Laser Dentistry

The latest research in sleep medicine, oral myofunctional therapy and orthodontic literature is showing that untreated lip and/or tongue ties can be a contributing factor in many health and growth issues ranging from poor feeding at birth, difficulty with and picky eating in young childhood, digestion troubles, poor jaw and facial development, malocclusion, speech issues and the development of mouth-breathing. Tongue-tie, especially, is considered a risk factor for developing Obstructive Sleep Apnea.

As members of the Academy of Laser Dentistry, we are pleased to offer Maxillary (lip) and Lingual (tongue) frenectomy procedures to patients of all ages, infants to adolescents, using state-of-art Lightscalpel© CO2 Laser.

We provide treatment to newborns that, along with their mothers, are struggling to breastfeed due to the presence of either a maxillary lip-tie or lingual tongue-tie, or often both. If possible, we like to work with your lactation consultant after the procedure to help best re-establish proper breastfeeding for you and your baby.

Research has shown that at ANY AGE, a restricted upper lip and/or a “tongue tie” that inhibits the proper resting position of the tongue on the roof of the mouth can lead to many dental and health issues such as restricted mid-face/maxillary growth, a narrow palate, dental malocclusion, sleep-disordered breathing and/or sleep apnea issues, along with nutrition and digestion troubles such as acid reflux and “gas” and speech struggles.

It is important to be aware and become informed about the presence of “lip- and tongue-ties” and the potential of dental and medical concerns that can result from lack of diagnosis or treatment. When indicated, a frenectomy procedure can be a simple, but often overlooked key element to your child’s general health, sleep, growth, and development.

A personal note from Dr. Lauren Ballinger – Board Certified Pediatric Dentist, Certified Orofacial Myology Specialist, and MOTHER of two children.

I often say “I wish I knew then what I know now” when it comes to understanding the link between breastfeeding, lip/tongue ties, growth and development and health. Thankfully in life, both personally and professionally, we are always learning. As a practitioner I feel lucky to know now, what I do, so that I can potentially help other families. I have 2 children, with two different stories, who both were diagnosed with tongue and lip ties – unfortunately not until they were 8 and 10 years old. When my son was born, I tried everything in my power to nurse. Long story short, for a “healthy” baby, he had a very difficult first 8 months of life. Hospitalized 2 days after birth for dehydration and jaundice, he also developed severe acid reflux that lasted for…well, honestly, I feel like I may have blocked it out, but at least 6 months. He was the sweetest baby, but he was in pain and uncomfortable most of the time. He had to be held “upright” all the time. None us of really got close to having any semblance of a restful sleep for about a year. I was trying to nurse, but it hurt so much. My nipples would bleed, I would barely produce any milk and any small amount I was able to pump, he would vomit right back up. After 6 excruciating weeks for my son and myself, he was placed on daily medication for his acid reflux, and I was using formula exclusively. At the time the thinking was to put a “cereal”, which is a grain, into his formula to help “thicken it up and help him keep it down”. I didn’t know this at the time, but later I was diagnosed with Celiac Disease. My son is now Gluten Intolerant, and I am sure that the early exposure to grains in his system is a big part of that. I NOW KNOW THAT THIS COULD ALL HAVE BEEN AVOIDED IF HE HAD HIS FRENUM ATTACHMENTS CHECKED AND RELEASED IN THE FIRST FEW DAYS OF LIFE. I missed it, my lactation consultant missed it, as did my Pediatrician – and I respected them then and I still do. We just didn’t know at the time what to look for.

When my daughter was born 2 years later, I was unable to even attempt to nurse because, in addition to being diagnosed with Celiac Disease years later, I also have Crohn’s Disease. Between my pregnancies, I had a flare, so I was advised to go back on my Crohn’s medication immediately after birth, which meant I could not nurse. However, knowing what I know now, there was so much I could have done with my daughter in terms screening for frenum attachments and having them released as an infant, even though she was exclusively bottle fed. Not only do tight frenums, or “lip and tongue ties” effect breast feeding for both baby and mom, tight frenums can affect the growth and development of the face, teeth and airway.

Most people do not realize that the mouth and is part of the upper respiratory system and how the mouth and its contents develop and function can have positive or negative effects on our ability to breathe through the nose and affect how healthy our airway is. When it comes to orofacial growth and development, an important factor in airway development is the tongue and where it is positioned in the mouth. Normally, the tongue should be positioned on the roof of the mouth. In this proper position, the tongue drives the correct growth of the mid-face (maxilla), which happens to be attached to every other facial bone in our cranium, except the mandible (lower jaw) that it articulates with. Proper tongue position is not only vital to allow for proper nursing, its position helps to establish healthy nasal breathing, assists in the development of a healthy airway, ensures that we have enough space for all of our teeth, establishes proper TMJ (Temporomandibular Joint) position and creates proper facial balance, growth and aesthetics. Tongue-ties can affect these processes in different ways in different people, but in the presence of a tongue tie tongue function and position is compromised and development is arrested at some level. A Lip-Tie not only can prevent the upper lip from flaring over the breast to create a good seal for efficient nursing, a strong lip-tie can also affect mid-face (maxillary) growth.

