Home Speech-Language Pathology Consider Experience as Part of Evidence-Based Practice to Evolve Our Profession

Consider Experience as Part of Evidence-Based Practice to Evolve Our Profession

by Robyn Merkel-Walsh
written by

I was happy to read Melanie Potock’s recent blog, “Three Structures in a Child’s Mouth That Can Cause Picky Eating.” The post sparked a considerable amount of discussion on social media. I also appreciated ASHA’s response about professional experiences, and the value they bring to our profession. I have several thoughts on this blog regarding evidence-based practice and tethered oral tissues (TOTs).

ASHA reminds us on the website that evidence-based practice (EBP) involves clinical expertise/expert opinion coupled with scientific evidence and client perspective.

To me, EBP means more than level-one research or large-sample, double-blind case studies. EBP evolves with new evidence and truly listening to our colleagues and their observations. After all, broader research evolves from patterns noted in clinical practice and individual case studies. Blogs are a way for clinicians to present their experiences and they often spark interest in our doctoral-level researchers for designing larger case studies.

As a speech-language pathologist with more than 20 years of treating and studying orofacial myofunctional disorders, feeding, and muscle-based speech disorders, I still look at each patient and case individually.

Potock’s article tackles an important yet controversial topic in this field—TOTs—commonly known as tongue-tie or ankyloglossia. Not all children with a tongue-tie are picky eaters and Potock reports only her observations from her clinical experience.

I’ve experienced similar findings. Many of my pediatric clients with oral-phase feeding issues and self-limited diets also have a restricted lingual frenulum. In many of these cases, the child was diagnosed by a medical physician who then referred the patient to me. If physicians believe treatment from an SLP is important for these children, shouldn’t we learn how we can help with this diagnosis?

The trend in our field to “take sides” and use absolute terms, such as “there isn’t any evidence,” alarms me. I’m no stranger to dealing with these absolutes as a long-time member—and current board chair—of the Oral Motor Institute. Can’t we view clinical observations from an SLP with specific training and extensive experience as a valid form of evidence?

As for evidence beyond Potock’s expertise, TOTs is a recent term coined by pediatric dentist Kevin Boyd at the 2014 Summit of the International Affiliation of Tongue-tie Professionals. Although not new information, this topic features more frequently in the fields of lactation, speech-language pathology, oral surgery, orofacial myology and otolaryngology.

One driving factor in the increased interest stems from research in 2015 linking sleep apnea to a short lingual frenulum. In addition, Bobby Ghaheri, a pediatric otolaryngologist who hosts a website and blog on TOTs, relates the increased awareness of this condition to the importance of breastfeeding supported by The World Health Organization. The ASHA Evidence Map for orofacial myofunctional disorders also highlights tongue-tie.

As more professionals learn about the condition, the ability to diagnose the signs and symptoms will improve. We’ve certainly seen this trend with other diagnoses in our field.

There may be a lack of published research specifically related to this area of practice in speech-language pathology, but the information on this topic continues to grow in related professions and on an international level. For example, the American Academy of Pediatrics published a 2004 study, “Congenital Tongue-tie and Its Impact on Breastfeeding.” Another relevant study from 2015—“A Comprehensive Treatment Protocol for Lingual Frenectomy with Combination of Laser and Speech Therapy”—was published in the International Journal of Laser Dentistry.

SLPs wanting to learn more about this—or other evolving topics—can attend symposiums and workshops where presenters often discuss ongoing research.

I know we have a lot to learn on this topic, but I also feel we should remain open to listening to all forms of evidence. Several related colleagues—like occupational therapists, lactation specialists and registered dental hygienists—already treat these complex disorders. Don’t certified SLPs also want to educate themselves in order to maintain our scope of practice and work interprofessionally with those currently treating TOTs?

Robyn Merkel-Walsh, MA, CCC-SLP, is a speech-language pathologist in Ridgefield, New Jersey, specializing in feeding, oral placement and myofunctional therapy. She is also chairs the board of the Oral Motor Institute. robynslp95@aol.com

Related Articles


Melanie Potock, MA, CCC-SLP October 17, 2017 - 4:26 pm

Beautifully stated Robyn. Thank you, not only from me, but from thousands of speech language pathologists who believe in supporting each other, listening to opinions and discussing observations with open minds. I’m grateful to ASHA for having a safe place for therapists to share their clinical knowledge and learn from each other’s experiences.

Caitlin Jones October 17, 2017 - 4:30 pm

What a wonderful post, thank you Robyn! Can you recommend a good CEU for learning more about TOTs and orofacial myofunctional disorders? I have a professional interest as a SLP and a personal interest as a mother; my daughter had a frenulectomy at 2 weeks old for posterior TT and does still have a lip tie. Thanks again!

Robyn Merkel Walsh October 22, 2017 - 9:19 pm

Lori Overland and I will be teaching a new course in 2018! There’s a Facebook clutsenlive coming up with Scott Siegel , and Autumn Read Henning teaches a TOTs class . The IAOM which is linked In the article will be a great resource as well .

Elissa Flagg, MHSc, PhD, SLP(C), Reg. CASLPO October 21, 2017 - 12:04 am

There is no doubt that the contemporary conceptualization of Evidence-Based Practice that our field has embraced includes clinical judgement/expertise, alongside research evidence and client values. Whatever one thinks of recent claims around oral frenula qua “tethered oral tissues,” duly trained and licensed Speech-Language Pathologists are working within their professional mandate when making individual treatment recommendations based on assessment observations and some combination of the three EBP components (intra-professional controversy about the strength of the research evidence on oral frenula aside). For this reason, focusing the discussion on whether clinicians should or shouldn’t include clinical experience in their decision-making may not advance this particular discussion. Rather, we need to switch the focus to transparently communicating the bases of our recommendations to one another, and especially to our clients. It would be ideal if SLPs would start openly acknowledging which aspects of our treatment recommendations relate to (specific) research evidence, which to clinical judgement and expert opinion, and which to client values. This way, we can all be clear on the foundation(s) of the treatment recommendations under consideration, when discussing their merits. In addition, we will become accustomed to helping clients better understand the source(s) of our recommendations during the informed consent process, as the difference between research evidence and clinical experience may have a significant impact on client preferences. For example, clients don’t only need to understand the potential risks and benefits of frenectomy/frenotomy, but the specific bases for such a recommendation too. Finally, when we are maximally transparent about the foundations of our clinical reasoning, we will be in the best position to recognize conflicting or corroborating evidence over time (both research and clinical) and to update our recommendations and client education accordingly, rather than falling prey to the danger of staying the course of our current professional opinions.

Robyn Merkel Walsh November 22, 2017 - 11:31 am

Great points! There’s more research on this in dentistry, lactation and otolaryngology so it’s important when looking for research that SLPs look beyond what’s been studied in our own profession. In writing my TOTs book, I found many case studies from India for example. I share with my patients the pros and cons of the various procedures and what evidence has been on Post operative outcomes .

Comments are closed.