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Tethered Oral Tissues (TOTS) can be either a tongue tie (ankyloglossia) or a lip tie. A tongue tie is when the thin piece of skin under a baby’s tongue (the lingual frenulum) restricts movement of the tongue. While a lip tie is where the upper lip is restricted due to being anchored to the gum.

When the frenulum is normal, it is elastic and does not interfere with the movements of the tongue (ie. sucking, eating, cleaning food off the teeth in preparation for swallowing and, of course, in speech). But, when the tissue is short, thick, tight or broad it has an adverse effect on the function of the muscles related to posture, speech, and feeding.

Ideally, the frenulum should disintegrate during embryonic development but in some cases won’t, thus, creating a “tethered-like” cord of tissue.

TOTS is a condition that often runs in families and is said to have a genetic component.

Unfortunately, all tongue ties do not present the same way – adding to the difficulty in diagnosing them. They can be thin and membranous, thick and white, short, long or wide, extending from the margin of the tongue all the way to the lower front teeth, or so short and tight that they make a web connecting the tongue to the floor of the mouth.

When it extends to the margin of the tongue, it can cause the tongue to take a heart-shaped appearance and a tongue tie may not be able to be seen. When it extends across the floor of the mouth, it causes pain when the tongue is elevated leading to a separation or inward tilting of the incisors.

What you should understand is that a baby with a tongue tie will look different from an older child with the same condition.

BEYOND BREASTFEEDING

Research of tongue tie with difficulties in breastfeeding covers a broad span; anywhere from 25-60% incidence. Difficulties include failure to thrive, maternal nipple damage, maternal breast pain, poor milk supply, difficulty latching and refusing the breast.

Some studies suggest for every day of maternal pain during the first three weeks of breastfeeding, there is a 10-26% risk of stopping breastfeeding.

Yet, difficulties with breastfeeding alone would not be the only concern when considering evaluation a baby for TOTS and/or intervention.

In one study, tongue tie was associated with displacement of the epiglottis and larynx. Infants with this disorder showed to have difficulty breathing. These infants’ arterial oxygen percent saturation (SaO2) levels were measured during three different times; asleep, sucking, and awake. The results showed that their SaO2 was unstable and slightly low; symptoms similar to those observed in victims of sudden infant death syndrome (SIDS) before their death. Unstable or low SaO2 levels can also lead to neurological and developmental issues in children.

In the case of an upper lip tie (ULT), the baby may not be able to obtain a proper latch or seal on the breast. A successful latch is when the baby is able to flair their upper lip and take both the areola and the nipple in their mouth. When a baby has an upper lip tie, they are unable to flair their top lip out effectively (like fish lips) and may only take the nipple into their mouth. This may lead to a poor seal and swallowing excessive amounts of air during feeding. The air in the baby’s belly can then lead to symptoms of colic or reflux and the use of unnecessary medications. Lip ties can also hold mother’s milk on the front surface of the upper teeth during night time feeding, leading to dental decay.

Children with TOTS may also have speech difficulties that may require extensive speech therapy.

COMMON SYMPTOMS RELATED TO TOTS

INFANTS

  • Several unsuccessful attempts at nursing
  • Colic, gassy, reflux
  • Failure to gain weight/thrive
  • Unsustained latch, calloused or blistered lips
  • Sinus congestion, snoring

MOTHER

  • Painful latch; cut or cracked areas
  • Bleeding nipples
  • Flattened, blanched or creased nipples
  • Failure to bond with infant leading to depression
  • Plugged ducts, engorgement, mastitis or thrush

WHY THE RISE IN TOTS?

One theory as to the rise in the number of detected cases of TOTS is the fortification of foods with folic acid.

In 1998, folic acid was added to foods; such as most enriched bread flours, cornmeal, pasta, rice and grains in the U.S. and Canada. The thought behind adding this synthetic B vitamin to foods was to help prevent neural tube defects (NTD) in babies.

Although adding folic acid to our food sources has reduced the number of NTD’s, it may have also lead to the rise in children being born with a particular genetic defect in what is called the “MTHFR” gene and subsequent poor postnatal folate status.

This particular gene is a key regulator of “methylation”; one of the most important biochemical reactions in our body needed for healthy DNA function and overall health.

It is recommended that women take the naturally active form of folate, not folic acid, during pregnancy. Folate is also found in its natural form in dark green leafy vegetables.

HOW TOTS AFFECTS STRUCTURE & FUNCTION

TOTS is considered a “mid-line” defect; meaning it affects the center or core of our body. The tongue is anatomically attached to the bone and fascial structures of the head and torso.

The tension caused by the tethered tissues can create long-lasting structural changes to the musculoskeletal system; especially in the neck, cranium, and face.

The changes in neck, cranium, and face can lead to adaptive changes within the body presenting as postural abnormalities or asymmetries. In infants, these postural challenges can lead to difficulties in reaching various developmental milestones such as: rolling over, creeping or crawling.

Developmental milestones are necessary for a child to develop a healthy sensory-motor system. Proper sensory input is essential for academic, social, emotional and motor skill learning and development.

If there is abnormal structure of any spinal regions, this critical sensory information may not make it to key areas of the brain. Thus, a child may develop a “disorganized” sensory-motor system. A child may later go on to receive the diagnosis of “Sensory Processing Disorder” and have trouble with attention, learning and /or behavior.

TOTS can also affect the subtle “pumping” movement of the cranial bones. This action is necessary in order for the cerebral spinal fluid (the fluid that protects the brain and spinal cord) to move toxins and away from the brain. The cerebral spinal fluid is like a sewer system that helps eliminates waste. But, when the cranial pumping motion is inhibited, toxins can affect brain function and development.

REVISION INTERVENTION OPTIONS

There are various degrees of lip and tongue ties with various opinions on the necessity for intervention.

It is important to understand that a child does not need to display feeding or speech issues in order for there to be a problem.

Dentists, pediatricians and ear, nose and throat doctors (ENT’s) are the primary professionals that perform revisions procedures.

There are two methods for revisions: one uses a laser and one uses scissors. With either option, parents should interview the practitioner on their method and success rate for their procedures.

It is critical that when seeking an opinion, the parent does research within their community to find a practitioner that is well versed in the different degrees of tongue/lip ties and that they also understand the structural implications of tethered oral tissues.

It is also important that the practitioner is versed in post-procedure wound care. The need for stretching exercises, cranial-sacral and chiropractic to prevent reattachment of the tissues is pertinent.

WHY CHIROPRACTIC & CRANIAL-SACRAL CARE IS IMPORTANT

Due to the structural changes associated with TOTS, it is imperative that pre and post revision care includes chiropractic care and cranial-sacral therapy.

The spinal column; especially the cervical spine (neck region) has a vast amount of neurological sensory input projecting to the brain.

If there are structural stressors on the spine or cranium, this will lead to poor neurological communication from the body to the brain which will alter proper neurological function and development. Specific spinal corrections can restore proper musculoskeletal structure, which in turn will restore neurological function.

*adapted from Tongue Tied? What’s The Fuss About Tots by Monika Buerger, B.A., DC