Immediately after birth, tongue and lip-ties can cause significant problems for both mom and baby. If the baby cannot adequately flare the upper and lower lips around the breast or if the tongue cannot adequately be free enough to reach the nipple and push it up along the palate to create a vacuum, then troubles can start as compensations are made. Initial issues may be pain during breastfeeding for the mother, slow or no infant weight gain (because of inadequate milk transfer), exceedingly long feeding sessions and frequent blocked ducts or mastitis. Ties can also lead to a decrease in milk supply and early termination of the breastfeeding relationship. Occasionally a “good-enough compensation” between mom and baby to get “get the job done” can be established, even if the latch is not perfect. The benefits of breastfeeding are numerous and well documented, but for various reasons not everybody can attempt to breastfed (as I could not for my second child) or may choose not to. But, even if early breastfeeding problems aren’t present or decent compensations are made, tongue and lip ties can continue to cause issues for your child into adulthood.

As a MOTHER and a Pediatric Dentist, my goal is to help eliminate existing problems and work to prevent future problems. In an ideal setting, your child should be able to grow up with a minimal need for doctor and dentist visits. Sadly, untreated tongue-ties can contribute to future problems, which is why it is so important to have a tie evaluated early. The following pages will help you educate yourself and understand how to make the best decision for your child, and your family.

Infant Airway Development

The infant airway is divided into three parts: the nasopharynx (nasal cavity), the oropharynx (mouth and back of the throat) and the hypopharynx (throat/wind-pipe). Tongue position is intricately related to the size of the oropharynx. The posterior (back) of the tongue is also the anterior (front) wall of the oropharynx. This means that as the tongue moves forward in the mouth that the airway actually gets larger. The presence of a tongue-tie, restricts the tongue’s movement and ability to move forward making the airway space of the oropharynx smaller. Especially when the child is laying down or sleeping. As a way to make breathing easier, the baby will begin to breathe through their mouth – which is unhealthy and can lead to many issues that can make breathing even harder, like inflamed adenoids and tonsils.

The tongue, in its proper position on the roof of the mouth, creates the force needed for the maxilla (midface) to develop properly – wide and forward. Since the roof of the mouth is also the floor of the nasal cavity, a properly developing (widening) maxilla will also create a wider, bigger nasal cavity space, making nasal breathing easier.

When the face doesn’t develop properly, the problem is much more than aesthetic. A smaller airway is directly correlated to health issues arising in the first weeks of life. Studies are beginning to show a correlation between tongue-ties and infant sleep apnea, which is tied to SIDS. As a child grows, a restricted airway increases the chances of asthma, allergies, and can decrease athletic performance. This is why it is so important for the tongue to be free to function properly, not only so the face will develop as it was designed to, but so healthy nasal breathing and airway development is established.

Breastfeeding Infant and Mother Symptoms

Tongue-ties and breastfeeding are a challenging combination. When a tongue and/or lip tie is present, the “simple” act of nursing can seem incredibly difficult, painful, frustrating and disheartening. The Academy of American Pediatrics (AAP) recommends that babies receive breast milk exclusively until six months of age and continue to be breastfed at least through the first year of their lives. In light of these recommendations, if a tongue or lip tie is impeding the breastfeeding relationship, it is in the best interest of your child’s health, to have them evaluated and addressed.

A common misconception is if a baby can stick their tongue out that they aren’t tongue-tied. The ability to stick your tongue out has nothing to do with the ability to lift your tongue up. During proper breast feeding, the tongue must be able to elevate to the roof of the mouth to properly express milk from the mother’s nipple. When the tongue is restricted by a tie, often “clicking’ will be heard during nursing because as the tongue tries to elevate, is pulled back down to the bottom of the mouth due to the tie/tissue tether, like the snapping of a tight rubber band. This can result in a baby that tuckers out and falls asleep at the breast or gives up too soon, only to want to nurse again shortly after because they didn’t get a full feed. Because the efficiency and ability to express the milk from the breast, is compromised, the baby may not be able to gain weight, the mother’s milk supply may become reduced or engorgement and ductal issues may occur because the mom and baby cannot find a balance.
When nursing, both the upper and bottom lip should be able to “flare” around the areola and the baby should be able to achieve a deep latch with a good “seal” – meaning no “air pockets” should form in-between the corners of the baby’s mouth and the mother’s breast. When a lip-tie is present (top or bottom lip) or the tongue cannot reach high enough (due to tongue-tie) to express milk from the breast (or a combination of lip and tongue tie), often the baby uses it lips to “suck” shallower on the mother’s nipple, which can cause nipple pain to the mother. Often, the baby will have a “blister” on the top or bottom of the lip and the mother’s nipple may look like a “lip-stick” after nursing. Additionally, because there is not an adequate seal around the breast, the baby can swallow a lot of air during nursing. This can cause gas and pain, distention after feeding, spitting up or vomiting. These are just a few possible symptoms that you and your baby may be experiencing. It is important to do the research and ask questions and get a screening if you are concerned that your baby may have a lip or tongue tie.

Our office wants to support breastfeeding moms to the utmost of our ability. When lip and tongue-ties are not released, breastfeeding problems will continue. We understand that it can be scary to consider putting your little one through a tongue or lip tie release, but the benefits to both mother and child are many. A tongue or lip tie is not something that will self-correct, and the consequences of ties can reach well beyond a difficult breastfeeding relationship.

What is a lip-tie? Why does it matter?

Often, it is easier to identify a lip-tie on your little one than it is to see a tongue-tie. The lip plays an important role in breastfeeding and needs to have proper mobility to flare outward around the breast, which allows for a deep latch. The lip “normally” attaches to the maxillary gum tissue by what we call a maxillary lip (Labial) frenulum. The issue is not that a baby has a maxillary frenum attachment, we all do. The upper lip frenulum only becomes a concern during nursing if there isn’t sufficient mobility of the lip to allow for proper breastfeeding. It is at this point that we would consider the upper lip tied.

