Frequently Asked Questions: Tethered Oral Tissues (Infants)

Below are answers to the most frequently asked questions about TOTs (tethered oral tissues – tongue, lip and buccal ties):

Is this a breastfeeding thing?

Tethered oral tissues are restrictions of mobility in the lip, cheek or tongue. Lip and tongue ties are made up of fascial tissue. Buccal ties are muscular tissue. They affect oral motor development and health throughout the lifespan, specifically:

  • Eating
    Ongoing feeding issues may range from difficulty coordinating sucking, swallowing and breathing to difficulty chewing and picky eating preferences for soft foods, swallowing disorders & more.
  • Breathing
    The tongue plays a major role in protecting the airway by resting in the proper position in the mouth. Due to the nature of the way our mouth is structured, the tongue also plays a role in the development of the upper airway. Nose breathing is the healthiest way we can breathe, however, mouth breathing can occur due to airway issues related to tethered oral tissues. Depending on genetics and other orthopedic factors, upper airway resistance syndrome, sleep disordered breathing, sleep apnea and other health concerns can be significant.
  • Talking
    Speech issues such as issues with pronunciation, lisps, slurred speech, etc can occur because tongue mobility is needed for full articulation.
  • French Kissing
    Not at the top of everyone’s list but nonetheless a factor is the ability of the tongue to fully extend, roll and mobilize to french kiss.
  • Healthy gums & teeth
    One of the responsibilities of the tongue is to clean the mouth. In addition, the way the tongue sits in the mouth affects the way the palate is shaped and teeth grow in. In addition, restriction under the lip or into the buccal cheek area can lead to later periodontal issues. Therefore, issues with dental caries, dentition, caries, periodontal disease and other issues can arise if tethered oral tissues are not resolved early.
  • Orofacial Structure
    Jaw development, narrow or high palate are some of the structural and functional implications of tethered oral tissues in addition to other genetic factors. TMJ pain is a common result of these structural and functional issues.

Keep in mind, if a release resolves breastfeeding issues, it does so because it enables proper oral motor development which would be expected to have a number of positive health impacts across the lifespan. For resources that detail this information further, see:

  • This resource which describes what tethered oral tissues are all about, their long & short term health implications as well as common misconceptions.
  • This resource which describes more in detail the process of going through a procedure for parents, including pre/post op care and additional resources.

Evaluating and decision making around releasing a restriction would take into account both short and long term implications as well as the pre and post care required. A team of professionals working together supports the best outcomes.

Is this a trend? Why all the rave?

Tethered oral tissues (tongue, lip and buccal ties) are true medical diagnoses and not a passing fad. The reason for the increased awareness is improved clinical research, improved technology and greater collaborative care where specialists in different fields are noticing the widespread impact of the problem for health across the lifespan. If you were born and raised in the 70s, 80s or even 90s you likely got checked for these issues in middle school, or if you were lucky early elementary school when you already had symptoms (feeding difficulties, picky eating, breathing issues, speech issues, dental or orthodontic problems). A generational shift has now occurred where early oral motor development issues are being looked at much earlier because oral motor development is now recognized for what it is: as a critical foundation for health across the lifespan. The assessments are being done in the newborn and early infancy period while the mouth and body are developing rather than when the issue is already progressed in a developed body. The earlier the intervention, there is an increased likelihood to resolve the issues and prevent them from having later life impacts. Early intervention also means that the intervention will likely be less intrusive to the body as compared to when structures have fully formed and long term habits have developed. In many ways, this is a great shift. However, it’s not easy to navigate as not all health care providers are well versed in these issues. In particular, it is difficult because while tethered oral tissues have many implications, the procedure itself doesn’t resolve all of those issues immediately and sometimes if at all if the necessary pre and post procedure steps aren’t taken. In other words, it’s not a quick fix nor is it a cure all for co-existing issues. It’s important as with anything to weigh risks and benefits, be fully informed and educated and understand that as in any aspect of medicine and wellness today, one should be wary of scare tactics, aggressive marketing, opportunistic professionals and pseudoscience.

My pediatrician or ENT didn't see a tongue tie. Is this something I should still worry about?

Oral surgeons and dental surgeons specialize in the mouth. IBCLCs and SLPs specialize in feeding. You may have a great pediatrician or ENT, but they are not oral specialists or feeding specialists. In addition, ties are not assessed by visibility alone – in other words, one cannot just look in the mouth, lift the tongue up and down, and say there is or is not a tongue tie. In addition, if the tie is further back in the mouth it may not be visible to an untrained eye at all. Assessment must be functional in nature including mobility assessment, palpation and feeding assessment. Diagnosis requires collaborative care and evaluation by a preferred provider – not all medical doctors and surgeons are created equally. Ties can be incorrectly diagosed and procedures can be done incorrectly. Just like you wouldn’t rely on your primary care specialist to tell you about a knee injury or recovery, you don’t want to rely on someone who is not an oral or feeding specialist to diagnose or treat ties. You’ll want to see a preferred provider with specialization (found here) to confirm or disconfirm a diagnosis of tongue, lip or buccal ties.

