Tongue ties, also referred to as tethered oral tissues (TOTs) can seem like a complex issue, but what it really comes down to is understanding when functional eating, speaking and sleeping are impaired.
This episode is a review of Merkel-Walsh and Overland’s book Functional Assessment and Remediation of TOTs. With the information in this book, SLPs gain a clear understanding of their role in diagnosing and treating clients with TOTs.
Therapists with a background in a muscle-based approach to speech therapy are best equipped to serve clients with TOTs. Here’s is a list of training resources the authors suggest:
Ages and Stages
Beckman and Associates
Chrysalis Feeding
International Association of Orofacial Myology
Northern Speech Services
Talk Tools
The Academy of Orofacial Myofunctional Therapy
The PROMPT Institute
— Useful Links —
Functional Assessment and Remediation of TOTs
International Affiliation of Tongue Tie Professionals
Music: Simple Gifts performed by Ted Yoder, used with permission
Welcome and intro to podcast
Welcome to The Speech Umbrella podcast. We are on episode 64 today. It’s hard to believe I’ve been doing this for two years! I owe a great big thank you to everybody who listens. And double thanks for leaving reviews!
The set up: What is the problem that needs a solution? Ask the intro question
The topic of the day is what we commonly call a “tongue tie”. There’s a movement to call it “tethered oral tissue” or TOTs for short. This is good reason for this—this is not just a case of SLPs coming up the longest term possible and I’ll be covering those reasons in a bit.
A lot of what I’ll be covering today comes from the book “Functional assessment and remediation of TOTs” by Robyn Merkel-Walsh and Lori L. Overland. This book is my TOTs bible, it’s got everything I need and more.
In case you’re wondering whether TOTs is an important topic, There are three reasons I can think of:
Professionals misdiagnosing it even when it is causing problems. You only have to google tongue tie to find videos of parents talking their experiences with undiagnosed TOTs to get a sense of the scope of this issue. It can be really problematic for some children.
OK, are you ready for some clarity on TOTs? What you’re about to hear is thanks to Robyn Merkel Walsh and Lori Overland, in this case I’m just the messenger.
Here’s what we’re going to cover today:
Promise: Here’s what I hope to deliver today—knowledge to speak confidently about when TOTs is a problem, knowing what to do post operatively, and resources for when need to know more, including resources for additional training on oral placement therapy should you desire to go the route.
The delivery
“Tongue-tie 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 tethers the bottom of the tongue’s tip to the floor of the mouth. A person 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, as well as interfere with breast feeding.” There is also research linking sleep apnea to a short lingual frenulum.
Why the term TOTs? (coined in 2014) Because it includes other tissue restrictions that can happen in the mouth: Buccal (cheek) and lip ties can also occur, and those can also affect eating and speaking. I have yet to see any lip or buccal ties, but now I know to look for them when doing an oral exam.
How do you distinguish between a normal and a pathological frenum—
Without knowing the symptoms you can’t. For it to be a “tie” it has to be causing a functional problem. You can’t tell just from photos whether the restriction is causing a problem because people react differently to various degrees of restriction. Until you’ve tried some therapy to see what the client can do, you won’t know if it’s pathological. And that’s preferably therapy that utilizes oral placement techniques.
I’m speaking of speech therapy, for infants of course you’d be looking at if they have feeding problems. That’s beyond the scope of my experience, but this book has extensive information on the diagnosis and treatment of TOTs in infants.
Speaking of varying degrees of restriction brings me to the next point: What’s a posterior tongue tie?
The first time I heard Posterior tongue tie, I was like “what in the heck is that?” the term intimidated me actually, but here’s an explanation that makes sense to me. I got this from the Alabama Tongue Tie Center’s website.
Some tongue ties are restricted at the tip, while others might have a frenum attaching 50% of the way to the tip, and yet another might be 25% attached.
A posterior tongue-tie is when the frenum attaches less than 50% of the way to the tip and therefore appears less obvious. An Anterior tongue tie is an almost to-the-tip restriction, and those are more obvious. It’s a spectrum of restriction.
You can think of it this way:
All sailboats have a mast (the thick posterior fascia that all tongue-ties have right on top of the genioglossus muscle) and some have their sail up (the thinner webbing of fascia that you traditionally think of as a frenum).
Here’s what really important (direct quote from Alabama website): all anterior ties have a posterior component-… if you just snip the sail, or anterior component, you did not get the whole restriction, and you should not expect a lot of great results. You might get a few good results, because you have given some function back to the patient.
I think this is why so many people think that treating a tongue-tie doesn’t work. They provide, or another provider did an incomplete release of fascia (connective tissue) and didn’t provide full mobility to the patient.
This website has nice pictures of posterior tongue ties that I found really helpful.
How can it affect someone?
Infants can be significantly affected —a tongue or lip tie can interfere with their suck-swallow pattern and this impacts their health, ability to self regulate, and ability to get nutrition. This can impact normal growth and development.
Babies who didn’t have trouble with the breast or bottle can have trouble transitioning to the spoon and solid foods, and they may become frightened and refuse food.
By 36 months a typically developing child has an adult like motor plan for eating, but a child with TOTs will likely have deficits in one or more of these areas: Eating, speech clarity, drooling, poor dental hygiene, and even changes to their dental structure may be evident.
In articulation, I have seen it affect clients’ ability to say R and the velar sounds k and g, but other sounds can be affected. If your tongue is so restricted that you can’t hold the body of your tongue on your palate, that can cause a range of oral motor issues. And let’s not forget sleeping issues, which of course affect healthy development.