Since a lip-tie can interfere with the baby’s ability to achieve a deep enough latch, it can affect both the mother and the baby. It can cause a pinching sensation for the mother as the lip–tie interferes with the baby’s ability to draw the nipple far back enough into the mouth. The nipple can become damaged or irritated by the forceful (and unintentional) sucking from the baby. In addition, if the latch isn’t deep enough, your baby’s mouth will slip or pop off during feedings. The popping off may not be a complete release but will often be associated with clicking or popping noises. These sounds are an indication that a deep latch may not be well established. The presence of gas, belly distention and spitting up after nursing may also indicate that the baby is not able to an adequate lip seal around the breast. The baby ends up swallowing a lot of air while nursing if a deep latch and good seal are not achieved. If the upper lip has sufficient mobility and these symptoms are not an issue, the lip tie does not need to be released at this point at time. It really depends on how well both the baby and the mother are functioning.

What is a tongue-tie? Why does it matter?

While the lip is important in breastfeeding, the role of the tongue is even more vital.  A tongue-tie can be a big obstacle to successful breastfeeding. Recent research has led to a change in the understanding of the mechanics of breastfeeding.   We now know that the tongue creates negative pressure in an infant’s mouth. This negative pressure is what causes the nipple ducts to open up and allow milk to flow into an infant’s mouth. This negative pressure is what we typically associate with a baby sucking. While nursing, the tongue is meant to be able to pull the mother’s areolar complex to the palate and push it up against the palate, thereby creating the vacuum that allows the milk will flow.

When an infant has a tongue-tie, it lacks the proper mobility to elevate the posterior (back) and sometimes the (front) anterior portion of their tongue to create a sufficient vacuum. Therefore, some infants will nurse for extended periods of time with only the smallest transfer of milk. This not only causes issues of undernourishment but can either cause a mother’s milk supply to decrease and/or the milk to stagnate resulting in blocked ducts and an increase in bacteria causing infection and mastitis. Since a tongue-tie means the tongue cannot move properly, the baby will often use their lower gums to chew on the nipple to get the milk out. This can cause the mother significant pain and the baby’s ridges may appear flattened and bumpy.

The good news is, when the tongue-tie and/or lip-tie is released, the breastfeeding relationship can be significantly changed for the better and symptoms mitigated. And we can help, by assessing and treating the ties, as well as many of the symptoms both baby and mother are experiencing. It is very common to find that if a baby has a tongue-tie, they may also have a lip-tie. If it is a combination of a lip and tongue-tie that are causing the problems with breastfeeding, we will recommend that both the lip and tongue tie be released. Occasionally, the baby may also have “buccal ties” or a “lower lip tie” that can cause additional nursing issues and we will assess for these as well.

Evaluating for a Posterior Tongue-Tie

The only way to identify the posterior tongue-tie is to examine the baby in a certain position and to use your fingers to try to lift the tongue upwards from underneath. It is easier to have someone else help you and have a two-person approach. Be sure that the person who is manually investigating the tie has washed their hands thoroughly and, if possible, is wearing gloves.

The first person should hold the baby in her/her lap so that they are facing each other – the “bottom half” will be on that person’s lap.

Have the first person lay the baby’s head into the second person’s lap so that the baby is facing upwards – the “upper half” or baby’s head is in their lap.

Do not forcefully enter the baby’s mouth. Tap her/his chin and wait until she opens her mouth and allows you to enter.

After baby has opened his/her mouth, insert one index finger into the baby’s mouth UNDER the tongue and then the other, with one finger on each side of under-side/ middle part of the tongue where it attaches to the floor of the mouth.

Press your fingers slightly deeper into the tissue under the tongue and then lift the tongue toward the roof of the mouth.

If there is a posterior tongue-tie, it may appear white-ish in color or less red and look and feel like a fibrous or thick band in between your fingers. You will notice the restricted upward mobility of the tongue as you gently try to lift the tongue up with your fingers underneath the tongue.

If you think you have identified a posterior tongue-tie in your child, then you need to be your child’s advocate and find a provider who understands the importance and is skilled in treating tongue-ties. Our office keeps open appointment space for the express purpose of releasing ties at short notice.

Why Should a Tongue or Lip-Tie be Released?

The lips and tongue naturally attach somewhere on the body. Everyone has tongue and lip “attachments”, but for some the tongue or lip attachment is “to tight” causing a restriction that can affect proper function and form. The real question is whether the restrictive attachment is causing problems right now or if it will cause problems in the future.  

The initial issues related to a tongue or lip-tie usually occur in the first few days of life while breastfeeding. Babies or mothers—or both—can have symptoms, including painful or prolonged nursing, reflux, gas, colic, blistering or bloody nipples.  If any of these issues are present, it would be a good idea to have your baby evaluated for ties. Having an evaluation is not a commitment to revise. It will equip you with the information you need to make the best decision for your family.  
It is possible that, even though there are no breastfeeding symptoms, there is a tie present. If the tongue has limited mobility, it can still cause issues with facial development. The tongue is what drives the growth of the middle part of the face, called the maxilla.  For the maxilla to develop as it was designed to, a person must have what is called a proper oral rest posture. This means that while the mouth is at rest, the lips are sealed, breathing occurs through the nose and—most importantly—the tongue is resting on the roof of the mouth. When one is tongue-tied, the tongue is almost always prevented from resting on the roof of the mouth. The tongue is such a powerful muscle that when it is resting on the roof of the mouth, it causes our maxilla to expand and develop forward. This is what creates the proper facial proportion and size. A short lingual frenulum can lead to an increased incidence of sleep disordered breathing and sleep apnea in not only adults, but in infants and children. Infant sleep apnea is beginning to be closely tied to SIDS. 

