speech therapy exercises for ankyloglossia

Tongue Tie and Speech Therapy

Tongue tie, also known as ankyloglossia, is a condition in which the bottom of the tongue is tethered to the floor of the mouth. The connecting band of tissue, called a lingual frenulum, is sometimes so strong that the condition may ultimately interfere with feeding, speech, and hygiene. 

Tongue tie is relatively common. In some cases, parents can opt for surgical treatments that remove the connective tissue. However, others may feel more comfortable with a wait-and-see approach before scheduling treatment. 

You should consult with your child’s pediatrician and with a speech language pathologist to determine if your infant’s tongue tie may cause problems down the road. It is very difficult to know how the limited lingual movement will impact skills in the future. Professionals are often making their “best guess” and relying on past experiences. 

What is Tongue Tie?

The cause of tongue tie is, essentially, a lack of separation between the tongue and the bottom of the mouth. When an infant is in the embryo stages, these areas of the mouth are fused. As the embryo grows, the tongue and the bottom of the mouth differentiate. Tongue tie occurs when this differentiation process is left incomplete.

When the tongue is not sufficiently separated from the floor of the mouth, several common activities can become challenging for infants and children:

• Feeding can sometimes be more challenging for infants, as the tongue can be limited to its ability to latch onto the breast or bottle.
• Children attempt to compensate for limited lingual range of motion so they create compensatory behaviors creating tongue movements that do not enhance feeding skills or speech sound productions
• Food can get caught beneath the tongue, leading to poor oral hygiene.
• Difficulty making some common speech sounds, such as “l,” “r,” “th,” “d,” “z,” “s,” “n”, and “t.”

Treatment for tongue tie can take several different forms. In some cases, a simple surgical procedure can sever the tissue tethering the tongue to the floor of the mouth. A surgeon will then provide the child with exercises that are designed to develop muscle movement and build kinesthetic awareness. However, surgery is not always necessary or advised.

Speech Therapy for Tongue Tie

The surgical procedure that severs the connective lingual frenulum is called a frenulectomy (or frenuplasty for more substantial tissue removal).

These two surgical procedures were once common ways to treat tongue tie, but both have waned in popularity over the years. In fact, there’s much debate in the medical community regarding the utility of surgery, so the decision will often come down to a family’s specific needs and the recommendation of their pediatrician.

Whether parents opt for surgery or not, children will likely benefit from speech therapy. For kids who have undergone a surgical “tongue clipping” procedure, a speech therapist will:

• Help develop new muscle movements that can help with enunciation.
• Improve awareness of the total range of motion that the tongue can present. Your child may have become quite accustomed to a limited range of motion.
• Address other speech delay issues that may have been inaccurately attributed to your child’s tongue tie.

Likewise, kids who have not undergone surgical correction may find speech therapy provides an essential avenue to develop vital speaking skills. For these children, a speech pathologist will:

• Work with your child to address speech delays that might be associated with tongue tie.
• Develop alternative tongue positions that your child may not have discovered on their own.
• Address other speech delay issues that may be inaccurately attributed to your child’s tongue tie.

Does T ongue Tie Always Require Speech Therapy?

While it’s true that the lingual frenulum may limit tongue mobility, some children may find other ways to compensate for limited tongue movement during speech. These alternative tongue positions may be just as effective as traditional tongue placements; however, the distortion in movement may impact other phonemes.

In this way, children may develop alternative ways to pronounce “d” or “t” sounds , for example. However, the sounds that may become most challenging for children with tongue tie are the “th”, “r”,  and “l” sounds, largely because it’s challenging for children to find alternative tongue positions that are effective with those sounds.

This is why evaluation is such an important step. Your child’s speech language pathologist will be able to examine which speech sounds your kiddo is pronouncing effectively and which might need a little extra work. 

Making Decisions About Tongue Tie and Speech

Tongue tie isn’t common, but it’s not exactly rare either. Somewhere between 0.2 and 2% of infants are born with lingual frenulums that are considered abnormally tight or that restrict movement. It’s also important to note that not all cases of tongue tie are equally severe, and it might be challenging to forecast just how much your child’s case may interfere with their daily lives as they grow.

That’s why decisions about tongue tie are not always cut and dry. There are varying degrees of treatment options from minor clipping of the lingual frenulum to more substantial removal of tissue. Most parents will make a decision about treatment possibilities in consultation with a pediatric surgeon and speech language pathologist.

If you have questions about what to expect if your child has tongue tie, a speech language pathologist will be able to tell you how the condition may impact certain speech capabilities. A speech language pathologist will also be able to recommend therapy options both before and after possible surgical treatment.

With the right approach, your child can enjoy meaningful communication and you can make informed decisions about your child’s tongue tie. Please contact us to learn more or schedule an appointment.

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

• Vaccines  
• Masking Guidelines
• Visitor Guidelines  

Tongue-Tie (Ankyloglossia)

The tongue attaches to the floor of the mouth with a web of tissue called the lingual frenulum. Tongue-tie, or ankyloglossia, is an inborn variation in this structure. The lingual frenulum may be shortened or thickened, restricting movement of the tongue, or it may tether the tongue too close to the tip.

Tongue-tie may affect an infant’s ability to latch effectively during breastfeeding and can cause maternal symptoms during breastfeeding, as well. Rarely, tongue-tie may cause mechanical difficulties in the child’s speech and oral hygiene.

What You Need to Know

• Tongue-tie typically affects boys more often than girls.
• Tongue-tie is not the only reason for breastfeeding difficulty.
• Surgical treatment of tongue-tie may not improve breastfeeding.
• Tongue-tie does not cause speech delay, but can affect a child’s speech articulation —the ability to form sounds and pronounce words.
• Tongue-tie diagnoses are increasing as breastfeeding becomes more commonplace.

Tongue-Tie Diagnosis

Variations in the underside of the tongue and how it attaches to the floor of the mouth are common and most are not cause for concern.

Tongue-tie may be suspected in infants or children who have difficulty with the following:

• Breastfeeding
• Lifting their tongue
• Sticking the tongue out (the tongue may appear notched or heart-shaped when the child attempts to do so)
• Moving the tongue from side to side
• Licking their lips or sweeping food debris from the teeth

The Coryllos ankyloglossia grading scale is a system for noting the type of tongue-tie.

• Type I : The frenulum is thin and elastic, and anchors the tip of the tongue to the ridge behind the lower teeth.
• Type II: The frenulum is fine and elastic, and the tongue is anchored 2 – 4 millimeters from the tip to the floor of the mouth close to the ridge behind the lower teeth.
• Type III: The frenulum is thick and stiffened, and anchors the tongue from the middle of the underside to the floor of the mouth.
• Type IV: The frenulum is posterior or not visible, but when touching the area with the fingertips, the examiner can feel tight fibers anchoring the tongue, with or without a thickened, shiny surface on the floor of the mouth.

A thorough evaluation considers not only the Coryllos grade, but also how well the child’s tongue is able to move. The Hazelbaker assessment tool for lingual frenulum function (HATLFF) or a similar tool, can be used to assess tongue function.

An otolaryngologist specializing in pediatrics can provide guidance to concerned parents. If the main complaint is difficulty in breastfeeding, a lactation consultant or infant feeding expert can help assess breastfeeding and provide non-surgical interventions.

Tongue-tie Treatment

If tongue-tie is interfering with feeding, speech or oral hygiene or if it is causing discomfort, treatment may be appropriate.

Frenotomy (also called frenulotomy) is a surgical procedure to release the frenulum so the tongue can move more freely. Most babies can feed immediately afterward.

Frenuloplasty is for more complex cases of tongue-tie or for revision procedures, and involves plastic surgery of the frenulum. Speech therapy and tongue exercises may be part of the recovery process.

While the procedures are, in general, safe, there are risks that can occur with frenulum procedures, including severe bleeding, infection, injury to the salivary ducts, and worsening breathing. A child should be assessed for possible contraindications to a frenotomy procedure.

Find a Doctor

Specializing In:

• Tongue Tie Ankyloglossia

Find a Treatment Center

• Dentistry Oral and Maxillofacial Surgery
• Oral and Maxillofacial Surgery and Dentistry
• Pediatric Otolaryngology (Johns Hopkins All Children's Hospital)
• Pediatric Otolaryngology (ENT)

Find Additional Treatment Centers at:

• Howard County Medical Center
• Sibley Memorial Hospital
• Suburban Hospital

Request an Appointment

Anatomy and Development of the Mouth and Teeth

Care of the Mouth and Teeth

Hearing Loss in Children

Related Topics

• Babies and Toddlers: Teething and Dental Health
• Vascular Anomalies

Tongue Tie Speech Therapy

Convenient & Effective Speech Therapy

What is a tongue tie?

A tongue tie, also known as ankyloglossia, is a condition where the tissue that connects the underside of the tongue to the floor of the mouth (called the lingual frenulum) is shorter, thicker, or tighter than usual. This can limit the movement of the tongue and potentially affect various functions and activities involving the tongue.

Tongue ties can occur in varying degrees of severity, ranging from mild to more pronounced. In some cases, it might not cause significant issues and might go unnoticed. However, in others, it can lead to difficulties with activities such as breastfeeding, speech articulation, and oral hygiene.

Breastfeeding: Infants with a severe tongue tie might have trouble latching onto the breast properly, leading to breastfeeding difficulties for both the baby and the mother.

Speech Articulation: As a child grows and starts to develop speech, a tongue tie could potentially affect the ability to pronounce certain sounds correctly. It might lead to issues with sounds that require significant tongue movement, such as "t," "d," "l," and "r."

Oral Hygiene: A tongue tie can sometimes make it harder to clean the mouth properly, potentially increasing the risk of dental issues like cavities or gum disease.

ROLES OF THE SPEECH THERAPISTS

What are the roles of the speech therapist when treating tongue tie?

Speech therapists can play a supportive role in the treatment of tongue ties, especially in cases where the tongue tie is impacting speech and communication. While the primary treatment for tongue ties typically involves a medical procedure called a frenotomy or frenuloplasty performed by a medical doctor (often an ear, nose, and throat specialist or pediatric dentist), speech therapists can contribute to the overall care and management of individuals with tongue ties in the following ways:

Assessment and Evaluation: SLPs can assess the impact of the tongue tie on speech and communication. They evaluate the range of motion, strength, and coordination of the tongue.

Collaboration: Speech therapists collaborate with medical professionals, such as pediatricians, ENT specialists, and dentists, to ensure that the decision to proceed with a frenotomy is well-informed and coordinated.

Preoperative and Postoperative Support: Before the medical procedure, SLPs may provide information and education to the individual and their caregivers about the expected impact of the procedure on speech and communication.

Speech and Language Therapy: For individuals whose tongue ties have impacted speech production, SLPs can provide targeted speech therapy interventions to address any compensatory behaviors that may have developed due to the tongue tie.

FORMS OF TONGUE TIE TREATMENT

What are some forms of treatment for tongue tie?

Here are some speech issues that may arise when treating tongue ties:

Limited Tongue Mobility: The primary issue with a tongue tie is restricted tongue movement. This limitation can affect a person's ability to produce certain speech sounds and engage in oral-motor activities necessary for speech and feeding.

Articulation Difficulties: Tongue ties can lead to articulation difficulties, particularly with sounds that require a free and flexible tongue movement, such as "l," "r," "s," and "t." A person with a tongue tie may have difficulty pronouncing these sounds correctly.

Speech Sound Errors: Due to limited tongue mobility, individuals with tongue ties may substitute sounds or distort speech sounds, making their speech less intelligible.

Feeding and Swallowing Issues: In infants, a tongue tie can lead to difficulties with breastfeeding or bottle-feeding, as the baby may have trouble latching onto the nipple properly. Speech therapists may need to work on feeding issues in addition to speech difficulties in these cases.

Oral-Motor Challenges: Limited tongue movement can affect oral-motor coordination, making it harder to perform the precise movements required for speech sound production.

TONGUE TIE SPEECH THERAPY TECHNIQUES

What are some common tongue tie speech therapy techniques?

Speech therapy techniques for individuals with tongue ties focus on improving speech sound production, articulation, and oral motor coordination. Here are some common techniques that speech therapists might use to address speech difficulties associated with tongue ties:

Tongue Mobility Exercises: These exercises help improve the range of motion and flexibility of the tongue. The goal is to gradually increase the tongue's ability to move freely for accurate articulation. Activities may involve touching specific areas of the mouth, tongue stretching exercises, and lateral tongue movements.

Tongue Placement Practice: Speech therapists work with individuals to teach proper tongue placement for different speech sounds. Visual and tactile cues may be used to guide the correct positioning of the tongue within the oral cavity.

Articulation Drills: Targeted practice of specific speech sounds that are challenging due to the tongue tie can help the individual develop accurate articulation patterns. This involves practicing the correct tongue movements and placements.

Strengthening Exercises: Oral muscle strength is important for clear speech production. Speech therapists might provide exercises that involve blowing, sucking, or pressing the tongue against various surfaces to strengthen the tongue muscles.

BENEFITS OF SPEECH THERAPY FOR TONGUE TIE

What are the benefits of speech therapy for tongue tie?

Speech therapy can be very beneficial for individuals with tongue ties. Here are some of the benefits of speech therapy for individuals with tongue ties:

Improved Articulation: Tongue ties can affect the movement of the tongue, making it difficult to produce certain speech sounds accurately. Speech therapy can help individuals learn proper tongue placement and movement for clear articulation of sounds.

Enhanced Pronunciation: Tongue tie can lead to difficulties in pronouncing certain sounds like "l," "r," "t," and "d." Speech therapists work on specific sound production, helping individuals overcome pronunciation issues.

Phonological Development: Tongue ties may lead to patterns of speech errors and substitutions. Speech therapy can address these phonological patterns, helping individuals acquire age-appropriate speech sound development.

Enhanced Speech Intelligibility: Clearer articulation and improved speech sound production resulting from speech therapy can lead to increased speech intelligibility, making it easier for others to understand the individual's speech.

Oral Motor Coordination: Individuals with tongue ties may struggle with oral motor coordination. Speech therapy exercises and techniques can help improve tongue and oral muscle strength, flexibility, and coordination.

Boosted Confidence: Speech difficulties associated with tongue tie can sometimes lead to self-esteem issues, especially in children. Speech therapy can boost confidence by providing tools to overcome speech challenges.

Clearer Communication: Effective communication is crucial in daily life. Speech therapy helps individuals communicate more effectively, reducing misunderstandings and improving interactions with others.

How to Improve Your Speech?

Join Better Speech

We'll Match You With  the Ideal Therapist

 No Waitlists - Start This Week

Improve Speech

Live Weekly Zoom Sessions 

150+ Licensed and Experienced Therapists

Our  speech therapists  are all licensed and certified, with ~10 years of experience. We cover every state in the USA. We offer speech therapy services for children   and   adults.

WHY PEOPLE LOVE US

Our Shining Testimonials

It's really convenient, easy and affordable. My son speech really got better.

We have seen our son just explode in terms of speech, language and confidence.  It gets our highest recommendation! 

I love the flexibility of the online schedule. Also with insurance, it was a fraction of the cost of a clinic, I wish I have tried Better Speech sooner. 

Get Free Guide to Improve Speech

Improve your communication skills

Improve your child’s speech

EPISODE 6:  Making Sense of Myo: Ankyloglossia, Voice, and Fluency

[INTERVIEW]

[00:01:04] MM:  Hello. Welcome, everyone, to another episode of Making Sense of Myo. My name is Madi Metcalf, and I will be your SpeechTherapyPD.com host for this episode for this podcast. Before we get started, we have a few items to alert you to. This episode is 60 minutes and will be offered for 0.1 ASHA CEUs. This evening, Patty Fisher will be our guest, and we’ll talk about how ankyloglossia or a tongue-tie can impact voice and fluency. As a reminder, so this is part of a larger series. So if you have questions about why are we looking at tongue-ties or how is that impacting other areas of our craniofacial complex, you can go back and listen to some previous Making Sense of Myo episodes.

Patty's financial disclosures includes that she receives an honorarium for this podcast. Her non-financial disclosures include her position of parliamentarian of the International Association of Orofacial Myology. She is also a member of the American Association of Speech and Hearing and the American – yes, sorry guys. And the telepractice thing. She's also an active in the Ohio Speech-Language-and-Hearing Association. Patricia is a speaker at these organizations, and she mentors. 

For myself, I receive an honorarium for hosting this podcast, and I do not have any relevant non-financial disclosures. We'll be taking questions as they are relevant to the content of our conversation throughout the episode. Then we'll also have a Q&A at the end. So if I don't ask you a question in the middle, we'll definitely get to it towards the end of the episode. 

Patty Fisher currently works with Speech and Language Associates of Dayton, providing services in the Dayton and Cincinnati, Ohio areas. She is certified in Orofacial Myology and Lidcombe,  an  Australian-based program for children that stutter. Patty has served as an adjunct faculty member at Miami University in Ohio and for the College of St. Rose in New York.  She is a fellow and has received Honors of the Association in Ohio. In addition, Patty has chaired the Consumer Affairs, Insurance Initiative, and Student Scholarship committees and was the Director of Public Information. She is a post-parliamentarian for the International Association of Orofacial Myology. She was honored to complete a research project with the Max Plank Institute in Germany on the effects of Orofacial Myology. 

Patty's returning to SpeechTherapyPD.com. She's been featured on the Speech Link Podcast, where she discusses methods to improve parental involvement on teletherapy and of the two-hour grand rounds discussing the relationship between ankyloglossia orofacial myology and voice. Now, without further ado, we welcome Patty Fisher to this evening's episode of Making Sense of Myo. Hi, Patty. 

[00:03:36] PF:  Hi. Boy, that was a long way to say hello, wasn't it? Thank you very much. I do want to make sure I am the past parliamentarian for the IAOM. But I'm no longer a parliamentarian. 

[00:03:49] MM:  S o sorry about that, that I misspoke there. 

[00:03:51] PF:  That’s okay. They made – you move on. 

[00:03:56] MM:  All right. So can we start off by first talking about what is an orofacial restriction or limitation?

