see a lactation consultant or feeding therapist before having an evaluation at our office to ensure that if there is another cause of these issues, that is addressed first. But with tongue-ties being so common, if your child or your patient’s baby has these similar symptoms, there is a very good chance there could be a tongue- or lip-tie (or maybe a less obvious posterior tongue-tie), so ensure to check appropriately.
The most common symptoms starting with babies are difficulty with nursing or bottle-feeding, painful nursing, choking or coughing, not getting full, slow weight gain, reflux, colic, gassiness, and excessive spit-up or hiccups. They can have any combination of those symptoms, so nursing a tongue-tied baby doesn’t always hurt, and many tongue-tied babies do gain weight well. We use our infant assessment form that parents fill out with over 35 common symptoms, and we look at the general number of symptoms. Most of our patients have 10-20 check marks on the form of significant struggles. We always recommend parents see a lactation consultant or feeding therapist before having an evaluation at our office to ensure that if there is another cause of these issues, that is addressed first. But with tongue-ties being so common, if your child or your patient’s baby has these similar symptoms, there is a very good chance there could be a tongue- or lip-tie (or maybe a less obvious posterior tongue-tie), so ensure to check appropriately.
For children, the three main areas we see issues are speech, solid feeding, and sleep quality. Most people, when they hear “tongue-tied,” only think of tripping over your words. In fact, all aspects of speech can be impacted by a tongue restriction, including speech delay, articulation (trouble with sounds, especially R, L, S, SH, TH, K, G), fluency (stuttering), effort to talk (getting tired while speaking), and even singing. We have recently released tight frenums on many singers, including opera singers and a member of a Grammy-award-winning band. At the same time, we had a patient recently who had a to-the-tip terrible restriction and had perfect speech articulation but had other issues that warranted a release. So you have to get a full assessment of related issues to determine the need for a release. Solid feeding issues include picky eating (especially with textures like meat or mashed potatoes), slow eating, choking or gagging, packing food in the cheeks, spitting out food, reflux, and even constipation. If the food doesn’t start the journey right, it won’t end the journey right!
Sleep issues include teeth grinding, snoring, restless sleep, mouth breathing, bedwetting, and other related airway issues. We are taught in school that bruxism is simply “stress-related.” I would agree in part, but it’s not necessarily psychological stress (it can be!) but rather physiologic stress. Your tongue is supposed to rest fully suction-cupped to your palate. (Where is your tongue right now?) If it rests in the middle or down, it has a tendency to fall back into the throat while you are sleeping. If you can’t breathe because your tongue is flopping back and restricting airflow while you are sleeping, your brain gets less oxygen and tries to put your body (restless sleeping) and your jaw (bruxism) in a different position to breathe better while also increasing sympathetic tone. The end result is poor sleep quality and fragmented sleep, which can lead to attention issues, hyperactivity, behavior issues for children, and brain fog or lethargy for adults. We see positive, life-changing results in speech, feeding, and sleep after a proper release in our office, and also when combined with therapy like myofunctional therapy, which helps to retrain the muscles to have proper resting posture and nasal breathing day and night.[7,8]
Adults with a tongue restriction will struggle with neck and shoulder tension, sleep issues like OSA, poor sleep quality, snoring, bruxism, mouth breathing, brain fog, fatigue with talking or singing, difficulty with sounds or mumbling, or possibly eating issues like slow or picky eating (there are 50 or so items we see related to adults). I had a restricted tongue for 30 years and didn’t realize it, so if I’m describing you, seek out a consultation with a knowledgeable provider!
How do we treat a tongue restriction? We always work with a team approach, so we want a baby working with a lactation consultant, a child working with a speech or feeding therapist, and an adult working with a myofunctional therapist before the release. Additional bodywork, therapists, and medical providers are also needed depending on the symptoms and complexity. Otherwise, it would be like having knee surgery but no physical therapy. Your outcome will be suboptimal. After taking a comprehensive history, a full assessment (coming from behind the patient), and checking tongue mobility, we discuss these findings with the parents. A proper release would involve releasing the mucosa and fascia (connective tissue) above the genioglossus muscle. We always stay midline to avoid the lingual nerve or deep lingual vein. The genioglossus muscle limits the depth of the release. A diamond-shaped window under the tongue is opened using various methods, including scissors, scalpel, electrosurge, diode laser, erbium laser, or CO2 laser.