The tongue acts like a “scaffold” for the upper jaw, allowing it to grow and form wide enough to allow for all the teeth to have enough room to come in. When the tongue can’t rest on the roof of the mouth the upper jaw (maxilla) collapses and gets smaller resulting in crowding of the teeth, an overbite, a very narrow smile, and a high palate. Our jaws and face are about 40% formed and developed by 4 years of age and by age 12, over 90% of the facial and jaw growth is complete. If a tie is not treated early in life, while kids are still growing, these facial and jaw growth deformities cannot be reversed. Braces can always, “straighten the teeth”, but they cannot un-do the growth irregularities in form. Additionally, if the “teeth” are fixed, but the underlaying issue – like the tongue-tie is not, many times the teeth relapse after the braces are off because the tongue does not rest properly in the roof of the mouth and act like “nature’s best retainer.”

In addition to facial development, if your little one’s tongue is tethered to the floor of his/her mouth, it can also cause delayed speech issues or a difficulty in making certain sounds.  The tongue must have full range of motion for it to be able to form certain sounds.  If a tongue is tied, speech therapy alone may not be enough to correct the issue and releasing the tongue may become necessary.

If the tongue-tie is released when your child is older, they will likely benefit from working with a Myofunctional Therapist or an Oral Myologist. Dr. Lauren Ballinger, in addition to being a Board Certified Pediatric Dentist, is also a Certified Orofacial Myology Specialist (COMS).  A Myofunctional Therapist or Oral Myologist can help your child learn proper tongue placement, how to strengthen the tongue and use its new-found mobility, improve speech, help eliminate food texture issues and many other things.  In fact, the actual tongue and lip-tie revision or release is just one part of the treatment solution. The best results come from the post-procedural exercises and stretching. This can be an intense 6 weeks of “physical therapy” after the tie is released, but it is crucially important for success. Because of our office has undergone extra training in myofunctional education and Dr. Lauren is a Certified Orofacial Myology Specialist, we can help you and your child achieve the best results from their release.

Even with no symptoms, the upper lip tie may need to be revised as well.  Depending on how far the upper lip tie extends it can cause a gap to form between the two front teeth and can it can lead to an increased possibility of decay on the front teeth. It can also restrict the growth and development of the maxillary arch and mid-face.

The Healing Process

Many patients want to understand what “normal healing “is and how they will know if their baby’s tongue or lip-tie has healed well or reattached. When we release a tie, we expect the frenulum to reform, but with less restriction.  Our goal is that the frenulum will reform in a way that allows for greater mobility of the tongue or lip. A successful procedure is one where the symptoms that the mom and baby were experiencing disappear by the end of the healing time. This can take weeks and require help from other professionals like lactation consultants and body workers.

Immediately after the tongue and lip are revised, you will be able to see a diamond shaped wound. This diamond is what allows for more mobility.  We do not want the top and bottom or the sides of the diamond shape to attach to each other while healing – this would result in a short, tight frenulum and little to no change. Our goal is that the wound will “fill – in” and form a new frenulum that is longer and gives the tongue or lip adequate mobility. Over the next couple of days, the diamonds will turn white, yellow and greenish; this is what a wound that is healing in the mouth looks like – it is basically a “wet” scab. Many parents get nervous that this is a sign of infection, but it is not.

Healing: What is Normal?

To facilitate the proper healing of lip and tongue releases, we strongly recommend a regimen of stretches/exercises to be done six times a day, no more than 4-6 hours apart.  This does mean you will likely have to stretch the wound site in the middle of the night, even if it means waking your little one. A goal may be to do five sets of stretches during waking hours and one during the night. As the wound heals, scar tissue will grow into the revision site to reform the frenulum. This is normal. The purpose of the stretches/exercises is to get this tissue to reform differently: longer and further back along the tongue, or less tightly attached to the top lip than it was before.  If stretches aren’t done, there is a high likelihood that tongue will form a short frenulum again, which may require another procedure.  Therefore, it is so important to be diligent and effective when it comes to the stretches.  Doing the stretches is one of the main components of a successful revision.

The healing process can feel like a rollercoaster ride. When your little one is returned to you right after the procedure you may or may not notice any difference in how breastfeeding goes.  Sometimes, it can feel “different” or “deeper” right after the release. Often, nursing is not painful in the way it was previously. Don’t be surprised if the latch right after the procedure is the best latch you have for a few days.  It may get worse before it gets better. The baby can get more sore and fussy in the days after the release and must be gently “pushed”. Some babies do well to be stretched right before breastfeeding, others will need to be stretched after. It can be very hard to keep up with the stretches because you may feel like your baby is sore already and the stretches are only making it worse, but without the consistent stretching, the release will not be a success. Good technique and quality breastfeeding are also EXCELLENT forms of post-operative “stretching” that promote proper healing. That is why enlisting the consistent help of a lactation consultant during the 6 weeks after a release is critically important for success. You and your baby must work together to find a new normal and this takes time, patience and guidance. Be strong and diligent; the benefits are worth the initial effort!

