In a March 2015 post titled Just Flip the Lip, we explored how the band of tissue or “frenum” that attaches the upper lip to gum tissue can affect feeding development if the frenum is too restrictive. Today, we’ll focus on the lingual frenal attachment that is the easiest to miss: The posterior tongue tie (sometimes referred to as a submucosal tongue tie), a form of ankyloglossia.
Consider that the normal lingual frenum inserts at about midline, just under the tongue and down to the floor of the mouth allowing free range of movement and oral motor skill development. While many pediatric professionals are familiar with a tongue-tie when the frenum attaches closer to the tongue tip (where it’s visible when the tip is gently lifted), the posterior tongue tie requires a specific technique to view. According to Bobby Ghaheri, an ENT surgeon who specializes in treating ankyloglossia, whether anterior or posterior terminology is used, the focus should be on function. As he describes in this article, many anterior ties also include a posterior restriction and releasing just the thin membrane is not always adequate for full tongue function necessary for feeding. The frenum, if visible at all, may appear short and thick, but is often buried in the in the mucosal covering of the tongue.
As a pediatric feeding therapist, I gently lift up the tip of every child’s tongue during the oral examination. But, if I suspect a posterior tongue tie, my next step is to follow the procedure noted in this video by Dr. Ghaheri. This gives me enough information to ask the family to consult further with their pediatrician or primary care provider and a then a pediatric ENT, pediatric dentist or oral surgeon, who may also use specific instruments to better view the attachment. I feel my role as an SLP is to screen, not diagnose.
There are clues that indicate that a posterior tongue tie may be present before following the procedure noted above. The following are just some of the more common indicators of possible restriction of the lingual frenum impacting feeding development:
- Square, heart shaped or indented tip of tongue at rest and/or upon attempted protrusion—this is often indicative of anterior tongue ties, but as noted by Dr. Ghareri, the posterior restriction my still be present.
- Dimpled tongue on dorsal surface, especially during movement.
Breast and Bottle Feeding
- Difficulty latching and/or slow feeding.
- Mother experiences pain while baby nurses.
- In addition, as seen with upper lip ties, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
- Gassiness; fussiness; “colicky baby.”
- Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing.
- Fatigue, resulting in falling asleep at the breast.
- Discomfort for both baby and mother, resulting in shorter feedings.
- Need for more frequent feedings around the clock.
- Poor coordination of suck, swallow, breathe patterns.
- Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.
- Read more information and see ultrasound images of how tongue-ties affect breastfeeding mechanics.
Spoon and Finger Feeding
- Retraction of tongue upon presentation of the spoon.
- Inadequate caloric intake due to inefficiency and fatigue.
- Tactile oral sensitivity secondary to limited stimulation/mobility of tongue.
- Over-use of lips, especially lower lip.
- Difficulty progressing from “munching” to a more lateral, mature chewing pattern.
- Tongue restriction may influence swallowing patterns and cause compensatory motor movements, which may lead to additional complications, such as “sucking back” the bolus in order to propel it to be swallowed.
- Possible development of picky, hesitant or selective eating because eating certain foods are challenging.
- Gagging and subsequent vomiting when food gets “stuck” on tongue.
- Secondary behaviors to avoid discomfort that are thus protective in nature, such as refusing to sit at the table or being able to eat only when distracted.
Oral Hygiene, Dental and Other Issues Related to Feeding
- Dental decay in childhood and adulthood because the tongue cannot clean the teeth and spread saliva.
- Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.
- Open bite.
- Messy eating.
- Requiring frequent sips of liquid to wash down bolus.
On sharing my findings with a child’s caregivers and primary care physician, a pediatric dentist, oral surgeon or ENT will determine next steps for the frenectomy. Linda Murzyn-Dantzer at Children’s Hospital Colorado shared her insight on the use of laser treatment for frenectomies. She noted that the laser can be used safely in a clinic setting, eliminating the need for treatment under sedation or general anesthesia. The laser itself provides some analgesia and often there is minimal need for other anesthetics, which may not be well-tolerated and may compete for other cell receptors and influence oxygen levels.
The laser can help to control bleeding and stitches may not be required. The laser offers precision when cutting tissue, and if the patient moves even slightly, the controls allow the beam to be stopped almost instantly. Traditional surgical techniques are also an option and used in a variety of situations, but Dr. Murzyn-Dantzer chooses the use of a laser over electrocautery techniques that may overheat or burn tissue, affecting cell layers beneath the targeted tissue and causing post-operative discomfort and increased healing time.
Melanie Potock, MA, CCC-SLP, treats children, birth to teens, who have difficulty eating. She is the co-author of “Raising a Healthy, Happy Eater: A Parent’s Handbook—A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating” (Oct. 2015), the author of “Happy Mealtimes with Happy Kids,” and the producer of the award-winning kids’ CD “Dancing in the Kitchen: Songs that Celebrate the Joy of Food!”