[00:04:05] PF:  Yes. I'm kind of glad we're going to start there because it happens to be the papers I have out in front of me. But it’s like that. I think it's a good place to start. A lot of people only look at like, “Oh, tongue-tie,” and that's about the only thing they're thinking about. But really, in our history as speech pathologists, we all know so much more than what we give ourselves credit. The things that when I went through school, we didn't spend as much time as maybe I would have liked to learn how to do a good orofacial examination, and I kind of had to learn along the way. Maybe I stumbled a few times, but it has become so important to my overall practice. 

So I want to make sure all of you have the same kind of background or look at it the same way. I know that when I look at the face, I start my diagnostics when the people are in their waiting room. I'm looking at the way they breathe and the way they interact, just the way they carry themselves. So one of the things when we do get into the mouth, we've all been taught to look to see the tongue, to look at the sides of the cheeks, the teeth, the pallet, that kind of thing. But the one thing that no one ever told me to do was lift that tongue and look under it. It was kind of a surprise to me one day when I started doing it. Oh, my gosh. I'm missing a lot of information. 

So the things that I look for overall in my questionnaire, I start to ask about how the child fed. Were they bottle-fed? Did they have nursing? Were they – did they have a [inaudible 00:05:41]? Did they have thumb sucking? So that would be one of the first things I start. That's a possible impairment or an obstacle. I look then to see if they have any upper airway disorders such as allergies, nasal congestion, obstructions, that kind of thing. As I'm doing the diagnostic, I'm working with the parent every step of the way. 

The third thing I look for is trauma or disease. I'm looking to see if there's something like thyroid issues or cancer, those kinds of things. You think maybe that wouldn't happen with a child. I will tell you, the first assignment I had in the first class I did an evaluation, the first child I met ended up having cerebral palsy. About three children later, the child was perfectly normal as far as I could tell, but he couldn't hear.

The fifth child I saw, I put in my little otoscope, and I saw that the light reflected back at me through the ear, there was cancer all through the jawbone. It turned out that these three children, families, I had to call my first night, and they were all related. They thought this new speech therapist within their town was nuts. But all three of those cases, it's true. That's what they had. But my evaluation, if I hadn't been looking for all those things, I really shudder to think what if I had missed. So it's sort of an important part. 

Even though we don't expect those traumas, even in young children, I look, of course, for the older people. I look to see if there's a history of Bell’s palsy, maybe multiple sclerosis or even vocal cord damage. But that's easier to identify in an older patient. But when you're looking for children, you have to make sure you're looking for the traumas as well. Another possible ideology or an atypical or what you might call an obstacle would be large tonsils or frequent sore throats, infections. It's funny because lots of families will say, “Oh, no. We don't have those kinds of things,” because they've only been to the doctor six or seven times that year. In my mind, I'm thinking, “Oh, my goodness. For every episode, that's maybe six weeks of affected area where they're not breathing normally.” 

So I really go through that kind of thing as well. I look for the thumber, thumb, finger, or tongue sucking. Most people, I think we're not trained to look for the tongue sucking, but that's the one that's hidden, and that's the hardest one to change. Then I also look for the structural limitations. That's where, of course, our tongue-ties come. It's interesting because when I first started, I had to see the tie under the tongue, and I had to see the heart shape and all the things that were normal characteristics. 

But as I've started to work, I now can look at the top of the tongue and see the dimple that tells me, “Oh, there's a restriction in the middle of the tongue.” I almost can hear when they talk now because I've gotten so accustomed to it, and I'll hear that they don't lift the middle part of the tongue, or they talk using the middle part of the tongue instead of the tip. As you get into orofacial myology, your abilities to be a speech pathologist and to hear and to identify those errors is going to sharpen. 

I wonder now how I ever survived before I started to understand this complex. It's amazing to me, but yet I wasn't trained. I don't think many of us were trained to pick that up early. I don't know about you, Madi. 

[00:09:17] MM:  Yes. No. I had no idea. I remember like one of my first patients. I was like sitting. I was like [inaudible 00:09:23]. They go [inaudible 00:09:23]. They go [inaudible 00:09:24]. They go [inaudible 00:09:25]. They were like thrust their tongue forward. I was like there's something going on. This kid is not able to like find this bracing. So that was the first patient that I started looking at the mouth a little bit differently. But I just learned, you know. You just work on the sounds, but there's so much more than just the sounds. 

I love that you already touched on some of these kids that have tongue ties are not moving their tongue the right way, or they're using the mid-blade to say some of those like lingual alveolars versus the tongue tip because that's been a huge kind of reoccurring theme is that we have to not just judge articulation based on the acoustic property but also what the placement looks like because that is a huge piece of this puzzle. 

[00:10:02] PF:  Right. You know what's also interesting, and I wonder if there are other speech therapists that will admit this, because I used to supervise at the university and, obviously, clinic, looking at diagnostics, and I can remember almost all my bright, beautiful graduate students. They come in, they give a beautiful articulation test, and they were accurate, writing and doing all this. They'd say words, but not once would they look up. They just write what they heard. So they never got the advantage of being able to look. I probably was doing it, too. But until I saw my students do it, it didn't dawn on me that, oh, my goodness, we're missing a whole show right in front of us. 

[00:10:43] MM:  Right. Absolutely. 

[00:10:45] PF:  It was interesting because I think that's normal. I think we do that. We don't understand that we should be looking, listening, and that the function is just as much important as the structure. But those are the basic ones that I look at, as far as looking for the tongue tie. One of the things that was in occurrence to me, when we're talking about having articulation disorders, I think that one's easy for people to understand that if you have a restriction, you're going to have that affect your production. 

But I can still remember. I would go and where I went to school, we had really great professors. They were the kind of people I was a little bit afraid of, but I can still remember one. Particularly, Dr. [Cowstall 00:11:34] would always talk about the function, the function, and all these kind of things. He was always into research. I remember when it dawned on me, when I finally understood the words that this oral complex, primarily, the function of it is to breathe or for [inaudible 00:11:53] to eat. These are biological factors, and you have to have those to live. 

I remember thinking, “Yes, that makes sense.” But the overlaid or the secondary functions, of course, were speech, voicing, using your mechanism to play an instrument, all those, or singing. We as speech pathologists sometimes grab the dog by the tail, and we're working on the sounds or we’re working on the voice. Or we're working on the fluency before working on the mechanism that making sure the primaries are working correctly. I remember when that dawned on me. I thought, oh, my gosh. This is really hard to understand that I would have missed that, but no one never kind of directed me that way. All they would talk about was the function, but they never told me the differences. I'm sort of a you got to give me the dots or the crumbs or I won't get there. I need everybody to give me a little help. 

[00:12:51] MM:  Absolutely. Don't we all?

[00:12:53] PF:  Yes. So that's where I am as far as the diagnostic. But one of the things that it led me to was – and the reason I am doing a lot of different diagnostics, I work with a study group of my dentist, orthodontist, and the ear, nose, and throat specialist in our area. I was fortunate to be invited to come to it. Then, of course, because you're invited, you better produce something. I remember sitting down at the table, and they were all giving something, and I thought, “Okay.” I scribbled this out one day and put it up, and it was – they liked it a lot. But I don't know if you've ever thought about the things that we know as speech therapist and we look for. 

I know that I always was aware of things like apneas, the OSA kinds of things, the breathing. I would consider that, and I did a chart to show them the difference between having upper respiratory resistance syndrome and what ends up to be OSAs. They just loved it in the fact that it kind of gave them something that we, when we're looking at young children, look at and then what they would see that turn into as adults. It was an accident. I was trying not to look foolish, but it has become a pretty good chart, and I use it now more and more. I think sometimes the things that we make out of haste turn out to be pretty good, so. 

[00:14:27] MM:   I have one question about diagnostic. You mentioned that heart-shaped tongue tip. Do you have to have that classic heart-shaped tongue tip to have a restricted frenum?

[00:14:37] PF:  No,  you don't. I think that's the important part that I want to make sure everybody understands. We know what we classically see as a tongue-tie, and we know what we're looking for. Yes, those are usually characteristics, or there'll be a restriction. But what's interesting is that not all restrictions need any alteration. I have a tongue-tie. It's a posterior tie, but I can do what I need to do. I think because I do the stretching exercises with my clients maybe 6 to 10 times a day, I may have a nice stretched mechanism. 

But there was a period of time when I went, was younger, where they told us, “We didn't do any tongue clippings or we didn't have anything like that.” But I think we have to come to a point where we realize sometimes someone needs a restriction relieved, and some of them don't. You got to know the difference, and you got to work with that. I hate the idea of one-size-fits-all for anything. 

[00:15:40] MM:  Absolutely.

[00:15:41] PF:  So I know that when I get my referrals, one of the things – most of my docs and I get a lot of referrals from oral surgeons now. I'm surprised. They've kind of jumped on board and want a lot more. Once I was able to describe to them that I try to introduce to somebody who might be a candidate, we do volitional exercises to see what they can do. Then I move them into neuromuscular exercises. See what outside influences can help them. The third level is I work on the stretches. I like very much to have the doc kind of go through it, too. 

Just recently, I had one of the dentist who's just a phenomenal dentist brought their child and sat in on every session. Then unbeknownst to me, they went and gave a talk at their study group, their private study group, and explained that you can't just read about this exercise and do it. There was so much more about learning how to move and what to check and how to stabilize the jaw. I don't think I could have ever done it if she hadn't sat there and watched every step. Then she turned to me three different sessions. She says, “If I weren't used to being in a person's mouth, I couldn't do this, and I couldn't understand it.” 

Yet we have a lot of people writing page after page, “Here's your exercise. Go home and practice it,” instead of learning the actual step and the movement. It’s amazing to me, but that's what's going on. So anyway, I'm working more and more on trying to do those volitional exercises, the neuromuscular, the stretching because they are the same exercises you need to do when you recover. 

[00:17:32] MM:  Would you – I know this wasn't one thing that we talked about, but you've piqued my curiosity. Could you explain the difference between these volitional oral motor exercises versus the neuromuscular reeducation exercises or the neuromuscular?

[00:17:44] PF:  I'll try. I don't know if it'll make sense, but volitional exercises are when you are teaching your client or asking them to do something that they have complete control over. So like lifting and putting the tongue down or in and out. But I teach them so that they have the jaw stabilized, and they're showing the upper teeth. That increases the musculation of the risorius muscle, the buccal muscle, and the masseter muscles. They voluntarily control the movement of the tongue, and that's the range. 

Now, after you have a release, within the first 24 hours after that release, they have to do volitional or voluntary exercises. But nothing will hurt because they will only do what they can control and what they will feel comfortable doing. The next level is the neuromuscular, and that's where you – you probably remember when you used to do these exercises where your own muscles against your own muscles to make them stronger or that kind of thing. Neuromuscular is where you are using brushing, icing, or tapping. All the muscles are around the main muscles respond and support the main muscle. So that's why you're doing it. You're helping the muscle learn. 

Like when they're going to – after they've had a release, they learn to point their tongue with aid that you can physically give them, and they get the feedback or ice so that they feel cold and they move their tongue to cover that position. It's a very interesting response. I'm so surprised at how well they can do it. It’s one of those um exercises that the parent really participates, and they really start to understand the movements. 

Then the last level, of course, is where we do the stretchings, where I go in to the molars, under the tongue, and we trace along the bottom and up the side of the frenum. They’re like Js on both sides. Then I do it down the front. But I try to teach the parent, and they're the one doing it with their child. Or the adult does it for themselves. It gives them power. They also know. I do this volitional exercises within 24 hours. I do the neuromuscular within three days. I start in with my stretching again within five days. When the diamond forms under the tongue after the release and falls, then I start the front stretches.

There is timing, and it just allows them to feel comfortable. They know what to do and also what they should eat or shouldn't eat kind of thing. So that it's easier for them to get through this session, through the period, and they recover quickly. 

[00:20:43] MM:  Elizabeth asked if you have any resources for learning about the process on volitional muscular, the neuromuscular reeducation exercises. 

[00:20:52] PF:   I've got something I kind of wrote up. It will help you. It'll guide you a little bit. But I don't know if you took any courses. Like when I got my com, I had to research it. I looked up to see who had done and written the neuromuscular exercises. It was Dr. Falk. I looked up his original studies, and I can get to that information. You can look at it. It's hard to read. I think it's very short, but it's hard to read because it was written so long ago. But the exercises are good, and they're helpful. 

What's – their results were kind of impressive because anyone who went through that program that they did, they don't report very many relapses because people just – the muscles responded. The supporting muscles helped. I don't always use it, but I use it when I have to. It's particularly helpful for kids or people who have other challenges such as some neuromuscular or even some of our challenged kids that we would be afraid to try these exercises, but the other kinds of things. 

I can give you that, but you look up Dr. Falk. It’s Marvin Falk, and he did the information. I know that originally, when they brought neuromuscular exercises over here, we had – they were taken from Australia, and there was a nun who was a nurse who did a lot of those kinds of exercises on patients that had polio. Then they brought them over to the United States somewhere in the 1930s, 1940s. They started doing those kinds of exercises. 

Particularly, Kaiser, you probably remember that name, he had a son that had polio, and he needed the exercises done. So he backed it, and there was a lot of money put in from Kaiser Industries to – that neuromuscular thing started because he had a son that was involved with that kind of problem. 

[00:23:04] MM:  Very interesting. 

[00:23:05] PF:  I didn't mean to get off there. That's a little tangent, but anyhow. 

[00:23:08] MM:  I know. Is it F-A-U-L-K?

[00:23:12] PF:  F-A-L-K. I think it is. 

[00:23:15] MM:  Okay. 

[00:23:16] PF:  It is Marvin Falk, was  the one who wrote it for speech. See, what happened is this. That particular – I believe it was in Michigan, and he was working with really challenged populations. People had like Parkinson's. They had different really challenging issues, cerebral palsy. They were doing those kind of exercises to help them to control their saliva and swallow better. 

Then one day, just out of the blue, somebody said, “You know, I wonder. It works so well on our challenged population. What if we used it on just populations that had normal muscle development?” Sure enough, when they tried it, it worked, and it worked twice as well and probably twice as fast. It makes sense, but he was a director of a speech program. I know that's how it got introduced into speech is from him. That's all I know. 

[00:24:12] MM:  So interesting. I did not know that. 

[00:24:14] ANNOUNCER:  Are you taking advantage of our new amazing feature, the certificate tracker? The free CE tracker allows you to keep track of all of your CEUs, whether they are earned with us at SpeechTherapyPD.com or through another provider. Simply upload your certificate to your registered account, and you're all set. So come join the fastest growing CE provider, SpeechTherapyPD. Com.

[INTERVIEW RESUMED]

[00:24:42] MM:  Yes. Katie or Kate, I see your question. I'm also having a hard time finding it. I was going to put a link in the chat if I could find it. But if you could – would you be able to email me a resource on Marvin Falk after we're done, Patty?

[00:24:54] PF:  Yes. It was written in 1977. His article was written in the IAOM research journal in 1977. That's all – that's where I found it. 

[00:25:04] MM:  Perfect. Thank you for that. I'll put that into the chat really quick for everybody if they want to look into that, and I'll try to find it as well. Okay. So we've kind of talked about how ankyloglossia can impact speech. That mid-blade can be down. We are not elevating for those lingual alveolars. Are there any other impacts we should know about how ankyloglossia can impact speech?

[00:25:27] PF:  Well, I particularly notice it in working with my voice clients and because I actually had one of my surgeons who had done a tongue release on. It was a young man. He was, I want to say, 20 years old. Yes, he was 20 years old and he was about 6'1”, very developed young man. They had done the tongue release. But all of a sudden, and he didn't have any of the preparation or anything like that. Because at this time, this surgeon wasn't thinking there was any related issue. But after they did the release, he sent him down to me because he said something's wrong. 

Sure enough, when I saw him, there was something wrong. He went through all the tests. Again, I didn't know what he was looking for. At the very end of our talk, the young man said, “Goodbye, thank you so much.” It suddenly dawned on me that his voice was so weird for a six-foot-tall 20-year-old man, young man. To talk like Minnie Mouse was very disturbing. I brought a sample of that, so everybody could hear it because the release had already been done. The family and the doctor expected the voice just to get better. They never really thought that they were going to have to do anything else. 

Well, because it didn't get better and he still sounded like Minnie Mouse, he had the tongue released, they sent them to a speech therapist, not even somebody they knew very well. To make things more difficult, as you can imagine, the surgeon came down to watch me to see what I was going to do. This is kind of scary because I didn't actually know what was wrong until I had a chance to work with them. But I brought the sample to show you what he sounded like on like the second day after evaluation and then what he sounded like by the time he had been with me for six weeks. 

If you guys will bear with me, I'm just going to let you listen to it and see if you can hear the difference of helping this person relocate where his larynx was because the tongue tie had been so tight. He felt more comfortable in a high position, and it never would have dropped because he just felt that was the right place to be. All right, I'll pull this up for you. I know that it's going to be a little difficult maybe for me to get the sound, but I want you to do the best you can to listen. Here's what he sounded like at the beginning. 

[00:28:06] MAN:  Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma is openly concerned about her appearance. Every afternoon, Emma asked to be excused to the ladies room to ensure that everything is just so. It is unacceptable not to be one of the in crowd.

[00:28:24] PF:  Now, I don't know if you can remember, six-foot-tall 20-year-old male. This is what he sound like by the sixth week. 

[00:28:32] MAN:  Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma is overly concerned about her appearance. Every afternoon, Emma asked to be excused to the ladies room to ensure that everything is just so.

[00:28:48] PF:  I want to remind you listen to what he sound like when he first walked in. 

[00:28:52] MAN:  Emma Oliver is approximately 11 years old. As many other adolescent girls, Emma –

[00:28:58] PF:   I think that's a dramatic difference, and that is definitely related to the oral motor issue. 

[00:29:06] MM:  Do  you think that this could also play a role, well, with muscle tension dysphonia? 

[00:29:10] PF:  Oh,  I'm sure. I'm sure. I just know that this was very interesting to me to see the change and what it did for this young man as far as overall presentation in life. I mean, he said to me after we worked, one of the things he said, no one had ever referred to him as sir in his entire life. They always called him ma'am. When he went through and he got a soda or something, they would look at him like there was something wrong. It was pretty amazing. It was dramatic. 

[00:29:47] MM:  Wow. T hat is really amazing. So we have a couple of questions about treatment. Elizabeth and Kate were both curious about if you could share some of the techniques that you used to help facilitate that change. 