As mentioned above, releasing the frenulum is only part of the picture. The baby may need help relearning how to use his/her new found “freedoms” of lip and tongue movements. This team is often made up of a lactation consultant, your pediatrician, your frenectomy provider, and a body work provider.  Working with other ‘team members”,  you and your baby will get the best support and the most success out of a release propceedure.  

Healing: What is Abnormal?

Many parents ask how they will know if the site becomes infected.  One of the wonderful aspects of the laser is that it sterilizes and cauterizes the tissue as it works. Infection from a laser frenectomy is unlikely, but if your baby does develop a fever, please call. It more likely may be do to a coincidental viral infection or “ear ache”, but its best to rule out any potential problems with us and your pediatrician.

Using the term reattachment to define an unsuccessful procedure is misleading.  As discussed earlier, a new frenum attachment will form, but the function should be better. If either mother or baby’s symptoms return, or the baby is unable (not just temporarily unwilling) to eat from either breast or bottle, contact your provider.
 

Why would the tongue or lip need to be revised again? 

Sadly, some baby’s end up having to have their lip or tongue released multiple times.  Our goal is to ensure that the first release is the only release.  There are several factors that affect the final mobility of the tongue or lip post-release. One is an incomplete release. Often, only the only “anterior” tongue-tie is released.  For most babies, this won’t be enough.  If a posterior tongue-tie is present and not released, your little one won’t have the proper upwards mobility of their tongue. Of course, each baby’s individual anatomy is different and dictates how far or deep the release can or needs to be. The goal is to identify if there is a posterior tongue-tie and release as much of it possible; certainly, enough to achieve good function while nursing. It is possible that a deep posterior tongue-tie that is released enough to allow for better and improved breastfeeding as an infant, may need a revision at an older age – along with orofacial myology/myofunctional therapy for better function as it relates to growth. Another factor that can lead to needing a revision is whether or not the post-operative stretches and exercises were completed as directed. What occurs during the time after the procedure is just as important as the procedure itself. The frenectomy “procedure” is just one part of the equation. The stretches and exercises are what insure good healing and proper function and play a huge role in the success of the treatment.

Older children and Tongue-Ties

It has only been with the cultural shift toward breastfeeding again that lip and tongue-ties are being re-identified in infants. Because of this, there are many adults who have tongue-ties, but are unaware. These unidentified tongue-ties can cause problems not only in infancy, but issues that can continue through adolescence into adulthood. It is never too late for a person to have their tongue-tie released. The benefits for some people can be life changing and well worth the time and effort.

SPEECH ISSUES: Movement and position of the tongue is crucial to properly form sounds. When the tongue is restrained through a tongue-tie, it may not be possible to form the sound. Some people can compensate for the lack of mobility, but not everyone. In those situations, the only way to properly produce the sound is to release the tongue enabling it to move. Some patients go through years of speech therapy with minimal improvements until their tongue-tie is released.

CROWDED TEETH: Tongue-ties and crowded teeth are directly related to each other. When the tongue has proper mobility, it rests against the roof of the mouth. This causes the upper jaw (maxilla) to expand laterally(wide), which allows for the proper amount of space in the jaw for all the adult teeth to come in. Often, parents comment that when their child had primary teeth, all of their teeth looked “perfect and straight”, but once their adult teeth came in they became crowded. We know that we see a child with perfectly straight primary teeth with NO GAPS, it is a red flag. Primary teeth should have large gaps and spaces between them. Adult teeth are significantly larger than primary teeth and therefore take up more space. If the primary teeth don’t have space between them, the adult teeth will likely be crowded. Baby teeth that are not spaced, have a “gummy smile” appearance and have a “deep overbite” are all indications that orofacial and jaw growth is not ideal and should begin to be addressed as soon as these things are discovered. Often tongue and lip-ties play a contributory role in this incorrect growth pattern and should be assessed in any orthodontic workup.

OVERBITE/UNDERBITE: In addition to growing the maxilla laterally, the tongue also drives the development of the face forward. When the tongue is tethered down, we will often see kids present with a deep overbite – where the top teeth cover the bottom teeth. This can be thought of as “maxillary melting” – the upper jaw is melting or growing down and back instead out out/forward. Sometimes we see an underbite occur – where the lower teeth jet out in front of the upper teeth. In this case, the upper jaw (maxilla) is not being guided by the forward forces of the tongue and can get “stuck” behind the lower jaw. These are not only esthetic issues but can be the cause of other health issues.

BREATHING, SLEEP and POSTURE: Since the tongue is attached to the mandible (lower jaw), when the mandible is recessed the tongue will be positioned or “pulled” farther back into the mouth and airway space making breathing more difficult. Especially when laying down and when sleeping, the tongue will be even more likely to interfere with the airway space and cause nighttime related airway issues like snoring, sleep arousals and apnea events. While awake and upright, people often compensate for this poor position tongue position by holding their head forward, which makes breathing easier – this is called Forward Head Position. In the short term, this opens their airway and improves their ability to breathe. However, this affects whole body alignment. The forward head posture stresses the muscles of the neck, back and torso over the long term and can lead to chronic pain.