Heat-based methods like electrosurge and diode laser can have unwanted collateral thermal damage but have minimal bleeding. Scissors or scalpels can be dangerous as they are sharp, and patients often move (at least a little bit) during the procedure since it is done under topical anesthetic for babies and young children and local anesthetic (a quarter carpule injected into the frenum) for an older child or adult. Also, as soon as one cut is made with a blade or scissors, it will start to instantly bleed and obscure the surgical site, preventing accurate follow-up cuts or identification of important anatomy. Also, bleeding must be stopped or controlled before returning the infant to the mother, or imagine a toddler spitting blood everywhere – not ideal! We used a diode laser for 18 months, and while effective at hemostasis, it was slow – about a minute per area. Two minutes on a crying baby can seem like an eternity. It also burns the tissue with a white-hot glass tip around 700-1000° C,[9,10] so it is not optically cutting the tissue as erbium or CO2 lasers do by vaporizing at 100° C, the boiling point of water. Without going too much into laser physics, erbium lasers in the 3000nm range have good cutting efficiency due to the high absorption of that wavelength in water, but they have poor coagulation. However, CO2 lasers at 9300 nm and 10,600 nm have high cutting efficiency (absorb well) as well as good hemostasis, so these are the ideal tools for the procedure for anyone who performs these procedures on a daily basis.
“We always work with a team approach, so we want a baby working with a lactation consultant, a child working with a speech or feeding therapist, and an adult working with a myofunctional therapist before the release… Otherwise, it would be like having knee surgery but no physical therapy.”
With the CO2 laser, it takes around 10-15 seconds per area to release the tissue fully. So treating a crying baby is very quick and simple, or a pre-cooperative toddler can sit still for the 10-second procedure with parents holding their hands, and treatment is no more traumatizing than a typical vaccine. Afterward, parents must stretch the wounds, or the tissues will reattach and close up again, limiting mobility. It would be the same as getting your ear pierced and then not wearing the earring. We recommend stretches on babies four times a day for 3 weeks. Toddlers and older children are twice a day for 3 weeks. Each stretch is simply massaging with gentle but firm pressure (around 10 seconds) on the wound to “trick” it into healing open instead of sticking back together.
With a proper release (diamond shape), appropriate aftercare, and follow-up at one week and more often as needed, symptoms improve in most cases. Leave a step out, and don’t expect improvement. If a tongue is clipped with scissors halfway with no aftercare or follow-up, then there won’t be much improvement. Unfortunately, this is often the case in hospital nurseries, ENT offices, and pediatrician offices, so tongue-tie treatment has been dismissed as a fad or unsuccessful. Each step must be carefully considered before treating, so if you are interested in treating these patients, seek extra training before purchasing a laser or using scissors to release restricted tissue.
For next steps, I’d recommend checking your existing patient base. Ask them questions when you see a tongue restriction. “Hey, mom, Johnny’s tongue appears tight. Any speech, feeding, or sleep concerns for him?” Be curious and open-minded. To learn more, we have a bestselling book on Amazon called Tongue-Tied that dives into more detail. To learn to do the procedure, we have an online comprehensive course, Tongue-Tied Academy, with 25 hrs of bite-sized Masterclass-style video lessons that have helped train hundreds of dentists. We donate 100% of the proceeds of the book, the online course, and our Advanced Live Patient Course at our office to charity. We truly want to help educate providers so they can best serve the patients in their care. Thank you for taking the time to educate yourself on this common condition, and you will probably see a tongue-tie (or three!) tomorrow at the office!
About the Author
Dr. Richard Baxter is a board-certified pediatric dentist, Fellow of the AAPD, and Diplomate of the American Board of Laser Surgery. He is an internationally recognized speaker on tongue ties, instructor of the online course Tongue-Tied Academy, and lead author of the bestselling book Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. He is passionate about educating parents and healthcare providers about the effects a tongue-tie can have throughout the lifespan. He lives in Birmingham, AL with his wife, Tara, and their three girls, Hannah, Noelle, and Molly. He is the founder and owner of the Alabama Tongue-Tie Center where he uses the CO2 laser to release oral restrictions. He had a tongue-tie himself, and all of his girls were treated as infants, so this field is a personal one. In his free time, he enjoys spending time with his family, running, and doing outdoor activities. He serves as a small group leader at his church and is on the board of Reach the Rest, a global missions organization.
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