[00:30:02] PF:  Yes.  I'm going to play a little bit of some of the things that helped with that. I don't know if it's going to help you enough because I know what I'm looking at, and you may feel kind like I'm just talking. But I want you to have an idea what it's like. I did help him by actual physically allowing him to feel his own larynx and then notice what it was like to bring it down to a different position. I use a lot of Joe Stemple’s work. You'll see him on the ASHA register. I use a lot of Melvin Hyman stuff. He’s from Bowling Green State University, those kinds of things. 

But I'm going to see if I can play a little bit. Here's the fourth day of treatment that I had with this young man. I know it's boring because you’ll think, “Oh, my gosh.” But I want you to – treatment isn't always entertaining, but this was a good treatment session you'll hear. 

[00:31:02] PF:  Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, ma. 

[00:31:08] MAN:  Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, ma. 

[00:31:13] PF:  [inaudible 00:31:13]. 

[00:31:15] MAN:  [inaudible 00:31:15]. 

[00:31:16] PF:  [inaudible 00:31:16]. Ma.

[00:31:21] MAN:  Ma.

[00:31:23] PF:  Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, mo. 

[00:31:28] MAN:  Mi, ya, me, ya, mi, ya, me, ya, mi, ya, me, ya, mo. 

[00:31:32] PF:  S o there you're playing with the mechanism, and you're helping him learn his range of voice. But he couldn't get there. What was interesting, of course, since I got the female voice, it was harder for me to get down to that register. But it actually turned out to be a good thing for me to be his therapist because I wasn't perfect in the way I produced my voice, and it gave him hope. When he started to get stronger, you could see it in the way he responded. He thought it was interesting. 

Here's another take from one of his therapy sessions, and I want you to listen to it because he's analyzing. This is right as he's changing his voice. 

[00:32:13] MAN:  [inaudible 00:32:13].

[00:32:17] PF:  Now, can  you do it with the opposite and have that same stability and not move the jaw?

[00:32:21] MAN:   [inaudible 00:32:21]. 

[00:32:25] PF:  E xcellent. Now, look at yourself as you do it and see if your jaw is moving. If it is moving, just move – put your finger here at the chin to help you remember. It's just the tongue that moves, just for this exercise. 

[00:32:37] MAN:  [inaudible 00:32:37]. 

[00:32:44] PF:  Right. Now,  smile. Aha. Did you catch a mistake there? What happened? Tell me what needed to change.

[00:32:51] MAN:  Well,  usually, when I smile, I tend to push a lower jaw forwards. I just push it back. 

[00:32:58] PF:  Y es, instead because you're used to it with your tongue-tie, [inaudible 00:33:02] your chin. But you really should be bringing the back teeth together nice and gently. 

D id that make sense? I'm just giving you that as somewhat of an example. I was going to show you or play for you another tape that I have. It’s not voice, but this is to drive home the articulation situation. We have this young lady who was in speech therapy since she was two. I want you to listen to the way she sounds, and I want you to listen a little bit to her story. Then I want to tell you something sad about not accepting orofacial myology in our society. But I want you to listen to her first. I'm going to move this. I'm going to move this up here. Listen. 

[00:33:48] WOMAN:  [inaudible 00:33:48]. 

[00:33:53] PF:  O kay. All right, how old are you?

[00:33:56] WOMAN:  Eighteen. 

[00:33:57] PF:  And  where are you going to be going this fall?

[00:34:00] WOMAN:   Miami University in Oxford. 

[00:34:02] PF:  O kay. Can you tell me a little bit about what vacation you're going to be taking shortly?

[00:34:07] WOMAN:  W e are going to the Mena convention in Dallas, Fort Worth. It is five days long over the Fourth of July week. 

[00:34:17] PF:   That'll be fun. What did they do there?

[00:34:21] WOMAN:  It’s, you know,  those like [inaudible 00:34:23], so people hang out and play games and just talk to each other. [inaudible 00:34:26] and things and then like the things called special [inaudible 00:34:29] that like people can like hang out in different suites and stuff. It was like a teen one, so we have a scavenger hunt and that kind of thing, and games, and stuff. 

[00:34:42] PF:  S ounds good. 

[00:34:43] WOMAN:  Yes. 

[00:34:43] PF :  A ll right, I'm going to ask you again. Can you give some advice to those students who are in high school that you would think they should keep in mind?

[00:34:52] WOMAN:  Just [inaudible 00:34:52]. Do [inaudible 00:34:55]  time and don't be mean to teachers, even when they dissolve it. Just behave yourself and do your [inaudible 00:35:01]. It’s all fine. 

[00:35:04] PF:  O kay then. Thank you very – I want to ask you. Is it all right with you if I videotape you to share with others, so they can learn a little bit about this?

[00:35:12] WOMAN:  Yes. 

[00:35:14] PF:  Have  you ever worked on your swallowing or any of that before?

[00:35:17] WOMAN:  No. 

[00:35:18] PF:  O kay. What have you worked on before? Sorry. 

[00:35:21] WOMAN:  Just the  S sound and SHs, the big ones. I've done a lot with the all sounds but not gotten it yet. 

[00:35:30] PF:  O kay. So this is first time you worked on this swallowing and that. Okay.

[00:35:34] MM:  Since  she was two. 

[00:35:36] PF:  S ince she was two. Now, let me –

[00:35:37] MM:  Oh,  my goodness. 

[00:35:39] PF:  L et me tell you the sad part. I know that at the time, I was just – I was a private therapist and, of course, I wanted to help her. But I was sure she had a restriction in her tongue. But she was on full scholarship, and she went off to the university. Of course, she got free therapy. They went back to the same thing they'd always done. She never got anything changed. 

In her IEP, I happened to come across the one that was written at school. Now, obviously, she's very bright. She's Mensa, so she’s a bright kid. It said in there she was so smart, she didn't need to worry about speaking articulately. It was really sad for me. I didn't find that. Of course, she moved to another facility. But my point is they took her as far as they could and the therapists that worked with her in my mind were the best therapists I've ever met. They were wonderful, and I had the deepest respect for those people. I honestly thought they did wonderful work. I have no question about that. I think it was the fact that it was unusual, and I think it was posterior tie. I don't think anyone, I don't think the doctors saw it. I don't think anyone really caught it. I don't think there was anything wrong with that at all. That was just something maybe they should have known about. 

But like we've talked before, we weren't trained. So I don't – I think that they were fabulous therapists, and I think they did a wonderful job to do as much as they did. Where I think the mistake occurred in my mind is she went into a program that's an excellent program. But, again, because they didn't look for the tongue-tie and didn't know about the – that it didn't have to show on the tip of her tongue, again, the training. Maybe we didn't have the training. So I can't say anything bad about any professional. I think they all did their job. I think they all did great. 

But I'm still kind of a lot – I have a little bit of guilt thinking I didn't know because she wasn't on my case. Who do I tell? It was one of those things where she passed through my life, but she made a big mark. I'm a better therapist for having met her. I really am. I don't know if any of you have ever had that person come through and you realize. Wow, wow. 

[00:37:52] MM:  Oh, yes. 

[00:37:54] PF:  Are  there some other questions I need to answer here? I see there are some –

[00:37:58] MM:  Yes. We  do have one. The similarity to those neuromuscular exercises we were talking about in craniosacral therapy, if there's any similarity between those. 

[00:38:09] PF:   I think there is, and I think we can work fairly closely with some of those. I've only approached it from the other end and I do have a sacral therapist I work with and I think she's wonderful. But I'm not trained there and I'd like to be trained better. 

[00:38:28] MM:  Yes.  I know in the episode with Christy Gado, we talked a lot about how the craniofacial complex is highly impacted by the body. So anytime we’re working with tongue-tie releases or – I don't know. If you see any postural things going on with your kid, I was always referring out to some sort of body work like a craniosacral therapist or PT, chiropractor, things like that. 

[00:38:53] PF:  Yes.  I'm lucky in the fact that I have the oral surgeons and the orthodontists that I'm working with. We do have a craniosacral person that is really good. For whatever reason, I don't usually interact with her, as much as the others. Then they interact with her. But I would like to work more with her. I think it's the right thing to do. 

[00:39:16] MM:  O kay. Then Lori said, “I agree. I'm starting to work with craniosacral therapists and OTs and a local orthodontist. I'm looking forward to it.” Go, Lori, building that interprofessional team. 

[00:39:28] PF:  B uild your team. 

[00:39:29] MM:  Y es. Love it. Okay. So how can – is there any – I know this is a really big question, but how is it that something that seems so small as a tongue tie can impact respiration, speech, and swallowing? Like how does that little string do that? 

[00:39:54] PF:  I t's what you do to adjust to it. Each of us –

[00:39:58] MM:   I love that. 

[00:39:59] PF:  I  think that's – you don't – you wouldn't have any response, and you wouldn't do it unless there was something that got in the way. Oh, somebody found our –

[00:40:09] MM:   I was trying so hard. Thank you, Elizabeth. I'm sharing to everybody. 

[00:40:14] PF:  G reat. Thank you so much. But I do think that's it. We accommodate, and we do this in everything. I know that I tripped over one of my grandchildren, and I broke my arm. But I compensated on my left side, broke the right side. My neck, my shoulder blade, my arm, my whole breathing, and my walking was affected by it. But it wasn't this that was really the problem, the break. It was what I did to respond to it. I think when you're restricted, you do unusual things. 

Like when a baby's born, we all have a tongue thrust. Every baby, if you remember, they have that look [inaudible 00:40:56], and the tongue's coming out as cute as can be. Sometime before the age of maybe 12 months, 15 months, it moves to the upper place [inaudible 00:41:05] instead, and that's where it's supposed to be. But if there is a tie or a posterior tie, it continues to go forward, usually. Then you add a bottle or a nipple or a thumb or a blanket or whatever on top. You can't get up, so you're compensating from that very early time. Then you create all kinds of things around it. I believe that's the pattern that usually happens. 

[00:41:30] MM:  Yes. So  I know there's an area that you've been kind of digging into, and that is how ankyloglossia is potentially related to fluency. Would you like to share a little a bit about that?

[00:41:43] PF:  Well,  I have some ideas on that. I'm not sure that everyone will jump on board, but I do think in all the experience I have with fluency, I watch those kids more often than not. They're the ones that really struggle with a full breath. They struggle with placement of where they should be just at relaxed state. They're the ones that if they get into something, they struggle with it and can't easily move from one to the next.

I have a little video of somebody that sort of started me thinking about this, and I think it's really interesting because we learn a lot about fluency. But I just gave a talk this summer, and one of the things I learned is that we're all scared to death of it. A lot of us are because we don't know what to do with what we know. We're afraid we're going to make things worse because we're asking them to do certain things like move slowly or breathe deeply or whatever. I'm going to show you a little tape, I hope, or let you listen to something. 

This is a soldier from one of the bases that I've been working with, and I just want you to listen. Then we'll talk a little about his motor movement. He's not – this is not an improvement tape. This is just something for you to listen for when you're working on fluency. 

[00:43:18] SOLDIER : Now,  the wind and rain could not get in the house. With a nice place to live in and give food to eat, they lived a good life. One day, when the son was digging in his garden, he found something that looked like [inaudible 00:43:39]. He took it to his mother to fix dinner in the house. 

[00:43:46] PF:   I don't know how that impacts you when you listen there to him. But you can hear him motorically. He is cutting off his own air. He doesn't allow flow. He's afraid to allow that. Yet when you put this same person into a position where like the feet are straight, his body is straight, he's breathing just fully in and out, his speech almost immediately starts to flow. Especially notice that with junior high and that kind of thing. It’s the same kind of therapy you always do. But add – and I don't know if you guys are familiar with [inaudible 00:44:35] and Nina Reardon, Scott Yaruss, all of those wonderful fluency specialists. They talk about fluency shaping, stuttering modification, holistic approaches, and that there are four stages they go through. 

First, you establish fluency skills. You teach them in a highly structured rehearsal. Then you stabilize by using the fluency like reading and monologues. Then you start to transfer. The child works on maintenance all the way through. The goal is never to be fluent. The goal is to modify, to shape, to allow your flow. It’s really interesting because it's in everything with that, and it's amazing because I've seen real improvement in all the therapy I do with my fluency cases. Once they feel like they have some control. 

Again, think of the biological, the function of the breathing, and the function of the mechanism is to chew and eat and swallow or to breathe correctly. If you work with those things, you're taking all the pressure away from the communication. They get that, and then they start back building up their strength and using it for communication. It’s just life-altering to them. I wish I had a few more things, but one of the things I found with the young kids that you can use just starting tomorrow, I used a lot of message therapy. That was Dr. [inaudible 00:46:21] message therapy. He’s from Canada 1984 somewhere there. 

But anyhow, if you are using these techniques and you use message therapy along with it, you can immediately start transfers. For example, you have Thanksgiving coming. So you give the young child a turkey message to deliver and on a little turkey. All they have is they take that message to mom, and it says, “Dad wants you to –” That's it. You're supposed to say it with your airflow. It's very interesting because you can change your messages every month. You can have a Christmas message or a Christmas tree message or a snowball message. Or you can have a Valentine message or a leprechaun message, just so that they can start to use immediately delivering something with airflow. It starts just at the word level and then phrases and then sentences. 

It’s very interesting because it takes in all the characteristics we want. You focus on the message. You develop the message. You deliver the message. You plan it. You consider your pragmatic elements. Then you build cognitive awareness. Guess what. Then you have introduced the motor, easy planning. It's really – we're so much smarter than we think. If I say nothing else, the one thing I have learned is that as speech therapists, we have a lot of knowledge. We're trained so darn well. We've got so many things, but it's hard for us to get that message across to everybody about we understand voice. We understand stuttering. We understand language. We understand articulation, all those things. 

Yet we're held to the fire in the fact that maybe we don't know one element like at that moment. But yet look at the knowledge we have. I feel very strongly we don't give ourselves credit for that, and that makes me feel very sad because I see it in the school therapist. I see it in the hospital therapist. I see it in the kids I supervise at the university. I can't stress enough that we need to give ourselves a little pat on the back for what we do know and the knowledge that we're carrying. We just have to put it in a different package for use. I worry that we're missing sometimes the boat because we're trying to have – we have too many balls in the air. We don't know that we actually have the answer right there at our fingertips. 

[00:49:12] MM:  That is  sad but encouraging because we do have that knowledge, and we just need to claim that as speech pathologists because we are well-educated. We are always looking to know more and do better and figure out more for our patients and we can do this. 

[00:49:28] PF:   That's right. That's right. I don't know if there's – we can't get into too many programs with the fluency, but I think that understanding it like you do with the voice. You can see that if you – I think so many of the things that we do – if we look at the primary function, and we look at the way it's supposed to be working, and we help them be able to manage it easier and keep in mind the goal is to make the mechanism itself work. We're supposed to be breathing correctly. We're supposed to be using the full range of the tongue. We’re supposed to be forming our sounds and stuff. But the other thing is to do it at a rate that's manageable for them. I think part of it is that's a self-imposed obstacle because that time management that gets in our way. 

I saw there's a couple questions. I'm getting nervous that I'm not answering questions for people. 

[00:50:36] MM:  Y ou're doing great.  So  we did have a couple people just say that they've also kind of seen that relationship between kiddos coming in with fluency problems. But then they have the restriction. We have one answer from Chabby. “What should one take into consideration when deciding whether or not to release the tongue on a baby? At that point, it's hard to predict what the ramifications will be.” 

[00:51:01] PF:  Yes.  I think that you have to have somebody who works with babies all the time and working with you. But I will tell you, if they see – my personal experience is this. When we catch and we know that a baby has the restriction and that we can do the release and they're very young, I see them recovering faster and easier than anyone because you can immediately put them on the breast. All the exercises that they need naturally occur. It’s, to me, like a very, very good thing. 

Where I have trouble and I probably shouldn't admit this but when I see a child between the ages of two and four, and they are asking me if there's a restriction, I'm probably going to say that I probably wouldn't do the release because I don't know that so many of those kids can do some of the exercises. I don't think they can do the voluntary things very easily. They can't follow you. 

[00:52:04] MM:  They  love the word no. So even if they can do it, they like to tell you no at that age. That’s been my experience, at least. 

[00:52:12] PF:  Right,  right. I don't think they're ready for some things, especially if you get into oral motor stuff. Really, until they're four or five, they're not ready. However, there are certain things that people can do. If you want to increase their ability to move their tongue, you could put a piece of cereal on a dental floss and have them move the tongue back and forth or up and down, tracing or moving that piece of cereal. That's okay if it's a game. But those kids I'm a lot less likely to, and most of my dogs feel the same way. That's a time when they can work on other stuff. But the release is not as often. It's pretty hard on them. It's hard on moms then, too.

[00:53:00] MM:  Y es. I definitely see that in my practice as well. With my providers that I have in my area, typically, after a year, we kind of hold off until they're able to kind of participate in a traditional myofunctional program. Then I do work with a lot of infants at my clinic. So I'll just share one of my favorite assessments. It's the Assessment Tool for a Lingual Frenulum Restrict or Function Created By Dr. Hazelbaker. One of the things that we kind of go off of is if they're having a functional issue at the time of feeding, that appears to be impacted by the frenum. We kind of use this Hazelbaker Assessment to determine if they have the optimal functioning and then what their – I like [inaudible 00:53:50] because it looks at structure and function. It kind of asked a few feeding questions as well. So that one's been really helpful for me in diagnosing them in infants and making that decision. 

Then, again, with infants, always made in conjunction with the – well, at any age, but especially those babies. Like making that decision with the parents, making sure that's what they want. If they choose not to, which I've had that, finding ways that we can help them compensate through those feeds. 

[00:54:17] PF:  Yes, I agree and I love the work that you're talking about there. I think that's very appropriate. One of the things I was going to say, somebody asked a question about the restriction with the –

[00:54:28] MM:  Yes, on the mid tongue. 

[00:54:30] PF:  Mid tongue. 

[00:54:31] MM:  Yes. 