My friend's son had a tongue tie and even after the revision, they still had issues. Why does this occur?

Although helpful to hear about others experience, you may not have all the context about what occurred and what supports were in place before or after a revision in your friends’ case. It can take up to 4-6 weeks or more to see full progress, and support is needed throughout the process to ensure complete recovery. It’s certainly possible that without all of these supports in place, there may be little progress or delayed progress – particularly if reattachment occurred. Keep in mind the release procedure is only one part of the process to successful outcomes. Bodywork is often needed before and after a procedure as well as targeted exercises to relearn. Reattachment can always occur and should be medically assessed in the weeks following if needed.

If my baby can bottle feed, why should I be worried about ties?

You can feed your baby in any way you choose. What’s important to know is that the first 4 months of feeding are all about learning so that later life feeding and other healthy habits can stay on track. It’s less about bottle vs breast and much more about skill development. Feeding of any kind, whether bottle, breast, cup, spoon, syringe, etc requires skills. Some feeding methods are easier than others, but this may not lead to the needed skill development. So much of early nutrition is striking a balance between what your child likes/will do and what’s best for them – in this case it’s not about the breast that’s best but that skill building is best. You can certainly bottle feed a baby with a tongue tie successfully, it’s important that you know how to do that in a way that encourages your baby’s learning.

Said otherwise: feeding in early life is a lot like math in elementary school – a lot of kids can do well in the early years but as math gets harder in later school years, learning issues and gaps in skill sets become more obvious. In that context, think of the breast is the word problem, and the bottle as a more simple equation. Both require skill to accomplish, one more than the other because one was designed to support skills and the other was designed to make something easier where skills lack. A bottle feeding assessment can help you get an understanding of not just how much milk your baby needs but also how well they are feeding and what you can do to help them be more effective, efficient and develop those skills.

Unfortunately, parents who bottle feed are often left without support and the assumption is it’s going to be easy. Often, feeding is not a smooth ride for babies with tongue ties regardless of the method of feeding you choose. Particularly so with bottle feeding as there’s a lot of noise to cut through to figure out all the various marketing claims vs true science when it comes to bottle choice, method, etc.

Generally, it’s important to have any possible ties fully evaluated and consider both short & long term implications as well as work on optimizing bottle feeding.

My baby is gaining weight well with breastfeeding and/or bottle feeding. Should I do anything about the tongue tie?

It’s great that your baby is gaining well. There are certainly many babies with ties who will be able to feed adequately in terms of getting their daily intake needs met. Evaluating and decision making around ties is very individual, and it’s important to know what your baby is dealing with and how it may impact them both now and later (and what the breastfeeding parent may be dealing with i.e. nipple damage, mastitis, oversupply). For instance, a baby may be gaining well but very fussy or with a lot of digestive discomfort (excess spit up, hiccups, aerophagia) and this can get worse over time. Going to see a trained medical specialist doesn’t mean you will have to do a procedure that same day – you can take your time to understand what this issue may mean for your baby, knowing that things can change over time and infant health is not defined by the sole criteria of weight gain. In fact, never in human nutrition across the lifespan except in infancy will you hear medical doctors solely focusing on weight gain, height and head circumference numbers as primary markers of health while discounting others symptoms.

My baby was assessed for ties, and we were told s/he has a "slight tongue tie." What does this mean?

Unlike other diagnostic criteria, tongue tie is evaluated by function not appearance alone. A tongue tie that appears “slight” may create severe functional issues. So, the answer to the question is, how severe are the functional issues? What a tongue tie means for your baby may take time to evaluate and ultimately requires a proper medical evaluation as well as a functional assessment by a lactation consultant.

What's a posterior tongue tie and why does it matter?

This blog post by ENT Dr. Bobby Ghaheri goes into detail with regard to what’s what when it comes to posterior ties. Posterior refers to the location of the tie in the mouth, which is in the back third section of the tongue – the tongue is divided into sections (L/R and front, mid and back). They are often not visualized unless seen by a trained eye, or difficult to visualize, but they are easily palpated and functionally assessed by a properly trained specialist. The back third of the tongue is responsible for proper swallowing as well as several other functions. A posterior tie can create the same or more issues as other ties depending on what’s happening functionally for your baby.