What Is Tongue-Tie

Our tongue is attached to the underside/floor of our mouth by an attachment called the lingual frenum. Abnormal lingual frenum attachment reduces the overall flexibility of the tongue thus causing it to be tied down more strongly to the floor of the mouth than it would normally be causing a ‘Tongue-tie’.^1-3 Signs and symptoms of tongue-tie are difficulties with breastfeeding in infants and nursing mothers, while for older children and adults, major difficulties are commonly related to speech. Diagnosis and management (conservative or simple outpatient surgery) generally help in treating the condition easily, but do require the attention of qualified and registered healthcare professionals.

Introduction

Our mouth is made of fixed structures (jaw bones, gums and teeth) and flexible or loose structures (lips and tongues).¹ These structures combined help us to perform important activities such as chewing or speaking. But, to function as one unit (i.e., our mouth) these structures need to be attached to one another. These attachments that allow the lips/tongues to be flexible while not loosening out are called ‘Frenum’. Frena (plural) are small band-like attachments made up of skin and some muscle fibres underneath that skin.¹

To keep our tongues inside our mouths and to prevent them from falling out of it while speaking or falling inside our throat while swallowing, they are attached to the floor of our mouth by a ‘Lingual Frenum’.^1,2 This attachment does not change throughout our life and in most individuals, it does not affect normal functioning.^1-3 However, in some individuals, abnormal lingual frenum attachment reduces the overall flexibility of the tongue thus causing it to be tied down more strongly to the floor of the mouth than it would normally be.^1-3 This is called Tongue-tie or scientifically known as Ankyloglossia (Ankylose = stiffen or unite, glossia = tongue).   

Ankyloglossia or Tongue ties are commonly noted in about 0.2-10.7% of infants in the UK. Due to easy and early diagnosis and treatment, infants show a higher percentage of being affected by tongue-tie than younger children, teenagers, or adults.² While its specific cause is unknown, it is a congenital (present since birth) condition hence it is possibly genetic or hereditary in origin.⁴ Its clinical presentation can also be syndromic in origin accompanied by cleft-lip and cleft-palate or abnormal number or size of the teeth as well.⁴ Some common signs and symptoms of tongue tie generally manifest around difficulties with breastfeeding and secondary problems arising from it in both the mother and the infant.² In older children and adults symptoms include functional difficulties involving the tongue, some common examples would be difficulties in speech, swallowing, and eating (e.g., licking an ice cream).^2,3 Treatment options for tongue ties are commonly based on the severity of the condition. But two broader options of treatment generally are – conservative (observation, speech therapy) and surgical (frenotomy, frenuloplasty or frenectomy).²

Types of Tongue-tie

Over time several different classification systems, based on the different characteristics of the attachment have been proposed, yet there is not currently an internationally recognised universal definition or classification of tongue-tie.⁶ But for easier understanding they can be divided into some of the following common types:

1. Based on where the tongue is attached to the floor of the mouth (Cleveland Clinic):

·  Anterior Tongue tie – Generally located on the front of the side of the tongue near the tip of the tongue. It commonly resembles a thin web in its appearance. They are the more commonly noted type of tongue-ties.  

·  Posterior Tongue tie – This is also known as a hidden tongue tie since they are often difficult to spot. They are commonly located further back where the tongue meets the floor mouth.

2. Based on their clinical presentation and limitations it may cause – symptomatic or asymptomatic.

Signs and symptoms of tongue-tie

Signs and symptoms of Tongue-tie commonly are^1-6:

Commonly seen in infants (Cleveland Clinic):

·  Difficulty latching or dribbling while breastfeeding

·  Breastfeeding might take longer than usually recommended times (new-borns – 20 minutes, older infants – 5-10 minutes)

·  Constant hunger

·  Low body weight or trouble gaining weight

·  Clicking sounds while your baby is feeding

Commonly noted from breastfeeding mother (Cleveland Clinic and GPIFN):

·  Sore and cracked nipples

·  Pain while nursing

·  Insufficient milk supply

·  Mastitis

·  Nipple biting and trauma to the nipples

Commonly noted signs and symptoms in younger children(Cleveland Clinic):

·  Difficulty with speech. Difficulty is commonly more pronounced with sounds that require the tip of the tongue to touch the roof of the mouth or backside of the upper front teeth such as l, r, t, d, n, th, sh, and z.