[00:54:32] PF:  The thing you hear or you see is that a restriction in the mid tongue, there usually will be a little dimple on the top of the tongue. But what you'll hear, of course, almost always there'll be a distortion on the ER and there'll be a distortion on the L. What I found is to overcome that if you aren't going to have a release done right away. If you are, you're going to go ahead and do the volitional exercises, and those things and things are going to improve. But if you're not, one of the things – 

I think I learned this from Linda [inaudible 00:55:02]. I'm pretty sure. Or it was [inaudible 00:55:05], one of the two. Anyhow, I just remember that you can still get some good sounds from that and strengthen, so they're ready by just putting the tongue midline wherever it's comfortable, and start by trying to form an SH sound, just shh, and have them feel where the tongue is in the middle of their mouth. You stay there, and you keep doing shh, and have them look at the roundness of their mouth. 

Then you add a vowel with it, and you go, “Sure.” You ask them not to move their tongue at all, and they will get it because their tongue now learns to form. It does work. It was amazing, and I've used it many times, and I thought I meant to thank them, whichever one showed me that. But one of them did, and it does work. It also is an indicator whether they're going to be able to do some range of motion or movement on their own, even without a release. So it's a measurement. It's also a good technique, and the kids love it. Also, that reminds me of an episode of Steinfeld when they used to say sure. 

[00:56:25] MM:  So do you ever do a tongue-tie release without doing therapy beforehand?

[00:56:32] PF:  I don't. I always do preparation. I've had two people who've come to me after they did their own preparation, and they didn't know what they were doing. Then they were sort of sad, again, that it didn't correct all their problems. The one was that young man that I showed you with the voice. That was an upsetting thing when they found out it didn't correct all the problems. I had one other one where the – and it was funny because the mom was so sure that it was going to correct every speech problem. She was very adamantly angry with the doctor that it didn't correct everything. 

It worked to my benefit because that doctor won't even touch anyone anymore unless he has me look at them. You know, it’s funny that people sometimes think, I don't know, that they think that magic wand will work, and I just haven't found the wand yet. 

[00:57:29] MM:  I know. We see that a lot in my clinic where the parents will come and be like, “Oh, we’ll just get the tongue-tie released, and it'll fix everything.” We have to talk, well, the tongue is a muscle, and there's learned patterns, and just because they have the range of motion doesn't mean that they're going to use those new patterns. 

[00:57:44] PF:  It sometimes does work that they get better, but it doesn't always happen that way. I think they're – it's sad because they do expect a miracle. I haven't seen it yet very often. 

[00:57:57] MM:  W e have another question, a bit of a case study. So Jennifer says, “I'm currently working with a five-year-old who has a tongue and lip tie, and they started to have this dysfluency over the past six months. He also has apraxia. How would you differentiate what is due to CAS versus tongue lip tie in terms of his dysfluencies? Do you know of any research for ties and fluency?”

[00:58:20] PF:   I think there probably is some pretty good research on that, but I'm going to say something. I hope it doesn't make you mad. I'm not sure it matters if you differentiate or not. I think what matters is that you get in there, and you get the primary function working. I would start right away with the movements that are going to give him the most success. You can apply it to your sounds. You can apply it to this or that later. I would do the things that would allow you to do that release in that I'm assuming that child's over eight but –

[00:58:53] MM:  A  five-year-old. 

[00:58:54] PF:  Five-year-old. Okay. But still,  you're in the right thing to get them ready and to allow them that release so that they have control over their own mechanism. I would definitely do that for that job. 

[00:59:09] MM:  Awesome. Well, let's see if – so we will see if anybody else has any more questions, and then we will wrap up. I have one other question. Do you ever see any impacts on lip, like do you ever do lip tie releases?

[00:59:25] PF:  Oh, yes. Oh, yes. 

[00:59:26] MM:  Yes. What are some of the indicators that a lip tie release is needed?

[00:59:32] PF:  I see it in people that if you're working with them, and they tend to cover their lips as they're talking, it will affect your PBNM. But more than that, it's their smile. It'll be an unusual smile. They particularly cover the top, and it's funny because it will affect – I don't know. It just affects the way they – to bite everything. I mean, you can see it just way they sit at rest. But those are fairly easy to correct, and it's not hard for the kid at all. 

[01:00:06] MM:  Well, Patty, this has been so great. I have learned so much from you about ankyloglossia and definitely gave me some really good tricks. I love that idea of putting a Cheerio on dental floss to have them move it. That was – I have not thought about that one, and it is. I have a kiddo that I can think of that I'm going to use that next week. 

[01:00:28] PF:  Put it here, so they lift. Or put it here. Go side to side. The other thing is just putting it here and have them reach out to touch it because they don't know what straight out means. If they're tied, they aren’t going to go so far. So you get it real close. But it gives them success, and then they get to eat the Cheerio or the Froot Loop or whatever it is. But it's the beginning of movement, and I've seen a lot of kids. They can get pretty far if you can give them a chance to get that range of motion improvement. 

[01:01:01] MM:  Oh, absolutely. Well, this was great. I love that we had on the big points that we do need to do pre-therapy work to get ready for releases. It’s not a magic wand. We do need to do some work after in majority of the cases, and then just kind of enlightening us on the relationship between voice and fluency in ankyloglossia, just a new way to think about it. Thank you so much for attending tonight, and we look forward to seeing you on another episode of Making Sense of Myo. 

[01:01:27] PF:  Thank you so much. This has been fun. You guys are great. 

[01:01:31] MM:  Thanks, Patty. 

[01:01:38] ANNOUNCER :  Thank you for joining us for today's course. To complete the course, you must log into your account and complete the quiz and the survey. If you have indicated that you are part of the ASHA Registry and entered both your ASHA number and a complete mailing address in your account profile prior to course completion, we will submit earn CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to reflect on your ASHA transcripts. Please note that if this information is missing, we cannot submit to ASHA on your behalf. Thanks, again, for joining us. We hope to see you next time. 

[END] 

Episode S11E6: Show Notes

Throughout our making sense of myo segment on the SLP Learning Series, we have interviewed incredible speech-language pathologists with great experience in myotherapy and today we continue on the trend as we welcome the wonderful Patty Fisher back to the podcast to discuss ankyloglossia, voice, and fluency. Tuning in, you’ll hear all about the signs of orofacial restriction and limitation, the differences between volitional oral motor and neuromuscular re-education exercises, how ankyloglossia impacts speech, how it’s related to fluency, and all things message therapy. We then delve into tongue ties as Patty explains why a heart-shaped tongue isn’t the only sign of a restriction before exploring how it impacts respiration, speech, and swallowing as well as when releases are necessary. Finally, we touch on our guest’s experience with lip ties. To hear all this and so much more, press play now!

Key Points From This Episode:

• An introduction to today’s incredible guest, Patty Fisher. 
• What an orofacial restriction or limitation is and the signs of these issues. 
• Why heart-shaped tongue tips aren’t the only sign of tongue tie and when they’re corrected.
• The difference between volitional oral motor exercises and neuromuscular exercises.
• Patty explains how ankyloglossia impacts speech and shares examples of two clients.
• How something as small as a tongue tie can impact respiration, speech, and swallowing. 
• Patty shares her theory about how ankyloglossia is related to fluency and message therapy.
• How to decide when to release tongue ties in babies and why Patty always does pretherapy. 
• Patty tells us about her experience with lip tie releases and some indications of lip ties. 

“ As you get into orofacial myology, your abilities to be a speech pathologist and to hear and to identify those errors is going to sharpen.” — Patty Fisher  [0:08:54]

“I think when [your tongue’s] restricted, you do unusual things.” — Patty Fisher  [0:40:44]

“As speech therapists, we have a lot of knowledge. We're trained so darn well. We've got so many things, but it's hard for us to get that message across to everybody.” — Patty Fisher  [0:48:00]

“I can't stress enough that [speech therapists] need to give ourselves a little pat on the back for what we do know and the knowledge that we're carrying.” — Patty Fisher  [0:48:46]

Links Mentioned in Today’ s Episode:

Patty Fisher on LinkedIn

Madi Metcalf on LinkedIn

Free CEU Tracker

Dr. Elise Davis-McFarland on X

Dr. Elise Davis-McFarland on LinkedIn

ASHA Code of Ethics

SpeechTherapyPD.com

Related Course

Related Notes

• ««
• »»
• Upcoming Courses
• Plans and Pricing
• All Podcasts
• Speech Link
• Keys for SLPs
• SLP Learning Series
• Brainstorms: Functional Neurorehab for SLPs

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• PubMed/Medline
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Treatment of ankyloglossia: a review.

1. Introduction

2. materials and methods, 4. discussion, 5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Amir, L.H.; James, J.P.; Beatty, J. Review of tongue-tie release at a tertiary maternity hospital. J. Paediatr. Child Health 2005 , 41 , 243–245. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Segal, M.L.; Stephenson, R.; Dawes, M.; Feldman, P. Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review—PubMed. Can. Fam Physician 2007 , 53 , 1027–1033. [ Google Scholar ]
• Boutsi, E.A.; Tatakis, D.N. Maxillary labial frenum attachment in children. Int. J. Paediatr. Dent. 2011 , 21 , 284–288. [ Google Scholar ] [ CrossRef ]
• Colombari, G.C.; Mariusso, M.R.; Ercolin, L.T.; Mazzoleni, S.; Stellini, E.; Ludovichetti, F.S. Relationship between Breastfeeding Difficulties, Ankyloglossia, and Frenotomy: A Literature Review. J. Contemp. Dent. Pract. 2021 , 22 , 452–461. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Yoon, A.J.; Zaghi, S.; Ha, S.; Law, C.S.; Guilleminault, C.; Liu, S.Y. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional–morphological study. Orthod. Craniofacial Res. 2017 , 20 , 237–244. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Yoon, A.; Zaghi, S.; Weitzman, R.; Ha, S.; Law, C.S.; Guilleminault, C.; Liu, S.Y. Toward a functional definition of ankyloglossia: Validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep Breath 2017 , 21 , 767–775. [ Google Scholar ] [ CrossRef ]
• Delli, K.; Livas, C.; Sculean, A.; Katsaros, C.; Bornstein, M. Facts and myths regarding the maxillary midline frenum and its treatment: A systematic review of the literature. Quintessence Int. 2013 , 44 , 177–187. [ Google Scholar ] [ CrossRef ]
• Suter, V.G.; Bornstein, M.M. Ankyloglossia: Facts and Myths in Diagnosis and Treatment. J. Periodontol. 2009 , 80 , 1204–1219. [ Google Scholar ] [ CrossRef ]
• Dollberg, S.; Botzer, E.; Grunis, E.; Mimouni, F.B. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: A randomized, prospective study. J. Pediatr. Surg. 2006 , 41 , 1598–1600. [ Google Scholar ] [ CrossRef ]
• Messner, A.H.; Lalakea, M.L. The effect of ankyloglossia on speech in children. Otolaryngol.-Head Neck Surg. 2002 , 127 , 539–545. [ Google Scholar ] [ CrossRef ]
• Kupietzky, A.; Botzer, E. Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management—PubMed. Padiatr. Dent. 2005 , 27 , 40–46. [ Google Scholar ]
• Lalakea, M.; Messner, A.H. Ankyloglossia: Does it matter? Pediatr. Clin. N. Am. 2003 , 50 , 381–397. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Guilleminault, C.; Huseni, S.; Lo, L. A frequent phenotype for paediatric sleep apnoea: Short lingual frenulum. ERJ Open Res. 2016 , 2 , 00043–02016. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Zaghi, S.; Valcu-Pinkerton, S.; Jabara, M.; Norouz-Knutsen, L.; Govardhan, C.; Moeller, J.; Sinkus, V.; Thorsen, R.S.; Downing, V.; Camacho, M.; et al. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. Laryngoscope Investig. Otolaryngol. 2019 , 4 , 489–496. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Baxter, R.; Merkel-Walsh, R.; Baxter, B.S.; Lashley, A.; Rendell, N.R. Functional Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release: A Prospective Cohort Study. Clin. Pediatr. 2020 , 59 , 885–892. [ Google Scholar ] [ CrossRef ]
• Fioravanti, M.; Zara, F.; Vozza, I.; Polimeni, A.; Sfasciotti, G.L. The Efficacy of Lingual Laser Frenectomy in Pediatric OSAS: A Randomized Double-Blinded and Controlled Clinical Study. Int. J. Environ. Res. Public Health 2021 , 18 , 6112. [ Google Scholar ] [ CrossRef ]
• Jadad, A.R.; Moore, R.A.; Carroll, D.; Jenkinson, C.; Reynolds, D.J.M.; Gavaghan, D.J.; McQuay, H.J. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin. Trials 1996 , 17 , 1–12. [ Google Scholar ] [ CrossRef ]
• Ruffoli, R.; Giambelluca, M.A.; Scavuzzo, M.C.; Bonfigli, D.; Cristofani, R.; Gabriele, M.; Giuca, M.R.; Giannessi, F. Ankyloglossia: A morphofunctional investigation in children. Oral Dis. 2005 , 11 , 170–174. [ Google Scholar ] [ CrossRef ]
• Srinivasan, B.; Chitharanjan, A. Skeletal and dental characteristics in subjects with ankyloglossia. Prog Orthod. 2013 , 14 , 44. [ Google Scholar ] [ CrossRef ]
• Jamilian, A.; Fattahi, F.H.; Kootanayi, N.G. Ankyloglossia and tongue mobility. Eur. Arch. Paediatr. Dent. 2014 , 15 , 33–35. [ Google Scholar ] [ CrossRef ]
• Bai, P.M.; Vaz, A.C. Ankyloglossia among children of regular and special schools in Karnataka, India: A prevalence study. J. Clin. Diagnostic Res. 2014 , 8 , 36–38. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ferrés-Amat, E.; Pastor-Vera, T.; Ferrés-Amat, E.; Mareque-Bueno, J.; Prats-Armengol, J.; Ferrés-Padró, E. Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Med. Oral Patol. Oral Cir. Bucal 2016 , 21 , e39–e47. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Komori, S.; Matsumoto, K.; Matsuo, K.; Suzuki, H.; Komori, T. Clinical Study of Laser Treatment for Frenectomy of Pediatric Patients. Int. J. Clin. Pediatr. Dent. 2017 , 10 , 272–277. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Daggumati, S.; Cohn, J.E.; Brennan, M.J.; Evarts, M.; McKinnon, B.J.; Terk, A.R. Speech and Language Outcomes in Patients with Ankyloglossia Undergoing Frenulectomy: A Retrospective Pilot Study. OTO Open 2019 , 3 , 2473974X19826943. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Kim, T.H.; Lee, Y.C.; Yoo, S.D.; Lee, S.A.; Eun, Y.-G. Comparison of simple frenotomy with 4-flap Z-frenuloplasty in treatment for ankyloglossia with articulation difficulty: A prospective randomized study. Int. J. Pediatr. Otorhinolaryngol. 2020 , 136 , 110146. [ Google Scholar ] [ CrossRef ]
• Tancredi, S.; De Angelis, P.; Marra, M.; Lopez, M.A.; Manicone, P.F.; Passarelli, P.C.; Romeo, A.; Grassi, R.; D’Addona, A. Clinical Comparison of Diode Laser Assisted “v-Shape Frenectomy” and Conventional Surgical Method as Treatment of Ankyloglossia. Healthcare 2022 , 10 , 89. [ Google Scholar ] [ CrossRef ]
• Jorgenson, R.J.; Shapiro, S.D.; Salinas, C.F.; Levin, L.S. Intraoral findings and anomalies in neonates. Pediatrics 1982 , 69 , 577–582. [ Google Scholar ] [ CrossRef ]
• Messner, A.H.; Lalakea, M.L.; Janelle, A.; Macmahon, J.; Bair, E. Ankyloglossia: Incidence and associated feeding difficulties. Arch. Otolaryngol. Head. Neck Surg. 2000 , 126 , 36–39. [ Google Scholar ] [ CrossRef ]
• Ballard, J.L.; Auer, C.E.; Khoury, J.C. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad. Pediatrics 2002 , 110 , e63. [ Google Scholar ] [ CrossRef ]
• Hogan, M.; Westcott, C.; Griffiths, M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J. Paediatr. Child Health 2005 , 41 , 246–250. [ Google Scholar ] [ CrossRef ]
• Friend, G.W.; Harris, E.F.; Mincer, H.H.; Fong, T.L.; Carruth, K.R. Oral anomalies in the neonate, by race and gender, in an urban setting. Pediatr. Dent. 1990 , 12 , 157–161. [ Google Scholar ]
• Kotlow, L.A. Pédiatrie Dentistry Ankyloglossía (tongue-tie): A diagnostic and treatment quandary classification of ankyloglossia. Quintessence Int. 1999 , 30 , 259–262. [ Google Scholar ] [ PubMed ]
• Pola, M.J.G.; García, M.G.; Martin, J.M.G.; Gallas, M.; Lestón, J.S. A study of pathology associated with short lingual frenum. ASDC J. Dent. Child. 2002 , 69 , 59–62. [ Google Scholar ]
• Horton, C.E.; Crawford, H.H.; Adamson, J.E.; Ashbell, T.S. Tongue-tie. Cleft Palate J. 1969 , 6 , 8–23. [ Google Scholar ]
• Nammour, S. Laser-Assisted Tongue-Tie Frenectomy for Orthodontic Purpose: To Suture or Not to Suture? Photobiomodulation Photomed. Laser Surg. 2019 , 37 , 381–382. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Brignardello-Petersen, R. Use of lasers seems to result in a small decrease in postoperative complications after labial frenectomy compared with scalpels. J. Am. Dent. Assoc. 2020 , 151 , e42. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Viet, D.H.; Ngoc, V.T.N.; Anh, L.Q.; Son, L.H.; Chu, D.-T.; Ha, P.T.T.; Chu-Dinh, T. Reduced Need of Infiltration Anesthesia Accompanied With Other Positive Outcomes in Diode Laser Application for Frenectomy in Children. J. Lasers Med. Sci. 2019 , 10 , 92–96. [ Google Scholar ] [ CrossRef ]
• Haytac, M.C.; Ozcelik, O. Evaluation of Patient Perceptions After Frenectomy Operations: A Comparison of Carbon Dioxide Laser and Scalpel Techniques. J. Periodontol. 2006 , 77 , 1815–1819. [ Google Scholar ] [ CrossRef ]
• Reddy, N.; Marudhappan, Y.; Devi, R.; Narang, S. Clipping the (tongue) tie. J. Indian Soc. Periodontol. 2014 , 18 , 395–398. [ Google Scholar ] [ CrossRef ]
• Derikvand, N.; Chinipardaz, Z.; Ghasemi, S.; Chiniforush, N. The Versatility of 980 nm Diode Laser in Dentistry: A Case Series. J. Lasers Med. Sci. 2016 , 7 , 205–208. [ Google Scholar ] [ CrossRef ]
• Barot, V.J.; Vishnoi, S.L.; Chandran, S.; Bakutra, G.V. Laser: The torch of freedom for ankyloglossia. Indian J. Plast. Surg. 2014 , 47 , 418–422. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ito, Y.; Shimizu, T.; Nakamura, T.; Takatama, C. Effectiveness of tongue-tie division for speech disorder in children. Pediatr. Int. 2015 , 57 , 222–226. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Yousefi, J.; Namini, F.T.; Raisolsadat, S.M.; Gillies, R.; Ashkezari, A.; Meara, J.G. Tongue-tie Repair: Z-Plasty Vs Simple Release. Iran J. Otorhinolaryngol. 2015 , 27 , 127–135. [ Google Scholar ]
• Ghaheri, B.A.; Cole, M.; Fausel, S.C.; Chuop, M.; Mace, J.C. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope 2017 , 127 , 1217–1223. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Lalakea, M.L.; Messner, A.H. Ankyloglossia: The Adolescent and Adult Perspective. Otolaryngol. Neck Surg. 2003 , 128 , 746–752. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Heller, J.; Gabbay, J.; O’Hara, C.; Heller, M.; Bradley, J.P. Improved Ankyloglossia Correction With Four-Flap Z-Frenuloplasty. Ann. Plast. Surg. 2005 , 54 , 623–628. [ Google Scholar ] [ CrossRef ] [ PubMed ]

Click here to enlarge figure

Share and Cite

Frezza, A.; Ezeddine, F.; Zuccon, A.; Gracco, A.; Bruno, G.; De Stefani, A. Treatment of Ankyloglossia: A Review. Children 2023 , 10 , 1808. https://doi.org/10.3390/children10111808

Frezza A, Ezeddine F, Zuccon A, Gracco A, Bruno G, De Stefani A. Treatment of Ankyloglossia: A Review. Children . 2023; 10(11):1808. https://doi.org/10.3390/children10111808

Frezza, Alessandro, Fatima Ezeddine, Andrea Zuccon, Antonio Gracco, Giovanni Bruno, and Alberto De Stefani. 2023. "Treatment of Ankyloglossia: A Review" Children 10, no. 11: 1808. https://doi.org/10.3390/children10111808

Article Metrics

Article access statistics, supplementary material.

