Ankyloglossia, commonly referred to as “tongue-tie,” has recently seen a surge in cases and awareness with a corresponding increase in diagnosis and treatment. The evidence linking tongue-tie release and breastfeeding improvement has been published previously. However, due to a lack of published evidence for children, many medical professionals still believe that a restricted tongue does not contribute to feeding or speech issues in older children. The condition of tongue-tie exists on a continuum with variable visibility and symptoms. Some restrictions, mainly anterior or “classic” tongue-tie, are highly visible and easier to detect. However, “posterior” or submucosal tongue-ties are often more challenging to diagnose. Recently, an increase in awareness and education has led to improved detection of these posterior tongue-ties. The data presented in these case studies will demonstrate that even posterior ties restrict movement and affect oral structures that are required for speech and feeding. In this case series, five patients with posterior tongue restrictions underwent CO2 laser frenectomy without any general anesthesia or sedation. After a quick in-office procedure, all five patients demonstrated increased lingual mobility evidenced by improved speech and feeding skills. Some improvements were observed immediately after the procedure by clinical staff and the child’s family. While these patients required continued intervention from a speech-language pathologist, their improved lingual mobility allowed for more significant and faster improvement in speech and feeding skills. These cases challenge the status quo that speech and feeding are not affected by posterior tongue-tie. Continued research is warranted to determine the impact that all classes of lingual restrictions can have on speech and feeding development.
INTRODUCTION
Infant feeding issues have been associated with tongue-ties in several studies in the last few decades. These feeding issues include a poor or shallow latch, reflux and excessive spitting up, poor weight gain, gagging or choking, milk leakage, and frustration at the breast or with bottles. Nipple pain, “lipstick”-shaped nipples, poor breast drainage, thrush, mastitis, and premature weaning are common for mothers with tongue-tied babies Unfortunately, the diagnosis and treatment of tongue-tie is debated and misunderstood, leaving many infants with an undiagnosed tongue or lip-tie. While some lingual and labial restrictions are identified when the child is an infant or toddler, many health professionals only consider severe restrictions a concern (i.e. anterior tongue-tie). With other medical issues such as autism or sleep apnea, the medical community realizes that these conditions fit more onto a continuum or spectrum rather than a single disease state. Tongue-tie is not different. Ankyloglossia should be appreciated as a spectrum of restriction from the anterior to posterior sections of the tongue, as well as varying levels of elasticity and thickness. We are proposing a paradigm shift in the thinking of medical and dental professionals to encompass a wider scope of oral restrictions that cause difficulty with nursing, speech, and feeding.
Recently, the concept of posterior-tongue tie began gaining recognition in medical literature. Many infants demonstrate problems with nursing that don’t improve through traditional intervention. These babies do not present with a classic tether at the tip of the tongue, but often have a “posterior” or submucosal restriction due to a thick, tight, or short frenum. Releasing the posterior tongue-tie has demonstrated breastfeeding improvement for nursing babies , but there are currently no case reports or studies showing improvement with speech or solid feeding. As these children grow up, they may develop speech and feeding disorders that impact communication skills and quality of life. However, since there is no classic heart shape or “to-the-tip” tongue-tie, this puzzling presentation is difficult to diagnose. Often, even an anterior or classic tongue-tie is not considered a potential cause of disordered speech or feeding. The tongue is the primary organ concerned with these important skills, among a host of other functions. If an anatomical restriction, anterior or posterior, is causing a functional limitation, then understanding the impact of these restrictions on feeding and speech should be recognized by all medical, dental, and related health professionals who are evaluating and providing treatment for children.
In most cases, the children were referred to our office by speech-language pathologists or pediatricians for evaluation and treatment of their restricted frena. Information regarding speech, feeding, and oral health was gathered through the use of a questionnaire to assess whether functional limitations were present. By performing a full intraoral exam using the Kotlow classification for tongue-tie and lip-tie, paired with the concept of “functional ankyloglossia” from a recent article by Yoon et al we were able to determine if the child had a restriction in tongue mobility that was likely causing an issue with feeding or speech. After obtaining informed consent from the parent, the release was performed in the dental office with no sedation or general anesthesia using a 10,600 nm LightScalpel CO2 laser (LS-1005, LightScalpel Inc. Bothell, WA) for all cases. Only local anesthesia was required. Post-operative stretches and exercises were recommended for 3 weeks, and a follow-up visit was scheduled 1 week after the procedure.
