Like many of you, when I finished dental school, I had some idea of what a tongue-tie is and how it can impact speech and possibly gum recession. But in four years of dental school, we had only one slide on tongue-tie treatment, and in pediatric residency, we read only one article on tongue-ties, which was already ten years old and outdated.1 It wasn’t until our twin girls were born and the lactation consultant told us they had a tongue-tie that I dove headfirst into the rabbit hole to learn more about this condition. It turns out that a restricted tongue or tongue-tie is quite common, with traditional estimates in the 4-10% range, but that estimate is mainly for one that is to-the-tip or close to it. So if you have ten patients a day, one patient is likely significantly tied. This statistic does not include less obvious or posterior tongue-ties, which can just as easily impact tongue mobility and function and therefore cause symptoms in many individuals, from babies to adults. A recent study from Brazil found that when properly assessing for tongue-tie, 32.5% of infants had a tongue restriction.2 In our office, in recently published research regarding our screening tool, we found that 26% of hygiene patients had significant symptoms and appearance that warranted a closer evaluation.3 So the number of patients affected is likely much closer to 20-25% in our dental offices. It’s extremely common, but just because something is common does not mean it’s normal. In the next few moments, I’ll give you the basics of tongue-tie assessment and symptoms, and point you to some resources if you want to learn more. Most medical providers will ask a patient to stick their tongue out to check the tonsils, and many also think that protrusion is a good test for tongue mobility. However, sticking the tongue out is the least specific test for tongue mobility. That’s one reason so many patients go undiagnosed. A better test is to check the elevation of the tongue. Ask the patient to open wide (without pain or discomfort) and lift their tongue to the incisive papilla behind the maxillary incisors. If they can lift less than halfway, they are significantly restricted. Some patients will “cheat” and not fully open their mouth when lifting, or without realizing it, the floor of the mouth will lift up to try to get the tongue higher. You can use a gloved finger to hold the floor of the mouth down when they lift to get an accurate picture of their true mobility. The functional grading system by Zaghi and Yoon says that if the patient lifts less than 25% of the way, it’s a grade 4 tongue restriction. Between 25%-50% is grade 3, 50-80% is grade 2, and over 80% is grade 1.4 To assess babies or children who are pre-cooperative, we use the knee-to-knee position and come from behind the head. Then use two fingers to lift under the tongue and isolate the frenum. This test is also useful during exams on adults to assess mobility during a hygiene check. You should check for a tongue restriction and assess mobility just like we screen for oral cancer. Oral cancer affects 1 in 10,000 adults.5 While obviously a very different diagnosis, tongue-tie affects an estimated 1 in 4 patients of all ages and can cause life-altering symptoms.2,3 Tongue elevation alone does not give us the full picture, and we have to marry symptoms and a patient’s quality of life with this clinical sign of tongue mobility. Now, if a patient is tied to the tip and can lift less than 25% of the way, it doesn’t take much imagination to see that they will have significant limitations and, therefore, many symptoms of a restricted tongue. What is interesting, though, is that some patients who can lift 75% also have significant symptoms that stem from restricted tongue mobility. So we use a screening tool, the TRQ, which includes fifteen of the most common symptoms and also asks the patient how significant these issues impact quality of life.3 If there is no impact on quality of life, then very likely no treatment would be recommended. With several symptoms and significant quality of life struggles, then it would likely benefit the patient to have the tongue-tie released properly.