ZIP-Document (ZIP, 114 KiB)

Further Information

Mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

You are using an outdated browser. It's time... Upgrade your browser to improve your experience. And your life.

Log In | View Cart

Username or Email Address

Remember Me

Log in | View Cart

This advice-column-style blog for SLPs was authored by Pam  Marshalla  from 2006 to 2015, the archives of which can be explored here. Use the extensive keywords list found in the right-hand column (on mobile: at the bottom of the page) to browse specific topics, or use the search feature to locate specific words or phrases throughout the entire blog.

R Therapy with Ankyloglossia

By Pam Marshalla

Q: Is the best approach for ankyloglossia to do a back r?

If the tongue-tip is tied down, the client will be unable to stretch the tip up and back far enough for a Tip R (retroflex R).  You will have no choice but to teach a Back R.  But, as you know, the Back R can be much harder for many kids.  That’s an excellent reason to have the frenum surgically altered.

I always refer a client with a restricting lingua frenum for surgery, no matter their speech problem.  This is because the restricting tongue-tip movement does not affect only speech.  It also affects oral rest, stage one swallow, stage two swallow, dentition, occlusion, and the client’s overall facial appearance.

The stage one swallow problem is perhaps the most important reason because without the ability to clear the mouth of all food particles in preparation for the swallow, the child can be at risk of aspiration.

0 thoughts on “R Therapy with Ankyloglossia”

Would you recommend clipping the lingua frenum of an infant in any case? My newborn grandson has a short frenum, but is able to suck well from breast and bottle. His pediatrician has said to wait, not sure why. I can see that the tongue tip is not pointed, but pulled in some.

I would. Most kids get them clipped right at birth. Please go to http://www.pammarshalla.com/blog/search/frenum to see more info on this.

Restricted frenums should be revised at any age, as soon as detected. A newborn may be “nursing well” but may have: colic, long or frequent feeding, or milk remaining on the tongue giving it the appearance of thrush. The mother may have sore nipples or mastitis. Dr. Kotlow, a pediatric dentist from Albany, NY has an excellent presentation on his website: http://www.kiddsteeth.com . Another good site is Carmen Fernando’s, who is an SLP from Australia: http://www.tonguetie.net . This condition is undetected or ignored by physicians far too often!

Leave a comment! Cancel reply

Keep the conversation going! Your email address will not be published.

• Feb 2, 2023

Lip Ties and Tongue Ties: Understanding Their Impact on Children's Speech

Lip ties and tongue ties are common congenital conditions that affect the oral structures and can have a significant impact on children's speech development. In this article, we will explore the medical terms for lip ties and tongue ties, their symptoms, and the role of a speech language pathologist in helping children with these conditions.

Medical Terminology

Lip tie, also known as Ankyloglossia, is a condition where the frenulum, the thin membrane connecting the lip to the gum, is too short, thick or tight, restricting the mobility of the lip. This can cause difficulties with nursing, feeding, and speaking. Tongue tie, also known as Ankyloglossia, is a condition where the frenulum, the thin membrane connecting the tongue to the floor of the mouth, is too short, thick, or tight, restricting the mobility of the tongue. This can cause difficulties with oral motor movements, speech, and swallowing.

Impact on Children's Speech

Lip and tongue ties can impact a child's speech development in various ways. Lip ties can result in difficulty with lip closure, resulting in speech that is hard to understand. Children with lip ties may also have difficulty producing certain sounds, such as “b,” “p,” and “m.” Tongue ties can also have a significant impact on speech. Children with tongue ties may have difficulty with tongue movement and coordination, resulting in speech that is difficult to understand. They may also have difficulty producing certain sounds, such as “t,” “d,” and “l.”

Role of Speech Language Pathologists

Speech-language pathologists (SLP's) are professionals who are trained to help individuals with speech and language difficulties. They can help children with lip ties and tongue ties by working on speech and oral motor exercises to improve speech clarity and accuracy. They can also help children to develop their oral motor skills, which can help improve their ability to speak and swallow.

Lip ties and tongue ties can have a significant impact on a child's speech development. However, with the help of an SLP children with these conditions can improve their speech and oral motor skills and develop alternative communication strategies if necessary. If you suspect your child may have a lip tie or tongue, seek out an evaluation from a pediatric dentist and an SLP.

Michelle Mikviman MS CCC-SLP

• Early Intervention
• Articulation
• Expressive & Receptive Language Del

Recent Posts

Boosting Speech and Language Development at Home: Tips and Tricks for Parents

Enhancing Early Speech Intervention: Effective Strategies for Parents at Home

Baby Sign Language

• Patient Care & Health Information
• Diseases & Conditions
• Tongue-tie (ankyloglossia)

Tongue-tie (ankyloglossia) is a condition in which an unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue's tip to the floor of the mouth. If necessary, tongue-tie can be treated with a surgical cut to release the frenulum (frenotomy). If additional repair is needed or the lingual frenulum is too thick for a frenotomy, a more extensive procedure known as a frenuloplasty might be an option.

Tongue-tie (ankyloglossia) is a condition present at birth that restricts the tongue's range of motion.

With tongue-tie, an unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue's tip to the floor of the mouth, so it may interfere with breast-feeding. Someone who has tongue-tie might have difficulty sticking out his or her tongue. Tongue-tie can also affect the way a child eats, speaks and swallows.

Sometimes tongue-tie may not cause problems. Some cases may require a simple surgical procedure for correction.

Products & Services

• A Book: Mayo Clinic Family Health Book
• Newsletter: Mayo Clinic Health Letter — Digital Edition

Signs and symptoms of tongue-tie include:

• Difficulty lifting the tongue to the upper teeth or moving the tongue from side to side
• Trouble sticking out the tongue past the lower front teeth
• A tongue that appears notched or heart shaped when stuck out

When to see a doctor

See a doctor if:

• Your baby has signs of tongue-tie that cause problems, such as having trouble breast-feeding
• A speech-language pathologist thinks your child's speech is affected by tongue-tie
• Your older child complains of tongue problems that interfere with eating, speaking or reaching the back teeth
• You're bothered by your own symptoms of tongue-tie

Typically, the lingual frenulum separates before birth, allowing the tongue free range of motion. With tongue-tie, the lingual frenulum remains attached to the bottom of the tongue. Why this happens is largely unknown, although some cases of tongue-tie have been associated with certain genetic factors.

Risk factors

Although tongue-tie can affect anyone, it's more common in boys than girls. Tongue-tie sometimes runs in families.

Complications

Tongue-tie can affect a baby's oral development, as well as the way he or she eats, speaks and swallows.

For example, tongue-tie can lead to:

• Breast-feeding problems. Breast-feeding requires a baby to keep his or her tongue over the lower gum while sucking. If unable to move the tongue or keep it in the right position, the baby might chew instead of suck on the nipple. This can cause significant nipple pain and interfere with a baby's ability to get breast milk. Ultimately, poor breast-feeding can lead to inadequate nutrition and failure to thrive.
• Speech difficulties. Tongue-tie can interfere with the ability to make certain sounds — such as "t," "d," "z," "s," "th," "r" and "l."
• Poor oral hygiene. For an older child or adult, tongue-tie can make it difficult to sweep food debris from the teeth. This can contribute to tooth decay and inflammation of the gums (gingivitis). Tongue-tie can also lead to the formation of a gap or space between the two bottom front teeth.
• Challenges with other oral activities. Tongue-tie can interfere with activities such as licking an ice cream cone, licking the lips, kissing or playing a wind instrument.
• Tongue-tie (ankyloglossia). American Academy of Otolaryngology-Head and Neck Surgery. http://www.entnet.org/content/tongue-tie-ankyloglossia. Accessed Feb. 13, 2018.
• Isaacson GC. Ankyloglossia (tongue-tie) in infants and children. https://www.uptodate.com/contents/search. Accessed Feb. 14, 2018.
• Chinnadurai S, et al. Treatment of ankyloglossia for reasons other than breastfeeding: A systemic review. Pediatrics. 2015;135:e1467.
• Baker AR, et al. Surgical treatment of ankyloglossia. Operative Techniques in Otolaryngology. 2015;26:28.
• Walsh J, et al. Diagnosis and treatment of ankyloglossia in newborns and infants. JAMA Otolaryngology-Head and Neck Surgery. 2017;143:1032.
• O'Shea JE, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systemic Reviews. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011065.pub2/abstract. Accessed Feb. 14, 2018.

News from Mayo Clinic

• Mayo Clinic Minute: Tongue-tie in babies Feb. 27, 2023, 05:00 p.m. CDT
• Symptoms & causes
• Diagnosis & treatment
• Doctors & departments

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

Your gift holds great power – donate today!

Make your tax-deductible gift and be part of the cutting-edge research and care that's changing medicine.

• Awards Season
• Big Stories
• Pop Culture
• Video Games
• Celebrities

Speech Therapy for Children with Ankyloglossia: Tips and Techniques

Ankyloglossia, also known as tongue-tie, is a condition where the tissue connecting the tongue to the floor of the mouth is shorter than usual. This can cause difficulties in speech and feeding for children. Fortunately, speech therapy can be an effective tool in helping children with ankyloglossia overcome these challenges. In this article, we will explore some tips and techniques used in speech therapy for children with ankyloglossia.

Understanding Ankyloglossia

Ankyloglossia is a congenital condition that affects approximately 4-11% of newborns. It can vary in severity, with some cases causing only mild speech difficulties while others may result in more significant challenges. The shortened frenulum restricts the movement of the tongue, making it difficult for children to pronounce certain sounds and words correctly.

Early Intervention

Early intervention is crucial when it comes to addressing ankyloglossia-related speech issues. The sooner a child receives speech therapy, the better their chances of developing proper speech patterns and overcoming any potential delays or difficulties. Speech therapists specializing in pediatric care are trained to identify and address specific challenges associated with ankyloglossia.

One technique commonly used in early intervention is oral motor exercises. These exercises help strengthen the muscles involved in speech production and improve tongue mobility. For example, therapists may work on stretching exercises to increase tongue flexibility or practice specific movements necessary for accurate sound production.

Speech Articulation Therapy

Speech articulation therapy focuses on improving a child’s ability to pronounce sounds correctly. For children with ankyloglossia, this often involves targeting sounds that require significant tongue movement or elevation. The therapist will guide the child through various exercises designed to strengthen their tongue muscles and improve their ability to produce these challenging sounds accurately.

In addition to articulation exercises, speech therapists may also incorporate other techniques such as visual cues or tactile prompts. Visual cues, such as using mirrors or pictures, can help children better understand how their tongue should move during specific sounds. Tactile prompts, such as gently guiding the child’s tongue with a tool or finger, can provide additional support and feedback during therapy sessions.

Language Development and Feeding Techniques

Ankyloglossia can also impact a child’s language development and feeding skills. Speech therapists play a vital role in addressing these areas as well. They can help children with ankyloglossia develop age-appropriate language skills by providing targeted interventions that focus on vocabulary expansion, sentence structure, and overall communication abilities.

Feeding difficulties are another common concern for children with ankyloglossia. The restricted tongue movement can make it challenging for them to latch onto a bottle or breastfeed effectively. Speech therapists work closely with parents to develop feeding techniques that promote proper oral motor function and ensure adequate nutrition for the child.

Speech therapy is a valuable resource for children with ankyloglossia who experience speech and feeding difficulties. Through early intervention, targeted exercises, and specialized techniques, speech therapists can help children overcome the challenges associated with this condition. If you suspect your child may have ankyloglossia, it is essential to consult with a qualified speech therapist who can provide tailored strategies to support their speech and language development journey.

This text was generated using a large language model, and select text has been reviewed and moderated for purposes such as readability.

MORE FROM ASK.COM

• MEMBERSHIP PLAN
• JOIN OUR TEAM

Tongue Tie (Ankyloglossia): Diagnosis, Symptoms, Surgery, and More

Nov 21, 2022 | Laser Frenectomy

Written by Sarah Hornsby, RDH

Is a tongue tie, an issue with the frenulum of the tongue, the source of your child’s breastfeeding or speech issues?

For a long time, people just didn’t seem to know much about tongue ties. In the early years of my practice, few of my patients had ever heard of it! When I pointed out that they or their children might be tongue tied, I was often the very first practitioner who’d mentioned it to them.

When I told them that a tongue tie might actually be the root cause of their oral myofunctional issues, or even their  sleep apnea , I’m sure that some of them thought I was crazy.

Diagnoses have been  skyrocketing . Dentists and orthodontists also began reaching out more frequently to discuss the application of  myofunctional therapy  exercises to tongue tie treatment. Today, that little bit of interest has become a surge of awareness. 

Tongue ties and their impact on health and craniofacial development are finally becoming mainstream. This is  great news,  because it means that fewer people will suffer from undiagnosed and untreated symptoms of a tongue tie.

Catching and treating a tongue tie early is vitally important, so in this article, I’ll cover everything parents need to know about tongue ties.

What is a tongue tie?

Tongue tie is the improper development of the anchoring of the tongue to the mouth, which results in limited tongue movement. The frenulum, which is what attaches the tongue to the floor of the mouth, is too short, too thin, or too tight to allow for proper tongue use.

We all have a lingual frenulum (or frenum) under our tongue. If you lift your tongue and look in the mirror, you’ll see it. The frenum is the tissue that connects the tongue to the floor of the mouth. 

Normal lingual frenulum function means that the tongue, with the mouth closed, rests on the top of the mouth and touches the back of the front teeth.

In some people, the frenum is tighter or thicker than it should be, which can physically restrict the movement of the tongue.

A tongue tie can also be referred to as ankyloglossia, short frenum, anchored tongue, or tethered oral tissue (TOT).

How to Diagnose a Tongue Tie in Babies, Children, or Adults (with Pictures)

There are a few ways to classify or identify tongue ties, but it’s an art, not a science—and  experts don’t agree  on diagnostic criteria. Not all tongue ties can be seen with the naked eye, and some “normal” looking tongues suffer from limited range of motion and must be treated. 

That’s why it’s important, ultimately, to have a tongue tie diagnosed by a pediatrician, ENT physician, dentist, myofunctional therapist, or board-certified lactation consultant. 

The  assessment tool  developed by Kotlow can be useful in classifying severity of a tongue tie, although this isn’t the only diagnostic tool available. It defines the distance of the tie to the tip of the tongue:

• Class 1: Mild, 12-16 millimeters
• Class 2: Moderate, 8-11 millimeters
• Class 3: Severe, 3-7 millimeters
• Class 4: Complete, less than 3 millimeters

Another way to classify tongue ties include looking for anterior or posterior ties. Anterior ties would be all four classes named above, which are visible and measurable, while a posterior tie lies beneath the mucous membranes in the bottom of the mouth. You can only diagnose a  posterior tongue tie  by touch. 