Healthy development and TOTs has been on my mind because of
a recent experience with a new client. This new client is 17. He had just been to the oral surgeon for a consult about upcoming jaw surgery, before his first visit with me. The surgeon diagnosed a tongue tie along with his need for jaw surgery—his parents had never had this issue even suggested to them before. His case history revealed that he had been in eating therapy when he was young. This, plus being adopted, plus sensory integration issues, plus a speech and language disorder. That’s a lot on a little guy’s plate. He’s been in therapy almost his whole life. I couldn’t help thinking that a lot of people missed his tongue tie along the way—not just SLP’s. We don’t know now what kind of difference a frenectomy would have had for him, but I can’t help thinking it would have helped with eating, and taken at least thing off his and his parents plate.
I have also seen people with tongue ties who experience no issues whatsoever. My nephew for one—when he was a newborn I mentioned his anterior tongue tie to my sister in law. It never was released and he never had a problem. Different people have different abilities to compensate for TOTs.
By now you’re probably wondering: How do we assess for TOTs and when do we refer?
While there are a few rating scales and protocols for TOTs (which you can find in Merkel-Walsh & Overland’s book) they wrote their book to help us look beyond rating scales, to help us look at the following functions:
Oral placement: means helping clients achieve correct placement of jaw, lips, and tongue.
Range of Motion: meaning the flexibility of the lips and tongue and dissociation from the jaw.
Oral imitation: ability to assume the oral positions needed for speech and eating.
Facilitated mobility: what can they achieve with tactile prompts as far as ROM.
Pre-feeding: baseline skills for safe, effective feeding.
Feeding: motor planning for swallowing.
Speech: precise movements of jaw, lips, tongue to speak clearly.
I’m not gonna lie, their book is pretty technical is some parts and some terms are not familiar to me. But this book is still my TOTs bible and here’s why:
They have lots of pictures of TOTs—pictures of under the tongue, with the tongue sticking out so you can see how the restriction pulls on the tip of the tongue, and pictures of surgically corrected TOTs. A picture is worth a thousand words, and you can see what TOTs looks like.
They list 8 different programs you can use post graduate to fill in the gaps you may have in oral placement knowledge—and yes my beloved PROMPT is on the list. I’ll put that list in the show notes.
They list the goals of each kind of a frenectomy (lingual, labial, buccal): in other words, this is what you want the client to achieve as a consequence of surgery. If these things aren’t a concern, or can be remediated without surgery, then you wouldn’t be likely to refer.
They have an extensive section on post-operative care and the SLP’s role.
What is our role as SLPs?
First I have a couple of stories:
My lingual re-attachment story
Preschool client: most anterior tongue tie I’ve seen, very limited mobility. Affecting his ability to say k & g. He wasn’t saying R yet, but he was only 4. He had a frenectomy—his mom canceled therapy the first week after surgery because she figured his mouth would be sore. When he came the next week she said the oral surgeon said I would give him exercises to do. Criminy— I felt very unprepared! I got on the internet and found some, and while I was doing that research I found references to pre-op exercises clients are suppose to do. Double criminy! I didn’t do any of that pre-op stuff.
BUT he said g, k and r his first week back in therapy so he got the function we were looking for. The next week, his tongue had re-attached, although he still had the ability to say k, g, and r and he kept that ability.
I still felt like I hadn’t done my job right, until I read this in the TOTs book:
“Generally there are two phases of post operative therapy. The first stage is stretching exercises that are scripted from the surgeon/physician’s office. Patients are instructed to “keep the diamond open.” There must be a diamond shaped wound in order to have full release of a tongue tie”
OK—so it was the surgeon’s role is to give instructions on keeping the diamond open, not mine. BTW, how to keep the diamond open is described in the book by a surgeon, in case you need to know. Basically post op patients need to consistently clear away adhesions that form under the tongue several times a day. The SLP’s role is to provide speech therapy with oral placement component. Which I was already doing with PROMPT therapy, both pre and post op, I just didn’t realize it. I felt guilty for way too long, even though the client had a good outcome speech wise. All this happened before I owned the book. It’s the reason I bought the book. I didn’t want to be caught off guard again.
If I’d had this book I would have known about the international affiliation of tongue tie professionals—with their online directory. This client’s mother did have a hard time finding someone to do the surgery and when she asked me for referrals, I didn’t have any.
Second story
A little knowledge can be a dangerous thing, and we typically don’t have much knowledge about TOTs coming out of university. With that little knowledge, as SLPs we can end up not referring to a doctor when it’s needed, or referring when it’s not needed.
I had a client who a previous speech therapist had measured his frenum and said that he had a borderline posterior tongue tie. His dentist said he was “borderline” but he would release any client with a speech issue. Too broad of an application—I could see no restriction. I did see oral motor issues, cleared those up and he learned R on his own actually.
One more tip: Use a good light—headlamp or throat scope. Another story about thinking I saw a posterior lingual tie, but checked the next week with better light, also client had improved mobility—there was no issue after all. Don’t need to jump to referral, see what they can do first with speech therapy.
So what’s our role:
Know how to assess function, so you know if TOTs is pathological.
Know the different degrees of restriction.
Have some knowledge of oral placement therapy or refer to an SLP who has knowledge in that area, if that’s not your thing.
Consider adding Functional Assessment and remediation of TOTs to your library.
Consider getting trained in oral placement therapy. It will take your articulation therapy to new heights, and in more ways than just treating TOTs.
Tagline
TOTs can seem like a complex issue, one where we don’t know enough. That may be true, but what it really comes down to is—simply understand whether function is being impaired or not.
I am a therapist and entrepreneur, clinic owner, published author, and creator of speech therapy materials.
The Speech Umbrella is run by Denise Stratton, Reach out with any questions.