Tongue Tie What is all the Fuss? - NCHN

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4/05/2016

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Tongue Tie – What is all the fuss?

Melissa Compton

Senior Speech Pathologist

Westmead Centre for Oral Health

Tongue TieWhat is all the Fuss?

Melissa Compton


Westmead Centre For Oral Health


4/05/2016


What is a Tongue Tie? The facts

It is hereditary

It is a congenital anomaly

Impaired tongue mobility due to a congenital anomaly

It can cause deficits in breastfeeding, bottle feeding, chewing, cleaning teeth and in articulation (degree of deficits unknown)

Incidence still remains around 5% (Dr David Todd, Centenary Hospital Canberra) “Mother nature does not create catastrophic increases in incidence of congenital anomalies….” Hazelbaker, A

Evidence

NHMRC 2012 Infant Feeding Guidelines state:

There is limited evidence that “tongue tie "occurs in 4-10% of healthy newborn infants (Evidence Grade D). There is limited evidence (Evidence Grade D) to suggest that Infants with “tongue Tie” more commonly experience breastfeeding difficulties

Level D Evidence is very low quality, based on no research evidence.

NHMRC concludes that

While surgical management of tongue tie has been tried….further controlled trials are required

www.nhmrc.gov.au/guidelines-publication/n56

Page 52 Breastfeeding-Common Problems and their Management


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Classification Systems

Hazelbaker:1993

Description of the tongue, attachments to the tongue and floor of mouth

Ballard:2002

Tip of tongue to alveolar ridge

Mid tongue-alveolar ridge

No mention of posterior TT

Coryllos:2004

Type 1, Type 2, Type 3, Type 4 (Base of tongue), alveolar ridge included

Griffiths/Hogan:2004/2005

100%: attached at tip, 75%:anterior tongue, 50%: mid tongue, 25%: Base of tongue (no mention of alveolar ridge)

Classification Cont….

Murphy 2010

Types 1 & 2 are “Anterior”; Types 3 & 4 are “Posterior”

Type 4 : no visible membrane above the mouth floor, all Submucosal

Type I Type II Type III

Type IV

Mahar, M, MD: WIC Annual ConferenceMarch 24. 105Photo Credit: James Murphy, MD


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Classic Vs Posterior Submucosal TT

Photo Credit: Catherine Watson genna

Posterior TT New trend which began around 2004, new

diagnosis of “posterior” or submucosal TT.

No research to date showing that a restriction at the base of tongue is an actual tongue tie

We need to look back at the anatomy of the tongue

Hazelbaker’s thought is that the tight shiny string of tissue under the mucosa at the tongue base may be the Septum of the Genioglossus Muscle

“A type of Fascia that connects the two halves of the genioglossus muscle together to stabilise the tongue in the mouth”

Using two fingers to press against the tongue base usually reveals the septum. Is this then the Posterior tongue tie?

We have to know what we are seeing before we start cutting!!!!!


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“Deep Cuts under babies tongue are unlikely to solve breastfeeding problems”http://theconversation.com

Unclear how many babies and infants are undergoing unnecessary procedures

Little to no evidence to support cutting or using a laser deeply into the base of tongue

Classic TT can be treated with a simple snip which is relatively painless

Babies who have had a deep cut or laser may become ‘fussier” on the breast after the procedure, sometimes leading to oral aversion

Treatment for “Posterior TT” ?

Assess muscle tone and look at why the tongue appears restricted

May see face, jaw and postural asymmetries with a posterior tongue tie

Is it an acquired soft tissue strain due to birth trauma or the type of birth?

Can this soft tissue strain be caused by the following:

forceps, vacuum delivery, posterior presentation, breech, epidural, umbilical strain, fundal pressure, small pelvis ????

All these questions need to be asked before we resort to surgery

Alison Hazelbaker is a Cranial Sacral Therapist trained in “Bodywork”

Can this type of restriction be resolved by using cranial sacral therapy?

It is not massage, bony manipulation (chiropractic or osteopathic) or energy transfer (Reiki)

It is soft tissue release

Is it too controversial

Who do we refer to or do we refer at all ?


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Speech Pathology AssessmentBabies and Children

Case history

Birth history

Family history of feeding/speech difficulties

Early feeding experiences

Transition to solids

Developmental milestones

Hearing and any middle ear problems

Allergies, nose problems, Snoring?