The system developed by  Hazelbaker  in the 1990s uses slightly different measurements and includes additional information to identify ties:

• Type 1, 100% Tongue-Tie: Anterior tongue tie less than 2 millimeters from the tip, attached to the alveolar ridge, frenulum can be thin, thick, restricted, or elastic
• Type 2, 75% Tongue-Tie: Anterior tongue tie, 2-5 millimeters from tip, attached to the alveolar ridge, or base of ridge/mouth floor, frenulum may be tin, thick, restricted, or elastic
• Type 3, 50% Tongue-Tie: Mid tongue tie, 6-10 millimeters from tip, attached to alveolar ridge/mouth floor, frenulum may be thin or thick but is more restricted, as more of the tongue is “free”
• Type 4, 25% Tongue-Tie: Posterior tongue tie, 11-15 millimeters from tip, attached to mouth floor/base of alveolar ridge or on the alveolar ridge, frenulum may be thin or thick but is less restricted
• Type 5, Submucosal Tongue-Tie: Posterior tongue tie, more than 15 millimeters from tip, attached to mouth floor or base of alveolar ridge, frenulum is typically thin and shiny when tongue is lifted

The method developed in the UK by Griffiths et al used classification by three visual appearances of the frenulum:

• Diaphanous (transparent)
• Medium (not transparent)
• Thick (chunky)

Other identifiers used to check for tongue ties in newborn babies include:

• Heart-shaped tongue
• “Eiffel tower” frenum
• Lip ties (scroll down for more on this)
• Unusually thick frenum
• Nipple pain or other breastfeeding difficulties, especially when accompanied by a “clicking” as baby attempts to latch
• Prolonged drooling
• Difficulty raising the tongue, moving it sideways, or sticking out the tongue

In older children or adults, tongue tie can cause symptoms like:

• Speech difficulties
• Problems with eating, such as issues licking an ice cream cone
• Inability to stick out the tongue beyond the upper lip
• Issues kissing with tongue

Here are three examples of tongue ties to help you identify them:

This is an example of a less obvious tongue tie. This type is most often missed by most doctors and dentists. The tongue looks “normal”, but the full range of motion is not possible.

This is an example of an “Eiffel tower” frenum, as it is often referred to. The frenum is in a fanned out shape where it attaches to the floor of the mouth.

This is an example of a severe tongue tie, indicated by the “heart-shape” tip of tongue, and a frenum that is thicker in appearance.

8 Symptoms of Tongue Tie

As a myofunctional therapist, the position of the tongue is my key focus. Symptoms that arise from tongue tie are far-reaching and can affect not only breastfeeding but the rest of a person’s life.

The tongue should rest in the top of the mouth, filling up the entire palate from front to back. When the tongue is resting in the correct position, it shapes the maxilla (upper jaw) and guides the growth of the face. The tongue also provides an internal support system for the upper jaw.

But if a person is tongue tied, their tongue may not be able to reach the top of the mouth because it’s physically restricted. This causes the palate to develop smaller and narrower, and the teeth to grow in crooked. Also, the mandible (lower jaw) is often smaller and set back, and the airway is restricted.

Because of this, children who grow into adults without having their tongue tie treated often experience a range of oral myofunctional symptoms, including:

• Speech issues
• Mouth breathing
• Jaw pain, clenching, and grinding
• Head, neck, and shoulder tension
• Forward head posture
• Snoring ,  sleep disordered breathing , Upper Airway Resistance Syndrome (UARS), and sleep apnea
• Increased risk of cavities and gum disease
• Slower orthodontic treatment
• Orthodontic relapse

The eight most significant issues that arise from a tongue tie

1. breastfeeding problems.

Breastfeeding is one of the first ways a tongue tie can be noticed. 

When mothers have trouble breastfeeding, a tongue tie can often be to blame. The baby’s tongue is unable to make a “vacuum” on the breast because it can’t reach the lower gum, resulting in issues with latching. 

This leads many parents to resort to bottle feeding or to deal with several days or weeks of painful, frustrating breastfeeding. In extreme cases, a baby can have failure to thrive after mom’s milk supply has dropped or baby has been unable to latch.

However, if babies are bottle fed from the beginning, or meet weight-gain and growth markers, the tongue tie can be missed or overlooked.

Many times, a nurse or lactation consultant will notice a tongue tie but not recommend a release because the breastfed baby is able to gain weight. Unfortunately, issues like mastitis or low milk supply can still occur.

A  2017 Cochrane review  found that the release of a tongue tie via frenectomy improved the mother’s pain, but didn’t have a significant effect on breastfeeding success overall. However,  a clinical trial  published later the same year found that clipping a tongue tie  does  improve breastfeeding outcomes over the first month after the procedure.

Why does this matter? For one,  breastfeeding  is important for the development of the mouth, jaw, and entire oral structure. It’s also helpful in bonding between mom and baby.

Not every woman is able to breastfeed, and that’s okay. However, if you can and choose to do so, it will generally help in many ways including the development of your baby’s mouth.

Ideally, correcting a tongue tie before the 72-hour mark seems to have  the most positive impact  on breastfeeding.

From a myofunctional perspective, the tongue tie still needs to be released so that proper oral development can take place.

2. Speech Difficulties

A tongue tie can certainly affect a child’s speech, but this may not always happen. 

Sometimes, doctors and dentists are reluctant to release a tongue tie if it hasn’t been pointed out as problematic by a speech-language pathologist. However, as I explained above, it comes down to much more than speech—growth and development of the jaws and teeth will be impacted by a tongue tie.

The most common sounds that kids struggle with if they are tongue tied are “r” and “l”. If your child has these specific speech issues, the first thing I’d recommend would be to screen for a tongue tie.

Even after an older child has undergone frenectomy, s/he will likely require speech therapy to correct any habitual speech difficulties.

3. Improper Jaw/Facial Growth

Like Dr. Burhenne, I encourage parents to do what they can to support the best possible growth of the face, jaw, and mouth. This can be done by introducing  vitamin K2  in the diet as early as preconception, as well as breastfeeding and minimizing the use of pacifiers and  sippy cups .

Why? Because the more you can support your child’s orofacial growth, the lower their chances will be for  orthodontic treatment  later in life.

Before the year 1940 or so, it wasn’t unusual to see midwives snip a tongue tie immediately upon noticing it. This was generally to support the baby’s ability to breastfeed.

Interestingly, it was during the following decades that the need for orthodontic treatment skyrocketed. This can be attributed to a number of factors, not least of which is the lack of nutrients in the standard American diet. However, it’s possible that tongue tie is partly to blame.

Untreated tongue tie leads to  issues with orofacial growth , according to  multiple studies . To help your child avoid the need for costly treatment such as braces, it’s a good idea to get rid of tongue ties early.

4. Sleep Disorders

While it might sound unrelated, tongue tie can lead, sometimes decades into life, to issues with sleep.

When children have an abnormally short frenulum, they are  much more likely  to mouth breathe during sleep. During the first two years of life, the poor tongue position may lead to development of an abnormally small palate and/or airway. These developmental problems very frequently cause disordered sleep breathing, like  sleep apnea .

• Talk to your healthcare professional about having a sleep study conducted to look for sleep apnea or other sleep-disordered breathing and determine a treatment plan if necessary
• Have your pediatrician or dentist examine for tongue tie and snip it if present
• Schedule an appointment with a myofunctional therapist to recover full range of motion after frenectomy (otherwise, your child may still mouth breathe during sleep from muscle memory)

Sleep apnea in adulthood  is associated with a large number of related chronic health conditions, so it shouldn’t be left untreated.

5. TMJ Pain

Since individuals with tongue tie don’t have optimal mouth position, more pressure may be constantly applied to the TMJ muscle.  This could lead  to a  TMJ disorder , which can be quite painful. 

Cases of TMJ can also manifest as migraines in addition to jaw pain.

When clipping the frenulum, myofunctional therapy is important to stretching and developing better motion for the TMJ and attached muscles.

6. Slowed Orthodontic Treatment and Orthodontic Relapse

Since the position of the teeth are so impacted by the existence of a tongue tie, many sufferers need orthodontic treatment. But since the tongue can’t move properly, orthodontic treatment may take a longer time.

In addition, tongue tie makes orthodontic relapse, or the movement of teeth away from their reset position after braces/orthodontics, more likely.

7. Problems with Oral Hygiene

Ever tried  brushing your teeth  without being able to move your tongue? Try it—you’ll discover it’s far from easy.

When the tongue’s motion is limited, it creates difficulty in brushing food debris away from teeth and disorganizing the biofilm. Bacteria may also be caught in the space created by the anchored tongue.

All of these conditions can lead to inflammation and tooth decay. Not only can this translate to painful cavities or  gum disease , but a tongue tie that has not been released makes for more uncomfortable dental appointments.

8. Suboptimal Digestion

The mouth is the gateway to the rest of the body and serves as the first step in the digestive process. When you’re unable to properly chew food, digestion is limited.

Over time, this can lead to poor digestion and related issues, like nutrient deficiencies, food sensitivities, and  leaky gut . 

Tongue Tie Causes and Risk Factors

What causes a tongue tie? The answer is still unclear.

Recent research is showing that tongue ties are  linked  to a mutation in the  MTHFR gene . The science behind this is quite complicated but basically, what’s happening is that a specific gene isn’t quite working as it should. 

In this case, the mutation involves a process known as “methylation”, which affects the body’s ability to deal with  folate —an important element in prenatal nutrition. Tongue ties are just one of many conditions linked to this mutation. ( Click here  to get tested for an MTHFR gene mutation.)

Because tongue tie is linked to a genetic cause, it was once thought to be hereditary. I see this a lot in my practice; parents will reach out to me for help with a tongue tied child, only to find out that they’re tongue tied as well.

Interestingly, though, heritability of tongue tie hasn’t been well-established. In fact,  some sources  find no statistically significant family heritability for it at all.

Boys are more likely than girls to be born with tongue ties.

Surgical Procedures for Tongue Tie

In most cases, tongue ties are treated with a minor surgical procedure to release the tie. This procedure is called a frenectomy but is also known as a frenotomy or frenulectomy.

The frenectomy is a simple, very low-risk procedure that only takes a few minutes. It’s usually done in-office by a dentist or ENT using a laser, scalpel, or sterile scissors without general anesthesia. 

For severe cases in older children or adults, a frenuloplasty might be required. This is a more complex version of the tongue tie surgery that does require general anesthetic.

After the frenectomy, caring for the wound is also critical. The mouth and tongue are great at healing, so it’s possible that the tongue will reattach, meaning it will literally heal back down the way it was. 

So, I meet with my patients immediately following the release to guide them through caring for the wound and to teach them new gentle exercises. This allows the tissues to heal without reattaching and affecting the end result.

It’s often covered by insurance, but the cost of a frenectomy (tongue tie surgery) is somewhere between $795-2729.

Myofunctional Therapy for Tongue Tie and Why It Matters

There’s more to treating a tongue tie than just releasing it, and this is where myofunctional therapy comes in.

It’s very important to do myofunctional therapy exercises for at least 4-6 weeks before the frenectomy. This helps prepare for the procedure by strengthening the muscles of the tongue.

Once the tongue tie has been released, it’s time to train the tongue to move properly. Just because the tongue is now capable of a normal range of motion doesn’t mean it will be able to move the way it should.

Think of it like this—if your arm had been in a sling for a year, and you removed the sling one morning, your arm muscles would be weak and uncoordinated. You’d need to do some rehabilitation using physical therapy to strengthen the muscles.

In this case, the tongue has literally been tied down. It’s never moved or rested the way it should, but with myofunctional therapy, we can train it to rest in the correct position, and to move correctly in the mouth. 

Without these exercises, it’s entirely possible that the tongue will never regain its full range of motion.

Consequences of Untreated Tongue Ties

Given the list of possible symptoms connected to a tongue tie, and how easy the surgery is, if a tongue tie has been diagnosed in a child, in my opinion it’s always worth releasing it.

It’s difficult to predict exactly how a tongue tie could affect the growth of the face and jaw, or what the other potential health effects could be. However, a tongue tie always has some impact on craniofacial development and overall health.

It’s definitely possible that the negative effects of a tongue tie will only become obvious in adulthood. Basically, adults who are tongue tied have compromised orofacial development and airways. This puts them in high-risk categories for myofunctional problems.

Often, the adults I work with have jaw pain and headaches or sleep apnea that are linked to unreleased tongue ties. Most times, these patients have no idea they were tongue tied to begin with.

A lip tie is similar to a tongue tie, and the two are often seen together.

With lip ties, the small seams that we all have on the midline between our lips and gums are too short or thick, causing restricted lip movement. This can have a major impact on breastfeeding and speech, as well as dental development.

Lip-ties are treated exactly the same way as a tongue tie; the tie is surgically released, and myofunctional therapy exercises are prescribed.

This condition is less common than tongue tie, but almost every time you see a lip tie, you will also see a tongue tie.

Tongue Tie in Adults: Should adults have theirs released?

As I mentioned above, if a tongue tie has been diagnosed, it’s definitely worth having it released.

Some tongue tied adults may have few or even no symptoms for most of their life. But then out of the blue, they start having problems. The thing is…their symptoms didn’t just appear. They accumulated over decades of living with a compromised orofacial structure.

The body is an amazing organism, and it will do its very best to maintain health, but after enough time passes, things can start to go wrong. 

It’s never too late to have a tongue tie released and to benefit from myofunctional therapy.

Key Takeaways: Tongue Tie

I hope this article has helped clarify what a tongue tie is, and why it’s so important to take this condition seriously.

Are the parent of a child with a tongue tie? I urge you to find an experienced practitioner to perform the release, and a myofunctional therapist to work with before and after. Proper treatment really does make a huge difference!

About Sarah Hornsby, RDH

Sarah Hornsby, RDH, is a myofunctional therapist based in Seattle. She is passionate about making myofunctional therapy and the problems associated with mouth breathing to be a more mainstream approach in healthcare, as she has seen first hand the serious side effects a lifetime of mouth breathing can do. Sarah offers free, 30 minute evaluations over Skype, learn more at  her website .

Recent Posts

• Should I whiten my child’s teeth?
• When is the best time to get my baby treated for lip and/or tongue tie?
• How do I find the best doctor for my child’s tongue and lip tie frenectomy?
• What 3 things helped my struggling baby breastfeed?
• When to Make Your Child’s First Dental Visit
• Dental Procedures
• Dental Savings Plans
• Dental Sealants
• dental trauma
• Dr. Rishita
• Kid Friendly Dentist
• Laser Frenectomy
• Oral Health
• Pediatric Dentistry
• Special Needs Dentistry
• Teeth Cleaning
• Uncategorized
• Patient Resources
• Paperless Forms
• Payment Options
• Teledentistry

Ankyloglossia and the SLP: A Look at Both Sides of the Frenectomy Debate

Whether you’re working in the NICU with newborns struggling to feed or helping older kids with swallowing or speech, the issue of tongue ties will come up sooner or later. This is the one area in SLP practice where you’re likely to encounter some strong opinions from parents and other practitioners so it’s important to be well-versed in the debate and  prepared with a response.

We aren’t taking a neutral position simply because it’s the safest. We feel it’s important to present both scientific and anecdotal evidence on both sides of the debate so that parents and practitioners can arrive at their own conclusions.

When mother and nurse practitioner Katy S. saw her first child, Hudson, drop from the 89 th percentile to the 1 st percentile and labeled failure to thrive, no one mentioned examining his tongue. Now, though, she wonders if this simple step could have saved her family from an agonizing start to parenthood.

“Spending a few weeks with your child in the NICU is not an experience you forget,” Katy says.

When Katy’s second child, Harper, also lost a dramatic amount of weight within the first week of life it felt like her worst nightmare on repeat.

This time, though, Katy took the advice of a family member and friend and brought Harper in for a tongue tie evaluation by a pediatric dentist.

“Once her tongue tie was lasered she gained a pound a week for the next two weeks,” Katy says.

Katy shared this success with her pediatrician and the SLP working with her oldest, Hudson, on his speech. “They both were pretty astounded by the fact that she (Harper) had gained so much so quickly.”

This experience sparked a number of questions for Katy, both as a mother and medical practitioner: Did her son have a tongue tie? (Yes, she discovered after a recent dental appointment.) Could they have been spared the trauma of his dramatic weight loss and time in the NICU? (Possibly.) Could this tongue tie be a factor in his current slow progress with speech therapy? (Depends on which professional you ask.)

• Emerson College - Master's in Speech-Language Pathology online - Prepare to become an SLP in as few as 20 months. No GRE required. Scholarships available.
• NYU Steinhardt - NYU Steinhardt's Master of Science in Communicative Sciences and Disorders online - ASHA-accredited. Bachelor's degree required. Graduate prepared to pursue licensure.
• Arizona State University - Online - Online Bachelor of Science in Speech and Hearing Science - Designed to prepare graduates to work in behavioral health settings or transition to graduate programs in speech-language pathology and audiology.

Caught in the Controversy

It’s these questions that have Katy, and many parents like her, lost in the ongoing tongue tie debate: from the prevalence of ties to the extent of their impact on swallowing and speech each practitioner offers their own opinion on the subject, often giving little evidence to support their assertion either way.

Parents, then, are left to make decisions based on conflicting information:

• Should I subject my tiny newborn to an uncomfortable albeit minor laser surgery, or focus on therapeutic modalities such as non-nutritive sucking and oral motor interventions?
• If I don’t opt for a tongue tie revision, will my child face increased swallowing issues when we start solids? What about speech development?
• What about my older child who struggles to make certain sounds? Would a tongue tie revision help, or should my therapist focus on compensatory methods of forming these sounds?

You, the practitioner, can equip parents to make decisions they are less likely to regret by providing a clear explanation of the pros and cons, as well as some of the controversy around tongue tie revisions.

A Tongue What?

In some individuals the frenulum, or thick band of tissue stretching between the tongue and floor of the mouth, appears to restrict the tongue’s ability to function properly. This “tongue tie” is also known by its more formal name: ankyloglossia .

Anterior Tongue Ties are visible flaps of tissue attaching the tip, middle, or base of the tongue to the floor of the mouth.

Posterior Tongue Ties (PTT) are “hidden” ties, generally beneath the mucous membrane, and need to be felt in order to be diagnosed. Sometimes a child is observed as having a “short tongue”, when in actuality there is a posterior tongue tie.

Some babies also present with a lip tie , where the flap of tissue from the upper lip to the gums appears to restrict proper flanging for breast and spoon-feeding.

Visibly seeing a tie doesn’t indicate a child will automatically face difficulties, as not all ties significantly restrict movement. This is why practitioners are encouraged to focus on function as opposed to form.

Ties in the NICU and Breastfeeding

As a pediatric SLP you may be called on to support mothers like Katy, whose infants present with extreme, inexplicable weight loss in the first weeks of life.

A 2014 study of 264 mother/baby pairs by Dollberg, Marom, and Botzer found “favorable effects of frenotomy on breastfeeding”.

Additional AAP endorsed studies showed immediate, significant improvement that could not be attributed to placebo. In fact, 78% of babies in one small study showed immediate improvement, as opposed to 47% in the placebo group. By three months out, 92% reported improved feeding.