·  Difficulty swallowing or eating (e.g., licking an ice cream)

·  It is often more difficult for children with a tongue tie to move their tongue even inside and outside the mouth

·  Difficulty playing a wind instrument

Commonly noted signs and symptoms in adults are (Cleveland Clinic):

·  Developing a habit of pushing the tongue against the front teeth (tongue thrust)

·  Mouth breathing

·  Jaw pain

·  Difficulty in kissing

·  Speech difficulties

Diagnosis and management

Diagnosis and management of a tongue tie needs to be done by a qualified and registered medical professional such as paediatricians, dentists, paediatric dentists, periodontists, or lactation consultants. Diagnosis is commonly done by taking an oral history of the individual or the mother (in the case of infants) followed by a clinical examination.^2,6 Follow-up investigations are generally not needed but if required scans or imaging may be requested as needed.

There are two broad management options for tongue ties:

·  Conservative – This line of treatment may be possible if the tongue tie is mild and symptomatic or mildly symptomatic.^1-6 This option of treatment generally includes observation, advice/support around lactation and speech therapy/speech pathology consultation.^2,7

·  Surgical – Surgical options are the most recommended/treatment option of choice. Three surgical options are available for the treatment of tongue-ties – Frenotomy (also known as frenulotomy), Frenectomy, Frenuloplasty.⁸ Which surgical option is most suitable is strongly dependent on the clinical evaluation of the patient. Like any other surgery, surgical options for treating tongue ties also carry some risks and possible complications which include bleeding, damage to surrounding anatomical structures (e.g., salivary glands), scarring, oral aversion, and airway obstruction.² However, these risks are known to be rare and in most cases, the surgical treatment is carried out as a single outpatient appointment possibly requiring 1-2 outpatient follow-ups after the surgery.

For any more information about any specific treatment plans or queries, Klarity recommends that you ask your treating clinician, as they might be best suited to guide you further.

Tongue-tie and breastfeeding

Tongue ties are more commonly noted in infants; hence it is important to discuss their importance around breastfeeding.  Tongue ties can be frustrating for both the baby and the nursing mother.⁹ Infants generally experience the symptoms described above such as difficulty latching, chewing on the mother’s nipple with their gums, nipple feeding rather than breastfeeding, feeling hungry and needing feeds more often with additional difficulties in gaining weight.⁹ Furthermore, tongue ties can be frustrating for nursing mothers as well since the inefficient attachment doesn’t remove the milk from the breast completely and isn’t easy to maintain (can lead to mastitis). Repeated trauma to the nipple can also be of significant discomfort. ⁹ All of this can contribute towards significant ill-health of infants and nursing mothers. Thus, it is important that while seeking treatment for tongue ties, nursing mothers also seek advice/referral from the treating clinician for further support around breastfeeding.

Some publicly available resources and information around tongue ties and breastfeeding can be found here – UNICEF, La Leche League International web page.

FAQ’s

Can tongue-ties be prevented?

Tongue ties are a congenital (i.e., present since birth) condition hence it is possibly genetic or hereditary in origin.⁴ This means they can only be treated but not prevented.

Are there feeding concerns around tongue-ties?

Yes in infants tongue-ties can pose a significant difficulty in feeding.⁹ Hence while treatment for tongue-tie should help with reducing the difficulties infants may have with breastfeeding, nursing mothers should be referred to appropriately qualified professionals for further advice on how breastfeeding difficulties may be overcome.

Summary

Ankyloglossia or Tongue ties are commonly noted in about 0.2-10.7% of infants in the UK. Overall diagnosis of tongue -ties in infants is higher than that in younger children and adults, with no racial or gender predilection. ² While its specific cause is unknown, it is a congenital (present since birth) condition hence it is possibly genetic or hereditary in origin.⁴ Its clinical presentation can also be syndromic in origin accompanied by cleft-lip and cleft-palate or abnormal number or size of the teeth as well.⁴ Some common signs and symptoms of tongue tie are generally around difficulties with breastfeeding and secondary problems arising from it in both the mother and the infant.² In older children and adults symptoms include functional difficulties involving the tongue, some common examples would be difficulties in speech, swallowing, and eating (e.g., licking an ice cream).^2,3 Treatment options for tongue ties are commonly based on the severity of the condition. But two broader options of treatment generally are – conservative (observation, speech therapy) and surgical (frenotomy, frenuloplasty or frenectomy).² It is important that while seeking treatment for tongue ties, nursing mothers also seek advice/referral from the treating clinician for further support around breastfeeding as this can be equally challenging and symptomatic for them. Some publicly available resources and information around tongue ties and breastfeeding can be found here – UNICEF, La Leche League International web page.