FOOD TEXTURE ISSUES: When babies/toddles with tongue-ties encounter solid foods, eating issues may arise. A child may tend to be a very picky eater or a gag on food as they try to eat it. The texture of foods may become an issue. Maybe a child will eat mashed potatoes but won’t eat cubes potatoes. Maybe they will have difficulty eating things like steak and prefer things that are easy to swallow. Kids may complain of indigestion or gas because they aren’t chewing their food well and swallowing a lot of air while eating. Often these children are loud and messy eaters and seem to always eat with their mouths open. You may notice that food is often left inside their checks and inside their lips. The tongue plays a crucial role in eating, mastication and the digestion of food. The tongue is designed to help move food around the mouth, create a “bolus” that is easier to swallow and also helps to clean the food out of the mouth as well. When someone is tongue-tied, the tongue can’t do these jobs. This can result in certain foods being very difficult to handle and manipulate in the mouth. The tongue will have a difficult time moving collecting the food in the mouth to be properly chewed. The tongue will not able to help form the proper the “bolus” of food in preparation of swallowing. It can make the act of “eating” and swallowing feel “scary”, unpredictable or uncomfortable. “Picky eating” and food avoidance may manafest because when foods are difficult to manage or swallow one will consciously or subconsciously avoid those foods. Indigestion can also be a side effect because food that isn’t adequately chewed is not digested well. Releasing the tongue-tie on toddlers can really improve their ability to eat and digest food. If any of these are problems that you are dealing with then consider having your little one’s tongue evaluated.

TMJ & CHRONIC HEAD AND NECK PAIN: One part of the body cannot be isolated from the rest of the body. All our body parts are connected and should work in harmony. The tongue is no exception. The tongue is connected to so many muscles and nerves throughout the upper body, head and neck and if its function is restricted, it can throw the body out of balance. In teenage (and adult) patients, a tongue-tie can manifest itself as chronic TMJ pain and disorders, headaches/migraines, head and neck tightness, snoring and sleep apnea, as well as postural issues and a chiropractic adjustment that won’t hold. The frenulum beneath the tongue is made up of thick collagen fibers which have only a slight ability to stretch. The tongue is a huge muscle that has many connections to other muscles, ligaments and bones in the head, neck, shoulder and chest regions. When the tongue is “tight”, many other parts of the body may be as well and can lead to muscular and skeletal imbalance. Releasing the tie can allow the body to relax into a posture that was not possible with a tongue tie, relieving years of tension-causing problems.

Questions to Ask When Choosing a Provider

More and more evidence-based research devoted to the subject is linking the presence of tongue and lip-ties to difficulties in nursing for both baby and mother. Research is also connecting the presence of ties later in life to orofacial growth issues and is considered a contributing factor in the development of sleep disordered breathing and a risk factor for the development of obstructive sleep apnea. Yet, general knowledge among the dental and medical community is still relatively low. Unfortunately, not all dental or medical providers have the training or experience to screen for the presences of tongue and lip-ties and often times parents don’t even know what to look for. Thankfully, this is changing as information becomes more widespread, and both parents and health providers take the time to do the research and make the effort to understand the connection between the presence of tongue/lip ties and health. Often it is the knowledge of a well-trained and experienced lactation consultant that first brings a lip or tongue-tie to the attention of a parent. It is important that you seek out a provider that has sought out training in the comprehensive treatment of releasing tongue and lip-ties, understands the link between breastfeeding and ties, and checks for the presence of a posterior tongue-tie. It is also important to find a provider that has knowledge or training in orofacial myology/myofunctional therapy or works closely with an Orofacial Myologist or Myofunctional Therapist.

How often do you perform (infant/child) tongue and lip tie releases?

It is important to know how experienced the provider is in working with all types of tongue and lip ties, but especially in infants and children. Your provider will need to be able to assess whether the frenulum is normal or needs release and whether bodywork is needed to help address issues like soft tissue tension or imbalance. Experience also makes a difference in terms of speed and efficiency. It is important that your provider has the ability to fully release the ties without going too deep, can help manage the post-procedure healing process, as well as any difficulties that may be encountered. Because of the increasing frequency of referrals, our office sees more and more tongue and lip-tie revisions each month. We are continually working on furthering our knowledge about tongue and lip-ties and training in laser frenectomy and post-op care, because there is always more to learn and room to grow. Learning is a continual process and responsibility we take seriously to better ourselves and to best serve our patients. Our commitment is to be able to provide the best and most up-to-date treatment for you and your family for the most successful results.

Do you use scissors, a scalpel or a laser? If you use a laser, what kind of laser does your office use?

The actual tool, method or technique used to revise a tongue or lip-tie is actually a less important factor than the skill and knowledge of the provider.  The use of scissors, a scalpel or a laser all can be equally effective in the “right hands” of the individual practitioner performing the release. However, it is important to know the differences in technique and how that impacts treatment and post-operative healing.

Our office uses a CO2 laser (Lightscapel.com) – insert site link. Unlike a diode laser, when using a CO2 laser, the tissue is “vaporized” rather than “burned”. Therefore, the CO2 laser is much gentler to body because it does not generate heat or cause damage to the surrounding tissues which can cause an increase in discomfort during healing. There is also very low to no bleeding because it “seals” the minor capillaries and cauterizes the wound as it works. If minor bleeding does occur, the CO2 also can help stop it by sealing it back up. The CO2 laser also “disinfects” the wound, so there is very little chance of infection. When scissors are used, bleeding is expected, and the entire tie may not be able to be released, especially in the hands of a provider who does not commonly perform releases. A scalpel release, done be a skilled provider, can be very effective. However, sutures/stiches are usually required, there is more bleeding and the procedure can take a lot longer than with a laser, making this option not a great choice for the infant or child.