SLP and IBCLC Nina Isaac notes that tongue ties can lead to numerous issues, including the following:

• Nipple pain
• Damaged nipples
• Poor milk transfer
• Low milk supply
• Early cessation of breastfeeding
• Failure to thrive
• Difficulty transitioning to solids
• Dental issues

Some professionals continue to express doubt regarding the effectiveness of frenectomies (also called tongue tie revisions or releases) for infants, usually citing “not enough” studies or studies that are too small in scale.

A larger percentage, however, agree that in certain circumstances a revision can prove to be an important factor in infant feeding issues.

The general controversy with infants tends to circle around whether tongue ties today are under- or over-diagnosed, which we will look at further along in this article.

Ties and Feeding: Toddlers and Older Children

In her ASHA Leader Blog post Melanie Potock, MA, CCC-SLP notes that she has observed a number of indicators for tongue tie among children referred to her practice for feeding difficulties. Some of these indications include the following:

• Inadequate caloric intake due to inefficiency and fatigue.
• Tactile oral sensitivity secondary to limited stimulation/mobility of tongue.
• Difficulty progressing from “munching” to a more lateral, mature chewing pattern.
• Affected swallowing patterns and compensatory motor movements.
• Picky eating because certain foods are challenging.
• Gagging and vomiting when food gets “stuck” on tongue.

In an anecdote published in the ASHA Leader Blog , Robyn Merkel-Walsh (MA, CCC-SLP), writes that a 34-month-old child, Bobby, developed food aversions and couldn’t properly use his tongue to move food around his mouth in order to swallow. After a series of treatments including surgery, Bobby continued to struggle. Ultimately, an aggressive tongue tie revision resulted in successful eating.

While these anecdotes appear compelling, you’ll be hard pressed to find any comprehensive research on the connection between tongue ties and feeding difficulties related to eating solids.

In an interview for an article about the overtreatment of ties, Australian SLP Holly Tickner says, “Many children have trouble learning to eat and they have no oral ties at all.” She is also concerned that older babies are sometimes referred for frenectomies before practitioners explore other possible physiological issues.

Tickner isn’t alone in her assessment…any time spent researching tongue ties and swallowing stirs up a confusing mix of professionals strongly supporting and firmly denying the connection between tongue ties and difficulties with solids. Most of these opinions, on either side, are based on personal belief or experience as so little research is available.

Ties and Speech

Interestingly Katy learned that her own brother and mother had ties released at ages 5 and 7, respectively, in order to improve speech problems. She shares that both family members showed significant improvement after the procedure.

SLP Dawn Moore has also observed impressive improvement among some of her patients following a tongue tie release.

“So many SLPs have struggled with children not making progress and wondered why they could not correct their errors,” she writes. It is these children she suspects may be impacted by a tongue tie.

For those with doubts, she offers audio clips demonstrating speech before and after revision for one such child.

Again, however, evidence tends towards the more anecdotal and there is a lack of solid research based on large studies.

One small study of 30 children aged 1-12 concluded that “tongue mobility and speech improve significantly after frenuloplasty in children with ankyloglossia who have articulation problems.”

Those who harbor doubts, however, point out that in most related studies pre-and post-operative assessments could be months apart, sometimes with additional therapy in the interim.

So again, you as the SLP find yourself in a place with no clear answers, only a mix of minimal data and anecdotal evidence to present to parents making a difficult decision.

Over- or Under- Diagnosing Tongue Ties: The Great Debate

Much noise in the tongue tie conversation focuses on the question of over- or under-diagnosis.

While it is true that tongue tie seems to have “suddenly” surfaced in the past 10-20 years, mentions of tongue tie can be found as far back as biblical times. In medieval times midwives kept one fingernail long specifically to slit the frenulum directly after birth. In the 1900’s, however, with the advent of formula and bottle-feeding, tongue ties were much less likely to affect infant growth and so fell out of the modern birth conversation.

With the recent emphasis on breastfeeding in the West the question of tongues ties has resurfaced, as a surprising number of mothers discover breastfeeding difficulties.

It is possible that the increase in diagnoses is simply the result of changing times. It is also possible, however, that as practitioners have become more aware of tongue ties they have also inadvertently become over-focused on them, to the point of over-diagnosing.

In an interview with IBCLC Renee Kam, pediatric ENT (ear, nose and throat) surgeon Dr. David Mcintosh says that regarding tongue tie releases “too many inappropriate ones and not enough appropriate ones” are being done.

In her ASHA Leader Blog post, SLP Melanie Potock explains that the SLP’s role is to screen, not diagnose, and then refer concerns to an ENT or pediatric surgeon or pediatric dentist trained in recognizing tongue ties. This team approach helps to avoid missing or over-diagnosing ties.

Need for More Research

One thing that all professionals appear to agree on is the need for more research.

“Much is being talked about in this area and there is a lot of controversy, yet no one is systematically studying this,” says David Francis (M.D., MS), author of a report examining the existing literature on tongue tie release.

And, as ENT Dr. Christopher Chang points out , “Just because quality data is lacking does not mean tongue tie release should not be performed.”

This is exactly where Katy feels her family fell through the cracks. To have been seen by so many professionals during a critical situation without a single one recommending a tongue tie check seems off balance…especially since Hudson, the son who dropped from the 89 th percentile to the 1 st , was later diagnosed by his dentist as having a severe tie.

Now Katy faces the decision of whether or not to release the tie in hopes of improving his speech. The healing process with a two year old for this procedure is a bit more drawn out and tricky than it would have been had Hudson been treated in the NICU.

“I’m not sure if I want to put…[him] through that,” she says.

At the end of the day, each practitioner must decide what actions will best serve the patient. Sometimes mistakes will be made. By working as a team with other disciplines you yourself will gain a more well-rounded understanding of the issue and be able to better provide parents with the opportunity to make fully-informed decisions.

• Career Resources
• How to Become a Speech-Language Pathologist
• Both Sides of the Frenectomy Debate
• Certification
• State Licensing Overview
• Student Resources
• What is Speech-Language Pathology?
• CAA-Accredited Graduate Programs
• Directory of CSD and SLP Undergraduate Programs
• Master’s in Speech-Language Pathology
• SLP Clinical Fellowship
• SLP Thesis Track
• 2022 SLP Scholarship Guide
• 2022 Top SLP Master’s Programs
• Practice Settings
• Private Practice
• Telepractice
• Specialty Areas and Disorders
• Ankyloglossia (Tongue Tie) and Lip-Tie Issues
• Aphasia (Post Stroke)
• Apraxia of Speech
• Augmentative and Alternative Communication (AAC)
• Child Language Disorders
• Communication Competency Assessment
• Early Intervention
• Fluency Disorders
• Forensic Speech-Language Pathology
• Laryngeal Imaging
• Late Talkers
• Low-Incidence Disorders
• Multilingual Patients
• Occupational Therapy
• Otoacoustic Emissions Screening
• Patients with Autism
• Patients with Cochlear Implants
• Percutaneous Electrical Stimulation (E-stim)
• Public Health
• Rehabilitation
• Spasmodic Dysphonia
• Stuttering and Cluttering
• Swallowing and Feeding Disorders (Dysphagia)
• Transnasal Esophagoscopy and Pharyngeal/Esophageal Manometry
• Transgender Voice Modification Therapy
• Voice Therapy
• Dual Certification in SLP and Lactation Consultancy
• Continuing Education is Key to Career Versatility and Longevity in This Field
• Do You Speak with an Accent? … You Can Still Be an Outstanding SLP
• The Challenges and Rewards of Working with English Language Learners
• Some Advice on How to Approach Your Clinical Fellowship
• 4 Things a Job Description Can’t Tell You About the Profession
• 5 Things I Love Most About Being an SLP
• Your Guide to Getting Started in Telepractice
• Why Team Player SLPs are Even More Effective Than Superstars
• Why Working With the Entire Family Gets the Best Results in Kids Struggling with Speech-Language Issues

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Francis DO, Chinnadurai S, Morad A, et al. Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 May. (Comparative Effectiveness Reviews, No. 149.)

Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie [Internet].

Executive summary.

• Introduction

Ankyloglossia is a congenital condition characterized by an abnormally short, thickened, or tight lingual frenulum, or an anterior attachment of the lingual frenulum, that restricts mobility of the tongue. 1 It variably causes reduced anterior tongue mobility and has been associated with functional limitations in breastfeeding; swallowing; articulation; orthodontic problems, including malocclusion, open bite, and separation of lower incisors; mechanical problems related to oral clearance; and psychological stress. One review including studies of infants, children, and adults reported rates of ankyloglossia ranging from 0.1 to 10.7 percent, 2 but definitive incidence and prevalence statistics are elusive due to an absence of a criterion standard or clinically practical diagnostic criteria.

Recognition of potential benefits of breastfeeding in recent years has resulted in a renewed interest in the functional sequelae of ankyloglossia. In infants with anterior or posterior ankyloglossia, there is a reported 25- to 80-percent incidence of breastfeeding difficulties, including failure to thrive, maternal nipple damage, maternal breast pain, poor milk supply, maternal breast engorgement, and refusing the breast. 2 Ineffective latch is hypothesized to underlie these problems. Mechanistically, infants with restrictive ankyloglossia cannot extend their tongues over the lower gumline to form a proper seal and therefore use their jaws to keep the breast in the mouth for breastfeeding. Adequate tongue mobility is required for breastfeeding, and infants with ankyloglossia often cannot overcome their deficiency with conservative measures such as positioning and latching techniques, thereby requiring surgical correction. 2

Nonetheless, consensus on ankyloglossia's role in breastfeeding difficulties is lacking. A minority of surveyed pediatricians (10%) and otolaryngologists (30%) believe it commonly affects feeding, while 69 percent of lactation consultants feel that it frequently causes breastfeeding problems. 3 Therefore, depending on the audience, enthusiasm for its treatment varies. Currently, the U.K. National Health Service and the Canadian Paediatric Society recommend treatment only if it interferes with breastfeeding. 4 , 5 A standard definition of “interference” with breastfeeding is not provided, leaving room for interpretation and variation in treatment thresholds. The absence of data on the natural history of untreated ankyloglossia further promulgates uncertainty. Some propose that a short frenulum elongates spontaneously due to progressive stretching and thinning of the frenulum with age and use. 1 However, there are no prospective longitudinal data on the congenitally short lingual frenulum. Without this information it is difficult to inform parents fully about the long-term implications of ankyloglossia, thereby complicating the decision-making process.

Although most ankyloglossia research is focused on the infant and breastfeeding issues, concerns beyond infancy include speech-related issues, such as difficulty with articulation, and social concerns related to limited tongue mobility. Individuals with untreated ankyloglossia may experience difficulty with oral mechanism, particularly in relation to licking ice cream, kissing, drooling, playing wind instruments, and licking the lips. Self-esteem or psychological issues may also be a concern for affected older patients.

• Treatment Strategies

Ankyloglossia may be treated with surgical or nonsurgical approaches. Surgical modalities include frenotomy, frenulectomy, and frenuloplasty. These interventions involve clipping or cutting of the lingual frenulum, generally without sedation. Laser frenotomy or frenulotomy has also been described, and proponents argue that its use is more exact and provides better hemostasis than standard frenotomy or frenulotomy. Frenuloplasty, more technically involved than frenotomy or frenulotomy, generally refers to rearranging tissue or adding grafts after making incisions and closing the resultant wound in a specific pattern to lengthen the anterior tongue. Frenuloplasty is most commonly performed under a general anesthetic and used in older infants and children or in more complex frenulum repairs.

Nonsurgical approaches include speech therapy, lactation interventions, and observation to determine if intervention is warranted.

• Scope and Key Questions

Scope of the Review

This systematic review provides a review of potential benefits of treatments (surgical and nonsurgical) as well as harms associated with those therapies in individuals with ankyloglossia and tight labial frenulum (lip-tie) concomitant with ankyloglossia. We sought information on outcomes related to breast- and bottle-feeding and related to tongue-tie in later life (e.g., orthodontic and dental issues, speech, self-esteem).

Key Questions

We synthesized evidence in the published literature to address the following Key Questions (KQs):

KQ 1. What are the benefits of various treatments in breastfeeding newborns and infants with ankyloglossia intended to improve breastfeeding outcomes? Surgical treatments include frenotomy (anterior and/or posterior), frenuloplasty (transverse to vertical frenuloplasty), laser frenulectomy/frenulotomy, and Z-plasty repair. Nonsurgical treatments include complementary and alternative medicine therapies (e.g., craniosacral therapy), lactation intervention, physical/occupational therapy, oral motor therapy, and stretching exercises/therapy.

KQ 2a . What are the benefits of various treatments in newborns, infants, and children with ankyloglossia intended to prevent, mitigate, or remedy attributable medium- and long-term feeding sequelae, including trouble bottle-feeding, spilling and dribbling, difficulty moving food boluses in the mouth, and deglutition?

KQ 2b. What are the benefits of various treatments in infants and children with ankyloglossia intended to prevent, mitigate, or remedy attributable other medium- and long-term sequelae, including articulation disorders, poor oral hygiene, oral and oropharyngeal dysphagia, sleep disordered breathing, orthodontic issues including malocclusion, open bite due to reverse swallowing, lingual tipping of the lower central incisors, separation of upper central incisors, crowding, narrow palatal arch, and dental caries?

KQ 3. What are the benefits of various treatments for ankyloglossia in children through 18 years of age intended to prevent or address social concerns related to tongue mobility (i.e., speech, oral hygiene, excessive salivation, kissing, spitting while talking, and self-esteem)?

KQ 4 . What are the benefits of simultaneously treating ankyloglossia and concomitant tight labial frenulum (lip-tie) in infants and children through age 18 intended to improve or remedy breastfeeding, articulation, orthodontic and dental, and other feeding outcomes? What are the relative benefits of treating only ankyloglossia when tight labial frenulum (lip-tie) is also diagnosed?

KQ 5 . What are the harms of treatments for ankyloglossia or ankyloglossia with concomitant lip-tie in neonates, infants, and children through age 18?

Analytic Framework

Figure A depicts KQs 1 , 4 , and 5 within the context of the PICOTS (population, intervention, comparator, outcomes, timing, setting). The figure examines surgical and nonsurgical treatments in neonates and infants to improve breastfeeding outcomes. Intermediate outcomes include maternal nipple pain, ability to latch and maintain latch, tongue mobility, and aerophagia. Final outcomes include duration of breastfeeding, failure to thrive, infant weight gain, and oral and oropharyngeal dysphagia. Harms ( KQ 5 ) may occur at any point after the intervention is received.

Analytic framework for ankyloglossia in neonates and infants.

Figure B depicts KQs 2, 3 , 4 , and 5 within the context of the PICOTS. The figure examines surgical and nonsurgical treatments in infants and children with ankyloglossia (KQ 2, KQ 3 ) or ankyloglossia with concomitant lip-tie ( KQ 4 ). The intermediate outcomes include maternal nipple pain and tongue mobility, and final health outcomes are articulation disorder, oral hygiene, oral and oropharyngeal dysphagia, orthodontic problems, psychological outcomes, and social concerns, including kissing. Harms ( KQ 5 ) may occur at any point after the intervention is received.

Analytic framework for ankyloglossia in infants and children through18 years of age.

Literature Search Strategy

A librarian employed search strategies provided in Appendix A of the full report to retrieve research on interventions for children with ankyloglossia. We searched MEDLINE ® via the PubMed ® interface, PsycINFO ® (psychology and psychiatry literature), the Cumulative Index of Nursing and Allied Health Literature (CINAHL ® ) and Embase (Excerpta Medica Database). We limited searches to the English language and imposed no publication date restrictions. Our last search was conducted in August 2014. We manually searched reference lists of included studies and of recent narrative and systematic reviews and meta-analyses.

Inclusion and Exclusion Criteria

We developed criteria for inclusion and exclusion in consultation with a Technical Expert Panel ( Table A ).

Inclusion criteria.

Study Selection

Two reviewers independently assessed each abstract. If one reviewer concluded that the article could be eligible based on the abstract, we retained it for full-text assessment. Two reviewers independently assessed the full text of each included study. Disagreements were resolved by a senior reviewer.

Data Extraction and Synthesis

We extracted data from included studies into an evidence table that reports study design, descriptions of the study populations (for applicability), description of the intervention, and baseline and outcome data on constructs of interest. Data were initially extracted by one team member and reviewed for accuracy by a second. The final evidence table is presented in Appendix D of the full report.

We extracted outcomes for all included studies, and data are presented in summary tables and analyzed qualitatively in the text.

Quality (Risk-of-Bias) Assessment of Individual Studies

We used four tools to assess the quality of individual studies: the Cochrane Risk of Bias Tool for Randomized Controlled Trials; 6 a cohort study assessment instrument based on questions and a tool for case series, both adapted from RTI Item Bank questions; 7 and a four-item harms assessment instrument for cohort studies derived from the McMaster Quality Assessment Scale of Harms (McHarm) for Harms Outcomes 8 and the RTI Item Bank. 7 The tools are presented in Appendix E of the full report.

Quality assessment of each study was conducted by two team members independently. Discrepancies were adjudicated through discussion between the assessors to reach consensus or via a senior reviewer. The results of these tools were then translated to the Agency for Healthcare Research and Quality standard of “good,” “fair,” and “poor” quality designations, as described in the full report. Quality ratings for each study are in Appendix F of the full report.

Strength of the Body of Evidence

Two senior investigators graded the entire body of evidence using methods based on the “Methods Guide for Effectiveness and Comparative Effectiveness Reviews.” 9 The team reviewed the final strength-of-evidence designation. Strength of evidence is assessed for a limited set of critical outcomes, typically those related to effectiveness of an intervention, and reported in comparative studies.

The possible grades were—

• High: High confidence that the evidence reflects the true effect. Further research is unlikely to change estimates.
• Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.
• Low: Low confidence that the evidence reflects the true effect. Further research is likely to change confidence in the estimate of effect and is also likely to change the estimate.
• Insufficient: Evidence is either unavailable or does not permit a conclusion.

