TOTs 101: Intro to Tongue Ties
Helpful Info on Oral Ties — A.K.A. tethered oral tissues (TOTs), tongue tie, lip tie, cheek/buccal tie, ankyloglossia…
Oral Ties + Impact on Function & Development
☆ This collection of videos provide a good overview of how a tongue tie impacts infant feeding as well as potential impact on future growth & oral development.
☆ More info on impact of ties to breastfeeding: https://youtu.be/RNJr-EyEq1E?si=tWQaHfwX1RDlKv_A
A Venn diagram depicting the three essential elements for effective infant feeding, particularly for latching comfortably and transferring enough milk at the breast.
Newborns practice sucking and swallowing and established patterns of movement for months prior to being born in order to prepare for oral feeding in the first hours of life. If an oral tie is restricting range of motion from the early stages of fetal development, then the strength and coordination of oral function will have been impacted.
TOTs Treatment
While there are many factors that may impact your family’s individual treatment plan, there are three elements that are generally recommended for all infants in order to achieve optimal outcomes.
Suck Training
This can involve a variety of different oral and facial exercises done with your infant to help them build the neurological coordination and muscular strength needed to use their tongue and other oral structures effectively. While this is beneficial for many babies, it’s critical for babies with oral ties both prior to and after a frenotomy procedure to support optimal oral development. Though a frenotomy procedure ideally provides them with greater range of motion, accessing those new abilities effectively can take time and practice.
This addresses both the strength and coordination elements essential to oral motor function.
Bodywork
Feeding is very much a full body activity for little bodies. Two common findings in young infants, especially with oral ties, are muscle tension and asymmetry. This can show up as not opening their mouth wide enough, having a head-turn preference, recessed jaw, “tented” upper lip, lip blisters, latching well to one side but not the other, colicky behavior and more. For this, bodywork such as craniopathy, craniosacral, chiropractic, physical therapy or osteopathy are highly recommended.
This addresses both the strength and coordination elements essential to oral motor function.
Frenotomy + Active Wound Management
If you choose to see a “release provider” for an evaluation - usually a dentist, oral surgeon, or ENT - and they do indeed diagnose an oral tie, they will likely recommend a frenotomy (aka, “release”, frenectomy, “clip” - all the same procedure).
A really important part of having a positive outcome, post-frenotomy active wound management typically involves stretching the wound for 5-10 seconds to ensure it heals with flexibility in the tissue as opposed to tough, inflexible scar tissue or adhesions that could further restrict movement. Follow your provider’s recommendation for how often to do them.
This addresses primarily the range of motion element essential to oral motor function.
Optimizing Outcomes ☆
☆ Both suck training & body work are beneficial and sometimes essential to begin prior to the procedure.
☆ Research has shown that the best outcomes are from addressing all three concerns: removing the restrictive tissue as well as focus on strength and coordination.
☆ While some babies do great with getting a release ASAP, especially in the first week of life, from a more holistic perspective it is generally recommended to seek a tie-savvy provider (IBCLC, dentist, etc) for evaluation and preparation. They can help guide you to the best recommendations to ensure adequate strength and coordination prior to having a frenotomy.
FAQs about Oral Ties
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Yes and it’s called a frenum! You have them multiple places in your mouth including under your tongue, tips and cheeks. What makes it a “tie” is how it impacts function: if it restricts movement of the way the mouth moves to the point that it negatively impacts function, that’s when we consider it a tie.
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I hear you, and this is incredibly frustrating and makes it very hard for you to know what’s best. Without knowing for sure, what I can tell you is that it’s very likely that I am the first provider you’ve seen that has specialized training on oral ties + oral function + feeding. This was not taught to me when I became a nurse and only very limited teaching when I became a board certified lactation specialist - I completed advanced training with Chrysalis Orofacial in the E3 Model of Care with well-respected speech pathologist and myofunctional therapist Autumn Henning.
Typically, if another provider has “assessed” and said their is no/a mild tie, they are only doing a visual inspection of the anatomy. However, what is most important to identifying a tie is oral function in addition to a thorough full-body assessment.
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Great question - many, not so simple answers.
Tongue ties and frenotomy procedures have been documented in medical literature as far back as Aristotle (300s BC). In fact reference to tethered oral tissues can be found pretty much through all of time, even biblically. So in fact, they are not new at all.
We have, however, been slower to identify the domino effect of issues that can result from oral ties, as well as the ability to differentiate between how the anatomy appears vs. the impact on overall function. For most of the last century, the primary instance of identifying tongue ties has either been class 1 ties on newborn who struggled to feed at all OR young children struggling with the tie’s impact on speech. Because of all we have learned about this in the last several decades, we are much less likely to regard this as an elective or unnecessary procedure. In fact, because it is a very low risk procedure the potential benefit has only become more clear.
This next piece is a lot harder to prove, but there’s in fact a really good chance that some things we’ve regarded as normal variations of anatomy or function - think colic, reflux, snoring, high palates, lisps, headaches, behavioral issues, etc - were impacted at least in part by oral development. It’s easy to think that’s an overstatement until you focus on two facts:
Oral development impacts survival in many essential ways - how we eat, breathe & communicate.
The tongue muscle is the beginning of a single, uninterrupted length of soft tissue (fascia) that extends through the midline of your entire body from the tip of your tongue, down your spine and legs all the way to your feet.
While there is still a lot to learn about this, emerging research indicates that there is an increasingly prevalent genetic mutation that causes poor metabolization of folate, which is an essential nutrient for fetal development of the spine and midline structures. If there is an increasing number of people who do not absorb folate well, this could explain an increase in midline variations during fetal development. Again, this is not fully settled upon scientifically, but could be a reason that we may actually be seeing an increase in tongue tie prevalence.
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Tongue development begins at about week 4-5 of gestation (pregnancy), and as those anatomical structures differentiate - meaning the mass of tissue separates into a distinct tongue, palate, etc - the frenums should undergo a series of planned cellular death (“apoptosis”) in which most of the frenum disappears. What should be left is only a thin, stretchy frenum located at the base of the tongue connecting it to the base of your mouth. The process is similar for lip and cheek frenums.
What happens in babies with ties is that the cellular messages for planned cellular death are incomplete or slow, and too much of the frenum is left behind. Why this happens is not entirely known, and likely is multi-factoral, but there is commonly a familial genetic component.
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