It is important to look for a provider that will provide you with excellent follow up care, wound management information and provide you with the tools needed to perform the correct stretching and exercises that are needed after a release for the best success.

How do you address posterior tongue-ties?

Many people, including many health care providers recognize only one “type” of tongue-tie, which is referred to as an “anterior tongue-tie” and its appearance can be obvious. This is often a thin piece of tissue that extends from the tip of the tongue to the floor of the mouth and is usually fairly easy to identify. However, when an anterior tie is present, it is likely that there is also a posterior tie. In fact, you can have a “posterior tongue-tie” without the presence of a more obvious looking “anterior tongue-tie.” Releasing the anterior tie only, is rarely enough to get the full benefits of a frenectomy and can often result in needing to have the tongue-tie further released. The posterior tie is the band of fibrous tissue that covers the deeper muscles of the tongue.  Because of where it is located, it is frequently missed and goes undiagnosed.  Every time there is an anterior tongue-tie, there is usually also a posterior tie associated with it that needs to be revised at the same time.    
What form of sedation (if any) will be used during the procedure?

In older children, some say that you can use a CO2 laser without local anesthesia or with just “topical numbing gel”, but we find the procedure is basically painless if we use local anesthesia at the site. There are many benefits to seeking care from a Pediatric Dentist and one of them is that we are excellent in providing good pain-control, i.e. getting your child “numb”, without them being scared or uncomfortable – it’s part of what we do every day! We also can use nitrous oxide in children that may be nervous about the procedure. We find that older children are mostly nervous about the “unknown” and do not know what to expect. Once we take the time to explain the procedure in an understandable and age appropriate way, they feel a lot better. In our experience, with or without the use of nitrous oxide, most kids think the procedure itself was so much easier than they imagined it would be! For infants and babies under 1 year of age, it is not recommended to use local anesthesia. This is an important reason why your provider should be experienced, proficient and efficient in infant tie releases. Prior to the release, we will discuss some recommendations that can make the procedure and the aftercare better for your baby. We find that as soon as the procedure is over, that babies are able to settle themselves very quickly and are immediately soothed by nursing or feeding right away.

What pain control options do we have?

Every baby and child have distinct personalities and can have very different experiences post frenectomy. We find some babies and children have little to no discomfort in the days following the release and others seem to be uncomfortable longer or more intensely. Many children return to school right away and a fairly normal diet can be resumed. We do recommend that your baby/child receive a dose of an over-the-counter pain medication prior to the procedure – our office can provide you with this. (Please do not give your baby any medication prior to treatment without first discussing it with us or your pediatrician) For the first few hours after having your baby or child’s tongue or lip revised with a laser there is not likely to be much pain.  We do recommend staying “ahead” of any pain and discomfort over the next few days and using a “pre-emptive” approach. The stretching and exercises need to start right away and are crucial during the first few hours and days after the procedure. It can feel a bit overwhelming to begin stretching and exercising when your baby/child is sore and fussy. Here are few options.

INFANT TYLENOL/acetaminophen (dose based on weight) can be used every 4-6 hours over the next days to help with pain.

ORAL ARNICA is a homeopathic remedy to treat inflammation and is very effective. It can be found at most health food stores (like Guido’s) and some pharmacies and grocery stores. Dissolve 10 Arnica Montana 30c tablets in 2-3 ounces of water or breast milk. Store CHILLED or FROZEN. Give approximately 2mls every 1-2 hours by mouth (you can either spoon it in or use a dropper OR you if you froze it, place a few small pieces of frozen Arnica/breastmilk or Arnica/water chips in your baby’s mouth) for the first few days and then as needed. May be given every 15 mins during a more acute episode.

TOPICALS- Hyland’s Teething Gel and Orajel Naturals (DO NOT use regular Orajel- or products containing benzocaine. This can be very dangerous in a young infant). We also do not recommend the use of vitamin E or coconut oil on the healing sites. We find that they can actually speed up the healing process TOO QUICKLY, which can result in the formation of a shortened attachment, which is what we want to avoid.

If your child is over 6 months old, you may also use Ibuprofen(Advil/Motrin). Make sure that you follow the directions for the dosage based on your child’s age and weight, and work in partnership with your pediatrician.

OLDER CHILDREN/TEENS typically do well with using Ibuprofen (dose/weight) every 6 hours for the first few days. It can be helpful to alternate the use of Ibuprofen and Tylenol at first for better relief (dose/weight) if needed. You can give a dose of each medication separately spaced 3 hours apart (dose of ibuprofen, then 3 hours later dose of Tylenol, then 3 hours later ibuprofen, then 3 hours later Tylenol)

ICE WATER – frequent sipping of ice water or holding some ice water under the tongue or under the lip can help prevent inflammation and discomfort!
Again, it is wise, especially in the first few days, to administer pain relief proactively. Warm baths can be helpful. Also, putting frozen breast milk chips under her/his lip or tongue can provide pain relief.

Will we need to do stretches and/or exercises after the procedure? 