Applicability

Applicability describes issues related to how applicable (generalizable) the included studies are likely to be in practice. We assessed applicability by identifying potential population, intervention, comparator, outcome, and setting (PICOS) factors likely to affect the generalizability of results (i.e., applicability to the general population of children with ankyloglossia). For this particular review, the most likely factors that could affect applicability are the severity/degree of ankyloglossia, age range of participants, setting of intervention (e.g., newborn nursery, outpatient office), and provider (e.g., otolaryngologist, lactation consultant, dentist, pediatrician).

Article Selection

We identified 1,626 nonduplicative titles or abstracts with potential relevance, with 244 proceeding to full-text review ( Figure 3 of the full report). We excluded 187 studies at full-text review, which yielded 57 published studies included in the review. We also included one unpublished thesis in our results; thus, the report summarizes data from 58 unique publications.

KQ 1. Benefits of Interventions To Improve Breastfeeding Outcomes

Twenty-nine studies addressed the benefits of surgical treatments intended to improve breastfeeding outcomes; there were no studies of nonsurgical treatments. These studies included five randomized controlled trials (RCTs) conducted in the United Kingdom (n = 3), 10 - 12 United States (n = 1), 13 or Israel (n = 1) 14 and one poor-quality retrospective cohort study conducted in the United States. 15 We rated the RCTs as good, 10 , 11 , 13 fair, 12 and poor 14 quality for outcomes related to breastfeeding effectiveness and maternal pain related to breastfeeding. One poor-quality retrospective cohort study and 23 case series also addressed outcomes of surgical treatment. We focused on RCTs of higher quality in this summary but noted that the lower quality studies typically reported improvements in breastfeeding effectiveness.

Two RCTs compared frenotomy to sham surgery, 11 , 13 one to usual care, 10 and one to intensive lactation consultation, 12 and one used a crossover design to compare frenotomy followed by sham surgery to sham surgery followed by frenotomy, with assessment of breastfeeding after each order of intervention (i.e., frenotomy and sham). 14 Similarly, the retrospective cohort study compared frenotomy to usual care. 15 For all studies, sham comparison involved taking infants to an intervention room for the same amount of time as the infants receiving the procedure and then returning them to the mothers.

The earliest reported RCT used nonblinded maternally assessed breastfeeding effectiveness and reported that 96 percent of frenotomized infants had improved feeding within 48 hours, compared with 3 percent in the control group, but this study had significant limitations. 12 In a later RCT, mothers again self-reported improved breastfeeding among infants immediately after frenotomy (78% in the treated group vs. 47% in the comparison group; p <0.02). 11

Three RCTs used an observer to assess breastfeeding effectiveness. In all three, the observer was blinded to the treatment. Among these, 10 , 11 , 13 one reported improvement in breastfeeding effectiveness based on the Infant Breastfeeding Assessment Tool (IBFAT; score range, 0 [poor feeding] to 12 [vigorous and effective feeding]) score immediately postfrenotomy compared with sham treatment (mean, 11.6 ± 0.81 vs. 8.07 ± 0.86; p = 0.026). 13 In contrast, in two of the three RCTs, the independent blinded observers did not detect a difference in breastfeeding improvement. Outcomes that failed to show a difference in these two RCTs included percent improvement (50% vs. 40%) immediately after intervention 11 and Latch, Audible swallowing, Type of nipple, Comfort, Hold (LATCH) and IBFAT change 5 days postintervention: LATCH change score median 1 (interquartile range [IQR], 0 to 2) versus median 1 (IQR, 0 to 2); p = 0.52 and IBFAT change score 0 (IQR, -1.8 to 1.0) versus 0 (IQR 0 to 1); p = 0.36. 10

One RCT reported significant and immediate improvement in maternally reported nipple pain among frenotomized infants compared with sham treatment. 13 Both remaining RCTs found nonsignificant reductions in maternally reported nipple pain between the frenotomy and sham groups at immediate 11 and 5-day 10 postprocedure assessments. However, in the one study that assessed pain at 5 days (the longest followup), a large number of infants in the control group had crossed over to receive frenotomy before outcomes were assessed. 10

Harms were rare and nonsignificant, and are discussed in more detail in KQ 5 .

KQ 2a. Benefits of Treatments To Mitigate Feeding Sequelae

Three studies examined medium- and long-term benefits related to feeding outcomes and sequelae of various interventions for infants and children with ankyloglossia. 12 , 16 , 17 One was an RCT 12 (fair quality for feeding outcomes) and one was a poor-quality retrospective cohort study; 16 the remaining study was a case series, so it provided no data for comparison. 17

In one RCT that included bottle-fed infants, 76 percent had major problems with dribbling and 71 percent had “excess wind” (gas). Mothers reported significant improvement in bottle-feeding in all eight infants who received the frenotomy and in none of the nine who did not. The interval to ascertainment of the outcomes was not specifically reported, but outcomes were obtained within the first 4 weeks of life. 12

The retrospective cohort study compared parent-reported (typically maternal) outcomes at age 3 years for three groups of children born in 2010: children who received frenotomy for tongue-tie (n = 71; frenotomy group); those whose parents were offered frenotomy for tongue-tie for their children but declined it (n = 15; no-frenotomy group); and children without ankyloglossia (n = 18; control group). 16 The frenotomy group performed better than the no-frenotomy group at age 3 years on cleaning the teeth with the tongue, licking the outside of the lips, and eating ice cream, and did not differ significantly from the comparison group without ankyloglossia.

KQ 2b. Benefits of Treatments To Prevent Other Sequelae

Two cohort studies attempted to assess the effectiveness of frenotomy for preventing other sequelae, 16 , 18 and one RCT compared two surgical approaches to frenotomy. 19 A speech- language pathologist measured speech outcomes in two studies, 18 , 19 with the third study using parental assessment. 16 No studies included data related to sleep disordered breathing, occlusal issues, and dysphagia in nonbreastfeeding children.

Two poor-quality cohort studies 16 , 18 reported an improvement in articulation and intelligibility with ankyloglossia treatment, but benefits in word and sentence accuracy and intelligibility and fluent speech were unclear. The one poor-quality RCT comparing surgical methods reported improved articulation in patients treated with four-flap Z-frenuloplasty compared with horizontal-to-vertical frenuloplasty. 19 Numerous noncomparative studies 20 - 26 reported a speech benefit after treating ankyloglossia; however, these studies primarily discussed modalities, with safety, feasibility, or utility as the main outcome rather than speech itself, and they provided no comparative data.

KQ 3. Benefits of Treatments To Prevent Social Concerns Related to Tongue Mobility

Only one poor-quality retrospective cohort study assessed outcomes related to social concerns other than speech in 3-year-old children who had received frenotomy as infants. 16 The group that had received frenotomy had better parent-reported ability to clean teeth with tongue, lick outside of lips, and eat ice cream compared with untreated participants.

KQ 4. Benefits of Simultaneously Treating Ankyloglossia and Lip-Tie

We did not identify any studies addressing this question.

KQ 5. Harms of Treatments for Ankyloglossia or Ankyloglossia With Concomitant Lip-Tie in Neonates, Infants, and Children Through Age 18

In order to identify all possible harms, we sought harms from all comparative studies and case series that we identified as potentially providing effectiveness data, and we sought case reports of harms. With this approach, we examined harms information from 46 studies that reported that they had looked for harms, either reporting actual harms or specifically indicating that they found none. These included 6 RCTs, 1 cohort study, 25 case series, and 15 case reports. Most studies that reported harms information explicitly noted that no significant harms were observed (n = 17) or reported minimal harms. Among studies reporting harms, bleeding was most frequently reported. Bleeding was typically described as minor and limited. Reoperation was noted in seven studies. Few studies described the specific methods they used to collect harms data.

Key Findings

Most of the studies included in this review addressed outcomes related to breastfeeding ( Table B ). Overall, three good-quality 10 , 11 , 13 and one fair-quality 12 RCT assessed whether surgical treatment of ankyloglossia improved breastfeeding effectiveness. Maternally reported breastfeeding effectiveness was significantly improved in the treated group compared with the untreated group in both RCTs that evaluated it either as a primary 12 or secondary 11 outcome. Only one of three RCTs that used blinded independent observers found significantly improved breastfeeding effectiveness among frenotomized infants immediately postprocedure. 13 A third RCT evaluated the mother's breastfeeding self-efficacy and found a significant improvement from baseline in the frenotomy group 5 days postprocedure. 10 In all, some evidence suggests that maternally reported breastfeeding outcomes improved, but data are unavailable to assess the durability of effects.

Strength of evidence for studies addressing surgical approaches for ankyloglossia.

These same studies had disparate findings about whether frenotomy decreased maternal nipple pain during breastfeeding. Only the RCT performed on infants at 6 days of age showed a significant reduction in maternal pain. 13 Those performed on infants a few weeks older did not report either an immediate 11 or 5-day 10 reduction in pain. The difference between earlier frenotomy and later frenotomy on nipple pain may relate to cumulative trauma on the breast from several additional weeks with inefficient latch from tongue-tied infants.

We identified three studies examining feeding outcomes other than breastfeeding: one RCT, 12 one-poor quality retrospective cohort study, 16 and one case series. 17 Bottle-feeding and ability to use the tongue to eat ice cream and clean the mouth improved more in treatment groups in comparative studies. Bottle feedings to supplement breast feeding decreased over time in the case series.

Following breastfeeding outcomes, outcomes related to speech were most often reported in the ankyloglossia literature. Two poor-quality cohort studies 16 , 18 reported an improvement in articulation and intelligibility with ankyloglossia treatment, but benefits in word and sentence accuracy and intelligibility and fluent speech were unclear. One poor-quality RCT reported improved articulation in patients treated with Z-frenuloplasty compared with horizontal-to-vertical frenuloplasty. 19 Numerous noncomparative studies reported a speech benefit after treating ankyloglossia; however, these studies primarily discussed modalities, with safety, feasibility, or utility as the main outcome, rather than speech itself. 23 , 26 - 28

Few studies addressed social concerns. One retrospective cohort study noted improvements in using the tongue to clean the teeth and for licking in the treatment group compared with untreated participants. 16 In two comparative studies reporting on tongue mobility, mobility improved in treated patients. 18 , 19

Harms of surgical interventions included minor bleeding, which was typically self-limiting, and need for reoperation, which was rare. Minor bleeding is not an unexpected occurrence in this type of surgical intervention. Eighteen studies reported that no significant harms were observed.

Strength of Evidence

Breastfeeding outcomes.

Very few higher quality comparative studies have addressed the effectiveness of surgical interventions to improve breastfeeding outcomes. In those few studies, mothers consistently reported improved breastfeeding effectiveness, but outcome measures were heterogeneous and very short term. Future studies could provide additional data to confirm or change the measure of effectiveness; thus, we consider the strength of evidence to be low at this time. We considered the strength of evidence (confidence in the estimate of effect) to be low for an immediate reduction in nipple pain. Improvements were reported in the current studies, but additional studies are needed to confirm and support these results. Only one poor-quality cohort study addressed effects on the length of breastfeeding; thus, we considered the strength of evidence to be insufficient.

Other Feeding Outcomes

With only two comparative studies, both with significant study limitations, existing data are insufficient to draw conclusions about the benefits and harms of surgical interventions for infants and children with ankyloglossia on medium- and long-term feeding outcomes. The studies used different populations and measured different outcomes.

Speech Outcomes

Given the lack of good-quality studies and limitations in the measurement of outcomes, we considered the strength of the evidence for the effect of surgical interventions to improve speech and articulation to be insufficient.

Social Concerns Related to Tongue Mobility

With only one poor-quality comparative study, strength of evidence related to the ability of treatment for ankyloglossia to alleviate social concerns is currently insufficient. Also, with only three comparative studies with small sizes and limitations in the measurement of outcomes related to tongue mobility, we considered the strength of evidence for the effect of surgical interventions to improve the short-term outcome of mobility to be insufficient.

We considered the strength of evidence for minimal and short-lived bleeding as a minor harm of surgical interventions as moderate based on an expanded search for harms reports in addition to the comparative data. We considered the strength of evidence for reoperation and pain as harms to be insufficient, given the small number of outcomes available for analysis. We acknowledge that harms are not systematically reported, and thus there may be substantial underreporting.

Newborns referred for treatment of ankyloglossia were born primarily at tertiary-care centers and recognized as having difficulty with breastfeeding concomitant with ankyloglossia. The frenotomy procedure itself is not technically difficult and is likely performed similarly across birthing sites; however, the criteria by which the decision is made to perform frenotomy are less clear. Moreover, newborns of mothers not choosing to breastfeed may not be recognized as having and/or diagnosed with ankyloglossia, as breastfeeding difficulties were used as an indicator to evaluate for ankyloglossia. At minimum, the studies in this report apply only to infants with both ankyloglossia and feeding difficulties; data on ankyloglossia absent feeding difficulties were unavailable.

In these studies, various clinicians were involved in making the ankyloglossia diagnoses. However, assessment of breastfeeding difficulty and diagnostic criteria for ankyloglossia were not universally described. Lack of a consistent objective measure to define and classify this condition may limit the reproducibility of findings. Furthermore, the age of patients in these studies varied from a median of 6 days of age in one study 13 up to a mean of 33 days of age (range, 6 to 115) in another study. 11 Applicability of findings to older infants cannot be gleaned from these data, nor can durability of results.

Frenotomy was the only intervention employed in the good-quality RCTs. 10 , 11 , 13 However, the specifics of the procedure were variably reported. The degree of posterior extension of the frenulum incision was not clearly defined and appears to be at the discretion and clinical expertise of the clinician. Also, the severity of the ankyloglossia was inconsistently reported, making interstudy generalizations difficult and, more importantly, limiting the broader applicability of findings.

The comparators used were sham surgery 11 , 13 and no intervention. 10 Both “no intervention” and “sham surgery” are perhaps misnomers, however, since these infant-mother dyads underwent usual care, which could include, but is not limited to, lactation consultation, supportive care, and bottle-feeding advice.

The population studied in the question of benefit of ankyloglossia repair for social concerns included children and adults with wide variation in ages.

Research Gaps

A critical unknown at this point is a good description of the natural history of ankyloglossia by severity, including long-term risk of feeding, social, and speech production difficulties. Future studies should consider direct comparisons of alternative treatments, as currently available literature addressed only the comparison of frenotomy with sham. In order to conduct these studies, it would be helpful if the field could agree on a standardized approach to identifying and classifying ankyloglossia; this would also improve our ability to synthesize the data across studies.

Given variation in outcomes that may be associated with earlier versus later frenotomy, future studies should assess timing of frenotomy to determine whether more significant reduction in maternal pain is achievable by earlier treatment and whether mothers are more apt to breastfeed longer if the frenotomy is done earlier.

A significant gap in research is in understanding the durability of outcomes. Good-quality comparative studies evaluated breastfeeding effectiveness immediately 11 , 13 or within 5 days of frenotomy; 10 however, none adequately assessed whether effectiveness and other outcomes (e.g., changes in maternal nipple pain) were maintained months or, if appropriate, years later. Longer term followup of both treated infants and controls is needed. Because of the paucity of available data on other feeding outcomes, this entire research question represents a gap and a potential area for future research.

Similarly, substantially more research is needed to consider whether treatment of ankyloglossia in infancy prevents future speech production difficulties, as well as whether treatment later in life with frenotomy leads to improvement when speech problems arise. To conduct this research effectively, methods for evaluating risk and presence of speech production difficulties will need to be standardized, and outcomes agreed on. Understanding of the natural history of speech concerns in children with ankyloglossia is lacking, as are comparative studies that use standardized measurement tools for speech outcomes.

No standard definitions of tongue mobility or established norms for mobility exist, and further research is needed to determine such parameters. Social concerns are difficult to measure objectively, so there will likely always be a subjective component to social outcomes. Larger studies that assess both treated and untreated individuals could provide useful data to minimize the potential bias found in the existing literature. Similarly, future research in objective measurement tools or validated self-report tools is needed.

Conclusions

A small body of evidence suggests that frenotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain. However, with small, inconsistently conducted studies, strength of evidence is low to insufficient, preventing us from drawing firm conclusions at this time. Research is lacking on nonsurgical interventions, as well as on outcomes other than breastfeeding, particularly speech and dental outcomes. In particular, there is a lack of evidence on significant long-term outcomes, such as exclusive breastfeeding at 6 months of age or at 1 year of age, growth, and other measures of health outcomes. Harms are minimal and rare; the most commonly reported harm is self-limited bleeding. Future research is needed on a range of issues, including prevalence and incidence of ankyloglossia and problems with the condition. The field is currently challenged by a lack of standardized approaches to assessing and studying the problems of infants with ankyloglossia.

• Cite this Page Francis DO, Chinnadurai S, Morad A, et al. Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 May. (Comparative Effectiveness Reviews, No. 149.) Executive Summary.
• PDF version of this title (1.8M)

In this Page

Other titles in these collections.

• AHRQ Comparative Effectiveness Reviews
• Health Services/Technology Assessment Texts (HSTAT)

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• Executive Summary - Treatments for Ankyloglossia and Ankyloglossia With Concomit... Executive Summary - Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

The Ultimate Guide To Tongue-Ties

The ultimate guide to tongue-ties.

Tongue-ties are a hot topic these days and are often overlooked.  Many providers aren’t up to date on the lifelong consequences related to tongue-ties, and many doctors simply don’t believe in tongue-ties.  The Ultimate Guide to Tongue-Ties was created so that you have a comprehensive guide to educate yourself about tongue-ties.

What are tongue-ties?

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 are tongue-ties diagnosed?

Some tongue-ties are are “low hanging fruit” and can be easily self-diagnosed.  Others 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.

Watch the “Do I have a tongue tie?” lecture.

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 infants 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 mothers 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 to the mothers 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.

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.

What are the symptoms of a tongue-tie?

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.  ( Watch Ditch the Tongue Tie to learn more about 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 correctly.

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 antisocial 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 a 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 childs crowded teeth as a genetic issue, but parents should be concerned about early tooth crowding rather than just passing it off as “having their dad’s teeth” or “the smith’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.  

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 alters the structural alignment and growth of the body. Early intervention is key.  

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 do everything 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. 

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.

Dr. Bieneman’s Tongue Tie & Post Frenectomy Instructions

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

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

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 are not understood by everyone in the medical or dental profession.  

Here are some great questions to ask:  

• How many releases do you perform each week?
• What ages do you work with?
• What method do you use and why?
• Do you give instructions for wound management?
• 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. 

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.