Commencement of speech, babbling, single words, intelligibility

Current feeding skills, foods eaten

Other Specialists involved eg ENT, Paediatrician

Assessing Tongue Tie

Cosmetic appearance

Oral Hygiene

Feeding skills

Lingual Movement

Oral Kinaesthesia

Speech

Emotional Status


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Tongue Tie Confusion to Clarity-Carmen Fernando

Hazelbaker Assessment Tool for Babies <6moFunctional Items 0 1 2

Lateralisation None Body of tongue but not tongue tip

Complete

Lift of tongue Tip stays at alveolar ridge or rises to mid-mouth only with jawclosure

Only edges to mid-mouth

Tip to mid-mouth

Extension of tongue Neither above ORanterior or mid-tongue humps

Tip to lower gum only

Tip over lower lip

Spread of anterior tongue

Little or None Moderate or Partial Complete

Cupping Little or no cup Side edges only, moderate cup

Entire edge, firm cup

Peristalsis None or reverse peristalsis

Partial:originating posterior to tip

Complete,anterior to posterior (originates at the tip)

Snapback Frequent or with each suck

Periodic None


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Appearance Items

0 1 2

Appearance of tongue when lifted

Heart-shaped Slight cleft in tip apparent

Round or Square

Elasticity of frenulum

Little or no elasticity

Moderately elastic

Very Elastic (excellent)

Length of lingual frenulum when tongue is lifted

Less than 1cm 1cm More than 1 cm or embedded in tongue

Attachment of lingual frenulum to tongue

Notched tip At tip Posterior to tip

Attachment of lingual frenulum to inferior alveolar ridge

Attached at ridge Attached just below ridge

Attached to floor of mouth Or well below ridge

Treatment Recommendations Based on Scoring14= Perfect Function regardless of appearance Item Score. Surgical treatment not recommended11= Acceptable Function score only if appearance item score is 10<11= Function score indicates function impaired. Frenotomy should be considered if management fails

Breastfeeding

Involves tongue resting forward on the lower alveolar ridge

If tongue unable to rest over lower gum, excessive pressure placed on nipple between gums

Reduced forward tongue movement, therefore, poor stripping of the breast and inefficient sucking

Increased popularity of breastfeeding in the past 2 decades. Resurgence of interest in tongue-tie as a cause of breastfeeding difficulties


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Breastfeeding Difficulties

Sore and painful nipples

Poor attachment

Poor infant weight gain

Early weaning

Poor sucking mechanics

General agreement, most infants with ankyloglossia will have no problems feeding with a bottle and transitioning to solids

Bottle feeding is not a solution for feeding problems in a mother who wants to breastfeed

Solids

Generally manage puree

May suck rather than move food around mouth

Difficulty chewing lumps and harder foods

Food gets stuck on hard palate

Messy eaters, cannot lick lips clean

Slower eaters due to restricted tongue movement, restricted lateral movement


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Speech /Articulation

Effect of AG on speech is not clearly defined

It is NOT the cause of speech and language delay or learning difficulties

Some children develop normal speech and compensate for limited tongue tip mobility (ie keeping mouth closed)

AG may contribute to some articulation errors or difficulty with the rate and range of articulation, therefore reducing speech intelligibility ( eg. mumbling)

Speech sounds commonly affected are

‘t, d, n, l, s, z, th’

Some children compensate by changing the placement of the tongue (eg. interdental lisp)

Mechanical & Social Effects

Reduced range of movement

Food may be cleared from the buccal cavity with fingers

Difficulty with intra-oral toileting eg. licking lips, sweeping teeth free of food

Difficulty playing wind instruments

Difficulty licking an ice-cream in a cone

Difficulty with French kissing


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Frenotomy Vs Frenectomy

Frenotomy More simple procedure that

removes the membrane or cutting the frenumlum

No anaesthetic used here at Westmead Hospital

Frenectomy Frenectomy is defined as complete

excision

This is a procedure where the entire frenulum is cut down to the tongue muscle or gum

Frenuloplasty“Various methods to release the tongue tie and correct the anatomical situation”

Snipping Vs Laser

Snipping

Can be done up to 4 months of age *ethical reasons

Use a blunt ended scissors and a retractor

Faster

Like a paper cut

Pain immediate but not persistent

Parents can be present

No after care, do not touch the wound under the tongue

Allow baby to breastfeed and sterilise everything that goes in the mouth

Laser Any age

Longer procedure

Parents are not allowed in the room due to guidelines

Delayed onset of pain (burn)

Lasers are expensive

Stretching exercises after lip and tongue-tie release help to reduce the risk of reattachment

Laser can be very dangerous when used by an untrained practitioner.

Different types of lasers

The wrong laser can damage collateral tissue and create excessive scar tissue

Currently no training for anyone who wants to start using lasers on babies.


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Post Surgical Aftercare- Babies

Research is limited

New Research suggest the frenum is a tendon (a type of fascia)

Stretching and breaking the wound many times a day actually causes excessive scar tissue formation

Psychologically the baby is experiencing pain everytime these exercises are carried out.

These exercises are recommended prior to a feed

Oral aversion then becomes a problem and these babies may refuse to breastfeed


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Post Frenectomy Tongue Exercises

Hold a paddle pop stick flat close in front of the child’s mouth. They are to push the stick with their tongue tip as hard as they can. This will strengthen their tongue.