YES! The best analogy we can think of in terms of the need for doing the stretches/exercises after frenectomy is the need for having physical therapy after orthopedic surgery. For example, just like the outcome of a “knee surgery” will not be as good without completing the recommended amount of physical therapy after the procedure, the results of the frenectomy will not be as successful if the proper “physical therapy” for the mouth is not done. This mouth “physical therapy” consists of stretches, massages and exercises. Depending on the age of the patient, the parent(s) may have to be 100% responsible for doing them for the infant/baby/toddler. Older children can certainly take on some responsibility for the exercises and stretches, but they will require “hands-on help” most of the time and very close monitoring. The 6 weeks after the frenectomy procedure will determine if good healing occurs or not. This is a critical window if time and it is important to give it your best shot. During first few weeks after the tongue and/or lip are revised you will need to stretch and massage the procedure site every 4-6 hours around the clock. A frenectomy creates an oral wound that looks like a diamond. The wound is moist and “sticky” and the sides will want to join and “stick” back together. If the sides start coming together while healing, the new frenum attachment can become even tighter than it was. The healing process starts hours after the procedure and you gave to get started right away. Your job is to prevent this by faithfully performing the stretches or exercises. The diamond shape should take a long-time to disappear and not be allowed to heal together. You want the “wound” that was created to “fill-in” with new tissue, rather than to attach back together.  The stretches and exercises keep the fibers that were released flexible and long and prevent them from “sticking” back together as they heal. If the fibers are allowed to contract and heal back together, the frenum site will be tight and restricted again. That is why, in addition to stretching and massaging and doing the exercises, eating and drinking should resume. You want to use the tongue and lips and make sure you are moving them around and not just letting them “sit there” without movement, because the wound will strat to heal and stick back together. Nursing helps keep the tongue and lips moving so that the wound doesn’t start to heal together. Working with a lactation consultant after frenectomy helps insure your baby is getting the right “exercise” while breastfeeding. With good breastfeeding technique (which may be new to the both of you now that a release was done) the tongue is able to utilize its NEW full range of motion and will build up muscle strength. If a lip-tie is released, the lips must now be trained to properly flare out. Nursing is a great form of post-op “exercise”, but the stretches and massages will still have to be performed. Older children will have exercises that we teach them how to do under your watchful eye and we will teach you how to help them with their stretches. Before and after the procedure we will review the stretches, exercises and post-op wound management with you and make sure you feel comfortable.

Do you have referrals for people who can help with the healing process?

Because tongue-ties can impact the whole body, it is important that your provider can assist you in finding an experienced team of other providers who can partner with the patient and parents to help them realize complete healing. This can include craniosacral therapists, chiropractors, cranio-osteopaths, lactation consultants (IBCLC) and Orofacial Myologist/Myofunctional Therapists. We are constantly building bridges with other providers who understand how important it is to work together in our approaches and care for the best results.

What follow up care is needed?

Ideally, we like to see infants and their moms 1-3 days after the procedure to ensure that the initial healing is going well and to make sure that stretches are being done properly.  Then, we like to see them about a week after and possibly two weeks later. At about 4-6 weeks after the procedure there is a final follow-up appointment.  At this visit, look to see that the baby’s and the mother’s symptoms have resolved.  If there are still residual symptoms, a plan is created to support the mom and her little one to ensure they get the support and care needed for complete health. With older children, we follow the same post-op timeline. 1-3 days after the procedure to make sure the healing site looks good and the exercises and stretches are being done correctly. Then usually again, 1 week after that visit. Depending on if the child is in current orthodontic, Myobrace or orofacial therapy with us or not will often determine how much we need to follow up during the 6 weeks. We strongly recommend that you child is in some sort of myofunctional treatment after frenectomy for best overall results.

What if we need a re-revision?
 
If you need a revision for any reason within the first six months there is no additional charge.

Building a Team

Myofunctional Therapy/Orofacial Myology

Like any other muscle in the body, the tongue can only move in ways that it has been trained or freed to do. It is possible to develop bad oral habits like leaving the mouth open, sucking on a finger, tongue thrusting, or developing an improper (reverse) swallow pattern. All of these habits negatively impact the growth and development of the face. In order to learn proper oral habits, we often recommend that a child work with an Oral Myologist/Myofunctional Therapist as they are trained to correct improper oral rest posture and can have a significant impact on the growth of your child. Dr. Lauren Ballinger is a Certified Orofacial Myology Specialist and all the Doctors and staff have had extensive myofunctional training. Any child over the age of 1 year old can benefit from working with an Orofacial Myologist/ Myofunctional Therapist after having their tongue-tie revised. They will now have increased mobility and movement in their tongue, but if proper habits and tongue position are not taught and learned, then the true benefits of releasing their tongue will not be realized.

Bodywork and Occupational Therapy

Before and after a tongue and lip tie release, it is ideal to be able to undergo gentle bodywork and manual therapy to release tight muscles and connective tissue, improve blood and lymph flow, and strengthen the connection between brain and muscles to improve coordination of the suck/swallow/breathe rhythm for efficient breast and bottle feeding.. Occupational therapists that specialize in feeding challenges and have taken advanced training in manual therapies, such as those listed above, can provide optimal support for parents and babies both before and after a tongue tie release. Speech Therapists that have training and an understanding of tongue and lip-ties and releases can also be a very helpful part of the team.

Prior to the release, manual therapy is very effective in opening and softening the tissues of the face, mouth, neck, and upper chest. After the release, manual therapy is helpful in minimizing scar tissue and maximizing mobility and coordination of the lips, tongue, and jaw for better feeding.

Lactation Support (IBCLC)

A lactation consultant is committed to helping remove any roadblocks that a mother and baby encounter in their breastfeeding relationship. After a tongue-tie release, it is ideal to work with lactation support as both baby and mother learn to breastfeed again. The support and knowledge offered by your lactation consultant will make a world of difference in leading to a happy, successful breastfeeding relationship