Ask them to lick the vegemite/ cream cheese/jam with their tongue (the aim is to curve their tongue tip up)

Put some vegemite/cream cheese/jam on a spoon and hold it with the scoop upright in front of the child’s mouth

Practice making click-clock noises with the tongue. This is the sound people make like horses hooves.

Lick ice-creams

Lick and egg out of a cup

Lick a plate

Maxilliary Lip Tie

4 classifications of lip tie

It is the upper lip attachment to the maxillary gingival tissue.

It is a segment of the mucous membrane located between the upper lip and anterior maxillary arch containing loose, connective tissue and inserts into the maxillary arch free (not attached to the bone) gingival or the attached gingival tissue

In babies the labial/maxillary frenum has a lower attachment than in children and adults. This is a variation of normal.

The labial frenum may keep a gap in the baby’s front teeth which is actually good.

As babies grow the upper gum line also changes

Spaces in primary dentition allows for less crowding of the permanent teeth, therefore, this is a normal space in the middle

Upper canines are the last teeth to erupt in the upper jaw, therefore the canines utilise the space between the central incisors to erupt

Breastfeeding does not require a Lip flange but mainly Lip Eversion


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Luca 8 months

Luca 5 years

Take Home Message Alison Hazelbaker: Modern Myths about Tongue Tie

“We are at the very beginning of our understanding of this congenital anomaly (Don’t let anyone tell you otherwise). That means no one knows the entire story yet. Time and more research will tell us what is true and not true about this phenomenon. Until then, we must exercise healthy scepticism, continue to ask the hard questions……..”

“Our vulnerable babies depend on us to keep them safe from harm, and that includes holding off on surgery if no evidence exists to put them through such surgery”

Article in Pathways to Family Wellness Magazine, Issue #48


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References

Breastfeeding-Common Problems and their Management : Infant Feeding Guidelines www.nhmrc.gov.au/guidelines-publications/n56

Deep Cuts Under babies tongues are unlikely to solve breastfeeding problems http:/theconversation.com/ 30/3/2016

Hazelbaker, A K (2010) Tongue Tie Morphogenesis, Impact, Assessment and Treatment

Fernando, C (1998) Tongue Tie from confusion to Clarity

O’Callahan,C., Macary, S., & Clemente, S (2013). The effects of office- based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol, 77 (5), 827-32

Suter, V. G. A., & Bornstein , M. M (2009). Ankyloglossia: Facts and Myths in Diagnosis and Treatment. J Of Periodondology, 80 (8), 1204-1219

Messner, A.H., Lalakea, L.K., Aby, J., Macmahon, J., Blair, E Ankyloglossia: Incidence & Associated Feeding Difficulties. Archives of Otolaryngology- Head & Neck Surgery 2000; 126,:32-39

Messner, A.H & Lalakea, M.L The Effect of Ankyloglossia on Speech in Children.Otolaryngology- Head & Neck Surgery 2002; 127: 539-545

Messner, A.H & Lalakea, M.L. Ankyloglossia: Controversies in Management.

International Journal of Pediatric Otorhinolaryngology 2000; 73: 881-883 Posterior Ankyloglossia A Case Report

References

Kotlow L. The Influence of the Maxillary Frenum on the Development and Pattern of Dental caries on Anterior Teeth in Breastfeeding Infants: Prevention, Diagnosis, and Treatment. J of Human Lactation. 2010 26:304-308

Prevalence and Variations of the median maxillary labial frenum in children, adolescents, and adults in a diverse population. Townsend, J A. Brannon, R B. Cheramie, T. Hagan,J March/April 2013

Kotlow L. Diagnosing and Understanding the maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. J of Human Lactation. Published online 2 July 2013

Infant Reflux and Aerophagia Associated with the Maxillary Lip Tie and Ankyloglossia (Tongue-tie) Kotlow, L 2011

Ballard, J.L., Auer, C.E., Khoury, J.C (2003) Ankyloglossia: Assessment, Incidence, and Effectof Frenuloplasty on the Breastfeeding Dyad. Paediatrics 2003; 110: pp e63

Griffiths, D.M. Do Tongue-Ties Affect Breastfeeding? Journal of Human Lactation 2004; 20: 409-414

Hogan, M., Westcott, C., Griffiths, M A Randomised Control Trial of Division of Tongue-Tie in Infants with Feeding Problems Journal of Paediatrics and Child Health; 2005: in press

Lalakea, M.L & Messner, A.H Ankyloglossia: Does it matter? The Pediatric Clinics of North America 2003; 50: 381-397

Edmunds, J., Hazelbaker, A., Murphy, J. G., & Philipp, B.L. (2012) 28:14 Roundtable Discussion: Tongue Tie


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Thank YouMelissa Compton


Westmead Hospital

[email protected]

Documents

Tongue Tie What is all the Fuss? - NCHN